ML20217K794

Informs That NRC Implementing,On Interim Basis,Integrated Matls Performance Evaluation Program for Use in Evaluation of Agreement State Programs.Review of Draft Rept Which Documents Results of Agreement States Review Encl

ML20217K794
Person / Time
Issue date:	08/08/1997
From:	Bangart R NRC OFFICE OF STATE PROGRAMS (OSP)
To:	Weidler M NEW MEXICO, STATE OF
References
NUDOCS 9708180124
Download: ML20217K794 (97)

Text

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pn ne:g i y* t UNITED STATES j

j g NUCLEAR REGULATORY COMMISSION

& WASHINGTON. D.C. 3066H001

+o # August 8, 1997 Mr. Mark E. Weidler, Secretary Environment Department 1190 St. Francis Drive P.O. Box 26110 Santa Fe, NM 87502

Dear Mr. Weidler:

The Nuclear Regu!Atory Commission (NRC) is implementing, on an interim basis, the Integrated Materia;s Performance Evaluation Program (IMPEP) for use in the evaluation of Agreement State programs. Enclosed for your review is the draft IMPEP report which documents the results of the Agreement State review held in your offices on July 1418, 1997. James L. Lynch, Regional State Agreements Officer, from Region lit, Lisle, Illinois, was the team leader for the New Mexico review. The review team's recommendations were discussed with you and your staff on July 18,1997. Due to the significance and number of deficiencies found in the New Mexico program that included an unsatisfactory finding for one indicator and satisfactory with recommendations for improvement for three indicators, the team will recommend that the Management Review Board (MRB) find the New Mexico program adequate to protect public health and safety but needs improvement, and compatible with NRC's program. The team will also recommend a period of probation for a duration to be established after consultation with New Mexico radiation control program management. See Enclosure 1, NRC Cffice of State Programs' Internal Procedure D.23, " Procedure for Placing an Agreement State on Probation."

NRC has significantly changed the manner in which periodic reviews are conducted for Agreement State programs to assure that public health and safety are adequately protected from the hazards associated with the use of radioactive materials and thst Agreement State programs are compatible with NRC's program. The new process, titled IMPEP, employs a team of NRC and Agreement State staff to assess both Agreement State and NRC Regional Office radioactive materials licensing antiinspection programs. All reviews use common criteria in the assessment and place primary emphasis on performance. Four additional areas have been identified as non-common performance indicators and are also addressed in ths assessment. The final determination of adequacy and compatibility of each Agreement State program, based on the review team's report, will be made by a Management Review Board (MRB) composed of NRC managers and an Agreement State progrem manager who serves as a liaison to the MRB.

In accordance with procedures for implementation of IMPEP, we are providing you with a copy of the draft team report (Enclosure 2) for review prior to submitting the report to the MRB. Your review of the draft report should focus on factual correctness of information reported by the team. I am asking that you provide your response to me as soon as possible, but no later than four weeks from receipt of this latter.

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The team will review the response, make any necessary changes to the report and issue it to the MRB as a proposed final report, We will coordinate with you to establish the date for the MRB review of the New Mexico report and will provide invitational travel for you or your designee to attend, if you have any questions regarding the enclosed ,teport, please cratact me at (301) 415 3340 or James Lynch at (630) 829 9661.

Sincerely, dl( . det Al Richard L. Bangart, Director Office of State Programs

Enclosures:

As stated cc: Benito Garcia, Chief Bureau of Hazardous and Radioactive Materials 9

e Mark E. Weidler 2- AUG - 8 1997 The team will review the response, make any necessary changes to the report aid issue it to the MRB as a proposed final report. We will coordinate with you to establish the date for the MRB review of the New Mexico report and will provide invitational travel for you or your designee to attend, if you have any questions regarding the enclosed report, please contact me at (301) 415-3340 or James Lynch at (630) 829 9661.

Sincerely, Odshel RICHARD L RT l Richard L. Bangart, Director

Office of State Programs

Enclosures:

As stated cc: Benito Garcia, Chief Bureau of Hazardous and Radioactive Materials DISTRIBUTION: DCD (SP01)

DIR R F. PDH (YES/)

- SDroggitis FCameron, OGC JHornor, RIV/WCFO HNewsome, OGC CHackney, RIV GDeegan, NMSS TFrazee, WA SMoore, NMSS LRakovan' KSchneider NM:;xico File DOCUMENT NAME: G:\KXS\97DRLTR.NM G:\KX M MP97.DFT *See previous concurrence.

Tm receive a copy of this document, Indicate in the bos: 'C' = Copy wnhout at( 9Q t!anctosure *E' = Copy with attachment / enclosure *N' = Ho copy l OFFICE - Rlli OSP:DD OSF$f l l lNAME JLLynch:gd:kk PHLohaus RLBangart lDATE 08/04/97* 08/07/97* 08($ 97 OSP FILE CODE: SP-AG 13 i

Mark E. Weidler 4 The team will review the response, make any necessary cha ges to the report and issue it

_ to the MRB as a proposed final report. We will coordinate ith you to establish the date for the MRB review of the' New Mexico report and will pro ide invitational travel for each of you or your designees to attend. If you have any ques ions ragarding the enclosed.

report, please contact me at (301) 415 3340 or James L ncn at (630) 829 9661.

Sincer ly, 4

Ric ard L. Bangart, Director Of ice of State Programs

Enclosures:

As stated i

cc: Benito Garcia, Chief Bureau of Hazardous and Radioactive Materials i

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a DISTRIBUTION: DCD (SP01)

DlR RF - PDR WtiS/)

SDroggitis FCe.neron, OGC .

JHornor, RIV/WCFO HNewsome, OGd l CH:ckney, RIV GDeegan, NMS!$

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LRakovan /

KSchneider

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DOCUMENT NAME: G:\KXSi97DRLTp/NM G:\KXS\MilMP97.DFT 'See previous concurrence.

Ta receive a copy of this document, Indicate in the dat TC* ;= Copy without attachment /enclosu,e *E* = Copy with attachment /enclosu,o *N' = No copy OFFICE Rill Oyi>@Q OSP:D - l

NAME JLLynch:gd:kk PHLdhdus RLBangart DATE 08/04/97* 08//f 97 08/ /97 OSP FILE CODE: SP-AG- l 3

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Mark E. Weldier The team will review the response, make any necessary changes to the report and issue it

/

to the MRB as a proposed final report. We will coordinate vdith you to establish the date for the MRB review of the New Mexico report and wl:l proyIde invitational travel for each of you or your designees to attend, if you have any questions regarding the enclosed report, please contact me et (301) 415 3340 or James Lynch at (630) 829-9661.

Sincerely,

/

/

Richard L./Bangart, Director Office of State Programs

Enclosure:

As stated

/

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cc: Benito Garcia, Chief Bureau of Hazardous and Radioactive Material f

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DISTRIBUTION: DCD (SP08)  ;

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DIR RF PDR (YES/)  !

EDO RF '

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SDroggitis JHornor, RIV/WCFO e

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CHackney, RIV TFrazse, WA

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NM::xico File ,/

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DOCUMENT NAME: G:\KXS\97DRLTR.NM G:\KXS\NMIMP97.DFT T3,eceive a copy of this document, Indicate in the boa: *C' = kopy without attachment /enclosu,e *E' = Copy with attachment / enclosure *N' = No copy l OFFICE Rlli OSP:DD/ l OSP:D. l [

lNAME JLLynch:gd,,,3 PHLohaug RLBangart lDATE 08/y/ 97 f r' 08/ / 9,7 08/ / 97 k y OSP FILE CODE:-_ SP-AG 13

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OFFICE OF STATE PROGRAMS

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INTERNAL PROCEDUME i

DIVISION I i

1 Post Agreement D.23 Procedure for Placing an Activities Agreement State on

! Probation f

l. INTRODUCTION t

i This procedure provides the guidelines to be followed when consideration is given

to placing an Agreement State program on probationary status, i -

This procedure also directs the steps to t,e taken when an Agreement State

[ program is placed on probationary status.

I 3 II. BACKGROUND F

Under Section 274 of the Atomic Energy Act, as amended, the Commission retains ,

L authority and the responsibility for ensuring that Agreement State programs j

continue to provide adequate protection of the public health and safety and are i

compatible with NRC's program. The Commission policy statement, " Statement of

j '

Principles and Policy for the Agreement State Program," established the option of

placing an Agreement State program on probationary status for serious program deficiencies that require heightened oversight (See Sections F through H of policy).

Ill. MINIMUM CRITERIA FOR CONSIDERING PROBATION j Probation will be considered when any of the following circumstances occur:

! A. When deficiencies in one or more of the common and nons:ommon

! performance indicators of the Integrated Materials Performance Evaluation l Program (IMPEP) are of such safety significance that assurance of the j- program's ability to protect the public health may be degraded, and j

heightened oversight by the NRC is required. (Example: The Agreement L State repeatedly fails to identify design deficiencies in follow-up analysis of

{ events or incidents involving sealed sources and devices.)

i l' B. When programmatic def ciencies have gone uncorrected for a significant j period of time and the NRC is not confident of the State's ability to correct i

auch deficiencies in en expeditious and effective manner without heightened l oversight by the NRC. (Example: inability to retain skilled staff resulting in increased backlog in inspections and deficiencies in the technical quality of inspm: tion and licensing programs.)-

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ENCLOSURE 1

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C. When a program has repeatedly been late in adopting required compatibility

{ elements and heightened oversight by NRC would yield improvements, i

(Example: Inability / difficulty in adopting regulations which could result in

- significant impacts across State boundaries or allows licensees to be subject .

t to less stringent requirements than NRC requirements determined to be l necessary for compatibility.) .

1 IV. MANAGEMENT REVIEW BOARD l A. The Management Review Board (MRB) is responsib'e for making the

~a dequacy assessment, and the compatibility determination, of each

, Agreement State program based on the IMPEP reviews of the arogram, using i

both common and non-common performance indicators. Tv URB may also I

convene to evaluate special reviews of an Agreement State p.wram conducted to assess a specific Agreement State program weakness. MRB meetings to discuss specific program review findings normally will be open and representative (s) from the State under review will be invited to ,

participate. '

The MRB consists of senior NRC managers, or their designees, to include: i l

Deputy Executive Director for Regulatory Programs l Director, Office of Nuclear Material Safety and Safeguards (NMSS) '

Director, Office of State Programs (OSP)

Director, Office for Analysis and Evaluation of Operational Data (AEOD)

General Counsel Agreement State Liaison to the MRB B. The MRB will consider the results of the Agreement State review and ar.y other appropriate information in making a determination of adequacy and compatibility of an Agreement State program, if the MRB identifies serious concems regarding the adequacy and/or compatibility of the State's program, but doet, not find the deficiencies so serious as to find the program inadequate to protect public health and safety, one of the options it has available to ensure continued protection of the public's health and safety is to recommend placement of the Agreement State on probationary status, if the MRB finds an Agreement State program inadequate, no option other than to suspend or terminate the Agreement is available, since NRC can relinquish its regulatory authority only to a State that has a radiation control program that is adequate to protect public health and safety.

C. If the MRB determines probationary status is warranted, a meeting to discuss NRC concoms will be conducted by the Chair of the MRB; the Director, OSP; the /.dministrator of the NRC Region in which the Agreement State is located; and the General Counsel (or their designees) with the responsible cabinet-level official of the pertinent State. Subsequent to this meeting, if it is the final recommendation of.the MRB that NhC place the Agreement State program in probationary status, OSP will be assigned the i 2 12/1g/g6 s

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.f. lead for preparation of a Ccomission Paper. The Commission Paper will 3

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contain the information supporting the MM8 roccvnmendation. The  !

I Commission Paper will be coordinated with Offices represented on the MRB l i and the Region in which the Agreement Statw !s located. I i

4 l 1

i D. If the Commission approves, the Agreement State program will be placed on 4

probationary status, i.

! V.- NRC ACTIVITIES UPON COMMISSION APPROVAL OF ACTION

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} A. A letter to the Govemor notifying him or her of the Agreams.it State

- program probotionary status will be sent (Appendix A). A copy of the letter i- will be placed in the Public Document Room. OSP will draft the letter for the

!. Chairman's signature and include it as an attachrnent to the Commission l

Paper recommending probation. The Chairman will usually discuss the letter l with the Governct by telephone before it is mailed.

8. OSP will prepare and dispatch a letter to the Agreement State program j

director requesting that the Agreement State develop a " Corrective Action l Management Plan" and submit it to the OSP within 30 days of receipt of the 4

letter. The plan should describe actions to be taken by the State to address

-deficiencies, including specific goals and milestones.

C. Notice of the probationary status of the Agreement State program will be l published in the EndtIAl Baalaint (Appendix B).

D. OSP will prepare and dispatch a letter to all Agreement and Non Agreement States notifying them of the action.

E. A press release will be prepared and issued by the Office of Public Affairs.

F. OSP will coordinate with the Office of Congressional Affairs in order to notify the appropriate Congressional committees and members of the State's Congresolunal delegation.

VI. AGREEMENT STATE AND NRC ACTIVITIES DURING PROBATIONARY PERIOD A. The Agreement State's ' Corrective Action Management Plan" will be reviewed by OSP, NMSS, OGC, and the Region. The NRC and the State may meet to discuss the plan, comment, and subsequently agree with the milestones, and determine the projected duration of the probationary period.

Normally, the probationary period would be one year or less, but could be extended based on extenuating circumstances. (Example: Training new staff and/or eliminating significant inspection backlog may require more than one year.) -

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4 B. The OSP, in coordination with NMSS, OGC, and the Region, will develop a f " Heightened Oversight Plan" that willinclude review or meeting frequency to assess the Agreement State's progress, expected NRC resource expenditure, and corrective action close out list. NRC will consider providing technical assistance to the Agreement State, as appropriate in accordance with Management Directive 5.7, ' Technical Assistance to Agreement States."

C. Once allitems in the " Corrective Action Management Plan" have been executed and deemed closed by the OSP after a review of the Agreement State's actions, the MRB will convene to review improvements and consider ,

lifting the probation.

D. In the event the Agreement State does not complete the actions identified in the " Corrective Action Management Plan" and extenuating circumstances do not exist, the MRB will consider whether the Agreement should be suspended or terminated (See Suspension Procedure, D.22 and Termination Procedures D 21).

Vll. CESSATION OF PROBATIONARY STATUS A.

Once the MRB determines that the State has met the commitments in the

" Corrective Action Management Plan" anti the MRB is satisfied with the performance of the State's program, the MRB will recommend to the j Commission that the probationary status cease.

B. OSP will be assigned the lead for proparation of a Commission Paper. The Commission Paper will contain the information supporting the MRB decision.

The Commission Paper will be coordinated with the Offices represented on the MRB and the Region in which the Agreement State is located.

C. If the Commission approves cessation of the probationary status, notification of such cessation will be made following the same process outlined in f Section V (A,C,D,E.F), above.

Attachments:

Appendix A,B (t 4 12/1gt96

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. * .t Appendix A Probation Procedure DMAFT SAMPLE: Letter to the Governor of IState) Probation

Dear Governor (Name):

As you are aware, under Section 274 of the Atomic Energy Act of 1954, as amended, the Nuclear Regulatory Commission (NRC) retains the authority and responsibility for ensuring that Agreement State programs continue to provide adequate protection of the public -

health and safety, and that they are compatible with NRC's program for regulating radioactive materials. The Commission may place a State's program on probation if the ComrJssion is not confident that the State can address program deficiencies in en expeditious and effective manner without heightened oversight by the NRC.

4 The last review of the IState) radiation control program found significant program deficiencies, correction of which is necessary to assure adequate protection of the public i

health and safety in (State). The Commission has further determined that while making the necessary corrections, the IState) program would benefit from increased NRC oversight. The Commission is, therefore, placing the (State) radiation control program on l probationary status. Staff from the IState) radiation control program have been involved in the discussions leading to this decision.

The (State) radiation control program staff will be requested to provide NRC staff a j ' Corrective Action Management Plan" describing actions to be taken to address the identified deficiencies, including specific goals and timetables. The NRC staff will work with your staff throughout the probationary status period. Normally, the probationary period would be less than one year, but could be extended based on extenuating circumstances. Once the Commission determines that the commitments in the " Corrective Action Management Plan" have been met, and that the radiation control program can be found to be adequate and cornpatible, the probationary status will be terminated. -

Let me assure you that the Commission has not taken this action lightly. I will be happy to answer any questions you may have, or your staff may contact (Name), Director, Office of State Programs, at Italephone number). -

Sincerely, Chairman A1 12/19/96

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Appendix B Probation Procedure DRAFT SAMPLE: EadAIAl BASlatat Notice Placement of State Radiation Control Program on Probationary Status l

AGENCY: I U.S. Nuclear Regulatory Commission (NRC)

ACTION: Notice of State Radiation Control Program Being Placed on Probationary Status

SUMMARY

The NRC is announcMg the placement of (State) radiation control program for regulation of certs;n Atomic Energy Act materials on probationary status - ,

and initiating heightened oversight of the program, as well as overseeing implementation of the " Corrective Action Management Plan" developed by the staff of the IState) program. Once the radiation control program has met

! the commitments made in the " Corrective Action Management Plan," and can be found by the NRC to be adequate to protect the public health and -

safety, and compatible with NRC's program, the probationary status will be terminated. There will be further announcements of that action.

{ FOR FURTHER INFORMATION CONTACT:

IOSP Contact), Office of State Programs, U.S. Nuclear Regulatory Commission, Washington, DC 20555, telephone Italephone number).

SUPPLEMENTARY INFORMATION:

Under Section 274 of the Atomic Energy Act, as amended, the Commission retains the authority and the responsibility to assure that Agreement State programs continue to provide adequate protection of the public health and safety, and to be compatible with NRC's program with respect to the regulation of the materials and uses authorized under the Agreemert.

Agreement States are States which have assumed regulatory authority from the NRC over the possession and use of certain radioactive matsrlais. The Commission policy statement, " Statement of Principles ai4 Folicy for the Agreement State Program," established the option of placing an Agreement State radiation control program on probationary status for serious program deficiencies that require heightened NRC oversight.

The Commission $ through its Management Review Board (MRB), has considered the State of IState's Namel radiation control program and has agreed wkh the fmdings of the MR8, as well as with its recommendation to place the program on probationary status. INarrative of the MRB findings).

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The State has been requested to develop a " Corrective Action Management

(. Man" and to submit it to the NRC within 30 days. The plan shoald describe action taken by the State to address deficiencies, including specific goals and milestones. The Commission expects that the probationary period will be one year or less.

Once the MRB determines that the State has met the commitments in the

' Corrective Action Wr+;;+ ment Man" and can be found adequate to protect the public health and asfoty and compatible with NRC's program, a recommendation will be made to the Commisalon that the probationary status be terminated. Upon Commisalon approval, the probationary status will be lifted. Notification of such cessation will be made to the State's Govemor, the State's Congressional delegation, and all other Agreement and Non-Agreement States. There also will be a f,adaga[ Register Notice and a press statement.

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INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW OF NEW MEXICO AGREEMENT STATE PROGRAM July 1418,1997 l

DRAFT REPORT U.S. Nuclear Regulatory Commission ENCLOSURE 2

New Mexico Draft Report Page1

1.0 INTRODUCTION

This report presento the results of the review of the New Mexico radiation control program.

The review was conducted during the period July 14 18,1997, by a review team comprised of technical staff members from the Nuclear Regulatory Commission (NRC) and the Agreement State of Washington. Team members are identified in Appendix A. The review was conducted in accordance with the " Interim Implementation of the integrated Materials Performance Evaluation Program Pending Final Commission Approval of the Statement of Principles and Policy for the Agreement State Program and the Policy

Statement on Adequacy and Compatibility of Agreement State Programs," published in the Federal Reaister on October 25,1995, and the September 12,1995, NRC Management Directive 5.6, " integrated Materials Performance Evaluation Program (lMPEP)." Preliminary results of the review, which covered the period August 13,1994 to July 13,1997, were discussed with New Mexico management on July 18,1997.

[Parr, graph on Results of MRB meeting will be included in final report.

The New Mexico Environment Department is the agency within the' State of Nsw Mexico

that regulates, among other public haalth issues, radiation hazards. The New Mexico Environment Department Secretary is appointed by and reports to the Governor. Within the Environment Department, the radiation control program is administered by the Radiation l Licensing and Registration Program (RLRP) under the direction of the Hazardous and Radioactive Materials Bureau (HRMB). The New Mexico Environment Department and t HRMB organization charts are included as Appendix B. The New Mexico program regulates

) approximately 245 specific licenses, which includes a megacurie poolirradiator, l manufacturers, broad academic programs, broad medical programs, nuclear pharmacies and l Industrial radiographers.

The review focused on the materials program as it is carried out under the Section 274b. I (of the Atomic Energy Act of 1954, as amended) Agreement between the NRC and the State of New Mexico.

In preparation for the review, a questionnaire addressing the common and non common performance indicators was sent to the State on April 10,1997. New Mexico provided its response to the questionnaire on June 16,1997. A corrected copy of the questionnaire was received on July 25,1997. A copy of that response is included as Appendix C to this report.

The review team's general approach for conduct of this review consisted of:

(1) examination of New Mexico's response to the questionnaire, (2) review of applicable New Mexico statutes and regulations, (3) analysis of quantitative information from the radiation control program licensing and inspection database, (4) technical review of selected licensing and inspection actions, (5) field accompaniments of three New Mexico inspectors, and (6) interviews with staff and management to answer questions or clarify issues. The team evaluated the information that it gathered against the IMPEP

New Mexico Draft Report Page 2 performance criteria for each common and non common performance indicator and made a preliminary assessment of the radiation control program's performance.

Section 2 below discusses the State's actions in response to recommendations made following the previous review, 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 summarizes the review team's findings, reccmmendations and suggestions. Suggestions made by the review team are comments that t.he review team believes could possibly enhance the State's program.

Recommendations made by the review team are comments the review team believes are <

areas to be addressed to maintain p7rformance by the State. A response will be requested I from the State to all recommendations in the final report. ,

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS The previous routine review concluded on August 12,1994, and the results were transmitted to Judith M. Espinosa, Secretary, New Mexico Environment Department, on

February 7,1995. The review findings resulted in recommendations in two program indicators. The team's review of the current status of these recommendations is as follows:

(1) At the time of the 1994 review, the New Mexico radiation protection regulations had last been amended on March 10,1989. Compatibility was withheld because the State had failed to meet the three-year time frame required for adopting regulations equivalent to nine NRC regulations deemed

( matters of compatibility; (1) bankruptcy notification, (2) quarterly aue of

}

the performance of radiographers, (3) welllogging requirements, (4) National Voluntary Laboratory Accreditation Program (NVLAP) certification of dosimetry processors, (5) decommissioning requirements, (6) emergency plans, (7) safety requirements for radiographic equipment, (8) 10 CFR Part 20 equivalent regulations, and (9) notifications of incidents.

Current Status: New Mexico's regulations equivalent to the nine NRC regulations listed above were part of a package of regulations which were adopted on April 3,1995, and which became effective on May 3,1995.

After reviewing the drafts of these proposed regulations, in a letter dated January 9,1995, the Office of State Programs (OSP) offered the State a tentative finding of compatibility pending NRC review of the final, published regulations. The review team evaluated the published regulations against the equivalent NRC regulations. Pending review by NRC's Office of General Counsel (OGC), the team recommends that these regulations be found compatible with NRC requirements. This recommendation is closed.

New Mexico Draft Report Page 3 i

(2) The 1994 review recommended that the State review and compile internal procedures for staff use in the interest of maintaining consistency in licensir g and compliance activities.

Technical staff membert wrote procedures for licensing, inspection and ai!egation follow up. The procedures have not been shared with all staff members, however, creating program inconsistencies which are discussed in Sections 3 and 4 of this report. This recommendation is 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 Staffing and Training, (3) Technical Quality of Licensing Actions, (4) Technical Quality of Inspections, and (5) Response to incidents and Allegations.

3.1 Status of Materials insoection Proorarn The team focused on four factors in reviewing this indicator: inspection frequency, overdue inspections, initialinspection of new licenses, and timely dispatch of inspection I findings to licensees. This evaluation is based on the New Mexico questionnaire responses relative to this indicator, data gathered independently from the State's licensing and inspection data tracking system, the examination of completed licensing and inspection casework, and interviews with managers and staff.

The team's review of the State's inspection priorities verified that the State's inspection frequencies for various types or groups of licenses are at least as frequent as similar license types or groups listed in the NRC inspection Manual Chapter 2000 (IMC 2800) frequency schedule, with one exception. The New Mexico inspection frequency for nuclear pharmacies is 2 years as opposed to one year in IMC 2800. Staff indicated that this difference was due to an oversight as the State copy of IMC 2800 was out of date. The review team reccmmends that the nuclear pharmacy inspection frequency be modified from 2 years to 1 year, in reviewing the State's priority schedule, the review team noted that none of the New Mexico inspection frequencies exceed 3 years. Specifically, examples of license categorios in which the State :equires more frequent inspections are as follows:

Tvoe of License New Mexico Frecuencv (vears) NRC Frecuencv (vears)

Well logging 2 3 Medical institution 2 3 or 5 Medical private practice 2 ' or 5 Academic Type B broad 2 o

New Mexico Draft Report Page 4

. Veterinary 2 5 Portable gauges 2 5  ;

Fixed gauges 3 5 in response to the questionnaire, New Mexico indicated that no inspections were overdue by more than 25% of the scheduled frequency. The team identified severalir.spections that were overdue compared to the State frequencies but would not be considered overdue with respect to IMC 2800 frequencies.

With respect to initialinspections of new licenses, the team evaluated the inspection tracking data system and verified that initialinspections were entered into the computerized tracking system together with existing licenses. Inspection due datas generated by the system for new licenses are combined by inspection priority with those for other materials licenses. A review of the inspection tracking system showed that initial inspections are not differentiated from routine inspections, since the tracking system does not display a six month due date for initialinspections. From interviews, team reviewers found that the inspection staff was generally able to identify licenses due for initial inspections by the license number. The higher numbered licenses are new issues indicating an initial inspection is necessary.

A review of 25 license files, with initial inspections due during the review period, identified eight licenses which had initial inspections performed within 6 months. Nine licenses had initialinspections performed late, ranging from 1 to 21 months past the six month window, and eight licenses were overdue for initialinspections at the time of the review, from 1 to 34 months past the six-month window. The review team recommends that initial inspections of licensees be performed within 6 months of license issuance or within 6 months of the licensee's receipt of material and commencement of operations, consistent with IMC 2800. Also, the review team recommends that the tracking system be revised to allow initialinspections to be readily identified to staff and management.

In their response to the questionnaire, RLRP reported that 148 reciprocal licenses were iss'ued; however, only about one-half of the reciprocity licensees filed notifications and received authorization to conduct activities during the review period. Of the 148 reciprocal licenses issued,45 were industrial radiographers,26 were wellloggers and four were teletherapy /high dose rate afterloader source replacements. Approximately one-half of the reciprocities were for gauge or portable device uses. RLRP performed only three inspections of reciprocity licensees, two industrial radiographers and one gauge user, during the review period.

Reciprocity requests are recorded in a log and are available for review by inspectors but inspections are rarely performed. Both program management and staff indicated that short lead times and significant travel distances were impediments to performing reciprocity inspections. The review team recommends that the State increase the number of reciprocity inspections to better evaluate the health and safety implications of out of state companies working in New Mexico.

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New Mexico Draft Report Page 5 i

The timeliness of the issuance of inspection findings was also evaluated during the i inspection file review. For the inspection findings examined, the correspondence for nine I Inspections was sent to the licensee within 30 days of the inspection date. Eight inspections were " clear," and in several cases the inspection correspondence was sent within 1 to 2 days af ter the inspection. For three inspections, the correspondence was sent to the licensee greater than 30 days past the inspection date. Allinvolved cases with deficiencies were noted by the inspector. (New Mexico's definition of " deficiency" is identical to NRC's definition of " violation." In this report, the two terms are interchangeable.) Inspection deficiency letters to New Mexico licensees require a higher level of signature (Chief, HRMB), rather than the inspector. Two of the three letters were dispatched within 40 days of the inspection date. The third was issued 3 months after the inspection date, in the longest (3 month) case, the inspector was relatively new and did not understand the significance of quickly informing the licensee, in writing, of the inspection findings. While the New Mexico program has a 'in cases where inspection results were issued late (i.e., past the 30 day IMPEP criterion), the review team found that performance in this area was generally acceptable.

Based on the IMPEP evaluation criteria, the review team recommends that New Mexico's performance with respect to the indicator Status of Materials Inspection Program, be found satisfactory with recommendations for improvement.

3.2 Technical Staffino and Trainina

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lssues central to the evaluation of this indicator include the radioactive materials program

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staffing level, technical qualifications of the staff, training and staff tumover. To evaluate these issues, the review team examined the State's questionnaire responses relative to this indicator, interviewed program management and staff, and considered any possible workload backlogs.

The RLRP Manager stated that all technical staff positions require a bachelor's degree in the sciences. Positions are classified as either Environmental Specialists, requiring 4 years experience or as Environmental Scientists, with 2 years experience.

The RLRP has a Staffing level of one manager, five Environmental Specialists and one secretary. One of the Environmental Specialist positions was vacated on July 1,1997, when a staff member retired. Another Environmental Specialist is expected to retire in 1997. This staff is responsible for radioactive materials program, the Naturally Ocqurdn3 Radioactive Material (NORM) program and the x-ray program. Approximately 55% of each Environmental Specialist's time is allocated for the Radioactive Materials Program. This equates to approximately 2.75. technical FTEs for the 245 license program. Based on review results, this staffing leve! appears to be a minimallevel for a program of this size.

With the recent departure of a retired staff member, the staffing levelis even lower and raises concerns about the general effectiveness of the program.

c New Mexico Draft Report Page 6 The HRMB Chief indicated that the vacant position and the upcoming vacancy would likely be filled in the near future. The authority to fill these positions has been granted. The review team recommends that the State maintain the RLRP staffing level to at least the level which existed throughout the review period.

I The radioactive materials staff is split between two offices, the main office in Santa Fe, with the RLRP Manager and two Environmental Specialists and an office in Albuquerque, with two (three until recently) Environmental Specialists. The RLRP Manager stated that he had tried to have staff perform inspection and licensing at both offices but he brought all of the licensing work back to the Santa Fe office to centralize and manape the licensing program move effectively. The Santa Fe office staff took full responsibility for licensing due to this reorganizat!on of responsibility.

With the exception of the individual who recently left the program and one outstanding course for one staff member, technical staff have attended the core NRC training courses.

Two areas of significant training need were identified during the review and inspector acccmpaniments. The first aren is irradiator technology, particularly important as the State licensed a megacurie pool type irradiator last year. Only limited training was received by one Environmental Specialist from the irradiator vendor as the facility was brought on line.

The other area in which additional training is needed is medical brachytherapy. New Mexico has several medicallicensees who utilize various brachytherapy modalities, including high dose rate afterloaders. None of the program staff have attended a brachytherapy training course or have had any other significant training or experience in this area.

The RLRP Manager stated that, as New Mexico does not charge fees to its licensees and the general fund allocation for training is extremely limited, there is little chance that RLRP personnel will attend any conventional NRC training courses, unless NRC reassumes the cost for wt:h training. Program management was directed to All Agreement States Letter SP-97-040, cated June 9,1997, which proposed criteda for States with financial need to receive training aid from NRC. The team believes that New Mexico may be a strong candidate for receiving funding from the NRC for training purposes. The team also discussed with the RLRP Manager potential alternative training methods which could be used to train staff in brachytherapy and irradiator technology. The review team recommends that the State provide training to technical personnelin the areas of medical brachytherapy and irradiator technology.

The RLRP Manager stated that he provides on-the-job training to staff, explaining program procedures, and accompanies each inspector on at least two inspections per year. There is no documented training and qualification program ir, place for the RLRP staff comparable to IMC 1246, " Formal Qualification Programs in the Nuclear Material Safety 6nd Safeguards Program Area." As an example, the review team noted that licensing md inspection procedures had been developed by various staff members but that not all staff had been trained in these new procedures. The review tearn recommends that the State develop a

New Mexico Draft Report Page 7 formalized training program comparable to IMC 1240, " Formal Qualification Programs in the Nuclear Material Safety and Gafeguards Program Area."

Based on the team's finding and the IMPEP evaluation criteria, the review team recommends that New Mexico's performance with respect to this indicator, Technical Staffing and Training, be found satisfactory with recommendations for improvement.

3.3 Technical Qualitv of Licensina Actions The review team examined completed licensing casework and interviewed the reviewers for 11 specific licenses. Licensing actions were evaluated for completeness; consistency; proper isotopes and quantities authorized; 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 and of its conditions and tie-down conditions, and overall technical quality.

i Casework was evaluated for timeliness; adherence to good health physics practices; reference to appropriate regulations; documentation of safety evaluation reports; product certifications or other supporting documents; consideration of enfor' cement history on renewals; pre-licensing visits; peer or supervisory review as indicated; and proper signature authorities. The files were checked for retention of necessary documents and supporting data.

• The license casework was selected to provide a representative sarnple of licensing actions which had been completed in the review period and to include work by all reviewers. The cross section sampling included several of New Mexico's major licenses and included the following types: nuclear laundry; pool irradiator; well logging; nuclear medicine; fixed gauge, academic research and development; veterinarian; and industrial radiography.

Licensing actions evaluated included three new licenses, two renewals, one pending renewal, three amendments, and two terminations, in discussions with the RLRP Manager, it was noted that there were no major decommissioning efforts underway with regard to agreement materialin New Mexico. Also, there were no identified sites with potential decommissioning difficulties equivalent to those sites in NRC's Site Decommissioning Management Plan. A list of the=e licenses with case specific comments may be found in Appendix D.

The Interstate Nuclear Services (INS) license renewal was selected for review because the State has expended considerable staff resources with this renewal and is faced with opposition. A series of public hearings were held in 1996 culminating when the Secretary of the Departraent issued an order to tenew the license subject to INS completing several conditions to the satisfaction of the Department. However, the main point of contention between the State ,;nd the opposition to renewal is the issue of " solubility" of radioactivo particulates in liquid effluents discharged to the sewage system and whether the State will acespt INS's proposed waste water treatment system. The State requested technical assistance from NRC. The State has sought to identify potential contractors to evaluate the proposed waste water system and has queried other Agreement States to determine

New Mexico Draft Report Page 8 how the " solubility" criteria are being addressed in those States. INS has not yet submitted complete information to address all conditions of the Secretary's order. The license reviewer intends to require the licensee to consolidate the interim submittals into a final renewal package. A final license application review will be performed when the renewal package is complete. Issuance of this renewalis still pending.

With respect to the overall licensing program, the RLRP Manager stated that licensing quality had suffered when licensing actions were being handled out of two different  :

offices. The RLRP Manager sought to improve licensing quality by bringing all licensing actions back to Santa Fe in early 1996. He also began performing many of the licensing reviews himself, concentrating on amendments and simple renewals to improve quality and consistency.

, Licensing actions of all types appear to be completed in a timely fashion with most

' renewals being completed within 6 months of the expiration date. The RLRP Manager noted that " construction" visits were performed for the new panoramic, wet storage irradiator and that an in-office consultation was held with another license applicant but there were no other pre licensing visits for the few complex licenses that New Mexico had issued. The RLRP Manager estimated that as many as 50% of new licenses were hand

[ delivered as a means of establishing open communications with new licensees.

Retention of supporting documentation is a program weakness. Required documents were found to be missing in 9 of 11 filea evaluated. These documents included: licensee application submittals, a renewal request, a licensee's response to a compliance letter that required a licensing change, detailed schedules for testing and maintenance, evidence of named users' training and experience, verification that sources had been transferred properly, misfiled correspondence, and the results of close out inspections. Documentation of the license reviewers work was particularly weak. Deficiencies identified by reviewers were apparently communicated by telephone in many cases with no record of the deficiency or its resolution unless the licensee's correspondence was clear. Reviewer checklists were present in new license files. The review team suggests that documentation of license reviewers

• actions be maintained in license files.

All new licenses are reviewed and signed by the HRMB Director before being issued. All renewed licenses and amendments are reviewed and signed by the RLRP Manager.

However, the RLRP Manager performs approximately one-half of alllicensing actions and signs his own work without significant peer or supervisory review. No potentially significant health and safety issues were identified.

The review team found that, despite documentation deficiencies, the licensing actions were thorough, complete, consistent, and of acceptable quality with health and safety issues adequately addressed. Speciallicense tie-down conditions were not observed. The licensee's compliance history was taken into account when reviewing renewal applications.

New Mexico's licensing guides and license policy procedures were revised and updated after the last program review. New Mexico's licensing guides and license conditions were

New Mexico Draft Report Page 9 adopted directly from the NRC's. Reviews of licensing actions showed reviewers appropriately used the revised licensing guides for new licenses and the absence of major findings indicates that the reviewers have a generally good understanding of applicable guidance.

Based on tt IMPEP evaluation criteria, the review team recommends that New Mexico's performann Nith respect to the indicator, Technical Quality of Licensing Actions, be found satisfactory.

3.4 Technical Quality of insoectionji The team reviewed the inspection reports, supporting documentation and correspondence to licensees for 12 materials inspections conducted during the review period. The casework included the State's four fully qualified materials inspectors and one inspector who left the program during the review period (another inspector left the program early in the review period, and her work was not reviewed). Inspection reports were selected to cover the whole review period and to emphasize higher-priority licensoes. The review team examined inspection casework of the following types of licensees: one medicalinstitution; l one pool-type irradictor; one nuclear laundry; one well logger; one nuclear pharmacy; one industrial radiographer; one portable gauge; two academic licensees; two research and development licensees (one of which " tagged" radionuclides to welllogging tracers) and one broad medical that included a high dose rate (HDR) remote afterloader; brachytherapy; nuclear medicine; and academic research and development. Following the casework evaluation, the review team interviewed each of the four inspectors. Appendix E provides a list of the inspection cases evaluatad in depth with case specific comments.

Overall, the review team found that the inspector accompaniments and most inspection reports showed acceptable, but not strong, technical quality of inspections, Interviews with inspectors backed up the review team's findings that inspections were being conducted regularly, but moderate to significant areas that needed improvement were apparent in the State's inspection program. '

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Three inspector accompaniments identified in Apoendix E were performed by a review team member on June 16 18,1997. The other two New Mexico inspectnrs had been accompanied during past reviews. During the accompaniments, inspectors demonstrated a range in skills and abilities for the specific types of inspections they were performing. In two of the three accompaniments, inspection techniques were observed to be primarily records review oriented, with missed opportunities when inspectors coud have observed licensee operations. The accompaniments demonstrated that inspectors were not missing critical safety areas, but the inspections were not thorough, either. For examp!e, on one accompaniment at a hospital, the inspector was not sufficiently trained in brachytherapy and missed opportunities to interview therapy technologists and ancillary persannel. In general, the inspections were adequate to assess the most significant radiological health and safety issues, although on some, the inspectors showed significant room for improvement, j

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New Mexico Draft Report Page 10 Inspection reports were evaluated to determine if the reports adequately documented the scope of the licensed program, licensee organization, personnel protection, posting and labeling, control of materials, equipment, use of materials, transfer and disposal. The review team also evaluated whether the reports adequately documented operations '

observed, interviews of workers, independent measurements, status of previous violations, substantiation of all violations and the substance of discussions during exit interviews with management. To assure consistency and quality of reports, the RLRP Manager provides review and signs inspection reports, i

For 9 out of the 12 inspections reviewed, inspectors did not perform observations of licensee operations. In fact, on some inspection reports, the inspectors specifically noted that they had not observed licensee operations. In interviews, the inspectors asked the review team what type of operations should be observed, especially when conducting office inspections of industrial licensees and afternecn inspections of diagnostic medical licensees. The review team noted that licensees can demonstrate actions (such as surveys, transportation practices, interlock checks, and so on), but the State inspectors did not indicate that such demonstrations or observations were being conducted on a routine basis during inspections. Even though the inspectors have attended the NRC inspection training course, the principalinspection effort seems focused on records review, which is l

contrary to the national (NRC and Agreement State) trend in inspecting for licensee l performance. The review team recommends that the State inspectors attempt to observo licensee operations or demonstrations during all inspections.

On three of the inspections evaluated, inspectors did not conduct independent measurements, in one case, the inspector's survey instrument malfunctioned. The inspectors could not provide adequate explanation regarding why independent measurements were not conducted during the other two inspections. In other cases, l independent measurements were performed but no specific results were indicated in inspection reports. Inspectors were knowledgeable that they should conduct independent measurements during inspections, and some inspectors even performed confirmatory measurements (i.e., side by side readings with licensee survey instruments), which is commendable. Conducting measurements for radiation levels should be an essential eternent of routine byproduct materialinspections. The review team recommends that the State inspectors conduct independent measurements on all inspections.

The review team noted that, on a number of inspections evaluated, that the State was not examining complex, technical radiation safety / health physics issues in sufficient detail during inspections. For iastance, on inspections of a medical institution using limited quantities of iodine 131 and on a tagging licensee, inspectors apparently did not review licensee effluent releases, even though the licensees had potential for material release.

Similarly, inspectors did not regularly review bioassay adequacy or estimate doses (when licensees did not conduct bioassays), review Annual Limits on intake and Derived Air Concentrations, provide dosimetry results on severalinspection reports, and provide sufficient detail on a licensee's respiratory protection program. In addition to this lack of technical complexity and detail, the review team observed that many of the inspections

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New Mexico Draft Report Page 11 omitted key program areas or were not sufficiently broad. For instance, the review team observed instances where RLRP inspections did not sufficiently close previous violations, address training, resolve emergency preparedness issues, address shipping or cover annual radiation protection program reviews. In response to these findings, the review team recommends that the State increase the ri0or of reviewing technical health physics issues during inspections, and increase the breadth and scope of inspections. Additionally, the review team noted that few, if any, ancillary worker (such as f acility housekeeping staff, students, administrative staff and medical assistants) interviews were conducted by the inspectors. The review team suggests that the State inspectors attempt to interview ancillary workers during inspections.

On 8 of the 12 inspections evaluated, the inspector conducted exit meetings with the licensee's radiation safety officer (RSO) or a principal authorized user. In a few of these l cases, the RSO was also a senior licensee manager. However, as determined through

! interviews, inspectors generally did not conduct exit meetings with senior licensoe managers, or did not make substantial efforts to conduct exit meetings with senior licensee managers (i.e., managers who control the radiation safoty program's authority, staffing /

and resources). This is in conflict with the State's own policy that, "An exit interview with l the highest available representative of administration or management shall be conducted by l the inspector...." A cause of this may have been that few inspectors knew about the i procedures. The review team recommends that the State inspectors attempt to conduct formal exit meetings with senior licensee management on all inspections.

The review team examined the State's performance regarding follow up on previously cited i

violations (deficiencies). On one of the inspections, the licensee was cited for f ailure to calibrate survey instrumentation, in response, the licensee stated what it had done to correct the problern. However, the licensee did not state what would be done to prevent this type of deficiency from occurring again in the future. On the same inspection, the licensee was cited for an unauthorized user. The licensee was told to amend its license to add an individual as an authorized user (the individual apparently was using material at the time of the inspection), but the file does not indicate that the licensee ever submitted an amendment request. On the next inspection, the licensee was again given a deficiency for the same type of issue (i.e., told to amend its licerise to add authorized users). Similar licensing issues were identified on other inspections. These findings led the review team to conclude that New Mexico needs a mechanism to ensure that licensee responses to deficiencies are adequate to address the cited problems, and that the deficiency is closed and folicwed up on a future inspection. The review team recommends that the State develop a formal process for reviewing licensee responses to deficiency letters and closing open deficiencies. The State's inspection finding regarding the unauthorized user also indicates that the State does not have a formal mechanism for transfer of information from the inspector to the license reviewer, or vice versa, and the review team confirmed this in interviews. The closest that inspectors come to passing along information to the next license reviewer is by telling them verbally about needed licensing actions. In the case noted above involving the unauthorized user, this method apparently did not work or was not used. The review team suggests that the State develop a formal process for inspectors

0 New Mexico Draft Report Page 12 and license reviewe.rs to document and transmit peninent information to each other for follow up.

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The review team also examined whether the State's inspection files were complete. On I two of the inspection files reviewed, the files did not contain responses to the licensees acknowledging their responses and stating that the issues would be followed up on future inspections. Through interviews, the review team learned that occasionally the licensee's response is filed in the license file in Santa Fe, without being transmitted to the Albuquerque inspector for review. The review team suggests that the State develop a process for ensuring that inspection files are complete, that all appropriate State documents are prepared and filed, and that licensee responses are received and filed, Also in the area of documentation, the review team examined the inspection casework for the State's new pool-type irradiator. The review team found that the first full, documented inspection was conducted nn July 1,1997. A site visit on October 28,1996, was also documented in a note to the inspection file. However, the July inspection listed a number of previous trips to the licensee's site where inspection activity was performed, but not documented (e.g., November 1996 source loading, December 1996 review of system operations and product dosimetry, etc.). Follow up interviews with the inspectors confirmed that the State had conducted site visits or inspections to tha irradiator that were not documented. This is significant with respect to the pool irradiator, because it is a new l

operation in New Mexico involving an extremely large inventory of licensed material. The review team recommends that the State begin documenting all trips to licensees' or applicants' facilities when inspecting licensed activities, performing special inspections, or performing pre-licensing site visits during construction. This documentation should be filed in the State's official inspection file.

The review team identified a number of problems, covering both content and documentation, in New Mexico's inspection program. The review team concluded that the RLRP Manager, who signs each of the inspection reports as a reviewer, had the opportunity to identify many of these issues during the supervisory review of the inspection reports.

The review team recommends that the State management exercise mors stringent supervisory review of inspection reports.

In the area of the State's programmatic policy r.nd management, the inspection procedures and techniques utilized by New Mexico were evaluated and determined to be generally consistent with, albeit in far less detail than, the inspection guidance provided in IMC 2800. Few of the inspectors were aware of the presence of inspection guidance within the State. Training on the State's internal procedures is discussed in Section 3.2.

The State's inspection report forms were reviewed and found to provide generalinspection areas consistent with tne types of information collected under NRC's Inspection Procedure (IP) 87100 field notes. On the two most complex inspection cases reviewed (the irradiator and an HDR), the State used NRC's field notes. On its own forms, the State already has

, developed an inspection report format with major subheadings and spaces for narrative

6 New Mexico Draft Report l Page 13 responses, a move away from the checklist format, which is the anproach that NRC is adopting for materials inspections. The State has been revising its inspection report for approximately the past 2 years, according to the inspector with lead responsibility for the inspection form revision, and in that interim time period RLRP inspectors have used a variety of " draft" inspection report forms that the review team observed in the inspection files. In interviews, the review team learned that RLRP inspoctors select their own forms f ar the type of inspection they are performing; the review team did not identify any internal requirement or standardization within the State to use a specific report form for documenting inspections. The review team also concluded that, because the inspection report forms frequently determine the areas examined during an inspection, the forms themselves may have contributed to the State's lack of breadth and technical complexity during its insoections. The review team suggests that the State complete its revision of the inspection report forms, insuring that each set of forms covers all key areas for the type of licensee being inspected, and that RLFtP inspectors begin using the standardized form (s).

Most inspection forms, correspondence, and documents were foun.d in the files.

Documented inspection findings generally led to appropriate deficiency letters. In interviews with the inspectors, none could recall any escalated enforcement cases during the review period. Of the files reviewed, the State cites deficiencies on about one third of its inspections, in response to the questionnaire, the State reported that supervisory inspector accompaniments were performed at least twice per year by the RLRP Manager for each inspector since the previous review. Performance evaluations are discussed with the l inspector and the accompaniments documented. Accompaniments of less-experienced j ctaff are also performed by senior inspectors.

The review team noted that RLRP has a sufficient number of calibrated, portable radiation detection instruments for use during routine inspections and response to incidents and emergencies. The State also has available the services of the State's Scientific Laboratory Division in Albuquerque, which appeared to provide exceptional services on one of the inspections reviewed.

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

3.5 Resoonse to Incidents and Alleoations in evaluating the effectiveness of the State's actions in responding to incidents and allegations, the review team examined the State's response to the questionnaire relative to this indicator and evaluated the incidents reported for New Mexico in the " Nuclear Materials Events Database (NMED)" agair st those contained in the New Mexico casework and license files. The team evaluated casework in the license files maintained in the Santa

New Mexico Draft Report Page 14 Fe office and in files from the Albuquerque office which were delivered to the review team.

The team compiled a list of 31 incidents that had occurred in the State during the review period, examined the list for possible trends or generic issues, and chose 11 of the more significant incidents for in depth review. The team also evaluated the State's response to the only two allegations reported by the State. A list of the incidents with comments is included in Appendix F.

The review of the incident casework revealed five serious generic deficiencies in RLRP's response to incidents. First, circumstances in 5 of the 11 incidents indicateu the need for onsite response fiom the State; however, only one of the five received an onsite response, and it was not documented, and thus could not be confirmed. The review team recommends *et the State make onsite, documented investigatSns of incidents, allegations, or misadministrations with potential health and safety effects (i.e., source disconnects, possible overexposures, lost sources, contamination, etc.).

Second, in all cases, documentation of the State's response was either missing or incomplete. The team found that the State has no procedures or forms in place to record information obtained in the incoming calls, to track the progress of the investigation, to ,

document management involvement, or to close out the incident investigation. In l evaluating the casework, the team found that in five cases, the individual taking the i

incident report was not identified in addition, none of the files contained the investigator's signature, evidence of management involvement or review, or any notation that the l

investigation was completed and closed out. The review team recommends that the State create an incident and allegation reporting form that would, at a minimum, identify the person taking the initial report, list the name and telephone number of the reporting party, provide the details of the incident or allegation as reported, record the State's convusation with the licensee or individual, describe corrective actions taken by the licensee, destnoe the investigation conducted by the State and the results, list citations or other regulatory actions, show the date the investigation was closed out and justification for closure, show date(s) incident was reported to the NRC or other agencies, and provide spaces for the signatures of the investigator and supervisor. A copy of the form should be maintained in the incident file and in the license file.

Third, none of the casework contained any indication that the State evaluated the licensee's response or corrective actions. It appeared the State relied entirely on the licensee's reports of the incident and their corrective actions. The review team recommends that the State establish a protocol for making independent investigations and evaluations of the licensee's actions.

Fourth, geretic deficiencies noted in five cases where the incident should have been followed up at the next inspection, but was not. The review team recommends the State initiate procedures to ensure incidents are followed up at the next inspection to verify that the licensee's corrective actions have been implemented.

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New Mexico Draft Report Page 15 Last, the team found that in five cases, licensees may have f ailed to comply with regulations but were not cited. The review team suggests that when evaluating incidents, the State cite appropriate items of deficiencies when applicable.

New Mexico does not have an incident tracking system. RLRP does not keep a centrallog of incident or allegation reports and does not maintain a separate incident file, incidents may be reported by the licensee directly to the Albuquerque inspector assigned to their territory, or they may be reported to the RLRP office in Santa Fe and documents involving incidents may be kept either place, From interviews with staff, the team found that events are assigned to the inspector normally responsible for the licensee involved. The inspector then routinely requires the licensee to investigate the incident and furnish a report with the details and corrective actions. That licensee's report is used when necessary to complete the NRC Event Report (Form 565) and then filed in the license file. The State has no provision to file reparts for incidents that do not involve Now Mexico licensees, in conducting the file reviews, the team had difficulty in assembiing informatior, necessary to evaluate the State's incident rresponse because documents could not be located and staff could not remember details of investigations. The review team recommends that the State (a) set up a separate incident and allegation file system in the Santa Fe office, keeping all documents and records pertaining to an incident in one location, with the data cross-referenced to the license / inspection files there and in the Albuquerque office, and (b) establish a system to centrally log and track the progress of incidents and allegations.

The New Mexico statewide emergency plan is the responsibility of the Department of j Public Safety, if other State agencies encounter incidents or emergencies related to

} radioactive materials, the responsibility is delegated to the RLRP The team found through interviews with staff and management that RLRP has no written internal procedures for incident response other than a November 1995 memorandum explaining the NRC event reporting criteria. In interviews with the review team, the inspectors stated that they were not aware of any emergency procedures and that they had not been trained in emergency response. The review team recommends that the State develop and implement written procedures for responding to events involving radioactive material and conduct training sessions until all technical staff are fully trained and qualified in emergency response.

These procedures and training should address the use of the forms and tracking system recommended above.

The State does have brief written procedures for investigating allegations. It is their policy to thoroughly investigate all allegations, including tbsa made anonymously, to seek out and interview corroborative witnesses, to investigate the reasons for confirmed events, and to document all conversations. It is also their policy to respect anonymity to the highest possible extent. The team noted, however, that New Mexico law does not protect the identity of individuals making allegations. The review team suggests that the State cons: der expanding the allegation procedures to include procedures for notifying the person making the allegation of the results of the investigation and including the allegation procedures in *e event reporting form, tracking system, and emergency response procedures.

New Mexico Draft Report Page 16 The team evaluatid the two allegations that oc. curred in the State during the review period, in both cases, the team found that the alk.gations were promptly evaluated to determine the validity and safety significance of the claims. Onsite investigations were conducted promptly in both cases. In one case, there was evidence that the State kept the individuals making the allegations informed of the resolution of their concerns;in the other, there was not. In one complex and lengthy case, the State held public haarings on the renewal of the license at the request of the alleging parties.

Except for the period between July 1995 and May 1996, the State provided quarterly I event reports to the NRC even though NRC has requested monthly reports. During the period between July 1995 and May 1996, the State did not provide reports to the NRC, ,

and little to no documentation of events exists. Two incidents that should have been reported were inadvertently omitted through oversights. The team instructed the State to report the events to NMED c :'1e next monthly report. In the one case of a leaking source, the NRC and regstr ' s agency of the manufacturer were both advised.

As discussed above, the team found frequent examples of incomplete, inappropriate, poorly documented, or delayed responses to incidents, and as a result, potential health and safety problems may exist. Therefore, based on the IMPEP evaluation criteria, the review team recommends that New Mexico's performance with respect to the indicator, Response to incidents and Allegations, be found unsatisf actory.

40 NON COMMON PERFORMANCE INDICATORS IMPEP identifies four non common performance indicators to be used in reviewing Agreement State programs: (1) Legislation and Hegulctions, (2) Sealed Source and Device Evaluation Program, (3) Low Level Radioactive Waste Disposal Program, and (4) Uranium Recovery Operations. New Mexico's agreement does not cover uranium recovery operations, so only the first thret non common performance indicators were applicable to this review.

4,1 Leaistation and Reaulations 4.1.1 Leaistative and Leont Authority Along with their rep 9se to the questionnaire, the State provided ther review team with copies of legislation Inat affects the radiation control progrcm. Legislative authority to create an egency and enter into an agreement with the NRC is granted in New Mexico Statutes,1978 Annotated, Chapter 74, Environmental improvement, Pamphlet 120 with 1989 Replacement Pamphlet, Art!cle 3, Radiation Control Act, Sections 74 31 through 74-3+16. In the Act, the New Mexico Environmental Department is d signated as the State's-radiation control agency. The review team evalusted the legislation which had not changed since the previous review and found State legislation to be adequate.

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l New Mexico Draft Report Page 17  !

i 4.1.2' Status and Comnatibilitv of Regulations l t

i The review team compared the State's regulations against the latest Chronology of l Amendments and found that the State had adopted equivalent rules for all amendments  !

which were due for adoption by the Agreement States through July 1,1996. However,  !

the State had failed to revise their equivalent regulations to the following NRC regulations l identified as compatibility items:

e

• Decommissioning Recordkeeping and License Termination: Documentation

. Additions," 10 CFR Parts 30,40,70, and 72 amendments (58 FR 39628) that became effective on October 25,1993, and which became due on October 25, i 1996, i e 'Self Ouarantee as an Additional Financial Mechanism,".10 CFR Parts 30,40, and 70 amendments (58 FR 68726 and 59 FR 1618) that became effective on  ;

January 28,1994, and which became due on January 28,1997. Note, this rule is  !

' designated as a Division 2 matter of compatibility. Division 2 compatibility allows the Agreement States flexibility to be more stringent (i.e., the State could choose ,

not to adopt self guarantee as a method of financial assurance). If a State chooses not to adopt this regulation, the State's regulation, however, must contain . _

provisions for financial assurance that include at least a subset of those provided in '

NRC's regulations, e.g., prepayment, surety method (letter of credit or line of credit), insurance or other guarantee method (e.g.,'s parent company guarantee).

l From reviewing the State's promulgation process and from Interviewing program .

management, the review team found that the time frame for adopting revised regulatior.s is ,

at least 11 months from the date the process begins. The State advised the review team that the Decommissioning Recordkeeping and Self Guarantee regulations are in planning stages and are expected to be adopted by May 30,1998.

The State was alerted that the following regulations will become due during the next 12 months: '

e ' Timeliness in Decommissioning of ' Materials Facilities," 10 CFR Parts 30,40, and 70 amendments (59 FR 36026) that became effective on August 15,1994, arid '

which will bereme due on August 15,1997, o " Preparation, Transfer for Commercial Distribution and Use of Byproduct Material for Medical Use," 10 CFR Parts 30, 32 and 35 amendments (59 FR 61767,59 FR ,

65243,60 FR 322) that became effective on January 1,1995, is under review and -

. is expected to become effective by the due date of January 1,1998. -

e " Low level Waste Shipment Manifest Information and Reporting," 10 CFR Parts 20 and 61 amendments (60 FR 15649,60 FR 25983) that will become effective March 1,1998, and which will become due on March 1,1998. The NRC delayed i

,. - . . . . , , . . . _ . , . , --,.-u.,-.n... , _ . , - .,-. n+., ---,-,,.,.~,,.,,.--n.., v.-~.-.<--, n-

New Mexico Draft Report Page 18 its effectiveness until the State could adopt compatible requirements so that the national manifest system will go into effect at one time, e " Frequency of Medical Examinations for Use of Respiratory Protection Equipment,"

10 CFR Part 20 amendments (60 FR 7900) that became effective on March 13, l

1995, and which will become due on March 13,1998. Note, this rule is designated as a Division 2 matter of compatibility. Division 2 compatibility allows the Agreement States flexibility to be more stringent (i.e., the State could choose to contirtue to require annual medical examinations).

liach of the listed regulations and amendments are scheduled to be adopted by May 30, 1998. The review team recommends that the Stato expedite promulgation of the compatibility related regulations now overdue and those which are due within the next 12 months.

The State was reminded of the following amendments which will need to be addressed:

e " Radiation Protection Requirements: Amended Definitions and Criteria,"

10 CFR Parts 19 and 20 amendments (60 FR 36038) that became effective August 14,1995, and which will become due on August 14,1998, e

" Medical Administration of Radiation and Radioactive Materials" 10 CFR Parts 20 and 35 amendments (60 FR 48623) that become effective on October 20,1995, and which will become due on October 20,1998, e " Clarification of Decommissioning Funding Requirements," 10 CFR Parts 30,40, and 70 amendments (60 FR 38235) that became effective November 24,1995, and which will become due on November 24,1998, e " Compatibility with the International Atomic Energy Agency," 10 CFR Part 71 amendment (60 FR 50248) that became effective April 1,1996, and which will become due on April 1,1999. NRC delayed the effective date of this rule until April 1,1996, so that the Department of Transportation (DOT) companion rule could be implemented at the same time. Since the rule involves the transport of materials across state lines, the States are encouraged to adopt compatible regulations as soon as possible, e Termination or Transfer of Licensed Activities: Recorceeping Requirements," 10 CFR Parts 20 and 30 (61 FR 24669) that became effective on May 16,1996,and which will become due on May 16,1999.

The team notes that NRC staff is currently reviewing all Agreement State equivalent regulations to Part 20, Standards for Protection Against Radiation. These reviews are being conducted outside the IMPEP process and the States will be notified of the results.

New Mexico Dratt Repc.t Page 19 DurinD the examination of the State's procedures for promulgating regulations, the team noted that proposed rules or revisions to rules must be publicly announced 60 days prior to adoption, and a pub lic hearing must be provided. The team examined the records of the last regulation package and found that the NRC was provided drafts of the proposed regulations early in the process and that the comments and suggestions made by the NRC staff were incorporated into the final regulations, it is the State's policy to saind copies of final regulations to the NRC; however, it could not be verified that copies of the previous final regulations were sent to NRC. The review team suggests that a file be maintained with the cover letters and ensuing correspondence of all draf t or final regulations sent to

-the NRC.

Based on the IMPEP evaluation criteria, the review team recommends that New Mexico's performance with respect to this indicator, Legislation and Regulations, be found satisfactory.

4.2 Sealed Source and Device Evaluation Proosam The review team did not review the State's sealed source and devi'ce (SS&D) program l

' even though New Mexico currently has responsibility for this area. The review team discussed with the Secretary, New Mexico Environment Department, as to whether Now Mexico has considered returning its authority for the Sealed Source and Device Evaluation

} Program. The Secretary stated that he would have the Governor send a letter to NRC turning back the SS&D evaluation authority. The State did not perform any SS&D evaluations during the period of the review.

4.3 Low level Radioactive Waste (LLRW) Discosal Proaram in 1981, the NRC amended its Policy Statement, " Criteria for Guidance of States and NRC in Discontinuance of NRC Authority and Assumption Thereof by States Through Agreement" to allow a State to seek an amendment for the regulation of LLRW as a separate category. Those States with existing Agreements prior to 1981 were determined to have continued LLRW disposal authority without the need of an amendment. Although New Mexico has LLRW disposal authority, NRC has not required States to have a program for licensing a LLRW disposal facility until such time as the State has been designated as a host State for a LLRW disposal facility. When an Agreement State has been notified or becomes aware of the need to regulate a LLRW disposal facility, they are expected to put in place a regulatory program which will meet the criteria for an adequate and compatible LLRW disposai program. There are no plans for a LLRW disposal facility in New Mexico.

Accordingly, the review team did not review this indicator.

5.0

SUMMARY

As noted in Sections 3 and 4 above, the review team found the New Mexico performance with respect to the performance indicators, Technical Quality of Licensing Actions and Legislation and Regulations, to be satisfactory. The review team found the State's

New Mexico Draft Report Page 20 performance with respect to Status of MaterialInspection Program, Technical Staffing and Training, and Technical Quality of Inspection to be satisfactory with recommendations for improvement. The team found the State's performance with respect to the common performance indicator, Response to incidents and Allegations, to be unsatisfactory. The evaluation of this indicator identified frequent examples of incomplete, inappropriate, poorly documented, or delayed responses to incidents, and as a result, potential health and safety problems may exist. These significant deficiencies, combined with the general weaknesses and problems identified throughout the radiation control program, are of great concern to the NRC.

The team found that the primary root cause for the deficiencies was directly attributable to i the need for management Improvement to effectively assess and respond to potential public health and safety issues. Although no specific examples of public health and safety degradation were identified by the review team, the lack of effective programmatic control certainly increases that possibility. Accordingly, the team recommends that the MRB find the New Mexico program adequate to protect public health and safety but needs '

improvement, and compatible with NRC's program.

Due to the significance and number of deficiencies found in the New Mexico program, at the time of review, that included an unsatisfactory finding for one indicator, the team recommends a na+>d of probation for a duration to be established after consuhetion with New Mexico radiation control program management.

Below is a summary list of suggestions and recommendations, as mentioned in earlier sections of the report, for action by the State.

1, The review team recommends that the nuclear pharmacy inspection frequency be modified from 2 years to 1 year. (Section 3.1)

2. The review team recommends that initial inspections of licensees be performed within 6 months of license issuance or within 6 months of the licensee's receipt of material and commencement of operations, consistent with IMC 2800. (Section 3.1)

3. The review team recommends that the tracking system be revised to allow initial inspections to be readily identified to staff and management. (Section 3.1)

4. The review team recommends that the State increase the number of reciprocity inspections to better evaluate the health and safety implications of out of state companies working in New Mexico (Section 3.1)

5. The review team recommends that the State maintain the RLRP staffing level to at least the level which existed throughout the review period. (Section 3.2)

WN&Wi M DL

} .

rw Mexico Draft Report Page 21

6. The review team recommends that the State provide training to technical personnel in the areas of medical brachytherapy and irradiator technology. (Section 3.2)

7. The review team recommends that the Stato develop a formalind training program comparable to IMC 1246, " Formal Qualification Programs in the Nuclear Material Safety and Safeguards Program Area." (Section 3.2)

8. The review team suggests that documentation of license reviewers' actions be maintained in license files. (Section 3.3)

9. The review team recommends that the State inspectors attempt to observe licensee operations or demonstrations during allinspections. (Section 3.4)

10. The review team recommends that the State inspectors conduct independent measurements on allinspections. (Se: tion 3.4)

11. The review team recommends that the State increase the rigor.of reviewing technical health physics issues during inspections, and increase the breadth and scope of inspections. (Section 3.4)

12. The review team suggests that the State inspectors attempt to interview ancillary workers during inspections. (Section 3.4)

13. The review team recommends that the State inspectors attempt to conduct formal exit meetings with the senior licensee management on allinspections. (Section 3.4)

14. The review team recommends that the State develop a formal process for reviewing licensee responses to deficiency letters and closing open deficiencies. (Section 3.4)

15. The review team suggests that the State develop a formal process for inspectors and license reviewers to document and transmit pertinent information to each other for follow up. (Section 3.4)

16. The review team suggests that the State develop a process for ensuring that inspection files are complete, that all appropriate State documents are prepared and filed, and that licensee responses are received and filed. (Section 3.4)

17. The review team recommends that the State begin documenting all trips to licensees' or applicants' facilities when inspecting licensed activities, performing special inspections, or performing pre licensing site visits during construction.

(Section 3.4)

18. .The review team recommends that the State management exercise more stringent supervisory review of inspection reports. (Section 3.4)

New Mexico Draft Report Page 22 t

19. The review team suggests that the State complete its revision of the inspection

report forms,insering thit each set of forms covers all key areas for the type of licensee being inspected, and that RLRP inspectors begin using the standardized s

form (s). (Section 3.4)

20. The review team recommends that the State make onsite, documented investigations of incidents, allegations, or misadministrations with potential health and safety effects (i.e., source disconnects, possible overexposures, lost sources, contamination, etc.). (Section 3.5) '

21. The review team recommends that the State create an incident and allegation reporting form that would, at a minimum, identify the person taking the initial report, list the name and telephone number of the reporting party, provide the details of the 2

incident or allegation as reported, record the State's conversation with the licensee i or individual, describe corrective actions taken by the licensee, describe the i investigation conducted by the State and the results, list citations or other regulatory actions, show the date the investigation was closed out and justification

, for closure, show date(s) incident was reported to the NRC or other agencies, and

} provide spr.ces for the signatures of the investigator and supervisor. A copy of the form shot.!d be maintained in the incident file and in the license file (Section 3.5)

22. The review team recommends that the State establish a protocol for making

• Independent investigations and evaluations of the licensee's actions. (Section 3.5)

23. The review team recommends that the State initiate procedures to ensure incidents are followed up at the next inspection to verify that the licansee's corrective actions have been implemented. (Section 3.5)

24. The review team suggests that when evaluating incidents, the State cite appropriate items of deficiencies when applicable. (Section 3.5)

25. The review team recommends that the State: (a) set up a separate incident and allegation file system in the Santa Fe office, keeping all documents and records pertaining to an incident in oha location, with the data cross referenced to the license / inspection files tnere and in the Albuquerque office, and (b) establish a system to centrally log and track the progress of incidents and allegations.

(Section 3.5)

26. The review team recommends that the State develop 6nd implement written procedures for responding to events involving radioactive material and conduct training sessions until all technical staff are fully trained and qualified in emergency response. (Section 3.5) i

27. The review team suggests that the State keep expanding the allegation procedures to include proceaures for notifying the person making the allegation of the results of

--_ , _ . . ~ , _. , _ _ - , _,_ _ _ - - ___,_ _

New Mexico Draft Report Page 23 the investigation and including the allegation procedures in the event reporting form, tracking system, and emergency response procedures. (Section 3.5)

28. The rev'w> team recommends that the State expedite promulgation of the compatibility related regulations now overdue and those which are due within the next 12 months. (Section 4.1.2)

29. The review team suggests that a file be maintained with the cover letters and ensuing correspondence of all draft or final regulations sent to the NRC. (Section 4.1.2) 4 l

-. o LIST OF APPENDICES AND ATTACHMENTS l

l Appendix A IMPEP Review Team Members Appendix B- New Mexico Organization Charts l

1 Appendix C New Mexico's Questionnaire Response .

Appendix D License File Reviews Appendix E Inspection File Reviews Appendix F incident File Reviews 4

9 0

b

+

9 APPENDlX A lMPEP REVIEW TEAM MEMBERS Name Area of Responsibility James Lynch, Rlli Team Leader - I Status of Materials inspection -

. Technical Staffing and Tralning Terry Frazee, Washington Technical Quality of Licensing Actions -

Scott Moore, NMSS Technical Quality of Inspections Jack Hornor, RIV, WCFO Response to incidents and Allegations Legislation and Regulations 4

i

G 4

I

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a APPENDlX C NEW MEXICO'S IMPEP QUESTIONNAIRE RESPONSE

_ . . _ _ - . . , _ _ _ _ _ _ _ _ - ~. _

j-  :

i j l .  ;

j IMPEP QUESTICIntAIRE

~

l i- Name New Mexico i

! Reporting Period August 13, 1994-July 13, 1997  !

i I. STATUS OF MArsRIALS INSPBCTION PROGRAM:

l 1. Please prepare table identifying the licenses with inspections I r that are overdue by more than 25% of the scheduled frequency  !

l set out in NRC Inspection Nanval Chapter 2800-- (issued [

j 4/17/95).  :

t 1 '

i 1. There are no licenses with inspections overdue by more

{ ,

than 254 (see Attachment #1 for schedule of inspection l 1 frequencies). l j 2. Do 3 ,u currently have an action plan for completing overdue  !

1 inspections? If so, please describe the plan or provide a l l written copy with your response to this questionnaire. _

f 2.- N/A f L

l' 3. Please identify individual licensees or groups of licensees the state / Region is inspecting lede frequently than called for *

, in NRC Inspection-Manual Chapter 2800'(issued 4/17/95) and ,

j state the reason for the change.

1

{: 3. Inspections are conducted more frequently than shown.In

[ NRC Inspection Manual Chapter 2800, issued 17/95, ,

=because staff is adequate to handle the - n er of '

inspections.in the inspection categories we have.:

i

4. How many licensees filed reciprocity notices in the reporting

~

i period?

148 reciprocal licenses were issued in the reporting period.

4,s..Of these,:how many were~' industrial radiography, well-logging or other users with inspection frequencies of three years or-less7:

4.a. See following table of reciprocitiess DM TT IR BDR WL BD NORM R&D GA PA 197.- 11 -0 7 1 8 -0 1 1- 4 1 96 '13 :0 10 1 6 ~0 13 2 2 5

95. 11 1 16 0 6 1 0 2- 3 4 94 11 t o 12 1- 6 2 0 1 1 4 Total: 148 *See-legends next page.  ;

1 gt8 E i

-...._.c..._._--.-.- ._ . _ ..,_ ___. -_-_____.-- _ _ _ _ . . _ - _ , . . . _ . . . . . . , _ _ . . - . - . - . , _ --4._,-._,..

• NOTE: D/M-density TT -Telethe/rapy moisture gauge IR -Industrial Radiographer EDR-Bigh Dose Remote Afterloader WL -Well Lgging/Tacer BD -Bone Density NORM-Naturally Occuring Radioactive Material R&D-Research and Development GA -Gauge (fixed Measuring levels)

PA -Paint Analyser 4.b. For those identified in da, how many reciprocity inspections were conducted?

4.b. Of the 148 out-of-state licensees granted reciprocity during the review period, 67 actually came into the state to perforin work at temporary job sites. NRC priority one and two licensees that came into the state included 18 industrial radiographers, 8 well loggers, and 6 source exchange services. Three inspections were conducted, consisting of two industrial radiographers and one gauge licensees.

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

5. During the review period one field inspection of an industrial radiography operations was accomplished out of the totals inspected IR licensees, 1997-12, 1996-12, 1995,-11, 1994-8.

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

6. N/A

7. 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 areast Administration, Materials Licensing & Compliance, Emergency Response, LLW, U-mills, and other. If these regulatory responsibilities are divided between offices, the table should be consolidated to include all personnel contributing to the radioactive materials program. Include all vacancies and identify all~ senior personnel assigned to monitor work of junior personnel.

2

. - - . _ - _ ~ . . _ .

If consultants were used to corr out the program's radioactive saterials responsibilities,yinclude their efforts.

The table heading should be 4 7A. HAME POSITION AREA EFFORT (PTE%)

William M. Floyd Program Manager Administration 75%

Material Licensing

& C rpliance 15%

Emetgency Response 2%

Other 8%

Margaret M. Lopez Environmental Materials Licensing Specialist & Compliance 55%

EmergencyResponse2%

Other 434 John A. Martinez Environmental Materials Licensing Specialist & Compliance 55%

Emergency Response 2%

Other 43%

Walter J. Medina Environmental Materials Licensing Specialist & Compliance 55%

Emergency Response 2%

Other 43%

Ralph Manchego Environmental Materials Licensing Specialist & Compliance 55%

EmergencyResponse2%

Other 43%

Jerrie Moore Environmental Materials Licensing specialist & Compliance 55%

Emergency Response 2%

Other 43%

8. Please provido a listing of all new professional personnel hired since the last review, indicate the degree (s) they received, if applicable, and additional training and years of experienes in health physics, or other disciplines, if appropriate.

8. See Attachment $2.

9. Please list all professional staff who have not yet met the qualification requirements of license reviewer / materials inspection staff (for NRC, Inspection Manual Chapters 1245 and 1246; for Agreement States, please describe your qualifica-tions and requirements for materials license reviewers and inspectors). For each, list the courses or equivalent training / experience they need to attend and a tentative schedule for completion of these requirements.

3 I

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9. Radiation Licensing and Registration Section staff have attended most all 11 3. NRC courses available to Agreement 8 tate licensing and inspection Lincluding the 5-weeks health physics course) . personnelTraining an teletherapy and Brachytherapy are needed for the staff. A minimum of six months experience is required before a newly-hired individual is allowed to attend U.S.

NRC-sponsored courses.

10. Please identify the technical staff who left the RCP/ Regional DNM8 program during this period.

10. Debra McElroy left the RCP during this review period.

121 ruegurcaL gunLrrr or 1,1causrae actrous

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

11. The new licenses issued that were complex and unusual included the following 1997- 1. The first NORM license was issued under the new Subpart 14 of the 20NMAC 3.1 regulations;-

2. A Research & Development laboratory license was issued that authorized the use of in-vitro radioisotopes instead of animals for toxicological research;-

1996- 1. A Co-60 Gamma Pool 7,rradiator was issued to Ethicon Endoeurgery, a Johnson & Johnson subsidiary, to irradiate surgical supplies; 1995 1. A Radiopharmacy license was issued in Las Cruces.

Major Amendments included the following:

1) The renewal process of Interstate Nuclear services, a nuclear laundry in Santa Fe, resulted in a public

. hearing. The. hearing has taken up a great deal of tiue and effort. The Secretary of the Department authorized renewal, but the City of Santa Fe will not allow discharge of radionuclides into - the Sa1J. , Fe Sewage system. The issue of non-soluble radionuellde discharge is unresolved and technical assistance is being sought; 4

a .

Y

2) A license that athorized the cleaning up of the depleted uranium at New Mexico Tech was terminated after the job was completed and material disposed of at an authorized facility;

3) All Industrial Radiography licenses were checkad and a survey conducted to determine compatibility of equipment and associated parts, with 10CFR, Part 34.20 and 20NMAC 3.1, subpart 5, paragraph 506;

4) The TMA/Eberline license was amended te allow for bench-scale testing of their the segmented Gate systen to volume-reduce soils contaminated with radium, transferred to the New Mexico site from a New Jersey site;

5) All Medical Institution licenses were amended to include brachytherapy and high dose-rate remote after-loader standard conditions.

I i 12. Please ideritify any new or amended licenses added or removed l from the liat of licensees requiring emergency plans?

12. A Radiosctive Material License was issued to Ethicon Endoeurgery, a Johnson & Johnson subsidiary, during this reporting period and requires an emergency plan.

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

13. No variances were granted during this reporting period.

14 What, if any, changes were made in your written licensing i procedures (new procedures, updates, policy memoranda, etc.)

during the reporting period?

14. Radioactive Material license application evaluation form was revised, radioactive material application form was updated. Reciprocal license log-ln procedures were revised and computerized. Inspection forms for industrial radiographers, medical inotitutions and density / moisture gauges were revised.

15. For NRC Rugions, identity by licensee name, license number and type, any renewal applications that have been pending for one year or more.

15. N/A s

o' IV. TECaNICAL QUALITY OF INSPECTIONS:

16. What, if any, changes were made to your written inspection procedures during the reporting period?

16. No changes were swde to written inspection procedures during this reperting period.

17. Psepare a table shcWiug the number and types of supervisory acdOmpaniments made during the review period. Include:

17. SygjgjAnx insoector Licen m GAL. Data 1994 Bill Floyd John Martinez AN 09 94 Jerrie Moore Ralph Manchego IR 09 94 Ralph Manchego Jazzie Moore TA 12 94 1995 Bill Floyd John Martinez RD 04 95 Bill Floyd John Martinez IV 04 95 5111 Floyd Jerrie Moore CS 05 95 Dill Floyd Jerrie Moore DM GJ 95 John Martinez Margaret Lopez TA 06 95 Dill Floyd Jerrie Moore MI 07 95 Margaret Lopez Walter Medina MI 07 95 Bill Floyd Margaret Lopez AN 07 95 Margaret Lopez Ralph Manchego BM 08 95 Bill Floyd Margaret Lopez LA 08 95 Bill Floyd Walter Medina MI 09 95 John Martinez Margaret Lopez GA 09 95 Ralph Manchego Walter Medina IR 10 95 Bill Floyd Walter Medina IR 12 95 Bill Floyd Walter Medina DM 12 95 Dill Floyd Walter Medina GA 12 95 Bill Floyd Walter Medina WL 12 95 Bill Floyd Ralph Manchego MI 12 95 1996 Bill Floyd Ralph Manchego DM 12 96 Bill Floyd Ralph Manchego MI 12 96 Bill Floyd Margaret Lopez WL 19 96 Bill Floyd Margaret Lopez WL 07 96 Bill Floyd Jerrie Moore IR 07 96 Bill Floyd Margaret Lopez GA 07 96 Bill Floyd Margaret Lopez DM 07 96 Bill Floyd Margaret Lopez WL 07 96 Bill Floyd Margaret Lopez WL 07 96 Bill Floyd Jerrie Moore DH 04 96 Bill Floyd John Martinez TA 06 96 Bill Floyd John Martinez DM 02 96 Bill Floyd John Martizez RD 02 96 Bill Floyd John M rtinez HI 02 9G John Martinez Margaret Lopez MI 02 96 6

Bill Floyd John Martinez itD 02 96 Bill Floyd John Martinez IV 02 96 Bill Floyd Margaret Lopez MD 01 96 1997 Bill Floyd Jerrie Moore MI 02 97 Bill Floyd John Martinez RD 03 97 Bill Floyd Msrgaret Lopez RP 01 97 Margaret Lopez Walter Medina GI 03 97 Walter Medina Margaret Lopez MI 01 97 Walter Medina Mar aret Lopez MI 01 97 Bill Floyd Ral h Manchego MI 01 97 Bill Floyd Ral h Manchego DM 01 97 III TECERiCAL QUALITY OF LICENSING ACTIONS: 1

18. Describe internal procedures for conducting supervisory accompaniments of inspectors in the field. If supervisory accompaniments were documented, please provide copies of the documentation for each accompaniment.

l 18. The Program Manager of the Radiation Licensing and Registration Section accompanies each inspection staff

, member on a minimum of two inspections per year.

. Additionally, senior inspection staff iccompany junior staff on occasion as part of internal training protocol.

19. Describe or provide an u instrumentation and methods of calibration. pdate Areon all yourinstruments properly calibrated at the present time?

19. See attachment i3.

v. RESPONSES TO INCIDENTS AND ALLEGATIONS:

20. Please provide a list of the agALeignificant incidents (i.e. ,

medical misadministration, overnapesures, 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.) that occurred in the Region / State during the review period. For Agreement States, .information included in previous submittals to NFC need not be repeated. The list should be in the following formatt

20. Reports on all incidents have been forwarded to NRC.

21. During this review period, did any incidents occur that involved equipment or source failure or approved operating procedures that were deficient? If so, how and when were other State /NRC licensees who might be affected notified?

7 s

i

21. 1996, On July 15,igh unusually h readings wh;.le surveying a radiographya radiographer in camera source tubes (35 mR/h). Leak tests were sent to the camera manufacturer, International Nuclear  !

Corporation (INC), and INC roguested the camera and tubes l be returned for further testing.

On July 22, INC found a small defect in the weld on the source, SN9510. Mr. Filbert Fong of the State of California was notified at the Berkeley office. Mr Fong later observed the defect.

On July 24, a preliminary actii'ication was sent out by Region IV staff in Arlington, Tx, regarding the defect.

(See Attachment $4). ,

i 21.a. For States, was timely notification made to the Office of State Programs? For Regions, was an appropriate and >

timely PN generated?

21a. Yes, U.S. MRC, Region IV, informed NMSS, OSP and  :

discussed the subject with the states of New Mexico '

and California. t

22. For incidents involving failure of equipment or sources, was

~information on the incident provided to the agency responsible for evaluation of the device for an assessment of possible I generic design deficiency?- Please provide details for each case.

22. - See above. Region IV was notified by the manufacturer.

I

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

23. See Attachment $5. ,

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

24.- No substantive changes occurred in the procedures for handling allegations during this reporting period. All -

allegations, including anonymous ahlegations, continue to be investigated thoroughly.

24a. For Agreement States, please identify any allegations referred to your program by the NRC that have not been closed.- t 24a. We are unaware of any allega'tions that have been referred

• to our program that have not been closed.  ;

e .

i

. - - . . _ _ _ . , - - - . - - - , - - ~ ~ - , - ~ _ _ - . . - , _ , - _ _ . . ~ , . . - . , - - . . . _ - - , - . , . . . - - ,

IV. 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.

25. Nine regulations that had not been adopted as matters of compatibility with U.S. NRC regulations at the time of the last review have now been adopted. These include the followingi

1. Bankruptcy Notification;

2. Quarterly Audit of the Performance of Radiographers;

3. Well Logging Requirements;

4. National Voluntary Laboratory Accreditation Program

5. Certification of Dosimetry Processors;

6. Emergency Plans;

7. Safety Requirements for Radiographic Equipment;

8. 10 CFR, Part 20 Equivalent Regulations; and

9. Notification of Incidents.

. The New Mexico Radiation Protection Regulations filed at the State Records Center on April 3, 1995 ( and which became effective May 3, 1995) include these nine regulatory requirements. Although we are still awaiting final word from NRC, The January 9, 1995 letter (attachment $6) from NRC signed by Dennis M. Sollenberger (for Paul H. Lohaus) offered a tentative finding that the revised regulations are compatible with the equivalent regulations of the commission.

At the time of the previous review 't was recommended that the New Mexico Radiation Control Program's internal procedures be reviewed and compiled in a manual that is easily referred to by all staf f members in order to maintain consistency in str.ff licensing and compliance activities. As a result of this recommendation, procedures covering internal processing of license applications, scheduling and documenting inspections, and enforcement activities, escalated enforcement actions, and other functions have been incorporated by the New Mexico RCP.

B. MON-COMMON PERFORMANCE INDICATORS:

I. REGULATIONS AND LEGAL AUTHORITY:

26. Provide a brief der,cription 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.

9

26. strengths:

1. The ability to establish new priorities for inspetions of RAM licensees by assignmer.t with empsasis on the most hasardous to the least hasardous.- i.e., each staff member has begun updating his her own inspection database)

2. The streamlining of the license review process and inspection process by providing cross-training i thereby allowing all staff to participate in licensag procedures. (i.e., inspections are assigned by individuals on rotating basis).

3. staff has reviewed all radioactive material licenses to determine which licensees fall under the decossaissioning rule, and all Industrial Radiography licensees have been checked for compatibility with 10 CFR, Part 34.31 and HMAC3.1, Subpart 5, Paragraph 506 equipment rule.

4. All staff have been trained with the exception of training in Brachytherapy.

5. License inspections are up-to-date.

Weaknesses

1. Programs under the Bazardous and Radioactive Materials Bureau have been streamlined by assignment of a Secretary to each program. Retraining is needed for the secretaries; this action should turn out to be a positive one, but time is needed for training and for adjustment to the workload.

2. The existing forms, standard conditions, license and inspection regulatory guides are in need of revision and implementation, (e.g. The Medical Human Use Guide).

3. There is a nesd for an cdditional Environmental Specialist, Option F, for the NORM regulation workload in licensing and inspection.

4. The creation of program databases for all general licensees, reciprocal licensees, -and vendor providers of radaation related services with the help of the Information Services Bureau's is needed.

The computer - systems are being worked --on with changes projected for the coming year. Along with this is the need for computer training for the newly purchased personal computers, not only in the 10 h ,

word perfect mode, but with the capability of gathering and generating data on the same system for reports.

Examples of Successesi

1. In 1996, The BRNB-RLRS hosted the National Conference of Radiation Control Program Directors in Albuquerque.

staff participated in all aspects of the five-day conference.

2. -Stati kept up-with workload in spite of lengthy public hearing process involving the renewal of the Interstate Nuclear Services Radioactive Material License.

27. Please list all currently effective legislation that affects

( the radiation control program (RCP).

27. Sections 74-1-9, 74-3-5_and 74-3-9 NMSA 1978.

28. Are your regulations subject to a " sunset" or equivalent law?

If so, explain and include the next expiration date for your regulations.

28. The New Mexico Radiation Protection Regulations are not subject to a " Sunset" or equivalent law.

29. Please complete the enclosed table based on NRC chronology of amendments. Identify those that have not been adopted by the state, explain = why they were not adopted, and any_ actions -

being taken to adopt them.

29. See attachment 97.

30. If you have not adopted all amendments within three years from the date of.NRC rule - promulgation, briefly- describe your State's procedures for amending rerjulations in or'ar to maintain compatibility with the NRC, showing the normal length of time anticipated to complete each step.

30. 1. Proposed regulations presented. to Radiation Technical Advison Council for advise and consent.

2. Proposed regulations presented to -Environmental Improvement Board BIB .for public approves or disappro(ves ) based on hearing- record.h e a r i n g -- E I B -

3. Amended regulations filed at State Records Center.

4.- Amended regulations effective 30 days after filing.

II. SEALED SOURCE AND DEVICE PROGRAM:

31. Prepare a table listing new and _ revised 88&D registrations of sealed sources and devices issued during the review period.

11-

The table heading should bet 88&D Manufacturer, Type of

-Registry Distributor or Device Munhar custom Utag or source

31. Note: No 58&D registrations are pending. If any are received, we will contract for evaluation assistance e[ther with private industry or will pay U.S. NRC for assistance in evaluation.

l 32. What guides, standards and procedures are used to evaluate l registry applications?

32. N/A

33. Please include information on the following questions in i section A, as they apply to the 88&D Progrant

! Technical Staffing and Training - A.II.7-10 Technical Quality of Licensing Actions - A.III.11, A.III.13-Responses to Incidents and Allagations - A.V. 20-23

-33. N/A III. LON-LEVEL WASTE PROGRAM:

34. Please include information on the following questions in Section A, as they apply to the Low-level Waste Programt Status of Materials Inspection Program- A.I.1-3, A.I.6 Technical staffing and Training - A.II.7-10 Technical Quality of Licensing Actions -A.III.11, A.III.13-14 Technical Quality of Inspections - A.IV.16-19 Responses to Incidents and Allegations -A.V.20-23

34. N/A IV. URABItSt MILL PROGRAM

35. Please include information on the following questions in Section A, as they apply to the Uranium Mill Progrant

Status of Materials Inspection Program -A.I.1-3, A.I.6 Technical staffing and Training -A.II.7-10 Technical Quality of Licensing Actions -A.III.11, A.III.13-14-Technical Quality of Inspections -A.IV.16-19 Responses to Incidents and Allegations -A.V.20-23

35. N/A-12

NRC INSPECTION PRIORITIES INSPECTION MANUEL 2000, 4/17/98 TYPE OF LICENSE: NRC PRIORITY IDEED PRIORITY l PRIORITY I BM BROAD MEDICAL 1 YEAR 1 YEAR GI GAMMA IRRADIATOR (POOL) 1 YEAR 1 YEAR IR INDUSTRIAL RADIOGRAPHY 1 YEAR 1 YEAR TA TAGGING 2 YEARS 1 YEAR RP RADIOPEARMACY 1 YEAR 1 YEAR PRIORITY II AC ACADEMIC 2 YEARS 2 YEARS BB BROAD LICENSE, TYPE B 3 YEARS 2 YEARS D/M DENSITY / MOISTURE GAUGE 5 YEARS 2 YEARS GL GENERAL LICENSE 5 YEARS 2 YEARS IA LAUNDRY 2 YEARS ,

2 YEARS MD MEDICAL DOCTOR-PP 3-5 YEARS 2 YEARS i4I MEDICAL INSTITUTION 3-5 YEARS 2 YEARS RD RESEARCH & DEVELOPMENT 2 YEARS 2 YEARS VT VETERINARY 5 YEARS 2 YEARS WL WELL LOGGING 3 YEARS 2 YEARS PRIORITIY III AN LABORATORY ANALYSIS 3 YEARS 3 YEARS CS CALIBRATION SERVICE 3 YEARS 3 YEARS DU DEPLETED URANIUM 5 YEARS 3 YEARS GA GAUGE 5 YEARS 3 YEARS IX ION EXCHANGE 3 YEAR 3 3 YEARS IV IN-VITRO 5 YEARS 3 YEARS PA PAINT ANALYEER 3 YEARS 3 YEARS SO STORAGE ONLY 3 YEARS 3 YEARS TW TRANSPORTATION / WASTE 3 YEARS 3 YEARS

!' . EDUCATION AND RADIATION RELATED COURSES A*ITENDED BY WALTER J, MEDINA

. pDUCATION: i BS Degree, New Mexico Highlands University,1974 a

Makr: Biology Minor: Chemistry and Math i Registered Medical Technologist (MT ASCP) l

1. Safety Aspects ofIndustrial Radiography (H 305), June 4 9,1995.

4

2. Medical Use ofRadionuclides, August 13 18, 1995..

, 3. 13 censing Practices and Procedures Course (0 109), September 11 15,1995.  :

4.- Inspection Procedures Course (0108), September 25 29,1995.

5. Safety Aspects of Well Logging (H 314), October 30-November 3,1995.

j 6. Applied Health Physics (H 109), February 5 March 8,1996.

7. DOE Workshop On Risk Assessment, June 11-12,1996. l t

8. Troxler Electronic 14borstories, Inc. Training Course For The Use of Nuclear Testing Equipment, October l 23,1996. ,

i i 9. Calculating and Understanding Risk From Radionuclides Released To The Environment, April 28 May 2,

1997.

j TRAINING /LOS ALAMOS NATIONAL LABORATORY i

1. PlutoniumMetallurgy, April 23,1981.

t b

2. Nuclear Criticality Safety, June 1416,1982. .

l: 3. Introduction to Materials Science, November 15-17,1982, 2

)

4. Scanning Electron Microscopy and X-ray Microanalysis, September 17-20,1984.

5. Advanced Scanning Electron Microscopy and X-ray Microanalysis, March 18 22,1985.

t

- 6; Materials Science and Rapaaaring II, January 20-23,1986. -<

j i

7. - X-ray Safety: Analytical, March 20,1987, i 8. Physical Metallurgy of Uranium and Plutonium, January 18 22,1988. -

9. Resource Conservation and Recovery Act Waste Generator Awareness, August 15,1990.

~

10. Fundamentals of Chemistry, January I l-15,1993.

AMcht&f -

. -- .- n---_. .- - . ..-- - -....._ .- - . -- -. . . - . - . - . - - . _ . -

4 1  :,

i RADIATION LICENSING AND REGISTRATION INSTRUMENTS JUNE 1997  !

L MODEL TYPE SERIAL USER

.e CALIBRATION / CONDITION / REPAIRS

• RO-3C ION 133 JAM -

l 'RO-3C 135 12/96 -

RO-3C 06 97 137 RALP8 06 97 RO-3C 624 JERRIE i

-RO-3C 06 97

! 646 MML- 06 97 RO-3C 635 JOHN 06 97 E-520 G/M 4602 JOHN 12 96 1- E-520 4605 06 97

) E-520- 4609 -

E-520/BP270 4176 06 11/97 POR CALIBRATION RALPH- 10 96 ,

E-530 HP270 847 JERRIE 10/96 E-530 HP270 849 ,

E-530 HP270 1665 PRM 6- 1053. 06 97 PRM 6 1055 SF 06 97 PRM 6 1245- SF 06 97 PRM 6 AC-37 1235 SF 10 96 PRM 6 AC-37 1306 ALB 02 97 '

PRM 7 uR 107 JOHN 06 97 PRM 7' 164 ALB 06 97 PRM 7 167 JOHN 06 07 PRM 7 696 RALPH 06 97 PRM 7 697 JERRIE 11 96 URMOD-3 68237 JERRIE PRM 4 ALPHA 107 ALB LUDLUM INSTRUMENT /S.P. 06/97 06/97 PNR-4/NRD 4331 02/97 PNR-4/NRD 4365 ALB KVP METER- 223 JOHN OK

• TABLE FOR QUESTION 29., k 10 CFR RULE mm DUE mm ADOPTED CURRENT EXPECTED Y '"

STATUS ADOPTION Any amendment due prior to 1991. Identfy 04/03/95 Ehecgency plan adopted April.'3,1995, effective each : ;M;m (reser to the Chronology at May 3, 1995' Amenenenes)-

t= - ,,, 7/27/91 04/03/95 N Parts 30,40,70 FJnergency Planneg; 4/7/93 04/03/95 Parts 30,40,70 Standards sur Protecton Agamet Radiaton; in/94 04/03/95

- Part 20 Sassey Requwesents for Radiograpluc '

in0f94 04/03/95 Egapment; Part 34 04/03/95

% orincasenes; 10n5,94

\ Pares 20, 30, 31,34. 39,40, 70 Quelty Managertunt Prograsu and J27/95 04/03/95 s

!_- hasaderustramons; Part 35 N t.icaname and R% Sasser 7ntes 04/03/95 1 Pw ' _.2:^2 sorirradmoors: Pet 36 DeAneon et Land Yd 7/22/g6 Not adopted N/A and Weste Site QA Pw Part 61

C= - - ' _ ; P= - , 6.Docu- 10f25496 Not a3 opted 6/98 menesson Addeions: Parts 30,40, 70 Self-Guarantee u an Addisonal Fmencial 1/28#97 Not adopted 6/98 Mechensem; Parts 30,40,70 Uramum Mill Tailings: C_." -- ; to EPA ' 7/1/97 Not adopted N/A-Standards: Part 40 Tunesness in cr. .-- >

an5#97 - Not adopted 6/98-Parts 30,40,70 Properaton Trans'ar for Commercial Dis- In198 Not' adopted '

6/98.

treumon, and Use of sypeduct bassenes for W Use: Parts 30. 32. 35 -)

81

. _.1

a i OR 4

DATE DATE

10 CFR RULE DUE ADOPTED CURRENT. EXPECTED i- STATUS ADOPTION -

1 j Fsequency of Medical Examinstons for Use 3/1W98 .

6/98

of Resswaeory P% Equenent -

. t

?-

j W Weste Shipenerd Momiset 31/98 kdonnehon and . -

c-1_

6/98 i

Portannonce Requussnents tw Radograshy e 6/98 Equpnent '

! Radekon Psceschon Requisesnones: 8/1498 6/98 l Asnended DeAneons and Cdenne ,

(l ' CW of Decosanusesosung Funding 11/240s 3

6/98 I

$ 10 CFR Part 71:Competihibey wth the 41/99 6/98 .;

] Internehonal Agosmc Energy Agency  ;

5- aseeces Adnunseerahon of Radinhon and 10f2tW9e 6/96- -!

4 P=diaartwe Materials,

. Tensunehon orTransferof boonced 5/16#99 6/98

^

Actutes ?= __ _ "-.__-_____ -

Resolukon of Duel Reguistion of Airboue 1/9410 6/98 ,

Emuones of Ph Motonais: Clean Air 't

m. ,

Recognelon of Asseement Stole bonness in 1/1300 6/98 Asees Under Eactueswo Federal Jwendicilon VWiehen an ?-;::- : ^ Stees

Catone for su Reisene of andwiduals 1/2m00 6/98 ,

4 Adnumsted p- %

5 k l.

i' l'

L -

i~

1 2-9 f -9 ,

. . . . _ __4.,

i e,

INVESTIGATION OF ALLEGATIONS OF IMPROPRIETIES %T" INS A11eantion FindInc .

Solution

1. Use of larger mesh 1. In'one instance 1. Entire new fil-on Sweco filter than it was noted that tration systea the 50 micron mesh larger mesh was specified in license has been in-application. ordered (and it stalled. Only was ordered by 6 proper filter M , who made size will be the allegation). used.  !

2.' Spray heads on air 2. Apparently this 2. Preventative filtration system was true; one I

sometimes becams maintenance

' clogged, allowing estimate was that program put in lint to escape to spray heads became place.,REPA l

,' environment. clogged twice a filter. vill

• year. replace water l -

scrubber.

3. Tank il leaked. 3. It did leak, but it was no. longer

3. Tank repaired.

- used after leak was discovered. -

' 4. Wash water holding 4. Did happen-at

' tanks sometimes least once 4. Alarm will sound overflowed, allowing is unclear).(why once tank is wash water to run full.

out beneath garage door onto ground. ,

LOPEZ REBUTTAL EX111 BIT 1 ..

i

{ f

- _ _. . _ _ . . . . . _ - _ - _ _ _ . _ _. _ __ __ _ _ __m . .

d l l

l

, I 1

l

5. Venting of sludge 5. Gas fixed dryer 5. All air exhaust dryer out vindow. apparently used at will go through one time but ceased HEPA filter with being used when it alarm to notify didn't work. Some of malfunction.

i former employees ,

remember it being booked up to BEPA -

• filter. No way exists to calculate what was exhausted out window.

Swipe from window ^

sill showed no evi-dence of contamination.

6. Hot spot (44mR/hr) 6. Hot spot did exist '6. MEnways cut on waste water holding tank #1. (identified in in- into tank; all ternal audit in 1994 sludge (in-and was monitored on cluding hot 2 regular basis since spot) removed

, that time). ' and barreled

' for burial as '

waste.

7. Overflow of wash 7. One former employee 7. Rh lar water pita in wash oonfirmed they did room. utenance overfloa at least '

program .

once due to clogging instigated.

with lint.

8. Leaking of black plastio line feeding 8. Probably did occur, 8. Doubly but leak repaired edcapsulated water fron. post- as soon as it was filtratica pits into discovered, flow lines wash water tank installed. -

building.

9. Workers instructed 3. Not verifiable; 9. Written pro-

' to allow air samples samples standardly cedural manuals to decay for up to a read at .24 and .'2 followed.

' month to show lower hours according to readings; also, procedural manual.

workers instructed Air filters run to allow air to fil- whenever employees ter to run 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> / are present regard-

' day even when dryers less of whether not running to cause dryers are running.

, lower readings.

' eh

- - - . - - . ~ . -

4 4

4 4

10.-License application 10. Only one scrubber 10. Drawing sub-schematic shows exists, but it has mitted water scrubber to two heads.

consist of two dif-forent systems; in .

actuality, only one water-scrubber exists.

- 11. Workers told to 11. No proof that work- 11. Manways cut shovel sludge out ers instructed to into ends-of holding tanks, shovel sludge since of tanks to in violation of confined space rule allow for c.onfined space - went into effect. No cleaning of

= rule, evidence that anyone tanks.

on corporate level -

instructed workers to 3

shovel sludge as *

, alleged.

12. Water samples taken 12. Yes, since this 12. Eolding from drip line from allows for a more , ta.1ks re-

{' holding pits,-not homogenous mixture.

from holding tanks. p1' abed so sample can

- be taken at

- point where waterenters I sewer.

13.-Washing machines 13. They are run empty, sometimes run empty but only to rinse

13. Procedural to dilute coppar and manuals will out machines between be followed.

zinc concentrations. loads so cross- -

contamination of laundry from dif-farent sources is ,

less likely to 4 occur.

14. Liquid waste.has 14. Tank drained and 14. Tank will be been seeping into cleaned in 1985. removed.

16,000 gallon under- A recent inspection ground storage tank by BRMB showed it to .

since the 1960's. contain a few inches of water; no evidence of leakage.

e

15. Voltage regulated 15., Voltage regulated 15. Procedural on clothing monitor based on customer manuals so that beta-gamma specifications, followed.

would not be read. some customers pay for clothing with a higher degree of decontamination.

16. There is no way of 16. Wash water has never 16. New fil-returning wasta even approached ex- tration water exceeding ceedence of effluent system acceptance level release levels; if it using to wash building. did, then portable' combination pumps could return it of Sweco to wash building for filter and additional filtration. sand filters installed.

W 9

s e

9 9 e

4

+

9 0

C at

• y t

UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON. D.C. 20$5M001 n

i

,,,,, Janucry 9,1995 Mr. William M. Floyd, Program Manager Radiation Licensing and Registration Section I8 Department of Environment 7Nf 1190 St. Francis Drive P.O. Box 26110 ,

Santa Fe, NH 87502

Dear Mr. Floyd:

New Mexico Radiation Protection Regulations, as submit 1994, and the revised draft dated December 8, 1994. ,

Federal Regulations, and the equivalent rules in the Sugge Regulations for the Control of Radiation (SSR).

1 i

l 1

as provided to you by facsimile and discussed in telepho November 29 and December 6, 1994.

that the previous issues have been appropriately addressed.Our review of the secon offer a tentative finding that the revised draft re Based on this, we with the equivalent regulations of the Connission. gulations are compatible A final determination will be made after the New Mexico regulations are adopted as final rules and become effective.

final regulations be provided to us when they are published.We request that a copy of the please contact me or Mr. Richard Blanton of my staff at ( ,

Sincerely,

& kI- V Paul H. Lohaus, Deputy Director Office of State Programs

[

1 IMS--FOST-REARING. EVALUATION SUBMISSION SUPPLEMENTAL INFORMATION 3-7-97 FINAL ORDER NOV. 04-1996

~ SUBJECT CONDITIONS FOR INS RENEWAL:

a.

install a new water filtration system; ,

Letter.of February 20, and final testing is .1997 states that inst,allation, inspection

.pending.- FeUrua'ry 24, 1997-testing and Santa Fe not allowing discharge into STP.results pending because

'materials-effoctive on March by an 1,1997 disallowing discharge-of any eradioactivCity Ord industrial user - until Letter from Jeoffrey Sloan to Caron Balkany, March 5their- criteria is met.

that INS will submit its operating procedures , 1997, states qua protocol for routinely that3 HRMBpretreating will approve and testing its wastewater for insolubles or- reject the and

. installation and final testing evaluations. submission pending b.

install a new air filter system:

Figure B-2 shows HEPA Air filtration system.

Appendix C, IV " Air Filtration, Measurement, and Safety Shutdown Systcm prior to exhaust. Air exhausted-system downstream of the Representative effluent' sampling is performed filter system in - the discharge . stack. The near isoxinetic conditions are achieved (air velocity ins campling velocity). inlet nozzle . is slightly- less than surrounding aire nooronriate._ Air samples for alpha, beta and - gamma activity..-an

, , a

Question:

Maintenance schedule--oeriodic' based on alarm system?- WhatWill this-be about filterroutine backups?or N'ill new sketch be submitted for - specifics for this new system.

c.

alarm effluent release sites for water and mig Air handling system is equip clarm and shutdown system. ped with a catastrophic filter failure pressure

-as would result in a-filter or sealing gasket failure,In event o en dryers alarm,will sound, in operation will shuttheoffexhaust as well. blower ian will shut off, and a Santa installed.Fe:1acility but pending construction permitsSystems are at the

, etc. not yet

\

O

2

d. provide more detailed reporting to the BRMB:

-All information requested has been forthcoming and BRMB believes it will be continued when INS is allowed to resume operations.

e.

schedule waste shipments by accumulated volume:

Appendix c-Waste disposal and Effluent Treatments I. On-hand quantities of processed radioactive waste will be limited also betoreturned.

a maximum to ofcustomerf 1,000 cubic fe9t. .Maste items may arrangements. d'epending on contractual III. ~ Solids produced from wastewater processing: Backwash sequence for s' olids settling in a mixing chamber where a polymer is added via pump and coagulated material flows to a conical-bottomed sludge thickener tank--Free water on top of thickener tank will be removed by decant lines located on the side of the tank andsolid-laden, returned to the beginning of the system.

Accumulated material in the bottom of sludge thickening tank will be m iodicallv_ pumped into a plate and

, frame filter press for further dewatering before discharge of batch.

system. Supernatant will be returned to the beginning of the Pressed process'aludge filterunit drying cake will ba loaded integrated with filterinto pressa batch-unit.

Dried material will be packaged and shipped per regulations.

Questions:

When will supernatant and water on top of conical tank be returned if it is stated as periodically?

Will there be a necessity for survey of sludge conical bottomed tank? What kind of exposure time for any employee necessary for this tasks?

f. ,

institute a regular' equipment maintenance program:

Appendix D-L, " Scheduled Equipment Preventive Maintenance" _Shduld be anddetermined manufacturersbasedoron suggested schedules as provided by equipment lacking that, experience maintenance person,and advice from other IMS locations of onsite .

g..

improve its documentation of in-house-training:

Appendix D, " Radiation Safety Program" E and E, " Trainings" B.2. Training is to be consultant. conducted by a qualified employee or Question:

Should not a statement concerning RSO duty of training.

or designating, in writing, the individual qualified to conduct training be written in this Appendices?

3 B.4. All training, including general employee and inside/outside management training shall be documented. and retained in each respective employee file.

Evaluator's comments:

Need reviewed TABLE OF CONTENTS, on file 5/9/96 to incorporate supplemental information of 3-7-97 and any forthcoming information for renewal.

Add duty of maintenance under Appendix E or Appendix D. and add who is responsible for this task.

Inspection: Should verify layout sketch as submitted. Need modified air filtration handling system sketch.

Verify how much waste on-hand before resumption of operations.

Need statement added to reference Appendix D, 3-7-97 a.(1),

"Effluont Concentration Limits" referring to protocol on waste water disposal to Sanitary sewerage treatment system, and statement for reference to seat Appendix C for Discharge air on Appendix D-B. c.(1).

Questions Appendix D.3.c., Contaminated areas action level of ten times Appendix F. What should it be?

Appendix D-D. Personnel Monitoring,1. Radiation Dosimeters. Seems too conservative to base radiation control' on lot of allowable exposure limits specified in Appendix D (B) (1 in any one calendar guarter. Should it not be annually or 50 mrem year.

I Look up gamma chest count >2E6 dpm as per Report 30, ICRP. and Uranium Bioassay action levels, 5 micrograms per liter.

Appendix D.3.a. " Records", records should be kept at both facilit3.es for the required l e n g t h o f t i m e ,- not as stated at facilhy or at the corporate-records vault.

Appendix D-E.2. " Wastewater Sampling " Compliance reports for City of Santa Fe will be sent to BRMB as well as the city on the reporting requirements.

Need Portal monitoring specifications and installation date.

Need date of : stainless steel shaker screen installation and complimentary hold-up tank system. Need explanation on waste water system schematic as submitted on 5-9-96.

Need timetable for installation of BEPA unit filtration system.

Have no contamination levels in our regulations concerning acceptable contamination-levels. We have been using Appendix F as submitted with this application and for other facilities.

i e

K }

7 .

4 This completes this evaluation as submitted and as it relates to

-the final order for renewal of INS.

Margaret M. Lopez, Environmental Specialist, April 16,-1997.

, o 4

O h q g@*

v ,

/,*. C

-f CHRONOLOGY OF RADIOACTIVE MATERIAL LICENSE RELD BY IN8's SANTA FE FACILITY Chronology of INS file data prior to hearing:

June 28, 1968 Application for renewal to AEC license for INS decontamination laundry services included amendments 1 through 7 on renewal of the referenced July 26, 1961' license by AEC.

January 1, 1970 Amendment $8 to AEC license.

December 30, 1974 Application to EID for the licensing under the accepted authority.

March 24, 1975 First license issued by EID to INS as found in file. ,,

March 4, 1980 Amendment number NM-IIL-LA-06 extended l

expiration date in Item 4 to March 31, 1985.

April 25, 1985 Application for renewal, signed by Gregg A Johnston, Corporate Health Physicist.

July 25, 1985 Rewritten license number .NM-IIL-IA-11, extending expiration date to July 31, 1990, signed by Benito Garcia, Program Manager. .

July 18, 1990 Application for renewal, signed by C. Renee Echols, -and George J. Bakevich, General Manager.

l l

September-26, 1990 Rewritten license number l

NM-IIL-LA-13, L extending expiration date .to June 30, 1995, signed by William M. Floyd, Program Manager.

March 15, 1995 Press release on INS laundry and the existence thereof.

March 15, 1995 Bill and Margaret from HMED attended press conference held at 107 Cienga St by CCNS where Bill was interviewed about INS licensing and stated that records were available for review upon request at the RLRS Office.

CCNS requested a list of RAM licensees in the Santa Fe Area, and requested the state to provide testing of effluents at the sewage outflow, and compile a history in sludge and water emanating from INS and waters downstream from the sewage plant.

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March 16, 1995 Bill Williams issued for immediate release NMED's official response to CCNS press release.

April 10, 1995 Application for renewal and supplemental documentation including SOP's is received by NMED for review. (Note: This application would have been evaluated for license renewal had not INS voluntarily submitted its September 5, 1995, application to conform with the NMRPR which became effective May 3, 1995).

June 30, 1995 INS's specific license for laundry decontamination services expiration date.

July 21, 1995 A letter to INS requested INS re include proprietary information in the application and be made available to the public.

July 28, 1995 Public Notice published on July 28, 1995 on renewal for INS.

l September 05, 1995 A revised application, signed by Kent Anderson, dated August 31, 1995 was submitted. The l primary reason for resubmission was the l

issuance of the New Mexico Radiation Protection Regulations, filed May 3, 1995, and INS's decision to come into compliance with the revised regulations. Additional minor changes were made to standardize format and content with the 12 other RAM licenses held by INS under the NRC's jurisdiction and that of other Agreement States. Changes made were minor changes in format and content, but included all necessary criteria on facility, security, equipment, and radiation protection program.

References were revised to reflect changes in exposure limit changes.

September 12, 1995' A letter to Mark Weilder, NMED Secretary, requested a public hearing on the INS license renewal.

Septerher 19, 1995 A 3etter to Thomas Duker, Public Records Officer, requesting NMED to provide the public accesa to INS file records.

September 22, 1995 Public Notice appeared in the New Mexican which informed any interested party the hearing was set for November 2 and 3, starting at 9:00 AM at the Barold Runnel's Building Auditorium.

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September- 27, 1995 NMED's response to September 19, 1995 request to provide the public access to information on INS files. -Response stated records .are available at . 2044 Galisteo in the Santa Fe office,. during working hours, except for proprietary information.

October 13, 1995 All files were made available for public review by any request received, including to CCNS.

The files were picked up from.Kinko's Copies on St. Michael's Drive af ter a request by CCNS to have all the information in the INS files copied as agreed after a brief review at the Santa Fe office on October 11, 1995. The SOP's for the April 10, 1995 application for renewal L

were not in the file on October 11, 1995, but were copied and provided to CCNS' as previously agreed to by Kathleen sabo and Margaret on October 13, 1995.

October.23, 1995 Deadline of 10 days prior to set hearing to

' provide the Secretary with a list of witnesses and a summary of testimony is required.

Reference to Section (307H) The requirement for an Environmental Impact Statement because INS is a commercial waste facility? INS is not a waste disposal facility. Any waste produced is--incidental to decontamination services provided as a laundry. The SOP states that any contaminated items that do not' meet INS criteria - (> 50 mR/hrjas being fit for laundering will be sent back to the client for disposal.

INS chronology continued August 7, 1995  !

Letter from. Mark Weidler, Secretary NMED, to Mr. Ray Schmidt, informing of the public hearing to be held on INS license renewal.

August 31, 1995 Re submittal application-for INS renewal, and request for withholding proprietary information Sections B-1;C-1;C-2; and Figures B-1;B-2;B-3; and D-2 from public disclosure.

September 22, 1995 Memo from William Floyd to Tracey Hughes, Legal Counsel, requesting attorney assistance in preparation for public hearing, ,

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October 3, 1995 Letter to Mark Weidler, Secretary, from CCNS requesticg an evening session for public comment-and replacement of Edgar Thornton, as hearingtofficer for Nov hearing on INS renewal.

October-10, 1995 Letter to Kathleen SaW, CCNS, from Tito Madrid, Bearing appointed hearing officer.

October 17, 1993 Letter from CCNS to Tito Madrid in response to his letter of October 10, 1996 requesting postponement of ' Nov. 2 & 3 hearing due to procedural and substantive irregularities by INS and NMED (the re-submittal of INS renewal application, claim of proprietary information, and other clean air act and disposal issues).

October 17, 1995 BRMB's motion for Prehearing Order to establish deadlines, statements and party status by interested persons and non-partles - with the '

opportunity to submit oral relevant issues, views or arguments and to examine witnesses.

October 20, 1995 Letter to Tito Madrid from REAL-Responsibla Enviroraent al Action League to be regarded as-

" Interested Persons".

October 20, 1995 Letter to Mike Bovino, INS, form U.S. EPA-Bank May, Radiation Project Co ordinator, Region 6, Dallas, Texas -Ret " Direct" Radiation vs.

Radiation from Emitted Radionuclidea" (NESBAP)

October 23, 1995 Letter to Tito Madrid from REAL submitting the filing _ of witness, exhibits, and summary of testimony-on Nov. 2 and 3 hearing.

October 23, 1995 Letter from Tito Madrid to "all interested persons", on Postponement of INS hearing in order to address certain significant procedural

-issues week.

raised for the-first time in the past October 24,_1995 Letter to Tito Madrid from-Potter, Mills &

Bays, INS attorneys 'in response to CCNS letter of October 17, 1995_ and to raise points to be considered &- ruled upen on in renewal proceedings.

October 26,~1995 Letter- from the Dept. to INS on Financial Assurance Requirements, Subpart 3, Section 311.

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November 1, 1995

-Prehearing Orders that:

Order-Bearing Officer finds and 1.

INS renewal application was submitted more than days- prior to June 30th, 1995

2. expiration INS Augustdate 31, and therefore is timely.

1995 letter does not 3.

constitute a new renewal application.

Clean Air Act violations not relevant to 4.

licensure issues under RPA.

5.

Proprietary issue claims not evaluated.

INS 15 days from this order shall support each claim of proprietary information or withdraw claim within two days of INS's submission to the Bearing Officer has made a ruling, and cause appropriate notation 6,

to be placed in the public file.

7, 8, proprietary issue.

9. Significant interest expressed 10.

public hearing of the application. merits 11.

310 A,B & D have been complied with.

References to " Parties", " Interested Persons" and "Any Person Who is or maybe Affected" are confusing and resolves as follows:

a.

INS & BRMB are deemed to be parties;

b. Information presented that is relevant and not cumulative or otherwise objectionable, any-interested person shall be permitted to testify under oath and is subject to cross-examination;

c. No interested person will be permitted organization to testify on behalf of an unless they have a signed, -summary testimony. prefiled ,

of November 9,: 1995 Letter from CCNS to Tito Madrid, Response to BRMB's motion for Prehearing Order and Response to INS letter, dated-October 24, 1995. (CCNS desires a set time on public testimony but no further restrictions. other than relevancy);

determination of propr(ietary information that should be made available for public review; and refrain from entering-a Prehearing Order until after'Prehearing Conference is convened).

November 14, 1995 Letter to Kathleen Sabo, CCNS, Sloan providing a list of documents withheldfrom Geoffrey 5

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November 15, 1995 by HRMB, not proprietary information claimed.

Certificate of Service from Thomas C.H. Mills, INS Attorney on Justification for withholdin certain information for proprietary reasoas.g November 15, 1995 Letter from Thomas Mills to William Floyd, NMED, INS submittal of information for public record of Justification for Withholding certain Information for Proprietary Reasons.

November 17, 1995 Letter from Geoffrey Sloan to Thomas Mills, on INS Decommissioning Funding Plan.

November 21, 1995 Letter to Tito Madrid from Geoffrey Sloan to transmit the original figures B-1;B-2; and D-2 provided in 8-31-95 renewal application. No copies of these figures were made by HRMB.

November 28, 1995 Letter to Keith Eye, INS Plan Manager, from l the State of Washin DOH, Division of Radiation Protection, gton, on Site Use Permit-Point of Origin 1995, Inspection conducted on November 18, on rules governing the use of the commercial low-level waste' dis?osal facility.

After a review of waste handl;.ng operations, no deficiencies pertaining to the program were found.

November 30, 1995 Letter to Tito Madrid from Kathleen Sabo, CCNS, for Party Status.

December 4, 1995 Letter from REAL to November 30, to Tito Madrid, in response Status. 95 CCNS letter for Party December 12, 1995 Letter to Tito Madrid from Geoffrey Sloan on error of copy given as proprietary, Figure B-1 instead of B-2 as ordered on November 20th.

(Figure B-1, INS, SF Site Drawing).

January 9, 1996 .

Letter from William Floyd to Mike Bovino, INS, Follow-up to December 19, 1995, plan & separation of proprietary information. decommissioning January 11, 1996 Order from Status Herring Officer denying CCNS Party January 25, 1996 Request from CCNS to Bearing Officer to reconsider the Ordt.r denying CCNS Party Status.

February 20, 1996 Letter petition form and CCNS t.o Tito affidavits for Madrid additional reconsideration of Party Status.

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February 26, 1996 REAL response to CCNS affidavits.

! February 28, 1996 Letter from William Floyd to Mike Bovino, j

approving INS Decommissioning Funding Plan.

March 1, 1996 Letter from INS attorney to Tito Madrid,

' Response in opposition to CCNS' Party Status Petition reconsideration request.

4 March 4, 1996 CCNS ' letter to Tito Madrid,, Party Status Reconsideration Request and to present evidence 5 witnesses in the public hearing in more than a generalized interest.

March 7, 1996 Department was informed of allegations by Leroy Romero and met with representatives from CCNS, and the City of Santa Fe.

March 11, 1996 Order denying CCF amended petition for Party Status.

March 26, 1996 Notice of Hearing-Renewal hearing May 20th and 21st from 9:00AM .to 5:00PM at State Capitol i

Building, Room 322, Corner Paseo de Peralta and Old Santa Fe Trail, and evening session at 7:00PM to 9:00PM reserved for public comment on May 20,1100 St Francis Auditorium, Copy of PreBearing Order may be obtained from Joyce d

Croker, Hearing Clerk-(505) 827-2824.

March 28, 1996 Inapection of INS by NMED and City of Santa Fe, on March 28 through April 1,1996, (See report i

dated April 4, 1996).

April 2, 1996 Letter from INS to William Floyd, in response to Letter of Credit, Decommissioning Funding Plan and standby Trust- Agreement, and question on page 3 of Appendix F, the setting aside.of funds to remove the buried sewer pipe from their tanks to the point of connection to-the ,

city sewer main on Siler Road. The term

" manhole" used to represent this connection point. Decommissioning Plan document expected on April 30, 1996.

- April 4, 1996 Letter from INS and News paper article copy on the State's Inspection of March 28 through April'1, 1996, and reference to the Inspection Order filed in District Court on April 3,1996.

April 9, 1996 Analytical results from Scientific Laboratory 7

Divis$.on of swipes taken of. INS inspection on March 29,1996 filed in hearhg folder 1 of 2.

AUGUST 6, 1996; CONTINUATION OF HEhRING:

April-9, 1996 New Mexican -Article of- March 28, 1996, INS Inspection by NMED. l April-22, 1996 SLD analytical results of samples taken en March 28, Water Tank-2.

-April 26,1996 SLD analysis, Sludge from Holding Tank #2, April 29,--1996 Official ccpy of April 26 Sampling Analysis.

April 26, 1996 Journal- North Article on protestors that

-condemn IANL plans and pre hearing Public Meeting on April 29, at the Barold Runnels Bldg., 1190 St Francis Drive, Santa Fe for parties to discuss hearing stipulations.

May 9, 1996 INS Letter of Credit Agreement, May 1, 1996 betweenand- Standby Trust of Boston, and NMED. INS, The Bank May 10, 1996 Letter from INS, Mike Bovino to Royallynn

- Allen,_ Water-Quality Division,, City of S.F.,

in response-to violations Notice of April 12, l

1996. Letter outlined mitigation measures to be completed by June 15, 1996:

May 14, 1996 City . of Sar ta Fe - Administrative Compliance Order - to ' I'AS.

discharge into cityC6ase sewer..and Desist from any May-15, 1996 Journal Nrrth news article on the fines imposed on INS over sludge in holding tanks.

May 17, 1996 SLD. analytical reports of roof lint cather of samples collected on May 16, 1996.

May_17, 1996 CCNS cepied information:from files _315 pages.

May 17,:1996 Letter to Bill Landin PE4, , Enginewr II City of S.F. Water Quality Division from-INS to make programmatic- and prevent facility modification to recurrence of cited. violations, eliminate possible sludge into sewer system and May 22, 1996. . . new New compliance sampling point.

Mexican -Article on waste at INS on 8

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Testimony that laundry lint is Radioactive, May 22,'1996 - Memo to file-from Bill:Floyd, report of fire-at INS. NMED verified.that the-welders were cutting doors for man-ways in holding-tanks.

May 24, 1996 Fax from City-of Santa Fe to Mike Bovino, INS on proposed facility modifications no written '

approval granted until review of May 21 plans.

May 28,_1996 INS letter outlining Engineering controls taken for man-way installation & sludge removal from

-tanks. ..

May 28, 1996 Radiation Survey of areas surrounding INS by John Martinez and Walter Medina.

May 29,_1996 Second Stipulated Supplemental Pre-Hearing Order from INS attorneys to Jeff Sloan, NMED.

l May 30, 1996 From INS attorney's to_ Jeff Sloan, NMED attorney Draft Notice of Resumption of . Hearing.

May 30, 1996 Article to Bill Floyd from Jeff Sloan on the -

Nation and_ Nuclear Weapons.

May 31, 1996 City.of Santa Fe, Peter Dwyer, to Jeff Sloan, a resolution for the city of appear befora-the Environment Dept. to intervene in renewal of INS RAM license. Attorney Privilege.

May NMED Notice to all interested persons in the renewal of INS license, that the hearing

-conducted on May 20 and 21 will resume ont he 6th day of August at 9 A.M. to 5 P.M. and will continue- until concluded. These notice supersedes notice-in Alb. Journal on June 6, 1996 and the New Mexican on June 13.

No Date ' Article by Kay - Bird, Santa Fe Reporter on

" Stricter Standards Set for Nuclear Laundry by City."

-May 31, 1996 CCNS'to Jeff Sloan concerning information on proposed expansion areas - and contamination clean-up..

June:3,.1996 Letter to Mike Bovino, INS to notify the State before sludge removal from tanks or any processing of sludge and protective = measures-taken.

-June 5, 1996-Representative from Yellow Freight concerned

.9-

.4 about possible exposure by INS to en.ployees.

Recommended he contact INS from WB counting.

Provided INS.

him with information of surveys at June 6, 1996 INS to Bill Landin, City Water Quality, response to supply requested information on TSS treshold limits.

June.7, 1996 Letter from INS keeping NMED informed of documents from City of SF to INS and meeting scheduled on Tuesday June 11 inspection" to release cease, & 9 desist A.M. for " final order.

June 13, 1996 City of SF Resolution to City Attorney and Public Utilities Dept. to revise and strengthen the waste water discharge permit held by INS

.and prohibiting radionuclide discharge in the city sewer and directing that such prohibitions be made part of all existing permits.

June 14, 1996 New Mexican article on City rule to keep radioactive waste out of sewer.

i June 27, 1996 i Letter from City of Santa Fe to INS regarding administrative order. AO will continue in effect until all changes are in place.

June 28, 1996 New Mexican Article INS files suit against the City of Santa Fe to reopen facility. 4 June 28, 1996 To Jeff Sloan from City of SF on upcoming local radionuclide regulatory requirement council meeting of June- 12 resolution was adopted regulating radionuclides into sewer.

July 2, 1996 New Mexican Article SF Prep, sampling paper. quoting Jay Shelton, July 10,-1996 Journal North Article on Radionuclide Tests privaterequired being residences.by City Council and affects on July 17, 1996 Unopposed motion for Issuance of Deposition Subpoena to Leroy Romero and CCNS before hearing.

July 17, 1996 Brief in support of unopposed motion for issuance'of Deposition Subpoena from INS.

July 17, 1996 Letter from INS to Tito Madrid with unopposed 10

motion for issuance of deposition subpoena to

-grant motion and issue subpoenas.

July 17, 1996-Joint _ motion INS and NMED to amend order denying City of SF Party Status.

July-25, 19i!6 Amended order denying City of SF Party Status.

July 30, 1996 SF City Council Resolution-to include NMEd as stakeholder in task force on regulation of radionuclide release to sewer.

July-30,-1996 Accompanied Jay Shelton and SF Prep student on taking sludge samples and surveys at the SF Sewage Treatment Plant.

August 1, 1996 - ,

Meeting with INS attorney and CCNS attorney for Leroy subpoena Romero before Tito Madrid to squash l

for depositAon. Tito ruled that a

!- subpoena could be issued and CCNS and Leroy Romero may not testify until these depositions are taken.

August 2, 1996 SLD results on six sludge / soil samples from INS samples taken on July 15, 1996.

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APPENDIX D LICENSE FILE REVIEWS 1 l

File No.: 1 Licensee: Espanola Hospital License No.: M1073 Location: Espanola Amendment No.: 20 License Type: Medical Institution Type of Action: Amendment Date Amendment Issued: 04/24/96 License Reviewer: WMF Comment:

a) No documentation in this file to indicate that the individual named as a temporary authorized user is qualified (by virtue of his own license issued by the State).

File No.: 2 Licensee: New Mexico Institute of Mining and Technology License No.: AC049 Location: Socorro Amendment No.: 4 License Type: Academic Type of Action: Amendment Date Amendment issued: 01/23/96 License Reviewer: RM Comments:

a) License was amended on the basis of an intended licensee response to a compliance letter that was required but never received, b) The license had an April 30,1996 expiration date but no documentation pertaining to the renewal was in the file The renewal (amendment 5) was found on a l computer and printed out for the file but the licensee's letter requesting renewal l was not found.

File No.: 3 Licensee: Ethicon Endo-Surgery License No.: Gl316 Location: Albuquerque Amendment No.: O License Type: Pool irradiator Type of Action: New Date Amendment issued: 01/19/96 License Reviewer: ML Corr.ments:

a) Documents ( financial surety and a hospital's commitment to treat potential radiation injuries) were required to be submitted after the construction license was issued and prior to operational approval. These were missing from the license file but found in the Albuquerque office with the inspector's facility application.

b) Detailad schedules for testing and maintenanco were also required to be provided prior to operational approval. Only the quarterly mechanical maintenence schedule was in the license file. Others were thought to be in the Albuquerque offico. There is no documentation that these documents were reviewed by the licensing reviewer.

c) A rource wipe test procedure was approved but no spe::ifiestions for the required meter were provided nor were detection limits discussed.

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New Mexico Draft Report Page D.2 License File Reviews File No.: 4 Licensee: Continental Testing and Inspection License No.: IR323

- Location: Signal Hill, CA/ Aztec, NM Amendment No.: O License Type: Industrial Radiography Type of Action: New  !

Date Amendment issued: 07/11/96 License Reviewers: ML/WJM Comments:

a) RSO qualification and f acility diagram submittals were not tied to license. l b) No training and experience was documented for one of the named radiographers.

File No.: 5 Licensee: Desert Industrial X Ray License No.: IR062 Location: Hobbs Amendment No.: 11 License Type: Industrial Radiography Type of Action: Termination

, Date Amendment issued: 07/31/96 License Reviewer: WMF l '

l Comments:

l a) No record of close-out survey l- b) No verification that sources were received by company's office in another State.

! c) Licensee's request for termination was misfiled. Found in " reciprocity" file.

File No.: 6 Licensee: John A. Romero, DVM License No.: VT234 Location: Santa Fe Amendment No.: 6 License Type: Veterinarian Type of Action: Renewal Date Amendment Issued: 12/09/96 License Reviewer: WMF Comments:

a) ' Checklist from previous renewalin 1987 was deemed acceptable by reviewer.

b) Tie down clause inappropriately included letter from 1992 in which licensee sought approval to use flushable litter in place cf holding animal waste for decay.

File No.: 7 Licensee: The BDM Corporation License No.: RD027 Location: Albuquerque Amendment No.: 6 License Type: Research and Development Type of Action: Termination Date Amendment issued: 03/18/96 License Reviewer: ML Comments: -

a) No record of close out survey by State. Indirect reference in licensee's request for termination noting use of a survey meter by State inspector. Licensee had possessed mainly tritium in sealed neutron source targets. No indication that smears were taken.

o New Mexico Draft Report Page D.3 License File Reviews b) No verification of transfer of sources. Licensee had been cited in 1995 for failure to have records of transfer for three multicurie tritium sources. No record of licensee response to citation, c) Termination amendment did not reference licensee's request (omitted date).

File No.: 8 Licensee: IMC Global Operations, Inc. License No.: GA099 Location: Carlsbad Amendment No.: 17 License Type: Fixed Gauge Type of Action: Amendment Date Amendment issued: 11/30/95 License Reviewer: JLM Comment:

a) Transfer of source verified but not documented. (It was also noted that this file was missing the original license application and supplementa' information as referenced in the license tie-down condition and that recent operathg and emergency procedures that were included in the file were not refere nced in the license.)

File No.: 9 Licensee: Atomic inspection Lab License No.: IR022 Location: Albuquerque Amendment No.: 14 License Type: Industrial Radiography . Type of Action: Renewal Date Amendment issued: 04/04/97 License Reviewer: WMF Comment:

a) No example examination was submitted for in-house training program.

File No.: 10 Licensee: Interstate Nuclear Services License No.: LA110 Location: Santa Fe Amendment No.: 54 License Type: Nuclear Laundry Type of Action: Renewal Date Amendment Issued: Pending License Reviewer: ML Comments:

a) No indication that allitems identified as deficiencies in the undated License Application Evaluation "The New Mexico Environment Department Lic. #2" and discussed with the licensee in the meeting on May 8,1996 had been resolved to reviewer's satisfaction. (Although the Post Hearing Evaluation of Supplemental Information, dated March 7,1997, covered some of the same items.)

b) -The practice of replacing pages in the licensee's renewal package as updated information is submitted without removing the outdated information has resulted in a confusing master document.

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New Mexico Draft Report .Page D.4-License File Reviews File No

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Licensee:. Rotary Wire Lir.e Service, Inc. License No.- WL300 Location: Hobbs: ~ Amendment No. L 0 =

. License Type:- Well Logging Type of' Action:;- Now Date Amendment issued: 07/10/95 License Reviewer: WJM

! Comments:

a) Procedure manual (from predecessor license) was not tied down, b) . Telephone deficiency call was not documented in the license file. The reviewer found documentation in his personal notes.

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APPENDIX E INSPECTION FILE REVIEWS-i t

File'No.: 1 Licensee: -- Kleinfelder, Inc. License No.: DM318 Location: Albuquerque inspection Type: Unannounced, Initial License Type: Muisture/ Density Gauge Priority: 2 inspection Date: 10/07/96 - Inspector: _JLM Comments: -

a)- Operations not observed; independent measurements were performed.

l b)- Exit meeting held with RSO, not senior licensee management, c) . --Only RSO was interviewed. Other staff not around during the inspection, according to the_ inspector.

d) Annual review of radiation protection program not addressed.

L- File No.: 2 Licensee: Mobile inspection Service, Inc. License No.: IR138 l4 Location: . Farmington inspection Type: Unannounced, Routine.

- License Type: Industrial Radiography . Priority: 1 Inspection Date: 08/29/96 Inspector: _ WM_

Comments:

a) Operations not observed.

b) A few areas not inspected / addressed, including required annual review of the radiation protection program, c). Exit meeting held with Alternate RSO, not senior licensee management. Inspector reported that Owner and RSO not present. -

d) Inspection report form in draft.

File No.: 3 Licensee:- Petro Wireline Service. License No.: WL162

~ Location: Farmington Inspection Type: Unannounced, Routine License Type: ' Well Logging Priority: 2 Inspection Date: 09/05/95 Inspector: WM/WF Comments:

a)- 1 Citation from previous inspection not followed up. 7/92 inspection informed licensee to amend license to add individual as an authorized user. Licensee did not -

submit amendment request,- This 9/95 inspection makes a repeat finding regarding Jamending license to indicate authorized users.- Individual still has not been added to the license, b) Deficiency letter sent to licensee late - 3 months after the inspection, which exceeds the 30 day post exit criterion, c) Operations not observed.

Jd): Exit meeting held with a non-authorized user, not senior licensee management.

'e) ' Acknowledgment letter (responding to licensee's reply to deficiencies) not in file.

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l New Mexico Draf t Report Page E.2 inspection File Reviews f) Key areas not inspected / addressed (training, inventory, and shipments not inspected; condition of equipment not reviewed; licensee conducting tracer studies, but bloassays not inspected).

g) Licensee's response to repeat deficiency on survey meter calibration does not l

address how future violations will be prevented.

File No.: 4 Licensee: Northeastern Regional Hospital License b'o.: M1153 Location: Las Vegas inspection Type: Unannounced, Routine License Type: Medical Insti;ution Priority: 2 Inspection Date: 09/10/96 Inspector: ML Comments:

a) Operations not observed; independent measurements not made (inspector's survey meter malfunctioned).

b) Key areas not inspected / addressed (dosimetry results not dne anted; did not inspect annual review of the radiation protection prograrr . .nspection of I 131 effluents; dose calibrator linearity not checked, even thougn this was a previous deficiency).

c) Exit meeting with RSO, not senior licensee management, d) Inspection report form in draft.

File No.: 5 Licensee: Science Applications International Corp. License No.: RD249 Location: Albuquerque inspection Type: Unannounced, Routine License Type: Research and Development Priority: 2 Inspection Date: 05/15/06 Inspector: JAM Comments:

a) Operations not observed; independent measurements nct made (licensee did no!

have material at the time of inspection).

b) No supervisory review of inspection report indicated.

c) Exit meeting with RSO, not senior licensee macagement.

d) Key areas not inspected / addressed (insufficient irnumation on security practices, receipts of material, transfers of waste, licensee surveys; waste disposal practice regarding holding for decay to background then disposal / transfer to Defense Nuclear Agency is not appropriate, since cobalt 60 has a half life longer than appropriate for decay in storage).

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t New Mexico Draf t Report Page E.3 Inspection File Reviews File No.: 6

< Licensee Ethicon Endo Surgery License No.: Gl316 Location: Albuquerque inspection Type: Unannounced, initial License Type: Pool lrradiator Priority: 1 l

{ inspection Date: 07/01/97 Inspector: JLM f Comments:

a) Independent measurements were made (but actual dose levels in control room were only characterized as "no abnormal readings," values not given),

b) Key areas not inspected / addressed (note on emergency response Indicates that the fire department "will be contacted" and that the fire chief has inspected the plant, ,

but fire department not yet trained on fighting fires at this large irradiator; '

insufficient inspection on whether dominerallrer resins are surveyed, other than on-i line monitoring, before release to commercial company for unrestricted use).

! c) Reference made in inspection report to previous trips, but only 10/28/96 visit documented. Others not documented at all, di Ancillary workers (administration, cleaning, warehouse workers) apparently not interviewed. Mainly spoke to RSO, engineers and Alternate RS0s.

e) Exit meeting with RSO, Alternate RS0s, and some staff, not senior licensee management.

File No.: 7 Licensee:' Biotech Pharmacy License No.: RP301 Location: Las Cruces Inspection Type: Unannounced, Routine

! License Type: Nuclear Pharmacy Priority: 2 Inspection Date: 01/15/97 Inspector: ML/WF Comments:

a) Operations not observed; independent measurements were made, but leve'*, not documented.

I- b) Key areas not inspected / addressed (insufficient detail on waste disposal; inspector does not recall whether inspection included wipe tests for removable contamination).

. c) Inspection report form in draft.

d) Unclear follow up ori licensing; 3/21/97 license revision did not follow through, as indicated, and make named Individual the RSO. Reason for making the individual the Alternate RSO, instead of changing the RSO, not documented

! e) Nuclear pharmacy used 1131 during review period, but no bloessays performed. No estimates of worker internal doses provided by licensee or inspectors. Licensee did not state, to the inspector, quantitles of l 131 used.

f) Delivery drivers not interviewed, although delivery and pick ups occurred during the inspection.

g) Inspector signed form for supervisor, h) Deficiency letter dated 02/25/97, more than 30 days post exit.

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New Mexico Draf t Rer. ort Page E.4 Inspection File Reviews File No.: 8 Ucensee: New Mexico Institute of Mining and Technology License No.: AC304 Location: Socorro inspection Type: Unannounced, Routine License Type: Academic Priority: 2

. Inspection Date: 02/18/97 Inspector: RM Comments:

a) Inspection dates inconsistent: Inspector reports 2/18/97, inspection form shows 2/20/97, letter to licensee statec 2/19/97.

b) Operations not observed; independent measurements not mada.

c) Key areas not inspected / addressed (surveys, security, receipt / inventory, transfers / shipping, and internal audits not addressed in inspection report; inspector does not recall whether he looked at licensee surveyt; insufficient detail on worker doses; process for wasto disposal described, but no information regarding whether waste was being disposed),

d) No interviews of students in authorized user's laboratory.

e) ' Exit meeting with RSO and authorized user, not senior university management.

File No.: 9 Licensee: ProTechnics International, Inc. License No.: TA172 Location: Albuquerque inspection Type: Unarsnounced, Poutine License Type: Tagging (similar to R&D, Distribution) Priority: 1 Inspection Date: 06/04/96 Inspector: JAM /WF i

Comments:

a) Reinspection recommended in June 1998, although this is a priority 1 licensee with two past incidents, bl Operations not observed.

) Key areas not fully inspected / addressed (shipments not fully addressed, although the licensee distributes; examination of annual audits not addressed; insufficient detail on bionssays, extremity doses, emergency response, and gaseous effluent levels).

File No.: 10 Licensee: University of New Mexico License No.: BM233 Location: Albuquergee Inspection Type: Unannounced, Routine License Type: Broad Medical Priority: 1 Inspection Date: 05/13 17/97 Inspectors: ML/JLM/WF Comments:

a) File notes " human subjects are used" for research. inspector reports that licensee is performing radiaticn experiments on people, inspector did not ask what the licensee was doing, b) ALis and DACs not enluated.

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New Mexicu Draf t Report Page E.5 Inspection File Reviews c) Inspection report makes reference to a

• diagnostic misadministration." That is unlikely, since almost all diagnostic doses of Tc 99m will not result in misadministration, as defined in the regulations, d) Effluents from laboratories not completely evaluated. Licensee told inspectors that the records were in boxes, but State apparently did not follow up.

e) The 1995 and 1996 inspection reports were not in the file although the staff indicated that the inspections had been performed.

f) Deficiency letter dated 06/26/97, more than 30 days post exit.

g) Some areas (laboratories, nuclear medicine) documented appropriately. Other areas (HDR, brachytherapy, poolirradiator source) not thoroughly documented.

h) Some inspection report forms in draf t, l) Respiratory protection program not fully inspected / addressed.

File No.: 11 Licensee: New Mexico State University License No.: BB151 Location: Las Cruces inspection Type: Unannounced, Routine License Type: Broad License, Type B (similar to Academic) Priority: 2 Inspection Date: 08/28/96 lospector: RM Commerits:

a) Operations not observed; independent measurements not documented, b) Key areas not fully inspected /afdressed (security not fully described, receipt / procurement not completely inspected although +his institution had an NRC

~

violation at a remote facility, dosimetry results not provided),

c) Students not interviewed regarding training. One significant authorized use under this license is to train students in the use of portable gauges, d) Acknowledgment letter (responding to licensee's reply to deficiencies) not in file, e) Exit meeting with RSO and users, not senior university management, f) Inspector examined storage area; reports that he did not observe gauge, itself.

File No.: 12 Licensee: Interstate Nuclear Services License No.: LA110 Location: Santa Fe Inspection Type: Unannounced, Special License Type: Nuclear Laundry Priority: 2 Inspection Date: 03/28/96 04/01/96 Inspector: ML/WM/WF Comments:

a) Effluent levels (quantities released to sewer and air) not addressed in inspection report or cover letter. Processes for handling effluents are described.

b) Good to conduct late shift inspection, c) This was the most technically detailed inspection examined by the review team, and it was well documented.

New Mexico Draft Report Inspection File Reviews Page E.6 in addition, a team member made the following inspection accompaniments as part of the onsite IMPEP review:

Accompaniment No.: 1 Licensee: ProTechnics International Location: Albuquerque License No.: TA172 inspection Type: Unannounced, Routine License Type: Manufacturing and Distribution inspection Date: 06/16/97 Priority: 1 Inspector: JAM Comments:

a)

Missed opportunities to interview personnel using RAM and ancillary personnel.

b) No wipe tests taken although potential for contamination existed.

Accompaniment No.: 2 Licensee: St. Joseph Hospital Location: Albuquerque License No.: MI210 Inspection Type: Unannounced, Routine License Type: Brachytherapy Inspection Date: 06/17/97 ' Priority: 2 inspector: ML Comments:

a) Inspector was not sufficiently trained in brachytherapy.

b) Therapies in progress were not observed (LDR, eye plaque, Ir 192 ribbons),

c) Missed opportunities to interview therapy technologists and ancillary personnel, d) Exit interview not with appropriate level of management.

Accompaniment No.: 3 Licensee: Atomic inspection Labs, Inc.

Location: Albuquerque License No.: IR022 inspection Type: Unannounced, Routine License Type: Industrial Radiography Inspection Date: 06/18/97 Priority: 1 Inspector: WJM

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APPENDlX F INCIDENT FILE REVIEWS File No.: 1 l Licensee: ProTechnics international l License No.: TA172 l Incident ID No: NM 97 04 I Location: Albuquerque Date of Event: 3/25/97 Type of Event: Contamination investigation Date: 3/28/97 1 Summary of incident and Final Disposition: Approximately 20 mci Ir 102 in oil soluble '

tracer and nitric acid under pressure blew lid frorn vial, burning and contaminating employee. Licensee performed decontamination, notified State who had them send employee to University of New Mexico hospital for further decontamination and internal evaluation. In interview with review team, inspector stated he thought he remembered conducting onsite investigation the next day. Licensee sent State report with medical and radiological evaluations and changes in nrocedure to prevent future occurrences. Report showed no radiation limits were exceeded.

Comments:

a) Incident significant enough to require immediate onsite response with in depth review of circumstances, including reenactment, verification of dose calculations, and confirmatory measurements of cleanup. Memorandum or report of results of onsite investigation never located; no record of inspector visit on licensee sign in log for dates in question.

b) Incomplete documentation of State's response actions, c) No evidence State reviewed licensee's response for adequacy, d) Not clear whether State evaluated event for possible regulatory action.

e) No close out information or signature; no record of management involvement or review.

f) Reported to NRC in quarterly report, w w -- - -r a

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i New Mexico Draft Report Page F.2 I

) Incident File Reviews l

File No.: 2

. Licensee: NOL X NDT Services l License No.: lH17

incident ID No: h.o 9610 Location: Temporary Job Site, Farmington Date of Event: 7/15/96 Type of Event Contamination Investigation Date: 7/16/96 Summary of incident and Final Disposition: Radiographer found ~35 mr/hr contamination when surveying guide tubes with source retracted. At State's suggestion, camera was returned to manufacturer, industrial Nuclear Corporation (INC), a Californla licensee. INC reported leaking source to California Radletion Control Program, who reported it to NRC RIV i (PND IV 96 040). Cause apparently pin hole leak in source, considered to be one time

failure. .

l Comments:

a) No documentation of State's response actions;intormation taken from reports  !'

fwnished to the State by NOL X NDT Services, and California Radiation Control Program.

b) No close out information or signature; no record of management involvement or review, c) incident was followed up in September 1996 inspection.

d) Reported to NRC in quarterly report. ,

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New Mexico Draf t Report Page F.3 Incident File Reviews File No.: 3 Licensee: H&G Inspection Co, Inc.

License No.: IR268 incident ID No: NM 9611 Location: Santa Fe

' Date of Event: Between 8/10/96 and 9/9/96 Type of Event: Possible Overexposure Investigation Date:- 9/30/96 l Summary of Incident and Final Disposition: When licensee returned dosimetry to vendor, they were advised of an exposure reading of 198 rem for a radiographer. -Licensee reported immediately to State, who ordered licensee to investigate and report back. Report from licensee included two medical evaluations concluding that the exposure was not real and statement that individual was assigned 242 mom, for period.

Comments:

- a) Significance of potentially high overexposure warranted onsite investigation by State with in depth review of radiographer's work schedule, comparison of dosimetry records with fellow workers, possible reenactment of individual's routine work

- habits and independent calculation of probable dose for period; no evidence State performed any independent investigation.

b) No documentation of State's response actions other than copy of letter to licensee.

c) No documentation of State's evaluation of licensee's response.

- d) No close out information or signature; no record of management involvement or review, e)- No evidence that inspector reviewed any issues concerning incident during next inspection.

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New Mexico Draft Report Page F.4 l Incid6..t File Reviews i File No.: 4 )

Licensee: Syncor, Inc.

License No.: RP261 incident ID No.: NM 95 03 Location: Albuquerque Date of Event: 3/22/95 Type of Event: Incorrect Dose investigation Date: 3/22/95 Summary of incident and Final Disposition: Syncor sent hospital correct dose quantity but wrong tagging agent (pharmaceutical). Hospital advised Syncor that patient was injected with incorrect radiopharmaceutical. Syncor reported error caused by not following procedures and promised improvement.

Comments:

a) No documentation of State's investigative or regulatory actions; no citation.

b) No documantation in file to identify perton tabng report from licensee; no close-out

'information or si 0nature; no record cf manaDement involvement or review, c) Same ID number assigned to two different incidents (X Ray Associates),

d) No documentation of State's evaluation of licensee's responso.

e) No evidence incident reviewed at next inspection.

File No.: 5 Lictnsee: Syncor, Inc.

License No.: RP261 Incident ID No.: NM 9611 Location: Albuquerque Date of Event: 11/11/96 Type of Event: Incorrect Doae Investigation Date: 11/12/96 Summary of incident and Final Disposition: Syncor sent hospital correct dose quantity but wrong tagging agent (pharmaceutical). Hospital advised Syncor that patient was injected with incorrect radiopharmaceutical. Syncor reported error caused by not following procedures and promised improvement.

Comments:

a) No documentation of State's investigative or regulatory actions.

b) No record of citation or follow through on repeated error by Syncor, c) No documentation in file to identify person taking report from licensee; no close out information or signature; no record of management involvement or review, d) Same ID number assigned to two different incidents (see File No. 3),

e) No documentation of State's evaluation of licensee's response, f) No evidence incident reviewed at next inspection.

New Mexico Draft Report Page F.5 Incident File Reviews File No.: 6 Licensee: Halliburton License No.: WLOB7 incident ID No.t NM 95 09 Location: Russell well site, San Juan County Date of Event: 5/11/95 Type of Event: Abandoned Source investigation Date: 5/11/95 Summary of incident and Final Disposition: Well logging source lost and abandoned down hole. Company sent complete report to State and NRC RIV indicating they followed appropriate capping procedures; copy of plaque was included in report.

Comments:

a) No record of State's response. Only documentation of incident was licensee report to State.

b) No documentation in file to identify person taking report from licensee; no close-out information or signature; no record of management involvement or review.

c) No documentation of State's evaluation of licensee's actions, d) Next inspection report states that no incidents had occurred, e) State did not report event to NRC for inclusion in NMED.

File No.: 7 Licensee: H&G Inspection Co., Inc.

License No.; IR268 incident ID No.: NM 95 02 Location: Gas pipeline near Colorado border Date of Event: 1/22/05 Type of Event: IR Source Disconnect Investigation Date: 2/27/95 Summary of Incident and Final Disposition: Radiographer failed to connect the pigtall properly to the drive cable (human error). Licensee reported error was discovered when camera was surveyed, at which time emergency procedures were followed; RSO returned source to camera. Exposures were reported to State.

Comments:

a) Although incident was significant enough to require immediate onsite response with in-depth review of circumstances, including reenactment, verification of dose calculations, worker interviews, etc., State did not send investigator to location, b) Documentation of State's response incomplete. License file did contain copies of two letters to licensee requesting more information along with licensee's response, but no evidence of investigation as to cause (training, inadequate procedures, etc.)

and no evidence of evaluation of licensee's response, c) Licensee not cited for event nor for late report.

d) No close out information or signature; no record of management involvement or review.

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New Mexico Draft Report Page F.6 incident File Reviews e) incident not followed up during next inspec; ion.

f) Included in NMED. ,

i File No.: 8 Licensee: University of New Mexico License No.: BM233 Incident ID No.: NM 97 01 Location: Albuquerque Campus Date of Event: 2/24/97

' Type of Event: Lost RAM Investigation Date: Unknown Summary of incident and Final Disposition: Two vials of 250 uCi esch of P 32 was taken from the radiation safety office. Only one vial was found in the box on receipt. Vial presumed disposed of in ordinary waste. Licensee report dated 3/12/97 states they investigated, estimated probable dose, and changed procedures as corrective action.

Comments:

a) No evidence of investigative actions taken by State although review team found six instances of lost sources at the University during the review period. Repeated instances of lost sources significant enough to trigger onsite investigation by State in order to evaluate licensee's radiation safety program and to determine reasons for loss of radioactive material, b) No record of any contact between State and licensee other than letter report from licensee to State dated 3/12/97.

c) Inspector's report for next inspection states that problem was discussed with RSO, who attributed problems to new computer system, but no citation was issued and discussion of incident was not included in enforcement letter to licensee, d) No documentation in file to identify person handling report from licensee; no close-out information or signature; no record of management involvement or review, e) Reported to NRC in quarterly report.

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New Mexico Draft Report Page F.7 incident File Reviews File No.: 9 Licensee: AGRA Earth and Environmental License No.: DM201 incident ID No.: NM 97 03 Location: Las Cruces Date of Event: 3/28/97 Type of Event: Transportation Investigation Date: 3/28/97 Summary of incident and Final Disposition: Vehicle carrying boxed and secured portaole moisture density gauge was involved in serious accident in which driver was killed. Police arrived soon after, contacted State, and were told to secure area. State contacted licensee's assistant RSO and gave instructions for safely removing gauge from scene and transporting to licensee's facility for tests for damage or leakage. Licensee reported geuge was not damaDed and all wipe tests were negative.

Comments:

a) No documentation of State's response actions; the only record of the incident was licensee's report to State which referred to telephone convarsation at timu of incident.

b) No evidence licensee's actions were verified, or that licensee's assessment of condition of gauge was evaluated, c) No documentation in file to identify person taking report from licensee; no close out inforrnation or signature; no record of management involvement or review.

File No.: 10 Licensee: None License No.:N/A Incident ID No.: NM 94 01 Location: New Mexico Tech University, Socorro Date of Event: 8/3/94 Type of Event: Contamination Investigation Date: 8/3/94 Summary of incident and Final Disposition: Radioactive contamination found on bed of Tri State Motors truck that came onto New Mexico Tech campus. University called State and was advised that since contamination was below DOT limits that truck driver should be advised to return to home State of Missouri.

Comments:

a) Incomplete record of State's response;in house memorandum dated 8/4/94 does not identify person taking report or who made decision. Some documents appeared to be missing from file.

b) NRC RIV reported State kept them abreast of situation and worked closely with them, c) Although incident oc';urred at end of last review period, it was reported to NRC in quarterly report during this period.

New Mexico Draft Repo1 Page F.8 Incident File Reviews i File No.: 11 Licensee: ProTechnics International License No.: TA172 incident ID No.: None '

Location: Albuquerque Date of Event: 9/22/04 Type of Event: Contamination investigation Date: 9/26/94 Summary of incident and Final Disposition: Licensee reported 100+ mCl11*J1 snilled in hood during routine laboratory work. Contamination not initially noticed, but whon  ;

discovered licensee reported they took corrective actions including decontaminatio,, air '

samples, bloassay, dose estimates by consultant.

Comments: -

a) incident and licensee's delay in reporting significant enough to require immediate onsite response with in depth review of circumstances, including reenactment, verification of dose calculations and confirmatory measurements of cleanup. State did not go to facility until 3 months later on routine inspection.

b) Only documentation of incident is memo to file af ter telephone call which does not contain names and shows spill es 100 pCl, contrary to licensee's report of 100 mCl.

c) No evidence State reviewed licensee's response for adequacy.

d) Licensee not cited for events causing incident nor for late reporting.

e) No close out information or signature; no record of management involvement or revjew.

f) Not reported to NRC.

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