DATED: MAY 23, 1997 SIGNED BY: HUGH L. THOMPSON, JR.

Mr. Ricky L. Boggan, Director

Bureau of Environmental Health

2423 North State Street

P.O. Box 1700

Jackson, Mississippi 39215

Dear Mr. Boggan:

On May 14, 1997, the Management Review Board (MRB) met to consider the

proposed final Integrated Materials Performance Evaluation Program (IMPEP)

report on the Mississippi Agreement State Program. The MRB found the

Mississippi program adequate to protect public health and safety and

compatible with NRC's program. 

Section 5, page 14, of the enclosed final report presents the IMPEP team's

recommendations. We request your evaluation and response to those

recommendations within 30 days from receipt of this letter.

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

scheduled in four years, unless program concerns develop that require an

earlier evaluation.

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

the review and your support of the Radiation Control Program. I look forward

to our agencies continuing to work cooperatively in the future.

Sincerely, /RA/

Hugh L. Thompson, Jr.

Deputy Executive Director

 for Regulatory Programs

Enclosure:

As stated

cc: Robert W. Goff, Director

Radiological Health Program

Mississippi Department of Health
bcc: Chairman Jackson

Commissioner Rogers

Commissioner Dicus

Commissioner Diaz

Commissioner McGaffigan

Distribution:

DIR RF DCD (SP01)

SBaggett PDR (YES_T NO_)

SDroggitis

CCardwell, TX KSchneider

RWoodruff, RII SMerchant, NMSS

CPaperiello, NMSS RQuillin, CO

MKnapp, NMSS GDeegan, NMSS

KCyr, OGC FCameron, OGC

DRoss, AEOD HNewsome, OGC

TCombs, OCA LRakovan, OSP

EBailey, CA Mississippi File
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF MISSISSIPPI AGREEMENT STATE PROGRAM

January 27-31, 1997

FINAL REPORT

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

1.0 INTRODUCTION

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

control program. The review was conducted during the period January 27-31,

1997, by a review team comprised of technical staff members from the Nuclear

Regulatory Commission (NRC) and the State of Texas. Team members are

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

"Interim Implementation of the Integrated Materials Performance Evaluation

Program Pending Final Commission Approval of the Statement of Principles and

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

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

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

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

Preliminary results of the review, which covered the period September 24, 1993

to December 31, 1996, were discussed with Mississippi management on January

31, 1997.

A draft of this report was issued to Mississippi for factual comment on March

11, 1997. The State of Mississippi responded in a letter dated April 14, 1997

(Attachment 1). The State's comments were incorporated into the final report. 

The Management Review Board (MRB) met on May 14, 1997, to consider the

proposed final report. The MRB found the Mississippi radiation control

program was adequate to protect public health and safety and compatible with

NRC's program.

The Department of Health (DOH) is the radiation control agency within the

State of Mississippi that regulates, among other public health issues,

exposure to radiation hazards. The State Health Officer is appointed by and

reports to the Governor. Within the DOH, the Mississippi radiation control

program is administered by the Division of Radiological Health (DRH) under the

direction of the Office of Health Regulation. The DOH and DRH organization

charts are included as Appendix B. The Mississippi program regulates

approximately 320 specific licensees. In addition to the radioactive

materials program, the DRH administers programs for machine produced

radiation, naturally occurring radioactive materials, and emergency

preparedness for the Grand Gulf nuclear power plant. 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 Mississippi.

In preparation for the review, a questionnaire addressing the common and noncommon indicators was sent to the DRH on November 18, 1996. Mississippi

provided its response to the questionnaire on January 7, 1997. A copy of that

response is included as Appendix C to this report. 

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

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

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

information from the DRH licensing and inspection data bases, (4) technical

review of selected files, (5) field accompaniments of two Mississippi

inspectors, and (6) interviews with staff and management to answer questions

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

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

indicator and made a preliminary assessment of the radiation control program's

performance. 

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

made following the previous review. Results of the current review for the

IMPEP common performance indicators are presented in Section 3. Section 4
Mississippi Final Report Page 2

discusses results of the applicable non-common indicators, and Section 5

summarizes the review team's findings and recommendations.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

The previous routine review concluded on September 24, 1993, and the results

were transmitted to Dr. F. E. Thompson, Jr., State Health Officer, Mississippi

State Department of Health, on June 3, 1994. 

Findings from the September 1993 routine review resulted in recommendations in

two program indicators: Status and Compatibility of Regulations and

Administrative Procedures. The State's corrective actions in response to the

recommendations were evaluated during a review visit which concluded on

September 24, 1994. All comments and recommendations were satisfactorily

resolved for the Status and Compatibility of Regulations indicator and closed

at that time. Results of the review visit were transmitted to Mr. E. S.

Fuente, Director, Division of Radiological Health, on December 5, 1994.

The September 1994 review visit findings resulted in continued recommendations

for the Administrative Procedures indicator. During the 1993 review NRC

recommended that the program review their written administrative procedures

for uniformity with their current regulatory practices, and revise as needed,

with particular emphasis on enforcement procedures, procedures for medical

misadministrations, procedures for handling, processing and tracking

allegations, and procedures for the evaluation and documentation of inspector

accompaniments. By written memorandum the Director, DRH, directed each

Section Supervisor to update all administrative procedures by the end of 1994. 

During the 1997 IMPEP review the team found a revised procedures manual was

available which contained implementing procedures for a wide range of program

tasks including enforcement actions, handling of misadministrations,

supervisory accompaniments, and processing and tracking allegations. Although

some procedures were completed just prior to the review, the DRH Director

indicated that the procedures were being implemented. This item 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 include:

(1) Status of Materials Inspection Program; (2) Technical Staffing and

Training, (3) Technical Quality of Licensing Actions, (4) Technical Quality of

Inspections, and (5) Response to Incidents and Allegations. 

3.1 Status of Materials Inspection Program

The team focused on four factors in reviewing this indicator: (1) inspection

frequency, (2) overdue inspections, (3) initial inspection of new licenses,

and (4) timely dispatch of inspection findings to licensees. The team

evaluation is based on the Mississippi questionnaire responses regarding this

indicator, data gathered independently from the State's licensing and

inspection data tracking system, the examination of licensing and inspection

casework files, and interviews with managers and staff.

The team's review of the State's inspection priorities verified that the

State's inspection frequencies for various types or groups of licenses are at

least as frequent as similar license types or groups listed in the NRC

Inspection Manual Chapter 2800 (IMC 2800) frequency schedule. In reviewing

the State's priority schedule, the review team noted that the State requires

more frequent inspections in some license categories as follows: teletherapy

licensees are scheduled to be inspected on a two year frequency vs. NRC's
Mississippi Final Report Page 3

three year frequency, medical private practice licensees on a two or three

year frequency vs. NRC's three (with quality management program) or five year

(without quality management program) frequency, and academic broad licensees

on a one year frequency vs. NRC's two or three year frequency.

In their response to the questionnaire, Mississippi indicated that as of

December 31, 1996, there were three licenses identified as core inspections in

IMC 2800 that were overdue by more than 25 percent of the NRC's frequency. 

This number is well within the 10 percent criterion for overdue inspections of

Management Directive 5.6. The team noted that two of the overdue inspections

were inspected before the review and the third overdue inspection was

conducted during the IMPEP review week.

Inspection data are continuously updated and tracked, and reviewed every six

months for inspection planning. With respect to initial inspections of new

licenses, the team reviewed the inspection tracking data system and verified

that initial inspections were entered into the tracking system together with

existing licenses. Inspection due dates generated by the system for new

licenses are combined by inspection priority with those for other materials

licenses. A review of the inspection tracking system showed that initial

inspections are not differentiated from routine inspections, since the

tracking system does not display a six month due date for initial inspections. 

From interviews, IMPEP reviewers found the inspection staff was able to

identify initial inspections by the license number. The higher-numbered

licenses are new issues indicating an initial inspection is necessary. 

Mississippi's schedule for initial inspections, however, does not fully

coincide with the guidance of the programmatic indicator. Although

inspections are to be performed within six months for priority 1, 2, and 3,

licensees, priority 4 licensees are scheduled for initial inspection on a oneyear interval. The State's priority 4 licensees include portable and

industrial gauges (except generally licensed gauges), small academic licenses,

medical licensee's in-vitro programs, gas chromatographs, and environmental

sampling facilities. 

The review team suggests that the tracking system be revised to allow initial

inspections to be readily identified. 

The inspection frequencies of licenses selected for inspection file review

were compared with the frequencies of the State's priority system and verified

to be consistent and as frequent as similar license types under the IMC 2800

system. A review of 19 files of recently issued licenses indicated that the

initial inspection was conducted within six months for five of the licenses. 

Initial inspection for the other new licenses ranged from 8-18 months after

license issuance or material receipt. Eight of the licenses were in the

State's priority 4 (one year interval) category. Of those, two were initially

inspected within one year, four were initially inspected within six months,

and two exceeded the one year frequency. Over half of the inspection reports

reviewed for new licenses contained at least one notice of violation. This

reinforces the need to perform initial inspections within the prescribed

schedule so that inspectors can discuss program responsibilities with the

licensee shortly after materials are introduced into operations. During the

MRB discussions, the DRH Director indicated that loss of some staff during

this evaluation period contributed to the delay in some initial inspections. 

The review team recommends that all initial inspections be performed within

six months of license issuance or within six months of the licensee's receipt

of material and commencement of operations, consistent with IMC 2800. 

The timeliness of the issuance of inspection findings was also evaluated

during the inspection file review. For the files examined, all inspection
Mississippi Final Report Page 4

correspondence had been sent within 20 days of the inspection date, well

within the goal of 30 days after completion of the inspection.

Mississippi reported in their response to the questionnaire that 110 different

licensees had submitted requests for reciprocity during the review period, of

which 46 were from licensees with inspection intervals of 3 years or less. 

The State reported that 29 of 46 licensees were inspected. 

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

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

Inspection Program, be found satisfactory.

3.2 Technical Staffing and Training

In reviewing this indicator, the review team considered the radioactive

materials program staffing level, the technical qualifications of the staff,

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

examined the State's questionnaire responses regarding this indicator,

interviewed DRH management and staff, and considered any possible backlogs in

licensing or compliance actions. 

At the time of the review, Mississippi's radiation control program had three

Sections: (1) the Environmental Section, (2) the X-Ray Section, and (3) the

Radioactive Materials Section (RMS). The RMS is authorized for a Health

Physicist (HP) Administrative (supervisor), one HP Senior position, two HPs,

and one HP Trainee position. The organization chart (Appendix B) shows each

of these positions, but not the number of staff assigned to each position. At

the time of the review, there was an additional individual assigned full

time in the HP position. The review team believes that based on the

satisfactory performance of the materials licensing and inspection programs,

this staffing level is adequate when all positions are filled and

the personnel trained. 

The technical quality of the staff was evaluated from interviews with the DRH

Director, review of the job descriptions, and a review of the training

records. The review team determined that successful candidates for technical

positions were required to have a bachelor's degree in science for the first

level (health physicist) and a master's degree and/or additional radiationrelated work experience for positions beyond entry level. The team concluded

that the DRH has been able to recruit qualified individuals, and that all of

the staff HPs have bachelor's degrees in science, most with several years of

practical experience in radiation safety practices.

The licensing and inspection functions of the program are integrated;

therefore, all health physicists performed duties in licensing, inspection,

and event response. Balance between the licensing and inspection functions is

achieved by basing staff assignments on program needs. Mississippi's efforts

to maintain the program while at the same time devoting significant effort in

hiring and training new staff by experienced staff throughout the review

period are commendable. As noted by the review team, two individuals, the HP

Administrative and Health Physicist Senior, performed a large majority of

licensing and inspection activities, and were responsible for the training of

the new staff.

According to the information provided in the questionnaire and the DRH

training procedures, all health physicists are required to attend training

courses which are equivalent to courses outlined in IMC 1246 as well as the

five-week health physics course. The records show that all of the radioactive

materials staff members have completed the five-week health physics course and

the basic NRC courses needed for licensing and inspection functions except for
Mississippi Final Report Page 5

two individuals. One staff member needs the Industrial Radiography course to

complete training requirements. The other person was new to the program and

has experience as a health physicist at a nuclear power facility, but will

need to attend the NRC or equivalent courses as they become available. 

Program management also explained their in-house and on-the-job training

processes. New staff are assigned increasingly complex licensing duties under

the direction of senior staff and accompany experienced inspectors during

increasingly complicated inspections. New staff inspectors are assigned

independent inspections after demonstrating competence during accompaniment

evaluations by the senior staff. The team noted that program management

exhibited a strong commitment to training during the review. However, the

Director, DRH, expressed concern about access to State funding for training

and increasing difficulty in obtaining approval for out of State travel for

training purposes without NRC funds for travel and training.

Information provided by the DRH shows that there have been two staff turnovers

in the RMS since the previous 1993 review, one in May 1994 and another in

March 1996. A replacement HP Trainee was hired in September 1995, received

the appropriate course training and was recently promoted to HP. The team

discussed plans with the DRH Director for involving this individual in routine

licensing and inspection activities since required course work was nearly

complete. Another replacement HP (experienced) was hired in November 1996 and

is currently undergoing additional training. The Program Director received a

promotion in June 1996 from HP Administrative (RMS Supervisor) which left the

RMS with only two fully trained HPs for a short period of time. As a result

of this staff turnover and a new Division Director change, the program

currently has the Health Physicist Trainee position vacant and is actively

recruiting for the position. 

The review team recommends that the State give priority to filling the vacant

HP Trainee position. 

In evaluating this indicator, the review team considered the staff changes,

noted that the program filled the vacancies in a timely fashion, except for

the vacated Trainee position, accelerated the training schedule for the

Trainee position, and hired an experienced Health Physicist as one of the

replacements. Although there currently are no routine licensing or inspection

backlogs, the Director, DRH, related that short-term inspection backlogs could

occur if additional staff effort is needed to respond to events, or if either

of the two senior staff left the program. 

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

Mississippi’s performance with respect to the indicator, Technical Staffing

and Training, be found satisfactory.

3.3 Technical Quality of Licensing Actions

The review team examined casework and interviewed the reviewers for

22 specific licenses. Licensing actions were reviewed for completeness,

consistency, proper isotopes and quantities used, qualifications of authorized

users, adequate facilities and equipment, and operating and emergency

procedures sufficient to establish the basis for licensing actions. Casework

was reviewed for timeliness, adherence to good health physics practices,

reference to appropriate regulations, documentation of safety evaluation

reports, or other supporting documents, consideration of enforcement history

on renewals, pre-licensing visits, peer or supervisory review as indicated,

and proper signature authorities. Licenses were reviewed for accuracy,

appropriateness of the license and of its conditions and tie-down conditions,
Mississippi Final Report Page 6

and overall technical quality. The files were checked for retention of

necessary documents and supporting data.

As part of the license renewal practice the licensee is requested to submit a

complete program description for DRH staff review at five-year intervals. 

When a license is issued, it includes the expiration date based on inspection

priority. During this five year period the DRH issues the licensee a letter

(also determined by inspection frequency) which requests information about

program status. The licensee identifies program changes or certifies that no

program changes occurred. Following review of the licensee's response, the

license is amended to extend the expiration date by the designated frequency. 

For example, priority 1 licensees are sent annual program status letters; the

licenses are then amended to extend the expiration date by one year. Priority

2 licenses expire two years from license issuance, with program status letters

sent just prior to license expiration. Following the licensee's response, the

expiration date is extended for another two years. Priority 3 and 4 licensees

are handled in a similar manner. This practice continues for five years from

the new or renewed license issue date. After the fifth year the licensee

submits a new application for DRH review and license renewal.

The cases were selected to provide a representative sample of licensing

actions which had been completed in the review period and to include work by

all reviewers. The cross-section sampling included three of Mississippi's

major licenses and included the following types: broad scope (research and

development), nuclear laundry, nuclear pharmacy, strontium-90 eye applicator,

nuclear medicine, teletherapy, portable and fixed gauges, and industrial fixed

radiography. Licensing actions included 2 new licenses, 13 five-year interval

renewals, 4 amendments, and 3 terminations. In discussions with the Director,

DRH, it was noted that there were no major decommissioning efforts underway

with regard to agreement material in Mississippi. A list of licenses that

were reviewed, with case-specific comments can be found in Appendix D.

The review team found that, overall, the licensing actions were generally

thorough, complete, consistent, and of acceptable quality with health and

safety issues properly addressed. Special license tie-down conditions were

almost always stated clearly, backed by information contained in the file, and

inspectable. The licensee's compliance history was taken into account when

reviewing renewal applications. Mississippi's licensing guides and license

policy procedures were revised and updated in March 1995. Mississippi's

licensing guides and license conditions were adopted directly from the NRC's. 

With few exceptions, file reviews showed reviewers appropriately used the

revised licensing guides.

From discussions with staff, the team found that State licensees have not been

notified of the need to file for reciprocity on sites which are under

exclusive Federal jurisdiction as identified in the NRC All Agreement States

Letter SP-96-022. Additionally, licenses which authorize temporary job sites

have not been amended to include a condition requiring the licensee to file

for reciprocity when at sites which are under exclusive federal jurisdiction. 

The team recommends that all "temporary job location" licensees be notified of

their responsibility for determining federal jurisdiction, and that the All

Agreement States letter SP-96-022 be utilized to revise the State's standard

license condition for use of material at temporary job sites. 

Team review of two license files authorizing use of strontium-90 eye

applicators showed that the license files did not contain information on the

method used by the licensee to assess the quantity of strontium-90 activity

before administering treatment to patients. Since recent NRC experience has

identified licensee misadministrations due to inadequate determination of
Mississippi Final Report Page 7

strontium-90 eye applicator activity, the team suggests that the RMS review

the methods used by strontium-90 eye applicator licensees to assess the

quantity of material prior to patient administration. 

All new or renewed licenses and amendments are peer reviewed and signed by the

Director, DRH, before being issued. No potentially significant health and

safety issues were identified. 

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

performance with respect to the indicator, Technical Quality of Licensing

Actions, be found satisfactory.

3.4 Technical Quality of Inspections

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

data base information for 20 materials inspections conducted during the review

period. The casework included the State's two fully-qualified materials

inspectors and one inspector who left the program during the review period. A

sample of the higher priority categories of license types was reviewed as

follows: three institutional medical for diagnostic use, one pool-type

irradiator, one industrial laundry, one institutional medical with

brachytherapy and isotope therapy, one institutional medical with an HDR unit,

one teletherapy, four nuclear pharmacies, one broad medical, five industrial

radiography, and two portable gauges. Appendix E provides a list of the

inspection cases reviewed in depth with case-specific comments.

The inspection procedures and techniques utilized by Mississippi were reviewed

and determined to be generally consistent with the inspection guidance

provided in IMC 2800 with one exception. Although follow-up and most field

site inspections were performed on an unannounced basis, the review team found

that almost all routine and initial inspections are conducted on an announced

basis. The team suggests that the State revisit their policy for conducting

announced routine inspections, and consider performing more routine

inspections on an unannounced basis, as permitted by available resources.

 

The State's primary inspection report form was reviewed and found to be a

comprehensive document providing general inspection areas consistent with the

types of information and data collected under IMC 2800 and 87100 documents. 

Except for a special medical form developed during the review period, the

State does not use separate supplements to the inspection report form for

various license types. During inspection preparation, the form is adapted by

the inspector to the special type of inspection to be performed, which is

equivalent to NRC field notes. Copies of revised inspection field notes

contained in IMC 87100 appendices covering the areas of industrial/research

development, well logging, industrial radiography, commercial irradiator,

medical broad-scope, and radiopharmacy were provided by the team. The review

team suggests that the State review its form and adopt, where appropriate,

field notes specific to the various types of licensees.

Inspection reports were reviewed to determine if the reports adequately

documented the scope of the licensed program, licensee organization, personnel

protection, posting and labeling, control of materials, equipment, use of

materials, transfer, and disposal. The reports were also checked to determine

if the reports adequately documented operations observed, interview of

workers, independent measurements, status of previous noncompliance items,

substantiation of all items of noncompliance, and the substance of discussions

during exit interviews with management. To assure consistency and quality of

reports, the Director, DRH, provided review and comment, and signed inspection

correspondence and field notes.
Mississippi Final Report Page 8

Overall, the review team found that the inspection reports showed very good

quality. Four reports needed additional information to fully document

performance areas covered during the inspection such as details of worker

interviews and licensee operations observed by the inspector. Other reports

contained only minor discrepancies from standard practice which were related

to insufficient detail. 

The files were found to be organized chronologically, with licensing and

inspection information readily accessible. Field notes, inspection forms, and

enforcement documents were found to be complete. Documented inspection

findings generally led to appropriate enforcement actions. Routine

enforcement letters were drafted by inspectors and were issued promptly to the

licensee by the Director, DRH.

In response to a finding from the previous NRC review, the State revised the

procedure which describes criteria for determining enforcement actions. The

State bases their enforcement program primarily upon onsite inspections and

written notices of inspection findings. The State defines a violation as any

item of non-compliance with existing rules and regulations of the Agency,

variation from the existing specific conditions assigned to a license or

variation from existing operating and emergency procedures of the licensee

approved through the Agency. A deficiency is defined as any item which, if

continued by a licensee has the potential to affect public health and safety

or could result in a violation. This item, in fact, however, does not

constitute a violation. When the licensee responds to a notice of violation

(NOV) or deficiency, the response is given to the inspector to evaluate the

licensee's response, and to draft a reply for the program director's

signature. The revised enforcement procedure includes provisions for monetary

penalties, orders (cease and desist, license suspension, and show cause),

written notices of noncompliance, and enforcement conferences. A concern in

implementation of the revised enforcement policy was identified during review

of inspection reports. The procedure indicates NOVs are issued when a

licensee does not comply with a particular regulation while deficiencies are

noted for less significant inspection findings, but not for a violation of

regulations. However, reports showed that deficiencies were used when citing

violations of regulations and did not provide clear significance to the

inspection findings. The team recommends the use of deficiencies closely

follow the revised enforcement procedure, particularly when regulations are

cited. 

The Director, DRH, stated that inspection results showed licensee compliance

for corrective actions taken to address violations was acceptable during the

review period and no escalated enforcement beyond issued NOVs was necessary. 

In one case the State held a meeting with licensee management to discuss

problems identified during an inspection, which resulted in the licensee's

commitment to take appropriate corrective action. The inspectors also

performed license reviews, further strengthening the continuity of the

regulatory and enforcement programs. The review team concluded that the

enforcement policy was effective. 

Two inspector accompaniments identified in Appendix E were performed by a

review team member on January 15, 1997 (hospital- nuclear medicine program)

and January 16, 1997 (radiopharmacy). The other inspectors were either new to

the program or were not yet qualified to perform independent inspections of

high priority licensees. During the accompaniments inspectors demonstrated

appropriate inspection techniques and knowledge of the regulations. The

inspectors were well prepared and thorough in the review of licensee radiation

safety programs. Inspection techniques were observed to be primarily

compliance oriented, with inspection report form information prescribing

inspection areas. The team suggested the State document their inspection
Mississippi Final Report Page 9

activities of performance-based methods such as observation of licensee

operations, worker demonstration of material handling and use, employee

interviews, and an increase in type and number of independent measurements. 

Overall, the technical performance of the inspectors was at a high level, and

the inspections were adequate to assess radiological health and safety at the

licensed facilities.

Mississippi has a policy of performing annual supervisory accompaniments of

inspectors. In response to the questionnaire, the State reported that

supervisory inspector accompaniments were performed at least annually by the

Director, DRH, on each inspector since the previous review. Performance

evaluations are discussed with the inspector and one annual accompaniment

documented. Accompaniments of junior personnel also are performed by senior

inspectors. 

It was noted that Mississippi has an ample number of portable radiation

detection instruments for use during routine inspections and response to

incidents and emergencies. Included in the State's meter inventory were ion

chambers, micro-R meters, high range detectors, GM tubes, ratemeters, liquid

scintillation detectors, high and low range pocket dosimeters, alpha and gamma

spectroscopy equipment, various calibration standards, and air sampling

equipment. The portable instruments used during the inspector accompaniments

were observed to be operational and calibrated. The DRH program office is colocated with the radiation counting laboratory and a holding area for

emergency response kits and vehicles. Portable instruments maintained at each

location in the building were available for use during routine inspections and

observed to be calibrated. 

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

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

Inspections, be found satisfactory.

3.5 Response to Incidents and Allegations

In evaluating the effectiveness of the State's actions in responding to

incidents and allegations, the review team examined the State's response to

the questionnaire regarding this indicator, reviewed the incidents reported

for Mississippi in the "Nuclear Material Events Database" (NMED) against those

contained in the Mississippi files and reviewed the casework of 14 reportable

incidents and two NRC referred allegations identified as involving byproduct

material. In addition, the review team interviewed the staff members assigned

to incident response.

Responsibility for initial response and follow up actions to radioactive

materials incidents and allegations rests with the DRH. Written procedures

require emergency response to events involving radioactive material licensees. 

The HP Administrative is the designated emergency coordinator, with backup

provided by DRH staff. The Director, DRH, or in his absence his designee,

will be advised of all incidents reported and response actions considered

before responders depart for the incident scene. The written procedures

specify that an on-site response will be made in the following situations: 1)

the DRH is requested to do so; 2) radioactive material other than gas is lost;

3) an actual or potential hazard to public health and safety is identified; 4)

media notification to the DRH of any real or suspected incident; or 5) a

determination by the Director or his designee that a response is necessary. 

After an initial screening, a total of 14 files were reviewed, 13 of which

were the most safety significant reportable incidents involving byproduct

material that occurred during the IMPEP review period. The incidents reviewed

included one equipment failure, one misadministration, three lost or stolen
Mississippi Final Report Page 10

radioactive material events, three contamination events, four cases of damage

to equipment, and two transportation events. Five of the incidents reviewed

were entered into the NMED. The information in NMED agreed with the

information in the Mississippi files. A list of the incident response case

work with comments is included as Appendix F. Eight of the incidents reviewed

had not been reported to NRC and referred to NMED. The review team recommends

that the State send in information of the reportable events that were not

previously reported to NRC and continue voluntary reporting of all reportable

events in the NMED database system collection of material events by providing

event information directly into the NMED system electronically or providing

compatible information in written form, in accordance with guidance contained

in the "Handbook on Nuclear Material Event Reporting in the Agreement States,"

Draft Report, March 1995.

For the most part, correct response procedures were followed. In most

instances actions were appropriate and timely. The level of effort was

generally commensurate with the hazard to the public, and suitable enforcement

actions were taken. There were, however, instances in which improvement was

needed.

The team identified two incident cases that the State did not conduct prompt

on-site investigations to identify the extent of radiation exposure and spread

of contamination. The first case involved a student at a licensed facility in

which I-125 contamination was found inside a building, on the student's hands,

clothing, shoes, and vehicle. Communications were made with the licensee at

the time the incident happened, but there was no response to the facility. A

second incident involved a fire in which three nuclear measurement gauges were

potentially damaged. The State approved the licensee's request to move the

gauges to an isolated storage building and instructed the licensee in

precautionary procedures to be used when moving the gauges but did not observe

the licensee's on-scene mitigative actions. 

The team recommends that the State review and revise, as appropriate, its

procedures for conducting onsite response to incidents whenever there is a

potential for radiation exposure or radioactive contamination of the public.

The two allegations received by the State during the review period that

involved byproduct radioactive materials were examined in detail. Allegations

were responded to promptly with appropriate investigations and follow up

actions. The review team reviewed the State's procedures, found them

adequate, and that they appeared to be followed. These procedures were used

for the control of information, and the results of the investigation were

promptly related to the alleger. No significant problems were observed.

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

Mississippi's performance with respect to the indicator, Response to Incidents

and Allegations, be found satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

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

(2) Sealed Source and Device Evaluation Program, (3) Low-Level Radioactive

Waste Disposal Program, and (4) Uranium Recovery Operations. Mississippi's

agreement does not cover uranium recovery operations, so only the first three

non-common performance indicators were applicable to this review.
Mississippi Final Report Page 11

4.1 Legislation and Regulations

4.1.1 Legislative and Legal Authority

In response to the questionnaire and discussions with the Director, DRH,

Mississippi reported to the review team the legislation which authorizes the

Mississippi radiation control program is identified in the Mississippi

Radiation Protection Law of 1976, and no changes were made during the review

period. House Bill No. 1357, which passed in 1992, provides authority for the

program to collect fees. There are no sunset laws in Mississippi and the

State indicated that regulations have no expiration date. 

4.1.2 Status and Compatibility of Regulations

All but one regulation required for compatibility identified as due or overdue

for adoption at the time of the 1993 routine review and September 1994 review

visit were adopted in October 1994 and July 1996. A license condition to

establish a legal binding requirement was used in the one case where

regulation promulgation was overdue. The rules received final NRC review and

approval on August 2, 1996 and with adoption of two comments made by NRC were

determined to be compatible. The first comment was editorial and was

corrected prior to the printing of the new regulations. The second comment

concerned Section 801 of the Mississippi Regulations as follows:

In 801.Q.7, (equivalent to 10CFR 36.21), amend subsection (a)(1)

to require that a sealed source have a certificate of registration

issued under 10 CFR 32.210, or the equivalent rule of the Agency

or another Agreement State. 

The Director, DRH, indicated that this comment would be incorporated into the

next rule adoption, which requires approval by the Board of Health and will be

addressed in 1997. Until final rules are adopted, the State has addressed the

second comment by including a license condition that requires licensees to

have a certificate of registration for sealed sources. 

With the following exceptions, Mississippi has adopted all compatible

regulations which will become due through 1998.

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

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

(59 FR 61767, 59 FR 65243, 60 FR 322) that became effective on

January 1, 1995, is under review and is expected to become effective by

the due date of January 1, 1998.

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

Part 20 and 61 amendments (60 FR 15649 and 60 FR 25983) that becomes

effective March 1, 1998 and will need to be adopted by March 1, 1998. 

The NRC delayed its effectiveness until the States could adopt

compatible requirements so that the national manifest system will go

into effect at one time.

! "Performance Requirements for Radiography Equipment," 10 CFR 34

amendments (60 FR 28323) that became effective June 30, 1995 and will

need to be adopted by June 30, 1998.

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

71 amendment (60 FR 50248) that became effective April 1, 1996 and will

need to be adopted by April 1, 1999. NRC delayed the effective date of

this rule until April 1, 1996 so that the DOT companion rule could be

implemented at the same time. Since the rule involves the transport of
Mississippi Final Report Page 12

materials across state lines, the States are encouraged to adopt

compatible regulations as soon as possible.

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

Parts 20 and 35 amendments (60 FR 48623) that became effective October

20, 1995 and will need to adopted by October 20, 1998.

The review team examined the procedures used in the Mississippi's promulgation

process and found the public is offered the opportunity to comment on proposed

regulations throughout the process. The quality management rule (QM), which

was enacted in October 1994, was one recent example of Mississippi's

willingness to cooperate with the NRC. 

The team notes that NRC staff is currently reviewing all Agreement States

equivalent regulations to Part 20, Standards for Protection Against Radiation. 

The reviews are being conducted outside the IMPEP process and the States will

be notified of the results.

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

Mississippi's performance with respect to the indicator, Legislation and

Regulations, be found satisfactory.

4.2 Sealed Source and Device Evaluation Program

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

program

even though Mississippi currently has responsibility for this area. The

review team discussed with the Director, DRH, as to whether Mississippi has

considered returning its authority for the Sealed Source and Device Evaluation

Program. Mississippi has not yet formulated a position on this issue. The

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

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

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

States and NRC in Discontinuance of NRC Authority and Assumption Thereof by

States Through Agreement" to allow a State to seek an amendment for the

regulation of LLRW as a separate category. Those States with existing

Agreements prior to 1981 were determined to have continued LLRW disposal

authority without the need of an amendment. Although Mississippi has LLRW 

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

licensing a LLRW disposal facility until such time as the State has been

designated as a host state for a LLRW disposal facility. When an Agreement

State has been notified or becomes aware of the need to regulate a LLRW 

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

which will meet the criteria for an adequate and compatible LLRW disposal

program. There are no plans for a LLRW disposal facility in Mississippi. 

Accordingly, the review team did not review this indicator.

5.0 SUMMARY

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

performance with respect to each of the performance indicators to be

satisfactory. Accordingly, the team recommended, and the MRB concurred in

finding the Mississippi program to be adequate to protect public health and

safety and compatible with NRC's program.

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

earlier sections of the report, for action by the State.
Mississippi Final Report Page 13

1. The review team suggests that the tracking system be revised to allow

initial inspections to be readily identified. (Section 3.1)

2. The review team recommends that all initial inspections be performed

within six months of license issuance or within six months of the

licensee's receipt of material and commencement of operations,

consistent with IMC 2800. (Section 3.1)

3. The review team recommends that the State give priority to filling the

vacant HP Trainee position. (Section 3.2)

4. The team recommends that all "temporary job location" licensees be

notified of their responsibility for determining federal jurisdiction,

and that the All Agreement States letter SP-96-022 be utilized to revise

the State's standard license condition for use of material at temporary

job sites. (Section 3.3)

5. The team suggests that the RMS review the methods used by strontium-90

eye applicator licensees to assess the quantity of material prior to

patient administration. (Section 3.3) 

6. The team suggests that the State revisit their policy for conducting

announced routine inspections, and consider performing more routine

inspections on an unannounced basis, as permitted by available

resources. (Section 3.4) 

7. The review team suggests that the State review its form and adopt, where

appropriate, field notes specific to the various types of licensees. 

(Section 3.4)

8. The team recommends the use of deficiencies closely follow the revised

enforcement procedure, particularly when regulations are cited. 

(Section 3.4) 

9. The team suggested the State document their inspection activities of

performance-based methods such as observation of licensee operations,

worker demonstration of material handling and use, employee interviews,

and an increase in type and number of independent measurements. 

(Section 3.4)

10. The review team recommends that the State send in information of the

reportable events that were not previously reported to NRC and continue

voluntary reporting of all reportable events in the NMED database system

collection of material events by providing event information directly

into the NMED system electronically or providing compatible information

in written form, in accordance with guidance contained in the "Handbook

on Nuclear Material Event Reporting in the Agreement States," Draft

Report, March 1995. (Section 3.5) 

11. The team recommends that the State review and revise, as appropraite,

its procedures for conducting onsite response to incidents whenever

there is a potential for radiation exposure or radioactive contamination

of the public. (Section 3.5)
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Mississippi Radiation Control Branch Organization Chart

Appendix C Mississippi's Questionnaire Response

Appendix D License File Reviews

Appendix E Inspection File Reviews

Appendix F Incident File Reviews

Attachment 1 Mississippi's Response to Review Findings
APPENDIX A

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Craig Gordon, RI Team Leader

Legislation and Regulations

Technical Quality of Inspections

Richard Woodruff, RII Technical Staffing and Training

Sally Merchant, NMSS Technical Quality of Licensing Actions

Cynthia Cardwell, Texas Status of Materials Inspection Program

Response to Incidents and Allegations
APPENDIX B

MISSISSIPPI RADIATION CONTROL PROGRAM

ORGANIZATION CHART
APPENDIX C

MISSISSIPPI'S QUESTIONNAIRE RESPONSE