Donald L. Shumway, Commissioner November 6, 2001

Department of Health and Human Services

129 Pleasant Street

Concord, NH 03301-3857

Dear Commissioner Shumway:

On October 26, 2001, the Management Review Board (MRB) met to consider the proposed

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

Hampshire Agreement State program. The IMPEP review was conducted June 25-29, 2001. 

The MRB found the New Hampshire program adequate but needs improvement, and not

compatible with NRCís program. Because of the significance of the concerns, the MRB intends

to enter a period of heightened oversight of the New Hampshire program. I request that bimonthly conference calls take place with the appropriate New Hampshire and NRC staffs to

discuss the status of the program. The Office of State and Tribal Programs will coordinate the

bi-monthly conference calls. I request that, two weeks prior to the calls, the New Hampshire

program submit a brief status report on the activities conducted since the last report and the

necessary statistical data. 

I also request that the New Hampshire program prepare and submit a program improvement

plan that addresses the recommendations in Section 5 of the enclosed final report. I ask that

this report be submitted within 30 days of this letter. Upon review of the program improvement

plan, the staff will schedule the first conference call and a more detailed outline for the status

reports. The initial conference call should be scheduled and conducted no later than January 7,

2002.

Based on the results of the current IMPEP review, a follow-up review will be scheduled during

the period November 2002 - January 2003. The follow-up review will cover the Stateís action

on the recommendations from the June 2001 review. 

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

your continuing support of the Bureau of Radiological Health. I look forward to our agencies

continuing to work cooperatively in the future. 

Sincerely,

/RA/

Carl J. Paperiello

Deputy Executive Director

 for Materials, Research and 

 State Programs

Enclosure:

As stated

cc: See next page
Donald L. Shumway

cc: John Wallace, Deputy Commissioner

Department of Health and Human Services

Kathleen A. Dunn, MPH, Director

Office of Community and Public Health

Department of Health and Human Services

Veronica Malberg, Director

Division of Community Support

Diane Tefft, Administrator

Bureau of Radiological Health

Department of Health and Human Services

Woodbury P. Fogg, Director

Office of Emergency Management

William Sinclair, Utah

OAS Liaison to MRB
Donald L. Shumway

cc: John Wallace, Deputy Commissioner

Department of Health and Human Services

Kathleen A. Dunn, MPH, Director

Office of Community and Public Health

Department of Health and Human Services

Veronica Malberg, Director

Division of Community Support

Diane Tefft, Administrator

Bureau of Radiological Health

Department of Health and Human Services

Woodbury P. Fogg, Director

Office of Emergency Management

William Sinclair, Utah

OAS Liaison to MRB

bcc: Chairman Meserve

Commissioner Dicus

Commissioner Diaz

Commissioner McGaffigan

Commissioner Merrifield

Distribution:

DIR RF DCD (SP01)

EDO RF PDR (YES)

SDroggitis

KSchneider KCyr, OGC

KHsueh, ASPO MVirgilio, NMSS

LRakovan

RWoodruff, RII

ADWhite, RI

J. Peterson, SC

DCool, NMSS

GDeegan, NMSS

STreby, OGC

JLieberman, OGC

TCombs, OCA (4)

New Hampshire State File

*See previous concurrence

DOCUMENT NAME: C:\Program Files\Adobe\Acrobat 4.0\PDF Output\2001 NH Final IMPEP Report ~.wpd

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

OFFICE RII STP:DD STP:D DEDMRS

NAME RLWoodruff:gd FCombs PHLohaus CJPaperiello

DATE 10/29/01 *via e-mail 10/31/01* 10/31/01* 11/6/01

STP-AG-18
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF NEW HAMPSHIRE AGREEMENT STATE PROGRAM

JUNE 25-29, 2001

FINAL REPORT

U.S. Nuclear Regulatory Commission
New Hampshire Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the New Hampshire radiation control program.

The review was conducted during the period June 25-29, 2001 by a review team comprised of

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

State of South Carolina. Team members are identified in Appendix A. The review was

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

Evaluation Program and Recission of Final General Statement of Policy,î 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 23, 1997 to June 29, 2001, were

discussed with New Hampshire management on June 29, 2001.

A draft of this report was issued to New Hampshire for factual comment on July 27, 2001. The

State responded in a letter dated August 23, 2001. At the time of the review, the review team

found New Hampshireís performance to be satisfactory for the common performance indicators

Technical Quality of Inspections, Technical Quality of Licensing Actions and Response to

Incidents and Allegations; satisfactory with recommendations for improvement for the indicator,

Technical Staffing and Training; and unsatisfactory for the indicators, Status of Materials

Inspection Program, and Legislation and Program Elements Required for Compatibility. 

Because of the significance of the concerns, the team recommended that a program of

heightened oversight be implemented to assess the progress of the State in implementing

corrective actions. 

On September 11, 2001, the Management Review Board (MRB) initially met to consider the

proposed final report with Mr. John Wallace, Deputy Commission, Department of Health and

Human Services and other New Hampshire staff. Due to national events, the meeting was

postponed and rescheduled at a later date. The MRB met on October 26, 2001, to reconsider

the proposed final report. The MRB concurred in the individual findings by the review team for

each indicator and concurred in the review teamís recommendation for a program of

heightened oversight to assess the progress of the State in implementing corrective actions. 

The MRB found the New Hampshire radiation control program was adequate, but needs

improvement, and not compatible with NRCís program.

The MRB directed that: (1) a program improvement plan be submitted in addition to the

responses to the recommendations found in Section 5; (2) that a follow-up review be conducted

during the period August - October 2001; and (3) that bimonthly conference calls take place

with New Hampshire staff, and that written progress reports be submitted two weeks prior to

each call.

The New Hampshire Agreement State program is administered by the Bureau of Radiological

Health (the Bureau). The Bureau contains the Radioactive Materials Section (the Section),

Radiation Machines Section, Radiochemistry Section, Emergency Response Section, and

Radon Section. The Bureau is located within the Office of Community and Public Health,

Department of Health and Human Services (the Department). The Department Commissioner

is appointed by and reports to the Governor. Organization charts for the Department and the

Bureau are included as Appendix B. At the time of the review, the New Hampshire Agreement
New Hampshire Final Report Page 2

State Program regulated approximately 80 specific licenses authorizing Agreement materials. 

The review focused on the regulatory 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 New

Hampshire. 

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

indicators was sent to the State on April 11, 2001. The State provided a response to the

questionnaire by e-mail on June 11, 2001, and the response was updated during the review. A

copy of the questionnaire response is included as Appendix F of the proposed final report and

can be found on the NRCís Agencywide Documents Access and Management System

(ADAMS) using the Accession Number ML013020147.

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

the responses to the questionnaire, (2) review of applicable New Hampshire statutes and

regulations, (3) analysis of quantitative information from the Bureauís licensing and inspection

data bases, (4) technical review of selected licensing actions and inspections, (5) field

accompaniments of two materials inspectors, and (6) interviews with staff and management to

answer questions or clarify issues. The review team evaluated the information gathered

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

a preliminary assessment of the Stateís performance. 

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

following the previous review. Results of the current review for the IMPEP common

performance indicators are presented in Section 3. Section 4 discusses results of the

applicable non-common indicators, and Section 5 summarizes the review team's findings, and 

recommendations. Recommendations made by the review team are comments that relate

directly to the performance by the Bureau. A response is requested from the Bureau to all

recommendations in the final report.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous routine review, which concluded on August 22, 1997, four

recommendations were made and the results were transmitted to Mr. Jeffery B. Schaub,

Director, Office of Health Management, Department of Health and Human Services, on

November 25, 1997. The teamís review of the current status of these recommendations is as

follows:

1. The review team recommends that core and non-core licensees be scheduled,

assigned, and inspected at regular intervals in accordance with the State's established

inspection priority system. (Section 3.1)

Current Status: At the end of calendar year 1999, the Bureau reported that all core

licensee inspections were completed. As noted in Section 3.1, the Bureau continues to

experience difficulty in completion of inspections. This recommendation will be

incorporated into the review teamís 2001 recommendation in Section 3.1.

2. The review team recommends that the State review and revise its inspection report

preparation process for those containing enforcement actions to ensure timely issuance

of inspection findings. (Section 3.1)
New Hampshire Final Report Page 3

Current Status: The current review found that the Bureau had communicated inspection

results to the licensee in a timely manner for 13 of the 16 core licenses inspected. This

recommendation is closed. 

3. The review team recommends that the State evaluate the number of staff needed to

implement the program. (Section 3.2)

Current Status: In the 1997 IMPEP, the Bureau had funding for 17 staff members with

3.0 FTE assigned to the radioactive materials program. As vacancies occurred through

1999, the Bureau was successful in filling vacancies. Currently, the Bureau has funding

for 16 staff members, with 2.6 FTE devoted to the radioactive materials program. As

noted in Section 3.3, the Bureau is experiencing difficulty in hiring new staff due to a

hiring freeze. This recommendation will be incorporated into the review teamís 2001

recommendation on Section 3.3.

4. The review team recommends that appropriate State follow-up to inspections be

conducted to confirm implementation of licensee corrective actions when significant

problems have been identified. (Section 3.4)

Current Status: The periodic meeting of September 10, 1998 documented that followup inspections were being scheduled for one year from the enforcement conferences. 

The teamís review of the casework noted that both routine and significant items of non

compliance are being followed up at the next scheduled inspection and documented in

the inspection reports. This recommendation is closed.

The 1997 review team also offered four suggestions for the Bureau to consider. The team

found that the Bureau considered the suggestions and implemented a policy concerning initial

inspections, increased their reciprocity inspections, conducted annual inspector

accompaniments, and issued a memorandum of their intent to adopt the guidance contained

in the 1997 NRC/OAS training and qualification report. This issue is further discussed in

Section 3.3. 

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) Status of Materials

Inspection Program; (2) Technical Quality of Inspections; (3) Technical Staffing and Training;

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

3.1 Status of Materials Inspection Program

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

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

licensees. The review teamís evaluation is based on the Bureauís questionnaire responses,

data gathered independently from the Bureauís inspection data tracking system, the

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

A review of the Bureauís inspection priorities revealed that the inspection frequencies for the

various types of licenses are the same as similar license types listed in NRC Inspection Manual
New Hampshire Final Report Page 4

Chapter (IMC) 2800. The Bureau has a procedure whereby the listing of inspections due is

available to the inspectors. The inspectors use this list to determine their inspection schedules. 

The Bureau can extend the inspection frequency based on the compliance history of the

licensee. The review team found that the Bureau was extending the inspection frequency but

the team was not able to determine the basis of any extensions granted during this period. The

review team recommends that the process for extending inspection frequency for good licensee

performance be clearly defined and that the Bureau maintain documentation of inspection

extensions.

At the time of the onsite review, 3 of 21 core inspections had not been completed and were

overdue by more than 25% of the NRC inspection frequency. One of the overdue core

inspections is a Priority 2, broad scope licensee, which is presently overdue by approximately

one and one-half years. Two additional overdue core inspections were conducted during the

review period. Thus, 5 of 21 inspections were either overdue when completed or were overdue

at the time of the review. 

The Bureau has experienced difficulty in completing core inspections for several years. In the

1997 IMPEP review, the review teamís preliminary findings were that the program be found

unsatisfactory because 33% of the core inspections conducted exceeded NRC frequencies. In

response to the draft report and at the MRB, New Hampshire management stated that they had

completed all the overdue inspections and implemented measures to ensure performance in

this area. Based on the information supplied and discussions held during the MRB, the finding

was revised to satisfactory with recommendations for improvement.

The Bureau had no overdue inspections in 1999, but was unable to maintain performance in

this area after 1999. The Section Supervisor explained that staffing shortages prevented the

Bureau from completing their inspection goals. 

The Bureauís policy is to conduct initial inspections of new licensees within one year of license

issuance for Priority 4 and lower priority licenses. The teamís evaluation of licensing actions

determined seven new licenses, Priority 4 or lower, were issued during the review period. Only

four of these licensees were due for inspection during the review period. One new licensee

was inspected within one year of license issuance, three were inspected more than one year

after license issuance. The team also noted that new licenses were hand delivered to the

licensees. The inspectors used the opportunity to discuss the requirements of the license and

regulations with the licensee, and to verify that the equipment and facilities were as represented

in the license application. The Bureau does not consider these new license visits as

substituting for the initial inspection. The review team noted that the Bureauís initial inspection

frequency is different from NRC IMC 2800, however, after the 1997 IMPEP review, the MRB

found the Bureauís policy to conduct initial inspections of Priority 1, 2 and 3 within six months,

and those licensees with inspection priorities lower than Priority 3 inspected initially within 12

months based on the risk to be acceptable. However, the Bureau was unable to meet their

inspection priority frequency. The review team recommends that the Bureau take the

appropriate management measures to conduct inspections (both initial and core) in accordance

with the Stateís established inspection priority system.

During the inspection casework review, the team evaluated the timeliness of the Bureau in

providing inspection findings to the licensee. Of the 16 inspections reviewed, three inspection

reports were issued more than 30 days after the inspection date. One was issued 5 days late,
New Hampshire Final Report Page 5

the other two were issued at 51 days and 90 days beyond the 30-day goal for issuance of

inspection reports.

To evaluate the reciprocity inspection program, the team reviewed reciprocity inspection files

and the Bureauís response to the IMPEP questionnaire. Overall during the review period, the

Bureau did meet the goals established in IMC 1220.

Under MD 5.6, if more than 25% of the core licensees are inspected at intervals that exceed

NRC frequencies, the indicator finding should be unsatisfactory. The review team determined

that 32% of the core inspections (including initial inspections) were conducted or will be

conducted at intervals that exceed NRC frequencies.

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

performance with respect to the indicator, Status of the Materials Inspection Program, be found

unsatisfactory.

3.2 Technical Quality of Inspections

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

notes and interviewed inspectors for 16 inspections conducted during the review period. The

casework included four of the Bureauís materials license inspectors, and covered inspections

of various types including industrial radiography, Irradiator, medical, academic and portable

gauge. Appendix C lists the inspection casework files reviewed for completeness and

adequacy with case-specific comments.

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

the licenseesí radiation control program. The review team found that the inspection reports

were thorough, complete, consistent, and of high quality, with sufficient documentation to

ensure that licenseesí performance with respect to health and safety was acceptable. The

documentation supported violations, and recommendations made to the licensee, unresolved

safety issues, and discussions held with the licensee during exit interviews. Team inspections

were performed when appropriate and for training purposes.

The inspection procedures utilized by the Bureau were consistent with the inspection guidance

outlined in NRCís IMC 2800. Inspection reports are in a format that covers all inspection areas

for each inspection type.

The Bureau has an adequate number and variety of survey instruments to support the current

inspection program. Survey instruments are calibrated at least annually by a contractor. The

team observed that the Bureau had appropriately calibrated survey instruments, such as GM

meters, scintillation detectors, ion chambers and micro-R meters. The Bureau also has a well

equipped on site laboratory, which includes a multi-channel analyzer, gas-flow proportional

counter, and liquid scintillation counting system for counting wipes, soil samples, water samples

and other samples.

During the review period, the Section Supervisor performed inspector accompaniments with

each of the staff at least annually. These accompaniments are documented in the inspection

reports.
New Hampshire Final Report Page 6

Two inspectors were accompanied by an IMPEP team member during the week of May 21,

2001. The accompaniments included inspections of a medical institution and a portable gauge

licensee. The facilities inspected are identified in Appendix C.

During the accompaniments, each inspector demonstrated appropriate inspection techniques,

knowledge of the regulations, and conducted performance-based inspections. The inspectors

were trained, well prepared for the inspection, and thorough in their audits of the licenseeís

radiation safety programs. Each inspector conducted effective interviews with appropriate

licensee personnel, observed licensed operations, conducted confirmatory measurements, and

utilized good health physics practices. Their inspections were adequate to assess radiological

health and safety at the licensed facilities. 

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

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

satisfactory.

3.3 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Bureauís 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 Bureau's questionnaire responses, interviewed

Bureau management and staff, reviewed job descriptions, and training records. The review

team also considered any possible workload backlogs in evaluating this indicator.

The Bureau is authorized for five positions in the Section. These positions include the Section

Supervisor, classified as a Health Physicist II position, and four Health Physicist I positions. All

Health Physicist staff performs duties in licensing, inspection, and event response based upon

their training and experience. In addition, the technical staff performs inspections and duties in

the Radiation Machine Section. The Bureau receives advice from the Radiation Advisory

Committee, which the Bureau Administrator is an ex officio member and by statute holds the

position of the Technical Secretary. The review team identified no conflict of interest concerns.

Successful candidates for technical positions are required to have a bachelor's degree in

science for a first level Health Physicist I position, and a master's degree or additional radiation

related work experience and training for positions beyond entry level. The team noted that all of

the staff had satisfied the degree requirements when hired.

The Bureau Administrator related that only a limited amount of funds were available for out of

State travel for training purposes, but the program was committed to providing training as

needed for the staff. The technical staff is required to obtain training in basic health physics,

and to take the core courses in radioactive material licensing, inspection procedures, industrial

radiography, medical uses of radionuclides, and radiological emergency response. The Bureau

has identified the required courses and additional training needed by the staff members, but a

schedule or plan for the completion of the training was not provided. 

The Bureau utilizes on-the-job training to supplement course work so that individuals may

achieve the required proficiency and broaden their work areas. As a part of the Bureauís inhouse and on-the-job training program, new staff members are assigned increasingly complex

licensing duties under the direction of senior staff and accompany experienced inspectors

during increasingly complicated inspections. New staff inspectors are assigned independent
New Hampshire Final Report Page 7

inspections after demonstrating competence during accompaniment evaluations by the senior

staff. 

The Section Supervisor determines when an individual is proficient and can perform assigned

tasks independently. However, there was no documentation to indicate that the individuals had

been approved for, or had achieved the required proficiencies. Although suggested in the 1997

IMPEP review, the Bureau does not have a documented training program. With the staff

turnover experienced by the Bureau, as described below, the review team discussed the

necessity of an aggressive written training plan to enable the Bureau to effectively and

efficiently qualify new staff members as they are hired. The review team recommends that the

Bureau document a training plan for personnel that is consistent with the guidance provided in

the NRC/Organization of Agreement States Training Working Group Report or the NRC

IMC 1246. 

The Bureau has experienced staff turnover since the previous review that in the review teamís

judgement, has impacted performance of the Section. All Health Physicist I positions were

vacated at least once during the period, and the Section currently has two vacant positions. 

One position became vacant on April 5, 2001, the other position became vacant during the

review week. The team was informed that these positions are currently frozen, and that a

waiver had been submitted to the Governorís office to hire a qualified replacement when the

earlier position became vacant. In addition to the Health Physicist positions, the Bureau lost

two Administrative and two Database Support personnel during the review period. 

The Bureau Administrator related that the turnover in staff resulted when experienced and

trained staff were able to transfer to other States and other programs for considerably more

money. The Bureau attempted to minimize the impact of these turnovers by transferring other

qualified technical personnel from the Radiochemistry Section to fill the Health Physics

positions, and the two administrative positions were filled from other State government

positions. The Nuclear Materials Event Database (NMED)/data support positions were lost. 

The team believes that these turnovers, and the difficulty in filling the frozen positions are part

of the root causes of the decline in the performance of the Bureau. As noted in Sections 3.1,

3.4, 3.5 and 4.1, the Bureau has experienced workload backlogs in conducting inspections,

completing evaluations of licensing applications, processing license documents, tracking

incidents and allegations, and adopting regulations for compatibility. The review team

recommends that the Department take the necessary actions to address the staff turnover and

staff vacancies as appropriate.

The Bureau reported that 2.6 FTEís were utilized by the Section which includes clerical time

and time for emergency exercises and incident response. The Bureau Administrator noted that

the four Health Physicists divided their activities equally between the Section and the Radiation

Machine Section. Section staff rotates from one Section to the other on a periodic basis,

currently every two months. These duties are also depicted in the Bureau organizational chart. 

The current staff favors working on assignments in both sections because it allows technical

staff to maintain their skills in each Section area and provides backup capabilities for each area. 

However, the team has concerns about the efficiency of frequent rotation of assignments and

discussed with management the impacts it has had on the inspection program, the timely

issuance of enforcement letters, and the timely review of license applications and issuance of

deficiency letters. The review team noted that a customer service survey was conducted by the

Radiation Advisory Committee to examine their licenseesí perspective on the Bureauís services. 
New Hampshire Final Report Page 8

Results of the survey are under review by Bureau staff.

 

The team believes that Bureau management needs to examine and change the business

process and organization of the Section on the basis of the high staff turnover and the staff

vacancies, as well as improving the effective use of personnel. The review team recommends

that the Bureau examine and change the business processes and organization of the Section to

improve the effectiveness and efficiency of the program. 

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

performance with respect to the indicator, Technical Staffing and Training, be found satisfactory

with recommendations for improvement.

3.4 Technical Quality of Licensing Actions

The review team examined completed licensing casework and interviewed the staff for

16 specific licenses. Licensing actions were evaluated for completeness, consistency, proper

isotopes and quantities used, qualifications of authorized users, adequate facilities and

equipment, and operating and emergency procedures sufficient to establish the basis for

licensing actions. Licenses were evaluated for overall technical quality including accuracy,

appropriateness of the license, its conditions, and tie-down conditions. Casework was

evaluated for timeliness; adherence to good health physics practices; reference to appropriate

regulations; financial assurance, documentation of safety evaluation reports, product

certifications or other supporting documents; consideration of enforcement history on renewals;

pre-licensing visits, peer or supervisory review as indicated; and proper signature authority. 

The files were checked for retention of necessary documents and supporting data.

The licensing casework was selected to provide a representative sample of licensing actions

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

industrial radiography, manufacturing, medical institution (diagnostic, therapy, brachytherapy,

and high dose afterloader), academic broad scope, research and development, calibration

service, fixed gauge, and portable gauge licenses. Types of licensing actions selected for

evaluation included two new licenses, 12 amendments to existing licenses, and two license

terminations. A list of the licensing casework evaluated with case-specific comments can be

found in Appendix D.

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

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

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

necessary to support their request. The review team noted that the Section Supervisor would

prepare guidance for new materials uses or modalities for use by the staff and/or licensees to

ensure that licensing actions properly addressed health and safety issues. Complicated

deficiencies were addressed in letters and telephone conversations were used to document

simple deficiencies and placed in the license file. The review team noted that the staff had

access to standard deficiency paragraphs but they were not always used. Additional impact on

the timeliness of licensing actions included: 1) the delay in assignment of actions to individual

reviewers; 2) the rotation of staff between the Section and the Radiation Machine Section every

two months during which time, the reviewer only conducts regulatory activities in the Radiation

Machine Section; and 3) the staff turnover during the review period. The review team found

that seven of the 14 amendments and new actions reviewed took more than six months to
New Hampshire Final Report Page 9

complete (range of seven to 32 months).

The Bureau has a policy to review and renew licenses in their entirety every seven years. 

Licenses are administratively renewed on an annual basis by issuing an amendment to the

license that updates the expiration date. This ìsimple renewalî is handled by the Bureauís

clerical staff with review by the Section Supervisor. The review team noted that the Bureau has

not conducted renewals of licenses during the review period. Some licenses were last reviewed

in the late 1980s, listed a large number of documents in the tie-down condition, and referenced

portions of the regulations that are now superceded. The Section Supervisor indicated that full

technical reviews of licenses were not done due to the backlog of new and amendment actions

as well as staffing issues. The team reviewed several licenses to determine if there were any

health and safety implications from the lack of license renewals during the review period. The

review team did not find any health and safety implications with the exception that the Stateís

two academic broad scope licensees were authorized radioactive material in quantities

requiring financial assurance for decommissioning but no financial assurance was submitted to

the State. Upon further evaluation by the review team and discussion with the Section

Supervisor, these licensees do not actually possess quantities of radioactive materials requiring

financial assurance for decommissioning. The Section Supervisor stated that action will be

taken to either have these licensees submit financial assurance or reduce their possession

limits to levels such that it is not required.

The review team found that the New Hampshire program is addressing health and safety issues

during the licensing process. Notwithstanding the quality of the licensing demonstrated by the

New Hampshire program, the review team believes that the problems with timeliness of new

and amendment licensing actions and the lack of a full review of a licenseeís radiation safety

program on a periodic basis (i.e., license renewal) could result in health and safety issues not

being addressed. The review team believes that the evaluation of the business processes in

the licensing area as part of the recommendation in Section 3.3 should address the goals of

improving timeliness and renewing licenses in full accordance with the Bureauís policy.

Deficiency letters are signed by the reviewer after discussion or review with the Section

Supervisor. The Section Supervisor documents his review of all licensing actions to ensure that

all health and safety issues are addressed. All licenses evaluated were signed by the Bureau

Administrator or the Section Supervisor. The Bureau has recently started to issue amended

licenses in their entirety which is superceding the long-standing practice of issuing

supplemental sheets which only addressed the amended portions of the license.

The team found that actions involving terminated licenses were well documented, and included

the appropriate material survey records. All files reviewed contained documentation of proper

disposal or transfer. No potentially contaminated sites formerly licensed by NRC have been

identified in New Hampshire. 

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

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 Bureauís actions in responding to incidents, the review
New Hampshire Final Report Page 10

team examined the Bureauís response to the questionnaire relative to this indicator, evaluated

selected incident files since the last review, including those reported for New Hampshire in the 

NMED against those contained in the Bureauís casework and license files, and supporting

documentation, as appropriate for eight incidents. A listing of the incident casework examined

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

response to eight allegations involving radioactive materials including one allegation referred by

the NRC during the review period. 

The review team discussed incident and allegation procedures, file documentation, the

Bureauís incident and allegation tracking system, NMED, and notification of incidents to the

NRC Operations Center with the Bureau management.

The team found that responsibility for initial response and follow-up actions to materials

incidents and allegations rest solely with the Bureau. The Supervisors from both the Section

and the Radiation Machine Section and other staff as appropriate, evaluate incidents to

determine the appropriate response. Bureau management evaluate all complex incidents, and

those with potential for affecting public safety.

 

The Bureauís files contained documentation on 17 materials incidents during the review period,

seven of which were reportable in the NMED system. Eight casework incidents selected for

review included: two misadministrations; two calibration errors; three incidents involving

contaminated scrap metal; and the recovery of a generally licensed gauge. The review team

found that the Bureauís response to incidents was complete and comprehensive. Initial

responses were prompt and well coordinated and the level of effort was commensurate with the

health and safety significance. The Bureau dispatched inspectors for on-site investigations

when appropriate, and took suitable enforcement and follow-up actions. Actions were

coordinated with other agencies, as appropriate, and the team determined that all incidents

required to be reported, were reported to the NMED contractor and the NRC as appropriate.

The Bureau has a current copy of the Handbook of Office of State and Tribal Programs (STP)

Procedure SA-300, ìReporting Material Events,î for use. However, because of recent turnovers

in the Section staff, the Section Supervisor is currently the only person trained on submitting

incident reports to NMED. The team noted that the Bureauís Incident and Allegation Tracking

System is currently not being utilized, and the Incident File Index has not been updated since

the last entry on October 16, 1998 because of staff turnover and higher priority work. Although

no performance issues were identified by the review team associated with the lack of use of the

Sectionís data systems for incidents and allegations, the review team was concerned about the

management oversight of activities conducted under this indicator. The review team believes

that as the Bureau examines its business processes to improve efficiencies and effectiveness

of the program, that activities under this indicator should also be reviewed to improve and

update practices. As part of the training plan recommended in Section 3.3, the review team

discussed the need to provide training in STP Procedure SA-300 for new staff with the Bureau

management. 

During the review period, one allegation was referred to the Bureau by the NRC, and the

Bureau received seven allegations directly. All allegations were reviewed by the team. The

casework indicated that the Bureau took prompt and appropriate action in response to the

concerns raised and made every effort to protect the allegerís identity. All of the allegations

reviewed were appropriately closed with written letters to the alleger, as appropriate. The team
New Hampshire Final Report Page 11

noted that allegations were treated and documented internally in the same manner as incidents. 

There were no performance issues identified from the review of the allegation files and

documentation. 

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

performance with respect to the indicator, Response to Incidents and Allegations, be found

satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

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

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

and (4) Uranium Recovery Program. The New Hampshire Agreement State Program does not

cover uranium recovery operations, 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

In evaluating this indicator, the team reviewed the Bureauís response to the questionnaire and

copies of legislation, and held discussions with the Bureau Administrator and the Section

Supervisor. The Department is authorized as the Stateís radiation control agency under the

New Hampshire Revised Statutes Annotated (RSA) 1990, Chapter 125. The radiation control

program is administered by the Bureau. No changes have occurred in the legal authority of the

Bureau since the previous review. 

4.1.2 Program Elements Required for Compatibility

The New Hampshire Rules for Control of Radiation pertaining to radiation control apply to all

ionizing radiation, whether emitted from radionuclides or devices. New Hampshire requires a

license for possession, and use, of all radioactive materials.

The review team examined the procedures used in the Sectionís regulatory process and found

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

regulations. The NRC is provided with drafts for comment. After preparation of a package of

draft regulations by the Bureau, the regulations require approval by the Department

Commissioner and are provided to the public for comment, including licensees and the NRC. 

Final approval of all regulations is done by the Joint Legislative Committee on Administrative

Rules. Rule promulgation typically requires six to 12 months. Final regulations in New

Hampshire are subject to sunset law and rules expire exactly eight years after adoption. After

expiration, these regulations must be resubmitted in their entirety to remain in effect. For

example, the major revision of Standards for Protection Against Radiation (10 CFR Part 20)

adopted by the State in 1995 will expire in 2003.

The team evaluated the Sectionís responses to the questionnaire, reviewed the status of

regulations required to be adopted by the State under the Commissionís adequacy and

compatibility policy and verified the adoption of regulations with data obtained from the STP
New Hampshire Final Report Page 12

Regulations Assessment Tracking System. Since the last IMPEP review, the State adopted 14

regulations in two rule packages that became effective in August 1998 and February 1999. 

The following nine regulations are overdue. Current NRC policy requires that Agreement

States adopt certain equivalent regulations or legally binding requirements no later than three

years after they are effective. The Bureau will need to promptly address these regulations in

upcoming rule making or by adopting alternate legally binding requirements.

! ìTimeliness in Decommissioning of Materials Facilities,î 10 CFR Parts 30, 40 and 70

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

! ìLow-Level Waste Shipment Manifest Information and Reporting," 10 CFR Parts 20

and 61 amendments (60 FR 15649 and 60 FR 25983) that became effective March 1,

1998. Agreement States were expected to have an equivalent rule effective on the

same date, and this rule is designated as category B for compatibility. 

! ìTermination or Transfer of Licensed Activities: Recordkeeping Requirements,î

10 CFR Parts 20, 30, 40, 61, 70 amendments (61 FR 24669) that became effective

June 17, 1996.

! ìResolution of Dual Regulation of Airborne Effluents of Radioactive Materials; Clean

Air Act,ì 10 CFR Part 20 amendment (61 FR 65120) that became effective January 9,

1997.

! ìRecognition of Agreement State licenses in Areas Under Exclusive Federal

Jurisdiction Within an Agreement State,î 10 CFR Part 150 amendment (62 FR 1662)

that became effective February 27, 1997.

! ìCriteria for the Release of Individuals Administered Radioactive Material,î 10 CFR

Parts 20 and 35 amendments (62 FR 4120) that became effective May 29, 1997. 

Portions of the Part 20 amendment are designated as category A for compatibility.

! ìRadiological Criteria for License Termination,î 10 CFR Parts 20, 30, 40, and 70

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

amendment are designated as A or B for compatibility. 

! ìDeliberate Misconduct by Unlicensed Persons,î 10 CFR Parts 30, 40, 61, 70, 71,

and 150 (63 FR 1890; 63 FR 13733) that became effective on February 12, 1998. 

! ìMinor Corrections, Clarifying Changes, and a Minor Policy Change,î 10 CFR

Parts 20, 35, and 36 amendments (63 FR 39477; 63 FR 45393) that became

effective October 26, 1998.

The Bureau will need to address the following four regulations in upcoming rule makings or by

adopting alternate legally binding requirements:

! ìTransfer for Disposal and Manifests: Minor Technical Conforming Amendment,î

10 CFR Part 20 amendment (63 FR 50127) that became effective November 20, 1998.
New Hampshire Final Report Page 13

! ìRespiratory Protection and Controls to Restrict Internal Exposures,î 10 CFR Part 20

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

! ìEnergy Compensation Sources for Well Logging and Other Regulatory Clarifications,î

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

! ìNew Dosimetry Technology,î 10 CFR Parts 34, 36, and 39 amendments (65 FR 63749)

that became effective January 8, 2001.

The review team determined that the State has currently not adopted 13 NRC amendments to

regulations required for compatibility. Eight of these amendments are overdue and will be

adopted in a time frame greater than three years after the effective date of their adoption by the

NRC. Three of these eight amendments are designated as A or B for compatibility as indicated

above, and the ìLow-Level Waste Shipment Manifest Information and Reporting," amendment 

requires that an Agreement State adopt the amendment in the same time frame as the NRC

but no later than six months after the effective date of the NRC amendment. 

The review team concluded the delay in the promulgation of regulations in a timely fashion was

caused in part by the high turnover in staff which requires the Section Supervisor and Bureau

Administrator to divert their time and efforts to other essential program elements such as

licensing, inspection, incident response, and training of new staff. The review team

recommends that the Bureau develop and implement an action plan to adopt NRC regulations

in accordance with current policy on adequacy and compatibility.

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

performance with respect to the indicator, Legislation and Program Elements Required for

Compatibility, be found unsatisfactory.

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

The team did not evaluate the Bureau's SS&D program during this review. Although New

Hampshire currently has responsibility for this area, the Bureau did not perform any SS&D

evaluations during the period of the review. The review team verified this information by review

of the national SS&D registry and confirmed that the Bureau had not issued any SS&D sheets

during this period of review.

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

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

Discontinuance of NRC Authority and Assumption Thereof by States Through Agreement" to

allow a State to seek an amendment for the regulation of LLRW as a separate category. Those

States with existing Agreements prior to 1981 were determined to have continued LLRW

disposal authority without the need of an amendment. Although New Hampshire has LLRW 

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

disposal facility until such time as the State has been designated as a host State for a LLRW

disposal facility. When an Agreement State has been notified or becomes aware of the need to

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

will meet the criteria for an adequate and compatible LLRW disposal program. There are no

plans for a LLRW disposal facility in New Hampshire. Accordingly, the review team did not
New Hampshire Final Report Page 14

review this indicator.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team found New Hampshireís performance to

be satisfactory with respect to the indicators, Technical Quality of Inspections, Technical Quality

of Licensing Actions, and Response to Incidents and Allegations. The team found New

Hampshireís performance to be satisfactory with recommendations for improvement for the

indicator, Technical Staffing and Training. The team found New Hampshireís performance to

be unsatisfactory for the indicators Status of the Materials Inspection Program and Legislation

and Program Elements Required for Compatibility. Accordingly, the review team recommended

and the MRB concurred in finding the New Hampshire Agreement State Program to be

adequate, but needs improvement and not compatible with NRC's program. The review team

recommended and the MRB concurred that a program of Heightened Oversight be

implemented to assess the progress of the State in implementing corrective actions discussed

at the MRB meeting. The MRB requested the State prepare and submit a program

improvement plan which addresses the recommendations below. The MRB also requested that

the State submit bi-monthly status reports and participate in bi-monthly conference calls to

discuss the progress to date on the Stateís action plan. The initial conference call should be

scheduled no later than January 7, 2002. Due to the events of September 11, 2001, the MRB

directed that the follow-up review be conducted approximately one year from the date of the

October 26, 2001 MRB meeting. 

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

evaluation and implementation, as appropriate, by the State.

Recommendations:

1. The review team recommends that the process for extending inspection frequency for

good licensee performance be clearly defined and that the Bureau maintain

documentation of inspection extensions. (Section 3.1)

2. The review team recommends that the Bureau take the appropriate management

measures to conduct inspections (both initial and core) in accordance with the Stateís

established inspection priority system. (Section 3.1)

3. The review team recommends that the Bureau document a training plan for personnel

that is consistent with the guidance provided in the NRC/Organization of Agreement

States Training Working Group Report or the NRC IMC 1246. (Section 3.3)

4. The review team recommends that the Department take the necessary actions to

address the staff turnover and staff vacancies as appropriate. (Section 3.3)

5. The review team recommends that the Bureau examine and change the business

processes and organization of the Section to improve the effectiveness and efficiency of

the program. (Section 3.3)

6. The review team recommends that the Bureau develop and implement an action plan to

adopt NRC regulations in accordance with current policy on adequacy and
New Hampshire Final Report Page 15

compatibility. (Section 4.1.2)
LIST OF APPENDICES

Appendix A IMPEP Review Team Members

Appendix B New Hampshire Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Attachment August 23, 2001 Letter from Donald L. Shumway

New Hampshireís Response to Draft IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Richard L. Woodruff, NRC/RII Team Leader

Technical Staffing and Training

Response to Incidents and Allegations

Duncan White, NRC/RI Inspector Accompaniments

Technical Quality of Licensing Actions

Legislation and Program Elements Required for

Compatibility

James Peterson, SC Status of Materials Inspection Program

Technical Quality of Inspections
APPENDIX B

DEPARTMENT OF HEALTH AND HUMAN SERVICES

ORGANIZATIONAL CHARTS

ML013020147



Attachment

August 23, 2001 Letter from Donald L. Shumway

New Hampshireís Response to Draft IMPEP Report

ML012400076