Inspection report details
Licence holderARPANSA Radiation Health Services Branch
Location inspectedYallambie, Victoria
Licence numberS0002
Date of inspection24/05/2022
Report numberR22/04726

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 source licence S0002. 

The scope of the inspection included an assessment of ARPANSA’s performance against the Source Performance Objectives and Criteria (POCs). The inspection consisted of a review of records, interviews, and physical inspection of sources. 

A radiation safety inspector from the Department of Health, Tasmania participated in the inspection to provide additional independence. 


Radiation Health Services Branch (RHSB) maintains systems for the measurement of radioactivity in the environment and potential exposure to people. This includes measurement of radioactivity and the analysis of samples including ultraviolet radiation, low frequency electric and magnetic fields (ELF), and radiofrequency (RF) radiation. RHSB is also responsible for the storage of radioactive material awaiting ultimate disposal.

RHSB is licensed under section 33 of the Act to deal with controlled material and ionising and non-ionising controlled apparatus.

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

  • Australian/New Zealand Standard: Safety in laboratories Part 4: Ionizing radiations (AS/NZS 2243.4:2018)
  • Radiation Protection Series C-6: Code for Disposal of Radioactive Waste by the User (2018) 
  • Australian/New Zealand Standard: Safety in laboratories - Non-ionizing radiations -Electromagnetic, sound and ultrasound (AS/NZS 2243.5:2004)
  • Australian/New Zealand Standard: Photo-biological safety of lamps and lamp systems (AS/NZS IEC 62471:2011)
  • Radiation Protection Series 12: Radiation Protection Standard for Occupational Exposure to Ultraviolet Radiation (2006)


The licence holder was found to be in compliance with the Act, the Regulations, licence conditions and relevant codes and standards. The inspection concluded that RHSB continues to demonstrate that they meet the principles of the Source POCs.  

Three (3) areas for improvement (AFIs) were identified. These AFI’s related to radiological risk assessment, alignment of emergency planning with ARPANSA Radiation Protection Guide RPS-G3 and improvements in the effective management of radiation safety related documentation. 

The 5 AFIs raised from the last inspection were reviewed. The Three AFIs related to effective control documentation, emergency procedures, and requirement for wipe testing of sources were found to have been completed. The actions taken for the AFI on the development of a change control procedure were reviewed, with draft Change Management Framework ARPANSA-FRM-0008 noted to have been developed and in the review and approval stages since 2019. The actions taken for the AFI on the development of more detailed investigation procedures were intended to be addressed by the ongoing roll out of an integrated safety and security computerised system which is currently being customised to ARPANSA’s needs. See below sections for more information. 

Performance Reporting and Verification

Quarterly reports since the last inspection in 2020 were examined by the inspectors. Safety and security reporting and changes under section 64 of the Regulations continue to be reported as per licence condition 3 of S0002. No radiological events have been reported since the last inspection under S0002. 

The minutes of the last 3 Radiation Safety Committee meetings were reviewed. The committee was noted to continue to conduct functions such as review and endorsement of procedures. 

The documentation covering conducts, dealings and operations with implications for radiological safety were examined, including the Radiation Safety Manual (ARPANSA-FRM-006), the Radiation Safety Strategy (ARPANSA-SOP-1429) as well as all referenced procedures and work instructions. It was found that the manual in some places referenced procedures which were in draft or no longer planned to be issued (for example procedures referenced - ARPANSA SOP 1444 Decontamination of Persons and Equipment and ARPANSA-SOP-1432 Emergency Procedures Radiation Exposure were found to not be in place. In addition, the Radiation manual contained redundant information on individual dose monitoring and in one instance referred users to two SOPs (1430 and 1434) with conflicting information on designation of hazardous areas. At the time of the inspection, it was noted that these documents were under review, but resourcing was compounding the timeline for reissue. This was raised as an area for improvement against Source POC – C7 Documentation and Documentation Control. 

Safety Management 

The Hazard Identification, Risk Assessment and Management Forms (HIRAMS) for key work conducted under S0002 were examined including Ultraviolet Radiation services, the Radiochemistry Laboratory procedures, and a project to remove a contaminated HEPA filter associated with the strong room and waste store ventilation system. Whilst the risk assessment and mitigation processes were noted to be in place, there was no documented potential doses and no consequence ranking for radiological impact in the risk categorisation matrix. This made it difficult to understand the hazards and whether the mitigations in place were effective. At the time of the inspection, it was noted that there were plans to improve the HIRAM process by including a radiological category for impact and by expanding either the associated procedures or the HIRAMS to contain more step-by-step details. An AFI against Source POC C9 Risk Assessment and Mitigation - was raised to track this progress. 

As noted above a draft change control framework ARPANSA -FRM-008 was noted to be at the review and approval stage at the time of the inspection. Examples of the Section 63 Determination ARPANSA-FORM-1493 for changes conducted since the last inspection in 2019 were inspected including for the change to the protective security policy framework and for the proposal for the purchase and installation of a Beta Secondary Source (although related to Source Licence S0003). No issues were raised with the determinations conducted. 

Training records were examined including the ARPANSA -Form-0940 dealings with UV radiation and the ARPANSA-FORM-1640 Record of ARPANSA Radiation Worker Authorisation. In addition, individual training records for the specific persons listed on these forms. The revised ARPANSA UVR safety Induction Training and authorisation process was reviewed in detail. No issues were raised. 

Radiation Protection 

Personal dose records for controlled persons are reported to ARPANSA quarterly and remain well below statutory dose limits (and well below 1mSv). Annual wipe tests were examined and noted to be complete as per ARPANSA Regulatory Guide Wipe testing of sealed sources and use of sealed sources beyond recommended working life (ARPANSA-GDE-1764). 

Recommended Working Life assessment was discussed in terms of relevance to the type of sources under S0002 and it was determined that whilst reasons for not conducting the assessment was provided these were still to be formalised/documented. 

A physical inspection of the workplace was conducted and a sample of sources and controlled apparatus inspected against the Source Inventory Workbook, which did not raise any issues. The workplace continues to be delineated into controlled or supervised areas. Signage was found to be in compliance with AS/NZS 2243.5:2004 and security arrangements were appropriate to the inventory. Personal protective equipment, emergency spill wash stations and calibrated monitoring equipment were available. Fume hoods were found to be serviced within the required timeframes. 

The calibration records were examined for 15 monitoring instruments and no issues raised. 

Radioactive Waste 

The procedures for managing radioactive waste (including liquid and gaseous discharges) were reviewed. The two low level solid waste stores under S0002 were inspected and waste noted to continue to be packaged appropriately and labelled in line with AS/NZS 2243.4. At the time of the inspection, it was noted that a project had been initiated to conduct minimisation of the solid waste in line with ARPANSA Radiation Safety Guide, Predisposal Management of Radioactive Waste RPS-16.

Emergency Preparedness and Response

Records of the last emergency exercise conducted in April 2022 and the lessons learned were reviewed. The emergency plan ARPANSA-SOP-1468 Yallambie Emergency Procedures was examined. It was noted that since the last inspection this document had been updated to include further response to radiological events. It was suggested that further improvement could be achieved by determining the Emergency Preparedness Category for the Yallambie premises in line with the ARPANSA

Guide for Radiation Protection in Emergency Exposure Situations RPS G-3 which has been published since the last inspection. 


Security controls for S0002 were reviewed and continue to be in compliance with the Code of Practice on the Security of Radioactive Sources (RPS 11) and no issues were identified. It was noted that security category aggregations of unsealed sources had been calculated, consistent with the recommendations of IAEA Nuclear Security Series No. 14, and that no amendment to the existing security arrangements was required for this inventory. 


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. Documentation covering conducts, dealings and operations with implications for radiological safety contains references to draft or non-existent standard operating procedures and in some cases contain conflicting or redundant information  
  2. Radiological risk assessments could be improved by application of consequence ranking for radiological impact in the existing risk categorisation matrix in order to demonstrate and document clearly the risks. 
  3. The emergency preparedness category for the whole Yallambie premises could be determined under ARPANSA RPS-G3 in order to confirm that the current level of preparedness and response aligns with that recommended under the Australian framework for the protection of emergency workers, helpers, the public and environment in emergency exposure situations. 

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

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