ML20035C324
| ML20035C324 | |
| Person / Time | |
|---|---|
| Issue date: | 11/30/1992 |
| From: | Bangart R, Dan Collins, Grobe J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II), NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III), NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| To: | |
| Shared Package | |
| ML20035C296 | List: |
| References | |
| NUDOCS 9304070054 | |
| Download: ML20035C324 (70) | |
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FINAL INDEPENDENT REVIEW TEAM REPORT OF FINDINGS AND RECOMMENDATIONS INDEPENDENT REVIEW OF THE ADEQUACY OF INSPECTION AND RELATED ACTIVITIES ASSOCIATED WITH ALLEGATIONS CONCERNING NUCLEAR ENERGY SERVICES Richard L. Bangan Douglas M. Collins Director, Division of Chief, Nuclear Materials i
Low-Level Waste Management and Safety and Safeguards Decor.missioning, office of Branch, Region II Nuclear Material Safety and Safagnards Roben L. Fonner John A. Grobe s Special Counsel for Tuel Cycle Chief, Nucient Materials and Safeguards Regulations, Safety Branch, Office of the General Counsel Region III i
Steve R. Ruffin Technical Assistant to the l
Deputy Executive Director for Nucient Materials Safety, safeguards and Operations Support g
CORRESPONDENCE PDR
,r. -
s TABLE OF CONTENTS EXECUTIVE
SUMMARY
'2 6
1 INTRODUCTION.
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1.1 Background
1.2 Independent Review Team Charter....
6.
7-1.3 Purpose.
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1.4 Scope.
1.5 Methodology.
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REVIEW AREAS DISCUSSION AND FINDINGS.
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2.1 Training and-Qualification 9
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2.1.1-National Program for Materials Licen~se
]'i Reviewers 9-
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2.1.2 Region I Implementation for Materials License Reviewers
'9-2.1.3 National Program for Materials. Inspectors::.
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2.1.4 Region I Implementation'for Materials z;
t Inspectors.
14-2.2 -Inspection Program...
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2.2.1 National Program 17-I l'j 2.3 Licensing Progran'.
25.
-1 2.3.1 National Program 25 l
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2.3.2 Region I Implamentation 27 2.3.3 Region I Implementation in the NES Case 29 2.4 Rules, Regulations and License Conditions.
32 2.4.1 Application of Regulations 32 2.4.2 10 CTR Part 19.
34 2.4.3 Exempt Sources 34 2.4.4 NES License Conditions 35 2.5 Allegation Management.
37 2.5.1 Management Involvement - Planning 37 2.5.2 Management Involvement - Issue Rasolution 43 2.6 Management Issues.
51 2.6.1 Former Attrition of DRSS Staff 51 2.6.2 Workload of Staff and Supervisors 52 2.6.3 Organizational Effectiveness 53 2.6.4 Supervisor Span of Control 54 2.6.5 Management Involvement 55 3
CONCLUSIONS 57 ATTACHMENT 1 - INDEPENDENT RIVIEW TEAM CHARTER ATTACHMENT 2 - INDEPENDENT REVIEW TEAM RECOMMENDATIONS
e EXECUTIVE
SUMMARY
The Inspector General (OIG) of the U. S. Nuclear Regdlatory Commission (NRC) issued a report on July 29, 1992, that was critical of Region I's handling of allegations made by a former corporate officer of Nuclear Energy Services (NES), an NRC licensee.
The OIG concluded that the Region I staff conducted an inadequate inspection and mishandled the allegations.
The investigation disclosed that the allegations were'not fully and adequately examined during an inspection conducted during July 1990.
On July 31, 1992, the Commission referred the matter to the Executive Director for Operations (EDO) for action.
On August 12, 1992, the Deputy Executive Director for Nuclear Material Safety, Safeguards and Operations Support (DEDS) established an Independent Review Team (IRT) to evaluate the concerns raised by the OIG.
The charter of the IRT included six specific activities:
(1)
Determine whether the first inspection or second inspection interpretations of NES' license conditions are correct.
(2)
Determine if the problem with the NES license is a function of the clarity of the license condition.
(3)
Determine if changes may be needed for such licenses on a generic basis.
(4)
Determine if the inspection guidance needs revision.
(5)
Make a report with recommendations to the Director, NMSS.
The report should discuss the level of Region I management involvement.
(6)
The Director, Office of Nuclear Materials Safety and Safeguards (NMSS), should advise the DEDS and EDO of changes (including schedule), and final recommendations.
The DEDS will keep the IG informed and will arrange to brief the IG of significant information.
The IRT was composed of staff from the NRC with a mix of representatives from the EDO, NMSS, Office of the General Counsel (OGC), and two regional offices other than Region I.
In order to accurately make the required determinations, the IRT interpreted its charter to include broad areas of review within the national i
and Region I materials program.
The five areas reviewed i
included:
- 1) training and qualification; 2) inspection; 3) licensing; 4) interpretation of rules, regulations and license conditions; and 5) allegations management.
General management 2
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issues were also addressed as part of the review.
Each of the areas was reviewed from the perspective of the national program, Region I implementation, and the NES allegations.
The IRT reviewed the OIG report, applicable Management Directives (MD),
the NRC Inspection Manual, materials program Policy and Guidance Directives (P&GD), Region I Operating Instructions (ROI), and the NES docket and allegations files in Region I.
Nineteen individuals, including Region I management and staff, former Region I staff, a former Radiation Safety Officer of NES, and NRC headquarters staff were interviewed by the IRT.
The IRT determined that a number of factors patentially 3
contributed to the problems associated with the handling of the i
allegations during the first inspection of FES in 1990.
These I
include:
1 (1)
Since the license was viewed by the inspectors and Section Chief as not being " active," the Section Chief concluded
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that regulatory requirements did not apply.
No materials program guidance existed that could have provided direction I
for the Section Chief in making that determination.
(2)
Once the determination was made that no license or rule requirements were applicable in the case of a license that had not been used, no further inspection was necessary.
(3)
While the junior inspector apparently knew of the correspondence in the docket file indicating that work under the license had been performed on two occasions, it is not apparent that information was brought to the attention I
of the lead inspector.
(4)
While the lead inspector does not clearly recollect being aware of correspondence in the docket file indicating operations had been conducted under the license, it is clear that a thorough review of the rather voluminous docket file should have identified such correspondence.
(5)
Circumstantially, it appears that use of the license by NES on one or two occasions was not viewed by the regional staff as being of such significant consequency as to " activate" the license.
This IRT contention is supported by the fact that during the inspection there was apparently some discussion with tha NES President about the use of the license at an A. D. Little project.
(6)
A decision by regional management to request that Region III inspect NES work at the Chemetron project in Ohio could have led to the understanding by regional management that the NES license had been in use.
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d (7)
The allecer could have been viewed by.some as a disgruntled former NES a= ploy 1 whose allegations were motivated by reasons other tha., concerns for safety.
Since some allegation panels appear to factor in credibility and reliability of the alleger, the octential for safety significance could have been discounted by the panel, the Section Chief, or the inspectors.
(8)
The perception by the inspection staff.and supervisor that the allegations did not involve safety significant issues.
(9)
The heavy workload and pressure to complete work activities.
(10) Little management involvement in the first inspection.
The IRT identified a number of findings and recommerdations surfacing from the above conclusions about the root causes of the problems attributed to the handling of the allegations during the firrt inspection.
Other recommendations for materials program str( :chening were also identified by the IRT as a result of its comprehensive review of the NRC's materials program and Region I's implementation thereof.
The recommendations are listed in.
Overall, however, the IRT concluded that the problems identified in the first inspection of the allegations against NES did not indicate that either the national materials program or Region I's implementation were insufficient to provide a reasonable assurance of safety in licensed operations.
The NES inspection in 1990 did not identify the violations cited as a result of the 1992 NES inspection.
The cause for this difference lies not in the fact that the Section Chief and inspectors relied too heavily on the statements from NES management during the inspection, but rather on:
(1) a lack of clear NRC policy on what requirements are "in force" during periods of time that a license is " inactive;" (2) the failurg of involved personnel to appreciate that the infrequent, short duration use of licensed materials required continuing implementation of the licanse l
requirements; and (3) the lack of any complex or safety i
significant activities conducted under the license.
The l
information reviewed by the IRT indicated that the inspectors involved in the first NES inspection obtained information about the use of the NES license from a variety of sources (docket file, licensee management statements, and records review).
The conclusion in the first inspection report was that the license was not " active."
In hindsight, this conclusion was erroneous and was likoly the result of informal decision-making by the inspectors and Section Chief.
With regard to the majority of the work conducted by NES, however, this conclusion is consistent with longstanding NRC policy that contractors performing activities for a licensee do so under the auspices of the licensee's license.
In addition, this decision with regard to A. D. Little appears to have resulted from their belief that 4
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the license had only.been used this one time in the past for a j
very short duration, the use (transportation) was incidental to the primary purpose for which the license was issued, the lack of
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programmatic or regional guidance addressing such an issue, and the lack of significant safety concerns.
t All Region I staff interviewed by the IRT indicated a complete understanding of appropriate inspection techniques and the
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importance of using a variety of techniques to obtain and corroborate information.
No general practice'of over-reliance on i
licensee statements is apparent in the Region I materials inspection program, based on information from those interviewed.
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1 INTRODUCTION This section discusses the circumstances that led to the formation of the NES IRT and the specific tasks assigned to the group.
It also explains the purpose and scope of the effort and describes the methodology used by the IRT.
1.1 Background
NRC's OIG issued a report to the Commission on July 29, 1992, which was critical of the Region I staff inspection and handling of allegations regarding an NRC broad scope materials licensee.
The OIG concluded that the Region I staff conducted an inadequate inspection and mishandled allegations made by a former corporate officer of NES, located in Danbury, Connecticut.
The investigation disclosed that during the first inspection, conducted in July 1990, the allegations were not fully and adequately examined.
A second inspection of the same issues, conducted from January to June 1992, identified seven violations at NES.
On July 31, 1992, the Commission referred the matter to the Executive Director for Operations (EDO) for action.
The Commission asked the EDO to review the matter and report to the Com=ission on the results of his evaluation and his recommendations.
On August 12, 1992, the DEDS established the IRT to evaluate the concerns raised by the OIG regarding the adequacy of the inspections and related act'.vities concerning NES, to conduct an assessment of the NES license conditions, and to evaluate the Region I responsiveness to allegations raised by the alleger.
Richard Bangart, Director, Division of Low Level Waste Management and Decommissioning (LLWM), was assigned team leader.
Other members were Robert Fonner, special Counsel for Fuel Cycle and Safeguards Regulations, Office of General Counsel; Douglas Collins, Chief, Nuclear Materials Safety and Safe' guards Branch, Region II; John Grobe, Chief, Nuclear Materials Safety (NMS)
Branch, Region III; and Steve Ruffin, Technical Assistant to the l
Deputy Executive Director for Nuclear Materials Safety, Safeguards and Operations Support.
1.2 -Independent Review Team Charter The charter (Attachment 1) for the IRT includes the following tasks:
1.
Determine whether the first inspection or the second inspection interpretations of NES' license conditions are correct.
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q 2.
Determine if the problem with the NES license is a-function.
'i of the clarity of the license condition.
iq 3.
Determine if changes may be needed'for.suchLlicenses on s generic basis.
4.
Determine if the inspection guidance needs revision.
-i 5.
Make a report with recommendations to the Director, NMSS.
The report should discuss the level of Region I management involvement-6.
The Director, NMSS, should advise the DEDS and EDO of_
changes (including schedule), and' final recommendations.
The DEDS will keep the OIG informed'and will arrange _to 1
brief the OIG of significant information.
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- E 1.3 Purpose After completing its overall assessment of the issues, the IRT is j
providing this report to the Director, 9005S.
The report describes the IRT activities directed by the charter, assesses
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five materials program areas from both a national'and Region I' implementation perspective, and contains recommendations to l'
strengthen the national or Region I materials program.
The five areas reviewed include: 1) training and_ qualification;-
- 2) inspection; 3) licensing; 4) interpretation of rules,.
regulations and license conditions; and 5) allegations management.
The report also. includes general management issues addressed during the review.
The Director, NMSS, is to advise the DEDS and EDO with final recommendations.
The report presents the factual findingsLand recommendations of the IRT regarding the'five nationalMand Region I program activities that could have had a bearing on how the 1
allegations against NES were handled.
1.4 Scope The scope of the IRT is limited to the Region I programs for l
nuclear materials licensing and inspection, training and-qualification, and allegations management; relevant NRC policy and materials program guidance and directives; applicable rules' and regulations; the NES license conditions and the Region I handling of the NES allegations.
In order to address the questions put before the IRT by the DEDS in the charter, the. team l
interpreted the tasks in the charter to; include broad areas of review within the national and Region I materials. program.
This 4
was necessary to assure that findings were correct and thct recommendations were placed in proper context.
The independent review process was intended ~to provide a review of the' 1
effectiveness'of both the Region I materials program and Headquarters guidance in so far as they-relate to Region I's 7
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'l activities.
This review also addresses t2ue first and-second inspections conducted at NES,-the NES license conditions and 1
-interpretations, and'10 CFR Part 19-posting requirements'and interpretations..The:IRT efforts were to: assess whether a l
breakdown in the management of NES allegations ~~ occurred and,lif l
so,Lto determine the root causes of the breakdown; to identify' l
strengths and weaknesses in the licensing,. inspection,.
r and allegation management program areas; and-to make recommendations inLareas where-improvements should be considered.
Some of the recommendations for: Region I may.also benefit other regional offices, if incorporated into.the National Program Review conducted by NMSS.'
l 1.5 Methodology The IRT compiled information from interviews with Region I.
t management, junior and senior license reviewers, junior and.
i senior inspectors, the senior allegations coordinator,-and
-l inspectors from both the first and second-inspection conducted at f
NES..Two of those interviewed are no longer' employed by NRC.-
A former executive with NES was also interviewed.- A-total of 19' interviews were conducted.
The documents reviewed relate to NRC-'
wide and Region I. policy guidance and procedures for licensing and inspections, trair.ing. and qualifications, and allegations management. -The IRT also reviewed the OIG report and exhibits, l
the 1990,-1991, and 1992'NMSS National Program Reviews, the NES.
j docket file, and NES allegation files.
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2 REVIEW AREAS DISCUSSION AND FINDINGS 2.1 Training and Qualification 2.1.1 National Program for Materials License Reviewers A.
Statement of Issue Does the training program for materials license reviewers assure that staff who are delegated authority to issue liqenses understand and can effectively implement NRC policies and procedures for issuance of materials licenses?
B.
Findings The training program for license reviewers is defined by NMSS in P&GD 91-04.
This P&GD specifies that license reviewers be provided Qualification Journals that outline training and experience necessary before qualification, including administrative matters, relevant laws and regulations, standard review plans, site visits, and case reviews under the direction of qualified reviewers.
The qualification is separated into two phases.
Phase I (termed Level I in Region I) qualification is for simpler licenses, including nuclear medicine, small research and development programs, gauges, self-contained irradiators, and service licenses.
Phase II (Level II in Region I) qualification is for more complex licenses, including teletherapy, industrial radiography, broad scope, nuclear pharmacy, vaste disposal service, nuclear laundry, source, and special nuclear material licenses.
In conclusion, based on information reviewed, the training program for materials license reviewers is well defined and outlines a program that provides for adequate training of staff in NRC materials licensing policies and procedures.
P&GD 91-04 does not require questioning of the license reviewer candidate by a Qualification Board.
This had no impact on Region I's review of the NES allegations.
The review of the NES application appeared to be in accordance with the policies and procedures in effect for the review of such applications.
C.
Recom=endations Qualifications Board reviews should be considered for license reviewers.
2.1.2 Region I Implementation for Materials License Reviewers 9
A.
Statement of Issue Does Region I implement the NRC's program for training and qualification of materials license reviewers in accordance with NRC policy and procedures?
B.
Findings P&GD 91-04 has been implemented in Region I through a series of memoranda from the NMS Branch Chiefs, the most recent dated November 8, 1990.
These memoranda have defined the type and number of reviews that must be adequately completed before a staff member will be delegated authority to sign licenses.
These memoranda have not specified training courses to be completed.
Region I qualifies all materials staff as license reviewers and inspectors.
Thus, staff will receive the training specified in P&GD 91-04 under the inspection qualification journal, but there is no documented system, such as a qualification journal reviewed by management, to assure appropriats course work is completed under the inspection qualification journal before a staff member is delegated authority to sign licenses.
The IRT found no cases where an individual had been delegated authority to sign licenses without completion of appropriate courses.
Several staff and management stated that, although it requires more staff and supervisory time, the Region I program for qualifying staff as both license reviewers and as inspectors results in a staff that has improved capability to perform each function.
As part of license reviewer qualification in Region I, a new license reviewer is assigned a mentor to assist with the training.
A trainee is provided license applications, starting with the simpler applications, and the guidance documents.
The trainee then reviews the applications using the guidance documents for acceptance criteria and develops a license or a request for additional information.
The application and the trainee's work product are reviewed by a qualified Level II license reviewer, who is normally the trainee's " mentor."
As part of this process, the qualified reviewer does another complete review of the application.
The qualified reviewer then discusses the case with the trainee, pointing out those areas where the review might not have been in accordance with NRC criteria.
This process continues until the trainee demonstrates a full understanding of NRC licensing criteria for the types of licenses assigned.
The trainee's Section chief also reviews the trainee's progress toward qualification.
After demonstrating understanding of licensing criteria, the trainee is delegated authority to sign licenses.
Generally the first delegation is for the less complicated licenses (Level I licenses).
The reviewer continues this process for the more complex applications (Level II licenses), with delegation to sign licenses given to i
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the reviewer only after demonstrating an understanding of the criteria for issuance of these more complex licenses.
The staff and management interviewed indicated that the program was being implemented well, with staff in training usually completing more cases to be reviewed by senior license reviewers than specified in the P&GD,or in the Branch Chief Memoranda.
The qualified reviewers interviewed demonstrated a good knowledge of licensing processes, policies, procedures and criteria.
Those staff in training to be qualified reviewers also indicated, through their answers during the interview process, a good understanding of licensing criteria and the qualification process.
Qualification records for the reviewer who issued the NES license were not available in Region I because the individual was no longer working in the Region.
The documents in the NES docket file related to the NES license application show that the reviewer had a good knowledge of NRC licensing policies and procedures.
i One experienced Section Chief that was interviewed commented that recently hired staff (within approximately the last two years) have significantly less training and experience in health physics than staff previously hired.
As a result, supervisors and managers have devoted a greater percentage of their time to the training of these staff members, and expect to continue a closer review of their work for a considerable time.
The individual stated that as a Section Chief previously involved with reactor programs, he had found time to give frequent technical training sessions to his staff.
He stated that in his current materials Section Chief position, he did not have time to conduct such training, even though he thought it was necessary.
Management indicated that the materials Section CMThfs' heavy workload is recognized.
In an effort to help maintain the technical expertise of the staff and to assure staff has a full understanding of program requirements, NMS Branch has conducted training approximately every two weeks.
The topics have ranged from nuclear medicine cardiology to enforcement issues.
In conclusion, the Region I program to train and qualify materials license reviewers is in accordance with P&GD 91-04 and is effective in that it results in a staff fully qualified to review license applications in accordance with NRC policies and procedures.
The docket file indicated that the individual who reviewed the license application from NES demonstrated a good understanding of NRC materials licensing policies and procedures in the review of the NES application.
The Region I mentoring
(" big brother / big sister") approach for indoctrinating and
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training new licensing staff is effective.
The belief of at least one Section Chief is that the education and experience level of newly-hired health physicists in Region I is generally below that of existing staff when they were hired.
This had no i
impact on the issuance of the NES license since the 1icense was issued in 1985.
C.
Recommendations
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NRC has had difficulty in hiring experienced, well qualified health physicists.
Efforts to " grow our own" health physicists through the Intern and Graduate Fellow Programs have been established in part to address the problem of staffing health physicist positions.
After obtaining advanced degrees in health physics, NRC should consider initially assigning Graduate Fellows to a regional office to obtain practical experience.
2.1.3 National Program for Materials Inspectors A.
Statement of Issue Does the training program for materials inspectors assure that qualified staff can effectively implement NRC policies and procedures for inspection of materials licensees and for implementation of the NRC enforcement policies and procedures?
B.
Findings The NRC qualification program for inspection staff is specified in NRC Inspection Manual Chapter (MC) 1245, Inspector Qualifications (and its predecessor MC 1231).
This MC specifies, for initial qualification, courses, independent reading, self-study questions, discussions with staff and management on procedures and criteria, inspection accompaniment, and en oral Qualification Board.
For each inspection specialty there is a Qualification Journal that includes qualification cards to track and document completion of required actions.
There is a qualification journal specific to materials radiation specialist inspectors.
In addition, MC 1245 has included supplemental training courses and encouraged, in the past, refresher training for previously-qualified inspectors.
The most recent version of
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MC 1245 now adds courses required to be completed within two years of initial qualification, lists supplemental training courses available, and specifies that refresher training, including a Pundamentals of Inspection Refresher course, be completed every three years.
The courses under MC 1245 for raterials radiation specialists include technical courses, such as HP Technology, Diagnostic and Therapeutic Nuclear Medicine, Industrial Radiography, and Teletherapy and Brachytherapy courses.
In addition, the MC includes NRC policy and procedures and inspection techniques 12
courses, Inspection Procedures or Pundamentals of Inspection, and Inspecting for Performance courses.
Within two ysars of qualification, staff must complete the following courses: OSHA Orientation, Transportation of Radioactive Materials, Internal Dosimetry and Whole Body Counting, and Effective Communication for NRC Inspectors.
Since the IG report questioned the inspection technique used in the NES inspection, the inspection technique courses were reviewed.
The main courses that provide training in inspection policy, procedures, and technique are either the Fundamentals of Inspection course or the Inspection Procedures course and the Inspecting for Performance course.
These courses are in addition to the training in policies, procedures and techniques provided by senior inspectors and the Section Chief during on the job training in the office and on inspection accompanisents.
The Inspecting for Performance course iu relatively new, and has been required under MC 1245 only since September 30, 1991.
The Fundamentals of Inspection course provides information on how to prepare for, conduct, and document inspections.
The course provides general information on preparation for materials inspections.
The course information on the conduct of inspections includes:
(1) encouraging a questioning attitude on the part of inspectors regarding written records and verbal statements by licensee staff; (2) encouraging a mix of observation of work in progress, interviews of workers focussing on the performance of licensed activities, review of documents, independent measur aments, and discussions with licensee staff; (3) outlining the application of the Enforcement Policy; and (4) providing an outline of how to approach allegations.
Staff who had taken the course noted that it was a good course, however, it was noted that most of the examples were reactor oriented.
The Inspection Procedures course, developed for Agreement State staff, is an adequate substitute for the Fundamentals of Inspection course under MC 1245 for materials inspectors.
This course is more specific to materials inspection in that it provides several case studies to the students that reflect a range of problems at materials licensee facilities.
The planning methods outlined in the course are specific to materials licensees.
The course also includes the actual performance of a mock thspection of a laboratory.
The course does not include cocprehensive training in NRC policies and procedures as does the Fundamentals of Inspection Course.
The interviews, review of course outlines, and first-hand experience indicates that Communication for Inspectors is an effective course, teaching different techniques for eliciting information from licensee personnel during inspections.
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Review of the Inspecting for Performance course outline indicates a method of inspection is described that emphasizes actual observation of ongoing activities as the primary resource for NRC inspections.
In addition, it emphasizes inspection effort in areas that have the greatest safety benefit.
The HP Technology course, in addition to providing technical training, provides a review of portions of the Fundamentals of Inspection course regarding inspection preparation, conduct, enforcement, and documentation of results.
The focus of these topics is in the HP inspection program area.
s In conclusion, the current program for qualification of materials inspectors is effective in developing materials inspectors who are qualified to inspect in accordance with NRC policies and procedures and capable of implementing the NRC enforcement policies and procedures.
The inspection policy, procedures, and technique courses clearly define that inspections should include a mix of observation of ongoing activities, discussions with licensee workers and management, interviews of workers focussing on the performance of licensed activities, reviews of records, and independent measurements.
There is an emphasis on the power reactor inspection program in the rundamentals of Inspection, Inspecting for Performance, and Communication Skills for Inspectors courses, particularly in the examples provided and in exercises.
This limits the usefulness of the courses to materials inspectors.
C.
Recommendations consideration should be given to conducting the Fundamentals of Inspection and other NRC courses in a manner similar to the HP Technology course, with separata examples / case studies related to materials licensees for materials inspectors.
2.1.4 Region I Implementation for Materials Inspectors A.
Statement of Issue Does Region I implement ths NRC's program for training and qualification of materials inspectors in accordance with NRC policy and procedures?
B.
Findings Region I implements MC 1245 by ROI 0410.1, Radiation Specialist Inspector Qualification Program for Power Reactor, Puel Facilities and Research Reactors.
The qualification journal for HP inspectors is defined in the Materials Health Physicist Qualification Journal (Journal).
This Journal was based on the program established in MC 1231 (and continued under MC 1245), but includes Region I-specific additions, including a series of self-14
study questions on technical issues, NRC policies and procedures, and inspection techniques.
This self study addition is an excellent tool for technical, procedural, and technical review.
The imple=entation of this Journal was last defined in a memorandum dated February 5, 1987.
The Journal is somewhat dated in that it outlines a two level inspector qualification process (for staff up to GG-11 and for those GG-12 and above) that is not in use in Region I and contains references to out-dated material.
Region I does use a system of interim inspector qualification, allowed by MC-1245, under which management authorizes staff to inspect specific licensee categories before the staff member receives final Board qualification to inspect the specified categories of licensees.
This interim process was last defined in a memorandum dated September 16, 1988.
The Division Director gives concurrence for interim qualification.
During the qualification process, the inspectors in training acco=pany several qualified inspectors to obtain on-the-job training on the inspection and enforcement process.
Prior to an inspector being recommended to go before a Qualification Board, the inspector is acco=panied by the Section Chief, who observes the inspector conduct inspections.
Recently, the NHS Branch Chief also has begun a program of accompanying inspectors in training to observe them conduct inspections before convening a Qualification Board for the inspector.
During interviews of the lead inspector for the first inspection of the NES allegations and the inspector's Section Chief at the time, it was determined that the inspector had been a fully qualified materials inspector for several years.
The training records were no longer available.
The inspector stated that the Fundamentals of Inspection course had been attended as part of qualifications training at the NRC.
The junior inspector who accompanied on the first NES inspection had not been qualified to perform independent inspections at that time.
The junior inspector stated that the Inspection Procedures course was attended while a state employee prior to joining the NRC.
During interviews of staff and management, it was clear that the process for qualification has generally been implemented well, as defined in NRC and Region I criteria.
There was one instance identified where an inspector had been qualified as a reactor radiation specialist, but had not completed qualification as a materials radiation specialist when he transferred to the NMS Branch.
Such re-qualification is required by MC 1245 and ROI 0410.1.
This re-qualification would have provided for training and experience in areas necessary for the new position that were not completed in the previous training, including the Teletherapy and Brachytherapy course.
This individual was qualified as a license reviewer, but apparently had not received training in teletherapy programs.
He stated that he had also independently inspected teletherapy licensees.
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In an effort to help maintain the technical expertise of the i
staff and to' assure staff has a full understanding of program requirements, the NMS Branch has conducted training approximately every two veeks.
The topics have ranged from nuclear medicine cardiology to enforcement issues.
In addition, DRSS held a training session on lessons. learned from the NES allegation review.
In conclusion, the Itagion I program to train and qualify-
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materials inspectors is in accordance with MC 1245 and is effective in that it generally results in a staff fully qualified
'I to inspect licensees for safety and compliance with requirements.
The Region I program, including on the job training with i
experienced inspectors, is an effective approach for indoctrinating'and training inspection staff.
The program of bi-weekly NMS Branch training sessions is an asset that assures:a continuing high level of technical expertise of the staff.
The technical questions included as part of the Qualification Journal i
is a strength, providing an excellent.self-study outline for technical, regulatory, and inspection technique review.
The Region I materials Health Physicist Qualification Journal lists several references that are'out of date and does not reflect the.
inspector qualification process currently in practice.- These 1
deficiencies in the Journal did not affect the qualification of inspectors in Region I.
The recent initiative of the 1005 Branch Chief to accompany each new inspector during field inspections 1
before the inspector goes before the Qualifications Board should result in better qualified inspectors before they sit for their?
Qualification Board.
There may be one instance where an inspector performed inspections of' licensees before he completed qualification to inspect that type of licensee. -This had no impact on Region I's review of the NES allegations because the inspector has not been involved in the NES case.
The initiative i
to conduct lessons learned training on the NES situation during-an NMS Branch training session was beneficial to staff.
[
C.
Recommendations
(
Lessons learned training conducted'for the DRSS' staff after the NES inspections should also be performed for other Region I staff involved in reviews of allegations.
Other Regions should also consider whether conducting similar training sessions would be beneficial.
l The Region I Materials Health Physicist Qualification Journal l
should be updated to reflect the single level qualification process now in use in Region I and to reference current documents.
l i
16 a
p e
2.2 Inspection Program 2.2.1 National Program A.
Statement of Issue Does the inspection program for materials licensees provide adequate policy, procedures and guidance for inspection of licensees, like NES, that offer comprehensive services to customers, but utilize the license infrequently and at " temporary job sites" at customers' facilities?
Do the Enforcement Policy and implementing procedures provide adequate guidance for categorizing inspection findings?
B.
Findings The inspection program for materials licensees is defined in MC 2800 (current version dated December 31, 1991) of the NRC Inspection Manual.
The April 6, 1990, version of MC 2800, which was in effect when the first NES inspection was conducted, was nearly identical to the current version in the areas discussed below.
This MC defines the process and frequency for inspection of materials licensees based on the " priority" assigned a licensee based on the potential hazard of the licensee's program.
The MC also specifies that there be an initial inspection of new, higher priority licensees "...within six renths after material is received and operations under the license have begun..."
The MC also directs, "Before scheduling an initial inspection, determine if the licensee possesses any radioactive material.
An initial inspection should not be attempted if it is determined that the licensee does not possess licensed material."
The MC does not provide guidance as to how many times or how long the initial inspection should be deferred.
In recognition of the potential problem of long-term deferral of initial inspections, NMSS issued on June 26, 1992, P&GD FC 92-XX, Issuance of New Licenses for Material Use Programs, for interim use.
On September 14, 1992, a final version of this guidance was issued as P&GD FC 92-04.
This P&GD specifies, among other things, that new licenses be conditioned to require that the licersee promptly notify the NRC Regional Office in writing when liccased activities will be initiated if there is a decision not to possess and use licensed material.
The P&GD also specifies that telephone calls be made to the licensee within six months of issuance of the license, as in MC 2800, and adds another call at 12 months if licensed material was not possessed at the time of the first call.
The P&GD states that a license will not normally be renewed in instances where licensed material has never been i
possessed.
There was no such formal guidance in effect at the i
time of the first NES inspection.
17
\\
l
MC 2800 further specifies that "An inspection should not be considered to have been performed (1) if, after arriving on an unannounced inspection, it is found that no radioactive material is possessed or used because of disposal or storage of the material, and no inspection activities have been performed..."
In such circumstances, the MC specifies that a note should be placed in the docket file recording the reason an inspection could not be performed and that a new inspection date be scheduled.
The MC contains no guidance as to how many times or how long an inspection should be deferred based on the finding that no radioactive materials are possessed or used.
The MC does not provide clear guidance regarding the need for an inspection if a licensee has possessed and used licensed material in the past (since the last inspection) but does not possess or use radioactive material at the time of the inspection.
With regard to inspections at temporary job sites or field offices, the MC specifies that an inspection at these sites should be attempted.
There is no further specific guidance as to when such inspections should be done or what actions to take if no such inspections are possible.
For scheduling of inspections for a licensee that operates in more than one region, the MC specifies that such scheduling is the responsibility of the region in which the licensee's main office is located.
This region is to request another regional office to conduct assist inspections when the licensee is operating outside the geographical area of the responsible region.
The MC specifies:
When requesting assist inspections, the regional offices shall take into consideration the sample size of inspections for which they are requesting assistance.
In this effort, the regions should differentiate between large and small licensees and establish different inspection programs for each general class of license.
Some licensees have many field offices and others have few.
The strength of the licensee ~'s internal inspection program is another factor in determining the sample size of the licensee's field operations.
There is no other, more specific guidance or criteria as to when field office or long-term temporary job sites in other regions should be inspected.
The MC also, in providing guidance on inspection methods, specifies that inspectors should: (1) make direct observation of work activities, (2) observe demonstrations of how licensee employnes perform NRC-required tests or activities, (3) interview licensee employees, (4) make independent measurements when i
appropriate, and (5) give less reliance on licensee record review.
18 4
.+~
o l
The only substantial difference between the current version of-1 MC 2800 and that in-effect during.the first NES-inspection in the 1
areas discussed above is'that the older version'had specific.
goals-for inspections of radiography temporary job sites rather
-t than encouraging inspections at various types of licensees' temporary job sites.
The NRC Enforcement Policy is contained in Appendix C of.10 CFR l
Part 2.
This Policy specifies procedures and. criteria to-be used j
in taking enforcement action.
These general procedures are j
supplemented by the Enforcement Manual.
These documents include:
i guidance on determination of severity Level of violations, the exercise of discretion for licensee identified violations andifor ii Severity V violationt., and the proper documentation:of
-i enforcement' decisions.
j The procedures for documenting inspections are outlined in j
The current version, dated January 14, 1991, is j
substantially the same as-the one in effect during the first NES j
inspection with regard to materials inspections.
This MC specifies that routine materials inspection'results should be' documented by issuance of'a completed NRC Form 591 (for inspections with no violations or very minor violations) or a
-l Notice of Violation (for more significant Severity Level IV violations) plus completed inspection field notes in the docket file.
The NRC Form 591.is designed to be signed by the.inspectore before the inspector leaves the site of the inspection.
Inspection field notes are signed by the inspector'and reviewed and signed by the Section' Chief.
A narrative report is required.
for special team inspections and actions involving an enforcement conference.
1 In conclusion, formal guidance does_not exist regarding the-l number of~ times that an initial inspection canlbe deferred,_the-i length of time of each deferral, or' actions that the NRC should-initiate if no licensed material is possessed by a licensee for j
an extended period.
In the same context, guidance does not exist i
on how to address these issues with an existing licenses that becomes inactive for an extended' period of time.
There is no H
guidance for inspection of and potential termination of I
" inactive" licenses after some period _of time other than the.
position that such licenses will not'normally be renewed.
There is currently no specific guidance on the inspection'of licensees' satellite facilities, e.g., academic remote campuses, medical satellite clinics, radiographers and portable gauge users with multiple field offices, etc.
C.
Recommendations Formal guidance should'be developed regarding deferral of inspections that addresses.the number of times inspections can be deferred, and actions to be taken (such as conditioning the 19
__4 j
1 l.
1 license to require region approval prior to' recommencement of:.
'j licensed 1 activities) if the license is not.used or is only used infrequently.
Formal guidance'should be developed regarding the1 inspection of satellite facilities, field offices and temporary job sites in the host and other Regions where there'are such activities.
]
2.2.2 Region I Implementation A.
Statement of Issue Does Region I implement the MC 2800 inspection program and i
anforc~ ment program appropriately?
B.
Findings l
1 Inspectors and Section Chiefs stated that Region I has used'the
-l
~
program in MC 2800, 10 CFR Part 2, and.the Enforcement-Manual to implement the regional materials inspection and enforcement program.
Descriptions of the inspection program being i
implemented in Region I provided during the interviews were j
consistent with MC 2800 and the Enforcement Policy.
l
-t Inspectors and Section Chiefs-stated that Section-Ch'iefs schedule tl inspections based on a."due' list" that specifies due dates' for l
inspections based on the. priority of_ licensees,-the most recent
~
inspection, and'the licensees' safety performance.- This'. schedule.
'is established quarterly, and modified as necessary to respond-to events, allegations, etc.
Specific inspections are; assigned by 4
section Chiefs to inspectors based on'the inspectors' training and experience.
This type of scheduling is different.from'that j
done in the past, when inspectors had a more significant input to
(
assigned inspections, based on personal preference.
Reactive.and
'l allegation inspections are assigned based on available personnel-l and their training and experience.
The Branch Chief reviews the--
schedule to assure that all "due" inspections'are scheduled.
j Inspectors and Section Chiefs stated that, for new licensees,'the
~
Region I procedure is to call the licensee-before conducting ~the j
inspection to determine if the licenses possesses licensed i
material.
If the licenses states'that-they have not' received d
licensed. material, the inspection _due date is moved 12 months and the process repeated.
This process is~ outlined in a hand written
" Procedure for Inquiry"..
There'is no guidance regarding how many 1
times the. inspection could be deferred.
J With regard to NES, the NES' docket file,.when reviewed-by the'IRT during August and September 1992, contained several documents related to.the use of licensed material under the license.- Those documents that related to the use of the license were:
20 1
4 j
?
t 1.
A letter dated July 25, l'986, from Region I to NES, docu=enting a telephone conversation with NES in which NES stated that NES had never used licensed material but planned to in the near future.
t 2.
An NRC Form 591 dated 5/18/87 providing the results of an inspection on that date and the field notes for the inspection.
The field notes document that NES had not used the license but intended to work at Qualicorp in approximately one month.
3.
A conversation record dated 3/3/88 that indicated that.the license had not baan used since the last inspection.
It should be noted that this conversation record contained a note from t)s NRC caller's Section Chief to the caller indicating that a letter documenting the telephone call had not been sent.
4.
A letter dated March 28, 1988, from the NRC to NES documenting that in the telephone conversation on March 3, 1988, a licensee representative stated that NES intended to initiate use of licensed material in the near future.
This letter was one of two letters that documented the March 3, 1988 telephone call.
5.
A second letter from Region I to NES documenting the March 3,
1988, phone call, this one dated June 20, 1988.
This second letter states that NES had not used licensed material since the last inspection.
This second letter, when combined with the note from the Section Chief referenced in (3) above, could indicate that the March 28, 1988, letter was not in the docket file at the time.
This could be indicative of filing problems with docket-related material in that the second letter appears to have been sent because the first letter may not have been in the docket file.
6.
A letter dated February 28, 1989, from NES to Region I informing the NRC that NES would use its license at Arthur i
D. Little.
It should be noted that this letter was found by i
the OIG filed in the Arthur D. Little license file and not in the NES file.
7.
A conversation record dated 5/11/89 noting that there had been two uses of the license, one at Arthur D. Little, and one in Ohio (the location of Chamstron).
The conversation record includes the date 5/10/89 in referring to the Chemetron site.
It should be noted that this is the date of the letter from NES regarding Chametron - see (8) below.
This conversation record specifies under action that the inspection be deferred "at this time".
-21
8.
A letter dated May 10, 1989, from HES to Region I informing the NRC that NSS intended to use the license at chemetron.
9.
A letter dated May 31, 1989, to NES from the NRC acknowledging the May 10 letter.
10.
A letter dated March 27, 1990, from the NRC to NES docu=enting a telephone call on' March 23, 1990, with NES in which an_NES representative stated that,NES had possessed licensed material under the license.
These documents show that in the NES case, Region I was calling NES approximately every 12 months to determine if NES possessed radioactive material under the license.
They also show that Region I, in this case, (id in fact do an inspection of NES even though Region I had been told verbally that NES had not used the license.
These documents show, if they were filed in the docket file in 1989-90, that an inspector who reviewed the docket file should have found that the NES license had been used in the 1989-90 time period.
The number of inspections to be completed in a fiscal year is established in the Regional Operating Plan based on requirements established by NMSS.
Core materials inspections, which are those that must be completed in a fiscal year, are inspections of new licensees, Priority 1, 2, and 3 licensees, and license closecut.
Inspectors perceived that it is of utmost importance to Regional management that these numerical goals be met.
Region I management indicated that the finding of reasonable assurance of safety is more important than meeting numerical goals.
Inspectors and their management stated that once inspections are scheduled, inspectors plan for the inspections by reviewing the docket file.
The docket file contains all licensing and inspection documentation, including general correspondence.
Generally, this review would include the license, application and other documents listed in the " tie down" condition, results of the last two inupections, and correspondence and licensee reports since the last inspection.
Only in rare circumstances would a Section Chief review the docket file before an inspection.
Generally, experienced inspectors do not discuss the inspection plans for routine inspections with the Section Chiefs.
Less experienced inspectors and inspectors preparing for special, reactive, or allegation inspections will usually discuss their i
plans with their Section Chief before the inspection.
Inspectors very seldom prepare written inspection plans.
Inspectors and Section Chiefs stated that if Region I materials inspectors encounter significant safety problems during inspections, or encounter situations for which they need assistance, the normal procedure is to call the Section Chief or other supervisor or manager in the regional office for 22 l
assistance.
Inspectors and Section Chiefs indicated that this interaction with inspectors in the field has a high priority with Section Chiefs, with one Section Chief stating that it was his highest priority.
In interviews, materials inspectors and management stated that inspections consisted of a. mix of techniques including emphasis on observation of licensed activities, discussions with licensee staff and supervisors, independent measurersnts, and review of records.
They stated that there had been an increased emphasis on observation of actual performance of licensed activities in the past few years.
They stated that they approached information from licensees with a questioning ettitude.
Inspectors and Section Chiefs state' that, for inspections where the inspector finds no violations, normally the debriefing of the Section Chief by the inspector upon return to the office is minimal.
Depending on the safety significance of the findings and the experience level of the inspector, debriefings for inspections with violations could be very brief or detailed.
Section Chiefs generally brief higher ~ management on inspection findings only if the findings indicate potential escalated enforcement.
All inspection field notes are reviewed by the Section Chief.
If the inspection does not involve escalated enforcement, the letter transmitting the Notice of Violation (Nov) or inspection report is signed by the Section Chief.
The Branch Chief reviews few materials inspections except for those that result in an inspection report.
The goal for the branch is to complete approximately one thousand inspections each fiscal year.
Several inspectors stated that the number of hours devoted to each inspection had decreased over the past several years.
Inspectors and management stated that this reduction in time to inspect has not, in their opinion, reduced the level of confidence in their reasonable assurance of safety determinations.
Inspectors stated that"If they did encounter a situation that required more than the nor=al amount of time, they were given the time to do the inspection well. Inspectors did state that they could do much better inspections if they had more ti=e to devote to each inspection.
With regard to the applicability of KRC requiraments for licensees who do not possess licensed material, inspectors and managers had differing views, ranging from the position that all 4
license conditions apply to the position that no license conditions apply.
If an inspector finds that no licensed material has been used, the Region may or may not conduct an j
inspection.
The purpose of such an inspection would be to verify that no licensed material was being used.
i ROI 1320.1, Violations, provides clear guidance on the classification of inspection findings that might be categorized as licensee identified non-cited violations (NCV).
23
4 y
.e 1
In. conclusion,. materials inspection scheduling appears to be affective.- The Section Chief assigns inspections based on' program' completion needs, an inspector's trainingLand_ experience and licensee. performance.
Inspection planning for routine-materials inspections 11s generally affective,- including : inspector review of the docket file which contains the licensei theilicense application, inspection documentation,.with back-up and j
correspondence since the last inspection.
The materials 1 j
inspection Section Chief rarely is involved in inspection planning or docket; file' review.
The Section Chiefs exercise l
judgement and only involve themselves when the issues are j
. particularly safety significant or complex, orfthe inspector.is less experienced.
Because of the volume of inspections,.there'is little input.fron'the Section Chief into the planning of routine:
inspections.
Inspection plansLfor routine, team,-and reactive j
inspections are rarely documented and do not normallyrreceive management review.
The materials inspection' process appears to l
be generally. effective with an appropriate focus on safety.-
Materials inspectors and DRSS management have a clear and common understanding of the needifor, and implementation of,La mix of' techniques during~ inspections,~ including appropriate emphasis onL l
observation of licensed activities, discussions;with licensee staff and supervisors,~ interviews of workers focussing on:the i
performance of-licensed-activities, independent. measurements,.and l
review of records.- Inspectors have reduced the-depth of j
inspection due to the heavy workload and emphasis on " numbers."
.l However, the inspectors do not believe-that the haavy workload-t has compromised the reasonable assurance of. safety.
Inspector interactions.withLSection chiefs during inspections is encouraged j
and.given a high priority by Section' Chiefs..The guidance as to-l when to " call home" is well understood.
Debriefs and management-review of inspections with no-identified violations:is minimal,~
j but field notes are-reviewed by Section Chiefs.
Materials inspection reports and NOVs are~ generally signed out by the' j
Section. Chief..The ROI on NCVs provides good guidance on l
documenting NCVs, including when NCys should.be listed in'a-l report.
j C.
Recommendations l
See Recommendations in Section 2.5, Allegation Management, that j
apply to Region I inspections.
l I
l l
i i
.f 24 t
tw-.-i
,%9 c,
f
'a 2.3 Licensing Program t
2.3.1 National Program
- 3 A.
Statement of Issue i
Were there adequate policies, procedures and criteria from the l
program office to Region I regarding the issuance.of the NES
.i license?
B.
Findings The general requirementsLfor a Type A broad scope license are outlined in 10 CFR Part 33, Specific Domestic Licenses of Broad Scope for Byproduct Material.
The NES license conta!ned elements-l of a Type A broad scope license.
As noted in Regulauory Guide 10.5, Applications for Type A Licenses of Broad Scope, dated l
December 1980, a Type A license'is intended to accommodate those
-l institutions involved in an extensive radioactive material i
program where the demand is' great for a variety:of radionuclides for many users.
A Type A license of broadLscope is primarily.
based on the administrative procedures and organizational qualification of the licensee to operate safely.
The licensee, through its radiation safety committee-(RSC) and its radiation l
safety officer (RSO), performs detailed reviews:of; specific i
activities, staff-qualifications,' equipment, and: procedures'.
This type of license is generally written.to cover a wide range l
of radionuclides and is intended for use by-licensees that cannot l
operate under a more limited specific license without. seriously _
inconveniencing-their programs.
i The policies and procedures.to be used by NRC staff'in the review of license applications are_ outlined in the system of P& gds.
The j
P&GD that provides guidance specificito review of applications for Type A broad scope licenses is P&GD 85-7, Standard Review Plan (SRP) for. Applications for Type A Licenses of Broad Scope.
The original version of this P&GD was issued on March 11, 1985.-
l Draft versions of P&GD 85-7 were provided to the' regions for-interim use and comment.
Thus, a draft version of this P&GD was.
1 available for use by Region I'in'the review of the NES license i
application, but the IRT did not review the older versions of the document.
Other P& gds provided guidance and policies on other materials licensing issues.
]
P&GD 83-20, Standard License conditions, provides a listing of-conditions regarding aspects of licensees' programs that should i
be added to licenses, dependent on the type of. license to be j
issued.
These standard conditions are to.be'used'to the maximum i
extent possible to maintain: consistency!throughout the NRC.
Several materials license reviewers stated that'they generally use the standard conditions, unmodified, even though such conditions at times are so general that the condition may include 25 i
. ~
y i
-l t
reference to things not authorized in the license, such as_
referring to sealed' sources in a leak test condition for's j
license.that only_ authorizes the possession _of plated sources.
l Whent a region hasla cituation that-is not covered by P& gds, there.
j
-is a system for regrasting assistance from NMSS_through a -
-}
Technical Assistanca Request (TAR).
NMSS then reviews the issues and develops a. policy applicable to'the issues and-provides a.
[
response to the region.. Since'about.1989; a11 regions haveLbeen-
- l provided copies'of responses to the TARS from any region. :The TARS, although potentially applicable to. issues in all' regions, are not maintained in a system-that would allow cross zeference i
by materials license reviewers..
-l 1
Several Region I and NMSS staff and managers stated that the? 4 was no clear policy on how to handle applications where the i
license would be used infrequently orLthe license would be used as a credential.
Several persons interviewed stated that cardiologists apply for and receive licenses only to demonstrate I
that they are " credentialed" to review nuclear medicine studies.
1 During interviews, staff and managers in' Region I and NMSS-indicated that they concluded that this may also have been a motive for NES to obtain a license, since it appeared the license was used principally as a marketing tool.
Several license reviewers and managers questioned whether it was appropriate to issue broad licenses, such as-the'NES license, When licensed activities are infrequent.
l In conclusion, some standard license conditions are written l
broadly to' address several different-types of licensed j
activities, e.g.,
leak test standard license conditions..Those l
standard license conditions do not litera11y' apply toall types of licenses for which they are used.
Guidance does not exist 4
regarding the use of NRC licenses primarily as,a credential to j
demonstrate competence.
There is no agency system for filing or l
cross referencing Technical Assistance-Requests'and their-responses except for the specific case, when it is filed in the i
docket.
j C.
Recommendations Guidance should be provided to the regions and licensees on the acceptability of the use of licenses as evidence of credentials.
Guidance should be provided regarding methods-to be used in L
licensing of infrequent. activities, for example, conditioning i
such 1icenses to require notification of the NRC of activities 30
~
days prior to license activation and/or requiring NRC review and acceptance of proposed activities.
i 26 j
i 1
Guidance should be considered -addressing the benefits of calling new licensees to review unique license conditions prior to license issuance.
Guidance addressing the extent to which standare license conditions can be modified should be considered.
Technical Assistance Requests should be incorpocated into en agency-wide system that will allow access and use for future similar licensing actions, like the NRR Health Physics Position system.
Guidance should be considered that identifies the required level of review and approval necessary for modification of standard license conditions and use of unique license conditions.
2.3.2 Region I Implementation A.
Statement of Issue Does Region I adequately implement the program office guidance in the review of materials license applications and issuance of licenses?
B.
Findings Materials license reviewers and their management stated that license applications are reviewed utilizing the guidance provided by NMSS, particularly through P& gds for routine cases and TARS for unique cases or in instances where there is need for policy guidance.
Reviewers were familiar with the material license application acceptance criteria and the process for reviewing applications and issuing licenses.
Region I processes approximately 2000 licensing actions per year when fully staffed.
Several materials license reviewers and managers stated that generally, once a materials license reviewer is delegated authority to sign licenses, there is little time for section
~
Chiefs to review completed actions.
Section Chiefs and the Branch Chief stated that unless the case was mnique or involved a licensee that had significant enforcement problems, their review was limited to an audit of actual completed licenses, and seldom, involved review of the application.
License reviewers and management knew how to apply the standard license conditions to specific cases.
In several instances license reviewers were not sure of the degree of flexibility they had in modifying standard license conditions.
In all instances, reviewers stated that before they made any significant change, they would discuss the proposed change with their supervisor.
In one instance, one reviewer stated that he would change standard 27 4
1
~
i conditions to rake them clearer, such as removing references that were not applicable.
With regard to implementation of license conditions that are not part of the standard conditions, reviewers and managers vers aware that such conditions needed to be approved by reviewers' management and that some' conditions might need to be approved by NMSS.
When questioned about the applicability of TARS to other similar cases, materials license reviewers and their management stated that the TARS are applied to the specific case in point and filed in the docket file for that case.
Materials reviewers stated that they do occasionally see copies of TARS for cases other than those they are working on, but they were not sure that they saw all TARS.
They indicated that they would like to see all TARS so that they could apply findings from one TAR to future similar Cases.
1 License reviewers and their management stated that there has been a heavy workload of licensing for the past several yearc, particularly considering that the staffing levels have been low and training efforts of new staff have been high.
License reviewers stated that they understood that the quality of review was the most important aspect of licensing and that if doing a quality review meant that numerical or timeliness goals would be missed, there was no compromise in the quality of the review.
Several license reviewers stated that because of the emphasis on numbers and timeliness by senior managers, it appeared at times that there was more concern in numbers than in quality.
l Several Region I staff members cnd managers told the IRT in interviews that there is no special program to assure that licensees understand all license cond9eions when a license is issued, other than the letter to the licensee that transmits the license asking that if some part of the license is not clear, that the licensee contact the region.
It was noted that during the first inspection of a licensee (normally conducted within six months of license issuance), any misunderstanding of license conditions would likely be disclosed since much of the inspection would be against the license conditions.
In August 1991, Region I established a Quality Improvement Team I
(QIT) to identify and improve the quality and timeliness of materials licensing.
The topics for improvement were vide-ranging, from improving the system for keeping technical staff abreast on new policy and guidance to improvement in communications with license applicants.
A Section Chief was assigned to lead the group, and periodic updates on the status of improvements are provided to the Branch Chief.
28
In conclusion, license reviewers are generally aware of the policies and procedures for licensing and the systems in place to obtain policies and procedures (eg. Policy and Guidance Directives, Technical Assistance Requests, etc.) for use in routine licensing and are aware of how to obtain information for special cases.
There is a heavy reliance on senior reviewers to provide guidance for and oversight of junior reviewers' work.
This system appears to have assured acceptable quality in licensing actions.
There is little Section Chief or Branch Chief review of licensing work.
Reluctance exists in licensing staff to modify standard license conditions when the standard condition may not fully apply to the specific licanse under review.
The review team did not identify any guidance that specifies the approval level for the use of non-standard license conditions.
Meeting numerical goals for issuing licensing actions and reducing backlog is a constant pressure.
This pressure does not appear to have reduced or affected the quality of license reviews.
C.
Recommendations None 2.3.3 Region I Implementation in the NES Case A.
State =ent of Issue Did Region I adequately implement the program office guidance in the review of the application from NES for a license and in the issuance of the NES license?
B.
Findings NES made application for a license by letter and enclosures dated November 1, 1984.
The application was for a license similar to a Type A broad scope license and for a source material license.
NES had submitted, on July 30, 1984, a Treedom of Information Act request for copies of licensing documents for several organizations which were licensed to perform similar activities.
The application from NES was made with these licensing documents as a background, as evidenced by the listing of authorized use, which very closely followed the wording of two similar licenses.
The application was reviewed by a senior license reviewer.
This reviewer is no longer employed by the NRC, so the IRT evaluated the review as documented in the docket file and did not discuss the review with the former staff member.
The documents available for the reviewer to reference were Regulatory Guide 10.5 dated December 1980, Regulatory Guide 10.4, dated March 1977, and the draft SRPs referenced above in Section 2.3.1.
29
i As part of the review of the application, the reviewer sent two written requests for additional information, and discussed the application with NES by phone.
In addition, because the application involved policy issues, Region I sent a TAR to NMSS dated May 2, 1985, requesting guidance regarding: (1)'the need for NES to develop a contingency plan, (2) the question of NRC authorizing activities at unlicensed sites and, if the NRC so authorizes, how the license should be worded to restrict the activity.
NMSS responded on August 8, 1985, providing guidance.
In this memorandum, NMSS noted that NRC's "... general policy is that decontamination and waste management activities are the responsibility of the waste generator, and should only be carried out under the customer's license.
Service licenses should not be granted broad authorization to conduct unspecified decontamination and waste management operations at unspecified sites.
Such broad authorization would lead to situations where responsibility for radiation safety is unclear, plus it would be difficult in any case to determine whether an applicant is qualified to perform any conceivable decontamination or waste management operation at any site.
However, there may be limited circumstances under which NES may need to possess radioactive materials and conduct decontamination at a temporary job site, such as a machine shop.
The NES application should only be reviewed under these limited circumstances."
In addition, the memorandum from NMSS to Region I noted that a representative of NES had, in a telephone conversation with NMSS, agreed to restrict the possession limit so that no contingency
{
plan would be required and agreed not to operate under the NES i
license at licensed sites.
The memorandum from NMSS stated that i
NES had agreed to provide a letter to Region I to that effect.
The NMSS memorandum also recommended that the NES license contain j
two license conditions:
1.
This license does not authorize the possession of imported equipment, samples, or packages containing radioactive material.
2.
This licenso does not authorize the possession of licensed material at licensed customer facilities or licensed
- customer temporary job sites except as may be specifically authorized under the customer's license.
This license is not intended to authorize operations at facilities or sites involving radioactive material for which an NRC license is not required, a customer's license has expired, or the requirement for an NRC license has not been determined.
Finally, the memorandum noted that the application did not appear to specify a permanent storage location nor did NES appear to 30 l
l 4
have an Agreement State license which covers a permanent location.
In an interview with the IRT, the NMSS staff member who drafted the August 8, 1985, memorandum stated that the final memorandum was the collective result of his work, that of a senior NMSS staff member, and an NMSS Section Chief.
The staff member stated that the purpose of the.second condition was to continus NMSS's position that a facility licensee is responsible for the operations conducted at the licensed facility and that another licensee cannot come in to the facility and take over responsibility for the operations.
During the staff member interview, he reviewed the license condition and stated that the meaning of the condition as written was ambiguous.
NES provided a letter and revised application dated July 30, 1985, that reduced the possession limits requested, so that a contingency plan was not required.
The letter did not discuss operation at licensed sites nor did it spicity a permanent storage location.
On August 30, 1985, Region I issued a license to NES.
The license contained, as conditions 15. and 16.,
the two conditions recom= ended by NMSS to be incorporated into the license.
The license did not specify a permanent storage location, but rather authorized use at temporary job sites where the NRC maintains jurisdiction.
The letter to NES that transmitted the license requested that NES notify Region I if they had any questions on the conditions of the license.
There was no indication in the docket file that NES ever questioned the meaning of the condition.
NES' understanding of License Condition 16 is reflected by correspondence or conversation records contained in the docket file which describe their notifications to Region I of actual license use or intended use (see Section 2.2.2).
In interviews with Region I staff and management, several interpretations of the meaning of original condition 16 were provided to the IRT.
These same individuals generally stated that the condition was not clear.
In an interview with the IRT, a former Radiation Safety Officer (RSO) for NES stated that he understood that the condition stated that NES could not use or possess licensed material at a licensed customer's facility or job site, except as specifically authorized under the customer's license.
He held the RSO position form the late mid-1980s to late 1989.
In conclusion, the application by NES for a license was thoroughly reviewed.
Certain policy issues were coordinated with NMSS.
The special license conditions recommended by NMSS were 31
s
'3 i
-i incorporated _by Region I into the NES license.
Special license
]
~
condition 16 was not cicarly or uniformly interpreted by NMSS and-regional staff, or by the licensee.
3 I
C.
Recommendation i
See Section 2.4.4.C.
i 2.4 Rules, Regulations.and License Conditions 2.4.1 Application of Regulations t
A.
Statement of Issue l'
o.
Do NRC's odified regulations specifically address =the issue'of i
applicability of regulations and. license conditions when a licensee is:not undertaking work under the. framework of its own
. license (hereafter referred to as an " inactive" licknse)?
- 'l B.
Findings
-i I
The record shows that the allegations against NES were not-pursued in greater depth during the first-inspection.because of L
the understanding of the inspectors, after consulting-with their.
I Section Chief, that at least st#e of the allegations were' immaterial.
These allegations were seen as' referring-to.
1 activities that are not required when the license ~is inactive.
]'
However, this understanding was not~ evident to the. lead; inspector until, after the inspection.was essentially complete and.
potential findings identified,. the' inspector's-Section Chief was called for advice on how to respond to the.NES president's assertion that the license was inactive.
It was the Section chief who' advised'the_ inspector that the NES president:vas essentially correct in his understanding!of what was required of-l the licensee when'the license was inactive.
j q
The Section Chief concluded that very limited use of the license j
(the transportation of licensed materials for other licensees) 1 was not sufficient to.* activate" the license. requirements.- This 1
conclusion was erroneous in light of the subsequent re-review of j
L licensed activities and the guidance Region >Itreceived-in March, j
~
1992. :It is. clear;that this conclusion wes not predicatedton j
erroneous' licensee' management statements, since licensee-1 management submitted a letter to the Regional officeLinforming1 j
the Region of the activity and-the_NES president stated to.the; j
inspectors that the ' license had been used for: transportation
.?
activities.
Considering.that erroneous conclusion, the Section j
Chief's: position that -license requirements did not. apply;to inactive licenses was not inconsistent with guidance-related to i
deferral of-initial l inspections and ' deferral of inspections-if
'l licensed material is transferred.
That guidance suggests that' j
license requirements do not apply in'those situations when the-l 3
32' j
1 a
1
~
l i
i 1
n i
licensee does not possess licensed materials.
No: specific guidance existed that addressed license requirements that apply _
when a license is used only infrequently.-
It_had been an agency i
practice not to inspect new licensees until the licensee had.
received material and was actually. working under the authority of.
l
~
the license.
Telephone calls are routinely used to ascertain the status of new licenses and known inactive licenses.
There are divergent views among inspectors and supervisors on how
-l Pong such deferral of inspection should contihue.
It is~not 1
clear whether such deferral of inspection is basedsupon a view j
that regulations and license conditions are inapplicable to an j
' inactive license, or on a view that an inspection of-an inactive i
license is not productive-and a waste of inspection resources.
l It appears that NES was not inspected routinely.on the basis of r
such telephone callo.
-l
't In the NES context this early absence of clear directive'is-j reflected in the divergent conclusions of the two inspections on the need for a fulltime RSO and the need for quarterly meetings of the radiation safety committee._ In a telephone conference i
call in March 1992, Region I managers were advised _by j
headquarters that.indctive licenses were subject to license
-I conditions and regulations on a continuing basis regardless of i
level of activity.
This more recent understanding has been
[
passed along to the Region 2 materials inspection and' licensing staffs in a series of lessons learned training sessions conducted j
in May 1992.
Region I materials licensing and inspection staff l
currently understand and agree that.some set of: regulatory-require =ents should always be implemented regardless of the
-j inactive status of the license,.but there is still no clear t
consensus as to what that set should be.
j l
C.
Recommendations j
i Develop program and policy guidance for_the licensing and h
inspection staff that will establish the set of regulatory.
requirements to be included in a license that an inactive licensee must follow in order to maintain the license.
The set'
-j of. requirements should be sucJs as to provide reasonable assurance f
that the licensee remains competent to receive and use material and undertake other permitted activities.
For the long term, l
consideration should be given to addressing the issue of inactive l'
licenses in the codified regulations.
Licensees should be informed by Information Notice of the-l requirements that are applicablo even though a license is j
. inactive.
I 33 I
h
o s.
2.4.2 10 CFR Part 19 A.
Statement of-Issue l
Is lo CFR Part 19' ambiguous as to posting requirements when;a i
license is inactive or when licensed activities are conducted-but radioactive material is not in possension?
B.
Findings There is language in Part 19 that' suggests that posting'of Form.
j 3, and other, documents, would be necessary only when the' licensee is undertaking activity with radioactive materials. See, e.g.,
i Sections 19.1 and 19.2, Secje and Purpose.. Section!19.11, however, refers to licensees, without limitation,-as-having to post licenses, operating procedures,-notices of. violations, and-l Form 3.
Following a. conference telephone call with headquarters staff and OGC on March 11, 1992, the Regional staff understands-that posting is an applicable requirement even.when'a. license is.
inactive.
In addition, the requirement to post'a Form 3 applies 1
at all locations where licensed activities occur, including, for l
example RSC meetings, even if no licensed material'is possessed-or used at that location.
~
C.
Recommendation.
t i
Prepare an Information Notice for materials licensees reminding _
l them of the requirement to keep their licenses and other notices j
required by Part 19 posted at all times and in all locations-where license-related activities occur.
Formalize materials program guidance on this matter.
2.4.3 Exempt Sources-l A.
Statement of Issue Are sources that are not subject to licensing under 10 CFR 30.18 j
also not subject to regulation when in the hands of licensees?;
i B.
Findings l
From a legal perspective the record suggests at least'two.
l regulatory problems regarding exempt sources in possession of licensees.
The first problem is reflected-in the record of the -
y telephone conference call.on March 11, 1992, noting tJte 1
headquarters advice that the NRC has no jurisdiction overiaxempt-sources.
Secondly, the same record indicates that mishandling of.
exempt sources by. licensees presents an unenforceable situation.
Review of the regulations suggests otherwise.
First, all byproduct material (unless jurisdiction _is relinquished to an Agreement State) is subject to NRC jurisdiction pursuant to 34
~ _ _.- _
4 Section 81 of the Atomic Energy Act of 1954, as amended.
Exemption of material from licensing is a act of regulatory discretion based on a minimal health risk from the material under the conditions of the exemption.
legal jurisdiction, not a release from it.The exemption is an exercise.of Pursuant to 10 CFR 30.18,.a person possessing only sources (or other quantities)
Appendix B, does not need a license.that do not exceed the limits of Section 301 These sources must be nanufactured or distributed under a license issued pursuant.to 10
~j CFR 32.18, 32.19 and 30.33.
Section 32.19 in particular.
4.
l stipulates that each source must be labeled to set forth appropriate radiation safety precautions and' instructions relating to the handling, use, storage and disposal of the source.
10 CFR Part 20 enjoins licer7eas to take into account all sources of radiation except background in providing radiation protection and calculation of permissible doses to workers and members of the public.
.See 10 CFR 20.1003 (definitions of occupational dose, public dose, and background), 20.1101, 20.1201, and 20.1301.
Thus, even if a source is not specifically covered by a license, in the administration of their radiation safety programs licensees are obligated to take into account t
sources that meet the criteria of 30.18 for exemption.
Failure
}
to do so, or to ignore the precautionary-label may present an enforceable event.
l C.
Recommendation in conjunction with the NF.SS staff, should review the
- OGC, applicable regulations in depth and provide a legal analysis on a i
i licensee's responsibilities with respect to sources that meet the j
require =ents of 10 CFR 30.18.
j 2.4.4 NES License Conditions 1
i A.
State =ent of Issue i
Is the NES license clear enough in its terms so that an inspector vould understand the limits on NES' authority?
B.
Findings condition 16 (15 in the amended license) of the NES license.is not precise.
This condition reads as follows:
i.
i This license does not authorize the possession or use of licensed material at licensed customer facilities or l
licensed customer temporary job sites except as may be l
i specifically authorized.under the customer's license.
i This license is not intended to authorize operations at j
facilities or sites involving radioactive material for i
t which an NRC license is not required, a customer's 4
J e
4 35 i
I I
i.
license has expired, or the requirement for an NRC license has not been determined.
This license condition was added to the license following a technical assistance request to headquarters.
The condition was copied verbatim from text provided by headquarters in a memorandum dated August 8, 1985.
However, no person interviewed was willing to state with certainty what it meant in terms of the licensee's activities.
The clearest indication of its intended meaning came from a former RSO and a headquarters staff person involved in the initial drafting of the condition.
These two looked at it as a limitation on licensee activities when working at a location already covered by another NRC license.
In those circumstances the NES license gave no authority in addition to the authority granted in the other license.
For example, if NES went to a reactor site to perform a service, its work would fall under the reactor license, not its own.
Occupational radiation safety would be the responsibility of the reactor licensee, not NES.
When the other license was broad enough to cover all the
'i work to be done, NES viewed itself as if it were an unlicensed contractor and gave no notice to Region I of its temporary jobsite.
On the other hand, the NES license appears to have been invoked on at least two occasions when NES contracted to provide services to NRC materials licensees whose licenses did not appear broad enough to cover the work contracted for.
But if condition 16 is interpreted literally, NES could not undertake work not specifically authorized by the customer's license.
However, no one questioned the undertaking of work at the two materials sites as a violation of the NES license.
For example, A. D. Little contracted with NES to package and ship a source in an NES cask.
A. D. Little apparently needed NES to perform this work because A. D. Little did not have a cask nor an approved quality assurance plan for a cask.
Pursuant to condition 18 of its license, NES infor=ed Region I of the A. D. Little temporary jobsite and performed the work.
The tension between license conditions 16 and 18 is obvious.
Condition 18 suggests that NES may do work under its own license, upon notice to Region I, at a temporary jobsite.
Condition 16 appears to limit NES activities to those of mere contractor to a licensee for activities to which the NES license appears irrelevant.
For work for which notice was given pursuant to condition 18, the NES license is considered active; for work that falls under condition 16 the license would be considered inactive.
The rarity of NES using its own license (only two cases are known) over a five year span has led some (including a former NES RS0) to conclude that the NES license amounted to little more than a " marketing tool".
36
Finally it is not clear whether condition 18, together with license condition 10 (limiting licensee use of licensed material to temporary jobsites of the licensee in United States where the NRC maintains materials jurisdiction, i.e. not in Agreement States), authorizes independent activity under the license in the absence of any other applicable NRC license.
There is no evidence, however, of any such use in the NES file.
The confusion over the meaning of these license conditions does not appear to have had much, if any, direct influence over the results of the two inspections of the allegations.
The differing results of those two inspections are better explained on the 4
grounds of the distinction drawn between active and inactive licenses with respect to the first inspection, and the advice received from headquarters in March 1992 following the second inspection and prior to the finalization of the second inspection report.
C.
Recommendation The NES license, and other licenses like it, should be reviewed and revised as necessary to make it clear under what circumstances the licensee will be considered as conducting activities under its own license and what is the allowable scope of those activities.
2.5 Allegation Management 2.5.1 Management Involvement - Planning A.
Statement of Issue What level of management involvement is necessary in the planning of allegation follow up activities?
B.
Findings NRC policy and procedure for allegation management activities are described in MD 8.8 (formerly MC 0517), " Management of Allegations" dated 4/30/90.
That Directive defines responsibilities for allegation management and provides comprehensive policy and procedural guidance regarding receipt and htn.dling of allegations, follow up of allegations and close out documentation for allegation resolution.
That policy is implemented in Region I through ROI 1210.1, Revision 5,
" Allegations and Complaints - General."
Revision 3 of ROI 1210.1 was in effect during 1990 when the NES allegations were received and initial inspection completed.
l 37
Allegation coordination and management in Region I were formerly delegated to the technical divisions with support from an administrative staff member in the Division of Resource Management and Administration.
In April 1991, Region I established the Senior Allegation Coordinator (SAC). position to assist with the coordination and management of allegations.
The SAC reports to the Enforcement Officer on the Regional Administrator's staff.
Region I practice for receipt of an allegation involves documentation of the allegation, including all_avhilable supporting information.
ROI 1210.1 provides comprehensive guidance on what is an allegation, how to interview an allager and elicit all necessary information, and how to document incoming allegations.
ROI 1210.1 includes a standard form for documenting allegations that assists in directing the staff to obtain all relevant information.
Through formal and on the job training, materials ntaff and management are aware of the need to fully document the details of an allegation.
Telephonically initiated allegations are transferred to a staff member of the appropriate technical section or the SAC.
ROI 1210.~1 includes procedural guidance for transfer of incoming telephonic inquiries and allegations.
Several Region I staff and management expressed concern over the significant increase in the number of allegations received over the past several years.
This was attributed primarily to the impact of a large number of allegations at the Millstone nuclear power plant.
However, there is some sense that the allegation workload in the materials area has also increased.
statistics on allegation workload for all categories of allegations during the five year period from 1986 through 1991 indicate that workload in Region I was at its lowest point in 1988 with the receipt of 125 allegations and at its highest point in 1991 with the receipt of 327 allegations.
Separating out materials allegations reveals a similar trend with a low of 26 allegations in 1986 and the highest workload occurring in 1991 with receipt of 49 materials allegations.
This trend of increasing allegation case load is contrary to that being experienced in all other Regions in the NRC and headquarters.
Summary data for the headquarters and regional offices are provided below for' comparison.
See chart next page...
38 i
ALLEGATION WORKLOAD FY86 - FY91 ALL CASES Office Lowest Workload Hichest Workload XtAr Cases X33r Cases I
1988 125 1991 327 II 1988 88 1986 340 III 1991 105 1986 202 IV 1988 87 1986 132 V
1988 63 1986 106 HQ 1991 57 1986 218 Note from this data that, except for Region I, all other regional offices peak allegation workload was in the mid 1980s, corresponding to the construction completion of many nuclear power facilities.
ALLEGATION WORKLOAD FY86 - FY91 MATERIALS CASES ONLY i
Office Lowest Workload Michest Workload l
X3Ar Cases
%3Ar Cases I
1986 26 1991 49 II 1988 11 1986 38 III 1991 34 1988 49 IV 1989 22 1986 41 V
1988/9 6
1987 11 39
~
h Several Region I staff and, management suggested that.MD 8.8:
should be revised to assign authority to the regional management allowing'certain' allegations to be closed without. inspection,-
based on the region's determination following initial review that the allegations are unlikely to result in. identification of an j
issue that has health'and safety significance.
l I
Allegation documentation is contained in region allegation files.
maintained by the SAC.
File organization is,in-chronological-l order with the most recent documentation in the front of the=
file.
Documents in the file are not bound or inventoried..There-
[
is no file contents listing for allegation files.- There were
.i several-separate files for the allegations regarding Nuclear ~
Energy! Services (NES).- The SAC stated that the files.hadibeen l
used so extensively that he was no longer confident 1that j
appropriate documentation remained in the files.
Those files were poorly organized with documents'aisfiled.in the wrong NES t
allegation file.
Several documents principally involving the support for the second inspection at NES.were missing'from.the file.
Those missing documents. involved alleger contacts and other records associated with the second Anspection of the allegations.
Copies of those missing records existed in the l
inspector's or Section Chief's file.
Following receipt of an allegation, Region I presents the'
'I allegation to an Allegation Panel.
For materials allegations, that panel is comprised of a senior DRSS manager and appropriate 1
supervisory and technical staff to describe and discuss the
}
nature of the allegation.
Formerly, the Allegation Panel met on an as needed basis to determine allegation follow up actions.. During tho' spring of 1992, due to the level of allegation workload and the DRSS Division Director's decision that more management involvement was necessary in the allegation area, the Allegation Panel was scheduled as a regular weekly meeting.
Beginning in the spring l
of 1992, the Allegation Panel not only addresses new allegations, but also reviews the progress on all open allegations during its l
weekly meetings.
]
.(
The purpose of the Allegation Panel regarding new allegations is to evaluate the safety significance of the allegations, to~
establish the priority for follow up, and to determine the next appropriate step in follow up of tha' allegation, e.g.,
recontact j
the alleger, conduct an inspection,Krefer the matter to another regulatory agency, etc.
These responsibilities-.are clearly'
.[
delineated in ROI 1210.1.
For allegations-that do not have
{
immediate safety significance,.several Region I staff and
'i supervisors indicated that they. consider the perceived motivation of the alleger, e.g., disgruntled employee, in the determination of follow up' priority.- Motivation also was considered by some to-cast doubt on-the credibility of the allegation.
i -
40
- l t
h
Another issue addressed by the Panel regarding assignment of follow up priority is the potential impact on other ongoing activities and the availability of staff to perform the inspection.
Finally, since early 1992, for those allegations that are inspected, the Allegation Panel determines whether the results of the allegation inspection activities should be presented to the Panel prior to closecut of the allegation.
According to DRSS management, the Allegation Panel currently reviews the results of approximately three-quarters of the allegations that are inspected.
The Allegation Panel decisions do not address details of the proposed course of action.
The details are delegated to the Section Chief and inspector.
Documentation of the Allegation Panel meetings is completed on a standard form contained in ROI 1210.1 that lists relevant identifying information regarding the allegation and the Panel as well as the course of action determined by the Panel.
The details of the Allegation Panel
' deliberations are not documented.
Consequently, successful incorporation of the Allegation Panel deliberations into detailed planning and execution of allegation follow-up activities is dependent on the memory of, or notes taken by, the cognizant Section Chief and inspection staff present.
Following the Allegation Panel, when recontact of the alleger is deemed the appropriate action, those contacts are normally made in writing by the SAC with little involvement of the technical staff.
The technical. staff does not normally make direct contact with the alleger in preparation for the inspection to assure that the NRC's understanding of the allegations is correct or get necessary additional information from the alleger.
Guidance and standard letters for the SAC contact with the alleger are contained in ROI 1210.1.
When the Panel directs performance of an inspection, the assigned inspector prepares for the inspection, including review of relevant docket file and allegation file materials.
Interviews with DRSS staff demonstrated a consistent understanding of the expectation and need for review of the docket file before
~
inspection. -There is no arpectation by DRSS supervisors or management that a formal or documented inspection plan be generated and inspector practice is not to have a documented inspection plan. 'Section Chief involvement in allegation inspection planning when a qualified inspector is performing the inspection is limited.
These aspects of allegation follow up are not addressed in ROI 1210.1.
Regarding the follow up of the allegations at NES, the allegations were presented to the Allegation Panel.
The Allegation Panel separated the allegations into three segments:
(1) those involving potential discriminatory actions which were held in abeyance pending the outcome of investigation by the 41
Department of Labor; (2) those involving activities at reactor licensees which were referred for action to the Division of i
Reactor Projects and the Office of Investigations; and (3) those involving activities with byproduct materials.
The Allegation Panel determined that an inspection into the byproduct materials allegations was appropriate and that the allegation inspection should be completed within the context of a routine inspection.
The Allegation Panel perceived the allegations to be of small safety significance, with the exception of the potential storage of radioactive materials in an unauthorized location.
Documentation existed in the NES docket file indicating that the NES license was used to perform licensed activities during 1989.
A letter from NES dated May 10, 1989, indicated that their license was going to be used at the Chemetron facility in Ohio.
The documentation from NES dated February 28, 1989, indicating license activation regarding transportation activities at the A. D. Little facility was filed in the A. D. Little docket file and not in the NES docket file.
The inspectors assigned to follow up'the NES allegation both indicated that they had reviewed the NES docket file.
One inspector identified documentation in the NES docket file indicating that the NES license had been used to perform licensed activities and documented that knowledge in an undated record of a conversation with the allager.
The other inspector does not recall identifying docket materials indicating that the NES license had been used to perform licensed activities.
There was no formal inspection plan developed indicating the activities or issues to be addressed or persons to be contacted to resolve the allegations at NES.
The Section Chief did not review the docket file review or have substantive involvement in inspection planning.
Both inspectors the allegations by review of allegatio, gad detailed knowledge of n documentation prior to the inspection.
One also had direct involvement with the alleger through interviews.
The inspectors were directed to conduct the allegation review within the context of a routine inspection.
C.
Recommendations The NRC should continue its policy that all allegations should be resolved and resolution documented.- The NRC should not adopt a policy that specific allegations would not be inspected due to an initial assessment that it would be unlikely that an inspection would result in the identification of a significant health and safety issue.
There have been allegations that began innocuously and resulted in very significant issues after review by the NRC.
j The Region I allegation file maintenance practices should be reviewed to assure that all documents relevant to the allegation are properly filed and canaot be inadvertently displaced from the 42
a l
file.
In addition, Region I should consider having a file l
document. list or inventory to assure that all documents are known.
Any changes to filing practices should be incorporated j
into a revision of ROI 1210.1.
l MD 8.8 should be revised to require written. inspection plans for allegation follow up that are reviewed by management.
.This would i
increase the assurance that issues would be addressed and persons j
would be contacted to address the allegation.
Regional-l procedures should address the unique aspects of. allegation i
inspection planning and the expectations for formalized preparation and review of inspection plans.
Region I should conduct training for regional staff and mar gement to assure that the evaluation of an allegation is not influenced by individual NRC employee perceptions of what may be j
an alleger's motivation to bring the issue forward, but only on the merits of the issue..
Senior Allegation Coordinator contacts with the alleger should i
include an appropriate technical staff member, when the i
allegation involves issues outside of the SAC's area.of.
expertise.
This practice should be reflected in a revision to ROI 1210.1.
l The NES allegation files should be reviewed to assure the files i
contain all relevant information and to verify that documents are correctly filed.
^
2.5.2 Management Involvement - Issue Resolution l
A.
Statement of Issue Do allegation inspection activities receive a sufficient level of j
management involvement to assure inspection objectives are met i
and issues are resolved?
B.
Findings MD 8.8. requires that allegations be resolved and the resolution l
be documented.
ROI 1210.1 assigns the responsibility to determine the method for evaluation and resolution of an i
allegation'to the Allegation Panel.
The. responsibility for j
implementation of the Allegation Panel's directives is assigned to the Action Office Contact (AOC), normally the appropriate Section Chief.
Allegation follow =up is usually assigned to an experienced inspector after consultation with the Allegation l
Panel..The selection of the inspector-is influenced by: (1) the immediacy of the issue; (2) the availability of staff; (3) the impact on ongoing' routine and reactive inspection effort; (4) the inspector's expkrience level; and (5) the inspector's involvement 43 i
[
l
in receipt of the allegation and attendance at the Allegation Panel meeting.
The assigned inspector is then responsible for planning, conducting and documenting the inspection activities.. It is standard practice to send two inspectors on allegation inspections.
In developing plans to conduct inspections, several materials staff and supervisors indicated that they are currently unsure of management's expectations regarding the scope and depth for allegation follow up inspections because of the activities undertaken to address the NES allegations after the matter was questioned by Senator Lieberman.
DRSS staff r7d supervisors had a consistent understanding of the balance bet.een different inspection techniques to verify the adequacy of licensed activities.
RI interviewers indicated that inspections depend most heavily on observation of work activities, interviews with licensee employees, and confirmatory measurements, with less emphasis on review of records.
This inspection approach was developed through formal NRC coursework and on the job training and supervision.
DRSS staff and managers also had a clear understanding of the NRC policies on protecting the identity of allegers described in MD 8.8 and ROI 1210.1.
Materials allegation inspections are l
normally conpleted within the context of a routine inspection with emphasis in the area of the allegation.
In most cases, this practice precludes the licensee from knowing that an allegation has been made regarding activities under that license.
Allegation inspection results are presented by the inspector to the Section Chief at the completion of the inspection and, if required, to the Allegation Panel.
If violations are identified during the inspection, they are documented with a transmittal letter and NOV in similar fashion to any routine inspection.
The division then generates a detailed internal memorandum that describes the specific allegations and what action was taken to resolve th.m.
This memorandum is transmitted to the SAC and utilized by the SAC to prepara a response letter to the alleger.
The Section Chief will be on concurr6nce for the close out letter to the alleger which is signed by the SAC.
These procedures and practices are discribed in ROI 1210.1.
With respect to the NES allegation followup inspection, after preparing for the inspection, the inspectors arrived on site and conducted an entrance interview with the company president.
One inspector related that the president confronted the inspectors regarding the reason for the inspection and stated that he believed he knew why they were inspecting the license, inferring they were following up on concerns from the alleger.
Placed in the uncomfortable situation of this confrontation and recognizing the NRC policy regarding not revealing the identity of an 44
alleger, the inspectors responded that they could neither confirm nor deny the president's statenents.
Due to the nature of the firm, involving field consulting and support activities to the nuclear power and materials industries, essantially no technical staff were available during the inspection other than the president.
One inspector related that the president informed the inspectors that all work they performed was conducted under the client's license with the exception of the transportation of an irradiator for A. D.
Little.
The other inspector recalled that, after completion of the inspection and potential findings were. identified, the president emphasized that the work NES performed occurred under the licenses of their clients.
Based on interviews, Ae inspectors performed a thorough review of the allegation involving the improper storage of sources, including contact of the involved parties, identification of the type, form and quantity of material, conduct of extensive surveys to verify no remaining material was improperly stored, and interviews with licensee personnel.
The inspectors discovered that the alleged improperly stored sources were quantities exempt from NRC requirements.
Consequently, while it may not be a good practice to store radioactive materials in a non-restricted area without the knowledge of workers in the area, there were no violations regarding this activity.
The inspectors confirmed that there was no safety issue.
The inspectors also reviewed available and retrievable records from NES work sites that addressed licensed activities, whether conducted under the NES license or a client's license.
The president insisted, at the end of the inspection, that those records and activities occurred under the clients' licenses, with the exception of work at A. D. Little, and should not be reviewed against the NES license.
The controversy over whether activities occurred under the NES license became a focal point in evaluating the inspection results.
The inspectors called their Section Chief in the regional office i
for consultation on the matter.
The Section Chief advised the inspectors that the requirements of the NES license would not 1
apply if no activities were conducted under the NES license.
j This interpretation resulted in frustration on the part of the inspectors who terminated further review of those activities.
While the inspectors and section Chief had varying degrees of awareness of the limited use of the license at the A. D. Little I
facility, they all arrived at the same conclusion that such limited use was inconsequential within the context of a license as broad as the NES license.
No conversations among the inspectors and the Section Chief about the use of the license at A. D. Little were described to the IRT or found in records.
No 45 l
national program or regional guidance existed at the time to assist Region I in establishing what requirements were applicable when a license was " inactive" or how to differentiate between an
" active" or " inactive" license.
However, the decision made by the Section Chief was not inconsistent with inferences that could be derived from the guidance related to' deferral of initial inspections if no radioactive material is possessed and the guidance indicating an inspection should not be performed if radioactive material is no longer in the possession of a licensee.
It has been long established NRC policy that most contract service work (inspection, maintenance, modification, new construction, vaste processing decontamination, etc.) performed i
at a licensees facility with ?lcensed materials be done under the pri=ary license authorizing possession and use of the licensed material, rather than such work being done under a license issued
. to a service company.
one exception to this policy is the performance of radiography at power reactors.
Power reactors are authorized possession and use of byproduct and special nuclear material incidental to operation of the reactor, but are not licensed under 10 CFR 34 to perform radiography.
Thus radiography is conducted at power reactor sites under the authority of the radiography company's license.
This policy, that work at a licensee's site be done under that company's license rather than a service company's license, has been well established as noted in the following documents:
IE Information Notice (IN) No. 79-09, dated March 30, 1979, Spill of Radioactively Contaminated Resin. This IN specified that contractor radwaste systems must be operated under the licensee's technical specifications.
IE Circular No. 80-18, dated August 22, 1980, 10 CFR 50.59, Safety Evaluations for Changes to Radioactive Waste Treatment Systems.
This Circular, a follow up to IN 79-09, outlined the process power reactors were to use for performing safety evaluations under 10 CFR 50.59, of changes to radioactive vaste treatment systems.
An All Agreement States letter dated May 6, 1986, which
~
enclosed a letter dated May 6, 1986, from F. Wayne Kerr and Edgar D. Bailey, regarding contractor services for radwaste processing.
This letter specified that, "The functions performed by mobile radioactive waste units at sites of nuclear power reactors and other licensed facilities must be conducted pursuant to the Part 50 operating license held by the utility the materials license in the case of other licensed facilities."
46
i w
I 1
i IE IN No. 87-07, dated February 3, 1987, Quality Control of
(
onsite Dewatering / Solidification. Operations by:Outside l
Contractors.. This IN stated, "The functions' performed by nobile transportable radwasta processing equipment for i
solidification or dewatering (e.g., usually skid mounted or truck mounted) are very often performed by outside contractor personnel. Such operations fall-within the scope of the operating reactor's license issued. pursuant to 10 CFR 50.
Therefore, regardless of the specific method.of' processing the waste or the contractorJinvolved, the licensee is responsible for ensuring that'all.such 1!
activities at his site are carried out:in a mahner consistent with_the facility operating license and.
applicable technical specification. process. control program, l
and regulations, in a manner that.p ovides adequate j
protection from health, safety, and environmental i
standpoint.
Regulatory Guide 3.65, Standard Format and Content of'
-l Decommissioning Plans for Licenses under 10 CFR Parts 30,
.j 40, and 70, dated August 1989.
In Section 2.4, this Guide' l
specifies, "The licensee may choose to accomplish some or all decommissioning activities and tasks by using.
contractors.
However, the responsibility for safety during l
decommissioning rests with the licensee.
For each-i contracting organization, the scope of work, the contractor.
i qualifications to perform work with radioactive material, j
and administrative controls to be used to ensure adequate health and safety' protection should be described.
The licensee should indicate which activities will_be performed
-i under subcontractor licenses and indicated the name, address.
.I and license number of the subcontractor."
-l 3
Draft regulatory guide DG-1005, dated-September 1989, l
" Standard Format and Content for Decommissioning Plans for
't Nuclear Reactors."
In Section 2,5, this Guide specifies,
'.{
"The licensee may choose to. accomplish.some or all; decommissioning activities and tasks by using contractors.
j However, the responsibility:for health.and safety during decommissioning rests with the licensee and al_ license.
l requirements must be complied'with.- For..each contracting
)
the administrative control system to be used-to ensure
' l organization, describe the scope of work to.be accomplished,.
4 l
adequate health and safety protection, and the qualifications and experience of the contractor."
i l
It is clear that the NRC policy has been that contractor services i
to licensed facilities must be conducted under the primary l
license that authorit(J possession.and'use of. licensed material.
3 This policy had been defined in numerous documents.
Thus,-the Section Chief's decision that work done by NES for other 47 1
~
I licensees had been done under those other licensees' license was consistent with long-standing NRC policy.
Nevertheless, one of the inspectors conveyed a view to the IRT that, upon reflection, the statement in the October 24, 1990, inspection report that the licensee had neither performed any services nor possessed any licensable radioactive material under the licence was incorrect.
Additionally, another possible contributor to thesa apparent contradictions is the suggestion that the inspection in certain areas, such as Form 3 posting, was primarily focussed on safety determinations and compliance on the day of the inspection, only, as opposed to a review during the entire period since the previous inspection.
Also while on site, the inspectors reviewed the allegation regarding the licensee's failure to have the Radiation Safety Officer (RS0) required by the license.
The licensee had filed a license amendment with the regional office contemporaneously with the inspection activities requesting addition of a new individual as the RSO.
The inspectors interpreted this matter as a licensee identified violation for which the licenses had taken action to correct.
Finally, the inspectors did not review retrospectively the allegations regarding the posting of NRC Form 3 or the unidentified container of material in the parking lot.
The inspectors confirmed that the licensee was currently in compliance with the 10 CFR Part 19 posting requirements and had no improperly stored material at the time of the inspection.
The inspectors believed that they had resolved any potential safety issues at the time they left the site.
The inspectors returned to the regional. office, debriefed with their Section Chief and documented their inspection findings.
The inspection report documented that the sources were exempt quantities, that the licensee had taken action to resolve the failure to have the named RSO, and that the NRC Form 3 was posted.
Regarding the RSO matter, the report states that the licensee was not conducting licensed activities while they were missing the RSO.
The report concluded that no violations were identified.
During interviews of the inspectors, they discussed the RSO matter as a non-cited violation.
The issue was not documented in the inspection report as a non-cited violation.
Pursuant to the NRC Enforcement Manual and regional instructions, this would have required further explanation in the report and cover letter regarding the licensee's identification and correction of the violation and the application of the Enforcement Policy for non-cited violations.
The report incorrectly stated that "The licensee has not performed any services nor has it possessed any licensable radioactive material under this license."
The report 48
was signed by one inspector and the Section Chief and the transmittal letter was issued on October 24, 1990 under the signature of the Section Chief with concurrence by both inspectors.
l The Section Chief also corresponded with the alleger on October 26, 1990, stating.that "No unsafe conditions were found and no violations were observed."
While this may be a factually correct statement, it is not relevant to the allegers concerns l
that violations had occurred in the past.
The letter to the alleger further stated that "The inspectors determined that the Radiation Safety Officer listed on the license still holds that position..."
This statement is incorrect within the context of the allegation that the RSO on the license had left the company.
The allegation was in fact substantiated as documented in the inspection report.
However, the letter to the alleger did not address the issue within the same context as the inspection report or the allegation.
The letter to the alleger further stated that "several NRC Form 3 forms were posted..."
Again, this statement regarding current compliance status does not address the allegation of past violation of the posting requirements in 10 CFR Part 19.
Finally, the letter to the alleger stated that "The inspectors noted that all work conducted by NES involving licensed radioactive materials has been performed under the authority of the NRC licenses issued to NES's customers."
While this statement is also reflected in the inspection report, this a
statement is clearly inconsistent with the information in the docket file and the knowledge of at least one of the inspectors.
The purpose of this letter to the alleger pursuant to ROI 1210.1 was to describe to the alleger what actions the NRC had taken in response to the identified concerns.
The letter to the alleger did not address the concerns identified *in the allegations, but rather discussed present day compliance.
This led the alleger to cotrent that NRC's findings in the matter were " wrong" and ask the question, "Is NRC that overworked or did NES deliberately dupe them?," as reflected in his margin comments on the October 26, 1990, letter.
The second inspection of the NES allegationn.was initie.ted in January 1992 in response to concerns on the part of regional management that the first inspection may not have been sufficient to resolve the allegations.
This issue was again surfaced through contacts from the allager and Senator Lieberman on behalf of the alleger.
The second inspection resulted in a thorough evaluation of all licensed activities and allegations raised regarding NES practices.
The transmittal letter with the enclosed inspection report sent to the licensee on June 12, 1992, documented seven 49
!c u.
violations of regulatory requirements including the failure'to j!
have the required Radiation Safety Officer, the-failure'to fulfill-the functions of'the Radiation Safety Committee, and the failure to~ follow transportation requirements'in the shipment of licensed' materials.
While the report underwent extensive review i
at many levels and in several offices within the NRC, the report l
was issued under the signature of the Section' Chief! responsible for the inspection activities, contrary to guidance contained.in.
ROI 1020.5, Processing of Inspection and Licensing j
Correspondence.
During the evaluation of the findings'of the second inspection,.
Region I staff and management discussed two issues with the Office of. Enforcement, Office of General Counsel, and the Office:
of Nuclear Materials: Safety _and Safeguards.
First, the conceptt i
4.
of which, if any, NRC license requirements and: regulations apply.
j to a licensee during periods of inactivity was discussed.- The j
conclusion, as described in a March 11 -1992' conversation record, j
was that all requirements apply after issuance'of a license.
The record also indicated it was the inspector'sLprerogative to cite based on safety significance.
The second. matter' discussed:
l concerned the applicability of.NRC requirements and license j
conditions to exempt quantities of byproduct materials.. The l
conclusion was that exempt quantities of byproduct materials aret exempt from all requirements.
In summary, the first inspection of the allegations regarding NES l
4 activities was. incomplete.
The shortcoming.of the first.
allegation followup appears to have been caused by several.
factors:.(1) the perception on the part of_the inspectors that-the license was inactive and that the'use.of the-license (that at l
l least one inspector, and perhaps both the other. inspector and_the i
Section Chief, were aware _of) was not significant; (2) the-understanding of the inspection staff and supervisor that-
-l requirements do not apply in situations when a license is-
.j inactive; (3) the perception by the inspection staff and supervisor that the allegations did not involve safety 1
significant issues; (4) the apparent perception by some-of the 1
Region I staff that the alleger.was a disgruntled employee raising insignificant concerns; and (5) the heavy ~ work. load and j
pressure to complete work activities.
The shortcomings cf the first inspection may have been averted had higher level management involvement _ occurred in formal-inspection planning and review and approval of inspection-findings.
50 1
. 1
C.
Recom=endations Region I management should conduct a sampling review of previously closed allegation case files to determine if the inspections were sufficient to properly address the allegation.
Regional management should consider additional training and/or revisions to regional operating instructions that address the weaknesses in considering the perceived motivation of allegers when evaluating allegations and conducting allegation follow-up inspections.
The Allegation Panel should evaluate its role in the allegation inspection planning process considering its recently enhanced role in evaluating the results of allegation inspections.
If the Allegation Panel has certain expectations regarding the follow up of the allegation and will review the inspection results, it may be more efficient to have a formalized mechanism to provide detailed inspection direction.
This would ensure that panel expectations are net in the field inspection.
The review and approval for allegation followup activities should be at the Branch Chief or higher level of management.
2.6 Management Issues In reviewing =atters associated with the handling of NES allegations, the IRT included management issues within the scope of its review.
This inclusion was necessary to address, in proper full context, the charter activity which stated that "The report should discuss the level of Region I management involvement."
2.6.1 Former Attrition of DRSS Staff A.
State =ent of Issue Has loss of staff within DRSS and the NMS Branch, specifically, during the recent few years, impacted the materials program operation?
B.
Findings Current'ly, DRSS is staffed at or near its authorized staffing level of approximately 80 staff.
However, during the previous two years, attrition experienced by DRSS was heavy and unavoidably impacted the operation of the Division.
In late 1990 and early 1992, DRSS was recruiting to fill approximately 15 positions, many of which were in the NMS Branch.
While any direct link to the handling of NES allegations is difficult to identify, some of the impacts of heavy attrition could have contributed indirectly to the manner in which the inspection 51 4
1 9
l l
i follow-up of the NES allegations was initially conducted.
For l
example, the junior inspector on the first NES allegations-i follow-up inspection had worked for NRC for approximately six j
months.
There also appeared to be pressure'in the minds-of some j
staff to close out allegations quickly.in order to_ maintain l
" production."
The importance of the need to achieve Operating Plan goals was identified by a number of-staff members as. placing too much management emphasis on " production."
Exacerbated by the staff.
shortage in the 1990 timeframe, it became increasingly more i
difficult for DRSS to accomplish Operating Plan goals for materials licensing and-inspection.
Recruiting efforts became so-important that it was necessary to detail some existing staff to I
actively recruit new employees.on a full-time basis, further i
reducing the ability of DRSS in the short term to accomplish 1
operating Plan goals in the materials program and increasing the backlog of licensing actions'and inspections.
once new staff were hired, demands were placed on Section chief
- ~
and senior staff time' ir order to train the new employees, again, 1
in the short term impacting the ability of DRSS to complete licensing actions and inspections.
For example, in one Section i
i no license reviewers are yet qualified for Level II reviews and the Section Chief must review licensing actions completed by
[
[
unqualified reviewers.
Additionally, several. staff members i
indicated that because of the backlog of work.that existed, there
_[
was a perception of pressure to train and qualify new employees as expeditiously as possible in order to obtain productive work.
i t
one lingering impact.from-the previous attrition problem, although not major, continues to. affect DRSS.
With the. influx of new hires in the last few years, DRSS will of necessity have to j
place reliance on a significant number of license reviewers and inspectors that do not have many years of experience with the i
agency.
See Section 2.1 on Training and Qualification.
l C.
Recommendation a -
None.
1 2.6.2.
Workload of Staff and Supervisors A.
Statement of Issua j
i Has the. apparent very heavy workload of senior staff and
]
supervisors within the NMS Branch been a factor which in large t
-part determines the amount of management involvement in issues f
g and the extent of review of completed work products?
j i
52
- i
)
B.
Findings A common theme among senior materials staff, NMS Branch Section Chiefs, and the NMS Branch Chief is the fact that all made comments about the large volume of work.
In fact, on several occasions the term " triage" was used to describe the process that is used by members of the NMS Branch to establish work priorities.
This heavy volume of work necessitates delegation of authority to lower levels within the NMS Branch.
For example, licensing actions are completed by qualified staff with either no review or review only by a senior license reviewer.
Only exceptional licensing cases in terms of policy or difficulty are brought to the attention of the Section Chief or Branch Chief.
Involvement by the Division Director in licensing case issues is rare.
Another indicator of the heavy workload is the fact that 1
the Section Chiefs sign out most inspection report letters of transmittal, including followup inspections of allegations and
.high priority inspections, without Branch Chief review on most occasions.
The heavy workload and the need to complete the large number of licensing actions and inspections identified in the operating Plan was commented on by several interviewees.
The commenters, all at the non-supervisory level, believed that too much amphasis was being placed on " production."
They believed that
" production" was of primary importance to management and that this " production" emphasis was potentially harming the morale of some staffers.
C.
Recommendation Managament should consider conducting training sessions for the materials program staff that would address the balancing between the need to establish the reasonable assurance of safety and the need to meet operating plan goals.
A clear message that production is secondary to safety assurance could likely benefit some staff.
2.6.3 Organizational Effectiveness A.
Statenant of Issue Is the manner in which inspection and licensing responsibilities are assigned to Sections and staff members impacting the quality of work products and the efficiency of the NMS Branch operations?
B.
Findings i
The Region I materials program is unique when' compared to most other Regions in that NMS Branch Sections have responsibility for both licensing and inspection.
The Medical Inspection and i
53 j
i
Medical Licensing Sections in Region I, where those functions are separated, are the exception.
Nearly all insp2ction and licensing staff and Section Chiefs that were interviewed by the IRT indicated that the benefi'ts of having staff doing both inspection and licensing outweighed the costs of such an approach.
Benefits include the addition of a broader perspective to both the licensing and inspection work of staff members and the addition of work variety that appeared to positively impact morale.
One cost of such an approach is reduction in licensing casswork efficiency because of the interruption in some reviews that is necessitated by the need to perform inspections.
Other costs are the extended period of time spent in the training and qualification process by new employees, lack of geographical efficiency in utilization of inspector resources, and lack of flexibility due to technical specialization.
Additionally, the programmatic span of control that must be exercised by the Fiction Chief is increased by such an approach, making the Section Tief's job more difficult.
Because of the workload associated with medical licensing and inspection, Region I management decided to organize the two medical sections such that one section would specialize in licensing and the other would specialize in inspection.
The efficiencies gained by such an organizational move is resulting in an increased number of medical licensing actions and inspections.
In this specific program area, these efficiencies are thought to outweigh the primary cost of reducing the ongoing cross-fertilization process associated with the same staff members conducting both licensing reviews and inspections.
C.
Recommendation 1
i None.
2.6.4 Supervisor Span of Control A.
Statement of Issue i
i 4
Does the volume of work, the number of staff in the NMS Branch I
and in each section, and the responsibility for both licensing and inspection make the span of control that NMS Branch supervisors must exercise too broad?
B.
Findings Approximately three thousand materials licensees are currently in existence in Region I.
Each year, if fully staffed, about two thousand licensing actions and one thousand inspections would be completed.
In order to complete this large number of licensing and inspection actions, the national program takes advantage of a number of efficiencies.
One of the programmatic approaches that 54 l
yields efficiency is to assign independent, or nearly independent, authority for action at the lowest practical level and not require multiple levels of internal review.
At least in i
Region I, this
..s evidenced by the fact that letters transmitting materials inspection reports are signed out by the Section Chief and that licensing actions are signed out by the license reviewer.
This is appropriate for many materials licenses because of the limited potential for a serious safety problem.
i However, this approach contrasts markedly when compared to the multiple levels of review that occur for licensing and inspection of reactors, especially when a reactive inspection or other event of an unusual nature occurs.
In the materials program the volume of completed licensing and inspection actions may essentially preclude review or sign out at higher levels.
Arguments can also be ma(; that a benefit accrues when the individual co=pleting the work can call the work product his or her own and take pride in the acco=plishment.
An observation of the IRT is the size of the NMS Branch.
It currently contains approximately 46 employees and has five Sections, the largest of which has about nine employees.
With this size and the responsibility for both licensing and inspection, the Branch Chief is able to be personally involved only with issues that would be similar in importance to issues that a Division Director addresses in other NRC program areas.
Similarly, primarily because of demands to develop newer staff, and supervise both the licensing and inspection (both routine and reactive) programs, Section Chiefs in the NMS Branch also do not perform the same detdiled level of review of products that occurs in other NRC program areas.
C.
Recommendations i
Region I management should consider whether the size of some materials program Sections and the Nuclear Materials Safety Branch is so large as to preclude an effective span of control, given the breadth of responsibility that is assigned.
Region I r.anagement should continue its evaluation of the need to split the Nuclear Materials Safety Branch into two smaller branches.
2.6.5 Management Involvement A.
Statement of Issue The Charter of the IRT identified as one of the team activities the need for the report to discuss the level of Region I management involvement.
)
j B.
Findings As discussed throughout this report, the involvement of Region I j
management, above the Section Chief level, with the first j
i 55
}
I
~
inspection-followup on the NES allegations.was in accordance with regional and NRC procedures.- However, with the exception of the direction from Allegations Review Panels, which were composedtof managers as high as the Division Director' level,: management ^above
- the Section chief had-no involvement with the first inspection of NES.
It was not until letters from Senator Lieberman were.
received that attention from management began to focus on the-allegations from Mr. Gunderson.
Management, including the.
Division Director, was involved with the planning for-the second inspection of the allegations conducted fron January to. June, 1992.
The Regional Administrator and headquarters office managers were involved in resolving the issues that surfaced fron-the second inspection.
Region I manat rs initiated.a number of actions to address concerns that were associated with the original inspection of the NES allegations. -One of'the most~important initiatives was to seek Headquarters guidance on the handling of: issues surfacing from the inspections of NES.
Another important. initiative was to conduct lessons-learned training for.all DRSSfmaterials program staff.
Additionally, the current evaluation of the need;to split the NMS Branch into two smaller Branches, in order to lessen the span of control that the Branch Chief must exercise, could. lead to additional supervisory involvement in planning for inspections of allegations and review of inspection findings.
C.
Recommendation None.
e W
O g
56
3 CONCLUSIONS The IRT charter identified five specific activities for the team to undertake.
Each activity and the team's determination follow.
1.
Determine whether the first inspection or second inspection interpretations of NES' license conditions are correct.
IRT Determination:
The correctness of interpretation of license conditions was not a critical question to the handling of the NES allegations, though certainly the intent of licence condition 16 is not clear.
The differing results of the two inspections are better explained on the grounds of the distinction drawn between active and inactive licenses.
The guid.nce related to requirements that are applicable when a license is inactive was received from NMSS, OGC, and the Office of Enforcement (OE) in March 1992.
This followed the second field inspection and was prior to the finalization of the second report.
This guidance was not in existence at the time of the first inspection of NES allegations; the lack of guidance may have contributed to the erroneous conclusion in the first NES inspection report that the license was inactive and no requirements were in effect.
The IRT supports the second inspection's handling of the NES inspection findings.
Questions were identified by the IRT, however, that indicate regulatory uncertainty exists about whether license requirements are applicable to exempt quantities of radioactive material possessed by licensees.
2.
Determine if the problem with the NES license is a function of the clarity of the license condition.
IRT Determination:
The lack of clarity associated with license condition 16 is certainly a problem in determining when, and if, the license'is invoked, or indeed if it can be invoked.
Though this lack of clarity was not instrumental to Region I's handling of the NES allegations, the IRT recommends that the NES license be revised to make it clear under what circumstances NES will be considered as conducting activities under its own license and what is the allowable scope of those activities.
3.
Determine if changes may be needed for such licenses on a generic basis.
IRT Determination:
There is a small number of licenses l
throughout the country with license conditions similar to license condition 16 in the NES license.
Because of the uncertainty about whether a licensee is or is not conducting activities under the authority of its license, the IRT I
57 I
e recommends that all licenses with such a condition be reviewed and revised as necessary to assure clarity.
4.
Determine if the inspection guidance needs revis' ion.
IRT Determination:
The IRT determined that the need for some revision and development of inspection guidance exists.
The IRT recommends that guidance be developed on:
- 1) deferral of inspections for inactive licenses; 2) inspection of satellite facilities, field offices, and temporary job sites; and 3) emphasizing review of inspection techniques during National Program Review inspector accompaniments.
The IRT also recommends that the Region I program for followup inspar tions of allegations could benefit from more detailed and formal inspection planning.
5.
Make a report with recommendations to the Director, NMSS.
The report should discuss the level of Region I management involvement.
IRT Action:
This report completes 'that activity described in the charter.
Section 2.6.5 describes the small amount of management involvement la the first inspection of the NES allegations and the heavy involvement in the second inspection.
Other parts of Section 2.6 describe Region I management actions to strengthen the materials licensing and inspection program.
Management involvement in other aspects of materials program implementation is also addressed in the report.
The few IRT recommendations in the management area support initiatives that are for the most part already underway within Region I.
The exception is the IRT recommendation to conduct training to assure the materials program staff that " production" to meet operating plan goals is secondary to the determination of reasonable assurance of safe licensee operations.
i The root cause determination of the apparent problems with the
~
handling of the NES allegations during the first inspection was a fundamental activity of the IRT.
A number of factors could have contributed to the method of handling allegations during first inspection.
They are listed as follows:
Since the license was viewed by the inspectors and Section Chief as not being " active," the Section Chief concluded that regulatory requirements did not apply.
No materials program guidance existed that could have provided direction for the Section Chief in making the determination.
Once the determination was made that no license or rule requirements were applicable in the case of a license that had not been used, no further inspection was necessary.
n.
O.
[
f t
While the junior inspector apparently knew'of the e
correspondence in the docket file indicating that work-l under the license had been performed on'two occasions, it is not apparent-that information was brought to.the attention of the lead inspector or the Section Chief.
i While the lead inspector.does not clearly recollect being e
aware of correspondence in the docket file indicating
~i operations had been conducted under.the license, it is clear l
that a thorough review of the rather voluminous docket file should have identified such correspondence.
l s
Circumstantially, it appears that use of the license by NES on one or two occasions was not viewed by the regional staff as i
being of such significant consequence se to." activate" the license.
This IRT contention _is supported by the fact that i
during the inspection there was apparently some discussion j
vith the NES President about the use of the license at an i
A. D. Little project.
Given that erroneous conclusion by the f
Section Chief, the decision that license requirements did not apply to NES was not inconsistent with guidance related to-initial inspection deferral and conduct of inspections when-i radioactive material has been transferred.
The Section Chief's conclusion was also consistent with NRC policies
~
specifying that service work performed by contractors for.
licensees be conducted under the licensee's license.
J Turther attempts to independently confirm the statements e
1 provided by the NES President, such as a request for Region III to inspect the NES activity at the Cheaetron site in Ohio, could have led to the discovery that the NES license-had been in use.
The alleger could have been viewed by some as a disgruntled former NES employee whose allegations were motivated by i
reasons other than concerns for safety.
Since-some allegation i
panels appear to factor in credibility and reliability of-the-i alleger,.the notential for safety significance could have been.
discounted by the-panel, the Section_ Chief, or the inspectors.
3 The perception by the inspection staff and supervisor _that the-I allegations did not involve safety significant issues.
I The heavy workload and pressure to complete work activities.
l e
Little management involvement-in the first inspection.
j e
The IRT identified some areas that could be' considered for..
~{
further strengthening of the materials licensing andLinspection j
program, both at the national and regional implementation levels.
+
See Attachment 2, Recommendations.
However,-the overall I
conclusion of the IRT is that the materials licensing and.
}
l 4
59 i
I l
i
?
s' inspection program of the NRC, both nationally and Region I's imple=entation thereof, is sound and provides a reasonable assurance of safety of licensed operations.
After independent review, the IRT concludes that the apparent problems with Region I's handling of the NES allegations during the first i
inspection did not result from any significant national or Region I materials program weaknesses.
A number of potential contributing factors were identified.
The NES inspection in 1990 did not identJfy the violations cited as a result of the 1992 NES inspection.
Tne cause for this difference lies not in the fact that the Section Chief and inspectors rel.ied too heavily on the statement from NES manageseht during the inspection, but rather on:
(1) a lack of clear NRC policy on what requirements are "in force" during periods of time that a license is " inactive;" (2) the failure of involved personnel to appreciate tlat the infrequent, short duration use of licensed materials required continuing implementation of the license requirements; and (3) t the lack of any complex or safety significant activities conducted under the license.
The information obtained by the IRT as a result of its rev.'ew indL;ated that the inspectors involved l
in the first NES inspection obtained information about the use of the NES license from
- variety of sources (docket file, licensee management statement and records review).
The conclusion in the first inspection report was that the license was not " active."
In hindsight, this conclusion was erroneous and was likely the result of informal decision-making by the inspectors and Section Chief.
With regard to the majority of the work conducted by NES, however, this conclusion is consistent with longstanding NRC policy that contractors performing activities for a licensee do so under the auspices of the licensee's license.
In addition, this decision with regard to A. D.
Little appears to bave resulted from their belief that the license had only been rsed this one time in the past for a very short duration, the ust (transportation) was incidental to the primary purpose for which the license was issued, the lack of programmatic or regional guidance addressing such an issue, and the lack of significant safety concerns.
All Region I staff interviewed by the IRT indicated a complete understanding of appropriate inspection techniques and the importance of using c variety of techniques to obtain and corroborate information.
No general practice of over-reliance on licensee statements apparent in the Region I materials inspection program, based on information from those interviewed.
60
.7
~ ATTACHMENT 1-
).
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i CHARTER INDEPENDENT REVIEW TEAM j
purpose:
Conduct'an independent review of the NES 11cer.se conditionf, inspections performed, and the Region I responsiveness to l
issues raised by.
regarding Nuclear i
Eners) services (NES).
Team Composition: R. Bangart, Team Leader i
Dous Collins, RI!
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- J. Crobe, Region !!!
Robert Fonner DGC Steve Ruffin - ED0 Staff i
3 Resource Support: The team may be expanded or acquire resources as nonssary to meet the schedule.
f Team Activities:
1.
Determine whether the first inspection er.second I
inspection interpretations of NE5' license conditions are correct.
2.
Determine if the probles with the NE$ license is a i
function of the clarity of the license condition.
3.
Determine if changes may be needed for such licenses i
on a generic basis.
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Determine if the' inspection guidance needs revision.
4.
5.
Make a report with recossendstions to the Director, 1
T NMSS. The report should discuss the level of Region I management involvement.
6.
The Director,16455, should advise the DEDS and ED0 of-changes (including schedule), and final i
recommendations. The DEDS will keep the IG informed i
and will arrange to brief the IG of significant information.
Priority:
This team assignment takes precedence over other assigned responsibilities.
Timing:
Tasks 1-5 should be completed by Detober 1,1992._
Conr'ete task 6 by November.1, 1992.
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Tcska 1 - 5 ED0 9200176/10tss 9200466 Du setss - 9/2s/92 Da EDO = 10/01/92 f.
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i vffp Tak 6 Approved:
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I ED0 9200176/10tss 9200467 8/12/g2 De ty Executive i to for
'Due setss = 10/28/92 Nuclear Materials,
- sty, Da EDO = 11/02/92 Safeguards, and Dperations.
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i ATTACHMENT 2 INDEPENDENT REVIEW TEAM RECOMMENDATIONS t
2.1 TRAINING AND QUALIFICATION 2.1.1 National Program for Materials License Reviewers Qualifications Board reviews should be considered-for' license reviewers.
2.1.2 Region I Implementation for Materials License Reviewers NRC has had difficulty in hiring experienced, well qualified l
health physicists.
Efforts to " grow our own"' health physicists through'the Intern and Graduate Fellow Programs have beenf established in part to address the problem.of staffing health-physicist positions.
After obtaining advanced degress'in health physics, NRC should consider initially assigning, Graduate Fellows.
to a regional office to obtain practical experience.
2.1.3 National Program for Materials Inspectors-Consideration should be given to~ conducting the Fundamentals of'
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Inspection and other NRC courses in a manner similar to:the HP-1 Technology course, with separate-examples / case studies related to-i materials licensees-for materials inspectors.
2.1.4 Region I Implementation'for Materials Inspectors Lessons learned-training conducted for.the DRSS staff afterLthe NES inspections should also be performed for other Region I staff involved in reviews of allegations.
Other Regions should also:
consider whether conducting similar training' sessions.would be beneficial.
The Region I Ma'terials-Health Physicist Qualification Journal should be updated to reflect the single level-qualification process now in use in Region I and to reference current documents.
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2.2 INSPECTION PROGRAM 2.2.1 National Program Formal guidance should be developed regarding deferral of inspections that addresses the number.of times inspections can be
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deferred, and actions to be taken (such as conditioning ~the.
license to require region approval prior to recommencement of licensed activities) if the license is not used or is-only_used-infrequently.
Formal guidance should be developed regarding the inspection of-satellite facilities, field offices and temporary job sites in-the host and other Regions where there are such activities.-
2.2.2 Region I Implementation See Recommendations in Section 2.5, Allegation Management, that' apply to Region I inspections.
2.3 LICENSING PROGRAM 2.3.1 National Program Guidance should be.provided to the regions'and licensees on the acceptability of the use of licenses as evidence of credentials.-
Guidance should be provided regarding methods to be used in
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licensing of infrequent activities,.for example, conditioning such licenses to require notification of the NRC of activities 30 days prior to license activation and/or requiring NRC review ~and acceptance of proposed activities; Guidance should be considered addressing the benefits of calling new licensees to review unique license conditions prior to license issuance.
Guidance addressing the extent to whL:h standard license conditions can be modified should be considered.
Technical Assistance Requests should be incorporated into an agency-wide system that.will allow access and use for future similar licensing actions, like the NRR Health Physics Position system.
Guidance should be considered that identifies the required level-of review and approval necessary for modification of standard license conditions and use of unique license conditions.
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,s 2.3.2 Region I Implementation None 2.3.3 Region I Implementation in the NES Case
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See Section 2.4.4.C.
2.4 RULES, REGULATIONS, AND LICENSI CONDITIONS-t 1
2.4.1 Application of Regulations:
Develop program and policy guidance for the licensing and inspection staff that will establish:the set of regulatory.
requirements to be included in a license that an inactive licensee must follow in order to maintain the license.
The-set of requirements should be such as to provide reasonable assurance that the licensee _ remains-competent to' receive and use material-and undertake other permitted activities.
For the long term,-
consideration should be given to addressing the. issue offinactive licenses in the codified regulations.
Licensees should be informed by Information Notice of..the requirements that are applicable even though a license is inactive.
2.4.2 10 CFR Part 19 Prepare an Information Notice for natifials licensees reminding them of the requirement to keep their licenses and other notices required by Part 19 posted at all times and in all locations 4
where license-related activities occur.
Formalize materials program guidance on'this matter.
2.4.3 Exempt Seuroes OGC, in conjunction with the NMSS' staff, should review the j
applicable regulations in depth and provide a legal analysis'on a licensee's responsibilities with respect to sources that seat the requirements of 10 CFR 30.18.
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2.4.4 NES License Conditions The NES license, and other licenses like it, should be reviewed I
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and revised as'necessary to make it clear.under what circumstances the licensee will be considered as conducting activities under its own license and what is the allowable scope:
.i of those activities.
j 2.5 ALLEGATION MANAGEMENT i
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2.5.1 Management Involvement - Planning The NRC should continue its policy that all allegations should be
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resolved and resolution documented..
The NRCishould not' adopt a.
1 policy that specific allegations would not be inspected due to an
.l initial assessment that it would be unlikely that an: inspection-l would result in the identification of a significant health and safety issue.
There have been allegations.that began innocuously.
1 and resulted in very significant issues after review by the NRC.
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The Region I allegation file ~ maintenance practices.should be
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reviewed to assure that all. documents relevant to the allegation-are properly filed and cannot be inadvertently displaced from the l
file.
In addition, Region I should consider having a file-document list or inventory to assure that all documents'are known.
Any changes to filing practices should be incorporated' l
into a revision of.ROI 1210.1.
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l MD 8.8 should be revised to require written inspection plans for allegation follow up that.are reviewed by nanagement..This would t
increase the assurance that-issues would be' addressed-and persons would be contacted to address the allegation.
Regional i
procedures should address the unique-aspects of allegation i
inspection planning and the expectations-for formalized i
preparation and review of inspection ~ plans.
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Region I abould conduct training for regional staff and management to assure that the. evaluation of anEallegation'is not
.j influenced by individual NRC employee perceptions of what may be j
an alleger's motivation to-bring the issue' forward, but only on i
the merits of the issue.
e Senior Allegation Coordinator contacts with the alleger should include an appropriate technical staff member, when~the j
allegation involves issues outside of the SAC's. area'of.
1 expertise.
This practice should be reflected-in a revision to
.j ROI 1210.1.
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~l The'NES allegation files should be reviewed to assure the files l
contain all relevant information and to verify that documents are correctly filed.
2.5.2 Kanagement' Involvement - Issue Resolution' Region-I management should conduct a sampling review of-I previcusly closed allegation case files to determine if the inspections were sufficient to properly address tho' allegation.
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Regional management should consider additional training and/or revisions to regional operating instructions that address the 1
vaaknesses in considering the perceived motivation of allegers i
when evaluating allegations and conducting allegation follow-up j
inspections.
The Allegation Panel should evaluate its role in!the allegation inspection planning process considering its recently enhanced role in evaluating the results of allegation inspections.
If.the-1 Allegation Panel has certain expectations regarding~the' follow up of the-allegation and will review the. inspection'results, it may be more efficient to have a formalized mechanism to provide-detailed inspection direction.
This would ensure that panel expectations are met in the field inspection.
The review and approval'for allegation followup' activities should be at the Branch Chief or higher level of management.
2.5 MANAGEMENT ISSETES 2.6.1 Former Attrition of DESS Staff None 2.6.4. Werkload of Staff and Supervisors Management should consider conducting training-sessions for the materials program staff that would address the balancing between the need to establish the reasonable assurance'of safety and'the need to meet operating plan goals.
A clear message that production is secondary to safety assurance could likely benefit some staff.
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,o 2.6.3 organisational Effectiveness None 2.5.4 supervisor span of control Region I management should consider whether the size of some materials program Sections and the Nuclear Materials Safety Branch
.s so large as to preclude an effective span of control, given the breadth of responsibility that is assigned.
Region I management should continue its evaluation of the need to split the Nuclear Materials Safety Branch into two smaller branches.
2.5.5 Management Involvement None i
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2.s.3 organisational Effectiveness None 2.5.4 supervisor span of control Region I management should consider whether the size of some materials program Sections and the Nuclear Materials Safety Branch.s so large as to preclude an effective span of control, given the breadth of responsibility that is assigned.. Region I management should continue its evaluation of the need to split the Nuclear Materials' Safety Branch into two smaller branches.
2.5.5 Management Involvement None 6
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