ML20148G548

Forwards Management Review Board Proposed Final Rept Documenting Integrated Matls Performance Evaluation Program Review of Mississippi Radiation Control Program.Review Conducted During Period 970127-31

ML20148G548
Person / Time
Issue date:	04/25/1997
From:	Lohaus P NRC OFFICE OF STATE PROGRAMS (OSP)
To:	Thompson H NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO)
References
NUDOCS 9706060008
Download: ML20148G548 (61)

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c. 4 UNITED STATES

• g NUCLEAR REGULATORY COMMISSION t WAsHINoToN, D.C. 20066 4 001 4 ,o 9***** April 25, 1997

' MEMORANDUM TO: Hugh L. Thompson, Jr.

Deputy Executive Director for Regulatory Programs Richard L. Bangart, Director Office of State Programs Carl J. Paperiello, Director Office of Nuclear Material Safety and Safeguards Karen D. Cyr, General Counsel Denwood F. Ross, Director Office for Analysis and Evaluation of Operational Data (p p - . . > -

FROM: Paul H. Lohaus, Deputy Director 3 Office of State Programs 4

SUBJECT:

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM (IMPEP) REVIEW OF MISSISSIPPI RADIATION CONTROL PROGRAM This memorandum transmits to the Management Review Board (MRB) a proposed final report (Attachment 1) documenting the IMPEP review of the Mississippi Radiation Control Program. The review of the Mississippi program was conducted by an interoffice team during the period January 27-31, 1997. The team issued a draft report to , Mississippi on March 20,1997, for factual comment. Mississippi's factual comments, received by letter dated April 14,1997, from Mr. Robert W. Goff, Director, Division of Radioicgical Health, Mississippi Department of Health (Attachment 2) have been incorporated into the proposed final report.

1 The review team found the State's performance with respect to the common and non-common indicators to be satisfactory. Based on these indicators, the review team recommends that the MRB find the Mississippi program to be adequate to protect public i health and safety and compatible with the NRC's regulatory program.

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Multiple Addressees 2 The MRB meeting to consider the Mississippi report is scheduled for Wednesday, May 14, 2

1997, from 3:30 - 5:30 p.m. In One White Flint North, Room 4 B-6. In accordance with Management Directive 5.6, the meeting is open to the public. The agenda for that meeting is attached (Attachment 3).

If you have any questions prior to the meeting, please contact me at 415-2326 or Craig 4

Gordon at 601-337-5216.

Attachments:

As stated ,

l cc: Robert W. Goff, MS 1

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Multiple Addressees 2

The MRB meeting to consider the Mississippi report is scheduled for Wednesday, May 14, 1997, from 3:30 - 5:30 p.m. in One White Flint North, Room 4-B-6. In accordance with Management Directive 5.6, the meeting is open to the public. The agenda for that meeting is attached (Attachment 3).

If you have any questions prior to the meeting, please contact me at 415-2326 or Craig Gordon at 601-337-5216.

Attachments:

As stated a

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cc: Robert W. Goff, MS '

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To r.c.i . copy of this document, indicate in the box: 'C' = Copy without attachment /enclosur%*E' = Copy with attachment / enclosure 'N' = No copy OFFICE OSP l OSP:DD l OSP:D NJ l l  ;

NAME KSchneider:gd PHLohausgp W RLBangart '

.; DATE 04/18/97* 04/;4/97 ft1 04/Jf/97 l OSP FILE CODE: SP-AG-15  ;

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Multiple Addressees 2 The MRB meeting to consider the Mississippi report is scheduled for Thursday, May 22, 2 1' 7, from 3:30 - 5:30 p.m. In One White Flint North, Room 8-B-11. In accordance with Man ement Directive 5.6, the meeting is open to the public. The agenda for that meeting is atta ed (Attachment 3).

If you have ny questions prior to the meeting, please cor'.oet ine at 415-2326 or Craig Gordon at 6 -337-5216. ,

Attachments:

As stated cc: Robert W. Go MS

[OAS Liaison to RB - need name]

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DIR RF DCD (SPO CGordon, RI PDR (YES/)

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! SMoore, NMSS HNewsome, OGC FCameron, OGC Mississippi File DOCUMENT NAME: G:\KXS\MSMRBMEM.KNS G:\KXS\MSIMP97.PFN To receive a copy of this document, indicate in the boa: *C" = Copy without attachment / enclosure "E" = Copy with attachment / enclosure * = No copy OFFICE OSPgg OSP:DD l OSP:D l \

NAME KSchneiderigd PHLohaus RLBangart \

DATE 04//g /97 04/ /97 04/ /97 \

OSP FILE CODE: TP-AG-16

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INTEGRATED MATERIALS PERFORMANCE EVALUATION P, ' 3 RAM REVIEW OF MISSISSIPPI AGREEMENT STATE PROGRAM January 27-31, 1997 i 1

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PROPOSED FINAL REPORT t

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U.S. Nuclear Regulatory Commission i

ATTACHMENT 1

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>a Mississippi Proposed Final Report Page 1

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{ This' report presents the results of the review of the Mississippi radiation control program.  !

The review was conducted during the period January 27-31, 1997, by a review team-

. comprised of technical staff members from the Nuclear Regulatory Commission (NRC) and i the State of Texas. Team members are identified in Appendix A. The review was j

conducted in accordance with the " Interim Implementation of the Integrated Materials Performance Evaluation Program Pending Final Commission Approval of the Statement of  !

l Principles and Policy for the Agreement State Program and the Policy Statement on  ;

Adequacy and Compatibility of Agreement State Programs," published in the Federal -

]- Reaister on October 25,1995, and the September 12,1995, NRC Management Directive-  ;

i 5.6, " Integrated Materials Performance Evaluation Program (IMPEP)." Preliminary results of - ,

the review, which covered the period September 24,1993 to December 31,1996, were j discussed with Mississippi management on January. 31,1997.

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[ Paragraph on results of the MRB meeting will be included in the final report.]

The Department of Health (DOH) is the radiation control agency within the State of l Mississippi that regulates, among other public health issues, exposure to radiation hazards.

! . The State Health Officer is appointed by and reports to the Governor. Within the DOH, the Mississippi radiation control program is administered by the Division of Radiological Health l

(DRH) under the direction of the Office of Health Regulation. The DOH and DRH organization charts are included as Appendix B. The Mississippi program regulates

{- approximately 320 specific licensees. - In addition to the radioactive materials program, the -

l- DRH administers programs for machine produced radiation, naturally occurring radioactive i materials, and emergency preparedness for the Grand Gulf nuclear power plant. The L review focused on the materials program as it is carried out under the Section 274b. (of

. the Atomic Energy Act of 1954, as amended) Agreement between the NRC and the State i of Mississippi, in preparation for the review, a questionnaire addressing the common and non-common 3

indicators.was sent to the DRH on November 18,1996. Mississippi provided its response

! to the questionnaire on January 7,1997. A copy of that response is included as Appendix C to this report.

l The review team's general approach for conduct of this review consisted of: (1) examination of Mississippi's response to the questionnaire, (2) review of applicable Mississippi statutes and regulations, (3) analysis of quantitative information from the DRH

' licensing and inspection data bases, (4) technical review of selected files, (5) field accompaniments of two Mississippi inspectors, and (6) interviews with staff and )

management to answer questions or clarify issues. The team evaluated the information  !

that it gathered against the IMPEP performance criteria for each common and non-common indicator and made a preliminary assessment of the radiation control program's performance, t . -

Section 2 below discusses.the State's actions in response to recommendations made l

! following the previous review. Results of the current review for the IMPEP common j j performance indicators are presented in Section 3. Section 4 discusses results of the i

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v applicable non-common indicators, and Section 5 summarizes the review team's findings  !

and recommendations. '

i 2.0 . STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS i The previous routine review concluded on September 24,1993, and the results were transmitted to Dr. F. E. Thompson, Jr., State Health Officer, Mississippi State Department {

of Health, on June 3,1994. .

Findings from the September 1993 routine review resulted in recommendations in two l program indicators: Status and Compatibility of Regulations and Administrative l Procedures. The State's corrective actions in response to the recommendations were  !

evaluated during a review visit which concluded on September 24,1994. All comments -

and recommendations were satisfactorily resolved for the Status and Compatibility of I Regulations indicator and closed at that time. Results of the review visit were transmitted to Mr. E. S.'Fuente, Director, Division of Radiological Health, on December 5,'1994. ]

,. i The September 1994 review visit findings resulted in continued recommendations for the i Administrative Procedures indicator. During the 1993 review NRC recommended that the J program review their written' administrative procedures for uniformity with their current j regulatory practices, and revise as needed, with particular emphasis on enforcement j procedures, procedures for medical misadministrations, r scedures for handling, processing l and tracking allegations, and procedures for the evaluatic,n and documentation of inspector accompaniments. By written memorandum the Director, DRH directed each Section i Supervisor to update all administrative procedures by the end of 1994. l During the 1997 IMPEP review the team found a revised procedures manual _was available l which contained implementing procedures for a wide range of program tasks including j enforcement actions, handling of misadministrations, supervisory accompaniments, and. ]

processing and tracking allegations. Although.some procedures were completed just prior i to the review, the RHP Director indicated that the procedures were being implemented. I This item is closed. ]

- 3.0 COMMON PERFORMANCE INDICATORS I lMPEP identifies five common performance indicators to be used in reviewing both NRC Regional and Agreement State programs. These indicators include: (1) Status of Materials i inspection Program; (2) Technical Staffing and Training, (3) Technical Quality of Licensing )

Actions, (4) Technical Quality of inspections, and (5) Response to incidents and J Allegations.

3.1 Status of Materials insoection Proaram The team focused on four factors in reviewing this indicator: (1) inspection frequency, (2) overdue inspections, (3) initial inspection of new licenses, and (4) timely dispatch of inspection findings to licensees. The team evaluation is based on the Mississippi

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1 Mississippi Proposed Final Report Page 3 l questionnaire responses regarding this indicator, data gathered independently from the State's licensing and inspection data tracking system, the examination of licensing and inspection casework files, and interviews with managers and staff.

The team's review of the State's inspection priorities verified that the State's inspection frequencies for various types or groups of licenses are at least as frequent as similar license types or groups listed in the NRC inspection Manual Chapter 2800 (IMC 2800) frequency schedule. In reviewing the State's priority schedule, the review team noted that the State requires more frequent inspections in some license categories as follows:

teletherapy licensees are scheduled to be inspected on a two year frequency vs. NRC's three year frequency, medical private practice licensees on a two or three year frequency vs. NRC's three (with quality management program) or five year (without quality management program) frequency, and academic broad licensees on a one year frequency vs. NRC's two or three year frequency.

In their response to the questionnaire, Mississippi indicated that as of December 31,1996, there were three licenses identified as core inspections in IMC 2800 that were overdue by more than 25 percent of the NRC's frequency. This number is well within the 10 percent criterion for overdue inspections of Management Directive 5.6. The team noted that two of the overdue inspections were inspected before the review and the third overdue inspection was conducted during the IMPEP review week.

Inspection data are continuously updated and tracked, and reviewed every six months for inspection planning. With respect to initial inspections of new licenses, the team reviewed the inspection tracking data system and verified that initial inspections were entered into the tracking system together with existing licenses. Inspection due dates generated by the system for new licenses are combined by inspection priority with those for other materials licenses. A review of the inspection tracking system showed that initial inspections are not differentiated from routine inspections, since the tracking system does not display a six month due date for initialinspections. From interviews, IMPEP reviewers found the inspection staff was able to identify initial inspections by the license number. The higher-numbered licenses are new issues indicating an initial inspection is necessary.

Mississippi's schedule for initialinspections, however, does not fully coincide with the guidance of the programmatic indicator. Although inspections are to be performed within six months for priority 1,2, and 3, licensees, priority 4 licensees are scheduled for initial inspection on a one-year interval. The State's priority 4 licensees include portable and industrial gauges (except generally licensed gauges), small academic licenses, medical licensee's in-vitro programs, gas chromatographs, and environmental sampling facilities.

The review team recommends that the tracking system be revised to allow initial inspections to be readily identified.

The inspection frequencies of licenses selected for inspection file review were compared with the frequencies of the State's priority system and verified to be consistent and as frequent as similar license types under the IMC 2800 system. A review of 19 files of recently issued licenses indicated that the initialinspection was conducted within six months for five of the licenses. Initialinspection for the other new licenses ranged from 8-18 months after license issuance or material receipt. Eight of the licenses were in the

Mississippi Proposed Final Report Page 4 r State's priority 4 (one year interval) category. Of those, two were initially inspected within one year, four were initially inspected within six months, and two exceeded the one year i frequency, Over half of the inspection reports reviewed for new licenses contained at least one notice of violation. This reinforces the need to perform initialinspections within the prescribed schedule so that inspectors can discuss program responsibilities with the licensee shortly after materials are introduced into operations. The review team recommends that allinitialinspections be performed within six months of license issuance or within six months of the licensee's receipt of material and commencement of  ;

operations, consistent with IMC 2800. l The timeliness of the issuance of inspection findings was also evaluated during the inspection file review. For the files examined, allinspection correspondence had been sent

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within 20 days of the inspection date, well within the goal of 30 days after cornpletion of i the inspection.  !

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Mississippi reported in their response to the questionnaire that 110 different licensees had submitted requests for reciprocity during the review period, of which 46 were from licensees with inspection intervals of 3 years or less. The State reported that 29 of 46 licensees were inspected.

Based on the IMPEP evaluation criteria, the review team recommends that Mississippi's  !

performance with respect to the indicator, Status of Materials inspection Program, be found satisfactory.

3.2 Technical Staffina and Trainina in reviewing this indicator, the review team considered the radioactive materials program staffing level, the technical qualifications of the staff, staff training, and staff turnover.

To evaluate these issues, the review team examined the State's questionnaire responses regarding this indicator, interviewed DRH management and staff, and considered any possible backlogs in licensing or compliance actions.

At the time of the review, Mississippi's radiation control program had three Sections:

(1) the Environmental Section, (2) the X Ray Section, and (3) the Radioactive Materials Section (FiMS). The RMS is authorized for a Health Physicist (HP) Administrative (supervisor), one HP Senior position, two HPs, and one HP Trainee position. The organization chart (Appendix B) shows each of these positions, but not the number of staff assigned to each position. At the time of the review, there was an additional individual assigned full time in the HP position. The review team believes that based on the satisfactory performance of the materials licensing and inspection programs, this staffing levelis adequate when all positions are filled and the personnel trained.

The technical quality of the staff was evaluated from interviews with the DRH Director, review of the job descriptions, and a review of the training records. The review team determined that successful candidates for technical positions were required to have a bachelor's degree in science for the first level (health physicist) and a master's degree and/or additional radiation-related work experience for positions beyond entry level. The

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team concluded that the DRH has been able to recruit qualified individuals, and that all of 1 the staff HPs have bachelor's degrees in science, most with several years of practical i experience in radiation safety practices, j The licensing and inspection functions of the program are integrated; therefore, all health  ;

physicists performed duties in licensing, inspection, and event response. Balance between the licensing and inspection functions is achieved by basing staff assignments on program needs. Mississippi's efforts to maintain the program while at the same time devoting significant effort in hiring and training new staff by experienced staff throughout the review period are commendable. As noted by the review team, two individuals, the HP Administrative and Health Physicist Senior, performed a large majority of licensing and I inspection activities, and were responsible for the training of the new staff.

According to the information provided in the ' questionnaire and the DRH training procedures, all health physicists are required to attend training courses which are 3

. equivalent to coursed outlined in IMC 1246 as well as the five-week health physics course. l The records show that all of the radioactive materials staff members have completed the l five-week health physics course and the basic NRC courses needed for licensing and inspection functions except for two individuals. One staff member needs the Industrial Radiography course to complete training requirements. The other person was new to the '

i program and has experience as a health physicist at a nuclear power facility, but will need to attend the NRC or equivalent courses as they become available.

Program management also explained their in-house and on-the-job training processes. New staff are assigned increasingly complex licensing duties under the direction of senior staff and accompany experienced inspectors during increasingly complicated inspections. New staff inspectors are assigned independent inspections after demonstrating competence during accompaniment evaluations by the tenior staff. The team noted that program management exhibited a strong commitment to training during the review. However, the Director, DRH expressed concern about access to State funding for training and increasing difficulty in obtaining approval for out of State travel for training purposes without NRC funds for travel and training.

Information provided by the DRH shows that there have been two staff turnovers in the RMS since the previous 1993 review, one in May 1994 and another in March 1996. A replacement HP Trainee was hired in September 1995, received the appropriate course training and was recently promoted to HP. The team discussed plans with the DRH Director for involving this individual in routine licensing and inspection activities since required crA - ,e work was nearly complete. Another replacement HP (experienced) was hired in l@ amber 1996 and is currently undergoing additional training. The Program -

Director received a promotion in June 1996 from HP Administrative (RMS Supervisor) which left the RMS with only two fully trained HPs for a short period of time. As a result of this staff turnover and a new Division Director change, the program currently has the Health Physicist Trainee position vacant and is actively recruiting for the position.

The review team recommends that it is prudent for the State to fill the vacant HP Trainee j position and recommends the State evaluate whether the hiring' action should be expedited.

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Mississippi Proposed Final Report Page 6 in evaluating this indicator, the review team considered the staff changes, noted that the program filled the vacancies in a timely fashion, except for the vacated Trainee position,

, accelerated the training schedule for the Trainee position, and hired an experienced Health Physicist as one of the replacements. Although there currently are no routine licensing or inspection backlogs, the Director, DRH related that short-term inspection backlogs could occur if additional staff effort is needed to respond to events, or if either of the two senior .

staff left the program.

Based on the IMPEP evaluation criteria, the review team recommends that Mississippi's performance with respect to the indicator, Technical Staffing and Training, be found satisfactory.

3.3 . Technical Quality of Licensino Actions

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The review team examined casework and interviewed the reviewers for 22 specific licenses. Licensing actions were reviewed for completeness, consistency, proper isotopes and q%ntities used, qualifications of authorized users, adequate facilities and equipment, ,

and operating and emergency procedures sufficient to establish the basis for licensing actions. Cnework was reviewed for timeliness, adherence to good health physics practkes, reference to appropriate regulations, documentation of safety evaluation reports, or other supporting documents, consideration of enforcement history on renewals, pre-licensing visits, peer or supervicory review as indicated, and proper signature authorities.

Licenses were reviewed for accuracy, appropriateness of the license and of its conditions and tie-down conditions, and overall technical quality. The files were checked for retention of necessary documents and supporting data.

As part of the license renewal practice the licensee is requested to submit a complete program description for DRH staff review at five year intervals. When a license is issued, it includes the expiration date based on inspection priority. During this five year period the DRH issues the licensee a letter (also determined by inspection frequency) which requests ,

information about program status. The licensee identifies program changes or certifies that '

no program changes occurred. Following review of the licensee's response, the license is amended to extend the expiration date by the designated frequency. For example, priority 1 licensees are sent annual program status letters; the licenses are then amended to ,

extend the expiration date by one year. Priority 2 licenses expire two years from license  !

issuance, with program status letters sent just prior to license expiration. Following the licensee's response, the expiration date is extended for another two years. Priority 3 and 4 licensees are handled in a similar manner. This practice continues for five years from the new or renewed license issue date. After the fifth year the licensee submits a new application for DRH review and license renewal.

The cases were selected to provide a representative sample of licensing actions which had I been completed in the review period and to include work by all reviewers. The cross-section sampling included three of Mississippi's major licenses and included the following types: broad scope (rasearch and development), nuclear laundry, nuclear pharmacy, strontium-90 eye soplicator, nuclear medicine, teletherapy, portable and fixed gauges, and industrial fixed rao yaphy. Licensing actions included 2 new licenses,13 five-year interval renewals,4 emendments, and 3 terminations. In discussions with the Director, l

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t Mississippi Proposed Final Report Page 7 DRH, it was noted that there were no major decommissioning efforts underway with regard to agreement materialin Mississippi. A list of licenses that were reviewed, with case-specific comments can be found in Appendix D.

The review team found that, overall, the licensing actions were generally thorough, complete, consistent, and of acceptable quality with health and safety issues properly addressed. Speciallicense tie-down conditions were almost always stated clearly, backed by information contained in the file, and inspectable. The licensee's compliance history was taken into account when reviewing renewal applications. Mississippi's licensing guides and license policy procedures were revised and updated in March 1995.

Mississippi's licensing guides and license conditions were adopted directly from the NRC's.

With few exceptions, file renews showed reviewers appropriately used the revised licensing guides.

From discussions with staff, the team found that State licensees have not been notified of the need to file for reciprocity on sites which are under exclusive Federal jurisdiction as identified in the NRC All Agreement States Letter SP-96-022. Additionally, licenses which authorize temporary job sites have not been amended to include a condition requiring the licensee to file for reciprocity when at sites which are under exclusive federal jurisdiction.

The team recommends that all " temporary job location" licensees be notified of their responsibility for determining federal jurisdiction, and that the All Agreement States letter SP-96-022 be utilized to revise the State's standard license condition for use of material at temporary job sites.

Team review of two license files authorizing use of strontium-90 eye applicators showed that the license files did not contain information on the method used by the licensee to assess the quantity of strontium-90 activity before administering treatment to patients.

Since recent NRC experience has identified licensee misadministrations due to inadequate determination of strontium-90 eye applicator activity, the team suggests that the RMS review the methods used by strontium-90 eye applicator licensees to assess the quantity of material prior to patient administration.

All new or renewed licenses and amendments are peer reviewed and signed by the Director, DRH, before being issued. No potentially significant health and safety issues were identified.

Based on the IMPEP evaluation criteria, the review team secommends that performance with respect to the indicator, Technical Quality of Licensing Actions, be found satisfactory.

3.4 Technical Quality of Inspections The team reviewed the inspection reports, enforcement documentation, and the data base information for 20 materials inspections conducted during the review period. The casework included the State's two fully-qualified materials inspectors and one inspector who left the program during the review period. A sample of the higher priority categories of license types was reviewed as follows: three irstitutional medical for diagnostic use, one pool-type irradiator, one industrial laundry, one institutional medical with

Mississippi Proposed Final Report Page 8 brachytherapy and isotope therapy, one institutional medical with an HDR unit, one teletherapy, four nuclear pharmacies, one broad medical, five industrial radiography, and two portable gauges. Appendix E provides a list of the inspection cases reviewed in depth with case-specific comments.

The inspection procedures and techniques utilized by Mississippi were reviewed and determined to be generally consistent with the inspection guidance provided in IMC 2800 with one exception. Although follow-up and most field site inspections were performed on an unannounced basis, the review team found that almost all routine and initial inspections are conducted on an announced basis. The tearn suggests that the State revisit their policy for conducting announced routine inspections, and consider performing more routine inspections on an unannounced basis, as permitted by available resources.

The State's primary inspection report form was reviewed and found to be a comprehensive document providing general inspection areas consistent with the types of information and data collected under IMC 2800 and 87100 documents. Except for a special medical form developed during the review period, the State does not use separate supplements to the inspection report form for various license types. During inspection preparation, the form is adapted by the inspector to the special type of inspection to be performed, which is equivalent to NRC field notes. Copies of revised inspection field notes contained in IMC 87100 appendir,es covering the areas of industrial /research development, welllogging, industrial radir, graphy, commercial irradiator, medical broad-scope, and radiopharmacy were provided by the team. The review team suggests that the State review its form and adopt, where appropriate, field notes specific to the various types of licensees, inspection reports were reviewed to determine if the reports adequately documented the scope of the licensed program, licensee organization, personnel protection, posting and labeling, control of materials, equipment, use of materials, transfer, and disposal. The reports were also checked to determine if the reports adequately documented operations observed, interview of workers, independent measurements, status of previous noncomp;.ance items, substantiation of allitems of noncompliance, and the substance of discussions during exit interviews with management. To assure consistency and quality of reports, the Director, DRH provided review and comment, and signed inspection correspondence and field notes.

Overall, the review team found that the inspection reports showed very good quality. Four reports needed additional information to fully document performance areas covered during the inspection such as details of worker interviews and licensee operations observed by the inspector. Other reports contained only minor discrepancies from standard practice which were related to insufficient detail.

The files were found to be organized chronologically, with licensing and inspection information readily accessible. Field notes, inspection forms, and enforcement documents were found to be complete. Documented inspection findings generally led to appropriate enforcement actions. Routine enforcement letters were drafted by inspectors and were issued promptly to the licensee by the Director, DRH.

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Mississippi Proposed Final Report Page 9

!n response to a finding from the previous NRC review, the State revised the procedure which describes criteria for determining enforcement actions. The State bases their enforcement program primarily upon onsite inspections and written notices of inspection findings. The State defines a violation as any item of non-compliance with existing rules and regulations of the Agency, variation from the existing specific conditions assigned to a license or variation from existing operating and emergency procedures of the licensee approved through the Agency. A deficiency is defined as any item which, if continued by a licensee has the potential to affect public health and safety or could result in a violation.

This item, in fact, however, does not constitute a violation. When the licensee responds to a notice of violation (NOV) or deficiency, the iesponse is given to the inspector to evaluate the licensee's response, and to draft a reply for the program director's signature. The revised enforcement procedure includes provisions for monetary penalties, orders (cease and desist, license suspension, and show cause), written notices of noncompliance, and enforcement conferences. A concern in implementation of the revised enforcement policy was identified during review of inspection reports. The procedure indicates NOVs are issued when a licensee does not comply with a particular regulation while deficiencies are noted for less significant inspection findings, but not for a violation of regulations.

However, reports showed that deficiencies were used when citing violations of regulations and did not provide clear significance to the inspection findings. The team recommends the use of deficiencies closely follow the revised enforcement procedure, particularly when regulations are cited.

The Director, DRH stated that inspection results showed licensee compliance for corrective actions taken to address violations was acceptable during the review period and no escalated enforcement beyond issued NOVs was necessary. In one case the State held a meeting with licensee management to discuss problems identified during an inspection, which resulted in the licensee's commitment to take appropriate corrective action. The )

inspectors also performed license reviews, further strengthening the continuity of the regulatory and enforcement programs. The review team concluded that the enforcement i policy was effective. l Two inspector accompaniments identified in Appendix E were performed by a review team l member on January 15,1997 (hospital- nuclear medicine program) and January 16,1997 3 (radiopharmacy). The other inspectors were either new to the program or were not yet qualified to perform independent inspections of high priority licensees. During the "

accompaniments inspectors demonstrated appropriate inspection techniques and knowledge of the regulations. The inspectors were well prepared and thorough in the  ;

review of licensee radiation safety programs. Inspection techniques were observed to be ]

primarily compliance oriented, with inspection report form information prescribing 4 inspection areas. The term suggested the State document their inspection activities of l performance-based methods such as observation of licensec operations, worker demonstration of material handling and use, employee interviev!s, and an increase in type y and number of independent measurements. Overall, the technical performance of the inspectors was at a high level, and the inspections were adequate to assess radiological {

health and safety at the licensed facilities.

l Mississippi has a policy of performing annual supervisory accompaniments of inspectors. i in response to the questionnaire, the State reported that supervisory inspecto'r

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accompaniments were performed at least annually by the Director, DRH, on each inspector -

since the previous review. Performance evaluations are discussed with the inspector and one annual accompaniment documented. Accompaniments of junior personnel also are performed by senior inspectors.

It was noted that Mississippi has an ample number of portable radiation detection instruments for use during routine inspections and response to incidents and emergencies.

Included in the State's meter inventory were ion chambers, micro-R meters, high range detectors, GM tubes, ratemeters, liquid scintillation detectors, high and low range pocket dosimeters, alpha and gamma spectroscopy equipment, various calibration standards, and air sampling' equipment. The portable instruments used during the inspector accompaniments were observed to be operational and calibrated. The DRH program office is co-located with the radiation counting laboratory and a holding area for emergency response kits and vehicles. Portable instruments maintained at each location in the building were available for use during routine inspections and observed to be calibrated. I I

. Based on the IMPEP evaluation criteria, the review team recommends that Mississippi's  !

performance with respect to the indicator, Technical Quality of Inspections, be found

• satisfactory.

l 3.5 9esoonse to incidents and Alleaations f

in evaluating the effectiveness of the State's actions in responding to incidents and I allegations, the review team examined the State's response to the questionnaire regarding this indicator, reviewed the incidents reported for Mississippi in the " Nuclear Material Events Database" (NMED) against those contained in the Mississippi files and reviewed the casework of 14 reportable incidents and two NRC referred allegations identified as l involving byproduct material, in addition, the review team interviewed the staff members assigned to incident response.

Responsibility for initial response and follow up actions to radioactive materials incidents and allegat: W : rests with the DRH. Written procedures require emergency response to events involving radioactive materiallicensens. The HP Administrative is the designated emergency coordinator, with backup provided by DRH staff. The Director, DRH or in his absence his designee, will be a'Jvised of allincidents reported and response actions considered before responders depart for the incident scene. The written procedures specify that an on-site response will be made in the following situations: 1) the DRH is requested to do so; 2) radioactive material other than gas is lost; 3) an actual or potential i hazard to public health and safety is identified; 4) media notification to the DRH of any real 1 or suspected incident; or 5) a determination by the Director or his designee that a response is necessary. J After an initial screening, a total of 14 files were reviewed,13 of which were the most safety significant reportable incidents involving byproduct material that occurred during

. the IMPEP review period. The incidents reviewed included one equipment failure, one misadministration, three lost or stolen radioactive material events, three contamination events, four cases of damage to equipment, and two trensportation events. Five of the ,

incidents reviewed were entered into the NMED. The information in NMED agreed with the i

Mississippi Proposed Final Report Page 11 i

information in the Mississippi files. A list of the incident response case work with comments is included as Appendix F. Eight of the incidents reviewed had not been ,

reported to NRC and referred to NMED. The review team recommends that the State send  !

in information of the reportable events that were not previously reported to NRC and  ;

continue voluntary reporting of all reportable events in the NMED database system i collection of material events by providing event information directly into the NMED system electronically or providing compatible information in written form, in accordance with guidance contained in the " Handbook on Nuclear Material Event Reporting in the  !

Agreement States," Draft Report, March 1995. '

For the most p.irt, correct response procedures were followed in most instances actions were appropriate and timely. The level of effort was generally commensurate with the l hazard to the puuk, and suitable enforcement actions were taken. There were, however, l instances in which improvement was needed.

The team identified two incident cases that the State did not conduct prompt on-site investigations to identify the extent of radiation exposure and spread of contamination.

The first case involved a student at a licensed facility in which l-125 contamination was found inside a building, on the student's hands, clothing, shoes, and vehicle.

Communications were made with the licensee at the time the incident happened, but there was no response to the facility. A second incident involved a fire in which three-nuclear measurement gauges were potentially damaged. The State approved the licensee's request to move the gauges to an isolated storage building and instructed the licensee in precautionary procedures to be used when moving the gauges but did not observe the licensee's on-scene mitigative actions.

The team recommends the State conduct prompt responses to incidents whenever radiation exposure or radioactive contamination is identified.

The two allegations received by the State during the review period that involved byproduct radioactive materials were examined in detail. Allegations were responded to promptly with appropriate investigations and follow up actions. The review team reviewed the State's procedures, found them adequate, and that they appeared to be followed. These procedures were used for the control of information, and the results of the investigation were promptly related to the alleger. No significant problems were observed.

Based on the IMPEP evaluation criteria, the review team recommends that Mississippi's performance with respect to the indicator, Response to incidents and Allegations, be found satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS IMPEP identifies four non-common performance indicators to be used in reviewing Agreement State programs: (1) Legislation and Regulations, (2) Sealed Source and Device Evaluation Program, (3) Lnw-Level Radioactive Waste Disposal Program, and (4) Uranium Recovery Operations. Mississippi's agreement does not cover uranium recovery operations, so only the first three non-common performance indicators were applicable to this review.

Mississippi Proposed Final Report Page 12 4.1 Leaislation and Reaulations 4.1.1 Lecislative and Leaal Authority In response to the questionnaire and discussions with the Director, DRH, Mississippi reported to the review team the legislation which authorizes the Mississippi radiation control program is identified in the Mississippi Radiation Protection Law of 1976, and no changes were made during the review period. House Bill No.1357, which passed in 1992, provides authority for the program to collect fees. There are no sunset laws in Mississippi and the State indicated that regulations have no expiration date.

4.1.2 Status and Comoatibility of Reaulations All but one regulation required for compatibility identified as due or overdue for adoption at the time of the 1993 routine review and September 1994 review vicit were adopted in October 1994 and July 1996. A license condition to establish a legal binding requirement was used in the one case where regulation promulgation was overdue. The rules received final NRC review and approval on August 2,1996 and with adoption of two comments made by NRC were determined to be compatible. The first comment was editorial and was corrected prior to the printing of the new regulations. The second comment concerned Section 801 of the Mississippi Regulations as follows:

In 801.Q.7, (equivalent to 10CFR 36.21), amend subsection (a)(1) to require that a sealed source have a certificate of registration issued under 10 CFR 32.210, or the equivalent rule of the Agency or another Agreement State.

The Director. DRH indicated that this comment would be incorporated into the next rule i adoption, which requires approval by the Board of Health and will be addressed in 1997. j Until final rules are adopted, the State has addressed the second comment by including a  ;

license condition that requires licensees to have a certificate of registration for sealed sources.

With the following exceptions, Mississippi has adopted all compatible regulations which will become due through 1998.

• " Preparation, Transfer for Commercial Distribution and Use of Byproduct Material for Medical Use," 10 CFR Parts 30,32 and 35 amendments (59 FR 61767,59 FR 65243,60 FR 322) that became effective on January 1,1995, is under review and is expected to become effective by the due date of January 1,1998.

e " Low-Level Waste Shipment Manifest Information and Reporting," 10 CFR Part 20 and 61 amendments (60 FR 15649 and 60 FR 25983) that becomes effective March 1,1998 and will need to be adopted by March 1,1998. The NRC delayed its effectiveness until the States could adopt compatible requirements so that the national manifest system will go into effect at one time.

7__ .

E i

.1

{ 1

Mississippi Proposed Final Report Page 13 e -- Performance Requirements for Radiography Equipment," 10 CFR 34 amendments -l 4

(60 FR 28323) that becam'e effective June 30,1995 and will need to be adopted l by June 30,1998.

l e ~ " Compatibility with' the International Atomic Energy Agency," 10 CFR Part 71 l j amendment (60 FR 50248) that became effective April 1,1996 and will need to be i

?

adopted by April 1,1999. NRC delayed the effective date of this rule until April 1,-

l 1996 so that the DOT companion rule could be implemented at the same time.-

Since the rule involves the transport of materials across state lines, the States are i encouraged to adopt compatible regulations as soon as possible, 3

i

" Medical Administration of Radiation and Radioactive Materials," 10 CFR Parts 20 Le-i and 35 amendments (60 FR 48623) that became effective October 20,1995 and i j will need to adopted by October 20,1998.  ;

L. The review team examined the procedures used in the Mississippi's promulgation process I and found the public is offered the opportunity to comment on proposed regulations  :

throughout the process. . The quality management rule (QM), which was enacted in October 1994, was one recent example of Mississippi's. willingness to cooperate with the ,

V NRC. '

The team notes that NRC staff is currently reviewing all Agreement States equivalent

s. regulations to Part 20, Standards for Protection Against Radiation. The reviews are being j_ conducted outside the IMPEP process and the States will be notified of the results.

! Based on the IMPEP evaluation criteria, the review team recommends that Mississippi's I performance with respect to the indicator, Legislation and Regulations, be found .

j satisfactory, j r j 4.2 Sealed Source arid Dojce Evaluation Proaram i The review team did not review the State's sealed source and device (SS&D) program even though Mississippi currently has responsibility for this area. The review team discussed with the Director, DRH, as to whether Mississippi has considered returning its  :

authority for the Sealed Source and Device Evaluation Program. Mississippi has not yet

. formulated a position on this issue. 'The State did not perform any SS&D evaluations  :

during the period of the review. j 4.3 Low-Level Radioactive Waste (LLRW) Disposal Proaram )

l In 1981, the NRC amended its Policy Statement, " Criteria for Guidance of States and NRC in Discontinuance of NRC Authority and Assumption Thereof by States Through Agreement" to allow a State to seek an amendment for the regulation of LLRW as a separate category. Those States with existing Agreements prior to 1981 were determined to have continued LLRW disposal authority without the need of an amendment. Although  ;

Mississippi has LLRW disposal authority, NRC has not required States to have a program '

'for licensing a LLRW disposal facility until such time as the State has been designated as a host state'for a LLRW disposal facility. When an Agreement State has been notified or

l Mississippi Proposed Final Report Page 14 i

becomes aware of the need to regulate a LLRW disposal facility, they are expected to put in place a regulatory program which will meet the criteria for an adequate and compatible LLRW disposal program. There are no plans for a LLRW disposal facility in Mississippi.

Accordingly, the review team did not review this indicator.

5.0

SUMMARY

i As noted in Sections 3 and 4 above, the review team found the State's performance with  !

respect to each of the performance indicators to be satisfactory. Accordingly, the team 3

recommends the Management Review Board find the Mississippi program to be adequate '

to protect public health and safety and compatible with NRC's program.

Below is a summary list of suggestions and recommendations, as mentioned in earlier I sections of the report, for action by the State.

l

1. The review team recommends that the tracking system be revised to allow initial inspectinns to be readily identified. (Section 3.1)

2. The review team recommends that allinitialinspections be performed within six months of license issuance or within six months of the licensee's receipt of material and commencement of operations, consistent with IMC 2800. (Section 3.1)

3. The review team recommends that it is prudent for the State to fill the vacant HP Trainee position and recommends the State evaluate whether the hiring action should be expedited. (Section 3.2)

4. The team recommends that all " temporary job location" licensees be notified of their responsibility for determining federal jurisdiction, and that the All Agreement States '

letter SP-96 022 be utilized to revise the State's standard license condition for use of material at temporary job sites. (Section 3.3)

5. The team suggests that the RMS review the methods used by strontium 90 eye applicator licensees to assess the quantity of material prior to patient administration.

, (Section 3.3)

6. The team suggests that the State revisit their policy for conducting announced routine inspections, and consider performing more routine inspections on an unannounced basis, as permitted by available resources. (Section 3.4)

7. The review team suggests that the State review its form and adopt, where appropriate, field notes specific to the various types of licensees. (Section 3.4)

8. The team recommends the use of deficiencies closely follow the revised enforcement procedure, particularly when regulations are cited. (Section 3.4)

Mississippi Proposed Final Report Page 15

9. The team suggested the State document their inspection activities of performance-based methods such as observation of licensee operations, worker demonstration of material handling and use, employee interviews, and an increase in type and number of independent measurements. (Section 3.4)

10. The review team recommends that the State send .in information of the reportable events that were not previously reported to NRC and continue voluntary reporting of all reportable events in the NMED database system collection of material events by providing event information directly into the NMED system electronically or providing compatible information in written form, in accordance with guidance contained in the " Handbook on Nuclear Material Event Reporting in the Agreement States," Draft Report, March 1995. (Section 3.5)

11. The team recommends the State conduct prompt responses to incidents whenever radiation exposure or radioactive contamination is identified. (Section 3.5)

, 7 . .- . 7__ _ _

! LIST OF APPENDICES AND ATTACHMENTS i

l' i ' Appendix A iMPEP Review Team Members Appendix B Mississippi Radiation Control Branch Organization Chart I Appendix C ' Mississippi's Questionnaire Response Appendix D License File Reviews Appendix E inspection File Reviews I i

Appendix F Incident File Reviews )

2

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l Attachment 1 Mississippi's Response to Review Findings  !

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APPENDIX A IMPEP REVIEW TEAM MEMBERS Name Area of Responsibility Craig Gordon, RI Team Leader Legislation and Regulations Technical Quality of Inspections ,

Richard Woodruff, Rll Technical Staffing and Training Sally Merchant, NMSS Technical Quality of Licensing Actions Cynthia Cardwell, Texas Status of Materials inspection Program Response to incidents and Allegations l

I 1

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APPENDIX B I l

MISSISSIPPI RADIATION CONTROL PROGRAM ORGANIZATION CHART l

l 1

Mississippi Sisie Department ofIleelsh l Stsie Health Officer I ,

n 30 Depesy Sines lieahh Officer M 8'"i(*8 FY 96 Prepared: July 1,1995 Ile.hh Com nicatiam and l%blic Reinien.

District Otraces (9) Information Syseems Censultant

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(( Insemal Affairs Poiry and Planning Sifnature Cowey liealth Departments (t21 Peblic IIcahh Noning I Omce of Administrative and Technical Support l l Omce of Community Health Services l I -

Epiduningy I I I i 1 B su et Ad unaemive B eeusfDan Finance .nd B.ees ef Pa.or-i l i I I I Suecost Division Fra=== Accounts Technical Seseert Division Acceensing Labormary Cassificatient Am m Sweeno m Heem W Iwamien Thiesis  !

Building and Network /

Division Ileshh Statistics Educmion Division Division Coveral Division Grunds W Bedgeting Phrmacy Copsion HIV/ AIDS Birth / Death Cironsc Illness Ceneal Supply Syseens Centracts Certificses Coordinatsen P.chasingt STD Canamanity lleash Copy Roern Property Eruployee Data Analysis Pronweien Benerets Mail Room Third Party Laber Statistics hiery Prevention Processing Mosor Pool Tobacco

$saff Prevession Prins Shop Development l OfDre ofIIeelth Regulation l l Ofuce of Personsb Ilealth Services l l

l l l l l l Bureau of Plesuiing Boreau of Bweae of Emetrennental Dereas of and Researco ChildrAdolescoes Women, Infant Bureau of Home llenhh Henkh IJcensure Division IIcahh and Ouldren Women's lleshlt Division Beihe and Disto Care Certificase of Need OsiMren's Medical Accountsna Breast /Cervecal Consinuing Pseasure vessel and Professional Progreen Cancee Educmion ,

Safety licensure Ileshh Plannmg Den Symems Division Damal Heahh Domestic Vielencer Professional Radelegical Revel Henkh Psed Deseriketion Rape Crisis Services Heahh Division Ensegency Early beavention Medical Services Sysiem Merusering Family Plannag Project Saniassion Division and Evalension lleme Division ITSDT Heshhy l%eares Licenswe and Nutrisies Operational Weser Supply Catircation Genetics Educauen PilRM/Bern lies Savices Division Division Prennent Services

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APPENDIX C MISSISSIPPl'S QUESTIONNAIRE RESPONSE

. j Approved by OMB2 No. 3150-0183 ,

Expires-4/30/98 l i

l INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGBAB OUESTIONNAIRE MISSISSIPPI  ;

o Reporting Period: September 24, 1993 to December 31, 1996 i

- A. COMMON PERFORMANCE INDICATORS

1. Status of Haterials Insoection Proaram

1. Please prepare a table identifying the licenses with inspections I that are overdue by more than 25% of the scheduled frequency set 4 out in NRC Inspection Manual Chapter 2800 (issued 4/17/95). The list should include initial inspections that are overdue.

Insp. Frequency Licensee Name (Years) Due Date Months 0/D ,

t Forrest Gen. Hosp. 1 9603 9 Johnson Controls 1 9606 6

, Syncor Inter. Services 1 9608 4

2. Do you currently have an action plan for completing overdue inspections? If so. please describe the plan or provide a written

copy with your response to this questionnaire.

It is anticipated that the above overdue inspections will be completed in January 1997.

1 Estimated burden per response to comply with this voluntary collection request: 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br />. Forward comments regarding burden estimate to the Information and Records Management Branch (T-6 F33). U.S. Nuclear Regulatory Commission. Washington, DC 20555-0001, and to the Paperwork Reduction Project (3150-0052). Office of Management and Budget. Washin'; ton, DC 20503. NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

. . + . , . . . . - - . a- - .,-.a.,.a ..a-, sa,w s -. a a > ~u- .a w- n ,n era- -m=...--. e m -a.-~.wawa -.s - s -.1o.- r- .a 4

q J

-3. Please identify individual licensees or groups' of licensees the  ;

j. - State / Region is. inspecting less frequently than called for in NRC ,

Inspection Manual Chapter 2800 (issued 4/17/95) and state the reason for the change. l None

4. How many licensees filed recipro-ity notices in the reporting period?

~

110-

a. ~

Of these, how many were industrial radiography. well-logging .

. or other users with inspection frequencies of three years or less? .

( 36-Industrial Radiography 7-Well Logging

_ 2-Teletherapy Source Exchange 1-Irradiator Source Exchange

b. For those identified in 4a. how many reciprocity inspections l

were conducted?  :.

, 29 l 5. Other than reciprocity licensees, how many field inspections of radiographers were performed? l 26 4

f 6. For NRC Regions, did you establish numerical goals for the number

. of inspections to be performed during this review period? If so.

please describe your goals, the number of. inspections actually performed, and the reasons for any differences between the goals ,

- and the actual number of inspections performed.

L N/A

$ II. Technical Staffino and Trainina i

7. Please provide a staffing plan, or complete a listing using the suggested format below, of the professional (technical) person-p years of effort applied to the agreement or radioactive material 2

. - .- . - -. = -

4 program by individual. Include the name, position, and, for l Agreement States, the fraction of time spent in the following areas: administration, materials licensing & compliance, emergency response LLW, U-mills, other. . If these regulatory responsibilities are divided between offices, the table should be l consolidated to include all personnel contributing to the radioactive materials program. Include all vacancies and identify.

i all senior personnel assigned to monitor work of junior personnel.

If consultants were used to carry out the program's radioactive materials responsibilities, include their efforts. The table heading should be:

NedE POSITION AREA 0F EFFORT Bob Goff Director Administration 70%

licensing & com-pliance 20%

Emergency response 5%

Low-level waste 5%

B. J. Smith H.P.Adm. Administration /

licensing & com-pliance 97%

Emergency resp. 1.5%  !

Low-level waste -'1. 5% l Melissa Parker H.P. Senior Licensing & .

compliance 98.5% )

Emergency resp. 1.5% l l

I James Curry H.P. Licensing & 98.5%

compliance Emergency resp. 1.5% ,

l Robert Nelson H.P. Licensing & 98.5% l compliance  ;

Emergency resp. 1.5%  ;

Vacant H.P. Trainee Licensing & 98.5%

compliance Emergency resp. 1.5%

(

Please provide a listing of all new professional personnel 8.

hired since the last review, indicate the degree (s) they 3

r received, if applicable, and additional training and years of experience in health physics, or other disciplines. if appropriate.

Lisa Dyt oloyment'Date 2-7-94-Health Physicist Trainee B.S. Mat? # ssissippi College-5/93 .

Training:

10/29-11/3/95 SAFETY ASPECTS OF WELL LOGGING 8/14-18/95 MEDICAL USES OF RADIONUCLIDES 6/5-9/95 SAFETY ASPECTS OF INDUSTRIAL RADIOGRAPHY 4

5/14-19/95 RER0-RADIOLOGICAL EMERGENCY RESPONSE OPERATIONS

4/24-28/95 TRANSPORTATION OF RAD. MATERIALS 1/14/95 LICENSING PRACTICES & PROCEDURES-G-109 9/26-30/94 INSPECTION PROCEDURES COURSE James Curry-Employment Date 9-1-95 -Health Physicist Trainee ,

B.S. Biology-Alcorn State University-12/94 Training:

9/15-20/96 RERO RADIOLOGICAL EMERGENCY RESPONSE OPERATIONS  !

9/9-13/96 DIAGNOSTIC & THERAPEUTIC N.NED. COURSE H-304 1 8/19-23/96 INSPECTION PROCEDURES COURSE l 7/8-8/9/96 FIVE WEEK APPLIED HEALTH PHYSICS COURSE l 4

6/3-7/96 LICENSING PRACTICES & PROCEDURES i 4/29-5/3/96 TRANSPORTATION OF RADIDACTIVE MATERIALS 12/11-15/95 SELECTED TOPICS IN RAD. ENGINEERING l l

11-13-95 RMD'S LPA-1 LEAD PAINT INSPECTION SYSTEM 10/19/95 NUCLEAR GAUGE SAFETY TRAINING PROGRAM Robert Nelson-Employment Date 11-1-96 -Health Physicist B.S. Biology-University of Mississippi Experience: )

Health Physics Technician Grand Golf Nuclear Station March 1985/May 1991 i

Technical Director for Dosimetry Processing  !

Grand Gulf Nuclear Station June 1991/ March 1996 Training:  !

4

g _ __ _ ._. _ _ _ .

4 1994 Interactions of Radiation with Tissue and TLDs:

Phillip Plato. Inc.

1991-1994 Panasonic International TLD Symposium 1991 DEC VAX System Manager Training 1990 Five Week Applied Health Physics Course 1985-1991 Bio Data Systems: Panasonic TLD System Operations 1985 Grand Gulf Training Department: Health Physics ,

Fundamentals ,

9. Please list all professional staff who have not yet met the  ;

qualification requirements of license reviewer / materials inspection staff (for NRC. Inspection Manual Chapters 1245 ,

and 1246; for Agreement States, please describe your

~

qualifications requirements for materials license reviewers and inspectors). For each, list the courses or equivalent training / experience they need to attend and a tentative schedule for completion of these requirements.

It has been the Agency's policy to send all new inspectors ,

and license reviewers to the basic courses. These basic  !

courses are as follows: )

1 l

Inspection Procedures Licensing Practices and Procedures Transportation of Radioactive Material Diagnostic & Therapeutic Nuclear Medicine l Safety Aspects of Industrial Radiography Safety Aspects of Well-Logging All of the above courses were usually completed within the I first two (2) years of employment. Inspection and licensee I reviewers usually complete the Five Week Applied Health  ;

Physics Course by the end of their third year of employment.

Health Physicist Seniors were usually sent to more advanced courses such as the Health Physics Technology Course as they i became available.

However, with the withdrawal of NRC funding for Agreement States training, the Agency may be forced to reduce the number of basic courses and rely more on in-house training.

Training will be limited by our budgetary restraints.

5

=-__ -. ..

The following individuals have not completed the following basic courses:

COURSE TENTATIVE SCHEDULE t

James Curry Safety Aspects of Health Physicist Industrial Radiography

• Robert Nelson Inspection Procedures 1997 Health Physicist Licensing Procedures 1998 :

Transportation Procedures

• Safety Aspects of Industrial Radiography

• Safety Aspects of Well-Logging

• Diagnostic & Therapeutic Nuclear Medicine *

• Training will be provided as funding becomes available.

10. Please identify the technical staff who left the RCP/ Regional DNMS program during this period.

Lisa Dye - Health Physicist Jonathan Barlow - Health Physicist Senior III, Igchnical Ouality of Licensina Actions

11. Please identify any major, unusual, or complex licenses which were isst ?d, received a major amendment, terminated or renewed in this period.

University of Mississippi Medical Center Renewal Mississippi State University Renewal INS-Licensee has temporarily suspended operations due to lost Entergy Contract.

12. Please identify any new or amended licenses added or removed from i the list of licensees requiring emergency plans?

None 6

i l

l

13. Discuss any variances in licensing policies and procedures or exemptions from the regulations granted during the review period.

None

14. What, if any changes were made in your written licensing l procedures (new procedures, updates, policy memoranda, etc.)

during the reporting period? )

A draft revision in its entirety has been prepared.

15. For NRC Regions, identify by licensee name, license number and i type, any renewal applications that have been pending for one year l or more.  !

l IV. Technical Quality of Insoections

16. What, if any, changes were made to your written inspection procedures during the reporting period?

A draft revision in its entirety has been prepared.

17. Prepare a table showing the number and types of supervisory accompaniments made during the review period. Include:

, l Suoervisor Insoector license Cat. Date ACCOMPANIMENTS BY H.P. ADMINISTRATIVE Bob Goff B. J. Smith NORM (decontamination) 12/1/94 )

• Bob Goff B. J. Smith Teletherapy 7/13/95 1

• Bob Goff B. J. Smith HDR 12/6/96 l Bob Goff M. Parker Industrial Radiography 7/27/94 Bob Goff M. Parker Nuclear Laundry 2/23-24/95

• Bob Goff M. Parker Nuclear Medicine 8/17/95 Bob Goff J. Barlow Well-Logging 8/17/94 Bob Goff Lisa Dye Gauge 9/8/94 Bob Goff Lisa Dye Industrial Radiography 4/1/95

• Bob Goff Lisa Dye Gauge 8/31/95 7

l

l Bob Goff Lisa Dye Gauge 10/3/95 B. J. Smith James Curry Gauge 5/22/96

• Accompaniments documented '

ACCOMPANIMENTS BY SENIOR PERSONNEL B. J. Smith M. Parker Teletherapy 4/6/94 B. J. Smith M. Parker Well-Logging 7/9/94 B. J. Smith M. Parker Nuclear Pharmacy 7/14/95 B. J. Smith M. Parker Well-Logging 7/18/95 B. J. Smith M. Parker Irraditor 9/28/95 B. J. Smith M. Parker Source Exchange 9/28/95 H. Parker Lisa Dye Gauge 7/13/95 M. Parker Lisa Dye Gauge 7/15/95 M. Parker Lisa Dye Gauge 9/7/95 M. Parker Lisa Dye Nuclear Medicine 11/9/95 l B. J. Smith Lisa Dye Industrial Radiography 11/16/95 M. Parker- Lisa Dye Industrial Radiography 11/13/95 l l

Lisa Dye James Curry Gauge 10/17/95 i Lisa Dye James Curry Gas Chromatograph 11/30/95 I Lisa Dye James Curry Gauge 11/30/95 Lisa Dye James Curry Gauge 1/11/96  ;

18. Describe internal procedures for conducting supervisory ,

accompaniments of inspectors in the field. If supervisory accompaniments were documented, please provide copies of the documentation for each accompaniment.

Inspectors are accompanied at least annually by the supervisor.

These have been documented since 1995 (copies enclosed).

In addition to the above, supervisory accompaniments are also performed by the Senior Personnel on Junior Personnel. These accompaniments are not documented.

19. Describe or provide an update on your instrumer:tation and methods of calibration. Are all instruments properly calibrated at the present time?

8

1 The following instruments have been added since the last review:

J Two (2) Ludlum Model LM-19 survey meters.  ;

. Three (3) Ludlum Model LM-3/44-2 survey meters.

Four (4) Ludlum Model 14-3/44-38/44-9 survey meters. 1 One (1) NDS Model 2000 survey meter.

. Six (6) NDS Model RA-500 alarming dose rate meters.

I Instruments are returned to manufacturer for calibration.  !

i 4

V. Resoonses to Incidents and Alleaations l C

20. Please provide a list of the most sianificant incidents (i.e.. l medical misa'dministration, overexposures, lost and abandoned '

sources, incidents requiring 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> or less notification, etc.)

that occurred in the Region / State during the review period. For Agreement States, information included in previous submittals to 1 NRC need not be repeated. The list should be in the following l

format: j i

LICENSEE NAME LICENSE # DATE OF INCIDENT / REPORT TYPE OF 1 INCIDENT i l

Perf-0-Log. Inc. MS-669-01 8-9-96 Abandoned j Well-Logging !

Source. j l

21. During this review period, did any incidents occur that involved l equipment or source failure or approved operating procedures that were  !

deficient? If so, how and when were other State /NRC licensees who might i be affected notified?

a. For States, was timely notification made to the Office of State j Programs? For Regions, was an appropriate and timely PN '

generated?

No incidents occurred that involved equipment or source failure or i approved operating procedures that were deficient.

However, a Mississippi licensee (Babcock & Wilcox-MS-002-01) reported a possible defect in an 9

l

Industrial Nuclear Corporation adaptor for a radiographic exposure device. Since this device was manufacturered in the state of California, details of the incident, photographs, and the adaptor ,

were provided to the California Radiation Division for their investigation. California's findings indicated that there were no manufacturer's defects in the adaptor.

22. For incidents involving failure of equipment or sources, was information on the incident provided to the agency responsible for evaluation of the

, device for an assessment of possible generic design deficiency? Please provide details for each case. I (See above)

23. In the period covered by this review, were there any cases involving c possible wrongdoing that were reviewed or are presently undergoing  !

review? If so, please describe the circumstances for each case. l 4

None

24. Identify any changes to your procedures for handling allegations that occurred during the period of this review.  ;

a. For Agreement States, please identify any allegations referred to your program by the NRC that have not been closed.  !

All allegations referred to the Agency by NRC have been

closed.

VI. General 1

25. Please prepare a summary of the status of the State's or Region's actions taken in response to the comments and recommendations following the last review.

Status and Comoatibility of Reaulations The Mississippi Regulations have been amended to include all regulations considered as a matter of compatibility with a due date prior to January  ;

1, 1998. (See Table for Question 29) . j Administrative Procedures l

The Administrative Procedures are currently being revised. It is  ;

anticipated that a final draft will be completed in January 1997. j 10

26. Provide a brief description of your program's strengths and weaknesses.

These strengths and weaknesses should be supported by examples of successes, problems or difficulties which occurred during this review period.

During the review period, the Division encountered problems with NORM legislation and lack of funding for a NORM Branch. It is estimated that approximately 11/2 to 2 FTE (Director & RAM Staff) were dedicated to NORM regulation, enforcement. and legislation.

Recent legislation has given the authority to regulate oil & gas NORM to '

the Mississippi Oil & Gas Board. As a result of this shift of authority, the NORM workload including legislation has been greatly reduced.  ;

Furthermore, the Mississippi State Department of Health (MSDH) has I requested an opinion from the Attorney General's Office to clarify whether the MSDH has any regulatory authority for the oil & gas NORM.

B. NON COMMON PERFORMANCE INDICATORS l

1. Reaulations and Leaal Authority

27. Please list all currently effective legislation that affects the radiation control program (RCP).

Mississippi Radiation Protection Law of 1976 House Bill No. 1357 (Fees) l l

28. Are your regulations subject to a " Sunset" or equivalent law? If so, I explain and include the next cxpiration date for your regulations. '

No l

29. Please complete the enclosed table based on NRC chronology of amendments.

Identify those that have not been adopted by the State, explain why they l were not adopted, and discuss any actions being taken to adopt them.

30. If you have not adopted all amendments within three years from the date of NRC rule promulgation, briefly describe your State's procedures for amending regulations in order to maintain compatibility with the NRC, showing the normal length of time anticipated to complete each step.

N/A 11

a -- s . . - - -- - a- - s.- - _

e ,

II. Sealed Source and Device Proaram i

31. Prepare a table listing new and revised SS&D registrations of sealec sources and devices issued during the review period. The table heading should be:

SS&D Manufacturer. Type of Registry Distributor or Device Number Custom User or Source N/A i 32. What guides, standards and procedures are used to evaluate registry applications?

N/A

33. Please include information on the following questions in Section'A as they apply to the Sealed Source and Device Program:

, Technical Staffing and Training - A.II.7-10 Technical Quality of Licensing Actions - A.III.11. A.III.13-14 Responses to Incidents and Allegations - A.V.20-23 N/A III. Low-level Waste Proaram

34. Please include information on the following questions in Section A. as they apply to the Low-level Waste Program:

Status of Materials Inspection Program - A.I.1-3. A.I.6 Technical Staffing and Training - A.II.7-10 Technical Quality of Licensing Actions - A.III.11. A.III.13-14 Technical Quality of Inspections - A.IV.16-19 Responses to Incidents and Allegations - A.V.20-23

- N/A IV. Uranium Mill Proaram

35. Please include information on the following questions in Section A. as they apply to the Uranium Hill Program:

Status of Materials Inspection Program - A.I.1-3. A.I.6 Technical Staffing and Training - A.II.7-10 12

1 Technical Quality of Licensing Actions _A.III.11. A.III.13-14 Technical- Quality of Inspections - A.IV.16-19 l Responses to Incidents and Allegations - A.V.20-23 l 1

N/A--

i 9

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f 13 e t

I

TABLE FOR OVESTION 29. .

OR DATE DATE 10 CFR RULE DUE ADOPTED CURRENT EXPECTED STATUS ADOPTION _

Any amendment due prior to 1991. Identify each reguisboa (refer to the Chronology of Amendments)

Decommessionmg; 7/27/91 10/14/92 Parts 30,40,70 Emergency Plannmg, 4/7/93 10/14/92 Parts 30,40,70 Standards for Protechon Agamst Redebon, 1/1/94 8/4/93 Part 20 Safety Requwements for Radographsc 1110/94 10/12/94 Equipment; Part 34 Noh6cahon ofincedents; 10f15/94 10f12/94 Parts 20,30,31,34,39,40,70 Quahty Management Program and 1/27/95 10/12/94 Misadmm.strations; Part 35 Licenssng and Radishon Safety 7/1/96 10/12/94 Requwements for Irradelors: Part 36 De6mtson of Land Disposal 7/22/96 NA and Waste Site QA F vy , Part 61 Decommessoning Recordkeeping Docu- 10/25/96 7/10/96 rrentahon Addshons; Parts 30. 40,70 Self-Guarantee as an fddihonal Financial 1/28/97 7/10/96 Mechanism; Parts 30,40,70 Urarnum Mill Tailings: Cor* 7dng to EPA 7/1/97 NA Standards: Part 40 Timekness in Decommissionmg 8/15/97 7/10/96 Parts 30,40,70 14

m- 5 _. _ a_ 4se& m 6 6 -' b 4 4m@.6 4 h,+_ sk .mi .aw. .a. .

e OR DATE DATE 10 CFR RULE DUE ADOPTED CURRENT EXPECTED ,

~

STATUS ADOPTION Propershon, Tronofer for Commercial Dis- 1/1/98 1998 inbution, and Use of Byproduct Matensi for Medical Use: Parts 30,32,35 Frequency of Medical Examinations for Use 3/13/98 7/10516 of Respratory Protecton Equipment Low-levelWaale Shipment Mansfest 3/1/98 1998 informsbon and Reportmg Performence Requirements for Radiography 6/30/98 1998 Equipment Radelion Protection Requirements. 8/14/98 7/10/98 i i

Amended Defirwhons and Criterie Clonficebon of Decommesiorwgl Funding 11/24/98 7/10/96 Requvements 10 CFR Part 71: Compellbility wilb the 4/1/99 1998 Intemahonal Atomic Energy Agency Medical Admmistration of Radebon and 10/20/98 1998 Radioactive Matenels l

I i

I 15 i

- _ - . . - . - _=

7 _ -.

i .

l f

APPENDIX D LICENSE FILE REVIEWS File No.: 1 Licensee: Black Warrior Wireline, Inc. License No.: 626 Location: Columbus Amendment No.: 7 ,

License Type: Well-logging Type of Action: Termination Date Amendment Issued: 06/24/93 License Reviewer: BJS File No.: 2 Licensee: Quinn Contracting, Inc. License No.: 763-01 Location: Falkner Amendment No.: 2 License Type: Troxler Gauge Type of Action: Amendment Date Amendment issued: 02/21/95 License Reviewer: BJS,MP Comments:

a) Sources moved to storage as licensee's corrective actions resulting from poor inspection findings.

b) No checklists or other licensing aids were included, nor were copies of all ',. tgoing communications.

File No.: 3 Licensee: Schlumberger Technology Corp. License No.: 463-01 Location: Houston, TX Amendment No.: 25 1 License Type: Well-logging Type of Action: Renewal Date Amendment issued: 10/01/96 License Reviewer: MP Comment:

a) Amendment 21 (8/27/92) amended license in entirety. No checklist or other method for ensuring completeness were included.

File No.: 4 Licensee: University of Mississippi License No.: EBL-01 Location: Jackson Amendment No.: 49 and 50 License Type: Broadscope - R&D Type of Action: Renewal Date Amendment issued: 01/24/96 License Reviewer: MP l Comments:

a) No checklists or other method of documenting review process were included.

b) No documentation of deficiency telephone call.

Mississippi Proposed Final Report Page D.2 License File Reviews File No.: 5 Licensee: Henley Operating Company License No.: 661-01 Location: Columbus Amendment No.: 10 License Type: Irradiator Type of Action: Renewal Date Amendment issued: 08/09/96 License Reviewer: BJS,MP Comments:

a) Outgoing deficiency correspondence not included (responses were included).

b) No checklists or other method of documenting review process were included.

I File No.: 6 l Licensee: Interstate Nuclear Services License No.: 495-01 Location: Vicksburg Amendment No.: 19 t icense Type: Nuclear Laundry Type of Action: Amendment Temporarily suspend operation - storage only license Date Amendment Issued: 05/02/95 License Reviewer: BJS,MP File No.: 7 Licensee: Syncor License No.: 493-04 Location: Tupelo Amendment No.:

License Type: Radiopharmacy Type of Action:New License Date Amendment issued: 08/01/96 License Reviewer: BJS,MP l

File No.: 8 l Licensee: Baptist Memorial Hospital License No.: 232-01 j Location: Oxford Amendment No.: 28 i License Type: Medical - Teletherapy Type of Action: Renewal l Date Amendment issued: 04/01/96 License Reviewer: BJS,MP  ;

i File No.: 9 Licensee: Methodist Medical Center License No.: 722-02 Location: Jackson Amendment No.:

License Type: Medical - HDR Type of Action: New Date Amendment issued: 08/23/96 License Reviewer: BJS,MP i

File No.: 10 Licensee: Jeff Anderson Regional Medical Center License No.: 267-01 Location: Meridian Amendment No.: 54 License Type: Medical Type of Action: Amendment '

Date Amendment issued: 10/30/96 License Reviewer: BJS,MP

7 -_ _ . .

l l'.-

a Mississippi Proposed Final Report Page D.3 j ,

License File P.cVisws i

File No.: 11 Licensee: James L.' Pettis, M.D. License No.: 219-01

- Location: Tupelo Amendment No.: 17 License Type: Sr-90 Eye Applicator Type of Action: Renewal i Date Amendment issued: 07/09/96 License Reviewer: BJS,MP Comments:

s) Requirement to assess quantity of material remaining after decay, before  !

administration, was not addressed in the license application, nor in the issued

+- license.

. b) Inspection: 4/22/94 (quality management rule not in effect) Inspection (MP and LD) did nct include a review ~of procedure for assessing the source strength of beachytherapy source (Sr-90 eye applicator) before administration.-

File No.: 12 Licensee: William C. Sams, M.D. License No.: 359-01 .

Location: Gulfport Amendment No.: ?

4 License Type: Sr-90 Eye Applicator Type of Action: Renewal Date Amendment issued: 06/09/95 License Reviewer: BJS,MP '

Comments:

a) Requirement to assess quantity of material remaining after decay (before 1 administratior.) was not addressed in the license application, nor in the issued l license. The original license application (6/17/76 for Dr. Flagg) contained a brochure for the eye applicator with instructions to calculate decay over time. The license did require that material be used according to procedures in the application.

b)- Inspection, 5/11/94, 2 violations: (1) 6-month inventory of unit not done, and (2) the applicator was not tested for leakage between 7/27/90 and 2/12/94. A letter describing acceptable corrective action, dated 5/19/94, was provided.

c) Inspection: 5/11/94 (quality management rule not in effect) Inspection did not note if licensee assessed source strength of brachytherapy source (Sr 90 eye applicator) before' administration.

File No.: 13-Licensee: King's Daughter's Hospital License No.: 270-01 Location: Brookhaven Amendment No.: 28 License Type: Medical Type of Action: Renewal Date Amendment issued: 02/06/96 License Reviewer: BJS,MP

)

File No.: 14 Licensee: Trace Regional Hospital License No.: 017-02 Location: Houston, MS Amendment No.: 36 License Type: Medical Type of Action: Renewal  !

Date Amendment issued: 10/95 License Reviewer: BJS l

I

I Mississippi Proposed Final Report Page D.4 License File Reviews 1 File No.: 15

Licensee: Magnolia Hospital License No.: 290-01 Location:Corinth Amendment No.: 48

} License Type: Medical - Brachytherapy Type of Action: Amendment Date Amendment issued: 04/02/96 License Reviewer: BJS i-File No.: 16

?

Licensee: Cardiovascular Associates License No.: 804-01

! Location: Jackson. Amendment No.:

License Type: Medical Type of Action: Renewal

' Date Amendment issued: 01/16/96 License Reviewer: BJS i' Comment:

a) 3/22/96, request to add physician as Authorized user. 4/3/96 deficiency letter, requesting clarification of training dates. -

ji 9/6/96 letter from Baptist Medical Center attesting to physicians competency over

- last 13 years. Specific dates for the 500 hours0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of supervised work experience and i

500 hour0.00579 days <br />0.139 hours <br />8.267196e-4 weeks <br />1.9025e-4 months <br /> of supervised clinical experience requirements were not provided. The

[ license was issued.

File No.: 17

' Licensee: Struthers industries, Inc. License No.:'259-01 Location: Gulfport Amendment No.: 37 -

License Type:. Industrial Radiography Type of Action: Renewal Date Amendment issued: 09/07/93 License Reviewer: BJS File No.: 18 Licensee: Sverdrup Technology, Inc. License No.: 653-02 Location: Stennis Space Center Amendment No.: 27 License Type: Radiography Type of Action: Termination Date Amendment Issued: 09/12/94 License Reviewer: BJS

' File No.: 19 Licensee: Rutter and Associates, Inc. License No.: 457-01 Location: McComb Amendment No.: 10 License Type: Troxler Gauge Type of Action: Renewal Date Amendment issued: 02/20/96 License Reviewer: BJS,MP Comrnent:

a) No documentation of outgoing correspondence.

t-

_ . - _ . . _ _ . . _ . _ _ . _ ..._... _ ...- - .._.. _ - _ . - -- - - --._ - - -- ---~m-i  !

l Mississippi Proposed Final Report Page D.5  !

License File Reviews

• File No.: 20-Licensee: Birmingham Steel Corporation License No.: 612-01 ,

Location: Jackson . .

Amendment No.: 7 i License Type: Gauge (level measurement) Type of Action: Termination ,

Date Amendment issued: 07/09/96 License Reviewer: BJS,MP l

File No.: .21 _  ;

Licensee: P.M.S.C. Irby Steel License No.: 750-01 Location: Gulfport Amendment No.: 7  :

License Type: Industrial Radiography Type of Action: Amendment ,

Date Amendment issued: 04/02/96 License Reviewer: BJS,MP  !

Comment

a). . License, which allows for temporary job sites, has not been amended to include a  !

requirement to file for reciprocity when on sites which are exclusive federal jurisdiction (in accordance with the All Agreement Letter SP-96-022 guidance).  !

File No.: 22 Licensee: Welding Testing X-Ray, Inc. License No.: 666-01 Location: Baton Rouge Amendment No.: 8  ;

License Type: Industrial Radiography Type of Action: Amendment Date Amendment issued: 03/01/96 License Reviewer: BJS,MP Comment. _

l License, which allows for temporary job sites, has not been amended to include a a) requirement to file for reciprocity when on sites which are exclusive federal  :

jurisdiction (in accordance with the All Agreement Letter SP-96-022 guidance).

1 I

6 i

i APPENDIX E -

INSPECTION FILE REVIEWS

• i File No.: 1  ;

Licensee: Gamma Med License No. 661  :

Location: Columbus inspection Type: Announced, Routine, Complete ,

License Type: Irradiator Priority: 1 l inspection Date: 12/18/96 Inspector: MP j Comments:

a) Inspection compliance oriented as opposed to performance-based; license required ,

surveillances not demonstrated for inspector.

b) Report does not show whether worker interviews performed to determine personnel qualifications.

File No.: 2 Licensee: Quinn Contracting, Inc. License No. 763

. Location: Falkner inspection Type: Announced, Initial, Complete License Type: Portable Gauge Priority: 4 Inspection Date: 01/19/95 Inspector: LD Comment:

a) Initial inspection delayed until 18 months after license issued.

File No.: 3 Licensee: Meridian Central License No. 784 Location: Meridian Inspection Type: Announced, Initial, Complete License Type: Pharmacy Priority: 1 Inspection Date: 06/14/95 Inspector: BJS Comments:  !

a) Initial inspection not performed within 6 months of license issuance.

b) Independent measurements (smear samples) not included in report.

File No.: 4 Licensee: Meridian Central License No. 784 Location: Meridian Inspection Type: Announced, Routine, Complete License Type: Pharmacy Priority: 1 inspection Date: 07/31/96 Inspector: MP File No.: 5 Licensee: Cox Nuclear Pharmacy, Inc. License No. 794 Location: Biloxi Inspection Type: Announced, initial, Complete License Type: Pharmacy Priority: 1  ;

inspection Date: 08/30/95- Inspector: MP )

Comments:

a) Initialinspection not performed within 6 months of license issuance.  !

I b) NOV not issued for improper control.of shield possibly contaminated with I-131.

i

1.

b

. i

- Mississippi Proposed Final Report Page E.2 Inspection File Reviews ]

j

- File' No.: 6 l Licensee: Cox Nuclear Pharmacy, Inc. License No. 794 Location: Biloxi inspection Type: Unannounced, Follow-up, Complete License Type: Pharmacy Priority: .1 Inspection Date: -12/27/96- Inspector: BJS Comment:

a). Inspection not performed within DRH recommended 6 months of initialinspection.

' File No :

. 7 Licensee: Interstate Nuclear Services License No. 495 Location: Vicksburg inspection Type: Announced, Routine, Complete License Type: Nuclear Laundry Priority: 2 inspection Date: 02/23-24/95 Inspector: BG File No.: 8 Licensee: St. Dominic-Jackson Memorial Hospital License No. 039 Location: Jackson inspection Type: Announced, Routine, Complete License. Type: . Medical Priority: 2 -

Inspection Date: 07/24/96 Inspector: MP--

Comment:

a) Status of lost check source not identified.

File No.: 9 Licensee: Baptist Memorial Hospital License No. 376 Location: Booneville inspection Type: Announced, Routine, Complete License Type: Medical Priority: 2 Inspection Date: 02/11/96 Inspector: BJS Comment:

a)' Unable to determine whether inspection finding recommending radiation safety l committee change followed-up by licensing amendment.

File No.: 10

- Licensee: Bethesda Regional Cancer Treatment Center License No. 734 j Location: Greenville inspection Type: Announced, Routine, Complete '

License Type: HDR . Priority: 1 Inspection Date: 12/05/96 Inspector: BJS  ;

Comment:

a) Previous inspection resulted in enforcement conference and identified need for follow-up inspection, but follow-up inspection not performed.

l l

_. _ _ _ _ . - _ . _ _ _ _ . _ . ~ . _ . . _ . _ - . _ . - _ . ,

4 Mississippi Proposed Final Report Page E.3_ i

. Inspection File Reviews  !

File No.:

Licensee:

11- .

Rankin Medical Center. License No. 311

'{:

Location: . Brandon inspection Type: Announced, Routine, Complete  !

License Type: - Medical . Priority: 3  :

Inspection Date: .08/17/95 Inspector: MP  !

1 I

File No.: .12 i Licensee: Rankin Medical Center License No. 311  !

Location: Brandon Inspection Type: Announced, Routine, Complete License Type: Medical Priority: 3 Inspection Date: 08/01/96 Inspector: MP P

Comment:  ;

a) Unable to determine whether worker interviews conducted.

File No.: '13 Licensee: King's Daughter Hospital _ License No. 383 Location: .Yazoo City inspection Type: Announced, Routine, Complete License Type: Hospital Priority:'2 ,

inspection Date: 10/27/95 Inspector: MP-l Comment.

a) Enforcement letter identifies recurrent violation, but does not describe significance -)

of the violation being repeated.

File No.: 14 Licensee: Longview Inspection, Inc. License No. 784 Location: Pascagoula inspection Type: Announced, Routine, Complete License Type: Industrial Radiography Priority: 1-Inspection Date: 10/03/96 - Inspector: BJS Comment:

al Report does not refer to status o,f NOV identified during previous field inspection.- ,

/

File No.: 15 Licensee:

James Atkins Engineering License No. 669 Location: Pontotoc inspection Type: Unannounced, Routine, Complete License Type: Portable Gauge Priority: - 4 j inspection Date: 01/23/95 Inspector: LD J l

l

-4 j

l Mississippi Proposed Final Report Page E.4 Inspection File Reviews File No.: 16 Licensee: Babcock and Wilcox License No. 201 Location: West Point inspection Type: Announced, Routine License Type: Industrial Radiography Priority: 1 l Inspection Date: 12/19/96 Inspector: MP Comments:

a) NOV not issued for failure to notify State about the incident.  !

b) Licensee failed to submit 30-day notification report.

1 File No.: 17 Licensee: Radiologic Clinic License No.104 j Location: Columbus Inspection Type: Announced, Routine, Complete 1 License Type: Teletherapy Priority: 2 Inspection Date: 04/04/95 Inspector: BJS File No.: 18 Licensee: Struthers industries, Inc. License No. 259 Location: Gulfport inspection Type: Announced, Routine, Complete License Type: Industrial Radiography Priority: 1 Inspection Date: 09/04/96 Inspector: BJS Comment:

a) Inspection overdue (interval exceeded the 1 year frequency by 6 months).

File No.: 19 Licensee: . Welding Testing X-Ray, Inc. License No. 666 Location: Baton Rouge, LA inspection Type: Unannounced, Routine, Complete License Type: Industrial Radiography Priority: 1 l inspection Date: 05/06/96 Inspector: MP I

File No.: 20-Licensee: P.M.S.C. Inby Steel License No. 750 i Location: Gulfport inspection Type: Announced, Routine, Complete 1 License Type: Industrial Radiography Priority: 1 l Inspection Date: 09/04/96 Inspector: BJS .

1 i

i r - - - - - - , - - - - , , e c- -

, _ __ .__.._....__..__.._.__..._..______._._.m._._ . . . _

j ' e .-  !

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Mississippi Proposed Final Report Page E.5

. Inspection File Reviews '

4 -

)

In addition, the following inspection accompaniments were mado as part of the on-site l

IMPEP review:

Accompaniment No.1 Licensee: Memorial Hospital at Gulfport License No. MS-284-01

j. Location: Gulfport inspection Type: Routine

} License Type: Hospital Priority: 2 ,

j . Inspection Date: 1/15/97- Inspector: MP l

. ' This was an accompaniment performed by C. Gordon, IMPEP team leader. $

k Comments:

i a) Good, thorough inspection of licensee operations. Inspector demonstrated proficiency to examine inspection areas effectively. '

i .b) Verification of worker training not fully confirmed through interviews. )

!. c) Record reviews detail oriented. Although inspection announced, observation of I

licensee operations comprised only a small portion of inspection activity. Safety issues adequately covered.  ;

i >

i Accompaniment No. 2  !

Licensee: Syncor international Corporation License No. MS-493_03 $

Location: Gulfport inspection Type: Routine  ;

License Type: Nuclear Pharmacy Priority: 1 inspection Date: 1/16/97 Inspector: BJS l This was an accompaniment by C. Gordon, IMPEP team leader.

)

Comments:

a) Inspection announced, but preparation and inspection plan complete. Inspector demonstrated thorough control over inspection activities.  ;

b) Surveys or wipe samples not taken in all areas where radioactive materials used

. (transportation vehicles).

c) Inspection concentrated on review of licensee documentation and recordkeeping, observation of licensee operations very limited.

d) Information and safety issues clearly communicated to licensee during inspection and at exit interview.

4 i

__ _, _ _ . _ . _ _ _ _ . _ . _ _ . _ _ . _ . . _ _ .___,-..m._ m.

• l i

APPENDIX F  !

INCIDENT FILE REVIEWS i File No.1 i Licensee: Syncor International Corp. License No: MS-493-01 Site of Event: Jackson, MS

.Date of Event: 5/14/96. Type of Event: Transportation  !

Investigation Date: 5/14/96 Investigation Type: Site 3 Summary of incident and Final Disposition: The licensee notified the State that a used [

Molybdenum-99. generator in a Yellow 11 package had fallen off the carrier's truck and had  ;

been taken to the Mississippi Department of Health Pharmacy. Also, the county emergency management notified the State that a White I box was reported found on a i street corner. The State surveyed the Yellow ll package and found no contamination or I elevated readinge,. Upon arrival by the State on the street corner where the White I box '

was found, the box had already been retrieved by the carrier. State visited the licensee on 5/16/96. No contamination was detected on the outside of the White I package. The State indicated to the licensee that the incident would be referred to the U.S. Department ,

of Transportation for their review.

Comments: ,

a) Good coordination with local authorities (county emergency management, fire dept.) {

b) Not in NMED.  ;

'c) No license number was on the incident report. l File No. 2 Licensee: Mississippi Dept. of Transportation License No.: MS-261-  !

01 Site of Event: Lucedale, MS Date of Event: 9/10/96 Type of Event: Damage to Equipment j investigation Date: 9/10/96 Investigation Type: Onsite i i'

Summary of incident and Final Disposition: A traffic accident in which a moisture / density gauge, with the source rod in the open position, became lodged underneath the rear axle of a car. The licensee roped off an area around the vehicle and contacted the MS Highway Patrol and the MS Emergency Management Agency. The DRH inspector dislodged the j gauge, shielded the source in the ground, and then was able to retract the source. The j licensee placed the gauge in a lead-lined box for transport back to Jackson and eventually j the manufacturer. The source was intact and no leakage was detected. '

Comments:

' a)- Not entered in NMED.

b) No license number was on the incident report.

c) The State promptly responded to the scene.

i I .

4 Mississippi Proposed Final Report Page F.2 incident File Reviews l

File No. 3 Licensee: APAC-Mississippi, Inc. License No.: MS-538-01 Site of Event: Corinth, MS Date of Event: 4/13/95 Type of Event: Damage to Equipment investigation Date: 4/14/95 investigation Type: Phone Summary of incident and Final Disposition: Two moisture / density gauges and an asphalt content gauges were involved in a fire. The containers of both Moisture / density gauges were damaged, but the gauges were intact. The asphalt content gauge was more heavily damaged. By phone, the DRH approved the licensee's request to move the gauges to an isolated storage building and instructed the licensee in precautionary procedures to be used when moving the gauges. The licensee's tests for leakage were negative and the gauge manufacturer arrived on-site several days later to package the gauges for disposal.

Comments:

a) Reported in NMED.

b) No on-site investigation by the State.

File No. 4 Licensee: N/A License No.: N/A Site of Event: Greenville, MS Date of Event: 1/3/95 Type of Event: Contamination investigation Date: 1/4/95 Investigation Type: Phone Summary of Incident and Final Disposition: A shipment of steel plates contaminated with Co-60 set off alarms at a steel company. The shipment was imported by a company in Oregon. The steel company in Mississippi received the plates from another steel company in Texas. The DRH contacted the Texas steel company, the Texas and Oregon radiation control programs, and the EPA. The steel plates were returned to the Texas steel company.

Comments:

a) Good coordination with multiple jurisdictions and companies.

b) Not in NMED.

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Mississippi Proposed Final Report Page F.3 incident File Reviews

- File No. 5 Licensee: Mississippi State University License No.: MS-EBL-02 Site of Event: MSU Campus Date of Event: 6/3/96 Type of Event: Contamination Investigation Date: 6/5/96 investigation Type: Phone Summary of incident and Final Disposition: A student doing an experiment using 1-125 was transporting some solutions containing a total activity of 3 to 5 microcuries. The student dropped the container of solution vials outside the building and picked up the

broken glass without gloves. The licensee found contamination inside and outside the building, on the student's hands, clothing, shoes, and vehicle. The licensee performed i thyroid bioassays and a CDE of < 1 rem to the thyroid was calculated, and notified the CRH. The licensee indicated they had revised the handling procedures for the student's research project and intended to purchase Nal detectors for labs on campus where non-beta emitters are to be used.

Comments:

l a) Not in NMED. ,

j b) No license number on the report. ,

c) On-site investigation was not conducted by the State. j File No. 6 Licensee: Mississippi Dept. of Transportation License No.: MS-261-01

. Site of Event: Raleigh, MS Date of Event: 5/28/96 Type of Event: Damage to Equipment l Investigation Date: 5/28/96 Investigation Type: Site Summary of incident and Final Disposition: A moisture / density gauge was run over by a  ;

bulldozer. The gauge was in the testing position with the probe imbedded in the roadbed. i The source rod appeared to be intact and the source was returned to its shielded position  ;

inside the gauge. The DRH confirmed that the source was in'the shielded position and that l no contamination was present. The gauge was transported to the licensee's f acility. 1 Results of a leak test of the source prior to return to the manufacturer showed no contamination.

Comments:

a) Not in NMED.

b) No license number in the incident report.

c) Prompt response by DRH.

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i Mississippi Proposed Final Report Page F.4

j. Incident File Reviews .

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File No. 7 Licensee: Grand Gulf Nuclear Station License No.: N/A  ;

Site of Event: Vicksburg, MS e Date of Event: 5/12-17/96 Type of Event: Contamination l Investigation Date: 5/31/96 Investigation Type: Site t

l Summary of incident and Final Disposition: Grand Gulf Nuclear Station (GGNS) notified the DRH that a contract employee, who had previously set off contamination alarms at l Millstone Neclear Power Station, set off alarms at GGNS. Cs 137 contamination was j: found on the employee's shirt DRH inspectors surveyed the employee's hotel room used  ;

L while working at GGNS. Neither the survey nor results of wipe tests showed the presence j 'of contamination.

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. Comments

F a) Prompt response to potential contamination in unrestricted area.

i b) Not in NMED.  !

4 - File No. 8  !

. Licensee: Syncor international Corp. License No.: MS-493-01 Site of Event: Jackson, MS ,

j -'Date of Event: Unknown Type of Event: Lost RAM investigation Date: 12/8/94 investigation Type: Site I i

Summary of incident and Final Disposition

An ammo box containing radiopharmaceuticals  ;

was found on the street. The DRH conducted inspections at the licensee's facility and at

the facility of the licensee that ordered the radiopharmaceuticals. The DRH was unable to

, determine whether the shipment was lost by the licensee or stolen. The DRH requested j- that the licensee submit revised procedures addressing the matter.

1 l Comment:

a) Reported in NMED i

File No. 9 Licensee: Methodist Medical Center License No.: MS-722-01 Site of Event: Jackson, MS ,

Date of Event: Unknown Type of Event: Lost RAM Investigation Date: N/A Investigation Type: None Summary of incident and Final Disposition: The licensee reported that a Co-57 reference

. source wi tn an actiiv ty of 50 microcuries was apparently left on an emergency room patient's hospital gown after a scan was completed. The licensee was unable to locate the reference source. The licensee reported that its methods for use and storage of the reference sources have been reviewed with the technologist to avoid reoccurrence.

' Comments:

a) No DRH report or response in the incident file.

Mississippi Proposed Final Report Page F.5 incident File Reviews File No.10 Licensee: Perf O-Log License No.: MS-664-01 ,

Site of Event: Seminary, MS '

Date of Event: 8/7/96 Type of Event: Lost RAM Investigation Date: 8/9/96 Investigation Type: Phone .

Summary of Incident and Final Disposition: A 50 millicurie Co-60 logging source was lost in a gas storage cavern while the licensee was pulling the wireline out of the hole. A camera was run in the casing and it appeared that the logging tool had fallen to the bottom of the storage cavern. The DRH discussed the requirements for abandoning well-logging sources with the licensee and the licensee stated that a plaque would be attached to the wellhead as per the requirements.

I Comments: i a) No license number was on the incident report, b) Not in NMED, File No.11 l Licensee: Babcock & Wilcox License No.: MS-002-01 Site of Event: West Point, MS

, Date of Event: 6/14/95 Type of Event: Equipment Failure investigation Date: June - Sept.1995 Investigation Type: Phone Summary of incident and Final Disposition: While attempting to retrieve a 24 cune source into an exposure device, the radiographer noticed that the control assembly appeared to be )

stack. Surveys conducted by the radiographer verified that the source had not returned to  ;

the shielded position. The radiographer secured the area and notified the RSO, who retrieved the source. The highest exposure recorded for any individual was 10 mrem. The licensee contends that the crank assembly adapter became loose and released tension on l the drive cable. Photographs provided by the RSO indicate that there may be some I differences in the design between this adapter and the new adapter supplied by the camera manufacturer. The California Radiological Health Branch was provided with details of the incident and the crank assembly adapter by the DRH. Their investigation found no manufacturing defect with the adapter and suggested that the failure to return the source to the shielded position may have been due to the licensee tampering the crank assembly adapter, which the licensee has denied. The DRH could not determine if the manufacturer had put the adapter together incorrectly or if it had been tampered with by the licensee.

Comments:

a) Reported in NMED.

b) Contacted California radiation control program on July 12,1995.

c) Follow-up was conducted during routine inspection on September .27,1995.

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^e l Mississippi Proposed Final Report Page F.6 incident File Reviews File No.12 Licensee: Bush Construction License No.: MS-508-01 Site of Event: DeSoto County, MS Date of Event: 4/22/94 Type of Event: Damage to Equipment i investigation Date: Unknown investigation Type: Unknown l

Summary of Incident and Final Disposition: A moisture / density gauge was run over by a  !

large piece of construction equipment (roller) at a temporary construction' site. The sealed  !

source was not damaged. The gauge was returned to the manufacturer for disposal. j Comments:

a) Reported in NMED. l b)- NRC Form 565 was in the incident file, but no report from DRH.

File No.13 Licensee: Cox Nuclear Pharmacy License No.: MS 794-01 Site of Event: Wiggins, MS Date of Event: 12/14/95 Type of Event: Transportation Investigation Date: 12/14/95 l investigation Type: Onsite Summary of incident and Final Disposition: An automobile accident involving radiopharmaceuticals occurred. Seven ammo boxes containing radiopharmaceuticals were scattered around the accident site. The DRH gave the licensee's RSO permission to enter i the area secured by the fire department to monitor the boxes while the DRH inspectors 1 were in route. The RSO's survey results were confirmed by DRH inspectors, who surveyed I the area and the vehicle. No contamination was found. The RSO cleaned up the site.

Comments:

a) Not in NMED.

b) No license number on incident report.

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Mississippi Proposed Final Report Page F.7 Incident File Reviews File No.14 Licensee: University of Mississippi Medical Center License No.: MS-MBL 01 Site of Event: Jackson, MS Date of Event:.5/21-23/96 Type of Event: Misadministration

~ Investigation Date: 5/24/96, 5/28/96 Investigation Type: Site Summary of incident and Final Disposition: The licensee reported a brachytherapy misadministration involving the use of sources with the incorrect activity. The licensee reported that two patients were undergoing manual afterloader brachytherapy procedures at the same time. One of the sealed sources from each of the patients was apparently switched so that each patient received a source with an incorrect activity. One patient was under dosed by about 33 percent and the second patient was overdosed by about 35 percent. The patient that received the overdose was scheduled to have her cervix removed at the end of the treatment, so no adverse medical effects are anticipated for either patient. The patients' referring physicians and relatives were notified. The licensee changed its procedures to state the medical physicist would only prepare one source configuration at a time and the sources would be loaded in the patient before preparing the next source configuration for the next patient. The DRH reviewed the modified procedures during an inspection on 6/5/96.

Comments:

a) Reported in NMED.

b) No license number on incident report.

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April 14,1997 $

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.o Mr. Richard L. Bangan, Director 2 3 Mce f Stam Programs $3D23) [

MISSISSIPPI STATE DEPARTMENTOF U.S. Nuclear Regulatory Commission "

Washington, D.C. 20555-0001 o 1 DM*n Of

Dear Mr. Bangart:

RadiologicalHeahh

! 3 N "d 7En My staff and I have reviewed the DRAFT Report-Integrated Materials Eckson. Mss!ssippi Performance Evaluation Program Review of Mississippi Agreement State

• " Program for the factual correctness ofinformation reported by the review team.

yyy7y With the exception of the minor corrections (enclosed), the report appears to be accurate.

. I am looking forward to meeting with the Management Review Board (MRB) l to further discuss the review. Should you have any questions, please contact me at (601) 354-6657. l l Sincerely,

$Y U N Robert W. Goff, Director Division of Radiological Health RWG:pm 1

Enclosure l 1

pc: Ricky Boggan j Craig Gordon i

4 N

womawney *

• " "

• ATTACHMENT 2

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. CORRECTIONS '

D

1. 3.1-Statue of Materimic Insnaction Program - Page 3 It is stated that " teletherapy licensees are scheduled to be inspected on a one-year frequency vs NRC's three year frequency, medical private practice licensees on a one year frequency."

Teletherapy licensees are inspected on a two year frequency and medical private practice licensees are inspected on a two or three year frequency.

2. 4.1.2-Statue and Compatibility of Reguistions "The Director, DRH indicated that both conunents would be incorporated in the next rule adoption. . .'."

The editorial comment was corrected prior to the printing of the new regulations. The other comment requires approval by the Board of Health and will be addressed in 1997.

3. Appendir F-Incident File Reviews - Page F.5 File No.10 review indicates a 50 microcurie Co-60 logging source was lost. The actual activity of the source was 50 millicuries.

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Aaenda for Manaaement Review Board Meetino Wednesdav, May 14,1997.3:30-5:30 p.m. - One White Flint North - Rm. 4-B6 l

1. Convention. MRB Chair convenes meeting. (HThompson)

2. Old Business - Approval of the past MRB Minutes. (KSchneider)

3. New Business - Consideration of Mississippi IMPEP Report.  :

A. Introduction of Mississippi IMPEP Tearn Members. (C. Gordon)  !

B. Introduction of Mississippi representative and other State representatives l participating through telephone bridge. (KSchneider) l C. Findings regarding Mississippi Program. (IMPEP Team)

Status of Inspection Program l Technical Staffing / Training 4 Technical Quality of Licensing Technical Quality of Inspections

- Response to incidents / Allegations

- - Legislation and Regulations D. Questions. (MRB Members)

E. Comments from State of Mississippi. (RGoff)

F. MRB Consultation / Comments on issuance of Report. (HThompson)

Recommendation for next IMPEP review

4. Status of Upcoming Reviews. (KSchneider)

5. Adjournment. (HThompson)

Invitees: Hugh Thompson, MRB Chair, DEDR Karen Cyr, MRB Member, OGC Carl Paperiello, MRB Member, NMSS Richard Bangart, MRB Member, OSP Denwood Ross, MRB Member, AEOD

[ Agreement State Liaison to MRB]

Robert Goff, Mississippi Paul Lohaus, OSP Don Cool, NMSS Craig Gordon, IMPEP Team Leader, RI Cythnia Cardwell, IMPEP Member, TX Sally Merchant, IMPEP Member Richard Woodruff, IMPEP Member Kathleen Schneider, OSP Lance Rakovan, OSP ATTACHMENT 3