Executive summary
Date(s) of inspection: April 2024
Aim of inspection
The purpose of the inspection was to review compliance of the Alexandra Hospital (AH) arrangements for class 7 radioactive material for road transport, covering consignor duties.
AH is part of the Circle Health Group and the inspection findings should be applied to all hospitals within the Circle Health Group.
Subject(s) of inspection
- Transport - Carrier Duties - Rating: Green
- Transport - Consignee Duties - Rating: Green
- Transport - Consignor Duties - Rating: Green
- Transport - Dangerous Goods Safety Advice - Rating: Green
- Transport - Emergency/Contingency Planning and Testing - Rating: Amber
- Transport - Incidents, Events and Reporting processes - Rating: Green
- Transport - Management Systems - Rating: Green
- Transport - Package Maintenance and Operation - Rating: Green
- Transport - Radiation Protection Advisor - Rating: Green
- Transport - Radiation Protection Programme - Rating: Green
- Transport - Radiation Risk Assessment - Rating: Amber
- Transport - Security - Rating: Green
- Transport - Training and Competence - Rating: Green
- Transport - Vehicle equipment and Placarding/Markings - Rating: Green
Key findings, inspector's opinions and reasons for judgement made
The inspector reviewed a range of topics and identified a number of examples of AH meeting relevant good practice in reducing risk to levels that are ALARP, including appropriate appointment of Safety Advisers and Radiation Protection Supervisors, transport documents, transport package certification, security, training, Dangerous Goods Safety Advisers report and management system.
The inspector also confirmed adequate equipment and signage on a vehicle used by AH's carrier and appropriate tie down of packages.
The inspector identified two areas of non-compliance and discussed these during the inspection. These were associated with the Radiation Risk Assessment for transport and emergency arrangements.
Conclusion
The inspection findings were presented to AH at the close of the inspection.
I judged an overall inspection rating of 'Green - no Formal Action' was appropriate for this inspection as there were no significant shortfalls identified in the delivery of safety.
AH is required to provide ONR either with evidence that the two identified non-compliances have been resolved, or an appropriate resolution plan with timescales for completion, by 7 June 2024. The non-compliances will be tracked to completion via a level 4 regulatory issue.