December 13, 2002

Mr. Clyde D. Graeber, Secretary

Kansas Department of Health and Environment

1000 SW Jackson

Topeka, KS 66612-1366

Dear Mr. Graeber:

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

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

Agreement State Program. The MRB found the Kansas program adequate to protect public

health and safety and compatible with the Nuclear Regulatory Commission’s (NRC) program. 

Section 5.0, page 17, of the enclosed final report presents the IMPEP team’s

recommendations for the State of Kansas. We request your response to the

recommendations within 30 days of your receipt of this letter.

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

four years. While the Bureau has acted to alleviate the short-term staffing problem, the team

and the MRB are concerned that long-term stability in hiring, training and retaining staff has not

been achieved. Therefore, the MRB requested that periodic conference calls take place with

the appropriate Kansas and NRC staffs to discuss the status of the program and that the

results of these calls be presented at MRB meetings. 

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

appreciate your continued support for the Radiation Control Program and I look forward to our

agencies continuing to work cooperatively in the future.

Sincerely,

/RA/

Carl J. Paperiello 

Deputy Executive Director 

 for Materials, Research and State Programs

Enclosure:

As stated

cc: Ronald Hammerschmidt, Division Director

Division of Environment

Department of Health and Environment

Thomas A. Conley, KS

William Sinclair, UT

OAS Liaison to MRB
Mr. Clyde D. Graeber, Secretary December 13, 2002

Kansas Department of Health and Environment

1000 SW Jackson

Topeka, KS 66612-1366

Dear Mr. Graeber:

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

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

Agreement State Program. The MRB found the Kansas program adequate to protect public

health and safety and compatible with the Nuclear Regulatory Commission’s (NRC) program. 

Section 5.0, page 17, of the enclosed final report presents the IMPEP team’s

recommendations for the State of Kansas. We request your response to the

recommendations within 30 days of your receipt of this letter.

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

four years. While the Bureau has acted to alleviate the short-term staffing problem, the team

and the MRB are concerned that long-term stability in hiring, training and retaining staff has not

been achieved. Therefore, the MRB requested that periodic conference calls take place with

the appropriate Kansas and NRC staffs to discuss the status of the program and that the

results of these calls be presented at MRB meetings. 

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

appreciate your continued support for the Radiation Control Program and I look forward to our

agencies continuing to work cooperatively in the future.

Sincerely,

/RA/

Carl J. Paperiello 

Deputy Executive Director 

 for Materials, Research and State Programs

Enclosure: As stated

cc: Ronald Hammerschmidt, Division Director Thomas A. Conley, KS

Division of Environment

Department of Health and Environment

-

William Sinclair, UT

OAS Liaison to MRB

Distribution:

DIR RF DCD (SP01) PDR (YES/) bcc: Chairman Meserve

KSchneider, STP ISchoenfeld, EDO Commissioner Dicus

LRakovan, STP TCombs, OCA (2 copies) Commissioner Diaz

JZabko, STP/ASPO FCameron, OGC Commissioner McGaffigan

DCool, NMSS/IMNS VCampbell, RIV Commissioner Merrifield

RStruckmeyer, NMSS/IMNS GMorell, RIV

KWeaver, CO RLeonardi, RIV

STreby, OGC JLieberman, OGC

Kansas File ML023400619

DOCUMENT NAME: G:\IMPEP\2002 KS Final Report and Letter2.wpd

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

OFFICE STP STP:DD STP:D DEDMRS

NAME RBlanton:kk JMPiccone PHLohaus CJPaperiello

DATE 12/2/02 12/5/02 12/5/02 12/13/02

 ML023400619 Pkg. OFFICIAL RECORD COPY
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF KANSAS AGREEMENT STATE PROGRAM

April 23 - 26, 2002

FINAL REPORT

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

1.0 INTRODUCTION

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

review was conducted during the period April 23 - 26, 2002, by a review team consisting of

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

State of Colorado. 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 November 5, 1999, NRC Management Directive 5.6,

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

review, which covered the period of June 20, 1998 to April 26, 2002, were discussed with

Kansas management on April 26, 2002. Subsequent to additional inspector accompaniments

conducted June 12-14, and July 18, 2002, revised preliminary results were discussed with

Kansas management in a telephone conference on September 3, 2002.

A draft of this report was issued to Kansas for factual comment on September 23, 2002. The

State responded by letter dated October 30, 2002. The Management Review Board (MRB)

met on November 22, 2002 to consider the proposed final report. The MRB found the Kansas

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

with NRC’s program.

The Kansas Agreement State program is administered by the Department of Health and

Environment (the Department). The Secretary of Health and Environment manages the

Department and reports directly to the Governor. The day-to-day operations of the program

are managed by the Bureau of Air and Radiation (Bureau). Radiation control program staff are

located in the Radiation and Asbestos Control Section (the Section) of the Bureau, under the

Materials Supervisor. Organization charts for the Department are included as Appendix B. At

the time of the review, the Kansas Agreement State program regulated 325 specific licenses

authorizing Agreement materials. The review focused on the materials program as it is carried

out under the Section 274b. (of the Atomic Energy Act of 1954, as amended) Agreement

between the NRC and the State of Kansas.

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

indicators was sent to the Bureau on January 29, 2002. The Bureau provided its response to

the questionnaire on April 4, 2002. A copy of the completed questionnaire response can be

found on NRC’s Agencywide Document Access and Management System using the Accession

Number ML022550488. 

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

the Bureau’s responses to the questionnaire; (2) review of applicable Kansas statutes and

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

data base; (4) technical review of selected licensing and inspection actions; (5) field

accompaniment of two Bureau 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 program’s performance. 
Kansas Final Report Page 2

Section 2 below discusses the program’s actions in response to recommendations made

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

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

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

findings and recommendations. Recommendations made by the review team are comments

that relate directly to 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 PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on June 19, 1998, the review team made

18 recommendations. These were transmitted to Mr. Gary Mitchell, the Department Secretary,

on September 23, 1998. During the follow-up review, which concluded June 17, 1999, the

review team closed three recommendations and made one new recommendation.

The team’s review of the current status of the recommendations is as follows:

1. Based on the record of overdue inspections during the review period, the review team

recommends: (1) that Kansas heighten its management oversight of the inspection

due dates of core licenses (Priority 1, 2, and 3 licensees) to ensure inspections are

performed at the required frequencies; and (2) that the new inspection tracking system

then under development include provisions for flagging initial inspections at an early

date to ensure they are inspected within 6 months of date of license issuance. In

addition, Kansas should consider updating procedure RHS-7 to incorporate procedures

on initial inspections as stated in NRC Inspection Manual Chapter (IMC) 2800, Section

04.03 a. (Section 3.1)

Current Status: (1) A written policy for increased management oversight was

developed and implemented. The backlog of overdue inspections was eliminated and

has not recurred. (2) The Bureau developed a radioactive materials licensing

information database which incorporates the recommended provisions for flagging new

inspections. The procedure RHS-7 was revised. This recommendation is closed.

2. The review team recommends that the State’s “Inspection Priority System” be revised

for reciprocity inspections to correspond to the inspection goals in IMC 1220. (Section

3.1)

Current Status: The Bureau has revised the procedure and incorporated the IMC 1220

goals. This recommendation is closed.

3. The review team recommends the State conduct reciprocity inspections at intervals

equal to those stated in IMC 1220. (Section 3.1)

Current Status: The 1998 team noted that Kansas procedure RHS-7 listed reciprocity

inspections as a Priority 5, to be conducted as resources allowed. The Bureau

changed the procedure such that reciprocity inspections now have priorities based on

the license type, as does IMC 1220. This recommendation is closed.
Kansas Final Report Page 3

4. The review team recommends that the inspection report form be strengthened by

including names of individuals contacted and interviewed in greater detail. (Section

3.2)

Current Status: Bureau staff implemented an inspection tracking program in the

radioactive materials database. The database generates inspection reports and stores

inspection data. The Bureau developed an electronic inspection form with fields for

listing the persons interviewed and those present at the exit meeting. Inspection data is

entered directly from the form into the database. This recommendation is closed.

5. The review team recommends that Kansas provide direction to the inspection staff to

help them identify poor licensee performance, identify when licensee root cause

evaluations should be conducted, and to help them assess licensee root cause

evaluations. Staff members’ skills could also be improved by attending a training

course that teaches these techniques as part of the inspector qualification process. 

(Section 3.2)

Current Status: The radioactive materials database incorporates features to track and

trend specific items of noncompliance. This facilitates identification of poor licensee

performance and assists in determining when to perform root cause evaluations. The

two fully qualified inspectors have completed root cause training. This recommendation

is closed.

6. The review team recommends that the State continue to maintain management

oversight of the inspection program. (Section 3.2)

Current Status: The radioactive materials database significantly strengthened oversight

of the program. The Materials Supervisor receives timely status reports, and reviews

and initials the inspection reports and compliance letters. This recommendation is

closed.

7. The review team recommends that the State document a training and qualifications

program equivalent to that contained in the “NRC/OAS Training Working Group

Recommendations for Agreement State Training Programs,” as appropriate, assess the

current training needs of all radioactive materials staff, and provide the necessary

training to ensure that all staff are properly trained to complete assigned tasks. 

(Section 3.3)

Current Status: The Bureau adopted, documented, and implemented a training and

qualifications program consistent with the recommendations in the Working Group

Report. Training is provided through a combination of NRC courses, and workshops

and courses arranged using other resources. Staff attend these courses as funds are

available. The Bureau developed a database to monitor training status, which the team

reviewed. All Kansas staff, except one recent hire, meet the qualifications criteria for

their primary assignments. This recommendation is closed.

8. The review team recommends that program management consider increasing

supervisory oversight to ensure that all pertinent items are adequately and properly
Kansas Final Report Page 4

addressed during the review process to provide quality assurance and to improve the

technical quality of licenses. (Section 3.4)

Current Status: The Bureau has increased supervisory oversight by using a two-tier

supervisory review of all licensing actions. The Materials Supervisor and the Section

Chief review completed licensing actions. Both sign the license document. This

recommendation is closed.

9. The review team recommends that the State conduct a self-evaluation of all existing

licenses to determine the technical quality and to identify potential health and safety

issues. This evaluation should be accomplished as soon as possible to identify and

correct other possible license deficiencies. In addition, the State should ask the

licensee to supply copies of any missing documents that should be included with the

application. (Section 3.4)

Current Status: The comprehensive review of all licenses was completed. No health

and safety issues were identified by the review. This recommendation is closed.

10. The review team recommends that the Radiation Control Program update the license

guidance to address and parallel the current Kansas Radiation Protection Regulations

to assist in the consistency and accuracy of the license review process. (Section 3.4)

Current Status: This recommendation was closed in the 1999 follow-up IMPEP report.

11. The review team recommends that licensing check lists be developed, used, and

retained in the file to ensure that all elements of the application have been submitted

and that the license is complete. (Section 3.4)

Current Status: This recommendation was closed in the 1999 follow-up IMPEP report.

12. The review team recommends that the State place documentation of any pre-licensing

visits in the appropriate licensing file. (Section 3.4)

Current Status: This recommendation was closed in the 1999 follow-up IMPEP report.

13. The review team recommends that the State revise their incident response procedure

to conform with the NRC Office of State and Tribal Programs (STP) Procedure SA-300,

including medical events. (Section 3.5)

Current Status: The team reviewed Kansas procedure RHS-35, “Investigation

Procedures,” dated April 3, 2002. The procedure outlines actions and establishes

responsibilities for the investigations. It directs staff to follow STP Procedure SA-300

for NRC reportable events. This recommendation is closed.

14. The review team recommends that a system be established to track the progress of

incident investigations and to verify that each investigation is evaluated by

management, that all reporting requirements are met, that follow-up actions and closeout information are documented. (Section 3.5)
Kansas Final Report Page 5

Current Status: The Section developed and implemented a database program similar

to the NRC Nuclear Material Events Database (NMED). The team determined that the

Kansas events database satisfies the 1998 recommendation. The recommendation is

closed.

15. The review team recommends that the inspection procedure be revised to include

narrative documentation of the inspector’s review of incidents and description of the

licensee’s corrective actions. (Section 3.5)

Current Status: With the implementation of the inspections database, the inspection

checklist now includes a specific item for documenting the inspector’s review of

incidents and corrective actions. This recommendation is closed.

16. The review team recommends the State send copies of final close-out reports to the

NRC in accordance with the STP Procedure, “Reporting Material Events - SA-300." 

(Section 3.5)

Current Status: The 1998 team found that four reportable events were initially reported

to NRC. However, close-out information was not provided unless NRC specifically

asked. The Section responded to this recommendation by sending final close-out

reports to NRC on August 20, 1998. The current team found that the State database

prompts close-out reports to NRC and NMED. This recommendation is closed.

17. The review team recommends that the State review and amend all remaining industrial

radiography licenses with license conditions necessary to meet the "Safety

Requirements for Industrial Radiographic Equipment" requirement, and expedite

adoption of the rule which was due January 10, 1994. (Section 4.1.2)

Current Status: The recommended review is complete. In addition, all industrial

radiography licenses were amended to include a license condition requiring the twoman rule. This recommendation is closed.

18. The review team recommends that the State compare the Kansas regulations involved

with the “Low-Level Waste Shipment Manifest Information and Reporting” and

“Radiation Protection Requirements: Amended Definitions and Criteria” amendments

against the final NRC rules and make any necessary changes to ensure compatibility. 

(Section 4.1.2)

Current Status: The Kansas staff reviewed the regulations and found no compatibility

issues. The team notes, however, that the comparison was made to Part 20 Appendix

F rather than Appendix G. Appendix F was removed and Appendix G became effective

and required for compatibility on March 1, 1998. The Department is adopting Appendix

G in their current rulemaking, and implementing the requirements by license condition

in the interim. This recommendation is closed.

One new recommendation was added in the 1999 follow-up IMPEP report:
Kansas Final Report Page 6

The review team recommends that the State complete a thorough review as well as a

supervisory or quality assurance review of all licensing actions to ensure that each

license is complete in accordance with Kansas guidance. (Section 2.1)

Current Status: As noted in regard to recommendation 8, above, the Bureau

developed a two-tier supervisory review of all licensing actions. This recommendation

is closed.

During the 1998 review, two suggestions were made for the Bureau to consider. The team

determined that the Bureau considered the suggestions and took appropriate actions. 

3.0 COMMON PERFORMANCE INDICATORS

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

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

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

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

3.1 Status of Materials Inspection Program

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

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

licensees. The review team’s evaluation is based on the Bureau’s questionnaire responses

relative to this indicator, data gathered independently from the radioactive materials database,

the examination of complete licensing and inspection casework, and interviews with managers

and staff.

The team's review of the inspection priorities list verified that priorities for material licenses are

the same as, or higher than, those listed in IMC 2800. The Bureau occasionally adjusted the

inspection frequency based on the compliance history of the license, more often to increase

rather than decrease inspection frequency. The team confirmed that deviations from

inspection schedules are coordinated between staff and management. Routine inspections in

western Kansas, which come due during November through March, are intentionally deferred

to avoid travel during winter weather conditions.

In their response to the questionnaire, the Bureau indicated that there were four overdue

inspections of core licensees. Two of those inspections were intentionally delayed by the

Bureau as candidates for accompaniment during the review. At the time of the review, the

team noted six overdue core inspections. Examination of the radioactive materials database

revealed that 18 of 183 core inspections were overdue when completed, but only seven of

these were in the last two years. 

The review team also determined that all initial inspections of new licenses were performed in

a timely manner. For new licensees, the Bureau designated the initial inspections as Priority

0.5. This resulted in a due date appearing in the radioactive materials database for the second

calendar quarter following license issuance. 
Kansas Final Report Page 7

The team calculated the percentage of overdue inspections to be 12.7% by the usual formula. 

Although this number exceeds the nominal 10% overdue criterion for a satisfactory finding, the

team considered three mitigating factors. First, the Bureau intentionally deferred inspections to

avoid travel in winter weather conditions, and two inspections were deferred for use as

accompaniments by the review team. Second, the team notes an improving trend after the

implementation of the radioactive materials database. Third, the team identified the staffing

problem discussed in Section 3.3 as a root cause for the six core inspections overdue at the

time of the review. The team concludes that the Program should be given credit for factors

one and two, and that the third factor should be addressed in Section 3.3.

The timeliness of the issuance of inspection findings was evaluated during the inspection file

review. The Bureau has an effective and efficient process which ensures that inspection

findings are communicated to licensees in a timely manner. A monthly report by the Materials

Supervisor indicates the average time required to mail out inspection letters. For 2000-2002,

inspection letters were sent within a few days. For example, in March 2002, the average time

to issue inspection findings was one day.

During the review period, the Bureau granted reciprocity permits to 101 core licensees based

on IMC 1220. The core licensees consisted of 82 Priority 1 licensees including 16 service

licensees performing teletherapy and irradiator source installations or changes, and 19 Priority

2 licensees. Kansas met the IMC 1220 criteria only in 1999. In the year 2000, they met the

criteria for Priority 1 licensees, but not service licensees or Priority 2. The Bureau attributed

the shortfall to the difficulty of reaching sites in Western Kansas where the majority of activities

under reciprocity are conducted. The team notes that the Bureau did meet the revised criteria

in Temporary Instruction 1220/001 for each year except 2001, when six inspections were due

but only two were completed. The review team believes this shortfall was primarily due to the

Bureau’s limited staffing.

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

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

satisfactory.

3.2 Technical Quality of Inspections

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

and interviewed inspectors for 14 radioactive materials inspections conducted during the

review period. The casework covered four materials’ inspectors, including one inspector that

left the program during the review period. The casework included inspections of various types

as follows: industrial radiography, medical broad scope, nuclear pharmacy, limited medical,

well logging and portable gauging licensees. Appendix C lists the inspection casework files

reviewed, with case-specific comments. 

On April 21 and 22, 2002, the team accompanied two Bureau inspectors to a large medical

licensee with a radiopharmacy. The accompaniment focused primarily on the junior inspector,

who had not previously been accompanied during an IMPEP review. The team learned later,

however, that the inspector was not qualified by the Bureau to inspect large medical programs. 

He normally inspected fixed and portable gauges, and other small industrial licensees. The

team concluded that the inspector’s performance was not accurately reviewed because he was
Kansas Final Report Page 8

assigned an inspection for which he was not qualified. The team determined that this

inspection resulted from a mis-communication between the team and the Bureau. 

The review team, therefore, determined that additional inspector accompaniments should be

conducted to evaluate the inspectors’ performance. On June 12-14, 2002, the team

accompanied the senior inspector at a medical center. On July 18, 2002, the team

accompanied the junior inspector at a portable gauge licensee and a licensee using an

industrial x-ray analyzer. The facilities inspected are identified in Appendix C. Both of the

Bureau’s inspectors followed the Bureau’s procedures and guidance during these inspections. 

Each inspector demonstrated appropriate inspection techniques and knowledge of the

regulations. The inspectors were trained, well prepared for the inspections, and thorough in

their audits of the licensees’ radiation safety programs. Each inspector conducted

confirmatory measurements, and utilized good health physics practices. Their inspections

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

evaluated the performance of both inspectors on these inspections as very good. The team

noted that the inspectors used a combination of compliance and performance based

inspection techniques. The team discussed with the inspector, the benefits of conducting

performance-based inspections.

The casework review found that inspection reports were in checklist format and had space for

narrative information in all inspection areas. Completed inspection reports were entered into

the Bureau’s radioactive materials database. The database was used to generate the

inspection reports that are issued to licensees. The team observed documentation

deficiencies in these inspection reports. Of the 14 database inspection reports reviewed, four

did not document inspector observation of licensed activities. Three did not document

interviews with personnel authorized to use licensed material. Two reports did not list licensee

personnel attending the entrance or exit briefing and two did not indicate that independent and

confirmatory surveys were conducted. None of these inspection reports discussed the relative

safety significance or root causes of the violations. Bureau hard-copy documentation

addressed some deficiencies in the database. The team discussed the documentation issues

with the Bureau staff.

The team believes that the Bureau’s staffing level was a root cause of the inspection program

issues, including the documentation issues. Because of the short staffing, inspectors tend to

economize on documentation of observations of licensee performance in order to maintain

inspection frequencies. The team noted that the Bureau’s radioactive materials database was

a significant resource for improving the efficiency and effectiveness of the inspection program

when the data was complete. Staffing is discussed further in Section 3.3.

The Materials Supervisor accompanied each materials inspector annually, and adequately

documented the accompaniments. The team noted that at the time of the review, the Bureau

had three experienced materials inspectors. One was the Materials Supervisor, and the other

was a recently hired inspector in training. Team inspections were conducted when

appropriate. 
Kansas Final Report Page 9

The Bureau had an adequate number and types of survey meters to support the inspection

program, as well as for responding to incidents and emergency conditions. Appropriate

calibrated survey instruments such as GM meters and micro-R meters were observed.

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

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

satisfactory.

3.3 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Bureau’s staffing level and staff

turnover, as well as the technical qualifications and training histories of the staff. To evaluate

these issues, the review team examined the Bureau’s questionnaire responses relative to this

indicator, interviewed the Materials Supervisor and staff, and considered any possible

workload backlogs. 

The Section Chief supervises three administrative staff and three unit supervisors. The

Materials Supervisor is responsible for the radioactive material and x-ray programs, and

supervises technical staff members classified as radiation control inspectors. 

License fees are collected and deposited in the State general fund, from which the Bureau’s

budget is allocated. This is significant to the performance of the program, since the Kansas

general fund is facing a significant shortfall. Programs budgeted from the general fund are

restricted from travel outside the State.

The review team found that the Section, when fully staffed, devotes approximately 4 full time

equivalents (FTE) of staff effort to the Agreement Materials Program. Of this, 1.25 FTE is

administrative and supervisory consisting of one Section Chief (0.3 FTE); the Materials

Supervisor (0.8 FTE); one Program Consultant (0.15 FTE). The staff effort consists of three

Radiation Control Inspectors (with a combined level of 2.70 FTE).

There were a total of six turnovers during the review period. The earlier vacancies were filled

quickly. As of April 26, 2002, the Section had two vacancies. The Section Chief position

became vacant April 19, 2002 and the Program Consultant position in March 2002. The

Bureau Chief expected to fill the positions within two months. However, the team learned after

the review that the Materials Supervisor was promoted to the Section Chief position, and that

the newest inspector resigned from the program. In addition, the supervisor for Emergency

Planning left the Department. 

The decommissioning of the Coleman facility in Wichita has been a significant resource drain

on the Section. The Materials Supervisor spent at least 0.15 FTE in FY 2002 on oversight and

technical review of the decommissioning activities at this facility. In addition, the newest 

inspector’s time was almost exclusively dedicated to the project. 

The Bureau developed and implemented a training and qualification program consistent with

the recommendations in the NRC/OAS Training Working Group Report. They also established

a database tracking system for staff training. Materials inspectors are required to have

bachelor’s degrees or equivalent training in the physical and/or life sciences. Before
Kansas Final Report Page 10

performing assigned tasks independently, new hires work with senior staff and under the

guidance of the Materials Supervisor until appropriate training and experience is received. 

However, due to staffing constraints and the Coleman decommissioning in FY 2002, the

newest inspector participated in only a small amount of on the job training.

The Bureau uses non-NRC training courses to supplement the training curriculum so that

individuals may broaden their work areas. Training courses are provided by device

manufacturers and academic institutions within the State. Department management is aware

that the inability to participate in out-of-State NRC training courses may further degrade the

technical quality of the program over time. 

During the review, the Bureau had only two staff members fully qualified to perform license

reviews and inspections. One of the staff members functions primarily as license reviewer and

conducts approximately five inspections per year. The other conducts the majority of the

inspections, occasionally as many as 15 - 20 inspections per month. The team concluded that

the lack of adequate staff was a root cause of issues observed in other indicators. The team

noted that the Kansas staff, with 2.7 FTE for licensing and inspection of 325 licensees, was

unusually small even at full strength. 

Since a third technical staff member (the newest inspector) was in training, the team

determined that the Bureau had a marginally adequate number of qualified personnel to carry

out the Agreement Materials Program. The team discussed with the Department management

the problems observed as related to the staffing shortage. Shortly after the completion of the

onsite portion of the review, the third technical staff member departed from the Program. At

that point, the team became concerned that absent strong corrective action, the Kansas

Agreement Materials Program would be unable to protect public health and safety. 

Subsequently, the Bureau received authorization to fill the positions despite a statewide hiring

freeze. As of August 17, 2002, the Bureau has interviewed and filled three of the vacant

positions. 

The team remains concerned that the Bureau may not be able to complete the training and

qualification of the new staff in an appropriate period of time, due to continuing fiscal

constraints. The team discussed, with Bureau and Department management, fiscal strategies

that have been successful in other States. The Department requested legislative approval of

similar strategies in prior years, and plans to request them again. The team recommends the

State ensure that the Agreement Materials Program has adequate resources and an adequate

complement of qualified staff.

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

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

satisfactory with recommendations for improvement.

3.4 Technical Quality of Licensing Actions

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

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

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

equipment, and operating and emergency procedures sufficient to establish the basis for
Kansas Final Report Page 11

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

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

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

regulations; documentation of safety evaluation reports, product certifications or other

supporting documents; consideration of enforcement history on renewals; pre-licensing visits,

peer or supervisory review as indicated; and proper signature authority. The files were

checked for retention of necessary documents and supporting data.

Licensing casework was selected to provide a representative sample of licensing actions that

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

academic (limited specific and broad scope), medical (institution, mobile, and private practice),

gauge (fixed and portable), industrial radiography, well logging, radiopharmacy, and veterinary

nuclear medicine. Licensing actions included two new licenses, five renewals, four

amendments, and four terminations. A list of the licenses evaluated with case-specific

comments can be found in Appendix D.

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

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

conditions were usually 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 used the Bureau's licensing

guides, license templates, standard conditions and checklists. No potentially significant health

and safety issues were identified.

Licensing actions were tracked via the amendment tracking system in the radioactive materials

database. The Office Assistant initially entered the appropriate information for each licensing

action into the database. The actions were then assigned to a license reviewer. The

amendment tracking system followed the status of licensing actions throughout the process. 

Good communication between staff was realized via the amendment tracking system. The

license reviewer documented issues in the database during the review process. This system

enabled other staff to efficiently address licensees’ questions regarding the status of actions

when the assigned reviewer was not available. 

The review team found that staff followed appropriate licensing guides to ensure that licensees

submit information necessary to support the request. The review team found the generic

checklists to be comprehensive, and when used in conjunction with the appropriate guidance

documents, provided consistency between staff. Letters and documented telephone

conversations contain appropriate regulatory language and address deficiencies. The use of

license templates by the staff also results in consistency between reviewers. Bureau staff

identified changes resulting from each licensing action to the licensee by bolding text in the

license document. 

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

the appropriate material transfer records and survey records. Confirmatory surveys for license

terminations were conducted when appropriate. An evaluation of selected termination records

revealed excellent communication between staff to prevent abandonment of radioactive

material. The files showed that documentation of proper disposal or transfer was provided.
Kansas Final Report Page 12

Licenses have two year terms. A simple renewal is granted every two years. However,

licenses are renewed in their entirety either after ten years or after five amendments. Licenses

under timely renewal are amended as necessary to assure that public health and safety issues

are addressed. Deficiencies are addressed by letters and documented telephone

conferences, which use appropriate regulatory language. Licensing actions undergo a two-tier

management review prior to issuance. All licenses are reviewed and signed by both the

Materials Supervisor and the Section Chief.

The review team determined that the Bureau had not fully implemented the financial

assurance requirements adopted by the State in 1996. The team’s examination of licenses

disclosed that several licenses authorized radioactive material in the types and quantities

requiring financial assurance documents. However, the licensees had not addressed the

financial assurance requirements. The review team recommends that the Section review all

Kansas’ licenses to ascertain if they require financial assurance, and take appropriate action

on each affected license to ensure that all licenses meet the State’s financial assurance

requirements. 

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

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

satisfactory.

3.5 Response to Incidents and Allegations

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

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

evaluated selected incidents reported for Kansas in NMED against those contained in the

Kansas files, and evaluated the casework and supporting documentation for 11 material

incidents. A list of the incidents examined is included in Appendix E. The team also reviewed

the Program’s response to six allegations involving radioactive materials including two

allegations referred to the Program by the NRC during the review period.

The 11 incidents selected for review included the following categories: overexposure, loss or

theft of radioactive material, release of radioactive material, misadministration, contamination

event, equipment failure, and deliberate misconduct. The review team found that the Bureau’s

response to incidents was generally complete and comprehensive. Initial responses were

prompt and well-coordinated, and the level of effort was commensurate with the health and

safety significance. The Bureau dispatched inspectors for onsite investigations when

appropriate, and took suitable enforcement and follow-up actions.

The review team discussed the Bureau’s event and allegation procedures, tracking system, file

documentation, the NMED, and notification of incidents to the NRC Operations Center with

Program management and staff. The Bureau’s event procedures include the reporting

requirements to NRC from STP Procedure SA-300, “Reporting Material Events.”

Kansas' incident and allegation response procedure appropriately lists steps to be followed by

professional staff while conducting an investigation in RHS-35, Investigation Procedures, April

3, 2002. Kansas staff took appropriate actions to ensure that response to incidents or
Kansas Final Report Page 13

allegations was coordinated and timely, including initial response by the person receiving

notice, investigation, and review by supervisory staff prior to closeout.

As noted in Section 2.0, the Bureau developed and implemented a database program similar

to the NRC NMED. The information provided by the Kansas events database was generally

complete and accurate. However, in several instances data were missing, for example,

selection boxes were not checked. This occurred, in part, because a database entry was

made prior to having complete data. The team discussed, with the Materials Supervisor, the

flagging of records with missing information for completion prior to incident closeout.

The Bureau documented 44 Agreement materials events during the review period. Event

records were in files for 1998 and 1999, and in the Kansas events database for 2000-2002. 

For the review period, 19 of the 44 events were required to be reported to the NRC NMED

system in accordance with STP Procedure SA-300, “Reporting Material Events.” All required

reports were submitted.

In a few cases, the Kansas events database records were missing key information. For

example, in four of the 44 cases, the record did not indicate the radionuclide involved, or

alternatively contain a finding that the radionuclide was unknown. 

During the review period, the Bureau received six allegations involving Agreement material,

two of which were from the NRC. The team reviewed the casework for all six allegations. The

casework indicated that the Bureau’s level of effort in responding to allegations was

commensurate with potential health and safety significance. The Bureau took prompt and

appropriate action in response to the concerns raised and appeared to have appropriately

protected the alleger’s identity. The allegations were treated and documented internally in the

same manner as events. No performance issues were identified in the team review of

allegation files and documentation.

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

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

satisfactory.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

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

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

and (4) Uranium Recovery Program. Kansas’ Agreement State Program does not cover

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

applicable to this review.
Kansas Final Report Page 14

4.1 Legislation and Program Elements Required for Compatibility

4.1.1 Legislation 

The Bureau gave the review team copies of legislation affecting the radiation control program. 

Legislative authority to create an agency and enter into an agreement with the NRC is granted

in Article 16 - Nuclear Energy Development and Radiation Control Act, Kansas Statutes,

K.S.A. 48-1601 to 48-1619. The Department Secretary is responsible by law for radiation

control. There has been no legislation passed since the last IMPEP review that affected the

radiation control program.

4.1.2 Program Elements Required for Compatibility 

The Kansas Regulations for Control of Radiation, found in KAR 28-35-133 through

KAR 28-35-363, apply to all ionizing radiation, whether emitted from radionuclides or devices. 

Kansas requires a license for possession, and use, of all radioactive material including

naturally occurring materials, such as radium, and accelerator-produced radionuclides. 

Kansas also requires registration of all equipment designed to produce x-rays or other ionizing

radiations. To the extent practical, the Kansas regulations follow the Suggested State

Regulations (SSRs) of the Conference of Radiation Control Program Directors, Inc. 

Kansas has a 12 step regulation promulgation process which includes a 60-day notice for

public comment prior to a public hearing. The entire process nominally takes about 36 weeks

from regulation drafting to full effect. The Materials Supervisor has responsibility for

maintaining the regulations.

Kansas did not promulgate any revisions to the regulations during the review period. The

Department is promulgating a complete revision of the regulations with an expected effective

date in December 2002. The amendments are drafted, and are under review by Agencies

outside the Department. Bureau management chose to revise the regulations in whole rather

than adopt individual NRC amendments partly because the required amendments entail

conforming changes to a significant number of references. They also chose to address the

x-ray program regulations first because those regulations were more out of date than the

radioactive materials regulations.

The team reviewed the status of the regulations required for adoption by the State under the

Commission’s Policy Statement on Adequacy and Compatibility of Agreement State Programs

(Policy Statement). The team compared the adoption of regulations by the State with data

obtained from the STP Regulation Assessment Tracking System, and NRC Chronology tables. 

 Interviews conducted with the staff confirmed that the Bureau uses license conditions when

regulations were not adopted within the 3-year time frame. The team noted that license

conditions or other legally binding requirements were being used for the following rules: 

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

10 CFR Part 20 amendment (60 FR 7900) that became effective March 13, 1995. 

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

61 amendments (60 FR 15649 and 25983) that became effective March 1, 1998. The
Kansas Final Report Page 15

Agreement States were expected to promulgate their regulations no later than March 1,

1998 so that NRC and the State would require this national system to be effective at

the same time. 

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

 (60 FR 28323) that became effective June 30, 1995.

! "Radiation Protection Requirements: Amended Definitions and Criteria," 10 CFR Parts

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

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

35 amendments (60 FR 48623) that became effective October 20, 1995.

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

70 amendments (60 FR 38235) that became effective November 24, 1995. 

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

amendment (60 FR 50248) that became effective April 1, 1996. 

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

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

June 17, 1996.

! “Resolution of Dual Regulation of Airborne Effluents of Radioactive Materials; Clean Air

Act,” 10 CFR Part 20 amendment (61 FR 65119) that became effective January 9,

1997.

! “Recognition of Agreement State Licenses in Areas Under Exclusive Federal

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

that became effective February 27, 1997.

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

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

! “Licenses for Industrial Radiography and Radiation Safety - Requirements for Industrial

Radiography Operations,” 10 CFR Parts 30, 34, 71, and 150 amendments (62 FR

28948) that became effective June 27, 1997.

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

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

! “Exempt Distribution of a Radioactive Drug Containing One Microcurie of Carbon-14

Urea,” 10 CFR Part 30 amendment (62 FR 63634) that became effective January 2,

1998.

! “Deliberate Misconduct by Unlicensed Persons,” 10 CFR Parts 30, 40, 61, 70, and 150

amendments (63 FR 1890 and 13773) that became effective February 12, 1998.
Kansas Final Report Page 16

! “License for Industrial Radiography and Radiation Safety Requirements for Industrial

Radiographic Operations; Clarifying Amendments and Corrections,” 10 CFR Part 34

amendment (63 FR 37059) that became effective July 9, 1998.

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

Parts 20, 32, 35, 36, and 39 amendments (63 FR 393477 and 63 FR 45393) that

became effective October 26, 1998.

! “Transfer for Disposal and Manifest; Minor Technical Conforming Amendments,” 10

CFR Part 20 amendment (63 FR 50127) that became effective November 20, 1998.

! “Radiological Criteria for License Termination of Uranium Recovery Facilities,” 10 CFR

Part 40, Appendix A (64 FR 17506) that became effective June 11, 1999.

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

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

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

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

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

63749) that became effective January 8, 2001. 

The review team examined eight licenses selected at random. All eight contained the

appropriate license conditions required as alternatives for applicable regulations. The team

concluded that the Bureau satisfactorily uses license conditions as alternatives to regulations. 

However, these legally binding requirements have not been submitted for NRC review. The

team recommends that, when the Bureau uses legally binding requirements as alternates to

rules, it submit the text of the requirements to NRC for review.

The Bureau believed that the following two regulations were found compatible at the last

IMPEP. Because of this belief, license conditions were not used. This team found that the

State regulations were older versions that did not incorporate the requirements added by the

amendments. The 1998 IMPEP found the State’s performance satisfactory based on the rule

adoption extension granted through the implementation of the Commission Policy until

September 3, 2000, not based on the content of the State regulations.

! “Timeliness in Decommissioning of Materials Facilities,” 10 CFR Parts 30, 40, and 70

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

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

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

that became effective January 1, 1995. 

The review team recommends the Bureau adopt the regulations “Timeliness in

Decommissioning of Materials Facilities,” and “Preparation, Transfer for Commercial

Distribution, and Use of Byproduct Material for Medical Use,” or adopt generally applicable

legally binding alternatives to the regulations.
Kansas Final Report Page 17

The Department has not addressed the regulation “Requirements for Certain Generally

Licensed Industrial Devices Containing Byproduct Material,” (65 FR 79162) parts of which were

due for adoption by the Agreement States by August 16, 2001. However, the Materials

Supervisor stated that currently there are no Kansas licensees authorized to distribute

generally licensed devices. The remaining portions of the regulation are due by February 16,

2004.

Based on the IMPEP evaluation criteria, the review team recommended that Kansas’

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

Compatibility, be found satisfactory with recommendations for improvement. At the 

November 22, 2002 MRB meeting, the MRB concluded that a rating of satisfactory was

appropriate for this indicator due to the State’s performance involving this indicator and past

IMPEP precedent.

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

At the time of the review, Kansas had no sealed source or device manufacturers nor were any

applicants anticipated in the near future. The State, however, does not wish to relinquish the

authority to regulate SS&D manufacturers in the future. The State has committed in writing in

a memorandum to their files to have a program in place prior to performing evaluations.

Accordingly, the review team did not review this indicator.

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

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

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

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

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

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

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

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

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

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

which will meet the criteria for an adequate and compatible LLRW disposal program. There

are no plans for a LLRW disposal facility in Kansas. Accordingly, the review team did not

review this indicator.

5.0 SUMMARY

As noted in Sections 3 and 4 above, Kansas’ performance was found to be satisfactory for five

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

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

and Legislation and Program Elements Required for Compatibility. The Kansas’ performance

was found satisfactory with recommendations for improvement for the common performance

indicator, Technical Staffing and Training. The review team recommended and the MRB

concurred in finding the Kansas Agreement State program adequate to protect public health

and safety and compatible with NRC's program. Although the review team recommended that

the next full review be in approximately two years, the MRB directed that the next IMPEP
Kansas Final Report Page 18

review be in approximately four years. While the Bureau has acted to alleviate the short-term

staffing problem, the team and the MRB are concerned that long-term stability in hiring,

training and retaining staff has not been achieved. Therefore, the MRB requested that

periodic conference calls take place with the appropriate Kansas and NRC staffs to discuss

the status of the program and that the results of these calls be presented at MRB meetings.

Below are the recommendations, as mentioned earlier in the report, for evaluation and

implementation, as appropriate, by the State.

RECOMMENDATIONS:

1. The team recommends the State ensure that the Agreement Materials Program has

adequate resources and an adequate complement of qualified staff. (Section 3.3)

2. The review team recommends that the Program review all Kansas’ licenses to ascertain

if they require financial assurance, and take appropriate action on each affected license

to ensure that all licenses meet the State’s financial assurance requirements. 

(Section 3.4)

3. The team recommends that, when the Bureau uses legally binding requirements as

alternates to rules, it submit the text of the requirements to NRC for review. 

(Section 4.1.1)

4. The review team recommends the Bureau adopt the regulations “Timeliness in

Decommissioning of Materials Facilities,” and “Preparation, Transfer for Commercial

Distribution, and Use of Byproduct Material for Medical Use,” or adopt generally

applicable legally binding alternatives to the regulations. (Section 4.1.1)
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Kansas Organization Chart

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Attachment October 30, 2002 Letter from Thomas A. Conley

Kansas’ Response to Draft IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Richard Blanton, STP Team Leader

Legislation and Program Elements Required for

Compatibility

Vivian Campbell, RIV Technical Quality of Licensing Actions

Technical Staffing and Training

Gregory Morell, RIV Technical Quality of Inspections

Inspector Accompaniments

Richard Leonardi, RIV Additional Inspector Accompaniments

Kenneth Weaver, CO Status of Materials Inspection Program

Response to Incidents and Allegations
APPENDIX B

KANSAS ORGANIZATION CHART

ML022560027




ATTACHMENT

October 30, 2002 Letter from Thomas A. Conley

Kansas’ Response to Draft IMPEP Report

ML023100186