ML23114A258
| ML23114A258 | |
| Person / Time | |
|---|---|
| Issue date: | 03/15/2023 |
| From: | Monica Ford Decommissioning, ISFSI, and Reactor Health Physics Branch |
| To: | |
| References | |
| Download: ML23114A258 (1) | |
Text
RHODE ISLAND DEPARTMENT OF HEALTH HEIGHTENED OVERSIGHT CONFERENCE CALL March 15, 2023 Nuclear Regulatory Commission Rhode Island Department of Health Attendees Attendees Monica Ford, RSAO Alex Hamm, Supervisor, Radiation Control Program Farrah Gaskins, RSAO Dennis Klaczynski, Senior Radiological Health Specialist Blake Welling, Director DRSS Maria Barnes, Radiological Health Specialist Melissa Ralph, Deputy Director DRSS Bethany Cecere, Chief, SALB Robert Johnson, Project Manager, SALB 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, the 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 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 initial PIP on September 19, 2021 (ADAMS accession number ML22276A108).
[Note: Due to the COVID-19 pandemic, the IMPEP review previously scheduled for July 2020 was delayed. It was subsequently rescheduled and was conducted in October 2021.]
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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.
Rhode Island PIP dated March 9, 2023: 03-09-2023 Rhode Island Program Improvement Plan.pdf (ML23075A026).
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Recommendation 1
- Rhode Island management take measures to ensure licensing and inspection documentation is complete and stored in a centralized filing system.
To address this recommendation, the Program defined four tasks with six associated milestones. Since the 2021 IMPEP review, all milestones have been completed. The Program is continuing to work on digitizing all of its licensing and inspection files. An audit was performed of all licenses issued by the Program to ensure that all documents associated with tie-down conditions on the most current license are captured in the electronic database. Additionally, the Program is including the last two inspection reports for each licensee in the electronic database.
Some of the historical inspection documentation has been mis-placed and the Program is working to locate/ obtain the missing documents to the best of its ability.
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. All tasks have been completed. The Program received a new portable gauge application which allowed them to practice using the Pre-Licensing guidance. The action was completed by the principal reviewer for that action. A secondary review of the action was completed by the Program Supervisor. Although all tasks associated with this recommendation are complete, ensuring proper use of the Pre-Licensing guidance will be an ongoing effort.
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. All tasks have been completed. The Program received a new portable gauge application which allowed them to practice using the RSRM checklist. The action was completed by the principal reviewer for that action. A secondary review of the action was completed by the Program Supervisor. Although all tasks associated with this recommendation are complete, ensuring proper use of the RSRM checklist will be an ongoing effort.
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 3
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 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. All tasks and milestones have been completed. The Program consists of four technical staff. At the time of the 2021 IMPEP review, of the four technical staff, only one was a qualified license reviewer. Since the 2021 IMPEP review, the Program has worked to qualify additional license reviewers. At this time three of the four staff are fully qualified as both license reviewers and inspectors and one staff is a fully qualified inspector only. In addition to the technical staff, the Program Supervisor is working on becoming qualified to review licensing actions. In order to help with knowledge transfer and ensure consistency, the Program has implemented a peer review process for licensing actions.
Other IMPEP Related Items Discussed.
A brief discussion was had related to all common and applicable non-common performance indicators falling under the IMPEP process. No major changes or concerns were identified during the discussion. The Program confirmed that refresher training for all qualified staff was being maintained. No inspections have been completed overdue during this review period. The Program is using a risk-informed process for completing reciprocity inspections. There is one challenging licensing action in house involving a broad scope medical licensee who is attempting to change its authorization to a limited scope license. The Program is in constant communication with this licensee as it works to complete this action. The Program has not received any incidents or allegations since the 2021 IMPEP review. Lastly, the Program adopts the NRCs regulations by reference, and all regulations are up to date. The Program is on track for the IMPEP review tentatively scheduled to be held in November 2023.
Summary The Program has addressed all of the recommendations and performance concerns associated with the 2021 IMPEP review. The initial PIP was submitted to the NRC for Approval in February 2022. Official approval was given by letter dated May 10, 2022 (ML22126A047). No action items or concerns were identified as a result of this call. The Program should update the PIP as appropriate with any additional items it wishes to track and resubmit it prior to the next heightened oversite call.
Next Heightened Oversight Call: May 2023. Digitally signed Monica by Monica L.
Ford 4
L. Ford Date: 2023.04.24 16:24:48 -04'00'