Inspection report details

Licence holder:

Australian Nuclear Science and Technology Organisation (ANSTO)
Location inspected:Lucas Heights
Licence number: F0262
Date of inspection:03/08/21
Report number: R21/08370

An inspection was conducted as part of ARPANSA’s baseline inspection program to assess compliance with the Australian Radiation Protection and Nuclear Safety Act 1998 (the Act), the Australian Radiation Protection and Nuclear Safety Regulations 2018 (the Regulations), and conditions of facility licence F0262.

The scope of the inspection included an assessment of ANSTO’s performance at the ANSTO Health Products facility against the Performance Objectives and Criteria (POC) for security, event protection and emergency preparedness and response. The inspection consisted of a review of records, interviews, and due to further outbreaks of COVID-19 was conducted via virtual means.


ANSTO’s Health Products facility is part of the greater Nuclear Medicine division at ANSTO (which also includes ANM) which falls under what ANSTO has defined as the Nuclear Precinct (OPAL, Nuclear Medicine and Waste Management Services).

It is a radiopharmaceutical production facility that primarily produces molybdenum-99/technetium-99m generators along with various other radioisotope products used for the treatment and/or diagnosis of disease (for example, cancer).



Areas for improvement from a previous security inspection undertaken in May 2020 (R20/04132) were discussed including:  

  • the security plan had not been endorsed as per RPS 11 (the Code of Practice for the Security of Radioactive Sources)
  • plans and arrangements did not integrate security more broadly
  • and the requirements of reviews (both periodic and on demand) had not been formalised.

Security documentation has been improved since the previous inspection with multiple plans (for both the site and the facility) being supplied to ARPANSA for review, comment and further advice where required. ANSTO’s tiered suite of documents are in their final stages before being rolled out across site.

ANSTO Health Products’ Plans and Arrangements (P&As) (00003892) indicate that periodic review of staff with access to the facility is undertaken as part of the annual review of P&As. Records of such a review were supplied from mid-2020. However, the review requirement appears inconsistent with ANSTO’s Security Manual (AG-1028) which describes a quarterly review of card holder access and access groups by the building manager in association with and support from ANSTO Security. ANSTO identified the latter requirement as being potentially too frequent with such reviews being more appropriately conducted based on a revision of the threat level. While the local security plan articulates an annual review of access, an area for improvement has been identified to ensure consistency across all security documentation.

Security-related maintenance is performed by contracted provider, Wormald. The provider undertakes scheduled testing of the infrastructure to ensure its performance continues as expected through tracking and resolving issues within expected time frames. ANSTO Security also conducts daily systems checks and registers issues to ensure outages are assessed and repaired. No issues were identified.

Evidence of security training (an export spreadsheet from ANSTO’s Learning Management System) was provided to inspectors which indicated that security training is being undertaken although it was not clear whether the mandatory annual security awareness training is being completed. This is considered an area for improvement. However, it was relayed to inspectors that a program of work has been undertaken to completely review training modules in place at ANSTO and develop a new security awareness training package.  

Inspectors asked for clarification of the effectiveness of the security controls in place. Effectiveness is evaluated through exercises and drills where the system is tested in its responsiveness and control of an event, leading to recommendations being made and improvements actioned. While not all tests are applicable to the Health Products facilities, the system has been tested in its entirety as required for facilities that have greater significance (i.e. OPAL).

Event protection

Normally, during a physical inspection, inspectors would conduct a walkthrough of the facility to ensure the status and maintenance of firefighting and emergency equipment (emergency eyewash stations and showers, fire extinguishers, etc.). Due to COVID restrictions, such an inspection was not possible. Numerous records were provided prior to the inspection giving confidence that maintenance of the related equipment has been performed.

Housekeeping audits were supplied, bushfire pre-season checks are undertaken annually, and clarification was provided in relation to the management of hazardous chemicals which could potentially exacerbate an external event. No issues were identified.

Emergency preparedness and response

Specific to each facility, building wardens are put in place who have a local responsibility for emergency preparedness and response (EPR) with refresher training scheduled every 3 years. However, ANSTO relayed that this does not align with Australian Standard (AS 3745) which requires annual refreshers. Therefore they intend to incorporate this into their annual drills.

Occupationally exposed radiation workers at the facility receive an array of training related to EPR which ranges from facility induction to specific radiation safety training including guidance for responders in an emergency scenario. Building specific training has also been developed with an added accreditation process which requires annual recertification. However, the current pandemic has hindered its roll out.

ANSTO has planned for specific EPR training to being rolled out to ANSTO’s first responders (Radiation Protection Advisers, Health Physics Surveyors, Work Health and Safety Advisors, Waste Operations, Reactor shift managers, etc). Two previous sessions had been previously organised but had to be cancelled due to COVID-19.

ANSTO’s Emergency Response Team (ERT) performs informal walkthroughs of all the facilities to ensure familiarisation with the facility environments in case any changes have occurred following their original induction. These visits are recorded on daily record sheets and reviewed by the emergency operations manager. However, these walkthroughs have also been impacted by COVID-19 and in order to reduce any potential spread the ERT are only entering facilities as needed. The ERT also undertake informal inspections, notify building managers of any issues which are logged in the GRC system and are then triaged by the facility’s building warden/s.

ANSTO has recently reviewed its EPR documentation to align with IAEA GSR Part 7 (Preparedness and Response for a Nuclear or Radiological Emergency). Among other things, this included re-categorisation of ANSTO facilities and re-evaluation of ANSTO emergency response capabilities with a focus on internal capacity up until the point where an external service is engaged. Cooperation between these organisations has previously been undertaken at ANSTO’s OPAL reactor but not for an emergency at the Health Products facility. Currently, tentative timeframes exist for conducting an exercise joined by outside emergency support. It was positive to hear that engagement between the stakeholders involved was already taking place.

No issues or areas for improvement were identified in relation to EPR.


The licence holder was found to be in compliance with the requirements of the Act, the Regulations, and licence conditions.

The inspection revealed the following areas for improvement:

  1. Ensure consistency of security requirements across ANSTO suite of security documentation.
  2. Evidence of mandatory security awareness training should be appropriately captured.

It is expected that improvement actions will be taken in a timely manner.

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