Santa Fe, NM 87502

Dear Dr. Kelley:

On September 28, 1998 the Management Review Board (MRB) met to consider the proposed

final report documenting the Integrated Materials Performance Evaluation Program (IMPEP)

follow-up review on the New Mexico Agreement State Program. The MRB found the New

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

program. The MRB acknowledged New Mexico’s efforts to significantly strengthen their

program over the past year.

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

Based on the results of the current IMPEP review, the next full review will be scheduled in three

years.

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

your support of the Radiation Control Program. I look forward to our agencies continuing to

work cooperatively in the future.

Sincerely,

&g&f for Regulatory Programs

Enclosure:

As stated

cc: Benito Garcia, Chief

Bureau of Hazardous and Radioactive Materials

Water and Waste Management Division

New Mexico Environment Department

William Floyd

Bureau of Hazardous and Radioactive Material

Water and Waste Management Division

Richard Ratliff, Organization of Agreement States

Liaison to MRB
Ed Kelley, Ph.D.

Director, Water and Waste Management Division

New Mexico Environment Department

Harold Runnels Building

1190 St. Francis Drive

P.O. Box 26110

Santa Fe, NM 87502

Dear Dr. Kelley:

On September 28, 1998 the Management Review Board (MRB) met to consider the proposed

final report documenting the Integrated Materials Performance Evaluation Program (IMPEP)

follow-up review on the New Mexico Agreement State Program. The MRB found the New Mexico

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

MRB acknowledged New Mexico’s efforts to significantly strengthen their program over the past

year. 

Section 5.0, page 19, of the enclosed final report presents the IMPEP team's recommendation. 

Based on the results of the current IMPEP review, the next full review will be scheduled in three

years.

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

your support of the Radiation Control Program. I look forward to our agencies continuing to work

cooperatively in the future.

Sincerely,

Hugh L. Thompson, Jr.

Deputy Executive Director

 for Regulatory Programs

Enclosure:

As stated

cc: Benito Garcia, Chief bcc: Chairman Jackson

Bureau of Hazardous and Radioactive Materials Commissioner Diaz

Water and Waste Management Division Commissioner McGaffigan

New Mexico Environment Department

William Floyd

Bureau of Hazardous and Radioactive Material

Water and Waste Management Division

Richard Ratliff, Organization of Agreement States

 Liaison to MRB

Distribution:

DIR RF EDO RF DCD (SP01)

SDroggitis PDR (YES_/__ NO___)

KSchneider DCool, NMSS FCameron, OGC

LRakovan JHornor, RIV/WC HNewsome, OGC

CMaupin/ASPO LMcLean, RIV CHackney, RIV

GDeegan, NMSS TTaylor, NMSS

New Mexico File

DOCUMENT NAME: G:\IMPEP\98FINLTR.NM, G:\IMPEP\NMFOL98.FNL

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 RIII OSP:DD OSP:D DEDR

NAME JLynch:nb PHLohaus RLBangart HLThompson

DATE 10/ /98 10/ /98 10/ /98 10/ /98

OSP FILE CODE: SP-AG-19
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

FOLLOW-UP REVIEW OF NEW MEXICO AGREEMENT STATE PROGRAM

JULY 7-10, 1998

FINAL REPORT

U. S. Nuclear Regulatory Commission

ENCLOSURE 1 
New Mexico Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the follow-up review of the New Mexico radiation control

program conducted July 7-10, 1998. The follow-up review was conducted by a review team

comprised of technical staff members from the Nuclear Regulatory Commission (NRC). 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 25, 1997, NRC

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

The follow-up review covered the State’s response to, and resolution of, 29 recommendations

and suggestions made during the July 14-18, 1997 IMPEP review. The follow-up review covered

the status of the program since the 1997 review. Preliminary results were discussed with New

Mexico management on July 10, 1998.

A draft of this report was issued to New Mexico for factual comment on August 6, 1998. The

State responded in a letter dated August 18, 1998 (Attachment 1). The State’s factual

comments have been incorporated into the final report. The Management Review Board (MRB)

met on September 28, 1998, to consider the proposed final report. The MRB found the New

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

with NRC’s program.

The New Mexico Environment Department is the agency within the State of New Mexico that

regulates, among other public health issues, radiation hazards. The New Mexico Environment

Department Secretary is appointed by and reports to the Governor. Within the Environment

Department, the radiation control program is administered by the Radiation Licensing and

Registration Program (RLRP) under the direction of the Hazardous and Radioactive Materials

Bureau (HRMB). The New Mexico Environment Department and HRMB organization charts are

included as Appendix B. The New Mexico program regulates approximately 245 specific

licenses, including a megacurie pool irradiator, manufacturers, broad academic programs, broad

medical programs, nuclear pharmacies and industrial radiographers. 

The primary intent of this follow-up review was to close out programmatic deficiencies identified

during the 1997 IMPEP review. Although not specifically evaluated during this review, the team

observed other evaluation criteria, under the various indicators, to ensure those portions of the

radiation control program remained adequate since the last review.

The review team’s general approach for conduct of the follow-up review included: 

(1) evaluation of the State’s implementation of their program improvement plan that was

accepted by the MRB at the October 23 and December 11, 1997 MRB meetings; (2) the status of

the program during the period of July 19, 1997 - July 10, 1998; (3) review of the status of

applicable New Mexico statutes and regulations; (4) review of quantitative information from the

radiation control program licensing and inspection database; (5) technical review of selected

inspection, licensing and incident response program documentation for response to issues

identified during the previous review; and (6) interviews with staff and management to answer

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

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

a preliminary assessment of the radiation control program’s performance.
New Mexico Final Report Page 2

2.0 STATUS OF PREVIOUS REVIEW

The previous routine IMPEP review, conducted on July 14-18, 1997, resulted in a finding for New

Mexico that the radiation control program was “adequate to protect public health and safety but

needs improvement, and compatible with NRC’s program.” Due to the significance and number

of deficiencies found in the New Mexico program, which included a finding of unsatisfactory in

one performance indicator, the review team recommended a period of probation for a duration to

be established after consultation with the New Mexico radiation control program management.

The MRB met on October 23, 1997 to consider the proposed final report. At the time of the

review, the IMPEP team found the State’s performance to be satisfactory for the indicators,

Technical Quality of Licensing Actions and Legislation and Regulations Required for

Compatibility; satisfactory with recommendations for improvement for the indicators, Status of

Materials Inspection Program, Technical Quality of Inspections, and Technical Staffing and

Training; and unsatisfactory for the indicator, Response to Incidents and Allegations. The review

team recommended that the New Mexico program be found adequate, but needs improvement,

and compatible. Because of the significance of the concerns, the team also recommended that

New Mexico be placed on probation and noted that heightened oversight was warranted. During

the MRB meeting, three main issues were identified that New Mexico should address in terms of

programmatic improvements: (1) level of program staff and amount of resource support; (2)

technical quality of staff and training needs; and (3) level of management support, involvement,

and oversight of New Mexico Agreement program activities. The MRB found the New Mexico

program adequate, but needs improvement, and compatible with the NRC’s program. The MRB

concluded that it would be appropriate for NRC management to meet with upper management of

the New Mexico program before the MRB voted on the recommendation for probation status for

the program.

On December 4, 1997, Hugh L. Thompson, Jr., NRC Deputy Executive Director for Regulatory

Programs and other NRC managers met with Secretary Mark Weidler, New Mexico Environment

Department and his staff to discuss performance concerns associated with the New Mexico

Agreement program.

On December 11, 1997, the MRB reconvened to discuss probation for the New Mexico program. 

Based on the New Mexico actions at the time of the meeting, and the commitments by Secretary

Weidler, the MRB concluded probation was not warranted. Based on implementation of new

procedures for response to incidents, the MRB directed the team to revise the finding for the

common performance indicator, Response to Incidents and Allegations, to satisfactory with

recommendations for improvement. The MRB directed that the follow-up review be conducted

within one year of the IMPEP review, that monthly conference calls take place with New Mexico

staff, and requested that written progress reports be submitted by the State every other month.

Monthly telephone conference calls, and one meeting at the Conference of Radiation Control

Program Directors annual meeting, were held with New Mexico management and staff. The calls

were effective in maintaining communication between NRC and New Mexico during the period of

heightened oversight.

Three bi-monthly progress reports were submitted by New Mexico on January 21, March 27 and

May 29, 1998. The reports chronicled the progress made by the State on the 29

recommendations and suggestions made during the 1997 review, including the hiring of two
New Mexico Final Report Page 3

staff, response to incidents, and improvements made to the inspection program. The progress

reports may be found in Appendix C.

Results of the follow-up review of the State’s response and resolution of the 29

recommendations and suggestions encompassing the IMPEP common and non-common

performance indicators are presented in Sections 3 and 4, respectively. Section 5 summarizes

the review team's findings and recommendations during the follow-up review.

3.0 COMMON PERFORMANCE INDICATORS

The IMPEP process uses five common performance indicators in reviewing both NRC Regional

and Agreement State programs. These indicators are: (1) Status of Materials Inspection

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

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

3.1 Status of Pending Issues Identified under “Status of Materials Inspection Program”

The review team focused on the four recommendations from the July 1997 IMPEP review. Each

recommendation and its current status is addressed below. New Mexico’s performance, with

respect to this indicator, Status of Materials Inspection Program, was found to be satisfactory

with recommendations for improvement during the 1997 review.

Recommendation

The review team recommends that the nuclear pharmacy inspection frequency be

modified from 2 years to 1 year. 

Current Status

The State indicated, in its October 10, 1997 response to the draft review report, that the two-year

inspection frequency for nuclear pharmacies was based on an out-dated copy of Inspection

Manual Chapter (IMC) 2800 “Materials Inspection Program,” which was believed to be current. 

The frequency was changed to 1 year immediately after identification by the team during the

1997 IMPEP review. IMCs are now centralized in a file maintained by a technical staff person. 

The review team verified that the State now inspects nuclear pharmacies on a one-year

inspection frequency. The staff also has access to the NRC inspection manual via the NRC’s

website. All of New Mexico’s inspection frequencies are now at least as frequent as NRC’s.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that initial inspections of licensees be performed within 6

months of license issuance or within 6 months of the licensee’s receipt of material and

commencement of operations, consistent with IMC 2800. 

Current Status

The review team evaluated the timing of initial inspections for six new licenses issued during the

review period. All six were inspected within 6 months of issuance. The Program Manager

maintains a tickler file for all new licenses issued by the Program. He personally calls licensees

at two-month intervals to determine if radioactive material has been received. If so, he
New Mexico Final Report Page 4

schedules an inspection. If the licensee has not yet received licensed material, he updates the

telephone log in the inspection file and schedules another call in 2 months. The Program

Manager stated that, if licensed material was not received within 1 year, he would schedule an

inspection regardless. This situation has not been encountered to date. Additionally, a standard

license condition is added to new licenses instructing licensees to notify the Program within 10

days after receipt of radioactive material.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the tracking system be revised to allow initial

inspections to be readily identified to staff and management.

Current Status

As discussed in the previous recommendation, the Program Manager tracks, in a hard copy

tickler file, all new licenses issued. The Bureau Chief, who signs all new licenses, has also

established a hard copy file in his office to track new license inspections. Both tracking files were

observed during the follow-up review. The computer database has been completely revamped

using a Microsoft Access-based program. Monthly reports are generated for Program managers

to alert them of inspections which are due, including initial inspections. Since licenses are

produced on the same database, the issuance dates on licenses are used to generate the

inspection due date reports.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State increase the number of reciprocity

inspections to better evaluate the health and safety implications of out-of-state companies

working in New Mexico.

Current Status

Reciprocity inspections are now a priority for the New Mexico program. Since the review, greater

than 75 percent of Priority 1 and approximately 50 percent of Priority 2 and 3 reciprocity 

licensees were inspected by the program. (Note: All New Mexico licensees are categorized as

Priority 1, 2 or 3). In most cases the reciprocity inspections were unannounced. A log is

maintained of all reciprocity requests with the date of inspection and the inspector’s name or, if

an inspection was not performed, the reason for the missed opportunity.
New Mexico Final Report Page 5

Some of the reciprocity inspections resulted in violations identified, including one out-of-state

radiographer, where the New Mexico inspector identified significant health and safety concerns

resulting from poor radiation safety practices by the licensee. New Mexico informed the

Agreement State, which licenses the radiographer, of the violations identified during the

reciprocity inspection.

Based on the follow-up review, the team considers this recommendation to be closed.

The primary intent of this follow-up review was to close out programmatic deficiencies identified

during the 1997 IMPEP review. Although not specifically evaluated during this review, the team

observed that other evaluation criteria, under this indicator, which were identified as satisfactory

during the last review remained adequate and did not show deterioration. These areas include

inspection backlog and inspection report timeliness.

Based on the team’s findings during the follow-up review and the IMPEP evaluation criteria, the

review team recommends that New Mexico’s performance with respect to the indicator, Status of

Materials Inspection Program, be upgraded to a finding of satisfactory.

3.2 Status of Pending Issues Identified under “Technical Quality of Inspections”

The review team focused on the seven recommendations and four suggestions from the 1997

IMPEP review. New Mexico's performance with respect to the indicator, Technical Quality of

Inspections, was found to be satisfactory with recommendations for improvement during the

1997 review.

The review team evaluated casework for 12 inspections, including the following types of licenses: 

well logging, industrial radiography, medical, portable gauge, research and development, and

nuclear pharmacy. There were no inspections of broad scope licensees during the review

period. 

Recommendation

The review team recommends that the State inspectors attempt to observe licensee

operations or demonstrations during all inspections. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that

Program management has begun more frequent accompaniments of inspection staff and will

continue doing so as new staff are hired. The “Standard Operating Procedures Manual for

License Inspections” has been revised and a copy has been given to each staff member. The

importance of performance-based inspections has been discussed at staff meetings and

inspection forms have been finalized to reflect performance-based inspections. With the

relocation of all but one inspector to a centralized location in Santa Fe, the Program Manager will

now be able to discuss inspections with inspectors and more readily determine what was found

during inspections and what additional areas need to be addressed. The inspector located in the

Albuquerque office brings all inspection reports to Santa Fe at least weekly to discuss findings

with the Program Manager as inspections are accomplished. 
New Mexico Final Report Page 6

The review team verified that inspectors are now observing licensee activities during inspections

and documenting such observations in the inspection report. The inspection report forms have

been revised to include a section to document observation of activities, and list various activities

to observe. The team also verified during staff interviews that all inspectors have copies of the

“Standard Operating Procedures Manual for License Inspections” and have been instructed in all

aspects of the manual. 

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State inspectors conduct independent

measurements on all inspections. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that the staff

has been advised of the importance of performing independent measurements during all

inspections. 

The review team found that independent measurements were routinely performed by the

inspectors, and when independent measurements were not performed, inspectors provided an

acceptable explanation in the inspection reports. The team verified, during staff interviews, that

each inspector was aware of the importance of performing independent measurements as a part

of the licensee evaluation process. The location of the independent measurements appeared

appropriate for the type of licensed program. 

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State increase the rigor of reviewing technical

health physics issues during inspections, and increase the breadth and scope of

inspections. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that the

inspection report forms and inspection guidance documents have been revised to reflect the

importance of in-depth inspections. Weekly staff meetings are used to discuss the revised forms

and guidance documents. 

The review team found that the depth and scope of technical health physics reviews have

improved since the last review. The inspectors evaluated programs in more detail, reviewing

applicable technical issues related to the type of program, including such areas as surveys,

storage and shielding of radioactive material, security, and dosimetry. Staff interviews identified

that all inspectors have increased the technical rigor of their inspections. Training received by

the staff since the last review has resulted in a greater knowledge of licensee operations, 
New Mexico Final Report Page 7

resulting in more in-depth inspections. The inspection reports have also been revised to include

more technical health physics issues.

Based on the follow-up review, the team considers this recommendation to be closed.

Suggestion

The review team suggests that the State inspectors attempt to interview ancillary workers

during inspections. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that staff

have been reminded of the importance of interviewing ancillary workers during inspections. The

staff was provided training in the regulations which pertain to consultation with workers during

inspections. 

The review team verified, during staff interviews, that all of the New Mexico inspectors routinely

attempted to interview ancillary personnel during inspections. In some cases, this was not

possible as the inspection was at a field site or was a reciprocity inspection, where no ancillary

personnel were present. There were two inspection reports of medical facilities where interviews

of ancillary personnel or a nurse were not documented, however, the inspectors indicated that

they had interviewed these personnel. The Program Manager stated that he would encourage

staff to ensure that all such discussions are documented in the inspection report.

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.

Recommendation

The review team recommends that the State inspectors attempt to conduct formal exit

meetings with the senior licensee management on all inspections. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that the

inspection forms and inspection guidance documents now indicate that the closeout conference

should be held with the licensee’s highest level of licensee management available and that

inspectors should always contact upper management upon entering a facility. This issue has

also been discussed at staff meetings. 

The review team found that the inspection forms now include a section to note those present at

the exit meeting or who was contacted. The review team found that inspectors were regularly

exiting with a high level of licensee management. If licensee management officials were not

available during an inspection, attempts were made to follow up with them after the inspection.

Based on the follow-up review, the team considers this recommendation to be closed.
New Mexico Final Report Page 8

Recommendation

The review team recommends that the State develop a formal process for reviewing

licensee responses to deficiency letters and closing open deficiencies. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that all

responses will be tracked using a tickler file; the Program Manager and the Bureau Chief will sign

off on the adequacy of licensee responses; and requests for additional information are now made

in writing, with copies of all correspondence placed in license folders. 

The review team found that staff have been made aware of the tickler file and the process for

using the file. The inspection files contained complete documentation for follow up of violations,

with the exception of one file, which was corrected during the review. Program management

signs off on the adequacy of all licensee responses. The system appears adequate to evaluate

and track licensee responses. 

Based on the follow-up review, the team considers this recommendation to be closed.

Suggestion

The review team suggests that the State develop a formal process for inspectors and

license reviewers to document and transmit pertinent information to each other for follow

up. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that weekly

staff meetings are held to discuss the previous week’s activities. Any need for documentation is

satisfied in writing. 

The review team found that the inspection forms include a section entitled “License Reviewer

Alert Memo,” which is used to address any licensing issues. Only one of the files reviewed

raised issues requiring the use of this system. In this case, the system worked very well in

communicating an inspection-identified issue to the license reviewer. A memorandum in the file

thoroughly documented the licensing issue and the licensing action was completed appropriately.

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.

Suggestion

The review team suggests that the State develop a process for ensuring that inspection

files are complete, that all appropriate State documents are prepared and filed, and that

licensee responses are received and filed. 
New Mexico Final Report Page 9

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that each

inspector will be held responsible for ensuring that all inspection files assigned to him or her are

complete and that responses to letters of violation are received in a timely manner. The Program

Manager and the Bureau Chief now approve the adequacy of licensee responses. Letters in

reply to licensee responses are signed by the Program Manager. The Program Manager is

reviewing license files each time a “circle of correspondence” is completed pertaining to licensing

actions, inspections, or incidents. 

The review team found that inspection files were complete, with the exception of one file, which

was corrected during the review (as discussed in a previous recommendation above). Inspection

reports, deficiency letters, and responses to deficiency letters were found, appropriately filed, in

the license file. 

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.

Recommendation

The review team recommends that the State begin documenting all trips to licensees' or

applicants' facilities when inspecting licensed activities, performing special inspections, or

performing pre-licensing site visits during construction. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that this

issue has been discussed with all staff. All information gained through trips to licensed facilities

is now documented via memoranda to file, which are signed by the Program Manager. 

The review team found that this recommendation has been implemented. Since the last review,

there was only one case of a special inspection involving the addition of a new site to a license. 

The inspection was documented in the license file. Additionally, the State instituted a telephone

log for each license file as needed to document communications with the licensee.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State management exercise more stringent

supervisory review of inspection reports. 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that by

relocating all but one of the inspectors to the central office in Santa Fe, inspection reports are no

longer being allowed to accumulate without management review in the Albuquerque office. The

Program Manager and Bureau Chief are reviewing licensee responses to cited violations 
New Mexico Final Report Page 10

for adequacy and are signing off on reviews. The Program Manager is signing off on all

documents entered in the files. 

The review team found that inspection reports were generally signed by management and that

deficiency letters were signed by the Bureau Chief. Of the 12 inspection reports evaluated, two

did not appear to have been reviewed by management. Both were inspections in which no

violations were identified and both were conducted by the inspector in the Albuquerque office. 

The Program Manager stated that some communication problems still existed between the Santa

Fe and Albuquerque offices. The Bureau Chief stated that the Department is planning to close

the Albuquerque office and consolidate the staff into the Santa Fe office, which should eliminate

communication difficulties.

Interviews with the Bureau Chief and Program Manager identified an awareness of the content of

inspection reports. The managers provided feedback to the inspectors to improve the inspection

reports and to instill a health and safety focus. This increased management involvement in the

inspection process resulted in more performance-based inspections.

Based on the follow-up review, the team considers this recommendation to be closed.

Suggestion

The review team suggests that the State complete its revision of the inspection report

forms, insuring that each set of forms covers all key areas for the type of licensee being

inspected, and that RLRP inspectors begin using the standardized form(s). 

Current Status

New Mexico responded, in its October 10, 1997 response to the draft IMPEP report, that all

inspection report forms were being finalized and distributed to the staff. Staff have been advised

as to how inspection forms are to be completed during staff training meetings. 

The review team found that the State has updated and revised the inspection forms. 

Specifically, the following forms have been implemented: 

- General Inspection Report Form, dated June 1998;

- Industrial Radiographer Inspection Report Form, dated September 1997;

- Medical Inspection Report Form, Revision 2, dated January 1998; and

- Density Moisture Gauge Inspection Report Form, dated October 1997.

The review team noted that the general inspection report form was used for two nuclear

pharmacy inspections as the State does not yet have a specific nuclear pharmacy inspection

form. In one case, the inspection report did not document certain technical areas, such as dose

calibrator calibrations. The review team showed the staff how to download NRC’s inspection

field notes from the Internet for their use, as needed. 

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.
New Mexico Final Report Page 11

The primary intent of this follow-up review was to close out programmatic deficiencies identified

during the 1997 IMPEP review. Although not specifically evaluated during this review, the team

observed that other evaluation criteria, under this indicator, which were identified as satisfactory

during the last review remained adequate and did not show deterioration. These areas include

supervisory accompaniments of inspectors and appropriate regulatory actions resulting from

inspection findings.

Based on the team’s findings during the follow-up review and the IMPEP evaluation criteria, the

review team recommends that New Mexico’s performance with respect to the indicator,

Technical Quality of Inspections, be upgraded to a finding of satisfactory.

3.3 Status of Pending Issues Identified under “Technical Staffing and Training”

The review team focused on the three recommendations from the 1997 IMPEP review. New

Mexico's performance with respect to the indicator, Technical Staffing and Training, was found to

be satisfactory with recommendations for improvement during the 1997 review.

Recommendation

The review team recommends that the State maintain the RLRP staffing level to at least

the level which existed throughout the review period.

Current Status

During the 1997 review exit meeting, Secretary Weidler committed to fill the two vacant

Environmental Specialist positions in the radiation control program. Effective February 16, 1998,

the positions were filled by Stanley Fitch and Mark Garcia, both with health physics experience. 

The program is now fully staffed.

New Mexico program management acknowledged, during the 1998 follow-up review, the need to

maintain the radiation control program staffing level to at least the current level.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State provide training to technical personnel in the

areas of medical brachytherapy and irradiator technology.

Current Status

In October 1997, a one-day brachytherapy training course was presented to staff by the

University of New Mexico Cancer Treatment Center. Refresher training is planned annually at

the University. In June 1998, a nuclear medicine/brachytherapy safety training course was

received from ProTechnics, a consultant. Staff indicated that both training courses were

beneficial.
New Mexico Final Report Page 12

The NRC-sponsored Teletherapy and Brachytherapy course (H-313) is part of New Mexico’s core

training program. The Program Manager intends to have staff attend this one-week course or an

equally comprehensive alternative training course.

In June 1998, ProTechnics also provided a one-day training course on irradiator safety to the

New Mexico staff. The training was coordinated with a visit to the Ethicon EndoSurgery pool

irradiator in Albuquerque. Staff also attended a Nordion irradiator training course at Ethicon in

September 1998.

The Program Manager plans to send one or two staff members to the NRC-sponsored Irradiator

Technology course (H-315), if training funds are received.

Discussions with inspection and licensing staff, during the follow-up review, indicated an increase

in knowledge and comprehension in brachytherapy and irradiator technologies. 

On April 15, 1998, the New Mexico Environment Department formally petitioned the NRC for

funding assistance in the pursuit of training. NRC responded to the request, in a June 11, 1998

letter to Secretary Weidler, asking for additional information in support of the request. This issue

is pending.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State develop a formalized training program

comparable to IMC 1246, “Formal Qualification Programs in the Nuclear Material Safety

and Safeguards Program Area.” 

Current Status

The State developed a “Radiation Protection Licensing and Inspection Training Procedure.” The

procedure provides a formal qualification protocol for inspectors and license reviewers. The

procedure is modeled after IMC 1246 and specifies core and specialized training courses,

requires oral qualification boards, and provides a qualification journal to each inspector and

license reviewer. Version 1 was approved by the Program Manager on July 6, 1998.

The team verified during interviews that all staff have been given copies of the procedure and

their own qualification journals. The two new staff members, hired in February 1998, are

presently in training status and are not yet performing independent inspections or license

reviews.

Based on the follow-up review, the team considers this recommendation to be closed.

The primary intent of this follow-up review was to close out programmatic deficiencies identified

during the 1997 IMPEP review. Although not specifically evaluated during this review, the team

observed that other evaluation criteria, under this indicator, which were identified as satisfactory

during the last review remained adequate and did not show deterioration.
New Mexico Final Report Page 13

Based on the team’s findings during the follow-up review and the IMPEP evaluation criteria, the

review team recommends that New Mexico’s performance with respect to the indicator,

Technical Staffing and Training, be upgraded to a finding of satisfactory.

3.4 Status of Pending Issues Identified under “Technical Quality of Licensing Actions”

The review team focused on the one suggestion from the 1997 IMPEP review. New Mexico's

performance with respect to the indicator, Technical Quality of Licensing Actions, was found to

be satisfactory during the 1997 review.

The team evaluated casework for 10 licenses, including the following types: pool irradiator, well

logging, medical institution, broad scope academic, research and development, industrial

radiography, source manufacturer, and nuclear pharmacy.

Suggestion

The review team suggests that documentation of license reviewers’ actions be

maintained in license files.

Current Status

The State responded in its monthly progress report, dated January 21, 1998, that several of the

documents that appeared to be missing from the files, were, in fact, present in the Albuquerque

office. Since the IMPEP review, all files have been returned to the centralized office in Santa Fe. 

The importance of documentation for every action taken by staff has been discussed with the

staff. A telephone log is being used to document any conversations with licensees. Additionally,

all requests for additional material from licensees will be in writing. 

Documentation of license reviewers’ actions has improved since the last review. Telephone logs

are used to document conversations with licensees. Deficiency letters are used to request

additional information from licensees. Additionally, license application evaluation forms are used

to review applications and complicated amendments. The evaluation form includes the criteria,

any comments by the license reviewer, and what is needed, either from the licensee or in the

license, as part of the amendment or application. 

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.

Based on the team’s findings during the follow-up review and the IMPEP evaluation criteria, the

review team recommends that New Mexico’s performance with respect to the indicator,

Technical Quality of Licensing Actions, remain as satisfactory.

3.5 Status of Pending Issues Identified under “Response to Incidents and Allegations”

The review team focused on the six recommendations and two suggestions from the 1997

IMPEP review. New Mexico's performance with respect to the indicator, Response to Incidents

and Allegations, was found to be satisfactory with recommendations for improvement during the

1997 review.
New Mexico Final Report Page 14

The team evaluated seven factors pertinent to this indicator: responsiveness, investigative

procedures, documentation, corrective actions, follow up, compliance, and notifications. To

evaluate the indicator, the team interviewed program management and staff, evaluated the

casework for the 10 incidents that occurred since the 1997 IMPEP review, and evaluated the

State’s response to the 1997 IMPEP review. 

During the 1997 review, the team found frequent examples of incomplete, inappropriate, poorly

documented, or delayed responses to incidents, including cases which had the potential to result

in health and safety problems. Therefore, at the time of the review, based on the IMPEP

evaluation criteria, the review team recommended that New Mexico’s performance with respect

to the indicator, Response to Incidents and Allegations, be found unsatisfactory. With their

October 10, 1997, response to the draft report, the State furnished copies of new incident

response procedures that appeared adequate to address the concerns. During the December

11, 1997, MRB meeting, it was noted that New Mexico had successfully implemented the new

procedures. Based on the implementation of the new procedures, the MRB directed the finding

to be revised to satisfactory with recommendations for improvement.

Recommendation

The review team recommends that the State make on-site, documented investigations of

incidents, allegations, or misadministrations with potential health and safety effects (i.e.,

source disconnects, possible overexposures, lost sources, contamination, etc.).

Current Status

The State’s new procedures offer specific guidance on determining the need for on-site

investigations. Evaluation of the casework showed that on-site investigations were indicated in

four of the ten incidents. In each case, the State responded promptly and appropriately. The

incidents were well documented, followed up, and closed out with signed and dated notations of

management review. 

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State create an incident and allegation reporting

form that would, at a minimum, identify the person taking the initial report, list the name

and telephone number of the reporting party, provide the details of the incident or

allegation as reported, record the State’s conversation with the licensee or individual,

describe corrective actions taken by the licensee, describe the investigation conducted by

the State and the results, list citations or other regulatory actions, show the date the

investigation was closed out and justification for closure, show date(s) incident was

reported to the NRC or other agencies, and provide spaces for the signatures of the

investigator and supervisor. A copy of the form should be maintained in the incident file

and in the license file. 
New Mexico Final Report Page 15

Current Status

In the response letter dated October 10, 1997, the State furnished a newly designed form,

“Incident Report for Radioactive Material Licensees,” to the NRC for review. Examination of the

form showed that it meets the criteria specified in the recommendation. During the evaluation of

casework, the team found that the form is being properly used by the investigators and that

copies were appropriately filed in the incident chronological file as well as the licensee’s file.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State establish a protocol for making independent

investigations and evaluations of the licensee’s actions. 

Current Status

The protocol for making independent investigations and evaluations of the licensee’s actions was

provided to the NRC in New Mexico’s letter dated October 10, 1997. Appropriate incident

investigations and evaluations of licensee’s actions were performed for all of the incidents

reviewed.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State initiate procedures to ensure incidents are

followed up at the next inspection to verify that the licensee’s corrective actions have

been implemented. 

Current Status

A section entitled, “Incidents/Reports” has been added to the inspection forms to ensure that 

inspectors review events that may have occurred since the last inspection of the licensee. Of the

21 incidents reviewed during the 1997 and 1998 reviews, the team identified eight licensees

which had subsequent inspections. Although one was missed early in the review period, seven

had been followed up appropriately. 

Based on the follow-up review, the team considers this recommendation to be closed.

Suggestion

The review team suggests that when evaluating incidents, the State cite appropriate

deficiencies when applicable. 
New Mexico Final Report Page 16

Current Status

In their October 10, 1997, response to the NRC, the State committed to sending deficiency

letters or citations when indicated. Of the incidents which occurred since the last review,

citations were appropriate for only one incident. That incident investigation was in process at the

time of this review, and a Notice of Violation had not yet been sent, but was planned for the near

future. The Program Manager stated that formal Notices of Violation would be issued for

deficiencies, found during incident investigations as is done in the routine inspection program.

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.

Recommendation

The review team recommends that the State: (a) set up a separate incident and

allegation file system in the Santa Fe office, keeping all documents and records

pertaining to an incident in one location, with the data cross-referenced to the

license/inspection files there and in the Albuquerque office, and (b) establish a system to

centrally log and track the progress of incidents and allegations. 

Current Status

The team found that the incident and allegation file system has been moved to the Santa Fe

office. Copies will be kept in the Albuquerque files until that office is closed. The team verified

that documents are cross-referenced to licensee files in both offices. A new computer system

has been established to log and track the progress of incidents and allegations. The staff was

able to successfully demonstrate the system by sorting and printing the information as requested

by the team. The team also compared the printed list with the incidents reported for New Mexico

in the "Nuclear Materials Events Database (NMED)" and found that they agreed.

Based on the follow-up review, the team considers this recommendation to be closed.

Recommendation

The review team recommends that the State develop and implement written procedures

for responding to events involving radioactive material and conduct training sessions until

all technical staff are fully trained and qualified in emergency response. 

Current Status

Three newly developed procedures: “Standard Operating Procedure for Response to Incidents

Involving Radioactive Materials,” “Incident Investigation Procedures,” and “Incident Reporting

System/Abnormal Occurrence Criteria” were found adequate by the NRC after they were

included with the October 10, 1997, letter from the State. The team verified that the procedures

were being followed by the investigators. The team also verified during staff interviews that all

responders had been given copies of the procedures and that they had been instructed in

emergency response during weekly meetings and discussions that take place after each event.

Based on the follow-up review, the team considers this recommendation to be closed.
New Mexico Final Report Page 17

Suggestion

The review team suggests that the State keep expanding the allegation procedures to

include procedures for notifying the person making the allegation of the results of the

investigation and including the allegation procedures in the event reporting form, tracking

system, and emergency response procedures. 

Current Status

The team found that the State’s allegation procedures have been completely rewritten. There

are provisions for notifying the person making the allegation of the results of the investigation. 

The procedures have been changed to include allegations in the event tracking system and

emergency response procedures.

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.

The primary intent of this follow-up review was to close out programmatic deficiencies identified

during the 1997 IMPEP review. Although not specifically evaluated during this review, the team

observed that other evaluation criteria, under this indicator, which were identified as satisfactory

during the last review remained adequate and did not show deterioration. These areas include

notifications of incidents to NRC and other Agreement States.

Based on the team’s findings during the follow-up review and the IMPEP evaluation criteria, the

review team recommends that New Mexico’s performance with respect to the indicator,

Response to Incidents and Allegations, be upgraded to a finding of satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

The team reviewed one non-common performance indicator that applied to the New Mexico

program, Legislation and Program Elements Required for Compatibility

4.1 Status of Pending Issues Identified under “Legislation and Program Elements Required

for Compatibility”

The review team focused on the one recommendation and one suggestion from the 1997 IMPEP

review. New Mexico's performance with respect to the indicator, Legislation and Program

Elements Required for Compatibility, was found to be satisfactory during the 1997 review.

Recommendation

The review team recommends that the State expedite promulgation of the compatibilityrelated regulations now overdue and those which are due within the next 12 months.
New Mexico Final Report Page 18

Current Status

The overdue compatibility regulations and those due through May 16, 1999, are in the process of

being adopted. Drafts of the 11 regulations listed below were sent to the NRC for review on

June 15, 1998, and the State was awaiting the results of that review at the time of the follow-up

IMPEP review. The State missed their projected adoption date for these regulations of June

1998 and have extended it to October 1998.

• "Decommissioning Recordkeeping and License Termination: Documentation Additions,"

10 CFR Parts 30, 40, 70, and 72 amendments (58 FR 39628) that became effective on

October 25, 1993, and became due on October 25, 1996.

• "Self-Guarantee as an Additional Financial Mechanism," 10 CFR Parts 30, 40, and 70

amendments (58 FR 68726 and 59 FR 1618) that became effective on January 28, 1994,

and became due on January 28, 1997. 

• "Timeliness in Decommissioning of Materials Facilities," 10 CFR Parts 30, 40, and 70

amendments (59 FR 36026) that became effective on August 15, 1994, and became due

on August 15, 1997.

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

Medical Use," 10 CFR Parts 30, 32 and 35 amendments (59 FR 61767, 59 FR 65243, 60

FR 322) that became effective on January 1, 1995, and became due on January 1, 1998.

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

61 amendments (60 FR 15649, 60 FR 25983) that became effective March 1, 1998, and

became due on March 1, 1998. 

• "Frequency of Medical Examinations for Use of Respiratory Protection Equipment," 10

CFR Part 20 amendments (60 FR 7900) that became effective on March 13, 1995, and

became due on March 13, 1998. 

• “Radiation Protection Requirements: Amended Definitions and Criteria,” 10 CFR Parts 19

and 20 amendments (60 FR 36038) that became effective August 14, 1995, and which

will become due on August 14, 1998.

• “Medical Administration of Radiation and Radioactive Materials” 10 CFR Parts 20 and 35

amendments (60 FR 48623) that became effective on October 20, 1995, and which will

become due on October 20, 1998.

• "Clarification of Decommissioning Funding Requirements," 10 CFR Parts 30, 40, and 70

amendments (60 FR 38235) that became effective November 24, 1995, and which will

become due on November 24, 1998.

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

(60 FR 50248, 61 FR 28724) that became effective April 1, 1996, and which will become

due on April 1, 1999. 
New Mexico Final Report Page 19

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

Parts 20 and 30 amendments (61 FR 24669) that became effective on May 16, 1996, and

which will become due on May 16, 1999.

In addition, the State plans to add the rule, “Licenses for Industrial Radiography and Radiation

Safety Requirements of Industrial Radiography Operations,” 10 CFR Parts 30 and 34

amendments (62 FR 28947) that became effective on June 27, 1997, to the current package. 

This rule covers all previous Part 34 requirements, some of which were apparently overlooked in

previous rule changes.

It is noted that Management Directive 5.9, Handbook, Part V, paragraph (1)(c)(iii), provides that

the above regulations should be adopted by the State as expeditiously as possible, but not later

than 3 years after the effective date of the new Commission Policy Statement on Adequacy and

Compatibility, i.e., September 3, 2000.

Until the overdue regulations become effective, the team considers this recommendation to be

open.

Suggestion

The review team suggests that a file be maintained with the cover letters and ensuing

correspondence of all draft or final regulations sent to the NRC.

Current Status

The State created a regulation correspondence file to track the progress of the promulgation and

review process. In reviewing the file, however, the team found that a cover letter was not sent

for the recent package of regulations presently under NRC review. The State explained that this

was apparently an oversight, and that the policy is to maintain cover letters in the regulation file.

Based on the follow-up review, the review team notes the actions taken by the State in response

to this suggestion, and considers this suggestion to be closed.

Based on the team’s findings during the follow-up review and the IMPEP evaluation criteria, the

review team recommends that New Mexico’s performance with respect to the indicator,

Legislation and Program Elements Required for Compatibility, remain as satisfactory.

5.0 SUMMARY

The New Mexico radiation control program has made significant strides since the July 1997

IMPEP review. The program is now fully staffed with experienced personnel, training

deficiencies are being addressed, and program management is providing an appropriate amount

of oversight and support.

The follow-up review team found the State’s performance in responding to and resolving 28 of

the 29 recommendations and suggestions to be satisfactory. The only remaining open

recommendation concerns the promulgation of regulations required for compatibility.

Funding for the program is still a major issue, especially regarding the training budget. Secretary

Weidler committed to submit a budget request for additional training funding or to pursue a
New Mexico Final Report Page 20

statutory amendment to initiate a licensee fees program with proceeds directed to a dedicated

program fund. Requested funding assistance from the NRC is seen as an interim measure until

an appropriate course of action is approved by the State legislature.

As discussed earlier in this report, the follow-up review team considers all of the common

performance indicator recommendations and suggestions to be closed. Progress has been

made on the one non-common performance indicator reviewed (the indicator was found

satisfactory during the 1997 review) and compatibility-required regulations should be adopted by

October 1998.

The review team recommended and the MRB concurred, that for each of the five common

performance indicators and the one non-common performance indicator, New Mexico’s

performance be found satisfactory and that the program as a whole be considered adequate to

protect public health and safety and compatible with NRC’s regulatory program. The MRB also

concurred in the team’s recommendation that the heightened oversight of the New Mexico

radiation control program be discontinued.

Below is the one remaining recommendation which is not considered closed, as mentioned

earlier in the report, for consideration by the State.

Recommendation

The review team recommends that the State expedite promulgation of the compatibility-related

regulations now overdue and those which are due within the next 12 months. (Section 4.1)
LIST OF APPENDICES

Appendix A IMPEP Follow-up Review Team Members

Appendix B New Mexico Organizational Charts

Appendix C New Mexico Progress Reports, January 1998, 

March 1998, and May 1998

Attachment 1 Letter dated August 18, 1998 from Ed Kelley, Ph.D., Director,

Water and Waste Management Division, New Mexico Environment

Department
APPENDIX A

IMPEP FOLLOW-UP REVIEW TEAM MEMBERS

Name Areas of Responsibility

James Lynch, RIII Team Leader

Status of Materials Inspection Program

Technical Staffing and Training

Jack Hornor, RIV/WCFO Response to Incidents and Allegations

Legislation and Program Elements Required

 for Compatibility

M. Linda McLean, RIV Technical Quality of Inspections

Torre Taylor, NMSS Technical Quality of Licensing Actions
APPENDIX B

NEW MEXICO ENVIRONMENT DEPARTMENT

AND

HAZARDOUS RADIOACTIVE MATERIALS BUREAU

ORGANIZATION CHARTS



APPENDIX C

NEW MEXICO PROGRESS REPORTS

JANUARY 21, 1998,

MARCH 27, 1998,

AND

MAY 29, 1998