Guide to the Safe use of Radionuclides at the University of Wisconsin - Milwaukee

Section 27:   Laboratory Audits and Enforcement

27.1 Laboratory Audits

The Radiation Safety Officer will conduct routine audits of each Authorized User’s program and activities. The frequency of these audits will be based on the activities within the laboratory and the radionuclide laboratory classification. Authorized User programs with type 1 & 2 labs will be audited at least semiannually and type 3 & 4 labs will be audited at least quarterly. Areas reviewed during audits will include personnel training, monitoring, surveys, record keeping, lab postings, and radiation safety concernsl.

27.2 Enforcement

Violations and infractions of University and federal radiation safety regulations can lead to suspension of the UWM NRC license, civil fines, or imprisonment of negligent faculty, staff, students and administrators. The University enforcement policy classifies violations according to the severity of an infraction and its frequency of occurrence. Three classes of violations, which range from "most severe" to "moderately severe" and are summarized as follows:

  1. Class A Violation

    Class A Violations are "most severe" and deal with personal injury (actual or potential contamination) to radionuclide users, other UWM personnel, or the general public. Class A Violations can only occur through gross negligence or blatant disregard of NRC regulations.

  2. Class B Violation

    Class B Violations are "severe" and focus on personnel overexposure or contamination and the uncontrolled spread of radioactivity.

  3. Class C Violations

    Class C Violations are "moderately severe" and focus on significant procedural errors or other administrative issues. A flow chart outlining the sequence of events after violation has occurred is shown below. The "Notice of Radiation Safety Violation" form is shown in Appendix Q.

Figure 2. Flow Chart for Violations

Class A Class B Class C
Authorized user immediately informed of violation. Immediate actions taken to promptly correct any potentially hazardous situation and prevent reoccurance. Written notice sent to User with cc: to Department Chair, Dean of College, Director of University Safety and Assurances. Authorization to use radionuclides may immediately be suspended. 1st Occurrence:

Written warning provided to Authorized User and others involved with cc: to Deptartment Chair, Dean of College and Director of University Safety and Assurances

 1st Occurrence:

Verbal warning provided to Authorized User and other involved.
Authorized User must respond in writing within 5 days. Authorized User must respond and establish procedures to correct/prevent reoccurrence Authorized User must respond and establish procedures to correct/prevent reoccurrence
  2nd Occurrence:

Written notice of violation sent to Authorized User with cc: to Department Chair, Dean of College and Director of University Safety and Assurances.

Authorized User must respond within 5 days with written explaination of why the violation occurred and written plan to prevent reoccurrence.

 2nd Occurrence:

Written warning provided to Authorized User with cc: to Department Chair, Dean of College and Director of University Safety and Assurances.

Authorized User must respond within 5 days with written explaination of why the violation occurred and written plan to prevent reoccurrence.
  3rd Occurrence:

User informed immediately of violation and written notice provided to User, Department Chair, Dean of College, and Director of University Safety and Assurances. Authorization to use radionuclides may immediately be suspended.

Meeting held with User, RSO, Director of University Safety and Assurances, Department Chair, and representative of campus administration to evaluate violation and status of Authorized User’s program.

 3rd Occurrence:

User informed immediately of violation and written notice provided to User, Department Chair, Dean of College, and Director of University Safety and Assurances. Authorization to use radionuclides may immediately be suspended

Updated March 4, 2008 by SAK