DATED: DECEMBER 30, 1997 SIGNED BY: HUGH L. THOMPSON, JR.

Mr. Mark E. Weidler, Secretary

Environment Department

1190 St. Francis Drive

P.O. Box 26110

Santa Fe, NM 87502

Dear Mr. Weidler:

On October 23, 1997 and December 11, 1997, the Management Review Board (MRB) met to consider the proposed final Integrated Materials

Performance Evaluation Program (IMPEP) report on the New Mexico Agreement State Program. The IMPEP review was conducted 

July 14-18, 1997. The MRB had received for consideration the actions described in your letter of October 10, 1997 and William M. Floyd’s letter

dated December 3, 1997. The MRB found the New Mexico program adequate but needs improvement, and compatible with NRC's program. 

Because of the significance of the concerns, the MRB recommends heightened oversight of the New Mexico program. I request that monthly

conference calls take place with the appropriate New Mexico and NRC staffs to discuss the status of the program. The Office of State Programs

will coordinate the monthly teleconferences. I also request that written progress reports addressing the IMPEP team's suggestions and

recommendations found in Section 5.0, page 19, of the enclosed final report be submitted to Richard L. Bangart, Director, Office of State

Programs, every other month. The first progress report is requested by February 1, 1998.

Based on the results of the current IMPEP review, the follow-up review will be scheduled for July 1998. The follow-up review will cover the State’s

action on the recommendations from the July 1997 review.

I appreciate the courtesy and cooperation extended to the IMPEP team during the review, to me and my staff during our December 4, 1997

meeting, and your continuing support of the Radiation Control Program. I look forward to our agencies continuing to work cooperatively in the

future.

Sincerely, /RA/

Hugh L. Thompson, Jr.

Deputy Executive Director

 for Regulatory Programs

Enclosure:

As stated

cc: Benito Garcia, NM

Ed Kelley, NM

William Floyd, NM
Mr. Mark E. Weidler, Secretary

Environment Department

1190 St. Francis Drive

P.O. Box 26110

Santa Fe, NM 87502

Dear Mr. Weidler:

On October 23, 1997 and December 11, 1997, the Management Review Board (MRB) met to consider the proposed final Integrated Materials

Performance Evaluation Program (IMPEP) report on the New Mexico Agreement State Program. The IMPEP review was conducted 

July 14-18, 1997. The MRB had received for consideration the actions described in your letter of October 10, 1997 and William M. Floyd’s letter

dated December 3, 1997. The MRB found the New Mexico program adequate but needs improvement, and compatible with NRC's program. 

Because of the significance of the concerns, the MRB recommends heightened oversight of the New Mexico program. I request that monthly

conference calls take place with the appropriate New Mexico and NRC staffs to discuss the status of the program. The Office of State Programs

will coordinate the monthly teleconferences. I also request that written progress reports addressing the IMPEP team's suggestions and

recommendations found in Section 5.0, page 19, of the enclosed final report be submitted to Richard L. Bangart, Director, Office of State

Programs, every other month. The first progress report is requested by February 1, 1998.

Based on the results of the current IMPEP review, the follow-up review will be scheduled for July 1998. The follow-up review will cover the State’s

action on the recommendations from the July 1997 review.

I appreciate the courtesy and cooperation extended to the IMPEP team during the review, to me and my staff during our December 4, 1997

meeting, and your continuing support of the Radiation Control Program. I look forward to our agencies continuing to work cooperatively in the

future.

Sincerely,

Hugh L. Thompson, Jr.

Deputy Executive Director

 for Regulatory Programs

Enclosure:

As stated

cc: Benito Garcia, NM bcc: Chairman Jackson

Ed Kelley, NM Commissioner Dicus

William Floyd, NM Commissioner Diaz

Commissioner McGaffigan

Distribution: DCD (SP01) LRakovan

DIR RF PDR (YEST) KSchneider

SDroggitis FCameron, OGC TFrazee, WA

JHornor, RIV/WCFO HNewsome, OGC SMoore, NMSS

CHackney, RIV GDeegan, NMSS New Mexico File

RScrano, RIV LHowell, RIV

DOCUMENT NAME: G:\KXS\97FINLTR.NM, G:\KXS\NMIMP97.FIN *See previous concurrence.

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

OFFICE RIII OSP OSP:DD OSP:D DEDR

NAME JLynch:kk KNSchneider PHLohaus RLBangart HLThompson

DATE 12/24/97* 12/24/97* 12/24/97* 12/ 24/97* 12/ 30/97*

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

REVIEW OF NEW MEXICO AGREEMENT STATE PROGRAM

July 14-18, 1997

FINAL REPORT

U.S. Nuclear Regulatory Commission
New Mexico Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the New Mexico radiation control program. The

review was conducted during the period July 14-18, 1997, by a review team comprised of

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

of Washington. Team members are identified in Appendix A. The review was conducted in

accordance with the "Interim Implementation of the Integrated Materials Performance Evaluation

Program Pending Final Commission Approval of the Statement of Principles and Policy for the

Agreement State Program and the Policy Statement on Adequacy and Compatibility of Agreement

State Programs," published in the Federal Register on October 25, 1995, and the September 12,

1995, NRC Management Directive 5.6, "Integrated Materials Performance Evaluation Program

(IMPEP)." Preliminary results of the review, which covered the period August 13, 1994 to July 13,

1997, were discussed with New Mexico management on July 18, 1997.

A draft of this report was issued to New Mexico for factual comment on August 8, 1997. The State

requested and received a month’s extension for replying to the draft report. The State of New

Mexico responded in a letter dated October 10, 1997 (Attachment 1). The State's factual

comments were incorporated in the final report. The Management Review Board (MRB) met on

October 23, 1997 to consider the proposed final report. At the time of the review, the review team

found the State’s performance to be satisfactory for the indicator, Technical Quality of Licensing

Actions; satisfactory with recommendations for improvements for the indicators, Status of

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

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

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

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

Mexico be placed on probation and noted that heightened oversight is warranted. During the

MRB meeting, three main issues were identified that New Mexico had to address in terms of

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

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

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

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

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

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

the program.

On December 4, 1997, Mr. Thompson, NRC and other NRC managers met with Secretary Mark

Weidler, New Mexico Environment Department and his staff to discuss performance concerns

associated with the New Mexico Agreement program. See Attachment 2, December 4, 1997

NRC/New Mexico Management Meeting Minutes.

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

Based on the New Mexico actions to date, and the commitments by Secretary Weidler, the MRB

concluded probation was not warranted. Based on implementation of new procedures for

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

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

recommendations for improvements. The MRB directed that the follow-up review be conducted
New Mexico Final Report Page 2

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

staff, and that written progress reports be submitted every other month.

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

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

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

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

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

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

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

which includes a megacurie pool irradiator, manufacturers, broad academic programs, broad

medical programs, nuclear pharmacies and industrial radiographers. 

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

Atomic Energy Act of 1954, as amended) Agreement between the NRC and the State of New

Mexico.

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

performance indicators was sent to the State on April 10, 1997. New Mexico provided its

response to the questionnaire on June 16, 1997. A corrected copy of the questionnaire was

received on July 25, 1997. A copy of that response is included as Appendix C to this report. 

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

New Mexico's response to the questionnaire, (2) review of applicable New Mexico statutes and

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

and inspection database, (4) technical review of selected licensing and inspection actions, 

(5) field accompaniments of three New Mexico inspectors, and (6) interviews with staff and

management to answer questions or clarify issues. The team evaluated the information that it

gathered against the IMPEP performance criteria for each common and non-common performance

indicator and made a preliminary assessment of the radiation control program's performance. 

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

previous review. Results of the current review for the IMPEP common performance indicators are

presented in Section 3. Section 4 discusses results of the applicable non-common performance

indicators and Section 5 summarizes the review team's findings, recommendations and

suggestions. Suggestions made by the review team are comments that the review team believes

could possibly enhance the State’s program. Recommendations made by the review team are

comments the review team believes are areas to be addressed to maintain performance by the

State. A response will be requested from the State to all recommendations in the final report.

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

The previous routine review concluded on August 12, 1994, and the results were transmitted to

Judith M. Espinosa, Secretary, New Mexico Environment Department, on February 7, 1995. The

review findings resulted in recommendations in two program indicators. The team’s review of the

current status of these recommendations is as follows:
New Mexico Final Report Page 3

(1) At the time of the 1994 review, the New Mexico radiation protection regulations had

last been amended on March 10, 1989. Compatibility was withheld because the

State had failed to meet the three-year time frame required for adopting regulations

equivalent to nine NRC regulations deemed matters of compatibility: (1)

bankruptcy notification, (2) quarterly audit of the performance of radiographers, (3)

well logging requirements, (4) National Voluntary Laboratory Accreditation Program

(NVLAP) certification of dosimetry processors, (5) decommissioning requirements,

(6) emergency plans, (7) safety requirements for radiographic equipment, (8) 10

CFR Part 20 equivalent regulations, and (9) notifications of incidents.

Current Status: New Mexico’s regulations equivalent to the nine NRC regulations

listed above were part of a package of regulations which were adopted on April 3,

1995, and which became effective on May 3, 1995. After reviewing the drafts of

these proposed regulations, in a letter dated January 9, 1995, the Office of State

Programs (OSP) offered the State a tentative finding of compatibility pending NRC

review of the final, published regulations. The review team evaluated the

published regulations against the equivalent NRC regulations. Pending review by

NRC’s Office of General Counsel (OGC), the team recommends that these

regulations be found compatible with NRC requirements. This recommendation is

closed.

(2) The 1994 review recommended that the State review and compile internal

procedures for staff use in the interest of maintaining consistency in licensing and

compliance activities.

Technical staff members wrote procedures for licensing, inspection and allegation

follow up. The procedures have not been shared with all staff members, however,

creating program inconsistencies which are discussed in Sections 3 and 4 of this

report. This recommendation is closed.

 

3.0 COMMON PERFORMANCE INDICATORS

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

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

Program, (2) Technical Staffing and Training, (3) Technical Quality of Licensing Actions, (4)

Technical Quality of Inspections, and (5) Response to Incidents and Allegations. 

3.1 Status of Materials Inspection Program

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

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

licensees. This evaluation is based on the New Mexico questionnaire responses relative to this

indicator, data gathered independently from the State's licensing and inspection data tracking

system, the examination of completed licensing and inspection casework, and interviews with

managers and staff.
New Mexico Final Report Page 4

The team's review of the State's inspection priorities verified that the State's inspection

frequencies for various types or groups of licenses are at least as frequent as similar license types

or groups listed in the NRC Inspection Manual Chapter 2800 (IMC 2800) frequency schedule, with

one exception. The New Mexico inspection frequency for nuclear pharmacies is 2 years as

opposed to one year in IMC 2800. Staff indicated that this difference was due to an oversight as

the State copy of IMC 2800 was out of date. The review team recommends that the nuclear

pharmacy inspection frequency be modified from 2 years to 1 year.

In reviewing the State's priority schedule, the review team noted that none of the New Mexico

inspection frequencies exceed 3 years. Specifically, examples of license categories in which the

State requires more frequent inspections are as follows:

Type of License New Mexico Frequency (years) NRC Frequency (years)

Well logging 2 3

Medical institution 2 3 or 5

Medical private practice 2 3 or 5

Academic Type B broad 2 3

Veterinary 2 5

Portable gauges 2 5

Fixed gauges 3 5

In response to the questionnaire, New Mexico indicated that no inspections were overdue by more

than 25% of the scheduled frequency. The team identified several inspections that were overdue

compared to the State frequencies but would not be considered overdue with respect to IMC 2800

frequencies. 

With respect to initial inspections of new licenses, the team evaluated the inspection tracking data

system and verified that initial inspections were entered into the computerized tracking system

together with existing licenses. Inspection due dates generated by the system for new licenses

are combined by inspection priority with those for other materials licenses. A review of the

inspection tracking system showed that initial inspections are not differentiated from routine

inspections, since the tracking system does not display a six month due date for initial inspections. 

From interviews, team reviewers found that the inspection staff was generally able to identify

licenses due for initial inspections by the license number. The higher-numbered licenses are new

issues indicating an initial inspection is necessary. 

A review of 25 license files, with initial inspections due during the review period, identified eight

licenses which had initial inspections performed within 6 months. Nine licenses had initial

inspections performed late, ranging from 1 to 21 months past the six-month window, and eight

licenses were overdue for initial inspections at the time of the review, from 1 to 34 months past the

six-month window. The review team recommends that initial inspections of licensees be

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

material and commencement of operations, consistent with IMC 2800. Also, the review team

recommends that the tracking system be revised to allow initial inspections to be readily identified

to staff and management.
New Mexico Final Report Page 5

In their response to the questionnaire, RLRP reported that 148 reciprocal licenses were issued;

however, only about one-half of the reciprocity licensees filed notifications and received

authorization to conduct activities during the review period. Of the 148 reciprocal licenses issued,

45 were industrial radiographers, 26 were well loggers and four were teletherapy/high dose rate

afterloader source replacements. Approximately one-half of the reciprocities were for gauge or

portable device uses. RLRP performed only three inspections of reciprocity licensees, two

industrial radiographers and one gauge user, during the review period.

Reciprocity requests are recorded in a log and are available for review by inspectors but

inspections are rarely performed. Both program management and staff indicated that short lead

times and significant travel distances were impediments to performing reciprocity inspections. The

review team recommends that the State increase the number of reciprocity inspections to better

evaluate the health and safety implications of out-of-state companies working in New Mexico.

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

review. For the inspection findings examined, the correspondence for nine inspections was sent

to the licensee within 30 days of the inspection date. Eight inspections were "clear," and in

several cases the inspection correspondence was sent within 1 to 2 days after the inspection. For

three inspections, the correspondence was sent to the licensee greater than 30 days past the

inspection date. All involved cases with deficiencies that were noted by the inspector. (New

Mexico’s definition of “deficiency” is identical to NRC’s definition of “violation.” In this report, the

two terms are interchangeable.) Inspection deficiency letters to New Mexico licensees require a

higher level of signature (Chief, HRMB), rather than the inspector. Two of the three letters were

dispatched within 40 days of the inspection date. The third was issued 3 months after the

inspection date. In the longest (3-month) case, the inspector was relatively new and did not

understand the significance of quickly informing the licensee, in writing, of the inspection findings. 

While the New Mexico program has a few cases where inspection results were issued late (i.e.,

past the 30-day IMPEP criterion), the review team found that performance in this area was

generally acceptable.

Based on the IMPEP evaluation criteria, the review team recommends that New Mexico's

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

satisfactory with recommendations for improvement.

3.2 Technical Staffing and Training

Issues central to the evaluation of this indicator include the radioactive materials program staffing

level, technical qualifications of the staff, training and staff turnover. To evaluate these issues, the

review team examined the State's questionnaire responses relative to this indicator, interviewed

program management and staff, and considered any possible workload backlogs.

The RLRP Manager stated that all technical staff positions require a bachelor’s degree in the

sciences. Positions are classified as either Environmental Specialists, requiring 4 years

experience or as Environmental Scientists, with 2 years experience.
New Mexico Final Report Page 6

The RLRP has a staffing level of one manager, five Environmental Specialists and one secretary. 

One of the Environmental Specialist positions was vacated on July 1, 1997, when a staff member

retired. Another Environmental Specialist is expected to retire in 1997. This staff is responsible

for the radioactive materials program, the Naturally Occurring Radioactive Material (NORM)

program and the x-ray program. Approximately 55% of each Environmental Specialist’s time is

allocated for the Radioactive Materials Program. This equates to approximately 2.75 technical

FTEs for the 245 license program. Based on review results, this staffing level appears to be a

minimal level for a program of this size. With the recent departure of a retired staff member, the

staffing level is even lower and raises concerns about the general effectiveness of the program.

The HRMB Chief indicated that the vacant position and the upcoming vacancy would likely be

filled in the near future. The authority to fill these positions has been granted. The review team

recommends that the State maintain the RLRP staffing level to at least the level which existed

throughout the review period.

The radioactive materials staff is split between two offices, the main office in Santa Fe, with the

RLRP Manager and two Environmental Specialists and an office in Albuquerque, with two (three

until recently) Environmental Specialists. The RLRP Manager stated that he had tried to have

staff perform inspection and licensing at both offices but he brought all of the licensing work back

to the Santa Fe office to centralize and manage the licensing program more effectively. The

Santa Fe office staff took full responsibility for licensing due to this reorganization of responsibility.

With the exception of the individual who recently left the program and one outstanding course for

one staff member, technical staff have attended the core NRC training courses. Two areas of

significant training need were identified during the review and inspector accompaniments. The

first area is irradiator technology, particularly important as the State licensed a megacurie pool

type irradiator last year. Only limited training was received by one Environmental Specialist from

the irradiator vendor as the facility was brought on line. The other area in which additional

training is needed is medical brachytherapy. New Mexico has several medical licensees who

utilize various brachytherapy modalities, including high dose rate afterloaders. None of the

program staff have attended a brachytherapy training course or have had any other significant

training or experience in this area.

The RLRP Manager stated that, as New Mexico does not charge fees to its licensees and the

general fund allocation for training is extremely limited, there is little chance that RLRP personnel

will attend any conventional NRC training courses, unless NRC reassumes the cost for such

training. Program management was directed to All Agreement States Letter

 SP-97-040, dated June 9, 1997, which proposed criteria for States with financial need to receive

training aid from NRC. The team believes that New Mexico may be a strong candidate for

receiving funding from the NRC for training purposes. The team also discussed with the RLRP

Manager potential alternative training methods which could be used to train staff in brachytherapy

and irradiator technology. The review team recommends that the State provide training to

technical personnel in the areas of medical brachytherapy and irradiator technology.

The RLRP Manager stated that he provides on-the-job training to staff, explaining program

procedures, and accompanies each inspector on at least two inspections per year. There is no
New Mexico Final Report Page 7

documented training and qualification program in place for the RLRP staff comparable to IMC

1246, “Formal Qualification Programs in the Nuclear Material Safety and Safeguards Program

Area.” As an example, the review team noted that licensing and inspection procedures had been

developed by various staff members but that not all staff had been trained in these new

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

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

Safeguards Program Area.”

Based on the team's finding and the IMPEP evaluation criteria, the review team recommends that

New Mexico's performance with respect to this indicator, Technical Staffing and Training, be

found satisfactory with recommendations for improvement.

3.3 Technical Quality of Licensing Actions

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

11 specific licenses. Licensing actions were evaluated for completeness; consistency; proper

isotopes and quantities authorized; qualifications of authorized users; adequate facilities and

equipment; and operating and emergency procedures sufficient to establish the basis for licensing

actions. Licenses were reviewed for accuracy, appropriateness of the license and of its

conditions and tie-down conditions, and overall technical quality. Casework was evaluated for

timeliness; adherence to good health physics practices; reference to appropriate regulations;

documentation of safety evaluation reports, product certifications or other supporting documents;

consideration of enforcement history on renewals; pre-licensing visits; peer or supervisory review

as indicated; and proper signature authorities. The files were checked for retention of necessary

documents and supporting data.

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

had been completed in the review period and to include work by all reviewers. The cross-section

sampling included several of New Mexico's major licenses and included the following types: 

nuclear laundry; pool irradiator; well logging; nuclear medicine; fixed gauge; academic research

and development; veterinarian; and industrial radiography. Licensing actions evaluated included

three new licenses, two renewals, one pending renewal, three amendments, and two terminations. 

In discussions with the RLRP Manager, it was noted that there were no major decommissioning

efforts underway with regard to agreement material in New Mexico. Also, there were no identified

sites with potential decommissioning difficulties equivalent to those sites in NRC’s Site

Decommissioning Management Plan. A list of these licenses with case-specific comments may be

found in Appendix D.

The Interstate Nuclear Services (INS) license renewal was selected for review because the State

has expended considerable staff resources with this renewal and is faced with opposition. A

series of public hearings were held in 1996 culminating when the Secretary of the Department

issued an order to renew the license subject to INS completing several conditions to the

satisfaction of the Department. However, the main point of contention between the State and the

opposition to renewal is the issue of “solubility” of radioactive particulates in liquid effluents

discharged to the sewage system and whether the State will accept INS*s proposed waste water

treatment system. The State requested technical assistance from NRC. The State has sought to
New Mexico Final Report Page 8

identify potential contractors to evaluate the proposed waste water system and has queried other

Agreement States to determine how the “solubility” criteria are being addressed in those States. 

INS has not yet submitted complete information to address all conditions of the Secretary*s order. 

The license reviewer intends to require the licensee to consolidate the interim submittals into a

final renewal package. A final license application review will be performed when the renewal

package is complete. Issuance of this renewal is still pending.

With respect to the overall licensing program, the RLRP Manager stated that licensing quality had

suffered when licensing actions were being handled out of two different offices. The RLRP

Manager sought to improve licensing quality by bringing all licensing actions back to Santa Fe in

early 1996. He also began performing many of the licensing reviews himself, concentrating on

amendments and simple renewals to improve quality and consistency. 

Licensing actions of all types appear to be completed in a timely fashion with most renewals being

completed within 6 months of the expiration date. The RLRP Manager noted that “construction”

visits were performed for the new panoramic, wet-storage irradiator and that an in-office

consultation was held with another license applicant but there were no other pre-licensing visits

for the few complex licenses that New Mexico had issued. The RLRP Manager estimated that as

many as 50% of new licenses were hand delivered as a means of establishing open

communications with new licensees. 

Retention of supporting documentation is a program weakness. Required documents were found

to be missing in 9 of 11 files evaluated. These documents included: licensee application

submittals, a renewal request, a licensee*s response to a compliance letter that required a

licensing change, detailed schedules for testing and maintenance, evidence of named users*

training and experience, verification that sources had been transferred properly, misfiled

correspondence, and the results of close-out inspections. Documentation of the license reviewers

work was particularly weak. Deficiencies identified by reviewers were apparently communicated

by telephone in many cases with no record of the deficiency or its resolution unless the licensee*s

correspondence was clear. Reviewer checklists were present in new license files. The review

team suggests that documentation of license reviewers’ actions be maintained in license files.

All new licenses are reviewed and signed by the HRMB Director before being issued. All renewed

licenses and amendments are reviewed and signed by the RLRP Manager. However, the RLRP

Manager performs approximately one-half of all licensing actions and signs his own work without

significant peer or supervisory review. No potentially significant health and safety issues were

identified. 

The review team found that, despite documentation deficiencies, the licensing actions were

thorough, complete, consistent, and of acceptable quality with health and safety issues

adequately addressed. Special license tie-down conditions were not observed. The licensee's

compliance history was taken into account when reviewing renewal applications. New Mexico's

licensing guides and license policy procedures were revised and updated after the last program

review. New Mexico's licensing guides and license conditions were adopted directly from the

NRC's. Reviews of licensing actions showed reviewers appropriately used the revised licensing
New Mexico Final Report Page 9

guides for new licenses and the absence of major findings indicates that the reviewers have a

generally good understanding of applicable guidance.

Based on the IMPEP evaluation criteria, the review team recommends that New Mexico's

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

satisfactory.

3.4 Technical Quality of Inspections

The team reviewed the inspection reports, supporting documentation and correspondence to

licensees for 12 materials inspections conducted during the review period. The casework

included the State's four fully-qualified materials inspectors and one inspector who left the

program during the review period (another inspector left the program early in the review period,

and her work was not reviewed). Inspection reports were selected to cover the whole review

period and to emphasize higher-priority licensees. The review team examined inspection

casework of the following types of licensees: one medical institution; one pool-type irradiator; one

nuclear laundry; one well logger; one nuclear pharmacy; one industrial radiographer; one portable

gauge; two academic licensees; two research and development licensees (one of which "tagged"

radionuclides to well logging tracers) and one broad medical that included a high dose rate (HDR)

remote afterloader, brachytherapy, nuclear medicine, and academic research and development. 

Following the casework evaluation, the review team interviewed each of the four inspectors. 

Appendix E provides a list of the inspection cases evaluated in depth with case-specific

comments.

Overall, the review team found that the inspector accompaniments and most inspection reports

showed acceptable, but not strong, technical quality of inspections. Interviews with inspectors

backed up the review team's findings that inspections were being conducted regularly, but

moderate to significant areas that needed improvement were apparent in the State's inspection

program.

Three inspector accompaniments identified in Appendix E were performed by a review team

member on June 16-18, 1997. The other two New Mexico inspectors had been accompanied

during past reviews. During the accompaniments, inspectors demonstrated a range in skills and

abilities for the specific types of inspections they were performing. In two of the three

accompaniments, inspection techniques were observed to be primarily records-review oriented,

with missed opportunities when inspectors could have observed licensee operations. The

accompaniments demonstrated that inspectors were not missing critical safety areas, but the

inspections were not thorough, either. For example, on one accompaniment at a hospital, the

inspector was not sufficiently trained in brachytherapy and missed opportunities to interview

therapy technologists and ancillary personnel. In general, the inspections were adequate to

assess the most significant radiological health and safety issues, although on some, the

inspectors showed significant room for improvement. 

Inspection reports were evaluated to determine if the reports adequately documented the scope of

the licensed program, licensee organization, personnel protection, posting and labeling, control of

materials, equipment, use of materials, transfer and disposal. The review team also evaluated
New Mexico Final Report Page 10

whether the reports adequately documented operations observed, interviews of workers,

independent measurements, status of previous violations, substantiation of all violations and the

substance of discussions during exit interviews with management. To assure consistency and

quality of reports, the RLRP Manager provides review and signs inspection reports.

For 9 out of the 12 inspections reviewed, inspectors did not perform observations of licensee

operations. In fact, on some inspection reports, the inspectors specifically noted that they had not

observed licensee operations. In interviews, the inspectors asked the review team what type of

operations should be observed, especially when conducting office inspections of industrial

licensees and afternoon-inspections of diagnostic medical licensees. The review team noted that

licensees can demonstrate actions (such as surveys, transportation practices, interlock checks,

and so on), but the State inspectors did not indicate that such demonstrations or observations

were being conducted on a routine basis during inspections. Even though the inspectors have

attended the NRC inspection training course, the principal inspection effort seems focused on

records review, which is contrary to the national (NRC and Agreement State) trend in inspecting

for licensee performance. The review team recommends that the State inspectors attempt to

observe licensee operations or demonstrations during all inspections.

On three of the inspections evaluated, inspectors did not conduct independent measurements. In

one case, the inspector’s survey instrument malfunctioned. The inspectors could not provide

adequate explanation regarding why independent measurements were not conducted during the

other two inspections. In other cases, independent measurements were performed but no specific

results were indicated in inspection reports. Inspectors were knowledgeable that they should

conduct independent measurements during inspections, and some inspectors even performed

confirmatory measurements (i.e., side-by-side readings with licensee survey instruments), which is

commendable. Conducting measurements for radiation levels should be an essential element of

routine byproduct material inspections. The review team recommends that the State inspectors

conduct independent measurements on all inspections.

The review team noted that, on a number of inspections evaluated, that the State was not

examining complex, technical radiation safety/health physics issues in sufficient detail during

inspections. For instance, on inspections of a medical institution using limited quantities of iodine131 and on a tagging licensee, inspectors apparently did not review licensee effluent releases,

even though the licensees had potential for material release. Similarly, inspectors did not

regularly review bioassay adequacy or estimate doses (when licensees did not conduct

bioassays), review Annual Limits on Intake and Derived Air Concentrations, provide dosimetry

results on several inspection reports, and provide sufficient detail on a licensee's respiratory

protection program. In addition to this lack of technical complexity and detail, the review team

observed that many of the inspections omitted key program areas or were not sufficiently broad. 

For instance, the review team observed instances where RLRP inspections did not sufficiently

close previous violations, address training, resolve emergency preparedness issues, address

shipping or cover annual radiation protection program reviews. In response to these findings, the

review team recommends that the State increase the rigor of reviewing technical health physics

issues during inspections, and increase the breadth and scope of inspections. Additionally, the

review team noted that few, if any, ancillary worker (such as facility housekeeping staff, students,

administrative staff and medical assistants) interviews were conducted by the inspectors. The
New Mexico Final Report Page 11

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

inspections.

On 8 of the 12 inspections evaluated, the inspector conducted exit meetings with the licensee's

radiation safety officer (RSO) or a principal authorized user. In a few of these cases, the RSO

was also a senior licensee manager. However, as determined through interviews, inspectors

generally did not conduct exit meetings with senior licensee managers, or did not make substantial

efforts to conduct exit meetings with senior licensee managers (i.e., managers who control the

radiation safety program's authority, staffing, and resources). This is in conflict with the State's

own policy that, "An exit interview with the highest available representative of administration or

management shall be conducted by the inspector...." A cause of this may have been that few

inspectors knew about the procedures. The review team recommends that the State inspectors

attempt to conduct formal exit meetings with senior licensee management on all inspections.

The review team examined the State's performance regarding follow up on previously cited

violations (deficiencies). On one of the inspections, the licensee was cited for failure to calibrate

survey instrumentation. In response, the licensee stated what it had done to correct the problem. 

However, the licensee did not state what would be done to prevent this type of deficiency from

occurring again in the future. On the same inspection, the licensee was cited for an unauthorized

user. The licensee was told to amend its license to add an individual as an authorized user (the

individual apparently was using material at the time of the inspection), but the file does not

indicate that the licensee ever submitted an amendment request. On the next inspection, the

licensee was again given a deficiency for the same type of issue (i.e., told to amend its license to

add authorized users). Similar licensing issues were identified on other inspections. These

findings led the review team to conclude that New Mexico needs a mechanism to ensure that

licensee responses to deficiencies are adequate to address the cited problems, and that the

deficiency is closed and followed up on a future inspection. The review team recommends that

the State develop a formal process for reviewing licensee responses to deficiency letters and

closing open deficiencies. The State's inspection finding regarding the unauthorized user also

indicates that the State does not have a formal mechanism for transfer of information from the

inspector to the license reviewer, or vice versa, and the review team confirmed this in interviews. 

The closest that inspectors come to passing along information to the next license reviewer is by

telling them verbally about needed licensing actions. In the case noted above involving the

unauthorized user, this method apparently did not work or was not used. The review team

suggests that the State develop a formal process for inspectors and license reviewers to

document and transmit pertinent information to each other for follow up.

The review team also examined whether the State's inspection files were complete. On two of the

inspection files reviewed, the files did not contain responses to the licensees acknowledging their

responses and stating that the issues would be followed up on future inspections. Through

interviews, the review team learned that occasionally the licensee's response is filed in the license

file in Santa Fe, without being transmitted to the Albuquerque inspector for review. The review

team suggests that the State develop a process for ensuring that inspection files are complete,

that all appropriate State documents are prepared and filed, and that licensee responses are

received and filed.
New Mexico Final Report Page 12

Also in the area of documentation, the review team examined the inspection casework for the

State's new pool-type irradiator. The review team found that the first full, documented inspection

was conducted on July 1, 1997. A site visit on October 28, 1996, was also documented in a note

to the inspection file. However, the July inspection listed a number of previous trips to the

licensee's site where inspection activity was performed, but not documented (e.g., November 1996

source loading, December 1996 review of system operations and product dosimetry, etc.). 

Follow-up interviews with the inspectors confirmed that the State had conducted site visits or

inspections to the irradiator that were not documented. This is significant with respect to the pool

irradiator, because it is a new operation in New Mexico involving an extremely large inventory of

licensed material. The review team recommends that the State begin documenting all trips to

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

inspections, or performing pre-licensing site visits during construction. This documentation should

be filed in the State's official inspection file.

The review team identified a number of problems, covering both content and documentation, in

New Mexico's inspection program. The review team concluded that the RLRP Manager, who

signs each of the inspection reports as a reviewer, had the opportunity to identify many of these

issues during the supervisory review of the inspection reports. The review team recommends that

the State management exercise more stringent supervisory review of inspection reports.

In the area of the State's programmatic policy and management, the inspection procedures and

techniques utilized by New Mexico were evaluated and determined to be generally consistent with,

albeit in far less detail than, the inspection guidance provided in IMC 2800. Few of the inspectors

were aware of the presence of inspection guidance within the State. Training on the State's

internal procedures is discussed in Section 3.2.

The State's inspection report forms were reviewed and found to provide general inspection areas

consistent with the types of information collected under NRC's Inspection Procedure (IP) 87100

field notes. On the two most complex inspection cases reviewed (the irradiator and an HDR), the

State used NRC's field notes. On its own forms, the State already has developed an inspection

report format with major subheadings and spaces for narrative responses, a move away from the

checklist format, which is the approach that NRC is adopting for materials inspections. The State

has been revising its inspection report for approximately the past 2 years, according to the

inspector with lead responsibility for the inspection form revision, and in that interim time period

RLRP inspectors have used a variety of "draft" inspection report forms that the review team

observed in the inspection files. In interviews, the review team learned that RLRP inspectors

select their own forms for the type of inspection they are performing; the review team did not

identify any internal requirement or standardization within the State to use a specific report form

for documenting inspections. The review team also concluded that, because the inspection report

forms frequently determine the areas examined during an inspection, the forms themselves may

have contributed to the State's lack of breadth and technical complexity during its inspections. 

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

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

that RLRP inspectors begin using the standardized form(s).
New Mexico Final Report Page 13

Most inspection forms, correspondence, and documents were found in the files. Documented

inspection findings generally led to appropriate deficiency letters. In interviews with the

inspectors, none could recall any escalated enforcement cases during the review period. Of the

files reviewed, the State cites deficiencies on about one third of its inspections. 

In response to the questionnaire, the State reported that supervisory inspector accompaniments

were performed at least twice per year by the RLRP Manager for each inspector since the

previous review. Performance evaluations are discussed with the inspector and the

accompaniments documented. Accompaniments of less-experienced staff are also performed by

senior inspectors. 

The review team noted that RLRP has a sufficient number of calibrated, portable radiation

detection instruments for use during routine inspections and response to incidents and

emergencies. The State also has available the services of the State's Scientific Laboratory

Division in Albuquerque, which appeared to provide exceptional services on one of the inspections

reviewed.

Based on the IMPEP evaluation criteria, the review team recommends that New Mexico's

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

with recommendations for improvement.

3.5 Response to Incidents and Allegations

In evaluating the effectiveness of the State's actions in responding to incidents and allegations,

the review team examined the State's response to the questionnaire relative to this indicator and

evaluated the incidents reported for New Mexico in the "Nuclear Materials Events Database

(NMED)" against those contained in the New Mexico casework and license files. The team

evaluated casework in the license files maintained in the Santa Fe office and in files from the

Albuquerque office which were delivered to the review team. The team compiled a list of 31

incidents that had occurred in the State during the review period, examined the list for possible

trends or generic issues, and chose 11 of the more significant incidents for in-depth review. The

team also evaluated the State's response to the only two allegations reported by the State. A list

of the incidents with comments is included in Appendix F.

The review of the incident casework revealed five serious generic deficiencies in RLRP’s

response to incidents. First, circumstances in 5 of the 11 incidents indicated the need for onsite

response from the State; however, only one of the five received an onsite response, and it was

not documented, and thus could not be confirmed. The review team recommends that the State

make onsite, documented investigations of incidents, allegations, or misadministrations with

potential health and safety effects (i.e., source disconnects, possible overexposures, lost sources,

contamination, etc.). 

Second, in all cases, documentation of the State’s response was either missing or incomplete. 

The team found that the State has no procedures or forms in place to record information obtained

in the incoming calls, to track the progress of the investigation, to document management

involvement, or to close out the incident investigation. In evaluating the casework, the team
New Mexico Final Report Page 14

found that in five cases, the individual taking the incident report was not identified. In addition,

none of the files contained the investigator’s signature, evidence of management involvement or

review, or any notation that the investigation was completed and closed out. The review team

recommends that the State create an incident and allegation reporting form that would, at a

minimum, identify the person taking the initial report, list the name and telephone number of the

reporting party, provide the details of the incident or allegation as reported, record the State’s

conversation with the licensee or individual, describe corrective actions taken by the licensee,

describe the investigation conducted by the State and the results, list citations or other regulatory

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

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

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

license file.

Third, none of the casework contained any indication that the State evaluated the licensee’s

response or corrective actions. It appeared the State relied entirely on the licensee’s reports of

the incident and their corrective actions. The review team recommends that the State establish a

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

Fourth, generic deficiencies were noted in five cases where the incident should have been

followed up at the next inspection, but was not. The review team recommends that the State

initiate procedures to ensure incidents are followed up at the next inspection to verify that the

licensee’s corrective actions have been implemented.

Last, the team found that in five cases, licensees may have failed to comply with regulations but

were not cited. The review team suggests that when evaluating incidents, the State cite

appropriate deficiencies when applicable. 

New Mexico does not have an incident tracking system. RLRP does not keep a central log of

incident or allegation reports and does not maintain a separate incident file. Incidents may be

reported by the licensee directly to the Albuquerque inspector assigned to their territory, or they

may be reported to the RLRP office in Santa Fe and documents involving incidents may be kept

either place. From interviews with staff, the team found that events are assigned to the inspector

normally responsible for the licensee involved. The inspector then routinely requires the licensee

to investigate the incident and furnish a report with the details and corrective actions. That

licensee’s report is used when necessary to complete the NRC Event Report (Form 565) and then

filed in the license file. The State has no provision to file reports for incidents that do not involve

New Mexico licensees. In conducting the file reviews, the team had difficulty in assembling

information necessary to evaluate the State’s incident response because documents could not be

located and staff could not remember details of investigations. The review team recommends that

the State (a) set up a separate incident and allegation file system in the Santa Fe office, keeping

all documents and records pertaining to an incident in one location, with the data cross-referenced

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

centrally log and track the progress of incidents and allegations.

The New Mexico statewide emergency plan is the responsibility of the Department of Public

Safety. If other State agencies encounter incidents or emergencies related to radioactive
New Mexico Final Report Page 15

materials, the responsibility is delegated to the RLRP. The team found through interviews with

staff and management that RLRP has no written internal procedures for incident response other

than a November 1995 memorandum explaining the NRC event reporting criteria. In interviews

with the review team, the inspectors stated that they were not aware of any emergency

procedures and that they had not been trained in emergency response. The review team

recommends that the State develop and implement written procedures for responding to events

involving radioactive material and conduct training sessions until all technical staff are fully trained

and qualified in emergency response. These procedures and training should address the use of

the forms and tracking system recommended above.

The State does have brief written procedures for investigating allegations. It is their policy to

thoroughly investigate all allegations, including those made anonymously, to seek out and

interview corroborative witnesses, to investigate the reasons for confirmed events, and to

document all conversations. It is also their policy to respect anonymity to the highest possible

extent. The team noted, however, that New Mexico law does not protect the identity of individuals

making allegations. The review team suggests that the State keep expanding the allegation

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

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

system, and emergency response procedures. 

The team evaluated the two allegations that occurred in the State during the review period. In

both cases, the team found that the allegations were promptly evaluated to determine the validity

and safety significance of the claims. Onsite investigations were conducted promptly in both

cases. In one case, there was evidence that the State kept the individuals making the allegations

informed of the resolution of their concerns; in the other, there was not. In one complex and

lengthy case, the State held public hearings on the renewal of the license at the request of the

alleging parties. 
New Mexico Final Report Page 16

Except for the period between July 1995 and May 1996, the State provided quarterly event reports

to the NRC even though NRC has requested monthly reports. During the period between July

1995 and May 1996, the State did not provide reports to the NRC, and little to no documentation

of events exists. Two incidents that should have been reported were inadvertently omitted

through oversights. The team instructed the State to report the events to NMED on the next

monthly report. In the one case of a leaking source, the NRC and regulating agency of the

manufacturer were both advised. 

As discussed above, the team found frequent examples of incomplete, inappropriate, poorly

documented, or delayed responses to incidents, and as a result, potential health and safety

problems may exist. Therefore, at the time of the review, based on the IMPEP evaluation criteria,

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

Response to Incidents and Allegations, be found unsatisfactory. In response to the draft report,

the State issued new procedures on response to incidents that appeared adequate to address the

concerns. The MRB noted that the new procedures appeared adequate to address the concerns

and if these procedures are properly implemented, New Mexico would receive a rating of

“satisfactory with recommendations for improvement” for this indicator. At the time of the October

23, 1997 MRB, no incidents had been reported since the new procedures were put into place. 

During the December 11, 1997 MRB, it was noted that New Mexico had implemented new

procedures for three incidents. Based on the implementation of the new procedures, the MRB

directed the finding to be revised to satisfactory with recommendations for improvement.

4.0 NON-COMMON PERFORMANCE INDICATORS

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

State programs: (1) Legislation and Regulations, (2) Sealed Source and Device Evaluation

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

Operations. New Mexico's agreement does not cover uranium recovery operations, so only the

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

4.1 Legislation and Regulations

4.1.1 Legislative and Legal Authority

Along with their response to the questionnaire, the State provided the review team with copies of

legislation that affects the radiation control program. Legislative authority to create an agency

and enter into an agreement with the NRC is granted in New Mexico Statutes, 1978 Annotated,

Chapter 74, Environmental Improvement, Pamphlet 120 with 1989 Replacement Pamphlet, Article

3, Radiation Control Act, Sections 74-3-1 through 74-3-16. In the Act, the New Mexico

Environmental Department is designated as the State’s radiation control agency. The review

team evaluated the legislation which had not changed since the previous review and found State

legislation to be adequate.
New Mexico Final Report Page 17

4.1.2 Status and Compatibility of Regulations

The review team compared the State’s regulations against the latest Chronology of Amendments

and found that the State had adopted equivalent rules for all amendments which were due for

adoption by the Agreement States through July 1, 1996. However, the State had failed to revise

their equivalent regulations to the following NRC regulations identified as compatibility items:

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

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

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

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

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

and which became due on January 28, 1997. Note, this rule is designated as a Division 2

matter of compatibility. Division 2 compatibility allows the Agreement States flexibility to be

more stringent (i.e., the State could choose not to adopt self-guarantee as a method of

financial assurance). If a State chooses not to adopt this regulation, the State’s regulation,

however, must contain provisions for financial assurance that include at least a subset of

those provided in NRC’s regulations, e.g., prepayment, surety method (letter of credit or

line of credit), insurance or other guarantee method (e.g., a parent company guarantee).

From reviewing the State’s promulgation process and from interviewing program management, the

review team found that the time frame for adopting revised regulations is at least 11 months from

the date the process begins. The State advised the review team that the Decommissioning

Recordkeeping and Self-Guarantee regulations are in planning stages and are expected to be

adopted by May 30, 1998.

The State was alerted that the following regulations will become due during the next 12 months:

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

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

become due on August 15, 1997.

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

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

FR 322) that became effective on January 1, 1995, is under review and is expected to

become effective by the due date of January 1, 1998.

• "Low-Level Waste Shipment Manifest Information and Reporting," 10 CFR Parts 20 and 61

amendments (60 FR 15649, 60 FR 25983) that will become effective March 1, 1998, and

which will become due on March 1, 1998. The NRC delayed its effectiveness until the

State could adopt compatible requirements so that the national manifest system will go into

effect at one time.

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

CFR Part 20 amendments (60 FR 7900) that became effective on March 13, 1995, and
New Mexico Final Report Page 18

which will become due on March 13, 1998. Note, this rule is designated as a Division 2

matter of compatibility. Division 2 compatibility allows the Agreement States flexibility to be

more stringent (i.e., the State could choose to continue to require annual medical

examinations).

Each of the listed regulations and amendments are scheduled to be adopted by May 30, 1998. 

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

regulations now overdue and those which are due within the next 12 months.

The State was reminded of the following amendments which will need to be addressed:

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

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

become due on August 14, 1998.

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

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

become due on October 20, 1998.

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

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

become due on November 24, 1998.

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

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

1999. NRC delayed the effective date of this rule until April 1, 1996, so that the

Department of Transportation (DOT) companion rule could be implemented at the same

time. Since the rule involves the transport of materials across state lines, the States are

encouraged to adopt compatible regulations as soon as possible.

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

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

become due on May 16, 1999.

The team notes that NRC staff is currently reviewing all Agreement State equivalent regulations to

Part 20, Standards for Protection Against Radiation. These reviews are being conducted outside

the IMPEP process and the States will be notified of the results.

During the examination of the State’s procedures for promulgating regulations, the team noted that

proposed rules or revisions to rules must be publicly announced 60 days prior to adoption, and a

public hearing must be provided. The team examined the records of the last regulation package

and found that the NRC was provided drafts of the proposed regulations early in the process and

that the comments and suggestions made by the NRC staff were incorporated into the final

regulations. It is the State’s policy to send copies of final regulations to the NRC; however, it

could not be verified that copies of the previous final regulations were sent to NRC. The review
New Mexico Final Report Page 19

team suggests that a file be maintained with the cover letters and ensuing correspondence of all

draft or final regulations sent to the NRC.

Based on the IMPEP evaluation criteria, the review team recommends that New Mexico's

performance with respect to this indicator, Legislation and Regulations, be found satisfactory.

4.2 Sealed Source and Device Evaluation Program

The review team did not review the State's sealed source and device (SS&D) program

even though New Mexico currently has responsibility for this area. The review team discussed

with the Secretary, New Mexico Environment Department, as to whether New Mexico has

considered returning its authority for the Sealed Source and Device Evaluation Program. The

Secretary stated that he would have the Governor send a letter to NRC turning back the SS&D

evaluation authority. The State did not perform any SS&D evaluations during the period of the

review.

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 New Mexico has LLRW disposal authority,

NRC has not required States to have a program for licensing a LLRW disposal facility until such

time as the State has been designated as a host State for a LLRW disposal facility. When an

Agreement State has been notified or becomes aware of the need to regulate a LLRW disposal

facility, they are expected to put in place a regulatory program which will meet the criteria for an

adequate and compatible LLRW disposal program. There are no plans for a LLRW disposal

facility in New Mexico. Accordingly, the review team did not review this indicator.

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team found the State’s performance to be

satisfactory for the indicator, Technical Quality of Licensing Actions; satisfactory with

recommendations for improvements for the indicators, Status of Materials Inspection Program,

Technical Quality of Inspections, Technical Staffing and Training; and unsatisfactory for the

indicator, Response to Incidents and Allegations. Based on implementation of new procedures for

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

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

recommendations for improvements. The review team recommended that the New Mexico

program be found adequate, but needs improvement, and compatible. Because of the

significance of the concerns, the team also recommended that New Mexico be placed on

probation and noted that heightened oversight is warranted. During the MRB meeting, three main

issues were identified that New Mexico had to address in terms of programmatic improvements: 

(1) level of program staff and amount of resource support, (2) technical quality of staff and training

needs, and (3) level of management support, involvement and oversight of New Mexico
New Mexico Final Report Page 20

Agreement program activities. The MRB found the New Mexico program adequate, but needs

improvement, and compatible with the NRC’s program. NRC management meet with upper

management of the New Mexico program on December 4, 1997, before the MRB voted on the

recommendation for probation status for the program.

The MRB reconvened to discuss probation for the New Mexico program. Based on the New

Mexico actions to date, and the commitments by Secretary Weidler, the MRB did not conclude

probation was now warranted. The MRB directed that the follow-up review be conducted within

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

and that written progress reports be submitted every other month.

Below is a summary list of suggestions and recommendations, as mentioned in earlier sections of

the report, for action by the State. 

1. The review team recommends that the nuclear pharmacy inspection frequency be modified

from 2 years to 1 year. (Section 3.1)

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

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

commencement of operations, consistent with IMC 2800. (Section 3.1)

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

inspections to be readily identified to staff and management. (Section 3.1)

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

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

working in New Mexico. (Section 3.1)

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

the level which existed throughout the review period. (Section 3.2)

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

areas of medical brachytherapy and irradiator technology. (Section 3.2)

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

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

and Safeguards Program Area.” (Section 3.2)

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

in license files. (Section 3.3)

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

operations or demonstrations during all inspections. (Section 3.4)

10. The review team recommends that the State inspectors conduct independent

measurements on all inspections. (Section 3.4)
New Mexico Final Report Page 21

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

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

inspections. (Section 3.4)

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

during inspections. (Section 3.4)

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

meetings with the senior licensee management on all inspections. (Section 3.4)

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

licensee responses to deficiency letters and closing open deficiencies. (Section 3.4) 

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

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

up. (Section 3.4)

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

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

licensee responses are received and filed. (Section 3.4)

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

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

performing pre-licensing site visits during construction. (Section 3.4)

18. The review team recommends that the State management exercise more stringent

supervisory review of inspection reports. (Section 3.4)

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

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

inspected, and that RLRP inspectors begin using the standardized form(s). (Section 3.4)

20. The review team recommends that the State make onsite, documented investigations of

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

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

3.5)

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

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

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

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

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

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

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

reported to the NRC or other agencies, and provide spaces for the signatures of the
New Mexico Final Report Page 22

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

and in the license file. (Section 3.5)

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

investigations and evaluations of the licensee’s actions. (Section 3.5)

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

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

implemented. (Section 3.5)

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

deficiencies when applicable. (Section 3.5)

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

file system in the Santa Fe office, keeping all documents and records pertaining to an

incident in one location, with the data cross-referenced to the license/inspection files there

and in the Albuquerque office, and (b) establish a system to centrally log and track the

progress of incidents and allegations. (Section 3.5)

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

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

technical staff are fully trained and qualified in emergency response. (Section 3.5)

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

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

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

system, and emergency response procedures. (Section 3.5)

28. The review team recommends that the State expedite promulgation of the compatibilityrelated regulations now overdue and those which are due within the next 12 months. 

(Section 4.1.2)

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

correspondence of all draft or final regulations sent to the NRC. (Section 4.1.2)
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B New Mexico Organization Charts

Appendix C New Mexico's Questionnaire Response

Appendix D License File Reviews

Appendix E Inspection File Reviews

Appendix F Incident File Reviews

Attachment 1 New Mexico’s Response to Review Findings

October 10, 1997

Attachment 2 NRC/New Mexico Management Meeting Minutes, 

December 4, 1997
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

James Lynch, RIII Team Leader

Status of Materials Inspection 

Technical Staffing and Training

Terry Frazee, Washington Technical Quality of Licensing Actions

Scott Moore, NMSS Technical Quality of Inspections

Jack Hornor, RIV, WCFO Response to Incidents and Allegations

Legislation and Regulations
APPENDIX B

NEW MEXICO 

ENVIRONMENT DEPARTMENT

HAZARDOUS AND RADIOACTIVE MATERIALS BUREAU

ORGANIZATION CHARTS


APPENDIX C

NEW MEXICO’S

IMPEP QUESTIONNAIRE RESPONSE