December 27, 2005

Mr. Richard B. Bays, Assistant Commissioner

Division of Regulatory Services

Texas Department of State Health Services

8407 Wall Street, Room S101

Austin, TX 78754

Dear Mr. Bays:

On December 14, 2005, the Management Review Board (MRB) met to consider the proposed

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

Agreement State program. The MRB found the Texas program adequate but needs

improvement and compatible with the U.S. Nuclear Regulatory Commission’s (NRC) program. 

The MRB determined the Texas program should continue the period of heightened oversight

and that a follow-up review should take place in approximately one year. Heightened oversight

is an increased monitoring process used by NRC to follow the progress of improvement needed

in an Agreement State program. It involves preparation of a program improvement plan,

bimonthly conference calls, and submission of status reports prior to each call with the

appropriate Texas and NRC staffs.

The Texas Agreement State program was initially placed on heightened oversight as a result of

a March 15, 2005 periodic meeting with the Texas Department of State Health Services (the

Department). The decision to place the State on heightened oversight was based on concerns

with staff turnover, status of inspections, timeliness of reporting events, and status of

regulations within the Department. The Department has made considerable progress in

addressing the concerns from the March 2005 periodic meeting during the short time the State

has been on heightened oversight. The enclosed report acknowledges the progress made by

the Department to restore the program to the fully satisfactory level. In particular, the

Department has made commendable efforts in addressing staffing levels, event reporting and

regulation adoption. Although the State has made significant progress, a period of sustained

performance at the satisfactory level must be demonstrated prior to removal from the

heightened oversight process.

I request that the Department revise and resubmit their program improvement plan as part of

the response to the recommendations in Section 5 of the enclosed final report. The revised

plan should be submitted within 30 days of this letter. If you have any questions regarding the

expectations of the program improvement plan, please have your staff contact Janet R. 

Schlueter, Director of the NRC’s Office of State and Tribal Programs. I request that the 

bimonthly conference calls between the Department and NRC staff continue during the period

of heightened oversight. The first call should take place approximately two weeks after the

submittal of the Department’s revised program improvement plan. Two weeks prior to each

subsequent call, the Department should provide a status report of actions associated with the

plan to the NRC.
R. B. Bays -2-

A follow-up review will be scheduled in approximately one year to cover the State’s actions on

the recommendations from the September 2005 review. The follow-up review will focus on

those performance indicators that were below the satisfactory level at the time of the

September 2005 IMPEP review. If the Department believes that all recommendations have

been adequately addressed and that the Department’s performance for all indicators is at the

satisfactory level before the tentatively scheduled date of the follow-up review, the NRC will

consider moving the follow-up review to an earlier time to release the State from the

requirements of heightened oversight if supported by the results of the review. Periodic

meetings with both the Department and the Texas Commission on Environmental Quality will be

held in conjunction with the follow-up review.

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

also wish to acknowledge your continued support for the Agreement State program and the

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

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

Sincerely,

/RA/

Martin J. Virgilio

Deputy Executive Director for Materials, Research, 

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure:

As stated

cc: D. Eden, Deputy Director

 Office of Permitting, Remediation & Registration, TCEQ

E. J. Sanchez, M.D. 

 Commissioner, TDSHS

K. H. White, Chairman, TCEQ

R. A. Ratliff, TDSHS

S. M. Jablonski, TCEQ

G. T. FitzGerald, TCEQ

R. Mulder, State Liaison Officer

R. G. Fletcher, MD

 Organization of Agreement States

 Liaison to the MRB
December 27, 2005

Mr. Dan Eden, Deputy Director

Office of Permitting, Remediation & Registration

Texas Commission on Environmental Quality

12100 Park 35 Circle, MC 122

Austin, TX 78753

Dear Mr. Eden:

On December 14, 2005, the Management Review Board (MRB) met to consider the proposed

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

Agreement State program. The MRB found the Texas program adequate but needs

improvement and compatible with the U.S. Nuclear Regulatory Commission’s (NRC) program. 

The MRB determined the Texas program should continue the period of heightened oversight

and that a follow-up review should take place in approximately one year. Heightened oversight

is an increased monitoring process used by NRC to follow the progress of improvement needed

in an Agreement State program. It involves preparation of a program improvement plan,

bimonthly conference calls, and submission of status reports prior to each call with the

appropriate Texas and NRC staffs.

The Texas Agreement State program was initially placed on heightened oversight as a result of

a March 15, 2005 periodic meeting with the Texas Department of State Health Services (the

Department). The decision to place the State on heightened oversight was based on concerns

with staff turnover, status of inspections, timeliness of reporting events, and status of

regulations within the Department. The Department has made considerable progress in

addressing the concerns from the March 2005 periodic meeting during the short time the State

has been on heightened oversight. The enclosed report acknowledges the progress made by

the Department to restore the program to the fully satisfactory level. In particular, the

Department has made commendable efforts in addressing staffing levels, event reporting and

regulation adoption. Although the State has made significant progress, a period of sustained

performance at the satisfactory level must be demonstrated prior to removal from the

heightened oversight process.

I request that the Department revise and resubmit their program improvement plan as part of

the response to the recommendations in Section 5 of the enclosed final report. The revised

plan should be submitted within 30 days of this letter. If you have any questions regarding the

expectations of the program improvement plan, please have your staff contact Janet R. 

Schlueter, Director of the NRC’s Office of State and Tribal Programs. I request that the 

bimonthly conference calls between the Department and NRC staff continue during the period

of heightened oversight. The first call should take place approximately two weeks after the

submittal of the Department’s revised program improvement plan. Two weeks prior to each

subsequent call, the Department should provide a status report of actions associated with the

plan to the NRC.
D. Eden -2-

A follow-up review will be scheduled in approximately one year to cover the State’s actions on

the recommendations from the September 2005 review. The follow-up review will focus on

those performance indicators that were below the satisfactory level at the time of the

September 2005 IMPEP review. If the Department believes that all recommendations have

been adequately addressed and that the Department’s performance for all indicators is at the

satisfactory level before the tentatively scheduled date of the follow-up review, the NRC will

consider moving the follow-up review to an earlier time to release the State from the

requirements of heightened oversight if supported by the results of the review. Periodic

meetings with both the Department and the Texas Commission on Environmental Quality will be

held in conjunction with the follow-up review.

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

also wish to acknowledge your continued support for the Agreement State program and the

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

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

Sincerely,

/RA/

Martin J. Virgilio

Deputy Executive Director for Materials, Research, 

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure:

As stated

cc: R. B. Bays, Assistant Commissioner

 Division of Regulatory Services, TDSHS

E. J. Sanchez, M.D. 

 Commissioner, TDSHS

K. H. White, Chairman, TCEQ

R. A. Ratliff, TDSHS

S. M. Jablonski, TCEQ

G. T. FitzGerald, TCEQ

R. Mulder, State Liaison Officer

R. G. Fletcher, MD

 Organization of Agreement States

 Liaison to the MRB
R. B. Bays -2-

A follow-up review will be scheduled in approximately one year to cover the State’s actions on

the recommendations from the September 2005 review. The follow-up review will focus on

those performance indicators that were below the satisfactory level at the time of the

September 2005 IMPEP review. If the Department believes that all recommendations have

been adequately addressed and that the Department’s performance for all indicators is at the

satisfactory level before the tentatively scheduled date of the follow-up review, the NRC will

consider moving the follow-up review to an earlier time to release the State from the

requirements of heightened oversight if supported by the results of the review. Periodic

meetings with both the Department and the Texas Commission on Environmental Quality will be

held in conjunction with the follow-up review.

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

also wish to acknowledge your continued support for the Agreement State program and the

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

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

Sincerely,

/RA/

Martin J. Virgilio

Deputy Executive Director for Materials, Research, 

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure:

As stated

cc: D. Eden, Deputy Director

 Office of Permitting, Remediation & Registration, TCEQ

E. J. Sanchez, M.D. 

 Commissioner, TDSHS

K. H. White, Chairman, TCEQ

R. A. Ratliff, TDSHS

S. M. Jablonski, TCEQ

G. T. FitzGerald, TCEQ

R. Mulder, State Liaison Officer

R. G. Fletcher, MD

 Organization of Agreement States

 Liaison to the MRB

Distribution: See next page.

DOCUMENT NAME: E:\Filenet\ML053560316.wpd

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

OFFICE STP STP STP STP:DD STP:D DEDMRS

NAME DMSollenberger:kk JGZabko

(ATMcCraw for)

ATMcCraw DKRathbun JRSchlueter MJVirgilio

DATE 12/21/05 12/21/05 12/21/05 12/22/05 12/22/05 12/27/05

 ML053560316 Pkg. OFFICIAL RECORD COPY
R. B. Bays -3-

Distribution: DCD (SP01) Chairman Diaz

DIR RF JRStrosnider, NMSS Commissioner McGaffigan

VCampbell, RIV TCombs, OCA (2 copies) Commissioner Merrifield

WRautzen, STP KDCyr, OGC Commissioner Jaczko

CMcKenney, NMSS FCameron, OGC Commissioner Lyons

MStephens, FL STreby, OGC

MSnee, OH CMiller, NMSS/IMNS

DStoffel, WA RStruckmeyer, NMSS/IMNS

HFelsher, OEDO

EDO RF

SISP Review Complete

: Publicly Available G Non-Publicly Available 

: Non-Sensitive G Sensitive

Identical letter sent to: Dan Eden, Deputy Director

 Office of Permitting, Remediation & Registration

 Texas Commission on Environmental Quality

 12100 Park 35 Circle, MC 122

 Austin, TX 78753
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF TEXAS AGREEMENT STATE PROGRAM

SEPTEMBER 7-16, 2005

FINAL REPORT

U.S. Nuclear Regulatory Commission
Texas Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the Texas Agreement State program. The

review was conducted during the period of September 7-16, 2005, by a review team consisting

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

States of Florida, Ohio, and Washington. Team members are identified in Appendix A. The

review was conducted in accordance with the "Implementation of the Integrated Materials

Performance Evaluation Program and Rescission of a Final General Statement of Policy,"

published in the Federal Register on October 16, 1997, and the February 26, 2004, NRC

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

Preliminary results of the review, which covered the period of September 1, 2001 to 

September 16, 2005, were discussed with Texas management on September 9, 2005 for the

Texas Commission on Environmental Quality (the Commission) and September 16, 2005 for

the Texas Department of State Health Services (the Department).

A draft of this report was issued to Texas for factual comment on October 21, 2005. The

Department responded to the findings and conclusions of the review by letter dated 

November 16, 2005, from Richard Bays, Assistant Commission for Regulatory Services. The

Commission relayed their comments by telephone on November 16, 2005. The Management

Review Board (MRB) met on December 14, 2005 to consider the proposed final report. The

MRB found the Texas Agreement State program adequate but needs improvement and

compatible with the NRC's program. Based on the results of the review, the review team

recommended and the MRB agreed that Texas remain on Heightened Oversight.

The Texas Agreement State program is administered by two State agencies, the Department

and the Commission. Organization charts for the Department and the Commission are included

as Appendix B.

The Department regulates approximately 1,650 specific materials licenses. The Department’s

responsibility includes regulatory authority for the 11e.(2) byproduct material (uranium recovery

activities) and currently regulates three conventional uranium mills, five in-situ uranium mines,

and has an application for a commercial 11e.(2) disposal facility. In addition to the radioactive

materials activities, the Department administers a laboratory program for environmental

sciences under the Laboratory Services Section in the Division of Prevention and

Preparedness. The Commission has regulatory responsibility for low-level radioactive waste

(LLRW) disposal (a commercial disposal site application is under review) and the

decommissioning/regulation of on-site burial activities.

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 Texas.

In preparation for the review, questionnaires addressing the common and non-common

performance indicators were sent to the Department and the Commission by letter dated

July 14, 2005. The Commission provided a response to the questionnaire dated August 12,

2005 and the Department provided a response to the questionnaire dated August 12, 2005. 

Copies of the complete questionnaire responses from each agency can be found on NRC’s 
Texas Final Report Page 2

Agencywide Document Access and Management System (ADAMS) using the Accession

Numbers ML052860421 and ML052860383, respectively.

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

Texas’ responses to the questionnaire; (2) review of applicable Texas statutes and regulations;

(3) analysis of quantitative information from the Department’s and the Commission’s licensing

and inspection databases; (4) technical review of selected licensing and inspection actions; 

(5) field accompaniments of five Department inspectors; and (6) interviews with staff and

management of both agencies to answer questions or clarify issues. The team evaluated the

information that it gathered against the IMPEP performance criteria for each common and

applicable non-common performance indicator and made a preliminary assessment of the

Agreement State program’s performance.

Section 2 below discusses the Department’s and the Commission’s actions in response to

recommendations made following the previous IMPEP 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 and recommendations. 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.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on August 31, 2001, three 

recommendations were made and transmitted to Mr. Bays, Associate Commissioner, the

Department, and Ms. Ing, Deputy Director, Office of Permitting, Remediation & Registration, the

Commission, on December 21, 2001. The team’s review of the current status of these

recommendations is as follows:

1. The review team recommends that the Department adhere to the policy of annual

supervisory accompaniments of all qualified inspectors. (Section 3.2 of the 2001 report)

Current Status: The accompaniments are now being coordinated between the Radiation

Inspection Group Manager and the Radiation Policy, Standards and Quality Assurance

(PSQA) Group Manager. The accompaniments are being split between these groups. 

The accompaniments are then rotated the next year so that the entire program is

audited by each group over a two-year period. This recommendation remains open and

is further discussed in Section 3.3.

2. The review team recommends that the Department report all significant and routine

events as well as follow-up event information to the NRC in accordance with the STP

Procedure SA-300, “Reporting Material Events.” (Section 3.5 of the 2001 report)

Current Status: As part of the preparation for the IMPEP review, the NRC staff 

reviewed all the reportable events that were reported to the Nuclear Material Events

Database (NMED) by the Department since the previous IMPEP review. The

Department has hired two new investigators and trained them on the Office of State and

Tribal Programs (STP) Procedure SA-300 and the use of the NMED system. The

Department staff has conducted a review of the Texas events in the NMED system to
Texas Final Report Page 3

determine if they are complete and can be closed. This recommendation remains open

and is further discussed in Section 3.5.

3. The review team recommends that the Department prepare necessary supporting

documentation identifying the bases for the licensing actions associated with

reclamation plans for the three conventional mills. (Section 4.4.4 of the 2001 report)

Current Status: The three conventional mills have significant groundwater issues and

closure will be a long-term project. The Department staff has continued to make

progress on the groundwater issues but has not developed the supporting

documentation for these closures. This recommendation remains open and is further

discussed in Section 4.4. 

Recommendation for the NRC from the 2001 IMPEP report:

1. The review team recommends that NRC, in coordination with the Agreement States, reevaluate the two-person rule to assess the effectiveness of the intended outcomes,

including experience from past events, and propose a strategy and rule interpretation

that best achieves the goal of safety. (Section 4.1.2)

Current Status: Texas has adopted and is implementing a version of the 10 CFR

34.41(a) regulation commonly know as the “Two-Person Rule” in a manner where

licensees are allowed the flexibility to determine when radiographic operations can be

conducted safely where the first radiographer and/or other radiographic personnel could

observe operations and prevent intrusion into the restricted area while the second

radiographer is nearby engaged in other job-related activities. The review team did not

attribute any events or incidents in Texas as a result of implementing 10 CFR 34.41(a)

in this manner. The NRC convened a working group composed of staff from NRC and

Agreement States to re-evaluate the two-person rule. The working group completed its

work and presented a report to the MRB that contained several options. The NRC is

continuing to hold in abeyance compatibility findings for those Agreement States that

have adopted and are implementing the 10 CFR 34.41(a) rule in this manner, until the

NRC issues a determination on a petition for rulemaking. On March 8, 2005, the

Organization of Agreement States (OAS) and the Conference of Radiation Control

Program Directors, Inc. executive boards decided that Texas would prepare a draft

petition for rulemaking on the two-person rule to be completed within six months. Texas

has drafted the petition and on September 14, 2005 submitted it to the OAS for review

and approval. OAS will submit the petition to NRC upon approval by the OAS. Upon

receipt of the petition, NRC will process it in accordance with its petition procedures. 

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) Technical Staffing and

Training; (2) Status of Materials Inspection Program; (3) Technical Quality of Inspections; 
Texas Final Report Page 4

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

Activities.

3.1 Technical Staffing and Training

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

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

these issues, the review team examined the Department's questionnaire response relative to

this indicator, interviewed Department management and staff, reviewed job descriptions,

training records, and considered any possible workload backlogs.

The 78th Texas Legislative Session passed House Bill 2292 that consolidated four legacy

agencies including the Texas Department of Health into a single department. On September 1,

2004, the Department was created and designated as the State’s radiation control agency. The

Department consists of four programs including the Division of Regulatory Services, which

retains the functions of the State’s radiation control program. The Department is organized into

functional groups rather than into program groups. The Radiation Program Officer is

designated as the radiation control program director and provides a coordinating role among

the functional groups.

Currently, the Department has a total of 128 employees working in the radiation control

program area. Among them, 91 employees work at the main office in Austin and 37 employees

work at 11 regional offices. The materials portion of the radiation control program has 29 staff

in the licensing and records management program, and 42 staff in the inspection,

environmental monitoring, quality assurance, and enforcement programs.

At the time of the review, there were seven vacancies reported in the materials area including

four regional inspectors, two environmental monitoring group staff, and one quality assurance

staff member. Two of the positions have been posted and interviews have been conducted

without finding qualified individuals. Due to the four inspector vacancies as well as the turnover

in inspection staff, the review team noted that the program has a backlog of inspections and a

high number of inspections conducted overdue (see discussion in Section 3.2). The

Department posts vacancy announcements as soon as they are administratively approved.

The Department’s response to the questionnaire indicated that 21 staff members left the

program, 16 staff members were hired, and 4 staff transferred into the materials program

during the review period. The qualifications of the staff were determined from the

questionnaire, training records, resumes and interviews of personnel. The review team found

the staff well-qualified from an education and experience standpoint. All have at least

Bachelor’s degrees in the sciences, or equivalent training and experience. The review team

noted that a qualification journal is used for each license reviewer and inspector. The journal

establishes minimum training requirements for personnel assigned to perform license reviews

or inspections for materials facilities. The qualification journal is based upon the guidance in

Manual Chapter (MC) 1246 and the Final Report of the NRC/OAS Training Working Group

Recommendations for Agreement State Training Programs. The technical staff including

license reviewers and inspectors is expected to receive basic training courses (or equivalent)

within the first two years of starting work with the Department. In addition to the training 
Texas Final Report Page 5

courses, inspectors are required to demonstrate competence during supervisory

accompaniments prior to being authorized to perform inspections independently.

The Department continues to be committed to staff training. Texas has hosted several NRC

courses in order to meet their training needs given their out-of-state travel restrictions. In

addition to NRC training courses, training alternatives that are less costly were also used. The

review team noted that some staff members are attending a basic health physics course offered

by Baylor University.

The review team discussed with Department management their concerns about the effect of an

aging workforce and their ability to maintain a highly qualified workforce in the years to come. 

There are ten retired staff that have been rehired. The State recently changed the rehire policy

to make the rehire option less attractive. The review team noted that one of the State’s highest

priorities is to effectively deal with potential loss of a qualified workforce because of retirement

of senior staff and managers in the near future. The legislature approved a seven percent pay

increase (4 percent in September 2005 and 3 percent in September 2006). The legislature also

approved a new health physics career series with additional promotion potential for existing

staff. The Department has proposed a new fee rule to fund the additional expenses for this

series and the Department management is reworking the position description to meet the new

series. The new series could become effective in early 2006. In an effort to retain qualified

staff and attract new staff, the Department has implemented several new work schedule options

during the review period, including work-at-home options for some inspectors, flex time, and

compressed work schedules options. The Department is also currently working on instituting

an intern program to attract entry-level staff.

The seven vacancies and the staff turnover have significantly contributed to the decline in the

performance of the Department in the indicators discussed below. The review team

recommends that the Department hire and retain sufficient qualified staff to return and maintain

the program at a satisfactory performance level.

The Texas Radiation Advisory Board (the Board) is composed of 18 members appointed by the

Governor. Currently the Board has four vacancies with eleven of fourteen members serving on

expired terms. The Board members reflect a variety of backgrounds in the use of radiation and

also includes three members of the public. The purpose of the Board is to review and evaluate

State radiation policies and programs; make recommendations and furnish technical advice to

the Department, the Commission and the Railroad Commission and review and comment on

proposed rules and guidelines relating to regulation of sources of radiation. Each member is

required to complete a training program including conflict-of-interest laws before the member

can vote, deliberate, or be counted as a member in attendance at a meeting of the Board. The

conflict-of-interest training and procedures for the Board appear adequate to address conflictof-interest issues. During the IMPEP review, the review team made a presentation on the

IMPEP process to the Board at their request

The Commission uses the same staff for their regulatory responsibilities under this performance

indicator as in the LLRW disposal activities. Because of their limited activity in the materials

area, the review team found their staffing and training acceptable based on the program in

place as discussed in Sections 4.3.
Texas Final Report Page 6

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

that Texas’ performance with respect to the indicator, Technical Staffing and Training, is

satisfactory but needs improvement.

3.2 Status of Materials Inspection Program

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

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

and the performance of reciprocity inspections. The review team’s evaluation is based on the

Department’s response to the questionnaire relative to this indicator, data gathered

independently from the Department’s licensing and inspection data tracking system, the

examination of completed inspection casework, and interviews with managers and staff.

The review team’s evaluation of the Department’s inspection priorities revealed that inspection

frequencies for each type of license were the same or more frequent than similar license types

listed in MC 2800. The Department requires more frequent inspections for the following license

categories: all type A broad scope licenses are inspected on a one-year frequency compared

with the NRC two-year frequency for type A broad scope industrial and academic licensees;

type B and C broad scope licenses are also inspected on a one-year frequency compared to

the NRC frequencies of three and five years respectively; portable gauge measuring systems

are inspected on a two-year frequency compared to the NRC frequency of five years and

general license distribution type licenses are on a four-year frequency compared to NRC’s fiveyear frequency.

In their response to the questionnaire, the Department indicated that there were a total of 81

inspections of Priority 1, 2, and 3 licensees that were overdue at the time of the review. This

information was compared to two reports generated by Department staff and management, one

containing dates of inspection for all licensees and the other containing dates of inspection for

initial licenses. Department staff generated a table for the review team to use indicating which

licensees were Priority 1, 2, and 3. From this information, the review team noted that 196

Priority 1, 2, and 3 inspections were completed overdue during the review period or were

overdue at the time of the review. The review team also noted that 92 initial inspections were

completed overdue during the review period or were overdue at the time of the review. The 288

overdue inspections represented 18 percent of the 1,593 core inspections performed by the

Department during the review period.

The timeliness of the issuance of inspection findings was evaluated during the inspection file

review. The Department has set a goal of issuing the compliance finding within 31 days of the

inspection. Field office notes are expected to be sent to the Austin office within 14 days after

the inspection. Findings should be issued by the Austin office to the licensee within 17 days

after receiving the field notes. The review team sampled inspection files for the timeliness of

issuance of inspection letters and found that 15 of 29 inspection letters were issued greater

than 31 days from completion of the inspection. The Department has instituted a quality

assurance review step in the processing of the inspection reports by the staff in Austin to

improve the quality of their inspection reports. However, this review step appears to contribute

to the delay in issuance of the inspection reports. The review team recommends that the

Department review their process for issuance of inspection letters and develop a process that

will allow the 31-day issuance goal for routine cases to be achieved on a consistent basis.
Texas Final Report Page 7

In their response to the questionnaire, the Department stated that 14 of 77 candidate licenses

requesting reciprocity were inspected during the review period. The information was discussed

with the radioactive materials inspection group management. Although this is close to the 20

percent criterion prescribed in MC 1220, the Department needs to be more diligent on

inspecting licenses operating under reciprocity. The Department agreed and believes that,

upon filling and training the vacant inspector positions, the Department will be able to meet or

exceed the 20 percent criterion for reciprocity inspections.

 

The Commission has regulatory oversight for the two on-site burial licensees with only one

active licensee conducting ongoing on-site burials. The Commission completed annual

inspections of the active licensee and inspections at 18-month intervals of the closed site. At

the time of the review, the inspections were up to date, and there was no backlog.

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

that Texas’ performance with respect to the indicator, Status of the Materials Inspection

Program, is satisfactory, but needs improvement.

3.3 Technical Quality of Inspections

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

inspectors for 29 radioactive materials inspections conducted during the review period. The

casework included work performed by 15 of the Department’s materials inspectors, and

covered a variety of license types including: academic; medical (diagnostic and therapy);

nuclear pharmacy; industrial radiography; pool irradiator; well logging; fixed gauge; storage

only; broad scope (academic and medical); manufacturing and distribution; processor of

unsealed radioactive material; and research and development. Appendix C lists the inspection

casework reviewed for completeness and adequacy with case-specific comments, as well as

the results of the inspection accompaniments.

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

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

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

documentation to ensure that a licensee’s performance with respect to health and safety was

acceptable. The documentation supported violations, recommendations made to the licensee,

and unresolved safety issues. Exit interviews were held with appropriate licensee personnel.

The review team found that routine inspections adequately cover the licensee’s radiation

protection program, included a written summary of the scope of the licensed activities, and

categorized violations in severity levels, if any. The majority of violations cited were recordkeeping infractions. The review team noted that the documentation in the inspection reports

issued early in the review period were not always complete; however, the evaluation of reports

issued in the last 18 months showed significant improvement in documentation. The

Department attributed this improvement to a new Radiation Inspection Report Quality

Assurance Review Standards procedure that was implemented. This procedure directs the

Radiation Policy, Standards, and Quality Assurance (PSQA) Group reviewers to review the

inspectors’ reports, identify any issues and categorize them as Level I - IV issues (Level IV

being the most significant). The quality and completeness of the inspection reports is one of

the major factors that is used for individual inspector’s performance evaluations. A report is

generated each quarter compiling the number of Level II - IV issues identified for each

inspector. This report is forwarded to the Radiation PSQA Group Manager and the Radiation

Inspection Group Manager to be used for the inspector’s annual performance appraisal. While
Texas Final Report Page 8

the quality of the documentation had significantly improved, the review team noted during the

review of inspection reports that the reports do not document the inspector’s observation of

licensed operations or handling of radioactive material. The review team observations during

the inspector accompaniments further identified that the inspectors are not conducting the

observations of licensed activities.

During the review of the inspection reports, the review team noted that there was no evidence

that management reviewed the inspection reports. In discussions with Department

management, the review team found that only reports returned to the inspector for correction

and those being considered for escalated enforcement are reviewed by management. Reports

returned to the inspector are reviewed by the Radiation PSQA Group Manager and the

Radiation Inspection Group Manager. Inspections being considered for escalated enforcement

are referred to an Enforcement Review Committee for consideration. The Committee consists

of the Enforcement Unit Manager, the Enforcement Group Manager, the Radiation PSQA

Group Manager, the State’s attorney, and the appropriate inspection staff members. 

Otherwise, completed inspection reports are signed by the inspector and the PSQA reviewer,

with no management review or concurrence, and the PSQA reviewer sends the compliance

letter informing the licensee of the final results of the inspection. The review team discussed

with management the benefits of management review of inspection reports and notices of

violations.

During the 1997 and 2001 IMPEP reviews, it was recommended that the Department adhere to

the annual supervisory accompaniment policy. The review team found that during this review

period, annual inspector accompaniments were not being conducted for all inspectors. The

Department’s policy is to conduct annual accompaniments by either the Radiation Inspection

Group Manager or a PSQA reviewer within the calendar year. The following year the groups

switch which inspectors they accompany. The Radiation Inspection Group Manager or a PSQA

reviewer did not conduct annual accompaniments for all the qualified inspection staff in

calendar years 2001 - 2003. In 2004, all the inspectors were accompanied by either the

Radiation Inspection Group Manager or a PSQA reviewer. At the time of the review, only three

inspectors had been accompanied for calendar year 2005. The Radiation Inspection Group

Manager or a PSQA reviewer will need to accompany the remaining seven inspectors within

this calendar year. Thus, as discussed in Section 2 above, the recommendation from the 2001

IMPEP report remains open.

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

the inspection program and for responding to incidents and emergency conditions. The

Department calibrates their own survey instruments at a six-month frequency. Appropriate,

calibrated survey instruments such as Geiger-Mueller (GM) meters, scintillation detectors, ion

chambers and micro-R meters were observed. The Department has portable multi-channel

analyzers and air monitoring equipment that can be used when needed. Contamination wipes

are sent to the State’s laboratory for analysis. The laboratory, which is administered by the

Laboratory Services Section under the Division of Prevention and Preparedness of the

Department, was visited on September 14, 2005 by an IMPEP team member. The laboratory

was found to have adequate staffing, facilities, and instrumentation to support the radiological

analysis needs of the Department. The laboratory also maintains a mobile laboratory van for

use in emergencies and emergency exercises.

Five Department inspectors were accompanied during inspections by a review team member

and an IMPEP qualified inspector during the weeks of August 1, 2005, August 8, 2005, and
Texas Final Report Page 9

September 5, 2005. Inspection accompaniments included the following license types: selfshielded irradiator and academic research and development, well logging and tracer studies in

oil wells, medical institution diagnostic/brachytherapy/teletherapy, and nuclear pharmacy. 

These accompaniments are identified in Appendix C. During the accompaniments, each

inspector demonstrated appropriate safety perspective and knowledge of the regulations. The

inspectors were trained, prepared, and thorough in their audits of the licensees radiation safety

programs. Each inspector utilized good health physics practices. However, the review team

noted that in most cases the inspectors did not apply performance-based inspection techniques

(observations of licensed activities) which are part of the Department’s inspection procedures

during the inspections. The inspectors’ primary focus was on review of records, collecting data,

performing independent, confirmatory surveys of the storage areas, and completing the detailed

inspection report. The inspector should observe work in progress that involves State-regulated

activities. If there is no opportunity, then the inspector should ask the workers to demonstrate

and explain selected licensed activities. Most of the inspectors only interviewed the licensees’

primary radiation safety staff, even when licensed activities were ongoing. During one

accompaniment, the inspector failed to observe a nuclear medicine technologist assay a unit

dose without using extremity dosimetry or gloves. The review team recommends that the State

develop a process to ensure that inspections are performed in accordance with their own

performance-based inspection procedures.

The Commission uses inspection procedures for their regulatory responsibilities consistent with

the procedures the Department uses. The review team evaluated the inspections for the two

materials licensees administered by the Commission. The inspections were thorough,

technically sound, and acceptable in quality. The inspector was accompanied by management

while conducting other inspection activities, but was not accompanied during a materials

inspection. The Compliance Manager agreed to include materials inspection accompaniments

in the future. The review team found the Commission’s performance in this area acceptable.

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

that Texas’ performance with respect to the indicator, Technical Quality of Inspections, is

satisfactory, but needs improvement.

3.4 Technical Quality of Licensing Actions

The review team interviewed license reviewers, evaluated the licensing process, and examined

licensing casework for 20 specific licenses. Licensing actions were reviewed for completeness,

consistency, proper radioisotopes and quantities, qualifications of authorized users, adequate

facilities and equipment, adherence to good health physics practices, financial assurance,

operating and emergency procedures, appropriateness of license conditions, and overall

technical quality. The casework files were also evaluated for timeliness, use of appropriate

deficiency letters and cover letters, reference to appropriate regulations, product certifications,

supporting documentation, consideration of enforcement history, pre-licensing visits, peer or

supervisory review as indicated, and proper signatures. 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

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

logging, industrial radiography, medical (institution, private practice, gamma knife, and broad

scope), nuclear pharmacy, academic/educational broad scope, research and development,

manufacturing and distribution, portable and fixed gauge licenses. Types of licensing actions
Texas Final Report Page 10

selected for evaluation included three new licenses, nine amendments, five renewals and three

license terminations. The work of eight license reviewers from the Industrial Licensing,

Medical/Academic Licensing, and Advanced Technology Licensing Programs was evaluated. A

list of the licensing casework evaluated with case-specific comments is included in Appendix D.

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

of high quality and properly addressed health and safety issues. The staff followed appropriate

licensing guides during the review process to ensure that licensees submit information

necessary to support their request. Deficiencies were addressed in timely letters to the

applicant/licensee. The deficiencies contained appropriate regulatory language and were noted

in the license file.

At the time of the review, the Department had approximately 90 renewal actions that were open

for more than one year. Priorities have been set to ensure that health and safety issues are

addressed in a timely manner. New licenses are given the highest priority followed by

terminations, amendments, and renewals. Licenses are amended while pending renewal. The

Department uses an electronic review sheet for each licensing action. This review sheet allows

for an explanation of the licensing action and for tracking the status of the action. The review

sheet is also used to record supervisory review of the licensing action.

The Department maintains original financial assurance instruments with Texas’ Comptroller of

Public Accounts and copies of supporting documents in the license files. Thirty-two of 33

licensees have the required financial assurance in effect. The Department is taking action to

bring the one remaining licensee into compliance. Eighteen State agency licensees have

submitted the required certifications. The review team concluded that the Department handles

financial assurance appropriately.

The review team found that actions terminating licenses were well-documented and included

the appropriate material survey records. The license terminations evaluation revealed a crosssection of licensees possessing both sealed sources and unsealed material. All files reviewed

contained documentation of proper disposal or transfer.

The team noted that the Department does not routinely verify the disposition of large sealed

sources when a licensee requests removal of the sealed source from their license. This was

discussed with the Radiation Licensing Group management and they agreed that they should

verify that sealed sources reach their intended disposal or transfer site prior to removing them

from a license. In the future, the licensing staff will verify that the sources have been received

by the recipient prior to deleting it from the senders license.

The Commission has regulatory responsibility for the burial of radioactive waste conducted

under Texas regulations compatible to 10 CFR Part 20. One license has been terminated and

the site released for unrestricted use. Licensing actions for the other two sites were reviewed. 

One site is in mediation. The other site’s license was renewed and they continue to dispose of

depleted uranium catalyst in their hazardous waste cell. There were no performance issues

identified by the review team during the review of the Commission’s files for this portion of the

Commission’s program.

During review of licensing casework, the review team identified two good practices being

conducted by the Commission and the Department as noted: (1) The Commission and the

Department include in the transmittal letter for amended licenses a description of the changes
Texas Final Report Page 11

(a roadmap) so that the changes are clearly identified; and (2) The Commission attached as an

appendix to the active on-site disposal license the closure criteria for the closed disposal cells

which keeps the as-closed conditions in the license even though new criteria have been

established for the newer cells.

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

that Texas’ performance with respect to the indicator, Technical Quality of Licensing Actions, is

satisfactory.

3.5 Technical Quality of Incident and Allegation Activities

In evaluating the effectiveness of the Department’s actions in responding to incidents and

allegations, the review team examined the Department’s response to the questionnaire relative

to this indicator and reviewed the incidents reported for Texas in NMED against those contained

in the Department’s casework and license files, and supporting documentation, as appropriate,

for nine incidents. A list of the incident casework reviewed is included as Appendix E. The

review team evaluated the Department’s response to the eight allegations received during the

review period involving radioactive materials including the five allegations referred to the

Department by NRC.

The review team discussed the Department’s incident and allegation procedures, file 

documentation, the Department’s equivalent to the Freedom of Information Act, NMED, and

notification of incidents to the NRC Operations Center with Department management and staff. 

Responsibility for initial response and follow-up actions to material incidents and allegations

rests with the Incident Investigation Program within the Environmental Monitoring Group under

the Radiation Branch. Written procedures exist for handling incidents and allegations referred

to as “complaints” by the Department. The procedures require on-site investigations for each

significant event and require actions to initiate a response to all allegations within 72 hours. All

incidents and allegations are tracked using a numerical identification system which can be

cross-referenced on the NMED report.

The 2001 IMPEP team had identified that the Department was not reporting significant or

routine events in a timely manner as defined by STP Procedure SA-300, “Reporting Material

Events.” The Department continued to have timeliness issues in reporting incidents as noted

during the periodic meetings conducted on December 2, 2002, June 8, 2004, and March 15,

2005. The Incident Investigation Program had staffing challenges during the review period. 

For the period of December 2002 to February 2005, the Incident Investigation Program was

partially staffed. The Incident Investigation Program had only one incident investigator from

June 2004 to February 2005. In February 2005, the Department lost the last member of their

experienced incident investigation staff. The Department then shifted two staff from other

program areas to fill the incident investigation positions. In preparation for the March 2005

periodic meeting, the Department completed a review of all reported incidents to identify any

missed reportable events. These events were then reported to NRC, even though reported

late. Since the March 2005 meeting, the Department has also conducted a completeness

review of all the events that had been reported to NMED and is in the process of updating

NMED with available information.

The Department had attempted to use the NMED system in 1998, but due to computer software

compatibility issues, the Department continued to verbally report significant events to NRC’s

Operation Center and provided written event information to NRC’s contractor. Because of the
Texas Final Report Page 12

continued reporting difficulties and the new incident investigation staff, the Department

requested training on the NMED system. NRC’s contractor provided training to the Incident

Investigation Program staff in the Department’s offices in June 2005. In July 2005, the

Department began using the NMED system to report incidents.

The review team noted that the Department had received notifications within the review period

of more than 500 incidents and allegations involving all types of radiation regulated by the

Department. Since the Department does not differentiate between material covered under the

Agreement with NRC (reportable) and other material incidents, the review team was unable to

determine the number of reportable material incidents recorded in the Department’s tracking

system. The review team queried the NMED system and identified 175 reportable incidents out

of a total of 246 reported by Texas during the review period. The review team evaluated the

timeliness of the events reported and noted that the Department had reported approximately 20

percent of the reportable events late over the review period. The review team discussed the

issue of reporting incidents and providing follow-up information with the Department. While the

Department has made improvements in their Incident Investigation Program, these

improvements have not been in place long enough for the review team to determine their

effectiveness. Thus, as discussed in Section 2 above, the recommendation from the 2001

IMPEP report remains open.

The nine incidents selected for evaluation included three medical events, two events involving

lost/stolen material, one misadministration, one procedure failure, two contamination events,

two leaking sources, one event involving exposure to members of the public, one equipment

failure and one transportation event. The review team found that the Department’s response

to incidents was complete and comprehensive. Initial responses were prompt and wellcoordinated, and the level of effort was commensurate with the health and safety significance. 

Inspectors were dispatched for on-site investigations when appropriate and the Department

took suitable enforcement action.

The evaluation of the eight allegation cases indicated that the Department took prompt and

appropriate action in response to the allegers’ concerns. Through review of the casework and

interviews with staff, the review team determined that the Department provided feedback to

allegers either verbally or in writing when possible. Any alleger requesting anonymity is

informed that every effort will be made to protect his/her identity, but cannot be guaranteed. All

interviewed staff were knowledgeable of the Department’s allegation procedure. There were no

performance issues identified from the review of allegation files and documentation.

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

that Texas’ performance with respect to the indicator, Technical Quality of Incident and

Allegation Activities, is satisfactory, but needs improvement.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

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

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

Program. 
Texas Final Report Page 13

4.1 Compatibility Requirements

4.1.1 Legislation

The legal authority for the Department is found in the Texas Radiation Control Act, Health and

Safety Code, Chapter 401. The Department is designated as the State radiation protection

agency with authority to regulate byproduct materials, source materials, and special nuclear

materials in quantities not sufficient to form a critical mass. The Commission’s legal authority

for LLRW activities is found in Chapters 401 and 403 of the same Act. The Department and the

Commission maintain a Memorandum of Understanding (MOU) that specifies the respective

responsibilities of the two organization for the uranium recovery program.

For currently effective legislation that affects the radiation control program, Texas noted in the

response to the questionnaire that their 78th Legislature added Sections 418.176 through

418.182 to Chapter 418 of the Government Code. These provisions make confidential certain

information related to terrorism, including information “collected, assembled, or maintained by

or for a governmental entity and is more than likely to assist in the construction or assembly of

... a radiological or nuclear weapon of mass destruction; or indicates the specific location of

radioactive material that is more than likely to be used in the construction or assembly of such a

weapon.” Texas’ Attorney General’s Office has interpreted this to include all sources in the

IAEA Categories I and II. This allow Texas to protect information from public disclosure that

could be useful to a terrorist.

All Texas agencies are subject to sunset review by the Texas Sunset Commission. The

Department was last reviewed in 2000 and the Commission was reviewed in 2001. The next

sunset review will be 12 years from the previous review, or in 2012 and 2013 for the

Department and the Commission, respectively.

4.1.2 Program Elements Required for Compatibility

The Department regulations for control of radiation are located in Title 25 of the Texas

Administrative Code and apply to ionizing and non-ionizing radiation, whether emitted from

radionuclides or devices. Texas requires a license for possession and use of radioactive

materials, including naturally occurring and accelerator-produced radionuclides. The

Commission’s regulations for control of radiation and disposal of LLRW are located in Title 30

of the Texas Administrative Code.

The review team examined the procedures used in the Department’s and the Commission’s

regulatory processes and found that the public and other interested parties are offered an

opportunity to comment on proposed regulations. The NRC is provided with drafts for

comment. With the State reorganization and creation of the Department, the Health and

Human Services Council Executive Commissioner has statutory rulemaking authority. In

addition, the State Health Services Council was established as an advisory council to the

Department. The Texas Radiation Advisory Board was maintained as an advisory board

charged with making recommendations on radiation control rules. The flow-chart of the new

Department’s internal rulemaking process is included in their response to the questionnaire. No

Departmental rule has yet gone through the entire rulemaking process. It is estimated that

radiation control rules may take anywhere from a year to 18 months to go from a draft stage to

an effective rule under this new process.
Texas Final Report Page 14

In the response to the questionnaire, the Department noted that Government Code, Chapter

2001.039, requires Texas State agencies to assess whether the reasons for adopting each rule

continue to exist and to review each rule to determine whether it is obsolete, whether it reflects

current legal and policy considerations, and whether it reflects current procedures of the

agency. As a part of this review, each agency is required to submit notice of intent to the Texas

Register for publication. Each rule is required to be reviewed four years from the last effective

date of the rule. Therefore, each Section of Title 25 of the Texas Administrative Code, Chapter

289 (Texas Regulations for Control of Radiation), has a different four-year review interval.

The review team evaluated the Department’s response to the questionnaire, reviewed the

status of regulations required to be adopted by the State under the NRC’s adequacy and

compatibility policy and verified the adoption of regulations with information contained on the

State Regulation Status (SRS) sheet by the STP. Since the last IMPEP review, the Department

adopted eight regulations in two rule packages that became effective in April 2003 and 

September 2004. The Department noted in the questionnaire that the SRS sheet was

inaccurate in regards to rule adoption. After discussion between NRC and Department

management, it was decided that the following amendments would be sent in for NRC review in

final, to accurately reflect the status of regulation adoption:

! “Safety Requirements for Radiographic Equipment,” 10 CFR Part 34 amendment (55 FR

843) that became effective on January 10, 1991.

! “Frequency of Medical Examinations for Use of Respiratory Protection Equipment,” 10

CFR Part 20 amendment (60 FR 7900) that became effective on March 18, 1995.

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

61 amendment (60 FR 15649), (60 FR 25983) that became effective on March 1, 1995.

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

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

! “Performance Requirements for Radiography Equipment,” 10 CFR Part 34 amendment

(60 FR 28323) that became effective on June 30, 1995.

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

Radiographic Operations,” 10 CFR Part 34 amendment (63 FR 37059) that became

effective on July 9, 1998.

In the response to the questionnaire, the Department stated that the following two amendments

are covered by statute or by existing rule:

! “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 on February 27, 1997.

! “Deliberate Misconduct by Unlicensed Persons,” 10 CFR Parts 30, 40, 61, 70, 71 and

150 amendment (63 FR 1890), (63 FR 13773) that became effective on February 12,

1998.
Texas Final Report Page 15

A regulations package containing these two amendments will be sent in for NRC review in the

near future.

The Department’s response to the questionnaire identified that the following two overdue rules

are in the rulemaking process:

! “Respiratory Protection and Controls to Restrict Internal Exposure,” 10 CFR Part 20

amendment (64 FR 54543), (64 FR 55524) that became effective on February 2, 2000.

! “Revision of the Skin Dose Limit,” 10 CFR Part 20 amendment (67 FR 16298) that

became effective on April 5, 2002.

These rules were published on September 16, 2005 as proposed rules, and a regulations

package is being prepared to be sent in for NRC review.

The Department had previously submitted their new medical rules to NRC for review prior to

NRC’s completion of its rulemaking process; therefore, NRC did not have a final rule to do a

comparison at that time. The Department stated that the following will soon be submitted to

STP for regulation review as a final rule:

! “Medical Use of Byproduct Material,” 10 CFR Parts 20, 32, and 35 amendment (67 FR

20249) that became effective on October 24, 2002.

While not currently due, the Department wanted to inform the review team that the rule would

be submitted for review within the allotted timeframe for Agreement State adoption.

The review team identified the following regulation changes and adoptions that will be needed

in the future, and Department management indicated that the regulations would be addressed

in upcoming rulemaking, incorporation by reference, or by adopting alternate legally binding

requirements:

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

(68 FR 57327) that became effective December 3, 2003.

! “Compatibility with IAEA Transportation Safety Standards and Other Transportation

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

October 1, 2004.

! “Medical Use of Byproduct Material - Recognition of Specialty Boards,” 10 CFR Part 35

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

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

Part 30 amendment (70 FR 2001) that became effective July 11, 2005.

The Commission’s response to the questionnaire identified that the following two rules were

adopted:

! “Respiratory Protection and Controls to Restrict Internal Exposure,” 10 CFR Part 20

amendment (64 FR 54543), (64 FR 55524) that became effective on February 2, 2000.
Texas Final Report Page 16

! “Revision of the Skin Dose Limit,” 10 CFR Part 20 amendment (67 FR 16298) that

became effective on April 5, 2002.

The review team identified the following regulation changes and adoptions that will be needed

in the future, and Commission management indicated that the regulations would be addressed

in upcoming rulemaking, incorporation by reference, or by adopting alternate legally binding

requirements:

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

(68 FR 57327) that became effective December 3, 2003.

! “Compatibility with IAEA Transportation Safety Standards and Other Transportation

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

October 1, 2004.

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

that Texas’ performance with respect to the indicator, Compatibility Requirements, is

satisfactory. 

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

In assessing the Texas SS&D evaluation program, the review team examined the information

provided in response to the IMPEP questionnaire, evaluated SS&D registry sheets issued

during the review period, and the supporting document files. The team also evaluated SS&D

staff training records, certain reported incidents involving products authorized in Texas SS&D

sheets, the use of guidance documents and procedures, and interviewed the staff currently

conducting SS&D evaluations. Three sub-indicators were used to evaluate the Department’s

performance regarding their SS&D Evaluation Program. These sub-indicators were (1)

Technical Staffing and Training; (2) Technical Quality of the Product Evaluation Program; and

(3) Evaluation of Defects and Incidents Regarding SS&Ds.

4.2.1 Technical Staffing and Training

SS&D evaluation responsibilities are distributed among the license review staff. The evaluation

staff currently consists of a lead license reviewer (0.25 FTE) and six secondary reviewers (0.05

FTE each). The Department has identified five license reviewers going through training for

SS&D evaluation but are not yet qualified.

New staff members develop SS&D evaluation experience by working with senior members on

evaluations, sometimes signing as a second concurrence signature, then by performing

concurrence reviews by themselves, and finally by performing the initial reviews on SS&D

applications. Assignment of casework is determined by the SS&D supervisor, with most staff

specializing in either industrial or medical.

The review team examined the training and experience documentation of the staff and

management involved in the evaluation program. The review team noted a blend of senior and

junior reviewers and a schedule for training new staff. The educational qualifications for the

current staff were evaluated and were found adequate.
Texas Final Report Page 17

4.2.2 Technical Quality of the Product Evaluation Program

The review team evaluated 6 of the approximately 76 SS&D evaluation amendments,

inactivations, and new registrations, which do not include the 15 SS&D registrations of NARM

isotopes, the Department completed during the review period, representing the work of five

SS&D reviewers. The cases selected were representative of the Program’s licensees and

SS&D reviewers. The Department stated that they currently manage 146 active SS&D

registrations. A list of SS&D casework examined along with case-specific comments may be

found in Appendix F.

Analysis of the casework and interviews with staff confirmed that the Department generally

follows the recommended guidance from the NRC SS&D training workshops, NUREG-1556,

Volume 3. All applicable and pertinent American National Standards Institute standards,

NUREG-1556 Series, NRC or Texas Regulatory Guides, and applicable references were

confirmed to be available and were used appropriately in performing the SS&D reviews. The

Department has regulations specific to SS&D requirements and legally do not need to

incorporate SS&D commitments into the license document for them to be legally enforceable. 

In reviewing emergent technology related products and new applications, the Department

performed evaluations based on sound conservative assumptions to ensure public health and

safety and also sought the input from other licensing jurisdictions that have experience with

similar products. Appropriate review checklists were used to assure that all relevant materials

were submitted and reviewed. The checklists are retained in the case files. Registrations

clearly summarized the product evaluation and provided license reviewers with adequate

information in the Limitations and Considerations of Use section on areas requiring additional

attention to license the possession, use, and distribution of the products. The review team

identified a few inconsistencies that were present in some files, but these were of a formatting 

nature and did not affect the technical quality of the evaluation itself.

The review team determined that product evaluations were thorough, complete, consistent, 

and adequately addressed the integrity of the products during use and in the event of likely

accidents. While the licensing staff obtains and documents adequate quality assurance and

quality control programs (QA/QC) for each SS&D registration, the review team determined that

the Department does not determine that these QA/QC programs are actually implemented by

the licensee. The review team recommends that the Department develop and implement an

inspection program to verify that the QA/QC requirements in the SS&Device Registry sheets

are being implemented by the manufacturer.

The review team discussed a few general issues with Department staff. This included the need

to amend some sheets that indicated that Special Nuclear Materials may be distributed under a

general license. The Department is currently working with the manufacturer to delete this from

the registrations. Also the review team estimates that there are at least 40, SS&D sheets that

are listed as active, but are currently either no longer being made/distributed or the licensee has

gone out of business. While NUREG-1556, Volume 3, places the burden of inactivating sheets

on the registry holder, the review team discussed with the Department that they consider

development of a long range plan to inactivate these sheets.

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

No occurrences in Texas of incidents or events related to defects or performance of SS&Ds

were reported to the Department during the review period for devices registered by the
Texas Final Report Page 18

Department. The Department has not received notification of any potential generic SS&D

issues discovered during NRC trend analysis of NMED events identified in accordance with

NRC in Policy and Procedure Letter 1.57, NMSS Generic Assessment Process as stated in

STP Procedure SA-108. Due to the large number of active SS&D sheets the Department

manages, the review team suggested that the Department develop a plan to periodically

determine if any products defects or failures have occurred in other States. This would allow

the Department to identify potential generic issues specific to Texas registered devices. There

were no generic design or performance issues identified from the review of SS&D incident files

and documentation. No allegations related to SS&Ds were reported during the review period.

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

that Texas’ performance with respect to the indicator, SS&D Evaluation Program, is

satisfactory.

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

The review team focused on five factors in reviewing the LLRW Disposal Program performance

indicator: (1) Technical Staffing and Training; (2) Status of LLRW Inspection; (3) Technical

Quality of Inspections; (4) Technical Quality of Licensing Actions; and (5) Technical Quality of

Incident and Allegation Activities. Based on the current status of the LLRW site licensing in

Texas, not all the sub-indicators apply to the program at this time. The results of the LLRW

disposal program review will be discussed under each of these sub-indicators.

The regulatory responsibility for LLRW disposal remains with the Commission. On May 31,

2003, the Texas legislature passed the bill that authorizes a private entity to own a commercial

LLRW disposal facility. The Commission’s Radioactive Material Licensing (RML) team is

currently reviewing a August 4, 2004, license application by Waste Control Specialists, LLC

(WCS) to receive, handle, process, store, and dispose of LLRW at a site near Andrews, Texas. 

The license application was declared administratively complete February 18, 2005. On April 26,

2005, the Commission provided an evaluation of merit of the application, as required by Texas

law. Since that date, Commission staff has been fully involved in performing the technical

review of the application. On July 20, 2005, the Commission provided WCS a courtesy letter

that highlighted numerous issues that would likely be provided in the first official Technical

Notice of Deficiency, to allow the applicant additional time to adequately address these issues. 

As of the IMPEP review, the Commission had not finalized the first official Technical Notice of

Deficiency. 

4.3.1 Technical Staffing and Training

The RML team currently has eight full-time and/or part-time staff members as well as seven

contractors with a total staffing effort level of 7.5 FTE. The LLRW program is also supported by

other Sections within the Commission and by various contractors. The staff and contractors

currently supporting the LLRW program include the RML team leader, a Technical

Advisor/Health Physicist, an administrative assistant, and staff and contractors with diversified

backgrounds in health physics, nuclear engineering, hydrogeology, geology, geotechnical

engineering, anthropology, financial assurance, ecology, land/mineral rights, law, and civil

engineering. Since the last review in 2001, two staff associated with the LLRW program left the

program. The RML team hired or acquired from other portions of the organization six staff

members to assist in the conduct of LLRW activities. The review team determined that the 
Texas Final Report Page 19

current staffing has the right mix of technical expertise and is adequate to maintain the quality

and performance of the LLRW program.

The RML team has a documented training and qualification program for staff to perform

licensing, inspection, and investigation for LLRW activities. The team has an established

procedure for staff training consistent with the NRC/OAS Joint Working Group Report and MC

1246. The RML team leader has established plans for new staff training and for staff assigned

to carry out new duties.

The review team examined the training and qualification records of the staff and found them upto-date and complete. The review team determined that most of the staff attended the required

training and recommended training courses in accordance with the Commission requirements

and consistent with MC 1246.

Based on interviews with the professional and administrative staff and an examination of staff

qualifications, duties, and functions, the review team concluded that the LLRW staff is qualified

with sufficient training to carry out regulatory duties regarding licensing of a proposed LLRW

site. 

4.3.2 Status of LLRW Disposal Inspection

Based on the current status of the program, the review team did not have any inspection

activities to review for this sub-indicator. The RML staff did perform a pre-licensing site visit in

June 2005, and some members of the staff accompanied a team from the hazardous waste

portion of the Waste Permits Division to review a fault found during construction at the licensed

hazardous waste disposal cell, that is co-located on site.

4.3.3 Technical Quality of Inspections

Based on the current status of the LLRW program, the review team did not have any inspection

activities to review for this sub-indicator.

4.3.4 Technical Quality of Licensing Actions

The RML team currently is reviewing the license application by WCS to receive, handle,

process, store, and dispose of LLRW at a site near Andrews, Texas. The license application

was declared administratively complete February 18, 2005. 

The review team reviewed the third Administrative Notice of Deficiency (dated January 14,

2005), the Evaluation of Merit (dated April 26, 2005), the courtesy letter (dated July 20, 2005),

the Commission guidance document for a license application titled, “Application for License to

Authorize Near-Surface Land Disposal of Low-Level Radioactive Waste” (dated January 23,

2004), the Commission guidance document for performing performance assessment titled,

“Performance Assessment: A Method to Quantitatively Demonstrate Compliance with

Performance Objectives for LLRW Facilities,” and interviewed most of the staff involved in the

preparation of these documents. The team found that these documents were thorough,

complete, consistent, and of acceptable technical quality.

The review team and the RML staff discussed performance assessment approaches and

methodologies used to review WCS’s demonstration of compliance with State dose criteria. 
Texas Final Report Page 20

The review team noted that NRC staff’s recommended performance assessment methodology

and approaches documented in NUREG-1573, “Performance Assessment Methodology for

LLRW Disposal Facilities - Recommendations of NRC’s Performance Assessment Working

Group,” were incorporated in the Commission’s guidance. Limited independent analyses had

been performed by the staff to date, although staff indicated that, where warranted,

independent analyses would be conducted in later parts of the review.

4.3.5 Technical Quality of Incident and Allegation Activities

The review team found that the RML team has procedures in place for handling incidents

and allegations. The procedures for handling incidents include information on what constitutes

an incident, appropriate documentation of the incident, reference to NRC abnormal occurrences

criteria, and tracking the incident by management. The procedures for handling allegations

include information on protecting the identity of the alleger, documentation of the allegation, and

tracking the allegation by management.

During the review period, there were no incidents or allegations pertaining to the LLRW

program.

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

that Texas’ performance with respect to the indicator, LLRW Disposal Program, is satisfactory.

4.4 Uranium Recovery Program

In conducting this review, five sub-indicators were used to evaluate the Department’s

performance regarding the uranium recovery program. These sub-indicators include: 

(1) Technical Staffing and Training; (2) Status of Uranium Recovery Inspection Program; 

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

(5) Technical Quality of Incident and Allegation Activities. The results of the uranium recovery

program review will be discussed under each of these sub-indicators.

Under an MOU (see Section 4.1.1) between the Department and the Commission regarding insitu uranium mining, the Department has primary responsibility for the licensing, inspection, and

enforcement activities for aboveground process plant facilities, including the review of the

design, construction, operation, record keeping, maintenance, and decommissioning,

decontamination, and surface reclamation. The Commission has primary responsibility for the

permitting, inspection, and enforcement activities for all wells permitted by the underground

injection control (UIC) program, wellhead assemblies, and groundwater monitoring

requirements. Both agencies are responsible for the review, permitting, licensing, inspection,

and enforcement activities for fluid holding ponds. The Department now has the responsibility

for the licensing, inspection, and reclamation of conventional uranium mill facilities.

At the time of the IMPEP review, Texas had three conventional mill licenses (three sites

currently under reclamation, but substantially finished with construction activities), four in-situ

licenses, and reclamation oversight of one revoked in-situ license. The Department is

reviewing an application from WCS to construct a new 11e.(2) byproduct disposal facility in

west Texas. Because the price of uranium has substantially increased, the Department has

received inquiries from potential applicants for two new in-situ facilities. These applications are

anticipated within six months, with the potential for more applications if the price of uranium

continues to rise.
Texas Final Report Page 21

4.4.1 Technical Staffing and Training

Licensing activities in the Department for in-situ and conventional uranium recovery facilities are

conducted by the Radiation Safety Licensing Branch, Technical Assessments Group. The

uranium recovery staff consists of four technical staff reporting to the Manager of the Technical

Assessments Group. The technical staff have expertise in various technical disciplines (i.e.

health physics, hydrogeology, and engineering). The review team examined the training and

qualifications of the personnel and interviewed Department staff. The hydrogeologist came to

the program in 2002 and the two engineers have only been with the Department since April

2005. Even though three of the technical staff are new to the Department, the staff is well

qualified by education and experience to carry out uranium recovery activities.

The Department does have a training plan that addressed the necessary training for the review

of reclamation plans and licensing activities at in-situ and conventional uranium mills. Texas

has a cap on out-of-state travel so the training plan has considered that limitation for each staff

member.

With the WCS application review for a new 11e.(2) byproduct material disposal facility, and the

renewed interest in applications for new in-situ uranium recovery facilities, the review team does

not consider the current number of current staff sufficient to accomplish the workload. There

has been a backlog of work in the uranium recovery program which has grown larger. 

Examples of the backlog of uranium recovery work are: required annual surety reviews are not

being conducted; groundwater evaluations at the conventional mills are in the early stages with

corrective action assessments, ecological and human health risk assessments not yet

conducted and reviewed as needed; and the 2001 IMPEP recommendation that the Department

prepare necessary supporting documentation associated with reclamation plan approvals for

the three conventional mills has not been addressed. The root cause of this backlog of work is

the staff turnover and inadequate staffing level. The review team recommends that the

Department conduct an evaluation of the uranium recovery program workload and hire the

necessary staff to adequately address the workload.

4.4.2 Status of Uranium Recovery Inspection Program

The inspection program for both conventional and in-situ uranium facilities has set inspection

priorities at one-year frequency, consistent with MC 2800 and MC 2801. Some inspections are

conducted more frequently (e.g., every six months) when escalated enforcement actions are

warranted. Currently, there are no overdue inspections. Although the uranium recovery

inspection position has been vacant, a qualified uranium recovery inspector from the materials

program has conducted the inspections.

4.4.3 Technical Quality of Inspections

In reviewing this sub-indicator, the review team examined inspection files, inspection reports,

and enforcement documentation. These reviews indicated that inspections of uranium recovery

facilities adequately covered the scope, completeness, and technical accuracy to determine

compliance with regulations, license conditions, and available guidance. Appropriate

enforcement actions were taken both by the Department and the Commission given the scope

of the violations noted. The inspections were thorough, including operations and records, and

the violations were communicated with licensees at exit interviews. However, it was noted that

letters to licensees documenting the inspection results were sent consistently beyond the 30
Texas Final Report Page 22

day timeframe. In some cases, letters were sent 60-90 days after the inspection had been

conducted. The delay in the issuance of inspection findings is discussed in Section 3.2 above. 

The team also determined that supervisory inspection accompaniments are performed

annually, in accordance with written procedures. Appendix C lists the inspection casework files

reviewed for completeness and accuracy.

There were no accompaniments of either Department or Commission inspectors of a uranium

recovery facility as part of this IMPEP review.

4.4.4 Technical Quality of Licensing Actions

The team examined files and documentation related to licensing in-situ and conventional mill

facilities, license amendment files, and other licensing documentation. Based on these reviews,

the team concluded that licensing actions were appropriate and that license conditions were

clear and well-written. Requirements associated with these conditions were based on a need to

meet regulations and to protect health and safety. Appendix D lists the licensing files reviewed

for completeness and accuracy.

The review team discussed the Department’s progress in development of documentation of

reclamation plans at three conventional uranium mill sites in South Texas. The lack of

documentation poses a major issue to the Department since: (1) Section 274(c) of the AEA

requires that, before a license can be terminated at a conventional uranium mill, an Agreement

State must determine that all applicable standards and regulations have been met; and (2) NRC

must concur in the State’s determination that the standards and requirements have been met,

based on a review of the State’s bases for making such a determination. Thus, as discussed in

Section 2 above, the recommendation from Section 4.4.4 of the 2001 IMPEP report remains

open.

4.4.5 Technical Quality of Incident and Allegation Activities

During the review period, only one minor incident, an on-site pipe leak at an in-situ facility, was

reported. The Department followed up on this incident; however, there was no documentation

in the file which documented the Department’s review and closed out the incident. This was

discussed with Department staff at the conclusion of the IMPEP review, and it was agreed that

documentation closing out all incidents, including minor ones, would now be included in the file. 

No allegations were reported during this review period.

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

that Texas’ performance with respect to the indicator, Uranium Recovery Program, is

satisfactory.

5.0 SUMMARY

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

satisfactory but need improvement for four of the nine performance indicators. The review

team found the other five performance indicators to be satisfactory. Accordingly, the review

team recommended and the MRB agreed that the Texas Agreement State program be found

adequate but needs improvement and compatible with NRC's program. Based on the results of

the current IMPEP review, the review team recommended and the MRB agreed that the State

of Texas remain on heightened oversight and that a follow-up review be conducted in
Texas Final Report Page 23

approximately one year.

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

implementation, as appropriate, by the State.

RECOMMENDATIONS FOR THE STATE:

1. The review team recommends that the Department hire and retain sufficient qualified

staff to return and maintain the program at a satisfactory performance level. 

(Section 3.1)

2. The review team recommends that the Department review their process for issuance of

inspection letters and develop a process that will allow the 31-day issuance goal for

routine cases to be achieved on a consistent basis. (Section 3.2)

3. The review team recommends that the State adhere to the policy of annual supervisory

accompaniments of all qualified inspectors. (Section 3.3) (Open recommendation from

the 2001 IMPEP report)

4. The review team recommends that the State develop a process to ensure that

inspections are performed in accordance with their own performance-based inspection

procedures. (Section 3.3)

5. The review team recommends that the Department report all significant and routine

events, as well as follow-up event information, to the NRC in accordance with STP

Procedure SA-300, “Reporting Material Events.” (Section 3.5) (Open recommendation

from the 2001 IMPEP report)

6. The review team recommends that the Department develop and implement an

inspection program to verify that the QA/QC requirements in the SS&D Registry sheets

are being implemented by the manufacturer. (Section 4.2.2)

7. The review team recommends that the Department conduct an evaluation of the

uranium recovery program workload and hire the necessary staff to adequately address

the workload. (Section 4.4.1)

8. The review team recommends that the Department prepare necessary supporting

documentation identifying the bases for the licensing actions associated with

reclamation plans for the three conventional mills. (Section 4.4.4) (Open

recommendation from the 2001 IMPEP report) 

GOOD PRACTICES:

The review team identified two good practices being conducted by the Commission and the

Department as stated below.

1. The Commission and the Department include in the transmittal letter for amended

licenses a description of the changes (a roadmap) so that the changes are clearly

identified.
Texas Final Report Page 24

2. The Commission attached as an appendix to the active on-site disposal license the

closure criteria for the closed disposal cells which keeps the as-closed conditions in the

license even though new criteria have been established for the newer cells.
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Texas Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Appendix F Sealed Source & Device Casework Reviews

Attachment 1 November 15, 2005 Letter from Richard Bays

Texas’ Response to Draft IMPEP Report

Attachment 2 Comment Resolution on the 2005 Texas Draft

IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Dennis Sollenberger, STP Team Leader

Technical Staffing and Training 

Vivian Campbell, Region IV Technical Quality of Inspections

Inspection Accompaniments (assisted by Richard 

 Leonardi)

Technical Quality of Incident and Allegation 

Activities

Michael Snee, Ohio Technical Quality of Licensing Actions

Chris McKenney, NMSS LLRW Disposal Program (assisted by James 

Shaffner)

William Rautzen, STP Status of Materials Inspection Program

Compatibility Requirements

Michael Stephens, Florida SS&D Evaluation Program

Dorothy Stoffel, Washington Uranium Recovery Program
APPENDIX B

TEXAS

ORGANIZATION CHARTS

ADAMS: ML052860195
APPENDIX C

INSPECTION CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS

ONLY. NO EVIDENCE OF LICENSED OPERATIONS BEING OBSERVED OR STAFF

PERSONNEL INTERVIEWED REGARDING LICENSED ACTIVITIES IS A COMMON

COMMENT FOR THE INSPECTION FILES, EXCEPT WHEN FIELD INSPECTIONS WERE

CONDUCTED. FOR BREVITY, THIS COMMENT WILL NOT BE REPEATED.

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

File No.: 1

Licensee: Precision Energy Services Inc. License No.: L04286

Inspection Type: Routine, Unannounced Priority: 1/NRC 3

Inspection Date: 6/8/05 Inspector: MU

Comment:

Compliance letter issued 85 days after inspection.

File No.: 2

Licensee: Precision Energy Services Inc. License No.: L04286 

Inspection Type: Routine, Unannounced Priority: 1/NRC 3

Inspection Date: 2/18/05 Inspector: RA 

Comment:

Compliance letter issued 115 days after inspection.

File No.: 3

Licensee: Precision Energy Services Inc. License No.: L04286

Inspection Type: Routine, Announced Priority: 1/NRC 3

Inspection Date: 1/26/05 Inspector: SF

Comment:

Compliance letter issued 57 days after inspection.

File No.: 4

Licensee: Precision Energy Services Inc. License No.: L04286

Inspection Type: Routine, Unannounced Priority: 1/NRC 3

Inspection Date: 3/17/05 Inspector: SP

Comment:

 Compliance letter, no violations noted, issued 32 days after inspection. 
Texas Final Report Page C.2

Inspection Casework Reviews

File No.: 5

Licensee: Texas Gamma Ray LLC License No.: L05561

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 5/12/05 Inspector: HD

Comments:

a) Inspection report stated that average exposure to personnel was 25 rem. PSQA

reviewer contacted inspector during IMPEP review and confirmed that record was in

error. File corrected.

b) Compliance letter issued 76 days after inspection.

File No.: 6

Licensee: Texas Gamma Ray LLC License No.: L05561

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 3/22/04 Inspector: HD

Comment:

 Compliance letter issued 107 days after inspection, but a significant enforcement action.

File No.: 7

Licensee: Tin Inc. License No.: L01029

Inspection Type: Routine, Unannounced Priority: 3/NRC 5

Inspection Date: 8/19/02 Inspector: HD

Comment:

Compliance letter issued 38 days after inspection.

File No.: 8

Licensee: Midland County Hospital District License No.: L00728

Inspection Type: Routine, Announced Priority: 3/NRC 5

Inspection Date: 9/16/04 Inspector: GS

File No.: 9

Licensee: Saint Joseph Regional Health Center License No.: L00573

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 4/22/04 Inspector: SP

Comment:

Compliance letter issued 84 days after inspection.

File No.: 10

Licensee: Baylor University License No.: L00400

Inspection Type: Routine, Unannounced Priority: 1/ NRC 3

Inspection Date: 8/24/01 Inspector: CD

Comment:

 Compliance letter, no violations noted, issued 48 days after inspection. 
Texas Final Report Page C.3

Inspection Casework Reviews

File No.: 11

Licensee: University of Texas Southwestern Medical Center at Dallas License No.: L00384

Inspection Type: Routine, Announced Priority: 1/NRC 2

Inspection Date: 11/19/03 Inspector: CL

File No.: 12

Licensee: Halliburton Energy Services Inc. License No.: L00442

Inspection Type: Routine, Announced Priority: 1/NRC 3

Inspection Dates: 9/15-16/04 Inspector: LC

File No.: 13

Licensee: Sterigenics US Inc. License No.: L03851

Inspection Type: Routine, Announced Priority: 1/NRC 2

Inspection Date: 11/4/03 Inspector: CL

File No.: 14

Licensee: Coastal Wireline Services Inc. License No.: L04239

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 3/13/03 Inspector: LC

File No.: 15

Licensee: Texas A&M University License No.: L00448

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 4/19/02 Inspector: CL

File No.: 16

Licensee: Baylor University License No.: L00343

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 3/1/04 Inspector: SP

File No.: 17

Licensee: National Scientific Balloon Facility License No.: L04717

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 12/11/03 Inspector: SF

File No.: 18

Licensee: Southern Methodist University License No.: L02887

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 5/10/04 Inspector: GS

File No.: 19

Licensee: Cardinal Health License No.: L02033

Inspection Type: Routine, Unannounced Priority: 1/NRC 2

Inspection Date: 6/29/04 Inspector: RW

Comment:

 Compliance letter, no violations noted, issued 51 days after inspection. 
Texas Final Report Page C.4

Inspection Casework Reviews

File No.: 20

Licensee: Nuclear Sources and Services Inc. License No.: L02991

Inspection Type: Routine, Announced Priority: 0.5/NRC 2

Inspection Date: 4/27/05 Inspector: ES

Comment:

 Compliance letter, no violations noted, issued 75 days after inspection.

File No.: 21

Licensee: Alcon Laboratories Inc. License No.: L01281

Inspection Type: Routine, Announced Priority: 1/NRC 5

Inspection Date: 9/21/04 Inspector: CL

File No.: 22

Licensee: Alcon Laboratories Inc. License No.: L01281

Inspection Type: Routine, Announced Priority: 1/NRC 5

Inspection Date: 9/17/02 Inspector: CL

File No.: 23

Licensee: Big Springs Hospital Corp. License No.: L00763

Inspection Type: Routine, Unannounced Priority: 3/NRC 5

Inspection Date: 5/20/03 Inspector: JH

Comment:

 Compliance letter, no violations noted, issued 58 days after inspection.

File No.: 24

Licensee: Diagnostic Nuclear Imaging License No.: L05769

Inspection Type: Routine, Unannounced Priority: 3/NRC 5

Inspection Dates: 2/2-3, 2/11, and 2/25/05 Inspectors: KZ,JO

Comment:

 Compliance letter issued 122 days after inspection.

File No.: 25

Licensee: Longview Inspection, Inc. License No.: L01774

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 3/17/05 Inspector: HD

Comment:

Compliance letter, no violations noted, issued 47 days after inspection.

File No.: 26

Licensee: Longview Inspection, Inc. License No.: L01774

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 2/28/05 Inspector: GS

Comment:

Licensee has not responded as of the date of the IMPEP review. Reviewer found no

follow-up letter requesting a response in the file.
Texas Final Report Page C.5

Inspection Casework Reviews

File No.: 27

Licensee: Longview Inspection, Inc. License No.: L01774

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 9/30/04 Inspector: SF

File No.: 28

Licensee: Longview Inspection, Inc. License No.: L01774

Inspection Type: Routine, Unannounced Priority: 1

Inspection Dates: 5/8-9/03 Inspector: RG

File No.: 29

Licensee: Christus Spohn Health System Corporation License No.: L02390

Inspection Type: Routine, Unannounced Priority: 2/NRC 3

Inspection Date: 9/6/01 Inspector: JC

File No.: 30

Licensee: URI INC Kingsville Dome License No.: L03653

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 7/13/05 Inspector: ES

Comment:

One violation noted by the inspector. The NOV letter had not been issued at the time of

the review (>60 days).

File No.: 31

Licensee: Mestena Uranium License No.: L05360

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 5/11/05 Inspector: ES

TEXAS COMMISSION ON ENVIRONMENTAL QUALITY

File No.: 32

Licensee: Solutia Inc. License No.: RW0219

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 4/29/02 Inspector: MA

File No.: 33

Licensee: Solutia Inc. License No.: RW0219

Inspection Type: Routine, Announced Priority: 2

Inspection Date: 6/21/04 Inspector: MA

File No.: 34

Licensee: Solutia Inc. License No.: RW0219

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 8/12/04 Inspector: MA

File No.: 35

Licensee: Solutia Inc. License No.: RW0219

Inspection Type: Routine, Announced Priority: 2

Inspection Date: 4/21/05 Inspector: MA
Texas Final Report Page C.6

Inspection Casework Reviews

File No.: 36

Licensee: Iso-Tex, Incorporated License No.: RW1937

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 1/10/02 Inspector: MA

File No.: 37

Licensee: Iso-Tex, Incorporated License No.: RW1937

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 11/5/04 Inspector: MA

File No.: 38

Licensee: Iso-Tex, Incorporated License No.: RW1937

Inspection Type: Follow up, Unannounced Priority: 2

Inspection Date: 4/20-21/05 Inspector: MA

INSPECTOR ACCOMPANIMENTS OF DEPARTMENT STAFF

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

Accompaniment No.: 1

Licensee: Texas Womens University License No: L00304

Inspection Type: Routine, Announced Priority: 1/NRC 3

Inspection Date: 8/2/05 Inspector: SP

Accompaniment No.: 2

Licensee: Schlumberger Technology Corporation License No: L01833

Inspection Type: Routine, Unannounced Priority: 1/NRC 3

Inspection Date: 8/9/05 Inspector: MU

Comments:

a) No interviews of staff radiation workers, who were on site, or observations of licensed

activities.

b) Inspection focused primarily on records and discussions with responsible radiation

safety personnel.

Accompaniment No.: 3

Licensee: Spohn Health Systems License No: L02495 

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 8/10/05 Inspector: RW

Comment:

Inspector failed to observe chief nuclear medicine technologist assay a dose without

using extremity dosimetry or gloves because focused on collecting information for the

detailed report.

Accompaniment No.: 4

Licensee: Spohn Health Systems License No: L02357 

Inspection Type: Routine, Announced Priority: 2/NRC 5

Inspection Date: 8/10/05 Inspector: RW
Texas Final Report Page C.7

Inspection Casework Reviews

Accompaniment No.: 5

Licensee: Medi Physics, Inc. License No: L05529

Inspection Type: Routine, Announced Priority: 1/NRC 2

Inspection Date: 9/6/05 Inspector: GS

Comments: 

a) No licensed activities observed or staff radiation workers interviewed.

b) Inspection focused primarily on records and discussions with responsible radiation

safety personnel.

Accompaniment No.: 6

Licensee: CHCA Womans Hospital LP License No.: L04834

Inspection Type: Routine, Announced Priority: 2/NRC 3

Inspection Date: 9/8/05 Inspector: KZ

Comments: 

a) No licensed activities ongoing during inspection. However, no request was made to the

personnel to demonstrate, or explain selected licensed activities.

b) The primary focus of the inspection was a record review and collection of data. 
APPENDIX D

LICENSE CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS

ONLY.

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

File No.: 1

Licensee: Columbia/St. Davids Healthcare System LP License No.: L05856

Type of Action: New Amendment No.: 00

Date Issued: 1/11/05 License Reviewer: HW

File No.: 2

Licensee: Conam Inspection & Engineering, Inc. License No.: L05010

Type of Action: Amendment Amendment No.: 87

Date Issued: 2/22/05 License Reviewer: BS

File No.: 3

Licensee: Texas Gamma Ray LLC License No.: L05561

Type of Action: New Amendment No.: 00

Date Issued: 5/31/02 License Reviewer: MD

File No.: 4

Licensee: Halliburton Energy Services, Inc. License No.: L00442

Type of Action: Renewal Amendment No.: 103

Date Issued: 3/30/05 License Reviewer: DF

File No.: 5

Licensee: Univ. of Texas - MD Anderson Medical Center License No.: L00466

Type of Action: Amendment Amendment No.: 91

Date Issued: 7/31/04 License Reviewer: FT

File No.: 6

Licensee: Independent Testing Laboratories License No.: L03795

Type of Action: Termination Amendment No.: 31

Date Issued: 12/16/04 License Reviewer: WS

File No.: 7

Licensee: Texas Tech Univ. - Health Sciences Center License No.: L01869

Type of Action: Renewal Amendment No.: 74

Date Issued: 5/31/05 License Reviewer: HW

File No.: 8

Licensee: Presbyterian Hospital of Dallas License No.: L01586

Type of Action: Amendment Amendment No.: 82

Date Issued: 2/17/05 License Reviewer: PS
Texas Final Report Page D.2

Licensing Casework Review

File No.: 9

Licensee: Thermo Measuretech License No.: L03524

Type of Action: Amendment Amendment No.: 67

Date Issued: 7/8/05 License Reviewer: DF

File No.: 10

Licensee: Qualitex Industrial X-Ray License No.: L04079

Type of Action: Termination Amendment No.: 15

Date Issued: 8/31/04 License Reviewer: MD

File No.: 11

Licensee: Colorado Fayette Medical Center License No.: L03470

Type of Action: Termination Amendment No.: 15

Date Issued: 7/22/05 License Reviewer: HW

File No.: 12

Licensee: Coastal Wireline Services, Inc. License No.: L04239

Type of Action: Renewal Amendment No.: 08

Date Issued: 5/26/04 License Reviewer: BT

File No.: 13

Licensee: Midland County Hospital District License No.: L00728

Type of Action: Renewal Amendment No.: 75

Date Issued: 5/12/05 License Reviewer: PS

File No.: 14

Licensee: Presbyterian Hospital of Winnsboro License No.: L03336

Type of Action: Amendment Amendment No.: 18

Date Issued: 8/5/04 License Reviewer: FT

File No.: 15

Licensee: Ludlum Measurements, Inc. License No.: L01963

Type of Action: Amendment Amendment No.: 69

Date Issued: 4/27/05 License Reviewer: DF

File No.: 16

Licensee: Computalog Wireline Services, Inc. License No.: L04286

Type of Action: Amendment Amendment No.: 54

Date Issued: 3/1/05 License Reviewer: WS

File No.: 17

Licensee: Texas Department of Transportation License No.: L00197

Type of Action: Renewal Amendment No.: 104

Date Issued: 9/30/04 License Reviewer: MD
Texas Final Report Page D.3

Licensing Casework Review

File No.: 18

Licensee: The Dow Chemical Company License No.: L05829

Type of Action: New Amendment No.: 00

Date Issued: 12/30/04 License Reviewer: BS

File No.: 19

Licensee: Cardinal Health License No.: L02033

Type of Action: Amendment Amendment No.: 96

Date Issued: 1/6/04 License Reviewer: FT

File No.: 20

Licensee: Alcon Laboratories, Inc. License No.: L01281

Type of Action: Amendment Amendment No.: 40

Date Issued: 12/16/04 License Reviewers: DF

File No. 21

Licensee: ExxonMobil Corporation License No.: L01431

Type of Action: Amendment of Reclamation Plan Amendment No.: 10 

Date Issued: 7/09/05 License Reviewers: UR Team

File No. 22

Licensee: Mestena Uranium License No.: L05360

Type of Action: New Amendment No.: 0

Date Issued: 10/04/02 License Reviewers: UR Team

TEXAS COMMISSION ON ENVIRONMENTAL QUALITY

File No.: 23

Licensee: Solutia Inc. License No.: RW0219

Type of Action: Amendment Amendment No.: 3

Date Issued: 3/8/04 License Reviewer: BB

File No.: 24

Licensee: Solutia Inc. License No.: RW0219

Type of Action: Renewal Amendment No.: 2

Date Issued: 6/25/02 License Reviewer: BB

Comment: 

Attachment A to the license contains historical license requirements remaining

applicable to the closed disposal units.
APPENDIX E

INCIDENT CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: Laredo Regional Medical Center License No.: L02192

Date of Incident: 11/26/02 NMED Number: 021164

Investigation Date: 12/23/02 Type of Incident: Contamination

Type of Investigation: Phone, Inspection

File No.: 2

Licensee: VHS San Antonio Partner LP License No.: L00455

Date of Incident: 7/20/04 NMED Number: 040748

Investigation Date: 8/18/04 Type of Incident: Misadministration

Type of Investigation: Phone, Inspection

File No.: 3

Licensee: National Central Pharmacy License No.: L04781

Date of Incident: 11/12/04 NMED Number: Not reportable

Investigation Date: 12/16/04 Type of Incident: Procedure failure

Type of Investigation: Inspection

File No.: 4

Licensee: Nuclear Sources and Services, Inc. License No.: L02991

Date of Incident: 12/1/04 NMED Number: 040854

Investigation Date: 12/2/04 Type of Incident: Contamination

Type of Investigation: Inspection, on-site during cleanup

File No.: 5

Licensee: VHS San Antonio Partner LP License No.: L00455

Date of Incident: 12/12/01 NMED Number: 011146

Investigation Date: 1/7/02 Type of Incident: Lost/stolen RAM

Type of Investigation: Inspection

File No.: 6

Licensee: Schlumberger Technology Corporation License No.: L01833

Date of Incident: 7/10/04 NMED Number: 040517

Investigation Date: 7/13/04 Type of Incident: Lost RAM

Type of Investigation: Inspection

File No.: 7

Licensee: Fugro South Inc. License No.: L00058

Date of Incident: 10/16/01 NMED Number: 010951

Investigation Date: 10/16/01 Type of Incident: Lost/stolen RAM

Type of Investigation: Phone, Written report
Texas Final Report Page E.2

Incident Casework Review

File No.: 8

Licensee: Longview Inspection License No.: L01774

Date of Incident: 10/18/03 NMED Number: 030880

Investigation Date: 10/20/03 Type of Incident: Transportation

Type of Investigation: Phone, Written report

File No.: 9

Licensee: Goolsby Testing Laboratories, Inc. License No.: L03115

Date of Incident: 12/30/02 NMED Number: 030085

Investigation Date: 1/3/03 Type of Incident: Equipment failure, Overexposure

Type of Investigation: Inspection

File No.: 10

Licensee: URI INC. Kingsville Dome License No.: L03653

Date of Incident: 10/28/03 NMED Number: Not Reportable

Investigation Date: 10/28/03 Type of Incident: Pipe break, liquid spill on-site

Type of Investigation: Phone

Comment:

File did not have clear closure to incident. 
APPENDIX F

 SEALED SOURCE AND DEVICE (SS&D) CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT ARE INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Registry No.: TX-1201-D-101-S SS&D Type: (D) Density Gauge

Manufacturer: Industrial Resolution Imaging Services, Inc. Model No.: IRIS-1A

Date Issued: 1/31/04 Type of Action: New

SS&D Reviewers: WS, SK

Comment:

Issuance date on Page 1 is 01/31/04 was not updated to match review and concurrence

date 02/06/04 on signature page.

File No.: 2

Registry No.: TX-634-D-138-D SS&D Type: (D) Gamma Gauge

Manufacturer: Thermo MeasureTech Model No.: 5201, 5201A

Date Issued: 1/09/02 Corrected Page 1 Type of Action: Corrected Page 1 (Amend)

SS&D Reviewers: DF, PM

Comments:

a) Last three sentences in “Conditions of Normal Use” section are repeated in “Safety

Analysis Summary” and word “simply” in the phrase “simply a radiation hazard” adds no

additional information and could mislead someone on the potential hazard.

b) SSR File does not match the sheet posted on NRC web site and file. Posted pages 2, 3

and 4 have the incorrect date and should be updated.

File No.: 3

Registry No.: TX-586-D-112-G SS&D Type: (D) Density Gauge

Manufacturer: Frame Engineering, AS Model No.: VxSM and VxSL, 

Distributor: Schlumberger Technology Corp Subsea Phase Watcher Vx

Date Issued: 11/24/04 Type of Action: New

SS&D Reviewers: MD, DF

Comment:

Principal type lists letter text first then letter instead of as stated in NUREG-1556,

Volume 3, Appendix D and C “(D) Density Gauge.”
Texas Final Report Page F.2

Sealed Source and Device Casework Reviews

File No.: 4

Registry No.: TX-1153-S-102-S SS&D Type: (X) Medical Reference Source

Manufacturer: International Isotopes Idaho Model No.: BM06 Series (BM05-33, BM06-37)

Date Issued: New 10/22/2002 SS&D Reviewers: SK, DF

Date Issued: Amended in Entirety 12/10/03 SS&D Reviewers: SK, DF

Comments:

a) Description of use starts on Page 1 of the SSR on new and amended sheets.

b) Principal type lists letter text first then letter instead of as stated in NUREG-1556,

Volume 3, Appendix D and C “(X) Medical Reference Source.”

File No.: 5

Registry No.: TX-642-D-102-B SS&D Type: (N) Ion Generator, Chromatography

Manufacturer: Thermo Finnegan LLC. Model No.: 115500

Date Issued: 12/11/02 Type of Action: Amended page 1

SS&D Reviewers: DF, PM

Comment:

Current sheet does not indicate that a Radium source LAB-784 is no longer available for

distribution as listed on previous amendment.

File No.: 6

Registry No.: TX-8134-D-105-S SS&D Type: (D) Density Gauge

Manufacturer: P.A., Inc. Model No.: 5-A

Date Issued: 12/05/03 Type of Action: Inactivation

SS&D Reviewers: DF, PM

Comment:

According to records these devices were never commercially made.
ATTACHMENT 1

November 15, 2005 Letter from Richard Bays

Texas’ Response to Draft IMPEP Report

ADAMS: ML053210174
COMMENT RESOLUTION ON THE 2005 TEXAS DRAFT IMPEP REPORT

Texas Department of State Health Services (the Department) responded by letter dated

November 15, 2005 and had the following comments on the draft report in addition to their

responses to the recommendations in the draft report.

Department’s Comment:

DSHS has taken actions to improve the adequacy of the Agreement State Program since the

NRC placed the program on “heightened oversight” in April of 2005. All regulations have been

adopted, the “Health Physicist” job classification is being implemented to assure recruitment

and retention of staff, and all incidents are being timely reported to NRC. The inspector

positions in AbiIene and Corpus Christi are being filled with experienced inspectors. I therefore

request that the DSHS Agreement State Program be removed from “heightened oversight”

status. 

Team’s Response:

The team agrees that the Department has made significant progress in moving the program

toward a program that is satisfactory in all indicators for the IMPEP program. However, as

indicated in the draft report, the Department has additional work to do in the four indicators that

were found to be satisfactory but needs improvement. The Team believes that, based on the

criteria in Management Directive 5.6 and the performance of the Department as reviewed in

September 2005, the Texas program should remain on heightened oversight to allow the

Department the time to demonstrate performance at the satisfactory level. A follow-up review in

approximately one year should allow sufficient time for the program changes to be reflected in

the program performance.

Department’s Comment:

In addition, the Texas Radiation Advisory Board (TRAB) has expressed concern over the

statement made on page 5 of the IMPEP draft report, which states, “The review team

determined that there appears to be no conflict-of-interest.” The TRAB chairman will address

the Board’s concerns to NRC directly.

The TRAB also clarified their comment with the following email text.

Thanks very much for the followup phone call. For the purpose of clarity, I would offer the

following comments:

Given the narrative regarding the TRAB within the NRC draft report:

1. The final sentence leaves the reader with the impression that, although "there appears

to be no conflict-of-interest," a conflict may indeed exist. I do not think, given my read of

the criterion, that this is a required or necessary conclusion. The criterion that I was

provided states as follows:

ATTACHMENT 2
2

"Does the Agreement State program have an oversight board or committee which

provides direction to the program and is composed of licensees and other members of

the public? If so, please describe the procedures used to avoid a conflict of interest."

All that is requested by the criterion is a description of the process used to vet

conflicts-of-interest, not a finding (conclusive or otherwise) as to whether conflicts may

exist.

2. Regarding the adequacy of staffing of the Board, an observation could be made that

although 18 members are identified in the statute, the TRAB currently has 4 vacancies,

and 11 of the 14 current members are serving on expired terms.

3. For clarity, the TRAB officially advises three state agencies (DSHS, TCEQ, and the

Railroad Commission of Texas, RCT).

Again, thanks very much for the call.

Michael S. Ford, CHP

Chair, Texas Radiation Advisory Board

Team’s Response:

The team’s write up was intended to state that the TRAB members are required to have training

in conflict-of-interest and operate under procedures that would avoid any such conflict. The

language in the report was modified to clarify this issue and correct other factual information.

Department’s Comment:

On page 10 of the draft report, we suggest deleting the paragraph from the final report, since it

does not reflect a systematic programmatic finding. If the paragraph stays in the final report,

we recommend that it be modified as shown below.

“The team noted that the Department does not routinely verify the disposition of large sealed

sources when a licensee requests removal of the sealed source from their license. This was

discussed with Radiation Licensing Group management and they agreed that they should do

routinely verify that sealed sources reach their intended disposal or transfer site prior to

removing them from a license, but had overlooked the disposition verification step in one

instance of a license amendment, rather than a license termination. In the future, the licensing

staff will verify that the sources have been received by the recipient prior to deleting it from the

senders license.”

Team’s Response:

The team disagrees with the recommended change. The team reviewer noted two cases

where the licenses were amended without verification and the discussions with the Radiation

Licensing Group management indicated that the verification step was not part of their current

practice. No change to the report was made.
3

Department’s Comment:

From the draft report, 4.2.2, paragraph four - This included the need to amend some sheets

that indicated that Special Nuclear Materials may be distributed under a general license. The

Department is currently working with the manufacturer to delete this from the registrations.

We recommend that this paragraph be removed from the final IMPEP report since it does not

fall within the prescribed review criteria of "All SS&D evaluations completed since the last

IMPEP review are candidates for review. Additionally it is not a recommendation or suggestion

and does not bear on the overall finding related to this indicator.

Team’s Response:

The team addressed this SS&D program issue during the IMPEP review because the program

issue was identified during the review period. The Department action to resolve the issue is

appropriate and will allow the issue to be closed. The team recommends that the paragraph

remain in the report which will show that the issue was addressed and allow the issue to be

closed. 

The Texas Commission on Environmental Quality (the Commission) relayed their comments by

telephone on November 16, 2005.

Commission’s Comment:

The final report should be clear that the “heightened oversight” status for the State of Texas

was not based on the activities of the Commission.

Team’s Response:

The final report will be clear that the heightened oversight status of the State of Texas was

based on the performance of the Department and not the performance of the Commission.