ML20136H467

Forwards for Comments & Approval,Draft Minutes of 970122 Mgt Review Board Meeting

ML20136H467
Person / Time
Issue date:	02/14/1997
From:	Schneider K NRC OFFICE OF STATE PROGRAMS (OSP)
To:	Bangart R, Paperiello C, Thompson H NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS), NRC OFFICE OF STATE PROGRAMS (OSP), NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
References
NUDOCS 9703190168
Download: ML20136H467 (26)

Text

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'EEB 14 WII] ,

MEMORANDUM TO: Management Re' view Board.Membeis: .,

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Hugh Thon ps n, EDO , l Richard Bangart, OSP . <

Carl Paperiello, NMSS c . / 1 l Karen Cyr, OGC '

.. i Denwood Ross, AEOD +

FROM: Kathleen N. Schneider, Senior Health Nysicist' ^ ^

Office of State Programs

SUBJECT:

DRAFT MINUTES: JANUARY 22,1997 MEETING Attached are the draft minutes of the Management Review Board (MRB) meeting, I

held on January 22,1997. These minutes are submitted for your comments and approval i

by March 7,1997. If there is an MRB meeting prior to March 7,1997, these minutes will be an item on the agenda for MRB approval. If you have any questions, please contact me at 301-415-2320.

Attachment:

As stated l

cc: Roland Fletcher, MD l Deb Thomas, NE '

Brian Hearty, NE i

Distribution: l DIR RF. iDCD (SPO1f ;POR (Yes i No _)

RLBangart PLohaus SDroggitis KSchneider DCool RBlanton CHaney PLarkins JHornor, RIV/WCFO FCameron JJ8hansen, RI RCady CMattson, CO HNewsome jj CHackney, RIV I NE File s

DOCUMENT NAME: G:\KXS\NEMRBMIN.97 OFFICE OSP E (SP:C)D -OS():17 NAME- KSchneider:nb PHLohh/s RLBanga)(t DATE 024$97 02/ N/97 02/ X97

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p t UNITED STATES

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j NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. - "1 February 14, 1997

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1 MEMORANDUM TO: Management Review Board Members:

1 Hugh Thompson, EDO Richard Bangart, OSP Carl Paperiello, NMSS 2

Karen Cyr, OGC i Denwood Ross, AEOD M

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FROM: Kathleen N. Schneider, Fenior Health Physicist $ 1 l Office of State Prograrn

SUBJECT:

DRAFT MINUTES: JANUARY 22,1997 MEETING Attached are the draft minutes of the Management Review Board (MRB) meeting I

held on January 22,1997. These minutes are submitted for your comments and approval i by March 7,1997. If there is an MRB meeting prior to March 7,1997, these minutes will l be an item on the agenda for MRB approval. If you have any questions, please contact me j at 301-415-2320.

Attachment:

As stated

! cc: Roland Fletcher, MD

Deb Thomas, NE Brian Hearty, NE j

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MINUTES: MANAGEMENT REVIEW BOARD MEETING OF JANUARY 22.1997 1

l These minutes are presented in the same general order as the items were discussed in the meeting. The attendees were as follows:

Hugh Thompson, EDO Frank Congel, AEOD Carl Paperiello, NMSS Karen Cyr, OGC Richard Bangart, OSP Roland Fletcher, MD Brian Hearty, NE Deb Thomas, NE

Paul Lohaus, OSP King Stablein, EDO Patricia Larkins, OSP Charles Mattson, CO

, Jenny Johansen, Rt Richard Blanton, OSP Ralph Cady, RES Don Cool, NMSS

! Kathleen Schneider, OSP Ross Scarano, RIV

. Charles Hackney, RIV Josie Piccone, NMSS i Scott Moore, OCM Cathy Haney, NMSS l

Howard Larson, ACNW

, By phone:

, Burke Casari, NE Jack Daniel, NE j Cheryl Rogers, NE Jay Ringenberg, NE

1. Convention. Hugh Thompson, EDO, Chair of the Management Review Board (MRB), convened the meeting at 1:00 p.m. Introductions of the attendees were conducted.

2. New Business. Nebraska Review introduction. Mrs. Patricia Larkins, OSP, led the

integrated Materials Performance Evaluation Program (IMPEP) team for the i Nebraska review. The format for presenting the review team results was modified for this MRB meeting. The team proposed presenting its individual findings for each indicator. The State of Nebraska asked to make its presentation and then the team will make its overall recommendation to the MRB.

Mrs. Larkins discussed how the review was conducted. Preliminary work included review of Nebraska's response to the IMPEP questionnaire. The onsite review was conducted July 15-19,1996. The onsite review included an entrance interview, detailed audits of a representative sample of licensing and inspection files, and i follow up discussions with staff and management. The onsite portion of the review concluded with exit briefings with Nebraska management. Following the review, 1 the team issued a draft report on October 16,1996; received Nebraska's comments dated September 10,1996, November 1,1996 and December 13, 1996; and submitted a proposed final report to the MRB on January 17,1997.

Status of items identified in Previous Reviews. Mrs. Larkins stated that there were i

no recommendations made during the 1994 routine review.

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Common Performance Indicators. Mr. Blanton presented the findings regarding j Technical Staffing and Training. His presentation ccrresponded to Section 3.2 of the IMPEP report. Mr. Blanton reported that IMPEP review team found that l Nebraska's performance with respect to the indicator to be found " unsatisfactory."

! Mr. Blanton stated that the review team found two root causes for this finding: (1) the failure of NDOH management to effectively address the reduced level of i program performance, and (2) lack of current written program procedures or the failure of staff to follow those procedures. The team made four recommendations.

The team recommends that the qualifications of contractor personnel be tied to the

contract as identified by the program manager or as accomplished by the LLRW

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l program in NDEO. The team recommended that a written program for staff l

qualification, including retaining training records, be developed. The team i f

recommended that the State develop comprehensive administrative procedures,

]. sufficient to guide the day to-day operation of the program in the event of another loss of senior staff. The procedures should include a formal process for bringing to the attention of upper management the increase of significant backlogs of licensing, inspection, or enforcement actions, or any other situation which increases the risk

to public health and safety. Licensing procedures should include prioritization of licensing actions based upon identified factors, including health and safety j significance, for new and previously received applications. The team recommended j that the program be observed with increased attention to the effects of the further reorganization. As discussed earlier, the MRB did not reaching a consensus on each ,

individual indicator until Nebraska staff made their presentation.

l l Ms. Johansen the finding for the common performance indicator - Status of the Materials Inspection Program. Her presentation corresponded to Section 3.1 of the IMPEP report. The review team found Nebraska's performance with respect to this

! indicator " satisfactory with recommendations for improvement." Mr. Hearty asked a question on recommendation 1 and 5 in the Proposed Final Report. He noted that the changes to the report as outlined in NRC Response to Comments provided by the State of Nebraska, Attachment 4, of the January 17,1997 memorandum to the

MRB had not been reflected in the proposed final report. Mrs. Larkins stated that was an oversight and that five comments will be delete from the final report as

] noted in Attachment 4. Also, Ms. Johansen noted, on page 5, first paragraph that the date "May 26,1996" should be " June 26,1996." The review team i recommended that the managers responsible for the Nebraska Radioactive Materials Program establish an action plan or procedure to assure inspections are completed

, at the frequencies stated in the Nebraska inspection Manual which is equal to the NRC's IMC 2800 and conduct reciprocity licensee inspections at the required

. frequencies stated in IMC 1220. The review team recommended that the managers 4

establish an action plan or procedure for coordinating deviations from the inspection schedule between staff and management based on the risk of license operations, past performance and need to temporarily defer the inspections to address more urgent or critical priorities. Also, the review team recommended that the managers

organize a "get well" plan for rescheduling missed or deferred inspections,

, especially due to loss of senior staff; and establish a plan or methodology to assure

' initial inspections are performed within 6 months of issuance of the license in accordance with the Nebraska inspection Manual and NRC's IMC 2800.

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i i Mr. Mattson discussed the indicator - Technical Quality of Licensing Actions. He l summarized findings in Section 3.3 of the report, which found Nebraska's licensing i actions to be generally thorough, complete, consistent, and of acceptable quality

-J l with health and safety issues properly addressed. The IMPEP team found j Nebraska's performance to be " satisfactory" for this indicator.

i j Ms. Johansen led the discussion of indicator - Technical Quality of Inspections,

which summarized Section 3.4 of the report. The team recommended that

! Nebraska's performance on this indicator was " satisfactory with recommendations

for improvement," and made three recommendations. The review team j recommended that the State consider for adoption a policy of annual supervisory

accompaniments of all individuals who perform inspections for the Radioactive l Materials Program. The review team recommended that the State develop a plan or

! procedure to assure that field notes, as well as, reports, and enforcement letters are promptly reviewed, signed and dated by a supervisor within the recommended

30 day time frame for issuance of inspection findings. The review team l recommended that the State perform an immediate review of all contractor field

! notes and draft enforcement letters in order to finalize and issue the findings of the j remaining 22 inspections to the licensees involved.

j The final common performance indicator assessed Nebraska's response to incidents and allegations. Mrs. Larkins led the discussion in this area. As discussed in j Section 3.5 of the report, the team found Nebraska's performance relative to this indicator to be " satisfactory with recommendations for improvement" and made j four recommendations. The review team recommended revising the allegations

procedures to incorporate key areas,i.e. documentation of any communications t with the alleger, documentation of the inspection findings, interviewing techniques,

- etc., identified in NRC Manual Directive 8.8, Management of Allegations. The

review team recommended that the staff use the draft " Handbook on Event

} Reporting in the Agreement States (Handbook)," published March 1995, for review j and reporting of material events to NRC. The review team recommended j establishment of comprehensive procedures for tracking, follow up and close out of I' events involving the use of radioactive material covered under the Atomic Energy

Act. Finally, the review team recommended that the State immediately begin j reporting current material events to NRC and send in information on the three events identified during the review as reportable, that were not previously reported l to NRC.

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l Non-common Performance Indicators. Mr. Blanton led the discussion of the non-i common indicator on Legislation and Regulations, which summarized Section 4.1 l of the report. Mr. Blanton noted that the State's regulations were not compatible

! with those of the NRC at the time of the review due to the failure to adopt I regulations equivalent to 10 CFR Part 36 by July 1,1996. At the time of the l review, the team recommended that Nebraska's performance with respect to this j indicator be found " unsatisfactory." Subsequent to the review, the State informed

the team that Section 019 of the Nebraska Code, " Licenses and Radiation Safety

{ Requirements for Irradiators," was adopted effective October 30,1996. In j response to the States adoption of 10 CFR Part 36 equivalent re#ations, the 3

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$. team, based on additional information, is rectrnmending that Nebraska's i performance with respect to this indicator be found " satisfactory " The team made i one recommendation. In accordance with the State's commitment, the team j recommended that Nebraska amend 180 NAC 1-012.22 to remove its applicability

to waste treatment and storage facilities.

l l Mr. Cady led the discussion of the indicator, Low-Level Radioactive Waste (LLRW) - ,

t Disposal Program, which was based on Section 4.2 of the report. The team found l l Nebraska's performance relative to this indicator to be " satisfactory" and made one

, suggestion for enhancement of the program. The team suggested that the LLRW ,

{ program assemble training documentation for individual staff and contractors and  !

i develop a consolidated training record to enable assessment of the progress of training across the entire program.

l-Mrs. Larkins summarized the team's overall recommendations at the time of the i draft report was that Nebraska's program was adequate, but needs improvement

! and not compatible. The team had recommended probation at that time. Based on  ;

the actions taken by the state, the finding at the time of the MRB meeting was that

! the State was compatible. The team wanted to defer on the recommendation for probation until the State had completed their presentation.

l 3. Report from the State of Nebraska. Attached are the briefing slides presented by i the State, which addresses the State's present organization and the corrective

! action plan put into place to address the deficiencies and weakness NRC identified.

l Ms. Deb Thomas, Director, Department of Regulation and Licensure and Mr. Brian l Hearty, Materials Program Manager represented Nebraska during the MRB meeting.

l The Department of Regulation and Licensure is a newly created cabinet level j Department. The Nebraska Radiation Control Program has been moved into to this

! new department from its traditional place in the Department of Health. Ms.

l Thomas believes that the Radiation Control Program will benefit in this organization

!' where the focus is narrowed to licensing and registration versus the responsibilities j of a State Department of Health. Ms. Thomas' position is a cabinet level position

and is appointed by the governor. Nebraska has formulated a two step corrective

! action plan which has a get-well plan and stay-well plan. The State has scheduled

! to complete its get well plan by July 1997 and will have in place the necessary

{ actions including high level management involvement to maintain a quality program.

! in summary, Ms. Thomas stated that it was the State's position that they did not

! disagree with the teams' findings in July 1996, but that the program has improved

( to date. She believes that probation is unnecessary and would take resource away I from the corrections that the Nebraska has undertaken. Ms. Thomas believes that they have accomplished the tasks to impros;e the program without the need for probation.

During both the review teams' presentatior, and the Nebraska presentation, the

MRB asked clarifying questions.

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4. MRB Consultation / Comments on lasur.nce of report. At the c.onclusion of the State's presentation, the review team took a short recess to consider the l

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information presented by the State before making their final recommendation to the j MRB on the overall findings for the Nebraska program and whether the team would

, still recommend probation. Mrs. Larkins concluded, based on the presentation by 4

Nebraska, actions taken to date, and discussion among the IMPEP review team, the

review team did not recommend at this time that Nebraska be placed on probation.

! The review team did recommend that the next IMPEP review be schedule in 1-1 %

l years from the July 1996 review. The MRB concurred in the individual team l findings for the performance indicators and the overall program finding that the Nebraska's program was adequate to protect public health and safety, but needs l improvement and compatible with the exception of the finding of " unsatisfactory" j for Technical Staffing and Training. The MRB directed that finding for Technical Staffing and Training be changed to " satisfactory, with recommendations for j improvements" in view of the actions taken by the State and the commitments

! made by State management. The MRB also concurred in the recommendation that Nebraska be scheduled for its next IMPEP review in 1-1 % years and that NRC 4

should remain in contact with the State and receive periodic information as to the l actions taken by the State in response to the 1996 IMPEP review.

5. Comments from the State of Nebraska. Ms. Thomas stated that she is an advocate for peer review and that the process does not need to be adversarial. She believes

the IMPEP process was such a review and it was time well spent by the State and j the NRC.

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6. Old Business. Approval of the lows and Region 11 MRB Minutes. At the 3

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completion of the New Business, the Region ll and lowa draft MRB minutes were offered for the MRB approval. Mr. Thompson discussed with Mrs. Schneider the

! need to revise the process of approval for draft minutes of MRB meetings that i occurred four months previously. Mrs. Schneider stated that she had oegun j discussions with her management and NMSS to offer the draft minutes and ask for

. approval within a month either by mail or scheduled MRB meeting. Mr. Thompson directed the staff to proceed with a revised process. The Region 11 and lows draft l, minutes as written, were approved as circulated with one minor editorial change to

the Iowa minutes.

i Mr. Thompson also directed the staff to streamline both the reports and the MRB

! presentations by the IMPEP team. Mrs. Schneider committed to work with the iMPEP review teams to accomplish streamlining of both items, especially the MRB presentations.

l i 7. Status of Remaining Reviews. Mrs. Schneider reported on the status of the l remaining IMPEP reviews and reports. Status charts as directed by the MRB were

! distributed. Mn'. Schneider discussed some difficulties encountered in timeliness of

{ the teams' draft report and some preliminary plans to sequester the review teams following the review to enable timely completion of draft report.

j 8. Adournment. The meeting was adjourned at approximately 3:45 pm.

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1 Nebraska Health and Human Services System Department of Regulation and Licensure Deb Thomas, Director Brian Hearty, Materials Program Manager IMPEP Management Review Board, January 22,1997 6

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l Nebraska Health and Human

Services System Department of Regulation and Licensure

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Deb Thomas, Director Brian Hearty, Materials Program Manager IMPEP Management Review Board, January 22,1997 I

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Regulation and Licensure Upper Management Organizational Chart DER THOMAS Director f

'"*JM*u^"In L ,,""' a latory Analysis /lategratio Performe c bGity , ,

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Public Health Assessment  !

Program Management Organizational Chart BURKE CASARI t

Public Health Assessment JACK DANIEL Public Health Assessment I

CHERYL ROGERS BRIAN HEARTY LLRW Radioactive Materials

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i Corrective Action Plan '

I. Get-Well Plan

l IMPEP Review July 15 19,1996 Goals

! l l Two Step Corrective Action Plan i A. Eliminate Backlogs

. I. Get-Well Plan B. Adopt Compatible Regulations i i

II. Stay-Well Plan '

C. Address Administrative Concerns i D. Plan Completed by July 1997 4

A. Eliminate Backlogs A. Eliminate Backlogs Get-Well Plan Actions Taken Get-Well Plan Actions Taken

1. Developed a Project Management 1. Developed a Project Management Plan j, Plan

a. Identified and Assigned Staff To Pending ll b. Created a Gantt Chart to Show Project Timeline and Task Linkages Inspection, Event and Licensing Actions

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l A. Eliminate Backlogs A. Eliminate Backlogs l

Get-Well Plan Actions Taken Get-Well Plan Actions Taken i 2. Implemented a Task Monitoring i l' 2. Implemented a Task Monitoring  !

System System

a. Materials Staff Performance Plan Forms b. Assignment Log Used to Monitor Staff j Rewritten to Coincide With Project ;i Performance ofIndividual Tasks Within the Management Plan Project Management Plan i

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A. Eliminate Backlogs A. Eliminate Backlogs ,

i Get-Well Plan Actions Taken Get-Well Plan Actions Taken

2. Implemented a Task Monitoring 2. Implemented a Task Monitoring i System System

c. Updated Licensing and Inspection d. Created an Event Log to be Used With Databases to Allow for Better Tracking the Nuclear Materials Events Database It i

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i A. Eliminate Backlogs _

A. Eliminate Backlogs i i l

, Get Well Plan Actions Taken Get-Well Plan Actions Taken I

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l 3. Increased Materials Program 3. Increased Materials Program 2

Oversite , , Oversite

a. Weekly Program Management Meeting with Burke Casari, Jack Daniel, and Brian l!

b. Monthly Upper Management Briefing with Deb Thomas, Burke Casari, Jack Hearty to Assess Tasks Assigned and -

Daniel, and Brian Hearty to Report on Plan Completed Progress  ;

4 A. Eliminate Backlogs A. Eliminate Backlogs Get-Well Plan Actions Taken Get-Well Plan Actions Taken

3. Increased Materials Program 4. Increased Materials Program Support Oversite a. Contracted With Stan Huber Consultants

c. Quarterly Status Report to the Governor's ,j to Perform 29 Radioactive Material Radiation Advisory Council  ;; Inspections January to June 1997

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-A. Eliminate Backlogs A. Eliminate Backlogs  ;

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Get-Well Plan Actions Taken Get-Well Plan Actions Taken

4. Increased Materials Program Support -

4 Increased Materials Program Support .

b. Inspection and Licensing Activities  !

c. Full Time Staff Assistant to Support Supplemented by Qualified Agency Staff Radioactive Materials Program Activities  ! l

i. LLRW Staff Have Performed Seven Inspections '

(Four Priority 1, one Priority 2, one Priority 3, and j 3 One Priority 5) and Completed Two Licensing Actions '

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B. Adopt Compatible B. Adopt Compatible  !

Regulations ,, Regulations Get Well Plan Actions Taken '

Get Well Plan Actions Taken

1. Compatible Irradiator Regulations 2. Implemented a Task Monitoring 4

Adopted October 30,1996 System )

a. Regulation Change Log to Track and '

Assign Resources to Changes in Program Regulation and Guidance

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i B. Adopt Compatible i C. Address Administrative Regulations li'! Changes  !

Get-Well Plan Actions Taken iI Get-Well Plan Actions Taken l 3. Increased Materials Program Support 1. Implemented Materials Program

a. Division Staff Support Assisting With . Policy Changes

Program Regulation Changes  !

a. Licensing Actions Submitted Directly for I i. Drafted Regulatory Guide 19.0 for Irradiators

Supervisory Review and Signature Without and is Drafting Regulatory Guide 7.0 for Medical '

Use Peer Review C. Address Administrative C. Address Administrative Changes  ; -

Changes Get-Well Plan Actions Taken . Get-Well Plan Actions Taken i '

l. Implemented Materials Program 1. Implemented Materials Program Policy Changes Policy Changes

b. Legible Handwritten Inspection Field c. NRC Inspection Field Notes for Remote Notes can be Submitted for Supervisory Afterloader and Broad Scope Licensees Review and Used as Final Documentation Converted and Used by Staff

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C. Address Administrative C. Address Administrative Changes .

Changes Get-Well Plan Actions Taken Get-Well Plan Actions Taken

1. Implemented Materials Program 2. Developed a Project Management Policy Changes ,, Plan

d. Implemented Inspection Plan Forms to be a. Identified and Assigned Staff To Used During Inspection Review -

Required Procedure and Manual Changes l

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C. Address Administrative I. Get-Well Plan '

Changes

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Get Well Plan Actions Taken The Plan Addresses Both Primary Root j

3. Increased Materials Program Support Causes identified in the Report by

a. Contractor Prepared Draft Program Increasing Management Oversight and Inspection Procedures and Qualifications Manual for Review Identifying Comprehensive Procedures

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II. Stay-Well Plan l' A. Maintain Quality Goals Stay-Well Plan Actions to be Taken A. Maintain a Quality Program That is '

l. Maintain Program Oversite  !

Continually Improving a. Routine Meetings with Upper and B. Program Anticipates and Responds Program Management to Assess Performance to Changes While Maintaining Adequacy and Compatibility '

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l A. Maintain Quality A. Maintain Quality Stay-Well Plan Actions to be Taken Stay Well Plan Actions to be Taken

1. Maintain Program Oversite  ! ; 2. Use Available Resources to Improve

b. Quarterly Status Report to the Governor's Program Quality Radiation Advisory Council a. Identify What NRC and Other States Do Right and Incorporate Into Program

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A. Maintain Quality ,

B. Respond to Change Stay-Well Plan Actions to be Taken I stay-Well Plan Actions to be Taken i 2. Use Available Resources to Improve ll 1. Procedural Controls

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Program Quality a. Implement a Procedure to be Used by

, b. Bring Lessons Learned at National U Pper Management in the Event of Loss of Meetings Into Program Quicker Program Staff

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B. Respond to Change II. Stay-Well Plan Stay Well Plan Actions to be Taken Plan Summary

1. Procedural Controls The Plan Builds on the Successes of the l

b. Implement a Procedure to be Used by Get-Well Plan to Ensure the Program .

Program Management to Identify and Will Maintain and Improve its Ability I Implement New Administrative Changes to Protect Public Health and Safety

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IMPEP Final Report A. Difticulty Identified Review Team Findings ,,

IMPEP Review Team Final Report j

A. Team Identified Eight Difficulties (1) Backlog ofNine Core Inspections l' .

! During the Review Eight Inspections Have Been Performed and l I

B. Team Made 15 Recommendations one is Awaiting Termination and Will not I

i Require an Inspection  ;

to the State I

A. Difficulty Identified A. Difficulty Identified i

IMPEP Review Team Final Report IMPEP Review Team Final Report

! (2) 22 Inspections Pending Supervisory I (3) Inspection Reports Were

Review and Notification of Ladings Incomplete i Review and Notification Completed August Incomplete Reports Have Been Identified 5,1996 and Assigned in the Task Monitoring System l l i

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A. Difficulty Identified A. Difficulty Identified IMPEP Review Team Final Repon IMPEP Review Team Final Repon 1

i (4) A Backlog of 101 Licensing

! (5) No Incident Reporting to NRC l

l Actions since June 1995  ;

Pending Actions Have Been Prioritized and ' '.

Routine Monthly Event Reporting Using l Assigned in the Task Monitoring System I NMED to Begin January 1997 l )

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A. Difficulty Identified A. Difficulty Identified 1 l

r IMPEP Review Team Final Repon IMPEP Review Team Final Repon l

, (6) Incomplete Documention of (7) Regulations Required for Incident Response and Response to Compatibility not Adopted in a Timely Allegations Fashion Prior Events are Being Documented in Program is Currently Compatible and Better Accordance With the Reporting Handbook Monitoring Will Ensure it is Maintained and Will be Provided to NRC in February ,

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t A. Difficulty Identified ,i B. Recommendations i

IMPEP Review Team Final Report IMPEP Review Team Final Repo[

(8) No Get-Well Plan .

2. Establish an Action Plan or  ;

A Get-Well Plan has Been Formalized as I ! Procedure to Ensure Inspections are  !

Part of the Corrective Action Plan i -

Conducted at Proper Frequencies Inspection Frequencies Have Been Updated in the Inspection Log Database and in the Draft Inspection Procedures

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eehwo- =-4 m*- *e m-ai e* * * - ew+, e B. Recommendations B. Recommendations IMPEP Review Team Final Report IMPEP Review Team Final Report

3. Establish an Action Plan or 4. Organize a Get-Well Plan for Procedure for Coordinating Deviations Rescheduling Missed or Deferred From the Inspection Schedule Inspections and Initial Inspections Inspection Scheduling Will be Addressed in Inspection Scheduling Will be Addressed in the Revised Inspection Procedures and in the the Revised Inspection Procedures and in the Upper Management Stay-Well Procedure Upper Management Stay-Well Procedure

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1 B. Recommendations B. Recommendations

. IMPEP Review Team Final Report i IMPEP Review Team Final Report ,

f 6. Incorporate Qualifications of  ; , 7. Develop a Written Program for Staff Contractor Personnel in Each Contract i i Qualification and Training Records

! Qualification Requirements and Agency A Qualifications Manual has Been Drafted Approval Were Tied Into the Current ji and Will be Implemented When Finalized Inspection Contract l'

! I B. Recommendations B. Recommendations IMPEP Review Team Final Report il IMPEP Review Team Final Report i l!

8. Develop Comprehensive 12. Perform Annual Supervisory Administrative Procedures j ' Accompaniments ofInspection Sta Procedures Required for Licensing, Accompaniments Will be Required in the Inspection, and Upper Management Qualifications Manual and Performed Notification Have Been Identified in the Annually Project Management Plan l

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-l B. Recommendations l B. Recommendations IMPEP Review Team Final Report -

IMPEP Review Team Final Report i

13. Develop a Procedure to Ensure 14. Review ContractorInspection i Timely Completion ofInspection

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'. Field Notes and Issue Findings j

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Documentation Review Completed August 5,1996 Inspection Documentation Requirements are Addressed in the Task Monitoring System M

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, B. Recommendations B. Recommendations i IMPEP Review Team Final Report IMPEP Review Team Final Report

15. Revise Allegation Procedures to .

16. Use the Draft Handbook on Event Incorporate Key Ideas of Management Reporting for Reporting Events to NRC Directive 8.8 The Allegation Section of the Program The Allegation Section of the Program Inspection Procedures Will be Revised to Inspection Manual Will be Revised to Reference the Handbook and Make It An Incorporate MD 8.8 Attachment to the Manual i

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i B. Recommendations B. Recommendations  ! l

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IMPEP Review Team Final Report , IMPEP Review Team Final Report )

17. Establish Procedures for Tracking, ,. 18. Begin Reporting Current Events l Follow up and Close out of Events '

and Report Past Events Immediately j

. An Event Tracking Log has Been Routine Reporting Will Begin January 1997 l Implemented for Tracking of all Possible and Past Events are Being Documented in

Materials Events and Will be Used With , Accordance With the Reporting Handbook NhED and the Allegation Procedures and Will be Provided to NRC in February i

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B. Recommendations B. Recommendations

, IMPEP Review Team Final Report IMPEP Review Team Final Report

19. Amend 180 NAC 1-012.22 to I 2 0. Develop a Consolidated Training i Remove Applicability to Waste f ;i Record for the LLRW Program Treatment and Storage Facilities ,'

, The State of Nebraska LLRW Program (Comprised of Both HHS Regulation & Licensure and NDEQ) Will set Regulation Revision in Process up an Administrative Procedure to Keep Track of Staff Training and Training Specifically Provided by the LLRW Program m.

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l Recommendation Status Findings Status Summary of Actions Taken lj IMPEP Review' Team Draft Report I

6. and 14. Completed I' Draft Report: October 16,1996 2.-4., 7.-8.,12.-l 3.,15.-20. To be ij 1 Satisfactory 4 Satisfactory With Recommendations '

Completed Prior to July 1997 2 Unsatisfactory Findings Status IMPEP Review Team Final Report Final Report: January 14,1997  ;

3 Satisfactory ,

3 Satisfactory With Recommendations 1 Unsatisfactory  :