September 20, 2005

Ms. Derrith Watchman-Moore

Deputy Secretary 

New Mexico Environment Department

1190 St Francis Drive, Suite N4050

P.O. Box 26110

Santa Fe, NM 87502 

Ms. Watchman-Moore:

On August 25, 2005, the Management Review Board (MRB) met to consider the proposed final

Integrated Materials Performance Evaluation Program (IMPEP) report on the New Mexico

Agreement State Program. The MRB found the New Mexico program adequate to protect

public health and safety and compatible with the U.S. Nuclear Regulatory Commission’s (NRC)

program.

Section 5.0, page 11, of the enclosed final report presents the IMPEP team’s recommendations

for the State of New Mexico. Your August 9, 2005, letter on the proposed final report contained

responses to these recommendations. After review, we conclude the actions taken by the

program adequately address the IMPEP recommendations and no further response is

requested at this time. During the biannual NRC periodic meetings with your staff and at the

next IMPEP review in 2009, we will evaluate the effectiveness of these actions as well as the

implementation of your overall program. We thank you for your prompt action in response to

the recommendations.

Based on the results of the current IMPEP review, the next full review will be in approximately

four years. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. 

I also wish to acknowledge your continued support for the Radiation Control Program and the

excellence in program administration demonstrated by your staff, as reflected in the team’s

findings. I look forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA B. Mallet Acting For/

Martin J. Virgilio

Deputy Executive Director for Materials, Research, 

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure: As stated

cc: See next page
D. Watchman-Moore - 2 -

cc: Ana Marie Ortiz, Director 

Field Operations Division

John Parker, Bureau Chief 

Radiation Control Bureau

Edgar Bailey, CA

OAS Liaison to the MRB 
September 20, 2005

Ms. Derrith Watchman-Moore

Deputy Secretary 

New Mexico Environment Department

1190 St Francis Drive, Suite N4050

P.O. Box 26110

Santa Fe, NM 87502 

Ms. Watchman-Moore:

On August 25, 2005, the Management Review Board (MRB) met to consider the proposed final

Integrated Materials Performance Evaluation Program (IMPEP) report on the New Mexico

Agreement State Program. The MRB found the New Mexico program adequate to protect

public health and safety and compatible with the U.S. Nuclear Regulatory Commission’s (NRC)

program.

Section 5.0, page 11, of the enclosed final report presents the IMPEP team’s recommendations

for the State of New Mexico. Your August 9, 2005, letter on the proposed final report contained

responses to these recommendations. After review, we conclude the actions taken by the

program adequately address the IMPEP recommendations and no further response is

requested at this time. During the biannual NRC periodic meetings with your staff and at the

next IMPEP review in 2009, we will evaluate the effectiveness of these actions as well as the

implementation of your overall program. We thank you for your prompt action in response to

the recommendations.

Based on the results of the current IMPEP review, the next full review will be in approximately

four years. 

I appreciate the courtesy and cooperation extended to the IMPEP team during the review. 

I also wish to acknowledge your continued support for the Radiation Control Program and the

excellence in program administration demonstrated by your staff, as reflected in the team’s

findings. I look forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA B. Mallet Acting For/

Martin J. Virgilio

Deputy Executive Director for Materials, Research, 

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure: As stated

cc: See Next page

DCD (SP01) SISP Review Complete

 : Publicly Available G Non-Publicly Available 

: Non-Sensitive G Sensitive

Distribution: See next page

DOCUMENT NAME:E:\Filenet\ML052590227.wpd

To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy with attachment/enclosure "N" = No copy

OFFICE STP STP:DD STP:D DEDMRS

NAME JGZabko:gd DKRathbun PHLohaus MVirgilio

DATE 09/13/05 09/14/05 09/15/05 09/20/05

OFFICIAL RECORD COPY

ML052590223
D. Watchman-Moore - 3 -

cc: Ana Marie Ortiz, Director 

Field Operations Division

John Parker, Bureau Chief 

Radiation Control Bureau

Edgar Bailey, CA

OAS Liaison to the MRB 

Distribution:

DIR RF

LMcLean, RIV

CMaier, RIV

JHarris, Kansas

CMaupin, ASPO

Osiurano, STP

JTobin, STP

CMiller, IMNS/NMSS

RStruckmeyer, IMNS/NMSS

STreby, OGC

FCameron, OGC

TCombs, OCA (2)

HFelsher, OEDO

Chairman Diaz

Commissioner Merrifield

Commissioner Jaczko

Commissioner Lyons
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF THE NEW MEXICO AGREEMENT STATE PROGRAM

June 6 - 10, 2005

 Final Report

U.S. Nuclear Regulatory Commission
New Mexico Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the New Mexico radiation control program. The

review was conducted during the period of June 6 -10, 2005, by a review team comprised of

technical staff members from the U.S. Nuclear Regulatory Commission (NRC) and the State of

Kansas. Team members are identified in Appendix A. The review was conducted in

accordance with the "Implementation of the Integrated Materials Performance Evaluation

Program and Rescission of a Final General Statement of Policy," published in the Federal

Register on October 16, 1997, and the February 26, 2004, NRC Management Directive (MD) 

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

the review, which covered the period June 22, 2001 to June 10, 2005, were discussed with New

Mexico management on June 10, 2005.

A draft of this report was issued to New Mexico for factual comment on July 8, 2005. The State

responded by Email from Walter Medina on August 9, 2005. The Management Review Board

(MRB) met on August 25, 2005 to consider the proposed final report. The MRB found the New

Mexico radiation control program adequate to protect public health and safety and compatible

with NRC's program.

The New Mexico Agreement State Program is administered by the Radiation Control Bureau

(the Bureau) in the Field Operations Division (the Division) of the New Mexico Environment

Department (the Department). The day-to-day operations are carried out by the Radiation

Protection Program (the Program) which is headed by the Program Manager, who reports to

the Bureau Chief. Organization charts for the Department and the Bureau are included as

Appendix B. 

At the time of the review, the New Mexico Agreement State Program regulated approximately

194 specific licenses authorizing Agreement materials. The review focused on the materials

program as it is carried out under the Section 274b. (of the Atomic Energy Act of 1954, as

amended) Agreement between the NRC and the State of New Mexico. 

In preparation for the review, a questionnaire addressing the common and non-common

performance indicators was sent to the Program on March 23, 2005. The Program provided a

response to the questionnaire on May 23, 2005. A copy of the State’s questionnaire response

can be found in ADAMS using the Accession Number ML051530206.

The review team's general approach for conduct of this review consisted of: (1) examination of

the Program's response to the questionnaire; (2) review of applicable New Mexico statutes and

regulations; (3) analysis of quantitative information from the Program licensing and inspection

data base; (4) technical review of selected licensing and inspection actions; (5) field

accompaniments of three Program inspectors; and (6) interviews with staff and management to

answer questions or clarify issues. The team evaluated the information that it gathered against

the IMPEP performance criteria for each common and non-common performance indicator and

made a preliminary assessment of the Program’s performance.

Section 2 below discusses the Program's actions in response to recommendations made

following the previous review. Results of the current review for the IMPEP common

performance indicators are presented in Section 3. Section 4 discusses results of the
New Mexico Final Report Page 2

applicable non-common performance indicators, and Section 5 summarizes the review team's

findings. Recommendations made by the review team are comments that relate directly to

performance by the Program. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on June 18-22, 2001, one

recommendation was made and transmitted to Mr. Mike Koranda, Director, Field Operations

Division, New Mexico Environment Department, on September 26, 2001. The team’s review of

the current status of this recommendation is as follows:

(1) The team recommended that the State adopt the regulations, or other legally binding

requirements, which are overdue for adoption. 

Current Status: The Program has adopted all the regulations needed for adequacy and

compatibility that were due during this review period. The current status of the

Program’s regulations is further discussed in Section 4.1. The team recommends that

this recommendation be closed.

3.0 COMMON PERFORMANCE INDICATORS

IMPEP identifies five common performance indicators to be used in reviewing both NRC

Regional and Agreement State programs. These indicators are: (1) Technical Staffing and

Training, (2) Status of Materials Inspection Program, (3) Technical Quality of Inspections,

(4) Technical Quality of Licensing Actions, and (5) Technical Quality of Incident and Allegation

Activities. 

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Program’s staffing level and staff

turnover, as well as the technical qualifications and training histories of the staff. To evaluate

these issues, the review team examined the Program's questionnaire responses, interviewed

Program management and staff, reviewed job descriptions, training plans, and training records. 

The review team also considered any possible workload backlogs in evaluating this indicator. 

The Program is authorized for eight positions. These positions include one Program Manager

and seven Environmental Specialists. All technical staff positions require a bachelor’s degree

in one of the sciences. Positions are classified as either Environmental Specialists, requiring

four years experience, or as Environmental Scientists, requiring two years experience. Based

on experience and training, staff are categorized as Basic, Operational or Advanced

Environmental Specialists. Currently the Program staff is made up of all Environmental

Specialists consisting of four Advanced, and three Operational qualified Environmental

Specialists. There is currently one vacant staff position. Of the six Environmental Specialists

working in the Program, one has 15 years experience with the program, one has eight years

experience, three have 1-2 years experience and there is one new staff member who has

worked in the Program for one month. With the exception of the one new staff, all of the

Environmental Specialists have 25-30 years of experience in operational radiation safety and
New Mexico Final Report Page 3

health physics. The Program Manager worked for the Program as an Environmental Specialist

for eleven years before being promoted to the position in January 2005.

The staff is responsible for both the radioactive materials and the x-ray regulatory programs. 

Approximately 50 percent of each staff’s time is allocated to the radioactive materials area. All

staff perform duties in inspection and event response with one staff member assigned primarily

to licensing. Another staff member is being trained as a back-up for the licensing position. The

inspection work load is split among four staff with the new member assisting as part of a staff

on-the-job training program. 

Three staff members left during the review period, and two of the positions were filled. The

Program has authority to fill the remaining vacancy. At the time of the review, a notice to post

the position was being developed, and the Program Manager expected the position to be filled

in the near future. The Program staff has increased by two positions since the 2001 IMPEP. 

The Program Manager indicated that the Program plans to increase the staff by one to two

positions in the future. Due to the adoption of a revised fee rule in 2002, the Program has

dedicated funds to be used in areas such as hiring and staff training. 

Prior to the establishment of the dedicated fund in 2002, there was limited opportunity for

Program staff to attend NRC training courses. Due to the availability of funds resulting from the

fee rule, the Program Manager indicated that staff has started, and will continue to attend NRC

training courses. With the exception of the newest member of the staff, all of the Program’s

inspectors have attended the NRC’s licensing practices and procedures and the NRC’s

Inspection procedures courses or have had equivalent training. The team discussed with the

Program Manager the use of alternate training methods, in addition to the NRC courses, to

meet the needs of the Program. These alternate methods included the use of the Program’s

two senior inspectors to mentor the junior inspectors (using on-the-job training) and attending

training being offered in-State by vendors and local colleges. Even though the inspection staff

has many years of health physics experience, four of the six inspectors have less than two

years experience in the type of radioactive materials licensees that the program regulates (e.g.,

radiography, well logging and complex medical). The Program Manager indicated that they

would consider these alternatives as a solution to the meet the short term staff training needs.

The Program has a documented training and qualification program, “Radioactive Materials

Licensing and Inspection Qualification Procedure, Version 2, June 3, 1999.” This procedure is

comparable to NRC’s Inspection Manual Chapter (MC) 1246, “Formal Qualification Programs in

the Nuclear Material Safety and Safeguards Program Area.” The team reviewed the

qualification journals that the Program uses for the staff. The review team found that the staff

are well qualified, with two senior staff being fully qualified and the rest of the staff working

toward full qualification. 

The Program receives advice and direction from two advisory panels, the Radiation Technical

Advisory Council (the Council) and the Environmental Improvement Board (the Board). The

Council members are required to have scientific or medical backgrounds, and they may be

authorized users on radioactive materials licenses. Currently, there are no radioactive materials

licensees serving on the Council or the Board. To avoid any conflicts of interest, the Program

plans to maintain the membership of advisory panels free of licensees. 
New Mexico Final Report Page 4

Based on the IMPEP evaluation criteria, the review team recommended and the MRB

concurred, that New Mexico's performance with respect to the indicator, Technical Staffing and

Training, be found satisfactory.

3.2 Status of Materials Inspection Program

The team focused on four factors in reviewing this indicator: inspection frequency, overdue

inspections, initial inspections of new licenses, and timely dispatch of inspection findings to

licensees. The evaluation is based on the Program’s questionnaire responses relative to this

indicator, data gathered independently from the Program’s licensing and inspection data

tracking system, the examination of completed licensing and inspection casework, and

interviews with Program Manager and staff.

The review of the Program’s inspection priority policy verified that the New Mexico inspection

frequencies for various types or groups of licenses are as frequent as, or more frequent than,

similar license types or groups listed in NRC MC 2800. The Program requires more frequent

inspections as described in the following license categories: wireline (well logging) services are

inspected at two-year intervals compared to NRC’s three year intervals; all broad scope

licenses are inspected at two-year intervals compared to NRC’s three-year intervals for type A

broad academic licenses and five-year intervals for type B and type C broad academic licenses;

self shielded irradiators greater than 10,000 curies are inspected at one-year intervals and self

shielded irradiators less than or equal to 10,000 curies are inspected at two-year intervals as

compared to NRC’s five-year intervals for all self shielded irradiators; medical licenses

authorized for therapy are inspected at one-year intervals compared to NRC’s three-year

intervals; and portable gauges are inspected at two-year intervals compared to NRC’s five-year

intervals.

The Program’s inspection priority policy for decommissioning and reclamation service licenses

also differs from that listed in NRC MC 2800. The Program requires that this type of license be

inspected at two-year intervals compared to NRC’s requirement that inspections be scheduled

at times when the licensee is performing decommissioning activities, as determined under NRC

MC 2602, “Decommissioning Inspection Program.” The review team determined that, for the

review period, the difference in inspection frequencies for this type of license was not an issue

because of the limited scope of materials decommissioning activities conducted.

During the review period, 180 priority 1, 2, and 3 inspections were conducted; and 44 initial

inspections were conducted. With two exceptions, all the initial inspections were conducted

within 12 months of the date each new license was issued. These two overdue inspections

were discussed with the Program Manager and he committed to conduct inspections of these

licensees as soon as possible.

In the questionnaire, the Program indicated that three inspections were overdue by more than

25 percent of the inspection interval. However, because the Program’s inspection intervals are

generally more frequent than those in NRC MC 2800, the review team found that only one

inspection was overdue in accordance with the NRC inspection criteria; and that this inspection

was not listed on the response to the IMPEP questionnaire provided by the Program. This was

verified during the inspection casework reviews, and review of the Program's Registration and

Licensing database. 
New Mexico Final Report Page 5

The team reviewed 16 inspection files and found that the Program dispatches inspection

findings to the licensees within 5 to 10 days after the inspection. 

In the questionnaire, the Program reported receiving 160 requests for reciprocity during the

review period, of which 142 were from licensees with priorities 1, 2 and 3. The Program

conducted 49 inspections, or 35 percent, of the “candidate” reciprocity licensees, which

exceeds the NRC MC 1220 goal for reciprocity inspections.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB

concurred, that New Mexico’s performance with respect to the indicator, Status of the Materials

Inspection Program, be found satisfactory.

3.3 Technical Quality of Inspections

The team evaluated inspection reports, enforcement documentation, and interviewed inspectors

associated with 16 radioactive materials inspections conducted during the review period. The

casework included work performed by all of the Program’s materials license inspectors, and

covered a variety of license types including: academic broad; medical (broad scope and

institutional); nuclear pharmacy; industrial radiography; pool irradiator; wireline services; and

research and development. Appendix C lists the inspection casework reviewed for

completeness and adequacy with case-specific comments, as well as the results of the

inspection accompaniments.

Based on the casework reviewed, the review team noted that the routine inspections covered all

aspects of the licensees’ radiation programs. The review team found that inspection reports

were very thorough, complete, consistent, and of high quality, with sufficient documentation to

ensure that the licensee’s performance with respect to health and safety was acceptable. 

Generally, the documentation supported violations and unresolved safety issues. During the

review, the team found that some of the files were misfiled and had missing documentation,

(e.g., response letters from the licensees). These files are listed in Appendix C. The team

mentioned these files with missing documentation to the Program Manager and these files were

corrected.

The Program uses team inspections for larger and complex licensees as well as for training

purposes. Inspection reports are in a format that covers all inspection areas for each inspection

type. Inspectors consistently document their observation of licensed activities and the results of

confirmatory measurements. Completed inspection reports were signed by either the Program

Manager or the Bureau Chief. Supervisory accompaniments are being conducted annually for

all inspectors. 

Licensees are required to respond to all Notices of Violations (NOV). All inspection findings are

documented in the report, and reviewed by the Program Manager before being sent to the

licensee with the letter detailing the results of the inspection.

The team found one occurrence where an initial inspection was conducted in 1997, and at that

time the inspector was told by the licensee’s radiation safety officer that no licensed material

was on site. Future attempts to inspect the licensee were unsuccessful, and no other

inspections were conducted by the Program. However, in 2000 and again in 2005, the same
New Mexico Final Report Page 6

licensee requested license renewals and requested to increase the possession limits on the

license. NRC MC 2800 requires that initial inspections be completed within 12 months of the

date the new license to determine if licensed material has been possessed or licensed

operations have been performed. If it is determined that the licensee has not possessed

licensed material or performed licensed operations, the Program should schedule the next

inspection within one year. This issue was discussed with management, and they indicated that

they would put the inspection of this licensee at a higher priority. 

The Program has adequate numbers and types of radiation survey instruments to support their

efforts. The review included a check of survey instruments and equipment monitoring,

including calibration frequency and repairs. The Program’s instruments include G-M meters,

scintillation detectors, ion chambers, micro-R meters, and neutron meters. The review found

that many of the instruments are not calibrated and are out-of-service, and that the instruments

were not labeled as such. The instruments were kept in the same location as the calibrated

instruments. This issue was discussed with Program management who stated that the out-ofservice, uncalibrated instruments would be segregated and labeled appropriately. The Program

contracts for instrument calibration and repair with authorized calibration and repair companies. 

Contamination wipes are sent to the State’s Scientific Laboratory Division for analysis. 

Three Program inspectors were accompanied during inspections by a review team member

during the week of May 9 -13, 2005. Inspection accompaniments included two medical

institutions and a nuclear pharmacy. These accompaniments are identified in Appendix C. 

During the accompaniments, each inspector demonstrated appropriate performance based

inspection techniques and knowledge of the regulations. The inspectors were trained,

prepared, and thorough in their audits of the licensees radiation safety program. Interviews with

licensee personnel were performed in an effective manner, and the inspections were adequate

to assess radiological health and safety at the licensed facilities. Overall, each inspector

utilized good health physics practices. 

Based on the IMPEP evaluation criteria, the review team recommended and the MRB

concurred, that New Mexico’s performance with respect to the indicator, Technical Quality of

Inspections, be found satisfactory. 

3.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed the staff for 15

specific licenses. Licensing actions were evaluated for completeness, consistency, proper

isotopes and quantities used, qualifications of authorized users, adequate facilities and

equipment, and operating and emergency procedures sufficient to establish the basis for

licensing actions. Licenses were evaluated for overall technical quality including accuracy,

appropriateness of the license, license conditions, and tie-down conditions. Casework was

evaluated for timeliness; adherence to good health physics practices; reference to appropriate

regulations; documentation of safety evaluation reports, product certifications or other

supporting documents; consideration of enforcement history on renewals; pre-licensing visits,

peer or supervisory review as indicated; and proper signature authority. The files were checked

for retention of necessary documents and supporting data. 
New Mexico Final Report Page 7

The licensing casework was selected to provide a representative sample of licensing actions

that were completed during the review period. The sampling included the following types: well

logging, industrial radiography, medical institution, medical private practice and broadscope,

nuclear pharmacy, academic, irradiator, research and development, analytical, stationary and

portable gauge. Licensing actions included three new licenses, five amendments to existing

licenses, six license renewals and one termination. A list of the licenses evaluated with casespecific comments can be found in Appendix D.

The Program has recently revised licensing procedures and license reviewer’s procedures. 

Some application forms were revised, and all licensing forms were revised. Revised documents

were entered into the database for accessibility by technical staff. Revision of standard license

conditions is an ongoing process to ensure conditions are current. Licensing templates are set

up for more efficient writing of new and amended licenses. The human use licensing guidance

was revised using the NUREG 1556, Volume 9: “Program-Specific Guidance About Medical

Use Licenses (Draft Report for Comment)” as the reference. Checklists based on NUREG

1556 are used as guidance.

Overall, the review team found that the licensing actions were thorough, complete, consistent,

and of acceptable quality with health and safety issues properly addressed. License tie-down

conditions were stated clearly, backed by information contained in the file, and available for use

by the inspectors. The licensee's compliance history was taken into account when reviewing

renewal applications and amendments. Reviewers appropriately used the State's licensing

guides, license templates, standard conditions and checklists. No potentially significant health

and safety issues were identified. 

The team observed written correspondence between the reviewer and the licensee to resolve

identified deficiencies through requests for additional information. The team did not observe

any performance issue, and noted that most license reviews were conducted by a single staff

member, and all licenses were signed by the Program Manager.

The Program renews licenses every five years. All licensing actions were completed in a timely

manner. The review team noted that most licensing actions were issued within days of the

requested action, and that no license action exceeded 60 days. 

The review team observed that licensees are allowed to renew their license for an additional

five year period by providing a statement that no changes have occurred since the last

amendment. Typically, a current radioactive material inventory is requested for the renewal to

be granted. The review team observed that license renewals were not being performed in their

entirety in some cases for many decades. The Program procedure for filing an application for

specific licenses is based on New Mexico regulation 20.3.3.307. The Program procedure for

performing renewal of licenses states in part: “If a license has not had any changes, a letter

requesting renewal is sufficient...” In every case reviewed, many changes to the license had

occurred over time even though there were no changes since the last amendment. Staff had

only been referencing the time since the last amendment to evaluate if there had been changes

to the license, not the entire period since the last renewal. The team indicated to Program

management that one method for determining the extent of review necessary to approve a

license renewal is found in NUREG-1556, Volume 20, Section 4.4. Following discussions with

the team, the Program management and staff agreed that the current practice is not
New Mexico Final Report Page 8

appropriate and they indicated that they have recently changed their practice to request a

completed application for renewal of licenses. The Program also plans to reflect this change in

their revised draft licensing procedure. The review team recommends that the Program

develop and implement a process that ensures an adequate evaluation of license renewal

information. This action will prevent loss of tie-down information in the license and ensure

correct documentation is captured in the license conditions. 

The review team observed that the closeout survey was not performed for one terminated

medical license reviewed. Twelve additional licenses, that were terminated during the review

period, were reviewed to verify if the lack of a closeout survey was a programmatic issue or an

isolated occurrence. Three of the twelve licenses reviewed were found to not contain

documented disposition of radioactive material including a closeout survey or current leak test

and transfer to authorized licensee. These three licensees were brought to the attention of the

Program Manager. The Program Manager committed to investigate these licenses further and

close them out appropriately. 

The review team recommends that the Program retrain its staff with regard to following its

established procedure for termination of radioactive material licenses and follow-up actions by

the inspectors regarding closeout surveys or additional documentation to support the

termination request. 

The review team observed that the Program re-uses license numbers. In one file reviewed, a

licensee terminated a radioactive material license and several years later applied for a new

license. The new license was issued with the same license number previously issued to this

licensee starting with amendment zero. This practice could lead to confusion from a historical

perspective. This was discussed with Program management and they agreed to issue new

license numbers in these cases.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB

concurred, that New Mexico’s performance with respect to the indicator, Technical Quality of

Licensing Actions, be found satisfactory with recommendation for improvement.

3.5 Technical Quality of Incident and Allegation Activities

In evaluating the effectiveness of the Program’s actions in responding to incidents, the review

team examined the Program’s response to the questionnaire relative to this indicator, evaluated

selected incidents reported by New Mexico to the Nuclear Materials Events Database (NMED)

against those contained in the Program’s files, and evaluated the casework and supporting

documentation for nine materials incidents. A list of the incident casework examined with casespecific comments is included in Appendix E. 

The Program received 22 materials event reports which were reportable under IMPEP criteria

during the review period. The Program’s response to the IMPEP questionnaire indicated that

two of these events had not been reported to the NMED. The Program Manager took action to

enter these events into the NMED system prior to the on site portion of the review. The events

which were selected for review included lost or stolen radioactive material, a potential

overexposure, and licensed material which had been abandoned. The review team found that

the Program’s response to events was complete and comprehensive. Initial responses were

prompt and well coordinated and the level of effort was commensurate with the health and
New Mexico Final Report Page 9

safety significance of the event. The Program dispatched inspectors for on-site investigations

when appropriate. Actions were coordinated with other agencies as appropriate.

The Program followed written procedures for responding to events. The procedures addressed

the actions to be taken upon the notification of an event, the event tracking system, event

evaluation and investigation, documentation, notification to the NRC Operations Center, and the

reporting of events to the NMED. The Program’s procedure is currently being reviewed and

updated. The team noted minor deficiencies in the casework, as noted in Appendix E.

The team noted that the Program has copies of the Handbook to the Office of State and Tribal

Programs (STP) Procedure SA-300, “Reporting Material Events.” With the exception of two

events, copies of event reports were sent to the NMED contractor. The team noted, however,

that the staff member responsible for entry of events into NMED left the Program in May 2005. 

The Program Manager has not yet identified a staff member to take over this responsibility. 

The Program Manager and the Bureau Chief received NMED training in April 2005 and the

Program Manager has recently taken on responsibility for entry of events into NMED until

another staff member is selected.

During the review period, the Program received seven allegations and an additional two NRCreferred allegations. The review team evaluated the Program’s response to these allegations

and determined that the Program took prompt and appropriate action in response to the

concerns raised and appropriately protected the alleger’s identity. The team was unable to

locate the follow-up documentation for one of the NRC-referred allegations during the

evaluation of the Program’s incidents and allegation files. The Program Manager indicated that

he did not have any record of receiving the first NRC-referred allegation. However, the second

NRC referred allegation was a duplicate of the first, concerning the same issue, only differing

by the date submitted. The Program Manager indicated that this may have been the cause of

the confusion. The Program took adequate steps to investigate the second NRC-referred

allegation and closed it out. The team found that the Program closes out allegations

appropriately including a response letter to the alleger.

The team found that responsibility for initial response and follow-up actions to materials

incidents and allegations rested solely with the Program. The staff members evaluate incidents

and allegations, then determine the appropriate response through discussion with the Program

Manager. The Program staff evaluates all incidents reported and investigates any incident that

has a potential for affecting public health and safety.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB

concurred, that New Mexico’s performance with respect to the indicator, Technical Quality of

Incident and Allegation Activities, be found satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

IMPEP identifies four non-common performance indicators to be used in reviewing Agreement

State programs: (1) Compatibility Requirements (2) Sealed Source and Device Evaluation

Program; (3) Low-Level Radioactive Waste Disposal Program; and (4) Uranium Recovery

Program. New Mexico's Agreement does not cover the sealed source and device evaluation

program or uranium recovery operations, so only two non-common performance indicators

were applicable to this review.
New Mexico Final Report Page 10

4.1 Compatibility Requirements

4.1.1 Legislation 

In evaluating this indicator the team reviewed Program’s responses to the IMPEP

questionnaire, the information contained on the States Regulation Status (SRS) data sheet as

maintained by the Office of State and Tribal Programs and the New Mexico statutes applicable

to radiation control. 

The New Mexico Radiation Protection Act authorizes the Board and the Department, through

the Governor, to enter into the agreement with the NRC. The law designates the Board as the

radiation control agency for the State of New Mexico, with the Department carrying out the dayto-day responsibilities. The review team noted that no new legislation was passed since last

review, which would affect the Agreement State program or its authority.

4.1.2 Program Elements Required for Compatibility 

The New Mexico Rules for Radiation Protection apply to all ionizing radiation, whether emitted

from radionuclides or devices. New Mexico requires a license for possession, and use, of all

radioactive material including naturally occurring materials, such as radium, and acceleratorproduced radionuclides. 

The review team interviewed Program staff and examined the procedures used to adopt rules. 

Draft rules are first reviewed by the Council and with their consent, the Program proposes

adoption of the draft rules. The Council must approve all rule changes before the process for

rule promulgation can proceed. Members of the public and other interested parties are offered

an opportunity to comment on proposed rules. The Board is the rule promulgating authority for

radiation and all other Department programs. 

Public notice of proposed new or revised rules is given at least 60 days prior to a public hearing

before the Board. When the Board approves the proposed rules, they are filed with the

Secretary of State and become effective in 30 days. The Program sends the proposed rules to

NRC when they are publicly noticed. Final rules are sent to NRC after they are filed with the

Secretary of State. The Program maintains documentation of transmitting the draft and final

rules to NRC.

The team found that the Program has adopted, and sent in for NRC review, all of the

regulations that were due for Agreement State adoption during this review period. 

The following regulations will become due in the future and are included here to assist the State

in including them in future rulemakings or by adopting alternate generic legally binding

requirements:

• “Medical Use of Byproduct Material,” 10 CFR Parts 20, 32, and 35 amendment

(67 FR 20249) that became effective October 24, 2002. 

• “Financial Assurance for Materials Licensees,” 10 CFR Parts 30, 40, and 70 amendment

(68 FR 57327) that became effective December 3, 2003.
New Mexico Final Report Page 11

• “Compatibility with IAEA Transportation Safety Standards and Other Transportation

Safety Amendments,” 10 CFR Part 71 amendment (69 FR 3697) that became effective

October 1, 2004.

• “Security Requirements for Portable Gauges Containing Byproduct Material,” 10 CFR 30

amendment (70 FR 2001) that became effective July 11, 2005.

• “Medical Use of Byproduct Material - Recognition of Specialty Boards,” - Part 35

amendment (70 FR 16336) that became effective April 29, 2005.

Based on the IMPEP evaluation criteria, the review team recommended and the MRB

concurred, that New Mexico’s performance with respect to the indicator, Compatibility

Requirements, be found satisfactory.

4.2 Low-Level Radioactive Waste (LLRW) Disposal Program

In 1981, the NRC amended its Policy Statement, "Criteria for Guidance of States and NRC in

Discontinuance of NRC Authority and Assumption Thereof by States Through Agreement" to

allow a State to seek an amendment for the regulation of LLRW as a separate category. Those

States with existing Agreements prior to 1981 were determined to have continued LLRW

disposal authority without the need of an amendment. Although New Mexico has LLRW

disposal authority, NRC has not required States to have a program for licensing a LLRW

disposal facility until such time as the State has been designated as a host State for a LLRW

disposal facility. When an Agreement State has been notified or becomes aware of the need to

regulate a LLRW disposal facility, they are expected to put in place a regulatory program which

will meet the criteria for an adequate and compatible LLRW disposal program. There are no

plans for a LLRW disposal facility in New Mexico. Accordingly, the review team did not review

this indicator.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team found New Mexico’s performance to be

satisfactory for five of the performance indicators reviewed; Technical Staffing and Training,

Technical Quality of Inspections, Status of Materials Inspection Program, Technical Quality of

Incident and Allegation Activities and Compatibility Requirements. The review team found New

Mexico’s performance to be satisfactory but needs improvement for one indicator; Technical

Quality of Licensing Actions. Accordingly, the review team recommended and the MRB

concurred, that the New Mexico Agreement State program be found adequate to protect public

health and safety and compatible with NRC's program. Based on the results of the current

IMPEP review, the review team recommended and the MRB concurred, that the next full review

will be in approximately four years.
New Mexico Final Report Page 12

Below are the recommendations, as mentioned earlier in the report, for evaluation and

implementation, as appropriate, by the Program. 

RECOMMENDATIONS:

1. The review team recommends that the Program retrain its staff with regard to following

its established procedure for termination of radioactive material licenses and follow-up

actions by the inspectors regarding closeout surveys or additional documentation to

support the termination request. (Section 3.4)

2. The review team recommends that the Program develop and implement a process that

ensures an adequate evaluation of license renewal information. (Section 3.4)
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B New Mexico Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Attachment August 9, 2005, E-mail from Walter Medina

New Mexico’s Response to Draft IMPEP Report 
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

John Zabko, STP Team Leader

Compatibility Requirements

Technical Staffing and Training

Linda McLean, Region IV Technical Quality of Inspections

Inspection Accompaniments

Christi Maier, Region IV Status of Materials Inspection Program

Technical Quality of Incident and Allegation 

Activities

James Harris, Kansas Technical Quality of Licensing Actions
APPENDIX B

New Mexico

Environment Department

ORGANIZATION CHARTS

ML051530206

pages 25-26
APPENDIX C

INSPECTION CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

File No.: 1

Licensee: Heart Hospital of New Mexico License No.: MI 363-11

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 5/10/05 Inspector: MO

Comment:

a) Response to violations from previous inspection not in file.

File No.: 2

Licensee: Biotech Pharmacy, Inc. License No.: RP 301-27

Inspection Type: Follow-up, Announced Priority: 1

Inspection Date: 5/11/05 Inspector: GA

File No.: 3

Licensee: Kaseman Presbyterian Hospital License No.: MI 114-14

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 5/12/05 Inspector: EV

Comment:

a) Response to violations from previous inspection not in file.

File No.: 4

Licensee: UniTech Services Group, Inc License No.: LA 110-21

Inspection Type: Routine, Announced Priority: 2

Inspection Date: 4/6/04 Inspector: WM

File No.: 5

Licensee: Basin Well Logging Wireline Services, Inc. License No.: WL 283-01

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 4/7/03 Inspector: WM

File No.: 6

Licensee: Blue Jet, Inc. License No.: WL 034-13

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 1/27/03 Inspector: WM

File No.: 7

Licensee: Eastern New Mexico University License No.: AN 357-01

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 2/18/03 Inspector: SM

Comment:

a) Response to licensee’s NOV from 2003 inspection sent out in 2005. 
New Mexico Final Report Page C.2

Inspection Casework Reviews

File No.: 8

Licensee: Lea Regional Medical Center License No.: 1/16/02

Inspection Type: Routine, Unannounced Priority: 2

Inspection Dates: 1/16/02, 4/20/04 Inspector: SM

File No.: 9

Licensee: Mountain View Regional Medical Center License No.: MI 386-06

Inspection Type: Routine, Unannounced Priority: 2

Inspection Dates: 5/14/03, 5/24-25/05 Inspectors: SM, MO

Comment:

a) Response to licensee’s NOV from 2003 inspection sent out in 2005. 

File No.: 10

Licensee: Longview Inspection License No.: IR 350-09

Inspection Type: Initial, Routine, Announced Priority: 1

Inspection Dates: 2/15/04, 1/27/05 Inspectors: WM, SM

File No.: 11

Licensee: Cardinal Health License No.: RP 396-00

Inspection Type: Initial, Routine, Unannounced Priority: 1

Inspection Dates: 11/21/03, 2/3/05 Inspectors: SM, WM, SF, MO, EV

File No.: 12

Licensee: Carlsbad Medical Center License No.: MI 083-25

Inspection Type: Routine, Unannounced Priority: 2

Inspection Dates: 1/12/04, 3/2/05 Inspectors: SM, MO

File No.: 13

Licensee: H & H X-Ray Services, Inc. License No.: IR 267-12

Inspection Type: Routine, Unannounced Priority: 1

Inspection Dates: 6/24/03, 6/8/04 Inspector: WM

File No.: 14

Licensee: Eastern New Mexico Medical Center License No.: MI 065-25

Inspection Type: Routine, Unannounced Priority: 2

Inspection Dates: 11/8/01, 4/5-6/04 Inspector: SM

File No.: 15

Licensee: University of New Mexico License No.: BM 233-70

Inspection Type: Routine, Announced Priority: 1

Inspection Dates: 10/16-18/02, 9/30-10/2/03, 10/18/04 Inspectors: SM, SF, WF

Comment:

a) File missing licensees response to NOV
New Mexico Final Report Page C.3

Inspection Casework Reviews

File No.: 16

Licensee: Ethicon Endo-Surgery License No.: GI 316-03

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 5/21/04 Inspector: SM, WF

Comment:

a) File missing licensees response to NOV

INSPECTOR ACCOMPANIMENTS

The following inspector accompaniments were performed prior to the on-site IMPEP review:

File No.: 1

Licensee: Heart Hospital of New Mexico License No.: MI 363-11

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 5/10/05 Inspector: MO

Comment:

a) Response to violations from previous inspection not in file.

File No.: 2

Licensee: Biotech Pharmacy, Inc. License No.: RP 301-27

Inspection Type: Follow-up, Announced Priority: 1

Inspection Date: 5/11/05 Inspector: GA

File No.: 3

Licensee: Kaseman Presbyterian Hospital License No.: MI 114-14

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 5/12/05 Inspector: EV
APPENDIX D

LICENSE CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

File No.: 1

Licensee: New Mexico Inst. Of Mining and Tech. License No.: AB373-07

Location: Socorro, NM License Type: Broadscope research

Amendment No.: 7 Type of Action: Amendment

Date Issued: 9/23/04 License Reviewer: WF

File No.: 2

Licensee: Ktech Corp. License No.: AN419-00

Location: Albuquerque, NM License Type: Analytical lab

Amendment No.: 0 Type of Action: New

Date Issued: 1/21/05 License Reviewer: MR

File No.: 3

Licensee: Bernalillo County Public Works Dept. License No.: DM029-30

Location: Albuquerque, NM License Type: DM Gauge

Amendment No.: 30 Type of Action: Amendment

Date Issued: 3/19/05 License Reviewer: MR

File No.: 4

Licensee: AMEC Earth & Environmental License No.: DM201-32

Location: Tempe, AZ License Type: DM Gauge

Amendment No.: 32 Type of Action: Renewal

Date Issued: 1/10/05 License Reviewer: MR

File No.: 5

Licensee: Lydick Engineers & Surveyors License No.: DM131-10

Location: Clovis, NM License Type: DM Gauge

Amendment No.: 10 Type of Action: Renewal

Date Issued: 7/17/03 License Reviewer: MR

File No.: 6

Licensee: Constructors, Inc. License No.: DM297-00

Location: Carlsbad, NM License Type: DM Gauge

Amendment No.: 0 Type of Action: New

Date Issued: 1/10/03 License Reviewer: MR

Comment:

a) No license application evaluation form was completed for this license action as required

by the Program’s procedure for issuance of radioactive material licenses. 
New Mexico Final Report Page D.2

License Casework Reviews

File No.: 7

Licensee: MolyCorp, Inc. License No.: GA139-17

Location: Questa, NM License Type: Fixed gauge

Amendment No.: 17 Type of Action: Renewal

Date Issued: 6/10/04 License Reviewer: MR

File No.: 8

Licensee: Atomic Inspection Labs, Inc. License No.: IR022-20

Location: Albuquerque, NM License Type: Industrial Radiography

Amendment No.: 20 Type of Action: Renewal

Date Issued: 4/1/02 License Reviewer: MR

File No.: 9

Licensee: Summit Medical Corporation License No.: MD365-03

Location: Farmington, NM License Type: Medical Private Practice

Amendment No.: 3 Type of Action: Amendment

Date Issued: 2/25/03 License Reviewer: MR

File No.: 10

Licensee: Alta Vista Regional Hospital License No.: MI415-00

Location: Las Vegas, NM License Type: Medical Institution

Amendment No.: 0 Type of Action: New

Date Issued: 11/2/04 License Reviewer: MR

File No.: 11

Licensee: Weston Solutions, Inc. License No.: RD245-20

Location: Albuquerque, NM License Type: Research and Development

Amendment No.: 20 Type of Action: Amendment

Date Issued: 9/23/03 License Reviewer: MR

File No.: 12

Licensee: Black Warrior Wireline Corp. License No.: WL032-10

Location: Hobbs, NM License Type: Well Logging

Amendment No.: 10 Type of Action: Amendment

Date Issued: 4/15/05 License Reviewer: MR

Comment:

a) Training information for IR362-13 found in this file.

File No.: 13

Licensee: Biotech Pharmacy, Inc. License No.: RP301-28

Location: Albuquerque, NM License Type: Radiopharmacy

Amendment No.: 28 Type of Action: Renewal

Date Issued: 5/12/05 License Reviewer: MR
New Mexico Final Report Page D.3

License Casework Reviews

File No.: 14

Licensee: UNM Radiation Safety License No.: BM233-70

Location: Albuquerque, NM License Type: Medical Broadscope

Amendment No.: 70 Type of Action: Renewal

Date Issued: 6/5/04 License Reviewer: MR

Comment:

a) The application for renewal referenced prior amendment BM233-69 but all the tie down

information relating to the prior amendments had been removed. License condition 10

requires compliance with the Radiation Safety Manual revised May 1989. The Radiation

Safety Manual revised July 1999 on file is not addressed.

File No.: 15

Licensee: Radiology Associates of Albuquerque License No.: MD177-10

Location: Albuquerque, NM License Type: Medical Private Practice 

Amendment No.: 10 Type of Action: Termination

Date Issued: 4/30/04 License Reviewer: WF

Comment:

a) Amendment states a closeout survey will be performed. No closeout survey was found. 

Discussion with staff indicates the communication with inspectors for the need to

perform closeout surveys or provide documentation to justify or support the termination

is frequently overlooked. Comment in body of this report.
APPENDIX E

INCIDENT CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

File No.: 1

Licensee: Baker Hughes Oilfield Operations, Inc. License No.: WL 241

Site of Incident: Hobbs, NM Incident Log No.: NM-xx-xx

Date of Incident: 9/22/01 Type of Incident: Abandonment of Well Logging Tool

Investigation Date: 4/26/02 Type of Investigation: Telephone

Comment:

a) Incident Log number was not recorded.

File No.: 2

Licensee: Western Technologies License No.: DM 244

Site of Incident: Cuba, NM Incident Log No.: NM-xx-xx

Date of Incident: 9/6/01 Type of Incident: Loss of Radioactive Material

Investigation Date: 9/6-14/01 Type of Investigation: On-site

Comments:

a) Event Report was not reviewed/signed by Program Manager.

b) Incident Log number was not recorded.

File No.: 3

Licensee: P&M Construction License No.: DM 159

Site of Incident: Ponderosa, NM Incident Log No.: NM-02-05

Date of Incident: 9/01 - 10/25/02 Type of Incident: Loss of Radioactive Material

Investigation Date: 12/13/02 Type of Investigation: On-site

File No.: 4

Licensee: H & G Inspection Company, Inc. License No.: IR 268

Site of Incident: Bloomfield, NM Incident Log No.: NM-02-03

Date of Incident: 7/8/02 Type of Incident: Overexposure

Investigation Date: 7/26/02 Type of Investigation: Telephone

File No.: 5

Licensee: Schlumberger Technology License No.: WL 197

Site of Incident: Eddy County, NM Incident Log No.: NM-02-01

Date of Incident: 4/26/02 Type of Incident: Abandonment of Well Logging Tool

Investigation Date: 4/26/02 Type of Investigation: Telephone

File No.: 6

Licensee: AMEC Earth & Environmental License No.: DM 201

Site of Incident: Rio Rancho, NM Incident Log No.: NM-05-03

Date of Incident: 5/5/05 Type of Incident: Transportation

Investigation Date: 5/5/05 Type of Investigation: Telephone
New Mexico Final Report Page E.2

Incident Casework Reviews

File No.: 7

Licensee: United Parcel Service License No.: N/A (non-licensee)

Site of Incident: Albuquerque, NM Incident Log No.: NM-xx-xx

Date of Incident: 12/23/04 Type of Incident: Found RAM

Investigation Date: 12/23/04 Type of Investigation: On-site

Comment:

a) Incident Log number was not recorded.

File No.: 8

Licensee: Riverside Technologies License No.: DM 345

Site of Incident: Santa Fe, NM Incident Log No.: NM-xx-xx

Date of Incident: Between 10/1/04 and 10/4/04 Type of Incident: Theft of RAM

Investigation Date: 10/04-12/04 Type of Investigation: Telephone

Comments:

a) Event Report was not reviewed/signed by Program Manager.

b) Incident Log number was not recorded.

File No.: 9

Licensee: H & G Inspection Company, Inc. License No.: IR 268

Site of Incident: Bloomfield, NM Incident Log No.: NM-xx-xx

Date of Incident: 2/7/05 Type of Incident: Overexposure

Investigation Date: 2/7-23/05 Type of Investigation: Telephone

Comment:

a) Incident Log number was not recorded.
Attachment 

August 9, 2005, E-mail from Walter Medina

New Mexico’s Response to Draft IMPEP Report 

ADAMS Accession Number: ML052310086