ML20129B486

Draft Integrated Matls Performance Evaluation Program Review of Nebraska Agreement State Program, on 960715-16

ML20129B486
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Issue date:	10/16/1996
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INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW OF NEBRASKA AGREEMENT STATE PROGRAM JULY 15-19,1996 j

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DRAFT REPORT I

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U. S. Nuclear Regulatory Commission 10/16/96 a

9610230026 961016 PDR STPRG ESGNE PDR l 'l y., o - - -

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1.0 INTRODUCTION

This report presents the results of the review of the Nebraska radiation control program.

The review was conducted during the period July 15-19,1996, by a review team i

comprised of technical staff members from the Nuclear Regulatory Commission (NRC) and 4

the Agreement State of Colorado. Team members are identified in Appendix A. The review was conducted in accordance with the " Interim implementation of the Integrated Materials Performance Evaluation Program Pending Final Commission Approval of the -

Statement of Principles and Policy for the Agreement State Program and the Policy i

Statement on Adequacy and Compatibility of Agreement State Programs," published in the j

Federal Register on October 25,1995, and the September 12,1995, NRC Management j

Directive 5.6, " Integrated Materials Performance Evaluation Program (IMPEP)." Preliminary results of the review, which covered the period June 25,1994-July 12,1996, were l

discussed with Nebraska management on July 19,1996.

l' (Paragraph on Results of MRB meeting will be included in final report. Attachment 1, a

State's response will be included in final report.)

The Nebraska Department of Health (NDOH) is the agency within the State of Nebraska govemment that regulates, among other public health issues, radiation hazards. The l

Director, NDOH, is appointed by, and reports directly to, the Governor. Within NDOH, the j

Nebraska radiation control program, excluding X-ray, is administered by the Division of

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i Environmental Health, under the Environmental Health Protection Section (EHPS). The Department of Health and the Environmental Health Protection Section organization charts j

are included as Appendix B. During the review period the Nebraska program regulated 157 specific licenses, which includes four large irradiators, manufacturers, broad academic, broad medical, radiopharmacy, radiographers, and the program is in the process of conducting a licensing review of a low-level radioactive waste disposal site. The low-level i-

!adioactive waste (LLRW) disposal regulatory program is jointly administered and managed by NDOH and the Nebraska Department of Environmental Quality (NDEO) through a Memorandum of Understanding, in addition to its radioactive materials and low-level

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j radioactive waste disposal programs, NDOH is responsible for the control of machine l

produced radiation and radon, and emergency response planning for two nuclear power l

plants. The review focused on the materials program as it is carried out under the Section i

274b. (of the Atomic Energy Act of 1954, as amended) Agreement between the NRC and l-the State of Nebraska.

i in preparation for the review, a questionnaire addressing the common and non-common indicators was sent to t% State on May 17,1996. Nebraska provided its response to the questionnaire on June 17,1996. A copy of that response is included as Appendix C to l

this report.

The review team's general approach for conduct of this review consisted of: (1) examination of Nebraska's response to the questionnaire, (2) review of applicable Nebraska statutes and regulations, (3) analysis of quantitative information from the i

radiation control program licensing and inspection database, (4) technical review of selected files, (5) field accompaniments of five Nebraska inspectors, and (6) interviews with staff and management to answer questions or clarify issues. The team evaluated the information that it gathered against the IMPEP performance criteria for each common and non-common indicator and made a preliminary assessment of the radiation control i

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Nebraska Draft Report Page 2

1 program's performance. As noted above, that preliminary assessment was discussed with program management before the team's departure.

2.0 STATUS OF PREVIOUS REVIEW The previous routine review concluded on June 23,1994, and there were no recommendations made following the previous review of the radiation control program.

Results of the current review for the IMPEP common performance indicators are presented in Section 3. Section 4 discusses results of the applicable non-common indicators, and j

Section 5 summarizes the review team's findings and recommendations.

3.0 COMMON PERFORMANCE INDICATORS The IMPEP process uses five common performance indicators in reviewing both NRC 4

regional and Agreement State programs. These indicators are: (1) Status of Materials inspection Program; (2) Technical Staffing and Training; (3) Technical Quality of Licensing Actions; (4) Technical Quality of Inspections; and (5) Response to incidents and Allegations.

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3.1 Status of Materials insoection Proaram i

The review team focused on four factors in reviewing this indicator: inspection frequency, overdue inspections, initial inspection of new licenses, and timely dispatch of inspection findings to licensees.

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Review of the State's inspection priorities showed that the State's inspection frequencies j

for the various types or groups of licenses are with few exceptions, at least as frequent as l

similar license types or groups listed in the frequency schedule in the NRC Inspection l

Manual Chapter (IMC) 2800. The State, in their response to the questionnaire, identified three types of licenses that were inspected at a frequency less than IMC 2800, as a result t

of not having yet incorporated the April 1995 revisions to IMC 2800 into their inspection

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Procedures Manual. Those categories for which NRC revisions to IMC 2800 were more conservative than the Nebraska frequencies are: (1) High-Dose Rate Remote Afterloaders l

(HDRs) were inspected on a three year basis in Nebraska vs. NRC's change to a one year i

frequency, (2) Mobile Nuclear Medicine Services were inspected on a three year frequency vs. NRC's change to a two year frequency, and (3) Instrument Calibration Services Only -

Other and Other Services were grouped together in Nebraska and inspected on a 3 or 5 year frequency vs. NRC's 1-7 year frequency based on the type of service provided. The l

l team noted that the State does not have a service license requiring inspections at one year intervals, but they do have a service license for which IMC 2800 indicates a two year inspection frequency and the State was conducting inspections at a three year interval.

The State indicated that they had completed incorporation of the new priorities into their inspection tracking system listing prior to our review. In their response to the questionnaire, the State indicated that all licenses will be reviewed and assigned the proper priority and inspection frequency and inspected accordingly, but inspection schedules were f

not completed. in discussions with the new program manager, the team found that the State intends to revise their inspection Manual to reflect the April 1995 revisions to IMC i

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l 2800 by January 1997. When these inspection priority findings were raised with the

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Nebraska staff, the staff indicated that the loss of three key personnel had prevented them l

from updating procedures.

in their response to the questionnaire, Nebraska indicated that as of July 12,1996, only j

nine licensees identified as core inspections in IMC 2800 were overdue by more than 25

. percent of the NRC frequency. The State also indicated they planned to complete these

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overdue inspections by January 1997. It should be noted, that the staffing shortages j

created a considerable backlog of inspections and, in response, the State hired a contractor to conduct inspections, comrpencing on January 15,1996, and ending no later j

than June 30,1996. The contractor performed 27 overdue inspections during this period which helped to reduce the backlog of overdue inspections. Although the State should be i

commended for this effort, the team noted that communication of.the results of the j

inspections, (i.e. inspection report results, recommendations, noncompliance, etc.) have i

been provided to only 5 of the 27 licensees inspected. In discussions, the program 1

manager stated that they retained a former staff member as a consultant to review the results of the contractor inspections, but they were unsuccessful in their efforts to have a

l the reviews completed in a timely fashion.

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The team reviewed the State's experience with overdue inspections during the entire review period and found, based on 20 license files reviewed,8 out of 12 core inspections were conducted as overdue inspections exceeding the 25 percent window allowed in IMC 2800. Four of the 8 overdue core inspections with a one-year inspection frequency were between 10 24 months overdue (averaging 15 months overdue), and four of the 8 overdue i

l core inspections with a three-year inspection frequency were between 15-21 months overdue (averaging 17.3 months overdue). Non-core inspections were conducted as resources allowed.

1 With respect to initial inspections of new licensees, the team reviewed the inspections due l

tracking system and the license files. Review of the tracking system identified twelve licenses, that required initial inspections. Of the 12 identified from the tracking system, three of these initial inspections had been identified as overdue in the State's questionnaire. Two of the 12 inspections due had been completed during the IMPEP review accompaniment process on July 16,1996, which leaves 10 inspections due. Of

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the 20 files reviewed by the team,4 were iniyial inspections, and 3 of the 4 initial I

inspections were not inspected within 6 months of issuance as required by IMC 2800.

The three overdue initial inspections were performed 16,13, and 8 months after the issuance of the license.

i The timeliness of the issuance of inspection findings was also evaluated during the inspection file review. From the 20 files examined both in detail for quality of the inspection program and for issuance of inspection findings,14 (inspections performed in i

1994 and 1995) had inspection correspondence sent to the licensee within 30 days after l

completion of the inspection, in the six remaining files (inspections performed in 1996 by l

the contractor) the inspection findings were in draft enforcement letters which had not l

l been issued to the licensee. The six draft enforcement letters had been in the license file from 45 to 142 days. As previously indicated, the inspections findings of only 5 of the 27 l.

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inspections performed in 1996 by the contractor, had been provided to the licensee after review by the State. Management was aware of the delays in getting these inspection reports issued. Delays in issuing inspection reports impairs the effectiveness of getting prompt corrective action by the licensee to any violations. Late reports make it difficult for

'1 the program to require a prompt response from the licensee. Finally, late reports open the program to criticism by licensees. The review team recommended that State management take immediate action to assure that the balance of the contractor completed inspection field notes and draft enforcement letters (22) are reviewed and issued to the i

j appropriate licensees.

On examination of the major cause for the lack of timeliness in performing inspections at j

the stated frequency and the timely issuance of inspection findings the IMPEP team noted the program lost three senior staff in the materials program and underwent two reorganizations during the review period. The team concluded that the failure to effectively manage the reduced level of program resources and performance and the lack of current, written, program procedures, are the primary root causes of the deficiencies found in the program.

1 A review of the results of previous program reviews of the Nebraska Radiation Control i

Program identified that similar problems were found in 1990 and 1992 that resulted in a i

finding of inadequate to protect public health and safety and not compatible with NRC's program for regulation of similar material for both reviews. During the 1992 review, i

significant problems were identified in the area of Status of Inspections and Staffing and 5

Training. The 1992 review indicated that there had been no improvement in problem areas identified during the 1990 review. D'uring the 1990 review significant problems were l

identified in the area of Status of the inspectio.n Program, Staffing and Training, Status and Compatibility of Regulations, Enforcement Procedures, and Management. The 1990 review indicated a continuation of the same problems found during two previous reviews 1

in 1988 and 1986. The 1994 review resulted in a finding of adequate and compatible l

based on the State filling four vacant positions that had remained open for over a year i

despite active recruiting, reduction of the inspection backlog, and expected continued i

reduction due to increased availability of staff. In 1994, the State also indicated that I

efforts were underway to develop and implement revised procedures. The team found that the efforts begun in 1994 to maintain adequate staffing and control inspection backlogs were unsuccessful, and the efforts to implement new procedures were not f

completed.

The State reported in its response to the ques'tionnaire that 31 licensees filed 163 requests l

for reciprocity during the review period; 20 of the 31 licensees were Priority 1,2, or 3 (7 industrial radiography, 7 well logging,1 mobile nuclear medicine service and 5 other i

service licensees). The State conducted 2 inspections of reciprocity licensees (industrial j

radiography) during the review period in its response to the questionnaire, the State reported that the program staff accompanied by an IMPEP team member performed one field inspection on a non-reciprocity industrial radiography licensee on May 26,1996. The j

review team recommends that the State follow the inspection frequency for conducting j

mapections of reciprocity licensees contained in IMC 1220, " Processing of NRC Form 241, i

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Report of Proposed Activities in Non-Agreement States, and Inspection of Agreement l

State Licensees Operating Under 10 CFR Part 150.20."

l In addition to the recomrrjendations stated above regarding the contractor performed Inspections, the review team recommended that the Nebraska Radioactive Materials l

Program: 1) establish an actiori plan or procedure to assure inspections are completod at j

the required frequencies stated in the NRC's IMC 2800 and conduct reciprocity licensee

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inspections at the frequencies stated in IMC 1220; 2) establish an' action plan or i

procedure for coordinating deviations from the schedule between staff and management

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based on the risk of license operations, past performance and need to temporarily defer the inspections to address more urgent or critical priorities; 3) organize a "get well" plan

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for roscheduling missed or deferred inspections, that takes into account unplanned loss of experienced staff; 4) establish a plan or methodology to assure initial inspections are 1

performed within 6 months of issuance of the license in accordance with the Nebraska j

j inspection Manual and NRC's IMC 2800; and 5) incorporate the inspection frequencies contained.n NRC's IMC 2800 into the NeDiaske inspection Manual.

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Based on the IMPEP evaluation criteria, the review team recommends that Nebraska's performance with respect to the indicator, Status of Materials inspection Program, be found Satisfactory with Recommendations for Improvement.

3.2 Technical Staffino and Trainina l

In reviewing this indicator, the review team considered the radioactive materials program and low-level radioactive waste program staffing levels, the technical qualifications of the j,

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staff, staff training, and staff turnover. To evaluate these issues, the review team

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examined the State's questionnaire responses regarding this indicator, interviewed program l

l management and staff, and considered the identified backlogs in licensing and compliance j

actions.

Regulatory responsibility for the control of radiation in Nebraska is split into four separate i'

organizational units, three in the NDOH, and one in the NDEO, which has primary responsibility for regulating a planned LLRW disposal site. Since the last State program j

review in 1994, there have been two reorganizations in the NDOH, which were completed in mid-1995. Prior to the reorganizations,'the radiation control program existed as a j

division with four subdivisions: radioactive materials (RAM), LLRW, machine produced radiation (X-ray) and emergency response. The RAM program was managed by the division director who also supervised the other three program managers. As a result of the reorganizations, radiation control is currently under the Division of Environmental Health, i

Environmental Health Protection Section (EHPS), in two programs: RAM and LLRW, (X-ray,

was placed under r,nother section). Emergency response activities are now the responsibility of the LLRW program. The RAM and LLRW program managers report to a i

section administrator. Additionally, technical staffing and training for the organizational unit located in the Department of Environmental Quality, Low-Level Radioactive Waste Disposal Program is addressed in Section 4.2.3 of this report. Organization Charts for NDOH and EHPS can be found in Appendix B.

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in the second reorganization, the division director position was lost without naming a-J permanent RAM program manager. NRC received notification through letters from the 4

State that an experienced inspection staff member had been designated Program Manager for Radioactive Materials on April 24,1995, and again in a letter dated June 13,1995, but this person left the program on June 23,1995. In a letter dated May 15,1995, the Low Level Waste Program Manager, was given the additional responsibility for all i

radiological emergency response activities. In a March 25,1996 letter, NRC was notified that the Section Administrator for Environmental Health Protection, would be handling i

matters related to radioactive materials. A permanent RAM program manager was not j

named until May 1996, a delay of nearly one year.

The current radioactive materials program technical staff consists of a program manager t

and three inspector / license reviewers while the low-level radioactive waste program i

technical staff consists of a program manager and two professional positions. The two staff of the LLRW program are cross-trained to provide technical support to the RAM 2

program on a short-term basis, as needed. Additionally, the RAM and LLRW programs s

supplemer.ted staff effort during the review period with contractors. The review team j

found that the current staffing level, with contractor support, and establishment of effective nanagement control systems, is adequate to administer the regulatory program.

With respect to contract support, the State did not include a provision specifying personnel l

qualifications in their Statement of Work. The contractor,in bid documents, specified the use of individuals who possessed the education and experience to meet the indicator, however, there was no specific provision concerning personnel qualifications included in I

the contract. This was identified by the progtam manager as a corrective action item for Lure contracts. The team concluded that the staff and the contractor (based on discussions with the program manager), has adequate educational qualifications, but i.

recommends that the qualifications of contractor personnel be tied to the contract'as identified by the program manager or as accomplished by the LLRW program in NDEO.

The program manager further stated that the contractor is an experienced consultant in the health physics area and personnel possessed appropriate technical qualifications.

j The team reviewed staff turn-over and qualifications, and found that three experienced i

members of the RAM staff left during the review perioo, all at approximately the same time as the second reorganization. The review team found that although it appears that management was responsive in filling two.of the vacant positions within a short period of time with cross trained staff from the X-ray and LLRW programs (with adequate 1

j educational background and experience), the fact that a key position that provides i

continuity, direction and support to the radioactive materials program staff, that of the Radioactive Materials Program Manager, was not filled for almost a year, and was one of the root causes of the difficulties experienced in the program. The team observed that these difficulties, identified below, accelerated at the time of the second reorganization l

and the nearly concurrent loss of three experienced staff members of the RAM program.

l Difficulties encountered during the review period include the following: (1) a backlog of 9 core inspections, (2) 22 inspections pending supervisory review and notification of the findings to the licensee, of which one contained health and safety issues, (3) inspection i

reports were incomplete, (4) a backlog of 101 licensing actions of which 73 could have

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i health and safety related issues, (5) no incident reporting to NRC since June 1995, (6) incomplete documentation of incident response and response to allegations, (7) regulations required for compatibility not adopted in timely fashion, and (8) no "get-well" plan. A!l of these factors considered _ collectively led the team to find that the performance with respect to the criteria for this indicator was inadequate. Details of these i

problems are discussed elsewhere in this report. The team found that the primary root causes for the deficiencies found in the prograrn are (1) the failure of NDOH management to effectively address the reduced level of program performance, (2) lack of current, written, program procedures or failure of staff to follow those procedures.

4 The Radioactive Materials Program manager and all thrse full time staff perform duties in i

licensing, inspection, and event response. Although the staff did try to achieve a balance between the licensing and inspection functions, the significant backlog found in the area of inspections and licenaing and other deficiencies found in the program demonstrate that the a

effort was not adequate to maintain the program. The team found it difficult to evaluate i

the training of the personnel involved with the materials control program, because there j

was no written program for staff qualification. According to the information provided in the questionnaire, all newly hired health physicists are required to attend the NRC core i

training courses outlined in the now suspended May 28,1992, Policy Statement (57 FR 2

224950), as well as the five-week health physics course. However, there was no written 4

documentation that stated this requirement had been met. There were no program records I

to show that existing materials program staff members have taken the courses. The only records found were those maintained by individual staff members.

The radioactive materials program staff also described in-house and on-the-job training processes in their response and during interviews..Briefly, new staff are assigned to j

review State regulations and procedures and to accompany senior license reviewers / inspectors, then are assigned increasingly complex licensing duties under the j

direction of senior staff and accompany experienced inspectors during increasingly i

complicated inspections. New staff are assigned independent inspections after i

demonstrating competence. The criteria for determining the progress of new staff have not been established. The team observed that the lack of criteria and the vacant radiation 3

program manager position for almost one year resulted in an inspector (hired in July 1995) not yet considered trained to conduct even low priority inspections after one year on the-job. The team recommends that a written program for staff qualification, including l

retaining training recordr., be developed.

l The team recommends that the State develop comprehensive administrative procedures, sufficient to guide the day-to-day operation of the program in the event of another loss of senior staff. The procedures should include a formal process for bringing to the attention of upper management the increase of significant backlogs of licensing, inspection, or i

enforcement actions, or any other situation which increases the risk to public health and safety. The team also notes that there is a legislative mandate to further reorganize by combining NDOH and four other Departments, to be completed by the end of calendar year 1996. The team recommends that NRC monitor the Nebraska program with increased attention to the offects of the further reorganization.

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Nebraska Draft Report Page 8 As identified in Section 3.1 above, the team found that the problems encountered during the period represent continuing trends of deficiencies found in previous reviews of the Nebraska program, with the exception of the 1994 review, wherein the previously j

identified staffing shortages were eliminated when the State filled four long vacant positions. But the team found that the State was unable to maintain adequate staffing beyond one year. The team found that the efforts begun in 1994, to maintain adequate

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staffing, reduce the inspection backlog, and implement revised procedures were unsuccessful. Collectively considering the historical weaknesses of the program, the consistent significant staffing problems, the consequences of the loss of three key staff i

members, other deficiencies found throughout the program and lack of program management effectiveness to address these weaknesses, the review team concludes that

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the State's response relative to the criteria for this indicator was inadequate.

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Based on the IMPEP evaluation criteria, the review team recommends that Nebraska's performance with respect to the indicator, Technical Staffing and Training, be found i

Unsatisfactory.

3.3 Technical Quality of Licensina Actions

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The review team examined casework and interviewed the reviewers for 12 licenses and 28 l

licensing actions completed during the review period covering June 25,1994-July 12, 1996. The review team was unable to review or evaluate statisticalinformation related to any backlog of cases prior to July 1995, since the program manager was unable to provide i

program records for that time period. Licensing actions were reviewed for completeness, i'

consistency, proper isotopes and quantities used, qualifications of authorized users, adequate facilities and equipment, and operating and emergency procedures sufficient to j.

establish the basis for licensing actions, Casework was reviewod for timeliness, i

adherence to good health physics practices, reference to appropriate regulations, documentation of safety evaluatior, reports, product certification or other supporting documents, consideration of safety evaluation reports, product certification or other 7

supporting documents, consideration of enforcement history on renewels, pre-licensing 2

visits, peer or supervisory review, and proper signature authorities. Licenses were reviewed for accuracy, appropriateness of the license and its conditions and tie-down conditions, and overall technical quality. The files were checked for retention of necessary documents and supporting data.

The cases were selected to provide a representative sample of licensing actions which had l

been completed in the review period and to include work by all reviewers. The cross-section sampling included 12 licenses of the following types: medical / academic broad scope, medical-institution and medical-mobile, industrial radiography, research and i

development, and portable gauges. Licensing actions included three new licenses and 25 amendments. A list of these licenses with case-specific comments is included in Appendix D.

i The review team found that the licensing actions completed were thorough, complete, i.

consistent, and of acceptable quality with health and safety issues properly addressed.

Special license tie-down conditions were stated clearly, backed by information contai.ned in 4

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i the file, and were inspectable. The team noted a few deviations in the files of minor significance such as the use of small yellow post-it pad notes to attach pertinent 4

information rather than a permanent form of documentation i.e., memorandum. All recent licensing actions included a peer review which was recorded on a License Action Review Record in the license file. No potentially significant health and safety issues were identified with completed licensing actions.

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j in response to the questionnaire, and discussions with the program manager, the State j-indicated that three staff perform both license reviews and inspections, and that Nebraska l

has approximately 157 specific licenses. Due to lack of records, we were unable to review or evaluate case backlog prior to July 1995. In the period from July through j

December 1995,38 licensing actions were completed. From January 1996 through June 21,1996,48 licensing actions were completed. During the review, the team noted that the new radioactive materials program manager, appointed in May 1996, has implemented a computer listing'of licensing actions, beginning with July 1995, to allow i

2 tracking of reviews, letters, replies, and license issue date. This tracking system is a great i

. improvement over the hand written sheets kept by individual reviewers, prior to July 1995, and will allow staff to keep better track of the licensing backlog.

In discussions with staff, priorities of licensing actions were stated to be based upon j

health and safety issues, and applicants need. The team noted, that the disruption caused by staff tumover has resulted in selected types of licensing actions not having been acted upon in a timely manner, i

A review of the licensing backlog indicated approximately 101 licensing ac, tion requests were received, but had not been completed, included in the backlog of 101 licensing actions were:

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New RSO - 9 Add authorized user -9 Add or new location of use - 10 Terminate - 5

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Renewal - 28 Delete location of use - 3 Short Form Renewal-9 Add new use - 2 Add RAM - 7 Other - 2 It was recognized by the IMPEP team that the indicator relates to technical quality of j

licensing actions completed, however, the team concluded that the backlog of licensing i

actions is another indicator of need for management improvement to adequately assess and control Agreement State activities.

i in order to reduce the backlog and to assve that licensing actions are being completed in an appropriate order, the team recommend =; that the following actions be taken:

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A written policy or procedure should be developed for prioritizing licensing actions based upon identified factors, including health and safety significance, for new and previously received applications, l

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A written procedure and schedule should be developed for elimination or reduction of the backlog of existing licensing actions.

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Based on the IMPEP evaluation criteria, the review team recommends that Nebraska's performance with respect to the indicator, Technical Quality of Licensing Actions, be j

found Satisfactory with Recommendations for improvement.

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3.4 Technical Quality of Insoections i

The team reviewed enforcement documentation, inspection field notes, and data base information for 20 materials inspections conducted during tha review period. The casework included inspections p9rformed by the current program manager, two health physicists who terminated their employment v.ith the State during the review period and i

inspections performed by a contractor hired to help with the inspection backlog created by the loss of three key staff and several reorganizations. The sampling included three i

nuclear medicine licensees, twc each pool irradiator, service, fixed gauge, portable gauge i

and academic broad licensees and one each nuclear medicine / brachytherapy, mobile nuclear medicine, self shielded irradiator, radiography, academic / radiography, academic non-broad and teletherapy licensees. Appendix E provides a list of inspection cases reviewed in depth with case specific comments.

The review team noted that the Nebraska program was adequate with respect to this indicator. Routine inspections usually covered all aspects of the licensee's radiation safety program. The team also noted that, during the accompaniment of State inspectors, the inspectors observed licensed operations or had operations demonstrued whenever j

possible. The observation of licensed activities provides the inspectors with an indicction j

of the effectiveness of the licensee's radiation protection program. Finally, during the review period, the State conducted tsam inspections of larger iicensees. Having multiple j

inspectors review a particular licensee's operations may lead to more thorough inspections j

and provide the opportunity for lest experienced inspectors to observe experienced

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inspectors as an effective training technique.

The team reviewed the inspection field notes and found them to be comparable with the j

types of information and data collected under NRC Inspection Procedure (IP) 87100. The inspection field notes provided documentation of inspection findings in a consistent manner. The State uses separate inspection field notes for various classes of licensees, such as nuclear medicine, portable gauges, radiography, and industrial / academic. The j

State has not yet developed field notes specific for the inspection of HDRs or nuclear pharmacies. The State uses the nuclear medicine field notes for these type of licensees.

j The inspection field notes provide documentation of the scope of the licensee's program including, posting; storage and use of radioactive material; receipt, transfer, and disposal of radioactive material; inventory; leak tests; radiation protection program; personnel monitoring, training; independent measurements; and inspection findings.

The team found several deficiencias during review of field notes in the ccmpliarme files, such as incomplete documentation of technical and administrative information, which are addressed in Appendix E, and further clarified later in this section. The team noted that

4 Nebraska Draft Report Page 11 during the accompaniments of State inspectors, the State inspectors examined appropriate j

radiation health and safety issues at licensees' facilities. All the inspectors, who were 4

accompanied by a team member, used the field notes to assure that all aspects of the J

program that could be reviewed were included in the scope of the inspection. The inspectors performed independent measurements whenever the licensee was using q

licensed material and also measured for radiation levels surrounding materials in storage.

Inspectors' written comments in the field notes and the team member's observations 2

during accompaniments indicate that safety issues were discussed with licensee personnel. The field notes indicated that the licensees' operations were observed when licensed operations were being conducted by the licensee and interviews with the State inspectors and observation by the team member during accompaniments support that they routinely tour licensee areas such as laboratories, other locations of use and storage areas.

The inspectors emphasized the observation of licensed activities to determine the 3

4 effectiveness of the licensee's radiation safety program and compliance to the l

requirements, a critically important inspection technique. The field notes indicated that the

- inspectors examined and when appropriate, closed-out previous violations. Also because

. health physicists serve both as inspectors and license reviewers, there was evidence that licensing issues were considered in the inspection process.

Four inspector accompaniments were performed by a review team member during the period of June 24-28,1996 and one accompaniment was performed during the review period on July 16,1996. The accompaniments included the following: (1) two l

inspections with two individuals from the LLRW program, the program manager and a health physicist, who are cross-trained and qualified as inspectors in the RAM program i

during an inspection of a radiography program (including a field site visit) and a mobile nuclear medicine program, respectively, and a second health physicist from the LLRW program, who was being cross-trained in the Materials Program assisted on these inspections; (2) a third inspection with the Low Level Radioactive Materials Program Manager and a staff health physicist during inspections of a large nuclear medicine and a self-contained blood irradiator program at a major medical facility; and a fourth inspection with another staff health physicist during the initialinspections of two separate por,aMe l

gauge programs, one of which also included a field site. These accompaniments are also identified in Appendix E. During the accompaniments the Nebraska lead inspectors demonstrated appropriate inspection techniques and knowledge of the regulations. The l

inspectors were well prepared and very thorough in their reviews of the licensee's radiation safety program. Each inspector emphasized observation of the licensee's activities and interviews with personnel to assess the effectiveness of the licensee's j

radiation safety program. Overall, the technical performance of the inspectors was satisfactory, and their inspections were adequate to assess radiological health and safety at the licensed facility. The technical quality of inspections and the knowledge of the inspectors is a strength in the Nebraska program. The review team noted that the State relies on the technical knowledge of the inspectors to identify root causes of non-compliance and poor licensee performance rather than having p ocedures in place which 4

normally could be used to assist the inspectors in this identification.

In response to the questionnaire, the State reported the number and type of supervisory accompaniments by senior program staff is not defined by a program procedure and they 1

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l Nebraska Draft Report Page 12 have not been documented in the past. However, in 1994, three inspectors were i

accompanied by a contract consultant who observed the inspector's performance. The l

consultant was performing a review of the program staff by accompaniment as part of his contract to develop an inspection and Enforcement Manual. Copies of the reports submitted for two of three staff evaluated were provided. There were no supervisory accompaniments of the Nebraska inspectors during 1995 and in the first six months of 1996. It should be noted that two of the three inspectors accompanied by the contractor in 1994 have since left the program and the third was promoted to program manager. The program manager indicated in discussions during the review that he was the lead inspector on several occasions and was accompanied by a staff health physicist for purposes of training, but had not performed an accompwniment in his capacity as the manager of the j

Radioactive Materials Program.

i Therefore, the review team recommends that the State consider for adoption a policy of annual supervisory accompaniments of allindividuals who perform inspections for the Radioactive Materials Program.

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In response to the questionnaire, the State indicated that a contractor was hired to develop an inspection and Enforcement Manual, which was completed in April 1994.

During the review, the team found that there was no indication, based on discussions with staff during accompaniments and with the program manager, that the Inspection and Enforcement Manuals were in use and applied by the staff. The revised inspection Manual contains standardized text covering compliance issues for use in issuance of Notice of 3-Violations (NOV) to licensees. Use of standardized text would enhance the efficiency of l

the compliance process; additionally, the Manual would prove very useful for training new staff. The program manager indicated that future plans included updating the Manual and j

implementing use of the Manual by the staff. Section 3.2 of this report covers procedures in greater detail, i

it was noted that the State has available a variety of portable instruments for routine confirmatory surveys and use during incidents and emergency conditions. The instruments 4

were a mix of low and high range Geiger-Mueller detectors and pancake probes, micro R meter, alpha detector, and available quantitative instruments in the Department of Health j

Laboratory. The portable instruments used during the inspector accompaniments were observed to be operational and calibrated. The team noted that the instruments are calibrated on an annual basis.

]

It was found that the State is generally performing unannounced inspections of materials i

licensees. Initialinspections and geographically-distant location inspections are usually announced.

A review was conducted of the procedures and documentation of inspector field notes or completed reports to determine that they are complete and reviewed promptly by supervisors or management. That review found that previous practice indicated that a supervisory review was conducted. The radiation program manager position was vacant as of June 1995, and the person delegatad responsibility for signing off on NOVs left the program on June 23,1995. At that time no one in the radioactive materials prugram had

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Nebraska Draft Report Page 13 j

j official supervisory signature responsibility until a new program manager was chosen in i

May 1996. The normal practice of a supervisory review was not practiced during this time.

l Inspection findings generally lead to appropriate and prompt regulatory action with the 1

exception of the six contractor inspections, for which enforcement letters had not been issur d.

In one case, as indicated in Appendix E, the team found that the enforcement 1

letter identified five violations to the licensee and the documentation in the field notes provided information for only two violations. The review team also found some other problems with the documentation of information on the field note reports as noted in the i

comments in Appendix E. The field notes on page one provide space for administrative i

information such as: inspection report no., license no., licensee (name and address),

j licensee contact, telephone no., priority, date of last inspection, date of this inspection, type of inspection, summary of findings and action, next inspection date and whether next i

inspection is at a normal, reduced or extended frequency, signature and date the inspector signed and signature and date supervisor approved the report. Eleven of the field note i

reports did not have all the administrative information required. Ten reports were not approved with a supervisor's signature and date; and a few of the typed inspection reports

^

did not contain any signature. The team believes that supervisory approval of inspection findings documented in the field notes prior to issuance of an enforcement letter is i

necessary to assure that the field notes contain sufficient information to support any j

violations or recommendations in an enforcement letter, in addition, seven of the fie:d i

note reports had no technicalinformation documented in areas such as: training of j

ancillary personnel; exit meeting attendees; pH, clarity and Cl or F concentrations in pool j

water; independent measurements, inventory of brachytherapy sources after retum to

)

storage, and Radiation Safety Committee (RSC) minutes / committee composition.

in discussions with the program manager, the team was informed that the previous requirement for typewritten field notes to be used as the documentation of inspection findings delayed the supervisory review until the field notes were typed. The new program j

manager stated that handwritten field notes would be accepted during the interim time period, while the staff try to complete the backlog of inspections. The new program j

manager stated that future plans include ctandardizing and automating the boilerplate inspection information.

i in addition to the recommendation stated above regarding annual supervisory accompaniments of allindividuals who perform inspections, the review team recommended that the program: (1) develop a plan or procedure to assure that field notes, as well as, reports, and enforcement letters are promptly reviewed, signed and dated by a j

supervisor within the recommended 30 day time frame for issuance of inspection findings; and (2) perform an immediate review of all contractor field notes and draft enforcement i

letters in order to finalize and issue the findings of the remaining 22 inspections to the licensees involved.

I Based on the IMPEP evaluation criteria, the review team recommends that Nebraska's performance with respect to the indicator, Technical Quality of Inspections, be found Satisfactory with Recommendation for Improvement.

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i Nebraska Draft Report Page 14 1

3.5 Resoonse to incidents and A!!anations In evaluating the effectiveness of the State's actions in responding to incidents and j

allegations, the review team examined the State's response to the questionnaire relative to j

this indicator and reviewed the incidents reported for Nebraska in the " Nuclear Material Events Database (NMED)" against those contained in the Nebraska casework and license i

files, and supporting documentation, as appropriate for six incidents. In addition the team interviewed the Radioactive Materials Program manager. Due to recent staff turnover the j

team was unable to interview other staff for this indicator.

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Responsibility for initial response and follow-up actions to material events rests with tho j

Radioactive Materials Program and the Low Level Radioactive Waste Program. Written j

procedures require a prompt response to incidents by the staff and provide additional procedural guidance. Written procedures for allegations also require prompt response, but contained no further procedural guidance. The review team found that allegations were j

handled as routine incidents and files contained incomplete or no documentation of

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inspection results or State action. The team noted in one case that investigative j

techniques were insufficient to appropriately resolve alleged issues. The review team recommended revising the allegations procedures to incorporate key areas, i.e.,

documentation of any communications with the alleger, documentation of the inspection findings, interviewing techniques, etc., identified in NRC Manual Directive 8.8, Management of Allegations.

The review team also noted that the staff did not have a procedure for tracking the status j

(i.e. identification, receipt, follow up, and closeout) of material events. The review team recommended that the staff use the draft " Handbook on Event Reporting in the Agreement j

States (Handbook)," published March 1995, for review and reporting of material events.

j The Handbook identifies the NRC Operations Center, Office for Analysis and Evaluation of j

Operational Data, as the proper group to receive voluntary notification of the occurrence of significant events in an Agreement State, and provides guidance on the identification, reporting, follow-up reporting, and closeout of material events.

The review team found, through discussions with the radioactive materials program manager, that the staff have been unable to voluntarily report to NRC the occurrence of any material events since June 1995, due to the loss of three experienced staff members.

Limited resources had to be redirected to other more critical areas. Therefore, the team was unable to evaluate whether or not the State provided information on all events that may have occurred during the reriod of review prior to June 1995. Two reportable events were found by the team during review of selected case files.

l Through a review of information provided in the questionnaire and through review of selected case files, the team found that four reportable events had occurred, three of which had not been reported to NRC, and subsequently NMED. Two of the reportable I

events were identified in the State's response to the questionnaire as significant events l

that had occurred during 1995. Two of the reportable events examined by the team l

involved equipment malfunctions at an irradiator facility, and one involved loss of material.

l Other case files reviewed included a 1994 event involving the loss of material, that had E

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Nebraska Draft Report Page 15 l

previously been reported to NRC, an event involving the unauthorized use of equipment, j

i and an event involving loss of control of radioactive material, both of which had not been reported to NRC. The team noted several case file deficiencies, i.e., one file contained no documentation of inspection results, another indicated insufficient follow-up action by the State to the loss of control of radioactive material, and a third indicated lack of State action to a late notification of the occurrence of an event by the licensee. With regard to the incidents that occurred at an irradiator facility, and one event involving equipment malfunction as a result of the unauthorized removal and replacement of equipment, the team discussed the need to report events involving equipment malfunction or possible j

defects of equipment with the program manager and the importance of documentation of contact with the aHeger. The review team concluded that the State's documentation and in one instance response, to the occurrence of events involvina the use of radioactive j

material and response to allegations needs improvement. They dia swt have a complete understanding of reporting requirements, and lacked proper procedures br handling j

allegations. A list of the incident reports examined is contained in AppenoN F.

j in addition to the above recommendation that the Nebraska staff revise the allegations procedures and incorporate use of the " Event Reporting Handbook," the team recommends establishment of comprehensive procedures for tracking, follow-up and close out of events involving the use of radioactive material covered under the Atomic Energy Act. The l

review tr;am also recommends that the State immediately begin reporting current material f

events to NRC and send in information on the three events identified during the review as i

reportable, to the State, bu'c were not previously reported to NRC.

j Based on the IMPEP evaluation criteria, the review team recommends that Nebraska's

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performance with respect to this indicator, Resporte to incidents and Allegations, be found Satisfactory with Recommendations for impovement.

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_ 4.0 NON-COMMON PERFORMANCE INDICA"(ORS 4.1 Leaislation and Reaulations 4.1 1 Leoislative and Leaal Authority Along with their response to the questionnaire, Nebraska provided the review team with l

copies of legislation that affects the radiation control program. The Department of Health is designated as the State radiation control program, while the Department of Environmental Quality is given responsibility for the regulation of the planned low-level j

radioactive waste site. Based on the response to the questionnaire, and on statements by the Director of the Department of Health that there had been no change to the State legislation that affected the duties or responsibilities of the materials programs, the review team did not review the legislation but relied on previous reviews where State legislation

)

was determined to be adequate. The team did note the legislative changes that will result in the reorganization of the Department.

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Nebraska Draft Report Page 16

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4.1.2 Status and Comoatibility of Reaulations 4

Nebraska's latest rules and amendments became effective May 30,1994. The equivalent i

NRC rules are: " Decommissioning, "10 CFR Parts 30,40, and 70; " Emergency Planning,"

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10 CFR Parts 30,40, and 70; " Standards for Protection against Radiation," 10 CFR Part j

20; " Safety Requirements for Radiographic Equipment," 10 CFR Part 34; " Notification of j

incidents," 10 CFR Parts 20,30,31,34,39,40, and 70; and " Decommissioning Recordkeeping and License Termination: Documentation Additions," 10 CFR Parts 30,40, 70, and 72. Not all of these regulations were promulgated within the three year period following the adoption of the NRC regulation. The team reviewed the final published j

Nebraska regulations equivalent to the above and found them to be compatible with the NRC regulations.

i There are four irradiators in use in Nebraska which would be subject to the regulations in

" Licensing and Radiation Safety Requirement for Irradiators," 10 CFR Part 30. Equivalent i

rules were in development when the reorganizations and personnel turn over discussed earlier in this report occurred. As a result of personnel reassignments, the rules were not j

adopted by their due date of July 1,1996. At the time of the review, the rules were j

scheduled for public hearing and adoption was expected by the end of the calendar year.

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The State has not established legally binding requirements equivalent to NRC requirements j

in 10 CFR Part 36 that are required for compatibility.

i Nebraska does not regulate uranium recovery operations, and does not have rules equivalent to NRC's regulations applicable to uranium recovery contained in 10 CFR Fart

40. Therefore, it will not adopt the regulations equivalent to " Uranium Mill Tailings i

Regulations: Conforming NRC Requirements to EPA Standards," 10 CFR Part 40 j

amendments (59 FR 28220) that became effective on July 1,1994, and will need to be l

adopted by July 1,1997. Nebraska has assumed regulatory authority for a low-level

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radioactive waste site, and has selected an enhanced technology for disposal. Therefore, t

i the State does not need to adopt the land disposal definition part of the " Definition of Land i.

Disposal and Waste Site QA Program," 10 CFR Part 61 amendments (58 FR 33886) that I

became effective on July 22,1993. The State has adopted the QA program portion of the 1

amendment.

3 1

l In addition to the above, the team found that work is in progress to develop equivalent j

rules to the following, which the program has scheduled for adoption in January 1997.

" Quality Management Program and Misadministration," 10 CFR Part 35 amendment (56 FR 34104) that became effective on January 27,1992. The Commission has determined that this rule will not be used to evaluate Agreement State compatibility until December 6,1996.

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"Self-Guarantee as an Additional Financial Mechanism," 10 CFR Parts 30,40,70 j

amendments (58 FR 68726,59 FR 1618) that became effective on January 28, 1994.

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i Nebraska Draft Report Page 17 t

" Timeliness in Decommissioning," 10 CFR Parts 30,40,70 amendments (59 FR j

j 36026) that became effective on August 15,1994.

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" Preparation, Transfer for Commercial Distribution and Use of Byproduct Material j

for Medical Use," 10 CFR Parts 30,32, and 35 amendments (59 FR 61767,59 FR j

65243,60 FR 322) that became effective on January 1,1995.

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" Frequency of Medical Examinations for Use of Respiratory Protection Equipment,"

10 CFR Part 20 amendments (60 FR 7900) that became effective on March 13, 1995. Note, this rule is designated as a Division 2 matter of compatibility. Division 2 compatibility allows the Agreement States flexibility to be more stringent (i.e., the State could choose to continue to require annual medical examinations).

" Low-Level Waste Shipment Manifest Information and Reporting," 10 CFR Parts 20 and 61 amendments (60 FR 15649,60 FR 25983) that will become effective March 1,1998. Nebraska and the other Agreement States are expected to have an equivalent rule effective on the same date.

l

" Radiation Protection Requirements: Amended Definitions and Criteria,"

1 10 CFR Parts 19 and 20 amendments (60 FR 36038) that became effective August 14,1995.

" Medical Administration of Radiation and Radioactive Materials," 10 CFR Part 20 and 35 amendments (60 FR 48628) that became effective October 20,1995.

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" Clarification of Decommissioning Funding Requirements," 10 CFR Parts 30,40, i

i and 70 amendments (60 FR 38235) that became effective November 24,1995.

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" Compatibility with the international Atomic Energy Agency," 10 CFR Part 71 amendment (60 FR 50248) that became effective April 1,1996.

i The review team examined the procedures used in the State's regulation promulgation l

process and found that the public is offered the opportunity to comment on proposed regulations during a comment period and in a public hearing that follows the comment period. According to the staff member responsible for rules development, NRC is provided with drafts for comment on the proposed regulations early in the promulgation process. A copy of the final regulation is submitted to NRC.

During discussions with the review team, the staff explained that they had begun the process of drafting revisions to the regulations which they expect to promulgate in January 1997 for new regulations due through 1998. The State is aware of the importance of maintaining compatible regulations, and the State plans to yearly update regulations to maintain compatibility.

l The review team identified a possible incompatibility in Section 012 of the Nebraska j

regulations, which are rules equivalent to NRC's 10 CFR Part 61. The Nebraska regul6tions, as written, apply the public dose limits in 180 NAC 1412.22 (equivalent to 6

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Nebraska Draft Report Page 18 10 CFR 61.41) to low-level radioactive waste facilities that process or store waste, as well as to disposal sites. Under NRC regulations, such facilities would not be subject to the j

equivalent public dose limits in 10 CFR 61.41, but rather to the public dose limit in 10 CFR Part 20. The Nebraska regulations may thus be more stringent than the equivalent NRC rules, however, both 10 CFR 61.41 and 10 CFR 20.1301 are Division 1 compatibility requirements.

The review team is interpreting the States's application of the limits in this rule to waste storage and treatment facilities as a radiation protection standard. To assist in resolving this issue, the review team requests that the Nebraska program provide an interpretation by legal staff as to whether the State considers the limits to be a radiation protection standard or whether they are intended as an ALARA goal or design objective when applied to storage and processing facilities. Agreement States have greater flexibility to 4

implement a goal or objective than a radiation protection standard without affecting 4

j compatibility under the Agreement. (Please see Section 4.1.2 of the report for further

information.)

i Based on the IMPEP evaluation criteria, the review team recommends that Nebraska's performance with respect to the indicator, Legislation and Regulations, be found unsatisfactory due to the failure to adopt regulations or other legally binding requirements equivalent to 10 CFR Part 36 by July 1,1996.

4.2 Low-Level Radioactive Waste Discosal Proaram i

j in the process of evaluating this performance indicator, the review team studied the State's response to the questionnaire, reviewed the terms of the Memorandum of Understanding between NDEO and NDOH, compared Nebraska LLRW statutes and regulations with those of the NRC, evaluated the qualifications of the technical staff and i

l contractors, reviewed the States proposed written procedures and plans, reviewed or discussed parts of the safety analysis report (SAR), audits, and contractor reports, and any r

other supporting documentation, as necessary, and interviewed all staff and managers l

assigned to the LLRW program. In addition, the team evaluated the effectiveness of the shared responsibility for regulation of LLRW in Nebraska.

4.2.1 Introduction The State of Nebraska received a License Application from U.S. Ecology on July 27,1990, to operate a low-level radioactive waste facility in the State. A site characterization plan was submitted to NDEO on June 6,1989. The State is presently reviewing the License Application submitted by U.S. Ecology, to develop a facility in the State; therefore, limited evidence may exist with respect to State activities for some of the performance indicators.

1 in the shared responsibility for regulation of LLRW, the NDOH and the NDEO programs have agreed to procedures that are detailed in Section 1, Licensing' Organization, of the Licensing Program Plan. As part of this agreement, there are monthly meetings attended by the LLRW Program Manager and Director from each department. These meetings l

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Nebraska Draft Report Page 19 appear to be an effective means to keep management aware of program issues and j

progress, and to resolve issues that could be disruptive to the program, l

4.2.2 Status of Low Level Radioactive Waste Discosal Proaram l

i With the program in the pre-licensing non-operational phase, inspections are not applicable.

1 2

4.2.3 Technical Staffino and Trainina NDOH staff assigned principally to the LLRW program include a program manager (a health l

physicist), a health physicist with a specialty in environmental surveillance, a health physicist with a specialty in performance assessment, a radiation-health specialist, and i

two staff assistants (one in Lincoln, NE and another in Butte, NE). In addition, there is a j

i vacant position for a health physicist with a specialty in nuclear engineering.

. The NDEO LLRW program include a program manager, an environmental specialist with i

specialties in health physics and performance assessment, an administrative assistant j

specializing in document preparation and public relations, a staff assistant specializing in j

i document control, and a secretary. The LLRW program receives occasional support from l

technical specialists in other NDEO programs as short-term needs arise.

The LLRW program relies upon contractors for additional technical support and to provide i

additional technical specialists as needed for the SAR review (approximately 78 contractor l'

staff). The NDEO LLRW program has continuing contracts with the University of Nebraska-Lincoln and a number of consulting engineering firms. The engineering firms provide their in-house expertise as well as sub-contracting for national expertise in selected technical areas. These areas include:

Hydrogeology Economics Surface-Water Hydrology Seismology

~ Biology Geology Nuclear Engineering Climatology / Meteorology

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Geotechnical Engineering Sociology Structural Engineering Quality Assurance Operational / Construction Geochemistry Mechanical Engineering Performance Assessment

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Health Physics Financial Assurance l

Environmental Engineering Regulatory Analysis i

Materials Engineering Project Management Civil Engineering l

The team reviewed the documentation of qualifications and training of staff in both the NDOH and NDEO LLRW programs. In addition, we reviewed the documentation of qualifications and Quality Assurance (QA) training that the program requires of review managers (8) and approximately 80 technical reviewers of the SAR. Staff and contractors i

are all highly qualified for their responsibilities in the LLRW program easily meeting the guidance specified in NUREG/CR-4352, " Suggested State Requirements and Criteria for a l

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Nebraska Draft Report Page 20 Low-Level Radioactive Waste Disposal Site Regulatory Program." The LLRW program has i

actively supported staff and contractor training in OA Procedures, Performance l

Assessment and other courses or workshops applicable to the program. The documentation to allow tracking or reporting of the status and history of staff and contractor training are not readily accessible and are not summarized. Training j

documentation is required and accessible during intamal audits or surveillance of the contractors that are part of the program but is not accessible outside of the context of the audit / surveillance. Formalized tracking of NDEO and NDOH program staff training is 1

apparently not required at the present time. The team suggests that the LLRW program j

assemble training documentation for individual staff and contractors and develop a consolidated training record to enable assessment of the progress of training across the j

entire program.

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4.2.4 Technical Quality of Licensina Actions i

With current program emphasis on review of the applicant's SAR and documentation of j

Evaluation Findings prior to preparation of the Draft Safety Evaluation Report, the IMPEP j

team examined the project's SAR review comments, comment tracking and reviewer i

qualification documentation. This involved tracing commervs either through to closure j

resulting from subsequent SAR modifications, or as persistent open issues.

l The program has a well organized Quality Assurance program to govern all program

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activities that might affect public health and safety. This OA program enabled the team to readily review and track the SAR review process.

A total of 195 comments in the subject areas of site characterization and performance i

assessment were tracked. Of these, the only questions arose due to seven comments submitted by a reviewer whose Technical-Review Qualification Statement was not on file.

This omission was corrected once it was brought to the attention of the program staff.

The team also reviewed a Quality Assurance Compliance inspection Audit, performed by a 4

LLRW audit team, of the U.S. Ecology's engineer of record for the project, Bechtel National i

inc., Oak Ridge, Tennessee. This audit was selected because it examined the OA associated with performance assessment calculations. The applicant was informed of this 4

audit on July 21,1995. The audit took place on August 1011,1995 at the Bechtel National Inc. offices at Oak Ridge, Tennessee and was performed by three auditors and 1

two technical specialists from the Nebraska LLRW program. The Quality Audit Checklist prepared prior to the audit contained 56 audit items; sbme were generic but many targeted directly at the applicant's program. The audit resulted in additional audit items, resulting in j

a total of 78 audit items. The audit resulted in 11 compliance nonconformances that were j

transmitted to the applicant on January 18,1996. The applicant responded on April 23, 1996 and is in the process of resolving the nonconformances.

l The team believes that the Nebraska LLRW program has a commendable Quality Assurance program for auditing the applicant and for internal auditing within the Nebraska i

LLRW program.

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Nebraska D. aft Report Page 21 l

Based on the IMPEP evaluation criteria, the review team recommends that Nebraska's performance with respect tn the non-common indicator, Low Level Radioactive Waste t

l Disposal Program, be found Satisfactory.

4 4.2.5 Technical Quality of insnections i

1 With the program in the license-application review phase, inspections are not applicable.

4.2.6 Resnonse to incidents and Allenations There were no incidents or allegations reported.

5.0

SUMMARY

As noted in Sections 3 and 4 above, the review team found the State's performance with each of the performance indicators to be satisfactory with recommendations, with two exceptions. The team found the State's performance unsatisfactory in Section 3.2 i

Technical Staffing and Training, and Section 4.1.2, Status and Compatibility of Regulations. A review of previous program reviews between 1986-1992 indicated similar problems were found in, staffing, inspection program, compatibility of regulations, 1

enforcement and management control. The team observed that the State experienced i

weaknesses and deficiencies throughout the program during the reporting period which were compounded by the loss of three key staff members and two reorganizations.

Difficulties identified during the review include: (1) a backlog of 9 core inspections; (2) 22 inspections pending supervisory review and notification of the findings to the licensee; (3) inspection reports were incomplete; (4) a backlog of 101 licensing actions:

(5) no incident reporting to NRC since June 1995; (6) incomplete documentation of 4

incident response and response to. allegations; (7) regulations required for compatibility not adopted in timely fashion; and (8) no "get well" plan. All of these factors considered collectively led the team to find that State's response to Section 3.2, Technical Staffing and Training was unsatisfactory.. The team found Section 4.1.2, Status and Compatibility 4

of Regulations, unsatisfactory due to the failure to adopt regulations equivalent to 10 CFR Part 36 by July 1,1996. The team found that the primary root causes for the deficienclos found in the program were directly attributable to (1) the need for management j

improvement to effectively assess and respond to the reduced level of performance in the Agreement State program, and (2) lack of current, written, program procedures or failure of staff to follow these procedures. Accordingly, the team recommends that the Management Review Board find the Nebraska program adequate to protect public health and safety but needs improvement and not compatible due to the failure to adopt 10 CFR t

Part 36 or equivalent legally binding requirements within the specified period of time. Due to the significance and number of deficiencies found in the Nebraska program that included unsatisfactory in two performance indicators, and the associated finding of incompatible, the team recommends a period of probation for a duration to be established after consultation with Nebraska radiation control program management.

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i Nebraska Draft Report Page 22 Recommendations

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Below is a summary list of recommendations and suggestions, as stated in earlier parts of 1

this report, for consideration and action by the State.

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1.

The review team recommends that the State follow the inspection frequency for conducting inspections of reciprocity licensees contained in NRC Manual Chapter 1220, " Processing of NRC Form 241, Report of Proposed Activities in Non-j Agreement States, and Inspection of Agreement State Licensees Operating Under j

10 CFR Part 150.20." (Section 3.1) j i

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2.

The review team recominands that the managers responsible for the Nebraska i

Radioactive Materials Program establish'an action plan or procedure to assure j

inspections are completed at the frequencies stated in the Nebraska inspection

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Manual which is equal to the NRC's IMC 2800 and conduct reciprocity licensee

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inspections at the required frequencies stated in IMC 1220. (Section 3.1) 3.

The review team recommends that the managers establish an action plan or procedure for coordinating deviations from the schedule between staff and l

management based on the risk of license operations, past performance and need to i

temporarily defer the inspections to address more urgent or critical priorities.

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(Section 3.1)

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4.

The review team recommends that the managers organize a "get well" plan for rescheduling missed or deferred inspections, especially due to loss of senior staff; 4

and establish a plan or methodology to assure initial inspections are performed within 6 months of issuance of the license in accordance with the Nebraska l

Inspection Manual and NRC's IMC 2800. (Section 3.1) 5.

The review team recommends the incorporation of the inspection frequencies contained in NRC's IMC 2800 into the Nebraska inspection Manual. (Section 3.1) 6.

The team recommends that the qualifications of contractor personnel be tied to the i

contract as identified by the program manager or as accomplished by the LLRW program in NDEO. (Section 3.2) 7.

The team recommends that a written program for staff qualification, including i

retaining training records, be developedc (Section 3.2) 8.

The team recommends that the State develop comprehensive administrative procedures, sufficient to guide the day to-day operation of the program in the event i

of another loss of senior staff. The procedures should include a formal process for i

bringing to the attention of upper management the increase of significant backlogs of licensing, inspection, or enforcement actions, or any other situation which mcreases the risk to public health and safety. (Section 3.2) 1 I

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Nebraska Draft Report Page 23 9.

The team recommends that the program be observed with increased attention to the effects of the further reorganization. (Section 3.2) 10.

The team recommends that a written policy or procedure should be developed for prioritizing licensing actions based upon identified factors, including health and safety significance, for new and previously received applications. (Section 3.3) l 11.

The team recommends that a written procedure and schedule should be developed i

for elimination or reduction of the backlog of existing licensing actions.

(Section 3.3) 12.

The review team recommends that the State consider for adoption a policy of annual supervisory accompaniments of allindividuals who perform inspections for the Radioactive Materials Programs. (Section 3.4) 13.

The review team recommends that the State develop a plan or procedure to assure that field notes, as well as, reports, and enforcement letters are promptly reviewed, signed and dated by a supervisor within the recommended 30 day time frame for issuance of inspection findings. (Section 3.4) 14.

The review team recommends that the State perform an immediate review of all contractor field notes and draft enforcement letters in order to finalize and issue the findings of the remaining 22 inspections to the licensees involved. (Section 3.4) 15.

The review team recommends revising the allegations procedures to incorporate key areas,i.e. documentation of any communications with the alleger, documentation of the inspection findings, interviewing techniques, etc., identified in NRC Manual Directive 8.8, Managemont of Allegations. (Section 3.5) 16.

The review team recommends that the staff use the draft " Handbook on Event Reporting in the Agreement States (Handbook)," published March 1995, for review and reporting of material events. (Section 3.5) 17.

The review team recommends establishment of comprehensive procedures for tracking, follow-up and close out of events involving the use of radioactive material covered under the Atomic Energy Act. (Section 3.5) 18.

The review team recommends that the State immediately begin reporting current material events to NRC and send in information on the three events identified dunng the review as reportable, that were not previously reported to NRC. (Section 3.5) 19.

The review team request that the program provide a legal analysis as to whether the State considers application of the limits in 180 NAC 1-012.22 to waste treatment and storage facilities as a radiation protection standard, or ALARA goal or design objective. The review team recommends that this issue remain open pending receipt and review of the legal analysis.

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Nebraska Draft Report Page 24 20.

The team suggests that the LLRW program assemble training documentation for individual staff and contractors and develop a consolidated training record to enable assessment of the progress of training across the entire program. (Section 4.2.3) 5 j

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LIST OF APPENDICES AND ATTACHMENTS 1

Appendix A iMPEP Review Team Members Appendix B NDOH and EHPS Organization Chart Appendix C Nebraska Questionnaire Response Appendix D License File Reviews Appendix E Inspection File Reviews Appendix F Incident File Reviews Nebraska's Responses to Review Findings (August 6,1996 and September 10, 1996) i I

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APPENDIX A IMPEP REVIEW TEAM MEMBERS Name Aces of Responsibility Patricia M. Larkins, OSP Team Leader Response to incidents and Allegations Jenny Johansen, Ri Status of Materials inspection Program Technical Quality of Inspections Richard Blanton, OSP Technical Staffing and Training -

Legislation and Regulations Charles Mattson, Colorado Technical Quality of Licensing Actions Ralph Cady, RES Low-Level Radioactive Waste Program l

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NEBRASKA DEPARTMENT OF HEALTH l

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ENVIRONMENTAL HEALTH PROTECTION SECTION J

ORGANIZATION CHART f

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= Rev. 7/12M6 ENVIRONMENTAL IIEALTil PROTECTION SECTION Jack L. Daniel, Administrator Mary llanneman, Admin. Asst. Jo Ann Wagner, Admin. Asst.(Regulations) AllERA Procram Asbestos Control Procram Encineerine Services Procrana Field Services Proeram Doug Gillespie, Program Manager Donald Madsen, Program Manager Subliash Jha, Program Manager Tom Michels, Program Manager Barb Eickmeier, Secretary Janell Miller, StafT Asst. Dawn McFarland, StalT Asst. Robert Donahue,IllllS Bob Lukowski, P.E. Tom Flodman, WSS Steve Schlife,IIIHS Steve Rowell, P.E. Daryl Guest, WSS Larry Steele, EIT Rich Koenig, WSS Ralph Naber, WSS Roger Rhylander, WSS Mike Wentink, WSS Doug Woodbeck, WSS Low Level Radioactive Waste Procram Monitorine E Comoliance Procram Radioactive Materials Procram Water Well Standards Promm Cheryl Rogers, Program Manager Scott Peterson, Program Manager Brian Hearty, Program Manager Rod Tremblay, Program Manager l Bev Spang, StafT Asst. Laura liardesty. WSS Joyce Davidson, IIP Pat Wilsey, StafT Asst. l John Fassell,llP Roger Lolley, ISA Jim DeFrain HP Tom Christopherson, WSS l Trudy Hill, RilS Gale Stenberg, WSS Bryan, Miller, HP Dave Sizer, WSS l Deb Larson, StafT Asst. (Butte) Stephanie Vap, WSS Joe Milone, RHS Iloward Shuman, HP }

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4 i APPENDIX C a INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 4 j (IMPEP) QUESTIONNAIRE l. l 5 5 i i 1-4 4 t i 4 4

. ?. j i ^ ~ Approved by OMB' No. 3150-0183 4 i Expires 4/30/98 INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM QUESTIONNAIRE Nebraska Department of Health, Nebraska Department of Environmental Quality NDOH Radioactive Materials Program, Brian P. Hearty, Manager M 4 ) NDOH Low Level Radioactive Waste Program, Cheryl K. Rogers, Manager NDEQ Low Level Radioactive Waste Program, Jay D. Ringenberg, Manager Reporting Period: June 25,1994, to July 12,1996 1 A. COMMON PERFORMANCE INDICATORS 1. Status of Materials insoection Proaram a 1. Please prepare a table identifying the !icenses with inspections that are i 2 overdue by more than 25% of the scheduled frequency set out in NRC Inspection Manual Chapter 2800 (issued 4/17/95). The list should include j initial inspections that are overdue. Licensee Name inspection License Number Frequency Due Months License Type (Years) Date Overdue Type Stanley S. Jaeger 3 01-69-01 03/01/89 88 Other Services initial i Nebraska Methodist Hospital 1 HDR Afterloader Routine 2 Estimated burden per response to comply with this voluntary collection request: 60 hours. Forward comments regarding burden estimate to the Information and Records Management Branch (T-6 F33), U.S. Nticlear Regulatory Commission, Washington, DC 20555-0001, and to the Paperwork Reduction Project (3150-0052), Office of Management and Budget, Washington, DC 20503. NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it i displays a currently valid OMB control number. 4 9 -m

~. !~ Lincoln General Hospital 1 i 02 06 03 05/01/95 14 ) HDR Afterioader Routine Nuclotron Oldelft 3 l Corporation 05/01/95 14 i 9949 01 Routine Other Services Immanuel Medical Center 1 1 01 04-01 01/01/96 6 HDR Afterloader Routine 3 ~ Center for Metabolic Imaging 1 01-72-01 01/01/96 6 Manufacturing Routine Bergan Mercy Medical Center 1 i 01-09 02 04/01/96 3 i HDR Afteriaader Initial j University of Nebraska 1 Medical Center 04/01/96 3 01-50-01 Routine l Medical Institution Broad Thiele Geotech, Inc. 5 01-84-01 06/01/96 1 Industrial Gauge initial 4 2. Do you currently have an action plan for completing overdue inspections? i If so, please describe the plan or provide a written copy with your response to this questionnaire. License No. 01-69-01, Stanley S. Jaeger, expired 9/30/93 without an 4. initial inspection having been performed. The Individual has submitted a renewal application, but has not responded to a subsequent deficiency intter. The application was not deemed timely filed. If the applicent is issued a license, an Initial inspection j will be performed within 6 roonths, otherwise a termination Inspection will be performed in 1996 to confirm the transfer of the dose calibrator calibration sources authorized by the license. ) 2 i e

O Nebraska Methodist Hospital, Lincoln General Hospital, and immanuel Medical Center, were not assigned a Priority 1 when an. HDR was added to each license. The ilconsees listed above will be inspected in 1996 and annually as described in A.I.3. below. Center for Metabolic Imaging has requested that 01-72-01 be terminated since the operation of the cyclotron has been taken over by Syncor International Corp. under license 01-65 02, which was inspected 3/19/96. Since operations are ongoing under another license a termination inspection will not be required. Bergan Mercy Medical Center, was authorized for an HDR in 8/95 and the license reviewer noted that an inspection should be performed within 6 months after start of HDR treatment. The licensee received their HDR 'n 10/95. The licensee will be inspected in 1996 and annually as described in A.I.3 below. Nucletron Oldelft Corporation was not assigned a Priority 3 when licensed in Nebraska. The licensee was inspected in 5/92 and assigned a 5 year inspection frequency. The licensee will be inspected in 1996 and every 3 years as described in A.I.3. below. The University of Nebraska Medical Center was inspected during the spring semester of 1995. To provide variability in the research activities that may be directly observed during the inspection, the licensee will be inspected during the fall semester of 1996. Thiele Geotech, Inc., will be inspected by program staff during the week of July 1519,1996, with NRC accompaniment. 3. Please identify individual licensees or groups of licensees the State / Region is inspecting less frequently than called for in NRC inspection Manual Chapter 2800 (issued 4/17/95) and state the reason for the change. Hiah Dose Rate Remote Afterloader: Licensees possessing an HDR have were previously inspected on a 3 year frequency. All licenses authorizing an HDR will be assigned a Priority 1 and inspected annually. Mobile Nuclear Medicine Service: Licensees of this type were previously inspected on a 3 year frequency. Licensees providing IMPEP Questionnaire 3 State of Nebraska

f mobile nuclear medicine services will be assigned a Priority 2 and be I inspected every 2 years. Instrument Calibration Services Only - Other: and Other Services: Service licensees were previously grouped together and inspected on a 5 year frequency. All service licensees will be reviewed and assigned the proper priority and inspection frequency, either 3 or 5 years, and inspected accordingly. Manual Chapter 2800 will be reviewed when revised and appropriate changes in the Program's inspection frequencies will be made if Justified. A copy of 2800, Enclosure 1, will be placed in the Program Staff Inspection Manuals for reference. 4. How many licensees filed reciprocity notices in the reporting period? 31 licensees filed 163 reciprocity notices. a. Of these, how many were industrial radiography, well-logging or other users with inspection frequencies of three years or less? l 20 licensees of Priority 1,2, or 3. (7 industrial radiography,1 mobile nuclear medicine service,7 well logging, and 5 other services) i l b. For those identified in 4a, how many reciprocity inspections were i conducted? 2 licensees (industrial radiography) were inspected. 5. Other than reciprocity licensees, how many field inspections of radiographers were performed? l 1 field Inspection will be performed. A field site (which the licensee hopes to add as a permanent radiographic facility) will be inspected l on 6/26/96 by program staff with NRC accompaniment. Of the other l 3 !ndustrial radiographers licensed in Nebraska,2 are fixed facility, and 1 has not used their sources since 5/27/94. 6. For NRC Regions, did you establish numerical goals for the number of inspections to be performed during this review period? If so, please l describe your goals, the number of inspections actually performed, and IMPEP Questionnaire 4 State of Nebraska l

1 the reasons for any differences between the goals and the actual number of inspections performed. N/A II. Technical Staffino and Trainina 7. Please provide a staffing plan, or complete a listing usir.g the suggested format below, of the professional (technical) person-years of effort applied to the agreement or radioactive material program by individual, include the name, position, and, for Agreement States, the fraction of time spent in the following areas: administration, materials licensing & compliance, emergency response, LLW, U-mills, other. If these regulatory responsibilities are divided between offices, the table should be consolidated to include all personnel contributing to the radioactive materials program. Include all vacancies and identify all senior personnel assigned to monitor work of junior personnel. If consultants were used to carry out the program's radioactive materials responsibilities, include their efforts. The table heading should be: RADIOACTIVE NAME MATERIALS AREA OF EFFORT PROGRAM POSITION Brian Hearty Program Manager Program Administration -40% Licensing / Compliance - 30% Regulations - 10% Emergency Response - 10% Jim DeFrain Health Physicist i Licensing / Compliance - 95% Emergency Response - 5% Vacant, Health Physicist i Licensing / Compliance - 95% Emergency Response - 5% Joyce Health Physicist i Regulations -70% Davidsop Licensing / Compliance 25% Emergency Response - 5% Cheryl Rogers Program Manager Licensing / Compliance - As LLRW Needed up 20% IMPEP Questionnaire 5 State of Nebraska

i. i '. l Howard Health Physicist il Compliance - As Needed up to Shuman LLRW 20% i Harold Radiological Regulations - As Needed Borchert Health Consultant Licensing / Compliance - As Needed Stan A. Huber Contract Compliance - Performance of Consultants, Consultant 27 inspections from 1/1/96 to j inc. 6/30/96. l Brian Hearty, Cheryl Rogers, and Joyce Davidson have been identified as senior personnel for reviewing work in materials licensing. Brian Hearty, Cheryl Rogers, and Howard Shuman have been identified as senior personnel for inspection accompaniments of junior personnel. l 8. Please provide a listing of all new professional personnel hired since the last review, indicate the degree (s) they received, if applicable, and additional training and years of experience in health physics, or other disciplines,if appropriate. Jim DeFrain, was hired as a Health Physicist Iin the Radioactive i Materlafs Program on July 20,1995. Jim has MPA in Public ~ Administration and has been with the Department of Health for 13 years. He has worked as a Radiological Health Specialist I and Health Physicist Iin the X-ray Program, and a Radiological Health Specialist ll and Health Physicist iin the Emergency Response and Environmental Surveillance Programs. Jim has attended the following training courses which directly relate to the Radioactive Materials Program: 6 Week Applied Health Physics, RadioloC cal i j Emergency Response Operations, Transportation of Radioactive Materials, inspection Procedures, Licensing Procedures, Medical Uses of Radionuclides, Safety Aspects ofindustrial Radiography, 4 Health Physics Technology, and Environmental Monitoring for j Radioactive Materials. 1 The vacant Health Physicist I will be hired in 6/96 and training and experience will be available at the time of the IMPEP review. 1 9. Please list all professional staff who have not yet met the qualification requirements of license reviewer / materials inspection staff (for NRC, inspection Manual Chapters 1245 and 1246; for Agreement States, i IMPEP Questionnaire 6 State of Nebraska i

l please describe your qualifications requirements for materials license reviewers and inspectors). For each, list the courses or equivalent training / experience they need to attend and a tentative schedule for completion of these requirements.

The qualifications requirements for Radioactive Materials Program license reviewers and inspectors consists of internal training, formal coursework, and on the job training. The infomal training consists of review of the program's inspection j and Enforcement Manuals, review of all appropriate Nebraska and Federal Regulations and regulatory guides, and review of program i policies. l The formal coursework required has included the following NRC and i FEMA sponsored courses: Radiological Emergency Response i Operations, Applied Health Physics, Licensing Procedures, i inspection Procedures, Medical Uses of Radionuclides, i Transportation of Radioactive Material, Health Physics Engineering, i Safety Aspects of Industrial Radiography. As more NRC sponsored courses become available to Agreement } State inspectors, the above core coursework may be expanded to include coursework that would be beneficial to the Program. Courses that program staff have found beneficial include: Health i Physics Technology, inspecting for Performance, Teletherapy and l Brachytherapy, Irradiator Technology, Safety Aspects of Well ] Logging, and Environmental Monitoring for Radioactivity. The l Diagnostic and Therapeutic Nuclear Medicine Course is also very i appropriate for program staff. i l The on the-job training for materials licensing consists of the direct i supervision of the trainee in the review and evaluation of Increasingly complex licensing actions. On-the job training for j inspections consists of the trainee accompanying senior staff on various inspections, and then the trainee acting as lead inspect,or while accompanied by senior staff on increasingly complex inspections. Brian Hearty has not yet attended the Safety Aspects of industrial Radiography Course and plans to attend during 1996. i j { IMPEP Questionnaire 7 State of Nebraska ) 4 .s.n .m. m ~ e-.

l .o Jim DeFrain has not yet attended the Health Physics Engineering Course and has submitted an application to attend the 8/12-16/96 offering. Jim is continuing to review increasingly complex licensing actions under supervision. Jim has accompanied on several inspections, and has started to act lead inspector while l accompanied by senior personnel. The vacant Health Physicist I will need to receive additional training dependent on the qualifications possessed at the time of hire. 10. Please identify the technical staff who left the RCP/Regbnal DNMS program during this period. NAME POSITION REASON FOR LEAVING Julie Peterson Health Physicist ll Accepted position as HP for U.S. Army Corps of Enginoers on 6/23/95. Michael Beard Health Physicist i Accepted a position as NDOH investigations Section Administrator on about 8/1/95. Subsequently, accepted a position as RSO at an irradiator in Nebraska. Ill. Technical Quality of Licensino Actions 11. Please identify any major, unusual, or complex licenses which were issued, received a major amenoment, terminated or renewed in this period. Crelahton Universitv. 01-82-01: Combined 11 educational and 5 l medical licenses into 'he broad scope license. Beroan Mercy Medical Center. 01-09-02: Received authorization for an HDR, a PET Scanner to be used with a Rb-82/Sr-82 infusion system, and a redesign of the nuclear tradicine area. IMPEP Questionnaire 8 State of Nebraska

Lincoln General Hospital. 02-06-03. and St. Ellrabeth Community Health Center. 02 35-01: The licenses were transferred from the radiology group to the facilities, the 02-06-03 license combined a separate nuclear medicine and an HDR (brachytherapy) license. g_ryan Enterprises. : Combined two large mobile nuc!aar medicine services under one license. See also 13. below. EndoTech. Inc. 0176 01: This research and developmerit licensee's requests resul:ed in the submission of financial surety for site reclamation, and a lowering of possession limits to avoid an emergency plan which was now being requested by the program. 12. Please identify any new or amended licenses added or removed from the list of licensees requiring emergency plans? N/A. Currently, no licensees have been required to submit an emergency plan. 13. Discuss any variances in licensing policies and procedures or exemptions from the regulations granted during the review period. Nebraska regulations require that an authorized user or on. site physician (40 hrs training in radiation safety) be at the facility dudng the performance of mobile nuclear medicine procedures. A policy was developed which allows a mobile nuclear medicine licensee to request an exemption allowing on site physicians to be at their office, but available by phone and able to respond within 30 minutes in an emergency. r An exemption was granted to Bryan Enterprises,02-39-01, to allow delivery of licensed material to a client's address of use for receipt by the licensee's staff at the mobile van. The above exemptions allowed diagnostic health care servicer in parts of rural Nebraska that would not have been feasible before. A variance in licensing practice was recently discovered regarding financial assurance for decommissioning with regards to the 3 commercial irradiator licensees in Nebraska. At the time the rule was adopted it was unclearif any Nebraska licensees would be required to submit a decommissioning funding plan. It is now clear the irradiator licensees are required to submit a funding plan for IMPEP Questionnaire 9 State of Nebraska

$75,000. The licensees will be notified and the plans reviewed upon receipt. l 14. What, if any, changes were made in your written licensing procedures (new procedures, updates, policy memoranda, etc.) during the reporting period? The standard license conditions have been revised. Several policy memorandum have been superseded by implementation of the 5/31/94 revision of the regulations. The licensing procedure manual, review guidance, and checklists have not been updated to reflect current requiremerits. Currently, materials licensing reviewers use updated Regulatory Gu! des, NRC checklists, and NRC deficiency paragraphs for guidance. The generation of updated procedures, guidance, and checklists will be completed as soon as possible to ensure thorough and timely review of licent ing actions. 15. For NRC Regions, identify by licensee name, license number and type, any renewal applications that have been pending for one year or more. N/A IV. Technical Quality of insoections 16. What, if any, changes were made to your written inspection procedures during the reporting period? An Inspection Manual was developed and implemented h late 1994. An Enforcement Manual containing boilerplate violations was developed and authorized for use as guld' ance in 2/95. The first use of the Enforcement Manual violations for actual drafting of a Notice of Violation has been by the contract inspector in 1996. 17. Prepare a table showing the number and types of supervisory accompaniments made during the review period. Include: 1 IMPEP Questionnaire 10 State of Nebraska I

t Supervisor inspector License Category Date Bill Schultz, Brian Hearty Medical Private 09/02/94 contract Practice consultant. Bill Schultz, Julie Peterson Medicalinstitution 09/01/94

• contract consultant.

Bill Schultz, Michael Beard industrial Radiography 08/31/94 contract - Fixed consultant. \\ 18. Describe internal procedures for conducting supervisory accompaniments of inspectors in the field. If supervisory accompaniments were documented, please provide copies of the documentation for each accompaniment. Currently, the number and type of supervisory accompaniments by senior program staff is not defined by program procedure and they have not been documented in the past. A consultant was hired to develop the inspection and Enforcement Manuals, and part of the contract was to review the program staff by accompaniment. Copies of the reports submitted for Julie Peterson and Brian Hearty are attached. 19. Describe or provide an update on your instrumentation and methods of calibration. Are all instruments properly calibrated at the present time? Proaram Maintained Detection and Measurement Instrumentation: Ludlum Model 5, dualintamal G M detectors. Ludlum Model 14C,intamal G M and extemal 44-6 G-M detector. Ludlum Model 12S, intemal Nal detector, R/hr meter. The above instruments are calibrated annually by the manufacturer and are in calibration at this time. Ebortint PAC-4S, AC-3 7 ZnS detector. The above instrument was calibrated by the manufacturer in 8/93 and is currently not calibrated for use. IMPEP Questionnaire 11 State of Nebraska ) )

,Available Detection and Measurement instrumentation: Ludlum Model 3,44-38 energy compensated G-M detector and 44 3 thin crystal Nal detector. The above instrument is calibrated annually by the manufacturer and is in calibration at this time. Eberline RO-2, lonization chamber. Ebertine E-520, HP 210 or HP 210T G-M probe. The above instruments are calibrated annually by the manufacturer or a calibration service and are in calibration at this time. Confirmatory wipe tests and gamma isotopic measurements are performed by the Nebraska Department of Health Lab using various instruments. V. Responses to incidents and Alleaations 20. Please provide a list of the most sianificant incidents (i.e., medical misadministration, overexposures, lost and abandoned sources, incidents requiring 24 hour or less notification, etc.) that occurred in the Region / State during the review period. For Agreement States, information included in previous submittals to NRC need not be repeated. The list should be in the following format: Licensee License Date of Name Number incident / Type of incident Report Nebraska 02-02-02 incident Licensee discovered a Civil Defense 01/93 missing Co-60 source (= 180 Agency (Assumed) Cl on 1/93) which was most likely disposed of in Reported the landfill. The NRC 08/07/95 agreement states officer was notified by telephone on 08/07/95. l IMPEP Questionnaire 12 State of Nebraska l

1 Sherwood 07 02 01 Incident Irradiatorlicensee Medical 09/09/95 performJng weekly maintenance check found Reported the low water switch not 09/12/95 functioning as intended. The sources were raised without correcting the problem or notifying the Agency as required by license condition. the switch functioned properly when ratested 09/11/95. The incident was not reported to NRC since 10 CFR 36 would allow the licensee to repair the switch without undue delay. Sherwood 07-02-01 incident An employee of the licensee Medical 11/30/95 called to allege a pos.sible violation involving barrier Reported doors malfunction. An 12/1/95 inspection of the licensee confirmed that barrier doors were not functioning as Intended when the licensee changed operation to index mode. It was determined by l observation and interview l that the barrier door or a l tote was blocking the entrance at all times during the incident. The inradiator manufacturer checked and repaired the program logic. This incident was not reported to NRC. 21. During this review period, did any incidents occur that involved equipment or source failure or approved operating procedures that were deficient? If so, how ~ and when were other State /NRC licensees who might be affected notified? I IMPEP Questionnaire 13 State of Nebraska l

1 l l l The equipment problems listed in A.V.20. above were reported by the licensee to the manufacturer. a. For States, was timely notification made to the Office of State Programs? l For Regions, was an appropriate and timely PN generated? The OSP was not notified of any equipment or source failures, or deficient procedures. An attempt was made to use the interim Nuclear Materials Events Database and Report Preparation Program to generate reports of events. There were several problems with the implementation, and a decision to wait for the final Microsoft Access version of NMED was made. 22. For incidents involving failure of equipment or sources, was information on the incident provided to the agency responsible for evaluation of the device for an assessment of possible generic design deficiency? Please provide details for each case. No. 23. In the period covered by this review, were there any cases involving possible l wrongdoing that were reviewed or are presently undergoing review? If so, please describe the circumstances for each case. No. 24. Identify any changes to your procedures for handling allegations that occurred during the period of this review. A procedure for response to allegations was drafted and implemented as part of the new Inspection Manual, a. For Agreement States, please identify any allegations referred to your program by the NRC that have not been closed. N/A VI. General

25. Please prepare a summary of the status of the State's or Region's actions taken in response to the comments and recommendations following the last review.

IMPEP Questionnaire 14 State of Nebraska

l. 4 1 } j The review completed June 24,1994, indicated that the Nebraska Program l met the guidelines in all 30 indicators, and no recommendations or j comments were identified. i i

26. Provide a brief description of your program's strengths and weaknesses. These 1

strengths and weaknesses should be supported by examples of successes, problems or difficulties which occurred during this review period. A strength of the Nebraska Radiation Control Program is its ability to obtain l sufficient resources, such as quallfled personnel, either intomally or through j contractual arrangements, to ensure that program activities are carried out at i an adequate level to protect the public health and safety. The contract for j inspection services and an increase in the allocation of time from LLRW Program Staff allowed the materials licensing backlog to be addressed during the staff shortage outilned in A.ll.10. above. However, it is a weakness of the Program that the frequency at which it is necessary to obtain outside resources has not decreased. A weakness of the Radioactive Materbis i Program is the time taken to review changes in NRC procedure for j l appropriateness to the program, such as the inspection frequencies in j inspection Manual Chapter 2800. An example of this is the overdue inspections of HDR licensees as outlined in A.I.3. 1 B. NON COMMON PERFORMANCE INDICATORS i 1. Reculations and Leoal Authority

27. Please list all currently effective legislation that affects the radiation control l

program (RCP). Radiation Control Act 713501 to 71-3520 I Nebraska Disaster and Civil Defense Act, as amended 81-829.36 to 81-829.74. l (This Act was amended this past legislative session and will become the j Emergency Management Act on 07/18/96). j Emergency, Govemor, Civil Defense Assumption of Control of State j Communications System 81-1120.25 1 l Administrative Procedures Act 84 920 l iMPEP Questionnaire 15 State of Nebraska ) 4

(.. ~ Low-Level Radioactive Waste Disposal Act 81-1578,(This Act was amended this past legislative session an will become effective 07/19/96.). l l Nebraska Partnership for Health and Human Services Act LB1044, Effective 01/01/97. l

28. Are your regulations subject to a " Sunset" or equivalent law? If so, explain and j

include the next expiration date for your regulations. i l No. 1 j

29. Please complete the enclosed table based on NRC chronology of amendments.

] Identify those that have not been adopted by the State, explain why they were not l adopted, and discuss any actions being taken to adopt them. 1 l

30. If you have not adopted all amendments within three years from the date of NRC l

rule promulgation, briefly describe your State's procedures for amending j regulations in order to maintain compatibility with the NRC, showing the normal length of time anticipated to complete each step. i l Program staff drafts changes in regulations by using the Conference of j l Radiation Control Program Director's Suggested State Regulations, NRC j Regulations, FDA, EPA, and DOT regulations. The drafts are then reviewed l by the appropriate Program Manager, Health Department Legal staff, and the Nebraska Radiation Advisory Council. The Council may then give approval j to go to Public Hearing. The drafts are then sent to the Govemor's Policy Research Office (PRO) for their approval to go to Public Hearing. Notice of l Public Hearing is published (IN A NEWSPAPER WITH WIDE CIRCULATION i THROUGHOUT NEBRASKA) at least 30 days prior [THIS IS LAWJ l (SOMETIMES MORE TIME IS GIVEN DEPENDING ON THE PROPOSED DRAFTS). j A copy of the Public Hear!ng notice is filed with the Nebraska Secretary of l State's Office and copies of the Public Hearing notice are sent out to all l licensees and registrants in Nebraska in addition to other interested parties. i Copios are also sent to the Nebraska Executive Board of the Legislature. l Copirss of the drafts are provided to alllicensees and anyone who requests a copy. At this time all Federal Agencies are also sent copies of the Public j Hearing Notice and a copy of the proposed draft regulations. IMPEP Questionnaire 16 State of Nebraska

l After Public Hearing comments are reviewed and any necessary changes are made, the final draft goes to the Attomey General's Office for their review, comments and approval. (USUALLY TAKES 30-DAYS, SOMETIMES LESS.) Upon approval by the Attomey General it then goes back to the Govemor's ] Office (PRO) for approval (USUALLY TAKES 30 DAYS SOMETIMES LESS.) Upon Govemor's approval and signature it is filed with the Nebraska Secretary of State's office. (EFFECTIVE DATE IS 5 DAYS LATER). Printing and distribution takes about 30 additional days. i II. Low-level Waste Procram

31. Please include information on the followinD questions in Section A, as they apply j

to the Low-level Waste Program: i Status of Materials inspection Program - A.I.1-3, A.I.6 { Technical Staffing and Training - A.ll.7-10 Technical Quality of Licensing Actions - A.lli.11, A.lll.13-14 l Technical Quality of Inspections - A.IV.16-19 Responses to incidents and Allegations - A.V.20-23 l i The Nebraska Low Level Radioactive Waste Program (LLRWP)is a joint effort j by the Nebraska Department of Health (NDOH) and the Nebraska Department of Environmental Quality (NDEQ). The application for construction, operation i and closure of the waste disposal facility is under review by the LLRWP; l therefore, responses to the following questions are not appropriate: Status of Materials inspection Program - A.I.1-3, A.I.6 { Technical Quality of LicensinD Actions - A.Ill.11, A.lli.13 Technical Quality of Inspections - A.IV.16-18 Responses to incidents and Allegations - A.V.20-23 l The responses to the remaining questions follow: 11. Technical Staffino and Trainino 7. Please provide a staffing plan, or complete a listing using the suggested format i below, of the professional (technical) person-years of effort applied to the agreement or radioactive material program by individual. Include the name, position, and, for Agreement States, the fraction of time spent in the following areas: administration, materials licensing & compliance, emergency response, l IMPEP Questionnaire 17 State of Nebraska I

LLRW, U-mills, other. If these regulatory responsibilities are divided between offices, the table should be consolidated to include all personnel contributing to the radioactive materials program. Include all vacancies and identify all senior personnel assigned to monitor work of junior personnel. If consultants were used to carry out the program's radioactive materials responsibilities, include their efforts. The table heading should be: l NAME LLRW PROGRAM AREA OF EFFORT POSITION l J. D. NDEQ LLRW Program LLRW program administration - Ringenberg Manager 100% Monitors work of LLRWP personnel. C.K. Rogers NDOH LLRW Program LLRW program administration 85% Manager NDOH, ER-10%, NDOH Environmental-5% Monitors work of LLRWP personnel

• H. Shuman NDOH HP ll -

LLRW program (application review Environmental and RESP)- 90% Survalliance. NDOH ER - 10%* Reviews work of LLRWP personnel l J. Fassell NDOH HP 11-LLRW program (application review Performance and IPA) - 90% Assessment NDOH ER - 10% G. Allen NDEQ LLRW program - 100% l Environmental Reviews work of LLRWP personnel. Specialist C. Felix NDEQ Administrative LLRW program 100% Assistant ll Reviews work of LLRWP personnel. 78 Expertise in various Names, resumes and areas of effort Contractors areas Have been or are on file and are available to the are involved in the NRC. review of the application. Vacant NDOH HP 11 - LLRW program (source term, waste Nuclear Engineer form etc.)- 100% IMPEP Questionnaire 18 State of Nebraska 9

j in addition to the foregoing the current LLRWP stan includes one NDEQ Staff i Assistant 11, one NDOH Secretary 11, one NDEQ Secretary 11, and one NDOH Staff Assistant (part time), i-i 8. Pleans provide a listing of all new professional personnel hired since the last l review, indicate the degree (s) they received, if applicable, and additional training l and years of experience in health physics, or other disciplines, if appropriate. l John Fassell joined the LLRW program in February 1996. He has a B.S.1.n j Geology (minor-Geochemistry) and a MS in Atmospheric Sciences (Specializing in Space Physics) and completed the U.S. Air Force Institute of Technology Basic Meteorology Program. He is a Registered Radiation j Protection Technologist by the NRRPT. Courses that he has completed i follow: l MfLG l Transportation of Radioactive Materials Course (1996) FEMA l Radiological Emergency Planners Course (1994) Rah.!cgical Trainer ill Train the Trainer) Course (1995) Exercise Evaluators Course (1994) Ingestion Pathway Course (1993) l Radiological Emergency Response Operations Course (1993) SCDNFEMA i Radiological Monitor Course (1993) i Radiological Responder Team Course (1993) l Radiological Officer Course (1993) Radiological Monitor instructor Course (1995) i instructional Techniques Course (1995) i k!EE8 l Agricultural Pathway Course (1993) EE8 EPA 400 Instructional Workshop (1993) i Radon Measurement Proficiency Course ) Emplovment Historv 4/1/95 to 3/1/96 NDOH Inspector X-ray Section l l l lMPEP Questionnaire 19 State of Nebraska 4 i I

}- 1/4/93 to 4/1/95 NDOH HP Section Chief for the Emergency Response, l Standards, Environmental Surveillance and Radon Section. 1983 to 1993 USAF Weather Officer serving in St Louis, MO, Okinawa, j Japan and Omaha, NE. Primary function was problem j solving in electronics, physics and environmental j applications. i 1 9. Please list all professional staN who have not yet met the qualification requirements of license reviewer / materials inspection staN (for NRC, inspection Manual Chapters 1245 and 1246; for Agreement States, please describe your qualifications requirements for materials license reviewers and inspectors). For each, list the courses or equivalent training / experience they need to attend and a tentative schedule for completion of these requirements. The review of the application for license is generally performed by consultants. There are 8 Review Managers assigned to specific technical areas of the application. Each Review Manager has several Technical i Reviewers with expertise in specific areas reporting to him. The l requirements for qualification as a Review Manager or as a Technical Reviewer are specified in LLRW Program Licensing Procedure LP-7. .i

10. Please identify the technical staff who left the RCP/ Regional DNMS program j

during this period. i NAME POSITION PEASON FOR LEAVING Asish Banerjee NDOH HP 11 Transferred to NDOH X-Ray Radiological Analyst Program on 12/1/95, i Beth Kemes-NDOH HP 11 Accepted a position as a j Krause Nuclear Engineer Nuclear Engineer at Cooper i NPS on 10/1/94. Charles NDEQ Retired 2/28/94 and became a Johnson Environmental part time consultant to the Engineer LLRW Program. 111. Technical Quality of Licensina Actions l

11. Please identify any major, unusual, or complex licenses which were issued, received a major amendment, terminated or renewed in this period.

i i IMPEP Questionnaire 20 State of Nebraska

l. The application review process has not progressed to the point where this question is appropriate.

13. Discuss any variances in licensing policies and procedures or exemptions from the regulations granted during the review period.

The application review process has not progressed to the point where this question is appropriate. 14. What, if any, changes were made in your written licensing procedures (new procedures, updates, policy memoranda, etc.) during the reporting period? Changes, Revisions and Additions to the Nebraska's LLRW Program's Licensing Program Plan Procedures from June 1994 to July 1996 Section or Title Revision Date of Procedure Number Revision Section 3 Review of the Safety analysis Report & 1 06/16/95 Preparation of Safety Evaluation Report Section 4 Review of Environmental Report & 2 06/30/95 Preparation of the Environmentalimpact Analysis Section 5 Preparation & lasuance or Denial of the 1 07/15/94 License Section 7 Non-Radiological Environmental 1 06/24/94 Surveillance Program 2 03/03/95 LP 5 Public Hearings 0 10/21/94 LP-8 Technical Review of the Safety Analysis 4 06/24/94 Report 6 06/16/95 LP-11 Assembly and Availability of the Draft. 2 06/20/95 Safety Evaluation Report LP-15 Technical Review of the Environmental 4 06/24/94 Report 6 06/30/95 LP-17 Preparation & Distribution of the Draft 2 06/20/95 EnvironmentalImpact Analysis IMPEP Questionnaire 21 State of Nebraska

~ LP-19 Notification of Decision to issue Draft 0 07/16/94 i License l LP-20 Preparation of Draft License 1 07/15/94 LP-22 Approval of LLRW Facility License 0 07/15/94 amendments LP-24 Notice of License Denial 0 07/15/94 LP-27 Changes Other than License 0 07/15/94 Amendments LP-36 Technical Review Comment Tracking & 1 06/24/94 Status LP-58 Environmental Data Analysis 0 03/03/95 LP-59 Sampling Plan Preparation 0 06/24/94 1 03/03/95 LP-60 Health and Safety Plan Preparation 0 06/24/94 LP-61 Environmental Data Management 0 03/03/95 JV. Technical Quality of Inspections

19. Describe or provide an update on your instrumentation and methods of calibration.

~ Are all instruments properly calibrated at the present time? The following fixed and portable instruments are currently in use by the LLRWP: E.!E1.Q Ggpie PC Gamma Spectroscopy S.f.19m Y Calibration procedure - NDOH-RAP-SOP-PR 17 Operation of the Genie PC Gamma Spectroscopy System

References:

Canberra Genie PC Users Manual ANSI N42.121980 ANSI N42.14-1991 ANSI N3231978 Canberra Model 2404 Aloha / Beta System IMPEP Questionnaire 22 State of Nebraska l

i Calibration procedure - NDOH-RAP-SOP-PR-21 Operation of the Canberra Model 2404 Alpha / Beta System

References:

Canberra Model 2400 Alpha / Beta System Users Manual Model 8394 Alpha / Beta / Gamma Control Software Users Manual ANSI N3231978 l Packard 2500 TR/AB Llauld Scintillation Analyzer j Calibration procedure-NDOH RAP SOP-06 Determination of Tritium in Water j

References:

Packard 2500 Tri Carb TR/AB Operation and Reference Manual j ANSI N42-16-1990 i j PORTABLE i Six Radeco Constant Flow (K Flow) Air Samoler 1 Calibration procedure - NDOH-RESPP 09 Radiological Environmental Monitoring of Air i

References:

SAIC Radeco Operation and Maintenance Manual-Air Flow Calibrator 4 ANSI N13.1 1969 Two Eberline Model ESP-2 portable Survey Meter i Calibrated by Commercial Vendor 1 One Ludlum Model 177 Alarm Ratemeter Calibrated by Commercial Vendor i j One Alnor Troe 8500 Thermo-Anemometer j Calibrated by Commercial Vendor CAllBRATION All of the instruments are properfy calibrated. l I i l t j IMPEP Questionnaire 23 Stateof Nebraska l i

. y TABLE FOR QUESTION 29.

OR DATE DATE 10 CFR RULE DUE ADOPTED CURRENT EXPECTED STATUS ADOPTION l Any amendment due prior to 1991. Identify each regulation (refer to the Chronology of Amendments) Decommissioning; 7/27/91 5/30/94 Parts 30,40,70 i Emergency P ..; rig, 4/7/93 5/30/94 Parts 30,40,70 Standards for Protection Against 1/1/94 5/30/94 Radiation; Part 20 Safety Requirements for 1/10/94 5/30/94 Radicyoptiic Equipment; Part 34 Notification ofincidents; 10/15/94 5/30/94 Parts 20, 30, 31, 34, 39, 40, 70 Quality Management Preyasii 1/27/95 Draft copy to the Nebraska Radiation 1/97 arx1 Misadministrations; Part 35 Advisory CouncII (Meeting C+,^_. A== 6, 1996) for their approval to go to public hearing (October 1998) and adoption in January 1997 txnMng any NRC changes in compatibility /ar enforcement. I' i ~ l IMPEP Questionnaire 24 State of Nebraska

4 OR DATE DATE 10 CFR RULE DUE ADOPTED CURRENT EXPECTED STATUS ADOPTION Licensing and Radiation Safety 7/1/96 IN PROCESS: Draft copy went to the 11/96-Requirements for Irradiators; Part Nebraska Radiation Advisory Council for 36 their approval to go to public hearing (June 7,1996). Draft to Govemor's Policy Research Office (PRO) week of (June 17,1996) to ask for approval to go to Public Hearing. Upon okay from the PRO, a public hearing will be set up (August 1996). Then on tu the Attomey General's Office for his approval (September 1996) and back to the Governor for his approval (October 1996). Pub 10 cation and out to licensees (November 1996). Definition of Land Disposal 7/22/96 NDOH and Waste Site QA Prcyam, Part 5/30/94 61 NDEQ 6/26/94 Decommissioning Recordkeeping: 10/25/96 5/30/94 Documentation Additions; Parts 30,40,70 Self-Guarantee as an Additional 1/28/97 Draft copy to the Nebraska Radiation 179 7 Financial Mechanism; Parts 30 Advisory Council (IWieeting September 8, 40,70 1996) for their approval to go to public l hearing (October 1996) and adoption in Jar y 1997. Uranium MillTailings: Conforming 7/1/97 N/A Nebraska relinquished this part of the to EPA Standarti. Past 40 A,...M to the NRC. l IMPEP Questionnaire 25 State of Nebraska (

OR DATE DATE 10 CFR RULE DUE ADOPTED CURRENT EXPECTED ~ STATUS ADOPTION Timeliness in DscciTiriissioning 8/15/97 Draft copy to the Nebraska Radiation 1/97 Parts 30,40,70 Advisory Council (Meeting September 8, 1996) for their approval to go to public hearing (October 1996) and adoption in January 1997 Preparation, Transfer for 1/1/98 Draft copy to the Nebraska Radiation 1/97 Commercial Distnbution, exi Use Advir, cry Council (Meeting September 8, of Byproduct Material for Medical 1996) for tP*3r approval to go to public Use; Parts 30,32,35 hearing (October 1996) and adoption in January 1997. Frequency of Medical 3/13/98 Draft copy to the Nebraska Radiation 1/97 Examinations for Use of Advisory Council (Meeting September 8, Respiratory Protection Equipment 1996) for their approval to go to public hearing (October 1996) and adoption in January 1997. Low-Level Waste Shipment 3/1/98 Draft copy to the Nebraska Radiation 179 7 Manifest Information and Advisory Council (M;;"J,,g September 8, g' Reporting 1996) for their approval to go to public c hearing (October 1996) and adoption in k January 1997. k Performance Requirements for 6/30/98 5I30/94 Radio iMiy Equipment s 5$ ~

1. 3=E IMPEP Questionnaire 26 State of Nebraska

OR -+ DATE DATE 10 CFR RULE DUE ADOPTED CURRENT EXPECTED STATUS ADOPTION Radiation Protection 8/14/98 Draft copy to the Nebraska Radiation 1797 Requirements: Amended Advisory Council (Meeting September 6, Definitions and Criteria 1996) for their approval to go to pub 5c hearing (October 1996) and adoption in January 1997. Clwification of Decommissioning 11/24/98 Draft copy to the Nebraska Radiation 1797 Fureng Requirements Advisory Council (Meeting September 6, 1996) for their approval to go to pubHc hearing (October 1996) and adoption in January 1997. 10 CFR Part 71: Compatibility 4/1/99 Draft copy to the Nebraska Radiation 179 7 with the Intemational Atomic Advisory Council (Meeting September 8, Energy Agency 1996) for their approval to go to public hearing (October 1996) and adoption in January 1997. Medical AG ;i ;etiaiion of 10/20/98 Draft copy to the Nebraska Radiation 179 7 Radiation and Radioactive Advisory Council (Meeting September 8, Materials. 1996) for their approval to go to putdic hearing (October 1996) and adoption in Jar==y 1997.. IMPEP Questionnaire 27 State of Nebraska

-+ i APPENDlX D l LICENSE FILE REVIEWS 5 ' File No: 1 Licensee: University of Nebraska at Omaha ~ License No: 01-48-01 Location: Omaha, NE Amendment: 9 1 License Type: R & D Reviewer: JD Date Amendment issued: 1/17/96 i Comments: 4 a) Amendments are issued to include only the items which have been changed for that amendment and are not a rewrite of the entire document. The expiration date of the 4 I license is only included on the complete rewrite which was Amendmert No. 5 issued .11/15/90. The use of computerized standard license formats for quis ser processing, and i for clarity both for the licensee and the Agency, was discussed with staff. j b) ~ A short form renewal was authorized by Brian Hearty since the licensee had stated there were no changes in the radioactive materials program since the previous renewal. [ The calibration procedure for s/m had changed since the previous renewal. t l File No: 2 Licensee: University of Nebraska, Biology License No: 01-48-02 l i Location: Omaha, NE Amendment: 5 l License Type: R & D Reviewer: JD 2 Date Amendment issued: 6/7/96 Comments: i ~ a) A rewritten Radiation Safety Manual was submitted with the application, but was not i included in the Amendment No. 5. It was still "pending" at the time of this inspection. b) The previous inspection was completed on 4/13/93. i i ' File No: 3 Licensee: Maxim Technologies License No: 01-22-01 Location: Omaha, NE Amendment: 21 and 22 License Type: Industrial Radiography Reviewer: BH Dates Amendments issued: 9/26/95 (renewal); 1/11/96 (amendment) Comments: a) The use condition allows use at temporary job sites of the licensee anywhere in Nebraska where the Agency maintains jurisdiction for regulating the use of radioactive materials. b) There was no " reciprocal recognition of license" condition in the license. This was discussed with staff. c) Amendment 22 was issued to delete Tech / Ops Model A-424-18, because of the implementation of the IR equipment regulations. i I l_.,- - - = - -

Nebraska Draft Report Page D 2 File No: 4 Licensee: EndoTech, Inc. License No: 01-76-01 Location: Spokane, WA Amendment: 5 License Type: R & D Reviewer: BH Dates Amendments lasued: 6/12/96 Comments: a) A "line of credit" had been implemented for the company based upon 2 years rent for their facility. The 5/29/96 letter did not appear adequate in terms of enforceability or retrievability by the Agency. b) The place of use authorized on the Amendment 4 (previous to the IMPEP inspection) allowed use at Veterans Administration Hospital in C;naha, Nebraska, but this was recognized as inappropriate and was removed by Brian Hearty. c) The request to " reactivate" the license was received on 9/8/94, a 15 item RFI was sent by the Agency, a response was received from the licensee on 3/8/96, and an additional 6 item RFI was sent on 3/29/96. 4 d) License includes a special condition for emergency contact when neither the RSO nor an authorized user is available. e) Amendments issued only include the items modified. I File No: 5 Licensee: Bryan Enterprises License No: 02-39-01 Location: Lincoln, NE Amendment: 2 through 10 License Type: Mobile Nuclear Medicine Reviewer: BH (9/10) Date Amendment issued: 2(7/20/94); 3(9/16/94); 4 (10/12/94); 5 (4/18/95); 6 (5/16/95); 7(6/26/95); 8 (12/12/95); 9 (4/19/96); 10(5/14/96) Comments: a) A computerized data base of physicians is available to the Agency to verify State licensure. b) A letter was included in file regarding the Agency and the Advisory Committee developing a program for "on-site physicians" when an outhorized user could not be available. Allowed nuclear medicine in remote parts of Nebraska. c) The 3/9/95 inspection included 2 items of non-compliance: Unauthorized user, and shipping papers not available. d) Amendments issued only included the items modified. The expiration date, 11/30/98, was included only on Amendment 8. e) The "on-site physician" authorization changed from Condition 12.S,19, to 13 from amendment to amendment. i

l Nebraska Draft Report Page D 3 File No: 6 Licensee: Corning Clinical Laboratories License No: 02-08-01 Location: Lincoln, NE Amendments: 29, 30, and 31 License Type: Laboratory Reviewer: 29, signed by HBorchert: 30, signed by CRogers; 31, JDavidson. Date Amendments issued: 29 (3/10/95); 30 (2/2/96); 31 (2/7/96) a) The license expired on 6/30/96; no renewal or timely filed letter was available in the file. b) It was not possible to determine responsibility for this licensee and St. Elizabeth l Community Health Center (02-35-01) which is licensed for same materials, with a different { location within the same building. This was discussed with staff, and a note was made to review that in the rer'ewal appi! cation. c) The use locations were identified as " locations designated in the applications dated 5/23/91 and 5/4/92." d) An inspection was completed on 2/7/96, with field notes in the file but not a completed report. Four items were cited. l l l File No: 7 Licensee: Harris Laboratories License No: 02-10-01 Location: Lincoln, NE Amendment: 20 License Type: Gas Chromatograph Reviewer: BH l Date Amendments issued: Renewal Applic. Rec'd 2/27/95; not yet completed. I a) Amendment request submitted 12/14/94; renewal application submitted 2/27/95; timely filed letter issued by Agency on 2/27/95; A 7 item RFIletter written on 2/15/96. File No: 8 Licensee: Harris Laboratories License No: 02-10-02 Location: Lincoln, NE Amendment: 15 License Type: R & D Reviewer: BH (RFI) Date Amendment issued: Pending I a) License expiration was extended to 11/30/94 due to delays in shipping new regulations to licensees. l

• J

Nebraska Draft Report Page D 4 File No: 9 Licensee: Omni Engineering, Inc. License No: 01-83-01 Location: Omaha, NE Amendment: New License License Type: Moisture / Density Gauge Reviewer: BH Date License issued: 11/17/95 a) A reciprocal recognition condition was not used in the license. b) The standard license condition requires the attendance at a manufacturers training course. This could be changed to include "or a course in the safe use and handling of portable gauges which has been accepted by the NRC or an Agreement State." File No: 10 Licensee: Thiele Geotech, Inc. License No: 01-84-01 Location: Omaha, NE Amendment: New,1, 1(Corr.) License Type: Moisture / Density Gauge Reviewer: JD Date License issued: New (11/15/95): 1 (3/21/96); 1 (Corr.) (3/27/96) i a) A documented telephone callindicated that a Troxler Alert Detector would be worn and a description of storage location and security, which may not be inspectable. i b) There wera no limits on the number of gauges which were authorized, making it difficult for license reviewers to determine compliance with 004.14 and 004.15 prior to J issuance of the new license. c) No close out of a previous facility was included in the file. d) A new location was requested on Amendment 1, but was not included in the licensed location of use. This was corrected in Amendment 1 (Corr.). e) There was no reciprocal recognition condition in the license. f) in this file and others, " yellow stickys" were used to include information that should have been part of the permanent record. File No: 11 Licensee: Bergan Mercy Medical Center License No: 01-09-02 Location: Omaha, NE Amendment: 85,86,87 License Type: Medical Reviewer: JP (85), BH (86, 87) Date License issued: 85(2/6/95); 86(8/30/95); 87(1/26/96) a) License expired 2/29/96; renewal received 1/31/96, and TF letter sent 2/1/96. On 2/1/96,2/6/96, and 3/7/96 requests were received to change information received on the renewal application. The renewalis pending. b) License Condition 15.A. in Amendment 85 (tie down) included "A. The previous license applications which certified qualifications of authorized users." Not inspectable. c) In writing amendments which wers not complete rewrites, the tie down was Condition 4 15, while there were 21 Conditions. ---e3 m =..,. a -s* m-

Nebraska Draft Report Page D 5 File No: 12 Licensee: Creighton University License No: 01 82-01 Location: Omaha, NE Amendment: New,1 License Type: Broad Reviewer: JP Date License issued: New (3/17/95); 1 (4/27/95) a) Authorization procedures for physicians, podiatrists, and dentists were identified by a license condition. Authorizations for non-medical users were included in the tie down. b) An official higher than the RSO should sign the application for a broad license. c) The chairman of the RSC should be identified on the license. Membership of the RSC should be included in the license file. d) This license combined 16 separate licenses into a broad license. e) On this license and others, reviewers had made notes and crossed out items. J 4

APPENDIX E INSPECTION FILE REVIEWS File No.: 1 Licensee: Immanuel Medical Center License No: 01-04-01 Location: Omaha, Nebraska inspection Type: Routine, Unannounced License Type: Nuclear Medicine / Brachytherapy Priority: ll (3 years) Inspection Date: 12/7,28/94 Inspectors: JP, MB Comments: a) Overdue inspection, completed at a scheduled frequency outside the 25% window. b) Enforcement letter issued and signed 1/27/95 by program manager, however, field notes report was not approved and signed by supervisor until 3/30/95, approximately 60 days after the enforcement letter issued. c) Field notes report indicates that inspection condu.cted in sufficient depth and scope to support findings of 3 violations. 6 File No.: 2 Licensee: Corning Clinical Labs License No: 02-08-02 Location: Lincoln, Nebraska inspection Type: Routine Announced License Type: Irradiator Self-Contained Priority: 11 inspection Date: 2/7/96 Inspector: Contractor Comments: a) Overdue inspection, completed at a scheduled frequency outside the 25% window. b) Field notes report not approved and signed by supervisor as of 7/19/96. c) Draft enforcement letter dated 2/23/96 not reviewed and signed by supervisor or sent to licensee as of 7/19/96. d) Repeat violations identified in field notes report not indicated as such in draft enforcement letter. e) Field notes report does not contain all administrative information required on page one such as: inspection report no., next inspection date and whether next inspection is at a normal, reduced or extended frequency, etc. f) No documentation provided in field notes report that ancillary workers such as secretarial, housekeeping or security personnel were interviewed as to training received from licensee per NE regulation 10.03 (equivalent to NRC 10 CFR 19.12) during the inspection.

Nebraska Draft Report Page E 2 File No.: 3 Licensee: Mary Laning Memorial Hospital License No: 14-03-02 Location: Hastings, Nebraska inspection Type: Routine Unannounced License Type: Teletherapy Priority: 11 Inspection Date: 11/21/94 Inspectors: MB, BH Comments: a) Overdue inspection, completed at a scheduled frequency outside the 25% window. j b) No documentation in field notes report to support close-out violations found in previous inspection on 5/9/90. Enforcement letter dated 12/20/94 states that there were no further questions on corrective actions taken on findings from previous inspection. c) No documentation in field notes report that RSC minutes and committee l composition reviewed and that exit meeting was held at the appropriate management level. d) Field notes report does not contain all administrative information required on page one such as: inspection report no., license no., licensee (name and address), licensee contact, telsphone no., priority, date of last inspection, date of this i inspection, type of inspection, summary of findings and action, next inspection j date and whether next inspection is at a normal, reduced or extended frequency, signature and date the inspector signed and signature and date supervisor approved the report. 4 File No.: 4 1 Licensee: Memorial Hospital of Dodge County License No: 05-02-01 Location: Fremont, Nebraska inspection Type: Routine, Unannounced i License Type: Nuclear Medicine Priority: 11 l Inspection Date: 4/19/96 Inspector: Contractor j Comments: j a) Overdue inspection, completed at a scheduled frequency outside the 25% window. l b) Field notes report not approved and signed by supervisor as of 7/19/96. j c) Draft enforcement letter dated 5/8/96 not reviewed by supervisor or sent to l licensee as of 7/19/96. d) Severity level not assigned to 2 of the 9 violations documented in the draft Notice j of Violation of the draft enforcement letter, j e) Field notes report does not contain all administrative information required on page one. l f) No documentation provided in field notes report that ancillary workers such as secretarial, housekeeping or security personnel were interviewed as to training received from licensee per NE regulation 10.03 (equivalent to NRC 10 CFR 19.12) during inspection. i i x

Nebraska Draft Report Page E 3 File No.: 5 Licensee: Becton Dickinson License No: 37-03-01 Location: Holdrege, Nebraska inspection Type: Routine, Unannounced License Type: Irradiator pool Priority: 1 (1 year) Inspection Date: 5/30/96 inspector: Contractor Comments: a) Overdue inspection, completed at a scheduled frequency outside the 25% window. b) Field notes report not approved and signed by supervisor as of 7/19/96. c) Draft enforcement letter dated 6/10/96 not reviewed by supervisor or sent to licensee as of 7/19/96. d) Field notes report does not contain all administrative information required on page one. e)- No documentation in field notes report as to whether pH, pool clarity, or Cl or F concentration in pool water was reviewed during inspection. f) No documentation provided in field notes report that ancillary workars such as secretarial, housekeeping or security personnel were interviewed as to training received from licensee per NE regulation 10.03 (equivalent to NRC 10 CFR 19.12) during inspection. g) No documentation in field notes report that any independent measurements were performed. File No.: 6 Licensee: Nordian International License No: 99-37-01 Location: Kanata, Ontario, Canada inspection Type: Routine, Unannounced License Type: Service Priority: 111 (5 years) Inspection Date:3/30/95 Inspector: MB Comments: a) Field notes report indicate a comprehensive inspection. Excellent b) Field notes report approved by supervisor on 5/31/95 after enforcement letter dated 4/14/95 issued. ] i f a

Nebraske.Oraft Report Page E 4 File No.: 7 Licensee: Bryan Enterprises Licensi Jo:02-39-01 Location: Lincoln, Nebraska inspection Type: Initia, Unannounced License Type: Mobile Nuclear Medicine Priority: !! Inspection Date: 3/9/95 Inspector: BH Comments: a) Initial inspection did not occur until 16 months after license was issued on 11/22/93. b) Field notes report and enforcement letter do not agree on the number of violations (field notes report documents 2 and enforcement letter 5) c) Letter from licensee dated May 8,1995 not in file. d) Field notes report does not contain all administrative information required on page one. e) Field notes report not approved and signed by supervisor. File No.: 8 Licensee: Maxim Technologies, Inc. License No:01-22-01 Location: Omaha, Nebraska inspection Type: Routine, Unannounced License Type: Radiography Priority: 1 Inspection Date: 3/22/96 Inspector: Contractor Comments: a) Overdue inspection, completed at a scheduled frequency outside the 25% window. b) Field notes report not approved and signed by supervisor as of 7/19/96. c) Draft enforcement letter dated 4/5/96 not reviewed by supervisor or sent to licensee. d) Field notes report does not contain all administrative information required on page one. File No.: 9 Licensee: Southeast Community College License No:16-01-01 Location: Milford, Nebraska inspection Type: Routine, Announced License Type: Academic / Radiography Priority: 1 Inspection Date: 2/6/06 Inspector: Contractor Comments: a) Overdue inspection, completed at a scheduled frequency outside the 25% window. b) Field notes report not approved and signed by supervisor as of 7/19/96. c) Draft enforcement letter not reviewed by supervisor or sent to licensee as of 7/19/96.

Nebraska Draft Report Page E 5 File No.: 10 Licensee: Arcadian Corp License No: 59-02-01 Location: Bellevue, Nebraska Inspection Type: Routine, Unannounced l License Type: Fixed Gauge Priority: !il Inspection Date: 4/21/94 Inspectors: MB, BH Comments: a) Field notes report indicates a comprehensive inspection, all octe cresent. Excellent b) Field notes report reviewed and approved by supervisor on 5/27/94,7 days after enforcement letter dated 5/18/94 issued. c) Field notes report identified need for change in name of RSO on license. File No.: 11 Licensee: Wayne State College License No: 27-01-01 Location: Wayne, Nebraska inspection Type: Routine, Announced License Type: Academic (Non-Broad) Priority: lli i inspection Date: 2/2/94 Inspector: MB Comments: 1 a) Overdue inspection, completed at a frequency outside the 25% window. j b) Field notes report indicates a comprehensive inspection. Excellent i i File No.: 12 Licensee: Panhandle Drilling & Testing License No: 21-06-01 l Location: Scottsbluff, Nebraska inspection Type: Initial, Announced License Type: Portable Gauge Priority: 111 i inspection Date: 3/1/94 Inspector: MB i Comments: a) Initialinspection did not occur until 13 months after license was issued on 2/9/93, outside the 6 month requirement. b) Field notes report indicates a comprehensive inspection. Excellent i i s

Nebraska Draft Report Page E 6 File No.: 13 Licensee: Kiewit Western Co. License No: 01-80-01 Location: Omaha, Nebraska inspection Type: initial, Announced License Type: Portable Gauge Prionty: lli inspection Date: 8/3/95 Inspectors: BH, JD Comments: a) Initial inspection did not occur until 8/3/95, 9 months after license was issued on 12/5/94, outside the 6 month requirement. b) Acknowledgment letter for licensee's letter dated 8/3/95 containing corrective actions not issued until 11/25/95, greater than 30 days after receipt of licensee's letter. c) Field notes report does not indicate who attended the exit meeting d) Field notes report does not contain all administrative information required on page one. e) Field notes report not approved and signed by supervisor. File No.: 14 Licensee: High Plains Corporation License No: 17-01-01 Location: Colwich, Nebraska inspection Type: Initial, Announced License Type: Fixed Gauge Priority: lli inspection Date: 3/13/95 Inspector: MB Comments: a) Field notes indicate a comprehensive inspection. Excellent File No.: 15 l Licensee: University of Nebraska License No: 02-01-03 Location: Lincoln, Nebraska inspection Type: Routine, Unannounced License Type: Academic Broad Priority: 1 Inspection Date: 2/8-16/95 Inspectors: JP, MB, BH Comments: a). Inspection close-out still pending as licensee's response dated 4/20/95 not reviewed and acknowledged as of 7/19/96. Enforcement letter dated 3/16/95 documented 9 violations and 10 recommendations. b) Field notes report does not contain all administrative information required on page one. c) Field notes report not approved and signed by supervisor. d) incident report found in license file, but not in separate file kept for incidents.

j l Nebraska Draft Report Page E 7 i File No.: 16 Licensee: Sherwood Medical License No: 07-02-01 Location: Norfolk, Nebraska inspection Type: Routine Unannounced ) License Type: Irradiator-pool Priority: 1 i inspection Date: 4/16/96 Inspector: Contractor ) Comments: a) Field notes report not approved and signed by supervisor as of 7/19/96. i b) Draft enforcement letter not reviewed by supervisor or sent to licensee as of 7/19/96. 1 a i File No.: 17 Licensee: Beatrice Community Hospital License No: 03-02-01 l Location: Beatrice, Nebraska inspection Type: Routine, Unannounced License Type: Nuclear Medicine Priority: ll Inspection Date: 9/1/94 Inspector: JP Comments: a) Field notes report not approved and signed by supervisor. ] b) Field notes report does not document evidence of observed operations, independent i measurements, or that ancillary workers such as secretarial, housekeeping or security personnel were interviewed as to training received from licensee per NE regulation 10.03 (equivalent to NRC 10 CFR 19.12) during inspection. 1 { File No.: 18 i Licensee: University of Nebraska Medical Center License No: 01 50-01 Location: Omaha, Nebraska inspection Type: Routine, Unannounced License Type: Academic Broad Priority: 1 inspection Date: 2/28-3/3/95 Inspectors:MB, JP, BH Comments: l a) Overdue inspection, compl'eted at a frequency outside the 25% window. b) No field notes report in file documenting findings to support the 4 violations and 4 recommendations indicated in the enforcement letter. c) Could not determine whether supervisory review occurred. I File No.: 19 Licensee: Children's Memorial Hospital License No: 01-07-05 e Location: Omaha, Nebraska inspection Type: Routine, Announced License Type: Nuclear Medicine Priority: ll inspection Date: 2/2/94 Inspector: JP i Comments: a) Field notes report indicate a comprehensive inspection, all data present. Excellent i 4

=-. - - -. - i-i j L j Nebraska Draft Report Page E 8 i File No.: 20 i Licensee: Great Plains Nuclear Services License No: 01-59-01 Location: Omaha, Nebraska inspection Type: Routine Announced License Type: Services-calibration Priority: 111 i inspection Date: 8/3/95 Inspectors: BH, JD Comments: a) Overdue inspection, completed at a frequency outside the 25% window. i b) Field notes report does not contain all administrative information required on page one. c) Field notes report not approved, dated or signed by supervisor. j d) Neither the handwritten or typed field notes report found in the file were signed by { the inspector. i j in addition the following inspection accompaniments were made as part of the on-site j IMPEP review: i 1 Accompaniment No.: 1 Licensee: Bishop Clarkson Memorial Hospital License No: 01-12-05 i Location: Omaha, Nebraska inspection Type: Routine, Unannounced License Type: Irradiator Priority: II (3 years) Inspection Date: 6/24,25/96 Inspector: JD i j Comments: a) This was an accompaniment by J. Johansen, a team member. I-Accompaniment No.: 2 i Licensee: Bishop Clarkson Memorial Hospital License No: 01-22-01 Location: Omaha, Nebraska inspection Type: Routine, Unannounced License Type: Nuclear Medicine Priority: ll 1 Inspection Date: 6/24,25/96 and 7/11/96 Inspector: 5H i Comments: i a) This was an accompaniment by J. Johansen, a team member on 6/24-25/96. b) Inspection was completed by NE inspectors on 7/11/96. Accompaniment No.: 3 j Licensee: Professional Service industries, Inc. License No: 01-08-03 Location: Omaha, Nebraska inspection Type: Routine, Unannounced i License Type: Radiography Priority: 1 (1 year) Inspection Date: 6/26,28/96 inspector: CR 4 i Comments: i a) This was an accompaniment by J. Johansen, a team member. b) The inspector is currently the program manager for the LLRW program. I 0 y m 4 - ~. -. -. -. . - ~.

Nebraska Draft Report Page E 9 Accompaniment No.: 4 Licensee: Radiology Nuclear Medicine License No: 01-52-01 Location: Omaha, Nebraska inspection Type: Routine, Unannounced License Type: Mobil Nuclear Medicine Priority: 11 Inspection Date: 6/27/96 Inspector: HS Comments: a) This was an accompaniment by J. Johansen, a team member. b) The inspector normally works in the LLRW program. Accompaniment No.: 5 Licensee: Daniel J. Thiele License No: 01-84-01 Location: Omaha, Nebraska inspection Type: Initial, Announced License Type: Portable Gauge Priority: 111 (5 years) inspection Date: 7/16/96 Inspector: JD Comments: a) This was an accompaniment by J. Johansen, a team member. Accompaniment No.: 6 Licensee: Omni Engineering License No: 01-83-01 Location: Omaha, Nebraska inspection Type: Initial, Unannounced License Type: Portable Gauge Priority: lli inspection Date: 7/16/96 inspector: JD Comments: a) This was an accompaniment by J. Johansen, a team member. 4

l APPENDIX F NEBRASKA INCIDENT FILES REVIEWED File No.1 Licensee: Nebraska Civil Defense Agency Location: Norfolk, NE License #: 02-02-02 Date of Event: Unknown Type of Event: Loss of material Summary of incident: This event was identified as significant in response to the questionnaire. A Co-60 capsule used in training exercises conducted at the Norfolk Fire Department, was discovered missing during an inventory check. Licensee conducted extensive investigation and concluded the capsule was probably discarded to a local landfill. Event was not reported to NRC. File No. 2 Licensee: Sherwood Medical Location: Norfolk, NE License #: 07-02-01 Date of Event: 09/09/95 Type of Event: Irradiator equipment failure Summary of incident: This event was identified as significant in response to the questionnaire. Licensee failed to report equipment failure event involving the failure of an irradiator poollevel switch. State follow up resulted in issuance of NOV for failure to report within 24 hours and operating with a failed component in violation of license condition. NOV issued 10/17/95 referenced 9/22/95 inspection which was not documented in the I file. Event was not reported to NRC. File No. 3 l Licensee: Sherwood Medical l Location: Norfolk, NE License #: 07-02-01 Date of Event: 11/30/95 Type of Event: Irradiator equipment failure Summary of incident: This event was identified as significant in response to the questionnaire. Event involved equipment problem at irradiator facility--barrier door malfunctioned when changed to index mode. The team found, in discussinns with the radiation program manager that, at State direction, licensee contacted manufacturer, Nordian, who corrected faulty PLC logic rung. File contained no documentation on State inspection, or follow up action. Documentation only included licensee letters and responses. File No. 4

Nebraska Draft Report Page F 2 Licensee: Univ. of Nebraska at Lincoln Location: Lincoln, NE License #: 02-01-03 Date of Event: Unknown Type of Event: Unauthorized transport of radioactive material, P-32 Summary of incident: Event involving loss of control of radioactive material, P-32. Unauthorized transport of P-32 between U. of NE-Lincoln and the East Campus via public transportation. Through discussions with radiation program manager, State performed routine inspection on 2/8-10/95. NOV issued March 10,1995, cited 9 violations and contained 10 recommendations, appeared to support a detailed inspection. The review team concluded that State response was not timely and documentation was inadequate, field notes were sporadically filled out in pencil--many areas not addressed. - No indication of supervisory review, and no notification to NRC in response to an inquiry to the States regarding events involving P-32. File No. 5 Licensee: Ecova Corporation Location: Kimball, NE License #: 71-01-01 Date of Event: 08/15/94 Type of Event: Unauthorized removal of equipment Summary of Incident: Licensee failed to timely report unauthorized removal and re ' cement of Ohmart SH-F1, Cs 137 level density gauge, Serial No. 66846, during routine maintenance on e!!utriator to which gauge was attached, which resulted in stuck shutter. Licensees event report to tha State, after the fact, indicated that proper corrective actions were taken by notifying manufacturer who repaired, reinstalled, surveyed and leak tested gauge prior to notification to State. In discussions, State staff indicated no response to LER necessary due to fact licensee took proper corrective actions. Any event involving equipment required by regulation or license condition to prevent releases exceeding regulatory limits should be reported within 24 hours of occurrence. This event was not reported to NRC. File No. 6 Licensee: Cinemark-8 Stockyard Movie Theater Location: Omaha, NE License #: GLO336 Date of Event: 09/09/94 Type of Event: Stolen material Summary of Event: Vandals stole f.even NRD Model T-4001 exit signs containing 8.4 Ci of H-3 Licensee advised to report theft to local police. No follow up action indicated by State. i l

l l ATTACHMENT 1 l l l i \\ l i f l l I

l STATE OF NEBRASKA ~ I del %RTMENT OF HEALTH Mark B. Horton, M.D., M.S.P.H. D"*" l e F August 6,1996 U.S. Nuclear Regulatory Cornmission Office ofState Programs E. Es $ ni Mail Stop 3D23 Washington, DC 20555 Attn: Patricia M. Larkins, Health Physicist IMPEP Team Leader

Dear Ms. Larkins:

This letter is in regards to the IMPEP review conducted by your team the week ofJu 1996. A preliminary finding identified for Performance Indicator I., Status of Materials Inspection Program, was the lack of timely review of the inspection reports and issuance enforcement letters for a group of 22 inspections performed by a contract inspecto that was placed on this matter by the review team encouraged immediate action on o complete the review. \\ As of August 5,1996, all contractor performed inspections have received a management re and the appropriate enforcement letters have been issued. Concems that the inspection i with the contractor drafted enforcement letters, such as the identification of repeat items o noncompliance and the proper listing ofseverity level, were addressed in the review proces corrected prior to issuance of the final notice of violation. 1 It is our intention to quickly address the other preliminary findings identified in your exit interview, and we welcome the ongoing review process. It is our hope that Nebraska's commitment to maintaining a radiation control program that ensu'res the public he will be evident. If you have any other questions prior to issuing the draft findings, please feel free to co Brian Hearty or Cheryl Rogers at (402) 471-2168. Sincerely, m J',.'/'J ' ' <,- / ack L. Daniel, Administrator J Environmental Heath Protection Section JLD/bph 301 CenterwalMas south

• PO. Som 95007
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STATE OF NEBRASKA DERUtTMENT OF HEALTH Mark B. Horton, M.D., M.S.P.H. Dweaor - G s September 10,1996. E. Begamin Nelson Conrnor U.S. Nuclear Regulatoly Commission Office of State Programs Mail Stop 3D23 Washington, DC 20555 Attn: Patricia M. Larkins, Health Physicist IMPEP Team Leader

Dear Ms. Larkins:

This letter is in regards to the IMPEP review conducted by your team the week of July 15-19, 1996. A preliminary finding identified for Performance Indicator I., Status of Materials Inspection Program, was the lack of a formal inspection plan. An inspection schedule, copy enclosed, was created for 1996 which will allow all overdue inspections and those that are coming due to be completed by the end of the year. Two of the inspections identified as overdue in the questionnaire have already been performed, Thiele Geotech,Inc., and Nucletron-Oldelft Corporation and are not included in the inspection schedule. The methodology used in the scheduling process will be formalized and included in the Program's inspection manual to ensure that all inspections will be completed in a timely manner. A preliminary finding identified for Performance Indicator Ill., Technical Quality ofInspections, was the lack of a management review of the inspection report prior to the Notice of Violation being issued. The delegation of authority to sign documents in the Radioactive Materials Program has been modified to require that the Program Manager sign all inspection reports, or field notes reports, if appropriate, prior to the inspector issuing the inspection letter. A copy of the revised delegation of authority is enclosed. On August 19,1996, a public hearing on the proposed regulations regarding the licensing of irradiators was held and no comments were made. The final proposed draft was brought before our Radiation Advisory Council on September 6,1996, and it was approved to go to the Board of Health. The Board meets on September 16,1996, a copy of the agenda for that meeting is enclosed. After approval by the Board, the draft regulations will be provided to the Attomey General, and with his approval offered for the Governor's signature. A preliminary review ( performed by the Assistant Attomey General found no obvious problems with statutory authority or constitutionality, a copy of the letter is enclosed. 301 Centenroel mao South

• PO. Bom 95007
• Lhoh. Nebrmaka 68509-5007

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1 Pstricia M. Larkins September 10,1996 Page 2 It is our intention to quickly address the other preliminary findings identified in your exit interview, and we welcome the ongoing review process. It is our hope that Nebraska's commitment to maintaining a radiation control program that ensures the public health and safety will be evident. If you have any other questions prior to issuing the draft findings, please feel free to contact Brian Hearty or Cheryl Rogers at (402) 471-2168. Sincerely, - - ~. / . <. ~. Jack L. Daniel, Administrator Environmental lleath Protection Seuion JLD/bph 4 j 't 4 4 b

l i-l 1996 RADIOACTIVE MATERIALS PROGRAM INSPECTION SCHEDULE r INSPECTION LICENSE LEAD INSPECTION DATE(S) No. INSPECTOR TEAM 9/12/96 01-69-01 Brian Hearty 9/25/96 02-26-01 Jim DeFrain Brian Hearty 10/2-4/96 02-06 03 Brian Hearty Jim DeFrain, Bryan Miller 10/3-4/96 01-04-01 Cheryl Rogers John Fassell 10/10/96 01-63-01 Brian Hearty Bryan Miller 4. 10/11/96 02-43-01 Bryan Miller Brian Hearty 10/16/96 11-02-01 Jim DeFrain Brian Hearty 10/18/96 01-58-01 Jim DeFrain Brian Hearty j 10/21-22/96 01 07-02 Howard Shuman John Fassell 10/28-11/1/96 01-50-01 Brian Hearty Jim DeFrain, Bryan Miller, Joyce Davidson i 11/5/96 02-10-03 Bryan Miller Brian Hearty j 11/7/96 02-16-01 Joyce Davidson Bryan Miller 11/13-15/96 01-09-02 Brian Hearty Jim DeFrain, Bryan Miller 11/21/96 02-26-02 Bryan Miller Brian Hearty 11/25-26/96 01-12-04 Brian Hearty Jim DeFrain 12/9-13/96 02-01-03 Jim DeFrain Brian Hearty, Bryan Miller, Joyce Davidson 12/17/96 01-38-01 Bryan Miller Brian Hearty R:\\lMDIO\\INSPSCHD,96 (Rev. September 3,1996)

r. STATE OF 3 EBRASKA DEPARTMENT OF HEALTH Mark O. Horton, M.D., M.S.P.H.

Descar 5 i E. 5 @ hison co-mo, MEMORANDUM Date: August 19,1996 From: Mark B. Horton, M.D., MSPH To: Burke E. Casari, Director Environmental Health Division RE: Delegation of authority to sign documents in the Radioactive Materials Program. I have attached a table dated August 19,1996, showing the delegation of authority to sign licensing, inspection and other documents generated by the Radioactive Material Program. XC: Jack Daniel, Administrator Environmental Health Protection Section ~ Brian P. Hearty, Manager Radioactive Materials Program 301 Ceneenraal WI South

• PO. Box 95007
• L> cob. Netreaka 68509-5007 FAX (402) 4714383
• TTY 4714421 An EqualOpporturury/ANwmadw Acean Emp%e e.

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' f: 4. G. ~ V l i Board of Health Education and Health Promotion Committee / September 16,1996 - 9:00 a.m. Conference Room 3A Aaenda Review Regulations 174 NAC 8, Report of Induced Termination of Pregnancy and Fetal Death Certificate - Jane Elliott, contact person 173 NAC 1, Rules and Regulations Concerning the Reporting and - Control of Communicable Diseases and Poisonings - Adi Pour, contact person I 178 NAC 10, Regulations Governing Licensure of Water Well and Pump Installation Contractors and Certification of Water Well Drilling, Pump Installation, and Water Well Monitoring Supervisors - Rod Tremblay, contact person 178 NAC 12, Regulations Governing Water Well Construction, Pump Installation and Water Well Decommissioning Standards - Rod Tremblay, contact person 178 NAC 13, Procedural Rules for Operation of Board - Rod Tremblay, j contact person i 180 NAC 1, Nebraska Regulations for Control of Radiation-lonizing - l Joyce Davidson, contact person Tobacco Resolution e 1996 Board of Health Retreat Report 4 1

{- {' l L. STATE OF NEBRASKA l i @ffice of the Attorneg General i Recato 2115 STATE CAPTTOL BUILDING DEPARTMENT OF HEA1.TH e UNCOLN, NE $4509-8920 .S = ** (402)471 2682 TD0 (402) 4712642 SEP 0 91996 CAPITOL FAX (402)4713297 y 1235 K ST FAX (402) 4714725 1 g DON STENBERG STEVE GRASZ Il ATTORNEY GENERAL l.AURIE SMITH CAMP DEPUTY ATTORNEYS GENERAL September 6, 1996 t' s Ms. Joyce Davidson, Health Physicist Radioactive Materials Program Nebraska Department of Health g h,. 301 Centennial Mall South i Lincoln, NE 68509-5007

Dear Ms. Davidson:

k At your request, I have conducted a brief, preliminary review of the draft regulations for Title 180 NAC 1 and have found no obvious problems with statutory authority or constitutionality. k th{ The materials which you sent for our review include the draft amendments to 180 NAC 1-004.21 and 180 NAC 1-015.26 and the new Section 019. As we discussed, the time constraints imposed by your request for a preliminary review of these regulations preclude a f[ comprehensive review of these complex regulations. You should alro qf be aware that, while I have reviewed the draft regulations, the l Attorney General has not yet reviewed the regulations as he would y review final regulations adopted by the Department. ib Please feel free to call if you have any questions concerning f this matter. ( o Sincerely, DON STENBERG Attorney General %A* Lynn A. Melson Assistant Attorney General ....u..u M:/.r.P '"r L'"," n;';'.% UN. E t a,n. %?t% i. L it. M'% O' = '/ a C t'. %*/. L, 2.,, /. ET" 27; O/a' Ci 'i'L-1 f gt g we,. t, t.. ii.~ u _ _. - _ _ _}}