DATED: APRIL 28, 1997 SIGNED BY: HUGH L. THOMPSON, JR.

Mr. J. Dale Givens, Secretary

Department of Environmental Quality

P. O. Box 82231

Baton Rouge, LA 70884-2231

Dear Mr. Givens:

On April 10, 1997, the Management Review Board (MRB) met to consider the

proposed final Integrated Materials Performance Evaluation Program (IMPEP)

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

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

program. 

Section 5, page 19, of the enclosed final report presents the IMPEP team's

recommendations. Note that there is one additional recommendation that was

identified at the MRB to implement the requirements of the "Decommissioning

Recordkeeping Documentation of Restricted Areas and Spill Sites" through legal

binding requirements until the Louisiana draft regulations have been

promulgated. Our understanding is that by conference call during the MRB

meeting, W. H. Spell, Administrator, Radiation Protection Division, committed

to implement this recommendation, as necessary. We have received your letter

dated February 28, 1997, and Mr. Spell's letter dated March 4, 1997, and

appreciate the positive actions that you and your staff have taken and are

continuing to implement with regard to our comments. No response to this

letter is necessary.

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

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

earlier evaluation.

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

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

to working with you in the future.

Sincerely, /RA/

Hugh L. Thompson, Jr.

Deputy Executive Director

 for Regulatory Programs

Enclosure:

As stated

cc: H. Bohlinger, Deputy Secretary

Department of Environmental Quality

G. Von Bodungen, Assistant Secretary

Office of Air Quality and Radiation Protection

R. Wascom, Deputy Assistant Secretary

Office of Air Quality and Radiation Protection

W. H. Spell, Administrator

Radiation Protection Division
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF LOUISIANA AGREEMENT STATE PROGRAM

OCTOBER 7-11, 1996

FINAL REPORT

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

1.0 INTRODUCTION

This report presents the results of the review of the Louisiana

radiation control program. The review was conducted during the period

October 7-11, 1996, by a review team comprised of technical staff

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

State of Georgia. Team members are identified in Appendix A. The

review was conducted in accordance with the "Interim Implementation of

the Integrated Materials Performance Evaluation Program Pending Final

Commission Approval of the Statement of Principles and Policy for the

Agreement State Program and the Policy Statement on Adequacy and

Compatibility of Agreement State Programs," published in the Federal

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

Directive 5.6, "Integrated Materials Performance Evaluation Program

(IMPEP)." Preliminary results of the review, which covered the period

September 4, 1993, to October 11, 1996, were discussed with Louisiana

management on October 11, 1996. 

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

February 14, 1997. The State of Louisiana responded in letters dated

February 28, 1997 and March 4, 1997 (attached). The State's comments

were incorporated into the final report. The Management Review Board

(MRB) met on April 10, 1997, to consider the proposed final report. 

Based on the existing NRC compatibility policy and the IMPEP evaluation

criteria, the review team recommended that Louisiana's performance with

respect to the indicator, Legislation and Regulations, be found

unsatisfactory. The compatibility findings for the Louisiana program

were re-evaluated and revised by the MRB based on the draft of

Louisiana's "Decommissioning Recordkeeping Documentation of Restricted

Areas and Spill Sites" regulation. The MRB recommended that the State

implement the requirements in the draft Louisiana's “Decommissioning

Recordkeeping Documentation of Restricted Areas and Spill Sites”

regulation through the legal binding requirements on a case-by-case

basis until the regulation is promulgated as final. The MRB final

recommendation for Legislation and Regulations is satisfactory with

recommendations for improvement. The MRB considered and concurred in

the team's overall recommendation and found the Louisiana radiation

control program was adequate to protect public health and safety and

compatible with NRC's program.

The Louisiana Office of Air Quality and Radiation Protection, within the 

Louisiana Department of Environmental Quality, is the agency that

regulates environmental radiation issues and radiation hazards. The

Secretary of this department is appointed by, and reports directly to,

the Governor. Within the Office of Air Quality and Radiation

Protection, headed by an Assistant Secretary who is also appointed by

the governor and who reports to the secretary, the Radiation Protection

Division (RPD) administers the State's radiation protection program. 

The RPD organizational charts are included as Appendix B. The Louisiana

program regulated 511 specific licenses at the time of the review. In

addition to radioactive materials, the Division is responsible for

control of machine-produced radiation, environmental surveillance,

emergency planning and response, and radon control. The review focused

on the materials program as it is carried out under the Section 274b.

(of the Atomic Energy Act of 1954, as amended) Agreement between the NRC

and the State of Louisiana.

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

non-common indicators was sent to the State on August 8, 1996. 
Louisiana Final Report Page 2

Louisiana provided its response to the questionnaire on September 16,

1996. A copy of that response is included as Appendix C to this report. 

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

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

of applicable Louisiana statutes and regulations, (3) analysis of

quantitative information from the Division's licensing and inspection

data base, (4) technical review of selected files, (5) field

accompaniments of three Louisiana inspectors, and (6) interviews with

staff and management to answer questions or clarify issues. The team

evaluated the information that it gathered against the IMPEP performance

criteria for each common and non-common indicator and made a preliminary

assessment of the radiation control program's performance. 

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

recommendations made following the previous review. Results of the

current review for the IMPEP common performance indicators are presented

in Section 3. Section 4 discusses results of the applicable non-common

indicators, and Section 5 summarizes the review team's findings and

recommendations.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

The previous routine review concluded on September 3, 1993, and the

results were transmitted to Mr. Kai David Midboe, then Secretary of the

Department of Environmental Quality on April 11, 1994. Findings of

adequacy and compatibility were withheld because of significant

deficiencies in the Indicator, Adequacy of Product Evaluations and the

fact that certain regulations were not promulgated within the 3-year

timeframe recommended by NRC. NRC conducted a follow up review of the

program on February 21-24, 1995, to evaluate the effectiveness of the

State's actions to address the recommendations from the 1993 review, and

to assess the current status of the State's program. The results of

this follow up review were transmitted to Mr. William A. Kucharski, a

later Secretary, Department of Environmental Quality on May 9, 1995. 

The Secretary was informed that the NRC staff determined that at that

time, the Louisiana program for regulation of agreement materials was

adequate to protect public health and safety, and compatible with the

regulatory program of the NRC, since all of the recommendations were

determined to have been satisfactorily resolved.

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 Staffing and Training, (3) Technical Quality of Licensing

Actions, (4) Technical Quality of Inspections, and (5) Response to

Incidents and Allegations. 

3.1 Status of Materials Inspection Program

The team focused on four factors in reviewing this indicator: 

inspection frequency, overdue inspections, initial inspection of new

licenses, and timely dispatch of inspection findings to licensees. This

evaluation is based on Louisiana's questionnaire responses to this

indicator, from data gathered independently from the State's licensing
Louisiana Final Report Page 3

and inspection data tracking system, the examination of licensing and

inspection casework files, and interviews with managers and staff.

Review of the State's inspection priorities showed that the State's

inspection frequencies for various types, or groups, of licenses are at

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

Inspection Manual Chapter 2800 (IMC 2800) schedule of frequencies. 

Inspection frequencies under the State's system range from one year to

five year intervals. The State requires more frequent inspections in

some license categories to maintain consistency with X-ray inspections. 

Some medical facilities are inspected on a two-year frequency when

compared with an NRC three-year or five-year frequency; broad academic

licenses have a one-year frequency compared with an NRC three-year

frequency; and portable gauges have a four-year frequency compared with

the NRC's five-year frequency. Level and density gauge licensees who

participate in the State's self-inspection program are extended to a

five-year inspection cycle. The inspection frequencies of licenses

selected for license and inspection file reviews were compared with the

frequencies listed in the State's data system and were consistent with

the State's system and at least as frequent as similar license types

under the IMC 2800 system.

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

October 12, 1996, only one core inspection identified in IMC 2800 was

overdue by more than 25 percent of the NRC frequency. This number is

well within the 10 percent criterion for overdue inspections of

Management Directive 5.6. This licensee was inspected on September 27,

1996. 

One new licensee was inspected at nine months rather than at a six-month

interval. One initial inspection was also found to be overdue but a

memo was in the file indicating that the inspection period had been

extended because the licensee had not received radioactive material. 

One other initial inspection of a new licensee was performed at a period

greater than the recommended six month period. During the review, it

appeared that this license was overdue by approximately 11 months. 

Subsequent to the review, the State has determined that an earlier

inspection by a regional inspector had been performed. The inspection

was performed at 8 months rather than 6 months.

Discussions with management and staff were conducted to determine how

inspections are assigned and entered into the system. The

administrative staff enters data on a monthly basis. It is noted that

the State uses a six-month interval for generating a printout. Quality

checks on the data are performed by inspectors and management using the

updated printout. Once reviewed, the computer printout is used for

inspection planning. 

The timeliness of the issuance of inspection findings was evaluated

during the inspection file review. Twenty-one files were examined. 

They covered approximately 50 inspections performed during the review

period. Most inspection correspondence was sent to the licensee within

30 days after an inspection. Inspections performed from late 1994 to

early 1996 had noticeably longer times between the inspection and the

issuance of the inspection report or Confirmatory Orders. Several cases

spanned a 10-month interval. One action was not issued, at the

direction of the Assistant Secretary, due to the long delay between the

inspection and the enforcement action. This licensee was promptly

reinspected. 
Louisiana Final Report Page 4

In early 1996, the long period of time between inspection and

enforcement action reversed. The State identified several problems in

coordinating its inspection and enforcement programs and corrected them. 

Inspection and enforcement actions are now being processed in a timely

manner.

Louisiana does not collect data on reciprocity inspections in a manner

similar to NRC. A direct statistical correlation cannot be made to the

suggested IMPEP criteria. The State reported in their response that 901

requests for reciprocity were received during the review period. In

response to the draft report, the State reported that a further review

of the Division’s database on reciprocity inspections during the review

period indicated a total of 855 reciprocity notifications, of which 249

were Priority 1, 2 or 3. These 249 notifications represented 23

different companies, some of which have Louisiana licenses. In

addition, a Texas industrial radiography licensee also having a

Louisiana license, comprised 92 of the 249 notifications (-37%). The

State reported the reciprocity database was originally written in a

manner that allowed overwriting of the previous inspection performance

data for a particular year. The State believes that this occured

because it was not anticipated that more than one reciprocity inspection

would be performed during the year. This resulted in a licensee having

only one reported (database) inspection in any year. The numbers

previously reported by the review team were lower than the actual number

of inspections performed by the Division for a particular year and also

lower than the total for the three-year review period. As a result of

the State’s additional review, a total of 10 inspections of 23 licensees

were retrieved from the database for the review period of July, 1993

through June, 1996.

Based on the new information submitted by the State, approximately 43%

of the licensees entering the State were inspected at least once. The

State noted that actual inspections were more than 10, indicating a

larger percentage of licensees being inspected during reciprocity

visits. The State indicated that their familiarity with specific

licensees in addition to compensating measures such as annual, or more

frequent, inspections by other regulatory authorities and information

sharing between the agencies provide sufficient assurance for safety. 

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

Louisiana's performance with respect to the indicator, Status of

Materials Inspection Program, be found satisfactory.

3.2 Technical Staffing and Training

Issues central to the evaluation of this indicator include the

radioactive materials program staffing level, technical qualifications

of the staff, training, and staff turnover. To evaluate these issues,

the review team examined the State's questionnaire responses relative to

this indicator, interviewed RPD management and staff, and considered any

possible workload backlogs. The RPD organization chart shows that the

Division was funded for 44 persons at the time of the review.

The Compliance Branch consists of the Surveillance Section (8

positions), the Inspection & Quality Assurance Section (5 positions),

and the Enforcement Section (7 positions). The Surveillance Section

personnel are located at seven RPD Regional Offices throughout the

State, and the personnel perform both materials inspections and x-ray

inspections. The Inspection & Quality Assurance Section personnel are
Louisiana Final Report Page 5

located in Baton Rouge, and they also perform both materials and x-ray

inspections. The personnel (15) utilized for materials inspections were

all determined to be qualified and trained in health physics and

inspection procedures. These inspectors have completed the core courses

for the types of licenses they are qualified to inspect. The team did

not identify any inspection backlogs.

The Regulatory Branch consists of a Licensing & Registration Section (9

positions), and an Emergency Planning and Response Section (6

positions). All of the materials licensing functions and the sealed

source and device evaluations are performed by 3 persons in the

Licensing & Registration Section. The Licensing Coordinator performs

most of the materials licensing actions, and was determined to have many

years experience in that function in addition to the NRC licensing

training. Two other staff persons and the Section Manager, have also

been trained in Licensing Practices. In addition, a Nuclear Engineer

attended the NRC Sealed Source & Device Workshop in September of 1995. 

The team did not identify any licensing or device evaluation backlogs

during the review. Additional discussion of Sealed Source & Device

(SS&D) personnel training is covered in Section 4.2.2.

The RPD has established qualifications for the technical positions of

Environmental Radiation Specialist (ERS) I, ERS II, and ERS III. 

Applicants at the entry level (ERS 1) are required to have a

baccalaureate degree and are assigned duties in the x-ray program until

additional training is received in health physics, nuclear medicine

uses, materials licensing, inspection procedures, industrial

radiography, well logging, and emergency response. After sufficient

training and experience, the ERS I's are eligible for promotion and for

assignment to materials licensing and/or inspection duties. Staff are

assigned increasingly complex licensing duties under the direction of

senior staff, and accompany experienced inspectors during increasingly

complex compliance inspections. Staff are required to demonstrate

competence during accompaniments by the supervisor. This information

was verified through discussions with managers and staff, review of the

questionnaire response, and review of the position descriptions. The

team determined that all staff utilized for the agreement materials

program were technically qualified by evidence of their training and

experience; however, additional training for the SS&D program is

discussed under Section 4.2.2.

The RPD Administrator reported that several persons (12) had left the

Division since the 1993 review, many left for higher paying jobs, or to

return to graduate school. Retaining qualified personnel was reported

as a continuing problem. The Division, however, has been able to

recruit qualified people and provide training as needed to maintain the

workload in the agreement materials area. The organization chart showed

2 vacancies in the Emergency Response Section, and 1 vacant ERS III

position and a vacant Coordinator position in the Inspection & Quality

Assurance Section. The Coordinator's position duties are currently

being fulfilled with an ERS III person. The State has demonstrated a

willingness to provide training for their staff and to shift qualified

personnel into the vacant positions in order to maintain current

workload in the agreement materials area.

Based on the training that program personnel have taken during the

review period, the State appears supportive of continued staff training,

and management demonstrated a commitment to staff training during the
Louisiana Final Report Page 6

review. However, the State has concerns as to the impact of NRC's

change in policy for funding State training will have on their program. 

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

Louisiana's performance with respect to the indicator, Technical

Staffing and Training, be found satisfactory.

3.3 Technical Quality of Licensing Actions

The review team examined completed licenses and casework for 60 license

actions in 36 specific license files, representing the work of two

license reviewers. The license reviewers and supervisor were

interviewed when needed to supply additional information regarding

licensing decisions or file contents. 

Licensing actions were reviewed for completeness; consistency; proper

isotopes and quantities authorized; qualifications of authorized users;

adequate facilities and equipment; and operating and emergency

procedures sufficient to establish the basis for licensing actions. 

Licenses were reviewed for accuracy; appropriateness of the license and

of its conditions and tie-down conditions; and overall technical

quality. Casework was reviewed for timeliness; adherence to good health

physics practices; reference to appropriate regulations; documentation

of safety evaluation reports; product certifications or other supporting

documents; consideration of enforcement history on renewals; prelicensing visits; peer or supervisory review as indicated; and proper

signature authorities. The files were checked for retention of

necessary documents and supporting data.

The license casework was selected to provide a representative sample of

licensing actions which had been completed in the review period and to

include work by all reviewers. The sampling included 26 of the State's

major licenses and included the following types: source and device

manufacturing and distribution, industrial radiography (temporary and

fixed job sites), mobile nuclear medicine, teletherapy, academic and

medical broad scope, and nuclear pharmacy. Licensing actions reviewed

included 2 new, 16 renewals, 38 amendments, and 4 terminations. A list

of these licenses with case specific comments can be found in

Appendix D.

In general, the review team found that the licensing actions were

thorough, complete, consistent, of acceptable or higher quality, and

with health and safety issues properly addressed. Special license tiedown conditions were stated clearly, backed by information contained in

the file, and inspectable. The nine exemptions identified by the State

in the responses to the questionnaire were reviewed for this review

period. All of them had valid justifications, including a State

analysis to grant an exemption for pipeliner licensees who requested the

exemption. Three of the exemptions were granted by letter and the six

pipeliner exemptions were granted by a special license condition. The

licensee's compliance history was taken into account when reviewing

renewal applications as determined from documentation in the license

files and/or discussions with the license reviewers.

The review team found that terminated licensing actions were well

documented, showing appropriate transfer records and survey records. 

However, the licensee was not always issued a letter stating that the

site could be released for unrestricted use if the site use had involved

loose material with a half life of greater than 10 days. The team
Louisiana Final Report Page 7

recommends that the State adopt a policy of issuing unrestricted release

letters in all cases where loose material has been used, and before the

license is terminated. The review team found that the State did not

have any problem contaminated sites at this time.

The State currently utilizes a standard license condition on broad

licenses and other licenses with multiple locations of use of material

(multiple sites) that does not differentiate between what radioactive

material is authorized at each different site or location of use. This

condition could allow all authorized material on the license to be used

at all sites listed, and which was not always the intent of the license

application reviewer. The State is in the process of amending Condition

1 of licenses which authorize multiple sites of use (use locations). 

The team recommends that each location of use on multiple site licenses

be revised by license condition to specify the material authorized for

each different location of use or site. 

The State license reviewers acknowledged that licensees have not been

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

exclusive federal jurisdiction according to All Agreement States Letter

SP-96-022. Licenses which allow for temporary job sites have not been

amended to include a requirement to file for reciprocity when on sites

which are exclusive federal jurisdiction. The review team recommends

that all licensees be notified according to the All Agreement States

Letter SP-96-022 which requests licensees to file for reciprocity when

performing work under exclusive federal jurisdiction. Licenses which

allow for temporary job sites should be amended to state that a

reciprocity request will be filed when conducting work under exclusive

federal jurisdiction.

Licenses were renewed on varying frequencies which generally

corresponded to the inspection frequency. The longest period for

renewal was five years and the shortest period was two years. Licensees

are tied down to previously submitted applications and supporting

documentation which is no older than seven years. An entirely new

application is required at least every seven years to maintain the most

current information in the license file. 

The license reviewer passes each licensing action up through the

supervisory chain for review. All licensing actions are signed by the

Assistant Secretary of the Office of Air Quality and Radiation

Protection.

The review team found that the current staff is well trained and

experienced in a broad range of licensing activities. The casework was

reviewed for adequacy and consistency with the NRC procedures. The

State does not have official, written administrative procedures for

licensing reviews. They follow their licensing guides during the review

process to ensure that licensees submit the information necessary to

support the license. The licensing guides were very similar to the NRC

guides. Based on the review of license files and discussions with the

staff, the review team does not believe that written administrative

procedures are necessary.

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

Louisiana's performance with respect to the indicator, Technical Quality

of Licensing Actions, be found satisfactory.
Louisiana Final Report Page 8

3.4 Technical Quality of Inspections

The team reviewed the inspection reports, enforcement documentation, and

the database information for more than 50 inspections conducted during

the review period. The casework included all but four of the State's

materials inspectors. The inspectors not included in the sampling are

the newest members of the staff and are not yet fully qualified. The

review covered a sampling of the high priority categories of license

types as follows: five industrial radiography, five medical, one

nuclear pharmacy, one broad medical, one broad academic, one academic,

one well logging, and one portable gauge, and five reciprocity

inspections. Appendix E provides a list of the inspection cases

reviewed with case-specific comments.

In addition, several spot checks were performed on the files to verify

proper inspection frequencies and that enforcement correspondence was

being maintained in a consistent manner. In almost every case the files

selected for review were determined to have the proper inspection

frequency. The review of inspection and licensing files was coordinated

during the review. This provided some insight into how the State

coordinates inspection findings with licensing actions. 

The inspection procedures and techniques utilized by the State were

reviewed and determined to be consistent with the inspection guidance

provided in IMC 2800. The inspection report forms were found to be

consistent with the types of information and data collected under IMC

2800. The report forms provided documentation of inspection findings in

a consistent manner and in accordance with State policies and internal

procedures. The State uses separate inspection report forms for various

classes of license types, such as medical, portable gauges, fixed

gauges, industrial radiography, accelerators, irradiators, gas

chromatographs, broad licenses, and service type licenses. The

inspection form provides documentation of licensee and radiation safety

organization, scope of the licensee's program, material uses,

procedures, leak tests, surveys, instrumentation, dosimetry, incidents,

interviews with staff, confirmatory surveys, items of noncompliance, and

exit interviews. The inspection form is used to create a narrative

report of the inspection. 

The review team found narrative inspection reports contained accurate

information and met the State's requirements. The narrative report

provides a brief, clear, discussion of the inspection and relevant

findings. The reports are sufficiently detailed to support escalated

enforcement actions. The State's enforcement letters are formal in

style, detail and language. The State uses a tracking system to follow

enforcement actions. This system was found to be up-to-date and was

used to verify the status of pending enforcement actions and in

resolving questions regarding missing documentation in the license file. 

Most files contained complete inspection findings and related

enforcement correspondence. However, the team noted in several cases

that certain documents related to inspections or related enforcement

documentation were not in the license file. The staff was generally

able to locate missing documents for selected files within a short time,

but not in all cases as documented in the inspection casework listing,

Appendix E. From a "performance" standpoint, the team believes that

better quality control is needed to assure that official documentation

concerning inspection and enforcement is maintained in the official file

folder. The review team suggests that the State re-evaluate their
Louisiana Final Report Page 9

document control system, and take appropriate measures to assure that

files are maintained, complete, and up-to-date. 

Three inspector accompaniments were performed by a review team member

during the period of September 23-24, 1996. Two inspectors were

accompanied in Shreveport, Louisiana area and one in Baton Rouge,

Louisiana. The accompaniments in Shreveport involved two fixed

radiographic facilities and one field radiography operation. 

These accompani- ments are described in Appendix E. Other inspectors

have been accompanied during previous reviews.

During accompaniments, the Louisiana inspectors demonstrated appropriate

inspection techniques and knowledge of the State's regulations. The

portable instruments used during the inspector accompaniments were

observed to be operational and calibrated. The inspectors were observed

to have TLD badges, an "Escort" badge, a direct reading dosimeter and

alarming rate meter on their person during the inspections. The

inspectors were well prepared and thoroughly knowledgeable of the

licensees' radiation safety programs. Overall, the technical

performance of the inspectors was exceptional. Their inspections

conformed to State guidance and were more than adequate in scope and

detail to assess radiological health and safety at the inspected

facilities.

In response to the questionnaire, the State reported that nine

inspectors were accompanied by supervisors during the review period. 

Based on a review of approximately 60 records, the State appears to have

a well organized supervisory accompaniment program. The evaluation

forms for each accompaniment were reviewed. The evaluations critically

assessed the inspector's ability to conduct inspections of specific

types of licensees as specifically indicated when an inspector is

qualified to perform specific types of unaccompanied inspections. 

Supervisors routinely accompany fully trained inspectors on an annual

basis. 

It was noted that the State has a variety of portable instruments for

routine confirmatory surveys and for use during incidents and emergency

conditions. The State has sufficient GM tubes, pancake probes, one inch

NaI detectors, micro-R meters, and high range instruments. A detector

with an alpha scintillator is available in the Baton Rouge office for

use by regional inspectors. Each inspector is provided a direct reading

dosimeter, a TLD badge, an "Escort" badge, and an alarming rate meter. 

Portable instruments maintained in the Baton Rouge office were also

observed to be calibrated. Program staff explained that instruments are

calibrated at least on an annual basis. The State uses a commercial

calibration and repair service.

It was found that the State performs both announced and unannounced

inspections of materials licensees. Inspections are weighted toward the

unannounced type. The State has offices distributed around the State. 

There was no geographical bias noted in the inspection program. There

appeared to be no difference in the quality of inspections between the

regional offices or between the regions and the main office in Baton

Rouge. There appeared to be no significant difference in inspection

frequency, quality or violations discovered between the samples of

announced and unannounced inspections that were reviewed. 

Inspectors sign all routine enforcement correspondence. All of the

inspection results and routine enforcement letters were verified as
Louisiana Final Report Page 10

having been reviewed and signed by the supervisor before issuing the

results to licensees. The review team concluded that this supervisory

review enhanced the quality of the inspection and enforcement documents. 

The inspectors are also cross-trained as license reviewers providing

continuity to the regulatory program. The review team agreed with

program management that the State's proposed LAN system would allow

additional standardization and implementation of inspection modules,

enforcement language, and tracking systems. 

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

Louisiana's performance with respect to the indicator, Technical Quality

of Inspections, be found satisfactory.

3.5 Response to Incidents and Allegations

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

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

to the questionnaire regarding this indicator, reviewed the incidents

reported for Louisiana in the "Nuclear Material Events Database" (NMED)

against those contained in the Louisiana files and reviewed the casework

of 14 incident files and two allegation files. No allegations were

referred from NRC to Louisiana during period covered by the review. In

addition, the review team interviewed the Administrator, the Assistant

Administrator, the Manager of the Inspection and Quality Assurance

Section and the Manager of the Enforcement Section. 

Responsibility for initial response and follow-up actions to materials

incidents and allegations rests with the Inspection and Quality

Assurance Section. Louisiana procedures require the prompt response by

RPD to each incident or allegation. Each incoming notification is

discussed with management and staff as appropriate and the response is

coordinated with the appropriate field staff including an on-site

inspection if appropriate. The managers related that all incidents,

complaints, and allegations are evaluated by management, followed up

with an inspection if possible, and recorded. 

The reviewer examined the State's response and documentation to all 14

events listed in Appendix F and verbally discussed the other events with

the Inspection and Quality Assurance Section Program Manager. This

effort included the State's incident and allegation process, tracking

system, file documentation, and notification of other Federal and State

Agencies. 

The review team found that the State's responses were well within the

performance criteria. Responses were prompt and well-coordinated, and

the level of effort was commensurate with health and safety

significance. Health Physicists were dispatched to the site when

appropriate. The State took suitable corrective and enforcement

actions, notified the NRC and other Agencies as appropriate, and

followed the progress of the investigation through until close out. 

Allegations were responded to promptly with appropriate investigations

and follow up actions. The State has procedures under their "Sunshine"

laws for the control of information, identification protection measures

are taken to protect the identity of allegers, and the results of the

investigations were documented and provided to the allegers. The review

team also found very good correlation of the State's response to the

questionnaire, the incident information in the files, and the event

information reported on the NMED system printout for Louisiana. Only

one discrepancy was noted, in that NMED event number 941466, dated March
Louisiana Final Report Page 11

18, 1994, was listed as a Baton Rouge, LA event, whereas, the event

occurred in Memphis, TN and was followed up by the State of Tennessee. 

The reason for this discrepancy was that the person (Licensee RSO) that

reported the event to the NRC Operations Center resides in Baton Rouge,

LA.

The reviewer noted that the State still has a manual system for tracking

and processing incidents and allegations. Although no performance

deficiencies were noted during the review in this area, the reviewer

discussed the merits of computerizing the tracking system, and the

utilization of the NRC national system to enter events and document

incident findings. In response, Program managers related that the RPD

is currently evaluating their needs on a Departmental level for

upgrading the various tracking functions. The review team suggested

that the State upgrade their system, and implement a computer based

system for tracking and documentation of events and allegations.

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

Louisiana's performance with respect to the indicator, Response to

Incidents and Allegations, be found satisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS

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

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

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

Radioactive Waste Disposal Program, and (4) Uranium Recovery. Louisiana

is not authorized, pursuant to its agreement with NRC, to regulate

uranium recovery operations, so only the first three non-common

performance indicators were applicable to this review.

4.1 Legislation and Regulations

4.1.1 Legislative and Legal Authority

Along with their response to the questionnaire, the State provided the

review team with copies of legislation that affects the radiation

control program. The Office of Air Quality & Radiation Protection,

Louisiana Department of Environmental Quality, is designated as the

State radiation protection agency in the Louisiana Code, Acts 1979. The

Louisiana Nuclear Energy and Radiation Control Law (LNERCL) authority is

found in Chapter 6, LA R.S. 30:2101 - 2134. Based upon discussions with

staff and the State's response to the questionnaire, the review team

confirmed that there have been no changes to the LNERCL since the

previous review on the regulation of agreement materials. The

legislative authority has been reviewed during previous reviews and

considered adequate authority to protect public health and safety. 

4.1.2 Status and Compatibility of Regulations

Louisiana's Environmental Regulatory Code, Part XV, Radiation

Protection, 5th Edition, was updated and published in January 1996. A

copy of these regulations was received and evaluated with the State's

response to the questionnaire to determine the status and compatibility

of the Louisiana regulations. The questionnaire also documents that the

regulations are subject to a "sunset" law, and will need to be reviewed

in 1999 under the law; however, the review team discussed the impact of

the review of the regulations with State management and believes that
Louisiana Final Report Page 12

the State will be able to accomplish the review with its current

resources.

At the time of the February 1995 follow-up review, the State's

regulations were found to be compatible with NRC regulations up through

the "Quality Management Program and Misadministrations," 10 CFR Part 35

amendment (56 FR 34104) which became effective on January 27, 1992. The

reviewer confirmed that these regulations and others needed as of this

1992 date had been adopted. In general, the State's practice has been

to adopt needed regulations within the recommended 3-year time frame

except as noted below.

Three NRC regulation amendments became effective in 1993 that were

listed on the "NRC Chronology of Amendments" as compatibility items, and

which needed to be adopted (if appropriate) during 1996. The first

regulation was "Licensing and Radiation Safety Requirements for

Irradiators," 10 CFR Part 36 (58 FR 7715) that became effective on

July 1, 1993. Louisiana does not have any irradiators or license

applications that would be subject to these provisions, and has elected

to postpone the adoption of the Part 36 irradiator regulations until an

application is received. Management related that the State is committed

to regulating these types of irradiators in compliance with Part 36

provisions if the need arises. In response to the questionnaire, the

State will utilize license conditions to incorporate the provisions of

Part 36, if an application for a large irradiator were to be received. 

The review team concurs on this position. The second regulation is the

"Definition of Land Disposal and Waste Site QA Program," 10 CFR Part 61

(58 FR 39628) that became effective on July 22, 1993. This regulation

is required only for those States with a low-level radioactive waste

disposal facility; however, since Louisiana has authority for disposal

of NORM waste, the State has drafted a revised definition of "Land

Disposal Facility" that is compatible with the NRC definition. The

third regulation is "Decommissioning Recordkeeping Documentation of

Restricted Areas and Spill Sites," 10 CFR Parts 30 and 40 (58 FR 39628)

that became effective on October 25, 1993. Louisiana has drafted

equivalent regulations for public comment, but they have not yet become

effective. Subsequent to the review, the State reported that both

revisions were submitted to the department’s Regulatory Development

Division on March 20, 1997, for publication of a “Notice of Intent” in

the Louisiana Register on April 10, 1997. Following the State’s

administrative procedures, a public hearing will be held, comments will

be addressed and, if necessary, the proposed regulations will be

revised. Louisiana anticipates completion about August 20, 1997. NRC

has reviewed these regulations and informed the State by letter dated

April 10, 1997 that the draft regulations were compatible. The

adoption of these regulations does not meet the 3-year timeframe for

adoption of regulations needed for compatibility.

The other regulations that will be needed for adoption are identified

from the "NRC Chronology of Amendments" as follows:

• "Self-Guarantee as an Additional Financial Mechanism," 10

CFR Parts 30, 40, and 70 amendments (58 FR 68726 and 59 FR

1618) that became effective on January 28, 1994. Note, this

rule is designated as a Division 2 matter of compatibility. 

Division 2 compatibility allows the Agreement States

flexibility to be more stringent (i.e., the State could

choose not to adopt self-guarantee as a method of financial

assurance). If a State chooses not to adopt this
Louisiana Final Report Page 13

regulation, the State's regulation, however, must contain

provisions for financial assurance that include at least a

subset of those provided in NRC's regulations, e.g.,

prepayment, surety method (letter of credit or line of

credit), insurance or other guarantee method (e.g., a parent

company guarantee).

• "Timeliness in Decommissioning of Materials Facilities," 10

CFR Parts 30, 40, and 70 amendments (59 FR 36026) that

became effective on August 15, 1994.

• "Preparation, Transfer for Commercial Distribution and Use

of Byproduct Material for Medical Use," 10 CFR Parts 30, 32

and 35 amendments (59 FR 61767, 59 FR 65243, 60 FR 322) that

became effective on January 1, 1995.

• "Frequency of Medical Examinations for Use of Respiratory

Protection Equipment," 10 CFR Part 20 amendments (60 FR

7900) that became effective on March 13, 1995. Note, this

rule is designated as a Division 2 matter of compatibility. 

Division 2 compatibility allows the Agreement States

flexibility to be more stringent (i.e., the State could

choose to continue to require annual medical examinations). 

• "Performance Requirements for Radiography Equipment," 10 CFR

Part 34 amendments (60 FR 28323) that became effective on

June 30, 1995.

• "Radiation Protection Requirements: Amended Definitions and

Criteria," 10 CFR Parts 19 and 20 amendments (60 FR 36038)

that became effective August 14, 1995.

• "Clarification of Decommissioning Funding Requirements," 10

CFR Parts 30, 40, and 70 amendments (60 FR 38235) that

became effective November 24, 1995.

• "Compatibility with the International Atomic Energy Agency,"

10 CFR Part 71 amendment (60 FR 50248) that became effective

April 1, 1996.

• "Low-Level Waste Shipment Manifest Information and

Reporting," 10 CFR Parts 20 and 61 amendments (60 FR 15649,

60 FR 25983) that will become effective March 1, 1998. 

Louisiana and other Agreement States are expected to have

that equivalent rule effective on the same date.

The review team examined the procedures used in the State's regulation

promulgation process and found that the public is offered the

opportunity to comment on proposed regulations and a public hearing that

follows the comment period. The procedures also require the proposed

regulations, proposed hearing date, hearing comments and analysis, and

the final regulations to be placed on the Department's internet home

page. Draft copies of the proposed regulations for "Decommissioning

Recordkeeping Documentation of Restricted Areas and Spill Sites,"

"Definition of Land Disposal and Waste Site QA Program," and "Timeliness

in Decommissioning" were provided during the review, and the final

regulations will be submitted to NRC.
Louisiana Final Report Page 14

The review team recommends that the State evaluate the process for

promulgating compatible regulations to better ensure that the State

meets the three-year time frame.

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

equivelent regulations to Part 20, Standards for Protection Against

Radiation. These reviews are being conducted outside the IMPEP process

and the States will be notified of the results.

Based on the existing NRC compatibility policy and the IMPEP evaluation

criteria, the review team recommended that Louisiana's performance with

respect to the indicator, Legislation and Regulations, be found

unsatisfactory. The compatibility findings for the Louisiana program

were re-evaluated and revised by the MRB based on the draft of

Louisiana’s “Decommissioning Recordkeeping Documentation of Restricted

Areas and Spill Sites” regulation. The MRB recommends that the State

implement the requirements in the draft Louisiana’s “Decommissioning

Recordkeeping Documentation of Restricted Areas and Spill Sites”

regulation through the legal binding requirements on a case-by-case

basis until the regulation is promulgated as final. The MRB final

recommendation for Legislation and Regulations is satisfactory with

recommendations for improvement.

4.2 Sealed Source and Device Evaluation Program

In evaluating the State’s SS&D program, the review team evaluated the

information provided by the State relative to this indicator in its

response to the questionnaire, reviewed the casework, registration

sheets and background files that were available, for all, except one, of

the certificates of registration sheets issued since September 1993 and

the 1994 follow-up review. The review team did not re-evaluate the

issuance of the SPEC Model 150 registration sheet because the State

worked closely with the NRC during this review process. A former State

staff member spent a week at NRC headquarters working with NRC staff on

the technical review of this application. During the IMPEP review, the

State was unable to locate some of the proprietary information that had

been stored separately from the non-proprietary information for several

SS&D applications. Subsequent to the review, the State has reported

that the proprietary information has been located. During the review,

NRC staff and Louisiana staff had recalled working with this

information. Further, the proprietary files were reviewed during the

1994 follow-up visit. It is important to note that although some

pertinent written supporting information and drawings could not be

located, the review team was able to use verbal NRC staff and State

staff interviews to address issues and questions that were identified

during the IMPEP review. This was only possible because the State and

NRC exchanged a lot of information during this review period. The

States's staff qualifications and handling of incident and defects

associated with sources and devices were also reviewed.

The State suffered a significant set back in its SS&D program by the

loss of a staff member who performed the majority of the product

evaluations. No reviews have been completed under the program since the

loss of this staff member. There are presently two administrative

actions waiting review and one unusual technical review involving

splicing of source assembly cables. The technical staff reviews the

product using NRC guidance and regulatory guides in this area. The

second signature is performed by the program manager; in this case the

program manager's review is only for administrative type issues. A
Louisiana Final Report Page 15

second, less technical review, is conducted by the Administrator on all

sheets before they are distributed, but the Administrator does not sign

them. 

4.2.1 Technical Quality of the Product Evaluation Program

The review team reviewed the files that could be located and performed

staff interviews for the nine new or revised SS&D registry sheets issued

since the September 1993 review, including the state review and approval

for licensing purposes of new radiography sources and brachytherapy

sources and a custom gauging source. Modification to the Omnitron

remote afterloading brachytherapy device registration was also made to

allow for, and storage of, higher activity sources in the storage

container prior to installation in the afterloader. The SS&D registry

sheets issued by the State and evaluated by the review team are listed

in Appendix G. Overall, the quality of the evaluations was good with

minor technical comments and showed a drastic improvement since the

September 1993 review of the program. The review team found that the

State had developed procedures for preserving the integrity of

proprietary information furnished by the manufacturer for issuing SS&D

registry sheets; however, they were not able to locate the files for

review during this evaluation. The missing information is necessary to

assess the effect of a change to a radiography source as a result of

some problems in the field. Note, the State had reported that the files

had been located. It is suggested that the State review this data

before making a determination of acceptability of the source. The

review team found that the State's plan to develop and modify

registration sheets identified in the 1993 review had not progressed. 

With the implementation of NRC 10 CFR 34.20 equipment requirements, the

registration sheets identified in the 1993 review which required

modification, are for products that are not legal to use. The State did

not expend any additional resources to address this issue nor did they

implement the additional staff review as stated in the plan. The review

team identified the following items that need action by the State: (a) 

An additional staff member with industry experience in source

fabrication, equipment design, and fabrication should be available to

supplement the staff responsible for review of the product evaluation. 

This item is critical now, given the lack of experience with the

industry of the State lead technical reviewer. (b) Review propriety

information that was previously missing before final action is taken on

pending source and device amendment requests. This is of particular

importance because of a pending request to splice/repair source

assemblies by using a compression sleeve in the middle of the cable. 

The State must carefully review this proposed change for affect on the

flexibility and on the endurance of the radiography system. c) Determine

how the custom gauging source chains are held together when they are

placed in use as insertion gauges.

4.2.2 Technical Staffing and Training

The State was developing a two-person team both with nuclear engineering

degrees to conduct product reviews. Both persons attended the NRC

Workshop on SS&D evaluations. The loss of the more experienced member

of this team poses a challenge for the State. The newest addition to

the team demonstrated to the review team the ability to understand and

interpret the information submitted by applicants as described in the

performance criteria. This member has attended the workshop but has not

performed independent SS&D evaluations. The State staff discussed with

the IMPEP review team a request granted for this State reviewer to work
Louisiana Final Report Page 16

with the Sealed Source Safety Section at NRC Headquarters, which the

Sealed Source Safety Section has extended. The State's management is

considering that option. The State expressed concern about the need for

attending virtually all the NRC courses and the lack of State funding to

pay for NRC course training. The review team is aware that the loss of

a fully trained and experienced reviewer presents potential for weakness

to develop in the program. However, we believe that these potential

weaknesses can be offset by: (a) an additional staff member with

industry experience in source fabrication, equipment design, and

fabrication available to supplement the staff responsible for review of

the product evaluation identified above in Section 4.2.1, and (b)

implementing a training program for SS&D technical reviews, to develop

an understanding of the industry and its unique environmental factors

that are associated with the use and manufacture of sources and devices. 

The review team recommends that the State develop and implement a

training program for SS&D reviewers.

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

The State evaluated incidents associated with two radiography cameras,

the SPEC 2-T and the SPEC 150. The SPEC 2-T incident was not fully

investigated because the effective date of the NRC equipment performance

rule made this camera no longer legal to use. The SPEC 150 camera was

investigated, and the vendor took corrective action in one case to

replace a drive cable connector with a stainless steel part and in

another case to redesign the source assembly to eliminate the solid

connector locking ball assembly to reduce the possibility of source

hangups. Because of the loss of staff, the State has not notified other

regulatory authorities of this design modification. The review team

recommends that the State follow up on this incident to ensure that the

SS&D sheet is modified and properly distributed.

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

the State of Louisiana's performance with respect to the indicator,

Sealed Source and Device Evaluation Program, be found satisfactory with

the recommendations for improvement noted above. 

4.2.4 Site Visit

On October 8, 1996, NRC staff and Louisiana staff performed a site visit

of Amersham Corporation’s service center located in Baton Rouge, LA. 

One objective of the site visit was to develop an understanding of the

operation and its interaction with the Amersham facility in Burlington,

Massachusetts. The second objective was to introduce the new sealed

source and device reviewer to the types of radiography equipment,

equipment problems, and service facilities that the radiography industry

depends on. The visit was also timely because this reviewer was

reviewing a radiography source assembly, and he had never seen an

assembly or how it relates to the radiography camera, guide tubes,

collimators, and control cables. We understand that the State has plans

for this reviewer to visit with other source and device vendors and

users as part of his development plan.

The Amersham facility provides service, repair and source exchange

operations for mostly local radiography firms. The facility also

repairs and calibrates survey meters, and analyzes leak test samples. 

The facility employs about five people and also sells an entire line of

film supplies and supporting equipment needed by radiographers. The

facility is audited periodically by Amersham Massachusetts for
Louisiana Final Report Page 17

conformance to the corporate quality assurance program. The facility

has a small hot cell with additional shielding behind the unit for

performing source exchanges. The Louisiana reviewer was able to witness

first hand the effects of environmental conditions and abuse of

radiography equipment. 

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

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

States and NRC in Discontinuance of NRC Authority and Assumption Thereof

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

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

existing Agreements prior to 1981 were determined to have continued LLRW

disposal authority without the need of an amendment. Although Louisiana

has 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, it is expected to put in place a

regulatory program which will meet the criteria for an adequate and

compatible LLRW disposal program. There are no plans for a LLRW

disposal facility in Louisiana. Accordingly, the review team did not

review this indicator.

5.0 SUMMARY

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

performance with respect to each of the common performance indicators to

be satisfactory and the non-common indicators Legislation and

Regulations and Sealed Source and Device Evaluation Program to be

satisfactory with recommendations for improvements. Accordingly, the

team recommended, and the MRB concurred in finding the Louisiana program

to be adequate to protect public health and safety and compatible with

NRC's program. 

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

in earlier sections of the report, for consideration by the State. 

1. The team recommends that the State adopt a policy of issuing

unrestricted release letters in all cases where loose material has

been used, and before the license is terminated (Section 3.3).

2. The team recommends that each location of use on multiple site

licenses be revised by license condition to specify the material

authorized for each different location of use or site (Section

3.3).

3. The review team recommends that all licensees be notified

according to the All Agreement States Letter SP-96-022 which

requests licensees to file for reciprocity when performing work

under exclusive federal jurisdiction. Licenses which allow for

temporary job sites should be amended to state that a reciprocity

request will be filed when conducting work under exclusive federal

jurisdiction (Section 3.3).

4. The review team suggests that the State re-evaluate their document

control system, and take appropriate measures to assure that files

are maintained complete and up-to-date (Section 3.4). 
Louisiana Final Report Page 18

5. The review team suggests that the State upgrade their tracking

system, and implement a computer based system for tracking and

documentation of events and allegations (Section 3.5).

6. The review team recommends that the State evaluate the process for

promulgating compatible regulations to better ensure that the

State meets the three-year time frame (Section 4.1.2). 

7. The MRB recommends that the State implement the requirements in

the draft Louisiana’s Decommissioning Recordkeeping Documentation

of Restricted Areas and Spill Site regulation through legal

binding requirements on a case-by-case basis until the regulation

is promulgated as final (Section 4.1.2).

8. The review team identified the following items and recommends

action by the State: (a) An additional staff member with industry

experience in source fabrication, equipment design, and

fabrication should be available to supplement the staff

responsible for review of the product evaluation. This item is

critical now, given the lack of experience with the industry of

the State lead technical reviewer. (b) Review proprietary

information that was previously missing before final action is

taken on pending source and device amendment requests. This is of

particular importance because of a pending request to

splice/repair source assemblies by using a compression sleeve in

the middle of the cable. The State must carefully review this

proposed change for effect on the flexibility and on the endurance

of the radiography system. (c) Determine how the custom gauging

source chains are held together when they are placed in use as

insertion gauges (Section 4.2.1).

9. The review team recommends that the State develop and implement a

training program for SS&D reviewers (Section 4.2.2).

10. The review team recommends that the State follow up on the

incident associated with the two radiography cameras to ensure

that the SS&D sheet is modified and properly distributed (Section

4.2.3).
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Richard L. Woodruff, RII Team Leader

Technical Staffing and Training

Response to Incidents and Allegations

Legislation and Regulations 

James Myers, OSP Status of Materials Inspection Program

Technical Quality of Inspections

Elizabeth Drinnon, Georgia Technical Quality of Licensing Actions

Steve Baggett, NMSS/IMNS Sealed Source and Device Evaluation

Program
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Louisiana RPD Organization Charts

Appendix C Louisiana's Questionnaire Response

Appendix D License File Reviews

Appendix E Inspection File Reviews

Appendix F Incident File Reviews

Appendix G Sealed Source and Device Evaluation Reviews
APPENDIX B

LOUISIANA RDP ORGANIZATION CHARTS