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Washington Dept. of Health, Heightened Oversight Call Summary October 2022 - December 2023
	ML24026A085
Person / Time
Issue date:	12/04/2023
From:	Randy Erickson; NRC/RGN-IV/DRSS
To:	;
References
	Download: ML24026A085 (14)
	v • d • e

WASHINGTON DEPARTMENT OF HEALTH CHRONOLOGICAL HEIGHTENED OVERSIGHT CONFERENCE CALL SUMMARIES

Nuclear Regulatory Commission Washington Department of Health (DOH)

Attendees Attendees Kevin Williams, Director MSST, NMSS Jill Wood, Director

Tammy Bloomer, Director, DRSS, Region IV Earl Fordham, Deputy D irector

Geoffrey Miller, Deputy Director DRSS, Brennagh Greene, Supervisor Region IV Adelaide Giantelli, Chief, SLPB, NMSS Various other staff members

Robert Johnson, IMPEP Project Manager, NMSS Randy Erickson, RSAO Region IV

Various other staff members

BACKGROUND

The Washington Agreement State Program (the Program) had experi enced a decline in Program performance since the 2013 IMPEP review (ML13212A225) where all indicators were found to be satisfactory, and the Program was found to be adequate to protect public health and safety, and compatible with the U.S. Nuclear Regulatory Commissions (NRC) program.

Then at the time of the 2018 IMPEP review (ML18208A461), the Program was found to be satisfactory for seven indicators and satisfactory but needs improvement for two indicators including Technical Quality of Licensing Actions and Compatibil ity Requirements (now known as LROPE). At that time, weaknesses in the Program were identified, two recommendations were issued, and the team considered whether or not the finding of adequate to protect public health and safety and compatible with NRCs program should be downgraded. After discussions, the team recommended that the Program be found adequate to protect public health and safety and compatible with NRCs program. The team further recommended that the next periodic meeting be one year with a full IMPEP review in four years. The MRB agreed with the teams recommendations.

Between the 2018 IMPEP review and the 2022 IMPEP review, Washington continued experiencing further declines in Program performance, now in several program areas. During the 2022 IMPEP review (ML22206A205), Washingtons performance was now found to be satisfactory fo r only four performance indicators, sat isfactory but needs improvement for three performance indicators including Technical Staffing and Training; Technical Quality of Inspections; and Legislation, Regulations, and Other Program Elements (LROPE), a nd unsatisfactory for two performance indicators including Technical Quality of Incident and Allegation Activities; and Technical Quality of Licensing Actions. Technical Quality of In cident and Allegation Activities had declined from satisfactory in 2018 to unsatisfactory in 202 2; and, Legislation, Regulations,

1 and Other Program Elements had declined from satisfactory but n eeds improvement in 2018 to unsatisfactory in 2022.

The team further recommended that one of the two 2018 IMPEP rev iew recommendations be closed, and that the other 2018 recommendation regarding staffi ng and training be left open and modified. Eight additional recommendations were also opened by the 2022 team. The Program was now found to be adequate to protect public health and safet y but needs improvement; and, since the team found that Washingtons program now had the pote ntial to create gaps, conflicts, duplication, or other conditions that could jeopardize an order ly pattern in the collective national effort to regulate agreement materials, Washington Agreement St ate Program was no longer found to be compatible with NRCs program.

Based on the results of the 2022 IMPEP review and the further d ecline in program performance, Washington was placed on a period of heightened oversight which 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 initially s ubmits a Performance Improvement Plan (PIP) to address any recommendations and any a reas of downgraded program performance, and then begi ns bimonthly calls between th e Program and the NRC. This summary documents the initial bimonthly call and successive calls between the NRC and the Program.

The Program sent in its initial draft PIP electronically on Sep tember 13, 2022, (ML22277A838) and after NRC review and comment, sent in a final revised PIP o n October 12, 2022, (ML22290A221) which was used for the initial call held on October 20, 2022. A letter approving the initial Washington PIP was sent to Washington senior manage ment on October 19, 2022, (ML22291A078). Subsequent calls were held with the Washington program on Ja nuary 5, 2023, (ML23346A165), March 14, 2023, (ML23074A049), April 11, 2023, (ML23101A085),

May 22, 2023, (ML23144A107), June 27, 2023, (ML23178A177), August 15, 2023, (ML23229A475), September 19, 2023, (ML23261C382), October 19, 2023, (ML23292A177),

and December 4, 2023 (ML23338A234).

Technical Staffing and Training

The 2022 IMPEP team found that Washingtons Radioactive Materia ls Section was comprised of 11 full-time equivalents including 1 supervisor, 8 technical staff members (three of which are program leads), 1 database manager, and 1 administrative staff member; and at the time of the review they had one vacancy. Washington had experienced signifi cant staff turnover throughout the review period, mainly in management turnover leading to inc onsistent management oversight of programmatic activities. The Radiation Control Pro gram Director (RCPD) retired in August 2020, and a new RCPD was hired in January 2021. The last long-term supervisor retired prior to the 2018 IMPEP review. During the review period, a tot al of seven individuals held the supervisor position. Two were short-term permanent employees wi th each serving approximately 1.5 years, and the remainder were current employe es in acting roles as the supervisor. This continued until a permanent supervisor was hir ed in December 2021.

Summary of the call with Washington on October 20, 2022

The program reported that the permanent supervisor hired in Dec ember 2021 was subsequently terminated by the Program in April 2022, and through the date o f this call, the supervisor position continued to be vacant. One of two current Deputy Dire ctors has been acting both as the supervisor and as the Deputy Director.

2 The Program also reported that in addition to the vacant superv isor position, they also lost additional staff members following the 2022 review. One staff m ember left the health department, and two of the three program leads also left. One p rogram lead left the health department while another left the Program to join another progr am within the health department.

The Program is planning to promote certain staff members to the lead positions soon and then begin the process for hiring entry level staff members.

The Program advised that they had reached out to the states of Arizona, Colorado and Minnesota and obtained copies of their training and qualificati on programs which had successfully made it through recent IMPEP reviews and used thos e as a template as they redesigned the Washington training and qualification program to ensure that it was aligned with and compatible with NRCs program. The Program also provided fi nal copies for NRC to review.

The Program reported that they had completed the revision of th eir training and qualification program on June 15, 2022, and would continue to revise it in th e future if they determined that additional revisions were needed. At the time of the call, staf f training on the updated training and qualification program had begun but had not yet been comple ted. Staff training also included training on the entire qualification process to includ e who can sign off on qual cards.

Washington is also working towards increasing salaries to be mo re competitive and to be able to retain staff following the departure of several staff member s who left for better opportunities.

Washington has also begun the process of modifying their recrui tment practices which will become the responsibility of the new section supervisor once hi red. Lastly, Washington plans to actively mentor newly hired employees which will be the respons ibility of the Deputy Director and the program leads.

Summary of the call with Washington on January 5, 2023

The program reported that they are beginning the process of rec ruiting new candidates for the entry level positions and will be posting for the supervisor (H P4) position soon.

Summary of the call with Washington on March 14, 2023

The program reported that since the last call, they have lost t heir last remaining lead (HP3) in late January. They also reported that they interviewed applican ts and have hired a new supervisor. They are also continuing the hiring process to repl ace the program leads as well as the vacated entry level positions (HP2). NRC is attempting to g et individuals into training classes.

Summary of the call with Washington on April 11, 2023

The program had nothing new to report. They continued to comple te the hiring process for new individuals and begin the training process.

Summary of the call with Washington on May 22, 2023

The program had nothing new to report. They continued to comple te the hiring process for new individuals and begin the training process.

3 Summary of the call with Washington on June 27, 2023

The program reported that they had sent several staff to the Or egon sponsored G-108 Inspection Procedures course in June. Additionally, they contin ued to complete the hiring process for new individuals and continue with the training proc ess.

Summary of the call with Washington on August 15, 2023

The program reported that they had recently terminated one of t he newly hired HP3 staff members and were going to repost the position to hire another i ndividual. They further reported that they are continuing to fill positions.

Summary of the call with Washington on September 19, 2023

The program had nothing new to report. They continued to comple te the hiring process for new individuals and continue forward with the training process.

Summary of the call with Washington on October 19, 2023

The program stated they are interviewing for the remaining posi tions and had recently offered a position to a trained individual formerly with the Arizona prog ram and were awaiting on their possible acceptance. They are continuing forward with the train ing process and noted that they have several individuals who will be attending the Oregon spons ored G-109 Licensing course in December.

Summary of the call with Washington on December 4, 2023

The program stated they continue interviewing for the remaining positions. They added that the individual from Arizona that they had recently offered a senior position declined the offer and went to work for Department of Energy. They are reposting for t hat position and with the other open positions. They are continuing forward with the training p rocess and noted that they have several individuals who will be attending the Oregon sponsored G-109 Licensing course the week of December 11-14th.

The program also reported that while they had completed their r eview and revision of the training program, they decided to reopen the program and reeval uate it to ensure that it is current with how they are operating. This review is currently o ngoing.

Status of Materials Inspection Program

The 2022 IMPEP team found that Washingtons inspection frequenc ies are the same as the NRCs inspection frequencies. The team also found that out of t he 179 Priority 1, 2, 3 and initial inspections performed over the review period, that only three w ere performed overdue and that only two inspection findings wer e transmitted to licensees greater than their 30-day goal. Of the reciprocity inspection performed over the review period, Washin gton did not meet their goal of 20 percent in two of the four-years due to issues associated wi th the pandemic. The team also noted that due to a contamination event at the University of Wa shington facility, the Program determined it was appropriate to revise their reciprocity proce dure to add a section to address unique operations such as blood and self-shielded irradiator so urce removals. Washington proposed adding procedures for granting reciprocity activities to include detailed review of the license, proposed work plan, and compliance history. Additional ly, Washington inspectors

4 committed to be on-site to observe reciprocity licensees engage d in pre-procedure, or dry run activities related to irradiator source installations, exchange s, and removals.

Summary of the call with Washington on October 20, 2022

Washington reported that the responsibility for the reciprocity revisions would be the reciprocity lead. While this revision had been initiated, at the time of th is call, that revision had not been completed.

Summary of the call with Washington on January 5, 2023

The program reported that they had completed the reciprocity re visions and were going to train the staff on it.

Summary of the call with Washington on March 14, 2023

The program reported they had completed a handful of gauge insp ections due to the lack of individuals with qualifications. Because they have no other tra ined individuals, the backlog of inspections continues to grow.

Summary of the call with Washington on April 11, 2023

The program reported no changes since the March call. The backl og continues to increase, but they are discussing entering into a contract with Arizona staff to travel to Washington and perform complex and overdue inspections.

Summary of the call with Washington on May 22, 2023

The program reported that they entered into a contract with Ari zona on May 5th and that they were scheduled to travel to Washington to being performing insp ections in June 2023.

Summary of the call with Washington on June 27, 2023

The program reported that Arizona had spent a week in Washingto n in June performing inspections and training staff. Arizona will not only perform i nspections but will also write and submit reports to Washington.

Summary of the call with Washington on August 15, 2023

The program reported that Arizona had returned to Washington in July for a 2-week period performing additional inspections and training staff. Multiple larger inspections had been performed and staff attended each in a training mode. Arizona a lso assisted the program with event follow-up on this trip. Following this trip, the Arizona contract was exhausted.

Summary of the call with Washington on September 19, 2023

The program reported that they were entering into a second cont ract with Arizona and this contract was currently making its way through the approval proc ess.

5 Summary of the call with Washington on October 19, 2023

The program reported that a new contract had been finalized wit h Arizona on September 25th.

While a date hasnt yet been confirmed, Arizona will be returni ng to Washington soon to perform additional inspections and train additional staff. The program further stated that while on-site in September, the NRC Assessment Team spent 2-weeks training their inspection staff.

Summary of the call with Washington on December 4, 2023

The program reported that Brian Goretzki from Arizona had just come out the week of November 27th to perform multiple inspections at some of their overdue and m ore complex inspections. They also reported that their backlog of overdue i nspections continues to drop.

Technical Quality of Inspections

The 2022 IMPEP team found that Washington inspectors used inspection checklists to assist in conducting broad-based regulatory reviews that included necessa ry focus elements. The team found that inspectors were able to identify issues, but the tea m noted that items of non-compliances did not include specific details of why the non -compliance occurred, the duration of the non-compliance, or the number of examples found . The Radioactive Material Sections Standard Operating Procedure had language similar to language found in IMC 2800, but the procedure had not been finalized and had been in draft form since 2018. The team found that some of the processes used by Washington for documen ting and issuing deficiencies and infractions on inspection forms only required the inspector s to list the regulation or license condition that was violated and did not require the licensee to describe or document why the violation occurred or any associated root causes. The review te am found that inspectors did consistently perform reviews of previous items of non-complianc e for closure; however, the inspectors typically did not document the basis for closing pre vious items of non-compliance.

The team also noted that annual supervisory accompaniments were either not consistently performed or were performed but not documented.

During pre-IMPEP inspector accompaniments, the team accompanied five radioactive material inspectors prior to the on-site review and observed several mis sed opportunities for evaluation of the licensees activities by the inspectors that could have easily been observed or performed.

The team found that these opportunities to perform or observe certain activities ca n be addressed through increased supervisory inspector accompaniment s.

The team also noted that Washington had a quality assurance pol icy requiring supervisory reviews of only 10 percent of inspection records which is not c onsistent and compatible with IMC 0610.

Summary of the call with Washington on October 20, 2022

Washington reported that they are currently in the process of r evising their inspection procedures to be consistent and compatible with NRCs procedure s and guidance. This revision was initiated on September 30, 2022, is currently ongoing, and once complete, the staff will be trained on the new procedure. Washington has also moved from a 10 percent review of inspection records to a 100 percent review to be consistent wit h the guidance in IMC 0610. The section supervisor is responsible for the review, and this will be a continuous and ongoing process. Washington also reported that for every qualified insp ector who performed an

6 inspection during the calendar year, a supervisory accompanimen t will be performed. This is the responsibility of the section supervisor.

Summary of the call with Washington on January 5, 2023

The program has completed the revision of the procedure on Sept ember 30, 2022, and trained the staff a month later. No supervisory accompaniments will be performed until staff is qualified when accompaniments will begin.

Summary of the call with Washington on March 14, 2023

The program reported there have been no additional changes and they continue forward with staff training and qualifications.

Summary of the call with Washington on April 11, 2023

The program had nothing additional to report.

Summary of the call with Washington on May 22, 2023

The program had nothing additional to report.

Summary of the call with Washington on June 27, 2023

The program had nothing additional to report.

Summary of the call with Washington on August 15, 2023

The program had nothing additional to report.

Summary of the call with Washington on September 19, 2023

The program had nothing additional to report.

Summary of the call with Washington on October 19, 2023

The program had nothing additional to report.

Summary of the call with Washington on December 4, 2023

The program had nothing additional to report.

Technical Quality of Licensing Actions

The 2022 IMPEP team found that over the review period Washingto n performed approximately 1000 licensing actions of various types. Of the 22 total licensing actions randomly selected for review by the team, the team found only 4 of the 22 to be thoro ugh, complete, consistent, and of high quality with health, safety, and security issues properly addressed, but identified inconsistencies in 18 of the 22 remaining actions reviewed. In part, these inconsistencies included license templates and written license conditions that differed from NUREG-1556 guidance documents; the use of non-standard license conditions; inconsistent guidance review

7 and use, and Quality Assurance (QA) checklists that were outdat ed and contained incorrect references, protection of Sensitive and Security-Related Inform ation in the transmittal of Radioactive Materials License to Licensees; and granting new li censing staff signature authority prior to completion of training.

Summary of the call with Washington on October 20, 2022

Washington reported that they are beginning the process of asse ssing the extent of condition involving inconsistencies identified by the review team for all licenses issued after May 4, 2018.

This assessment is to ensure t hat maximum possession limits are accurate and in accordance with applicable licensing guidance; ensure that only material r equested by a licensee is put on a license; ensure that locations of use and storage are accurate; ensure that license reviewers considered the licensees inspection and enforcement history fo r license renewal review; and revise licensing templates to be consistent with NRC guidance. This was to begin following PIP approval and will be conducted by the program leads. Washington plans to review 10 licenses of each type or 10 percent of each license type whichever is gr eater and if more than a few are found to be in error, they plan to move that number up to a 50 percent review.

Washington reported that they are in the process of revising th eir licensing procedure to be compatible with NUREG-1556 licensing guidance and to ensure tha t the procedure includes a periodic assessment and smart sampling of work performed to ens ure work is being performed in accordance with the procedure. This was initiated on October 31, 2022, and at the time of the call was in progress.

Washington also reported that they are in the process of revisi ng their Radioactive Material Sections Standard Operating Procedure to include guidance for the electronic transfer of sensitive security-related documents. This is a task that has b een assigned to the Lab Program Lead, was initiated on April 30, 2022, and is awaiting completi on.

Lastly, Washington is reviewing their QA Checklists to ensure t hat obsolete wording is removed and that any printed forms with obsolete wording are identified and destroyed. Each of the program leads is responsible for this action and the program re ports it was completed on June 30, 2022.

Summary of the call with Washington on January 5, 2023

The program reported as of December 2022, they had revised thei r licensing procedure to ensure consistency in the licensing process. They also reported that they had revised their Radioactive Material Section Standard Operating Procedure to pr ovide guidance for electronic transfers of sensitive security-related documents.

Summary of the call with Washington on March 14, 2023

The program did not have any additional changes to report durin g this call. They continue to work on potentially contracting with other entities for licensi ng assistance.

Summary of the call with Washington on April 11, 2023

The program reported that they would be contracting with Califo rnia license reviewers to provide assistance with licensing reviews.

8 Summary of the call with Washington on May 22, 2023

The program reported that they entered into a contract with Cal ifornia license reviewers on April 15th to provide them with assistance with licensing actions, primar ily license renewals. At approximately the same time, Washington entered into a separate agreement with Texas for technical assistance with licensing actions, primarily amendmen t requests.

Summary of the call with Washington on June 27, 2023

The program stated that the contract with California was workin g well; and, that Texas has been providing them with their immediate licensing amendment needs.

Summary of the call with Washington on August 15, 2023

The program reported that the licensing contract with Californi a had been exhausted and California had chosen not to extend it. They also reported that on July 16th, Texas notified them that due to a loss of staff and a backup of work, they would no longer be able to provide assistance. The program further reported that during the Organi zation of Agreement States meeting in Seattle during the week of August 7 th, that Washington had made inquiries with a consulting company for licensing assistance. The program stated that the contract was being written and would be submitted to management soon.

Summary of the call with Washington on September 19, 2023

The program reported that the NRC assessment team was on-site a nd evaluating their program to include their licensing needs. They further stated that the contract with the consultant company was very close to being signed.

Summary of the call with Washington on October 19, 2023

The program reported that the licensing contract with the consu lting company had been signed by management and had been forwarded to the consulting company for signature but had not been signed as of the date of this call. The program further re ported that NRC staff had provided the program with licensing templates to use as guidanc e as they develop the remainder of their templates.

Summary of the call with Washington on December 4, 2023

The program reported that the contract with the consulting comp any had been finalized and they were now beginning to perform licensing work for the program.

Technical Quality of Incidents and Allegation Activities

The 2022 IMPEP team found that over the review period, 109 inci dents were reported to Washington and of those, 38 rose to the level of being reported to the Nuclear Material Events Database (NMED) database. The team evaluated 14 radioactive mat erials incidents reviewed of which the team found that Washington dispatched inspectors for on-site follow-up for four of those cases. The team identified 2-non-reported incidents shoul d have been reported to NMED.

When notified of an incident, a staff member was assigned to fo llow-up with the person reporting the incident and made all decisions regarding follow- up and closure of the incident. In

9 most cases reviewed, there was no documentation that showed man agement involvement in the decision-making process. In general, the team found that do cumentation of the review of incidents was brief and, in some cases, did not contain informa tion that was supportive of the violations (or lack thereof) issued. The team also found that f or each case requiring NRCs Headquarters Operations Officer (HOO) reporting, that Washingto n reported the incidents within the require time frame. Overall, the team found that Washington s evaluation of incident notifications and its response to incidents was generally well balanced with respect to radiation safety significance.

Much of the review teams efforts were involved with the review of a significant contamination event that occurred at the University of Washington and the pro grams response to it. This review identified several problems with Washingtons incident p rocedures, how staff are trained and the supervision of staff during event follow-up. The team a lso found that documentation regarding the event was minimal or didnt exist at all.

The team also evaluated the progr ams response to allegations r eceived and continued to find significant issues involving procedures and documentation. The team noted there was little to no documentation for several of the Washington allegation files, a llegations were closed with little documentation including no indication in some cases that concer ned individuals had been provided the results of their investigation. The Washington inc ident and allegation procedures were evaluated and made the following assessments:

The team found that the Washington procedure described one pro cess in the section Incidents and Allegations that was used for both incidents an d allegations, and that this process did not require some of the actions necessary for prope rly handling of allegations commensurate with NRCs MD 8.8, Management of Allegations. Washingtons procedure did not require protection of alleger identity and did not incl ude details of the allegation process (e.g., methods of intake, alleger identity protection, processing the received allegation, allegation evaluation, and allegation closure).

The team found that Washingtons procedure required that all i ncidents/allegations be documented in a local database and on a local drive under incid ents. However, the team requested to review five allegations, of which documentation fo r only two were found for review in the allegation database and one was listed as an inci dent. The team noted that Washington was not following their procedure.

The team noted that Washingtons procedure incorrectly indicat es that all credible incidents/allegations will also be sent to NMED. Allegations sh ould not be sent to NMED.

The team noted that Washingtons procedures required inspector s to adequately prepare for an inspection by reviewing any outstanding open items and deter mining whether any events had been reported by the licensee. The team could not determine if inspectors performed an NMED search as part of their inspection preparation.

The team noted that Washingtons procedures did not require fo llow-up with licensees to verify the implementation of corrective actions. The team could not verify these actions were performed because there was no documentation in the file.

The team determined that Washingtons incident response and all egation procedures were in place and followed; however, the allegation procedure did not i nclude all required elements. The

10 procedures did not address the need to protect the allegers id entity, methods of intake, processing the received allegation, issuing acknowledgment lett ers to the alleger, and closure documentation. The team noted that without documentation, the t eam could not confirm that appropriate follow-up actions were taken to ensure prompt compl iance by licensees. Follow-up inspections were not scheduled and completed, as necessary. Non e of the incidents or allegations reviewed by the team included any discussion of sch eduling of follow-up inspections.

Summary of the call with Washington on October 20, 2022

The program reported that they were taking steps to address the missing documentation from the Washington contamination event and the actions they took in response to that event. These included the actions taken and basis for release at a personal residence, a restaurant and state vehicle, dose assessments of those involved in the event includ ing external and internal contamination assessments. Washington has assigned the task of obtaining written documentation to the affected individuals and dose assessments to the Deputy Director. This was initiated on September 30, 2022, and is currently ongoing.

Washington reported that revisions to their incident and allega tion procedures to ensure that each part of the procedure contains the appropriate sections in cluding the protection of alleger identity as allowed by law, ensure proper and complete document ation of the receipt and closure of incidents and allegations, ensure that follow-up ins pections are scheduled and completed, ensure allegations are properly maintained with alle gations and not mixed with incidents, and ensure that allegations are documented and easil y retrievable should begin around December 31, 2022, was assigned to the medical program l ead; however, at the time of the call had not yet been started.

Washington also indicated that the proper storage and accessibi lity of incident and allegation records will require the establishment of secure electronic sto rage which at the time of the call had not yet been initiated.

The program also reported that they are working to locate all a llegation records received during the review period to assess whether appropriate closure actions were taken; and, to verify that the allegation files are complete, accurate and documented in t he tracking system should begin around December 31, 2022, was assigned to the radioactive mater ials staff; however, at the time of the call had not yet been started.

Summary of the call with Washington on January 5, 2023

The program reported that as of the date of this call, they hav e not yet had the time to address this recommendation.

Summary of the call with Washington on March 14, 2023

The program reported that as of the date of this call, they hav e not yet had the time to address this recommendation.

Summary of the call with Washington on April 11, 2023

The program reported that as of the date of this call, they hav e not yet had the time to address this recommendation.

11 Summary of the call with Washington on May 22, 2023

The program reported that they have addressed and completed the recommendation related to the University of Washington contamination incident that occurr ed in 2019, including locating written reports from parties involved and locating and verifyin g the missing information as well as verifying dose information. The program further reported tha t they had revised their incident and allegation procedures and made records readily available an d retrievable.

Summary of the call with Washington on June 27, 2023

The program reported that they had made not additional progress on the other recommendations.

Summary of the call with Washington on August 15, 2023

The program reported that they had made not additional progress on the other recommendations.

Summary of the call with Washington on September 19, 2023

The program reported that they had made not additional progress on the other recommendations.

Summary of the call with Washington on October 19, 2023

The program reported that they have addressed and completed the recommendation related to locating all allegation records received during the review peri od and have confirmed that appropriate closure actions were taken. They also verified that allegation files were complete, accurate, and documented in the tracking system.

Summary of the call with Washington on December 4, 2023

The program reported that they have completed all the recommend ations in the Incidents and Allegations indicator.

Legislation, Regulations, and Other Program Elements

The 2022 IMPEP team found, that during the review period, Washi ngton submitted six proposed regulation amendments, no final regulation amendments, and no l egally binding requirements or license conditions to the NRC for a compatibility review. Two o f the amendments were overdue for State adoption at the time of submission.

During this review period, responsibility for regulation review s was transferred from one staff member to another and this caused delays. The new staff member submitted six proposed amendments. Of the two overdue amendments, RATS 2018-1 was submitted March 7, 2022, and RATS 2018-2 was submitted on November 17, 2021. Neither of the proposed amendments met their due dates for State adoption. RATS ID 2018-1 should h ave been adopted by January 14, 2022, and RATS ID 2018-2 should have been adopted b y December 21, 2021. The team noted that RATS ID-2018-1 was a lengthy, complex amendment because it dealt with the medical regulations which have a potential for cross jurisdicti onal boundary issues.

12 Regarding other program elements, the team noted that Washingto ns procedures were not compatible with IMC 1248, IMC 0610, NUREG-1556 licensing guidan ce, and MD 8.8. The team also noted that Washington used non-standard license conditions which had not been submitted to the NRC for a compatibility review.

Summary of the call with Washington on October 20, 2022

Washington reported that they are currently identifying any non-standard license conditions needing NRC approval and then plan to submit those to NRC for approval with proper justification and removing any other non-standard license conditions from existing licenses. These tasks have been assigned in part, to the program leads and the Deputy Director for follow-up. This task was initiated in part, on September 30, 2022, with the remaining part (submit non-standard license conditions to NRC for approval) is scheduled to begin around December 31, 2022; however, at the time of the call had not yet been started.

Washington also reported that at the time of the call, had submitted RATS IDs 2018-1 and 2018-2 to NRC and that review was completed in June and August of 2022. They are now awaiting final adoption through the Washington rule adoption process.

The program reported they are in the process of revising procedures to remain compatible with NRC guidance including IMC 1248, IMC 0610, NUREG-1556 licensing guidance, and MD 8.8.

The task of compatibility with IMC 0610 was assigned to the sec tion supervisor and completed.

Summary of the call with Washington on January 5, 2023

The program reported they had identified one non-standard licen se condition and submitted it to NRC for review and NRC disapproved it. The program then removed that condition from all licenses. The program also reported that they have completed ad option of RATS ID 2018-1 and 2018-2. The program further reported that the section superviso r now completes 100 percent review of inspection findings, and this requirement has now bee n added to the procedure to better align them with NRC Inspection Manual Chapter 0610.

Summary of the call with Washington on March 14, 2023