July 21, 2005

Mr. Gary Wright, Assistant Director

Illinois Emergency Management Agency

Division of Nuclear Safety

1035 Outer Park Drive

Springfield, IL 62704

Dear Mr. Wright:

On June 26, 2005, the Management Review Board (MRB) met to consider the proposed final

Integrated Materials Performance Evaluation Program (IMPEP) report on the Illinois Agreement

State Program. The MRB found the Illinois program adequate to protect public health and

safety and not compatible with the U.S. Nuclear Regulatory Commission’s (NRC) program. The

MRB recognized the excellence in program administration demonstrated by your staff, as

reflected in the team’s findings. The MRB also agreed with the team finding that the Illinois

program needs to complete the process of adopting regulations, or other legally binding

requirements, which are overdue for adoption and send them to the NRC for review. Adoption

of these outstanding regulations will allow the State to meet compatibility requirements as

addressed in the Non-Common Performance Indicator: Compatibility Requirements. Section

5.0, page 19, of the enclosed final report presents the IMPEP team’s recommendation for the

State of Illinois.

Because of the overdue regulations, the MRB determined the Illinois program should undergo a

period of heightened oversight. Heightened oversight is an increased monitoring process used

by NRC to follow the progress of improvement needed in an Agreement State program. It

involves preparation of a program improvement plan, bimonthly conference calls, and

submission of status reports prior to each call with the appropriate Illinois and NRC staffs.

We request that you prepare and submit a program improvement plan as part of your response

to the recommendations in Section 5 of the enclosed final report, “Integrated Materials

Performance Evaluation Program, Review of Illinois Agreement State Program - Final

Report.” I ask that you have your staff dialogue with Paul Lohaus on the required elements of

this plan to ensure that the “get-well” path and measures of success are clearly identified. The

plan should be submitted within 30 days of this letter. Upon review of the program

improvement plan, the staff will schedule the first conference call. The initial conference call

should be scheduled and conducted no later than September 6, 2005. Based on the results of

the current IMPEP review, a follow-up review will be scheduled during the period April - August

2006 or sooner if final regulations are adopted at an earlier date. The follow-up review will

cover the State’s action on the recommendations from the April 2005 review.
G. Wright - 2 -

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

I also wish to acknowledge your continued support for the Radiation Control Program and I look

forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA Paul H. Lohaus Acting for/

Martin J. Virgilio

Deputy Executive Director for Materials, Research,

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure: As stated

cc: William C. Burke, Director

Illinois Emergency Management Agency

Paul Eastvold

Bureau of Radiation Safety

Illinois Emergency Management Agency

Pearce O’Kelley, SC

OAS Liaison to the MRB
G. Wright - 2 -

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

I also wish to acknowledge your continued support for the Radiation Control Program and I look

forward to our agencies continuing to work cooperatively in the future.

Sincerely,

/RA Paul H. Lohaus Acting for/

Martin J. Virgilio

Deputy Executive Director for Materials, Research,

 State and Compliance Programs

Office of the Executive Director for Operations

Enclosure: As stated

cc: William C. Burke, Director

Illinois Emergency Management Agency

Paul Eastvold

Bureau of Radiation Safety

Illinois Emergency Management Agency

Pearce O’Kelley, SC

OAS Liaison to the MRB

bcc: Chairman Diaz

Commissioner Merrifield

Commissioner Jaczko

Commissioner Lyons

Distribution:

EDO R/F

DIR RF SISP Review Complete

VCampbell, RIV DCD (SP01) : Publicly Available G Non-Publicly Available 

JLynch, RIII : Non-Sensitive G Sensitive

TBrock, STP

SSmith, STP

CMiller, OEDO

CMiller, NMSS/IMNS

RStuckmeyer, NMSS/IMNS

STreby, OGC

JCaverly, NMSS

EJameson, GA

DOCUMENT NAME: E:\Filenet\ML052010292.wpd

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DATE 07/18/05 07/18/05 07/20/05 07/21/05

 ML052010282 OFFICIAL RECORD COPY
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF ILLINOIS AGREEMENT STATE PROGRAM

April 4 - 8, 2005

FINAL REPORT

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

1.0 INTRODUCTION

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

review was conducted during the period of April 4-8, 2005, 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 "Implementation of the Integrated Materials Performance Evaluation

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

Register on October 16, 1997, and the February 26, 2004, NRC Management Directive 5.6,

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

review, which covered the period March 9, 2001 to April 8, 2005, were discussed with Illinois

management on April 8, 2005.

A draft of this report was issued to Illinois for factual comment on May 5, 2005. Illinois

responded to the findings and conclusions of the review by letter dated June 3, 2005, from

Gary Wright, Assistant Director, Illinois Emergency Management Agency, Division of Nuclear

Safety. The Management Review Board (MRB) met on June 28, 2005 to consider the

proposed final report. The MRB found the Illinois radiation control program adequate to protect

public health and safety and not compatible with the NRC's program. Due to the noncompatible finding, the length of time that rules had been overdue for adoption, and the fact

that Illinois has rules in draft, not final form, the MRB placed the Illinois program on Heightened

Oversight.

In July 2003, the Illinois Department of Nuclear Safety (the Department) became a division of

the Illinois Emergency Management Agency (the Agency). The Director for the Department

was appointed the Assistant Director of the Agency and retained the management responsibility

over activities that had been conducted by the Department. In March 2005, the Assistant

Director became responsible for the five technical bureaus in the Agency: Bureau of

Operations; Bureau of Disaster Assistance and Preparedness; Bureau of Nuclear Facility

Safety; Bureau of Environmental Safety; and Bureau of Radiation Safety. The Illinois

Agreement State program is administered by the Bureau of Radiation Safety (the Bureau), with

support by other bureaus in the Agency, which is discussed in further detail later in the report. 

The Bureau has one field office located in West Chicago, Illinois. 

Organization charts for the State of Illinois and the Agency are included as Appendix B. The

Illinois Agreement program regulates approximately 742 specific licenses authorizing

Agreement materials. The review focused on the program as it is carried out under the Section

274b. (of the Atomic Energy Act of 1954, as amended) Agreement between the NRC and the

State of Illinois.

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

performance indicators was sent to the State on November 29, 2004. A copy of the official

letter and questionnaire can be found on NRC’s Agencywide Document Access and

Management System (ADAMS) using the Accession Number ML043350221. The State

provided a response to the questionnaire on March 16, 2005. A copy of the State’s

questionnaire response can be found in ADAMS using the Accession Number ML051100389.
Illinois Final Report Page 2 

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

Illinois' response to the questionnaire; (2) review of applicable Illinois’ statutes and regulations;

(3) analysis of quantitative information from the Bureau’s licensing and inspection database;

(4) technical evaluation of selected licensing and inspection actions; (5) field accompaniments

of three Illinois inspectors; and (6) interviews with staff and management to answer questions

or clarify issues. The team evaluated the information that it gathered against the IMPEP

performance criteria for each common and applicable non-common performance indicator and

made a preliminary assessment of the Illinois Agreement State program’s performance.

Section 2 discusses the State’s actions in response to the previous IMPEP review

recommendation and the team’s conclusions regarding the closure of the recommendation. 

Results of the current review for the IMPEP common performance indicators are presented in

Section 3. Section 4 discusses results of the applicable non-common performance indicators,

and Section 5 summarizes the review team's findings and recommendation. Recommendations

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

State. A response is requested from the State to all recommendations in the final report.

2.0 STATUS OF ITEMS IDENTIFIED IN THE PREVIOUS REVIEW

During the previous IMPEP review which concluded on March 9, 2001, one recommendation

was made and the results transmitted to Mr. Thomas W. Ortciger, Director, Illinois Department

of Nuclear Safety, on June 6, 2001. The review team’s evaluation of the current status of the

recommendation is as follows:

1. The review team recommends that the State adopt the regulations, or other legally

binding requirements, which are overdue for adoption. (Section 4.1.2 of the 2001

report)

Current Status: The review team evaluated the status of the actions that the State has taken to

address this recommendation since the 2001 IMPEP review. The team acknowledges that the

State has drafted rules to meet the requirements of a number of the overdue amendments and

submitted them to the Bureau’s legal staff for review. At the time of the on-site portion of the

IMPEP review, these draft rules had not yet been adopted as final rules by the State or sent to

the NRC for review as required by STP Procedure SA-201, Review of State Regulatory

Requirements. The status of the regulations is discussed in further detail in Section 4.1 of this

report. This recommendation remains open.

3.0 COMMON PERFORMANCE INDICATORS

IMPEP identifies five common performance indicators to be used in reviewing both NRC

Regional and Agreement State programs. These indicators are: (1) Technical Staffing and

Training; (2) Status of Materials Inspection Program; (3) Technical Quality of Inspections;

(4) Technical Quality of Licensing Actions; and (5) Technical Quality of Incident and Allegation

Activities.
Illinois Final Report Page 3 

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Bureau’s turnover, as well as the

technical qualifications and training histories of the staff. To evaluate these issues, the review

team examined the Bureau's questionnaire response relative to this indicator, interviewed

Bureau management and staff, and considered any possible workload backlogs.

The Agency has assigned approximately 23 full time equivalent (FTE) total, including

management and contractor support, to implement the Agreement State program and has

adequate funds to support the program. This Section of the report will discuss the staffing and

training for support of the materials program. Staffing and training for the Sealed Source and

Device Evaluation Program are discussed in Section 4.2. Staffing and training for the Uranium

Recovery Program are discussed in Section 4.4. 

The Bureau has three Sections: the Radioactive Materials Section (the RAM Section), the

Registration and Certification Section, and the Electronic Products Section. The RAM Section

has two Units: the Materials Licensing Unit and the Inspection and Enforcement Unit. These

two units are responsible for the routine licensing and inspection of 742 specific materials

licensees with 12.7 budgeted FTE. The State’s General License (GL) program is managed in

the Registration and Certification Section with approximately 1 FTE. As a result of the

reorganization in July 2003, the Low-Level Radioactive Waste and Site Decommissioning

Section (the Decommissioning Section) was transferred to the Bureau of Environmental Safety

within the Agency. However, the Decommissioning Section continues to provide technical

support to the Bureau by managing the uranium recovery, financial assurance, and orphan

source programs. They also provide decommissioning and license termination support. The

Decommissioning Section has 3.6 FTE budgeted for this support. An internal policy

memorandum describes the coordination of assignment and responsibility between the two

bureaus. 

The Bureau has an experienced staff and low staff turnover. The Bureau lost three staff

members since the last IMPEP: one retired; one requested reassignment; and the Senior

Project Manager for regulatory affairs was reassigned to the Bureau of Nuclear Facility Safety

during the 2003 reorganization. The Radioactive Materials Section Head assumed the

regulatory affairs responsibilities, but was deployed for military duty on October 1, 2004. The

remaining two positions were filled expediently with staff from within the Agency. 

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

interviews of personnel. The staff are well qualified through both education and experience. 

All staff have at least a Bachelor’s degree in the sciences, or equivalent training and

experience.

The Bureau has a documented training and qualification program for technical staff that is

modeled after NRC’s Inspection Manual Chapter (MC) 1246, “Formal Qualification Programs in

the Nuclear Materials Safety and Safeguards Program Area.” The Bureau uses a combination

of self-study, formal training, and on-the-job experience to qualify both inspectors and license

reviewers. 
Illinois Final Report Page 4 

The Illinois Radiation Protection Advisory Council was created by the General Assembly

in 1959. It is composed of seven members appointed by the Governor and two ex officio

members. The members reflect a variety of backgrounds in the use of radiation sources. A

Conflict of Interest Questionnaire form is filed and maintained on each member of the Council.

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

concurred that Illinois' performance with respect to the indicator, Technical Staffing and

Training, be found satisfactory.

3.2 Status of Materials Inspection Program

The team focused on five factors in reviewing this indicator: inspection frequency and overdue

inspections of Priority I, II, and III licensees; initial inspection of new licenses; timely dispatch of

inspection findings to licensees; and the performance of reciprocity inspections. The review

team’s evaluation is based on the Bureau’s response to the questionnaire relative to this

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

system, the examination of completed inspection casework, and interviews with managers and

staff.

The review team’s evaluation of the Bureau’s inspection priorities verified that inspection

frequencies for various types or groups of licenses are as frequent, or more frequent, than

similar license types listed in the NRC MC 2800. As examples, the Bureau requires more

frequent inspection in the following license categories: Type A broad scope academic licenses

are inspected on a one-year frequency compared with the NRC three-year frequency; nuclear

laundry licenses on a two-year frequency compared with the NRC three year frequency; nuclear

pharmacy licenses on a one-year frequency compared with the NRC two-year frequency; Type

A broad scope research and development licenses on a one-year frequency compared with the

NRC three-year frequency; and Type B and C broad scope academic licenses on a two-year

frequency compared with the NRC five-year frequency.

The Bureau tracks all inspection activities in a database. The Bureau provided a list of all

inspections conducted during the review period, including inspections of non-Agreement

material and telephone contacts. The Bureau conducts approximately 400 inspections per

year. The Bureau’s database did not have the capabilities to provide status information for all

inspections conducted during the review period. The review team obtained the information

manually through examination of the review files. 

In response to the questionnaire, the Bureau indicated that there were no inspections currently

overdue by more than 25 percent of the NRC frequency. This information was verified during

the examination of 104 inspection files during a time frame, May through June 2004, and the

review of the monthly inspection reports provided to the team. None of the inspections were

conducted overdue. Of the 104 inspection files reviewed, 25 were initial inspections. Initial

inspections were scheduled and conducted within one-year of license issuance. 

The timeliness of the issuance of inspection findings was evaluated by the team’s review of

inspection casework. In the majority of the cases, the response letters and inspection reports

to the licensee regarding the inspection results were sent within 30 days of the inspection date. 
Illinois Final Report Page 5 

Also as a result of the problems experienced in manipulating the data tracking system, the team

was not able to apply the reciprocity inspection frequency criteria prescribed in NRC MC 1220,

Appendix III. The team was unable to determine the amount of reciprocity licensees inspected

each year based on the number of candidates for inspection. The Bureau’s inspection data

tracking system provided that 40 licensees had submitted requests for reciprocity during the

review period. The review team verified that out of the 40 licensees, the Bureau inspected 26,

which provides that 65 percent of the licensees were inspected over the review period. 

Although the team was unable to determine that at least 20 percent of the reciprocity

candidates were inspected each year, the overall percentage of licensees inspected over the

review period was determined to be an acceptable alternative.

The review team’s difficult experience with the Bureau’s data tracking system was discussed

with managers and staff. The Bureau provided that the issues would be discussed with

information technology staff and that steps would be taken to decrease the level of difficulty

associated with manipulating and retrieving data from the tracking system. Notwithstanding the

difficulty, the review team did not identify any licensees that were inspected overdue. The

Bureau inspects their licensees at least as frequent, and often more frequently than NRC. The

Bureau communicates inspection results to the licensees in a timely fashion, and inspects an

acceptable number of reciprocity licensees. 

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

concurred that Illinois’ performance with respect to the indicator, Status of the Materials

Inspection Program, be found satisfactory. 

3.3 Technical Quality of Inspections

The team evaluated the inspection reports, enforcement documentation, and interviewed staff

members for 20 radioactive materials inspections conducted during the review period. The

casework included work performed by all of the Bureau’s material inspectors, and covered a

variety of license types including: academic; medical; nuclear pharmacy; industrial radiography;

pool irradiator; service provider; manufacturing and distribution; well logging; and research and

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

adequacy with case-specific comments, as well as the results of the inspection

accompaniments.

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

aspects of the licensees’ radiation programs. The review team determined that inspection

reports were generally very thorough, complete, consistent, and of high quality, with sufficient

documentation to ensure that a licensee’s performance with respect to health and safety was

acceptable. The documentation supported violations, recommendations made to the licensee,

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

inspections were performed for larger and complex licensees and for training purposes.

The previous IMPEP evaluation in 2001 identified that the majority of violations cited by Bureau

staff were record keeping infractions and that many inspections were not conducted in a

performance-based, risk-informed manner. Inspections evaluated during this review identified

that a performance-based, risk-informed approach is now utilized by the program.
Illinois Final Report Page 6 

The Inspection Unit Supervisor, who signs compliance letters to licensees, reviewed completed

inspection reports. Field Compliance Reports are sometimes issued in the field by inspectors

when no violations are identified during an inspection. Supervisory accompaniments were

conducted annually for all inspectors.

The team identified that inspection findings were appropriate, and prompt regulatory actions

were taken, as necessary. All inspection findings were clearly stated and documented in the

reports, and reviewed by the inspection supervisor. The Bureau has the ability to require

management meetings and impose civil penalties when it is deemed that the licensee has had

a significant breakdown in operations affecting health and safety. The enforcement program

and administrative proceedings are detailed in the State’s regulations found in Title 32 of the

Illinois Administrative Code, Parts 310 and 200, respectively. Escalated enforcement actions

are issued by the Assistant Director of the Agency.

The Bureau has adequate numbers and types of radiation survey instruments to support their

radiation control program efforts. These instruments are calibrated by Agency laboratory

personnel at their Regional Calibration Laboratory located in Springfield, which is managed by

the Bureau of Nuclear Facility Safety. Appropriate, calibrated survey instruments such as GM

meters, scintillation detectors, ion chambers, micro-R-meters, and neutron meters were

observed. Portable multi-channel analyzers are used in response to incidents and recycling

facility alarms. Air monitoring equipment is also available. 

The Radiochemistry Laboratory, in Springfield, which is managed by the Bureau of

Environmental Safety, evaluates water samples, soil samples and wipe tests. The Bureau has

a satellite radiochemistry laboratory in West Chicago, near the Kerr-McGee decommissioning

site.

Three Bureau inspectors were accompanied during inspections by a review team member in

February and March 2005. Inspection accompaniments included: a pool irradiator; a well

logger; and a reciprocity transportation inspection, as identified in Appendix C. During the

accompaniments, each inspector demonstrated appropriate performance-based inspection

techniques and knowledge of the regulations. The inspectors were trained, prepared, and

thorough in their audits of the licensees’ radiation safety programs. Each inspector also utilized

good health physics practices during the inspections. Interviews with licensee personnel were

performed in an effective manner, and the inspections were adequate to assess radiological

health and safety at the licensed facilities.

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

concurred that Illinois’ performance with respect to the indicator, Technical Quality of

Inspections, be found satisfactory.

3.4 Technical Quality of Licensing Actions

The review team interviewed license reviewers, evaluated the licensing process, and examined

licensing casework for 27 licensing actions. Licensing actions were reviewed for completeness,

consistency, proper radioisotopes and quantities, qualifications of authorized users, adequate

facilities and equipment, adherence to good health physics practices, financial assurance,

operating and emergency procedures, appropriateness of license conditions, and overall

technical quality. The casework files were also evaluated for timeliness, use of appropriate
Illinois Final Report Page 7 

deficiency letters and cover letters, reference to appropriate regulations, product certifications,

supporting documentation, consideration of enforcement history, pre-licensing visits,

supervisory review as indicated, and proper signatures. The files were checked for retention of

necessary documents and supporting data.

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

which were completed during the review period by eight different license reviewers. The crosssection sampling focused on the new licenses, amendments, renewals, and license

terminations issued during the review period. The sampling included the following types of

licenses: academic (including broad scope); pool irradiator; well logging; industrial radiography;

research and development (including broad scope); source manufacturing and distribution;

nuclear pharmacy; veterinary medicine; mobile nuclear medicine; medical private practice; and

medical institution (including therapy and broad scope). Licensing actions evaluated included

3 new licenses, 8 renewals, 13 amendments, 1 financial assurance update, and 2 termination

files. A listing of the casework licenses evaluated with case specific comments may be found in

Appendix D.

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

and of high quality with health and safety issues properly addressed. License tie-down

conditions were stated clearly, backed by information contained in the file, and inspectable. 

The licensee’s compliance history was taken into account when reviewing renewal applications

and amendments. Reviewers appropriately utilize the State’s licensing guides, license

templates, standard conditions, and application review checklists to ensure consistency on

licensing actions. The exemptions noted in the questionnaire response were determined to be

appropriate, implemented uniformly, and well documented by license conditions.

Licensing actions are all tracked via “blue sheets.” The blue sheets are generated by the

clerical staff upon receipt, the information entered into the database, and then the action is

assigned to a license reviewer. The blue sheets follow the status of the licensing action

throughout the process. Good communication was recognized between licensing and

inspection staff via “green sheets” placed in license files. These sheets are utilized for license

reviewers and inspectors to communicate any issues or problems identified during the review

process or inspection. Additionally, for some complex licensing actions, license reviewers

performed a pre-licensing inspection of the facility prior to issuance of the license. This

inspection provided the reviewer with a more in-depth understanding of the licensee’s program,

which aided in an effective licensing action. 

The review team found that the staff follows appropriate licensing guides, similar to NRC’s

NUREG 1556 series, during the review process to ensure that licensees submit information

necessary to support their request. The review team found the checklists used for each type of

program to be comprehensive and incorporated excellent notes to assist the staff with their

review of the applications. Letters and documented telephone and electronic conversations

contained appropriate regulatory language and addressed deficiencies. The use of license

templates by the staff, incorporating standard conditions, also resulted in notable consistency

between reviewers. Overall, the review team found that the licensing actions were thorough,

complete, consistent, of high quality, and properly addressed health and safety issues.
Illinois Final Report Page 8 

The review team found that terminated licensing actions were well documented. The files

included the appropriate material transfer reports and survey records. An evaluation of the

selected termination records indicated excellent communication between the licensing,

inspection, and decommissioning staff to prevent abandonment of radioactive material. The

files showed that documentation of proper disposal or transfer was provided.

When a licensing action is completed by a reviewer, the entire package is given to the Materials

Licensing Unit Supervisor who approves and signs the licensing action. Licenses are issued for

a five-year term. The Bureau has instituted an expedited renewal process, where a licensee

submits an application and identifies any parts of his radiation safety program that have

changed, and confirms that all other portions are still current. Licenses that are under timely

filed status are amended as necessary to assure that public health and safety issues are

addressed during the period that the license is undergoing the renewal process.

The Bureau requires certain licensees to maintain financial assurance for decommissioning. 

Surety instruments are maintained in a locked cabinet in the Decommissioning Section Head’s

office. The Decommissioning Section determines the financial assurance requirements for the

licensing staff. The review team noted good communication between the Materials Licensing

Unit and the Decommissioning Section, and evaluated the contents of several financial

assurance folders, which were found to be in good order. 

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

concurred that Illinois’ performance with respect to the indicator, Technical Quality of Licensing

Actions, be found satisfactory.

3.5 Technical Quality of Incident and Allegation Activities

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

team examined the Bureau’s response to the questionnaire relative to this indicator, evaluated

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

those contained in the Illinois files, and evaluated the casework and supporting documentation

for ten material incidents. A list of the incident casework examined is included in Appendix E.

The team also reviewed the Bureau’s response to 30 allegations involving radioactive materials

including 12 allegations referred to the State by NRC during the review period.

The review team discussed the Bureau’s incident procedure, file documentation, the State’s

equivalent to the Freedom of Information Act, Nuclear Materials Event Database, and

notification of incidents to the NRC Operations Center with the Program Manager and selected

staff. 

The Bureau maintains a telecommunications center that is operational 24 hours a day, 7 days a

week. The on-duty staff maintains contact with the Radiological Duty Officer who will assess

the reported hazard, provide advice and verbal assistance, and, if appropriate, dispatch a

response team to the scene. The Bureau uses the NMED data entry software program and

provides updates to the NMED national database in a timely manner per the Office of State and

Tribal Programs Procedure, SA-300: Reporting Material Events. The Bureau has worked

directly with the NMED contractor to identify and suggest fixes to bugs found in the software. 
Illinois Final Report Page 9 

The Bureau responded to 147 radioactive material incidents as reported to NMED during the

review period, and of those, 97 were NRC required reportable incidents. During the last four

years there were no incidents involving occupational or public exposures that exceeded the

regulatory dose limits. A sample of 10 incidents was selected for review. The incidents

included: loss of radioactive material, damaged gauges, leaking sources, medical events, and

an abnormal occurrence. The review team found that the Bureau’s response to incidents was

complete and comprehensive. Initial responses were prompt and well coordinated. Staff

communicated well with each other and provided back up when needed. Inspectors were

dispatched for on-site investigations, when appropriate, and the State took suitable

enforcement action including coordination with the license reviewers and follow up, as

appropriate. Staff use the NMED local data entry program and database to store and upload

incident data to the NMED national database. The Bureau provides complete and timely

incident reports to NMED. 

The Bureau has instituted an orphan source program that is funded through a “Recovery and

Remediation Fee” assessed over the first two-year period to all new licensees. These fees go

into a special fund to be used for the recovery and remediation of radioactive materials. When

sources are abandoned, the Bureau stores these sources in a secure storage facility and tracks

the status of these sources in a database. Periodically, the Bureau sends their staff to collect

these sources and package them for disposal. The Bureau then contracts with a broker to

pickup and arrange for disposal of the orphan material using the special funds. This fund would

be used when the costs cannot be recovered from a responsible party or available financial

assurance. The review team recommends the Bureau’s orphan source program as a good

practice.

The team reviewed the Bureau’s response to 30 allegations received during the review period

involving radioactive materials including 12 allegations referred to the Bureau by NRC. The

evaluation of the 30 allegation cases indicated that the Bureau took prompt and appropriate

action in response to the allegers’ concerns. Through review of the casework and interviews

with staff, the review team determined that the Bureau provided feedback to allegers either

verbally or in writing when possible. Any alleger requesting anonymity is informed that every

effort will be made to protect his/her identity, but it cannot be guaranteed. All interviewed staff

was knowledgeable of the Bureau’s allegation procedure. There were no performance issues

identified from the review of allegation files and documentation.

Based on the IMPEP evaluation criteria the review team recommended and the MRB concurred

that Illinois’ performance with respect to the indicator, Technical Quality of 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 evaluating Agreement

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

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

and (4) Uranium Recovery Program. 
Illinois Final Report Page 10 

4.1 Compatibility Requirements

Legislation

The State provided, in their response to the questionnaire, a listing of legislation that affects the

radiation control program. The Agency is designated as the State radiation protection agency

under the provisions of the Radiation Protection Act of 1990, as amended [420 Illinois Compiled

Statutes (ILCS) 40]. The Bureau implements the program for the Agency. The Act grants the

Agency the authority to promulgate rules and regulations to be followed in the administration of

the radiation protection program. The Illinois Emergency Agency Act [20 ILCS 3305] and the

Nuclear Safety Law of 2004 [20 ILCS 3310] resulted in the subsuming of the Illinois Department

of Nuclear Safety into the Illinois Emergency Management Agency in July 2003. The current

legislation that affects the radiation control program is as follows:

The Radioactive Waste Storage Act [420 ILCS 35], the Illinois Low-Level Radioactive Waste

management Act [420 ILCS 20] and the Uranium and Thorium Mill Tailings Control Act [420

ILCS 42] statutes provide authority for the low-level radioactive waste disposal and uranium

recovery programs.

Other statutes which affect the radiation control program include: Central Midwest Radioactive

Waste Compact Act [45 ILCS 140]; Department of Nuclear Safety [20 ILCS 2005]; Freedom of

Information Act [5 ILCS 140]; Freedom of Information Act [5 ILCS 140/1 - 140/11]; and Illinois

Administrative Procedure Act [5 ILCS 100].

Public Act 91-752, which was effective June 2, 2000, extended the sunset date for the

Radiation Protection Act until January 1, 2011. The other aforementioned statutes do not have

sunset provisions.

Program Elements Required for Compatibility

The State regulations for control of radiation are located in Title 32 of the Illinois Administrative

Code and apply to all ionizing radiation, whether emitted from radionuclides or devices. Illinois

requires a license for possession and use of radioactive materials, including naturally occurring

and accelerator-produced radionuclides.

The review team examined the State's rulemaking process and found that the process takes

approximately six months after preparation of a draft rule. An additional review of regulations

by the Governor’s office has been implemented since the last IMPEP review. The Bureau staff

does not believe this will affect the normal time for rule promulgation. Proposed rules are

published in the Illinois Register with a minimum 45-day comment period, and may include a

public hearing. At this point, the proposed rules are sent to NRC for review. After resolution of

comments, the Bureau provides the comments and responses to the Joint Committee on

Administrative Rules (JCAR), a bipartisan committee consisting of legislators from the Illinois

House of Representatives and Senate. After resolution of JCAR comments, the rule must be

re-published for comment if substantial changes were made or scheduled for a vote at the next

available monthly JCAR meeting. Approved rules are published as final in the Illinois Register. 

Final rules are sent to the NRC for a final review and compatibility determination and updated

on the Bureau’s website. The Bureau has the authority to issue legally binding requirements

(e.g., license conditions) in lieu of regulations until compatible regulations become effective.
Illinois Final Report Page 11 

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

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

compatibility policy, and verified regulation status with data obtained from the Office of State

and Tribal Programs’ Regulation Action Tracking System (RATS). Current NRC policy requires

that Agreement States adopt certain equivalent regulations or legally binding requirements no

later than three years after they are effective. 

The Bureau has had continuing challenges in this area of their program, as identified during the

1997 and 2001 IMPEP reviews. In 1997, the review team recommended that the Bureau’s

performance be found unsatisfactory for this indicator. However, based on information

provided during the MRB meeting, the MRB determined that the State’s performance was

satisfactory. During the 2001 IMPEP, the review team found the Bureau was continuing to face

challenges. The review team recommended that the State adopt regulations, or other legally

binding requirements, which were overdue for adoption. The MRB affirmed the finding of

satisfactory with recommendations for improvement (now “satisfactory, but needs

improvement”) for this indicator. The status of this recommendation was discussed during the

2002 and 2004 periodic meetings and continued to be unresolved.

Bureau staff explained to the current review team that there has been a “philosophical shift” in

the last two years and the Bureau intends to comply with the requirement that Agreement State

regulations be adopted and compatible with NRC regulations. The Bureau also faced staffing

challenges in this area during the last two years. As discussed in Section 3.1 of this report, the

Bureau lost the senior project manager for regulatory affairs to the Bureau of Nuclear Safety

during the 2003 reorganization. The Radioactive Materials Section Head assumed these

responsibilities, but was deployed for military duty on October 1, 2004. In the meantime, the

Materials Licensing Unit Supervisor is acting for the Section Head. 

Based on information contained in the State Regulation Status Sheet (SRS), the State has

ten rule amendments overdue. Seven of the overdue rule amendments are in draft form at

various stages in the Bureau’s legal review process. The State agreed to send the NRC the

draft version of these seven rules for review. The remaining three overdue amendments will be

superceded when the State adopts the amendment “Medical Use of Byproduct Material” (RAT

ID 2002-2 due for adoption October 24, 2005). This amendment is currently in draft form within

the Bureau. In addition to the ten currently overdue amendments, during the review period, the

State adopted 14 amendments late, (i.e., past the three-year window for Agreement State

adoption). All the rules mentioned above are summarized below with their current status.

The following seven rule amendments are overdue for adoption but they are currently in draft

form and undergoing legal review within the Bureau. They have not been sent into the NRC for

review as required by STP Procedure SA-201. The State has agreed to send these draft rules

to the NRC for review.

• "Compatibility with the International Atomic Energy Agency," 10 CFR Part 71

amendment (60 FR 50248 and 61 FR 28724) was due for adoption on October 20, 1998

[RATS ID 1996-1].

• "Resolution of Dual Regulation of Airborne Effluents of Radioactive Materials: Clean Air

Act," 10 CFR Part 20 amendment (61 FR 65119) was due for adoption on January 9,

2000 [RATS ID 1997-1].
Illinois Final Report Page 12 

• "Transfer for Disposal and Manifests; Minor Technical Conforming Amendment,"

10 CFR Part 20 amendment (63 FR 50127) was due for adoption on November 20,

2001 [RATS ID 1998-6].

• "Respiratory Protection and Controls to Restrict Internal Exposures," 10 CFR Part 20

amendment (64 FR 54543 and 64 FR 55524) was due for adoption on February 2, 2003

[RATS ID 1999-3].

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

was due for adoption on January 8, 2004 [RATS ID 2000-2].

• “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

Material,” 10 CFR Parts 30,31,32 amendments (65 FR 63749) were due for adoption on

February 16, 2005 [RATS ID 2001-1].

• “Revision of the Skin Dose Limit,” 10 CFR Part 20 amendment (67 FR 1629) was due

for adoption on April 5, 2005 [RATS ID 2002-1].

The following three amendments are overdue for adoption. The team notes that they will be

superceded when the State adopts the amendment “Medical Use of Byproduct Material,”

10 CFR Parts 20,32, and 35 amendments (67 FR 20249) that will become due for adoption on

October 24, 2005 [RATS ID 2002-2]. The State has drafted rules to meet the requirements

of 2002-2. The State has agreed to send in the draft rules for NRC review.

•· Quality Management Program and Misadministrations," 10 CFR Part 35 amendment

(56 FR 34104) was due for adoption and on January 27, 1995 [RATS ID 1992-1]. 

• “Preparation, Transfer for Commercial Distribution, and Use of Byproduct Material for

Medical Use,” 10 CFR Parts 30, 32, 35 (59 FR 61767; 59 FR 65243; 60 FR 322) was

due for adoption on January 1, 1998 [RATS ID 1995-1].

• “Frequency of Medical Examinations for Use of Respiratory Protection Equipment,”

10 CFR Part 20 amendment (60 FR 7900) was due for adoption on March 13, 1998

[RATS ID 1995-2].

For the following 14 amendments, the State has final regulations or other legally binding

requirements in place. These amendments have not been submitted to NRC for a final

compatibility determination. The State adopted all of these amendments late (i.e., past the

three-year window for State adoption). The State has agreed to send in the final, as adopted,

rule for NRC review.

• “Safety Requirements for Radiographic Equipment,” 10 CFR Part 34 amendment

(55 FR 843) was due for adoption on January 10, 1994 [RATS ID 1991-1].

• “Radiation Protection Requirements: Amended Definitions and Criteria,” 10 CFR

Parts 19, 20 amendments (60 FR 36038) was due for adoption on August 14, 1998

[RATS ID 1995-5].
Illinois Final Report Page 13 

• “Clarification of Decommissioning Funding Requirements,” 10 CFR Parts 30, 40, seven

amendments (60 FR 38235) were due for adoption and on November 24, 1998 [RATS

ID 1995-6].

Status: The rule will be superceded when the State adopts the amendment ”Financial

Assurance for Materials Licensees,” 10 CFR Parts 30, 40, 70 amendments

(69 FR 3697) [RATS ID 2003-1] which will become due for adoption and a final

compatibility review on December 3, 2006. The State has drafted rules to meet

the requirements of RATS ID 2003-1. 

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

35 amendments (60 FR 48623) were due for adoption and on October 20, 1998 [RATS

ID 1995-7]

• “Deliberate Misconduct by Unlicensed Persons,” 10 CFR Parts 30, 40, 61, 70, and

150 amendments (63 FR 1890 and 63 FR 13773) was due for adoption on February 12,

2001 [RATS ID 1998-1]. 

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

32, 35, 36, and 39 amendments (63 FR 39477 and 63 FR 45393) was due for adoption

on October 26, 2001 [RATS ID 1998-5].

• “Notification of Incidents,” 10 CFR Parts 20, 30, 31, 34, 39, 40, 70 amendment

(56 FR 64980) was due for adoption on October 15, 1994 [RATS ID 1991-4].

Status: The proposed rule was reviewed by NRC in January 2004 and comments were

provided to State staff. Final rule was promulgated.

• “Low-Level Waste Shipment Manifest Information and Reporting,” 10 CFR Parts 20,

61 amendments (60 FR 15649, 60 FR 25983) was due for adoption on March 1, 1998 

[RATS ID 1995-3].

Status: NRC reviewed the proposed rule in November 1999 and comments were

provided to State staff. Final rule was promulgated.

• “Performance Requirements for Radiography Equipment,” 10 CFR Part 34 amendment

(60 FR 28323) was due for adoption on June 30, 1998 [RATS ID 1995-4].

Status: NRC reviewed the proposed rule in January 2004 and had no comments. Final

rule was promulgated.

 

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

70 amendments (62 FR 39057) were due for adoption on August 20, 2000 [RATS

ID 1997-6]. 

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

10 CFR Part 39 amendment (65 FR 20337) was due on May 17, 2003 for adoption

[RATS ID 2000-1].
Illinois Final Report Page 14 

• “Licenses for Industrial Radiography and Radiation Safety Requirements for Industrial

Radiographic Operations; Clarifying Amendments and Corrections,” 10 CFR

Part 34 amendment (63 FR 37059) was due for adoption on July 9, 2001 [RATS

ID 1997-5].

Status: NRC reviewed the proposed rule in January 2004 and comments were provided

to State staff. Final rule was promulgated.

• “Licensing and Radiation Safety Requirements for Irradiators,” 10 CFR Part 36

amendment (58 FR 7715) was due for adoption on July 1, 1996 [RATS ID 1993-2]. 

Status: The Bureau has implemented the rule through generic license condition. A final

rule has been promulgated.

• “Criteria for the Release of Individuals Administered Radioactive Material,” 10 CFR Parts

20 and 35 amendments (62 FR 4120) were due for adoption on May 29, 2000 [RATS ID

1997-3]

Status: The Bureau has implemented the rule through generic license condition. The

amendment will be addressed when the regulations identified in RATS ID 2002-2

are approved. 

The following two amendments are overdue for adoption. However, the State does not have

any current facilities subject to this provision and until they receive a license application subject

to these provisions, they do not need to adopt RATS ID 1994-2. In addition, the State has

identified that the current uranium recovery facility is grandfathered under the last sentence of

10 CFR 40, Appendix A, Criterion 6 (6) and, therefore, does not need to adopt RATS ID

1999-1. Therefore neither of these amendments are being counted as overdue with respect to

this indicator. The States SRS will be updated to reflect these conditions. 

• “Uranium Mill Tailings Regulations: Conforming NRC Requirements to EPA Standards,”

10 CFR Part 40 amendment (59 FR 28220) was due for adoption and on July 1, 1997 

[RATS ID 1994-2]. 

• "Radiological Criteria for License Termination of Uranium Recovery Facilities," 10 CFR

Part 40 amendment (64 FR 17506) was due on June 11, 2002 for adoption and final

compatibility determination [RATS ID 1999-1].

The following amendment will become due during the next IMPEP review cycle and is included

here to assist the Bureau in including them in future rulemakings or by adopting alternate

generic legally binding requirements:

• “Compatibility with IAEA Transportation Safety Standards and Other Transportation

Safety Amendments,” 10 CFR Part 71 amendment (69 FR 3697) is due for adoption and

a final compatibility review on October 1, 2007 [RATS ID 2004-1]. 

The team recommends that the 2001 IMPEP recommendation discussed above remain open

and that the State adopt the regulations, or other legally binding requirements, which are

overdue for adoption and send them to the NRC for review. 
Illinois Final Report Page 15 

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

concurred that Illinois' performance with respect to the indicator, Compatibility Requirements,

be found unsatisfactory.

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

In assessing the Illinois SS&D Evaluation Program, the review team examined the information

provided in response to the IMPEP questionnaire. The team evaluated SS&D registry sheets

issued during the review period and the supporting document files. The team also evaluated

SS&D staff training records, certain reported incidents involving products authorized in Illinois

SS&D sheets, the use of guidance documents and procedures, and interviewed the staff

currently conducting SS&D evaluations. Three sub-indicators were used to evaluate the

Bureau’s performance regarding their SS&D Evaluation Program. These sub-indicators were

(1) Technical Staffing and Training; (2) Technical Quality of the Product Evaluation Program;

and (3) Evaluation of Defects and Incidents Regarding SS&Ds.

4.2.1 Technical Staffing and Training

Presently, the SS&D Evaluation Program is under the Materials Licensing Unit, and three staff

members conduct the reviews. The Bureau has budgeted .3 FTE for this program. One

previously qualified and experienced SS&D reviewer is currently on military duty. Additionally,

the staff can obtain engineering and technical assistance from engineering staff in the

Decommissioning Section. The review team evaluated the qualifications of the individuals

authorized and currently performing SS&D evaluations. All reviewers were qualified through

previous training and experience, as was documented in a staff memorandum dated

October 30, 2004. All have regulatory experience, have attended the NRC SS&D Workshop,

and have been performing reviews for greater than ten years. The review team noted that

SS&D reviewers have degrees in engineering, environmental science, or equivalent training

and experience. 

The SS&D Evaluation Program has had a constant staffing level during the review period,

attributing approximately ten percent of the staff time to SS&D reviews. When compared with

the previous review period, there have been fewer SS&D actions, mainly attributable to the

relocation of two large manufacturers out of Illinois. This staffing is deemed adequate.

4.2.2 Technical Quality of the Product Evaluation Program

The review team evaluated 8 of the 62 SS&D evaluation actions completed during the review

period. The 62 actions consisted of 26 amendments, 32 inactivations, and 4 new registrations,

that represented the work of all SS&D reviewers. The cases selected were representative of

the Bureau’s licensees and SS&D reviewers. A list of SS&D casework examined along with

case-specific comments may be found in Appendix F.
Illinois Final Report Page 16 

The team’s review of the casework and interviews with the staff confirmed that the SS&D

reviewers used NUREG-1556, Volume 3, and the American National Standards Institute

(ANSI)/Health Physics Society (HPS) standards. All pertinent ANSI/HPS standards, regulatory

guides, and applicable references were confirmed to be available and were used when

performing SS&D reviews. The appropriate review checklist was used to assure relevant

materials had been submitted and reviewed. The checklists were retained in all of the

registration files examined. In reviewing emergent technology related products and new

applications, the SS&D reviewers performed evaluations based on sound health physics

principles and used conservative assumptions to ensure the protection of public health and

safety. Registration certificates clearly summarized the product evaluation and provided license

reviewers with adequate information on areas requiring additional attention to license the

possession, use, and distribution of the products. Overall, the review team found the

evaluations were of high quality with health and safety issues properly addressed. 

The registration files contained all correspondence, engineering drawings, radiation profiles,

and results of tests conducted by the applicant. The files were well organized in a consistent

manner. Deficiency letters clearly stated regulatory positions and health and safety issues were

properly addressed. The review team determined that product evaluations were thorough,

complete, consistent, of acceptable technical quality, and adequately addressed the integrity of

the products during use and in the event of likely accidents.

4.2.3 Evaluation of Defects and Incidents Regarding SS&D

The Bureau responded to one incident/product failure or defect concerning devices registered

by the Bureau. This incident is included in Appendix E. At the time of this review, the

investigation was still being conducted. The SS&D staff, in conjunction with inspection staff,

conducted a thorough review of the event history, as well as a comparison with similar reported

events, to establish the root cause. Currently, the staff is conducting an audit of the licensee’s

QA/QC program. The outcome of the investigation will determine if there is a generic design or

performance issue with this product. The Bureau provided a timely and adequate response in

the investigation and resolution of the events. No allegations related to SS&Ds were reported

during the review period.

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

concurred that Illinois’ performance with respect to the indicator, SS&D Evaluation Program, be

found satisfactory.

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

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

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

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

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

disposal authority without the need of an amendment. The State’s LLRW program is currently

inactive, and it is anticipated that there will be no further activity with the program for several

years. Therefore, the staff are working on other projects. Accordingly, the review team did not

review this indicator.
Illinois Final Report Page 17 

4.4 Uranium Recovery Program

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

regarding the uranium recovery program. These sub-indicators include: (1) Technical Staffing

and Training; (2) Status of Uranium Recovery Inspection Program; (3) Technical Quality of

Inspections; (4) Technical Quality of Licensing Actions; and (5) Response to Incidents and

Allegations. The results of the uranium recovery program review will be discussed under each

of these sub-indicators. In 1990, the Illinois Agreement was amended to include the authority

for 11e. (2) byproduct material and the facilities that generate such material.

The Decommissioning Section administers the Bureau’s uranium recovery program. The

Bureau has only one licensee in the program, the Kerr-McGee Chemical Corporation

(Kerr-McGee), Rare Earths Facility, located in West Chicago, Illinois. This facility is in the

process of decommissioning. During the review period, the operations at the site included

excavation of contaminated material, transport and handling of contaminated materials, water

treatment and groundwater monitoring. 

4.4.1 Technical Staffing and Training

The technical staff consists of two engineers (mechanical and mining), one health physicist,

and a geologist with a support contractor supplying additional expertise in these and other

technical areas. The Bureau has four FTE budgeted for contractor support in addition to the

Decommissioning Section FTE discussed in Section 3.1 of this report. The health physicist is

the onsite resident inspector located in West Chicago and has been in the position since 1996. 

Other staff in the Bureau of Environmental Safety provides additional technical support. The

Bureau has outlined the training requirements for staff in the Employee Training Requirements. 

The requirements consist of technical training, personal instruction, in-house training, outside

training and on-the-job training. The review team examined the training, education, and

experience of the staff members and found that the qualifications of the technical staff are

commensurate with the expertise needed to regulate the radioactive material at the KerrMcGee site. 

The Bureau has contracted with consultants for support of quality assurance at the KerrMcGee site and technical review of licensing actions. The review team reviewed the

qualifications of the consultants. Both the prime and sub-contractors are well qualified. The

consultants have employed staff that are well trained in a variety of technical fields. The prime

contractor appropriately utilizes sub-contractors for actions with technical issues outside of their 

specialization. The Decommissioning Section Head has oversight responsibility for the work

performed by the contractor staff. 

The review team determined that the qualifications of the technical staff are commensurate with

expertise identified as necessary to regulate the uranium recovery facilities. Bureau

management has developed and implemented a satisfactory training program for staff that is

consistent with the review requirements.
Illinois Final Report Page 18 

4.4.2 Status of Uranium Recovery Inspection Program

The Bureau has an annual inspection frequency for the Kerr-McGee site. The frequency is

consistent with the criteria in NRC’s MC 2801 and has been applied since the licensee began

decommissioning operations in 1994. The Bureau’s resident inspector conducts daily, weekly

and monthly operation checks, and observes site operations daily. In addition, an engineering

company under contract with the Bureau supports the resident inspector and performs

environmental surveys. The contractor reports its findings to the resident inspector or directly

to the Decommissioning Section Head. 

The Springfield office staff conducted four annual compliance inspections since the last review. 

One inspection was outside the 30-day reporting period (31 days) due to the unique nature and

extent of decommissioning activities on the project and the depth of the reporting

documentation. The review team determined that the inspections were performed at intervals

that are consistent with NRC’s guidance. 

The Bureau reviews the annual environmental monitoring report submitted by the licensee and

determines compliance for the environmental program. These reviews are conducted by a

consultant and are conducted on a separate schedule from the annual compliance inspections.

The Environmental Monitoring and Transportation Section Head has oversight responsibility for

these reviews.

4.4.3 Technical Quality of Inspections

The review team examined inspection reports and files, and reviewed documentation for the

Kerr-McGee site, including the last four annual inspection reports. The last two environmental

monitoring data reviews and quality assurance audits were also reviewed. The review team

determined that the reports for the inspections and audits were thorough, complete, consistent,

and of high quality, with adequate documentation to determine compliance with regulations,

license conditions, and available guidance. Findings noted in earlier inspections were

investigated and the proposed resolutions verified at the next inspection. 

The onsite resident inspector regularly inspects site operations and reviews data and sampling

information required under license condition. Regular meetings are held between the resident

inspector, contractors and Springfield staff. These meetings are documented in meeting

minutes. 

During the review period, the Bureau performed two audits of Kerr-McGee’s quality assurance

program in order to evaluate the licensee’s checks on activities. The Bureau’s contractor

performed the audit under the supervision of the Bureau staff. Findings were identified as a

result of the audits and recorded in an Audit Finding Notice. 

4.4.4 Technical Quality of Licensing Actions

The review team evaluated 10 amendments for the Kerr-McGee license issued since the last

review. In examining the amendments and selected documentation in the file, the review team

found that many of the license amendments were to change the volume of material leaving the

site for disposal and to authorize the receipt of radioactive material brought on to the site from

the adjacent areas and residential clean-up activities. Other actions included revision of the air-
Illinois Final Report Page 19 

monitoring program and an application for alternate concentration limits for groundwater. A

significant license amendment incorporated new groundwater protection requirements,

specifying groundwater constituents and monitoring frequency. The Bureau and its contractors

have performed extensive review on the groundwater monitoring plan and application for

alternate concentration limits, which were approved in 2001. The listed groundwater

constituents are identified in 10 CFR Part 40. The review team determined that the Bureau

used the appropriate regulations and guidance documents for this review.

Based on a review of the licensing file, the team concluded that licensing actions were

appropriate and that the license conditions were clear and well written. Requirements

associated with these conditions were based on a need to meet the regulation and to protect

health and safety. The review team informed Bureau staff of updated NRC guidance to be

used in the future, NUREG-1620, “Standard Review Plan for the Review of a Reclamation Plan

for Mill Tailings Sites Under Title II of the Uranium Mill Tailings Radiation Control Act of 1978.”

4.4.5 Response to Incidents and Allegations

There were no incidents or allegation pertaining to the Kerr-McGee activities during this review

period.

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

concurred that Illinois’ performance with respect to the indicator, Uranium Recovery Program,

be found satisfactory.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team recommends that Illinois’ performance be

found satisfactory for seven performance indicators reviewed, but unsatisfactory for the

Compatibility Requirements indicator. Accordingly, the review team recommended and the MRB

concurred in finding the Illinois Agreement State program adequate to protect public heath and

safety and not compatible with NRC's program. The review team recommended and the MRB

concurred that a period of heightened oversight be implemented to assess the progress of the

State, including preparation of a program improvement plan, bimonthly conference calls, status

reports before each call, and a follow-up IMPEP review in one year.

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

and implementation, as appropriate, by the State.

RECOMMENDATION

1. The review team recommends that the State adopt the regulations, or other legally

binding requirements, which are overdue for adoption and send them to the NRC for

review. (Section 4.1)
GOOD PRACTICE:

The review team identified a good practice, and the MRB concurred, in noting that the Bureau

has instituted an orphan source program that is funded through a “Recovery and Remediation

Fee” assessed over the first two-year period to all new licensees. These fees go into a special

fund to be used for the recovery and remediation of radioactive materials. When sources are

abandoned, the Bureau stores these sources in a secure storage facility and tracks the status

of these sources in a database. Periodically, the Bureau sends their staff to collect these

sources and package them for disposal. The Bureau then contracts with a broker to pickup and

arrange for disposal of the orphan material using the special funds. This fund would be used

when the costs cannot be recovered from a responsible party or available financial assurance.
LIST OF APPENDICES

Appendix A IMPEP Review Team Members

Appendix B Illinois Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Appendix F Sealed Source and Device Casework Reviews

Attachment June 3, 2005 Letter from Gary Wright

Illinois‘ Response to Draft IMPEP Report 
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Vivian Campbell, Region IV Team Leader

Technical Staffing and Training

James Lynch, Region III Technical Quality of Inspections Program

Inspector Accompaniments

Terry Brock, STP Technical Quality of Incident and Allegation Activities

Compatibility Requirements

Shawn Smith, STP Status of Materials Inspection Program

Jill Caverly, NMSS Uranium Recovery Program

Eric Jameson, Georgia Technical Quality of Licensing Actions

Sealed Source and Device Evaluation Program
APPENDIX B

ILLINOIS ORGANIZATION CHARTS

ML051230486
APPENDIX C

INSPECTION CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: JANX License No.: IL-02168-01

Inspection Type: Initial, Unannounced Priority: 1

Inspection Date: 3/11/03 Inspector: GM

File No.: 2

Licensee: Bard Brachytherapy, Inc. License No.: IL-02062-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 6/29/04 Inspector: WH

File No.: 3

Licensee: Medi-Physics, Inc. License No.: IL-01052-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 2/8/05 Inspector: AG

Comment:

a) No mention of second pharmacy location authorized on license.

File No.: 4

Licensee: NuClin Diagnostics, Inc. License No.: IL-01551-01

Inspection Type: Routine, Announced Priority: 1

Inspection Date: 5/18/04 Inspectors: JK, RM, DP

File No.: 5

Licensee: Methodist Medical Center of Illinois License No.: IL-01204-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Dates: 8/3-4/04 Inspector: GM

Comment:

a) Inspection letter issued late (42 days).

File No.: 6

Licensee: Schlumberger Well Services License No.: 77-00347-01

Inspection Type: Reciprocity, Unannounced Priority: 2

Inspection Date: 1/20/05 Inspector: GM

File No.: 7

Licensee: Cardinal Health, Inc. License No.: IL-01721-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Dates: 2/2-3/05 Inspector: WH
Illinois Final Report Page C.2

Inspection Casework Reviews

File No.: 8

Licensee: Abbott Laboratories License No.: IL-01478-02

Inspection Type: Initial, Announced Priority: 1

Inspection Date: 12/3/04 Inspector: JK

Comment:

a) Supervisory review of Field Compliance Report not documented in report.

File No.: 9

Licensee: REVISS Services, Inc. License No.: IL-02058-01

Inspection Type: Routine, Announced Priority: 3

Inspection Date: 12/22/04 Inspector: JP

File No.: 10

Licensee: Lixi, Inc. License No.: IL-01339-01

Inspection Type: Initial, Announced Priority: 1

Inspection Date: 6/30/04 Inspector: JP

File No.: 11

Licensee: Loretto Hospital License No.: IL-01378-01

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 9/23/04 Inspector: JP

File No.: 12

Licensee: Sterigenics U.S., Inc. License No.: IL-01220-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 6/15/01 Inspector: WH

File No.: 13

Licensee: Illinois Institute of Technology License No.: IL-01739-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 2/18/05 Inspectors: RM, AG

Comment:

a) Supervisory review of Field Compliance Report not documented in report.

File No.: 14

Licensee: Team Cooperheat-MQS, Inc. License No.: IL-01136-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 12/22/04 Inspector: GM

File No.: 15

Licensee: Steris, Inc. License No.: IL-01123-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 3/2/05 Inspector: WH
Illinois Final Report Page C.3

Inspection Casework Reviews

File No.: 16

Licensee: Landauer, Inc. License No.: IL-01376-01

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 8/30/04 Inspector: RM

File No.: 17

Licensee: Northern Illinois University License No.: IL-01773-01

Inspection Type: Routine, Announced Priority: 1

Inspection Dates: 3/24-25/04 Inspector: JP

File No.: 18

Licensee: Baxter Healthcare Corporation License No.: IL-01278-02

Inspection Type: Special, Announced Priority: 3

Inspection Date: 3/8/04 Inspector: KG

Comment: 

a) Decommissioning wipe test results were not in file, but were located by inspector. 

License file will be updated.

File No.: 19

Licensee: Rush Copley Medical Center License No.: IL-01207-01

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 11/12/04 Inspector: JK

File No.: 20

Licensee: Illini Hospital License No.: IL-01772-01

Inspection Type: Routine, Unannounced Priority: 3

Inspection Date: 7/25/03 Inspector: JK

Comment: 

a) Supervisory review of Field Compliance Report not documented in report.

INSPECTOR ACCOMPANIMENTS

The following inspector accompaniments were performed prior to the on-site IMPEP review:

Accompaniment No.: 1

Licensee: MDS Nordion License No: 77-00129-01

Inspection Type: Reciprocity, Unannounced Priority: 1

Inspection Date: 2/2/05 Inspector: RM

Accompaniment No.: 2

Licensee: Steris Isomedix Services License No: IL-01123-01

Inspection Type: Routine, Unannounced Priority: 1

Inspection Date: 3/2/05 Inspector: WH

Accompaniment No.: 3

Licensee: Warrior Well Services License No: IL-01825-01

Inspection Type: Routine, Unannounced Priority: 2

Inspection Date: 3/9/05 Inspector: GM
APPENDIX D

LICENSE CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: Bard Brachytherapy, Inc. License No.: 86-02062-01

Type of Action: Renewal Amendment No.: pending 

Date Issued: Pending License Reviewer: MEB 

File No.: 2

Licensee: Bard Brachytherapy, Inc. License No.: 86-02062-01

Type of Action: Amendment Amendment No.: 18

Date Issued: 1/28/05 License Reviewer: MEB

File No.: 3

Licensee: STERIS, Inc. License No.: IL-01123-01

Type of Action: Amendment Amendment No.: 12

Date Issued: 1/24/05 License Reviewer: GWM

File No.: 4

Licensee: STERIS, Inc. License No.: IL-01123-01

Type of Action: Renewal Amendment No.: 11

Date Issued: License Reviewer: SMK

File No.: 5

Licensee: Sterigenics USA, Inc. (formerly Ion Beam Applications) License No.: IL-01220-01

Type of Action: Amendment Amendment No.: 29

Date Issued: 2/23/05 License Reviewer: SMK

File No.: 6

Licensee: Cardinal Health, Inc. License No.: IL-01721-01

Type of Action: Amendment Amendment No.: 36

Date Issued: 3/11/05 License Reviewer: MEB

File No.: 7

Licensee: Cardinal Health, Inc. License No.: IL-01721-01

Type of Action: Renewal Amendment No.: 33

Date Issued: 4/25/03 License Reviewer: MEB

File No.: 8

Licensee: Rush University Medical Center License No.: IL-01766-01

Type of Action: Amendment Amendment No.: 18

Date Issued: 5/24/04 License Reviewer: SMK
Illinois Final Report Page D.2

Licensing Casework Reviews

File No.: 9

Licensee: Rush University Medical Center License No.: IL-01766-01

Type of Action: Renewal Amendment No.: 14

Date Issued: 6/25/02 License Reviewer: MEB

File No.: 10

Licensee: G. D. Searle LLC License No.: IL-01469-01

Type of Action: Termination Amendment No.: 16

Date Issued: 8/2/04 License Reviewer: GWM

File No.: 11

Licensee: G. D. Searle LLC License No.: IL-01469-01

Type of Action: Amendment Amendment No.: 14

Date Issued: 10/8/03 License Reviewer: GWM

File No.: 12

Licensee: University of Illinois – Champagne-Urbana License No.: IL-01271-01

Type of Action: Renewal Amendment No.: 26

Date Issued: 5/7/04 License Reviewer: SMK

File No.: 13

Licensee: Michael Reese Medical Center Corporation License No.: IL-01097-02

Type of Action: Termination Amendment No.: 12

Date Issued: 9/30/02 License Reviewer: SMK

File No.: 14

Licensee: Advanced Radiation Oncology Center License No.: IL-02178-01

Type of Action: Amendment Amendment No.: 4

Date Issued: 6/25/04 License Reviewer: SMK

File No.: 15

Licensee: Advanced Radiation Oncology Center License No.: IL-02178-01

Type of Action: New Amendment No.: 00

Date Issued: 2/25/03 License Reviewer: MEB

File No.: 16

Licensee: Methodist Medical Center of Illinois License No.: IL-01204-01

Type of Action: Amendment Amendment No.: 53

Date Issued: 11/30/04 License Reviewer: TLH

File No.: 17

Licensee: Methodist Medical Center of Illinois License No.: IL-01204-01

Type of Action: Renewal Amendment No.: 47

Date Issued: 3/11/03 License Reviewer: TLH
Illinois Final Report Page D.3

Licensing Casework Reviews

File No.: 18

Licensee: Resurrection Medical Center License No.: IL-01034-02

Type of Action: Expedited renewal Amendment No.: 26

Date Issued: 6/9/04 License Reviewer: CGV

File No.: 19

Licensee: Resurrection Medical Center License No.: IL-01034-02

Type of Action: Amendment Amendment No.: 27

Date Issued: 6/28/04 License Reviewer: TLH

File No.: 20

Licensee: Michael Reese Medical Center Corporation License No.: IL-01097-01

Type of Action: Amendment Amendment No.: 25

Date Issued: 3/18/05 License Reviewer: JCB

File No.: 21

Licensee: Warrior Well Services License No.: IL-01825-01

Type of Action: Amendment Amendment No.: 8

Date Issued: 6/30/04 License Reviewer: DP

File No.: 22

Licensee: Veterinary Specialty Center License No.: IL-02071-01

Type of Action: Expedited renewal Amendment No.: 5

Date Issued: 10/6/04 License Reviewer: SMK

File No.: 23

Licensee: U.S. Inspection Services License No.: IL-02188-01

Type of Action: Amendment Amendment No.: 2

Date Issued: 8/31/04 License Reviewer: MEB

File No.: 24

Licensee: U.S. Inspection Services License No.: IL-02188-01

Type of Action: Amendment Amendment No.: 1

Date Issued: 4/15/04 License Reviewer: MEB

File No.: 25

Licensee: U.S. Inspection Services License No.: IL-02188-01

Type of Action: Amendment Amendment No.: 00

Date Issued: 11/19/03 License Reviewer: MEB

File No.: 26

Licensee: Diagnostic Health Services License No.: IL-01397-01

Type of Action: Amendment Amendment No.: 61

Date Issued: 12/17/04 License Reviewer: DSP
Illinois Final Report Page D.4

Licensing Casework Reviews

File No.: 27

Licensee: Alion Science and Technology License No.: IL-02187-01

Type of Action: New Amendment No.: 00

Date Issued: 9/9/03 License Reviewer: MEB

Comment:

a) License Condition 19 states that closeout records of facilities prior to their release for

unrestricted use shall be maintained for two years. The standard condition states a

five-year retention period. Staff commits to issue a corrected copy of the license.
APPENDIX E

INCIDENT CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY.

File No.: 1

Licensee: Crompton Corp. License No.: IL-01314-01

Date of Incident: 8/21/01 NMED No.: 010794

Investigation Date: 8/22/01 Type of Incident: Damaged Gauges by Fire

Type of Investigation: Inspection

File No.: 2

Licensee: Non-licensee License No.: NA

Date of Incident: 10/30/01 NMED No.: 011012

Investigation Date: 10/30/01 Type of Incident: Abandoned Source Found at a scrap yard

Type of Investigation: Inspection

File No.: 3

Licensee: Saint Alexius Medical Center License No.: IL-01512-01

Date of Incident: 1/22/02 NMED No.: 020130

Investigation Date: 1/23/02 Type of Incident: Radioactive Material Released in a Hospital

Type of Investigation: Phone, Written Report

File No.: 4

Licensee: Medi-Physics License No.: IL-01109-01

Date of Incident: 2/14/02 NMED No.: 020451

Investigation Date: 2/20/02 Type of Incident: Lost and Found Radioactive Material

Type of Investigation: Phone, Written Report

File No.: 5

Licensee: Children’s Memorial Hospital License No.: IL-01165-01

Date of Incident: 5/14/2002 NMED No.: 020640

Investigation Date: 5/15/02 Type of Incident: Radioactive Material Released

 in a Research Lab 

Type of Investigation: Phone, Written Report

File No.: 6

Licensee: SCI Engineering Inc. License No.: IL-01413-01

Date of Incident: 9/17/02 NMED No.: 020893

Investigation Date: 9/18/02 Type of Incident: Lost and Recovered Gauge

Type of Investigation: Phone, Written Report
Illinois Final Report Page E.2

Incident Casework Reviews

File No.: 7

Licensee: Conam Inspection, Inc. License No.: IL-01225-22

Date of Incident: 3/17/03 NMED No.: 

Investigation Date: 3/20/03 Type of Incident: Lost and Found Radioactive Material

Type of Investigation: Phone, Written Report

File No.: 8

Licensee: Rush Copley Medical Center License No.: IL-01052-01

Date of Incident: 7/28/03 NMED No.: 030624

Investigation Date: 7/30/03 Type of Incident: Medical Event (Abnormal Occurrence)

Type of Investigation: Inspection

File No.: 9

Licensee: Saint James Hospital & Health Center License No.: IL-01289-01

Date of Incident: 8/3/04 NMED No.: 040603

Investigation Date: 8/4/04 Type of Incident: HDR Equipment Failure

Type of Investigation: Phone, Written Report 

File No.: 10

Licensee: Construction & Geotechnical Material Testing, Inc. License No.: Il-02179-01

Date of Incident: 11/8/04 NMED No.: 040851

Investigation Date: 11/9/04 Type of Incident: Damaged Gauge

Type of Investigation: Inspection

File No.: 11

Licensee: Bard Brachytherapy License No.: IL-02062-01

Date of Incident: 10/26/04 NMED No.: 040777

Investigation Date: 10/29/04 thru present Type of Incident: Transportation, Product QA

Type of Investigation: Phone, Written report, QA audit

Comment:

a) Investigation is on going; staff is evaluating licensee’s QA/QC procedures
APPENDIX F

SEALED SOURCE AND DEVICE CASEWORK REVIEWS

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS

ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP TEAM.

File No.: 1

Registry No.: IL-1072-D-101-S SS&D Type: (J) Self-Contained Gamma Irradiator

Manufacturer: Hopewell Designs, Inc. Model No.: PI1C APD Irradiator

Date Issued: 1/3/01 Type of Action: initial issue, custom device

SS&D Reviewers: SMK, CGV

Comments:

a) Custom evaluation, Matsushita Industrial Equipment Corporation of America

b) Reference letter dated 11/12/1998 not in file

File No.: 2

Registry No.: IL-8127-D-803-S SS&D Type: (G) Moisture Density Gauge

 (was NR-610-D-103-S)

Manufacturer: Soiltest, Inc. Model No.: NIC-5 Series

Date Issued: 2/20/03 Type of Action: Inactivation

SS&D Reviewers: MEB, CGV

File No.: 3

Registry No.: IL-1074-S-101-S SS&D Type: (AA) Manual Brachytherapy

Manufacturer: Bard Brachytherapy, Inc. (SourceTech Medical) Model No.: STM 125I

Date Issued: 9/25/01 Type of Action: Amendment

SS&D Reviewers: DMP, CGV

File No.: 4

Registry No.: IL-1074-S-101-S SS&D Type: (AA) Manual Brachytherapy

Manufacturer: Bard Brachytherapy, Inc. (SourceTech Medical) Model No.: STM 125I

Date Issued: 10/7/03 Type of Action: Amendment

SS&D Reviewers: MEB, CGV

Comment:

a) Telefax dated 3/27/03 not in file

File No.: 5

Registry No.: IL-1079-D-101-G SS&D Type: (D) Gamma Gauge; (E) Beta Gauge

Manufacturer: Indev Gauging Systems Model No.: DRN 07736 (was 105.002)

Date Issued: 9/24/02 Type of Action: Amendment

SS&D Reviewers: MEB, CGV
Illinois Final Report F.2

Sealed Source and Device Casework Reviews

File No.: 6

Registry No.: IL-1082-S-101-S SS&D Type: High Energy Gamma Source

Manufacturer: REVISS Services, Inc. Model No.: RSL2089 (formerly CKC.LSA

Date Issued: 4/6/04 Type of Action: Amendment

SS&D Reviewers: CGV, JGK

File No.: 7

Registry No.: IL-136-S-338-S SS&D Type: (AA) Manual Brachytherapy

Manufacturer: Medi-Physics, Inc. Model No.: 6711 (OncoSeed)

Date Issued: 2/27/03 Type of Action: Amendment

SS&D Reviewers: MEB, CGV

File No.: 8

Registry No.: IL-136-S-338-S SS&D Type: (AA) Manual Brachytherapy

Manufacturer: Medi-Physics, Inc. Model No.: 6711 (OncoSeed)

Date Issued: 10/18/04 Type of Action: Amendment

SS&D Reviewers: SMK, CGV
ATTACHMENT

June 3, 2005 Letter from Gary Wright

Illinois’ Response to Draft IMPEP Report

ADAMS: ML051580351