CA Radiation Protectionprogram

RADIATION PROTECTION PROGRAMAUGUST 2006

RADIATION PROTECTION PROGRAM

OVERVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 REGULATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3 REGISTRATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4INSPECTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

5PERSONNEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 5 .1Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 5 .2Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 5 .3Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 5 .4TrainingandSupervision . . . . . . . . . . . . . . . . . . . . . . . . . 6

6 RECORDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6 .1Self-Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6 .2Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6 .3Receipt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6 .4UtilizationLogs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 6 .5Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

7 NOTIFICATION OF INCIDENTS . . . . . . . . . . . . . . . . . . . . . . . . 8

8 OPERATION REQUIREMENTS . . . . . . . . . . . . . . . . . . . . . . . . . 9 8 .1PerformanceRequirements . . . . . . . . . . . . . . . . . . . . . . . 9 8 .2Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 8 .3EquipmentSecurity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 8 .4Storage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 8 .5OperatingandEmergencyProcedures . . . . . . . . . . . . . 10

9 CONTRABAND DETECTION . . . . . . . . . . . . . . . . . . . . . . . . . 11

0 SUPPLEMENT AND APPENDIXES . . . . . . . . . . . . . . . . . . . . . 11

PROGRAM CHECKLIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

CONTENTS

RADIATION PROTECTION PROGRAM 2

August 2006

Dear Friend of the Courts:

The Emergency Response and Security Unit of the Administrative Office of the Courts is pleased to provide you with this radiation protection program to comply with California regulations pertaining to X-ray screening devices.

These regulations are a requirement for any entity, including courts, that are in pos-session of a radiation-emitting device. This report has consolidated the regulations applicable to the courts and includes the necessary reporting forms in an effort to make this process as simple as possible.

If you have any questions, I encourage you to contact the Emergency Response and Security Unit at 415-865-8048.

Sincerely,

Malcolm Franklin Senior Manager, Emergency Response and Security


OVERVIEWConcealed weapons screening is a vital part of any court systems security program, helping to ensure the safety of judges, court staff, jurors, and the public. X-ray screening devices used by the courts contain a reportable source of radiation, which must be registered with the California Department of Health Services, Radiologic Health Branch. The California Code of Regulations, title 17, governs the registra-tion, use, and inspection of radiation-emitting devices and the requirements for an effective radiation protection program.

While the radiation emitted by Priority 2 X-ray screening devices is minimal, ranging from approximately 0.08 to 0.16 milliroentgen (mR) radiation dose per exam, courts are still required to implement and maintain a radiation protection program.

The following program outlines the applicable requirements of these regulations and the necessary reporting maintenance for any inspection by the Department of Health Services (hereafter the department).

2 REGULATIONSCalifornia court facilities possessing X-ray equipment as a part of their security pro-gram must comply with the California Code of Regulations (Cal. Code Regs.), title 17, division 1, chapter 5, subchapters 4, 4.5, and 4.6. These regulations, which incor-porate the standards from title 10, Code of Federal Regulations, part 20, govern the use, inspection, and registration of radiation machines. The department requires all users possessing a reportable source of radiation to maintain a hard copy of the applicable regulations on site (see section 10). Internet access to such regulations does not satisfy this requirement.


3 REGISTRATIONAll X-ray screening devices must be registered with the department within 30 days of acquisition (Appendix A). Registration renewal occurs every two years and must be completed on or before the registration renewal date. A late fee of 25 percent of the registration fee will be charged for any fee 30 days past due. Registration fees are approximately $172 per year, per device, and are nonrefundable. If an X-ray device is replaced, all registration fees paid will be transferred to any replacement radiation machine for the remainder of the registration period.

Changes in name, address of the registrant, location of the installation, receipt, sale, transfer, disposal, or discontinuance of use must be reported in writing (Appendix B) to the department within 30 days (Cal. Code Regs., tit. 17, 3011030145).1

4 INSPECTIONCourt facilities possessing X-ray screening devices are subject to inspection by the department approximately every five years. These inspections are automatic, and no action is required on the part of the court to initiate the inspection. Inspectors will be looking for the following:

Proof of registration of the reportable source or sources of radiation with the Department of Health Services (DHS), Radiologic Health Branch (RHB). See section 3 above.

Verification that the registration information is current (i.e., registrants name, address, phone number, number of machines, and serial numbers). See section 3.

Possession of a current copy of the California Code of Regulations, title 17. See section 10.

Posting of a current copy of the form Notice to Employees. See section 5.2.

Posting of operator instructions and safety procedures. See section 5.2.

Evidence that all operators have been trained in the safe use and operation of the machine or machines. See section 5.4.

1 Citations are to Cal. Code Regs., tit. 17.


During an inspection, the court must allow the department reasonable access to inspect materials, machines, activities, facilities, premises, and records. Inspectors may choose to consult privately with staff regarding applicable provisions and regu-lations, during which time staff can alert inspectors to any past or present condition that they have reason to believe violated the California Code of Regulations.

Any individual concerned about a possible violation of, or noncompliance with, the radiation control regulations can request an inspection by submitting a Radiation Safety Complaint, form RH-1027 (Appendix C) directly to the department. The department will then forward a copy to the court, alerting it of the concern; the complainants name and personal information will, however, not be provided. If there are reasonable grounds to believe a violation has occurred, an inspection by the department will be made ( 30254).

5 PERSONNEL5.1. INSTRUCTIONSThe courts are responsible for informing all individuals working near a source of radiation of the following:

Health problems associated with exposure to radiation;

Precautions or procedures to minimize exposure;

The need to observe, to the extent within their control, the applicable provi-sions of department regulations;

Their responsibility to promptly report to the court any condition that may lead to or cause a violation of department regulations;

The provisions for personnel during inspections; and

The appropriate response to warnings made in the event of any unusual occurrence or malfunction that may involve exposure to radiation ( 30255).

5.2. NOTICESThe courts are required to post the following information. If posting these docu-ments is not practicable, the user may post a notice that describes the documents and where they may be found.


A current copy of section 30255 (Appendix D);

Operating and emergency procedures applicable to working with sources of radiation;

Notice to Employees, form COMP-RHB-2364 (Appendix E); and

Any notices of violation involving radiological working conditions and any required response from the court. These documents and the courts response, if any, must be posted within two working days after receipt from the depart-ment and will remain posted for a minimum of five working days or until action correcting the violation has been completed, whichever occurs later ( 30255).

5.3. REPORTSThe court is not obligated to provide reports of an operators annual radiation expo-sure resulting from the minimal amount of radiation emitted by the machines in the courts. Title 17 requires that monitoring and exposure reports be provided to opera-tors or employees at their request if their annual exposure exceeds 10 percent of the reportable occupational exposure of 5 rem per year. The X-ray machines operating in the courts never approach these levels ( 30255).

5.4. TRAINING AND SUPERVISIONThe court must not permit any individual to operate an X-ray screening device until such individual:

Has knowledge of the safe use and proper operation of that X-ray equip-ment;

Has received copies of and instruction in, and has demonstrated understand-ing of, these regulations and the courts operating and emergency proce-dures; and

Has demonstrated competence in using the X-ray screening device.

The court should also conduct an annual evaluation of each person assigned screen-ing duties to ensure that he or she has a satisfactory record of performance and attention to duty and demonstrates the current knowledge and skills necessary to effectively perform screening functions ( 30333).


6 RECORDSAll records associated with the radiation protection program should be maintained in a centralized place and include who is responsible for maintaining all required records, where the records will be stored, and what procedures should be followed for recordkeeping at additional authorized sites. The necessary logs for tracking of inspections, maintenance, and utilization are provided in Appendix F ( 30332.6).

6.1. SELf-INSPECTIONThe courts must implement a program for self-inspection of X-ray screening devices to ensure the proper functioning of components important to safety. The operator should note the types of checks performed, the interval at which they are conduct-ed, actions taken if problems are noted, and who is responsible for those checks. All self-inspections should be documented and maintained ( 30332.7).

6.2. MAINTENANCEThe manufacturers required maintenance should be documented and performed according to its specifications. All other types of maintenance should also be docu-mented and records maintained ( 30332.6).

6.3. RECEIPTThe court must retain each record of receipt of an X-ray screening device in its possession for three years after the sale, transfer, or replacement of the device. All records such as letters, drawings, and specifications must include all pertinent infor-mation such as stamps, initials, and signatures ( 30293).

6.4. UTILIzATION LOGSEach court must maintain current logs, which will be kept available for inspection at the address specified in the registration, containing the following information for each device:

The make, model, and serial number of the device;

The identity of the individual to whom assigned; and

The location where used and dates of use ( 30332.6).


6.5. AUDITSThe radiation protection program must be audited annually. The Emergency Response and Security Unit of the Administrative Office of the Courts can assist with these audits and provide necessary changes or updates to the program. Audits should address:

Identification of inspection types or program audits conducted, including radiation machines, personnel, and procedures;

Identification of who is responsible for performing self-inspections or audits;

Identification of where and at what intervals the inspections or audits are conducted;

Procedures for conducting the inspections or audits; and

Instructions on identification of proper use of instrumentation if staff per-forms machine maintenance or calibrations ( 30333.1).

7 NOTIfICATION Of INCIDENTSThe courts must notify the department of an incident as soon as possible after it occurs, but not later than four hours after the discovery of an event that prevents immediate protective actions necessary to avoid exposure to radiation or radioac-tive materials that could exceed regulatory limits. Reports to the department can be made by telephone to 916-440-7888 and, to the extent that information is available at the time, should include:

The callers name and call-back number;

A description of the event, including date and time;

The exact location of the event; and

Any personnel radiation exposure data available.

A written follow-up report must be submitted to the department within 30 days of the initial report and must include:

A description of the event, including the probable cause and the manufac-turer and model number of the equipment that failed or malfunctioned;

The exact location of the event;


Date and time of the event;

Corrective actions taken or planned and the results of any evaluation or assessment; and

The extent of exposure of individuals to radiation or to radioactive materi-als, without identification of individuals by name ( 30295).

In addition to the requirements above, the court must provide a written report to the department within 30 days of the occurrence of any of the following incidents involving X-ray screening devices:

Unintentional disconnection of the source assembly from the control cable;

Inability to retract the source assembly to its fully shielded position and to secure it in this position; or

Failure of any component critical to safe operation of the device in such a way that it properly performs its intended function.

Each report submitted that relates to any of the above occurrences must include:

A description of the equipment problem;

Cause of each incident, if known;

Manufacturer and model number of equipment involved in the incident;

Place, time, and date of the incident;

Actions taken to establish normal operations;

Corrective actions taken or planned to prevent recurrence; and

Qualifications of personnel involved in the incident ( 30332.8).

8 OPERATION REQUIREMENTS8.1. PERfORMANCE REQUIREMENTSEvery X-ray screening device must have attached to it a durable, legible, clearly vis-ible label bearing the following:

Chemical symbol and mass number of the radionucleide in the device;

Activity and date on which this activity was last measured;


Model number and serial number of the sealed source;

Manufacturer of the sealed source; and

Licensees name, address, and telephone number ( 30332).

8.2. MODIfICATIONModification of any screening device is prohibited ( 30332).

8.3. EQUIPMENT SECURITyEach X-ray screening device must be provided with a lock to prevent unauthorized access or exposure and must be kept locked at all times, except during authorized use or when under the direct surveillance of a trained individual ( 30332.1).

8.4. STORAGEAny device in storage is not subject to inspection and maintenance, provided that inspection and maintenance are completed before the first use ( 30332.7).

8.5. OPERATING AND EMERGENCy PROCEDURESThe courts will maintain and keep current written operating and emergency proce-dures. These may consist of the operating manual that comes with a radiation unit and that often includes safety procedures. If safety procedures are not included in the manual, however, they must be developed. The procedures must be posted on the machine or where the operator can observe them while using the machine. The oper-ating and emergency procedures must include the following detailed instructions:

The handling and use of X-ray screening devices and the manner in which they are used to control and limit radiation exposure to individuals;

Methods and occasions for conducting radiation surveys;

Methods and occasions for controlling access to radiography areas;

Methods and occasions for locking and securing X-ray screening devices;

Personnel monitoring;

Procedures in the event of an accident, including sealed source handling, mini-mizing radiation exposure to individuals, and notifying the proper persons;

Maintenance of records; and

The inspection and maintenance of X-ray screening devices ( 30333.1).

RADIATION PROTECTION PROGRAM

9 CONTRABAND DETECTIONAll X-ray screening devices used exclusively to detect contraband must have all of the following:

A physical barrier, photoelectric safety interlock, or other means that will make it impossible to insert any part of the human body into the primary X-ray beam;

A lock-and-key control that will ensure that X-ray generation is not possible with the key removed;

An illuminated indicator that will show when X-rays are being generated; this indicator must be prominently visible to operating personnel in their normal working positions; and

An operators X-ray control switch that is of the dead-mans type (a dead-mans switch is a safety feature that causes the machine to stop moving or shut down if the switch is released) ( 30337).

0 SUPPLEMENT AND APPENDIxES The supplement and appendix forms can be found in the following locations:

Supplement: www.courtinfo.ca.gov/reference/emergency/

Appendix A: www.dhs.ca.gov/publications/forms/pdf/rh2261.pdf

Appendix B: www.dhs.ca.gov/rhb/PDF/Name and Address Change Request Form.pdf

Appendix C: www.dhs.ca.gov/publications/forms/pdf/rh1027.pdf

Appendix D: www.courtinfo.ca.gov/reference/emergency/

Appendix E: www.dhs.ca.gov/publications/forms/pdf/rh2364.pdf

Appendix F: www.courtinfo.ca.gov/reference/emergency/

for additional resources or to obtain updated forms, please contact:California Department of Health,

Radiologic Health Branch

Telephone:916-440-7888

Website:http://www.dhs.ca

.gov/rhb/

for all other inquiries, please contact:Emergency Response and

Security, Administrative

Office of the Courts

Telephone:415-865-8048

E-mailaddress:ers@jud .ca .gov


PROGRAM CHECKLISTRadiation Protection Program records must include the following:

Does the court have a current hard copy of the federal and California regulations?

Is the court registered with the California Department of Health Services, Radiologic Health Branch?

Have all registration fees been paid, and is the registration current?

Have all personnel operating the X-ray screening device been noti-fied of the exposure risk, importance of observing department regu-lations, ways to report potential problems, inspection provisions, and responses to malfunctions or alarms?

Is a current copy of California Code of Regulations section 30255 posted?

Are operating and emergency procedures posted?

Is a current copy of the form Notice to Employees posted?

Are any recent notices of violation posted?

Is the initial record of receipt of the screening device included in the records?

Does the X-ray screening device have a label with the required information attached to it?

Does the machine have a lock to prevent unauthorized access?

Are the utilization logs current and being maintained?

Are the operators routinely self-inspecting the machines?

Are the written operating and emergency procedures current and being properly maintained?

Judicial Council of California455 Golden Gate Avenue

San Francisco, California 941023688www.courtinfo.ca.gov

ERS0001.06.1

CA Radiation Protectionprogram

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