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WS 0 1991 MEMORANDUM FOR: John B. Martin, Regional Administrator Region V FROM:
Glen L. Sjoblom Deputy Director Division of Industrial and Medical Nuclear Safety, NMSS
SUBJECT:
FINAL 1991 NATIONAL PROGRAM REVIEW REPORT REGION Y Enclosed is the 1991 National Program Review (NPR) report for Region V.
This report covers the period between our last two NPR team visits (roughly April 1990 through March 1991).
For the second year, the report includes not only all regional activities under NMSS' oversight authority, but also the enforcement activities related to these licensees, as reviewed by the Office of Enforcement.
NMSS circulated a draft version of this report to the region's Division of Radiation Safety and Safeguards.
These comments have been incorporated into
. this final version of. the NPR report, as appropriate.
As always, we appreciate the efforts of your regional staff throughout the year and we welcome any additional thoughts you might have that might lead to further improvements in our review process.
Glen L. Sjoblom, Deputy Director Division of Industrial and Medical Nuclear Safety, NMSS
Enclosure:
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REPORT OF NMSS NATIONAL PROGRAM REVIEW AT NRC REGION V. FEBRUARY 26-27, 1991 1 BACKGROUND AND PURPOSE This report provides the results of the Office of Nuclear Material Safety and Safeguards (NMSS) review of Region V programs under the Headquarters responsi-bility of NMSS. The Headquarters team participating in this review consisted of two persons from the Division of Industrial and Medical Nuclear Safety of NMSS, one from the Division of Safeguards and Transportation, and one from the Division of Low-Level Waste and Decomissioning (Attachment 1). Additional input from other elements of NMSS and the Office of Enforcement was used in the preparation of'this report. The principal regional activities are primarily under the responsibility of the Region V Division of Radiation Safety and Safeguards (DRSS). The DRSS organization chart is shown on Attachment 2.
A January 25, 1991 memorandum from Richard Cunningham listed the areas to be covered and transmitted a questionnaire to the regions.
Region V responses to the questionnaire are shown on Attachment 3.
The National Program Review (NPR) is based not only on the visit to the Region, but also on the collective Regional / Headquarters interfaces throughout the year, through review of some licensing casework, inspection reports, accompaniments or region-based inspectors, casework and inspection statistics, resource utiliza-tion, technical assistance and coordination, and the quest 1canaire. The NPR is intended to provide a review of effectiveness of both the Region and Headquarters activities insofar as they relate to Region V activities and to identify sugges-tions for improving the effectiveness of the joint efforts of NMSS, OE and Region V.
The ernphasis relates to achieving two goals:
technical quality and timely completion of licensing casework and inspections, on the basis that both elements contribute to assuring the safety and safeguards of operations involving NRC licensed activities.
The report is organized so as to present an integrated summary in each of the following areas:
1
'4 1.
Background and Purpose 2.
Licensing 3.
Inspections 4.
Enforcernent 5.
Training 6.
Initiatives 7.
Interfaces of Region / Headquarters 8.
Resource Utilization 9.
Recomendations/ Suggestions 1
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2 LICENSING a.
Materials Safety Region V currently regulates approximately 300 byproduct materials licensees.
In FY90, they completed 209 licensing actions, as compared against an adjusted Operating Plan Target of 190 (110 percent). They received 243 cases during this timeframe. Through February 28, 1991, the Region had completed 96 cases, which helped to reduce the number of pending cases to 49, and put them ahead of their licensing goal for the fiscal year.
The Region continues its diligent oversight of " backlogged" cases. At the time of the NMSS visit, all but two of the 11 backlogged cases required special technical support from NMSS on financial and/or decommissioning issues.
The Region still has two cross-qualified reviewers to support the materials licensing program. These people split their effort as reviewers and inspectors and have reduced the burden on the primary license reviewer.
The Headquarters staff reviews a fraction of completed materials licensing actions and inspection reports as they are completed by the Regions. Both licensing and inspection actions are in accordance with Standard Review Plans.
Inspection Manual Chapters, and other guidance documents. Region V staff has sought guidance via telephone or technical assistance requests on matters that are technically complex or may have policy implications. They have suggested that Headquarters continue to upgrade certain reviewer guides, such as well-logging, license conditions and model licenses. The Region continues to use telephone contacts for minor deficiencies in licensing submissions to maintain excellent turnaround time.
One item pf concern to the Regional staff relates to the poor oversight exercised over radiation safety by Veterans Administration licensees, and the lack of clear assignment of responsibilities and authorities at certain hospitals.
Region Y recommended that the Regions and Headquarters work together to develop licensing 4
and inspection strategies to iniprove licensee oversight of radiation protection i
3 i
l 4
programs at facilities with medical licenses of broad scope.
Region Y management volunteered to take a major role in this area.
)
Region V is developing a quality assurance program for materials licensing reviews.
The procedure involves documented evaluation and peer review of licensing actions. Currently, the Branch Chief is reviewing 100 percent of licensing actions.
NMSS supports this initiative but recomends that Region V consider what appropriate sample size should be selected.
Region V staff con-tinue to follow NMSS guidance and to inform NMSS when unusual or significant issues arise during licensing actions.
Region V reviewers expressed a desire to have NMSS-Regional workshops which focus on resolution of licensing issues.
NMSS was requested to expedite the issuance of final guidance documents once coments on drafts have been received.
If a decision is made not to issue guidance, NMSS should quickly inform the Regions.
NMSS was asked to encourage prompt training when rule changes occur.
In parti-cular, training in the revised 10 CFR Part 20 and the status of equipment changes in response to revisions of 10 CFR Part 34 were noted as priority items.
The Region also recomended that NMSS should update guidance on the current status of the Service and Training Information System.
b.
Safeguards Licensing Region V received and completed two 10 CFR 70.32 case reviews during FY90 and had no inventory of cases at the end of the fiscal year. These reviews were performed in a sound technical manner and were consistent with NRC policy and guidance.
Regional management indicated that additional guidance was needed regarding route and port surveys. One particular issue was the use of cellular telephones as a second form of comunication. This has been programed and will be finished late in FY91.
c.
Low-Level Waste Licensing pos s e re s f r e aluat on p rio
4 3 INSPECTIONS a.
Materials Inspections In FY90, 152 materials safety inspections were completed compared to a goal of 125. The Region exceeded its unadjusted goal by 22 percent. This figure includes a large percentage of inspections of the Department of Agriculture, U.S. Air Force and U.S. Navy permittees, which are licensed by other regions.
Through January 1991, the Region had completed 37 inspections.
The annual goal is 133, so the Region was somewhat behind due to the additional effort required for the inspections / investigations and escalated enforcement for Tripler Army Medical Center and Fewell Geotechnical Engineering and the response to the contamination and inspection at San Ofego VA Medical Center.
It was also noted, they had only one (priority V) inspection overdue.
Based on a review of scheduled future inspections, the Region does not expect to have a problem meeting its inspection goal.
The Region is encouraging safety-oriented, performance-based inspections that emphasize the licensees' implementation of safety programs rather than paperwork.
The Region's response to incidents at the Tripler Army Hospital and the San Diego VA Hospital were particularly noteworthy.
As further evidence of Region V's close, contact with its licensees, they held a workshop for medical licensees in Hawait in FY90 to discuss the regulatory requirements of 10 CFR 35 and the proposed quality assurance rule.
This work-shop was well received and may have contributed to the reporting of the signi-ficant exposure of a nursing infant at a Hawaiian medical facility. The Region is considering a similar workshop this year in Alaska where medical licensees are even more isolated than in Hawaii.
The vacancy created by the retirement of one of the materials inspectors was filled by the reassignment of an inspector from the Emergency Preparedness Section. However, the inspection program was still understaffed by one at the time of the visit. Regional management expected to fill the vacancy soon, perhaps by reassignment of Regional personnel. The Region not only met FY90 program requirements for numbers of inspections but maintained an outstanding average turnaround time for inspection documentation of 12 to 13 days. The 5
Region continues to support NMSS program goals by use of performance evaluation factors, prompt acknowledgement of licensee corrective actions in response to Notices of Violation and use of Fo'a 591 to document minor violations.
Regional and NMSS managers diset h d the use of the core program in planning the materials inspections. Agri meant was achieved that the expectation was to complete all inspections in the Operating Plan. Core inspections are expected to be completed under all circumstances.
Non-core inspections are to be repro-grammed only if Regional management identifies to NMSS significant, unbudgeted safety initiatives which require urgent attention.
Regional staff raised issues concerning measurement of on-site or direct-inspection-effort (DIE), more contact with inspectors at other Regions, and the use of counterpart meetings to resolve policy issues. Regional management holds inspectors responsible for scheduling inspection time to achieve 27 percent DIE.
NMSS representatives recommended that Regional management review scheduling of inspections, particularly travel time, to determine if this was the appropriate standard.
In particular, NMSS has budgeted slightly higher labor rates to Region V to account for geographic considerations not relevant to more compact Regions. Regional staff supported the concept of inter-regional team inspections of significant materials and fuel cycle programs.
Regional staff supported counterpart meetings at all management levels. The recent Division-level meeting Wds noted to have been particularly productive.
The Region suggested a trial program of announced inspections of radiographers in order to observe more field activities. NMSS supports this initiative which is permitted under current guidance in Inspection Manual Chapter 2800 and asks Region V to provide periodic feedback on its experience with this activity.
b.
Safeguards Inspections With the transfer of Material Control and Accounting (MC&A) inspection activities to Headquarters and the closing of the GA Category I Fuel Facility, region &l inspection activities were decreased accordingly in FY90. As a result, Region V completed three physical security inspections during FY90.
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Safeguards Transportation Inspection programs Region V completed one safeguards transportation inspections in FY90.
No route surveys were request by Headquarters in FY90.
d.
Fuel Cycle Inspections The fuel cycle inspection program is conducted by a Senior Fuel Facility inspector, who was reassigned into the Nuclear Materials and Fuel Fabrication Branch during the past year. He receives technical support from other specialist.
in the Regions and from NMSS licensing staff. There appear to have been no adverse effects from the minor reorganization, which has helped to centralize nearly all of the NMSS functions in one Branch.
Based on NMSS' review of completed inspection reports, Region V prepares clear, understandable inspection reports that demonstrate good recognition of the safety issues. The reports reach defensible conclusions and are completed with the best overall turnaround time of any Region. The Region also initiates appropriate enforcement actions, as necessary.
During the past year, the inspector, along with a co-op student, completed the reorganization of all fuel cycle facility files. This has allowed him to pre-pare more thoroughly for upcoming inspections, and to maintain more complete historical records on Region V facilities.
At the time of the NMSS visit, the inspector was preparing to participate in an operational safety team inspection in Region II, and was inviting a Region II inspector to participate in his assessment of ANF, tentatively scheduled for August. These interregional efforts should help assure a healthy exchange of ideas between Regional inspectors.
In FY90, the Region did not fully expend its budgeted resources in the fuel cycle program. However, there was no program impact.
Because of this, NMSS recommends the possi.ble transfer of some fuel cycle inspection resources to the materials inspection program.
7
e.
Safety Transportation Inspections Programs Region Y continues to conduct inspections of transportation activities as part of its materials, reactor, and fuel cycle inspection program activities. The appropriate inspection modules are used by inspectors.
Review of Region V's program shows that inspection programs are being conducted generally by inspec-tors who are knowledgeable of and experienced in the transportation regulations.
Reports are of very high quality.
It was noted that inspectors had available appropriate reference material such as Title 49 of the Code of Federal Regula-tions (Transportation) Parts 100-199.
New reference materials will be sent by NMSS to the Region as those materials become available.
e.l.
Material Inspection program During FY90, 104 materials inspections involving transportation issues were performed.
Eleven items of noncompliance were observed.
None of these items were escalated. Through February 1991, 9 inspections with one item of noncom-pliance were observed.
Each of these inspections took an hour or more to perform.
For these inspections, the field note format was used. This format contains a section related to transportation. This section is consistent with Inspection Module 86740. A review of current inspection reports showed that the transpor-tation section had been completed as appropriate. Documented violations included failures in properly completing shipping papers, failure in properly labeling packages, and failure in adequately blocking and bracing packages during transport.
Folicwup was adequate.
e.2.
Fuel Facilities - All licensea fue.1 facilities were inspected using Module 86740. These inspections were performed primarily by one inspector whose trans-pori.ation knowledge and experience greatly contributed to transportation safety.
No violations were identified. Up to 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> of effort was involved.
e.3.
Reactors - During FY90, transportation activities were inspected at all operating reactors according to the SALP inspection frequency. Procedure 86750 was used. One item of noncompliance related to proper blocking and bracing was noted.
e.4.
Research Reactors - Six inspections with no items of noncompliance were performed between January 1990 and February 1991. The appropriate inspection module was used in all cases.
f.
Low-Level Waste The Region V low-level waste licensing program was reviewed in the reactor, fuel cycle, and materials areas. The review consisted of interviews with the Director of DRSS, the appropriate Branch Chief, inspectors responsible for conducting low-level waste inspections, and examination of the inspection files.
Region V con-ducted inspections of low-level waste related issues for all reactor sites, fuel cycle facilities and disposal sites and for materials licensees, as appropriate during FY90. All inspectors in the Region are required to perform the full range of inspection activities for these facilities and appear knowledgeable in the area of low-level waste.
In the area of reactor inspections, the inspection effort apparently exceeds the SALP inspection frequency and one facility has received attention as a Regional initiative.
No storage problems were identified for reactor facilities.
In the fuel cycle area, one inspector is responsible for conducting low-level waste inspections. One fuel-facility has a large quantity of stored material which is being processed through incineration.
In the raaterials area, most waste is held for decay.
There were no escalated low-level waste enforcement actions during this period.
The Region inspected the special nuclear material licenses of U.S. Ecology's Richland, Washington disposal site on September 11, 1990.
The inspector was accompanied by a project manager from NMSS and they looked at the areas of training, radiation protection, receipt and transfer of material, environmental monitoring and items contained in the facility performance reporting require-ments section of the license. No apparent violations were found.
9
i 4 ENFORCEMENT l
The Region V performance in the enforcement drea are being formally evaluated by the Office of Enforcement. Nonetheless, the NMSS team leader met briefly with a member of the Region enforcement staff and other Region V personnel.
From these discussion, a few observations were made:
i Regional staff noted that enforcement actions would be less complex if requirements were clearly stated in unambigious terms.
In particular, the use of annual or semi-annual requirements for tests or audits may be subject to various interpretations. Guidance regarding interpretation of supervision by authorized users at medical facilities was requested by Regional staff.
Region Y management noted that recent strong enforcement actions appear to be effective in notifying other licensees of the importance of complying with NRC requirements. One firm posted a manpower article about an enforcement action and told employers that the "NRC means business."
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10
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5 TRAINING Region V provided HMSS with the training records for the six staff members of the Nuclear Materials and Fuel Fabrication Branch. The Region continues to use the current, but soon-to-be-revised training requirements as stated in Inspection Manual Chapter 1245 and, with minor exceptions, the staff has met all such requirements. NMSS provided the Region with a copy of the new requirements so that the Region V staff could schedule themselves for upcoming courses.
In particular, some members of the Region should try to enroll in (H-312) Whole Body Counting / Internal Dosimetry, and two of the newly required courses - OSHA Orientation (H-107) and Effective Canmunications for NRC Inspectors. Overall, the Region deserves credit for enrolling appropriate staff members in courses as they are announced.
In the case of Region V, this has sometimes required extensive travel to attend courses offered in Chattanooga or in another Region.
In addition, approximately 35 technical, administrative and computer training courses were offered in the Region between December 1989 and February 1991.
Most of these were one-day courses many of which were offered two or more times to allow attendance by most members of the regional staff.
The Region is aware of the fact that once its inspector vacancy is filled, that individual will need to begin completing the new IMC 1245 required courses. The Region also learned that refresher training in the transportation area will be available soon from the new NMSS Sr. Transportation Specialist.
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6 INITIATIVES BY THE REGION The following Region V initiatives were under way throughout the past year:
The Nuclear Materials and Fuel Fabrication Branch was created. This reorganization brought the fuel cycle inspector into the' Branch with the nuclear materials staff.
In so doing, nearly all of the NMSS functions are now performed by this one organizational unit.
The Division of Radiation Safety and Safeguards, in an attempt to conserve resources, has abolished its Section Leader positions.
This move has helped to reduce overhead to some extent, although it has placed additional administrative responsibilities on the Branch Chiefs and some senior staff members.
(It should be noted that in Region IV, the move was made to abolish Branch Chiefs, but retain Section Leaders.)
The Region continues to expand its cross-training program.
In past years, the concern had been that the materials licensing and fuel cycle inspec-tion functions were carried out by only one person each and that inadequate backups were available. However, the Region has done a fine job in the last two years to support these two key individuals. This is a constant concern in a Region with relatively few resources, but Region V seems to have struck the proper balance in its staffing.
A medical workshop was held in Hawaii to discuss the regulatory requirements of 10 CFR 35 and the proposed quality assurance rule. Their work may have led to the reporting of a significant event a short time later at a medical facility.
12
J 7 HEADQUARTERS / REGION V INTERACTIONS Both NMSS and Region V believe that interactions have been useful and effective in all the areas in inspection and licensing. Region V has been very responsive to HMSS requests for information or short-term requests for special inspections.
NMSS and Region V cooperated closely in investigations at the Tripler Army Medical Center and the San Diego VA Hedical Center.
The interaction between the Region V fuel cycle inspector and Headquarters licensing staff was considered excellent. NHSS is expected to provide support for the upcoming team assessment later this summer. The counterpart calls also worked out well.
Region V materials licensing and inspections staff and HMSS staff cooperated at i
the medical workshop conducted during the past year. Regional staff expressed a need for more NRC staff workshops and counterpart meetings.
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e 8 RESOURCE UTILIZATION The table on the following page shows Full Time Equivalent (FTE) allocations for FY90 and FY91 through January 1991.
Because Region V has the fewest materials licensees, only about 300, it has the fewest resources allocated to support NMSS activities.
This makes it essen-tial for the Region to maintain full staffing for each of its budgeted positions and to assure that cross-training has occurred for functions performed primarily by one person.
To the Region's creoit, this cross-training approach continues to work well.
The primary materials license reviewer is receiving some support from two other individuals who were primarily inspectors.
The fuel facility inspector receives good support from other technical specialists in the Division and from his licensing counterparts at Headquarters.
The safeguards inspector also has a qualified backup.
At the time of the review, two vacancies existed. One was due to the difficulty of finding suitable candidates.
The other was the Licensing Assistant position.
Recruiting external candidates has always been difficult for Region V because of the high cost of living in the Bay Area.
Nonetheless, recruitment efforts were under way to fill both positions and the process was moving without delay.
HMSS agreed to refer any qualified Health Physicists to Region V to help fill the inspector position.
The Region continues to adjust its inspection activities in accordance with changes in licensee operations at several of its fuel facilities.
Therefore,
for the second consecutive year, it did not fully expend its budgeted allotment in FY90 and is not expected to do so in FY91.
During the visit, NMSS recommended that any unspent resources be reprogrammed from fuel cycle to the materials pro-gram to allow the Region to complete the full FY91 materials licensee inspection program goals required in the FY91 Operating Plan, and to address any unplanned events.
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J In order to reduce overhead and conserve resources, the Division of Radiation Safety and. Safeguards abolished Section Leader positions.
Those functions are now perfonned by the Branch Chiefs and some senior staff members. The long-term impact of thess changes is uncertain, but no major problems surfaced during the review. This. organizational change should be contrasted with a recent change in Region IV in which Branch Chief positions were abolished.
The Region has good clerical support and a conscientious temporary Licensing Assistant. This helped them control their small licensing backlog at the time of the review. The selection process for a permanent replacement was moving along well at the time of the review.
REGION Y RESOURCE UTILIZATION The following table shows FTE allocations and expenditures for the review period FY91 FY90 ANNUAL BUDGET EXPENDED PROGRAM ACTIVITY BUDGET EXPENDED BUDGET OCT-JAN OCT-JAN %
Fuel Facility Licensing 0
0 0
0 0
0 Fuel Facility Inspection 2.0 1.01 51 2.2 0.7 0.30 Materials Licensing 2.0 1.8 90 1.8 0.6 0.53 Materials Inspections 3.2 3.2 100 3.4 1.1 1.26 Event Evaluation 0.6 0.8 133 0.8 0.3 0.29 Transportation Insp.
& Plans 0.3 0.15 50 0.26 0.09 0.01 SG Fuel Facility Lic.
0.1 0.03 30 0.1 0.03 0
SG Fuel Facility Insp.
0.2 0.11 55 0.2 0.07 0
Low-Level Waste 0.2 0.15 75 0.25 0.08 0.03 Decommissioning 0
0 0
0 0
0 Reactor Decomm.
0.2 0
0 0.3 0.1 0.06 Materials Decomm.
0.1 0.2 200 0.2 0.07 0.05 NMS Section Supr.
1.0 0.9 90 1.0 0.33 0
i NMTS Section Sup.
0 0.04 0
0.1 0.03 0
LLW Section Supr.
0.1 0.05 50 0.1 0.03 2.53 TOTAL 10.0 8.44 84 10.71 3.57 2.53 79-NOTE:
FY90 expenditures from regional input provided in response to FYP/ Green Book update in January 1991.
15
9 RECOMMENDATIONS / SUGGESTIONS a.
For NMSS:
1.
Conduct future license reviewer workshops which focus on resolution of issues, not mere discussions of topics.
2.
Expedite the issuance of final guidance documents once comments on a draft have been received.
3.
Encourage RES to provide prompt training when rule changes occur. Part 20 and Part 39 were noted as priority items.
4.
Provide additional guidance on route and port surveys and the use of cellular telephones.
5.
Consider additional reprograming of resources from the fuel cycle area to the materials program.
6.
Develop guidance to clarify standard / license conditions ragarding semiannual and annual tests or audits and to interpret supervision by authorized users of medical facilities.
7.
Review programmatic oversight issues related to medical broad scope j
programs.
8.
Provide status update on the Service and Training Infonnation System.
b.
For Region V:
l 1.
Periodically review the need to perform a 100 percent quality assurance audit of all completed licensing work.
2.
Review its inspection schedules and its travel time to detennine if its direct inspection effort goal is realistic.
16
C 2
3.
Considar conducting announced inspections of radiographers in order to observe more field activities.
4.
Continue to strive for full compliance with the soon-to-be-released training requirements in IMC 1245 (particularly the new courses listed in Section 5 of this report).
5.
Keep NMSS posted on the progress being made to fill staffing vacancies.
17
9 Headquarters Review Team John E. Glenn, Chief, Medical, Academic and Commercial Use Safety Branch, Division of Industrial and Medical Nuclear Safety, NMSS George J. Deegan, Sr. Program Analyst, Operations Branch, Division of Industrial and Medical Nuclear Safety, NMSS Michael Wangler, Sr. Transportation Specialist, Domestic Safeguards and Regional Oversight Branch, Division of Safeguards and Transportation, NMSS Leroy S. Person, Project Manager, Operations Branch, Division of Low-Level Waste Management and Decommissioning, NHSS
- Team Leader 18
4 Jnc./,,e er Taole II-Page l'of 1 ORGANIZATI0rt STRUCTURL i
il DIVISION OF RADIATION SAFETY AND SAFEGUARDS' 4
DIRECTOR - Ross Scarono Deputy Director - Frank Wenolowski Secretary - Chrte. Sorrfgo Secretory - Gene Moller-Duck
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