DATED: JULY 21, 1998 SIGNED BY: HUGH L. THOMPSON, JR. 

Donald E. Williamson, M.D.

State Health Officer

Alabama Department of Public Health

RSA Tower

P.O. Box 303017

Montgomery, AL 36130-3017

Dear Dr. Williamson:

On July 8, 1998 the Management Review Board (MRB) met to consider the proposed final

Integrated Materials Performance Evaluation Program (IMPEP) report on the Alabama

Agreement State Program. The MRB found the Alabama program adequate to protect public

health and safety and compatible with NRC's program. 

Section 5.0, page 12, of the enclosed final report presents the IMPEP team's recommendations

and suggestions. We have received the June 16, 1998 letter from Kirksey E. Whatley, Director,

Division of Radiation Control, which described the actions taken in response to the team’s

recommendations and suggestions. We request no additional information.

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

years.

Mr. Whatley effectively represented the State of Alabama at the MRB meeting. During the

meeting, he noted the current and past contributions from radiation control program staff and

management that have been key to the success of the Alabama program. The MRB also noted

the commitment from Mr. Whatley to continue the use of high performance standards in the

conduct of his program’s activities.

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

your support of the Radiation Control Program. I look forward to our agencies continuing to

work cooperatively in the future.

Sincerely, /RA/

Hugh L. Thompson, Jr.

Deputy Executive Director

 for Regulatory Programs

Enclosure:

As stated

cc: Steven Collins

Organization of Agreement States Liaison

 to the Management Review Board

Kirksey E. Whatley, Director

Division of Radiation Control

Alabama Department of Public Health
Donald E. Williamson, M.D.

State Health Officer

Alabama Department of Public Health

RSA Tower

P.O. Box 303017

Montgomery, AL 36130-3017

Dear Dr. Williamson:

On July 8, 1998 the Management Review Board (MRB) met to consider the proposed final

Integrated Materials Performance Evaluation Program (IMPEP) report on the Alabama

Agreement State Program. The MRB found the Alabama program adequate to protect public

health and safety and compatible with NRC's program. 

Section 5.0, page 12, of the enclosed final report presents the IMPEP team's recommendations

and suggestions. We have received the June 16, 1998 letter from Kirksey E. Whatley, Director,

Division of Radiation Control, which described the actions taken in response to the team’s

recommendations and suggestions. We request no additional information.

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

years.

Mr. Whatley effectively represented the State of Alabama at the MRB meeting. During the

meeting, he noted the current and past contributions from radiation control program staff and

management that have been key to the success of the Alabama program. The MRB also noted

the commitment from Mr. Whatley to continue the use of high performance standards in the

conduct of his program’s activities.

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

your support of the Radiation Control Program. I look forward to our agencies continuing to

work cooperatively in the future.

Sincerely,

Hugh L. Thompson, Jr.

Deputy Executive Director

 for Regulatory Programs

Enclosure:

As stated

cc: Steven Collins, bcc: Chairman Jackson

Organization of Agreement States Liaison Commissioner Diaz

to the Management Review Board Commissioner McGaffigan

Kirksey E. Whatley, Director

Division of Radiation Control

Alabama Department of Public Health

DISTRIBUTION: see next page *See previous concurrence

DOCUMENT NAME: A:\AL98FLTR.WPD, G:\IMPEP\AL98FNL.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 OSP C OSP:DD OSP:D DEDR

NAME RLBlanton:gd PHLohaus RLBangart HLThompson

DATE 07/13/98* 07/14/98* 07/17/98* 07/ /98
Donald E. Williamson, M.D. - 2 -

Distribution: DCD (SP01)

DIR RF PDR (YES/)

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Alabama File

OSP FILE CODE: SP-AG-1
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF ALABAMA AGREEMENT STATE PROGRAM

April 20 - 23, 1998

FINAL REPORT

U.S. Nuclear Regulatory Commission
1.0 INTRODUCTION

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

review was conducted during the period April 20 - 23, 1998, by a review team comprised of

technical staff members from the Nuclear Regulatory Commission (NRC) and the Agreement State

of Texas. Team members and their assignments 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 November 25, 1997, revised NRC Management

Directive 5.6, "Integrated Materials Performance Evaluation Program (IMPEP)." 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 Alabama. 

Preliminary results of the review, which covered the period June 23, 1995, to April 23, 1998, were

discussed with Alabama management on April 23, 1998. 

A draft of this report was issued to Alabama for factual comment on May 27, 1998. The State

responded in a letter dated June 16, 1998 (Attachment 1). The State’s factual comments have

been incorporated into the final report. The Management Review Board (MRB) met on July 8,

1998, to consider the proposed final report. The MRB found the Alabama radiation control

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

The Alabama Agreement State program is administered by the Department of Public

Health (DPH), Office of Radiation Control (ORC). The Director of the ORC reports to the State

Health Officer, who serves as the Director of the Department of Public Health. The State Board of

Health is the designated radiation control agency. Organization charts for the DPH and the ORC

are included in Appendix B. At the time of the review, the ORC regulated 404 specific licenses.

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

was sent to the State on November 12, 1997. The State provided a response to the questionnaire

on March 19, 1998. A copy of the response is included in Appendix F to the draft report. 

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

Alabama's response to the questionnaire; (2) review of applicable Alabama statutes and

regulations; (3) analysis of quantitative information from the radiation control program licensing

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

accompaniments of two ORC 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 applicable non-common indicator and made a

preliminary assessment of the State’s performance.

Section 2 below discusses the State'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 applicable non-common indicators, and

Section 5 summarizes the review team's findings, recommendations, and suggestions. 

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

performance by the State. A response is requested from the State to all recommendations in the

final report. Suggestions are comments that the review team believes could enhance the State’s

program. The State is requested to consider suggestions, but no response is requested. 
Alabama Final Report Page 2

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

After the previous routine review, which concluded on June 23, 1995, the results were transmitted

to Donald Williamson, M.D., State Health Officer, Alabama DPH on September 18, 1995. The

review initially resulted in one recommendation, and the withholding of a finding for compatibility

because the State had not adopted a regulation equivalent to the “Quality Management (QM)

Program and Misadministrations,” 10 CFR 35.32 amendment (56 FR 34104) that became effective

on January 27, 1992. 

Subsequent to the letter of September 18, 1995, NRC reinitiated an evaluation of the QM rule. It

was decided that pending the completion of the re-evaluation, the absence of a compatible QM

rule would not be used as a basis for withholding of a finding for compatibility. In a letter dated

October 24, 1995, the State was notified of this action and subsequently all Agreement States

were notified of the results of this re-evaluation by SP-95-184 dated December 6, 1995.

The compatibility category of the QM rule under the new Commission policy on Adequacy and

Compatibility, which became effective on September 6, 1997, has been set as “D” with

paragraphs (a), (b), and (c) of the rule identified as having provisions important to health and

safety. Consistent with SECY 97-054 (see SP-97-057), staff will review the compatibility of both

draft and final Agreement State equivalent QM rules as they are promulgated. However, the

results of such reviews will not affect IMPEP review findings. A separate review of the current

Alabama rule equivalent to 10 CFR 35.32(a), (b), and (c) has been completed, and the rule found

to meet the compatibility and health and safety category.

Based on the above, the team determined that this recommendation should 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) Status of Materials Inspection

Program; (2) Technical Quality of Inspections; (3) Technical Staffing and Training; (4) Technical

Quality of Licensing Actions; and (5) Response to Incidents and Allegations. 

3.1 Status of Materials Inspection Program

The team focused on four factors in reviewing the status of the materials inspection program:

inspection frequency, overdue inspections, initial inspection of new licensees, and timely dispatch

of inspection findings to the licensees. This evaluation is based on the Alabama questionnaire

responses relative to this indicator, data gathered from reports generated from the licensee

database, the examination of inspection casework, and interviews with the management and staff

of the ORC.

A DPH memorandum dated April 16, 1998, entitled “License and Registration Inspections Priority”

requires that inspections be conducted in accordance with the priority schedule in NRC Inspection

Manual Chapter (IMC) 2800, with the following modifications: 

1) All programs assigned to Priority 7 by NRC are changed to Priority 5; 
Alabama Final Report Page 3

2) Medical Institutions and Medical Private Practices not requiring a QM Plan are

assigned to Priority 3 instead of Priority 5; 

3) Academic Type B is assigned to Priority 2 instead of Priority 3; and

4) Stereotactic Radiosurgery is added with a Priority 1.

The April 16, 1998 memorandum further established a policy and procedure for extending

inspection intervals on the basis of good licensee performance. The memorandum also

established a policy and procedure for reducing inspection intervals, using a point system based

on violation severity and frequency. The inspection interval extension/reduction policy differs from

NRC’s in two aspects: 1) in Alabama the interval extension policy “may be applied” as compared

to NRC’s “shall be applied;” and 2) in Alabama the decision to grant an extension is made at the

time the licensee’s next inspection is due, versus the IMC 2800 provision for the decision to be

made at the time the current inspection is completed. The application for an increase in interval

and the documentation required are essentially the same for both Alabama and NRC. No

licensees had been granted interval extension prior to the review, however, there were four

licensees subject to interval reduction at the time of the review.

The licensee database contains fields for 43 items of information, and is accessible to both

licensing branch and inspection branch staff. Certain fields, such as the next inspection date, are

changed only by management. Information retrieval can be formatted to give the type of report

and information desired. For example, a monthly ‘inspection due’ report is generated for

scheduling purposes. The report fields indicate the inspection due date, date of the last

inspection performed, the licensee, and the State region(s) where the licensee is located. The

inspectors use this report to formulate an inspection itinerary, which is submitted for management

approval prior to departure.

The Radioactive Materials Compliance Branch (RMCB) of the ORC conducts an average of 130

inspections per year. Currently, the ORC has no overdue inspections. This performance meets

and surpasses the IMPEP criteria for this indicator.

Initial inspections of new licensees are scheduled for five months after the date the license is

issued. At that time, an inspector contacts the licensee. If the licensee has not acquired material

during this period, the inspector asks when the licensee expects to acquire material. Depending

on the licensee’s response, the inspection due date may be extended up to another five months. 

If material is not acquired during this period, an inspection is performed before the end of the first

year post license issuance. There were 40 initial inspections performed during the review period,

all within the scheduled intervals for new licensees.

Alabama allows 30 days of possession of materials in State under reciprocity without payment of a

fee. After 30 days, an out-of-State Alabama license (and fee payment) is required. Holders of

out-of-State licenses are required to give a 3 day notification of any planned use of radioactive

material at a temporary job site in Alabama. The ORC considers the out-of-State licensees to

effectively be operating under reciprocity. The inspections of Priority 1 and Priority 3 licensees

granted reciprocity (including the Priority 1 and Priority 3 out-of-State licensees using materials in
Alabama Final Report Page 4

State) during the review period fell short of the goals indicated in IMC 1220. Seventeen percent of

the Priority 1 and 14 percent of the Priority 3 licensees were inspected. Inspection of teletherapy

and irradiator source services licensees and Priority 2 licensees met IMC 1220 goals. 

The ORC identified this shortfall in a self-audit, but noted that many of these licensees enter into

the State for jobs that require only a short time, often only a few hours, and that the job sites are

frequently located in remote areas of the State. The ORC indicated that this, coupled with the

costs of travel, makes inspection of these licensees very difficult. The review team suggests that

the Alabama ORC continue their efforts to find ways to increase the percentage of high priority

reciprocity licensees, and out-of-State licensees working in Alabama, to be inspected each year.

Fifteen inspection files were reviewed for report timeliness. The procedure for reporting

inspection results is initiated by the inspector, usually immediately upon return from the field. The

inspector transfers information from handwritten field notes to a computer-form, then drafts a cover

letter to the licensee. The draft cover letter and computer-form notes comprise the draft report. 

Management reviews the draft report, and sends it to the secretarial staff to be finalized. The

inspector receives the report back from the secretarial staff, assures its accuracy and

completeness, and delivers it to the Director of the RMCB for signature. This procedure appears

to be working very well. For the reports reviewed, seven were signed within two weeks of the

inspection, and all were signed within 24 days.

In summary, Alabama meets or surpasses the IMPEP criteria in Management Directive 5.6 for the

four areas reviewed for this performance indicator. Based on this, the review team recommends

that Alabama’s performance with respect to the indicator, Status of Materials Inspection Program,

be found satisfactory.

3.2 Technical Quality of Inspections

The team reviewed the inspection reports, enforcement documentation, and inspection field notes,

and interviewed inspectors for 12 material inspections conducted during the review period. The

casework reviewed included inspections by three materials license inspectors, two of which are

presently assigned to perform inspections. The third is no longer performing radioactive materials

inspections, but is still with the program. The casework reviewed covered inspections of various

license types, including: industrial radiography, portable gauge, academic broad scope, nuclear

pharmacy, medical private practice, and medical institution. Appendix C lists the inspection files

reviewed in depth. 

To review inspectors’ performance in the field, a team member accompanied two inspectors on

February 11, 1998, and during the period February 25 - 27,1998. Each inspector was

accompanied on two unannounced inspections. One inspector was accompanied during the early

morning inspection of a nuclear pharmacy on February 11, 1998, and at a nuclear medicine facility

on February 25, 1998. The other inspector was accompanied February 26 - 27, 1998, on

unannounced inspections of a medical licensee with brachytherapy (including an HDR therapy

unit), and an industrial radiography licensee. These accompaniments are also identified in

Appendix C. During the accompaniments, the inspectors demonstrated appropriate inspection
Alabama Final Report Page 5

techniques and knowledge of the regulations. Both inspectors were well prepared and thorough

in their reviews of the licensees' radiation safety programs. Overall, the technical performance of

the inspectors was excellent, and their inspections were adequate to assess radiological health

and safety at the licensed facilities.

During the onsite review, the review team determined that the ORC is performing inspections of

materials licensees on an unannounced basis, except for initial inspections. The inspectors use a

packet of note forms for each major type of inspection. The inspectors used the appropriate

inspection field note forms in the files reviewed. Each inspector has the forms on his computer,

and prints the appropriate forms as necessary for the inspection. The review team observed that

the inspectors were reviewing open items from previous inspections and any incidents or

allegations that had occurred since the previous inspection. Approximately half of the inspections

reviewed by the team resulted in no items of non-compliance, with appropriate letters being issued

to the licensees. In the other cases, the ORC issued appropriate Notices of Violation.

During the review period, the RMCB supervisor accompanied two of the three individuals who had

performed material inspections. The accompaniment reports contained sufficient details to

document the areas covered. The accompanied inspector is provided a copy of the

accompaniment report and receives an oral report of his performance. 

The senior materials inspector had not been accompanied during the review period, until just

before the review. The lack of accompaniment was identified during the ORC's self-audit, and an

accompaniment of the senior materials inspector was conducted. The review team suggests that

the ORC accompany all material inspectors on a yearly basis.

The review team found that the ORC maintains a sufficient number and variety of survey

instruments to perform radiological surveys of material licensees. The review team examined the

State’s instrumentation and observed that the survey instruments were calibrated and operable. 

Inspectors obtain instruments from the stock for each inspection. The ORC performs its own

calibration at three month intervals, with a source that is National Institute of Standards and

Technology (NIST) traceable. A copy of the procedures was examined and appeared adequate. 

For repairs, the instrument is either returned to the manufacture or is sent to a facility that

performs this service.

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

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

3.3 Technical Staffing and Training

Issues associated with this indicator include radioactive materials program staffing levels,

qualification of the staff, training, and staff turnover. To evaluate these issues, the review team

examined the State’s questionnaire responses related to the indicator, conducted interviews with

management and staff of the ORC, and reviewed workload for backlog.

The staff of the ORC was relatively stable over the review period. There were no new hires, and

only two staff members departed, both due to retirement. One was the Director of Emergency
Alabama Final Report Page 6

Planning/Environmental Monitoring Section, the other was the Director of Naturally Occurring

Radioactive Material Section. Due to fiscal constraints, the positions vacated by the retirements

were lost. Thus, the ORC had no vacant positions during the review period. However, the losses

did not cause an observable reduction in the performance of the Agreement materials program. 

Due to a historic low rate of turnover, the staff consists of experienced personnel. The minimum

educational requirement for a new hire is a baccalaureate degree. All current staff exceed the

qualifications. The ORC has 14 technical positions, including branch directors, that are

apportioned as follows: Radioactive Materials Compliance 3, Radioactive Materials Licensing 1,

Emergency Planning & Environmental Monitoring 3, Mammography 1, X-Ray Compliance 5, and

the Program Director. The ORC has a secretarial staff of three. 

In addition to the four technical staff members in the Radioactive Materials Licensing and

Compliance Branches, the Program Director spends about 23% of his time in radioactive materials

licensing and inspection activities. Based on the lack of backlogs and the quality of the licensing

actions and inspection reports, the team concluded that the number and distribution of staff

appear to be adequate to maintain the program.

The ORC receives support from the Alabama Department of Environmental Management's

(ADEM) radiation measurements laboratory, which performs sample counting and assay services. 

Discussions with both ORC and laboratory staff established that the support is timely and

dependable. The U.S. Environmental Protection Agency's (EPA) radiation measurements

laboratory is located close to the ADEM lab, and is available for backup. 

Training and qualification requirements for licensing and inspection staff are set out in a DPH

memorandum dated October 20, 1997, Policy No. 417. The memorandum sets forth essentially

the same training and qualification recommendations developed by the NRC - Organization of

Agreement States Joint Working Group. A lead inspector is required to obtain specialized training

appropriate for the type of licensees being inspected. Inspector requirements include NRC, or

equivalent, training courses when available. Inspectors are also required to be accompanied by a

senior staff member on an inspection prior to authorizing this inspector to perform an independent

inspection. Prior experience in inspecting in the specialized area(s) is required to be a license

reviewer or writer.

The training requirements set forth by the October 20, 1997, memorandum are presently met by

all of the radioactive materials staff for their respective positions. All have taken the NRC courses

deemed appropriate for their tasks, including the five week health physics course. The training

records demonstrate that DPH management is committed to a high degree of training for the staff. 

However, the State Health Officer expressed concern that the cost of training, especially the five

week course, may become a financial obstacle for the State in the future.

The team noted the apparent benefits to the ORC from staff participation in the nationwide

materials regulatory program outside their regular work. The Director of the Licensing Branch has

served on committees and working groups including the joint working group currently considering

revisions to 10 CFR Part 35. The Director of the RMCB has served previously on IMPEP review

teams. The ORC Director and other staff members have participated in activities of the

Conference of Radiation Control Program Directors. The knowledge and experience gained from
Alabama Final Report Page 7

these activities have been reflected back to the ORC. The team particularly notes and commends

the self-audit function initiated by the ORC during the review period.

Based on the IMPEP evaluation criteria, the team recommends that Alabama’s performance with

respect to the indicator, Technical Staffing and Training, be found satisfactory.

3.4 Technical Quality of Licensing Actions

The review team interviewed the Alabama license reviewer, evaluated the licensing process, and

examined licensing casework for 30 specific licenses. The ORC reported having 404 specific

materials licenses, issuing 51 new licenses and terminating 47 licenses since the 1995 review. 

The ORC utilizes one full time license reviewer, and the ORC Director performs a technical

supervisory review before each licensing action is issued. All licenses are signed by the ORC

Director and the State Health Officer. The State issues licenses for a five year period. The State

utilizes a timely renewal system, NRC licensing guides and policies, as appropriate, and standard

licensing conditions. 

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

which were completed during the review period and included all amendments to the selected

licenses since the previous review. The cross-section sampling focused on the State’s major

licenses, new licenses, renewals, and licenses terminated during the review period. The sample

included the following licensing types: broad academic; broad medical; research and

development; source material; nuclear laundry; industrial radiography; portable gauges;

institutional nuclear medicine; private clinics; mobile nuclear medicine; radioisotope and sealed

source radiotherapy; and nuclear pharmacy. Licensing actions reviewed included 11 new, 4

renewals, 39 amendments and 6 termination files. A listing of the casework licenses with case

specific comments can be found in Appendix D.

Licensing actions were reviewed for completeness, consistency, proper radioisotopes and

quantities, qualifications of authorized users, adequate facilities and equipment, adherence to

good health physics practices, operating and emergency procedures, appropriateness of the

license conditions, and overall technical quality. The casework files were also reviewed for use of

appropriate deficiency letters and cover letters, timeliness of correspondence, reference to

appropriate regulations, information notices, product certifications or other supporting documents,

consideration of enforcement history, pre-licensing visits, supervisory review as indicated, and

proper signatures. The files were checked for retention of necessary documents and supporting

data including the terminated license files.

The review team found (with the exception of one termination as discussed below) that the

licensing actions were consistently very thorough, complete, of high quality, with health and safety

issues properly addressed, and sufficient to establish the basis for the licensing action. The

licensee's compliance history is taken into account when reviewing renewal applications and

amendments as determined from documentation in the license files and/or discussions between

the license reviewer and the inspectors. As discussed in the questionnaire, five exemptions were

issued by the ORC during this review period. All were determined to be appropriate and well

documented.
Alabama Final Report Page 8

A review of the termination actions taken over the review period showed that most of the

terminations were for licensees possessing only sealed sources and/or for uses of

radiopharmaceuticals with short half lives. Six termination files were selected for review based

upon the potential for residual contamination, and to confirm that the State’s termination

procedures were being implemented. In general, the review team found that terminated licensing

actions were well documented, showing appropriate transfer records or appropriate disposal

methods and records, confirmatory surveys, and survey records. 

One case file involved the transfer of a portable gauging device to a specific licensee located in

another Agreement State. The records included a handwritten "Bill of Sale" from the Alabama

licensee. Other documentation in the file, and the licensee's compliance history, raised a question

concerning the validity (authenticity) of the transfer records. It was also undetermined if the

sealed source had been leak tested prior to the transfer.

The team considered the potential for the device to end up at an unlicensed facility, such as a

metals processor. Following the team’s discussion concerning this case, the ORC Director

initiated a call to the State program having jurisdiction over the new owner and confirmed that the

new owner had a valid license. The new owner was also contacted by telephone to confirm the

transfer of the device and that the device had been leak tested. The review team recommends

that NMSS evaluate the risks associated with the termination of licensees with poor compliance

history, particularly where the history suggests a lack of reliability, and provide guidance on how

and when a regulatory program should obtain confirmation of the validity of the license of the

receiving licensee and that the materials or devices were actually received by the receiving

licensee.

In discussions with the program management, the team noted that there were no major

decommissioning efforts underway with regard to agreement material in Alabama. The State is

working with the NRC Region II office concerning the decommissioning of the NRC licensed

Ft. McClellan site located near Anniston, Alabama (NRC license number 01-02861-04). The State

is assisting NRC with environmental sampling and analysis, including groundwater samples.

The sample analyses are being performed by the ADEM laboratory located in Montgomery. 

Discussions were held with ORC staff concerning the adequacy and timeliness of results from

samples sent to the laboratory for analysis. A visit was also conducted by the IMPEP team to

evaluate the capabilities of the laboratory. The team noted that the EPA’s Montgomery radiation

laboratory is located in adjoining property (Gunter Air Force Base). The ORC Director related that

the ORC staff has a good working relationship with the EPA staff.

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

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

satisfactory.

3.5 Response to Incidents and Allegations

In evaluating the effectiveness of the ORC's actions in responding to incidents, the review team

examined the response to the questionnaire relative to this indicator, reviewed the incident reports

for Alabama in the Nuclear Material Events Database (NMED) against those contained in the
Alabama Final Report Page 9

ORC's files, and reviewed reports and supporting documentation as appropriate for six incidents. 

In addition, the team reviewed the files for two allegations.

The six incidents selected for review included the following incident types: stolen radioactive

material, overexposures, lost radioactive material, transportation accident, improper disposal of

radioactive material, and damaged equipment. A list of the incidents reviewed in depth, with

comments, is included in Appendix E.

The responsibility for the initial response and follow-up actions to material incidents may be

assigned to any member of the materials program. When a report is received, it is given a unique

number and logged into the incident log. A brief description of the incident along with the date the

incident is eventually closed are also placed in the log. Documentation related to the incident is

placed in an incident file and in the appropriate license file.

ORC staff responded to two of the incidents reviewed. One of the investigations was conducted

on the same day the notification was received, and the other was conducted within a week of the

notification. The program reviews the licensee’s report of the incident at the next inspection. The

review team determined that Alabama took prompt, appropriate action in response to the incidents

reviewed. The team observed that Alabama consistently addressed health and safety issues in

the incident follow-up. 

All incidents that required notification to the State were reported to the NRC. Reports of incidents

that required notification to the State within 24 hours were provided immediately to the NRC. 

However, prior to this year, reporting to the NMED of follow-up and routine event reports was

performed on a yearly basis. This year reporting has been performed on a quarterly basis. The

review team recommends that Alabama adopt a procedure providing that follow-up and routine

event reports to NMED be provided within 30 days of receipt of the report from the licensee.

In evaluating the effectiveness of Alabama's actions responding to allegations, the team examined

Alabama's response to the questionnaire relative to this indicator and reviewed the casework for

two allegations. Prior to 1997, allegations were not separated from incidents. For 1997,

allegations were provided a separate tracking number. During the review period, it is estimated

that Alabama received less than 12 allegations per year for both Agreement materials and other

radiation regulatory programs. During 1997, eight allegations were received, of which four were

related to Agreement materials.

One of the files reviewed was of an anonymous allegation which was not substantiated. In the

other file, the alleger contacted the program directly and did not request confidentially. The

investigation substantiated the allegation and the licensee was cited. The results were provided

to the alleger. 

Alabama evaluates each allegation and determines the proper level of response. The team’s

review of Alabama's responses and files determined that the responses are appropriate and that

investigations or determinations are adequately documented.
Alabama Final Report Page 10

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

performance with respect to the indicator, Response to Incidents and Allegations, be found

satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

State programs: (1) Legislation and Program Elements Required for Compatibility; (2) Sealed

Source and Device Evaluation Program; (3) Low-Level Radioactive Waste Disposal Program; and

(4) Uranium Recovery Program. Alabama's agreement does not authorize regulation of uranium

recovery activities.

4.1 Legislation and Program Elements Required for Compatibility

4.1.1 Legislation

Along with their response to the questionnaire, the State provided the review team with the

opportunity to review copies of legislation that affects the radiation control program. Legislative

authority to create the program and enter into an agreement with the NRC was granted in 1963

(Acts of 1963, No. 582). The State Board of Health is designated as the State's radiation control

agency. The authority to enter the Southeast Interstate Low-Level Radioactive Waste Compact

was granted in 1982 (Acts of 1982, No. 328). The team noted that the legislation had not

changed since the previous review. 

4.1.2 Program Elements Required for Compatibility

In its response to the questionnaire, Alabama indicated that all of the NRC regulatory

amendments, due for adoption through March 1998, that have been identified as needed for

compatibility or as having provisions significant to health and safety, have been adopted. A copy

of the effective Alabama regulations, including the last amendments which became effective as of

March 18, 1998, was given to the team. Separately, NRC staff has reviewed the final Alabama

regulations adopted March 18, 1998, and as a result of the review, determined that the regulations

meet the compatibility and health and safety categories established in OSP Internal Procedure

B.7.

The March 18, 1998 rulemaking included two amendments, the Clarification of Decommissioning

Funding Requirements effective for NRC licensees November 24, 1995, and exempt distribution of

a radioactive drug containing one microcurie of C-14 Urea effective for NRC licensees January 2,

1998. Alabama has not adopted the amendment to 10 CFR 19.12 contained in Radiation

Protection Requirements: Amended Definitions and Criteria (due 8/14/98). The other provisions

of that particular NRC rulemaking have been addressed by the State. The Program Director

indicated that the change to § 19.12 will be addressed, and that generally rule changes can be

completed in approximately three months. 
Alabama Final Report Page 12

! “Fissile Material Shipments and Exemptions,” 10 CFR Part 71 amendment (62 FR 5907)

that became effective February 10, 1997.

! “Licenses for Industrial Radiography and Radiation Safety - Requirements for Industrial

Radiography Operations,” 10 CFR Parts 30, 34, 71, 150 amendments (62 FR 28947) that

became effective June 27, 1997.

! “Radiological Criteria for License Termination,” 10 CFR Parts 20, 30, 40, 70 amendments

(62 FR 39057) that became effective August 20, 1997.

It is noted that Management Directive 5.9, Handbook, Part V, paragraph (1)(c)(iii), provides that

the above regulations should be adopted by the State as expeditiously as possible, but not later

than 3 years after the effective date of the new Commission Policy Statement on Adequacy and

Compatibility, i.e., September 3, 2000.

Based on IMPEP evaluation criteria, the review team recommends that Alabama’s performance

with respect to the indicator, Legislation and Program Elements Required for Compatibility, be

found satisfactory.

4.2 Sealed Source and Device (SS&D) Evaluation Program

During the review period, no SS&D certificates were issued by the State. The team reviewed the

State’s plans for reviewing a source or device if required. Although the State does not have a

branch dedicated to conducting reviews, it does have the authority to collect the full cost of an

evaluation, and to contract for a review by qualified persons. The team did not evaluate this

indicator further.

4.3 Low-Level Radioactive Waste Disposal Program

Alabama continues to be a member of the Southeast Interstate Low-Level Radioactive Waste

Compact, and is not designated as the host State. There is no activity to establish a low-level

radioactive waste disposal site in the State. The team did not evaluate this indicator further.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team found that Alabama’s performance with

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

recommended and the Management Review Board concurred, in finding the Alabama program to

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

Below is a summary list of recommendations and suggestions, as mentioned in earlier sections of

the report, for evaluation and implementation, as appropriate, by the State and others. 
Alabama Final Report Page 13

RECOMMENDATION TO THE ALABAMA:

The review team recommends that Alabama adopt a procedure providing that follow-up and

routine event reports to NMED be provided within 30 days of receipt of the report from the

licensee. (Section 3.5)

RECOMMENDATION TO NRC:

The review team recommends that NMSS evaluate the risks associated with the termination of

licensees with poor compliance history, particularly where the history suggests a lack of reliability,

and provide guidance on how and when a regulatory program should obtain confirmation of the

validity of the license of the receiving licensee, and that the materials or devices were actually

received by the receiving licensee. (Section 3.4)

SUGGESTIONS:

1. The review team suggests that the Alabama ORC continue their efforts to find ways to

increase the percentage of high priority reciprocity licensees, and out-of-State licensees

working in Alabama, to be inspected each year. (Section 3.1)

2. The review team suggests that the ORC accompany all material inspectors on a yearly

basis. (Section 3.2)

GOOD PRACTICE:

The review team identified the ORC’s self-audit as a good practice. The ORC initiated the selfaudit to assess the status of the comments and recommendations from the 1995 program review,

and to measure the current program against the IMPEP indicators. Corrective actions and

improvements in several areas were identified and implemented.
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Alabama Organization Chart

Appendix C Inspection File Reviews

Appendix D License File Reviews

Appendix E Incident File Reviews

Attachment 1 Alabama’s Response to Review Findings
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Richard Blanton, OSP Team Leader

Technical Staffing and Training

Legislation and Program Elements Required for 

 Compatibility

Sealed Source and Device Evaluation Program

William Silva, Texas Technical Quality of Inspections

Response to Incidents and Allegations

Joe DeCicco, NMSS Status of Materials Inspection Program

Technical Staffing and Training

Richard Woodruff, RII RSAO Technical Quality of Licensing Actions
APPENDIX B

ALABAMA OFFICE OF RADIATION CONTROL 

ORGANIZATION CHARTS


STATE OF ALABAMA DEPARTMENT OF 

PUBLIC HEALTH 

Donald E. Williamson, MD 

State Health Officer 

June 16, 1998 

Richard L. Bangart, Director 

Office of State Programs 

United States Nuclear Regulatory Commission 

Washington, D.C. 20555-0001 

Dear Mr. Bangart: 

. . 

‘& 

4 

I have reviewed, with the assistance of staff, the drafl IMPEP report for the State of Alabama 

Agreement State Program review which was held in our offices during April 20-23, 1998. In your 

May 27, 1998, letter you identified one recommendation, which requires a response and three 

suggestions. Iwill comment on the recommendation and suggestions as follows: 

“The review team recommends that Alabama adopt a procedure providing that reports of 

incidents that require immediate notification to the State be provided to the NRC within 24 

hours of notifkation, and that reports of incidents that require notification to the State within 

30 days be provided to the NRC monthly.” 

The recommendation is made not for a failure to report, but for failure to repon within 30 

days. Reports had previously been submitted on a quarterly basis instead of monthly. To my 

knowledge all required reports have been submitted to NRC. 

The Office of Radiation Control (ORC) recognizes the importance of submitting reports of 

this nature and strongly supports the process. ORC has revised internal procedures to require 

that the reports be submitted to NRC as recommended by the review team. 

The RSA Tower l 201 htonroc Srrcct l Monrpomcry, AL 3610-l 

P.O. Box 303017 . hkwgomcr~, AL 36130-301i 

ATTACHMENT 1 
Richard L. Bangart 

Page 2 

June 16, 1998 

Please be advised that NRC and Agreement States will be notified as early as possible of any 

incident/problem that might have impact on NRC or Agreement State licensees. We will not 

wait 30 days. As an example, the IMPEP draft report, Page F-2, contains the report of a 

review for “File No. 33”, and a statement that this occurrence did not meet the criteria for 

reporting to NRC. However, ORC did report to NRC and the event synopsis was published 

by NRC as an event. 

The recommendation has been implemented by ORC. 

&ggestion: 

“The review team suggests that the Alabama ORC continue their efforts to find ways to 

increase the percentage of high priority reciprocity licensees, and out-of-state licensees 

working in Alabama, to be inspected each year.” 

Pesponse; 

ORC recognizes the importance of inspecting licensees working under reciprocal recognition 

of other agency licenses. ORC accepts the suggestion of the review team an will increase 

efforts to inspect more reciprocity and out-of-state licensees. 

Several factors make this a difficult task. Examples include the thirty day reciprocity limit 

provided by the rules, the location of a high percentage of work done under reciprocity (City 

of Mobile shipyards, off-shore work, and oil & gas fields in Southwest Alabama - all of which 

involve 200 plus miles of travel), scheduling difficulties, short advance notification times, etc. 

Again, efforts will be made to increase inspection numbers (percentages) in this area. 

“The review team suggests that the ORC accompany alI material inspectors on a yearly basis.” 

During an internal review of ORC, staff discovered that a required accompaniment for one 

inspector had not been made within the previous year as required by both ORC and NRC. The 

accompaniment had been scheduled previously; however, due to conflicts it had been 

canceled. Upon recognition of the problem, an accompaniment was immediately scheduled 

and conducted by management -prior to the review. 
Richard L. Bangart 

Page 3 

June 16, 1998 

It is the policy, and has been the policy, of ORC that supervisory accompaniments of all 

inspectors will be conducted at least once each year. The failure was actually corrected prior 

to the review. 

“The review team suggests that during termination of licenses with poor compliance 

history....confirmation of the validity of the license of the receiving licensee be obtained 

directly from the agency having jurisdiction, and that confirmation that the materials (devices) 

were received be obtained directly from the receiving licensee.” 

The suggestion resulted from actions taken with the termination of one license. That licensee 

did have a poor performance history. The license was terminated following standard 

office procedure. The licensee had submitted to ORC a record of transfer containing proper 

information, a signed record of receipt from the receiving company including the recipient’s 

license number and a business card of the recipient. These records were in the terminated file. 

That would have normally been sufficient information for termination. 

Please note that this suggestion Sould not imply that records were not submitted to ORC 

with the termination request. The problem is that ORC staff did not contact.the receiving 

out-of-state licensee to verify receipt of the americium 24 1 roof gauge nor was contact made 

with the Agreement State licensing stafF to verify that the recipient actually had a license to 

possess the device. ’ 

The suggestion made by the review team is accepted and internal procedures have been 

implemented to apply this suggestion when terminating any license with poor compliance 

history. This suggestion had not previously been made. 

The recommendation and three suggestions made by the review team are accepted, and each 

has been implemented, by the Office of Radiation Control. 

For the record I would like to address several phrases and statements made in the body of the 

draft report as follows: 

1. The draft report, page 3, states that ORC currently has no inspections overdue by 

more than 25% of the established interval. That statement is factual but does not paint 

a true picture. There are no overdue inspections - neriod. The 25% limit is a limit - 

the standard is “to keep up-to-date.” 
d 

, 

Richard L. Bangart 

Page 4 

June 16, 1998 

2. On page 3 of the drafl report a statement is made that if a new licensee does not 

possess licensed material during the first five months of the license that the inspection 

frequency is extended another five months. That extension is not automatic. An 

inspector contacts the licensee and depending upon the judgement -of the inspector 

and his supervisor, the inspection m be extended for five months. 

3. On page 5 of the draft report a statement is made that ORC performs calibration of 

instruments at six month intervals. Actually calibrations are performed at three (3) 

month intervals. 

4. Refer to Appendix D, Page D. 1, of the draft report, License File No. 3. The initials 

of the inspector should be “RP” (Ron Pass), not “DP”. 

5. Refer to Page E.5 of the draft report. The comment under File No. 26, as written, 

could be interpreted that no documentation was in the file, when the intent should be 

that ORC did not verify the validity of the documentation which was actually in the 

file. 

I would like to commend the review team of Richard Blanton, William Silva, Joe DeCicco, 

Richard Woodruff, and Paul Lohaus for their professionalism and courtesy. The recommendation 

and suggestions made by the team are accepted without contention and have, in fact, been 

implemented. 

In Article V of the Alabama/NRC Agreement there appears the following statement: 

“Ihe State will use its best efforts to cooperate with the Commission and other Agreement 

States in the formuIation of stanabrds and regulatory programs....... ” 

That commitment, made almost thirty two (32) years ago, remains our commitment today. 

The support and assistance of NRC is recognized and appreciated. 

have any questions regarding this letter. 

Please contact me if you 

Sincerely, 

KEWljsm 

Kirksey E. Whatley, Director’ 

Office of Radiation Control