June 9, 2004

Ms. Karen Stachowski

Deputy Commissioner of Environment

Tennessee Department of Environment and Conservation

401 Church Street, 21st Floor, L&C Tower

Nashville, TN 37243-0435

Dear Ms. Stachowski:

On May 13, 2004, the Management Review Board (MRB) met to consider the proposed final

Integrated Materials Performance Evaluation Program (IMPEP) report on the Tennessee

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

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

MRB also directed that the increased monitoring of the Tennessee program be terminated.

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

for the State of Tennessee. We request your evaluation and response to recommendations

within 30 days from receipt of this letter.

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

four years. 

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/

Martin J. Virgilio

Deputy Executive Director 

 for Materials, Research and State Programs

Office of the Executive Director for Operations

Enclosure: 

As stated

cc: Lawrence E. Nanney, Director

Division of Radiological Health

Robert Greger, CA

OAS Liaison to the MRB
bcc: Chairman Diaz

Commissioner McGaffigan

Commissioner Merrifield

Distribution: DCD (SP01) PDR (YES)

DIR RF

KSchneider, STP GPangburn, RI

AMcCraw, STP FCostello, RI

CMaupin, STP UBhachu, NMSS

JStrosnider, NMSS RGattone, RIII

RStruckmeyer, NMSS SSeeley, Maine

TCombs, OCA (2 copies) LRakovan, STP

JGray, OGC

FCameron, OGC 

STreby, OGC 

KCyr, OGC

VCampbell, RIV

CMiller, NMSS

MBailey, NMSS

ISchoenfeld, EDO

Tennessee File

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OFFICE STP STP:DD STP:D DEDMRS

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JMPiccone PHLohaus MVirgilio

DATE 6/ 3 /04 6/ 4 /04 6/ 4 /04 6/ 9 /04

OFFICIAL RECORD COPY

ML041560270
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF TENNESSEE AGREEMENT STATE PROGRAM

February 23-26, 2004

 FINAL REPORT

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

1.0 INTRODUCTION

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

review was conducted during the period of February 23-26, 2004, by a review team comprised

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

Agreement State of Maine. 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 August 26, 2000 to February 26, 2004 for the indicators

Staffing and Training, Technical Quality of Licensing, and Sealed Source and Device Evaluation

Program and the period October 26, 2001 to February 26, 2004 for the other performance

indicators were discussed with Tennessee management on February 26, 2004.

A draft of this report was issued to Tennessee for factual comment on March 25, 2004. The

State responded by letter dated April 12, 2004. The Management Review Board (MRB) met on

May 13, 2004 to consider the proposed final report. The MRB found the Tennessee radiation

control program adequate to protect public health and safety and compatible with NRC’s

program.

The Tennessee Agreement State program is located in the Department of Environment and

Conservation (the Department). The Department is divided into three program areas, State

Parks and Conservation, Finance and Business Services, and Environment. The Division of

Radiological Health (the Division) is located under the Deputy Commissioner for Environment

who in turns reports to the Department Commissioner. The Division consists of the Office of

the Director and four sections: Administrative Services, Licensing/Registration/Policy,

Technical Services, and Inspections and Enforcement (I&E). Each section in the Division is

headed by a Manager who reports to the Division’s Deputy Director and Director.

Organization charts for the Department and the Division are included as Appendix B. The

Tennessee program regulates approximately 550 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

Tennessee.

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

performance indicators was sent to the State on November 25, 2003. The Division provided a

response to the questionnaire on February 13, 2004. A copy of the questionnaire response can

be found on NRC’s Agency-wide Document Access and Management System using the

Accession Number ML040620709. 

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

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

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

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

(5) field accompaniments of six Tennessee 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-
Tennessee Final Report Page 2

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 noncommon 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 Division. A response is requested from the Division to 

all recommendations in the final report. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on August 25, 2000, ten recommendations

were made and transmitted to John M. Leonard, Assistant Commissioner for Environment, on

November 17, 2000. Additionally, during a follow-up IMPEP review which concluded on

October 26, 2001, one additional recommendation was made and eight recommendations

were closed (Numbers 2, 4 through 10 from the 2000 report). The final follow-up report was

transmitted to Mr. Leonard on February 5, 2002. The team’s review of the current status of all

open recommendations follows:

Open recommendations from the 2000 IMPEP Review report:

Recommendation 1

The review team recommends that the Division take actions to ensure that: (1)

inspections are conducted in accordance with their assigned inspection frequencies; and

(2) inspection reports are issued in a timely manner. (Section 3.1 of the 2000 report and

Section 2.1 of the 2001 report)

Current Status: The Division has taken actions to ensure that inspections are

conducted in accordance with their assigned inspection frequencies. At the time of the

review, there were no overdue inspections. With the exception of five reports issued by

one inspector, all inspection reports are issued in a timely manner. Division 

management has committed to correct this weakness. See Section 3.2 for further

discussion. This recommendation is closed.

Recommendation 3 (revised in 2001)

The review team recommends that the Division ensure that inspection findings are fully

supported in documentation of the inspection and that cited violations are fully

supported in the inspection report. The review team also recommends that in order to

enhance both the quality and documentation of inspections, the Division establish and

implement additional guidance for ensuring consistent, appropriate, and prompt

regulatory actions including incorporating root cause identification, especially of repeat

violations. (Section 3.2 of the 2000 report and Section 2.2 of the 2001 report)
Tennessee Final Report Page 3

Current Status: The team reviewed the Division’s inspection findings and determined

that conclusions and violations were appropriately supported. The team observed

during inspector accompaniments and noted during the review of inspection

documentation that consistent, appropriate, and prompt regulatory actions were taken. 

The team also noted that inspections conducted by the Division incorporated root cause

identification and addressed repeated violations. This recommendation is closed.

Open Recommendation from the 2001 follow-up IMPEP Review report

Follow-up Recommendation 1

The review team recommends that the Division establish a management plan for the

development, tracking, and adoption of regulations in a timely manner, and to adopt the

current regulations needed for adequacy and compatibility in accordance with the Office

of State and Tribal Programs (STP) Procedure SA-201, “Review of State Regulations or

Other Generic Legally Binding Requirements.” (Section 3.1.2 of 2001 the report)

Current Status: The staff responsible for regulation development prepares a report for

the Deputy Director on developing, tracking, and adopting regulations. The last two

regulation review packages submitted by the Division to NRC for review have followed

the guidance provided in STP Procedure SA-201, “Review of State Regulations or Other

Generic Legally Binding Requirements.” As noted in Section 4.1.2, when the five

amendments reviewed by NRC in December 2003, and the three submitted for NRC’s

review on February 13, 2004 are adopted, Tennessee will have all necessary

regulations adopted for adequacy and compatibility. In addition, the Division will have

one regulation adopted before its due date. 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 Division’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 Division’s questionnaire responses relative to this

indicator, interviewed Division management and staff, reviewed job descriptions and training

records, and considered any possible workload backlogs.

The Division devotes a total of 19.5 full time equivalents (FTE) to the radioactive materials

program, including administration but excluding clerical support. A total of 12.2 FTE is allotted

to I&E and Technical Services Sections for radioactive materials compliance and emergency

response programs. Inspection staff members are based out of four regional field offices in

Nashville, Chattanooga, Memphis, and Knoxville. Inspection staff members also perform other

duties including x-ray and other inspections for which the Division is responsible. Radioactive

materials licensing and the sealed source and device evaluation programs have been allotted
Tennessee Final Report Page 4

5.6 FTE and are performed by the Licensing/Registration/Policy Section in the Nashville central

office. The remaining FTE is allotted for administration and policy/regulatory guidance

distributed between the Director’s office and the Technical Services Section.

Eleven staff members left the Division during the review period and seventeen staff members

were hired during the same period. Five of the individuals hired had previously worked for the

Division. This turnover is approximately one-half of the staff turnover during the previous

IMPEP review period (1996-2000). The Division currently has five vacant positions

representing 2.5 FTE. Two of these positions were recently vacated when staff members were

promoted into higher positions. The Division filled the vacant I&E Manager position by

promotion in October 2003. Division management indicated that low initial salary for new hires

make it very difficult to attract and retain qualified individuals. Important factors in the Division’s

ability to retain staff are economic conditions and the availability of other job opportunities. 

Based on the Division’s overall performance, the review team concluded that staffing is

adequate for the radioactive materials program.

Division management indicated that approximately 91.5 percent of the Division’s funding is

dedicated revenue from licensee fees with the balance from the State’s general funds. In 2001,

the Division increased fees to materials licensees by approximately 50 percent.

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

interviews of personnel. The Division has a documented training program which specifies

minimum training requirements as well as supervisory sign off on the completion of training. 

The staff is 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. 

Division management indicated that training of new staff may be delayed due to current

restrictions on out-of-state travel. In response to the out-of-state travel restrictions, the Division

conducted an alternative training course to meet the medical core course requirement for

inspectors and also sponsored the NRC’s “Inspecting for Performance” course at an instate

location. In the long term, both the review team and the Division believe that the lack of access

to out-of-state training may degrade the technical quality of the program. The use of on-the-job

training has also been used to supplement formal course work so that individuals may broaden

their work experience.

In general, inspection staff members 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. It is the goal of the I&E Manager to cross train most staff at all

Regional Offices to conduct x-ray and materials inspections of the most common groups of

licensees and registrants. 

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

issues was identified.

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

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

was satisfactory.

3.2 Status of Materials Inspection Program
Tennessee Final Report Page 5

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

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

the Division’s licensing and inspection data tracking system, the examination of completed

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

A review of the Division’s inspection priorities revealed that the inspection frequencies for

various types of licenses are at least as frequent as similar license types listed in the November

25, 2003 revision to NRC Inspection Manual Chapter (IMC) 2800. The Division has a goal to

inspect waste processing, complex industrial, and manufacturing licensees once every six

months, a greater frequency than listed in IMC 2800. The Division does not extend or

compress inspection frequencies based on compliance history.

The Division normally inspects new licensees in accordance with guidance in the previous IMC

2800; within six months of receipt of radioactive material, but no later than one year after

issuance of the license. Current NRC guidance in the revised IMC 2800 is to perform initial

inspections within one year of license issuance. The Division intends to use the six month

frequency as a goal, but plans to eventually adopt the new frequency.

In response to the questionnaire, the Division indicated that no core inspections were currently

overdue by more than 25 percent of the NRC frequency. The team reviewed lists of information

for all inspections conducted and all new licenses issued during the period and verified this

information. The Division conducted 214 core inspections and 52 initial inspections in

eliminating the inspection backlog identified since the 2001 follow-up review. Overall, only 10

routine core and initial inspections were conducted overdue since the 2001 follow-up review. 

Given the status of 28 percent overdue inspections conducted overdue or still overdue at the

time of the follow-up review, the Division’s efforts to address and correct this weakness are

commendable. 

The review team evaluated the timeliness of the communication of inspection results to the

licensees by reviewing inspection data and files for 30 inspections throughout the Division’s four

regional inspection offices. For three of the offices, the random sampling indicated that results

were communicated within 30 days after the date of the inspection, with one exception for a

complex team inspection with multiple violations issued 3 months late. In one regional office,

however, the reports of a single inspector were not issued within 30 days after the date of the

inspection. The review team evaluated eight out of nine inspections conducted by this

individual since the follow-up review. For five of these inspections, inspection results were

communicated to the licensee two months to two years after the inspection was conducted. For

the remaining three inspections evaluated by the review team, inspection findings had not been

issued at the time of the review, including one inspection that was conducted approximately 3

years ago. The review team examined the timeliness for the remaining inspectors and

identified no additional performance issues with the issuance of inspection findings for that

region. The review team also noted that this region was identified during the 2000 review and

2001 follow-up review as having difficulty meeting the 30-day goal for issuance of inspection

results. 

The review team discussed this weakness with the I&E Manager and the Deputy Director and

determined that this individual inspector had been assigned a significant number of inspections
Tennessee Final Report Page 6

to perform and had responded to several incidents. The individual accomplished the field work

in a timely manner at the expense of the timely completion of the inspection documentation. 

The I&E Manager has committed to reinspect those licensees where the findings have not been

issued and are significantly late. Tennessee management has committed to work with this

specific inspector to assist with identification and elimination of the backlog of inspection

documentation. With strong management commitment by the Division to address this area, the

improved performance of the Division for this indicator since 2000 and the large majority of the

inspection findings communicated to licensees in a timely fashion, the review team does not

believe that a recommendation is warranted at this time. 

The review team determined that the Division granted 21 core reciprocity licenses during the

review period. The Division satisfied the 20 percent criteria prescribed in NRC IMC 1220 by

conducting 10 inspections of core reciprocity licensees during the review period. In addition,

the Division inspected 28 percent of non-core reciprocity licensees during the review period. 

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

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

Program, was satisfactory. 

3.3 Technical Quality of Inspections

The review team evaluated inspection reports, enforcement documentation, and inspection field

notes and interviewed inspectors for a total of 23 radioactive materials inspections. The

casework examined included inspections conducted by 16 current inspectors. The review team

examined core inspections of various types including manufacturing and distribution, broad

medical, medical private practice, medical - written directive required, medical - written directive

not required, well logging and subsurface tracers, industrial radiography, service and

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

for completeness and adequacy with case-specific comments.

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

aspects of the licensee’s radiation programs. The Division has revised its inspection field note

forms and each Region is starting to utilize these during inspections. The review team found

that inspection reports were generally thorough, complete, consistent, and of good quality, with

sufficient documentation to ensure that the licensee’s performance with respect to health and

safety was acceptable. The inspection documentation supported violations, recommendations

made to the licensee, unresolved safety issues, and discussions held with the licensee during

exit interviews. The review team noted that some files did not contain an inspection report. 

This matter is discussed in detail in Section 3.2.

The inspection procedures utilized by the Division are described in “Division of Radiological

Health's Inspection and Enforcement Policy and Procedures” and are generally consistent with

the inspection guidance outlined in NRC’s IMC 2800. Inspection reports cover all appropriate

areas for each inspection type and addressed all relevant health and safety elements. The

reports contain the inspector’s narrative of what was observed and reviewed during the

inspection. Inspection reports are reviewed by the Field Office Manager, generally within one

week after the completion of the inspection. If no violations were observed, inspection results

are generally sent to the licensee within two weeks of the completion of the inspection. If any

violations were observed, a draft notice of noncompliance (NON) is prepared by the inspector. 
Tennessee Final Report Page 7

All inspection correspondence is issued from the respective field office where the inspection

was performed. For inspections conducted by Field Office Managers and any inspection

involving a facility that has financial assurance for decommissioning, the I&E Manager will

perform the second review on the inspection documentation and correspondence.

During the review period, supervisory accompaniments were conducted for all non-supervisory

inspectors on an annual basis. The team found, however, that not all supervisory inspectors

who routinely conduct inspections were accompanied. The I&E Manager has developed a plan

to ensure that all personnel, particularly the field office managers, are accompanied annually. 

The Division expects to accompany all supervisory inspectors by the end of 2004. In addition,

to improve the quality and efficiency of the inspection process and the overall communication

among the Regional Offices, the I&E Manager has been holding monthly teleconferences with

the Regional Field Office Managers to review inspection and enforcement issues.

The review team accompanied six Division inspectors from all four Regional offices during the

week of November 17, 2003 during inspections of a medical institution licensed for diagnostic

nuclear medicine, a nuclear pharmacy, and a sealed source manufacturer and distributor, as

well as industrial radiography facilities. The accompaniments are identified in Appendix C. 

During the accompaniments, each inspector demonstrated appropriate inspection techniques,

as well as knowledge of the regulations and the specific license requirements for each licensee

being inspected. The inspectors were well prepared and thorough in their review of the

licensee’s radiation safety programs. The inspections were adequate to assess radiological

health and safety at the licensed facilities.

The Division has an adequate supply of survey instruments to support the current inspection

program, as well as responding to incidents and emergency conditions. The Division has

commercial contractors who calibrate their survey instruments on an annual basis. Appropriate

calibrated survey instruments such as GM meters, scintillation detectors, ion chambers, and

micro-R meters were observed to be available. Media samples collected by Division staff are

analyzed by the radiochemistry laboratory in the Department of Public Health’s Division of

Laboratory Services located in Nashville. The laboratory is capable of a number of analyses

including gamma spectroscopy, liquid scintillation, and low background gross alpha and beta

counting.

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

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

was satisfactory.

3.4 Technical Quality of Licensing Actions

The review team examined the completed licenses and casework for 20 materials licensing

actions representing the work of five license reviewers. The licensing actions were reviewed for

completeness, consistency, proper radioisotopes and quantities, qualifications of authorized

users, adequate facilities and equipment, and operating and emergency procedures sufficient

to establish the basis for licensing actions. Licenses were reviewed for accuracy,

appropriateness of the license and its conditions and tie-down conditions, and overall technical

quality. Casework was evaluated for adherence to good health physics practices, reference to

appropriate regulations, supporting documents, peer or supervisory review and proper
Tennessee Final Report Page 8

signature authorities. The files were checked for retention of necessary documents and

supporting data.

The licensing actions reviewed included the following types of licensees: industrial radiography,

radioactive waste processing, broad scope research and development, medical institution -

written directive required, contaminated metals processing, medical private practice, nuclear

pharmacy, leak test service, and sealed source manufacturer. Licensing actions included two

new, three renewals (including associated decommissioning financial assurance), one

termination, and 14 amendments. A listing of the casework licenses evaluated with casespecific comments is enclosed in Appendix D.

All license reviewers have signature authority and sign their own licensing actions. The

licensing staff generated licenses and correspondence with standardized conditions and

formats. The Division issues licenses for a ten-year period under a timely renewal system. The

review team noted that the licensing staff used the computer database effectively and efficiently

to obtain needed information for completing licensing actions. Due to their prompt assignment,

review, and resolution of incoming licensing requests, the licensing staff has effectively

managed their casework.

The review team found that the licensing actions were thorough, complete, timely, 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 license or sealed source

and device registry files and are inspectable. Deficiency letters state regulatory positions, are

used at the proper time, and identify deficiencies in the licensee’s documents. Terminated

licensing actions are well documented, showing appropriate transfer and survey records. The

licensee’s compliance history was taken into account during the review process and the review

team found that there was good two-way communication between the licensing and inspection

staffs regarding pertinent licensee information. 

For each licensing action, licensing staff used the Division’s licensing guides and completed a

checklist specific to the type of license. Since the last review in 2000, the Division revised a

number of their licensing guides and updated license conditions and specific licensing operating

procedures. The team reviewed the Division’s recently revised Medical and Industrial

Radiography License Application Guides and found these documents were complete, well

organized, available to licensing staff and are used.

Based on the IMPEP evaluation criteria, the review team recommends that Tennessee’s

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

satisfactory.

3.5 Response to Incidents and Allegations

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

team examined the Division’s response to the questionnaire relative to this indicator, reviewed

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

those contained in the Division’s 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 Division’s
Tennessee Final Report Page 9

response to 12 allegations involving radioactive materials. Four allegations were referred to the

Division by the NRC during the review period.

The incidents selected for review included the following event categories: contamination event,

fire, damage to equipment, equipment failure, transportation, release of radioactive material,

leaking source, and stolen radioactive material. The review team found that the Division’s

responses to incidents were complete and comprehensive. Initial responses were prompt and

well-coordinated and the level of effort was commensurate with the health and safety

significance of the event. The Division dispatched inspectors for on-site investigations when

appropriate and took suitable enforcement and follow-up actions when indicated.

The responsibility for initial response and follow-up actions to materials incidents are assigned

to the appropriate Regional office. A majority of incident notifications are received at the

Regional offices, but all notifications are logged in and assigned a tracking number by the

Division Director’s office. For most incidents, the staff in the Regional offices decides on the

appropriate response. For significant events, the Regional office will consult with Division

management prior to taking action. The Regional office conducts the investigation of the

incident and prepares appropriate documentation. The completed documentation is forwarded

to the Deputy Director for final review and documentation including the entering of pertinent

information into NMED. 

The Division follows the NRC’s “Handbook on Nuclear Material Event Reporting in the

Agreement States” for the reporting requirements of incidents. Prior to the on-site review, the

review team identified 39 reportable and 80 other incidents in NMED for Tennessee during the

review period. Reports and follow-up information are generally submitted electronically monthly

using the NMED software by the Deputy Director. Documentation for individual events are

maintained in the incident files and include a tracking form, documentation on the Division’s

response to the incident, documentation if the event was entered into the local NMED

database, and any follow-up correspondence with the NMED contractor. When the Division’s

local NMED events were compared to those events in the national database, the team noted

that two reportable events were in the local database but not in the national database. The

Division believed that the files for these two events were transferred to the NRC contractor

along with other events that were incorporated into the national database. The NRC contractor

could not locate these two events in the database or the transfer files. 

Subsequently, the Division submitted the information for the two events to the NMED

contractor.

In evaluating the effectiveness of Tennessee’s actions responding to allegations, the review

team examined the Division’s questionnaire responses relative to this indicator and the

Division’s allegation procedure. The casework for 12 allegations were reviewed. During the

review period, four allegations were referred to the State by the NRC and 14 were reported

directly to the State. The Division evaluates each allegation and determines the proper level of

response. The review of the casework and the files indicated that the Division took prompt and

appropriate action in response to the concerns raised. Each of the allegations reviewed were

appropriately closed, and the allegers were informed of the results when possible. There were

no performance issues identified from the review of the casework documentation. 

All communication with the Division is considered public record under Tennessee’s Open

Records Law. Any alleger requesting anonymity is informed that every effort will be made to
Tennessee Final Report Page 10

protect their identity, but it cannot be guaranteed. All investigations involving potential criminal

activity are immediately brought to the attention of the Division’s senior management for a

determination if the case should be forwarded to the I&E Division for action.

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

that Tennessee'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. Tennessee’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

Along with their response to the questionnaire, the Division 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 Title 68,

Chapter 202-101 through 202-704 of the Tennessee Code Annotated. The Division 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 is adequate. 

4.1.2 Program Elements Required for Compatibility

The Tennessee radiation control program’s regulations are found in the “Rules of the

Department of Environment and Conservation,” Chapters 1200-2-4 through 1200-2-12, and

apply to all ionizing radiation from agreement materials, machine produced radiation, and

accelerators. Tennessee requires a license for possession, and use, of all radioactive material

including naturally occurring materials, such as radium, and accelerator-produced

radionuclides.

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

that the public and other interested parties are offered an opportunity to comment on proposed

rules. Tennessee has different procedures for amending four types of regulations: Rulemaking

Hearing Rules, Proposed Rules (non-controversial filed without a public hearing), Emergency

Rules, and Public Necessity Rules. The Division generally uses the Rulemaking Hearing Rules

procedures. Under the Rulemaking Hearing Rules procedures, all proposed rules are reviewed

internally by the Department’s Office of the General Counsel (OGC) and by outside interested

parties before a rulemaking hearing is established. The proposed rules are published in the

Tennessee Administrative Register during the month prior to the public hearing. Comments are

accepted at the hearing and for a two-week period following the hearing. Any changes are

made to the rules as needed and reviewed by the OGC, signed by the Department’s
Tennessee Final Report Page 11

Commissioner, reviewed by the Attorney General’s Office, filed with the Secretary of State, and

become effective after a waiting period of 75 days. After the rule becomes effective,

representatives of the Division and the OGC are scheduled to appear before the Government

Operations Committee of the legislature for the Committee’s approval. Rules adopted during

the year are subject to sunset on June 30 of the following calendar year, unless approved by

the legislature. 

In response to a telephone inquiry from a legal firm after the on-site review, STP identified that

Tennessee’s equivalent to 10 CFR Part 20.2003, “Disposal by Release into Sanitary

Sewerage,” a Category A compatibility requirement, is more restrictive. STP subsequently

reviewed the Tennessee rule and sent comments to the Division in a letter dated April 12, 2004. 

During the MRB meeting held on May 13, 2004, the review team discussed with the MRB and

Division staff that this regulation had originally been adopted prior to the 1991 revision to Part

20. Review of NRC files indicated that NRC corresponded with Tennessee on December 18,

1997 and again on December 23, 1998 in response to Tennessee’s February 6, 1998 letter on

the compatibility of this regulation. However, the 2000 IMPEP review team and the 2001 followup review team did not identify this inconsistency. The current review team also did not identify

this inconsistency and did not discuss this issue during the on-site review, nor in the draft or

proposed final reports. Shortly before the May 13, 2004 MRB meeting, the review team

informed the Division of their intention of discussing this issue during the meeting. During the

discussion, the Division Director indicated that the State disagreed with including discussion of

this issue in the IMPEP report. Following consideration of the State’s views, the MRB agreed

with the review team’s inclusion of discussion relating to this rule and the team’s

recommendation presented below, in the final IMPEP report. The Division Director indicated

that after appropriate review and consideration by the Division, Tennessee will respond in

writing to the April 12, 2004 letter. The review team recommends that the Division promptly

adopt the current version 10 CFR 20.2003.

In his June 1, 2004 letter responding to the revised language in the final IMPEP report

(Attachment 2), Lawrence E. Nanney requested that the recommendation above be changed to

recommending that “the Division promptly respond to the letter dated April 12, 2004, in order to

address the differences in the State’s equivalent rule to 10 CFR Part 20.2003.” Although the

NRC acknowledges the Division’s commitment to reply to the April 12, 2004 letter, the review

team and the MRB believe that retaining the recommendation as originally proposed more

clearly conveys the intent of the discussions held at the May 13, 2004 MRB meeting.

The team evaluated the Division’s responses 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

STP Regulation Assessment Tracking System. Since the follow-up IMPEP review, the Division

adopted 16 amendments in one rule package that became effective in October 2002. NRC’s

review letter dated February 1, 2002 indicated that NRC had completed its review with

comments on 15 final regulations. The review team found that 16 amendments were submitted

to NRC by the State for review, but the amendments were not identified individually. On a

cursory review by the team, it appears that the Division addressed all NRC comments in the

February 2002 letter. During the on-site review, it was identified that the following regulation

had not been reviewed by NRC:

 “Radiological Criteria for License Termination,” 10 CFR Parts 20, 30, 40, and 70
Tennessee Final Report Page 12

amendments (62 FR 39057) that became effective August 20, 1997. Parts of this

amendment are designated as A and/or B for compatibility. The State submitted their

final regulation for this amendment for NRC review on April 7, 2004. The NRC sent one

comment to the State on this final regulation in a letter dated May 6, 2004. If this

comment is addressed, this regulation would meet the necessary compatibility criteria.

The team identified seven rules needed for compatibility. The NRC reviewed the State’s

proposed regulations for the following amendments in December 2003, and determined that

they meet the NRC’s compatibility requirements when the three comments identified are

addressed. Presently, this rule package has been signed by the Department’s Commissioner

and is currently with OGC for review.

 “Minor Corrections, Clarifying Changes and a Minor Policy Change,” 10 CFR Parts 20,

35 and 36 amendments (63 FR 39477 and 45393) that became effective October 26,

1998. The State has drafted proposed regulations for this amendment and submitted

them to the NRC for review on October 22, 2003. 

 “Transfer for Disposal and Manifests: Minor Technical Conforming Amendment,” 

10 CFR Part 20 amendment (63 FR50127) that became effective November 20, 1998.

The State has drafted proposed regulations for this amendment and submitted them to

the NRC for review on October 22, 2003. 

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

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

State has drafted proposed regulations for this amendment and submitted them to the

NRC for review on October 22, 2003. 

 “Energy Compensation Sources for Well Logging and Other Regulatory Clarifications,”

10 CFR Part 39 amendment (65 FR 20337) that became effective May 17, 2000. 

 “New Dosimetry Technology,” 10 CFR Parts 34, 36, and 39 amendments (65 FR 63749)

that became effective January 8, 2001. 

The State has drafted proposed regulations for the amendments identified below and submitted

them to the NRC for review on February 13, 2004. The NRC sent comments to the State on

these proposed regulations in a letter dated March 25, 2004. 

 "Timeliness in Decommissioning of Materials Facilities," 10 CFR Parts 30, 40, and 70

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

 "Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

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

February 16, 2001. The Division addressed the reporting requirements for generally

licensed device distributors which was due by August 16, 2001 by amending the

licenses for the State’s distributors of generally licensed device in June 2001.

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

effective on April 5, 2002. 
Tennessee Final Report Page 13

The Division will need to address the following regulations in upcoming rulemakings or by

adopting alternate legally binding requirements:

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

20249), that became effective on April 24, 2003.

 “Financial Assurance for Materials Licensees,” 10 CFR 30, 40, and 70, amendments (68

FR 57327), that became effective on December 3, 2003.

 “Compatibility with IAEA Transportation Safety Standards (TS-R-1) and Other

Transportation Safety Amendments,” 10 CFR 71 amendments (69 FR 3698), that will

become effective on October 1, 2004.

During the 2000 IMPEP review, the review team found the State’s performance for this indicator

unsatisfactory based on the 17 overdue regulations needed for compatibility and no

management plan to address regulations. During the 2001 follow-up review, the State’s

performance was found satisfactory with recommendations for improvement, based on

development of a management plan, preparation and submittal to NRC of 15 proposed

amendments addressing regulations needed for compatibility and that only three additional

regulations were overdue. The current review team found the continued progress made by the

Division in addressing regulation promulgation commendable. 

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

that Tennessee’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 conducting this review, three sub-indicators were used to evaluate the Division’s performance

regarding SS&D evaluation. These sub-indicators include: 1) Technical Staffing and Training;

2) Technical Quality of the Product Evaluation; and 3) Evaluation of Defects and Incidents

Regarding SS&Ds.

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

information provided in response to the IMPEP questionnaire. The team reviewed selected

new, amended SS&D evaluations and inactivations, deficiency letters, interactions with the

applicant, and supporting documents covering the review period. The review team noted the

Division’s use of guidance documents and procedures, interviewed the staff involved in the

evaluations, and verified the use of regulations and license conditions to enforcement

commitments made in the applications.

4.2.1 Technical Staffing and Training

The Division has four individuals who perform SS&D evaluations as secondary duties. The

Manager of Radioactive Materials Specific Licensing was the principal reviewer and the

Manager of the Licensing/Registration/Policy Section served as a concurrence reviewer. These

two individuals have several years of experience performing SS&D reviews. During the review

period, two other license reviewers attended the NRC/State SS&D Workshop held in 2001. 

One individual is now fully qualified to perform SS&D evaluations after completing reviews of
Tennessee Final Report Page 14

new and amendment applications for a sealed source and a device in collaboration with a

senior reviewer. The second individual has limited independent reviewer and signature

authority. Both individuals have the proper training and qualifications in accordance with the

Division’s Training Policy and have documented training and authorizations in their training files.

All four individuals have many years of experience in health physics and have attended the

NRC/State SS&D Workshop. The current SS&D reviewers have extensive health physics

experience for the performance of SS&D reviews. None of these individuals have formal

engineering training. This matter is discussed further in Section 4.2.2.

According to the Division’s response to the questionnaire, the Division expends approximately

0.35 FTE on SS&D evaluations. The review team concluded that the current SS&D staffing

level is adequate for the needs of the Division.

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

performance with respect to this sub-indicator, Technical Staffing and Training, be found

satisfactory.

4.2.2 Technical Quality of the Product Evaluation Program

During the review period, 18 SS&D certificates related to byproduct materials were issued by

the Division. The review team examined a total of 12 certificates and their supporting

documentation including four new applications, seven amendments, and one inactivation

representing the work of all four reviewers. The SS&D registration certificates examined by the

review team are listed with case specific comments in Appendix F.

In 1997, a major distributor of gauging devices with byproduct materials that are manufactured

in Germany moved to the State. This licensee currently has 16 active SS&D certificates issued

by the Division which constitutes the majority of all byproduct material SS&D casework. The

Division also evaluated the SS&D applications for other manufacturers and distributors, but a

majority of these products use naturally occurring and accelerator produced materials.

Analysis of the files and interviews with the staff confirmed that the Division follows the

recommended guidance from the NRC/State SS&D Workshop and NUREG-1556, Volume 3

issued in July 1998. The team found, however, that the reviewers did not consistently use the

review checklist provided in NUREG-1556, Volume 3, Appendix C. The team determined that

reviewers did not use the checklist for amendments but did use them for new applications. 

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

available and generally used when performing SS&D reviews. The team found that the Division

did not use the latest version of the applicable industrial standards in five of the cases reviewed.

For example, the team determined that the Division staff was not aware that the requirements

of the standard ANSI/ISO/ASQ 9001-1994 “Quality Management Systems - Requirements”

(ISO-9001) are no longer used and accreditation to the 1994 version became invalid in

December 2002. SS&D manufacturers frequently use and are accredited by ISO 9001. The

NRC position on the International Quality Standards is documented in the policy paper entitled

“Approaches for Adopting More Widely Accepted International Standards” (SECY-03-0117,

dated July 9, 2003). The paper primarily addressees the applicability of International Quality
Tennessee Final Report Page 15

Standards to Safety related items of commercial nuclear power plants, but the conclusions are

also applicable for SS&Ds.

The Division was not aware of the NRC’s position on ISO 9001 since it was not circulated

outside the agency. The team also noted that the Division was depending on the industry and

consensus standards listed in NUREG-1556, Volume 3 and was not aware of the revisions of

some of these consensus standards. The use of the latest industry and consensus standards

for the SS&D product evaluations is an important component to furthering national consistency

in this area. The team recommends that NMSS and STP develop a procedure to identify and

periodically notify the Agreement States of agency positions that affect SS&D evaluations and

the revision of industry and consensus standards for SS&D product evaluations in an All

Agreement States letter.

The review team concluded that the overall technical quality of the product evaluations varied. 

The review team found that the use of the checklist resulted in a significant improvement in the

overall evaluation of the applications. Consequently, the overall technical quality of product

evaluations for the new applications was better then major amendments and showed 

improvement over the review period. The review team and Division staff discussed this finding

and staff indicated that they will consider also using the checklist for major amendments.

In three of the cases reviewed, the team found that the Division did not adequately follow-up

and evaluate advanced engineering and materials of construction related information provided

by the licensee. At the time of the review, the Division had no access to mechanical

engineering expertise for seeking advice or a second opinion on unique engineering and

materials related issues. The review team recommends that the Division acquire or provide a

mechanism for staff to have access to expertise commensurate with the complexity of SS&D

casework.

The review team and Division staff discussed the need to closely follow the format for

documenting product evaluation since the registry certificates are used nationally. For

example, the team noted that some certificates did not have legible attachments or essential

drawings available in English. The review team recommends that the Division prepare

registration certificates consistent with the current version of NUREG-1556, Volume 3.

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

performance with respect to this sub-indicator, Technical Quality of the Product Evaluation

Program, be found satisfactory with recommendations for improvements.

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

There was one reported incident involving a registration certificate issued by the Division as

indicated in Appendix E. The incident took place in Louisiana and involved the failure of the

shutter on a Model LB 7442-CR level gauge mounted on a centrifuge which resulted in the one

curie source coming out of the shield. The review team determined that the Division handled

the incident promptly and appropriately, determining the root cause and notifying other

licensees with the same device in a timely manner. As a result of the incident, the Division

required the manufacturer to conduct additional vibrational tests on the failed model. The

Division is still reviewing the results of these tests. The Division is considering submitting a

technical assistance request to the NRC regarding some specific aspects of the test results. In
Tennessee Final Report Page 16

addition, the Division issued a revised SS&D registry sheet with a revised welding procedure for

the shutter mechanism.

Based on the IMPEP evaluation criteria, the review team recommends that Tennessee’s

performance with respect to this sub-indicator, Evaluation of Defects and Incident Regarding

SS&Ds, be found satisfactory.

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

that Tennessee’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 Tennessee 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 Tennessee. 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 Tennessee’s

performance to be satisfactory for all seven performance indicators. Accordingly, the review

team recommended and the MRB concurred in finding the Tennessee Agreement State

program to be adequate to protect public health and safety and compatible with NRC's

program. The MRB also directed that the increased monitoring of the Tennessee program be

terminated. Based on the results of the current IMPEP review, the review team recommended

and the MRB agreed that the next full review should be in approximately four years.

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

evaluation and implementation by the State.

1. The review team recommends that the Division promptly adopt the current version 10

CFR 20.2003. (Section 4.1.2)

2. The review team recommends that the Division acquire or provide a mechanism for staff

to have access to expertise commensurate with the complexity of SS&D casework.

(Section 4.2.2)

3. The review team recommends that the Division prepare registration certificates

consistent with the current version of NUREG-1556, Volume 3. (Section 4.2.2)
Tennessee Final Report Page 17

Below is a recommendation, as mentioned in a earlier section of the report, for evaluation and

implementation, as appropriate by the NRC.

1. The team recommends that NMSS and STP develop a procedure to identify and

periodically notify the Agreement States of agency positions that affect SS&D

evaluations and the revision of industry and consensus standards for SS&D product

evaluations in an All-Agreement State letter. (Section 4.2.2)
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Duncan White, Region I Team Leader

Technical Staffing and Training

Response to Incidents and Allegations

Kathleen Schneider, STP Status of Materials Inspection Program

Legislation and Program Elements Required

 for Compatibility

Robert Gattone, Region III Technical Quality of Licensing Actions

Shawn Seeley, Maine Technical Quality of Inspections

Response to Incidents and Allegations

Inspector Accompaniments

Ujagar Bhachu, NMSS Sealed Source and Device Evaluation Program

Richard Woodruff, Region I Inspector Accompaniments
APPENDIX B

TENNESSEE ORGANIZATION CHARTS

ML040620701
m ELECTORATE 

Jolni 

Legislative 

Committee 

correction 

Pubtic 

Defenders 

Attomep 

General 

Criminal 

AgrfcuHure Insurance 

I 

viii 
TENNESSEE DEPARTMENT OF ENVIRONMENT AND CONSERVATION 

Archaeology 

Director - 

r PUBLIC AFFAIRS 

Groundwater Superfund 

Protection, Director - Director 

Director 

DOE Oversight 

Director 

- 

IWater Supply SolidlHazardous 

Director 

- Waste Management - Director 

C HOMELAND SECURITY 

Director 

2/12/04 

t INTERNAL AUDIT 

Director 

I 

Recreation Edudational 

Services, Director 

I 

Natural Heritage 

Director 

I 

TN Historical 

Commission, Director 

L 

DRAFT 

Commissioner 

21" Floor, L&C Tower, 401 Church Street 

Nashville, Tennessee 37243 

Telephone (615) 532-0106 

Facsimile (61 5) 532-01 20 

www.tdec. net 

I LEGISLATION 

I OFFICE OF GENERAL 

COUNSEL 

I STATEPARKSAND 

CONSERVATION 

Deputy Commissioner 

I State Park Operations - 

Director 

I 1 Resort Ooerations- 1 

I Director I 

I Facilities Management 

Director 

I Natural & Cultural Res. 

Mgt., Director 

I FINANCE AND BUSINESS 

SERVICES 

Assistant Commissioner 

Fiscal Services 

Director 

I I Information Svstems C 

I I Directo; 

Strategic Planning 

Director 

Director 

Policy Oftice 

Director 

I ENVIRONMENT 

Deputy Commissioner 

Air Pollution Control Underground Storage 

Director Director Tanks, Director 

Community Assistance Water Pollution 

Director - - Control, Director 

Regional Environmental 

Assistance Centers 

1-888-891-TDEC 

- 

I I I 

Director 

West TN River Basin 

Authority Director 
DIVISION OF RADIOLOGICAL HEALTH 

OFFICE OF THE DIRECTOR 

(327.32) - I 

ADMINISTRATIVE SERVICES 

OFFICE SERVlCESlRECORDS MAINTENANCE 

ASA 4 5000.01 Ruth Kitchens 19 

Clk3 2592.16 Jeff Young 19 

Sec 5000.12 Winona Muir 19 

Clk2 5091.16 vacant 19 

ADM ASSISTANCE TO TECH PROGRAMS 

ASA 3 0100.02 Connie Pinkerton 19 

HPPM 2 0100.06 Billy Freeman 

HPD 0100.01 Lawrence E. Nanney, Director 19 

HPPM 3 0100.04 Debra Shults, Deputy, Director 19 

HP CONS 2592.01 Sandra Szendy 19 

Adm Sec 5091.15 Jan Gregory 19 

ASA 5 5091.14 Mary Helen Short, Adm. Asst. Director 19 

I 'I 

LICENSING / REGISTRATION / POLICY 

HPPM 2 0100.07 Johnny Graves 19 

RADIOACTIVE MATERIAL SPECIFIC LICENSING 

HPPM 1 2500.01 Charles Amott 19 

HPSPV 1 2592.05 Ron Parsons 19 

HP3 2509.01 Sasi Krishnasarma 19 

HP3 0102.01 Jerry Bacon 19 

MACHINE /DEVICE PERMITTING - RI EVALUATION 

HPSPV 2 25091.04 Robert Young 19 

HP3 5000.08 vacant 19 

SEC 5292.17 Carolyn Sekoral 19 

CLK 2 5000.1 1 Marilyn Vetter 19 

CLK 2 2500.08 released 12/3 19 

POLICY / REGULATORY GUIDANCE 

HSPV 1 5093.03 Michael Singleton 19 

H P3 5000.06 released 1213 19 

I 

TECHNICAL SERVICES 

HPPM 2 5091.01 Ruben Crosslin 19 

PERSONNEL / ENVIRONMENTAL MONITORING 

HPPM 1 2503.01 Mark Hammon 19 

HP3 5000.07 Jerry Bingaman 19 

HPSPVl 5093.01 Jim Talley 19 

HP3 2500.09 Seble Aynachew 19 

HP3 2592.06 John Sullivan 19 

RADIOACTIVE WASTE MANAGEMENT 

HPSPV2 5091.18 Roger Fenner 19 

HP3 2592.10 Pam Chandler 19 

STANDARDS DEVELPMENT / PROCESSING 

HPSPV2 5091.10 Barbara Davis 19 

HP3 5000.05 19 

EMERGENCY PREPAREDNESS I TRAINING 

HPSPV 2 3000.01 Liz Flanagan 19 

HP3 0100.03 Bruce House (HP1) 19 

NASHVILLE EAC 

HPFOM 2592.02 

HPSPV 2 2592.09 

HP3 2500.10 

HP3 2592.07 

HP3 5091.07 

HP3 2592.03 

HPSPV 1 2594.03 

HP3 2592.04 

Roger Perry 

Paula Richardson 

Jamie Bunch 

Robin Heriges 

Beth Murphy 

Dean Baker 

Travis Barber 

Gerald N. Kwazu 

Clk 3 0100.20 Martha Fish 

19 

19 

19 

19 

19 

19 

19 

19 

19 

I CHATTANOOGA EAC 

HPFOM 5091.03 John Politte 33 

HP3 2592.15 WadeBrewer 33 

HP3 0100.14 SteveSeeger 33 

I 

MEMPHIS EAC 

HPFOM 5091.02 Allen Grewe 79 

HPSPV 2 2594..01 Grigsby Stevens 79 

HP3 2500.03 Dell Montgomery 79 

HP3 2592.14 (requested 10H5) 79 

HPSPV 1 2594.04 John Garland 79 

HP3 5091.11 Nicole Wells (HPl) 79 

HP3 5000.03 Solomon Sahle (HP1) 79 

1 

KNOXVILLE EAC 

HPFOM 

HPSPV 2 

HPSPV 1 

HP3 

HP3 

HPSPV 1 

HP3 

HPSPV 1 

HP3 

HPSPV 1 

HP3 

HP3 

H P3 

0100.10 

5091.05 

5093.06 

5091.06 

5091.12 

5000.12 

2500.06 

5093.07 

5091.08 

2592.13 

5000.04 

5091.13 

2592.12 

Mark Andrews 

in process 

Chuck Johnson 

Stacy Hamiiton (HP1) 

Kim Gilliam 

Darlene Nalepa-Whitmill 

Myra Norwood 

Jon Thompson 

Marsha Smith 

Shawn Drake 

Roger Macklin 

Nathan Foutch 

Chris Millsaps 

47 

47 

47 

47 

47 

47 

47 

47 

47 

47 

47 

47 

47 
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Tennessee Organizational 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 1 April 12, 2004 Letter from Lawrence E. Nanney

Tennessee’s Response to Draft IMPEP Report

Attachment 2 June 1, 2004 Letter from Lawrence E. Nanney, Tennessee’s

Response to Revised Language in Final IMPEP Report
ATTACHMENT 1

April 12, 2004 Letter from Lawrence E. Nanney 

Tennessee’s Response to the Draft IMPEP Report

ML041140518
...... 

...... 

STATE OF TENNESSEE 

DEPARTMENT OF ENVIRONMENT AND CONSERVATION 

DIVISION OF RADIOLOGICAL HEALTH 

L & C Annex, 3rd Floor 

401 Church Street 

Nashville, TN 37243-1532 

Phone: 61 5-532-0360, Fax: 61 5-532-7938, E-mail: Eddie.NanneyG2state.tn.w 

April 12,2004 

Duncan White, CHP 

Regional State Agreemats Officer 

Division of Nuclear Materials Safety 

475 Allendale Road 

King of Prussia, PA 19406-1415 

Dear Mr. White: 

I am responding to your letter dated March 25,2004, to Ms. Karen Stachowski. We have 

reviewed your letter and the attached draft IMPEP report, which documents the preliminary 

findings of the review team relative to its evaluation of the Tennessee Agreement State program. 

Attached are our comments regarding the draft report. Thank you for the opportunity to provide 

these comments. 

We appreciate very much the courtesy and professionalism exhibited by you and your team, and 

by the NRC management representatives who attended the on-site closeout meeting on February 

26,2004. It has been a pleasure working with you. 

Sincerely, 

Lawrence E. Nanney 

Director 

'd 

cc: Karen Stachowski 

LEN:jhg 
ATTACHMENT 

3.1 Technical Staffing and Training 

Page 8, L 1 Please change “non-radiological” to “other”. These inspections 

include spent nuclear fuel, NORM, NARM, etc. 

3.3 Technical Oualitv of Inspections 

Page 11, P. 1, L 10 This sentence is incorrect. Inspection correspondence is issued 

fiom the respective field office where the inspection was 

performed. 

4.1.2 Program Elements Reauired for Compatibilitv 

Page 14, P.2, L 12 Please insert “reviewed by the Attorney General’s office” after the 

word “Commissioner”. 

4.2.1 Technical Staffing and Training 

Page 17, P.4, L 5 Please delete “and 2003, respectively.” The two reviewers only 

attended the 2001 workshop. 

Appendix F Sealed Source and Device Casework Reviews 

File No.: 2 

The source classification was made under the standard current at that time. It was 

approved in the original registration dated July 24, 1997. The “new” standard was 

approved in November 1997. 

The registrant requested the logo change to “BT” in letter dated November 27,2000. This 

change was approved in the previous amendment to the registration dated November 28, 

2000. 

File No.: 3 

c,g) The registration attachments denote dimensions, and the locations of the sealed 

sources. 

The sealed source label would not be applicable for these device drawings. 
File No.: 4 

a) The AMC.D3 source remains under an Amersham name registration. 

FileNo.: 5 

It is not required that these audit results be submitted to the Division, but that they be 

maintained for inspection by the State of Tennessee. 

File No.: 6 (Issue date June 26,2001) 

a) This registration only authorizes Berthold Technologies, U.S.A., LLC sources. 

We do not require the registrant to submit operations manuals to us. 

File No.: 7 

These sources were registered by another jurisdiction. We assume that sources approved 

in other jurisdictions were evaluated with standards that were current at the time of 

testing . 

File No.: 9 

Page 2 of the registration states that the device has seven guide tubes, and that each guide 

tube contains a sealed source attached to a cable. Page 3 indicates that a hole in the upper 

end of the extension rod accepts a roll pin which secures the cable to the rod. Also, it is 

stated the cables are composed of braided stainless steel and have a diameter of 1.5 mm. 

File No.: 10 

c) A review of the file revealed that the March 17, 2003, letter requested a Model LB 

7409-3 device. The registration was issued April 24,2003. 
ATTACHMENT 2

June 1, 2004 Letter from Lawrence E. Nanney 

Tennessee’s Response to the Revised Language

in the Final IMPEP Report

ML041530609