ML18297A008
| ML18297A008 | |
| Person / Time | |
|---|---|
| Issue date: | 09/21/2018 |
| From: | Office of Nuclear Material Safety and Safeguards, NRC Region 1, State of GA, Dept of Natural Resources |
| To: | |
| References | |
| Download: ML18297A008 (5) | |
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GEORGIA DEPARTMENT OF NATURAL RESOURCES (DNR)
QUARTERLY CONFERENCE CALL September 21, 2018 U.S. Nuclear Regulatory Commission (NRC) Attendees Georgia Environmental Protection Division (EPD) Attendees Monica Ford, Region I Karen Hays, Chief, Air Protection Branch Lance Rakovan, NMSS David Matos, Manager, Radiation Protection Programs Irene Bennett, Manager, Radioactive Materials Program DISCUSSION:
During the May 2016 Integrated Materials Performance Evaluation Program (IMPEP) review of the Georgia Agreement State Program, the team evaluated the States performance with respect to five common performance indicators and one non-common performance indicator.
On August 4, 2016, the Management Review Board (MRB) met to consider the teams proposed final IMPEP report. The MRB found the States performance satisfactory for five performance indicators and satisfactory, but needs improvement, for one performance indicator. Overall the MRB found the State adequate to protect public health and safety and compatible with the U.S.
Nuclear Regulatory Commissions (NRC) program. Five recommendations were made to improve program performance. The MRB directed that the State be removed from Heightened Oversight and that a period of Monitoring be initiated. Additionally, the MRB directed that calls between the staffs of the Georgia Agreement State Program and the NRC be conducted quarterly and that two periodic meetings should take place. One periodic meeting was to be held approximately one year from the 2016 IMPEP review and a second periodic meeting was to be held approximately 18 months after the first periodic meeting. A periodic meeting was held on May 22, 2017, and discussed at a special MRB meeting held on August 29, 2017. The MRB directed that the State remain on Monitoring, quarterly calls continue, that a second periodic meeting be held in approximately 18 months, and that the IMPEP review be held as scheduled in 2020.
This is the fourth quarterly call since the August 29, 2017 MRB. This summary is a reflection of that call.
DISCUSSION OF PROGRAM STATUS Technical Staffing and Training (2016 IMPEP: Satisfactory)
The Georgia Agreement State Program is made up of one Program Manager - 2 who oversees both the Radioactive Materials Section and the Environmental Radiation Team, one Program Manager - 1 who oversees the Radioactive Materials Section, one Team Leader who oversees the Environmental Radiation team, and 10 technical staff positions. There are 11.5 full time equivalents (FTE) dedicated to the Georgia Agreement State Program with 2.5 managerial FTE and 9 technical FTE. Since the 2016 IMPEP review, three people have left. One position was filled in October 2016 (Program Manager - 2) and the other two staff level positions were filled in November 2017. The positions were all filled within a year of the vacating staffers departure.
2 The Georgia Agreement State Program revised its training manual in June 2013 to incorporate changes that were made in the NRCs Inspection Manual Chapter 1248. This revised training manual is being used by newly hired staff and staff going through the qualification process.
Staff is attending the NRCs training courses when available. Six technical staff are going through the license reviewer and inspector qualification process. Fully qualified inspection and licensing staff are aware of the requirement to complete 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of refresher training every 2 years and are working to meet this requirement. Technical staff members track their own refresher training and management reviews it as part of the technical staffs annual performance review. The Georgia Agreement State Program uses staff developed monthly trainings, NRC courses, and conference attendance to meet the requirements.
Recommendation 1: The MRB recommends that the Georgia Agreement State Program management develop a strategy to address staff retention and implement corrective actions to mitigate the causes of the Georgia Agreement State Programs turnover to ensure satisfactory program performance is sustained.
Status: The Georgia Agreement State Program analyzed the reasons staff gave as to why they left the program. Although an explicit reason was not identified, as reasons for departure varied widely, salaries and lack of promotion potential were common contributing factors. The Air Protection Branch Chief met with the Human Resources Director and with the Director of the Georgia Environmental Protection Division to discuss issues involving staff retention not only for the radioactive materials program, but for the entire air branch since this issue is not unique to the radioactive materials staff. One corrective action was to create a path for upward mobility.
This was accomplished in April 2017 by creating a Program Manager - 1 position and a team leader position within the Radiation Protection Programs Section. In September 2018 Human Resources expanded the Environmental Specialist 4 (ES - 4) position to include Subject Matter Experts. Individuals who add high value to the organization, show team leadership ability, have exceptionally high technical proficiency and display excellent judgement and decision making skills can be recommended by management to the Division for this promotion.
Although the ES - 4 position is reserved for a select few high performing individuals, the expansion of this position to include Subject Matter Experts offers another opportunity for promotion to the staff. Now technical staff have promotion potential positions to work towards rather than looking for those opportunities elsewhere. The Branch Chief continues to meet with human resources representatives to discuss position reclassification for staff. The process is still ongoing and will take some time to accomplish. This is not a current priority for human resources since the Program is fully staffed. The reclassification will most likely happen the next time a vacancy occurs and the position is advertised.
As part of a separate effort, the Air Protection Branch Chief met with all staff individually to obtain thoughts and ideas on how the program could be improved. Some of the feedback obtained involved: having staff do only licensing or inspection (not both), creating more templates for licensing to ensure accuracy, and improving the training process to make it more efficient. After collecting all of the feedback, the Branch Chief decided that the most critical need was to ensure licensing accuracy. A charter was put in place for an initiative, which was led by a lean six sigma green belt, with the objective of consolidating, revising, and adding adequate technical detail to existing procedures and developing licensing templates for the major licensing types. The Directors presentation for this effort occurred on May 17, 2018, and the work that was completed and the suggested path forward were approved. The Georgia Agreement State Program held training on June 26, 2018, for the staff to go over all of the revisions to the procedures and the flowcharts that were created.
3 Status of Materials Inspection Program (2016 IMPEP: Satisfactory)
Inspection frequencies are the same as the NRCs inspection frequencies that are listed in Inspection Manual Chapter 2800. A discussion was held regarding the changes made to the NRCs Inspection Manual Chapter 2800 with regards to inspection frequency timeliness. The Georgia Agreement State Programs goal is to stay within the +/- 25 % window which is more restrictive that the NRCs revised policy of +/- 50% for Priority 1 licensees and +/- 1 year for Priority 2 and 3 licensees. The Georgia Agreement State Program policy however, will match the current requirements in Inspection Manual Chapter 2800. Since the last IMPEP review, the States in house information technology staff built a web-based database that is being used to track several items including inspections. Inspection reports are typically issued within 30 days of the close of the inspection.
Four Priority 1, 2, and 3 inspections have been completed overdue since the last IMPEP review.
All of the inspections completed overdue occurred as a result of incorrect Priority codes listed in the database. All four late inspections were mistakenly listed as a Priority 5 in the database.
However, one inspection should have been listed as a Priority 2 and three inspections should have been listed as a Priority 3. The errors were not discovered until inspectors started to prepare for each inspection at the Priority 5 interval. At the time of this call, no Priority 1, 2, or 3 inspections were overdue. Three initial inspections were completed overdue since the last IMPEP review. Two initial inspections were completed overdue because of database errors and one initial inspection was the 2nd initial inspection being performed for a new licensee. At the time of the first inspection, the licensee did not possess material and was not performing licensed operations. Per the NRCs Inspection Manual Chapter 2800, another inspection should have been completed within 12 months. The Program was not aware that the grace period did not apply to the second inspection. Therefore, this initial inspection was performed overdue by 51 days.
Recommendation 2: The MRB recommends that Georgia Agreement State Program management implement corrective actions and make necessary adjustments to ensure satisfactory program performance is sustained with regard to reciprocity inspections.
Status: The Georgia Agreement State Program is mindful of reciprocity inspections and is working to meet the goal of inspecting 20 percent of candidate licensees each calendar year.
Management implemented a policy that each staff person must perform at least one reciprocity inspection every year. This should ensure that the requirement of inspecting 20 percent of candidate licensees every calendar year is met. Management recognizes that for this to be accomplished, all staff need to be qualified to inspect those types of licensees that typically come in under reciprocity. The Georgia Agreement State Program is working on ensuring that all staff are qualified to perform these types of inspections. Until that occurs, staff that are qualified will be performing additional inspections to ensure the requirement is met. Qualified inspectors have the ability to pick the reciprocity inspection they wish to perform, however the management stated that if the 20% inspection criteria is not met half way through the year, reciprocity inspections will be assigned to ensure the 20% inspection criteria is met each calendar year.
The Program Manager - 1 has been given the responsibility to track reciprocity inspections to ensure that the goal of inspecting 20 percent of candidate licensees is met. For calendar year 2016, eight inspections out of 38 reciprocity candidates (21 percent) were performed. For calendar year 2017, 37 reciprocity candidate licensees have performed work in Georgia. Nine
4 of those licensees were inspected for a total of 24 percent. For calendar year 2018, six inspections on 29 candidate licensees (20.6 percent) have been performed.
Technical Quality of Inspections (2016 IMPEP: Satisfactory)
Inspection guidance used by the Georgia Agreement State Program is equivalent to the NRCs Inspection Manual Chapters and Inspection Procedures. Inspection findings are not issued in the field. Inspection findings are routinely sent to licensees within 30 days of the completion of an inspection. All supervisory accompaniments in calendar years 2016 and 2017 were completed. Management has completed five of seven supervisory accompaniments in calendar year 2018.
Recommendation 3: The review team recommends that the Georgia Agreement State Program develop and implement training for inspections on the examination of the written directives and NRC inspection procedure 87132, Brachytherapy Programs.
Status: After the 2016 IMPEP, the Georgia Agreement State Program expressed concern to the NRC that in-house expertise did not exist in a manner to allow for the development of training. The NRC suggested that, as a start, training located on the NRCs Agreement State Webpage (Update on Inspection Procedure 87132, Brachytherapy Programs) be used to address part of this recommendation. Additionally, the NRC developed a training that was offered to all Agreement States as a webinar on April 4, 2017, entitled Medical Webinar Training Series: Brachytherapy Medical Events/Reporting - Y-90 Microsphere and High Dose Rate Brachytherapy. Management and nine technical staff viewed this training and felt that it increased staff knowledge of written directives used in brachytherapy procedures. Management stated that staff has not raised any additional concerns to date in regards to these types of inspections. Additionally, the biggest hurdle being faced is that authorized licensees are either not performing this type of treatment or perform one or two over the entire inspection period. In most cases the inspection encompasses a records review only of the licensees program.
Technical Quality of Licensing Actions (2016 IMPEP: Satisfactory but needs improvement)
The Georgia Agreement State Program has approximately 409 specific licensees. All licensing actions have been in-house for less than one year and no backlog exists.
Recommendation 4: The review team recommends that the Georgia Agreement State Program verify that all previously approved radiation safety officers (RSO) for medical licenses have an attestation by a preceptor RSO, including that the individual has completed training in the radiation safety, regulatory issues, and emergency response procedures for the appropriate license type.
Status: All documentation for medical RSOs that are currently on a specific license has been reviewed. Over 200 RSOs needed additional documentation. As of the June 2018 call, all work on this recommendation has been completed. The Georgia Agreement State Program stated that the revised procedures direct staff to review this information when doing a licensing action, and are regularly being followed.
Recommendation 5: The review team recommends that the Georgia Agreement State Program management develop and implement training and guidance that provides the staff with the tools necessary to accurately complete the pre-licensing requirements for each new license.
5 Status: The Georgia Agreement State Program redesigned its pre-licensing guidance and the forms associated with the guidance and provided training to the staff before the MRB meeting in August 2016. When new license applications are received, the revised guidance is used and is periodically evaluated along with the actions completed to see if additional revisions are required. The actions that have been evaluated since putting the new guidance in place have not resulted in any revisions. The Risk Significant Radioactive Materials checklist was revised in June 2017 with Agreement States required to adopt equivalent guidance by January 2018. The changes to this checklist along with other changes to licensing procedures were incorporated in the lean six sigma initiative. Additionally, the NRC has revised its Pre-Licensing Guidance and issued the revisions to the Agreement States via a Radiation Control Program Director letter on August 9, 2018. This revised guidance will be required to be implemented by the Agreement States by February 9, 2019. Two webinars explaining the changes to the guidance were held.
These webinars will be uploaded to a secure portion of the NRCs Agreement State website for future viewing.
Technical Quality of Incident and Allegation Activities (2016 IMPEP: Satisfactory)
The Georgia Agreement States Program has processes in place to maintain effective responses to incidents and allegations. Nineteen events have been reported to the NRC since the last IMPEP review. For events requiring reporting to the NRCs Headquarters Operations Officer, additional follow-up information is updated in the NRCs Nuclear Materials Events Database system.
Six allegations have been received since the 2016 IMPEP review, three of which were referred to the State by the NRC. Each allegation is evaluated when it is received and onsite follow-up is performed, when appropriate. Closure letters to the concerned individuals are issued in a timely manner. Due to Georgias open records act, the Georgia Agreement State Program is unable to guarantee protection of an allegers identity.
Compatibility Requirements (2016 IMPEP: Satisfactory)
No legislative changes affecting the Program have occurred since the last IMPEP review. All required regulation changes have been incorporated from the one Regulation Amendment Tracking Sheet that at the time of adoption was overdue. These changes were presented to the Department of Natural Resources Board in December 2017. The rule changes were approved and became effective 20 days after they are filed with the Secretary of State. No other regulation changes are overdue and the program is up to date. There are a few outstanding comments associated with compatible regulations that are being addressed through the annual administrative clean-up. The rules will be presented to the Department of Natural Resources Board in October 2018 and are on track for final adoption in January 2019. The regulation review process takes approximately one year to complete. The rules are not subject to sunset requirements.
CONCLUSIONS:
The Georgia Agreement State Program has addressed the five recommendations made as a result of the 2016 IMPEP review and will continue to make improvements to ensure compliance with IMPEP requirements. No programmatic concerns are noted at this time.
Periodic Meeting: December 10, 2018