ML20195J611

Final Rept, Integrated Matls Performance Evaluation Program Review of Region III Matls Program,990315-19

ML20195J611
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INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW OF REGION lll MATERIALS PROGRAM MARCH 15-19,1999 ,

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FINAL REPORT l

i U.S. Nuclear Regulatory Commission ATTACHMENT 1 1

9906210052 990609 f PDR ORG NRRA {l PDR g

I Region ill Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the Region !!! (Rlll) nuclear materials licensing, inspection, incident response, and allegation programs, as well as the Rill fuel cycle inspection program and Rlil's Site Decommissioning Management Plan (SDMP) program. The review was conducted during the period March 15-19,1999, by a review team comprised of technical staff members from the Nuclear Regulatory Commission's (NRC's) Office of Nuclear Material Safety and Safeguards (NMSS); Office of State Programs (OSP); Region 1; and the State of Georgia.

Team members are identified in Appendix A. The review was conducted in accordance with the

" Implementation of the Integrated Materials Performance Evaluation Program and Rescission of a Final General Statement of Policy," published in the Federal Recister on October 16,1997, and the November 25,1998, NRC Management Directive (MD) 5.6, " Integrated Materials Performance Evaluation Program (IMPEP)." Preliminary results of the review, which covered the period April 25,1997, to March 19,1999, were discussed with Rlli management through the Regional Administrator on March 19,1999.

The Management Review Board (MRB) met on May 24,1999, and approved issuance of the final report without any substantive changes.

The Division of Nuclear Materials Safety (DNMS) administers the Rill materials, fuel cycle, and SDMP programs. Within DNMS, responsible branches include the Materials Licensing Branch, Materials inspection Branch 1, Materials inspection Branch 2, Fuel Cycle Branch, ~

Decommissioning Branch, and the Administrative Support staff. An organization chart for the Rill DNMS program is shown in Appendix B. At the time of the review, the Regional materials program regulated 2221 specific licenses, including licensing, inspection, and enforcement for all major types of medical, industrial, and academic licensees. This figure accounts for approximately 38 percent of all materials licensees under NRC's jurisdiction, in preparation for the review, a questionnaire addressing the common and non-common indicators was sent to the Region on February 5,1999. Region ill provided a response to the questionnaire on March 1,1999. During the review, discussions with the Rlll staff resulted in the responses being further developed. A copy of the amended Rlli questionnaire response is included in Appendix G to this report.

The review team's general approach for conduct of this review consisted of: (1) examination of Region lil's response to the questionnaire; (2) analysis of quantitative licensing and inspection information from the Licensing Tracking System (LTS); (3) technical review of aelected licensing, inspection, incident, and allegation actions; (4) field accompaniments of three Rlll materials inspectors; and (5) interviews with staff and management to answer questions or clarify issues.

The review team evaluated the information that it gathered against the IMPEP performance l criteria for each common and non-common indicator and made a preliminary assessment of the Rlli nuclear materials program's performance.

Section 2 below discusses the Region's and NMSS' actions in response to recommendations made following the previous IMPEP review in April 1997. 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 performance indicators, and Section 5 smnmarizes the review

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Region lli Final Report Pye2 team's findings and recommendations. Recommendations are made by the review Offices. Region Ill's response to the proposed ,

sufficient, final repo believes could enhance the Region's rprogram. The Re program, the review team did not make any suggestions. suggest 2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVlEWS During the previous IMPEP review, which concluded on April 21-25 1997 five comments and t acommendations were made to Rill or NMSS, and the results wer t Regional Administrator, Region lit, on August 5,1997 in the final reporte ransmitted t

. Rlli had formally addressed the status of these recommendations in its response port.

to the 1997 The 1999 review team assessed the status took actions to close the recommendations.o our The r of these items of thereview five resulted in current status of these recommendations is as follows: e recommendati 1.

NMSS should examine the need for guidance for initialinspections a of new are issued in the case of an ownership change, mailing office location in control. ,

Current Status:

Following the 1997 Region !!! iMPEP review, NMSS considered the licensee changes (e.g., ownership changes, ,

ges mailing o Industrial and Medical Nuclear Safetys on(IMNS) is trac Operating issued. Plan. This recommendation remains open, until the revised guidan 2.

NMSS and Rlll management should closely monitor implementation ry of the la quality assurance / quality control (QA/QC) program and progress on the g Current Status:

the laboratory QA/QC program, and the laboratory get-wel .

s the Rill laboratory is provided in Section 3.2. recommendation is closed, 3.

Laboratory (RESL)), should ensure that independen conducted to ensure that an adequate QA/QC program is implemented and m Current Status:

laboratory have been conducted during e n the the review perio future. Also, the review team observed that an adequate m has laboratory QA/Q 4 _

. c a Region 111 Final Report Page 3 been implemented and is being adequately maintained. This recommendation is closed and specific information on this issue is provided in Section 3.2.

4. Rill should examine all procedures or documents relating to the handling of allegations to ensure that they are consistent with MD 8.8 and Inspection Manual Chapter (IMC) 2800. Guidance on electronic transmittal of allegation-related material should be included in the procedures. In addition, the procedures or documents should explicitly state that information referring to an allegation should not be included in the docket file.

Current Status: Rlli revised its regional allegation proceQe RP 0517A in March 1998, to provide guidance on electronic transmittal of allegation-related material. On March 10, 1999, Rlli revised RP 0517A to specifically state that allegation documents or other information that could identify an issue as an allegation must not be placed in the docket file. Because Rill revised the procedures, as directed in the 1997 IMPEP recommendation, this recommendation is closed. On the 1999 IMPEP review, the team

• opened two new recommendations related to the 1997 finding. The new '

recommendations are discussed in Section 3.5.

5. NMSS should review existing inspection procedures and manual chapters regarding performance of reactive inspections, to ensure applicability and adequacy for fuel cycle facility inspections.

Current Status: NMSS reviewed the existing guidance and determined that additional guidance was needed for reactive inspections at fuel cycle facilities. On August 10,1998, NMSS issued Inspection Procedure (IP) 88003, " Reactive Inspection for Events at Fuel Cycle Facilities Program." The recommendation is closed.

In summary, the review team considers all of the 1997 IMPEP review recommendations for Rlli closed, and one of the two recommendations for.NMSS closed. )

3.0 COMMON PERFORMANCE INDICATORS IMPEP identifies five common performance indicators to be used in reviewing both NRC Regional and Agreement State programs. These indicators are: (1) Status of Materials inspection Program; (2) Technical Quality of Inspections; (3) Technical Staffing and Training; (4)

Technical Quality of Licensing Actions; and (5) Response to incidents and Allegations.

3.1 Status of Materials inspection Proaram The 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. The review team's evaluation is based on the Region's questionnaire responses l relative to this indicator, data gathered independently from the LTS, an examination of l completed licensing and inspection casework, and interviews with Rlll managers and staff.  !

The review team examined Rlil's inspection priorities and verified that the inspection 4

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l Region ill Final Report Page 4 frequencies for different types of licenses are established in the LTS. The LTS inspection frequencies are managed by NMSS/IMNS, and are based on the inspection frequencies in IMC l 2800. Therefore, the Region is using exactly the same standard frequencies in IMC 2800 for core and non-core materials inspections as the rest of NRC, with two exceptions involving portable gauge and broad-scope licensees. During the review period, Rlli requested approval from IMNS on a regionalinitiative to defer non-core inspections of portable gauge licensees during the winter months, because the Region wanted to optimize the opportunity to inspect the gauges in the field. Many portable gauges are not used during the winter for soil compaction or soil moisture measurements, because most outdoor construction work is not conducted during the winter within Rlll's geographic area. IMNS agreed to the change, and the review team observed that Rlli did conduct a number of gauge inspections in the field during this review period. The Region also implemented a broad-scope inspection initiative to visit selected broad-scope materials licensees more frequently than specified in IMC 2800 to conduct limited, .

performance-based inspections of activities in progress at the licensee's site. The Region intends to complete the full scope of inspection activities with each licensee over the entire IMC 2800 inspection cycle. Regionalinspectors conduct these limited inspections approximately quarterly, and the number of ineoectors on each trip is fewer than the number needed for a full team review of a broad-scope licensee. The review team found that the Region's broad-scope inspection initiative increased the frequency of inspector contact with major broad-scope licensees. Finally, the review team noted that the Region conducts follow-up inspections on licensees with escalated enforcement actions, in accordance with IMC 2800 Section 05.04. The Region schedules follow-up inspections, following escalated enforcement, for 6 months after the violation was first identified. The review team determined that the Region is following the IMC 2800 inspection frequencies, or has special regional initiatives in place that justify minor changes to the inspection frequencies.

The review team examined a partial listing of Rlli licensees (471 licensees) from the LTS, and found that for about one-quarter of the licensees (117), the inspection interval for the next inspection had been extended for good performance. For less than one-tenth of the licensees (41), the inspection interval had been reduced. Inspectors were actively completing the front sections of the inspection field notes, which prompt inspectors to indicate whether the next inspections should be maintained at the standard frequencies, extended, or reduced. In an intery;ew with a Rlll inspection Branch Chief, the review team learned that the supervisor questions inspectors about whether the next inspection should be extended, especially in cases where no violations were identified. The review team concluded that the Rlli is actively I extending or reducing individual licensee inspection intervals, based on licensee performance, and the ratio of extensions to reductions is similar to the practices of most other regions.

In respon=e to the questionnaire, Rllt indicated that (as of the date of the questionnaire)it had  ;

no inspections overdue by more than 25 percent of the assigned frequency in IMC 2800. The manual chapter allows a 25 percent scheduling margin, or a year, whichever is shorter, around the " inspection due date" to conduct the inspection, before it becomes overdue. That is, at the time of the questionnaire, Rlli reported no overdue inspections. The review team checked the Region's answer by reviewing the March " inspection due list" from the LTS that Rill uses to schedule inspections. The review team did not identify any overdue routine inspections, either core or non-core, at the time of the on-site IMPEP review. It appeared that a small number of inspections may have been overdue at different times during the review period, but the review

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Region lli Final Report Page5 team did not analyze this further because the total number was so small (and far below the MD 5.6 IMPEP criterion of less than 1',, aercent overdue core inspections). It is noteworthy that )

Rlll had no overdue core or non-core reutine inspections at the time of the on-site IMPEP l review, which demonstrates exemplary performance by the Rlli inspectors in scheduling inspections, and effective management of the inspection scheduling process.

With respect to initial inspections, the review team examined an LTS listing of 154 new licenses I

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issued by Rill between December 1996 and August 1998 (from 5 months before the start of the review period to 6 months before the end), and cross-checked the new licenses with the dates 1 of initial inspections, The review team performed an exhaustive check of the docket files, for all initial inspection dates that appeared questionable, based on LTS data. After subtracting out licensees that were inspected before this review period (four), licensees that were not true "new

3 licensees as a result of change of ownership or address (four), licenses that were issued and l terminated before being inspected (three), and deferred inspections under the regional initiative j for portable gauge inspections (two),141 new licensees remained. Of the remaining 141 I licensees, Rlll inspected 73 within 6 months, and another 55 within 7 to 12 months, for a total of I 128 inspections conducted within the IMC 2800 criteria for initial inspections. Twelve new licensees remained that had not been inspected, but all were within a year of license issuance, '

so they had not exceeded the IMC 2800 criteria. The review team only identified a single initial inspection that Rlli conducted late during the review period, and it was a fixed gauge licensee that was inspected in the 13th month after license issuance (i.e.,1 month late). In addition, from i documentation in the docket files and interviews with Rlll personnel, the review team learned j that the Region has an effective program to contact new licensees by telephone at points approximately 3,6, and 9 months after license issuance to inquire whether the licensee has obtained licensed material, and to schedule an initialinspection accordingly. The review team also noted several cases where the Region scheduled licensees for early re-inspection, following initial inspections where the licensees did not possess material (but were due for initial inspections under IMC 2800 requirements). This re-inspection practice indicates strong Rlli oversight of new licensees, and it exceeds the inspection requirements in IMC 2800. Region Ill i demonstrated strong performance in scheduling and conducting initial inspections during the review period.

The timeliness of inspection findings was evaluated during the inspection file review. The review team observed that inspection findings were being communicated to the licensee within 30 days after completion of the inspection. The team did note a trend regarding the number of field notes exceeding the 30-day goal, when a NRC Form 591 was issued in the field. Rlll managers told the review team that they performed a self-assessment of field note timeliness in April 1998.

This self-assessment found untimely field note completion, and as a result, Rlli took corrective actions by instructing inspectors to tum in field notes within 2 weeks after completion of <

inspections. Since the self-assessment, Rill has begun tracking the timeliness of field notes.

Since April 1998, field note timeliness was found to be adequate, and it appeared to the review i team that Rlll's corrective actions were successful. l l

In response to the questionnaire, Rlli provided statistics regarding the numbers of reciprocity inspections completed in calendar years (CY) 1997 and 1998. The review team assessed the numbers of reciprocity inspections against the inspection priorities in IMC 1220, " Processing of NRC Form 241, ' Report of Proposed Activities in Non-Agreement States," and Inspection of i I

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Region ill Final Report Page 6 Agreement State Licensees Operating under 10 CFR Part 150.20," using data in the Region's questionnaire response. The Region noted that its reciprocity inspections in calendar years 1997 and 1998 did not meet the IMC 1220 inspection frequencies and that the Region had identified this during a self-assessment. Specifically, in CY 1997, Rlli performed 14 inspections of reciprocity licensees (9 of which were assist inspections for other regions), but missed the IMC 1220 requirement by a single priority 1 inspection, in CY 1998, Rlli performed two reciprocity inspections, and missed the IMC 1220 requirements by three inspections of different- j priority reciprocity licensees. In interviews with the review team, Rlll management described a '

corrective action plan to increase the number of reciprocity inspections conducted in the future.

In the DNMS reorganization, effective March 28,1999, Rlli assigned an inspector in the Decommissioning Branch to perform all reciprocity and assist inspections. Regional management believes that clearly assigning the reciprocity inspection responsibility to a single  !

group, with a designated individual to perform reciprocity inspections, rather than having diffuse Division-wide responsibility for reciprocity inspections, will improve regional performance in this area. The review team considered Rlli's self-identification of the issue and Rlli's corrective actions, and concluded that the Region is addressing this issue appropriately. The review team does not have any recommendations for Rlll in the area of reciprocity inspections.

In summary, Rlli surpassed or met the IMPEP standards for all four of the areas on this performance indicator: The inspection frequencies were being followed, in accordance with IMC 2800, and inspection intervals were being reduced or extended based on licensee performance. l Rlli's inspection program had an extremely low number of overdue inspections during the review period, and nor.e at the time of the on-site review. The Region conducted nearly allinitial inspections within the IMC 2800 requirements, and demonstrated a strong commitment to l contacting new licensees and scheduling initial inspections. Finally, most inspection findings were communicated to licensees within 30 days.

, Based on the IMPEP evaluation criteria, the review team recommends that the Region's performance with respect to the indicator, Status of the Materials inspection Program, be found satisfactory.

3.2 Technical Quality of Inspections The review team examined the inspection field notes and other follow-up documentation and interviewed the responsible inspectors, when available, for 18 files documenting materials inspections conducted during the review penod. These inspections were performed by 12 Rlli inspectors. The reviewed cases covered 13 license types, including limited and broad licenses of medical, academic, and industrial programs. In the file review, the team observed that Rlli inspectors used the appropriate and most recent version of the inspection field notes to document inspections, as well as reports, where appropriate. Appendix C lists the inspection casework files reviewed for completeness and adequacy with case-specific comments.

Altogether, Rlil's DNMS Division Director, Deputy Division Director, two Branch Chiefs, three members of the Licensing Assistance Staff, and 12 inspectors were interviewed.

On March 9-11,1999, a review team member performed accompaniments of three Rlll inspectors on separate inspections of three licensed programs (see Appendix C). One of the

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Region ill Final Report Page 7 inspections was an announced, initial inspection and the other two were routine, unannounced inspections. The inspector accompaniments were performed at a medical facility, an academic broad-scope program, and a research and development facility. During the accompaniments, the Rlli staff demonstrated appropriate inspection techniques and knowledge of NRC regulations and policies. The inspectors were well prepared and thorough in their reviews of the licensees' radiation safety programs, including follow-up of previous violations and incidents that had occurred during the inspection period. Inspectors observed licensee activities, interviewed licensee staff, toured facilities, took independent measurements and reviewed licensee records.

Overall, the performance of the inspectors was sufficient to assess radiological health and safety at the licensed facilities and the inspectors demonstrated appropriate technical skills.

The team reviewed IMC 2800 and found that Rill is implementing the manual chapter appropriately. The review team performed a detailed assessment of the following topics:

extension of inspection intervals for good performance, documentation on NRC Form 591, number of inspections conducted at permanent field offices, and inspection of Year 2000 (Y2K) compliance.

In almost all cases, docket files were complete and in order. Inspection results were well-documented, including follow-up on previous violations, witn the exception of inspection location.

In cases where more than one location of use was authorized on the license, field notes did not reflect where the inspection took place. This occurred because of the revision of field notes by NMSS during this review period, which no longer prompts the inspectors to list the location of .

the inspection. The review team recommends that NMSS revise all inspection field notes to include the location (s) that the inspection is performed.

The team determined that Rlli is performing inspections on an unannounced basis, except for initial inspections or reactive inspections where advance contact with licensee personnel is needed. Inspectors issued NRC Form-591 in the field when appropriate. Documents reviewed were of sufficient detail to substantiate the findings of the inspection, and were completed in a timely manner with the exception of field note timeliness discussed earlier in Section 3.1.

Inspection frequency was properly determined after inspections were completed and this frequency was found to be properly updated in the Region's tracking system. Inspection results were reviewed and approved by supervisors within a few days after completion of the documentation.

The team determined that accompaniments by supervisors were performed on an annual basis, with the exceptica of one inspector whom the Region noted in Ps response to the questionnaire.

A review team member accompanied this inspector, as discussed earlier in this section, and found his inspection performance to be at an appropriate level to assess health and safety issues.

The team reviewed a memorandum, dated November 17,1997, from the Director, IMNS, to the Regions, that discussed the effort of inspectors in the review of Y2K problems at licensees' facilities. Discussions with inspectors and review of docket files indicate that inspectors are reviewing Y2K issues at licensees' sites. The review team did find that documentation of Y2K reviews could be more explicit in field notes and that inspectors should avoid using words, such as "none," that require further clarification about what was reviewed. But the review team dJ

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Region ill Final Report Page 8 not link documentation to inspection performance, and the review team concluded that Rlli is appropriately reviewing Y2K issues on materials inspections.

The team also reviewed survey meter calibration, availabiGty, and use. Adequate and appropriate instrumentation was available for, and was used by, inspect, ors to perform surveys during inspections. Confirmatory and independent measurements were reported in the inspection documents, with a description of the instrumentation used. A staff member maintains a database with the assignment of meters and calibration due dates. On expiration of the calibration date, this individual obtains the instrument from the inspector and gives the inspector ;

a replacement instrument that is in calibration. Also, inspectors stated that they return -

instruments when the calibration date is approaching the due date. The review team found ,

survey meter calibration, availability, and use to be adequate.

The review team also examined the technical quality of inspections and surveys for non-SDMP

. decommissioning inspections. (See also Sections 4.3.3, " Termination Radiological Surveys,"

and 4.3.4, " Inspections," within the SDMP non-common performance indicator, for additional information on how these activities were performed by Rlll staff.) The review team found that sites are inspected in accordance with IMC 2002, " Decommissioning Inspection Program for Fuel Cycle Facilities and Materials Licensees." Region lll staff use IP 87104, " Decommissioning Inspection Procedure for Materials Licensees," and the review team also noted that Rlll staff use IP 83890, " Closeout inspection and Survey," and IP 83822, " Radiation Protection."

Rill's non-SDMP inspection: were planned, carried out, and documented in accordance with NRC procedures. Inspection documentation was complete, and Rlli issued inspection results within 30 days. In response to the questionnaire, Region ill identified both routine decommissioning inspections and "in-process" inspections of licensee final surveys that had j been conducted during the review period. "in-process" inspections are defined in IP 87104 as inspections of licensees' final surveys. Confirmatory surveys are defined as surveys conducted by NRC (or an NRC contractor) to verify the results of the licensees' surveys. The review team found that several of Rlli's in-process inspections included confirmatory surveys. The review team discussed the use of these confirmatory surveys with the Decommissioning Branch staff.

IP 87104 recommends use of. limited confirmatory surveys unless there is significant doubt i about the licensees' final survey results. The review team found that Rll!'s confirmatory surveys were generally performed by NRC staff, were limited in scope consistent with the guidance in the IP, were successful in detecting contamination not found by the licensees' final surveys, and I were thus appropriately used. Appendix F identifies decommissioning cases reviewed by the team.

In summary, from reviews of files, interviews with staff, and inspection accompaniments, the review team found that Rlll inspection staff were performing inspections that were of appropriate scope and technical quality, inspection findings were well-founded and well-documented. Rlli inspection staff properly addressed health and safety issues, and they demonstrated strong technical performance on this indicator.

The review team supplemented its case review with a review of the upgrading of the Rlll laboratory used for analysis of Rill and RIV samples. The review of the laboratory was limited to an assessment of the actions taken on the two recommendations from the 1997 IMPEP review.

Region lli Final Report Page 9 The first recommendation was that NMSS and Rlll management should closely monitor implementation of the laboratory QA/QC program and progress on the get-well plan. The second recommendation was that Rlli, in coordination with NMSS and its contractor, RESL, should ensure that independent audits of the laboratory are conducted to ensure that an adequate QA/QC program is implemented and maintained.

Rlll had an assist visit in August 1998 by RESL, which performed an independent review of the laboratory program at that time. As a result, Rill instituted a specialinitiative that included actions for all of the items identified by RESL, as well as many items Rill had self-identified.

Under this initiative, Rill developed a chart to ensure that every item, including the development of an adequate QA/QC program, was tracked and that corrective actions were taken. The get-well plan was completed as cf December 9,1998.

RESL planned an additional assist visit during the week of March 22,1999, to close-out previous items identified during the August 1998 visit. Also, a full audit of the program is scheduled for August 1999. An in-depth look at the laboratory was not completed during this IMPEP review, because of these planned visits by RESL, which will focus exclusively on the Rll!

laboratory program.

Overall, the review tear'1 found that Rill, NMSS, and RESL, have ensured that independent audits of the laboratory have been conducted and will be conducted in the future. The review team observed that an adequate laboratory QA/QC program has been . implemented and is being adequately maintained. Also, the review team found that NIylSS and Rllt management closely monitored implementation of the laboratory QA/QC program and the get-well plan.

Based on the IMPEP evaluation criteria, the review team recommends that the Region's performance with respect to the indicator, Technical Quality of Inspections, be found satisfactory.

3.3 Technical Staffino and Trainina Issues central to the evaluation of this indicator include the DNMS materials program staffing level and staff turnover, as well as the technical qualifications and training histories of the staff.

To evaluate these issues, the review team examined the Region's questionnaire response relative to this indicator, interviewed DNMS management, interviewed the training coordinator in Rlll's Division of Resource Management and Administration (DRMA), considered any possible workload backlogs, and reviewed the DNMS staffing plan for the reorganization that became effective on March 28,1999.

The DNMS organizational structure had not changed since the time of the 1997 IMPEP review, although at the time of the 1999 on-site review, the Division was about to undergo a reorganization, effective March 28,1999. Technical staff in the Rill materials program were organized during the review period into five branches within DNMS: Materials Licensing Branch:

Materials inspection Branch 1; Materials Inspection Branch 2; Fuel Cycle Branch; and the Decommissioning Branch. Until January 1998, administrative staff were assigned to an Administrative Support Branch in January 1998, the administrative staff were detailed to the

I Region lli Final Report Page 10 licensing and inspection branches. On March 28,1999, DNMS was to reorganize into a four-branch structure, with the two inspection branches combined into a single branch and some materials inspection activities (e.g., reciprocity inspections) assigned to the Decommissioning Branch. After the reorganization, the administrative support staff, including the licensing assistant, were to be permanently assigned to the Materials Licensing Branch.

At the time of the on-site review, DNMS had 12 materials inspectors and 9 license reviewers.

Two of the 9 license reviewers are in part-time positions, and another has both licensing and inspection responsibilities. In addition, DNMS had nine technical staff in the Decommissioning Branch who cover decommissioning inspections, non-SDMP decommissioning licensing actions and project management, the regional laboratory, reactor decommissioning, and dry cask storage issues. Technical staffing and qualileations of the fuel cycle inspectors are discussed in i Section 4.2. The review team concluded that the Region has a good mix in staffing for materials licensing and inspection activities, as well as decommissioning activities. In addition, it appeared to the review team that adequate administrative support is available.

Rlli's DNMS staffing situation remained extremely stable during the review period. In its response to the IMPEP questionnaire, the Region reported that no new professional personnel have been hired since the last review. The Region also indicated tnat, since the last review, four DNMS technical staff members transferred to positions outside of DNMS within the Region, and  ;

one transferred to NMSS. These staffing losses come at a time of decreasing resource allocations for the DNMS program, especially once Ohio becomes an Agreement State, so some level of attrition is beneficial. At the time of the on-site review, DNMS reported three l vacancies or upcoming vacancies, including the Division Secretary position, which becomes a team leader position at the time of the reorganization; a fuel cycle inspector position that will be J vacated when the incumbent moves to a reactor retident inspector position soon; and an administrative support staff position that will open when the incumbent transfers to a position in another Rlli division soon. At the time of the on-site review, the Region was interviewing for, or had issued, a solicitation of interest or a job announcement for several of the open positions. In i addition, the Region had a GG-14 Lead inspector position that was to be filled via a solicitation from the current GG-14 staff, essentially leading to a re-titling of a current GG-14 position.

Additional discussion of resource utilization appears in Section 4.1 of this report.

The region reported in its response to the questionnaire that all Rlli materials inspectors have  !

completed the training requirements in IMC 1246, Section 11. " Training Requirements for j Materials Radiation Specialist Inspector," except for one inspector scheduled to attend the next

• Inspecting for Performance" (G-304) course and two inspectors who need to complete the

" Health Physics Technology" (H-201) course. The review team noted that all three inspectors have been with the Rllt materials program for a number of years. The two inspectors who need to complete the H-101 course were previously grandfathered, and did not need to complete the course under the previous IMC 1246 provisions, but DNMS management has elected not to l exempt any inspectors from the course, and the remaining two inspectors will complete the i

training. The review team checked the Region's master training roster, and the inspector still requiring the G-304

• Inspecting for Performance" course is scheduled to take it in June 1999.

The review team also checked the training files for two materials inspectors who wea qualified, through oral boards, at the start of this review period, and found the qualification documento.on to be in order. The review team concluded that all materials inspectors were well qualified to l l

Region 111 Final Report Page 11 perform their inspection duties.

The Region also replied. in its response to the questionnaire, that all Rlll license reviewers have completed all of the training requirements in IMC 1246,Section I,

• Training Requirements for Materials License Reviewers," except for three reviewers who have not completed the H-201 course, " Health Physics Technology." These three license reviewers had previously been waived from the course. The review team explicitly checked the training records kept by DRMA's training coordinator against the IMC 1246 requirements for license reviewers, to verify the Region's questionnaire response. With the single exception of a fourth license reviewer the team identified who needs to complete the H-201 course, the Region's analysis of staff qualifications is accurate. Except for two reviewers with substantial licensing experience who had the G-109, " Licensing Practices and Procedures" course waived, and the four individuals who had not completed the H-201 course (all of whom could legitimately have been grandfathered from the course), all Rlli license reviewers have completed all core training, and many have completed a number of specialty-training courses as well (such as " Internal Dosimetry and Whole Body Counting," " Air Sampling for Radioactive Material," and " Root  ;

Cause/ Incident investigation Team" training). Identical to the decision regarding inspectors j completing the H-201 course, DNMS management has elected not to exempt any license reviewers from the H-201 course either, and the remaining four license reviewers will complete the training before or during FY 2000. In addition to the coursework, the Region noted in the response to the questionnaire that Rill requires each license reviewer to be granted signature authority before independently signing a licensing action for a particular category of licensee.

The Region reported that all reviewers have signature authority for medical, gauges, and academic /research/ development licensees, and many also have signature authority for broad scope licenses, radiography, and teletherapy licenses. The review team concluded that all materials license reviewers were well qualified to perform their licensing duties.

In the area of decommissioning training, the Region reported in the questionnaire response that all decommissioning inspection staff have met the qualification requirements of IMC 1246. The review team checked the requirements in IMC 1246,Section IX, " Training Requirements for Decommissioning Inspections," against the Region's lists of completed training for the six staff in the Decommissioning Branch who conduct materials decommissioning inspections or materials decommissioning program management activities. The review team found that all six had either:

taken the required courses, been exempted from the required courses as a result of prior education and experience, or were, in just one materials case, projected to take the training in FY 1999. Pegional managers and training staff did note that the limited availability of the

" Environmental Transport (including groundwater transport)" course, which is not offered internally by NRC, and the " Finance for Nonfinancial Professionals" course, continues to be a problem for the Region. Region ill is sending its decommissioning inspectors to a commercially available course for " Environmental Transport," and the financial course is available through videotape. The review team, after noting that a number of Rlli decommissioning inspectors have not completed both of these courses, checked with NMSS' Division of Waste Management (DWM) on the training policy. The program office's reply was that the two courses are currently optional; they no longer are required for decommissioning inspection qualification. This same issue was raised during the Region i IMPEP last year by RI decommissioning managers, and DWM addressed the problem by making the courses optional for decommissioning inspector qualification. In addition, the Rlll review team learned through interviews that the significant

i Region ill Final Report Page 12 drop in the Region's training budget during this review period has strained the Region's ability to send materials staff to outside (NRC Form 368) training, or to authorize much Priority 2 (supplemental) or Priority 3 training. Overall, the review team concluded that the Rill materials decommissioning inspectors and project managers were well qualified to perform their decommissioning duties.

The review team spot-checked completed training lists, sample agendas from Regional inspector training, the Region's training priority list, and supervisors' training documents. The review team also interviewed the DNMS Director, the Deputy Director, a Branch Chief, and the DRMA training coordinator regarding staff training, and attended a DNMS Division Meeting where technicalissues were discussed. The review team determined that Rill has a well-organized system for planning, approving, conducting, and tracking training, that includes DNMS I Deputy Division Director participation on a regional Training Council. Regional managers were generally cognizant of the qualification status and training plans for their staff, and Rlll management displayed a strong commitment to training. Technical staff attended specialty j training courses and refresher training, and appeared to maintain technical currency for their i assigned positions. All technical staff appeared to the review team to have the basic technical  !

skills to perform their jobs adequately, and some Rlli staff have advanced training or certification (e g., one Decommissioning Branch staff member became a Certified Health Physicist during the review period). The review team determined that Rlli adequately implements the training requirements of IMC 1246, and manages an appropriate regional training program for the materials program.

Based on the IMPEP evaluation enteria, the review team recommends that the Region's performance with respect to this indicator, Technical Staffing and Training, be found satisfactory.

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3.4 Technical Quality of Licensina Actions i l

The review team examined completed licensing casework for 15 specific license files, evaluated the licensing process and procedures, and interviewed the Branch Chief and nine of the staff's l license reviewers. The total number of licensing actions reviewed included four new licenses, three renewals, five amendments, and three terminations. Licensing documents were evaluated for completeness, consistency, proper isotopes and quantities used, qualifications of authorized users, adequate facilities and equipment, and operating and emergency procedures sufficient to establish the basis for licensing actions. Licenses were reviewed for accuracy, appropriateness of the license conditions, and tie-down conditions, and overall technical quality. Each case was evaluated for timeliness, adherence to good health physics practices, reference to appropriate regulations, documentation of safety evaluation reports, product certifications and/or other supporting documents, consideration of enforcement history on renewals, pre-licensing visits, peer or supervisory review as indicated, and proper signature authority. The files were checked for retention of necessary documents and supporting data. Deficiencies were addressed by letters and/or documented telephone inquiries that used appropriate regulatory language. A list of the licenses evaluated during the review, with case-specific comments, can be found in Appendix D.

The licensing casework was selected to provide a representative sample of licensing actions i

Region ill Final Report Page 13 that were completed during the review period. The cross-section sampled by the review team included the following types: medicalinstitution broad; academic type A broad; medical private practice; mobile nuclear medicine; irradiator; hot cell operations; industrial radiography; portable and fixed gauges; Measuring systems; and byproduct material storage only. The appropriate licensing checklists and NRC Policy & Guidance Directives were being used. Finalized volumes of NUREG-1556," Consolidated Guidance About Materials Licensees," were also being used by Rlli as they pertain to specific types of licenses. Region ill has a signature authorization and qualification policy for licensing in place and has implemented the policy. Signature authorization is approved by the Branch Chief as each reviewer becomes qualified to work on certain types of licenses. The Region completed 2705 licensing actions during this review period, which included 195 new licenses, 74 renewals,2426 amendments, and 10 terminations.

The few deficiencies that were identified by the review team in licensing cases were minor, isolated, or administrative in nature, and most were corrected during the on-site visit. The review team did identify two cases involving two separate licenses, that had incorrect program codes assigned to the licenses, in one case, a license was assigned a program code for a manufacturing and distribution license, but the license was actually for a portable gauge. In the second case, the licensee was assigned a program code for research and development, but the program code should have been for a " Measuring Systems - Other" tpe license. Each cnse was discussed with the responsible license reviewer, and the appropriate steps were taken to correct the program codes at the time of the review. The review team did not find this program code issue to be a systemic proben for the Region, so the review team has no recommendation on this issue. See Appendix D for further detail.

The review team also examined the technical quality of non-SDMP decommissioning licensing actions. The areas reviewed included license termination documentation in the docket files, an in-progress decommissioning plan review by Rlli staff, and, to a limited degree, financial assurance for decommissioning.

The review team found that Rlll's docket files contain license closeout documentation, such as NRC Form 314, a license amendment terminating the license, and final and confirmatory surveys, where necessary. However, IMC 2605, " Decommissioning Procedures for Fuel Cycle and Materials Licensees," states that all personnel implementing the decommissioning program shall use the guidance in NUREG/BR-0241, the NMSS Decommissioning Handbook. Appendix F of the Handbook contains a " Materials License T$rmination/ Retirement Form," a checklist of items that license reviawers are to consider and address before terminating a license. The review team found that this checklist was not being used by license reviewers.

The review team also examined Rlll's application of the decommissioning timeliness rule provisions. One of the first steps in the license termination process is a notification by a licensee ofits intent to cease operations, under the provisions of the decommissioning timeliness rule,10 CFR 30.36(d). The Decommissioning Handbook, Appendix E, has a checklist of actions to be completed by NRC staff on receipt of such notification. For example, the reviewer is prompted by the checklist to determine the type of decommissioning (from one of four decommissioning types of varying complexity), which then defines a number of other parameters, such as whether a decommissioning plan is needed from the licensee, and whether an environmental review is required by NRC staff. The review team found that the Appendix E checklist is also not being

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used by decommissioning and licensing staff. With regard to the review team's findings that Rlli l is not using two checklists from the Decommissioning Handbook, the review team recommends that Rlli implement the tools prescribed in the Decommissioning Handbook for ensuring that f decommissioning and license termination reviews are complete and fully documented.

The review team examined one decommissioning review that was being processed by Rlll's

. Decommissioning Branch staff, for McDermott Technology, an active fcensee with research i facilities in Alliance, Ohio. The licensee has several on-site burials that require re-evaluation in accordance with Information Notice 96-47, "Recordkeeping, Decommissioning Notification for Disposals of Radioactive Waste by Land Burial Authorized under Former 10 CFR 20.304, 20.302, and 20.2002," August 16,1996. The licensee has submitted a remediation plan for these on-site burials. Regional staff has been working closely with the licensee on the documentation that is required for NRC review. The review team found Rlli's decommissioning i reviewers to be focusing on appropriate risk-significant issues regarding the remediation plan, and Ritt staff were reviewing McDermott Technology's remediation plan in a technically sound manner.

l The review team also conducted a limited review of financial assurance for decommissioning.

The review team found that Rlli conducted its annual evaluation of the financial assurance j instrument security program in December 1998, and completed the evaluation report in January I

1999. Rlil's evaluation report identified several minor, administrative errors that Rlli is correcting. As part of this IMPEP review, the team also discussed Rlil financial assurance review capabilities with Headquarters staff. The review team found that the Region is addressing financial assurance for decommissioning in an appropriate manner. The review team was told that Rlll routinely coordinates its financial assurance reviews with NMSS to

! ensure that they are performed correctly.

Overall, the review team found that the Region's system for processing licensing actions remains formal, structured, clear, and appears to be operating in an efficient manner Region lli licensing staff were performing license reviews that were generally thorough, complete, consistent, and of appropriate technical quality. Region 111 licensing staff properly addressed health and safety issues, and they demonstrated strong technical performance on this indicator.

i Based on the IMPEP evaluation criteria, the review team recommends that the Region's i performance with respect to the indicator, Technical Quality of Licensing Actions, be l found satisfactory.

3.5 Response to incidents and Alleoations in evaluating the effectiveness of the Region's actions in responding to incidents and allegations, the review team examined the Region's response to the questionnaire relative to this indicator and reviewed 10 files containing incident reports, as well as 10 allegation files. In addition, the review team conducted interviews with DNMS Branch Chiefs, the Regional State Agreement Officer, the Regional Office Allegation Coordinator and allegation staff, and several  !

materials inspectors.

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Region 111 Final Report Page 15 The review team cross-checked the incidents listed in the Nuclear Material Events Database (NMED) against those contained in Rill's license files and supporting documentation. The 10 incidents selected for review included the following incident types: three misadministrations; three lost or stolen radioactive material; one equipment failure; one overexposure; one loss of control of radioactive material; and one receipt of a contaminated package. A list of the incidents reviewed in depth, with comments, is included in Appendix E.

The incident investigations were reviewed for health and safety significance, technical quality of the Region's response, coordination, level of response effort, regional follow-up and corrective actions, and compliance issues. The review team found that the Region's response to incidents was very prompt, appropriately coordinated, well-documented, and of good technical quality, with health and safety issues properly addressed. Licensees' noncompliance issues were adequately and clearly identified and, as appropriate, enforcement actions were initiated to assure prompt compliance. All 10 incident case files reviewed were found in the NMED system.

All of the review team's questions about specific incident files were resolved during discussions ,

with the Rill staff.

The review team compared the inspection reports and licensee incident reports for this review period with lists of documents shown on the corresponding NMED records. From this comparison, the review team identified that two inspection reports and three licensee reports related to incidents were not identified on the NMED records. The review team learned that all five reports had moved through NRC's Document Control Desk, and all five reports have been assigned accession numbers in NRC's Nuclear Documents System (NUDOCS). Rill has processed the reports correctly and they should have been available for NRC's NMED contractor to capture as reference documents on the corresponding NMED records. To improve the accuracy and thoroughness of the NMED records, the review team recommends that NMSS evaluate the causes for omission of reference documents from NMED reports, and take appropriate follow-up action in response to any findings.

This Rlli IMPEP review was the first time that an IMPEP review of regional response to incidents and allegations was conducted at the same time as NRC's Agency Allegation Advisor (AAA) annual audit of the regional allegation program. The two reviews were scheduled concurrently, this year, to minimize the impact on regional operations and to reduce overlap between the separate reviews.

Before the on-site review, the review team coordinated with AAA staff to avoid duplication of AAA's efforts to audit regionalimplementation of MD 8.8, " Management of Allegations." The IMPEP review team focused on technical effort commensurate with the potential health and safety significance of the allegations, corrective action, and notifications to the appropriate internal and external organizations. To a lesser extent, the team reviewed procedural aspects of materials allegation handling. The AAA audit covered a detailed review of the processing of l both materials and reactor allegations and regional compliance with MD 8.8 requirements, including whether the technical effort was commensurate with the potential health and safety significance of the allegations. The IMPEP review team and the AAA audit team shared information and compared results throughout the on-site review. The IMPEP review team also reviewed an April 17,1998, memorandum documenting results of the 1997 Rlli allegation l

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Region 111 Final Report Page 16 program audit.

Rlli staff who are responsible for coordinating allegations are assigned to the Regional Administrator's Office. The Office Allegation Coordinator has responsibility for tracking all Rlli allegations, and coordinating the allegation review boards. Agency guidance for processing allegations is contained in MD 8.8, with supplementary information in IMC 2800. Regional guidance for processing allegations is contained in RP 0517A,

• Management of Allegations,"

dated March 5,1998, and revised on March 10,1999.

Discussions with the Regional Office Allegation Coordinator and allegation staff indicate that they follow the guidance in MD 8.8 and RP 0517A. The IMPEP team reviewed allegation procedure RP 0517A and found that guidance on electronic transmittal of allegation-related information is included in the procedures. On March 10,1999, the Region revised RP 0517A to specifically state that allegation documents or other information that could identify an issue as an allegation must not be placed in the docket file. This regional procedure will soon be revised in its entirety to incorporate the changes in a recent revision to MD 8.8, dated February 4,1999.

During the review period, 77 materials allegations were opened in Rlli (power reactor and I gaseous diffusion plant (GDP) allegations are excluded here; fuel cycle facility allegations are discussed in Section 4.2]. Of those,64 cases were closed and 13 remain open. The review team examined the allegations reported by Rlliin the Allegations Management System (AMS) i against those contained in the Rill allegation files and supporting documentation. Ten allegation I files involving a variety of health physics issues were selected for in-depth review. Three of the l 10 cases were also reviewed in the AAA audit to compare findings. The AAA audit covered a total of 21 reactor and materials allegation files. Of those 21 cases,11 of the AAA audit cases involved materials allegations. During the week on-site, two IMPEP team members and the AAA audit team also observed an Allegation Review Board relating to materials allegations.

The review team found that allegations were responded to promptly, actions taken were appropriate, and internal and extemal coordination was conducted with appropriate parties on a timely basis. Rlil's DNMS routinely refers cases involving potential wrongdoing to the Office of Investigations for resolution. In addition, the review team noted that allegations involving Agreement States were appropriately managed.

The review team found tha' Rill addressed potential health and safety issues when following up l on allegations and the review team concluded that Rlll's technical response to materials '

allegations was being performed in an appropriate manner.

During the assessment of the inspection files, the review team found that three docket files contained allegation infonnation. Two of the files contained allegation information dated in 1988-1992 and 1994, respectively. Docket files containing allegation information were also identified during the 1997 Rll! IMPEP revies ' investigating further, the review team learned from Rlli managers that the Licensing Assistance staff has been removing allegation information from the docket files as they pull the records to file more recent documents (such as licensing and inspection documents). However, the two files identified by the review team contained inspection documents dated after the 1997 IMPEP review, and the allegation information that was highlighted by bold cover sheets had not been removed from the docket file. The review I

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Region til Final Report Page 17 team spoke to the administrative staff and inspection staff about their responsibilities with regard to removing allegation material from the docket files. The staff told the review team that they remove allegation information from the docket files if they see it in the files, but the staff did not have the understanding that it was their responsibility to actively search the docket file for allegation information, and pull the allegation information if found. In a third case, the review team found inspection field notes dated after the 1997 IMPEP review, that had been in the docket file. These field notes had redacted sections, but they still contained a reference to concems raised by an individual. Both the Office Allegation Coordinator and a DNMS Branch Chief had reviewed the document. The review team consulted with the AAA and concluded that the references to " concerns raised," " concerned individual," and the date that the concerns were raised were not appropriate for publicly available inspection field notes. .In response to the allegation material found in the files, the review team recommends that Rlli develop and implement a process to remove allegation material from the docket files.

The review team examined the Regional Procedure 0517, " Management of Allegations." This procedure was revised on March 10,1999, to specifically state that allegation documents or other information that would identify an issue as an allegation must not be included in the docket file. Most Rlli personnel were aware of this policy, but the review team found that some staff had different understandings of the exact wording that could and could not be placed in a docket file.' The review team recommends that Rlll train the DNMS staff on what allegation language, if any, is acceptable to place into the docket file.

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

4.0 NON-COMMON PERFORMANCE INDICATORS In addition to the common performance indicators addressed in the preceding Section 3.0, IMPEP identifies four non-common performance indicators to be used in reviewing Regional programs: (1) Performance Against Operating Plan Goals; (2) Regional Fuel Cycle Inspection Program; (3) SDMP Program; and (4) Uranium Recovery Program. Region Ill's nuclear materials program does not regulate uranium recovery licensees, so the uranium recovery non-common performance indicator was not evaluated during this IMPEP review. Only the first three Regional non-common performance indicators were applicable to this review.

4.1 Performance Aoainst Operatino Plan Goals During this review period, the format and function of the Regional Operating Plan shifted dramatically. The Regional Operating Plan evolved during this review period from a document that previously set broad regional priorities, objectives, goals, and planned accomplishments,

. with associated resource data, into a document that tracks progress and resource expenditures against highly detailed performance measures (outcome and output measures) and defined metrics. The Operating Plan now contains metrics for quantity, quality, timeliness, efficiency, and effectiveness, that Rlli uses to appraise regional performance.

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Region lli Final Report Page 18 Like the rest of the Agency, Rlll updates its operating plan quarterly, so the details in the Regional Operating Plan present a current, comprehensive picture of the Region's performance.

, Because of the new level of detail and amount of data tracked in the Regional Operating Plan,

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l and the increased number of managers and staff reviewing regional performance against the Operating Plan metrics, an IMPEP review cannot and should not match tbc scrutiny of regional ]

performance against the Regional Operating Plan that is occurring under simultaneous, parallel Agency processes. Therefore, the review team performed a less-detailed assessment of Rill's performance on this non-common indicator than in past Rlll IMPEP reviews. Essentially, the Region's performance against Operating Plan goals is being reviewed more frequently, in far greater detail, by more NRC staff now, so the IMPEP review team reduced effort on assessing this non-common indicator on this review. Because the Regional Operating Plan changed, a natural consequence is that the role of this non-common performance indicator must also change on this and future IMPEP reviews.

For these reasons, the following discussion just covers broad highlights of regional performance j against the Operating Plan.

! Materials Licensina. During the first 6 months of the review period, Rlli made dramatic progress

( in reducing the number of pending, "old" pending, and backlogged licensing cases. The Region

began the review period with 304 pending licensing cases, of which 93 were considered "old" (new applications, amendments, and terminations greater than 90 days pending, and renewals greater than 180 days pending). Over the first 6 months of this review period, Rlli cut the j number of pending actions by one-third, and cut the number of "old" pending cases from 93 to j

25. The Reg on made similar cuts in backlogged cases, from 55 at the start of the review period -

I to 7 at the end of fiscal year (FY) 1997. This was a remarkable achievement for Rill's licensing j staff, and it demonstrates clear commitment by Rlli staff and management to eliminating the old, '

often complex cases and improving licensing timeliness. At the beginning of FY 1998, the licensing casework statistics leveled off for pending cases and backlogged cases, while the number of pending "old" cases continued to drop. By February 1999, the latest month for which j licensing casework statistics were available, NMSS reported that the Region had brought the number of pending cases down to 198 actions, with only 18 pending "old" cases, and only 7 backlogged licensing cases. For comparison purposes, Rill averaged about 110 licensing i

action completions per month during the review period, so the number of 198 pending cases, in the most recently available data, represents less than 2 months of pending licensing actions for

, the Region. The licensing casework data for the review period is summarized in the following i

table:

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Rlli Licensing Casework Statistics Pending "Old" Pending Backlogged March 1997 304 93 55 FY 1997 Year End 192 25 7 FY 1998 Year End 200 20 6 FY 1999 (as of 2/99) 198 18 7 I

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Region til Final Report Page 19 From this licensing data, the review team concluded that Rlli licensing staff made substantial reductions in the pending casework at the start of the review period, then maintained a nearly constant pending licensing casework load of about 1.8 months of licensing work throughout the rest of the review period. This compares reasonably with the other regions, in terms of months of licensing work pending. The regions ranged from about 1.5 months to 2.6 months of pending wori.at the end of FY 1998. In terms of gross number of pending actions, Rlli had the highest of all four regions in FY 1998 and as of February 1999, but Rlll also had the highest number of licensing action completions by far (1324 completions in FY 1998, vs. 960 completions in Region 1). The review team also concluded that the number of backlogged licensing actions dropped sharply at the start of the review period, then remained relatively constant throughout the rest of the review period. The Region showed substantial progress in reducing the number of "old" pending cases and backlogged cases, dropping the numbers to 19 percent and 13 percent, respectively, of the levels at the start of the review period.

Overall, the review team concluded that Rlli performed at an appropriate rate on its licensing actions during the review period. Rlli demonstrated rapid licensing progress for the first 6 months of the review period, then steady progress in completing licensing actions for the rest of the review period. The Region considerably reduced the number of "old" pending and backlogged licensing cases, while performing a very high volume of licensing actions throughout the review period. These accomplishments demonstrate effective management of the Rlll licensing program, as well as hard work by Rill's materia ls licensing staff.

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

Resource Utilization. The review team examined the Rlli budget figures and expenditure data for FY 1998 and FY 1999 (through January 2,1999) that were provided by NMSS' Program Management, Policy Development, and Analysis Staff (PMDA)in advance of the Rlll IMPEP review. The resource utilization table provided by PMDA is shown later in this Section. The review team discussed the resource expenditure data with the DNMS Director and Deputy Director, and compared the PMDA resource data with the Region's own, internally generated resource data. The FY 1998 PMDA data were similar to, but not the same as, the Rl!I-generated resource data. The review team tried to resolve the differences be. tween the two sets of data, but was not able to do so. This is noteworthy, since the two sets of r3 source expenditure information were generated from the same raw data, namely the Rlli staff's Regulatory Information Tracking System (RITS)-hours reports. The FY 1999 PMDA data matched the Region's data much more closely, which may indicate that the problem has been resolved this fiscal year. The review team has observed small discrepancies on other Regional IMPEP reviews in the past, and the review team discussed this issue with the DNMS management. The DNMS Division Director emphasized that the Agency needs a method of t . tying RITS hours directly to the Operating Plan line items. The review team agrees with Rlli on this issue, and the review team leader committed during the exit meeting to address the RITS-hours reporting issue with PMDA. This problem with the FY 1998 data potentially may have been an Agency-wide issue, although it appears to the review team to be resolved with the current FY 1999 data. For the purposes of the Rill IMPEP review, resource analysis practices l

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are beyond the traditional scope of the IMPEP process, and the problem may have been

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resolved in FY 1999. Therefore, the team has no recommendation on this issue. For the review

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team's analysis, PMDA's data are discussed here, because they were taken from regional input l provided in response to the FY 2000 President's budget update (December 1998).  ;

In FY 1998, Rlil expended 34.9 full time equivalents (FTE) (direct staff effort) versus 37.7 FTE budgeted for NMSS program activities (93 percent). [Rll!'s own resource data show 38.4 FTE direct staff expenditures against 38.7 FTE budgeted for NMSS programs, total, resulting in a higher resource expenditure rate of 99 percent.] For the first quarter of FY 1999, Rlli expended 7.8 FTE versus 9.8 FTE budgeted for the first quarter, for an 80 percent expenditure rate. [For comparison, the Rlli data showed 8.04 FTE expended for the same quarter, which results in an expenditure rate slightly closer to the budgeted levels.] In FY 1999, the Region is budgeted 36.2 )

FTE for materials programs for the whole year. Data for FY 1998 and FY 1999 (first quarter) reveal that Rll!'s expenditures are generally close to the levels budgeted for the different materials activities. For instance, in FY 1998, Rlli had a slight overexpenditure on event evaluation, incident response, and allegations activities, whereas Rlli slightly underexpended on fuel cycle and decommissioning activities, according to the data. Region til materials licensing and materials inspection expenditures nearly matched the budgeted levels in FY 1998. During the first quarter of FY 1999, Rlli expenditures for decommissioning and materials rulemaking are I higher than bud 0eted levels, whereas allegation activities and fuel cycle activities appear to be underexpended. Overall, it appeared to the review team that the Region is following the general i priorities in the Regional Operating Plan, as indicated by resource expenditures. The review j team also concluded that in the first quarter of this fiscal year, it is probably too early to draw conclusions from the FY 1999 expenditure data. In general, the review team observed that Rill has been successful at keeping expenditures close to budgeted levels, which demonstrates strong resource management.

REGION 111 RESOURCE UTILIZATION FY 1998 FY 1999 Program Activity Annual Expenged  % Annual Budget Expended  %

Budget Budget Octpc Oct-Dec8 Matenals Licensing 7. 3 7.3 99 6.7 1.8 1.8 100 Matenats inspection 11 4 11 4 100 10.7 29 2.3 79 Matenals Rulemaking 28 1.5 54 1.1 0.3 0.5 167 Evt Eval / Incident Response 3.9 5.1 131 4.8 1.3 08 62 Allegations Fuel Cycle 60 49 82 58 1.6 1.1 69 Low-Level Waste 00 0.0 0 0.0 00 00 Decommissioning 50 40 80 36 1.0 1.3 130 uranium Recovery 00 0.0 0 0.0 0.0 00 0 spent Fuel 04 04 100 04 0.1 Agreement states 0.8 0.3 38 3.1 08 00 TOTAL 37.7 34.9 93 36.2 9.8 7.8 80

' F Y 1996 expenditures from regionat input promded in response to tne f Y 2000 President s Duoget upcate 12/98 8 FY 1999 budget and expenced resources are from September 27,1998, through January 2.1999 (i e , fourteen weeks )

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Region 111 Final Report Page 21 l

The review team did examine one significant Rlli resource issue in-depth during the IMPEP review. Just before the on-site IMPEP review, as part of routine budget activities, NMSS performed a resource analysis on regional labor rates in FY 1996 - FY 1998 for materials inspections. The results appeared startling for Rlli. They appeared to show that all regions had an average labor rate of 0.015 to 0.019 FTE/ inspection over the 3 years. However, Rlli's labor rate appeared to increase from 0.015 FTE/ inspection in FY 1996, to 0.020, to 0.022, respectively, in succeeding years. More detailed analysis showed that although Rlll's inspection preparation / documentation and travel times were consistent with the other regions, Rlli's actual inspection hours appeared far higher than the other three regions (16.3 hrs / inspection in FY 1998, compared with the other three regions, which had 7.2-7.9 hrs / inspection). The review team looked closely at this issue, and discussed it with the DNMS Branch Chief who compiles Rlli's resource statistics, as well as the Fuel Cycle Branch Chief. They explained, and the review team agrees, that the inspection hours probably include fuel cycle inspection hours and GDP resident inspection hours, along with the materials inspection expenditures, for Rill. The same problem does not appear to affect the data for the other three regions. When the review team subtracted the fuel cycle inspection hours and the GDP resident hours from the resource expenditures, the Rlli on-site inspection hours drop significantly to 8.9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> / inspection and come closer to the rates of the other three regions. The Rlll supervisors explained that an apparent cause of the problem is the manner in which RITS captures and aggregates staff hours against certain program activities. During the on-site review, Rlll contacted Region ll's fuel cycle i staff to address the issue and discuss possible solutions. The review team concluded that the materials inspection hours shown in the original resource data from NMSS do not indicate actual hours spent on materials inspections (alone). However, the issue serves as another example where the Agency's resource data tracking system does not closely match the materials program activities, and this difference had the potential to lead program managers to erroneous conclusions about regional efforts.

The Region is budgeted for materials rulemaking in FY 1998 and FY 1999, and these resources are intended to support NMSS rulemaking and guidance-development pronram initiatives. The Region continues to be a strong contributor to such initiatives. Rlli provideu le review team with information showing that Rlli staff and management participated as team members, team leaders, or reviewers of at least 13 guidance-development activities. In some cases, such as the NUREG-1556 radiopharmacy and bankruptcy / change of ownership guidance teams, the Region both participated on the writing teams, and also had a supervisor participate on the review teams for the same guides. In addition to the NUREG-1556 activities, Rlli staff or managers participated on NMSS teams involving the Part 35 Risk Assessment, Radiography Cable Break Investigation, Medical Inspection Temporary instruction, Veterans' Affairs Master Materials License, License Renewal Review and Streamlining, Standard Review Plan for Decommissioning and License Termination, and a prototype inspection of the U.S. Department of Energy by NRC's External Regulation Task Force. In the area of regional support for NMSS l program initiatives, the review team determined that Rlli is providing appropriate support for i NMSS program activities. In addition to NMSS initiatives, the Region has expended considerable resources supporting and preparing for Ohio to become an Agreement State. Rlli performed extensive administrative tasks in preparation to turn licenses over to the State of Ohio, conducted one-week training sessions for nine Ohio Department of Health staff members, and wrote to all Ohio licensees with temporary job sites to determine whether they desire to i

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maintain an NRC license for work outside of Ohio, after an Agreement is signed. The Region hs performed these additional efforts, while continuing to maintain Rill's routine materials licensing and inspection activities on schedule.

Based on the review team's analysis of the resource expenditures and the Region's productive use of the resources, the review team recommends that the Region's performance with respect j to this non-common indicator, Performance Against Operating Plan Goals, be found satisfactory.

1 4.2 Epaional Fuel Cycle inspection Proaram

-l l 4.2.1 Introduction The Rlll fuel cycle inspection program inc:udes the ABB Combustion Engineering fuel fabrication facility in Hematite, Missouri; the Allied Signal uranium conversion facility in

Metropolis, Illinois; and two GDPs in Paducah, Kentucky, and Portsmouth, Ohio. The regional fuel cycle inspection program is currently staffed at full levels. This includes two resident inspectcrs at each GDP and two region-based inspectors.  !

l l t l 4.2.2 Status of Fuel Cvele Procram inspections at fuel facilities (including the two GDPs) are coordinated between NMSS and the

• i regions through an integrated Fuel Cycle Master inspection Plan (MIP). Inspections are scheduled based on considerations of risk and licensee performance. Rlll uses the guidance provided in IMC 2600, " Fuel Facility Operational Safety and Safeguards inspection Program

• for the Allied Signal and Combustion Engineering facilities, and IMC 2630, " Gaseous Diffusion Plant Operational Safety and Safeguards inspection Program," for the GDPs, to schedule and plan inspections at the four facilities within the Region's program. At the beginning of each fiscal year, the Region transmits its plan to NMSS for scheduling purposes. Once this baseline schedule has been approved, all changes are resubmitted throughout the year. The review  !

team evaluated this process and reviewed the Region's effectiveness in adequately ,

implementing both the baseline schedule and all modifications. The review team observed that I during the review period, Rlll scheduled inspections according to the requirements in IMC 2600 and IMC 2630. Additionally, any modifications to the initial schedules were based on changes in  !

the performance of the particular licensee. The review team also observed that changes were properly reviewed and approved by regional management and transmitted to NMSS for inclusion in the MIP.

l l Rlll fuel cycle inspection reports were usually issued in a timely manner when measured against  ;

! the IMPEP performance indicator of 30 days for routine inspection reports. Instances of late i j inspection reports were a result of the Region placing a higher priority on ensuring the quality of l the reports over timeliness. The review team noted that at the time of the IMPEP review, Rlll's average time to issue a fuel facility inspection report was approximately 21 days.

The review team also noted that Rill has a program in place to summarize performance strengths and weaknesses for each of the fuel cycle facilities. Rlli keeps the " Plant issues

Region 111 Final Report Page 23 Matrix" (PIM) current for each facility, and the PIM is used by both regional and Headquarters inspectors in the planning phase of the inspection process, to focus on areas of weak licensee performance.

Currently, Rlll and other regions are using the Inspection Follow-up System (IFS) to track the results of fuel cycle inspections. The IFS system is not Y2k compliant, and NRC plans to replace IFS soon with a new program that currently does not address fuel cycle inspections.

NMSS is working with the Office of the Chief Information Officer to extend the capabilities of the Inspection Reporting and Analysis Module (lRAM) of the Office of Nuclear Reactor Regulation's Reactor Program System (RPS) to track the results of fuel cycle inspections, as a replacement for IFS. Work on this effort is scheduled to be completed by August 1999. In parallel with this effort, Rlli's Fuel Cycle Branch has begun evaluating options to track the open items from inspection reports to facilitate an effective transition from IFS to the new mking system.

4.2.3 Technical Quality of Inspections The review team observed that Rlll's fuel cycle inspection findings were well-founded and well-documented throughout the assessment period. The review team evaluated a ccoss-section of reports against the requirements in IMC 610, " Inspection Reports," and found that the Rlll inspection reports meet the manual chapter requirements. The review team found that the reports received proper peer and management review.

Rlll's fuel cycle inspection program, and the specific reports examined as part of the IMPEP review, appear to focus on the higher-risk functional areas. As mentioned above, Rlll has a program in place to track past issues at each facility. These issues include past inspection findings, events, and routine activities at each site. Rlli maintains the PIM current for each facility, and it is used by the inspectors in the planning phase of the inspection, to focus on areas that may be weak. The inspection effort does address past findings, and programs are in place to track the status of open inspection items.

The review team evaluated 12 inspection reports written during the review period. These reports covered inspections from all four plants in the Region's fuel cycle program and all seven fuel cycle inspectors. The review focused on the quality of the Region's inspection effort and Rlll's focus on the safety significance of licensee performance. Additionally, the review team evaluated the Region's follow-up inspection effort to ensure that items opened during previous inspections were tracked and closed in a timely and technically sound manner. The review team noted strong regional performance in this area, with inspection findings focusing on the facility's performance weaknesses, follow-up inspections addressing previously identified items, and inspection findings leading to prompt and appropriate regulatory action.

All inspections were led by qualified inspectors and, in most cases, supervisory accompaniments were performed on an annual basis.

4.2.4 Technical Staffino and Trainina The staffing of the fuel cycle inspection program in Rlil has remained relatively stable during the review period. Rlll has a senior resident inspector and a resident inspector at both GDPs, and

Region lli Final Report Page 24 two safety inspectors based out of the regional office. Through a review of Rlll's training and qualification records, the review team found that Rlli's fuel cycle inspectors met the qualification requirements of IMC 1246, " Formal Qualification Programs in the Nuclear Material Safety and Safeguards Program Area," and the associated resident inspector training programs, with two exceptions. Both the senior resident and the resident at the Ponsmouth Gaseous Diffusion Plant were appointed to their positions within this review period. Both of these individuals are qualified fuel cycle inspectors, and both will complete their specific position training for resident inspectors during CY 1999.

One challenge Rlli will face over the next few months will be to fill a regional-based fuel cycle inspector position that will become vacant in May 1999, when the incumbent moves to a reactor resident inspector position. The review team found that the current fuel cycle inspector performed a very high volume of inspection work over the past year. Rlll will be challenged to seamlessly fill the vacancy with someone who can quickly step into the position, with appropriate background and skills, and begin conducting quality inspections at the fuel cycle facilities. At a management retreat during the on-site IMPEP review, Rlli decided to post this position, and will begin actively recruiting to fill it.

4.2.5 incidents and Alleaations During the review period, Rlli received 47 allegations regarding activities at fuel cycle facilities.

As of March 18,1999, only 13 remained open. The review team examined the inspection reports used to close 12 allegations. These reports supported the timely closure of the allegations, and Rlli inspectors presented technically-sound findings in the inspection reports.

Rill's responses to fuel cycle events appeared to be appropriate, throughout the review period, and the Region coordinated with NMSS on fuel cycle incidents, as needed. During this review period, the Rill incident Response Center (IRC) was activated once in response to a fuel cycle event, for a fire at a fuel cycle facility. The review team found that this activation was conducted appropriately. Rlli has a program in place to ensure full staffing of the IRC, and the region tracks and provides training for critical Branch personnel, to support their incident response duties. The review team observed that the Rill IRC is well-staffed, and appears prepared to support an event at a fuel cycle facility.

Based on the IMPEP evaluation criteria, the review team recommends that the Region's performance with respect to this non-common performance indicator, Regional Fuel Cycle Inspection Program, be found satisfactory.

4.3 SDMP The SDMP includes sites that involve unique and difficult issues requiring special attention to ensure timely decommissioning. The SDMP sites may have buildings, former waste disposal areas, large piles of tailings, and groundwater and/or soil contamination. In all cases the issues associated with the sites are sufficiently complex that they are included in this special NRC program.

F . .. .

l i

Region lli Final Report Page 25 4.3.1. Quality of SDMP Decommissionina Reviews Region lli has project management responsibility for a single SDMP site, Advanced Medical

. Systems (AMS) in Cleveland, Ohio. Project management or licensing responsibility for the l other SDMP sites in Region lli is the responsibility of NMSS/DWM. The Region coordinated j very closely with NMSS on all actions involvin'g the AMS site during the review period. Because '

Rill has just the single SDMP site, which involved frequent and thorough communication with

' NMSS throughout the review period, the review team did not review this performance area.

4.3.2 Financial Assurance for Decommissionina As noted in Section 4.3.1, Rlli has responsibility for SDMP project management of just the AMS site. On that site, Rlli coordinated extremely closely with NMSS/DWM on NRC's review of AMS' financial assurance, which eventually led to the staff denying AMS' license renewal. Because NMSS/DWM was so heavily involved in the AMS financial assurance review, and because financial assurance reviews for other SDMP sites are not performed by Rlli, the review team did not review this performance area as it applies to other SDMP sites. Section 3.4, " Technical Quality of Licensing Actions," addresses Rill's financial assurance reviews for non-SDMP sites.

4.3.3 Termination Radioloaical Surveys Within this performance area, the review team assessed how the Region ensures that sufficient radiological surveys are being performed before license termination and site release, as outlined in IMC 2605, and that licensee survey results are validated by the Region through a closeout inspection or confirmatory survey, where necessary. Only one Rll! SDMP site, the former Clevite Corporation site in Cleveland, Ohio, has been removed from the SDMP list since the last IMPEP review. The review team examined the termination surveys for that site and also ,

examined a survey for the release of " Area D" at the RMI Environmental Services site in l Ashtabula, Ohio. I 1

The review team concluded that Rill's surveys and decommissioning inspections are adequate to ensure that residual radioactivity levels comply with release criteria. The review team also  !

found that Rlli is performing confirmatory surveys for licensees' sites, as outlined in IMC 2605 and IP 87104, " Decommissioning inspection Procedure for Materials Licensees." Rlli routinely

. validates licensee survey results through a closecut inspection or confirmatory survey, given the extent and significance of any residual contamination. Section 3.2 of this report," Technical Quality of Inspections," also discusses Rll!'s performance of termination surveys for non-SDMP sites.

4.3.4 Inspections The review team examined the technical quality of inspections and surveys for SDMP l decommissioning inspections. (See Section 3.2, " Technical Quality of Inspections," for additionalinformation on the performance of non-SDMP inspections by Rlli decommissioning

( staff.) As for the SDMP sites, the review team found that these sites are inspected in accordance with IMC 2602, " Decommissioning Inspection Program for Fuel Cycle Facilities and Materials Licensees," and IP 87104.

l

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Region ill final Repori Page 26 Rill's SDMP decommissioning inspections were planned, carried out, and documented in accordance with IP 87104. Inspection documentation was complete, and with one exception,

, Rlli issued inspection results within 30 days. Inspections were well-coordinated with other groups. In a number of cases, SDMP project managers from NMSS/DWM participated in the inspections. In addition, State personnel accompanied the team on many decommissioning inspections. In the response to the questionnaire, Region lli stated that it has maintained an outstanding relationship with affected States for SDMP sites and other sites undergoing decommissioning, and the review team agrees with the Region's assessment, based on information obtained in interviews and in the inspection files. Appendix F identifies decommissioning cases reviewed by the team.

4.3.5' Staff Qualifications Qualifications of the Decommissioning Branch staff are discussed in Section 3.3," Technical l i

Staffing and Training." In general, Rlli's decommissioning staff were well-qualified through training and work experience to perform decommissioning license reviews and inspections.

4.3.6 SDMP Milestones Within the SDMP program, Rlli is responsible for inspections and NRC surveys at SDMP sites, and program management of the AMS site. SDMP milestones are often tied to the decommissioning and final survey plan reviews conducted by NMSS/DWM and thus require close coordination between Headquarters and the Regions. Rlli staff plans and schedules inspections in consultation with DWM to ensure that the scope of each inspection is appropriate, and that the inspections are timely. In some cases during the review period, inspections were deferred by Rlli and NMSS because no activities were being performed at the SDMP site.

NMSS/DWM staff accompanied Rlli inspectors on many of the SDMD inspections during the i review period. Except for coordinating SDMP inspection activities with NMSS/DWM, the Region {

has no specific responsibility to track decommissioning milestones or update the SDMP i database. With respect to the SDMP inspection coordination with DWM, the review team observed that Rlll was performing in a successful manner in this performance area.

4.3.7 SDMP Summary I' Based on the IMPEP evaluation criteria, the review team recommends that the Region's performance with respect to this non-common performance indicator, SDMP, be found satisfactory.

5.0

SUMMARY

l

, As noted in Sections 3 and 4 above, the review team found Region Ill's performance to be i satisfactory for all common and non-common indicators. Accordingly, the review team recommends that the MRB find the Rlll nuclear materials, fuel cycle inspection, and SDMP programs to be adequate to protect public health and safety.

Below is a summary list of recommendations, as mentioned in earlier sections of the report, for I

p

)l Region 111 Final Report Page 27 i

evaluation and implementation, as appropriate, by Rlli and NMSS. '

RECOMMENDATIONS:

1. The review team recommends that NMSS revise all inspection field notes to include the location (s) that the inspection is performed. (Section 3.2) l

2. The review team recommends that Rill implement the tools prescribed in the  !

Decommissioning Handbook for ensuring that decommissioning and license termination reviews are complete and fully documented. (Section 3.4)-

i

3. The review team recommends that NMSS evaluate tne causes for omission of reference l documents from NMED reports, and take appropriate follow-up action in response to any  ;

findings. (Section 3.5)

4. The review team recommends that Rill develop and implement a process to remove .

allegation material from the docket files. (Section 3.5)

5. The review team recommends that Rill train the DNMS staff on what allegation language, if any, is acceptable to place into the docket file, (Section 3.5)

SUGGESTIONS:

The review team did not identify any suggestions for Rlli on this IMPEP review.

GOOD PRACTICES:

Although the review team noted a number of areas where Rlli exhibited strong performance, the review team did not identify specific " good practices" that differed greatly from processes used by other regional and Agreement State programs. The Rlli materials program demonstiated .

sound, steady performance throughout the review period, using standard NRC practices.  !

F' , .. ..

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LIST OF PPENDICES AND ATTACHMENTS . I i

. Appendix A iMPEP Review Team Members .;

Appendix B Region lli Organization Charts i Appendix C Inspection Casework Reviews l

l 2 Appendix D License Casework Reviews  !

Appendix E incident Casework Reviews i

Appendix F SDMP and Decommissioning Files Reviewed

!s - Appendix G . Region lil's Questionnaire Response i

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APPENDIX A j i

IMPEP REVIEW TEAM MEMBERS i l

)

Name Area of Responsibility  !

Scott Moore, NMSS/IMNS Team Leader l

Status of the Materials inspection Program Technical Staffing and Training Performance Against Operating Plan Goals j Sheri A. Minnick, Region I, DNMS Technical Quality of Inspections inspection Accompaniments l

I Cynthia Sanders, State of Georgia Technical Quality of Licensing Actions i

Kevin Hsueh, OSP Response to incidents and Allegations Garrett Smith, NMSS/FCSS Regonal Fuel Cycle inspection Program James Kennedy NMSS/DWM Decommissioning /SDMP l

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L APPENDIX C INSPECTION CASEWORK REVIEWS NOTE: ALL INSPECTIONS LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

File No. 01 -

Licensee: Mallinckrodt Medical, Inc. License No.: 24-17450-02MD Location: St. Paul, MN inspection Type: Routine, unannounced License Type: 02500, Nuclear Pharmacy Priority: 1 Inspection Date: 4/29/97 ' inspector: JC

. File No. 02 Licensee: RC Associates License No.: 21-25870-01

. Location: Saginaw, MI Inspection Type: Routine, unannounced License Type: 03121, Portable Gauge Priority: 5 Inspection Date: 5/28/97 Inspector: AK Comments:

a) Branch Chief signature on field notes greater than 30 days post inspection.

File No. 03 -

Licensee: RC Associates License No.: 21-25870-01 Location: Saginaw, Ml inspection Type: Special, unannounced License Type: 03121 Portable Gauge Priority: 5 Inspection Date: 3/0/97 Inspector: JJ Comments:

l a) Field nota r,ompletion three months post inspection.

!- Incorrect License Type (03221) and priority (4) listed on field notes.

b)

File No. 04 l Licensee: Concordia College License No.: SNM-773 l Location: Moorhead, MN Inspection Type: routine, unannounced License Type: 22120, PuBe source Priority: 5 Inspection Date: 6/2/97 Inspector: RH t

Region til Proposed Final Report Page C.2 Inspection Casework Reviews File No. 05 Licensee: St.' Mary's Medical Center License No.: 13-03226-04  !

Location: Evansville, IN Inspection Type: special, unannounced -

.L License Type: 02120, Medical QMP {

Priority: 3 l Inspection Date: 6/12/97 Inspector: WS, TG '

Comments:

a) Two locations of use authorized on license, however no place in field notes to ,

document location (s) of inspection.

File No. 06 Licensee: Midwest Imaging Diagnostic, Inc. License No.: 34-26753-01 Location: Cincinnati, OH inspection Type: Special, unannounced License Type: 02200, Medical Private QMP Priority: 3 Inspection Date: 7/21/97 Inspector: DW Comments:

a) Two locations of use authorized on license, however no place in field notes to document location (s) of inspection.

I i

File No. 07 Licensee: VA Edward Hines Jr. Med. Center {

License No.: 12-01087-01 Location: Hines, IL Inspection Type: Routine, unannounced License Type: 02110, Medical Broad Priority: 1 inspection Date: 8/15/97 Inspector: JC Commente:

a) Feld notes issued greater than 30 days post inspection.

File No. 08 Licensee: Oakwood Hospital License No.: 21-04515-01 ,

Location:

Dearborn,

Mi inspection Type: Routine, unannounced i License Type: 02230, HDR Priority: 1 Inspection Date: 9/23/97 Inspector: SM i

File No. 09 Licensee: The Ohmart Corporation License No.: 34-00639-01 Location: Cincinnati, OH inspection Type: Routine, unannounced License Type: 03212, Manufacturing Priority: 3 ,

inspection Date: 10/28/97 Inspector: DW i

i

,3,:,- .,

L .

Region lli Proposed Final Report Page C.3 Inspection Casework Reviews

! ' File No.10 ' .

L Licensee: Lengview inspection, Inc. License No.: 48-17480-01 l- Locationi Brookfield, WI _

. inspection Type: Routine, unannounced L License Type: 03320, Radiography Priority: 1

Inspection Date: 11/3/97-11/5/97 Inspector: LAM -

L Comments:

L , a) Field site included in the inspectiont File No.11 Licensee: Longview Inspection, Inc. License No : 48-17480-01

- Location

Brookfield, WI . .

Inspection Type: Unannounced, feld site l' License Type: 03320, Radiography Priority: 1 Inspection Date: 6/3/97 Inspector TG File No.12

, Licensee: SW Indiana Rad. Oncology Center License No.: 13-25945-01 lf Location: Evansville, IN _ . . Inspection Type: Routine, unannounced l

' License Type: 02300, teletherapy Priority:-3 Inspection Date: 4/9/98 Inspector: SM l

!. File No,13 L Licensee: U6ieersity Hospital of Bedford License No.: 34-17783-01 i' Location: Bedford, Ohio L Inspection Type: Routine, unannounced l License Type: 02120, medical Priority; 3.

!~

. Inspe_ction Date: 4/7/98 inspector: GP L File No.14 Licensee: Denison' University License No.: 34-06325-04 l_

Location: Granville, Ohio inspection Type: Routine, unannounced -

License Type: 03620, R&D other Priority: 5 Inspection Date:'4/16/98 Inspector: TG

' File No.15 Licensee: MQS inspection, Inc. License No..: 12-00622-07 l . Location: Elk Grove Village, IL Inspection Type: Special E . License Type: 03320, Radiography Priority: .1 -

Inspection Date: 11/19/97-2/10/98 Inspector: DP L l

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P:. , ,

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L l -

Region til Proposed Final Report Page C.4 Inspection Casework Reviews File No.16 i- Licensee: Mallinckrodt Medical, Inc. License No.: 24-04206-10MD Location: Warren, MI Inspection Type: Routine, unannounced License Type: 02500, Radiopharmacy Priority: 1 l

Inspection Date: 1/8/99 Inspector JC Comments:

a) . File reviewed for inspection of special condition regarding Y2K. Documentation

. under special license conditions or issues (Y2K) indicated "none". j File No.17

Licensee

Midwest Mobile imaging License No.: 13-26658-01 Location: Valparaiso, IN Inspection Type: Routine, unannounced l License Type: 02220, Mobile Nuclear Medicine Priority: 2 Inspection Date: 10/27-28/98 Inspector: RG -

Comments:

a) Fi!e reviewed for inspe: . . of special condition regarding Y2K. Documentation under special license conditions or issues (Y2K) indicated "none".

J l

File No.18 i Licensee: Abott Northwestern Hospital License No.: 22-04588-01 Location: Minneapolis, MN Inspection Type: Routine, unannounced License Type: 02120, Medical, QMP Priority: 1 Inspection Date: 10/21/98 Inspector: DP File No.19 Licensee: Lester E Cox Medical Center License No.: 24-01143-06

' Location: Springfield, MO - Inspection Type: Routine, unannounced l ' License Type: 02230, HDR Priority: 1 L Inspection Date: 12/3/98 ~ Inspector: TY File No. 20 Licensee: Wendt Bristol Healthcare Services Corp. License No.: 34-32104-01 Location: Columbus, OH Inspection Type: Initial, announced l License Type: 02230, HDR Priority: 1 l Inspection Date: 1/14/99 Inspector: TG L

l I

l. l

p ..

Region 111 Proposed Final Report Page C.5 Inspectiori Casework Reviews INSPECTOR ACCCMPANIMENTS

. The following inspection accompaniments were performed as part of the on-site IMPEP review.

Accompaniment No.: 1 Licensee: Cardiovascular Clinics . License No.: 13-32122-01 Location: Merrillville, IN Inspection Type: Initial, announced License Type: 02201, Medical Priority: 5 Inspection Date: 3/9/99 Inspector: SM Accompaniment No.: 2 ,

Licensee: Purdue University License No.: 13-02812-04 Location: West Lafayette, IN inspection Type: Routine, unannounced License Type: 01100, Academic Broad . Priority: 2 Inspection Date: 3/10/99-3/11/99 Inspector: KN Accompaniment No.: 3 Licensee: Wabash College License No.: 13-07419-02 Location: Crawfordsville, IN inspection Type: Routine, unannounced License Type: 03620,22120, R&D Other, PuBe Priority: 5 Inspection Date: 3/11/99 Inspector: RH i

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APPENDIX D ~

LICENSE CASEWORK REVIEWS NOTE: ALL LICENSES LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

File No.: 1 L;censee: Advanced Cardiac Health Care doing business as (d/b/a) Bronson Medical Group License No.: 21-26784-01 Location: Kalamazoo, MI Amendment No.: NA License Type: Medical Private Practice Type of Action: New Date issued: 04/28/97 License Reviewer: GW File No.: 2 Licensee: MNC, Inc.,

d/b/a Metropolitan imaging Center ,

License No.: 48-32008-01 Location: Milwaukee, WI Amendment No.: NA License Type: Mobile Nuclear Medical Services Type of Action: New Date Issued: 10/31/97 License Reviewer CC File No.: 3 Licensee: East Jordan Iron Works, Inc. License No.: 21-13462-02  !

Location: East Jordan, MI Amendment No.: 09 License Type: Fixed Gauge Type of Action: Renewal Date issued: 11/03/98 License Reviewer: LH File No.: 4 Licensee: Soil Materials Engineering, Inc. License No.: 21-17158-02 Location: Plymouth, MI Amendment No.: 09 License Type: Portable Gauge Type of Action: Renewal Date Issued: 12/17/97 License Reviewer: JM ,

l File No.: 5 Licensee: Saint Louis University License No.: 24-00196-07 Location: St. Louis, MO Amendment No.: 23  ;

License Type: Medical Institution Broad Type of Action: Renewal Date Issued: 07/11/97 License Reviewer: KN

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Region 111 Proposed Final Report Page D.2 Licensing Casework Reviews File No.: 6 Licensee: American Engineering Testing, Inc.

Location: St. Paul, MN License No.: 22-20271-02 )

Amendment No.: NA License Type: Inductrial Radiography Temporary Job Site Type of Action: New Date issued: 03/16/98 License Reviewer, JM File No.: 7 Licensee: Padia Environmental, Inc. License No.: 34-32101-01]

Location: Worthington, OH Amendment No.: NA License Type: Portable Gauge Type of Action: New Date issued: G7/07/98 License Reviewer: WR Comment: I a) The LTS program code for this license was listed as 3212 (Manufacturing and Distribution Type B Broad). A review of the license revealed that this is a Portable Gauge license, so the program code should have been 3121. This finding was discussed with the license reviewer, and Region til took action to correct the program code.

File No.: 8:

Licensee: Purdue University License No.: 13-02812-04 Location: West Lafayette, IN Amendment No.: 66  ;

License Type: Academic Type A Broad Type of Action: Amendment l Date Issued: 07/18/97 License Reviewer: CF l

File No.: 9 Licensee: Shared Imaging Services License No.: 48-20331-01  ;

Location: Prairie Du Sac, WI Amendment No.: 18 License Type: Mobile Nuclear Medical Services Type of Action: Amendment Date issued: 08/01/97 License Reviewer: MW File No.: 10

. Licensee: Sterigenics International License No.: 04-19644-01 Location: Fremont, CA Amendment No.: 36 License Type: Irradiators other >10,000 Curies Type of Action: Termination Date issued: 01/20/98 License Reviewer: PP j Comment:

a) _ License Number 04-19644-01 was terminated, and was replaced with the issuance of a new NRC License Number 34-32057-01. This termination was due only to a change in the licensee's mailing address.  ;

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Region ill Proposed Final Report Page D.3 Licensing Casework Reviews File No.: 11-Licensee: University Laboratories, Inc. License No.: 21-26212-01 Location: Novi, MI ' Amendment No.: 02 License Type: Byproduct Material Possession Only Type of Action: Termination Date issued: 05/04/98 License Reviewer: CG Comment:-

a) This action involved the termination of a nickel-63 detector cell authorized for storage i only, incident to final dispositioni lt was returned to the manufacturer for disposition.

File No.: 12 Licensee: Hitachi Medical Corporation of America License No.: 34-26756-01 Location: Twinsburg, OH Amendment No.: 01 -

License Type: Research and Development Type of Action: Amendment {

Date issued: 11/05/97 License Reviewer: PP

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a) The LTS program code for this license was listed as 3620 (Research and Development).

A review of the license revealed that this is a Measuring Systems - Other license, so the program code should have been 3124. This finding was discussed with the license reviewer, and Region 111 took action to correct the program code.

File No.: 13 Licensee: SMV License No.: 34-26121-01 Location: Twinsburg, OH Amendment No.: 10  ;

License Type: Measuring Systems Other Type of Action: Amendment  !

Date issued: 04/13/98 License Reviewer: GW l 1

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Licensee: Battelle Columbus Division License No.: 070-00008 Location: Columbus, OH Amendment No.: 14 )

License Type: Hot Cell Operations Type of Action: Amendment Date issued: 11/24/97 License Reviewer: MM I

File No.: 15 Licensee: Department of the Army License No.: 12-00722-07 Location: Rock Island, IL Amendment No.: 21 License Type: Measuring Systems Other Type of Action: Renewal Date issued: 04/25/97 License Reviewer: KN i

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APPENDIX E

! INCIDENT CASEWORK REVIEWS i NOTE: ALL INCIDENTS LISTED WITHOUT COMMENT ARE INCLUDED FOR l COMPLETENESS ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP l TEAM.

File No.: 1 Licensee: Cleveland Clinic Foundation Licensee No.: 34-00466-01 Site of incident: Cleveland, OH Incident Log No.: PNO-ill-98-043 Date of incident: 8/11/98 Type of incident: Misadministration Investigation Date: 9/9/98 Type of Investigation: On-site Summary of Incident and Final Disposition: A misadministration event involved the administration of approximately 17 mci of Y-90 labeled antibody instead of 28.5 mci to a

! patient. The event occurred because a project scientist who prepared the dose relied on readings from a dose calibrator, which did not coincide with volumetric calculations that were based on assay data provided by the Y-90 supplier. The project scientist decreased the volume of the dose until calibrator readings were within acceptable levels. The change in the injection volume resulted in the underdose to the patient.

Comments: Inspection report (NUDOCS accession number: 9810200085) could not be found on the corresponding NMED records.

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i File No.: 2 l Licensee: Harper Hospital Licensee No.: 21-04127-02 i Site of incident: Detroit, MI Incident Log No.: PNO-Ill-98-028 Date of incident: 3/19/98-3/20/98 Type of incident: Misadministration I investigation Date: 3/26/98-3/27/98 Type of Investigation: On-site Summary of incident and Final Disposition: Treatments to wrong site. During the course of treatment, the licensee used a High Dose Rate (HDR) remote afterloader with a sealed source l- containing approximately 6.6 Ci of Ir-192. The primary cause of the misadministration was due l to programmatic weakness in the implementation of the licensee's quality management program.

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Region lll Proposed Final Report Page E.2 incident Casework Reviews i File No.: 3 Licensee: McLaren Regional Medical Center Licensee No.: 21-04171-04 Site of incident: Flint, Mi incident Log No.: PNO-ill-97-090 Date of incident: 11/10/97 Type of incident: Misadministration investigation Date: 11/17/97 Type of Investigation: On-site Summary of incident and Final Disposition: A patient was administrated 4.6 mci of I-131 instead of the prescribed 8 mci. The patient was being treated for a hyperthyroid condition. The cause of this event was that the technologist administering the dosage failed to read the label on the dose container and to verify that dose container was empty prior to completing the administration.

Comments: Inspection report (NUDOCS accession number: 9712300053) could not be found on the corresponding NMED record.

File No.: 4 Licensee: Community Hospitals of Indiana, Inc. Licensee No.: 13-06009-01 Site of incident: Indianapolis, IN Incident Log No.: PNO-ill-98-053 Date of incident: 11/3/98 Type of incident: Lost Source investigation Date: 12/1/98-12/2/98 Type of Investigation: On-site Summary of Incident and Final Disposition: Loss of three 376 Ci 1-125 brachytherapy seeds.

The cause of this event was that the licensee did not secure from unauthorized removal or limit access to the 1-125 brachytherapy sources, nor did the licensee control and maintain constant surveillance of this licensed material.

Comments: Inspection report (NUDOCS accession number: 9901190197) could not be found on the corresponding NMED records.

File No.: 5 Licensee: Bowser-Morner, Inc. Licensee No.: 34-17390-01 Site of incident: Dayton, OH incident Log No.: PNO-Ill-97-060 Date of incident: 7/25/97 Type of Incident: Stolen source Investigation Date: 7/25/97 Type of Investigation: On-site l Summary of incident and Final Disposition: A Troxler moisture / density gauge was stolen from

! the back of a locked pickup truck parked at an employee's residence. The truck door was forced open, and the chain securing the device was cut. The gauge contained 9 mci of Cs-137 and 40 mci of Am-Be.

Comments: Licensee report (NUDOCS accession number: 9709080023) could not be found on the corresponding NMED records.  :

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d Region ill Proposed Final Report Page E.3 L . Incident Casework Reviews.

- File No.': 6' L . Licensee: Geotechnical Consultants, Inc. Licensee No.: 34-26022-01 Site of incident: Westerville, OH Incident Log No.: N/A -

l Date of incident: 6/13/98. Type of incident: Stolen source

' Stolen Source Investigation Date: 7/8-7/9/98 Type of Investigation: On-site l-l Summary of incident and Final Disposition: Theft and recovery of a moisture / density gauge.

The gauge was stolen form a parked vehicle in'a parking lot. L The gauge contains a 50 mci Am-

-Be source and a 10 mci Cs-137 source. An individual contacted the licensee RSO, approximately three hours after the theft, and reported that he had found the device.

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L File No.: 7 l- Licensee: Wisconsin Centrifugal, Inc Licensee No.: 48-11641-01 Site of incident: Waukesha, WI incident Log No.: PNO-Ill-98-005 Date of Incident: 1/13/98 Type of incident: Equipment Malfunction investigation Date: 1/14/98,1/15/98,1/20/98- Type of Investigation: On-site Summary of incident and Final Disposition: A failure of a spring-loaded shutter on a radiography device which is located in a shielded room. The unit contains a 669.5 Ci Co-60 source and has a ,

-spring-loaded shutter that is closed when the unit is not energized. The cause of the l: unretracted source event was that the broken shutter spring did not maintain the' source in the ,

l:  ; shielded position after the exposure time had elapsed.

File No.: 8 'l Licensee: University of Minnesota - Licensee No.: 22-00187-46

- Site of incident: Minneapolis, MN Incident Log No.: PNO-Ill-98-021 Date of incident: 2/6/98 ~ Type of incident: Loss of control of radioactive material ]

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- Investigation Date: 3/2/98-3/4/98 Type of Investigation: On-site j ' Summary of' Incident and Final Disposition: A ribbon containing six 1r-192 seeds, with a total

. activity of approximately 3 mCl, was found to have been left in an applicator following a brachytherapy procedure. The incident occurred because the personnel responsible for

[ - performing an inventory of brachytherapy sources and performing surveys of the ,

applicator / needles after source removal, did not follow the procedures.

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n Region 111 Proposed Final Report Page E.4

' incident Casework Reviews

- File No.: 9 Licensee: Syncor Intemational Corp. Licensee No.: 04-26507-01 Site of incident: St. Louis, MO incident Log No.: PNO-ill-97-040 Date of Incident: 5/6/97 . Type of incident: Contamination investigation Date: 5/27/97-5/30/97 ' Type of investigation: On-site Summary of incident and Final Disposition: A Syncor driver picked up two empty packages from -

a client facility. Upon return to the Syncor facility, Syncor personnel detected removable contamination on the outside of the packages of 1,400,000 dpm. The cause of the event was a dropped needle at the client's facility which contained Tc-99m. This dropped needle resulied in contamination of the outside of the packages returning to Syncor.

File No.: 10 Licensee: Mallinckrodt Medical, Inc. Licensee No.: 24-04206-01 Site of incident: Maryland Heights, MO Incident Log No.: PNO-Ill-97-045 Date of incident: 5/14/97-5/15/97 Type of incident: Overexposure investigation Date: 5/16/97,5/22/97,5/29/97 Type of Investigation : On-Site .

Summary of incident and Final Disposition: An employee went home without properly frisking himself for contamination. When returned to work the next day, he performed a contamination survey of himself and detected significant levels of contamination on his left thumb. The isotope was determined to be Re-186. The employee became contaminated while handling l contaminated materials with a faulty glove. Contaminated locations in the employee's vehicle and home were decontaminated by the licensee to remove loose contamination.

Comments: Licensee report (NUDOCS accession number: 9707250074) could not be found on

-.the corresponding NMED records.

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APPENDIX F REGION 111 SDMP AND DECOMMIRSIONING FILES REVIEWED File No.1 Licensee: Aerospace America (formerly Wellman Bronze and Aluminum Company)

Location: Bay City, MI License No.: STB-00136 (terminated)

License Type: Source Material File No. 2 Licensee: General Electric Co., Tungsten Products Plant Location: Euclid, OH

' License No.: SMB-191 License Type: Source Material File No. 3:

Licensee: Department of the Army Location: Independence, MO (Lake City Ammunition Plant)

License No.: SUB-1380 License Type: Source Material File No. 4:

Licensee: RMI Environmental Services Location: Ashtabula, OH License No.: SMB-602 License Type: Source Material File No. 5 Licensee: Bayer Corporation Location: Kansas City, MO License No.: 24-03830-01 License Type: Measuring Systems, Fixed Gauges File No. 6 Licensee: Battelle Memorial Institute Location: Columbus, OH License No.: SNM-7 License Type: Reactor and Fuel Research File No. 7 Licensee: American Smelting and Refining Co.

Location: Whiting, IN License No.: SUB-0465 (terminated)

License Type. Source Material

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- Region 111 Proposed Final Report Page F.2 '

- SDMP and Decommissioning Files Reviewed Files No. 8,9, & 10:'

Licensee: Clevite Corporation (now Gould Electronics) :

Location:. Cleveland, OH .

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License No.: - SNM-183 (terminated) .

License Type: Source Material -

File No.11 -

Licensee: - Metropolitan Council Wastewater Services Location: St. Paul, MN q

- Licenee No.: .22-18829-03

- License Type: Measuring Systems, Gas Chromatographs t

. File No.12 j

' Licensee: Mallinckrodt Specialty Chemical Co. i Location:' St. Louis, MO

- License No.: 24-0584-04 License Type: Research and Development Type B Broad I

File No.'13 '

Licensee: Monsanto Company.

Location: St.' Louis, MO License No.: = 24-01113-23. -

License Type: Research and Development. l File No.14 Licensee: University of Cincinnati Location: Cincinnati, OH License No. 34-06903-09 .

- License Type: Exempt Distribution File No.15:

Licensee: - Merrill Pharmaceutical (now Hoechst Marion Roussel)

Location: Cincinnati, OH License No.: 34-03643-01 License Type: Research and Development Type B Broad File No.-16 Licensee: McDermott Technology, Inc.

' Location: Alliance, OH .

License No.: 34-03043-03 SUS-1259

- License Type: Research and Development Type A Broad Source Material I

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i APPENDlX G REGION lli QUESTIONNAIRE RESPONSE 1

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asnaGu UNITEo STATES N

/ 'o,, NUCLEAR REGULATORY COMMISSION 8 o- REGloN lit 3 y 801 WARRENVILLE ROAD LISLE,ILLINOls 60532 4351 f

/ . March 1, 1999 MEMORANDUM TO: Carl J. Paperiello, Director, NMSS FROM: James E. Dyer, Regional Administrator h g21 /

SUBJECT:

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW - COMPLETED QUESTIONNAIRE As requested in your February 5,1999 memorandum, Region Ill has prepared the attached response to the Integrated Materials Performance Evaluation Program (IMPEP) questionnaire. In adoition, we have attached a copy of Regional Procedure 0517A,

• Management of Allegations," and the Management information Status Report covering the period through January 31,1999, to supplement the responses to the IMPEP questionnaire. -

Attachments: As stated (3) cc w/atts: D. Cool, NMSS S. Moore, NMSS CONTACT: Monte Phillips, DNMS 630/829-9806

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l lNTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM OUESTIONNAIRE RESULTS 1

l REGIONlli REPORTING PERIOD: MARCH 1997 TO PRESENT A. COMMON PERFORMANCE INDICATORS

1. Status of Materials insoection Proaram

1. Please prepare a table identifying the licenses with inspections that are overdue l by more than 25% of the scheduled frequency set out in NRC Inspection Manual Chapter 2800. The list should include initialinspections that are overdue.

Insp. Frequency Licensee Name (Years) Due Date Months O/D

[ Region lil currently has no overdue inspections that exceed the 25 percent scheduling frequency set out in NRC Inspection Manual Chapter (MC) 2800 after having been extended / reduced based on performance. In addition, there are no overdue initial inspections.

2. Do you currently have an action plan for completing overdue inspections? If so, please describe the plan or provide a written copy with your response to this questionnaire.

Not applicable.

3. Please identify individual licensees or groups of licensees the State / Region is inspecting more or less frequently than called for in NRC inspection Manual Chapter 2800 and state the reason for the change.

Routine inspections are currently performed in accordance with MC 2800, including the option for extending for good performance or reducing for 1 poor performance the inspection frequency. This approach is part of the I manual chapter, as specified in Section Ob.01. Followup inspections for l

! escalated enforcement cases are routinely scheduled within 6 months of the exit date for the inspection that identifies the escalated enforcement l item. This is assured through assignment into the action item tracking system (AITS) for the conduct of the followup inspection. In addition, i

Region lli continues to implement its broadscope inspection initiative.

i. Through this initiative, major broadscope licensees are visited more frequently than specified in MC 2800 to allow for performance-based l

Inspections of limited scope of activities in progress, with the intent being 4 that over an entire MC 2800 inspection cycle, the full scope of inspection activities would be completed. Otherwise, Region ill does not have any other specific licensees or groups of licensees which are routinelv inspected less frequently than dictated in the manual chapter.

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4. Please complete the following table for licensees granted reciprocity during the reporting period.

Number of Licensees Number of Granted Reciprocity Licensees

. Priority Permits Each Year inspected Each Year j Service licensees CY97-1 CY97-1 performing CY98 - 0 CY98-0

! teletherapy and irradiator source installations or changes CY97-3 CY97 - 1 *

-1 CY98-3 CY98 - 1

• t CY97-0 CY97-0 2 CY98-0 CY98 - 0 l CY97-5 CY97-2

l. 3 CY98-4 CY98 - 1

• There are no priority 4 4 licensees CY97 - 6 CY97 - 1 l All Other CY98 - 8 CY98 - 0*

l Reciprocity assist requests CY97 - 9 i from other Regions N/A CY98 - 0 l - Note that this does not meet MC 1200 inspection frequencies. This was

, identified by the Region during one of its self-assessments. Corrective

! actions are in progress.

l 5. Other than reciprocity licensees, how many field inspections of radiographers were performed?

Region 111 performed 13 field inspections of radiographers in 1997 and 14 field inspections of radiographers in 1998,

6. For NRC Regions, did you establish numerical goals for the number of inspections to be performed during this review period? If so, please describe your goals, the number of inspections actually performed, and the reasons for any differences between the goals and the actual number of inspections performed.

Region 111 established numerical inspection targets to coincide with the number used in the budget formulation process. These were not used as numerical goals as NMSS had specified that no numerical goals were 2

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required. For FY 97 and FY 98 the target number was 680. In actuality, we completed 675 inspections in FY 97, and 682 inspections in FY 98.

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operating plan the total number of inspections due during the fiscal year (the budgeted number is 630). Through the second quarter of FY 99, the l number due was 118 in the first quarter, and 118 due in the second quarter.

We completed 127 inspections during the first quarter of FY 99, and 65 inspections through the first month of the second quarter of FY 99.

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11. Technical Quality of insoections t 7. What, if any, changes were made to your written inspection procedures during i

the reporting period?

L in addition to the inspection procedures delineated in the NRC Inspection l Manual Chapters and Management Directives that were revised (such as l MC 87), the Region also maintains regional procedures that closely parallel l many agency procedures, such as handling of allegations, commu1ications with outside agencies, etc. These procedures are routinely reviewed on a two-year frequency and modified as necessary.

Regional procedures that have been modified since the last IMPEP are as follows:

l RP 0238, " Inspector Objectivity," revised 1/16/97 RPO400F, " Notice of Enforcement Discretion," revised 6/1/98 l RPO400K, "Non-cited Violations," issued on 12/30/98 I

4 RP 0517A," Management of Allegations," revised 3/5/98 i

RP 0518, " Handling Fitness-for-Duty Matters," revised 3/11/98 RP 0610A," Inspection Reports," revised 9/29/97 RP 0615, " Augmented Inspection Team Reports," revised 1/'7/98 i RP 0721," Processing 10 CFR Part 21 Reports," revised 4/2/98 l RP 0725," Recommending Third party Assistance to Licensees," revised j 11/3/97 l

l RP 0961," Release of Draft NRC Reports and Other Documents," revised j 11/3/97 RP 1204," Assignment of Inspection Responsibilities," revised 6/6/97 RP 1209, " Team inspections," revised 5/13/97 l

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In addition to this process, the regional DNMS inspection staff conducts a quarterly assessment of inspection-related activities. Out of these assessments, " lessons learned" documents are generated, if necessary, and forwarded to the inspection staff for implementation. Divisional procedures or " lessons learned" developed and implemented during this assessment period were as follows: " Lessons Learned from Recent Escalated Enforcement Cases," " Materials inspection Assessment -

Extension and Reduction of Inspection Frequencies," " Lessons Learned from the Suspension of the Black Rock, Inc., License,"" Major issue:

^ Lessons Learned from LaFarge inspection Effort," " Transmittal of Results of Materials inspection (Medical Events) and Lessons Learned," " Major issue: Lessons Learned from University of Michigan Allegation Response," " Lessons Learned - Contested Enforcement Cases,"

" Assessment of Reciprocity Program," and " Review of Misadministration / Medical Event Followup inspections."

8.

Prepare a table showing the number and types of supervisory accompaniments made during the review period. Include:

Inspector (s) Supervisor 4 License Cateoories D_gle Nelson Jorgensen Contaminated Site 3/7/97 Hays Phillips Teletherapy, Radiopharmacy, Med w/QMP 3/19-21/97 Slawinski Madera Med with QMP  ?./20-21/97 House Jorgensen License Termination 4/28-5/1/97 Kulzer/ Lee Jorgensen Contaminated Site 5/13-14/97 Kock / Cameron Phillips General Licensee, Man. & Dist. Broad. 5/23/97 Kock / Young Phillips Port. Gauge, Radiography, Med w/QMP 7/23-25/97 Landsman Jorgensen Decommissioning Power Reactor 8/26/97 Kutzer/ Lee Jorgensen Contaminated Site 9/10-11/97 Gattone Madera Fixed Gauge 9/17/97 Kulzer/ Lee Jorgensen Contaminated Site 10/10-11/97 Landsman Jorgensen ISFSI 11/12/97 Snell Jorgensen ' Decommissioning Power Reactor 11/12/97 Nelson Jorgensen Contaminated Site 12/18/97 Weber Madera Contaminated Site & Storage 12/5/97 Cameron / Kock Wright Man & Dist. Broadscope 1/12-16/98 Leemon Jorgensen Decommissioning Power Reactor 1/20-23/98 Jones Wright Medical Broadscope 2/17-19/98 Mitchell Wright Academic / Medical Broadscope 3/2-3/98 Cameron Wright Academic Broadscope 3/4/98 Wiedeman Madera Medical Broadscope 3/26-27/98 Young Wright Academic / Medical Broadscope 4/1/98 McCann Jorgensen Contaminated Site 4/8-10/98 Leemon Jorgensen Decommissioning Power Reactor 4/19-21/98 House Jorgensen Decommissioning Power Reactor 4/22/98 Parker Madera Port. Gauge, Med w/o QMP, Storage only 4/20-24/98 Mulay Wright in-Vitro lab, Med. & Academic Broad 4/30/98 Nelson / Landsman Jorgensen Decommissioning Power Reactor 5/13/98 Null Madera Lost Source Potential Disposal Site 5/18/98 4

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inspector (s) Supervisor License Cateaories pa_te t

Null Madera Academic Broadscope 5/22/98 Young Wright Port. Gauge 6/22-23/98 Kock Wright Port. Gauge, Med w/o QMP 7/15-16/98 Nelson Jorgensen Contaminated Site 7/16/98 Landsman Jorgensen ISFSI 7/21-22/98 Go Madera Portable Gauge 7/27-28/98 LaFranzo Madera Radiography 7/29/98 Piskura Madera Med w/QMP & HDR 7/30/98 Leemon Jorgensen Decommissioning Power Reactor 8/12-14/98 Gattone Madera Port. Gauge, Med. w/QMP 8/24-25/98 McCann Jorgensen Contaminated site 8/31-9/1/98 Landsman Jorgensen ISFSI 9/4/98  !

Cameron Wright Radiography 9/8/98 '

House Jorgensen Decommissioning Power Reactor 9/17-18/98 Wiedeman Madera Academic / Medical Broadscope 9/28/98 Mulay Wright Fixed Gauge, Med w/QMP 9/28-29/98 Kulzer/ Lee Jorgensen Contaminated site 9/29/98 Leemon orgensen Decommissioning Power Reactor 9/30/98 l Leemon Jorgensen Decommissioning Power Reactor 11/13-14/08 i McCann/ House Jorgensen Contaminated site 12/15/98 Leemon Jorgensen Decommissioning Power Reactor 1/12-13/99 House Jorgensen Decommissioning Power Reactor 1/21/99 NOTE: With the exception of Mr. Hays and Ms. Piskura, all inspectors were accompanied by a branch chief on at least one occasion during both FY 97 and FY 98.

Mr. Hays' inspection performance was observed and assessed on several inspections by two GG-14 senior inspectors during FY 98. Ms Piskura was transferred to licensing in the middle of FY 97, so no accompaniment was conducted.

9. 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.

Supervisory accompaniment of inspectors is performed in accordance with Regional Procedure 0316, dated November 13,1996. This procedure gives the division director the authority to establish processes for branch chief site visits and documentation. DNMS management's expectation has been i that each branch chief is to accompany each inspector at least twice per year, with one of these accompaniments being one-on-one (inspector /

branch chief only). The expectation to document accompaniments was only recently implemented, specifically, DNMS management has requested that branch chief's complete an Inspector / Reviewer Assessment Form upon completion of each accompaniment beginning in July 1998.

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l i 10. Describe or provide an update on your instrumentation and methods of calibration. Are allinstruments property calibrated at the present time?

l Fixed laboratory primary instruments (gamma spectroscopy, liquid scintillation and proportional counter) are calibrated annually and after any major modifications or repairs which could affect their calibrated statiss, l Approved laboratory procedures have been prepared to address calibratiori of each system and these procedures are available for auditor review.

l Traceable calibration standards are used. In late 1998, the laboratory was removed from service temporarily for installation of a new gamma l

' spectroscopic system and to accomplish procedure upgrades and other QA/QC program formalization. Each system was calibrated to support laboratory reactivation in December 1998, and all systems are properly l calibrated at the present time.

The mobile laboratory is presently out of service for repairs to the detector.

It will be calibrated prior to return to service with newly procured electronics and software. A draft calibration procedure will be exercised, under the oversight of a vendor representative, to accomplish the calibration and to identify any neet.ed procedure enhancements before l Issuance as a final, approved procedure.

Portable instruments are calidrated by a certified contractor, with laboratory calibrations conducted in accordance with our laboratory procedures. Details are maintained in an ACCESS database maintained by the laboratory staff. There has been no change in portable instrumentation since the last IMPEP.

111. Technical Staffina and Trainina

11. Please provide a staffing plan, or complete a listing using 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 j areas: administration, materials licensing & compliance, emergency response, LLW, U-mills, other, if these regulatory responsibilities are dividad between l

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 p'ersonnel. If consultants were  !

used to carry out the program's radioactive materials responsibilities, include their efforts. The table heading should be:

Name Position Area of Effort FTE%

G.Bonano Lab Operations Spec. Laboratory 100  ;

J. Cameron Sr. Radiation Spec. Inspection 100 C.Casey Health Physicist Licensing 100 C. Frazier Sr. Health Physicist Licensing 100 R. Gattone Radiation Specialist inspection 100 C. Gill Sr. Health Physicist Licensing 100 6

Name Position Area of Effort FTE%

T.Go Radiation Specialist inspection 100 R. Hays Radiation Specialist inspection 100 J. House Sr. Radiation Spec. Lab /Decom. Insp. 90/10 L. Hueter Health Physicist Licensing . 100 J. Jones Sr. Radiation Spec. Inspection 100 E. Kulzer Radiation Specialist Decom. Insp. 100 M. LaFranzo Radiation Specialist inspection 100 R. Landsman Project Engineer ISFSI/ Dry Cask insp. 100 P. Lee Radiation Specialist Lab /Decom. Insp. 20/80 R. Leemon Rx Decom. Insp. Rx Decom. Insp. 100 M. McCann Sr. Radiation Spec. Project Mgmt. 100 S. Mulay Radiation Specialist inspection 100 J. Mullauer Health Physicist Licensing 100 D. Nelson Radiation Specialist Decom. Insp. 100 K. Null Sr. Radiation Spec. Inspection 100 G. Parker Radiation Specialist inspection 100 P. Pelke Health Physicist Licensing 50 D. Piskura Radiation Specialist inspection 100 W. Reichhold Health Physicist Licensing 50 W. Snell Health Physics Mgr. Lab /Proj. Mgmt. 50/50 G. Watson Health Physicist Licensing 100 M. Weber Health Physicist Licensing /AMS Insp. 50/50

• D. *Wiedeman Sr. Radiation Spec. Inspection 100 T. Young R9diation Specialist inspection 100 Region lli has no vacancies, and consultants were not used to carry out  ;

any program responsibilities.

l

12. Please 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 '

and years of experience in health physics, or other disciplines, if appropriate. ,

l No new professional personnel have been hired since the last review.

i

13. Please list all professional staff who have not yet met the qualification I requirements of license reviewer / materials inspection staff (for NRC, inspection  !

! Manual Chapters 1246; for Agreement States, please describe your qualifications requirements for materials license reviewers and inspectors). For l each, list the courses or equivalent training / experience they need to attend and a 4 tentative schedule for completion of these requirements. l Qualification requirements for material ir,spectors are specified in MC 1246, Section ll. All Region lli inspectors have completed the training requirements specified in MC 1246, Section 11, except for the following:

Kevin Null is scheduled to take the next scheduled " Inspecting for Performance" (H-304) course. D. Wiedeman and/or J. Jones will attend the next scheduled " Health Physics Technology" (H-201) course. Of note, the requirement to attend the H-201 course resulted from the last issuance of 7

MC 1246. Prior to that time, inspectors could be grandfathered out of the course based on a recommendation from the branch and approval by the Regional Administrator. The two individuals remaining to take the H-201 course had been previously grandfathered. However, Region lli DNMS hr.s elected ngt to exempt any inspectors from the H-201 course based on MC 1246. Region lliis and continues to be supportive of the H-201 course.

Qualification requirements for materials license reviewers are specified in MC 1246, Section 1. All Region ill license reviewers have completed all of the training requirements specified in MC 1246, Section i except for the following: Cassandra Frazier, Gidget Watson, and Bill Reichhold have not yet completed the H-201 course. Prior to October 1996 all reviewers had been waived from this course; however, DNMS has decided that all reviewers will complete the course, if possible, by the end of calendar year 2000, in addition to meeting the qualification requirements of MC 1240, Region lli also requires that each reviewer have signature authority for a given category of license prior to independently signing a licensing action in that category. All reviewers have signature authority for medical, gauges, and ARDL (academic, research and development) licenses. In addition, most reviewers have signature authority for broad scopes, radiography, and teletherapy licenses. Reviewers obtain signature authority by completing a major amendment or renewal action for a given category under the -

subsequent review of an individual who has signature authority for that category. If the license action is completed without any errors, the reviewer is granted signature authority for that category. ]

14. Please identify the technical staff who left the RCP/ Regional DNMS program during this period.

Andrea Kock, Wayne Slawinski, and Mark Mitchell transferred to the Division of Reactor Safety. Toye Simmons transferred to the Enforcement and investigations Coordination Staff. Pat Vacherlon accepted a job in NMSS.

15. List the vacant positions in each program, the length of time each position has been vacant, and a brief summary of efforts to fill the vacancy.

As noted in our response to question 11, there are no vacant materials technical or administrative positions.

W. Technical Quality of Licensina Actions

16. Please identify any major, unusual, or complex licenses which were issued, received a major amendment, were terminated, decommissioned, submitted a bankruptcy notification or renewed in this period. Also identify any new or amended licenses that now require emergency plans.

8

.s o 1 Unusual or complex licensing actions reviewed and issued during the reporting period include, but are not limited to, the following:

Advanced Medical Systems. Inc. 34-19098-01: License renewal denied due to inadequate decommissioning financial assurance.

Washinoton University. 24-00167-11: Renewal requiring a major consolidation of various licenses and revamping of the HDR program under the new guidance.

Zeneca AG Products. 04-26799-01: New license issued authorizing field studies using Carbon-14 to study the migration of radioisotopes, industrial and Research Measurements Systems. Inc. 34-18214-0jl New license issued for Type A Broad Scope Manufacturing and Distribution program.

Indiana University and Medical Center.12-02752-08: Washinaton University and Medical Center. 24-00167-11: University Hospitals of Cleveland. 34-05469-01 and Ohio State University. 34-00293-02: Amendment issued granting the licensee authorization to use cobalt-60 sources in a Gamma Knife unit.

Cleveland Clinic Foundation. 34-00466-05: New license issued granting the licensee authorization to use cobalt-60 sources in a Gamma Knife Unit.

Curators of The University of Missouri. 24-00513-32: Amendment requesting several changes, including adding a new Rad Waste Building (approved); disposal of incinerator ash (approved); receipt of analytical samples (approved); approval to allow exempt sources received from licensees to remain exempt (approved); change in the release criteria for patient animals (approved); and approval to utilize Tc-99m in diagnostic procedures performed on patient animals which are considered food animals (not approved- pending a request for additional information).

(Partial TAR)

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

For the period April 1997 to March 1999, Region 111 submitted over 44 requests for technical assistance to NMSS. We do not deviate from licensing policies and procedures without first coordinating with NMSS.

A number of TARS that we submitted involved licensee requests for exemptions to the regulations; however, in almost all cases, the outcome was to not grant the exemption and to have the licensee agree to void the action rather than go through a formal denial. Examples of variances in licensing polices and procedures or exemptions from the regulations that were granted, subsequent to NMSS approval include, but are not limited to:

9

c Maximum Technolooies. 22-01376-021 Licensee requested an interpretation of 10 CFR 34.41, two-person rule.

St. John's Reaional Medica! Center: License amended to reflect a joint venture to license a second, different corporation under the hospital's license.

Christ Hospital. 34-03831-02: Riverside Methodist Hospital. 34-01055-01:

and St. Vincent Hospital. 13-00133-02: Amendment issued to authorize the licensees the use of Ir-192 seeds encased in nylon ribbon for intralumenal and intravascular brachytherapy.

University of Cincinnati. 34-32001-01 Amendment issued authorizing the licensee to use a Capintec, Inc., " Beta C" beta counter dose calibrator.

18. What, if any, changes were made in your written licensing procedures (new procedures, updates, policy memoranda, etc.) during the reporting period?

All licensing reviews were conducted in accordance with NRC Policy &

Guidance Directives and the recently issued final volumes of NUREG 1556 as they pertained to specific classes of licensees. These changes were in accordance with the requirements issued by NMSS. In addition, the Region also adopted a computer assisted licensing process, utilizing the computer to more efficiently generate and issue all licenses. This process was implemented the beginning of April 1998, greatly improving the efficiency of issuing licenses. Licensing staff conducted self-assessments of the quality assurance program for license issuance, licensing correspondence, and financial' assurance records. Out of these assessments, " lessons learned" documents were generated. Divisional or Branch procedures developed and implemented during this assessment period were as follows: " Branch Procedure for Quality Assurance Program Team Review." in addition, the recommendations from the two other self-assessments were implemented, although a specific divisional or branch procedure was not issued.

19. For NRC Regions, identify by licensee name, license number and type, any renewal applications that have been pending for cne year or more.

There are two renewal applications that have been pending for one year or i more as of February 28,1999.

Date Actions to be Received Licensee License No. License Type Completed 9/26/97 Dowelanco 13-26398-01 Type A R&D Awaiting licensee's LLC broadscope response to deficiencies 10

1 f

Date Actions to be Received Licensee License No. License Type Completed 9/20/94 Battelle SNM-007 Everything - source Awaiting submittal of Columbus material, critical an acceptable Labs mass special nuclear financial assurance '

material, type A R&D instrument from broadscope licensee NOTE: Battelle review complete except for obtaining a satisfactory financial assurance instrument (FAI). Several FAls have been submitted, reviewed by NMSS, and subsequently returned to licensee as deficient.

Dowelanco review has been delayed due to several extended vacations by RSO resulting in extended response times for deficiencies and delayed initiation of review.

V. Resoonses to incidents and Alleaations

20. Please provide a list of the reportable incidents (i.e., medical misadministration, overexposures, lost and abandoned sources, incidents requiring 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or less notification, etc. See Handbook on Nuclear Material Event Reporting in Agreement States for additional guidance.) that occurred in the Region / State during the review period. For Agreement States, information included in previous submittals to NRC need not be repeated (i.e., those submitted under OMB clearance number 3150-0178, Nuclear Material Events Database). The list  ;

should be in the following format:

The following is a list of event notifications received by Region lil's duty l officer that DID NOT involve nuclear criticality safety violations, classified material loss, loss of control of classified material, safeguards violations, ofIsite notification events, or Bulletin 91-01 events for the Gaseous 1

0.ffusion Plants. Also not included are events at decommissioned j reactors that still have fuel on site. In the future, we would recommend this question be deleted from the IMPEP questionnaire, or modified to only request a listing of incident reports that were not reported to the NRC's Operations Center and assigned an Event Number.

Date of Licensee Name License No, incident Type of incident Army-ACALA-Ft, Drum 12-00722-06 02/28/97 H-3 contamination event Paducah GDP GDP-1 03/04/97 Redundant equipment inop Paducah GDP GDP-1 03/05/97 Safety System Actuation Marion Steel Company 34-21123-01 03/10/97 Sealed source found in middle of site road reading > 200 mr/hr Gunderson Clinic 48-01277-02 03/06/97 l-131 underdose misadministration 11 L

1 I

l Date of Licensee Name License No. Incident Type of incident Paducah GDP GDP-1 03/14/97 Stress corrosion cracking of cylinder packing nuts Paducah GDP GDP-1 03/18/97 2 of 3 criticality detection systems inoperable Paducah GDP GDP-1 03/18/97 Fire sprinklers obstructed i Army-ACALA-Ft. Lewis 12-00722-13 03/13/97 Lost Arnericium-241 source Paducah GDP GDP-1 03/19/97 Fire sprinkler system inoperable Army-ACALA-Ft. Devons 12-00722-06 03/21/97 Worker and area contamination event l Paducah GDP GDP-1 03/22/97 Fire sprinkler system had obstructions and heads installed incorrectly j ie tsmouth GDP GDP-2 03/24/97 Small UF6 release from X-330 bldg Victoreen, Inc. 34-25957-01 04/15/96 i

Part 21 concerning radiation survey  ;

instruments - resistors could crack Paducah GDP GDP-1 03/26/97 High pressure fire water system in I bidg. C-331 declared inoperable Paducah GDP GDP-1 03/27/97 UF6 release detection & isolation system declared inoperable Paducah GDP GDP-1 04/03/97 Branch line of HP fire system disconnected in bidg. C-333 Portsmouth GDP GDP-2 04/03/97 Autoinatic isolation of autoclave Portsmouth GDP GDP-2 04/07/97 Top enrichment exceeded license limit Portsmouth GDP GDP-2 04/09/97 Surveillance requirements for HP fire system not met Portsmouth G P GDP-2 04/09/97 High level alarm in autoclave Paducah GDP GDP-1 04/09/97 Fire sprinkler systems declared inop Paducah GDP GDP-1 04/09/97 Valid actuation of water inventory control system Paducah GDP GDP-1 04/14/97 Branch line of HP fire system disconnected in Bldg. C-337 Army-ACALA-Ft. Riley 12-00722-13 04/14/97 Leaking Am-241 source with potential personnel contamination Army-ACALA-Aberdeen, 12-00722-06 04/14/97 instructor contaminated while MD improperly removing sources 12

I f... ,

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Date of I

Licensee Name License No. Incident Type of incident Army-ACALA-Ft. Polk 12-00722-06 04/08/97 Broken H-3 source '

Paducah GDP GDP-1 04/15/97 Branch lines of fire water system not connected in Bldgs. C-333 & C-337 l Paducah GDP GDP-1 04/16/97 Fire water system not connected in l Bldgs. C-331 & C-337 Ohio State University 34-00293-02 03/28/97 Missing P-32 shipment Paducah GDP GDP-1 04/21/97 Condensate alarm due to faulty probe Steelastic Company, LLC General Lic. 04/22/97 Missing gauge containing Am-241 Army-ACALA-Europe 12-00722-13 04/22/97 Lost 2,184 AM-241 sources and

& -14 319 Ni-63 sources Paducah GDP GDP-1 04/23/97 Actuation of Q safety system due to valid signal Paducah GDP GDP-1 04/23/97 Sprinkler system deficiencies Army-ACALA-Ft. Devons, 12-00722-06 04/24/97 Broken & missing H-3 sources at Ft. Riley, & Aberdeen, MD various bases Paducah GDP GDP-1 04/25/97 Sprinkler system deficiencies Paducah GDP GDP-1 04/24/97 Autoclave declared inoperable Paducah GDP GDP-1 04/26/97 Sprinkler system deficiencies in Bldgs. C-315 and C-337 Paducah GDP GDP-1 04/30/97 Sprinkler system deficiencies in Bldg. C-315 Theda Clark Hospital 48-09494-01 12/20/96 Medical underdose misadministration Paducah GDP GDP-1 05/01/97 Installed actuators on autoclaves underrated (40 pal vs 80 psi)

Paducah GDP GDP-1 05/01/97 Sprinkler system deficiencies in i Bldg. C-331 I Paducah GDP GDP-1 05/05/97 UF6 release in building C-337 Paducah GDP GDP-1 05/04/97 Sprinkler system deficiencies in 1 Bldg. C-315 Army ACALA-Ft. Stewart 12-00722-06 05/05/97 H-3 source found in a landfill _

Syncor/ Washington Univ. 24-00167-11 05/06/97 Contaminated package received from Wash. University 13

. . +

Date of Licensee Name License No, incident Tyra afincident Community Hospi?al of 13-06009-01 05/12/97 Medical underdose misadministration Indianapolis, IN Portsmouth GDP GDP-2 05/13/97 Autoclave declared inoperable Mallinckrodt 24-04206-01 05/14/97 Hand overexposure event Anheuser Busch. Inc. General Lic. 05/16/97 Lost two Am-241 sources Partsmouth GDP GDP-2 05/18/97 Autoclave declared inoperable Army-ACALA-Ft. Hood 12-00722-14 05/20/97 Lost Ni-63 source Portsmouth GDP GDP-2 05/19/97 Inadvertent deactivation of smoke detectors Bureau of Mines 22-19667-01 05/22/97 Five Kr-85 smoke detectors missing Toledo Hospitel 34-01710-05 05/22/97 l-125 seed inadvertently sent to landfill Paducah GDP GDP-1 05/22/97 Alarm inaudible in C-310 building Portsmouth GDP GDP-2 05/23/97 Autoclave isolated due to high pressure -

U. S. Steel General Lic. 05/24/97 Damaged Am-241 thickness gauge Private residence NONE 05/27/97 Source found in basement of home Columbia Hospital 48-02417-01 05/29/97 Medical underdose misadministration Paducah GDP GDP-1 05/30/97 Cascade cell trip function inadvertently turned off Portsmouth GDP GDP 2 06/01/97 Steam shutdown of autoclave during heating of cylinder Marquette General Hospital 21-05432-04 06/02/97 Medical underdose & wrong treatment site misadministration Portsmouth GDP GDP-2 04/07/97 Part 21 on lifting lugs for UF6 cylinders Portsmouth GDP GDP-2 06/10/97 Steam shutdown of autoclave during j heating of cylinder Paducah GDP GDP-1 06/15/97 Inop. UF6 release detection system Portsmouth GDP GDP-2 06/24/97 Part 21 concerning computer software )

error for crane analyses program Paducah GDP GDP-1 07/01/97 Loss of C-510 criticality accident alarm system i

14 i

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I Date of l Licenren Name License No. Incident Type of incident '

Conam inspection Services 12-1059-01 02/27/96 Radiography overexposure

• l Paducah GDP GDP-1 07/13/97 Alarm inaudible in C-310 building Army-ACALA-Ft. Irwin 12-00722-13 07/15/97 Lost Am-241 source j Paducah GDP GDP-1 07/14/97 Autoclave steam isolation Missouri DOT 24-20415-01 07/17/97 Troxler gauge involved in traffic accident - gauge not damaged Portsmouth GDP GDP-2 07/21/97 Steam shutdown of autoclave during heating of cylinder Bowser-Morner, Inc. 34-17390-01 07/25/97 Stolen Troxler gauge Michigan DOT 21-03039-01 08/01/97 Two gauge's damaged Paducah GDP GDP-1 07/10/97 Automatic actuation of crane hoist brake Middletown Regional Hosp. 34-08279-02 08/13/97 l-131 contamination event l Mercy Hospital 21-15638-01 08/13/97 Unintended site misadministration Lutheran Hospital 34-01869-01 10/18/94 Medical misadministration 1-131 overdose

• CTL Engineering, Inc. 34-18533-01 08/20/97 Stolen CPN gauge Univ. of Cincinnati Hosp. 34-06903-05 08/22/97 Three 1-125 seeds possibly missing Paducah GDP GDP-1 08/31/97 Steam leak on autoclave during heating of cylinder Anco Testing 24-24459-01 09/05/97 Density gauge run over lay car i

MQS Testing, Inc. 12-00622-07 09/08/97 Undamaged sealed source removed from a damaged guide tube Portsmouth GDP GDP-2 09/02/97 Steam . shutdown of autoclave during heating of cylinder Portsmouth GDP GDP-2 09/13/97 Smoke detectors actuated due to instrument line kink Syncor Pharm., St. Paul, 04-26507- 09/15/97 Empty package from St. Cloud MN 01MD hospital found to be contaminated University of Michigan 21-00215-04 09/15/97 Medical 1-131 underdose misadministration 15

. 4 .

I I

Date of Licensee Name License No. Incident Type of incid*nt Army-ACALA-Picatiny 12-00722-06 10/03/97 Radioactive material shipped from NY Arsenal Army National Guard inappropriately  !

Paducah GDP GDP-1 10/07/97 UF6 leak on purge air instrument line j

Paducah GDP GDP-1 10/06/97 Autoclave isolation during cylinder heating Portsmouth GDP GDP-2 10/09/97 Autoclave isolation during cylinder heating l Harper Hospital- 21-04127-02 10/10/97 Contaminated empty package received Mallinckrodt Pharmacy 24-04206- from Harper Hospital 10MD Hammond Fire Department n/a 10/18/97 Troxler gauge found along roadway Portsmouth GDP-2 10/18/97 Autoclave isolation during cylinder l feeding to cascade l

Paducah GDP GDP-1 10/21/97 Power supply trip affecting alarm i capability during UF6 withdrawal l Paducah GDP GDP-1 10/21/97 Autoclave isolation on high steam pressure Portsmouth GDP GDP-2 10/20/97 Two cells had temperatures lower than allowed Portsmouth GDP-2 10/23/97 Inoperable cylinder high pressure steam cutoff valve Grant Riverside Methodist 34-03424-03 10/29/97 Medical misadministration with Co-60 Hospital teletherapy machine l Enders Construction 48-18547-02 10/30/97 Earth mover ran over CPN gauge Portsmouth GDP GDP-2 11/06/97 Recirc water drains found plugged with sludge Western Atlas Loggirig 42-02964-01 11/08/97 Possible external exposure of Services -Crawford, MI 4 personnel to neutrons Blanchard Valley Medical 34-18674-02 11/03/97 Medical underdose misadministration Associates with I-131 Case West. Reserve Univ. 34-00738-04 10/31/97 P-32 contamination event McLaren Reg. Med. Ctr. 21-04171-04 11/10/97 Medical 1-131 underdose misadministration 16

1

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Date of Licensee Name License No. Incident Type of incident

)

MQS Inspections, Inc. - 12-00622-07 11/16/97 Radiography source stuck in Lima, OH collimator due to drive cable failure Shannon & Wilson 24-18839-01 11/17/97 Damaged moisture density gauge S. C. Johnson & Son, Inc. 48-06453-01 12/02/97 Kay-ray level detector damaged leaving source exposed I

Cancer Treatment Center 34-25978-01 12/05/97 Co-60 teletherapy medical overdose misadministration {

]

Calumet Testing Services 13-16347-01 11/21/97 Radiography source assembly l separated from control cable Bittner Engineering 21-26010-01 12/11/97 Part of Cs 137 source rod found loose in unrestricted area

{

]

Medcentral Health System 34-02007-02 12/16/97 Medical Co-60 teletherapy under dose misadministration Portsmouth GDP GDP-2 12/19/97 Actuation of high condensate level shutoff system during cylinder heatup Health System Mn - 22-01519-02 12/30/97 Potential medical under dose Methodist Hospital misadministration Washington Univ. 24-00167-11 12/15/97 l-131 contaminated hospital waste l

transferred to landfill i Paducah GDP GDP-1 01/12/98 Autoclave isolation during heatup of UF6 cylinder Wisconsin Centrifugal Co. 48-11641-01 01/13/98 Spring-loaded Co-60 teletherapy shutter failure & possible overexposure Washington Univ. 24-00167-11 01/15/S8 Medical misadministration due to Sr-90 pellets being stuck in catheter in patient Paducah GDP GDP-1 01/21/98 High voltage UF6 detection system equipment failure  !

j Army-ACALA-Schofield 12-00722-06 01/22/98 H-3 contamination event i Barracks, HI Miami Valley Hospital 34-00341-06 01/23/98 Receipt of contaminated package Paducah GDP GDP-1 01/23/98 inoperable criticality accident alarm j system i l

Allied Signal, Inc. SUB-526 01/27/98 Alert declared due to UF6 release 17 i

Date of Licensee Name License No. Incident Type of incident Paducah GDP GDP-1 02/01/98 Autoclave isolation during UF6 cylinder heatup Portsmouth GDP GDP-2 02/11/98 Small UF6 release from cascade cell Army-ACALA-Baumholder, 12-00722'13 02/12/98 Lost (& found) Am-241 source Germany Portsmouth GDP GDP-2 02/24/98 Autoclave isolation during UF6 cylinder heatup Army-ACALA-Camp Lejune 12-00722-06 02/26/98 H-3 contamination event - 5 people contaminated Clayton Lab Services General Lic. 01/30/98 Two Ni-63 sources lost in shipment Allied Signal, Inc. SUB-526 02/28/98 Standby diesel failed to operate 1

Detroit Macomb Hospital 21-01190-05 07/14/97 Possible medical Ir-192 underdose misadministration Paducah GDP GDP-1 03/01/98 Partial loss of facility process gas lead <

detection safety system alarm Soil Consultants, Inc. 24-20039-01 03/09/98 Undamaged Humboldt gauge involved in traffic accident q Lexalite international Corp. General Lic. 02/16/98 Lost Po 210 static eliminator )

l Corydon Crushed Stone Co 13-26644-01 03/14/98 Troxler gauge damaged by fire Detroit Macomb Hospital 21-01190-05 01/06/97 Medical tr-192 under dose misadministration

• Paducah GDP GDP-1 03/19/98 Steam blowdown testing creating very loud noise to drown out audible alarm Grandview Hospital SNM-1603 03/19/98 Pu 239 in cardiac pacemaker inadvertently incinerated i Army-ACALA-Schofield 12-00722-06 03/19/98 H-3 source rupture Barracks, Hi Harper Hospital 21-0412-02 03/23/98 Medical HDR misadministration Portsmouth GDP GDP-2 03/27/98 Autoclave isolation valve found to be '

operating backward United Hospital 22 01914-02 03/02/98 Missing 1.1 mci Pd-103 seed Paducah GDP GDP-1 04/07/98 Criticality accident alarm system inop in Bldg. C-720 18

C Date of Licensee Name License No. Incident Type of incident Allied Signal,Inc. SUB-526 04/08/98 Seven-band weather radio failure Univ. of Michigan 21-00215-06 04/08/98 Stuhk 20,000 Cl Co-60 source in panoramic wet irradiator Portsmouth GDP GDP-2 04/09/98 Autoclave containment valves failed test Army-ACALA-Ft. Lewis, WA 12-00722 04/17/98 Lost Am-241 source in CAD Portsmouth GDP GDP-2 04/27/98 Smallleak of UF6 from tails withdrawal Army-ACALA-Ft. Campbell, 12-00722-13 04/17/98 Lost Am-241 source in CAD KY.

Paducah GDP GDP-1 05/02/98 Autoclave isolation durir g UF6 cylinder feeding to cascade i Portsmouth GDP GDP-2 05/02/98' Autoclave isolation during UF6 cylinder heat up Paducah GDP GDP-1 05/03/98 Autoclave isolation during UF6 cylinder heat up Paducah GDP GDP-1 05/11/98 Criticality accident alarm system inop Paducah GDP GDP-1 05/12/98 Criticality accident alarm system inop Eljer Plumbing Ware 34-12906-02 05/12/98 Shutter for Cs-137 source on fixed gauge failed to close Allied Signal, Inc. SUB-526 05/15/98 HP vacuum pump not powered by standby diesel generator Army-ACALA-Ft. Riley, KS 12-00722-13 05/13/98 Lost Am-241 CAD Paducah GDP GDP-1 05/14/98 Criticality accident alarm system inop !

Paducah GDP GDP-1 05/15/98- Autoclave isolation during UF6 cylinder heat up Paducah GDP GDP-1 05/19/98 Criticality accident alarm system inop Army-ACALA-Germany 12-00722-13 05/13/98 Two lost Am-241 CADS j KTl Construction Services Reciprocity 04/11/98 Troxler Gauge damaged

]

Paducah GDP GDP-1 ' 05/21/98 Criticality accident alarm system inop l Paducah GDP GDP-1 05/26/98 Small UF6 release 19 x .

a.

F Date of.

Licensee Name License No. Incident Type of incident Pelton Cast Steel 48-02669-02 05/31/98 Permanent radiographic facility received > $1,000 damage Brucker Engr. Company 24-32076-01 05/29/98 Lost / stolen Humboldt scientific gauge Paducah GDP GDP-1 06/02/98 Failure of C-310 high voltage release ,

detection safety detector head '

I Paducah GDP GDP-1 06/06/98 Criticality accident alarm system inop Paducah GDP GDP-1 06/07/98 Autoclave isolation Army-ACALA-Germany 12-00722-13 06/10/98 One lost Am-241 CAD Nosag Products Corp. None 06/10/98 Steel contaminated with Co-60 Geotechnical Consultants 34-26022-01 06/13/98 Stolen & recovered CP gauge Ohio Dept. of Public Health None 06/18/98 Co-60 container found in deceased father in-law's estate Lexalite international Corp. General Lic. 06/25/96 Lost Po-210 static eliminator Paducah GDP GDP-1 06/27/98 Criticality accident alarm system inop William Beaumont Hosp. 21-01333-01 01/29/98 Potential generic implications event -

malfunction of HDR unit Paducah GDP GDP-1 07/06/98 Autoclave isciation during UF6 cylinder heat up Univ. of Wisconsin 48-09843-18 07/13/98 Medical P-32 underdose misadministration L'niv. of Wisconsin 48-09843-18 07/14/98 Missing 4.5 mCl of C-14 NTH Consultants 21-04206-01 07/20/98 Damaged moisture density gauge Allied Signal, Inc. SUB-526 07/20/98 Alert declared due to UF6 release offsite Medi-physics, Inc. 34-26239- 07/21/98 Delivery truck involved in an accident 01MD Guardian Automotive General Lic 07/06/98 Lost 2 Po 210 static eliminator guns Radarium Foundation 24-19486-01 08/10/98 Medical Co-60 teletherapy over dose Hosp. misadministration Paducah GDP GDP-1 08/10/98 Thirty pounds of chlorine gas released inside waste treatment bidg.

Army-ACALA-Ft. Stuart, GA 12-00722-13 08/17/98 Lost 2 Am-241 CADS 20

W Date of Licensee Name License No. Incident Type of incident Paducah GDP GDP-1 08/27/98 Exceeded pressure safetylimit Garden City Hospital 21-04072-01 09/01/98 Medical brachytherapy underdose misadministration Clevel'and Clinic. 34-00166-01 08/11/98 Medical Y-90 underdose misadministrations Riverside Methodist Hosp. 34-01055-01 08/12/98 Missing one 1-125 seed Portsmouth GDP GDP-2 09/06/98 Small UF6 release Army-ACALA-Toole, UT 12-00722-06 09/09/98 H-3 contamination event Army-ACALA-Picatiny, NJ 12 00722-06 09/09/98 Two aiming post lights (H-3) missing Army-ACALA-Korea 12-00722-13 09/21/98 Lost 3 Am-241 CADS Univ, of Michigan 21-00215-04 09/22/98 l-131 contamination event -  !

Combustion Engineering SNM-33 09/24/98 Site contamination event Detroit Water & Sewage 21-23397-01 09/29/98 Stolen (& returned) CPN gauge Dpt. -

Huffy Sports General Lic. 10/02/98 Missing Po 210 static eliminator r

Army-ACALA-Germany 12-00722-13 08/25/96 Missing.Am-241 CAD St. Joseph's Med. Ctr. 13-02650-02 10/06/98 Missing an 1-125 seed i Army-ACALA-Ft. Irwin, CA 12-00722-13 10/06/98 Missing an Am-241 CAD Wayne State Univ. 21-00741-08 10/06/98 Missing two Ni-63 sources U.S. Steel - Gary Works 13-26104-02 10/12/98 Damaged 2.0 Ci Am-241 thickness gauge American Engineering 22-20271-02 10/13/98 Radiography source would not fully Testing, Inc. retract due to dented guide tube Paducah GDP - GDP-1 10/15/98 incoming shipping container with external contamination Paducah GDP GDP-1 10/17/98 Exceeded pressure safety limit NTH Consultants 21-14894-01 10/19I98 Troxler gauge run over & damaged Sinal Hospital 21-00299-06 10/19/98 Medical misadministration - incorrect treatment dose 1

William Beaumont Hospital 21-01333-01 10/19/98 Medical 1-131 misadministration I underdose l

21 l

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1 Date of Licensee Name License No. Incident Type 9f incident Paducah GDP GDP-1 10/23/98 Autoclave isolation during UF6 g

cylinder feeding to cascade Paducah GDP GDP-1 11/01/98 UF6 cylinder valve failed to close NE Ohio Reg. Sewer Dist. General Lic. 10/29/98 Lost Cs 137 compensating cell l

Community Hospital 13-06009-01. 11/04/98 Missing three b125 seeds St. Joseph Health Center 24-02704-01 11/04/98 Unplanned overexposure to fetuses ,

H.C. Nutting 34-18882-01 11/13/98 Damaged Troxler gauge (run over)

Cleveland Clinic 34-00466-01 11/17/98 Source stuck during brachytherapy treatment with experi. mental after loader Paducah GDP GDP-1 11/19/98 Power lost to CAAS beacons Portsmouth GDP GDP-2 11/23/98 Autoclave leaking steam during UF6 I cylinder heat up Army-ACALA-Honolulu, HI 12-00722-06 12/01/98 Missing 1.6 Ci H-3 source l Indiana Univ. Med. Ctr. 13-02752-08 12/01/98 Medical gamma knife misadministration - wrong site Qualitech Steel Corp. 13-32086-01 08/09/98 Co 60 source damaged during molten steel spill Bothwell Reg. Health Ctr. 24-16275-02 11/12/98 Medical teletherapy misadministration Portsmouth GDP (3 ens) GDP-2 12/09/98 Fire causing loss of cellintegrity Portsmouth GDP GDP-2 12/10/98 Safety equipment failure in X-330 bldg. l Portsmouth GDP GDP-2 12/13/98 Safety equipmen+ failure in X-326 bldg.

Mid West Testing 24-24609-02 12/14/98 CPN gauge stolen from licensee Army-ACALA-Ft. Irwin 12-00722-13 12/14/98 Lost Am-241 CAD Marquette University 48-02931-06 01/06/99 Loss of a 2 uCi Am-241 source Army-ACALA-Anniston, AL 12-00722-06 G1/12/99 Shipment received with excessive surface contamination Army-ACALA-Ft. Campbell, 12-00722-06 01/21/99 H-3 contamination event KY Army-ACALA-Ft. Shafter, HI 12-00722-06 01/21/99 H-3 contamination event Army-ACALA-Korea 12-00722-13 01/07/99 Missing Am-241 CAD 22

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Date of Licenmee Name License No. Incident Type of incident Army-LOC 12-00722-07 01/19/99 Stolen LAW Detroit Macomb Hospital 21-01190-05 01/28/99 Medical misadministration i Research Medical Center ' 24-17998-02 02/05/99 Medical gamma knife underdose misadministration Army-ACALA-Kuwait 12-00722-06 02/10/99 Lost H-3 source l

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Paducah GDP GDP-1 02/17/99 UF6 cylinder received with removable i surface contamination j i

• - Identified during an inspection, subsequently reported to NRC as required.  !

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 l and when were other State /NRC licensees who might be affected notified? For States, was timely notification made to NRC? For Regions, was an appropriate and timely PN generated?

Calumet Testina Services. Inc: During a radiographic operation with an

- Amersham 660B gamma camera, the source assembly separated from the' control cable after an exposure. The source was subsequently retrieved in accordance with the licensee's procedures and NRC and the manufacturer (Amersham) were notified regarding the incident. A PN was issued.

Washinaton University School of Medicine: During an experimental clinical trial protocol approved by the FDA, the strontium-90 sources failed to retract back into the hand-held remote applicator. The . licensee's investigation into this matter indicated that the cause was probably due to a kink in the treatment catheter and excessive torque to the Touhy-Bou st valve which caused the failure to retract the sources. New procedures were developed to correct the problem. The Iicensee notified NRC, and Region ill notified the FDA. A PN was issued.

MQS: The licensee notified NRC that during a radiographic operation with an Amersham 660B gamma camera, the source assembly separated from the control cable after an exposure. The source was subsequently retrieved in accordance with the licensee's procedures and the manufacturer (Amersham) was notified regarding the incident. The licensee (MQS) filed a Part 21 report. A PN was issued.

Cancer Treatment Center: The licensee notified the NRC that the AECL Theratron 780 teletherapy unit failed to retract to the safe position after the termination of a treatment. The licensee notified the manufacturer (AECL) and they subsequently determined that the cord reel caused the cord to tangle when the source drawer attempted to return to the safe position.

The cord jammed and held the drawer in the open (exposed) position. The

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cord reel _ was replaced and the unit functioned properly. A PN was not issued because it did not meet the PN issuance criteria.

Harrison Steel Castinos Comoany: The licensee notified the NRC that while performing radiography with a AEA Technology (formerly Amersham) cobalt-60 cantera with a M/N 957 automatic exposure controller, the source failed to retract to its safe (shielded) position. The licensee notified the manufacturer anci it was subsequently found that the slide on the Posilock closed before the source was fully retracted. It was determined that the slide on the Posilo :k was not properly set before the source was cranked out to the exposed position, which was contrary to the licensee's procedures. A PN was not issued because it did not meet the PN issuance criteria.

Wisconsin Centrifuaal. Inc.: The licensee notified the NRC that during radiography with a Picker Cyclops unit, the source failed to retract into the safe (shielded) position. it was subsequently determined that the cause of the failure was due to a broken shutter spring. A PN was issued.

Cleveland Clinic Foundation: The licensee notified the NRC that during a Manual Brachytherapy Remote After loader (MBRA) treatment setup with a U.S. Surgical Corp. MBRA unit the source failed to retract to the safe (shielded) position. NMSS and FDA were notified regarding the device failure. A PN was not issued because it did not meet the PN issuance -

criteria.

Ohio State University & Veterans Administration. Iowa City: The licensee's have implemented a blind protocol using Sn-117m that could result in patient's being released from the hospital and exposing members of the patient's family to radiation doses in excess of regulatory limits. NMSS was immediately notified and coordination has occurred between NMSS, Region 111, and FDA to address the deficiencies in the protocol. Also, a list of all hospitals participating in the protocol was obtained and forwarded to all NRC Regions for followup.

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 a assessment of possible generic design deficiency? Please provide details for )

each case. ,

As noted above, in all cases the manufacturer was notified concerning each event. In addition, regarding the events at Calumet Testing and MQS (described above), special inspections were performed in Regions I and 111 and the States of Massachusetts, Louisiana and Texas. These were coordinated with NMSS, which subsequently issued NUREG-1631 describing the generic defect involving the Amersham Model 660 radiography system.

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23. In the period covered by this review, were there any cases involving possible wrongdoing that were reviewed or are presently undergoing review? If so, please describe the circumstances for each case.

[ Region lil's answer to Question #23 contains certain sensitive, predecisional information. The Region's answer to Question #23 is omitted here.]

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24. Identify any changes to your procedures for handling allegations that occurred during the period of this review.

Region ill revised Regional Procedure 0517A on March 5,1998. While the revision was extensive, it did not involve any changes to how allegations were to be inspected, but addressed such items as conduct of allegation review boards (ARBS), scheduling of ARBS, correspondence with allegers (content and frequency), review of documentation submitted by 01 or allegers, data entry into the AMS system, issuance of reports from the AMS system, etc. A copy of the revised regional procedure is attached for your use.

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.

NMSS conveyed the results of the 1997 National Program Review to Region 111 in a memorandum dated August 5,1997. As noted in that memorandum, Region lil had already provided its response to Recommendations 2,3, and 4, in its comments on the draft report, and no additional information was required as a result of the final IMPEP report.

The actions described in our comments were completed as of March 10, 1999, when a specific revision to the regions allegation procedure was issued making it explicit that no allegation material was to be placed or  ;

contained in the docket files. '

26. Provide a brief description of your program's strengths and weaknesses. These strengths and weaknesses should be supported by examples of successes, problems or difficulties which occurred during this review period.

Proaram Strenoths: Our incident response efforts have been numerous, prompt and through. Several routine inspections, i.e, Midwest Testing, Harper Hospital, University of Wisconsin-Oshkosh, DAS Consulting, Detroit i Sinal Hospital, Midwest imaging Diagnostic, Inc. and Advanced Medical Systems, have identified significant management breakdowns and/or escalated enforcement issues.

27

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in addition to completing our core programs in licensing and inspection, we have been able to balance special projects assigned from Headquarters as well as those assigned internally. Examples of projects which we have completed or are ongoing included: summer / spring inspections of l

portable gauge licensees, quarterly / semi-quarterly inspections of l broadscope university licensees, and participation in the writing of several l guidance consolidation project NUREGs. Other special projects included:

medical risk analysis, Part 35 guidance, inspection performance indicators (medical), and risk and barrier analysis for numerous programs.  ;

Self-assessments for the follow up to escalated enforcement cases and incidents indicated that Region lit has met the requirements for a six-month follow up inspection.

Region 111 initiated a trial scheduling program (1997 to present) for scheduling all core /non-core inspections, including reciprocity inspections, assist inspections and follow up inspections. This system was developed by the GG-14 Senior Health Physicists and is updated each month. Each month the inspectors meet to discuss the next months strategy and assignment of inspections to ensure that all core /non-core inspections are scheduled in a manner that is efficient and cost effective for the agency.

During this IMPEP assessment period the Region has issued se /eral escalated enforcement cases in record breaking time. As an example, Harper Hospital was issued a Severity Level 111 violation for a programmatic breakdown in its QMP within 8 days of the end of the inspection. Other examples include University of Minnesota, a Severity Level 111 violation was I issued in 37 days, and University of Wisconsin-Oshkosh, a Severity i Level ill violation associated with a management control breakdown was l issued in 42 days.

The Region has a continuous self-assessment program that over this IMPEP cycle include assessments of misadministration and medical events followup, compliance with MC 2800, i.e, extension / reduction of inspections, reciprocity inspections, non-escalated enforcement, etc.

1 The Region successfully completed development of a strong QA/QC  :

program for the fixed laboratory, including the upgrading of several assessment instruments. Management support to the laboratory was strong, and ensured continued analytica: services to the NRC were 1 maintained while the laboratory equipment was being upgraded.

I Staff experience and qualifications has been strong with very little turnover in inspection, licensing, or laboratory staff. Region lil's staff is experienced, and includes staff with M.S. and Ph.D. degrees; one certified H.P., one certified industrial hygienist, reactor experience as well as materials experience, and two former NRC section chiefs.

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Our process for issuance of licensing actions was improved with the computer assisted development and issuance of licensing actions during the last half of this IMPEP cycle. It has resulted in a significant improvement in the timeliness of issuance of licensing actions (93%

average timeliness compared to the 80% goal).

In the conduct of decommissioning activitsos, Region ill has maintained an outstanding relationship with the affected States. This included routine communications and accompaniments by State staff.

A strength of the Region 111 fuel cycle program over this period has been the ability to respond to emergent issues or events. This was best j evidenced by the Region's responses to the several material release events

{

at Allied Signal (one of which was an AIT), and the AIT response to the i Portsmouth GDP fire, in addition, special team inspections were conducted at the Portsmouth GDP regarding the nuclear criticality safety program, compliance plan issues, the catastrophic failure of the onsite steam plant, and the dropping of an empty UF6 cylinder at the Paducah GDP. Another strength has been the ability to shift resources between the GDP resident and regional-based inspectors to address emergent issues.

Region lli also supported inspections in other Regions (Rll and RIV) with reduced resources in 1998. Inspection reports were generally issued in a timely manner, identified good technical issues, and were of high technical quality. Good communications among all Fuel Cycle Branch staff has helped to identify declining performance trends between the sites.

We have developed and are implementing a structured process to ensure a coordinated transfer of licenses to facilitate Ohio's becoming an agreement state. This is done through bi-weekly phone conference calls between Region lit, Office of State Programs, NMSS, and State representatives.

l Despite downsizing of our administrative staff, we have been able to I improve the efficiency of operations such that we have maintained the same level of administrative support.

Proaram Weakness: Self-assessments conducted in the areas of report (field notes) timeliness indicated that the Division was deficient in the area of field note and report timeliness. Efforts have been implemented to improve both areas.

Efforts to bring the Region lil laboratory up to acceptable QA/QC standards has required significant management involvement and has been a labor intensive effort for a long period of time.

The overall Agency program for site and facility decommissioning continues to evolve, so there are often situations with neither prior precedent nor clearly applicable regulatory foundation. Criteria are inconsistent between decommissioned reactors and materials facilities.

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- o. o e in addition, the conventional regulator / regulated relationship does not exist for a number of contaminated sites as they are owned by parties that have not been licensed by the NRC.

Our self-assessments determined that the Region was deficient in meeting the reciprocity inspection goals specified in MC 1220. This is partially due to the extremely short notification provided by licensees prior to initiating work (usually a day or less) and inspection scheduling difficulties. For j

example, in the case of one radiographer, on two separate occasions the >

Region dispatched an inspector to the proposed location to find that the radiographer had not shown up. On both occasions, the jobs had been subsequently canceled after the NRC determined where the jobs were being performed.

Another weakness has been the addressing of complex allegations in a timely manner. In addition, the GDP resident training program needs enhancements to facilitate resident development in a more detailed fashion (similar to the program in the Division of Reactor Projects for reactor residents). l B. NON COMMON PERFORMANCE INDICATORS

1. SDMP Proaram

. 27. For each site listed in the SDMP where the Region has project management responsibility, provide the following information:

What is the status of meeting the milestones in SECY 97-2427 Describe the action plan that is in place by the responsible parties for site remediation.

Were any significant delays identified and corrective actions put in place in a timely manner?

Identify policy issues under consideration, and describe how they are being resolved in a timely manner.

NMSS is the project manager for all SDMP sites in Region !!! except Advanced Medical Systems, Inc. (see the answer to Question 28). In the case of AMS, the licensee will not actually begin any decommissioning of its active license unless the denial of its license renewal is upheld in hearing.

28. For each site listed in the SDMP where the Region does not have project management responsibility, provide the following information:

The information requested in question 27 above.

- Licensing and inspection support by the Region to the lead project office.

Milestones of SECY 97-242 are on target. Chemetron was removed from the SDMP list in February 1999, and we expect two additional projects 30

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(NEORSD and Elkem) in Region lll will be removed from the SDMP list later this FY.'

The action plans are summarized in the SDMP database.

Significant delays which necessitated corrective action by NRC were not encountered.

Region lil conducts essentially 100% of the SDMP inspection program, with NMSS project manager accompaniment in some cases. An integrated licensing and inspection planning and scheduling document is used which is available for audit. Each SDMP site is inspected at least once each year, unless NMSS and Region lli agree to an exception due to site-specific circumstances. In FY 97 the only exceptions were Clevite and Horizons, where no activities meriting inspection occurred. In FY '98 the only exceptions were Elkem and Jefferson Proving Ground, where no activities meriting inspection occurred.

11. Decommissionina

29. For each non-SDMP site where the Region has project management responsibility, provide the following information:

Status of meeting planned milestones.

Describe the action plan that is in place by the responsible parties for site remediation.

Identify any significant delays in decommissioning progress, and describe any corrective actions put in place.

Identify any policy issues associated with the site, and describe how they are being resolved.

The following summaries address non-SDMP projects in Region III, for which Region lli has project management responsibility.

Advanced Liohtina: Advanced Lighting is a current licensee in Coldwater, Michigan, which has made notification under the " timeliness rule" regarding plans to transfer activities involving licensed materials to another facility (in Ohio) in mid 1999 and has requested authorization to proceed with decontamination. The proposed activities are outside the  ;

normal scope of decontamination activities previously accomplis,hed under I the license. The proposal is under review, and the schedule is being j followed to determine an appropriate inspection activity. l Alliant Techsystems: This is a former munitions manufactory in Minneapolis, Minnesota, and a munitions testing facility in Elk River,  !

Minnesota. Both projects are under license, with an approved decommissioning plan at Elk River; however, a request has been made to l defer submittal and implementation of a proposed decommissioning plan i for the Minneapolis site,in order to consolidate decommissioning of the i radiologically contaminated portion of a major facility with the anticipated i 31 l

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i shutdown of the entire facility in about two years. The proposal in under review.

American Smeltina: This is a former foundry operation in Whiting, Indiana, for which the ORNL terminated license review project identified a lack of documentation concerning closeout. The buildings that still remain have been surveyed and no contamination found. A slag pile remains to be surveyed; it is under different ownership than the buildings and is also being regulated by the State of Indiana EPA. If significant contamination is found, slag pile remediation will be addressed jointly with the State.

Battelle Columbus Laboratories: The Battelle research facilities in West Jefferson, Ohio, are being decommissioned under contract and with primary funding by DOE. A research reactor, a spent fuel storage pool and several high-level " hot cells" are among the facilities to be demolished, issues at this site include financial assurance, overall schedule (which is strongly controlled by DOE funding levels), and the apparent need for a possession limit above NRC " formula quantities." The State of Ohio will become an Agreement State in approximately July,1999, but will not receive regulatory authority for Battelle if the possession limit is above

" formula."

BP America: This is a research and production facility in Cleveland, Ohio, where lab-scale work was performed to develop the catalytic process using depleted uranium which BP adopted at their Lima, Ohio, facility. The Cleveland facility holds an NRC license for some gauges, and has requested that this license be amended to allow continued possession of a contaminated " reactor" which is still in service for nonradioactive work and fixed materials within an electrical equipment room's walls. This request is under review.

Chevron: The Chevron company (a non-licensee) owns a building (the

" Government Dullding") at the Engelhard property in Cuyahoga Heights, Ohio. This building was contaminated by processing of uranium by the Harshaw Chemical Company, for the Manhattan Engineering District, before AEC/NRC licensing came into effect. Little progress has been made since discovery in about 1995-6 that the levels of contamination were much higher than previously believed. Funding for cleanup is being evaluated by the DOE.

Enoelhard: Engelhard (a non-licensee) owns the entire former Harshaw Chemical complex in Cuyahoga Heights, Ohio, with the exception of the Chevron /" Government" building. The property on the South side of Harvard Avenue, which constitutes a relatively small fraction of the total, has been fully surveyed and remediated as necessary. Completion of the remainder of the work will be affected by the ultimate actions to clean up the Chevron building, since the grounds immediately adjacent to the building are the responsibility of Engelhard but can not reasonably be cleaned up until after the Chevron building is cleaned up and/or removed.

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e Mallinckrodt: Mallinckrodt owns property in St. Louis, Missouri, which became contaminated by processing various types of ores. The project is under NRC license. A final decommissioning plan is pending, with issues relating to suspected onsite intermixture of materials regulated by NRC with both high-background materials (boiler ash, bricks) and with materials -

from a DOE facility located immediately adjacent to the licensee's property.

McDermots-Tech: A current NRC licensee with research facilities in Alliance, Ohio, McDermott-Tech has several former 20.302 or 20.304 burial sites. One or more of these sites may not meet reevaluation criteria associated with the " Timeliness Rule." Licensee investigations are underway, with submittals expected in the relatively near future. The original approach has been abandoned in favor of a dose-based approach, using the 25mRr.m criteria of the license terinination rule. This has caused some delay in the e saluation.

Michiaan Chemical Co/Velsicol: Michigan Chemical (now owned by Velsicol) is a former licensee which processed ores for extraction of rare earths at a plant in St. Louis, Michigan. a shallow land burial site was used for disposal of various waste products at a 3-acre site near Breckenridge, Michigan. The integrity of the burial site was found compromised during an NRC/ State of Michigan survey in late 1996, following up on a contact from a concerned local citizen through the local State Representative.

Region 111 has been working with Velsicol's Memphis Environmental Center i since early 1997 on thorough site characterization and appropriate remediation.

Shelwell Services: Shelwell is a current licensee which has requested license termination for a site in Hebron, Ohio, where a source-damage incident in 1983 resulted in widespread, low level contamination with Cs-137 in the form of micro spheres. A Commission Paper, an Environmental Assessment, and a public meeting have all been utilized in the termination process, to make notification about the results of detailed staff inspections and analyses of conditions at the site which the staff .

deems consistent with the license termination rule. The license termination is expected to be completed by about April 1,1999, pending removal of some obsolete AmBe neutron sources by DOE, and removal of a small volume of contaminated soil.

30. Identify all licensees that initiated decommissioning during the review period (do not include those licensees that were terminated during the review period, as DWM will use the LTS to compile this information).

The only two sites that initiated decommissioning during the review period are Advanced Lighting and McDermott Technology. Both of these sites are discussed in the answer to question 29 above.

31. List the decommissioning inspections that were carried out during the review period. Please indicate if the inspection schedules required by Manual Chapter 2602 were prepared for licensed facilities undergoing decommissioning 33

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and if this schedule was developed, indicate inspections that are overdue by

'[' more than 25% of the inspection due date. Indicate which inspections revealed that licensees were not conducting their decommissioning in accordance with the i approved decommissioning plan and describe how these projects were  ;

managed.

j Materials decommissioning inspections are scheduled and conducted considering several factors. For SDMP projects, the integrated licensing and inspection plan schedules for decommissioning projects is used. For {

non-SDMP projects, contacts with the licensee to determine scheduled activities serve to identify the most risk-informed timing for inspection. {

1 The reactor inspections are scheduled according to a Master inspection 1

- Plan (MlP) for each facility, which is developed pursuant to the governing Manual Chapter, MC 2561.

No inspections were more than 25 percent overdue, in rare cases involving SDMP facilities, the normal, once-per year inspection scher'ule was extended with the concurrence of the program office due to i considerations involving schedule or lack of activity.

In the Summer of 1997, violations of the approved decommissioning plan requirements were identified at the BP Chemical facility in Lima, Ohio.  ;

These related to failure to fully implement details of practices specified in i the QA/QC program, which was incorporated in the license by reference.

Although the noncompliances ultimately proved primarily administrative in nature, they were sufficiently numerous and varied that Region 111, working j closely with NMSS, determined the quality of information to demonstrate  !

compliance was inadequate and placed ultimate approval of the removal of the project from the SDMP list at risk. Region lli and NMSS confronted the licensee with a Confirmatory Action Letter (CAL), a management meeting,  ;

and enforcement. There was a temporary shut down of the project  ;

(construction of a waste cell) on two occasions while both the level of control of activities and the level of detail in the QA/QC plan were normalized to each other.

Materials decommissioning inspections conducted during the review period were as follows:

SDMP Sites Advanced Medical Systems, Inc., Cleveland, OH = 6/1011/97; 2/25-26/99 BP Chemical, Lima, OH = 7/21-23/97; 11/12-13/97; 4/1/98; 7/15-16/98 Brooks & Perkins/AAR Manufacturing, Livonia & Detroit, M1 = 5/15/97; 8/13/98 Chemetron, Newburgh Heights, OH = 3/31-4/4/97; 7/14-17/97; 8/4-7/97; 8/11-12/97; 3/23/98; 5/8-9/98 (with mobile lab); 7/6-10/28/98 34

, . o SDMP Sites Clevite Corporation, Cleveland, OH = Exempt FY 97; 1/14-15/98; 2/23-3/6/98; ;

5/14/98 (final closeout)

Dow Chemical, Midland and Bay City, MI = 5/12-14/97; 7/23-25/97; 10/28-29/97; 9/28-30/98;12/8-9/98 l Elkem Metals, Inc., Marietta, OH = 8/21-22/97; Exempt FY 98; 10/14-15/98 Hartley & Hartley = 9/25/97; 8/98 Jefferson Proving Ground, Madison, IN = 8/28-29/97; Exempt FY 98 Lake City Army Ammunition Plant, independence, MO = 1/8/97; 5/11-12/98; 7/21-22/98; 11/18-19/98;1/13/99;1/19/99 Lamotite (Horizons Inc.), Cleveland, OH = Exempt FY 97; 9/98 3M, Pine City, MN = 8/1/97; 9/23/98 Northeast Ohio Regional Sewer District, (NEORSD), Southerly, Cleveland, OH = 4/3-4/97; 4/8/97; 7/1r/97; 3/4/98; 7/7/98 RMI Titanium Company, Ashtabula, OH = 9/29-10/1/97; 1/14-16/98; 2/4/98; 7/98 Shieldalloy Metallurgical Corporation, Cambridge, OH = 8/21/97; 5/1/98; 8/20/98; 9/21/98 ,

Non SDMP Contaminated Sites

. Alliant Techsystems, Inc. = 5/7-8/97 (MN); 7/29-8/1/97(MN); 7/8/97(IL); i 9/24-11/6/98(IL)

American Metal Products = 4/12/98 American Smetting = 1/13-14/99 Armour Research = 3/31/98 (Gary)*; 4/30/98 (LaPorte)* (ORNL - closed, both sites)

Battelle Memorial Institute = 8/25-27/97; 4/8-10/98; 11/16-18/98 Bayer Corporation = 2/11-12/98 4 B P America = 11/20/98 Engelhard = 7/16/97; 8/5/97; 10/20-21/97; 12/18-19/97 (building closeout);

3/4/98 -

Ethyl Corporation = 9/98 (ORNL - pending)

Fermi 1 Nuclear Power Plant = 7/10-11/97 General Electric, Tungsten Products = 5/13/98 (final closeout) '

McDermott Technologies = 9/1/98 Merril Pharmaceutical = 9/21-22/98 Mose Cohen & Sons = 9/26/98 (ORNL - closed)**

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. Non-SDMP Contaminated Sites Roof Consultants = 11/20/97 l

Schering Plough = 8/5-20/98 Shelwell Services = 4/29-5/1/97 l

St. Eloi Corporation = 9/23/98 (ORNL - pending)*

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! Wellman Bronze & Aluminum = 8/13/98 (ORNL - closed)*

- residual contamination identified, licensed.

" residual contamination identified, NORM.

32. Identify all licenses (both terminated and otherwise) that have received in-process inspections of licensees' final survey programs and confirmatorv surveys, in accordance with IP 87104 and IP 88104, during the review period.

Describe the inspection activities covered during inspections of these licensees.

in-process inspections of final surveys were conducted as listed below.

The inspection report listed contains the description of the inspection activities and is available for audit upon request.

Facilitv/ Licensee Report Number Note (s)

Dow Chemical Co. 040-00017/97001(DNMS Selected areas TRW - Port Clinton, OH 040-07855/97001(DNMS) ORNL Closeout

• Phamacia Adria 030-13645/97001(DNMS) ORNL closeout Red Wing Pottery 040-03616/97001(DNMS) ORNL closeout 3M (three sites) 070-00228/97001(DNMS) ORNL closeout AVCO/Sanyo C40-06304/97001(DNMS) ORNL closeout" AutoJumble Letter to RIV dated 9/22/97 RIV assist Ajax Magnathermic 040-02894/97001(DNMS) ORNL closeout Peskin Sign 040-02894/98002(DNMS) ORNL closeout UCAR (National Carbon) 040-02692/97001(DNMS) ORNL closeout Hoechst Marion Roessel 030-05696/97001(DNMS) Lic. term.

Battelle Columbus Labs 070-00008/97001(DNMS) Selected building (s)

Dow Chemical Company 040-00017/97003(DNMS) Selected area (s)

Bayer Corp. 030-05089/98001(DNMS) License termination American Metal Products 040-04554/98001(DNMS) ORNL closeout l and letter dated 1/7/99 '

Armour Research 040-01007/98001(DNMS) ORNL closeout  !

G E Tungsten Products 040-00534/98002(DNMS) Final closeout Chemetron 040 08724/98001(DNMS) Cell construction &

closeout Clevite 070-00133/98001,02,03(DNMS) Final Closeout B P Chemicals 040-07604/98002(DNMS) Selected area Schering Plough 030-07609/D8001(DNMS) Lic. term.

Wellman Bronze & Alum 040-01790/98001(DNMS) ORNL closeout

}

St. Elol Corp. 040-02371/98001(DNMS) ORNL closeout y

040-02275/98001(DNMS) l Mose Cohen & Sons 040-08081/98001(DNMS) ORNL closeout Ethyl Corporation 030-90032/98001(DNMS) ORNL closeout 36 L

Facilitv/ Licensee Report Number Note (s)

Dow Chemicals 040-00017/98002(DNMS) Selected area (s)

Alliant Techsystems 040-08830/98001(DNMS) Elk River area closeout Elkem Metals 040-07208/98001(DNMS) Final Closeout Battelle Columbus Labs 070-00008/98002(DNMS) Selected building American Smelting 040-06653/98001(DNMS) Buildings only

- residual contamination identified - licensed

- residual contamination identified - NORM The items designated "ORNL closeout" are reports of inspection of former licensee facilities identified in the ORNL review of terminated license files as lacking documented closeout details.

33. List all appropriate staff who have not yet met the qualification requirements of Decommissioning Inspector as identified in Manual Chapter 1246. List the courses or equivalent training / experience they need to attend and a tentative schedule for completing these requirements.

All decommissioning inspection staff have met the qualification requirements of MC 1246.

34. Identify by name, license number and type all licensees with outstanding decommissioning financial assurance (DFA) reviews. Describe the outstanding issue and the plans to resolve the issue.

Dow Chemical Company 00265-06, research and development type A broadscope. Deficiencies in the licensee's latest response were provided back to the licensee by letter dated January 6,1999. We are awaiting a l

response from the licensee to address those deficiencies.

Battelle MemorialInstitute -license number SNM 7 and the new ipplication (will be license number 34-26608-01 if issued prior to Ohio becc.aing an '

Agreement State), currently licensed for everything (source material, special nuclear material in critical mass quantities, industrial measuring {

equipment, hot cell operations, and research and development type A  !

broadscope). DWM has determined that the licensee's methodology for establishing DFA was unacceptable. In a conference call with the licensee on February 18,1999, the licensee was provided with a description of the defleiencies and NRC's options regarding its renewal application and initial application for a broadscope license given that the licensee has no current  ;

viable financial assurance instruments for either.

Frontier Technology Corporation - license number SNM-1957, manufacturing and distribution type B broadscope. Deficiencies were provided to the licensee on August 13,1998. The licensee has been contacted on several occasions to provide its response, the most recent 37

E . .

4 being January 20,1999. We are still awaiting the licensee's response to the deficiencies.

Qual-X incorporated -license number 34-16907-02, manufacturing and distribution non-broadscope. Deficiencies were provided to the licensee on October 22,1998. The licensee was subsequently contacted to provide its response on January 20,1999. We are still awaiting the licensee's response to the deficiencies.

Quanterra - license number 24-24817-01, other service license. Deficiencies were provided to the licensee on October 1,1998. The licensee was subsequently contacted to provide its response on January 20,1999. We are still awaiting the licensee's response to the deficiencies.

35. Describe the existing status of Region I!!'s analytical laboratory and mobile laboratory. Provide data on types of uses, types and amounts of analytical procedures performed, performance t~esting program, staffing, and capacity utilitization history during the reporting period.

Mobile laboratory: The mobile laboratory was utilized in the field on two occasions: in May 1997 to conduct immediate analyses of samples of soil  ;

and water collected at Shelwell Services Inc., in Hebron, Ohio, where l characterization and in-process remediation were being conducted on a I site contaminated with many micro-spheres of Cs-137. The other use was an extended, in-process analytical assignment at the Chemetron Bert ,

Avenue disposal site in Newburgh Heights, Ohio. About 200 samples were 1 analyzed as the disposal cell was built, to promptly confirm acceptability of disposed material. The mobile laboratory was in place in the field for about three months (summer of 1998) to conduct this assignment.  ;

i The analytical equipment in the mobile laboratory includes a 50 percent efficient germanium detector, which is superior to the nominal 17 percent efficient detector which served the fixed laboratory until November 1998.

For a substantial portion of the time when the mobile laboratory was not in use, the detector system was moved into the fixed laboratcry and used as a backup there. '

The mobile laboratory was taken out of service in late 1998 for periodic maintenance on the detector by the vendor. The detector needs more repair that contemplated and remains with the vendor. When the work is complete, the detector will be returned to service with new computer hardware and software procured in late 1998 with the new fixed lab equipment.

Fixed Laboratory: The fifed laboratory operated under a set of Region I procedures, informally implernented, until the laboratory was removed from service in September,1998, for installation of newly-procured, upgraded gamma spectroscopic equipment and to complete many enhancements and corrective actions identified as needed to ensure complete implementation of the NMSS Quality Assurance Plan. This 38

i temporary shut down was consistent with a recommendation contained in a report of assessment from an " assist visit" at the end of August,1998, by staff from the Radiological Environmental Sciences Laboratory (RESL).

The sheer number and variety of action items identified (about 180) lent itself to use of a GANTT chart approach for monitoring progress and completion of actions. Weekly meetings were held to brief DNMS l management in Region ill and NMSS was kept informed via weekly transmittal of the current GAN'IT chart to a contact person and periodic telephone briefings.

Detailed tracking of the number of analyses performed in the Region ill lab is not readily available for the period of interest in FY 1997. From the l

beginning of FY 1998 to date, the fixed lab received an average of about 100 samples per month, for a total of approximately 1,530 samples. Nearly all of the analyses performed by the Region ill lab were either soil (586 samples) or smears (796 samples). In addition, ORISE analyzed 133 samples on behalf of Region ill during late 1998 when the laboratory was temporarily out of service. Details are contained in Quarterly

! laboratory reports, which are avai:able for audit.

4 One of the Region 111 performance " metrics" for Fiscal Year 1998 was 100%

successful performance on laboratory intercomparison samples. The I laboratory met this target. In at least one case, however, results were not reported timely from the Region lit lab. This was addressed by initiating a requirement that all subsequent intercomparison samples be tracked as to timeliness in the DNMS Action item Tracking System.

36, Describe the measures taken by the Region during the reporting period to improve the capabilities of the Rill analyticallaboratory. Describe any considerations still to be resolved.

All aspects of laboratory capability have been improved, including quantity and quality of management oversight, counting hardware and software, staff training, procedures, etc. These actions ensured proper ,

implernentation of the NMSS QA Manual for the Region 111 labs. Details of most actions taken are contained in files maintained by the Health Physics Manager (HPM); a summary is represented in the GANTT chart mentioned in item 35 above. Both sets of records are available for audit.

37. Describe Rill's plans for operation of the laboratory for the next 2-4 years.

Computer hardware and software upgrades are planned in the immediate future for the liquid scintillation and proportional counting systems, to I meet Y2K considerations and to improve speed and compatibility with the  !

Windows NT standard used throughout the NRC for reports, e-mail, etc.

Staffing will continue to be dedicated at a level of about 1.7 FTE each year, with one person dedicated full time, HPM oversight about half-time, and backup analysts for the remainder. Staff training will be a focus, to 39 l

j Improve capability and to ensure familiarity with developments in the specialized field of radio analysis.

\

A " customer service" philosophy, with the inspectors and inspection programs in both Regions til and IV being the customers, will remain a priority. Requested analyses will be promptly completed and documented

{

in clear, accurate terms in a format useful in the preparation of inspection reports. {

)

No major hardware purchases are contemplated in the next 2 - 4 years. We will evaluate whether the mobile lab will be replaced. {

111. Fuel Cvele inspection Proaram Status of Insoection Proaram

38. List in chronological order the fuel cycle inspections (or assessments, in the case of non-licensee facilities) performed during the reporting period by facility and type (i.e., U= unannounced routine inspections, R := reactive inspections, D = decommissioning inspections, etc.). Please include the inspection procedure number (e.g., IP 88020). A sample format is shown below.

JR Licenseg Number Dates Tvoe ABB-CE 97001 2/3 - 2/7/97 Routine Regional ABB-CE 97002 4/14 - 4/18/97 Routine Regional ABB-CE 97003 8/4 - 8/8/97 Routino Regional ABB-CE 97004 12/1 -12/5/97 Routine Regional ABB-CE 98001 4/6 - 4/9/98 Routine Regional ABB-CE 98002 5/12 - 5/13/98 Routine Regional (Security]

ABB-CE 98003 7/13 - 7/17/98 Routine Regional ABB-CE 98004 9/14 - 9/18/98 Routine Regional ABB-CE 98005 11/2 -11/6/98 Routine Regional AlliedSignal 96007 12/16/96- ReactiveSpecial 1/10/97 4 ~

AlliedSignal 97001 01/06 - Routine Regional 01/10/97 AlliedSignal 97002 06/23 - Routine Regional 06/27/97 40

l' 4

l

\

l

@ I Licensee Number Dates Tvoe AlliedSignal 98001 ' 01/06 - Routine Regional 01/23/98 AlliedSignal 98002 01/28 - Reactive Special [AIT]

02/06/98

)

AlliedSignal 98003 03/02 - Routine Regional [AIT 03/06/98 F/U]

AlliedSignal 98004 05/27 - Routine Regional 05/28/98 AlliedSignal 98005 07/21/98 & Reactive & Routine 08/31 - Regionalinters Md {

09/03/98 AlliedSignal 98006 11/30-12/4/98 Routine Regional [EP]

AlliedSignal 99001 02/16 - Routine Regional 02/19/99 Paducah 97002 3/3 - 4/21/97 Routine Resident Paducah 97003 4/22 - 6/2/97 Routine Resident Paducah 97004 6/3 - 7/14/97 Routine Resident &

Regional Paducah 97005 5/5-5/9/97 Routine Security  !

w/DFS  !

Paducah 97007 7/15-9/12/97 Routine Resident &

Regional Paducah 97008 8/26-10/7/97 Routine Resident &  !

Regional i Paducah 97009 9/8- 9/12/97 Routine Regional [QA]

Paducah 97010 9/19/97- Special(Cylinder 2/16/98 Drop]

Paducah 97011 10/8 -11/4/97 Routine Resident &

Regional Paducah 97012 10/6-10/10/97 Routine Regional Paducah 97014 11/25/97 - Routine Resident 1/20/98 Paducah 98002 1/20 - 30/98 Routine Regional 41

I 18 Licensee Number Dates Tvoe Paducah 98003 1/20 - 03/9/98 l Routine Resident l

Paducah 98004 02/23 - Routine Regional 02/27/98 [DFS]

Paducah 98005 02/23 - Routine Regional 02/27/98

Paducah 98006 03/10 - Routine Resident 04/20/98 Paducah 98007 03/16- Routine Regional 03/20/98 Paducah 98008 03/31 -

Routine Regional [EP]

1 04/02/98 Paducah 98009 04/20 - 06/98 Routine Resident Paducah 98010 05/18 - 22/98 Routine Regional Paducah 98011 06/09 - Routine Resident 07/20/98 4

Paducah 98012 06/22 - Routine Regional I 06/26/98 l Paducah 98013 07/21 - Routine Resident i 09/01/98 Paducah 98014 08/03 - Routine Regional 08/07/98 Paducah 98015- 09/08 -- Routine Regional l

09/11/98 Paducah 98016 09/02 - Routine Resident 10/14/98 Paducah 98017 10/15- Routine Resident I

11/30/98 Paducah 98018 11/30/98 - Routine Resident & l 1/12/99 Regional Paducah 99002 1/25 - 1/29/98 Routine Regional l Portsmouth 97002 3/3 - 4/06/97 Routine Resident Portsmouth 97003 4/7 - 5/18/97 Routine Resident &

Regional 42 LL

a 18 Licensee Number Dates Tvoe Portsmouth 97004 5/19- 6/29/97 Routine Resident Portsmouth 97005 6/30-8/10/97. Routine Resident &

Regional Portsmouth 97006 9/2 - 9/5/97 Routine Regional

[DFS]

Portsmouth 97007 7/29 - 8/1/97 Reactive Special

[ Steam]

Portsmouth 97008 8/11 - 9/21/97 Routine Resident Portsmouth 97009 9/11 - 9/13/97 Routine Regional [EP]

Portsmouth 97010 9/22-11/2/97 Routine Resident &

Regional l Portsmouth 97011 11/3-11/7/97 Routine Regional Portsmouth 97012 11/3-12/14/97 Routine Resident 1 Portsmouth 97013 12/8/97 - Reactive Special[NCS) 1/9/98 Portsmouth

)

97015 12/15/97- Routine Resident I 1/25/98 Portsmouth 98002 1/6 - 1/16/98 Routine Regional Portsmouth 98003 1/26 - 3/8/98 Routine Resident Portsmouth 98004 3/2 - 3/6/98 Routine Regional Portsmouth 98005- 3/9 - 5/8/98 Routine Resident &

i Regional -

1 Portsmouth 98007 4/20 - 6/8/98 Routine Resident Portsmouth 98008 4/27 - 5/8/98 Routine Regional Portsmouth 98009 6/8 - 11/98 Routine Regional (Security)

Portsmouth 98010 6/1 - 6/5/98 Routine Regional Portsmouth 98011 6/8 - 7/20/98 Routine Resident Portsmouth' 98012 7/27 - 7/31/98 Routine Regional Portsmouth 98013 7/20-8/30/98 Routine Resident 43 J

y

]

=

Licensee s

Number Dates Type Portsmouth 98014 8/31 - 9/4/98 Special[ Compliance Plan)

Portsmouth 98015 8/31 - 10/13/98 Routine Resident Portsmouth 98016 _10/19 - Routine Regional 10/23/98 Portsmouth 98017- .10/13 - Routine Resident 11/23/98 i i

Portsmouth 98018 11/23 -1/12/99 Routine Resident Portsmouth 98019 12/9/98 - Reactive Special[AIT l 1/8/99 Fire] 1 l

INSPECTION PROCEDURE BY REPORT NUMBER FOR 1997-1999 i

[ Requirements Dictated in MC2600 (Fuel Facilities) & MC2630 (GDPs i l COMBUSTION *

        , PROCEDURE         FREQUENCY       ALLIEDSIGNAL      ENGINEERING
                                                                                                            )

PADUCAH PORTSMOUTH 1

             '88100            MONTHLY             MA               N/A         97002 97003    97002 97003 GDP Operations                                                                                     3 97004 97007    97004 97005  '

97008 97011 97008 97010 98003 98006 97012 97015 98009 98011 98003 98005 98013 98014 98007 98011 98018 98017 98013 98015 l

                                                                                   -98018      98017 98018 88101-          ANNUAL             N/A               N/A         97002 97003    97003 97004 GDP.                                                            97004 97007 Configuration                                                                        97006 97010 98013 98014    97012 97015 Control 98003 98007 98011 98013 98015 98017 98018 88102            ANNUAL             N/A               N/A         97002 97003    97002 97003 GDP                                                              97004 97007    97004 97005 Surveillances                                                         97008 97011    97008 97010  ,

98003 98006 97015 98005 98009 98011 98011 98013 98013 98016 98015 98017 88103 ANNUAL N/A N/A 97002 97003 97003 97004 GDP 97004 97007 97005 97006 Maintenance 97008 97011 97010 98003 98003 98017 98011 98013 98018 98015 98018 44 w

cc s a . . COMBUSTION PROCEDURE FREQUENCY ALLIEDSIGNAL ENGINEERING PADUCAH PORTSMOUTH

                 '88105          ANNUAL            N/A GDP Mgmt. Org.                                         N/A         97002 97003       97002 97002
                 & Cntrl.                                                    97004 97007       97008 97010 97008 97011 98003 T12600/003       SEMIANNUAL'    97001 97002    97001 97002     97012 98002 FF Operations                                                                       97011 98012 98001 98002    97003 97004-    98012 98018 Safety Review 98003 98004    98001 98003-98016      'l 98005 98006    98004 98005 1

88005 ANNUAL 97001 98004 FF Mgmt. Org. 97001 97002 97010 98005 97011 98002 98004 98005 98006 97003 97004 and Controls 98005 98006 98010 98001 98003 98012 98004 98005 ' 88010 ANNUAL 97001 97002 97001 97002 97009 97010 Operator 97007 97011 98002 98004 98005 97003 98001 97012 98002 Training & 98004 98005 98008 98006 98004 98005 98005 98007 Retraining 98012 98016 98010 98012 98015 88020 ANNUAL N/A Regional 97001 97002 97002 97003 97002 97003 97004 97003 97004 97004 97010 97007 97010 Criticality Safety 98001 98003 97012 98002 97011 97012 97013 98004 98005 98018 97015 98003 98012 98016 88025 ANNUAL 97001 98003 97001 97002 97012 98002 97007 97008 97011 FF Maint. and 98004 98005 97003 97004 98005 98010 98002 98004 98005 Surveillance 98006 98004 98005 98012 98015 98008 98010 98012 Testing 98014 98018 98016 83822 SEMIANNUAL 97001 97002 97001 97002 97008 98012 97005 97010 98002 Radiation 98003 98005 97004 98003 98015 98018 98008 Protection 98006 98004 88035 & 84850 ANNUAL 97001 98003 97001 97004 97007 97008 97003 97005 98002 Red. Weste 9800$ 98006 98003 98004 .' 1010 98015 98008 Mgmt. & Weste Generator Req. . 88045 ANNUAL 97001 97002 97002 98001 97007 98010 97003 97005 98002 Environmental 98001 Protection 98008 88050 . ANNUAL 98002 98003 97002 98003 97004 98008 97008 97009 97010 Emergency 98005 98006 Preparedntss 98012 99002 97015 98010 86740 ANNUAL 97001 98001 97001 98005 97002 98005 97008 98004 Rad. Material 98003 98005 Transportation 81401 ANNUAL N/A 98002 97005 97008 97006 98009 Security Plans i 98004 i ANNUAL N/A 98002 97005 97008 Rp 97006 98009 Safeguard Event 45

1 I COMBUSTION PROCEDURE FREQUENCY _ALLIEDSIGNAL ENGINEER.NG PADUCAH PORTSMOUTH 81431 ANNUAL N/A 98002 97005 97008 t PP of Low SNM 97006 98009 t 98004 81820 AS NEEDED N/A Phys. & Ntnl. N/A 97005 98004 97006 Security Protection i 92702 AS NEEDED 97001 98004 97004 98001 97004 97007 97004 97012 98007 F/U on Vios. 98005 98006 98003 98005 97008 97011 98009 98010 98011 97014 98002 98012 98015 98016 98003 98004 98017 98006 98009 98010 98011 98015 90712 AS NEEDED N/A N/A 97002 97003 97003 97004 Inoffice Review of Events 97004 97007 97008 97012 97008 97011 97015 98007 97014 98003 98011 98013 98006 98009 98015 98017 98011 98016 98018 98017 98018 92703 AS NEEDED N/A N/A 97002 97003 N/A Confirmatory Action Letters 40500 AS NEEDED N/A N/A 97009 96014 Self-Assessment 35701 AS NEEDED N/A N/A 97009 97010 N/A Quality 98002 ' Assurance 3 Program Rev. 1

39. Please identify any individual licensees with planned inspection frequencies different from the normal frequencies listed in Table 1 of the Appendix to inspection Manual Chapter 2600, and indicate the inspection p ocedure(s) so affected.

Planned inspection frequencies were documented and approved by both regional and headquarters management on the Master inspection Plan. The minimum inspection frequency for the various inspection procedures has been met for all facilities in the Region tilinspection program. The only deviation is that in several instances the Region 111 fuel cycle inspection goals were exceeded as a direct result of the Region's response to events and emergent issues. The following table is a list of the reactive /special inspections conducted which were not planned on the MlP and those inspections which had a significant change in the content of the inspection (as defined in the MIP) due to emergent issues: 46

l l  ! t l . i 18 1ig?nsee Number _ Dates . Description AlliedSignal 96007 12/16/96- SpecialInspection conducted due to 1/10/97 declaration of an ALERT on 12/16/96 Portsmouth 97007 7/29 - 8/1/97 Special inspection regarding the loss of onsite steam supply Paducah 97010 9/19/97 - Special inspection conducted due to the 2/16/98 dropping of an empty UF, cylinder Portsmouth 97013 12/8/97 -1/9/98 Specialinspection of the nuclear criticality ( safety program initiated because of { extensive issues with NCS program l AlliedSignal 98002 01/28 - 02/06/98 Reactive AITinspection due to the declaration of an ALERT and injury of three onsite personnel Paducah 98005 02/23 - 02/27/98 Routine inspection, however content was changed to all t.aining due to recent training issues AlliedSignal 98005 07/21/98 & Reactive inspection conducted due to the 08/31 - 09/03/98 declaration of an ALERT Portsmouth 98014 8/31 - 9/4/98 Specialinspection of the implementation _ and completion of the Compliance Plan Portsmouth 98019 12/9/98 - 1/8/99 Reactive AITinspection due to fire in the I purge cascade and subsequent breach of containment systems Technical Ouality of Insoections

40.  !

With reference to the inspections described in item 1 above, please indicate the supervisory accompaniments made during the review period, and by whom.  ! Also, briefly describe the way the accompaniments were conducted and documented. 1 l Inspector . Supervisor Licensee Date O'Brien/Jacobson G. Shear  ! Paducah GDP 1/8-10/97  ! ! Cox/Hartland G. Shear Portsmouth l 1/20-22/97 O'Brien/Jacobson G. Shear Paducah 2/10-12/97 O'Brien/Jacobson P. Hiland Paducah GDP 6/11 & 13/97 < Jacobson/Reidinger P. Hiland AlliedSignal 6/12/97 Cox/Hartland P. Hiland Portsmouth GDP 6/16-17/97 O'Brien/Jacobson P. Hiland Paducah GDP 7/21-25/97 Cox/Hartland/ P. Hiland Portsmouth GDP 7/31-8/1/97

Reidinger/Blanchard 47

                                                                                                      ]

InsDeClor SuDervisor Licensee Date I hartland P. Hiland Portsmouth GDP 8/25-27/97 O'Brien/Jacobson P. Hiland Paducah GDP 12/4/97 i Jacobson P. Hiland AlliedSignal 12/5/97 O'Brien/Krsek P. Hiland Portsmouth GDP 12/11 12/97 Hartland P. Hiland Portsmouth GDP 12/15-17/97 Jacobson P. Hiland AlliedSignal 1/28-30/98 Jacobson P. Hiland Paducah GDP 2/5/98 Jacobson P. Hiland AlliedSignal 2/6/98 Hartland P. Hiland Portsmouth GDP 3/11-14/98 Hartland/Krsek P. Hiland Portsmouth GDP 4/8-9/98 ] Hartland/Krsek P. Hiland Portsmouth GDP 4/20-22/98 j Haitland t P. Hiland Portsmouth GDP 6/1-5/98 Hartland/Blanchard P. Hiland Portsmouth GDP 7/6-10/98 Hartland/Blanchard P. Hiland Portsmouth GDP 11/2-3/98 Jacobson j K. O'Brien (Acting) Paducah GDP 11/2-6/98 Jacobson/Blanchard T. Reidinger (Acting) AlliedSignal 11/30-12/14/98 Hartland/Blanchard K. O'Brien (Acting) Portsmouth GDP 12/7-11/98 Hartland/Blanchard K. O'Brien (Acting) Portsmouth GDP 1/6-7/99 ' Hartland/Blanchard/ P. Hiland Portsmouth GDP 2/5/99 O'Brien [AIT Exit] Supervisory accompaniments of inspectors were conducted through direct field observations of onsite inspection activities and through directly observing inspectors' communications with licensees and certificatees. Accompaniments were routinely scheduled to coincide with inspection exit meeting. Documentation of some supervisory accompaniments is contained in the associated inspection report's " contact list." in addition, the Division tracks supervisory accompaniments monthly using the Management information Statistics Report (MISRE) in the section entitled " Branch Chief Site Visits." Results of inspector accompaniments are routinely discussed with Division management during the monthly " Branch Update Meeting." Technical Staffino and Trainino 41, Please list the professional (technical) personnel assigned to perform inspections in the fuel cycle facilides inspection program, and the fractional amount of person-years of effort to which they are normally committed in the program. Also, include the general inspection areas of responsibility (e.g., E= environmental protection, N= nuclear criticality, O= operations, P= physical security, R= radiation protection, T= other). For those who joined the program since the last review, and any others who have not yet met the qualification requirements of fuel cycle facility inspectron staff, please indicate when they joined the staff, the degrees they received, the years of experience in the general areas they inspect (e.g., health physics, engineering, etc.), and the extent to which they are qualified as NRC inspectors. A sample format is shown below. 48

I. . .. . Name Qualification . Levelof Effort insoection Area (s) Courtney Blanchard' Fuel Cycle Safety 100% E,N,0,R,T David Hartland Resident inspector 100 % E,N,0,R,T John Jacobson Fuel Cycle Safety /R 100 % E,N,0,R,T Jim Kniceley Physical Protection 80% P,T Rob Krsek ' Fuel Cycle Safety 100 % E,N,0,R,T . Ken O'Brien

                                                       ~

SRl/Ri 100 % E,N,0,R,T Tim Reidinger Senior Fuel Cycle Safety 100 % E,N,0,R,T [E= Environmental Protection, N= Nuclear Criticality Safety, O= Operations, P= Physical Security, R= Radiation Protection, T=Other; RI = Resident inspector, SRI = Senior Resident inspector] Since the last review, the following individuals in the Fuel Cycle Branch have assumed new positions and have not yet met the current position's training qualification requirements: l Courtney Blanchard: Mr. Blanchard joined the fuel cycle staff in October 1996 and has a B.S. In Mechanical Engineering, certification as a Professional Engineer (PE), and 17 years of work experience from a Naval Shipyard. Mr. Blanchard was qualified as a Fuel Cycle Safety inspector in September 1997. In 1998 Mr. Blanchard was selected to fill the vacated resident inspector position at the Portsmouth GDP. Mr. Blanchard reported on site in July 1998 and has completed about 30 percent of the training requirements for certification as a resident inspector. Training includes system walkdowns, review of applicable SAR, TSR, and NRC requirements, and cral discussions with the Portsmouth SRI. Below is Mr. Blanchard's schedule for completion of his resident inspector training: Activity Completion Activity Completion Date Date Liquid Cylinder- 2/99 Cranes and Scales 5/99 Operations Feed / Transfer 3/99 Plant Utilities 7/99 Stations Uranium Recovery 3/99 TSR Admin. Controls 8/99 Ops. CAAS Operation 4/99 Site Emergency Plan 8/99 UF, Leak Detection 4/99 G.L 91-18 /10 CFR 9/99 76.68 Fire Protection 5/99 Final Qualification 10/99 Systems ' 49 L

i- - ' ' David Hartland: Mr. Hartland joined the fuel cycle staff in August 1996 and has a B.S. in Nuclear Engineering, a Masters Degree in Business Administration, and 15 years related work experience. Mr. Hartland is a qualified resident inspector for both reactor plants and the gaseous diffusion plants. Mr. Hartland was selected for the vacated senior resident inspector at the Portsmouth GDP in November 1997 and has completed approximately 98% of the requirements toward full qualification as a senior resident inspector. Below is a tentative schedule for the completion of Mr. Hartland's qualifications as a senior resident inspector. Completion Completion Activity Date Activity Date Personal Management 5/99 EEO Information for Course Date Practices (Req'd Mgrs. & Supvs. TBD Course) (Req'd Course) 42. Please identify any professional or technical staff who left the fuel facility inspection program during the review pericd, and if possible, describe the reasons for their departures. In August 1997, Charles Cox was selected to fill a position as a mechanical engineer, in the Special Projects Branch, NMSS/FCSS at NRC Headquarters, in January 1999, Rob Krsek was selected to fill the position of Resident inspector at the Palisades Nuclear Power Plant, Division of Reactor Projects, Region 111. Mr. Krsek will report to Palisades in approximately May 1999.

43. Describe what plans and procedures are in place to assure full coverage of the specified fuel cycle inspection procedures, as specified in inspection Manual Chapter 2600, in view of the possible impacts of retirements and other tumover on a small inspection staff. Also, please describe the extent to which current fuel cycle inspection program goals have been achieved, and the reasons for any differences between the goals and the actualimplementation of your program as the result of such personnelissues.

Manual Chapter 2600 is reviewed prior to the development of the MlP to assure that all inspection modules are addressed as required. The MIP, developed each fiscal year, is the primary tool to assure full implementation of the fuel cycle inspection procedures. The MIP provides the inspection procedures to be used by each assigned inspector during a planned inspection. Additionally, the branch maintains a calender which tracks personnel planning and scheduling. Regardl7g personnel turnover, succession planning within the Fuel Cycle Branch has included qualification as a fuel cycle inspector with subsequent assignment as a Gaseous Diffusion Plant (GDP) resident. Both of the Fuel Cycle Senior Residents were also previously qualified as reactor resident inspectors. The net result is that the branch has a diverse and experienced inspection staff. The last two open fuel cycle inspection 50

-, c I positions were filled from candidates within the branch. During the time positions were vacated, required inspections were conducted by qualified staff, i.e., both GDP residents are qualified to perform routine inspections at all fuel facilities. Tumover of Fuel Cycle staff is anticipated to remain at manageable levels, and any vacancy will be filled in accordance with the . Region til personnel guidelines. Regarding the frequency of inspections performed at the fuel cycle facilities over the past two yeas, the Region ill fuel cycle inspection goals have been bettered. The added inspections we:e a direct result of the Region's response to events and issues. Currently, the operating plan quarterly metrics review is used to track performance goals.

44. How are you managing available resources based on the overall safety / safeguards risk posed by each facility (i.e., matching available expertise to areas of greatest risk and weak licensee performance)?

Resources are dedicated as required for each licensee in response to the results of the licensee performance review (LPR) process. The LPR process identifies functional areas that require additional NRC inspection resources to focus attention on areas with of perceived performance problems. Annual senior management screening meetings have been conducted for each licensee to discuss overall performance. - Inspection resources were initially assigned in the MIP based on identified risk. Adjustments in the inspection process are continuous based on performance issues. Several special inspections, including two AITs, have been conducted following significant events. Another method utilized to manage branch resources to perceived needs is the " task-assignment" of experienced inspection staff to supplement inspection resources. Task astignments typically are of short duration and assure the branch matches the available expertise to the area of greatest risk. Also, the branch utilizes NMSS and DNMS resources when specific inspection findings or perceived problems require expertise that is not available within the branch. Any request for assistance is discussed at the branch level both for NMSS anil DNMS.

45. How are you managing inspection resources based on projected licensee activities (new system startups, etc., to assure that the right technical expertise will be available when needed)?

The on-going activity or schedule of Region lli Fuel Cycle licensees does play a part in our scheduling of resources. For the most part, inspections of unique activities such as an emergency exercise are coordinated far in advance to assure available resources. Other "special inspections" are l managed utilizing resources from the Region's DNMS and NMSS (e.g., AlliedSignal AIT follow-up). Where practical, routine inspections are modified by adding necessary resources to encompass both the routine inspection requirements as well as any needed special inspection initiatives (Paducah QA inspection). 51

') 46. How are you managing available inspection resources to assure adequate agency emergency resoonse to credible fuel facility events / accidents? The branch has cont'nued to manage the emergency response aspect of the program by utilizing regional and resident staff resources to respond to significant fuel facility events. The branch has maintained a diverse grouping of expertise among the inspectors, which provides resources for both ongoing inspection activities and effective response to fuel facility events. When additional resources were needed to respond to an event, the branch has requested assistance from DNMS (Paducah dropped cylinder), NMSS/FCSS (AITs), and Rlll Division of Reactor Safety (Portsmouth Steam Plant and Paducah QA). The branch ensures adequate technical response to the emergencies through active participation in site emergency exercises and through inspection of the applicable site emergency preparedness program. At both the GDPs, where NRC resident offices are established, the Region maintains continuous coverage through the use of the resident inspectors. In instances where neither resident inspector is in the immediate area of the plant, the Region utilizes either regional or NMSS/FCSS resources to provide site coverage, or ensures that an NRC inspector is no greater than six hours away from the respective plant to respond to an event. In addition, the Paducah resident inspectors, who reside in close proximity to AlliedSignal, have promptly responded to several events at AlliedSignal over the past two years. A response tabletop exercise was conducted with NRC resident staff, Region ill management, and Environmental Protection Agency management to better define roles and responsibilities in response to a hypothetical event at a Gaseous Diffusion Plant involving an offsite release of UF6. The following are examples of the managemer.t of resources which ensured agency response to significant accidents and events. Resident and regional staff at the Paducah GDP were dispatched to AlliedSignal to monitor recovery activities regarding events and accidents in December 1996, July 1997, January 1998, and, July 1998. In December of 1998, an  ! NMSS/FCSS staff member was providing site coverage at the Portsmouth GDP and promptly responded to a significant fire. Region lil's Division of j Reactor Safety and NMSS/FCSS resources were utilized over the past two years in special inspections and augmented inspection teams at both the i AlliedSignal and Portsmouth plants.

47. How do you assure that all licensee events are promptly reviewed and appropriate response taken, commensurate with the safety / safeguards risk?

(This includes event evaluation for generic implication, adequacy of licensee 6 immediate corrective actions, compensatory actions, and completion of long term actions.) 52

For all Region lli event notifications, the branch chief is notified by the Region lil Duty Officer. If the event is being reported from one of the GDPs, the resident staff is generally informed of the event in parallel with the licensee's report to the NRC Operations Center or Regional Duty Officer. For an event reported from a GDP, the resident staff performs an initial assessment of the significance and discusses proposed inspection follow-up with the branch chief. For the other Fuel Cycle facilities, an initial dialogue within the branch is conducted to evaluate the significance and propose follow-up activities. During these initial discussions, additional NRC staff consultations occur (e.g., NMSS/FCSS) dependent on the specific event. All Region lli events are discussed at the daily DNMS "0745 meeting" with divisional management and a representative from NMSS. Following the division's meeting, all events are then briefed by the Fuel Cycle Branch Chief at the Region's "0815 meeting." Attendees at the 0815 meeting include senior regional managers, regional council, and representatives from the Region's Public Affairs Office, State and Government Affairs Office, and the Office of Investigation. The daily event briefings assures at the earliest stage in the event review process that each event is communicated to a broad audience to solicit insights regarding significance, trends, or generic implications. The division maintains an event notification log which is used to track all ' event reports. This tracking system provides a method to monitor the branch's follow-up actions regarding the review of licensee corrective actions, compensatory actions, and long term actions. For the GDPs, the inspection staff's initial review of each event is documented in their routine inspection report or memorandum as appropriate. For all significant  ; events, the follow-up of the written licensee event report is conducted as a i routine inspection activity, and the results are documented in an ) inspection report. Inspections are scheduled based upon safety and l safeguards risks. The event notification log is reviewed on a weekly basis by the divisional management team. l

48. What do you feel is/will be your greatest challenge for the next year?

Training and implementation of the new enforcement policy will be a challenge. In addition, replacement and training of future fuel cycle inspectors may be a challenge due to budget constraints.

49. What has been your greatest unexpected challenge over the past year?

Over the past year, the greatest challenge for the Fuel Cycle Branch has been to complete all assigned routine inspections and respond to significant events or issues with reduced resources. During this past year, the normal staff complement for the Fuel Cycle Branch was affected by temporary rotational assignments for the branch chief, senior fuel cycle inspector, and senior resident inspector. In addition, early in the year, the 53

E

 . o     .

time required to replace a vacated resident position required close monitoring of available resources.

50. If you were given any additional resources, where would you put them or what would you focus them on (include things that you are, or would like to do)?

Additional resources would permit better succession planning, particularly with resident inspectors. As currently exists, there is no defined pathway for development of future Fuel Cycle resident inspectors. Based on the lack of interest for two vacated Fuel Cycle resident positions over the past two years, the need for a pipeline to recruit and train replacement inspectors is evident. Additional staff would be devoted to addressing LPR identified weaknesses at the various licensees. The added staff would also assist the GDP inspection program and conduct allegation reviews as assigned.

51. What was your most significant accomplishment of the past year? Greatest disappointment?

The most significant accomplishment over the past year was effectively implementing the MIP and performing necessary reactive inspections with reduced resources. Of particular note were the inspection findings at AlliedSignal and the performance assessments for the GDPs. The greatest disappointment over the past year was the slow rate of performance improvement at the Portsmouth facility despite our efforts to

                  " add value."

IV. General

52. Summarize any significant reprogramming actions taken during the review period, and the basis for these actions (e.g., moved 2 budgeted FTE from non-core materials inspections to materials licensing to eliminate a backlog). List any major program accomplishments or initiatives not cited in other answers.

Indicate any areas in which DNMS did not meet its Operating Plan goals. Debbie Piskura was temporarily reassigned from materials inspection to materials licensing to reduce the pending backlog of licensing actions. This temporary assignment lasted 6 months and had minimal impact on the core inspection program. B. J. Holt was reassigned from Chief, Materials Licensing Branch, to Director, Division of Resource Management and Administration. For several months during this review period senior license reviewers assumed the duties of the branch chief. During the period before a permanent selection was made, the Materials Licensing Branch completed j over 93 percent of alllicensing actions timely, and the licensing backlog  ! remained approximately at the level it was at prior to the re-assignment.  ! 54 { i

i l Monte Phillips was reassigned from Chief, Materials inspection Branch 2, to the allegations staff to reduce the backlog of allegation cases, develop the regional allegation procedure, and provider oversight to allegation activities. During this period one of the senior inspectors assumed the duties of the branch chief. This temporary assignment lasted 6 months and had minimal impact on the core inspection program. i in the decommissioning branch, significant reprogramming occurred in I two areas: assumption of responsibility for conduct of the inspection program at the Zion nuclear plant in June 1998, and implementation of a specialinitiative to upgrade the Region 111 laboratory at the start of FY 1999. The Zion inspection effort involved assignment of a " lead" l inspector, to whose existing duties this responsibility was added, and ' ' performing an ongoing, every-week inspection activity utilizing a rotating cadre of five personnel, including the " lead." The FTE utilization rate amounted to almost one full FTE. The laboratory special initiative involved f I l ' temporary (about three months) assignment of the health physics manager, and the Decommissioning Branch Chief, on an all-day, every-day basis to join with the full-time assigned laboratory operations specialist in ! completing more than a hundred specifically identified and tracked " action i items." A senior radiation specialist took on many of the normal branch chief duties during the period from September 1998 into December 1998 while this initiative was performed. Over the past two years the Fuel Cycle Branch has effectively utilized available resources to complete the inspection program responsibilities. Significant program accomplishments included support to the NRC's performance evaluations for the GDPs, and the conduct of LPRs for l AlliedSignal and Combustion Engineering. Also during the last two years, l the branch has been effective at identifying areas of concern which warranted special inspections, including the steam plant failure at Portsmouth, dropped cylinder at Paducah, criticality safety inspections at Portsmouth, compliance plan inspections at Portsmouth, corrective action program inspection at Portsmouth, AIT and follow-up inspection at j AlliedSignal, and the AIT and follow-up inspection at Portsmouth. Other j major accomplishments were the significant inspection findings which included Portsmouth's failure to maintain mechanical components, programmatic breakdown of the criticality safety program at Portsmouth, fai!ure to properly implement certain compliance plan issues at Portsmouth, and the identification of procedural adherence problems at Combustion Engineering. In addition, the branch was very effective at evaluating the risk significance of safety limit violations at Paducah, and the branch was an effective team member during NMSS' resolution of Paducah seismic deficiencies. Region ill met all operating plan goals but two for the first quarter of 1999. Specifically, the Fuel Cycle Branch was late with three inspection reports, although all inspections required to be performed were completed. In one 55 1

case, the report was three days late, and the other two late reports were the result of unplanned illness of the inspector.

53. Provide any comments and recommendations regarding the effectiveness of Headquarters support to regional activities and the Region / Headquarters interface. Identify any regionalinteraction with Headquarters and licensees to improve the quality of your licensing / inspection program.

Overall, Headquarters support to regional activities has been excellent in certain areas. The interface between Region ll1 and Headquarters is very good, and has been consistently improving. The implementation of the regional coordinator position and the daily call have been useful in conveying information between the staff. This has resulted in an increasingly more timely response to most of our questions. Headquarters support and effectiveness of the Region / Headquarters interface in the decommissioning area were outstanding and were identified as a " Strength" in response to question 26, above. The integrated licensing and inspection plan for decommissioning was a particular initiative which, while still relatively new in use, is considered a significant advance in resource planning and management. Support for the laboratory upgrade was critical in the successful completion of the project and took the form of senior management attention, resources (contracted substitute services and consulting, equipment purchases) and technical direction and advice. The interface with Headquarters regarding complex, major, or unusual regulatory questions has been invaluable to the Region and has served to improve the quality of our licensing and inspection programs, and improve the timeliness of enforcement actions. As noted above, the Region lil initiatives to inspect major broad scope licensees and portable gauge licensees have resulted in significant improvements to the inspection program. As a result of these initiatives, inspections have been performance based and focused on observing licensees' use of material, and radiological work practices rather than a review of licensee records. Headquarters should strive to improve communications with other program offices, e.g., Office of General Council and Office of Enforcement, to ensure a timely response to TARS and regional requests regarding change of ownership and bankruptcy cases. As an example the Region has had a longstanding TAR on two licensees (UCAR and Gelman Sciences) regarding disputed violations related to change of ownership. When the Region received the response regarding these issues it appeared to contradict the guidance in the " draft" NUREG which was in the final stages of being published. Further communication with OGC was necessary to resolve the issues in these cases. l 1 I 56 i

I . . . The quality of licensing actions has shown improvement with the issuance of the consolidated guidance documents (NUREG-1556 series). However, there are areas where improvement could be made. For example the quality of many of the currently active standard review plans (SRPs) that have not been superceded by a NUREG-1556 document is not good (e.g., the checklist for reviewing HDRs and medical applications differs from the SRP). TARS submitted to NMSS need to be processed and the results issued to the Regions in a more timely manner to allow the Regions to complete the associated licensing action within the timeliness goals. In the area of fuel cycle licensees, support to the Region, and the interface l by headquarters staff has been very effective. Headquarters has provided timely evaluation of technical and licensing issues, needed resources, and 1 has served as a partner in developing the Region's inspection strategies. The headquarters staff consistently fosters an open dialogue on significant issues at all levels, which has resulted in a team approach to resolving inspection findings. Some examples over the review period include, the inspection and management of criticality program issues at Portsmouth, the AlliedSignal AIT follow-up inspection findings, and more recently, the l j full participation on the NRC response to the Portsmouth fire. ' One suggestion to improve the quality of the fuel cycle inspection program is to expand our existing program of inspection accompaniments between I regional inspectors (e.g., Rlil to Ril and Ril to Rlli) to also include l i headquarters staff. These inspections could be preplanned and easily integrated into the MIP with input and feedback from both regional and headquarters management.

54. In which areas of licensing and inspection guidance do you need the most training? Please provide a list by priority, highest first.

A policy should be developed and training provided to the Regions on how licensing actions will be handled frorn mailing by the licensee through issuance by the license reviewer in the new " electronic" environment of ADAMS. For example, we have heard that NMSS is considering a I centralized receipt for all license action requests, rather than the current i practice of licensee's sending the request to the Region. As major l NUREG-1556 volumes become final, training should be provided to the licensing and inspection staff on how the two roles (inspection and licensing) will complement each other in determining an adequate level of safety as new licenses are issued under the new guidance. Finally, )

training should be provided to license reviewers on the " streamlined i renewal process."

in both the inspection and licensing arena, additional training is needed in the areas involving the new Part 35 requirements and handling of change of control / ownership and bankruptcy cases. 57

REGION 111 MANUAL REGIONAL PROCEDURE 0517A' MANAGEMENTOF ALLEGATIONS A. Soope

            . This document presenbes the regional procedures and poGcy for the irnplementation of the NRC allegation management poGeyin accordance with NRC Management Drechve (MD) 8.8, " Management of Allegations", and those portions of NUREG/BR-0195, Revision 1 "NRC Enfon:ement Manual", applicable to the handling of 01 reports or allegabons. Users of this procedure shall familiarize themselves with MD DirecGve and Handbook 8.8.

B. References NRC Management Drective 8.8, " Management of Allegations" NRC Management Directive 7A, "Reportirg Suspected Wrongdoing and Processing OlG

           , Refemds"

• NUREG/BR 0195, Revision 1 "NRC Enforcement Manual" NUREG-1600, "NRC Enfon:ement Policy" '

NRC Manual Chapter 1007, "Interfadng Activibes Between Regional Offices of NRC and OSHA" Regional Procedure 0518, " Handing Fstness for Duty Matters" Regional Procedure 1007A, " interface Activities Between Regional Office and OSHA" Regional Procedewe 1215, " Handling Office of Investigation Reports and informabon" Regional Procedure 1460," Working Arrangements forimplementing the Memorandum of Understanding with the Department of Laixx" Emergency Preparedness and Environmental Health Physics Sechon Policy & Guidance Procedure 002-C. Specific Responsibility Speedic responsibilities for all personnel are speedied in Attachment 3. They are broken down by responsabi0bes of the Regiot.al Administrator (RA) and Deputy Regional Administrator (DRA), tedinical Division Drectors, technical Branch Chiefs, technical staff, the Senior Office At-"~1 Coordinator (SOAC), Office Abegation Coordinator (OAC), Enforcement Officer (EO), Enforcement and investigation Coordination Staff Admmistrative Assistant (EICS-AA), Regional Counsel, Field Dweetor for the Office of Invesbgations, dmsion and branch Secretaries, State Uaison Officer, Regional Agreement States Officer, and the recepGonist. CONTACT: J. A. Hopkins Revised 3/05/98 { SeniorOffice Allegations Coordinator l l

V .' ,; .. RP 0517A D. Generalinformation Alleoation_: A declaration, statement or assertion of impropriety or inadequacy associated with NRC-regulated achvibes, the validity of which has not been established. This term is further defined in Attadunent 5. Confidentiality: In Reaion ill, confidentiality can be offered only by the Reaional Adnmis . tor. This authodty may be de8egated. If at any time, for any reason, confidenhakty is breached orjeopardu:sd, the Regional Administrator must be informed and the concemed individual (Cl) should be advised, the reason explained and remedial measures taken, if possible, to reduce the impact of disclosure, i Cc6T, dent;&idy is not to be granted as a roubne matter, rather confidentsality should be granted only when necessary to acquim information in the best interest of the agency. It may be offered to those Os who by their schons would not readily make the desired information available orwhere there are other circumstances that might warrant it. The offer of a confidentiafn/ anteement should be ce6;;,4061 upon an assessment of the usefulness of the information provided if such a determination can be made in a tunely manner. For the majority ofindividuals, confidenhality need not be provided. The details on granting of confidentiartty, as well as the specifics of the confidenhality agreement, are addressed in Management Dimchve 8.8, Handbook Sechon lit. As a general rule, however, the "need to know" principle should be implemented where the idenhty of any Cl is concemed. For those Cis with a confidenhality agreement this means that~the identity of the source must be protected by not refemng to the Q or other idenGfymg informabon in <Gemelons unless absolutely necessary and by expurgetsng the i name and other identifying informabon from documents before disseminating these to the

                   ' staff. For those Cis without a confidentiality agreement, this means avoidance of unnecessary use of the identity of the source and other iden;;i/,rg information in                   ,

discussions and in documents. It must be made clear to all concemed if, and on what

                                                                                                                       .i terms, the anonymity of a person making an " 72 w is to be released. A clearrecord should be maintained for the files to preclude later misunderstandmg. fed ~t files contaming the identity of Cis mest be protected to prevent the identrty of Cis from being '

disclosed.

          . E.      Procedure 1.0      Receivino Alleastions 1.1 Allegations or concems may be received in Region ill by one of four ways:

1. . A direct call to one of the allegation coordinators (such as over the allegation hotAne);

2. A contact by an inspector or other technical staff with a Cl, either by phone or in persca;

3. A document is left with an inspector or maaled to the Region lit office; or

        .    .*   a I

RP 0517A

4. The allegation is referred to the region by an NRC Headquarters office, another region, or another agency.

With the exception of the latter two, either of the OACs should be involved, g possible, in the receipt of the allegation. Inspedors should use good judgment when atternpting to involve the OAC staff and should take an allegation if involving the OAC staff would be deinmental to receipt of complete and can&d informatm or K no member of the OAC staffis immediately available to assist in taking the allegabon. Delays in taking an allegatson or diens**ing the issues with a Cl, solely because the OACs are not avaliable, may leave a Cl with the wrong impression and delay our assessment of the safety significance of a CI's issues. 1.2 ff neither OAC is available, the inspedor should, at a minimum: (1) take the allegation (see the following sedion for the information to obtain from and provide to the Cl); (2) obtain the Crs name, address, and telephone number; and (3) dmxanent the allegatson in as much detail as possible and forward the informabon to the immediate supervisor or cc.,vc ,izani Branch Chief and SCS via E mail (address: OAC3) within three workdays. DO NOT indude the Ct's name, address, or telephone numberin the Egnail. Provide that information to the OAC through the mail in an ' addressee only" envelope or by telephone. The OACs will contact the Cl K a follow up call is needed.- Attachment 1 provides staff guidance in taking allegatsons. The information to be obtained is described in detaR in Sechon 2.1. 1.3 Individuals wanting to report safety concems or violabons of NRC requirements caa contact the Rill Office Allegation Coordinators by caBing 1-800 695-7403 (allegatson hotline) as shown on NRC Form 3, No6oe to ITip;ca, or through the Region 111 Switchboard at 1-800-522-3025. 1.4 Off-hours allegation calls made to the r":;='M, hodine are forwarded to the Headquarters Duty Officer, Operabons Center, and then to the Regional Duty Officer. The informdion should be given to one of the OACs the next working day. 1.5 Drop in Visits by Aueoers if an individual appears in person at the Regional Office and wants to speak with one of the OACs, the individual should be referred to BCS. The individual SHALL NOT sign in at the NRC recap 6on area. The recapbonist shat cat the SCS-AA and inform her that an individual is in the waiting area who vnshes to speak with one of the OACs. The SCS AA shall noGfy one of the OACs, or K nor,e are avalmle, the Enforcement Officer, who will escort the individual to the BCS confonmoe room, where the individual will sign in as a visitor. The information to be obtained is described in detailin Section 2.1 below. 2.0 information to be Obtained from/Provided to the C1 2.1 Any e.. glcy;; contaded by a CI should attempt to refer the CI to one of the OACs, K possible; however, K an OAC is not immediately available, then the employee should obtain the followng essentialinformation-

                                                                                                            )
                                                                                                            }

RP 0517A

a. Fullname.

b. Home mailing address.

c. Whether the Cl objects to having his/heridentity revealed.

d. Whether the Cl objects to having the concoms forwarded to the lioensee for foBow up (consistent with pre;scGr.g his/her identity).

e. Telephone number where the individual may be contaded (both home and work N possible). Ask what is the best method to contad them.

f. . Posibon or i:'Ex,stJp to facihty or actmty involved, g.

Nature of allegation (s) (who, what, when, where, why, how)

h. Any documents?

I. Have you told your management or Employee Concems Program? What was their response?

j. Does the Cl believe there is an immediate threat to public health and safety or to plant equipment? If so, why?

Restate each of the concerns to the Cl to ensure you clearly understand. If the Cl is alleging employment discrimination, remind the Cl that he must file a written complaint with DOL-OSHA within 180 days of the alleged discriminatory act to obtain personal relief. 2.2 If the Cl declines to prowde the above informahon, attempt to establish the reason (s) usmo the following guidanos: Inform the individual that Public 1.aw 95601 affords protechon to the Cl by prohibilmg an employer from  ! discriminatng against an eir$,= for contadmg the NRC. If the indhndual says that they wlR provide the information if their name is kept con 6 den 6at, inform the person that it is NRC policy to protect individual idenGties when posable whether ) cerE+^~'ils granted ornot. However, if the person wants a confidenbality agreement, it will have to be coordinated through the Regional Ollios (see  ! Sedion 2.9 on the process for granting eurEa1 ~'s), The Ci should be 1 infonned that only the Regional Administrator is authorized to grant confidentiality, and if the Ci still persists in requestag ev -E+M iprior to giving the ' information, the Ci should be told to contad one of the OACs, who will handle the Ct's request. j m 2.3 Consistent with MD 8.8, the Cl must be informed of the degree to whidt their identity can be protected. This is necessary since some Cis may incorrectly assume that the NRC can or wR protect their identity under au circumstances, j Therefore, individuals to whom the NRC has not granted sere + ' ~i abould be i informed that the NRC intends to take au reasonable efforts not to disclose their identity and of the droumstances under whidt their identity may be revealed (see MD 8.8, Part 1(A)(2). The information contained on the laminated card provided to all technical staff entdied "Disdosure of Allegahon identity"(NRC Form 613) shaN be provided to the Ci after obtaining as much information as possible, if at any time it becomes necessary to release the idenuty of an alleger for the reasons described on the lammated card, with the excephon of ,,,4er...r.iit discriminabon orwrongdoing inveshgabons, the Regional Administrator or Nputy Regional AdministratorwlN be consulted and approve the .~.46am,. Reasonable efforts will be made to contad the Cl and explam the need for ***=e unless it is documented in the AMS file that the Ci has dearty indicated no objection to bemg - idenutied

7; ,- , l I-I i l RP 0517A 2.4 in the event a Cl provides information which may be safeguards or classified information, the Ci should be advised that he/she will be contacted to arrange a personalinterview. Excephons applyif the infonnation involves an immediate health and safety matter. 2.5 The Ci should be informed that the NRC employee with whorn he/she is in contact with cannot at the time evaluate the information, determine follow up ac6on, or - estabbsh NRCJuris&chon. It may be necessary that someone else contact the

                  . aboger foraddhanalinformation.

, 2.6 The Cl may be informed also, that unless an objechon is registered he/she will ! receive wittten notificahon within 30 days regardng the :":r' s, at an address designated by the Cl, which will also =4+:d I-# the receipt of the allegatson This process will permit the Cl an opportunity to review the informabon and provide some assurance that the information has been correctly translated by the NRC. 2.7 if the ci persists in not provi&ng theiridentificabon after the above explanahons, document the ":M' m in as much detall as possible and advise the Cl that follow up information related to the concems will not be avaRable. 2.8 For allegates of disenminahon that fall under Sec6on 211, " Employee Protechon", of the Energy Reorganizabon Act, advise the alleger that a written complaint must be filed with the Department of Labor within 180 days of the commence of the disonmination event to assure personal employee rights and remedies are protected (sudi as ,W="' wd, back pay, etc.). (Also see Regional Procedure 1460, ' Working Arrangements for implementing the Memorandum of Understandang with the Department of Labor.")

         ' 2.g    For those cases where the Cl will not provide the concem to the NRC without           i obtaining confidenhality, a discussion between the Cl and OAC wNI be held to          !

determme the following-  ! (a) has the Ci provided the information to anyone else (for example, is the information akeady widely known, with the Cl as its source); (b) does the NRC already know of the infonnsbon, obvi1 sting the need for a parbcdar confidenhal source; j (c) does the Cl have a history that would weigh eitherin favor of or against . grantag confidenhaDty in this instance (for example, has the Ci abused grants I of confidenhalityin the past); l 1 (d) is the information that the Cl is offering within the jurisdichon of the NRC;  ! (e) why does the Cl desire con'-fE"P (what i would be the consequences to the Cl if his or her idenuty was revealed?);

                                                                                                        )

I I t

E , e e l l l I l i RP 0517A (f) - does it appear that the Cl caused the condition or committed the violation and could likely be subject to dvil or criminal prosecubon (MD 8.8, Sechon 111.B.1). 1 Based on the information pnmded, the OAC will consult with the Regional Administrator on whether confidentiality should be granted using the guidance provided in Management Drective 8.8. If the decision is not to grant confidenGality, the Cl will be so informed. If the decision is to grant confidentiality, 1 two copies of the " Confidentiality Agreement"(Exhibit in Management Drective  ! 8.8) wlN be signed by the regional administrator and provided to the Cl with  ;

                   "instruc6ons to sign both copses and retum one to the region. Upon receipt of the
                  - Confidenhality Agreement" signed by the Cl, the Cl wiu then be treated as a Confidential Source per Management Directive 8.8.

j 3.0 Alleoatens Received by Mail 3.1 All correspondence that appears to contain allegaGon material, including intemal NRC memoranda addressing allegadens, shou'd be forwarded promptly.to the ) SOAC for handling and coordination. To avoid the distribubon of material that - ! may tend to identify individuals as Cis, the complete cordents of such l correspondence and the envelopes should be forwarded to the SOAC. No copies j should be made. , 4.0 initial Review of Alleostions i 4.1. The individual receivmg the anegation shau document the informahon (normany, this will be one of the OACs). Clearly list each concern. Provide any other information that will help datify the concems and aid in the 'mspection. The j infonnation should be documented in a memorandum and provided to the SOAC 1 in hard copy and by E-mail within three woriang days of receipt. The E-mail version shau not include the name of the Cl, and will be transmitted eledronically to E-mar address OAC3. This memo should be conwned in by the individual's supervisor and no copies of the memo "meluding the CI's name should be made. This win help control the identity of the Cl and mwwnize inadvertent disdosure. 1 I l 4.2. Upon receipt of the ":;n~ i, one of the OACs wiu reviewthe allegabon to i I idenufy the specific conoems and whether an emergency ARB is necessary. The

         ,      OAC will then contact the appropnate dnnsional management (DRS and DRP for reactors, DNMS for materials) If the OAC determines that an emergency
                . f:;4:-5 Review Board (ARB) is necessary orif there is a queshon as to which Branch should be assigned the lead if an emergency ARB is necessary, it wul be                   ;

scheduled as soon as possible (normally within the next two hours). ' 4.3 As necessary, the OAC will coordmate allegation informahon with the assigned l technical staff and determine whether a valid allegabon easts. If necessary, the OAC (with divisional support, as needed) wRI re<mntact the Cl to obtain any additional informabon. In some cases, the Cl may coil bedt to discuss the status of an auegation, or to obtain addebonalinformation from the Cl. In either case,if a , phone call occurs between a member of the Region lit staff and a Cl, the call rnust '

 ,   ,   a 4

RP 0517A be documented in a conversation record or memorandum and provHied to ElCS for inclusion in the allegation file. 4.4 Tedinicalissues in the allegation that involve an individual's failure to meet i requirements have the potential for bemg willful or deliberate violatsons. However, i in the absence of specific allegations of willfulness or deliberateness, such issues i will normally be tracked separately as technicalissues and resolved using

       .             prograrn resources.                                                                  !

{ 4.5 Due to their potentsalimpact on safety, all matters involving potential wrongdoing will be handled on a priority basts. Potentsal wmngdoing idenGfied thmugh the allegation process wiu be promptly brought by the OAC to the attenbon of the Field Director of the Office ofInvestsgatsons (Of), in addihon to the appropriate Division Diredor. Potentsal wrongdong identified through the inspec6on process  ! will be prompey raised through the inspectors' management chain and to the OAC

                  ' who will then notify the 01 Feeld Office Director.

4.6 Allegations regarding suspected improper conduct by NRC employees and NRC contractors will be brought to the attenhon of the Deputy Regional Adtninistrator , for possible referral to the Office of Inspector General (OlG). ?Mdi~ts of this nature are not entered into the AMS. (

Reference:

NRC Management Dwechve 7.4.) 4.7 Allegations that fan within the purview of OSHA are to be tumed over to OSHA I through the Region lli State Liaison Officer, and are not to be entered in the AMS. (

Reference:

Regional Procedure 1007A, NRC Manual Chapter 1007 and MD 8.8, Sechon I.D.1.g). 4.8 AMdM that involve agreement state matters should be coordinated with the Regional State Agreement Officer in those cases where the :":;=R-a involves wmngdoing on the part of Agreement State personnel or deals with the adequacy  ; of the Agreement State's regulatory cn.cagd, the guidance in AM-"~1 , Guwiance Memorandum g7-02 wBl be implemented. Namely, the case will be referred to the Office of State Proy.n4 allegation coordinator for foNow up. 5.0 Initial Documentation and C;;Jheat of Anna.p.i pige 5.1 The OAC wul erder the aHegation infomsation into the AM-"~1 Management System (AMS), listang each concem and facRity for the specific Cl. This wRl be done as soon as possble, but no later than 30 days after receipt of the :":p%n. If related conoems are identified that can be traced to other allegations already in the AMS system, a cross <eference for that concem will be induded under the "related suegabon" tab idenGfying the concem and aRegation number where the related concem can be found. The concem for that aBegabon numberwill also be , annotated with a "related auegation* adion tab showing the new allegation number and concem. Spedfic achon tabs to be ordered indude " initial ARB Meeteg"(planned date is 30 days from receipt date). 'tMionth ARB Meeting" ' (planned date is 6 months from receipt date), and if a spedfic Cl is identified,

• acknowledgment letter" (planned date is 30 days from receipt _date) and "dosure letter" (no planned or assigned dates).

I  :; o o 1 l !.. RP 0517A l 5.2 The OAC entering data into AMS will establish an allegation file including the following spedfic serial items: 1) Identification Sheet (identifies the Cl with address and phone numbers); 2) List of Specific Conoems (specifies each concem in the allegation and its regulatory basis if known); 3) documentaten receeved or developed that identifies the actual text of the allegation and specific concems. In addition, records of any conversatxms with the Cl, related documents, etc. shall be included in the case file. 5.3 For those allegabons where a specific Cl is identified, the OAC entering the data into AMS shaN at the same time prepare the Acknowledgment Letter to the Cl using the boilerplate letter provided in the G:\EICSBOILERS\ACKNOWLBOL file. The specsfic concems placed in AMS should be electronicaNy cut and pasted into the letter to the Cl to ensure that the AMS file is accurate. The Admowledgment Letter to the Cl must be developed to address whether the Cl has objected to identity release or referral to the licensee, and whether the allegation involves discrimination or not. The admowledgment letter should show the sender to be the OAC, with a copy to the appropnate AMS file,1here are no concurrences for the acknowledgment letter. The acknowledgment letter will be sent to the Cl by certified mail, with a retum receipt request, and will not be mailed in an envelope canying an NRC logo or label, or NRC metered postage.

                                                                                                           ~

5.4 After entering the allegation data into AMS, the OAC shall prepare a " Receipt of New ANahf memo to the cognizant Brandi Chief that specifies the upcoming  ! date for the ARB and specifies what is to be decided at the ARB conoeming that

                      ":;5:=i. A copy of the background informabon, and " List of Speal6c Conoems" (which documents the concem and regulatory basis, if known) will be included with the "New /Whn" memo. The ElCS AA wiu provide copies of the "New Allegation" memo with attadiments as follows: the Division Duector/ Deputy (DRS for reactor cases, DNMS only for materials cases), Of Regional Feeld Office, and Regional Counsel wul receive copies of the memo, "Ust of Specl6c Concems",

and buy,vand information only (with the aueger's identity concealed). The Deputy Regional Administrator will receive a copy of the memo and "Ust of Specific Concems". The original of the memo wBl be placed in the case file, and . win indude an attendance and approval sheet for the upcoming ARB with a preliminary descriphon for the basis of safety signincanoe for the allegebon. The addressee wiu recorve the memo, "Ust of Sped 6c Concems", background information (with the aneger's identity wc i $, and an ?v5 Adion" page for eadi concom, and a recommended adion by the OAC. 5.5' All documents containing the identity of the aReger, other than publidy available j information, wlR be handled as NOT FOR PUBUC DISCLOSURE. 5.6 - At the 8:15 moming meetmo. a member of the EICS staff (usuaNy the Enforcement Of6oer; wlE brief the Division Diredars and other attendees by providing the name of the faci 0ty where the conooms are alleged to have ocouned and the date when the ARB wul be held to discuss the concems for those conoems received the previous day.

i 1 d RP 0517A 6.0 initial Auecation Rewsw Boards (ARB) 6.1 Regular ARBS are held every Monday in the EICS conference room as follows: Materials cases fmm g:30 until 10:30 a.m.; and Reactor cases from 2:05 p.m. until 3:30 p.m. The ARB will include all cases received and processed into the AMS during the seven day penod between Thursday aftemoon and the following

  ,                 Thursday moming. In no case should the initial ARB be delayed more than 30 days from the date of asceipt of the allegation. The purpose of the initial ARB is twofold; namely, to ensure that au concerns have been identrfied in the aRegation package, and that an appropriate course of action is specified to dose out each of the concems.

6.2 The foRowing individuals or their deputies /adors shan attend each ARB: Regional Counsel, Ol Field Office Drector, SOAC or OAC, the crv4.61 technical Branch Chief, the DRP Bnmdi Chief with responsibility for the facuity, and the ARB Chairman. The ARB Chairman is the Diredor of Reactor Projects or Reactor Safety, as designated by the Regional Administrator, for reac or cases; and the Dredor of Nuclear Materials Safety for matenals cases. These individuals should coms prepared to discuss (1) the safety significance of the aRegation (2) the rationale for the safety significance, (3) the pnonty of the aRegation (immediate inspedsors inspedion within 30 days,60 days, etc.) assuming that the auegation is true, and (4) the priority for en Of investigation, if warranted. i 6.3 Eadt Thursday, the SCS AA w0l distribute the ARB packages as noted in Sechon 5.4 above and 12.5 below. The ElCS AA wiR also prepare and distribute ] the ARB agenda via E-mar to at technical divisional management and their secretaries. It is the responsibuity of technical division secretanes to ensure that indiwduals acting for the Branch Chief are provided a copy of the ARB agenda Monday moming. If the cognizant Branch Chief wlR not be prepared to discuss the case by the scheduled ARB date, he should contact the OAC, responsible Dewseon Director, and the Board Chairman and have the case rescheduled to the followng week. Sudi re-scheduling requires ARB Chairman approval , l l 6.4 Prior to the ARB, the cognizant technical Eranch Chief shaR review the I back0round informahon provided with the "New ARegation" memo and venfy that all concems of the Cl have been listed on the *t.ist of Specific Conoems". If this renew identifies concoms that were not previously listed, one of the OACs should be onntacted immediately to ensure that the conoems list is updated, AMS is updated, and the newly identified concems are eser==4 at the upcoming ARB. 6.5 Also prior to the ARB, the cogruzant technical Branch Chief for the conoom wul review the recommended course of adson from the list prowded on the " Allegation  : Action" page and either concur or revise the recommended acuon. Just prior to l the ARB, the Branch Chief will prowde the marked page to the OAC in attendance at the ARB. 6.6 The ara will decide IF there is an issue requmng NRC follow up, and if so, then WHO should follow up to close the issue. NormaRy, this will be one of the following three ophons: refer it to the licensee, perform an inspechon, or referthe i

[( c . a l l ( l l 1 RP 0517A concem to the Office of Investigations. This latter option will be the normal choice for cases where wrongdoing is likely or employment discrimination has occurred. ' NOTE: When referring cases to 01, the cognizant Branch Chief must be prepared to do the following: clearly identify what specific requirement was violated; provide a copy of the procedure or technical specrfication that has been violated; provide a copy of any problem report or other documents related to the concem; and provide a basis that would show that the '.iolaten was likely to have been wilful as opposed to inadvertent or based on a lack of knowledge of the requirement. Cases should not be referred to O! unless this basis has been established. In some cases, the NRC may chose to close the concem without taking any action because the concem is too vague to be followed up, the concem lacks merit, or the concem is outside NRC's regulatory responsibilities. Things the ARB should consider in assigning re5=*'~':: and schon dates are described in Management Dweetrve 8.8, Sec6on I.E.2.c, and include the following: Safety concems requinng u' nmediate regulatory adon j Feedback to the Cl ' Tedinicalissues W.TE.gdei.y concems and the pf.disiumisen ofinvestigations  ; Potential for chilling effects . Potential for the allegation being generic Appropnate schons to dose the concems Referrals to licensees or other organizations Significanoe and status of allegation as it relates to ongoing licensing or escalated enforcement schons Wmdow of opportunity to observe the alleged activity Opportunity for cover <sp Startup orconhnued opershons decisions if the :::;EE-i were true l Scope of potenhal conodive aeons if the allegahon were true 6.7 ARBS should refer as many allegations as possible to the licensee for schon and I response unless any of the following factors apply (see MD 8.8, Sec6on I.C.1): the informabon cannot be released in sufficient detail to the licensee l without co...pivi.Aiag the idenkty of the Cl (unless the Cl has no objection to his or her name being released) or the release of the informabon could { J bring harm to the Cl; f.

RP 0517A the licensee could compromise an investigation or inspection because of knowledge gained from the referral; the concem is made against the licensee's management or those parties

                             ; who would normally receive and address the concem; or                        l the basis of the concem is information received from a Federal agency that does not approve of the information bemg rele.ased in a referral.
                    - in determining whether to refer concems to a licensee, provided the above four        I situatsons do not apply, consideration should be given to the following -             l' (see MD 8.8, Sechon 1.C.1.b):

What is the licensee's history of allegabons against it and past record in  ! dealing with allegations, includmg the likelihood that the licensee will effectively investigate, document, and resolve the concem? j Has the Cl already taken this conoom to the licensee with unsatisfactory results? If the answeris yes and the conoom is within NRCjurisdiction, then the concem should normaRy not be referred to the licensee. I Are resources to invesbgate available within the region? and Has the Cl voiced objechon to the release of the concem to the license?  ! 6.8 The deliberations of the ARB will be documented by the OAC in attendance. This documentation will be approved at the ARB by the ARD Chairman. The document i;en must contain the followng per MD 8.8, Section I.E.3:

":;E4:-n number; date of ARB; attendees; .

purpose of the AR8; plants affected (m' ciuding generic applications); applicable action items and sduxiules for the ac6on office or Ol; ARB assessment of the safety significanoe of each concem; pnority level for 01 ime: ff'?:{, (if 01 assigned the achon); pmposed inspechons and lw;:C':{.s; 1 rationale for referrals to hoensees; and the basis for the ARB decasions regenhng safety significanoe, O! pnonty,

 -                              and proposed inspections orinvesbgabons.

The minutes of the ARB will be provided by the attending OAC to the ElCS-AA for entry of adsons into the AMS system and indusion of the rmnutes in the allegabon file. Assigned tedinical branches will be informed of specific schons assigned to them via the t'~;c:di ireportmg system of open f:;=%i achons. If the ARB determmes that a concem will be refened to the licensee, the OAC shall ensure that the Cl does not object and that he is informed, if possible, of the refenal. This will preferably be done via the issuance of the sent;i4,nent letter to the CI (see Section t.C.1.d of MD 8.8 and Sedion 5.3 of this procedure).

e 3,J . RP 0517A

                -6.9 If the ARB condudes that a concem has generic implications, should be referred to another govemmental agency, or an Agreement State, the actions assigned for that concem will be implemented by the OAC as follows:

6.9.1 Alleoation involves Generic Imolications: The OAC will contact the affected Offices which should result in a mutual i agreement as to which Office or Region should have the lead. . If agreement l cannot be reached at the OAC level, then the Deputy Regional Administrators or Office Dwectors will resolve which Office or Region should take the lead. Unless  ! Region til is the lead office, the OAC will document transfer of the allegation to the i lead Office or Region for follow up. The Riti allegation will be closed when the Cl has been informed that the concem has been transferred to the other Region or Office. l 6.9.2 Allecation to be Referred to an Aoreement State: i The OAC will prepare a transfer letter to be sent to the Agreement State transferring the concems. The letter will be signed by the Dwector, DNMS, and concurred on by the cognizant DNMS Branch Chief and Agreement State Programs Officer. The aleg.;;rwi will be closed with the transfer of the concem to the Agreemerd State if the Cl has agreed to the release of theiridentity to the State. However, if the Cl does not agree to the release of theiridentdy to the State, the 15-3 must remain open until a copy of the response from the State is received and provided to the Cl. The allegation will be closed when the closure letteris issued to the Cl. If the Cl does not agree to release of theiridentdy to the i State, the referral letter will be treated in acooniance with Sechon 8 below, except the referral will be to a State, and not a licensee. 6.9.3 Allegation to be Referred to Another Govemmental Aoenev (ees as OSHAh Referrals to OSHA shall be done in accordance with NRC Manual Chapter 1007. Specifically, the OAC shall document the concems on the OSHA referral fonn and forward it to the Region all State Unison Officer. A copy of this documerd will be used to close the action tab for OSHA referral. Referrals to other govemment agencies shall be drafted by the OAC for issuance by the Enforcement Officer after concurrence by the Region ill State Unison Officer. The concera may be dosed in AMS when the closure letter is issued to the Cl informing him that the conoem is not under NRC)urisdiction and that the conoom has been forwa;ded to the appropnate govemmental agency for follow up. A copy of the referral letter should be attached to the dosure letter to the Cl. As noted above, the ARB will normally assign one of three adums to address each concem. These actions are conduct an inspechon, referral of the allegation to the licensee for follow up, or referral of the concem to 01 forinveshgation. The follomng sechons of the procedure address the handling of the concem based on whid of these s ' three options is chosen by the ARB.

E3- ... . 4 i RP 0517A 7.0 ,C_onduct an insoedion to Close conoems j l 7.1- in cases where the ARB has decided that the assigned technical branch will

                                                                                                       }

Perform the follow up, the aduty assigned (contad Cl, perform inspec6on, obtain headquartets assistance, etc.) should be completed well withh the time frame, J usually 30 or 60 days, spedfied by the ARB. The closure memo from the assigned technical branch will be issued within the time frame assigned at the ARB. 7.2 If an inspechon is performed such that an inspechon report is issued that involves the review of one or more of a CI's concems, it should be written in a style that does not contain the name of, or material that could be used to identify, the Cl or that the issue was prompted as a result of an allegation. Normally, a report should be written only for those cases where a violation is identified (either cited or non-dted). If an inspechon report is to be written, it should be written in Manual Chaptr r 0610 format and a signed copy of he report must be forwarded with the closure memo to ElCS. 7.3 If an inspechon is performed, the inspedor must ensure that esdi of the conoems identdied by the ARB for follow up by inspechon is spedfically addressed in the inspecuen. The inspechon may include a contact with the CI (which must be documented), to ensure that the inspector clearly understands the conooms and any badypound informahon that may be related to the concem. For example, the  ! conoom may be that the Cl was not property trained, when the specifics are that the pradical exam given to the Cl was in fad a coaching session and not an examinaten. A review oflicensee re'.ords in this case would not be capable of establishing whether the concem was substantiated. The inspection must determine not only the vandity of the c mcom (substanhated/urs=Marthated), but I also the regulatory significance. For example, the concem that a test was not l performed may be substanhated, but there may be no requirement for the test, j hence no regulatoryviolabort j f.4 Upon ceT,9 chi of the action assigned by the ARB, the assigned technical brandt shall always prepare a closure memo desenbeg the NRC's conclusions. This memo is a stand alone document and should dearly identify each conoom identified on the itemmed list of corx: ems that is maintained in the allegation file, the details of what was done to resolve the conoom (moluding who was talked to, what was reviewed or observed and where it was observed, etc.), the NRC's , conclusions regardeng the concem (e.g., whether it was substantiated, partially l

               =Marshated, or unsubF 2 -), and the safety significance of the finding The     .

l memo must also dearty provide the basis for the NRC's condusion. Any documentation should be wittien in a style that does not belittle or disparage the l Cl, or the significance of the concems identified to the NRC. Both documents (closure memo and inspection report) will then be sent under the Branch Chief's or higher signature to ElCS, both electronically (E-rnail address OAC3) and hard Copy. i l

                                                                                                             .. i RP 0517A 8.0      Refenals of Concems to the Ucensee for Follow uo 8.1 Referral letters to the licensee request the licensee to perform the follow up to the concem ensuring that the follow up is independent and addresses the concem.

They are mailed out under the signature of the Enforcement Offmer, with the licensee's response to be sent to the Enforcement Officer. Concurrences for the referral are the OAC, Branch Chief of the branch assigned to do the review of the i licensee's response, and the Enforcement Officer Referralletters are not docketed and contain no distribubon. The only copy other than that mailed to the leoensee will be placed in the AMS case file. The referral letter will contain the AMS case no. and will request that the licensee's response include the AMS case no. foridentsfying purposes. 1 8.2 . Normally, the OAC will prepare the standard referral letter to the licensee using i the concem as the basis for the referral. The referralletter will normally request a i response in 45 days. However, if the ARB elects to request addibonal informabon, the referral letter will be danfted by the lead technical Branch within seven days of the ARB and provided ' ev,-P";to e-mail address OAC3. One of the OACs will then finalize the referralletterwithin the next seven days. i The goal shall be to issue referralletters to he licensee within 14 days of the '

      '            decision to refer the conoom to the licensee. Upon issuance, the %ferralletter" action tab will be closed with the issue date, and a new action tab

• response to referral" (or awaiting licensee response) will be opened and assigned to ElCS for closure with a planned completion date of the date the response is due to be rooerved by the region from the licensee.

8.3 When the licensee's response is received in EICS, the ElCS-AA wlit make a copy of the response and forward it to the assigned branch with a forwarding memo; place the original in the AMS case file, update the AMS to ciose the " response to referral" action tab with the date received, and assign a new acbon " Review Submittal" to the assigned branch responsible for the review of the referral response. The planned complebon date will be 30 days from the date the response is forwarded to the assigned branch. . 8.4 Upon receipt, the assigned brandi will evaluate the response to venfy the accuracy of the details. The evaluabon should first be made to determine if the licensee conduded an independent review of the issue (s) and compare the response with any known facts. The evalumbon should then determine if the licensee's review #5=eseecad the appropriate issue (s) as well as comp;ehensiveness of the response. Upon completion of the review, a closure memo shall be completed synopsizing the licensee's and NRC's conclusions. This memo is a stand alone document and should clearly idenOfy the conoem, the details of what was done to resolve the conoom (including the faci that it was * - refened to the licensee), and the NRC's conclusions regarding the conoom (e.g., whether it was substanbated, parbally substanbated, cr unsubstanbated). The rnemo must also cicarty provide the basis for the NRC's conciusion. If the response indicates that a violabon may have existed that warrants enforcement P.g., not a candidate for enforcement discrebon), then the closure memo should irs $.cate that enforcement is under consideration. (NOTE: In this case, the ' closure letter to the Ci should indcate that the conoom was substantiated, is a

y,. . l l l RP 0517A violation, and that enforcement action is under consideraten.) Any documentation should be written in a style that does not behttle or disparage the Cl, or the significanoe of the concems identified to the NRC. Both documents i (dosure memo and inspechon report) will then be sent under the Branch Chiefs signature to EICS, both elect.T,,-Jcelly (E-mail address OAC3) and hard copy. 8,5 in those cases where the assigned branch condudes, after review of the licensee's response, that there is insufficent informate available to dose the concem, the assigned branch shall develop a course of ac6on to obtain the necessaryinformabon. This proposed course of action shall be discussed with the cognizant Division Director, and upon agreemord, an e-maH or memo should be sent to OAC3 or EICS, descritung what ada w0l be taken and when it will be completed, if the deosion is to re refer the concem to the licensee, the assigned branch will write the letter to the licensee to be issued under the cognizant Division Director's signature, otherwise, steps 8.2 through SA will be repeated for the re-referral 9.0 Refenals of Conoems to Of forconduct of an inveMM 9.1 in cases where the ARB suspects wrongdoing, such as cases of employment

• disenmination or willful violations, the concems wGI be referred to the Office of Investigations for follow up at the ARB. Of wHI open a case file and conduct its investigation based on the priority established for the case (high, normal, and low).. Guidance for establishing investigabon prioribes is outlined in Part IV of Management Directrve 8.8. Es.,Tif4es of vanous priorities are as follows:

              .Hi9_It (1) Ucensee or contractor management (second line supervision or above), Reactor Operator, or Radiation Safety Officer directing, performing, or cGr,dGit,g any deliberate violatm, indudmg providing false information to the NRC or crs.;; ,g false licensee moonis; (2) any individual diredmg, performing, or condorung a deliberate violate where, without considersbon of iritent, the underlyng violation is at least aq'ir'st to a Sevedty Level I,11, or til violabon;   .

(3) disonminate issues where the aneged disonmination is, as a result of providing informaten directly to the NRC, or caused by a licensee or contractor manager above first level supervisor, orwhere a history of findings of disonminsten or DOL settlements suggests a programmatic rather than an ' isolated issue, or alleged blatant or egregious discnmination appears to have occuned; (4) an individual knowingly provides ir,r.e.,W: and inaccurate informahon to the NRC or a licensee with the purpose ofinfluencing a sigrWficant regulatory decision, issuance of a license amendment, or not pi+r 2,9 with an escalated enforcomord schon; (5) an individual wulfully covered 'up a matter so that a required report to the NRC was not made where it would have been likely for the NRC to have promptly responded to the report; (6) an individual willfully provided inaccurale or incomplete informabon to the NRC or a licensee that resulted in the NRC or licensee making a wrong decision; (7) an individual tampered with vital equipment at a power reactor indicating a potential act of sabotage; or (8) any case which would otherwise be dassified at a normal prionty but, there is a need for an immediate invesbgation to ensure evidence is not lost or tampered with.

      +

RP OS17A NORMAL: Cases that are not of high orlowpnonty, including disenmination not amounting to a high poority, relatsvely isolated dekberate failures to file an NRC

                 ' Form 241 (" Report of proposed Achvibes in Non-Agreement States"), and cases where an individual directed, performed, or condoned a deliberate violabon that without consideraison of intent would be categorized at Severity Level IV.

LGMf; (1) situations in which, without consideration, the undertying violation would be characterized s's a minor violation; (2) relatively isolated falsification of a record or falsification of records that are not significant; (3) violatsons caused by careless disregard not covered in higher pnorities; and (4) licensee- or contractor-identified willful violabons of limited safety significance committed by individuals holding relatively low level posihons g.2 Of will provide a copyof the " investigation Status Record"to SCS. The SCS-AA will create an entryin the Of Case Log form (G:\SCS\ TRACKING \0l_ STAT) identifying the AMS file number and the of case number. In addition, the BCS-AA will file the " investigation Status Record"in the allegation file, mark the outerJacket of the allegation file'to show the Of case number, and update AMS to show the appropriate conoom as being under 01 invesbgation with the appropriate pnonty, g.3 NormaDy, 01 will conduct or sdiedule an interview of the Cl within 30 days of ace,; .g the case. In those cases, a copy of the interview transenpt wiB be provided by Of to SCS. Upon receipt, the SCEWW wBl prepare the forwarding memo to the assigned technical branch (G:\SCS\BOILERSiOl_INTRV.LTR), create an action tab for the concem entitled " Review Of Transcript" to the assigned branch with an assigned date of the transmittal date of the interview, and a due date of 30 days after the assigned date, g.4 Upon receipt of the E Q and memo from BCS, the assigned Division should issue an AITS item to complete the transcnpt review and forward the results to SCS by the assigned due date in the memo from BCS. The E,icW shall be reviewed by the assigned tedinical branch to detemune if any new concems have been described and to determine if any change should be made to the 01 priority for the case onginally established at the ARB. Upon complebon ofits review, the assigned tedinical brandi wiR issue a memo to SCS with a copy to 01 indicating, if any new technical concems were identified, and if so, what they are, and whether the 01 invesbgabon priority should be dianged or if the irwestigabon j should be terminated (i.e., no indicatsorts that wmngdoing was reaRy alleged or i that a discriminsbon case can be pursued). g.5 Upon receipt of the 01 interv ew response memo from the assigned technical brandi, the SCS-AA wRI place the memo in the i;=E , tRe and update AMS to { 1 indicate that the brandi review was completed as of the date of the memo. The ' AMS adion tab '01 investigation" wRI not be modified. If the memo indicates a diange in pnority, the existence of new concems, or a proposal that the invesbgation be terminated, the memo wul be' provided to one of the OACs to schedule a tollow up ARB (proposal to terminate investigation or diange 01 j poority) or create a new allegation case file (existence of new concems). . t l,

Fa , . l i l 1 RP 0517A 9.6 Upon receipt of the Of investigation report, the BCS-AA will provide one copy to the Enforcement Officer and the other copy to one of the OACs for forwarding to

                  ' the assigned technical branch. The SCS-AA willalso update the Ol Case Log form (G:\EICS\ TRACKING \OI._ STAT). The OAC will first review the synopsis to determine whidi of three categories the report falls under: willful violation          '

identified, no willful violations identified, or case closed based on resource s considerations. Depending on which category, the following steps will be taken to  ! close the allegation file: 9.6.1 Case Closed - Investiaation Completed: The OAC will prepare a forwarding { memo for the report depending upon the results of the investigation l (G:\EICS\BolLERS\OHtEPOR.YES or.NO) requesting the assigned technical i branch to review the report, determine if there are any new tedinscal concems ' identified from the exhibits, and determine if they agree with the condusions in the report. The results of this review will be provided via a closure memo to SCS I within 15 days of receipt of the report for review. The AMS will be updated by

• closing the '01 investigation" tab with the date of report issuance; creating a  !

                 " Review 01 Report" tab assigned to the ef+cer,i;ete technical brandt with a 15 day due date from the date of the memo transmitting the report; and creating an

• Awaking OE Memo
• tab assigned to ECS with a due date of 21 days after receipt )'

of the Of report. 9.6.1.1 The assigned Division, upon receipt of the report from BCS, win assign an AITS kem for es.T.f/e:'ei, of the review with a due date as specified on the  ; memo tier.eir.;t;; w the report. The assigned technical brandi wlH review i the report to determine what enforcement should be taken orif they disagree with Ol's conclusions AND determine if any unresolved tedinical issues exist. Upon completion of the review a closure memo shall be completed providing the NRC's condusions, and, if sf+ief,i;ete, the basis , for disagreeing witn Ol's condusions. This memo is a stand alone document and shouki dearly identsfy the concem, the details of what was done to resolve the conoom (includeg the fact that M was referred to 01), , and the NRC's condusions regarding the conoom (e.g., whether M was , substanhated, partsaNy substantsated, or unsubstantiated). The memo must also dearty provide the basis for the technical division's condusion if i M disagrees with Ol's conclusion, and whether there are any unresolved technical issues, and if so, what they are. The memo should be written in a style that does not belittle or disparage the Cl, or the significanoe of the conoems identified to the NRC. The memo shall be sent to the Enforcement Officer, with copies to 01 and the SOAC under the Brandi 1 Chief's or higher signature both eledror.ically (E-mail address OAC3) and hard copy. 9.6.1.2 Upon receipt of the dosure memo from the assigned technical branch by - EICS, one of the OACs wn! dose the assigned schon tab "Rewow Ol Report" using the date of the memo. The case file wHI remain open until receipt of the three week OE memo. Upon receipt of the OE memo, the , EICS-AA wiu make a copy and place R in the allegation file as well as ( provide a copy to the Enforcement Officer. AMS wSI be updated to dose t

7 . -1 3 .. . I RP 0517A the adion tab ' Awaiting OE Memo" based on the receipt date of the memo. The allegation file will be provided to one of the OACs to review and determine if the OE memo is in agreement with the conclusions reached by the assigned technical branch, i.e. no enforcement adion is necessary, if so, the case can be cdosed (proceed to Sechon 10 of this procedure), if not, an assigned adion tab

• Enforcement Adion" wit! be created for the concem with the assigned technical branch being responsible for closure. The assigned date will be the date of review of

                                                                                                                ~l the allegation file, and the due date will be 30 days after receipt of the          l Oi report. Also, if the case involves a determination that the licensee or contractordisawninated against an employee for raising safety concems, a "chillmg effect* letter will be issued to the licensee as described in Sechons 11.1 and 11.2 of this procedure.

9.6.1.3 For those cases where the region disagrees with OE or 01, or the region agrees that enforcement action is spfA,,iiee, an Enforcement Panel will be held within 4 weeks of the issuance of the 01 report (per Section 7.5.4.4 of the Enforcement Manual) to resolve the course of action for the issue. The condusions of the enforcement panel will be documented in an "OE Understands" memo, whmh will be provided to ElCS by OE. Upon receipt, the ElCS-AA will make a copy of the memo for the r":;&{. file and prowde both the r":Tl:{i file and memo to one of the OACs for review. The OAC will determine if enforcement is being taken. If not, the " Enforcement Action" tab can be dosed with the completion date being the date ofissuanoe of the "OE Understands" memo. If enforcement is being taken, the closure of this tab will occur with the issuance of the enforcement action (EXCEPTION - If there is no Cl or the CI does not wish to be informed of the results of the NRC's review of his concems, the closure of the tab, the allegabon, and AMS files will occur with the receipt of the "OE Understands

• memo).

9.6.1 A Upon issuance of the enforcement acbon, a copy will be made by the EICS-AA and placed in the allegation file. The " Enforcement Adion" tab . will be closed based on the issuance date of the enforcement schon. The

                          " Closure Letter" tab will receive an assigned date of the issuance date, with a due date of 30 days after the issuance date. The :"7^+i file will then be pmwded to one of the OACs for complebon of the closure letter

{ (see Sechon 10.3 of this procedure).  ; 9.6.2 Case Closed - Investmabon Not Performed due to Hiaher Priority Woric The OAC will prepare a forwarding memo (GAEICSBolLERSci-ADMIN. LOW) for the  ; 01 report requesteg the assigned technical branch to rewsw the report and i determine if there are any new techncal concems based on a rewow of the exhibits and determine if further resources should be expended to resolve the concem. The AMS will be updated by dosing the "Oi inveshgation* tab with the date of report issuance; creatmg a

• Renew Of Report" tab assigned to the  !

appropriate technical brandi with a 30 day due date from the date of the memo l transmittmg the report; and creating an 'Awasteg OE Memo

• tab assigned to EICS with a due date of 30 days after receipt of the 01 report. ,,

a

RP 0517A 9.6.2.1 The assigned technical brand will issue a memo to SCS stating whether there are any new technical conoem(s), and if so, what those conoem(s) are. In addition, the memo will also provide a moommendation regardmg the expenditure of further resources to resolve the original concem(s). The memo will be provided to SCS both by hard copy and via e-mail (e-rnail address is OAC3). 9.6.2.2 Upon receipt of the technical branch memo by BCS, one of the OACs will close the assigned schon tab

• Review 01 Report' using the date of the memo. The allegation and AMS fi'es will remain open until receipt of the OE memo. Upon receipt of the OE memo, the BCS AA wlE make a copy arW place it in the allegaten file as well as provide a copy to the Enforcement Omoor. The AMS file will be updated to dose the action tab "Awastmg OE Memo" based on the receipt date of the memo. The adion tab
• Follow up ARB" will be opened and assigned to SCS with an assigned date, of the date of receipt, of the brand's memo, and a due date of 10 days after receipt of the memo.

9.6.2.3 Regardless of the positica taken in the technical brarxn memo, a follow up ARS is necessary to obtain regional management agreement to resolve the concera(s), with or without additenal expenditure of resources (see MD 8.8, Sedion IV.F.2 and Enforcement Manual section 7.5.3). One of the OACs will s&edule a follow up ARS within 10 days of receipt of the memo from the assigned technical Brand. A copy of the OE and techtical brandt memos wiu be included in the package provided to the board members for the follow up ARB. 9.7 If any of the above-specified assagned technical brared reviews identify new technical cc,,ces,(s), one of the OACs wCIinitiate processing them irdo the allegation system in accordance with Sedion 4 above. New concems simuld not be added to an existing case file unless the conoems are a subset of those conoems already in the file. For example if the "new' concem is that the root . cause evaluation for a diesel generator failure to start event was inadequate, but the original concem is that the diesel generator is inoperable, this could be considered a subset of the original concem, since ensuring the diesel was operable would necessitate ensunng that a failure everd had been M+;;ti evaluated and comeded. Conversely, if the "nev conoom were that the diesel generator testing records were iniw,upi.T/ discarded, this would not be a subset of the enginal conoem, and would be entered into the system as a new allegation. 9.8 FWi,g issuance of the 01 report in which 01 finds that there was not suffident evidence to substanhate the alleged wrongdoeng, OE issues a memo statmg that it does not appear that enforcement is warranted and providag three weeks for addressees to review the report and provide dissenting views. 9.9 At the point where a dosure letter can be written to the Cl, (e.g., after the OE memo discussed in Sedion 9.8 has been issued and the three weeks have elapsed or the apparerd violabons, if appropriate, have been issued to the' licensee) a copy of the synopsis of the 01 report will be provided as an enclosure

} ', - , . l, I l 'l i ! RP 0517A  !' I to the closure letter sent to the Cl. (NOTE: In those cases where enforcement l action was taken, the synopsis will not be sent to the Cl until the letter to the licensee enclosing the synopsis has been sent). IN ADDITION, a copy of the synopsis will normally be nailed by the OAC directly to the licensee or contrador informeng them that the Of investigation has been dosed for those cases where the licensee has not otherwise been informed in writing (i.e., cases where l wrongdoing is found and enforcement action is proposed). The synopsis will not i be provided to the licensee or contractor if the " C's review of it determines that the synopsis contains information that would disdose the identity of the Cf. In that l case, the letter to the licensee should summarize the Of condusions without  ; i

                   . providing a copy of the synopsis. The letters can be sent provided the approving               I l                     official of the Of report and the Diredor, OE, concurin the letter to the licensee.

l Their concurrence indicates no dissentog views were received or the dissenting , views were resolved, DOJ dedined the case or completed its action, and the NRC does not intend to take enforcement action on the wrongdoing issue. Copies of the letter to the licensee or contractor will be placed in both the ::::S file and in the public document awn, and a copy af the letter to the Cl will be plaed in the l allegation file.  ! 1 l 10.0 Closure of Alleoation and AMS Files 10.1. Upon receipt of the dosure memo (with attached inspechon report, if appropriate) from the assigned branch, the EICS AA will place the hard copy of the memo in the allegation file, dose out the action tab in AMS assigned to the branch based l. ' on the receipt date of the electronic e mailed letter, and place an assigned and planned ~wnplebon date on the "dosure letter" adson tab. The assigned date is the date of receipt of the closure memo, and the planned completion date is 30 days thereafter, in addihon, if the '64Aonth ARB Meetag" adson tab is still open, this tab will be deleted from the required actions. The ElCS-AA will inform the SOAC that the file is ready for review and issuance of a closure letter. 10.2 in those cases where there is no need for a dosure letter to the Cl, such as anonymous, inspector-idenhfied, iwz e: 1,1~ :1 or cases where the Cl . refuses additional contact, the allegatio cad AMS files will be dosed. The AMS l file will be updated to show that the allegas*mn file is closed effective with the l issuance of the dosure memo, if the *G4Aonth ARB Meeteg" adion tab is still ! open, this tab will be deleted from the requwed ac6cas. The ElCS-AA willinfonn ! the SOAC that the file is ready for review. Upon sW::N of the review, if all concems were property addressed, the ::::Z:s file will be marked CLOSED" on the frord outside Jacket of the file and retumed to its appropriate file locahon. ) If conoems were not property addressed, the technical brandi will be contaded to provide appropnate informathon to dose the concom. 10.3- In cases where escalated enforcement is p ,,cs.d to address one of the CI's concems as noted in the brandi's dosure memo to EICS, one of the OACs shall update the AMS file by opening the " enforcement" achon tab and assigning the item to ElCS for complebon. A best estwnste of the expected-enforcement action issue date should be placed in the *due date" field, and the assigned date should be the date of the dosure memo. Upon issuance of the schon, the achon tab will ,

y R . L l RP 0517A be closed and a copy of the enforcement action included as an endosure to the closure letter sent to the Cl. 10.4 ~ In those cases whera a Cl exists and has not refused addnional contact from the NRC, a closure letter will be issued to the Cl describing the results of the NRC's review of all of the CI's conoems. If a status letter has previously been issued that dosed one or more of the CI's concems, a reference to the status letteris acceptable in the closure letter for the specific concem being closed. One of the OACs will review the file to ensure all conooms were property dosed. If so, the closure .. Merwill be prepared using the appropriate portes of the bouerplate contained in the GAEICS\SolLERSCLOSURE.BOL example. The dosura letter l must describe how eadi conoom was evaluated, and results of the NRC's review, including any enforcement that may have been taken. In those cases where the results of the follow up to the concem results in escalated enforcement orwhere an 01 investigation conduded that a willful violation oocuned, the dosure letter must itdude documentation of the results. This means, it: the cases where enforcement results, the dosure letter shall include a copy of the enforcement schon issued to the licensee (mciuding of cases resulting in enforcement). Additionally, for Of investigation cases, the synopsis of the 01 repost should be induded as an endosure to the closure letter to the Cf. In cases where the information in the file is insuffident to support dosure of a concem, the technical brarch will be contacted to provide appropriate documentation to support closure of the concem. 10.5 The closure letterwill be prepared by one of the OACs to be signed by the assigned Dnnsion's Oweetor. Concummces willindude the EICS ollicer, assigned Brandi Chief, appropnate Projects Branch Chief, Regional Counsel, and the assigned Division Diredor. The dosure letterwill be sent to the Cl by certified mail, with a retum receipt request.~ 10.6 Prior to mailing the closure letter to the Cl, the SOAC will determine, on a case by case basis, whether the Ci should be contacted prior to mailing of the closure . letter. If so, one of the OACs wiR make reasonable attempts to contact the Cl, with technical assistance as necessary, by phone prior to issuanoe of the closure letter. As always, if the Clis contaded, the phone conversabon will be documented and maluded in the mRegabon fue. 10.7 Upon mailing of the dosure letter, the ElCS-AA shau make a copy of the letter, place it in the allegation file, and make an entry in AMS indicating the date the closure letterwas maRed.' The AMS file wul be closed with the closure date being the maRing date for the closure letter. The auegabon file win be ' marked "Cl OSED" on the front outside Jacket of the file and retumed to its appropnate file location. 11.0 Special Considerations for Cases involvino Discrimination (DOL Involvement) 11.1 Allegations conoeming employment disenmination have an addibonal potential to cause an envronment at a licensee's facility where s.,T,pk i ;;; fall to bring up safety conooms for resolubon. This *chiRing effect" must be addressed by the NRC. For concems involvmg *diilled envuonment", the ARB must decide whether 1

i [ ,. . , i

     .                                                                                                       i f

1 l RP 0517A 1

                     - the licensee should be issued a " chilling effed" letter in addition to any other activities the NRC may perform to resolve the conoem. If an employment discriminaGon concem has been substantiated either by NRC or DOL or if the ARB deades that a

• chilling eNed* letteris to be issued, the adion tab in AMS

                      *chillmg eNect letter" will be assigned to EICS with a due date of 30 days fmm the     )

I date of the AR8. One of the OACs will prepare a chiHing eNed letter to the licensee to be signed by the assigned technical Division Director or Regional Administrator. The letter will request the licensee to respond to the NRC with what achons it is taking to eliminate the potential that employees will not raise safety conoems. 1 11.2 Allegations conceming employment discriminabon, in addNion to the above process, also include the potential for a duplicate invesbgaban to be performed by the Department of Labor, Occupational Safety and Health Administration (DOL-OSHA) as requirged by Section 211 of the Energy Reorganizabon Act The NRC may become aware of these concems directly from the Cl, or indirectly from ' DOL in these cases, it is important that the a5egabon file.contain the required informabon regarding both he NRC's and DOL's invesbgative efforts. In cases where the aneged concom involves employment descrimmation, the OAC will ensure that the AMS shows the allegation as a *Sechon 211 - yes" and the concem win show the "211 box" cheded. ' If the NRC does not have a copy of a DOL complaint for this concem, an schon tab "dwclt DOL status" wul be assigned '- to ElCS with a due date of 185 days after the date of the aueged disaiminatory act. "Ihe case will remain open unti 185 days even if 01 has closed its ' investigation to ensure that the 180 days allowed by law for the Cl to file a

            .      complaint has expired.

l 11.3 ff no subsequent filing is received from DOL-OSHA specific to the concem, one of the OACs will contad the appropriate DOL-OSHA field offices to determine if a complaint was filed on the assigned due date for the "decic DOL status." If a complaint was not filed, the *checic DOL status" adion tab wRI be dosed as of the date of the phone call, and a record of the conversabon documenbng "no DOL case was filed" wRI be placed in the aNegation file. It is imperatrve to wait for the . due date prior to making the call to allow the ciodt for filing a DOL complamt to expire. A call earlier than the due date could lead to false information, as the Cl could stRI legally file a valid complaint after the call. If the Cl did file a disaimination case with DOL-OSHA, the OAC wlH request a copy of the comolaint be provided dwectly to the NRC Region 111 Enforcement Officer, and request that any future documentaban conceming the case (AD Deasion, field invesbgator's narrative report, appeal of AD decision) also to be pmvided diredly to the NRC Region Ill Enforcement Officer upon issuance. . 11.4 Upon receipt of the disenmmabon complaint from DOL-OSHA, the ElCS,AA will make a copy and include it in the applicable a5egation file, and update AMS to show a completed date for the " DOL Complaint Filed" achon tab of the date the complaint was received. The ongeal will be provided to the Enforcomant Officer, if it exists, the "Chedt DOL Status

• ac6cn tab will be closed effedwe with the date of receipt of the complaint. In addition. a new ac6on tab
• DOL AD Decision" will be entered into AMS and assigned to ElCS with a due date of 45 days from the i

     ,   < 0

\ a RP 0517A ) date of the filing of the complaint by the Cl. The EICS-AA will update the file G:\EICS\ TRACKING \DOLTRACK.TBL" to show the appmpriate information. 11.5 Unless the Area Directors (AD's) decision and field investigators narratsve r. sport have already been received, one of the OACs will contact the appropnate DOL-OSHA Area Director on the due date in AMS to determine the results af the 1 DOL-OSHA investsgation into the disenmination ceT+1,.,,E The AMS will fee updated to reflect the new s&edule forissuanoe of the decision, if one itas not yet been issued, if the decision has been issued, the OAC will request a copy of the AD decision and field invesugators narrative report be sent to the NRC- i i Region III Enforcement Officer as soon as possble. The OAC wlR also request j i ' that a copy of au future correspondence regarding the case be sent to the NRC l Region tu Enforcement Officer. .

                                       ^

l 11.6 Upon receipt of the AD Decision and field investigators narratrve report from DOL-OSHA, the ElCS-AA will make copies and provide one to 01. The onginal j will be provided to the Enforcement Officer. Also, a copywiu be placed in the i applicable auegation file, and AMS will be updated to show a completed date for  ; the "AD Decision" schon tab of the date the AD Decision was received. A new { action tab

• DOL Appeal Filed" wNI be assigned to ElCS with a due date of 15 days .

from the date of the dedsion. The ElCEMA wlR update the file  ;

                    "G:\EICS\ TRACKING \DOLTRACK.TBL" to show the appropriate informabon.                     I 11.7   Unless the Haquest for Appeal" has already been received, one of the OACs wul contact the DOL Administrative 1.sw Judge (AU) Oflice on the due date in AMS to            .

determine the status of an appeal of the AD's decision. It is imperative to wait for the due date prior to making the caN to allow the dod for filing an appeal to expire. A call earlier than the due date could lead to false informahon, es the CI or licensee could stiu legaNy file an appeal after the cau. The AMS wlN be updated to reflect either that the AD's decision is final (e.g., the " DOL Appeal Filed" antim tab will be deleted and the AD decision annotated as being final), or that the appeal has been requested from the AU Office. If an appeal has been filed, the , ) OAC will request a copy of it be sent to the NRC Region lit Enforcement Officer as  ; soon as possible. The OAC wiu also request the AU Office to include the NRC  ! Region 111 Enforcement Oflicer on the service list for aN issuances pertaining to the case. In those cases where the appeal is filed by the licensee or contrador, a diluing effed letter wlN be issued per Sedian 11.2 above (See enforcement manual Section 7.7.3.2.b) if one was not already issued 11.8 Upon receipt of the DOL appeal filing documentation, the EKEAA will make s l copy and place it in the applicable allegabon 15e. The onginal wiu be provided to the Enforcement Officer, in addition, the EICEMAwill annotate the DOL case number on the cover of the auegation file, and AMS will be updated to show a completed date for the " DOL Appeal FNed" adson tab of the date the appeal was received. Two new schon tabs," DOL Hearing S&eduled" and *AU Deasion" will be assigned to EBCS. No due date win be assigned for Au decision, however, the DOL Heanno tab wiu show an assigned due date of 45 days from the date of . receipt of the appeal. The EICS-AA wHI update the file "G:\EICS\ TRACKING \DOLTRACK.TBL" to show the appropriate information

~

                                                                                                                  )

RP 0517A 11.9 Unless the hearing schedule has already been received, one of the OACs will mntact the DOL Administrative Law Judge (AU) Office on the due date in AMS to determine the status of the hearing. If the ALJ's Office provides a hearing date, the OAC will enter that date into AMS as the due date for the action tab. If the heanng has been held, the AMS action tab will be closed with the completion date being the date the hearing was completed. 11.10 Upon receipt of the AU Recommended Deasion, the BCS-AA will make copies and provide one to 01. Also, a copy will be placed in the applicable allegation file, and AMS will be updated to show a completed date for the 'AU Decision" action tab of the date the AU Recommended Decision was received. The original will be provided to the Enforcement Officer. A new adion tab " DOL ARB Decision" will be assigned to SCS with no due date. The BCIMA will provide the allegation file to one of the OACs and update the file: i "GASCS\ TRACKING \DOLTRACK.TBL" to show the appropnate information. Of  ! note, the AU's Decision is only a recommendation and does not constitute final  ! action by DOL However, NRC will initiate enforcement at this point if the Au decides that discrimination occuned. In addstion to direct receipt, copies of the AU Recommended Decision can be obtained over the Intemet at the DOL address "http://www.oalj. dol. gov /public/wbic=/in,dwinistm.htm". 11.11 Upon receipt of the Administrative Review Board's final deasion, the BCS-AA will make copies and provide one to OL Also, a copy will be placed in the applicable  ! allegation file, and AMS will be updated to show a completed date forthe  !

• DOL ARB Decision" action tab of the date the Fsnal Decision was received. The ,

original will be provided to the Enforcement Officer. At this point the DOL ' proceeding has concluded and the Final Decision constitutes DOL's final dedsion on the case. The BCS-AA will update the file "GABCS\ TRACKING \DOLTRACK.TBL" to show the appropriate information. Final decisions can also be obtamed over the intemet at the address shown I above. If this was the only concem renwining open in the n'tM=i, the closure letter can be issued to the Cl as desaibed in Section 10 of this procedure. 11.12 In many instances, the DOL proceeding is settled at some stage between the CI's' submittal of a complaint and the Administrative Review Board's final decision. In those cases, there is usually no conclusion to establish whether discriminsbon occuned. Upon leaming of a settlement agreement, the OAC will dose all DOL- ' related action tabs and assign the " DOL Settlement" adion tab to BCS with a  ! completed date of the date the settlement was approved by DOL (either the Area l Dwector or Administrative Review Board may approve the settlement). The OAC will ensure that the allegation file contains a copy of the Settlement Agreement and DOL approval documentation. The concem may be dosed at this point only if the NRC has already reached its own decision on the validity of the concem via an 01 investigation, if this is not the case, a follow up ARB must be heid to determine what schon will be taken to resolve the conoem. The follow up ARB will be scheduled withe 30 days of receipt of the Settlement A0reement, and a copy of the agreement will be provided as beyvund for the ARB meebog 11.13 in those instances where 01 completes their investigation of a disenmanation concem with a finding on the ments prior to complebon of a hearing before the --

., f .- ) RP 0517A DOL ALI on the same discnmination concem, the Of report will be evaluated by OE, who will determine ifit is to be released to both parties in the DOL proceeding, regardless of the findings. The OAC will contact OE and advise them that a DOL pmoeeding is ongoing - OE will determine when the parties to the DOL proceeding will be informed of Ol's conclusions. OE will inform the region of its decision dunng the weeldy conference call or in the three week nMunorandum. Once OE has approved releasing Ol's findings to the parties to the heanng, one of the OACs will prepare the transarttalletters to the parties. The letters will inform both parbes of Ol's conclusion and note that the conclusion is under review by the staff and is not the final agency posihon. The synopsis will be induded as an attachment if a predecisional enforcemerd conference is to be held for a discrimination ccec.T., the Dunctor, OE will decide whether the licensee will be provided a redacted copy of the 01 report (to be provided by 01) rather than the synopsis. if the redacted. report is provided to the licensee, the redacted report will be placed in the POR and the Cl will also be provided a copy of the redacted report. The letter should also inform both parties that the complete report may be requested under the Freedom of information Act if the synopsis only is sent to the parties. The letter to the licensee or contractor will be conouned in by the Duector, OE and the approving of5cial of the 01 report. A copy of both letters will be placed in the " ;:Swi and enforcemerd files. 11.14 Informa6on developed by DOL or obtained frorn DOL, which was not made available to the public by DOL, will be pmoessed in accordance with 10 CFR l 2.790(a). Examples of the DOLinformation whidiis EXEMPT FROM PUBLIC DISCLOSURE are DOL investigation Reports and Settlement Agreements. Any request for this information under either the Freedom of information or Privacy  ; Acts must be identified to DOL through the OAC and FotA Coordinator. ' l 12.0 ref,eJ,c Statusina of Open Alleastion Files: The agency goal for complebon of allegabon cases is 180 days from the date of receipt of the ": ="= to the date the Cl is provided feedback on the results of the NRC's evaluation of his/her evi,ce,T,(s). it;;;ve , there are cases that may not be completed within the goal due to the need for Oi or DOL involvement, or compleaaty of the issues. This , section addresses actions taken to managa those cases where the ":;ER-3 may  ; not be completed within the spedfied agency goal. l 12.1 Once eadi month, or as requested by the Dmsion Duector, the EICS-AA will . generate it e full set of status reports for all open :":;nxi cases. The titles of i the reports, distributson, and conterd are as described in Attachment 4 to this J the ElCS-AA will generate status reports 5,6, and 10 as procedure. Ei ;;;;' y, described in Attachment 4 for distribubon to the tedvucal branch chiefs. 12.2 Once each month, normally the first Friday of the month, the Regional Administrator will meet with all technical Division Duectors, the Enforcement Officer, and the OACs to discuss the status of all allegabons open greater than 180 days from the date of receipt. This meebng is routinely sdwduled by the ElCS-AA, who will also prepare the " Allegation Snefing Sheet" as described in Attachment 4. This sheet is distributed two days prior to the meetmg with the Regional Administrator. The purpose of the meeting is to discuss what actions are prevenhng the file from being dosed and establish prionties and sdiedules to l

F 7, .. .

                                                                                                              .m RP 0517A expedite completion of the case. For those cases involving 01, the discussion will also include whether the Of priority should be raised during the next 01 monthly status meeting.

12.3 Once each month, normally the third Friday of the month, the Deputy Regional Administrator wil! meet with all technical Division Diredors, Regional Counsel, the Enforcement O.Ticer, and the OACs to discuss the status of all allegations open greater than 120 days from the date of recespt. This meeting is routinely scheduled by the ElCS-AA. The meeting has a two-fold purpose, namely, to serve as the follow up ARB for those cases where technical concems remain open and the last ARB was more than four months previous, and to allocate resources to addmss those concems not involving DOL or of follow up to resolve issues prior to them becoming greater than 180 days old. For those cases where this meeting serves as the follow up ARB, the OAC shall document the results of the discussions for the case in the allegation file and update the AMS system to incorporate the' decisions made at this meeting. 12.4 Once each month a. status briefing is held between Of and the technical Division Diredors to discuss the status of all currently open 01 cases. One of the OACs will attend this status briefing. The primary purpose of the trs:.c,g is to ensure the 01 prionbes are appropriate, given the safety significance and age of the case and obtain a projechon on when the investigation will be completed.~ 12.5 in addihon to the follow up ARBS described in Sechon 12.3 above, the OAC will include cases requitmg follow up AR8s based on the information developed during O! report or transcript reviews or inspec6on actrvibes (for example, where

                  ~ the inWM determines that the violation may have been willful) determine that a follow up ARB is needed. These follow 4sps will be included in the next regulatty-scheduled weeldy ARB. The OAC shall prepare a " Follow up ARB' memo to the cognizant Branch Chief that specifies the upcoming date for the ARB, why a follow up ARB is bemg held, and specifies what is to be deaded at the ARB concoming that allegation. A copy of the background information will be included with the memo. The ElCS-AA will pmvide copies of the memo with               .

attactiments as follows: the DRS Division Diredor for reactor cases, DNMS Division Dwedor only for materials cases,01 Regional Field Office, and Regional Counsel. 'The original of the memo will be placed in the :": :'l:-;i file (which will be provided to the DRP DMSION Diredor prior to the ARB), and will include an attendance and approval sheet for the upcoming ARB. The EICSWM will also update AMS by puttog a " Follow up ARB* achon tab in if one does not already exist with a due date of the date of the scheduled follow up ARB. 12.6 Prior to the ARB, the cognizant technical Branch Chief for the concem will review the recommended course of adion based on the addibonal background information obtained from the list provuled on the " Allegation Adion" page and esther concur or revise the recommended action. Just prior to the ARB, the Branch Chief will provide the marked page to the OAC in attendance at the ARB rrs;.i,g. Documentation of the results of these follow up ARBS.will be done in accordance with Sechon 6,8 above. I

< :. 4 . I l l J l l 1 RP 0517A 12.7 When follow up ARB information is placed in the AMS System by the OAC, a - check will be made to determine if the Cl has been contacted with a status to the concems. If not, the OAC will prepare a status letter using the "G:\EICS\ BOILERS \ STATUS.BOL* de' aft. This letterwillindicate which,if any, concems have been resolved and their results. The letter will have the same  ; concurrences and signature as a closure letterif there are examples of concems I being closed; otherwise, it will have the signature for an acknowledgment letter 1 (See Sechons 5.3 and 10.4 above). l I 12.8 Ead Monday moming prior to the EICS 8:00 a.m. meeting, the EICS-AA shall print out the following reports from the AMS system Initial ARBS Due, Referral Letters Due, Acknowledgment Letters Due, Closure Letters Due, Days Since Last Contact,64Aonth ARBS Due, and 10-Month ARBS Due. Copies of these reports will be provided to both of the OACs and the Enforcement Officer for review. The OAC shall evaluate each report and implement the action necessary to , prevent the item from exceeding the overdue date. 12.9 in cases where follow up ARBS are required, the OAC will ensure they are i sdeduled within the following three weeks, but prior to exceeding the required I time frame for follow up ARBS (180 days after initial, subsequently every 120 days). l i 12.10 in cases where referral or acknowledgment letters have not been issued, the OAC will ensure that they are drafted and provided for signature within the following two weeks. Similarly, if the last contact with the Cl has been in excess of 150 days, a status letterwill be prepared and issued to the Cl within the following three weeks. Attachments: 1. Guidance for Handling incoming Allegations i

2. AMS Action Tab Usage I

3. Assegnment of Responsibilities

4. Reports Generated from AMS l S. Glossary of Terms

RP 0517A INSPECTOR GUIDANCE FOR HANDLING INCOMING Al i FGATIONS i l

      'the following guidance is provided to ensure that a Region lil OAC is involved, to the extent possible, in receiving an allegation.

Method of Allegation Receipt Appropriate NRC Staff Response

1. Cl goes to the resident office or other 1. Attempt to get one of the OACs on the phone, private office space to speak to an inspector, to take the allegation. If one of the OACs is not immediately available orif the CIis unwilling to  !

participate in the call, take the allegation, document it, and forward it to one of the OACs. The inspector should provide a copy of NUREG/BR41240, " Reporting Safety Concems to the NRC," to the Cl.

2. Cl calls an inspector (Resident orRegion 2. If the phone has 3rti party add <m capability, try Based) on the phone. to get one of the OACs on the phone to take the allegation, othenese, take the allegation. If one  ;

of the OACs is not immediately available orif the l Cl is unwilling to partacipate in the call, take the ) allegation, document it, and forward it to the l OAC.

3. Ci speaks to an inspectorin the field. 3. (a) Invite the Cl back to an appropriate office space (e.g. the resident's office) and try to get one of the OACs on the phone to take the allegation. If an OAC is not immediately available or if the CI is unwilling to participate in the call, take the allegation, document it, and forward it to the OAC . The inspector should provide a copy of NUREG/BR-0240, " Reporting Safety Concems to the NRC", to the Cl.

(b) If the Cl is unwilling to go with the inspector to an office space, take the allegation in the field, document it, and forward it to the OAC .

4. Inspector receives an anonymous 4. Take the allegation, document it, and forward message via answering machine or voice it to the OAC.

mail. Note. If the OAC is unavailable, the inspector should, at a minimum: (1) take the e".eg.tisa; (2) obtain the Ct's name, address, and t;';,A,Gne number; (3) determine if the Cl will allow follow up of the concem by the licensee and whether he refuses to have his identity disclosed; and (4) document the allegation and forward the information to the Branch Chief and OACs via E-mail within three workdays. Do not include the CI's name, address, or telephone number in the

   - Egnait. Provide that information to the OAC through the mail in an

• addressee only" envelope or by telephone. The OACs will contact the Cl if a follow <sp call is needed NOTE if e6plGyiweat disenmination concem, remind Cl they have'180 days to file with .

DOL-OSHA. l

RP 0517A Al i FGATION MANAGEMENT SYST1EM ACTION TAB USAGE The AMS system uGlizes action tabs to assign schons for each conoem identsfied in an allegation

            ' file. The use _of the action tabs is as spedfied in the procedure, and is summarized in the following table:

AC110N TAB ' fASSIGNED DUE DATE COMPLETED USE DATE . DATE

' %xt:1;-Tient AV% -               30 days after      Date letter       Adi-ri:i;=5 recespt of concems Latter                   receipt date        allegation        mailed             from Cl, advises DOL nghts, and i-                                              receipt                              desaibes idendty protechon status (Sec6on 5.3).
' Status Latter            Upon                6 months          Date letter        Provides Cl with periodic feedback determining .       after ack.         mailed             on the status of NRC's review of the need based on       letter issued .                      concerns Per MD 8.8, required i

I status report every 6 months (Sections 12.7 and l 12.10).

     . wre Letter         Date of receipt     30 days after      Date letter       Provides Cl with results of NRC's       !

of closure _ assigned date mailed review of the concems (see memo for last Section 10.3). open concem initial AR8 Meeting Allegation 30 days after Date of ARB Determines NRC's actions to resolve receipt date allegation meeting the concems (see Sections 5.1, 6.1, receipt and 6.8). 6 Month ARB Upon 5 months Date of ARB Required for all allegations still open Meeting . determining after initial meeting after 180 days from receipt,that do  ; need based on ARB (delete if not involve DOL or 01 (see status report not needed) Section 12.3). Follow up ARB Upon As required by Date of ARB Required for every case open Meeting determining ARBS, or meeting beyond 10 months and where initial need based on every 4 ARBS recommend fouow-ups, except status report months after for 01 or DOL cases (see 6 month ARB Section 12.5). Of Investigation Date accepted Leave blank Date report Used when Of takes a concem for at ARB (01 allowed with a follow up review (see Section 9.1). 18 months for synopsis of closure) condusions provided to EICS

i l RP 0517A ACTION TAB ASSIGNED DUE DATE COMPLETED USE DATE DATE RIviewOf Report Date forwarding 15 days after Date of receipt Used to assign review of the 01 memo sent to forwarding to of memo from ' report to the assigned technical  !

            ',           technical         assigned        assigned branch division to determine next course of      )

technical technical action upon 01 completion (see branch branch i Section 9.6 and subparts).  ! Review Of Date . 30 days after Date of receipt Used when Of conducts an initial Transcript forwarding forwarding to of memo from interview with Cl prior to continuing memo sent to assigned assigned investigation (see Sections 9.3, 9.4, technical technical technical and 9.5). < branch branch branch l Referral Letter Date of ARB 30 days after Date letter Used to refer concems to the that assigned ARB decides mailed to licensee, OSHA, or other agencies the action letter to be licensee for follow up (see Sections 6.9.1, issued 6.9.2, 6.9.3, 8.1, and 8.2). Response to Date letter Date specified Date response Used to track receipt of the . Referral. mailed to - in letter for received from response from the licensee (see licensee licensee to licensee Sections 8.2 and 8.3). send response Review Submittal Date response 30 days after Date of receipt .Used to track review of the received from response of closure licensee's response by the assigned licensee forwarded to memo from technical division and receipt of a assigned technical closure memo for the referred technical branch concems (see Sections 8.3 and 8.4). branch latter from Alleger Date of receipt Leave blank Same as Used when a document is received of letter assigned date from the Cf. Phone Call Date assigned Leave blank Date call Used when a phone callis assigned I w/ alleger by ARB or date completed by the ARB or occurs between a call occurs . member of the NRC staff and the Cl. Check DOL Status Date 185 days Date telecon Used to determine if a DOL case ) discnmination after date of with DOL was filed (see Sections 11.3, 11.4 l concem placed alleged made and 11.5).  ! in AMS discrimination confirrning status DOL Complaint Date of filing Leave Blank Same as Used when a !7L complaint of i Rled Discrimination assigned date discrimination fo. raising safety- ) complaint with concems is filed with DOL (see DOL Sections 11.4 and 11.5). I

                                                                                                                    . l' 1

o RP 0517A ACTION TAB - ASSIGNED DUE DATE COMPLETED USE DATE DATE DOL Appeal Filed Date AD - 10 days after Dale of car to Used to determine if an appeal of Decisionissued assigned date AU ordate of the AD decision has been made, or appeal filing to record appeal date (see Sections 11.7,11.8, and 11.9). DOL Hearing Date Appeal Date Hearing Last date of Used to track in AMS the date of S&eduled filed with AU is scheduled hearing the hearing (see Sections 11.9 and 11.10). AU Decision Date Appeal initially - 60 Date AU Used to track issuance of AU filed with AU days after Recommended decision (see Section 11.11). Due hearing, (see decision issued date is updated every 30 days after uses) reviewing AU issued Decisions via the intemet. DOL AD Decision Date OAC 45 days after Date decision Used when a complaint of determines a DOL issued by DOL discriminsbon is being invesbgated by complaint was Complaint filed Area Director DOL (see Sec6ons 11.6 and 11.7).. filed with DOL 4 ARB Decision Date AU Initially - 45 Date DOL AR8 Used to track DOL case closure. Recommended days after Final Order decision issued The ARS decision is final (see ) hearing, (see issued Sections 11.11 and 11.12). i uses) issue Chilling Date assigned 30 days from Date letteris Used to specify issuance of a letter to Effect letter by ARB assigned date 'usued to the licensee when the ARB licensee detemdnes a chmod environment exists orenforcement for discrimination has been proposed  ; (see Sechons 9.6.1.2,11.1 and 11.2). i Asegabon Assign N/A N/A N/A Not Used. l Form ARB Meetmg N/A N/A N/A Not Used. Other Date placed in NormaNyleft Upon Used to specify adsons not aarrently AMS blank complebon of available in the AMS system adon the action tabs. As such, itis rarely used. , spec iied in the descriptive text Summary N/A N/A N/A Not Used.

~ 9 9 o RP 0517A ACTION TAB ASSIGNED DUE DATE COMPLt:1 t:0 USE DATE. DATE Awaiting OE Memo Date Of report 21 days after Date mem'o received by assigned date Used to track OE concurmncein received from investigation conclusions (see EXCS OE Sechons 9.6.1, 9.6.1.2, 9.6.2, 9.6.2.2, and 9.8) DOL Setnement Date of recey,i Leave Blank Same as of DOL Used to track set 6ement of DOL assigned date cases, indicatm0 NRC must stillmake setuement agreement. a separate determinatum of whether disenmination occurred (see Sechon 11.13). NA At Conversion N/A N/A N/A Not Used. i' -iecuen Date assigned as specified Date of receipt by ARB by ARB Used to track issuance of the of closure closure memo by the assigned memo from technical branch upon completion of branch its inspection efforts (see Section 7.1). . Related Allegation Date entered in Leave Blank. Same as  ! Used when a Cl has provided AMS assigned date. ' concems in more than one' allegation, or the same concem is identified in more than one an .gs for the same facility. Enforcement Date of review' Due date per Date Action Used to track issuance of the of AMS file enforcement enforcement enforcement action when there is a j after OE memo manual for action issued. Clin need of a closure letter (see i received. issuance. Sections 9.6.1.2, and 9.6.1.3). es *

[,

• o l

RP 0517A ( ARRIGNAAENT OF RESPONSIBillTIFS l

1. Reoional Administrator (RA): Appoints the SOAC and OAC as spea6ed in Management Direc6ve 8.8, Sechon 0311(C); grants confidentiality, and conducts monthly meehngs with Division Management to discuss allegabon cases open 1180 days. Specific sections l addressing Regional Administrator achvibes are 2.9.11.1,12.1, and 12.2.

2. Deputy Reaionsi Administrator fDRA): Conducts monthly meehngs with Division Management to discuss :":;M-a cases open1120 days and grants con 6denhalsty in the absence of the Regional Administrator. Specific sections addressing Deputy Regional Administrator actswties are 2.9, 4.6,12.1, and 12.3.

3. Division Dweetors or Deou6es (DRP. DRS. DNMS): Attends ARBS (DNMS chairs matenals ARBS, DRP chaws reactor ARBS), dea'**a= allegahon cases open 1120 days *

! with RA and DRA, determines need for emer9ency ARBS, signs correspondence to Cis l deaseeing the dosure of concems, and oversees ac6vities conduck1 by the technical oranches. Spedlic sechons addressing Division Dwector schwities are 4.5,4.6,5.5,5.6, 6.1, 6.2, 6.3, 6.6 through aR of 6.9 and its parts, 8.1, 8.2, 8.4, 8.5, 9.1, 9.4, 9.6.1, 9.6.1.1, 9.6.1.3, 9.6.2, 9.6.2.3,10.5,11.1,11.14,12.0 through 12.5, and 12.7.

4. Technical Branch Chiefs (DRP. DRS. DNMS): Recommend course of adion to address eadi concem at ARBS, attend ARBS, potenbaNy take aBegations from Cis, issue closure memos for each concem assigned, and oversee schwities assigned to the branch to dose out 2":;M- is. Spedlic sections addressing Branch Chief adivities are 1.1 through 1.5, 2.1 through 2.9,4.1,4.3,5.5,6.1 through 7.4,8.1 through 8.5,9.1,9.4,9.6.1,9.6.1.1, 9.6.1.3,9.6.2, 9.6.2.1,12.0,12.5,12.6, and Attachment 1.

5. Enforcement Officer (EO): Provides oversight to ensure the properimplemer4 tion of this procedure and MD 8.8 for the Regional Administrator, signs referralletters te hensees, and coordinates enforcement activibes associated with Ot and DOL findings. Specific sodions addressing Enforooment Officer adsvibes are 5.5, 8.1,9.6,9.6.1.1 through ,

9.6.1.4,9.6.2.2, 9.8,10.3.,11.3 thmugh 11.8,11.10,11.11,11.13,11.14,12.1,12.2,12.3, and 12.8.

6. Reaional Counsel (RC) Attends ARBS, provides legal advice to ARB on potenhal for wotabons orwrongdomg, and evaluates dosure and status letters to ensure they clearty address conoom and are understandable to Cl. Specific sedsons addressing Regional Counsel achvibes are 4.5,5.5,6.1,6.2,6.3,6.6,6.7,6.8,6.9 and at ofits subparts,10.5, 11.1,11.14,12.3,12.5, and 12.7. .

7. Field Dwector. Office of Investiaatsons f00: Attends ARBS and oversees the conduct of investgabons performed to address concoms that involve wrongdoing or discriminabon.

M sections addressing Of achvibes are 4.5, 5.5,6.1,6.2,6.3,6.6,6.7. 6.8,6.9 and allits subparts,9.1 through 9.4. 9.6,9.8,9.9.11.1,11.6,11.10,11.11,11.13,11.14,12.4, and 12.5. .

        ,s   +          o-RP 0517A 8.

State Liaison Officer- Serves as the region's interface with the Occupational Safety and I Health Adtrurustration (OSHA) in the referral of industrial safety concems to OSHA. in I accordance with Regional Procedure 1007A

• Interface Activities between Regional Offices and OSHA'. Specific sections addressing State Uaison Officer activities are 4.7 and 5.5.

9. Reoional State Aoreement Officer (RSAO): Serves as the region's interface with the I Office of State Programs and the Agreement States within Region Ill. -M sections addressing RSAO achvibes are 4.8 and 5.5. I

10.  !

Senior office AW-5 c==J,rietor fSOAC): in addihon to the achvities specified below for the OAC, the SOAC is also responsible for oversight of the allegabon program, developing traming matenals and conduct!,g annual training of Region ill personnel on the allegabon program, and serves as the primary point of contact with the Department of Labor, the Agency ^"c-'is Advisor, and is the pik,dpal interface between Region ill and the OACs of NRR, NMSS and other regions. The specific sechons addressing the ackvi6es of the SOAC are identical to those listed below for the OAC. 11. Office AReoabon f**dinator(OAC): Serves as the focal point for receipt and  ! processmg of all r 2=%:{s. As sudt, is normallyinvolved in every aspect of the auegation process, includsng initial receipt, case file development, attendance at the ARB, assignment of tasks in AMS, issuance of all conospondence to the Cl, issuance of referral letters to licensees and other agendes, and advisor to the todmical staff on aNegahon program matters. The speedic sections addressing the achvides of the OAC are al of the steps in the procedure except sechons 1.2, 7.1 through 7.4,10.7,11.4,11.6, - 11.8, and 11.11. l

12. -

Tecimical Staff (DRS. DRP. DNMS): Receives :":r:54, performs inspechons or reviews oflicensee/OI reports to determine if all concems have been iden6fied, and documents results of resolu6on of concems in closure memos. Specific sechons addressing technical staff ackvibes are 1.1 through 1.4,2.1 through 2.9,4.1,5.5,7.1 through 7.4, 8.4, 8.5, 9.4, and 12.0. 13. Enforcemerd and Inve='_-s&#4 SLM.Administr=twe A=*i=* ant (EICS-AA): Provides administrahve support it, the OACs. M sechons addressing ElCS-AA achwities are 1.6, 3.1, 5.5,6.1, 6.2, 6.3, 6.8, 8.1, 8.3, 9.2, 9.3, 9.5, 9.6, 9.6.1.2, 9.6.1.3, 9.6.1.4, 9.6.2.2, 10.1,10.2,10.7,11.4,11.6,11.8,11.10,11.11,11.14,12.1,12.2,12.3,12.5, and 12.8. 14. Dnnsion and Branch Secretaries: Ensures documents sent from ElCS for todmical review are entered into AITS and promptly processed. W sechons addressmg division and branch secretary ackvibes are 3.1, 5.5, 9.4, and 9.6.1.1.

15. Office Receotionist: Identifies visitors that wish to meet with OAC personnel and ensures they are property routed to ElCS without signing the normal visitorlog (see Sechon 1.6).

E 3 , o RP 0517A J l I REPORTS GENERATED BY AMS End month or as requested by the Division Drectors, the ElCS-AA generates the following reports for distribution The reports generated and their distnbubon are as follows: TAB iII LE SORTED BY REPORTCONTENT NO.; DISTRIBUT10N 1 All Reactor Allegations Alpha bysite FacilityName, Aliegabon No., DeputyRegional Received On Date, Days Old, Administrator, DRS Assigned Dmsion, Concem Division Director, DRP Description, Assigned Action, Date Division Director, SCS. Assigned, Planned Completion Date, Division, Branch Assigned. 2 ReactorAllegabons Days Old Allegation No., Received On Date, Deputy Regional Open1180 Days Days Old. Assigned Dmsion, Facility Admmistrator, DRS l Name, Concem Desenphm, Drector, DRP Drector, l Assigned Achon, Date Assigned, SCS.  ! Planned Completion Date. Dvision, Branch Assigned, Adion Assigned Desmphve Text. 1 3 ReactorLtd ~ts Allegation No. Allegabon No., Received On Date, Deputy Regional l between 120 and 180 Days Old, Assigned Division, Facility Administrator, DRS days old Name, Conoem Descriphon, Dredor, DRP Director,  ! Assigned Action, Date Assigned, BCS. Planned Complebon Date, Division, Branch Assigned, Action Assigned Desaiptrve Text. - 4 BCS Open Days Old Facility Name, Allegabon No., Days Deputy Regional I ARegations Old, Assigned Drvisson, Concem Administrator, DRS Descriphon, Assigned Achon, Date Drector, DRP Drector, l Assigned, Plannad Complebon Date, DNMS Drector, SCS. Dvision, Brand Assigned, Achon Assigned Desenphve Text. 5 Allegations by Branch Branch / Site Facility Name, AWdM No., Days Deputy Regional (DRP) then Days Old Old, Assigned Division, Concem Administrator, SCS, Description, Assigned Achon, Date DRP Division Drector  ; Assigned, Planned Completion Date, (who should have copies Division, Branch Assigned, Action distributed to individual Assigned Desenphve Text. DRP Branch Chiefs for their selected sites). l

.,-                (

RP OS17A TAB IIILE SORTED BY NO. REPORTCON t:NT DISTRIBUTION 6 Allegations by Branch Branch then Facility Name, Allegation No., Days Deputy Regional (DRS) Days Old Old, Assigned Division, Concem l Administrator, BCS, Description, Assigned Action, Date DRS Dmsion Director Assigned, Planned Completion date, (who shoukihave copies Dmsion, Branch Assigned, Action Assigned Denenptrve Text. distributed toindividual

       ~7 DRS Branch Chiefs).

All Materials Alpha by site Allega@ms Facility Name, Allegation No., Deputy Recional Received On Date, Days old, Admiristrator DNMS Assigned Division, Concem Division Duector SCS. Desmption, Assigned Achon Date Assigned, Planned Compledon Date, i j Drvision, Branch Assegned. 8 Materials Allegations Days Old Allegation No., Received On Date, Deputy Regional Open1180 days Days Old, Assigned Division, Facility AdderJA.ior, DNMS  ! Name, Concem Desenphon, Division Duector, EICS. Assigned Achon, Date Assigned, Piarmed Comple6on Date, Division, Branch Assigned, Achon Assigned D=Mp6ve Text. g Materials Allegations Days Old Allegation No., Received On Date, Deputy Regions! between 120 and 180 Days Old, Assigned Division, Facility days old Administrator, DNMS  : Name, Conoom Descrip6on, Division Director, BCS.  ! Assigned Action, Date Assigned, Planned Cr.,mpleton Date, Dmsion, Branch Assigned, Action Assigned ) Desenptive Text. 10 Materials Allegatxms Alpha by site l by Branch Facility Name, ?M-d~1 No., Days Deputy Regional t Old, Assigned Division, Conoom Adnunistrator, SCS,  ; Desaiphon, Assigned Achon. Date DNMS Division Dweetor  ! Assigned, Planned Complebon date, (who should have copies Dmsion, Branch Assigned, Achon distributed toindividual A=W D==',4;; Text. DNMS Branch Chiefs). In addition to the above, once each month, the BCS-AA will prepare the " Allegation Briefing Sheet". This sheet is distributed at the 8:15 a.m. meeting on the Wednesday prior to the RA Briefing to all attendees, and gives the total number of open allegabons, total received during the year, total dosed during the year, total number of cases open greater than or equal to 180 days (both for reactors and matenals), the number outside of the region's immediate control and why (Oi, DOL, etc.); and the number within the regions' control. ' For this last group, the briefing sheet will ' itemin the allegaGon number, site, and assigned Technical Division responsible for the allegation. Finally, the briefin sheet wR1 specify how many cases are greater than 120 days old and the breakdown between reactors and materials for this group. Aeeaahe**asse A

l, , 3 J l RP 0517A GLOSSARY OF TERMS (from MD 8.8) Action Office: The NRC program office or redon that is responsible for reviewing and talcing action, as appropriate, to resolve an anegation. For the purpose of Management Dweetsve (MD) 8.8, the Office of Investigations /01) and Office of the inspector General (IG) are not considered achon offices. Administrative Review Board (DOL's ARB): The Secretary of Labor's authonzed , iefs.566tative to review the dedssons of Administrative Law Judges and issue Orders finalizing l the determinsbon for the Department of 1. abor. ARB decisions are final adions, sutiect only to I appeal to the Federal Court system.  ! Agency Allegation Advisor (AAA): A designated staff memberin NRC headquartem who develops and oversees the agency wide implementation of the NRC ?":gri Management , Program, manages the allegation management system (AMS), and conducts periodic program  ! reviews of each adion office's aRegation program, as set forth in MD 8.8 and related documents.

         ?_":;- ":s: A declaration, statement or asserbon of impropnety or inadequacy assodated with NRC-regulated actrvibes, the validity of which has not been ***=h83*hed. This term includes all conoems idenbfied by sources such as individuals or orgaruzabons, and technical audit efforts from Federal, State orlocal govemment offices regarding activibes at a licensee's site.

l NOTE: Exduded from this definition are inadequacies provided to NRC staff by licensee managers admg in their official capadty (for example, A conoem(s) twought to NRC by the A managerin describmg how they were being addressed), matters being handled by more formal i pre-ea< sudi as 10 CFR 2.206 pet: bons, misconduct by NRC employees or NRC contractors,  ! norwadiological =' d~ial health and safety issues; inspechon findings, and matters involving j law enforcement and other Govemment ageoc;c.s. Also exduded from this definition are Endings identdied by lilinois Department of Nuclear Safety (IDNS) resident inspectors as part of the inspechons they implement to assist in completion of NRC's inspechon program. These , exdusions apply to inadequades discussed dunng official rouhne conversabons tsetween Econsee managers and NRC staff members unless the informahon provided concems a wrongdoing issue. . Allegation File: An allegabon file is established for documentabon cric.,Tk,g the aNegabon, l Induding consspondence, memorandums to file, interviews, and summaries of telephone conversations, dia-i~is, and meebngs, inspechon reports, and 01 investigaban reports (an l oiher 01 investigabve documentabon will be retained in the Of case file). This file must be maintained by the office auegation coordinators (OACs) in the official files of the adion office in an officiaBy designated locahon. An documentation must be maintained in this file and dearly marked wah the allegabon number. Only the anegabon number, name of facaity, corresponding Of case number, or corresponding DOL case number, may be placed on the outside of the file; neither the CI's name nor any other personal idenbfier may be placed on the outside of the file. Records pertinent to IG referrals should not be kept in the allegation file, but forwarded to the Regional Counsel A";i,.Gw. Management System (AMS): A computerized informabon system that contains a sumtriary of significant data periment to eadi allegation.

y, , .,.  ! RP 0517A Allegation Review Board (ARB): A board estabisshed by the regional administrator consis the Regional Counsel; Of Field Office Director; SOAC; the cognizant technical Branch Chief; th DRP Brarxh Chief with responsibility for the facility; and the ARB Chairman, who is the Director of Reactor P,$, cts for reactor cases, or the Director of Nuclear Materials safety for materials cases; to determine the safety significance and appropriate NRC follow up for each ":;-*h The ARB permits eW%s resolution of allegations. Staff from the Office of Enforcement and the Office of the General Counsel participate, as necessary. Chilling Effect: A term that refers to the negative effect a hostile environment (e.g., an employee being termmated for being involved in protected adsvibes) may have on employees raising concems to the NRC, or those who may want to raise conoems. Concerned individual (Cl): An individual or organization who makes an allegation. The individual or organization may be a concemed private citizen, a public interest group, the news media, a licensee, a current or former employee of a licensee, vendor or contractor, or a representative of a local, State or Federal agency. Confidentiality: A term that refers to the protedion of data that direc0y or otherwise could idenbfy an indhndual by name or the fact that a confidentsal source provided suhiw ..etion to the NRC. Confidential Source: An individual who requests and is grarded confidenhality in sw.wde6ce with Management Direchve 8.8 and who usually signs a " Confidentiality Agreement". Inspection: For purposes of this procedure, a special achvity usuaNy conducted by an inspector and used to evaluate and resolve an allegatson. Investigation: An actrvity conducted by the Office of Investigations (OI) to gather and evaluate teshmonial, documentary, and physical evidence to assist the staff, the Office of Enforcement, or the Department of Jusboe in resolving wrongdoing anegabons. Office ?":pe-r, Coordinator (OAC): A designated staff memberin the region who serves as - one of the points of contact for that region reganding the processing of i;=Gr.s. This person is normally appoorded by the Regional Adtrunistrator or his designee per Management Dractrve 8.8. Overriding Safetyissue: Immediate threat to public health, safety, or security, warranting immediate action by the NRC or licensee to evaluate and address the issue. Protected Activities: Adsvibes protected within the meaning of Sechon 211 of the Energy Reorganization Act and the Commission's regulations, for example,10 CFR 50.7. E.nWi;;e of licensees and their contractors are engaged in protected actrvitses when they are raising safety concems to their management, as well as when they raise these concems to the~NRC. Receiving Office: The office vr region that irutsally receives an allegatson, in some cases, the adson office and the receiving office will be the same if the a5egation falls within the functional responsibility of the receiving office. Aee neese sas,d C

I RP 0517A Redact: The process of removing any proprietary, safeguards, or 10 CFR 2.7g0 information from a document prior to its being issued to an indmdual outside of the agency.

    - Regional State Agreement Officer (RSAO):- A designated staff memberin a region who serves as the point of contact for the region and the Ofrx:e of State Programs, regarding Agreement State radiatum control programs, and who conducts isd.r.icsl reviews of Agreement State radiation control programs.

Sanitian: The process of ensuring that any NRC document developed as a result of an iyR does not reveal the identity of the alleger. Secwo Files: Files that are locked when not in use and for which access is controlled on a need4o-know basis. Senior Office Allegation Coordinator (SOAC): A designated staff member in the region who serves as one of the pomts of contact for that region regarding the processmg of allegatums, and is also responsible for the oversight of the allegation program within the region. This person is normaDy appointed by the Regional Administrator or his designee per Management Drectrve 8.8. Staff: NRC technical, investigative, and other staff members. - Wrongdoing: Wrongdoing consists of either(a) an 'mtenbonal violabon of regulatory 1 requirements or(b) a violation resultmg from careless disregard of, or recidessm' difference to i regulatory requirements, or both (See Part IV of Management Drective 8.8). j j

j l DIVISION OF NUCLEAR MATERIALS SAFETY l FISCAL YEAR 1999 l 1 INSPECTION PROGRAM STATUS-MONTH ENDING JANUARY 31,1999 , 4 INSPECTIONS COMPLETED I INSPECTION STATUS - ALL PRIORITIES NNNN NNbh $hI Nk NN Nhbb . _ _ TOTAL BUDGETED 52 208 [630] TOTAL DUE 34 152 [612) TOTAL COMPLETED 66 193 CORE 27 81 [377] REACTIVE 1 13 NON-CORE 38 98 [235] RECIPROCITY: Against Goal 0 0 Assists 0 0 FISCAL YEAR 1999-MATERIALS INSPECTIONS E0ll Er 99 OCT NOV DEC JAN FEB MAR APR MAY lyn JUL AUG SEP {111} DUE 55 34 29 34 38 46 41 40 41 42 36 65 CPL 52 45 30 66 BR.1 32 18 16 36 BR. 2 20 27 14 30 Contact Marcia Pearson, DNMS, X9840 Data is Through January 31,1999 Info CompiledlExtracted from LTS and Matrack

  ;a- ;W      .                                                                      l OVERDUE COREINSPECTIONS GREEEEER?"" EsEsstwasimase&!alardis N                        O                    N          E
                                                                                    =

DOUBLE OVERDUE COREINSPECTIONS 7'; @ {gis

                                                 ~
         ....                        Q(Lic1g;                           ih'gfMQ[*$

N O l N E I

                    - RECIPROCITY FILINGS / INSPECTIONS (CALENDAR YEAR 98)

Yearto Date (Roundedto Nearest Tenth) Goal 2.0 Completed Against Goal 0 Assist inspections 0

[' . l l (NSPECTION DOCUMENTA TION AND TIMELINESS FY1999 ,c

                                                   *** ROUTINE REPORTS *
                                               .gypu %.m.%,,,q,qqq Law. CURRENT @ONTH,ggg.

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                                                                                                             ..a.   ..
                                                                                                                         .s, ... _m.gu TQDATEy TOTAL ISSUED                                               69                                             226 591's                                             57                                              158 Lenem                                                12                                               68 TIMELINESS (DAYS) including 591's                                      2.8                                             4.7 Excluding 591's                                        16.1                                           15.7 i
                                       *** TEAM INSPECTION REPORTS ***
                                                                                                                                         )

kk%TfgaynE- k%[{$%%jjyj TOTAL ISSUED 0 0 TIMELINESS (DAYS) 0 0 l l l I 1

                                                       " FIELD NOTES" 4

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                                                        .' ant.i !nikativ"*"- 3 ' iP * , A sy". ' 11   " 'D;in.sa.si..;*ar> ~;         -

TOTAL ISSUED 33 175 1 TIMELINESS (DAYS) 12.8 12.8 i i l  ! f i I t l l

4

         -o f.

I l l i l l  : MATERIALS LICENSING PROGRAM STA TUS FOR MONTH ENDING JANUARY 31,1999 l l l LICENSING ACTIONS COMPLETED LICENSING ACTION STATUS- ALL ACTION TYPES I l l kk hh h.ETEQY M COMPLETED ACTION TYPE MONTH YTD FY MONTH YTD CORE ' (NEWS / AMENDMENTS) 110 440 1320 110 410 NON-CORE (RENEWALS) 1 4 13 0 3 l TOTAL 111 444 1333 110 413 , PENDING ROUTINE MATERIALS LICENSilNG CASEWORK l . CORE APPLICATIONS (NEWS AND AMENDMENTS) I i OVERDUE DOUBLE OVERDUE l- . TOTAL CORES PENDING > 90 days but < 180 days > 180 Days 169 6 10 ) NON-CORE APPLICATIONS (RENEWALS) l NON-CORES OVERDUE DOUBLE OVERDUE t TOTAL PENDING >180 days but < 365 days > 365 Days 3 0 2

STATUS OFWPIRED LICENSE CLOSEOUTS AVERAGE CLOSED CURRENT CLOSED YEAR TO TIMELINESS PENDING CASES MONTH _DATE YTD 0 0 0 0 l l UPIRED LICENSE CLOSEOUTS PENDING > 120 DA YS l l STATUS OF SUSPENDED / REVOKED LICENSE CLOSEOUTS i UCENSES CLOSED UCENSES CLOSED ' PENDING SUSPENSIONS CURRENT MONTH YEAR TO DATE 2 0 0 - SUSPENDED / REVOKED LICENSE CLOSEOUTS PENDING > 120 DA YS _ UCENSEE UCENSE NO. SUSPENSION DATE CLOSEOUT STATUS Stack Licensee Engineering 24-24708-01 5/9/96 reinspected 1/99 Licensee contacting Roof 24-26009-01 11/7/97 LFMB for payoff Consultants figure. Final disposition pending.

F', , , h ORNL Terminated Sites Program Closeout Progress JANUARY 1999 Number of Site inspections / Evaluations Completed ) Loose Sealed Material Sources FY 1992 6 1 FY 1993 15 1 FY 1994 30 0 FY 1995 22 7 FY 1996 26 14 FY 1997 24 6 FY 1998 7 31 FY 1999 October 2 0 November 1 2 December 0 0 January 1 4 February March April May June l July l August Total FY99 4 6 Sites inspected 134 66 Sites Pending 2 8 t t i

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                                                           )

l l l DMSION OF NUCLEAR MATERIALS SAFETY l INTERNAL TRACKING l , FOR I l

• INSPECTION REPORT STA TISTICS B Y BRANCH
• FIELD NOTE STATISTICS BYBRANCH
• TIMELINESS OF ACTIONITEMS
• STAFF ACCOMPANIMENTS BYBRANCH 1 1

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4 i INSPECTION REPORT TIMELINESS BY BRANCH MaterialsInsoection Branch 1 ROUTEINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 36 100 591'S - 32 85 NON-591'S 4 15 I TIMELINESS (DAYS) INCLUDING 591'S 1.9 1.8 EXCLUDING 591'S 17.5 12.0 PERCENT TIMELY (NON-591'S) 50 % 87 % Ebbkh$3$bdkhb5hhNk$ 2 2 l Routine Recorts Over21-Dav Goal Licensee No. of Days I

             - Community Hospitals of Indiana                                       35 l              Indiana University School of Medicine                                 25              ;

l TEAMINSPECTION REPORTS t'* CURRENT MONTH YEAR TO DATE TOTAL ISSUED 0 0 l TIMELINESS (DAYS) 0 0 Team Reoorts Over 30-Dav Goal Licensee No. of Days NONE i

  ,   . -      .                                                                                   1 e                                                                                              i i

FIELD NOTE TIMELINESS BY BRANCH Materials Insoection Branch 1 FIELD NOTES CURRENT MONTH YEAR TO DATE TOTALISSUED 13 88 TIMELINESS (DAYS) 9.9 9.5 PERCENT TIMELY 92 % 97 % h) lj 1 3 l eistnamiiiieniidham i l Field Notes Over 21-Day Goal Licensee No. of Days

          - Community Hospitals of indiana                                         35              l l

n INSPECTION REPORT TIMELINESS BY BRANCH j Materials Insoection Branch 2

                                                                                      )

ROUTEINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 27 87 591'S 25 73 NON-591'S 2 14 TIMELINESS (DAYS) INCLUDING 591'S 1.2 2.4 EXCLUDING 591'S 15.5 14.8 PERCENT TIMELY (NON-591'S) 100% 100 % Ihkhkk(b[k5k$$1)$$h$$ 0 0  ; l Routine Reoorts Over 21-Day Goal Licensee No. of Days i i NONE . l TEAMINSPECTION REPORTS CURRENT MONTH YEAR TO DATE TOTAL ISSUED 0 0 TIMELINESS (DAYS) 0 0 Team Reoorts Over 30-Dav Goal Licensee No. of Davs NONE

a g g s FIELD NOTE TIMELINESS BY BRANCH Materialsinsoection Branch 2

                                     ' FIELD NOTES CURRENT MONTH                   YEAR TO DATE TOTAL ISSUED                         19                          85 TIMELINESS (DAYS)                  14.0                        16.0 PERCENT TIMELY                    100 %                       88 %

kkhMhAf$$$$$$$$Nd 0 10 Field Notes Over21-Day Goal Licensee No. of Days NONE l

E ,- I l l INSPECTION REPORT TIMELINESS BY BRANCH Materials Decommissionina Branch ROUTEINSPECTION REPORTS CURRENT MONTH YEAR TO DATE ! TOTAL ISSUED 3 25 TIMELINESS (DAYS) 10.0 12.8 l PERCENT TIMELY 67% 80% ! M DMEmiad2l$ 1 5 Routine Reoorts Over 21 Jay Goal Licensee No. of Days i Battelle 26 TEAM INSPECTION REPORTS l I CURRENT MONTH ' YEAR TO DATE TOTAL ISSUED 0 0 l TIMELINESS (DAYS) 0 0 l l ' Team Routine Reoorts Over 30-Dav Goal l Licensee .No. of Days NONE

P, . . l \ FIELD NOTES I CURRENT MONTH YEAR TO DATE l TOTALISSUED 1 2 i-l TIMELINESS (DAYS) 27 21 i l PERCENT TIMELY 0% 50% IhbbbMN*$$$$N 1 1 i Fleid Notes Over 21-Day Goal Licensee No. of Days Batte!Ie Memorial 27 l l j l l l

fi, . , l' ! I INSPECTION REPORT TIMELINESS BY BRANCH t FuelCycle Branch ROUTEINSPECTION REPORTS CURRENT MONTH . YEAR TO DATE l TOTAL ISSUED 3 -14 TIMELINESS { DAYS).. 21.6 25.5 PERCENT TIMELY 67% 50 %

          $Ei                                      1                               7 Routine Reoorts Over 21-Day Goal Licensee                                          No. of Days Allied Signal                                                     32 TEAMINSPECTION REPORTS CURRENT MONTH                 YEAR TO DATE TOTAL ISSUED                             0                             0 TIMELINESS (DAYS)                        0              1              0 Team Routine Reports Over30 Day Goal Licensee                                          No. of Days l

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i BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF , FY 1999 i NUCLEAR MATERIALS INSPECTION BRANCH 1 i. PURPOSE (ESC. ENF. EXIT. INSPECTOR ACCOMPANIMENT, LICENSEE DATE OR OTHER) GATTONE GO LAFRANZO 1 l NULL l l PARKER l-

PISKURA WlEDEMAN l

    .                                                                         1 F:       ,

1 BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF l FY 1999 NUCLEAR MATERIALS INSPECTION BRANCH 2 PURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT' INSPECTOR LICENSEE DATE OR OTHER) CAMERON HAYS JONES Sinal Detroit Hospital 11/9/98 Exit Meeting Veterans Admin. 1/13-14/99 HQ Meeting MUI.AY YOUNG l i

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                  - BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF FY 1999 NUCLEAR MATERIALS LICENSING BRANCH PURPOSE (ESC. ENF. EXIT, REVIEWER                                          ACCOMPANIMENT, LICENSEE               DATE     OR OTHER)

CASEY Calumet Testin9 '10/16/98 Accompaniment l FRAZIER l GILL HUtitR American Biotech 11/30/98 Accompaniment I i MULLAVER PELKE REICHHOLD WATSON l L i-

fI' l e-PURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, LICENSEE DATE REVIEWER OR OTHER) WEBER Calumet Testing 10/16/98 Accompaniment U

L o , BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF FY 1999-DECOMMISSIONING BRANCH FURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, INSPECTOR LICENSEE DATE OR OTHER) OTHER HOUSE Battelle 12/15/98 Accompaniment KULZER LANDSMAN Point Beach 1,2 10/01/98 Accompaniment LEE MCCANN Battelle 12/15/98 Accompaniment j NELSON i SNELL Dresden 1 12/18/98 Accompaniment (BIG ROCK POINT) 1/12-13/99 Site Visit LEEMON 1 (ZION) 1/21/99 Site Visit i l

o .

BRANCH CHIEF ACCOMPANIMENTS OF TECHNICAL STAFF I FY 1999 FUEL CYCLE BRANCH PURPOSE (ESC. ENF. EXIT, ACCOMPANIMENT, INSPECTOR LICENSEE DATE OR OTHER) KNICELEY NO SIGNIFICANT INSPECTION ACTIVITIES KRSEK 4 REIDINGER NO SIGNIFICANT INSPECTION ' ACTIVITIES (PADUCAH) ' O'BRIEN

. JACOBSON 1/11-15/99 Accompaniment (O'Brien) l (PORTSMOUTH) i l

  ~

HARTLAND 157/99 Site Visit (O'Brien) t 1 BLANCHARD 167/99 Site Visit (O'Brien) i I

r- , ,o r t l i ATTACHMENT 1 REGION lli'S RESPONSE TO REVIEW FINDINGS

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   #g8 8800q'o                                        UNITED STATES NUCLEAR REGULATORY COMMISSION

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                #                                 801 WARRENVILLE ROAD LISLE. ALLINOts 60532-4351 k.,         ,o#                                   April 29, 1999 MEMORANDUM TO:                 Carl J. Paperiello, Director Office of Nuclear Material Safety and Safeguards FROM:                          James E. Dyer, Regional Administrator, Rlll       (( 8f

SUBJECT:

COMMENTS ON DRAFT 1999 REGION lil INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (l'4 PEP) REPORT AND RESPONSE TO RECOMMENDATIONS We have reviewed the subject draft report and have provided our specific comments as Attachment 1 to this memorandum. In addition, we have reviewed the recommendations and have provided a description of the specific actions that we have implemented to address each

                                                                                                        )

of the recommendations that pertain to Region ill performance. This description is included as Attachment 2 to this memorandum. l Thank you for the opportunity to comment on the draft report. The team that performed the Region 111 IMPEP was very professional, and this repo,rt is of very high quality. We understand that this memorandum and its attachments will be included as part of your final i report when it is issued. If you have any questions concerning Region ill comments, please call  ! Monte Phillips of my staff at (708) 829-9806. Attachments: As stated l cc w/att: S. Moore, NMSS/IMNS l j l l 1 - l l l l

V w , i I a

                                                                                                                 \

Attachment 1 COMMENTS ON DRAFT 1999 REGION lli INTEGRATED l MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) REPORT 1. Pace 8. second full caraaraob: The following sentence, which appears in the middle of the paragraph, is not clear: "The review team found that several of Rll!'s in-process inspections included confirmatory surveys, although NRC policy emphasizes "in-process" inspections more than confirmatory surveys." is it complimentary that the Region also does confirmatory surveys, or critical in that additional resources are used? i Please clarify what is meant by this sentence. I

2. Paae 9. Section 3 3. second oaracraoh: The sentence discussing the licensing assistance staffis in error. For a portion of the review period (from last IMPEP to January 1998), a separate Administrative Support Branch existed. In January 1998, the administrative staff were detailed to the licensing and inspection branches. After the IMPEP, the Region's March 28,1999, reorganization permanently assigned the remaining administrative support staff, including the licensing assistant, to the Materials Licensing Branch,  !

1

3. Paae 10. Section 3.3. carrv-over caracraoh The section discussing vacancies is in error. DNMS reported 3 vacancies, with an additional GG-14 titled position (Lead j inspector) to be filled via a solicitation from the current GG-14 staff. This really consists of a re-titling of a current GG-14 position.

4. Pace 10. Section 3 3. carsaraoh discussina license reviewer cualifications: The text in the previous paragraph also applies to this paragraph, namely, that DNMS management i has elected not to exempt the reviewers from the course, and the remaining reviewers ' who can take the course will complete the training during or prior to FY2000.

5. Pace 16. Section 3.5. third caraaraoh from end of section: Suggest that the reference to ' members of the Licensing Assistance staff" te replaced with

• administrative staff' since we have no designated unit by the name of " Licensing Assistance staff."

6. Pace 19. Section 41. first caraaraoh concemino resource utilization: As written, this section implies that an NMSS recommendation is warranted to work with the appropriate headquarter's staff to develop a tracking system to match FTE expenditures with budget l line items in Operating Plans.

7. Paae 21. Section 41. second from last caraaraoh: In the discussion of resource utilization, mention is made of the resources we have devoted to the guidance consolidation project, the VA Master Materials License, and DOE extemal regulation pilot.- However, no mention is made of the unusual number of resources we have l' _ expended in supporting and preparing for Ohio to become an Agreement State, especially since Ohio is running 7 months behind schedule. During the review period, we have copied approximately 200 licenses that will remain NRC licenses after Ohio becomes an Agreement State, conducted one week training sessions for 9 Ohio Department of Health personnel, and done a 100 percent quality assurance check of each Ohio docket file. In addition, we have wntten to all Ohio licensees with temporary i

job sites to determine if they wish to maintain an NRC license for work outside of Ohio. Some mention of this effort is probably appropriate for this section. L

[ * - l l 8. General Comment concemino all of Section 4.2 and its Suboarts: The terms " generally" and "in general" are used throughout these sections. This is not the case in other areas. ! Based upon the team's positive exit meeting results, we would suggest that the use of l j these terms is not necessary. 9. Pace 24. Sections 4.3.1 and 4.3.2: Both of these sections are in error as they state that Region lit has no project management for any SDMP sites. Region 111 does maintain i project management status for the Advanced Medical System facility in Cleveland, Ohio, as noted in our response to question 27 of the questionnaire. l l 1 l m

9 -n l ) Attachment 2 REGION til RESPONSE TO RECOMMENDATIONS IN DRAFT 1999 IMPEP REPORT J As noted in the report, of the five recommendations made, Recommendations 1 and 3 apply to NMSS. The remaining recommendations apply to Region lil, and our actions conceming those recommendations are as follows: Recommendation 2: The review team recommends that Rill implement the tools prescribed in the Decommissioning Handbook for ensuring that decomrnissioning and license termination reviews are complete and fully documented. Reoion lli Actions: Promptly after the IMPEP exit, reviewers were instructed to use the checklists contained in the Decommissioning Handbook. On April 19,1999, a divisional procedure was issued in final. This procedure, entitled " Procedure for Handling Terminations, Location of Use Changes, and Notifications of Intent to Decommission - DNMS Only," describes the methodology for processing and evaluating termination requests and notifications of intent to decommission. The use of the Decommissioning Handbook is described in that procedure, including the use of the required (Appendix F) and optional (Appendix E) checklists in the Handbook. This procedure should ensure that alllicense terminations will include a completed Appendix F checklist in thb docket file, and licensee's providing notification of intent to decommission will include a completed Appendix E as well. Recommendation 4: The review team recommends that Rlli develop and implement a process to remove allegation material from the docket files. Reoion til Actions: By memorandurn dated April 23,1999, a temporary procedure was issued to all DNMS technical staff to conduct a review of the docket files when they are accessed to either complete a licensing action or prepare for an inspection. This review is intended to determine if any allegation-re!.,ted material is present in the file, and then alert division management so that appropriate action can be taken regarding the material that is found (e.g., shredding, redacting the inappropriate material from the document, or leaving the document in the file if appropriate). 4 Recommendation 5 The review team recommends that Rlll train the DNMS staff on what allegation language, if any, is acceptable to place into the docket files. Reoion ll! Actions: On April 6,1999, a memorandum was issued to all DNMS technical staff describing what language should be used in reports and other documents that would eventually be placed in the docket file. The memorandum was titled " Acceptable Language for Closing Allegations ir Field Notes, inspection Reports, or Other Documents to be Placed in the Docket File." This guidance is scheduled to be incorporated into the Region's allegation management procedure, RP 0517A, before the end of this fiscal year. A training session has been set up dunng the upcoming inspector Seminar in June 1999 to discuss allegation documentation.}}