August 3, 2009 

Mr. Jim Craig, Director 

Office of Health Protection 

Mississippi State Department 

 of Health 

570 East Woodrow Wilson 

P.O. Box 1700 

Jackson, MS 39215-1700 

Dear Mr. Craig: 

On July 13, 2009, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Mississippi Agreement State Program 

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

Commission=s (NRC) program. 

Section 5.0, page 15, of the enclosed final report contains a summary of the IMPEP review 

team=s findings and recommendations. Your letter dated June 10, 2009, adequately discusses 

the State’s proposed actions for resolving the review team’s recommendations. No further 

response is requested at this time. 

I encourage you to prioritize your efforts toward the review team’s recommendation on 

addressing staff turnover, which is an open recommendation from the 2005 IMPEP review of the 

Mississippi Agreement State Program. Addressing this recommendation will provide depth and 

stability in the program, which will allow managers and senior staff to complete the necessary 

actions to adequately resolve the review team’s other recommendations. 

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

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

tentatively scheduled for April 2010. Typically, periodic meetings take place approximately 2 

years after an IMPEP review, but because of the importance of addressing the staff turnover 

issue, the MRB directed that a meeting be held sooner. During the periodic meeting and at the 

next IMPEP review, NRC will evaluate the effectiveness of your State’s response to the review 

team’s recommendations, as well as the overall implementation of your Agreement State 

program. 
J. Craig - 2 -

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: 

Mississippi Final IMPEP Report 

cc w/encl: Art Sharpe, Director 

 Emergency Planning & Response 

 B.J. Smith, Director 

 Division of Radiological Health 

 Jared Thompson, Arkansas 

 Organization of Agreement States 

 Liaison to the MRB 
J. Craig - 2 - 

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: 

Mississippi Final IMPEP Report 

cc w/encl: Art Sharpe, Director 

 Emergency Planning & Response 

 B.J. Smith, Director 

 Division of Radiological Health 

 Jared Thompson, Arkansas 

 Organization of Agreement States 

 Liaison to the MRB 

Distribution: See next page.

 ML091970289 EDATS: FSME-2009-0023 

OFFICE FSME/MSSA FSME/MSSA FSME/MSSA Tech Editor 

NAME ATMcCraw:knm1 ADWhite (KSchneider 

for) 

RJLewis CPoland (PTressler 

for) 

DATE 07/21/09 07/21/09 7/27/09 7/28/09 

OFFICE FSME DEDMRT 

NAME CLMiller (GPangburn 

for) 

MVirgilio 

DATE 7/30/09 08/03/09 

OFFICIAL RECORD COPY
Letter to J. Craig from Martin J. Virgilio dated: August 3, 2009 

Distribution: EDATS: FSME-2009-0023 

MSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Jaczko 

LMcLean, RIV/RSAO Commissioner Klein 

JKatanic, FSME/MSSA Commissioner Svinicki 

Charlie Hamilton, Florida SECY 

WRautzen, FSME/MSSA 

MBeardsley, FSME/MSSA 

TReis, FSME 

ARivera, OEDO 

SBurns, OGC 

JGray, OGC 

BJones, OGC 

MDapas, RI 

APowell, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE MISSISSIPPI AGREEMENT STATE PROGRAM 

April 20-24, 2009 

FINAL REPORT
Mississippi Final Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of April 20-24, 2009, by a review team comprised of 

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

Florida. Team members are identified in Appendix A. The review was conducted in accordance 

with the “Implementation of the Integrated Materials Performance Evaluation Program and 

Rescission of Final General Statement of Policy,” published in the Federal Register on 

October 16, 1997, and NRC Management Directive 5.6, “Integrated Materials Performance 

Evaluation Program (IMPEP),” dated February 26, 2004. Preliminary results of the review, 

which covered the period of May 17, 2005, to April 24, 2009, were discussed with Mississippi 

managers on the last day of the review. 

A draft of this report was issued to Mississippi for factual comment on May 11, 2009. The State 

responded by letter on June 10, 2009, from Jim Craig, Director, Office of Health Protection (the 

Office). A copy of the State’s response is included as the attachment to this report. The 

Management Review Board (MRB) met on July 13, 2009, to consider the proposed final report. 

The MRB found the Mississippi Agreement State Program adequate to protect public health and 

safety and compatible with NRC’s program. 

The Mississippi Agreement State Program is administered by the Division of Radiological Health 

(the Division). The Division is part of the Office, which is under the Department of Health (the 

Department). Organization charts for the State, the Department, and the Division are included 

as Appendix B. 

At the time of the review, the Mississippi Agreement State Program regulated 333 specific 

licenses authorizing byproduct, source, and certain special nuclear materials. 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 NRC and the State of 

Mississippi. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Division on December 29, 2008. The Division 

provided its response to the questionnaire on April 1, 2009. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML091260125. 

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 Mississippi statutes and 

regulations; (3) analysis of quantitative information from the Branch’s databases; (4) technical 

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

interviews with staff and managers. 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 Mississippi Agreement State Program’s 

performance. 

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

made during previous reviews. Results of the current review of the common performance 
Mississippi Final Report Page 2 

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, covering the period of May 26, 2001, to May 20, 2005, the 

review team made two recommendations regarding to program performance. The current 

status of the recommendations is as follows: 

1. The review team recommends that the State take additional actions, such as increasing 

salary and benefits, to stabilize staffing and ensure continued successful program 

implementation (Section 3.1 of the 2005 IMPEP Report). 

Current status: Since the 2005 review, the Division had one salary increase, a $1,500 

incentive given to all State employees. This increase only affected those individuals 

that were with the State at the time; therefore, the increase did not alter the starting 

salary structure for new hires. Because of this, the staff retention issue that was 

identified during previous reviews continues to plague the Division, as discussed in 

greater detail in Section 3.1 of this report. The current review team found little evidence 

of upper management action to address this issue. This recommendation remains 

open. 

2. The review team recommends that the State ensure that individuals who make 

allegations are informed of the resolution of their concerns (Section 3.5 of the 2005 

IMPEP Report). 

Current status: During the 2005 review, the Division revised its allegation procedure to 

require notification to the alleger of the resolution of the concerns. The review team’s 

evaluation of allegation casework revealed that, when the alleger’s identity was known, 

the alleger was appropriately notified of the resolution of their concern(s). This 

recommendation is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

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

radioactive materials programs. 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

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

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

these issues, the review team examined the Division’s questionnaire response relative to this 
Mississippi Final Report Page 3 

indicator, interviewed Division and Branch managers and staff, reviewed job descriptions and 

training records, and considered any possible workload backlogs. 

The Division, which administers the Agreement State program, is headed by the Division 

Director and is comprised of three branches: the Radioactive Materials Branch (the Branch), 

the X-Ray Branch, and the Environmental Branch. Each branch has a director that reports to 

the Division Director. 

The Branch is responsible for the day-to-day operations of the Agreement State program, such 

as licensing, inspecting, and responding to radioactive materials incidents. The Branch is 

authorized for five positions to perform its duties: the Branch Director position and four Health 

Physicist positions. 

Each of the Health Physicist positions may be filled at the Health Physicist Trainee, the Health 

Physicist, or the Health Physicist Senior level, depending on the candidate’s education and 

experience. Candidates for technical positions are required to have a Bachelor's degree in 

science for the Health Physicist Trainee level and a Master's degree and/or additional radiationrelated work experience for positions beyond the Health Physicist Trainee level. A Health 

Physicist Trainee can be promoted to a Health Physicist and then to a Health Physicist Senior 

within 3 years, with satisfactory performance. 

During the review period, four technical staff members left the program. One staff member 

transferred to another branch within the Division, and the other three left the Branch for other 

career opportunities. Of the three that left the Division, two were Health Physicist Seniors that 

took a considerable number of years of experience with them, and the other was a Health 

Physicist Trainee that left the Branch after just 4 months of employment. 

Also during the review period, the former Division Director retired. In addition to maintaining his 

own duties and responsibilities, the former Branch Director assumed the responsibilities of the 

Division Director position until the position was filled. The Division Director position remained 

vacant for approximately a year before the former Branch Director was officially promoted to the 

Division Director position in 2008. In turn, the Division Director continued to execute the 

responsibilities of his former position until that position was filled almost a year later. In 

February 2009, a Health Physicist Senior was promoted to the Branch Director position. 

The staff departures during this review period constituted a high degree of staff turnover relative 

to the size of the program. The Division Director and the Branch Director are the only 

individuals in the program that were with the program at the time of the last review. Previous 

review teams also noted a high degree of staff turnover in the program. Attributing the high 

turnover rate to the State’s low salaries, the 2005 review team made a recommendation to the 

State to address the high turnover rate by increasing salaries or offering other incentives. As 

indicated in Section 2.0, the State had a one-time salary increase for existing employees during 

the review period. The increase did not affect the State’s starting salary structure, and 

therefore, the State’s starting salaries remained comparatively low to neighboring Agreement 

State programs and private industry. Based on information obtained from the State’s website, 

the review team found that the salaries for the Branch’s inspectors are also comparatively low to 

inspectors in other units within the State government. Until the Branch’s salary issue is 

addressed, the review team believes that the Branch will continue to struggle to retain a full 
Mississippi Final Report Page 4 

complement of qualified individuals. Thus, the review team kept the recommendation to 

address staff turnover from the 2005 review open. 

The high level of turnover limited the availability of resources to address the Branch’s workload. 

For the past year, the Division Director and the Branch Director were the only qualified 

inspectors and license reviewers in the program and were performing all of the technical work in 

the Branch. At the time of the review, the Division Director was spending approximately 75 

percent of his time performing work for the Branch, including inspections and licensing reviews. 

Because of the efforts of these two individuals, there was no backlog of any high-priority 

regulatory actions at the time of the review. As discussed in Section 3.2 of this report, the 

review team identified evidence of a backlog of low-priority inspections; however, the review 

team concluded that the Branch is appropriately prioritizing its work given its limited resources. 

The review team also recognized that, primarily because of the efforts of these two individuals, 

the Branch was able to address a number of federally mandated security initiatives that were 

implemented during the review period and complete all of the required actions in a timely 

manner. The Branch also used the services of a contractor, the former Division Director, to 

address the regulation amendment workload, as discussed in Section 4.1.2 of this report. The 

review team ultimately concluded that the Branch’s staffing level will be adequate for its 

workload when fully staffed and qualified. 

Despite the State’s low starting salary structure, the Branch has not experienced difficulty in 

recruiting competent individuals for the Health Physicist positions and, therefore, was able to fill 

technical vacancies in a timely manner. At the time of the review, two of the four Health 

Physicist positions were filled by a Health Physicist Senior and a Health Physicist Trainee. The 

Health Physicist Senior transferred to the Branch from the Environmental Branch around April 

2007, and the Health Physicist Trainee was hired in March 2009. At the time of the review, 

there were also two vacancies in the Branch. The vacancies have been open since February 1, 

2009, when the Branch Director received his promotion; and March 6, 2009, when a Health 

Physicist Trainee tendered her resignation. At the time of the review, the Branch was in the 

process of filling both vacancies. Subsequent to the review, the Division Director notified the 

review team that one of the vacancies was filled and that the Branch Director was conducting 

interviews for the other vacancy. During the review, the review team cautioned State and 

Division managers to be wary of the ease of recruiting competent individuals during the nation’s 

economic downturn, as it may not be indicative of the program’s ability to recruit competent 

individuals in the future. To ensure the long-term health of the program and to promote stability 

in the Branch, the State needs to take action to address the staff turnover issue. 

The Branch has a documented training plan for technical staff that is consistent with the 

requirements in the NRC/Organization of Agreement States Training Working Group Report and 

NRC’s Inspection Manual Chapter (IMC) 1246, “Formal Qualification Programs in the Nuclear 

Material Safety and Safeguards Program Area.” The Branch uses on-the-job training to 

supplement formal coursework. As part of the Branch’s qualification process, new staff 

members are assigned increasingly complex licensing and inspection duties under the direction 

of the Division Director, the Branch Director, or senior staff. After demonstrating proficiency in 

an area, the Division Director or the Branch Director provides oral authorization for the individual 

to independently perform regulatory actions. The review team interviewed technical staff 

members about the Branch’s qualification process and found the staff to be cognizant of the 

required training courses and expectations. The review team examined the staff training files 
Mississippi Final Report Page 5 

and found that there were records of the training courses and accompaniments that each 

individual had completed toward their qualification in their respective file; however, the 

qualifications of each individual were difficult to ascertain from the files because there was no 

documentation of supervisor approval of the individual’s qualifications. The review team 

discussed with the Division Director the benefits of having a formal qualification journal for the 

technical staff that would clearly indicate each individual’s qualifications and would serve as a 

written record of the supervisor’s endorsement. The Division Director indicated that he will 

consider the use of a qualification journal for the technical staff. Overall, the staff training files 

demonstrated the Branch’s commitment to training and qualifying technical staff. 

Given the high rate of turnover in the Branch, the review team discussed with the Division 

Director the value of having a knowledge management program. The review team observed 

that many of the Branch’s policies and procedures were outdated and in need of revision. 

Because of the Branch’s focus on completing high-priority regulatory actions, the revision of 

existing procedures and the development of new procedures had been set aside. Instead, the 

review team observed that the Branch primarily uses verbal communication to implement new 

policies and practices. Specific examples of where the Branch relied on verbal communications 

can be found in Sections 3.3 and 3.4 of this report. This practice can be effective in a small 

program where there is limited turnover; however, in a program with a high turnover rate, the 

documentation of policies and practices is very important. The review team determined that the 

vast majority of the program’s knowledge resides in the Division Director and the Branch 

Director. In the event of one of these individuals leaving the Division, the immediate future of 

the Mississippi Agreement State Program would be uncertain. Nevertheless, the review team 

believes that the Branch has appropriately focused its limited resources on the activities that are 

directly related to ensuring the adequate protection of public health and safety; however, when 

the Branch becomes fully staffed and qualified, it will need to address this concern to ensure the 

long-term health of the Agreement State program. The review team recommends that the State 

update its existing procedures and develop new procedures, if necessary, to memorialize the 

policies and practices of the Agreement State program and to serve as a knowledge 

management tool. 

An important aspect of a knowledge management program is an effective data management 

system. The Branch has computer-based databases to track licensing and inspection activities; 

however, the databases have limitations that create inefficiencies in the Branch. The review 

team observed several lists maintained by the Division Director and the Branch Director, all of 

which could be automatically generated by an effective data management system. Despite the 

apparent inefficiencies in the Branch’s current data management system, the review team 

verified that all high-priority regulatory activities were performed in a timely manner. In 

reviewing information from the Branch’s existing databases, the review team identified a number 

of errors in program codes and inspection due dates. The review team also found that the 

database is incapable of maintaining historical records, as the records are overwritten upon 

completion of the inspection and entry of new data. As described in Section 3.2, this limitation 

caused the review team to evaluate the timeliness of inspections through an inspection 

casework review. Understanding that this issue may not be addressed until the Branch is fully 

staffed and qualified, the review team believes that the Branch could gain efficiencies in its data 

management with a more effective database. The review team recommends that the State 

implement a reliable and comprehensive licensing and inspection database that serves as an 

effective planning, tracking, and data management tool. 
Mississippi Final Report Page 6 

The review team discussed the appropriate finding for this indicator. The review team 

considered a finding of unsatisfactory because of the chronic issue of staff turnover and the 

apparent lack of upper management action on the issue. In reaching a conclusion on a finding 

for this indicator, the review team recognized that the efforts of the Division Director and the 

Branch Director to ensure that public health and safety were adequately protected throughout 

the review period and that all high-priority regulatory actions were completed in a timely manner. 

The review team believed that a finding of satisfactory, but needs improvement, was the more 

appropriate finding for this indicator. 

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

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

found satisfactory, but needs improvement. 

3.2 Status of Materials Inspection Program

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

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

licensees, and performance of reciprocity inspections. The review team’s evaluation was based 

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

Branch’s databases, an examination of completed inspection casework, and interviews 

conducted with the Division Director and Branch Director. 

The review team compared the Branch=s inspection frequencies for various types of licenses to 

those prescribed by NRC’s IMC 2800, “Materials Inspection Program.” The Branch’s inspection 

frequencies are generally the same as those prescribed in IMC 2800; however, some categories 

of licenses are inspected more frequently, including nuclear pharmacy and certain types of 

medical and academic licenses. In addition, the Branch does not have any inspection intervals 

longer than 4 years, whereas IMC 2800 prescribes an interval of 5 years for several license 

types. The Division Director indicated that the reduced inspection intervals were established as 

a means to put additional emphasis on the protection of public health and safety. 

Information regarding inspections conducted during the review period could not be obtained 

through a review of the Branch’s inspection database. The review team attempted to use the 

database to ascertain the current status of the inspection program; however, the database only 

contained information related to the most recent inspection performed, because previous 

inspection information was overwritten each time an inspection was performed and the new 

information was entered. As a result, the review team reviewed a sample of inspection files to 

evaluate the timeliness of inspections. Of the 24 high-priority (Priority 1, 2, and 3 licensees and 

initial) inspections reviewed, 1 inspection was conducted a few days overdue and another was 

found to be greater than 1 year overdue at the time of the review. For the one that was overdue 

at the time of the review, the review team noted that the licensee did not have a physical 

location in Mississippi and had not conducted licensed activities in Mississippi during the 

inspection interval. 

The review team also looked at a small sample of low-priority (Priority 5) inspections. Based on 

interviews with the Division Director and the Branch Director and a review of a list of low-priority 

licensees, the review team found sufficient evidence to suggest a growing backlog of low-priority 

inspections. The Division Director related that this was a management decision to ensure that 
Mississippi Final Report Page 7 

high-priority activities were completed in a timely manner. The Division Director was confident 

that the Health Physicist Trainee can be qualified to perform the low priority inspections in a 

short timeframe. The Health Physicist Trainee’s focus will be addressing the growing backlog 

once he is qualified. 

The review team evaluated the timeliness of the issuance of inspection findings to licensees. Of 

the 30 inspection findings reviewed, only 1 inspection findings letter was issued to the licensee 

greater than 30 days after the inspection. In this case, the letter to the licensee did not contain 

any violations and was issued approximately 2 weeks past the 30-day goal. Most inspection 

findings were issued very promptly, within a few days of the inspection date. 

The Branch also has a database of licensees that filed for reciprocity in Mississippi. Similar to 

the previously discussed inspection database, the reciprocity database consisted of inspection 

information that was overwritten with each subsequent inspection. As a result, the database did 

not have the capability to retrieve the historical information for reciprocity inspections conducted 

during the review period. The Branch does not identify candidates for inspection based upon 

the criteria in IMC 1220, “Processing of NRC Form 241 and Inspection of Agreement State 

Licensees Operating under 10 CFR 150.20.” Instead, the Branch attempts to perform as many 

reciprocity inspections as time and resources allow. Due to the lack of statistical data, the 

review team could not calculate the percentage of reciprocity inspections of candidate 

licensees; however, the review team examined inspection casework and inspection schedules 

and determined that the Branch conducted a considerable number of reciprocity inspections 

despite being short-staffed at times during the review period. 

The review team determined that the Branch did not maintain a list of licensees subject to the 

Increased Controls. The Branch Director was able to quickly produce a list from memory, based 

on his knowledge of the licensees. The review team verified this list with the license files. At 

the time of the review, the Branch had 32 licensees that had been issued the Increased 

Controls requirements. The Branch did not document a prioritization methodology for 

performing the initial round of Increased Controls inspections, as requested per All Agreement 

States Letter STP-05-079, dated November 4, 2005. Instead, the Branch attempted to conduct 

all inspections when they were due for their routine inspection or as soon as they could possibly 

be scheduled. Due to the lack of retrievable inspection data, the review team examined all 32 

Increased Controls inspection files and found that 28 inspections were completed within 3 years 

from the date of implementation of the Increased Controls or at the first inspection after 

issuance of the license. Of the other four files reviewed, one was a new license and its initial 

Increased Controls inspection was pending, one was an out-of-State licensee that had not 

performed licensed activities in Mississippi since issuance of the Increased Controls, and two 

were fixed gauge licensees that do not believe that they meet the criteria for Increased Controls. 

To date, the Branch has taken the licensees’ words that the Increased Controls do not apply. 

The review team encouraged the Branch to determine whether the Increased Controls are 

applicable to the two fixed gauge licensees via on-site inspection and verification. 

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

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

Program, was satisfactory. 
Mississippi Final Report Page 8 

3.3 Technical Quality of Inspections

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

and interviewed the two qualified inspectors. The review team examined the inspection 

casework for 19 specific licenses and 4 reciprocity licensees. The casework consisted of 

inspections performed by the two qualified inspectors and two former inspectors. The casework 

included inspections of various license types, including: nuclear medicine, high dose-rate 

remote afterloader, medical broad scope, industrial radiography, well logging, self-shielded 

irradiator, gamma knife, mobile nuclear medicine, nuclear pharmacy, portable gauge, and fixed 

gauge licensees. Appendix C lists the inspection casework files reviewed and includes casespecific comments. The review also included an examination of inspection casework for 28 

Increased Controls inspections that the Branch performed. 

Based on the evaluation of casework, the review team determined that inspections were 

sufficient in scope to review the licensees’ radiation safety and security programs. The review 

team noted that the inspection records were generally thorough, complete, and of high quality. 

Inspection records sufficiently documented observations of licensed activities, discussions held 

with licensees during exit interviews, and the inspector’s overall assessment of licensees’ 

radiation safety program, as applicable. 

The Division has detailed checklists/inspection forms for inspections of various license types. 

Following the inspection, these checklists/inspection forms are retained in the license file as the 

inspection record. The review team determined that the inspectors’ use of the checklists aided 

in performing thorough performance-based inspections. The Branch also has a written 

inspection procedure for general conduct of inspections, as well as supplemental guidance for 

inspections of various license types. Both the Division Director and the Branch Director noted 

that the procedure and supplemental guidance are not consistent with the Branch’s current 

inspection practices and need to be revised. This relates to the recommendation made in 

Section 3.1 of this report regarding knowledge management. 

The Branch requires licensees to respond within 10 days of the date of issuance of the violation. 

Through the casework evaluations, the review team identified eight inspections where the 

inspection findings were dated prior to the date of management review. The review team found 

that the inspectors date the letters before providing them to management for review. This 

practice gives the appearance that the inspection findings, including the issuance of violations, 

were being issued to licensees prior to the management review. The practice also appears to 

give the licensee fewer than 10 days to respond to any violations. This matter was discussed 

with the Division Director, who assured the review team that the inspection findings are not 

dispatched without management review. Based on the review team’s observation, the Division 

Director stated that the Branch may revisit its process for dating, reviewing, and issuing 

inspection findings. 

The review team noted that violations of health and safety requirements were well documented, 

with sufficient information to support the violations and provide for appropriate followup during 

the next inspection; however, violations of the Increased Controls were often not well 

documented. Sufficient information to support security violations was not documented in the 

letter to the licensee, the issued violation, or in the inspector’s written notes. The 

documentation in the inspection file did not provide either general or specific information as to 
Mississippi Final Report Page 9 

how the violation occurred, what caused the violation, how long the violation existed, or other 

relevant information; however, when interviewed, the inspector could relate the full details of 

why the violation was issued and the specifics of the violation. 

The lack of documentation can make it difficult for future inspectors to follow up and review the 

adequacy of the licensee’s corrective actions during the next inspection. The review team 

identified one violation, a complete failure to implement the Increased Controls, that appeared 

not to receive the appropriate level of followup based on the documentation in the inspection 

file. The review team found the licensee’s response to the violation inadequate relative to the 

significance of the violation. The Branch’s records indicated that the followup inspection did not 

take place until 2 years later. When interviewed, the Division Director indicated that there were 

several phone calls with the licensee to follow up on their efforts to comply; however, these 

conversations were not documented in the inspection file. 

As discussed in Section 3.1 of this report, a knowledge management program is critical for a 

program with a high level of turnover. The proper documentation of inspection findings is 

necessary to ensure that licensees fully understand any identified violations and that inspectors 

can appropriately follow up on the violations at a future inspection, particularly those violations 

related to the Increased Controls. The review team determined that the historical knowledge of 

violations and followup has not routinely been captured in the inspection file. Instead, the 

Branch relied on undocumented verbal interactions between managers and inspectors. Due to 

the lack of documentation, the Branch Director had to contact former staff members for 

information regarding licensees and previous inspection findings. Lack of previous inspection 

documentation may result in critical items not being reviewed for followup during the next 

inspection. Efforts to more thoroughly document the information necessary to support violations 

and corrective actions taken by the licensees can facilitate consistency among the inspection 

staff and can aid in the development of new or lesser experienced staff members. The review 

team recommends that the State implement a process to ensure that violations are adequately 

documented, licensee corrective actions are reviewed for adequacy and documented, and 

sufficient followup of violations is performed and documented consistent with the safety or 

security significance. 

The Branch maintains two separate files for licensees subject to the Increased Controls: one 

that contains the routine licensing and inspection information and a second file that pertains to 

the inspection of the licensee’s implementation of the Increased Controls. The Branch 

implemented this policy for better control of potential security-related information, as the second 

file is stored in a locked file cabinet. During the evaluation of inspection casework, the review 

team noted that some information regarding the licensee’s implementation of the Increased 

Controls or other security-related requirements was incorrectly filed in the uncontrolled file. The 

review team also observed this during the evaluation of licensing casework. Discussions with 

the Division Director and the Branch Director revealed that the Division does not have a written 

procedure for the control of sensitive or security-related information. The review team did not 

discover any evidence that indicated there was any inadvertent release of sensitive or securityrelated information, but recognized the potential for an inadvertent release of this information 

due to the lack of a documented policy. The review team recommends that the State develop 

and implement a procedure for the control of sensitive or security-related information that 

provides guidance to identify, mark, handle, and protect such information. 
Mississippi Final Report Page 10 

The review team found that the Division maintained an adequate supply of appropriately 

calibrated radiation detection and measurement instrumentation to support the inspection 

program, as well as for response to radioactive materials incidents and emergencies. The 

Branch also has access to the Division’s analytical laboratory for additional support, including 

alpha/beta spectroscopy, radiochemical analysis, and liquid scintillation counting. 

The Branch has a policy of supervisory accompaniments of all qualified inspectors annually. 

The review team verified that all non-supervisory inspectors were accompanied annually during 

each year of the review period. During the review period, the accompaniments of the Branch 

Director and non-supervisory inspectors were completed by the Division Director. The 

accompaniments covered a variety of license types, including Increased Controls inspections. 

The review team found that the Division Director’s performance in the field was not reviewed 

during the review period, despite performing a considerable number of inspections. The 

Division Director’s written documents are routinely reviewed by the Branch Director. 

A member of the review team accompanied the Branch’s two qualified radioactive materials 

inspectors on inspections during the week of March 23, 2009. The licensees inspected were a 

nuclear pharmacy, an industrial radiography jobsite, and a well logging field office. Appendix C 

lists the inspector accompaniments and includes the review team’s observations. The 

inspectors demonstrated performance-based inspection techniques and knowledge of the 

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

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

interviews with appropriate personnel, observed licensed operations, conducted confirmatory 

measurements, and utilized good health physics practices. The inspectors held entrance and 

exit meetings with the appropriate level of licensee management. When appropriate, the 

inspectors telephonically informed the licensees’ corporate radiation safety officers of the results 

of the inspection. The review team determined that the inspections were adequate to assess 

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

The review team discussed the appropriate finding for this indicator. The review team 

considered a finding of satisfactory, but needs improvement, because of the lack of 

documentation to support cited violations and corrective actions, especially those of the 

Increased Controls, and the lack of followup related to violations of the Increased Controls. In 

reaching a conclusion on a finding for this indicator, the review team recognized that the lack of 

documentation is not necessarily indicative of an inspection of poor quality, but more of a lack of 

guidance to inspectors on expectations of documentation. After discussing the benefits of 

documentation with the Division Director and the Branch Director, the review team is confident 

that there will be a more conscious effort to ensure that all inspection findings are adequately 

documented in the inspection records. The review team; recognizing the adequacy of the 

Branch’s inspections to assess radiological health, safety, and security; believed that a finding 

of satisfactory was more appropriate. 

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

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

was satisfactory. 
Mississippi Final Report Page 11 

3.4 Technical Quality of Licensing Actions

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

28 licensing actions involving 25 specific licenses. Licensing actions were reviewed for 

completeness, consistency, proper radioisotopes and quantities, qualifications of authorized 

users, adequacy of facilities and equipment, adherence to good health physics practices, 

financial assurance, operating and emergency procedures, appropriateness of license 

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

appropriate correspondence, reference to appropriate regulations, supporting documentation, 

consideration of enforcement history, pre-licensing visits, peer or supervisory review, and proper 

signatures. 

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

completed during the review period. Licensing actions selected for evaluation included 4 new 

licenses, 16 amendments, 6 renewals, and 2 license terminations. Files reviewed included a 

cross-section of license types, including: medical diagnostic and therapy, brachytherapy, 

gamma knife, nuclear pharmacies, academic and medical broad scope, research and 

development, industrial radiography, and well logging. A listing of the licensing casework 

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

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

high quality, and properly addressed health and safety issues. The staff followed appropriate 

licensing guides during the review process to ensure that licensees submit information 

necessary to support their request. Deficiency correspondence was used, as appropriate, to 

obtain additional information from the applicant or licensee. The Branch uses license templates, 

which promotes consistency between reviewers. There were no licensing backlogs identified 

during the review period. 

The Branch initially issues licenses for a period of 1 year as a mechanism to help ensure that 

the initial inspection is performed in a timely manner. Thereafter, high-priority licenses are 

issued for periods that match the associated inspection frequency for (i.e., Priority 1 industrial 

radiography licenses expire annually), with a full review every 5 years. Licenses with lower 

priorities are issued for a period of 5 years. Inspectors review the license for accuracy during 

each inspection. The Division Director related that this process enabled the Branch to be more 

knowledgeable concerning the licensee’s operations. 

At the time of the review, the Division Director and Branch Director were performing all of the 

Branch’s licensing actions and reviewing each other’s work. When fully staffed, licensing 

actions receive peer reviews from other staff members before being reviewed by the Branch 

and then the Division Director. All licenses are signed by the Division Director. This process 

serves as a valuable learning tool for the junior staff members. The review team determined 

that the peer and supervisory reviews contributed to the consistency between reviewers and the 

high quality of licensing documents. 

The review team found that actions terminating licenses were well documented, and included 

the appropriate material survey records. All files reviewed contained documentation of proper 

disposal or transfer. 
Mississippi Final Report Page 12 

The Branch has an undocumented method for determining when and how to perform prelicensing visits of new applicants or licensees requesting radioactive material possession limits 

in quantities of concern. The Branch’s method incorporates the essential elements of the 

NRC’s pre-licensing guidance. The review team evaluated the casework file for the only prelicensing visit of a new applicant performed during the review period and found that the visit was 

appropriately performed and well documented. Consistent with the recommendation from 

Section 3.1 regarding knowledge management, the Branch’s policies and practices for 

conducting pre-licensing visits should be documented for future reference. 

The review team examined the Branch’s licensing practices in regard to the Increased Controls, 

Fingerprinting Orders, and the National Source Tracking System. The review team noted that 

the Branch added legally binding license conditions to the licenses that met the criteria for 

implementing these requirements in a timely manner with a few exceptions. The review team 

discussed the files that did not have the appropriate license conditions with the Division Director 

and the Branch Director. They indicated that the majority of the cases were an oversight on 

their part and would be corrected immediately. The Branch has a method to ensure that new 

license applications and license amendments are evaluated to determine the applicability of 

enhanced security requirements. 

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

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

Actions, was found satisfactory. 

3.5 Technical Quality of Incident and Allegation Activities

In evaluating the effectiveness of the Branch’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 Mississippi in NRC’s Nuclear Material 

Events Database (NMED) against those contained in the Branch’s files, and evaluated the 

casework for 22 radioactive material incidents. A listing of the incident casework examined can 

be found in Appendix E. The review team also evaluated the Branch’s response to four 

allegations involving radioactive material received during the review period. 

The Branch had 45 radioactive materials incidents reported to them during the review period, 14 

of which were required to be reported to NRC’s Headquarters Operations Center. The review 

team evaluated the casework for all 14 incidents that required reporting, plus 8 additional 

incidents that did not require reporting. The incidents selected for review included medical 

events; lost, stolen, and recovered radioactive material; damaged equipment; and transportation 

events. 

Based on the casework evaluations, the review team determined that the Branch dispatched 

inspectors for on-site investigations in appropriate situations and took suitable enforcement and 

followup actions, when necessary. 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 always commensurate with the health and safety significance of the incident. 

The review team also evaluated the Branch’s timeliness in reporting incidents to NRC’s 

Headquarters Operations Center, and determined that, following notification from the licensee, 
Mississippi Final Report Page 13 

the Branch reported all incidents within the required time frame. During the review period, the 

Branch lost the one employee that was trained to use the software to enter event information 

into NMED directly. The Branch now relies on NRC’s Headquarters Operations Center to relay 

the appropriate event information to NRC’s contractor responsible for maintaining NMED. The 

Branch uses an event form to help ensure that inspectors have all the necessary information for 

a complete NMED record. The review team noted a number of NMED entries for Mississippi 

that were not closed, although the investigation had concluded. The review team discussed the 

process for closing event entries with the Division Director and the Branch Director. The Branch 

Director transmitted a request to NRC’s contractor responsible for maintaining NMED to close 

the event entries while the review team was still on site. 

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

examined the casework for four allegations involving radioactive material. The Branch received 

all four of the allegations directly from concerned individuals or licensees. The review team 

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

noted in Section 2.0, the review team found that allegers were appropriately notified of the 

outcome of the Branch’s investigations. 

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

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

Allegation Activities, was satisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS 

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

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

Agreement with the State of Mississippi does not relinquish the authority for a uranium recovery 

program; therefore, only the first three non-common performance indicators were applicable to 

this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Mississippi became an Agreement State on July 1, 1962. The Mississippi Radiation Protection 

Law of 1976 designates the Department as the radiation control agency for the State. This act 

gives the Department specific powers and duties, including the authority to promulgate 

regulations, issue licenses, perform inspections, and collect fees. The review team noted that 

the only legislation affecting the Branch that was passed during the review period was a 

radiological fee increase. 

4.1.2 Program Elements Required for Compatibility

Mississippi’s regulations pertaining to radiation control apply to all ionizing radiation, whether 

emitted from radionuclides or devices. Mississippi requires a license for possession and use of 

all radioactive materials. 
Mississippi Final Report Page 14 

The review team examined the State’s regulatory process and found that the process takes 6 to 

12 months. The Division is responsible for drafting and revising the State’s regulations 

pertaining to radiation control. After preparation of a package of draft regulations, the Division 

obtains approval from the Radiation Advisory Council and then the Board of Health. Draft 

regulation packages are classified as “intent to adopt” and are mailed to registered interested 

parties, such as licensees and NRC, with an opportunity for comment. After addressing any 

comments, the Division submits the regulations to the Board of Health for final approval. Once 

approved, the final regulations are sent to the Secretary of State for adoption. Mississippi’s 

rules and regulations are not subject to sunset laws. The Division also has the authority to 

issue alternate legally binding requirements, such as license conditions, in lieu of regulations. 

The review team evaluated the Division’s response to the questionnaire relative to this indicator, 

reviewed the status of regulations required to be adopted by the State under the Commission’s 

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

from the State Regulation Status sheet that NRC Office of Federal and State Materials and 

Environmental Management Programs (FSME) maintains. 

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

legally binding requirements no later than 3 years after the effective date of NRC’s regulations. 

During the review period, the State addressed 14 amendments via rulemaking or adopting 

alternate legally binding requirements. Ten of the amendments were addressed in a rulemaking 

package that became effective on May 8, 2009, six of which were adopted beyond the 3-year 

Agreement State adoption period. With this package, the State is up to date on all amendments 

that are required through November 2010. The Division Director was cognizant of the 

amendments that were adopted overdue. Given the staff turnover in the Branch, the Division 

Director had to focus his efforts on other aspects of the program. Despite the lack of focus on 

rulemaking for a portion of the review period, the Division was able to address the high-priority 

regulation amendments; such as the Increased Controls, the fingerprinting requirements, and 

the National Source Tracking System requirements; in a timely manner. To bring the 

regulations up to date, the former Division Director came back under contract to push the 

rulemaking package through the process. 

The review team identified the following NRC amendment that the State will need to address in 

the future through rulemakings or adoption of alternate legally binding requirements: 

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

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

adoption by November 30, 2010. 

When considering a finding for this indicator, the review team recognized the level of effort that 

went into ensuring that high priority amendments were addressed in a timely manner and that 

all regulations were up to date shortly after the time of the on-site review. The review team 

originally considered a finding of satisfactory, but needs improvement, based on the number of 

regulations adopted overdue during the review period; however, after recognizing the effort 

expended for rulemaking in light of all the other actions completed during the review period, the 

review team decided a finding of satisfactory was more appropriate. 
Mississippi Final Report Page 15 

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

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

satisfactory. 

4.2 Sealed Source and Device Evaluation Program

Since becoming an Agreement State in 1963, Mississippi has not performed any sealed source 

and device evaluations; therefore, the review team did not review this indicator. 

4.3 Low-Level Radioactive Waste Disposal Program

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

Discontinuance of NRC Regulatory Authority and Assumption Thereof by States Through 

Agreement” to allow a State to seek an amendment for the regulation of low-level radioactive 

waste (LLRW) as a separate category. Those States with Agreements prior to 1981 were 

determined to have continued LLRW disposal authority without the need of an amendment. 

Although the Mississippi Agreement State Program has LLRW disposal authority, NRC has not 

required States to have a program for licensing a LLRW disposal facility until such time as the 

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

State has been notified or becomes aware of the need to regulate a LLRW disposal facility, it is 

expected to put in place a regulatory program that will meet the criteria for an adequate and 

compatible LLRW disposal program. At this time, there are no plans for a commercial LLRW 

disposal facility in Mississippi. Accordingly, the review team did not evaluate this indicator. 

5.0 SUMMARY 

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

improvement, for the performance indicator, Technical Staffing and Training, and satisfactory for 

all other performance indicators reviewed. The review team kept open one recommendation 

from the 2005 review and made four new recommendations regarding program performance. 

Overall, the review team recommended, and the MRB agreed, that the Mississippi Agreement 

State Program was adequate to protect public health and safety and compatible with NRC's 

program. The review team also recommended, and the MRB agreed, that a periodic meeting 

take place in approximately 1 year to assess the State’s progress in addressing the review 

team’s recommendations, with an emphasis on the actions taken to counteract staff turnover. 

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 additional actions, such as increasing 

salary and benefits, to stabilize staffing and ensure continued successful program 

implementation (Section 3.1 of the 2005 IMPEP Report). 

2. The review team recommends that the State update its existing procedures and develop 

new procedures, if necessary, to memorialize the policies and practices of the 

Agreement State program and to serve as a knowledge management tool (Section 3.1). 
Mississippi Final Report Page 16 

3. The review team recommends that the State implement a reliable and comprehensive 

licensing and inspection database that serves as an effective planning, tracking and data 

management tool (Section 3.1). 

4. The review team recommends that the State implement a process to ensure that 

violations are adequately documented, licensee corrective actions are reviewed for 

adequacy and documented, and sufficient followup of violations is performed and 

documented consistent with the safety or security significance (Section 3.3). 

5. The review team recommends that the State develop and implement a procedure for the 

control of sensitive or security-related information that provides guidance to identify, 

mark, handle, and protect such information (Section 3.3). 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B Mississippi Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source & Device Casework Reviews 

Attachment June 10, 2009 Letter from Jim Craig 

 Mississippi’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Aaron McCraw, FSME Team Leader 

 Technical Staffing and Training 

 Compatibility Requirements 

Janine Katanic, FSME Status of Materials Inspection Program 

 Technical Quality of Inspections 

 Inspector Accompaniments 

Charlie Hamilton, FL Technical Quality of Licensing Actions 

Linda McLean, Region IV Technical Quality of Incident and Allegation 

 Activities 
APPENDIX B 

MISSISSIPPI ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML091260142 
APPENDIX C 

 INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: GE Inspection Services License No.: 863-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/8/06 Inspectors: JE, JM 

Comment: 

Inspection was overdue at the time of the review, because the licensee does not have a 

physical location in Mississippi and has not recently performed work in the State. 

File No.: 2 

Licensee: St. Dominic-Jackson Memorial Hospital License No.: 039-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Dates: 7/12/06, 12/9/08 Inspector: JM 

File No.: 3 

Licensee: Baptist Cancer Institute License No.: 942-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 7/25/06, 8/1/08 Inspector: BS 

File No.: 4 

Licensee: Northrup Grumman Litton Ingalls Shipbuilding License No.: 246-01 

Inspection Type: Routine/Special, Announced Priority: 1 

Inspection Dates: 2/14/07 Inspector: BS 

Comment: 

The inspector’s notes and other documentation did not provide sufficient information to 

support the validity of the violation issued. 

File No.: 5 

Licensee: Mississippi Baptist Medical Center License No.: 023-05 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 1/22/09 Inspector: JM 

File No.: 6 

Licensee: American Diagnostic Technologies, LLC License No.: 927-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/10/05 Inspector: JA 

File No.: 7 

Licensee: King’s Daughters Hospital License No.: 270-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/25/09 Inspector: JM 
Mississippi Final Report Page C.2 

Inspection Casework Reviews

File No.: 8 

Licensee: United Blood Services License No.: 869-01 

Inspection Type: Routine/Special, Announced Priority: 5 

Inspection Date: 4/3/08 Inspector: BS 

File No.: 9 

Licensee: Entergy Operations, Inc. License No.: 681-01 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 6/14/06 Inspector: JE 

File No.: 10 

Licensee: Entergy Operations, Inc. License No.: 681-02 

Inspection Type: Routine/Special, Announced Priority: 2 

Inspection Dates: 3/21/07, 4/16/08 Inspectors: JA, JM, JM 

File No.: 11 

Licensee: Entergy Operations, Inc. License No.: 681-03 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 6/14/06 Inspector: JE 

File No.: 12 

Licensee: Central Mississippi Medical Center License No.: 722-05 

Inspection Type: Initial/Special, Announced Priority: 2 

Inspection Date: 2/13/08 Inspector: BS 

Comments: 

a) The inspector’s notes and supporting information did not provide sufficient information to 

support the validity of the violation issued. 

b) The inspection file did not indicate the licensee’s proposed corrective actions or the 

anticipated date when full compliance would be achieved. 

File No.: 13 

Licensee: SABIC Innovative Plastics US, LLC License No.: 689-01 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 6/30/05 Inspector: JE 

File No.: 14 

Licensee: University of Mississippi Medical Center License No.: MBL-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 2/16-20/09 Inspector: JM 
Mississippi Final Report Page C.3 

Inspection Casework Reviews

File No.: 15 

Licensee: University of Mississippi Medical Center License Nos.: 683-01 

Inspection Type: Routine/Special, Announced Priority: 5 

Inspection Dates: 8/7-11/06, 2/17/09 Inspectors: JE, JM 

Comments: 

a) The inspector’s notes and supporting documentation did not contain sufficient 

information to support the violation issued. 

b) Licensee’s written response to the violation did not adequately address the violation. 

Subsequent information obtained from the licensee was not documented in the file. 

File No.: 16 

Licensee: University of Mississippi Medical Center License Nos.: 683-02 

Inspection Type: Routine/Special, Announced Priority: 5 

Inspection Dates: 8/7-11/06, 2/17/09 Inspectors: JE, JM 

Comments: 

a) The inspector’s notes and supporting documentation did not contain sufficient 

information to support the violation issued. 

b) Licensee’s written response to the violation did not adequately address the violation. 

Subsequent information obtained from the licensee was not documented in the file. 

File No.: 17 

Licensee: NuMedRx Pharmacy Solutions License No.: 1006-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Dates: 11/27/07, 3/24/09 Inspectors: BS, BS 

File No.: 18 

Licensee: Schlumberger Technology Corporation License No.: 463-01 

Inspection Type: Routine/Special, Announced Priority: 3 

Inspection Dates: 2/17/07, 3/9/07, 3/23/09 Inspectors: JA, JA, JM 

File No.: 19 

Licensee: Welding Testing X-ray Inc. License No.: 666-01 

Inspection Type: Routine/Special, Unannounced Priority: 1 

Inspection Date: 10/30/08, 3/24/09 Inspectors: JM, JM 

File No.: 20 

Licensee: Alpha Omega Services, Inc. License No.: CA 3925-19 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 8/24/07 Inspectors: JA, JM 

File No.: 21 

Licensee: Varian Medical Systems License No.: NRC 45-30957-01 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 3/31/06 Inspectors: JA, JE 
Mississippi Final Report Page C.4 

Inspection Casework Reviews

File No.: 22 

Licensee: Ewer Testing & Inspection, Inc. License No.: ND 33-32610-01 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 10/18/05 Inspector: JE 

File No.: 23 

Licensee: Coastal Wireline Services, Inc. License No.: TX L04239 

Inspection Type: Reciprocity, Unannounced Priority: 3 

Inspection Date: 12/13/07 Inspectors: JA, JE 

 INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Schlumberger Technology Corporation License No.: 463-01 

Inspection Type: Routine/Special, Announced Priority: 3 

Inspection Date: 3/23/09 Inspector: JM 

Comment: 

The inspector could have benefited from asking additional followup questions related to the 

licensee’s implementation of certain requirements. 

Accompaniment No.: 2 

Licensee: NuMedRx Pharmacy Solutions License No.: 1006-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/24/09 Inspector: BS 

Accompaniment No.: 3 

Licensee: Welding Testing X-Ray Inc. License No.: 666-01 

Inspection Type: Routine/Special, Unannounced Priority: 1 

Inspection Date: 3/24/09 Inspector: JM 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Central Mississippi Medical Center License No.: 722-05 

Types of Action: New, Amendment Amendment Nos.: 0, 1 

Dates Issued: 6/6/07, 10/4/07 License Reviewers: BS, BS 

Comment: 

License did not include two required license conditions. 

File No.: 2 

Licensee: Mississippi State University License No.: ELB-02 

Type of Action: Amendment Amendment No.: 60 

Date Issued: 5/30/08 License Reviewer: BS 

Comment: 

License did not include a required license condition. 

File No.: 3 

Licensee: Jacobs Technology, Inc. License No.: 1020-01 

Types of Action: New, Amendment Amendment Nos.: 0, 3 

Dates Issued: 9/14/07, 10/30/08 License Reviewers: JA, JM 

File No.: 4 

Licensee: Acuren Inspection, Inc. License No.: 784-01 

Type of Action: Amendment Amendment No.: 37 

Dates Issued: 1/26/09 License Reviewer: JM 

File No.: 5 

Licensee: Gray Wireline Service, Inc. License No.: 1031-01 

Type of Action: New Amendment No.: 0 

Date Issued: 2/6/09 License Reviewer: BS 

File No.: 6 

Licensee: Liberty Heart Center License No.: 935-01 

Type of Action: Amendment Amendment No.: 4 

Date Issued: 12/20/07 License Reviewer: BS 

File No.: 7 

Licensee: SABIC Innovative Plastics US License No.: 689-01 

Type of Action: Renewal Amendment No.: 18 

Date Issued: 9/12/06 License Reviewer: JM 

Comment: 

License did not include a required license condition. 
Mississippi Final Report Page D.2 

Licensing Casework Reviews

File No.: 8 

Licensee: Baptist Cancer Institute License No.: 942-01 

Type of Action: Amendment Amendment No.: 4 

Date Issued: 1/10/06 License Reviewer: BS 

File No.: 9 

Licensee: Pritchard Engineering, Inc. License No.: 865-01 

Type of Action: Amendment Amendment No.: 7 

Date Issued: 10/14/05 License Reviewer: BS 

File No.: 10 

Licensee: Triad Isotopes, Inc. License No.: 794-01 

Type of Action: Amendment Amendment No.: 28 

Date Issued: 6/6/08 License Reviewer: BS 

File No.: 11 

Licensee: King’s Daughters Hospital License No.: 270-01 

Type of Action: Renewal Amendment No.: 41 

Date Issued: 7/18/07 License Reviewer: JA 

File No.: 12 

Licensee: American Diagnostic Technologies License No.: 927-01 

Type of Action: Amendment Amendment No.: 23 

Date Issued: 12/19/07 License Reviewer: JA 

File No.: 13 

Licensee: Hall, Blake and Associates, Inc. License No.: 965-01 

Type of Action: Renewal Amendment No.: 5 

Date Issued: 3/18/09 License Reviewer: JM 

File No.: 14 

Licensee: Turner Specialty Services, LLC License No.: 950-01 

Type of Action: Amendment Amendment No.: 5 

Date Issued: 5/26/06 License Reviewer: BS 

Comment: 

A required license condition was not issued in timely manner. 

File No.: 15 

Licensee: Team Industrial Services, Inc. License No.: 515-01 

Type of Action: Renewal Amendment No.: 30 

Date Issued: 6/20/05 License Reviewer: BS 

File No.: 16 

Licensee: Gulf Cities Testing Laboratories, Inc. License No.: 948-01 

Type of Action: Amendment Amendment No.: 9 

Date Issued: 1/11/07 License Reviewer: JM 
Mississippi Final Report Page D.3 

Licensing Casework Reviews

File No.: 17 

Licensee: Baptist Memorial Hospital License No.: 543-01 

Type of Action: Amendment Amendment No.: 37 

Date Issued: 5/5/08 License Reviewer: BS 

File No.: 18 

Licensee: Land Shaper, Inc. License No.: 921-01 

Type of Action: Termination Amendment No.: 7 

Date Issued: 7/26/06 License Reviewer: BS 

File No.: 19 

Licensee: Team Inspection Services License No.: 949-01 

Type of Action: Termination Amendment No.: 3 

Date Issued: 6/28/05 License Reviewer: RG 

File No.: 20 

Licensee: NuMedRx Pharmacy Solutions License No.: 1006-01 

Types of Action: New, Amendment Amendment Nos.: 0, 2 

Dates Issued: 12/7/06, 3/3/08 License Reviewers: BS, JA 

File No.: 21 

Licensee: Mississippi Tank Company, Inc. License No.: 064-01 

Type of Action: Amendment Amendment No.: 57 

Date Issued: 10/20/06 License Reviewer: BS 

File No.: 22 

Licensee: University of Mississippi License No.: MBL-01 

Type of Action: Renewal Amendment No.: 49 

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

File No.: 23 

Licensee: The Heart Care Center License No.: 917-01 

Type of Action: Renewal Amendment No.: 9 

Date Issued: 7/3/08 License Reviewer: JE 

File No.: 24 

Licensee: USM Department of Marine Science License No.: 976-01 

Type of Action: Amendment Amendment No.: 2 

Date Issued: 6/23/08 License Reviewer: JM 

File No.: 25 

Licensee: Mississippi Emergency Management Agency License No.: 033-01 

Type of Action: Amendment Amendment No.: 87 

Date Issued: 11/23/06 License Reviewer: DY 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Baptist Desoto Hospital License No: 675-01 

Date of Incident: 10/30/08 Event No.: 08013 

Investigation Date: 10/30/08 Type of Incident: Medical event 

 Type of Investigation: Site 

File No.: 2 

Licensee: Wal-Mart License No: GL 

Date of Incident: 10/21/08 Event No.: 08011 

Investigation Date: N/A Type of Incident: Lost material 

 Type of Investigation: N/A 

File No.: 3 

Licensee: University of Mississippi Medical Center License No: MBL-01 

Date of Incident: 10/9/08 Event No.: 08010 

Investigation Date: None Type of Incident: Material spill 

 Type of Investigation: None 

File No.: 4 

Licensee: W.G. Yates & Sons Construction Co. License No: 656-01 

Date of Incident: 7/14/08 Event No.: 08008 

Investigation Date: 7/14/08 Type of Incident: Equipment damage 

 Type of Investigation: Site 

File No.: 5 

Licensee: N/A License No: N/A 

Date of Incident: 5/28/08 Event No.: 08007 

Investigation Date: 5/28/08 Type of Incident: Transportation 

 Type of Investigation: Site 

File No.: 6 

Licensee: N/A License No: N/A 

Date of Incident: 5/23/08 Event No.: 08006 

Investigation Date: 5/23/08 Type of Incident: Recovered material 

 Type of Investigation: Site 

File No.: 7 

Licensee: Acuren Inspection License No: 789-01 

Date of Incident: 3/23/09 Event No.: 09004 

Investigation Date: 4/2/09 Type of Incident: Equipment failure 

 Type of Investigation: Written report 
Mississippi Final Report Page E.2 

Incident Casework Reviews

File No.: 8 

Licensee: JANX License No: NRC 21-16560-01 

Date of Incident: 1/15/09 Event No.: 09001 

Investigation Date: 1/15/09 Type of Incident: Transportation 

 Type of Investigation: Site 

File No.: 9 

Licensee: NuMedRx License No: 106-01 

Date of Incident: 10/25/07 Event No.: 07007 

Investigation Date: 10/25/07 Type of Incident: Transportation 

 Type of Investigation: Site 

File No.: 10 

Licensee: Biloxi Regional Medical Center License No: 198-02 

Date of Incident: 8/29/06 Event No.: 06012 

Investigation Date: 9/20/06 Type of Incident: Medical event 

 Type of Investigation: Site 

File No.: 11 

Licensee: University of Mississippi Medical Center License No: MBL-01 

Date of Incident: 12/11/07 Event No.: 08004 

Investigation Date: 4/4/08 Type of Incident: Medical event 

 Type of Investigation: Site 

File No.: 12 

Licensee: Dunn Road Builders License No: 870-01 

Date of Incident: 2/3/09 Event No.: 09002 

Investigation Date: 2/3/09 Type of Incident: Equipment damage 

 Type of Investigation: Site 

File No.: 13 

Licensee: Burns Colley Dennis, Inc. License No: 619-01 

Date of Incident: 7/9/06 Event No.: 06008 

Investigation Date: 7/9/06 Type of Incident: Equipment damage 

 Type of Investigation: Site 

File No.: 14 

Licensee: N/A License No: N/A 

Date of Incident: 2/21/06 Event No.: 06005 

Investigation Date: 2/21/06 Type of Incident: Recovered material 

 Type of Investigation: Site 

File No.: 15 

Licensee: Newcomb Engineering License No: 967-01 

Date of Incident: 2/14/06 Event No.: 06003 

Investigation Date: 2/14/06 Type of Incident: Equipment damage 

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

Incident Casework Reviews

File No.: 16 

Licensee: Cardinal Health License No: 493-01 

Date of Incident: 2/20/06 Event No.: 06004 

Investigation Date: None Type of Incident: Transportation 

 Type of Investigation: None 

File No.: 17 

Licensee: Metal Processors, Inc. License No: GL-384 

Date of Incident: 8/7/06 Event No.: 06010 

Investigation Date: None Type of Incident: Equipment damage 

 Type of Investigation: None 

File No.: 18 

Licensee: Cardinal Health License No: 493-01 

Date of Incident: 9/22/06 Event No.: 06011 

Investigation Date: 9/22/06 Type of Incident: Transportation 

 Type of Investigation: Site 

File No.: 19 

Licensee: Cardinal Health License No: 493-01 

Date of Incident: 11/7/06 Event No.: 06014 

Investigation Date: None Type of Incident: Stolen material 

 Type of Investigation: None 

File No.: 20 

Licensee: Building & Earth Sciences License No: AL-1266 

Date of Incident: 12/20/07 Event No.: 07010 

Investigation Date: 12/21/07 Type of Incident: Recovered material 

 Type of Investigation: Site 

File No.: 21 

Licensee: Pepsi Bottling Group License No: WI-R0831 

Date of Incident: 8/15/07 Event No.: 07004 

Investigation Date: 8/15/07 Type of Incident: Wrong transfer of RAM 

 Type of Investigation: Site 

File No.: 22 

Licensee: Aquaterra Engineering License No: 724-01 

Date of Incident: 1/27/07 Event No.: 07001 

Investigation Date: 2/5/07 Type of Incident: Stolen material 

 Type of Investigation: Site 
ATTACHMENT 

June 10, 2009 Letter from Jim Craig 

Mississippi’s Response to Draft IMPEP Report 

ADAMS Accession No.: ML091671819