ML20126B948
| ML20126B948 | |
| Person / Time | |
|---|---|
| Issue date: | 06/03/1985 |
| From: | Murley J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Sencer D NEW YORK, NY |
| References | |
| NUDOCS 8506140259 | |
| Download: ML20126B948 (6) | |
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d June 3, 1985 f
David J. Sencer, M.D., M.P.H.
Commissioner of Health New York City Department of Health 125 Worth Street New York, New York 10013
Dear Dr. Sencer:
This is to confirm the discussion Mr. John McGrath, Region I State Agreements Officer, held with Mr. Jean Cropper on April 26, 1985 following our review and evaluation of the Department's radiation control program.
The review covered the principal administrative and technical aspects of this program and included an examination of the program's legislation and regulations, organization, management and administration, personnel, licensing and compliance.
Field evaluations of New York City inspectors were conducted on April 22-23, 1985.
The review was performed in accordance with the NRC policy defined in the
" Guidance for NRC Review of Agreement State Radiation Control Programs." Those guidelines were published in the Federal Register on December 4, 1981, and define 30 indicators that are used for evaluating Agreement State programs. A description of how the indicators are used in reporting the results of program reviews to State management is enclosed (Enclosure 1).
As a result of our review of the Department's program and the routine exchange of information between the NRC and the Department, the staff believes that the Department's program for regulating agreement materials is adequate to protect the public health and safety. We must once again, however, defer a finding of compatibility until such time as the Department's radiation control regulations are formally adopted.
During our last review of the Department's program, we commented on the fact that although some amendments to the Department's regulations had been prepared, additional changes would have to be considered.
Since that time, the Department's staff has provided revised drafts for NRC review.
NRC comments were provided and a final draft is awaiting NRC concurrence. We appreciate the Department's efforts in this area and will provide our concurrence as soon as possible so that the Department can proceed with the process of formally adopting the amendments.
We have commented in the past on the Bureau's burdensome paperwork requirements.
The Bureau generates an extraordinary volume of paper, particularly in the compliance area in terms of both the number of field forms and the administra-tive forms prepared by the supervisory staff.
The effort spent by the technical staff on these tasks can be more efficiently utilized.
In addition, there is a need to make the documentation of compliance activities more coherent in terms
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8506140259 850603
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r David Sencer, M.D., M.P.H.
2 of what needs to be, and what does not need to be, documented. We believe that the Bureau needs to conduct a thorough review of the forms currently being used with a view toward streamlining and reducing the number of forms. We believe that a more effective use of the Bureau's automatic data processing capabilities is an important aspect of improving overall documentation practices.
Another aspect of documentation practices is filing.
During the review of licensing and compliance actions we noted numerous documents that were misfiled or missing altogether from files. The Bureau staff was unable, in two days, to locate one entire license file.
In addition, and notwithstanding the staff's opinion to the contrary, there did not appear to be a coherent filing system.
Because of the current paperwork requirements, the present clerical staffing level is not adequate to perform all necessary tasks. Technical staff are required to devote too much of their time to clerical duties. We believe that it is essential for the Bureau to get a better handle on the paperwork situation and should (1) simplify and reduce the number of forms; (2) develop a systematic filing system, and (3) provide adequate clerical staff to relieve the technical staff of clerical duties.
Additional comments and recommendations regarding other areas of our review are contained in Enclosure 2.
We would appreciate your review and response to these and the above comments.
In accordance with NRC practices, I am enclosing a copy of this letter for placement in the City Public Document Room, or other-wise to be made available for public review.
I appreciate the courtesy and cooperation extended by Mr. Cropper and other members of your staff to Mr. McGrath during the review.
Sincerely, Original BYstedW ThomasE. Murlex Thomas E. Murley Regional Administrator
Enclosures:
As Stated cc:
L. Solon, MYCH Distribution:
D. Axelrod, NYSH TMurley L. Roberts, NYSL JAllan H. Williams, NYDEC JMcGrath G. W. Kerr, OSP DNussbaumer NRC Public Document Room SP01 City Public Document SAO E
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JRMcGrath/mrf GWKerr W
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Application of " Guidelines for NRC Review of Agreement State Radiation Control Programs" The " Guidelines for NRC Review of Agreement State Radiation Control 1
Programs,' were published in the Federal Register on December 4, 1981 as an NRC Policy Statement. The Guide provides 30 Indicators for evaluating Agreement State program areas.
Guidance as to their relative importance to an Agreement State program is provided by categorizing the Indicators into 2 categories.
Category I indicators address program functions which directly relate to the State's ability to protect the public health and safety.
If significant problems exist in several Category I indicator areas, then the need for improvements may be critical.
Category II indicators address program functions which provide essential technical and administrative support for the primary program functions.
' Good performance in meeting the guidelines for these indicators is essential in order to avoid the development of problems in one or more of the principal program areas, i.e. those that fall under Category I indicators. Category II indicators frequently can be used to identify underlying problems that are (ausing, or contributing to, difficulties in Category I indicators.
It is the NRC's intention to use these categories in the following manner.
In reporting findings to State management, the NRC will indicate the category of each comment made.
If no significant Category I coments are provided, this will indicate that the program is adequate to protect the public health and safety.
If at least one significant Category I comment is provided, the State will be notified that the program deficiency may seriously affect the State's ability to protect the public health and safety and should be addressed on a priority basis. When more than one significant Cat c y I comment is provided, the State will be notified that the ne % of 1provement in the particular program areas is criticab
' ro (C would request an immediate response, and may perform.,oV.s op review of the program within six months.
If the State program has not improved or if additional deficiencies have developed, the NRC may institute proceedings to suspend or revoke all or part of the Agreement. Category II coments would concern functions and activities which support the State program and therefore would not be critical to the State's ability to protect the public. The State will be asked to respond to these comments and the State's actions will be evaluated during the na t regular program review.
1 ENCLOSURE 2 COMMENTS AND RECOMMENDATIONS ON THE NEW YORK CITY DEPARTMENT OF HEALTH RADIATION CONTROL PROGRAM I.
Training Training is a Category II indicator
' Comment The~ Bureau staff, although having a technical background, have not all had additional formal training in radiation protection.
Recommendation We recommend that Mr. Mazzola and the Bureau's new staff person, who we understand does not have formal radiation protection training, attend the NRC sponsored 5-week course in Health Physics and Radiation Protection.
In addition, we recommend that Mr. Kamble attend the NRC courses in licensing practices and procedures, in view of his new duties in the licensing area.
II.
Technical Quality of Licensing Actions Technical Quality of Licensing Actions is a Category I indicator.
The following comments and recommendations are considered minor in nature.
Comment The Bureau has issued licenses authorizing material and. procedures not requested in the licensee's application, specifically the authorization for Group III when'no isotope generators were requested.
Recommendation The Bureau should review licenses more carefully to assure that licenses authorize the material and procedures requested and that authorization for Group III is fully supported by information in the file.
2 Comment The Bureau has issued. licenses for Group VI materials and procedures where applicants did not provide information on periodic inventories or procedures for transporting sealed sources within the institution.
Recommendation Notwithstanding the fact that the City Health Code requires a quarterly inventory, the Bureau should assure that an applicant's procedures address this point.
The Bureau should also assure that the applicant,has adequate procedures for transporting sources.
III. Enforcement Procedures Enforcement Procedures is a Category I indicator.
The following comment and recommendation is considered minor in nature.
Comment Licensee violations of the Health Code or li. cense condition are currently being written up on Department Form 148E and lef t by the inspector at the licensed facility.
148E's are not always prepared in a manner that clearly describes the violation.
Bureau inspectors have, at management's direction, specifically refrained from referencing the Code Section or license condition being violated.
When a 148E is followed up by an enforcement letter, the violation is clarified and an appropriate Code Section or license condition is cited.
Recommendation We recommend that all enforcement correspondence be clear and specific as to'the violation, referencing the appropriate Code Section or license condition.
During our summary meeting with Deputy Commissioner Cropper, the use of Form 148E was discussed in detail.
As a result of that discussion it is our understanding that the Bureau could discontinue the practice of leav-ing a 148E at each " site" inspected and instead provide the inspection results to the licensee in an enforcement letter summarizing the " site" inspections. We feel that this would be a substantial improvement in the Bureau's procedures.
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IV.
Inspection Reports Inspection Reports is a Category II indicator.
Comment The documentation of inspection findings remains a problem area for the Bureau.
On the one hand, the Bureau uses a variety of forms and produces an extraordinary amount of paper.
On the other hand, however, the documentation does not always provide useful information in a readily retrievable, convenient form.
For example, some inspections result in multiple copies of Forms 148E, RC-10, RC-16, and RC-17 (for some licenses as many as 100 copies each).
However, in some cases the information pro-vided by the inspectors is not in sufficient detail to draw conclusions about the adequacy of the licensee's program.
Recommendation We believe that the Bureau should consolidate and simplify the forms that are now being used in the radioactive materials inspection program.
The Bureau also needs to assure that inspection documentation provides sufficient detail to assess the adequacy of the licensee's radiation protection program.