February 5, 2002

Mr. John M. Leonard

Assistant Commissioner for Environment

Department of Environment and Conservation

401 Church Street

L&C Tower, 21st Floor

Nashville, TN 37243-0435

Dear Mr. Leonard:

On January 22, 2002, the Management Review Board (MRB) met to consider the proposed final

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

Agreement State program. The follow-up IMPEP review was conducted on October 22-25, 2001. 

The MRB found the Tennessee program adequate but needs improvement, and compatible with

NRC’s program.

Based on the follow-up review, the Tennessee program has improved. Of the four indicators

reviewed during the follow-up review, the MRB supported changing the performance rating to the

next higher rating for three indicators (Technical Quality of Inspections, from unsatisfactory to

satisfactory with recommendations for improvement; Response to Incidents and Allegations, from

satisfactory with recommendations for improvement to satisfactory; and Legislation and Program

Elements Needed for Compatibility from unsatisfactory to satisfactory with recommendations for

improvement). The performance rating for the remaining indicator, (Status of Materials Inspection

Program, unsatisfactory) will remain the same. The MRB concluded that the inspection program

has made progress, but the timeliness of inspections, issuance of the reports, and some technical

aspects of the inspection program are still in need of improvement. 

Section 4.0, page 13, of the enclosed final report presents the follow-up IMPEP team’s

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

recommendations within 30 days from receipt of this letter. In your response to the

recommendations, we would like an outline of the actions and expected dates for operation of the

program without a significant inspection backlog and the schedule for adoption of regulations

needed for compatibility and adequacy.

Based on the results of the current IMPEP follow-up review, the next full review will be in

approximately two years. Also the next periodic meeting will take place in one year and the

Regional State Agreements Officer will conduct quarterly calls with Division management to follow

the Division’s progress.
John M. Leonard - 2 -

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

continuing support of the Division 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: Milton H. Hamilton, Commissioner

Tennessee Department of Environment 

 and Conservation

Lawrence E. Nanney, Director

Division of Radiological Health
John M. Leonard - 2 -

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

continuing support of the Division 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: Milton H. Hamilton, Commissioner

Tennessee Department of Environment 

 and Conservation

Lawrence E. Nanney, Director

Division of Radiological Health

bcc: Chairman Meserve

Commissioner Dicus

Commissioner Diaz

Commissioner McGaffigan

Commissioner Merrified

Distribution:

DIR RF DCD (SP01) 

SDroggitis PDR (YEST)

KSchneider 

LRakovan

LBolling, ASPO

RWoodruff, RII

JPelchat, RII

FCameron, OGC

BHamrick, CA

STreby, OGC

JLieberman, OGC

DCool, NMSS 

GDeegan, NMSS

TCombs, OCA (2) 

Tennessee File

DOCUMENT NAME: I:\Reviews\TN02\2002 TN Final IMPEP Rpt and letter.wpd

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

OFFICE STP STP:DD STP:D DEDMRS

NAME DMSollenberger:gd JMPiccone PHLohaus JPiccone for CJPaperiello

DATE 02/4/02 02/4/02 02/4/02 02/5/02

 STP-AG-26
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

FOLLOW-UP REVIEW OF THE TENNESSEE AGREEMENT STATE PROGRAM

October 22-25, 2001

FINAL REPORT

 U. S. Nuclear Regulatory Commission
Tennessee Follow-Up Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the follow-up review of the Tennessee Department of

Environment and Conservation (the Department), Division of Radiological Health (the Division),

conducted October 22-25, 2001. This follow-up review was directed by the Management Review

Board (MRB) based on the results of the August 21-25, 2000 Integrated Materials Performance

Evaluation Program (IMPEP) review. The MRB directed that a follow-up review of the common

performance indicators, Status of Materials Inspection Program, Technical Quality of Inspections,

and Response to Incidents and Allegations, and the non-common performance indicator,

Legislation and Program Elements Required for Compatibility, be conducted in one year based on

the unsatisfactory finding for three indicators and satisfactory with recommendations for

improvement finding for the fourth indicator. The follow-up review also included evaluation of

actions taken by the State to address the eight recommendations made during the August 21-25,

2000 IMPEP review. 

The follow-up review was conducted by a review team consisting of technical staff members from

the Nuclear Regulatory Commission (NRC) and the State of California. Team members are

identified in Appendix A. The follow-up review was conducted in accordance with the “Policy

Statement on Adequacy and Compatibility of Agreement State Programs,” published in the

Federal Register on September 3, 1997 (62 FR 46517), and the November 5, 1999, NRC

Management Directive 5.6, “Integrated Materials Performance Evaluation Program (IMPEP).”

A draft of this report was issued to Tennessee for factual comment on December 3, 2001. 

Tennessee sent factual comments by letter dated January 4, 2002 from Mr. Lawrence E. Nanney,

Director, Division of Radiological Health, Tennessee Department of Environment and

Conservation. The Management Review Board (MRB) met on January 22, 2002 to consider the

proposed final report. The MRB found the Tennessee program adequate but needs improvement,

and compatible with NRC’s program.

Based on the follow-up review, the Tennessee program has improved. Of the four indicators

reviewed during the follow-up review, the MRB supported changing the performance rating to the

next higher rating for three indicators (Technical Quality of Inspections, from unsatisfactory to

satisfactory with recommendations for improvement, Response to Incidents and Allegations, from

satisfactory with recommendations for improvement to satisfactory, and Legislation and Program

Elements Needed for Compatibility from unsatisfactory to satisfactory with recommendations for

improvement). The performance rating for the remaining indicator, (Status of Materials Inspection

Program, unsatisfactory) will remain the same. The MRB concluded that the inspection program

has made progress, but the timeliness of inspections, issuance of the reports, and some technical

aspects of the inspection program are still in need of improvement. 

The Tennessee Agreement State program is administered by the Commissioner who reports

directly to the Governor. The Division, which is located in the Department, is responsible for

implementation of all radiation programs for the State including the Agreement State program. 

The organizational chart for the Division is presented in Appendix B. At the time of the follow-up

review, the Tennessee program regulated approximately 565 specific licenses, including all types

of major licensees except for uranium mill tailings.
Tennessee Follow-Up Final Report Page 2

Prior to the follow-up review, the NRC conducted a heightened oversight program for the

Tennessee program. The program included Tennessee developing and submitting a program

improvement plan in response to the 2000 IMPEP review, followed by bimonthly conference calls

with NRC. Conference calls were held February 1, 2001, April 3, 2001, June 5, 2001, and August

8, 2001. The communications for the heightened oversight program are in Appendix C to this

IMPEP report. Tennessee’s actions and their status were reviewed in preparation for this followup review. 

The review team’s approach for conducting the follow-up review consisted of: (1) examination of

the Division’s actions during the period of heightened oversight; (2) in-depth review of the four

program indicators identified above for the period of August 26, 2000 through October 25, 2001;

(3) field accompaniments of five Division inspectors; (4) discussion of the status of the Division’s

actions to address the seven recommendations in the 2000 report; and (5) 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 the three common performance indicators,

and one non-common performance indicator, for activities conducted during the period of August

26, 2000 through October 25, 2001. Preliminary results were discussed with Tennessee

management on October 25, 2001.

Section 2 below discusses the results of the follow-up review of the Tennessee program for the

three common performance indicators. Section 3 below discusses the results of the follow-up

review of the Tennessee program for the one non-common performance indicator. Section 4

summarizes the review team's findings and recommendations resulting from the follow-up review. 

The Division’s progress in addressing other recommendations from the 2000 review and general

status of the program covered in a periodic meeting can be found in Appendix D. 

2.0 COMMON PERFORMANCE INDICATORS

The follow-up review addressed three of the five common performance indicators used in

reviewing both NRC Regional and Agreement State programs. The three indicators are: 

(1) Status of Materials Inspection Program, (2) Technical Quality of Inspections, and (3) Response

to Incidents and Allegations. 

2.1 Status of Materials Inspection Program

During the follow-up review, the review team evaluated actions taken by the Division in response

to the finding of unsatisfactory made during the 2000 IMPEP review, as well as the status of the

inspections performed since the 2000 review, and the current status of due and overdue

inspections. 

The team reviewed the timeliness of inspections performed since the last review period, the

current and projected backlog of overdue inspections, and timeliness in communication of

inspection results to licensees. The team reviewed data provided by the Division from their

inspection tracking system to determine the timeliness of inspections, and reviewed inspection

files to determine the date of the issuance of inspection results to licensees relative to the date of

inspection. 
Tennessee Follow-Up Final Report Page 3

The review team’s evaluation of the Division’s response to the first recommendation is presented

below.

Recommendation 1

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

(1) inspections are conducted in accordance with their assigned inspection frequencies; 

(2) inspection reports are issued in a timely manner;

(3) inspection reports and associated information are filed in a manner that the information

can be retrieved; and 

(4) deficiencies in the inspection tracking system are corrected. (Section 3.1 of the 2000

report)

Current Status

In response to this recommendation, the Division prioritized the outstanding overdue inspections

from the last review period, in order from the most overdue to the least overdue. This ensured

that those inspections that had been most delinquent (up to 42 months overdue), were performed

right away; however, it also had the result of creating a new backlog, as many inspections falling

due and becoming overdue during this period were postponed to reduce the already existing

backlog. This issue is discussed in more detail later in this section.

The Division has made some progress with respect to the timely communication of inspection

results to licensees; however, they still experience significant delays in communication in one

inspection region (one report was delayed for 10 months after the date of inspection). This issue

is discussed in more detail later in this section.

The Division has made improvements in following up on the submission of inspection reports and

related materials to the central office since the last review period. There is still a delay in the

submission of reports in one region. The problems with the inspection tracking system identified

during the last review have been corrected. 

Since the last review period, the Division performed 128 core inspections which includes initial

inspections. To evaluate the Division’s materials inspection program, the team examined the

status of 111 inspections which were not included in the previous review. There were 32 of 111

inspections (28.8%) that were overdue when performed. In addition, the Division will have

another 24 inspections that will become overdue before December 31, 2001.

Of those core inspections performed overdue during the review period, the most delinquent

inspection was performed 10 months after it became overdue, and the average delay was about

three and one-half months beyond the date after which they became overdue. The most

delinquent initial inspection was performed approximately twelve months after the date of license

issuance, and the average delay for initial inspections performed on an overdue basis was nine

months after license issuance. 

In terms of the length of delay of core inspections, the Division has improved substantially over the

last review period; however, they still have not been able to reduce the percentage of inspections
Tennessee Follow-Up Final Report Page 4

that are performed on an overdue basis. In fact, the Division has experienced an increase in the

percentage of inspections performed on an overdue basis during this review period relative to the

last (28.8% in 2001 versus 26% in 2000). The Division will be implementing a new database

management system that will allow real time status for inspection information. Division

management believes that this system should aid them in conducting the work in a more timely

manner. 

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

licensees by initially reviewing approximately two inspection files for each inspector throughout the

Division’s four regional inspection offices. For three of the offices, the random sampling indicated

that results were almost always communicated within 30 days after the date of the inspection, and

the delays identified beyond 30 days were insignificant (one to five days). In one region, however,

the initial review of two files indicated that the results of the inspections were not communicated to

the licensee until approximately 180 days after the inspection. Due to the significant delay in

these two cases, additional inspection files from this region were reviewed. In a review of 18

additional inspection files, there were 14 inspections for which the results were communicated to

the licensee more than 150 days after the date of the inspection. In one case, the delay was 300

days after the date of the inspection. The team concluded that this regional office may not have

adequate trained staff, thus impacting the timeliness for submission of inspection reports. 

Based on the follow-up review, the team considers items (1) and (2) of this recommendation open

until such time as the Division is able to reduce the percentage of inspections, performed on an

overdue basis, below 10 percent for a period of at least one year, and until steps have been taken

to ensure the timely communication of inspection results to the licensee and timely submission of

these inspection reports to the central office, for all inspection regions.

The review team concludes that the materials inspection program has shown some improvement

since the 2000 IMPEP review. However, due to the percentage of inspections still performed on

an overdue basis, and the substantial delays in communicating results of inspections to the

licensees in one inspection region, the review team believes that continued improvement in the

program is needed. Based on the IMPEP evaluation criteria, the review team recommends that

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

continues to be found unsatisfactory. 

2.2 Technical Quality of Inspections

During the follow-up review, the review team evaluated actions taken by the Division in response

to the finding of unsatisfactory made during the 2000 IMPEP review, as well as the status of the

technical quality of inspections performed since the 2000 review. 

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

interviewed inspectors for eight inspections conducted during the review period, and conducted

five inspector accompaniments. The casework included five of the Division’s materials license
Tennessee Follow-Up Final Report Page 5

inspectors, and covered inspections of various types of licensees including diagnostic nuclear

medicine facilities, a high dose-rate remote afterloader device manufacturer performing a source

replacement under reciprocity, nuclear pharmacies, academic, and industrial radiography. 

Appendix E lists the inspection casework files reviewed for completeness and adequacy and

accompaniments including case-specific comments.

The following two recommendations, including the recommendation from the indicator, “Technical

Staffing and Training” were evaluated together because training was a contributing factor to

program deficiencies for the “Technical Quality of Inspections” indicator.

Recommendation 2

The review team recommends that the Division follow the Tennessee inspection policy

and procedures. (Section 3.2 of 2000 report) 

Recommendation 5

The review team recommends that the inspection staff be trained in the Division’s policies

and procedures on the conduct of inspections. (Section 3.3 of 2000 report)

Current Status

In response to the 2000 IMPEP recommendations, the Division reviewed its inspection procedures

and provided additional training to the staff on the conduct of inspections including performancebased concepts. The Division concluded that no changes were required in the procedure. The

training was a combination of formal class work and meetings with regional staff. Topics covered

were proper documentation of inspection findings, support for notices of non-compliance,

timeliness of the conduct of inspections, and timeliness of issuance of inspection findings. The

formal class training for Division inspection staff included an “Inspecting for Performance” course

solely for Division staff (24 staff), “Inspection Procedures” course (9 staff), and “Root Cause and

Incident Investigation” course (9 staff). 

During the review period, each of the Division’s regional area managers or the supervisors

performed annual inspection accompaniments with each of their inspectors. The Division initiated

in July 2001 documentation of these accompaniments as part of their on-the-job training program. 

The review team noted that three of the four regional area managers, who perform routine

inspections, were not accompanied by Division management on an annual basis. The new

Inspection and Enforcement Manager acknowledged that he was aware of the need to conduct

the accompaniments, but did not conduct them due to other high priority work and the State travel

restrictions. Division management stated their intention is to conduct annual accompaniments for

all inspectors in the future. 

Five inspectors were accompanied by an IMPEP team member during the weeks of 

September 3 and October 8, 2001. The accompaniments included inspections of a medical

institution performing diagnostic nuclear medicine, a high dose-rate remote afterloader device

manufacturer performing a source replacement under reciprocity, a blood bank using a self-
Tennessee Follow-Up Final Report Page 6

shielded irradiator and two firms performing industrial radiography. The facilities inspected are

identified in Appendix D.

During the accompaniments, each inspector demonstrated appropriate knowledge of the

regulations and the license requirements for the licensee being inspected. Each inspector used a

combination of performance-based and compliance-based inspection techniques. The inspectors

were well prepared for the inspection, and thorough in their audits of the licensee’s radiation

safety programs. Generally, Division inspectors observed licensed operations, conducted

effective interviews with appropriate licensee personnel, requested appropriate demonstrations of

licensee radiation safety practices, and conducted confirmatory radiation measurements. No

poor health physics practices were observed during any of the accompaniments. The inspections

were adequate to assess radiological health and safety at the licensed facilities. 

The accompanying review team member observed two isolated instances where Division

inspectors missed opportunities to observe certain licensed activities. These observations were

discussed with individual inspectors and their managers after completion of their respective

inspections. In each case, the Division inspectors and their managers were openly receptive to

the observations and to suggestions regarding methods for observing licensed activities as part of

conducting a performance-based inspection. 

Recommendation 3

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

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

in the inspection report. (Section 3.2 of 2000 report) 

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

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

inspection guidance outlined in NRC’s Inspection Manual Chapter (IMC) 2800. Inspection reports

are in a format that covers all inspection areas for each inspection type.

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

significant aspects of the licensees’ radiation safety program. The review team found that the

inspection reports were generally complete, with sufficient documentation to ensure that licensees’

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

exceptions, adequately supported violations cited in Notices of Non-compliance (NONs) issued to

licensees.

The review of inspection documentation indicated that Division inspectors identified from zero to

16 violations in their reports. Three inspections identified from 8 to 16 violations, with one

inspection having six repeat violations. The review team found that the language in the NONs

sent to the licensees did not reflect increased regulatory concern over the number of documented

violations. In one case, the inspector recommended in a memorandum that Division management

consider escalated enforcement against the licensee. The cognizant regional area manager and

the Inspections and Enforcement manager did review the case, but elected to not take any

escalated enforcement. The Division has no criteria for consistently characterizing the severity of

violations or for consistently determining when escalated enforcement should be considered. 
Tennessee Follow-Up Final Report Page 7

Division management indicated that they had sent NRC’s Severity Level system to the Tennessee

Office of General Counsel (TN-OGC) for consideration in the development of a system for use by

the Division. 

A poorly performing licensee was not scheduled to be inspected any earlier than at the routine five

year interval. Division personnel stated that while it was technically possible to amend scheduled

future inspection dates, there was no Division policy or procedure to assist the staff in considering

adjustments in the inspection frequency based on poor licensee performance. In discussions with

Division management and staff, they agreed that development and implementation of a policy for

adjusting inspection frequency up or down based on licensee performance would be useful to the

program. 

The review team reviewed three inspections in which repeat violations were identified. In general,

the inspection reports did not document any inspector evaluation of the reasons why the violations

had recurred or why the corrective actions previously described by the licensee were ineffective in

preventing the recurrence of the violations. The review team discussed with Division staff and

management the need to understand and document the root cause of repeat violations, especially

those that may suggest systemic weakness in a licensee’s radiation safety program. The review

team offered to provide example language that the Division could use to develop and implement

standard language to be added to the text of NONs for communicating the Division’s heightened

regulatory concern over the number and the nature of repeat violations. 

An NON issued for several violations was not supported by the associated inspection report which

did not contain the inspector’s basis for the violations, nor a discussion of the inspector’s review of

the program areas in which these violations were identified. For another inspection file, a

supplemental letter asked the licensee to commit to specific corrective actions, including a specific

item to be documented for which there was no regulatory basis. Two other NONs identified

citations against the license’s “tie-down” condition and lacked specific information about the

regulatory requirement being cited as well as specific information about how the requirement was

violated. The review team discussed with Division management and staff the usefulness of

additional guidance to the inspection staff on (1) the structure and content of NONs to improve the

consistency of NONs, (2) the regulatory basis for cited violations, and (3) the supporting

documentation for each violation which should be included in the inspection report documenting

the finding. The review team discussed with the Division that they may want to review standard

violation language developed by the NRC and other Agreement States and consider modifying

and adopting standard violation citations. The review team also discussed with Division

management and staff the importance of ensuring senior licensee management attended closeout meetings at the conclusion of inspections that either document a large number of violations,

repeat violations, or violations that would represent a serious radiation safety concern. 

During the January 22, 2002 MRB meeting, the MRB directed the review team to expand

Recommendation 3 to indicate that the review team’s concerns are not limited to documentation of

inspections. Based on these discussions, the review team has expanded Recommendation 3 from

the 2000 IMPEP review to read as follows: “The review team recommends that the Division

ensure that inspection findings are fully supported in documentation of the inspection and that

cited violations are fully supported in the inspection report. The review team also recommends

that in order to enhance both the quality and documentation of inspections, the Division establish
Tennessee Follow-Up Final Report Page 8

and implement additional guidance for ensuring consistent, appropriate, and prompt regulatory

actions including incorporating root cause identification, especially of repeat violations.” 

The Division has an adequate number and variety of appropriately calibrated radiation survey

instruments distributed to each of the regional area offices to support the current inspection

program. Available radiation survey instrumentation include G-M meters, scintillation detectors,

ion chambers and micro-R meters. Radiation survey instruments are calibrated at least annually

by Division personnel. 

Based on the evaluation performed during the follow-up review, the review team recommends that

the previous Recommendations 2 and 5 be closed and that the revised Recommendation 3 remain

open. 

The review team concludes that the technical quality of the inspection program has shown

improvement since the 2000 IMPEP review based on the limited items identified during inspection

accompaniments and review of inspection documentation. Although the 2000 IMPEP report found

the performance with respect to this indicator to be unsatisfactory, the review team is proposing a

change in the finding from the 2000 report. Based on the IMPEP evaluation criteria, the review

team recommends that Tennessee’s performance with respect to the indicator, Technical Quality

of Inspections, be changed to satisfactory with recommendations for improvement.

2.3 Response to Incidents and Allegations

During the follow-up review, the team evaluated actions taken by the Division in response to the

finding of satisfactory with recommendations for improvement made during the 2000 IMPEP

review, as well as the status of the Division’s performance since the 2000 review.

The team reviewed the Division’s revised “Complaint/Allegation/Incident (CAI) Event Investigation

Procedure,” and examined six investigations completed during the review period, all of which were

reported in the Nuclear Material Events Database (NMED). A list of the incident casework

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

Division’s response to six allegations involving radioactive materials, including three allegations

referred to the Division by the NRC during the review period. 

The review team’s evaluation of the Division’s response to Recommendations 6, 7 and 8, is

presented below. The recommendations are discussed together, as the Division’s responses to

these recommendations are related.

Recommendation 6

The review team recommends that the Division ensure that independent, documented

evaluations of the licensee’s actions and root cause analyses are completed as part of an

incident investigation. (Section 3.4 of 2000 report)
Tennessee Follow-Up Final Report Page 9

Recommendation 7

The review team recommends that the Division formally close incident files, including a

review to ensure that all the necessary documentation is included in the file. (Section

3.4 of 2000 report)

Recommendation 8

The review team recommends that supervisory reviews be conducted to ensure

thoroughness of investigations of allegations, including that allegations are closed out with

the alleger. (Section 3.4 of 2000 report)

Current Status

In response to these recommendations, the Division instituted a supervisory review by the Deputy

Director of all closed investigations and allegations to ensure that properly documented

evaluations were included in the final investigation or allegation package, that all other relevant

information was included in the final investigation or allegation package, and that allegations had

been appropriately closed out with the alleger.

The review team evaluated six events, including a fire, the receipt of a contaminated shipment,

two unplanned contamination events, lost sources, and a therapeutic misadministration. The

review team found the Division’s response to incidents were complete and comprehensive. Initial

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

health and safety significance. The Division dispatches inspectors for onsite investigations when

appropriate, and took suitable enforcement and follow-up actions. In each of the six files, the

inspector’s reports generally provided adequate detail including root cause to support the

resolution of the investigation. All incident files had been reviewed by the Deputy Director prior to

closing each incident file. 

The review team also evaluated six allegation files, three of which were referred to the Division by

the NRC. The three allegations received directly by the Division, and their subsequent

investigation, were very well documented. The casework indicated that the Division took prompt

and appropriate action in response to the concerns raised. Two of these three were closed out in

writing with the alleger. The file for the third allegation documented diligent attempts by the

inspector to contact the alleger with the results, and was closed only after those attempts failed. A

review of the allegations referred to the State by the NRC Region II office indicated that there

were no outstanding NRC issues related to the referrals, and that the State had been very

responsive to the Regional requests when replies were needed to close out the allegations.

 

Based on the follow-up review, the review team considers these recommendations closed.

The review team concludes that the Division’s response to incidents and allegations has improved

since the 2000 IMPEP review and no performance issues were identified. Based on the IMPEP

evaluation criteria, the review team recommends that Tennessee’s performance with respect to

the indicator, Response to Incidents and Allegations, be changed to satisfactory.
Tennessee Follow-Up Final Report Page 10

3.0 NON-COMMON PERFORMANCE INDICATOR - LEGISLATION AND PROGRAM

ELEMENTS REQUIRED FOR COMPATIBILITY

3.1.1 Legislation

The review team noted that no legislation affecting the radiation control program was passed

since the previous review in which the State legislation was found adequate. Legislative authority

to create an agency and enter into an agreement with the NRC is granted in Title 68, Chapters

202-101 through 202-704 of the Tennessee Code Annotated. The Division is designated as the

State’s radiation control agency. 

3.1.2 Program Elements Required for Compatibility

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

of Environment and Conservation,” Chapters 1200-2-4 through 1200-2-12, and apply to all

ionizing radiation from agreement materials, machine produced radiation, and naturally-occurring

and accelerator-produced materials. Tennessee requires a license for possession, and use, of all

radioactive material including naturally occurring materials, such as radium, and acceleratorproduced radionuclides.

Division representatives related that there had been no changes to the process for the adoption or

amendment of regulations. Under the Rulemaking Hearing Rules procedures, all proposed rules

are reviewed internally by the Department’s OGC and by outside interested parties before a

rulemaking hearing is established. The proposed rules are published in the Tennessee

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

the hearing and for a two week period following the hearing. Any changes are made to the rules

as needed and reviewed by the OGC, signed by the Department’s Commissioner, sent to the

Attorney General’s Office for review, and become effective 75 days after being filed with the

Secretary of State. After the rule becomes effective, representatives of the Division and the OGC

may be scheduled to appear before the Government Operations Committee of the legislature for

the Committee’s approval. Rules adopted during the year are subject to sunset on June 30 of the

following calendar year, unless approved by the legislature. Historically, all rules approved by the

OGC have been approved by the legislature.

During the 2000 IMPEP review, this indicator was found to be unsatisfactory and one

recommendation applicable to regulations was made by the team. The status of the actions taken

by the Division to address the finding and recommendation is provided below.

Recommendation 9

The review team recommends that the Division adopt the regulations needed for

compatibility as expeditiously as possible and provide the proposed regulations to the STP

for compatibility review in accordance with the procedure SA-201 “Review of State

Regulations.” (Section 4.1.2 of 2000 report)
Tennessee Follow-Up Final Report Page 11

Current Status

The Division provided the NRC with a package of proposed regulations on February 28, 2001. 

The proposed regulations were reviewed for compatibility and adequacy, and the NRC comments

were provided verbally to a staff person on April 4, 2001, and to the Division by letter dated June

8, 2001. A public hearing was held on the rulemaking on April 23, 2001 in Nashville, Tennessee. 

Eight of nine NRC comments regarding compatibility were incorporated into the proposed

regulations. At the time of this follow-up review, the rulemaking package was under review by the

State Attorney General’s Office. When approved, the package will be filed with the Secretary of

State and become effective 75 days later. The team discussed with Division managers the need

to provide the “as published” regulations to NRC for review as requested in the Office of State

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

Legally Binding Requirements.” 

The review team noted that the comment that had not been addressed was identified as the

provisions of 10 CFR 34.42(a). This provision is designated as a category “C” for compatibility,

and needed to be adopted by June 27, 2000. The Division management stated that this provision

was inadvertently missed and would be adopted in the next rule package. 

The team also compared data obtained from the STP State Regulation Status tracking system

with the rulemaking package and information provided during the review. The rulemaking

package above did not address all of the regulations needed for compatibility and in particular

those regulations designated as H&S that are needed for adequacy. The following rules were

identified as needed for compatibility and/or adequacy. 

! "Quality Management Program and Misadministrations," 10 CFR Part 35 amendment (56

FR 34104) which became effective on January 27, 1992. The Division is monitoring the

development and status of the 10 CFR Part 35 revision and will initiate rulemaking as

appropriate when the new Part 35 becomes effective. The team believes this action is

appropriate.

! “Clarification of Decommissioning Funding Requirements,” 10 CFR Parts 30, 40, and 70

amendments (60 FR 38235) that became effective November 24, 1995. 10 CFR 30.35

and 30.36 provisions are H&S compatibility categories needed for adequacy.

! “Termination or Transfer of Licensed Activities: Recordkeeping Requirements,” 10 CFR

Parts 20, 30, 40, 61, and 70 amendments (61 FR 24669) that became effective June 17,

1996. Provisions of this rule are H&S categories needed for adequacy.

! “Radiological Criteria for License Termination,” 10 CFR Parts 20, 30, 40, and 70

amendments (62 FR 39058) that became effective August 20, 1997. Provisions of this rule

are designated as A and/or B for compatibility, or H&S for adequacy.

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

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

1998. Provisions in this rule are designated either as category A, B, C, or H&S.
Tennessee Follow-Up Final Report Page 12

Regulations needed in the future were identified as follows:

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

amendment (64 FR 54543 and 64 FR 55525) that became effective February 2, 2000. 

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

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

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

that became effective January 8, 2001. 

! “Requirements for Certain Generally Licensed Devices Containing Byproduct Material” 10

CFR Parts 30, 31, and 32 amendments (65 FR 791629) published December 18, 2000

that became effective February 16, 2001. Provision of this rule are designated as A or B

for compatibility and require early implementation (6 months).

Management Directive 5.9, Handbook, Part V, (1)(C)(III) provides that regulations issued prior to

September 3, 1997 should be adopted by the State as expeditiously as possible, but not later than

three years after the September 3, 1997 effective date of the Commission Policy Statement on

Adequacy and Compatibility, i.e., September 3, 2000. The team discussed Management Directive

5.9, the rules needed for compatibility, and the rules designated as H&S that are needed for

adequacy. The review team noted that several rules have not been adopted within the 3 year

time frame, and the Division did not have a plan for the timely consideration, tracking, and

adoption of rules needed for compatibility and for adequacy. The team also believes that the

Division needs to evaluate all H&S category rules identified above to determine if the Tennessee

rules address the essential objectives for adequacy, and amend their rules, as appropriate. 

The review team identified that there was a misunderstanding within State staff of the

requirements for adopting regulations needed for adequacy. Through discussions with Division

management and review of the NRC guidance documents, this misunderstanding was addressed. 

Based on these considerations, the review team has reworded Recommendation 9 from the 2000

IMPEP review for clarity to read as follows: “The review team recommends that the Division

establish a management plan for the development, tracking, and adoption of regulations in a

timely manner, and to adopt the current regulations needed for adequacy and compatibility in

accordance with the STP Procedure SA-201, “Review of State Regulations or Other Generic

Legally Binding Requirements.” 

During the January 22, 2002 MRB meeting, the review team informed the MRB that the final rules

package had been submitted to NRC on December 21, 2001 for review. These rules will be

published in February 2002. The review team noted that no additional changes were made to the

package since the preliminary review in October 2001. Based on the preliminary acceptability of

this rule package, the review team recommended and the MRB concurred that the preliminary

finding for this performance indicator would be changed from unsatisfactory to satisfactory with

recommendations for improvement. In the letter issued February 1, 2002, the NRC found this

regulation package compatibility with the exception of the comments noted in the letter. Based on

the IMPEP evaluation criteria, the review team recommends that 
Tennessee Follow-Up Final Report Page 13

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

Required for Compatibility, be changed to satisfactory with recommendations for improvement.

4.0 SUMMARY

The follow-up review team evaluated Tennessee’s performance in responding to three

unsatisfactory and one satisfactory with recommendations for improvement findings and resolving

the specific recommendations made during the 2000 IMPEP review for the three common and one

non-common performance indicators, Status of Materials Inspection Program, Technical Quality of

Inspections, Response to Incidents and Allegations, and Legislation and Program Elements

Required For Compatibility. The follow-up review team concludes that the inspection program has

made progress, but the review team noted that the timeliness of inspections, issuance of the

reports, and some technical aspects of the inspection program are still in need of improvement. 

The development of a plan and use of an effective regulation tracking system to ensure timely

issuance of compatible and adequate regulations would resolve the regulation issue. Based on

this information, the review team recommended and the MRB concurred in finding the Tennessee

program to be adequate but needs improvement and compatible with NRC’s program. 

Based on the status of the Tennessee program, the follow-up review team recommended and the

MRB concurred that the Tennessee Agreement State program receive a full IMPEP review in two

years with a periodic meeting in about one year. Also, the Regional Agreement State Officer will

conduct at least quarterly calls with the Division management to go over the status/progress of

reducing the overdue inspections, to discuss activities to improve documentation supporting

inspection findings, and to discuss development of a plan for updating State regulations. At the

periodic meeting, the status of the Division’s actions to address the findings and recommendations

can be evaluated. The detailed evaluation (casework review) would follow one year later (routine

IMPEP). 

Below is a summary list of open recommendations from the 2000 report and the new

recommendations from this follow-up review.

Open Recommendations from the 2000 IMPEP report:

Recommendation 1

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

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

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

2.1 of follow-up report) 

Recommendation 3 (revised)

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

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

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

the quality and documentation of inspections, the Division establish and implement

additional guidance for ensuring consistent, appropriate, and prompt regulatory actions
Tennessee Follow-Up Final Report Page 14

including incorporating root cause identification, especially of repeat violations. (Section

3.2 of 2000 report; Section 2.2 of follow-up report)

New recommendations from the follow-up review:

Follow-up Recommendation 1

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

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

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

Procedure SA-201, “Review of State Regulations or Other Generic Legally Binding

Requirements.” (Section 3.1.2)
LIST OF APPENDICES

Appendix A IMPEP Follow-up Review Team Members

Appendix B Division of Radiological Health Organizational Chart

Appendix C Heightened Oversight Program Correspondence

Appendix D Periodic Meeting Summary Including Status of Other

Recommendations from the Previous Review

Appendix E Inspection Casework Reviews and Accompaniments

Appendix F Incident Casework Reviews

Attachment January 4, 2002 Letter from Lawrence E. Nanney

Tennessee’s Response to Follow-Up Draft IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Dennis Sollenberger, STP Team Leader

Barbara Hamrick, CA Status of Materials Inspection Program

Response to Incidents and Allegations

Richard Woodruff, Region II Legislation and Program Elements Required 

for Compatibility 

John Pelchat, Region II Technical Quality of Inspections

Inspector Accompaniments
APPENDIX B

TENNESSEE ORGANIZATIONAL CHART

FOR THE DIVISION OR RADIOLOGICAL HEALTH

(ML013310611)

APPENDIX C

HEIGHTENED OVERSIGHT PROGRAM CORRESPONDENCE

Minutes of Bimonthly Conference Calls:

1. February 1, 2001 conference call minutes.

2. April 3, 2001 conference call minutes.

3. June 5, 2001 conference call minutes.

4. August 8, 2001 conference call minutes. 

Letters from/to Tennessee:

1. January 2, 2001 letter from J. Leonard to C. Paperiello, responding to the November 27,

2000 final IMPEP report including actions to address recommendations in the report. 

(ML010120195)

2. January 29, 2001 letter from C. Paperiello to J. Leonard requesting additional information

for the program improvement plan. (ML010260424)

3. March 26, 2001 letter from L. E. Nanney to D. Sollenberger, second bimonthly progress

report. (ML010940237)

4. May 22, 2001 letter from L. E. Nanney to D. Sollenberger, third bimonthly progress report. 

(ML013300612)

5. July 20, 2001 letter from D. Shults to D. Sollenberger submitting a copy of Tennessee’s

“Inspection and Enforcement Policy and Procedures” manual. (ML012150118)

6. July 31, 2001 letter from L. E. Nanney to D. Sollenberger, fourth bimonthly progress report. 

(ML012190331)
Tennessee Follow-Up Final Report Page C.2

MINUTES: TENNESSEE TELECONFERENCE OF FEBRUARY 1, 2001

These minutes are presented in the same general order as the items were discussed in the

meeting. The participants were as follows:

Dennis Sollenberger, STP Frederick Combs, STP

Kathleen Schneider, STP Lance Rakovan, STP

Richard Woodruff, RII Barbara Hamrick, CA

L. Edward Nanney, TN Johnny Graves, TN

Debra Shults, TN Roger Fenner, TN

John Politte, TN Ruben Crosslin, TN

1. Letter to J. Leonard and Requested Information Program Improvement Plan to

include Management Commitments. Mr. Sollenberger discussed the proper

management level for correspondence with the State. Mr. Sollenberger and Mr. Nanney

discussed a table to track the State’s progress including updating due dates. Mr. Nanney

stated that he was hoping to have the format ready, but it was not at the time of the call.

2. Status of Actions in January 2, 2001 Letter. 

Inspection Program. Mr. Sollenberger stated the need to know problems with the

inspection program ASAP. Ms. Shults reported that of the 48 inspections overdue at the

time of the review, 15 had not been completed (7 in-State and 8 out-of-State). She also

reported that at the time of the call there were 42 overdue inspections. The State reported

that they are working on two tracking systems (one internal and one interdepartmental)

and that there doesn’t seem to be any problems at this time. State staff are currently

performing audits of files from the last two years in an attempt to ensure that files are

consistent with each other.

Training Program. The State reported that they are following the NRC/OAS Training

Working Group Report in their attempts to create a written training program, and that NRC

will have the opportunity to comment on the program in concurrence with State staff. The

State hopes to provide a draft approximately March 1, 2001.

Incidents and Allegations. Mr. Sollenberger discussed the need to review policy and

procedures as they are drafted. State staff attendance at the Root Cause Course was

discussed.

Items Needed for Compatibility. The State commented a package containing 12 of the

18 regulations required for adoption was out for comment to staff members. The State

was hoping to move the regulations out of the office the week following the teleconference. 

STP staff and the State discussed the “D/H&S” Compatibility Category and the need to

adopt regulations under this category. 
Tennessee Follow-Up Final Report Page C.3

SS&D Reviewer Qualification. The upcoming SS&D Workshop was discussed,

including the need for only 2 State attendees and the expense of hotel rooms.

3. Discussion of Changes to Items or Dates for Completion. STP staff and the State

discussed regulation review by NRC and STP Procedure SA-201.

4. Contents of Future Status Reports (Due 2 weeks prior to next call). Mr.

Sollenberger stated that he would share the tracking table he was using with the State. 

The need to get all State commitments down on paper was highlighted, as well as the

need for a procedure detailing the expectations of both NRC and States during a period of

heightened oversight.

5. Date for Next Conference call (date and time). The next call was set up for Tuesday,

April 3 at 10:00 am EST.
Tennessee Follow-Up Final Report Page C.4

MINUTES: TENNESSEE TELECONFERENCE OF APRIL 3, 2001

These minutes are presented in the same general order as the items were discussed in the

meeting. The participants were as follows:

Dennis Sollenberger, STP Paul Lohaus, STP

Lance Rakovan, STP Richard Woodruff, RII

Barbara Hamrick, CA L. Edward Nanney, TN

Debra Shults, TN Johnny Graves, TN

Roger Fenner, TN Barbara Davis, TN

Billy Freeman, TN Mary Helen Short, TN

Steve Seegar, TN Melissa Wolford, TN

1. Status of Actions in January 2, 2001 Letter. 

Inspection Program. Ms. Shults reported that staff members are attending a number of

NRC-sponsored courses such as Inspecting for Performance, Inspection Procedures, and

Root-Cause/Incident Investigation. She stated that at the time of the call there were 65

inspections due, 27 of which were overdue. She also stated that of the 48 inspections

overdue at the time of the review, only 4 have yet to be completed. These inspections

should be conducted by the end of the month. In terms of staff turn-over, Ms. Shults

stated that two staff members had left the program and three had been hired. She noted

that the program has the potential to hire five additional staff members. She stated that

Tennessee is on schedule with their inspection procedure evaluation.

Training Program. The State said that a copy of the draft revision to their training

program would be sent to Mr. Sollenberger for review.

Incidents and Allegations. Mr. Sollenberger and Ms. Hamrick commented that they had

received and reviewed revised incident and allegation procedures. 

Items Needed for Compatibility. Mr. Woodruff stated that he is currently reviewing the

package of regulations submitted by the State. He noted that he is about three fourths of

the way done and has no significant comments thus far. He promised to review the results

of the review with State staff prior to sending the results to NRC Headquarters. The State

was asked to follow the guidance in STP Procedure SA-201, including highlighting

regulations that have been revised, to help expedite the review process. The importance

of adopting regulations designated as “D/H&S” was discussed. Mr. Lohaus noted that the

criteria in Management Directive 5.6 for a satisfactory rating for the common performance

indicator, Legislation and Program Elements Required for Compatibility, includes adopting

regulations necessary for both compatibility and health and safety. The State noted that

they are attempting to achieve compatibility as quickly as possible. The adoption of the

financial assurance rule was discussed. 

SS&D Reviewer Qualification. The State mentioned that they are working on a set of

qualifications for SS&D reviewers that would not necessarily require attendance at the
Tennessee Follow-Up Final Report Page C.5

NRC SS&D Workshop. Mr. Nanney discussed the budget problems faced by the

Tennessee program and the importance of management support.

2. Discussion of Changes to Items or Dates for Completion. Mr. Sollenberger noted

that there have been no changes to expected completion dates.

3. Future Status Reports. Mr. Sollenberger and the State discussed the format for

progress reports.

4. Date for Next Conference call (date and time). The next call was set up for Tuesday,

June 5 at 10:00 am EDT.

5. Additional Topics. Mr. Lohaus asked for clarification on a statement made in the State’s

progress report on the increased interaction with NRC. Mr. Nanney noted the State’s

emphasis on improving programmatic obligations. Mr. Lohaus asked for clarification on

how the NRC could lessen the number of interruptions and improve the heightened

oversight process. Mr. Lohaus and Mr. Nanney discussed the heightened oversight

process and areas of possible difficulty and confusion. The State asked if IMPEP team

members’ guidance forms completed during the review could be shared with States. Mr.

Lohaus said he would consider the request. Mr. Freeman commented that IMPEP team

members should give more directions with their comments and should focus on making all

comments performance-based. He also stated that he would be more than willing to come

to the main office for the follow-up IMPEP review to ensure proper communication with

team members. 

The State commented on the need for IMPEP team members to fully discuss findings with

State staff during the onsite review, especially the need to discuss matters with regional

staff members in larger programs. Mr. Lohaus agreed and indicated that STP would reenforce the importance of this issue during the upcoming IMPEP training as well as

revising the language in the STP procedures dealing with reviewing IMPEP indicators. 
Tennessee Follow-Up Final Report Page C.6

MINUTES: TENNESSEE TELECONFERENCE OF JUNE 5, 2001

The minutes are presented in the same general order as the items were discussed in the meeting. 

The participants were as follows:

Dennis Sollenberger, STP Paul Lohaus, STP

Douglas Collins, RII L. Edward Nanney, TN

Johnny Graves, TN Barbra Davis, TN

Roger Fenner, TN Anthony Hogan, TN

Mary Helen Short, TN John Politte, TN

1. Status of Actions in January 2, 2001 Letter

Inspection Program. Mr. Nanney reported that the 48 in-state licenses that had been

overdue previously were all inspected now. Six out-of-state licenses cannot be inspected

until they conduct work in Tennessee. In the month of May, 19 inspections were

completed. He stated that there was a correction for the number of in-state licenses. The

May 22 letter stated that there were 8 in-state licenses. In actuality, there are 5 in-state

licenses. Furthermore, as of the first of June only 2 are overdue. Mr. Sollenberger

inquired as to whether or not Tennessee had modified their inspection procedure and if

the staff was knowledgeable of the new policies. He expressed a desire to have the staff

understand the policies before NRC begins the follow-up review by initiating

accompaniments of Tennessee inspectors. Mr. Nanny responded that he thought that

Tennessee might be ready, but was not certain. Mr. Lohaus requested that the State’s

expectation for the conduct of inspections be communicated to him by some means. Mr.

Nanney agreed to make arrangements to do this, but stated that he felt it was unclear what

was wanted in the inspection program. It was also agreed that a follow-up phone call

should be arranged to further discuss Tennessee’s procedures once they had sent a

summary of those procedures. It was agreed that Tennessee’s procedures would be

reviewed and any specific problems could be addressed during an offline follow-up

discussion.

Training Program. Mr. Nanney stated that the training policy would be completed and

approved in June. He also reported that Debra Shults was meeting with Roger Fenner to

discuss the program’s implementation. Mr. Sollenberger said that the documentation of

the training program would be evaluated as part of the follow-up review.

Incidents and Allegations. Mr. Sollenberger commented that he had reviewed the

incidents and allegations procedures and that they looked acceptable. The

implementation of these procedures will be reviewed during the follow-up review.

Items Needed for Compatibility. Mr. Sollenberger expressed regret for not having been

able to send out the final comments on the package of regulations sooner. Mr. Lohaus

arranged to have them faxed later in the day. Tennessee stated that Mr. Woodruff had

already discussed the comments with them. Barbara Davis stated that a public hearing

had occurred and no one appeared. Also, a comment period was held and one letter was
Tennessee Follow-Up Final Report Page C.7

received and addressed. Tennessee expects TN-OGC to follow up in approximately 5 - 6

weeks.

SS&D Reviewer Qualification. Mr. Sollenberger stated that NRC would review the

SS&D qualifications and documentation for the reviewers during the follow-up review. 

2. Discussion of Changes to Items or Dates for Completion. No dates have changed.

The regulations are being developed on the dual track as discussed earlier. 

3. Future Status Reports. Tennessee will submit a status report prior to the August 8, 2001

conference call. 

4. Date for Next Conference Call (date and time). The next call was set up for Tuesday,

August 7 at 10:00 am EDT. Following the conference call Debra Shults called and

requested that the call be moved to Wednesday, August 8, 2001 at 10:00 Eastern, 9:00

central time. 

5. Additional Topics. Mr. Sollenberger requested a list of inspections for July and August

and a list of qualified inspectors be sent to him. Mr. Nanney agreed to do so. Mr.

Sollenberger also recommended that accompaniments be spaced between the four

regions. Anthony Hogan stated that there would be drills during the last week of August. 

As such, that period would not be convenient for accompaniments. The follow-up review

will be scheduled in September or, if need be, October.

Mr. Lohaus informed the State that sharing IMPEP forms with States was under

consideration.
Tennessee Follow-Up Final Report Page C.8

MINUTES: TENNESSEE TELECONFERENCE OF AUGUST 8, 2001

The minutes are presented in the same general order as the items were discussed in the meeting. 

The participants were as follows:

Dennis Sollenberger, STP Paul Lohaus, STP

Lance Rakovan, STP John Pelchat, RII

L. Edward Nanney, TN John Politte, TN

Johnny Graves, TN Debra Shults, TN

Anthony Hogan, TN Billy Freeman, TN

Mary Helen Short, TN Other TN staff

1. Status of Actions in January 2, 2001 Letter

Inspection Program. Mr. Sollenberger commented that NRC had received the State’s

July 20, 2001 letter including a copy of their “Inspection and Enforcement Policy and

Procedures” manual. Mr. Pelchat noted that he would work with the State to schedule

inspector accompaniments in September. Mr. Nanney commented that the State’s

tracking system was still in the design phase, but they expect that it will be operational by

the end of October. The State noted that 17 inspections were completed in July. Six

overdue in-State inspections are still incomplete, as well as nine out-of-State inspections

which can be completed only if the licensees enter the State again to perform licensed

actions. 

Training Program and Incidents and Allegations. Mr. Sollenberger discussed what the

State could expect during the upcoming follow-up review.

Items Needed for Compatibility. The status of the State’s regulation adoption was

discussed. The State noted that the staff member that usually handles regulation adopted

has been out due to illness. It was estimated that a complete review of regulations would

take approximately 3-4 weeks. The State noted that adoption of the “H&S” rules has been

delayed due to the staff member’s absence.

SS&D Reviewer Qualification. No discussion.

2. Date for Next Conference Call (date and time). It was agreed that there was no need

for another conference call as long as inspector accompaniments and the follow-up review

could be scheduled without complications.

3. Potential Timeframe for Inspection Accompaniments and Follow-up Review. 

Mr. Pelchat and the State discussed possible weeks for the inspector accompaniments. 

The weeks of October 22 and 29 were suggested for the onsite follow-up review. Mr.

Sollenberger noted that the team expects the review to start Monday afternoon with the

exit meeting Thursday afternoon. The team will not be looking at licensing or SS&D. The

State and Mr. Sollenberger discussed having a day during the review when all State
Tennessee Follow-Up Final Report Page C.9

inspectors would be available to talk with review team members, if necessary. Mr.

Pelchat noted that he plans to debrief with the field office manager and the inspector after

each accompaniment. Mr. Sollenberger noted that he would contact the State about the

week for the review after he had the chance to talk with the rest of the review team.

4. Additional Topics. Mr. Freeman noted that there was still some confusion on the part of

the State as to what should be done with some of the comments made in the IMPEP

report. Mr. Sollenberger noted that some of the comments may have resulted from lack of

communication between the review team and State staff during the onsite review. Mr.

Pelchat promised he will work hard to keep communications open and clear. All parties

agreed to more forward and not focus on past issues. Mr. Nanny stated that he

appreciates the promise of open communication and believes that his program will do well

during the upcoming review. 

Mr. Sollenberger summarized the actions the review team intends to take due to this

teleconference: (1) The review team will complete their examination of the inspection

procedure and will call if there are any questions; (2) Mr. Pelchat will work with the State to

schedule inspector accompaniments for September; and (3) Mr. Sollenberger will get back

to the State with a proposed date for the review (The review was scheduled for the week

of October 22, 2001).













APPENDIX D

 PERIODIC MEETING SUMMARY 

INCLUDING STATUS OF OTHER RECOMMENDATIONS FROM THE PREVIOUS REVIEW 

A periodic meeting was held with Division management by Dennis Sollenberger, Team Leader,

and Richard Woodruff, Regional State Agreements Officer, during the follow-up review pursuant to

STP Procedure SA-116, “Periodic Meeting with Agreement States Between IMPEP Reviews.” 

Those topics normally documented during the periodic meeting that were reviewed and

documented as part of the follow-up review will not be discussed in this Appendix. The following

topics were discussed. 

Action on Previous Review Findings

The August 2000 IMPEP report made ten recommendations for action by the Division. Eight of

these recommendations were discussed in earlier sections under their respective indicators. The

status of the remaining three comments is discussed below.

Recommendation 4

The review team recommends that the Division develop and document a training and qualification

program which address the training requirements in the NRC/OAS Training Working Group Report

or NRC Inspection Manual Chapter 1246. 

Current Status

The Division developed a training policy document that included individual training summaries and

on-the-job documentation sheets. The policy was issued effective on July 1, 2001. It was

distributed for implementation to all license reviewers and inspectors by internal memorandum on

July 12, 2001. The individual training files had been set up. However, the individual training

history sheets had not been completed at the time of the follow-up review. The review team

recommends that this recommendation be closed with the implementation of the individual

qualification sheets being reviewed during the next IMPEP review. 

Recommendation 10

The review team recommends that all persons conducting principal and concurrent reviews for

SS&D registrations be fully qualified and have documented authorizations on file. 

Current Status

Two individuals attended the April 2-6, 2001 SS&D workshop. These individuals were also

assigned SS&D amendment casework under the direct supervision of their manager. The

assignments were completed and evaluated by the supervisor, training was documented, and the

individuals approved for independent SS&D device amendment assignments. The individuals will

perform new device assignments under management supervision as new device applications are

received. The review team recommends that this recommendation be closed. 
Tennessee Follow-Up Final Report Page D.2

Periodic Meeting Summary

Program Strengths and/or Weaknesses

The Division management related that the strength of the program was in the senior, experienced

managers, and that the staff had good attitudes concerning inspection and enforcement issues. 

The Division reported good support from the Department and legislature. This support is in the

form of stable sources of funding, and adequate administrative, legal, and laboratory services. 

The Division was able to increase the materials license fees by 50% which are earmarked for the

Division. The Division funding is now approximately 92% fee based. 

Staff retention and salaries are still issues. Since the August 20, 2000 review, seven staff have

left the program and 10 staff have been hired. Although this appears to be a positive staff gain for

the program, two staff who left the program were senior inspectors (one was a regional manager). 

The Department received a step increase for all employees and an additional step increase for the

licensing staff. They are also trying to get an additional step increase for all staff. A step increase

is between 4-5%. 

Out of State travel has been either restricted or prohibited. The Division Director was unable to

attend the Annual Meeting of the Organization of Agreement States, and staff participation was not

permitted at out-of-State training locations. The only exception was for two individuals to attend

the SS&D workshop for training in April of 2001.

The Division identified staff training needs in Industrial Radiography and Medical Uses. The team

leader discussed options that may be available to the program from Oak Ridge Institute for

Science and Education (ORISE) or through State supported educational institutions.

Feedback on NRC’s Program

No significant issues were identified. The Division Director noted that the IMPEP review had

helped their program, that their program had benefitted from the exchange of information received

from the IMPEP team members.

Status of Program and/or Policy Changes

There have been no significant changes in the organizational structure of the Division of

Radiological Health as described in the 2000 IMPEP review. An updated organizational chart is

attached to the follow-up report as Appendix B. 

No significant changes were noted or discussed concerning legislative changes or the

redistribution of responsibilities with respect to the agreement materials program. A new manager

is in charge of the Inspection and Enforcement program.
Tennessee Follow-Up Final Report Page D.3

Periodic Meeting Summary

Impact of NRC Program Changes

The NRC representatives discussed the status of the new 10 CFR Part 35 amendment, security

issues, the status of the NRC web site and the passcode needed for access to the site.

Internal Program Audits and Self-Assessments

The Division managers reported that currently no self-assessments were being performed;

however, the Materials Supervisor at the Memphis regional office had shared his experiences on

IMPEP teams with the other staff and in planning for the previous IMPEP review. Peer reviews

are conducted on all licenses issued, and all inspection reports receive at least one level of

supervisory review. Enforcement letters receive the same type of reviews and are issued out of

the field office. Feedback is also being provided to the inspectors through the Inspection and

Enforcement Manager, and during training and inspector accompaniments. See additional

discussion under Section 2.2 of the follow-up report.

Status of Allegations Previously Referred

This is discussed in Section 2.3 of the follow-up report.

Nuclear Material Events Database (NMED) Reporting

A general discussion was held with the representatives concerning the NMED reporting system.

The Division was informed that upgraded software had been installed by the INEEL contractor,

and that Sam Petijohn, at NRC, could be contacted for training and installation of the new

software in Tennessee. 
ATTACHMENT

January 4, 2002 Letter from Lawrence E. Nanney

Tennessee’s Response to Follow-Up Draft IMPEP Report

ML020140051