ML25133A028
| ML25133A028 | |
| Person / Time | |
|---|---|
| Issue date: | 05/15/2025 |
| From: | Laura Smith NRC/NMSS/DMSST/ASPB |
| To: | Robert Lewis NRC/EDO/DEDMRS |
| References | |
| Download: ML25133A028 (1) | |
Text
Comment No.
Location Comment Accepted Remarks 1
Section 3.5 In Section 3.5, Technical Quality of Incident and Allegation Activities, paragraph 1 of the discussion, it is noted that Nebraska did not conduct on-site follow-up inspections for any of the cases reviewed. In accordance with Radioactive Materials Inspection Procedure (RMPP) 3.01, the Manager, RPM, or designee, has the authority to determine whether an immediate inspection is warranted or if the issue should be addressed during the next scheduled inspection. In Bullet 1 of the Evaluation of the same section, Nebraska disagrees with the statement that incident response and allegation procedures are not in place and followed. As noted above, in the two cited instances, documentation for a reactive inspection was not generated because no inspection was conductedconsistent with Nebraskas procedures, which do not require such documentation when an inspection is not warranted.
Not Accepted Nebraska issued violations shortly after being notified of the incident and allegation in question, suggesting that Nebraska did not make a determination to review at the next inspection (or to perform no follow-up). The only other option available to Nebraska per RMP 3.01 is to conduct an "immediate inspection." The fact that these reviews were not performed on-site does not necessarily disqualify them from being an inspection. Moreover, Nebraska's response to the IMPEP Questionnaire (specifically, "B.II Inpsections Completed 02.01.2021-12.18.2024.xslx" and "B.V Inspection Letters, 37-03-01 BD Allegation 250130.pdf") describes both reviews as "reactive inspections", and the team was told during the review that a reactive inspection was performed in response to the incident in question.
2 Section 3.5 In Section 3.5, Technical Quality of Incident and Allegation Activities, paragraph 2 of the discussion, the team found it difficult to assess whether Nebraskas evaluation of incident notifications and responses was thorough, as Procedure 4.02 does not require documentation of decision-making. However, NRC policy (SA-105) does not require Agreement States to document decision-making for incident evaluations. Rather, SA-105 instructs IMPEP team members to verify that inquiries are conducted in accordance with the States procedures. Nebraska follows its established procedures, including RMPP 3.01, as stated in the above paragraph, which authorizes the Manager, RPM, or designee, to determines if a reactive or special inspection is warranted, whether it should be performed promptly or can be included in the next routine inspection; and assigns an inspection, if appropriate. Additionally, RMPP 4.02 allows for closure of an event when there is no further risk to public health and upon approval by the Manager, RPM. By conducting staff interviews during the IMPEP evaluation, the IMPEP team was able to determine that Nebraskas evaluation and response to incidents were appropriate and that public health and safety were maintained throughout the process. In Bullet 2 of the Evaluation of the same section, the IMPEP team found that Nebraskas evaluation and response to incidents were effective and that public health and safety were maintained throughout the process.
These conclusions indicate that the team was able to assess the adequacy of Nebraskas actions based on available documentation and staff interviews. Therefore, Nebraska believes the information provided was sufficient for evaluation, and the statement in Bullet 2 should be removed.
Not Accepted The team considered the performance-related review criteria in Section V.C.3 in evaluating whether Nebraska's incident response procedures were compatible with SA-105. The procedure also repeats the MD 5.6 criteria in Section V.E, but to cite these criteria seem self-referential (the program is satisfactory because the procedure is compatible with the criteria that the procedure is compatible with the criteria the the procedure is compatible... and so on), and there were no other criteria to consider. As such, the team determined that Nebraska's procedures as written were incompatible with an evaluation of V.C.3.f (whether inquires made to evaluate the need for on-site investigations are conducted in accordance to the Program's procedure) or V.C.3.h (whether follow-up of incidents is conducted during the next scheduled inspection). In both cases, Nebraska's incident procedures provided no indication on how these evaluations should be documented, nor any indication on how follow-up inspections should be tracked, so the reviewer was unable to determine whether Nebraska followed its procedures in these regards.
The bullet reflects that the team found it difficult to conclude whether Nebraska met this performance objective. The exact wording from the report is: "staff interviews provided insight into Nebraskas evaluation and response to incidents and communicated that health and safety were maintained during the process." The IMPEP team did not conclude that "evaluation and response to incidents were effective and that public health and safety were maintained." Nebraska verbally communicated this claim to the team, but the absence of documation made it difficult for the team to draw its own conclusion. Nebraska's claim is probably accurate, but even reaching this quasi-conclusion took the team a great deal of effort. Nebraska initially provided almost no information regarding its response to incidents, and it is only because of the grace and determination of the assigned reviewer that performance of any kind could be evaluated and conclusions of any kind could be drawn.
3 Section 3.5 In Section 3.5, Technical Quality of Incident and Allegation Activities, paragraph 3 of the discussion, the team states that in two of the four incidents, Nebraska issued a Notice of Non-Compliance to the licensee but did not complete a narrative inspection report or field team notes as required by Radioactive Materials Procedure (RMP) 3.04. Nebraska believes this statement should be revised for accuracy. A Notice of Non-Compliance was issued for one incident and one allegationnot two incidents, as stated. Additionally, the assertion that Nebraska did not follow RMP 3.04 is incorrect. In both cases, the Manager of the Radioactive Materials Program (RPM), after consultation with staff, determined that an immediate inspection was not warranted. Follow-up actions were conducted via email, telephone, and written correspondence. As no inspections were performed, there would be no narrative inspection reports or field notes required under RMP 3.04.
Partially Accepted Nebraska is correct that one Notice of Non-Compliance was issued for one incident and one allegation - not two incidents as originally stated. The report has been revised accordingly.
However, the team disagrees that the follow-up activities conducted by inspector were not inspections. Nebraska's response to the IMPEP Questionnaire describes both reviews as "reactive inspections," consistent with the basic concept of a prompt evaluation by a Lead Inspector into the circumstances of an incident or allegation. As stated in response to comment 1, the fact that these reviews were not performed on-site does not necessarily disqualify them from being an inspection. The reviews that Nebraska performed are also inconsistent with the available alternative per RMP 3.01: follow up at the next routine inspection (or the implicit alternative to perform no follow-up).
4 Section 3.5 In Section 3.5, Technical Quality of Incident and Allegation Activities, paragraph 4 of the discussion, the team noted that Nebraska did not record a second incident in its inspection history log and did not document confirmation that the licensees corrective actions were complete and effective. While the incident was not recorded in the inspection history log, Nebraska procedures do not require this. The subsequent inspection report referenced the reported event and provided information on where the event details could be found, indicating to the RPM that the incident had been reviewed and closed during that inspection.
Additionally, the NMED report narrative for the incident stated that the component causing the event had been replaced and that safety operations had returned to normal. Although one incident was not followed up at the next inspection, the licensees corrective actions were ultimately reviewed and verified during the license renewal process, which occurred approximately six months after the incident, confirming the necessary measures were implemented and maintained. Nebraska acknowledges that its procedures for event reporting could be improved to provide clearer guidance on where documentation should be recorded and maintained to ensure consistent follow-up during future inspections. However, Nebraska believes this should be addressed as a recommendation rather than a contributing factor to the overall finding. Nebraska has revised this procedure to include where documentation of events is to be maintained in the licensee file.
Not Accepted The fact that Nebraska's procedures do not require documenting the need to follow-up on incidents in its inspection history log (or anywhere else) demonstrates why its procedures are not compatible with SA-105 review criteria. The team found no formal process or mechanism for ensuring that a follow-up inspection occurs when one is determined to be necessary. RMP 3.02, "Inspection Preparation," for example, does not instruct inspectors to check NMED, review recent incident and allegation history, etc., when preparing for an inspection.
5 Section 3.5 In Bullet 3 of the Evaluation, it is noted that one event involving lost material was not reviewed during the next inspection. While this is accurate, Management Directive 5.6 states that a finding of "Satisfactory, but Needs Improvement" is warranted when follow-up inspections are completed in more than a few, but less than most, of the cases reviewed.
Nebraska had four incidents and two allegations during the review period, with only one event not reviewed at the subsequent inspection. Based on this, Nebraska does not believe this single instance justifies a "Satisfactory, but Needs Improvement" finding.
Not Accepted The team agrees that criteria "Followup inspections are not completed in more than a few, but less than most, of the cases reviews" was not met, as 1 of 6 can reasonably be interpreted as "less than a few". However, the team's recommendation on SBNI is not predicated solely on the number of missed follow-ups, it is also and primarily predicated on the absence of formal documentation that contributed to the missed follow-up as well as to the other performance concerns and uncertainties described in the report.
Comment Resolution Document Letter from Becki Harisis, Program Manager, Radiation Control Program Office of Radiation Control Nebraska Department of Health and Human Services Dated May 7, 2025 - ML25128A303 Nebraska IMPEP Review - February 24-28, 2025 ML25133A028