ML20129B628
| ML20129B628 | |
| Person / Time | |
|---|---|
| Issue date: | 09/17/1996 |
| From: | Thompson H NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO) |
| To: | Hall E OREGON, STATE OF |
| References | |
| NUDOCS 9609230163 | |
| Download: ML20129B628 (26) | |
Text
_
l.
' 4 UNITED STATES
,j NUCLEAR REGULATORY COMMISSION WASHINGTON. D.c. 20565 4 001
%...../
September 17, 1996 Ms. Elinor Hall, Administrator Health Division Oregon Department of Human Resources Suite 950 800 NE Oregon Street, #21 Portland, Oregon 97232
Dear Ms. Hall:
This is to transmit the results of the NRC follow-up review and evaluation of the Oregon radiation control program. This review, which concluded on July 11,1996, was conducted by James Lynch, State Agreements Officer, Region lil; and Jack Homor, State Agreements Officer, Region IV Walnut Creek Field Office. The results of this review were i
discussed with you and your staff on July 11,1996.
The previous July 1995 review of your program determined that the Oregon program for the regulation of certain Atomic Energy Act radioactive materials was compatible with the regulatory program of the NRC. However, the NRC withheld a finding that the program was adequate to protect the public health and safety. The decision to withhold adequacy was due to significant deficiencies in three Category i Indicators: " Status of Inspection Program," " Responses to incidents and Alleged incidents," and " Enforcement Procedures."
This follow up review determined that the deficiencies identified during the 1995 review had been corrected and that solutions have been implemented to avoid similar problems in the future. The inspection backlog was eliminated in a 12-month period with an accelerated inspection program. Responses to incidents are now thoroughly done, documented and tracked. Appropriate, timely enforcement actions are now performed, D
when needed.
- summarizes our review findings for program indicators where the 1995 review identified recommendations for improvements. As all of the recommendations have been satisfied and closed, a response to this report is not necessary.
/
Please note, as discussed during the exit summary, future program reviews will be conducted under the integrated Materials Performance Evaluation Program (IMPEP). The final determination of adequacy and compatibility of each Agreement State program, based on the review team's report, is made by a Management Review Board (MRB) composed of NRC managers and an Agreement State program manager who serves as a liaison to the MRB. The results of the Oregon follow-up review and evaluation were transmitted to the NRC members of the MRB.
9609230163 960917 PDR STPRG ESGOR PDR
L Ms. Elinor Hall.
Ws ara ple sed th2t withholding of th3 finding'of ad:quacy for your radiation control program is no longer necessary and that your program is compatible. The MRB reviewed and concurred with the review team's recommendation that the Oregon program be found adequate to protect public health and safety and compatible with NRC's regulatory program. This effort, over the past 12 months, exhibits your commitment to a strong Oregon agreement program. The next review of your radiation control program willlikely be scheduled in approximately 2 years.
Your letter of July 28,1995, committed to submitting quarterly progress reports regarding the status of your recovery program. With the positive findings generated by this follow-up review, those progress reports are no longer needed.
I appreciate the courtesy and cooperation extended to the NRC staff during the follow-up review. Should you have any questions concerning this review, please contact Mr. Lynch at (630) 829-9818.
Sincerely, Originalsigned by elugh L Thompson,Jr.
Hugh L. Thompson, Jr.
Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support
Enclosure:
Status of Previous Findings and Summary of Follow-up i
Review Findings for the Oregon Radiation Contro! Program July 29,1995 to July 11,1996 cc w/ encl:
R. Paris, Manager Radiation Protection Services Oregon Health Division T. Johnson, Assistant Administrator Oregon Health Division bec w/ encl:
Chairman Jackson Commissioner Rogers Commissioner Dicus Commissioner Diaz Commissioner McGaffigan Distribution: See next page.
DOCUMENT NAME: G:\\KXS\\0 REG 0N.96
- See previous concurrence.
- Concurrence received at Region III Ta receive a copy of this document, Indicate in the boa: *C' = Copy without attachment! enclosure
- E' = Copy with attachrnentlenclosure
- N * = No copy 0FFICE RIII l RIII l
RIV/WCF0 l OSP l
OSP:DD l
OSP:D l
NAME JLynch/cah McBarger JHornor KSchneider:gd PLohaus RLBangart DATE 08/08/96*
08/08/96*
08/08/96*
08/09/96*
08/13/96*
08/15 /9ff*
f NAME KCyr CPaperiello ELJordan HLTffhhip' son DATE 09/09/96**
08/28/96*
- 08/16/96**
09/11 /96 1
090099 OSP CODE: :SP-AG-23
.0
-v3 w
.g e
') Y,
t' i., /
y
l Ms. Elinor Hall Distribution:
DIR RF ED0 RF CPaperiello, NMSS HLThompson, DEDS RLBangart, OSP PLohaus, OSP SDroggitis,0SP KSchneider, OSP ELJordan, AE00 FCameron, 0GC HNewsome, 0GC JHornor, RIV/WCF0 TCombs, OCA LCallan, RIV.
JLynch, RIII DKunihiro,RIV/WCF0 Oregon' File ABBeach,.RIII KCyr, 0GC
l l
l l
- s.
t
/.
'y 5
h e
s 04e
. Ms. Elinor H-il '
F Wa cro piersed that withholding cf thi finding of adsquacy for your radiation control 2 -
program is no longer necessary and that your program is compatible. The MRB reviewed
[
and goncurred with the review team's recommendation that the Oregon program be found adeq to to protect public health and safety and compati-)le with NRC's regulatory progra This effort, over the past 12 months, exhibits your commitment to a strong i
Oregon a sement program. The next review of your radiation control program willlikely
]
be sched in approximately 2 years.
i i
.Your letter of uly 28,1995, committed to submitting quarterly progress reports regarding 1
the status of y recovery program. With the positive findings generated by this follow-
}
up review, those ogress reports are no longer needed.
4 j
i appreciate the co esy and cooperation extended to the NRC staff during the follow-up review. Should you ve any questions concerning this review, please contact Mr. Lynch 7
at (630) 829 9818.
1 4
Sincerely, 4
Hugh L. Thompson, Jr.
i l
Deputy Executive Director for 1
j Nuclear Materials Safety, Safeguards, and Operations Support
Enclosure:
Status of Previous Findi s and Summary of Follow-up Review Findings for the egon Radiation Control Program i
July 29,1995 to July 11, 996 cc w/ encl:
R. Paris, Manager Radiation Protection Services Oregon Health Division T. Johnson, Assistant Administrator I
Oregon Health Division c w/ encl:
~
hairman missioner Rogers Commissioner 'cus si L
u
'Ane-jf-f-Distnbution: See next page.
' DOCUMENT NAME: G:\\KXS\\0REGON.96
- SeePreviousconcurrgce.
- Concurrencereceiveda(.RegionIII r - c,y. tin.it. cam.. nci.
m
-p..
y n
- w..
,y.e me. e we m m. wm c - c.,,.=som.ei-am.nu.ncio.
OFFICE RIII l RIII l
RIV/WCF0 l OSP l
OSP:DD 1
OSP:IyH/
i NAME JLynch/cah McBarger JHornor KSchneider:gd PLohaus
\\
RLBa6%Wt maammmmmenisums = =
n,8/13/96*-messenemmeium ade[s/96 08/09/96*
0 08/
DATE 08 08 96*
08'08'96*
men /,08/96*
08 muuammann namis simummmmmme
- mens 0FFICE OGC NMSS AE00 DEDS 1
NAME KCyr CPaperiello ELJordan HLThompson DATE 09/9 /96**
08/28/96 **
08/16/96**
08/. /96 OSP CODE:
. Ms. Elinor Hill 4 l
Wo tre ple sed that withholding of the finding {.of adequacy for your radiation con program is no longer necessary and that your krogram is compatible. The MRB reviewed and concurred with the review team's recommendation that the Oregon program be found l
adequate to protect public health and safety an'd compatible with NRC's regulatory i
program. This effort, over the past 12 months,! exhibits your commitment to a strong
]
Oregon agreement program. The next review of your radiation control program willlikely be scheduled in approximately 2 years.
Your letter of July 28,1995, committed to subm tting quarterly progress reports regarding j
the status of your recovery program. With the positive findings generated by this follow-up review, those progress reports are no longer needed.
\\
i I appreciate the courtesy and cooperation extended to the NRC staff during the follow-up j
review. Should you have any questions conceming' this review, please contact Mr. Lynch j-at (630) 829 9818.
(
a i
Sincerely, \\.
\\
i
\\
Hugh L. Tho!mpson, Jr.
Deputy Executive Director for Nuclear Materials Safety, Safeguards, and Operations Support 4
\\
Enclosure:
Status of Previous Findings and Summary'of Follow-up Review Findings for the Oregon Radiation Control Program July 29,1995 to July 11,1996 I
cc w/ encl:
1 R. Paris, Manager k
Radiation Protection Services
\\
Oregon Health Division j
i
\\
\\
}
T. Johnson, Assistant Administrator l
Oregon Health Division g
\\
j bec w/ encl:
1 j
The Chairman i
l Commissioner Rogers
\\
Commissioner Dicus
\\
l Distribution: See next page.
k i
\\
DOCUMENT NAME: G:\\KXS\\0REGON.96-i
- Concurrence received at Region III n
- w...m w m. w. m m m. h
- C' s Cm wkhow enschenenUenckswo 'P e Cm wkh enochenenUenckowe T e p cm l
OFFICE RIII l RIII l
RIV/WCF0 l OSP
]
OSP:DD l
OSP:Qfm NAME JLynch/cah Mc8arger JHornor KSchneider:gd PLohaus RLBa6%%ft DATE 08/08/96*
08/08/96*
08/08/96*
08/09/96*
08/13/96*
08/w nudu unimmmummun i sum unimmuummu a um ammesminuma aum udelu/96 inum mmumn imuum iumim minunummmes mmummmmu -
0FFICE OGC o ( ),
NMSS AE00 DEDS NAME KCyr D #/4/
CPapertello ELJordan HLThompson DATE 0$/u)/96 08/ /96 08/ /96 08/ /96 OSP CODE:
\\
2
. Ms. Elinor H:ll 2-Wa cro pl:: sed that withh:Iding cf th3 finding of adequacy for your radiation control program is no longer necessary and that your' program is compatible. The MRB reviewed 1
and concurred with the review team's recommendation that the Oregon program be found i
adequate to protect public health and safety and compatible with NRC's regulatory j
program. This effort, over the past 12 months,[ exhibits your commitment to a strong i
Oregon agreement program. The next review of your radiation control program willlikely i
j be scheduled in approximately 2 years.
\\
i 1
Your letter of July 28,1995, committed to submitting quarterly progress reports regarding the status of your recovery program. With the po'sitive findings generated by this follow-up review, those progress reports are no longer ne' ded.
e i
\\
I appreciate the courtesy and cooperation extended to the NRC staff during the follow up j
review. Should you have any questions concerning 'this review, please contact Mr. Lynch at (630) 829-9818.
\\
s Sincerely, \\
\\
i
\\
\\
Hugh L. Thompson, Jr.
)
Deputy Executive Director for j
j Nuclear Materials Safety, Safeguards, l
and Operations Support i
i
Enclosure:
Status of Previous Findings and Summary of follow up l
Review Findings for the Oregon Radiation Coritrol Program July 29,1995 to July 11,1996
\\
I
\\
j cc w/ encl:
\\
4 R. Paris, Manager Radiation Protection Services Oregon Health Divirion
\\
\\
T. Johnson, Assistant Administrator
\\
Oregon Health Division i
l I
bec w/ encl-I I
The Chairmen
\\
j Commissioner Rogers
\\
Commissioner Dicus
\\
\\
\\
Distribution: See next page.
I 1
DOCUMENT NAME: G:\\KXS\\0REGON.96
- Concurrence received at Region III n
w..
,.em.e me mm. w e.c.,,wan.oi.u.ca nu.nei r copy wiin.ei.ca ni/
io.
n-p 0FFICE RIII l RIII l
RIV/WCF0 l OSP l
OSP:DD l
OSP:!/iffl i
NAME JLynch/cah McBarger JHornor KSchneider:gd PLohaus RL8a6%Wt DATE 08 08 96*
g0896*
g0 Og09/96*
g8 g j8 0FFICE OGC l
NM AE00
)
NAME KCyr CPapetjello ELJordan HLThompson DATE 08/ /96 08/29f96 08/ /96 08/ /96 i
i'
. Ms. Elinor Hill 1
]
Wa cro plssed that withholding of the f(nding of cd:quacy for your radiation control i
program is no longer necessary and that your program is compatible. The MRB reviewed and concurred with the review team's recpmmendation that the Oregon program be found j-adequate to protect public health and safejy and compatible with NRC's regulatory program. This effort, over the past 12 months, exhibits your commitment to a strong
~
Oregon agreement program. The next revie of your radiation control program willlikely be scheduled in approximstely 2 years.
i Your letter of July 28,1995, committed to submitting quarterly progress reports regarding up review, those progress reports are no longe (rtneeded.
the status of your recovery program. With the positive findings generated by this follow-I i
\\
I appreciate the courtesy and cooperation extended to the NRC staff during the follow-up l
review. Should you have any questions concernihg this review, please contact Mr. Lynch at (630) 829 9818.
\\
Sincerely, 1
Hugh L. Tho'mpson, Jr.
Deputy Execu,tive Director for
,i Nuclear Materials Safety Safeguards, i
and Operations Support
\\
Enclosure:
Status of Previous Findings and Summary of, Follow-up i
Review Findings for the Oregon Radiation Control Program July 29,1995 to July 11,1996
\\
cc w/ encl:
}
R. Paris, Manager
.\\
i Radiation Protection Services Oregon Health Division k
\\
d T. Johnson, Assistant Administrator
\\
l Oregon Health Division
\\\\
bec w/ encl:
The Chairman Commissioner Rogers Commissioner Dicus 4
Distribution: See next page.
- DOCUMENT NAME:
G:\\KXS\\0REGON.96
\\
- Concurrence received at Region III n
- w..
,.e m.
- i. we m m. n.m c = c.,,.4hout.n.ch n.nu.nclosure *P = Copy wth.ttach,n.rst/.nclosure "N* = po copy 0FFICE RI!! l RIII l
RIV/WCF0 l OSP l
OSP:DD \\ l OSP:Ifd, NAME JLynch/cah Mc8arger JHornor KSchneider:gd PLohaus -
RLBa6%Wt 4
DATE 08 08 96* go g0896*
,Og09/96*
]8/13/96* ]8 0FFICE OGC l
NMSS AE DEDS NAME KCyr CPaperiello El Xrdan HLThompson DATE 08/ /96 08/ /96 08///7/96 08/ /96 OSP CODE:
SP-AG-23 j
. Ms. Elinor Hall.
Wa cra pleased that withha{ ding cf the finding of cd:qurcy for your radiction control program is no longer neces ry and that your program is compatible. The MRB reviewed and concurred with the revie team's recommendation that the Oregon program be found adequate to protect public he Ith and safety and compatible with NRC's regulatory program. This effort, over the\\past 12 months, exhibits your commitment to a strong Oregon agrsement program. The next review of your radiation control program willlikely be scheduled in approximately 2 ears.
Your letter of July 28,1995,com itted to submitting quarterly progress reports regarding the status of your recovery progra. With the positive findings generated by this follow-up review, those progress reports a no longer needed.
I appreciate the courtasy and coopera on extended to the NRC staff during the follow-up review. Should you have any question (s concerning this review, please contact Mr. Ly at (630) 829-9818.
i Sincerely, H h L. Thompson, DEDO
Enclosure:
Status of Previous Findings and Summary of Follow-up Review Findings for the Oregon R diation Control Program 4
July 29,1995 to Joiy 11,1996 cc w/ encl:
I R. Paris, Manager Radiation Protection Services i
2 Oregon Health Division T. Johnson, Assistant Administrator Oregon Health Division bec w/ encl:
The Chairman Commissioner Rogers Commissioner Dicus Distribution: See next page DOCUMENT NAME: G:\\KXS\\0REGON.96
- Concurrence recei\\ red at Regign III Ta seceive a espy of shie destamaant. Indeste in the bea: "C" = Copy without attachment / enclosure
'E' = Copy with attachmerQnpfbsu(
"N" = No copy 0FFICE RIII l
RIII l
RIV/WCF0 l OSP l
OSPf0(L(,)
OSP:D NAME Lynch /cah*
McBarger*
Hornor*
Schneider:gd*
PloHaus V\\
RBangart DATE 08 08/96 08/08/96 08/08/96 08/09/96 08 R/96 08/ /96 monsminum a seem
.. = =
unna uma um a us a musam mfissum muum 0FFICE OGC NMSS AE00 DEDS
\\
j NAME KCyr CPaperiello EJordan HThompson
\\
DATE 08/ /96 08/ /96 08/ /96 08/ /96
\\
i i
d m
Ms. Elinor Hall We are pleased that withholding of the finding of adequacy for your radiation control program is no longer necessary and that your program is compatible. The MRB reviewed and concurred with the review team's recommendation that the Oregon program be found adequate to protect public health and safety and compatible with NRC's regulatory program. This effort, over the past 12 months, exhibits your commitment to a strong Oregon agreement program. The next review of your radiation control program willlikely be scheduled in approximately 2 years.
Your letter of July 28,1995, committed to submitting quarterly progress reports regarding the status of your recovery program. With the positive findings generated by this follow-up review, those progress reports are no longer needed.
I appreciate the courtesy and cooperation extended to the NRC staff during the follow-up review. Should you have any questions concerning this review, please contact Mr. Lynch at (630) 829-9818.
Sincerely,
/
' ril 1 p
Hu h L. Thompson, J.
Ds y Executive D' cto or Nuclear Materials Safety, Safeguards, and Operations Support
Enclosure:
Status of Previous Findings and Summary of Follow-up Review Findings for the Oregon Radiation Control Program July 29,1995, to July 11,1996 cc w/ encl:
R. Paris, Manager Radiation Protection Services Oregon Health Division T. Johnson, Assistant Administrator Oregon Health Division
4 STATUS OF PREVIOUS FINDINGS AND
SUMMARY
OF FOLLOW-UP REVIEW FINDINGS FOR THE OREGON RADIATION CONTROL PROGRAM JULY 29, 1995, TO JULY 11, 1996 SCOPE OF REVIEW This follow-up program review with Oregon representatives was held during the period July 9-11, 1996, in Portland. This program review was conducted in accordance with the Commission's Policy Statement for reviewing Agreement State Programs published in the Federal Reaister on May 28, 1992, and the internal procedures established by the Office of State Programs. The State's program was reviewed against the seven program indicators remaining open from the previous' review conducted in July 1995. The review included discussions with program management and staff, technical evaluation of selected license, compliance and incident files, and review of the State's policies and procedures.
The State was represented by Ray Paris, Manager, Radiation Protection Services (RPS); Martha Dibblee, Manager, Radioactive Materials, and Nickolas Goevelinger, Manager, Emergency Response.
CONCLUSION The State's program for the regulation of Atomic Energy Act radioactive materials is, at this time, adequate to protect the public health and safety.
The finding of adequacy had been withheld, since the last program review, because of significant deficiencies in three Category I Indicators, " Status of Inspection Program," " Responses to Incidents and Alleged Incidents," and
" Enforcement Procedures." Those deficiencies have been resolved by the State.
The State's program was found to be compatible with NRC's program as a result of NRC's 1995 review.
STATUS OF PROGRAM RELATED TO PREVIOUS NRC FINDINGS The results of the previous review were reported to the State in a letter to Ms. Elinor Hall, Administrator, Health Division, dated December 26, 1995.
Of the 30 program indicators, 7 were determined to be deficient, with 3 of those comments considered significant. The NRC was unable to offer a finding, at that time, that the Oregon program was adequate to protect public health and safety. This follow-up review addressed the seven program indicators which had deficiencies.
Since July 1995, the Oregon Health Division has taken l
actions to satisfy all seven indicators. The current status of those previous comments is as follows:
2 4
ENCLOSURE 1
'I 1
The issues addressed in the following comments have been satisfactorily l
resolved and are considered closed.
j
- 1. Manaaement (Category II) 5 Comments from the July 1995 Review i
l The results of this review showed deficiencies in five other program indicators that point to the need for increased management oversight.
During discussions with the Radiation Control Program Director, the i
Radioactive Materials Manager, and the Emergency Response Manager, it was noted that communication among the three of them could be improved.
Some developing problems had been overlooked:
e Reviews of the files and computer records showed that backlogs were allowed to develop in the radioactive materials licensing and compliance j
programs.
}
e Although the records indicated that the State's initial response actions to incidents were satisfactory, over half of the incident investigations j
were not completed or properly closed out.
o There were'no records to indicate that one of the two new inspectors had 1
been accompanied by the compliance supervisor or that annual field evaluations had been conducted for all inspectors.
e Enforcement actions did not always follow the prescribed procedure.
j I
o The quality of the inspection reports was not adequate to meet the guidelines, a finding repeated from the previous review.
During file reviews, it was noted that the Radiation Protection Services Manager signs all licenses and escalated enforcement letters.
The head of the Radioactive Materials section reviews and signs off on all licensing actions and inspection reports.
l Program management receives monthly computer-generated reports on the status of licensing and compliance actions.
Program managers meet once a month; the Radioactive Materials staff meet daily, and full staff meetings are held monthly.
In reviewing the minutes of 28 staff meetings, however, it was noted that the growing backlogs were never discussed.
In her July 28, 1995,. letter to Mr. Bangart, Ms. Hall acknowledged that she and her staff recognize problems exist in the Oregon program and l
assured the NRC that plans are in place to resolve those problems.
t j
2 ENCLOSURE 1 m
Recommendations from the July 1995 Review a)
We recommend that emphasis be placed on achieving stricter managerial accountability, not only to the commitments made in the July 28 letter for increasing oversight of inspections and incidents, but for overseeing enforcement actions and inspection reports, and for performing inspector accompaniments.
b)
We recommend that the program managers implement actions, such as more frequent meetings to discuss current and potential problems, 1.e., inspection backlogs, open incidents, and problem cases.
c)
We recommend that the program managers more effectively forecast program needs and allocate resources for backlogs in licensing and compliance. This may require changing the formats of the computer reports to place more emphasis on overdue licensing and compliance actions.
Current Status in July 1996 l
As may be seen in the following indicators, Oregon program management has increased its level of involvement in the management of the operations of the radiation control program. Managerial accountability is evident at all levels, including the Radiation Protection Services and Health Division managers. Managers have increased oversight in the inspection i
and licensing areas, enforcement, incident response, documentation and assignment responsibilities.
P The RPS and Materials managers meet several times weekly to discuss the i
condition of the radioactive materials program.
Inspection and licensing 1
workloads, incident response, enforcement actions and staffing matters are routinely discussed during these meetings. These meetings appear to have i
improved communications between the managers.
i Monthly status reports with inspection and licensing workloads are provided to managers and staff so that everyone is aware of program ne;ds.
The tracking system allows managers to look at the future scheduled inspection workload and to forecast needed resources.
Based on a management analysis of progte resource needs, an additional health physicist position was assigned i the Materials program shortly after the 1995 review. The individual selected for that position devotes j
most of her time to the licensing pr. gram and provides laboratory and inspection support. Her training is ongoing, but she has not yet attended any NRC-sponsored training cou::,s.
After the last review, the State volunteered to submit quarterly status reports to the NRC to establish accc tability and allow the NRC to verify that progress was being made to recti y shortcomings in the program.
i These reports were made on July 28, 1995, November 14, 1995, February 14, i
1996, and May 21, 1996.
1 3
ENCLOSURE 1 1
The responsibility for managing incidents was reassigned to the Emergency Response section of RPS. This change has resolved the uncertainty about the lines of responsibility for incident handling and has freed the Materials staff for other duties.
- 2. Status of Inspection Proaram (Category I)
Comments from the July 1995 Review Based on review of computer reports, at the time of the review, the State had 61 inspections that were overdue by more than 25 percent of their inspection frequency. Of these,12 were initial inspections, 25 were Priority 1, 2, and 3 licenses.
In a letter dated July 28, 1995, the Health Division Administrator provided an action plan to reduce the inspection backlog.
Concerns about the adequacy of the plan were discussed by telephone with the Radiation Control Program Director and the Radioactive Materials Manager on August 22, 1995.
In a letter to Mr. Hornor dated the same day, Mr. Paris explained that the plan would be revised at the end of the first 3-month period, and that the revised plan would be sent to the NRC, along with the first quarterly progress report.
Recommendation from July 1995 Review We recommend that the State eliminate the backlog of overdue inspections and that the State complete the action plan provided in the July 28, 1995, letter.
In addition, we recommend that the action plan be revised to:
a) show the inspection priority, due date, and overdue date; b) schedule staff assignments so as to complete an average of 12 inspections a month so that the backlog can be eliminated by i
December 1996; and c) place priority on conducting overdue inspections of licenses with the highest potential hazards of licensed operations, taking into consideration the date the original inspection was due.
Current Status in $uly 1996 l
The plan to eliminate overdue inspections was revised to incorporate NRC's suggestions ar.d a progress report was provided quarterly to the Office of State Programs and to the Region IV State Agreements Officer. The State exceeded their own expectations and completely eliminated the overdue backlog in 12 months instead of the projected 18 months.
Management has initiated the use of a monthly status report to keep all staff abreast of the number of inspections completed along with lists of inspections coming due and inspection assignments for the month. The review team compared the monthly reports to the inspection files and 4
ENCLOSURE 1 l
)
computer records and concluded that the. reports accurately reflected the status of the inspection program.
Because of the success in eliminating the inspection backlog, the review team advised Oregon management that it would no longer be necessary to submit quarterly progress reports to the NRC.
- 3. Responses to Incidents and Alleaed Incidents (Category I)
Comments from the July 1995 Review According to the files and incident log, 81 incidents or allegations were reported to the State during the 2-year review period.
Summaries of all 81 events were examined, and six cases were reviewed in-depth. There were no therapeutic misadministrations or incidents requiring WRC Abnorral Occurrence Reports. Also, none occurred which appeared to be related to equipment failure or design deficiency.
The records showed that the State responded promptly to most incidents and that the initial investigative efforts were commensurate with potential
-health and safety significance. However, the follow-up actions were often inadequate.
In six out of six cases selected for in-depth review, the investigations had not been completed or closed out properly.
In one case, the State failed to follow through with an appropriate search for a plutonium (Pu) pacemaker that was apparently discarded as medical waste.
In another, no action was taken on an allegation from a former worker at a State. licensed facility becaJse the facility is, according to the State, now an EPA-Superfund site.
In a third case, a licensee was not cited for u:,ing an unauthorized user; no action was taken when the licensee failed to follow the State's order to provide a report of the disposition of the source from a damaged gauge; and the incident report was not cross-referenced to the license file, so the incident was not reviewed during the next inspection. -Of the remaining three, two were not assigned case numbers or entered in the log.
In the sixth case, the incident was entered in the log, but there was no indication that an incident report had been prepared.
Examination of the log showed that 42 of 81 incident investigations in the incident log remained open. At the time of the review, 6 of 34 incidents L
that had been investigated in 1993 remained open, as did 25 of the 40 that
[
were investigated in 1994.
Responsibility for responding to incidents and allegations is divided between the Emergency Response and Radioactive Materials programs.
In discussions with program managers and staff, it appeared that the lines of i
responsibility were unclear as to follow-up and reporting responsibilities. As a result, details pertaining to incident investigations were sometimes misplaced or not entered into the tracking system. To further complicate the situation,~ Radioactive Materials used two different-numbering systems in the incident log, while Emergency F
Response.'used a third. As an example of the less than clear assignment of-L 5
ENCLOSURE 1 e
i responsibility, neither manager was aware that someone on the RPS staff had reported the 1994 incidents to the NRC as requested.
l In ~ her July' 28 letter, Ms. Hall stated"that realignment of documentation f
and assignment responsibilities had already been accomplished and that stricter accountability has been established in the incident oversight portion cf the program.
l Recomendations from the-1995 Review i
l a)
We recommend that the procedures for initial incident response i
assignments, enforcement, tracking, follow-up, cross referencing, j
reporting, and management review responsibilities be analyzed by r
management and revised as necessary to provide for adequate follow-l up actions.on incidents.
b)
We also recommend that open incidents be reviewed and the program institute necessary follow-up or close out actions.
j i
Current Status in July 1996 l
I The process for managing the incident response program was redesigned after the last review. Direct responsibility for managing incident response was assigned to the Emergency Response group.
The Emergency Response Manager reviews the opening and closure of an incident file. The Emergency Response group maintains incident files and tracks investigations. The-incident files are maintained in a file drawer in chronological order and reference sheets are placed in license files directing attention to the appropriate incident file.
Ten-license files were examined to verify that incident reference sheets were present and cross-referenced to the incident files.
No discrepancies were identified.
Details of the file reviews are attached in Appendix A.
Incident investigations for the 10 files appeared to be complete, logical, and the information received from licensees confirmed by inspectors.
The Health Division Policy and Procedure Manual allows inspection of license files by members of the public.
i Incident files were cross-referenced to the NRC's Nuclear Materials Events Database.
Oregon is voluntarily providing incident data on a regular i
basis to the database.
Good correlation was seen between the files and database.
l l
A large number of incident files remained open at the time of the last i
review. A review of these files indicated, with one exception, that all 4
of those incident files have been adequately reviewed and closed. The remaining incident, concerning a damaged moisture-density gauge, had been prematurely closed without proper documentation of radioactive source disposition. During this follow-up review, the necessary documentation
~ '
was retrieved from the licensee and the file was properly closed.
The i
only open incident files, at this time, are current investigations. New i
incident _ files are now closed in a reasonable time period. All of the e
6 ENCLOSURE 1 l
l t
incidents reviewed since July 1995, were closed within 60 days, most within 30 days.
- 4. Inspector's Performance and Capability (Category I)
Comments from the July 1995 Review On July 20,-1995, the NRC reviewer accompanied a State inspector during an unannounced, routine inspection of a fixed radiography licensee.
The inspector was given high marks for the depth of his inspection, his exchange of information with the licensee, and his thorough knowledge of the regulations. The items of non-compliance were correctly identified and the recommendations were appropriate. How'ever, the inspector failed to check his survey instrument before the inspection or to adequately interview ancillary workers. The exit meeting should have been held at a i
higher management level, and the inspector should have prioritized his findings for the exit discussion. The results of the accompaniment were discussed with the inspector and his immediate supervisor.
~ The other two inspectors who perform the majority of the State's inspections have been accompanied by-the NRC during previous reviews, and their performance was satisfactory.
There was no documentatinn that annual field evaluations were conducted by a supervisor dur by r)93 or 1994.
In June 1995, several accompaniments of i'
a_new inspector L.:e appropriately documented.
However, there is no
[
indication that the Emergency Response staff member who is now performing independent gauge inspections has been evaluated by the Radioactive Materials Supervisor.
j Recommendation from the 1995 Review i
f We recommend that the compliance supervisor:
~
a) accompany each new inspector during an inspection of a licensee typical of the type that will fall within an inspector's purview l
before independent inspections are assigned to the inspector; and b) conduct annual field evaluations of each inspector to assess j
performance and to help maintain consistency in the application of the State's policy.
1 i
Current Status in Julv M96 Program management erpressed the commitment to properly train and evaluate
]
inspectors on each type of licensee program for which an inspector would 1
have responsibility. One inspector, currently authorized for gauge i
inspections only, was accompanied by the Materials manager on a gauge i
inspection in December 1995. A new health physicist in the program has not performed any independent. inspections and thus has not yet been accompanied.
She has, however, served in an observational role on several inspections.
7 ENCLOSURE 1
P'-*" ' -
m
--r*
m
Within the last year, the Materials manager accompanied the three individuals who are currently authorized for independent inspections, including the Emergency Response staff member mentioned in the 1995 review comments. The manager maintains records of her accompaniments as well as peer accompaniments performed by senior staff. The accompaniments did not identify any significant weaknesses on the part of the inspectors and allowed the manager an opportunity to comment on inspection techniques and to increase dialogue with the inspectors.
- 5. Enforcement Procedures (Category I)
Comments from the July 1995 Review Review of the written enforcement procedures confirmed that the State has enforcement procedures-that should be sufficient to ensure licensee compliance with regulatory requirements. The enforcement system assigns points equated with the seriousness of the violations and has action levels above which escalated enforcement is required. The Radiation Control Program Director explained that although the State has no civil penalties, they achieve the necessary compliance by using the other methods available to them, such as follow-up inspections, management meetings, enforcement conferences, changes to license conditions, confirmatory action letters, orders, and license suspension or revocation.
Results of the file reviews indicate the enforcement policy is effective.
j The file reviews indicated that anforcement and acknowledgement letters were issued promptly. The letters used appropriate regulatory language and were clearly written. The items of concern are clearly differentiated from the items of non-compliance.
Licensees are required to respond to enforcement letters within 30 days, and the inspector and program manager review the licensee responses.
In the 15 cases sampled, the licensees had responded within the specified time period.
However, during the file reviews, it was found that the appropriate enforcement action was not carried out in three separate cases.
The failure to cite a licensee for an unauthorized user was discussed above in the assessment for the indicator, " Responses to Incidents and Alleged Incidents."
In two instances, the escalated enforcement required by the procedures was not taken.
In the first case, the inspector recommended a follow-up inspection in three months after the severity level of the i
violations exceeded the specified number of points. At the time of this review, 15 months after the inspection, the follow-up inspection had not been conducted.
In the second case, the inspection report identified a repeat severity level II violation; however, the inspection over letter to the licensee stated that there were no items of non-comp ance and that no action would be necessary.
8 ENCLOSURE 1 4-
7 -
i' p
Recommendation from the 1995 Review 4
We recommend that actions be taken, such as increased management oversight
-of the inspection results and enfercement actions, to assure that i
i appropriate enforcement actions are taken in accordance with the State's
~
enforcement' procedures.
4 Current Status in July 1996 Program management oversight of enforcement actions has increased to i
ensure that Oregon's enforcement procedures are followed.
Inspection I
debriefs with the Materials manager and communications between levels of i
program management are routine. An " inspector debrief" form is completed by the inspector for each inspection to assist with the communication.
t This increased oversight was evident in routine enforcement cases involving simple notices of violations and also with escalated enforcement
}
cases involving management meetings.
Since the last review, six j
management meetings have been held with licensees.
. Several inspections, including the deficient enforcement cases identified during the last review, were tracked by the review team to determine if appropriate action had been taken, as specified by State procedures.
Oregon inspections result in a rating being given to each license j
j inspected. That rating determines whether a license will have an early reinspection. At the time of the review, four Oregon licensees had i
ratings requiring early reinspections.
Each of these four license files 7
was reviewed in detail. Two other cases were also tracked, by the review team, to completion. Appropriate enforcement actions were taken in all cases, including early reinspections and management meetings.
t
- 6. Inspection Reports (Category II) i l
Comments from the July 1995 Review Deficiencies were found in 12 of the 15 inspection reports reviewed in
+
depth.
l Inspection forms had no place to record review of the licensee's incident file. As a result, two cases were identified in which the licensee's 1
corrective actions to prevent further occurrences of similar incidents were not reviewed or documented.
In two cases, the enforcement letter boilerplate was inaccurate in describing the point system.
In other cases, deficiencies appeared to be caused by lack of attention to detail in completing the inspection form.
In two instances, the inspector's independent measurements were not adequately documented.
In 10 other cases, one-of-a-kind errors or omissions also indicated failure to follow the procedures.
l 9
ENCLOSURE 1
-=
Recommendations from July 1995 Review a)
We recommend that the inspection forms be revised to include review of the licensee's incident file.
b).
We recommend that the program examine the process for preparation, review, and issuance of inspection reports and institute actions to ensure inspection reports are completed and adequately document the results of inspections.
Current Status in July 1996 a)
The inspection forms have been modified to include review of the licensee's incident file, and the file reviews indicated that inspectors are documenting review of the licensee's incidents during the inspection.
b)
Each inspection report contains a control sheet to track all inspection and enforcement actions.
This control sheet has been revised to include peer or supervisory review of all inspection reports and correspondence.
The review team had no health and safety concerns in the 12 inspection reports which were reviewed in depth. Details of the files reviewed are attached in Appendix B.
- 7. Status and Compatibility of Reaulations (Category I)
Comments from the July 1995 Review Oregon has adopted equivalent regulations to all NRC regulations which were deemed matters of compatibility and which needed to be adopted through 1995.
Each rule and the accompanying documents and correspondence were reviewed to verify that the State provided drafts of the proposed regulations to the NRC and made the suggested changes before subnitting them for final adoption.
It was also verified that the public had opportunity for input by reviewing the Public Hearing Officer Comments.
During this review period, the following regulations were adopted by the State:
" Decommissioning Rule," 10 CFR Parts 30, 40, and 70, amendments which were needed by July 27, 1991, were adopted on May 6, 1994;
" Emergency Planning Rule," 10 CFR Parts 30, 40, and 70, amendments which were needed by April 7, 1993, were adopted on May 6, 1994; " Standards for Protection Against Radiation," 10 CFR Part 20, amendment which was needed by January 1, 1994, was adopted on May 6, 1994; " Safety Requirements for Radiographic Equipment," 10 CFR Part 34, amendment which was needed by January 10, 1994, was adopted on April 26, 1995; " Notification of Incidents," 10 CFR Parts 20, 30, 31, 34, 39, 40, and 70, which were needed by October 15, 1994, were adopted on May 6,1994; " Quality Management Program and Misadministrations" 10 CFR Part 35, which was needed by January 27, 1995, was adopted on April 26, 1995; and " Decommissioning 10 ENCLOSURE 1
Recordkeeping:
Documentation Additions" 10 CFR Parts 30, 40, and 70, which are needed by October 25, 1996, was adopted May 6, 1994.
The State has no large irradiators and plans to defer adoption of 10 CFR Part 36, " Licensing and Radiation Safety Requirements for Irradiators."
The State is reminded of the following NRC regulations that will require equivalent State regulations in order to maintain compatibility:
e " Licenses and Radiation Safety Requirements for Irradiators," 10 CFR Part 36 (58 FR 7715), that became effective on July 1, 1993, and may need to be adopted by July 1, 1996. With respect to this rule, however, State management staff indicated that the State has no licensees that are subject to this rule and they are aware of no plans or current interest in the public or private sector to build a large irradiator.
If there are no licensees in the State that would be subject to this rule, it is acceptable to the NRC that the State defer adoption of the rule. To defer adoption, the State is requested to confirm to NRC that l
there are no facilities subject to the rule and that if an application for an irradiator subject to the rule were to be received, the State i
would take action to adopt a compatible Part 36 rule, and until such i
rule became effective, to incorporate the provisions of Part 36 through license conditions.
e "Self-Guarantee as an Additional Financial Mechanism," 10 CFR Parts 30, 40, and 70, amendments (58 FR 68726 and 59 FR 1618) that became effective on January 28, 1994, and which will need to be adopted by January 28, 1997.
e " Timeliness in Decommissioning of Materials Facilities," 10 CFR Parts 30, 40, and 70, amendments (59 FR 36026) that became effective on August 15, 1994, and which will need to be adopted by August 15, 1997, e " Preparation, Transfer for Commercial Distribution, and Use of Byproduct Material for Medical Use," 10 CFR Parts 30, 32, and 35, amendments (59 FR 61767, 65243, and 60 FR 322) that became effective on January 1, 1995, and which will need to be adopted by January 1, 1998.
e " Frequency of Medical Examinations for Use of Respiratory Protection Equipment," 10 CFR Part 20, amendment (60 FR 7900) that became effective on March 13, 1995, and which will need to be adopted by March 13, 1998.
j e " Low-Level Waste Shipment Manifest Information and Reporting," 10 CFR Parts 20 and 61 (60 FR 15649) that becomes effective on March 1, 1998, and which will need to be adopted by March 1, 1998.
Four of the six regulations adopted during the review period required more than 3 years to promulgate. The delay in adoption of regulations during this past review period was due to staffing turnover, several regulations needing adoption since the last review period, and all regulations needing Oregon legislative approval (Oregon legislature meets biannually).
11 ENCLOSURE 1
ll Recommendation from the 1995 Review i
Oregon management should examine their rule procedures and should adopt l
. compatible regulations within the three-year time frame.
Current Status in July 1996 l
Program managers examined the State rule process and have committed to a f
proactive approach to adoption of regulations, acknowledging the time limitations caused by the biannual legislature sessions.
Increased early i
j involvement of Agreement States in NRC rulemakings will aid this process.
~
One regulation came due since the 1995 review, " Licenses and Radiation f
Safety Requirements for Irradiators," 10 CFR Part 36, needing adoption by l
i l
July 1, 1996.
In a February 14, 1996, letter to NRC, Ms. Hall stated that l
Oregon has no large irradiators and is not aware of any proposed facilities subject to the irradiator rule. As such, the State has postponed promulgation of an irradiator rule until such a regulation is i
needed.
Provisions of 10 CFR Part 36 will be incorporated through license
. conditions for a license application received, prior to adoption of an j
i irradiator rule through the State's Administrative Rule process. This i
approach is acceptable to NRC.
With a look to the future, the State has initiated the legal review of i
. "Self-Guarantee as an Additional Financial Mechanism," 10 CFR Parts 30, i
40, and 70, amendments which need adoption by January 28, 1997.
SUMMARY
OF DISCUSSIONS WITH STATE REPRESENTATIVES 6
9 Mr. Lynch and Mr. Hornor presented the results of this follow-up review to l
Ms. Hall, Mr. Johnson, Mr. Paris and Ms. Dibblee in a summary meeting held on July 11, 1996. Mr. Ross Scarano, Region IV Director, Division of Nuclear a
i Materials Safety, represented NRC management at the meeting.
The State was congratulated on their marked radiation control program improvement in the past year. Mr. Lynch stated that the preliminary I
conclusions of the follow-up review team were that all outstanding issues from the 1995 review were now closed.
j 1
Mr. Lynch and Mr. Hornor commented that the State's approach to the previous j
review findings appropriately considers improvements in the radiation control program from which the program will continue to benefit.
Ms. Hall commented that the previous negative review findings have resulted in greater management awareness which will benefit the program in the long term.
The NRC In% grated Materials Performance Evaluation Program (IMPEP) was discussed in some detail. The State was informed that future reviews would be performed under IMPEP. Mr. Scarano shared his experience with a recent Region IV IMPEP review.
12 ENCLOSURE 1 4
a wm e-1
T L.
1 i
The State was thanked for their cooperation and professionalism during this l
follow-vo review. Ms. Hall thanked the team for the review and suggestions i
and r-rated that Oregon was committed to having a strong radiation control
- progr, i
Attachments:
1.
Appendix A - Incident File Reviews l
2.
Appendix B - Compliance File Reviews
)
l i
l 4
s 8
13 ENCLOSURE 1
APPENDIX A INCIDENT FILE REVIEWS 7
File No.:-l
' Licensee: Providence Medical Center License No.: 90053 Location: Portland Closure Date: 01/96 Incident Type: Neclear pacemaker lost Incident Date: 12/17/93 Incident No.: 93-34 Comment:
Suggest amendment to land deed identifying that pacemaker source is likely a) buried in a specific portion of the landfill File No.: 2 Licensee: Dames.and Moore License No.: 90405
! Location: Portland Closure Date: 10/95 1
Incident Type: Moisture-density gauge damaged Incident Date: 03/94 Incident No.: 94-13 c
Comment:
i a) Closure without documentation of gauge disposition, documentation retrieved i
l.
from licensee during this follow-up review File No.: 3 Licensee:. oregon Institute of Technology-License No.: 90021 r
Location: Klamath Falls Closure Date: 09/95 Incident Type: Neutron howitzer found Incident Date: 02/95 Incident No.: 95-8 File No.: 4 Licensee: Teledyne Wah Chang License No.: 90001 Location: Albany Closure Date: 10/95 Incident Type: Contaminated soil j
Incident Date: Allegation Incident No.: 95-12A File No.: 5 Licensee: Oregon Steel Mills License No.: Non-Licensee Location: Portland Closure Date: 07/95 i.
Incident Type: Monitor trip Incident Date: 07/95 Incident No.: 95-20 File No.: 6 Licensee: Mallinckrodt Medical License No.: 90702 Location: Portland Closure Date: 08/95 Incident Type: _ Lost package of Sr-89.
. Incident Date: 06/95-Incident No.: 95-24 d
g n
~
File No.: 7 Licensee: Longview Inspection License No.: 90621 Location: Clackmas Closure Date: 09/95 Incident Type: Industrial radiography source disconnect Incident Date: 08/95 Incident No.: 95-26 File No.: 8 Licensee: Metro Central Waste' Haulers License No.: Non-Licensee Location: Portland-Closure Date: 04/96 Incident Type: Radioactive materials in trash Incident Date: 03/96' Incident No.: 96-6 File No.: 9 Licensee: Professional Service Industries License No.: 90056 Location: Portland closure Date: 05/96
- Incident Type: Potential overexposure to radiographer Incident Date: 05/96 Incident No.: 96-10 File No.: 10' Licensee: Oregon Steel Mill License No.: Non-Licensee Location: Portland Closure Date: Open Incident Type: Monitor trip Incident Date: 06/96 Incident No.: 96-17 Connent:
a) Investigation is open, pending laboratory analysis l
1 e
2
i APPENDIX B COMPLIANCE FILE REVIEWS File No.: 1 Licensee: OHD Rad Protection Services License No.: 90269 Location: ' Portland Inspection Type: Routine, unannounced j
License Type: Service (calibrate, paint, analyze,etc.)
Priority: 5 Inspection Date:-06/27/96 Inspector: DL File No.: 2 Licensee: NDE Professionals License No.: 90641 location: Portland Inspection Type: Special, termination closeout License Type: Industrial Radiography Priority: 1 Inspection Date: 12/13/95,05/30/96 Inspectors: BC & MD i
File No.: 3 License No.: 90005 Licensee: Oregon State University Location: Corvallis Inspection Type: Routine, announced License Type: Academic Broad Type A Priority: 2 Inspection Date: 02/26-29/96 Inspectors: TL & MD File No.: 4 Licensee: Syncor International Corporation License No.: 90509
. Location: Portland Inspection Type: Routine, unannounced License Type: Nuclear Pharmacy Priority: 1 Inspection Date: 01/09/96 Inspector: TL File No.: 5 Licensee: Oregon Health Sciences Univarsity License No.: 90013 Location: Portland Inspection Type: Special License Type: Medical Broad Type A Priority: 1 Inspection Date: 11/13-15/95 Inspector: MD i
File No.: 6 Licensee: Medical Image Consultants License No.: 90580 Location: Dallas, OR Inspection Type: Follow-up, field License Type: Mobile Nuclear Medicine Priority: 2 Inspection Date: 02/16/96 Inspector: MD File No.: 7 Licensee: Wildish Land Company License No.: 90473 Location:-Eugene Inspection Type: Routine,' unannounced License' Type: Portable Gauge Priority: 4 Inspection Date: 01/18/96 Inspector: DL j
4
~
1 File No.: 8 i
Licensee: Oregon State Highway Division License No.: 90108 i
Location: Salem Inspection Type: Special, announced License Type: Broad Type A Portable Gauge User Priority: 2 Inspection Date: 03/20/96 Inspector: MD i
File No.: 9 i
Licensee: Sulzer Bingham Pumps, Inc.
License No.: 90027 Location: Portland Inspection Types: Routine and Follow-up, unannounced License Type: Industrial Radiography - Fixed Priority: 1 Inspection Dates: 07/20/95 and 02/12/96 Inspectors: TL & MD i
i File No.: 10 j.
Licensee: Three Rivers Community Hospital License No.: 90287 l
Location: Grants Pass Inspection Type: Routine, unannounced i
License Type: Medical Priority: 3 l
Inspection Date: 09/19/95 Inspectors: MD & TL 2
1 l
File No.: 11 Licensee: Wacker Siltronic Corp.
License No.: 90472 Location: Portland Inspection Type:
Routine, 1-day announced License Type: Fixed Gauge Priority: 5 Inspection Date: 03/26/96 Inspector: TL File No.: 12 Licensee: Antec License No.: 90469 Location: Corbett Inspection Type: Routine, announced License Type: Gas Chromatograph Priority: 7 Inspection Date: 03/18/96 Inspector: TL 2
4
.