Inspection report details 
Licence holder:Australian Nuclear Science and Technology Organisation (ANSTO)
Location inspected: Secondary Standard Dosimetry Laboratory, Lucas Heights NSW
Licence number: F0244
Date of inspection: 11-18 February 2021
Report number: R21/01855

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 F0244. 

The scope of the inspection included an assessment of performance at the Secondary Standard Dosimetry Laboratory (SSDL) against the facility Performance Objectives and Criteria (POCs). The inspection consisted of a review of records, interviews, and physical inspection of the facility. 


Licence holder is authorised under section 32 of the Act to operate an irradiator (prescribed radiation facility). The facility is not currently being used and ANSTO have committed to relocating the source and decommissioning the facility within approximately 6 months.

The ANSTO SSDL provided a traceable calibration for instruments used at radiotherapy centres in hospitals throughout Australia. However, the facility had been used increasingly less frequently in the period up to 2016 and has not been used for irradiations since 2017. The SSDL is licensed to contain a cobalt-60 source with a maximum activity of 220 TBq and its current activity is around 10 TBq. This makes it a category 2 security enhanced source.

The main codes and standards applicable to this facility are those that appear in section 59 of the Regulations plus: 

  • Code of Practice for the Design and Safe Operation of Non-Medical Irradiation Facilities (RHS24)
  • Code of Practice for the Security of Radioactive Sources (RPS11)
  • Australian/New Zealand Standard: Safety in laboratories Part 4: Ionizing radiations (AS/NZS 2243.4).


In general, the management of safety and security at the SSDL facility was found to be adequate.  In some cases, however, there was room for improvement including with respect to, maintenance, testing, calibration, inventory control and record keeping.

Performance reporting and verification

Submissions of quarterly reporting were on time and generally accurate. A sealed radiation source had been re-located to another area of ANSTO. While this was documented in a handwritten log, it was not reflected in the site source database as being in a new location, or in quarterly reports or other submissions to ARPANSA. Effective accounting of sources is important ahead of any decommissioning, and this is considered an area for improvement. It was noted that ANSTO is undertaking work to improve the source register, including interface with ARPANSA.

The facility nominee is the Chief People Officer (CPO), People Culture and Security. However, the facility officer has an operational reporting line that does not include the nominee. This setup differs from similar facilities at ANSTO. These differing reporting lines could hinder the timely reporting of issues and visibility of the operational experience that assists the nominee in maintaining effective oversight. However, documents required to be reviewed and approved by the nominee were actioned as appropriate.

Configuration management and change management

As described in the ARPANSA guidance Possess or control of a controlled facility, a possess or control licence is intended for extended shutdowns. While this facility is effectively in a shutdown state the facility continues to be covered by an operating licence. As such all requirements of the operating facility licence continue to apply. 

The primary document which outlines the safety systems of the facility is the Safety Analysis Report (SAR). This was last reviewed and re-issued in 2016 and includes a summary of risk assessments, control measures and potential emergency response associated with the facility. The current configuration differs from that described in the risk assessments and associated documents in that the facility is non-operational. While a decline in operations is noted in the current SAR, the documentation includes requirements for maintenance of the facility and testing of interlocks. It does not include provisions for extended shutdown. 

The latest plans and arrangements document (revised late 2020) did not reference the maintenance document, while the previous version of the document did. Removal of the requirement to perform maintenance requires an assessment of the risks. Formal assessment ensures that individuals are not left to determine the applicability of safety and security measures which may be critical to safety.

Another example of not maintaining the safety measures outlined in the SAR is that one of the fixed radiation monitors listed in the SAR was not present. The radiation detector that is part of the interlock system also experienced a fault and was being repaired which leads to the facility not being accessible. This represents a reduction in the defence in depth of the facility with only one fixed detector operational instead of three as outlined in the SAR. Not maintaining the facility in the state that is outlined in the SAR is considered as part of the non-compliance identified in the inspection testing and maintenance section of this report.

ANSTO has submitted a timeline for moving the source to a different secure facility at ANSTO and decommissioning the SSDL facility. The movement and surrender of the licence will be subject to further approval by ARPANSA. This will ensure that the full implication of the changes are understood by all parties, and that risks are documented and controlled appropriately. 

Inspection, Testing and Maintenance

Maintenance is required under:

  • RHS24 which requires periodic maintenance (paragraphs 12.1.2 and 12.3) and regular testing such as of interlocks (paragraph 18.2)
  • The SAR covers maintenance and states “Gammax Pty Ltd (formerly Radcons) performs annual preventive maintenance, inspection and servicing”, and “Periodic functional tests shall be performed on the safety interlocks to ensure their operability at all times and records of such tests shall be maintained”
  • The Plans and arrangements listed local rules and procedures for ‘Maintenance of SSDL and associated equipment documents’ 

No preventative maintenance and no systematic documented check of the interlock system has been carried out since 2016. This last maintenance report recommends that “annual preventative maintenance service and inspection be scheduled as suggested by the manufacturer of the Eldorado machine”. This is considered an area of non-compliance. The lack of preventative maintenance of a facility which was not being used without assessment of the change was also highlighted during an inspection in 2017 of a similar facility the ANSTO Gamma Irradiator Suite (GIS).

Recent calibration of the radiation monitors was carried out in June 2020. However, no records of the calibration from the previous few years were available.  This is considered an area of non-compliance together with the above. The last regulatory inspection of this facility in 2016 similarly noted that calibration of the current year was available but that previous (2015) calibrations were unavailable and that the area monitor had not been calibrated since 2013. A recent inspection of the ANSTO GIS facility observed that a wall mounted monitor had not been calibrated within the last 12 months.


There has been no formal training due to the lack of operation of the facility and no new staff. The risk of the loss of specialist knowledge should be considered, particularly for facilities which are in an extended period of shutdown. However, as ANSTO has committed to relocating the source into secure storage within six months, further training or knowledge capture would be of limited benefit. 


Compliance with RPS 11 is required under section 59 of the Regulations. This includes the requirement for a security plan to be endorsed by an accredited assessor. The facility had not previously had this in place. However, documents submitted ahead of this inspection process were assessed as meeting the requirements and endorsement was granted on 5 February 2021. Testing of the assumptions underlying response times and delay is being undertaken by ANSTO. Security measures observed in place were broadly consistent with the security plan.

Radiation protection

Radiological area (health physics) surveys were evident and last performed in February 2020. These include taking a smear test for contamination. Additionally, a ‘source integrity check’ was performed in 2016. However, neither of these tests referred to the activity that was detected, or the minimum detection level, in Becquerel. Clearly stating the test performed and readings in Bq would facilitate comparison with the requirements for the removable contamination (wipe) test requirements in both AS2243.4 and RHS24. This is considered an area for improvement.

Emergency preparedness, response and event protection

Site-wide measures for emergency response and event protection were in place. The facility is of solid construction for radiation protection and deterioration has not been observed. As the facility is due to be decommissioned there is little benefit in any additional measures at this time. It was noted that response testing for security would also be beneficial for emergency response purposes, and that learnings from response exercises at other similar facilities are transferable.

Safety culture and performance management

This facility has had a decrease in activity for some years followed by an extended period of no use. For such a facility it can be difficult to maintain an accurate picture of the operational experience. For example, knowledge possessed by experienced staff can be lost if they leave. Records were generally maintained but were in different systems such as logs, maintenance reports, and GRC events. Examples include the failure of an interlock monitor in 2018 which also failed immediately prior to the inspection, and issues raised in maintenance reports such as the air compressor system in 2013 and 2015. There were also some examples of information not recorded in a log such as the entry logs not always being used. 

Accurate record keeping in a consolidated log would help to maintain an accurate picture of the status of the facility. IAEA Specific Safety Guide 50 (SSG-50) Operating Experience Feedback for Nuclear Installations outlines how organisations should identify and feed into their operating experience program all issues, events, potential problems relating to equipment and human performance, and safety and security related concerns. This is considered an area for improvement.

ANSTO operates a number of irradiator facilities which have similar hazards due to security enhanced sources. Some improvements from previous inspections were observed such as the addition of a monthly check for source presence – identified in a 2020 inspection. However, some areas were not addressed such as the change management and security plan requirements - identified in a 2017 inspection. Learnings could be shared more effectively to ensure risks identified in one facility are addressed in similar facilities.


The inspection revealed the following non-compliance/s:

  1. Mandatory Inspection Testing and Maintenance requirements were found not to be consistently followed. 

The inspection revealed the following areas for improvement:

  1. Ensure effective inventory control and timely submissions to ARPANSA on source movements.
  2. ANSTO should review the process for facilities that may benefit from moving to a possess and control and identify any barriers that may hinder the effective transition.
  3. Recording of wipe tests results, showing alpha/beta/gamma in Bq, or otherwise clearly documenting the results in a manner that ensures it can be traced to the required detection/action levels.
  4. Recording of logs, events, and deviations could be improved. A review of the requirements and guidance on, and auditing of, event reporting may assist in ensuring a consistent and transparent approach is applied. 

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


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