As a licensee you are required to conduct an annual audit of your Radiation Safety Program. The audit will re-familiarize you with the requirements of your license.
You should note that the “flow” of this audit matches the “flow” of the APNGA example of a radiation safety program example. This will allow you an apples-to-apples approach to the safety program and the audit.
The annual audit will likewise keep you prepared for the eventual regulatory inspection
The RSO should conduct the audit along with senior management.
To assist you in conducting the annual audit you should print out a copy of the NRC Audit Checklist (nrc.gov) or you can find the checklist on the APNGA Homepage under “Industry listings – Helpful Checklists” or appendices. Or, use your Agreement State checklist if available & applicable.
1. Audit History
The first section of the audit reviews past audits. You should be keeping a documented record of your audits.
For this new audit, keep records of the checklist and your notes. If desired, you can complete the Annual Audit “How To” and print out a copy of the certificate that the tutorial generates at its completion.
Audit History 1.a
- To begin, retrieve a copy of your last audit and note that audit’s date on your new audit checklist. Return the previous audit to the file.
Audit History 1.b
- Check to make sure that you or previous RSO’s have conducted an audit since the original inception date of your license.
Audit History 1.c
- Make sure copies of all previous audits have been kept on file.
Audit History 1.d
- Next, check to see if there are any recurring deficiencies in your Radiation Safety Program that have been likewise noted in the previous 2 audits. RSO’s are required to note any deficiencies in their programs that may occur during the year, investigate and record them, and state what corrective actions have been taken.
- An example of a deficiency would be forgetting to take your inventory on time (every 6 months) or leak tests on time.
- If you have had deficiencies in your program during the last 2 years of audits you should make a list and attach it to this audit.
- Note: – You are far better off to acknowledge & correct your deficiencies and oversights by yourself than to have a licensing agent discover them during an inspection.
Audit History 1.e
- Did you take corrective actions when deficiencies were discovered?
- If deficiencies do occur you should take steps, and document the steps, to make sure such deficiencies do not happen again. Pay special attention to recurring deficiencies.
- Attach the corrective actions you have taken.
2. Organization & Scope of Program
This 2nd section focuses on the information on file with your licensing agency.
Grab a copy of your current license and, if available, your original license application.
Organization & Scope of Program 2.a
- Has your address changed or have you changed the other locations where your gauge is stored and/or used?
- If so, did you file an amendment with the licensing agency?
- If you didn’t – do so, note the deficiency and what steps you will take to make sure it won’t happen again.
Organization & Scope of Program 2.b
- Are there new owners of the company?
- If so, did you notify your regulatory agency and obtain prior approval?
- Did the owners/company file for bankruptcy?
- If so, was the regulatory agency notified?
Organization & Scope of Program 2.c
- Is there a new RSO since the last audit?
- If so, was the license amended?
- Does the new RSO have prerequisite training requirements – Gauge Safety Certification, HAZMAT Training and any additional Agreement State Requirements?
Organization & Scope of Program 2.d
- Every company must designate an individual that will be the spokesman when communicating with your regulatory agency. Ideally, that person should be the RSO.
- If the designated contact person (If different than the RSO) changed, did you notify the regulatory agency?
- If notification is necessary, do it now.
Organization & Scope of Program 2.e
- Read your license as to which gauge models, radioactive sources and millirem activity levels are allowed. Make sure you have not added any models & sources that are not listed and likewise make sure millirem quantities of the sources are not exceeded.
Organization & Scope of Program 2.f
- Do you have a copy on file of the Sealed Source and Device (SSD) Certificate or Sheet for each type of gauge you own? Copies can be obtained from the manufacturer – see their website.
- Do you own manufacturer operation & maintenance manuals for each type of gauge? If not, download from the manufacturer website.
Organization & Scope of Program 2.g
- Are you using the gauges the way they are intended? – see the authorized uses as stated on your license and SSD sheets.
Organization & Scope of Program 2.h
- Are you, the RSO, fulfilling your duties? See the “RSO Responsibilities” section under “Regulatory” headings on the “APNGA Homepage”.
- Make sure to check with your regulatory agency for any other requirements.
3. Training & Instructions to Workers
This section will review the training and instruction required of all workers using portable nuclear gauges as well as employees involved in preparing gauges for transport.
Training & Instruction to Workers 3.a
Code of Federal Regulation (CFR) 19.12 requires that all employees expected to receive an excess of 100 mrem/yr occupational dose be given special instructions. Although gauge users typically receive less than this amount it is assumed that they may exceed this limit and are therefore subject to these instructions
10 CFR 19.12 states workers be instructed in:
- storage, transfer & uses of gauges
- exposure issues and ALARA
- required safety training
- how to report overexposure concerns
- emergency response procedures
- how to obtain their exposure reports
Workers are to receive annual refresher training on these topics
- Have workers received initial instructions on these issues and have they received an annual refresher? (The APNGA Annual Refresher Training Module can be used to guide you with this training – it is included with your annual dues)
Training & Instruction to Workers 3.b
- Did each gauge operator complete an approved gauge safety course before using the gauge? (The APNGA Gauge Safety Training Course is approved in most states & is included in annual dues – check the list for your state’s status)
Training & Instruction to Workers 3.c
- Do you have training certificates on file for each worker? Each worker should have a record for Initial Gauge Safety Training, HAZMAT Training and Annual Refresher.
Training & Instruction for Workers 3.d
- Did you conduct interviews with each worker to determine if they are knowledgeable with emergency procedures ( see the “Emergency Procedures” section under the “Regulatory” heading on the “APNGA homepage” and your regulatory agency for guidance.
Training & Instruction to Workers 3.e
- Did you observe each worker operating the gauge in the field?
- Did you observe each worker performing routine cleaning & lubrication?
- Did you observe each worker transporting the gauge?
- Did you observe each worker checking a gauge in and out of storage?
Training & Instruction to Workers 3.f
- Did each worker demonstrate safe handling and security during operation, transportation and storage of the gauge?
Training & Instruction for Workers 3.g
- Was USDOT HAZMAT (CFR 172.700-704) training provided for each worker involved in preparing and/or transporting a gauge? (APNGA annual dues include a USDOT HAZMAT course that is accepted in every state).
- Make sure HAZMAT training records are kept on file.
4. Radiation Survey Instruments
Radiation Survey Meters, also known as hand–held Geiger Counters, allow you to detect the presence of radiation. All license holders should be in possession of a survey meter. In the event of an accident they can be used to detect the location of a dislodged source, determine the Transport Index of a damaged gauge or determine the radiation levels around a storage area. Check the “Survey Meters” section under the “Industry” heading on the “APNGA Homepage” for guidance in buying a survey meter.
Radiation Survey Instruments 4.a
- Does your survey meter meet the criteria of your regulatory agency? Typically this requires a survey meter that is able to detect gamma radiation and be recalibrated annually.
Radiation Survey Instruments 4.b
- If you do not own your own survey meter you will need to show you have immediate access to one. Do you have a plan for accessing a survey meter?
Radiation Survey Instruments 4.c
- If you are licensed for and performing non-routine maintenance you must own a survey meter that is calibrated annually. Non-routine maintenance would include removal of the source rod. Do not remove the source rod if you do not have a special license to do so.
Radiation Survey Instruments 4.d
- Do you have survey meter calibration records on file?
5. Gauge Inventory
An inventory of your gauges should be completed every 6 months. Keep a inventory sheet attached to a clipboard and place it at the storage area with the date of the next inventory. Complete a hands-on inventory of each gauge and keep the completed document on file.
Gauge Inventory 5.a
- Do you have a receipt for each gauge in inventory that shows the date each gauge was obtained and entered into your inventory?
Gauge Inventory 5.b
- Are each of your gauges physically inventoried every 6 months?
Gauge Inventory 5.c
- Do you have all physical inventory documents on file?
6. Personnel Radiation Protection
It is recommended that all license holders provide personnel dosimetry to their employees. Dosimetry measures any exposure that workers receive and provides a record of this exposure.
The Dosimetry, typically in the form of a film badge, TLD (Thermoluminescent Dosimeter, or OSL (Optically Stimulated Luminescence) ensures that ALARA practices are being met and also creates a record that documents that employees are receiving minimal exposure levels.
Personnel Radiation Protection 6.a
- The key component of a sound Radiation Protection Program is a solid adherence to ALARA considerations. Are ALARA considerations (time, distance & shielding) being taught and practiced and incorporated into the Company Radiation Protection Program?
Personnel Radiation Protection 6.b
- If any gauge workers are not provided dosimetry is documentation provided confirming that they are receiving less than 500 mrem per year?
Personnel Radiation Protection 6.c
- Did the activities of gauge workers not wearing dosimetry change to where the possibility of receiving greater than 500 mrem per year exist?
- If so, was a new evaluation performed?
Personnel Radiation Protection 6.d
- Is dosimetry currently provided for your workers?
- Are any workers currently receiving more than 500 mrem?
- Is the dosimetry supplier NVLAP approved?
- Are film badges changed monthly? TLD’s quarterly?
- Are the dosimetry reports reviewed by the RSO as they are received?
- Are NRC or equivalent Agreement State forms being used?
- NRC-4 “Cumulative Occupational Exposure History
- NRC-5 “Occupational Exposure Record for a Monitoring Period”
- If a worker declared her pregnancy was she limited to a maximum of 500 mrem for the term of the pregnancy? Were embryo/fetus dose records kept on file?
- Are all exposure, survey, monitoring and evaluation records kept on file?
7. Public Dose
One of the primary responsibilities of a license holder is to protect the general public (non-gauge workers) from exposure to radiation.
Assurances must be made to keep exposure levels to the general public below 100mrem in a year or 2mrem in any 1 hour.
Public Dose 7.a
- Are gauges stored in a manner that keeps dose limits to the public below 100mrem in a year?
Public Dose 7.b
- Has a survey or evaluation of public access areas been performed around the storage area to ensure that exposure levels are below 100mrem per year?
- Has there been any gauge additions or changes to the storage area, security or use of the surrounding areas that would necessitate a new survey or evaluation?
Public Dose 7.c
- Do public access area radiation levels exceed 2mrem in any one hour?
Public Dose 7.d
- Are gauges being stored in a manner that would prevent unauthorized use or removal?
Public Dose 7.e
- Are storage survey and evaluation records being kept on file?
8. Operating & Emergency Procedures
Each licensee RSO must develop, implement and maintain Company Operating & Emergency Procedures.
All workers must have a copy of these procedures and know what steps to take in the event of an emergency.
Please refer to Appendix H of the NRC’s NUREG Guide 1556 Vol 1, “Operating & Emergency Procedures” for an outline or use your Agreement State procedures.
This APNGA website also contains information to complement your regulatory agency requirements.
Procedures should include these instructions:
- Using & maintaining the gauge
- Security during transport and storage
- Control & surveillance during use
- Keep exposures ALARA
- Constant accountability during use
- How to deny access to a damaged gauge
- Steps to take and who to contact when a gauge is damaged
Operating & Emergency Procedures 8.a
- Have Operating & Emergency Procedures been developed?
Emergency & Operating Procedures 8.b
- Do they contain the required elements as specified by the regulatory agency?
Emergency & Operating Procedures 8.c
- Does each gauge worker and gauge case have a current copy of the operating & emergency procedures, including RSO office, cell & home telephone numbers as well as the manufacturer’s and regulatory agency emergency contact numbers?
9. Leak Tests
Performing leak tests on your gauges is an important safety requirement of your license. These tests will ensure that contamination and/or increased levels of radiation do not harm workers or the public.
Forgetting to perform a leak test is one of the most frequent violations of gauge licensees.
Leak Tests 9.a
- Was each sealed source on each gauge leak tested on time (per the time interval stated on your license)?
Leak tests 9.b
- Was the leak test performed per the descriptions and requirements of the regulatory agency and your license?
Leak Tests 9.c
- Are leak tests results kept on file?
Leak tests 9.d
- Were any sources found to be leaking and, if so, was the gauge pulled from service and the regulatory agency notified?
10. Maintenance of Gauges
Keeping your gauges clean and lubricated will result in optimum safety and performance of the gauge.
Remember, you are not allowed to remove the source rod unless specifically licensed to do so.
Maintenance of Gauges 10.a
- Are the gauges routinely cleaned and lubricated per the manufacturer’s procedures?
Maintenance of Gauges 10.b
- Does the source rod remain attached to the gauge during cleaning?
Maintenance of Gauges 10.c
- Are you licensed to remove the source rod for non-routine cleaning?
- If so, did you adhere to the special requirements pertaining to procedures, dosimetry, survey instruments, individuals and compliance?
The best way to complete the transportation portion of the audit is to accompany the worker while a gauge is in transport. Every worker should be viewed transporting a gauge to assure that HAZMAT requirements are understood and met.
The evaluation should commence at the storage area and conclude upon return to the storage area.
- Was an undamaged, manufacturer-provided and approved, Type “A” package gauge case used during every transport of a gauge?
- Are the Type “A” Package test results for every different type of gauge case in use kept on file?
- Is a “Certificate of Competent Authority” kept on file for each different type of source used in the gauge? (This will satisfy the requirement for documenting special form certificates).
- These special form certificates can be obtained through the manufacturer and can usually be downloaded on their website.
- Did the gauge case display 2 Yellow Radioactive ll labels that legibly show the Transport Index (TI), gauge sources & activities, and hazard class (7)?
- Does each gauge case display a Type “A” package label denoting UN3332, “Radioactive Material”, “Special Form” and “RQ” requirements?
- Was the gauge case closed and locked for every transport of every gauge?
- Were applicable bill of lading and emergency response sheets used during every shipment?
- Were shipping documents filed for every shipment?
- Did the shipping papers contain the proper entries? (Shipping name (Radioactive Materials), Hazard Class (7), UN ID Number (3332), Total Quantity (number of gauges), Package Type (Type A), Nuclides ( Cesium137 and/or Am241), RQ (if necessary), Description (Radioactive Material), Special Form, Activity (in Becquerels and Millicuries), Yellow ll labels, Transport Index (TI), Shipper’s name, Certification and signature, Emergency Response Telephone number, Cargo Aircraft Only label.
- Were the shipping papers (Bill of Lading & Emergency Response Sheet) within eyesight, driver’s reach and readily accessible during every gauge transport?
- Was the gauge case secured against movement?
- Were double, independent, locked cables, chains or other security devices used during transport?
- Was the gauge concealed while temporarily stored in a vehicle?
- Were any incidents reported to the USDOT?
12. Auditor’s Independent Survey Measurements (if made)
If any independent survey measurements were made describe the type, location and results of measurements. Do any radiation levels exceed regulatory levels?
13. Notification & Reports
This section relates to incidents that require notifications to the regulatory agency. This does not include non-emergency oversights that must be noted and corrected in your Gauge Safety Program.
Notification & Reports 13.a
- Were any gauges lost or stolen since the last audit?
- Was your regulatory agency and/or NRC notified and reports made?
Notification & Reports 13.b
- Did any reportable incidents occur? Were reports made?
Notification & Reports 13.c
- Did any overexposures or high radiation levels occur? Were they reported?
Notification & Reports 13.d
- If any reportable events (a-c) did occur what were the causes?
- Were the corrective actions appropriate and/or effective?
Notification & Reports 13.e
- Are you aware of the NRC Emergency Operations Center 301-816-5100 telephone number? You should call this number for any of the above incidents – they will in turn contact your Agreement State, if appropriate.
- Do you have the Agreement State emergency telephone number?
14. Posting & Labeling
- You are required to post or make available certain documents and/or posters for public viewing. Make sure you are familiar with your regulatory agency’s requirements, be it NRC or Agreement State.
- Keep all originals under lock and key. Only post copies of the documents and posters (keep originals on file).
Posting & Labeling 14.a
- Is the “Notice to Employees” poster posted?
- The poster should be viewable in an area accessible to all employees.
Posting & Labeling 14.b
- Are regulations and license documents posted, or is a notice posted indicating where these documents can be viewed (post copies in a publicly viewable area).
- Be aware and post any documents required by your regulatory agency or other state or local authorities.
15. Recordkeeping for Decommissioning
Regulatory agencies require a minimum of 60 days notice before terminating your license and transferring or disposing of all of your gauges. Be aware of their requirements and maintain all decommissioning, transfer and disposal documents.
Recordkeeping for Decommissioning 15.a
- Have you maintained records important for decommissioning?
Recordkeeping for Decommissioning 15.b
- Do records contain all information outlined and required?
16. Bulletins & Information Notices
You should be on the mailing list or email list for documents issued by the NRC and/or your Agreement State. Go to www.nrc.gov to sign up for NRC Bulletins, Information Notices and NMSS Newsletters. Do the same for your Agreement State.
Bulletins & Information Notices 16.a
- Are you receiving pertinent NRC and Agreement State notices?
Bulletins & Information Notices 16.b
- Has appropriate training and actions been taken in response to these notices?
17. Special License Conditions or Issues
Have you reviewed any special license conditions or issues pertaining to your license (e.g., non-routine maintenance)?
18. Deficiencies Identified in Audit and Corrective Actions Planned
This section discusses any deficiencies or oversights that you have discovered during the audit and what corrective actions that you will plan and take to rectify the issue.
Deficiencies Identified in Audit and Corrective Actions Planned 18.a
- Summarize the problems and/or deficiencies discovered during the annual audit.
Deficiencies Identified in Audit and Corrective Actions Planned 18.b
- Describe the corrective actions planned or taken to rectify the deficiencies.
- Are corrective plans or actions being carried out at all of your licensed facilities?
Deficiencies Identified in Audit and Corrective Actions Taken 18.c
- Provide any other recommendations for improvements.
19. Evaluation of Other Factors
- Is senior management constructively involved with the RSO in conducting the Annual Audit?
- Does the RSO have sufficient time to perform Radiation Safety Duties?
- Does licensee have sufficient staff to support the Radiation Safety Program?
- Completion of Audit
- Make notes or comments of any other issue pertaining to the Annual Audit.
- Keep all notes and checklists used to complete the audit. These documents should be filed for future reference and proof of audit.