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The Royal Cornwall Hospital NHS Trust, compliance inspection

  • Site: Transport Competent Authority
  • IR number: 20-023
  • Date: October 2020
  • LC numbers: N/A

Executive summary

ONR regulates the civil transport of radioactive material by road, rail and inland waterway in Great Britain (GB). The ONR Transport Competent Authority (TCA) is responsible for delivering non-nuclear transport inspection and enforcement activities. This particular inspection forms part of that delivery function with reference to Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009 (CDG) and the Ionising Radiations Regulations 2017 (IRR17). CDG refers to the European Agreement concerning the International Carriage of Dangerous Goods by Road (ADR) and ADR 2019 was used during this inspection (www.unece.org).

Purpose of Intervention

The purpose of the inspection was to review The Royal Cornwall Hospital NHS Trust (RCHT) arrangements associated with the road transport of radioactive material. ONR carried out this remote inspection (via Microsoft Teams) at the Truro site on 5 October 2020.

Interventions Carried Out by ONR

The chosen inspection sample included:

  • notification, registration or consent – IRR17 Regulation 5, 6 or 7;
  • a suitable and sufficient radiation risk assessment (RRA) – IRR17 Regulation 8;
  • suitable and sufficient measures to restrict exposure – IRR17 Regulation 9;
  • suitable and sufficient Contingency Planning and/or Emergency Arrangements – IRR17 Regulation 13 and CDG 2009 Regulation 24 & Schedule 2;
  • adequate information, instruction and training – IRR17 Regulation 15 and ADR 1.3.1;
  • adequate Security arrangements – ADR 1.10;
  • a suitable and sufficient Management System  – ADR 1.7.3.

Key Findings, Inspector's Opinions and Reasons for Judgements Made

The inspector sampled the arrangements deployed by RCHT for the safe transport of radioactive materials, including the associated arrangements for protecting workers against the effects of ionising radiations and reducing risks as low as reasonably practicable (ALARP). 

The inspector compared relevant statutory requirements with both prescribed arrangements and actual practice. A number of examples were identified were the duty holder met relevant good practice in reducing risk to levels that are ALARP, including: having a comprehensive set of procedures and arrangements covering all aspects of transport; having its own Radiological Protection Advisor (RPA); testing emergency arrangements regularly; routinely monitoring vans for dose uptake to drivers; providing procedures for laboratory based employees that need to respond to transport emergencies and ensuring that adequate contamination monitoring of packages takes place.  A non-compliance was identified because RCHT had not considered whether it needed an emergency plan under CDG and this was discussed during the inspection.

During the inspection, the inspector also suggested certain improvements to transport practices that would be prudent for RCHT to consider.

Conclusion of Intervention

 RCHT demonstrated that for most aspects of its operations it met the requirements of CDG, ADR and IRR17. Based on the inspection sample, the inspector identified one non-compliance with relevant legislation and suggested five improvements. The inspector discussed these during the inspection and a commitment was obtained from RCHT to address the non-compliance.

RCHT was given until 6th November 2020 to provide ONR either with evidence that the finding has been resolved, or an appropriate resolution plan with timescales for completion.

For this intervention, an overall IIS Rating of GREEN is given to reflect that Legal duties were complied with, although there was one minor contraventions of specific administrative requirements.

The non-compliance will be managed through ONR’s Issues Management arrangements.