DATED: FEBRUARY 12, 1997 SIGNED BY: HUGH L. THOMPSON

Ms. Deb Thomas, Director

Department of Regulation and Licensure

Nebraska Health and Human Services System

301 Centennial Mall South

P. O. Box 95007

Lincoln, NE 68509-5007

Dear Ms. Thomas:

On January 22, 1997, the Management Review Board (MRB) met to consider the

proposed final Integrated Materials Performance Evaluation Program (IMPEP)

report on the Nebraska Agreement State Program. The MRB considered and

concurred with the review team's recommendation that the Nebraska program be

found adequate to protect public health and safety but needs improvement, and

compatible with NRC's program. Due to the significance and number of

deficiencies found in the Nebraska program at the time of the review, that

included unsatisfactory in one performance indicator, the team recommended a

period of probation for a duration to be established after consultation with

Nebraska radiation control program management. 

In consideration of the corrective actions already taken and action plans

identified by the State at the MRB meeting, the review team revised their

recommendation from probation to a follow-up IMPEP review, to be conducted

within one to one and one-half years from the date of the last IMPEP review,

but not later than September 1997. The team also recommended that the State

keep NRC apprised of the status of corrective actions and plans. Due to the

State's current staffing level (all vacancies staffed), the MRB revised the

review team's Unsatisfactory recommendation for Section 3.2 Technical Staffing

and Training, to Satisfactory with Recommendations for Improvement. The MRB

considered and concurred with the review team's revised recommendation for a

follow-up review no late than September 1997, based on the State's

performance, unless program concerns develop that require an earlier

evaluation. 

NRC recognized the efforts already taken and planned by the State to address

the 15 recommendations made by the review team to improve the performance of

the Nebraska radiation control program. During the MRB meeting, the MRB

discussed with the State representatives the need to ensure that sufficient

staffing is maintained to reduce the backlogs in licensing, inspection and

enforcement actions, or any other situation which increases the risk to public

health and safety. Discussions also covered when the State expected to

complete most of the corrective actions identified in their action plans

presented at the meeting. The State representatives responded that they

planned to have all corrective actions completed by July 1997.
Deb Thomas 2

Section 5 page 23 of the enclosed final report presents the IMPEP team's

recommendations. We request that you provide: (1) a copy of your actual

Corrective Action Plan (Step I and II), and (2) updates of the status of

corrective actions taken in response to the review team's recommendations at

two month intervals, beginning with receipt of this letter.

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

the review.

Sincerely, /RA/

Hugh L. Thompson, Jr.

Acting Executive Director

 for Operations

Enclosure:

As stated
Deb Thomas 2

Section 5 page 23 of the enclosed final report presents the IMPEP team's

recommendations. We request that you provide: (1) a copy of your actual

Corrective Action Plan (Step I and II), and (2) updates of the status of

corrective actions taken in response to the review team's recommendations at

two month intervals, beginning with receipt of this letter.

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

the review.

Sincerely,

Hugh L. Thompson, Jr.

Acting Executive Director

 for Operations

Enclosure:

As stated

bcc: Chairman Jackson

Commissioner Rogers

Commissioner Dicus

Commissioner Diaz

Commissioner McGaffigan

Distribution:

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RLBangart KSchneider

PLohaus CHaney, NMSS

SDroggitis RBlanton 2/13/97 Mailed to

PMLarkins RCady, RES Mark B. Horton

KCyr, OGC JJohansen, RI State Liaison Officer

FCongel, AEOD CMattson, CO

CPaperiello, NMSS RScarano, RIV

TCombs, OCA CHackney, RSLO, RIV

FCameron, OGC DCool, NMSS

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DATE 02/06/97* 02/07/97* 02/07/97* 04/ /97

OSP FILE CODE: SP-AG-17
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF NEBRASKA AGREEMENT STATE PROGRAM

JULY 15-19, 1996

FINAL REPORT

U. S. Nuclear Regulatory Commission

02/07/97
1.0 INTRODUCTION

This report presents the results of the review of the Nebraska radiation

control program. The review was conducted during the period July 15-19, 1996,

by a review team comprised of technical staff members from the Nuclear

Regulatory Commission (NRC) and the Agreement State of Colorado. Team members

are identified in Appendix A. The review was conducted in accordance with the

"Interim Implementation of the Integrated Materials Performance Evaluation

Program Pending Final Commission Approval of the Statement of Principles and

Policy for the Agreement State Program and the Policy Statement on Adequacy

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

Register on October 25, 1995, and the September 12, 1995, NRC Management

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

Preliminary results of the review, which covered the period June 25, 1994-July

12, 1996, were discussed with Nebraska management on July 19, 1996.

A draft of this report was issued to Nebraska for factual comment on October

16, 1996. The State of Nebraska responded in a letter dated November 1, 1996

(attached), that covered all but one issue. The State responded to the one

outstanding issue regarding the applicability of the State's Part 61

equivalent rule to low-level radioactive waste facilities that process or

store waste, as well as disposal sites, in a letter dated December 13, 1996

(attached). The State's response that the "Department intends to amend the

regulation and anticipates this can be done by June 30, 1997," resolves the

issue. The State's comments were incorporated into the proposed final report. 

The Management Review Board (MRB) met on January 22, 1997, to consider the

proposed final report. The MRB concurred in the team's overall recommendation

and found the Nebraska radiation control program was adequate to protect

public health and safety but needs improvement, and compatible with NRC's

program. 

Due to the significance and number of deficiencies found in the Nebraska

program that included unsatisfactory in one performance indicator at the time

of the review, the review team recommended a period of probation for a

duration to be established after consultation with the Nebraska radiation

control program management. In consideration of the corrective actions

already taken, and action plans presented by the State at the MRB meeting, the

review team revised their recommendation for probation to a follow-up review

of the State's radiation control program, to be conducted within one to one

and one-half years from the date of the last IMPEP review, but not later than

September 1997. The team also recommended that the State keep NRC apprised of

the status of corrective actions and plans. The MRB concurred in the team's

revised recommendation and, in consideration of the State's current staffing

level and corrective actions and plans, revised the Unsatisfactory for Section

3.2, Technical Staffing and Training, to Satisfactory with Recommendations.

The radiation control program, formerly managed by the Nebraska Department of

Health (NDOH), was reorganized January 2, 1997, by combining five departments

into three. The radiation control program is now located in a new cabinet

level department of the Nebraska Health and Human Services System (NHHS). The

Director, NHHS, is appointed by, and reports directly to, the Governor. 

Within NHHS, the Nebraska radiation control program is administered by the

Department of Regulation and Licensure, under the Public Health Assessment

(PHA) division. The Department of Regulation and Licensure and the Public

Health Assessment (PHA) division organization charts are included as Appendix

B. During the review period the Nebraska program regulated 157 specific

licenses, which includes four large irradiators, manufacturers, broad

academic, broad medical, radiopharmacy, radiographers, and the program is in

the process of conducting a licensing review of a low-level radioactive waste

disposal site. The low-level radioactive waste (LLRW) disposal regulatory

program is jointly administered and managed by NHHS and the Nebraska

Department of Environmental Quality (NDEQ) through a Memorandum of
Nebraska Final Report Page 2

Understanding. In addition to its radioactive materials and low-level

radioactive waste disposal programs, NHHS is responsible for the control of

machine produced radiation and radon, and emergency response planning for two

nuclear power plants. 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 Nebraska.

In preparation for the review, a questionnaire addressing the common and noncommon indicators was sent to the State on May 17, 1996. Nebraska provided

its response to the questionnaire on June 17, 1996. A copy of that response

is included as Appendix C to this report.

The review team's general approach for conduct of this review consisted of: 

(1) examination of Nebraska's response to the questionnaire, (2) review of

applicable Nebraska statutes and regulations, (3) analysis of quantitative

information from the radiation control program licensing and inspection

database, (4) technical review of selected files, (5) field accompaniments of

five Nebraska 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 noncommon indicator and made a preliminary assessment of the radiation control

program's performance. As noted above, that preliminary assessment was

discussed with program management before the team's departure.

2.0 STATUS OF PREVIOUS REVIEW

The previous routine review concluded on June 23, 1994, and there were no

recommendations made following the previous review of the radiation control

program. Results of the current review for the IMPEP common performance

indicators are presented in Section 3. Section 4 discusses results of the

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

findings and recommendations.

3.0 COMMON PERFORMANCE INDICATORS

The IMPEP process uses five common performance indicators in reviewing both

NRC regional and Agreement State programs. These indicators are: (1) Status

of Materials Inspection Program; (2) Technical Staffing and Training; (3)

Technical Quality of Licensing Actions; (4) Technical Quality of Inspections;

and (5) Response to Incidents and Allegations.

3.1 Status of Materials Inspection Program

The review 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.

Review of the State's inspection priorities showed that the State's inspection

frequencies for the various types or groups of licenses are with few

exceptions, at least as frequent as similar license types or groups listed in

the frequency schedule in the NRC Inspection Manual Chapter (IMC) 2800. The

State, in their response to the questionnaire, identified three types of

licenses that were inspected at a frequency less than IMC 2800, as a result of

not having yet incorporated the April 1995 revisions to IMC 2800 into their

Inspection Procedures Manual. Those categories for which NRC revisions to IMC

2800 were more conservative than the Nebraska frequencies are: (1) High-Dose

Rate Remote Afterloaders (HDRs) were inspected on a three year basis in

Nebraska vs. NRC's change to a one year frequency, (2) Mobile Nuclear

Medicine Services were inspected on a three year frequency vs. NRC's change to

a two year frequency, and (3) Instrument Calibration Services Only - Other and
Nebraska Final Report Page 3

Other Services were grouped together in Nebraska and inspected on a three or

five year frequency vs. NRC's one-seven year frequency based on the type of

service provided. Subsequently, the team found that the State does not have a

service license requiring inspections at one or two year intervals, but they

do have a service license for which IMC 2800 indicates a three year inspection

frequency and the State was conducting inspections at a three year interval. 

Although the revised inspection frequencies had not been incorporated into the

Inspection Procedures Manual, the State indicated that they had completed

incorporation of the new priorities into their inspection tracking system and,

as a result, the State indicated that they planned to review all licenses and

assign the proper priority and inspection frequency and inspect accordingly,

but inspection schedules had not been completed. In discussions with the new

program manager, the team found that the State intends to revise their

Inspection Manual to reflect the April 1995 revisions to IMC 2800 by January

1997. When these inspection priority findings were raised with the Nebraska

staff, the staff indicated that the loss of three key personnel had prevented

them from updating procedures. 

In their response to the questionnaire, Nebraska indicated that as of July 12,

1996, only nine licensees identified as core inspections in IMC 2800 were

overdue by more than 25 percent of the NRC frequency. The State also

indicated they planned to complete these overdue inspections by January 1997. 

It should be noted, that the staffing shortages created a considerable backlog

of inspections and, in response, the State hired a contractor to conduct

inspections, commencing on January 15, 1996, and ending no later than June 30,

1996. The contractor performed 27 inspections, of which 14 were overdue,

during this period which helped to reduce the backlog of overdue inspections. 

Although the State should be commended for this effort, the team noted that

communication of the results of the inspections, (i.e. inspection report

results, recommendations, noncompliance, etc.) have been provided to only 5 of

the 27 licensees inspected. In discussions, the program manager stated that

they retained a former staff member as a consultant to review the results of

the contractor inspections, but they were unsuccessful in their efforts to

have the reviews completed in a timely fashion.

The team reviewed the State's experience with overdue inspections during the

entire review period and found, based on 20 license files reviewed, 8 out of

12 core inspections were conducted as overdue inspections exceeding the 25

percent window allowed in IMC 2800. Four of the 8 overdue core inspections

with a one-year inspection frequency were between 10-24 months overdue

(averaging 15 months overdue), and four of the 8 overdue core inspections with

a three-year inspection frequency were between 15-21 months overdue (averaging

17.3 months overdue). Non-core inspections were conducted as resources

allowed. 

With respect to initial inspections of new licensees, the team reviewed the

inspections due by date in the numeric tracking system and the license files. 

Review of the tracking system identified 11 licenses, that required initial

inspections. Of the 11 inspections due, identified from the tracking system,

2 had been identified as overdue in the State's questionnaire. Two of the 11

initial inspections due had been completed during the IMPEP review

accompaniment process on July 16, 1996, which leaves 9 inspections due.

Subsequent to the review, the State informed the team that 2 of the

inspections due licenses are issued to nuclear power plants authorizing the

use of radioactive material at temporary job sites in the event of an

emergency situation, one is an out-of-state licensee from Wisconsin

authorizing non-AEA material, and one other is an out-of-state service

licensee for which no activity has occurred and is currently in a deferred

status, which reduces the number of inspections due to 5. 
Nebraska Final Report Page 4

Of the 20 files reviewed by the team, 4 were initial inspections, and 2 of the

4 initial inspections were not inspected within the stated frequencies

identified in IMC 2800. The 2 overdue initial inspections were performed 16

and 13 months after issuance of the license. Subsequent to the review, the

State informed the team that in response to suggestions made by the team, the

State has implemented a condition for new licenses that requires the licensee

to notify the State of receipt of materials and the beginning of licensed

activities in addition to the telephone contacts now used by the program. 

The timeliness of the issuance of inspection findings was also evaluated

during the inspection file review. From the 20 files examined both in detail

for quality of the inspection program and for issuance of inspection findings,

14 (inspections performed in 1994 and 1995) had inspection correspondence sent

to the licensee within 30 days after completion of the inspection. In the six

remaining files (inspections performed in 1996 by the contractor), the

inspection findings were in draft enforcement letters which had not been

issued to the licensee. The six draft enforcement letters had been in the

license file from 45 to 142 days. As previously indicated, the inspections

findings of only 5 of the 27 inspections performed in 1996 by the contractor,

had been provided to the licensee after review by the State. Management was

aware of the delays in getting these inspection reports issued. Delays in

issuing inspection reports impair the effectiveness of getting prompt

corrective action by the licensee to any violations. Late reports make it

difficult for the program to require a prompt response from the licensee. 

Finally, late reports open the program to criticism by licensees. The review

team recommended that State management take immediate action to assure that

the balance of the contractor completed inspection field notes and draft

enforcement letters (22) are reviewed and issued to the appropriate licensees.

On examination of the major cause for the lack of timeliness in performing

inspections at the stated frequency and the timely issuance of inspection

findings, the IMPEP team noted the program lost three senior staff in the

materials program and underwent two reorganizations during the review period. 

The team concluded that the failure to effectively manage the reduced level of

program resources and performance and the lack of current, written, program

procedures, are the primary root causes of the deficiencies found in the

program.

A review of the results of previous program reviews of the Nebraska Radiation

Control Program identified that similar problems were found in 1990 and 1992

that resulted in a withholding of findings of adequacy to protect public

health and safety and compatibility for both reviews. During the 1992 review,

significant problems were identified in the area of Status of Inspections and

Staffing and Training. The 1992 review indicated that there had been no

improvement in problem areas identified during the 1990 review. During the

1990 review, significant problems were identified in the area of Status of the

Inspection Program, Staffing and Training, Status and Compatibility of

Regulations, Enforcement Procedures, and Management. The 1990 review

indicated a continuation of the same problems found during two previous

reviews in 1988 and 1986. The 1994 review resulted in a finding of adequate

and compatible based on the State filling four vacant positions that had

remained open for over a year despite active recruiting, reduction of the

inspection backlog, and expected continued reduction due to increased

availability of staff. In 1994, the State also indicated that efforts were

underway to develop and implement revised procedures. The team found that the

efforts begun in 1994 to maintain adequate staffing and control inspection

backlogs were unsuccessful, and the efforts to implement new procedures were

not completed.
Nebraska Final Report Page 5

The State reported in its response to the questionnaire that 31 licensees

filed 163 requests for reciprocity during the review period; 20 of the 31

licensees were Priority 1, 2, or 3 (7 industrial radiography, 7 well logging,

1 mobile nuclear medicine service and 5 other service licensees). The State

conducted 2 inspections of reciprocity licensees (industrial radiography)

during the review period. In its response to the questionnaire, the State

reported that the program staff accompanied by an IMPEP team member performed

one field inspection on a non-reciprocity industrial radiography licensee on

June 26, 1996. The review team recommends that the State follow the

inspection frequency for conducting inspections of reciprocity licensees

contained in IMC 1220, "Processing of NRC Form 241, Report of Proposed

Activities in Non-Agreement States, and Inspection of Agreement State

Licensees Operating Under 10 CFR Part 150.20."

In addition to the recommendations stated above regarding the contractor

performed inspections, the review team recommended that the Nebraska

Radioactive Materials Program: (1) establish an action plan or procedure to

assure inspections are completed at the required frequencies stated in the

Nebraska Inspection Manual which is equal to the NRC's IMC 2800 and conduct

reciprocity licensee inspections at the required frequencies stated in IMC

1220; (2) establish an action plan or procedure for coordinating deviations

from the schedule between staff and management based on the risk of license

operations, past performance and need to temporarily defer the inspections to

address more urgent or critical priorities; (3) organize a "get well" plan

for rescheduling missed or deferred inspections, that takes into account

unplanned loss of experienced staff; and (4) establish a plan or methodology

to assure initial inspections are performed within 6 months of receipt of

licensed material, 6 months of beginning licensed activities or within 1 year

of license issuance, whichever comes first, in accordance with the Nebraska

Inspection Manual and NRC's IMC 2800.

Based on the IMPEP evaluation criteria, the review team recommends that

Nebraska's performance with respect to the indicator, Status of Materials

Inspection Program, be found Satisfactory with Recommendations for

Improvement.

3.2 Technical Staffing and Training

In reviewing this indicator, the review team considered the radioactive

materials program and the NHHS low-level radioactive waste program staffing

levels, the technical qualifications of the staff, staff training, staff

turnover, prompt management attention and review to staffing problems, and

development of corrective action plans, when necessary. To evaluate these

issues, the review team examined the State’s questionnaire responses regarding

this indicator, interviewed program management and staff, and considered the

identified backlogs in licensing and compliance actions. 

The NHHS has primary responsibility for regulation and control of radiation in

Nebraska. Responsibility for regulating a proposed LLRW disposal site is

shared by both NHHS and NDEQ. Since the last program review in 1994, there

have been three reorganizations in the NHHS, the last of which was completed

after the IMPEP review, in January 1997. Under the reorganization, the

radiation control program continues to exist as two units (RAM and LLRW) in

the Division of Public Health Assessment, under NHHS. Emergency response

activities are the responsibility of the NHHS LLRW program manager. The RAM

and LLRW program managers report to a section administrator. Additionally,

technical staffing and training for the organizational unit located in the

Department of Environmental Quality, Low-Level Radioactive Waste Disposal

Program, consisting of both NDEQ and NHHS LLRW staff, is addressed in Section
Nebraska Final Report Page 6

4.2.3 of this report. Organization charts for NHHS and PHA can be found in

Appendix B.

In the second reorganization, implemented July 1, 1995, the division director

position was lost without naming a permanent RAM program manager. NRC

received notification through letters from the State that an experienced RAM

staff member had been designated program manager for Radioactive Materials on

April 24, 1995, and again in a letter dated June 13, 1995, but this person

left the program on June 23, 1995. In a letter dated May 15, 1995, the LLRW

program manager, was given the additional responsibility for all radiological

emergency response activities. A July 20, 1995 internal memorandum that was

provided to the IMPEP team during the review, designates the LLRW program

manager as Acting RAM program manager, but based on statements made by program

staff to the team, it was not clear to the RAM staff that the designated

duties went beyond signature authority for licenses. In a March 25, 1996

letter, NRC was notified that the Section Administrator for Environmental

Health Protection would be handling matters related to radioactive materials. 

A permanent RAM program manager was not named until May 1996, a delay of

nearly one year. 

The current radioactive materials program technical staff consists of a

program manager and three inspector/license reviewers while the LLRW program

technical staff consists of a program manager and two professional positions. 

The two staff members of the LLRW program are cross-trained to provide

technical support to the RAM program on a short-term basis, as needed. 

Additionally, the RAM and LLRW programs supplemented staff effort during the

review period with contractors. The review team found that the current

staffing level, with contractor support, and establishment of effective

management controls, is adequate to administer the regulatory program. 

With respect to RAM contract support, the State did not include a provision

specifying personnel qualifications in their Statement of Work. The RAM

program contractor, in bid documents, specified the use of individuals who

possessed the education and experience to meet the requirements of this

indicator, however, there was no specific provision concerning personnel

qualifications included in the contract. This was noted by the program

manager as a corrective action item for future contracts. The team concluded

that the contractor (based on discussions with the RAM program manager), has

adequate educational qualifications, but recommends that the qualifications of

contractor personnel be tied to the contract as identified by the program

manager or as accomplished by the Nebraska LLRW program. The program manager

further stated that the contractor is an experienced consultant in the health

physics area and personnel possessed appropriate technical qualifications.

The team reviewed staff turn-over and qualifications, and found that three

experienced members of the RAM staff left during the review period, all at

approximately the same time as the second reorganization. The review team

found that although it appears that management was responsive in filling two

of the vacant positions within a short period of time with cross-trained staff

from the X-ray and LLRW programs (with adequate educational background and

experience), management was unresponsive to the critical need to staff the

vacant Radioactive Materials program manager position. The program manager

position (which provides continuity, direction and support to the radioactive

materials program staff) was not permanently filled for almost a year, and was

one of the root causes of the difficulties experienced in the program. The

team observed that these difficulties, identified below, accelerated at the

time of the second reorganization and the nearly concurrent loss of three

experienced staff members of the RAM program. Difficulties encountered during

the review period include the following: (1) a backlog of 8 core inspections,

(2) 22 inspections pending supervisory review and notification of the findings
Nebraska Final Report Page 7

to the licensee, of which one contained health and safety issues, (3)

inspection reports were incomplete, (4) a backlog of 101 licensing actions of

which 73 could have health and safety related issues; included in the backlog

of 101 licensing actions were:

New RSO - 9 Add authorized user -9

Add or new location of use - 10 Terminate - 5

Renewal - 28 Delete location of use - 3

Short Form Renewal - 9 Add new use - 2

Add RAM - 7 Other - 2 

(5) no incident reporting to NRC since June 1995, (6) incomplete

documentation of incident response and response to allegations, (7)

regulations required for compatibility not adopted in timely fashion, and (8)

no "get-well" plan. 

All of these factors considered collectively led the team to find that the

performance with respect to the criteria for this indicator was inadequate. 

Details of these problems are discussed elsewhere in this report. The team

found that the primary root causes for the deficiencies found in the program

are (1) the failure of NHHS management to effectively address the reduced

level of program performance, and (2) lack of current, written, program

procedures or failure of staff to follow those procedures. 

The Radioactive Materials program manager and all three full time staff

perform duties in licensing, inspection, and event response. Although the

staff did try to achieve a balance between the licensing and inspection

functions, the significant backlog found in the area of inspections and

licensing and other deficiencies found in the program demonstrate that the

effort was not adequate to maintain the program. The team found it difficult

to evaluate the training of the personnel involved with the materials control

program, because there was no written program for staff qualification. 

According to the information provided in the questionnaire, all newly hired

health physicists are required to attend the NRC core training courses

outlined in the now suspended May 28, 1992, Policy Statement (57 FR 224950),

as well as the five-week health physics course. However, there was no written

documentation that stated this requirement had been met. The team found no

program records to show that existing materials program staff members have

taken the courses. The only records found were those maintained by individual

staff members. Subsequent to the review, the team was informed that database

records for a majority of the training received by program staff was

available, but were unknown to the new program manager.

The radioactive materials program staff also described in-house and on-the-job

training processes in their response and during interviews. Briefly, new

staff are assigned to review State regulations and procedures and to accompany

senior license reviewers/inspectors, then are assigned increasingly complex

licensing duties under the direction of senior staff and accompany experienced

inspectors during increasingly complicated inspections. New staff are

assigned independent inspections after demonstrating competence. The criteria

for determining the progress of new staff have not been established. The team

observed that the lack of criteria and the vacant radiation program manager

position for almost one year resulted in an inspector (hired in July 1995) not

yet considered trained to conduct even low priority inspections after one year

on the job. The team recommends that a written program for staff

qualification, including retaining training records, be developed. 

The team recommends that the State develop comprehensive administrative

procedures, sufficient to guide the day-to-day operation of the program in the

event of another loss of senior staff. The procedures should include a formal

process for bringing to the attention of upper management the increase of

significant backlogs of licensing, inspection, or enforcement actions, or any
Nebraska Final Report Page 8

other situation which increases the risk to public health and safety. 

Licensing procedures should include prioritization of licensing actions based

upon identified factors, including health and safety significance for new and

previously received applications. The team also noted that there was a

legislative mandate to further reorganize by combining NDOH and four other

Departments, to be completed by the end of calendar year 1996. The team was

informed that the fourth reorganization took place January 1997, and the NDOH

is now the Nebraska Health and Human Services System (NHHS). The team

recommends that NRC monitor the Nebraska program with increased attention to

the effects of the further reorganization.

As identified in Section 3.1 above, the team found that the problems

encountered during the period represent continuing trends of deficiencies

found in previous reviews of the Nebraska program. The exception was the 1994

review, wherein the previously identified staffing shortages were eliminated

when the State filled four long vacant positions. But the team found that the

State was unable to maintain adequate staffing beyond one year. The team also

concluded that the efforts begun in 1994, to maintain adequate staffing,

reduce the inspection backlog, and implement revised procedures were

unsuccessful. Collectively considering the historical weaknesses of the

program, the consistent significant staffing problems, the consequences of the

loss of three key staff members, other deficiencies found throughout the

program and lack of program management effectiveness to address these

weaknesses, the review team concludes that the State's program relative to the

criteria for this indicator was inadequate. 

Based on the IMPEP evaluation criteria, the review team recommended at the

time of the review, that Nebraska's performance with respect to the indicator,

Technical Staffing and Training, be found Unsatisfactory. Subsequent to the

review, at the January 22, 1997 MRB meeting to review the Nebraska IMPEP

report, the MRB, in consideration of the corrective actions already taken and

action plans identified by the State, revised the teams recommendation, and

changed the recommendation from Unsatisfactory to Satisfactory with

Recommendations for Improvement.

3.3 Technical Quality of Licensing Actions

The review team examined casework and interviewed the reviewers for 12

licenses and 28 licensing actions completed during the review period covering

June 25, 1994-July 12, 1996. The review team was unable to review or evaluate

statistical information related to any backlog of cases prior to July 1995,

due to the fact that the licensing program records for that time were

contained in a handwritten logbook that did not easily allow for statistical

review of pending actions. The team noted that the new RAM program manager

has implemented a computerized tracking system, beginning with July 1995, to

allow tracking of reviews, letters, replies, and license issue date. This

tracking system is a great improvement over the handwritten sheets kept in the

logbook and updated by individual reviewers prior to July 1995, and will allow

staff to keep better track of the licensing backlog. Licensing actions were

reviewed 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. Casework was reviewed for timeliness, adherence to good

health physics practices, reference to appropriate regulations, documentation

of safety evaluation reports, product certification or other supporting

documents, consideration of safety evaluation reports, product certification

or other supporting documents, consideration of enforcement history on

renewals, pre-licensing visits, peer or supervisory review, and proper

signature authorities. Licenses were reviewed for accuracy, appropriateness

of the license and its conditions and tie-down conditions, and overall
Nebraska Final Report Page 9

technical quality. The files were checked for retention of necessary

documents and supporting data. 

The cases were 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 cross-section sampling included 12 licenses of the

following types: medical/academic broad scope, medical-institution and

medical-mobile, industrial radiography, research and development, and portable

gauges. Licensing actions included three new licenses and 25 amendments. A

list of these licenses with case-specific comments is included in Appendix D.

The review team found that the licensing actions completed were thorough,

complete, consistent, and of acceptable quality with health and safety issues

properly addressed. Special license tie-down conditions were stated clearly,

backed by information contained in the file, and were inspectable. The team

noted a few deviations in the files of minor significance such as the use of

small yellow post-it pad notes to attach pertinent information rather than a

permanent form of documentation i.e., memorandum. All recent licensing

actions included a peer review which was recorded on a License Action Review

Record in the license file. No potentially significant health and safety

issues were identified with completed licensing actions. 

In response to the questionnaire, and discussions with the program manager,

the State indicated that three staff perform both license reviews and

inspections, and that Nebraska has approximately 157 specific licenses. Due

to problems encountered by the team in trying to review the handwritten

licensing logbook, we were unable to review or evaluate case backlog prior to

July 1995. In the period from July - December 1995, 38 licensing actions were

completed. From January - June 21, 1996, 48 licensing actions were completed. 

Subsequent to the review, the State informed the team that they had completed

48 licensing actions from July - December 1995, and 70 licensing actions

January 1 - June 21, 1996. During the review, the team noted that the new

radioactive materials program manager, appointed in May 1996, has implemented

a computer listing of licensing actions, beginning with July 1995, to allow

tracking of reviews, letters, replies, and license issue date. This tracking

system is a great improvement over the handwritten sheets kept by individual

reviewers, prior to July 1995, and will allow staff to keep better track of

the licensing backlog. 

In discussions with staff, priorities of licensing actions were stated to be

based upon health and safety issues, and applicants need. The team noted,

that the disruption caused by staff turnover has resulted in 101 licensing

actions not having been acted upon in a timely manner, as indicated in Section

3.2, Technical Staffing and Training.

Based on the IMPEP evaluation criteria, the review team recommends that

Nebraska's performance with respect to the indicator, Technical Quality of

Licensing Actions, be found Satisfactory.

3.4 Technical Quality of Inspections

The team reviewed enforcement documentation, inspection field notes, and data

base information for 20 materials inspections conducted during the review

period. The casework included inspections performed by the current program

manager, two health physicists who terminated their employment with the State

during the review period and inspections performed by a contractor hired to

help with the inspection backlog created by the loss of three key staff and

several reorganizations. The sampling included three nuclear medicine

licensees, two each pool irradiator, service, fixed gauge, portable gauge and

academic broad licensees and one each nuclear medicine/brachytherapy, mobile
Nebraska Final Report Page 10

nuclear medicine, self-shielded irradiator, radiography, academic/radiography,

academic non-broad and teletherapy licensees. Appendix E provides a list of

inspection cases reviewed in depth with case-specific comments.

The review team noted that the Nebraska program was adequate with respect to

this indicator. Routine inspections usually covered all aspects of the

licensee's radiation safety program. The team also noted that, during the

accompaniment of State inspectors, the inspectors observed licensed operations

or had operations demonstrated whenever possible. The observation of licensed

activities provides the inspectors with an indication of the effectiveness of

the licensee's radiation protection program. Finally, during the review

period, the State conducted team inspections of larger licensees. Having

multiple inspectors review a particular licensee's operations may lead to more

thorough inspections and provide the opportunity for less experienced

inspectors to observe experienced inspectors as an effective training

technique.

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 separate

inspection field notes for various classes of licensees, such as nuclear

medicine, portable gauges, radiography, and industrial/academic. The State

has not yet developed field notes specific for the inspection of HDRs or

nuclear pharmacies. The State uses the nuclear medicine field notes for these

type of 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 found several deficiencies during review of field notes in the

compliance files, such as incomplete documentation of technical and

administrative information, which are addressed in Appendix E, and further

clarified later in this section. The team noted that during the

accompaniments of State inspectors, the State inspectors examined appropriate

radiation health and safety issues at licensees' facilities. All the

inspectors, who were accompanied by a team member, used the field notes to

assure that all aspects of the program that could be reviewed were included in

the scope of the inspection. The 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 field notes indicated that the licensees' operations were

observed when licensed operations were being conducted by the licensee and

interviews with the State inspectors and observation by the team member during

accompaniments support that they routinely tour licensee areas such as

laboratories, other locations of use and storage areas. The inspectors

emphasized the observation of licensed activities to determine the

effectiveness of the licensee's radiation safety program and compliance to the

requirements, a critically important inspection technique. The field notes

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

previous violations. Also because health physicists serve both as inspectors

and license reviewers, there was evidence that licensing issues were

considered in the inspection process.

Four inspector accompaniments were performed by a review team member during

the period of June 24-28, 1996, and one accompaniment was performed during the

review period on July 16, 1996. The accompaniments included the following: 
Nebraska Final Report Page 11

(1) two inspections with two individuals from the LLRW program, the program

manager and a health physicist, who are cross-trained and qualified as

inspectors in the RAM program during an inspection of a radiography program

(including a field site visit) and a mobile nuclear medicine program,

respectively, and a second health physicist from the LLRW program, who was

being cross-trained in the Materials Program assisted on these inspections;

(2) a third inspection with the Radioactive Materials program manager and a

staff health physicist during inspections of a large nuclear medicine and a

self-contained blood irradiator program at a major medical facility; and a

fourth inspection with another staff health physicist during the initial

inspections of two separate portable gauge programs, one of which also

included a field site. These accompaniments are also identified in Appendix

E. During the accompaniments the Nebraska lead 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 observation of

the licensee's activities and interviews with personnel to assess the

effectiveness of the licensee's radiation safety program. 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 technical quality of inspections and the knowledge of

the inspectors is a strength in the Nebraska program. The review team noted

that the State relies on the technical knowledge of the inspectors to identify

root causes of non-compliance and poor licensee performance rather than having

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

this identification.

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

supervisory accompaniments by senior program staff is not defined by a program

procedure and they have not been documented in the past. However, in 1994,

three inspectors were accompanied by a contract consultant who observed the

inspector’s performance. The consultant was performing a review of the

program staff by accompaniment as part of his contract to develop an

Inspection and Enforcement Manual. Copies of the reports submitted for two of

three staff evaluated were provided. There were no supervisory accompaniments

of the Nebraska inspectors during 1995 and in the first six months of 1996. 

It should be noted that two of the three inspectors accompanied by the

contractor in 1994 have since left the program and the third was promoted to

program manager. The program manager indicated in discussions during the

review that he was the lead inspector on several occasions and was accompanied

by a staff health physicist for purposes of training, but had not performed an

accompaniment in his capacity as the manager of the Radioactive Materials

Program. 

Therefore, the review team recommends that the State consider for adoption a

policy of annual supervisory accompaniments of all individuals who perform

inspections for the Radioactive Materials Program.

In response to the questionnaire, the State indicated that a contractor was

hired to develop an Inspection and Enforcement Manual, which was completed in

April 1994. The revised Enforcement Manual contains standardized text

covering compliance issues for use in issuance of Notice of Violations (NOV)

to licensees. Use of standardized text would enhance the efficiency of the

compliance process; additionally, the Manual would prove very useful for

training new staff. The program manager indicated that future plans included

updating the Manual and implementing use of the Manual by the staff. Section

3.2 of this report covers procedures in greater detail.

It was noted that the State has available a variety of portable instruments

for routine confirmatory surveys and use during incidents and emergency
Nebraska Final Report Page 12

conditions. The instruments were a mix of low and high range Geiger-Mueller

detectors and pancake probes, micro R meter, alpha detector, and available

quantitative instruments in the Department of Health Laboratory. The portable

instruments used during the inspector accompaniments were observed to be

operational and calibrated. The team noted that the instruments are

calibrated on an annual basis.

It was found that the State is generally performing unannounced inspections of

materials licensees. Initial inspections and geographically-distant location

inspections are usually announced.

A review was conducted of the procedures and documentation of inspector field

notes or completed reports to determine that they are complete and reviewed

promptly by supervisors or management. That review found that previous

practice indicated that a supervisory review was conducted. The radiation

program manager position was vacant as of June 1995, and the person delegated

responsibility for signing off on NOVs left the program on June 23, 1995. 

Subsequently, the team was provided with a July 1, 1995, internal memorandum

designating the LLRW program manager as acting RAM program manager, but RAM

program staff were not clear as to whether this went beyond signature

authority for licensing actions. Therefore, it was not clear to the team or

to the RAM staff that any one in the radioactive materials program had

official supervisory signature responsibility prior to the announcement of a

new program manager in May 1996. The normal practice of a supervisory review

was not practiced during this time. 

Inspection findings generally indicated that the State planned to take

appropriate regulatory action with the following exceptions. As previously

indicated, inspection findings, in the form of a letter to the licensee, had

not been issued for 22 of the 27 inspections conducted by the contractor. 

Additionally, the team found that six of the 22 pending inspection findings

resulted in a recommendation for enforcement action that had not yet been

issued to the licensee. In one case, as indicated in Appendix E, the team

found that the enforcement letter identified five violations to the licensee

and the documentation in the field notes provided information for only two

violations. The review team also found some other problems with the

documentation of information on the field note reports as noted in the

comments in Appendix E. The field notes on page one provide space for

administrative information such as: inspection report no., license no.,

licensee (name and address), licensee contact, telephone no., priority, date

of last inspection, date of this inspection, type of inspection, summary of

findings and action, next inspection date and whether next inspection is at a

normal, reduced or extended frequency, signature and date the inspector

signed, and signature and date supervisor approved the report. Eleven of the

field note reports did not have all the administrative information required. 

Ten reports were not approved with a supervisor's signature and date; and a

few of the typed inspection reports did not contain any signature. The team

believes that supervisory approval of inspection findings documented in the

field notes prior to issuance of an enforcement letter is necessary to assure

that the field notes contain sufficient information to support any violations

or recommendations in an enforcement letter. In addition, seven of the field

note reports had no technical information documented in areas such as: 

training of ancillary personnel; exit meeting attendees; pH, clarity and Cl or

F concentrations in pool water; independent measurements, inventory of

brachytherapy sources after return to storage, and Radiation Safety Committee

(RSC) minutes/committee composition. The team noted that Nebraska Code 10.03,

effective May 30, 1994, and compatible to 10 CFR 19.12, does not contain the

August 1995 revisions to 10 CFR 19.12.
Nebraska Final Report Page 13

In discussions with the program manager, the team was informed that the

previous requirement for typewritten field notes to be used as the

documentation of inspection findings delayed the supervisory review until the

field notes were typed. The new program manager stated that handwritten field

notes would be accepted during the interim time period, while the staff try to

complete the backlog of inspections. The new program manager stated that

future plans include standardizing and automating the boilerplate inspection

information.

In addition to the recommendation stated above regarding annual supervisory

accompaniments of all individuals who perform inspections, the review team

recommended that the program: (1) develop a plan or procedure to assure that

field notes, as well as, reports, and enforcement letters are promptly

reviewed, signed and dated by a supervisor within the recommended 30 day time

frame for issuance of inspection findings; and (2) perform an immediate review

of all contractor field notes and draft enforcement letters in order to

finalize and issue the findings of the remaining 22 inspections to the

licensees involved.

Based on the IMPEP evaluation criteria, the review team recommends that

Nebraska's performance with respect to the indicator, Technical Quality of

Inspections, be found Satisfactory with Recommendation 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 and reviewed the incidents

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

those contained in the Nebraska casework and license files, and supporting

documentation, as appropriate for six incidents. In addition the team

interviewed the Radioactive Materials program manager. Due to recent staff

turnover the team was unable to interview other staff for this indicator.

The incident investigations were reviewed for responsiveness, coordination,

health and safety significance and appropriate level of effort, investigative

procedures, corrective actions, follow-up, compliance and notifications, as

necessary.

Responsibility for initial response and follow-up actions to material events

rests with the Radioactive Materials Program and the Low-Level Radioactive

Waste Program. Written procedures require a prompt response to incidents by

the staff and provide additional procedural guidance. Written procedures for

allegations also require prompt response, but contained no further procedural

guidance. The review team found that allegations were handled as routine

incidents and files contained incomplete or no documentation of inspection

results or State action. The team noted in one case that investigative

techniques were insufficient to appropriately resolve alleged issues. The

review team recommended revising the allegations procedures to incorporate key

areas, i.e., documentation of any communications with the alleger,

documentation of the inspection findings, interviewing techniques, etc.,

identified in NRC Management Directive 8.8, Management of Allegations. 

The review team also noted that the staff did not have a procedure for

tracking the status (i.e. identification, receipt, follow up, and closeout) of

material events. The review team recommended that the staff use the draft

"Handbook on Event Reporting in the Agreement States (Handbook)," published

March 1995, for review and reporting of material events to NRC. The Handbook

identifies the NRC Operations Center, Office for Analysis and Evaluation of

Operational Data, as the proper group to receive voluntary notification of the
Nebraska Final Report Page 14

occurrence of significant events in an Agreement State, and provides guidance

on the identification, reporting, follow-up reporting, and closeout of

material events. 

The review team found, through discussions with the Radioactive Materials

program manager, that the staff have been unable to voluntarily report to NRC

the occurrence of any material events since June 1995, due to the loss of

three experienced staff members. Limited resources had to be redirected to

other more critical areas. Therefore, the team was unable to evaluate whether

or not the State provided information on all events that may have occurred

during the period of review prior to June 1995. Two reportable events were

found by the team during review of selected case files.

Through a review of information provided in the questionnaire and through

review of selected case files, the team found that four reportable events had

occurred, three of which had not been reported to NRC, and subsequently NMED. 

Two of the reportable events were identified in the State's response to the

questionnaire as significant events that had occurred during 1995. Two of the

reportable events examined by the team involved equipment malfunctions at an

irradiator facility, and one involved loss of material. Other case files

reviewed included a 1994 event involving the loss of material, that had

previously been reported to NRC, an event involving the unauthorized use of

equipment, and an event involving loss of control of radioactive material,

both of which had not been reported to NRC. The team noted several case file

deficiencies, i.e., one file contained no documentation of inspection results,

another indicated insufficient follow-up action by the State to the loss of

control of radioactive material, and a third indicated lack of State action to

a late notification of the occurrence of an event by the licensee. With

regard to the incidents that occurred at an irradiator facility, and one event

involving equipment malfunction as a result of the unauthorized removal and

replacement of equipment, the team discussed the need to report events

involving equipment malfunction or possible defects of equipment with the

program manager and the importance of documentation of contact with the

alleger. The review team concluded that the State's documentation and in one

instance response, to the occurrence of events involving the use of

radioactive material and response to allegations needs improvement. They did

not have a complete understanding of reporting requirements, and lacked proper

procedures for handling allegations. A list of the incident reports examined

is contained in Appendix F.

In addition to the above recommendation that the Nebraska staff revise the

allegations procedures and incorporate use of the "Event Reporting Handbook,"

the team recommends establishment of comprehensive procedures for tracking,

follow up and close out of events involving the use of radioactive material

covered under the Atomic Energy Act. The review team also recommends that the

State immediately begin reporting current material events to NRC and send in

information on the three events identified during the review as reportable, to

the State, but were not previously reported to NRC.

Based on the IMPEP evaluation criteria, the review team recommends that

Nebraska's performance with respect to this indicator, Response to Incidents

and Allegations, be found Satisfactory with Recommendations for Improvement.

4.0 NON-COMMON PERFORMANCE INDICATORS

4.1 Legislation and Regulations

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

reviewing Agreement State programs: (1) Legislation and Regulations, (2)

Sealed Source and Device Evaluation Program, (3) Low-Level Radioactive Waste
Nebraska Final Report Page 15

Disposal Program, and (4) Uranium Recovery. Nebraska's agreement does not

cover uranium recovery operations, so only the first three non-common

performance indicators were applicable to this review.

4.1.1 Legislative and Legal Authority

Along with their response to the questionnaire, Nebraska provided the review

team with copies of legislation that affects the radiation control program. 

The Nebraska Department of Health regulates use of radioactive material. NDEQ

and NHHS have shared responsibilities for regulation of the planned low-level

radioactive waste site. Based on the response to the questionnaire, and on

statements by the Director of the Department of Health that there had been no

change to the State legislation that affected the duties or responsibilities

of the materials programs, the review team did not review the legislation but

relied on previous reviews where State legislation was determined to be

adequate. The team did note the legislative changes that will result in the

reorganization of the Department.

4.1.2 Status and Compatibility of Regulations

Nebraska's latest rules and amendments became effective May 30, 1994. The

equivalent NRC rules are: "Decommissioning," 10 CFR Parts 30, 40, and 70;

"Emergency Planning," 10 CFR Parts 30, 40, and 70; "Standards for Protection

against Radiation," 10 CFR Part 20; "Safety Requirements for Radiographic

Equipment," 10 CFR Part 34; "Notification of Incidents," 10 CFR Parts 20, 30,

31, 34, 39, 40, and 70; and "Decommissioning 

Recordkeeping and License Termination: Documentation Additions," 10 CFR Parts

30, 40, 70, and 72. Not all of these regulations were promulgated within the

three year period following the adoption of the NRC regulation. The team

reviewed the final published Nebraska regulations equivalent to the above and

found them to be compatible with the NRC regulations. 

There are four irradiators in use in Nebraska which would be subject to the

regulations in "Licensing and Radiation Safety Requirement for Irradiators,"

10 CFR Part 36. Equivalent rules were in development when the reorganizations

and personnel turn over discussed earlier in this report occurred. As a

result of personnel reassignments, the rules were not adopted by their due

date of July 1, 1996. At the time of the review, the rules were scheduled for

public hearing and adoption was expected by the end of the calendar year. 

Nebraska does not regulate uranium recovery operations, and does not have

rules equivalent to NRC's regulations applicable to uranium recovery contained

in 10 CFR Part 40. Therefore, it will not adopt the regulations equivalent to

"Uranium Mill Tailings Regulations: Conforming NRC Requirements to EPA

Standards," 10 CFR Part 40 amendments (59 FR 28220) that became effective on

July 1, 1994, and will need to be adopted by July 1, 1997. Nebraska has

assumed regulatory authority for a low-level radioactive waste site, and has

selected an enhanced technology for disposal. Therefore, the State does not

need to adopt the land disposal definition part of the "Definition of Land

Disposal and Waste Site QA Program," 10 CFR Part 61 amendments (58 FR 33886)

that became effective on July 22, 1993. The State has adopted the QA program

portion of the amendment.

In addition to the above, the team found that work is in progress to develop

equivalent rules to the following, which the program has scheduled for

adoption in January 1997.

• "Quality Management Program and Misadministration," 10 CFR Part 35

amendment (56 FR 34104) that became effective on January 27, 1992. An
Nebraska Final Report Page 16

NRC staff evaluation of whether this rule will be used to evaluate

Agreement State compatibility continues.

• "Self-Guarantee as an Additional Financial Mechanism," 10 CFR Parts 30,

40, 70 amendments (58 FR 68726, 59 FR 1618) that became effective on

January 28, 1994. Note, this rule is designated as a Division 2 matter

of compatibility. Division 2 compatibility allows the Agreement State

flexibility to be more stringent (i.e., the State could choose not to

adopt self-guarantee as a method of financial assurance. If a State

chooses not to adopt this regulation, the State's regulation, however

must contain provisions for financial assurance that include at least a

subset of those provided in NRC's regulations, e.g., prepayment, surety

method (letter of credit or line of credit), insurance or other

guarantee method (e.g., a parent company.)

• "Timeliness in Decommissioning," 10 CFR Parts 30, 40, 70 amendments 

(59 FR 36026) that became effective on August 15, 1994.

• "Preparation, Transfer for Commercial Distribution and Use of Byproduct

Material for Medical Use," 10 CFR Parts 30, 32, and 35 amendments (59 FR

61767, 59 FR 65243, 60 FR 322) that became effective on January 1, 1995.

• "Frequency of Medical Examinations for Use of Respiratory Protection

Equipment," 10 CFR Part 20 amendments (60 FR 7900) that became effective

on March 13, 1995. Note, this rule is designated as a Division 2 matter

of compatibility. Division 2 compatibility allows the Agreement States

flexibility to be more stringent (i.e., the State could choose to

continue to require annual medical examinations). 

• "Low-Level Waste Shipment Manifest Information and Reporting," 10 CFR

Parts 20 and 61 amendments (60 FR 15649, 60 FR 25983) that will become

effective March 1, 1998. Nebraska and the other Agreement States are

expected to have an equivalent rule effective on the same date.

• "Radiation Protection Requirements: Amended Definitions and Criteria,"

10 CFR Parts 19 and 20 amendments (60 FR 36038) that became effective 

August 14, 1995.

• "Medical Administration of Radiation and Radioactive Materials," 10 CFR

Part 20 and 35 amendments (60 FR 48628) that became effective October

20, 1995.

• "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.

The review team examined the procedures used in the State's regulation

promulgation process and found that the public is offered the opportunity to

comment on proposed regulations during a comment period and in a public

hearing that follows the comment period. According to the staff member

responsible for rules development, NRC is provided with drafts for comment on

the proposed regulations early in the promulgation process. A copy of the

final regulation is submitted to NRC.

During discussions with the review team, the staff explained that they had

begun the process of drafting revisions to the regulations which they expect

to promulgate in January 1997 for new regulations due through 1998. The State
Nebraska Final Report Page 17

is aware of the importance of maintaining compatible regulations, and the

State plans to update regulations yearly to maintain compatibility. 

The review team identified a possible incompatibility in Section 012 of the

Nebraska regulations, which are rules equivalent to NRC's 10 CFR Part 61. The

Nebraska regulations, as written, apply the public dose limits in 180 NAC 1-

012.22 (equivalent to 10 CFR 61.41) to low-level radioactive waste facilities

that process or store waste, as well as to disposal sites. Under NRC

regulations, such facilities would not be subject to the equivalent public

dose limits in 10 CFR 61.41, but rather to the public dose limit in 10 CFR

Part 20. The Nebraska regulations may thus be more stringent than the

equivalent NRC rules, however, both 10 CFR 61.41 and 10 CFR 20.1301 are

Division 1 compatibility requirements. In response to the team's request for

clarification regarding application of the public dose limits in the State's

equivalent regulations to 10 CFR Part 61, the State responded in a letter

dated December 13, 1996. The State responded that they do not currently have

any brokers, treatment facilities, or storage facilities to which this

regulation has been applied. In accordance with the report that identified it

as a Division 1 compatibility requirement which can only be applied to land

disposal facilities, the Department intends to amend the regulation and

anticipates this can be done by June 30, 1997. The State included a copy of

the proposed amendment to 180 NAC 1-012.22 (equivalent to 10 CFR 61.41). 

Since there are no licensees to which the more stringent standard is

applicable and Nebraska has committed to revise 180 NAC 1-012.22, the review

team believes this matter is not a significant issue. In accordance with the

State's commitment, the team recommends that Nebraska amend 180 NAC 1-012.22

to remove its applicability to waste treatment and storage facilities. 

(Section 4.1.2)

Based on the IMPEP evaluation criteria, at the time of the review, the team

recommended that Nebraska's performance with respect to the indicator,

Legislation and Regulations, be found unsatisfactory due to the failure to

adopt regulations equivalent to 10 CFR Part 36 by July 1, 1996. Subsequent to

the review, the State informed the team that Section 019 of the Nebraska Code,

"Licenses and Radiation Safety Requirements for Irradiators," was adopted

effective October 30, 1996, and inquired whether the team reviewed the area

of other legally binding requirements. After review, NRC informed the State

on December 9, 1996, that the regulations were compatible. Note, the option

of legally binding license conditions equivalent to the requirements contained

in 10 CFR Part 36 had not been officially implemented at the time of the

review, therefore, the reviewer did not look at this option. In response to

the States adoption of 10 CFR Part 36 equivalent regulations, the team, based

on additional information, is recommending that Nebraska's performance with

respect to this indicator be found Satisfactory.

4.2 Low-Level Radioactive Waste Disposal Program

In the process of evaluating this performance indicator, the review team

studied the State's response to the questionnaire, reviewed the terms of the

Memorandum of Understanding between NDEQ and NHHS, compared Nebraska LLRW

statutes and regulations with those of the NRC, evaluated the qualifications

of the technical staff and contractors, reviewed the States written procedures

and plans, reviewed or discussed parts of the safety analysis report (SAR),

audits, and contractor reports, and any other supporting documentation, as

necessary, and interviewed all staff and managers assigned to the LLRW

program. In addition, the team evaluated the effectiveness of the shared

responsibility for regulation of LLRW in Nebraska. 
Nebraska Final Report Page 18

4.2.1 Introduction

The State of Nebraska received a License Application from U.S. Ecology on July

27, 1990, to operate a low-level radioactive waste facility in the State. A

site characterization plan was submitted to NDEQ on June 6, 1989. The State

is presently reviewing the License Application submitted by U.S. Ecology, to

develop a facility in the State; therefore, limited information may exist with

respect to State activities for some of the performance indicators.

In the shared responsibility for regulation of LLRW, the NHHS and the NDEQ

programs have agreed to procedures that are detailed in Section 1, Licensing

Organization, of the Licensing Program Plan (LPP-01). As part of a commitment

made in response to NRC recommendations following the 1990 program review,

there are monthly meetings attended by the LLRW Program Manager and Director

from each department. The meetings are not required as part of LPP-01. These

meetings appear to be an effective means to keep management aware of program

issues and progress, and to resolve issues that could be disruptive to the

program. 

4.2.2 Status of Low-Level Radioactive Waste Disposal Program

With the program in the pre-licensing non-operational phase, inspections are

not applicable.

4.2.3 Technical Staffing and Training

NHHS staff assigned principally to the LLRW program include a program manager

(a health physicist), a health physicist with a specialty in environmental

surveillance, a health physicist with a specialty in performance assessment, a

radiation-health specialist, and three staff assistants (one in Lincoln, NE

and two in Butte, NE). In addition, there is a vacant position for a health

physicist with a specialty in nuclear engineering.

The NDEQ LLRW program includes a program manager, an environmental specialist

with specialties in health physics and performance assessment, an

administrative assistant specializing in document preparation and public

relations, a staff assistant specializing in document control, and a

secretary. The LLRW program receives occasional support from technical

specialists in other NDEQ programs as short-term needs arise.

The LLRW program relies upon contractors for additional technical support and

to provide additional technical specialists as needed for the SAR review

(approximately 78 contractor staff). The NDEQ LLRW program has continuing

contracts with the University of Nebraska-Lincoln and a number of consultingengineering firms. The engineering firms provide their in-house expertise as

well as sub-contracting for national expertise in selected technical areas. 

These areas include:

Hydrogeology Economics 

Surface-Water Hydrology Seismology

Geology Biology

Nuclear Engineering Climatology/Meteorology

Geotechnical Engineering Sociology

Structural Engineering Quality Assurance

Operational/Construction Geochemistry

Mechanical Engineering Performance Assessment

Health Physics Financial Assurance

Environmental Engineering Regulatory Analysis

Materials Engineering Project Management

Civil Engineering
Nebraska Final Report Page 19

The team reviewed the documentation of qualifications and training of staff in

both the NHHS and NDEQ LLRW programs. In addition, the team reviewed the

documentation of qualifications and Quality Assurance (QA) training that the

program requires of review managers (8) and approximately 80 technical

reviewers of the SAR. Staff and contractors are all highly qualified for

their responsibilities in the LLRW program, easily meeting the guidance

specified in NUREG/CR-4352, "Suggested State Requirements and Criteria for a

Low-Level Radioactive Waste Disposal Site Regulatory Program." The LLRW

program has actively supported staff and contractor training in QA Procedures,

Performance Assessment and other courses or workshops applicable to the

program. The documentation to allow tracking or reporting of the status and

history of staff and contractor training are not readily accessible and are

not summarized. Training documentation is required and accessible during

internal audits or surveillance of the contractors that are part of the

program but is not accessible outside of the context of the

audit/surveillance. Formalized tracking of NDEQ and NHHS program staff

training is apparently not required at the present time. The team suggests

that the LLRW program assemble training documentation for individual staff and

contractors and develop a consolidated training record to enable assessment of

the progress of training across the entire program.

4.2.4 Technical Quality of Licensing Actions

With current program emphasis on review of the applicant's SAR and

documentation of Evaluation Findings prior to preparation of the Draft Safety

Evaluation Report, the IMPEP team examined the project's SAR review comments,

comment tracking and reviewer qualification documentation. This involved

tracing comments either through to closure resulting from subsequent SAR

modifications, or as persistent open issues. 

The program has a well organized QA program to govern all program activities

that might affect public health and safety. This QA program enabled the team

to readily review and track the SAR review process.

A total of 195 comments in the subject areas of site characterization and

performance assessment were tracked. Of these, the only questions arose due

to seven comments submitted by a reviewer whose Technical-Review Qualification

Statement was not on file. This omission was corrected once it was brought to

the attention of the program staff.

The team also reviewed a Quality Assurance Compliance Inspection Audit,

performed by a LLRW audit team, of the U.S. Ecology's engineer of record for

the project, Bechtel National Inc., Oak Ridge, Tennessee. This audit was

selected because it examined the QA associated with performance assessment

calculations. The applicant was informed of this audit on July 21, 1995. The

audit took place on August 10-11, 1995 at the Bechtel National Inc. offices at

Oak Ridge, Tennessee and was performed by three auditors and two technical

specialists from the Nebraska LLRW program. The Quality Audit Checklist

prepared prior to the audit contained 56 audit items; some were generic but

many targeted directly at the applicant's program. The audit resulted in

additional audit items, resulting in a total of 78 audit items. The audit

resulted in 11 compliance nonconformances that were transmitted to the

applicant on January 18, 1996. The applicant responded on April 23, 1996 and

is in the process of resolving the nonconformances. 

The team believes that the Nebraska LLRW program has a commendable QA program

for auditing the applicant and for internal auditing within the Nebraska LLRW

program.
Nebraska Final Report Page 20

4.2.5 Technical Quality of Inspections

With the program in the license-application review phase, inspections are not

applicable.

4.2.6 Response to Incidents and Allegations

There were no incidents or allegations reported.

Based on the IMPEP evaluation criteria, the review team recommends that

Nebraska's performance with respect to the non-common indicator, Low-Level

Radioactive Waste Disposal Program, be found Satisfactory.

4.3 Sealed Source and Device Program

The review team did not review the State's sealed source and device (SS&D)

evaluation even though they currently have responsibility for this area

because the State has indicated that it plans to formally relinquish its SS&D

authority. The State has performed only one SS&D review in the past 25 years

and did not perform any SS&D evaluations during the period of review. 

5.0 SUMMARY

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

performance with each of the performance indicators to be satisfactory or

satisfactory with recommendations for improvement, with two exceptions. The

team found the State's performance unsatisfactory in Section 3.2, Technical

Staffing and Training, and Section 4.1.2, Status and Compatibility of

Regulations. A review of previous program reviews between 1986-1992 indicated

similar problems were found in staffing, inspection program, compatibility of

regulations, enforcement and management control. The team observed that the

State experienced weaknesses and deficiencies throughout the program during

the reporting period which were compounded by the loss of three key staff

members and two reorganizations. Difficulties identified during the review

include: (1) a backlog of 9 core inspections; (2) 22 inspections pending

supervisory review and notification of the findings to the licensee; (3)

inspection reports were incomplete; (4) a backlog of 101 licensing actions;

(5) no incident reporting to NRC since June 1995; (6) incomplete documentation

of incident response and response to allegations; (7) regulations required for

compatibility not adopted in timely fashion; and (8) no "get-well" plan. All

of these factors considered collectively led the team to find that State's

response to Section 3.2, Technical Staffing and Training, was unsatisfactory

at the time of the review. Subsequently, at the January 22, 1997 MRB meeting,

the MRB, in consideration of the current staffing level and the corrective

actions already taken and actions plans identified by the State, revised the

team's recommendation for Section 3.2, from Unsatisfactory to Satisfactory

with Recommendations. The team found Section 4.1.2, Status and Compatibility

of Regulations, unsatisfactory, at the time of the review, due to the failure

to adopt regulations equivalent to 10 CFR Part 36 by July 1, 1996. However,

subsequently this regulation was promulgated on October 30, 1996, with the

minor exception of the applicability of a more stringent radiation protection

standard to a non-existent class of licensees, the Nebraska program is

currently compatible. 

The team found that the primary root causes for the deficiencies found in the

program were directly attributable to (1) the need for management improvement

to effectively assess and respond to the reduced level of performance in the

Agreement State program, and (2) lack of current, written, program procedures

or failure of staff to follow these procedures. Accordingly, the team
Nebraska Final Report Page 21

recommended that the MRB find the Nebraska program adequate to protect public

health and safety but needs improvement, and compatible with NRC's program. 

Due to the significance and number of deficiencies found in the Nebraska

program, at the time of review, that included unsatisfactory in one

performance indicator, the team recommended a period of probation for a

duration to be established after consultation with Nebraska radiation control

program management. Subsequently, at the January 22, 1997 MRB meeting, in

consideration of the corrective actions already taken and actions plans

presented by the State, the team revised their recommendation from probation

to a recommendation that NRC conduct a follow-up IMPEP review of the State's

program, within one to one and one-half years from the date of the last IMPEP

review, but not later than September 1997. The team also recommended that the

State keep NRC apprised of the status of corrective actions and plans. The

MRB considered and concurred with the review team's recommendation.

Recommendations

Below is a summary list of recommendations and suggestions, as stated in

earlier parts of this report, for consideration and action by the State.

1. The review team recommends that the managers responsible for the

Nebraska Radioactive Materials Program establish an action plan or

procedure to assure inspections are completed at the frequencies stated

in the Nebraska Inspection Manual which is equal to the NRC's IMC 2800

and conduct reciprocity licensee inspections at the required frequencies

stated in IMC 1220. (Section 3.1)

2. The review team recommends that the managers establish an action plan or

procedure for coordinating deviations from the inspection schedule

between staff and management based on the risk of license operations,

past performance and need to temporarily defer the inspections to

address more urgent or critical priorities. (Section 3.1)

3. The review team recommends that the managers organize a "get well" plan

for rescheduling missed or deferred inspections, especially due to loss

of senior staff; and establish a plan or methodology to assure initial

inspections are performed within 6 months of issuance of the license,

beginning licensed activities, or within one year of license issuance,

whichever comes first, in accordance with the Nebraska Inspection Manual

and NRC's IMC 2800. (Section 3.1) 

4. The team recommends that the qualifications of contractor personnel be

tied to the contract as identified by the program manager or as

accomplished by the LLRW program in NDEQ. (Section 3.2)

5. The team recommends that a written program for staff qualification,

including retaining training records, be developed. (Section 3.2)

6. The team recommends that the State develop comprehensive administrative

procedures, sufficient to guide the day-to-day operation of the program

in the event of another loss of senior staff. The procedures should

include a formal process for bringing to the attention of upper

management the increase of significant backlogs of licensing,

inspection, or enforcement actions, or any other situation which

increases the risk to public health and safety. Licensing procedures

should include prioritization of licensing actions based upon identified

factors, including health and safety significance, for new and

previously received applications. (Section 3.2)
Nebraska Final Report Page 22

7. The review team recommends that the State consider for adoption a policy

of annual supervisory accompaniments of all individuals who perform

inspections for the Radioactive Materials Program. (Section 3.4)

s8. The review team recommends that the State develop a plan or procedure to

assure that field notes, as well as, reports, and enforcement letters

are promptly reviewed, signed and dated by a supervisor within the

recommended 30 day time frame for issuance of inspection findings. 

(Section 3.4)

9. The review team recommends that the State perform an immediate review of

all contractor field notes and draft enforcement letters in order to

finalize and issue the findings of the remaining 22 inspections to the

licensees involved. (Section 3.4)

10. The review team recommends revising the allegations procedures to

incorporate key areas, i.e. documentation of any communications with the

alleger, documentation of the inspection findings, interviewing

techniques, etc., identified in NRC Manual Directive 8.8, Management of

Allegations. (Section 3.5)

11. The review team recommends that the staff use the draft "Handbook on

Event Reporting in the Agreement States (Handbook)," published March

1995, for review and reporting of material events to NRC. (Section 3.5)

12. The review team recommends establishment of comprehensive procedures for

tracking, follow up and close out of events involving the use of

radioactive material covered under the Atomic Energy Act. (Section 3.5)

13. The review team recommends that the State immediately begin reporting

current material events to NRC and send in information on the three

events identified during the review as reportable, that were not

previously reported to NRC. (Section 3.5)

14. In accordance with the State's commitment, the team recommends that

Nebraska amend 180 NAC 1-012.22 to remove its applicability to waste

treatment and storage facilities. (Section 4.1.2)

15. The team suggests that the LLRW program assemble training documentation

for individual staff and contractors and develop a consolidated training

record to enable assessment of the progress of training across the

entire program. (Section 4.2.3)
LIST OF APPENDICES

Appendix A IMPEP Review Team Members

Appendix B NHHS/DRL and PHS Organization Chart

Appendix C Nebraska Questionnaire Response

Appendix D License File Reviews

Appendix E Inspection File Reviews

Appendix F Incident File Reviews

Appendix G Background Information
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Patricia M. Larkins, OSP Team Leader

Response to Incidents and Allegations

Jenny Johansen, RI Status of Materials Inspection Program

Technical Quality of Inspections

Richard Blanton, OSP Technical Staffing and Training

Legislation and Regulations

Charles Mattson, Colorado Technical Quality of Licensing Actions

Ralph Cady, RES Low-Level Radioactive Waste Program
APPENDIX B

NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM

DEPARTMENT OF REGULATION AND LICENSURE

AND

PUBLIC HEALTH ASSESSMENT DIVISION

ORGANIZATION CHART
APPENDIX C

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

(IMPEP) QUESTIONNAIRE