December 29, 2008 

Carol A. Couch, Ph.D., Director 

Georgia Department of Natural Resources 

Environmental Protection Division 

2 Martin Luther King, Jr. Drive, SE 

Suite 1152, East Tower 

Atlanta, Georgia 30334 

Dear Dr. Couch: 

On December 4, 2008, the Management Review Board (MRB) met to consider the proposed 

final Integrated Materials Performance Evaluation Program report on the Georgia Agreement 

State Program. The Georgia Agreement State Program was found satisfactory, but needs 

improvement for four performance indicators and satisfactory for all other indicators reviewed. 

Overall, the MRB found the Georgia Agreement State Program adequate to protect public 

health and safety, but needs improvement, and compatible with the U.S. Nuclear Regulatory 

Commission’s (NRC) program. The MRB directed NRC staff to initiate a period of monitoring of 

the Georgia Agreement State Program. Monitoring is an informal process that will allow NRC 

staff to monitor the effects of the state-wide hiring freeze, staff attrition, and weaknesses in the 

training and qualification programs and to take appropriate action, if necessary. 

Sincerely, 

 /RA/ 

Martin J. Virgilio 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Georgia Final IMPEP Report 

cc w/enclosure: See next page
cc w/encl.: Cynthia Sanders, Manager 

 Georgia Radioactive Materials Program 

 Jim Sommerville, State Liaison Officer 

 Georgia Program Coordination Branch 

 Barbara Hamrick, California 

 Organization of Agreement States 

 Liaison to the MRB 
December 29, 2008 

Carol A. Couch, Ph.D., Director 

Georgia Department of Natural Resources 

Environmental Protection Division 

2 Martin Luther King, Jr. Drive, SE 

Suite 1152, East Tower 

Atlanta, Georgia 30334 

Dear Dr. Couch: 

On December 4, 2008, the Management Review Board (MRB) met to consider the proposed 

final Integrated Materials Performance Evaluation Program report on the Georgia Agreement 

State Program. The Georgia Agreement State Program was found satisfactory, but needs 

improvement for four performance indicators and satisfactory for all other indicators reviewed. 

Overall, the MRB found the Georgia Agreement State Program adequate to protect public 

health and safety, but needs improvement, and compatible with the U.S. Nuclear Regulatory 

Commission’s (NRC) program. The MRB directed NRC staff to initiate a period of monitoring of 

the Georgia Agreement State Program. Monitoring is an informal process that will allow NRC 

staff to monitor the effects of the state-wide hiring freeze, staff attrition, and weaknesses in the 

training and qualification programs and to take appropriate action, if necessary. 

Sincerely, 

 

 /RA/ 

Martin J. Virgilio 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Georgia Final IMPEP Report 

cc w/enclosure: See next page 

Distribution: See next page. ML083400204 EDATS: FSME-2008-0058

OFFICE FSME/DMSSA FSME/DMSSA FSME/DMSSA Tech Editor 

NAME ATMcCraw:knm1 ADWhite RJLewis (TReis for) CPoland 

DATE 12/08/08 12/09/08 12/09/08 12/11/08 

OFFICE FSME DEDMRT 

NAME GPangburn MJVirgilio 

DATE 12/16/08 12/29/08 

OFFICIAL RECORD COPY
Letter to Carol A. Couch, Ph.D., from Martin J. Virgilio dated: December 29, 2008 

Distribution: 

DMSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Klein 

RErickson, RIV Commissioner Jaczko 

JKottan, RI/RSAO Commissioner Lyons 

BParker, RI Commissioner Svinicki 

KNull, RIII SECY 

Stephen James, OH 

Kenath Traegde, MA 

MOrendi, FSME/DMSSA 

KSchneider, FSME/DMSSA 

ARivera, OEDO 

CMiller, FSME 

KCyr, OGC 

BJones, OGC 

CCasto, RIV 

APowell, OCA (2 copies) 
Enclosure

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE GEORGIA AGREEMENT STATE PROGRAM 

September 22-26, 2008 

 

FINAL REPORT
Georgia Final Report Page 1 

1.0 INTRODUCTION 

This report presents the results of the review of the Georgia Agreement State Program. The 

review was conducted during the period of September 22-26, 2008, by a review team comprised 

of technical staff members from the U.S. Nuclear Regulatory Commission (NRC), the 

Commonwealth of Massachusetts, and the State of Ohio. 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 Final General 

Statement of Policy,” published in the Federal Register on October 16, 1997, and NRC 

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

dated February 26, 2004. Preliminary results of the review, which covered the period of 

August 27, 2004, to September 26, 2008, were discussed with Georgia managers on the last 

day of the review. 

The review team issued a draft of this report to Georgia for factual comment on 

October 27, 2008. The State responded via letter from Dr. Carol A. Couch, Director, 

Environmental Protection Division (the Division), on November 21, 2008. A copy of the State’s 

response is included as the attachment to this report. The Management Review Board (MRB) 

met on December 4, 2008, to consider the proposed final report. The MRB found the Georgia 

Agreement State Program adequate to protect public health and safety, but needs 

improvement, and compatible with NRC’s program. The MRB directed NRC staff to initiate a 

period of monitoring of the Georgia Agreement State Program. Monitoring is an informal 

process that allows NRC to maintain an increased level of communication with an Agreement 

State Program. As part of the monitoring process, NRC will conduct quarterly calls with the 

appropriate representatives from the Georgia Agreement State Program. 

The Georgia Agreement State Program is administered by the Georgia Department of Natural 

Resources (the Department) and is located within the Program Coordination Branch (the 

Branch) of the Division. The Branch is divided into six District Offices and five Atlanta-based 

programs. The Environmental Emergency Response and Radiation Control Program are 

Atlanta-based programs under the Branch and include the Radioactive Materials Program (the 

Program) and the Environmental Radiation Program that is responsible for environmental 

radiological surveillance and emergency response. Both are under the supervision of a single 

Program Manager. The Program administers the licensing and inspection duties, as well as the 

State’s sealed source and device (SS&D) registration program. Organizational charts for the 

Department, the Branch, and the Program are included in the report as Appendix B. 

At the time of the review, the Georgia Agreement State Program regulated 521 specific licenses 

authorizing the possession and use of byproduct, source, and certain special nuclear materials. 

The review focused on the radioactive materials program as it is carried out under Section 274b. 

(of the Atomic Energy Act, as amended) Agreement between NRC and the State of Georgia. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Program on June 13, 2008. The Program 

provided its initial response to the questionnaire on September 4, 2008, and provided 

supplemental information on September 9, 2008. A copy of the questionnaire response and 
Georgia Final Report Page 2 

supplemental information can be found in the NRC’s Agencywide Documents Access and 

Management System (ADAMS) using the Accession Numbers ML082520665 and 

ML082540271, respectively. 

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

Georgia’s response to the questionnaire; (2) review of applicable Georgia statutes and 

regulations; (3) analysis of quantitative information from the Program’s database; (4) technical 

review of selected regulatory actions; (5) field accompaniments of five inspectors; and (6) 

interviews with managers and staff. The review team evaluated the information gathered 

against the established criteria for each common and applicable non-common performance 

indicator and made a preliminary assessment of the Georgia Agreement State Program’s 

performance. 

Section 2.0 of this report covers the State’s actions in response to recommendations made 

during the previous review. Results of the current review of the common performance indicators 

are presented in Section 3.0. Section 4.0 details the results of the review of the applicable noncommon performance indicators, and Section 5.0 summarizes the review team's findings and 

recommendations. The review team’s recommendations are comments that relate directly to 

program performance by the State. A response is requested from the State to all 

recommendations in the final report. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous review, which covered the period of April 8, 2000, to August 26, 2004, the 

review team made nine recommendations in regard to program performance. The current 

status of each of the previous recommendations is as follows: 

1. The team recommends that the Program update its inspection procedures to eliminate 

extensions of license inspection due dates. (Section 3.2 of the 2004 IMPEP report) 

Current Status: Following the 2004 review, the Program modified its inspection 

procedures and eliminated the provision that allowed the extension of inspection 

intervals based on licensee performance. This recommendation is closed. 

2. The review team recommends that the Program ensure that Notices of Violation and 

licensee acknowledgment letters receive appropriate supervisory review and approval.

(Section 3.3 of the 2004 IMPEP report) 

Current Status: Following the 2004 review, the Program modified its procedures 

to require management review and approval of Notices of Violations and licensee 

acknowledgment letters. The review, approval, and disposition of these 

documents are tracked through an approval log. This recommendation is closed. 

3. The review team recommends that the Program develop and implement a process for 

conducting annual accompaniments of all radiation compliance inspectors by a 

supervisor. (Section 3.3 of the 2004 IMPEP report) 
Georgia Final Report Page 3 

Current Status: The Program developed a process to help ensure that all inspectors 

receive annual supervisory accompaniments after the 2004 review. The Program 

performed supervisory accompaniments with all staff until late 2006 when the Program 

began to experience significant turnover. In an effort to expedite the training of new 

staff, management made the decision to forego accompanying the more experienced 

staff in lieu of accompanying the newer staff members. The more experienced staff did 

not receive supervisor accompaniments from 2007 up to the time of the review. This 

recommendation remains open pending a period of demonstrated implementation of the 

process, including accompaniments of the experienced staff. 

4. The review team recommends that the Program revise and implement procedures to 

address the handling of cases where inspections reveal a systemic breakdown in a 

licensee’s radiation safety program and when a large number of health and safety 

violations are identified. (Section 3.3 of the 2004 IMPEP report) 

Current Status: Following the 2004 review, the Program established 

enforcement guidance that addressed the importance of licensee compliance 

with Program requirements. The procedures describe the significance and 

severity of violations and provide a framework to address noncompliance with 

Program requirements. This recommendation is closed. 

5. The review team recommends that the staff receive training on STP Procedure SA-300, 

identifying abnormal occurrences, and the schedule of reporting of significant events to 

the NRC Headquarters. (Section 3.5 of the 2004 IMPEP report) 

Current Status: The review team verified that the Program had provided training to the 

staff on formerly Office of State and Tribal Programs (STP), now Office of Federal and 

State Materials and Environmental Management Programs (FSME) Procedure SA-300, 

“Reporting Material Events.” This recommendation is closed. 

6. The team recommends that the Program qualify one additional reviewer in SS&D 

evaluations to provide backup for the principal reviewer. (Section 4.2 of the 2004 IMPEP 

report) 

Current Status: In January 2008, the Program hired an engineer as the backup to the 

primary SS&D reviewer; however, approximately 1 month later, the individual left the 

Program for another opportunity. Before the resulting vacancy could be filled, the 

Department imposed a hiring freeze. As a result, the Program Director must now 

perform all secondary SS&D reviews. This recommendation remains open. 

7. The review team recommends that the Program develop written qualification 

requirements for SS&D reviewers. (Section 4.2 of the 2004 IMPEP report) 

Current Status: In November 2006, the Program developed and implemented written 

procedures that identify the qualification and training requirements for SS&D reviewers. 

This recommendation is closed. 
Georgia Final Report Page 4 

8. The team recommends that the Program establish an objective method to address 

defects and incidents involving SS&D evaluations that includes the identification of 

generic issues, trend analysis, and the communication of findings with other regulatory 

agencies. (Section 4.2 of the 2004 IMPEP report) 

Current Status: Following the 2004 review, the Program established a written procedure 

for the investigation of SS&D defects and incidents. The Program also developed a 

license condition that requires manufacturers and distributors to report defects, 

deviations, or operations affecting the integrity of their products. This recommendation 

is closed. 

9. The review team recommends that the staff with primary review and concurrence 

responsibilities for SS&D evaluations attend a training course on root cause analysis 

such as the NRC course “Root Cause/Incident Investigation Workshop” (G-205). 

(Section 4.2 of the 2004 IMPEP report) 

Current Status: In November 2005, the primary SS&D reviewer completed NRC’s Root 

Cause Analysis Course (G-205). This recommendation is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

Five common performance indicators are used to review NRC Regional and Agreement State 

radioactive materials programs. The indicators are: (1) Technical Staffing and Training, (2) 

Status of Materials Inspection Program, (3) Technical Quality of Inspections, (4) Technical 

Quality of Licensing Actions, and (5) Technical Quality of Incident and Allegation Activities. 

3.1 Technical Staffing and Training

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

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

this indicator, the review team examined the Program’s response to the IMPEP questionnaire 

relative to this indicator, interviewed managers and staff, reviewed job descriptions and training 

records, and considered any possible workload backlogs. 

When fully staffed, the Program is comprised of a Program Manager, eight Environmental 

Radiation Specialists (Specialist), one Environmental Engineer (Engineer), one Technical 

Assistant, and one administrative staff member. The Engineer position is currently vacant due 

to a hiring freeze that was imposed earlier in the year. Specialists are assigned to one of six 

geographical regions within the State and are responsible for licensing, inspection, and incident 

response activities within that region. The Specialists share responsibility for licensees in the 

Atlanta metropolitan area. To be considered for a Specialist position, each candidate must 

possess, at a minimum, a Bachelor’s degree in a science field. 

The review team noted that six Specialists and one Engineer left the Program during the review 

period. Five were fully qualified and experienced staff, and two were new hires who accepted 

job offers outside the Program shortly after starting with the Program. The Program 

successfully filled the Specialist vacancies and, for a time, was almost fully staffed. The two 
Georgia Final Report Page 5 

senior Specialists have an average of 10 years experience with the Program; five of the staff 

members average 2 to 3 years experience; and the newest staff member was hired early in 

2008. 

The Program has a documented training program for Specialists that is similar to the training 

program established in NRC’s Inspection Manual Chapter (IMC) 1246, “Formal Qualification 

Programs in the Nuclear Material Safety and Safeguards Program Area.” The Program 

Manager indicated that she is committed to ensuring that newly hired Specialists receive the 

training required to qualify them for their positions. In addition to NRC training courses, the 

Program also sends Specialists to the 5-week health physics course held in Oak Ridge, 

Tennessee. 

While the Program has a documented training program, they do not have a documented 

qualification program. Specialists are qualified through a combination of education and 

experience, formal classroom training, in-house and on-the-job training, completion of specific 

tasks, and mentoring by more experienced staff. The Program has not developed a procedure 

designed to determine an individual’s competency in each program area prior to authorizing 

them to work independently. Specialists are notified verbally by the Program Manager when 

she determines they are qualified to perform certain types of license reviews and inspections. 

At the time of the review, five of the eight Specialists were considered fully or mostly qualified by 

the Program. As discussed further in Sections 3.3 and 3.4, the review team identified key areas 

where Specialists that were considered qualified could have benefitted from additional 

experience or on-the-job training prior to being approved to work independently. The 

development and implementation of a formal qualification program would address the technical 

quality issues that the review team identified, as documented in Sections 3.3 and 3.4. The 

review team recommends that the State develop, document, and implement a formal 

qualification program for licensing and inspection activities that includes written documentation 

and supervisor endorsement of competency in each program area. 

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

that Georgia’s performance with respect to the indicator, Technical Staffing and Training, was 

satisfactory, but needs improvement. 

3.2 Status of Materials Inspection Program

The review team focused on five factors while reviewing this indicator: inspection frequency, 

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

licensees, and performance of reciprocity inspections. The review team based its evaluation on 

the Program’s questionnaire response relative to this indicator, data gathered from the 

Program’s database, examination of completed inspection casework, and interviews with 

managers and staff. 

The review team verified that the Program’s inspection priorities, with one exception, are 

consistent with the inspection priorities prescribed by NRC’s IMC 2800, “Materials Inspection 

Program.” The review team noted that inspection reports for all gamma stereotactic 

radiosurgery units (gamma knife) indicated the next inspection was due in three years from the 

previous inspection, which is inconsistent with the Priority 2 designation identified in IMC 2800. 

Staff stated that that the Program categorized the gamma knife as a teletherapy device, which is 
Georgia Final Report Page 6 

a specific license type identified in IMC 2800 having a 3-year inspection frequency. The 

Program committed to changing the priority code for gamma knife devices to match the 2-year 

inspection frequency found in IMC 2800. 

The review team determined that, during the review period, the Program performed 229 

Priority 1, 2, and 3 inspections. The Program completed 27 of these inspections overdue with 

four being overdue at the time of the review. The Program also completed 76 initial inspections, 

of which 13 were conducted overdue (greater than 12 months after license issuance). One 

initial inspection was overdue at the time of the review. The review team determined that the 

Program performed approximately 15 percent of the total Priority 1, 2, and 3, and initial 

inspections overdue during the review period. Discussions with Program staff revealed that 

most of the overdue inspections were due to staff turnover during the review period. The 

Program is now better staffed and the Program has a plan in place to catch up on overdue 

inspections. To maintain this level of performance, the Program will need to remain nearly fully 

staffed and address any future vacancies in a timely manner. 

The review team determined that the Program adequately planned for the initial set of Increased 

Controls inspections. The review team evaluated the Program’s prioritization methodology and 

found it acceptable. The Program identified 25 licensees that were subject to the Increased 

Controls and performed all of the initial inspections in a timely manner. At the time of the 

review, the Program had not performed any subsequent Increased Controls inspections of 

affected licensees. This issue is further discussed in Section 3.3. 

The review team evaluated the Program’s timeliness of issuing inspection reports. The 

Program has an effective and efficient process that helps ensure that inspection findings are 

communicated to licensees in a timely manner. Inspection findings are normally communicated 

to the licensee by issuing a Compliance Letter, a Notice of Violation, or a Consent Order. For 

minor and significant violations, the Program issues a Notice of Violation. Consent Orders are 

issued for escalated enforcement actions. Based on the 32 inspection files reviewed, the review 

team determined that the appropriate inspection correspondence was generally issued within 30 

days of the inspection. 

During the review period the Program granted approximately 180 reciprocity permits. Most of 

the licensees were candidates for inspection based upon the criteria in IMC 1220, “Processing 

of NRC Form 241 and Inspection of Agreement State Licensees Operating under 10 CFR 

150.20.” The review team determined that the Program inspected 20 percent of candidate 

licensees in only one of the four years covered by the review period; and, in each of the 

remaining years the Program inspected between 11 and 17 percent of candidate licensees. 

The review team noted staff turnover and the focus on completing routine inspections as factors 

why the Program did not inspect 20 percent of candidate reciprocity licensees each year. Being 

nearly fully staffed and almost caught up on the routine inspection backlog, the Program should 

be able to resume inspecting at least 20 percent of candidate reciprocity licensees in the future. 

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

that Georgia’s performance with respect to the indicator, Status of Materials Inspection 

Program, was satisfactory, but needs improvement. 
Georgia Final Report Page 7 

3.3 Technical Quality of Inspections

The review team evaluated inspection reports, enforcement documentation, inspection field 

notes, and interviewed the responsible inspectors for 32 radioactive materials inspections 

conducted during the review period. The casework examined included a cross-section of 

inspections conducted by three former and seven current inspectors and covered a wide variety 

of inspection types that included medical, academic, and research and development broadscope licensees; industrial radiography; self-shielded irradiator; medical; nuclear pharmacy; and 

reciprocity licensees. Appendix C lists the inspection casework files reviewed and includes 

case-specific comments. 

The review team found that the Program’s inspection procedures are generally consistent with 

the inspection guidance found in IMC 2800. Specialists are responsible for conducting 

inspections of all the various types of licensees in their assigned region. Specialists use a 

specific inspection form for each license type to help ensure that all relevant aspects of a 

particular program are reviewed. Inspection documentation parallels the inspection form, 

limiting the amount of narrative documentation contained in routine reports; however, reports 

involving violations generally have additional documentation to support the enforcement action. 

The review team noted that inspection reports were generally consistent between Specialists 

and addressed unresolved safety issues from previous inspections. The reports also noted 

discussions held with licensees during exit interviews. 

All routine inspection documentation is entered into the Program’s electronic filing system. 

Upon completion of the inspection, Specialists complete a “Change Form” identifying the 

inspection date, next due date, and inspection results. This form is then submitted to an 

administrative staff member who updates the Program’s database with the new information. 

The Program does not require management review of inspection documentation where no 

findings were identified, including both routine and Increased Controls inspections. Inspections 

identifying violations are sent to the licensees from the office following management review and 

approval. Based on the evaluation of casework, the review team determined that the 

Specialists reviewed the applicable components of the licensees’ radiation safety programs. 

As noted in Section 3.2, the Program successfully completed the initial round of Increased 

Controls inspections. In one instance the review team identified an Increased Controls 

inspection where violations were identified and a Notice of Violation was issued to the licensee, 

but the Program did not follow up with the licensee to ensure that the violations had been 

corrected. The review team further found that the Program’s inspection procedures and 

enforcement guidance did not include requirements for followup of Increased Controls 

inspections to ensure that previously identified violations had been corrected. The review team 

recommends that the State update their inspection procedures and enforcement guidance to 

include the requirements for timely followup of Increased Controls violations. 

The review team determined that documents involving Increased Controls inspections were 

protected, segregated from the electronic file storage system, separated from license files, and 

maintained in a locked file cabinet with limited access. The documents observed were 

sufficiently marked as sensitive information to be withheld from public disclosure. 
Georgia Final Report Page 8 

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

inspection efforts. Calibrated survey instruments, such as Geiger-Mueller detectors, scintillation 

detectors, micro-R meters and ion chambers, were available on site for the staff’s use. Survey 

instruments and dosimeters are calibrated by licensed service providers and through a contract 

with the South Carolina Department of Health and Environmental Control. Laboratory sample 

analysis is provided through the mobile laboratory maintained by the Environmental Radiation 

Program. If needed, additional laboratory capabilities are available from licensed academic and 

research facilities within the State. 

The review team noted that, over the review period, annual management accompaniments were 

not always performed on a routine basis. All Specialists were accompanied in 2005 and again 

in 2006. A significant number of staff left the Program in subsequent years and management 

made the decision to concentrate efforts on training new employees rather than accompanying 

the two senior staff. These two individuals were not accompanied by management from 2007 

up to the time of the review. Program management intends to continue accompaniments 

through the end of Calendar Year 2008 and plans to include these two individuals. As noted in 

Section 2.0, the recommendation from the 2004 review regarding supervisory accompaniments 

remains open. 

A member of the review team accompanied five of the Program’s Specialists during the week of 

August 4, 2008. The Specialists conducted inspections at two hospital nuclear medicine 

departments, one using therapeutic radioisotopes and one using only diagnostic radioisotopes; 

a nuclear pharmacy; a cancer center using a high dose-rate remote afterloading device (HDR); 

and a custom source manufacturer. Appendix C lists the inspector accompaniments. The 

Specialists were generally prepared for the inspections, having reviewed the previous inspection 

reports, and were thorough in their administrative audits of the licensees’ radiation safety 

programs. They conducted interviews with licensee personnel and performed confirmatory 

measurements. The Specialists held entrance and exit meetings with the appropriate level of 

licensee management. 

The review team determined that, while the inspections observed during the accompaniments 

were generally adequate to assess basic radiological health, safety, and security at the licensed 

facilities, the Program’s newer inspectors would have benefitted from additional training prior to 

being authorized to work independently. The review team noted that the newer inspectors 

rarely observed licensed activities in progress and, instead, focused almost exclusively on 

documentation. One Specialist commented during his inspection that he did not understand the 

meaning of some of the documentation he was reviewing. Another Specialist inspecting an 

HDR unit stated he believed he was authorized to inspect HDR units independently before he 

was comfortably ready to do so. 

The review team interviewed the Specialists during accompaniments and noted that some 

expressed concerns that they may have been released to work independently before they were 

fully ready. Specialists added that there were times when they performed inspections without 

the added benefit of having attended a training class for the type of inspection being performed, 

primarily because they were unable to get into the classes. Additionally, some of the staff 

stated that because they did not have backgrounds in health physics, they did not always fully 
Georgia Final Report Page 9 

comprehend all the complexities and nuances associated with some of the program areas they 

were responsible for licensing and inspecting. They indicated that while they have access to 

more experienced staff while in the office, they don’t always have that luxury when in the field. 

When notified of these observations, the Program Manager indicated that as the primary trainer 

for the Program with a large number of staff to train, there are certain restrictions on her time. 

She acknowledged that with her own administrative workload, little help to train the staff, and a 

pressing need to keep up with the work, she is often forced to shorten the training period so that 

work can be completed timely. The Program Manager stated that in an attempt to alleviate this 

problem, she had attempted to reorganize the current staff to assist with training, but was 

unsuccessful. She added that she is always available to help with questions and concerns, and 

that any Specialist can receive additional training, if requested. 

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

that Georgia’s performance with respect to the indicator, Technical Quality of Inspections, was 

satisfactory, but needs improvement. 

3.4 Technical Quality of Licensing Actions

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

31 specific licenses. Licensing actions were reviewed for completeness, consistency, proper 

possession authorizations, qualifications of authorized users, adequacy of facilities and 

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

emergency procedures, appropriateness of license conditions, and overall technical quality. 

The casework was also reviewed for timeliness, use of appropriate deficiency letters and cover 

letters, reference to appropriate regulations, supporting documentation, consideration of 

enforcement history, pre-licensing visits, supervisory review, and proper signatures. 

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

during the review period. Licensing actions selected for evaluation included 1 new license, 

6 renewals, 18 amendments, and 6 license terminations. Files reviewed included a crosssection of license types, including: academic, medical diagnostic and therapy, brachytherapy, 

industrial radiography, and fixed and portable gauges. The casework sample represented work 

from each of the Specialists. A listing of the licensing casework reviewed, with case-specific 

comments, can be found in Appendix D. 

The administrative staff member assigns licensing actions directly to the Specialist who is 

responsible for the region from which the licensing request originated. Tracking numbers are 

assigned and logged into a computer tracking system. Due to an unusual level of staff turnover 

since the 2004 review, several new Specialists are independently responsible for a geographical 

region. Periodically, these newer Specialists receive licensing requests in program areas where 

they have little or no experience in reviewing, with little formalized on-the-job training. Some 

Specialists expressed concerns that they felt unqualified to conduct these reviews. 

Currently, on-the-job training in the licensing process is informal and lacks an established set of 

qualification criteria. Using State of Georgia licensing guidance that parallels NRC’s NUREG1556 series, Specialists independently review all casework assigned to them, including 

casework in program areas where they have little experience. The Program Manager works 
Georgia Final Report Page 10 

with the Specialist and provides training during the review of the licensing action. The Specialist 

then submits the casework to the Program Manager for final review and signature. The 

Program Manager provides additional training to the Specialist, as needed, prior to issuance of 

the license. The Program Manager provides a verbal clearance when a reviewer can 

independently sign licensing actions. 

Overall, the review team concluded that licensing actions were adequate to protect the public 

health and safety; however, based on the evaluation of casework, the review team noted 

repeated examples of issues with thoroughness, completeness, consistency, clarity, technical 

quality, and adherence to existing licensing guidance. Specific examples included license 

terminations that were completed without receiving required documentation from the licensee 

verifying the appropriate disposal of radioactive sources or verifying that sealed sources were 

not leaking prior to transfer to another licensee; license amendments that were issued releasing 

locations of use where both long- and short-lived radionuclides were used without receiving 

close-out surveys that demonstrated the absence of residual contamination; and an industrial 

radiography license that did not authorize temporary job sites as requested in the licensee’s 

application. The review team noted issues involving possession authorizations, and the 

application of the Increased Controls and fingerprinting requirements. Followup interviews with 

Specialists also revealed inconsistencies among reviewers in their application of licensing 

guidance that is used to perform licensing reviews. 

The review team evaluated the Program’s financial assurance program. The review team noted 

that all of the instruments were originally executed documents with original signatures and were 

stored in a locked safe. The review team determined that the Program’s financial assurance 

program was adequate and that the instruments were properly secured from unauthorized 

access. 

The review team evaluated the Program’s industrial radiographer certification process. The 

Program offers a proctored examination to applicants several times each year in a variety of 

locations throughout the State. Exams are contracted through the State of Texas, which grades 

the examinations and provides results to the Program. The review team determined the 

Program’s overall implementation of this process is adequate. 

The review team reviewed the State’s program for the implementation of pre-licensing guidance. 

At the time of the review, the State had incorporated the essential objectives of the original prelicensing guidance that requires site visits and background checks of applicants requesting risksignificant quantities of radioactive materials. The State had not yet incorporated the essential 

objectives of the revised pre-licensing guidance that added site visits for any unknown applicant. 

 As detailed in FSME Letter RCPD-08-020, dated September 22, 2008, States have 6 months 

from the date of the letter to incorporate the essential objectives of the revised pre-licensing 

guidance into their respective licensing program. 

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

that Georgia’s performance with respect the indicator, Technical Quality of Licensing Actions, 

was satisfactory, but needs improvement. 
Georgia Final Report Page 11 

3.5 Technical Quality of Incident and Allegation Activities

In evaluating the effectiveness of the Program’s actions in responding to incidents and 

allegations, the review team examined the response to the questionnaire relative to this 

indicator, evaluated selected incidents reported for Georgia in the Nuclear Material Events 

Database (NMED) against those contained in the Program’s files, and evaluated the casework 

for 17 radioactive materials incidents. A listing of the casework examined can be found in 

Appendix E. The review team also evaluated the Program’s response to three allegations 

involving radioactive materials reported directly to the State during the review period. 

When notified of an incident or an allegation, management and staff discuss the event and 

determine the level of initial response based on the health and safety risk associated with the 

incident. The Program maintains a database for tracking the status of all incidents and 

allegations. The actions taken in response to an incident are documented and filed, and if the 

incident meets the reporting thresholds, as established in FSME Procedure SA-300, the 

Program notifies NRC. If an investigation is complex and extends over a period of time, NMED 

is appropriately updated. The Program does not use the NMED data entry software program to 

place events into NMED, but instead uses an internal standardized form to document the 

response to incidents and allegations, and e-mails this form to the NMED contractor. Since the 

2004 review, the review team identified a total of 67 incidents for Georgia in NMED, of which 28 

required reporting to NRC. The review team evaluated the Program’s timeliness in reporting 

incidents to the NRC Headquarters Operations Center, and determined that, following 

notification from the licensee, the Program was generally timely in reporting incidents. 

The incidents selected for review included medical events; lost, stolen, or abandoned 

radioactive material; contamination events; damaged equipment, and transportation incidents. 

The review team determined that the Program’s responses to incidents were thorough, 

complete, and comprehensive. Initial responses were prompt and well coordinated, and the 

level of effort was commensurate with the health and safety significance. The Program 

immediately dispatched inspectors to a site when the possibility of an immediate threat to public 

health and safety existed. When no immediate threat was present and the Program determined 

that the licensee had qualified, competent individuals investigating the incident, the Program 

generally responded telephonically with an on-site followup at a later date. The review team 

noted that at the conclusion of investigations, Specialists documented findings and made 

appropriate notifications. 

In evaluating the effectiveness of the Program’s response to allegations, the review team 

evaluated the casework for three allegations. The review team concluded that the Program 

consistently took prompt and appropriate action in response to concerns raised. The review 

team noted that the Program thoroughly documented the investigations and retained all 

necessary documentation to appropriately close the allegations. The Program notified the 

allegers of the outcomes of the investigations when the allegers’ identities were known. The 

review team determined that the Program adequately protected the identity of allegers. 

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

that Georgia’s performance with respect to the indicator, Technical Quality of Incident and 

Allegation Activities, was satisfactory. 
Georgia Final Report Page 12 

4.0 NON-COMMON PERFORMANCE INDICATORS 

Four non-common performance indicators are used to review Agreement State programs: 

(1) Compatibility Requirements, (2) Sealed Source and Device Evaluation Program, (3) LowLevel Radioactive Waste Disposal Program, and (4) Uranium Recovery Program. Georgia’s 

Agreement does not relinquish the authority for regulation of uranium recovery activities, so only 

the first three non-common performance indicators were applicable to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Georgia became an Agreement State in December 1969. Legislative authority to create an 

agency and enter into an Agreement with NRC was established in the Georgia Radiation 

Control Act (O.C.G.A. Title 31 Chapter 13, et seq., as amended). The Department is 

designated as the State’s radiation control agency. The review team was informed that no new 

legislation was passed since the last review that would affect the Program or its authority. 

4.1.2 Program Elements Required for Compatibility

The Georgia Regulations for Control of Radiation, found in Chapter 391-3-17, Rules and 

Regulations for Radioactive Materials, apply to all ionizing radiation emitted from radionuclides. 

Georgia requires a license for possession and use of all radioactive material. 

The review team examined the procedures used in the State’s regulatory process and found 

that the process takes 9-12 months for rule promulgation. The public and other interested 

parties are offered an opportunity to comment on proposed rules during a 30-day comment 

period and during a public meeting. NRC is provided with drafts of the proposed rules for 

review and comment before the public comment period. Proposed rules are submitted to the 

Board of Natural Resources (the Board) for review and approval. The Board’s calendar for rule 

adoption is tentatively set in January for that calendar year. All programs in the Department 

wishing to promulgate rules must get on the Board’s calendar. After the proposed rules are 

approved by the Board, they are filed with the Secretary of State. The rules become final 20 

days after filing with the Secretary of State. The Department’s Rules and Regulations are not 

subject to “sunset” laws. 

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

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

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

Regulations Status sheet that FSME maintains. 

Since the previous review, the Program adopted nine amendments combined into one rule 

package that was approved by the Board on September 24, 2008. The package was then 

approved by the Secretary of State’s Office with an effective date of November 6, 2008. 

Additionally, the State adopted the Increased Controls requirements on November 10, 2005, 

and the fingerprinting requirements on June 2, 2008, both through the issuance of license 

conditions. 
Georgia Final Report Page 13 

The review team recognized the amount of progress since the last review to address the 

number of overdue regulations. With the adoption of the previously mentioned rulemaking 

package, the State is up to date with regulation development. The Program is committed to 

ensuring that the State maintains compatibility with the NRC by addressing upcoming regulation 

changes. 

Current NRC policy requires that Agreement States adopt certain equivalent regulations or 

legally binding requirements no later than 3 years after they become effective. The review team 

determined that the Program was up to date on all required NRC amendments as of the 

adoption of the State’s latest rulemaking package. 

The Program will need to address the following amendments through rulemakings or by 

adopting alternative legally binding requirements: 

● “Requirements for Expanded Definition of Byproduct Material,” 10 CFR Parts 20, 30, 31, 

32, 33, 35, 61, and 150 amendment (72 FR 55864), that is due for Agreement State 

adoption by November 30, 2010. 

● “Exemptions from Licensing, General Licenses, and Distribution of Byproduct Material: 

Licensing and Reporting Requirements,” 10 CFR Parts 30, 31, 32 and 150 amendment 

(72 FR 58473), that is due for Agreement State adoption by December 17, 2010. 

● “Occupational Dose Records, Labeling Containers, and Total Effective Dose Equivalent,” 

10 CFR Parts 19 and 20 amendment (72 FR 68043), that is due for Agreement State 

adoption by February 15, 2011. 

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

that Georgia’s performance with respect to the indicator, Compatibility Requirements, was 

satisfactory. 

4.2 Sealed Source and Device Evaluation Program

In reviewing this indicator, the review team used three subelements to evaluate the Program’s 

SS&D Evaluation Program. These subelements were: (1) Technical Staffing and Training; (2) 

Technical Quality of the Product Evaluation Program; and (3) Evaluation of Defects and 

Incidents Regarding SS&Ds. 

In assessing the Program's SS&D evaluation activities, the review team examined information 

contained in the Program’s response to the IMPEP questionnaire for this indicator. The review 

team evaluated 8 of 27 SS&D actions processed during the review period. The Program 

completed seven new SS&D evaluations and issued 20 amendments and corrections to existing 

registrations since the last review. The review team noted the staff's use of guidance 

documents and procedures, interviewed staff members involved in SS&D evaluations, and 

verified the use of regulations and inspections to enforce commitments made in the 

applications. 
Georgia Final Report Page 14 

4.2.1 Technical Staffing and Training

The Program currently has two individuals who are qualified to perform safety evaluations of 

SS&D applications, one staff Specialist and the Program Manager. The Program previously 

had more trained Specialists capable of performing SS&D reviews; however, due to the 

significant staff turnover since the last review, the Program lost those other Specialists. In 

response to those losses, the Program successfully hired an Engineer in January 2008; 

however, approximately 1 month later, the Engineer left the Program. As noted in Section 2.0, 

the recommendation from the 2004 regarding training a backup SS&D reviewer remains open. 

The review team interviewed staff members involved in the reviews and determined that they 

were familiar with the procedures used to evaluate sources and devices. They also had access 

to applicable reference documents. 

4.2.2 Technical Quality of the Product Evaluation Program

The review team examined eight certificates and supporting documentation (five new 

registrations and three amendments) for five vendors. Each of the actions was initially reviewed 

by a fully qualified Specialist and received secondary reviews by one of three other qualified 

Specialists. A listing of the SS&D certificates evaluated, with case-specific comments, can be 

found in Appendix F. 

Analysis of the casework and interviews with staff members confirmed that the Program follows 

the recommended guidance from NRC’s SS&D Workshop and NUREG-1556, Volume 3, 

Revision 1, “Consolidated Guidance About Materials Licenses – Applications for Sealed Source 

and Device Evaluation and Registration,” with one exception as noted below. The review team 

determined that the depth and scope of the SS&D evaluations during the review period were 

adequate and addressed both the physical integrity of the product and the health and safety of 

the users, the public, and the environment. The registrations clearly summarized the product 

evaluation and provided Specialists with adequate information to license the possession and 

use of the product. 

The review team identified one amendment adding a new sealed source to a device certificate 

that was incorporated as a corrected page. This practice is not consistent with the guidance in 

NUREG-1556, Volume 3. The addition of a new sealed source must be evaluated for 

engineering design and safety prior to being added to the certificate. The primary Specialist 

noted that the new source had the same dimensions as the other registered source and that 

radiation profiles had been provided and approved; however, each affected page must be 

amended to add a new registered source. 

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

The review team noted that following the 2004 review, the Program added a license condition to 

the licenses of manufacturers requiring them to report defects affecting the integrity of their 

products. The Program also developed written procedures for the investigation of defects and 

incidents involving SS&D devices. The procedure requires the primary SS&D reviewer to query 

NMED on a monthly basis to identify generic issues, analyze trends, and to communicate 

findings with other regulatory agencies. The review team noted that these queries were 
Georgia Final Report Page 15 

conducted twice in April 2007 and once in September 2008, which is not in accordance with the 

new procedures. The review team discussed with the Program the possibility of amending the 

NMED query procedure so that reviews are performed at a less frequent interval. The review 

team noted that the Program is aware of issues affecting the SS&D program via routine 

inspections and the Part 21 equivalent license condition. 

The review team noted the Program’s responsiveness to customer complaints involving devices 

manufactured under Georgia licenses by performing quality assurance inspections on two 

manufacturers since the 2004 review. These inspections were directly related to problems with 

devices registered by Georgia and demonstrated the Program’s sensitivity to complaints. 

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

that Georgia’s performance with respect to the indicator, Sealed Source and Device Evaluation 

Program, was satisfactory. 

4.3 Low-Level Radioactive Waste Disposal Program

In 1981, 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 low-level radioactive waste (LLRW) as 

a separate category. Those States with Agreements with NRC prior to 1981 were determined to 

have continued LLRW disposal authority without the need of an amendment. Although Georgia 

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

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, it is expected to put in place a regulatory program that will 

meet the criteria for an adequate and compatible LLRW disposal program. There are no plans 

for a commercial LLRW disposal facility in Georgia. Accordingly, the review team did not 

evaluate this indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, Georgia’s performance was found satisfactory, but needs 

improvement, for four performance indicators: Technical Staffing and Training, Status of 

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

Licensing Actions. Georgia’s performance was found satisfactory for the three other 

performance indicators reviewed. The review team made two recommendations regarding the 

performance of the Georgia Agreement State Program and left two recommendations from the 

2004 review open. Accordingly, the review team recommended, and the MRB agreed, that the 

Georgia Agreement State Program was adequate to protect public health and safety, but needs 

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

the review team recommended, and the MRB agreed, that NRC initiate a period of monitoring of 

the Georgia Agreement State Program. The review team recommended, and the MRB agreed, 

that a periodic meeting will take place in approximately 1 year and that next full review of the 

Georgia Agreement State Program will take place in approximately 4 years. 
Georgia Final Report Page 16 

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

implementation, as appropriate, by the State. 

1. The review team recommends that the State develop, document, and implement a 

formal qualification program for licensing and inspection activities that includes written 

documentation and supervisor endorsement of competency in each program area. 

(Section 3.1) 

2. The review team recommends that the State update their inspection procedures and 

enforcement guidance to include the requirements for timely followup of Increased 

Controls violations. (Section 3.3) 

3. The review team recommends that the Program develop and implement a process for 

conducting annual accompaniments of all radiation compliance inspectors by a 

supervisor. (Section 3.3 of the 2004 IMPEP report) 

4. The team recommends that the Program qualify one additional reviewer in SS&D 

evaluations to provide backup for the principal reviewer. (Section 4.2 of the 2004 IMPEP 

report) 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Georgia Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source & Device Casework Reviews 

Attachment November 21, 2008, Letter from Carol A. Couch 

 Georgia’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Randy Erickson, Region IV Team Leader 

 Compatibility Requirements 

 Inspector Accompaniments 

James Kottan, Region I Technical Staffing and Training 

 Technical Quality of Incident and Allegation 

 Activities 

Bryan Parker, Region I Status of the Materials Inspection Program 

Kevin Null, Region III Technical Quality of Licensing Actions 

Stephen James, Ohio Technical Quality of Inspections 

Kenath Traegde, Massachusetts Sealed Source and Device Evaluation Program 
APPENDIX B 

GEORGIA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML082520656 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Hurst Boiler and Welding License No.: GA 918-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/23/08 Inspector: KR 

File No.: 2 

Licensee: Hurst Boiler and Welding License No.: GA 918-1 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 4/4/07 Inspector: ED 

File No.: 3 

Licensee: JANX Integrity Group License No.: GA 1369-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 5/23/08 Inspectors: EJ, JM 

File No.: 4 

Licensee: JANX Integrity Group License No.: GA 1369-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 1/31/08 Inspectors: EJ, JM 

File No.: 5 

Licensee: JANX Integrity Group License No.: GA 1369-1 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 9/7/06 Inspector: LP 

File No.: 6 

Licensee: Acuren Inspection License No.: GA 1115-1 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 3/19/08 Inspector: JF 

File No.: 7 

Licensee: Acuren Inspection License No.: GA 1115-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 11/15/06 Inspector: ED 

File No.: 8 

Licensee: Acuren Inspection License No.: GA 1115-1 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 11/15/06 Inspector: ED 
Georgia Final Report Page C.2 

Inspection Casework Reviews 

File No.: 9 

Licensee: Sowega Testing Services License No.: GA 923-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 8/15/08 Inspector: KR 

File No.: 10 

Licensee: Sowega Testing Services License No.: GA 923-1 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 4/12/07 Inspector: LP 

File No.: 11 

Licensee: Sowega Testing Services License No.: GA 923-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 2/14/07 Inspector: LP 

File No.: 12 

Licensee: Theragenics License No.: GA 881-5 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/27/08 Inspectors: EJ, KR, CS 

File No.: 13 

Licensee: Theragenics License No.: GA 881-5 

Inspection Type: Special, Announced Priority: 2 

Inspection Date: 4/23/08 Inspector: EJ 

Comment: 

 Inspection report sent 4 months after inspection date. 

File No.: 14 

Licensee: Theragenics License No.: GA 881-5 

Inspection Type: Initial, Announced Priority: 2 

Inspection Date: 11/15/05 Inspector: EJ 

File No.: 15 

Licensee: Hopewell Design License No.: GA 1434-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/15/06 Inspector: EJ 

Comment: 

 Inspection report sent 4 months after inspection date. 

File No.: 16 

Licensee: Atlanta Oncology Associates License No.: GA 1178-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 4/14/08 Inspector: TC 
Georgia Final Report Page C.3 

Inspection Casework Reviews 

File No.: 17 

Licensee: Cardinal Health License No.: GA 463-3MD 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 3/26/08 Inspectors: JM, IB 

File No.: 18 

Licensee: The Medical Center License No.: GA 392-2 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/7/08 Inspector: TC 

File No.: 19 

Licensee: Newton Health System License No.: GA 632-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/4/08 Inspector: KS 

File No.: 20 

Licensee: St. Joseph’s Hospital License No.: GA 296-4 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 7/20/06 Inspectors: LS, LP, KS 

File No.: 21 

Licensee: Analytics, Inc. License No.: GA 742-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/8/08 Inspector: EJ 

File No.: 22 

Licensee: Analytics, Inc. License No.: GA 742-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/20/05 Inspector: EJ 

File No.: 23 

Licensee: GE Healthcare License No.: GA 1166-1MD 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/6/08 Inspector: IB 

File No.: 24 

Licensee: GE Healthcare License No.: GA 1166-1MD 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 11/27/06 Inspector: IB 

File No.: 25 

Licensee: Columbus Radiation Oncology License No.: GA 1256-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 1/22/08 Inspector: TC 
Georgia Final Report Page C.4 

Inspection Casework Reviews 

File No.: 26 

Licensee: Medical College of Georgia License No.: GA 1110-1 

Inspection Type: Special, Announced Priority: 2 

Inspection Dates: 6/12-16/06 Inspector: ED 

File No.: 27 

Licensee: Landis International License No.: GA 941-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 1/14/08 Inspector: KR 

File No.: 28 

Licensee: Emory University License No.: GA 153-1 

Inspection Type: Special, Announced Priority: 3 

Inspection Date: 2/22/07 Inspector: LS 

File No.: 29 

Licensee: Emory University License No.: GA 153-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Dates: 7/10-13/06 Inspector: LS 

File No.: 30 

Licensee: St. Joseph Hospital License No.: GA 359-1 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 8/5/08 Inspector: JF 

File No.: 31 

Licensee: Rome Imaging Center License No.: GA 1413-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 8/28/08 Inspector: JM 

File No.: 32 

Licensee: Nucletron License No.: Reciprocity 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 3/19/08 Inspector: IB 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Newton Health System License No.: GA-632-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/4/08 Inspector: KS 
Georgia Final Report Page C.5 

Inspection Casework Reviews 

Accompaniment No.: 2 

Licensee: St. Joseph Hospital License No.: GA-359-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/5/08 Inspector: JF 

Accompaniment No.: 3 

Licensee: GE Healthcare License No.: GA-1166359-1MD 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/6/08 Inspector: IB 

Accompaniment No.: 4 

Licensee: The Medical Center License No.: GA-239-2 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/7/08 Inspector: TC 

Accompaniment No.: 5 

Licensee: Analytics, Inc. License No.: GA-742-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/8/08 Inspector: EJ 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Allmond Lab Services License No.: GA 1340-1 

Type of Action: Termination Amendment No.: 03 

Date Issued: 6/2/06 License Reviewer: KR 

Comment: 

License was terminated without following up on licensee’s statement that two licensed 

devices had been stolen. 

File No.: 2 

Licensee: Ram K. Puri, M.D License No.: GA 1533-1 

Type of Action: Termination Amendment No.: 01 

Date Issued: 10/18/06 License Reviewer: LP 

File No.: 3 

Licensee: Savannah State University License No.: GA 1102-1 

Type of Action: Amendment Amendment No.: 03 

Date Issued: 4/1/08 License Reviewer: JF 

Comment: 

 Location of use was removed without a close-out survey. 

File No.: 4 

Licensee: PET Imaging Center of Savannah License No.: GA 1122-1 

Type of Action: Amendment Amendment No.: 02 

Date Issued: 7/16/08 License Reviewer: JF 

Comment: 

 Location of use was removed without a close-out survey. 

File No.: 5 

Licensee: Evans Memorial Hospital License No.: GA 999-1 

Type of Action: Renewal Amendment No.: 04 

Date Issued: 9/20/07 License Reviewer: JF 

File No.: 6 

Licensee: Piedmont Hospital. License No.: GA 292-1 

Type of Action: Amendment Amendment No.: 54 

Date Issued: 9/2/08 License Reviewer: TC 
Georgia Final Report Page D.2 

License Casework Reviews 

File No.: 7 

Licensee: The Medical Center License No.: GA 239-2 

Type of Action: Amendment Amendment No.: 26 

Date Issued: 4/9/08 License Reviewer: TC 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 8 

Licensee: St. Joseph’s Hospital License No.: GA 296-4 

Type of Action: Amendment Amendment No.: 65 

Date Issued: 7/8/08 License Reviewer: KS 

File No.: 9 

Licensee: Hurst Boiler and Welding, Inc License No.: GA 918-1 

Type of Action: Amendment Amendment No.: 17 

Date Issued: 6/2/08 License Reviewer: KR 

Comment: 

License did not authorize temporary job sites as the licensee had requested in its 

application for license renewal. 

File No.: 10 

Licensee: Northside Hospital License No.: GA 39-1 

Type of Action: Amendment Amendment No.: 46 

Date Issued: 6/2/08 License Reviewer: CS 

File No.: 11 

Licensee: Northeast Georgia Medical Center License No.: GA 199-1 

Type of Action: Amendment Amendment No.: 36 

Date Issued: 3/21/08 License Reviewer: IB 

File No.: 12 

Licensee: Phoebe Putney Memorial Hospital License No.: GA 338-1 

Type of Action: Amendment Amendment No.: 52 

Date Issued: 4/30/08 License Reviewer: KR 

File No.: 13 

Licensee: Grady Memorial Hospital Corp. License No.: GA 258-2 

Type of Action: Renewal Amendment No.: 11 

Date Issued: 8/29/08 License Reviewer: IB 
Georgia Final Report Page D.3 

License Casework Reviews 

File No.: 14 

Licensee: Columbus Rad. Oncology Assoc. License No.: GA 1256-1 

Type of Action: Amendment Amendment No.: 10 

Date Issued: 8/17/05 License Reviewer: LP 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 15 

Licensee: Atlanta Oncology Associates License No.: GA 1178-1 

Type of Action: Renewal Amendment No.: 17 

Date Issued: 9/5/08 License Reviewer: TC 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 16 

Licensee: Memorial Health University Medical Center License No.: GA 84-1 

Type of Action: Renewal Amendment No.: 58 

Date Issued: 6/10/08 License Reviewer: JF 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 17 

Licensee: John Archibold Memorial Hospital License No.: GA 78-1 

Type of Action: Amendment Amendment No.: 39 

Date Issued: 11/13/07 License Reviewer: KR 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 18 

Licensee: Athens Regional Med. Center License No.: GA 4-1 

Type of Action: Amendment Amendment No.: 52 

Date Issued: 12/11/07 License Reviewer: KS 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 19 

Licensee: Medical Center of Central Georgia License No.: GA 764-1 

Type of Action: Amendment Amendment No.: 35 

Date Issued: 9/18/08 License Reviewer: KR 
Georgia Final Report Page D.4 

License Casework Reviews 

File No.: 20 

Licensee: Oconee Regional Cancer Center License No.: GA 1227-1 

Type of Action: Amendment Amendment No.: 18 

Date Issued: 6/10/08 License Reviewer: KR 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 21 

Licensee: Radiology Associates of Macon License No.: GA 1319-1 

Type of Action: Amendment Amendment No.: 06 

Date Issued: 7/17/08 License Reviewer: KR 

Comment: 

 License amendment was issued without a required license condition. 

File No.: 22 

Licensee: IBT License No.: GA 1366-1 

Type of Action: Termination Amendment No.: 09 

Date Issued: 10/17/06 License Reviewer: EJ 

Comment: 

The termination was issued without verifying that the licensee had properly disposed of 

their sealed sources. 

File No.: 23 

Licensee: Analytics, Inc. License No.: GA 742-1 

Type of Action: Amendment Amendment No.: 24 

Date Issued: 10/25/05 License Reviewer: EJ 

File No.: 24 

Licensee: Redmond Regional Medical Center License No.: GA 165-1 

Type of Action: Renewal Amendment No.: 42 

Date Issued: 9/13/07 License Reviewer: EJ 

File No.: 25 

Licensee: Northside Hospital License No.: GA 748-1 

Type of Action: Renewal Amendment No.: 19 

Date Issued: 11/23/05 License Reviewer: IB 

File No.: 26 

Licensee: Emory Eastside Medical Center License No.: GA 728-1 

Type of Action: Amendment Amendment No.: 28 

Date Issued: 6/11/07 License Reviewer: IB 
Georgia Final Report Page D.5 

License Casework Reviews 

File No.: 27 

Licensee: Digirad Imaging License No.: GA 1529-3 

Type of Action: New Amendment No.: N/A 

Date Issued: 6/11/08 License Reviewer: IB 

File No.: 28 

Licensee: Chickasha of Georgia License No.: GA 1294-1 

Type of Action: Termination Amendment No.: 05 

Date Issued: 11/7/07 License Reviewer: EJ 

Comment: 

No evidence that sealed sources were not properly leak-tested prior to transfer or upon 

receipt of sources by the transferee. 

File No.: 29 

Licensee: Brown & Williamson Tobacco Corp. License No.: GA 460-1 

Type of Action: Termination Amendment No.: 32 

Date Issued: 7/2/04 License Reviewer: RH 

Comment: 

No evidence that sealed sources were not properly leak-tested prior to transfer or upon 

receipt of sources by the transferee. 

File No.: 30 

Licensee: State University of West Georgia License No.: GA 129-2 

Type of Action: Termination Amendment No.: 07 

Date Issued: 10/18/07 License Reviewer: SS 

File No.: 31 

Licensee: Wellstar Kennestone Hospital License No.: GA 328-1 

Type of Action: Amendment Amendment No.: 58 

Date Issued: 2/28/07 License Reviewers: LS 

Comment: 

 License amendment was issued without a required license condition. 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Medical Center of Central Georgia License No.: GA-364-1 

Date of Incident: 9/22/04 NMED Log No.: 040838 

Investigation Dates: 10/25-11/17/04 Type of Incident: Lost Material 

 Type of Investigation: Telephone/Report Review/Site 

File No.: 2 

Licensee: GA Department of Transportation License No.: GA-50-1 

Date of Incident: 12/16/2004 NMED Log No.: 050111 

Investigation Date: 12/16/2004 Type of Incident: Damaged Equipment 

 Type of Investigation: Telephone/Report Review 

File No.: 3 

Licensee: Southern Regional Medical Center License No.: GA-1039-1 

Date of Incident: 9/15/05 NMED Log No.: 050676 

Investigation Date: 9/30/05 Type of Incident: Medical Event 

 Type of Investigation: Telephone/Report Review 

File No.: 4 

Licensee: Emory University License No.: GA-153-1 

Dates of Incident: 10/5-6/05 NMED Log No.: 050738 

Investigation Date: 10/11/05 Type of Incident: Contamination Event 

 Type of Investigation: Telephone/Report Review 

File No.: 5 

Licensee: East Coast Isotopes, Inc. License No.: SC-705 

Date of Incident: 12/21/05 NMED Log No.: Not Reported 

Investigation Date: 12/21/05 Type of Incident: Lost Material (Recovered) 

 Type of Investigation: Telephone 

File No.: 6 

Licensee: Gwinnitt Medical Center License No.: GA-677-1 

Date of Incident: 1/10/06 NMED Log No.: 060047 

Investigation Date: 1/17/06 Type of Incident: Medical Event 

 Type of Investigation: Telephone/Report Review 

File No.: 7 

Licensee: Contour Engineering License No.: GA-1398-1 

Date of Incident: 4/26/06 NMED Log No.: 060306 

Investigation Date: 4/26/06 Type of Incident: Damaged Portable Gauge 

 Type of Investigation: Telephone/Report Review 
Georgia Final Report Page E.2 

Incident Casework Reviews 

File No.: 8 

Licensee: Miller Breweries East, Inc. License No.: GA-564-1.13 

Date of Incident: 3/20-25/06 NMED Log No.: 060281 

Investigation Date: 4/20/06 Type of Incident: Loss of Control 

 Type of Investigation: Telephone/Report Review 

File No.: 9 

Licensee: Gallet and Associates License No.: GA-1316-1 

Date of Incident: 9/27/06 NMED Log No.: 070034 

Investigation Date: 10/5/06 Type of Incident: Damaged Equipment 

 Type of Investigation: Telephone/Report Review 

File No.: 10 

Licensee: Sumpter Regional Hospital License No.: GA-5-1 

Date of Incident: 3/1/07 NMED Log No.: 070173 

Investigation Date: 3/4/07 Type of Incident: Loss of Material 

 Type of Investigation: Site 

File No.: 11 

Licensee: Nova Engineering License No.: GA-1323-1 

Date of Incident: 3/27/07 NMED Log No.: 070182 

Investigation Date: 3/27/07 Type of Incident: Loss of Material 

 Type of Investigation: Telephone/Report Review 

 

File No.: 12 

Licensee: GE Healthcare License No.: NA 

Date of Incident: 11/13/07 NMED Log No.: 070753 

Investigation Date: 11/13/07 Type of Incident: Transportation 

 Type of Investigation: Site/Report Review 

File No.: 13 

Licensee: Kaiser Permanente License No.: GA-1276-1 

Date of Incident: 11/19/07 NMED Log No.: 080385 

Investigation Date: 1/25/08 Type of Incident: Medical Event 

 Type of Investigation: Telephone/Report Review 

File No.: 14 

Licensee: Morehouse School of Medicine License No.: GA-703-1 

Date of Incident: 2/4/08 NMED Log No.: NA 

Investigation Date: 2/6/08 Type of Incident: Security 

 Type of Investigation: Telephone/LLEA Followup 

File No.: 15 

Licensee: Imperial Sugar License No.: GA-917-1 

Date of Incident: 2/7/08 NMED Log No.: NA 

Investigation Date: 2/7-9/08 Type of Incident: Damage to Fixed Gauge 

 Type of Investigation: Site 
Georgia Final Report Page E.3 

Incident Casework Reviews 

File No.: 16 

Licensee: Southern Regional Medical Center License No.: GA-1039-1 

Date of Incident: 5/30/08 NMED Log No.: 080388 

Investigation Date: 5/30/2008 Type of Incident: Medical Event 

 Type of Investigation: Telephone/Report Review 

File No.: 17 

Licensee: Analytics, Inc. License No.: GA-742-1 

Date of Incident: 8/22/08 NMED Log No.: NA 

Investigation Date: 8/28/08 Type of Incident: Leaking Source 

 Type of Investigation: Telephone/Report Review 
APPENDIX F 

SEALED SOURCE & DEVICE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Registry No.: GA-0716-D-110-S SS&D Type: Neutron Gauge 

Manufacturer: Scantech International Pty, Ltd. Model No.: ANALYZER-5 

Date Issued: 2/4/08 Action Type: New 

Comment: 

 Thermal tests for the cast neutron shielding were not performed for a period of one hour 

as specified in ANSI N43.6-1997; thermal tests were instead performed for a period of 

only 30 minutes. 

File No.: 2 

Registry No.: GA-1077-D-101-S SS&D Type: Neutron Gauge 

Manufacturer: EADS SODURN North American Inc. Model No.: POLAB CNA Series 

Date Issued: 4/4/07 Action Type: Amendment 

File No.: 3 

Registry No.: GA-0269-D102-S SS&D Type: Medical Teletherapy 

Manufacturer: Elekta Instrument AB Model No.: 23004 & 24001 

Date Issued: 2/28/07 Action Type: Amendment 

Comments: 

a) The amendment for a new sealed source was incorporated on the registration as a 

correction page when it should have been incorporated as a full amendment, an action 

that does not comply with the guidance in NUREG-1556, Vol. 3, Rev. 1. 

b) The amendment letter was not referenced at the conclusion of the certificate. 

File No.: 4 

Registry No.: GA-0716-D-104-S SS&D Type: Sulfur, Ash, Moisture Analyzer 

Manufacturer: Scantech International Pty Ltd Model No.: 9000 & 9000 Mk2 

Date Issued: 3/23/07 Action Type: Amendment 

File No.: 5 

Registry No.: GA-0269-D-104-S SS&D Type: Medical Teletherapy 

Manufacturer: Elekta Instrument AB Model No.: Leksell Gamma Knife Perflexion 

Date Issued: 2/26/07 Action Type: New 

File No.: 6 

Registry No.: GA-1138-D-105-S SS&D Type: Dosimeter Irradiator 

Manufacturer: Hopewell Designs, Inc. Model No.: GC88 

Date Issued: 7/26/05 Action Type: New 
Georgia Final Report Page F.2 

Sealed Source & Device Casework Reviews 

File No.: 7 

Registry No.: GA-1061-S-102-S SS&D Type: Medical Brachytherapy 

Manufacturer: International Brachytherapy SA Model No.: OptiSeed103 Model 1 032p 

OptiStrand103

Date Issued: 2/16/05 Action Type: New 

File No.: 8 

Registry No.: GA-0645-D-103-S SS&D Type: Medical Brachytherapy 

Manufacturer: Theragenics Corporation Model No.: TheraSight TM Ocular Brachytherapy 

System Model 5000 

Date Issued: 7/28/04 Action Type: New 
ATTACHMENT 

November 21, 2008, Letter from Carol A. Couch 

Georgia’s Response to Draft IMPEP Report 

ADAMS Accession No.: ML083400032