ML24009A260

Good Practices- Process for Impep

ML24009A260
Person / Time
Issue date:	09/29/2023
From:	NRC/NMSS/DMSST/ASPB
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Download: ML24009A260 (1)

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Good Practices Table of Contents List of Acronyms................................................................................................................................................................................ 2 Technical Staffing and Training (TST)................................................................................................................................................ 3 Status of Materials Inspection Program (SMIP) ................................................................................................................................. 5 Technical Quality of Inspections (TQI) ............................................................................................................................................... 7 Technical Quality of Licensing Actions (TQLA) .................................................................................................................................11 Technical Quality of Incident and Allegation Activities (TQIAA) ........................................................................................................ 18 Legislation, Regulations, and Other Program Elements (LROPE) ................................................................................................... 21 Sealed Source and Device Evaluation Program (SSD) ................................................................................................................... 22 Low-Level Radioactive Waste Disposal Program (LLRW) ............................................................................................................... 26 Uranium Recovery (UR) .................................................................................................................................................................. 28 General ........................................................................................................................................................................................... 29 1

List of Acronyms Bureau Medical Event Review Team (BMERT)

Division of Nuclear Material Safety (DNMS)

Division of Radiation Control and Emergency Management (DRCEM)

General license (GL)

Information Notice (IN)

Integrated Materials Performance Evaluation Program (IMPEP)

Management Review Board (MRB)

National Sealed Source and Device Registry System (NSSDR)

New York State Department of Health (NYSH)

Nuclear Material Events Database (NMED)

Office of Radiation Control (ORC)

Quality assurance (QA)

Quality control (QC)

Radiation Protection Service (RPS)

Sealed Source & Device (SS&D)

Texas Commission on Environmental Quality (TCEQ)

Texas Department of State Health Services (TDSHS) 2

Technical Stang and Training (TST)

Year Program ADAMS Good Practice ML041350191 Emergency response outreach program. Washington had an outreach program for ML033380227 providing emergency response training to first responders, hospital staff, and local ML040680383 government health agencies for response to radiological events including incidents 2014 Washington ML033510162 resulting from terrorist activities. The training included the use of actual radiation sources ML041210379 and realistic scenarios and proved to be an effective tool for augmenting the capability of ML043630504 first responders.

Job skill criteria. NRC Region II developed Skills Lists (one for materials and one for fuel 2014 Region II ML20247N288 cycle positions). These lists allowed the Region to identify important attributes for recruitment and to help provide back-up staff to assure complete program coverage.

Monthly current issue meetings. The New York State Department of Health (NYSH) used monthly TeleVideo conferences to discuss ongoing issues and to keep their staff current on health physics and program issues. The review team identified one good 2014 New York ML20155G820 practice involving monthly teleconferences. After a brief discussion involving NRC training courses and in-house training, the MRB agreed to identify NYSH's use of teleconferences to keep their staff current on health physics and program issues as a good practice.

Physicist outreach program. Minnesota initiated an outreach program for licensee 2014 Minnesota ML14154A407 physicists. Approximately semi-annually, Minnesota hosts general information meetings with medical physicists and health physicists.

Cross training. The team recommended that the Regions cross-training and qualification of staff from the materials and reactors programs be found a good practice and the MRB agreed. Specifically, Region III faced significant challenges in meeting the fuel cycle inspection program goals during the IMPEP period. Region III effectively managed the unexpectedly high workload and very high turn-over in the fuel cycle inspection program through the cross-training and qualification of staff from the materials and reactors ML040580537 programs. This was separate from the systematic cross-training of senior materials 2003 Region III ML031690180 program staff in inspection and licensing, which is now a common practice within the Regions and many Agreement States. In the experience of the IMPEP team members, they had not previously seen the same level of inter-program training and qualification within the Regions. The inter-program approach was highly beneficial both to the involved individuals and to the Region and Agency. This approach of increasing staff fungibility (or the ability to interchange staff as needed to meet emergent needs) is also consistent with the Agencys long-term goals for work force planning.

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Staff from states with letters of intent supplement Iowa's program. During the discussion of the Iowa periodic, the MRB identified Iowas actions to supplement their staff as good practice. Iowa invites staff from States seeking Agreements (Wisconsin and ML022180782 2002 Iowa Minnesota) to participate in Iowa team inspections. This supplements the Iowa staff during ML020810634 inspections and trains staff in those States preparing to become Agreement States. The MRB recommended that Iowas good practice be included in the periodic good practice paper identifying other such practices.

ML043430514 Video feedback for instructors. The Florida staff assembled and presented a basic ML003711791 1999 Florida health physics training module that included the use of video recording the instructor ML993640268 practice sessions for self-critique and improvement on the course presentation.

ML20195G924 Cross training between radioactive materials and radiation machine sections. The MRB discussed the practice of the New Hampshire health physicists exchanging duties on a monthly basis between radioactive materials and the radiation machine sections. The 1994 New Hampshire ML20086F486 MRB asked Mr. O'Dowd if he believed this to be a good practice for a small program. He stated that he believed it strengthened their program and noted that New Hampshire is examining the frequency of the exchange to determine if monthly is the optimum time interval.

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Status of Materials Inspecon Program (SMIP)

Year Program ADAMS Good Practice Access Database for Reciprocity. Each year of the review period, North Dakota performed greater than 20 percent of candidate reciprocity inspections. Since the last IMPEP, North Dakota created an access database for reciprocity. When North Dakota receives a reciprocity notification, the information (e.g., date(s), location of work in North Dakota, licensee, type of 2019 North Dakota ML19256A024 authorized licensed activity, etc.) is entered into an access database. This database allows inspectors to perform a query and get a list of reciprocity licensees for a given date. The inspector can supplement their workload and complete reciprocity inspections in the vicinity of their routine inspections. The MRB suggested that the team consider identifying this as a good practice.

Notification of temporary job sites. North Carolina utilized a license condition that required all licensees authorized to use radioactive material at temporary locations to notify North Carolina of work being performed in the State and to provide information on when and where 2014 North Carolina ML20197C604 the work will take place. This information was posted on a bulletin board along with requests for reciprocity. Staff could select field inspections as needed and perform the inspections in an efficient manner.

Notification of reciprocity. Utah used a custom database management system programmed ML041350191 to provide the staff with a pop-up window, each day upon logging in, that indicates who is ML033350244 2014 Utah working in the State under reciprocity during the next 7-day period. If there are no licensees ML041210379 working under reciprocity during that time period, the pop-up window indicates this as well.

ML043630572 The system also tracks who has been in the State, when, where, and for how long.

Compliance checks on reciprocity applicants. Nevada has a policy of checking on the compliance history of a licensee requesting reciprocity approval with the Agreement State or NRC Region that issued the radioactive materials license. If the check reveals that a reciprocity 2010 Nevada ML092650359 applicant has outstanding compliance issues with their licensing authority (Agreement State or NRC Region), Nevada will deny the reciprocity application. This practice does not necessarily have to lead to the denial of a reciprocity application but could also be used to make an informed decision on whether or not to perform a field inspection of the reciprocity licensee.

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Better tracking of reciprocity licensees. Since the previous IMPEP review, the Program implemented a new policy to address inspection of reciprocity licensees. Each time the Program grants a reciprocity license, the time and location where the licensee will be working is 2010 Nevada ML092310540 placed on a shared calendar that can be accessed by managers, supervisors, and inspectors.

This new method allows the supervisors to better track reciprocity licensees and allows them to immediately assign these inspections to a program inspector working in the geographical area where the reciprocity licensee is working.

Pop-up window to identify reciprocity. The review team noted the Divisions custom database management system is programed to provide the staff with a pop-up window, each day upon logging in, that indicates who is working in the State under reciprocity during the next 2004 South Carolina ML040970372 7-day period. If there are no licensees working under reciprocity during that time period, the pop-up window indicates this as well. The system also tracks who had been in the system for tracking licensees that are working in the State under reciprocity be considered a good practice. The MRB agreed that the use of such a notification is a good practice.

Licensing and Inspection Database. In our reviews, we noted that managers made extensive use of computer databases to help establish and track inspection schedules. The Illinois Department of Nuclear Safety (IDNS), for example, had established an integrated user-friendly ML20116F573 1996 Illinois licensing and inspection database which tracked inspection due dates, along with a host of ML20007B039 other information regarding specific licensees. This system allowed staff to readily retrieve inspection and licensing information in preparation for inspections or the conduct of licensing reviews.

Note: Non-hyperlinked ADAMS documents mean they were not found in ADAMS or via Google search.

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Technical Quality of Inspecons (TQI)

Year Program ADAMS Good Practice Law enforcement at initial security inspections. As part of the preparation of the initial site visit to a licensees facility, Kentucky inspectors encouraged their licensees to invite a ML082830949 representative of the respective local law enforcement agency to attend the initial on-site visit 2014 Kentucky ML083100855 to evaluate the Increased Controls. This practice was conducive to communicating the intent and clarifying the requirements of the Increased Controls, as well as helping the local the law enforcement agency understand their role in the Increased Controls.

Customer satisfaction survey. Utah employed a unique customer satisfaction survey approach to its inspections. At the conclusion of the inspection, the inspector would leave a copy of a brief questionnaire with the licensee. It identified the inspector by name and ML003711791 requested the licensee to rate both the inspection (scope, duration, clarity) and the inspector 2014 Utah ML20116F573 (knowledge, professionalism, responsiveness). The form also requested the licensees views ML20007B039 on how the Utah program might better serve their needs. The Utah program showed a very strong commitment to Total Quality Management and this mechanism of getting customer feedback fit very well into that overall program. Utah has subsequently expanded this program to include customer satisfaction surveys for licensing actions as well.

Inspection photography. North Dakota inspectors included photographs of licensee ML043640435 2014 North Dakota operations in the inspection files. The photographs helped supervisors and future inspectors ML20197C604 have a visual indication of licensees facilities, equipment, and operations.

Inspection program self-audit. NRC Region III conducted a quarterly inspection self-assessment program. Each quarter, a senior inspector and a GG-13 inspector from each inspection branch spent a day reviewing one area of inspections. Topics included ML20148E216 documentation using the field notes, completion of Inspection Follow-up System (IFS) data, 2014 Region III ML20007J341 and inspection of events. The inspectors selected appropriate documents for review and ML20197C604 presented their findings, in writing, to the inspection branch chiefs. Findings have resulted in development of additional written guidance in the form of memoranda to the staff, as well as additional in-house training.

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Violation response checklist. New Hampshire used a violation response review checklist to document staff reviews of how the licensee addressed their response to each Notice of Violation. Specifically, when the licensee responds to a notice of violation (NOV), the New ML043640403 2014 response is given to the inspector to evaluate the licensee's response, and to draft a reply for Hampshire ML20197C772 the Radioactive Material Section Supervisor's signature. The review team noted a good practice in that the State uses a violation response review checklist to document staff reviews of the licensee response to each NOV.

ML043640352 ML20196K151 Peer reviewed notes and correspondence. The New York State Department of Labors 2014 New York ML20196K166 inspection field notes and inspection correspondence were peer reviewed by one of the ML20151V526 senior inspectors to assure consistency, thoroughness, and quality of reports.

ML20237E333 Rule requirement checklist. Oregon employed a unique method for educating the licensee of Oregons regulations, as they pertain to the licensees operation. At the conclusion of the inspection, the inspector would provide a checklist to the licensee that specified the Oregon administrative rule requirements applicable to the licensee. The licensee may use this 2014 Oregon ML043630580 checklist to facilitate the annual review of their radiation safety program. Additionally, the inspectors routinely utilized a form to document the vertical slice approach to their inspections, where several types of radioactive sources are tracked from their receipt to final disposal.

Field operations database. NRC Region IV kept a database of sites where licensees may 2014 Region IV ML041830510 conduct field operations. Inspectors used the database in conducting unannounced field inspections when they are in the vicinity for a routine inspection.

Post-inspection violation protocol. If inspection findings are determined to be violations after the conclusion of the inspection, the Iowa Bureau of Radiological Health contacts the ML080080168 licensee via telephone to give the licensee a heads up before the formal Notice of Violation 2014 Iowa ML073390153 is issued. The inspector and the licensee discuss each violation in detail so the licensee ML073180536 clearly understands the cited violations. This helps to ensure that the licensee initiates corrective actions in a timely manner.

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Pre-inspection plan. The section has implemented the use of a pre-inspection plan, which is used by each inspector. The plan includes basic information about the licensee, priority areas being reviewed, major elements of the program, documents used during preparation and the ML17039A487 type of equipment being used. This is also used to ensure all required information is 2014 Wisconsin ML14288A110 addressed during special or follow-up inspections. The use of these plans contributed to the consistent, high technical quality of inspections during the period of high staff turnover. Their preparation and use were evaluated during the review and inspector accompaniments.

Inspectors stated that these were instrumental in assuring a good quality inspection. The review team identified this as a Good Practice."

Web-Based Licensing (WBL) system. The program instituted the use of the NRCs WBL system and converted to a paperless system for document management in March 2014. The WBL system is an electronic system used to track assignment progress and completion of all 2014 Colorado ML14192A009 licensing actions and inspections. The review team noted that Colorado is the first state to fully embrace the live WBL system. The review team identified this as a good practice by the State.

Digital images. The Division makes efficient use of digital images to document site and shipment conditions. Variations are photographed for future use or to send to the shipper in ML032450231 the case of a violation. The team recommends that this be found a good practice as it 2003 South Carolina ML032600931 efficiently documents violation information and the exact details of the violation to the shipper.

ML043630149 The practice could be extended to other inspection processes such as radiography field inspections or gauge inspections.

Prompt inspection of change ownership licensees. The State requires that a new license be issued if a licensee undergoes a change in ownership or controlling interest. These ML033070007 licensees are also inspected as new licensees and included in the initial inspection data. The 2003 Florida ML043430534 MRB noted that promptly inspecting a licensee whose license authority has been transferred ML041350191 to a new owner not only protected public health and safety, but also promoted the common defense and security of materials. The MRB found this policy a good practice.

Inspection compliance history form. The Utah program utilized an inspection compliance history form both for the materials program and the low-level radioactive waste disposal ML003711791 program. The compliance history form included all of the past inspection findings for the 2000 Utah ML043640235 facility and was used not only to help the inspector prepare for the inspection, but also as a teaching tool during the inspection to help the licensee better understand the issues and past history.

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Review alert and user's declaration forms. The MRB asked the IMPEP team if they believed that California's use of a "review alert form" (Form 2033), a document that ML043430482 communicates inspection findings to licensing staff, was a "good practice." The IMPEP team 1996 California ML20148N224 stated that the use of such a form was a good practice. The MRB also discussed California's ML20197C604 use of a "user's declaration form," a form that allows a licensee to voluntarily sign an agreement to take immediate action, including cease and desist. The MRB and IMPEP team identified the use of this form as a good practice.

Note: Non-hyperlinked ADAMS documents mean they were not found in ADAMS or via Google search.

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Technical Quality of Licensing Acons (TQLA)

Year Program ADAMS Good Practice Tracking and streamlining actions. To better track and streamline licensing actions, Illinois implemented a licensing process to better apply resources and reduce the workload on the licensing staff. The team noted that Illinois leveraged newer Microsoft applications (Teams, Power BI, and Power Query) to integrate with existing databases and display a live-time dashboard of outstanding licensing actions. Succinct information could be displayed on the 2023 Illinois ML23219A199 days in house, assigned reviewer, status, as well as the nature and date of last contact with the licensee. This affords not only a caseload management tool for reviewers, but a dynamic supervisory tool to instantly assess progress on aging actions. This effort is being expanded to several other performance indicators allowing Illinois to better manage its program.

State specific versions of NUREG-1556. Illinois has begun to develop state-specific versions of the NUREG-1556 series volumes. Specifically, Illinois license reviewers used license applications and authorized user forms specific to these areas of authorized use (i.e., medical, portable gauges, radiography, etc.). The tailored applications clearly request the needed 2023 Illinois ML23219A199 information identified in the Illinois-specific guidance from the licensee. Staff and program performance metrics indicated the quality of submittals has improved as a result. Additionally, it was noted that the amount of correspondence required decreased, and the average completion time of licensing actions steeply declined.

Web-Based Licensing (WBL). The Program instituted the use of the NRCs Web-Based Licensing (WBL) system and converted to a paperless system for document management in March 2014. The WBL system is an electronic system used to track assignment progress and 2014 Colorado ML14192A009 completion of all licensing actions and inspections. The review team noted that Colorado is the first state to fully embrace the live WBL system. The review team identified this as a good practice by the State.

Change of ownership/controlling interest. Chapter 404 of the Florida Statutes required that ML041350191 a new license be issued if a licensee undergoes a change in ownership or controlling interest.

ML041210379 These licensees were also inspected as new licensees and included in the initial inspection 2014 Florida ML031080630 data. It was noted that promptly inspecting a licensee whose license authority was transferred ML033070007 to a new owner or had a change in controlling interest not only protected public health and ML043430534 safety, but also promoted the common defense and security of materials. The MRB found this policy a good practice.

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Computerized license templates. The Illinois Department of Nuclear Safety developed extensive licensing guidance for its staff, as well as an effective system of using licensing templates for individual reviewers via personal computer. These templates were contained on 2014 Illinois ML20007B039 the Departments computer network. Each reviewer had a personal computer tied into the network and was able to generate a completely new document each time the license is amended, which reflected the changes in the license in boldface type.

License information tracking system. The Illinois Department of Nuclear Safety used an administrative control technique referred to as blue sheets. These blue sheets were prepared by an administrative assistant, who also enters critical license application data onto the Departments computer network. The blue sheets were found to be effective for tracking the ML20116F573 2014 Illinois progress of licensing actions for fees, technical evaluations, telephone calls, deficiency letters, ML20007B039 responses, acknowledgment letters, mailing dates, and supervisory reviews. This same blue sheet information was used to generate periodic internal reports via the network. These reports were used to identify licensing actions by type, program code, date, licensee name, and reviewer name.

Simple license renewal - fee collection. New Hampshire used a different approach to fee collection, which also provided a mechanism to assure that basic administrative information about the licensee was up to date. The approach was referred to as a simple license renewal, which differed from New Hampshires standard 5-year technical license renewal. Under this ML20116F573 system, licenses expired on an annual basis. Each year, the licensee received a letter 2014 New Hampshire ML20007B039 informing them of the pending expiration of the license. To renew the license, the licensee was required to return the annual fee along with a form, which updated key information about the facility. This enabled the State to keep its records about licensee operations current, at least, on an annual basis. It was noted that all proposed changes to the licensed program had to be submitted by a separate letter requesting amendment of the license.

Licensing action quality control team. NRC Region III used a unique quality control approach in its materials licensing program. In this approach, a quality control team of license ML20116F573 2014 Region III reviewers would meet on a monthly basis to review 1-5 percent of the completed casework ML20007B039 before it was dispatched. This helped to assure uniform quality and provided timely feedback on appropriate licensing procedures to licensing staff.

Licensee responsibility cover letter. Nevada tied every new or renewed license through ML043640369 2014 Nevada license condition to an attached cover letter, which clearly explained the licensees ML20203A331 responsibilities when the licensee receives the license.

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ML030910547 Financial assurance spreadsheet. The Massachusetts program developed a spreadsheet to 2014 Massachusetts ML030350143 assist in determining the amount of financial assurance required based on the possession limit ML022550688 of radioactive material on the license.

Portable gauge model numbers. Iowa identified a potential problem associated with model number designations involving Troxler 3400 Series and other Troxler Model 34XX portable ML041350191 gauges. To avoid the potential problem, Iowa revised all portable gauge licenses that 2014 Iowa ML041210379 authorized Troxler 3400 Series by removing the 3400 series authorization and specifying each ML032970349 portable gauge in the series by its own model number. This licensing practice can be extended to other portable gauges distributed by manufacturers that use model numbers.

Pre-screening of licensing actions. NRC Region IV pre-screened licensing actions prior to assigning them to the license reviewers. The process involved the Branch Chief and the senior staff of the Licensing Branch meeting weekly to pre-screen every licensing action to determine if the licensee and/or applicant had provided adequate information for license reviewers to review the application. Applications with insufficient information (i.e., no signature, missing 2014 Region IV ML041830510 referenced information, no supporting documentation, etc.) were provided to the staff for follow-up. After the licensee had responded with the additional information, the review could be completed. This pre-screening approach to the licensing process had greatly increased the timeliness of licensing actions, reduced the need for lengthy deficiency correspondence, and increased the effectiveness and efficiency of reviewing licensing actions.

Identification of changes to licenses. Texas included in the transmittal letter for an 2014 Texas ML053560316 amended license a description of the changes (a roadmap), so that the changes to the license were readily visible and easily identified by the licensee.

Transmission of licenses via certified mail. Minnesota instituted a policy for license issuance that requires all licenses to be sent by certified mail with return receipt requested.

ML100670527 This practice, if used for licenses containing sensitive unclassified, non-safeguards information 2014 Minnesota ML080150246 (SUNSI), places additional control on SUNSI documents by helping to ensure that the license ML073530505 document is received by the correct licensed facility and is delivered to the appropriate addressee. First class mail does not provide this level of protection.

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License condition for terminated licenses. Louisiana implemented a unique license condition in terminated licenses that states If the Department determines that the information supplied is incorrect or defective, the applicability of a specific license may be reassessed.

With this approach, the condition effectively holds the former licensee liable when inaccurate ML082060098 information provided by the licensee in the termination of the license. In such cases, the 2014 Louisiana ML082240019 Department has a right to pursue actions against the former licensee, if warranted. For example, if radioactive material is found at a facility after the radioactive materials license is terminated, the former licensee is held legally responsible for ensuring proper disposition of the radioactive material. The review team recommended, and the MRB agreed, that use of this standard license condition on terminated licenses is a good practice.

Document for termination of licensed activites. RIII developed a document entitled "Information that Should be Submitted to the NRC Staff for Decommissioning and Termination ML20007J341 2014 Region III of Licensed Facilities" (Attachment B in ML20197C604). The document is provided to ML20197C604 licensees intending to request authorization for release of a room or building for unrestricted use or for termination of licensed activities.

Database of persons listed on licenses. Alabama has developed a searchable database to maintain records of authorized users, authorized nuclear pharmacists, authorized medical physicists, and radiation safety officers listed on licenses in the State. Alabama creates a record for each individual and lists each license on which that individual holds one of the aforementioned positions and, for authorized users, the modalities for which that individual has met the training and experience requirements. This database increases the efficiency of 2010 Alabama ML102090068 Alabamas review of an individuals qualifications when a licensee requests that an individual be added to their license for a particular position or modality. With this database, Alabama can quickly verify if the individual is already listed on another license in the State and if that individual is indeed qualified to perform the duties for the position requested by the licensee.

The database was created during the States normal licensing workload over the course of several years.

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Sharing medical licenses with nuclear pharmacies. Washington developed a practice of transmitting copies of medical licenses they have amended within a calendar quarter to each of their nuclear pharmacy licensees. This enables a pharmacy to cross-reference the copy of the license provided by the client with the copy provided by the State. The States nuclear ML081900089 pharmacy licensees support this practice, as it allows them to have a current copy of their 2008 Washington ML082100311 clients licenses. Washingtons nuclear pharmacy licensees have agreed to maintain appropriate document control over the license documents in their possession. The review team recommends that the States practice of transmitting copies of amended medical licenses to nuclear pharmacies for verification of license possession limits be found a good practice.

Decommissioning guidance website. NRC Region III developed a decommissioning guidance website. The website contains links to pertinent information and guidance documents for decommissioning, such as NUREGs, and includes a number of out-of-print and 2007 Region III ML073330421 hard-to-find documents. Maintenance of the website is performed in-house by the Division, and as additional useful documents are identified or suggested, the webmaster adds them to the website. The review team recommended, and the MRB agreed, that the Divisions decommissioning guidance web site be identified as a good practice.

Picture gallery. The Division has created a picture gallery of radioactive material-related photographs. The gallery, which is organized by types of use and modality, contains photographs and schematic diagrams of devices, sources, and facilities. The gallery provides the Division with the ability to include pictures and diagrams in incident briefings to enhance the effectiveness of the briefings to individuals that may not be knowledgeable of such 2007 Region III ML073330421 sources, devices, or facilities. The gallery also provides the Division with an excellent source of visual aids for inclusion in non-incident related discussions and presentations, such as in-house training courses or topical seminars. The gallery can also be used to educate new staff members on the appearance and use of such devices, sources, and facilities. The review team recommended, and the MRB agreed, that the Divisions picture gallery be identified as a good practice.

Quality control reviews. The team found Region IIs use of a senior license reviewer to perform quality control reviews on licensing actions to be found a good practice. The MRB ML022170775 discussed the good practice identified by the team, and noted that it is management initiatives 2002 Region II ML021830216 to resolve licensing inconsistencies, and not the quality controls reviews, that should be ML021130620 identified as the good practice. The MRB directed that the report be revised to identify the good practice as the identification of an issue, establishment of the expectations to address the issue, and the successful resolution of the issue by management.

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Periodic peer review. Region II established a periodic peer review through a Regional Office Instruction (ROI) in 1998. The peer review is a semi-annual review of completed licensing actions by license reviewers and DNMS managers. These reviews are intended to be a quality check to determine the appropriateness of license conditions and documents references, identify any grammatical or clerical errors, deficiencies in the license application, and ML021130620 2002 Region II completeness of licensing files. In addition, RII now requires licensing actions to undergo an ML021690576 independent review by a senior license reviewer prior to issuance of the license action. The 2000 IMPEP self-assessment identified further inconsistencies and errors. However, the periodic peer review reduced the magnitude of the problem and the additional senior license reviewer check prior to issuing the action is an aggressive corrective action and recognized as a good practice during this IMPEP review.

Quality control review. The review team recommends the Region IIs management approach of identification of an issue, establishment of the expectations to address the issue and the successful resolution of issue by management be identified as a good practice. This approach was used to resolve licensing inconsistencies identified during IMPEP self-assessments. RII 2002 Region II ML021690576 management initiated a process which used a senior license reviewer to do a quality control review on all licensing actions prior to issuing the action. As one of the empowerment initiatives being pursued in the Materials Arena and since expectations have been established for license reviewers, RII management is changing the practice from reviewing all actions to a more statistical sampling of outgoing actions.

Certify understanding of license. The Department requires authorized users and radiation safety officers for medical licenses to certify that they have familiarized themselves with the ML013530314 2001 Texas conditions of the license application and agreed to abide by the statements, representations, ML043630135 and procedures as submitted with the application prior to approving them in their requested role.

Property owner affidavit. The Texas Department of Health requires an affidavit statement ML013530314 from a property owner in cases where licensed activities were to be conducted on leased 2001 Texas ML043630135 property to ensure that the property owner know that the tenant will be storing and using radioactive material at the site.

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License templates. The Illinois Department of Nuclear Safety (IDNS) has developed extensive licensing guidance for its staff as well as an effective system of using licensing templates for individual reviewers via personal computer. These templates are contained on 1996 Illinois ML20116F573 the IDNS computer network. Each reviewer has a personal computer tied into the network and is therefore able to generate a completely new document each time the license is amended, which shows the changes in the license in bold-face type.

Customer satisfaction survey. Utah employed a unique customer satisfaction survey approach to its inspections. At the conclusion of the inspection, the inspector leaves a copy of a brief questionnaire with the licensee. It identifies the inspector by name and requests the licensee to rate both the inspection (scope, duration, & clarity) and the inspector (knowledge, ML003711791 professionalism, responsiveness). The form also requests the licensee's views on how the 1996 Utah ML20116F573 Utah program might better serve their needs. Utah has a very strong commitment to Total ML20007B039 Quality Management and this mechanism of getting customer feedback fits very well into that overall program. Utah has subsequently expanded this program to include customer satisfaction surveys for licensing actions as well as inspections. Copies of both survey forms are included as Attachments 2 and 3 (see ML20116F573).

License database automation. NRC Region IV made advances in license automation using ML20116F573 1996 Region IV Word Perfect macros and search techniques, which allowed the Region to search its database ML20007B039 to respond more promptly to queries about specific or generic licensing issues.

Note: Non-hyperlinked ADAMS documents mean they were not found in ADAMS or via Google search.

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Technical Quality of Incident and Allegaon Acvies (TQIAA)

Year Program ADAMS Good Practice Recovery and remediation fee. Illinois had instituted an orphan source program that was funded through a Recovery and Remediation Fee assessed over the first two-year period to all new licensees. These fees went into a special fund to be used for the recovery and remediation of radioactive materials. When sources were abandoned, the State stored these 2014 Illinois ML092160030 sources in a secure storage facility and tracked the status of the sources in a database.

Periodically, the State sent their staff to collect these sources and package them for disposal.

Illinois then contracted with a broker to pick up and arrange for disposal of the orphan material using the special funds.

Team review of incidents and allegations. In Maryland, all complex events and allegations, as well as those with the potential for impacting public safety, were evaluated by the radioactive materials supervisor, management, and staff, in order to determine an appropriate 2014 Maryland ML20197C604 response. The response varied based on the safety significance of the event, from resolution through telephone discussion to immediate response by a team of two health physicists, and, in some cases, included issuance of a press release to the media.

Audits of allegations. NRC Region I conducted bi-monthly staff and semi-annual management audits of selected radioactive materials allegations. These audits verified such 2014 Region I ML20248E226 items as the completeness and clarity of allegation information, the timeliness of correspondence and Allegation Panels, and the appropriateness of panel actions and closure letter.

Quality Assurance Health Physicist. The California program utilized a Quality Assurance ML003711791 2014 California Health Physicist. The position strengthened the Programs performance and ensured that ML043430521 health and safety issues were properly addressed.

ML041350191 Incident initial responder list. North Dakota compiled a list of trained personnel in the State ML071640192 who would be willing to respond to a radiation incident, such as a transportation incident, and ML040580560 to provide initial assessment of the incident or assist during the incident until State 2014 North Dakota ML031840353 radiological emergency response personnel can arrive. The list included the names of ML031990487 volunteers, their location within the State, the types of equipment they have available, and ML071880009 their contact telephone numbers.

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Creation of interdepartmental incident review board. The review team identified a good practice by Ohio regarding its creation of a board whose members included management from other Divisions including X-Ray and their legal department, to review all medical events and any other events involving potential overexposures in order to formulate a comprehensive and informed response by all board members. Specifically, if the incident involves a medical event or other potential exposure event, the Bureau Medical Event Review Team (BMERT) is assembled. The BMERT is chaired by the Radiation Protection Bureau Chief and is ML14149A298 2014 Ohio composed of administrators from the Nuclear Materials Safety, Technical Support, and X-Ray ML14055A239 Sections, the Supervisor overseeing the incident, the Office of General Counsel, and other personnel as requested. Participation by both radioactive material and x-ray program representatives allows the Bureau a comprehensive view of radiation use in the State. The process has resulted in the identification of cross-cutting issues amongst the represented sections who regulate the same licensees, but different activities such as linear accelerators and brachytherapy. The BMERT also tracks escalated enforcement and allegation cases. The review team identified, and the MRB agreed, this as a good practice by the State.

Unwanted radioactive material and Orphan Source Recovery Program. In 2006, the Bureau of Environmental Safety expanded their Orphan Source Recovery Program to include Illinois high schools. This initiative is a non-emergency response hazard mitigation program ML092390301 2009 Illinois that collects and properly disposes of unwanted radioactive material from the schools. The ML052010292 collection of unwanted radioactive material is at no cost to the schools. The review team recommends that the States expansion of its orphan source recovery initiative to high schools be identified as a good practice.

Picture gallery. NRC Region III created a picture gallery of radioactive material-related photographs. The gallery, which is organized by types of use and modality, contains photographs and schematic diagrams of devices, sources, and facilities. The gallery provides the ability to include pictures and diagrams in incident briefings to enhance the effectiveness 2007 Region III ML072980403 of the briefings to individuals that may not be knowledgeable of such sources, devices, or facilities. The gallery also provides an excellent source of visual aids for inclusion in non-incident-related discussions and presentations, such as in-house training courses or topical seminars. The gallery can also be used to educate new staff members on the appearance and use of such devices, sources, and facilities.

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Allegation handling training. In addition to Agency-mandated allegation training, Region II required new hires to attend a PowerPoint presentation regarding allegation management, as well as listen to sound clips of actual allegations. While listening to the sound clips, new hires filled out forms to document the allegations. Once all of the training modules were completed successfully, the individuals were certified to accept allegations. Specifically, the review found that Region II staff were well-trained and knowledgeable in the accepting and 2006 Region II ML062780415 handling of allegations. The review team found this additional training particularly beneficial to inspectors, who have direct interface with potential allegers. The review team discussed with Regional management the benefits of sharing their practice of additional training with other NRC Regions and Offices. The review team recommended and the MRB agreed that the Region's practice of performing additional allegation training above and beyond the Agency-mandated training was a good practice.

Issuance of generic communications. Wisconsin reviewed and analyzed all incidents to establish and evaluate root causes, to recognize generic issues, and to notify affected licensees of their findings if a trend is identified. In particular, after responding to several incidents resulting from MICK Applicator malfunctions, Wisconsin researched the issue through NMED. The State discussed the issue with the relevant hospitals, the device manufacturer, other Agreement States, and the NRC. The State concluded that the malfunction was a generic issue and issued an Information Notice (IN) on June 9, 2005. The 2005 Wisconsin ML053360519 IN informed Wisconsin medical licensees of the incidents and alerted them to issues associated with the applicator. The information was shared with the NRC, and shortly thereafter, on June 23, 2005, the NRC issued IN 2005-17: Manual Brachytherapy Source Jamming, using Wisconsins IN as an attachment. The review team recommended and the MRB agreed that Wisconsin's process of actively reviewing and analyzing incidents to establish and evaluate root causes, to recognize generic issues, and to notify affected licensees of their findings be identified as a good practice.

Note: Non-hyperlinked ADAMS documents mean they were not found in ADAMS or via Google search.

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Legislaon, Regulaons, and Other Program Elements (LROPE)

Year Program ADAMS Good Practice Reading proposed regulations aloud. The California program reviewed draft regulations by reading the regulations out loud to available staff. This practice provided the technical and ML003711791 2014 California administrative staffs, the individuals responsible for implementing the regulations, and those ML043430521 most often in contact with the licensees the opportunity to identify potential problems before the regulations were finalized.

ML030910547 Adoption by reference. Adopting regulations by reference allowed the State of Oklahoma to ML030770604 2014 Oklahoma implement regulations quickly and avoid potential compatibility conflicts. It also reduced ML043630189 confusion for reciprocity and multi-State licensees.

ML023010554 A checklist for the licensee. The Radiation Protection Service (RPS) employs a unique method for educating the licensee of Oregons regulations as they pertain to the licensees operation. At the conclusion of the inspection, the inspector provides a checklist to the licensee that specifies the Oregons administrative rule requirements applicable to the 1998 Oregon ML043630580 licensee. The licensee can use this checklist to facilitate the annual review of their radiation safety program. Additionally, the inspectors routinely utilize a form to document their vertical slice approach to their inspections where several types of radioactive sources are tracked from their receipt on through to disposal.

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Sealed Source and Device Evaluaon Program (SSD)

Year Program ADAMS Good Practice Documenting the reasons for the amendment. The Branch incorporated a good practice California and 2019 ML20024E166 example from the State of Ohio by documenting the reasons why an SS&D license/registration Ohio was amended into the reviewers notes section as part of its SS&D registrations.

Historical Overview. The Program maintains all SS&D records in its electronic database. The team found that the Program references records that provide a readily accessible historical overview of all the current, as well as the previous, actions on the SS&D registration. Addition of the revision history to the SS&D sheets makes it easier for license reviewers to understand 2019 Ohio ML19141A224 how a device has changed over time. It is worth noting that this concept was included in NUREG-1556, Volume 3, Revision 2, issued in September 2015, based on a suggestion from a working group member from the State of Ohio. Since this occurred during the review period the team is recommending that this effort be identified as a good practice.

Screening of applications. The NRC SS&D evaluation program instituted a screening ML003711791 process for all SS&D applications. The initial screening of an application saved time and effort.

2014 NRC ML012340316 An application was initially reviewed to determine if there was enough information to perform ML20210T413 the review. If incomplete, or if information was lacking, the application was returned to the applicant without further review.

QA/QC of registrants. Georgia conducted quality assurance and quality control (QA/QC) inspections on all SS&D registrants to ensure accuracy and consistency in the production of sources and devices. A letter was sent to all manufacturers and distributors of SS&Ds which informed the registrants (licensees) that a QA/QC inspection was being implemented to ensure that products are being constructed according to design specifications. The Program developed a QA Inspection Form for SS&Ds and a Gauge Distribution Inspection Form for ML012880439 2014 Georgia use during the QA/QC inspections. These inspections were completed during the period of ML043430523 July 1997 through June 1998 and were in addition to the normal routine inspections conducted on each license. The team believes that this method to evaluate SS&D registrants QA/QC programs should be considered a good practice. The review team identified the Programs policy of conducting quality assurance and quality control inspections on all SS&D registrants to ensure accuracy and consistency in the production of sources and devices as a good practice.

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Linking SS&D casework to material license. When Ohio completed SS&D casework, the updated SS&D registration was tied to the applicants radioactive materials license. When a ML050750271 2014 Ohio sealed source and/or a device was introduced in an applicants product line, a design or ML050210356 radioactive material strength was modified, or an error was corrected, all these actions were reflected in applicants license.

Central registration files. Massachusetts maintained a records filing system that provided a readily accessible historical overview of all the current as well as the previous actions for each SS&D registration. Specifically, all actions ranging from initial approval through consequential amendments, changes, and corrections to the latest action were maintained and stored in one file. In the file, the individual actions were clearly separated from each other and fully documented. Specifically, the review team found that the SS&D files were maintained in an 2014 Massachusetts ML062360274 orderly manner and correspondence was filed chronologically. The review team noted that the records filing system is organized in a comprehensive manner to maintain all previous actions regarding the SS&D registration certificates. As a result, the records filing system provides, for each SS&D registration, a most readily accessible historical overview of all the current as well as the previous actions. The review team recommends that the Commonwealths filing system for SS&D casework files be identified as a good practice.

Safety evaluation checklists. In performing the SS&D safety evaluations, Massachusetts used a checklist for each case to assure that all aspects of the safety evaluation had been 2014 Massachusetts ML062360274 satisfactorily completed. Both reviewers initialed and dated the check list, and in addition, the SS&D supervisor also reviewed, initialed, and dated the checklist, thus, providing an additional quality assurance check for the safety evaluation process.

Additional quality assurance measures. Maryland completed each SS&D case using two checklists unique to its SS&D program in addition to the universally-used technical checklist in NUREG-1556, Volume 3, Revision 1. Maryland uses a "completeness review checklist,"

2014 Maryland ML073190603 which delineates in great detail the specific issues that must be addressed in the registration certificate, and a "concurrence review checklist," which assures that the concurring SS&D reviewer would not miss the significant issues in completing the casework.

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Event analysis. Maryland developed an Event Flow Chart, which leads to decision points to identify major issues involved in the event evaluation through a series of yes/no questions.

The major issues addressed by the flow chart include human errors, the manufacturers root 2014 Maryland ML073190603 cause analysis, and the need for engineering analysis. Maryland also retroactively applied the Event Flow Chart to incident reviews that had already been closed out in order to determine the validity of its earlier resolutions.

Comprehensive SS&D procedures. California developed a comprehensive procedure to conduct safety evaluations of events and SS&D incidents (Procedure No. 04-03-005). For example, the procedure defines the roles and responsibilities for the supervisor as well as for 2014 California ML081770326 the staff, delineates how to interface with other organizations, describes how to conduct the investigation for the event, and specifies the documentation requirements. Such a procedure can help a program ensure completeness of technical reviews of SS&D incidents, including identification of generic issues.

Completeness review and Concurrence Review Checklists. Maryland uses a completeness review checklist, which delineates in great detail the specific issues that must 2007 Maryland ML073461080 be addressed in the registration certificate, and a concurrence review checklist, which helps ensure that the concurring SS&D reviewer does not miss the significant issues when completing the casework.

Checklist. The review team noted that the program maintains a records filing system, which provides for each SS&D registration, a most readily accessible historical overview of all the 2006 Massachusetts ML062580079 current as well as the previous actions. The review team also noted that in performing the SS&D safety evaluations, the program uses a checklist for each case to assure that all aspects of the safety evaluation had been satisfactorily completed.

Registering sources as parts of devices. Georgia registered sealed sources as part of device evaluations when a source was not previously registered. The sealed source was ML050120165 2004 Georgia registered as part of the device and the registration certificate noted in the text that the source ML043410257 was approved for use in such an application only. Georgia made such source registrations prominent by placing a note on the first page in the sealed source designation place.

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National database. The Section has recently developed a database entitled, National Sealed Source and Device Registry System (NSSDR), to aid staff in effectively and efficiently finding specific information on SS&Ds. Section staff demonstrated the use of this database for the 2001 NRC ML020230187 review team and the team found that the database allows the Section to retrieve information expeditiously. The newly developed SS&D database, NSSDR, which permits flexible searches based on manufacturer, model, nuclide, use, and other characteristics, is identified as a good practice.

Spreadsheet. Section staff also discussed with the review team their use of a spreadsheet to aid in SS&D file organization. The spreadsheet contains information on enclosed documents and like the database, aids Section staff in finding information expeditiously. The addition of a 2001 NRC ML020230187 spreadsheet, listing the enclosed documents, at the front of the package of documents for a given action makes it much easier to review each package and find appropriate information, and is identified as a good practice.

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Low-Level Radioacve Waste Disposal Program (LLRW)

Year Program ADAMS Good Practice Site and shipment photography. South Carolina made efficient use of digital images to ML041350191 document site and shipment conditions. Variations were photographed for future use or to send 2014 South Carolina ML041210379 to the shipper in the case of a violation. This practice efficiently documented violation information and the exact details of the violation to the shipper.

Modular inspections. Utah implemented modular inspections, as compared to annual ML041350191 inspections, of low-level waste disposal facilities to enable the Division to utilize technical staff 2014 Utah ML041210379 more efficiently, provide for more timely inspections, and provide better oversight of waste ML043630572 facility operations and performance.

Security plan as license condition. Utah incorporated the security plan into the license as a ML041350191 specific license condition, and thus made the licensee more accountable for incoming/outgoing 2014 Utah ML041210379 radioactive material at the site. The State was in a better position to monitor, inspect, and ML043630572 enforce safety and security aspects regarding release of contaminated tools, containers, and materials from the site.

Roadmap and closure criteria. Two good practices were identified during the Texas IMPEP review: (1) the Texas Commission on Environmental Quality (TCEQ) and the Texas Department of State Health Services (TDSHS) include in the transmittal letter for amended 2006 Texas ML060330260 licenses a description of the changes (a roadmap) so that the changes are clearly identified; and, (2) the TCEQ attaches, as an appendix to the active onsite disposal license, the closure criteria for the closed disposal cells, which keeps the as-closed conditions in the license even though new criteria have been established for the newer cells.

Modular inspections. The review team noted that Utah implemented the use of modular inspections, as compared to annual inspections, to enable the Division to utilize the technical staff more efficiently, provide for more timely inspections, and provide better oversight of the 2004 South Carolina ML040970372 waste facility operations and performance. The review team commends the Division for adopting a modular approach for inspection of the low-level radioactive waste facility and recommended to the MRB that this be considered as a good practice. The MRB agreed that the use of modular inspections is a good practice.

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Security plan as license condition. The review team noted that the Division incorporated the licensee's security plan into the license as a specific license condition and makes the licensee more accountable for incoming/outgoing material at the site. The Division will be in a better 2004 South Carolina ML040970372 position to monitor, inspect, and enforce safety and security aspects regarding release of contaminated tools, containers, or materials from the site. The team believes that this emphasis will enhance the site safety and security aspects. The review team recommended that incorporation of the security plan on the license be considered a good practice. The MRB agreed that the incorporation of security plans as a license condition is a good practice.

Compliance history form. The Utah program utilizes an inspection compliance history form both for the materials program and the low-level radioactive waste disposal program. The ML043640235 2000 Utah compliance history form includes all of the past inspection findings for the facility and is used ML003711791 not only to help the inspector prepare for the inspection, but also as a teaching tool during the inspection to help the licensee better understand the issues and past history of the license.

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Uranium Recovery (UR)

Year Program ADAMS Good Practice ML012880439 Construction photography. Colorado utilized photographic documentation of 2014 Colorado ML043430526 decommissioning construction activities.

ML011210441 ML041350191 Notification of change in business structure. The State of Washington put conditions in ML033380227 licenses that the licensees must notify the State in writing 30 days prior to any change in their ML040680383 2014 Washington business structure. This license condition provided the State with the opportunity to evaluate if ML033510162 changes in the licensees business structure could adversely affect the licensees ability to ML041210379 continue to provide adequate decommissioning funding.

ML043630504 Cross-training. NRC Region III used cross-training and qualification of staff from the materials and reactors programs to effectively manage an unexpectedly high 2004 Region III ML041350191 workload and very high turn-over in the fuel cycle inspection program. The inter-program approach was highly beneficial both to the individuals involved and to the Region and Agency.

Written guidance. The team identified the Region II detailed, written guidance targeting 1998 Region II ML20247N288 specific fuel cycle plant operations and functional areas for emphasis during inspections as a good practice.

Info to support license termination. The review team identified the Region IV document entitled "Information That Should Be Submitted to the NRC Staff for Decommissioning and 1997 Region IV ML20007H201 Termination of Licensed Facilities," for distribution to terminating licensees, as a good practice, and recommends that its use be considered by other Regions and Agreement States.

Facility integration matrix. Region II maintains a facility integration matrix for each fuel cycle ML20117H061 facility to help identify trends and patterns of licensee performance with regard to violations 1996 Region II ML20117K846 and reported incidents. This information is also used in managing and planning fuel facility ML20197C604 inspections.

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General Year Program ADAMS Good Practice Safety culture. As part of its mission of protecting the public from unnecessary exposure to radiation, the Program partnered with its licensees to help promote an environment of positive safety culture in the work place. Program staff engaged licensees to learn what was 2019 New Jersey ML19176A361 important to them regarding a safe work environment and used that information to develop a safety culture poster that is suitable for work-place posting. The poster defines ways to practice a positive safety culture environment and identifies positive safety culture traits. The team is recommending that this effort be identified as a good practice.

Self-assessment. The Program conducted a self-assessment utilizing the IMPEP indicator guidance criteria prior to the 1998 IMPEP, and the MRB acknowledged that this was a good 2001 Alabama ML993640277 practice. The Materials Compliance Branch Director has participated on two IMPEP teams and the Program Director related that this participation was helpful to them to better understand the IMPEP program and helpful in the assessment of their own program.

Self-Evaluation Program. The IMPEP review team identified the Divisions Self-Evaluation Program as a good practice. The Division Director initiated a Self-Evaluation Program to assess the Divisions status relative to the comments and recommendations made after the 1995 program review. In addition to examining the previous review findings, the Self-Evaluation Program provided an opportunity for Division staff to measure their current program against the new IMPEP indicators. Strategies were then developed to address the licensing backlog, the need to develop licensing and inspection guidance, and to revise rules 1998 Arkansas ML043430500 and regulations. The self-evaluation initiative led to the issuance of several Action Plans.

These Action Plans identify a specific topic to be addressed (e.g., revision of rules and regulations) and are numbered for tracking purposes. A project leader and team are named and beginning and projected completion dates are established for each Action Plan. There is a provision for amending the completion date; however, the Division Director must approve and document any changes. Upon completion of the tasks identified in the Action Plan, management will review and approve the completed work by signature.

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General license program tracking. In 1984, the Radiation Protection Service (RPS) instituted a program that tracks registered general license (GL) devices (i.e., gamma gauges and in-vitro test kits). Although other States track such devices, Oregons implementation 1998 Oregon ML043630580 practices of the program are unique. In addition to requiring accountability of the devices, the State will also perform onsite inspections and request additional information (e.g., leak test results) from the general licensee. The program for registering these GL devices has been recognized by NRC which is considering adoption of a similar system nationwide.

Self-audit. The review team identified the Office of Radiation Control's (ORCs) self-audit as ML043640562 a good practice. The ORC initiated the self-audit to assess the status of the comments and 1998 Alabama ML993640272 recommendations from the 1995 program review, and to measure the current program ML20236V328 against the IMPEP indicators. Corrective actions and improvements in several areas were identified and implemented.

Self-assessment. The team also noted Region ll's self-assessment program as a good practice. This self-assessment program covered all aspects of the Region II Division of Nuclear Material Safety (DNMS) program. Region II conducts a formal self-assessment ML021830216 program. The program is very effective in providing the regional management with 1996 Region II ML021690576 information on regional performance. In all the common and non-common performance ML20197C604 indicators, the review team found issues which in following-up on the issues, the team would determine that the recent IMPEP self-assessment had identified the same or similar issues and RII had already initiated corrective measures.

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