INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM

REVIEW OF NRC REGION I PROGRAM

APRIL 4-8, 2005

FINAL REPORT

U.S. Nuclear Regulatory Commission

ADAMS ML051670411
Region I Final Report Page 1

1.0 INTRODUCTION

This report presents the results of the review of the Region I (RI) materials program. The

review was conducted during the period of April 4-8, 2005, by a review team comprised of

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

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

accordance with the "Implementation of the Integrated Materials Performance Evaluation

Program and Rescission of a Final General Statement of Policy," published in the Federal

Register on October 16, 1997, and the February 26, 2004, revision to NRC Management

Directive (MD) 5.6, "Integrated Materials Performance Evaluation Program (IMPEP)." 

Preliminary results of the review, which covered the period March 2001 to April 2005, were

discussed with RI management on April 8, 2005.

A draft of this report was issued to RI for factual comments on April 27, 2005. RI responded by

memorandum dated May 13, 2005. The Management Review Board (MRB) met on June 15,

2005, to consider the proposed final report. The MRB found the RI nuclear materials program

adequate to protect public health and safety.

The RI materials program is administered by the Director, Division of Nuclear Materials Safety

(DNMS), who reports directly to the Regional Administrator. The DNMS organization chart is

included as Appendix B. At the time of the review, the RI materials program regulated more

than 2400 specific material licenses. In addition, the Division has inspection responsibility for

seven power reactors in decommissioning status (three active and four SAFSTOR); 18 complex

materials decommissioning sites; and all independent spent fuel storage installations in RI. The

Division also has liaison and oversight responsibilities for 14 Agreement States. 

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

indicators was sent to RI on January 28, 2005. RI provided a response to the questionnaire on

March 18, 2005. A copy of the completed questionnaire response can be found on NRC’s

Agency-wide Document Access and Management System (ADAMS), using Accession Number

ML051170112.

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

of RI’s response to the questionnaire; (2) analysis of quantitative information from the licensing,

inspection, and allegation databases, as well as ADAMS; (3) technical review of selected

licensing, inspection, incident response, allegation, and decommissioning actions or files; (4)

field accompaniments of six RI inspectors; and (5) 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 indicator and made a

preliminary assessment of RI’s performance.

Section 2 below discusses RI’s actions in response to recommendations made after 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

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

team had no recommendations.
Region I Final Report Page 2

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS

During the previous IMPEP review, which concluded on March 19, 2001, one recommendation

was made. The team’s review of the current status of the recommendation is as follows:

1. The review team recommends that RI follow the financial assurance requirements of MD

8.12 and that RI effectively followup on issues and comments raised in the annual

evaluations of the financial assurance files (Section 4.2.2).

Current Status: RI is following the financial assurance requirements of MD 8.12 and is

effectively following up on issues and comments raised in the annual evaluations of the

financial assurance files. 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) 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 radioactive materials program

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

issues, the review team examined RI's questionnaire responses relative to this indicator,

interviewed DNMS management and staff, interviewed RI Division of Resource Management

staff, and considered any possible workload backlogs.

At the end of Fiscal Year 2004 (FY04), RI completed consolidation of regional materials

programs between Regions I and II. The result of the consolidation was a 2 Full-TimeEquivalent (FTE) savings to the Agency. All management positions are located in King of

Prussia and the Division reorganized so that the branches have staff located in King of Prussia

and Atlanta. DNMS was reorganized with four branches ((1) Medical Branch, (2) Commercial

and R&D Branch, (3) Materials Security and Industrial Branch, and (4) Decommissioning

Branch) and a Licensing Assistance Team at the Division level. Including non-technical

overhead positions, DNMS had 55 staff members on-board at the time of the review, four of

whom were Atlanta-based staff. Funding for direct technical positions comes from the Nuclear

Materials Safety Arena (30.7 FTE), the Nuclear Waste Safety Arena (6.4 FTE), Nuclear

Materials Security Arena (6.5 FTE), and the Office of State and Tribal Programs (2.25 FTE). 

 

As a result of internal transfers to Region II programs and retirements from both Atlanta and

King of Prussia, the consolidated program has been challenged in reaching its full complement

of staff. Nineteen new technical staff members have been hired into DNMS since the last

IMPEP review. During the review period, 16 DNMS staff members left the program. DNMS

had three vacancies [2 Health Physicists (HPs); 1 Branch Chief(BC)] at the time of the onsite
Region I Final Report Page 3

review. The HP positions have been vacant for approximately 5 months. DNMS is addressing

these vacancies within the constraints of overall Regional FTE. The BC for the

Decommissioning Branch transferred within the region, and DNMS filled this position internally.

The review team examined the training spreadsheet, sampled some individual inspectors’

qualifications, and interviewed managers, concerning technical training in accordance with

Inspection Manual Chapter (IMC) 1246 requirements. The review team found a good balance

of personnel between licensing and inspection. With RI’s organization, most technical staff in

DNMS complete both licensing and inspection actions, rather than having separate license

reviewers and inspectors. All staff members in each branch are fully qualified for the work they

perform. Eleven staff are in the inspector qualification process -- the remainder of the staff

being fully qualified inspectors. Seven of the 11 in the qualification process are interim-qualified

and are expected to complete the process by October 2005. The remaining four will complete

the process after October, but within the time frame contained in IMC 1246. Of the technical

staff members who work on materials and decommissioning licensing issues, 19 have full

signature authority, 9 have limited signature authority, and 14 technical staff have no signature

authority for licensing actions. Except for training purposes, staff members are assigned

licensing work for which they have independent signature authority. Licensing work that a staff

member performs as part of his/her training program and for which he /she does not have

signature authority is reviewed and signed by a qualified reviewer or supervisor. The review

team determined that the number of license reviewers with full or limited signature authority is

sufficient to complete RI’s materials licensing work, and allows for readjustments in the

workload between materials licensing and inspection, as necessary.

RI’s continued strength is its highly qualified, experienced, and diverse technical staff. The staff

includes a number of individuals with Masters and Doctorate degrees, as well as certification by

the American Board of Health Physics. Many of the staff have extensive experience in both

materials and reactor applications of health physics, as well as State and private sector

experience. The staff is also actively involved in professional societies, such as the Health

Physics Society, at both local and national levels. RI has implemented a mentoring program,

whereby senior staff members meet with new hires to ensure that these staff are progressing in

their training and development, to attain licensing and inspection qualifications. This program

enhances the training and development experience for these staff and reduces the impact on

the BCs.

RI identified the management of remotely-located staff in Atlanta as a challenge for the

consolidated RI materials program. RI recognizes the need to continue its effort to assure that

staff members in Atlanta are fully integrated into its operations and receive the tools and

training to perform licensing and inspection functions consistently. The team found that RI is

working to meet this challenge, and recognizes that this will be a continuing effort.

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

that RI's performance with respect to the indicator Technical Staffing and Training be

found satisfactory.
Region I Final Report Page 4

3.2 Status of Materials Inspection Program

The team focused on five factors in reviewing this indicator: (1) inspection frequency; 

(2) overdue inspections; (3) initial inspection of new licenses; (4) the timely dispatch of

inspection findings to licensees; and (5) the performance of reciprocity inspections. The

evaluation is based on RI’s questionnaire responses relative to this indicator, data gathered

independently from NRC’s Licensing Tracking System (LTS), the examination of completed

inspection casework, and interviews with RI’s managers and staff.

At the beginning of FY04, RI completed a consolidation of Regions I and II Materials programs.

RI increased the number of inspections it performs annually by approximately 50 percent, to

630 inspections, as a result of the 800 licensees added as a result of the consolidation. 

The team reviewed RI’s inspection priorities during the period and found that the inspection

frequencies for various types of licenses were consistent with program office guidance, as

provided in IMC 2800, dated November 25, 2003. This was verified by cross-checking the

actual inspection frequencies entered in the LTS with the IMC 2800 frequencies. In all cases

reviewed, the inspection frequencies in the database match the IMC 2800 inspection

frequencies unless the next inspection date is intentionally reduced by the regional staff. In

accordance with IMC 2800, RI reduced an individual licensee’s inspection schedule, based on

the licensee’s inspection findings (i.e., escalated enforcement).

In its response to the IMPEP questionnaire, RI indicated that there were two initial inspections

overdue by more than 25 percent of the assigned frequency. Both were priority 5 licensees and

RI completed the inspections before to the end of the onsite IMPEP review. 

During the review period, RI issued 483 new licenses. Nearly all of these (481 of 483) were

inspected within the assigned inspection frequency. The other two licensees were inspected

within 14 months.

During the review period, RI consistently met the reciprocity inspection goals as established in

IMC 1220.

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

casework review. For the casework reviewed by the team, 24 of 25 of the inspection findings

were sent to the licensees within 30 days.

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

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

3.3 Technical Quality of Inspections

The team evaluated the inspection reports, enforcement documentation, and inspection

documentation, and interviewed inspectors for 24 materials inspections conducted during the

review period. Twenty-two of RI’s materials inspectors’ casework were reviewed. The

casework covered inspections of various license types, including: (1) medical institutions; (2)

high- dose-rate remote afterloaders (HDRs); (3) industrial radiography; (4) portable gauges; 
Region I Final Report Page 5

(5) waste disposal; (6) research and development; (7) decommissioning reactor; (8) complex

decommissioning: and (9) independent spent fuel storage installation. Appendix C lists the

inspection casework files reviewed for completeness and adequacy with specific comments.

During the review, the team determined that RI is performing inspections of materials licensees

in accordance with IMC 2800, dated November 25, 2003. Inspectors reviewed previous open

items and past violations during the inspections. For the cases reviewed, inspection reports

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

licensees’ performances with respect to health and safety issues were acceptable. Inspection

findings lead to appropriate and prompt regulatory action. Based on the casework, routine

inspections covered all aspects of the licensees’ radiation programs commensurate with

licensed activities.

The team determined that DNMS BCs are accompanying all inspectors at least once each year. 

The experience level of the inspector is taken into account in the accompaniment schedule,

with a higher priority given to new inspectors. 

Six Regional inspectors (two were in training) were accompanied during inspections by a review

team member during the weeks of March 14 and March 21, 2005. Inspection accompaniments

were conducted on inspections as follows: two broad-scope medical; industrial radiographer;

and research and development. These accompaniments are identified in Appendix C.

During the accompaniments, each inspector demonstrated appropriate inspection techniques

and knowledge of the regulations. The inspectors were trained, prepared, and thorough in their

inspections of the licensees’ radiation safety programs. Overall, each inspector used good

health physics practices; their interviews with licensee personnel were performed in an effective

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

licensed facilities.

The team found that RI maintains a sufficient number of various models of survey instruments

to perform radiological surveys of materials licensees. The review team examined

instrumentation and observed that the survey instruments in RI’s office at the time of the onsite

review were calibrated and operable. Instrument calibrations are performed by a licensed

calibration facility. All samples are sent to a contractor radioanalytical laboratory for analysis.

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

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

3.4 Technical Quality of Licensing Activities

The review team examined completed licensing casework and interviewed the staff regarding

28 specific licenses, and interviewed the BC and various license reviewers. Licensing actions

were evaluated for: (1) completeness; (2) consistency; (3) proper isotopes and quantities used;

(4) qualifications of authorized users; (5) adequate facilities and equipment; and (6) operating

and emergency procedures sufficient to establish the basis for licensing actions. Licenses were

evaluated for overall technical quality, including accuracy, appropriateness, license conditions, 

and tie-down conditions. Casework was evaluated for: (1) timeliness; (2) adherence to good
Region I Final Report Page 6

health physics practices; (3) reference to appropriate regulations; (4) documentation of safety

evaluation reports, product certifications, or other supporting documents; (5) consideration of

enforcement history on renewals; (6) pre-licensing visits; (7) peer or supervisory review as

indicated; and (8) proper signature authorities. The files were checked for retention of

necessary documents and supporting data.

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

which were completed during the review period. The sampling included the following types: 

(1) medical broad; (2) broad academic; (3) nuclear laundry; (4) industrial radiography; 

(5) service provider; (6) portable gauge; (7) self-shielded irradiator; (8) mobile medical; 

(9) gamma knife; (10) medical -- both diagnostic and therapy; and (11) medical distribution. 

Types of licensing actions selected for evaluation included: (1) five new licenses; (2) four

renewals; (3) twelve amendments; (4) two notifications; (5) two financial assurances; and (6)

five terminations. A list of the licenses, evaluated with case-specific comments, can be found in

Appendix D.

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

quality, and properly addressed health and safety issues. The files contained appropriate

deficiency letters, and documentation of telephone communications with the licensee. The

license reviewers generally signed all new or renewed licenses or amendments. For those

licensing actions for which the license reviewer did not have signature authority, the licenses

were signed by a senior reviewer with full authority, or by the BC.

Licensing files were found to be maintained very well. The review team found that each of the

reviewed docket files was complete and orderly.

Based on the IMPEP evaluation criteria, the review team recommends that RI's performance

with respect to the indicator Technical Quality of Licensing Actions be found satisfactory.

3.5 Technical Quality of Incidents and Allegation Activities

The review team examined RI’s response to the questionnaire relative to this indicator;

evaluated selected incidents from the list of Nuclear Material Events Database (NMED) entries

reported in the questionnaire against those contained in RI’s licensing files; and evaluated the

efforts and supporting documentation for 10 material incidents. A list of the incidents examined,

with case-specific comments, is included in Appendix E. The team also reviewed RI’s response

to 11 allegations, the actions taken, and the files associated with them.

The review team discussed RI’s incident and allegation procedures, file documentation, and

NMED, with RI staff and management. All incidents reviewed were evaluated quickly for the

need for onsite investigations, with several special inspections occurring within a relative short

time (a few days to a week of an incident notification). RI took prompt, appropriate, action, in

response to incidents. For less significant health and safety issues, RI appropriately deferred

review of licensee actions to the next routine inspection. Of the 10 incidents reviewed, the

review team considered DNMS’ level of effort expended on incidents correct and

commensurate with the potential health and safety significance of the incidents. RI staff

adequately and clearly identified licensees' noncompliance issues and, as appropriate, initiated
Region I Final Report Page 7

enforcement actions. In addition, RI coordinated materials incident responses with other NRC

offices and, when appropriate, with other regulatory jurisdictions (i.e., States) in a timely and

effective manner. When comparing the Preliminary Notices (PNs) generated for some of the

incidents, the review team found good correlation between the PNs issued, the incident

information in the licensing files, and the incident information on the NMED system.

The review team noted RI staff’s efforts to work with the NMED system. There has been

increased efforts to complete NMED records by providing essential details necessary to classify

an NMED record as “complete.” There has been increased e-mail correspondence between RI

staff and the NMED contractor, to provide detailed information to contractor inquiries to

complete records. The review team also noted that an inspector indicated that the NMED

system is scanned for licensee entries before beginning an inspection at a licensee’s facility. 

The review team examined Rl's response to the questionnaire relative to allegations, and

compared 11 allegations in the Allegations Management System against those contained in Rl’s

allegations files, and supporting documentation contained in the licensee file and ADAMS. The

review team noted that the results of the last annual audit of the allegation program, performed

on April 19-21, 2004, did not identify any findings the program needed to address. In addition,

the review team held interviews with the Regional Allegations Coordinator, RI managers, and RI

technical staff, on allegation handling.

The Senior Allegations Coordinator generates a monthly report that details the status of all

open allegations, and disseminates this information to all Rl managers. DNMS management

and the allegations staff hold a monthly meeting to discuss the status and progress in meeting

its allegation performance goals, and to focus on actions necessary to ensure prompt and

procedurally correct follow-up of open allegations. These meetings provide the opportunity for

DNMS managers to provide close attention to allegations under their responsibility. A new

performance matrix since the last IMPEP tracks: (1) percent of allegations received by the

Senior Allegation Coordinator within 5 days of initial contact with an alleger; (2) the number of

Allegation Review Boards (ARBs) conducted with 30 days of initial contact of an allegation; 

(3) acknowledgment of an allegation by letter timeliness within 30 days; and (4) the time to

closing an allegation, within 150 days. The last three monthly reports reviewed indicate that the

all matrix goals have been meet 100 percent of the times for material allegations. 

ARB meetings are scheduled bi-weekly; this routine scheduling allows for easily meeting the

30-day matrix goal between receipt and ARB review of an allegation. The team observed an

ARB meeting on April 6, 2005. The meeting was well-attended, with representatives from: 

(1) the technical division responsible for the allegation; (2) the responsible BC; (3) the

Allegation Coordinator’s Office; (4) Office of Investigation; (5) Office of Enforcement; and 

(6) the Deputy DNMS. A recorder present concentrated on documenting, via computer

projection, the proceedings, decisions, and actions determined in the meeting, eliminating

transcription, concurrence delays, and circulation of meeting minutes. The meeting was brisk,

focused, and aggressive in determining the next appropriate action to address the allegation

issues and bring the issue to closure. 

The review team noted that the filing system maintained by the Office Allegation Coordinator

indicates great care and effort in the meticulous organization and completeness of the records.
Region I Final Report Page 8

Based on the IMPEP evaluation criteria, the review team recommends that Rl's performance

with respect to the indicator Technical Quality of Incidents and Allegation Activities be found

satisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS

IMPEP identifies three non-common performance indicators to be used in reviewing Regional 

materials program: (1) the Uranium Recovery Program; (2) Regional Fuel Cycle Inspection

Program; and (3) Site Decommissioning Management Plan and Decommissioning Activities. 

RI’s material program does not cover the Uranium Recovery and Regional Fuel Cycle

Inspection Program, so only the third non-common performance indicator was applicable to this

review.

4.1 Site Decommissioning Management Plan

The Complex Site Decommissioning Plan includes sites that involve decommissioning issues

that present varying degrees of radiological hazard, remediation complexity, and cost. These

unique and difficult sites have: (1) buildings; (2) former waste disposal areas; (3) large piles of

tailings; (4) ground water; and (5) soil contaminated with low levels of uranium or thorium

(source material), or other radionuclides. In RI, complex decommissioning sites that required

substantial decommissioning actions, such as remediation or final radiological surveys, were

the responsibility of the Decommissioning Branch. Non-complex decommissioning license

terminations, such as for Group I licensees, were assigned to the appropriate licensing branch.

In conducting this review, five sub-indicators were reviewed to evaluate RI’s performance

regarding complex site decommissioning. These sub-indicators included: (1) Quality of

Decommission Reviews; (2) Financial Assurance for Decommissioning; (3) Termination

Radiological Surveys; (4) Inspections; and (5) Staff Qualifications. In performing this review,

the review team interviewed DNMS management and staff, examined decommissioning files,

group I licensee files, and reviewed financial assurance documents. Appendix F contains the

complex site decommissioning files reviewed. 

4.1.1 Quality of Complex Decommissioning Reviews

To assess RI’s performance on reviews for license terminations, the review team interviewed RI

staff and examined files for three complex sites and two non-complex sites that were terminated

or undergoing decommissioning activities during the review period. 

Decommissioning licensing review actions undertaken by RI staff for complex sites included: 

(1) reviewing the status of sites in accordances with timeliness requirements; (2) establishing

radiological criteria for release of sites; (3) reviewing licensees’ decommissioning plans; 

(4) ensuring adequate financial assurance; (5) reviewing licensees’ final status survey plans

and reports; and (6) conducting confirmatory surveys.
Region I Final Report Page 9

The review team found that licensees’ decommissioning plans were appropriately reviewed by

RI in accordance with IMC 2605, “Decommissioning Procedures for Fuel Cycle and Materials

Licensees;” the Decommissioning Handbook; and the new NUREG-1727, “NMSS

Decommissioning Standard Review Plan,” when applicable. Through a review of the docket

files and discussion with license reviewers and the BC, the review team concluded that RI

decommissioning actions addressed licensee health and safety conditions appropriately.

Decommissioning licensing review actions undertaken by RI staff for non-complex sites

included: (1) reviewing the status of sites in accordance with timeliness requirements; 

(2) reviewing/approving radiological criteria for release of sites; (3) reviewing licensees’

decommissioning plans; (4) ensuring adequate financial assurance; (5) reviewing licensees’

final status survey plans and reports; and (6) conducting confirmatory surveys.

Licensee decommissioning plans, where required, first status survey results and closeout

documentation, were reviewed and documented by DNMS in accordance with applicable NRC

guidance.

4.1.2 Financial Assurance for Decommissioning

The review team evaluated RI’s financial assurance program for conformance with

requirements of MD 8.12, “Decommissioning Financial Assurance Instrument Security

Program.” 

To assess the performance of RI for financial assurance, the review team examined the LTS;

reviewed RI’s “FY2005 Inventory List of Original Financial Assurance Instruments”; reviewed 10

financial assurance instruments in the file, including a comparison with the inventory list

information; and evaluated RI’s annual self-evaluations of the security of decommissioning

financial assurance instruments, for the period of the review, required by MD 8.12. The review

team followed up on these activities with reviews of selected docket files and interviews with

decommissioning staff.

The review team confirmed that RI has staff assigned as Decommissioning Financial

Assurance Instrument Custodian (FAIC); Alternate Decommissioning Financial Assurance

Instrument Custodian (AFAIC); and FAIC Manager, in accordance with MD 8.12. The FAIC

Manager is the Chief of the Decommissioning Branch. The review team confirmed that the

FAIC, AFAIC, and FAIC Manager have been designated in writing, and that no one has access

to the financial assurance records other than through these individuals, as required by MD 8.12. 

The review team confirmed that the decommissioning financial assurance instruments are

stored in a fire-rated safe, having a fire rating in accordance with MD 8.12. The review team

also confirmed that the FAIC maintains an inventory list of the financial assurance instruments

held in the safe, and this inventory contains the information required by MD 8.12.

The team reviewed the self-assessment required by MD 8.12, for 2005. MD 8.12 requires the

annual self-assessments review of 100 percent of the files on the inventory list, against the

guidelines in the Handbook. Additionally, MD 8.12 requires that two evaluations of financial

assurance instruments be conducted annually, one by the Custodian or Alternate, and one by

the Manager. All the reviewed audits met the requirements of MD 8.12.
Region I Final Report Page 10

The team reviewed the security of the financial assurance instruments. RI has established

check out/in procedures. Each time the safe is opened and closed, an entry is made on a log

sheet. Instruments that are taken from the safe are returned before the end of the business

day.

The team compared the inventory list of the financial assurance instruments with the LTS. The

team found minor administrative discrepancies between the inventory list and LTS. These

minor discrepancies would not prevent the execution of the financial instruments.

4.1.3 Termination Radiological Surveys

The review team discussed termination surveys with RI staff and managers and evaluated

casework for adequacy of licensee and NRC surveys to support license termination. The

review team observed that licensee final status survey plans and reports have been prepared in

accordance with NUREG/CR-5849, “Manual for Conducting Radiological Surveys in Support of

License Termination”; NUREG-1575, “Multi-Agency Radiation Survey and Site Investigation

Manual (MARSSIM)”; or other appropriate methods, and are reviewed by RI staff. The review

team concluded that RI’s reviews are adequate to ensure that residual radioactivity levels

comply with release criteria. NRC confirmatory or closeout surveys are performed, as

necessary, for each licensee’s site, by RI or NRC’s contractor, to validate licensee survey data,

as outlined in IMC 2605, and in Inspection Procedure 87104, “Decommissioning Inspection

Procedure for Materials Licensees.” 

4.1.4 Inspections

The review team evaluated the number of inspections performed at complex decommissioning

sites during the review period. RI indicated that it has performed all inspections in accordance

with IMC 2602, “Decommissioning Inspection Program for Fuel Cycle Facilities and Materials

Licensees,” and that no decommissioning inspections were overdue. Closeout inspections are

performed, as appropriate, to terminate licenses.

4.1.5 Staff Qualifications

Refer to Section 3.1 of this report.

4.1.6 Conclusion

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

with respect to the indicator Site Decommissioning Management Plan be found satisfactory.
Region I Final Report Page 11

5.0 SUMMARY

As noted in Sections 3 and 4 above, the review team found RI’s performance with respect to

each of the performance indicators to be satisfactory. Accordingly, the review team

recommends finding the RI material program to be adequate to protect public health and

safety. Based on the results of the current IMPEP review, the review team recommends that

the next full review be in approximately 4 years.
LIST OF APPENDICES AND ATTACHMENTS

Appendix A IMPEP Review Team Members

Appendix B Region I Organization Charts

Appendix C Inspection Casework Reviews

Appendix D License Casework Reviews

Appendix E Incident Casework Reviews

Appendix F Decommissioning Casework Reviews

Attachment May 13, 2005 Memorandum from George Pangburn

 Region I’s Response to Review Findings
APPENDIX A

IMPEP REVIEW TEAM MEMBERS

Name Area of Responsibility

Charles R. Cox, NMSS/IMNS Team Leader

Andrew Mauer, STP Technical Staffing and Training

Christopher Martin, RIII Status of Materials Inspection Program

Technical Quality of Inspections

Site Decommissioning Management Plan

Pamela Bishop, Oklahoma Technical Quality of Licensing Actions

Joseph DeCicco, NMSS/IMNS Technical Quality of Incidents and Allegation

Activities
APPENDIX B

REGION I

DIVISION OF NUCLEAR MATERIAL SAFETY

ORGANIZATION CHART
APPENDIX C

INSPECTION CASEWORK REVIEWS

NOTE: ALL INSPECTIONS LISTED WITHOUT COMMENT ARE INCLUDED FOR

COMPLETENESS ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP

TEAM.

File No.: 1 

Licensee: Arch Chemicals, Inc. License No.: 06-08166-02

Location: Cheshire, CT Inspection Type: Routine

Inspection Date: 6/11/02 Priority: 5

Inspector: JJ

File No.: 2 

Licensee: Canberra Dover, Inc. License No.: 29-04236-01

Location: Dover, NJ Inspection Type: Routine

Inspection Date: 7/14/04 Priority: 2

Inspector: KM

File No.: 3 

Licensee: Certified Testing Laboratories, Inc. License No.: 29-14150-01

Location: Bordentown, NJ Inspection Type: Routine

Inspection Date: 5/23/01 Priority: 1

Inspector: JJ

File No.: 4 

Licensee: Chase Environmental Group, Inc. License No.: 201-605-90(KY)

Location: Paterson, NJ & Springhouse, PA Inspection Type: Reciprocity

Inspection Date: 8/26/2004 Priority: 3

Inspector: BU

File No.: 5 

Licensee: Clara Maass Medical Center License No.: 29-03163-03

Location: Belleville, NJ Inspection Type: Routine

Inspection Date: 12/9-10/03 Priority: 2

Inspector: SC

File No.: 6 

Licensee: Danville Regional Medical Center License No.: 29-14150-01

Location: Danville, VA Inspection Type: Routine

Inspection Date: 8/3/04 Priority: 2

Inspector: SG/RR

File No.: 7 

Licensee: Digirad Imaging Solutions, Inc. License No.: 31-30666-01

Location: Bemus Point, NY Inspection Type: Routine

Inspection Date: 2/14/05 Priority: 3

Inspector: MB
Region I Final Report Page C.2

Inspection Casework Reviews

File No.: 8 

Licensee: Eastern Isotopes, Inc. License No.: 45-25221-01MD

Location: Sterling, VA Inspection Type: Routine

Inspection Date: 2/2/05 Priority: 2

Inspector: TT/DE

File No.: 9 

Licensee: Hayes Testing Laboratory, Inc. License No.: 201-168-05(KY)

Location: Louisville, IN Inspection Type: Reciprocity

Inspection Date: 8/5/04 Priority: 1

Inspector: TG

File No.: 10 

Licensee: HNTB Corporation License No.: 29-19862-01

Location: Fairfield, NJ Inspection Type: Routine

Inspection Date: 8/8/01 Priority: 5

Inspector: ST-S/KM

File No.: 11 

Licensee: St. Lukes Hospital License No.: 37-07939-01

Location: Bethlehem, PA Inspection Type: Routine

Inspection Date: 8/17/04 Priority: 2

Inspector: RM

File No.: 12 

Licensee: Department of the Navy License No.: 45-23645-01NA

Location: Bethesda, MD Inspection Type: Routine

Inspection Date: 4/23/04 Priority: 2

Inspector: JS/DD-T

File No.: 13 

Licensee: Radiation Medicine Specialists of Northeast License No.: 37-30549-01

 Pennsylvania, P.C.

Location: Bethesda, MD Inspection Type: Routine

Inspection Date: 2/17/04 Priority: 2

Inspector: RM

File No.: 14 

Licensee: St. Joseph’s Regional Medical center License No.: 29-10191-02

Location: Paterson, NJ Inspection Type: Routine

Inspection Date: 12/23/03 Priority: 2

Inspector: RM

File No.: 15 

Licensee: Testwell Laboratories, Inc License No.: 2930-4164(NY)

Location: Ossining, NY Inspection Type: Reciprocity

Inspection Date: 9/18/02 Priority: 2

Inspector: KM/DW
Region I Final Report Page C.3

Inspection Casework Reviews

File No.: 16 

Licensee: Thomas Jefferson University Hospital, Inc. License No.: 37-00148-06

Location: Philadelphia & Doylestown, PA Inspection Type: Routine

Inspection Date: 12/16-19/03 Priority: 2

Inspector: JD

File No.: 17 

Licensee: Thomas Jefferson University Hospital, Inc. License No.: 37-00148-07

Location: Philadelphia, PA Inspection Type: Routine

Inspection Date: 12/16-19/03 Priority: 5

Inspector: JD

File No.: 18 

Licensee: Thomas Jefferson University Hospital, Inc. License No.: 37-00148-08

Location: Philadelphia, PA Inspection Type: Routine

Inspection Date: 12/16-19/03 Priority: 2

Inspector: JD

File No.: 19 

Licensee: Glen A. Vahjen, M.D. License No.: 06-28707-01

Location: Hamden, CT Inspection Type: Routine

Inspection Date: 9/16/04 Priority: 3

Inspector: SC

File No.: 20 

Licensee: University of Virginia License No.: 06-45-00034-26

Location: Charlottesville, VA Inspection Type: Reactive

Inspection Date: 3/15-17/04 Priority: 2

Inspector: BP/JD

File No.: 21 

Licensee: Women’s Medical Hospital License No.: 37-30485-01

Location: Philadelphia, PA Inspection Type: Routine

Inspection Date: 8/17/04 Priority: 2

Inspector: DE/SH

File No.: 22 

Licensee: York Hospital License No.: 37-07161-01

Location: York, PA Inspection Type: Routine

Inspection Date: 10/8/02 Priority: 2

Inspector: MB/SG

Accompaniment No.: 1

Licensee: Bayer Pharmaceuticals Corporation License No.: 06-13053-04

Location: West haven, CT Inspection Type: Routine

Inspection Date: 3/15/05 Priority: 3

Inspector: JN
Region I Final Report Page C.4

Inspection Casework Reviews

Accompaniment No.: 2

Licensee: Hackensack Medical Center License No.: 29-02641-03 

Location: Hackensack, NJ Inspection Type: Routine

Inspection Date: 3/16/05 Priority: 2

Inspector: MB/MS

Accompaniment No.: 3

Licensee: Huntington Testing and Technology License No.: 47-23076-01

Location: Kenova, WV Inspection Type: Routine

Inspection Date: 3/21/05 Priority: 1

Inspector: DJ

Accompaniment No.: 4

Licensee: Washington Hospital Center License No.: 08-03604-03

Location: Washington, DC Inspection Type: Routine

Inspection Date: 3/22-23/05 Priority: 2

Inspector: PL/RR 

Accompaniment No.: 5

Licensee: Washington Hospital Center License No.: 08-03604-05

Location: Washington, DC Inspection Type: Routine

Inspection Date: 3/22-23/05 Priority: 2

Inspector: PL/RR
APPENDIX D

LICENSE CASEWORK REVIEWS

NOTE: ALL LICENSES LISTED WITHOUT COMMENT ARE INCLUDED FOR

COMPLETENESS ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP

TEAM.

File No.: 1

Licensee: Eastern Technologies, Inc License No.: 01-30362-01

Location: Ashford, AL Amendment No.: NA

Date Issued: 11/10/2004 Type of Action: New

License Reviewer: (J5)

File No.: 2

Licensee: CFC Logistics License No.: 37-30804-02

Location: Quakertown, PA Amendment No.: NA

Date Issued: 8/27/2003 Type of Action: New

License Reviewer: (Q2)

File No.: 3

Licensee: Health Physics Associates License No.: 37-28246-01

Location: Lenhartsville, PA Amendment No.: NA

Date Issued: 01/25/2005 Type of Action: New

License Reviewer: (L7)

File No.: 4

Licensee: Advanced Care Pharmacy, LLC License No.: 06-37064-02MD and -01

Location: Woodbury, CT Amendment No.: NA

Date Issued: 12/24/2002 Type of Action: New

License Reviewer: (P7)

Comments:

b) An e:mail mentioned in other documents and a deficiency letter dated November 26,

2002 were not in file or ADAMS.

c) License No 06-37064-02MD was not in ADAMS.

File No.: 5

Licensee: Tenet Health System - MCP License No.: 37-30485-01

Location: Philadelphia, PA Amendment No.: 09

Date Issued: 8/29/2003 Type of Action: Amendment

License Reviewer: (P6)
Region I Final Report Page D.2

License Casework Reviews

File No.: 6

Licensee: University of Pennsylvania License No.: 37-00118-07

Location: Philadelphia, PA Amendment No.: 62

Date Issued: 12/10/2002 Type of Action: Amendment

License Reviewer: (P6)

Comment:

a) An attachment mentioned in a fax received 4/11/2002 was not in the file or in ADAMS

File No.: 7

Licensee: University of Pennsylvania License No.: 37-11826-01

Location: Philadelphia, PA Amendment No.: 42

Date Issued: 12/10/2002 Type of Action: Amendment

License Reviewer: (P7)

Comment:

a) No amendment application could be found in the file or in ADAMS. Per the cover letter

for the renewal dated February 24, 2004, this amendment was separated out from the

renewal application to expedite issuance of the renewal.

File No.: 8

Licensee: Foundation Engineering License No.: 52-23072-02

Location: San Juan, Puerto Rico Amendment No.: NA

Date Issued: 4/20/2001 Type of Action: New

License Reviewer: (G4)

File No.: 9

Licensee: County of Henrico License No.: 45-17293-03

Location: Richmond, VA Amendment No.: 05

Date Issued: 10/4/2002 Type of Action: Renewal

License Reviewer: G7

File No.: 10

Licensee: Inova Alexandria Hospital License No.: 45-09358-02

Location: Alexandria, VA Amendment No.: 38

Date Issued: 7/17/2001 Type of Action: Renewal

License Reviewer: (G7)

Comment:

a) The deficiency letter, telephone call or e:mail to which the licensee responded on June

29, 2001 was not documented in the file or in ADAMS.
Region I Final Report Page D.3

License Casework Reviews

File No.: 11

Licensee: Southeastern Imaging License No.: 45-25272-01

Location: Martinsville, VA Amendment No.: 05

Date Issued: 4/14/2004 Type of Action: Renewal

License Reviewer: (H0)

Comment:

a) The deficiency letter, telephone call or e:mail to which the licensee responded on April

13, 2004 was not documented in the file or in ADAMS.

File No.: 12

Licensee: Spin X License No.: 52-25577-01

Location: Dorado, Puerto Rico Amendment No.: 02

Date Issued: 4/23/2004 Type of Action: Termination

License Reviewer: (G4)

Comment:

a) Documentation of the receipt of sources by Mechanical Integrity Solutions 52-25615-01

was not in the file or in ADAMS. 

File No.: 13

Licensee: Lessig Nuclear Associates License No.: 07-16167-01

Location: Newark, DE Amendment No.: 24

Date Issued: 9/14/2001 Type of Action: Termination

License Reviewer: (J1)

File No.: 14

Licensee: Capital Health System At Fuld License No.: 29-06134-01

Location: Trenton, NJ Amendment No.: 46

Date Issued: 3/29/2005 Type of Action: Termination

License Reviewer: (J2)

File No.: 15

Licensee: SAIC – Frederick, Inc License No.: 19-21091-01

Location: Frederick, MD Amendment(s) No.: NA

Date Issued: 8/10/2004 Type of Action: Financial Assurance

License Reviewer: (Q5)

File No.: 16

Licensee: Conopco License No.: 29-30984-01

Location: Englewood Cliffs, NJ Amendment No.: NA

Date Issued: 3/21/2005 Type of Action: New and Financial Assurance

License Reviewer: (L4)
Region I Final Report Page D.4

License Casework Reviews

File No.: 17

Licensee: Cardiology Associates License No.: 06-30793-0

Location: Norwich, CT Amendment No.: NA

Date Issued: 10/08/2004 Type of Action: Notification

License Reviewer: (H0)

File No.: 18

Licensee: Virginia Heart Group License No.: 45-25258-01

Location: Philadelphia, PA Amendment No.: 3

Date Issued: 3/7/2005 Type of Action: Notification and Amendment

License Reviewer: (Q9)

File No.: 19

Licensee: Robert Wood Johnson Univ. Hospital License No.: 29-10173-02

Location: New Brunswick, NJ Amendment No.: 45

Date Issued: 2/19/2002 Type of Action: Amendment

License Reviewer: (K3)

File No.: 20

Licensee: Alonso & Carus Iron Works License No.: 52-21350-01

Location: Cantaño, Puerto Rico Amendment No.: 4

Date Issued: 6/27/2001 Type of Action: Amendment

License Reviewer: (G8)

Comments: 

a) Approved sources and devices are not listed on the license.

File No.: 21

Licensee: Chandra K. Sacheti, M.D. License No.: 06-30781-01

Location: Vernon, CT Amendment No.: NA

Date Issued: 8/17/2004 Type of Action: Notification

License Reviewer: (Q8)

File No.: 22

Licensee: University of Delaware License No.: 07-01579-19

Location: Newark, DE Amendment No.: 30

Date Issued: 9/12/2003 Type of Action: Amendment

License Reviewer: (K8)
Region I Final Report Page D.5

License Casework Reviews

File No.: 23

Licensee: National Aeronautics & Space Admin. License No.: 19-05748-03

Location: Greenbelt, MD Amendment No.: 26

Date Issued: 11/12/2003 Type of Action: Amendment

License Reviewer: (P3)

File No.: 24

Licensee: Greater Southeast Community Hospital License No.: 08-11182-01

Location: Washington, DC Amendment No.: 60

Date Issued: 9/7/2001 Type of Action: Amendment

License Reviewer: (K4)

File No.: 25

Licensee: Mobile Diagnostics, LLC License No.: 47-30941-01

Location: Huntington, WV Amendment No.: 01

Date Issued: 3/23/2005 Type of Action: Amendment

License Reviewer: (J3)

File No.: 26

Licensee: St. Vincent Health Center License No.: 37-05125-01

Location: Erie, PA Amendment No.: 72

Date Issued: 3/31/2004 Type of Action: Amendment

License Reviewer: (J3)

File No.: 27

Licensee: Allegheny Lab License No.: 37-20734-01

Location: Kennerdell, PA Amendment No.: 10

Date Issued: 10/10/2001 Type of Action: Termination

License Reviewer: (Q2)

File No.: 28

Licensee: Ocean Radiation Oncology License No.: 29-30518-01

Location: Lakewood, NJ Amendment No.: 01

Date Issued: 3/29/2005 Type of Action: Termination

License Reviewer: (J2)
 APPENDIX E

INCIDENT CASEWORK REVIEWED

NOTE: ALL INCIDENTS LISTED WITHOUT COMMENT ARE INCLUDED FOR

COMPLETENESS ONLY; NO SIGNIFICANT COMMENTS WERE IDENTIFIED BY THE IMPEP

TEAM.

File No.: 1

Licensee: Foundation Engineering Science License No.: 45-25374-01

Site of Incident: Norfolk, Va. Incident ID No.: NMED 040753

Date of Incident: 10/18/04 Type of Incident: Stolen licensed material

Investigation Date: 10/25/04 Type of Investigation: Phone

File No.: 2

Licensee: Sentara Southside Hospitals License No.: 45-00131-02

Site of Incident: Norfolk, Va. Incident ID No.: NMED 040411

Date of Incident:4/6/04 Type of Incident: Equipment failure

Investigation Date: 4/21/04 Type of Investigation: Special inspection

File No.: 3

Licensee: Pennsylvania State University License No.: 37-00185-04

Site of Incident: University Park, Pa. Incident ID No.: NMED 040086

Date of Incident: 9/18/03 Type of Incident: Equipment failure

Investigation Date: 11/4/03 Type of Investigation: Routine inspection

File No.: 4

Licensee: Exelon Power Laboratory License No.: 37-30768-01

Site of Incident: Coatesville, Pa. Incident ID No.: NMED 030832

Date of Incident: 10/16/03 Type of Incident: Equipment failure

Investigation Date: 10/17/03 Type of Investigation: Special inspection

File No.: 5

Licensee: Washington Hospital Center License No.: 08-03604-03

Site of Incident: Washington, DC Incident ID No.: NMED 030385

Date of Incident: 5/6/03 Type of Incident: Equipment defect, medical event

Investigation Date: 5/19/03 Type of Investigation: Special inspection

Comment: 

a) One document submitted by the licensee, placed in the license file, contained the

patients name and treatment. However, the ADAMS file had the patient’s name

redacted, and the document not publically available.
Region I Final Report Page E.2

Incident Casework Reviews

File No.: 6

Licensee: Tenet Health System Graduate, LLC License No.: 37-28359-01

Site of Incident: Philadelphia, Pa. Incident ID No.: NMED 020963

Date of Incident: 10/22/02 Type of Incident: Leaking source

Investigation Date: 11/07/02 Type of Investigation: Phone

File No.: 7

Licensee: University of Pennsylvania License No.: 37-00118-11

Site of Incident: Philadelphia, Pa. Incident ID No.: NMED 020872

Date of Incident: 6/20/02 Type of Incident: Equipment failure

Investigation Date: 6/27/02 Type of Investigation: Phone

File No.: 8

Licensee: George Washington University Medical Center License No.: 08-30607-01

Site of Incident: Washington, DC Incident ID No.: NMED 020503

Date of Incident: 5/9/02 Type of Incident: Equipment failure

Investigation Date: 5/13/02 Type of Investigation: Reactive inspection

File No.: 9

Licensee: Tenet Health System Graduate, LLC License No.: 37-28359-01

Site of Incident: Philadelphia, Pa. Incident ID No.: NMED 20232

Date of Incident: 2/5/02 Type of Incident: Leaking source

Investigation Date: 2/11/02 Type of Investigation: Phone, verified on 

next routine inspection

File No.: 10

Licensee: Mallinckrodt Medical, Inc License No.: 24-04206-17MD

Site of Incident: Bethlehem, Pa. Incident ID No.: NMED 20213

Date of Incident: 12/7/01 Type of Incident: Radioactive material release

Investigation Date: 11/23/03 Type of Investigation: Routine inspection
APPENDIX F

DECOMMISSIONING CASEWORK REVIEWS

CASEWORK REVIEWS FOR COMPLEX SITES

File No.: 1

Licensee: Viacom, Inc.

Location: Pittsburgh, PA

License No.: SMB-1527

File No.: 2

Licensee: Dominion Nuclear Connecticut, Inc.

Location: Waterford, CT

License No.: DPR-0065

File No.: 3

Licensee: West Valley Demonstration Project

Location: West Valley, NY

License No.: P00M-032

FINANCIAL ASSURANCE INSTRUMENT FILES REVIEWED

File No.: 1

Licensee: Sterigenics East Corporation

Location: Rockaway, NJ 

License No.: 29-30308-01

File No.: 2

Licensee: Wyeth-Ayerst

Location: Collegeville, PA

License No.: 37-00401-03

File No.: 3

Licensee: University of Pennsylvania

Location: Philadelphia, PA

License No.: 37-00118-07
Region I Final Report Page F.2

Decommissioning Casework Reviews

File No.: 4

Licensee: Becton Dickinson Caribe. Ltd.

Location: Cayey, Puerto Rico

License No.: 52-21502-01

File No.: 5

Licensee: AstraZeneca Pharmaceuticals, L.P. 

Location: Wilmington, DE

License No.: 07-03990-01