ML20237E333

Forwards Integrated Matl Performance Evaluation Program (Impep) Review of New York Radiation Control Program During Period 980126-0424

ML20237E333
Person / Time
Issue date:	08/07/1998
From:	Lohaus P NRC OFFICE OF STATE PROGRAMS (OSP)
To:	Bangart R, Paperiello C, Thompson H NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS), NRC OFFICE OF STATE PROGRAMS (OSP), NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
References
NUDOCS 9808310149
Download: ML20237E333 (5)

Text

{{#Wiki_filter:e 5e:ti g k UNITED STATES ) fi 'j 2 NUCLEAR HEGULATORY COMMISSION 1 WASHINGTON, D.C. 20066-0001 g# August 7, 1998 MEMORANDUM TO: Hugh L. Thompson, Jr. Deputy Executive Director for Regulatory Programs Richard L. Bangart, Director Office of State Programs Carl J. Paperiello, Director Office of Nuclear Material Safety and Safeguards Karen D. Cyr, General Counsel Thomas T. Martin, Director Office for Analysis and Evaluation of Operational Data , /i

                                                                                               /j' FROM:                          Paul H. Lohaus, Deputy Director     I iQ Office of State Programs           V[M-                    /M

SUBJECT:

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) REVIEW OF THE NEW YORK RADIATION CONTROL PROGRAM This memorandum transmits to the Management Review Board (MRB) a proposed final report (Attachment 1) documenting the IMPEP review of the New York Radiation Control Program. The review of the New York program was conducted by an interoffice team during the period January 26-30,1998 for New York City Department of Health (NYCH), February 23-27,1998 for New York State Department of Labor (NYDL), March 30-April 3,1998 for New York State Department of Health (NYSH), and April 20-23,1998 for New York State Department of Environmental Conservation (NYDEC) with an exit meeting on May 12,1998 with all Departments as well as New York State Energy Research and Development staff. The team , issued a draft report to all New York programs on June 24,1998, for factual comment. Factual comments were sent by Neal L. Cohen, M.D., Commissioner, NYCH, in a letter dated July 15, 1998; Rita Aldrich, Principal Radiophysicist, NYDL, in a letter dated July 27,1998; Karim J( ' Rimawi, Director, Bureau of Environmental Radiation Protection, NYSH, in a letter dated July 20,1998; and Paul J. Merges, Ph.D., Director, Bureau of Pcsticides and Radiation, Division of Solid and Hazardous Materials, NYDEC, in a letter dated July 24,1998 (letters are contained in Attachment 2 to proposed final report). The review team found New York's performance with respect to each of the performance indicators to be mixed with 22 satisfactory,4 satisfactory with recommendations for improvement, and 1 unsatisfactory. Accordingly, the team recommends that the Management 01001b b3

                                          .. - ,e a 08. ]

pe uja- g, 9908310149 900807 PDR STPRO ESON u - _ - _ _ -- - -

i MRB Members 2 AUG - 7 1998 Review Board find the New York program to be adequate, but needs improvement, and compatible with NRC's program. The MRB meeting to consider the NYCH, NYSH, and NYDEC portions of the report is scheduled for Tuesday, August 18,1998, from 1:00 - 4:00 p.m. In Two White Flint North, Room T3B45. The MRB meeting to consider the NYDL portion of the report, as well as to finalize the overall finding for the New York program in its entirety is scheduled for September 1,1998, from 1:00 - 3:00 p.m. In One White Flint North, Room 03B4. In accordance with Management Directive 5.6, these meetings are open to the public. The agendas for the meetings are attached (Attachment 3). ' If you have any questions prior to the meeting, please contact me at (301) 415-2326 or Dennis Sollenberger at (301) 415-2819. Attachments: As stated cc: New York City Health New York State Labor New York State Health New York State DEC New York State ERDA 4 l

MRB Members 2 AUG - 7 $993 Review Board find the New York program to be adequate, but needs improvement, and compatible with NRC's program. The MRB meeting to consider the NYCH, NYSH, and NYDEC portions of the report is scheduled for Tuesday, August 18,1998, from 1:00 - 4:00 p.m. In Two White Flint North, Room T3B45. The MRB meeting to consider the NYDL portion of the report, as well as to f nalize the overall finding for the New York program in its entirety is scheduled for September 1,1998, from 1:00 - 3:00 p.m. In One White Filnt North, Room 03B4. In accordance with Management Directive 5.6, these meetings are open to the public. The agendas for the meetings are attached (Attachment 3). If you have any questions prior to the meeting, please contact me at (301) 415-2326 or Dennis Sollenberger at (301) 415-2819, Attachments: As stated cc: New York City Health New York State Labor New York State Health New York State DEC New York State ERDA Distribution: DIR RF DCD (SP01) SDroggitis PDR (YES_f.__ NO ) KSchneider DWhite, R1 MStephens, FI JCameron, Rlli JMcNees, Al DBroaddus, NMSS LCox, NC JCook, RIV AGrewe, TN GDeegan, NMSS DCool/FCombs, NMSS FCameron, OGC HNewsome, OGC RBores, SLO /RI RBlanton TO'Brien DOCUMENT NAME: G:\lMPEP\NY98MRB.5NPD / G:\NYlMP98.PFN *SEE PREVIOUS CONCURRENCE. l To recolve a copy of this document, Indicate in the box: "C'= Copy without attachment / enclosure 'E" = Copy Mth attachment / enclosure

                                                                                                                                       *N' = No copy OFFICE                        OSP           l             OSP             l            OSP:DD            l            OSP:D('I 7l                    l NAME                   LRakovan:nb                 DSollenberger                 PHLohaus                        RLBangar'W DATE                         08/06/98

• 08/06/98
• 08/07/98
• 08/01/98 OSP FILE CODE: SP-AG-20; SP-20-1; SP-AG-20-2; SP-AG-20-3; SP-AG-20-4

MRB Members 2

                                                                                                                                                      /

Review Board find the New York program to be adequate, but needs improvenfent, and

                                                                                                                                       /

compatible with NRC's program. The MRB meeting to consider the NYCH, NYSH, and NYDEC portionsp the report is _,

               "  scheduled for Tuesday, August 18,1998, from 1:00 - 4:00 p.m. In Jwo White Filnt North, Room T3B45. The MRB meeting to consider the NYDL portion of)he report, as well as to finalize the overall finding for the New York program in its er.tiretyis scheduled for September 1,1998, from 1:00 - 3:00 p.m. In One White Filnt North, Room 03B4. In accordance with Management Directive 5.6, these meetings are open to the p lic. The agendas for the meetings are attached (Attachment 2).

If you have any questions prior to the meeting, please contact me at (301) 415-2326 or Dennis Sollenberger at (301) 415-2819. Attachments: As stated cc: New York City Health

                                                                                 /

New York State Labor New York State Health New York State DEC / [' New York State ERDA Distribution: DIR RF DCD (SP01) SDroggitis PDR (YES_f_ NO ) KSchneider DWhite, RI MStephens, FI JCameron, Rlil JMcNees, Al DBroaddus, NMSS LCox, NC JCook, RIV AGrewe, TN GDeegan, NMSS DCool/FCombs', NMSS FCameron, OGC HNewsome,'OGC RBores, SLO /RI RBianton TO'Bridn DOCUMENT NAME: G:\lMPEP\NY98MRB.WPD / G:\NYlMP98.PFN *SEE PREVIOUS CONCURRENCE. To receive a copy of this document, indicate in the box: "C"- Copy without attachment / enclosure *E" =C$>py with attachment / enclosure "N"- No copy OFFICE OSP l OSP l OSP:DD) / OSP:D l NAME LRakovan:nb DSollenbeoer PHLohaus ' \ RLBangart I DATE 08/06/98 * , 08/06/98

• 08/ //98 08/ /98 OSP FILE CODE: SP-AG-20; SP-20-1; SP-AG-20-2; SP-AG-20-3; SP-AG-20-4

MRB Members 2 Review Board find the New York program to be adequate, but needs improvement, and compatible with NRC's program. j

                                                                                                                                       /

The MRB meeting to consider the NYCH, NYSH, and NYDEC portions of thefeport is scheduled for Tuesday, August 18,1998, from 1:00 - 4:00 p.m. In Two White Flint North, Room T3B45. The MRB meeting to consider the NYDL portion of the repo'rt, as well as to finalize the overall finding for the New York program in its entirety is sche'duled for September 1,1998, from 1:00 - 3:00 p.m. In One White Flint North, Room 03B4. In accordance with Management Directive 5.6, these meetings are open to the public. . de agendas for the meetings are attached (Attachment 2). If you have any questions prior to the meeting, please contact me at (301) 415-2326 or Dennis Sollenberger at (301) 415-2819. Attachments: As stated cc: New York City Health New York State Labor [ New York State Health New York State DEC New York SERDA Distribution: DIR RF DCD (SP01) SDroggitis / PDR (YES_f_ NO ) KSchneider / DWhite, RI MStephens, FI JCameron, Rlli JMcNees, Al DBroaddus, NMSS LCox, NC / JCook, RIV AGrewe, TN GDeegan, NMSS DCool/FCombs, NMSS FCameron, OGC' HNewsome, OGC RBores, SLO /RI RBlanton / TO'Brien/ DOCUMENT NAME: G:\lMPEP\NY98MRD.WPD / G:\NYlMP98.PFN To receive a copy of this document, Indicate in the box: *C" = Copy without attachment / enclosure 'E' = Copy with attachment / enclosure "N" = No copy OFFICE OSP /9 OSFl\AK - OSP:DD l OSP:D l l NAME LRakovan:nb T DSollenbdrger PHLohaus RLBangart gTE 08/ W/98 08/I /98 08/ /98 08/ /98 OSP FILE CODE: SP-AG-20; SP-20-1; SP-AG-20-2; SP-AG-20-3; SP-AG-20-4

l l l l INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM REVIEW OF NEW YORK AGREEMENT STATE PROGRAM January 26 - April 24,1998 PROPOSED FINAL REPORT l U.S. Nuclear Regulatory Commission l t 4 4 fr 7 i 5 0 i y' W 7 0 P/ f '

New York Proposed Final Report Page 1

1.0 INTRODUCTION

This report preser>ts the results of the review of the New York radiation control program. The New York program is divided into four independent programs which were reviewed separately with the results of those reviews integrated into this report. The reviews were conducted during the period January 26 - April 24,1998, by four separate review teams comprised of technical staff members from the Nuclear Regulatory Commission (NRC) and the Agreement States of Alabama, Florida, North Carolina, and Tennessee. Team members are identified in Appendix A. The review was conducted in accordance with the " Implementation of the integrated Materials Performance Evaluation Program and Rescission of a Final General Statement of Policy," published in the Federal Reaister on October 16,1997, and the November 25,1997, revised NRC Management Directive 5.6, " Integrated Materials Performance Evaluation Program (IUPEP)." Preliminary results of the review, which covered the period March 31,1995 to April 24,1998, were discussed with New York management on May 12,1998. [A paragraph on the results of the MRB meeting will be included here in the final report.] The New York Agreement State program is administered by: (1) the New York City Department of Health, Bureau of Radiological Health (NYCH), which has jurisdiction over medical, academic, and research uses within the five boroughs of New York City; (2) the New York State Department of Labor, Radiological Health Unit (NYDL), which has jurisdiction over commercial and industrial uses of radioactive materials, including the possession of radioactive material to be disposed of at a commercial disposal site; (3) the New York State Department of Health (NYSH), which has jurisdiction over medical, academic, and research uses of radioactive materials except in New York City; and (4) the New York State Department of Environmental Conservation, Bureau of Pesticides and Radiation (NYDEC), which has jurisdiction over 4 discharges of radioactive material to the environment, including releases to the air and water, l and the disposal of radioactive wastes in the ground. Organization charts for the four programs I are included as Appendix B. At the time of the review, the combined New York programs l regulated approximately 1500 specific licenses, including all types of major licensees except for

 , uranium mill tailings.

The review focused on the materials orogram as it is carried out under the Section 274b (of the Atomic Energy Act of 1954, as ameno3d) Agreement between the NRC and the State of New York. In preparation for the review, a questionnaire addressing the common and non-common performance indicators was sent to: (1) NYCH, November 21,1997; (2) NYDL, December 15, 1997; (3) NYSH, February 6,1998; and (4) NYDEC, February 12,1998. Each New York l program provided a response to the questionnaire on: (1) NYCH, January 14,1998; (2) NYDL, l January 27,1998; (3) NYSH, March 13,1998; and (4) NYDEC, March 27,1998. During the

review, discussions with each program's staff resulted in the responses being further j developed. A copy of these final responses are included in Appendix G to this report.

The teams' general approach for conduct of these reviews consisted of: (1) examination of New York programs' responses to the questionnaire; (2) review of applicable New York State and City statutes and regulations; (3) analysis of quantitative information from the radiation control programs' licensing and inspection data bases; (4) technical review of selected licensing . l l l

i i i New York Proposed Final Report Page 2 and inspection actions; (5) field accompaniments of at least one inspector from each program, and (6) interviews with staff and management to answer questions or clarify issues. The teams evaluated the information that they gathered against the IMPEP performance criteria for each , common and non-common performance indicator as applicable to each program and made a i preliminary assessment of each radiation control program's performance for each indicator. Section 2 below discusses each programs'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 dist .;sses results of the applicable non-common performance indicators, and Section 5 summarizes the review team's findings and recommendatiores. Recommendations made by the team are comments that relate directly to each program's performance. A response is requested from each program to all recommendations in the final report. Suggestions are comments that the team beUeves could enhance each of the individual programs. Each program is requested 4 ponsider suggestions, but no response is requested.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS During the previous routine review, which concluded on March 30,1995, ten recommendations l were made and the results were transmitted to the respective Secretaries / Commissioners of the three New York State agencies and the New York City agency on March 18,1996. The team's review of the current status of these recommendations is as follows: f NEW YORK CITY DEPARTMENT OF HEALTH (NYCH) (1) Status and Compatibility of Regulations. NYCH needed to revise its OM rule definitions by December 6,1996 in order to maintain compatibility with the NRC. [ Current Status: The NRC reinitiated an evaluation of whether the OM rule should be used as a basis for the determination of an Agreement State program's compatibility. It was decided that pending the completion of the re-evaluation, the absence of a compatible QM rule would not be used as a basis for withholding of a finding for compatibility. The compatibility category of the QM rule under the new Commission policy on Adequacy and Compatibility, which became effective on September 6,1997, l has been set as "D" with paragraphs (a), (b), and (c) of the rule identified as having provisions important to Health and Safety. Based on the above, and because Part 35 is being amended in its entirety, the team determined that this recommendation should be l closed. (2) Inspection Procedures. It was recommended that NYCH develop a formal written policy on conducting unannounced iraspections. l l Current Status: As part of the review of the indicator " Technical Quality of Inspections" (see Section 3.2.1), the team examined NYCH's inspection procedures manual. In Section 5.C.3.a. of the manual, there is a discussion regarding NYCH's policy regarding announced versus unannounced inspections. This section of the manual clearly states it is the general policy of NYCH to perform toutine inspections on an unannounced

New York Proposed Final Report Page 3 j basis. The review team also determined that NYCH inspectors were following the City's i policy regarding the conduct of routine inspections on an unannounced basis. Based on these findings, the team determined that this recommendation should be closed. NEW YORK STATE DEPARTMENT OF LABOR (NYDL) (1) Status and Compatibility of Regulations. It was recommended during the last review

                                                                                                                                        ]

that NYDL reconsider its decision not to adopt the amendments to 10 CFR Part 36, 1

                                " Licenses and Radiation Safety Requirements for irradiators" that became effective on July 1,1993.                                                                                             )

Current Status: During this review, the team determined that NYDL has prepared a ) pekage of regulations, including those for Part 36, which is currently in legal review I (see Section 4.1.2.2). As part of the team's review of the indicators " Technical Quality of Licensing" and " Technical Quality of Inspections," the team noted that NYDL was implementing the requirements of Part 36 through the use of checklists during the licensing and inspection of the only commercial irradiator facility under NYDL's 4 jurisdiction. Use of the checklist ensures that the licensee has committed to all the requirements in 10 CFR Part 36 even though not required to by regulation. The 4 licensee's commitments are incorporated into the licenses. Based on the team's finding l that NYDL is implementing Part 36 through licensing and inspection unti! the adoption of l the rule, the team determined that this recommendation should be closed. l NEW YORK STATE DEPARTMENT OF HEALTH (NYSH) (1) Status and Compatibility of Regulations.

a. It was recommended that NYSH adopt the Decommissioning Rule as soon as possible to maintain compatibility with the NRC.

Current Status: The NYSH has implemented the rule through license conditions. The team reviewed the list of licensees that are subject to the financial assurance requirements and reviewed the application of these license conditions. The team found that the licensees requiring financial assurance either had license conditions in place or had been issued letters requesting additional information prior to issuance of license conditions. The NYSH also implements other decommissioning provisions through regulations and other decommissioning license conditions (see Section 4.1.2.2). The team considers this approach to implementing the financial assurance and decommissioning requirements to be acceptable, and determined that this l. recommendation should be closed, i i

b. The NYSH needed to revise its OM rule definitions by December 6,1996 in order

to maintain compatibility with the NRC.

Current Status: The NRC reinitiated an evaluation of whether the QM rule should be used as a basis for the determination of an Agreement State program's compatibility. It was decided that, pending the completion of the re-evaluation, the absence of a compatible OM rule would not be used as a basis for withholding of a finding for l

l l I ( New York Proposed Final Report Page 4 i compatibility. The compatibility category of the OM rule under the new Commission policy on Adequacy and Compatibility, which became effective on September 6,1997, t ' has been set as "D" with paragraphs (a), (b), and (c) of the rule identified as having provisions important to Health and Safety. Based on the above, and because Part 35 is being amenaed in its entirety, the team determined that this recommendation should be closed.

c. The NYSH should perform a review of its licensees based on the requirements of the emergency planning (EP) rule, document the review, and if any licensees meet the requirements of the rule, incorporate applicable section of the rule into licenses until the rule can be promulgated.

l Current Status: The team reviewed NYSH's evaluation of its licensees against the requirements of the EP rule and concurred with NYSH's conclusion that the possession limits of alllicensees were below that requiring an EP plan. The team determined that this recommendation should be closed. (2) Responses to incidents and Allegations. It was recommended that NYSH perform timely and on-site investigations to independently assess allegations based on health and safety considerations; develop criteria to determine which allegations can be referred to licensees; assess licensee's evaluation of allegations; and maintain complete files. Current Status: During the review of the common indicator " Response to incidents and Allegations" (see Section 3.5.3), the team evaluated NYSH's response to these recommendations . Based on the findings detailed in Section 3.5.3 of this report, the team determined that this recommendation should be closed. NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION (NYDEC) (1) Technical Quality of Licensing Actions. It was recommended that NYDEC expeditiously complete the inspection of NYCH licensees to determine if any where subject to NYDEC permitting requirements. Current Status: The team evaluated NYDEC's response to this recommendation during its review of the common indicators " Technical Quality of Licensing" and " Technical Quality of Inspections". The team concluded that NYDEC staff took prompt action to identify those NYCH licensees requiring NYDEC permits. Periodic memoranda to NYDEC management documenting the progress of this evaluation were prepared by staff. Based on the team's findings during this review, the team determined that this recommendation should be closed. 1 3.0 COMMON PERFORMANCE INDICATORS The IMPEP identifies five common performance indicators to be used in reviewing both NRC Regional and Agreement State programs. These indicators are: (1) Status of Materials Inspection Program; (2) Technical Quality of Inspections; (3) Technical Staffing and Training; 1

New York Proposed Final Report Page 5 (4) Technical Quality of Licensing Actions; and (5) Response to incidents and Allegations. 3.1 Status of Materials inspection Proaram The team focused on four factors in reviewing this indicator: inspection frequency, overdue inspections, initial inspection of new licenses, and timely dispatch of inspection findings to licensees. This evaluation is based on the individual programs' questionnaire responses relative to this indicator, data gathered independently from each program's licensing and inspection data tracking system, the examination of completed licensing and inspection casework, and interviews with managers and staff. 3.1.1 New York City Department of Health (NYCH)- Status of Materials inspection Program NYCH's inspection priority system closely matches NRC's system. The team's assessment of the current inspection priorities verified that inspection frequencies for various types or groups of licensees are equivalent to or more frequent than those listed in NRC Inspection Manual 1 Chapter 2800 (IMC 2800) frequency schedule. In reviewing NYCH's priority schedule, the team noted that NYCH continues to have priority categories which are inspected more frequently than those of the NRC. The NYCH has only five categories of licensees, with a total of three priorities. The NYCH priorities are either Priority 1 for once every 12 months, Priority 2 for once every 24 months, or Priority 3 for once every 36 months. In their response to the questionnaire, NYCH indicated that as of January 1998, six licenses identified as core inspections in IMC 2800 were overdue by more than 25 percent of NRC's frequency. The NYCH's current inspection schedule identified 21 Priority 1 licenses; however, the team discovered that the software-based system did not identify approximately 19 additional Priority 1 licenses for inspection purposes. Tracking of those, five were overdue at the time of the review and were not scheduled for inspection. Overall, NYCH's inspection scheduling j system tracked only 243 of the 440 active licenses. The team estimates that NYCH would need 1 to perform approximately 220 inspections each year in order to keep pace with its due j inspections (the estimate assumes that all Priority 1 licenses, one-half of all Priority 2 hcenses,  ; and one-third of all Priority 3 licenses were inspected each year). Each year of the review 1 period, NYCH budgeted approximately 266 inspections for completion. In fiscal years (July to l June) 1995,1996 and 1997, NYCH completed 127,263, and 154 inspections, respectively. Due to difficulties in obtaining information from NYCH's inspection tracking system, the true status of the materials inspection program could not be accurately assessed. Since there was not an adequate database to evaluate the status of inspections, the team did a sampling by examining the inspection histories of 25 out of the 40 total NYCH Priority 1 licenses. Since the last rev'ry,33 inspections of those licenses have been completed. Of those inspections (33 percent),19 inspections (58 percent) were overdue based on NYCH's

priotity at the time that the NYCH conducted them; however, only 11 inspections were overdue (33 percent) based on IMC 2800 priorities (8 of the 19 were teletherapy). The review team recommends that the NYCH correct the software anomalies that limit NYCH's ability to effectively track licenses for inspection, set and adhere to yearly inspection goals, and communicate NYCH management's expectations with regard to inspection goals, such that NYCH is able to eliminate all overdue inspections.

l I i

l l l l , New York Proposed Final Report Page 6 i With respect to initial inspections of new licenses, the team reviewed the inspection tracking system and found that initial inspections were usually entered into the system together with existing licenses. The NYCH's inspection supervisor assigns all inspections, and is able to identify new licenses by the license number. NYCH currently has a six month inspection frequency for all initial inspections, which is consistent with NRC's initial inspection requirement I in IMC 2800. From the review of the inspection database and examination of license files, NYCH was not consistently implementing its six month initial inspection policy. The team examined 22 new licenses issued since February 1995. Of those new licenses, NYCH conducted initial inspections within six months of issuance for nine licenses (41%). The inspections that did not meet the six month inspection goal ranged from 8 to 22 months after the licenses were issued. The review team recommends that all initial inspections of licensees be performed within six months of license issuance or within six months of the licensee's receipt of material and commencement of operations, consistent with IMC 2800 and NYCH policy. j The timeliness of the issuance of inspection findings was also evaluated during the inspection file review. Of the 15 files examined, in 11 cases the inspection correspondence was sent to the licensee within 30 days of the inspection date. Correspondence from three of the remaining inspections was sent between 32 and 39 days. In the fourth case, Brooklyn Hospital Center, License No. 91-2924-01, NYCH completed its inspection on June 21,1996, but did not transmit i the inspection findings until November 1,1996 (134 days). Based on the sampling done by the team, it appears that NYCH is not conducting its inspection program for core licensees in accordance with IMC 2800. The lack of an adequate tracking system significantly contributed to this finding which was presented at the exit meeting with NYCH on January 30,1998. In response to the teams's findings presented at the exit meeting on January 30,1998, Mr. Kenneth R. Daniel, Jr., Deputy Director, Bureau of Radiological Health, Department of Health, submitted a letter dated February 17,1998 (Attachment 1), providing additional information regarding this indicator. The letter indicated that the software anomaly had been corrected and that NYCH was able to effectively track all of its licenses for inspection. The team's review of the inspection due list for the following 12 months ending in February 1999 appeared to indicate that all licenses were now captured in the scheduling system. However, the team could not reconcile the inspection dates in the updated list with the last known inspection dates identified during the review. Through further discussions with NYCH, some of these discrepancies have been cleared up; however, the database needs additional quality control that will occur over time with the use of the database. The NYCH's February 17,1998, letter did not address the team's findings with regard to the conduct of initial inspections. The NYCH will need to continue to address the tracking, the timely scheduling and completion of inspections for all current licenses, and initial inspections for new licenses. Based on the IMPEP evaluation criteria, the review team recommends that NYCH's performance with respect to the indicator, Status of the Materials Inspection Program, be found unsatisfactory. 3.1.2 New York State Department of Labor (NYDL) - Status Materials of inspection Program The t'eam's review verified that NYDL's inspection priorities aie at least as frequent as similar

_ _ _ _ _ _ _ _ _ _ _ _ ----~ ' -_-- k i

                                                                                                               \

i New York Proposed Final Report Page 7 license types or groups listed in NRC IMC 2800. Of particular note is the greater number of inspections completed by NYDL choosing to designate its 110 Moisture / Density Gauge licenses as inspection Priority 2, while the NRC frequency for a similar licensee is Priority 5. { l Designating such a large number of licensees under such a high priority requires NYDL to perform more frequent inspections of such licensees, while allowing some flexibility in inspection frequency in comparison to IMC 2800. Similar to IMC 2800, NYDL management has the ability to extend the interval between inspections for licensees on the basis of good licensee performance. In 1997, NYDL extended f 1 37 license inspections by approximately one year due to good compliance histories. As noted in their response to the questionnaire, no routine inspections completed by NYDL during the review period were overdue by more than 25% of the scheduled frequency set out in IMC 2800. In June 1994, the NYDL reciprocity limit was changed to thirty days in a calendar year. As a result, companies that perform work in New York with any frequency are reqJred to apply for and receive a license from NYDL. This resulted in the issuance of licenses to 47 out-of-state companies. These licensees are scheduled for inspections at the same priority interval as in-state licensees. Fifty four companies requested reciprocity during 1997 and 10 were inspected while performing licensed activities in the State. The NYDL does not keep records of the types or the priorities of reciprocity licensees. Thus, NYDL does not schedule reciprocity inspections consistent with a priority schedule. It is the decision of NYDL management to focus resources on NYDL licensee inspections, and thus complete reciprocity inspections only as resources allow. The team also examined NYDL's performance in completing initialinspections of new licensees, and noted that in general, initial inspections are not always completed within six months of the commencement of licensed activities. The team sampled 10 newly issued licenses during the review period, and found that three received an initial inspection within the six month guideline. Of the remaining seven, five of them received an initialinspection within seven months of the commencement of licensed activities. The two remaining initial inspections were performed 56 days and 314 days beyond the six month guideline. The review team recommends that NYDL perform initial inspections of licensees within six months of the licensees' receipt of licensed material, or commencement of licensed activities. Contrary to IMC 2800, NYDL does not complete an initial inspection of a licensee within one year of the issuance of the license if the licensee does not receive licensed material. If no material is received by a licensee within six months of license issuance, NYDL begins correspondence with the licensee to ensure knowledge of the receipt of licensed material. At the same time, NYDL attempts to persuade the licenses to cancel their license if the licensee believes no radioactive material will be received. The team recognizes this policy as an Mceptable alternative to the guidelines established in IMC 2800. The timely dispatch of inspection findings was also evaluated during the inspection file review. Of 20 inspection findings examined, the correspondence for 17 inspections was sent to the licensee within 30 days of the inspection date. For the other two inspections, the

New York Proposed Final Report Page 8 correspondence was sent to the licensee from 1 and 35 days beyond the 30 day guideline. The team does not believe that the issuance of inspection findings is a problem for this program. 1 Based on the IMPEP evaluation criteria, the review team recommends that NYDL's I performance with respect to the indicator, Status of Materials inspection Program, be found I satisfactory. l 3.1.3 New York State Department of Health (NYSH)- Status of Materials inspection Program The team's review of NYSH's inspection priorities verified that NYSH'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 IMC 2800 frequency schedule. Fourteen program codes are scheduled for more frequent inspections by NYSH than similar NRC licensees. With respect to initialinspections of new licenses, the team evaluated the inspection tracking data system and verified that initial inspections were entered into the computerized tracking system together with existing licenses. A review of the inspection tracking system showed that initial inspections are differentiated from routine inspections by including the issuance date of the license in bold in the column listing the last inspection. Although new licenses are clearly marked in the tracking system and scheduled within six months of issuance, a significant number (12 of 27) of the initialinspections were not completed within six months as suggested by IMC 2800. A review of the database identified 67 new licenses issued since the 1995 review of NYSH. The team selected 27 of these licenses in which the initialinspection was due. Of these 27,11 licenses were inspected within the six month window, four were inspected one month late, seven were inspected two to six months late, and five were inspected over six months late. The team determined that NYSH policy is that initial inspections are to be scheduled for inspection within six months of issuance. The NYSH management assigns inspections to inspectors twice a year and monitors the progress of inspections completed on a monthly basis. However, , inspectors are not required by management to complete new inspections within six months. The review team recommends that NYSH modify its inspection program to ensure that initial inspections are performed within six months of the licensee's receipt of licensed material, within six months after commencement of licensed activities, or within one year of license issuance, whichever comes first, consistent with IMC 2800. In their response to the questionnaire, NYSH indicated that three inspections were overdue by more than 25% of the scheduled frequency. At the time of the on-site review, these inspections had been performed. The timeliness of inspection of core licensees at regular intervals in accordance with IMC 2800 was evaluated during the inspection file review. The team selected 31 inspections for review and determined that three of the inspections were performed at intervals that exceeded IMC 2800 inspection frequencies by more than 25% These three l Inspections were overdue by one, two and three months when next inspected. l The timeliness of the issuance of inspection findings was also evaluated during the inspection file review. Of 16 inspection findings examined, the correspondence for all of these inspections was sent to the licensee within 30 days of the inspection date. This total included five escalated 1

New York Proposed Final Report Page 9 enforcement actions that required more documentation to be prepared and reviewed by NYSH staff and management. I Based on the IMPEP evaluation criteria, the review team recommends that NYSH's j performance with respect to the indicator, Status of the Materials inspection Program, be found satisfactory with recommendations for improvement. j ( 3.1.4 New York State Department of Conservation (NYDEC) - Status of Materials Inspection Program The team's review of NYDEC's inspection priorities showed that inspection frequencies are i based primarily on the magnitude of the permi'ted dis::harge of radioactive material to the environment (i.e., the maximum average annual concentration of the effluent that may be discharged to the environment) instead of IMC 2800. The inspection priorities range from one to four years. Based on the limited scope of NYDEC's regulatory oversight for facilities (i.e., discharges to environment only) and the priorities of the inspections, the team concluded that these frequencies were adequate to protect public health and safety and to assure permittee (licensee) compliance. In their response to the questionnaire, NYDEC indicated that it had no overdue inspections. The team confirmed this by reviewing the current permittee list which indicates the last inspection of the permittee and by file review. Since the NYDEC only regulates environmental discharges, reciprocity does not apply to this portion of the New York program. It was noticed by the team that the procedures for inspection priorities utilized by NYDEC states that "new permittees will continue to receive pre-permit inspection whenever possible, and will always receive an initialinspection within the first year of operation." The IMC 2800 states that the initialinspection be done within six months. The NYDEC has been inspecting almost all ! initial permittees within six months and performs a pre-permit inspection of the facilities. In l- order to make NYDEC's initial inspection policy consistent with NRC policy and practice, the l Program Director stated that the wording of the inspection priority memo would be revised to require an initialinspection within six months instead of within one year, in response to the draft IMPEP report, NYDEC indicated that the inspection priority memo has been revised to require initial inspections within six months. ] l For initial inspection of new licensees, the team reviewed the inspection schedules for the ! review period. For the seven new permits that were issued, inspections were conducted at six ! facilities within six months, and the other was done at eight months. In addition to the initial inspection, the permittees also receive a pre-permitting inspection. i During inspection file reviews, the team evaluated NYDEC's timeliness in issuing inspection findings. The team found that inspection findings were generally sent well within the 30 day

  . time frame with two of ten inspections exceeding the 30 day guideline (one at 49 days and one at 335 days).

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

New York Proposed Final Report Page 10 3.2 Technical Quality of Inspections 3.2.1 New York City Department of Health (NYCH) - Technical Quality of Inspections The team reviewed the inspection reports, enforcement documentation, and inspection field notes and interviewed inspectors for 15 materials inspections conducted during the review period. The 15 inspections selected for review included at least one inspection for each of the j NYCH's inspectors and two team inspections of major broad scope licenses. The inspections included four medical broad scope licenses, two academic broad scope licenses, two teletherapy licenses, five limited medical use licenses, and two private practice physicians. 1 Appendix C-1 lists the inspection files reviewed in depth with case-specific comments. Of the 15 inspections reviewed, seven resulted in no violations being identified. For the remaining eight, violations were identified in transmittal letters to licensees. Of those violations,13 were not described in the field notes documenting the results of the inspections. In a majority of the cases reviewed, the inspections identified technically valid violations; however, neither the techniques employed nor the manner in which inspections were j documented provided many insights into the performance of NYCH's licensees, other than the j status of the licensees' compliance with NYCH regulations. The review team recommends that NYCH inspectors follow the guidance in the NYCH inspection procedure manual which includes l the information necessary for properly documenting violations. In NYCH's letter dated February j 17,1998, the NYCH respond 6d to this recommendation by stating that a copy of the student manual for the inspecting for Performance course has been obtained and they plan to conduct an in-house training course in the near future for their materials inspectors. For 14 of the violations issued in the inspections reviewed, the licensees provided information in their responses that appeared to dispute the violation. When a licensee disputes a Notice of Violation (NOV), the licensee must take the dispute to the Tribunal. If the licensee does not appear, the NOV stands and the fine must be paid. In none of these cases, did NYCH's files indicate whether the violations were upheld or retracted. The team could not determine the status of these violations and their final disposition. The review team suggests that NYCH establish a policy that the results of all Tribunal's be placed in the appropriate inspection files. The NYCH has a polic/ of performing annual supervisory accompaniments of inspectors. In response to the questionnaire, NYCH reported that each inspector was accompanied by the supervisor at least once a year during the review period. Interviews of NYCH inspectors determined that the supervisor accompanies the inspectors more frequently, but in those other occasions, the supervisor acted as the lead inspector. Following those inspections, the supervisor provided feedback to the inspector. Four inspection accompaniments identified in Appendix C were performed by two team members. During the week of October 28 - 31,1997, a team member performed accompaniments of three inspectors on an inspection of an academic broad scope licensee. A ! second team member performed accompaniments of four inspectors during an inspection of a j medical broad scope licensee that included the source loading of a gamma knife unit, during the week of December 1 - 5,1997. Two additional incpection accompaniments were performed l on January 20 and 21,1998 with each of newest inspectors in the program. These k i L

New York Proposed Final Report Page 11 l accompaniments were performed at licensces that these inspectors were qualified to independently inspect. l The team determined that the performances of the inspectors during team inspections were compliance, rather than performance, oriented. For example, during the December 1997 inspection exit meeting attended by the team member, the reviewer wes not able to determine l whether the inspection findings discussed were violations, concerns, or recommendations. The NYCH's exit did not reference specific regulatory requirements that were violated, or distinguish poor practices from violations, in a few cases, the inspectors appeared to impose their , personal preference in the conduct of some operations rather than limit themceives to the l enforcement of NYCH's regulations. The review team recommends that .NYCH inspectors follow the guidance in NYCH inspection procedure manual which emphasizes the use of j performance-based inspection techniques rather than compliance-based techniques and provide training to its inspectors through NRC's inspecting for Performance Materials Course or similar course. During the inspection accompaniments performed in January 1998, the two inspectors demonstrated appropriate inspection skills and knowledge of the regulations. The inspectors were thorough in their review of the licensee's radiation safety program. Inspection techniques were observed to be generally performance oriented. These inspections were adequate to assess the licensee's radiological health and safety performance. The team noted that the NYCH has an adequate number of portable radiation detection I instruments for use during routine inspections and response to incidents and emergencies. l The NYCH uses an outside vendor for instrument service and calibration. The portable instruments used during the inspector accompaniments were operational and calibrated. Based on the IMPEP evaluation criteria, the review team recommends that the NYCH's performance with respect to the indicator, Technical Quality of Inspections, be found satisfactory with recommendations for improvement. 3.2.2 New York State Department of Labor (NYDL) - Technical Quality of Inspections The team reviewed the inspection reports, enforcement documentation, and the data base information for 21 materials inspections conducted during the review period. The casework included NYDL's three materials inspectors and covered a sampling of different license types as follows: two broad scope commercial; one research and development; three portable gauges; two fixed gauges; three industrial radiography; three nuclear pharmacies; two service; one manufacturer; one waste broker; one gas chromatograph; one storage; and one commercialirradiator. Appendix C-2 provides a ht of the inspection cases reviewed in-depth with case-specific comments. The inspection procedures and techniques utilized by NYDL were reviewed and determined to i be generally consistent with the inspection guidance provided in IMC 2800. Specific guidance for certain classes of licensees or facilities are also included in the procedures manual maintained in th9 Manhattan office where al' inspectors are based. The team reviewed inspection reports and found them to be comparable with the types of information and data

I New York Proposed Final Report Page 12 collected under NRC Inspection Procedure 87100. Inspections are generally performed on an announced basis. The inspection field notes provided excellent, consistent documentation of inspection findings. ' The NYDL uses supplementary field notes for different types of inspections covering the areas of manufacturing (quality assurance), industrial radiography, fixed gauge, and gas chromatograph licenses, inspection reports were reviewed 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 reports were also checked to determine if the repo,-ts adequately documented operations observed, interview of workers, independent measurements, status of previous noncompliance items, substantiation of all items of noncompliance, and the substance of discussions during exit interviews with management. The reviewer completes an inspection review form which becomes part of the inspection file. Overall, the team found that peer review of the inspection documentation and correspondence resulted in their consistent excellent quality. The review team notea a good practice !n that NYDL's inspection field riotes and inspection correspondence are peer reviewed l by one of the senior inspectors to ensure consistency, thoroughness, and quality of reports. Routine enforcement letters were drafted and issued to licensees by the inspector. When the licensee responds to a NOV, the inspector evaluates the licensee's submittal and prepares a response. Once the inspector determines that the licensee has satisfactorily responded to the NOV and has acknowledged their response, the inspection field notes and correspondence is given to another senior inspector for review. The inspectors told the team that they discuss any atypical issues regarding the inspection findings with the program manager prior to issuing the inspection findings to the licensee. When significant commitments are made in response to NOVs, NYDL staff performed a follow-up inspection to confirm that the commitments made in the licensee's correspondence were implemented. For the casework reviewed, documented inspection findings led to proper regulatory actions and appropriate enforcement. The program manager stated that escalated enforcement action beyond the issuance of NOVs was limited to the issuance of orders. The NYDL held four enforcement conferences which resulted in the issuance of orders. The team discussed with NYDL management at the exit meeting that the incorporation of a wider range of enforcement tools into the enforcement policy such as severity levels and civil penalties would provide NYDL with alternative methods to emphasize the importance of prompt, comprehensive identification and correction of conditions important to safety. l One inspector accompaniment identified in Appendix C-2 was performed by a team member on December 11 and 12,1997 at an industrial radiography storage location and a temporary job site of the licensee. The remaining two inspectors were accompanied during the previous review. During the accompaniment, the inspector demonstrated appropriate inspection skills and knowledge of the regulations. The inspector was well prepared and thorough in the review of the licensee's radiation safety program and performance of licensed activities in the public i domain. Inspection techniques were observed to be performance oriented, and the technical performance of the inspector was at a high level. The inspection was adequate to assess the licensee's radiological health ano safety pedormance. l

3 l l New York Proposed Final Report Page 13 The NYDL program manager performs annual supervisory accompaniments of all inspectors and documents each evaluation on an inspection accompaniment form. The team noted that NYDL has an ample number of portable radiation detection instruments for 3 use during routine inspections and response to incidents and emergencies. Instrument j calibration is performed by NYDL inspectors at the Manhattan office using NIST traceable j alpha, beta, and gamma sources. The NYDL procedures also include laboratory and instrument calibration procedures. The NYDL uses an outside vendor for instrument service. The portable instruments used during the inspector accompaniment was observed to be 1 operational and calibrated. The instrument storage area is co-located with the radiation  ! counting laboratory and storage area for emergency response kits. A sampling of portable instruments maintained were found to be within calibration. The NYDL's radiation counting 4 laboratory includes a low background alpha and beta proportional counter, liquid scintillation counter, and a sodium lodide detector coupled to a multichannel analyzer. The program's germanium lithium detector is no longer functional and has not yet been replaced. The inspection staff is responsible for analyzing their own samples and maintaining the laboratory counting equipment. I Based on the IMPEP evaluation criteria, the review team recommends that NYDL's performance with respect to the indicator, Technical Quality of Inspections, be found { j satisfactory. l l 3.2.3 New York State Department of Health (NYSH) - Technical Quality of Inspections The team reviewed the inspection reports, enforcement documentation, and inspection field I notes and interviewed inspectors for 16 materials inspections conducted during the review I period. The casework included 11 of the NYSH's materials license inspectors, and covered  : inspections of various types including medical, academic, teletherapy and pharmacy. Appendix C-3 lists the inspection files reviewed in depth with case-specific comments. During the week of February 23,1998, a team member performed accompaniments of four NYSH inspectors on separate inspections of licensed facilities. During the 1995 review of NYSH, there was a preliminary recommendation to modify the inspection report format to include sections to identify how previous items of noncompliance were addressed by the licensee and to document findings presented to licensee management during exit meetings. The NYSH has modified its field note format to include both of these topics. The NYSH now documents whether or not previous items of noncompliance were resolved and there is now an area to document the exit meeting and subsequent discussions. During this review, the team noted that there was a lack of documentation of tne substance of discussions at the exit meetings. The review team suggests that the NYSH's inspection documentation of exit meetings should contain substantive discussions of issues with the Radiation Safety Officer (RSO) and/or licensee management. l The inspection procedures and techniques utilized by NYSH were reviewed and determined to be generally consistent with the inspection guidance provided in IMC 2800. The team reviewed  ! inspection reports and found them to be comparable with the types of information and data collected tnder NRC Inspection Procedure 87100 and NYSH procedures. Thirteen of the 16 inspections reviewed were performed on an unannounced basis. 9

l 1 I New York Proposed Final Report Page 14 The inspection field notes provided good, consistent documentation of inspection findings. The NYSH uses the same field note format " Inspection of Radionuclides Installations" for different  ; types of inspections covering the areas of academic, research and development, medical, and . teletherapy licenses. Inspection reports were reviewed 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 reports were also checked to determine if the reports adequately documented operations observed, interview of l workers, independent measurements, status of previous noncompliance items, substantiation of allitems of noncompliance, and the substance of discussions during exit interviews with management. Although it is evident that some workers were interviewed, it is rarely documented that ancillary personnel, authorized users, or the RSO were involved in this process. Of the 16 inspections reviewed, not one documented interviewing ancillary personnel. The review team suggests that NYSH incorporate a field for documentation of interviewing ancillary personnel, authorized users, technicians, and RSOs into their field notes. To assure consistency and quality of reports, it was evident the Radioactive Material Section Field Supervisor and Section Chief provided thorough reviews but until recently did not document this review. Six out of the 16 inspections reviewed did not have documented supervisor review. Also, the inspection correspondence and field notes are not signed by supervision. Only the inspector's signature is available on this paperwork. The NYSH has initiated a new process to have the field supervisor and/or the section chief sign a separate memo sized paper documenting their review. This piece of paper is maintained in the inspection file folder. Overall, the team found that the inspection reports showed excellent quality and attention to detail. Reports contained no major discrepancies from standard practices or established NYSH procedures. When the licensee responded to a NOV, the response was given to the inspector to evaluate the licensee's response and, in each case, a response was sent to the licensee within 30 days of receipt. The team, as noted previously, identified a concern related to the documentation of supervisory review of enforcement letters and licensee responses. For the casework reviewed, documented inspection findings led to proper regulatory actions and appropriate enforcement. Inspection results showed licensee compliance was acceptable during the review period and that escalated enforcement action in the process of Administrative Tribunals (Hearing Board) occurred only five times. A thorough review of all Administrative Tribunals revealed that this process is very effective in obtaining eventual compliance whether the end result is a fine, an American Coliege of Radiology audit commitment, or other compliance commitment. Four of the five cases reviewed were dealt with expeditiously through negotiation with NYSH which is a preliminary step in the Tribunal process. All five cases have been inspected or have been scheduled to be inspected within the next 6 to 12 months. l Four inspector accompaniments identified in Appendix C-3 were performed by a team member. ( During the accompaniments, inspectors demonstrated appropriate inspection skills and knowledge of the regulations. The inspectors were well prepared and thorough in the review of licensee radiation safety programs. The technical performance of the inspectors was at a high level. During these accompaniments, the reviewer observed that the inspectors focused on records reviews and checking off the field notes instead of observing the licensees operations; l

New York Proposed Final Report Page 15 therefore, the reviewer identified that the inspectors would benefit from more training in inspecting for performance. The inspections were adequate to assess radiological health and safety at the licensed facilities. The review team suggests that the NYSH inspectors attend additional training in inspecting for performance techniques. The NYSH has a policy of performing annual supervisory accompaniments of inspectors. In response to the questionnaire, NYSH reported that 10 out of the 12 inspectors had accompaniments in 1997. The two inspectors that did not have accompaniments were a field supervisor and another inspector not assigned inspections for 1997. The team noted that NYSH has an ample number of portable radiation detection instruments for use during routine inspections and response to incidents and emergencies. The NYSH has a dedicated person in the Department for assuring and performing all instrument calibrations. The portable instruments used during the inspector accompaniments were observed to be operational and calibrated. The instrument storage area is located within the Department and at each field office. A sampling of portable instruments maintained at each location was available and found to be within calibration. Based on the IMPEP evaluation criteria, the review team recoinmends that NYSH's performance with respect to the indicator, Technical Quality of Inspections, be found satisfactory. 3.2.4 New York State Department of Conservation (NYDEC) - Technical Quality of Inspections The team reviewed the inspection reports, enforcement documentation, and interviewed inspectors for 10 materials inspections conducted during the review period. The casework included seven of the NYDEC's materials license inspectors, and covered inspections of various types including air, water, and incinerator permits. Appendix C-4 lists the inspection files reviewed in depth with case-specific comments. A representative cross-section of completed inspection reports was reviewed and found to be very thorough with inspection findings well documented. Inspection findings were consistently compared to the permit and regulatory requirements. Prior to the inspection, a full briefing is held among the inspector, their supervisor, and the Radiation Section Supervisor to discuss the inspection. Unresolved issues, recent changes to the permit, and specific concerns of the inspector are well documented in the inspection reports. The completed reports were reviewed by supervisory personnel in a very prompt time frame. Escalated enforcement procedures are in place and followed, as needed. The escalated actions include referral to the General Counsel in preparation for an enforcement conference which may result in a fine and/or a Consent Order. This process is used approximately once a year. The team reviewed the latest version of Part 380 Permit inspection Procedures, revised l September 1996, Enforcement Guidance Memorandum Radiation dated May 17,1995, and all current inspection forms. In general, all procedures and forms appear to be consistent with the applicable guidance found in IMC 2800 and IP 87100. l

k

                                                                                                        \

New York Proposed Final Report Page 16 Supervisory accompaniments of inspectors are conducted on a routine basis. All of the inspectors have been accompanied at least once a year and most of the supervisors have been accompanied during the review period. Two inspector accompaniments identified in Appendix C-4 were performed by a team member on April 7,1998. Of the remaining three inspectors, two were accompanied during previous reviews and the other was re asaigned to other work within NYDEC. During the accompaniments, the inspectors demonstrated appropriate inspection skills and knowledge of the regulations. The inspectors were well prepared and thorough in the review of licensee radiation safety programs. Inspection techniques were observed to be performance oriented. and the technical performance of the inspectors was at a high level. The inspections were adequate to assess radiological health and safety of the licensee's effluent monitoring program. The team found that NYDEC has a variety of survey instruments. The instruments include a good mix of microroentger. meters, GM meters, ion chambers, velometers, and other portable survey meters. The meters are calibrated annually using an outside vendor. The NYDEC also has available a high purity germanium detector, tritium monitor, TLD reader /irradiator, and a neutron detector. Samples are also sent to an outside laboratory for analysis. Based on the IMPEP evaluation criteria, the review team recommends that NYDEC's performance with respect to the indicator, Technical Quality of Inspection, be found satisfactory. 1 3.3 Technical Staffino and Trainina Issues central to the evaluation of this indicator include the radioactive materials program staffing level, technical qualifications of the staff, training, and staff turnover. To evaluate these issues, the team examined each program's questionnaire responses relative to this indicator, , interviewed program managemera and staff, and considered any possible workload backlogs in I licensing or compliance actions as well as the status of regulation development and other program activities. 3.3.1 New York City Department of Health - Technical Staffing and Training l At the time of the review, NYCH's radioactive materials program was staffed by the Deputy Bureau Chief, licensing section with a supervisor and four staff, and compliance section with a section supervisor, scientist, and five staff. The Bureau Chief position had been vacant for 18 months, filled for four months, and then vacant again as of the week after the review. In , general, the team found that the current staffing level is adequate except the team noted that the vacancy at the Bureau Chief position was affecting several aspects of the program as identified in this report. The review team suggests that the NYCH Bureau Chief position be filled as soon as possible so that attention can be applied to management oversight of the l program shortfalls identified in this review. At the time of the review, all staff had been with the program for the majority of the review period. Two staff members joined the program shortly after the last review in 1995. Both performed well on their inspection accompaniments. The Bureau Chief resigned in July 1996 with a successor hired in October 1997. The new Bureau Chief resigned in January 1998, i 1 i l

l l New York Proposed Final Report Page 17 effective February 6,1998. In addition, the Assistant Commissioner that oversees the Bureau was dismissed in mid-January 1998 with the Deputy Commissioner being dismissed in February 1998. In an additional organizational change, the Departments of Health and Mental Health are being combined into one department. The final organizational chart for this new Department will not be available until the City Council approves the reorganization. At the time of the review, it appears that the NYCH will remain intact. i l From supervisor interviews and a review of the position der riptions, the team determined that successful candidates for technical positions are required to have a Bachelor's degree in science and at least one year of experience. From the review of the technical qualifications of the current staff, the review team concluded that the NYCH has been able to hire qualified individuals. The NYCH has one Certified Health Physicist (CHP) and one individual that has passed Part 1 of the CHP examination. In interviews with the staff and a review of documents, the team determined that there was no written training policy or qualifications criteria. The review team recommends that NYCH document its training program to include overall policy and minimum training requirements to be qualified to conduct the responsibilities of the program for both the licensing and compliance staff. In NYCH's letter dated February 17,1998, the NYCH responded to this recommendation by indicating that although their Policy and Procedures Manual contains a written policy for staff training, the manual is currently being updated and will include these recommendations. The team's review of NYCH's training records and interviews with the staff identified that several staff members should attend at least one course to fully address their training needs, in discussions with senior management, they pointed out that getting approval for out-of-city travel was difficult and that they would seek as much training as they could from institutions within New York City. They have been utilizing several one day seminars in the appropriate training areas. The review team recommends that NYCH review the staff's training against their > training requirements, clearly document how the training was achieved, and acquire the necessary training, as appropriate. Based on the IMPEP evaluation criteria, the review team recommends that NYCH's performance with respect to the indicator, Technical Staffing and Training, be found satisfactory with recommendations for improvement. 3.3.2 New York State Department of Labor - Technical Staffing and Training At the time of the review, NYDL's radioactive materials program was staffed by the principle radiophysicist and seven associate radiophysicists. In general, the team found that the current staffing level is adequate, except that the team noted that the inspection staff has a very heavy workload attributed to the fact that one of the four inspectors was restricted to office duties only. The principle radiophysicist also carries a very heavy licensing caseload that may have affected the status of regulatory development. The staffing and training will be impacted by the recommendations in the SS&D section (4.2) with the recommendation for significant additional training for both of the SS&D staff. The review team suggests that NYDL management consider whether additional staffing is warranted when considering the impacts of the licensing and inspection workloads, the regulation development needs, and the SS&D program improvement needs. l I L-___-_-_-___-____.

New York Proposed Final Report Page 18 The licensing and inspections functions of the program are segregated with all the licensing conducted in Albany and inspections conducted out of the Manhattan office. Licensing duties are performed by the principle radiophysicist and three associate radiophysicists. Inspection duties are performed by four associate radiophysicists. All staff perform duties in incident and emergency response. At the time of the review, all staff had been with the program for the entire review period. From supervisor interviews and a review of the position descriptions, the team determined that successful candidates for technical positions are required to have a Bachelor's degree in science and at least three years of experience. Twenty-four graduate credit hours in radiological science may be substituted for up to one year of experience. To be considered for a position, an individual must successfully complete a technical examination to be placed on the registry from which individuals are selected. From the review of the technical qualifications of the current staff, the team concluded that the State has been able to hire qualified individuals. The NYDL program has one CHP with one other person working on their certification. l 1 In interviews with the staff and review of documents, the team determined that there was no written training policy. The principle radiophysicist committed in a memo to upper management to follow the recommendations in the NRC/OAS Training Working Group report as the ) l program's overall training plan. They also are required to submit annual training plans to upper management. All formal training is documented complete in a computer database. On the-job training is documented in signature cards signed by the mentoring staff person. The review of their training records and interviews with the staff identified that one staff member should attand the industrial radiography course and that most staff desired additional training in internal dosimetry and decommissioning. The review team recommends that NYDL document its training program to include overall policy and minimum training requirements for both the licensing and compliance staff. l Based on the IMPEP evaluation criteria, the review team recommends that NYDL's I performance with respect to the indicator, Technical Staffing and Training, be found i satisfactory. I 3.3.3 New York State Department of Health (NYSH) - Technical Staffing and Training At the time of the review, the NYSH radioactive materials program was staffed by the Director, two supervisors, and eleven staff. The team found that the current staffing level appeared adequate. The staff of the materials program is segregated into four field offices and the main office in Albw/. Compliance duties are performed by both supervisors and the eleven staff. The field staff perform only compliance activities including compliance work for the x-ray and other radiation programs. The Albany staff conduct all the licensing and a portion of the compliance activities. Licensing duties are performed by the supervisor and four staff. All Albany staff j perform duties in incident and emergency response. I At the time of the review, all staff, except one, had been with the program for the entire review period. The new individual was transferred from the laboratory to the licensing / compliance staff in Albany. The individual has attended several training courses and is a senior staff member

l I New York Proposed Final Report Page 19 based on his 20 plus years working as a radiochemist in the laboratory. All work, by this individual both inspections and licensing actions, is reviewed by qualified staff prior to issuance. From supervisor interviews and a review of the position descriptions, the team determined that successful candidates for technical positions are required to have a Bachelor's degree in science and at least one year of experience. To be considered for a position, an individual must successfully complete a technical examination to be placed on the registry from which individuals are selected. From the review of the technical qualifications of the current staff, the re'fiew team concluded that the State has been able to hire qualified individuals. There is one certified health physicist (CHP) in the NYSH program with six others that have passed Part I of the CHP examination. The NYSH has a written training policy and requirements. The team reviewed the policy and l requirements and found them acceptable. The NYSH has a training matrix where they enter ' the courses that have been completed. The review of this matrix identified several courses which are needed for individual staff. These were: two for inspection procedures, one for licensing practices and procedures, most of the staff for teletherapy / brachytherapy, three for transportation of radioactive materials, and, as recommended in Section 3.2.3, additional training in inspecting for performance for the inspection staff. Although these individuals have not attended specific courses, they have had some on-the-job training and short seminars to cover these areas. The team considered that in every training area the program had multiple qualified individuals that have been provided the on-the-job training, therefore, from a programmatic standpoint, the program has sufficiently trained staff. Through management review, all staff, except for the recent transfers, have been qualified to perform independent j work. NYSH's program conducts monthly TeleVideo conferences with its regional and Albany staff. These sessions cover current health physics topics and other programmatic matters, as needed. The review team considers the TeleVideo conferences to be a good practice to bring and keep their staff current on health physics and program issues. Based on the IMPEP evaluation criteria, the review team recommends that NYSH's performance with respect to the indicator, Technical Staffing and Training, be found satisfactory. 3.3.4 New York State Department of Environmental Conservation (NYDEC) - Technical Staffing and Training At the time of the review, NYDEC's radioactive materials program was staffed by the Bureau Chief, Radiation Section Leader, and ten staff. There are currently two vacancies in the radiation section. Both positions are for contaminated sites and environmental analysis to support contaminated site evaluations. In response to the draft IMPEP report, NYDEC indicated that, subsequent to the team visit, they have filled both of these positions. About half of the staff time is spent on contaminated sites and events that are not directly covered under the agreement with NRC. The permitting (licensing) and compliance functions of the program are integrated with six staff performing both functions part of the time. All staff perform duties in incident and emergency resporise. At the time of the review, all staff had been with the program for the entire review period. Two l l

I 1 l I New York Proposed Final Report Page 20 staff left the program in 1997, and one staff member was assigned work outside the Bureau which amounted to half of his time. From supervisor interviews and a review of the position descriptions, the team determined that successful candidates for technical positions are required to have a Bachelor's degree in science or engineering and at least two years of experience in the environmental radiation field. From the review of the technical qualifications of the current staff, the team concluded that the State has been able to hire qualified individuals, in interviews with the staff and a review of documents, the team determined that there was no written training policy. Because of the small number of inspectors and permit reviewers, NYDEC does not have a formal qualification program. New staff have been trained in performing inspections and reviewing permit applications individually by the permit unit supervisor. Inspectors in training move through the following stages: (1) accompanying experienced inspectors as observers; (2) assisting experienced inspectors; (3) taking the lead in inspections, assisted by experienced inspectors; and (4) pedorming inspections independently. Inspectors move through these stages based on the assessment o' the unit supervisor. The same staff are trained to review permit applications by reviewing first minor amendments and routine renewals, then applications of increasing complexity. All permitting decisions are reviewed by the permit unit supervisor and the radiation section supervisor. The review team recommends that NYDEC document its training program to include overall policy and minimum training requirements for both the permitting and compliance staff. Based on the IMPEP evaluation criteria, the review team recommends that NYDEC's J performance with respect to the indicator, Technical Staffing and Training, be found satisfactory. 3.4 Technical Quality of Licensino Actions The teams examined completed licensing casework and interviewed the reviewers for specific licenses as specified for each of the four New York programs. Licensing actions were evaluated for completeness, consistency, proper isotopes and quantities used, qualifications of authorized users, adequate facilities and equipment, and operating and emergency procedures sufficient to establish the basis for licensing actions. Licenses were reviewed for accuracy, appropriateness of tne license and of its conditions and tie down conditions, and overall technical quality. 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 enforcement 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. 3.4.1 New York City Department of Health (NYCH)-Technical Quality of Licensing Actions The licensing casework was selected to provide a representative sample of licensing actions which had been completed in the review period and to include work by all reviewers. The cross-section sampling included all of NYCH's major licenses as defined by NYCH in the questionnaire, and included the following types: broad scope mec'ical; broad scope academic; l t i

l l New York Proposed Final Report Page 21 gamma knife; hospital nuclear medicine; private practice physicians nuclear medicine; teletherapy; high dose remote afterloaders; blood irradiators; bone mineral analyzers; and in vitro laboratories. Nineteen license files were reviewed. Licensing actions included three new licenses, nine renewals,28 amendments, two terminations, and one license rescinded. A list of these licenses with case-specific comments can be found in Appendix D-1. In discussions with NYCH management, it was noted that there are no major decommissioning efforts underway with regard to agreement material in New York City. Also, there are no identified sites with potential decommissioning difficulties equivalent to those sites in NRC's Site Decommissioning Management Plan. The only exemptions issued were to physicians requesting the carbon 14 urea breath test recently approved by NRC. l The team found that the licensing actions were thorough, complete, consistent, of high quality, l and with health and safety issues properly addressed. The licensee's compliance history l appeared to be taken into account when reviewing renewal applications as determined from 1 documentation in the license files or discussion with license reviewers. The review of the two gamma knife licenses indicates license reviewers should pay close attention to the conditions of  ! use listed in the SS&D registry for these type of devices. The team discussed with NYCH staff how they addressed these conditions since there was limited documentation in the file. Several of the conditions were individually considered by NYCH staff and others were not because NYCH staff considered them as being covered through the manufacturer operating procedures and/or training program. The review team suggests that NYCH consider documenting how the SS&D conditions of use were addressed for the two gamma knife licenses and will be addressed in future SS&D licensee's actions. In NYCH's letter dated February 17,1998, the NYCH responded to this suggestion by adding a memo to the license reviewer's handbook that instructs reviewers to include as license conditions the specific language from the SS&D Registry dealing with the restrictions of use or recommendations conceming safety matters as appropriate. 1 I The team found that terminated licensing actions and the license rescinded were well  ! documented, showing appropriate transfer records and survey records. For the case that the license was rescinded, NYCH took possession of licensed material for proper disposal. Licenses are renewed on a 5-year frequency. Licenses that are under timely renewal are  ! amended as necessary to assure public health and safety issues are addressed during the period that the license is in the renewal process. Each licensing action receives management i review before the action is finalized and issued. Interviews with the licensing staff indicate that i there is discussion between reviewers and management on complex licensing actions  ; completed by management. The license reviewers submit all deficiency letter replies and a  ; date stamped finallicensing action to management for review and management signature. If

approved, management signs the action, then the license is held for license fee payment. The l date of payment is the issuance date of the license action. The difference between these two dates may cause initial inspection scheduling difficulties. The review team suggests that NYCH l list the date the licensing action is issued (date of fee payment) on the license and in their i database, instead of the date of management signature. In NYCH's letter dated February 17, j 1998, the NYCH responded to this suggestion by upgrading their radiation database to trigger an inspection due date based on the actual date of issuance of the new license rather than the l date the license was signed.  !

I I i Q

l I l New York Proposed Final Report Page 22 The casework was reviewed for adequacy and consistency with the NYCH procedures. The casework review also indicated that the NYCH reviewers follow their licensing guides during the review process to ensure that licensees submit the information necessary to support the license. The licensing guides are similar to NRC guides. Based on the IMPEP evaluation criteria, the review team recommends that NYCH's performance with respect to the indicator, Technical Ouality of Licensing Actions, be found satisfactory. 1 3.4.2 New York State Department of Labor (NYDL) - Technical Quality of Licensing l Actions I l The team examined completed licenses and casework for 16 ficense actions, representing the work of four license reviewers. The license reviewers and program manager were interviewed to supply additional information regarding licensing decisions or file contents. The license casework was selected to provide a representative sample of licensing actions which had been completed in the review period, and to include work by all reviewers. The i sampling included the foiiowing types: research and development; manufacturing and distribution; industrial radiography; portable gauges; fixed gauges; gas chromatograph; commercial broad scope, and nuclear pharmacy. Licensing actions reviewed included two new licenses, six renewals, six amendments, and two terminations. A list of these 16 licenses with case specific comments can be found in Appendix D-2. In discussions with NYDL staff, the j team noted that NYDL is currently performing confirmatory measurements at the { decommissioning of the Cintichem facility with regard to agreement materialin New York. The team found that the licensing actions were very thorough, complete, consistent, of high quality, and with health and safety issues properly addressed. The licensee's compliance history is taken into account when reviewing renewal applications as determined from documentation in the license files and/or discussions with the license reviewers. Generic j notices were issued to specific classes of licensees to address particular safety concerns, such j as, a notice on bumpers for Amersham 660 radiography cameras. j One of the licensing actions examined by the team required the licensee to submit financial  ! assurance. The originals of financial documents could not be located. Based on discussions with the program manager and a review of the original financial assurance documents maintained in NYDL's Manhattan office, the team determined that some licensees: (1) are no i longer required to have financial assurance; (2) were inconsistent in designating the obligee; j and (.3) did not have a trust agreement with each financial mechanism. Prior to this review, { NYDL sent a letter to its licensees requesting them to review their financial assurance and - update their financial mechanism. The review team suggests that NYDL continue to audit their j financial assurance files to ensure that they contain all required information and are current with j NYDL requirements. j i  ; The team found that terminated licensing actions were well documented, showing appropriate transfer records and survey records. A review of the licensing actions over the period showed that most terminations were for licensees possessing sealed sources. These files showed that documentation of proper disposal or transfer was available. l 4 l

New York Proposed Final Report Page 23 Licenses are renewed on a 3-year frequency. The NYDL performs a complete review du ing every other 3-year cycle to ensure that the license's radiation safety program is adequate and meets current NYDL requirements. Licenses that are under timely renewal are amended as necessary to assure that public health and safety issues are addressed during the period that the license is in the renewal process. Unless revievad by the two individuals with signature authority, each licensing action receives a supervisory chain review. At the time of the review, there were 57 renewals greater than a year old, and 27 amendments and two new applications greater than 6 months old. Based on discussions with NYDL program manager, the program receives approximately 300 licensing actions a year and the total number of pending actions is approximately 200 actions. The total number of pending actions has been reduced in half compared to the last review period. The team found that the current staff is well trained and experienced in a broad range of licensing activities. The casework was reviewed for adequacy and consistency with NYDL procedures. The casework review indicated that NYDL staff follows their licensing guides during the review process to ensure that licensees submit the information necessary to support the license. The licensing guides are similar to NRC guides. The NYDL has developed simplified licenses for fixed gauges and gas chromatograph licenses that do not require a license tie-down condition. The NYDL also issues notices to its licensees to alert them to changes in ragulatory requirements or to emphasize a particular area of concern identified by NYDL or another agency. Based on the IMPEP evaluation criteria, the review team recommends that NYDL's performance with respect to the indicator, Technical Quality of Licensing Actions, be found satisfactory. 3.4.3 New York State Department of Health (NYSH) - Technical Quality of Licensing Actions The team examined completed licensing casework and interviewed the reviewers for 21 specific licenses. The licensing casework was selected to provide a representative sample of licensing actions which had been cornpleted in the review period and to include work by all reviewers. The cross-section sampling included all of NYSH's major licenses as defined by NYSH in the questionnaire and included the following types: academic-broad; research and development-specific; research and development-broad; irradis. tor; medical (broaa with high dose remote aftertoader, private practice, hospital, nuclear cardiology, mobile nuclear medicina site, brachytherapy, teletherapy, and high dose remote afterloader); and clinicallaboratory. Licensing actions included six new licenses, seven renewals, one amendment, and seven

                                                                                                                                                                                                   )

j terminations. A list of these licenses with case-specific comments can be found in Appendix l D-3. I i The team found that the licensing actions were very thorough, complete, consistent, of high 1' l quality, and with health and safety issues properly addressed. The licensee's compliance history is taken into account when reviewing renewal applications as determined from documentation in the license files and/or discussions with the license reviewers. Generic notices were issueo to specific classes of licensees to address particular safety concerns, such

                                                  ~

as, a notice on HDR issues. j

New York Proposed Final Report Page 24 in discussions with NYSH management, it was noted that there were no major decommissioning efforts underway with regard to agreement materialin the NYSH program. Also there were no identified nites with potential decommissioning difficulties equivalent to those sites in NRC's Site Decommissioning Management Plan. The team found that terminated licensing actions were well documented, showing appropriate transfer records and survey records, i Based on the IMPEP evaluation criteria, the review team recommends that NYSH's j performance with respect to the indicator, Technical Quality of Licensing Actions, be found i satisfactory. 3.4.4 New York State Department of Environment! Conservation (NYDEC) - Technical Quality of Licensing Actions The team examined completed licenses and casework for 14 license actions in 14 specific license files, representing the work of six license reviewers. The license reviewers and the Section Chief were interviewed when needed to supply additionalinformation regarding licensing decisions or file contents. The license casework was selected to provide a representative sample of licensing actions which had been completed in the review period and to include work by all reviewers. The sampling included the following types of permits issued under Part 380 of the New York State Code of Regulations: air effluents, incinerators, water discharge, and environmental study. Licensing actions reviewed included three new licenses, three renewals, two amendments, three terminations, and three inquiries. Inquiries are permit applications or facility evaluations initiated by the radiation staff to determine if licensees discharging radioactive materials to the environment in their effluent exceed the 10% exemption threshold. A licensee is required to have a permit if the annual average effluent concentration of the licensee's discharge exceeds 10% of the NYDEC's regulatory limit in Table 11 of Part 380. If the licensee's discharge is less than 10% of NYDEC limits, then a permit is not needed; however, the licensee is still required to survey and maintain appropriate records to demonstrate compliance with Part 380. A list of the 14 permits and inquiries reviewed with case specific comments can be found in Appendix D-4. The team found that the licensing actions were very thorough, complete, consistent, of high quality, and with health and safety issues properly addressed. The licensee's compliance history appeared to be taken into account when reviewing renewal applications as determined from documentation in the license files and/or discussions with the license reviewers. No exemptions were issued by NYDEC during this review period. The team found that terminated licensing actions were well documented, showing either appropriate survey records or documentation that the licensee's effluents did not exceed the 10% exemption limit. A review of the licensing actions over the period showed that a majority of terminations were for permittees whose effluents wera reduced to less than the 10% i exemption limit. Permits are issued or renewed with a 5 year erpiration period. The radiation staff occasionally issues a permit for a shorter period, but this is done to coincide expiration dates with other NYDEC permits issued to the facility. Permits that are under renewal are amended as I

I l New York Proposed Final Report Page 25 necessary to assure that public health and safety issues are addressed during the period that t the permit is undergoing the renewal process. Each licensing action receives a supervisory chain review. l The team found that the current staff is well trained and experienced in licensing activities related to discharge of radioactive materialinto the environment. The casework was reviewed for adequacy and consistency with the NYDEC procedures. The casework review indicated that the radiation staff follow their licensing guides during the review process to ensure that licensees submit the information necessary to support the license. The team found the i checklists and the worksheets for each type of permit to be comprehensive and incorporated excellent notes to reviewers to assist in the review of applications. Based on the IMPEP evaluation criteria, the review team recommends that NYDEC's performance with respect to the indicator, Technical Quality of Licensing Actions, be found satisfactory. 3.5 Response to incidents and Allegations 3.5.1 New York City Department of Health (NYCH)- Response to incidents and Allegations in evaluating the effectiveness of NYCH's actions in responding to incidents and allegations, the team examined NYCH's response to the questionnaire relative to this indicator, reviewed the incidents reported for NYCH in the " Nuclear Material Events Database (NMED)", and those contained in the City's casework and license files, and supporting documentation, as appropriate for eight incidents. A list of the incident casework with comments is included in Appendix E-1. The team reviewed NYCH's response to six allegations received during the review period. The eight incidents selected for review included two misadministration, one lost package of radioactive material, two loss of control of radioactive material, two overexposure, and one procedural failure. Of the six allegations reviewed in detail, the NRC Region I office referred one to NYCH and the others came directly from allegers. During the review period, NRC referred 10 allegations to NYCH. All of these allegations have been closed out. Responsibility for iniS! response and follow-up actions to material incidents and allegations gests with NYCH staff. When NYCH is notified of either an incident or an allegation (also referred to as " complaints") during working hours, an inspector takes the incoming notification and briefs the materials inspection supervisor or the Director of NYCH to determine the approach to be taken. Incoming complaints are considered either immediate or non-immediate based on their apparent safety significance. The supervisor assigns the complaint to one of the inspectors who will respond the same day or next if the complaint is immediate, or a longer period if non-immediate. The NYCH provides a 24-hour emergency number for anyone to report emergencies involving hazardous materials. The NYCH can also receive notification through the State Warning Point (State operated emergency line). When a radiologicalincident is reported after work hours, NYCH staff is contacted at home. )

New York Proposed Final Report Page 26 The review of incident casework, licensing casework, and interviews with staff revealed that incidents are promptly evaluated for the need for on-site investigations. For those incidents not requiring on-site investigations, copies of letters tc licensees were in the incident and licensing . files indicating that the incident would be investigated during the next scheduled inspection. In response to incidents, NYCH took prompt, appropriate action. The review of casework indicated that incident reports were thorough and well-documented. The team found that NYCH's complaint file is maintained manually with a copy in the appropriate specific license file. Documentation on incidents or allegations involving non-licensees are maintained solely in the complaint file. These reports included sections on the background, findings, conclusions / recommendations, instruments used, and signatures. The team noted that some of the non-immediate complaints were documented on a preprinted two sided complaint control record" form. The incident reports were reviewed and signed by the inspection supervisor. The team did note that follow up to incidents at the next inspection was not always documented in the field notes. The review team suggests that NYCH investigated incidents be clearly documented in the field notes at the next inspection. The team reviewed NYCH's process for reporting significant events immediately or 24 hour notification. The team determined that NYCH was inconsistent in reporting significant events to the NRC Operations Center. The team also queried the incident information reported on the NMED system for NYCH which identified 11 reported material incidents. These incidents were not based on reports submitted by NYCH, but through other notification mechanisms such as preliminary notification or calls to the NRC Operations Center. Although NYCH staff has been provided training on the NMED system, they have not been providing periodic reports on , reportable events. During the exit meeting on January 30,1998, and their letter dated l February 17,1998, NYCH and Department managernent committed to providing information on reportable events to NMED including those reportable events that occurred during fiscal years 1996 and 1997. The review team recommends that NYCH notify the NRC Operations Center  ; within 24 hours for all significant events and provide complete follow-up documentation to NMED on reportable events. The review of the atiegation files indicated that NYCH took prompt and appropriate action in response to allegers' concerns. These actions included detailed interviews with the allegers, prompt investigation and routine follow up at the next inspection, when warranted. The NYCH protects the identity of the alleger if requested. The review of the casework and interviews of

staff determined, however, that NYCH staff did not document any feedback to the alleger on NYCH's investigation into the allegation and NYCH's findings. The review team suggests that NYCH include written documentation that the alleger has been contacted regarding the results of NYCH's findings into the alleger's concerns. In NYCH's letter dated February 17,1998, the NYCH responded to this suggestion by confirming that documentation to file will indicate that allegers were notified of the results of investigations.

Based on the IMPEP evaluation criteria, the review team recommends that NYCH's performance with respect to the indicator, Response to Incidents and Allegations, be found j satisfactory. l

New York Proposed Final Report Page 27 3.5.2 New York State Department of Labor (NYDL)- Response to incidents and Allegations in evaluating the effectiveness of NYDL's actions in responding to incidents, the team examined NYDL's response to the questionnaire relative to this indicator, NYDL's written procedures for incident response, and the incidents reported for NYDL in the " Nuclear Material Events Database (NMED)." The team examined NYDL's incident and license files and supporting documentation for.13 incidents. In all cases reviewed, once notification was received, NYDL promptly responded and adequately protected public health and safety. Incidents were adequately documented in the files and when they involved a licensee of NYDL, the incident was also reviewed at the next routine inspection. Issues and concerns arriving out of these incidents that involved other regulatory agencies were referred to the appropriate agency by NYDL. A list of the incident casework with comments is included in Appendix E-2. The team reviewed NYDL's process for reporting significant NYDL events (immediate or 24-hour notification). The team determined that NYDL was inconsistent in reporting significant events to the NRC Operations Center. During the review period, NYDL had made only one summary report of incidents for inclusion in the NMED system. For the NMED system to effectively identify in a timely manner any generic problems with equipment or procedures, NYDL must routinely submit the vital information on the incidents that occur in their jurisdiction to the NMED system. The review team recommends that NYDL notify the NRC Operations Center within 24 hours for all significant events, and provide complete follow-up documentation to NMED on 'll reoortable events. In evaluating the effectiveness of NYDL's actions in responding to allegations, the team examined NYDL's response to the questionnaire relative to this indicator and NYDL's written procedures for response to allegations. The team reviewed NYDL's response to seven allegations, including the allegation referred to NYDL by NRC. NRC referred a total of three , allegations to NYDL. All of them have been closed out. All possible allegations are evaluated  ! by NYDL's Director to determine the level of investigation they may merit. Not all allegations  ! referred to NYDL by the NRC were considered allegations by NYDL. Two of the NRC referred allegations selected for review were not in NYDL's allegation files but had been answered by letters to NRC from the Director, because in her evaluation they should not be included as NYDL investigated allegations. Based on the information provided by NYDL, NRC closed these allegations. The NYDL responded promptly with on-site investigations to the four allegations l reviewed with potential ongoing conditions that could lead to excessive exposures. The NYDL's  ; response to allegations was timely and appropriate for the significance of the allegation. NYDL ) protects the identify of the alleger, when requested. In two of the seven files reviewed, NYDL's allegation tracking system did not document that a closed investigation had in fact been closed out. The NYDL's tracking system does not indicate if the alleger was informed of the results of the investigation nor is this required by the NYDL's allegation procedures. The review team suggests that attention be given to NYDL's tracking system for allegations to ensure that the system accurately indicates when the response to each allegation has been completed and the matter is considered closed out. Based on the IMPEP evaluation criteria, the review team recommends that NYDL's performance with respect to the indicator, Response to incidents and Allegations, be found satisfactory.

1 f New York Proposed Final Report Page 28 3.5.3 New York State Department of Health (NYSH) - Response to incidents and Allegations in evaluating the effectiveness of NYSH's actions in responding to incidents and allegations, the team examined NYSH's response to the questionnaire relative to this indicator, the incidents reported for New York in the " Nuclear Material Events Database (NMED)," those incidents contained in NYSH's casework and license files, and supporting documentation, as appropriate for 12 incidents. A list of the incident casework with comments is included in Appendix E-3. The team reviewed NYSH's response to five allegations received during the review period. The 12 incidents selected for review included three misadministration, one leaking source, two loss of control of radioactive material, one overexposure, two equipment failures, two releases of radioactive material, and one contamination event. Of the five allegations reviewed, the NRC Region I office referred one to NYSH and the others came directly from allegers. The NYSH use the same process for handling incidents and allegations. Responsibility for initial response and follow-up actions to materialincidents and allegations rests with the staff. When NYSH is notified of either an incident or an allegation during working hours, an inspector takes the incoming notification and briefs the Section Chief in Albany or the field supervisor in . Syracuse to determine the approach to be taken. Either supervisor will evaluate the potential l safety significance of the incident / allegation to determine the type of response that NYSH will take. Although staff and supervisors are located in five different offices around the State, the , team noted effective use of NYSH's e-mail system to communicate and document actions  ! taken for any of the events. The NYSH has a 24-hour number to report radiological l emergencies through the State Warning Point. The notification list includes after work hours phone numbers for NYSH staff. The review of incident and licensing casework, and interviews with staff revealed that incidents 1 are promptly evaluated for the need for on-site investigations. For those incidents not requiring on-site investigations, copies of letters to licensees were in the incident and licensing files indicating that the incident would be investigated during the W scheduled inspection. In response to incidents, NYSH had taken prompt, appropriate action. The review of casework indicated that incident reports were thorough and well-documented. The team found that incident and allegations events are tracked on a computerized system and filed on monthly basis. Each event is classified by the type of accident / incident (including a category for allegations) and includes a summary sheet with an event description, contact person, site name and responsible party, follow up, outcome, and if the event has been closed out. Detailed information on each event such as telephone conversations and close out memorandums are maintained in the incident file and, if a specific licensee is involved, in the appropriate docket file. Documentation on incidents or allegations involving non-licensees are maintained solely in' the incident file. The event reports are reviewed and signed by the Bureau Chief on a monthly basis. The team did note that incidents were generally followed up at the next inspection. l l The team reviewed NYSH's process for reporting significant (immediate or 24-hour notification) events. The team determined that NYSH was inconsistent in reporting significant events to the NRC Operations Center. The team also queried the incident information reported on the NMED system for NYSH which identified six reported materialincidents plus one abnormal occurrence. Although NYSH staff has been provided training on the NMED system, they have not been providing periodic reports on reportable events. The team determined that NYSH last reported l

New York Proposed Final Report Page 29

   ..icidents to the NMED system in April 1997. The NMED system does not include NYSH reports since that time. During the exit meeting on April 3,1998, NYSH staff and management indicated that a new tracking system was under development to track incidents and allegations, and that NYSH would explore interfacing their software to allow transfer of reportable events to NMED. The review team recommends that NYSH notify the NRC Operations Center within 24 hours for all significant events, and provide complete follow up documentation to NMED on all reportable events.

The review of the allegation files indicated that NYSH has taken prompt and appropriate action in response to the allegers' concerns. The review of casework and interviews of staff determined staff provided feedback on the follow-up findings to the alleger. The identity of the alleger is protected by NYSH. Based on the IMPEP evaluation criteria, the review team recommends that NYSH's performance with respect to the indicator, Response to incidents and Allegations, be found satisfactory. 3.5.4 New York State Department of Conservation (NYDEC) - Response to incidents and Allegations in evaluating the effectiveness of NYDEC's actions in responding to incidents and allegations, . the team examined NYDEC's response to the questionnaire regarding this indicator, the incidents reported for State of New York in the NMED against those contained in the NYDEC l files, and the casework and supporting documentation for four material incidents and five l allegations. The four incidents selected for review included two releases of radioactive material, one damage to equipment and one release of equipment resulting from equipment and procedural failure and are listed in Appendix E-4. Of the five allegations reviewed, NRC Region I office referred four to NYDEC and the other one came directly to NYDEC from an alleger. The team noted during file reviews and confirmed during discussions with staff that a majority of the incidents received by the Radiation Section are radiation alarms at solid waste and regulated medical waste facilities involving patient excreta, exempt material, or NARM material. Responsibility for initial response and follow-up actions to material incidents and allegations rests with Radiation Section staff. When the NYDEC is notified of an incident during working hours, either the Section Chief or the Program Director is consulted to evaluate the safety significance of the event and determine the course of action to be taken. For incidents dunng I non-work hours, NYDEC's radiation management can be contacted through the New York's State Warning Point. Radiation Section management also indicated that NYDEC sometimes j coordinates the response to an incident with one of the State licensing agencies (NYCH, NYSH, and NYDL) which have staff in regional offices in the vicinity of tha incident.  ! l

The review of incident and licensing casework, and interviews with staff revealed that incidents I

are promptly evaluated for the need for on-site investigations. For those incidents not requiring on-site investigations, copies of letters to licensees were in the licensing files indicating that the incident would be investigated during the next scheduled inspection. The team noted that the Radiation Section is currently evaluating the radiation detection systems at solid waste and regulated medical waste facilities in an effort to prepare guidance for setting a radiation level for i l

New York Proposed Final Report Page 30 rejecting a shipment of waste containing radioactive material. Solid waste and regulated medical waste facilities are required by permit to monitor incoming waste for radioactivity, store the radioactive materialin shielded areas, and report an alarm to NYDEC. In responding to incidents and allegations, NYDEC took prompt, appropriate actions. The review of casework indicated that incident reports are thorough and well-documented. The incident reports were reviewed and signed by the section supervisor. The team noted that documentation relating to the follow up to allegations pertaining to licensed material or operations is maintained in the licensing files. The other allegations are in the incident / allegation file. It was also noted that the Radiation Section's procedural manual does not address the handling of incidents and allegations. The review team recommends that NYDEC incorporate the handling of incidents and allegations into their inspection procedures. The team reviewed NYDEC's process for reporting significant (immediate or 24-hour notification) events. The team determined that NYDEC was inconsistent in reporting significant events to the NRC Operations Center. The NYDEC's response to the questionnaire indicated that reporting of events to NMED is not their responsibility. During the team's discussions with NYDEC management, they indicated that the licensing agency (NYDEC issues permits) would be responsible for reporting events to NMED and to NRC. A review of the information reported on an NMED system printout for the State of New York indicated one event reported to NMED by NYDL that NYDEC also treated as an incident. The review team recommends that NYDEC coordinate with the appropriate New York licensing agency, the notification to the NRC Operations Center within 24 hours for all significant events, and to NMED for all reportable events involving permitted activities. NYDEC maintains a chronological file of radiation alarms at solid waste and regulated medical waste facilities. Other incidents repoded to the Radiation Section are maintained in the appropriate licensing file, but there is no corresponding incident file for these events. The review team suggests that NYDEC maintain one file for all types of incidents involving radioactive material. l Based on the IMPEP evaluation criteria, the review team recommends that NYDEC's performance with respect to the indicator, Response to incidents and Allegations, be found satisfactory. 4.0 NON-COMMON PERFORMANCE INDICATORS The IMPEP identifies four non-common performance indicators to be used in reviewing l Agreement State programs: (1) Legislation and Program Elements Required for Compatibility; (2) Scaled Source and Device Evaluation Program; (3) Low-Level Radioactive Waste Disposal Program; and (4) Uranium Recovery Program. The New York agreement does not cover the I uranium recovery program, so only the first three non-common performance indicators were l applicable to this review. 4.1 Legislation and Proaram Elements Reauired for Compatibility

                                                                                                                                  )

1 4.1.1 New York City Department of Health (NYCH) - Legislation and Program Elements  ; Required for Compatibility  ; l L___- . - _ - _ _

i 1 New York Proposed Final Report Page 31 4.1.1.1 Legislation Along with their response to the questionnaire, NYCH provided the team with the opportunity to review copies of legislation that affect the radiation control program. Legislative authority for NYCH's portion of the Agreement State program is granted in Chapter 22 of the New York City , Charter (specifically Section 556(s)). NYCH's radiation program is delegated from the NYSH l program under Part 16 of the New York State Health Code which provides for delegation to local governments when covering greater than two million individuals. The team noted that the legislation and delegation has not changed since being found adequate during the previous review, and found that the City Charter is adequate. 4.1.1.2 Proaram Elements Reauired for Compatibility

                                                                                                                                                                                                            ]

l r The NYCH Regulations for Control of Radiation, found in Article 175 of the New York City Health Code - Radiation Control, apply to all ionizing radiation, whether emitted from f radionuclides or devices. New York City requires a license for possession, and use, of all radioactive material including naturally occurring materials, such as radium, and accelerator-produced radionuclides. New York City also requires registration of all equipment designed to produce x-rays or other ionizing radiations. The team examined the procedures used in NYCH's regulatory process and found that it is a six step process that takes between six months to a year to complete depending on the complexity of the rule change. The team evaluated NYCH's responses to the questionnaire and reviewed the regulations adopted by NYCH since the 1995 review to determine the status of the NYCH regulations under the Commission's new adequacy and compatibility policy. The team found that the NYCH did not promulgate any new regulations since the last review. NYCH has not adopted the following regulations within the 3-year time frame: e " Timeliness in Decommissioning of Materials Facilities," 10 CFR Parts 30,40, and 70 amendments (59 FR 36026) that became effective August 15,1994. The rule is being evaluated by NYCH's Office of General Counsel with an expected date for adoption of September 1998. , e " Frequency of Medical Examinations for Use of Respiratory Protection Equipment," 10 CFR , Part 20 amendment (60 FR 7900) that became effective March 13,1995. The NYCH has decided to not proceed with a rulemaking and will retain the more stringent requirement of annual medical examinations. At this time, NYCH does not have any licensees that use respiratory protection equipment. e " Low-Level Waste Shipment Manifest Information and Reporting," 10 CFR Parts 20 and 61 amendments (60 FR 15649 and 25983) that became effective March 1,1998. The Agreement States are to promulgate their regulations no later than March 1,1998 so that NRC and the State would require this national system to be effective at the same time. NYCH has this rule under review with their General Counsel to determine whether any additional rulernaking is needed, since NYDEC has this rule in place and it applies to all NYCH licensees. j i

i New York Proposed Final Report Page 32 NYCH has not yet adopted the following regulations that are applicable to the NYCH program, but intends to address them in timely rulemakings or by adopting alternate generic legally binding requirements: e " Radiation Protection Requirements: Amended Definitions and Criteria," 10 CFR Parts 19 and 20 amendments (60 FR 36038) that became effective August 14,1995. e " Clarification of Decommissioning Funding Requirements," 10 CFR Parts 30,40 and 70 amendments (60 FR 38235) that became effective November 24,1995. e "10 CFR Part 71: Compatibility with the International Atomic Energy Agency," 10 CFR Part 71 amendment (60 FR 50248 and 61 FR 28724) that became effective April 1,1996.

                   *   " Medical Administration of Radiation and Radioactive Materials," 10 CFR Parts 20 and 35 amendments (60 FR 48623) that became effective October 20,1995.

e " Termination or Transfer of Licensed Activities: Recordkeeping Requirements," 10 CFR Parts 20,30,40,61, and 70 amendments (61 FR 24669) that became effective May 16, 1996. e " Recognition of Agreement State Licensees in Areas Under Exclusive Federal Jurisdiction Within an Agreement State," 10 CFR Part 150 amendment (62 FR 1662) that became effective January 13,1997.

                   *   " Criteria for the Release of Individuals Administered Radioactive Materials," 10 CFR Parts 20 and 35 amendments (62 FR 1662) that became effective May 29,1997.

e " Radiological Criteria for License Termination," 10 CFR Part 20,30,40, and 70 amendments (62 FR 39058) that became effective August 20,1997. l The review team recommends that NYCH place the regulatory changes agenda and establish { specific schedules to address the regulatory changes in Section 4.1.1.2 within three years of  ! the regulations becoming effective NRC rules. l

                                                                                                                                                                               )

Based on the IMPEP evaluation criteria the review team recommends that NYCH's performance with respect to the indicator, Legislation and Program Elements Required for Compatibility, be found satisfactory, 4.1.2 New York State Department of Labor (NYDL)- Legislation and Program Elements Required for Compatibility l 4.1.2.1 Legislation Along with their response to the questionnaire, NYDL provided the team with the opportunity to review copies of legislation that affect the radiation control program. Legislative authority for NYDL to administer its portion of the Agreement State program is granted in Section 27 of the Labor Law and Article 28-D of the General Business Law. The NYDL is designated as the radiation control agency for industrial ar.d commercial uses of radioactive materials. The team i L______________________ _

New York Proposed Final Report Page 33 noted that the legislation has not changed since being found adequate during the previous review and found that the State legislation is adequate. 4.1.2.2 Proaram Elements Reauired for Compatibility The NYDL Regulations for Control of Radiation, found in Part 38 of Title 12 of the Official Compilation of Codes, Rules and Regulations of the State of New York (12 NYCRR Part 38) apply to all commercial and industrial uses of radioactive materials. The NYDL requires a license for possession and use of all radioactive material for commercisl and industrial purposes including naturally occurring materials, such as radium, and accelerator-produced radionuclides. The team examined the procedures used in NYDL's regulatoly process and found that it is a 6-step process that takes between six to 12 months to complete. The team evaluated NYDL's responses to the questionnaire and reviewed the regulations adopted by the State since the 1995 review to determine the status of the NYDL regulations under the Commission's new adequacy and compatibility policy. The team found that the NYDL addressed the following NRC regulation amendments; however, they have not been finalized and, therefore, they have not been adopted within the 3-year time frame:

  *   " Licensing and Radiation Safety Requirements for Irradiators," 10 CFR Part 36 (58 FR 7715) that became effective July 1,1993. See Section 2.0 for interim actions being taken by NYDL to implement this rule on a case-by-case basis.
  *   " Decommissioning Recordkeeping: Documentation Additions," 10 CFR Parts 30,40, and 70 amendments (58 FR 39628) that became effective October 25,1993.
  *   "Self-Guarantee as an Additional Financial Mecha,nism," 10 CFR Parts 30,40, and 70 amendments (59 FR 1618) that became effective January 28,1994.
  *   " Timeliness in Decommissioning of Materials Facilities," 10 CFR Parts 30,40, and 70 amendments (59 FR 36026) that became effective August 15,1994.
 *    " Preparation, Transfer for Commercial Distribution, and Use of Byproduct Material for Medical Use," 10 CFR Parts 30,32, and 35 amendments (59 FR 61767 and 65243) that became effective January 1,1995.

e " Low-Level Waste Shipment Manifest Information and Reporting," 10 CFR Parts 20 and 61 amendments (60 FR 15649 and 25983) that became effective March 1,1998. Note: The Commission delayed the effective date to March 1,1998 so that the Agreement States could promulgate and implement these requirements at the same time. These rule changes, as well as others, are in a package that has been under review by NYDL's General Counsel's office for approximately a year. The requirements in these rules are being implemented through license conditions as an interim measure. The review team recorr. mends that NYDL management take appropriate action to move the rule package through the rule promulgation process. At the State exit meeting on May 12,1998, the team was informed that l

New York Proposed Final Report Page 34 this rule package was released from the General Counsel's office and should be final by the end of 1998. The NYDL has not yet adopted the following regulations, but intends to address them in timely rulemakings or by adopting alternate generic legally binding requirements: e " Radiation Protection Requirements: Amended Definitions and Criteria," 10 CFR Parts 19 and 20 amendments (60 FR 36038) that became effective August 14,1995.

           *   " Clarification of Decommissioning Funding Requirements," 10 CFR Parts 30,40 and 70 amendments (60 FR 38235) that became effective November 24,1995, e   " Termination or Transfer of Licensed Activities: Recordkeeping Requirements," 10 CFR Parts 20,30,40,61 and 70 amendments (61 FR 24669) that became effective May 16, 1996.

e " Recognition of Agreement State Licensees in Areas Under Exclusive Federal Jurisdiction Within an Agreement State," 10 CFR Part 150 amendment (62 FR 1662) that became effective January 13,1997.

           *   " Licenses for Industrial Radiography and Radiation Safety - Requirements for Industrial Radiography Operations," 10 CFR Parts 30,34,71 and 150 amendments (62 FR 28947 that became effective June 27,1997.
           *   " Radiological Criteria for License Termination," 10 CFR Part 20,30,40 and 70 amendments (62 FR 39058) that became effective August 20,1997.

Based on the IMPEP evaluation criteria, the review team recommends that NYDL's performance with respect to the indicator, Legislation and Program Elements Required for Compatibility, be found satisfactory. 4.1.3 New York State Department of Health (NYSH)- Legislation and Program Elements Required for Compatibility 4.1.3.1 Legislation Along with their response to the questionnaire, the NYSH provided the team with the opportunity to review copies of legislation that affect the radiation control program. Legislative authority for NYSH's portion of the agreement with the NRC is granted in New York Public Health Law, Article 2, Title 11, Sections 201 and 225. NYSH is responsible for regulating the medical, academic and research uses of radioactive materials. The review team noted that the legislation has not changed since being found adequate during the previous review, and found that the State legislation is adequate. 4.1.3.2 Program Elements Required for Compatibility The NYSH Regulations for Control of Radiatic.1, found in 10 NYCRR Chapter 1, Part 16 (lonizing Radiation), Part 76 (Public Health Administrative Tribunal), and Part 405 (Hospitals - l l

i New York Proposed Final Report Page 35 Minimum Standards) of the New York State Public Health Code apply to ionizing radiation, whether emitted from radionuclides or devices used for medical, academic, or research and development. NYSH requires a license for possession and use of all radioactive material, including naturally occurring radioactive materials, such as radium, and accelerator-produced radionuclides for medical, academic, or research and development. NYSH also requires registration of all equipment designed to produce x-rays or other ionizing radiations. The team examined the procedures used in NYSH's regulatory process and found that it is a ten step process that takes approximately 12 to 18 months, depending on the complexity of the action. The team evaluated NYSH's responses to the questionnaire and reviewed the regulations adopted by the State since the 1995 review to determine the status of the NYSH regulations under the Commission's new adequacy and compatibility policy. The team noted that NYSH addressed the following NRC regulation amendments:

 *   " Termination or Transfer of Licensed Activities: Recordkeeping Requirements," 10 CFR Parts 20,30,40,61 and 70 amendments (61 FR 24669) that became effective on May 16, 1996.

The NYSH has decided to address the above decommissioning and financial assurance regulations with the use of license conditions. The NYSH identified nine licensees that are subject to the financial assurance requirements. NYSH has imposed license conditions on five of these licensees and has requested information from the others so that appropriate conditions can be developed. The team reviewed the license conditions and verified that they are being used. Additionallicense conditions addressed the timeliness and records retention requirements in that the licensees must submit a decontamination plan to NYSH for approval 90 days prior to ceasing operations and must keep all records of spills and incidents until the license is terminated. The team considers these license conditions j adequate implementation of the intent of the decommissioning and financial assurance I rules.

 *   " Emergency Preparedness for Fuel Cycle and Other Radioactive Materials Licensees," 10 CFR Parts 30,40 and 70 amendments (54 FR 14051) that became effective April 7,1990.

The team reviewed the assessment done by NYSH and agree that they do not have any licensees that are subject to this requirement. Therefore, they have not adopted this rule.

 *   " Licensing and Radiation Safety Requirements for Irradiators," 10 CFR Part 36 (58 FR 7715) that became effective July 1,1993. The NYSH authority in this area would only apply to large research irradiators not commercial operations. Therefore, NYSH has not adopted 10 CFR Part 36 equivalent regulations, but has licensed a facility using the safety requirements in their Part 16.12(f), which are equivalent to the requirements moved from 10 CFR Part 20 to Part 36 when it was promulgated. In addition to these safety requirements, NYSH has imposed the other Part 36 requirements through license conditions. The team i

found this approach acceptable, o " Notification of incidents," 10 CFR Parts 20,30,31,34,39,40 and 70 amendments (56 FR 64980) that became effective October 15,1991. The team reviewed the requirements in l f L

New York Proposed Final Report Page 36 Part 16.15 and identified that they do not fully address the notification requirements in this rulemaking. The NYSH indicated that they would review this issue further.

  * " Frequency of Medical Examinations for Use of Respiratory Protection Equipment," 10 CFR Part 20 amendment (60 FR 7900) that became effective March 13,1995. At this time, the NYSH does not have any licensees that use respiratory protection equipment. They are considering this rule in the next rule amendment package.

e " Medical Administration of Radiation and Radioactive Materials," 10 CFR Parts 20 and 35 amendments (60 FR 48623) that became effective October 20,1995. The team reviewed the requirements in Parts 16.123 and 16.7 and found that the objectives of the rule had been adopted. The NYSH has not yet adopted the following regulations, but intends to address them in timely rulemakings or by adopting alternate generic legally binding requirements: e " Radiation Protection Requirements: Amended Definitions and Criteria," 10 CFR Parts 19 and 20 amendments (60 FR 36038) that became effective August 14,1995.

  * " Recognition of Agreement State Licensees in Areas Under Exclusive Federal Jurisdiction Within an Agreement State," 10 CFR Part 150 amendment (62 FR 1662) that became effective January 13,1997.
 *    " Criteria for the Release of Individuals Administered Radioactive Materials," 10 CFR Parts 20 and 35 amendments (62 FR 1662) that became effective May 29,1997.

e " Radiological Criteria for License Termination," 10 CFR Part 20,30,40, and 70 amendments (62 FR 39058) that became effective August 20,1997. Based on the IMPEP evaluation criteria, the review team recommends that NYSH's performance with respect to the indicator, Legislation and Program Elements Required for Compatibility, be found satisfactory. 4.1.4 New York State Department of Conservation (NYDEC) - Legislation and Program Elements Required for Compatibility 4.1.4.1 Leaisfation Along with their response to the questionnaire, the NYDEC provided the review team with the opportunity to review copies of legislation that affect the radiation control program. Legislative authority to create an agency and implement a portion of the agreement with the NRC is granted in New York State Environmental Conservation Law Articles 1,3,17,19,27, and 29. The NYDEC is designated as the agency responsible for effluents from licensed facilities and environmental contamination r its portion of the State's radiation control program. The review team noted that the legislation has not changed since being found adequate during the previous review, and found that the State legislation is adequate. I l l l i L _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .

New York Proposed Final Report Page 37 4.1.4.2 Procram Elements Reauired for Compatibility The NYDEC Regulations for Control of Radiation, found in Title 6, Par's 380,381,382, and 383 of the New York Codes, Rule, and Regulations (NYCRR) apply to environmental releases and the disposal of radioactive materials. The NYDEC requires a pemtt for release of radioactive materials to the environment including the disposal of radioactim materials, including naturally occurring materials, such as radium, and accelerator-produced radionuclides. The team examined the procedures used in NYDEC's regulatory process and found that it is a eight step process that takes approximately 12 to 18 months. The team evaluated NYDEC's responses to the questionnaire and reviewed the regulations adopted by the State since the 1995 review to determine the status of the NYDEC regulations under the Commission's new adequacy and compatibility policy. The team found that the State addressed the following NRC regulation amendments: e " Low-Level Waste Shipment Manifest information and Reporting," 10 CFR Parts 20 and 61 amendments (60 FR 15649 and 25983) that became effective March 1,1998. The NYDEC adopted this rule by reference on July 9,1997. The team noted that the reference listed in Section 381.18 was as of January 1,1996. Subsequent changes were made to the regulation that are not incorporated by reference. The NYDEC will adopt the more recent regulation by reference at the next opportunity to change the rule. e "10 CFR Part 71: Compatibility with the International Atomic Energy Agency," 10 CFR Part 71 amendments (60 FR 50248 and 61 FR 28724) that became effective April 1,1996. The NYDEC has adopted the DOT and NRC transportation regulations by reference on July 9, 1997; therefore, no further action is required to make this regulation effective on NYDEC permittees. The team noted that the incorporation by reference was as of January 1,1996 which does not include the corrected tables which were published in 1996. In addition, NYDEC reference includes those items that are limited to NRC implementation. The NYDEC is reviewing these issues and will address them in a future rulemaking, if necessary. The NYDEC has not yet adopted the following regulations, but intends to address them in timely rulemakings or by adopting alternate generic legally binding requirements: e " Radiation Protection Requirements: Amended Definitions and Criteria," 10 CFR Parts 19 and 20 amendments (60 FR 36038) that became effective August 14,1995. e " Termination or Transfer of Licensed Activities: Recordkeeping Requirements," 10 CFR Parts 20,30,40,61 and 70 amendments (61 FR 24669) that became effective May 16, 1996. e " Resolution of Dual Regulation of Airborne Effluents of Radioactive Materials; Clean Air Act," 10 CFR Part 20 amendment (61 FR 65119) that became effective January 9,1997. I e " Criteria for the Release of Individuals Administered Radioactive Materials," 10 CFR Parts 20 and 35 amendments (62 FR 1662) that became effective May 29,1997. 1 I I 1 l i

New York Proposed Final Report Page 38 e ' " Radiological Criteria for License Termination," 10 CFR Parts 20,30,40 and 70 amendments (62 FR 39058) that became on effective August 20,1997. Based on the IMPEP evaluation criteria, the review team recommends that NYDEC's performance with respect to the indicator, Legislation and Program Elements Required for Compatibility, be found satisfactory. 4.2 Sealed Source and Device (SS&D) Evaluation Proaram The NYDL has the responsibility for commercial and industrial use of radioactive materials; therefore, NYDL is the only New York program that has responsibility for the SS&D evaluation program and is the only program reviewed under this indicator. In assessing NYDL's SS&D evaluation program, the team examined information provided by the iJYDL in response to the IMPEP questionnaire on this indicator. A review of all completed SS&D evaluations and supporting documents covering the review period was conducted. The team interviewed the staff and supervisor responsible for SS&D evaluations, and examined the staff's use of new guidance documents and procedures. l Since the last review, NYDL has performed one SS&D review which was completed in 1997 involving .a static eliminator. Historically, NYDL has performed few SS&D reviews due to the limited number of manufacturers (currently 2 licensees) in New York. Prior to 1997, the last l SS&D review was performed over six years ago by a former employee prior to his retirement. Due to the infrequent number of SS&D reviews and limited scope and complexity of

manufactured SS&Ds in the State, NYDL management has not put forth the effort to bring the SS&D program in line with the specific guidelines in Management Directive (MD) 5.6. The

NYDL management does not feel it is an efficient use of its resources to qualify and maintain qualification for staff in a discipline that is infrequently needed.

The NYDL has adopted or issued a number of guidance documents to assist in the review of SS&Ds, and to help to ensure that all pertinent issues are addressed. These include NRC's NUREG-1550, " Standard Review Plan for Applications for Sealed Source and Device Evaluations and Registrations"; Regulatory Guide 6.9," Establishing Quality Assurance Programs for the Manufacture and Distribution of Sealed Sources and Devices Containing l Byproduct Material"; Policy & Guidance Directive 84-22, Revision 1,"What Source and Device ! Designs Require an Evaluation"; and a memorandum as standard reviewer guidance issued l . February 2,1996, containing draft regulations covering the licensing of manufacturers or initial transferrers of products containing sealed sources to persons generally licensed. Staff uses ! the checklist from NUREG-1550 to assist in the review of SS&Ds, and help to ensure that all pertinent issues are addressed, in addition, the NYDL has at its disposal a number of f additional guidance documents including national and international standards, various j regulatory guides, and SS&D workshop materials ('95 and '97 manuals). The supervisor also l indicated that they have recently received NUREG-1556, Volume 3," Applications for Sealed Source and Device Evaluation and Registration," and will incorporate it into their review . procedures. This document was received after the one SS&D action was reviewed. 4.2.1 Technical Quality of the Product Evaluation Proaram I a

l l New York Proposed Final Report Page 39 The team examined the one new SS&D registration certificate action and a " custom" product evaluation and their supporting documentation. The evaluations reviewed covered the period since NYDL's last review. The one SS&D registration certificate issued by the NYDL and i evaluated by the team is listed with case-specific comments in Appendix F. The review team suggests that NYDL consider the comments identified in Appendix F, and take action as NYDL deems appropriate. l Interviews with the two staff responsible for SS&D evaluations indicated that nct all staff were aware of, or did not consult, the current NYDL SS&D policies and procedures during the SS&D review. The team believes that in order to have a sound program and ensure that reviews are performed consistently, it is important that SS&D reviewers be aware of, and follow, the standard policies and procedures established by NYDL's management. The team noted three items in particular. Interviews with staff indicated that:

      . Not all reviewers were aware of, nor followed, the memorandum directing the staff to use, as guidance, the draft NYDL regulations concerning the requirements for licensing persons to manufacture or initially distribute products to persons generally licensed. The SS&D reviewers were generally aware of the types of requirements placed on persons wishing to manufacture or initially transfer products to persons generally licensed and were aware of the February 2,1996, memorandum containing the draft regulations. However, the SS&D reviewers were not aware of the specific requirements contained in the draft regulations and

, did not consult them during their review.

      . Not all staff were aware of, or completely understood, the policy for reviewing Quality Assurance and Quality Control (OA/OC) programs for manufacturers and distributors of SS&Ds. The first reviewer indicated that the review of OA/OC programs was accomplished during the licensing review rather than the SS&D review and, therefore, did not perform a l

review of the OA/OC program. The concurrence reviewer indicated that he was not aware of the policy to review OA/QC programs during the licensing review, and assumed that the first reviewer adequately reviewed the OA/OC program during the first review and, therefore, did not perform a review of the OA/OC program.

      . Both reviewers relied heavily on the checklist in NUREG-1550 to identify specific items that should be reviewed during their evaluation rather than using it as a guide to help identify areas that should be evaluated. The SS&D reviewer should have then consulted additional guidance documents and regulations, as necessary, to identify specific items that must be evaluated or that must be addressed by the applicant.

The review team recommends NYDL establish and use additional procedures for conducting SS&D reviews based on the guidelines presented in the SS&D Workshop and tailored to NYDL's specific policies, requirements, and regulations.

  . There was no clear NYDL established policy on what constitutes a concurrence review. During the interviews, neither the reviewers nor the supervisor indicated that a concurrence review should involve an independent technical evaluation of the file such that the concurrence reviewer may determine if all areas were adequately addressed and all applicable regulations I   were met. The concurrence review performed for the registration certificate completed during

l Il New York Proposed Final Report Page 40 the review period relied heavily on the ability of the first reviewer and the enmpleteness of his j review (as indicated by the checklist) and little independent review of the file was performed. I i Furthermore, under the NYDL program, there is no formal process for granting signature authority, nor for determining if a reviewer is qualified to perform all areas of an evaluation prior ' to obtaining signature authority. The purpose of these guidelines is to ensure that each area of the evaluation is addressed by two qualified individuals. Full signature authority should be given only to those reviewers that have demonstrated that they are qualified to perform all areas of the evaluation. The review team recommends that NYDL establish a clear policy for what constitutes a concurrence review in accordance with guidelines in Management Directive 5.6. 4.2.2 Technical Staffina and Trainina The NYDL reported that two staff members currently have authority to sign SS&D evaluations, with a combined staff effort equaling approximately 0.07. FTE dedicated to performing safety evaluations. The remainder of their time is spent in licensing actions and inspections. The superybor has a Bachelor of Science in Physics, and a Masters in Chemistry and is responsible for oversight of the SS&D evaluation program. The supervisor does not perform technical evaluations of SS&D actions. However, interviews with the SS&D reviewers and the supervisor indicate that it is standard practice for the supervisor to review all documents (including SS&D certificates) prior to issuance. There are two staff members who have signature authority. The first staff member has an Masters Degree in Physics and a Bachelors of Arts degree in Psychology. The second staff member has a Bachelors of Science degree in Biology. Neither staff member has any previous experience performing safety evaluations of products or similar types of evaluations, nor has worked in a related field. Both reviewers have attended NRC's SS&D Workshop. Since joining the State, the majority of the reviewers' experience has been performing licensing actions. In general, SS&D staff are well trained in Health Physics F.rinciples. Due to the fact that only one action was processed by the State during the review period, the basis for assessing the adequacy of the engineering design analysis skills of the staff was limited in addition, the complexity of the design of the one action process and the level of potential radiation hazard from the product was low. However, based on the interviews with the staff, it appears that neither staff has a strong background, through formal trainirig or prior experience, in the area of engineering design analysis. To address this issue, the Supervisor indicated that the use of qualified engineering staff in another division has been prc;.osed and was under consideration. This option was attempted during the " custom" review, but resulted in limited success. The supervisor indicated that this request may have met with limited success due to a lack of understanding of what was expected of the engineering staff and a lack of emphasis placed on , the importance of the engineering review by the engineering staff's management. However, the ! supervisor indicated that the process for requesting additional engineering help was also under ,

review and possible revision, so that the next request would be more successful. '

l The team identified that NYDL's policy for granting signature authority is to assign signature authority to persons who both meet the minimum criteria for a licensing reviewer and have also I attended an NRC SS&D Workshop. No further evaluation of the reviewers qualifications is - performed to ensure they meet the criteria in MD 5.6.

                                                                                                                                                                         )

f l I  ! l I

1 1 New York Proposed Final Report Page 41 The team discussed the importance of a qualification program in the SS&D area. Such a program would ensure that reviewers given SS&D signature authority would first be evaluated to ensure that the reviewer meets established minimum standards, through experience, l training, and/or formal education, to enable the reviewer to fully address all issues in the areas for which they are being granted signature authority. A qualification program would also ensure that reviewers complete a sufficient number of cases which are critiqued by a qualified SS&D reviewer to determine whether the reviewer adequately identified and addressed all pertinent issues. The review team recommends that NYDL develop a formal qualification program for granting signature authority which would ensure that reviewers meet both the qualifications j listed in Management Directive 5.6 and are able to apply these qualifications appropriately during an SS&D evaluation. ( The training should include the following subject areas: I

         -- engineering materials and their properties and uses
         - reading and understanding engineering drawings and blueprints
         -- understanding the interrelationship of conditions of use and prototype testing, and
         -- interpreting test results (e.g., prototype and performance testing)

Prior to performing another SS&D review, on-the-job training should be provided to the reviewers to gain additional experience in performing reviews that includes being critiqued by qualified SS&D reviewers. The team indicated that this training would be offered by the section within NRC responsible for performing SS&D reviews and would require a minimum of two weeks per reviewer. This type training could provide the reviewers additional understanding and experience in applying SS&D procedures and applicable regulations, and understanding and application of basic engineering principles as they apply to SS&D reviews. The NYDL receives a very limited number of SS&D evaluation requests and does not currently have any SS&D reviewers that meet the MD 5.6 criteria. Therefore, NYDL does not have the casework, nor a qualified SS&D reviewer to conduct a qualification program for the existing staff. In addition, NYDL indicated that hiring additional reviewers who already have

 , demonstrated qualifications to perform SS&D reviews would not be cost effective given NYDL's current budget and workload. The review team recommends that NYDL explore one of the following options to meet the qualifications for an SS&D program for New York:

a. Prior to performing another review, provide additional structured training for the SS&D reviewers in the area of engineering principles and materials and their application. This training must provide the reviewers with sufficient knowledge and understanding in the areas listed in Management Directive 5.6 to perform adequate SS&D safety reviews commensurate with the types, complexity, and radiation hazards anticipated for an SS&D safety review.

b. If NYDL determines that maintaining SS&D evaluation authority with a staff that has sufficient qualifications and training to conduct adequate reviews is not viable, return the SS&D program to NRC.

1 l,

1 New York Proposed Fina? Report Page 42 4.2.3 1 Evaluation of Defects and Incidents Recardino SS&Ds The NYDL reported one incident involving a product failure. This incident involved a Troxler portable moisture density gauge. A user reported that the tip of the source rod fell off following i a measurement. The manufacturer was made aware of the incident and followed up with an investigation. A determination was made by the manufacturer that the failure was caused by abuse and lack of maintenance and was not a generic issue. The incident file did not indicate { whether the NYDL agreed with this determination, but the NYDL took actions against the ' licensee in an attempt to assure that the user would follow appropriate use and maintenance instructions. In addition, the NYDL sent a notice to all of its portable moisture density gauge licensees concerning the importance of proper maintenance and use of these devices and modified NYDL's inspection procedures to add a review of maintenance records to all inspections of portable moisture density gauge licensees. The team examined the NYDL's evaluation of this incident, and determined that relevant issues were addressed. The IMPEP team members were unable to reach consensus on the rating for this indicator. Based on the IMPEP evaluation criteria in MD 5.6, the reviewer of this indicator recommended NYDL's performance be found unsatisfactory and the team leader recommended the performance rating be found satisfactory with recommendations for improvement. When IMPEP team consensus on an indicator rating is not achievable, the team leader recommendation is used as the rating of record. 4.3 Low-Level Radioactive Waste (LLRW) Disposal Proaram The New York State Department of Labor (NYDL) and the New York State Department of Environmental Conservation (NYDEC) split responsibilities for the low-level radioactive waste program in the State of New York. NYDL is responsible for the occupational exposure of individuals and control of radioactive material as it affects occupational exposures. This includes the on-site radiation control program. NYDEC is responsible for all environmental releases and the permitting of the disposal units (design, construction, and operation of the disposal facility). This includes waste package receipt and inspection and temporary storage of waste prior to emplacement in waste disposal units. The State of New York has stopped activities for siting a commercial low-level waste disposal site. Therefore, the programs are not staffed nor prepared to process a new license application. The team finds this acceptable given the status of the LLRW siting process. The State does have two former radioactive waste disposal sites: The State Licensed Disposal Area (SDA) at West Valley, and the Radiation Disposal Site (RDS) at Cornell University. The SDA is a portion of the West Valley Nuclear Services Center site and was operated as a commercial radioactive waste disposal site. The site ceased operations in 1975, and has been under State ownership and control. The New York State Energy, Research, and Development l Authority (NYSERDA) is the State agency responsible for the site and is permitted by NYDEC and licensed by NYDL. NYDEC has issued three permits to NYSERDA for this site. One air Nissions permit, one Research and Development (R&D) permit for the cover design study, and the disposal permit that limits the discharges from the disposal area itself. Now that the testing phase of the cover study is completed, the R&D permit will soon be combined with the disposal permit. NYDEC inspects the site on an annual basis with NYDEC staff and visits the site on a much more frequent basis. The team reviewed the latest inspection report (June 4, l l l l

New York Proposed Final Report Page 43 1997, see D-4) and found the inspection thorough and timely. The disposal area has been covered with the R&D cover or a synthetic membrane cover. The State is monitoring the water levels in the trenches to determine the effect of the covers. The NYDL is responsible for the occupational activities at the site due to a storage building with a small amount of LLRW being stored. The NYDL inspects the site on an annual basis to determine if the materials are properly stored and if the licensee has maintained an acceptable radiation protection program. The NYOL has conducted these inspections during the review period. The Cornell disposal site dates back to the early radiation programs through the mid-1970's. The NYDL has no responsibility at this site since it was not a commercial disposal site, Cornell holds a radioactive materials license from the NYSH. The site is being remediated through a consent order with a sister Bureau within the NYDEC other than the Bureau of Pesticides and Radiation (BPR). The consent order includes the requirements that would be imposed by a permit from BPR. Upon completion of all activities under the consent order, BPR will issue a permit for the ongoing monitoring activities for this site. The site has been partially remediated by covering the waste disposal area with a synthetic cover and a layer of soil to protect the ' synthetic cover. There is still ground water remediation needed for non-radiological contamination at the site. The Cornell site is inspected on an annual basis. The team reviewed the last inspection and determined that the scope and quality of inspection was appropriate. Based on the IMPEP evaluation criteria, the review team recommends that NYDL's and I NYDEC's performances with respect to the indicator, Low-level Radioactive Waste Disposal Program, both be found satisfactory. 5.0

SUMMARY

As noted in Sections 3 and 4 above, the review team found that the performance of the four New York agreement programs with respect to each of the performance indicators to be mixed with 21 satisfactory,4 satisfactory with recommendations for improvement, and 1 unsatisfactory. The most significant concerns were associated with the NYCH program. Accordingly, the team recommends the Management Review Board find the New York program to be adequate, but needs improvement, and compatible with NRC's program. The review team recommends that a follow-up review be scheduled for the NYCH program to assess the progress of the program in implementing their responses to the recommendations in this report. Below is a summary list of suggestions and recommendations, as mentioned in earlier sections of the report, for evaluation and implementation, as appropriate, by the individual programs. NEW YORK CITY DEPARTMENT OF HEALTH (NYCH) RECOMMENDATIONS:

1. The review team recommends that the NYCH correct the software anomalies that limit NYCH's ability to effectively track licenses for inspection, set and adhere to yearly inspection goals, and communicate NYCH management's expectations with regard to inspection goals, such that NYCH is able to eliminate all overdue inspections. (Section 3.1.1) l

New York Proposed Final Report Page 44

2. The review team recommends that allinitial inspections of licensees be performed within six months of license issuance or within six months of the licensee's receipt of material and commencement of operations, consistent with IMC 2800 and NYCH policy. (Section 3.1.1)

3. The review team recommends that NYCH inspectors follow the gu'idance in the NYCH inspection procedure manual which includes the information necessary for properly documenting violations. (Section 3.2.1)

4. The review team recommends that NYCH inspectors follow the guidance in NYCH inspection procedure manual which emphasizes the use of performance based inspection techniques rather than compliance-based techniques and provide training to its inspectors ,

through NRC's Inspecting 'or Performance Materials Course or similar course. (Section 3.2.1)

5. The review team recommends that NYCH document its training program to include overall policy and minimum training requirements to be qualified to conduct the responsibilities of the program for both the licensing and compliance staff. (Section 3.3.1)

6. The review team recommends that NYCH review the staff's training against their training requirements, clearly document how the traiaing was achieved, and acquire the necessary training, as appropriate. (Section 3.3.1)

7. The review team recommends that NYCH notify the NRC Operations Center within 24 hours for all significant events, and provide complete follow up documentation to NMED on all reportable events. (Section 3.5.1)

8. The review team recommends that NYCH place the regulatory changes agenda and establish specific schedules to address the regulatory changes in Section 4.1.1.2 within three years of the regulations becoming effective NRC rules. (Section 4.1.1.2)

SUGGESTIONS:

1. The review team suggests that NYCH establish a policy that the results of all Tribunals for their licensees be placed in the appropriate inspection files. (Section 3.2.1)

2. The review team suggests that the NYCH Bureau Chief position be filled as soon as possible so that attention can be applied to management oversight of the program shortfalls identified in this review. (Section 3.3.1)

3. The review team suggests that NYCH consider documenting how the SS&D conditions of use were addressed for the two gamma knife licenses and will be addressed in future licensing action. (Section 3.4.1) j 4. The review team suggests that NYCH list the date the licensing action is issued (date of fee payment) on the license and in their database, instead of the date of management signature. (Section 3.4.1)

                                                                                                                                                          )

r 1 I

New York Proposed Final Report Page 45

5. The review team suggests that NYCH investigated incidents be clearly documented in the field notes at the next inspection. (Section 3.5.1)

6. The review team suggests that NYCH include written documentation that the alleger has been contacted regarding the results of NYCH's findings into the alleger's concerns. 1

              - (Section 3.5.1)                                                                                )

NEW YOP't STATE DEPARTMENT OF LABOR (NYDL) RECOMMENDATIONS:

1. ' The review team recommends that NYDL perform initial inspections of licensees within six months of the licensees' receipt of licensed material, or commencement of licensed activities. (Section 3.1.2)

2. The review team recommends that NYDL document its training program to include overall policy and minimum training requirements for both the licensing and compliance staff.

(3.3.2)

3. The review team recommends that NYDL notify the NRC Operations Center within 24 hours for all significant events and provide complete follow-up documentation to NMED on all reportable events. (Section 3.5.2)

4. The review team recommends that NYDL management take appropriate action to move the rule package through the rule promulgation process. (Section 4.1.2.2)

5. The review team recommends NYDL establish and use additional procedures for conducting SS&D reviews based on the guidelines presented in the SS&D Workshop and tailored to NY DL's specific policies, requirements, and regulations. (Section 4.2.1)

6. The review team recommends that NYDL establish a clear policy for what constitutes a concurrence review in accordance with guidelines in Management Directive 5.6. (Section 4.2.1)

7. The review team recommends that the NYDL develop a formal qualification program for granting signature authority which would ensure that reviewers both meet the qualifications listed in Management Directive 5.6 and are able to apply these qualifications appropriately during an SS&D evaluation. (Section 4.2.2)

8. The review team recommends that NYDL explore one of the following options to meet the qualifications for an SS&D program for New York:

a. Prior to performing another review, provide additional structured training for the SS&D reviewers in the area of engineering principles and materials and their application. This training must provide the reviewers with sufficient knowledge and understanding in the areas listed in Management Directive 5.6 to perform adequate l

o

New York Proposed Final Report Page 46 SS&D safety reviews commensurate with the types, complexity, and radiation hazards anticipated for an SS&D safety review.

b. If NYDL determines that maintaining SS&D evaluation authority with a staff that has sufficient qualifications and training to conduct adequate reviews is not viable, return the SS&D program to NRC. (Section 4.2.2)

SUGGESTIONS:

1. The review team suggests that the NYDL management consider whether additional staffing is warranted when considering the impacts of the licensing and inspection workloads, the regulation development needs, and the SS&D program improvement needs. (Section 3.3.2)

2. The review team suggests that NYDL continue to audit their financial assurance files to ensure that they contain all required information and are current with NYDL requirements.

(Section 3.4.2)

3. The review team suggests that attention be given to the NYDL's tracking system for .

allegations to ensure that the system accurately indicates when the response to each L allegation has been completed and the matter is considered closed out. (Section 3.5.2) { l

4. The review team suggests that NYDL consider the comments identified in Appendix F, and take action as NYDL deems appropriate. (Section 4.2.1)

GOOD PRACTICES:

1. The review team noted a good practice in that NYDL's inspection field notes and inspection correspondence are peer reviewed by one of the senior inspectors to assure consistency, thoroughness, and quality of reports. (Section 3.2.2)

NEW YORK STATE DEPARTMENT OF HEALTH (NYSH)  ! l RECOMMENDATIONS- i 1

1. The review team recommends that NYSH modify to its inspection program to ensure that initialinspections are performed within six months'of the licensee's receipt of licensed material, within six months after commencement of licensed activities, or within one year of license issuance, whichever comes first, consistent with IMC 2800. (Section 3.1.3)

2. The review team recommends that NYSH notify the NRC Operations Center within 24 l hours for all significant events, and provide complete follow-up documentation to NMED on all reportable events. (Section 3.5.3) l l

New York Proposed Final Report Page 47 SUGGESTIONS:

1. The review team suggests that NYSH's inspection documentation of exit meetings should contain substantive discussions of issues with the Radiation Safety Officer (RSO) and/or licensee management. (Section 3.2.3)

2. The review team suggests that NYSH incorporate a field for documentation of interviewing ancillary personnel, authorized users, technicians, and RSOs into their field notes. (Section 3.2.3)

3. The review team suggests that the NYSH inspectors attend additional training in inspecting for performance techniques. (Section 3.2.3)

GOOD PRACTICES:

1. The review team considers monthly TeleVideo conferences to be a good practice to  ;

bring and keep their staff current on health physics and program issues. (Section 3.3.3) NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION (NYDEC) RECOMMENDATIONS:

1. The review team recommends that NYDEC document its training program to include overall policy and minimum training requirements for both the permitting and compliance staff. (Section 3.3.4)

2. The review team recommends that NYDEC incorporate the handling of incidents and allegations into their inspection procedures. (Section 3.5.4)

3. The review team recommends that NYDEC coordinate with the appropriate New York licensing agency the notification to the NRC Operations Center within 24 hours for all significant events, and to NMED for all reportable events involving permitted activities. 1 (Section 3.5.4)

SUGGESTIONS:

1. The review team suggests that NYDEC maintain one file for all types of incidents l involving radioactive material. (Section 3.5.4)

t l' LIST OF APPENDICES AND ATTACHMENTS Appendix A IMPEP Review Team Members Appendix B B-1 NYCH's Organization Charts l B-2 NYDL's Organizational Charts B-3 NYSH's Organizational Charts l B-4 NYDEC's Organizational Charts Appendix C C-1 NYCH inspection File Reviews C-2 NYDL Inspection File Reviews C-3 NYSH Inspection File Reviews C-4 NYDEC Inspection File Reviews Appendix D D-1 NYCH License File Reviews D-2 NYDL License File Reviews D-3 NYSH License File Reviews D-4 NYDEC License File Reviews Appendix E E-1 NYCH Incident File Reviews E-2 NYDL incident File Reviews E-3 NYSH Incident File Reviews E-4 NYDEC Incident File Reviews Appendix F NYDL Sealed Source and Device Reviews

          . Appendix G                                                          G-1                                          NYCH's Questionnaire Response    i G-2                                          NYDL's Questionnaire Response G-3                                          NYSH's Questionnaire Response G4                                           NYDEC's Questionnaire Response Attachment 1                                                         February 17,1998 letter from Mr. K. Daniel, Jr., NYCH                         )

J Attachment 2 New York Programs' Comments on the Draft IMPEP Report i

l L APPENDIX A IMPEP REVIEW TEAM MEMBERS New York City Department of Health. Bureau of Radioloalcal Health (NYCH) Name Area of Responsibility Dennis Sollenberger, OSP Team Leader Technical Staffing and Training Legislation and Program Elements Required for Compatibility Duncan White, RSAO, Region i Response to incidents and Allegations Technical Quality of Inspections Michael Stephens, Florida Technical Quality of Licensing Actions Jamnes Cameron, Region 111 Status of Materials inspection Program Technical Quality of Inspections New York State Department of Labor. Radioloalcal Health Unit (NYDL) Name Area of Responsibility i Dennis Sollenberger, OSP Team Leader Technical Staffing and Training Legislation and Program Elements Required for Compatibility Low-Level Radioactive Waste Disposal Program Duncan White, RSAO, Region i Technical Quality of Licensing Actions Technical Quality of Inspections

James McNees, Alabama Response to incidents and Allegations Technical Quality of Inspections ..

Douglas Broaddus, NMSS Sealed Source and Device Evaluation Program Lance Rakovan, OSP Status of Materials inspection Program

l New York Proposed Final Report Page A.2 IMPEP Review Team Members l l New York State Department of Health. Bureau of Environmental Radiation Protection (NYSH) l Name Area of Responsibility i Dennis Sollenberger, OSP Team Leader Technical Staffing and Training Legislation and Program Elements Required for

Compatibility Duncan White, RSAO, Region i Status of Materials inspection Program Response to incidents and Allegations Lee Cox, North Carolina Technical Quality of Inspections Jacqueline Cook, Region IV Technical Quality of Licens 1g Actions New York State Department of Environmental Conservation. Bureau of Pesticides and Radiation (NYDEC)

Name Area of Responsibility Dennis Sollenberger, OSP Team Leader Technical Staffing and Training Legislation and Program Elements Required for Compatibility Low-Level Radioactive Waste Disposal Program Duncan White, RSAO, Region i Technical Quality of Licensing Actions Response to Incidents and Allegations Inspector Accompaniments Allen Grewe, Tennessee Status of Materials inspection Program Technical Quality of Inspections

t j l APPENDIX B-1 New York City Department of Health, Bureau of Radiological Health (NYCH) ORGANIZATION CHARTS ( l-

    .3, f                                                                                                                                                                                        -#

t p yll 21 ah4 - ij

                           ,i$i-
                                   !!W    li!

i _ id11 . 3,,,, 1gj] "h i f Iy th Ijil -lI d pl '-]pl 3 1 iii . i W I,y . . 18lrji Fl il 11 ~ {H 11 i ll' 3 II 91llr!ll 11 I t.. t i, ,

 !! llI:   II n                                                                 t ia                                                                h

- d - e t n hy e - Ilb e A p s nt n r d f s re enu kk ns

                                                                    -o NS.o X                                            n                                                    a            S               e4 I

D N t i ' ga S.u R r r B. N K. B i t n ta s r A C. AE g am _ eS is E so /  ;; s M. C v. P M  ; A T P A i Mt n - i h dr

                                                                                                                                       . g
                                                                                                                                       . g   .

o- - Wtle ,ur t hI> n . g e a P r tnis _ ic F. R "DJ. B.p, g nWiM. t is e S le J. n c _ q n ke SO je S e L

                                  /s

_ t l _ it fe U n s r M t ye ms s v ,d L S e e a g,n 8 A e a 8 , o E v ,m 8 H n ,c e R. L A e c d M ts a r 3 H. t ggWP K WSe( n/ r3 tn e n G i c o2 d O .S

                           -   r s on     de4                                                  A L                t r    ir (

O _. J 2

                      ;        c. Dt e                                              l N   C C    e hain I                ir A

R t n e Dw t t e D. i r h s/ DK O s _ U AE c o

                                                                .               l rN n

u igs A E s s a MsA R A. yt - U nn}t e m l ss oc i B d e Rr Ae c i' eo le C g - a Wy l t 5s s

                                                                                                      ,-            o9o d8n
                                                                                                     .              a# v r         a
                                                                              '                   1   M t            P "58 R.

hs -C K s 3 t A S t Eh g dgni e eN Rt t

                                                         - cc                                         p e

rSM n to r u e d,

                                                                                        ,            d                  le t i

c on A. ei r eJ e

                                                                                        ,            S                  mn e ne

_ y t D. S r n hc S. t l s c l a s s t s g S. E A y Is J s A t s nn d e ew 'eip S thmi o e l hw t n a MT I

i j

                                                                       ' APPENDIX B-2                                              .
                                                    .                   New York State Department of Labor, Radiological Health Unit (NYDL)
                                                                                                                                       ]

ORGANIZATION CHART ' l l l l l

                 .5 I

\' 1 i. i (e l u l' . o l ... _

                                                                                                                                  !'              l!1,!                -

lI c. e J. l m my laI t oo h n I ar y de te c a. nS e E Pl a ep n i. u F s-c n a. r. N I J ;. 7 Y e c i f f O y n a y

            $M m

b l A m@n. t d1a i k, t s n 'k o dr o J t s i yh i t s c is y yMs@s, r l p p Bil o: . l eo n . _ d "- Kid toR nR tr a ye e eR at ne bot e 0 l a nt a e Ci c ei Do cs Ri ac pMn n% A o s s A s o s s ns ii A

            $fa, Da Ww,,
                                -                              r          '

r ht oh t 8'

• t osct ch Ea i

r e a " n

                                       'm o            r                t r c

_ r m :mo mn cI ii U ee mb oi o eI r D. f a M' h ol a va c t " h ea C. et iD, & s ' s Me-t y y c ist 8' o, S C. . of " l _ i pt e o ot c st i o r l ik r DP Af a a t k r ao mY i

                                .n
                                .t e i se r I     c uS a i iSr l #'l     a c

im~ s sa is Peew rN r WeD om Ct ra p i sk r a o c aW r Cf o dr n a o hi ci s k l i h e Cis fo o n h' ig

                                                                          *o I l d' io I
                                                                        ^d o                V                       ri v            a iRiv c      !

o s e ei 'R a t e i n D eD I' m n P " is%n p J a C o jWw Mn R i t s c i t s o YpDn is l t l y i a n eI ah c _ wp e d y i p v r - Aio d S ot a wa r e hvM. b

           ?p

i. eR r

d e nt Ai ca dr b a o y Pr c T ye r rS e p# e o K gbn _

      '                                                                                    s s

A . h -

           $Mw, 2                                                              W d

Y . w e t t t s _ s s N i c i c _

                                                                                                                           *J.,                                             -

is t is l r y t y ah eh ht p l 1, r P p o oi o a! . l ei id Kd a h Mda r

a. R a

sR mR .

                                                                                                                                                    . e jte e                ie J t                           mta a

ri a l a oi Bc o e Rc o s w s _ s s s A A A

                                                                                                                                       .Iill!                       Il    '

I:, l 1 l APPENDIX B-3

                                                                             - New York State Department of Health, Bureau of Environmental Radiation Protection (NYSH)

ORGANIZATION CHARTS l t 6

ATTACEMENT II Appendix B Governor DOM commissioner I 1 office of office of Health Public Health systems Management I 1 wadsworth ctr. Center for to'r Labs. and center for Research Environmental community Health Health I I l Div. of occupational Health and Div. of Environ. Environ. Epidemiology Protection Div. of Environ. Health Assessment , i I

  '                                                                                                            I Bur. of community                Bur. of Environ.                                              Bur. of Public Sanitation and                      Radiation                                                  Water Supply Food Protection                    Protection                                                                             )

i I I ErWironmental Field Radioactive Radiation - Radiation offices Materials Equipment l section section section ! 1 I I I Butfalo New Rocha11e Syracuse Rochester

kP ~bd T -!L jp __ IL 1 , ij , l,

                                                         =                  U        U
                                                         ]    [gf    -

1"

                                                                            .[   ~   jg h                     _                                                         l;!

U -- I-o l I 1 IlI r E I I jp _l l - r i, a j i T i

    !n  l-g                   -

I! I l I b

                 $  gi  -                                                              -

I= til

        <a i

il L, I - II T s i 8 I irs sil i Ff l]}

                              =

g .- [g a] i-lr.o a y e _ l 1 I I O - D 5 - 1

                                                                    -   !!                       1

! 5 l lj }) jI g- ig LE-f - 1 i ii a ml-i-p. l} il {} -- h j , 11 ! l.I __ - 3l Il ll i _2l 1- - il l a ji l I,

                                           ![!!

l.-ll 1

1. d l i

i I I

L. F. l l-l APPENDIX B-4 I New York State j Department of Environmental Conservation, Bureau of Pesticides and Radiation (NYDEC) l

         ,                                                                    ORGANIZATION CHARTS o

I [. i

                                                                                                                                                       -l l

i _m____=____ . _ _ _ _ _ _ _ _ _ ___ . . _ _ _ . _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ )

S s E & E = s DCI) fN C Y NG) SC

                                                                                                  )

S T S

                                                                                                                                  .e   n NVC               Do i

E OC LED E gu o wARASE( Unn AAe I CLA AC( , g

                                                                                                            ,          n 0
                                                                                                                                  ,s t

EGSn e RRn , s at CNNg law SO No(o UUe e F

                                                                                                                       &    t a     , s I

AnH. ton ASu 8 n .t aa mR Oe I s NS RER wHR. E C N OA EAT D. HID P Mm v CET. m& T5 E D. R P eemn J L a m A m E m O -- M - E V. t c n N A o E d n E

                                                                                          &N)             m                           a o

i YIOC c fT( f lI r ADe UEre A D e m e n.

                   )                                                                                                                  w n8                                                                         O M C.                                      s REE o9                                                                        ER i

M v1 9 - T A _- r e s y W n r o a Cu l e n t ma . e e n u n wJ n e m( R

• T) e g t A

i mT vR n E N O g g g h. EN T E C S A M (r D s t E m O w EA I c wee G l a _ f I oI S S P. sam o t s e dC I M n RNe I A l. A t o n AMC - e M ho mN - - t O J _ eO g I e C DT eA MZ I SI s t kro N tg m t o o ps t - YA N O 4 y n m us k e wG t _ I; TC m s e e s a P NeR AA a h O R Tt (e lI C se s

                                                                                                                                =m n e e

g Su e a m r L N e I l g m e o E IMT. n e m o e S N S g o ne G D ses wU. s A p c s r o O e ECs C m A O_ _ - - m e F v mALRre. y s g a

                                                            ,                                                                                     o OE .        t n

G _ N E o , o _ a , t . O g g e s - t

                                                        -      _                 s  W                                                             r o

f - e d o p A F D c e P r A r, l i YR 4 e s e N 4 T E 9 e WL e N O M UNs P Ou m A o f E G B W) & S a C o L C C c r h es e eeW e te I M EI A sm e nM Ao mo I T) dss n CC E cE E M(e s n wE(T A u E C eM t oE RISE OMD. t s L I S n r Ft Fa Ac s s l o e EO C s R mnO I NMO - -- h e Cu Lo n e l mPu Ra 0 8 8 pe tm eu p EO SC MS. MO ef u p e m m m o OCt e nE UA G W oU E E C U A L PF _ - _

• P

 ,llllll1\             l   i'

e W *bf h$ 1v se - se - . a3 ;is es a 1 l]3 in a a- , ' # , (' ) E f 3 > 5 5 45 I z - 5hI 1.-J u h-a I< s= -{hil ah - a$< asp -

a

   ,,                                                  '             f          o L         )

g

                                   ;            o a                  <        ,

ff. ., s e,.  !!!hsan u !- ' ' > . j ;1 w t  ; v. s." 5T 4 r , y fi f. f f,fj_

     .                (        y i          ,         ,.--
   .h 3   1            >             g I'E l

lHI qu li! 11! e!

                                  ?

ill i!1 ll - e E i l P 'I k j g ~ 1 f. Ul~ t,l), !,!l s-e il

                                                                         ,i        s
                  -:J  i i= .e                 ,             s le        r*

3 s 4 ' ' ' i ( J i

ll \ ;l I1l' t s e c i nl i R 2 oa t i tr 8 h9 s c yS c0 ne h p ht R m2 / oE 44 J oS en ia r i T m '8 h' Y 0 B ao a' Mbye @ lI e y K l h l l i r aa l l e w a n e n m h

                 .l Bt re
                   .l c ie h

t iS c2 bS AR u1 RSR aI - - MR In I

                  .J                                                                                                    }

n S o f nE nE h hE i t e h o - o i a i h J R J d C a n R ni o

       &                               otc d

i s e i t cS e S g e k e i o s a

                                                                                                      )t n

W h n e c r c c a c i t s i ob g e 2 r aI a W V l e n t a n d VS P o i da uo aS R I ( W f rt oi a i

                                  \.                  KRE                    mE a

1 o t RY n i S h u cd a h l R a e a r o l i E h e .iR r a J W t r . br t u D. D & B h a ems B a M . i n P rd

                 ,gi M

T s oi c y f er t a gP s r e l k a r M t e a S eloP k v G m Mtn o r f i2 n i p1 i eI a . J ou l I S S S rS r I aR g u Ca e aR s uR ME l r or anr dE kE n P P iB o u n a r a n A t n i r a , S M i o d o t at i a Rc er d i _ a D R f l o , n .f' e 1 o  ? t i t a c d yi cn h C e

                                                                                 .t 2'          l s

y a

                                                                                                               ;2 6
                                                                                                                ..t o                                       n      eo                         s y             n                s L                            $$ne
                                     $           t aSi r s c t
                                                                               . l a           A           kic g e o h;3@jp d

1 f oee pcS pi v , NA, e

                                                                                 .n             l t

a n bl t i e o e h t ifm a Zl ta Wg G Qn$w i t l u S e cym a S rb. "e. I nn h e m n o l en - il iee omn r ni r n a e. J

                                      $sw ni d

ir u nol h ta o . o i v n un e g crc ,i r E Li g iim drR eo b e d ,v n t .n

                                     %      hkn T, a      Ln                   <E                 m c
                                                                                                                 .E.

l a f , A V [$@@a

                                                            '                                              ?

r

                                                                                       ;      l
            ~

I APPENDIX C-1 NYCH INSPECTION FILE REVIEWS NOTE: ALL INSPECTION FILES LISTED WITHOUT COMMENT WERE DETERMINED BY l THE IMPEP TEAM TO BE ACCEPTABLE. l 1 l File No.: 1 l Licensee: NY University Medical Center License No.: 75-2955-01 Location: New York City, NY Inspection Type: Unknown ! License Type: Medical Broad Scope Priority: 1 Inspection Date: 3/19/96 Inspector: TK  ! l l- Comments: ) a) No description of inspection history or indication of follow up on previous findings (previous inspection 3/2/94, identified 5 violations). b) No description of licensed program scope. i ! c) Licensee did not appear on inspection due listing.  ! l d) Inspection overdue. File No.: 2 l Licensee: Montefiore Medical Center License No.: 75-2885-01 i Location: New York City, NY Inspection Type: Unknown License Type: Medical Broad Scope Priority: 1 Inspection Date: 2/3/97 Inspector: TK Comments: a) Field notes include personal privacy information (patient name and social security number). t b) Licensee did not appear on inspection due listing. File No.: 3 Licensee: NY University Medical Center License No.: 74-2955-02 Location: New York City, NV inspection Type: Unknown License Type: Non-Human use Broad Scope Priority: 2 l Inspection Date: Unknown Inspector: Unknown 1 Comment: a) License file did not include field notes or NOV from last inspection, only licensee's response. l l l

New York Proposed Final Report . Page C-1.2 NYCH Inspection File Reviews File No.:! 4 Licensee: Lenox Hill Hospital License No.: 92-2926-01 Location: New York City, NY Inspection Type: Unannounced, Routine License Type: Teletherapy Priority: 1

         ~lnspection Date: 4/26/96                                                                                   Inspector: TK
        ' Comments:

l .a) 2 of 3 violations not supported by information in field notes. b) Third violation cited against regulation that had been superseded two years prior and no L longer in force. c) Licensee did not appear on inspection due listing. l File No.: 5 Licensee: Lenox Hill Hospital License No.: 91 2926-01 Location: New York City, NY Inspection Type: Announced, Routine License Type: Limited Medical

                                                                                              ~

Priority: 2 1; inspection Date: 1/16/97; 9/11/95 Inspectors: EC; TK Comments:

l. a) . Transmittal letter includes four violations, none described in field notes. One violation contradicts information contained in field notes (1997).

b) Field notes do not include follow up on previous inspection findings (one violation l previously identified) (1997). l: c) Field notes for 1995 inspection include description of three violations, none include any l supporting information.

        . d)       Supervisor overruled two of the violations for lack of information, only issued one violation (1995),

i o File No.: 6 l Licensee: Mt. Sinal Medical Center License No.: 91-2909-01

     ,    Location: New York City, NY                                 Inspection Type: Unannounced, Routine

. License Type

Limited Medical Priority: 2 inspection Date: 3/7/96 Inspector: BK Comment:

a)' Field notes include personal privacy information. i

1 L

i l i

1 New York Proposed Final Report Page C-1.3 NYCH Inspection File Reviews File No.: 7 Licensee: NYCHHC/ Lincoln Medical License No.: 91-2915-01 Location: New York City, NY Inspection Type: Announced, Routine License Type: Limited Medical Priority: 2 Inspection Date: 4/28/95 Inspector: TK Comments: a) Transmittal letter includes two violations, one not discussed at all in field notes. b) Licensee response provides information to dispute one violation, no response from NYCH providing analysis of licensee's response indicating whether violation upheld or - retracted, c) Licensee did not appear on inspection duo listing. File No.: 8 Licensee: Young F. Eng, M.D. License No.: 91-3025-01 Location: New York City, NY Inspection Type: Unknown License Type: Limited Medical Priority: 2 , inspection Date: 7/9/96 Inspector: EC Comments: a) No discussion of inspection history in field notes or follow up on previous violations. Previous inspection identified five violations. b) Licensee did not appear on inspection due listing. File No.: 9 Licensee: Joseph Greenberg, M.D. License No.: 91-2998-01 Location: New York City, NY Inspection Type: Unknown License Type: Limited Medical Priority: 2 Inspection Date: 12/12/96 Inspector: CS Comments:  ; a) No discussion of inspection history in field notes or follow up on previous violations. j Previous inspection identified hve violations. b) Licensee did not appear on inspection due listing. File No.: 10 Licensee: St. Vincent's Hospital and Med Ctr of NY License No.: 75-3009-01 Location: New York City, NY Inspection Type: Unknown License Type: Medical Broad Priority: 1  ; Inspection Date: 3/4/97 Inspector: EC  : Comments: a) Field notes include personal privacy and proprietary information.  ; l b) Licensee did not appear on inspection due listing. i l l i

New York Proposed Final Report Page C-1.4 NYCH Inspection File Reviews File No.: 11 Licensee: Brooklyn Hospital Center License No.: 92-2924-02 Location: New York City, NY Inspection Type: Announced, Routine License Type: Teletherapy Priority: 1 Inspection Date: 1/29/97 Inspector: AA Comment: a) Licensee did not appear on inspection due listing. File No.: 12 Licensee:' Brooklyn Hospital Center License No.: 91 2924-01 Location: New York City, NY Inspection Type: Unknown License Type: Limited Medical Priority: 2 Inspection Date: 6/21/96 Inspector: AA Comments: a) Two of three violations not fully supported in field notes; one violation not described at all. b) Licensee did not appear on inspection due listing. c) Licensee response appears to oispute two of the violations. NYCH's response does not indicate whether violations were upheld or retracted. File No.: 13 Licensee: Columbia Presbyterian Med Ctr License No.: 75-2878-01 Location: New York City, NY inspection Type: Unannounced, Routine License Type: Medical Broad Scope Priority: 1 Inspection Date: 12/5/97 Inspectors: RB, Team Comments: a) Nine violations cited. Description of several does not address whether violation was isolated (as observed by inspector on a specific date) or programmatic. b) One violation described in field notes, but not cited, c) Not all violations fully supported through documentation in field notes. File No.: 14 Licensee: Columbia Presbyterian Med Ctr License No.: 74-2878-03 Location: New York City, NY Inspection Type: Unknown License Type: Non-Human Use Broad Scope Priority: 2 Inspection Date: 8/28/97 Inspectors: RB, Team Comment: a) Five of the nine violations cited are not supported through documentation in field notes. l t l

New York Proposed Final Report Page C-1.5 NYCH Inspection File Reviews File No.: 15 Licensee: Columbia University License No.: 74-3030-01 Location: New York City, NY Inspection Type: Routine License Type: Broad Scope R&D Priority: 2 Inspection Date: 10/28-31/97 Inspectors: BK,CS,VC Comments: a) Two separate violations cited for same generic issue. b) Five out of 10 violations cited were questioned by licensee; licensee provided documentation in reply letter to support that information was available during inspection. c) One of two significant violations cited in letter was a repeat violation from previous inspection, but was not noted as a repeat violation in the cover letter. Field notes did note the previous violation, but the violation was closed out. d) Basis for one violation cited in cover letter was not supported by documentation in field notes. e) Cover letter specifically requested full RSC review of reply letter and specific attention to significant violations. In addition, a team member made the following inspection accompaniments as part of the on-site IMPEP review: Accompaniment No.: 1 Licensee: Columbia University License No.: 74-3030-01 Location: New York City, NY Inspection Type: Routine 1 License Type: Broad Scope R&D Priority: 2 l Inspection Date: 10/28-31/97 Inspector: DK,CS,VG i l Comments: l a) RSO not present during inspection. b) RSC meeting minutes not reviewed during on-site inspection. c) Inspection was checklist driven, not performance based. d) Although inspectors identified numerous violations, including two significant safety violations (one of which was a repeat violation from the previous inspection), lead inspector failed to address these programmatic issues during the exit meetings with I licensee's management. e) RSC members not contacted during inspection nor were present at exit meetings. i I i i l E------------------_______ _ _ _ _ _ _ _ _ - - - - - - - - - - ----- - - - - - - - - - - - - - . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ a

l New York Proposed Final Report Page C-1.6 NYCH Inspection File Reviews Accompaniment No.: 2 l Licensee: NYC DOH - Bureau of Lead Poisoning License No.: 52-2624-01 Location: New York City, NY Inspection Type: Routine l License Type: AnalyticalInstruments Priority: 3 l Inspection Date: 1/20/98 Inspector: CS I Comments: a) Inspector requested location of authorized users in field to conduct field inspection, but licensee could not locate any users during the inspection. b) Management representative not available for exit meeting. Accompaniment No.: 3 Licensee: Harvey Stern, MD License No.: 91-2969-01 Location: Brooklyn, NY Inspection Type: Routine License Type: Nuclear Medicine Priority: 2 Inspection Date: 1/21/98 Inspector: VG Accompaniment No.: 4 Licensee: Columbia Presbytenan Medical Center License No.: 75-2878-01 Location: New York City, NY Inspection Type: Routine License Type: Medical Broad Scope Priority: 1 Inspection Date: 12/5/97 Inspector: RB, Team Comment: b) The team inspection did not have a focus for the individual team members. c) The inspectors did not clearly indicate what were violations or poor practices. d) In some cases inspectors presented their opinion on a practice not the licensees commitment or the regulatory requirement, e) The field notes were not completed for all areas inspection. l l l

APPENDIX C 2 NYDL INSPECTION FILE REVIEWS NOTE: ALL INSPECTION FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. File No.: 1 Licensee: Empire isotopes License No.: 2770-4012,2771-4012MD Location: Albany, NY Inspection Type: Announced, initial License Type: Nuclear Pharmacy Priority: 1 Inspection Date: 1/7-9/98 Inspector: JM Comment: a) initial inspection performed 7 months after license issued. Filo No.: 2 Licensee: CoPhysics Corp. License No.: 2691-3949 Location: Middletown, NY Inspection Type: Announced, initial License Type: Gas Chromatograph Priority: 5 Inspection Date: 11/29/95 inspector: RP File No.: 3 Licensee: Buffalo X-Ray Company License No.: 0286-0511 Location: Buffalo, NY Inspection Type: Unannounced, Routine, Field License Type: Industrial Radiography Priority: 1 Inspection Date: 7/19-20/95 and 8/7/95 inspector: AA Cornment: a) Location of temporary job site not indicated in field notes. File No.: 4 Licensee: Atlantic Testing Labs License No.: 2125-2253 Location: Endicott, NY inspection Type: Unannounced, Routine License Type: Portable Gauge Priority: 2 Inspection Date: 10/8 - 9/97 Inspector: BK Comment: a) Licensee had seven locations authorized under license; only main office inspected. File No.: 5 Licensee: Bausch and Lomb License No.: 0771-3533 Location: . Rochester, NY Inspection Type: Announced, Routine License Type: Research and Development Priority: 2 Inspection Date: 5/1/96 Inspector: RP s t _ _ _ . _ _ _ . ---___---___.________-----------a -

1 New York Proposed Final Report Page C-2.2 NYDL Inspection File Reviews File No.: 6 Licensee: Isomedix Operations License No.: 2583-3814 Location: Chester, NY Inspection Type: Announced, Routine License Type: CommercialIrradiator Priority: 1 Inspection Date: _4/29 - 30/97' Inspector: RP Comment: a) Inspection overdue; last inspection performed 2/95. File No.: 7 Licensee: MOS Inspection License No.: 1349-0452 Location: Flushing, NY Inspection Type: Unannounced, Routine, Field License Type: Indus. rial Radiography Priority: 1 Inspection Date: 12/11 -12/97 Inspector: RP File No.: 8 Licensee: Wyeth - Ayerst Research License No.: 0716-0007 Location: Bedford Inspection Type: Unannounced, Routine License Type: Broad Scope - Commercial Priority: 1 Inspection Date: 4/25 - 27/95 and 5/2/95 Inspector: JM File No.: 9 Licensee: Mick's Radio-Nuclear Instruments, Inc. License No.: 2252-3034 Location: Bronx, NY Inspection Type: Announced, Routine License Type: Medical Distribution Priority: 1 Inspection Date: 6/19/97 Inspector: JM Comments: a) No field activities at time of inspection. File No.: 10 Licensee: Finch, Pruyn and Company License No.: 0358-0260 Location: Glen Falls, NY Inspection Type: Announced, Routine License Type: Fixed Gauge - Priority; 3 Inspection Date: 9/19/96 Inspector: JM File No.: 11 Licensee: NDL Organization License No.: 1226-1422 Location: Peekskill, NY Inspection Type: Unannounced, Routine l License Type: Waste Broker Priority: 1 i inspection Date: 6/14/95 Inspector: RP File No.: 12 Licensee: SyncorInternational License No.: 2364-3250, 2365-3250GL, 2366-3250MD Location: Troy, NY inspection Type: Announced, Routine License Type: Nuclear Pharmacy Priority: 1 Inspection Date: 4/9 - 11/96 Inspector: BK I

New York Proposed Final Report Page C-2.3 NYDL Inspection File Reviews File No.: 13 Licensee: Bethlehem Steel Corporation Licenra No.: 0742-0119 Location: Lackawanna, NY Inspection Type: Unannounced, Routine License Type: Fixed Gauge Priority: 3 Inspection Date: 4/17/95 Inspector: RK Comment: a) Supervisory review of inspection documentation identified safety issues that were not addressed by the inspector, but were subsequently addressed in later correspondence with licensee. File No.: 14 Licensee: Carlin-Simpson Associates NRC License No.: 29-19641-01 Location: North Castle, NY Inspection Type: Unannounced, Routine, Reciprocity License Type: Portable Gauge Priority: NA Inspection Date: 7/11/96 Inspector: JM File No.: 15 l Licensee: Self Powered Lighting License No.: 1308-1611 Location: West Nyack, NY Inspection Type: Announced, Routine License Type: Manufacturing and Distribution Priority: 1 Inspection Date: 5/13-15/97 Inspector: BK File No.: 16 Licensee: Design Plumbing and Heating License No.: 2479-3583 Location: Staten Island, NY Inspection Type: Routine, Announced License Type: Portable Gauge Priority: 5 Inspection Date: 10/22/96 Inspector: RP File No.: 17 Licensee: Medi-Ray, Inc. License No.: 2077-2157 Location: Tuckahoe, NY Inspection Type: Routine, Announced License Type: Storage & Transport Priority: 5 Inspection Date: 1/28/98 Inspector: BK l File No.: 18 Licensee: Municipal Testing License No.: 2072-1988 Location: Hicksville, NY Inspection Type: Routine, Announced License Type: Radiography Priority: 1 Inspection Date: 6/20/97 Inspector: RP File No.: 19

Licensee

SyncorInternational License No.: 2613-3868 l Location: Buffalo, NY Inspection Type: Routine, Announced License Type: Nuclear Pharmacy Priority: 1 Inspection Date: 2/11-13/97 Inspector: JM l

New York Proposed Final Report Page C-2.4 NYDL Inspection File Reviews File No.: 20 Licensee: Wyeth-Ayerst License No.: 0716-0007 Location: Pearl River, NY Inspection Type: Routine, Announced License Type: Broad Research & Development Priority: 2 Inspection Date: 6/13/97 Inspector: BK Comments: a) Inspection report lists releases to the sewer in total curies of activity. Calculations should have been made of concentrations released to verify compliance with sewer release section of the regulations. File No.: 21 Licensee: Nucletron Inc. License No.: 2674-3822 Location: Mt. Sinal Hospital, NY Inspection Type: Routine, Announced License Type: Service Priority: 3 inspection Date: 1/15/98 Inspector: BK in addition, a team member made the following inspection accompaniment as part of the IMPEP review: Accompaniment No.1 , Licensee: MOS Inspection License No.: 1349-0452 Location: Flushing and Manhattan, NY inspection Type: Unannounced, Routine License Type: Industrial Radiography. Priority: 1 Inspection Date: 12/11-12/97 Inspector: RP i l I o

New York Proposed Final Report Page C-2.4 NYDL Inspection File Reviews File No.: 20 Licensee: Wyeth Ayerst License No.: 0716-0007 Location: Pearl River, NY Inspection Type: Routine, Announced-License Type: Broad Research & Development Priority: 2 Inspection Date: 6/13/97 Inspector: BK Comments: a) Inspection report lists releases to the sewer in total curies of activity. Calculations should have been made of concentrations released to verify compliance with sewer release section of the regulations. File No.: 21 Licensee: Nucletron Inc. License No.: 2674-3822 Location: Mt. Sinal Hospital, NY Inspection Type: Routine, Announced License Type: Service Priority: 3 Inspection Date: 1/15/98 Inspector: BK in addition, a team member made the following inspection accompaniment as part of the IMPEP review:

 . Accompaniment No.1 Licensee: MOS Inspection                                                                                                               License No.: 1349-0452 Location: Flushing and Manhattan, NY                                                                       Inspection Type: Unannounced, Routine License Type: Industrial Radiography                                                                                                                 Priority: 1 Inspection Date: 12/11-12/97                                                                                                                    Inspector: RP l
                                                                                                                                                                   )

i i L i l l

APPENDIX C-3 NYSH INSPECTION FILE REVIEWS NOTE: ALL INSPECTION FILES LISTED WITHOUT COMMENT'WERE DETERMINED BY > THE IMPEP TEAM TO BE ACCEPTABLE. File No.: 1 Licensee: Canisius College License No.: 500 Location: Buffalo, NY . Inspection Type: Announced, Routine

                                          ' License Type: Academic                                                                                                                          Priority: 4 Inspection Date: 12/8/94                                                                                                               Inspector: BI
                                          ' Comment:

a) No documentation of supervisory review. File No.: 2 Licensee: Cardiology Associates of Schenectady License No.: 3107 Location: Schenectady, NY Inspection Type: Unannounced, Routine-License Type: Nuclear Cardiology Priority: 4 Inspection Date: 2/25/98 Inspector: CC Comments: a) No documentation of substantive discussions during the exit meeting. b).. No documentation of interviewing ancillary personnel or the authorized user. File No.: 3 Licensee: Ellenville Community Hospital License No.: 1162 Location: Ellenville, NY Inspection Type: Unannounced, Routine License Type: Hospital . Priority: 3 Inspection Date: 8/11/95 Inspector: AB Comment: a) No documentation of supervisory review. File No.: 4 Licensee: Ellis Hospital License No.: 484 l Location: Schenectady, NY Inspection Type: Unannounced, Routine l License Type: Hospital Priority: 3 l- Inspection Date: 2/26-3/4/98 Inspector: CB l ! Comments:

a) No documentation of supervisory review.

i b) . No documentation of interviewing ancillary personnel.

New York Proposed Final Report Page C-3.2 NYCH Inspection File Reviews File No.: 5 Licensee: Genesee Hospital License No.: 26 Location: Rochester, NY Inspection Type: Announced, Routine License Type: Hospital Priority: 3 Inspection Date: 3/20/96 Inspector: EC Comment: a) No documentation of interviewing ancillary personnel or the AU. File No.: 6 Licensee: Geneva General Hospital License No.: 1766 Location: Geneva, NY Inspection Type: Unannounced, Routine License Type: Medical Hospital Priority: 3 Inspection Date: 2/23/98 Inspector: RS Comments: a) No documentation of interviewing ancillary personnel. b) No documentation of substantive discussions during the exit meeting. c) No documentation of possible ingestion of material as a repeat item of violation. File No.: 7 Licensee: Newark-Wayne Community Hospital License No.: 1777 Location: Newark, NY Inspection Type: Unannounced, Routine License Type: Medical / Hospital Priority: 3 Inspection Date: 2/24/98 Inspector: WK File No.: 8 Licensee: NYS Div. Of Military and Naval Affairs License No.: 29 Location: Albany, NY Inspection Type: Unannounced, Routine License Type: Civil Defense Priority: 5 Inspection Date: 7/3/96 Inspector: RD Comments: a) 3 years overdue in inspection frequency. b) No documentation of supervisory review, c) No documentation that previous violations had been reviewed and no indication that repeat violations had been addressed. l File No.: 9 Licensee: Oswego Hospital License No.: 1175 , Location: Oswego, NY Inspection Type: Unannounced, Routine License Type: Medica!/ Hospital Priority: 3 Inspection Date: 5/7/96 Inspector: VG Comment: a) No documentation of interviewing ancillary personnel. l l L_________________-__

New York Proposed Final Report Page C-3.3 NYSH inspection File Reviews File No.: 10 Licensee: Vassar College License No.: 410 Location: Poughkeepsie, NY Inspection Type: Announced, Routine License Type: Academic Priority: 4

                             . Inspection Date: 10/8/97                                                                                                      Inspector: MV Comments:

a) No documentation of supervisory review. b) No documentation of interviewing ancillary personnel. File No.: 11 Licensee: Adirondack Medical Center License No.: 1130 Location: Saranac Lake, NY Inspection Type: Announced, Routine License Type: Medical / Hospital Priority: 3 Inspection Date: 7/17/96 Inspector: AD Comments: a) No documentation of supervisory review. b) No documentation of interviewing ancillary personnel. c) No documentation of substantive discussions during the exit meeting. Note: .There were five other inspection files reviewed associated with the Administrative Tribunals. File No.: 12 Licensee: Alfred Univ. License No.: 402 Location: Alfred, NY Inspection Type: Unannounced, Routine

                             ' License Type: Academic, specific                                                                                                               Priority: 4 Inspection Date: 11/7/96                                                                                                        Inspector: AD File No.: 13 Licensee: Samaritan Hospital                                                                                             License No.: 498-2 Location: Troy, NY                                                                                   Inspection Type: Unannounced, Routine License Type: Teletherapy                                                                                                                      Priority: 1 Inspection Date: 11/30-12/4/95                                                                                                       Inspector: BD i

File No.: 14 Licensee: Good Samaritan Hospital License No.: 490 Location: Suffren, NY inspection Type: Unannounced, Routine License Type: Medical / Hospital /HDR Priority: 1 Inspection Date: 7/9/96 Inspectors: BD, SG ( File No.: 15 l Licensee: Good Samaritan Hospital License No.: 575 Location: West Islip, NY Inspection Type: Unannounced, Routine License Type: Medical / Hospital /HDR Priority: 1 Inspection Date: 5/21/97 Inspector: AB I

I l l l ! New York Proposed Final Report Page C-3.4 NYSH Inspection File Reviews File No.: 16 Licensee: Immunosciences, Inc. License No.: 2991 Location: New Hyde Park, NY Inspection Type: Reactive License Type: Possession only Priority: 1 Inspection Date: 6/20/97 Inspector: SG in addition, a team member made the following inspection accompaniment as part of the IMPEP review: Accompaniment No.: 1 Licenst 3: Geneva General Hospital License No.: 1766 Locar .i: Geneva, New York inspection Type: Unannounced, Routine Licer - a Type: Medical / Hospital Priority: 3 inst action Date: 2/23/98 Inspector: RS

 .,omments:

a) Inspector looked at QA records with no performance purpose. 1 b) Inspector should have asked about injection areas outside the restricted area such as l patient rooms, and the ensuing procedures for surveys, transport of material to the { rooms, etc. .

                                                                                                                    ]

c) Inspector should have done a more involved physical survey of the hot lab and adjoining areas. Accompaniment No.: 2 Licensee: Wayne Community Hospital License No.: 1777 Location: Newark, New York Inspection Type: Unannounced, Routine License Type: Medical / Hospital Priority: 3 Inspection Date: 2/24/98 Inspector: BK Comments: a) Inspector should have asked about injection areas outside the restricted area such as patient rooms, and the ensuing procedures for surveys, transport of material to the rooms, etc. i b) Inspector should have done a more involved physical survey of the hot lab and adjoining areas. There was a waste can in the imaging room in a cabinet labeled " Caution Rad. l: Materials" that went unnoticed. Inspector during record review should have questioned emergency scans on the l c)  ; weekend and holidays, and looked for quality assurance testing on those days. l d) Inspector should have questioned how unused unit doses are shipped back to the pharmacy and the compliance with the pertinent DOT regulations. l \ l ? _.____________.._______________w

New York Proposed Final Report Page C-3.5 NYSH Inspection File Reviews Accompaniment No.: 3 Licensee: Cardiology Associates of Schenectady License No.: 3107 Location: Schenectady, New York inspection Type: Unannounced, Routine Ucense Type: Imaging / Cardiologist Priority: 3 Inspection Date: 2/25/98 Inspector: CC I Comments: ) a) Inspector should have done a more involved physical survey of the hot lab and adjoining areas. b) Inspector during record review should have questioned emergency scans on the j weekend and holidays, and looked for quality assurance testing on those days. c) Inspector should have questioned how unused unit doses are shipped back to the pharmacy and the compliance with the pertinent DOT regulations, d) inspector should have checked " clean trash cans" for contamination. ., Accompaniment No.: 4 Licensee: Ellis Hospital License No.: 484 Location: Schenectady, NY Inspection Type: Unannounced, Routine License Type: Medical / Hospital Priority: 3 Inspection Date: 2/26/98 . Inspector: CB Comment: a) Inspector should have done a more involved physical survey of the hot lab and adjoining areas. b) Inspector during record review should have questioned emergency scans on the weekend and holidays, and looked for quality assurance testing on those days. c) Inspector should have questioned how unused unit doses are shipped back to the pharmacy and the compliance with the pertinent DOT regulations, d) Inspector should have checked " clean trash cans" for contamination. i

I APPENDIX C-4 NYDEC INSPECTION FILE REVIEWS NOTE: ALL INSPECTION FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. l File No.: 1 l Licensee: Wyeth Ayerst Research License No.: 168-2 Location: Chazy, NY Inspection Type: Unannounced, initial License Type: Water Priority: 4 Inspection Date: 7/29/97 Inspector: RR, AG File No.: 2 Licensee: University of Rochester Licence No.: 129-1 Location: Rochester, NY Inspection Type: Unannounced License Type: Incinerator Priority: 2 Inspection Date: 5/20-21/97 Inspector: MS, AG File No.: 3 Licensee: Trudeau institute, Inc. License Number: 96-1 Location: Saranac Lake, NY inspection Type: Unannounced License Type: Incinerator Priority: 2 Inspection Date: 7/30/97 Inspector: AG,RR File No.: 4 Licensee: Syncor International Corp. License No.: 150-3 Location: Cheektowaga, NY inspection Type: Unannounced License Type: Air Priority: 3 Inspection Date: 8/28/96 Inspector: RR, JA File No.: 5

                                          . Licensee: United Biomedical,Inc.                                                                                                                                                                       License No.: 156-3 Location: Hauppauge, NY                                                                                                                                     Inspection Type: Announced, Special License Type: Air                                                                                                                                                                                                Priority: 4 Inspection Date: 8/28/95                                                                                                                                                                                      inspector: JA
                                            . File No.: 6 Licensee: Syncor international Corp.                                                                                                                                                                    License No.: 140-3 Location: Franklin Square, NY .                                                                                                                                  Inspection Type: Unannounced License Type: Air                                                                                                                                                                                                Priority: 3      '

Inspection Date:.12/12/96 Inspector: AG,RR . I File No.: 7 Licensee: Progenics Pharmaceuticals,Inc. License No.:.168-3 j Location: Terrytown, NY Inspection Type: Unannounced, Initial I l License Type: Air Priority: 4 l Inspection Date: 6/19/96 Inspector: JA, WG l

New York Proposed Final Report Page C-4.2 NYDEC Inspection File Reviews File No.: 8 Licensee: NRD License No.: 53-3 Location: Grand Island, NY Inspection Type: Unannounced License Type: Air Priority: 2 Inspection Date: 9/9/97 Inspector: BY Comment: a) Inspection letter not sent out within 30 days File No.: 9 Licensee: Mt. Sinal Medical Center License No.: None issued Location: New York City, NY Inspection Type: Announced, Special License Type: Air Priority: N/A Inspection Date: 2/10/97 Inspector: MS File No.: 10 Licensee: New York University Medical Center License No.: None issued Location: New York, NY inspection Type: Announced, Special License Type: Air Priority: N/A inspection Date: 7/9/97 inspectors: SH,AG

                                   - File No.: 11 Licensee: NYSERDA                                               License Nos.: 137-5,137-6,137-3 Location: West Valley, NY -                                 Inspection Type: Announced, Routine License Type: Bio-Engineering, Land Burial, Air                                         Priority: 1 Inspection Date: 6/4/97                                                       Inspectors: WT, JK in addition, a team member made the following inspection accompaniment as part of the IMPEP review:
                                        ' Accompaniment No.1 Licensee: University of Rochester-Laboratory for Laser Energetics            License No.: 170-3 Location: Brighton, NY -                                 Inspection Type: Unannounced, Initial License Type: Academic Broad Secoe                                                     Priority: 2 Inspection Date: 4/7/98                                                     inspectors: MS, SH l

l

                                                                                                                                            \

APPENDIX D-1 NYCH LICENSE FILE REVIEWS NOTE: ALL LICENSE FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. File No.: 1 Licensee: Montefiore Medical Center License No.: 75-2885-01 Location: Bronx, NY Amendment No.: 7, 8 License Type: Broad Scope-Medical Type of Action: 2 Amendments Date issued: 7/25/97,10/23/97 License Reviewer: JB, RH File No.: 2 Licensee: Albert Einstein College of Medicino of Yeshiva University License No.: 75-2919-01 Location: Bronx, NY Amendment No.: 2, 3 License Type: Broad Scope-Medical Type of Action: 2 Amendments Date issued: 3/15/96, 7/8/97 License Reviewer: DH,DH File No.: 3 Licensee: Columbia-Presbyterian Medical Center License No.: 74-2878-03 Location: New (ork City, NY Amendment No.: 4, 5 License Type: Broad Scope-Academic Type of Action: Renewal, Amendment Date issued: 2/8/97,4/9/97 License Reviewer: GM, RH File No.: 4 Licensee: Columbia-Presbyterian License No.: 75-2878-01 Location: New York City, NY Amendment No.: 6,7,8,9,10,11 License Type: Broad Scopc-Medical Type of Action: Renewal,5 Amendments Date issued: 4/10/96,8/15/96,10/8/96 License Reviewer: GM, DH, RH 12/4/96,7/10/97,9/25/97 RH, GM, RF File No.: 5 Licensee: St. Lukes-Roosevelt Hospital Center License No.: 75-2898-01 Location: New York City, NY Amendment No.: 0,1,2,3,4,5 License Type: Broad Scope-Medical Type of A, tion: Renewal,5 Amendments Date issued: 7/20/95,6/4/96,10/7/96 License Reviewer: DH, GM, RH 11/19/96, See comment, 11/19/97 RH, unknown, RH Comment: a) Amendment 4 not found in the file l l [

New York Proposed Final Report Page D-1.2 NYCH License File Reviews File No.: 6

    ! icensee: New York University Medical Center                              License No.: 93-2955-05 Lt.a.ation: New York City, NY                                                  Amendment No.: 0,1 License Type: Gamma Knife                                        Type of Action: New, Amendment Date lacued: 3/4/97, 6/20/97                                            License Reviewer: GM, GM Comment:

a) SS&D registry sheet strongly recommends nine license conditions that address potential health and safety issues. Six of these conditions were not fully addressed in the tie-down l condition or other license conditior.s. File No.: 7 Licensee: Columbia Presbyterian License No.: 93-2878-05 Location: New York City, NY License Type: Gamma Knife Type of Action: New Date Issued: 10/31/97 License Reviewer: GM Comment: a) Same comment as file number 6 above. File No.: 8 Licensee: NYCHHC-Lincoln Medical & Mental Health Center License No.: 91-2951-01 Location: Bronx, NY Amendment No.: 2,3 License Type: Hospital Type of Action: 2 amendments Date Issued: 6/21/95,11/18/97 License Reviewer: RH,DH File No.: 9 Licensee: NYCHHC - Metropolitan Hospital Medical Center License No.: 91-2802-01 Location: New York City, NY Amendment No.: 3,4,5,6,7 License Type: Hospital Type of Action: amendment, renewal,3 amendments

   .Date issued: 6/19/95,8/14/96,6/12/97                                License Reviewer: JB, JB, RF 10/23/97,1/9/98                                                         JB,RF File No.: 10 Licensee: Steven W. Prufer, MD                                            License No.: 91 2836-01
   ~ Location: New York City, NY                                                    Amendment No.: 1 License Type: Human Use-Out Patient                                    Type of Action: Termination Date issued: 8/12/97                                                         License Reviewer: DH File No.: 11 Licensee: Maimonides Medical Center                                       License No.: 91-2844-01 Location: Brooklyn, NY                                                          Amendment No.: 2 License Type: Hospital                                                    Type of Action: Renewal Date issued: 6/26/96                                                         License Reviewer: RH t

I

New York Proposed Final Report Page D-1.3 NYCH License File Reviews File No.: 12 Licensee: Lenox Hill Hospital License No.: 91-2926 01 Location: New York City, NY Amendment No.: 2,3,4,5 License Type: Hospital Type of Action: 4 Amendments Date issued: 12/12/95, 7/10/96,10/23/97,11/2/97 License Reviewer: RH, RH, RF, JB File No.: 13 Licensee: Amiel Rodavsky, MD License No.: 91-3053-01 Location: New York City, NY License Type: Human Use-Out Patient Type of Action: Renewal Date Amendment issued: 6/14/96 License Reviewer: DH File No.: 14 Licensee: Mittal Brij, MD License No.: 91-2895-01 Location: New York City, NY Amendment No.: 0,1, Other License Type: Human Use-Out Patient Type of Action: New, Amendment, Rescind Date issued: 4/18/95,12/11/95,1/24/96 License Reviewer: RF, GM, Commission Order Comments: a) License rescinded b) NYCH confiscated radioactive material File No.: 15 Licensee: Richard A. Herrmann, MD License No.: 16611-1 Location: New York City, NY Amendment No.: 4 License Type: In vitro Use Type of Action: Termination Date issued: 12/5/95 License Reviewer: GM File No.: 16 Licensee: Modern Medical Laboratories, Inc. License No.: 52-2660-01 Location: Brooklyn, NY Amendment No.: 6 License Type: Hospital Type of Action: Renewal I Date issued: 5/22/96 License Reviewer: RF File No.: 17 Licensee: Brooklyn Hospital Center License No.: 92-2924-02 j Location: Brooklyn, NY Amendment No.: 0,1, 2 I License Type: Teletherapy Type of Action: Renewal,2 Amendments Date issued: 6/14/96, 6/18/96, 8/8/96 License Reviewer: JB File No.: 18 Licensee: The Brookdale Hospital License No.: 92 2841-02 Location: Brooklyn, NY Amendment No.: 3 License Type: Teletherapy Type of Action: Amendment Date issued: 4/30/97 License Reviewer: DH I - _ - . - - . - _ . - _ _ _ _ . _ _ - _ _ - - a

New York Proposed Final Report Page D-1.4 NYCH License File Reviews File No.: 19 Licensee: Kings County Hospital License No.: 92-0148-04 Location: Brooklyn, NY License Type: Teletherapy Type of Action: Renewal Date issued: Pending License Reviewer: RF, JB Comments: a) Reviews failed to timely follow up on lack of licensee response. l l' l l i. l l 9 4

l APPENDlX D-2 N'YDL LICENSE FILE REVIEWS NOTE: ALL LICENSE FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. File No.: 1 Licensee: Syncor International License Nos.: 2328-3174, 2329-3174 G L, 2330-3174 M D Location: Cheektowago, NY Amendment No.: 2 License Type: Nuclear Pharmacy Type of Action: Renewal Date issued: 1/6/98 License Reviewer: RA a File No.: 2 Licensee: Entec Consultants, Inc. License No.: 2630-3897 Location: Albany, NY Amendment No.: 2 License Type: Industrial Radiography Type of Action: Amendment Date issued: 2/10/98 License Reviewer: CB File No.: 3 Licensee: Glynn Geotechnical Engineering License No.: 2458-3528 Location: Lockport, NY Amendment No.: 3 License Type: Portable Gauge Type of Action: Renewal Date issued: 11/9/97 License Reviewer: RK Comment: a) Deficiency letter sent to licensee prior to supervisory review. File No.: 4 Licensee: Eastman Kodak Company License No.: 1347-0255 Location: Rochester, NY Amendment No.: 3 License Type: Broad Scope - Commercial Type of Action: Renewal i Date issued: 9/18/97 License Reviewer: RA l l Comment: l a) Correspondence incorporated into license dates back to 1983. File No.: 5 Licensee: Auburn Steel Company License No.: 2079-2159 Location: Auburn, NY Amendment No.: 2 License Type: Fixed Gauge and Contaminated Waste Type of Action: Termination Date issued: 11/18/97 License Reviewer: RA File No.: 6 l Licensee: Orentreich Foundation for the Advancement of Science License No.: 2448-3499 I Location: Cold Spring-on-Hudson, NY Amendment No.: 2 License Type: Research and Development Type of Action: Renewal Date issued: 9/10/97 License Reviewer: DG

New York Proposed Final Report Page D-2.2 l NYDL License File Reviews j File No.: 7 Licensee: Self Powered Lighting License No.: 1308-1611 Location: West Nyack, NY Amendment No.: 36  ! License Type: Manufacturing Type of Action: Amendment Date issued: 9/24/96 Li.:ense Reviewer: CB Comments: a) Original standby trust agreement and financial mechanism not in NYDL files. File No.: 8 Licensee: Certified Testing Laboratories License No.: 1920-1896 Location: Bronx, NY Amendment No.: 1 License Type: Industrial Radiography Type of Action: Amendment Date issued: 10/31/97 License Reviewer: DG Comment: a) One facsimile not included in license tie-down condition. File No.: 9 Licensee: Northeast Technology Corporation License No.: 2684-3943 Location: Kingston, NY Amendment No.: 1 License Type: Research and Development Type of Action: Amendment Date issued: 10/16/96 License Reviewer: CB Comments: a) Special condition authorizing a location of use in a non-Agreement State pending reciprocity approval by the NRC. b) Device incorporating a Cf-252 source not reviewed using sealed source and device criteria since licensee's use was only for research and development at one location. File No.: 10 . Licensee: PVS Chemicals Inc. License No.: 2646-3915 Location: Buffalo, NY f Amendment No.: 2 License Type: Fixed Gauge Type of Action: Renewal Date issued: 9/30/97 License Reviewer: RK , Comment: a) License'is written using NYDL's generic fixed gauge license format which does not i contain tie-downs. 1

                                                                                                                                                                   )

File No.: 11 Licensee: OccidentalChemicalCorp. License No.: 0297-0685 Location: Niagara Falls, NY Amendment No.: 3 License Type: Fixed Gauge and Gas Chromatograph Type of Action: Amendment Date issued: 8/21/97 License Reviewer: CB i

New York Proposed Final Report Page D-2.3 NYDL License File Reviews File No.: 12 Licensee: Pharmaceutical Discovery Corp. License No.: 2637-3909 Location: Elmsford, NY Amendment No.: 2 License Type: Research and Development - Type of Action: Amendment Date issued: 5/30/97 License Reviewer: CB File No.: 13 Licensee: Advanced Environmental Services, Inc. License No.: 2275-3076 Location: Niagara Falls, NY Amendment No.: 3 License Type: Gas Chromatograph Type of Action: Renewal Date issued: 11/25/96 License Reviewer: RK Comment: a) License is written using NYDL's generic gas chromatograph license format which does not contain tie-downs. File No.: 14 Licensee: Pali Corporation License No.: 2198-2951 Location: Glen Cove, NY Amendment No.: 2 License Type: Research and Development . Type of Action: Termination Date issued: 9/5/96 License Reviewer: CB File No.: 15 Licensee: Empire Isotopes License No.: 2770-4012,2771-4012MD Location: Albany, NY License Type: Nuclear Pharmacy Type of Action: New Date issued: 6/20/97 License Reviewer: DG File No.: 16 Licensee: Conam inspection License No.: 2713-3965 Location: Itasca, IL License Type: Industrial Radiography Type of Action: New Date issued: 6/10/96 License Reviewer: CB Comment: a) Licensee request to perform source exchanges not addressed.

APPENDIX D-3 NYSH LICENSE FILE REVIEWS NOTE: ALL LICENSE FILES OSTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. File No.: 1 Licensee: University at Albany State University of New York (SUNY) License No.: 459-1 Location: Albany, NY. Amendment No.: 45 License Type: Academic-Broad Type of Action: Renewal Date issued: 9/26/96 License Reviewer: CC I File No.: 2 Licensee: North Shore University Hospital License No.: 1016 Location: Manhasset, NY Amendment No.: 16 License Type: Medical-Broad with HDR Type of Action: Renewal Date issued: 1/26/96 License Reviewer: CC File No.: 3 Licensee: Upstate Open MRl/ Diagnostic Imaging License No.: 3152 Location: East Syracuse, NY Amendment No.: 4 License Type: Medical-Private Practice Type of Action: Amendment Date issued: 3/20/98 License Reviewer: RD File No.: 4

Licensee: Forest Laboratories, Inc. License No.: 3185

! Location: Farmingdale, NY Amendment No.: N/A License Type: Research & Development-Specific Type of Action: New Date issued: 10/9/96 License Reviewer: CC File No.: 5 ! Licensee: Immunosciences, Inc. License No.: 2991 Location: New Hyde Park, NY Amendment No.: 4 License Type: Research & Development-Specific Type of Action: Renewal l. Date issued: 11/5/96 License Reviewer: CC Comments: a) Renewal frequency for this licensee has been increased to yearly to allow for re-evaluation of whether the unit will be used in the future or disposed of. File No.: 6 Licensee: Cold Spring Harbor Laboratory License No.: 574 Location: Cold Spring Harbor, NY Amendment No.: 26 l License Type: Research & Development-Broad Type of Action: Renewal Date issued: 7/30/96 License Reviewer: CC

New ork Proposed Final Report Page D-3.2 NYSH License File Reviews File No.: 7 - Licensee: Capital Cardiology Associates, P.C. License No.: 3186 Location: Albany, NY License Type: Medical-Private Practice Type of Action: New Date issued: 10/17/96 License Reviewer: CB File No.: 8 Licensee: Lakeshore Health Care Center License No.: 3201 Location: Irving, NY License Type: Medical-Hospital Type of Action: New Date issued: 6/12/97 License Reviewer: CC

                                     ' File No.: 9
                                  ' Licensee: Skyline Oncology Associates, P.C.                                         License No.: 3216' Location: Newburgh, NY License Type: Teletherapy (Storage only)                                    . Type of Action: New Date issued: 3/12/98                                                      License Reviewer: BD
                                   - File No.: 10 Licensee: Guthrie Medical Group, P.C.                                           License No.: 3175 Location: Horseheads, NY License Type: Medical-Nuclear Cardiology                                     Type of Action: New Date issued: 3/12/96                                                      License Reviewer: CC File No.: 11 Licensee: Heart and Lung Center                                                 License No.: 3199
                                   - Location:' Liverpool, NY License Type: Medical Nuclear Cardiology -                                   Type of Action: New Date issued: 7/14/97                                                      License Reviewer: CC
                                    - File No.: 12

, Licensee: Nassau County Police Department '

                                                                                                                       ' License No.: 2887 Location: Mineola, NY                                                           Amendment No.: 4

License Type: Research & Development-Specific Type of Action: Termination Date Issued: .1/22/98 License Reviewer: MV

                                   . File No.: 13 Licensee: Great Neck Public Schools                                              License No.: 1164 Location: Great Neck, NY                                                      . Amendment No.: 7 License Type: Self-Shielded Irradiator                                Type of Action: Termination Date Issued: 10/23/96 -    .                                               License Reviewer: CC I

New York Proposed Final Report Page D 3.3 NYSH License File Reviews

      - File No.: 14 l       Licensee: Pomona Scanning                                                                                             License No.: 3085
     . Location: Pomona, NY                 ,

Amendment No.: 1

License Type: Mcbile Nuclear Medicine Site Type of Action: Termination

': Date issued: 10/9/97 License Rev! ewer: CB Comment: a) License was terminated when new license was issued for same location. b) Authorized for diagnostic procedures and calibration of instrumentation. No storage authorized. Radioactive materials must be received through Nuclear Imaging Systems, Inc. File No.: 15 i Licensee: State University of New York (SUNY) Health Science Center License No.: 47-2

Location

Syracuse, NY Amendment No.: 7 License Type:- Medical-Brachytherapy Type of Action: Termination

!' Date issued: 11/19/97 License Reviewer: CB i !- File No.: 16 Licensee: Samaritan Hospita! License No.: 498-2 Location: Troy, NY Amendment No.: 18 ,_ License Type: Teletherapy Type of Action: Termination l Date issued: 2/4/98 - ' License Reviewer: BD I File No.: 17 Licensee: Leonard Hospital License No.: 1757 Location: Troy, NY Amendment No.: 16 License Type: Medical Hospital with Brachytherapy Type of Action: Termination l Date issued: 11/30/95 License Reviewer: CC i , File No.: 18 Licensee: Bender Hygienic Laboratory License No.: 511

                                                                                                                                                          ]

l. Location: Albany, NY Amendment No.: 15 License Type: Clinical Laboratory Type of Action: Termination Date issued: 1/22/98- License Reviewer: CB File No.: 19

     ' Licensee: Rensselaer Polytechnic Institute License No.: 1035 Location: Troy, NY '                                                                                                Amendment No.: 30 License Type: Academic-Broad                                                                                  Type of Action: Renewal Date issued: 3/24/97                                                                                              License Reviewer: BD
     . File No.: 20.

Licensee: Our Lady of Victory Hospital License No.: 1170

     ' Location:~ Lackawanna, NY                                                                                           Amendment No.: 32 License Type: Medical-Hospital                                                                                Type of Action: Renewal Date issued: 3/26/98                                                                                             License Reviewer: MV L

u

i l New York Proposed Final Report Page D 3.4 NYSH License File Reviews File No.: 21 Licensee: Institute of Ecosystem Studies,Inc. License No.: 2826 Location: ~ Millbrook, NY Amendment No.: 8 License Type: Research & Development-Specific Type of Action: Renewai Date issued: 7/11/97 License Reviewer: CB l l I

l APPENDIX D-4 NYDEC LICENSE FILE REVIEWS NOTE: ALL LICENSE FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. File No.: 1 Licensee: Syncor international License No.: 159-3 Location: Bronx, NY License Type: Nuclear Pharmacy, Air Permit Type of Action: New 3 Date issued: 11/27/97 License Reviewer: JA ) Comment: a) Permit issued 22 months after radiation review completed due to delay in completing another Department permit and public hearings. File No.: 2 Licensee: Wyeth-Ayerst Research License No.: 147-3 Location: Pearl River, NY License Type: Research and Development Broad Scope, Air Permit Type of Action: Renew Date issued: 9/5/97 License Reviewer: RR Comment: a) S!nce emmissions at two release points exceed the effluent concentration values in Table ll, permit limits were set to limit the potential dose to the maximally exosed member of the public. File No.: 3 Licensee: Cornell University License No.: 155-3 Location: Ithaca, NY License Type: Academic Broad Scope, Air Permit Type of Action: Amendment Date issued: 1/21/98 License Reviewers: AG and SH File No.: 4 Licensee: New York Medical College License No.: NA Location: Valhalla, NY License Type: Research and Development, Air Permit Type of Action: Inquiry l Date issued: 5/1/96 License Reviewer: JA

                                                                                                                                                                                                                          ]
                                                                                                                                                                                                                          'l Comment:

a) Permit not required after review of application. Facility's effluents met 10% exemption limit. l l I i 1 i

                                                                                                                                                                                               ----- - _ _ --- _ _------ D

l l l New York Proposed Final Report Page D-4.2 l NYDEC License File Reviews l ' File No.: 5 Licensee: St Luke's/ Roosevelt Hospital Center License No.: NA Location: New York, NY l License Type: Research and Development, Air Permit Type of Action: Inquiry Date issued: 10/24/96 License Reviewer: MS l Comment: l a) Permit not required atter review of application. Facility's effluents met 10% exemption l limit. File No.: 6 Licensee: New York State Department of Health-Wadsworth Lab License No.: NA Location: Albany, NY License Type: Research and Development, Air Permit Type of Action: Inquiry Date issued: 5/1/96 License Reviewer: AG Comment: a) Permit not required after review of application. Facility's effluents met 10% exemption limit. File No.: 7 Licensee: University of Rochester-Laboratory for Laser Energetics License No.: 170-3 Location: Brighton, NY License Type: Aedemic Broad Scope, Air Permit Type of Action: New Date issued: 2/2/98 License Reviewer: MS Comment: a) Permit issued to existing facility where activities and use of licensed materials increased requiring a permit. i File No.: 8 Licensee: Rensselaer Polytechnic Institute License No.: 70-1 Location: Troy, NY License Type: Academic Broad Scope, incinerator Permit Type of Action: Renewal Date issued: 7/25/96 License Reviewer: JA File No.: 9 Licensee: Wyeth-Ayerst Research License No.: 168-2 Location: Moultonboro, NH License Type: Research and Development, Water Permit Type of Action: New

                                                                               ' Date issued: 5/21/97                                                   License Reviewers: WT and SH f

\

New York Proposed Final Report Page D-4.3 NYDEC License File Reviews File No.: 10 Licensee: NYS Energy Research and Development Authority License No.: 137-5 Location: West Valley, NY Amendment No.: Reissued in entirety License Type: LLRW Disposal, Waste Burial Permit Type of Action: Amendment

 ' Date Issued: 5/28/97                                                                  License Reviewer: WT File No.: 11 Licensee: New York State Department of Health-Griffin Laboratory                          License No.: 111-1 Location: Albany, NY License Type: Research and Development, incinerator Permit                       Type of Action: Termination Date issued: 4/1/98                                                                    License Reviewer: AG File No.: 12 Licensee: Bristol-Myers Squibb                                                             License No.: 15-3 Location: Syracuse, NY License Type: Research and Development Broad Scope, Air PermitType of Action: Termination Date issued: 5/15/97                                                                   License Reviewer: MS Comment:

a) Permit terminated since a permit is not required after review of application. Facility's effluents met 10% exemption limit. File No.: 13 Licensee: Self Powered Lighting License No.: 108-3 Location: Elmsford, NY License Type: Manufacturing / Distribution, Air Permit Type of Action: Termination Date issued: 8/21/97 License Reviewer: RR - File No.: 14 Licensee: Medi-Physics License No.: 133-3 Location: Port Washington, NY License Type: Nuclear Pharmacy, Air Permit Type of Action: Renewal Date issued: 6/4/97 License Reviewer: AG l i

APPENDlX E-1 NYCH INCIDENT FILES REVIEWED NOTE: ALL INCIDENT FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. BLANKS ARE INFORMATION THAT HAS BEEN OMITTED IN COMPLlANCE WITH STATE LAW. File No.: 1 Licensee: New York University Medical Center License No.: 75-86-96 Location: New York City, NY Date of Event: 11/4/97 Type of Event: Loss of control Investigation Date: 11/5/97 investigation Type: Site inspection Summary of Incident and Final Disposition: Technician left 2.7 mci of Y-90 in taxi cab when transferring material between campuses. Taxi driver later found package and returned to licensee. NYCH issued summons and monetary fine to the licensee as a result of incident. File No.: 2 Licensee: Mt. Sinal Medical Center License No.: 91-2909-01 Location: New York City, NY Date of Event: 6/2-3/97 l Type of Event: Lost RAM l Investigation Date: 6/3-4/97 investigation Type: Site inspection Summary of incident and Final Disposition: Approximately 170 mci of I-125 seeds were taken from unlocked room at licensee's oncology center. The material was never found and believed to disposed as trash. NYCH issued letter to licensee on 6/6/97 from Assistant Commissioner level ordering licensee to take certain actions to prevent recurrence l File No.: 3 l Licensee: Lenox Hill Hospital ! License No.: 91-2926-01 l Location: New York City, NY Date of Event: 5/96 Type of Event: Loss of Control Investigation Date: 5/29/96 and 6/6/96 Investigation Type: Site inspection Summary of incident and Final Disposition: Waste (contaminated diaper) set off radiation alarm at Connecticut incinerator, traced back to licensee and material returned. Closed with no further action due to low hazard to members of public. Comment: a) No follow up of incident indicated at next inspection conducted 1/97. l

New York Proposed Final Report Page E-1.2 NYCH Incident File Reviews File No.: 4 - Licensee: License No.:

    . Location:

Date of Event: 8/16/95 Type of Event: Misadministration

    - Investigation Date:' 8/16/95 investigation Type: Telephone and next inspection                                                                    .

Summary of incident and Final Disposition: Patient injected with incorrect radiopharmaceutical

due to technician error. Licensee provided written report of incident to NYCH. NYCH reviewed and closed out incident at next inspectio'1.

    . File No.: 5
    ' Licensee: St. Mary's Hospital.

- Ucense No.

91-2929-01

     ' Location: Brooklyn, NY ~

Date of Event: 6/95-7/95.

     . Type of Event: Overexposure Investigation Date: 9/25/95 and 10/4/95 investigation Type: : Site Inspection        .

Summary of incident and Final Disposition:- Several monthly badges used by individuals in - radiology /cardic!ogy departments had elevated exposures including one with a dose of 6 rem

    . from medium energy gamma radiation. NYCH's investigation concluded that individuals did not receive dose measured by badges.' individuals' personal dosim6try records were adjusted to

l. remove elevated readings.

File No.: 6 Licensee:

    - License No.:

Location: l , - Date of Event: 9/25/96 Type of Event: Misadministration i

     . investigation Date: 5/25/97 investigation Type: Phone and next inspection                                                                                          f Summary of incident and Final Disposition: Incorrect brachytherapy seeds were implanted into a
    . patient due to packaging of seeds for three patients at the same time. Licensee provided written report of incident to NYCH.~ NYCH reviewed and closed out incident at next inspection.                                                  ,

4

New York Proposed Final Report Page E-1.3 NYCH incident File Reviews File No.: 7 Licensee: License No.: Location: Date of Event: 4/11/96 Type of Event: Overexposure Investigation Date: 8/30/96 Investigation Type: Site inspection - Summary of incident and Final Disposition: NYCH identified incident during review of licensee's RBC meeting minutes. Student received dose of 21 rads to hand transporting unshielded vial of I-125 during training exercise. Licensee was issued an ALARA violation and civil penalty as result of NYCH investigation into incident. File No.: 8 Licensee: Columbia Presbyterian Medical Center License No.: 75-2878-01 Location: New York City, NY Date of Event: Week of 8/97 Type of Event: Procedural Failure Investigation Date: 8/26-29/97 investigation Type: Site inspection Summary of incident and Final Disposition: Garbage truck set off radiation alarm at Pennsylvania landfill due to contaminated diaper. While determining origin of RAM, NYCH determined that one of two dock radiation monitors at the licensee's facility was not operational due to insdequate daily operational checks. Licensee corrected monitor problem. NYCH conducted two follow up visits in 10/97 and 12/97. Comment: l a) Incident file was not signed by supervisor. I 1 l l l l I-L

APPENDIX E-2 NYDL INCIDENT FILES REVIEWED NOTE: ALL INCIDENT FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. 9 File No.: 1

    ' Licensee: Trans World Airlines -

License No.: General License -Common Carrier incident ID No: 95-43 Location: New York City, NY Date of Ev(nt: 11/4/95 Type of Event: Contamination event / transportation investigation Date: 11/7/95 investigation Type: Response to site Summary of incident and Final Disposition: One of eight spent Tc-99m generators was damaged during package handling at JFK Airport. Three days later the damaged package was repackaged and the S' ate notified. The NYDL responded and surveyed the repackaged item for contamination and external radiation. The radioactive package was damaged at approximately 5:00pm on 11/4/95 yet the ground carrier that delivered the packages to the airport, Medical Delivery Systems, was not contacted by airport authorities until approximately 10:00 a.m. on 11/6/95. Medical Delivery Systems, also a general licensee, sent a representative to the site on 11/6/95, however, this individual took no action except to return the next day with a representative of the nuclear pharmacy from whom they had accepted the packages fo_r transport. The personnel at JFK failed to call the emergency telephone number on the damaged. package when they noticed the damage.. The NYDL requested NRC to review the SSD registry sheets for the generator whose shielding failed.

   ' File No.: 2 Licensee: Del Med License No.: General Licensee -Contract Carrier incident ID No: 96                                                                                                                                       '

Location:- Bronx, NY Date of Event: 4/23/96. Type of Event: Loss of control investigation Date: 4/23/96 investigation Type: - Response to site

   -. Summary of incident and Final Disposition: A package containing a spent Tc-99m generator
   . was stolen from a contract carrier's vehicle and subsequently disassembled by unauthorized individuals." The package was in interstate transport from an NRC licensee in Massachusetts to a location in New Jersey. The carrier, Del Med, allows the driver to stop at his residence in' Bronx, NY to rest. The package was stolen from the transportation vehicle while it was parked l

at the driver's residence. The NYDL responded and supervised retrieval and packaging of the waste. The shipper, an NRC licensee located in Massachusetts, apparently does not provide any shipping papers to the carrier, NRC Region I, was notified of this problem, but no information was in the file of any follow up action that may have been taken by NRC on this matter. The U.S. DOT was contacted by NYDL concerning the problem. I 1 w.

New York Proposed Final Report Page E-2.2 NYDL incident File Reviews File No.: 3-Licensee: Unknown License No.: None incident ID No: 96-21

      - Location: Westbury, NY.

Date of Event: Unknown -first identified 6/19/96

      . Type of Event: Abandon Radioactive Material investigation Date:: 6/20/96 AnvestigationType: Response to site Summary of incident and Final Disposition: A 75 mci Cs-137 source was found in a load of ~
       . trash. - Source was recovered by NYDL. An extensive effort was made by NYDL to identify the licensee that had last possessed this source.
       - File No.: 4 Licensee: Design Plumbing & Heating    '

License No.: 2479-3683 incident ID No:. 97-21 Location: Staten isbnd, NY Date of Event: 4/20/97 Type of Event; Equipment Failure' investigation Date: 5/12/97 investigation Type: Reactive Inspection Summary of incident and Final Disposition: The source rod on a moisture density gauge failed

       . causing the source to become detached. The failure was due to an improper abusive method of '

use not in accordance with training or procedures. The licensee replaced the source in the shield and shipped the unit to the manufacturer who notified the NYDL. NYDL restricted the licensee to storage only due to deliberate abuse of the device. C, amment: a) . No indication was given in the report as to if the other of the two devices possessed by i

    ,            the licensee had been examined by the inspector to determine if it had also been -
                - improperly used.

File No.: 5 4  :( Licensee: Mt.SinalHospital

       -License No.: NYCH Licensee incident ID No: 97-27 Location: New York City, NY Date of Event: 6/3/97-Type of Event: Loss of Control RAM
      . Investigation Date: 6/3/97 investigation Type: Response to Site i

Summary of incident and Final Disposition: The NYCH li:ensee lost 176 mci of I-125 seeds

l. l which were presumed to have been carried out with trash. NYDL responded and assisted 'j NYCH by surveying the waste transfer facility. Sources were never found. j i

New York Proposed Final Report Page E-2.3

                ~ NYDL incident File Reviews i

L - File No.: 6 l Licensee: Wyeth-Ayerst Research ' License No.: 0716-6007.

                - Incident ID No: 97-28.

Location: Pearl River, NY

               ~ Date of Event: 5/21/97-l Type of Event: Procedure failure resulting in release of RAM Investigation Date: 6/13/97 investigation Type: Reactive inspection -

l Summary of incident and Final Disposition: 724 mci of H-3 was accidentally released via a fume hood. The cause of the H-3 leakage was presumed to be the use of a stopcock type L grease on the fittings of the reaction vessel. Procedures were revised by the licens,ee to warn against this practice. Incident reviewed during the 6/13/97 inspection. NYDEC also investigated this incident. File No.: 7 Licensee: Unknown License No.: none incident ID No: 97-36 l Location: Bronx, NY - . Date of Event: 8/25/97 !- ) Type of Event: . Release of RAM

                . Investigation Date: 8/26/97                       ..         _

Investigation Type: Telephone, Follow-up site visit.

               , Summary of incident and Final Disposition: Contaminated trash (diaper) rejected by a landfill.

Material is exempt from regulation and was stored by holder for decay. NYDL staff re-surveyed the trash after decay-in-storage and approved disposal.

             ~

File No.: 8 l Licensee:l Syncor international

           ,      License No.:

Incident ID No: 97-37 Location: ' Saw Mill River Road, Westchester County, NY l

               . Date of Event: 8/28/97                                                                               -

Type of Event: Transportation < ' investigation Date: . 8/28/97 investigation Type: Telephone . l Summary of incident and Final Disposition: A nuclear pharmacy delivery vehicle was involved in J a traffic accident. The licensee responded to the scene, surveyed and recovered the packages. -i No contamination was found at the accidern site.

                                                                                                                          )

1 1

                                                                                                                        -l 1

l 4 . 4

New York Proposed Final Report Page E-2.4 NYDL incident File Reviews

                           ' File No.':- 9 Licensee: Nucletron License No.: 2674-3822
                           - Incident ID No: 9'/-28 Location: Poughkeepsie, NY Date of Event: 8/28/97 Type of Event:- Equipment Failure       -
                           ' investigation Date: 8/28/97
                           . Investigation Type: Telephone interview Summary of incident and Final Disposition: A 8.6 Ci source of Ir-192 became Immobile in an HDR source exchanger during a source exchange by Nucietron at Vassar Brothers Hospital.

The technician had to manually push the source back into the shipping pig. Source exchanger was retumed to Holland for analysis and repair. The State of Maryland was advised on the incident by NYDL. File No.: 10. Licensee: Municipal Testing License No.: 2066-1988 incident ID No: 97-44 {

                           - Location: Brookhaven, NY                                                                                  l
                           . Date of Event: 10/12/97 Type of Event: Equipment Failure investigation Date:,10/14/97
                           - Investigation Type: Field Inspection _                                                             .       I Summary of incioent and Final Disposition: A 21 Ci radiography source failed to retract into the           j camera. The licensee's RSO manipulated the source into another camera. The malfunctioning  .

j camera was sent to the manufacturer for evaluation. Licensee was cited for failure to notify the State within 24 hours and for performing an unlicensed activity. The State of California, which has jurisdiction over the camera manufacturer, was promptly notified.

         ,                   File No.:_11 Licensee: Universal Testing & Inspection Services, Inc.

License No.: 2570-3788 Incdent ID No: 97-40 Location: North Valley Stream Court Shopping Center, Valley Stream, NY Date of Event: 9/8/97: Type of Event: Damage to Equipment

c E - Investigation Date

9/8/97 Investigation Type: Site i Summary of incident and Final Disposition: A moisture / density gauge was crushed by an asphalt roller bending the source rod and cracking the body of the gauge. The NYDL responded t '

and assisted in securing the device for shipment and surveying the device for external radiation b and contamination. i

    -}.'

O . - _ _ _ _ _ _ _ _ _ ._ ._ _ _ . _

I New York Proposed Final Report Page E 2.5 NYDL incident File Reviews File"No.: 12 Licensee: Geocore & Environmental Services l- License No.: NRC Licensee (Reciprocity).

. Incident ID No

97-48 l Location: Commac, NY

! ' Date of Event: 10/17/97 i _ Type of Event: Stolen RAM Investigation Date: 10/18/97 Investigation Type:l Telephone

                                                                                                                                                                        -l L                                                   : Summary of Incident and Final Disposition: A vehicle containing a Troxler model 3430 gauge F                                                      was stolen on 10/17/97. Vehicle was recovered but gauge was not in it. Gauge was found on L-
                                                   ' road side on 11/12/97. The licensee was cited for bringing a gauge into New York without filing for reciprocity.

File No.: .13 Licensee: Mallinkrodt Medical,'inc. License No.: 2312-3141 ! Incident ID No: 97-56 L Location: Queens, NY Date of Event: 12/2/97

Type of Event: Transportation Investigation Date: 12/2/97 investigation Type:~ Site .

                                                                                                                                                                        -{

Summary of incident and Final Disposition: A package containing a Mo/Tc generator was ' l damaged at Laguardia Airport. NYDL staff surveyed and wiped the package at the airport. There was no release of radioactive materials and no removable contamination. l l l'. I-4

APPENDIX E-3 NYSH INCIDENT FILES REVIEWED NOTE: ALL INCIDENT FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. BLANKS ARE INFORMATION THAT HAS BEEN OMITTED IN COMPLlANCE WITH STATE LAW. File No.: 1 i Licensee: License No.: Location: Date of Event: 5/17/94 Type of Event: Misadministration , Investigation Date: 5/1/95 Investigation Type: Site inspection Summary of incident and Final Disposition: This incident was identified during a routine inspection of licensee. Two misadministration involving Sr-90 eye applicators resulted from the physician's failure to correct device output for decay, and lack of adequate quality assurance. The licensee was required to submit and implement a OA program and hire a third party auditor. Escalated enforcement was pursued which resulted in a civil penalty. File No.: 2 Licensee: Buffalo General Hospital License No.: 39-2 Location: Buffalo, NY Date of Event: 8/95 Type of Event: Leaking Source Investigation Date: 9/7/95 Investigation Type: none Summary of incident and Final Disposition: Leakage of depleted uranium collimators in teletherapy machine in excess of limits. Manufacturer replaced with tungsten collimators. Comments: a) No follow up of incident indicated at the next inspection b) Incident report was not in docket file. File No.: 3 Licensee: Roswell Park Cancer Institute License No.: 2923 Location: Buffalo, NY Date of Event: 5/30/96 Type of Event: Contamination Event Investigation Date: 6/6/96 and 6/26/96 investigation Type: Site inspection Summary of incident and Final Disposition: Individual working with P-32 called NYSH due to concern that shirt became contaminated during experiment. Surveys and i;ioassay performed to determine extent of contamination. Licensee's radiation safety committee revoked principal investigator's authorization for failing to provide the individual with training. l

i i i

                   - New York Proposed Final Report                                                             Page E-3.2 NYSH Incident File Reviews File No.: 4 Licensee: White Plains Hospital License No.: 1059 Location: White Plains, NY
                  ' Date of Event: 5/25/96                                                                                   3
                  ; Type of Event:~ Release of RAM-1 investigation Date: 5/26/96
                   - InvestigationType: Telephone j

i Summary of Incident and Final Disposition:. Patient died 5 days after receiving therapeutic dose

                   ; (241 mci) of l-131. Hospital and funeral home needed to coordinate special funeral arrangements to permit handling by the family. . NYSH provided guidance to licensee.

File No.: S

                   - Licensee: . University of Rochester License No.: 436            _

Location: Rochester, NY Date of Event: 12/8/96 Type of Event: Equipment Failure investigation Date: Next inspection investigation Type: None _

                   ' Summary of incident and Final Disposition: Source failed to retract in a Shepherd Model 81-14A irradiator during a six month safety test due to loss of air in pneumatic valve. Manufacturer .
                  , performed service on irradiator to correct problem.

File No.: 6 Licensee: License No.: Location: Date of Event: 10/29/96' Type of Event: Overexposure investigation Datei 12/12/96 -

                  - Investigation Type: Site inspection .

b Summary of incident and Final Disposition: Six month pregnant individual received 150 mci of I-4 .131. Individual apparently lied to licensee about her condition.. NYSH contacted medical

           ,         expertise to determine best course of action. Child not seen until recently by pediatric
            \        endocrinologist due to mother's apparent failure to seek post natal care. Incident still tracked by l             4       NYSH.

t r i 4 i 2

1 1 New York Proposed Final Report Page E-3.3 NYSH Incident File Reviews File No.: 7 Licensee: License No.: Location: Date of Event: 12/9/97 )

                           -Type of Event: Equipment Failure                                                                  4 Investigation Date: 12/9-11/97 investigation Type: Site inspection                                                               4 Summary of incident and Final Disposition: HDR source did not appear to move from one             j position to the next during treatment; source did not retract when treatment interrupted but did retract when emergency signal used. Manufacturer replaced two boards and power supply.

Licensee submitted report on incident to NYSH. NYSH to follow up at next inspection. File No.: 8 Licensee: License No.: Location: Date of Event: 8/13/97 Type of Event: Misadministration Investigation Date: 8/14-25/97 Investigation Type: Phone Summary of Incident and Final Disposition: Patient removed tandems, catheter and packing during brachytherapy treatment. Licensee provided report to NYSH. NYSH to follow up at next inspection. File No.: 9 Licensee: License No.: Location: Date of Event: 10/17/97 Type of Event: Misadministration Investigation Date: 12/16/97 Investigation Type: Site inspection Summary of incident and Final Disposition: Four cardiac stress patients were injected with Tc-99m pertechnetate instead of Tc-99m sestamibl. Licensee took preventative measures and investigated root cause. i L__-__-_____. __- _

New York Proposed Final Report Page E-3.4 NYSH incident File Reviews I ' File No.: 10 i Licensee: St. Mary Hospital 4 License No.: 35 Location: Rochester, NY { j Date of Event: 1/26/96 Type of Event: Release cf RAM Investigation Date: 1/27/90 - 2/4/98 investigation Type: Phone  ; Summary of incident and Final Disposition: Medical waste rejected in South Carolina due to l elevated radiation levels, returned to point of origin. Waste originated from nursing home patient L treated with I-131 for ablation as an out-patient. Waste returned to hospital for decay-in-storage. In a letter to the licensee, NYSH stated that they would be inspecting the licensee to ensure compliance with State guidelines and to review the licensee's corrective actions. File No.: 11 Licensee: Herbert Ross, M.D. License No.: 1186 Location: White Plains, NY Date of Event: 12/96 Type of Event: Lost RAM Investigation Date: 12/27/96 investigation Type: Site inspection Summary of incident and Final Disposition: Two Cs-137 sources discovered lost during termination of license. Extensive search by license and NYSH did not turn up sources. License terminated. l 1 File No.: 12 ' Licensee: Good Samaritan Hospital License No.: 575 Location: West Islip, NY ,

                ,                 Date of Event: 10/96 Type of Event: Lost RAM Investigation Date: 5/21/97
                                . Investigation Type: Site inspection                                                                 1 Summary of Incident and Final Disposition: During a routine inspection, the staff identified that   )
                                -the licensee failed to locate and report a missing Pd-103 seed during patient implant. Licensee       I cited for failure to report lost material and poor investigation of incident. NYSH reviewed licensee's corrective action for follow up at next inspection.

i-l 1

APPENDIX E-4 NYDEC INCIDENT FILES REVIEWED NOTE: ALL INCIDENT FILES LISTED WITHOUT COMMENT WERE DETERMINED BY THE IMPEP TEAM TO BE ACCEPTABLE. File No.: 1 Licensee: SyncorInternational License No.: 152-3 Location: Troy, NY Date of Event: 4/23/96 Type of Event: Damage to Equipment and Facility Investigation Date: 4/23/96 investigation Type: Phone Summary of incident and Final Disposition: High winds destroyed roof mounted blower which caused the failure of the licensoe's fume hood. Licensee suspended work in hood until repairs made. The incident was reported to NMED by NYDL. Comments: a) No specific follow up of the incident at the next inspection. File No.: 2 Licensee: Buffalo General Hospital

License No.

NA Location: Buffalo, NY Date of Event: 1/29/96  ;

Type of Event: Release of RAM Date: 2/1/96 Investigation Type: Site inspection Summary of Incident and Final Disposition: A disgruntled employee placed approximated 3.6 mci of P-32 in medical waste stream which was incinerated at the facility's incinerator. NYDEC l conducted on-site inspection to evaluate potential off-site doses. File No.: 3 l Licensee: Wyeth-Ayerst Research l License No.: 147-3

l. Location: Pearl River, NY Date of Event: 5/21/97 Type of Event: RCsase of RAM Date: 6/2-9/97 l Investigation Type: Phone Summary of incident and Final Disposition: A<;adental release of approximately 724 mci of l

tritium during a labeling procedure. NYD8EC evaluated licensee's event report and amended the

                  , permit to allow testing of the system. Release did not exceed dose threshold. Event occurred during renewal of permit. Permit issued with licensee's corrective actions. The incident was also investigated by NYDL.

l

R New York Proposed Final Report Page E-4.2

             - NYDEC incident File Reviews
                    ~

File No.: 4 Licensee: ICN East - License No.: 5-3 Location: Orangeburg, NY ' Date of Event: April and May 1996 Type of Event: Equipment Failure and Release of RAM Date:' 6/3/96,7/11/96 Investigation Type: Phone, Site inspection Summary of incident and Final Disposition: Accelerated filter aging resulted in release of 1.3 mci of I-125 in axcess of permit's 0.2 mCilimit. Probable causes of the release were lack of ' filter maintenance, inaoaquate HP oversight and audits, and changes in labeling protocol of RAM prior to filter deterioration. Enforcement conference conducted as a result of NYDEC's iL - ' inapection. Licensee's corrective actions where incorporated into a consent order.

APPENDIX F NYDL SEALED SOURCE AND DEVICE REVIEWS File No.: 1 - Registry No.: NY-0502-D-1'10-G Manufacture: NRD, Inc. SS&D Type: Static Eliminator Date issued: 12/31/97 Comments: a) The determination of what is considered tamper resistant screws was left to the applicant. b) Applicant was not requested to identify the conditions of use under which the device would be used. c) Certificate limits the condition of use to an undefined " extreme conditions" and not on a known set of conditions, such as the ANSI class!!ication. d) The materials of construction and methods of attachment for several components of the device were not specified. e) The visibility and durability of the labels were not reviewed. f) - The applicant did not provide justification for a leak test frequency greater than 6 months. g) The applicant did not provide dose scenarios and mounting instructions for the general licensees installing the device. . h) The quality assurance and quality control procedures submitted by the applicant were not reviewed. i) The licensee's response to a deficiency request regarding the most vulnerable surface of the device was not adequate. j) Applicant did not provide historical use data to support claim regarding the lack of injury or significant radiological failures, k) Information contained in two letters were not referenced in the certificate but were listed in the tie-down condition of the license, was not accurately reflected in the certificate.

1) The wording of the leak testing requirement in the certificate could lead to misinterpretation.

m) The drawings of the device components did not contain tolerances for all components. I l l

                                                                                        ~ APPENDIX G-1 New York City
                                                                 . Department of Health, Bureau of Radiological Health (NYCH)

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) QUESTIONNAIRE i f r L l' l l

Approved by OMB' No. 3150-0183 Expires 4/30/98 INIEGBAIED MATERIALS PERFORMANCE EVALUATION PROGRAM QUESTIONNAIRE Name of State / Regional Program: City of New York, Department of Health, Bureau of Radiological Health Reporting Period: April 01,1995, to January 1998. ! A. COMMON PERFORMANCE INDICATORS

1. Status of Matanals inanar+ inn Prnpram

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

Insp. Frequency Licensee Name (Yaarm) Dum Date Months O/D See attached list oflicenses. We have discovered 3 Priority 2 licenses and 1 Priority 3 license that are overdue and these willbe inspected within the week.

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

See above.

3. Please identify Individuallicensees or groups oflicensees the State / Region is inspecting more or less frequently than called br in NRC Inspection Manual Chapter 2800 and state the reas:.n kr the change.

None. l l l 2 Estimated burden per response to comply with this voluntary collection request: 60 hours. Forward comments regarding burden estimate to the Information and Records Management Branch (T-6 F33), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, and to the Paperwork Reduction Project (3150-0052), Office cf Management and Budget, Washington, DC 20503. NRC may not corxiuct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. l-l

4

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

Number of Lloensees Gras,ted Reciprocity Number of Licensees Priority Permits Each Year inspected Each Year Service Licensees performing YR YR teletherapy and irradiator source YR YR installations or changes YR YR YR YR YR YR 1 YR YR YR YR YR YR YR YR 2 m m I YR YR l YR YR YR YR 3 YR YR YR YR YR YR 4 All Other Seven out of state or city licensees were granted reciprocity by this Bureau l betnen April,1995 and the present. These were Neutron Products, Theratronics, Alpha-Omega Services, Elekta, Quality Assurarace Services, Ultra Company,Inc., and the State UniversMy of New York @ Stony Brook. A total of 223 reciprocity i notices were Bled with this Bureau during the reporting period. Of this total,195 were HDR source exchanges and 23 involved teletherapy licenses. A total of 13 teletherapy installations, source exchanges, and source removals were ( inspected. *

5. Other than reciprocity licensees, how many Reid inspections of radiographer were perktmed?

None. Industrial radiography is under the pu view of the New York State Department ofLabor, not the Bureau.

6. For NRC Regions, did you establish numericalgoals kr the number of 1' inspections to be perkrmed during this reviewperiod? If so, please describe your goals, the number ofinspecinons actually performed, and the reasons br 2

i

any ditkronces between the goals and the actual number ofinspections peribimed. N/A. II. TechnW=r M*v af '==== n

7. What, if any, changes were made to your written inspection procedures during the reportingperiod?

We adopted the NRC inspection forms. No other substantive changes.

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

In'"r  % erviene t zeer,,, cg Ahmed Arafa Richard Borri Nuclear Medicine 9/25/97 - TerryKirschenbaum RichardBoni Teletherapy 9/25/97 Victor Goretsky Richard Borri Nuclear Medicine 9/18/97 Chris Saganich Richard Borri NuclearMedicine 9/16/97 Edward Cutler Richard Borri Nuclear Medicine 8/26/97 Ahmed Arafa Richard Borri Nuclear Medicine 8/21/97 Victor Goretsky Richard Boni Academic 7/15/7 Chris Saganich Richard Borri Medical (Broad) 7/11/97 l Edward Cutler Richard Borri Academic 7/9/97 Chris Saganich Richard Borri Teletherapy 6/29/97 Ahmed Arafa Richard Borri Pvt. Office Med. I1/26/96 TerryKirschenbaum RichardBorri Medical (Broad) 11/20/96 Edward Cutler Richard Boni Medical (Broad) 11/13/96 Ahmed Arafa Richard Borri Pvt. Office Med. 8/28/96 Victor Goretsky Richard Borri Teletherapy 6/25/96

Chris Saganich Richard Boni Medical (Broad) 6/21/96 l TerryKirschenbaum RichardBorri Medical (Broad) 4/3/96

!' Ahmed Arafa Richard Borri Medical (Broad) 3/26/96 TenyKuschenbaum RichardBoni Nuclear Medicine 3/5/96 Edward Cutler Richard Boni Academic 1/23/96 Edward Cutler Richard Borri Nuclear Medicine 12/28/95 Victor Goretsky Richard Borri Academic 12/12/95 l Chris Saganich Richard Borri Academic 11/21/95 Ahmed Arafa Richard Boni NuclearMedicine 10/21/95 TenyKirschenbaum RichardBorri Nuclear Medicine 9/9/95 TerryKirschenbaum B.Kamble Medical (Broad) W29/96 Edward Cutler B. Kemble Teletherapy sG97 Chris Saganich B. Kamble Broad (Non-Human) 1W1/96 3 i j L.____________________________ _ _ _ _ _ _ _

I

                   ' Edward Cuder           . B. KamNe            Broad (Non-Human)       10/1/96 Chris Saganich _       B. KamNe             Broad (Non-Human)       12/21/96 Broad (Human Use)       12/21/96 AhmedArafa Edward Cuder Victor Goretsky Edward Cuner            B. KamNe             NudearMedicine          7/1H6 Edward Cuder            B.KamNe              NuclearMedicine         12)2W95 Chris Saganich          B.KamNe              NuclearMedicine         12/28/95 Edward Cuder            B.KamNe              Broad (Human Use)       11/12/96 AhmedArafs                                    &(Non-Human)

Victor Goretsky B.KamNe RchardBoni Broad (Human Use) 10'31.97 ' B.KamNe RichardBorri Broad (Human Use) 9/25/97 , B.KamNe RichardBorri Broad (Human Use) 7/3/96 RichardBorri L. Friedman Broad (Human Use) 11/12)97 , 1

9. Describe intemalprocedures for conducting supervisory accompaniments ofinspectors \

in the Meld. Ifsupervisory accompaniments were documented, please provide copies of the documentation kr each accompaniment. Supervisory accompaniments consist of a supervisorJoining one or more Inspectors during the course of an inspection to con 6tm that all violations of Article 175 NYCHC are identined, documented and reported, using procedures as statedin the inspection procedure manual, as applicable. Results of the accompaniments are discussed with the inspector as soon as possible after the accompaniments end., i Supervisory accompaniments also provide a setting forinbrmal, on the spot training. Written documentation of accompaniments is not made unless brmal, written charpes will be filed against the inspector; then documentation will be made suWicient to support the charges. During the reporting period no such l actions were taken. l 10. Describe orprovide ait uodate on yourinstrumentation and methods of calibration. Are allinstruments property calibrated at the present time? The Bureau for Radiologwal Health estaNishes a Nanket order kr the calibration of fieldinstrumentation with Ludum Measurements of Sweetwater, Texas. Ludium is authorized by the State of Texas Rodological Health Bureau to operate an instrument calibraton facility. The Bureau calibrates allReldinstrumentation used by the Radioactive Materials (RM) Drvosson on either an annual basis or after any instrument repair. Ludum calibrates the following instruments for the Bureau: Model 14C GM Counter with Model44-7 GMprobe & Model 44-9 Scintillation Probe 4 l 1

Model 1g Micro-R Scintillation Meters Model 6112B Autom&ss Stretch GM Probe ModelESP-1 Eberline Neutron Probe with Model NRD Probe Each inspectoris issued a copy of the calibration ibr the Reld instrument assigned to him. AH Bureau instruments are property calibrated at the present time. In those situations requiring more sophisticatedlaboratory analyses, the Bureau has access to the resources of Brookhaven NationalLaboratory. Ill. Techniemi stamng nnd Training 1

11. Please provide a statnng plan, or complete a listing using the suggested format 1 below, of the professional (technical) person-years of effort applied to the agreement or radioactive material program by individual. Include the name, position, and, forAgreement States, the fraction of time spentin the ibliowing areas:

administration, materials licensing & compliance, emergency response, LLW, U-mills, other. If these regulatory responsibHities are divided between olYices, the table should be consolidated to include allpersonnel contributing to the radioactive materials program. Include all vacancies andidentify aH seniorpersonnel assigned to monitor work ofJunior personnel. If consultants were used to cany ou! the program's radioactive materials responsibuities, include their efforts. The table heading shouldbe: ' NAME POSITION AREA OF EFFORT FTE% i Gene Miskin Head- Licensing Administration 70 Ucensing 30 l Jane Bragg Scientist Licensing 90 Linac registration 10 Raymond Ford Scientist Licensing 90 Unac registration to Richard Harmon Scientist Licensing 90 i Unac registration 10 Daniel P. Hayes, Ph.D.,CHPScientist Licensing 90 Unac registration 10 5 l \

I NAME POSITION AREA OF EFFORT FTE% RehardBorri Sr. Scienkst Materialslicensing & Compuence 80 Eargency Responses . 20

BapuKamNe Sciendst Meterialslicensing & Compliance 85 Emrgency Responses 15 AhmedArafa Asst. Scientist Meterials nicensing & Compliance 65 EmigencyResponses 15 Edward CunerAsst. Scientist . Meterials Jicensing & Compliance 85 EmergencyResponses 15

'~ Victor GoretskyAsst. Sciendst Meterials Mcensing & Compliance go Emergency Responses 10 T. Kuschenbaum Asst Scientist Meterials hcensing & Compliance 90 EmergencyResponses 10 Chris Sagenich Asst. Scientist Materialslicensing & Compliance 85 Emergency Responses 15 l

12. Please provide a listing of all new professional personnel hired since the Inst review,-

indicate the degree (s) they received, if applicable, and additional training and years of experience in health physics, or other disciplines, if appropriate. Laurence F. Friedman, Ph.D., CHP, started as Director on 1WW97. Dr. Friedman has ont thirty-Rve years esperience, hcludmg overthirteen years with NRC-Region I. No othernewhires sincelest review.

            .13. Please hist nHprofessional stew who have notyet met the quali6 cation requirements oflicense mneworhnatorials hspeckon staW(for NRC, Ir+Gia Manuel Chapters

.1246; for Agreement States, please describe your qualtlicadons requirements br materials license reviewers and hspectors). For each, nst the courses or equivalent trainingVespenence they need to attend and a tentative schedule for completion of

                    . these requirements.

AM of the staWis tramed. The Joenshg staWhave en attencied core courses provided by NRC, attended an h house nicensing class and have been reviewed b all the l types ofMcerwng done by this Bureau. The materials hspection staWhave attended core courses provided by NRC and perbem unsupervised and supervised inspections of each of the types oflicenses 6

1 I Issued by this Bureau, in addition to having had training and experience in c Emergency Response. 1 i {

14. Please iden6fy the technical steff who left the RCP/ Regional DNMS program dunng l this period.

Robert R. Kulikowski, Ph.D., Director, resigned his position ettective 7/19/96. Laurence F. Fnedman, Ph.D., CHP, Duector, resignedhis postbon eWective 2/698. i l l

15. List the vacantposibons in each program, the length of bme each position has been

{ vacant, and a brief summary of eWorts to Ril the vacancy. The Bureau Duector posibon was vacant ibr 15 months kom July of 1996 until l i- October of 1997. This position is now vacant again with the resignation of Dr. Friedman and this vacancy has been reposted. l

                                                                                                    .]

IV. Technie=I nu=Inv of I leansing be* inns '

16. Please identify any major, unusual, or complex licenses which were issued,

received a major amendment, terminated, decommissioned, bankruptcy notiRcation 1

{ or renewed in this penod. Also identify any new or amended licenses that r;ow

require emergency plans. )

l \ Two Gamma Knife licenses were issued- one to New York Uninrsity Medical j Center and one to Columbia Presbyterian Medical Center. l l A consolidated.non-human use license was issued to New York Hospital-Comell Medical Center which eliminated about 100 individuallicenses for this institution.

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

Any physician wishing to use the "C-Urea capsules may request a variance from the Bureau and will receive a letter from us granting such variance for ordering purposes.

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

v Thefollowing License Guides have been updated during the reportingperiod: I License Guide 10.2, Revision 2, April,1997 l License Guide 10.5 Revision 2.1, April,1997 License Guide 10.6, Revision 2, January,1996 7

License Guide 10.7, Revision 2, April,1997 License Guide 10.8, Revision 2, December,1997

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

hVA V, Reennnene in Innbients and AnanaNnns

20. Please provide a list of the reportable incutents (i.e., medical misadministration, overexposure, lost asui abandoned sources, incidents requiring 24 hour or less nott6 cation, etc. See Handbook on Nuclear MaterialEvent Reporkng in Agreement Stetes kr add 60nalguidance.) that occurredin the RegiorvState during the review period. For Agreement States, inkimation included in previous submittals to NRC need not be repeated (i.e., those submitted under OMB 3150-0178). Thelistshould be in the following krmat-LICENSEE NAME LICENSEi MH TYPE OFINCIDENT annar Columbia. 9/97 A serious deficiency in management ano Presbyterian Medical proceduralcontrols in a majorarea; Center wrongdoing. The center failed to ettectively monitorits regular waste stream for radioactive contamination . Though the Center installed Rxed portal monitor systems, when one broke down it was not promptly repaired, and the Assistant RSO ordered a technichian to make up false records showing the system to be operational. When waste from the center was 16und to have radioactive contamination, these false records were displayedto Bureau representatms.

I l Mt. SinalMedical 697 Theft or dintsion oflicensed material. Center When a sh& ment of about 200 mClof bodine-125 seeds was receindatthe Center, it was left unsecured in an open onice area. When it was needed the next day, M was gone. A search of the Center by the radiation safetystaff and representatives of the Bureau failed to Jocate the shipment and M remains missing 8

New York Uninosity MedicalCenter 11/97 Improper shpment and loss oflicensed material The Center attempted to transport 3 mci of Wrium-90 between its two campuses via a techmcian using a taxicab The Wrium-90 was lost when the taxidrove ofIwith the matenalstill h the trunk. It was retumed to the Center the next day by the taxi company when another drint noticedRin the trunk. For at of these hcidents, a Nobce of Vdebon was issued and civepenalties were imposed.

21. Dunng this review period, did any Mcdonts occur that hvolved equipment or source fauvre or l

apprond operahng procedures that were de6 cent? If so, how and when were other State /NRC licensees who might be aMiected noti 6ed? For States, was timely notincation made to NRC7 For Regions, was an appropriate and timely PN generated? i > No.

22. For hcidents involvong linHure of equpment or sources, was l6 vah&GOn on the Mcident provided to l

the agency responsde W evaluabon of the device W an assessment ofpossible generic design \ deRciency? Pbesse provide detaHs W each case. There werent any. l 23. In the period cowred by this review, were there any cases hvolving possible wrongdoing that were l reviewed or are presently undergoing review? If so, please describe the circumstances for each j case. During June 1997 we determined that en Assistant RSO at Mt. Sinal Hospital was ordering a technician to make out and sign false records ofradhtion monitonng equipment, showing them as operating property when in fact they were not. In December of 1995, this Bureau revoked the license of a nuclear cardiologist when it was learned that preceptor statements that had been submitted as proof of experience & this hdividual dd not meet the requirements ofArbcle 175 of the New York cry Nealth Code. The onginallicense was Mrst i amended to read ' storage only untilproof of dM- ER-n of allradioactin materials ~ and then was [ cancehed after a &&w%,,&uy hspection by this Bureau.

24. Identify any changes to your procedures W handling aNegations that occuned durling the period of this review.

s. For Agreement States, please identify any aNegebons refened to your progrom by the NRC '

\. thathan notbeen cioned. . None.

    . VI. General 9

l I 4 i

a 4

25. Please prepare a summary of the status of the State's or Region's actions taken in response to the comments and mcommendsbons Mowing the inst aview.

In a letter dated Sf29/05 to Rehere L. Bangert, Benjamin Mojica, M.D., M.P.H., Acting Commissioner of HeaNh responaed to the comments andrecommendsbons made by NRC following the last program i review.

26. Provide a brief descr> bon of your program's strengths and weaknesses. These strengths and weaknesses shouki be aMpported by exemphs of successes, problems or ditticulties which occurred during this reviewperiod.

, 1 One atmous weakness is the inct the this Bureau has been without a director W most of the reporting . period. Desphe this, Bureaupersonnelhen managed to memten an etFective radiation sakty program ) in New York City. (1 NON-COMMONPERFORMANCEINDICATORS f, Lg!=!=:- n and Prnaram hmerde Rannhed for Camna+ihili+v

27. Please list all currently effectin legislation that effects the radiation controlprogram (RCP).

Artete 175 of the New York City Health Code- Radiation Control Part 16 of the New York Sanitary Code 6 NYCRR Part 380 and Part 381, New York State Department of Environmental Conservation.

28. Are your regulations subject to a ' Sunset' or aquivalent law? If so, explain and include the next expiration date foryour regulations.

No.

29. Please complete the enclosed table based on NRC chtordogy of amendments. kientify those that han

, not been adopted by the State, explain why they were not adopted, and discuss any accons being taken to adopt them, identify the regulebons that the State has adopted through legally binding requirements other than regulebons.

Please see table. The Bureau is cunently reviewing with our OMce of General Counsel the Timeliness in Decomtrussioning Rule and the LowLen! Weste Shipment Mardhst Rule. The Bureau has decided l to retain our more stnnpent Frequency of Medical Examinabons W Use of Respiratory Protection j Equpat

30. If you han not adopted all amendments within three years from the date of NRC ruie promulgation, briefly descnbe your State's procedures W amendmg requiabons in order to maintain compatibility with the NRC, showing the normalkngth of hime anbcpated to complete each step.

Rule makmg lenguage is done by Bureau personnel and this is then sent out h comment to NRC, State Health, and an advisory committee of the New York Academy of Medicine. A draft of the rule after comments is the sent to our Ottice of General Counsel, which prepares the proposed rule W approval 10

l i l e by the Board ofHealth republication h The CHv R=emt There is a thirty day period for comment and a public meeting is held on the last day of the comment peniod. Assessment of comments received is then done and the nnel rule is prepared br Board of Health approval. With approval, the rule is then published in The cHv Raemd and then becomes Mnal within thirty days. Complexity of the proposed nde making is the determining factor krlength of time to adoption. On smage, the I.de melung process takes about six months to complete. II. ?^^'^ A"ce and Davien %=m

31. Prepare a table heting new and revised SS&D registrabons of sealed sources and devices issued during the reviewperiod. The table heading should be:

SSAD Manufacturer, Type of Registry Distnbutoror Device Date Number n + m Unar or Source issued None. Approvals perbrmedby State.

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

N/A

33. Please include inktmation on the following quesbons M Section A, as they apply to the Sealed Source and Device Program:

N/A III. Low-Level WncM Penoram

34. Piease include information on the following questions in Section A, as they apply to the Low leel Weste Program:

N/A IV. Uranium um Prnaram

35. Please hclude laivar,& tion on the followsng questions M Section A, as they apply to the Uranium Mill Program:

WA 1 l 11

T C I 9 CT 9 EP 1 PO t p XD e EA S f e s n u o C l ar R e O n e T G NS f o EU e R TA c RT f n US C O r u o y b d l e e u l a v e g i n e b i s e lu R D ETE T P AO D D A 4 6 EE T 1 4 9 5 6 9 7 T A U 3 3 4 9 5 8 6 M 5 9 7 S 8 DD 7 2 8 7 8 1 0 1 1 f 7 2 M 1 2 2 2

                                                                                        /

8 2 8 1 5 1 8 1

                        /      /     /      /       0        7        /         /       0           7      /         f
                                                                                                                            /

7 4 1 1 1 1 7 7 1 1 7 S 1 t s yf  ; n n e

• r N o o  !

e - o m - A tny n sf og a e i t c l c P i Dai l - c ir n E - Moo l F d a i h u 1 o 0 e l ae r 1.n R a p d n  % q 6 D7 t y

                                                                                             . MF 6

1 g it ca r eM r 9 or r , 0, Pa p4 t 1 s g a y l n g _ 9 h n o 0 r e n n mtc 1 C l e i 7 m ie  ; 0, im mu5 to e d r i a o0 _ g a 0, 5 la m; 3 F o n od3 _ rh A R r g3 S l aa ' s N 7 f o Co r 4 sr d t r i s ot n otr '. rt d 0, o _ 9 ir a pt r o W s: 9, r Pa o N6 n og pr o vc A4 C i s & yp sP n0, t 2 i n3 m r B P t s s iP . N ee g c e t n; ro3

                                                                                                 ;          s         m     kf3 uf         :     n      e    t n4     d 4,      es d r       f DA      Es a3                g o     s o O            dre        g i

n t o e3 i c 3 mn oa gon sat s Mn 0 RP dO t ( 4 c net I n0 n0 r mtr M1, nn e 0 asa nn a7 P eio n ae r T i eo iN ea at r S E e n7 o f P iPr f 3 gr ot o d s; Li t nd eP TaP D7 TrUP E L U mNo t)s n is 0, y4 0, ks u q t; o 0, nt s nr f S ab onte sin i od sA dr  ; n 1 N I t r 0, t

                                                                                                                                 .d:

n U degm nta. 4 e en o Nn30, Mk oi r s4 c f ot Ms s4 Q R im 0, i Re ga s mo ei r s nd s N oaU r e 0, n 0, t f , R e r e2 ym Md o a un enl R F med a r n m3 g3 e0 ym c n d s a NW mW Ga u r a n3 reNio p ns e a nn t r d2 d n os et s oh t en e O C ych e ct nt kiu it ei Rd cn h f- c nn ets pud nam DP ea r ma SP SE NP OA r era eq oa v t r s c e n ee le e ea mr eb e F E L 0 1 AeA EP t M ihDa L D m SM US TP r t ia Pt r ir B A T

, ,i ,! l;ll jlll llllll, l l1l Dt E TK M 6 9 9 CT 1 _ EP PO XD EA t. S p e - _ l e s n r u e o p e C t 1 e - R f o r e O ^ n _

                             . e                                                                                                                                     _

_ T . G _ NS . f o EU e R T c RA T  ; F R US C y O r u _ o y

                               , b w

r i e u v - o er g r - e M p d e n e u h - .e r 3 a a. 1 63 u n C _ D E E T T' A P DO D A 6 6 E T E 6 6 6 9 9 9 0 O 0 0 o AU 9 6 9 9 4 9 0 9 0 0 M e M e DD 3 8 O 4 2

                                                          /               M      2      6         D           0    r z            9           7                     o t

f 1

                                 /

J f 1 1

                                                                          /      &      1 W         M           f f    r            2 F

2 m 3 3 W W 1 4 f 1 2 2' G a

                       . f

• o de s y e r f n

_ e s h p d n y N 4v i e An s n Mn so M s o n _ U' a e N o eN s e b r r g m M d e d n c me oo p s c n6 du nd m i t o A n h a A bl ir es s a n m s u y r C r s e da  ; F t n d e i e ct i e yI le r e - nt in

• hc e ne o A fr s.

n Ur u sf hot rd T Non R s Ae

n. E n , W e J pfR wg t f ee s . e oe l i r r s a e r s na da e d f g ^a of r s e

b yA c - nre m e r ff n m m u>nn A ab

                                                     .                    t ny            U^         0e          o   Sed0                      o      .n             e t       s               '

R 0s MA ~i o .- iA og t - i hg f sd s M .F e eq t f u e0 n o ev sr f e nFe t

                                                                                                                                                    . s, n Nn   e        ;

o u n EnE e en . e R ks- qe 8 yo n -

                                                 ".ie                       pE    n           .

v e meS es _n w - l n r n n e# m eivt se t e ;o A ao sofs os t - i cnc hp Se hu n# o s -

                                                                .           oic   roi e  n ;

a Rcs l W esn r s e A p o M"s e r n e e de eR q nr - Cm t p t T'. r eo h S gh Acm sd s .e u s e AM insd 0 t R e cC sf t- 1s

o ises r , Do t ud l ne ReR dtyp no E fP n

e e om f o 7A Ma nA o tRc f e feeo rg r e hd Mhr eyO r C t. U o Y Wa n c Pr s a n ";. tl r a de n ; u fA r o neA l e bSh p r e yr e n n t o a n r o _ no f s od rr c vNo l op Po t AW nnn e nor a na R a e nn n _ o n c0 t . d fA s n0 e oo e . Rne es f c o nts A enUa s R er ee mm NW c M un e gsn eW sng n n ir -; co o o oo so r f F' ui p lm foQ od n Fm dd 0 m o ah i r on n Ce qs - r dA m C ee wo r eq u ae s ee r e slu en s s c ereN Sd edd c oe e 0 1 FR r of LI n PE RD C'. 8 0t 1 i n f AR T r- RE i F RAH CA r URR R i! llllll ,

LJoones inspectone Due By Priority and By Date Due 1

 . Weense8 MooneeType Prierhy                                                                    Date Duo        Date Overtius Name                                                                 Borou9h 2969                                          75                                       1       12/1347         03/13/06 Rocheloner University                                               MN 2924                                          92                                       1       01/J0/96       04/29/96 Brooklyn Hospnel Center                                              BK 2885                                          75                                       1       0244/96        05/05/96 Montortore Med Ctr                                                   BX 3009                                          75                                       1       03/05/96       06/03/96 St. Vincenre Hooplint and Modecal Center                             MN 2643                                          92                                       1       03/08/96       0606/96 Lon0 letand Conege Hospital                                           BK 161                                          92                                      1       03/25/96        08/23/96 Memortel L. " .;4                                                   MN 165                                         75                                       1       03/25/96       06/23/96 MemortalSteen.Kettering                                              MN 2847                                          92                                       1       0444/96        07/03/96 Peninsule Hospital Center                                            ON 2004                                          91                                       1       04M1/96        07MOS6 New York Hosphal Medwal Center of Queens                               ON 131                                         92                                       1       04/24/96       07/23/96 Staten letand Ureversity Hospital                                    St 126                                         92                                       1       04/34/96       07/23/96 Staten leiend Univ. Hoop                                             St 2830                                         92                                        1       0649/96        08/07/96 ManfredL Orlando L M.D.                                              Si 2009                                         91                                        1       06/2146        06/19796 Mt Sinal School of Medicine                                          MN 2041                                          92                                       1       06/24/96       08/22/96 Brookdale Hospital Medcol Center                                     BK        i 2919                                        75                                         1       06/0$lB6       0903/96 Albert Esnotam Cate9e of Medicine                                     BX 2089                                         92                                        1       0608/96        08/04/96 Animed Medical Center                                                MN 2000                                         92                                        1       06/06/96       0904/96 AnimalMedicalCenter                                                   MN 166         .                              82                                        1       06/22/96       09/20S6 Memonal Steen Kamertn0 Cancer Ctr                                     MN 2955                                         92                                        1       07/08/96        1046/96 NYU Modest Center                                                    MN      l 76                                        92                                                07/29796       10/27/96 Lenom Hin Hospital 289603                                          92 1

0847/96 11/05/96 Memortal L. "f ;4 MN

                                                                                                                                                                                                                  )

1 MN 2957 91 1 09/17/96 12/16/96 NY Hosp. Comed Med Ctr MN 2697 92 1 09/24/96 12/23/96 Both tornel Medice! Ctr MN 86 75 1 10/12/96 01M0/99 NYU Med Center MN l 2966 75 1 10/1646 01'14/99 Lon0 taland .iewish Med. Ctr. ON 2950 93 1 10/17/96 01M5/99 NYU Modenal Center MN 2955 75 1 10/17/96 01M5/09 NYU Medcol Center MN 2676 92 1 10/27/96 01/25/09 Columna Presbyterten Modest Center MN 2922 92 1 10/26/96 01/26/99 Catwini Medice! Center MN 2896 75 1 10/3146 01/29/99 St Luke'eWtoceeweit HospNel Ctr MN 3026 92 1 11/07/96 02@5/99 SUNY HeeNh & Science Center Brooklyn BK 82 92 1 11/07/96 02/0549 SUNY Heefth & Sciences Center Brooldyn BK 44 92 1 11/07/96 0225/99 SUNY Health & Science Brooklyn BK l 146 92 1 11/28/96 02/26/99 NYCHHC Kin 9e County Hospital BK 2676 52 1 12/05/96 0345/99 Columbse Presbyterten Medwal Center MN ! 2676 75 1 12/05/96 03@599 Columble Presbyterten Medical Center MN 2646 92 1 12/24/96 03/24/99 Catwory Hospital BX 2934 75 1 01M8/99 04/1899 SUNY-Health & Soonce Ctr of Brooklyn BK  ; < 2663 92 1 02/13/99 05/14/99 Montellors Med. Center BX ' l Total 39 Priority Date Due Date Overtive Nome Borough 2909 74 2 07/22/96 01M8/97 Mt Sine! School of Medsene MN l 2661 91 2 02/0847 08@7/97 Nestedt, Louis MD. MN l 2915 91 2 04/26/97 1025/97 NYCHHC Uncoln Medical and Montal Hestth Ctr BX l 1516 91 2 09/21/97 03/20/96 Victory Memortel HospNel BK i 2919 74 2 10/12/97 04/1046 Albert Einstein Conege of Medmine BX l 2903 91 2 01/04/96 07/03/96 NYCHHC - Harlem HospNel Center MN j 3003 91 2 01/24/96 07/2346 Annand, Azad K. MD ON 2731 91 2 01/24/96 07/23/96 Lu0o Sante9o, Ems MD ON 2932 91 2 01/20/96' 07/27/96 Parkwey Hospital ON l 1515 91 2 01/3046 07/29796 Norm Shore Univoralty HospNo! ON i 2000 91 2 03/22/96 09/1846 Our Lady Of Moray BX 2644 91 2 03/2646 06'22/96 Maimonides Med.Ctr. BK l 3075 91 2 03f3050 09/2546 fiereld M. Tine ON 00G8/96 Devkl Greenbests, M.D. 4 3069 91 2 03/30/96 MN 2843 91 2 04M3/96 09t30/96 L&a0 leland Cone 9e Hospital BK 1641 '91 2 04/11/96 104846 NYCHHC Norm Centrei Brons Hospital BX 3070 91 2 04/11/96 1006@6 Daniel Larher ON 2882 91 2 04/16/98 10/13/96 St Qare's Hoopleal & HeeNh Center MN . 10/16/96 BloomAeld, Moren E.MD ( 2642 2005. 91 91 2 2 04/1996 04/23/06 10G0/96 Cecoswo, Naholes MD MN BK l 1 3002 91 2 05 @ 5/98 11/01/96 Blake .lemme MD MN 3020 91 2 0500/96 11/04/98 Thanswels. Shirte5 K. MD ON 165 91 2 06/0046 11/04/96 Weinsteen.Violor MD . ON 2766 91 2 05/0996 11/05/96 Wolmer, tra MD. MN 2914 91 2 06/15/96 11/11/96 NYCMHC.ColorMemortalHospitet MN i 2680 91 2 06/15/96 11M1/96 Rosenthal,Deved,M.D. BK { l 02/17/96

I Uoonee inspemone Due By Priertly and by Date Due

 ,            1540        91 ,  2 05/17/96      11/13/96 Docnort Hosphal of Staten leiend                S1 2732        91  . 2 06/22/96      11/16/98 Poule M. Rotheus, M.D.

2796

                             ~.                                                                          MN 91    2 05/23/96      11/19/96 Bier, Steven MD                                 MN 3039        91    2 06/23/96      11M926 Jacobs, Deved R. MD 3053 MN 91    2 06/24/06      11/2046 Rudevsky, AmielZechery,M.D.                      MN 2761        91    2 06/2 M 6      11/2H6 Kaufman, D MD                                     BX 2955        74    2 OM1/96        11/27/96 NYU Medical Center                              MN 295504         74    2 06/31/96      11/27/96 New York Univoretty                             MN 2795         91    2 064M6         12/02/96 Reismen, Steven, MD                             MN 2961         91    2 08/17/96      12/14/98 Potense, Robert MD                              BX 1672        91    2 08/1M6        12n546 Spor 9el, Gabriel MD                              BK 2765         91    2 06/1M6        12/15/98 Pre 9er, Men:MD                                 BX l             2024         W1    2 06/21/96      12/16/96 Brootoyn Hospital Center                        BK l             2006         91    2 06/26/96      12/25/96 North General Hoopen!                           MN l             2642         91    2 07/03/06      12/3046 Methodist Hoopstal                               BK 3025         91    2 07M046        01J0649 En9, Youn9 F, . M.D.                             S!

2616 91 2 07 DSS 6 01M1/99 Sheinbrot. Start /Insin, Singer BK 3023 91 2 07M6/96 01M4/99 Novick, Mark MD ON 3077 91 2 07/30/96 01/2649 Joseph Hung Me, M.D. ON 3004 91 2 0641/96 01/26/99 LNele Neck Community Hosp. ON 2760 91 2 06/12/96 02/0649 Seplenze, N MD BK 3005 91 2 08/13/96 02/0H9 Liaonn, Neal, MD MN 3036 91 2 08/14/96 02/1049 DoeN, Leone MD BK 2646 91 2 06/15/96 02/11/99 Lichy, Jacob MN 2630 91 2 06/17/96 02/13/09 Mermedi, Ortendo L .M.D. Si 2651 91 2 06/2046 02N649 St. John's Episcopet Hospite! QN 3014 91 2 06/2946 02/2549 Rezzedeh, Rudy MD MN 2797 91 2 09/04/96 03/03/99 Schaefer, Kenneth MD Si 2796 91 2 09/10/96 03/0999 Doohi, Leone M.D. ON 2960 91 2 09/1046 034049 N.Y Flushing Hosp, Med. Car, ON 2636 91 2 09/11/96 03N099 Lorber DanielMD ON 2771 91 2 09/1646 03/15/99 Brendes, Vincent T MN 3022 91 2 09/24/96 03/23/99 Both Israel . Kin 9e M9hway Dnnaion BK l 2944 91 2 09/26/96 03/2549 DoeN, Leone M.D. BK 3041 91 2 OS/27/96 03/2649 Rosenthal, Devid, M., MD BK 2621 91 2 09/27/96 03/2659 Gmde, Rowndro MD BK 2957 91 2 1001/96 03/30/99 Meng, Henry M.D. MN 3034 91 2 1001/96 03/30/99 Lefkowitz, Deved 14.D. MN 3042 74 2 1041/96 03/3049 CUNY-City College MN 2663 91 2 10/01/96 03/30/99 Kampf, Jemey MD MN

           ~ 3056         91    2 1043/96       04/01/99 Tertell, Joy MD                                 ON 2657         91    2 10CS/96       04/07/99 LJesh, James MD                                 BK 2739         91    2 10/11/96      04/09/99 Schort, P MD (Hilcreet)                         ON 2666         91    2 10/16/96      04/16/99 Thanewate, Shinah K. MD                         BX 3051         91    2 1 & 22/96     04/20/99 Semil, Mohoon MD                                ON 2941         91    2 10/2346       04/21/99 Hessen, Khalid MD                               BK 1619         91    2 10/2346       04/21/99 Westem Queene CommirWty Hospetal                ON 2006         91    2 10/25/96      04/2349 Fett, Sheldon, MD                                ON 3050         91    2 10/30/96      04/26/99 Levine, Even MD                                 BX 2933         91    2 1141/96       04/3049            Hershed MD                            SI 1640         91    2 11J0M6        0547/99             , Howard J                           MN 2635         91    2 12/0386       0641/99 Grunther & Stou M.D.                             MN 2976         91    2 12/06/96      06/03S9 A. Messine, MD & A. Uebereidnd, MD               MN 2646         91    2 12/05/96      06/0359 WyckoN Heights Medical Center                    BK 2929         91    2 12/05/96      06/03/99 CMC 80. St Mary's Hospitel                      BK 2649         91    2 12/0H6        0604/99 SL Bemebee Hospho!                               BX 2946         91    2 12/06/96      06/04/99 Bradley Moore, Pearlck MD                       ON 2969         74    2 12/12/06      06f1049 Roc *eleber Univoretty                           MN 2996         91    2 12/13/96      06n149 Greenber9 Joseph M.D.                             MN 3045         91    2 12M M6        06/1849 Muten. Edward E. MD                              ON 3054         91    2 12/21/96      06d999 Luthoren Med. Ctr.                                BK
           - 2917         91    2 12/23/96      06/21199 Rosemen,8 MD                                    MN j             2616         91    2 12/2H6        06/24/99 Hospnel lor Joint Dieseseolorthopaede lastitute MN l

2923 91 2 12/31/96 062999 Jamaica Hosp. ON 2002 91 2 01/02/99 07/01/99 NYCHHC . Coney telend Hospital BK 696 91 2 01/07/99 07/06/99 S#worberg, Amold I. MD BK 2950 91 2 01/07/99 07/06/99 Brorm Lebanon HoopNel Center BX 2656 91 2 01/06/99 07/07/99 RetWner, Herbert, MD ON 2001 91 2 01n099 07/0999 NYCHHC-Queene Hospital Ctr ON ! 02/17/96 l l

f Usense inspec8ons Due By Priertty and By Date Due

 ,          2896           91      - 2           01/1/ 2 9       07/1199 Heimes, Aheon B. MD                                    MN 2649           91_ ,. :4 ~ 2         01/1'99         07/14/99 NYCHHC.Woodhull r 4 Mntl Hith Ctr                     BK 3055        .- 41 ' .- er 2          01/; *.99       07/14/99 D'Alessandro, Thomas M.D.                             MN 2945           91   ,_       2

• 01N/99 07M549 Interiellh Med. Car BK 2926 91  ; 2 01MtW99 07/1549 Lenom NH Hospital ~

MN 2671 91 2 01/17/99 07/1649 CMCSQ . St Joseph 4 Hoop Divisaan QN 3 2827 91 2 01/23/99 07/22/99 Novlek, Mark MD BK 3021 91 2 01/23/99 07/22/99 Rareop. Peter K MD QN 2979 91 2 01/23/99 07/22/99 Toten, Ke19i M.D. MN 2926 91 2 01/2999 07/28/99 CMC 8Q St John's Hosp.Dw ON 2910 91 2 02/06/99 08/05/99 New York Downtown Hospital MN 2007 91 2 02/07/99 08/06/99 NYCHHC Elmhurst Hospital QN 2670 91 2 02/07/99 08/0699 Youn0. Iven S. MD MN - 3059 91 2 02/1399 08/12/99 McCarthy, Joseph M.D. BK Total 100 I Priority Date Due Date Overdue Name Borough 3006 52 3 0*!28/97 10/25/97 St. John's Univoretty f

QN t 3066 52 3 03/30/96 12/25/98 Oichent, Merlo MD BK 3073 52 3 03/3096 12/25/98 Pelsen Technolo9es,Inc. MN 2722 52 3 0502/96 01/27/99 Dreckter, tenac MD MN 2662 52 3 0505/96 01/3049 Advanced Forshty Services MN ,

2660 52 3 05/11/96 02/05/99 Modem Modecal Laboratory BK 3060 52 3 05/12/96 02/0649 Profeselonal Chnical Labs MN l 1555 52 j 3 05/1646 02/1090 Quenen Medical Lab BK < 2939 52 3 05/1996 02/13/99 Hoffman Center For Hohobc Modsome MN l 1686 52 3 05/23/96 02/17/99 Morrte Park Test L.ab BX j 1614 52 3 05/23/96 02/17/99 Gilson, Saul B MN i 1556 52 3 05/25/96 02/19799 Bendiner & Schissin9ar inc MN 2942 52 3 0607/96 03/04/99 Metropolitan Dee9nostc Labs. inc. { ON i j 2831 52 3 06/07/96 03/04/99 Bio Tech Labe Inc. BK 2851 52 3 06/08/96 0305/99 Museum Of Modem Art MN i 1566 52 3 06/1548 03/12/99 NYC Medical Examiner's Olhoe MN l 1604 52 3 06G3/96 03/2049 Overeoich Medical Group MN l 296011 52 3 07/2546 04/21/99 NY Hosp..Comen Med Ctr MN j i 3076 52 3 08/3046 05/27/99 GenQuest MN l 2719 52 3 090646 06/03/99 CUNY Med9er Evers Colie9e BK 3015 52 3 09/06/96 06/03/99 NYC Housing Preservebon land Development Centrol Lead MN 1674 52 3 09/2648 06/2349 San 9er, Joseph PC MN 2966 52 3 1003/96 06/3049 Univ Diagnombc Lab BK 2920 52 3 1004/96 07/01/99 Bu> Chem Technolo9y Lab.Inc. MN 2911 52 3 10/25/96 07/22,99 CUNY. Brooidyn Cobo9e BK 2975 52 3 11/21/96 08/1899 CUNY. Queens Colle9e QN 126 52 3 11/23/96 06GOS9 Montenore Med. Center BX 122 52 3 11/27/96 08G449 Montenore Med. Center BX 131 52 3 11/27/96 08/2449 Montstore Med. Center BX 120 52 3 11/27/96 08/24/99 Montenore Med Center BX 130 52 3 11/27/96 08/24/99 Montenore Med. Center BX 143 52 3 11/27/96 08/2449 Montenore Med. Center BX 113 52 3 11/27/96 08/2449 Monte 6ere Med Center BX 110 52 3 11/27/96 08/24/99 Merits 6cre Med. Center BX 104 52 3 11/27/96 08/2449 Montenore Med. Ctr. BX 102 52 3 11/27/96- 08/2449 Montenore Med. Center BX 114 52 3 11/27/96 08/24/99 MonteGore Med. Center BX 3044 52 3 11/27/96 08/24/99 Montortore Med. Ctr BX 115 52 3 11/27/96 06'2459 Montenore Med. Center BX 286502 52 3 11/27/96 08/2440 Montenore Med Ctr BX 116 52 3 11/27/96 08/24/99 Montenore Med. Center BX 103 52 3 11/2746 08G4/99 Monto6cre Med. Ctr BX 140 52 3 11/27/96 06/2449 Montenore Med. Center BX 132 52 3 11/2748 08/2440 Montenore Med. Center BX 109 52 3 11/27198 08/24/99 Montenore Med. Center BX 123 52 3 11/27/96 08/24/99 Montenore Med. Center BX 106 52 3 11/27/96 OGG4/99 Montenore Med. Ctr. BX 111 52 3 11/27/96 08/24/99 Montenore Med. Center BX 105 52 3 11/2748 08/2449 Montenore Med. Ctr. sX 267605 93 3 12/05f96 09/01/99 Columbis Presbyterian Med Ctr MN 2667 52 3 12/20/98 09/1649 Aeron Demond AIDS Research Center MN 2906 52 3 01/03/99 09/3049 Putdic Hoofth Research inettute MN 147 52 3 01/05/99 10/02/99 CUNY. Hunter MN 02/17/96 l l l l

l unense inspecmons Dw By Priorky and By Date Due l l 140 52 3 01/05/99 1M2/99 CUNY. Hunter MN 148 52 9 01/05/99 10/02/99 CUNY Hunter MN 123 #. 3 01/05/99 10/02/99 CUNY Hunter MN 126 52 3 01/05/99 10/02/99 CUNY Hunter MN 156 52 3 01/05/99 10/02/99 CUNY. Hunter Cone 9e MN 3031 52 3 01/05/99 10/02/99 EMA Mechcal Labs QN 153 52 3 01!O5/99 1092/99 CUNY Hunter MN 139 52 3 01/05/99 10/02/99 CUNY Hunter MN 128 52 3 01/05C9 10/02.99 CUNY Hunter MN 136 52 3 01/05/99 10/02,99 CUNY Hunter MN 130 52 3 01/0599 10/02/99 CUNY-Hunter MN 3049 52 3 01/05/99 10/02/99 NYC Dep.Heefth Bur.of Labs MN 135 52 3 01/05/99 10/02/99 CUNY Hunter MN 134 52 3 01/05/99 10/02/99 CUNY Hunter MN 127 52 3 01/05/99 10/02/99 CUMY-Hunter MN 124 52 3 01/0699 10/D2/99 CUNY Hunter MN 131 52 3 01/05/99 10/02/99 CUNY Hunter MN 133 52 3 01/05/99 10/02/99 CUNY Hunter ] MN l 125 52 3 01/05/99 10/0199 CUNY Hunter MN ' 142 52 3 01/05/99 10/03/99 NYCHHC. Hartern Hospital Center MN 2958 52 3 02/01/99 10/29/99 Levin, Aaan A.MD QN 1 Total 74 j l l

                                                                                                                                       )

l { I l j i 1 f 02, l 1 l I ' i i I

ll , l l l i l l { APPENDIX G-2 i New York State Department of Labor, Radiological Health Unit (NYDL) - i INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) QUESTIONNAIRE l l

Appmved by OMB' No. 3150-0183 Expires 4/30/98 INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM OUESTIQNNAIRE New York State Department of Labor / Radiological Health Unit O Reporting Period: Month XX, [ YEAR), to Month XX, [ YEAR] . $

                                  -                                                                      G m
                                                                                                         ~
                                                                                                              .O A.      COMMON PERFORMANCE INDICATORS                                                      ]
                                                                                                        .      3 I.      Status of Materials Insocetion Program a-

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

Insp. Frequency Ucensee Name (Years) Due Date Months O/D None

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

NA 2 L~ Estimated burden per response to comply with this voluntary collection request: 60 l hours. Forward comments regarding burden estimate to the Information and Records l Management Branch (T 6 F33), U.S. Nuclear Regulatory Commission, Washington, DC I- 20555-0001, and to the Paperwork Reduction Project (3150@52), Office of Management and I

           - Budget,' Washington, DC 20503. NRC may not conduct or sponsor, and a person is not                    ,

required to respond to, a collection of information unless it displays a currently valid OMB j control rtumber, i

                                             -                                                                     i l

l ' 3. Please identify individual licensees or groups of licensees the State / Region is l- inspecting more or less frequently than called for in NRC Inspection Manual Chapter 2800 and state the .easca for the change. t. l All of our licensees are inspected at intervals that are as frequent, or more frequent than NRC's inspection latervals. A list of license categories and inspection frequencies is attached.

4. Please complete the following table for licensees granted reciprocity during the reporting period Number ofIJceasees Granted Reciprocity Nember of IJesasses Prioriy Permuts Each Year Inspected Each Year Service Ucensees perfoamns n YR teletherapy and irradiator source YR YR YR YR metallations or changes YR n i n YR n n YR n n n 2 R R n n YR YR n n 3 R R YR YR YR YR 4

All Other We do not keep records of the priorities of reciprocity applicants. Fifty-four companies requested reciprocity during 1997 and 10 were inspected while in the state.

5. Other than reciprocity licensees, how many field inspections of radiographer were performed? 8

6. For NRC Regions, did you establish numerical goals for the number of inspections to be performed during this review period? If so, please describe your goals, the number ofinspections actually performed, and the reasons for 2

l any differences between the goals and the actual number ofinspections performed. NA II. Technical Ouality ofInsoections I 7. What, if any, changes were made to your wrinen inspection procedures during l the reporting period? We revised and updated three of our inspection forms: the general form, l the industrial radiography supplemental form and the Exed gauge form. S. Prepare a table showing the number and types of supervisory accompaniments E made during the review period. Include: 1 Insdector Suoervisor License Cat. pgte ! Rose Marie Pratt Rita Aldrich Lg. Research (1) 9557 Jin. Mull Rita Aldrich lad Rad (1) 4/1657 Brajesh Kothari Rita Aldrich Ind Rad (1) 9/1657

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

/ L Copies of evaluation forms for these accompaniments are attached.

i. 10. Describe or provide an update on your instrumentation and methods of calibration. Are all instruments properly calibrated at the present time?

Instruments are still calibrated in our laboratory using a Tech / Ops Model 773 calibration device in accordance with accepted procedures. All instruments in use are properly calibrated at the present tinae. A list of !- typical instrument is attached. III. Technical Staffine and Traininn

11. Please provide a staffing plan, or complete a listing using the suggested format below, of the profeuional (technical) person-years of effort applied to the agreement or radioactive material program by individual. Include the name, position, and, for Agreement States, the fraction of time spent in the following areas: administration, materials licensing & compliance, emergency response, 3

r-LLW, U-mills, other. If these regulatory responsibilities are divisen between  ; offices, the table should be consolidated to include all personn 2 convibuting to j the radioactive materials program. Include all vacancies and identify all senior personnel assigned to monitor work ofjunior personnel. If consuhants were used to cany out the program's radioactive materials responsibilities, include l their efforts. The table heading should be: > g POSITION AREA OF EFFORT LTEh i ! Rita Alrich Prin. Radiophysicist Program Director & licensing 95 % Clayton Bradt Assoc. Radiophysicist Licensing 95 %

Desmond Gordon Licensing 100 %

! Robert Kelly Licensing 100 % ' Andrew Awal* Inspection 80 % Brajesh Kotharl* " Inspection / licensing 80 % James Mull

• Inspection / licensing 90 %

Rose Marie Pratt* Inspection / licensing 80 % i l

• Manhattan ofDce staff rotate supervisory responsibilities for the field ofDee and laboratory.

,. 12. Please provide a listing of all new professional persor.nel hired since the last L review, indicate the degree (s) they received, if applicable, and additional training and years of experience in health physics, or other disciplines, if i appropriate. No new professional personnel were hired since the last review. I

13. Please list all professional staff who have not yet met the qualification l requirements oflicense reviewer / materials inspection staff (for NRC, Inspection Manual Chapters 1246; for Agreement States, please desente your qualifications requirements for materials license reviewers and inspectors). For i cach, list the courses or equivalent training / experience they need to attend and a tentative schedule for completion of these requirements.

l All staff meet basic training qualification requrlements for license review / materials inspection staff, as outlined in the NRC/OAS Training Working Group Recommendations (October,1997).

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

No professional personnel have left the program since the last review. 4 k

i

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

NA IV. Technical Ouality of Licensina Actions

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

Empire Isotopes Issued Syncor, Cheektowaga Renewed Self Powered Lighting Renewed

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

No variances or exemptions were issued.

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

We continuously review and try to improve our inspection and licensing procedures, documents and guides. During the review period we updated many of our guides and procedures and developed some new ones. This is an evolutionary process.

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

NA V. Resnonses to, Incidents and Allegations

20. Please provide a list of the reportable incidents (i.e., medical misadministration, overexposure, lost and abandoned sources, incidents requiring 24 hour or less notification, etc. See Handbook on Nuclear Material Event Reporting in i Agreement States for additional guidance.) that occurred in the Region / State '

during the review period. For Agreement States, information included in )

- previous submittals to NRC need not be repeated (i.e., those submitted under j OMB 3150-0178). The list should be in the following format

l 5 i i l. t.

LICENSEE NAME LICENSE # DATE OF INCIDENT / REPORT TYPE OF INCIDENT Incidents that occured up to May 16,1997 were sent to NRC on June 22,1997. A list and summary ofincidents 6ccurring from that date through December, 1997 is attached. ,

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? For States, was timely notification made to NRC? For Regions, was an appropriate and timely PN generated?

j l During the review period we had an incident in which a Mallinkrodt generator's { shielding failed. This was reported to NRC and copies of the reports are  ! attached. We also had in incident in which procedures used by MDS Nordion during an irradiator source change allowed a worker to fall into the storage poot Our correspondence with Nordion on procedures to prevent a recurrence was copied to the U.S. NRC since Nordion is also their licensee. Finally, there was an incident invoMag a theft of a tro11er gauge that appeared to be due to NRC-approved operating procedures. An NRC licensee brought the gauge into New York, where it was stolen, because the licensee had no secure storage location for it and left it in his truck although it was not to be used in - New York.

22. For incidents involving failure of equipment or sources, was information on the incident provided to the agency responsible for evaluation of the device for an assessment of possible generic design deficiency? Please provide details for each case.

Equipment manufactured / distributed by four companies was involved in incidents in New York State during the review period. In all cases the states that licensed the companies were given all available information for their follow up; including a report to NRC if equipment defects were found to be involved. To our knowledge the causes were all due to user error or abuse, and an information notice was sent to New York State licensees and the states that license the manufacturers, pointing out the need to properly train staff and maintain i equipment so as to avoid accidents. (See incidents 97-2 and 97-21 in our 4/96-5/97 report to Pat Larkins, and incidents 97-38 and 97-44 on the enclosed list and summary). 6 l

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

No

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

a. For Agreement States, please identify any allegations referred to your program-by the NRC that have not been closed.

None. l VI. General

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

NRC recommended that we formally adopt regulations compatible with Part 36. We have developed a detailed licensing guide incorporating all the rule's requirements, we use a 15 page checklist outline of these requirements for inspections, and have submitted a draft regulation adopting 10CFR Part 36 to our omce of counsel and are awaiting action.

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

Our program's strengths are evident in the quality of our licensing, inspection and incident response actions which protect workers and the public while permitting the beneficial use of radiation sources in New York State. B. NON-COMMON PERFORMANCE INDICATORS

1. Legislation and Program Elements Reauired for Comeantility

27. Please list all currently effective legislation

• that affects the radiation control program (RCP).

i The Department of Labor's radiation control program derives its authority from Section 27 of the Labor Law and Article 28.D of the General Business Law. 7

28. Are your regulations subject to a " Sunset" or equivalent law? If so, exp!ain and include the next expiration date for your regulations.  !

No. l 1

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                                                                .

discuss any actions being taken to adopt them. Identify the regulations that the State has  ! adopted through legally binding requirements other than regulations. l See attached table.

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

NA

H. Scaled Source and Device Procram

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

SS&D Manufacturer, Type of Registry Distributor or Device Date Number Custom User or Source Issued , NY 0502 D 110 G NRD, Inc. Static Eliminator 12/31/97

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

NRC Reg. Guides: 10.10,10.11 NUREGS: 1550,1556 V.3 ISO 2919 " Sealed radioactive sources - classification" ANSI N542 - 1977 " Sealed Radioactive Sources, Classification" ANSI N540 " Classification of Radioactive Self-Luminous Light Sources" NRC SS&D Workshop reference materials _ _ _ _ _ _ _ _ - - - _ _ _ _ _ _ _ . _ - - _ _ - _ _ _ _ _ - - _ - _ - ._ .i

33. Please include information on the following questions in Section A, as they apply to the Scaled Source and Device Program:

3 Technical Staffing and Training - AE.11-15 Technical Quality of Licensing Actions - A.IV.16-18 Responses to Incidents and Allegations - A.V.20-23 AE. Technical Staffine and Training (11-15)

11. Please provide a staffing plan, or complete a listing using the suggested format below, j of the professional (technical) person-years of effort applied to the agreement or radioactive material program by individual.' Include the name, position, and, for Agreement States, the fraction of time spent in the following areas: administration, materials licensing & compliance, emergency response, LLW, U-mills, other. If these I 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 ofjunior personnel. If consultants were used to carry out the program's radioactive materials responsibilities, include their efforts.

NAME . POSITION AREA OF EFFORT FTE% Clayton Bradt Assoc. Radiophysicist SS&D Review 1% Desmond Gordon Assoc. Radiophysicist SS&D Review 1%

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

No new professional personnel were hired since the last review.

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

these requirements. - No training qualification requirements for SS&D review personnel have been established by NRC. 9

s 33.(coat.)

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

No professional personnel have left the program since the last review.

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

! NA A.IV. TechnierJ Oualitv of Licensine Actions (16-18) l 16. Please identify any major, unusual, or complex licenses which were issued, received a majo*c amendment, terminated, decommissioned, bankruptcy notification or renewed in this period. Also identify any new or amended licenses that now require emergency pla.ts. Only one SS&D review was conducted during this period as listed in item 31, above.

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

No variances or exemptions were issued.

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

No changes were made. f 10 1 _ _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ _ l

l l 33.(cont.) A.V. Responses to Incidents and Allegations (20-23) r {

20. Please provide a list of the reportable incidents (i.e., medical misadministration, overexposure, lost and abandoned sources, incidents requiring 24 hour or less notification, etc. See Handbook on Nuclear Material Event Reporting in Agreement States for additional guidance.) that occurred in the Region / State during the review period. For Agreement States, information included in previous suir atals to NRC need not be repeated (i.e., those submitted under OMB 3150-0178). The list should be in the following format:

Incidents that occured up to May 16,1997 were sent to NRC on June 22,1997. A list and summary ofincidents occurring from that date through December, 1997 is attached.

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? For States, was timely notification made to NRC? For Regions, was an appropriate and timely PN generated?

None invcMng devices or sources reviewed by NYS DOL

22. For incidents invoMng failure of equipment or sources, was information on the incident provided to the agency responsible for evaluation of the device for an assessment of possible generic design deficiency? Please provide details for each case.

NA

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

, No. III. Low-Level Waste Program

34. Please include information on the following questions in Section A, as they apply to the Low-level Waste Program:

j Status of Materials inspection Program - A.I.1-3, A.I.6 i 11 f

i Technical Quality ofInspections - A.II.7-10 - Technical Stahg and Training - A.III.11-15 l Technical Quality of Licensing Actions - A.IV.1618 Responses to Incidents and Allegations - A.V.20-23 NA IV. Uranium Mill Program

35. Please include information on the following questions in Section A, as they apply to the Uranium Mill Program-Status of Materials Inspection Program - A.I.1-3, A.I.6 Technical Quality ofInspections - A.II.7-10 Technical Stang and Training - A.III.ll-15 Technical Quality of Licensing Actions - A.IV.16-18 Responses to Incidents and Allegations - A.V.20-23 NA 9

12

i

                                     , ywa
                                       ^

11 l 5

                $5 il          .

1 1 1 1 1

                                                                                      \
                                                   'l        :!    -!   {    {

i i i i i

                                                   .I        l     .I   .)

i 1 l 1  % 1 1 1 1 I e I I t if i i e s g 'e - 8

                          ! i ! ! ! !

n E 5 I l rn !n !

                     ]e
                                   'l 3

l- . e . f i 1 s , . ,

                                                                             )v i

l p b j ll J Y W 4 l::: ,,g , lR <

l j i

e  ! 'iI l:4 I >L,! d ny ji1 :i h i 113 e

                . r4 u ap; p, ri n
                                        . b   ij   p:    ii h n ou 1 %ju;m i                                           .  -

i5 . t

lll l i]){ !ji{ lh j 1 1ll I l ,' i1 DN E0 Tl Cf"

               ! l                                                                                                                                                                                                       -

Po l XD r g A R O T - N15 E 1 R1 RA U ST C

                                                                                                              ..      L.             L            ;

L., L L. -. L. L k L-

                                                                   ;           e.                            .                                     ;
                                                                                                                                                                                 ..       -e r                     -..

r r r r r r r r r r e e e e e e e e e e r 4 l l l l di e l m l m m m m w d d di d 1 u m m u m o m n u n m n t i i t i t i u i u D ' l f r. T' 4 4 AM 9 A 9 DM # N W I A i

     .ft    f                                                                t T                 8                                                   1 t

s AO Dt 9 W R 9 8 9 8 9

                                                                /

9

                                                                             /

4 9 9 W 9 9 e n e 0 2 o m 0 o o I l

                                      /

W 4 1 2

                                                                             /

9

                                                                                           /

l t 2

                                                                                                        /            W               m         w f          7                  9 2

7 w 9 f N W. W / t 1 1

                                                                                           /

4 0 l

                                                                                                                     &               /

l

                                                                                                                                               /

2

                                                                                                                                                          /                  2
                                                                                                                                                                             /         2
                                                                                                                                                                                       /

2 1 1 1 2 2 5 6 W ts n n e s a d e e n v a u e

                        #e           i s

a d s l t f Aa n r e e s ic s s , n n e i e F. i n e n i n y d i t nn n d e n l fa h n g v e n ii i n r n i g e m d i t n r e s n si l e d R m hs o I n i n d e n c o i e nW A n f s t s y ic A e n l s i a A br e sp n e e din a e i n n te i h yc n de n e n d R r d a s

                                                                    .       t t

n a iAir e e n e h e ;. i i m R es , iweg h s s n fA o n F. n bh d e

                                                                                                                                                                                           . l a

T ei c s s s e r e e ,itr e n M n n ',A e c ia l a s d n n m s i n i R 3 s. s e d , s n e t n m y 1 nl m s e i S w n u e Fr m ;. e i s e n u p N'

.re g f o #een e

s i emC . t n h I f

                                                                                                                                                                                      ".I d
                                                                                                                                                                                           .n             L i

c n s n le ;s -. o _ p e e e n r e e e gl .. iel a R r r n Ri e ia o

                                                                                                ,i l i ae           u e

r - l ks f s nr e e e s l f e fo - ht w c l S m ni te c si i u u Rr e , ede al a ns u l s k g n r Cisn n e a ax e e g i;. C e ne i l t o a ' pF l i e r e e en R n M* mn a I n TR hM A , e 1: i s a e Reem w eI R f % R L.. uel f o s 7A r

                                                                                                                                ,   t         l f           .d               d n.                 en Wng                                                                          M                                a nmnr i

e e I U o 1y e T. s nt n t r d

• n:

f ev oit n e o h hM I i O a :J,S i c e t r n ps R n-- Pa e n l yr c n l e erc - n e e e ^ v o ., n c s a c t r e a R nes v p ee a n ni n hn n se c hc i t a .. oa n M ige n n fin v f i e c p T e n hi e Ri t l a n n" t n e e t R n. n iloRA ietc t i m p pw lr- R i r F e ul le s c v nw ~ ym i - fo Cnre s i i C ifr pi ic ia o e ee

                                                           '                                                                                                                                              i i i s          i n                                    n e u                            n mes                     e             df aa                        de da          n              s i

s cd .t e er &a 0 1 FR I a mdn  % r' RD a e l CR 0tn MR TR e m ef n e nt r e d na Lf a p 1 1 I Ro Fe RUA CR I So R _ i

l. I l t APPENDIX G-3 New York State Department of Health, Bureau of Environmental Radiation Protection (NYSH) INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) QUESTIONNAIRE l L f' j l 1 -

I f Approved by OMB' No. 3150-0183 Expires 4/30/98 . i 1 l i INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM QUESTIONNAIRE l New York State Department of Health, Bureau of Environmental Radiation Protection Reporting Period: April 1995, to March 1998 A. COMMON PERFORMANCE INDICATORS

 ' l.      Status of Materials insoection Proaram

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

Chapter 2800. The list should include initial inspections that are overdue.

i insp. Frequency Licensee Name (Years) Due Date Months O/D l New I NE!)g Inso Frea Date issued Months O/D i Ramaiyer Narayan, M.D. 4 8/18/97 1 Northeast Radiology 4 12/19/96 8 j Pomona Scanning 4 12/31/96 8 in addition, several other facilities were not inspected within 25% of the scheduled frequency, however this was due to program decision to not inspect within the regular schedule. A list of these facilities and inspection schedule is available. - l 8 l 1 1 Estimated burden per response to comply with this voluntary collection request: 45 hours. Forward comments regarding burden estimate to the Information and Records Management Branch (T-6 F33), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, and to the Paperwork Reduction Project (3150-0183), Office of Management and Budget, j Washington, DC 20503. If an information collection does not display a currently valid OMB { control number, NRC may not conduct or sponsor, and a person is not required to respond to, I the information collection. (

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

questionnaire. Yes. All overdue inspections have been assigned and will be completed by the first quarter of this year.

3. Please identify individual beensees or groups of licensees the State / Region is inspecting more or less frequently than c ti led for in NRC inspection Manual Chapter 2800 and state the reason for(no change.

Teletherapy licenses are currently inspected ever other year (more frequent than NRC). All other categories are inspected on the same schedule as NRC inspection Manual Chapter 2800.

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

No licensees were granted reciprocity during the reporting period. Number of Ucensees Granted Reciprocity Number of Licensees Priority Permits Each Year inspected Each Year Sennee Licensees performmg u m teletherapy and irradator source vn m installations or changes vn m m a vn m 1 vn vn vn vn vn vn vn m 2 vn vn vn vm vn vm vn VR 3 vn VR vn VR vn vn d M other

5. Other than r4Wty iconsees, how many field inspechons of radiographer were performed?

2

f l-

        .            None (Not Applic ,: le).                                                       .

l 6. For NRC Regions, did you estabhsh numerical goals for the number of l inspections to be performed during this review penod? If so, please describe l your goals, the number of inspections actually performed, and the reasons for l any differences between the goals and the actual number of inspections performed, ll. Technical Qualrty of insoechons

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

A section was added to include the review of previous items of non-l compliance at the entrance interview in the section titled " BASIC L INSPECTION PROCESS" and "3".

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

Insnector Suoervisor License Cat. Daig See Attachment 1

9. Describe intemal procedures for conducting supervisory accompaniments of inspectors in the field. If supervisory accompaniments were documented, piease provide copies of the documentation for each accompaniment.

As noted ir, the Bureau's inspection manual, inspectors are accompanied on inspections of radioactive materials licenses annually. Inspection accompaniments are arranged by the field supervisor with each staff performing inspections. The field supervisor or other designated reviewer (senior inspector) utilizes the NRC inspector Field Work Evaluation Checklist. The reviewer's role is primarily limited to observationlevaluation only but may provide limited assistance, if felt necessary by the reviewer. The reviewer summarizes comments on various aspects of the inspectors performance with the inspector to help the inspector improve performance. The inspector's performance is reviewed with the inspector's supervisor, the Field Supervisor, and the Radioactive Materials Section Chief.

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

The Eureau has numerous survey meters - Micro R, GM and lonization chambers. in-house calibrations are performed for the GM and lonization chambers. The Micro R meters are sent out to a contractor for calibration. All instruments in use are calibrated. The Department laboratory support, 3

I equipment and facilities remain the same as described during our last NRC review. - lli. Technical Staffino and Trainina l 11. Please provide a staffing plan, or cs,. fete a listing using the suggested format below, of the professional (technical) person-years of effort applied to the l . agreement or radioactive material program by individual. Include the name, position, and, for Agreement States, the fraction of time spent in the following areas: admirustration, materials licensing & compliance, emergency response, l LLW, U-mills, other. N these regulatory responsibihbes are divided between { i offices, the table should be consohdated to include all personnel contributing to ( the radioactive materials program. Include all vacancies and identify all senior l personnel assigned to monitor work of junior personnel. N consultants were I used to carry out the program's radioactive materials responsibilities, include their efforts. The table heading should be: N6ME POSITION AREA OF E870RT M5 I See Attachment 2

12. Please provide a listing of all new professional personnel hired since the last review, indicate the degree (s) they received, N applicable, and additional training and years of experience in health physics, or other disciplines, W appropriate.

No ade;itional hires. However, Mark Virgil has been assigned to the radioactive materials section. Mr. Virgil has over 20 years experience in l health physics, B.S. Chemistry and a MBA.

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

Mark Virgil - needs additional training in inspection procedures as well as

licensing policies and procedures. In house training is being provided. In l addition, a request was submitted for Mr. Virgil to attend the NRC l " inspecting for Performance" course.

l l 14. Please identify the technical staff who left the RCP/ Regional DNMS program during this period. Christopher Parker, Associate Radiological Health Specialist Ferenc Tibold, Senior Radiological Health Specialist l

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

4 1 1

No vacancies. . IV. Technica10uality ofIIc nsina Ar*ians

16. Please identNy any major, unusual, or complex licenses which were issued, received a major amendment, were term'mated, decommissioned, submitted a bankruptcy notification or renewed in this period. Also identNy any new or amended licenses that now reques emergency plans.

, See attachment 3 l l- 17. Discuss any variances in licensing policies and procedures or exemptions from l- the regulations granted during the review period. Authortzstion was granted to dispose of an old Co-57 flood source via normal trash; a license was issued to a physician (who did not meet the ' training requirements) for C 14 H Pylori.

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

Implemented new process for processing and evaluating license renewals; additional requirements for information necessary for renewals / amendments. ig. For NRC Regions, identify by licensee name, license number and type, any renewal applications that have been pending for one year or more. V. Rennenses to incidents and A!leset:or.;

20. Please provxle a list of the reportable incidents (i.e., medical misadministration, overexposure, lost and abandoned sources, incidents requiring 24 hour or less notification, etc. See Handbook on Nuclear Material Event Reporting in Agreement States for additional guidance.) that occurred in the Region / State during the review period. For Agreement States, information included in previous submittals to NRC need not be repeated (i.e., those submitted under OMB l clearance number 3150-0178, Nuclear Material Events Database). The list I

should be in the following format: LICENSEE NAME LICENSE # DATE OFINCIDENT/ REPORT TYPE OF INCIDENT See attachment 4

21. During this review penod, 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? For States, was timely notification made to NRC7 For Regions, was an appropriate and timely PN generated?

5

I Three incidents: 1.) A JL Shephard irradiator malfunctioned during a QA check. ' This incident was reported to the NRC. 2.) An ir-192 HDR source became stuck in hs transport cask when trying to retrieve it during a source exchange procedure. This incident was reported to the responsible regulatory agency. 3.) A Nuclotron HDR unit did not respond as programmed in the treatment plan. It automatically switched dwell positions after a new source was installed. It is not certain if this would be considered an equipment failure since the unit did indicated that the dwell positions were reset to their default values after the source exchange. All Nuclotron licensees were notified of this problem a few months earlier in a Nucletron notification.

22. For incidents involving failure of equipment or sources, was information on the incident provided to the agency responsible for evaluation of the device for an assessment of possible generic design deficiency? Please provide details for each case.

Nucietron equipment .The manufacturer issued notification to all of its customers (and MD?) JL Shepard-reported to NRC only. Stuck fr-192 < sported to NYSDOI. I

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

There were two unusual cases that were previously reported to NRC: 1.) Two j individuals arrested for conspiracy to commit murder (with Ra-226); ' 2.) Unauthorized use of a license (NRC information notice 98 06). 24. Identify any changes to your procedures for handling allegations that occurred,during the period of this review. )

a. For Agreement States. please identify any allegations referred to your program by the NRC that have not been closed j

No cases referred by NRC that have not been closed. I I 6

1

        - A  General                                                                                                                                   ,

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

Our response was oudined in a letter dated April 29,1996 (Attachment 5). The items identified were the decommissioning funding rule and three definitions in Part

35. Our position on the decommissioning funding rule rermins the same. This is further supported by the proposed NRC rulemaking to allow hospitals and universities to self. guarantee funding for decommissioning (Federal Register notice, April 30,1997, vol. 82, number 83).

We do not believe that by adopting the three definitions as worded in Part 35 it would increase the effectiveness of our regulations. Nor is there any conflict, duplication or gaps by not adopting these definitions. However for the purposes of

                        " compatibility" we will consider adopting this wording after Part 36 goes through its current amendment process.

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

l. Leatslation and Program Elements Reautred for Comnatibiltty

27. Please list all currently effective legislation that affects the radiation control prog am (RCP).

New York State Public Health Law; Article 2, Title 11 6 201 - Function , Powers and Duties of the Department cf Health 5 226 - Public Health Council; Powers and Duties; Sanitary Code 10 NYCRR Chapter 1 Part is lonizing Radiation Part 76 Public Health Administrative Tribunal Part 406 Hospitals - Minimum Standards

28. Are your regulations subject to a " Sunset" or equivalent law?.if so explain and include the m next expiration date for your regulatens. No.

I

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 discuss any actions being taken to adopt them. Identify the regulations that the State has adopted through legally binding requirements other than regulations.

7 i

4 l 30. If you have not adopted all amendments within three years from the date of NRC rule i ' promulgation, briefly describe your State's procedures for amending regulations in ordar to maintain compatibility with the NRC, showing the normal length of time anticipated to complete each step. l See Attachment 6 l ll. Realed Soures and Device Prneram

31. Prepare a table listing new and revised SS&D registratens of sealed sources and devices issued during the review period. The table heading should be:

SS&D Manufacturer, Type of Registry Distributor or Device Date Number Custom User or Source jagggd . We do not have a Sealed Source and Device Program. l 32. What guides, standards and procedures are used to evaluate registry applications?

33. Please include informabon on the following questions in Section A, as they apply to the Sealed Source and Device Progrnm:

Technical Stahing and Training - A.Ill.11-15 Technical Quality of Licensing Actions - A.IV.1618

Responses to incidents and Allegations - A.V.20 23

 ~

i 111. Low-Level Waste Procram -N/A

34. Please include informaten on the following questens in Section A, as they apply to the Low-level Waste Program:

Status of Materials inspection Program - A.I.1-3, A.I.6 Technical Quality of inspectens - A.ll.7-10 Technical Staffing and Training - A.lli.11-15 Technical Quality of Licensing Achons - A.IV.16-18 Responses to incidents and Allegations - A.V.20-23 IV. Uranium Mill Pronram - N/A

35. Please include informabon on the following questions in Section A, as they apply to the Uranium Mill Program:

Status of Materials inwc;;en Program - A.I.1-3 A.I.6 Technical Quality of inspections - A.II.7-10 Technical Staffing and Training - A.lli.11-15 8 i l

Technica1 Quality of Licensing Actions - A.IV.16-18 , Responses to incidents and Allegations - A.V.20 23 4 I 9 l j

DN - - EO TI CT EP ' _ PO _ XD EA t s n e _ i d C r e d R e i N r I r e w 5 iuq f o W _ 9 n c 9 e o o _ 1 r W o d e ld e l u c e h e t o ll f r i n w o o e l e N n - R u W i o O s . d it s s e u T i t t b is . s i p NS ih m o t rl EU t R d is ac RT f n a du R TA o o eea l s n l e a i U C S i o s e w c e r c s s e em s u s o g . mre c is p n5 a1 mh op d e v h c61 c o e a t n o es e s h ho an ll he r t ( s wi i sg n o een yc t d n n n n en io lo o t - g sa ne es n C o ll il i t lae nP l i d e sn o d d i d uu n e l s e n n n gd o R

                                             ,                    nI ed          e      e                o     o             o     en c                                                   n              C     C e)  H ~.                         e    er     m      o                e     e C      t

r. e i r

is o e Ode ow O m su e s s n e D . vo d e l L n n s n Dt s _ miv o .- t o c e d e e e e Ste 0 i e NE n c c Ye 1 Lr Nis S a i L W i L Nm D E E T 2 2 2 T A P W F 0 9 f 0 9 F DO 0 D 3 3 3 A A / 2 A f 2

                                                                                   /

2 A A A - N 1 N 1 1 N N N 4 E T E 1 9 3 4 D p i 5 8 8 9 7 7 _ AU 7 9 4 9 F S 9 4 8 9 9 f l S 9 f 7 9 9 f 8-DD 7 2 J 7

                                               /

1 0 1 t f 0 7 2 7 1 2 2 2 f 8 2 f 1 S 1 9

                                                                                                                              /

1

                               /

7 1 4

                                               /

1 f i 1 f 1 7 1 0 l f f 1 1 7 1 i 7 O 1 t e yf , n f n o r dr yo e - o i l ll m o u e A sf _ eg le c c d P i De r t do d i le r o n E l I l

                         ,o                     e     h                             g          1 D   0  e      o l

ae p 8 - 7 n ie 1 n R a d e i t cs 9o r t r g n R t r o g 0, n F g n eu r . 9 h e n a y l a o 0 P ip 4, d mt _ i n 4 1 t c o Ce r le de 7, n e  ; e0 o mu5 g a f i0 r e Co 3, od

9. t 0 r 5 a l m e3 l 7 2 rW o

i A R , 4, g3 S aa sr ets e, f n r 2 ir o n r otr r n og s r oa d0 o r p3 N pt r o h I t e0 n Po e pro cP A 4, C. by I e 3, i O se g do e tP n

                                                                                   #8 e3    isP        e     n0     e            te0 sf 3 ef              n              t n4      d 4           e s: dt      DA       R s,    e3     g        .

I dre  ; i n t d 3, gon n0 io s s T ( g n e o3 mn e ea dQ e s st n4 m net asa S mtr gmo n t i r ni nn r i0 a0 P n1 RP r ae ind ea C 07 l ea I et E E e o )s n o 7, P 7, l r t e 3, e d s, LN l eP To r r _ iuqtP, r er U L m$e i s0 y0 f o 0 ne nr aas f S iod l n; t u P n i0, T.nnd:UesP U de n c no 3, ei s o e sA em Q s 4, n 4, nde s en s M s, s4 R egma i m0 t Mi n ge nl o in r s s io a,U R R med e0 n Re ym s0 s2 ym im n oh mo oi s n mra d e 0, t anl _ m3 e0 u l g3 oo mle ei a n3 r o a _ uW r n e g d O F a he os r et s d2 t p R s l e e nr ln id nn R e ts a nic F C yc nam ct eo r mor nt tero ei faqu Wt r oo u s ol cr o Ad e n oo ie mtn e d t aa mr pud ebe 0 Qhu io r t r E. , 1 AeA DP EP SP SE NP Use Da Dm SM US TP PtiM r t B A T ' l = iII m

_ DN E TIO

    -          CT                                                                                                                                                  '

EP PO _ XD _ EA R e y l g y y w n n l s t p r e 1 t oi n u o d v 8 alo i e e 3 t hr t t vp o t a w r

                                                 - e t

o t l u o a e g H P ev lu a n e c e R rh i n s s W e e e R deM r e l e C s f t s Y #uo t n e n e t n n et N hh t s a r y m e m sc en l O i p t r n R r m e e wm eo r e d e o r d n ud er i v e O on S. r g m w o t a n m T f e e a 0 p r o e a NS om e t 1 0 r a p e y EU ya nt e r o>ev i e r o ht setor RT ax s t del i l c c n o es _ R TA t e en i h

                                              $ii    vc        u        i t

n s i ngu U n e CS t r i e et sahe h ecs o r a 7

                                                                                               )

3

                                                                                                   .      l e                   .

ee cr t i G n o Wree oe r t s e t s 8 1 (

                                                                                               )

l r e sB ee xe t oI r n (c t s n e W ic d yo .t r R p e h 4 o n emn no ele m osr s sl e o r u d e r ek p o m e d e 1 6 e crf o l r vie r t i r r 1 hr l ono dis u ol a e u . e t I f to nl l v c

                        ,hI   j h

e ce. ya4 r hl e q e~ r c o h d e o t oe r

                        . g                   dt
                        . nr  t e               ae l

u y. d y e r S

a. nlu e ed d i

o eh . r l e e rC s ni w e r l . eo - c- v no sn e

                                                                              .R e cd      h               l as hp                                 o         fE                                                   i es i

C eaJ l t s t r s c oD W oCo v e l u n E r u-; si ,T

                                                                              ~

s "

                                                                                                   ,        eS sY               eec csr r

r o s c D S tadn sirv i i iss h e n .O D i s aN e ine l Wed d r e 1 1 e he l Mre Y odu t o S N - ocn n Ta N MInO Nd T, U T ". Rt NLU i U D EE T T A P 3 DO 9 D A A A A f f A A N N 7 N N f i N EE T AU 8 9 t 8 9 8 9 f 8 9 4 8 9 f 4 9 9 8 9 f 0 9 9 f 0 0 0 0 f 0 O D t 0 0 f 0 D

                                                                                                                                                  /

0 0 f 0 DD 3 1 f i t r 0 3 1 1 f 2

                                                              /

1 f t f 2 r 0 8 1 f f t l 1 f 7 2 f 9 2

                                                                                                                                          /

7 2 f 2 3 3 8 8 1 4 1 O i 2 2 S 6 8 f . o d s y e e r l n e s hp d n g u lr e An i  ; hnso M o l o U a e n elI e le r o p m 9 e d n id mo oe A sc i du nd in f o A m i a A p l l nd ee s a n m s t e i d s u fy i

                                                                                         =

d i r C . cl r l e yI e r e nt e e F hc n o A s, i LuJ ba l hrlu pfRo T t r l n em o C gon t R g fl wg no . l e n e n ie oa lel kd r e a sl e o a r a= i d e ar hl r s in m M o m e i n nyA os nre n e do gt a o n ein n mi p f s r o eyg R L l. _ l We ot a Sede iMn l e aqu t l n iu o s de m ic _ me eM e F.. f t _ eg n t n q e f o o l u t n et f o ee L ExE mi e e d n =s pn r

                                                                                                        . ge       n e      eFs       I eN    Rir            r meS

_ n pd m Rie n . e v sc l u aq1 o l ao Np o e ner m nE e e f eJ ee m elvt ao f Rr

                                                                                                                    $ een e

h o oic mla n eo i r e te cit Se u olle c Cm ed l a r ue l l l eR r TeC ic q l e r en l gt ed u y e de et t eR e I cC te d D 1l

o t e ia sl r

g ue r S Acm ue ReR dl , ur E. Mro fo P sd en R on f ot e 7A n iM r on D=t fRc l d e fo Ee r r g hd e neC I t ay C Wan e n m i r en r a tl np o fA o l N r e dv e neA tr e a c oSh p ntn Pnns on y t yr l en Po Ae oe no o t e od ee r f s or na c R co elo vl a e n m gu eo #a s l l r H e ek Bt e M NI nUe nn t t sl e ig o R nta er ee n ek Rle a= ca nd un e gsn n eig st l F uip Lm oip leln Rr u Fm ir moc l oe ss o i di n ea lo qs - r wo a q Ce s u c ah eem eRld l

      .         C                       f r u eq aeda idd ea      r           eR       o                            cee d

e e r e erei l of e 0l n ee f rd 0 1 FR LI n PE RD l CR 1I MR TR RE F l RAW CA i LRR R

l l Attachment 2 -Stamng

   ,                              Cemrnl Office Hame         Enshinn                        &a of Effort           IIE    ,

l K. Rimawi Bureau Director Admini=*ation 20 % S. Gaviu Prin. Rad. Health Spec. Admini=*ation 35 % Licensing / compliance 60 % l Incident re.p 5% l R. Dansereau Assoc. Rad. Health Spec. Licensing / compliance 95 % l Incident seeyasse 5% . C. Costello Sr. Rad. Health Spec. Licensing / compliance 95 % Incident response 5%

A. Damiani Sr. Rad. Health Spec. Compliance 30 %

l l l C. Burns Sr. Rad. Health Spec. Licensing / compliance 95 % ! Incident response 5% / M. Virgil Assoc. Rad. Health Spec. Licensing / compliance 95 % Incident response 5% I 1

i l

l 12

Reninm1 Office Name' Engition Area of Effort EIE G. Baker Prin. Rad. Health Spec. Field Supervisor 50 % E. Carter Assoc. Rad. Heahh Spec. C g li= = 30 % V. Goyal Assoc. Rad. Heakh Spec. Compliance 30 % B. Ignatz Assoc. Rad. Heahh Spec. C7 1ia= 30 % W. Kelleber Sr. Rad. Health Spec. Compline 30 % R. Snyder Sr. Rad. Health Spec. Compliance 30 % A. Bass Assoc. Rad. Health Spec. Compliance 80 % Total FTE for Radioactive Materials Program 8.3/546 licensees

      = 1.5 FTE/100 licensees 13 d

Attachment 3 s. Unusual / Complex Licensing Actions Renewels License No- NAER h 574 Cold Spring Martxt R&D Brood 448 NYS WCL&R R&D Brood 1030 NYU Med. Ctr. Acaderric Broad 1016 NSUH Medss!Broed 1035 RPl Acadenic Broad 469 SUNY ESF Acadernic Broad 47 SUNY HSC Medical Broad 459-1 SUNY Albany Academic Brood unusual 3185 Forest Laboratones R&D Speel6c 2991 Immunoscences irradiator(Type-1) 3152 Upstate Open MRI Medical Prwate . Spec.1le 4 l 1 14

i

• e.

Radioactive Matenals ' - +-- A=---_

                                                                                  ' "-      - 1995-1997                                 ~1 l                                                                                                                                         -
           '=i+ e --       Reviewer       Facility Name                 1 -; - = No        Facility Type Snyder                                                                                                          Date            i Baker          Geneva General H=: ='         1766               Medical Specific - Hospital i

Dansereau Baker Khrmm Dia7 -T-c 3080

                                                                                                                            '27.AorU  -

C--, Medical Specific- Private Prac. 04 Mav 95' l Baker University of Rochester 836 L .y/-HDR Snyder I1-May-95 Baker Newark Wayne Community Ho 1777 Medical Speci6c- Hospital Samson Dansereau 14-Jun-95 NYSDOH tm) XRF hiani Bass Cold S,.. Hasbor 14-Aua-95 Phillips 574 R & D - SE+::f-c 22-Aug 95 Baker Slocum Dickson Snyder 1122 O-3-: ' 1 =i 05 Sep.95 Baker r r I =-- ;-E P------ ' 1874 Medical Si="'-: - H=:: i 19-Sep 95 Wormuth Baker Sienna Collese 560 Academic Il-Oct-95 l = == Baker RoswellPark Kelleher Baker U,r OpenMRI 1082 L. i 26-Oct 95 1152 Medical SH_6 - Hospital 02-Nov-95 Bass . Baker Arden Hill F _-: 1 1171 Medical Speci6e- Hospital 13-Nov 95 Samson IBaker Steven Alavaad r Goyal  ; Baker 5146 Clinical 1 = rf 20-Nov 95 L SUNYHSC 44 TL..,i Carter 13-Dec-95 Baker 1 w Genesee H-:=-;: ' 26 Medical - H-=.- =! 20-Mar-% l iCostello I6ppIEWd" ' Albany Cardiology 2994 iMedical-Private Practice 28-Mar 96 l ISamson IBaker Mount Vemon F-:+i-si 1006 IMedical Specific- Hospital 14-May 96 l 'Phillips iBaker IBurke Rehabilation c -ei 1859 Research Instmae 15-May 96 Burns ' Baker  : United Hospital 1005 Medical- Private Practice i 16-May % ! Parker ' Baker iSUNY HSC 47 Broad - Medical 09 Jul-% Damiani Dansereau 'Adirondack Medical Center 1130 Med, cal Specific - Hospital Snyder 17-Jul 96 iBaker Clifton Sv. g Hospital 1873 Medical Specific-Hospital 04-Oct-96 1E == Baker Buffalo Cardio. and Pulm. ,2880 l Medical-Private Pracuce 09-Oct % Dansereau Baker 'Bassett Hospital 1836 Medical f- =:'r Hospital w/ 17-Oct 96 iBass  : Baker iN. Dutchess Hospital 1195 Medical Specific - F=;:i .1 07 Nov-96

       'Kelleher iBaker         ISt. Joseph's i==-ine           2881              . Medical Private Practice          16-Dec 96
 . iWormuth        : Baker        tNuclear Imaeinz Systems       B907
       !Goyal                                                                           l Mobile Nuclear Medicine Facil 20-Dec 96!
                       ! Baker        . Oneida City Hospital          1709              : Medical Specific- Hospital
       !CBums i 27-Dec 96:

iBaker :St. Joseph Hospital 1824  : Medical-Hospital i 17 Mar 97:

      'WKelleher ' Baker             ;Watertown Cardiology            2974              ' Medical- Nuclear Cardiology ! 05-Jun 97 IVGoyal         iBaker         ! Rome Memorial Hospital         8                  Medical Hospital               ! 26-Jun-97 iBIsnatz        IBaker         (Mount St. Mary's Hospital       1018               Medical- Hospital 02.Jul-97
      !ADamiani IBaker               IC&w. unity Memonal Hospital 2982                 ' Medical- Hospital                    17 Jul-97
      'RSnyder        ' Baker        ! Lakeside Memorial Hospital    3090                Medical- Hospital                  09-Oct-97 MVirgil         Baker         IMasonic Medical Research Lab 492                   Research & Development- Sp        05 Nov 97l RDensereau Baker               University at Alb .y           459-1               Academic- Broad                   03-Dec-97 '

CCostello Dansereau Albany Memorial H=c=1 1151 Medical- H=:: i 10-Dec-97 ABass Baker Good Samantan H ,; ! 490 Medical-H= : t w/HDR 18-Dec-97 4

l APPENDIX G-4 New York State Department of Environmental Conservation, Bureau of Pesticides and Radiation (NYDEC) , . INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) QUESTIONNAIRE

i 5 I Approved by OMB' No. 3150-0183 ' Expires 4/30/98 I INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM i QUESTIONNAIRE L' NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION Reporting Period: APRIL 1995 TO APRIL 1998 _ .A. COMMON PERFORMANCE INDICATORS

1. Patus of Materials insoection Prooram

1. Please prepare a table identifying the licenses with irupections that are overdue by more than 25% of the scheduled frequency set out in NRC Inspection Manual 4 Chapter 2800. The list should include initial inspections that are overdue.

                                                                                                                                                                                   ]

Insp. Frequency Licensee Name (Years) Due Date Months O/D l There are no overdue inspections at this time.

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

questionnaire. l There are no overdue inspections at this time. , t 2 Estime.M burden per response to comply with this volunt'ary collection request: 45 hours, forward conrnents regarding burden estimate to the Infortnation and Records Management Branch (T-6 F33), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, and to the Paperwork Reduction Project (3150-0183). Office of Management and Budget, Washington DC 20503. If an information collection does not display a currently valid OMB control number, NRC may not l conduct or sponsor, and a person is not required to respond to, the information collection, i

(

3. Please identify individual licensees or groups of licensees the State / Region is  ;

inspecting morm or less frequently than called for in NRC inspection Manual l Chapter 2800 L.nd state the reason for the change. ' Since our program concentrates on discharges and disposal of radioactive material to the environment, our inspection frequencies are not based on ] NRC Inspection Manual Chapter 2800. l l 4. Please complete the following table for licensees granted reciprocity during the reporting j period. Not applicable. t l Number of Licensees i l Granted Reciprocity Number of Licensees Priority Permits Each Year Inspected Each Year ! Service Licensees performing YR YR teletherapy and irradiator source YR YR installations or changes YR YR YR YR YR YR 1 YR YR YR YR YR YR YR YR 2 YR YR YR YR YR YR l YR YR 3 YR YR YR YR YR YR 4 All Other

                                                                                                                                         ~

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

Not applicable. l

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

any differences between the goals and the actual number of inspections performed. , O i 2 i i

Not applicable.

11. Technical Quality of inspections l

l

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

Our Part 380 permit inspections procedures were revised in j September 1996. The revision provides more specific guidance to inspectors and clarifies the Department's purpose, policy and

                                                                                            )

l authority to conduct these inspections. l

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

Inspector Supervisor License Cat. Dait J. Abunaw S. Hinkel Air (Sy Bronx) 4/95 R. Rommel S. Hinkel Air (SPL) 5/95 W. Tetley P. Merges Land Burial (WV) 6/95 ( B. Youngberg P. Merges Air (NRD) 9/95 A. Gray l B. Youngberg Air (Cornell) 10/95 M. Spivak S. Hinkel Conf (MSKCl) 5/96 J. Abunaw B. YounghJrg Air (Sy Bronx) 8/96 M. Spivak S. Hinkel Conf (St. Lukes) 8/96 W. Tetley P. Merges LB (WV) 10/96 A. Gray l B. Youngberg incin & Air (BMS) 1/97 M. Spivak S. Hinkel Conf (Mt. Sinal) 2/97 W. Tetley S. Hinkel Air (ICN) 3/97 R. Rommel B. Youngberg Air (SPL) 3/97 M. Spivak S. Hinkel Air (Empire) 8/97 M. Spivak S. Hinkel Air (CPMC) 10/97 A. Gray B. Youngberg Conf (SUNY SB) 10/97 l A. Gray B. Youngberg Air (MPI) 10/97 i M. Spivak S. Hinkel Air (CPMC) 1/98

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

            . Part 380 permit inspectors are to be accompanied annually, if possible. During management accompaniments, supervisors evaluate the inspectors' performance. Supervisors provide feedback after the inspection, either verbally or via a written 3

i i

1 I 1

            ' evaluation. Usually, any written evaluation is provided directly, and only, to the inspector.

10. Describe or provide an update on your inctnJmentation and methods of calibration. Are allinstruments properly calibrated at the present time?

See attached !!st of instruments and calibration dates. Ill. Technical Staffine and Training

11. Please provide a staffing plan, or complete a listing using the suggested format 1809/, of the professional (technical) person years of effort applied to the I

agreement or radioactive material program by individual. Include the name, ) position, and, for Agreement States, the fraction of time spent in the following areas: administration, materials licensing & compliance, emergency response, LLW, U-mills, other if these regulatory responsibilities are divided between offices, the table should be consolidated to include all personnel contributing to the radioactive materials program. Include all vacancies and identify all senior , personnel assigned to monitor work of junior personnel. If consultants were used to carry out the program's radioactive materials responsibilities, include l their efforts. The table heading should be: I

NAME POSITION AREA OF EFFORT EIE%

i l l h l l l e 4 l m

                    ^

Name- Pssif: i Area of Effort FTE Paul J. Merges Chief, Bureau of . administration 50 Pesticides & Radiation Jill A. Baille - Secretary 1 administration 20 Barbara Environmental administration 50 Youngberg Radiation Specialist (ERS) 3 Permitting & compliance 20 contaminated sites 30 Marie Johnston Keyboard Specialist administration 100 ! Sandra Hinkel ERS 2 permitting and compliance 100 l Markus Spivak ERS1 permitting and compliance 100 Ann Marie Gray ERS1 permitting and compliance 100 Robert Rommel ERS1 permitting and compliance 10 contaminated sites 90 Timothy Rice ERS 2 permitting and compliance - 10 former burials & contaminated sites 90 John Kadlocek ERS 2 contaminated sites 100 William ERS1 contaminated sites 50 l Varcasio John Mitchell ERS 2- contaminated sites 100 John Abunaw ERS1 contaminated sites 5 RMW and SW facilities

• 95 John Zeh Environmental Analyst 2 transportation of LLRW 35 (to be hired) ERS1 contaminated sites 100 (to be hired) Environmental Analyst 1 to be determined 50

     ' 'radiation monitoring at solid waste and regulated medical waste facilities 5

i l

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

No new staff have been hired since the last review.

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

l The minimum qualifications for an environmental radiation specialist are a bachelor's degree in science or engineering and at least two years of l experience in the environmental radiation field. l Bscause of our small number of inspectors and permit reviewers, we do not have a formal qualification program. New staff have been trained individually by the permit unit supervisor, in performirg inspections and reviewing permit applications. Inspectors in training move through the following stages: (1) accompanying experienced inspectors, as observers; (2) assisting experienced inspectors; (3) taking the lead in inspections, assisted by experienced inspectors, and (4) performing inspections independently. Inspectors move through these stages based on the l assessment of the unit supervisor. The same staff are trained to review l permit applications by reviewing first minor amendments and routine renewals, then applications of increasing complexity. All permitting decisions are reviewed by the permit unit supervisor and the radiation j section supervisor.

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

William Tetley, ERS 2, and William Gilday, EA 1, left the program in 1997. In addition, William Varcasio, ERS 1, was assigned to work part-time as the Department's emergency response coordinator, which was an initial commitment of 0.3FTE. Due to emergencies in New York State, he has actually spent about 0.5FTE working outside the radiation program.

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

6

ERS 1 - vacated in November 1997, when Timothy Rice was promoted to fill the vacancy left by William Tetley. EA 1 - vacated in August 1997, when William Gilday left the Department. We recently received approval to fill these positions (an exemption from the current hiring freeze was required). The vacancies were posted from March 13, through March 24,1998. We plan to fill these positions by June 1,1998. 0.3 FTE ERS 1 -lost when W. Varcasio was assigned (by the Commissioner) to be the Department's SEMO Liaison and Emergency Response Coordinator. IV. Technical Quality of Licensino Actions

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

Complex permitting actions that have occurred during the review period include the following facilities:

a. State Licensed Disposal Area at West Valley - permit modifications in 1996,1997, and 1998

b. Self-Powered Lighting - issued a new permit for its new location in 1996 and terminated its old permit at its former location in 1997

c. ICN East, Inc. - permit modification in accordance with a consent order in 1995

d. Cornell University - permit modification in accordance with a consent orderin 1995

e. Columbia Presbyterian Medical Center Cyclotron - new permit l issued in 1996, permit modified in 1996,1997, and 1998

f. University of Rochester Laboratory for Laser Energetics -issued a new permit in 1998 7

1

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

Since July 1995, we issued three separate variances to the G!nna Nuclear Power Plant for disposal of.soll, concrete, and robar containing traces of radioactive material. The waste was added to the spoils pile on the Ginna Power Plant Site.

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

We made minor revisions to our permit application review checklists 1 and Part 380 permit guidance documents, as they were needed to more clearly explain the application requirements.

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

Not applicable l V. Resoonses to incidents and Alleontions

20. Please provide a list of the reportable incidents (i.e., medical misadministration, )

overexposure, lost and abandoned sources, incidents requiring 24 hour or less notification, etc. See Handbook on Nuclear Material Event Reporting in Agreement States for additional guidance.) that occurred in the Region / State during the review period. For Agreement States., information included in previous submittals to NRC need not be repeated (i.e., those submitted under OMB clearance number 3150-0178, Nuclear Material Events Database). The list ) should be in the following format:- j l LICENSEE NAME LICENSE # DATE OF INCIDENT / REPORT TYPE oE INCIDENT

                       ~Not applicable. DEC is not the New York State agency responsible for reporting to the Nuclear Materials Events Database. We do respond to numerous reports of radiation alarms at solid waste and regulated medical waste facilities. During this reporting period, they all involved either patient excreta, exempt material, or non AEA material (i.e., radium-226).

l

21. During this review period, did any incidents occur that involved equipment or source failure or approved operating procedures that were deficie'nt? If so, how and when were i other State /NRC licensees who might be affected notified? For States, was timely notification made to NRC? For Regions, was an appropriate and timely PN generated? 1

                                                                                                               )

Not applicable 8 I ( L_________________

22. For incidents involving failure of equipment or sources, was information on the incident provided to the agency responsible for evaluation of the device for an assessment of possible generic design deficiency? Please provide details for each case.

Not applicable

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

One incident involving possible wrongdoing is under review. We will provide a description of the circumstances during the IMPEP team visit.

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

a. For Agreement States, please identify any allegations referred to your program by the NRC that have not been closed.

None VI. General

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

There was one recommendation following the last review: We recommend that the NYSDEC expeditiously complete the inspection of New York City licensees and determine whether there are any licensees subject to its regulation. If licensees are determined to need NYSDEC permits, the agency should take steps to carry out its regulatory responsibilities with regard to these licensees' activities. Since the last review, we have continued to implement our July 1994 action plan for implementing part 380 in New York City. We have inspected eight NYCDOH licensees, selected as the most likely to require a Part 380 permit. Columbia- ' Presbyterian Medical Center was identified as requiring a Part 380 permit. That ! permit was issued in 1997. We are working with one other facility, likely to require a permit for a new cyclotron. Complete reports of our activities for the calendar years 1995,1996, and 1997 were written and will be available for review during the IMPEP team's visit. l 26. Provide a brief description of your program's strengths and weaknesses. These strengths and weaknesses should be supported by examples of successes, problems or difficulties which occurred during this review period. 9

                                                                                             - - - - - _ _ _ _ - - - - - _ _ _ _ _ _ J

[. l l Stre'ngths ! We have an experienced staff. The average length of tenure in the program is nine years, the range is 3.5 to 15 years, and two thirds of the staff have been here for l more than six years. We are well supplied with radiation survey and analytical equipment, velometers, and field sampling equipment. Much of our equipment is state-of-the-art, particularly our Ultrasonic Ranging Data System, new TLD reader, and TLD irradiator. Weaknesses There is no direct connection between the State's environmental radiation monitoring program, implemented by the State Health Department, and our program. We receive the results of that program years after the data is collected. l As is true for most programs, we could use more staff, particularly staff to work on contaminated sites. The Radiation Program Control Director was named Chief of a new Pesticides & Radiation Bureau in 1995. As a result, his time is now divided between the radiation control program and the DEC's pesticides program, with the pesticide program requiring the larger portion of his time (it includes three separate regulatory , programs and a statewide staff five times the size of the radiation staff). The RCP l-Director is far less available to the radiation staff. In addition, the radiation section supervisor is called upon to serve as acting Chief of the Bureau of Pesticides & Radiation for about 20% of the work year, which decreases the time she can spend i on the radiation program. B. NON COMMON PERFORMANCE INDICATORS l Legislation and Proaram Elements Reauired for Comoaiibility I. 27, Please list all currently effective legislation that affects the radiation control program (RCP). New York State Environmental Conservation Law Articles 1,3,17,19,27, and 29 i

28. Are your regulations subject to a " Sunset" or equivalent law? If so, explain and include the next expiration date for your regulations.

Our regulations are not subject to a " sunset" provision.

29. Please complete the ends,ed table based on NRC chronology of amendments. Identify those that have not bean adopted by the State, explain why they were not adopted, and 10 l . -. . - .. . . . ..

o

discuss any actions being taken to adopt them. Identify the regulations that the State has 1 adopted through legally binding requirements other than regulations. l l See attached table.

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 regulations in order to

                           ,                                                   maintain compatibility with the NRC, showing the normal length of time anticipated to complete each step.

These are the basic steps in our rulemaking process, with an estimate of the time needed in parentheses. Those times can vary considerably, depending on the nature of the rule.

1. A Rulemaking initiation Memorandum is written, describing the proposed rulemaking. Once all internal approvals are obtalaed, including those of the Commissioner and Counsel's Office, staff can begin work on the rulemaking.

(2 months)

2. Input from the public is solicited before and during the drafting of the proposed rule. This may include mailings and workshops. (2 months)

3. The draft rule and supporting documents ( including a draft environmental impact statement, if required) are written. (2 months)

4. Once approved inside the Department, the draft rule is sent to the Governor's Office of Regulatory Reform (GORR) for review. ( 1- 6 months)

5. After GORR approves, notice of the draft rule and the text or a summary are published in the State Register. (1 month)

6. A public hearing must be held no sooner than 45 after notice of the rulemaking was published in the State Register. The comment period closes no less than 5 days after the last day of hearing. (2 months) i

7. After the close of the comment period, staff responds to comments, and if no revised proposed rule is needed, writes the final rule and supporting documents.

(3 months)

8. The final rule is submitted to State Environmental Board for approval. (2 3 l months) l 9. Once the Board approves the rule, it is submitted to the Commissioner for l approval, then filed with the Department of State and published in the State j Register. (2 months) i 11 L

                                                      .       10. The rule becomes effective 30 days after the date of publication in the State Register. (1 month)

The entire process takes 18 months to 2 years. l 11. Sealed Source and Device Proaram - Not applicable t l

31. Prepare a table listing new and revised SS&D registrations of sealed sources and devices issued during the review period. The table heading should be:

SS&D Manufacturer, Type of Registry Distributor or Device Date Number Custom User or Source issued

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

33. Please include information on the following questions in Section A, as they apply to the Sealed Source and Device Program:

Technical Staffing and Training - A.lli.11-15 Technical Quality of Licensing Actions - A.IV.16-18

Responses to incidents and Allegations - A.V.20-23 l

lil. Low-Level Waste Proaram - Our LLRW Program is in abeyance (although our regulations are still in effect), except for our Part 381, LLRW transportation manifest and permit program. ! 34. Please include information on the following questions in Section A, as they apply to the Low-level Waste Program: 1 Status of Materials inspection Program - A.I.1-3, A.I.6 We have not had the staff needed to inspect LLRW transporters. Technical Quality of Inspections - A.ll.7-10

                                                               ' We have not had the staff needed to inspect LLRW transporters.

Technical Staffing and Training - A.Ill.11-15 See responses to A.lli.11-15 Technical Quality of Licensing Actions - A.IV.16-18 Not applicable Responses to incidents and Allegations - A.V.20-23 l 12 I-

1 See responses to A.V. 20-23 IV. Urahium Mitt Proaram Not applicable {

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

Status of Materials inspection Program - A.I.1-3, A.I.6 Technical Quality of Inspections - A.ll.7-10 Technical Stamng and Training - A.llt.11-15 Technical Quality of Licensing Actions - A.IV.16-18 Responses to incidents and Allegations - A.V.20 23 1 i 1 i L i

                                                                                                    )

13

CT ^ EP PO XD EA f

                                                                                                             "e 1 o                   c 6t                     n

_ t n a r ei s a _ r Pms eo u 7 s8 s9 Rt p Ft a is a1 _ C Sdeyn i i _ 0Cdelt 1 Rn[ sa u 83 2 t N *o req 1 a[ f e* t hyent "s olcmrPa t - R _ O fevt i r iit iohateetde i t _ T lc cish t in p NS " e t o ol afe k dd EU t a daea R T R TA sssmu ao w p C' yd w s e -_ US C t i sedan _ nd e Dah e e eh mdor d u e n t w noo3 la W "o

                                                                                                          ,       l t
                                                                                                            ]). nr er m gt      n 991           t

_ a v e oo1 (3 o eo f in )s cy hbA t a .e d(i 2. t l a f o o )n p0u t _ e s et t oo 38 q p pe* e po sida h f" o r upd .ae h r paiyrga c st eoni h el A A A A A A h lsoc e r p A A A N N N N N N TaCfapi n N N N - D

        ' E E

T T 4 7 _ A P 9 38 9/ _ DO D

                                         /

4 / 1 43 / 2 1 _ A / 3 / 2 31 E e 4 T E - 6 u 1 4 9 5 6 9 7 AU ed r 9

                           /

3 9 4 9 9 t 5

                                                        /

9

                                                                     /

6 9 / 5 9 7 DD n e 7 / 0 1 7 9 / 2 2

                                                                                                                                      /

9 ov

                                         /

2 7 1 / / 8 / 2 r 1

                           /      /                     0                   1        2                                                2        1 No          7      4
                                         /

1

                                               /

1 1 1

                                                                     /      /

7

                                                                                     /

7 0 1

                                                                                                                                      /

1

                                                                                                                                               /

7 - t s y n, n Wony f io e m - l a A - eg t ia e u c ic P Ido d ic iu r o0 n E lo a h q 1 a o 1, n R p d e 6 D 7 n t a t i g 9 or t s r g n R r o 0, F n 9 h n 0 a y P .4 la - io i 1 o e C i a d 7 m t e  ; m0, n m r _ 9 t rh A g R a 0 4

                                                                , a r

g5 S f a laa m

3

                                                                                                                                - s d to0 i

i 7, ofn o _ 2 ot r o n r o3 s ogro Jt d0 . i , , n r o Po A 4, C r N o s9 - pt Pt o pr

                                                                                                                            - :s f       t                 r

_ O ee r g li c s n3 o it 6 iPs n0  : I uf , n e tn4 e d 4, tnP e; le3 D A o3 s g T dre g in t o e3 ic 3 dt r R. n o s s in0 _ S ( n n m eo dQ l 4 mt geds et t r , E E nn i0 e o)o , P , o n7 la0 7 P ea r in1 3 e RP n ae ;i

                                                                                                                            . it
                                                                                                                            , d        eo r

lat r U mis r r P o f a Li t eP To A d lan t t i0 s y 0 f iu; 0, nw ao nr f S - d l P l Q qt n3 ce J_ A tn a ;m M s: i t R nue s4 cn 4, s en io0 , Mf a t

                                                                                                                              .n egm       im0,          dr     Rem ga       nt s                                    .

r s R R med r m3 e0 g3 e0 y p ta2 ym i nd sa i io e io u n mr ai ua d a hen os ic s O F r d2 le d it a Gah C et s nt ftei fi t le e nrr inW t id F 0 1 na m cteo ma yc r AeA DP EP SP SE NP QM r t era u aq oo t r ui s eI icr Lf o f en Da d _.t Cm SM US n f c nn e le e raa t E. t B l A T

l l!]) lll ll i8lj Il l DN E TI O CT ' E P 9 PO 9 9 9 9 9 9 9 XD / 2 2

                                                                                                                           /            /

2

                                                                                                                                                           /

EA 1 1 1 2 1 _ d w _ ntr e aoi v "c i ol l fPe r b e u n om pist e _ hein v i t e r f r - ot e r e mdn bmu _ R mu) e cM r O muR T f" o( onm NS s i u EU ni sd RT ohn R TA it t er i e U C S inda f un el e dcM n - si nio n l l w w w ioWi t ie ie e _ s ia v v iv e e lo?i e w t r r r eIn le psog l r l e e edn m m m e e e bl l a nm aai k t n t n t n lic io pt le I r e i r e i r e pau d d n d - a pR n u u n ycu . u 5 _ A A A A l nc0 A A N N A A M 1 N N N N O "o 38 N N R R N N I R D E ET 7 7 TP 9 f 9

                                                                                                     /

A DO 9 0 0 9 D / 7

                                                                                                     /

A 0 7 0 EE T 7 9 8 8 8 8 9 8 9 9 0 0 0 AU / 8 9 9

                                            /

8 9 9 f 9

                                                                     /
                                                                                    /

4 9 9 0

                                                                                                                /

9 0 0 0 0

                                                                                                                                                 /

0 DD f f 5 / 3 / 0 4 2 / 2 8 f 0 7 9

                                                                                    /                          /

1

                  /

1

                               /

1 I 1

                                                   /

3/ 1

                                                                     /              1 1
                                                                                                    /          0        1
                                                                                                                        /

9 1 2 2

                                                                                                                                      /      /   /        /

8 1 3 3 8 8 1 4 1 8 1 2 2 5 f o y d e s e d e ir n r hp it s n e An s

                                 - o isf          U                   a n

e g n i v n o iso eW Da l ir l r o r g m i d e d n it c mo oe it p sic ae f t o A n h a A bl C nd es s s s i u t y n d m ice t nt e d a s e ir e icir la o h r eM on f in R t n F, it m. it s A s, E x LuJ ul a n idir f l mtc Ne e a e . w le oa el f. nmp r o m a m e i d l o ar ve _ mu5 nr _ 4 M yf d n it

f. e a ic ot e de imi t t od 3, t r _

R y L; e a Sede InM Co r 2 aqu n eg 4 i u l bg R f

                                                                                                                                .. it s     s n             q                   _        l e

r f o o iM t n et f o ov pne

                                                                  .                                                                          t r

oyp 3, ExE l u n eFa m# ,

                                                                  . e                                         n r      .. gev    e         t eH f

rB0 lao n io pr .

                                                                  . Rte    r mE         os     f e

eN m meSvt sc ef 3 hp . ne s- ein ao _ icit - oc ll la n ; Rc ip es eo fs o s dc Se 2; ol i i ei a: e r u e

                     ~          net r        et e   eR               i t

cC r Cm r r t e TrRg l eo h S glcm led l 0 C 7, ruP aso t sd  : C+  : o ie st uid Axe ReR - E Mro en R t ed f 1 t 7A nM r on Dat la fo Ee r e in 0 T, d ; so ~r on o . i - L Wan at r a 4 i fRc of A i r rg hd U nn e. y P s n tl r a m e np e neA tr re 4 s4 a , k a, U yr co l e io nn nn o .. o Po n dw AM ioe e no o s t e od oe e0 t nt a vt oe oo W e i c t ak bt M inn d f t ei s snl ea R F in3 r o a ehic er ui p Lm mm r oip ii t t lei le1_ l Rt a F laa ico irnd un le nUe gsn l n C l e ts mr pud eb e q e es of r-u ro feq r u df in ee i - r ; e : Cme dd ea i mo r c lo e sefRu is o i c ah ri e Mm 0 io r i r n l 0t n MR ee s erei t r d

 .          1     TP         PtrM         FR      LI          PE    RD              CR              1   I               TR           RE i

F RAW CA

1 1 Attachment 1 February 17,1998 Letter from M. K. Daniel., Jr., NYCH I l

                                                                                                                             \

I i l I l t i I l I J

                                                                    ~

l \ t \ o THE CITY OF NEW YORK l 1EPARTMENT OF HEALTH j g I 7:nsr r.udolph w. Giuhant Beqjamin Mojica. M.D.. W.P.H. ) m uor Acanoc ommusw f l Bureau of Radiological Health 2 Lafayette Street - 11th Floor, New York, N.Y.10007 l Telephone: 012)#7s.1558, Fax: p12)s7s.154s Febnery 17,1998 Denms M. Sonenberser Office of State Programs U.S. Nuclear Regulatory Commission Washington, D.C. 20555-0001 l

Dear Mr. Sollenberger:

The following responses are being made to the prehmmary findmgs +==~4 at the IMPEP closcout l meetmg on January 30,1998.

1. Status of Materials Inspection Program- Unsatisfactory 19 Priority 1 inspections were overdue by more than the 25% of the required 1 year intervals.

Response: I In reviewing our records of Prionty 1 license inspections, for 1997, the Bureau came up with a total of 12 that had been overdue by more than 25 % of the inspection intervals during the reportmg period. Of this total,2 inspections were overdue by 12 days, I was overdue by 3 days, I was overdue by 25 days and one was overdue by 27 days. We have just completed a validation check of our new RAD Data base and have enclosed a printout of our inspections due during the next year. Please note that there are now no overdue Priority 1 inspections (Rockefeller University is being inspected at this time). Based on our actions to ensure that no Priority 1 mapections will be overdue in the future, we request that you reconsider your finding of l unsatisfactory for C-man Performance Indicator 1.

2. Technical Quality ofInspections- Satisfactory with recommendations for Improvement.

Inspections are compliance rather than performance driven. Two inspectors should be sent to a Performance Inspection trammg course. There was no documentation of follow-ups for results of hearmgs following bsuance of NOVs P =any:

             'Ibe Bureau has requested and received the Student Manual"Inspectmg for Performance " from NRC and plans to conduct an in- house course for the matenals irssiva in the near future.

l b .% e

f Supemsors and staffhave een r Wt o '= =t the findings of all hearmgs resultmg from the issuance ofNOVs. An Inspection checklist is being developed to include the follow-up uport on hearmgs.

3. Techmcal Staff Trammg- Satisfactory with recommendations / suggestions.

The Bureau needs a written policy for staff traming needs. This should include checklists for on-the-job trammg forinspections and s' ==% Out of State tranung should be part of budget proposals. j Response- l The Bureau's Policy and hh Manual cantamm wntren policy for staff trammg needs. ) This manual is currently being updated The Bureau is exploring the possibility ofincluding the costs ofout of state traimng in the current reevaluation of our fee- base schedule. l

4. Technical Quality of Licensmg- Satisfactory with suggestions.

Licensms actions which involve material from the Scaled Source and Device Registry should ira.wiyo-.ete conditions, restrictions of use etc. as bcense conditions where appropnate. The dating ofnew licenses should more closely reflect the date the licenses are actually effective so that inspections of these facilities would be withm the presenbed time frame. Response-A memo will be added to the License Reviewer's Handbook that instructs reviewers to include as license conditions specific language from the Scaled Source and Device Registry dealing with restrictions of use or recommendations concemmg safe handling etc., as appropriate. The Rad Data Base has been uptnded to trigger an inspection due date based on the actual date ofissuance of the new license, rather than the date oflicense signing.

5. R~ pan =~ to Incidents and Allegations- Satisfactory with recommendations Files need to be hmented that allegers were notified of results ofinvestigations.

The NMED System should be used for reportable incidents. 9 ~~~n=- Documentation in the form of a memo to files will indicate that allegers were notified of the results ofinvestigations. I Management and supervisory staff have received trammg in the use ofNMED System from Mr. John Pettijohn of the NRC. The Bureau will enter all incidents back to k; le of 1996 into the NMED System

6. Non<- Performance Indicator 1, I.egislation- Satisfactory with recommendations. l The Bureau needs to act on the Uniform Manifest Rule which is due 3/1/98. t The Bureau is overdue in incorporating the Timeliness in D + "Moning Rule which was due  !

I by 8/15/97 ' I s 1 4

Response- I The New York State Dewst of Envu. . ..- 41 Conservation has mcorporated the Uniform f Manifest Rule by reference (6 NYCRR Part 381, July 1997). We are working with our Office of General Counsel to determine whether the Bureau needs to incogorate this rule makmg into Article 175 of the New York City Health Code and if so, whether we may also incorporate it by reference. If we decide to incorporate this rule by reference, we will present the appropnate material to the Board ofHealth in the June,1997 meetag We have also asked the Office of Genen! Counsel to -t on the inclusion of the Timeliness in D=c  !== toning Rule into our regulations vs. handling these situations on a case by case basis through license conditions for the types of heensees regulated by this Bureau. We hope this has addressed all the issues that were discussed during our closcout meeting. Ifyou have any questions, please feel free to contact me or Gene Miskin. Sincerely, fl. - Kenneth R. Daniel Jr., Deputy Director I 1

i Licones inspectone Due . By Pnority and By Date Due Usense f Moonee Type Priority Date Due Date Overulus Meme Borou0h 2989 75 1 12/13/97 03/1346 Rockefol;er University MN 2924 92 1 01/29/98 04/29/96 Brooklyn Hospital Center BK 2885 75 1 02/04/96 05/05/96 Monter6cre Med Ctr BX 3009 75 1 0345/96 OWD3/96 St Vlnoont's Hospital and Medes! Center MN 2843 92 1 03/DW96 06/0646 Lan0 loland Col *0e Hospital BK 161 92 1 03/25/96 06/23/96 MemonalSloorWattering MN 165 75 1 03/25/96 08/23/96 Memortaf Sioen Kettering MN 2847 S2 1 04/04/96 07/03/96 Peninsula Hosptal Center QN 2894 91 1 04/1146 07/10/96 New York Hospitet Medal Center of Queene QN 131 92 1 04G4/96 07/23/96 Staten Island Univoretty Hospital SI 126 22 1 04/24/96 07/23/96 Staten lelend Unbr. Hoop Si 2830 92 1 08/DW96 08/07/96 Manfredi, Ortendo L . M.D. Si 2909 - 91 1 05/21/96 08/1998 Mt Sinal Smool of Medicine MN 2841 92 1 05G4/96 OW22/96 Brookdale Hospital Medical Center BK 2919 75 1 0845/96 0903/96 Albert Einstein College of Medone BX > 2869 92 1 06/DW98 0944/96 AnimalMedalCenter MN 2899 92 1 0806/96 0944/96 Anime!MedalCenter MN 166 92 1 06/22/96 09/2046 Memons! A-. C W Corar Ctr MN l 2955 92 1 07/08/96 10/06/96 NYU Medcol Center MN I 76 92 1 07/2926 10/2746 Lenox Hill Hospital MN 269803 92 1 08/07/96 11/05/96 Memortal Sioen Ketterino MN 2957 91 1 09/17/98 12/16/96 NY Hosp Camell Med Ctr MN 2897 92 1 09G4/96 12/23/96 Beth lereel Medcol Ctr MN 86 75 1 10/12/96 01M0/99 NYU Med Center MN [ 2966 75 1 10/1696 01M4/99 Lon0 leland . lowish Med. Ctr. QN l 2950 93 1 10/17/96 01M5/99 NYU Modecal Center MN 2955 75 1 10/17/96 01M5/99 NYU Medical Center MN 2876 92 1 10/27/96 01/25/99 Columbia Presbyterten Medical Center MN 2922 92 1 10/28/96 01/26/99 CabriniMedicalCenter MN 2696 75 1 10/31/96 01/29/99 St Luke'sRoosevelt Hospital Ctr MN 3026 92 1 11/07/96 02/05/99 SUNY Health & Scence Center Brooklyn BK 82 92 1 11/07/96 02/05/99 SUNY Hostth & Soonces Center Brooklyn BK 44 92 1 11/07/96 02/05/99 SUNY Health & Soonce Brooklyn BK 146 92 1 11/28/96 02/26S9 NYCHHC.Kinos County Hospital BK l 2876 52 1 1245/96 03/0549 Columbia Presbyterian Medcol Center MN 2676 75 1 12/05/96 03/0549 Columbia Presbytenen Medicat Center MN 2848 92 1 12/24/96 03/2449 Cahrery Hospital BX 2934 75 1 01/18/99 04M649 SUNY Health & Soonce Ctr of Brooklyn BK 2663 92 1 02n3/99 05/14/99 Montenore Med. Center BX Total 39 Priority Date Due Date Overulue Name Borough 2909 74 2 07/22/96 01/18/97 Mt Sinal School of Moderne MN 2861 91 2 02/08/97 06/07/97 Nestedt. Louis MD. MN 2915 91 2 04/28 S7 10/25/97 NYCHHC Lincoln Medical and Mental Health Ctr BX 1516 91 2 09/21/97 03/2046 Victory Memorial Hospital BK 2919 74 2 10/12/97 04n0S6 Albert Einstein Conege of Movec6ne BX l 2003 91 2 01/04/96 07/03/96 NYCMHC.Hertem Hospitaf Center

• MN I 3003 91 2 01/24/96 07/23/98 Annand, Azad K. MD QN 2731 91 2 01/24/96 07/23/96 Lu90 Sante9o, Emo MD ON 2932 91 2 01/28/96 07/27/96 Partnvey Hospital QN 1515 91 2 01/30/96 07/20S6 North Shore Unrveralty Hospital ON 2900 91 2 03G2/96 09/18/96 Our Lady Of Mercy BX 2844 91 2 03G646 00G2/96 Maimonides Med. Ctr. BK 3075 91 2 03/30/96 09G6/96 Harold M.Tios ON l 3069 91 2 03/3048 09/26/96 David Greenblatt, M.D. MN 2843 91 2 04/03/96 09/3096 Long Island Cohege Hospital BK 1641 91 2 0451/96 10/08/96 NYCHHC Norm Central Bronx Hospital BX

3070 91 2 04/11/98 1048/98 Daniel Lorber QN l

2862 91 2 04/18/96 10/13/96 St. Clare's Hospital & Health Center MN 2642 91 '2 04/1996 10/1646 Bloomnoid, Maren E. MD MN 2005 91 2 04/23/96 10/2046 Caccovo, Nlectes MD BK 34 91 2 054548 11/01/98 Blake ,lemos MD MN 3020 91 2 05/08/96 11/04/98 Thanswels, Shirteh K. MD QN 165 91 2 0508/96 11/04/96 Weinstein Vetor MD _ ON 2786 91 2 06/DW96 11/05/96 Weimer,its MD. MN 2914 91 2 05/15/96 11/11/96 NYCHHC Color Memonal Hospital MN 2660 91 2 0555/96 11M1/98 Rosenthal. David,M.D. BK 02/17/96

l I usanne wasmenone Due By Pnorny and By Dei Due

    ,         1540         91  2  05/17/06      11/13796 Doolor's Hoopliel of Staten latend                $1 2732         91  2  OW22/96       11/14/98 Poule M. Rotheus, M.D.                            MN 2796         91  2  06/23/96      11/19/96 Seer, Steven MD                                   MN 3039         91  2  06/23/06      11/19/96 Jacobs, Devid R. MD                               MN 3053         91  2  06/24/96      11/J0/96 Rudovelry Amio!Zechery,M.D.                       MN 2761         91  2  05/29/96      11rJ5.98 Kaufman, D MD                                     BX 2055         74  2  06/31/96      11/27/96 NYU Medical Center                                MN 296604          74  2  06/31/96     ,11/27/98 New York Unhersity                                MN 2795         91  2  06/05/96      12/02/96 Reismen, Steven, MD                               MN 2001         91  2  08/17/96      12M4/98 Potenze, Robert MD                                 BX 1872         91  2  08/10/98      12/16/98 Spor 9el,GetztelMD                                BK 2785         91  2  08/18/96      12NS/98 PreGer, Marc MD                                    BX l              2024         91  2  06/21/96      12/18/98 Brooldyn Hospital Center                          BK i              2956         91  2  06/28796      12/25/96 Nor0) General Hospital                            MN l              2342         91  2  07/03/96      12/30/98 Methodet Hospliet                                 BK 3025         91  2  07/10f96      01/06/99 Eng, Youn0 F. . M.D.                              Si 2618         91  2  07M6/06       01/11/99 theintwot,Stuart/Irwin, Singer                    BK

, 3023 91 2 07/18/96 01/14/99 Novick, Mark MD ON ! 3077- 91 2 07/30/06 01/20/90 Joseph Hun 0 Me, MD. ON 3004 91 2 0a01/96 01/28/99 Use Neck Community Hosp. QN 2700 91 2 08/12/96 02/08/99 Sapienze, N MD BK 3005 91 2 08/13/96 02/09/96 Usenn, Nes!, MD MN 3036 91 2 06/14/96 02/10/09 DoeN, Laene MD BK l 2646 91 2 08/15/96 02/11/89 Uchy,Jeoob MN 2830 91 2 08/17/98 02/13/99 Manfredi OrlandoL M.D. Si 2651 91 2 08/20/96 02N6/99 St. John'c Episcopel Hospite! QN 3014- 91 2 08/29/96 02/25/99 Razzedeh, Rudy MD MN 2797 91 2 OSO4/96 03/03/99 Schaefer, Kenneth MD Si 2796 91 2 09/10/96 03/09/99 Doohl, Laons MD. QN 2900 91 2 09/10/96 03/09/99 N.Y FeueNng Hosp. Med. Ctr. QN 2636 91 2 09/11/96 03/10/09 tar 0er DanielMD ON l 2771 91 2 09/16/96 03/15/99 Brandes,VIncontT MN i 3022 91 2 09/24/96 03/23/99 Be9) larmel . Kings Highway Drvision BK f 2944 91 2 09/26/96 03/25/99 DoeN, Leons MD, BK l 3041 91 2 09/27/96 03/26/99 Rosenthat Devid,M.,MD BK j 2821 91 2 09/27/96 03/26/99 Ginde, Ravindre MD BK i 2957 91 2 10/01/96 03/30/99 Mang. Henry M.D. MN 3034 91 2 1001/96 03/30/99 Lefkowitz, Devid M.D. MN 3042 74 2 10/01/96 03/30/99 CUNY, City College MN , 2663 91 2 10/01/96 03/30/99 Nampf, Jeffrey MD MN l 3056 91 2 1043/96 04/01/99 Tertell, Jay MD ON i 2657 91 2 1099/98 04/07/99 Lesh, James MD BK 2739 91 2 10/11/98 04/09/99 Schort, P MD (Hherest) QN 2066 91 2 10/18/96 04N6/99 Thenewsle, Shirtsh K. MD BX 3051 91 2 10/22/96 04/20/99 Semii, Moheen MD ON 2941 91 2 10/23/96 04/21/99 Hessen, Khalid MD BK 1619 91 2 10/23/96 04/21/99 Wootem Queene Comminity Hospite! QN 2006 91 2 10/25/96 04f23/99 Felt.Sheldon,MD ON 3050 91 2 10/30/96 04/26/99 Lavine, Even MD BX 2933 91 2 11/01/96 04/30/99 Perekh, Hershed MD SI 1640 91 2 11/08/98 05/07/99 Schneider,Howard J MN 2635 91 2 12/03/96 08/01/99 OrunIher & Stoll MD. MN 2976 91 2 12/05/98 06/03/99 A. Memoins, MD & A Weberskind, MD MN ,. 2846 91 2 12/05/96 0643199 Wyckoff Heights Medical Center BK ! 2929 91 2 12/05/96 06/03/99 CMCBQ.St Mary's Hospital BK 2849 91 2 12/06/96 06/04/99 SL Bemebee Hospital BX l i 2946 91 2 12/06/96 06/04/99 Bradley Moore, Patr6ck MD ON ! 2969 74 2 12/12/98 06/10/99 Rocheleger Universty MN l 2006 91 2 12/13796 06/11/09 Greenberg Joseph M.D. MN 3045 91 2 12MS/96 08/18799 Mullen Edward E. MD ON 3054 91 2 12/21/96 06/19/99 LaGuten Med. Ctr, BK , 2917 91 2 12/23/96 08/21/90 Recomen,9 MD MN 2616 91 2 12/26/96 06/24/99 Hosptist forJoint Desenes/Orthopeeclic institute MN 2923 91 2 12/31/96 06/29/99 Jomsica Hosp. ON 2002 91 2 01/02/99 07/01/00 NYCHHC.ConeyIsland Hospitel BK 996 91 2 01/07/99 07/08/99 Silverberg, Amold t. MD BK 2950 91 2 01/07/99 07/06/99 Brorut Latenen Hospitel Center BX 2056 91 2 01/08/99 07/07/99 Rotuner, Hertiert, MD ON 2901 91 2 01N0/99 07/09/99 NYCHMC.Queene Hospital Ctr QN 02/17/96

Ucones inspectons Due By Priority and By Date Due 2006 91 2 01/14/99 07/13/99 Heimes, Abson B. MD MN 3649 91 2 01/15190 07M449 NYCHHC Woodhub Med Mnti Hith C1r BK 3055 91 2 01/15/99 07M4/99 D'Alessandro, Thomas M.D. MN ! 2945 91 2 01M6/09 07MSSB Interleith Med. Car BK f 2026 91 2 01/16/09 07M5/99 Lenom HW Hospito! ' MN 2671 91 2 01/17/99 07M640 CMCBQ.St Joseph's Hosp DMelon QN 2027 91 2 01/23/99 07/22/99 Novick, Mark MD BK 3021 91 2 01/23/99 07/22/99 Nontop, Peter K MD QN , 2979 91 2 01/2350 07/22/99 Tobin, Kolm M.D. MN i 2926 91 2 01rJBf89 07/28/99 CMCBQ.St. John's Hosp. Div QN 2910 91 2 0358/99 Mf06ep New York Downtown Hospital MN ' 2007- 91 2 02M759 OBf0849 NYCHHC Elmhurst Hospito! QN 2670 91 2 02/07/99 08/06/09 Youn9,Iven S. MD MN l 3059 91 2 02/13/99 08/12/99 McCarthy, Joseph M.D. BK ! Total 100 l Priority OateDue noteoverdue Nome Sorough 3106 52 3 01/2857 't0G547 St. John's University QN 3086 52 3 03r3046 12/25/96 Sicheni, Merto MD BK i 3073 52 3 03r3048 12/25/98 Pelsen Technologies,Inc. MN [ 2722 52 3 0542/98 01/27/09 Dmckter, toesc MD ' MN 2082 52 3 06/0546 01/30/99 Advanced Fortsty Servions MN 2060 52 3 05/11/96 02/05/99 Modem MedselLaboratory BK 3060 52 3 05/12/96 02/0649 Proteesional Chnks! Labs MN 1555 52 3 05/16/96 02h040 Quenen Medical Lab BK 2939 52 3 05/10/96 02/13/99 HoHmmn Center For Holste Madone MN

   ,        1666             52           3      05/23/96        02n7/99 Monts Park Test Lab                                  BX 1614             52           3      06f23/96        02/17/99 Glison, Saul B                                      MN

! 1566 52 3 05/2546 ' 02f1949 Bendiner & Schinein9er inc MN 2942 52 3 06m7JD6 03/04/99 Metoposten Degneste Labs. Inc. QN 2831 52 3 06l07/96 0344/99 Bio Tech Labs Inc. BK 2651 52 3 06/0046 03/0549 Museum Of Modem Art MN 1566 52 3 06/15/98 03/12/99 NYC Medical Examiners Olnce MN 1604 52 3 06/23/96 03/2049 Oronteich Medical Group MN l 296011 52 3 07/25/96 04/21/99 NY Hosp Comeu Med Ctr MN l 3076 52 3 08/30/96 05/27/99 GenQuest MN 2719 52 3 09/0648 0643/99 CUNY- Medger Evers Conege BK 3015 52 3 09/06/98 06/D3/99 NYC Houesne Preserveton and Development.Centret Lead MN 1674 52 3 09/2646 06/2399 Singer, Joseph PC MN 2966 52 3 10/03/96 06/3049 Univ Diagnostc Lab BK l 2920 52 3 1004/96 07/01/99 Beo Chem Technology Lab. inc. MN 2911 52 3 10r25/96 07/22/99 CUNY. Brooidyn Conege BK 2975 52 3 11/21/96 08/18/90 CUNY-Queens Conege QN 128 52 3 11/23/96 0&2049 Monastore Med. Center 3X 122 52 3 11/27/98 08/24/99 Mcntenore Med. Center BX 131 52 3 11/27/96 08/24/99 Montenore Med. Center BX 120 52 3 11/27/e5 08/24/99 Montenore Med Center BX 130 52 3 11/27/u6 08/24/99 Montenore Med. Center BX l 143 52 3 11/27/96 0544/99 Montstore Med. Center BX 113 52 3 11/27/96 08/24/99 Montenore Med Center BX 110 52 3 11/2746 08/24/99 Morestore Med. Center BX 104 52 3 11/2746 08f24/99 Montenore Med. Ctr. BX 102 52 3 11/27/98- 08/24/99 Monashore Med. Center BX 114 52 3 11/27/96 08/24/99 Montenore Med. Center BX 3044 52 3 11/27/96 08f24/99 Montertore Med. Ctr BX 115 52 3 11f27/96 08/24/99 Montenore Med. Center BX 208502 52 3 11/27/96 08/24/99 Montenore Med Ctr BX 116 52 3 11/27/96 08/24/99 Montstore Med. Center BX 103 52 3 11/27/96 08/24/99 Montenore Med. Otr BX 140 52 3 11/27/96 08r24/99 Monestore Med. Center

• BX i

132 52 3 11/27/96 08/24/99 Monashore Med. Center BX l 100 52 3 11/27/96 08G4/99 Montshore Med. Center BX 123 52 3 11/27/96 08G4/99 Monestore Med. Center BX 106 52 3 11/27/98 00G4/99 Montstore Med. Ctr. BX 111 52 3 11f27/96 08f24/99 Montenere Med. Center BX 105 52 3 11f27/96 08f24/99 Montenore Med. Ctr. BX 267605 93 3 12/05/96 0801/99 Columble Presbyterten Med Ctr MN 2667 52 3 12/20/96 09/1699 Aaron Demand AIDS Reseertm Center MN ! 2006 52 3 01J03c9 09/30/99 Putsc HeeMn Reseertm inettute MN 147 52 3 01/05/99 1002/99 CUNY Hunter MN 02ti7/96

h W Due By Pitanty and By Date Due 140 52 3 014 MPB 1(WD2/99 CUNY. Hunter MN 148 52 3 0141W99 1(WO2/99 CUNY. Hunter 123 MN 52 3 0125/99 1042/99 CUNY Hunter 126 MN 52 3 01/05/99 1042/99 CUNY Hunter 156 MN 52 3 01/OtW99 itWO2/99 CUNY. Hunter Cohege MN 3031 52 3 01/05/99 1002/99 EMA Modecol Lats QN 153 52 3 01/05/99 10/02/99 CUNYh MN 139 52 3 01/05/99 1002/99 CUNYh MN 128 52 3 0145/99 1042100 CUNY Hunter MN 136 52 3 01106/99 1002/99 CUNYh MN 130 52 3 01/05 S 9 109249 CUNYh MN 3049 52 3 01/0549 1042/99 NYCDep.Heenh Bur.of Lats MN 135 52 3 01/0549 1042100 CUNY Hunter MN 134 52 3 01/OtW99 10/02/99 CUNY Hunter MN 127 52 3 01/05/99 1002/99 CUNY-Hunter MN 124 52 3 01/0!W99 1042/99 CUNY Hunter MN 131 52 3 01/0!W99 1(WO2/99 CUNY Hunter MN 133 52 3 01/0!W99 10/02/99 CUNY-Nunter MN 125 52 3 01/05/99 10/02/99 CUNY Hunter MN 142 52 3 01J06/99 1003/99 NYCHHC. Honom Hosphal Center MN 2958 52 3 02/01/99 itW2949 Levin, Amen A. MD ON Total 74 l l l l l l 02/17/98

i i l 4 J l Attachment 2 New York Programs' Comments on the Draft IMPEP Report l i i I

                                                                                                     . > , a, s   )

i l OCP

• 1 DEPARTMENT OF HEALTH L21 t III $ 2 *"**'""**""'"'*"E" g Nkit t c@su, u:o.

commissioner l tas wonTH svassr July 15,1998 Tat (atai vas sas s NsW YORK, NY 10013 FAX (ala) 964 Od7a i Richard L. Bangart, Director Office of State Programs U.S. Nuclear Regulatory Commission ' Washington, D.C. 20555 0001 l l

Dear Mr. Bangart:

< The following responses are being made by the New York City Bureau of ( Radiological Health to the IMPEP draft team report dated June 24,1998. l l '(Section 3.1.1) L 1. The software anomalies of our RAD database have been cleared up. l Management can now call up inspections due on a weckly, monthly and yearly basis, in addition to being able to ascertain which licenses have been inspected for these periods. l l 2. The initial inspection is now being scheduled when the new license is mailed l out. This is accomplished through the RAD database with a "Need (. Inspection" activation button or code. The new license is then included in the l inspections due list that is reviewed on a monthly basis by the radioactive l-

                       . materials field supervisor in charge of scheduling.

l l (Section 3.2.1)

3. As pointed out, the procedures for properly documenting violations are l'

included in our inspection procedure manual. in-services, in addition to , supervisory review, are being stepped up to ensure that inspectors are fully i aware of these procedures. A radioactive materials inspection log has been developed as an addition to the inspection forms that includes NOV # and date of hearing and results of the hearing. . 4.. The in services mentioned above will include emphasis on performance-based ratherthan compilance-based inspections. The Bureau has obtained the " Inspecting for Performance Materials" student manual from NRC which will be used as a classroom resource for the in services. The Bureau is also pursuing the feasibility ofincorporating projected training fund requirements for professional staff in upcoming fee schedule revisions. 4 g u. o ...J 3y. 1

                         .m o y         -

l

Mr. Richard L. Bancart July 15,1998 (Section 3.3.1)-

5. The Bureau has had documentation of overall policy and minimum training 4 requirements for its professional staff since the inception of the scientist i titles. (See enclosure)  !

6. The Bureau maintains an on-going Training Log for each Assistant Scientist, Scientist and Senior Scientist. This log includes all NRC courses, DOT {

courses, FEMA courses, seminars and in-house training these individuals ] participated in. Please note that there is an error on page 16 of the draft team report in section 3.3.1, first paragraph. The compliance section supervisor is the senior scientist and the field supervisor is a scientist. (Section 3.5.1)

7. The Bureau is unaware of any instance when a significant event occurring within New York City was not reported to NRC within 24 hours. Follow up documentation has been provided to Region 1 and/or Headquarters as appropriate. The NMED software has been installed in the Bureau's stand-alone PC connected to the Internet. -

(Section 4.1.1.2) 4

                                                                                                  ]

8. Bureau management and NYCDOH Office of General Counsel have been meeting to discuss upcoming rule-making requirements so that the three year time limits for adoption can be met.

We appreciate the effort that went into issuing this complicated draft'.eam report in such a timely manner. If you or the review team members have any questions, please contact Mr. Kenneth Daniel, Deputy Director, at 212/6761558. Sincerely, , /L .*/ / 4, & n o Neal L. Cohen, M.D. Commissioner enc. " Assistant Scientist (Radiation Control) Notice of Examination 11/24/82" cc: B. Mojica, M.D, A. Goldberg G. Miskin R.Berri

0 --v v~ - --- --- e o

      =         CCO;PATP.1L' nP.T*'

L*P:"ht*:'!CT P.*J"*R T0!!'1 A Dh 404 ASSISTANT SCIENTIST (RADIATION CCHTROL) ( ' EXAM. NO. 2046 l 11 CE OF EXAMINATION AMENDED NOTICE (11/24/82) l The Notice of Examination has been amended to delete the cualifying written j ( . , _ i multiple-choice test. 20: GE!I?AL PROVISIO;iS OF C*.? flOTICE OP EXAMI!'ATIO11 At;D T!'T. GCtIRAI, EXM1!NATIO!i REGULATIONS OF TFE DTSAR"TtE!*T OF PERSO!PIL AnPLY TO THIS EXA'4IHAT TE Gr*iEPAL PROVISIOUS AMD 'mE GC1ERAL PART OF THIS UOTICE OF EXA!!IMATION. EXAff2!W70N REGULATIONS ARE POSTED AND COPIES ARE AVAIIABII IN TVI SECTION OF THE DEPARTMENT OF PERSOMNCL AT 49 THottAS STREET, tid 4 YORK, N.Y. The City of flew York is an Equal Coportunity Employer. Application FILING DATES: From October 6, 1982 through October 2G, 1902.Either way, properly Forms may be filed in person or by mail. Date of receipt, cation Forms HUSTRBE _ECEIVED BY THE IAST DATE FOR FILING. rather than date of postmark, will be contro11ino. Emerience Paper Form A mus't be filled out completely and in detail and filed l with your Application. p,<. . TEST: There will be no competitive test other than an evaluation of your education and/or experience. . . . . . . . - . . . . . . - - - - - e. > sArAW AND vacAMense

                                                . the appointment sete for this position as s30,903 pes *

, annum. There are vooancies in the Department of Health, l Paployees in the title of Assistant Scientist PROMOTION OPPORTUNITIF.Ss K adiatien Centrel) are accorded promotion opportunities, when sligible, to the title of Scientist (Radiation Control). Checks or 815.00f payable when you submit your application. l FILING TEE: money orders shovid be made savable to the New York City Department of P REOUIREMF.NTS e-(a) A baccalaureate degree from an accredited college includino MINIMUM REOUIREftENTS: or supplemented by 24 credits in physics, chemistry, bioloay, engineering or a related field plus one year of full-time paid professional exnerience or radiation in the i field of health physics'; radiological health, radiation physics i d/or i

                 > hygiener or (b) a master's degree in radiological health, or (c) educat on an wperieace which is equivalent to (a) and/or (b).                                         llege send To verify course credits you will later be required to have your co us an official transcript.                                                              f applications.             ,

The minimum recruirements must be met by the last date for filing o *ile Candidates who were educated in countries other than the United fitatso mustForei form DP-404 for evaluation of foreign educatien. d ation evaluated by the Denartment of Personnel to determine comparability to e u received in domestic accredited educational' institutions. i i f d and It', at the time of appointment interview, in the judgment of the appo nt ng officer the candidate has not demonstrated sufficient A can-l

            f qualifying English oral test conducted by the Department shall not be qualified for appointment.

y , _. Ton.-.Dr.SCRIPTIOM Under munervision, performs scientific work ociatedof DUTIES AFD FT.Sn0?fSIBILITIES: moderate professional responsibility with respect to measurements ass I with radiation hvcione and safetys nerforms related work.

   .                                                                                                                     STATE OF NEW YORK DEPARTMENT OF LABOR l                                                    g                                                   DIVISION OF SAFETY AND HEALTH i                                                         Radiological Health Unit L                                          L                                                                  Building #12, Room 134-A                       '

State Office Building Campus Albany, NY 12240 55 July 27,1998 Richard L. Bangart U.S. Nuclear Regulatory Commission a 11555 Rockville Pike Rockville, Maryland 20852-2738 Dear Mr. Bangarti We have received the June 24,1998 draft report on the recent NRC evaluation of our program and have reviewed it for factual correctness, as requested. Our comments regarding the factual accuracy of specific sections of the report are attached. However, we feel that it is also both appropriate and necessary to comment on a procedural problem that was evident during the evaluation, and which figures prominently in the draft report. We found the Team Leader, Dennis Sollenberger, and his associate, Duncan White, to be highly professional in their conduct of our evaluation. They related to myself and my staff on a peer basis, and seemed quite comfortable with the concept that our policies and procedures need not be the same as NRC's in order for us to achieve equivalent or better performance outcomes: i.e., they placed primary emphasis on performance, in keeping with the new IMPEP process philosophy. However, there was one area of the evaluation where this philosophy was conspicuously lacking, and this was in the review of our sealed source and device (SS&D) evaluation program by a member of NRC's SS&D evaluation unit. For some

     -                                                                      reason, this part of the review was not only not performance-based; it seemed to deliberately ignore performance. To begin with, we were told at all three levels of exit
                                                                   . meetings for this review that the SS&D registration certificate for the only SS&D evaluation performed during the review period by our program was satisfactory, that applicable health and safety issues had been properly addressed and that our staff are l                                                                              capable, but could use more experience. In other words, our actual performance in this j                                                                              area during the review period had been satisfactory. However, we were also told that the NRC reviewer for this " performance" indicator who had spent the entire week analyzing Telephone: 518-4571202                                                                              FAX: 518-485-7406 9&o#Uaap: - @-

i

                                                                                                                                                                                )

1 July 27,1998 s f how our staff had approached this one evaluation, their first, wanted to find us unsatisfactory! , l i The reasons for his findings were incomprehensible to us at the time and remain l incomprehensible. Although the draft report modifies his findings, as a result of the team I leader's overriding opinion, it still asserts deficiencies in our SS&D program which are j [ not supported by the facts or by the specific guidelines in Management Directive (MD) 5.6, and which are inconsistent with our actual performance.  ;

                                                      ~

For example: the draft report posits as an " issue" that neither of our SS&D reviewcrs "has a strong background, through formal training and prior experience, in the area of engineering design analysis." However, nowhere in MD 5.6 is this criterion given as a requirement or even as a guideline. MD 5.6 states only that evaluation of SS&D review staffing and training should be conducted in the same manner and as part of the Common Performance Indicator 3, except with a focus on training commensurate with the conduct of the SS&D reviews. It then goes on to state that staff should have a l bachelor's degree or equivalent training in the physical and/or life sciences; should be able to understand and interpret prototype tests and results, to read and understand blueprints and drawings, and to understand and utilize basic knowledge of engineering materials and their properties - training and abilities which both of our reviewers have. MD 5.6 does not specify the means by which these abilities should be acquired, nor should it, and it most certainly does not require " formal training and prior experience, in the area of engineering design analysis." It is evident to us that a person who has had such specific " formal training and prior experience" will almost cenainly be a graduate of l an engineering program. It was equally evident during our IMPEP review that the NRC reviewer was using this criterion as his personal standard for judging our staffs technical training and experience. However, such personal preferences have no place in an objective evaluation of a program's performance. Nothing in the draft report supports a factual finding that our staff do not meet the criteria listed in MD 5.6 for SS&D review staffing and training, and we also note that our performance with regard to Common Performance Indicator 3 was found to be satisfactory. We are also at a loss to understand the statement made in the draft report that "NYDL management has not put forth the effort to bring the SS&D program in line with the specific guidelines in management Directive (MD) 5.6." We meet every single one of the indicators for satisfactory performance that are listed in MD 5.6, as evidenced by our actual satisfactory performance, and this is a result of significant effort on our part. We also disagree wholeheartedly with the report's statements that "The NYDL management does not feel that it is an efficient use of its resources to qualify and l maintain qualification for staff in a discipline that is infrequently needed", and that j "Neither staff member has any previous experience performing safety evaluations of products or similar types of evaluations, nor has worked in a related field." As stated above, our staff are " qualified" to perform the reviews in question, and they need ng be engineers in order to competently perform such reviews. Also, radioactive materials l __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

July 27,1998 licensing, and health physics in general, is most definitely a "related field." Both reviewers are experienced licensing staff who have attended NRC's training on the conduct of SS&D evaluations, and who frequently review and critique SS&D certificates in the process oflicensing companies to use sources and devices. Contrary to NRC's concept of these certificates as " approvals", we consider them simply to be sources of information, and can and do require additional safeguards during hcensing if we consider it appropriate, as do the other NYS radioactive materials licensing agencies. In one case,

                                                        .the three NYS agencies required a device to be ret'rofitted with an additional safety-feature before we even allowed NYS licensees to acquire and use it. Evaluating                                 .l radioactive sources and devices is not a separate and unique discipline; it is, and has                         !

always been, a part of radioactive materials licensing and should not be a separate and )

                                                         "non-common" performance indicator for IMPEP reviews.                                                           !

l The current IMPEP approach fails to recognize that all states and, we assume, NRC regional offices perfonn " custom" SS&D evaluations, and they all respond to incidents and accidents involving source and device product failures. Yet only state programs that conduct non-custom SS&D evaluations have their " custom" evaluations ' reviewed under IMPEP, and only they are required to evaluate the root causes of defects and incidents regarding SS&D's under IMPEP (including'SS&D's that they didn't

evaluate). This is true regardless of the relative numbers of custom or non-custom evaluations performed by a state or region, or the number of product failures involving SS&D's that they may have investigated. Therefore, a state or region that may have performed a large number of custom SS&D evaluations (but no non-custom evaluations),

and may have responded to a number of incidents involving SS&D product failures, during the IMPEP review period will not have its performance in these areas reviewed. However, the NYDL which performed one custom and one non-custom SS&D evaluation l and responded to one SS&D product failure incident during the review period, had each  ! of these three actions reviewed in exhaustive detail. This is neither fair nor equitable, and ) I it does not promote the kind of uniform evaluation of state and regional programs, which is one of the stated purposes of the IMPEP process. In summary, it appears that the SS&D portion of our program evaluation was

                                                                                                ~

conducted under the "old" rules for NRC evaluations,'not the IMPEP approach; and that conclusions were based on how closely our way of achieving satisfactory performance paralleled NRC's way, rather than on the satisfactory performance outcome itself. It also appears that the current IMPEP approach of treating a program's competence to perform source and device evaluations as a non-common performance indicator is invalid, and unfairly fails to hold all programs to the same standards.: The attachment to this letter contains our specific factual objections to statements (. made in the draft report.- However, we strongly urge that NRC management review the manner in which the SS&D component ofIMPEP evaluations is being addressed by NRC staff; and especially whether staff are placing " primary emphasis on performance" as directed. Conversations with other Agreements State programs indicate that our experience is not unique, and that the approach being used for this one performance l l

                                                                                                                                                 ._-____-_______-_-___O

l . July 27,1998 indicator during IMPEP reviews is not performance-based. NRC management should l- also review and reevaluate the practice of treating evaluations of radioactive sources and l devices, and-investigation of source and device product failures as a perfonnance j l indicator only for states that perform non-custom SS&D evaluations. This performance indicator clearly should apply to all Agreement States and NRC regional offices. I Sincerely, Rita Aldrich Principal Radiophysicist RA/fdh Enc. cc: Peter Chiefari l [

i.  !

l 1 i [. I I

July 27,1998 NYDL Comments on June 24,1998 j Draft IMPEP Report Section 3.1.2: This section discusses the reciprocity inspections performed by the NYDL, and it j states that we do not schedule reciprocity inspections consistent with any priority schedule, and goes on to say that we are focusing resources on inspection of our own licensees. However, we should have brought to the reviewers' attention the fact that in June, 1994 we reduced our reciprocity limit to thirty days in a calendar year. As a result, the companies that performed work in NYS with any frequency were required to apply for and receive s license from NYS. This resulted in the issuance of 47 out-of-state licenses, and these licensees are scheduled for inspection at the same priority interval as our in-

                                ' state licensees. Therefore, the companies we would be most concemed about, due to the scope of their operations in NYS, no longer operate under reciprocity and are inspected
                                . by this agency on a regular basis.

We would also like to make a comment on the draft report's statement that

                                  " reciprocity licensees should be inspected to assure the health and safety of both radiation workers as well as the public." Since any member of the public reading this statement might find it alarming, the statement should be deleted or appropriately qualified.
                                  " Reciprocity licensees" are inspected - by the agency that issued their license. We give reciprocity based on the understanding that such licensees are regulated by their licensing authorities as stringently as we regulate our licensees, including regular inspections by those authorities to assure that these companies operate in a manner that assures the health and safety ofradiation workers and the public. Indeed, one of the purposes of the Agreement State Program is to provide a basis for confidence in granting reciprocity. We
      ,                            require advance notification by companies wishing to enter the state under reciprocity, to
                                . afford us the opportunity to inspect their operations if we so choose. This is a matter of discretion on our part - not a responsibility. Our first obligation is the inspection of
                                . companies licensed by this agency.

NRC should also consider the resource implications of their position on inspection of reciprocity licensees. If an industrial radiography licensee is inspected annually by a state that issued their license, and in the course of a year does work under reciprocity in three other Agreement States and in NRC jurisdiction, is it an intelligent use oflimited resources to have them inspected four additional times in that year? The !i performance of reciprocity inspections is a matter that must be left to the judgment of the authority that grants reciprocity, and each authority must have the latitude to make its judgements based on its own priorities and the availability of resources. 4 4

July 27,1998 Section 3.3.2: This section states that our staffing and training will be impacted by recommendations made further on in the draft report for "significant additional training" of our SS&D staff. Since, as stated in our cover letter, our staff are almady appropriately trained, we do not expect routine ongoing trainir.g in this area to impact on staffing resources. The section also states that to be considered for a position in this program, an individual must have a bachelor's degree in science and at least one year of experience. This is incorrect in that a candidate must have three years of specific qualifying professional experience.- Also, twenty-four graduate credit hours in radiological science may be substituted for up to one year of the experience. The section also states that there is no written training policy although the program had committed in a memo to upper management to follow the recommendations of the NRC/OAS Training Working Group Report, and goes on to state that one staff member should attend an industrial radiography course and that other staff desired additional training in intemal dosimetry and the conduct of decommissioning surveys. The program is located in the NYDL's Division of Occupational Safety and Health, and all programs in the Division prepare overall training plans, annual training

         - plans and annual training and conference timelines. The report of the NRC/OAS Working Group was submitted to Division management as our program's overall training plan, and we have also submitted annual plans and timelines which are specific to the training planned for a particular year and also contain topical meetings and conferences we plan to attend. All formal training completed by program staffis documented in a computer database. On-the-job training is documented in signature cards signed by the mentoring staff person. These documents constitute our written training policies and plans.

Section 3.4.2: This section comments on an NRC review of financial assurance documents submitted by licensees, especially one case in which a document was a copy rather than the original. We have since been advised by our finance office and by counsel, that we do not need original documents but do need original signatures and that a standby trust is not required by the State of New York for surety bonds. We are continuing our review of financial assurance documents on file, but our policy on licensees that no longer need

         . financial assurance, due to changes in operations or changes made in our regulations in 1994, is to advise them of this during license renewals.

July 27,1998

.                            Section 3.5.2:

This section discusses our reponing ofincidents requiring immediate or 24-hour reponing to us by licensees, to NRC. It also states that during the review penod we made only one " summary repon" ofincidents to NRC, and describes our reponing as

                           " inconsistent."

However, of the thirteen incident files reviewed by NRC during this IMPEP, only l . four required immediate or 24-hour notification to our program by licensees under current regulations. In spite of this, five of the thirteen incidents were reported to NRC, and four of the thirteen were reported to other Agreement States having a regulatory involvement. We consido . hat quite consistent. l The " summary report" referred to was not a report of"immediate or 24-hour incidents", it was simply a printout of our computer database for all of the incidents (reponable or not) that occurred during a one year period. Periodically we receive a request from NRC for this data and are happy to provide it. We will continue to share information on incidents of concern to NRC and the states to these agencies. Section 4.1.2: This section discusses regulations that NRC desires the state to adopt or to enforce by alternate legally binding requirements. However, it focuses on a ruleniaking package that had been under review by counsel at the time of the IMPEP as the only means to accomplish this. The package has since been approved by counsel's office, which had been otherwise tied up with th: review of a number of emergency rulemakings. This section should be modified to acknowledge that the NYDL is effectively implementing the requirements in question, during the licensing and inspection of relevant facilities through the use oflicensing guides, license conditions and inspection reports and checklists. This would also make the draft report internally consistent, since . Section 2.0 closes out a recommendation from the previous review through a finding that we are implementing one of the regulations in question through licensing and inspection protocols. Section 4.2: 1 This section is a four-page discussion of our SS&D evaluation' program and the one SS&D evaluation performed since the current program manager took over the program in 1993. The staff member who had previously performed these evaluations retired early in 1994, and this unit began petitioning NRC to provide training in the conduct of these evaluations since NRC was the sole arbiter of what a satisfactory evaluation was. In September 1995, NRC did hold a training workshop on the evaluation l i

                   . -- - _ _ _ _ _ _       - _ _ _ _ -      ._                                                                              l

i July 27,1998 of SS&D's and two of our staff attended. In a follow-up letter to our Commissioner dated October 27,1995, the Director of the Office of State Programs, Richard Bangart,

                              . stated that as a result of the workshop "we believe that sufficient instruction and reference information was provided to Agreement State staff to enable them to conduct adequate SS&D evaluations." This was a reasonable statement, especially if the staffin question had good health physics backgrounds and solid radioactive materials licensing experience, which our staff did. Therefore, this combination of training, knowledge and experience constituted our qualification program for staff who would perform SS&D evaluations.

We are now being told that we must establish an elaborate program for " signature authority" for these evaluations, in a qualification program in which reviewers are to

                               " complete a sufficient number of cases which are critiqued by a qualified SS&D reviewer."

We have already commented in our cover letter that the N' RC reviewer for this indicator seemed to be comparing our program to his personal preferences rather than to

                           - something reasonably approximating the contents of MD 5.6 for this and similar indicators. We have never been asked for a similar elaborate program for " signature authority" for licensing in general (and SS&D evaluations are a part oflicensing), or for L

inspection correspondence; nor does the phrase " signature authority" have any meaning in our program. The NYDL is responsible for the actions of all Department staff while they are acting in their official capacities. It is the responsibility of the program manager to authorize staff to perform specific functions, and at what level ofindependence they may operate. For example: all current inspection staff are authorized to sign final inspection letters, only myself and one staff member are authorized to sign licenses and only two staff members are authorized to perform SS&D evaluations. Licensing actions

and SS&D evaluations also require a concurrence review and sign off by designated staff.

These concunence reviews include an independent technical review of the materials submitted by the applicant, and the' documents prepared by the initial reviewer (but not to the same level of detail as the initial review and do not involve a review of every page of the applicant's submittal) and address each area addressed in the initial review. Concurrent reviewers must make an independent determination that the documents prepared by the initial reviewer address all relevant health and safety issues, are well-supported by the material submitted by the applicant, that all regulatory requirements are met, that the draft documents are clear and complete and that it is safe and appropriate to l- . issue them in final form. Typically, a checklist is used to assist in ensuring that all L necessary topics are covered and to document the consistency of reviews. However, we g have no prohibition against collaboration between the initial and concunence reviewers, l and this is true for both licensing and SS&D actions. In the case of unusual or infrequent actions I encourage as much dialogue and collaboration as possible since we find that this

                           ~ helps to surface issues and improve our final product, as well as to provide maximum experience benefit to the reviewers. In the case of this first SS&D evaluation, the two reviewers approached it as a team effort, with the concurrence reviewer fully involved as the work progressed. However, a full concurrence review was performed; the reviewer 4

L . . . _ . _ . _ _ _ _ . _ . _ _ - . _ _ _ _ . _ . _ . - _ _ _ _ _ - - _

f July 27,1998 evaluated each area addressed during the initial review, following the same checklis: and referring back to the applicant's submittal; the reviewer focused on ensuring that the SS&D met all requirements, would not pose health or safety concerns and that the draft regist' ration certificate provided an adequate basis for licensing. This meets all the criteria in MD 5.6. Appendix F of the draft report contains specific comments by the review team on the one non-custom SS&D evaluation reviewed. Our response to each of these comments is contained in the attached memo from Clayton Bradt to myself, which itselfincludes

              - attachments.

There are also three panicular items raised in the draft report that are based on an l hours-long question and answer session conducted separately with each of our two l' reviewers by the NRC SS&D team member. One item faults the reviewers for not reviewing our draft regulations for GL manufacture and distribution during the SS&D evaluation, although it is also stated that the reviewers were aware of the relevant requirements and no specifi' eficiency is alleged to have resulted. Another item faults the concurrence reviewer because he "was not aware of the policy to review QA/QC programs during the licensing review, and assumed that the first reviewer adequately reviewed the QA/QC program." This was a matter of memory. The concurrence review was conducted several months before this interview and the reviewer did not recall that it was noted on the review checklist that the QA/QC program review was done as part of the license renewal, and he himself had not done a renewal of one of our three - manufacturing licenses. The third item faults both reviewers because they " relied heavily on the checklist in NUREG-1550 to identify specific items that should be reviewed.~..rather than using it as a guide to help identify areas that should be evaluated", and goes on to say that additional guidance documents and regulations should have been consulted "to identify specific items that must be evaluated" or addressed. We disagree with the NRC reviewer's concept of a checklist and can find no items or areas that we failed to evaluate as a result ofits use. We like the checklist, believe that il served our needs and are working on modifying it to make it even more useful. As stated earlier, we use checklists in all of our licensing activities, including SS&D evaluations, and find them very useful. We would also quote from the third paragraph of Section 4.2 of the draft report, which states " Staff uses the checklist from NUREG-1550 to assist in the review of SS&D's, and help ensure that all pertinent issues are addressed." That is

              ; correct.

f t

4 4 NYSDOL Division ofSafety& Health L Memo-L To:- Rita Akhich From: Clayton Bradt Date: 07/23/98 Re: P-~ to IMPEP Draft Report Appendix F of the Draft IMPEP Report contains speedic comments from the renew team relating to Scaled Source and Device Reviews. Each of these comments is listed below with my me following.

                             . a)       The detmananon ofseatis anaderrdtanper rristant erurs sw kft to the qopkast.
                              'Ihis is not accurate. The applicant = yin A the type of screws to be used in the drawings sohmin A, and a prototype device was also pnmded. 'Ibe restwer concurred with the applicant's determination that the screws were tamper resistant. It is our und-tandhg that the IMPEP team also concurred that these screws were,indeed, tamper resistant.

b) Appicant nas not trque.dedk idenap the anddons ofua under m%b the deshe souldbe sad The applicant stated in the application that the device was " ...normally placed in an atmospheric pressure air stream so that air flow delivers .the generated ions to the work area." This was interpreted (cc,s%) by the renewer to mean that the device wouki be exposed only emironments suitable for human occupancy. c) Cernfunte Smits the andson ofun to an and$ned "edrwne andnon" and not on a knome at of. anstions, ah attheANSIhef" Under "ConAidans of Narm*1 Use" SS&D Registry Sheet No. NY 0502 D 110 G (see attached) states: "The device is normaDy placed in an atmospheric pressure air stream so.that the airflow delivers ions generated by the dence to the work area." Under "Timiestions and/or other candidana of Use" it states that the devices are not intended for use in extreme environments. Taken together these two statements, along with the description of the dence and its ANSI A=- Leion (both of which are included on the sheet), prende adequate information for a license renewer to detemune whether a proposed application .of the device poses an unwarranted L radiation hazard. This, after all,is the purpose of the registry sheet. l-I l 1..

Cv- this with SS&D Registry' Sheet No. NR 504 D 807 G (see attacimi). This is for a density gauge containing up to 2.5 cudes of Cs-137. Under "Crediens of Nnemal Use" it states:

                                                     "Ibese dences are intended for use in munitions phnts where 6res and -=6aa= are possible.
                                                     'Ibese dences would not typicany be subjected to corrosive or eaa a, abrasne aw-:-y- = ="

And under "E !=*-m anA/or Oth-c Cnn=iA-men < of Use" no further information about the dence's use condinons is pronded. In addition, the mand emner was not even required to submit prototype testing information on this dence! Also compare SS&D Registry Sheet No. NR 504 D 803 S (see attached). His is for a source holder containmg a maxunum of 2.66 cunes of Co-60. Under "ConAiens of Nncmal Use" it states: "h source holder was intended to be able to be instaDed in a vadety of dences in a variety of iae Mal applications." No =AAiea=1 information on the environmental conditions under which this device can be safely used is pronded soywhere in the sheet. Also, a with the above deaany gauge, no prototype testing was required. It is difficult to understand how a device as innocuous as the subject static chmmator requaes such specific information as to its intended use conditions, while two potentially lethal devices require so liede. d) The matmals ofmunmaar andmethadr of_m%tpranalamepnents ser at spea)ial His is too non-spec 2fic to aBow a response. h relevant question is whether the safety of the device was compromised by these aBeged oversights. e) The nabtfuy andduminity oflabelt ser not merud

                                                    %e prototype model submitted had an appropriate and visible hbel, and the drawings submuted reflected this a well. Since, by license condition, these desces are only distributed under a 12-month lease agreement (see also the reference to the 12-moeth lease agreement under "I. imitations and/or Other Conditions of Use"), the durability of the labelis not an issue.

f) The oppkant Ed atpersdej-V-fora leak kstfmysemygrater tlar 6 months.

                                                    & Po-210 foil source used i 1 this device had previously been approved for 13 month leak test intervals. & renewer saw no basis to consider a stricter interval for this pamcuhr device, nor did the NRC renewer suggest one.

g) The appkant Ed atpmside dox sanarios and moundng insomunspr the premt hawsers indauing the desia.

                                                                                                                                                                          .l Mounting insuuctions, ine14ng Aiagmm, are included in the instruction manual provided to general licensees. nese were included in the application and reviewed by the reviewer. Scenarios                        -

for doses to workers under worst-case and normal use conditions were submitted by the l applicant. nese were reviewed and the results confinned by inA*panA-at calcuhtions by the reviewer. 2-l 4 m _ _-__-_E._________.--_ _ _ _ _ _ _ _ _ _ - . . _ _ . . _ . . - - 4

b) Tk quaEg asamar andquaEg arntm/pnaders adersned1 9 the 4pp6amt am not manwd l

                                                              & applicant's quality assurance and quahry control procedures were reviewed during the l                                                              lic-a ing review process. It is an unwarranted waste of resources to repeat the renew during the l                                                              SS&D evaluation.

i) The krnm's urspann to a dje aeng rrquen orgarding the mst minemWe afax of the dnht aus ad adgana. L We disagree. h applicant's response was adequate and reasonable. J & sd natpnnade kawwaluse data e sapport dain orgmEng the lack ofinjury a-a& md%ullad"rri bre can be no historical record of things which did not happen. What would the applicant have prended? The applicant has been a DOL heensee for decadea, and is required to report nAnlagiemi incidents involving their dences to the Department. If there were a history ofinjuries or signine=at adalagie*I failure, the Dpsnt would already have the mformation. In fact, there is no history ofincidents involving the failure of meni1=r devices, or ofinjuries caused by them. k) Inpreadon antainedin tue htters ner at r)renadin the arnfante but nar Eutedin the de-den ansdon ofthe same, nas not aamteh rrfatedin the araficate.

                                                            'Ihis is unclear. Please specify what letters are being referenced and how the infonnation not       l reflected accurately in the certi6cate compromises radiation safety.

I) The senEng ofthe leak k.dng rrgarronentin the irrnjcate awidleadto nrianterprrtad n.

                                                            'Ihe subject wording is: " Units should be retumed to the manufacturer for leak testing at intervals not to exceed 13 months. This will be accomplished under terms of a 12-month lease agreement between the manufacturer and the general heen ee."                  It is unclear how this could be misinterpreted in such a way as to compromise safety.

m) The dmaings ofthe deirs naponents Ed not antam klemnaprallanrponents

                                                            'Ihe missing tolerances do not compromise the safety of the device given its design and intended use, and the fact that it has no moving parts.

I I

                                                                                                       )

I l REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE HQI NY 0502 D 110 G DM: December 31,1997 PAGE 1 OF 5 ) DEVICE TYPE: Static Eliminator MODEL: Nuclecel Ionizer Model P-2063 DISTRIBUTOR: NRD Inc. (formerly Nuclear Radiation Development, Inc.) 2937 Alt Boulevard GrandIsland,NewYork 14072 MANUFACTURER: NRD Inc. (formerly Nuclear Radiation Development, Inc.) 2937 Alt Boulevard GrandIsland,NewYork 14072

      ,'     - SEALED SOURCE MODEL DESIGNATION:                 NRD Model P-001 ISOTOPE:                                          MAXIMUM ACTIVITY:

Polonium - 210 31.5 millicuries (1.17 GBq) LEAK TEST FREOUENCY: 13 months PRINCIPAL USE: (O) Ion Generators, Static Eliminators CUSTOM DEVICE: YES X NO f _ __[

l

                                                                                               ~

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE HQ; NY 0502 D 110 G M: December 31,1997 PAGE 2 OF 5 DEVICE TYPE: Static Eliminator 1 DESCRIPTION: The P-2063 consists of a stainless steel cylindrical grid wrapped with a polonium foil source. The foil is secured around the cylinder with tape and covered by a sainless steel strap for protection from physical abuse. The cylinder is protected from crushing by aluminum plates at each end. Access to the interior of the cylinder is prevented by wire guards, fastened in place by tamper resistant screws. There is no access to the radioactive foil unless the assembly is intentionally tampered with or destroyed. LABELING: All devices are labeled in compliance with 10 CFR 32.51. (See diagram in Attachment 2.) DIAGRAM: See Attachments I through 5. CONDITIONS OF NORMAL USE:

                                         - The purpose of the Model P-2063 is to neutralize static electrical charges in static sensitive operations. The device is normally placed in an atmospheric pressure air stream so that the airflow delivers ions generated by the device to the work area. Types of users include
                                         - manufacturers of electronic devices, aircraft, cloth, plastic, paper, rocket engines, powders,    t J

l l etc.. Installation is simple and is done by the general licensee, in accordance with instructions provided by the manufacturer (See diagram in Attachment 3.) The useful life of the Model P-2063 is 12 months. The devices are distributed by the L manufacturer under a 12 month lease agreement. i t t-

5ee L l REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE EQ1 NY 0502 D 110 G DATE: December 31,1997 PAGE 3 OF 5 DEVICE TYPE: Static Eliminator i PROTOTYPE TESTING: Prototype testing was perfonned by the manufacturer in accordance with ANSI N542 and 150-2919. The respective classifications for the source-device combination are ANSI 77C22222 and ISO /C22222. EXTERNAL RADIATION LEVELS: Polonium-210 decays almost exclusively by alpha emission, although there is one very low abundance (0.0011%) 0.803 MeV gamma. Extemal exposure rates are therefore minirnal. The manufacturer has measured these using a calibrated sodium iodide detector / multichannel analyzer system, and found the exposure rate at 6 inches from the source to be less than 5 microroentgens per hour. (See radiation profiles, Attachments 4 and 5.) I OUALITY ASSURANCE AND CONTROL:

  -             The manufacturer maintains a Quality Assurance program adequate for licensing purposes.

Outgoing units are 100% inspected for defects in workmanship, functionality, and radioactive leakage. LIh0TATIONS AND/OR OTHER CONDITIONS OF USE:

• The Model P-2063 may be distributed to persons generally licensed pursuant to 12 NYCRR 38, Section 38.41, Table 3, Item (b), or equivalent provisions of the UShTC or an Agreement State.

e These devices are not intended for use in extreme environments.

• Units should be retumed to the manufacturer for leak testing at intervals not to exceed 13 l months. This will be accomplished under the tenns of a 12-month lease agreement I

I between the manufacturer and the general licensee.

1

1

      .                                                                                                  j l

l REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE l EQI NY 0502 D 110 G M: December 31,1997 PAGE 4 OF 5 DEVICE TYPE: . Static Elirninstar LIMITATIONS AND/OR OTHER CONDITIONS OF USE:

• This registration sheet and the information contained in the references shall not be changed without written consent of the New York State Department of Labor.

SAFETY ANALYSIS

SUMMARY

Based on our review of the information submitted and test data cited below, we conclude that NRD, Inc. has submitted sufficient information to provide reasonable assurance that:

e. The device can be safely operated by persons having no training in radiological protection.

• Under ordinary conditions of handling, storage, and use of the device, the radioactive . l material contained in the device will not be released or inadvertently removed from the device, and it is unlikely that any person will receive in 1 year a dose in excess of 10 percent of the annual limits specified in Section 20.1201(a), of 10 CFR 20.

        . - Under accident conditions associated with handling, storage and use of the device, it is
            - unlikely that any person would receive an external radiation dose or dose commitment in excess of the dose to the appropriate organ as specified in the table below:

Part of Body Dose (rem /Sv) Whole body; head and trunk; active blood forming i organs; gonads; orlens of eye 15 / 0.15 Hands and forearms; feet and ankles; localized areas - of skin averaged over areas no larger than 1 square centimeter 200/ 2.0 l Other organs 50/0.5 L I-

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETYEVALUATION OF DEVICE N_Q; NY 0502 D 110 0 DATE: December 31,1997 PAGE 5 OF 5 DEVICE TYPE: Static Eliminator ' SAFETY ANALYSIS

SUMMARY

e - Thousands ofsimilar devices containing P-001 foils have been in use for decades th no reports ofinjury or significant radiological misadventure. We conclude that the Model P-2063 will perform at the same level of safety.

REFERENCES:

The following supporting documents are hereby incorporated by reference and made part of

                                                                     ^

this registry document.

• NRD, Inc. Manufacturing and Testing Protocol for the Nuclecel Ionizer Model P-2063, dated October 15,1995, revised June 11,1997.
• NRD, Inc. letter dated June 11,1997.

ISSUING AGENCY: State ofNew York Department of Labor

                                                                          '-        u Date:    December 31.1997             Reviewer:        I     76             G t

CTayton J{ Brac Date: __ December 31.1997 Concurrence: /Et l Desmdnd C. Ocirdon u____--------______

L REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE DAIE: December 31,1997 Attachment I HQ: NY 0502 D 110 G

                                                                                        - en-                                                                                                    b.. . w F Ii i i                      aM 6.

g. T '==.~~

                                                                                                              * = st'-=~
                                                                                                                                                                                                   ~>

1 / t

                                                                                 ...(       l e                                                                                  '/.-                                        /
                                           .                        v  w.             .

4 . /./ 1 , s g g . j' .#  ! ds- /,

                                                                                                                                                       .y./
                                                                                                                                                                          .       $s.s..                            \ '

k .. / ./ s \<'8. , < * . un m.a - a g*'.,..,/ s., s.

                                                                                                                                                                                                   'y ,s:

Ef*,,'d,5$ . d',> ,.'

                                                                                                                                                                                                               = .r -

If

                                       . .s-= . .                                                                                                           T

('?

                                                                  , /'

j' / z.'s..> _ ,/f.s J( s.

                                                                                                                                                           /
                                                                                                                                                                                    /

vf. .

s. s.- .k'/-

                                                                                                                                                                                */

fV k .s .' c s. .

: l31~.  ;%!.W

                                                          . ' s. -     .                                '.>                                                     ./.                   ,          .   -                        . . , -
                                                                                                                                                                                                     "d' L"                 ;Q
                                                                                                                         , . " s. ss -

fi

                                                                                                  /                                                                                                  w                        ~

6(

                                                                                                                                                                                                 >          .c

c. s. , >

                                                                                      ./                        ,,..
                                                                                                                                                                                        .                 . . . .           i .,. _

s.s (

• l

                                                                      ,W                      ,/
                                                                                                                                                    *%lU^?'. ".".'"
                                                                                                                                                                          %G-?h                .

N R O == m._

j. .

                                                                                      /                                                             'E ~e*

s

                                                                                                                                                                    ~'"

uccet e.nu asscuco V- -

                                                                                 /                                                                  - . ,
                                                                                                                                                                          * * "                                                       i
                                                                           '                                                                             C0NOT
                                                                                                                                                                                                     ==-i
                                                                                                                                                                      "" h b Cla.l"" l" e4cio4 l~_         l SCALE PRINT u

NUCLECEL MODEL P-2063

   .                                                                                                                                                                                                                                      ')

i

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE F.Q.; NY 0502 D 110 G M: December 31,1997 Attachment 2 l i i I. arwsms age Onet goet l ggca,.go. ,,,.d CA I Ca l l l t' i l SOCR LCTTCRING ON BLACK SACxCRouNO WACCNfA LCTTCRINC ON YCLLow BACxCROUNO

                                              \                                                         /      \

i _- . i , c. 1ON CELL . ..A.. .. . W_ - - -...

                                                                                                                          - ,, .=~. -._ :.:. w 2::._ : 2 e::.::
                                                                                                                                          ,                                     .                          =.
                                                                                                                                                                                                                         =c c=.      0.sJ
                                                                                                                 - -  =..   ._.:-=:.-                                         - :  _    :.a     - 4    6 i
                                                                                                ..,        o
                                             .eman . - =r                                                   w v=.=-e._.:=...:..--=_....
                               -                                                                                           a .                                                   u_ _                                        .. == 1 m _m_.                                            ,

ai x . . l SILvCR WINOOwS SOCR LCTfCRINC ON ta vt it tun <in it 1/ ti, w N0fCS:

1. MATCRIAL: 0.003 fMICK uYLAR CR 0.002 ALUMfNUM 8A$C wtTH 0.001 WYLAR CvCALAY

2. tjeCL fo MAvC A PRC$$uRC SCN$lffvt ACHC$1vC 8ACXfNC.

J. OlWCNSIONS ARC IN INCNC$ UNLC$$ OTMCRW!!C $PCC:ffC3.

                                                                                                                                                   ,,.n.-.....                       s.c **.vnt s     c4i( .
                                                                                                                                                       - . . - . . = _ e ov.-.                       .%               , _ N1D p_, ,                             l 7*"**' 
                                                                                                                                                     , , , , , , ,                *g*                          m.r er ame.no ena.e ex . oaa .an
                                                                                                                                                     >==.-*a                                                                               LAEEL

_d" * ' ' . 7a' c.t muci.e., F0t MCOEL P-20G3 *

                                                                                                                                                                                                             * * ' ' ' '    5"  orts CONOT SCALE PRINT B Iw" . (L l~ ' 9580;'7 i"9 LABEL l

i-i L__ _ ___ _ _ _ _ __

I t REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OFDEVICE FLQ.; NY 0502 D 110 G p_aIE: December 31,1997 Attachment 3 l l P-2063 NUCLECEL IONIZER MR FLCM

                                     .   ~

Y y' 'f 1

                                 %tt          %

i

                                             ^- *= c !
                                                  $2        i
                                            ~,

xg / a

• g~ & *

                                                          \

m t l 4 I l TYFACAL MOUNTING PLATE ( 4

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES ! SAFETY EVALUATION OF DEVICE l HQ: NY 0502 D I10 0 DATE: December 31,1997 Attachment 4 P-2036 Gamma Radiation Profile Exposure Rate = 0.005 mR/hr 90'

                                                                                                                 #,,                               --j- ~~,,
                                                                                                       ,#                                                                       l                                     ~%
                                                                                                    '                                                                      4-                                                    %
                                                                                      -                                                                                                                                              s
                                                                                 /                               's#,-                                                                                     ,%

s  % 135*/ - l '% s 'sA45'

                                                                  ,s/                    ,/                                                                                    :
                                                                                                                                                                                                ~~,*% %                         s
                                                                                                                                                                                                                                   \

N /

                                                                                                                                                                                                                                              / \

l \/ s'

                                                                                                                     #                                                         [

y s

                                                                                                                                                                                                                            \

( \

                                                                                                                                                                                                                                                          \
                                                      /
                                                          /
                                                                      /

f g

                                                                                    /\

v f'

                                                                                                               /
                                                                                                                    /,- "~g'%                                                 l
                                                                                                                                                                                                            's %              g</
                                                                                                                                                                                                                              / \
                                                                                                                                                                                                                                                 \

g g

                                                    /             /
                                                                                /                     \ /                                                                                                             \ /               \                              \78 f

j f

                                                                              /                      j g
                                                                                                        ^              y ' , k =l % 's _                                                                             f g
                                                                                                                                                                                                                        ^                 \
                                                                                                                                                                                                                                                                        \
                                                                            #                                                                                                                                                 \                 5"R       \
                                              /             /

j / ,% , g g g g

                                             #            I             /
                                                                                        /
                                                                                                             /                                                                                                        \           \             \              \            \

l I y

                                                                                     /

f c

                                                                                                                                                                                                                        \3* R y                   g              \           \

l I  ; / j y  ;, t 1 l l I , I ., g g i l 1

                     , J _ _L _4_ _ L _ _'g_ A _ __                                                                                                                                                         -- -l_ - i - - r --j--i c-I            I                          '                                t'
                                                      \
                                                                   \
                                                                                 \
                                                                                                       \                                                                                                                  I           I            I              I           I I                                                               \                                                                                                                                         I              I           I
                                                      \
                                                                  '\              \                                                                                                                                      /           I
                                         \                           \                                    \                                                                                                            /           /             /              I           I
                                          \             \              \-           \                       %                                                                                                        /           /             /              /            /
                                            \         ~I                                                      f'M                                                                                                              /             /             /              /
                                                                        \                  g
                                             \             \                                                                                                                                                                 /
                                               \
                                                \
                                                             \
                                                               \
                                                                          \
                                                                            \
                                                                              \
                                                                                                    \

g / f A4 s s*-4 I

                                                                                                                                                                                              ",e'                 f
                                                                                                                                                                                                                           /
                                                                                                                                                                                                                           \         /
                                                                                                                                                                                                                                         /
                                                                                                                                                                                                                                           /
                                                                                                                                                                                                                                                     /
                                                                                                                                                                                                                                                       /
                                                                                                                                                                                                                                                         /
                                                                                                                                                                                                                                                                     /
                                                                                                                                                                                                                                                                       /
                                                                                                                                                                                                                                                                         /          '
                                                  \              \               \                               g                                                          i                                   /             \ /                 /                /
                                                    \
                                                                   \            / g
                                                                                     >/                              %
                                                                                                                         %                                                  l                    *,s'                          ^

f g

                                                                                                                                                                                                                                           /
                                                                                                                                                                                                                                               /               /
                                                      \                                              y                                          ~~_                                                                      s,                                /
                                                                                                         \                                                                  '                                        #
                                                          \                                                                                                                                                                                            /
                                                             \

j\ g g

                                                                                                                 %                                                         I                                  /

f f N \ /

                                                                \ #                 %                                 '*._l,"'                                                                                                /                  >                                                  !

225'g % s 1

                                                                                                                                                                                                                      /                   '/     315*

i - s  %~~~ _,,,**#- ,/ j #

                                                                                                             * ,~                                                 ,.

2 7C' l Horizental axis survey. l 1 l

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETYEVALUATION OF DEVICE

                                                                                                                                                                                                                                         ~

EQ.; NY 0502 D 110 G p.6H: December 31,1997 Attachment 5 P-2036 Gamma Radiation Profile Exposure Rate = 0.005 mR/hr e 90'

                                                                                            ,s*,                           l
                                                                                                                                                                  .,,' ~ ,'
                                                                                    -                                      i                                                                                  's %
                                                                                                                  ===                                 m
                                                                ,/-                             s#,,                                                                         ~%                                              %
                                                            /
                                                                                                                          !                                                                         N             s             's 45*

135'f ,/ s A

                                             /

AN /

                                                                                                /

s' I- ,*% % N N/

                                                                                                                                                                                                                                  / \
                                                                                                                                                                                                                                              \
                                          /                N/                              /                              I                                                                                %                 /\
                                       /                                             j
                                                                                       '               ,o**"*-            .                                                                                              / \
                                                        /                                                                                                                                                                            \

Y f' l 's % g

                                 /
                                   /
                                                /
                                                    /
                                                                   /\                          /                          .                                                                                        /<\ \               \
                                                                                                                                                                                                                                           \
                               /              /
                                                               /                      \/

j ,-, \[ \ l  % /\ l / , / \ s' , . s/ \ \ $ \

                          /               /                                   /                 N/              rs=m1                                                              /g N
                                                                                                                                                                                                                     \                           \             \

f f

                                                         /                                      /N               Q                 i
                                                       /
                                                                    'f
                                                                                             /      \            l.;; i G.,                                         /
                                                                                                                                                                                                       \               \                           \             \

I s l I

• l'ie / / \

                                                     .                                                                                                                                                                                                      -     1 f              f                            f
                                                                                           /

s' .. \

                                                                                                                                                                                                              \
                                                                                                                                                                                                                         \
                                                                                                                                                                                                                          '                          I I                     j I                        C
                                                                                                                         $h'                                                                                                                                        ',

I l ' p 'e

                                                                                                                                         /

I I- .

                                                                                                                                                                                                                                       )              I I

3 3 c. - _t- - . I i I l-_c-'_-----.kg,w,:-----,'--j-- L - '- - j c' I I l

                  .g g-                     1                                 1 k.s                                                                                 /           I                          J g
                                                                                        \                                                                                                                                 /                          I             I
                                                                                                        / /lD': IF                            s                                                               /

I I \ I / / / I g g g

                                                                                            \       /

f lh

k. i j.hl  :.

Ng \ / / / / I x '

                         \               \                             \                        p'              {pamh                                                              Y                              j            ,

l j ,I

                            \              \
                                                            \                               /         %                                             ,

s / / / p

                                             \                                                               *'" w           == "ta                                                                                        /

j N *, q

                              \                               \                                                                                                                                   j             %                         /              /
                                \              \                 \                           N g                                                                                     p                           \/                 /                7
                                  \              \                  >/\                             %
                                                                                                                                                                             #                                      A              /                l
                                     \
                                                     \           /                    y               ~~~~                                                                                                    ,'                /               ,
                                        \
                                                          ,(s                            '%                              -

p

                                                                                                                                                                                                       -                  ,'A                /
                                            \
                                              \

4

                                                      ,             N g
                                                                                                  ~~'-                   ,
                                                                                                                                              .a ** ~s" p j
                                                                                                                                                                                                                   /
                                                                                                                                                                                                                      -           s /
                                                                                                                                                                                                                                  / 315'
                                          .44. b. g y                                                                    ?                                                                                                  ,/                                           \

s

                                                                                          %,~'m.__                                              **',s                                                                  /                                                 \
                                                                      %g                                                 s s
                                                                                                                                                                                                            ,/,
                                                                                         ~                               .
                                                                                                  %                                                                      ,es #                    s.
                                                                                                       **em,,.'e                                 .se         "                               /            ,%

O d I-l Ve:tical axis survey. I r l 1 l

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATIOJ OF DEVICE 9 EQ,1 NR-504-D-807-G DATE: September 28, 1995 PAGE 1 OF 5 DEVICE TYPE: Density Gauge MODEL: PLG-2 MANUFACTURER / DISTRIBUTOR: Nuclear Research Corporation 125 Titus Avenue Warrington, PA 18976 SEALED SOURCE MODEL DESIGNATION: Nuclear-Chicago Model 850233 3M Model 4P6E ISOTOPE: MAXIMUM ACTIVITY: Cesium-137 2.5 curies (92.5 GBq) l l I I LEAK TEST FREOUENCY: 6 Months

                                                                                             ~
                                                                                                   ~

PRINCIPAL USE: (D) Gamma Gauge CUSTOM DEVICE: YES X NO 49W+cVH % Spf

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE Ehl,NR-504-D-807-G DATE: September 28, 1995 PAGE 3 OF 5 DEVICE TYPE: Dcnsity Gauge LABELING: The manufacturer indicated the devices are labeled in accordance with Section 32.51, 10 CFR Part 32 requirements for devices generally licensed at the time of distribution. CONDITIONS OF NORMAL USE; These devices are intended for use in munitions plants where fires and explosions are possible. These devices would not typically be subjected to corrosive or excessively abrasive atmospheres. PROTOTYPE TESTING: These devices were manufactured and distributed under a specific license issued to the Industrial Nucleonics (Accuray) since 1969. Nuclear Research Corp. and the manufacturer did not supply prototype testing for these devices, but rather, relied on the design, construction, material selection and past historical use data of the model PLG-1 devices for assurance of the integrity of the device. EXTERNAL RADIATION LEVELS: ,

       -When loaded with maximum activity, radiation levels on the surface of the source holder do not exceed 8.5 mR/hr (85 ySv/hr),
       .and at 12" (30.5 cm) from the surface are less than 5 mR/hr (50 ySv/hr) with the source fully shielded. The plastic shield keeps personnel from placing their hands in the primary beam when the source is exposed.

QUALITY ASSURANCE AND CONTROL: Nuclear Research Corporation did not supply quality assurance and control information for these devices. The devices were originally approved for distribution by Industial Nucleonics (Accuray) under an Atomic Energy commission specific license. Nuclear Research Corporation assumed all responsibility for these devices in 1984. L_

i

 =     .

i REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE l i l EL,1,NR-504-D-807-G DATfd September 28, 1995 PAGE 5 OF 5 i DEVICE TYPE: Density Gauge ISSUING AGENCY: U.S. Nuclear Regulatory commission Date: Sentember 28. 1995 Reviewer: b Dougfas A. Broaddus Sectember 28, 1995 \ Date: Concurrence: l

                                                  ,      Steven L.'Baggett      I L

r e 4

{ - REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE EQ.a.i. NR-5 04 -D-8 07-G DATE: September 28, 1995 ATTACHMENT 1 au-mm sc.%. 4%Vxx wisias A4%w<<a l$ 1 V/////AMnMM W RR

                                                                                                                                            ~

9, seeveu n.s- Y. A y/(/Qf ym

                                             ' ". TacYeo"u"*,'?E                                                                 _

w - . s -- CIE acuace

                                                                                                                        @ Tweesstew j

o , p - s -

                                                                                                              ..    ,           = . = , - .

g'i-_ d., ll I A  ! wQ t ir r / l_yf,J\ '- - - ;j . . . . , 4 .. _ _ _ _ _ _

                                                                        /-
                                                                                                                        ~'....,l
                                                                                                                                  = *o**      l _" '

SoustCC HOLOCR ASalMELY AuToadATIC SmuTTER quo 7s l 4

   .                                                                                                                                                                                                      l REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE l

EQ 1,NR-504-D-807-G DATE: September 28, 1995 ATTACHMENT 2 l

                                                                                                 '           l      ,s t ese es.s a.              , g ;a e amm veAvte.

1 J. l rl = %. l 4ll I. _ _r - - - p e ---[-- _-,\1 .  ; 5 I l 4.. ..t ~ '-- ,l I e i ;'

                                                                             ^-                                                                                                     '^~

i r - - - - i. _ _. . r-j lli -

                                                                                                                                                                                \

N j ' i=..' - - Y q.4_

w. .1F.~ $w' + b A i &s 4

3 8

                                                                                                               .s   s s s s     s    s s s s              s       .s     .

i A ._ _ .z-- F -

F, - -.c-. I -

                                                                                                                                          .l.                   /_                              -

a i- ir _ ,_j. --- I -- " I

                                                                          *m-e

[ t..__. g- U N. t Adh

                                                                                                . ,r . _                                                             r to     eens aseenpdv I

s e, sses a sunmose ] l j I

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES

    ,                                                                                                                                              SAFETY EVALUATION OF DEVICE EQa.l. NR-504-D-803-S                                                                                                               DATE: September 28, 1995      PAGE 1 OF 4 DEVICE TYPE:                                                                                    Source Holder MODEL;.               S-4 MANUFACTURER / DISTRIBUTOR                                                                                                                Nuclear Research Corporation 125 Titus Avenue Warrington,   PA  18976 SEALED SO'URCE MODEL DESIGN 7. TION:                                                                                                           Nuclear Research Corp. SC-9 ISOTOPE:                                                                                                                                       MAXIMUM ACTIVITY:

Cobalt-60 2.66 curies (98.4 GBq) LEAK TEST FREOUENCY: 6 Months .

                                                                                                                                                                                                     ~

PRINCIPAL USE: (D) Gamma Gauge - CUSTOM DEVICE: YES X No cCfr/+/ 6 o/35- 7N -

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE EQ i. NR-504-D-803-S DATEL September 28, 1995 PAGE 3 OF 4 DEVICE TYPE: Source Holder PROTOTYPE.TE1 TING.i These devices were manufactured and distributed under an Atomic Energy Commission specific license by the Nuclear Research Corporation since 1963. The manufacturer did not supply

        . prototype testing for these devices, but rather, reliad on the design, construction, and material selection for assurance of the integrity of the device.

EXTERNAL RADIATION LEVELS: The manufacturer provided a radiation profile of the source holder containing the maximum activity in the "off" position. This profile indicates a maximum radiation level of approximately 9 mR/hr (0.9 mSv) at 12" from the device. OUALITY ASSURANCE AND CONTROL: . Nuclear Research Corporation did not supply quality assurance and control information for-these_ devices. The devices were approved for distribution by Nuclear Research Corp under an Atomic Energy Commission specific license in 1963.  ! LIMITATIONS AND/OR OTHER CONSIDERATIONS OF USE:

                                                                                 ~
              . The source holder is to be used only by persons specifically
                . licensed by the NRC or an Agreement State.

Handling, storage, use, transfer, and disposal: To be determined by the licensing authority. The source holder shall be leak tested at intervals not to , exceed 6 months using techniques capable of detecting

0.005 microcurie (185 Bq) of removable contamination. { l l j i + This registration sheet and the information contained within 1 the references shall not be changed without the written -

consent of the NRC.

                                                                                   )

l REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE EQ.r.J. NR-5 04 -D-8 0 3 -S DATE: September 28, 1995 ATT7sCHMENT 1 l se 9 l i 1,

                                  .,e.'.'t.2 g.; .
                                       .E'4'
                      }               .p,.-
                           . . . .           *d-
             . . . ;a

' ~~

7

                                                           .1,:.

e

y. .

• 1 .

                                                                                                                                   .:4-                6,. WS *.
               ;                         .%-                                    '~                                                  -: -

[Oi,.e . ' *W '*;.- 'C' , syy,q.5r,~- cL. L.: '

                                                        *hj ,. . L.,3j             T
                                                                                                                                  , 'l;,q.         :

U.  ::i;@r M.

             ...;,.y..N*.v?:'yL,f.7-                    .*
                                                                                                                                 '#' '             ., &- m .Q .,
                        '                                        -          :p .                -

g  ; . WR - '

                                                                                 *)~4%s?-%,n j

b ;. .

g .w k;=y.;.n.:g.

a. -5

                                                                                                                                                                         ;.*j.

Li- $1?~ y

          @!@;6g3R'W^pf -                                                 g__ _ $"NlE.                                        "                =.--      -M

m. cen.

r. s.1.v - F'p[

                                                                                                                                                                         .;v-4.'$ ' ' '

g.k/[.,'[4 1

                                                                                                                                                                      ..-$. . ' .I O ..y .,.,. N.. W,.5'-

25 ., p.-l. ElCN.,,i*..:. h>.

                                                                                       ...        .g ..l.
                                                                                                                                                                      ;.y7-
         .$p.W.7.9 9;$.j.,.      .
                                                                   -&                n-l. '<.' .:       -

9.u$

                                                                                                      -                                                                 %E Q:g.7.      .
                       . .i
                   . . * . e%p.                                                                                                                                          .*

g 4%. ,.:t M w

                                . .;;; 9                                                                                                                                       ;.

s

          .. ..; ,, u                      .,

w. w.

        ,..,,.     .. a ... .w..                        .        ...
        .r          .c            at;,               + s 2 7*.,Q                                                                               .

i j *. -*

                                          . . ,. ; y'   ."s .~ : .f *.,. g ,'. ' t,          ..                    - -                                                     .

I

        .i. .di .dGh. is%'G ..

I \ s na n..

                                                            . a.nr ,          ,          s-4 nuu w a                           ,    u-n-.~ r       . a.s. n a m

REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE ' EQ., t. NR-504-D-8 03-S DATE: September 28, 1995 ATTACHMENT 2 l

                                                                                 $             .$ ?

I . , ."* l

                                                                                 ,.                                                                                                                                                             l
                                                                              .\                l                                                                        -

m m ,.mw _ - y.. ...-----4 .. E 'f l a( - N ^ , , s / E ,' ) .

k. l h' $ '

b.?

                                     .s
                                             . v*

fi l i W, i

                           . t'      i f,

i

                                                           .~                                                     ,                               <,                                 ,                                  .

{Q'<*'. \ '$,7- ' 5 hI '

                    .        .,        s  c
                                               ,/. .j     ,
                                                                                                                                                       ,                             l hk',. ,                                     '

l

s. ' t

                                                    .i sy)' 7                                            ,                    ,,
                                                                                                      ^                     '
                                                                                                                                   ,,.3                ,:
                                                                                                                                                       ' t                           '
                                                                                      'w , %y' '< fy s .          $Qf,.y',Q
                                                                                                , 1                                                   .. ;
                                                           .        i,,                                                                   .                                                                                               ,,

1 t> .:

                                               , .'/ >
                                                                              ..' /. > y };,;
                                                                                        .                                     ..                          1.                         -

n

• l,' / , .

                                                                        ',              "(.

j p :; ,.'Y;'. ' fff '^i ~';! .f . l i sit  :

                                      %                                                                      /                                                                      l     -

tri ' ,\,9 ' , < .

                                                                        .v                          -

6 ,

                                                                                                                       ,s                           .t i,;                     s y wsaw usr-m n
                                                                                                               ~
                                                                                                                    ~ y vss ~ ~_" Q _~_ _~_ ~_ ~_,,

f 0;, < 1, 2e, - I R e; i g \s ss: 'r - - I m w. sa u < u,h

                                     %                      IN             $     T                               ---

k- k $ ~tl yt: h " '

p h

                                                            !!% /f3                                 ==n W
                                                                                                                                                                                  \

1

                                   'W//// ' '/ F__l% l/AlV/l
                                                                                                                                                ~
                                                                                 ,YlMW                            i i

h l l l t i __ _ _ _ - . - - . _ _ _ _ _ - . _ _ _ _ _ _ _ _ _ _ _ .

O REGISTRY'OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE j M9 1 NR-504-D-803-S DATE: September 28, 1995 ATTACHMENT 3

• AC T"u A t ce4 S W 6 T*C M M x v4 FuttNiaggg gingy An. t)(MW) .

O sY NuC.I.E. Ass tat.ht A8t CM -co , r e x N s. A.. s. N'N. . r a

                                                                                                                                                                                                          ~\'                        ..,~.,
                                                                                                                                                                                                                                         \, _\
                                                                         'a                                                                              .

f . , , -A

                                                                      }p'? .'.                                                                 *; y a                       ..                                                                                                                                                             . .
                                       ,,. .. .. ?f                 .

i 8, ;; , . - 5l ' . , .

• T v 'a, . , , ,

                                                                                                                                                                    '          I    -
                              . . . . , ? ' , -? ,h*-,q,k?.,,.                                                                                                                 *%
                                   -   . ' '*. : ew. 2 ,                .

g, - f \ ','

                                                                                                                                                        . f.                                                                                                      .

r- e

                                                                                                                                                       *4                        -            i;
                                                                                                                                                        . t $tg*,       lr,"E s }h f ,./                                 *%**kh.( r'.*5                                                                           s                                                                                                          .t
                                                                                                                                                                  , , . .n n; ,,

o _J. \. 'Q' / ,  % / o

                                                                                                                                                             'Y g       . . ' k '.r. , * -
                                                                                                                                                                                     -lj                        _.

1i 'a. q.' = .M i i 6 .. 1- e

3. i A _...,.___... r m .__. g .. _v.t...

                           .                                                                                .                               s                       I                                     /                                                                  t
                            'g e
                                                                                                                                                \,                     \       1
                                                                                                                                                                            '- v p
                                                                                                                                                                                      /g                 /

t I

                                                                                                                                                                                                                                              /                             t f '\ ',, ' \                                                      '~

j

                                                                                                                                                                                                                                                                 ,!l
                               \. ,                                                                                                                                            .
                                                                                                                                                                                                                                    ,/                         /
                                                                                                                                                                                                                                                                            .i
                                                                                                                                                                                                             ..        ,/

I - g ', - j

                                                            \. Q l                        ,.
                                                                                                                                                                                                                /- /                                                                \

t p .*** e I l - l e I , j 3.000 2  %  :

                   .                                              t                              '

l \ jii l

     .               REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE M9 J.NR-504-D-803-5                                           DATEt September 28, 1995                                                                                                            ATTACHMENT 4 l
                                                                                                                                                       't N           s
                                   /                                                    '
                                                                                                                                                                                ~'.: nN
                             ./,/                                                       t
                         ./      *
                                                                                                                                                                                                    . 's
                      .Yl                           *
                                                                                                                                                                                       .,      . . ' < ' 'ge
                                                                                            ;.ya

1 '.::.. .

                                                                                                                                                                                      - ;m , . . '

y.

                                                                       -        ,=.                                                                                                                              1
                                                           .             r            f                      n
                    . u 4. n,                                        ,f                                                                            18" h 41.eJIA i\
                        - ..                                    iy y*t%

4 ,. ~, N 3, .- . ,g:-w..-

                                                                   %.'.'.         h'          .
                                                                                                           ;         ,', \.
                                                                                                                                                                             .%9.
                                                                                                                                                                                        .-h'pr
                                                                                                                                                                                                      ,j. ..   .
                                                                                                                                                                                                                      .1'
                                                                                                                                                                                                                        't.
                                                              % ,.                                 li.       ,       at 6                       .
                                                                                                                                                                                        '4,.

i

• t D s , f*/')

tj ,-

                                                                                                                  / # 
                                                                                                                                                                                           '.',                            f s

s, v ._ s\ s .,,, I -,,,, f . . i. .-v.... [*[. ',*. . { .. s .* ,i

             \                                                                                                                                                                                             .

f .%

           - { \..\                                                                  I
                                                                                                                                                                                                                       /
                                                                                                                                                                                                                      /
               .\.  \          '

i / J \ '., g  %, . /. . '

                                                                        '                                                                                                                                    /
                                                                                                                                                                                                           /
                           \'                         .
                                                                                                                                                           .                                    t'5T *
                                                                                                                                                                                          , .t ' *

• s ,% ,,. .

                                                                                                                              -                                                         .         ..j, .*
                                                                                                                                                                                                                                  \

) l . I i i t l t

y* 9 O REGISTRY OF RADIOACTIVE SEALED SOURCES AND DEVICES SAFETY EVALUATION OF DEVICE EQ.at. NR-504-D-803-S DATE September 28, 1995 ATTACHMENT 5

                                              =..                                ,, ,.                       .

e. . ***

                                  .      =A   '.
                                                     .5   g
                                     ..s.
                               .e.
                                         . . . . ,zr : . .                          .-

a. < .

s. . . . n. . . .. . . .  :. . .

J.'.qfg . '. , . ; . . Ii ' , . . ,

                                 $5,tRMy,t..cm
                                 .g.g,:.v                                                                         ..y .
                                                                                               .sv.          ..

E.f.'i'ii.YN.s$T.'3 g, M .,. a , &.

                                   =. .w: . wm-
                                                   .t         ..
                                                                    .~.?r                 +                                                        .

v - m,.....

                                     - a-                                            u                                        <
      '                                                                                                                     y i                                                                                  !

o f . I r t a

                                                                                                                                                        -        l
                                                                                                                                                               . I
                                                                                                                     .f i                            .
                                                                                                                    \.
                                . i-                                                                               1
                                                 ~

l

                                             ..                                  /      //
                              . *                ,p g
                            . ' ! Ppat,T, $r C.% M A. A -

l t l l

i l

    " y'W A                       STATE OF NEW YORK l.

O I DEPARTMENT OF HEALTH ll UniversMy Place Albany. New York 12203-3399 l Barbara A. DeBuono. M.D., M.P.H. Dennis P. Whale'n Commissioner Executive Deputy Commissioner Dennis Sollenberger, Ph.D. Mail Stop 0-3-H 20 Office of State Prog.ams US Nuclear Regulatory Commission Washington, D.C. 20555 July 20,1998

Dear Dr. Sollenberger:

Enclosed are our comments on the draft report " Integrated Materials Performance Evaluation Program, Review of New York Agreement State Program, January 26-April 24, 1998." These comments address editorial changes that we feel should be made to the report. We also plan to submit a separate response to the recommendations made by the team in the report. I would like to emphasize the point that is included in the attached comments, on the need to maintain confidentiality of facilities reporting medical misadministration to our department. This confidentiality is required by New York State Public Health Law, and therefore, we ask that all identifiers to licensees that reported such misadministration to us be removed from the IMPEP report, as well as from all other NRC reports or documents available to the public. ' If you have any questions, or need additional information, contact Steve Gavitt at 518/458-6485. l Sincerely, l Karim Rimawi, Ph.D., Director Bureau of Environmental Radiation Protection cc: Stephen Gavitt l

 .f$0-fD3 M 05 ~ 20$ -                                                          ,

NYS Department of Health Comments on draft IMPEP report ne following comments concem only those portions of the draft IMPEP report relating to New York State Health Department program: Page 8 The report indicates that there are 24 overdue inspections of new licensees (out of 34 reviewed), however there is no mention of the significance of these findings. For example, seven of these overdue inspections are former General Licensees

                        - (which are not inspected by NRC) which .ve decided to convert to specific licensees for tracking purposes; one is a depleted uranium licensee; three licensees where not overdue since the facilities did not have materials on-site until sometime after the license issuance date (this information is contained in the license file); and two licenses were inspected previously but a change in ownership initiated a new license to the new owners but the facilities and equipment remained unchanged.

Page 24 ne report notes that certain standard conditions are in some licenses but not others. It then goes on to indicate a potential problem "a license reviewer informed the team that this standard condition should be put on all licenses." But it is then resolved "As this issue was pursued, the team was then informed that this standard condition is now in the regulations." It is unclear as to the significance of the above. When a standard license condition is made into a regulation it is taken off the licenses as they are renewed. Therefore licenses that have not been renewed will have the condition until their renewal. We do not believe this is a problem. In the same paragraph there is a focus on our " list of standard license conditions." This list isjust a compilation of all various license conditions. We do not use this list to generate licenses. Licenses are not created from a blank document. Each category oflicense has its own "boilerplate" that is kept up to date with all applicable license conditions. When a new license condition is created, it is added to the appropriate "boilerplate" and to our list of standard license conditions. When a license condition becomes obsolete it is deleted from the boilerplate but not from the " list". So while it is true our list of standard license conditions contains outdated conditions - this does not affect our licensing process and has no significance. Page 36 We did adopt the " Criteria for Release ofIndividuals Administered Radioactive f Materials" see section 16.123 of Part 16. Appendix E-3 Please note that NYS law prohibits the disclosure of the name of any facility that l

[ i provides reports pursuant to Part 405. Therefore you cannot print the name, location and license # for files nos. 6,7,8, and 9 in Appendix E-3 and we ask that these be removed from all copies of the reports and any other public documents NRC issues or maintains. File no.1 is allowed since we took an enforcement action against this licensee and that information is available for public review. Page 18 There are 4 field offices (Buffalo, Rochester, Syracuse and New Rochelle) and the main office. Page 19 We do have a written training policy which was provided to the IMPEP team (copy attached). Page 19 We only have one CHP in the program. Six others passed Part I of the certification exam last year, four of whom were eligible and took Part 11 this year. F I h l I l ___-- _ __.-__m_. -___.__-__m_ ________

v. , .

BERP INSPECTOR QUALIFICATION PROCEDURE

                -01      PURPOSE 01.01 To provide training guidelines for personnel to achieve initial qualification as an inspector through local, formal classroom, and on-the-job training.

01.02 To identify mandatory and optional requirements for inspectors after achieving initial inspector qualification status. 01.03 To provide addltional training opportunities for the experienced inspector in identified specialty areas.

               -02     OBJECTIVES                  ,

02.01 To ensure that inspectors meet minimum knowledge and qualification standard. 02.02 To provide a standardized methodology. for determining that-an inspector has met the minimum training requirements.

               -03     POLICY Inspector personnel must understand the facilities, processes, and activities for those areas they inspect in addition to the          l criteria, techniques, and mechanics of inspection. They must also
            ' be keenly aware of the potential for negative impact on safety if the inspection process is allowed to become overly intrusive in areas of operation where problems are not occurring. In addition, the inspector must be sensitized to the potential for negative regulatory impact. Newly hired personnel seldom possess all of       -

these required qualifications. Therefore, formal classroom, self-study, and on-the-job training are needed to ensure that the newly hired inspector obtains the required knowledge and understanding necessary to be considered qualified to implement the inspection program. I Each inspector must complete the appropriate required training outlined in Appendix A of this procedure or verify, through l Lsuccessful completion of a written equivalency examination, that the desired level of knowledge in a particular specialty area has been obtained. Training requirements for new inspectors will be documented by the Bureau of Environmental Radiation Protection in a Qualification Journal which is identified in Appendix B of this chapter. Coupletion of the Training and Qualification Journal constitutes the minimum inspector qualification requirements, and encompasses regulatory, administrative, and technical practices pertinent to each area of inspection. Other requirements' such as

\,.

• l 1.

j Page 2 local training may be used to supplement or enhance training. The passing grade for each course examination or equivalency examination is 70%. . Once an inspector has completed the training identified in Appendix A, that inspector will be evaluated by the appropriate Section Chief or Field Supervisor to determine that the minimum requirements are met. In a situation where qualification is delayed as a result of an inspector not being able to schedule certain formal training courses, or for other time restraint consideration, the appropriate Section Chief,'the BERP Field Supervisor or Bureau Director delegate) may provide interim qualification for those areas w(or his here the inspector is considered qualified. Inspectors who are receiving on-the-job training in preparation for meeting qualification requirements, can perform inspection activities under the direction of an inspector. With the exception of inspectors who are receiving on-the-job training, an inspector ' is expected to be qualified for the area being inspected. In some cases where an inspector has taken most but not all of the required training, this may require the issuance of interim qualification. An inspector who changes disciplines or is assigned to perform inspections in additional areas of discipline, must meet the training and qualifications requirements for the new discipline. It is expected that similar training requirements between disciplines will not have to be repeated, and credit for the previous similar training will be indicated in the current ' qualification journal. This procedure and qualification journal are periodically revised to reflect the training needs of inspectors as determined by changes to the inspection procedures. An inspector that is qualified prior to the time any revisions are made to this procedure will continue to remain' qualified. The supervisor of a qualified inspector will determine whether or not the inspector should take new courses added to this procedure as they are

offered. This determination is based on the inspector's prior work experience and current inspection activities.

1 Special circumstances (e.g., training opportunities) may make it ( impossible to provide empio;ees with requi. red formal classroom l training within the time frames specified in Appendix A. When this j occurs, the appropriate Section Chief will issue a memorandum indicating the affected training courses, circumstances involved. and reinstatement dates. If a new or proposed course listed in j the procedure is not available at the time an inspector.has  ! satisfied all other requirements, and the course is not critical { to performing inspections as a qualified inspector, certification i l N

f i . l l l may be gfven with the condition that the remaining course requirement be satisfied when the course is "next available."

l Page 3 Temporary instructions (tis) that focus on specific " Area of Emphasts" may require special training requirements for inspectors prior to their performing the inspection. These special training requirements will be identified by the appropriate Section Chief. The schedule for preparation of any special training should allow enough lead time to prepare the required training course and implement it prior to inspection being performed using the TI.

             -04    DEFINITIONS COURSE SERIES.

technology. A progressive sequence of courses in a particular Equivalency Examination. specific course attendance. An Examination administered in lieu of On-Site Training. Required training for inspectors designed to thoroughly acquaint the inspector with specific site systems, structures, and management organization. Required Training. Formal classroom and on-the-job training representing field. the minimum acceptable level of knowledge in a given Supplemental Training. Additional training courses beyond those identified for " Required Training " The additional courses will be determined by the inspector's supervisor and will depend on the inspector's previous work experience and planned inspection activities in specific area. j Refresher Training. Required training designed to update and maintain qualification. Training and Qualification Journal. A document that establishes the minimum training requirements for formal classroom instruction, on-the-job training, local training sessions, and self-study. This document establishes the basic generic training requirements for inspector types identified in Appendix A, and IIsts the qualification journals in Appendix B. i Interim Qualification. Qualification of an inspector by the Bureau Director or Section Chief or Field Supervisor (or his l delegate) to conduct independent inspections in specified areas of i the inspection program before that inspector completes all required I training. i

R Page 4

        -05    RESPONSIBILITIES AND AUTHORITIES 05.01 Director, Bureau of Environmental Radiation Protection establishes the training requirements for ;nspector positions listed in Appendix A.                                                I 05.02 Section Chiefs / Field Supervisor, Bureau of Environmental Radiation Protection, ensure that inspectors achieve and maintain     i qualifications procedures.

in accordance with the guidelines provided in this

       -06     TRAINING ACTIVITIES 06.01 All staff whose principal job assignment is to perform inspections in their assigned areas of expertise, must successfully complete the training requirements for their individual inspection areas as listed in Appendix A.

a. Written examinations may be used to determine whether inspectors have obtained the 70% level of knowledge and understanding, b.

Inspectors who fail courses may be given the opportunity to acquire the knowledge ~1evel required through self-study and re examination or to repeat the course. 1

c. Program management assumes that inspectors possess the necessary motivation and ability to achieve such a level of knowledge and understanding. In the rare situation where such is not the case, program management will decide what action to take on an individual basis.

06.02 classroom and simulator training are designed to supplement the inspector's education, experience, and on-the-job training by providing basic theory and knowledge as well as job related techniques.

     -07     BERP TRAINING AND QUALIFICATION JOURNAL

{ 07.01 The BERP is responsible for developing and maintaining the Training Qualification Journal. The use of the Journal is described in Appendix B of this chapter. l 07.02 The BERP Journal provides the minimum training requirements to develop Training and Qualification Journals. Newly hired inspectors, except those in the intern program, will have a detailed series of activities and study areas to be completed in a specific period, usually within the first 2 years of employment. i L

I 1 Page 5 { The journals cover self-study and seminars or group discussions in the following areas:

a. Code of Federal Regulations,

b. NYSDOH regulations,

c. Pertinent inspection and environmental health manual procedures.

d.

           . e.

Technical areas of inspection, methods, and knowledge. Schedule of orientation and required training as delineated in Appendix A. 07.03 Development, maintenance, and periodic review of these journals will be provided by the BERP, l j

     -09 MANAGEMENT CERTIFICATION OF INSPECTOR QUALIFICATION DOH management may, in certain circumstances, certify that an inspector is qualified to perform inspections without regard to the requirements of this procedure. The Director, Bureau of Environmental Radiation Protection will ensure the completion of the Qualification Journal including technical training and/or equivalent training.

t h

4 4 PAGE 6

            -10    INTERIM INSPECTOR QUALIFICATION In general, only those inspectors who have successfully completed the required training will be allowed to independently perform inspections. However, if responsible management evaluates the background and performance of an individual inspector and concludes that the inspector has diconstrated an ability to perform inspections in specific 4reas, even though the required training has not been completed, the Section Chief, the BERP Field Supervisor or Bureau Director, or designee as appropriate, can authorize the individual to perform inspections in those areas.

When this approach is used, the successful completion of the training is still required to be completed within the time limits specified. It is not the intent of this proce' dure to require persons to participate in each of the defined training activities if they already possess the type and level of knowledge that would be achieved by completing the prescribed training. If inspectors, when hired, through previous work experience and training, are

        ' deemed to possess the appropriate knowledge level for a prescribed training area, then equivalency examination (s) may be taken and thereby-satisfy the training requirements. However, if work experience or previous training .is determined to be equivalent to a given course, that course may be waived by appropriate management (Section Chief or Bureau Director) and a justification entered in the trainee's qualification journal.

10.01 An inspector who has not completed all requirements for final certification in one of the arets listed in A may obtain interim qualification to independently perform inspections in specified areas for which prescribed training has been completed. 10.02 To establish an interim certification, the inspector's supervisor will evaluate the inspector's qualifications and identify the portions of the inspection program for which interim qualification is appropriate. 10.03 Interim qualification will be approved by the the BERP j Field Supervisor, the appropriate Section Chief or the Bureau Director, or his designee for interim qualification in the identified areas. . i

. 10.04 Approval of the interim qualification will be documented l' and record kept in the individual's training file.

                                                                                  )

l i

Page 7

                           -11                      EXCEPTIONS 11.01 Inspectors, who through prior experience and education,
                        . pot.ess sufficient knowledge to meet minimum requirements, may validate a course though satisfactory completion of an equivalency examination.
                        '11.02                           At the discretion of the Section Chief or Field Supervisor, inspectors may be qualified for certain types of inspections before they complete all of the training requirements for certification.

For example, an inspector may be qualified to perform inspections of academic materials licensees before completing the specialized courses and becoming qualified for inspecting medical licenses. 11.03 The Bureau Director has the authority to waive any requirement listed for an inspector in this procedure. Justification for the waiver will be documented, and entered into the inspector's training file. 1245-12 POST QUALIFICATION TRAINING This procedure identifies training requirements beyond those that are required for initial qualification for'the experienced inspector. For the inspector who has received certification of f initial qualification, mandatory and optional training requirements - are identified in the sections entitled " Training Required Within Two Years of Certification," " Supplemental Training Courses, " and

                        " Refresher Training." 'These sections are listed for purpose' in Appendix A to this procedure. The purpose of this additional                                                                                   {

training is to recognize that inspector training does not stop with

            .           initial qualification; that training'should be made available for the experienced inspector on the basis of need, special circumstances, and to keep current with the inspection program.

In particular, the Fundamentals of Inspection Refresher Course (G- 1

                       '102) provides the inspector current views on regulatory policy and                                                                            )

' philosophy as it relates to the inspection program and the j Principles of Good Regulation. I END Appendices

1. Appendix A, Training Activities

2. Appendix B, NRC Training and Qualification Journals I

l

s APPENDIX A TRAINING ACTIVITIES A. PURPOSE To ensure that inspectors are qualified to: I. Know their role and mission.

2. Understand the responsibilities and legal authority of an inspector.

3. Know inspection techniques and procedures and'are capable of-'

performing the inspector function.

4. Have the type and level of technical knowledge needed to adequately perform inspection activities.

j

5. Understand the inspection program.

B. TRAINING REQUIREMENTS j Each section of this appendix provides the inspector training requirements for a particular inspection activity as indicated ,

                                                                                                                             )

below. - l Section Area of inspection I-A Radiation Producing Equipment Inspector I-B HCFA Mammography Inspector I-C Radioactive Materials Inspector II-A Next Inspector II-B FDA Compliance Testing Inspec'*.r i I l eeuwe S l (. _

SECTION I-A TRAINING REQUIREMENTS FOR RADIATION PRODUCING EQUIPMENT INSPECTOR A. APPLICABILITY The training described below is required for all radiation producing equipment inspectors assigned to perform radiological safety inspection activities at radiation equipment registrant facilities. B. TRAINING

1. Required initial training. This training is required for initial certification of the radiation equipment inspector,

a. Required local on-the-job training.

(1) Orientation (2) Code of Federal Regulations (21 CFR 1000) (3) NYSDOH Regulations (10 NYCRR 16, 76, 89) 4 (4) NY Public Health Law (5) NCRP Reports No. 66, 85, 99, 100, 102, 104, 105, 107 (6) DOH Memorandums (7) NYS Guides on Radiation Safety / Quality Assurance Programs (8) FDA Inspection Manual (9) Industry Codes and NIST Standards (10) Radiological Safety Inspection Accompaniments. These include.at a minimum accompaniment inspections at least two hospitals including or supplemented by at least four surveys of each of the following units: fluoroscopic, mammographic, radiographic, dental, Computerized Tomographic (CT), and non-human use other than veterinary. (11) NYSDOH Inspection Procedures

b. Required Formal Training Courses. This training is provided in formal classroom or workshop environments and is conducted by the BERP or FDA staff or contractors.

(1) Basic Radiation Protection / Health Physics (2) Medical X-ray Protection

2. Training Required Within Two Years of Certification. This training is required within two years of initial formal certification and-is conducted by Eastman Kodak Corporation.

a. Kodak Moore 2 m____________._________..________

3. Supplemental Training Courses. Depending on the inspector's previous work experience and planned inspection activities, these additional courses may be required in order to gain knowledge necessary for specialized inspection activities. Program management will make this determination on an individual basis.

a. Accelerator Health Physics

b. Radiological Emergency Response Course

c. Radiological Accident Assessment Course

d. Enforcement Procedures

4. Refresher Training. Refresher training will be conducted as needed and as determined by management.

9 I l s

l n SECTION I-B i TRAINING REQUIREMENTS FOR HCFA MAMMOGRAPHY SURVEYOR A. APPLICABILITY The training described below is required for all HCFA mamography program inspectors assigned to perform radiological safety inspection activities at HCFA mammographic facilities. B. TRAINING

1. Required initial training. This training is required for initial certification of the radiation equipment inspector.

a. Required local on-the-job training.

                                                 ~

(1) Orientation (2) Code of Federal Regulations (42 CFR 494.50 to 494.64) (3) NYSDOH Regulations (10 NYCRR 16, 76, 89) (4) NY Public Health Law (5) NCRP Reports No. 66, 85, 99, 100, 102, 104, 105, 107 (6) DOH Memorandums (7) NYS Guides on Radia. tion Safety / Quality Assurance Programs (8) HCFA Inspection Manual (9) Industry Codes and NIST Standards (10) HCFA Mammographic Survey Accompaniments. These must include at a minimum accompaniment inspections at least five HCFA mammographic surveys. (11) NYSDOH Inspection Procedures (12) ASPEN

b. Required Formal Training Courses. This training is provided in formal classroom or workshop environments and is conducted by the BERP or FDA staff or contractors.

(1) HCFA Mamography Certification Course

2. Training Required Within Two Years of Certification. This training is required within two years of initial formal certification and is conducted by Eastman Kodak Corporation.

a. Kodak Moore 2

3. Supplemental Training Courses. Depending on the inspector's previous work experience and planned inspection activities,

! additional courses may be required in order to gain knowledge i necessary for specialized inspection activities. Program management will make this determination on an individual basis.

l

                                                                                                                \

4. Refresher Training. Refresher training will be conducted as needed and as determined by management.

s SECTION I-C TRAINING REQUIREMENTS FOR RADIOACTIVE MATERIALS INSPECTOR A. APPLICABILITY The training described below is required for all radioactive materials inspectors assigned to perform radiological safety inspection activities at material licensee facilities. G. TRAINING

1. REQUIRED INITIAL TRAINING. This training is required for initial certification of the materials inspector,

a. Required Local Training.. This training is conducted in the local office using the appropriate Training and Qualification Journal.

(1) Orientation (2) ' Code of Federal Regulations (3) NYSDOH Regulations (4) NY Public Health Law

                      -(5) NYS DEC Regulations (6) Updated Safety Analysis Report (if applicable)

(7) Regulatory Guidance (8) NRC' Inspection Manual (9) Industry Codes and Standards (10) Radiological Safety Inspection Accompaniments (11) NRC Manual (12) NYSDOH Inspection Procedures j

b. Required Formal Training Courses. This training is provided in formal classroom or workshop environments and I is conducted by USNRC staff and USNRC contractors.

                     -(1)~ Health Physics (USNRC)
                     -(2) Medical use of Radionuclides Nuclear Medicine Course (USNRC)

(3) Teletherapy (USNRC) for teletherapy inspections (4) Inspection Procedures Course (GPA/SP) or Fundamentals'of Inspection Course (G-101)

2. Training Required Within Two Years of Certification. This

                      ~

training 1s required within two years of initial formal l certification and is conducted or arranged by NRC staff,

a. OSHA Orientation Course

b. Transportation of Radioactive Materials Course (H-308)

c. Internal Dosimetry & Whole Body Counting Course'

d. Effective Communications for NRC Inspectors i

       ~

1

3. Supplemental Training Courses. Depending on the inspector's previous work experience and planned inspection activities, these additional courses may be required in order to gain knowledge necessary for specialized inspection activities. Regional management will make this determination on an individual basis,

a. In-Place Filter Testing (H-105

b. Radiological Emergency Response) Course (H-303)

c. Radiological Accident Assessment Course (H-307)

d. Health Physics in Radiation Accidents Course (H-309)

e. MORT - Accident Incident Investigations Workshop (G-200)

f. MORT - Management Oversight and Risk Tree Analysis Seminar (G-201) g.

h. Air Sampling for Radioactive Materials (ORAU) Engineering Licensing Practices and Procedures (G-109) ,

1. Safety Aspects of Well Logging (H-314) j.

Irradiator Technology course (H-315)

k. Environmental Sampling and Analysis Course (H-310)

1. Health Physics topical Review Course (H-401)

J. Inspecting for Performance Course (G-303)

4. Refresher Training. Refresher training will be conducted every three years following initial certification and will be determined by Regional management. Refresher training will also include the following course:

I

a. Fundamentals of Inspection Course (G-102) l I

l

n SF.CTION II-A - TRAININd REQUIREMENTS FOR i NEXT SURVEYOR A. APPLICABILITY The training described below is required for all NEXT program inspectors assigned to perform radiological safety inspection activities at NEXT facilities. 4 B. TRAINING i

1. Required initial training. This training is required for initial certification of the NEXT surveyor,

a. Required local training.

(1) Orientation (2) Code of Federal Regulations (21 CFR 1000) (3) NYSDOH Regulations (10 NYCRR 16, 76, 89) (4) NY Public Health Law I (5) NCRP Reports No. 66, 85, 99, 100, 102, 104, 105, 107 ' (6) DOH Memorandums (7) NYS Guides on Radiation Safety / Quality Assurance Programs (8) NEXT Survey Procedures Manual (9) Industry Codes and NIST Standards j (10) BERP Inspection Procedures

b. Required Formal Training Courses. This training is j provided in formal classroom or workshop environments and l 1s conducted by the BERP or FDA staff or contractors. '

(1) NEXT Surveyor Training Course 4

2. Training Required Within Two Years of Certification. Not applicable.

3. Supplemental Training Courses. Each year, NEXT surveyors are expected to complete the Next Surveyor Training Course for that year since changes in inspection procedures and areas of coverage i usually occur.

4 Refresher Training. Refresher training will be conducted each year as needed. l l l I l

               ,                               e.

1 n . APPENDIX B BERP INSPECTOR TRAINING AND QUALIFICATION JOURNAL A. PURPOSE To establish a method of conducting and documenting successful completion of the training requirements set forth in this procedure. B. BACKGROUND The BERP Training and Qualification Journal is designed to ensure that a uniform method of' conducting and documenting training is being followed for all inspectors. The Journal establishes the minimu'm training requirements that must be met for all required general and formal training courses listed in Appendix A and serves as a guide for development of other training and qualification journals (i.e., local and vendor journals). C. BASIC REQUIREMENTS The BERP Journal must be used to conduct and document training activities for all inspectors. The BERP is responsible for developing and maintaining the Training and Qualification Journals. The Training and Qualification j Journals included as part of this Appendix B establish the minimum i requirements for a Training and Qualification Journal that must be completed for each inspector type listed in this and defined in l Appendix A, l 6 N

N:w Ycrk St:t] D:p:rtment cf Envir nm:nt:1 C:n crv;ti:n Division of Solid & Hazardous Materials Bureau of Pesticides & Radiation 60 Wolf Road, Albany, New York 12233-7255 518-485 8981 FAX 518-485-8390 John P. Cahill Commissioner

• July 24,1998 g 2.

Mr. Dennis Sollenberger E Office of State Programs Eo US Nuclear Regulatory Commission y j Mail Stop 3-d-23 - Washington, D.C. 20555-0001 [ co

Dear Mr. Sollenberger:

We have reviewed the Draft Report of the Integrated Materials Performance Evaluation Program Review of the New York Agreement State Program (January 26- April 24,1998), which was transmitted to this Department by a June 24,1998 letter from Richard Bangart. For the most part, we found the sections of the report addressing this Department's radiation control program to be factually correct. Our suggested corrections are enclosed. 1 I I We appreciate the suggestions and recommendations offered by IMPEP team, both during their visit and in the draft report. We are reviewing them, and will respond when the final report is issued. Thank you for the opportunity to Ieview the draft report. If you have any questions, please contact me or Barbara Youngberg. Sincerely, l W Paul J. Merges, Ph.D. Director, Bureau of Pesticides & Radiation Division of Solid & Hazardous Materials Enc. cc: D. White, USNRC, Region 1 l R. Aldrich,NYSDOL G. Miskin, NYCDOH < K. Rimawi, NYSDOH J. Spath, NYSERDA L B M P-3 / 0 / ! & 6 k - t

New York State Department of Environmental Conservation Division of Solid & Hazardous Materials Bureau of Pesticides & Radiation Comments on Dran Report Integrated hlaterials Performance Evaluation Program Review of New York Agreement State Program January 26 - April 24,1998

1. Page 9, Section 3.1.4 Status of Materials Inspection Program The draft repor t notes that although initial inspections are usually performed within six months of permit issuance, our inspection policy memorandum called for initial inspections to be performed within one year of the date the permit is issued. This was inconsistent with IMC 2800, which requires initial inspections within six months. The draft report also states that the Program Director committed to revising the policy memorandum accordingly. This has been done.

2. Page 19, Section 3.3.4 NYDEC - Technical Staffing and Training The two vacancies noted in the dran report have been filled.

3 Pages 42 - 43, Section 4.3 Low-Level Radioactive Waste (LLRW) Disposal Program The draft report states, "NYDL is responsible for the occupational exposure of individuals and control of radioactive material up to the point of placement in the disposal unit or release from the site." This is not completely accurate. The Department of Labor does have responsibility for occupational exposures and therefore, has authority over the radioactive material as it affects occupational exposures; however, DEC has authority, under Articles 17 and 29 of the Environmental Conservation Law, over most aspects of the design, construction, and operation of the disposal facility. This includes waste package receipt and inspection and temporary storage of waste prior to emplacement in waste disposal units. DEC's authority is reflected in our regulations for LLRW Disposal Facilities,6 NYCRR Parts 382 and 383. In the second paragraph of this section, the last sentence would be more consistent with commonly used acronyms ifit read, "The State does have two former radioactive waste disposal sites: the State Licensed Disposal Area (SDA) at West Valley, and the Radiation Disposal Site (RDS) at Cornell University."

                                                                                                            +
             . We suggest changing the first sentence of the third paragraph of this section to read, "The i     SDA is a portion of the West Valley Nuclear Services Center site and was operated as a -

[ commercial radioactive waste disposal site." The operation of the SDA predates the adoption of the radioactive waste classification system. Some of the waste placed in the SDA would vary Page 1 of 2 o

from the criteria for classification as LLRW pursuant to 10 CFR Part 61. The reference to LLRW in the fourth sentence should also be deleted. In the first complete paragraph on page 43, the second sentence should be changed to read, "The NYDL has no responsibility at this site since it was not a commercial disposal site. Cornell holds a radioactive materials license from the NYS Department of Health."

4. Appendix D-4 NYDEC License File Reviews, Page D-4.1, File No. 2 We suggest revising the comment to read, "Since emissions at two release points exceed -

the effluent concentration values in Table 11, permit limits were set to limit the potential dose to the maximally exposed member of the public."

5. Appendix D-4 NYDEC License File Reviews, Page D-4.3, File No.13 The comment states that the tennination application and licensee's closcout survey were

                                                             - not in the file. This is true, and as was explained to the IMPEP reviewer at the time, it was due to the fact that the documents were large and therefore not stored in the file drawer. At that time, only the SPL project manager, who was not in the office when the question was posed, knew where the documents were. The documents were always in the office. We have since made
                                                             . room in the file drawer for them, and they are stored with the rest of the SPL file.

i l i Page 2 of 2

i- ) i' Aaenda for Manaaement Review Board Meetina l Tuesday. Auaust 18.1998 .1:00 -4:00 D.m.. TWFN. T3B45

1. Convention. MRB Chair convenes meeting (H. Thompson)

2. New Business - Consideration of New York IMPEP Report A. Introduction of NYCH, NYSH, and NYDEC iMPEP Team Members (D. Sollenberger)

B. Introduction of New York representatives and other State representatives participating through videoconference or teleconference. C. Findings regarding NYCH, NYSH, and NYDEC Programs (IMPEP Team) Status of Materials inspection Program Technical Quality of Inspections Technical Staffing and Training Technical Quality of Licensing Actions Response to incidents and Allegations Legislation and Program Elements Required for Compatibility D. Questions. (MRB Members) E. Comments from State of New York

3. Old Business - Approval of the Arkansas and Alabama MRB minutes

4. Status of Upcoming Reviews

6. Adjournment (H. Thompson)

Attendees: Hugh Thompson, MRB Chair, EDO Richard Bangart, MRB Member, OSP Karen Cyr, MRB Member, OGC Carl Paperiello, MRB Member, NMSS Thomas Martin, MRB Member, AEOD Roland Fletcher, OAS Liaison to MRB Gene Miskin, NYCH Kenneth Daniels, NYCH Allen Goldberg, NYCH Richard Borri, NYCH Stephen Gavitt, NYSH Karim Rimawi, NYSH Paul Merges, NYDEC Sandra Hinkle, NYDEC Dennis Sollenberger, IMPEP Team Leader, OSP Duncan White, IMPEP Team Member, RI Jamnes Cameron, IMPEP Team Member, Rlli Michael Stephens, IMPEP Team Member, FL  ! Jacqueline Cook, IMPEP Team Member, RIV Lee Cox, IMPEP Team Member, NC l i Allan Grewe, IMPEP Team Member, TN Paul Lohaus, OSP L Kathy Schneider, OSP t Lance Rakovan, OSP l l ATTACHMENT 3 l

Aaenda for Manaaement Review Board Meetina Seotember 1.1998.1:00 - 3:00 a.m.. OWFN 384

 .1.      Convention. MRB Chair convenes meeting (H. Thompson)

2. - New Business - Consideration of New York IMPEP Report

        . A. Introduction of NYDL IMPEP Team Members (D. Sollenberger)

B. Introduction of New York representatives and other State representatives participating through teleconference. C. Findings regarding NYDL Program (IMPEP Team) Status of Materials Inspection Program Technical Quality of Inspections Technical Staffing and Training Technical Quality of Licensing Actions Response to incidents and Allegations 1 Legislation and Program Elements Required for Compatibility Sealed Source and Device Evaluation Program D. Questions. (MRB Members) E. Comments from State of New York F. MRB Consultation / Comments on issuance of Report (H. Thompson)

                                                                                                                                          ..l Recommendation for next IMPEP review 3.-     Status of Upcoming Reviews

4. Adjournment (H. Thompson)

Attendees: Hugh Thompson, MRB Chair, EDO Richard Bangart, MRB Member, OSP Karen Cyr, MRB Member, OGC Carl Paperiello, MRB Member, NMSS Thomas Martin, MRB Member, AEOD Roland Fletcher, OAS Liaison to MRB Rita Aldrich, NYDL Clayton Bradt, NYDL Dennis Sollenberger, IMPEP Team Leader, OSP Duncan White, IMPEP Team Member, RI Jim McNees, IMPEP Team Member, AL  ; Lance Rakovan, IMPEP Team Member, OSP Doug Broaddus, IMPEP Team Member, NMSS Paul Lohaus, OSP Kathy Schneider, OSP ATTACHMENT 3}}