ML20236N235
| ML20236N235 | |
| Person / Time | |
|---|---|
| Issue date: | 08/27/1987 |
| From: | Hornor J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | Nussbaumer D NRC |
| Shared Package | |
| ML20236N197 | List: |
| References | |
| FOIA-87-708 NUDOCS 8711160075 | |
| Download: ML20236N235 (12) | |
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AUG 2 71981 8%1 SEP 2I A gg, gy Nemorandua For:
Don'ald A. Nussbaumer 7
Assistant Director for State Agreement Prograa Office of State Programs
( )# 9{kA Through Joel 0. Lubenau, Senior Projects Manager State Agreement Programs, OfficeofStatej s
From:
Jack W. Bornor, Region V State Agreements Representat I
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Subject:
FOLLOW-UP REPORT AND STAFF EVALUATION NEVADA RADIATION CONTROL PROGRAN JUNE 1981 lV 1
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Enclosed is the subject report and staff evaluation.
Findings of adequacy and compatibility continued to be withheld pending further leprovements in the program. Deficiencies were'still found-In two Catagory 1 1
Indicators, Enforcement Procedures ~and Status of Inspection Program. Also, the staffing levn1 had dropped to less than half of that recommended, and there were seriout concerns relating to the program management.
j Based on the results of the follow-up meeting, the staff recommends that the next routine review be held in six months.
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Memorandua Fort Donald' A. Nussbaumer Assistant Director for State Agreement Programs Office of State Programs Through Joel 0. Lubenau, Senior Projects Manager State Agreement Programs. Office of State Programs From:
Jack W. Bornor, Region V State Agreements Representative subject:
FOLLON-11P RENRT AND $7AFF EVALUATION NEVADA RADIATION CONTROL PROGRAN JUNE 1987 Enclosed is the subject report and staff evaluation.
Findings of adequacy and compatibility continued to be withheld pending further improvements in the program. Deficiencies were still found in two Catagory I Indicators, Enforcement Procedures and Status of Inspection Program. Also, the staffing level had dropped to less than' half of that recommended, and there were serjous concerns relating to the program management.
Based on the results of the follow-up meeting, the staff recommends that the next routine review be held in six months.
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1 N STAFF REPORT AND FOLLOW-UP EVALUATION OF THE NEVADA RADIATION CONTROL PROGRAM FOR THE PERIOD NOVEMBER 21, 1986, TO JUNE 5, 1987 A follow-up review to the 12th regulatory program review meeting with Nevada representatives was held during the period June 2 through June 5, 1987, in Carson City.- The. State was represented by Stanley Marshall, Supervisor, Radiological Health Section, and the review was conducted by Jack W. Hornor, NRC Region V State Agreement Representative.. The purpose of the follow-up i
review was to evaluate the corrective actions tuken by the. State in response.to the findings of the November 1986 routine review and to assess the current status of the adequacy and compatibility of the program.
CONCLUSIONS The determination of adequacy and compatibility continued to be withheld pending further corrective actions in the program. Deficiencies were found in two Category I Indicators, Status of Inspection Program and Enforcement j
Procedures.. Also, although improvements were noted in some areas of concern i
identified during the November review, satisfactory actions were not taken on j
all findings.
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SUMMARY
DISCUSSION WITH STATE REPRESENTATIVES A summary meeting to present the results of the follow-up review was held on June 5, 1987, with Jerry Griepentrog. Director, Nevada Department of Human Resources, and William C. Schneider, Chief, Nevada Bureau of Regulatory Health Services. Mr. Hornor explained the reasons for withholding adeq'?cy and j
compatibility and discussed measures the State could take to correct the program deficiencies. Specifically, the State representatives were urged to establish written-enforcement procedures including severity levels and to take action on violations at the waste site; to place a high priority on increasing the staffing level; and to provide more direction and guidance to the current program manager. Mr. Griepentrog acknowledged the need for program changes and expressed the State's commitment to returning the program to adequacy and compatibility.
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l PROGRAM CHANGES RELATED TO NOVEMBER 1986 REVIEW FINDINGS 1
I.
Management and Administration l
A.
Administrative Procedures Summary of Review Findings and Recommendations
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It was found that Nevnda used no written procedures for internal i
processing of license applications, inspection and enforcement policies and procedures, license termination, instrument calibration or low-level waste sito inspections. The RCP also had no administrative procedures for maintaining regulatory guides or i
other documents furnished by the NRC, for tracking licensing or i
enforcement actions or for keeping up-to-date inspection records.
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2 The need for these procedures was evidenced by program
. discrepancies in both licensing and compliance. The lack of 1
written procedures had been an issue in previous reviews and it was I
again recommended that the State develop and use written internal j
procedures for the program functions specified above.
State Response The State did not respond to this finding beyond the procedures discussed in the licensing and enforcement sections below.
Follow-up Findings The task of developing administrative procedures had been delegated a
to a staff member in addition to'his duties as the only license reviewer and the only materials and X-ray inspector in the Carson City office.
In spite of the obvious time restraints, he had followed many of the suggestions given to the State by the NRC during the last review, and drafts of some administrative and technical procedures had been prepared prior.to the time he left the program in April 1987. Several essential procedures were not written, however, including enforcement policies. Instrument
-l calibration, license termination or low-level waste site inspections.. Apparently, the staff had begun to use NRC guides and procedures in addition to the working drafts he had developed although the Supervisor did not know which guides or procedures the staff had been using.
I II.
Personnel A.
Staffinz Level Summary of Review Findings and Recommendations At the time of the review, Nevada's staffing level for radioactive materials was 0.75 person-years per 100 licenses, significantly lower than the 1.0 to 1.5 figure found by NRC and other Agreement States to be necessary to adequately control radioactive materials.
The Director and his staff were cautioned that failure to maintain an adequate staffing level would cause further problem in program effectiveness and preclude the development of procedures and staff training necessary to correct program deficiencies.
State Response Two Radiation Control Specialist positions have,been required in the 1988-89 executive budget. The positions will be utilized to increase the professional staffing ratio to acceptable levels for licensing, inspection and administrative activities.
Favorable legislative action to add the positions to the Radiological Health Section budget will enable recruitment to begin by July 1, 1987.
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'Foilew-un Findings As of May 1987 Nevada's staffing level had dropped to 0.41 person years per 100 licenses, excluding the waste site. As noted previously, one staff member resigned in April, leaving the Carson City headquarters office staffed only by the Supervisor. The State
'had been recruiting to fill this position.and at the time.of.the review had'made an offer to an experienced reviewer / inspector from another State. The two additional positions had not received final legislative approval, but it was expected during the-legislative session in progress at the time of the review.
III. Licensing A.
Licensing Procedures g_ussary of Review Findings an'd Recommendations E
1.
It was found the State used no internal licensing guides, nor did they have a workable set of NRC guides; no checklists or standard license formats had been developed; standard license conditions had not been established; policy memoranda from-l the Office of State Programs had not been retained, reviewed-and assimilated into standard operating procedures:-the SS&D Registry had not been updated since March 1985.
It was felt that the failure to provide the necessary guidance to reviewers related to the license deficiencies noted in review
'l of the program. _It was recommended the State develop Internal licensing procedures including standard license conditions, 11 censing guides, checklists and model licenses.
During the week of the review the NRC staff provided additional reference material and assisted the State staff in organizing the information and developing a method to keep it readily available to the reviewers.
State Response Standard licensing conditions are now computerized.
Licensing formate will be complete by February 1987. The Sealed Source and Device Registry is currently being updated on a monthly basis. Shelving and other office equipment and supplies have been obtained to maintain the material for these activities.
Follow-up Findings The staff had made many Japrovements in the licensing procedures. The State is now using NRC standard conditions, model licenses and licensing guides and the staff had completed working drafts of other procedures. The reference material had been assembled and organized so it was more readily available to the reviewers. The SS&D registry had been updated through April.
However, the State sti)) does
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.not use licensing' checklists to ensure that all elements of the application have been submitted and that the license is complete..
2.
No regulatory guides are available for applicants in Nevada.
We recommended all applicants, including applicants for renewals, be furnished with copies.of applicable guides and regulatory positions. This finding and' recommendation was repeated from previous years.
State ResDonse Regulatory guides and supplemental licensing information for distribution to applicants will be completed by March 31, 1987.
Follow-up Findings The State has not developed their own licensing guides; however, they now send NRC guides to applicants.
3.
Many licensing flies were not in the proper drawers, j
information was missing from the flies and documentation of j
telephone discussions was not always maintained. Tha RCP had
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no system for tracking incoming licensing actions, and there l
was no method to determine the number of. cases pending in-j house. Technical assistance was given during the review to 1
set up a tracking system for licensing actions and it was then recommended that the RCP implement procedures for maintaining the flies in the proper manner.
State ResDonse Organization of regulatory guides and other documents furnished by the NRC and completion of administrative policies and procedures for tracking licensing and enforcement will be in place by March 16, 1987. The conversion of flies to support the new licensing and inspection tracking system is expected to be complete by May 30, 1987.
Policy memoranda will be incorporated into -
standard operating procedures by June 30, 1987.
Follow-up Findings The administrative assistant for the program had acted on the suggestions made by the NRC reviewers for improving the filing system, and with the help of the reviewer, she had reorganized all of the license files and reference material and set up a system to track licensing actions, l
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- Lechnical Quality of Licensing Actions
~B.
e Summary of Review Pindings and Recommendations In several cases, the State had issued licenses that were not compatible with policies of the NRC and which had potential health and safety implications.
In addition to the development and use of proper licensing procedures, we suggested the staff adhere to the regulatory guidance applicable to the license under consideration.
and we recommended second party and/or thorough supervisory review of all licensing actions.
The significant discrepancies with the State's response and the current status of the license are listed below; a.
The State authorized a radiographer to use a source without checking the SS&D catalog. A source of identical design had been involved jn a radiation incident resulting in radiation injuries to member of the public and approval to use this design was withdrawn five years ago.
State Response The licensee was contacted regarding the issue and the ifcense was amended to delete the unauthorized source in November 1988.
Current License Status The license was amended as stated on November 24, 1986.
b.
The same industrial radiographer had been granted an exemption from posting high radiation areas without supporting justification.
State ResDonse
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The same license will be amended by February 28, 1987, after concurrence is gained by the licensee to post high radiation areas as required until a justification is obtained for the exception.
1 Current License Status The license was amended as stated on February 9, 1987.
c.
A company was issued a license in lieu of proper enforcement
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action. A gauge with the shutter open which had been abandoned by a bankrupt licensee was found during an Inspection of the premises during a routine inspection.
Rather than impound the source, the State issued a license for storage purposes to the new property owners who did not want it, did not submit an application and had no authorized users, with the stipulation the new owners dispose of the source.
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i State Response We anticipate a decision will be reached to impound the j
source and take action to dispose of the source.
J Current License Status The new property owners also went out of business and they g
also abandoned the source. The State declared an energency, j
impounded the source and plans to bury it at the Beatty site.
1 d.
A physician ucer was authorized without submitting proper evidence of his qualifications.
l State Response The physician had-been authorized for use of radioactive
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material under Nevada Radioactive Material License No.
03-12-0171-01 Jesued to Valley Hospital Medical Center. The licensing staff recognized the physician had adequate credentials but. failed to ensure that evidence of his qualifications was submitted in support of the private j
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phy::Jcian license application submitted by him. New policy requires all information to be submitted with an application j
without reference to another Nevada Radioactive Materials
- License, j
Current License Status Examination of file referred to by the State revealed that here again he had been approved without submitting evidence of his qualifications. The brief' statement of his past experience found in the file referred to his working under a third Nevada license and in that letter he asked that group of physicians not be contacted because they were unhappy with-his leaving. Examination of that license file did not show him as an authorized user. As of the date of this review, the matter had not been resolved.
e.
The use of 30 aCl of open I-131 was authorized without requiring use of a hood or a bloassay program.
f.
The use of Xenon was authorized without a safety evaluation of the ventilation system for the places of use.
(The State gave only one response to items e and f although the issues pertained to two different licenses.)
State Response The use of. unsealed Iodine 131 and radioactive Xenon gas is being addressed by the licensing staff. An inspection of the license was requested after notice of these audit findings.
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Inspection staff documented'that~the physician was.not using 9
A review'of the current 31 cense revealed.that the license does not authorize the' possession or use of Jodine 132 in any form.
Current License Status (e)'
The State looked at the wrong license and no action was taken.
(f)
The license is now in timely renewal.. The physician still wishes to use Xenon and has purchased a trap. A review of the safety and use of the. trap is to:he made before the license is renewed.
g.
A license that was suspended for cause was reinstated without evidence that qualified. users were available.
State Response j
The licensing staff contacted the licensee who had moved all l
radioactive sources in their possession to an. authorized user j
outside Nevada. The licensee indicated that no further activities were intended in Nevada. The license was terminated on January'15, 1987.
Current License Status As indicated, the license was terminated. A close-out inspection was performed and no radioactive material was found.
IV.
Compliance A.
Enforcement Procedures Summarv of Review Findings and Recommendations 9
1.
One licensee, the University of Nevada, had eighteen types of violations with 140 items of noncompliance, many of then repeated from previous years. The 3$censee's response after an enforcement conference was not t,isfactory, but no further action was taken on the pat.. of the RCP.'
State Response I'
The University of Nevada System has been contacted concerning the inadequate response to our enforcement letter. Another management conference is scheduled in February 1987. A revised response from the University and resolution of the violations is expected.
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Follow-up Findings-
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l Since the review, several deficiency letters and responses l
have been exchanged, and another enforcement conference with-University officials was held in February 1987. However..the State failed to follow through in their handling of the case, l
and the response from the University dated J.pril 10, 1987,=is l
L still awaiting manageaent review and evaluation.
j 2.
Several cases were found in which enforcement letters were as much as six months overdue, some in which the necessary.
enforcement letters had not been sent at all, and others in which the RCP did not reply to the licensec response or i
follow through on unresolved issues.
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State Response Written administrative procedures are being developed and will be completed by March 30, 1987, to provide the technical staff with guidance for maintaining inspections on the required frequency and for completing the inspection reports, enforcement correspondence, and ensuring licensee compliance through corrective actions and follow-up inspections. 'The 1
incide' of late enforcement referred to during the exit-l confers ;e have been addressed by the staff.
Follow-up Findings The State had satisfactorily completed the enforcement correspondence on the cases identified during the last review, but in reviewing the' files, six additional cases were found in which the acknowledgement letter was more than thirty days overdue, with some several months overdue.
ADDITIONAL FINDINGS DURING FOLLOW-UP REVIEW l
I.
Management and Administration A.
Management It was pointed out in the exit meetings and in the correspondence that an-underlying factor-in the problems appearing in the program seem to relate the lack of effective management.
In discussions with the program manager. it was noted that contrary to the guidelines, he had not made sufficient effort to assess workload trends, resources and changes in legislative and regulatory responsibilities or to forecast program needs.
In fact, he not l
only had taken no part'in developing new procedures, he was not aware of all administrative and technical procedures that had been developed by his staff since the last review. He also had not made a practice of reading the letters the Office of State Programs sends to the program directors of all Agreement States containing s
policy directives, tochnical information, changes in legislative and regulatory responsibilities and other items of mutual interest.
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Thus he ecs set fctiller eith cr had not teksn th2.sppropricto.
j actions on letters regarding such important items as establishing
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controls over. redistribution of generators, Insituting new inspection procedures and priorities, and new incident reporting 1
requirements.. During the last review the NRC analyzed the program needs and provided him.with a 11'st.of suggested management priorities with milestones and~ dates for' making specific program improvement, but he had misplaced the list and was unable to explain his progress. We recommended' direction and training in establishing priorities and decision making.be provided to the l
program manager.
11.
Personnel J
A.
Staff Continuity It was noted that during the last year the staff continuity has not been adequately maintained, and the fifty percent turnover in the technical staff has adversely effected the program.
Had the State been able to hire a replacement before the last reviewer / inspector left, the overlap period could have been used to orientate and train the new staff member. Also, although the only. technical person remaining in Carson City was the radiation control program director, no qualified coverage had been arranged in his absence.
III. Compliance A.
Status of Inspection Program The inspection tracking system in Nevada is maintained manually using a card file. During this review, random files were examined and checked against the information shown in the card file. Eight of the thirty-four records examined revealed errors or omissions in the card file. Also, Nevada now has five initial inspections overdue, four by more than fifty percent of the six month interval.
It was recommended.that a new tracking system be developed or the card file be corrected and updated by checking.it against each compliance and license file. We also recommended in the correspondence that the State develop a written rction plan with milestone dates to eliminate the backlog of overdue initial inspections.
B.
Responses to Incidents and Alleged Incidents The manager was unable to provide information on the number of reportable incidents that had occurred since the last review.
During the last review meeting, the reporting requirements described in the July 22, 1986 All Agreement State letter were pointed out to the manager and he was given a supplementary form to i
facilitate the review process. The manager had misplaced the information and et the time of the follow-up, the State was still not reviewing their incidents against the reporting requirements.
New copies of the documents were provided during this review.
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~1 C.
' Enforcement Procedures The reviewer examined the records of the Beatty. low-level waste disposal site and found evidence of 104 violations during the past i
year. One escalated enforcement action was taken in a serious case, and approximately ten telephone calls were made to various users requiring written response from them.
The remaining 90 percent had no enforcement action taken.
It was pointed out that this' inadequacy appears to be directly related to.the lack of a definitive-enforcement policy indicating the proper measures to be taken at each severity level.. In the exit interview, the State was asked to provide the reviewer a schedule for the task of establishing written severity levels by July 15, 1987.
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