ML20007H339

Impep Review of Region III Matls Program 970421-25 Proposed Final Rept

ML20007H339
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Issue date:	04/25/1997
From:	NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS)
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INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW OF REGION 111 MATERIALS PROGRAM i

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APRIL 7,1-25,1997 1

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PROPOSED FINAL REPORT

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i Office of Nuclear Material Safety and Safeguards j

U.S. Nuclear Regulatory Commission I

9707140185 970708 E

CF SUdJ O&M-8APPRAIS CF

1.0 INTRODUCTION

This report presents the results cf the review of the Region ill (Rill) radioactive materials i

licensing and inspection program as well as the Rlll fuel cycle inspection, and Site Decommissioning Management Plan (SDMP). The revim was conducted by an interoffice I

team from the Offices of Nuclear Material Safety and Safeguards (NMSS) and State

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Programs (OSP), Regions I and 11, and an Agreement State team member from the State of Colorado, over the period of April 21-25,1997, in Lisle, Illinois. Mernbcrs of the review i

team are listed in Appendix A. The review approach was based on the common i

performance indicators of the Integrated Materials Performance Evaluation Program (IMPEP) as described in SECY-94-011, Management Directive (MD) 5.6, " Integrated Materials Performance Evaluation Program," and the various non-common indicators circulated to the 1

Region in advance of the review. Preliminary results of the review -- which covered the period of April 1995 to April 1997 -- were discussed with Rlli management through the Acting Deputy Regional Administrator on April 25,1997. The Region will have the opportunity to comment on this draft, and the comments will be factored into the final l

version of this report following a Management Review Board (MRB) meeting.

[ Paragraph on results of MRB meeting will be inci'.ded in the final report. The Region's response will a!:,o be included in the final report.}

i The Rlli materials, fuel cycle, and SDMP programs are administered by the Division of Nuclear Materials Safety (DNMS). Within DNMS, responsible branches include the Materials Licensing Branch, Materials Administrative Support Branch, Materials inspection Branch 1, Materials inspection Branch 2, Fuel Cycle Branch, and Decommissioning Branch.

The Rlli organization is shown in Appendix B.

t The Rill materials program included licensing, inspection, and enforcement for approximately 2200 materials licenses at the time of the review. This figure accounts for approximately 36 percent of all materiat licenses under Nuclear Regulatory Commission (NRC) jurisdiction.

Section 2.0 below discusses Rill's actions relative to the findings of the previous IMPEP review held in Spring 1995. The results of the current review for the common 1

performance indicators of the IMPEP are cresented in Section 3.0 below. Section 4.0 discusses the results of the review outside the common performance indicators, including the fuel cycle inspectiors, and SDMP programs. Finally, Section 5.0 summarizes the review team's findings and recommendations.

2.0 STATUS OF ITEMS IDENTIFIED IN THE 1995 IMPEP REVIEW Five recommendations were identified as part of the April 1995 IMPEP review. The status of these recommendations was formally addressed by Rlliin a memorandum dated September 21,1995. The 1997 review team assessed the status of these items to determine whether or not the Rlli program took actions to close the recommendations. A brief discussion and evaluation of each recommendation is summarized below 1

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Region ill Proposed Final Report Page 2 1

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Recommendation 1. Rlli should take appropriate v to ensure that initial inspections of new licenses take place according _ the requirements of Inspection l

Manual Chapter (IMC) 2800, "Msterials inspection Program."

Current Status: This recommendation is closed. Rill has revised its process for tracking the next inspection date for new licenses. New licenses are assigned a next inspection date of three months post issuance At three months, the administrative staff contacts the licensee to determme if it has possessed material j

or begun operations. Quarterly contacts continue until either material has been l

possessed or operations begun or until nine months (post license issuance) have j

elapsed. At that time, the next inspection date is established as 12 months post license issuance and an inspection is conducted.

Recommendation 2. NMSS should review Poli: / and Guidance Directive (P&GD) l-92-04, "lssuances of New Licenses for Materials Use Programs," to determine if additional guidance is necessan; if the region's practice relative to issuance of new licens" % acceptable.

Current Status: This recommendation is closed. NMSS completed its review of P&GD 92-04. Actions are underway ta delete the P&GD.

Recommendation 3. NMSS should review the region's trial program against the guidance of MD 8.8 and IMC 2800 and provide appropriate guidance to ensure l

uniformity for documentation of allegations throughout NRC.

Cuirent Status: This recommendation is closed. NMSS reviewed the region's trial j

program. Comments were provided to the region in a memorandum dated j

September 8,1995. NMSS indicated that if the Rill Trial Program was modified so as to ensure references to allegations are confined to allegation files and excluded I

from licensing files, then the Program would be consistent with agency policy.

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Recommendation 4. Rill should continue its efforts to improve inspection planning l

and ensure coverage of IMC 2600, " Fuel Cycle N.cility Operational Safety and Safeguards Inspection Program," inspe: tion procedures at fuel facilities and keep l

NMSS informed of its progress.

Current Status: Tis recommendation is closed immediately following the April l

1995 IMPEP revio. - and during the succeeding review period, Rlli developed and maintained a matrix displaying the types of fuel cycle inspections performed, and the frequer*cies with which they were conducted. In ad'1 tion, NMSS has now developed a Fuel Cycle Master inspection Plan (MIP) to coordinate all regional and i

l Headquarters fuel cycle inspections. This MIP will permit automated review of all fuel cycle inspections to establish that IMC 2600 inspection requirements are being met.

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Region 111 Proposed Final Report Page 3 Recommendation 5. NMSS/ Division of Fuel Cycle Safety and Safeguards (FCSS) should revise the appropriate inspection procedure and coordinate with Rlli as well as other 4 wions to ensure that fuel facility inspections cover licensee record retention.equired for decommissioning.

Current Stalus: This > commendation is closed. Following the April 1995 IMPEP review, NMSS revise IMC 2600 to provide specific guidance to inspectors I

reviewing licensee records, that records required for decommissioning are to be included in such inspections.

in summary, the team considers all of the above 1995 recommendations closed.

i 3.0 COlMION PERFORMANCE INDICATORS l

The IMPEP is based on five common performance indicators to be used in the review of

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both NRC Regional and Agreement State materials programs. These indicators include: 1)

Status of Materials inspection Program; 2) Technical Staffing and Training; 3) Technical Quality of Licensing Actions; 4) Technical Quality of Inspection; and 5) Response to j

Incidents and Allegations. In preparation for the review, NMSS issued a questionnaire to Rlli on February 20,1997. Rill responded to the questionnaire on March 21,1997. A copy of that respon?e will be included in the final version of this report.

The review tearn's approach consisted of: 1) examination of the regional response to the questionnaire; 2) review of selected quantitative information from the Licensireg Tracking I

System (LTS); 3) technical review of selected licensing, inspection, incident, and allegation files; and 4) interviews with staff and management to clarify issues raised by 1),2), and 3) above. With assistance from inspectors in RI and Ril, the team also accompanied three Rlli inspectors to observe their conduct of inspections at six facilities. The team evaluated the information that was gathered against the performance criteria contained in MD 5.6 and made a preliminary assessment of regional pe brmance.

3.1 Status of Materials inspection Proaram I

The team focused on four factors it. reviewing this indicator: (1) inspection frequency, (2) overdue inspections, (3) initial inspections of new licenses, and (4) timely dispatch of inspection findings to licensees. The review team examined the Rlli questionnaire 4

responses relative to this indicator, reviewed data gathered independently from the LTS, and examined docket files. In addition, the team interviewed the DNMS Acting Director, 1

DNMS Acting Deputy Director, and the two DNMS Branch Chiefs who have principal responsibility for the inspection program.

The team's review of Rill's inspection priorities found that the inspection frequencies for different types of Rill licenses are established in the LTS. The LTS inspection frequencies are managed by the Division of Industrial and Medical Nuclear Safety (IMNS), NMSS, and are based on the inspection frequencies in IMC 2800. Therefore, the Region is using l

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Region 111 Proposed Final Report Page 4 exactly the same standard frequencies as in IMC 2800. _ The team determined that the Region is aggressively implementing the IMC 2800 policies that direct individual licensee inspection frequencies to be extended or reduced, based on inspection findings and previous licensee performance. The Region implements this performance-based measure by indicating the next inspection date on the fieldnotes which are signed by their

.immediate supervisor and on their inspection planner. The administrative staff enters the next inspection date into the LTS system when they receive the inspection planner. If the supervisor changes the next inspection date after reviewing the fieldnotes, the Branch Chief forwards the revised date to the administrative staff via an LTS Data Entry Form.

Printouts of the " inspection due lists" from LTS showed numerous examples where Rlli had extended or reduced inspection frequencies, and appropriately coded the change in the LTS. The Region appeared to extend more inspections than it reduced, which is consistent

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with IMPEP teams' observations in other NRC regions. In general, the review team -

j determined that Rillis following the IMC 2800 inspection frequencies and is actively 1

extending or reducing individual licensee inspection intervals, based on licensee performance.

i in its response to the questionnaire, the Region indicated that (as of the date of the questionnaire) it had no inspections overdue by more than 25 percent of the assigned frequency in IMC 2800. The team noted that there were no overdue inspections at the time of the review. In FY 96, the region performed 732 inspections as compared to 705 inspections that they had budgeted to complete. As of February 1997, the region had performed 248 inspection as compared to the regional projection of 225 inspections. The team noted that in early FY 97 there was a small backlog of core and non-core inspections.

1 Regional management had identified the backlog and took immediate actions to reduce the

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backlog.

With respect to initial inspections, the review team examined a LTS listing of 17 new licenses issued by Rill between January 1996 and June 1996, and cross-checked the new licenses with dates of irstial inspections. Of the 17 new licenses issued,14 were inspected within the time frames for initial inspections specified in IMC 2800. Of the remaining three licensees, one was scheduled for inspection during the month of the IMPEP review, one was not required to be inspected because the new license was issued because the licensee had allowed its license to expire, and the third license was not inspected because the license was issued because of a change in the ownership of the organization.

In the second case, MC 2800 does not require an initial inspection if the licensee files for a new license within six months of license expiration. In the third case, MC 2800 does not contain any guidance. The review team recommends that NMSS examine the need for guidance for initial inspection of new licenses that are issued in the case of an ownership change, mailing office location change, or change in control. Overall, the Region is within the IMPEP evaluation criteria that inspections of new licenses are " generally conducted" within six months of issuance or in accordance with IMC 2800 provisions.

The timeliness of inspection findings was evaluated during the inspection file review. The majority of inspection findings were communicated to the licensee within 30 days after completion of the inspection. The team did note a trend regarding the number of reports exceeding tile 30 day goal in the decommissioning area, based on the data provided to the

Region ill Prop 3 sed Final Report Page 5 team in Rlli's " Monthly Information Status Reports (MISRe)." In FY 96, according to the MISRe " Report Timeliness By Branch" data for the end of the fiscal year,7 of 45 (approximately 15%) of the Decommissioning Branch inspection reports were issued after 30 days. In FY 97, according to a MISRe report dated March 10,1997,7 of 21 (approximately 33%) of the Decommissioning Branch inspection reports were issued after 30 days. During interviews with the DNMS Acting Director and Acting Deputy Director, it was learned that in early FY 97, DNMS management instituted a policy that allinspection findings were to be signed by the Director or Deputy Director of the Division. They recognized that this might delay the transmittal of inspection findings; however, they believed it war necessary to review the correspondence at this level. This policy change was made to ensure consistency within the Division and to ensure the reports were technically accurate. The DNMS Acting Director indicated that in the near future the plan was to return some signature authority to the Branch Chiefs. The team considered this information and determined that Rlli is meeting the IMPEP evaluation criteria that "a large majority" of inspection findings are communicated to licensees in a timely manner.

In its response to the draft IMPEP report, Rill stated that they believed the material provided to the reviewer [concerning the timeliness of decommissioning inspection report issuance] concerned reports from the Fuel Cycle Branch. The Region stated in the response, "For the Decommissioning Branch, only 5 of 26 reports were issued in excess of 30 days for FY 97 (less than 20%), and of that, only one of 14 was issued in excess of 30 days since January 1,1997." The Region concluded, "This would not support any trend regarding the number of late reports increasing in the Decommissioning Branch." The -

i review team based the findings on Rill's own MISRe report data regarding Decommissioning Branch inspection reports, which indicated that 7 of 21 reports were j

issued in excess of 30 days for FY 97. Although the Region responded with different numbers than shown in the Rill MISRe reports, the review team found that the Region's own documents (MISRe) support the team's statement about a trend regarding the number of reports eueeding the 30 day goal. While the review team also looked at Fuel Cycle Branch report timeliness, issues regarding fuel cycle inspection report timeliness were resolved by the team.

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In its response to the questionnaire, Rlli provided statistics regarding the number of initial reciprocity requests and the number of reciprocity inspections completed during the review period. The region received 33 initial reciprocity requests during the review period (many licensees had filed more than one initial request during the review period). Of these, six j

l licensees were industrial radiography; two were teletherapy and panoramic irradiator source installers, source changers, or source removals; and eight were for other services.

The region conducted 15 reciprocity inspections during the review period. The team l

determined that the region has a program in place to process reciprocity requests and to

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identify those licensees that should be inspected and appears to meet the inspection goals l

detailed in IMC 1220, " Processing of NRC Form 241, ' Report of Proposed Activities in Non-Agreement States,' and inspection of Agreement State Licensees Operating Under 10 CFR Part 150.20."

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Region 111 Proposed Final Report Page 6 Based on the evaluation criteria contained in MD 5.6, the team recommends that the Region's performance with respect to this indicator, Status of Materials inspection Program, be found satisfactory.

3.2 Technical Staffino and Trainina issues central to the evaluation of this indicator include the DNMS materials program staffing level, technical qualifications of the staff, training, and staff turnover. To evaluate these issues, the review team examined the Rill questionnaii response relative to this indicator and met with the DNMS Branch Chiefs to discuss staffing and training issues, including the qualification status of license reviewers and inspectors.

Technical and licensing support staff in the Rill materials program are organized into the five branches within DNMS: Materials Licensing Branch, Materials Inspection Branch 1, Materials inspection Branch 2, Fuel Cycle Branch, and Decommissioning Branch.

At the present time, there are 15 materials inspectors (one inspector is currently on a detail outside DNMS) and 11 license reviewers (three individuals are part-time and one is on detail to NMSS). There are also nine technical staff in the fuel cycle area and eight in the decommissioning area. Recently, it was noted that regional manag3 ment has transferred individuals within the region to address workload variations. The review team concluded that the Region haJ a gaod mix in staffing for licensing and inspection activities. In l

addition, it appears that adequate administrative support is available. Additional discussion l

of resource utilization appears in Section 4.1 of this report.

in its response to the IMPEP questionnaire, the Region reported that ten individuals had left DNMS during the ieview period. Three left for other careers, two retired and five l

transferred out of the Division. Six individuals were hired during the review period. Of the six, one left the NRC and two transferred to another Division. The team noted some positions within the Division had been lost riuring the budget process. It was also noted that some vacant positions had been filled by rotational assignments.

With respect to quarcations, NMSS and the regions undertook a major ef fort during the review period to establish formal training standards for most materials-staff positions, culminating in the issuance of IMC 1246, " Formal Qualification Programs in the Nuclear Material Safety and Safeguards Program Area," on June 7,1996. This resulted in the training requirements for many of the regional materials inspectors and license reviewers changing in the middle of this review period. Individuals already qualified in a discipline l

were given three years to complete any new formal classroom training requirements.

Personnel in the process of qualifying when IMC 1246 was issued were allo' to continue to qualify under the original requirements, with three years from tne revision date to complete any new requirements. Regional Administrators may waive or extend any IMC 1246 requirements, and materials staff with prior experience and education may, on rare occasions, request to complete equivalency examinations in lieu of course attendance.

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k Region 111 Proposed Final Report Page 7 The Region reported in its response to the questionnaire that five individuals in the non-fuel i

cycle area have not been qualified to IMC 1246. (Qualification of fuel cycle inspectors is discussed in detail in Section 4.2.) The region expects that three will be qualified in the next few months. One individual will be qualified within the year and the other individual is currently on rotation to NMSS and will pursue qualification when she returns to Rill. The region indicated that in Fall 1996, DNMS management made a decision that alllicense reviewers and inspectors would be required to take the Health Physics Technology Course a

(H-201). Prior to this, regional management had waived the requirement to complete this course. The region's plan is to have alllicense reviewers and inspectors complete this course by October 1999.

The review team determined that Rlli has a well-organized system for planning, approving, and tracking training. The team noted that the region has established a Training Council.

This Council functions to ensure consistent and effective implementation of the Rlil training program and to assign priority to training needs. The Acting Division Director is a member of the Council.

J In addition, the team noted that DNMS managers were fully cognizant of the qualification status and training plans for their staff, and management displayed a commitment to training. Technical staff regulariv attended specialty training courses and refresher training, and appeared to maintain technical currency for their assigned positions. ~ All technical staff appeared to the resiew team to have the basic technical skills to perform their jobs.

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Based on the evaluation criteria contained in MD 5.6, the review team recommends that the Region's performance with respect to this indicator, Technical Staffing and Training, be found satisfactory.

3.3 Technical Quality of Licensino Actions The review team examined license files and related documentation and interviewed the responsible license reviewers for 21 specific licenses that had 29 licensing actions completed during the review period. The 29 licensing actions examined by the team included 4 new licenses,7 renewals,12 amendments, and 6 terminations. Nine of the license files reviewed involved complex license types, including the following:

e 1 Academic broad scope a

1 - R/D Broad Scope -

4 Medical, one required quality management plan 1 HDR Brachytherapy, quality management plan required e

2 Industrial radiography, temporary job sites Completed casework from several license reviewers as well as several types of licensed facilities were included in the team's evaluation. A list of the licensing actions reviewed is contained in Appendix D. In addition, the team interviewed license reviewers and i

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Region 111 Proposed Final Report Page 8 supervisors, as necessary, to supply information regarding the team's questions on licensing decisions or docket file contents.

The licensing actions were reviewed for completeness, consistency, proper isotopes and quantities, qualifications'of authorized users, adequate facilities, operating and emergency procedures, and authorized user training sufficient tn ectabbh +.he basis for the licensing action. Casework was reviewed for timelinese, adherence to good health physics j

practices, reference to appropriate regulations, documentation of the basis for the licensing l

decision, and consideration of enforcement history on renewals. The files were checked for orderliness and retention of necessary documents and supporting data.

j The licensing actions were thorough, complete, consistent, and of acceptable quality with health and safety issues properly addressed. Tie-down and specific conditions were clearly stated, backed by information contained in the file and were considered to be inspectable.

In instances where compliance actions had not been completed, or where license reviewers had questions about the status of inspections, the reviewers routinely discussed the issues with the inspection staff to assure that licensing actions were in agreement with the compliance actions. The team noted that license reviewers provided information to the

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inspectors for follow-up during the next inspection. New licenses contained the appropriate license conditions.

The supervisory review of licenses is accomplished monthly by a team of three staff, including a senior licensing person and two other licensing staff, based on availability. Six to eight licenses are selected at random from licenses which are completed and ready to mail. The review consists of eitner individuals reviewing licenses and then meeting as a group for discussion, or a review bv the team of each license as a group. If minor errors are found which need to be corrected, the license is given back to the staff person for correction. If a major issue was observed by the review team, the team would review the issue with the Branch Chief. No major issues of a systematic or programmatic nature were apparent in the discussion of supervisory review with a senior licensing person.

The review team found that any deficiencies in the licensing actions reviewed were minor, isolated or administrative in nature, and most deficiencies were corrected during the on-site review. The Region's system for licensing remains forraal, structured, clear, and appears to work well, as noted in the 1995 IMPEP review. No potentially significant health and safety issues were identified in the team's review of Rill's licensing practices.

The review team examined Rlli licensing actions regarding terminated sites to determine if sufficient radiological surveys were performed before license termination and relean, to ensure that residual radioactivity levels comply with release criteria, and to ensure that licensee survey results were validated through use of a closeout inspection or confirmatory survey, as required. All of the files that the team reviewed were for facilities that did not require final status surveys or decommissioning plans. Most of Rlll's terminated licenses were facilities that possessed radioactive materials in the form of sealed sources, or gauges, with documented leak tests, ar J the sourcer were shipped back to the manufacturer for disposal. Based on a samplint terminated license files, the review 4

team determined that the license reviews for these terminations were conducted properly

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Region 111 Proposed Final Report Page 9 by the Region. In addition, the regional staff, on their own initiative, prepared a document entitled, "Information that Should be Submitted to the NRC Staff for Decommissioning and Termination of Licensed Facilities." This document, for distribution to the licensee community, lists the sections of 10 CFR Parts 30,40, and 70 applicable to decommissioning sites. The regional document also provides information regarding surveys during and after license termination. The review team identifies this document for terminating licensees as a good practice and recommends that its use be considered by other regions and Agreement States.

The Rlli decommissioning financial assurance instrument program was evaluated for 4

routine, non-SDMP decommissioning projects and active licensees to determine if financial assurance instrument security programs are in place and to ensure that complete instrument files are being maintained. The evaluation was performed in accordance with l

MD 8.12, " Decommissioning Financial Assurance Instrument Security Program."

The staff provicted the review team complete, detailed, well-organized inventories that listed individual financial assurance instruments. Access to the safe in Rill was controlled.

i Two Branch Chief and two staff members have keys. A Financial Assurance Instrument Custodian (FAIC), an alternate (AFAIC) and two Branch Chiefs (FAIC Managers) have the keys. NRC Security Forms 702 (Security Checklist) have been observed to be used, and a log for removal or input of financial assurance instruments has been developed. During the review, the review team identified no performance-based issues regarding the financial assurance files.

MD 8.12, Section E, requires that the financial assurance instruments be maintained in a

" fire rated safe."

Based on the evaluation criteria in MD 5.6, the review team recommends that the Region's performance with respect to this indicator, Technical Quality of Licensing Actions, be found satisfactory, i

3.4 Techrical Quanty of Inspections The team reviewed the inspection field notes and other follow-up documentation and i

interviewed the responsible inspectors, when available, for 30 files documenting 36 materials inspections conducted during the review period. These inspections were performed by 21 Rlli inspectors. The reviewed cases covered 17 license types including limited and broad licenses of medical, academic, and industrial programs. In the file review, the team observed that Rlll inspectors used the appropriate and most recent version of the inspection field notes and the Quality Management field notes to document inspections, as well as reports where appropriate. Appendix E provides a list of the inspection cases reviewed in full.

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A senior health physicist from Region 11 and a team member from Region I accompanied three Rlliinspectors on a tdtal of 6 inspections of 7 licenses. Inspector accompaniments I

were performed of three limited medical institutions, an academic facility with a limited research license and a PuBe license, an academic Type B broad scopa facility, and an

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Region lli Proposed Final Report Page 10 l

l assist inspection of a RIV manufacturer and distributor of gauges with a location in Rlli.

On the accompaniments, the Rill staff' demonstrate.d appropriate inspection techniques and knowledge of NRC regulations and policies. The inspectors were well-prepared and thorough in their reviews of the licensees' radiation safety programs. Inspectors observed licensee activities, toured facilities, and reviewed licensee records. Overall, the performance of the inspectors was satisfactory, and their inspections were adequate to assess radiological health and safety at the licensed facilities.

The docket files appeared to be complete and in order. In almost all cases inspection results were well organized and easily retrievable. The team determined that Rill is performing inspections of materials licensees on an unannounced basis, except for initial inspections or when necessary to insure the presence of licensee personnel (i.e., special inspections or geographically distant licensees or inspections). Inspectors issued NRC Form-591 appropriately in the field. Documentation was complete and consistent with NRC guidance. Documents reviewed were of sufficient detail to substantiate the findings of the inspection, and were completed in a timely manner. Generally, inspection results were reviewed and approved by the supervisors within a few days after c?mpletion of documentation. However, a large number of inspections were given additional time prior to completion for the purpose of review of information in the office. In some cases, the end date of the inspection was several weeks later than the initial date of the site inspection. A self-assessment performed by Rill inspectors, as part of a new program discussed later in this report, also determined that some inspections were unnecessarily extended for in-office review. This resulted in clarification of circumstances for which extension is appropriate. Division managers are aware of this and monitoring work to ensure that fewer inspections will be extended unnecessarily for in-office review in the coming year.

The review team also interviewed 10 materials inspectors and the two materials inspection branch chiefs regarding the inspection process. Inspections were performed on an unannounced basis, except in the case of initialinspections. Inspections were scheduled using a list of licensees' inspection due dates, which is issued monthly. Inspectors selected for inspection those licensees having the closest due dates so that no overdue inspections resulted, and then filled trips efficiently with other inspections due in the near future. Branch chiefs approved trips prior to inspection preparation. Inspectors also briefed supervisors as needed, bringing unusual issues, such as an apparent violation of security requirements, to their attention.

The review team determined the accompaniments by supervisors were performed as required. The review team also examined the communication between Rllilicer. sing and inspection staff and found that appropriate information was discussed between inspectnrs and license reviewers before and after inspections.

During the IMPEP review, a team member attended an Enforcement Panel of two materials cases and selected five inspection-related Regional Procedures for review nspectors were prepared to discuss the enforcement-related issues. The five Regional cedures, each new or revised during the past two years according to the Rlli response to the IMPEP questionnaire, were consistent with other NRC guidance.

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Region ill Proposed Final Report Page 11 The team also reviewed information regarding the " quarterly inspection self-assessment" program which began in 1996. Each quarter, a senior inspector and a GG-13 inspector from each inspection Branch spend a day reviewing one area of inspection. Topics to date i

have included documentation using the field notes, completion of IFS data, and inspection of misadministrations and events. The inspectors selected appropriate documents for review and presented their findings in writing to the inspection branch chiefs. Findings have resulted in development of additional written guidance in the form of memoranda to the staff, as welk as additional in-house training. The review team finds the " quarterly inspection self-assessment" to be a " Good Practice." In its response to the draft IMPEP report, the Region noted that other Rlli materials branches also perform self-assessments.

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However, the review team observed that the quarterly inspection self-assessment, in particular, was a new initiative and selected it as a good practice to highlight to other regions and Agreement States.

The review team supplemented its case review with a review of survey meter calibration, availability, and use. Adequate and appropriate instrumentation was available for, and was uscd by, inspectors to perform surveys during inspections. Confirmatory and independent measurements were r,orted in the inspection documents, with a description of the i

instrumentatiori ue 4 The team reviewed the database used to track the inventory and assignment of r r instruments. This database is also used to track calibration information, ano. used to ensure that meters are calibrated in a timely manner. The team found survey rneter calibration, availability, and use to be adequate.

The review team also supplemented its case review with a revew of the Rill laboratory

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used for analysis of samoles by Rill and RIV. The principal counting equipment in use included an intrinsic germanium detector with a multi-channel analyzer for gamma spectroscopy, a gas-flow proportional counter for alpha and beta analyses, and a Packard 2500 liquid scintillation counter primarily for analyses of *-itium and low-energy beta emitters. At the time of the IMPEP review, the liquid scintillation counter was not operational. Although both the gamma counter and the gas-flow proportional counter are operating and in calibration, there are deficiencies in the procedures and practices to demonstrate good quality assurance (QA) and quality control (OC) programs for the laboratory instrumentation. Laboratory personnel stated that they are in the process of upgrading the laboratory QA/QC programs to ensure that results of sample analyses are i

defensible.

Laboratory personnel : ated that, prior to 1995, the emphasis was on use of the mobile laboratory in the Confirmatory Measurements Program, and little use was made of the Rlli j

" fixed" laboratory. With the change to use of the Rlli laboratory primarily for analyses of samples from decommissioning sites, and to provide analyses for the RIV office, they are j

working to improve in-house laboratory procedures. Standard counting geometries have been established for the gamma counter, the instrumentation in use has been calibrated, and data is being collected to establish control charts for instrumentation operation.

However, additional improvements in the QA/QC programs are needed prior to re-

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establishing participation in a sample analysis cross-check program.

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Region lli Proposed Final Report Page 12 A self-assessment of the laboratory perfen d during the period of February 14-23,1996, was documented in an undated " audit re,_ct" provided to the review team. Overall, the self-assessment determined that data from t.+ Uboratory was reliable, but that improvements wen

• ded in the QA/QC pros ns, particularly in the area of documentation of pro %dures. A plan for improvement of the laboratory was described in a memorandum dated December 5,1996 from the DNMS Division Director to the Rlli Acting Deputy Regional Administrator. This memorandum, known in Rill as the "get-well plan" fm the laboratory, addresses 27 findings in 7 areas, i d provides proposed corrective actions for each finding. Sixteen findings related to the need to revise or develop procedures for i

laboratory activities, including QA/QC procedures. Two findings directly related to the QA/QC programs. A third document entitled " Lab Accomplishments" was undated, but stated to be the status summary as of February 1997 of the progress on the corrective actions in the "get-well plan." The docugept appears to be the quarterly report of

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laboratory activities that is required by regional procedures, but it does describe

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improvements made recently in the laboratory. Based on a comparison of this report to the

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"get-well plan," it appears that progress was made in completing actions in accordance i

with the schedule in the " pet-well g.lan."

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Although Rill was aware of the problems in the laboratory and was working on corrective action, the review team believes that the validation of the data from the laboratory is important to the support of the inspection program for both materials and decommissioning programs. The team recommends that (1) NMSS and Rllt management closaly monitor implementation of the laboratory QA/QC program and progress on the "get-well plan" and (2) Rill, in coordination with NMSS and its contractor (RESL), ensure that indepena n audits of the laboratory are conducted to ensure that an adequate QA/QC program is implemented and maintained.

Based on the evaluation criteria in MD 5.6, the review team recommends that the Region'e performance with respect to this indicator, Technical Quality of Inspections, be found satisfactory.

3.5 Response to incidents and Alleaations The review team examined the Rlli questionnaire response relative to this indicator and reviewed 10 incident report files and 17 allegation files. In addition, the team interviewed the Regional Office Allegations Coordinator and his technical staff, the Regional State Agreements Officer, a Materials inspection Branch Chief, and seveial materials inspectors.

Within Rlli, the responsibility for follow-up actions of material events is located in DNMS.

Rlli follows the guidance provided in IMC 2800, " Materials inspection Program," and Inspection Procedure 87103, " Inspection of incidents at Nuclear Material Facilities."

The team examined the regional response to 10 selected events that the Region identified as significant events in response to the questionnaire. The 10 incidents included: 1 medical misadministration (brachytherapy), 2 potential overexposures, 2 damaged equipment / sources (due to heat and explosion / fire),1 unintentional exposure, 3

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Region til Proposed Final Reporr Page 13 i

contamination (loss of control) incidents, and 1 incident involving stolen material. A list of l

the incident reports examined is contained in Appendix F.

i The examination of incident investigations found that the Regional response tc snts was timely, appropriately coordinated, well documented, and of acceptable quality with j

health and safety issues properly addressed. The medical misadministration incluc'ed appropt.e follow-up and a consultant was on board within 5 days. Any questionable items were resolved during discussions with the staff. Licensee corrective actions were identified as adequate to the licensee and appropriate follow-up measures were taken.

l Discussions with management indicated that NMED had recently been made av@hle to the Region and that they were currently incorporating it into their incident management program.

The Regional Allegations Coordinator has the responsibility for tracking all allegations, and coordinating the Allegeden Review Board. Agency guidance for processing allegations is contained in Allegation Guidance Memoranda (AGM) 96-01, " Additional Measures to Protect the Identity of Allegers and Confidential Sources," dated November 12,1996; 1

AGM 96-02, " Assuring the Technical Adequacy of the Basis for Closing an Allegation,"

dated November 12,1996; MD 8.8, " Management of Allegations," and IMC 2800.

Regional guidance for processing allegations is contained in Regional Procedure 0517A,

" Management of Allegations," dated September 16,1996 and a " Branch Trial Program for Documenting Allegations," memorandum dated June 8,1993.

e Discussions with the Regional Allegations Coordinator and his staff indicate they utilize MD 8.8, both AGMs, IMC 2800, Regional Procedure 0517A, and the Branch Trial Program memorandum as guidance. Discussion with DNMS management indicated that the Branch Trial Program memorandum is no longer in effect. The Branch Trial Program was recommended for revision in a NMSS memorandum issued September 8,1995 in response to a 1995 IMPEP team recornmendation. Although Rlli practice in the handling of allegations is in compliance with MD 8.8 and IMC 2800, the current status of the Branch Trial Program, and the NMSS suggested revisions to it, was not clear. The team recommends that Rill examine all procedures or documents relating to the handling of allegations to ensure that they are consistent with MD 8.8 and IMC 2800. Guidance on electronic transmittal of allegation related material should be included in the procedures. In addition, the procedures or documents should explicitly state that information referring to an allegation should not to be included in the docket file.

During the review period,151 material allegations were opened in Rill. Of those,130 cases were closed and 21 remain open. Seventeen allegation files were selected for review involving a variety of technical and administrative issues from a list provided by the NMSS Allegations Officer. The allegations involving materials were reviewed for responsiveness, coordination, control, technical effort commensurate with the potential health and safety significance oi the allegations, corrective actions, notifications to appropriate internal and external organizations, follow-up and documentation. There were ont;< two instances of' improper handling of allegation related material noted. The first instance was found in an allegation file and involved the electronic transmittal (e-mail) of an alleger's identity from a RI inspector to Rlli management. Although the e-mail

Region lli Proposed Final Report Page 14 documentation was correctly placed in the allegation file, MD 8.8 states that the identity of an alleger or confidential source should be deleted from e-mail transmittals. Discussion with the Allegations Coordinator indicated that regional policy is to delete the e-mail on the receiving and sending end when it contains allegation related material. The other instance was found in a docket file which included a cover memo to field notes that stated the inspection was performed as a follow-up to an allegation concerning improper radiography.

The Allegations Coordinator was informed and the docket file was delivered to his office.

The team found that allegations were responded to promptly, actions taken we'e appropriate, and internal and (when necessary) external coordination was taken with the appropriate parties on a timely basis. With the two exceptions noted above, proper procedure for control of information and maintenance of records was followed and information was available in the allegation files, docket files, and electronic records maintained by the Regional Allegations Coordinator.

Based on the evaluation criteria in MD 5.6, the review team recommends that the Region's performance with respect to this indicator, Response to incidents and Allegations, be found satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS j

in addition to the common performance indicators addressed in the preceding Section 3.0, the review team also examined Rlll's performance relative to various NMSS programs or initiatives. For Rill, the team examined the Region's performance relative to operating plan goals, its use of NMSS program resources, the fuel cycle inspection program, SDMP program, and uranium recovery inspections. These areas are discussed in the following sections:

4.1 Performance aoainst Operatino Plan Goals Materials Licensina, in FY 96, Rill completed 1892 materials licensing actions, compared with a goal of 1475. (Note, many of these cases were a result of the one-time extension in license duration.) As of the end of February 1997, the region had completed 520 actions, as compared to a budget of 590 actions. The review team determined that the number of non-core (renewals) licensing cases exceeding ninety days has decreased significantly since FY 96. At the end of FY 96,73 cases exceeded the ninety day mark.

At the end of March 1997, only 31 cases exceeded the ninety day mark. The number of core (new and amendments) cases has also decreased from FY 96. At the end of FY 96, 68 cases exceeded the mark as compared to the current backlog of 40 cases.

In FY 96, performance goals no longer measured completions against a prescribed target.

Rather, the emphasis was shifted to control of pending casework and reduction of backlog.

The review team discussed the licensing backlog, and Rill's plans to eliminate the backlog, with DNMS management. DNMS has been working to reduce the backlog, with steady success. Backlog reduction remains a very high priority for R!li and NMSS managers.

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- Region ill Proposed Final Report Page 15

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DNMS has committed to the Rill Regional Administrator that all renewals exceeding the j

ninety day mark would be completed by the end of calendar year 1997. In an effort to 1

accomplish this task DNMS management has taken the following actions: (1) reassigned individuals on a temporary basis from the inspection Branch to the Licensing Branch; (2)

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requested monthly briefings on the status of outstanding actions; and (3) limited licensing staff to licensing issues, e.g. used inspection staff for special projects such as support to NMSS. Rlli and IMNS mangement will continue to monitor progress on reducing the licensing backlog.

Materials inspections. See Section 3.1. Regional performance on materials inspections is compared in Section 3.1 to timeliness goals, rather than total numbers of inspections

. performed. The P?ll FY 97 Operating Plan also provides DNMS' nuclear materialinspection assignments ar.: candards in terms of inspection timeliness and quality, rather than gross numt ers of ins; :.ctions completed.

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Resource Utilization. In FY 96, Rill expended 39.8 full time equivalents (FTEs) vs. 41.8 FTEs budgeted for NMSS program activities (95 percent). Based on expenditure data through December 31,1996, Rlll had expended 9.8 FTEs as compared to a prorated j

budget of 11.1 FTEs for the first quarter of FY 97 (annual budget 39.7 FTEs). FY 96 regional expenditures foi event evaluation (151 %) and FY 97 expenditures, to date, for event evaluation (140%) and decommissioning (158%) dominate resource utilization of budgeted resources.

On balance, the review team found the Region's resource utilization to be responsive to program needs, and in accordance with program office goals. Attachment 2 presents this data in more detail in tabular form.

The Region's FY 97 Operating Plan specifies that, " Emphasis should be placed on eliminating the number of backlogged licensing actions, and overdue inspections, particularly those in the core program, and issuing inspection reports in a timely manner.

The Region will also apply resources to conduct reactive inspections, and to respond to incidents and allegations in a timely manner. Priority will be given to reactive inspections, core licensing, core inspections, decommissioning activities associated with Site Decommissioning Management Plan sites, non-core licensing, non-core inspections and non-routine decommissioning activities not addressed in the SDMP, in that order. Also, the Region will apply resources to program initiatives to enhance and improve program activities as appropriate." Based on the review team's interviews with regional managers, examination of PMDA's budget data, and consideration of the Region's performance across all materials areas, the review team concluded that Rill is closely adhering to the priorities given in the Operating Plan in accomplishing DNMS' mission.

Based on the review team's analysis of the resource expenditures and the Region's productive use of its resources, t.he review team recommends that the Region's performance visith respect to tNs non-common indicator, Performance Against Operating Plan Goals, be founo saGractory.

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l Region 111 Proposed Final Report Page 16 4.2 Fuel Cycle Inspection Proaram t-4.2.1 Introduction The Rlli IMPEP review was conducted while pilot-testing a new draft non-commt.,.

performance indicator (and accompanying evaluation criteria) for regional fuel cycle inspection programs. This indicator is composed of four sub-indicators covering (1) Status 1

of Fuel Cycle Inspection Program,-(2) Technical Staffing and Training, (3) Technical Quality of inspections, and (4) Response to incidents and Allegations. These sub-indicators parallel the corresponding common performance indicators for the materials program, with the exception of the' licensing function which is performed exclusively by FCSS in NMSS.

The fuel cycle inspection program at Rill, and NRC-wide, i e ureirgone significant modifications during the review period. Two new FCSS inspecuon programs for nuclear criticality safety (NCS) and chemical safety were initiated, v/

Se regions retaining responsibility for operational aspects of NCS inspections.

A MIP now encompasses all fuel cycle facilities regulated by the NRC. This plan

- coordinates fuel cycle inspections conducted by all regions and FCSS. As part of this new, integrated approach, inspectors are now conducting inspections across regional boundaries in a process called " Cross-Fertilization." This program broadens the experience base of the inspec. tors, and helps promote cross-regional consistency. It also provides a larger cadre of inspectars who are knowledgeable of all the fuel cycle facilities, which may be important in incident response, and in ensuring the availability of certified inspectors.

A new Fuel Cycle Licensee Performance Review (i PR) Program also has been initiated by FCSS. This LPR Program is designed to render a " big picture" view of licensee performance for senior NRC management, and provide a basis for adjusting the fuel cycle facility inspection program, including such areas as inspection focus, frequency, and resources. It also informs licensees on how NRC management perceives their performance in protecting public health and safety. Each region has the lead responsibility for conducting LPRs for its own facilities. The details of the program are described in a new 1

IMC 2604, " Licensee Performance Review," which was issued on August 26,1996.

During the review period, FCSS also developed, and is in the process of refining, a new Fuel Cycle inspection Management System (FCIMS), which will provide automated tools to improve the management of the fuel cycle inspection program, both in the Regions and FCSS. FCIMS is used to schedule inspections, iden;ify specific inspectors for each inspection, and specify what functional areas the inspections should cover. IMC 2600,

" Fuel Cycle Facility Operational Safety and Safeguards inspection Program," and several inspection procedures were revised, and new inspection procedures were developed during the_ review period. The draft non-common performance indicator for the regional fuel cycle inspection programs also recognizes these new developments.

The Rlll fuel cycle inspection program includes the ABB Combustion Engineering (CE) fuel fabrication facility in Hematite, Missouri, the Allied Signal uranium conversion facility in

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Region 111 Proposed Final Report Page 17 3

l Metropolis, Illinois, and two gaseous diffusion plants (GDP) in Paducah, Kentucky and i

Portsmouth, Ohio.

The GDPs were recently placed under NRC's regulator / oversight after a 120-day transition I

period, following wtification. (The GDPs, which are oeing operated by the United States j

Enrichment Corporation (USEC), were certified rather than licensed, as established under the Energy Reorganization Act of 1992, and each have compliance plans for coming into 3

full compliance with NRC regulations.) During this transition period, and for an extended period before certification, beginning early in the review period, Rill and Headquarters conducted extensive observation visits. Two NRC Resident inspectors are assigned to each GDP.

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i 4.2.2 Status of Fuel Cycle Inspection Proaram During the review period, Rlli conducted 48 inspections or observation visits at licensed j

fuel cycle faciSties and the GDPs. (Reports on the GDP visits were identified as i

" observation reports" prior to March 3,1997, since the GDPs were not under NRC l

regulatory oversight.) No reports were available of NRC inspections that occurred after March 3,1997, when NRC assumed regulatory oversight. Rill maintains a timeliness goal of issuing inspection reports no later than 30 days following the conclusion of each inspection, consistent with IMC 0610, " Inspection Reports." During the review period, i

fuel cycle facility inspection reports were issued an average of 21.8 days after conclusion of each inspection. FCSS did not expect that the timeliness goals normally established for inspection reports would be imposed on the observation reports.

As the result of a finding during the 1995 IMPEP review for Rlli, the Fuel Cycle Branch, DNMS, established the practice of keeping a log in the form of a matrix to track.the j

completion of fuel cycle inspections by type. The reviewer examined the matrix and i

determined that it was current and that it permitted an independent reviewer to establish quickly and clearly that the body of inspections performed during the review period conformed to the requirements of IMC 2600. In the future, it is expected that there will be an automated way of checking conformance of both completed and planned inspections with IMC 2600 requirements, based on the FCIMS now being used for integrated management of the fuel cycle inspection programs in all regions and at Headquarters.

4.2.3 Technical Staffina and Trainina During the review period, the Rlli fuel cycle program added four new staff members and lost two resident inspectors to other positions within NRC. One existing fuel cycle inspector, and one of the newly hired staff, became resident inspectors for the GDPs, to replace the two residents who left. The turnover of two resident inspectors who took j

other NRC positions are considered normal attrition. The remaining three new hires were being trained as fuel cycle inspectors. However, one of them was recently reassigned to i

NRR, and is no longer in the Fuel Cycle Branch. Of the' remaining two r.3w fuel cycle inspectors, one is expected to be certified as a fuel cycle inspector within a month, and

l Region 111 Proposed Final Report Page 18 l

i another within six months. They both have appropriately maintained qualification journals.

The reviewer determined that they are making normal progress towards certification.

In addition to the prescribed training for fuel cycle inspectors in i i 1246, Rlli fuel cycle inspectors who inspect GDPs, including the residents, are also pre d training in the

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safety of overhead crane operations and in other safety areas significant to GDP

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operations. After the recent hiring there are currently two resident inspectors at each GDP, however, only one resident inspector at each facility is a certified resident inspector.

1 Recently, it was announced that the Branch Chief of the Fuel Cycle Branch, DNMS, will be transferred to a position in the Rlli reactor safety program. The limited availability of experienced technical staff who are certified inspectors, and of management who are knowledgeable of fuel cycle facilities, is of concern to FCSS. The review team recommends that Rill management focus attention on staffing stability and qualification in the fuel cycle and GDP area. Subsequent to the IMPEP review, Rlliinformed NMSS that both GDPs are now fully staffed with two certified, experienced resident inspectors and 3

two_very experienced and technically sound inspectors soon approaching full " resident" certification. Also, Rlli stated that another regional inspector has become fully certified, and an additional inspector is expected to be fully certified within the next calendar quarter. Furthermore, it was stated that the newly assigned Branch Chief for the Fuel Cycle Branch already has attained a good working knowledge of the fuel cycle facilities, i

and has contributed to the program.

r 4.2.4 Technical Quality of insoections l

During the review period, the Fuel Cycle Branch Chief, DNMS,' accompanied hel cycle

[

inspectors on 22 separate inspections. Each fuel cycle inspector was accompanied at least l

once during each calendar year during the time they were assigned to the Fuel Cycle Branch.

Much of the inspection effort at the GDPs is provided by the four resident inspectors.

There appears to be a strong program for integrating the residents' inspection efforts with those of the project inspectors, both from the Region and Headquarters. The region i

conducts daily telephone conferences between the Region and both GDPs to discuss l

inspection-related matters. To address the large number of anticipated potential violations l

that will be identified during the initialinspections of the GDPs, after March 3,1997, enforcement panel teleconference meetings are now being held during the week following completion of each regional or Headquarters inspection. Regional and Headquarters inspectors and management, the Office of Enforcement, the NMSS Enforcement Coordinator (a new position), and the GDP Resident inspectors, all participate in these enforcement panels to ensure a consistent NRC position in handling violations.

I The GDP Resident inspectors cumulatively report their findings to the Region and to the management of the GDPs every six weeks. At the conclusion of each six-week reporting period, a teleconference pre-exit briefing is held between the Resident inspectors and regional management, and a post-exit briefing is also conducted, if necessary, to convey to i

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r Region 111 Proposed Final Report Page 19 l.

regional management any significant responses the certificate holder provides at each exit meeting. Furthermore, the Fuel Cycle Branch, DNMS, rotates the locations of Branch meetings among Rlli and each of the GDP sites.

4.2.5 Resnonse to incidents and Alleaations

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There were six safety significant incidents at licensed fuel cycle facilities during the review period. Two of these incidents gave rise to reactive inspections, and an additional one was investigated by an Augmented inspection Team MIT). The reviewer examined the AIT report, and several reports for the reactive inspections. The fuel cycle inspection staff also monitored incidents that occurred at the GDPs. The incidents reviewed occurred before NRC assumed regulatory oversight responsibility for the GDPs, and were investigated by I

the Department of Energy (DOE).

The Region's responses to incidents were well supported technically, and focused primarily on safety, it was not clear, however, what procedures should be used by staff when responding to incidents at fuel cycle facilities. Guidance for reactive inspections and inspections by AITs exist (e.g., MD 8.3, "NRC incident investigation Program"; IMC 0325,

" Augmented Inspection Team"; IMC 1301, " Response to Radioactive Material incidents That Do Not Require Activation of the NRC incident Response Plan"; and IP 87103,

" Inspection of Incidents at Nuclear Materials Facilities"), but they~were developed for application to the regional materials inspection programs, other than for fuel cycle, and rarely provide examples or specific references to fuel cycle safety concerns.

For example, the section on " Additional Guidance on Non-Reactor Events" in IMC 0325, i

for selection of operational events for AIT responses (0325-05.03), does not address significant nuclear criticality issues, such as events where significant pathways to a nuclear criticality may be identified with no controls remaining in place. It was noted that some of these documents are included in the qualification journals of the two inspectors currently being trained, but IP 87103, which has the most practical guidance for conduct of reactive inspections, is not included. The review team recommends that NMSS review existing inspection procedures and manual chapters regarding performance of reactive I

inspections to ensure applicability and adequacy for fuel cycle facility inspections.

Supplements to the Response Technical Manual, developed by Headquarters for each GDP, are available in Rlll for response to major incidents at the GDPs. In addition, updated maps of the surrounding areas for each facility are available in the Rlliincident Response Center, as well as in the Headquarters Operations Center.

Rlli participated in a " table top" exercise for emergency response at a GDP in November 1996, along with Headquarters, DOE, USEC, and GDP site representatives, and they plan to participate in a site exercise for Portsmouth in September 1997. During the " table-top" exercise, participants discussed possible implementation ~of two additional communications measures that could prove valuable during an emergency at a GDP. These included 4

l establishment of a Health Physics Network (HPN) for ma;ntaining open line voice communications during an emergency, and maintaining a direct digital information

Region 111 Proposed Final Report Page 20 connection with the NRC Operations Center for transmitting health physics information, also termed a Historian Data Line. Although neither of these measures are required in NRC regulations, nor recommended in existing or draft NRC guidance, USEC had expressed a willingness at the " table-top" exercise to consider their implementation. In recently reviewing preparations for incident response at the GDPs, Rlll made inquiries to determine the status of these communications proposals, but had not yat received a response from i

Headquarters. The team has since learned that transmission capability for the Historian Data Line has been established between the GDPs and the NRC Operations Center, and that Rill may also be able to access the Historian Data Line through the NRC's Response i

Communications System, which links the NRC Operations Center with the Regions.

Neither NMSS, nor AEOD, are aware of any further progress on implementing the HPN, although FTS 2000 lines are currently in place to link the NRC Resident inspector offices at the GDPs with Headquarters and Rlli.

The Region has had to respond to relatively few allegations involving fuel cycle facilities during the review period. Only one allegation was required to be fully investigated, involving a possible mis-shipment of sewage sludge. Two additional allegations had been received and were scheduled for review by an Allegations Review Board during the weeks following this IMPEP review. It appeared that these allegations were being addressed

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appropriately, with concornitant safety implications being duly considered.

4.2.6 Summarv Based on the draft evaluation criteria for the fuel cycle inspection program non-common performance indicator, the review team recommends that Rlli's performance with respect to this indicator, Fuel Cycle Inspection Program, be found Satisfactory.

4.3 Site Decommissionina Manaaement Plan (SDMP)

This non-common indicator was reviewed in a pilot program to evaluate the Site Decommissioning Management Plan (SDMP) program at the Rill office in Lisie, Illinois. The non common performance indicator for evaluating the SDMP includes: 1) quality of SDMP decommissioning reviews; 2) Financial assurance for decommissioning: 3) termination radiological surveys; 4) inspections: 5) staff qualifications; and 6) SDMP Milestones. In performing this review the reviewer conducted interviews with the Rlli decommissioning inspection and licensing staff and examined inspection, licensing and financial assurance files in the Region's Administrative Support Branch. Staff interviewed in Ritt included four decommissioning inspectors and two license reviewers from the Materials Licensing Branch. The Branch Chiefs from the Material Licensing Branch and the Decommissioning Branch were also interviewed. In addition, several licensing-SDMP project managers from the Division of Waste Management, NMSS, located in Rockville, Maryland, were interviewed.

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Region 111 Proposed Final Report Page 21 F

4.3.1 Quality of SDMP Decommissionina Reviews

-f Files for 7 SDMP sites were examined. These included the Chemetron Corporation, BP Chemicals, Dow Chemicals, Mallinckrodt Chemicals, Jefferson Proving Ground, and Elkem j

Metals.

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The quality of SDMP actions taken in Rlll was assessed by performing an evaluation to determine if significant decommissioning actions at facilities listed on the SDMP (and l

l inspected in Rlli) were reviewed and approved in advance of actual decommissioning activities by the licensee. Second, a determination was made to evaluate if 4

decommissioning plan reviews are conducted in accordance with IMC 2605, "NMSS Handbook for Decommissioning Fuel Cycle and Materials Licensees."

Regional success with the first element often required coordination between Rlliinspectors and DWM licensing project managers because the staff and licensing project manager responsibilities are functionally and physically separated. The review team found good indication that this communication process was working well as evidenced by i

documentation in the docket files showing that many inspections were conducted just before significant decommissioning actions. Rlli was also found to conduct inspectione following a request from the licensing project manager. Information obtained from l

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interviews with licensing project managers and inspectors indicated that Rlliinspectors l

often contacted the licensing project managers when issues were raised on inspections regarding the meaning or intent of conditions in the SDMP facility license or when policy

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issues were raised during inspections.

t Regional success with the second element is demonstrated by inspecting decommissioning sites at appropriate milestones and performing the inspections in accordance with the IMC.

Rlli was evaluated by determining if inspections that were conducted following issuanca of the IMC 2605 (November 1996) used the methodology contained in the IMC and if r

i decommissioning inspection reports covered areas referenced in the two new IPs (IP 87104, " Decommissioning inspection Procedure for Materials Licensees" and 88104,

" Decommissioning inspection Procedure for Fuel Cycle Facilities") identified in IMC 2605.

4 An examination of the 7 SDMP inspection files (and corresponding inspection reports)

? valuated for this review indicated that the new decommissioning guidance contained in IMC MC 2605 and referenced in IP 87104 and 88104 had been used extensively since its formal issuance in July of 1996.

All of the inspection reports reviewed indicated that decommissioning inspectors were aware that licensee decommissioning activities must be in accordance with decommissioning timeliness requirements. Interviews with inspectors in Rlli revealed that inspectors were aware of the new inspection manual chapter, associated check lists, and the new inspection procedures. Decommissioning inspectors were usually aware of major inspection issues regarding decommissioning activities and were using the new inspection guidance in an effective manner.

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Region til Proposed Final Report Page 22 4.3.2 ' Financial Assurance for Decommissionina This sub-performance indicator contains three areas for examination by the review team: 1) has adequate financial assurance for the decommissioning of SDMP sites been established in accordance with regulatory requirements; 2) has financial assurance been provided for the estimated costs for an independent third party to perform decommissioning and 3) have financial assurance mechanisms been reviewed and maintained properly.

The Rlli financial assurance review focused on the security of instruments contained in the Region's financial assurance safe. There is a Financial Assurance Instrument Custodian (FAIC), an Alternate FAIC, and two FAIC Managers. Four people in the Region have the keys to the safe. In addition, a check of 63 files found that the access to the log and the safe was properly controlled, a proper accounting log was being maintained, the log accurately reflected the cost and number of instruments, and the safe was properly fire rated as required by MD 8.12.

4.3.3 Termination Radioloaical Surveys This sub-indicator assesses how the Region ensures that sufficient radiological surveys are conducted, as outlined in IMC 2605, for license termination and that licensee survey results are validated by the Region through a closecut surnr. To assess this indicator, inspection files for 10 terminated sites were reviewed along with lice ise files for these same sites.

New requests for terminations in Rill are first handled by license reviewers in the Materials Licensing Branch. If a licensee's request for termination is a Type 1 decommissioning, as described in the Decommissioning Handbook (i.e. the radioactive materialis contained in a sealed source or gauge that hasn't leaked and/or the half life of the radioactive materialis less than sixty days), the license reviewer makes the determination that a final survey is not required, makes sure that the licensee provides for disposition of the remaining radioactive material, and issues an amendment to terminate the license. If the reviewer has a question regarding the type of decommissioning action that should be assigned, the reviewer refers the case to the Decommissioning Branch and an experienced license reviewer / inspector from this Branch would conduct the review to support termination of the license. Based on interviews with inspectors and license reviewers, this procedure is working, in all cases reviewed, reviewers have used the guidance provided in IMC 2605.

The review team found evidence that NUREG 5849 (" Manual for Conducting Radiological Surveys in Support of License Termination") was used for review of the decontamination of partially contaminated areas, as recommended in IMC 2605.

4.3.4 Insoections This sub-indicator of the SDMP program establishes whether the Region conducts decommissioning inspections in accordance with established frequencies and procedures i

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1 Region 111 Proposed Final Report Page 23 I

l contained in IMC 2605 and IPs 87104 and 88104. The review team examined the Rlli decommissioning inspections with focus on safety of licensee procedures, ielease of j

effluents to the environment, general public and worker exposure, and suitability of I

decontaminated areas and structures for release.

The review team found that the llegion performed in accordance with frequencies i

established in IP 88104 and IP 87104. The review team also examined the l

decommissioning inspection files and observed that most Rlli decommissioning inspections l

referenced the use of IP 87104, often covered the areas listed in the new procedures, and l

made extensive use of the check list contained in the procedures.

4.3.5 Staff Qualifications All of the decommissioning inspectors in Rill are qualified as materials inspectors, with the i

exception of two inspectors relatively new to the Decommissioning Branch. The two new inspectors are pursuing additional qualification courses in IMC 1246 for decommissioning i

inspectors (the staff has a 3 year period to complete qualification course requirements).

One inspector is an experienced reactor inspector and should add expertise to the Decommissioning Branch inspections. The Region has a highly qualified staff.

4.3.6 SDMP Milestones j

l Successful performance under this sub-indicator would require that decommissioning milestones summarized in the SDMP and applicable to the Region are being met, that any I

delays are identified in the SDMP data base, that mechanisms are in place to ensure that appropriate corrective actions are taken by the Region, that policy issues affecting the j

decommissioning of SDMP sites are being identified to DWM, and that Regional staff are updating the SDMP data base in a timely manner.

The areas of this sub-element are not applicable to Rlll because the licensing functions are managed by DWM with the exception of identifying policy issues to the SDMP site project managers in DWM. The regional office has only irspection responsibility for SDMP sites.

The regional inspectors have raised important policy issues for resolution and often recommended corrective actions to the SDMP site project manager. This communication helped to speed along licensing actions.

Based on the draft evaluation criteria for the fuel cycle inspection program non-common performance indicator, the review team recommends that the Region's performance with respect to this indicator, Site Decommissioning Management Plan, be found satisfactory.

The IMPEP team identifies the Rlli document entitled, "Information that Should be Submitted to the NRC staff for Decommissioning and Termination of Licensed Facilities,"

for distribution to lic'ensees with terminating sites,' as a good practice, and recommend =

that its use be considered by other regions and Agreement States.

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- Region lli Proposed Final Report Page 24 j

4.3.7 Summarv,

i Based on the draft evaluation criteria fm this non-common performance indicator, the review team recommends that the Rogion's performance with respect to this indicator, Site i

Decommissioning Management Plan, be found satisfactory.

5.0

SUMMARY

r As noted in Sections 3.1 through 3.5, the review team found the Region's performance with respect to each of the common performance indicators to be satisfactory. In addition, the team found that Rlli was making appropriate use of budgeted resources and that the quality of the fuel facility inspection program was satisfactory. The review team also found that Rlli's implementation of its SDMP and uranium recovery programs was satisfactory. Accordingly, the review team recommends that the MRB find the Rill program to be adequate to protect public health and safety.

I Recommendations. Below is a summary list of recommendations, as mentioned in earlier parts of this report, for action by Rill, or NMSS:

1.

NMSS should examine the need for guidance for initialinspection of new licenses that are issued in the case of an ownership change, mailing office location change, or change in control. (Section 3.1) 2.

NMSS and Rill management should closely monitor implementation of the laboratory QA/QC program and progress on the "get-well" plan. (Section 3.4) 3.

Rlli, in coordination with NMSS and its contractor (RESL), should ensure that independent audits of the laboratory are conducted to ensure that an adequate QA/QC program is implemented and maintained. (Section 3.4) 4.

Rill should examine all procedures or documents relating to the handling of allegations to ensure that they are consistent with MD 8.8 and IMC 2800.

Guidance on electronic transmittal of allegation re;ated material should be included in the procedures, in addition, the procedures or documents should explicitly state that information refernng to an allegation should not to be included in the docket file. (Section 3.5) 5.

Rill management should focus attention on staffing stability and qualification in fuel cycle and GDP area. (Section 4.2.3) l 6.

NMSS should review existing inspection procedures and manual chapters regarding j

performance of reactive inspections to ensure applicability and adequacy for fuel cycle facility inspections. (Section 4.2.5) 4 l

l

l Region lli Proposed Final Report Page 25 Good Practice. Along with the recommendations for Rill or NMSS improvement, the review team identified the following good practices:

1.

The team identified the Rlli " quarterly inspection self izssessment" program as a good practice. Each quarter, a senior inspector and a GG-13 inspector from each Inspection Branch spend a day reviewing one area of inspection. Topics to date have neluded documentation using the field notes, completion of IFS data, and inspection of misadministrations and events. The inspectors selected appropriate j

documents for review and presented their findings in writing to the inspection i

branch chiefs. Findings have resulted in development of additional written guidance in the form of memoranda to the staff, as well as additional in-house training.

i 2.

The review team identified the Rlli document entitled "Information That Shwld Be Submitted To The NRC Staff For Decommissioning and Termination of Licensed Facilities," for distribution to terrninatmg licensees, as a good practice, and recommends that its use be considered by other regions and Agreement States.

l l

1 i

e

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LIST OF APPENDICES AND ATTACHMENTS APPENDIX A:

REGION 111 IMPEP TEAM MEMBERS APPENDIX B:

REGION lil ORGANIZATIONAL CHART APPENDIX C:

REGION 111 RESPONSE TO QUESTIONNAIRE APPENDIX D:

LICENSING FILES REVIEWED APPENDIX E:

INSPECTION FILES REVIEWED APPENDIX F:

INCIDENT FILES REVIEWED APPENDIX G:

DECOMMISSIONING FILES REVIEWED ATTACHMENT 1:

GOOD PRACTICE DOCUMENT: "lNFORMATION THAT SHOULD BE SUBMITTED TO THE NRC STAFF FOR DECOMMISSIONING AND TERMINATION OF LICENSED FACILITIES" ATTACHMENT 2:

TABULAR SUMMoAY OF REGION lli MATERIALS BUDGET AND EXPENDITURES l

l l

c l

~ _. -.. -.. ~.

i APPENDIX A i

REGION Ill IMPEP TEAM MEMBERS i

Name Areas of Responsibility Cathy Haney, NMSS/IMAB Team Leader Technical Staffing and Training Status of Materials inspection Program Operating Plan / Resource Utilization t

l Chuck Mattson, Colorado Technical Quality of Licensing j

Betsy Ullrich, Regior. I Technical Quality of Inspections Inspection Accompaniments l

Tom O'Brien, OSP Response to incidents and Allegations Lance Lessler, NMSS/FCSS Fuel Cycle inspection Program

)

l LeRoy Person, NMSS/DWM Decommissioning /SDMP David Collins, Region ll Inspector Accompaniments l

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k APPENDlX B 1

REGION lli ORGANIZATIONAL CHART i

(Will be acided to final version of the report) i i

4 4

m k

d d

I l

a

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4 1

1

i i

APPENDIX C l

l 1

REGION 111 RESPONSE TO QUESTIONNAIRE (Will be added to final version of the report) i l

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i

t APPENDIX D REGION lil LICENSING FILES REVIEWED File Noi 1 Licensee: Hiram Walker & Sons License No: 21-20408-01 Location: Livonia, Michigan Amendment: 5 License Type: Gas Chromatograph Type of Action: Amendment Dates Amendment Issued: 12/20/96 Reviewer: GW b

File No: 2 Licensee: Computerized Medical imaging License No: 48-24533-01 Location: Eau Claire, Wisconsin Amendments: 25/26 License Type: Medical Type of Action: Amendment Dates Amendments issued: 8/26/96 Reviewer: EM Comments:

a) Cover letter said " Amendment 10.A. has been amended..." It should have i

been " Condition 10 A."

File No: 3 Licensee: Edward W. Sparrow Hospital License No: 21-01430-02 Location: Lansing, Michigan Amendments: 23/24 License Type: Teletherapy Type of Action: Amendment; Term.

Dates Amendments issued: 7/28/95 Reviewers: PP (23); EM (24-Term) l File No: 4 i

Licensee: Carondelet Foundry Co.

License No: 24-26136-01

)

dba The Carondelet Corp.

l Location: Pevely, Missouri Amendments: 5/6 l

License Type: Industrial Radiography Type of Action: Amendments Dates Amendments issued: 11/1/96;11/27/96 Reviewers: RG (5) JM (6) l File No: 5 Licensee: Genetic Visions, Inc.

License No: 48-26077-01 Location: Madison, Wisconsin Aroendments: 3/4 License Type: R&D Type of Action: Amendments Dates Amendments issued: 8/26/96;10/17/96 Reviewer: JM (3) RG (4) l l

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Region 111 Proposed Final Report Page D.2 Licensing files Reviewed r

I File No: 6 Licensee: Midwest Imaging Diagnostic Inc., LTD License No: 34-26753-01 Location: Cincinnati, Ohio Amendment: New License Type: Medical Type of Action: New i

Date issued: 10/14/96 Reviewer: MW File No: 7 Licensee: Mid America inspection Services, Inc.

License No: 21-26060-01 Location: Gaylord, Michigan Amendments: 10/11 License Type: Ind. Radiography Type of Action: Amendments Date issued: 10/15/96;4/9/97 Reviewers: DP (10) KN (11) i File No: 8 Licensee: Thorn Automated Systems, Inc.

License No: 34-23722-01 Location: Westlake, Ohio Amendment: 2 License Type: Possession of Smoke detectors Type of Action: Amendment incident to distribution i

under 34-23722-02E.

Date issued: 8/26/96 Reviewer: JJ Comments:

a) Typographical error -Item 3 should reference application dated 5/25/95 File No: 9 Licensee: Westside Imaging & Oncology Center License No: SUB-1464 Location: Brook Park, Ohio Amendment: 2 (Renewal)

License Type: Shielding for Linear Accelerator Type of Action: Renewal Date issued: 6/12/96 Reviewer: GW Comments:

a) Second line of "U depleted in" shifted to " Cadmium plated metal Uranium 235" l

(Typo).

l

\\

l File No: 10

)

Licensee: Aurora Health Center License No: 48-26600-01 Location: Kenosha, Wisconsin Amendments: 1/2 License Type: Medical Type of Action: Amendments l

Date issued: 7/12/95;7/20/96 Reviewer: PV (1); CC (2) a s

. ~

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.. _ _ _ = _. - - - -

I t

l Region til Proposed Final Report Page D.3 l

Licensing Files Reviewed I

i File No: 11 f

Licensee: Voith Sulzer Paper License No: 48-18811-02 Technology North America, Inc.

Amendment: New l

Location: Appleton, Wisconsin License Type: Kr-85 Thickness gauge Type of Action: New

{

Date issued: 4/11/96 Reviewer: PV l

File No: 12 I

Licensee: Copper Range Co.

License No: 21-11806-01 Location: White Pine, Michigan Amendment: 17

)

License Type: Fixed and Portable Gauges Type of Action: Termination Date issued: 5/21/96 Reviewer: MW File No: 13 Licensee: Ingham County Road Commission License No: 21-24465-01 Location: Mason, Michigan Amendment: 06 (Renewal)

License Type: M/D Gauge Type of Action: Renewal Date issued: 12/14/95 Reviewer: CG File No: 14 Licensee: Regional Oncology Center License No: 34-26535-01 of Williams County, Inc.

Location: Bryan, Ohio Amendment: New License Type: HDR Brachytherapy Type of Action: New Date issued: 9/19/95; 10/26/95 (corrected)

Reviewer: CC Comments:

a) Original license contained four " minor" typos.

File No: 15 Licensee: Krones, Inc.

License No: 48-20448-01 Location: Franklin, Wisconsin Amendment: 5 (Termination)

License Type: Service / installation Type of Action: Termination of Am-241 filllevel gauges I

Date issued: 10/30/95 Reviewer: PV i

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Region lli Proposed Final Report Page C.4 licensing Files Reviewed

- File No: 16 Licensee: Trijicon, Inc.

License No: 21-19874-01 Location: Wixom, Michigan Amendments: 7(Renewa!)/8/9 License Type: R/D; Type of Action: Renewal (7); Amend (8/9)

H-3 gun sights; C-14 luminescent light sources Dates issued: 8/1/95;10/4/95;3/12/97 Reviewer: JM File No: 17 Licensee: Circuit Science License No: 22-24422-01 Location: Plymouth, Minnesota Amendment: 6 (Terminction) l License Type: Lixiscope (industrial)

Type of Action: Termination Date issued: 6/21/95 Reviewer: WR File No: 18 Licensee: Spect Imaging, Inc.

License No: 21-26636-01 Location: Madison Heights, Michigan Amendment: New License Type: Medical Type of Action: New l

Date issued: 4/6/95 Reviewer: JM File No: 19 Licensee: Mallinckrodt/NMA Medical Physics License No: '34-16272-01 l

24-26664-01 Location: Cleveland, Ohio Amendment: 26 (Term); New/1 l

License Type: Services Type of Action: Term; New; Amend 1 Date issued:

Reviewer: LH l

l File No: 20 l

Licensee: Ferris State University License No: 21-15237-01 i

Location: Big Rapids, Michigan License Type: Specific R/D l

Comments:

i l

a) The LTS still lists the Univ. as "1100" which is Type A Broad Academic.

l i

File No: 21 Licensee: Eli Lilly & Co.

License No: 13-01133-02 l

Location: Indianapolis, Indiana Amendment: 49 License Type: R/D Broad Scope Type of Action: Amendment Date issued: 1/20/95 Reviewer: PP

l l

APPENDIX E-REGION 111 INSPECTION FILES REVIEWED File No. 01 Licensee:

Michigan State University City, State:

East Lansing, MI License Number:

21-00021-29 Priority:

2 i

Program Code:

01100, academic broad scope Type A Lead Inspector:

RH inspection Type:

limited to closure of NOV items, inspection Date:

2/14/96 issue Date:

see comments Comments:

1) No letter transmitting inspection results in docket file; no copy of 591 in docket file.

File No. 02 Licensee:

Michigan State University City, State:

East Lansing, MI License Number:

21-00021-29 Priority:

2 Program Code:

01100, academic broad scope Type A Lead Inspector:

DS Inspection Type:

routine, unannounced inspection Date:

10/23-27/95 issue Date:

12/12/95 File No. 03 Licensee:

Ferris State University City, State:

Big Rapids, MI License No.:

21-15237-01 Priority:

2 -- see comments Program Code:

01100, academic broad scope Type A, see comments Lead Inspector:

MM inspection Type:

special, unannounced inspection Date:

2/6/96 issue Date:

2/16/96

l 1

Hegion 111 Proposed Final Report Page E.2 l

Inspection Files Reviewed File No. 04 Licensee:

Ferris State University

)

City, State:

Big Rapids, MI License No.:

21-15237-01 Priority:

2 - see comments i

Program Code:

01100, academic broad scope Type A, see comments Lead inspector:

MM inspection Type:

special, unannounced Inspection Date:

7/10/95 issue Date:

8/7/95 Comments:

1) Inspection report issued 8/7/95 states that licensing action changed this to an academic broad scope Type C license (program code 01120, Priority 3) but LTS was not updated to reflect this change.

File No. 05 Licensee:

University of Wisconsin - Milwaukee Citv, State:

Milwaukee, WI License No.:

48-09944-01 Priority:

3 Program Code:

01110, academic broad scope Type B Lead inspector:

ML Inspection Type:

routine, unannounced inspection Date:

4/7-9/97 (site), open for additional office review of information as of 4/23/97 issue Date:

Not issued as of 4/23/97 File No. 06 Licensee:

Washington University' Medical School City, State:

St. Louis, MO License No.:

24-00167-11 Priority:

1 Program Code:

02110, medicalinstitution broad scope Lead Inspector TY Inspection Type:

routine, unannounced Inspection Date:

4/19 through G/2/97; additional sites 5/23-24/97;in office through 8/8/97. Telecon exit meeting 8/8/96.

Issue Date:

Letter daced 8/29/96

Region 111 Proposed Final Re. cort Page E.3

.y inspection Files Reviewed i

l File No. 07 Licensee:

Crittenton Hospital Radiology City, State:

Rochester, MI License No.:

21-13562-01 Priority:

3 Program Code:

02120, medical institution, LMP Lead inspector:

TG Inspection Type:

routine, unannounced Inspection Date:

10/2/95 issue Date:

' Form 591 dated 10/3/95 File No. 08.

Licensee:

Amherst Hospital City, State:

Amherst, OH License No.:

34-26314-01 Priority:

3 Program Code:

02120, medical institution, QMP lead inspector:

ML Inspection Type:

routine, unannounced Inspection Date:

1/23/96 and 2/7/96 issue Date:

Clear letter dated 2/27/96 File No. 09 Licensee:

Huron Memorial Hospital City, State:

Bad Axe, MI 48413 License No.:

21-17093-01 Priority:

3 Program Code:

02120, medicalinstitution, QMP Lead Inspector:

TG inspection Type:

rou'r,, unannounced inspection Date:

12/40/96 issue Date:

Form 591 dated 12/20/96 File No.1Q j

Licensee:

H.B. Magruder Memorial Hospital j

i City, State:

Port Clinton, OH License No.:

34-11202-02 Priority:

3 Program Code:

02120, medical institution. QMP j

Lead Inspector:

DW Inspection Type:

routine, unannounced Inspection Date:

11/25/96 issue Date:

Form 591 dated 11/25/96

-m Region 111 Proposed Final Report Page E.4 Inspection Files Reviewed File No.11 Licensee:

VA Medical Center City, State:

North Chicago, IL License No.:

12-10057-04 Priority:

3 Program Code:

02120, medical institution, QMP; also R&D Lead Inspector:

SM inspection Type:

routine, unannounced Inspection Date:

6/11/96 (site) through 6/25/96 (in office), with telecon exit 6/25/96.

Issue Date:

Letter with NOV dated 7/9/96 Comments:

1) Not clear what additional issues were reviewed in-office.

2) Licensee is also authorized for R&D (primary program code 02120 with secondary 03620) and may be required to be considered a medical broad scope license (program code 02110).

File No.12 Licensee:

Cardiology Associates of Western Michigan City, State:

Kalamzoo, MI License No.:

21-26690-01 Priority:

5 Program Code:

02201, medical private practice, no QMP Lead inspector:

TG.

Inspection Type:

routine, announced, initial inspection Date:

8/6/96 issue Date:

Form 591 dated 8/6/96 FiL, m.

13 Licensee:

American Oncologic Associates of Michigan City, State:

Pontiac, MI I

Lie,se No.:

21-26488-01 Priority:

1

- Program Code:

02230,HDR 4

Lead Inspector:

JC Inspection Type:

routine, unannounced Inspection Date:

5/24/96 l

Issue Date:

Form 591 dated 5/24/96 i

)

i Region ill Proposed Final Report Page E.5 Inspection Files Reviewed File No.14 Licensee:

Farmington Hills Radiation Oncology Center City, State:

Farmington Hills, MI License No.:

21-26516-01 Priority:

1 Program Code:

02230,HDR Lead Inspector:

TY Inspection Type:

routine, unannounced Inspection Date:

could not be verified issue Date:

unknown - see comments Comments:

1) According to " inspections completed" list, this licensee was inspected in 9/95 by TY. However, documentation is not in docket fi!e.

1 File No.15 Licensee:

Community Hcapital of Indiana,Inc City, State:

Indidnapolis, IN License No.:

13-06009-01 Priority:

1 Program Code:

02230 (primary) HDR,02120 (secondary) medical institution, QMP Lead inspector:

JM inspection Type:

routine, unannounced Inspection Date:

1/30/97 issue Date:

Form 591 dated 1/30/97 Comments:

1) Priority code listed in field notes does not match that for the program code (HDR is Priority 1).

2) Tony Go is listed as the inspector under PEFs.

File No.16 Licensee:

Mallinckrodt Medical, Inc City, State:

Maryland Heights, MO, inspection at Dayton, OH licensed location of facility.

License No.:

24-04206-18MD Priority:

1 Program Code:

02500, nuclear pharmacy Lead inspector:

ML Inspection Type:

routine, unannounced (both)

Inspection Date:

3/24-/97 (site) through 3/31/97 (office)

Issue Date:

clear letter dated 4/15/97

Region ill Proposed Final Report Page E.6 Inspection' Files Reviewed File No.17 Licensee:

Mallinckrodt Medical, Inc City, State:

Maryland Heights, MO, inspection at Dayton, OH licensed location of facility.

License No.:

24-04206-18MD Priority:

1 Program Code:

02500, nuclear pharmacy Lead Inspector:

95-001 JJ Inspection Type:

routine, unannounced (both)

Inspection Date:

12/26/95 and 1/3/96 issue Date:

1/11/96 File No.18 Licensee.

Mobay Chemical Corporation, now Bayer Corporation City, State:

Kansas City, MO

)

License No.:

24-03830-01 Priority:

5 Program Code:

03120, measuring systems - fixed gauges Lead Inspector:

RH Inspection Type:

routine, unannounced inspection Date:

7/16-18/97 issue Date:

Form 591 issued 7/18/97 Comments:

1) LTS lists this license as program code 03620, R&D other. License appears to be primarily R&D but does have gauges.

File No.19 Licensee:

Newman Manufacturing incorporated City, State:

Kendallville, IN License No.:

13-24902-01 Priority:

5 l

Program Code:

03120, fixed gauge l

Lead inspector:

RG Inspection Type:

routine, unanr.ounced Inspection Date:

4/28/95 (tate), telephone exit 5/30/95 i

issue Date:

Letter with NOV issued 6/12/95 l

._..___m Region lli Proposed Final Report Page E.7 inspection Files Reviewed l

l File No.20 Licensee:

Kinnscan, Incorporated i

City, State:

Williamsburg, MI j

License No.:

21-21045-01 Priority:

5 i

Program Code:

03121, measuring systems - portable gauges Lead Inspector:

TY

{

inspection Type:

routine, unannounced Inspection Date:

7/30/96 issue Date:

Form 591 dated 7/30/96 File No. 21 Licensee:

Ingham County Road Commission j

City, State:

Mason, MI License No.:

21-24465-01 3

Priority:

5 Program Code 03121, measuring systems portable gauges 1'

Lead inspector:

-AK i

inspection Type:

routine, unannounced Inspection Date:

9/17/96 I

lssue Date:

. Form 591 dated 9/17/96 l

1 File No. 22 i

Licensee:

Michigan Department of Transportation

)

City, State:

Lansing, Mi i

License No.:

21-03039-01 4

Priority:

5 Program Code:

03121, measuring systems - portable gauges j

Lead Inspector:

AK i

4

~

Inspection Type:

routine, unannounced Inspection Date:

9/16/96 Issue Date:

Letter with NOV dated 10/9/96 I

J File No. 23 l

Licensee:

Pitiik and Wick, Inc.

- dity, State:

Eagle River, WI License No.:

48-26650-01 Priority:

5 Program Code:

03121, measuring systems - portable gauges

' Lead inspector:

DG Inspection Type:

routine, announced, initial Inspection Date:

11/13/95 issue Date:

- Form 591 dated 11/13/95

' Region lli Proposed Final Report Page E.8 Inspection Files Reviewed File No. 24 Licensee:

PCC Airfoils City, State:

Mentor, OH License No.:

34-21109-02 Priority:

7 Program Code:

03122, measuring systems (Kevex analyzer)

LeadInspec'~-

TS i

inspection Type:

routine, unannounced, initial Inspection Date:

7/22/96 Issue Date:

Form 591 dated 7/22/96 i

I

' File No. 25 Licensee:

Advanced Medical Systems City, State:

Cleveland, OH I

License No.:

34-19089-01 Priority:

1 Program Code:

03211, manufacturing and distribution broad scope Type A Lead Inspector:

MM i

inspection Type:

routine, announced, limited to shipment of sources from hot cell for disposal Inspection Date:

11/13 through 12/6/96 issue Date:

Clear letter dated 3/7/97 File No. 26 Licensee:

Apollo Fire Detectors Ltd.

City, State:

Pontiac, MI

' License No.:

21-23805-01 Priority:

3 Program Code:

03214, manufacturing and distribution other Lead Inspector:

JJ Inspection Type:

routine, unannounced Inspection Date:

10/24/96 issue Date:

Form 591 dated 10/24/96

... _ _ ~

l Region ill Proposed Final Report Page E.9 Inspection Files Reviewed i

Fit th 27 Licensee:

GE/Reuter Stokes City, State:

Twinsburg, OH

- License No.:

34-18156 Priority:

3 Program Code:

03214, manufacturing and distribution other Lead Inspector:

TS Inspection Type:

routine, unannounced inspection Date:

7/25/96 (site) through 8/9/96 (office) l Issue Date:

Clear letter dated 10/2/96 Comments:

1) Notes are not clear as to why inspection continued in the office.

I File No. 28 Licensee:

Missouri Steel Castings l

City, State:

Joplin, MO License No.:

24-15152-01 Priority:

1 Program Code:

03310, industrial radiography - fixed Lead Inspector:

RH inspection Type:

routine, unannounced Inspection Date:

5/8/95 lssue Date:

Form 501 dated 5/8/95 t

File No. 29 Licensee:

Glitsch Field Services /NDE Inc l

City, State:

North Canton, OH License No.:

34-14071-01 Priority:

1 Program Code:

03320, radiography - temporary job sites Lead inspector:

WS i

inspection Type:

routine, unannounced (both)

Inspection Dates:

9/29/95 Dates issued:

letter with NOV dated 11/9/95 I

l 9

l Region lli Proposed Final Report Page E.10 Inspection Files Reviewed j

File No. 30 Licensee:

Eli Lilly and Company City, State:

Indianapolb License No.:

13-01133-02 Priority:

2 - see comments Program Code:

03610 R&D broad scope Type A; 03611 R&D broad scope Type B Lead Inspector:

MB inspection Type:

unannounced, limited special to review corrective actions Inspection Dates:

7/19-20/1995 Issue Dates:

clear letter issued 8/8/95 l

File No. 31 l

Licensee:

Eli Lilly and Company City, State:

Indianapolis,1N l

License No.:

13-01133-02 Priority:

2 - see comments Program Code:

03610 R&D broad scope Type A; 03611 R&D b oad scope Type B Lead Inspector:

TG

~

Inspection Type:

routine, unannounced Inspection Dates:

1/28-29/97 through 2/11/97 i

Issue Dates:

clear letter issued 2/21/97 Comments:

1) Licensing action in August 1992 changed this from an R&D broad j

scooe Type A license to an R&D broad scope Type B license but LTS not updated. This was noted in the 97-001 inspection, not in 95-001

)

inspection.

l l

- File No. 32 Licensee:

Proctor and Gamble Company City, State:

Cincinnati, OH License No.:

34-01572-01 Priority:

2 Program Code:

03610, R&D broad scope Type A Lead inspector:

DP l

inspection Type:

routine, unannounced inspection Date:

6/18-20/96 issue Date:

Clear letter dated 7/25/96 Comments:

1) Section 8 states that "RSO collects samples at nearby sanitary l

plant on 6 occasions per month. These water samples are analyzed via LSC to ensure releases are within Part 20 limits." However, concentrations at the sanitary plant would not demonstrate compliance with 20.2005 release criteria from the licensee's fac2ity.

i t

Region 111 Proposed Final Report Page E.11 Inspection Files Review 2d File No. 33 Licensee:

Mallinckrodt, Inc.

City, State:

St. Louis, MO License No.:

STB-401 Priority:

3 Program Code:

11700, rare-earth extraction and processing Lead Inspector:

KL Inspection Type:

routine, announced Inspection Dates:

2/13/96 issue Date:

clear letter and report dated 3/14/96 File No. 34 Licensee:

Mallinckrodt, Inc.

City, State:

St. Louis, MO License No.:

STB-401 Priority:

3 Program Code:

11700, rare-earth extraction and processing Lead inspector:

DM inspectior. Type:

routine, announced, limited to a review of decommissioning plans Inspection Dates:

11/21/96 issue Dete:

clear letter and report dated 1/27/97 Fi!e N o. 3 5 Licensee:

Remtex, Inc City, State:

Worth, IL (inspection at home office of records of field activities in NRC stat's) e License No.:

11-01137-01 Priority:

NA - reciprocity inspection Program Code:

NA; activity is for se vice of teletherapy units Lea t inspector:

RH Inspection Type:

routine, unannounced, reciprocity inspection Date:

2/4/97 Issue Date:

Clear letter dated 2/25/97

Region ill Proposed Final Report Page E.12 Inspection Files Reviewed File No.' 3F Licensee:

Glitsch Field Services /NDE Inc City, State:

North Canton, OH License No.:

34-14071-01 Priority:

1 Program Code:

03320, radiography - temporary job sites Lead Inspector:

WS inspection Type:

routine, unannounced (both)

Inspection Dates:

1/29/97 (site) through 2/11/97 (in-office review)

- Dates issued:

clear letter dated 2/14/97; in addition, the following inspection accompaniments were made as part of the on-site IMPEP review:

Accomnaniment No.1. D. J. Collins, Ril Licensee:

NDC Systems / instrumentation Resources, Inc.

City, State:

Minnetonka, MN (Branch Office, assist inspection to RIV)

License No.:

04-23264-O',

Priority:

5 togram Code:

03121, portable gauges Lead Inspector:

SM inspection Type:

routine, unannounced, assist inspection Date:

April 7,1997 Accompaniment No. 2. D. J. Collins, Ril i

Licensee:

Mankato State University City, State:

Mankato, MN License Nos.:

22-05944-03, SNM 397 Priority:

5 (both licenses)

Program Codes:

03620 R&D other, 22120 SNM sealed Pu source Inspection Type:

routine, unannounced Lead Inspector:

SM inspection Date:

April 8,1997 Accompaniment No. 3. D. J. Collins, Ril Licensee:

Naeve Hospital

- City, State:

Albert Lea, MN License No.:

22-15252-01 Priority:

3 Program Code:

02120, medical institution, QMP f spection Type:

routine, unannounced Lead Inspector:

SM Inspection Date:

April 9,1997

l l

l Region lil Proposed Final Report Page E.13 Inspection Files Reviewed Accomoaniment No. 4. E. Ullrich RI Licensee:

University of Wisconsin - Milwaukee i

City, State:

Milwaukee, WI License No.:

48-09944-01 Priority:

3 Piogram Code:

01110, academic broad scope Type B inspection Type:

routine, unannounced Lead Inspector:

'l Inspection Date:

April 7-9,1997 l

l Accomoaniment No. 5. E. Ullrich. RI Licensee:

Lorain Community /St. Joseph's Hospital City, State:

Lorair., OH License No.:

34-04474-01 i

Priority:

3 Program Code:

02120, medical institution, QMP Inspection Type:

routine, unannounced j

Lead inspector:

TG j

inspection Date:

April 10,1997 l

Accompaniment No. 6. E. Ullrich, R1 Licensee:

Kaiser Permanente Medical Center City, State:

Parma, OH License No.:

34-26092-01 Priority:

3 Program Code:

72120, medical institution, QMP Irispection Type:

routine, unannounced Lead Inspector:

70 inspection Date:

April 12,1997 l

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APPENDIX F REGION 111 INCIDENT FILES REVIEWED File No.1 Licensee:

University of Michigan Location:

Ann Arbor, MI License #:

21-00215-04 Date of Event:

April 20,1995 investigation Date:

April 24,1995 Incident Log Number:

950118 Investigation Type:

Inspection Type of Event:

Loss of Control of Radioactive Material (Offsite Contamination)

Summary uf 'ncident:

Researchers had insufficient understanding of proper survey procedure for lab workers resulting in P-32 contamination on and off-site of the University.

File No. 2 Licensee:

MOS Inspection

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Location:

Elk Grove Village, IL I

License #:

12-00622-07 Date of Event:

December 13,1995 Investigation Date:

December 20,1995 l

Incident Log Number:

Not in NMED Investigation Type:

Inspection Type of Event:

Potential Whole Body Overexposure Summary of incident:

116 rem on WB film badge of radiographer. RSO determined only badge was exposed (to x-ray unit). REACT-TS cytogenetic study done and indicated results did not correlate to dose.

File No. 3 Licensee:

Indiana Department of Transportation Location:

Seymour, Indiana License #:

13-26342-01 Date of Event:

June 30,1995 Investigation Date:

. July 3,_1995 l

Incident Log Number:

950921 investigation Type:

Phone Type of Event:

Stolen Moisture Density Gauge Summary of incident:

_ Moisture Density gauge (8 mci Cs-137,40 mci Am-241) stolen from trailer construction site in Columbus, IN.

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Region lli Proposed Final Report Page F.2 incident Files Reviewed File No. 4 Licensee:

Providence Hospital Location:

Southfield, Ml License #:

21-02802-03 l

Date of Event:

- July 251995 Investigation Date:

August 3,1995 l

incident Log Number:

951007 investigation Type:

Inspection Type of Event:

Misadministration l-Summary of incident:

Brachytherapy using 9.5 mci Ir-192. Failure to treat intended l

site and to furnish written report to patient within 15 days.

i File No. 5 Licensee:

North Star Steel Company l

Location:

Youngstown, OH License #:

GL Date of Event:

August 27,1995 investigation Date:

September 5,1995 Incident Log Number:

951136 Investigation Type:

Inspection

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Type of Event:

Damage to Level Gauge Summary of incident:

Gauge damaged by molten steel. Lead shielding partially melted resulting in 830 mrem /hr at gauge surface. Maximum personnel dose was 25 mrem.-

File No. 6 Licensee:

US Army.

Location:

ACALA-Ft Irwin License #:

12-00722-06 Date of Event:

October 18,1995 Investigation Date:

See comment incident Log Number:

951185 investigation Type:

N/A Type of Event:

Damage to Sources Summary of incident:

Three H-3 (approximately 19 Ci total) and one Am-241(250 Ci) l sources involved in explosion and fire.

Comments:

This event and many other issues currently being addressed in a Confirmatory Order sent to the Army on 3/26/97, i

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Region til Proposed Final Report Page F.3 Incident Files Reviewed j

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File No. 7 Licensee:

, Allied Signal Location:

Metropolis, IL License #:

SUB-526 Date of Event:

December 3,1996 Investigation Date:

December 16,1996 incident Log Number:

960809 investigation Type:

Inspection Type of Event:

Loss of Control of Radioactive Material Summary of incident:

Loss of power caused dust collectors to fail and natural 4

uranuim ore dusts were released irito Feed Materials Building, a

File No. 8 a

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- Licensee:

University of Wisconsin Location:

Madison, WI License #:

48-09842-28 Date of Event:

September 11,1995 Investigation Date:

October 16,1995 incident Log Number:

951144 investigation Type:

Inspection Type of Event:

Unintentional exposure of workers i

Summary of incident:

Two individuals performing maintenance / repair activities on a JL' Shepard irradiator disabled shielding interlock and were exposed to scattered radiation (maximum dose received was 20 mrem).

File No. 9 Ueensee:

Ohio State University Location:

Columbus, OH i

License #:

34-00293-02 l

Date of Event:

March 6,1996 investigation Date:

April 26,1996 incident Log Number:

960160 Investigation Type:

Inspection j

Type of Event:

Loss of Control of Radioactivity (Contamination) l Summary of incident:

Stopper on vial of P-32 (2.5 mci) leaked. Individual was not wearing gloves and contaminated thumb. Hand was i

subsequently decontaminated.

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Region ill Proposed Final Report Page F.4 l

Incident Files Reviewed File No.10 Licensee:

Longview Inspection l

Location:

Temporary Jobsite in Indiana License #:

48-17480-01 Date of Event:

February 26,1997 l

investigation Date:

February 27,1997 l

Incident Log Number:

Not Yet Enterr

• in NMED Investigation Type:

Inspection Type of Event:

Potential Whole Body Overexposure Summary of Incident:

Radiographer TLD read 240 and 510 rem (dual chip readout).

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Operations Center notified by licensee of potential whole body overexposure. Awaiting cytogenetic testing results and confirmation of dosimeter readout.

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r APPENDIX G REGION 111 SDMP AND DECOMMISSIONING FILES REVIEWED SDMP SITES File No.1 l

Licensee:

Chemetron Corporation Location; Newburgh Heights, Ohio f

License Number:

SUB-1397

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License Type:

Source Material i

File No. 2 l

Licensee:

BP Chemicals Location:

Lima, Ohio License Number:

SUB-908 License Type:

Source Material l

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File No. 3 i

l Licensee:

Dow Chemical Location:

Midland & Bay City, Michigan l

License Number:

STB-527 License Type:

Source Material i

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Licensee:

Mallinckrodt Chemical, Inc.

l Location:

St. Louis, Missouri License Number:

STB-401 License Type:

Source Material l

l File No. 5 Licensee:

Jefferson Proving Ground Location:

Madison, Indiana t

l License Number:

SUB-1435 l

License Type:

Source Material l

l-i File No. 6 Licensee:

RMI Titanium Company Location:

Ashtabula, Ohio License Number:

SMB-602 License Type:

Source Material

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Region lli Proposed Final Report Page G.2 Decommissioning Files Reviewed l

I File No. 7 Licensee:

Minnesota Mining and Manufacturing Company

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Location:

Minneapolis-St Paul, Minnesota l

License Number:

SNM-764 i

License Type:

Special Nuclear Material l

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TERMINATED SITES File No.1 I

Licensee:

Elkem Metals j

Location:

Marietta, Ohio 1

License Number:

34-19812-01 License Type:

Measuring system File No. 2 Licensee:

Assgrow Seed Company Location:

Kalamazoo, Michigan License Number:

21-26656-01

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License Type:

R&D File No. 3 Licensee:

Apex Bioscience, Inc.

Location:

Detroit, Michigan License Number:

21-17174-01 License Type:

In-vitro File No. 4 Licensee:

Detroit Police Department Location:

Detroit, Michigan License Number:

21-26339-01 License Type:

In-vitro File No. 6 Licensee:

Epikon Corporation Location:

Bedford Heights, Ohio License Number:

34-26625-01 License Type:

R&D 4

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i Region ill Proposed Final Report Pace G.3 Decommissioning Files Reviewed File No. 7 Licensee:

Stolle Research & Development Corp.

Locatic,:

Cincinnati, Ohio License Number:

34-26227-01 License Type:

R&D File No. 8 Licensee:

Case Western Puerve University Locatian:

Cleveland, Ohio Lic;.me Numbet:

SNM-159 License Type:

Special Nuciear Mate.ial File No. 9 Licensee:

Inland Steel Mining Company Location:

Virginia, Minnesota License Number:

SNM-1974 License Type:

Special Nuclear Material Fi'e No.10 Licensee:

Cyprus North Shore Mining Location:

Silver Bay, Minnesota License Number:

SN'M-1562 License Type:

Special Nuclear Material File No.11 Licensee:

University of Michigan-Dearborn Location:

Dearborn,

Michigan Leense Number:

SNM-1570 License Type:

Special Nuclear Material File No.12 Licensee:

Radiation Safety Service Location:

Morton Grove, Illinois License Number:

12-204:e.1 1 License Type:

Service Orqanization l

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Good Practice Document j

"Information that Should be Submitted to the NRC Staff for Decommissioning and Termination of Licensod Facilities" p

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Information that Should be Submitted i

F to the NRC Staff for Decommissioning l

and Termination of Licensed Facilities The following information is needed from licensees who request authorization i

from the NRC for the release of a room. building or outdoor area for unrestricted use:

i 1)

A list of the radiological isotopes that were actually used at the site.

l To the extent possible (and reasonable), the quantities and dates of use of these isotopes should also be provided.

2)

The physical form of each isotope' i.e.

was it a sealed source or was j

the isotope used in a loose form.

1 3)

-Information regarding major radiological spills of any licensed isotopes l

such as the location of the spill (s) and pertinent radiological i

information'about the spill (s).

(Major spills for the purpose of this i

document means a spill that resulted in off-site contamination or c.ny

.j other spill where more than minimal decontamination effort is required.

e.g., s) ills requiring assistance in cleanup and monitoring from persons I

other tlan the user.)

l.

4)

Information on any leaking sealed source used or stored at the site

'I being released, including isotope, amount of leakage contamination of' l

other areas or personnel description of cleanup, and dis)osition of the source.

If no sources were determined to be leaking at t1e facility.

1 the licensee should state this fact.

5)

The results of the licensee's final surveys as required by 10 CFR Parts 30.36(j)(2). 40.42(j)(2), and 72.54(1)(2).. This includes submitting

' data in the following units: gamma radiation in units of mSv/hr (pR/hr) 2 at one meter from surfaces. radioactivity in units of MBq/100cm 2

(dpm/100cm ) (removable and fixed) for surfaces. MBq/ml (mci /ml) for water, and Bq/g (pCi/g) for' soils and concrete.

(See Attachments 1 and 2) 6)

_The survey instrumentation used for the final survey along with the certification that each instrument has been properly calibrated and

-tested and the minimum detectable activity (MDA) for each instrument.

This information is needed for instruments used for measuring exposure rates and for those used for analysis of wipes, soil and water sa.nples, etc.

(See Attachment 3) 7)

Maps and/or drawings which clearly indicate the locations where wipes and fixed measurements were taken.

If contaminated drain lines (or other buried or inaccessible pipes) are an issue, blueprints or drawings should be included that show the locations of the drain lines, including where they originate and end.

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8)

If other than minimal contamination efforts are necessary. both the before and after decantamination survey data should be provided as part

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of the final survey report, including the locations of these areas.

9)

The release criteria used as a basis for demonstrating the site can be released for unrestricted use.

(See Attachment 4) i 10)

If the licensee intends te leave certain portions of the site i

i contaminated in excess of the release guidelines. a risk assessment of the potential dose consequences.

11)

The disposition of radioactive waste resulting from any remediation f

efforts.

Under normal circumstances the NRC will not conduct a closecut or confirmatory insoection until all waste (and other licensed

-i materials / sources) have been removed from the site.

If these materials i

have not been removed prior to the licensee's submittal of the final j

survey data, then these areas will have to be surveyed following removal i

of the waste and the data submitted and reviewed before an onsite inspection and/or license termination.

Attachments; (1) 10 CFR Part 30F40 or 70 (as applicable)

(2) Survcy 1aformation to Support License Terminatim L. Section 5.0. NUREG/CR-5849. Manual for Conducting "diological Surveys in Support of License Terminations (4) Guidelines for Decontamination of Facilities and Equipment Prior to Reiease for Unrestricted Use or Termination of Licenses for Byproduct. Source or Special Nuclear Material i

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ATTACHMENT 2 SURVEY INFORMATION TO SUPPORT LICENSE TERMINATION In performing the decommissioning of its facility the licensee should first 4

identify any areas in the facility that were involved in licensed material use by reviewing facility records and conducting a survey of the licensed material use area. This survey should be similar to the routine contamination surveys conducted under.the licensee's radiological safety plan.

The licensee should then remediate all surfaces in the areas at the facility that were involved in licensed material use or storage and dispose of all radioactive material and waste as discussed in the NRC regulations at 10 CFR 20 Subpart K.

If the licensee elects to demonstrate that its facility is suitable for unrestricted use by conducting a Final Status Survey. the licensee should design the survey so as to be of sufficient scope and quality to make this demonstration.

In preparing for the Final Status Survey. the licensee should establish a method to identify individual measurement / sampling points such as establishing reference grids on each surface in the indoor area that was involved in licensed material.

At a minimum, the licensee's termination survey should consist of:

1) 100% scanning of all surfaces in the area at the facility where licensed material was used or stored using an appropriate radiation detection instrument (including scan sensitivity);

2) evaluations for total and removable radioactive material at each i

area exhibiting elevated radiation levels or at a frequency of one wipe i

2 comprising 100 cm per grid; and

3) evaluations of radiation levels at one meter above surfaces Particular attention should be afforded any drains. air vents or other fixtures or equi ament that may have become contaminated during licensed material use.

T11s is especially significant in situations where renovations have occurred and potentially contaminated areas may be inaccessible under i

current conditions.

l The information that should be submitted to the NRC to support the final l

status survey should consist of:

1

1) a brief description of the remediation activities undertaken by the licensee:

l

2) a detailed drawing of the licensed material use areas indicating the sampling locations:

3) a table showing the results of the radiation levels and removable i

contamination surveys keyed to the detailed drawing (organized by survey unit):

l

4) the training and qualifications of 'the individual (s) performing the decontamination and' surveys:'and.

i

5) a description of the type of equipment used by the licensee to evaluate the wipes and perform the surveys.

This description should include all information required to determine the appropriateness of the equipment for determining the radiological status of the facility such as last calibration date. type'of radiations detected, sensitivity of f

detection, efficiency, etc-

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' TABULAR

SUMMARY

OF REGION 111 MATERIALS BUDGET AND EXPENDITURES l

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01/31/97 The following table shows FTE allocations and expenditures for tne review period REGION II: RESOURCE UTILIZATION FY 1996 FY 1997 ANNUAL ANNUAL BUDGET EXPENDEO PROGR#i ACTIVITY BUDGET EXPENDED BUDGET OCT-DEC OCT-DEC

)

Materials Lic & Insp 25.30 22.30 88 23.90 6.00 4.90 82 Event Evaluation 3.70 5.60 151 3.90 1.00 1.40 140 Fuel Fac Lic & Insp

1. 50 1.10 73 1.50 1.60 0.50 31 Fucl Cycle Pgm Asses 0.50 0.10 2r 0.40 0.10 0

0 Uranium Enrich Insp 5.00 5.00 10u 5.00 1.20 1.10 92 LLW Lic & Insp 0.20 0

0 0

0 0

0 Decommissioning 5.60 5.70 102 5.00 1.20 1.90 158 i

10TAL 41.80 39.80 95 39.70 11.10 9.80 88 NOTES:

1.

FY 1996 expenditures from regional input provided in response to the FY 1997 President's budget update during 11/96.

2.

FY-1997 expenditures from RWAT report dated 1/29/97.

Expenditures are i

through 12/31/96.

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MEMORANDUM TO:

Carl J. Paperiello, Director j

Office of Nuclear Materials Safety and Safeguards FROM:

A. Bill Beach, Regional Administrator

SUBJECT:

DRAFT 1997 REGION lliINTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) REPORT Thank you for the opportunity to review and comment on your draft report of the program j

review recently performed in Region Ill. We believe that the team lead by Cathy Haney j

was very professional and performed a very thorough review.

Pursuant to your request, our specific comments regarding the draft report are provided in to this memorandum.

Although not required at this time we are also providing you a summary of our actions taken in response to three of the four recommendations pertaining to Region lli addressed 1

at the exit meeting and referenced in the draft report. These are summarized in to this memorandum.

White we don't disagree with three cf the four recommendations, ve do disagree with the reason for the team's recommendation to increase management wention in the area of the fuel cycle facilities because of the availability of experienced technical staff and management knowledgeable of those types of facilities. We have and will continue to provide sufficient management oversight of the fuel cycle program because of the newness of the GDP's to the regulatory process. We also recognize that in depth knov.' ledge of fuel cycle facilities is a desirable attribute for the branch chief responsible for that area, and we believe it will be easily obteined by our current branch chief. It is not the only attribute necessary for effective oversight of the project. The current branch chief has many desirable attributes, including over 27 years of technical, engineering, and regulatory experience demonstrating proven ability to provirie effective oversight of any complex program which would easily include the fuel cycle program. Our decision to move a proven; experienced branch chief, one who has consistently achieved cutstanding performance, was made with the knowledge that the NRC, the region, and the individual manager would benefit from that assignment. To date, the individual already has attained a good working knowledge of those facilities and has contributed to that program, thus providing a new perspective and enhancing our regulatory oversight of the fuel cycle facilities in Region 111.

1 Regarding the availability of experienced technical staff in the fuel cycle area, please note that both GDP's are fully staffed with two certified experienced resident inspectors, and two very experienced and technically sound inspectors soon approaching full " resident" i

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C. Paperiello 2-i certification. In addition, since the IMPEP review, another regional inspector has become f

fully certified and is performing independent inspect' en activities. An additional regional 4-

. inspector is expected _to be fully certified within the next calendar quarter.

l We look forward to the Management Review Board to be scheduled in the near future and i

trust that the team will consider our response to the recommendations in their l

deliberations.-

_l if you have any questions regarding our comments or response, please call Mr. Roy Caniano at (630) 829-9801.

l Attachments: As stated i

cc w/atts: C. Haney, NMSS a

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RESPONSE TO '

l INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM j

1997 REGION lil REVIEW r

1.0 Introduction next to last sentence of first paragraph: The discussion with Region til management occurred on April 25, not March 25.

3.1 Status of Materials inspection Proaram last sentence, first paragraph: The Branch Chiefs have principal responsibility for the inspection program, not just the scheduling of inspections, top of page 4,8th line down: This shouM read " supervisor changes the next inspection date after reviewing the field notes,..."

bottom of page 4, last paragraph, last full sentence on this page and sentence that goes to top of page 5: We believe the material provided to the reviewer concerned reports from the Fuel Cycie Brr.nch, so it may be that the discussion of a " late" trend re!:t:s to that group. For the Decommissioning Branch, only 5 of 26 reports j

were issued to excess of 30 days for FY 97 (less than 20%), and of that, only one of 14 was issued in excess of 30 days since January 1,1997. This would not i

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support any trend regarding the number of late reports increasing in the l

Decommissioning Branch.

top of page 5, sixth line down: This should read " transmittal of inspection findings; however, they believed it was..."

l 3.2 Technical Staffino and Trainina l

second paragraph, second line: The correct number of branches is five.

page 6, first full paragraph, first line: The word should be individuals, not l

individual.

page 6, first full paragraph, last line: This should read "that some vacant positions had been filled by rotational assignments."

page 6, third full paragraph, seventh line; and third full paragraph, last line: The requirement to attend H-201 applies to both license reviewers and inspectors, not just license reviewers.

t page 1 of 4

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3.3 Technical Quality of Licensina Actions first full paragraph, first sentence: This should be clarifie'd so ; bat the reader understands there were 29 licensing actions reviewed for 21 ficense files. For example: "... license reviewers for 21 specific licenses that had 29 licensing actions..."

page 8, third line: The correct verb should be "was observed."

page 8, second full paragraph, fourteenth line: The corsect verb is

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page 8, third full paragraph, seventh and eighth lines: Four staff members have keys to the safe (our region does not use combination locks). The keys are kept by two Branch Chiefs, which are called FAIC Managers, in addition to the two other titles ste. 4.

3.4 Technical Quality of Inspections second paragraph, next to last sentence: This should read " Inspectors observed licensee activities, toured facilities, and reviewed licensee records."

page 10, fourth paragraph, last sentence: An end of quotation ir 'issing after the word self-assessment. The title is " quarterly inspection self-asses. 4ent" Of note, these self-assessments are not limited to the materials inspection area. Self-assessments are also performed by the Fuel Cycis Branch, Decommissioning i

Branch, and Materials Licensing Branch.

page 10, fifth paragraph, first sentence: The word "the" should be' deleted in front of survey meter.

1 page 10, fifth paragraph, last sentence: The word "that" should be deleted in front of survey meter.

page 10, sixth paragraph, second sentence: the verb should be " included" instead of include.

I page 11, third futi paragraph, first sentence: The sentence should utilize the past tense in discussing the region's awareness ~of the problems and implementation of corrective actions, as this was identified by the region several months before the review team arrived.

page 11, third full paragraph, second sentence:..The correct word is " recommends" rather than recommendation.

j 3.5 Response to incidents and Alleaations l

first paragraph, last sentence: This should read a " Materials inspection Branch Chief."

1 page 2 of 4

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fifth paragraph, fifth line: The title of AGM 96-02 should be rechecked. As written, the word "and" should'be "an" in the title, page 13, first full paragraph, tenth line: The line should read "an alleger's identity' i

from..." Also, although not stated in the report, it should be noted that the e-mail j

in question involved an inspection conducted by another region and the information forwarded to Region Ill.

j 4.1 Performance Aaainst Oneratina Plan Goals second paractaph under Materials Licensina. ninth and tenth lines: Item 1 of the list should clarify tiiat the reassignments are on a tamporary basis. In addition, th'

(???) shoutcl be deleted on the tenth line and the item modified to " monthly" i

briefings rather than bi-monthly.

page 15, first" paragraph, tenth line: The quotation mark should be in conjunction with the previous sentence's period, rather than the next sentences beginning, e.g.,

"...as appropriate." Based 4 ' the..."

page 15, second full paragraph, second line: The correct word is "its" rather than "the" in the sentence "...and the Region's productive use of its resources, the review..."

i 4.2.3 Technical Staffino and Trainina l

first paragraph, lines two, six, and eight: Delete the word " project" preceding the j

word " inspector" when used in the context of fuel cycle inspectors. Allinspectors in the Fuel Cycle Branch have the title " Senior Fuel Cycle Inspector" or " Fuel Cycle

~l Inspector."

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4.2.5 Response to incidents and Alleastions second paragraph, first sentence: The use of the term " grounded" is not clear. We suggest using the word founded, supported, or based.

page 19, last paragraph in section 4.2.5, first sentence: This should be clarified to indicate that the few allegation responses are associated solely with the Fuel Cycle facilities. We suggest the sentence be expanded as follows: "... to relatively few allegations involving fw ;ycle facilities during the review period."

4.3 Site Decommissionina IVlanaaement Plan First paragraph, eighth line: The word should be Region's.

4.3.1 Quality of SDMP Decommissionina Reviews First paragraph, second line: The word Mallinckrodt is misspelled.

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page 3 of 4

All paragraphs in sections 4.3 1, 4.3.2, 4.3.3, 4.3.4, 4.3.5, and 4.3.6: The present tense is used throughout these sections, rather than the correct use of the past tense. Almost all verbs need to be revised to incorporate the correct use of the past tense, i.e., are becomes mre, is becomes was, requires becomes required, reflects becomes reflected, etc.

fourth paragraph, first sentence: A "the" should be added before IMC for clarity.

M.2 Financial Assurance for Decommissionina second paragraph, second and third sentences: As noted earlier, the region has four individuals who have keys to the safe. These sentences should state: "There is a Financial Assurance Instrument Custodian, Alternate Financial Assurance Instrument Custodian, and two Financial Assurance Instrument Custodian Managers. Four people in the region he.ve the keys to the safe."

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4.3.3 Termination Radioloaical Surveys l

first paragraph, first line: The correct word is ensures" rather than " insures."

second paragraph, second word: Tbc word should be "requetts" rather than

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request.

page 22, sixth line: The Decommissioning Branch inspectors do the fulllicense review for termination, rather than just oversee the effort. This line should read as follows: "... from this Branch would conduct the review to support termination of the license."

5.0 Summary recommendation 2: the end of the sentence should state " program and progress on the "get-well" plan."

Aooendix F Reaion 111 incident Files Reviewed File 6 - a Confirmatory Order was sent to.he Army, not a Confirmatory Action Letter.

Aooendix G Reaion ill SDMP and Degornmissionina Files Reviewed File 4 - Mallinckrodt is misspelled as Mallinkrodt.

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i Attachr t 2 l

REGION lli RESPONSE TO 1997 IMPEP TEAM RECOMMENDATIONS f

Recommendation # 2: MIS!} tad Reaion til manaaament should closelv monitor implementetion of the laboratorv QA/OC proaram and oroaress on the "oet-well" olan, i

$tgtion 3.4)

RESPONSE: Region til concurs with this recommendation. Since the time of the IMPEP review the"get-well" program has been formalized into a specific action plan. The plan l

addresses every "get-well" program item, along with other items deemed likely to benefit from specific tracking; it assigns specific dates and responsible parties; and, it provides for periodic Region ill management review. This plan has been shared with senior NMSS l

management and responsible staff, and provisions have been made to keep headquarters staff informed of progress on the plan. In addition, a senior NMSS manager has been invited (and has agreed) to visit Region lil and review our progress in action plan implementation. Lastly, as part of Region Ill's initiative to perform self assessments of l

various program areas, we are planning to perform a self assessment of our progress on the act:on plan. This is planned for mid-FY 1998, approximately six months after I

completion of a formal RESL audit of the same area, which is planned for early FY 1998.

NMSS will be informed of the results of that audit.

i Recommendation # 3: Reaion 111. in coordination with NMSS and its contractor (RESL).

f;hould ensure that independent audits of the laboratory are conducted to ensure that an adeauate QA/OC oroaram is imolemented and maintained. (Section 3.4) l RESPONSE: Region lli concurs with this recommendation. Laboratory inter-comparisun

. samples are now processed routinely. Region ill DNMS management have established a formal bi-monthly schedule for management review of the results of the rest,lts of intercomparisons. This information will be made aveitable to NMSS on a routine basis, in addition, as discussed with the region at the IMPEP exit, NMSS has assured that funds will s

be available to permit a formal RESL audit of Region lliin early FY 1998. Region lli fully l

supports this audit proposal.

Recommendation # 4: Reaion 111 should examine all procedures or documents relatina to the handlina of clieaations to ensure that they are consistent with MD 8.8 and IMC 2800.

Guidance on elvetronic transmittal of alleaation relatea material should be included in the orocedures. In addition, the orocedures or documents should exoticitiv state that information referrina to an alleaation should not be included in the docket file. (Section 3.5)

RESPONSE: Region lit concurs with this recommendation. The Regional Administrator has placed a great deal of emphasis on how Region ill handles allegations. As part of that, special assigned staff are currently in the process of revising the regional procedure on the handling of allegations. It is our intent that this procedure will be consistent with MD 8.8 and IMC 2800. It willinclude guidance on what documents should not be placed in the U

docket file and guidance on electronic transmittal of allegations, it is expected that the j

regional procedure will be issued shortly, in the interim, staff has been provided guidance j

on proper document control related to allegations.

Recommendatiens #1 and #6 were directed to NMSS.