ML18086A776
| ML18086A776 | |
| Person / Time | |
|---|---|
| Issue date: | 02/14/2018 |
| From: | Binesh Tharakan Division of Nuclear Materials Safety IV |
| To: | Beverly Smith State of MS, Dept of Health |
| Tharakan B | |
| References | |
| Download: ML18086A776 (5) | |
Text
MISSISSIPPI DEPARTMENT OF HEALTH QUARTERLY MONITORING CALL
SUMMARY
FEBRUARY 14, 2018 NRC Attendees Mississippi Department of Health Attendees Binesh Tharakan, Regional State Agreements Officer, Region IV Bobby Smith, Director, Division of Radiological Health Paul Michalak, Chief, Agreement State Program Branch Melanie Vail-Fuller, Team Leader, Quality Improvement Team Jayson Moak, Director, Radioactive Materials Branch Jeff Algee, Health Physicist Robert Sims, Health Physicist Benjamin Culpepper, Health Physicist Tameka Johnson, Health Physicist
Background:
On July 27, 2017, a Management Review Board (MRB), which consisted of U.S. Nuclear Regulatory Commission (NRC) senior managers and an Organization of Agreement States liaison, met to consider the recommendations from the April 2017 Integrated Materials Performance Evaluation Program (IMPEP) review of the Mississippi Agreement State Program (the Program). Based on the recommendations of the team, the MRB found the Program satisfactory for three out of six performance indicators that were reviewed (Technical Staffing and Training, Status of Materials Inspection Program, and Technical Quality of Inspections).
The MRB found the other three indicators satisfactory, but needs improvement (Technical Quality of Licensing Actions, Technical Quality of Incident and Allegation Activities, and Compatibility Requirements). Accordingly, the MRB found the Mississippi Agreement State Program adequate to protect public health and safety, but needs improvement, and compatible with the NRCs program. The MRB directed that a period of Monitoring be initiated for the Mississippi program and a periodic meeting be conducted approximately one year from the IMPEP review.
Monitoring is a process by which NRC monitors the progress of an Agreement State or NRC Region through a series of periodic conference calls, typically held quarterly with the program.
The purpose of the calls is to review the programs progress towards implementing recommendations made by the IMPEP review team, as well as to discuss the status of the IMPEP indicators and any changes that could impact the programs performance.
The first quarterly Monitoring call with the Mississippi Agreement State Program was held on November 1, 2017 (ADAMS Accession Number ML17338A647). The following summary documents the second quarterly Monitoring call was held on February 14, 2018.
2 Summary:
The 2017 IMPEP review team made one recommendation in Technical Quality of Licensing Actions which was expanded and modified by the MRB to include Technical Quality of Incidents and Allegation Activities. The MRB recommended that the Program review its guidance, including licensing, incident and allegation guidance; update this guidance, as appropriate; and provide training to all Program staff on the new procedures.
To address the recommendation and other issues identified during the 2017 IMPEP review, the Mississippi State Department of Health (the Department), Division of Radiological Health (the Division), established a Quality Improvement (QI) team on September 14, 2017. All members of the Radioactive Materials Branch (the Branch) serve as QI team members and meet weekly to identify program weaknesses, determine root causes, and recommend improvements using continuous quality improvement methods for all IMPEP performance indicators. The QI Team has taken several actions to address deficiencies, including performing a root cause analysis of program weaknesses and proposing corrective actions.
Procedures and Guidance Reviewed by Mississippi The Division reviewed the regulatory requirements for training of all Radiation Safety Officers (RSOs) authorized on medical use radioactive material licenses. The Division will ensure that RSOs will be qualified according to Mississippi State Regulations under Rule 1.7.19. This includes written attestation signed by a preceptor RSO that indicates the individual has satisfactorily completed the requirements in Rule 1.7.19. The Division will also ensure that an RSO has training in radiation safety, regulatory issues, and emergency procedures for the types of use for which a licensee seeks approval.
The Division issued a letter to all medical licensees with RSOs added to the license on or after 2012 (year of adoption of current state regulations) explaining the requirements and enclosed a Radiation Safety Officer Training and Experience and Preceptor Attestation form. There were 118 RSOs that were in the affected population of RSOs required to complete the form.
Currently, all 118 RSOs have the required training documentation.
All licensees who possess radioactive material meeting the threshold for the International Atomic Energy Agencys (IAEA) Code of Conduct for Category 1, Category 2, or quantities of radioactive material aggregated using the sum of fractions methodology that meet or exceed the threshold for a Category 2 quantity of radioactive material will be licensed according to Table 1, 10 CFR Part 37, Appendix A. The Division reviewed the applicable licenses and procedures to ensure that a specific Part 37 license condition was included in all applicable licenses until such time of adoption of 10 CFR Part 37 into Mississippi regulations.
Status of license conditions and regulations As of February 17, 2018, Mississippi has adopted NRC regulations by reference.
The need for the specific license condition on Category 1 and 2 licenses was eliminated. In addition, all Agreement Letters for Reciprocity to be issued with a specific Part 37 condition is no longer necessary; however, at the time of the monitoring call, all active Agreement Letters for
3 Reciprocity have been reviewed, and if necessary, were reissued with a specific Part 37 condition prior to the adoption of Part 37 by reference.
Procedures have been modified to ensure all allegations will be investigated to determine whether they are substantiated or unsubstantiated. All allegations will be documented and filed in the allegation file for each year. Allegations will be investigated and closed out with the alleger according to interim Division of Radiological Health Allegations Policy/Procedure. An improved allegation policy, which is under development, should be completed within the next quarter.
Training Provided to the Mississippi Staff All Radioactive Material Branch staff have been trained on the use of licensing checklists to include review of 10 CFR Part 37 licensing requirements. All Radioactive Material Branch staff have been trained on the updated Part 37 licensing requirements based off Table 1, 10 CFR Part 37, Appendix A which includes the threshold for IAEAs Code of Conduct for Category 1, Category 2, or quantities of radioactive material aggregated using the sum of fractions methodology that meet or exceed the threshold for a Category 2 quantity of radioactive material.
All Radioactive Material Branch staff have been trained on the licensing requirements, and regulation in Rule 1.7.19 for RSOs authorized under a medical use license. Licensing checklists have also been amended to include review of RSO training requirements under Rule 1.7.19.
All Radioactive Materials Branch staff have been trained on the policy and procedure for reporting nuclear material events in Agreement states to include the reporting requirements in Appendix A of SA-300, 10 CFR 30.50, and reporting requirements in the Mississippi State Department of Health Regulations. All incidents have been documented, filed, and reported to the NRC according to Appendix A of SA-300, 10 CFR 30.50, and reporting requirements in the Mississippi State Department of Health Regulations. Since the IMPEP review, Mississippi has reported three incidents involving licensed material to the NRC in a timely manner, including one incident involving a fixed gauge stuck shutter.
Resolution of Comments on the Regulations The 2017 IMPEP review team identified that some regulation amendments were not adopted by Mississippi within the designated three-year adoption period. To ensure future compliance with NRC compatibility requirements, on November 7, 2017, the Department submitted regulations to the NRC for review, which adopted NRC regulations by reference. These regulations became effective on February 17, 2018. On February 27, 2018, the NRC responded with 31 comments related to the review of the Mississippi regulations adopted by reference. The Mississippi program acknowledged the comments and plans to resolve the comments prior to their July 2018 meeting with the Mississippi State Board of Health to receive approval to incorporate the changes. Once the changes are approved, the corrected final regulations will be part of the Mississippi Administrative Code on or about August 15, 2018.
4 Changes to Other Processes as a Result of the IMPEP Review The QI team is reviewing staff retention and career ladder promotions. The QI team identified that, in addition to potential pay raises, shortening the time spent at certain grade levels within the career ladder could reduce the attrition rates that the program has seen historically. The QI team also made improvements to ensure tracking of training was made open, transparent, and visual by listing staff training accomplishments and needs on an office white board. Since the last monitoring call, the program also conducted a table top exercise, developed a draft licensing policy, and implemented an electronic workflow management system to ensure timely and accurate reviews of licensing actions.
Program/Staff Changes/External Inputs/Budget The program continues to qualify newer staff members on all license types. One new staff member was hired into the program in May 2017 and has started the qualification process.
There have been no changes to the budget since the last IMPEP review. The program is fully funded by fees charged to its licensees.
==
Conclusion:==
The Mississippi program continues to make progress in addressing the IMPEP recommendation and appears to have resolved the compatibility issues by adopting NRC regulations by reference. No further monitoring calls are scheduled. The periodic meeting is scheduled for April 25, 2018.
5
SUBJECT:
Mississippi Monitoring Call Summary Distribution: (SP08)
MShaffer, RIV/DNMS LHowell, RIV/DNMS KWilliams, MSST PMichalak, MSST/ASPB LRakovan, MSST/ASPB LRoldan-Otero, MSST/ASPB RErickson, RIV/RSAO State of MS DOCUMENT NAME: S:\\DNMS\\!SAO\\Monitoring Program\\Mississippi\\2.14.18 Mississippi Monitoring Call Summary.docx ML18086A776 SUNSI Review By: BKT ADAMS Yes No Publicly Available Non-Publicly Available Non-Sensitive Sensitive Keyword:
IMPEP OFFICE RIV:RSAO ASPB NAME BKTharakan KMeyer SIGNATURE DATE 03/07/18 03/27/18 OFFICIAL RECORD COPY