August 27, 2008 

Harold Leggett, Ph.D., Agency Secretary 

Louisiana Department of Environmental Quality 

602 N. 5th Street 

Baton Rouge, Louisiana 70802 

Dear Dr. Leggett: 

On August 5, 2008, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Louisiana 

Agreement State Program. The MRB found the Louisiana Agreement State Program adequate 

to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s program. 

Section 5.0, page 18, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendations. We request your evaluation and response to the 

recommendations within 30 days from receipt of this letter. 

Based on the results of the current IMPEP review, the next full review of the Louisiana 

Agreement State Program will take place in approximately 4 years, with a periodic meeting 

tentatively scheduled for May 2010. 

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

I also wish to acknowledge your continued support for the Agreement State Program. I look 

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

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: 

Louisiana Final IMPEP Report 

cc w/encl.: See next page 
 

cc w/encl.: Jeffrey Meyers, Administrator 

 Louisiana Emergency and 

 Radiological Services Division 

 Ann Troxler, Manager 

 Louisiana Emergency and 

 Radiological Services Division 

 Karen Beckley, Nevada 

 Organization of Agreement States 

 Liaison to the MRB 
August 27, 2008 

Harold Leggett, Ph.D., Agency Secretary 

Louisiana Department of Environmental Quality 

602 N. 5th Street 

Baton Rouge, Louisiana 70802 

Dear Dr. Leggett: 

On August 5, 2008, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Louisiana 

Agreement State Program. The MRB found the Louisiana Agreement State Program adequate 

to protect public health and safety and compatible with the U.S. Nuclear Regulatory 

Commission=s program. 

Section 5.0, page 18, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendations. We request your evaluation and response to the 

recommendations within 30 days from receipt of this letter. 

Based on the results of the current IMPEP review, the next full review of the Louisiana 

Agreement State Program will take place in approximately 4 years, with a periodic meeting 

tentatively scheduled for May 2010. 

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

I also wish to acknowledge your continued support for the Agreement State Program. I look 

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

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: 

Louisiana Final IMPEP Report 

cc w/encl.: See next page 

Distribution: See next page. EDATS: FSME-2008-0037 

 ML082240020 

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

NAME ATMcCraw:knm1 ADWhite RJLewis CPoland(P.Tressler for)

DATE 08/11/08 08/13/08 08/13/08 08/14/08 

OFFICE FSME DEDMRT 

NAME CMiller (G.Pangburn for) MJVirgilio 

DATE 0818/08 08/27/08 

OFFICIAL RECORD COPY
Letter to Harold Leggett, Ph.D., from Martin J. Virgilio dated: August 27, 2008

Distribution: EDATS: FSME-2008-0037 

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RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Klein 

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DJanda, RI Commissioner Lyons 

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TSimmons, RIII SECY 

Joshua Daehler, MA 

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WRautzen, FSME/DMSSA 

DSollenberger, FSME/DMSSA 

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CMiller, FSME 

KCyr, OGC 

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MSatorius, RIII 

APowell, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE LOUISIANA AGREEMENT STATE PROGRAM 

May 12-16, 2008 

FINAL REPORT
Louisiana Final Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of May 12-16, 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 Texas. 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 the February 

26, 2004 NRC Management Directive 5.6, “Integrated Materials Performance Evaluation 

Program (IMPEP).” Preliminary results of the review, which covered the period of November 1, 

2003, to May 16, 2008, were discussed with Louisiana managers on the last day of the review. 

A draft of this report was issued to Louisiana for factual comment on June 18, 2008. The State 

responded by letter on July 1, 2008, from Dr. Harold Leggett, Secretary, Department of 

Environmental Quality (the Department). A copy of the State’s response is included as the 

Attachment to this report. The Management Review Board (MRB) met on August 5, 2008, to 

consider the proposed final report. The MRB found the Louisiana Agreement State Program to 

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

The Louisiana Agreement State Program is administered by the Department. The Department 

Secretary is appointed by and reports directly to the Governor. The Emergency and 

Radiological Services Division (the Division), within the Department, houses the Surveillance 

and Enforcement Program and Licensing Program, which comprise the radioactive materials 

program. Organization charts for the Department and the Division are included as Appendix B. 

At the time of the review, the Division regulated 548 specific licenses authorizing the possession 

and use of byproduct, source and small quantities of special nuclear material. The review 

focused on the radioactive 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 

Louisiana. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Division on April 1, 2008. The Division 

provided its response to the questionnaire on April 15, 2008. A copy of the questionnaire 

response may be found in the NRC’s Agencywide Documents Access and Management System 

(ADAMS) using the Accession Number ML081640068. 

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

the Division’s response to the questionnaire, (2) review of applicable Louisiana statutes and 

regulations, (3) analysis of quantitative information from the Division’s database, (4) technical 

review of selected regulatory actions, (5) six field accompaniments of four Louisiana inspectors, 

and (6) interviews with staff and managers to answer questions or clarify issues. 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 

Louisiana Agreement State Program’s performance. 
Louisiana Final Report Page 2 

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 for the common performance 

indicators are presented in Section 3.0. Section 4.0 details the results of the review of the 

applicable non-common 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 IMPEP review, which concluded on October 31, 2003, the review team 

made five recommendations in regard to program performance. The results were transmitted to 

L. Hall Bohlinger, Secretary, Department of Environmental Quality, on February 3, 2004. The 

current status of the recommendations is as follows: 

1. The review team recommends that the Surveillance Division finalize their training and 

qualification program of radioactive materials inspectors, including the qualifications 

required to complete independent inspections of various license types. (Section 3.1 of 

the 2004 IMPEP report) 

 Current Status: The Division established a database program that tracks the training and 

qualifications for radioactive materials inspectors and includes the qualifications required 

to complete independent inspections of various license types. This recommendation is 

closed. 

2. The review team recommends that the Department review their existing databases, 

identify all routine and initial inspections that need to be conducted and complete those 

inspections. (Section 3.2 of the 2004 IMPEP report) 

 Current Status: The Division implemented a database that identifies all routine and initial 

inspections. On a monthly basis, each regional office is sent an electronic copy of the 

inspection due list for all the facilities in the respective region. Regional inspectors 

review the list for accuracy. Any discrepancies are immediately addressed through the 

database. At the time of the review, the Division had no overdue routine or initial 

inspections. This recommendation is closed. 

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

ensuring that all new licensees receive a timely initial inspection. (Section 3.2 of the 

2004 IMPEP report) 

 Current Status: After a satisfactory pre-licensing inspection and upon issuance of a 

license, the new license is placed on the inspection due list as an initial inspection and is 

given a 6-month inspection due date. The list is reviewed periodically by a supervisor to 

ensure all new licenses are inspected within 6 months of the license issue date. At the 

time of the review, the Division had no overdue initial inspections. This recommendation 

is closed. 
Louisiana Final Report Page 3 

4. The review team recommends that the Department inspect implementation of SS&D 

authorizations during routine inspections. (Section 3.3 of the 2004 IMPEP report) 

 Current Status: The Division incorporated the inspection of SS&D authorizations into 

their inspection protocol for applicable licensees. This recommendation is closed. 

5. The review team recommends that the Department develop and implement a process for 

conducting annual accompaniments of all radiation compliance inspectors by qualified 

individuals. (Section 3.3 of the 2004 IMPEP report) 

 Current Status: A manager or the section technical staff member conducts supervisory 

accompaniments on an annual or more frequent basis. A copy of the accompaniment 

evaluation is provided to the inspector and inspection supervisor. This recommendation 

is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

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

and Agreement State radioactive materials programs. These indicators are: (1) Technical 

Staffing and Training, (2) Status of Materials Inspection Program, (3) Technical Quality of 

Inspections, (4) Technical Quality of Licensing Actions, and (5) Technical Quality of Incident and 

Allegation Activities. 

3.1 Technical Staffing and Training

Areas of interest central to the evaluation of this indicator included staffing levels and turnover, in 

addition to staff technical qualifications and training histories. The review team examined the 

Division’s questionnaire response relative to this indicator; interviewed managers and staff; 

reviewed job descriptions, training plans, training records and considered possible workload 

backlogs in evaluating this indicator. 

The Division is managed by the Division Administrator from the Central Office located in Baton 

Rouge. The radioactive materials program, which is housed in the Division, consists of two 

sections, the Licensing and Surveillance Sections. The Division devotes approximately 

16 full-time equivalents (FTE) to the surveillance (i.e., inspection), enforcement, and emergency 

response programs, including supervisory duties. Thirteen inspection staff members are based 

out of six regional offices. Inspection staff members also perform other duties, including x-ray 

and non-radiological inspections. Licensing is performed out of the Central Office. The Division 

devotes approximately 5 FTE to radioactive materials licensing and approximately 4 FTE to 

administrative functions. 

During the review period eight staff members, including two managers, left the Department and 

eight staff were hired. At the time of the review, the Division was in the process of adding a 

senior technical position to the radioactive materials program. 

The review team determined the qualifications of the staff from the Division’s response to the 
Louisiana Final Report Page 4 

questionnaire, training records, and interviews with personnel. The staff was well qualified from 

an education and experience standpoint. In general, inspection and licensing staff become 

qualified to complete x-ray registrations and inspections and, after approximately 1-2 years of 

experience with x-ray tasks, are then trained to perform radioactive materials licensing and 

inspections, starting with the least complex and progressing to more complex as experience is 

gained. The Division has a documented training and qualification program for radioactive 

materials license reviewers and inspectors that is consistent with the NRC and Organization of 

Agreement States Training Working Group Recommendations for Agreement State Training 

Programs. The review team noted that the training program consisted of classroom instruction 

and on-the-job training. Qualification journals were maintained electronically for each technical 

staff member. Division managers were supportive of and actively identified staff training 

opportunities. Eleven staff members have attended the NRC’s Security Systems and Principles 

Course and are qualified to perform Increased Controls inspections. 

The review team concluded that the Division has an adequate, well-balanced, and adequately 

trained staff to carry out its regulatory responsibilities. The review team noted that the 

Department had stable funding during the review period due to dedicated revenue from licensee 

fees. 

Louisiana does not have an active radiation oversight board. 

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

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

satisfactory. 

3.2 Status of Materials Inspection Program

The review team focused on five factors to review 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’s evaluation was based 

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

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

managers and staff. 

The review team verified that the Division’s inspection priorities for various license types were at 

least as frequent as similar license types listed in NRC Inspection Manual Chapter (IMC) 2800, 

“Materials Inspection Program.” Seven of the 15 license categories established by the Division 

were assigned inspection priority codes that resulted in a more frequent inspection schedule 

than those established in IMC 2800. The Division inspects the following license categories on a 

more frequent schedule than IMC 2800 describes: industrial radiography, nuclear pharmacy, 

self-shielded irradiators, academic broad scope, research and development, medical institutions, 

and portable and fixed nuclear gauges. 

The review team determined that the Division conducted approximately 766 high priority 

(Priority 1, 2, and 3) inspections and 86 initial inspections during the review period. None of 

these inspections were performed overdue by more than 25 percent of the inspection priorities 

listed in IMC 2800, nor were any inspections overdue at the time of the review. 
Louisiana Final Report Page 5 

To evaluate the Division’s timeliness in providing inspection correspondence to licensees, the 

review team examined 25 inspection reports, covering a cross-section of the staff, and 

determined that inspection correspondence was generally communicated to licensees within 30 

days after the inspection. 

Over the review period, the Division granted 87 reciprocity permits that were candidates for 

inspection based on 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 Division exceeded the goal of inspecting 20 percent of all candidate licensees in each of the 

4 years covered by the review period. 

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

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

found it acceptable. The Division identified 89 licensees subject to the Increased Controls. The 

review team noted that all initial Increased Controls inspections had been completed at the time 

of the review. After the initial inspection, the Division performs Increased Controls inspections at 

the routine inspection interval. 

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

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

Program, was satisfactory. 

3.3 Technical Quality of Inspections

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

notes, and interviewed the responsible inspector for 25 inspections conducted during the review 

period. The casework examined included a cross-section of inspections conducted by nine 

inspectors and covered a wide variety of inspection types, including: broad scope medical, 

manufacturers, well logging, industrial radiography, self-shielded irradiators, nuclear pharmacy, 

Increased Controls, and reciprocity. Appendix C lists the inspection casework files reviewed, 

with case-specific comments, as well as the results of the inspector accompaniments. 

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

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

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

documentation to ensure that licensees’ performances with respect to health, safety, and 

security were acceptable. Inspection report documentation supported violations, 

recommendations, unresolved safety issues, and adequately documented exit interviews. 

The inspection procedures utilized by the Division are consistent with the inspection guidance in 

IMC 2800. The reports and notices are reviewed by the staff scientist reviewer, signed by the 

radiation section manager and promptly sent to the licensee. Inspection results were clearly 

stated and documented. The Division requires licensees to respond to violations within 30 days 

of issuance of a Notice of Violation. The staff scientist reviewer evaluates the licensees’ 

responses for adequacy, with concurrence by the inspector when necessary. The review team 

also noted that inspection correspondence involving the Increased Controls was appropriately 

labeled as sensitive information and withheld from public disclosure. 
Louisiana Final Report Page 6 

The senior technical staff member or a supervisor conducted supervisory accompaniments at 

least annually for all inspectors. The review team noted that Increased Controls inspections are 

included in the supervisory accompaniments. 

The review team verified that the Division maintains an adequate supply of appropriately 

calibrated survey instrumentation to support its inspection program, as well as to respond to 

incidents and emergencies. The survey instruments are calibrated annually by a qualified 

contractor. Laboratory support is provided by the Laboratory Services Division in the Office of 

Environmental Assessment. 

The review team accompanied four of the Division’s inspectors during the weeks of April 7 and 

April 23, 2008. The inspectors were accompanied during health and safety inspections of 

medical, industrial radiography, and portable gauge licensees. The accompaniments are listed 

in Appendix C. During the accompaniments, the inspectors demonstrated appropriate 

inspection techniques, knowledge of the regulations, and conducted performance-based 

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

their audits of the licensees’ radiation safety programs. The inspectors conducted interviews 

with appropriate personnel, observed licensed operations, conducted confirmatory 

measurements, and utilized good health physics practices. The inspections were adequate to 

assess radiological health, safety, and security at the facilities. 

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

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

satisfactory. 

3.4 Technical Quality of Licensing Actions

The review team examined 20 licensing actions and interviewed the responsible license 

reviewers. Licensing actions were reviewed for completeness, consistency, proper possession 

authorization, authorized user qualifications, facility adequacy, equipment, health physics 

practices, financial assurance, operating and emergency procedures, appropriateness of license 

conditions, and overall technical quality. The casework was also reviewed for timeliness, 

correspondence, reference to appropriate regulations, supporting documentation, enforcement 

history, pre-licensing visits, peer/supervisory review, and signatures. 

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

completed during the review period and included six new licenses, four renewals, seven 

amendments, and three license terminations. Files reviewed included a cross-section of license 

types, including: medical diagnostic and therapy, industrial radiography, portable and fixed 

gauges, medical broad scope, research and development, and nuclear pharmacies. A listing of 

the licensing casework reviewed, with case-specific comments, can be found in Appendix D. 

The review team noted that licensing actions were generally thorough, complete, consistent, and 

of high quality, and properly addressed health, safety, and security. Licensing staff appropriately 

used the Division’s licensing guides and policies. When appropriate, licensees’ compliance 

histories were taken into account during licensing actions. License conditions were clearly 
Louisiana Final Report Page 7 

stated and supported by information contained in the license file. 

Licenses and correspondence were created using a standardized format, which included 

standardized license conditions. 

The Division uses a unique license condition in terminated licenses that states “If the 

Department determines that the information supplied is incorrect or defective, the applicability of 

a specific license may be reassessed.” The condition holds the former licensee liable if 

inaccurate information is provided by the licensee in the termination of the license. In such 

cases, the Department has a right to pursue actions against the former licensee. For example, if 

radioactive material is found at a facility after the radioactive materials license is terminated, the 

former licensee is held legally responsible for ensuring proper disposition of the radioactive 

material. The review team recommended, and the MRB agreed, that use of this standard 

license condition on terminated licenses is a good practice. 

Actions are reviewed by a peer reviewer, the licensing supervisor, the compliance staff, and the 

departmental manager and are subsequently signed by the Assistant Secretary of the Office of 

Environmental Compliance. Typically licensing actions are completed within 30 days of receipt. 

Deficiency letters reviewed clearly stated regulatory positions and were used appropriately. In 

addition to using formal written requests, the staff frequently telephones and/or e-mails licensees 

for clarification or to obtain additional information. Use of these methods promotes timeliness of 

licensing actions; however, the review team found that telephone conversations are not always 

captured, which results in disconnects between the licensing request and the final action. The 

review team discussed this issue and potential resolutions with the licensing supervisor. The 

licensing supervisor will review this matter with the staff to ensure that all communications with 

licensees regarding licensing actions are properly recorded. 

The review team evaluated the Division’s decommissioning financial assurance program and 

noted that the Division had identified 14 licensees required to comply with Louisiana’s financial 

assurance requirements. The original financial instruments are secured and located in the 

Department of Financial Services. The review team found that terminated licensing actions were 

well documented and noted that confirmatory surveys were conducted when appropriate. 

Division inspectors conduct pre-licensing visits of new applicants, including those that meet the 

criteria for Increased Controls, to verify compliance with health, safety, and security 

requirements before a license is issued. 

The review team examined the Division’s increased controls licensing practices. The team 

noted that the Division added legally binding license conditions that met the criteria for 

implementing the Increased Controls. The review team determined the Division’s methodology 

for identifying licenses requirng the Increased Controls license condition was thorough and 

accurate, and that the Division had correctly identified those licenses requiring compliance with 

the Increased Controls. 

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

that Louisiana’s performance with respect to the indicator, Technical Quality of Licensing 

Actions, was satisfactory. 
Louisiana Final Report Page 8 

3.5 Technical Quality of Incident and Allegation Activities

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

allegations, the review team examined the Division’s response to the questionnaire relative to 

this indicator, evaluated all of the incidents reported for Louisiana in the Nuclear Material Events 

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

for 21 radioactive material incidents. A listing of the incident casework examined can be found 

in Appendix E. The review team also evaluated the Division’s response to ten materials 

allegations including two that the NRC referred to the State during the review period. 

The incidents selected for review included medical events, lost/stolen radioactive material, 

damaged equipment, and overexposures. When notification of an incident is received, the 

Division determines the appropriate level of initial response. The review team determined that 

the 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 Division dispatched inspectors for on-site investigations in appropriate 

situations and took suitable enforcement and followup actions, when necessary. 

The review team identified 90 byproduct material incidents for Louisiana in NMED that required 

reporting during the review period. The review team evaluated the Division’s timeliness in 

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

notification from the licensee, the Division reported all incidents within the required time frame. 

Division staff members incorporated incident information into their incident database and 

provided that information electronically to the NRC’s contractor. 

The review team found that, following a reported event, the licensees’ corrective actions 

submitted to the Division subsequent to the event were not reviewed during the next routine 

inspection or were not being documented. The review team recommends that the State take 

measures to evaluate corrective actions of all radioactive materials incidents, ensure proper 

documentation of the review, and appropriately follow up on the corrective actions at subsequent 

inspections. 

In evaluating the effectiveness of Louisiana's response to allegations, the review team 

determined that the Division took prompt and appropriate action in response to all concerns. 

The allegations were appropriately closed, and affected individuals were notified of the actions 

taken when possible. The review team noted that Louisiana law requires that public documents 

be made available upon request. The Division makes every effort to protect an alleger’s identity, 

but cannot guarantee full protection. During initial contact, an alleger is advised that their 

anonymity cannot be guaranteed. 

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

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

Allegation Activities, was satisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS 
Louisiana Final Report Page 9 

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

State Programs: (1) Compatibility Requirements; (2) Sealed Source and Device Evaluation 

Program; (3) Low-Level Radioactive Waste Disposal Program; and (4) Uranium Recovery 

Program. Louisiana’s Agreement does not cover a uranium recovery program, so only the first 

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

4.1 Compatibility Requirements

4.1.1 Legislation

Louisiana became an Agreement State in 1967. The statutory authority for the Louisiana 

program is found the Radiation Control Law, Chapter 6, R.S. 30:2101-2134. The Department is 

designated as the State's radiation control agency. The review team noted that no legislation 

affecting the radiation control program was passed during the review period. 

4.1.2 Program Elements Required for Compatibility

The Department’s regulations for control of radiation, found in Part XV, Radiation Protection, 

Louisiana Environmental Regulatory Code, apply to all radioactive materials and devices 

designed to produce radiation.

The review team examined the State’s administrative rulemaking process and found that it takes 

approximately 6 months after preparation of a draft rule to become final. Proposed rules are 

submitted to the Legislative Fiscal Office for consideration and approval to proceed with public 

comment. Public notice of proposed rule revisions is made and a 30-45 day public comment 

period, including a public hearing, is conducted. After resolution of comments and the State 

Legislative Oversight Committee’s approval, final draft rules are sent to the Louisiana Register

for adoption. 

The review team evaluated the Department’s response to the questionnaire relative to this 

indicator, reviewed the status of regulations required to be adopted by the State under the 

NRC’s adequacy and compatibility policy, and verified the adoption of regulations with data 

obtained from the Office of Federal and State Materials and Environmental Management 

Programs’ State Regulation Status Sheet. 

The review team noted that the Department has expended considerable effort in regulation 

development since the last review in 2003. Since the previous review, the State submitted 

twelve packages to the NRC for compatibility review. 

The review team identified the following regulation as overdue for adoption at the time of the 

review. The State plans to submit the regulation to the NRC for review by June 2008: 

● “Compatibility with IAEA Transportation Safety Standards and Other Transportation Safety 

Amendments,” 10 CFR Part 71 amendment (69 FR 3697), that was due for Agreement State 

adoption by October 1, 2007. 
Louisiana Final Report Page 10 

The review team identified the following regulation changes and adoptions that will be needed in 

the future, and the State related that the regulations would be addressed in upcoming 

rulemaking or in the adoption of alternate legally binding requirements: 

● “Minor Amendments,” 10 CFR Parts 20, 30, 32, 35, 40 and 70 amendment (71 FR 15005), 

that is due for Agreement State adoption by March 27, 2009. 

● “Medical Use of Byproduct Material – Minor Corrections and Clarifications,” 10 CFR Parts 32 

and 35 amendment (72 FR 45147, 72 FR 54207), that is due for State adoption by October 

29, 2010. 

● “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 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 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 State adoption by February 

15, 2011.

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

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

satisfactory. 

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

In evaluating this indicator, the review team used three subelements to evaluate the Division’s 

performance regarding the 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 Division’s SS&D evaluation activities, the review team examined the Division’s 

response to the IMPEP questionnaire on this indicator, performed a search of the Sealed Source 

and Device Registry for registrations issued by Louisiana, and performed NMED searches of 

manufacturers and distributors identified on SS&D registrations issued by Louisiana. A review of 

all new, amended, and corrected SS&D evaluations and supporting documents covering the 

review period was conducted. The review team noted the staff’s use of guidance documents 

and procedures; interviewed managers and staff; and verified the use of regulations, license 

conditions, and inspections to enforce commitments made in the applications. 

 

4.2.1 Technical Staffing and Training 

During the review period, three qualified SS&D reviewers left the Division and one reviewer was 

qualified. At the time of the review, the Division had two qualified SS&D reviewers with full 

signature authority and obtained assistance from another qualified SS&D reviewer from the 
Louisiana Final Report Page 11 

NRC. The Division indicated that one additional qualified SS&D reviewer with a position in 

another division of the Department is also available to perform SS&D reviews but did not 

perform any reviews during the review period. 

The Division completed two new SS&D registrations, one amended SS&D registration, and one 

corrected SS&D registration during the review period. The Division’s two qualified reviewers 

with full signature authority each have greater than 10 years of experience with the Division, and 

each have obtained either a bachelor’s or master’s degree in science. One of the reviewers has 

attended the NRC SS&D workshop. The other reviewer has reviewed the SS&D workshop 

manual, has obtained experience by performing SS&D reviews with the qualified NRC SS&D 

reviewer, and is scheduled to attend the NRC SS&D workshop in September 2008. The Division 

had one pending SS&D evaluation. The review team determined that the staffing level is 

adequate for the Division’s SS&D workload. 

4.2.2 Technical Quality of the Product Evaluation Program 

During the review period, the Division processed four SS&D actions. The actions were two new, 

one amended, and one corrected SS&D registrations. The casework review included all 

supporting documentation, licensing actions, and inspections. A listing of the SS&D 

registrations evaluated, with case-specific comments, can be found in Appendix F. 

The review team confirmed that the Division’s policy is to follow the recommended guidance 

from the NRC SS&D training workshops and NUREG-1556, Volume 3, Revision 1, 

“Consolidated Guidance About Materials Licenses - Applications for Sealed Source and Device 

Evaluation and Registration.” 

The review team verified that appropriate review checklists were used to ensure that all relevant 

materials had been submitted and reviewed. The checklists were retained in the SS&D files 

along with other documents that clearly identified the responsible reviewer. The review team 

verified that pertinent American National Standards Institute standards, NRC Regulatory Guides, 

and applicable references were available and used when performing SS&D reviews. 

The review team noted that three out of four registrations did not follow the format and content 

recommended in NUREG-1556, Volume 3. In cases where the format and content were not 

followed, the Division relied upon the format and content provided by the applicant without 

checking the NUREG. For example, in two registrations reviewed, each applicant submitted that 

the use code was “(V) General Medical Use.” A check of Appendix C of the NUREG would have 

alerted the reviewer that such use code was discontinued in 2002 and that the correct use code 

for the two registrations is “(AC) Photon-emitting Remote Afterloaders.” These formatting issues 

did not adversely impact the technical quality or content of the reviews; however, because the 

registrations are used nationally, the documents should be consistent with national standards. 

The review team recommends that the State adhere to the document format and content 

guidance in current version NUREG-1556, Volume 3. 

The registration files contained all correspondence, engineering drawings, photographs, 

radiation profiles, and details of the applicant’s quality assurance and quality control program. 

The registrations clearly summarized the product evaluation to provide license reviewers with 

adequate information to license the products. Deficiency letters clearly stated regulatory 
Louisiana Final Report Page 12 

positions and all health and safety issues were properly addressed. The review team found that 

the evaluations were of good quality. The Division enforces the requirements of SS&D 

registrations through conditions made part of specific licenses issued to the distributors of SS&D 

products. 

The review team noted that the Division had terminated a specific license associated with SS&D 

registrations and did not address inactivation of the registrations. The review team also 

identified that the Division did not address inactivation of two additional SS&D registrations. The 

review team concluded that no adverse health and safety issues resulted. The review team 

discussed with the Division managers the benefits of performing inactivations of registrations 

prior to or in unison with performing license terminations. Division managers agreed to evaluate 

the need to inactivate the registrations in question and to inactivate the registrations consistent 

with the guidance in NUREG-1556, as applicable. 

 

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds 

Based upon the Division’s response to the questionnaire, interview of Division managers, and 

the review team’s searches of NMED, the review team selected a sample of three incidents 

and/or equipment failures reported during the review period that occurred in Louisiana or that 

occurred nationally involving SS&D products registered in Louisiana. The listing of casework 

examined, with case-specific comments, can be found in Appendix E. The Division reported that 

there were no allegations received by the Division related to SS&D products registered in 

Louisiana during the review period. 

The review team determined that the Division analyzed the events, reviewed the issues, and 

followed up on the incidents adequately and in accordance with their procedures. One of the 

events involved both a device and a source failure, and the failures were determined to 

potentially be generic. The Division notified the appropriate regulatory agencies and locations 

where the affected products had been distributed. The Division ensured that the sources and 

the failed component of each device were recalled. The Division identified and documented 

possible root-causes and continued to investigate. The Division received an application from the 

source manufacturer to amend the related sealed source registration. The Division anticipated 

that the device manufacturer may also provide an application to amend the related device 

registration. 

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

that Louisiana’s performance with respect to the indicator, SS&D Evaluation Program, was 

satisfactory. 

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program

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

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

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

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

disposal authority without the need of an amendment. Although Louisiana 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 
Louisiana Final Report Page 13 

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 Louisiana. Accordingly, the review team did not evaluate the State’s 

performance with respect to this indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, Louisiana’s performance was found satisfactory for all seven 

performance indicators reviewed. The review team made two recommendations regarding 

program performance and identified one good practice. Accordingly, the review team 

recommended, and the MRB agreed, that the Louisiana Agreement State Program was 

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 agreed, that 

the next full IMPEP review take place in approximately 4 years. 

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 take measures to evaluate corrective 

actions of all radioactive materials incidents, ensure proper documentation of the review, 

and appropriately follow up on the corrective actions at subsequent inspections. 

(Section 3.5) 

2. The review team recommends that the State adhere to the document format and content 

guidance in current version NUREG-1556, Volume 3. (Section 4.2.2) 

 

Below is the good practice, as mentioned earlier in the report: 

The Division uses a unique license condition in terminated licenses that states “If the 

Department determines that the information supplied is incorrect or defective, the 

applicability of a specific license may be reassessed.” The condition effectively holds the 

former licensee liable if inaccurate information is provided by the licensee in the 

termination of the license. In such cases, the Department has a right to pursue actions 

against the former licensee. (Section 3.4)
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Louisiana Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source and Device Casework Reviews 

Attachment July 1, 2008, Letter from Harold Leggett 

 Louisiana’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Donna Janda, Region I Team Leader 

 Technical Staffing and Training 

Eric Skotak, Texas Status of Materials Inspection Program 

Technical Quality of Inspections 

Toye Simmons, Region III Technical Quality of Licensing Actions 

Linda McLean, Region IV Technical Quality of Incident and Allegation 

 Activities 

 Compatibility Requirements 

 Inspector Accompaniments 

Joshua Daehler, Massachusetts Sealed Source and Device Evaluation Program 

Richard Leonardi, Region IV Inspector Accompaniments 
APPENDIX B 

LOUISIANA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML081640072 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Alpha Omega Services License No.: LA-10025-L01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 12/21/07 Inspector: JR 

Comment: 

Report was issued 59 days after inspection due to preparation for assessment of 

potential penalties through escalated enforcement. 

File No.: 2 

Licensee: Source Production & Equipment Co License No.: LA-2966-L01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/18/07 Inspector: KJ 

File No.: 3 

Licensee: QSA Global, Inc. License No.: LA-5934-L01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 9/27/07 Inspector: SB 

File No.: 4 

Licensee: Oncology Systems, Inc. License No.: LA-11598-L01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 2/26/08 Inspector: KJ 

File No.: 5 

Licensee: Sunland Fabricators License No.: LA-3462-L01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 1/8/08 Inspector: SB 

File No.: 6 

Licensee: Oceaneering International, Inc. License No.: LA-7396-L01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 8/21/07 Inspector: SB 

 

File No.: 7 

Licensee: Acuren Inspection, Inc. License No.: LA-7072-L01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 7/2/07 Inspector: JR 
Louisiana Final Report Page C.2 

Inspection Casework Reviews

File No.: 8 

Licensee: Acuren Inspection, Inc. License No.: LA-7072-L01 

Inspection Type: Field Routine, Unannounced Priority: 1 

Inspection Date: 8/28/07 Inspector: JB 

File No.: 9 

Licensee: Janx Integrity Group License No.: LA-11202-L01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 9/5/07 Inspector: JG 

File No.: 10 

Licensee: Petro Chem Inspection Services License No.: LA-10239-L01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 10/8/07 Inspector: KJ 

File No.: 11 

Licensee: Energy Wireline, Inc. License No.: LA-4408-L01A 

Inspection Type: Routine, Not indicated Priority: 3 

Inspection Date: 8/7/06 Inspector: JB 

File No.: 12 

Licensee: Pathfinder Energy Services License No.: LA-9089-L01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/25/05 Inspectors: RC 

File No.: 13 

Licensee: LSU Health Sciences Center License No.: LA-0005-L01 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 1/24/08 Inspector: JB 

File No.: 14 

Licensee: Medical Center of LA - New Orleans License No.: LA-1329-L01 

Inspection Type: Routine/Special, Announced Priority: 2 

Inspection Dates: 3/20/08 Inspector: JN 

File No.: 15 

Licensee: University Medical Center License No.: LA-0746-L02 

Inspection Type: Routine, Not indicated Priority: 3 

Inspection Date: 6/6/07 Inspector: JF 

File No.: 16 

Licensee: Louisiana Regional Medical Center. License No.: LA-7424-L01 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 9/11/06 Inspector: RC 
Louisiana Final Report Page C.3 

Inspection Casework Reviews

File No.: 17 

Licensee: East Jefferson Radiation Oncology License No.: LA-11456-L01 

Inspection Type: Initial, Announced Priority: 2 

Inspection Date: 4/24/07 Inspector: KJ 

File No.: 18 

Licensee: Shreveport Nuclear Pharmacy License No.: LA-3751-L01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 1/25/07 Inspector: JB 

File No.: 19 

Licensee: Medi-Physics Inc./GE Healthcare License No.: LA-5470-L01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/19/08 Inspector: KJ 

File No.: 20 

Licensee: Hematology-Oncology Associates 

 of Baton Rouge License No.: LA-11314-L01 

Inspection Type: Initial, Announced Priority: 3 

Inspection Date: 6/22/06 Inspector: JN 

File No.: 21 

Licensee: Northeast Louisiana Cancer Institute License No.: LA-10206-L01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/17/07 Inspector: JG 

File No.: 22 

Licensee: Sunland Fabricators License No.: LA-3462-L01 

Inspection Type: Field, Unannounced Priority: 1 

Inspection Date: 1/8/08 Inspector: SB 

File No.: 23 

Licensee: Marco Inspection Services License No.: TX-L06072 

Inspection Type: Reciprocity Priority: 1 

Inspection Date: 3/27/08 Inspector: MC 

File No.: 24 

Licensee: AITEC, USA License No.: TX-L00578 

Inspection Type: Reciprocity Priority: 1 

Inspection Date: 11/21/06 Inspector: KJ 

File No.: 25 

Licensee: CIS-US, Inc. License No.: MA-20-9734 

Inspection Type: Reciprocity Priority: 3 

Inspection Date: 3/14/08 Inspector: JB 
Louisiana Final Report Page C.4 

Inspection Casework Reviews

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Winn Parish Medical Center License No.: LA-6544-L01 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 4/8/08 Inspector: JE 

Accompaniment No.: 2 

Licensee: Balar Associates, Inc. License No.: LA-10969-L01 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 4/8/08 Inspector: MC 

Accompaniment No.: 3 

Licensee: Willis Knighton Medical Center License No.: LA-1194-L01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 4/7/08 Inspector: MC 

Accompaniment No.: 4 

Licensee: David G. Baker, M.D. License No.: LA-10913-L01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 4/23/08 Inspector: JF 

Accompaniment No.: 5 

Licensee: Cardiovascular Institute of the South License No.: LA-5851-L01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 4/23/08 Inspector: JF 

Accompaniment No.: 6 

Licensee: Turner Specialty Services, LLC License No.: LA-10185-L-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 4/22/08 Inspector: JR 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: LSU Bogalusa Medical Center License No.: LA-0037-L02 

Type of Action: Renewal Amendment No.: 23 

Date Issued: 11/03/04 License Reviewer: JR 

File No.: 2 

Licensee: Ochsner Clinic Foundation License No.: LA-0002-L01 

Type of Action: Renewal Amendment No.: 48 

Date Issued: 5/24/04 License Reviewer: MH 

File No.: 3 

Licensee: RADS S.L., Inc. License No.: LA-5093-L01 

Type of Action: Termination Amendment No.: 27 

Date Issued: 9/19/03 License Reviewer: MH 

File No.: 4 

Licensee: Gramercy Alumina LLC License No.: LA-0673-L01 

Type of Action: Renewal Amendment No.: 34 

Date Issued: 4/14/05 License Reviewer: JR 

Comment: 

 File contained insufficient information to follow reviewer’s logic for the licensing action. 

File No.: 5 

Licensee: Tommy Causey, M.D. License No.: LA-11437-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 7/14/06 License Reviewer: KR 

File No.: 6 

Licensee: Foti Nuclear Pharmacy Services License No.: LA-6165-L01 

Type of Action: Amendment Amendment No.: 24 

Date Issued: 8/30/06 License Reviewer: KR 

File No.: 7 

Licensee: Honeywell International License No.: LA-10814-L01 

Type of Action: Renewal Amendment No.: ?? 

Date Issued: 5/7/07 License Reviewer: BS 

File No.: 8 

Licensee: Denton-James, LLC License No.: LA-11586-L01A 

Type of Action: New Amendment No.: 0 

Date Issued: 5/27/07 License Reviewer: BS 
Louisiana Final Report Page D.2 

License Casework Reviews

File No.: 9 

Licensee: Cembele Industries Inc. License No.: LA-11671-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 7/17/07 License Reviewer: BS 

File No.: 10 

Licensee: Saraj Tampera, M.D. License No.: LA-10998-L01 

Type of Action: Termination Amendment No.: 2 

Date Issued: 8/14/07 License Reviewer: KR 

File No.: 11 

Licensee: Lafayette Arthritis & Endocrine Clinic License No.: LA-4845-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 8/31/07 License Reviewer: KR 

Comment: 

 File contained insufficient information to follow reviewer’s logic for the licensing action. 

File No.: 12 

Licensee: Morehouse General Hospital License No.: LA-1155-L02 

Type of Action: Amendment Amendment No.: 18 

Date Issued: 10/19/07 License Reviewer: KR 

File No.: 13 

Licensee: Cardiology Associates of Central Louisiana License No.: LA-11746-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 10/24/07 License Reviewer: KR 

File No.: 14 

Licensee: Seaboard Wireline License No.: LA-11728-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 10/30/07 License Reviewer: BS 

File No.: 15 

Licensee: Conoco Phillip Company License No.: LA-5199-L01 

Type of Action: Amendment Amendment No.: 26 

Date Issued: 10/30/07 License Reviewer: BS 

Comment: 

 File contained insufficient information to follow reviewer’s logic for the licensing action. 

File No.: 16 

Licensee: MDS Pharma Services (US), Inc. License No.: LA-4095-L01 

Type of Action: Termination Amendment No.: 36 

Date Issued: 1/09/08 License Reviewer: KR 
Louisiana Final Report Page D.3 

License Casework Reviews

File No.: 17 

Licensee: Qualitech Services License No.: LA-6346-L01 

Type of Action: Amendment Amendment No.: 26 

Date Issued: 1/28/08 License Reviewer: BS 

File No.: 18 

Licensee: Gonzales Industrial Xray, Inc. License No.: LA-4611-L01A 

Type of Action: Amendment Amendment No.: 4 

Date Issued: 1/28/08 License Reviewer: JW 

File No.: 19 

Licensee: Tulane University Health Science Center License No.: LA-0004-L01 

Type of Action: Amendment Amendment No.: 52 

Date Issued: 4/18/08 License Reviewer: MB 

File No.: 20 

Licensee: Southern Isotope License No.: LA-10477-L01 

Type of Action: Amendment Amendment No.: ?? 

Date Issued: 4/28/08 License Reviewer: KR 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Bayou Inspection Services, Inc. License No.: LA-7112-L01 

Date of Incident: 12/03/03 NMED No.: 030974 

Investigation Date: 12/5/03 Type of Incident: Lost RAM 

 Type of Investigation: Site 

File No.: 2 

Licensee: Global X-Ray & Services, Corp. License No.: LA-0577-L01 

Date of Incident: 1/23/04 NMED No.: 040163 

Investigation Date: 2/2/04 Type of Incident: Equipment failure 

 Type of Investigation: Site 

File No.: 3 

Licensee: Cardinal Health License No.: LA-7096-L01 

Date of Incident: 2/27/04 NMED No.: 04049 

Investigation Date: 3/31/04 Type of Incident: Medical Event 

 Type of Investigation: Telephone 

File No.: 4 

Licensee: Tulane University License No.: LA-0004-L01 

Date of Incident: 10/10/04 NMED No.: 040742 

Investigation Date: 10/11/04 Type of Incident: Medical event 

 Type of Investigation: Written report 

File No.: 5 

Licensee: Schlumberger License No.: NR (TX License) 

Date of Incident: 7/26/05 NMED No.: 050498 

Investigation Date: 7/27/05 Type of Incident: Lost RAM 

 Type of Investigation: Telephone 

File No.: 6 

Licensee: D & S Wireline License No.: LA-7657-L01 

Date of Incident: 7/21/05 NMED No.: 050510 

Investigation Date: 2/26/05 Type of Incident: Abandoned source 

 Type of Investigation: Written report 

File No.: 7 

Licensee: Team Industrial Services License No.: LA-5601-L01 

Date of Incident: 6/1/06 NMED No.: 060375 

Investigation Date: 6/7/06 Type of Incident: Overexposure 

 Type of Investigation: Site 
Louisiana Final Report Page E.2 

Incident Casework Reviews

File No.: 8 

Licensee: Owensby & Kritikos, Inc. License No.: LA-2234-L0 

Date of Incident: 1/10/05 NMED No.: 060086 

Investigation Date: 1/30/06 Type of Incident: Overexposure 

 Type of Investigation: Site 

File No.: 9 

Licensee: Cardinal Health Nuclear Pharmacy License No.: LA-9089-L01 

Date of Incident: 5/22/06 NMED No.: 060378 

Investigation Date: None Type of Incident: Loss of control of RAM 

 Type of Investigation: Written report 

File No.: 10 

Licensee: Lafayette General Medical Center License No.: LA-0581-L01 

Date of Incident: 4/4/07 NMED No.: 070206 

Investigation Date: 4/4/07 Type of Incident: Lost RAM 

 Type of Investigation: Site 

File No.: 11 

Licensee: Nondestructive & Visual Inspection License No.: LA-5601-L01 

Date of Incident: 3/9/06 NMED No.: 060257 

Investigation Date: 3/27/06 Type of Incident: Equipment damage 

 Type of Investigation: Written report 

File No.: 12 

Licensee: Nondestructive & Visual Inspection License No.: LA-5601-L01 

Date of Incident: 2/16/06 NMED No.: 060135 

Investigation Date: 3/15/06 Type of Incident: Overexposure 

 Type of Investigation: Site 

File No.: 13 

Licensee: Mary Bird Perkins Cancer Center License No.: LA-2651-L01 

Date of Incident: 11/22/05 NMED No.: 060046 

Investigation Date: None Type of Incident: Medical event 

 Type of Investigation: Written report 

File No.: 14 

Licensee: Schlumberger License No.: LA-2789-L01 

Date of Incident: 7/15/05 NMED No.: 050498 

Investigation Date: 7/21/05 Type of Incident: Lost RAM 

 Type of Investigation: Not recorded 

File No.: 15 

Licensee: Global X-Ray & Testing Corp. License No.: LA-0577-L01 

Date of Incident: 7/14/05 NMED No.: 050462 

Investigation Date: Not recorded Type of Incident: Equipment failure 

 Type of Investigation: Not recorded 
Louisiana Final Report Page E.3 

Incident Casework Reviews

File No.: 16 

Licensee: Christus Saint Francis Cabrini Hospital License No.: LA-070403 

Date of Incident: 6/29/07 NMED No.: 1121-L01 

Investigation Date: 7/9/07 Type of Incident: Medical event 

 Type of Investigation: Site 

File No.: 17 

Licensee: Alpha Omega Services License No.: LA-10025-L01 

Date of Incident: 7/11/07 NMED No.: 070426 

Investigation Date: 7/11/07 Type of Incident: Lost RAM 

 Type of Investigation: Site 

File No.: 18 

Licensee: Eustis Engineering License No.: LA-2922-L01 

Date of Incident: 11/15/07 NMED No.: 070762 

Investigation Date: None Type of Incident: Damaged equipment 

 Type of Investigation: N/A 

File No.: 19 

Licensee: Team Industrial Services, Inc. License No.: LA-9098-L01 

Date of Incident: 1/25/08 NMED No.: 080135 

Investigation Date: 3/7/08 Type of Incident: Overexposure 

 Type of Investigation: Site 

File No.: 20 

Licensee: Metco Nondestructive Testing License No.: LA-8043-L01 

Date of Incident: 5/24/06 NMED No.: 060427 

Investigation Date: None Type of Incident: Equipment failure 

 Type of Investigation: N/A 

File No.: 21 

Licensee: Gilchrist Construction License No.: LA-7890-L01 

Date of Incident: 7/20/06 NMED No.: 060468 

Investigation Date: 7/21/06 Type of Incident: Stolen Gauge 

 Type of Investigation: Site 
Louisiana Final Report Page E.4 

Incident Casework Reviews

SEALED SOURCE AND DEVICE INCIDENT CASEWORK REVIEWS 

File No.: 22 

Licensee: Oncology Systems, Inc. License No.: LA-11598-L01 

Date of Incident: 2/9/08 NMED No.: 080087 

Investigation Date: 2/26/08 Type of Incident: Equipment failure 

 Type of Investigation: Site 

Comments: 

a) The Division did not provide NMED with any updates between the initial report submitted 

February 11, 2008, and May 15, 2008. The Division provided a substantial update to 

NMED on May 15, 2008. 

b) At the time of the review, the Division continued to investigate the incident and, therefore, 

the incident was not closed in NMED. 

File No.: 23 

Licensee: Central Testing Co. License No.: LA-2393-L01 

Date of Incident: 11/17/04 NMED No.: 050003 

Investigation Date: 11/29/04 Type of Incident: Equipment failure 

 Type of Investigation: Site 

File No.: 24 

Licensee: Savoy Technical Services License No.: LA-11235-L01 

Date of Incident: 7/23/2007 NMED No.: 070473 

Investigation Date: 8/1/2007 Type of Incident: Equipment failure 

 Type of Investigation: Site 
APPENDIX F 

SEALED SOURCE AND DEVICE REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Registry No.: LA-0612-D-102-U SS&D Use Code: (A) Industrial Radiography 

Applicant=s Name: Source Production 

 & Equipment Co. Type of Action: Amended registration 

Date Issued: 5/5/08 SS&D Reviewers: JP, AT 

Comments: 

a) The first page information section of the registration did not contain any use code letter. 

The use code letter should be AA.@

b) The header section of the registration incorrectly indicated AU@ for unknown. The header 

should instead indicate AS@ to acknowledge use of the device for only specific licensees. 

c) The issuing agency section of the registration indicated APrepared By@. The issuing 

agency should acknowledge the AReviewer@ instead of the preparer of the registration. 

d) The diagrams section of the registration referred to an appendix without specificity to the 

list or number of pages attached. The attachments should be numbered (e.g. 

Attachment 1 of X) and include the header information. 

File No.: 2 

Registry No.: LA-0760-S-102-S SS&D Use Code: (V) General Medical Use 

Applicant=s Name: Alpha-Omega Services, Inc. Type of Action: Corrected registration 

Date Issued: 11/19/03 SS&D Reviewer: MH 

File No.: 3 

Registry No.: LA-1281-D-101-S SS&D Use Code: (V) General Medical Use 

Applicant=s Name: Oncology Systems Type of Action: New registration 

Date Issued: 8/7/07 SS&D Reviewers: TH, AT 

Comments: 

a) The first page information section of the registration incorrectly indicated the use code as 

A(V) General Medical Use@. Such use code was discontinued in 2002. The use code 

should be A(AC) Photon-emitting Remote Afterloaders.@

b) The FDA Approval Summary was not included in the registration. 
Louisiana Final Report Page F.2 

Sealed Source and Device Casework Reviews

File No.: 4 

Registry No.: LA-0612-S-115-S SS&D Use Code: (V) General Medical Use 

Applicant=s Name: Source Production 

 & Equipment Co. Type of Action: New registration 

Date Issued: 8/7/07 SS&D Reviewers: JP, AT 

Comments: 

a) The first page information section of the registration incorrectly indicated the use code as 

A(V) General Medical Use@. Such use code was discontinued in 2002. The use code 

should be A(AC) Photon-emitting Remote Afterloaders.” 

b) The FDA Approval Summary was not included in the. 

c) The header section of the registration indicates ASafety Evaluation of a Device@. The 

header should instead indicate ASafety Evaluation of a Sealed Source.@

d) The diagrams section of the registration identifies diagrams which were made part of the 

pages of the registration instead of as attachments to the registration. Attachments 

should be numbered (e.g. Attachment 1 of X) and be included after the pages of the 

registration. 
ATTACHMENT 

July 1, 2008, Letter from Harold Leggett 

Louisiana’s Response to Draft IMPEP Report 

ADAMS Accession No.: ML082040290