The advantages of creating a positive radiation safety culture in the higher education and research sectors^*

Whilst a strong safety culture is essential to protect employees, it is equally essential in protecting students and is a significant factor in the promotion of safety awareness and the development of safety skills.

The Public's perception of radiation risk can be greatly affected by the context in which the radiation is used and this perception can be skewed significantly by poor knowledge of benefit and detriment. Therefore it remains as important for us to communicate risk factors as it is the many benefits to society that can result from research using radioactivity.

To continue to increase public knowledge we must:

• define the concepts of risk in lay terms;
• use a simple vocabulary to explain radiation; and
• educate the public and the media about radiation and its benefits and risks.

However, increased public knowledge will not necessarily lead to an increase in public trust. Organisations and individuals can positively affect public perception by being seen to work closely with the regulators to strive for continual improvements in environmental and health and safety compliance. An example would be to improve the public's awareness of a research organisation's responsibilities to apply Best Available Techniques (BAT), legally required under environmentally protection legislation, but also ethically as a duty of care to external stakeholders. Academia, in particular, could benefit here by taking a lead from the nuclear industry that has worked to publish an industry code of practice for BAT compliance; additionally, they hold open days and stakeholder meetings around their permitted sites.

Many organisations depend on universities and R&D companies undertaking robust and trustworthy scientific research, publishing learned articles founded on good science, developing products, and enhancing humanity's knowledge.

Yet there are many ways in which the failure to follow good basic practices as part of a strong RP safety culture can lead to the ruination of scientific data and the knock-on effects can be significant. Examples of poor practice include:

• Failure to carry out suitable and sufficient monitoring for radioactive contamination in a laboratory area used for handling unsealed radioactive substances leading to contamination spreading onto liquid scintillation vials which when counted yield erroneous results.
• Failure to calibrate instruments causing an unnoticed measurement error of radiation outputs from x-ray generators.
• Failure to ensure regular servicing of equipment leading to unsafe operational conditions and subtle malfunctions that impact measurements.
• Failure of management to ensure that safety issues are addressed in project proposals and in project reports/papers submitted for publication.
• In-house maintenance carried out by persons unqualified to make such repairs leading to unsafe and incorrect equipment performance.

Many good practices can be viewed by academics and researchers as mundane and of low priority or simply interference in research productivity. As a result, they can be performed incompletely, incorrectly or just not at all. Frequently there is a lack of understanding of how crucial routine laboratory tasks can be to obtaining reliable measurement data. In addition, this lack of understanding can be promulgated amongst junior staff and students by the importance of such tasks being treated glibly, overlooked and missed during in-house training.

Business Continuity Management is about establishing and maintaining an organisation's capability to retain continuous critical business processes, regardless of what disruptive event may occur.

Continuity of activities (teaching, learning, research, support services and other business activities) is a priority in education and research. It is the responsibility of all component areas (University Councils/Research Boards, Committees, Directorates, Schools and Services) to take all reasonable steps to avoid any foreseeable incident that may require an emergency management or business continuity planning response. If such an incident does occur, component areas will need to minimise any impact on the organisation and its stakeholders.

The objectives of emergency management and business continuity planning are to ensure that an organisation:

• Understands its critical activities and maintains the capability to resume operations within agreed timeframes, following the deployment of a suitable response.
• Increases resilience by protecting critical assets and data (electronic and otherwise) through a co-ordinated approach to management and recovery.
• Minimises impacts using a focused, well-managed response.

The establishment of a radiation protection policy that includes a regularly-reviewed radiation risk register is a significant step towards a good radiation protection culture and will secure better contingency plans and thus business continuity.

Although policies, plans and registers may not cover every conceivable contingency in a crisis, responsible decision-making, good judgement and good communication are paramount in a crisis to protect the organisation's ability to meet its mission of teaching, research and public service.

In university and research organisations, crises can result not just in the loss of vital resources such as buildings, equipment, infrastructure, technology and personnel, but also in teaching downtime and loss of manpower due to injury or stress, not forgetting the cost of remediation and the potential for significant damage to institutional reputation (see the next section).

A poor radiation protection culture can lead to bad practices which may adversely affect the health of staff, students and members of the public. This can lead to costly civil litigations and negative media coverage.

Likewise, a poor radiation protection culture may result in non-compliances with the radiation legislation, notably the Ionising Radiations Regulations 1999 (Health & Safety Executive 2000) and the Environmental Permitting Regulations 2010, amongst others. This can lead to regulatory actions such as prohibition notices and prosecutions by the Health and Safety Executive (HSE) and the Environment Agency (EA). This might escalate to significant fines being levied against the organisation, the severity of which will reflect the level of transgression.

Significant reputational damage may emanate from adverse media coverage, for example, from reporting of legal action and fines to compensation claims or clean-up costs—which can lead to loss of trust resulting in falling student numbers and loss of revenue. This can also result in an adverse change in the attitudes of potential collaborators and grant funding bodies leading to a lowering in research rating, smaller number of grant awards and the inability to attract the best academic staff. Bid documents for commercial contracts invariably ask for details of any such legal actions, in preceding years, across the whole organisation.

Radiation Safety training as with other health and safety related training is an essential part of the University's commitment to achieving a safe and healthy workplace for staff, students and visitors.

Staff must be provided with sufficient information, instruction and training to ensure that they are aware of radiation hazards and know what safe working procedures to follow to reduce the risk of injury or work related ill health, to themselves and others. Training is also essential in raising the level of staff and students awareness of health and safety policies and procedures, such as Local Rules, and to ensure their effective implementation.

All new staff or those that have been redeployed or relocated must receive general health & safety induction from their line manager or other appointed person, and specific induction from the Radiation Protection Supervisor (RPS) in the area in which they will be working. This requirement also applies to those on temporary contracts and agency staff.

The importance of knowing what health and safety training is needed is key to the selection and design of workshops. These needs should be assessed on appointment, when members of staff take on a new role with increased safety responsibilities, or new equipment is introduced. Training needs should also be reviewed as part of staff appraisals, from reviews of radiation safety performance and risk assessments.

Communication is key to the promotion of good safety practice and in learning environments such as universities and research establishments, leading by example is especially important as students will follow examples set by academics and senior research staff. Communication can be in many forms from the traditional safety posters, newsletters and weekly bulletins to the modern day emails, texts and Twitter messages.

Much of what is known about safety has been learned from accidents, incidents and near-misses. By using a lessons-learned approach, educational and research organisations are able to engage with staff and students and provide a challenge to think about how safety measures could have prevented an accident or incident, or at least have minimised the consequences. It is important therefore to establish robust accident/incident reporting systems and investigation procedures to identify root causes and formulate plans to implement mitigating actions.

Safety cases were developed by the oil, nuclear and rail industries in response to high-profile accidents and disasters. In a strong safety culture, members of staff collect evidence from a range of sources to build a sound safety case, with supporting evidence that systems are safe and risks are controlled and monitored.

The core of the safety case is typically a risk-based argument and corresponding evidence to demonstrate that:

• all risks associated with a particular system have been identified;
• appropriate risk controls have been put in place; and
• there are appropriate processes in place to monitor the effectiveness of the risk controls and the safety performance of the system regularly.

By applying safety case methodology in the university and research settings, institutions would be able to:

• promote structured thinking about risk amongst academics and researchers;
• integrate evidence sources;
• aid communication among stakeholders; and
• make the implicit explicit.

The OTHEA database (http://relir.cepn.asso.fr) is provided by a network of radiation protection stakeholders who have a joint interest in sharing feedback and experience from radiological incidents, in order to improve the protection of persons working with similar radiation sources. More generally, the aim is to encourage good practice within different sectors including medical and veterinary, industrial, research and education sectors, etc.

Incidents and reports are selected on the basis of the value of sharing the lessons learned and therefore the database includes a wide variety of incidents: not just accidents and incidents, but also any situation, event, behaviour or anomaly with the potential to cause an unplanned radiation exposure, or a significant decrease in the existing standard of radiation protection. This could include 'near misses', contamination spills as well as more serious radiological incidents.

Within this audit there needs to be ongoing assessment of the radiation protection management structure. There must be a mechanism to identify and then encourage the removal of any disconnect that exists between: (a) the management of radiation protection at the 'coal face' and (b) senior site management (see management structure performance indicator below).

The engagement of an external auditor to examine periodically the current state of culture (and its development) against recognised standards may be expensive, but is no doubt beneficial in testing the culture, and it is impartial.

It should be noted that regulatory inspectors (e.g. from the HSE or EA) 'have a powerful opportunity to offer support and encouragement for developing an effective radiation protection culture' (Cole et al 2014). Indeed, annual inspection regimes conducted by the radiation regulator are important in ensuring a compliance culture and thereby act to promote a radiation safety culture. It is useful to have good working relationships with the regulators and local inspectors.

It is important to assess whether initiatives to develop and improve RP safety culture are making any difference. Only in this way can one evaluate strategies for improvement so that managers use the most effective methods.

As highlighted by Cole et al (Cole et al 2014) such indicators might include the:

• Annual collective dose of radiation workers.
• Annual number of radiation-related incidents or near-misses.
• Number of non-compliances with permit conditions (e.g. leading to prosecutions, notices, or RASCAR [Radioactive Substances Compliance Assessment Report] points) or in-house rules.
• Number of persons attending radiation safety training (including refresher training) as a percentage of those registered/intending to attend.
• Number of late and non-returned personal dose-meters.
• Number of outstanding actions identified from audits/inspections.

This data needs to be garnered from surveys of all staff and areas within the organisation, and students. Information needs to be recorded and databases interrogated to produce periodic reports on the organisation's website. Comparing trends in RP indicators against overall safety indicators for the organisation may also show up comparisons that could be helpful in identifying areas of relative success or failure.

Universities and research establishments are increasingly interested in retaining the right talents whilst targeting new talents; measuring attitude provides an indication of how successful they are in fostering a working environment which is conducive to nurturing a positive culture amongst both staff and students. The more that senior management know about their staff and student's feelings, the easier it is to manage their behaviour. Surveys can also be a powerful tool for management to demonstrate that they value staff and student input and that it will be integrated into decision making processes.

It may not be easy to illicit weaknesses in RP culture in an organisation, for example, fear of blame will suppress reporting near-misses, and fear of unfair disciplinary proceedings will inhibit staff expressing concerns on poor attitudes to safety by line managers. An attitude survey, if carried out so that staff are confident the data will be anonymised (such as through an independent external body), will provide senior managers with useful insight into the weaknesses of RP culture perceived by employees. Exit interviews can also give useful data.

As a knowledge-driven sector, higher education is essentially people-driven and employee engagement levels are therefore very important. The quality of HE employees' contribution to teaching, research, enterprise and the various supporting activities are key to the success of individual institutions and the sector's reputation as a whole. Employee commitment is vital to meeting student and other HE stakeholder expectations and satisfaction, and without an engaged workforce, HE would not meet the significant challenges currently facing the sector. For this reason, the Universities and Colleges Employers Association (UCEA) and Universities Human Resources (UHR) have commissioned a joint web-based toolkit on employee engagement (www.ucea.ac.uk/en/publications/eetoolkit/index.cfm). This toolkit provides institutions with the essential advice and guidance on how to secure, maintain and develop employee engagement with their institutional visions and missions.

Whatever the size or nature of the organisation, the key factors to manage for health and safety are:

• leadership and management (including appropriate business processes);
• a trained/skilled workforce; and
• an environment where people are trusted and involved.

The HSE guidance INDG417 (Health & Safety Executive 2013) sets out an agenda for the effective leadership of health and safety by all directors, governors, trustees, officers and their equivalents in the private, public and third sector. It applies to organisations of all sizes. The guidance is based on the HSE's approach to health and safety of 'Plan, Do, Check and Act'.

The Health and Safety Laboratory's Safety Climate Tool (www.hsl.gov.uk/products/safety-climate-tool) can be used to gauge corporate safety culture. It measures key areas of health and safety climate, giving a snapshot of the underlying safety culture. Using the Tool helps organisations benchmark their performance against similar organisations in the industry and shows where to target resources, providing a baseline to measure improvements in safety culture.

CHaSPI is a free web-based tool, available to all large organisations employing over 250 people–in public, business and charity/voluntary sectors. It is available at www.chaspi.info-exchange.com and can also be accessed via the HSE's website.

CHaSPI can be used internally by organisations to help them manage and track their health and safety performance and to bring about any necessary improvements over time. It can also help organisations to benchmark their performance against others within the same sector, using a recognisable set of indicators. The organisation's CHaSPI score is determined from this set of indicators. A rating between zero and 10 is calculated, where zero is the worst possible score and 10 is the best.

A laboratory worker was contaminated with ¹³¹I in a radiopharmaceutical company in Finland on 28th February 2013. The worker was wearing two pairs of gloves and, when changing gloves, had noticed a break in the right inner glove, but not any obvious break in the outer latex glove.

Only 3–4 h later, routine monitoring revealed heavy contamination of the dorsal part of the right hand. Immediate actions to decontaminate the hand were undertaken on site. On the next day, besides persisting heavy contamination of the hand, activity was also found in the thyroid gland, and the Finnish Radiation and Nuclear Safety Authority (STUK) was notified. Stable iodine had not been administered. Based on original measurements on site and later follow-up at STUK, including surface contamination measurements and whole body counting, the original activity of the hand was estimated at 11 MBq and the equivalent skin dose at 25 Sv, affecting an area of about 10 cm². The estimated equivalent dose to the thyroid was 430 mGy and the estimated effective dose 22 mSv. On her first visit at STUK, the worker was advised to wear a glove and change it frequently in order to protect the surrounding and promote decontamination by sweating and washing. Three days later little activity was left in the hand but 11 d after the incident the skin was dry and slightly desquamating. After 15 d the skin was intact with no desquamation left. No further signs of skin damage have occurred.

This company develops and manufactures radiopharmaceutical for nuclear medicine applications. There are many similar companies worldwide carrying out similar unsealed radioactive work. It is probable that similar exposures of this type might go undetected. There seems to have been a PPE (double glove) failure, combined with a lack of monitoring so that the hand contamination went unnoticed (for up to four hours). It is not clear if the thyroid contamination is a result of transfer from the hand, or due to an inhalation intake at the workplace (during the initial contamination incident), but clearly there was a severe lack of radiological hygiene standards and failures to monitor for contamination which may have arisen from poor training.

Within a large university veterinary teaching hospital, a senior academic surgeon felt that a 370 MBq ⁹⁰Sr brachytherapy sealed source 'plaque' required repairing. Without informing anybody within the hospital, he took the source home in his own private car to 'fix' it by manually gluing the source back onto its metallic rod mount. He was not wearing any form of dose monitor or using any PPE during the process.

A week later the RPS discovered that the source was missing when she was preparing for a multi-regulator inspection. She notified all the appropriate stakeholders and raised the alarm. The RPA immediately informed the EA and the HSE. The senior academic said nothing but he knew that the source was still at his house.

There ensued an extensive site search but the source could not be located. The senior academic continued to say nothing even though he was fully aware of the brouhaha caused by his actions.

The regulators investigated and eventually, believing the source to have been lost in an inappropriate and non-radioactive waste stream, they issued a prohibition notice to the hospital. ⁹⁰Sr sealed sources could no longer be used on this site. Eight weeks later, and in a clandestine fashion, the senior academic returned the source to the source store room where it was discovered.

This case illustrates that some academic attitudes to following safe procedures can lead to serious non-compliances with the legislation and the potential for fines, bad press coverage and even custodial sentences. It also highlights that inventory checks should be routinely and frequently carried out and not just in preparation for a regulatory inspection. The hospital and academic concerned were fortunate that this incident did not result in any more serious actions by the regulators and the police.

A large research intensive university uses ³²P radiolabel for studies into DNA and RNA. To monitor control of the radiolabel, researchers were required to complete paper copies of stock and disposal documentation. Multiple sheets of paper were required to complete the record, including a primary stock record, solid waste records, and aqueous waste record, along with separate contamination records.

There were a number of multi-user laboratories with up to three research groups and fifteen individual researchers in each facility. All records for each facility were retained in a single folder holding the documentation. All stocks were held in a single central storage facility although each group had their own storage space in either a fridge or a freezer. The paper records were maintained at the same site as the storage.

Access to the central storage was controlled via a single key. Control of the key was from a separate office and had to be signed in and out with date and time.

There were a number of issues starting to build up:

• A degree of trust had built up regarding access to the key and therefore to the radioisotope storage facility.
• There was poor control over who can or who is completing the stock and disposal recording. There was evidence of records being completed at a later date based on spot checks made by the Radiation Protection Officer (RPO)
• It was not easy to identify how the holdings and use of radioactive materials related to the EA Permits.
• When errors had been made, then corrections were overwritten and it was not always clear as to what the original mistake had been.
• There was no decay correction being applied for the use of short half-life radioactive substances, leading to inaccuracies in disposal records.
• There was no notification to the RPS or RPO of how long waste had been accumulated on site other than a dated label.
• Due to the lack of any decay correction or accumulation times of activity, it was difficult to accurately audit stocks and waste.
• A culture had developed where it was easier to procure an activity for two or three assays based on a maximum activity that might be required rather than optimising the activity per assay. This is not using Best Available Techniques (BAT).

During a period of increased productivity in one lab a researcher believed they had enough reagent left for a final experiment. However, they discovered that the last 10 μl of ³²P reagent in their own stock vial had disappeared. It was determined that this could not be due to under filling of the initial stock or from evaporation of the stock. This was reported immediately to the RPS. The resulting investigation identified that another researcher had run out of reagent from their batch but had found some more in the central storage facility. They proceeded to use the newly found stock with the intention of notifying the original owner the following day when they had returned to work. Unfortunately, due to staff absences, increased pressure to get results and resulting stress, the stock records did not get completed and the original owner did not get informed. The error was not discovered until several days later when the reagent was needed again. The incident was reported to the appropriate regulators and corrections were made to the stock records. The regulator requested that a more robust method of regular audit was introduced and that refresher training of the individuals concerned was undertaken. As a result of this incident an in-house web-based radioactive stock accountancy programme was introduced within three months. Training was provided to over 150 researchers over 1 week on the new system. All researchers were told to only use the web based system.

There are a number of advantages with the web-based inventory:

• Staff wishing to use the system had to apply for a unique log-in. The inventory could only be accessed by approved users who had undertaken training.
• Recording of stock and disposal by an individual was easily identifiable, dated and timed.
• All recording is undertaken on a single web page and not on multiple sheets of paper.
• The RPS could undertake regular, easier and more effective auditing of the radioactive stock.
• The RPS and RPO was automatically notified if any of the EA Permit Schedules had been breached or were within 50% of the limit.
• All radioactive materials are decay-corrected automatically.
• There is no requirement for the researchers to undertake complex calculations to use the correct activity or volume. This in turn makes the creation of secondary stocks or retained sample activities more accurate.
• There is an accurate record of total accumulation of stocks and wastes both on site and in each storage facility available immediately.
• Monthly and annual records of waste returns and stock holdings takes 2–3 min to process for the entire University as opposed to days or weeks of checking spreadsheets.

Since the introduction of the web-based system the number of recording incidents has been significantly reduced. The researchers all use the same system and are familiar with it. This makes it more practical for research groups to interact, for staff movement between groups and for training to be undertaken by the RPS. The RPSs are able to give more time to supervision and to research, since less time and effort is required to effectively audit stocks. The system is easy and intuitive to use and the researchers are more proactive in completing the stock and disposal records. The culture and awareness of use of radioactive materials has significantly improved since the introduction of this web based system.

A university chemistry department procured the use of a laser system for a transient absorption spectroscopy (TAS) research project for 12 months. The system is a complex one involving two Class 4 lasers, an Optical Parameter Amplifier (OPA) and the spectrometer. There were multiple stakeholders involved including the laser manufacturer, the laser installation engineers, the owner of the system, the 3rd party facility that ran the laser loan pool, and the university where the TAS project took place.

Once the system had been installed and 'handed over' to the university, the chemistry research group were aware that they were responsible for safety during its routine usage. With the assistance of the university's Laser Safety Officer (LSO), the research project leader had drawn up a risk assessment and a set of laser safety local rules for the routine use. All relevant members of university staff had received laser safety training and appropriate laser safety glasses for routine use had been purchased. The lab where the equipment was to be installed was assessed and deemed suitable by the university's LSO.

However, at the point when the installation phase was about to commence, once the engineers were on site, some problems were discovered. The installation engineers seemed unaware that they were responsible (or at least partly responsible) for laser safety during the installation process. They had asked the university to sign a declaration to accept this full responsibility. The university refused to sign it. In addition, it was unclear who the installation engineers, the laser manufacturer, and the laser loan pool had appointed as their LSO. Nobody from this group of three appeared able to provide any evidence of laser (safety) training; in fact the engineers were surprised that they were asked to provide any. There was no risk assessment or safety operating procedures made available. At one point one of the engineers asked if he can borrow a pair of the university's laser safety glasses as they didn't have enough pairs.

The installation lasted for approximately one week. It went ahead despite advice from the university's LSO that it should not until the question of responsibility was clarified and copies of the full safety documentation from the engineers or loan pool was forthcoming. For the installation week it was unclear as to which stakeholder had overall control of safety and compliance during the installation.

This is a case of miscommunication between the university's in-house personnel and external parties during the installation of a complex and hazardous piece of equipment. Also, there was little comprehension of the LSO's concerns or motivation to address them. Each of the parties thought that one of other parties was responsible, but no one took the crucial steps to find out for sure who was responsible for what parts of the project. As a result, during the installation week the university was potentially liable for any safety-related incidents with an installation process, about which they knew scarce details and had little practical involvement, which was carried out by persons who may not have been adequately trained.

No adverse incidents occurred during the installation which was completed successfully. Nevertheless, as a result of this installation, the university were instructed by their LSO and Safety Officer to review and recast their policy and procedures for the installation of any hazardous equipment by 3rd party engineers.