February 3, 2004

L. Hall Bohlinger, Secretary

Office of the Secretary

Department of Environmental Quality

602 N. 5th Street

Baton Rouge, LA 70802

Dear Mr. Bohlinger:

On January 12, 2004, the Management Review Board (MRB) met to consider the proposed 

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

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

health and safety and compatible with the Nuclear Regulatory Commission’s program.

Section 5.0, page 14, of the enclosed final report presents the IMPEP team’s recommendation

for the State of Louisiana. We received your letter dated December 12, 2003, and request no

additional information at this time.

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

four years. However, due to the communications and oversight issues highlighted in

recommendations made in Sections 3.2 and 3.3, the review team recommended, and the MRB

agreed, that a periodic meeting take place with the State approximately one year from the

IMPEP 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 Radiation Control 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/

Carl J. Paperiello 

Deputy Executive Director 

 for Materials, Research and State Programs

Enclosure: 

As stated

cc: Listed on page 2
L. Hall Bohlinger - 2 -

cc: Robert Hannah, Deputy Secretary

Department of Environmental Quality

Linda Levy, Assistant Secretary

Office of Environmental Services

Jim Brent, Assistant Secretary

Office of Environmental Assessment

Thomas Bickham, Assistant Secretary

Office of Management and Finance

Bruce Hammatt, Assistant Secretary

Office of Environmental Compliance

Michael E. Henry, Senior Advisor

Steve Collins, IL

OAS Liaison to the MRB
February 3, 2004

L. Hall Bohlinger, Secretary

Office of the Secretary

Department of Environmental Quality

602 N. 5th Street

Baton Rouge, LA 70802

Dear Mr. Bohlinger:

On January 12, 2004, the Management Review Board (MRB) met to consider the proposed 

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

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

health and safety and compatible with the Nuclear Regulatory Commission’s program.

Section 5.0, page 14, of the enclosed final report presents the IMPEP team’s recommendation

for the State of Louisiana. We received your letter dated December 12, 2003, and request no

additional information at this time.

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

four years. However, due to the communications and oversight issues highlighted in

recommendations made in Sections 3.2 and 3.3, the review team recommended, and the MRB

agreed, that a periodic meeting take place with the State approximately one year from the

IMPEP 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 Radiation Control 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/

Carl J. Paperiello 

Deputy Executive Director 

 for Materials, Research and State Programs

Enclosure:

As stated

cc: Listed on page 2

bcc: Chairman Diaz

Commissioner McGaffigan

Commissioner Merrifield

Distribution: See next page

*See previous concurrence.

DOCUMENT NAME: C:\NRC\Others\2004 LA Final IMPEP Report and Letter.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:DD STP:D DEDMRS

NAME LJRakovan:gd

(ATMcCraw for)

JMPiccone PHLohaus CJPaperiello

DATE 1/22/04* 1/26/04* 1/27/04* 2/3/04

OFFICIAL RECORD COPY
L. Hall Bohlinger - 2 -

cc: Robert Hannah, Deputy Secretary

Department of Environmental Quality

Linda Levy, Assistant Secretary

Office of Environmental Services

Jim Brent, Assistant Secretary

Office of Environmental Assessment

Thomas Bickham, Assistant Secretary

Office of Management and Finance

Bruce Hammatt, Assistant Secretary

Office of Environmental Compliance

Michael E. Henry, Senior Advisor

Steve Collins, IL

OAS Liaison to the MRB

Distribution: DCD (SP01) PDR (YES/)

DIR RF

KSchneider, STP

AMcCraw, STP

LMcLean, RIV

MVirgilio, NMSS

RStruckmeyer, NMSS

TCombs, OCA (2 copies)

JLieberman, OGC

FCameron, OGC 

STreby, OGC 

KCyr, OGC

VCampbell, RIV

CMaier, RIV

MStephens, FL

JZabko, STP

CMiller, NMSS

MBailey, NMSS

ISchoenfeld, EDO

Louisiana File
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF LOUISIANA AGREEMENT STATE PROGRAM

October 27 - 31, 2003

 FINAL REPORT

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

1.0 INTRODUCTION

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

review was conducted during the period of October 27-31, 2003, by a review team comprised of

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

State of Florida. Team members are identified in Appendix A. The review was conducted in

accordance with the "Implementation of the Integrated Materials Performance Evaluation

Program and Rescission of a Final General Statement of Policy," published in the Federal

Register on October 16, 1997, and the November 5, 1999, NRC Management Directive 5.6,

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

review, which covered the period March 4, 2000 to October 31, 2003 were discussed with

Louisiana management on October 31, 2003.

A draft of this report was issued to Louisiana for factual comment on December 1, 2003. The

State responded by letter dated December 12, 2003. The Management Review Board (MRB)

met on January 12, 2004 to consider the proposed final report. The MRB found the Louisiana

radiation control program adequate to protect public health and safety and compatible with

NRC’s program.

The Louisiana Agreement State program is located in the Department of Environmental Quality

(the Department). The Department is divided into four Offices which are organized by function

rather than by program specialty and report to the Secretary of the Department. The Office of

Environmental Services contains the Permits Division; the Office of Environmental Compliance

contains the Surveillance and Enforcement Divisions; the Office of Management and Finance

has the Laboratory Services Division; and the Office of Environmental Assessment includes the

Environmental Planning Division. All Department inspection and compliance activities, including

emergency response, are performed by the Surveillance Division. This Division inspects

radioactive materials, hazardous materials, radiation-producing machines, air quality, water

quality, asbestos, underground storage tanks, tire disposal, etc. The Permits Division is

responsible for all licensing/permitting in the same manner. The radioisotope laboratory is part

of the Laboratory Services Division. Enforcement is performed by the Enforcement Division. 

Regulations are developed and maintained by the Environmental Planning Division.

In response to a request made during the previous IMPEP review, a Senior Advisor was

designated as the single point of contact for the Department for all radioactive materials

matters. For this review, the Senior Advisor coordinated Department efforts to complete the

questionnaire, arranged for inspector accompaniments, and arranged for meetings and

interviews. 

Organization charts for the Department, the Office of Environmental Compliance, and the

Permits Division are included as Appendix B. Additional organization charts were unavailable at

the time of the review. The Louisiana program regulates approximately 540 specific licenses

authorizing agreement materials. The review focused on the 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 Louisiana.

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

performance indicators was sent to the State on July 29, 2003. The Department provided a

response to the questionnaire on October 13, 2003. A copy of the questionnaire response can
Louisiana Final Report Page 2

be found on NRC’s Agencywide Document Access and Management System using the

Accession Number ML033350411. 

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

Louisiana's responses to the questionnaire; (2) review of applicable Louisiana statutes and

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

inspection data base; (4) technical evaluation of selected licensing and inspection actions; 

(5) field accompaniments of three Louisiana inspectors; and (6) interviews with staff and

management to answer questions or clarify issues. The team evaluated the information that it

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

performance 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 IMPEP review and the team’s conclusions regarding close-out of the

recommendations. 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 Department. A response is requested from the

Department to all recommendations in the final report. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on March 3, 2000, four recommendations

were made and the results transmitted to J. Dale Givens, Secretary, Department of

Environmental Quality, on June 8, 2000. The review team’s evaluation of the current status of

the recommendations is as follows:

1. The review team recommends that the Department modify the inspection frequency for

High Dose-rate Afterloaders (HDRs) to one year. (Section 3.1)

Current Status: The State has changed the inspection frequency for HDRs to a one year

frequency. The review team noted that HDRs are being inspected at the proper

frequency. This recommendation is closed.

2. The review team recommends that the Department implement measures to ensure that

staff receive appropriate and adequate training in health physics and operational topics. 

(Section 3.3)

Current Status: The canceling of training for Louisiana staff that occurred about the

same time as the last IMPEP review was a one-time action. As discussed in Sections

3.1 and 4.2.1, staff is receiving necessary training for assigned tasks. This

recommendation is closed. 

3. The review team recommends that the Department review all licenses to ascertain if

financial assurance for decommissioning is required, and appropriately request

licensees to provide a financial assurance mechanism. (Section 3.4)
Louisiana Final Report Page 3

Current Status: The Department reviewed all licenses and identified two licensees

requiring financial assurance mechanisms. The Department has reviewed and approved

the financial assurance mechanisms for both licensees. This recommendation is closed.

4. The review team recommends that the Department either use the existing site

characterization to terminate the cesium-137 contamination possession license;

recharacterize the site using current decommissioning criteria; or require the licensee to

begin decommissioning activities in accordance with the Decommissioning Timeliness

Rule. (Section 3.4)

Current Status: The Department recharacterized the site and found that it did not meet

the criteria for license termination. The Department contacted the Environmental

Protection Agency (EPA) for assistance in decontaminating the site. EPA accepted this

site to their Super Fund program. The EPA has completed remediation of the site and

the Department is awaiting the final closure documents from the EPA prior to terminating

the license. 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; (4)

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

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 responses relative to

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

training records, and considered any possible workload backlogs.

The Department devotes a total of 13.7 full time equivalent (FTE) to the radioactive materials

program, including administration. A total of 7.3 FTE is allotted to the Surveillance Division’s

radioactive materials compliance and emergency response programs. Inspection staff

members are based out of six regional offices, including the Baton Rouge compliance field

office. Inspection staff also perform other duties including x-ray and non-radiological

inspections for which the Department is responsible. The radioactive materials licensing staff

has been allotted 4.4 FTE. Radioactive materials licensing is performed by the Permits Division

in the Baton Rouge main office. The remaining FTE is allotted for administration or distributed

among the other Divisions.

Three staff members left the Department during the review period and four staff members were

hired during the same period. The Department currently has no vacant positions, although one

inspector was called up for active military duty in May 2003, and his position is being held for his

return. Staff members from other Regions are handling inspections in his Region while he is

away. The review team concluded that staffing is adequate for the radioactive materials

program. The review team noted that the Department had stable funding during the review

period due to dedicated revenue from licensee fees. 
Louisiana Final Report Page 4

The qualifications of the staff were determined from the questionnaire, training records, and

interviews of personnel. The staff are well qualified from an education and experience

standpoint. All staff have at least a Bachelor’s degree in the sciences, or equivalent training

and experience. All experienced technical staff members have taken the NRC courses deemed

appropriate for their tasks. New staff plan to attend appropriate core courses when available.

In general, inspection and licensing staff become qualified to complete x-ray tasks and are then

trained to perform radioactive materials tasks, starting with the most simple and working

towards the more complex. During the review period, the Department took the initiative to take

all staff with experience and training in x-ray tasks and gradually train them to complete

radioactive materials tasks. The Permits Division has a training and qualification program that

sets forth expected training and experience necessary to complete various types of license

actions. However, the Surveillance Division does not have such a program. Prior to the July

1999 reorganization, a training and qualification program was used by inspection staff. After the

reorganization, a new training and qualification program was drafted, but was never finalized. 

Although the review team did not find any issues with inspection staff training and qualifications,

the review team believes that a documented training and qualification program is needed,

especially in light of the Department’s policy of gradually training existing staff to perform

radioactive materials inspections. The review team recommends that the Surveillance Division

finalize their training and qualification program for radioactive materials inspectors, including the

qualifications required to complete independent inspections of various license types.

Louisiana does not have a radiation oversight board. No evidence of any conflict of interest

issues were identified.

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

that Louisiana's performance with respect to the indicator, Technical Staffing and Training, was

satisfactory.

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 licensees, the timely dispatch of inspection findings to

licensees, and the performance of reciprocity inspections. The evaluation is based on the

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

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

completed licensing and inspection casework, and interviews with managers and staff.

In September 2002, the Department adopted the inspection frequencies for various types of

material licenses listed in NRC Inspection Manual Chapter (IMC) Temporary Instruction

2800/033, “Revised Materials Inspection Program.” The staff uses TEMPO, a database

management system, for their tracking system. The data is maintained on a network and is

available to all staff. The Department staff acknowledged that they were still in transition for

implementing the inspection intervals in NRC’s Temporary Instruction. The review team verified

that inspection intervals for various types of material licenses are generally at least as frequent

as, or more frequent than, similar license types listed in NRC IMC 2800. Specifically, the

Department inspects nuclear medicine and well logging licensees more frequently than NRC. 
Louisiana Final Report Page 5

In their response to the questionnaire, the Department indicated that no routine inspections

were overdue by more than 25 percent of the NRC frequency. The Department also indicated

that four initial inspections were conducted overdue during the review period and that two initial

inspections had not been conducted and were currently overdue. The team reviewed lists of

information for all inspections conducted and all new licenses issued during the period. 

The review team found it difficult to review the Department’s reports from TEMPO. 

Interpretation of the data required coordination and comparison of several reports from more

than one database. The review team discussed the results with several staff members in order

to verify the findings. Of the 84 routine inspections sampled, the review team determined that

four routine inspections were conducted overdue during the review period, from one to 21

months overdue.

With respect to initial inspections of new licensees, the review team compared a list of new

licenses issued during the period with a list of all inspections conducted during the period. The

review team confirmed the results through review of records in TEMPO and by coordination with

Department staff. Of the 69 new licenses sampled, the review team determined that five new

licensees had not been inspected and were overdue at the time of the review, from one to 21

months overdue. In addition, the review team identified 19 new licensees that were inspected

overdue in the review period, from five days to 26 months overdue. This represents 35 percent

of the new licenses sampled that had not been inspected within the 12 month interval after

license issuance. The review team recommends that the Department develop and implement a

process for ensuring that all new licensees receive a timely initial inspection.

Through discussions with Department staff, the review team believes that there are two root

causes that contributed to the deficiency involving the conduct of initial inspections. First, the

TEMPO database is cumbersome to use and is not an effective management tool for

Department staff. Department staff appear to have difficulties finding information in the

database. For example, each activity is linked to an agency interest (AI) number that is site

specific. A single licensee may have multiple AI numbers associated with physical relocations. 

This makes it difficult to determine when a licensee is due for inspection. The Department’s

performance matrix goal for inspections is to inspect 50 percent of the Department’s licensees

each year. The goal does not specify any categories of licensees to be inspected, and it does

not appear that the Department has a mechanism to monitor inspections based on the license

category or use. Department staff have developed their own management tools that appear to

be effective for monitoring routine inspections, but ineffective for monitoring initial inspections of

new licensees. The second root cause identified by the review team is a communications

breakdown. The Permits Division issues licensing actions and the Surveillance Division

conducts the inspection, but a communication breakdown exists somewhere in the new

license/initial inspection process. The review team and the Senior Advisor discussed the

benefits of having a periodic counterpart meeting with all Department staff that conduct

radioactive materials tasks.

Overall, approximately 18 percent of routine core and initial inspections were conducted

overdue during the review period or were overdue at the time of the review. During the onsite

review, the review team’s data analysis identified problems with the Permits Division’s tracking

of inspections, including licensees in need of an inspection that Department staff were not

aware were overdue for an inspection. The review team recommends that the Department

review their existing databases, identify all routine and initial inspections that need to be

conducted, and complete those inspections. 
Louisiana Final Report Page 6

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

casework review. Of the 19 inspections reviewed, all inspection findings were transmitted to the

licensee at the end of the inspection. 

During the review period, the Department processed approximately 400 reciprocity requests per

year. The review team determined that the Department met and exceeded NRC’s current

criteria of inspecting 20 percent of candidate core licensees operating under reciprocity for the

entire review period.

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

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

Program, was satisfactory with recommendations for improvement.

3.3 Technical Quality of Inspections

The review team evaluated field interview forms, inspection reports, and enforcement referrals

for 19 radioactive materials inspections conducted during the review period. The review team

also interviewed radiation compliance inspectors to clarify casework information. The casework

reviewed included inspections conducted by eight current and one former Department radiation

compliance inspectors, and covered inspections of various types including manufacturing and

distribution, medical, mobile nuclear medicine, well logging and subsurface tracers, industrial

radiography, and nuclear pharmacy. Appendix C lists the inspection casework files reviewed for

completeness and adequacy with case-specific comments. 

The inspection procedures utilized by the Department are outlined in “Standard Operating

Procedures for Compliance Inspections Conducted by Office of Environmental

Compliance/Surveillance Personnel” and are generally consistent with the inspection guidance

outlined in IMC 2800. A Field Interview Form is completed by the inspector at the conclusion of

each inspection. This form documents the inspection findings and is signed by the licensee.

The inspector writes a narrative inspection report for the Department’s internal files. Inspection

reports are reviewed by supervisors, generally within one to three weeks. However, because of

the Department’s overall organization, the supervisors are not knowledgeable in health physics

or radiation safety. Therefore, additional technical reviews are conducted on most inspection

reports by senior staff members with a background in health physics and/or radiation safety. If

violations are noted, a copy of the Field Interview Form and the inspection report are routed

through the Enforcement Division for potential escalated enforcement.

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

the licensees’ radiation programs, with the exception of Sealed Source and Device (SS&D)

issues. Although the Department does not utilize specific inspection procedures for each

license type, the review team found that inspection reports were generally thorough, complete,

consistent, and of good quality, with sufficient documentation to ensure that licensee’s

performance with respect to health and safety was acceptable. The documentation supported

violations, recommendations made to the licensee, unresolved safety issues, and discussions

held with the licensee during exit interviews. 

The review team determined that the radiation compliance inspectors did not evaluate any

SS&D information during inspections. There was no determination that products were

manufactured in accordance with the SS&D registry sheets, that changes were made in

materials or processes described in the SS&D registry sheets, that any product lines were
Louisiana Final Report Page 7

discontinued, and that quality controls were in place for sources and/or devices. The

communications breakdown between the Permits Division and the Surveillance Division that

may be a root cause of this deficiency was also discussed in Section 3.2 . The review team

recommends that the Department inspect implementation of SS&D authorizations during routine

inspections. 

After the on-site review, the Department added SS&D registrations as a condition to all their

distribution licenses to provide a mechanism to enforce commitments referenced in SS&D

registrations.

During the review period, supervisory accompaniments were not accomplished for all of the 

radiation compliance inspectors on an annual basis. Four out of nine inspectors were not

accompanied by their supervisors in calendar year (CY) 2001 and five out of nine inspectors

were not accompanied by their supervisors in CY 2002. In CY 2003, eight out of nine

inspectors were accompanied by their supervisors on at least one inspection. The one

inspector who was not accompanied in CY 2003 was activated for military duty and not

available for a large part of CY 2003. Although the required accompaniments were

accomplished in CY 2003, the Department does not appear to have an individual responsible for

oversight of all the radiation compliance inspectors and a process for accomplishing the 

required supervisory accompaniments of these inspectors.

The team noted that other than the annual inspector accompaniments, the inspectors are

isolated, particularly in the Lake Charles office. Through discussions with staff members, the

review team noted that inspectors have limited opportunities to discuss their findings or other

issues they may encounter during inspection activities. The review team believes that because

of the lack of centralized oversight of the radiation compliance program and the lack of direct

supervision by individuals knowledgeable in radiation safety, annual accompaniments by

qualified individuals are important to ensure the continued consistency and quality of

inspections and inspection reports. The review team recommends that the Department develop

and implement a process for conducting annual accompaniments of all radiation compliance

inspectors by qualified individuals. 

A member of the review team accompanied three Department inspectors during the weeks of

August 25 and September 9, 2003. The accompaniments included inspections at medical

institutions licensed for diagnostic nuclear medicine and radiopharmaceutical therapy, and

industrial radiographers. The accompaniments are identified in Appendix C. 

During accompaniments, the inspectors demonstrated appropriate inspection techniques and

knowledge of the regulations. The inspectors were prepared for their review of the licensees’

radiation safety program. The inspections were adequate to assess radiological health and

safety at the licensed facilities. It was noted however, that the inspections were more record

review driven, rather than performance based. The inspectors relied heavily on inspection

checklists in the performance of the inspection. Although no health and safety issues were

identified, the benefits of including a performance and risk-based inspection approach rather

than the predominantly record review inspection method was discussed with Department staff

and management. 

It was noted that the Department has an adequate supply of survey instruments to support the

current inspection program. Appropriate, calibrated survey instrumentation such as Geiger

Mueller (GM) meters, scintillation detectors, ion chambers, and micro-R meters were observed
Louisiana Final Report Page 8

to be available. The instruments are calibrated at least annually by a commercial calibration

service. The Division of Laboratory Services radiological laboratory provides support to the

program through radiological analyses of samples taken by inspectors during inspections.

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

that Louisiana’s performance with respect to the indicator, Technical Quality of Inspections, was

satisfactory.

3.4 Technical Quality of Licensing Actions

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

licensing casework for 16 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 the license conditions, and overall

technical quality. The casework files were also reviewed 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,

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

which were completed during the review period. The cross-section sampling focused on the

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

sampling included the following type of licenses: well logging, x-ray fluorescence, service

providers, industrial radiography, portable level gauges, fixed gauges, decay-in-storage,

analytical laboratory, source manufacturers/distributor, radiopharmacy, mobile nuclear

medicine, medical-outpatient-diagnostic only, and medical institution. Licensing actions

reviewed included six new licenses, three renewals, 19 amendments, and three termination

files. A listing of the casework licenses evaluated with case specific comments can be found in

Appendix D.

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

and of high quality with health and safety issues properly addressed. License tie-down

conditions were stated clearly, backed by information contained in the file, and inspectable. The

licensee’s compliance history was taken into account when reviewing renewal applications and

amendments. The exemptions noted in the questionnaire responses were determined to be

appropriate and well documented by license conditions, however the exemptions for the

industrial radiography pipeliners expired on October 31, 2003. A review of termination actions

found that terminated licensing actions were well documented, showing appropriate transfer

records or appropriate disposal methods and records, confirmatory surveys, and survey

records. 

The administrative staff receives and routes all licensing actions to the appropriate permit writer

based on license type. The permit writer enters the information into the Department’s database,

TEMPO. The status of all actions is also tracked in a license database maintained by the

Permits Division. All correspondence is reviewed and signed by the Permit Supervisor. When

the permit writer completes a licensing action, a second technical review is performed by the

Permits Supervisor. The Permits Manager conducts an administrative review before forwarding

the action to the Assistant Secretary of the Department for signature. While the Permits
Louisiana Final Report Page 9

Division does not use templates to generate correspondence and licenses, each permit writer

maintains a standard format for each license type. 

Licenses are initially issued with a five-year term. After the five-year term, licensees are allowed

to submit a letter stating the program is unchanged, or discuss minor changes. This is

considered a simple renewal and is issued with a four-year term. Licensees are required to

submit a complete renewal application every 10 years to maintain current information in the file. 

The Permits Division utilizes licensing guides based on NRC licensing guides (NUREG-1556

series), as appropriate.

The Department has been certifying industrial radiographers in accordance with the State’s

regulations. The Department administers the radiographer certification examination developed

by the Texas Department of Health and offers testing every other month for 50 - 125

candidates. 

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

that Louisiana’s performance with respect to the indicator, Technical Quality of Licensing

Actions, was satisfactory.

3.5 Response to Incidents and Allegations

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

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

evaluated selected incidents reported for Louisiana in the "Nuclear Material Events Database”

(NMED) against those contained in the Louisiana files, and evaluated the casework and

supporting documentation for 12 materials incidents. A list of the incident casework examined,

with case-specific comments, is included in Appendix E. The team also reviewed the

Department’s response to three allegations involving radioactive materials referred to the

Department, by NRC, during the review period. By their definition, the Department received no

other allegations during the review period in addition to the three referred by the NRC.

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

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

notification of incidents to the NRC Operations Center, with the program managers and selected

staff.

Incidents and allegations are investigated by staff from the Surveillance Division. It is the policy

of the Department to investigate every allegation, complaint, and reported incident related to

ionizing radiation activities. Department staff do not differentiate between incidents and

allegations investigations. All event reports are forwarded to the Inspection Coordinator in the

Surveillance Division. The Coordinator reviews all available data and assigns the case to an

inspector who has received sufficient training to review the specific type of event. All

investigation reports and documentation are archived in the appropriate license or

correspondence file, and archived in the Department’s electronic document management

system.

The review team found that the Department’s responses to incidents and allegations were

complete and comprehensive. Initial responses were prompt and well-coordinated. The level of

effort was commensurate with the health and safety significance of the event. Inspectors were

dispatched for on-site investigations when appropriate and the Department took suitable
Louisiana Final Report Page 10

enforcement action when indicated. The review team found the documentation of the incidents

and allegations to be consistent. 

During the review period, each incident meeting the criteria for reporting to the NMED system

was reported to NRC and the NMED contractor for entry into NMED, as required. INEEL

communicates directly with the Department’s staff, via e-mail, to request additional information

and/or clarification of existing data. The Department has an NMED coordinator who manages

the Department’s submissions to NMED.

The Department received three allegations during the review period. The team’s evaluation

indicated that the Department took prompt and appropriate action in response to the concerns

raised. All communication with the Department is considered public record under Louisiana’s

Open Records Law. Any alleger requesting anonymity is informed that every effort will be made

to protect his/her identity, but cannot be guaranteed. All investigations involving potential

criminal activity are immediately brought to the attention of the Department’s senior

management staff for a determination if the case should be forwarded to the Enforcement

Division for action.

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

that Louisiana's performance with respect to the indicator, Response to Incidents and

Allegations, was satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

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

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

and (4) Uranium Recovery Program. Louisiana's Agreement does not cover a uranium recovery

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

review.

4.1 Legislation and Program Elements Required for Compatibility

4.1.1 Legislation

Louisiana became an Agreement State in 1967. Along with their response to the questionnaire,

the State provided the review team with the opportunity to review copies of legislation that

affects the radiation control program. Legislative authority to create an agency and enter into

an agreement with the NRC is granted in the Louisiana Nuclear Energy and Radiation Control

Law, Chapter 6, R.S. 30:2101-2134. The Department is designated as the State's radiation

control agency. The review team noted that no legislation affecting the radiation control

program was passed since being found adequate during the previous review, and found that the

State legislation remains adequate.

4.1.2 Program Elements Required for Compatibility

The Regulations for Control of Radiation, found in Part XV, Radiation Protection, 2002 Edition of

the Louisiana Environmental Regulatory Code, apply to all ionizing radiation, whether emitted

from radionuclides or devices. Louisiana requires a license for possession, and use, of all
Louisiana Final Report Page 11

radioactive material including naturally occurring materials, such as radium, and

accelerator-produced radionuclides. 

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

found that the process takes approximately six months after preparation of a draft rule. 

Proposed rules are submitted to the Legislative Fiscal Office for consideration and approval to

proceed with public comment. Public notice of proposed rule revisions is made and a 30-45 day

public comment period, including a public hearing is conducted. Proposed rules are sent to

NRC for a compatibility ruling. After resolution of comments and the State Legislative Oversight

Committee’s approval, final draft rules are sent to the Louisiana Register for adoption. Final

rules are then sent to licensees and the NRC. The Department also has the authority to issue

legally binding requirements (e.g., license conditions) in lieu of regulations until compatible

regulations become effective.

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 Commission’s adequacy and

compatibility policy, and verified the adoption of regulations with data obtained from the NRC

Office of State and Tribal Programs Regulation Assessment Tracking System. All regulations

required to be adopted are currently in effect. However, the State did not submit one rule

amendment during the review period, “Transfer for Disposal and Manifests; Minor Technical

Conforming Amendment,” (63 FR 50127) that became effective November 20, 1998. The State

did adopt equivalent rules in November 1998 that meet the requirements of this amendment. 

The team’s preliminary review of this amendment found the amendment compatible. The State

was advised to send this amendment to the NRC for official documentation and review. The

State agreed to this plan of action.

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

future, and the State related that the regulations would be addressed in upcoming rulemaking or

by adopting alternate legally binding requirements:

! "Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

Material”, 10 CFR 30, 31 and 32, amendment 65 FR 79162, that became effective on

February 16, 2001.

! “Revision of the Skin Dose” 10 CFR 20, amendment 67 FR 16298, that became effective

on April 5, 2002.

! “Medical Use of Byproduct Material, 10 CFR 20, 32,and 35, amendment 67 FR 20249,

that became effective on April 24, 2003.

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

that Louisiana’s performance with respect to the indicator, Legislation and Program Elements

Required for Compatibility, was satisfactory.

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

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

information provided in response to the IMPEP questionnaire. The team evaluated all of the

new and four of the seven amended SS&D registry sheets issued during the review period, and
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the supporting document files. The team also evaluated the use of guidance documents and

procedures, and interviewed the staff currently conducting SS&D evaluations.

4.2.1 Technical Quality of the Product Evaluation Program

The review team evaluated five of the eight SS&D evaluations the Department completed during

the review period. The cases were representative of the Department’s licensees and SS&D

evaluation personnel. The cases were completed between March 2000 and October 2003 and

specific comments are found in Appendix F.

The SS&D evaluators reported that they used the guidance in NUREG-1556, Volume 3. The

team’s review of the casework, and interviews with the staff, confirmed that the State followed

the NRC SS&D guidance. The Department does not maintain official hard copy of files. All

documents are scanned and placed in the Department-wide image retrieval program, TEMPO. 

This includes all letters, notes, blueprints, registrations, photographs, engineering drawings, etc. 

The review of this indicator was difficult due to the fact that they transitioned to this system

starting at the beginning of the review period. This system has evolved over the last four years

and the way documents have been stored has been inconsistent. These inconsistencies cause

difficulty in locating all electronic records. Some electronic records were identified by the

TEMPO database but were not retrievable. SS&D reviewers retained hard copies of selected

documents, and these registration files contained the correspondence, photographs,

engineering drawings, radiation profiles, and results of tests conducted by the applicants. 

Appropriate standards, Regulatory Guides, and NRC SS&D training workshop references were

available and used when performing SS&D reviews.

The depth and scope of the SS&D evaluations during the review period were good. The

evaluation documentation found in staff members’ files was also good. The team noted that the

SS&D licensees generally submitted applications that were complete and of high quality. The

SS&D evaluators needed to request little additional information. Current SS&D evaluators

indicated that the licensees promptly supplied the information that they requested. The review

team did not identify any missed safety issues in the reviewed evaluations. However, minor

technical errors were noted, as detailed in Appendix F.

The State handles proprietary information by placing it in separate files. During the last IMPEP

review, some of this information was misplaced. During this review, the staff could produce all

files. 

During the onsite review, the team noted that SS&D registrations were not listed on the

distributor’s license. The Department does not have regulations specific to SS&D and the

documents listed in reference section of the SS&D registry sheets were not included in the

license. The Permits Supervisor and the senior SS&D reviewer indicated that the SS&D registry

sheets were not included as part of the license. After the onsite review, the Department added

the SS&D registrations as a condition to all of their distribution licenses. The registry sheets

were provided to the review team. The team noted that this new license condition provides a

mechanism to enforce commitments referenced in SS&D registrations.

4.2.2 Technical Staffing and Training

Since the last review, one qualified SS&D evaluator left the program. While this individual is no

longer in the Permits Section, she is still part of the Department and is available for assistance if
Louisiana Final Report Page 13

needed by current evaluators. The Department has four other qualified evaluators who perform

SS&D evaluations as secondary duties due to the limited number of SS&D evaluation requests. 

At the time of the review, the Department had no one permanently assigned to SS&D

evaluations as a primary duty.

The review team evaluated the qualifications of the three new individuals authorized and

currently performing SS&D evaluations. One has a Physics degree; the other has a degree in

Radiation Physics with extensive experience with HDR devices and their use; and the third has

a Biology degree. All have substantial regulatory experience and all have attended the NRC

SS&D training. 

4.2.3 Evaluation of Defects and Incidents Regarding SS&D

There were no new defects or incidents involving SS&D of Louisiana registry. There was one

allegation of a source incompatibility with another manufacturer’s device. The Department

provided a timely and adequate response in the investigation and resolution of the allegation.

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

that Louisiana's performance with respect to the indicator, Sealed Source and Device

Evaluation Program, was satisfactory.

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 Louisiana has such disposal

authority, NRC has not required States to have a program for licensing a 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 Louisiana. Accordingly, the review team did not evaluate this

indicator.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team and the MRB found Louisiana’s

performance to be satisfactory for six performance indicators, and satisfactory with

recommendations for improvement for the performance indicator, Status of Materials Inspection

Program. Accordingly, the review team recommended and the MRB concurred in finding the

Louisiana Agreement State program to be adequate to protect public health and safety and

compatible with NRC's program. Based on the results of the current IMPEP review, it was

agreed that the next full review should be in approximately four years. However, due to the

communications and oversight issues highlighted in recommendations made in Sections 3.2

and 3.3, the review team recommended and the MRB agreed that a periodic meeting take place

with the State approximately one year from the IMPEP review.
Louisiana Final Report Page 14

Below is a summary list of recommendations, as mentioned in earlier sections of the report, for

evaluation and implementation, as appropriate, by the State.

RECOMMENDATIONS

1. The review team recommends that the Surveillance Division finalize their training and

qualification program for radioactive materials inspectors, including the qualifications

required to complete independent inspections of various license types. (Section 3.1)

2. The review team recommends that the Department review their existing databases,

identify all routine and initial inspections that need to be conducted and complete those

inspections. (Section 3.2)

3. The review team recommends that the Department develop and implement a process for

ensuring that all new licensees receive a timely initial inspection. (Section 3.2)

4. The review team recommends that the Department inspect implementation of SS&D

authorizations during routine inspections. (Section 3.3)

5. The review team recommends that the Department develop and implement a process for

conducting annual accompaniments of all radiation compliance inspectors by qualified

individuals. (Section 3.3)
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Lance Rakovan, STP Team Leader

Technical Staffing and Training

Vivian Campbell, Region IV Status of Materials Inspection Program

Technical Quality of Licensing Actions

Linda McLean, Region IV Inspector Accompaniments

Christi Maier, Region IV Technical Quality of Inspections

John Zabko, STP Response to Incidents and Allegations

Legislation and Program Elements Required

 for Compatibility

Michael Stephens, Florida Sealed Source and Device Evaluation Program
APPENDIX B

LOUISIANA ORGANIZATION CHARTS

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LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Louisiana Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Appendix F Sealed Source and Device Casework Reviews

Attachment December 12, 2003, Letter from L. Hall Bohlinger, Secretary, 

Department of Environmental Quality
ATTACHMENT

December 12, 2003 Letter from L. Hall Bohlinger

Louisiana’s Response to Draft IMPEP Report

ML033630731