October 26, 2004

William D. Hacker, M.D.

Commissioner

Cabinet for Health and Family Services

Department for Public Health

275 East Main Street

Frankfort, KY 40621-0001

Dear Dr. Hacker:

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

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

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

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

Section 5.0, page 18 of the enclosed final report presents the IMPEP team’s recommendations

for the Commonwealth of Kentucky. We request your evaluation and response to the

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. However, the review team recommended, and the MRB agreed, that a periodic

meeting take place with the Commonwealth approximately one year from the date of the IMPEP

review to assess the Commonwealth’s progress in implementing the action plan that resulted

from the radiation control program’s self-audit.

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: Robert L. Johnson, Manager

Alice Rogers, TX

OAS Liaison to the MRB
William D. Hacker, M.D.

bcc: Chairman Diaz

Commissioner McGaffigan

Commissioner Merrifield

Distribution:

DIR RF DCD (SP01) PDR (YES/)

KSchneider, STP

JZabko, STP

AMcCraw, STP

ISchoenfeld, OEDO

JStrosnider, NMSS

CMiller, NMSS/IMNS

TEssig, NMSS/IMNS

RStuckmeyer, NMSS/IMNS

SMinnick, RI

RBlanton, STP

RErickson, RIV

MAbbaszadeh, TX

KVon Ahn, OH

STreby, OGC

KCyr, OGC

JGray, OGC

FCameron, OGC

TCombs, OCA (2 copies)

Kentucky File

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OFFICE Region I STP:DD STP:D DEDMRS

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DATE 10/18/04 10/18/04 10/18/04 10/26/04

OFFICIAL RECORD COPY
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF KENTUCKY AGREEMENT STATE PROGRAM

July 19-23, 2004

FINAL REPORT

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

1.0 INTRODUCTION

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

review was conducted during the period July 19-23, 2004, by a review team consisting of

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

States of Ohio and Texas. Team members are identified in Appendix A. The review was

conducted in accordance with the "Implementation of the Integrated Materials Performance

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

Federal Register on October 16, 1997, and the February 26, 2004, NRC Management Directive

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

review, which covered the period of July 22, 2000 to July 23, 2004, were discussed with

Kentucky management on July 23, 2004.

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

State responded by letter dated September 24, 2004. The Management Review Board (MRB)

met on October 12, 2004 to consider the proposed final report. The MRB found the Kentucky

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

NRC’s program.

The Kentucky Agreement State program is administered by the Radiation Health and Toxic

Agents Branch (the Branch). The Radioactive Materials Section (the Section) along with

Radiation Producing Machines and Radiation/Environmental Monitoring Sections comprise the

Branch. The Branch is part of the Division of Public Health Protection and Safety within the

Department for Public Health (the Department). The Department is part of the Cabinet for

Health and Family Services (the Cabinet). The Branch Manager reports to the Division Director

who in turn reports to the Commissioner of the Department. Organization charts are included in

Appendix B. At the time of the review, the Kentucky Agreement State program regulated

approximately 430 specific licenses authorizing Agreement materials. The review focused on

the materials program as it is carried out under the Section 274b. (of the Atomic Energy Act of

1954, as amended) Agreement between the NRC and the Commonwealth of Kentucky.

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

performance indicators was sent to the Branch on April 27, 2004. The Branch provided a

response to the questionnaire on July 9, 2004. A copy of the questionnaire response can be

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

Number ML042110358.

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

Kentucky’s responses to the questionnaire; (2) review of applicable Kentucky statutes and

regulations; (3) analysis of quantitative information from the Branch licensing and inspection

database; (4) technical review of selected licensing and inspection actions; (5) field

accompaniments of four Branch inspectors; and (6) interviews with staff and management to

answer questions or clarify issues. The review 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 Kentucky Agreement State

program’s performance.
Kentucky Final Report Page 2

Section 2 below discusses the Commonwealth’s actions in response to recommendations made

following the previous IMPEP review and the review team’s conclusion 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. 

Recommendations made by the review team are comments that relate directly to performance

by the Commonwealth. A response is requested from the Commonwealth to all

recommendations in the final report.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on July 21, 2000, four recommendations

were made and transmitted to Jimmy D. Helton, Secretary of the Cabinet of Health Services, on

October 27, 2000. The team’s review of the current status of the recommendations are as

follows:

1. The review team recommends that the Branch revise their inspection manual to ensure

that core licenses authorizing the conduct of activities from multiple permanent field

offices are inspected at the same frequency as specified in Inspection Manual Chapter

(IMC) 2800. (Section 3.1)

Current Status: The Branch revised their inspection manual to eliminate the listing of

multiple, individual field offices on licenses. The Branch issued a separate license to

each field office and treat each as an individual licensee. This recommendation is

closed.

2. The review team recommends that the Branch ensure that reciprocity licensees are

inspected in accordance with the frequency criteria specified in the Branch’s inspection

manual. (Section 3.1).

Current Status: The Branch now inspects reciprocity licensees in accordance with the 

frequency criteria specified in the Branch’s inspection manual. The Branch’s reciprocity 

inspection frequencies are more frequent than the frequencies identified in IMC 1220. 

This recommendation is closed.

3. The review team recommends that the Branch revise their training program to include

documentation of staff’s equivalent training and experience in lieu of completing a

required basic training course, including supervisory sign off for each completed area of

training. (Section 3.3).

Current Status: The Branch has revised their training program to include supervisory

sign-off to demonstrate’s staff’s equivalent experience and training. Although the team

noted that documentation in some cases was limited, the Branch Manager and Section

Supervisor committed to improving the documentation for staff as the Branch’s policy

and procedures are revised. This recommendation is closed.
Kentucky Final Report Page 3

4. The review team recommends that the Branch commit the necessary resources to

complete all Sealed Source and Device (SS&D) registry re-evaluations prior to the next

IMPEP review period. (Section 4.2.1)

Current Status: Since the last IMPEP review, two of the 11 registrations were amended,

and updated information on the remaining registration certificates were received in May

2004. The Branch staff will be re-evaluating the submitted information as their workload

permits. This matter is further discussed in Section 4.2.2, Technical Quality of the

Product Evaluation, and the review team has made a new recommendation. 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) Technical Quality of Incident and Allegation

Activities.

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the program’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 Branch’s questionnaire response relative to this

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

records, and considered any possible workload backlogs.

The Branch is located in the Department for Public Health offices in Frankfort. There are no

field offices. The Branch Manager is responsible for the Section, Radiation Producing Machines

Section, and the Radiation/Environmental Monitoring Section. The Radioactive Materials

Section Supervisor (Section Supervisor) is primarily responsible for materials licensing and

compliance activities. There is one dedicated administrative support position.

The Section experienced a complete turnover in staff during the review period. The four

individuals currently in the Section and the Branch Manager have been hired since the last

IMPEP review. Three former staff members left the Branch upon retirement from the

Commonwealth. The other two former staff members were transferred to other Branches within

the Department. Although there were a complete staff turnover, the team found little or no

evidence of transfer of knowledge between the former Branch Manager and the current one. 

Between June and November of 2002, the Branch operated with neither a Branch Manager nor

Section Supervisor. The new management was unaware of some practices of the former

management. For example, the former management maintained a separate database to track

initial inspections that compensated for some of the limitations in the Department-wide system

(see Section 3.2). In order to assess the condition of the radioactive materials program, the

current Branch Manager performed a self-audit of the program. The audit identified a number of

weaknesses in performance that the review team confirmed during this review. The identified

performance weaknesses also served as a basis for two new positions in the Section that were

recently authorized. Finally, the Branch developed an action plan with specific goals identified

and time frames to achieve satisfactory performance. For example, the action plan addresses
Kentucky Final Report Page 4

the need to revise the Branch’s policy and procedure manuals to reflect current inspection and

licensing practices.

At the time of the review, there were five technical staff members with various degrees of

involvement in the radioactive materials program. The review team determined that currently a

total of 3.25 full time equivalents (FTE) is dedicated to the materials licensing and inspection

programs, and 0.3 FTE to emergency response, reciprocity, and transportation. With the one

current vacant position and the authorization of two new positions, the radioactive materials

program will have approximately 7 FTE once the positions are filled.

There was at least one vacant position for all but nine months of the review period, due to the

Commonwealth’s budgetary problems and an associated hiring freeze. Additional vacant

positions remained unfilled for an average of approximately six months. At the time of the

review, the Section had one vacancy, which the Branch had recently been given authority to fill. 

Applicants had been interviewed, and the Branch is waiting for a response from the selected

candidate. In addition, the Section recently received authorization for two new positions, for

which position descriptions were under development. The Branch is seeking approval to make

one of the positions a senior position. If approved, the Section will have two senior and four

junior positions under the Supervisor.

The technical staff members are classified as Materials Specialists (MS). Currently, MSIII is the

entry/junior level, and MSIV is the senior level. Minimum qualifications are specified in the MSIII

position description, and require a bachelor’s degree or equivalent experience in the physical

sciences. Equivalency determinations are made by the Commonwealth’s Department of Human

Resources prior to listing the candidate for interview by the program. Most current staff

members have equivalent training through the military or health career speciality training and

working experience. The team did not identify any performance issues that could be related to

a lack of a formal degree.

The Branch has a documented training and qualification program for licensing and inspection

staff that is consistent with the NRC/Organization of Agreement States Joint Working Group

report on training for Agreement State staff. Qualification is established through a combination

of education and experience. In house and on-the-job training may be substituted for formal

classroom training. The Section considers both attendance at NRC-sponsored courses and

alternate resources for training.

The review team observed that Branch management has exhibited a strong commitment to

training. The Branch has developed an in-house training program featuring monthly sessions

with topics selected through management assessment of staff needs. The Section maintains a

training and qualification binder with a sign-off qualification record for each technical staff

member. Staff members must complete each module and receive management sign-off on the

qualification record prior to being authorized to independently perform the tasks associated with

that module. All staff members review licenses and conduct inspections. At management

direction, training starts with licensing activities, then proceeds to inspection activities when the

individual’s licensing knowledge is demonstrated to be adequate.
Kentucky Final Report Page 5

Management sign off on a module is granted only after successful completion of the inspection

portion of the module, and indicates qualification in both licensing and inspection. Memoranda

in the training binder documented inspection participation, and recommended granting of

qualification in most cases where management had signed off. Similar documentation of

training and experience for the licensing portion of the module is not retained in the binder. 

Training requirements can be waived by the Branch Manager for sufficient reason. However,

the review team did not find documentation of the basis for the waivers granted in the training

binder.

The previous review team recommended that the Branch revise their training program to include

documentation of staff’s equivalent training and experience in lieu of completing a required

basic training course, including a supervisory sign off for each completed area of training. A

supervisory sign off is now performed, but documentation of training and experience is limited. 

In view of the recent high staff turnover, the review team concluded that the Branch should

improve their documentation of training and experience. The Branch Manager and Section

Supervisor committed to improve the documentation as the Branch’s policy and procedures are

revised.

The Branch is authorized to charge annual fees for specific licenses and for the registration of

radiation machines. All fees are deposited in a Division fund, then appropriated back to the

Branch. The fee structure was increased during the review period, and is posted on the

Kentucky web site. The Branch currently obtains approximately 80 percent of its radioactive

materials funding through fees.

The Branch does not have a standing advisory committee, but does have authority to empanel

an advisory committee to provide advice on specific issues. The establishment of a permanent

committee under statutory authority was considered during the review period, but is not being

pursued currently.

The review team considered a finding of satisfactory, but needs improvement for this indicator

based on the complete turnover of staff and the number of identified weaknesses. However, the

review team notes that the Branch identified a number of needed improvements, developed and

in some cases implemented action plans to correct specific performance issues. In addition, the

Branch continued to perform the core inspection and licensing functions and has recently

received authorization to fill one vacant position and to add two new positions. The review team

concluded that the Branch has an adequate plan to sufficiently staff the Section and make the

necessary improvements to the program. Based on the IMPEP evaluation criteria, the review

team recommended and the MRB agreed that Kentucky’s performance with respect to the

indicator, Technical Staffing and Training, was satisfactory.

3.2 Status of Materials Inspection Program

The review team focused on five factors in reviewing the status of the material inspection

program: inspection frequency, overdue inspections, initial inspections of new licensees, timely

dispatch of inspection findings to licensees, and the performance of reciprocity inspections.
Kentucky Final Report Page 6

The review team’s evaluation is based on the Branch’s questionnaire response relative to this

indicator, data gathered independently from the Branch’s licensing and inspection data tracking

system, the examination of complete licensing and inspection casework, and interviews with

management and staff.

The team's review of the Branch’s inspection priorities verified that inspection frequencies for

various types of Kentucky material licenses are generally the same as those listed in NRC

Manual Chapter (MC) 2800. However, there are some categories of licenses that were

assigned inspection priority codes that prescribe a more frequent inspection schedule than

those currently prescribed in MC 2800. These reduced inspection intervals are assigned to

activities the Branch has determined to be of higher risk, or for licensees who have

demonstrated poor performance.

In their response to the questionnaire, the Branch indicated that there were 10 core licenses

currently overdue by more than 25 percent of the NRC inspection frequency. This information

was verified during the inspection casework reviews. However, the team also noted that several

initial license inspections exceeded the one year frequency specified in MC 2800. Out of 398

core and initial licenses inspected by the Branch during the review period, a total of 38

inspections (9.6 percent) were performed overdue or are overdue now. Nearly all of the 38

overdue inspections were new licenses requiring an initial inspection. The previous Branch

Manager maintained a separate database for initial licenses, but this information was not

conveyed to the new Branch Manager. The Branch believes that not knowing about the

Branch’s initial licensee database was a significant contributor to the higher than normal number

of initial license inspections that were not performed timely. The review team noted that over the

last year of the review period, the number of overdue initial inspections has been reduced by the

Branch.

The review team determined that Branch staff members prior to calendar year 2002 did not

have access to the Department’s database and maintained records of inspections manually. In

2003, the Branch was granted limited access to the Department’s database and has been in the

process of building a workable database to accurately maintain inspection data. The Branch

indicated that many of the overdue initial inspections identified by the review team and other

omitted licensee data could be attributed to issues with the databases. The review team

recommends that the Branch upgrade their database so that all relevant licensee data are

incorporated and maintained to ensure that inspections can be scheduled and performed in

accordance with the requirements of MC 2800.

The timeliness of the issuance of inspection findings was also evaluated. The Branch has an

effective and efficient process which ensures that inspection findings are communicated to

licensees in a timely manner. The Branch’s procedures require that inspection findings be

issued to the licensee within 30 days. Of the 27 inspection files reviewed, all inspection

correspondence was issued to the licensee within 30 days.

Based on records available to the review team, for the period of January 1, 2002 to July 19,

2004, the Branch granted 49 core reciprocity licenses. The Branch exceeded the minimum 20

percent criteria prescribed in MC 1220 by inspecting 16 licensees.
Kentucky Final Report Page 7

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

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

Program, was satisfactory.

3.3 Technical Quality of Inspections

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

notes and interviewed inspectors for a total of 27 inspections conducted during the review

period. The casework reviewed included each of the Branch’s current and former materials

inspectors. The review covered inspections of various types as follows: industrial radiography,

academic broad scope, medical broad scope, medical institution with written directive required,

nuclear cardiology, nuclear pharmacy, gamma knife, brachytherapy, blood irradiators, well

logging, portable and fixed gauges, and research and development. Appendix C lists the

inspection casework files reviewed for completeness and adequacy with case-specific

comments.

Based on the casework file reviews, the review team found that routine inspections covered all

aspects of each licensee’s radiation protection program. The inspection reports were thorough,

complete, consistent, and of high quality, with sufficient documentation to ensure that each

licensee’s performance with respect to health and safety was acceptable. The review team

found that routine inspections adequately cover each licensee's radiation protection program,

include a written summary of the scope of the licensed activities and categorize violations into

severity levels which can later be used for escalated enforcement if necessary. The

documentation adequately supported the cited violations. Exit interviews were held with

appropriate licensee personnel.

The current Branch Manager conducted formal, unannounced accompaniments of materials

inspectors in calendar year 2004, and prior to the calendar year 2002 staff turnover, annual

accompaniments were conducted by the previous Branch Manager. However in the interim

period between calendar years 2002 and 2004 during the staff turnover, there was a period of

five months when the Branch did not have a Branch Manager and an additional 15 months

where the Branch did not have a Section Supervisor. During this period, no formal

accompaniments were conducted, however the staff improvised an accompaniment program

where more experienced inspectors accompanied less experienced inspectors while conducting

inspections. The current Branch Manager indicated that the staff is stable now and annual

unannounced accompaniments will continue on a routine basis.

The review team noted that out of 27 inspection files examined, there were two instances where

licensees failed to respond to the Branch’s inspection correspondence. In both of these

instances the Branch did not follow up on the failure of the licensee to respond to the inspection

correspondence. There were no safety issues identified by the team due to the licensee’s

failure to respond. Both of these instances occurred during a transition period of high staff

turnover.

Members of the review team accompanied four Kentucky inspectors from June 1 to 4, 2004,

and observed their activities during inspections of an industrial radiography facility, a small

medical facility licensed for diagnostic nuclear medicine and radiopharmaceutical therapy, a

broad scope medical facility, and a Type A Broad Scope academic licensee which are identified

in Appendix C. During the accompaniments, the inspectors demonstrated appropriate
Kentucky Final Report Page 8

inspection techniques and knowledge of the regulations. The inspectors were well prepared

and thorough in their review of each of the licensee's radiation safety programs. The

inspections were adequate to assess radiological health and safety at each of the licensed

facilities.

The Branch has an adequate number and selection of survey instruments to support the

inspection program. Each inspector is assigned a calibrated dual function (GM and micro-R)

survey meter that is carried with them at all times to facilitate a rapid response in emergency

situations. The meters are calibrated by the manufacturer or a properly licensed facility. The

Branch Manager indicated that the Branch has plans to set up a calibration facility to calibrate

their meters. The task of ensuring the survey meters are calibrated has been assigned to a

senior member of the inspection staff. The Branch also oversees a Radiation/Environmental

Monitoring Section which maintains a well equipped and adequately staffed analytical

laboratory. Members of the review team toured the facility. The laboratory has broad analytical 

capability including liquid scintillation counters, gas proportional counters, intrinsic germanium

detectors, multichannel analyzers, alpha spectroscopy, and radiochemistry. The laboratory is

capable of analyzing a broad range of environmental media.

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

that Kentucky’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 types: medical broad scope, general license distribution,

manufacturing and distribution, medical (institution and private practice), research and

development, nuclear pharmacy, industrial radiography, self-shielded irradiator, laboratory

analysis and source material. Licensing actions reviewed included three new, seven renewals,

five amendments and one termination file. 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
Kentucky Final Report Page 9

amendments. The review team confirmed that there were no exemptions issued as indicated

on the Branch’s questionnaire response.

The team reviewed three licenses which had possession limits that required financial assurance

for decommissioning but the licensees had not provided either a decommissioning funding plan

or financial assurance. This matter was discussed with the Branch Manager who indicated that

the Branch discussed the need for financial assurance with one of the licensees, but not with

the other two licensees. The Branch Manager indicated that there may be additional licensees

that require financial assurance for decommissioning. The review team recommends that the

Branch identify those licensees who require financial assurance and take appropriate action to

have them comply with the Commonwealth’s decommissioning and financial assurance

requirements.

Licensing actions are assigned to one of the Branch’s license reviewers. Once the reviewer

completes the action, the Branch Manager signs each licensing action. Licensing checklists are

used for each type of program and are included in the license file. The status of all licensing

actions are tracked using a log book. The Branch generates licenses and correspondence with

standardized conditions and formats. The Branch issues licenses for a one-year period based

on the collection of an annual fee. A comprehensive technical renewal is performed every five

to seven years. The Branch utilizes appropriate licensing guides, standard licensing conditions,

and issues a complete license for each licensing action.

The review team noted that some license conditions still in use have been superceded either by

regulations or change in policy and consequently, were no longer required. The review team

discussed this matter with the staff and the Branch Manager. The Branch Manager indicated

that the Branch’s procedures and standardized license conditions are in need of review. The

update and revision of the licensing procedures and standard license conditions are included in

the Branch’s action plan. This matter is discussed further in Section 4.1.2, “Program Elements

Required for Compatibility.”

The review team found that terminated licensing actions were well documented, showing

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

and survey records. In discussions with Branch staff, the review team noted that there were no

major decommissioning efforts underway with regard to Agreement material in the

Commonwealth.

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

that Kentucky's performance with respect to the indicator, Technical Quality of Licensing

Actions, was satisfactory.

3.5 Technical Quality of Incident and Allegation Activities

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

team examined the Section’s responses to the questionnaire relative to this indicator, reviewed

the incident reports for Kentucky in the Nuclear Material Events Database (NMED) against

those contained in the Section’s files, and evaluated reports and supporting documentation for

ten incidents. A list of the incident casework examined with case-specific comments is included

in Appendix E. The review team also reviewed the Section’s response to eight allegations

involving radioactive material. Three allegations were referred to the Section by the NRC during
Kentucky Final Report Page 10

the review period.

The incidents selected for review included the following categories: medical event, lost/stolen

material, overexposure, leaking source, and damaged equipment. The review team found that

the documentation of the Section’s response to incidents was deficient. Section procedures

specifying documentation requirements were not followed. This had been identified as a

corrective action item by the Branch’s self assessment prior to the review. For seven of the ten

incidents, the only documentation was a copy of the NMED report.

Based on the limited documentation available in the NMED reports, the initial responses to the

incidents appeared prompt and well coordinated, and the level of effort appeared

commensurate with the health and safety significance. The Section dispatched inspectors for

on-site investigations when appropriate. However, follow up and enforcement actions were fully

documented in only three cases.

Six license files were examined for documentation of the incidents and follow up during the next

inspection. Documentation of the incidents was limited or missing in all six files. Three of the

files had no documentation of follow up to the incident or review of licensee’s corrective actions

during the next inspection.

Notification of an incident or allegation may be received by any staff member. When a

notification is received, the Branch Manager or Section Supervisor determines what level of

initial response is appropriate and assigns appropriate staff. After the investigation is

completed, the pertinent information is forwarded to NMED.

The review team identified 32 incidents in NMED for Kentucky during the review period,

including 10 incidents that required reporting. For incidents that require immediate notification,

Section procedures require reporting to the NRC within 24 hours of receiving notification from

the licensee. Reports to NMED are to be submitted when the initial investigation is finished,

and follow-up reports are made as needed to close the incident and NMED report. During the

period of staff turnover, these procedures were not consistently followed as those staff members

assigned this task departed from the Branch. This was identified by the Section as a corrective

action item. Currently, cases requiring follow up and closure are tracked by the Section

Supervisor.

During the review period, the Branch received eight allegations, three of which were referred to

the Branch by NRC. The casework for all allegations was reviewed. The review of the

casework and the Section’s files indicated that the Section took prompt and appropriate action

in response to the concerns raised. All of the allegations were appropriately closed except one

that was still under investigation. The team noted that Branch procedures call for allegations to

be treated and documented internally in the same manner as incidents. Based on the review of

the casework documentation, the team found that the documentation procedures were not

followed since the staff turnover in 2002. This was discussed with the Branch Manager and

Section Supervisor who were aware of the situation and have plans to address it through inhouse training.

The review team recognizes that the Section has identified the need to document responses to

incidents and allegations through their self assessment and included this item in their corrective

action plan. Documentation of the Section’s responses will also facilitate the follow up to the
Kentucky Final Report Page 11

incident or review of licensee corrective actions during the next inspection. The review team

recommends that the Branch document incident and allegation responses in accordance with

their procedures and provide training on the procedures to all technical staff.

Although the Branch makes an effort to protect the identity of an alleger, the team noted that

Kentucky law requires that all public documents be made available for inspection and copying

unless specifically exempted from disclosure under Kentucky’s Open Records Act. The Branch

procedure, “Availability of Files to the Public,” Section 414, Title 400, of the Branch

Administrative Manual provides guidance to the staff on handling public documents. Legal

council is available in the Department to assist the staff in deciding whether or not to release

information.

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

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

Allegation Activities, be found satisfactory, but needs improvement.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

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

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

Program. Kentucky’s Agreement does not authorize uranium recovery, so only the first three

non-common performance indicators were applicable to this review.

4.1 Compatibility Requirements

4.1.1 Legislation 

In addition to their response to the questionnaire, the Branch provided the review team with the

opportunity to review copies of legislation that effect the radiation control program. The current

effective statutory authority for the Branch is contained in Kentucky’s Revised Statutes (KRS)

Title XVIII, Chapter 211, which names the Cabinet as the radiation control agency of the

Commonwealth. The Branch is designated as the Commonwealth’s radiation control agency. 

Chapter 211 also authorizes the Cabinet to regulate the registration and licensing for the

possession or use of any sources or ionizing or machine produced radiation, handling and

disposal of radioactive waste, and establishing and assessing fees. The review team noted that

no legislation affecting the Branch was passed during the review period.

4.1.2 Program Elements Required for Compatibility 

The Kentucky Regulations for Control of Radiation, found in 902 Kentucky Administrative

Regulations (KAR) Chapter 100, Regulations for Radioactive Materials, apply to all ionizing

radiation, whether emitted from radionuclides or machine sources. Kentucky 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 Commonwealth’s administrative rulemaking process and found

that the process takes approximately 12 months after the Branch submits the drafted

amendment for Cabinet review. The public and other interested parties are provided an
Kentucky Final Report Page 12

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

comments during the promulgation process. The Commonwealth can adopt other agency’s

regulations by reference and has the authority to issue legally binding requirements (e.g.,

license conditions) in lieu of regulations until compatible regulations become effective. The

regulations are not subject to sunset provisions.

The review team evaluated the Branch’s response to the questionnaire, reviewed the status of

regulations required to be adopted by the Commonwealth under the Commission’s adequacy

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

Office of State and Tribal Programs’ State Regulation Status Data Sheet. Since the previous

IMPEP review, the Branch adopted six amendments that became effective in March 2001,

February 2002, and June 2004.

Current NRC policy requires that Agreement States adopt certain equivalent regulations or

legally binding requirements no later than three years after they become effective. The review

team found that the Branch currently has the following six overdue NRC amendments:

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

35 amendments (60 FR 48623) that became effective October 20, 1995. The Branch

submitted proposed revisions to their regulations for this amendment for NRC review in

a letter dated September 27, 2004.

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

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

26, 1998.

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

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

! “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.

! “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

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

effective February 16, 2001. The Branch has amended the appropriate licenses with

license conditions compatible with the requirements in 10 CFR 32.52 (a) and (b). The

Branch has not adopted the remainder of the amendment. 

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

adopting alternate legally binding requirements:

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

became effective April 5, 2002.

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

20249) that became effective October 24, 2002. The Branch submitted proposed
Kentucky Final Report Page 13

revisions to their regulations for this amendment for NRC review in a letter dated

September 27, 2004.

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

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

! “Compatibility with IAEA Transportation Safety Standards and Other Transportation

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

October 1, 2004.

The team discussed the status of overdue NRC amendments with the Branch Manager and 

Section Supervisor. As discussed in Section 3.1, the Branch self-audit identified the need to

adopt overdue NRC amendments. The Branch’s action plan specifies schedules for the

adoption of overdue NRC amendments during 2005. In addition, the Branch also recognized

the need to update their various policy and procedure manuals to reflect changes in the

regulations. These planned revisions are also reflected in the Branch’s action plan with planned

completion in late 2005. Since the Branch has already developed an action plan to adopt the

overdue NRC amendments, the review team determined that a specific recommendation was

not needed.

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

Kentucky’s performance with respect to the indicator, Compatibility Requirements, was

satisfactory, but needs improvement.

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

In conducting this review, three sub-indicators were used to evaluate the Branch’s performance

regarding their SS&D Evaluation Program. 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 Branch's SS&D evaluation program, the review team examined information

provided by the Branch in response to the IMPEP questionnaire on this indicator. A review of

two amended SS&D registration evaluations and supporting documents covering the review

period was conducted. The review team interviewed the Section Supervisor and Branch

Manager and assessed the use of regulations and license conditions to enforce commitments

made in the applications.

4.2.1 Technical Staffing and Training

During the review period, the former Section Supervisor performed the initial reviews for

amendments issued during the review period. Two members of the current Branch staff each

performed one concurrence review of the amendments.

In April 2001, one concurrence reviewer attended the NRC/State SS&D Workshop and received

management approval for performing SS&D reviews. This reviewer is presently the only

reviewer with management approval to perform SS&D reviews. A second reviewer attended the

SS&D workshop in September 2003, but does not have documented management approval to

perform SS&D reviews, yet signed as a concurrence reviewer for one of the amended
Kentucky Final Report Page 14

registration certificates in May 2002. This reviewer stated that verbal approval to be a qualified

reviewer was given by the former Branch Manager in 2002 prior to signing as a concurrence

reviewer. A third staff member also attended the September 2003 workshop, but has not

attained management approval for performing SS&D reviews.

The review team determined that the Branch did not establish a training program with

qualification criteria or maintain documentation indicating that SS&D reviewers met the

qualifying criteria specified in Management Directive 5.6. Additionally, the team could not 

identify any documented training review experience for the Branch’s two concurrence reviewers. 

The review team recommends that the Branch establish, implement and document a training

program for SS&D reviewers.

4.2.2 Technical Quality of the Product Evaluation

There is currently one device manufacturer in the Commonwealth with 11 registration

certificates. During the review period, the Branch performed three amendments which included

the review of two device registration certificates including one of which was amended twice. 

The review team examined all three amendments and supporting documentation and the

manufacturer’s license. The SS&D registration certificates examined by the review team are

listed with case-specific comments in Appendix F. 

A review of the files and interviews with staff confirmed that the Branch has available for use the

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

Revision 1. This includes ANSI 43.8-2001 “Classification of Industrial Ionizing Radiation

Gauging Devices,” ANSI N43.6-1997 “Sealed Radioactive Sources, Classification,” and NRC

Regulatory Guide 6.9. Various National Council Radiation Protection reports were also

available.

The amendments reviewed by the Branch were minor amendments to use additional sealed

source models within the devices and to increase the activity and shielding on another device. 

The team found the amended information in the registration certificates was satisfactory. 

However, for all three amendments issued, there was no documentation of the scope of the

reviews and only the amendment request and the completed registration were in the Branch’s

files. The team did find sufficient documentation of prior reviews in the files, but not of device

reviews conducted during the current review period.

The review team could not determine if the review checklist from NUREG-1556, Volume 3, was

used for amendments issued during the current review period. The amendment evaluations

performed by the Branch did not update and review the existing information in the registrations

to conform to current guidance found in NUREG 1556, Volume 3. The review team did review

the contents of the entire registration certificates and identified a number of issues detailed in

the comments of Appendix F. These included (1) the consistency and justification between

prototype testing, ANSI ratings, and normal conditions of use; (2) verification that listed sealed

sources are still active and applicable to be used in a device, and/or indicate when sealed

sources no longer have an active registration; and (3) commitments made by the manufacturer

in their applications and referenced in the registration certificates are consistent and

enforceable with Kentucky regulations.

The review team and the Branch staff discussed the need to review the contents of the entire
Kentucky Final Report Page 15

certificate and follow the format for documenting the product evaluations since the registration

certificates are used nationally. The review team recommends that the registration certificate

evaluation criteria and document format be consistent with NUREG 1556, Volume 3.

The team identified three registration certificates for products manufactured outside Kentucky

for specifically licensed custom users in the Commonwealth. None of the three custom users

were identified as current licensees. There is also a device manufacturer that is no longer

located in the Commonwealth but in an adjacent Agreement State that still has 12 active

Kentucky registration certificates. The review team recommends that the Branch review and

determine the status of SS&D registrations issued to non-Kentucky manufacturers and take

appropriate action to either update or inactivate the registration certificates.

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

The review team identified eight reported incidents related to the use of registration certificates

issued by the Branch during the review period. Two incidents were related to accident

conditions unrelated to the device. The remaining six incidents involved leaking sealed sources

and sealed sources becoming disconnected from the device and falling into the user source

well. These six device failures are listed under Appendix E. Four of the five incidents were for

multiple source disconnects with the same devices at the same location. The review team

concluded that for the four incidents at the one facility indicated that there may have been other

factors to consider in the device failures.

The six device failures occurred prior to current Branch management who were unaware of the

scope of the incidents. The review team identified little documentation that the Branch fully

evaluated the root causes of all defects and incidents involving the devices covered by the

registration certificates. For example, the review team did identify a note involving a discussion

between the NRC and the Branch regarding one of the incidents that the NRC would investigate

the incident and contact the Branch if the Branch was to perform any additional action. Any

knowledge of the events, reports, personal notes or undocumented follow-up actions relating to

device failures and defects were lost to the current staff when the previous Branch management

retired.

The review team did discuss the need for the Branch to periodically review the NMED database

for incident reports that may be related to potential design and manufacturing SS&D issues for

follow up and root cause analysis during license renewals, license inspections, and device

registration amendments. The review team also determined that there is no requirement for

manufacturers in the Commonwealth to report failures of safety-related systems and document

follow-up actions. The review team recommends that the Branch implement an enforceable

mechanism (e.g., rule or license condition) to have the manufacturers report defects, deviations

or non-conformance of safety-related systems, structures, or components and document 

follow-up actions.

During the MRB meeting, NRC management discussed the potential implications of having

Agreement States requiring manufacturers under their jurisdiction report defects, deviations and

items of non-conformance for devices which they have issued SS&D registry sheets without the

benefit of a compatibility requirement. During the MRB’s discussion, it was noted that some

Agreement States apply this requirement as either a regulation or legally binding requirement. 

The MRB recommended that the NRC’s Office of Nuclear Materials Safety and Safeguards,
Kentucky Final Report Page 16

Office of State and Tribal Programs, and Office of the General Counsel review the basis for the

lack of a compatibility requirement for reporting defects, deviations and items of nonconformance for devices registered by Agreement States and make appropriate

recommendations if the lack of such a requirement results in gaps in the collective national

effort to regulate materials under the Atomic Energy Act.

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

that Kentucky’s performance with respect to the indicator, Sealed Source and Device Evaluation

Program, was satisfactory, but needs improvement.

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

The Maxey Flats site is located in eastern Kentucky near Hillsboro in Fleming County. The site

operated as a commercial LLRW disposal facility authorized by the Commonwealth from May

1963 through December 1977. The site was listed on the National Priority list in 1986 and a

Record of Decision was issued in September 1991 by the Environmental Protection Agency

(EPA) under its Comprehensive Environmental Response, Compensation, and Liability Act

(CERCLA) authority to stabilize the site and treat contaminated leachate (mainly tritium) from

tanks and trenches. Dewatering and leachate treatment was initiated in 1988 and was

completed in 2000. The remaining activities over the last few years were the construction of a

cap, erosion control measures, perimeter drainage system and groundwater intercept channel.

Currently, the Natural Resources and Environmental Protection Cabinet (NREPC) is responsible

for monitoring and maintaining the site. NREPC assumed responsibility for the site in 1978. 

NREPC is licensed by the Branch.

4.3.1 Technical Staffing and Training

The Branch staff, whose qualifications and training are discussed in Section 3.1, serve as

license reviewers and inspectors. Since the facility is closed and operations at the site are

limited to environmental sampling and monitoring, the Branch’s radioactive materials

qualification and training requirements are adequate for technical staff to perform LLRW

licensing actions and inspections. The laboratory technical staff in the Radiation/Environmental

Monitoring Section involved with the Maxey Flats site consist of five professional chemists, who

have been trained in radiochemistry, environmental sampling, and analysis and evaluation. The

review team discussed the qualifications of the laboratory technical staff with the Branch

Manager and determined that their qualifications are commensurate with expertise needed to

regulate the closed LLRW disposal site.

4.3.2 Status of Low-Level Radioactive Waste Disposal Inspection

The Branch's inspection frequency for the site is every two years. NRC has not established an

inspection frequency for closed LLRW sites. The Branch conducted an inspection of the site in

January 2004. The previous inspection was conducted in February 2000. No formal inspection

was conducted in 2002 due to staffing issues discussed in Section 3.1. Despite the lack of a

formal radioactive materials inspection in 2002, the Branch Manager stated that other oversight

activities are routinely conducted at the site including on-site sample collection on a monthly

and quarterly basis. Quarterly and monthly site visits for environmental sampling and

monitoring are conducted by the laboratory technical staff. In addition, NREPC conducts
Kentucky Final Report Page 17

quarterly inspections at the site and provides detailed reports to the EPA and the Branch. The

Branch Manager committed to continue the two-year inspection frequency for the site.

Regarding the timeliness of the Branch inspection reports, the review team noted that for the

inspection conducted in January 15, 2004, the report was issued to NRECP on July 12, 2004. 

The Branch Manager and Section Supervisor indicated that the delay was due to higher priority

activities.

4.3.3 Technical Quality of Inspections

The inspection of the NRECP license is handled in the same manner as the other radioactive

materials licensees. The review team reviewed the January 2004 inspection report and

interviewed select members of the inspection staff. The inspection was conducted as a team

and included the Section Supervisor who accompanied the inspection team for training

purposes. Branch management also participated in preparation, review and approval of the

inspection report. The review team concluded that the scope and quality of the inspection was

appropriate. Appendix C lists the inspection casework reviewed for completeness and

adequacy with case-specific comments.

As discussed in Section 3.3, the review team visited the Radiation/Environmental Monitoring

Section laboratory and found the facility equipped to support monitoring activities at the site. 

Periodic site visits are made by the laboratory technical staff on at least a monthly basis and

also during major rainfall for environmental sampling and monitoring purposes. Sampling

includes surface water from creeks and storm water runoff from the site. Results of

environmental monitoring are maintained at the laboratory. The Branch maintains an adequate

variety of calibrated radiation survey instruments as discussed in Section 3.3. Survey

instruments are also available at the laboratory.

4.3.4 Technical Quality of Licensing Actions

NREPC’s license authorizes the possession of the wastes previously disposed of at the site,

management and maintenance of the site, and possession and treatment of radioactive solids

and liquids generated as a result of management and maintenance activities at the site. The

license covers the on-site radiation control program, occupational exposure of individuals, and

control of radioactive materials as it affects occupational exposures.

The review team examined a total of eight licensing actions, including one renewal and seven

amendments. A listing of the casework evaluated with case-specific comments can be found in

Appendix D. In examining the technical quality of completed licensing actions, the review team

found that all correspondence including deficiency letters related to the issuance of the license

was well documented and the license meets standard licensing practices such as possession,

activities, location, Radiation Safety Officer qualifications, compliance with regulations, and tiedowns. The tie-down condition cites the renewal application, health and safety plan, radiation

protection program, Consent Decree Statement of Work, and other letters as appropriate. All

tie-down documents were on file. Applicable guidance documents related to licensing actions

are available and used as needed.

4.3.5 Technical Quality of Incident and Allegation Activities
Kentucky Final Report Page 18

There was one allegation received by the Branch since the last review, but the concern raised

was not in the Branch’s jurisdiction. There were no incidents at the site since the last review.

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

that Kentucky’s performance with respect to the indicator, Low-Level Radioactive Waste

Disposal Program, was satisfactory.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team found Kentucky’s performance to be

satisfactory for five performance indicators and satisfactory, but needs improvement, for three

performance indicators. Accordingly, the review team recommended and the MRB agreed on

finding the Kentucky Agreement State program to be adequate to protect public health and

safety and compatible with NRC's program. The team considered a finding of adequate, but

needs improvement, but noted that the Branch identified a number of needed improvements,

developed and in some cases implemented action plans to correct specific performance issues

and has been approved to expand the Section’s staff. The team also recommended and the

MRB agreed that the next periodic meeting be conducted in approximately one year to assess

the Branch’s progress with implementing their action plan. The status of the Branch’s progress

with the action plan will be reported to the MRB to determine if any changes in the program

finding is needed. Based on the results of the current IMPEP review, the review team

recommends that the next full review should be in approximately four years.

Below are the recommendations, as mentioned earlier in the report, for evaluation and

implementation, as appropriate, by the Commonwealth.

RECOMMENDATIONS:

1. The review team recommends that the Branch upgrade their database so that all

relevant licensee data are incorporated and maintained to ensure that inspections can

be scheduled and performed in accordance with the requirements of MC 2800. 

(Section 3.2)

2. The review team recommends that the Branch identify those licensees who require

financial assurance and take appropriate action to have them comply with the

Commonwealth’s decommissioning and financial assurance requirements. (Section 3.4)

3. The review team recommends that the Branch document incident and allegation

responses in accordance with its procedures and provide training on their procedures to

all technical staff. (Section 3.5)

4. The review team recommends that the Branch establish, implement and document a

training program for SS&D reviewers. (Section 4.2.1)

5. The review team recommends that the registration certificate evaluation criteria and

document format be consistent with NUREG 1556, Volume 3. (Section 4.2.2)

6. The review team recommends that the Branch review and determine the status of SS&D

registrations issued to non-Kentucky manufacturers and take appropriate action to either
Kentucky Final Report Page 19

update or inactivate the registration certificates. (Section 4.2.2)

7. The review team recommends that the Branch implement an enforceable mechanism

(e.g., rule or license condition) to have the manufacturers report defects, deviations or

non-conformance of safety-related systems, structures, or components and document

follow-up actions. (Section 4.2.3)

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

implementation, as appropriate, by NRC staff:

1. The MRB recommended that NMSS/STP/OGC review the basis for the lack of a

compatibility requirement for reporting defects, deviations and items of non-conformance

for devices registered by Agreement States and make appropriate recommendations if

the lack of such a requirement results in gaps in the National Materials Program.
LIST OF APPENDICES AND ATTACHMENT

Appendix A IMPEP Review Team Members

Appendix B Kentucky 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 September 24, 2004 Letter from William D. Hacker

Kentucky’s Response to Draft IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Duncan White, Region I Team Leader

Technical Quality of Licensing Actions

Compatibility Requirements

Richard Blanton, STP Technical Staffing and Training

Technical Quality of Incident and Allegation Activities

Randy Erickson, Region IV Status of Materials Inspection Program

Technical Quality of Inspections

Inspector Accompaniments

Sheri Minnick, Region I Inspector Accompaniments

Muhammadali Abbaszadeh, Texas Low-Level Radioactive Waste Disposal Program

Karl Von Ahn, Ohio Sealed Source and Device Evaluation Program
APPENDIX B

KENTUCKY ORGANIZATION CHARTS

ADAMS: ML042170062
COMMONWEALTH OF 

KENTUCKY 

CABINET FOR HEALTH & 

FAMILY SERVICES 

James W. Holsinger, Jr., M.D. 

Secretary 

DEPARTMENT FOR PUBLIC 

HEALTH 

William D. Hacker, M.D. 

Commissioner 

DIVISION OF PUBLIC HEALTH 

PROTECTION & SAFETY 

Clyde Bolton 

Director 

I 

RADIATION HEALTH & TOXIC 

AGENTS BRANCH 

Robert L. Johnson 

Manager 

RADIOACTIVE MATERIALS 

SECTION 

Matthew McKinley 

Supervisor 

RADIATION PRODUCING 

MACHINES SECTION 

Dewey Crawford 

Supervisor 

~~ 

RADIATION / 

ENVIRONMENTAL 

MONITORING SECTION 

Eric Scott 

Supervisor 
RADIATION HEALTH & TOXIC AGENTS 

BRANCH 

Robert L. Johnson 

Manager 

~~ 

RADIOACTIVE 

MATERIALS 

SECTION 

Matthew McKinley 

Supervisor 

Rick Horky 

Steven Berrier 

Robert Gresham 

RADIATION 

PRODUCING 

MACHINES SECTION 

Dewey Crawford 

Supervisor 

James Barnes 

Steve Mays 

Ken McIlwain 

Julie Keightley 

E.J. Dewitt 

Vanessa Breeding 

RADIATION / 

ENVIRONMENTAL 

MONITORING 

SECTION 

Eric Scott 

Supervisor 

Philip Mills 

Stephanie Brock 

Steve Hampson 

Mark Keene 

Carl Peterson 

James May 

Contract Employees from University 

of Kentucky 
ATTACHMENT

September 24, 2004 Letter from William D. Hacker

Kentucky’s Response to the Draft IMPEP Report

ADAMS: ML042780161
ERNIE FLETCHER 

GOVERNOR 

CABINET FOR HEALTH AND FAMILY SERVICES 

DEPARTMENT FOR PUBLIC HEALTH 

275 EAST MAIN STREET, HSI GWA 

FRANKFORT, KENTUCKY 40621-0001 

JAMES W. HOLSINGER, JR., M.D. 

SECRETARY 

(502) 564-3970 (502) 564-9377 FAX 

September 24,2004 

Mr. Duncan White, C.H.P. 

Regional State Agreements Officer 

Division of Nuclear Materials Safety 

Region I 

475 Allendale Rd. 

King of Prussia, PA. 19406 

RE: Kentucky Integrated Materials Performance Evaluation Program (IMPEP) Review 

Dear Mr. White 

We have received the draft Kentucky IMPEP report and reviewed the findings it 

outlines. The contents are as briefed on your departure, are consistent with what we 

agreed as the status of all areas reviewed, and we have no questions, corrections or 

challenges at this time. 

We appreciated the visit, staff felt it to be a valuable tool for our program, and we are 

moving vigorously with internal program action plans based on the recommendations 

outlined in your draft program evaluation. It is our intent to have Mr. Robert L. Johnson, 

Radiation Safety Branch Manager attend the Management Review Board where the 

report will be finalized. 

Thank you for this opportunity to provide comments. Should there be questions or 

further clarification we can provide, Mr. Johnson will be available or you can contact my 

office any time at 502-564-3671. 

Sincerely, 

WILLIAM D. HACKER, M.D. 

Acting Commissioner 

Cc: Mr Bolton 

Mr Johnson 

An Equal Opportunity Employer M/F/D