X-Ray Radiation Safety Management Program - The University of Tulsa

X-Ray Radiation Safety Management Program

The University of Tulsa
July 11, 2013


  1. Oklahoma Administrative Code (OAC) 252:410, titled “Radiation Management”
  2. 10 Code of Federal Regulation (CFR) titled “Standards for Protection Against Radiation” or abbreviated NRC10 CFR 20
  3. X-Ray license # XR-114

Summary: The radiation safety management program is based on references incorporated from the Nuclear Regular Commission (NRC) and Oklahoma Department of Environmental Quality (DEQ) requirements for managing our X-ray machines and protecting the public and us from injury.

The radiation safety officer (RSO) is Matt Polson.

A written radiation protection plan is required by OAC 252:410-1-6(1) and OAC 252:410-3-32(a). The RSO is responsible for ensuring this written plan is implemented as described and ensuring that the X-ray machines are used safely.

X-ray Machines Use

X-Ray machine users are responsible for attending the radiation safety management program training and for using the X-ray machines safely.

The X-ray machines are to be stored and operated as designed. Improper use or loss of an X-ray machine should be reported promptly to the RSO. Acquisition or transfer of an X-ray machine must be approved by the RSO.

(A) Training

  1. Each X-ray operator will receive 1 hour of initial training covering the following subjects:
    1. radiation hazards associated with the use of the equipment
    2. the warning, safety devices and interlocks incorporated into the equipment
    3. recognizing symptoms of an acute localized radiation exposure and knowing how to report a suspected actual exposure
    4. proper operating procedure for the equipment
  2. Refresher training is required for each X-ray operator annually. Refresher training will consist of a review of the proper operating procedures and any changes to the radiation management plan
  3. No person shall operate an X-ray machine until that individual has received radiation training, completed an examination with a passing score, and demonstrated the ability to use the X-ray machine in a safe and competent manner. The RSO will be responsible for making sure that each X-ray operator is properly trained and competent before authorizing the person to use an X-ray machine

(B) Training Records

Records of training will be maintained for three years of which following will be documented: dates and names. Records will be maintained at the facility for three years for DEQ inspectors review

(C) Dosimetry

  1. Personnel badges will be submitted to a National Voluntary Laboratory Accreditation Program (NVLAP)-approved laboratory quarterly for processing. If the badge is lost, stolen, or damaged the user will notify the RSO immediately.
  2. The RSO will review the dosimetry records quarterly for elevated levels of radiation exposure. If there are elevated levels of radiation exposure, the RSO will investigate.
  3. Any maintenance involving the removal, assembly, rearrangement, and/or realignment of the local component will require a ring badge to be worn and be performed with the approval of the RSO.
  4. An area survey will be performed after any machine maintenance. Records of the maintenance performed and the area survey will be kept on file for three years.
  5. If an X-ray operator is declared pregnant, the pregnant woman may voluntarily notify the RSO in writing. The RSO will work to ensure compliance with NRC 10 CFR 20.1208.

(D) Area Surveys

  1. Will be performed:
    1. when the X-ray system is installed
    2. every 12 months after installation
    3. following any changes in the initial arrangement of the local components
    4. following the maintenance requiring removal or disassembly of the local component of the system
    5. during the performance of maintenance or alignment
  2. Each area survey record will include the following information:
    1. Manufacturer, make, model, and serial number of the X-ray machine
    2. The kV and mA settings
    3. The make, model, and serial number of the survey instrument
    4. The background reading
    5. The highest result recorded
    6. The date the survey was performed
    7. Who performed the survey

(E) Survey Meter Requirements
Survey meters will be calibrated annually or whenever there is a service/repair performed on the survey instrument excluding battery replacement. Calibration reports will include the following information:

    date and name of company performing the calibration

(F) Safety Devices or Interlocks
Safety device or interlocks will not be bypassed by routine operators. If there is a malfunction in the X-ray machine, the X-ray machine will be immediately shut down and repaired by an appropriately trained party with the approval of the RSO.
(G) X-ray Machine, Posting, and Labeling Requirements

  1. Each room containing x-ray equipment will be posted with a sign bearing the radiation symbol and words “Caution – X-Ray Equipment”
  2. Each X-ray machine will have a warning light labeled “X-Ray On” that will light up only when the X-ray tube is on
  3. Each X-ray machine will be labeled with a sign bearing the radiation symbol and words “Caution Radiation – This Equipment Produces Radiation When Energized” near the switch that energized the tube
  4. X-ray tube housing, which is visible and assessable without the use of tools, will have a label “Caution – High Intensity X-ray Beam”

(H) Notice of Transfer
If an X-ray machine is sold, transferred, leased, assembled, or installed, DEQ will be notified within 15 days after the transfer in writing with the following information:

  1. the name and address of the transferee
  2. the manufacturer, model and serial number of each transferred machine
  3. the transfer date

(I) Updating Registration

If a new X-ray machine is acquired or an X-ray machine is transferred or disposed of, an updated registration form “Registration of Industrial and Analytical X-Ray Machines” will be submitted to DEQ within 30 days after the acquirement, disposal, or transfer of the machine. The forms are available from the DEQ website.

(J) Reporting Overexposures

If a user suspects that he/she has had an overexposure of radiation, the employee will notify the RSO immediately and the incident will be investigated.  If the employee feels that the investigation was not handled properly, he/she may contact Oklahoma DEQ.

If the radiation is proved to cause or threatens to cause a person to receive a:

  1. dose exceeding 5 rems, or
  2. a lens dose exceeding 15 rems, or
  3. a shallow dose to the skin or extremities exceeding 50 rems;

The RSO will notify DEQ within 24 hours of the discovery of the incident. A report will be submitted to the DEQ within 30 days containing the following information:

  1. estimates of each individual’s dose:
  2. level of radiation involved;
  3. cause of the elevated exposures and dose rates; and
  4. corrective steps taken or planned to ensure against, recurrence, including a schedule

(K) Use and Safety
The X-ray machine will not be left unattended. When not in use, the X-ray operator will:

  1. take the key out and store in a secure place of which only the X-ray operators have access to; or
  2. have a password to operate the machine which will not be given to any individual but X-ray operators; or
  3. lock the room to prevent unauthorized access.

(L) Review of Radiation Safety Program

The Radiation Safety Plan will be reviewed annually for program content and implementation by the RSO and will include:

  1. Reviewing the Oklahoma Administrative Codes annually
  2. Performing a documented audit annually of the radiation safety plan to ensure that safety and compliance are being met