EPR10 Management System Contents 1. Structure of Management System 1.1 Statement of management intent 1.2 Commitment to resources 1.3 Organisational structure 1.3.1 Responsibilities of appointed persons 1.4 Procedural structure Document Control Summary Date of publication: August 2015 Author: Document status: Related documents: Approved by: I. Williamson / S. Clipstone Final Local Rules / risk assessments /Standard Operating Procedure I Williamson and S Clipstone in conjunction with EPR10 Management System Page 1 of 17
Radman Associates Approval date: September 2015 1. Structure of Management System Review date: September 2016 (following Safety Sub-Committee) The Management System comprises the following component parts: Statement of management intent Commitment to resources Organisational structure Procedural structure 1.1 Statement of management intent This EPR10 Management Document has been formulated to assist, so far as reasonable practicable, Keele University to comply with the Management conditions prescribed within the Company s Permit for the keeping and use of category 5 radioactive sealed sources: Schedule 1 of the Company s registration open sources and Schedule 1 of the Company s Certificate of Authorisation to Accumulate and Dispose of Radioactive Waste. Keele University is committed to compliance with all provisions of the Environmental Permitting Regulations 2010, so far as is reasonably practicable. As such Keele University fully accepts its responsibility to protect others and the environment that may be affected by its activities. To this end environmental protection is an integral part of Keele University s EPR10 Management System and every effort shall be made to provide suitable procedures to underpin this policy. The Document will undergo periodic review or whenever there are significant legislative or company changes concerning the use of radioactive materials. Signed:............................... Keele University Name: I.Williamson, Head of Department of Occupational Health and Safety............................... EPR10 Management System Page 2 of 17
1.2 Commitment to resources Keele University shall, via the organisational structure below, ensure sufficient financial and other resources are made available to achieve regulatory compliance. Resources shall be made available for: the employment of competent staff, as required to achieve compliance; staff training in company procedures for managing radioactive materials; providing the necessary facilities for safe handling and limiting contamination; maintaining systems and equipment required to meet the requirements of BAT with respect to radioactive waste; checking all relevant systems, equipment and procedures; a competent RPA and RWA consultancy service. Funds shall be made available, as required, to meet the following: Application fees (EPR10) Variation fees (EPR10) Annual subsistence charges (EPR10) Waste disposal costs Refurbishment of facilities to meet BAT guidelines 1.3 Organisational structure Keele University has established a management structure for ensuring the proper control of radioactive materials and reporting radiological incidents. Key appointments within this structure are given in the following organogram: Vice Chancellor Director of Human Resources and Student Support Head of Occupational Health and Safety Advisor Health and Safety Standing Committee (HSSC) Radiation Protection Advisers Radman Associates University Radiation Protection Officer Departmental RPS s Radiation Hazards Sub-Committee Registered Radiation Workers EPR10 Management System Page 3 of 17
1.3.1 Responsibilities of appointed persons The Vice Chancellor Keele University being the radiation employer (IRR99) and the User (EPR10), takes responsibility for radiation safety and environmental protection. The User is responsible for overall compliance with EPR10. The Vice Chancellor ensures that all staff act in accordance with the relevant procedures for radiation safety and environmental protection. The Director of Human Resource and Student Support (HRSS) The Director of Human Resources and Student Support, with the Human Resource Department takes responsibility for ensuring that the appointment of all staff and visiting workers/academics, meets the requirements for basic security checks. Whilst strict security vetting will not be required, the Director will ensure that there are suitable procedures to enable suitable references to be obtained for the individual concerned. Radiation Protection Adviser (RPA) The University Radiation Protection Officer in association with the Head of Occupational Health and Safety, on behalf of the Vice Chancellor, appoints the Radiation Protection Adviser (RPA) in his/her capacity as a Qualified Expert on compliance with all aspects of the EPR10. The RPA is formally appointed under Regulation 13 of the IRR99. Radioactive Waste Adviser (RWA) The University Radiation Protection Officer in association with the Head of Occupational Health and Safety, on behalf of the Vice Chancellor, appoints the Radioactive Waste Adviser (RWA) in his/her capacity as a Qualified Expert on compliance with all aspects of the EPR10. University Radiation Protection Officer The University Radiation Protection Officer with the Head of Occupational Health and Safety takes a key role in controlling the use and disposal of radioactive material on and from the University s facilities. The duties include: (i) coordinating the activities of all Departmental RPSs, (ii) collating and reviewing the Local Rules and associated procedures, (iii) inducting new radiation workers, (iv) periodically auditing radiation areas, and (v) liaising with the RPSs, the RPA, and regulatory authorities. Departmental Radiation Protection Supervisor (RPS) The Departmental RPS has the role of supervising the radiation work in their area in accordance with the requirements of the Local Rules. They liaise with the University Radiation Protection Officer and Head of Departments for authorising new staff and work with radiochemicals. They also draft and implement Local Rules. Registered Radiation workers Registered radiation workers are all those who work with radioactive materials as part of their employment or studies (i.e. staff or students). They are responsible for completing risk assessments, as required, and complying with Local Rules. Radiation Hazards Sub-Committee The Radiation Hazards Sub-Committee meets every 6 months to discuss issues concerning sources of ionising radiation and review any incident reports. The Committee is chaired by the University Radiation Protection Officer. On occasions the appointed RPA may attend. Minutes are taken and distributed to all EPR10 Management System Page 4 of 17
attendees. Significant issues are summarised to the Occupational Health and Safety Committee. The Radiation Hazards Sub - Committee shall periodically review the BAT Statement. 1.4 Procedural structure Company documentation concerning the environmental management of radioactive materials is organised in to the following hierarchy: University Standard Operating Procedure for the Use of Ionising Radiations Prior risk assessment Management System (EPR10) BAT Statement Local Rules for Radiochemical Work EPR10 Management System Page 5 of 17
1.5 Evidence of compliance with certificates of Registration and Authorisation Registration ref:.ea/02/aw2035........................ Authorisation ref: BJ3853....................... 1.5.1 Evidence of compliance with the certificates of Registration Condition Detail Means of demonstrating compliance Supporting document ref Purposes for which registered substances are kept or used 1. The user shall keep or use the registered substances only for the purposes specified in para 2 of Schedule 2. Supervision of registered substances 2a. The user shall ensure that the keeping and use of the registered substances are supervised by a person competent and able to secure compliance with the limitations and conditions specified in this certificate. 2b. The user shall ensure that the name of the person supervising the keeping and use of registered substances is clearly displayed with the copy of this Certificate of Registration posted on the premises as required by section 19 of the Act. Noted Appointed RPS (refresher completed 22.9.15) Lennard Jones building Appointment letter Keeping and use of registered substances 3. The user shall not lend or let on hire a registered substance, or cause or permit to be lent or let on hire except to a person who is registered under the Act to keep or use such a substance. 4. The user shall so far as is reasonably practicable prevent a. the loss of any registered substance; and b. access to any registered substance by any person not authorised by the user. Noted a. Security provisions. b. Personnel checks and induction for new radiation workers 5. The user shall, so far as is reasonably practicable ensure that each registered substance is kept either: 5a under continuous surveillance; or Safeguarding sources included in induction training. 5b in a suitable container in a suitable store both of which: i. are so constructed, maintained and used as to prevent the loss or unauthorised removal of the substances; ii are constructed of non-combustible materials; iii. do not contain nor are located close to any corrosive, explosive or flammable material; and iv. are clearly and legibly marked with the word radioactive, with the ionising radiation symbol conforming with BS 3510: 1968 or ISO 361 and any other information necessary for the identification of the registered substances present. 6. The user shall so far as is reasonably practicable minimise the amount of radioactive waste which arises from the keeping and use of each registered substance. i, ii, iii. Sources stored in secure store or fridge/freezer with adequate fire protection and away from flammables. iv. Source pots and stores/fridges/freezers are marked with the radiation trefoil. iv. Source pots additionally marked with unique ID. Considered at project approval. a. Inspection report b. Induction record Induction record Condition Detail Means of Supporting EPR10 Management System Page 7 of 17
7. The user shall so far as is reasonably practicable ensure that all relevant parts of the premises are constructed, maintained and used in such a manner that - a. they do not readily become contaminated; and b. any contamination which does occur can easily be removed. demonstrating compliance Considered at design and build of facilities. Considered at design and build of facilities. document ref Monitored Loss or theft of registered substances 8. a. without delay inform the Police and the Environment Agency; b. so far as is reasonably practicable recover the substances; and c. as soon as is practicable report the circumstances in writing to the Environment Agency. Contingency plans included in the Local Rules. Local Rules Escape of registered substances 9. If the user believes or has reasonable grounds for believing that a registered substance is escaping or has escaped from any container or location in which it is kept or used he shall a. without delay inform the Environment Agency; b. so far as is reasonably practicable i. prevent any further escape; and ii. minimise the spread of any contamination. c. ensure that any discharge of radioactive gas to the atmosphere is made in a manner which prevents so far as is reasonably practicable its entry into any building; Contingency plans included in the Local Rules. Local Rules EPR10 Management System Page 8 of 17
and d. as soon as is practicable report the circumstances in writing to the Environment Agency. Change of name or cessation of use 10. The user shall give the Environment Agency not less than 21 days notice in writing of his intention to a. change the name of the user; or b. cease to occupy the premises; or c. cease to keep or use registered substances on the premises. Records 11. The user shall make upto-date, clear and legible records for each registered substance showing a. the radionuclide present, the date on which it was received and the activity on that date; b. so far as is reasonably practicable its location on the premises; c. if it has been removed from the premises, the date of removal, the activity on that date and the name and address of the person to whom it was transferred; d. the activity present on the premises at the end of each calendar month; and e. such other information as an authorised person may required. Noted. a, b, c, d & e. Stock record card raised for each source pot received for recording the use from receipt to disposal. logs all required details. Stock record cards in Lennard Jones 1.5.2 Evidence of compliance with the certificates of Authorisation EPR10 Management System Page 9 of 17
Condition Detail Means of demonstrating compliance Supporting document ref 12. The user shall keep, unless notified to the contrary in writing by an authorised person, the records referred to in this certificate and in any Records collated and maintained by the Principal RPS. certificate referred to in paragraph 3 of Schedule 2 available for inspection at any reasonable time by an authorised person in such a place and in such a manner as an authorised person may require. 13. The user shall supply on demand and without charge such copy or copies of all or part of the records kept as referred to in this certificate as an authorised person may reasonable require. Noted. Supervision of accumulation and disposal 1. The user shall ensure a. that the accumulation and disposal of the radioactive waste is supervised by a person competent and able to secure compliance with the limitations and conditions specified in this certificate; and b. that the name of the person supervising the accumulation and disposal of the radioactive waste is clearly displayed with the copy of the Certificate of Authorisation posted on the premises as required by section 19 of the Act. Accumulation of radioactive waste 2. The user shall so far as is reasonably practicable prevent a. the loss or escape of any accumulated radioactive waste; and b. the access to any accumulated radioactive waste by any person not authorised by the user. 3. The user shall so far as is reasonably practicable ensure that accumulated radioactive waste is kept either: a. in a suitable container under continuous surveillance; or b. in a suitable container in a suitable store both of which i. are so constructed, maintained and used so as to prevent the loss or unauthorised removal of the waste; and ii. are constructed of non-combustible materials; and iii. do not contain nor are located close to any corrosive, explosive or flammable materials; and iv. are clearly and legibly marked with the work 'Radioactive' and with the ionising radiation symbol complying with BS 3510: 1968 or ISO 361 and any other information necessary for the identification of the waste present. a. RPS appointment includes this duty. b. Principal RPS name posted (ie departmental responsibility). a. control procedures on radioactive waste storage. b. Key for waste store in custody of RPS. a. Suitable bench level waste containers provided. b. Waste store designed to be secure, fireproof, away from flammables, and is marked appropriately. Terms of reference included in appointment letter. Procedural EPR10 Management System Page 10 of 17
Condition Detail Means of demonstrating compliance Supporting document ref 4. The user shall so far as is reasonably practicable ensure that all relevant parts of the premises are constructed, maintained and used in such a manner that a. they do not readily become contaminated; and b. any contamination which does occur can be easily removed. Considered at design and build of facilities. Disposal of radioactive waste 5. The user shall ensure so far as is reasonably practicable that the means, under his control, by which disposals of radioactive waste are made are maintained and kept in good repair. Loss of accumulated radioactive waste 6. If the user believes or has reasonable grounds for believing that any accumulated radioactive waste has been lost or stolen he shall a. without delay inform the Police and the Environment Agency; b. so far as is reasonably practicable recover the waste; and c. as soon as is practicable notify the Environment Agency in writing of the circumstances of the occurrence and the means taken to recover the waste. Escape of accumulated radioactive waste 7. If the user believes or has reasonable grounds for believing that any radioactive waste is escaping or has escaped from any container or location in which it is accumulated he shall a. without delay inform the Environment Agency; b. so far as is reasonably practicable:- i. prevent any further escape; and ii. minimise the spread of any contamination; c. ensure that any discharge of radioactive gas to the atmosphere is made in a manner which prevents so far as is reasonably practicable its entry into any building; and d. as soon as is practicable report the circumstances in writing to the Environment Agency. Accumulation or disposal in excess of authorised limits 8. If the user believes or has reasonable grounds for believing that the accumulation or disposal of radioactive waste is occurring or has occurred which does not comply with this certificate he shall a. without delay inform the Environment Agency; b. so far as is reasonably practicable prevent the further accumulation or disposal of radioactive waste; and c. as soon as is practicable report the circumstances in writing to the Environment Agency. Noted. Contingency plans included in the Local Rules. Contingency plans included in the Local Rules. Contingency plans included in the Local Rules. Local Rules Local Rules Emergency Management Team may be called Local Rules EPR10 Management System Page 11 of 17
Condition Detail Means of demonstrating compliance Supporting document ref Change of name or cessation of accumulation and disposal 9. The user shall give the Environment Agency not less than 21 days notice in writing of his intention to a. change the name of the user; or b. cease to occupy the premises; or c. cease to accumulate and dispose of radioactive waste. Noted. Records and provision of disposal returns 10. The user shall make, on the day of accumulation or disposal as appropriate, clear and legible records of accumulation and of disposal of radioactive waste. 11. The user shall keep, unless notified to the contrary in writing by an authorised person, the records referred to in this certificate and any certificate referred to in paragraph 2 of Schedule 2 available for inspection at any reasonable time by an authorised person in such a place and in such a manner as an authorised person may require. 12. The user shall supply a. the Environment Agency with a report in the format given in the final Schedule, for each disposal route for which annual or monthly disposal limits are specified in Schedule 3 and subsequent Schedules, stating the total disposal made of each radionuclide or group of radionuclides listed in the relevant Table of the relevant paragraph of the Schedule together with such other information as may be specified in writing by an authorised person, (i) not later that 31 January each year for disposals made during the preceding calendar year; and (ii) together with any notice given under paragraph 9(b) or 9(c) for disposals made during the current calendar year; and b. on demand and without charge, such copy or copies of all or part of records referred to in this certificate, as an authorised person may reasonably require. Sampling and analysis of waste and other substances 13. The user shall a. take and analyse such samples of radioactive waste and conduct such other tests and surveys as are necessary for the purposes of this authorisation; b. take and analyse such samples of waste and conduct such other tests and surveys as an authorised person may require. c. make and keep a record of each such analysis, test or survey; and d. retain such samples as may be directed by an authorised person. Accumulation records kept on each waste container and collated into waste log. Aqueous disposal records maintained by lab workers at designated sinks. Organic liquid and solid disposal records maintained by lab workers and collated by RPS. Records collated and maintained by the Principal RPS. a. Principal RPS to make annual return by the required date. b. Noted. a. Noted b. Noted. c. Noted. Ref records for accumulations and disposal of: Aqueous Organic liquid Solid VLLW Pollution inventory Return copy held. EPR10 Management System Page 12 of 17
14. The user shall, if so directed by an authorised person a. despatch specified samples of waste for tests at a specified laboratory; b. comply with any specified requirements as to the packaging of the samples; c. supply the Environment Agency with such information in writing as may be directed in relation to the samples; and d. ensure that the samples and residues thereof are collected from the laboratory within three months of receiving written notification that testing and repackaging in accordance with the appropriate transport regulations are complete. a. Noted. b. Noted. c. Noted. d. Noted 1.6 Evidence of compliance with Standard Rules Permit Permit ref: AE6060/CD1835 Condition Detail Means of demonstrating compliance Supporting document ref 1. Management 1.1 General Management 1.1.1 The keeping and use of sealed radioactive sources shall be managed and operated:: (a) in accordance with a management system, which identified and minimises risks that a source may be damaged, lost or stolen, including risks arising from operations, maintenance, accidents, incidents and non-conformances, and those drawn to the attention of the registration holder as a result of complaints; and (by sufficient persons who are competent in respect of the responsibilities to be undertaken by them in connection with those operations.. 1.1.2 Records demonstrating compliance 1.1.1 shall be maintained 1.1.3 Any person having duties that are or may be affected by the matters set out in this registration shall have convenient access to a copy of it kept at or near the place where those duties are carried out. 1.2 Accident management plan 1.2.1 The registration holder shall: (a) Implement and maintain an accident management plan; (b) Review and record at least every 4 years or soon as practicable after an accident (whichever is earlier) weather changes to the plans should be made; (c) Make any appropriate changes to the plan identified by a review. Management system document Management system document Local rules 1.3 Site security EPR10 Management System Page 13 of 17
Condition Detail Means of demonstrating compliance Supporting document ref 1.3.1 (d) Site security measures shall prevent unauthorised access to the radioactive material, as far as is reasonably practicable. Campus CCTV and authorised access required to storage areas 2. Operations 2.1 Registered activities 2.1.1 The operator is only authorised to carry out the activities specified in schedule 1, table 2.1 ( the activities ) 2.2 The Marking of sources 2.2.1 No article which incorporated or is a sealed source shall be kept or used unless it uniquely and legibly marked, as far as is reasonably practicable. Regular inspections carried out with report EPR10 Management System Page 14 of 17
Condition Detail Means of demonstrating compliance Supporting document ref 3. Information 3.1 Records 3.1.1 All records required to be made by this registration shall: a. be legible; b. be made as soon as reasonably practicable; c. if amended, be amended in such a way that the original and any subsequent amendments remain legible, or are capable of retrieval; and d. be retained, unless otherwise agreed in writing by the Agency, for at least 6 years from the date when the records were made, except for records made pursuant to condition 3.1.2 which shall be kept for at least 6 years after the date on which a sealed source is removed from the premises.. 3.1.2 Records shall be made on the day of receipt or removal, as appropriate, of each sealed source showing: a. the radionuclide present, the date on which it was received and the radioactivity on that date; b. the identification number of the source and of any container in which it is kept or used; c. its location on the premises; and d. if it has been removed from the premises, the date of removal, the radioactivity on that date and the name and address of the person to whom it was transferred; and e such other information as the agency may require 3.1.3 Any records required to be made by this registration shall be supplied to the Agency within 14 days, where the records have been requested in writing by the Agency. 3.1.4 Sufficient records shall be made to demonstrate compliance with the limitations and conditions of this registration. RPS maintains and retains all relevant records Written booking in and out system in place On request - noted 3.1.5 All records made under the terms of any previous registration issued to the registration holder relating to sealed sources at the premises must be retained in accordance with condition 3.1.1 3.2 Reporting 3.2.1 All reports and notifications required by this registration shall be sent to the Agency using the contact details supplied in writing by the Agency 3.2.2 The registration holder shall send a report to the Agency within one month of the end of the year. The report shall confirm that each radioactive source, and all radioactive sources taken together, kept and used on the premises during the previous year remained within source category 5. As required - noted Noted EPR10 Management System Page 15 of 17
Condition Detail Means of demonstrating compliance Supporting document ref 3.2.3 If, when this registration came into effect, the registration holder kept or used only gaseous tritium light devices (GTLDs), the registration holder r shall send a report to the Agency within one month of the end of the year. The report shall confirm whether the registration holder continues to hold only GTLDs on the premises. 3.2.4 If, when this registration came into effect the registration holder held an authorisation under s13 or s14 of the act, the registration holder shall send a report to the Agency within one month of the end of the year. The report shall confirm whether the registration holder continues to hold that authorisation. 3.3 Notifications The Agency shall be notified without delay following the detection of 3.3.1 any malfunction, breakdown or failure of equipment or techniques or accident, which has caused or may cause a radioactive source to be damaged or lost - 3.3.2 Written confirmation of actual or potential damage or loss shall be submitted within 24 hours. 3.3.3 Prior written notification shall be given to the Agency as soon as practicable prior to the permanent cessation of the keeping or use of sealed sources on the premises. EPR10 Management System Page 16 of 17
Condition Detail Means of demonstrating compliance Supporting document ref 3.3.4 The shall be notified within 14 days of the occurrence of the following matters except where such disclosure is prohibited by Stock Exchange rules:- a. Where the registration holder is a registered company; any change in the registration holder trading name, registered name or registered office address; or any change to particulars of the registration holders ultimate holding company (including details of an ultimate holding company where a registration holder has become a subsidiary) or any steps taken with a view to the registration holder r going into administration, entering into a company voluntary arrangement or being wound up. b. Where the registration holder is a corporate body other than a registered company: any change in the registration holder,s name or address; and any steps taken with a view to the dissolution of registration holder. c. In any other case: the death of any of the named registration holders (where the registration holder consists of more than one named individual); or any steps taken with a view to the registration holder, or any one of them, going into bankruptcy, entering into a composition or arrangement with creditors, or, in the case them being in a artnership, dissolving the partnership. 3.3.5 If a sealed source has been lost or stolen, or theft of a sealed source has been attempted, or there are reasonable grounds for believing that such an event has occurred: a. the Police and the Agency shall be notified without delay; and b. the circumstances, including any actions taken, shall be reported in writing to the Agency as soon as is practicable. Emergency plans will be initiated 3.4 Interpretation 3.4.1 In this registration the expressions listed in schedule 2 shall have the meaning givenin that schedule, except where otherwise specified 3.4.2 Except where otherwise specified, words and expressions defined in the Act shall have the same meanings when used in this registration as they have in that Act. 3.4.3 Nothing in this registration shall be taken as applying to sealed soruces held under the terms of an exemption under the Act or a registration under section 10 of the Act. EPR10 Management System Page 17 of 17
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