ML22178A129
| ML22178A129 | |
| Person / Time | |
|---|---|
| Issue date: | 06/23/2022 |
| From: | Monica Ford NRC Region 1 |
| To: | |
| References | |
| Download: ML22178A129 (4) | |
Text
RHODE ISLAND DEPARTMENT OF HEALTH HEIGHTENED OVERSIGHT CONFERENCE CALL May 25, 2022 Nuclear Regulatory Commission Rhode Island Department of Health Attendees Attendees Monica Ford, RSAO Region I Alex Hamm, Supervisor, Radiation Control Program Farrah Gaskins, RSAO, Region I Dennis Klaczynski, Sr. Radiological Health Specialist Blake Welling, Director DRSS, Region I Maria Barnes, Radiological Health Specialist Tamara Bloomer, Deputy Director DRSS, Bill Dundulis, Risk Assessment Toxicologist Region I BACKGROUND The Rhode Island Agreement State Program (the Program) has experienced challenges maintaining an adequate and compatible program since 2011. In 2011, based on findings presented by the Integrated Materials Performance Evaluation Program (IMPEP) team, a Management Review Board (MRB) found Rhode Island adequate to protect public health and safety, but needs improvement, and compatible with the U.S. Nuclear Regulatory Commissions (NRC) program and subsequently placed the Program on Monitoring. In 2016, as a result of the IMPEP teams findings, the MRB again found the Program adequate to protect public health and safety, but needs improvement, and compatible with the NRCs program. Additionally, the MRB directed that the Program continue to be on Monitoring, that quarterly calls between the Rhode Island Department of Health and NRC staffs be conducted, and that two periodic meetings take place one at approximately 12 months and the other at approximately 30 months from the date of the 2016 IMPEP review. In January 2022, as a result of the IMPEP teams findings, the MRB found the Program adequate to protect public health and safety but needs improvement and compatible with the NRCs program. The Program experienced challenges in maintaining a first line supervisor during the review period and in the area of Technical Quality of Licensing Actions. Therefore, the IMPEP team recommended, and the MRB agreed that a periodic meeting should occur in one year, the next full IMPEP review should take place in two years, and the Program should enter a period of Heightened Oversight. Heightened Oversight is a formalized process that allows the NRC to maintain an increased level of communication with an Agreement State. As a part of the Heightened Oversight process a Program should submit a Performance Improvement Plan (PIP) to address any areas of downgraded program performance and bimonthly calls between the Program and the NRC should commence. The Program sent in its revised PIP on May 23, 2022 (ADAMS accession number ML22144A210). This summary documents the second bimonthly call between the NRC and the Program.
[Note: Due to the COVID-19 pandemic the IMPEP review previously scheduled for July 2020 was rescheduled and was conducted in October 2021.]
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DISCUSSION OF PIP/ STATUS OF RECOMMENDATIONS October 2021 IMPEP Review Findings:
Rhode Islands performance was found satisfactory for the performance indicators:
- Status of Materials Inspection Program
- Technical Quality of Inspections
- Technical Quality of Incident and Allegation Activities
- Legislation, Regulations, and Other Program Elements.
Rhode Islands performance was found satisfactory but needs improvement for the performance indicator:
- Technical Staffing and Training.
Rhode Islands performance was found unsatisfactory for the performance indicator:
- Technical Quality of Licensing Actions.
The team recommended and the MRB Chair agreed that two of the three previous recommendations be closed, and the recommendation related to accessibility of licensing and inspection documentation remains open with the following modifications:
- Rhode Island management take measures to ensure licensing and inspection documentation is complete and stored in a centralized filing system.
The team also recommended and the MRB Chair agreed with the following three new recommendations for improved program performance.
- Implement the Pre-Licensing guidance (and any updates, as necessary) and provide training to ensure staff understands how to properly identify unknown applicants and transfer of control requests, and how to document the basis for the known entity determination
- Implement the Risk Significant Radioactive Materials (RSRM) checklist (and any updates, as necessary) and provide additional training to ensure staff understand when to use the checklist
- Implement a financial assurance program consistent with State regulations; that licenses that authorize possession of radioactive material in excess of quantities requiring financial assurance post financial assurance; and, that financial assurance license conditions be consistent with possession limits authorized on the license The team determined that the declining performance from the 2016 IMPEP review was mainly due to:
(1) significant management turnover, (2) inconsistent management oversight of programmatic activities primarily involving licensing actions, and (3) incomplete licensing and inspection documentation.
Recommendation 1
- Rhode Island management take measures to ensure licensing and inspection documentation is complete and stored in a centralized filing system.
In order to address this recommendation, the Program defined four tasks with six associated milestones. Since the 2021 IMPEP review three milestones involving integrating a new organization system, acquiring adobe acrobat for all staff and the transfer of data from one individuals inbox have been completed. Two milestones are currently in progress, and one has not yet been started. Program management stated that the first priority was to ensure that none of the data was lost. The Program was able to successfully retrieve all licensing data from the one license reviewers personal drive 2
associated with their computer. The Program manager stated work is still being done to retrieve data from individuals computers who are no longer with the Program. The Program is continuing to work on digitizing all of the current licenses and is adding all newly received amendments and all new license actions into the SharePoint library. As of this call the Program has completed work for 8 of its 42 licenses. For files with security related information, those files are marked appropriately and access to those files is limited to the Program and IT individuals. The Program expects to finalize the digitization by August 31, 2022. The Program is auditing licensee files as work continues and will do so until all files are finalized in the electronic system. During the March 2022 call, it was noted by the NRC that it would be beneficial to share audit results during the upcoming periodic meeting. The Program stated that if audit results were available at that time, it would share that information.
Recommendation 2
- Implement the Pre-Licensing guidance (and any updates, as necessary) and provide training to ensure staff understands how to properly identify unknown applicants and transfer of control requests, and how to document the basis for the known entity determination.
The Program identified three tasks, each of which has an associated milestone, to address this recommendation. The Program held pre-licensing guidance training March 23, 2022. To practice using the checklist the Program used previously completed actions that should have had the checklist in the file and filled it out for training and completeness of the file. This action was completed on April 28, 2022. No actions have been received by the Program since the IMPEP review that require the use of the Pre-licensing Guidance. The Program has put a plan in place to have other reviewers check each others work for accuracy and completeness. This effort is ongoing.
Recommendation 3
- Implement the RSRM checklist (and any updates, as necessary) and provide additional training to ensure staff understand when to use the checklist.
This recommendation is being handled similar to recommendation 2 with three identified tasks, each with an associated milestone. The training for the RSRM checklist was given on March 23, 2022.
Similar to recommendation 2, the Program used previously received actions that should have had the RSRM checklist in the file and completed the checklist for completeness. No missed implementation of security requirements was identified as a result of the missing paperwork. This task was completed on April 28, 2022. The Program has put a plan in place to have other reviewers check each others work for accuracy and completeness. This effort is ongoing.
Recommendation 4
- Implement a financial assurance program consistent with State regulations; that licenses that authorize possession of radioactive material in excess of quantities requiring financial assurance post financial assurance; and, that financial assurance license conditions be consistent with possession limits authorized on the license.
The Program identified three tasks with eleven associated milestones to address this recommendation.
Since the 2021 IMPEP review, the Program has contacted all licensees who were authorized to possess quantities of material requiring financial assurance. Two licensees chose to maintain a license that authorizes possession of material in quantities requiring financial assurance. All other licenses were amended to lower the licensees possession limits to below amounts that require financial 3
assurance. The appropriate financial assurance documentation was collected from both licensees and is being stored in a secure location. The Program has developed a process to review licenses to determine if financial assurance is required based on amounts authorized to be possessed on a license. All tasks and milestones have been completed associated with this recommendation.
Performance Concern 1 (Technical Staffing and Training)
- Develop a balance in the staffing of licensing and inspection programs The Program identified three tasks with eight associated milestones related to this item. Five of the milestones have been completed, one is part way to completion and the other two are ongoing efforts.
At the time of the 2021 IMPEP review, the Program had only one qualified license reviewer. The Program is working to re-qualify an inspector who was previously qualified. This is expected to be completed in July 2022. Additionally, the Program is qualifying a second inspector and the program manager to perform licensing actions. The program manager stated that becoming qualified to perform licensing actions will aid in their managerial review of licensing actions and support the workload if any staff turnover should occur. The Program plans to implement a peer review process of all licensing actions once additional staff are qualified. Until then the program manager is performing quality reviews of actions completed by the one qualified license reviewer.
Summary The Program continues to address the recommendations and performance concerns associated with the 2021 IMPEP review. The PIP was submitted to the NRC for Approval in February 2021. Official approval was given by letter dated May 10, 2022 (ML22126A047). Overall, the Program is making good progress in addressing the open items. The item regarding financial assurance has been completed. All other items are on track to be completed by the end of 2022. No action items or concerns were identified as a result of this call. The Program should update the PIP as appropriate and resubmit it at the time of the next bimonthly call.
Next Bimonthly Call: July 20, 2022.
Monica Digitally signed by Monica L. Ford L. Ford Date: 2022.06.23 08:45:27 -04'00' 4