University of California, Santa Barbara Radiation Safety Committee6/08/2004Radiation Safety Policy on Non-ComplianceThis policy on non-compliance is designed to encourage the participation andcooperation of users of radioactive material, and to ensure that the use of such material isconsistent with state and federal regulations, university policy, conditions of ourradioactive material license, and safe practices.In the event that non-compliance with radiation safety program policies and practicesis identified, a laboratory audit report will be issued by the Radiation Safety Office,EH&S to the permit holder of the authorization. A time-table for correcting the item ofnon-compliance will be identified in the audit report, unless the item of non-compliancewas corrected at the time of the laboratory inspection.If the noted problem is corrected, and the violation is not severe, no further action isusually necessary. If the problem is not corrected during the corrective action time-frame,and is identified on the next EH&S laboratory inspection, a sanction suitable to theseverity level of the violation will be applied.Violations are classified into 3 severity levels: minor, moderate, severe.The severity levels are derived from Nuclear Regulatory Commission regulations andfrom UCSB’s recent safety history. The campus Radiation Safety Manual should beconsulted for clarification or more information on policies and procedures. Irrespective ofthe severity level, all violations must be corrected.Spills and accidents are not considered violations, unless they are the result of a failure tocomply with conditions of an authorization’s approved protocol or radiation safety policyand practices.Violations listed here are not all-inclusive. The list may change as deemed necessary bythe Radiation Safety Committee.Minor Violations:Laboratory Records1. Radioisotope use logs not completed2. Survey records not maintained or incomplete3. Surveys not conducted with proper instrumentsRadioactive Material Use and Storage4. Radioactive material (RAM) containers not properly labeled5. RAM not properly shielded6. RAM work surfaces not properly covered during use7. Survey meters not calibrated or unavailable for use8. Dosimeters not worn when appropriate9. Potentially contaminated items not properly labeled10. Lab coats, gloves not worn when using radioisotopesUniversity of California, Santa Barbara Radiation Safety Committee6/08/200411. Prohibited items in radioactive waste containerSanctions for minor violations:When four minor violations have occurred with the calendar year:1. Radiation safety office staff meet with the permit holder and laboratorypersonnel as part of a refresher training session.2. Written notice sent to the authorization permit holder.3. Failure to take corrective actions within the requested time frame will result inthe authorization’s suspension of radioisotope ordering/receiving untilcorrective actions have been implemented.Moderate violations:1. Storage or use of food, drink or cosmetics in a radioisotope use area2. Failure to properly secure radioactive material3. Use or storage or radioactive material in an unauthorized area4. Contamination levels outside of exclusive use areas of lab greater than thecontamination limits of the campus Radiation Safety Manual5. Improper disposal/release of radioactive material (e.g., sink, prohibitive itemsin containers).Sanctions for moderate level violations:When two moderate violations have occurred in a calendar year:1. Radiation safety staff meet with the permit holder and laboratory staff as partof a refresher training session.2. Written notification sent to the authorization permit holder by the RSO, with acopy sent to the department chair.3. Failure to take corrective actions within the requested time frame will result inthe termination of radioisotope ordering privileges until corrective measureshave been implemented.Severe violations:1. Intentional falsification of required radiation safety records2. Failure to immediately report known loss or theft of radioactive material3. Unauthorized external shipment or receipt of radioactive material from anexternal source (i.e., unapproved transfer of radioactive material)4. Radioactive material use not in accordance with the type of investigationspecified in the radioactive material authorization5. Failure to respond to a written notice from the RSO for corrective actions.Sanctions for a severe violation:1. Immediate notification of authorization permit holder by the RSO.University of California, Santa Barbara Radiation Safety Committee6/08/20042. Written notice sent to the authorized permit holder and the authorized user’sdepartment chair and the Radiation Safety Committee Chair.3. Suspension of radioisotope ordering/receipt privileges until corrective actionsare implemented to the satisfaction of the RSO and the Radiation SafetyCommittee.4. Possible suspension/termination of authorization to use radioactive materialfollowing review by the Radiation Safety Committee.5. Prior to reinstatement of the authorization, authorized permit holder andlaboratory personnel attend a radiation safety refresher