Codes of Practice

The Radiation Safety Act 2016 (the Act) sets out the fundamental requirements in sections 9 to 12. Codes of practice (Codes) are issued following sections 86 to 90 of the Act. Codes specify technical requirements that a person who deals with a radiation source must comply with to meet the fundamental requirements. Also, guidance is provided in compliance guides and in the questions and answers on this page.

On this page:

Radiation sources and practices vary, presenting a range of radiation safety and security risks. The Act enables the making of regulations and the issuing of codes of practice (Codes). These set out specific requirements and controls that are appropriate to the level of risk.

Every person who deals with a radiation source (refer to section 8 of the Act) must comply with the applicable provisions set out in Codes. This is regardless of whether a natural person or an organisation requires an authorisation under section 13 of the Act.

Codes are supplemented by compliance guides. These give practical guidance on how to comply with specified regulatory requirements. These are predominantly technical requirements in Codes. Under normal circumstances, a person following such guidance will be meeting the associated regulatory requirement. A person does not need to follow the guidance given and is free to use alternative approaches to meet regulatory requirements.

Codes of practice for medical purposes

Codes of practice for security and transport

Codes of practice for non-medical purposes

Compliance guides

Questions and answers

These questions and answers provide managing entities with examples of how to implement various aspects of the recently published codes of practice. They are intended for use as general guidance only. For advice specific to your situation please consult your qualified expert.

See questions for:

Industrial radiography (C7)

What additional precautions need to be taken to protect a member of staff from ionising radiation (radiation) following the member of staff notifying a pregnancy?

An actual or suspected pregnancy notified by an employee to an employer is not considered to be a reason for the employee to be excluded from work on radiation safety grounds.

Clause 8 the Code of Practice for Industrial Radiography ORS C7 2019 (ORS C7) requires manging entities to establish, implement and maintain procedures and local rules. This includes receiving and responding to a notification of an actual or suspected pregnancy.

Procedures and local rules should be directly derived from the safety assessments that managing entities need to conduct and periodically review under clauses 2(b)(i) and 8(l) of ORS C7. Safety assessments must, among other things, review potential occupational exposures from the use of a radiation source or from reasonably foreseeable incidents involving radiation.

In carrying out a safety assessment the managing entity must consider that Schedule 3 the Radiation Safety Act 2016 (the Act) applies a dose limit of 1 mSv (effective dose) in a year to an embryo or a foetus. In relation to a worker, the safety assessment needs to recognise the potential during industrial radiography for this dose limit to be exceeded.

Also, the managing entity will need to specify and implement procedures and local rules to inform persons occupationally exposed to radiation of the applicable dose limits, and to facilitate and support notification to an employer of an actual or suspected pregnancy.

Schedule 3(3) of the Act means that working conditions for a person during the term of the person’s pregnancy will be such that the level of protection from radiation is broadly the same to that required for a member of the public.

If it is required, the employer and the employee will need to agree adapted working conditions for the employee to satisfy radiation safety requirements.

How many people do you need to control the barriers for site radiography?

This is a job specific consideration. The minimum for any site radiography job is one licensed radiographer and a radiography assistant. However the radiography team must be able to ensure at all times during radiography no unauthorised persons enter the controlled area (and if they do it is noticed immediately and the source is wound in).

For smaller controlled areas with clear visibility of the boundaries this may be achieved with a team of two. For larger more complex controlled areas, particularly those involving multiple levels then additional personnel will be needed to patrol the controlled area.

Can the client provide personnel to assist with the patrolling of barriers during industrial radiography?

Yes. These personnel would be working under the direct supervision of the lead radiographer. Sufficient direction would need to be given by the radiographer to ensure they can work safely. The radiographer must be physically present and able to intervene. These personnel would have to be provided with personal dosimeters and treated as other radiation workers in terms of dose monitoring and recording (unless all their activities can be performed outside of the controlled area).

My company is always swapping around gamma radiography cameras between different branches. Do we have to notify you every time we ship a camera to another branch?

You must notify the ORS of the change of storage location using the prescribed form. The location of the cameras and sources must be accounted for at all times and recorded in the movement log.

How do I transport a gamma camera “in a manner that impedes unauthorised removal”?

There are two aspects to consider when securing a gamma camera inside an enclosed vehicle during transport; security and physical restraint. Some methods of restraint address both aspects simultaneously, and these are listed here in order of most secure to least secure:

  • inside a locked toolbox that is bolted or welded to the vehicle
  • within a locked metal frame that is bolted or welded to the vehicle
  • locked chain (>7mm) through the handles or other secure fixing point so that is also adequately restrained from movement to secure eyelets that are bolted or welded to the vehicle.

The camera must not be left unattended for long periods of time as these security measures assume a degree of supervision by the radiographer.

Veterinary radiography (C9)

Do large animal veterinarians and their assistants have to have their own dose badges?

Yes they must have their own individual dose monitors. The safety assessment will identify the fact that they work within a controlled area and have the potential to exceed 10% of the dose limits.

Do I have to provide personal dosimeters for workers conducting small animal radiography?

Yes. Your safety assessment will identify those workers who work within the controlled area e.g. when manually restraining animals during radiography, and these workers must be issued an individual dosimeter that cannot be shared.

Where can I get personal dosimeters?

See a list of personal dosimetry service providers.

What should my quality assurance procedures include?

The quality assurance must include procedures for ensuring image quality such as a:

  • repeat exposure analysis
  • satisfactory x-ray performance such as checking collimation and machine condition
  • integrity of personal protection equipment
  • satisfactory image processing for film or digital imaging including satisfactory viewing of images using light boxes (for film) or monitors (for digital)
  • reviewing technique charts
  • reviewing working procedures for radiation safety and quality assurance procedures
  • reviewing the lists of equipment, training, and authorisations. 

I have a unit that I use in different rooms in my practice. Is this unit considered a fixed or a portable unit, and how often must it be tested?

The new code ORS C9 does not differentiate between fixed and portable units for the purpose of performance testing, all x-ray units must be tested at least every three years by a licenced x-ray service engineer.

Now that I have changed to a digital imaging system and seldom need to repeat x-rays, do I still need to do reject/repeat analysis?

Yes, you still need a system in place to record any rejected or repeated exposures to ensure that images are of an acceptable quality and the technique chart is current. You will find with digital imaging systems that you should get fewer rejects due to over or under exposing. The system is able to manipulate the image after the exposure, but rejects due to positioning errors, collimation and movement, will still be occurring and should still be investigated.

Now that I am digital imaging, how can I tell if I am over or under exposing? I used to be able to tell from the darkness of the film.

You can compare the exposure index (EI) to the ranges supplied by your imaging systems manufacturer. Note that each manufacturer uses different ranges for exposure index, and may also be called the S-value. You should also regularly review your technique chart to ensure it is up to date.

Can I use the control badge for a new member of staff until their personal dose badge arrives?

No, the control is to be kept with the badges and records background radiation while they are not being worn and during transport to and from the dosimetry provider. The background reading from the control is then subtracted from the exposure received by the worker’s badges and this net dose is the value reported.

Can I wear my dosimeter on a lanyard around my neck?

It is important that the dosimeter is always worn in the same position, and in most veterinary situations outside the lead apron if it is worn and ideally at collar height to better estimate the dose to the thyroid and lens of the eye.

With this in mind a lanyard is not ideal as when holding animals it will fall closer to the animal than the wearer’s actual position. Also if the dosimeter has an angular dependence to its response the estimated dose reading may be compromised.

Veterinary nuclear medicine (C9)

How often do I need to calibrate my survey meter?

The recommended frequency for calibration of radiation survey meters is in accordance with manufacturer guidelines and at least every two years.

I am a vet and understand that I don’t need a user licence for taking x-rays as long as I have a current APC from the Veterinary Council. Do I still need to get a user licence if I also administer I-131 to cats?

Yes, given the specialised extra radiation hazards associated with handling unsealed radioactive material, both ORS approved training in this area and a use licence is required for administering radioactive material to animals.

The source licence for your vet facility will also need to be upgraded if it hasn’t already been done so, to include the management or control of this radioactive material.

We are a veterinary facility treating cats with radioiodine. Can we order in bulk and dispense I-131 into syringes for the individual cats or can we only administer?

No, you can’t dispense radioactive material, your use licence only authorises administration. It requires a full nuclear medicine hot lab with specialised equipment and especially trained staff to dispense radioactive materials safely.

You need to order pre-loaded syringes or capsules calibrated with the correct activity. 

What precautions do my staff who take care of our I-131 administered cats need to take? Do they need to monitor themselves after each time they do this?

Yes, your staff should be wearing standard personal protective equipment (surgical gloves and disposable gown). When leaving the area where the treated cats are housed, your staff should always check their thyroid, hands, sleeves and bottom of feet for contamination with your survey meter and record that this has been done.

X-ray inspections (C10)

One of our baggage scanner operators is pregnant. Can they still work around the x-ray unit?

Yes. There should be no need to restrict access around the x-ray equipment for pregnant operators. However, best practice would be to issue a personal dosimeter primarily for reassurance purposes.

For x-ray inspection equipment that complies with all the technical requirements in terms of features such as shielding, interlocks, radiation warning lights, preventing access to the primary beam and so on, then the safety assessment should show that operators are afforded the same level of protection as members of the public in terms of radiation exposure. Note that public dose limits are set to protect the most vulnerable in society, notably the unborn child.

This can easily be demonstrated by performing a radiation survey around the operating x-ray unit.

The public dose limit of 1mSv per year and the public dose constraint of 0.3mSv per year will be achieved if the dose rate is less than 0.5µGy/h (0.5 µSv/h), averaged over an area of 100cm2 at positions 5cm outside the shielding.

Do I have to provide individual dosimeters for my staff?

You need to perform a safety assessment to determine whether there is potential for receiving significant radiation doses (greater than 1/10 of the relevant dose limit). If the equipment is designed, maintained and operated properly, and the dose rate in accessible areas is less than 0.5uSv/h then radiation doses should be very low, well below the 1/10 threshold and therefore personal dose monitoring would not normally be necessary.

However, it may be beneficial to perform individual dose monitoring to provide reassurance. These can help demonstrate that radiation exposures are being properly restricted and are especially useful for new users and during pregnancy.

There are also requirements for general workplace monitoring and these can normally be met through the normal radiation surveys at commissioning, after servicing/maintenance and during the regular safety audit.

Handheld XRF (C10)

Do I need a use licence to operate a hand held XRF unit?

Yes there needs to be at least one use licensee. Other operators may work under the direct supervision or written instruction of the use licence holder. Note, the managing entity must also hold a source licence.

How often does the operator have to get re-trained?

Managing entities must ensure all operators have sufficient training to perform their duties safely by regularly reviewing competencies and providing refresher training. There is no specified refresher training frequency, but should be done every few years to keep operators familiar with changes to working techniques, equipment and legislation.

Who can service my X-ray system?

The equipment must only be repaired/maintained by properly trained and authorised persons. Equipment should be immediately taken out of use if it is suspected of being damaged or any of the safety and warning systems are not working.

If the equipment is not being sent back to the manufacturer for repair then the maintenance must be performed by a service engineer with a valid user licence for servicing and installation of irradiating apparatus.

What is the controlled area?

You need to perform a safety assessment to identify any area that needs special controls for managing the radiation exposure, and this area must be designated as a controlled area. For hand held analysers the area 3 to 5 metres in the path of the primary beam and 1 metre to each side of the device would need to be a controlled area due to the elevated radiation levels.

Do I have to provide personal dosimeters for my staff?

The safety assessment above would also identify that personal dosimetry is required for handheld XRF operators due the operator being within the controlled area during measurements. The most appropriate dosimeter would be a finger TLD.

For other analysers that are not hand held then a trial period post commissioning with a whole body dosimeter to establish workplace exposure would be appropriate. 

Disposal of unsealed radioactive material (C11)

Why is the disposal limit for C-14 lower in the new unsealed radioactive material code (ORS C11) as compared to the old code of practice?

The levels in Appendix 3 of C11 are not disposal limits, they are levels above which the managing entity must carry out an assessment to show that the public dose limits will not be exceeded for a proposed disposal via air, sewer or landfill and submit a waste management plan to the Director.

We have some uranyl acetate, uranyl nitrate and thorium salts used for staining in electron microscopy etc. that we are collating for disposal if possible. In the old CSP1 code there were specified limits for liquid disposal for uranium and thorium (natural) that would've meant an easy gradual disposal to sewer, but we can’t find specified limits in the new unsealed radioactive material code ORS C11.

Uranium and thorium compounds are a special case where ORS intends to control the disposal of these materials more tightly through an annual accounting requirement to meet international obligations (this system is under development) and this is why there are no values for these isotopes given in Appendix 3. This means that the managing entity must carry out an assessment to show that the public dose limits will not be exceeded for a proposed disposal via sewer, landfill or discharge to air, and submit a waste management plan to the Director in the same manner as for disposals in excess of the Appendix 3 levels. In the near future managing entities will also need to submit an annual declaration with details of uranium and thorium obtained, disposed of, or consumed in the previous 12 months.

Can I discharge any radioactive material into the sewer?

First, reference is made to Schedule 2 of the Radiation Safety Act 2016, as discharges below these levels are too low to even be considered radioactive material for the purposes of the Act and may be discharged without further consideration. Appendix 3 of ORS C11 provides for higher discharges under certain conditions, however uranium and thorium are not listed in Appendix 3 due to strict accounting controls for nuclear material that are unrelated to safety. For discharges in excess of those listed in Appendix 3 or for those nuclides not listed (including uranium) the managing entity is required to produce a waste management plan and have it approved by the Director for Radiation Safety. Approved waste management plans demonstrate how discharges will not lead to public dose limits being exceeded.

Nuclear density meters (C12)

What is the controlled area for a nuclear density meter (NDM)?

Any area that has special controls for managing the radiation exposure must be designated and delineated as a controlled area. For NDMs this can be fulfilled by the operator maintaining the area 2m around the gauge during measurements where there are elevated radiation levels.

Do I need to issue individual dosimeters to NDM operators?

Yes due to the fact that the operator must enter the controlled area to operate the gauge as well as the potential to exceed 10% of the occupational dose limit, operators must be issued with individual dose monitors.

What measurements are required for workplace monitoring?

C12 requires managing entities to establish a programme of workplace monitoring, which for NDMs are confirmatory radiation measurements that are done with a survey meter. A typical workplace monitoring programme would consist of regular dose rate measurements around the source store, at the operator position during measurement, on the bottom of the NDM after a measurement to confirm the tungsten shutter is fully closed, and measurements before transport to confirm the transport index and dose rate to the driver.

Do I need a user licence to operate a nuclear density meter?

Use of a nuclear density meter is authorised by your facility source licence. You only need a use licence if you are a service engineer who is performing servicing and/or maintenance of the equipment.

I have two new staff members that I need to get trained to use an NDM before they can be listed as authorised users. Do I have to send them on an external training course or can I train them in-house?

Most NDM users attend a recognised external training course, however it is possible to train your staff in-house. The training procedure, material and assessment must cover all required aspects of radiation safety and protection, and be clearly documented.

Can I rent my NDM to another company when I don’t need to use it?

You can rent your NDM to another company who holds a current source licence authorising the management, control, possession and use of nuclear density meters. You must notify the ORS of this change using the prescribed form.

I have been told that the NDM and transport case have to be locked during storage and transport. We always used R-clips in the handle. Why can’t we keep using that?

The R-clip prevents the inadvertent opening of the shutter and exposing the source. A padlock achieves this but also provides an extra layer of security. Along with the lock on the transport case, these help to deter and delay unauthorised access and use of the radiation source.

My company is always swapping around nuclear density meters between different branches. Do we have to notify ORS every time we ship a source to another branch?

You must notify the ORS of the change of storage location using the prescribed form. The location of the NDM must be accounted for at all times and recorded in the movement log.

When should a nuclear gauge containing sealed radioactive material be decommissioned?

There are a number of factors to consider. Most importantly it is critical that the source encapsulation is not compromised and there is no leakage of radioactive material. As a source ages the possibility that the encapsulation starts to fail increases. That is why the Code (ORS C12) mandates a programme of wipe testing at least once every 2 years after the source is more than 10 years old. It is generally recommended that a sealed radioactive source is decommissioned before it is 30 years old. In some cases this should be earlier, particular when the gauge and/or source is exposed to harsh environmental conditions.

In addition operators should consider any specific recommendations from the manufacturer regarding source lifetime and under what conditions. Any extension of life beyond 30 years should be subject to a thorough safety case being made and additional measures such as a more rigorous frequent inspection and wipe testing regime put in place.

I am attending an overnight job out of town. Should I leave my NDM in the car or should I bring it into my accommodation?

In the first instance the NDM must return to home base. The NDM should not be taken home for convenience and should never be stored overnight in a vehicle in the same city as the home depot. If this is not possible, and would require significant travel time, you should prearrange a temporary storage location which meets both the safety and security requirements (equivalent to home base). This can be on the job site or another suitable facility or location.

If this is not possible the NDM should remain in your vehicle and not brought into your accommodation.

In this case, ensure the following:

  • the source exposure mechanism and transport case are locked
  • the vehicle is locked
  • if installed, the vehicle security alarm is engaged
  • the NDM transport case is covered so it does not attract attention
  • other tools and valuables are hidden from sight or removed from the vehicle to reduce the potential of an opportunistic break-in
  • the vehicle is parked on private property (off public roads), and if staying in a motel then in close proximity to your room (preferably right outside your room)
  • the NDM is more than 3 meters from high occupancy areas e.g. a bedroom
  • transport placards are not required on the vehicle while the vehicle is parked on private property.

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