December 20, 2002

Fay Boozman, M.D., M.P.H.

Director

Arkansas Department of Health

4815 West Markham Street, Slot 30

Little Rock, Arkansas 72205-3867

Dear Dr. Boozman:

On November 26, 2002, the Management Review Board (MRB) met to consider the proposed

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

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

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

Section 5.0, page 14, of the enclosed final report presents the IMPEP team’s recommendations

for the State of Arkansas. 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. 

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 the excellence in

program administration demonstrated by your staff as is reflected in the team’s findings. I look

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

Sincerely,

/RA by Paul H. Lohaus for/

Carl J. Paperiello 

Deputy Executive Director 

 for Materials, Research and State Programs

Enclosure:

As stated

cc: Jared Thompson, Program Leader

Radioactive Materials Section

Bernard Bevill, Team Leader

Radiation Control and Emergency

 Management Program

Steve Collins, IL

OAS Liaison to MRB
Fay Boozman, M.D., M.P.H. December 20, 2002

Director

Arkansas Department of Health

4815 West Markham Street, Slot 30

Little Rock, Arkansas 72205-3867

Dear Dr. Boozman:

On November 26, 2002, the Management Review Board (MRB) met to consider the proposed

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

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

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

Section 5.0, page 14, of the enclosed final report presents the IMPEP team’s recommendations

for the State of Arkansas. 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. 

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 the excellence in

program administration demonstrated by your staff as is reflected in the team’s findings. I look

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

Sincerely,

/RA by Paul H. Lohaus for/

Carl J. Paperiello 

Deputy Executive Director 

 for Materials, Research and State Programs

Enclosure:

As stated

cc: Jared Thompson, Program Leader

Radioactive Materials Section

Bernard Bevill, Team Leader

Radiation Control and Emergency

 Management Program

Steve Collins, IL

OAS Liaison to MRB

bcc: Chairman Meserve

Commissioner Dicus

Commissioner Diaz

Commissioner McGaffigan

Commissioner Merrifield

Distribution: See next page ML023440432

DOCUMENT NAME: G:\IMPEP\ML023440435.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 PMLarkins:gd JMPiccone PHLohaus CJPaperiello

(PLohaus for)

DATE 11/27/02 11/27/02 12/10/02 12/20/02
Distribution:

DIR RF DCD (SP01) PDR (YES)

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Arkansas File
INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF ARKANSAS AGREEMENT STATE PROGRAM

September 9-13, 2002

FINAL REPORT

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

1.0 INTRODUCTION

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

review was conducted during the period September 9-13, 2002, by a review team consisting of

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

State of Florida. 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 March 28, 1998 to September 8, 2002, were discussed with

Arkansas management on September 13, 2002.

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

State responded by electronic mail dated November 8, 2002. The Management Review Board

(MRB) met on November 26, 2002 to consider the proposed final report. The MRB found the

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

compatible with NRC’s program.

The Arkansas Agreement State Program is administered by the Department of Health (the

Department). The Department reorganized in FY2000. Under the reorganization, the

Radioactive Materials Section (the Section), which is managed by the Radioactive Materials

Section Program Leader (the Program Leader) has direct responsibility for the Agreement State

materials program. The Section is located in the Radiation Control and Emergency

Management Team, under the Health Systems Group, which consists of five sections, as

follows: Programs and Emergency Management, X-Ray, RT Licensure, Mammography, and the

Radioactive Materials Section. Each Section reports to the Team Leader for Radiation Control

and Emergency Management. The Team Leader is also responsible for budget, administrative

operations, and coordination between upper management and the five sections. The Team

Leader reports to the Health Systems Group Leader. The Group Leader reports to the

Statewide Services Leader who reports directly to a seven member Agency Leadership Team

(ALT), responsible for strategic agency-wide oversight and fiduciary responsibility. The ALT

reports directly to the Department’s State Health Officer. The less hierarchal team leader

organization structure provides staff increased access to the Department ‘s State Health Officer,

who reports directly to the Governor. Organization charts for the Department and the Section

are included in Appendix B.

At the time of the review, the Arkansas Agreement State program regulated 265 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 Arkansas.

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

performance indicators was sent to the Department on July 2, 2002. The Department provided a

response to the questionnaire dated August 21, 2002. During the review, the review team

identified several areas in the questionnaire response that needed to be clarified or modified. 

The Department provided an amended questionnaire response on September 24, 2002. A copy

of the final questionnaire response can be found on NRC’s Agencywide Document Access and

Management System using the Accession Number ML022890596.
Arkansas Final Report Page 2

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

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

regulations; (3) analysis of quantitative information from the radiation control program licensing

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

field accompaniments of three Department inspectors; and (6) interviews with staff and

management to answer questions or clarify issues. The review 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 Arkansas

Agreement State program’s performance.

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

the previous IMPEP 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. 

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 March 27, 1998, seven 

recommendations were made and transmitted to Sandra B. Nichols, M.D., Director, Arkansas

Department of Health on July 8,1998. The team’s review of the current status of the

recommendations are as follows:

1. The review team recommends that the Section continue to develop and implement the

civil penalty portion of the updated escalated enforcement procedure in order to enhance

its compliance program. (Section 3.1)

Current Status: The review team found that the Section implemented Procedure RAM -

03.8, “Escalated Enforcement Actions” in 1998, and has continued its use of

management conferences as an effective escalated enforcement practice to resolve

serious compliance issues. This recommendation is closed.

2. The review team recommends that the Section continue efforts to move its reciprocity

inspection program towards the guidelines established in IMC 1220. (Section 3.1)

Current Status: The review team found that the Section developed Procedure RAM -

03.9, “Guideline for Compliance Inspection Frequency of NRC/Agreement State

Reciprocity Licensees.” Since 1998, the Division continued efforts to move its reciprocity

inspection program towards the guidelines established in the previous version of IMC

1220. The review team found that the Section had exceeded the previously established

reciprocity guidelines. The team discussed the current revised guidelines for reciprocity

inspections, that contain a reduction in the level of effort for inspecting licensees from 50

to 20 percent. This recommendation is closed. 

3. The review team recommends that the Section proceed expeditiously with its review and

updating of compliance program guidance. (Section 3.2)
Arkansas Final Report Page 3

Current Status: The review team found that the inspection and compliance program

guidance has been revised and implemented. This recommendation is closed.

4. The review team recommends that the Section staff revise the license reviewer guidance,

including checklists, to address comprehensive radiation protection program reviews,

annual program audits, and the need for financial assurance. (Section 3.4)

Current Status: The review team found that the revision to the radioactive materials

licensing guidance checklists for specific activities, i.e., addressing comprehensive

radiation protection program reviews, annual program audits, and the need for financial

assurance, have been addressed through the manual addition of the elements to the

checklist by each reviewer for each action. Due to time and personnel constraints,

efforts to revise and update the generic licensing procedures that can be applied to all

licensed activities have been limited. The review team has incorporated this item into the

current recommendation in Section 3.3. This recommendation is closed.

5. The review team recommends that the State adequately document and closely follow the

progress of investigations of incidents through close out. (Section 3.5)

Current Status: The review team found that the Section has performed appropriate and

thorough investigations when deemed necessary, and that they have been documented

adequately. This recommendation is closed.

6. The review team recommends that the State continue to report events and participate in

the Nuclear Material Events Database (NMED) system by providing event information

and close -out status to be added to the NMED system or by providing compatible

information in accordance with the guidance contained in the “Handbook on Nuclear

Event Reporting in the Agreement States.” (Section 3.5)

Current Status: The review team found that the Section has developed internal policies

and procedures for the use of the NMED system based on Office of State and Tribal

Programs (STP) Procedure SA-300, Handbook on Nuclear Event Reporting in the

Agreement States. Staff training has been provided on the implementation of these

procedures and the Section has successfully submitted event information into the NMED

system and all events closed by the State have been closed out in NMED. This

recommendation is closed.

7. The review team recommends that any events involving a defective device or source in a

device, be evaluated for possible generic implications and such information passed onto

the manufacturer and NRC. (Section 4.2.3)

Current Status: The review team found that the Section has investigated events that

involve defective devices or sources in a device. The team found that the Section is

promptly notifying the NRC and the vendor of any events involving apparent defective

devices, but the Section does not evaluate any apparent defective devices discovered for

generic implications. This recommendation is closed.
Arkansas Final Report Page 4

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

team determined that the Department 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 review team focused on four factors in reviewing the status of the materials inspection

program: inspection frequency, overdue inspections, initial inspections of new licensees, and

timely dispatch of inspection findings to the licensees. The review team’s evaluation is based on

the Department’s questionnaire responses relative to this indicator, data gathered from reports

generated from the licensee database, examination of completed licensing and inspection

casework, and interviews with the Program Leader, and licensing and inspection staff.

The Section’s RAM-01.09 procedure dated January 30, 2002, entitled “Assigning and Tracking

Radioactive Material and Particle Accelerator Inspections,” established that inspections should

be conducted at least as frequent, or more frequent than the priority schedule in NRC Inspection

Manual Chapter (IMC) 2800. The Section has an aggressive inspection schedule. Except for

Priority 1 licenses, all other licenses are inspected more frequently than IMC 2800. For

example, nuclear medicine licenses are Priority 1 or 2 based on volume of use in the Section’s

schedule versus Priority 3 in IMC 2800. Medical-private practice licenses which are Priority 5 in

IMC 2800, are Priority 2 in the Section’s schedule. Portable and fixed gauges are Priority 2 or 3

based on the number of sources possessed versus Priority 5 in IMC 2800. The review team

noted that at the time of the review the Section had 72 Priority 1 licensees that were inspected

annually. Thirty-three of the 72 Priority 1 licensees were inspected more frequently than the

intervals specified in IMC 2800. 

The Section’s RAM-01.12 procedure dated January 30, 2002, entitled “Extension and Reduction

of Inspection Frequencies” established a policy and procedure for changing inspection

frequencies. Although the Section has procedures for extending inspection intervals on the

basis of good licensee performance, the Program Leader indicated that they have rarely

extended inspection intervals. The Section does, however, reduce inspection intervals based on

poor licensee performance. Presently, 19 of the 72 Priority 1 licensees were on the annual

inspection schedule because of poor performance. 

The licensee database contains sufficient information for proper management of the inspection

program. The review team noted that the number of inspections performed each year is 

increasing. In calendar year 1998, the Section performed approximately 92 inspections, 112

inspections in 1999, 135 inspections in 2000; and 152 inspections in 2001. The Section’s

Program Leader stated that resources had been focused on inspections to ensure that potential

health and safety issues resulting from the licensing renewal backlog were identified and

addressed. The licensing backlog is further discussed in Section 3.4.
Arkansas Final Report Page 5

At the time of the review, there were no overdue core inspections, including initial inspections. 

The review team examined the Section’s tracking information for a total of 115 licenses, which

included 42 initial inspections. During the review period, ten core inspections, including eight

initial inspections were overdue when conducted. The overdue inspections ranged from two to

31 months overdue when conducted. The Section has had difficulty inspecting licensees

authorized to conduct licensed activities at temporary jobsites when their corporate offices are

located out-of-state and they do not have permanent field offices within the State. The Section

management recognized that they were not able to meet the inspection goals for these

licensees. In order to provide a reasonable opportunity to perform an inspection, the Section

amended these licenses to require notification two days prior to entering the State to conduct

licensed activities. 

During the review period, the Section granted 179 reciprocity permits. The Section’s RAM-01.09

procedure is used to establish the priority for inspection frequencies of reciprocity licensees. 

Consequently, the Priority 3 reciprocity licensees identified in the Section’s response to the

questionnaire were industrial gauge licensees which are not core inspections under the guidance

in IMC 1220. Notwithstanding the aggressive inspection schedule, the Section met and

exceeded the reciprocity inspection goals identified in the previous version of IMC 1220

throughout the review period. As noted in Section 2.0, the review team also discussed the

current revised guidelines for reciprocity inspections contained in IMC 1220, dated June 6, 2002. 

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

review. The Section has an ambitious goal of transmitting inspection reports with items of

noncompliance to the licensee within seven working days after the inspector returns to the office. 

The review team noted that the Section generally met their goal. For all casework reviewed, all

inspection findings were sent to the licensees within 30 days.

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

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 reports, enforcement documentation, and inspection field

notes, and interviewed inspectors for 23 materials inspections conducted during the review

period. The casework reviewed included inspections by five inspectors, and covered inspections

of various types including: industrial radiography, portable gauge, large academic,

radiopharmacy, medical private practice, service provider, well logging, gamma knife, medical

institution and irradiator facilities. Appendix C lists the inspection casework files reviewed for

completeness and adequacy with case-specific comments.

Based on the casework file reviews, the review team found that routine inspections covered all

aspects of a licensee’s radiation protection program. Inspection reports generally were

thorough, complete, consistent, and of high quality, with sufficient documentation to ensure

acceptable performance with respect to health and safety by the licensee. In most cases, the

documentation adequately supported the cited violations, recommendations made to licensees,

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

inspections were performed when appropriate and for training purposes.
Arkansas Final Report Page 6

During the review period, the Program Leader accompanied all individuals who performed

materials inspections. The accompaniment reports contained sufficient details to document the

areas covered. The accompanied inspectors are provided a copy of the accompaniment report

in their personnel file and receive an oral report of their individual performance. 

The review team accompanied three inspectors during the period of August 12 -16, 2002. One

inspector was accompanied on inspections of an academic licensee and a large medical

licensee. The second inspector was accompanied on inspections of a large medical licensee,

with the first inspector and a radiopharmacy licensee. The third inspector was accompanied on

inspections of an industrial radiography licensee and a private practice medical clinic. The

facilities inspected are identified in Appendix C. During the accompaniments, the inspectors

demonstrated appropriate performance-based inspection techniques and knowledge of the

regulations. Each of the inspectors was well prepared and thorough in their reviews of the

licensees’ radiation safety programs. The review team noted that all technical staff members are

equipped with a cell phone for communication. Inspectors can contact the office immediately if

there is a problem in the field. The inspectors can be reached anywhere in the State of

Arkansas if the need arises. Overall, the technical performance of the inspectors was excellent,

and their inspections were adequate to assess radiological health and safety at the licensed

facilities.

The Section maintains a sufficient number and variety of survey instruments to perform

radiological surveys of licensees. The review team examined the staff’s instrumentation and

observed that the survey instruments were calibrated and operable. Inspectors are assigned

calibrated instruments for their routine use. The staff perform their own calibration of survey

meters at least annually, with a source that is National Institute of Standards and Technology

traceable.

The Section staff receive support from the Arkansas Department of Health Radiochemistry

Laboratory, which performs sample counting and assay services. Discussions with Section staff

established that the support is timely and dependable. The review team toured the laboratory

facilities and discussed laboratory procedures and instrument quality control with the laboratory

supervisor. The laboratory is capable of providing accurate and defendable analysis results to

support the staff’s needs.

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

performance with respect to the indicator, Technical Quality of Inspection, be found satisfactory.

3.3 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Department’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 Department’s questionnaire responses relative to

this indicator, interviewed Department management and staff, reviewed job descriptions and

training records, and considered any possible workload backlogs.

Under the recent reorganization, the Section has direct responsibility for the Agreement

materials program. The review team found that the Section has 6 full-time technical positions,

including the Program Leader, devoting approximately 5.2 FTE to the Agreement material

program. The review team found that the Program Leader spends about 0.3 FTE of his time in
Arkansas Final Report Page 7

radioactive materials licensing and inspection activities, and 0.6 FTE in supervisory and

administrative activities. The remaining five technical Health Physicist staff, spend about 0.8

FTE in administration, with a combined level of 3.5 FTE in radioactive material licensing and

inspection activities. Currently, the Section has no vacant positions. As noted in Section 3.1,

the Department was reorganized in FY2000 to a less hierarchal organization based on the team

leader concept. The less hierarchal organization structure provides staff increased access to the

Department ‘s State Health Officer, who reports directly to the Governor. 

The review team learned that staffing has been relatively stable since December 1999. Prior to

that time, and during the previous IMPEP review period, staffing turnovers impacted the

program, resulting in considerable time spent training new staff. During the current review

period, there were two new hires, and two inspection staff members departed. The team found

that the Program Division Director retired in July 2001. The Section management informed the

team that the Program Division Director position was subsequently abolished as part of the

reorganization to a less hierarchal organizational structure. As a result of the reorganization the

Section lost two staff positions. The review team also learned that the Department recently hired

the retired Program Division Director, as a consultant, on a part-time short-term base, (for 20

hours per week). The Section management indicated that the consultant contract is renewable

on a six month basis, based on available funds. 

As a result of the increased stability in staffing since 1999, the Section currently has well trained

experienced personnel to carry out regulatory duties. The review team found that the technical

quality of staff products is high. Monthly staff training meetings include discussions of major

licensing and compliance issues. The review team also found a significant licensing renewal

backlog pending since the 1995 and 1998 program reviews. The backlog involves

approximately one-half of the Section’s licensees, indicating an imbalance in the current staffing

plan between licensing and inspection activities. Section management indicated they have

focused resources on inspections to ensure that potential health and safety issues resulting from

the licensing renewal backlog are identified and addressed. Although the team found that the

consultant has begun working on the licensing renewal backlog, the review team concluded that

this effort alone would not address the licensing backlog actions in addition to any new licensing

activities. The review team concluded that Department management should consider reviewing

the current level of effort to maintain the current level of quality throughout the licensing and

inspection program and address any backlogs. Additionally the team found that efficiencies

could be achieved through automation of some licensing processes and standardized model

templates. The review team recommends that Department management review the current

staffing plan to achieve a more effective balance between licensing and inspection activities. 

This item is further discussed in Section 3.4.

The review team found that the minimum educational requirement for a new hire is a bachelor’s

degree and preferably 1-2 years of experience or equivalent training and experience. Two

current staff exceed or meet the educational and experience qualifications including a bachelors

degree and three staff meet the qualifications through a combination of training and equivalent

experience. 

The review team found that five of the six Section staff, including the Program Leader are fully

qualified and one staff member is interim qualified. All technical staff members have taken the

NRC courses deemed appropriate for their assigned tasks. In addition, the review team noted

that new licensing and inspection staff members usually attend three to four NRC training
Arkansas Final Report Page 8

courses, including the five week health physics course, in their first two years with the Section,

depending on availability of training courses and training funds. 

The review team found that although all but one of the current staff are fully qualified, the

training and qualification requirements for licensing and inspection staff have not been formally

established in a policy or procedure and were not captured in a tracking system. The review

team was provided a copy of a memorandum qualifying one staff member for radioactive

material inspections, that identified completed training courses, and inspections and

accompaniments used to support the qualification; although similar qualification documents

were not available for all members of the staff. Based on discussions with the Program Leader,

inspector requirements include NRC, or equivalent, training courses when available. The team

was provided with copies of training certificates for some staff members. The Program Leader

stated that inspectors are also required to be accompanied by a senior staff member on an

inspection prior to authorizing the inspector to perform an independent inspection. The Program

Leader also indicated that prior experience in inspecting in a specialized area is preferred for

new license reviewers. The review team discussed the issue of formally documenting the

training and qualification process to facilitate training and qualification of new staff, and periodic

retraining of current staff. Guidance on training and qualification requirements are provided in

the NRC/Organization of Agreement States Training Working Group Recommendations for

Agreement State Training Programs report, and NRC IMC 1246.

The review team noted that the Section receives approximately 23.4% of its funding through a

licensee fee program and the balance through general funds. The team learned that the

Department has approved a request for development of a General License registration program,

and plans to seek approval from the State Legislature for this additional activity. The

Department has also approved a request for an increase in the licensee fee program, and plans

to seek approval from the State Legislature. The team noted that although the Department has

authority to issue civil penalty fines, Section management indicated it has never implemented it’s

authority in this area due to the rather cumbersome process. 

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

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

3.4 Technical Quality of Licensing Actions

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

licensing casework for 15 specific licenses. Licensing actions were reviewed for completeness,

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

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

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

technical quality. The casework files were also reviewed for timeliness, use of appropriate

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

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

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

documents and supporting data.

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

were completed during the review period. The sampling focused on the State’s new licenses,
Arkansas Final Report Page 9

amendments, renewals, and licenses terminated during the review period. The sampling

included the following types: academic, broad medical, research and development, industrial

radiography, portable and fixed gauges, institutional nuclear medicine, private clinics,

radioisotope and sealed source radiotherapy, and a large irradiator facility. Licensing casework

activities reviewed included, 4 new actions, 5 renewals, over 50 amendments contained in 15

case files, and 1 termination file. The Section completed a total of 1175 licensing actions from

January 1999 through August 2002, that included 1073 amendments. A list of licenses

reviewed with case-specific comments for license reviews can be found in Appendix D. 

Of the 265 active licenses, 121 licenses have been in timely renewal status for more than one

year, and 57 of these 121 renewal applications have been in timely renewal for four or more

years. The review team found that staff has recently begun processing renewals received in

1997, and several license expiration dates were administratively extended for 1-2 years during

1999-2000. This issue was discussed during the 1995 and 1998 IMPEP reviews. The Program

Leader indicated they have focused resources on inspections to ensure that potential health and

safety issues resulting from the licensing renewal backlog are identified and addressed. Due to

the licensing renewal backlog, the review team encountered difficulty finding renewals completed

during the review period that provided a representative sampling of licensed activities and

license reviewers. The team found that the majority of the correspondence covering license tiedown conditions dated back to 1992 and 1993. Recently renewed licenses contained

corresponding tie-down conditions dating back to 1995 and 1996. The Section did not have a

backlog of amendments, which are usually processed within seven days.

The review team learned that staff routinely hand delivers new licenses. The staff considers

hand delivery of licenses to be a pre-licensing visit. The visit is documented on a one-page

form. License files included all current inspection data, in addition to incident data, providing

license reviewers with incident reports and inspection reports during the renewal period. 

Incidents are cross-referenced in licensing files.

In discussions with management, it was noted that there were no major decommissioning efforts

underway with regard to Agreement material in Arkansas and the State is not a certifying entity

for industrial radiographers but will accept certification from other certifying entities. 

License reviewers have adequate supporting information and documentation readily available in

the file to complete renewal license reviews. Monthly staff training meetings include discussions

of major licensing and compliance issues.

Application packages containing guidance are sent to license applicants. The applications are

reviewed following standard procedures that are similar to those used by the NRC. The

licensing guidance, as well as other applicable guidance from NRC, are available, although staff

has not had time to convert references to NRC regulations to Arkansas regulations. At the time

of the 1998 IMPEP, the Program Leader indicated that they had a management Action Plan to

address the recommendation to update licensing guidance documents and revise checklists

used for license reviews. The 1998 IMPEP recommended several specific activities that should

be included in the revised licensing checklists, such as addressing comprehensive radiation

protection program reviews, annual program audits, and the need for financial assurance. The

review team found that the program had partially implemented the Action Plan and addressed

the 1998 IMPEP recommendation, in part, through individual reviewers adding activities to the
Arkansas Final Report Page 10

licensing checklist form, on a case-by-case basis. The team found that the program was using

essentially the same licensing guidance documents that were used during the 1998 IMPEP

review.

At the time of the review, the Section did not track amendment requests received to compare

against completed amendment requests. While each license reviewer maintains a paper log of 

amendment assignments, there is no integrated Section tracking system in place. The current

manual process does not provide the Section management with any measures to determine if

program and timeliness standards are achieved.

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

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

applications and amendments. Some amendments issued were a result of compliance issues

found during inspections because the licensee had submitted changes to their program or

possession limits in the renewal application, which had not been processed. Until the renewal

backlog is reduced, these amendments are expected to increase as the approved radiation

protection programs become more outdated.

The license reviewer reviews licenses and the Program Leader performs a technical review and

supervisory review on all licensing actions. As of March 2002, two senior licensing reviewers

have been authorized to also perform the technical and supervisory review on other reviewers

work on an as needed basis. Only these three individuals have signature authority for the

Section. This authority is designated in writing. All licenses are signed by the Program Leader

or, on an as needed basis, by an individual who has signature authority.

The review team found that, during the review period, termination actions were well documented,

showing appropriate disposal methods and records, confirmatory surveys, and survey records. 

The review team recommends that Department management develop and implement an action

plan to reduce the licensing renewal backlog. In support of this effort, the team encourages a

review of the Section’s business processes, which could include the examination of: an office

wide tracking system for all licensing actions to include renewals, new actions and amendments;

development of standard license templates and standard license condition templates and

models. The review team recommends completion of revisions to update licensing guidance

documents and checklists (this item was identified in the 1998 IMPEP review). In their response

to the draft IMPEP report, the Department commented that they have implemented a centralized

tracking system for licensing actions.

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

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 Section’s actions in responding to incidents, the review

team examined the Section’s responses to the questionnaire relative to this indicator, reviewed

the incident reports for Arkansas in NMED against those contained in the Section’s files, and
Arkansas Final Report Page 11

evaluated reports and supporting documentation for eleven incidents. A list of the incident

casework examined with case-specific comments is included in Appendix E. The review team

also reviewed the Section’s response to four allegations involving radioactive material. The NRC

did not refer any allegations to the program during the review period. 

The incidents selected for review included the following categories: misadministrations, stolen

gauges, overexposures, equipment failure, and damaged equipment. The review team found

that the Section’s response to incidents was complete and comprehensive. Initial responses

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

safety significance. The Section dispatched inspectors for onsite investigations when

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

The responsibility for initial response and follow-up actions to materials incidents may be

assigned to any member of the Section. Upon receipt, Section staff reviews a report, decides on

the appropriate response, and logs it into the incident log. Documentation related to an incident

is placed in the appropriate license file. 

The review team identified 23 incidents in NMED for Arkansas during the review period and

reviewed 11 case files. As noted in Section 2.0, the Section has adopted a procedure providing

that reports of incidents that require immediate notification to the State be provided to the NRC

within 24 hours of notification, and that reports of incidents that require notification to the State

within 30 days be provided to the NRC monthly. The review team noted that all significant

events (requiring 24 hour notification) were provided on a timely basis. Routine events and/or

event updates (requiring 30-60 day notification) were reported to the NRC on a monthly basis

since the previous IMPEP review in accordance with STP Procedure SA-300, “Reporting

Material Events.” The review team noted that the Section was generally responsive in providing

requested followup information to the NMED contractor. The team noted that the Section was

using the NMED Agreement State data entry program to provide event information to the NMED

contractor. 

The Section received and was using the latest NMED software by one staff member who had

completed the new Microsoft Access 2000 NMED software training. The Section staff indicated

that the NMED training was very helpful and that the latest version of the NMED software is an

improvement over the older version, and is very user-friendly. The Section uses the NMED

software to track all radioactive material incidents.

In evaluating the effectiveness of Arkansas' actions responding to allegations, the review team

examined the Section’s questionnaire responses relative to this indicator. The casework for four

allegations reported directly to the State were reviewed. The Section evaluates each allegation

and determines the proper level of response. The review of the casework and the Section files

indicated that the Section took prompt and appropriate action in response to the concerns

raised. All of the allegations reviewed were adequately documented and appropriately closed,

with one remaining open due to an ongoing legal investigation. The review team also noted that

allegations were treated and documented separately from the licensing and incident files, similar

to the NRC system. There were no performance issues identified from the review of the

casework documentation. 

The review team noted that Arkansas law requires that all public documents be made available

for inspection and copying unless specifically exempted from disclosure under the State’s

Freedom of Information laws. The State makes every effort to protect an alleger’s identity, but it
Arkansas Final Report Page 12

cannot be guaranteed. During the initial telephone contact, the alleger is advised that their

anonymity cannot be guaranteed.

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

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. Arkansas’ Agreement does not authorize regulation of

sealed source and device evaluation and uranium recovery activities, so only the first and third

non-common performance indicators were applicable to this review.

4.1 Legislation and Program Elements Required for Compatibility

4.1.1 Legislation

Along with the Section’s response to the questionnaire, the staff provided the review team with

the opportunity to review copies of legislation that affects the radiation control program. 

Legislative authority to create the program and enter into an Agreement with the NRC was

granted in 1963. The Arkansas Department of Health is designated as the State's radiation

control agency. The currently effective statutory authority for the Department is contained in

“Arkansas Code of 1987 Annotated, Volume 20A, Title 20, Chapter 21.” The legislative statute

authorizing a Low-Level Waste Program is the “Arkansas Code of 1987 annotated, Volume 6A,

Title 8, Chapter 8.” The review team noted that the legislation, except for appropriation

legislation, had not changed since the previous IMPEP review. 

4.1.2 Program Elements Required for Compatibility

The State regulations for control of radiation are located in the Rules and Regulations for Control

of Sources of Ionizing Radiation of the Arkansas State Board of Health and apply to ionizing

radiation, whether emitted from radionuclides or devices. Arkansas requires a license for

possession and use of radioactive materials, including naturally occurring and

accelerator-produced radionuclides. A copy of the effective Arkansas regulations, including the

last amendments which became effective as of July 1, 2002, was given to the review team. 

The review team examined the procedures used in the State’s rule-making process and found

that the public and other interested parties are offered an opportunity to comment on proposed

regulation changes. Rule-making responsibility is assigned to the Radiation Control and

Emergency Management Team. It was noted that draft regulations were sent to the NRC for

review and comment, and when necessary, the NRC comments were incorporated. The

package of proposed regulations prepared by the Department, requires review by the Arkansas

Legislative Council and approval from the State Board of Health. The State has emergency rule

capability, if public health and safety are at risk. It was noted that the State’s rules and

regulations are not subject to “sunset” laws.

The review team evaluated the Department responses to the questionnaire, reviewed the status
Arkansas Final Report Page 13

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

compatibility policy and verified the adoption of regulations with data obtained from the State

Regulation Status Data Sheet. Since the previous IMPEP review, the Department adopted 17

regulation amendments in one rule package that became effective July 1, 2002.

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 Team Leader stated that

currently there are no Arkansas licensees authorized to distribute generally licensed devices. 

The Department stated that they could use legally binding requirements to enforce this rule if a

licensee was authorized to distribute generally licensed devices. The remaining portions of the

regulation are due by February 16, 2004.

The State has no overdue regulations required for compatibility. The Department will need to

address the following four regulations in upcoming rule makings or by adopting alternate legally

binding requirements:

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

that became effective January 8, 2001.

 “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct

Material,” 10 CFR Parts 30, 31 and 32 amendments (65 FR 79162) that became effective

February 16, 2001.

 “Revision of the Skin Dose Limit,” 10 CFR Part 20 amendment (67 FR 16298) that

became effective April 5, 2002.

 “Medical Use of Byproduct Material,” 10 CFR Parts 20, 32 and 35 (67 FR 20249)

amendments that became effective on October 24, 2002.

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

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

found satisfactory.

4.2 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 Regulatory 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 the Arkansas

Agreement State program 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 Arkansas. Accordingly, the

review team did not review this indicator.
Arkansas Final Report Page 14

5.0 SUMMARY

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

six performance indicators. Accordingly, the review team recommended and the MRB concurred

in finding the Arkansas Agreement State program adequate to protect public health and safety

and compatible with NRC's program. Based on the results of the current IMPEP review, the

review team recommended and the MRB concurred that the next full review should be in

approximately four years. 

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

as appropriate, by the State. 

1. The review team recommends that Department management review the current staffing

plan to achieve a more effective balance between licensing and inspection activities. 

(Section 3.3)

2. The review team recommends that Department management develop and implement an

action plan to reduce the licensing renewal backlog. (Section 3.4)

3. The review team recommends completion of revisions to update licensing guidance

documents and checklists (this items was identified in the 1998 IMPEP review).
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Arkansas Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Attachment November 8, 2002 Email from Jared Thompson

Arkansas Response to Draft IMPEP Report
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Patricia Larkins, STP Team Leader

Technical Staffing and Training

Response to Incidents and Allegations

Vivian Campbell, Region IV Status of Materials Inspection Program

Legislation and Program Elements Required

for Compatibility

Jamnes Cameron, RIII Technical Quality of Inspections

Inspection Accompaniments

Michael Stephens, Florida Technical Quality of Licensing Actions
APPENDIX B

ARKANSAS DEPARTMENT OF HEALTH

ORGANIZATION CHARTS

ML022890342