Sustaining Excellence in Radiological Operations Through Peer Surveillance

1. Sustaining Excellence in Radiological Operations Through Peer Surveillance C. Schaefer, CHP D. Ryan, CHMM

2. Surveillance vs. Assessment • A sufficient amount of data must be collected on an on-going basis to establish that a management system is uniformly implemented, functioning well and continually improving • Periodic compliance assessments typically do not provide enough data to allow this conclusion to be drawn

3. Surveillance vs. Assessment (cont.) • 10CFR835.102 is the driver for BNL’s Triennial Assessment Program • All functional elements (19) must be audited for both content and implementation every 36 months • These assessments demonstrate compliance to requirements, but have limited impact on improving: • consistency of implementation • organizational performance in radiological operations

4. RCD’s Peer Surveillance Program • Surveillances are checklists containing 10-20 questions developed directly from implementing procedures (removes ambiguity from the surveillance process) • Effective mechanism for identifying trends or recurrences • Designed to be used by field-deployed professionals and Radiological Control Technicians • Typically require 2-4 hours to complete • Can be used when observing work or reviewing field program documents (e.g., RWPs, surveys, ALARA records, etc.)

5. RCD’s Peer Surveillance Program • RCD has eleven (11) approved Surveillance Checklists: • Posting and Labeling • Sealed Source Control & Radiation Generating Device Programs • Radiological Work Control & Area Monitoring Programs • Radioactive Material Control • Airborne Radioactivity Sampling and Analysis • Radiological Records • ALARA & Bioassay Programs • Radiological Survey Program

6. RCD’s Peer Surveillance Program • Each surveillance is available electronically through the RCD Homepage to improve document control (no hoarding of outdated surveillance forms on individual PCs) • Surveillance questions are answered either as “Yes”, “No” or “N/A” • In most cases, a “No” response means a procedural requirement is not being implemented • A “No” response requires the assessor to provide written comments

7. RCD’s Peer Surveillance Program • RCD Self-Assessment web page

8. RCD’s Peer Surveillance Program • The assessor provides comments and suggestions to improve programs, implementing procedures, and/or clarifications to surveillance questions. • After signing the surveillance, the assessor forwards it to the RCD Quality Assurance representative for review. • RCD Self-Assessment web page

9. RCD’s Surveillance Process • 7 Facility Support Representatives (field-deployed professionals) are assigned to conduct a quarterly surveillance of their assigned facilities • 7 Radiological Control Technicians conduct quarterly surveillances of peer facilities • Total: 14 surveillances per quarter which generate ~ 200-250 radiological control program sampling events

10. RCD’s Surveillance Process • Completed surveillances are turned in to the Division’s Quality Assurance Representative (QAR) • The QAR assigns a tracking #, trends low-level issues, signs each surveillance and forwards the surveillance to the Facility Support (FS) Manager • QAR periodically provides RCD Management with surveillance trending results so that appropriate follow up action(s) can be taken

11. RCD’s Surveillance Process • FS Manager reviews and signs each surveillance, and assists the RCD Manager in developing corrective actions and follow up to opportunities for improvement • RCD Manager reviews each surveillance for PAAA applicability, approves each surveillance, and forwards appropriate surveillances to the BNL PAAA Coordinator • RCD Manager forwards approved surveillances to the RCD FATS Coordinator for tracking of corrective actions • The FS Manager periodically disseminates results to FS personnel during staff meetings

12. Recent Surveillance Program Issues • RWP dose estimates not always completed IAW procedure requirements • No objective evidence that the FS Rep. and Line Management annually reviewing individuals for inclusion in the BNL Confirmatory Bioassay Program • PPE Donning and Doffing instructions not always posted at work sites • PPE Donning and Doffing instructions not always consistent with RWP PPE requirements

13. Recent Surveillance Program Issues • Frisking instructions not always posted at Frisking Stations (some confusion when RCT continuous coverage provided) • Radiation Generating Device (RGD) User Lists not always available • Dose rate (mrem/hr) and exposure rate (mR/hr) units recorded on radiological surveys inappropriate for the instrumentation used • BNL Sealed Source Database contains outdated information

14. Recent Opportunities for Improvement • To improve consistency, all ERP radiological area postings modified to state “Contact HP for RWP” • Posting surveillance identified opportunity to reduce Collider-Accelerator Radiation Area footprint in Bldg. 912 • Sealed Source Database does not reflect recent BNL organizational changes (e.g., transfer of PET from Chemistry to Medical) • Some organizations not using BTMS to track staff qualifications (share with Training Coordinator) • Include BNL ALARA Program Coordinator on distribution of monthly safety meeting minutes

15. Recent Opportunities for Improvement • Simplify the RGD Program by merging the System-Specific Checklist and Authorized Users List (completed 11/2007) • Clarify requirements for participation in BNL Confirmatory Bioassay Program (Plant Engineering TBD approved in 2007) • Review proper response to EPD alarms as part of pre-job briefing when EPDs are worn for RWP work in High Radiation Areas

16. Conclusion • RCD’s Surveillance Program provides several advantages: • Provides Management with additional data on management system performance • Allows for early identification of adverse trends • Helps promote uniformity of implementation across multiple organizations • Provides field-deployed staff with a venue for offering Opportunities for Improvement

17. Questions?