Mr. Gary R. Mitchell, Secretary

Kansas Department of Health and Environment

Landon State Office Building, Room 620

900 S.W. Jackson Street

Topeka, KS 66612-1290

Dear Mr. Mitchell:

On September 9, 1998, the Management Review Board (MRB) met to consider the proposed

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Kansas

Agreement State Program. The MRB found the Kansas program adequate, but needs

improvement and compatible with NRC’s program. 

Section 5.0, page 17, of the enclosed final report presents the IMPEP team’s recommendations 

and suggestions.

Based on the results of the current IMPEP review, a follow-up review focusing on the technical

quality of licensing will be scheduled next year. The timing of the next full review will be

coordinated with your staff.

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: Ronald Hammerschmidt, Director

Division of Environment

Kansas Department of Health and Environment

Vick L. Cooper, Chief

Radiation Control Program

Bureau of Air and Radiation

Kansas Department of Health & Environment

bcc: Chairman Jackson

Commissioner Diaz

Commissioner McGaffigan

Distribution: See next page.

*See previous concurrence.

DOCUMENT NAME: G:\IMPEP\KS98FNLT.WPD, G:\IMPEP\KSIMP98.FNL 

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 OSP:DD OSP:D DEDR

NAME JHornor:kk PHLohaus RLBangart HLThompson

DATE 09/17/98* 09/ /98 09/ /98 09/ /98
OSP FILE CODE: SP-AG-10 

- 2 -

Distribution:

EDO RF LHowell, RIV

DIR RF CHackney, RIV DCD (SP01)

SDroggitis LMcLean, RIV PDR (YES_/__ NO___)

KSchneider FCameron, OGC

LRakovan HNewsome, OGC

JThompson, AR LBolling/ASPO

JJohansen, NMSS TCombs, OCA (2 copies)

GDeegan, NMSS KCyr, OGC

DCool, NMSS CPaperiello, NMSS

FCameron, OGC TMartin, AEOD

HNewsome, OGC RQuillin, CO

LBolling/ASPO FCombs, NMSS

Kansas File

 
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF KANSAS AGREEMENT STATE PROGRAM

June 15-19, 1998

FINAL REPORT

U.S. Nuclear Regulatory Commission

ATTACHMENT 1
Kansas Final Report Page 1

1.0 INTRODUCTION

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

review was conducted during the period June 15-19, 1998, by a review team comprised of

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

State of Arkansas. 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 November 25, 1997, revised NRC Management Directive 5.6,

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

review, which covered the period May 19, 1995, to June 19, 1998, were discussed with Kansas

management on June 19, 1998. The State detailed the preliminary steps taken to address the

review findings in a letter dated July 9, 1998 (Attachment 1).

A draft of this report was issued to Kansas for factual comment on July 22, 1998. The State

responded in a letter dated August 20, 1998 (Attachment 2). The State’s factual comments were

considered by the team and accommodated in the final report. The Management Review Board

met on September 9, 1998 to consider the proposed final report. The MRB found the Kansas

radiation control program was adequate, but needs improvement, and compatible with NRC’s

program. A progress report as of September 4, 1998 was also submitted to NRC by the State

(Attachment 3).

The Kansas Agreement State program is administered by the Secretary, Department of Health and

Environment (DHE), who reports directly to the Governor. The radiation control program is

administered by the Radiation Control Program (RCP), under the direction of the Bureau of Air

and Radiation, Division of Environment. DHE and RCP organization charts are included as

Appendix B. The radioactive materials inspection program is administered by the supervisor of

the X-Ray and Materials Unit, under the direction of the RCP radiation control program director

(RCPD).

At the time of the review, the Kansas program regulated approximately 315 specific licenses,

including manufacturers, broad academic programs, broad medical programs, brachytherapy, high

dose afterloaders, nuclear pharmacies and industrial radiographers. 

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 Kansas.

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

performance indicators was sent to the State on February 25, 1998. The State provided a

response to the questionnaire on May 18, 1998. During the review, discussions with the State

staff resulted in the responses being further developed. A copy of the final response is included in

Appendix F of this report. 
Kansas Final Report Page 2

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

Kansas' response to the questionnaire; (2) review of applicable Kansas statutes and regulations;

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

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

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

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

IMPEP performance criteria for each common and non-common indicator and made a preliminary

assessment of the radiation control program's performance.

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

performance 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 made by the review team 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. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous routine review, which concluded on May 19, 1995, three comments and

recommendations were made and the results transmitted to James O'Connell, Secretary, DHE, on

October 31, 1995. The team’s review of the current status of these recommendations is as

follows:

(1) The Kansas program had not adopted amendments equivalent to three NRC regulatory

amendments: "Emergency Preparedness for Fuel Cycle and Other Radioactive Material

Licensees," 10 CFR Parts 30, 40, and 70; "Safety Requirements for Industrial

Radiographic Equipment," 10 CFR Part 34; and "Notification of Incidents," 10 CFR 

Parts 30, 40, and 70. In addition, the requirements of the State's regulation on financial

assurance for decommissioning were not compatible since they differed significantly from

the NRC 10 CFR Parts 30, 40, and 70 Decommissioning Rule which became effective July

27, 1988. It was noted in regard to the Emergency Preparedness Rule that at the time of

the review, there were no major manufacturers or processors in Kansas and that perhaps

no licensee was authorized to possess radioactive materials in excess of the criteria

specified in 10 CFR 30.72, Schedule C, in which case the rule was not required. It was

recommended that an audit of licenses be performed as soon as possible, to determine if

adoption of the Emergency Preparedness Rule, as discussed above, is required. The other

rules should be promulgated as soon as possible, and license conditions should not be used

in substitution for the Industrial Radiography Equipment Rule.
Kansas Final Report Page 3

Current Status: The Notification of Incidents Rule, the Emergency Preparedness Rule,

and the revised Decommissioning Rule became effective November 1, 1996. The

Industrial Radiography Equipment Rule was not formally adopted by the State. The State

is currently enforcing this rule by license condition. The State advised that, immediately

after the previous review, the former program director conducted a review of licensees

and determined that none of the licensees met the possession limits specified in the

Emergency Preparedness Rule. The “Safety Requirements for Industrial Radiographic

Equipment” Rule was re-evaluated under the new Commission Policy Statement on

Adequacy and Compatibility and will be addressed in Section 4.1.2. This recommendation

is closed.

(2) The Kansas program should modify the informal policy of waiting for the Suggested State

Regulation (SSR) to be issued before starting the adoption of a rule or amendment which

is required for compatibility. Consideration should be given to adding a policy provision

which requires drafting a proposed rule based directly on the equivalent NRC rule if an

SSR is not available in time to permit adoption of a Kansas rule which would become

effective within 3 years after NRC adopts the rule.

Current Status: The State advised they are aware of the importance of adopting rules or

amendments which are required for compatibility within the three-year time requirement. 

Therefore, if the SSR is not available, the State’s policy is to base equivalent Kansas

regulations on the NRC rule, with every effort made to meet the three-year time limit. 

This recommendation is closed.

(3) If the response to an actual incident is to be used as a basis to meet the NRC guideline for

emergency drills, we recommend that there should be a formal evaluation of the response

actions compared to the planned actions to provide a feedback of lessons learned, and to

form the basis for modifications to the plan or to provide additional training of responders,

as indicated. The plan itself should also be modified, if necessary, to provide guidance for

such a critique.

Current Status: As a result of this recommendation, procedure RHS-47 “Emergency

Response Documentation” was developed to provide guidance for an evaluation of the

response actions compared to the planned actions. This recommendation is 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. 
Kansas Final Report Page 4

3.1 Status of Materials Inspection Program

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

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

licensees. 

The team’s review of the State's inspection priorities, as documented in procedure RHS-7,

“Inspection Priority System Radioactive Materials” dated January 3, 1986, showed that the State's

inspection frequencies for the various types or groups of licenses are at least as frequent as similar

license types or groups listed in the frequency schedule in the NRC Inspection Manual Chapter

(IMC) 2800. Some licensees, such as medical private practice and portable gauge licensees are

inspected every 4 years while the NRC inspects them every 5 years.

The staff informed the team that the current tracking system projects the next inspection due date

and is able to sort inspection data by type of license, name, priority, and inspection dates. All

history for a particular license, such as types and number of violations or recommendations from

previous inspections and dates of previous inspections must be extracted manually from the

specific licensee’s file. Program management explained that their old D-Base III program is

outdated and that funding has been approved to acquire a new computer system that will provide

the capabilities needed to track inspection and compliance data. 

The supervisor stated that every 6 months, he prints a list of licenses with inspections due in the

next 6 months. The inspectors are given the list and divide the inspections among themselves. 

Management does not assign inspections by priority and geographical location. Once an

inspection is completed, the inspector updates the tracking system. The supervisor monitors the

tracking system monthly to ensure that inspections have been performed and the dates in the

tracking system have been changed by the inspector. 

In their response to the questionnaire, Kansas indicated that as of May 20, 1998, only four

licenses identified as requiring core inspections in IMC 2800 were overdue by more than 25

percent of the NRC frequency. These inspections were performed during the week of June 1-5,

1998, with the inspector accompanied by an IMPEP review team member. The team verified

from the records that as of June 15, 1998, there were 315 active licenses and all inspections were

current.

The team looked at the State's experience with overdue inspections during the entire review

period and concluded that for much of the period, the State operated with a significant backlog of

overdue inspections. This weakness was identified by the State prior to the review and was

detailed in their questionnaire response. The actual extent and severity of the backlog throughout

the period could not be accurately determined because of the tracking system’s inability to extract

the status of the inspection program at earlier dates. Therefore, the conclusions made by the team

are based on the results of file reviews and interviews with the staff. From the casework

reviewed, 6 of the 14 inspections for core licenses were conducted as overdue inspections,
Kansas Final Report Page 5

exceeding the 25 percent window allowed in IMC 2800. In reviewing 7 Priority 1 licenses for

routine inspections, it was found that 5 were overdue by 6 months to 2 3/4 years.

The team noted in reviewing RHS-7 that the procedure allows for modification of the frequency

based on experience with individual licensees; however, no specific criteria comparable to that

stated in IMC 2800 for extension or reduction of inspection frequencies is included in RHS-7. 

The State did not administratively extend the inspection frequency of any licensees during the

review period.

With respect to initial inspections of new licensees, the State’s policy is to inspect all new

licensees within 6 months regardless of whether the licensee receives radioactive material. Four

of the 22 files reviewed were initial inspections, and all were overdue at the time of the initial

inspection. The team also reviewed casework involving nine additional new licenses to ensure an

accurate determination of whether the initial inspections were completed within the Kansas

standard of 6 months after the license is issued. In 3 of the 9 additional files reviewed, the team

found that the license had not been inspected in accordance with the Kansas policy, for a total of

7 of 13 overdue initial inspections. The inspections were completed 1 to 7 months late. Of the 46

new licenses issued within the review period, the tracking system identified only two recently

issued licenses that had not been inspected.

On examination of the factors contributing to the lack of timeliness in performing inspections at

the stated frequency, the IMPEP team noted the program was not fully staffed during 6 months of

the review period. The team also concluded that the lack of RCP management oversight during

the period between the former section chief’s retirement in mid-1996 until a new section chief was

selected in January 1997 may also have contributed to the deficiencies found in the program

during the review period. 

Based on the record of overdue inspections during the review period, the review team

recommends: (1) that Kansas heighten its management oversight of the inspection due dates of

core licenses (Priority 1, 2, and 3 licensees) to ensure inspections are performed at the required

frequencies; and (2) that the new inspection tracking system currently under development include

provisions for flagging initial inspections at an early date to ensure they are inspected within 6

months of date of license issuance. In addition, Kansas should consider updating procedure RHS7 to incorporate procedures on initial inspections as stated in IMC 2800, Section 04.03 a. 

The State reported in its response to the questionnaire that 73 licensees were granted reciprocity

permits during the review period. Seven of 45 Priority 1 licensees were inspected; 1 of 9 Priority

2 licensees was inspected; and no Priority 3 licensees were inspected. Further review of the

records showed that 50 separate licensees were granted 214 reciprocity permits during the period. 

According to the State’s records, 11 reciprocity inspections were performed during the review

period, 10 of which were in 1997 and 1998. The State did not meet the inspection percentage

goals for conducting inspections of reciprocity licensees as outlined in Appendix III of NRC

Inspection Manual Chapter 1220 (IMC 1220). RHS-7 lists reciprocity as a Priority 5 inspection
Kansas Final Report Page 6

frequency, as resources allow. The review team recommends that the State’s “Inspection Priority

System” be revised for reciprocity inspections to correspond to the inspection goals in IMC 1220. 

The review team recommends the State conduct reciprocity inspections at intervals equal to those

stated in IMC 1220.

The timeliness of the issuance of inspection findings was also evaluated during the review of

completed inspections. Of the casework examined, 19 of 22 inspections performed during the

review period had inspection correspondence issued to the licensee within 30 days after

completion of the inspection. Sixteen of the 19 were issued within 10 days of the inspection. In

the three remaining instances, two inspection findings were issued within 35 days and one was

issued 6 months after the inspection. 

Based on the IMPEP evaluation criteria, the review team recommended that Kansas' performance

with respect to the indicator, Status of Materials Inspection Program, be found unsatisfactory. 

Due to the State’s actions in eliminating the inspection backlog and increasing management of the

inspection program, the MRB found Kansas’ performance with respect to this indicator to be

satisfactory with recommendations for improvement. 

3.2 Technical Quality of Inspections

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

and interviewed inspectors for 22 materials inspections conducted during the review period. The

casework included all five of the State's materials inspectors, including the supervisors, and

covered inspections of various types including medical (broad scope, institutions, research, private

practice and mobile services), radiography, well logging, fixed and portable gauge, self-shielded

irradiator, academic, service and other industrial licensees. A review team member performed

accompaniments of three State inspectors on four separate inspections of licensed facilities. 

Appendix C lists the completed inspections reviewed in depth with case-specific comments as well

as the results of the accompaniments.

Kansas Enforcement Procedures outlined in RHS-24 identify actions such as hearings, orders and

civil penalties. In discussing the policy, the RCPD stated there had been only one escalated

enforcement case during the review period. The 22 files reviewed by the team contained routine

notifications to the licensees of clear inspections, except for one case in which violations resulted

in a follow-up inspection. 

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

licensee's radiation safety program. Some deficiencies were noted and are documented in

Appendix C. The team also noted the inspectors observed licensed operations or had operations

demonstrated whenever possible. According to program management, the State occasionally

conducts team inspections of licenses depending on the type, size, and inspection history of the

licensee. The unit supervisor estimated that there were 3-5 team inspections per year during the

review period.
Kansas Final Report Page 7

The team reviewed the inspection field notes and found them to be comparable with the types of

information and data collected under NRC Inspection Procedure (IP) 87100. The inspection field

notes provided documentation of inspection findings in a consistent manner. The State uses one

standard form of inspection field notes applicable to all types of licensees, such as nuclear

medicine, portable gauges, radiography, and industrial/academic with a supplemental sheet added

to cover additional specific requirements at medical and industrial radiography licensees. The

inspection field notes provide documentation of the scope of the licensee's program including,

posting; storage and use of radioactive material; receipt, transfer, and disposal of radioactive

material; inventory; leak tests; radiation protection program; personnel monitoring; training;

independent measurements; and inspection findings. 

The team noted that the inspection reports did not document the names of all individuals

contacted and interviewed during the inspection other than those identified in the “Exit Summary”

part of the form. The review team recommends that the inspection report form be strengthened

by including names of individuals contacted and interviewed in greater detail. The inspection

form also does not adequately document review of incidents and the licensee’s corrective actions. 

This is addressed in Section 3.4 of this report.

The team noted that all Kansas inspectors used the inspection report form in procedure RHS-28

to ensure that all aspects of the program that could be reviewed were included in the scope of the

inspection. Inspectors performed independent measurements whenever the licensee was using

licensed material and also measured for radiation levels surrounding materials in storage. 

Inspectors' written comments in the field notes and the team member's observations during

accompaniments indicate that safety issues were discussed with licensee personnel. The

inspection reports indicate, and the team member’s observations during accompaniments support,

that inspectors routinely toured licensee’s areas such as laboratories, other locations of use, and

storage areas. Operations were observed when licensed operations were being conducted by the

licensee. Interviews with the licensee’s users and staff were conducted by the State inspectors. 

The inspectors emphasized the observation of licensed activities to determine the effectiveness of

the licensee's radiation safety program and compliance to the requirements. The inspection

reports indicated that the inspectors examined, and when appropriate, closed-out violations found

in previous inspections. 

A review team member accompanied three Kansas inspectors to four separate licensed facilities

during the period of June 1–5, 1998. The accompaniments included an inspection of a

radiography program (office only); an initial inspection of a portable gauge licensee (office only);

an inspection at a hospital having diagnostic and outpatient radiotherapy authorization; and a

hospital licensed for diagnostic, radiotherapy, brachytherapy, and teletherapy procedures, as well

as nuclear pharmacy distribution. During the accompaniments, the Kansas inspectors

demonstrated appropriate inspection techniques and knowledge of the regulations. The

inspectors were well prepared and very thorough in their reviews of the licensee's radiation safety

program. Each inspector emphasized, to the extent possible, observation of the licensee's

activities and interviews with personnel to assess the effectiveness of the licensee's radiation
Kansas Final Report Page 8

safety program. Three of these licensees were sent enforcement letters with recommendations

and/or violations clearly documented. Overall, the technical performance of the inspectors was

satisfactory, and their inspections were adequate to assess radiological health and safety at the

licensed facility. 

The IMPEP team noted that the State relies on the technical knowledge of the inspectors to

evaluate licensees’ assessments of root causes of noncompliance and poor licensee performance

rather than having procedures in place which normally could be used to assist the inspectors in

this evaluation. The review team recommends that Kansas provide direction to the inspection

staff to help them identify poor licensee performance, identify when licensee root cause

evaluations should be conducted, and to help them evaluate licensee root cause assessments. 

Staff members’ skills could also be improved by attending a training course that teaches these

techniques as part of the inspector qualification process.

In response to the questionnaire, the State reported only the number and type of supervisory

accompaniments performed during 1997 and 1998. In discussing accompaniments during the

May 1995 to November 1997 time frame, which is not covered in the questionnaire, three staff

members recalled being accompanied by the previous program director. However, no records

could be found documenting the earlier accompaniments. The new program management

explained to the review team that Kansas is now committed to conducting annual

accompaniments and that a new form has been developed to document the accompaniments. 

According to the questionnaire, two of the three inspectors, as well as both supervisors, were 

accompanied within the past 12 months. The third inspector was accompanied just prior to the

review. The review team suggests that the State continue to adhere to their policy of annual

supervisory inspector accompaniments.

As noted in the questionnaire, the State has available a variety of portable instruments for routine

confirmatory surveys and use during incidents and emergency conditions. The instruments are a

mix of low and high range Geiger-Mueller (GM) detectors and a variety of probes, micro R

meters, neutron and alpha detectors, ion chambers, rate meters, and a multi-channel analyzer. The

portable instruments used during the inspector accompaniments completed by the review team

were observed to be operational and calibrated. The reviewer noted that the instruments are

calibrated on an annual basis against radiation standards which are traceable to the National

Institute of Standards and Technology.

The IMPEP reviewer inquired as to the Kansas policy on unannounced versus announced

inspections. Program management indicated that the policy was to conduct unannounced

inspections whenever possible. Announced inspections usually involved initial inspections or

inspections at licensees in geographically-distant locations from Topeka. The IMPEP reviewer

noted that 14 of the 22 files reviewed were unannounced inspections. To ensure the presence of

knowledgeable licensee staff, all of the inspections performed with a review team member

accompaniment were announced.
Kansas Final Report Page 9

Inspectors have been delegated the authority to sign all routine enforcement correspondence. 

Inspection findings generally lead to appropriate and prompt regulatory action. However, the

supervisor apparently did not review and sign the field notes documenting the findings of the

inspection prior to the issuance of the inspection findings letter for 13 out of 22 of the inspections 

reviewed by the team. It was noted that for the five cases reviewed for inspections performed in

1998, all had management review as indicated by the materials supervisor’s signature. This is a

marked improvement from the lack of review in the May 1995 to December 1997 time frame. 

The review team recommends that the State continue to maintain management oversight of the

inspection program. 

Based on the IMPEP evaluation criteria, the review team recommends that Kansas' performance

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

3.3 Technical Staffing and Training

Issues central to the evaluation of this indicator include the radioactive materials program 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 State's questionnaire responses relative to

this indicator, interviewed program management and staff, and considered any possible workload

backlogs. 

The RCPD identified 3 FTEs of technical effort in the materials program. At the time of the

review, 2 of the staff members were devoted exclusively to the radioactive materials program, and

1 staff member was devoted exclusively to mammography inspections. The RCPD stated that the

technical staff member currently completing mammography inspections would soon be working in

the radioactive materials program except for approximately 12 x-ray inspections per year (80%

RAM and 20% mammography). These technical staff members perform both inspection and

licensing functions. The RCPD also identified 0.5 FTE devoted to the materials program from the

X-Ray and Materials Unit Chief, who provides both management and technical effort.

The RCPD directs all areas of the RCP including radioactive materials, x-ray, radon, emergency

response, environmental monitoring, and emergency preparedness. There are two units in RCP: 

the Environmental Monitoring and Emergency Preparedness Unit and the X-Ray and Materials

Unit, each headed by a supervisor.

Based on the response to the IMPEP questionnaire and discussions with program management,

the review team noted that during the review period, the RCPD position was vacant from June

1996 to January 1997 when an RCP staff member was promoted to fill the position. The position

of X-Ray and Materials Unit Chief was created during a reorganization and filled in October

1997. One new radiation materials inspector/reviewer was hired during the review period. The

deficiencies in the Kansas program, including the inspection backlog over the review period and

the concerns associated with the technical quality of licenses, may be related to the current
Kansas Final Report Page 10

staffing level. Kansas staffing levels are below those of NRC Regional programs and may be

below some Agreement State programs of similar size.

Although no vacancies exist in the radioactive materials program, one environmental technician

position and one x-ray inspector position within the section were vacant at the time of the review. 

Also, one of the radioactive materials inspectors was working almost exclusively in the

mammography inspection program. During interviews, staff commented that the use of

radioactive materials staff for other radiation-related tasks could affect the ability of the staff to

complete assigned duties. The review team suggests that the State assess whether the

radioactive materials program staffing level was a contributing factor to the program deficiencies

during the review period and evaluate the impact of the open positions in the RCP on radioactive

materials staff to determine if added staffing or reassignment of duties is necessary.

The review team determined that successful candidates for technical positions are required to have

a Bachelor’s degree in science or comparable education and experience. From the review of

technical qualifications of current staff, the review team concluded that Kansas has been able to

hire qualified individuals. 

The State does not have a documented training program; however, the State has a formal

“Training Qualification Form” modeled after the recommendations made by the joint NRC/OAS

Training Working Group Recommendations for Agreement State Training Programs. Thus, if an

employee has not taken a required class, it may not be apparent that they are still expected to take

it. 

The Kansas staff is lacking formal course work in a number of different areas. Although formal

course work on the transportation of radioactive materials was designated as being required for

radioactive materials inspectors, none of the current radioactive materials inspectors in the State

have attended this class. Also, none of the current inspectors have had formal training in

teletherapy/brachytherapy even though two inspectors who have been with the program for 6 and

12 years, respectively, complete such inspections routinely. In interviews, staff members

expressed the need for training in several areas, including teletherapy/brachytherapy and refresher

training in a variety of subjects. Also, the unit supervisor has not received formal training in

licensing work, although one of his primary tasks is a supervisory review of all licensing actions. 

Staff members expressed concern about completing some assigned tasks without the proper

training. The review team recommends that the State document a training and qualifications

program equivalent to that contained in the “NRC/OAS Training Working Group

Recommendations for Agreement State Training Programs,” assess the current training needs of

all radioactive materials staff, and provide the necessary training to ensure that all staff are

properly trained to complete assigned tasks. 

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

Kansas' performance with respect to the indicator, Technical Staffing and Training, be found

satisfactory with recommendations for improvement.
Kansas Final Report Page 11

3.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed the reviewers for 18

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 reviewed for accuracy, appropriateness of the license and its conditions, tie-down

conditions, and overall technical quality. 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 authorities. The files were checked for retention of necessary documents and

supporting data.

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

which had been completed in the review period, and to include work by all reviewers. The crosssection sampling included all of the State's major licenses as defined by the State in the

questionnaire and included the following types of licenses: broad academic; broad medical;

academic; industrial radiography; medical - private practice and high dose remote afterloader;

nuclear pharmacy; well logging; portable gauges; manufacturing and distribution. Licensing

actions included three new licenses, five renewals, nine amendments, and three terminations. 

Licensing actions during the review period included 46 new licenses and 474 amendments

(including 65 terminations), for 520 licensing actions. A list of the licenses reviewed with casespecific comments can be found in Appendix D.

Overall, the IMPEP review indicated chronic problems with respect to thoroughness,

completeness, consistency, and clarity of licensing actions. Of the 18 licensing files reviewed, 16

had documentation missing. In evaluating the thoroughness and completeness of the licenses, the

following deficiencies were found: tie-down documentation missing from the license file;

amendment issued without a management signature; letter for amendment request with supportive

documentation not referenced as tie-down condition; and evaluation for financial surety and

required emergency planning for licensee with a significant increase in their possession limit of H3 and C-14. One file was missing four separate tie-down documents. In another license, the

applicant did not designate a Radiation Safety Officer (RSO), yet the authorized user was named

RSO when the license was issued even though there was no documentation indicating that the

matter was addressed with the licensee. It was also noted in the terminated file reviews that there

was lack of documentation of a licensee’s close-out survey and determination of transfer of a

radiography camera.

Inconsistencies between similar licenses were noted, including in the use of the Kansas Standard

License Condition for transportation of radioactive material, application of the Quality

Management Plan, and requirements for a radiation protection program. Another inconsistency

found was the application of a standard license condition involving radiographic exposure devices
Kansas Final Report Page 12

and associated equipment requirements for radiographers. This topic is discussed further in

Section 4.1.2.

Clarity of licensing actions was also a problem in the licensing casework reviewed. In one of the

Academic, Broad A licenses, the frequency of audits was not addressed during the reviews, and it

was unclear who would conduct these reviews. In a similar license, the frequency of the annual

audits was listed as “periodic.”

The lack of documentation throughout the entire licensing review process affects the technical

quality of licenses, and could lead to potential health and safety problems. For example, two

separate licenses reviewed did not adequately address proper radiation protection procedures,

even though they were licensed to use plutonium-238 in any form, and uranium-233 and 235 in

research and development procedures, respectively. The pharmacy incorrectly licensed to use

plutonium was also licensed to transfer the plutonium as well as nickel-63 to an authorized

recipient “to possess and use the radiopharmaceuticals.” As discussed previously, a Quality

Management Plan was not requested or reviewed for a medical licensee. These items are

discussed in greater detail in Appendix D. The number of the potential health and safety issues

due to licensing inadequacies cannot be accurately assessed because of the lack of file

documentation. 

The review team recommends that program management consider increasing supervisory

oversight to ensure that all pertinent items are adequately and properly addressed during the

review process to provide quality assurance and to improve the technical quality of licenses.

The review team also recommends that the State begin a self-evaluation of all existing licenses to

determine the technical quality and to identify potential health and safety issues. This evaluation

should be accomplished as soon as possible to identify and correct other possible license

deficiencies. In addition, the State should ask licensees to supply copies of any missing

documents that should be included with the application.

The review process was discussed with the primary reviewers and staff. Application packages

containing guidance are sent to each license applicant. Reviewers use this guidance as the main

reference to verify that all appropriate items are adequately addressed in the licensing actions. 

Other applicable guidance from the NRC is available for additional reference. Inspection

compliance history is evaluated to determine license adequacy and to identify potential health and

safety issues. During interviews with the staff, it was indicated that the latest Kansas regulations,

issued in 1996, are not reflected in the license guidance. The review team recommends that RCP

update the license guidance to address and parallel the current Kansas Radiation Protection

Regulations to assist in the consistency and accuracy of the license review process. 

License applications are reviewed following standard procedures, which are similar to those used

by the NRC. Reminder notices are sent to the licensees 30-60 days prior to the expiration date. 

Timely renewal letters were found in the license files. Staff typically uses Standard Licensing
Kansas Final Report Page 13

Conditions similar to those used by the NRC. Licenses are issued for 2 years and can be easily

renewed if there are no significant changes in the radiation protection program. Licenses are

amended in entirety after 10 years or if five major amendments are requested. Renewals are

processed, reviewed and often completed within 30 days of receipt. Currently, there is no

licensing backlog. License files have all current inspection data, providing license reviewers with

incident reports and inspection reports during the renewal period. Incidents are, for the most

part, cross-referenced in the licensing files. 

Generally, licensing actions receive supervisory review and are signed by management. These

reviews are conducted by the unit supervisor or RCPD. Requests for additional information or

clarifications are returned to the primary reviewer as needed. The RCPD conducts a final review

prior to signature and issuance of the license. There is no documented checklist or verification of

secondary reviews, and only the signature of the RCPD indicates that the licensing actions are

complete. 

Primary and secondary reviewers do not use check lists or document verification of the

thoroughness and completeness of the licensing actions. Staff members indicated that, based on

their technical experience and familiarity with the licensees, the license reviews are assumed to be

thorough and complete, and there is no unique documentation of the reviewer’s assessment. 

Interviews with the staff indicated that unless additional information was requested, it is assumed

that all items are satisfactory. Deficiencies are addressed in letters to the licensee using

appropriate language. License reviewers frequently use telephone conversations to communicate

with the licensee requesting additional information. Documentation of telephone conversations

was not available in many files during the IMPEP evaluation. The review team recommends that

licensing check lists be developed, used, and retained in the file to ensure that all elements of the

application have been submitted and that the license is complete.

RCP staff may perform pre-licensing visits on a case-by-case basis for unusual licensing requests. 

However, the RCPD stated that it is not Kansas policy to complete pre-licensing visits. During

interviews with staff members, one member indicated that he conducted pre-licensing visits

approximately 10-15 percent of the time and that he hand-delivered licenses occasionally if there

were inspections due in that part of the State. No documentation of pre-licensing visits or handdelivered licenses was observed or reviewed during the IMPEP evaluation. The review team

recommends that the State place documentation of any pre-licensing visits in the appropriate

licensing file.

Of the 18 licensing files reviewed, only four deficiency letters were found, and the deficiencies 

identified in the letters were minor. Though it is not impossible for so few problems to be present

in this size sample of licenses, the review team is concerned about the small number of

deficiencies identified by the State in this casework, the quick turn around time for license

reviews, and the technical quality of the licenses reviewed.
Kansas Final Report Page 14

Based on the IMPEP evaluation criteria, the review team recommended that the Kansas’

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

unsatisfactory. Due to the State’s actions in responding to the review team’s findings, the MRB

found Kansas’ performance with respect to this indicator to be satisfactory with recommendations

for improvement.

3.5 Response to Incidents and Allegations

In evaluating the effectiveness of the State's actions in responding to incidents and allegations, the

review team examined the State's response to the questionnaire relative to this indicator, reviewed

the incidents reported for Kansas in the "Nuclear Material Events Database (NMED)" against the

Kansas records, interviewed the incident respondents, and reviewed in depth the four reportable

incidents that occurred during the review period. The team also reviewed the State's response to

two allegations including the one allegation referred to the State by the NRC during the review

period. A list of the incident casework with comments is included in Appendix E.

The records showed that 41 incidents and two allegations were reported to the State during the

review period. The team reviewed the incident log and performed a cursory review of the

incident files and found that only four of the incidents involving AEA material required a report by

the licensee.

The Kansas Department of Emergency Management (DEM) has the lead for all hazardous

materials accidents within the State. Except for reports from licensees during office hours, all

events are reported to DEM, which sends first responders equipped with survey meters to isolate

and barricade the area until the RCP can respond and assume responsibility for handling the event. 

Allegations and incidents involving Kansas licensees are traditionally handled by the RCP X-Ray

and Materials Unit, while all other incidents are assigned to the Environmental Monitoring and

Emergency Preparedness Unit. However, staffs of both units are cross-trained and respond as

needed. 

The team found that incident response procedures are in place except for misadministrations. The

incident response procedures were last revised in 1983 and have not been revised to incorporate

NMED per OSP procedure “Reporting Material Events - SA-300,” dated 

February 25, 1998. The team recommends that the State revise their incident response procedure

to conform with OSP procedure, SA-300, including medical events. 

The team found the procedures for handling allegations were adequate (note, the State refers to

allegations as “complaints”). 

In the incident and allegation cases reviewed in depth, the State responded promptly with on-site

investigations; however, the quality of the investigation and documentation was inconsistent. In

four of the six, the investigations were thorough and well documented; necessary follow-through

and close-out actions were taken; violations were cited or other corrective actions were taken to
Kansas Final Report Page 15

ensure prompt licensee compliance; proper notifications were made; and there was good

coordination with other agencies. However, in the case of one incident and one allegation, there

was no management closure, no indication of management input or review, and no record of the

incident in the licensee’s file. The casework for this incident had apparently been lost for months,

and thus there was no information that the investigation was complete. In response to the

allegation in question, the State did respond by sending an inspector to interview the Radiation

Safety Officer at the facility where the alleged exposure occurred, but from the documentation it

appeared that the investigative actions were incomplete. There was no evidence of interviews

with the former employee allegedly involved, no re-enactment, and no indication the alleger was

notified of the State’s actions or the results of the investigation. The State contacted the out-ofstate company involved and they responded that they had no knowledge of any potential

exposure.

The RCP procedures call for management involvement and evaluation of incident responses. In

reviewing the incident log and non-reportable incident records, the team found several instances

where a copy of the incident investigation report was missing from either the incident file or the

licensee’s file. Only about half were signed off with management review and evaluation and/or

closure information. The review team recommends that a system be established to track the

progress of incident investigations and to verify that each investigation is evaluated by

management, that all reporting requirements are met, that follow-up actions and close-out

information are documented.

The inspection reports indicated that nearly all incidents were reviewed at the next inspection. 

However, the inspection report form uses only a check mark to indicate the review, and the

results of the review or corrective actions taken by the licensee are not fully documented. The

review team recommends that the inspection procedure be revised to include narrative

documentation of the inspector’s review of incidents and description of the licensee’s corrective

actions.

Records showed that the four reportable events reviewed by the team were initially promptly

reported to the NRC operations center and to Region IV, and all appeared in the NMED listing. 

However, no follow-up or close-out information was provided to the NRC unless the State was

specifically asked. The review team recommends the State send copies of final close-out reports

to the NRC in accordance with the OSP procedure, “Reporting Material Events - SA-300." The

State responded to this recommendation by sending final close-out reports to the NRC in an

August 20, 1998 letter from the RCPD.

Based on the IMPEP evaluation criteria, the review team recommends that Kansas' performance

with respect to the indicator, Response to Incidents and Allegations, be found satisfactory.
Kansas Final Report Page 16

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. Kansas’ Agreement does not include a uranium recovery

program, so only the first three non-common performance indicators were applicable to this

review.

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 affect the radiation control program. Legislative

authority to create an agency and enter into an agreement with the NRC is granted in Article 16 -

Nuclear Energy Development and Radiation Control Act, Kansas Statutes, K.S.A. 48-1601 to 48-

1619. The Bureau of Air and Radiation, RCP, is designated as the State's radiation control

agency. The review team noted that the legislation had not changed since being found adequate

during the previous review.

4.1.2 Program Elements Required for Compatibility 

The Kansas Regulations for Control of Radiation, found in KAR 28-35-133 through

KAR 28-35-363 of the State of Kansas Radiation Protection Regulations apply to all ionizing

radiation, whether emitted from radionuclides or devices. Kansas requires a license for

possession, and use, of all radioactive material including naturally occurring materials, such as

radium, and accelerator-produced radionuclides. Kansas also requires registration of all

equipment designed to produce x-rays or other ionizing radiations.

Kansas has a nine-step process to adopt regulations including 61-day minimum period for public

comment and holding a public hearing. The process normally takes 16 to 25 weeks from the

regulations being submitted to their taking effect. The RCPD has responsibility for maintaining

the State’s regulations.

The team evaluated Kansas’ responses to the questionnaire and reviewed the regulations adopted

by the State since the May 19, 1995, review to determine the status of the Kansas regulations

under the new Commission Policy Statement on Adequacy and Compatibility. The team also

verified that the compatibility table in the questionnaire was accurate. 

All regulations adopted by the State during the review period (adopted November 1, 1996) were

sent to the NRC as both draft and final regulations for approval. The NRC reviewed these

regulations, and the State’s final rules reflected the NRC’s comments. 
Kansas Final Report Page 17

The team found that the State had adopted all regulations required for compatibility as of the time

of this review except for the “Safety Requirements for Industrial Radiographic Equipment” rule

which is currently being enforced by license condition. The team checked a sampling of 14

industrial radiography licenses and found that nine had been amended to include the equipment

requirement. The review team recommends that the State review and amend all remaining

industrial radiography licenses with license conditions necessary to meet the "Safety Requirements

for Industrial Radiographic Equipment" requirement, and expedite adoption of the rule which was

due January 10, 1994. 

Also, two regulations adopted by the State, prior to the review period, were adopted before the

NRC rules were published as final in the Federal Register:

! “Low-Level Waste Shipment Manifest Information and Reporting,” 10 CFR Parts 20 and

61 amendments (60 FR 15649) that became effective March 1, 1998. This amendment

was published in final form March 27, 1998.

! “Radiation Protection Requirements: Amended Definitions and Criteria,” 10 CFR 19 and

20 amendments (60 FR 36038) that became effective August 14, 1998. This amendment

was published in final form July 13, 1995.

Both of these rules were adopted by Kansas on October 17, 1994. Because the drafts of these

NRC rules were revised prior to being published in their final form, the Kansas regulations may

contain incompatibilities. The review team recommends that the State compare the Kansas

regulations involved with the “Low-Level Waste Shipment Manifest Information and Reporting”

and “Radiation Protection Requirements: Amended Definitions and Criteria” amendments against

the final NRC rules and make any necessary changes to ensure compatibility.

The State has not adopted the following regulations, but intends to address them by rulemaking or

by adopting generic legally binding requirements: 

! "Clarification of Decommissioning Funding Requirements," 10 CFR Parts 30, 40, and 70

amendments (60 FR 38235) that became effective November 24, 1995. 

! "Compatibility with the International Atomic Energy Agency," 10 CFR Part 71

amendment (60 FR 50248) that became effective April 1, 1996. 

! “Medical Administration of Radiation and Radioactive Materials,” 10 CFR Parts 20 and

35 amendments (60 FR 48623) that became effective October 20, 1995.

! “Termination or Transfer of Licensed Activities: Record Keeping Requirements,” 10 CFR

Parts 20, 30, 40, 61, 70 amendments (61 FR 24669) that became effective June 17, 1996.
Kansas Final Report Page 18

! “Resolution of Dual Regulation of Airborne Effluents of Radioactive Materials; Clean Air

Act,” 10 CFR Part 20 amendment (61 FR 65119) that became effective January 9, 1997.

! “Recognition of Agreement State Licenses in Areas Under Exclusive Federal Jurisdiction

Within an Agreement State,” 10 CFR Part 150 amendment (62 FR 1662) that became

effective February 27, 1997.

! “Criteria for the Release of Individuals Administered Radioactive Material,” 10 CFR Parts

20 and 35 amendments (62 FR 4120) that became effective May 29, 1997.

! “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 the IMPEP evaluation criteria, the review team recommends that Kansas’ 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

At the time of the review, Kansas had no sealed source or device manufacturers nor were any

applicants anticipated in the near future. The State, however, does not wish to relinquish the

authority to regulate SS&D manufacturers in the future. The State has committed in writing in a

memorandum to their files to have a program in place prior to performing evaluations.

Accordingly, the review team did not review this indicator.

4.3 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
Kansas Final Report Page 19

disposal authority without the need of an amendment. Although Kansas 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 Kansas. Accordingly, the review team did not review this indicator.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the MRB found that Kansas’ performance with respect to the

performance indicators, Technical Quality of Inspections, Response to Incidents and Allegations,

and Legislation and Program Elements Required for Compatibility, were satisfactory. The State’s

performance with respect to the performance indicators, Status of Materials Inspection Program,

Technical Staffing and Training, and Technical Quality of Licensing Actions, were found

satisfactory with recommendations for improvement. 

The team recommended and the MRB concurred, in finding the Kansas Agreement State Program

adequate, but needs improvement and compatible with NRC’s program. The team also

recommended placing the Kansas program on heightened oversight, a process that would involve

monthly teleconferences with the State and bimonthly written progress reports from the State. A

follow-up review was recommended for FY 1999. The MRB directed that a follow-up review

focusing on Kansas’ licensing program be completed in 1 year, and did not place the State into

heightened oversight status.

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

the report, for evaluation and implementation, as appropriate, by the State. 

RECOMMENDATIONS:

1. Based on the record of overdue inspections during the review period, the review team

recommends: (1) that Kansas heighten its management oversight of the inspection due

dates of core licenses (Priority 1, 2, and 3 licensees) to ensure inspections are performed

at the required frequencies; and (2) that the new inspection tracking system currently

under development include provisions for flagging initial inspections at an early date to

ensure they are inspected within 6 months of date of license issuance. In addition, Kansas

should consider updating procedure RHS-7 to incorporate procedures on initial

inspections as stated in IMC 2800, Section 04.03 a. (Section 3.1)

2. The review team recommends that the State’s “Inspection Priority System” be revised for

reciprocity inspections to correspond to the inspection goals in IMC 1220. (Section

3.1)
Kansas Final Report Page 20

3. The review team recommends the State conduct reciprocity inspections at intervals equal

to those stated in IMC 1220. (Section 3.1)

4. The review team recommends that the inspection report form be strengthened by including

names of individuals contacted and interviewed in greater detail. (Section 3.2)

5. The review team recommends that Kansas provide direction to the inspection staff to help

them identify poor licensee performance, identify when licensee root cause evaluations

should be conducted, and to help them assess licensee root cause evaluations. Staff

members’ skills could also be improved by attending a training course that teaches these

techniques as part of the inspector qualification process. (Section 3.2)

6. The review team recommends that the State continue to maintain management oversight

of the inspection program. (Section 3.2)

7. The review team recommends that the State document a training and qualifications

program equivalent to that contained in the “NRC/OAS Training Working Group

Recommendations for Agreement State Training Programs,” as appropriate, assess the

current training needs of all radioactive materials staff, and provide the necessary training

to ensure that all staff are properly trained to complete assigned tasks. (Section 3.3)

8. The review team recommends that program management consider increasing supervisory

oversight to ensure that all pertinent items are adequately and properly addressed during

the review process to provide quality assurance and to improve the technical quality of

licenses. (Section 3.4)

9. The review team also recommends that the State begin a self-evaluation of all existing

licenses to determine the technical quality and to identify potential health and safety issues. 

This evaluation should be accomplished as soon as possible to identify and correct other

possible license deficiencies. In addition, the State should ask the licensee to supply

copies of any missing documents that should be included with the application. (Section

3.4)

10. The review team recommends that RCP update the license guidance to address and

parallel the current Kansas Radiation Protection Regulations to assist in the consistency

and accuracy of the license review process. (Section 3.4)

11. The review team recommends that licensing check lists be developed, used, and retained in

the file to ensure that all elements of the application have been submitted and that the

license is complete. (Section 3.4)

12. The review team recommends that the State place documentation of any pre-licensing

visits in the appropriate licensing file. (Section 3.4)
Kansas Final Report Page 21

13. The team recommends that the State revise their incident response procedure to conform

with OSP procedure, SA-300, including medical events. (Section 3.5)

14. The review team recommends that a system be established to track the progress of

incident investigations and to verify that each investigation is evaluated by management,

that all reporting requirements are met, that follow-up actions and close-out information

are documented. (Section 3.5)

15. The review team recommends that the inspection procedure be revised to include narrative

documentation of the inspector’s review of incidents and description of the licensee’s

corrective actions. (Section 3.5)

16. The review team recommends the State send copies of final close-out reports to the NRC

in accordance with the OSP procedure, “Reporting Material Events - SA-300." (Section

3.5)

17. The review team recommends that the State review and amend all remaining industrial

radiography licenses with license conditions necessary to meet the "Safety Requirements

for Industrial Radiographic Equipment" requirement, and expedite adoption of the rule

which was due January 10, 1994. (Section 4.1.2)

18. The review team recommends that the State compare the Kansas regulations involved with

the “Low-Level Waste Shipment Manifest Information and Reporting” and “Radiation

Protection Requirements: Amended Definitions and Criteria” amendments against the

final NRC rules and make any necessary changes to ensure compatibility. (Section 4.1.2)

SUGGESTIONS:

1. The review team suggests that the State continue to adhere to their policy of annual

supervisory inspector accompaniments. (Section 3.2)

2. The review team suggests that the State assess whether the radioactive materials

program staffing level was a contributing factor to the program deficiencies during the

review period and evaluate the impact of the open positions in the RCP on radioactive

materials staff to determine if added staffing or reassignment of duties is necessary.

(Section 3.3)
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Kansas Organization Charts

Appendix C Inspection Casework Reviews

Appendix D Licensing Casework Reviews

Appendix E Incident Casework Reviews

Attachment 1 July 9, 1998 Letter to Richard L. Bangart from Vick L. Cooper

Attachment 2 Kansas' Response to Review Findings

Attachment 3 Kansas’ Progress Report as of September 4, 1998 
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Jack Hornor, RIV, SAO Team Leader

Response to Incidents and Allegations

Jenny Johansen, RI Status of Materials Inspection Program

Technical Quality of Inspections

Lance Rakovan, OSP Technical Staffing and Training

Legislation and Program Elements Required for

Compatibility

Jared Thompson, Arkansas Technical Quality of Licensing Actions
APPENDIX B

KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT

ORGANIZATION CHARTS


KANSAS

DEPARTMENT OF HEALTH & ENVIRONMENT

BILL GRAVES, GOVERNOR

Gary R. Mitchell, Secretary

July 9, 1998

RICHARD L BANGART DIRECTOR

NUCLEAR REGULATORY COMMISSION

ONE WHITE FLINTNORTH

11555 ROCKVILLE PIKE 3RD FLOOR

ROCKVILLE MD 20852

Dear Mr. Bangart:

Per our conversation on June 29TH, these are some of the steps we have initiated. We have begun

a comprehensive review of the licensing process and those identified by the IMPEP team were

corrected. We have initiated a bi-monthly conference call system with Jack Hornor and Linda

Mclean, State Agreement Officers, to update them on our progress. Listed below are some of

the actions that have taken place. We continue to be pro-active in our endeavor to correct our

shortcomings.

Licensing:

1. Develop a comprehensive checklist to be used by license reviewers to ensure consistency

and completeness of licenses. This checklist is to be used when reviewing a new license

or a license amendment in its entirety and requires signatures of the primary reviewer,

secondary reviewer and management.

Status: Non-medical license reviewer checklist complete. Checklists for medical

applications are under development. Another checklist has been developed to be used by

management to ensure all items of a license arc included as well as all inspection

information is current.

Completion: Concurrent with item 3.

2. Review and revision of licensing guides to be used by licensees and license review,

Status: Radiographer and portable gauge license guides complete. Revisions to the

medical guides are under development.

Completion: Concurrent with item 3.

.

Division of Environmint, Bureau of Air and Radiation (785) 296-1560

Radiation Control Program, Forbes Field, Bldg. 283 FAX (785) 296-0984

Topeka,KS 66620-0001 Internet Address:http://www.ink.org/kdhe/bar/barrad.html

Printed on Recycled Paper

ATTACHMENT 1
3. A comprehensive review (utilizing the above checklist) will be performed of the core .

licensees (priority one excluding radium dial shops).

Status: Have begun review of radiography licenses. Note: these licenses will be reviewed

as groups (i.e. radiography, medical, etc.) to ensure consistency.

Completion: This review will be completed by October 31, 1998.

4. All other licenses will be reviewed back to the last amendment in its entirety as they are

up for renewal.

status: on-going

Completion: All licenses are renewed for two years, therefore this review will be

completed within two years.

5. Review the license action log on a biweekly basis to ensure all license actions are acted

upon in a timely manner.

Status: Established and on-going.

6 . Correct specific license problems pointed out by the IMPEP team.

Status: Completed

7. Ensure radioactive material properly disposed or transferred upon termination of a

license.

Status: Discussed the proper use of RHS-38 with all inspectors.

Completion: Completed

Inspection:

1. Ensure inspections are completed on a timely basis per the inspection priority with no

inspections exceeding the due date by more than 25%.

Status: The RAM/X-ray Supervisor meets with inspectors on a quarterly basis to discuss

and assign inspections. The inspector is then responsible for scheduling and completing

the inspections during the quarter. Status is tracked on a monthly basis through each

inspectors’ monthly report and review of the inspection tracking database.

2. Modify the inspection tracking database to allow tracking the assignment of inspections.

Status: A field has been added to the database to indicate which inspector is assigned to

perform each inspection.

Completion: Complete

3. Evaluate modification of the inspection tracking database to improve tracking and

trending of inspection data.

Status: Have contacted Texas and California to obtain information about their software

systems. In addition, the information services group is currently working on writing

visual basic software for licensing and inspection tracking.

Completion: Dependent on information services support.

4. Review inspection priorities for appropriateness.

Status: This is evaluated as part of the license reviews.

Completion: Core licensees - October 31,1998, Others - Two years.
Revise procedures to ensure consistency and closure of investigations.

Status: RHS-47 was revised to provide-guidelines for documenting investigations.

Guidelines are also provided to ensure NRC notification is performed as appropriate and

ensure reports are filed in the investigation file and if appropriate the license/registration

file.

Completion: Completed

2. Review training needs for all inspectors and schedule training as appropriate.

status:

a Three facilities have been contacted for proposals to provide teletherapy training

for inspectors. Awaiting responses.

b. Applied for admittance to the NRC licensing and teletherapy courses.

C. Contacted a licensee to inquire about attending a transportation course they

provide in-house.

d. Conducted in-house refreshers of licensing guides and checklists.

Completion: This will be an on-going effort to ensure inspectors and reviewers maintain

qualifications and are kept abreast of the latest developments in licensing and inspection

procedures.

3. Ensure Kansas regulations meet compatibility requirements with NRC regulations.

Status: Work has begun on drafting a revision to the Kansas radiography regulations to

-incorporate the latest changes to 10 CFR Part 34.

Completion: Based on the legislative process

Richard, we appreciate the support you have given us. If further information is needed regarding

this letter, please do not hesitate to contact me.

tick L. Cooper, Chief 

Radiation Control Program

Bureau of Air and Radiation

VLC/psw

Division of Environment, Bureau of Air and Radiation (785) 296-l560

Radiation Control Program, Forbes Field, Bldg. 283 FAX (785) 296-0984

Topeka, KS 66620-0001 Internet Address: http://www.ink.org/kdne/bar/barrad.html

Printed on Recycled Paper

Page 4 Paragraph 2 the sentence “the team verified from records that as of June 15, 1998,

there were 3 15 active licenses and all inspections were current.” As pointed out in our .

responses to the IMPEP Questionnaire, this was the result of self identification of

overdue inspections and corrective action taken to eliminate the backlog of inspections.

The IMPEP Handbook “Evaluation Criteria” states “In some cases, there may be

additional considerations not listed here that are indicative of a program’s performance in

a particular area.” We feel self identification and correction of this problem warrants

such consideration. Therefore, consideration should be given, in lue of the above

statement made by the team and that our inspections continue to be up to date, to the

overall performance rating of this section and a satisfactory rating with recommendations

should be given.

3.3 Technical Staffing and Training

Page 8 Paragraph 2 the sentence, “1 FTE was devoted exclusively to mammography

inspections.” This is inaccurate, this FTE was moved from a mammography inspection

position to a RAM inspection position. During the time of this review, we were finishing

an MQSA contract, this FTE is 80 % RAM 20 % mammography for fiscal year 1999.

Paragraph 4, the statement, based on review results, this staffing level is adequate for a

program of this size. This statement will hinder our efforts to add staff to our program,

we feel that it should be removed from the report for the following reasons:

1. This statement is inconsistent with one in paragraph 5, the review team suggests

that the state evaluate the impact of open positions in the RCS and the effect of

these vacancies on radioactive materials staff to determine if added staffing or

reassignment of duties is necessary. On one hand you state that we are adequately

staffed and on the other we need staff sends mixed messages to management.

2. This was a self identified problem and steps had been made to correct it.

3. In discussions with your staff, it has been indicated using the old formula the

NRC used to calculate the FTE status for a program , # inspectors / # licensees *

100, using that formula 2.8 FTE / 3 15 * 100 = .89 FTEs per 100 licenses we feel

that this is inadequate for a program of our size.

4. The NRC regions have a ratio of 1.5 to 2.5 FTEs per 100 licenses. We would like

to be compatible and equal in this area.

Page 9 Paragraph 2 the sentence, “thus if an employee has not taken a required class, it

may not be apparent that they are still expected to take it.” It has been and continues to

be a supervisory responsibility to ensure that staff receive required training. However,

getting into NRC required courses has been difficult in the past due to the availability of

space for Agreement State personnel. This also was a self identified problem and steps

have been put into place to correct the void in training through other means such as:

2
Examples:

Local Nuclear Facility -Training in root cause effect,

Transportation , DOT regulation

Local Medical Oncology Facilities-Brachytherapy and Teletherapy workshop

3.4 Technical Quality of Licensing Actions

Page 10 Paragraph 5 the sentence, “the magnitude of the potential health and safety

issues due to licensing inadequacies cannot be accurately assessed because of the lack of

file documentation.” We feel that this statement is very strong and harsh because the

team only found 2 potential health and safety issues. We have completed a

comprehensive self-evaluation of 48 priority 1 licenses beginning with the medical and

have not found any other potential health and safety issues . We feel replacing the

word magnitude with number or equivalent would be more accurate. We are in the

process of reviewing the remaining licensees.

In addition, with respect to the rating for this section The IMPEP Handbook states in part

that a Satisfactory with Recommendations should be given when the “Review indicates

that some licensing actions do not fully address health and safety concerns or indicates

reseated examples of problems with respect to thoroughness, completeness, consistency,

clarity, technical quality, and adherence to existing guidance in licensing actions.” This

is contrasted with the criteria which states in part that an Unsatisfactory should be given

if the “Review indicates that licensing actions frequently fail to address important health

and safety concerns......” We feel two potential health and safety issues do not constitute a

frequent failure to address important health and safety issues. Therefore, we request the

wording be changed and that a satisfactory with recommendations rating be given in this

area.

VLC/psw

Enclosure
Responses to Integrated Materials Performance Evaluation Program (IMPEP)

Recommendations

Recommendation 1:

Based on the record of overdue inspections during the review period, the review team

recommends: (1) that Kansas heighten its management oversight of the inspection due dates of core

licenses (Priority 1, 2, and 3 licensees) to ensure inspections are performed at the required

frequencies; and (2) that the new inspection tracking system currently under development include

provisions for flagging initial inspections at an early date to ensure they are inspected within 6

months of the date of license issuance. In addition, Kansas should consider updating procedure

Inspection Priority System Radioactive Materials ( RHS-7) to incorporate procedures on initial

inspections as stated in IMC 2800, Section 04.03a.

Response:

1. In our response to the IMPEP Questionnaire Item “A VI 26” regarding program strengths and

weaknesses we stated in part:

“... difficulties in tracking inspection and license actions resulting in overdue inspections or

license actions which have “fallen through the cracks.” This was recognized by management

and the backlog of inspections and license actions has been brought under control through

increased management attention.”

As a result of this increased management oversight the backlog of overdue inspections was

eliminated prior to the IMPEP team’s visit.

To ensure there is no recurrence of a backlog, this oversight will continue, specifically:

a.

a.

b.

C.

Quarterly the Radioactive Materials and X-ray Section Supervisor will prepare a list

of inspections due in the upcoming quarter and meet with the inspectors to discuss

assignments.

At this meeting the inspections due in the upcoming quarter will be assigned to

specific inspectors.

The inspectors will be responsible for scheduling their assigned inspections to be

completed within that quarter.

The Supervisor will monitor the progress of these inspections on at least a monthly

basis to ensure the inspections stay on track.

Scheduled completion:

Complete - Increased management oversight is ongoing.

2. The new inspection tracking system currently under development will include the ability to

flag initial inspections at an early date to ensure they are inspected within 6 months of the

date of license issuance. This will be accomplished by having the ability to assign priorities

which will automatically set inspection due dates at six month intervals. For example, the

priorities will be real numbers from 0 to 5 which the software will use to calculate the
inspection due date. For a new license, a priority of 0.5 can be assigned which will result in

an inspection due date six months from the license issuance date. This will also allow more

flexibility in setting inspection due dates for other licensees, for example, if it is felt a

licensee should have a follow up inspection in three months then the priority can be set to

0.25 which will then flag an inspection due at the appropriate time.

In addition, Procedure (RHS-7) “Inspection Priority System Radioactive Materials” will be

revised to reflect these changes and incorporate procedures for initial inspections consistent

with IMC 2800.

Scheduled Completion:

In progress by June 1999

Until the new system is fully implemented, we will continue using the current database system with

increased management oversight to ensure inspections are completed appropriately.

Recommendation 2:

The review team recommends that the State’s “Inspection Priority System” be revised for

reciprocity inspections to correspond to the inspection goals in IMC 1220.

Response:

The RHS-7 procedures dealing with inspection priority and reciprocity will be revised to

ensure reciprocity inspections are conducted at intervals comparable to the inspection goals in IMC

1220.

Scheduled completion:

Completed Prior to the MRB

Recommendation 3:

The review team recommends that the State conduct reciprocity inspections at intervals equal

to those stated in IMC 1220.

Response:

The corrective action for recommendation number 2 encompasses this recommendation.

The new computerized inspection tracking system will also allow the tracking of reciprocity

inspections and priorities in a similar manner as Kansas licensees.

The program enhancements and improvements in the responses to recommendations 1 and

2, will also ensure reciprocity inspections are conducted at comparable intervals to IMC 1220.

Scheduled Completion:

In conjunction with recommendation 2.

Until completion, reciprocity inspections will be tracked by management to ensure completion at

the appropriate intervals.

2
Recommendation 4:

The review team recommends that the inspection report form be strengthened by including

names of individuals contacted and interviewed in greater detail.

Response:

The implementation of the computerized inspection tracking system is planned to include

the electronic generation of inspection reports and storage of inspection data. A new inspection form

has been developed which includes a listing of the persons interviewed and those present at the exit

meeting. This will be implemented as the new computerized system is completed.

Scheduled Completion:

In conjunction with recommendation 1, this is an ongoing process.

Recommendation 5:

The team recommended Kansas develop a procedure to help identify poor licensee

performance, when licensee root cause evaluations should be performed and to assist in assessing

licensee root cause evaluations. Also a training course that teaches these techniques was

recommended as part of the inspector qualification process.

Response:

The computerized inspection tracking system also incorporates features to track and trend

specific items of noncompliance. This will allow staff to readily identify poor licensee performance

and assist in determining when root cause evaluations should be performed.

Training will be provided to staff as availability and funds allow. A procedure will be

developed after staff has had an opportunity to attend training. The methods used to provide training

is a combination of courses provided by the NRC (as they are available) and workshops/courses

arranged using other resources such as ORNL, Universities, Medical Facilities, Utilities or

Industrial facilities.

Scheduled Completion:

Determined by training availability, continuous ongoing

Recommendation 6:

The review team recommends that the State continue to increase management oversight of

the inspection program.

Response:

The State of Kansas is committed to improving the inspection process and to continue the

efforts already taken to ensure inspections are performed in a timely and accurate manner. The

specific actions taken or being taken in the responses to recommendations 1 through 5 demonstrate

a strong commitment to increased and continued management oversight.
Scheduled Completion:

Increased management oversight is a continuous and ongoing effort. Refer to recommendations 1

through 5 for details.

Recommendation 7:

The review team recommends the State document a training and qualifications program

equivalent to that contained in IMC 1246, assess the current training needs of the staff and provide

the necessary training identified by this assessment.

Response:

Using IMC 1246 as a guide, a matrix has been created to determine which individuals require

training and identify which training is needed. The methods used to provide training are a

combination of courses provided by the NRC (as they are available) and workshops/courses arranged

using other resources such as local schools, hospitals or industrial facilities.

Specifically, the following have been performed to address training needs:

a. A teletherapy/brachytherapy course has been jointly developed by three Kansas

licensees and will be presented to all the RAM & X-ray section staff the week of

August 24, 1998. This course is designed to be equivalent to the NRC

teletherapy/brachytherapy course.

b. Application has been made for admission to the NRC licensing course in September

1998, as well as the NRC brachytherapy course in March 1999.

C. A local nuclear power plant has been contacted to determine availability of courses

for transportation of radioactive material and root cause analysis.

Staff will attend these as available.

Scheduled Completion:

Assessment of training needs: Complete

Completion of training: As training courses and funding are available.

Recommendation 8:

The review team recommends that program management consider increasing supervisory

oversight to ensure that all pertinent items are adequately and properly addressed during the review

process to provide quality assurance and to improve the technical quality of licenses.

Response:

The State of Kansas recognizes the need for increased management oversight in all areas of

the Radiation Control Program and is committed to ensuring the technical quality of our licenses.

The responses to recommendations 9 through 12 are offered as examples of this commitment.

Scheduled Completion:

Continuous and ongoing
Recommendation 9:

The review team also recommends that the State begin a self-evaluation of all existing

licenses to determine the technical quality and to identify potential health and safety issues. This

evaluation should be accomplished as soon as possible to identify and correct other possible license

deficiencies. In addition, the State should ask the licensee to supply copies of any missing

documents that should be included with the application.

Response:

We are currently performing a comprehensive review of all licenses to ensure the technical

quality and verify there are no health and safety issues present. All priority 1 licensees have been

reviewed. This review has served to verify the teams’ findings that there are inconsistencies in the

way licenses have been written, however none of the inconsistencies created health and safety issues

to the citizens of Kansas. The responses to recommendations 10 and 11 are designed to reduce

inconsistencies. Other licensees are being reviewed in their entirety whenever there are any license

actions, inspections or renewals of those licenses processed. This will ensure that, at a minimum,

all the licenses will be reviewed within one renewal cycle (2 years). Reviews of licenses for which

no actions are current will be reviewed as resources are available based upon priority.

Scheduled Completion:

Priority one licenses: Complete

All others: Complete by June 2000

Recommendation 10:

The review team recommends that Radiation Control Staff update the license guidance to

address and parallel the current Kansas Radiation Protection Regulations to assist in the consistency

and accuracy of the license review process.

Response:

The Radioactive Materials and X-ray Section collectively revised the non-medical licensing

guides using the “Consolidate Guidance About Materials Licenses” as well as other Agreement State

guides appropriate for the particular Kansas guide. The Kansas Medical Guides are currently being

revised. It should be noted that since Kansas does not have any large irradiators, these guides have

not been developed and guidance from NRC and other Agreement States will be used should a large

irradiator be located in Kansas

Scheduled Completion:

Non-medical guides: Complete and in use

Medical guides: Complete and in use

Recommendation 11:

The review team recommends that licensing check lists be developed, used, and retained in

the file to ensure that all elements of the application have been submitted and that the license is

complete.
Response:

Using NRC Licensing Guides and other Agreement State Guides as reference, licensing

checklists have been developed for licenses. These are in use and have been included in the license

files for all license actions as well as reviews being performed per recommendation 9.

Scheduled Completion:

Non-medical: Complete and in use

Medical: Complete and in use

Recommendation 12:

The review team recommends that the State place documentation of all pre-licensing visits

in the appropriate licensing file.

Response:

The Kansas inspection procedure is being revised to require all pre-licensing visits to be

documented using the regular inspection process, which includes placing all appropriate

documentation in the licensing file.

Scheduled Completion:

Complete by January 1999, in the interim we have instructed personnel to place pre-licensing report

in licensing file. This is being monitored by management.

Recommendation 13:

The team recommends that the State revise their incident response procedure to conform with

OSP procedure, SA-300, including medical events.

Response:

The RHS Procedures on incident response are being revised to be consistent with OSP

procedure, SA-300. All future reportable events will be reported per this procedure.

Scheduled Completion:

Completed Prior to the MRB

Recommendation 14:

The review team recommends that a system be established to track the progress of incident

investigations and to verify that each investigation is evaluated by management, that all reporting

requirements are met, that follow-up actions and close-out information are documented.

Response:

RHS-47 “Emergency Response Documentation” has been revised to require that each

investigation of incidents, allegations and reportable mis-administrations be evaluated by

management, all reporting requirements be met, and that follow-up actions and close-out

information is documented and sent to NRC. In addition, a Case Number is assigned to each

investigation for tracking and logged in the Investigation File.

6
Scheduled Completion:

Complete and in use

Recommendation 15:

The review team recommends that the inspection procedure be revised to include narrative

documentation of the inspector’s review of incidents and description

actions.

of the licensee’s corrective

Response:

As stated in recommendation 5, the inspection form is being revised. This revision will

include more detail of the inspector’s review of incidents and corrective actions.

Scheduled Completion:

In conjunction with recommendation 5.

Recommendation 16:

The review team recommends the State send copies of final close-out reports to the NRC in

accordance with the OSP procedure, “Reporting Material Events - SA-300.”

Response:

This information requested has been provided to the Region IV NRC Office and we feel this

recommendation should be closed.

Scheduled Completion:

Combined with 13, the 4 close-out reports in question have been sent to NRC. We consider this

recommendation complete.

Recommendation 17:

The review team recommends that the State review and amend all remaining industrial

radiography licenses with license conditions necessary to meet the Safety Requirements for

Industrial Radiographic Operations

Response:

All industrial radiography licenses have been reviewed and license actions have been taken

to ensure the inclusion of the radiography equipment rule condition as appropriate.

Scheduled Completion:

Complete

Recommendation 18:

The review team recommends that the State compare the Kansas regulations involved with

the “Low-Level Waste Shipment Manifest Information and Reporting” and “Radiation Protection

Requirements: Amended Definitions and Criteria” amendments against the final NRC rules and

make any necessary changes to ensure compatibility.

7
Response:

These regulations have been reviewed by the staff and no compatibility issues were

identified. Kansas regulation 28-35-23 1 b “Transfer for Disposal and Manifests” contains language

virtually identical to 10 CFR 20.2006 “Transfer for Disposal and Manifests” and Appendix F. It is

our understanding that States have three years after the effective date of regulations in order to

implement them. We plan to promulgate regulations implementing 10 CFR 20.2006 with respect

to Appendix G within that time frame.

The “Radiation Protection Requirements: Amended Definitions and Criteria” amendments

were reviewed and the Kansas regulations are either equivalent or more restrictive.

Scheduled Completion:

Complete
KANSAS

DEPARTMENT OF HEALTH & ENVIRONMENT

BUREAU OF AIR AND RADIATION

BILL GRAVES, GOVERNOR

Gary R. Mitchell, Secretary

July 9, 1998

RICHARD L. BANGART DIRECTOR.

NUCLEAR REGULATORY COMMISSION

ONE WHITE FLINT NORTH

11555 ROCKVILLE PIKE 3rd FLOOR

ROCKVILLE, MD 20852

PROGRESS REPORT

As of September 4, 1998

Dear Mr. Bangart:

Per our conversation on June 29th, these are some of the steps we have initiated. We have begun

a comprehensive review of the licensing process and those identified by the IMPEP team were

corrected. We have initiated a bi-monthly conference call system with Jack Hornor and Linda

Mclean, State Agreement Officers, to update them on our progress. Listed below are some of the

actions that have taken place. We continue to be pro-active in our endeavor to correct our

shortcomings.

Licensing:

1. Develop a comprehensive checklist to be used by license reviewers to ensure

consistency and completeness of licenses. This checklist is to be used when reviewing a

new license or a license amendment in its entirely and requires signatures of the

primary reviewer, secondary reviewer and management.

.

Status: Non-medical reviewer checklist completed and in use. Checklists for medical

applications are under development completed and in use. Another checklist has been

developed to be used by management to ensure all items of a license are included as well

as all inspection information is current completed and in use.

2. Review and revision of licensing guides to be used by licensees and license reviewers.

Status: Radiographer and portable gauge license guides completed and in use.

Revisions to the medical guides are under development and in progress.

Completion: Concurrent with item 3.

Division of Environment, Bureau of Air & Radiation Phone (785) 296- 1561

Radiation Control Program, Forbes Field, Bldg. 283 Fax (785) 296-0984

Topeka, KS 66620-0001 http://www.ink.org/kdhe/bar/barrad.html

ATTACHMENT 3
3. A comprehensive review (utilizing the above checklist) will be performed of the core

licensees (priority one excluding radium dial shops).

Status: Have begun review of radiography licenses. Note: these licenses will be reviewed

as groups (i.e. radiography, medical, etc.) To ensure consistency. (Medical was first)

Completion: This review will be completed by October 3 1, 1998. Completed August 13,

1998, we have begun the work on priority II s beginning with the medical

4. All other licenses will be reviewed back to the last amendment in its entirety as they are

up for renewal.

Status: On-going , We have reviewed a total of 90 licenses

Completion: All licenses are renewed for two years, therefore this review will be

completed within Two years.

5. Review the license action log on a biweekly basis to ensure all license actions are acted

upon in a timely manner.

Status: Established and on-going. On-going

6. Correct specific license problems pointed out by the IMPEP team.

Status: Completed June & July 98.

7. Ensure radioactive material properly disposed or transferred upon termination of a

license.

Status: Discussed the proper use of RHS-38 with all inspectors.

Completion: Completed special staff meeting June 98.

Inspection:

1. Ensure inspections are completed on a timely basis per the inspection priority with no

inspections exceeding the due date by more than 25%.

Status: The RAM/X-ray Supervisor meets with inspectors on a quarterly basis to discuss

and assign inspections. The inspector is then responsible for scheduling and completing

the inspections during the quarter. Status is tracked on a monthly basis through each

inspector’smonthly report and review of the inspection tracking database.

On going new database to track the inspection process has been developed .

2. Modify the inspection tracking database to allow tracking the assignment of inspections.

Status: A field has been added to the database to indicate which inspector is assigned to

perform each inspection.

Completion: Completed will be in use October 1, 1998.
3. Evaluate modification of the inspection tracking database to improve tracking and

trending of inspections data.

Status: Have contacted Texas and California to obtain information about their software

systems. In addition, the information services group is currently working on writing

visual basic software for licensing and inspection tracking.

Completion: Dependent on information services support. Database has been developed

and will be in use October 1, 1998.

4. Review inspection priorities for appropriateness;

Status: This is evaluated as part of the license reviews. We are visiting the process of

changing the priority status of some of our licenses based upon their previous

inspection history. This is in progress.

Completion: Core licensees - October 31, 1998 , Completed August 13, 1998 Other -

Two years.

Other

3. Revise procedures to ensure consistency and closure of investigations.

Status: RHS-47 was revised to provide guidelines for documenting investigations.

Guidelines are also provided to ensure NRC notifications as appropriate and ensure

reports are filed in the investigation file and if appropriate the license/registration file.

Completion: Completed and in use

2. Review training need for all inspectors and schedule training as appropriate.

St&US:

a. Three facilities have been contacted for proposals to provide teletherapy training

for inspectors. Awaiting response.

Completed August 24-28, 1998

b. Applied for admittance to the NRC licensing and teletherapy courses.

Application made for March 1999 course

C. Contacted a licensee to inquire about attending a transportation course they

provide in-house.

Contact made and seminar will be held November or December 98

d. Conducted in-house refreshers of licensing guides and checklists.

Completion: This will be an on-going effort to ensure inspectors and reviewers

maintain qualifications and are kept abreast of the latest developments in licensing

and inspection procedures. On-going
3. Ensure Kansas regulations meet compatibility requirements with NRC regulations.

Status: Work has begun on drafting a revision to the Kansas radiography regulations to

incorporate the latest changes to 10 CFR Part 34.

Completion: Based on the legislative process. This is in progress

Richard, we appreciate the support you have given us. If further information is needed regarding

this letter, please do not hesitate to contact me.

Vick L. Cooper, Chi

Radiation Control Program

Bureau of Air and Radiation

VLC/psw