Hazardous and Radioactive Materials Management and Health and Safety Practices
/ DOECAP Checklist: 6 Rev. 4.3Effective Date: March 2017 Page 29 of 29
Audit ID: Laboratory: Auditor:
U. S. Department of Energy
Consolidated Audit Program
Checklist 6 - Hazardous and Radioactive Materials Management
& Health and Safety Practices
Version 1.0 of Revision 4.3
Self-Identifying Checklist
March 2017
Use of this DOECAP checklist is authorized only if the user has satisfied the copyright restrictions associated with TNI-EL-V1-2009 and ISO 17025:2005. DOECAP does not control or restrict the use of copyrighted standards that have been incorporated into this checklist; however, TNI and ISO do restrict use of their standards.
Audit ID: / Date:Areas of Review During Audit
____SOPs/Waste Management Plan / __ Radioactive Materials Management and Control
__ Analytical Process Waste and Excess Sample Material / __ Waste Storage Area
__ Waste Container Management / __ Chemical Hygiene Plan
__ Laboratory Contingency Plan and Emergency Procedures / __ Laboratory Facility Safety
__ Sample Receiving / __ Sample Control and Building Security
A = Acceptable U = Unacceptable NA = Not Applicable NO = Not Observed
F = Finding O = Observation
Referenced regulations are accessible at the following URLs:
· http://www.p2s.com/?page=1526
NOTE:
· When audit findings are written against site-specific documents (i.e., SOPs, QA Plans, licenses, permits, etc.), a copy of the pertinent requirement text from that document must be attached to this checklist for retention in DOECAP files.
· Fully document any deviation from the LOI or the requirements of QSM
· Refer to the last page of this document for the record of revision.
· Refer to Errata Document 10-25 for interim changes to the QSM Rev.5.0 requirements
Item Number / Line of Inquiry / Status / Facility Response/Comments / Status / Summary of Observations/Objective /
1.0 / Radioactive Materials Management and Control
1.1 / Does the laboratory comply with all applicable federal and state regulations governing radioactive materials control and radiological protection?
QSM Rev. 5.0, Section 6.1.1
1.2 / Does the radioactive materials license authorize possession of isotopes, quantity, physical form, and use of radioactive material and is it sufficient for the laboratory’s scope of work in support of DOE sites?
QSM Rev. 5.0, Section 6.1.2
1.3 / Does the laboratory have facilities and procedures in place to handle the isotopes, quantity, and physical form of radioactive material specified on the radioactive material license?
Does the laboratory ensure adherence to all radioactive materials license and procedural requirements?
QSM Rev. 5.0, Section 6.1.3
1.4 / Is the Radiation Safety Officer (RSO) listed in the Radioactive Materials License and is the RSO available to monitor the radioactive materials and control programs and provide rapid response to any radiological emergencies?
QSM Rev. 5.0, Section 6.1.4
1.5 / Does the laboratory have an alternate or backup RSO who has the necessary training and experience to perform the duties of the RSO in the event that the RSO is not available?
QSM Rev. 5.0, Section 6.1.4
1.6 / Does the laboratory have in place a radioactive materials inventory program capable of tracking standards, tracers, and all radiological samples?
QSM Rev. 5.0, Section 6.1.5
1.7 / Is the radioactive material inventory updated according to the schedule established by laboratory Radioactive Material License?
QSM Rev. 5.0, Section 6.1.5
1.8 / If no schedule is established by the license, does the laboratory update the inventory within seven days of receipt of radioactive materials?
QSM Rev. 5.0, Section 6.1.5
1.9 / Are the radioactive and mixed wastes segregated from non-radioactive waste?
QSM Rev. 5.0, Section 6.1.6
1.10 / Are the roles, responsibilities, and qualifications for the Radiation Safety Officer (RSO) and the backup RSO been well defined and does the person filling the RSO position meet those requirements?
10 CFR 30.33 (a)(3)
1.11 / Does the laboratory review, at least annually, the radiation protection program content and implementation, and do they maintain records of audits, reviews, and inspections for the last three years?
10 CFR 20.1101, Section 2103a
1.12 / Is a survey or monitoring program in place to assess the extent of potential radiological hazards?
10 CFR 20.1501(a)
1.13 / Does the laboratory monitor external exposure for those employees likely to receive, in one year from sources external to the body, a dose in excess of 10% of the limits in 10 CFR 20.1201(a)?
Note: Review the laboratory process and documentation.
10 CFR 20.1502(a)
1.14 / Does the laboratory monitor internal exposure of those employees likely to receive, in one year, an intake in excess of 10% of the applicable Annual Limit(s) on Intake [ALI(s)]?
10 CFR 20.1502(b)
1.15 / Are the Total Effective Dose Equivalents (TEDE) and Total Organ Dose Equivalents (TODE) within limits, i.e., summing internal and external dose?
10 CFR 20.1201 and 1202
1.16 / Are all individuals in or frequenting any portion of a restricted area instructed in the health protection problems associated with exposure to radioactive materials or radiation, precautions/procedures to minimize exposure, and the purpose and functions of protective devices employed?
10 CFR 19.12(a)(2)
1.17 / Has the laboratory developed and implemented a program of radiological controls and procedures for radioactive material handling, emergency action plan, and use of instrumentation?
10 CFR 20.1101a
1.18 / Is licensed material secure from unauthorized access or removal?
10 CFR 20.1801 and 1802
1.19 / Are instrument and equipment calibration records showing the results of daily calibration checks and calibrations for radiation daily checks of instruments maintained and retained for three years?
10 CFR 20.2103(a)
1.20 / Are airborne releases of radioactivity to the environment monitored, evaluated, and controlled?
10 CFR 20.1501(a) and 1701, EPA NESHAPS
1.21 / Does the effluent released to the sanitary sewer meet these four provisions of 10 CFR 20.2003, i.e.:
• Is it readily soluble?
• Does the quantity released into the sewer not exceed concentration listed in Appendix B to Part 20,
• Have fractional limits been determined, and
• Have the sum of those fractions for each radionuclide been determined?
10 CFR 20.2003
1.22 / Are waste packaging, control, and tracking performed in accordance with 10CFR20 Appendix G, Section III requirements, i.e., classification, labeling, QC program, and preparing/ forwarding manifests?
10 CFR 20.2006(d)
1.23 / Does the laboratory remove or deface all sample container labels prior to container disposal such that they are rendered illegible?
QSM Rev. 5.0, Section 6.4.4; 10 CFR 20.1904(b)
1.24 / Are laboratory operations involving material release, effluent release, and waste disposal implemented in accordance with a documented policy such that any potential resulting dose to individual members of the public is maintained within regulatory limits and minimized to the extent reasonably achievable?
10 CFR 20.1101(b)(d); 10 CFR 20.1301
1.25 / Are waste shipments transferred to qualified facility/person specifically licensed to receive waste?
10 CFR 20.2001(a)
1.26 / Are records of waste disposal maintained?
10 CFR 20.2108
1.27 / Are areas of radioactive material handling and contamination posted according to 10 CFR 20.1902? Are conspicuous signs bearing the radiation symbol and the words “CAUTION-RADIATION AREA”, “CAUTION-HIGH RADIATION AREA”, and “CAUTION-VERY HIGH RADIATION AREA” used?
10 CFR 20.1902
2.0 / Toxic Substances Control Act (TSCA) Material
2.1 / Does the laboratory comply with all federal regulations governing TSCA materials control and protection?
QSM Rev. 5.0, Section 6.2.1
2.2 / Does the laboratory segregate all radioactive TSCA materials from all other analytical samples and residues?
QSM Rev. 5.0, Section 6.2.2
2.3 / Does the laboratory have a procedure for return of radioactive TSCA materials for which there is no commercial treatment or disposal options to the customer?
QSM Rev. 5.0, Section 6.2.3
2.4 / Is TSCA PCB waste stored for less than one year from the date the material was first placed in storage?
40 CFR 761.65(a)
2.5 / Are TSCA PCB waste containers labeled with the accumulation start date?
40 CFR 262.34(a)(2)
2.6 / Does the TSCA one-year waste storage area meet the storage facility requirements for PCB waste? (floor curbing, above 100 year flood plain, no floor drains, etc.)
40 CFR 761.65(b)
3.0 / Laboratory Safety and Health
3.1 / Does the laboratory comply with all state and federal regulations governing laboratory health and safety?
QSM Rev. 5.0, Section 6.3.1
3.2 / Is a laboratory safety inspection program in place?
QSM Rev. 5.0, Section 6.3.2
3.3 / Does the program include routine inspections of laboratory areas for safety related concerns?
QSM Rev. 5.0, Section 6.3.2
3.4 / Are chemical hazards labeling on chemical containers in accordance with the laboratory’s approved Chemical Hygiene Plan?
QSM Rev. 5.0, Section 6.3.3
3.5 / On an annual frequency, do all visitors, maintenance personnel, and auditors have a recorded safety orientation prior to entering the laboratory?
QSM Rev. 5.0, Section 6.3.4
3.6 / Are all visitors briefed on the safety practices and policies?
QSM Rev. 5.0, Section 6.3.4
3.7 / Does the laboratory have a Hazardous Waste Operator and Emergency Response (HAZWOPER) trained person on staff?
QSM Rev. 5.0, Section 6.3.5
3.8 / Do backup personnel have appropriate training (HAZWOPER) for Emergency Response?
QSM Rev. 5.0, Section 6.3.5
3.9 / Does the laboratory have reentry procedures defined in the Emergency Action Plan?
QSM REV. 5.0, Section 6.3.6
4.0 / Waste Management and Disposal
4.1 / Does the laboratory comply with all federal and state regulations governing waste management and disposal?
QSM Rev. 5.0, Section 6.4.1
4.2 / Does the laboratory have a waste management plan in place which is capable of:
a) Identifying all waste streams generated by the laboratory including universal wastes such as batteries, thermostats, etc.;
b) Identifying the process for management and disposal of the various waste streams; and
c) Tracking the disposition of waste samples by Sample Delivery Group (SDG)?
QSM Rev. 5.0, Section 6.4.2
4.3 / Does the waste management plan include the following:
a) Administrative programs to demonstrate compliance for effluent discharges as required by regulatory agencies and applicable DOE Orders;
b) Training procedures, schedules, and management of training records in the areas of waste management, shipping, waste handling, and radioactive materials control;
c) Radioactive volumetric and surface release policies;
d) Permits and licenses to handle hazardous and radioactive waste;
e) Policy or direction on how to conduct waste brokering and Transport, Storage, and Disposal Facility (TSDF) evaluation to ensure proper disposition of waste;
f) Tracking of individual sample container from receipt to final disposition; and
g) Waste minimization and pollution prevention programs including substitution (when permitted), segregation, and recycling?
QSM Rev. 5.0, Section 6.4.3
4.4 / Are waste brokering and TSDF evaluation based upon the results of a site visit to the waste facility or a desktop review that includes information from audits of the facilities conducted by state or federal agencies?
QSM Rev. 5.0, Section 6.4.3
4.5 / Does the evaluation include liability coverage, financial stability, any Notices of violations (NOVs) from the last three years, relevant permits and licenses to accept the waste, and other relevant information?
QSM Rev. 5.0, Section 6.4.3
4.6 / Are reviews of waste brokering and TSDF evaluations performed every three years, unless there are changes in the facilities operations that require the reviews to be conducted on a more frequent basis (e.g., NOVs, change of ownership, notices of fines, and penalties)?
QSM Rev. 5.0, Section 6.4.3
4.7 / Has the laboratory developed criteria for the evaluation of waste brokers and TSDFs?
QSM Rev. 5.0, Section 6.4.3
4.8 / Is documentation of the evaluations maintained?
QSM Rev. 5.0, Section 6.4.3
4.9 / Does the laboratory maintain a list of the facilities that are approved?
QSM Rev. 5.0, Section 6.4.3
4.10 / Note: Refer to EPA public domain Enforcement and History Online (ECHO) and “Envirofacts” websites for information on TSDFs.
4.11 / Is analytical process waste segregated and removed to a designated storage area to minimize the potential for cross contamination?
QSM Rev. 5.0, Section 6.4.5
4.12 / Is laboratory analysis derived waste characterization repeated at a frequency adequate to account for all known variation in the waste streams?
QSM Rev. 5.0, Section 6.4.6
4.13 / Are samples that are consumed during analysis included in the sample accountability tracking?
QSM Rev. 5.0, Section 6.4.7
4.14 / Does the laboratory have provisions for the disposition of excess samples?
QSM Rev. 5.0, Section 6.4.8
4.15 / Is the laboratory aware of the requirements for the receiving Publicly Owned Treatment Works (POTW) or wastewater treatment system for excess samples that are bulked and drain disposed?
QSM Rev. 5.0, Section 6.4.9
4.16 / Does the laboratory have a program that meets and demonstrates compliance with these requirements?
QSM Rev. 5.0, Section 6.4.9
4.17 / Are characterization records, including analytical test results and process knowledge determinations, kept for at least three years?
40 CFR 252.40
4.18 / Are laboratories accumulating no more than 55 gallons of hazardous and mixed waste or no more than one quart of acutely hazardous waste at, or near, any point of generation (satellite point)?
40 CFR 262.34c
4.19 / Are wastes from samples containing PCBs at greater than 50 ppm segregated from other laboratory wastes as TSCA regulated waste?
(NOTE: This does not apply to the extracted sample residual, BUT it does apply to the extract and other laboratory process wastes.)
40 CFR 761
4.20 / Are laboratory-generated TSCA PCB wastes stored in a Temporary Storage Area more than 30 days from the time of generation without being placed in an area that meets one year storage facility requirements?
40 CFR 761.65
4.21 / Are TSCA PCB waste containers and sample storage areas marked with the required TSCA PCB labeling as identified in 40 CFR 761.45?
40 CFR 761.45
4.22 / Are radioactive and mixed wastes generated during laboratory sample processing properly labeled as Radioactive?
10 CFR 20.1904
5.0 / Waste Storage Areas
5.1 / For RCRA Large Quantity Generators:
Are waste containers stored over 90 days in the accumulation/storage area?
40 CFR 262.34(a) and (b)
5.2 / For RCRA Small Quantity Generators:
Are waste containers stored over 180 days (270 days if transported over 200 miles) in the accumulation/storage area?