October 14, 2010 

Roderick L. Bremby 

Secretary of Health and Environment 

Kansas Department of Health and Environment 

Curtis State Office Building 

1000 SW Jackson 

Topeka, Kansas 66612 

Dear Mr. Bremby: 

On September 23, 2010, the Management Review Board (MRB) met to consider the proposed 

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Kansas 

Agreement State Program. The MRB found the Kansas 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. Based on the results of the current IMPEP review, the 

next full review of the Kansas Agreement State Program will take place in approximately 4 

years, with a periodic meeting tentatively scheduled for June 2012. 

During the periodic meeting and at the next IMPEP review, NRC will evaluate the effectiveness 

of the State’s response to the review team’s recommendations, as well as the overall 

implementation of your Agreement State program. 

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 Michael F. Weber/ 

Michael F. Weber 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Kansas Final IMPEP Report 

cc w/encl.: Thomas Conley, CHP, Section Chief 

 Radiation and Asbestos Section 
Roderick L. Bremby 

Secretary of Health and Environment 

Kansas Department of Health and Environment 

Curtis State Office Building 

1000 SW Jackson 

Topeka, Kansas 66612 

Dear Mr. Bremby: 

On September 23, 2010, the Management Review Board (MRB) met to consider the proposed 

final Integrated Materials Performance Evaluation Program (IMPEP) report on the Kansas 

Agreement State Program. The MRB found the Kansas 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. Based on the results of the current IMPEP review, the 

next full review of the Kansas Agreement State Program will take place in approximately 4 

years, with a periodic meeting tentatively scheduled for June 2012. 

During the periodic meeting and at the next IMPEP review, NRC will evaluate the effectiveness 

of the State’s response to the review team’s recommendations, as well as the overall 

implementation of your Agreement State program. 

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 Michael F. Weber/ 

Michael F. Weber 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

Kansas Final IMPEP Report 

cc w/encl.: Thomas Conley, CHP, Section Chief 

 Radiation and Asbestos Section 

Distribution: See next page.

 ML102710007 EDATS: FSME-2010-0274 

OFFICE FSME/MSSA FSME/MSSA FSME/MSSA FSME/MSSA 

NAME MOrendi DWhite TReis RLewis TReis for 

DATE 9/29/10 9/30/10 10/1/10 10/6/10 

OFFICE Tech Editor FSME DEDMRT 

NAME PTressler for CPoland CCarpenter for CMiller MFWeber 

DATE 10/07/10 10/07/10 10/14/10 

OFFICIAL RECORD COPY
Letter to R. Bremby from Michael F. Weber dated: 

Distribution: EDATS: FSME-2010-0274 

MSSA RF DCD (SP01) 

EDO RF 

RidsEdoMailCenter 

RidsFsmeOd 

RidsSecyCorrespondenceMailCenter Chairman Jaczko 

MBeardsley, FSME/MSSA Commissioner Svinicki 

RBrowder, RI/RSAO Commissioner Apostolakis 

SXu, FSME/MSSA Commissioner Magwood 

JKatanic, FSME/MSSA Commissioner Ostendorff 

Charles Hamilton, FL SECY 

AHowe, RIV 

KBrock, OEDO 

CCarpenter, FSME 

BJones, OGC 

DLew, RI 

Gibb Vinson, IL 

JOlmstead, OGC 

APowell, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE KANSAS AGREEMENT STATE PROGRAM 

JUNE 14-18, 2010 

FINAL REPORT 
Kansas Final Report Page 1

1.0 INTRODUCTION 

This report presents the results of the review of the Kansas Agreement State Program. 

The review was conducted during the period of June 14-18, 2010, by a review team composed 

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 April 22, 2006, to June 18, 2010, were discussed with 

Kansas managers on the last day of the review. 

A draft of this report was issued to Kansas for factual comment on August 9, 2010. The State 

responded by letter dated September 8, 2010, from Thomas Conley, CHP, Section Chief, 

Radiation, Asbestos, and Right-to-Know Section (the Section). A copy of the State’s response 

is included as the Attachment to this report. The Management Review Board (MRB) met on 

September 23, 2010, to consider the proposed final report. The MRB found the Kansas 

Agreement State Program adequate to protect public health and safety and compatible with 

NRC’s program. 

The Kansas Agreement State Program is administered by the Section, which is located within 

the Department of Health and Environment (the Department). Organization charts for the 

Section are included as Appendix B. 

At the time of the review, the Kansas Agreement State Program regulated 300 specific licenses 

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

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

274b (of the Atomic Energy Act of 1954, as amended) agreement between NRC and the State 

of Kansas. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Section on February 12, 2010. The Section 

provided its response to the questionnaire on May 26, 2010. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML101880154. 

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

the Section’s response to the questionnaire, (2) review of applicable Kansas statutes and 

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

review of selected regulatory actions, (5) field accompaniments of three 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 Kansas Agreement State Program’s 

performance. 

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

during previous reviews. Results of the current review of the common performance indicators 
Kansas Final Report Page 2

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

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

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

recommendations in the final report. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on April 21, 2006, the review team made 

two recommendations regarding the Kansas Agreement State Program’s performance. One of 

the recommendations was carried over from the 2002 IMPEP review of the State. 

1. The review team recommends that the State ensure that the Agreement Materials 

Program has adequate resources and an adequate complement of qualified staff. 

(Section 3.1 of the 2002 IMPEP report) 

Status: The State adopted a radiation control fee fund in 2004 that provides adequate 

resources for staffing of the Agreement State program. Although two individuals left the 

program during the current review period, two joined the program. At the time of the 

review, the Section was fully staffed with five technical staff members. Four of the 

current staff members were fully qualified inspectors/license reviewers and one was 

undergoing training. The individual going through training was qualified to independently 

inspect some types of licensed activities and was making steady progress toward full 

qualification. The review team concluded that, at the time of the review, the State had 

adequate resources and an adequate complement of qualified staff. This 

recommendation is closed. 

2. The review team recommends that the State place greater emphasis and resource 

allocation towards reciprocity inspections in accordance with program goals and the 

criteria in NRC Inspection Manual Chapter (IMC) 1220, “Processing of NRC Form 241 

and Inspection of Agreement State Licensees Operating Under 10 CFR 150.20.” 

(Section 3.2 of the 2006 IMPEP report) 

Status: The review team found that the State devoted a significant amount of resources 

to perform inspections of licensees working under reciprocity during the review period. 

The Section’s reciprocity inspection goals are equivalent to the requirements in IMC 

1220, which requires inspection of 20 percent of candidate licensees operating under 

reciprocity annually. The review team found that the Section inspected 9 percent of 

candidate licensees in 2006, 16 percent in 2007, 28 percent in 2008, and 24 percent in 

2009. These inspection activities have taken considerable effort given that: (1) many 

reciprocity licensees do not provide much advanced notice to the State when working in 

Kansas; (2) most perform licensed activities in geographically challenging areas, such as 

far west Kansas; and (3) licensed activities often occur during short windows and it can 

be difficult to reach the location in time to conduct an inspection. Although the State did 

not meet IMC 1220 goals in 2006 and 2007, they have shown steady improvement and 

exceeded IMC 1220 goals in 2008 and 2009. From January-May 2010, 18 licensees 

had filed for reciprocity and the State had performed 2 reciprocity inspections (11 

percent). This recommendation is closed. 
Kansas Final Report Page 3

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 Section’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 Section’s questionnaire response relative to this 

indicator, interviewed managers and staff, reviewed job descriptions and training records, and 

considered any possible workload backlogs. 

During the review period, the Kansas Agreement State Program experienced an organizational 

realignment. At the time of the previous review, the Kansas Agreement State Program was 

located within the Bureau of Air and Radiation, which was part of the Division of Environment 

within the Department. On July 1, 2009, the entire Section was moved into the Bureau of 

Environmental Health within the Division of Health, which is still part of the Department. This 

realignment resulted in no staffing changes within the Section and was essentially a physical 

move that did not impact the day-to-day activities of the Section. 

When fully staffed, the Kansas Agreement State Program is composed of a Section Chief, 

program support staff, and technical staff in the Radioactive Materials Licensing and Inspection 

Unit (the Unit). A Supervisor heads the Unit. Program support staff includes administrative 

professionals and a Regulatory Affairs and Training Coordinator. Technical staff in the Unit 

conducts inspections, performs licensing actions, and responds to incidents and allegations 

based on individual qualifications. The technical staff also has some emergency response 

duties regarding Kansas’ operating nuclear power plant. Based on information provided by the 

Section, the review team estimated that the Section expends approximately 6.5 full-time 

equivalents (FTE) to administer the Agreement State program. 

During the review period, two individuals left the Agreement State program and two individuals 

joined the program. Both of the individuals that joined the program were transfers from the 

State’s asbestos program. The Section was fully staffed at the time of the review. As time and 

resources allow, the Section is cross-training four other individuals with the State’s asbestos 

program and x-ray program to perform materials inspections and licensing actions. These 

efforts to “home-grow” current State employees provide some depth to the Section and has 

been a successful model for the Section to obtain timely, high-quality transfers from these 

programs when there were vacancies in the Section. 

The Section 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 

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

Program Area.” In April 2010, the Section revised its training program. The training program 

was revised, in part, to better integrate the training program into the Section’s new training 

database. The electronic database allows the Section Chief, the Unit Supervisor, and the 
Kansas Final Report Page 4

Regulatory Affairs and Training Coordinator to track each employee’s qualification status, as 

well as to monitor what formal training courses or on-the-job training the staff needs. The 

database also allows employees to see this information themselves and to keep track of 

coursework via a “transcript” of courses taken over their careers with the State. 

The Section uses on-the-job training, mentoring, and inspector accompaniments to supplement 

formal coursework. Technical staff members are typically assigned increasingly complex duties 

as they progress through the qualification process. Technical staff members are authorized to 

perform regulatory duties independently after taking formal coursework and having on-the-job 

training in various program areas, such as industrial radiography, diagnostic nuclear medicine, 

or Increased Controls. After completion of formal coursework and on-the-job training in the 

individual program areas, the Unit Supervisor, in consultation with the Section Chief, assesses 

each individual’s competency. Individuals are verbally informed by the Unit Supervisor or the 

Section Chief that they are qualified in an applicable program area. There is no formal written 

sign off on staff qualifications and, at the time of the review, this information was not being 

captured in the training database. The Section Chief and the Regulatory Affairs and Training 

Coordinator noted that they would be making enhancements to the database, including a more 

formal “approval of qualification” process wherein the Unit Supervisor and the Section Chief can 

electronically sign off or approve individuals in the various program areas. 

As discussed in more detail in Sections 3.3 and 3.5, the review team identified weaknesses in 

the technical staff’s evaluation of medical licensee performance against the requirements in 10 

CFR Part 35 “Medical Use of Byproduct Material,” which the State has adopted by reference. 

Based on information obtained from the inspection and incident casework evaluations, 

interviews with the Unit Supervisor and technical staff, an inspection accompaniment by a 

review team member; the review team found a lack of familiarity with 10 CFR Part 35, especially 

with respect to therapeutic modalities involving sealed sources, devices, and unsealed 

materials. Examples of these modalities include high dose-rate remote afterloading (HDR) 

brachytherapy, temporary and permanent manual brachytherapy, gamma knife stereotactic 

radiosurgery, and therapy using iodine-131. In reviewing staff training records, the review team 

found that only one of the four qualified inspectors had taken NRC’s formal course H-313, 

“Brachytherapy, Gamma Knife, and Emerging Technologies.” One other technical staff member 

was scheduled to take an upcoming offering of the course. 

In 2004, two of the qualified inspectors and the Unit Supervisor took a medical course that the 

Section Chief deemed equivalent to NRC’s H-313 course. The review team noted that NRC’s 

course is a 37-hour course and that the course taken by the Unit Supervisor and two members 

of the technical staff contained approximately 18 hours of formal classroom and laboratory 

demonstrations related to byproduct material use in medicine. Some portions of the course 

attended by the Section staff members also covered diagnostic nuclear medicine; therefore, 

only a portion of the total time related to therapeutic modalities involving sealed sources, 

devices, and therapeutic use of unsealed materials. 

Because the more senior technical staff would benefit from additional experience in performing 

inspections of therapeutic modalities, it is possible the more junior inspectors may not have 

received the benefit of this additional experience during on-the‐job training for reviewing 10 CFR 

Part 35‐related requirements during inspections. As discussed in greater detail in Section 3.3, 

the review team determined that the Section’s inspectors performed thorough reviews of 
Kansas Final Report Page 5

requirements related to occupational radiation safety, inventories, receipt and transfer of 

materials, surveys, and postings; however, the inspectors should place more emphasis on 

reviewing 10 CFR Part 35‐related requirements for risk significant activities involving therapeutic 

modalities. The review team recommends that the State ensure that inspectors gain increased 

familiarity with the regulations in 10 CFR Part 35, as well as be provided appropriate formal 

training in addition to mentoring and/or on-the-job training to ensure familiarity with various 

therapeutic modalities involving byproduct materials such that these areas will be appropriately 

reviewed during inspections. 

The review team noted that the Section Chief encourages and supports training opportunities 

based on program needs. During the review period, the Section hosted five NRC-sponsored 

courses, including G-108, “Licensing Practices,” and G-109, “Inspection Procedures.” The 

Section will be hosting an additional NRC-sponsored course later in 2010. Hosting the courses 

allows the State to have a higher number of attendees than they would normally be allotted for a 

course held at another location. 

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

that Kansas’ performance with respect to the indicator, Technical Staffing and Training, be 

found satisfactory. 

3.2 Status of Materials Inspection Program 

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

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

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

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

Section’s licensing and inspection database, examination of completed inspection casework, 

and interviews with the Section Chief, the Unit Supervisor, and technical staff. 

The review team determined that the Section’s inspection frequencies for various license types 

are as frequent, or more frequent, than the NRC’s inspection frequencies for similar license 

types listed in IMC 2800, “Materials Inspection Program.” The Section feels that more frequent 

inspections allow them to better supervise license performance and ensure a higher margin for 

public health and safety. The Section requires more frequent inspections for a number of 

license categories. For example, the Section inspects medical broadscope programs, gamma 

knives, and nuclear pharmacies annually, whereas IMC 2800 prescribes a 2-year inspection 

frequency for these license types. The Section also inspects academic broadscope programs, 

research and development licenses, some medical licenses, and portable gauge licenses more 

frequently than prescribed in IMC 2800. 

Based on the Section’s questionnaire response, the review team evaluated the Section’s 

performance with regards to Priority 1, 2, and 3 (per IMC 2800) and initial inspections. During 

the review period, out of 181 Priority 1, 2, and 3 inspections conducted the Section, 17 

inspections were conducted overdue. The review team also evaluated the Section’s timeliness 

for conducting initial inspections within 12 months after issuance of the new licenses. During 

the review period, the Section conducted 7 initial inspections, one of which was conducted 

overdue. As a result, the review team calculated that approximately 8.8 percent of Priority 1, 2, 

and 3 and initial inspections were performed overdue by more than 25 percent of the inspection 
Kansas Final Report Page 6

frequency prescribed by IMC 2800. The review team noted that some technical staff members 

were new and undergoing training during the review period and that some of the staff was called 

away for several weeks to assist in the State’s response to the aftermath of natural phenomena. 

The review team verified that there were no overdue Priority 1, 2, and 3 or initial inspections at 

the time of the review. 

The review team evaluated the Section’s timeliness in issuing inspection reports to licensees 

through a review of inspection casework and data obtained from the Section’s licensing and 

inspection database. The review team noted that date of report issuance in the Section’s 

database differed from the actual inspection report issuance date. This occurs because the 

report generation template that the staff uses automatically prints the current date on the 

letterhead; however, the Unit Supervisor often does not review and approve the inspection 

reports until several days later. In order to obtain the actual inspection report issuance date, the 

staff had to manually search its inspection files for the date of supervisory approval. After 

obtaining this data, the review team calculated that approximately 11 percent of inspection 

reports were transmitted to licensees greater than 30 days after the inspection date. The 

Section Chief and the Unit Supervisor noted that they would enhance their database to develop 

a method to accurately date and record transmission of inspection reports to ensure timeliness. 

The review team’s evaluation of the Section’s performance of reciprocity inspections is 

discussed under the status of Recommendation 2 from the 2006 IMPEP report in Section 2.0 of 

this report. 

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

that Kansas’ performance with respect to the indicator, Status of Materials Inspection Program, 

be found satisfactory. 

3.3 Technical Quality of Inspections 

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

notes, and interviewed the responsible technical staff for 31 radioactive materials inspections 

conducted during the review period. The casework examined consisted of inspections 

conducted by five current inspectors and two former inspectors who conducted inspections 

during the review period. The casework examined covered a variety of license types, including: 

academic broadscope, medical broadscope, industrial radiography, self-shielded irradiator, 

service provider, gamma knife, HDR, nuclear pharmacy, and fixed gauge. The review also 

included initial and follow-up Increased Controls, reciprocity, and decommissioning inspections. 

Appendix C lists the inspection casework files reviewed and includes case-specific comments. 

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

most aspects of the licensees’ radiation safety and security programs. The majority of casework 

reviewed indicated thorough attention to areas of occupational radiation doses, inventories of 

licensed materials, radiation surveys, transfer and receipt of licensed materials, postings, and 

other areas relevant to radiation safety; however, the review team noted instances that 

inspection reports for certain medical licenses, were lacking documentation or indicated that 

certain risk-significant licensed activities were not adequately reviewed during the inspection. 

Through interviews with the technical staff, the review team confirmed that these activities were 

not routinely reviewed during inspections. For example, when inspecting a prostate implant 
Kansas Final Report Page 7

brachytherapy program, the inspector would review source receipt and inventory, but not review 

written directives, post-implant dose determinations, or other items relevant to patient safety. 

Likewise, for HDR units, the staff would review source receipt, but not review implementation of 

safety precautions, calibration measurements, or requirements associated with written 

directives. 

A review team member accompanied three of the Section’s inspectors during April 19-21, 2010. 

The inspectors conducted inspections of a medical broadscope licensee, an industrial 

radiography licensee (office and temporary jobsite inspections), and a cyclotron production 

licensee. The inspectors demonstrated appropriate performance-based inspection techniques 

and were well-prepared for the inspections. In general, the inspectors conducted interviews 

with appropriate personnel, observed licensed operations, conducted confirmatory 

measurements, utilized good health physics practices, and held entrance and exit meetings with 

the appropriate level of licensee management. Those portions of the inspections that focused 

on licensee radiation safety programs were thorough; however, during the inspection of the 

medical broadscope licensee, the inspector did not place the appropriate emphasis on 

potentially risk-significant areas, such as HDR brachytherapy and the use of unsealed iodine131 for thyroid therapy. Instead, the inspector focused on areas that are considered to be of 

low safety significance, such as diagnostic nuclear medicine activities. Following the 

accompaniment, the review team member discussed this observation with the Section Chief, 

who along with the Unit Supervisor, made some changes to their inspection guidance and 

documentation to place greater emphasis on risk-significant activities. In light of the review 

team’s findings during the on-site portion of the review, the review team determined that the 

underlying issue was not that the inspectors did not understand risk significance, but that they 

were not sufficiently inspecting areas they were unfamiliar with, such as therapeutic modalities 

and their related requirements in 10 CFR Part 35. The review team believes that by addressing 

the recommendation in Section 3.1 of this report the Section’s technical staff will have sufficient 

knowledge and skills to perform adequate inspections of medical facilities. 

The review team found that inspection reports and findings were generally appropriate and that 

prompt regulatory actions were taken, as necessary. The Section issues inspection letters to 

licensees conveying the results of all inspections. When a licensee is found to be in noncompliance, the Section issues a written notice of non-compliance. The notice requires the 

licensee to provide a written statement responding to the violations. The review team 

determined that the Section’s inspection findings resulted in licensee corrective actions that 

were appropriate to address the underlying issues and sufficient to prevent recurrence. 

Depending on the severity of the violations issued, the Section can place licensees on 

“heightened oversight,” which reduces the time interval between inspections. The Section has 

the authority to impose civil penalties or issue orders to suspend or cease operations, based on 

the severity or safety significance of the violations. 

The review team found that supervisory accompaniments were conducted annually for all 

inspectors. The Unit Supervisor discusses performance observations with each inspector 

during the accompaniment and uses “inspection notes” to communicate general inspection 

guidance to the staff. 

At the start of the on-site review, the review team noted that documents that contained 

information that the team considered sensitive or security-related information were not marked 
Kansas Final Report Page 8

or identified as such. These documents, including inspection records related to licensee 

implementation of the Increased Controls, were being stored in a main file room. Although the 

file room had access controls, because files related to other programs, such as right-to know 

and asbestos, were also stored in the file room, many individuals other than the Section 

managers and staff could access the files. Although the review team did not identify any 

instances of improper release of information, the review team was concerned that without 

proper control of the files, the likelihood of release was much greater. The review team 

provided the Section with NRC Regulatory Issue Summary (RIS) 2005-31, “Control of SecurityRelated Sensitive Unclassified Non-Safeguards Information Handled by Individuals, Firms, and 

Entities Subject to NRC Regulation of the Use of Source, Byproduct, and Special Nuclear 

Material.” This RIS provides screening criteria that can be used to identify security related 

sensitive information. This document can also be found in ADAMS at ML053480073. 

The review team discussed this matter with the Section Chief, who noted that any document 

that is required to be kept under State or Federal law is a public record and subject to the 

Kansas Open Records Act (KORA). The Section Chief acknowledged that although the 

documents were subject to release under KORA, due to potential harm from inadvertent release 

or unauthorized disclosure, there was a need to better control the applicable files. As a result, 

the Section Chief developed a policy for license files related to the Increased Controls (or other 

files as designated by Section management). The policy was distributed to the Section staff 

immediately. Implementation of the policy resulted in the subject files being removed from the 

main file room and placed into a separate location where their access could be restricted to the 

Section managers and staff. The policy also prescribed, in part, that the outside of the files be 

conspicuously marked and that files not be left unattended. 

The review team further inquired about outgoing correspondence from the Section, such as 

inspection reports or notices of violation that described licensee implementation of the 

Increased Controls. These outgoing documents were also not being marked or noted as 

containing sensitive or security-related information. This matter was discussed with the Section 

Chief, who modified the template for Increased Controls inspection reports to include the 

statement, “This letter and/or its attachments may contain sensitive information and should be 

reviewed against the licensee’s policies on control of sensitive information.” The review team 

recommends that the State further develop the policy that was instituted during the onsite 

review and provide additional guidance for identifying, marking, handling, transmitting, and 

storing documents containing sensitive information. 

Based on the IMPEP evaluation criteria, the review team recommended that Kansas’ 

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

but needs improvement. However, the MRB disagreed with the team’s recommendation and 

found that Kansas’ performance with respect to the indicator, Technical Quality of Inspections, 

be found satisfactory. 

3.4 Technical Quality of Licensing Actions 

The review team interviewed license reviewers, evaluated the licensing process, and examined 

licensing casework for 32 licensing actions. The casework was 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, 
Kansas Final Report Page 9

security requirements, operating and emergency procedures, appropriateness of the 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. The sampling included the following types of use: medical 

broadscope, including one with gamma knife authorization; academic broadscope; academic 

research and development; industrial research and development laboratory; self-shielded 

irradiator; medical institution; medical private practice; nuclear pharmacy; cyclotron; industrial 

radiography; well logging and portable gauge. Types of licensing actions selected for evaluation 

included 7 new licenses, 10 renewals, 11 amendments to existing licenses and 4 license 

terminations. The casework sample represented work from each of the license reviewers. 

A listing of the licensing casework evaluated, with case-specific comments, can be found in 

Appendix D. 

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

and of high quality with health, safety, and security issues properly addressed. License tiedown conditions were stated clearly, backed by information contained in the file, and 

enforceable. Deficiency letters clearly stated regulatory positions, were used at the proper time, 

and identified substantive deficiencies in the licensees’ documents. The Section uses templates 

to generate correspondence, as well as new and renewed licenses. The Section uses standard 

formats and license conditions for each license type and utilizes licensing guidance based on 

NRC licensing guidance or other guidance documents, as appropriate. 

The Section’s Research Analyst receives all licensing actions and logs receipt of the action. 

The technical staff members then enters all pertinent information and/or changes into the 

Section’s database, which tracks the status of all licensing actions. Technical staff completes 

licensing actions on a first-come, first-serve basis. One of the technical staff members has 

become so experienced and proficient with licensing and is considered the senior license 

reviewer. This senior license reviewer completes the majority of licensing actions. For staff 

members with less experience in a given area, the senior license reviewer or other experienced 

members of the technical staff will provide additional oversight or mentoring. The review team 

found that all completed licensing actions are reviewed by the Unit Supervisor and reviewed and 

signed by the Section Chief. 

Since the last review period, the Section has phased out the process of renewing licenses on a 

2-year frequency in favor of a 5-year frequency. The Section staggered the licenses’ expiration 

dates to avoid numerous licenses coming due for renewal at the same time in the future. 

The review team found that actions terminating licenses were well documented. The terminated 

license files included appropriate documentation and records. The Section conducted 

confirmatory surveys for license terminations when appropriate, and documented the results. 

The license files included documentation related to the proper disposal or transfer of licensed 

materials. The review team also evaluated license termination files related to a large 

decommissioning project involving an industrial research and development laboratory with 

widespread carbon-14 contamination. The review team determined that the Section provided 
Kansas Final Report Page 10

thorough oversight and review of the project, ultimately resulting in the termination of the license 

and the release of the facility for unrestricted use. 

During the review period, the Section implemented a policy for conducting pre-licensing reviews 

of all new applicants. The policy incorporated the essential elements of NRC’s revised prelicensing guidance to verify that the applicant would use requested radioactive materials as 

intended. The Section checked applicants that did not possess a radioactive materials license 

from NRC or another Agreement State against other types of licensure or registration, including 

various on-line search mechanisms and interagency communications, to verify the identity of 

individuals. If a pre-licensing visit was necessary, the license reviewer or other inspector 

performed the site visit. 

The review team evaluated the Section’s licensing practices regarding the Increased Controls 

and fingerprinting requirements. The review team confirmed that the licensing staff evaluated 

renewal applications and license amendments for applicability of the Increased Controls and 

fingerprinting requirements. There were no new Increased Controls licenses issued during the 

review period. 

As noted in Section 3.3, the review team made a recommendation regarding sensitive or 

security-related information. This recommendation also applies to documents related to 

licenses, outgoing licensing actions, and incoming licensing action requests. 

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

that Kansas’ performance with respect to the indicator, Technical Quality of Licensing Actions, 

be found satisfactory. 

3.5 Technical Quality of Incident and Allegation Activities 

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

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

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

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

for 18 radioactive materials incidents. A listing of the casework examined, with case-specific 

comments, can be found in Appendix E. The review team evaluated the Section’s response to 

seven allegations, including one that NRC forwarded to the State during the review period. 

The Section has implemented two procedures for incident and allegations activities. These two 

procedures are RCP-9, “Complaint Process,” and RCP-11, “Investigation of Accidents, Incidents 

or Overexposures.” The State has an after-hours hotline number for emergencies under the 

Department and the Kansas Division of Emergency Management. The afterhours support staff 

is knowledgeable about contacting the Section Chief to inform him of events that involve 

radioactive materials. Several of the incidents reviewed followed this particular reporting 

pathway, and the Section subsequently responded in a timely manner. When the Section 

receives a notification of an incident, the technical staff and managers discuss whether the 

incident warrants the need for an on-site investigation based on the safety significance of the 

incident or event. The Section uses the local NMED software to track and manage incidents 

and allegations. The Section uploads incident information to the national NMED electronically, 

based on the reportability thresholds established in the Office of Federal and State Materials 
Kansas Final Report Page 11

and Environmental Management Programs (FSME) Procedure SA-300 “Reporting Material 

Events.” The Section also notifies the NRC Headquarters Operations Center by telephone for 

the incidents that meet the reportability thresholds. 

The incidents selected for review included lost, stolen, or abandoned radioactive material; 

damaged equipment; transportation; and equipment failures. The review team determined that 

the Section’s responses to incidents were thorough, complete, and comprehensive, with the 

exception of the lost cesium-137 incident and associated potential medical event discussed in 

detail below. The Section physically responded to incidents that had safety significance, and 

the review team determined that the responses were prompt and well coordinated, with a level 

of effort that was commensurate with the health and safety or security significance. When no 

immediate threat was present and the Section determined that the licensee had qualified, 

competent individuals investigating the incident; the Section generally responded telephonically 

with subsequent review of the licensee’s written report or an on-site follow-up at a later date. 

The Section maintains investigation reports and supporting documentation in the local NMED 

software. Two levels of management reviewed the technical staff’s final investigation reports. 

The review team noted that the staff’s level of detail provided in investigation reports and the 

thoroughness in evaluating incidents increased over the review period. The review team 

attributed this increase to the training, qualification, and maturation of the new staff members as 

they gained regulatory experience with radioactive materials during the review period. 

Of the 18 radioactive materials incidents reviewed, the review team identified two radioactive 

material incidents that met the criteria for reporting per FSME Procedure SA-300 that were not 

reported to the NRC Headquarters Operations Center nor submitted for inclusion in NMED. The 

Section subsequently reviewed the incidents, updated NMED, and contacted the NRC 

Headquarters Operations Center with the event information. One of the incidents involved a lost 

static eliminator containing polonium-210 in excess of 10 times the 10 CFR Part 20 Appendix C 

quantities. The second incident involved a lost cesium-137 source at a medical facility in 

excess of 10 times the 10 CFR Part 20 Appendix C quantities. 

During the review team’s casework evaluation under Technical Quality of Inspections (Section 

3.3 of this report), the review team discovered that the cesium-137 source that had been lost at 

a medical facility had been documented by the technical staff during an inspection of the facility. 

In the particular case, a cesium-137 source used in a manual temporary brachytherapy 

procedure was lost and later found by the licensee in the medical facility’s laundry room. The 

Section issued a notice of violation to the licensee for failure to report the lost source incident 

under State regulations; however, the Section did not capture the incident in the local NMED nor 

report the event to the NRC Headquarters Operations Center. During the on-site review, the 

review team requested that the Section report the event to the NRC Headquarters Operations 

Center and enter the event into NMED. The Section reported the event to the NRC 

Headquarters Operations Center on June 18, 2010. Following the on-site review, the review 

team evaluated the event report and found that the circumstances described in the event report 

provided additional information that was not documented in the inspection report or discussed 

during the on-site portion of the review. Specifically, the event report indicated that “It was 

determined that the source never reached its destination in the patient and most likely fell into 

the bed linens during insertion.” The review team questioned whether the incident also 

constituted a medical event per 10 CFR 35.3045 either due to potential underdosing of the 

patient or due to dose to an unintended site, depending on where the source was located on the 
Kansas Final Report Page 12

linens when not within the patient. The review team discussed this with the Section Chief. The 

Section Chief noted that the licensee did not identify any clinical complications with the patient 

and decided that the incident did not warrant further follow-up by the Section as a potential 

medical event due to the length of time that has passed since the event occurred. 

As previously discussed in Sections 3.1 and 3.3 of this report, the review team identified a 

weakness in the area of performing inspections of medical licensees and made a 

recommendation in this area. Regarding the Section’s review of the above incident, the review 

team noted that the technical staff adequately pursued the issue regarding the lost source; 

however, the technical staff failed to recognize a potential medical event. The review team 

believes that by addressing the recommendation in Section 3.1 of this report the Section’s 

technical staff will increase their skills and knowledge to better identify and pursue potential 

medical events in the future. 

The review team evaluated the one allegation that NRC forwarded to the Section and six 

allegations that the Section received directly during the review period. The review team 

concluded that the Section consistently took prompt and appropriate action in response to 

concerns raised. The review team noted that the Section thoroughly documented the 

investigations and retained all necessary documentation to appropriately close the allegations. 

The Section notified the concerned individuals of the conclusion of the investigation. The review 

team determined that the Section protected the identity of concerned individuals in accordance 

with the State of Kansas’ open records request laws. Based on the Section’s description of the 

process, it appears that the identities of concerned individuals would be protected with the 

exception of specific disclosure requirements as required by other regulations, hearings, or 

subpoenas. 

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

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

Allegation Activities, be found 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 Kansas does not relinquish regulatory authority for a uranium recovery 

program; therefore, only the first three non-common performance indicators applied to this 

review. 

4.1 Compatibility Requirements 

To assess Kansas’ status with respect to this performance indicator, the review team examined 

the Section’s response to the questionnaire relative to this indicator; reviewed Kansas’ State 

Regulation Status Data Sheet (SRS), as maintained by FSME; and conducted interviews with 

managers and staff responsible for this program area. 
Kansas Final Report Page 13

 4.1.1 Legislation 

Kansas became an Agreement State on January 1, 1965. Legislative authority to create an 

agency and enter into an Agreement with NRC is granted in Article 16 – Nuclear Energy 

Development and Radiation Control Act, Kansas Statutes, K.S.A. 48-1601 to 48-1625. The 

Department Secretary is responsible by law for radiation control under Statute 48-1606. 

4.1.2 Program Elements Required for Compatibility 

Kansas’ regulations for the control of radiation are located in Department regulations K.A.R 28-

35-133 through 28-35-505 for “Radiation” and apply to all ionizing radiation, whether emitted 

from radionuclides or produced by machines. Kansas’ regulations are not subject to any sunset 

laws. 

The review team verified that the State’s rulemaking process offers the public and other 

interested parties an opportunity to comment on proposed regulation changes. Proposed 

rulemaking packages are initially reviewed by the Secretary of Administration and then by the 

Attorney General for legality. The Department then offers the public and other interested parties 

an opportunity to comment on the proposed regulation changes when it is published in the 

Kansas Register. The Department sends the proposed regulation changes to NRC for a 

compatibility review during the public comment period. The Joint Committee on Administrative 

Rules and Regulations is responsible for legislative oversight of regulations and also reviews 

the proposed regulatory package during the public comment period. Once the proposed 

regulation is adopted, it is then published in the Kansas Register and typically takes effect within 

15 days. The review team determined that the process takes approximately 16-25 weeks, once 

it has gone through the Department’s internal legal review. The Department has the ability to 

adopt certain rules by license condition, such as with the Increased Controls and fingerprinting 

requirements. 

The review team noted that the Section revised its entire section of radiation regulations during 

the previous IMPEP review period. NRC issued a letter to the State on May 18, 2006, indicating 

that there were no compatibility comments on the 22 regulatory packages that were submitted. 

The review team also noted that the Section hired a Regulatory Affairs and Training Coordinator 

in 2006 to help ensure that the State’s regulations remained compatible with NRC’s regulations. 

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. 

At the time of this review, the following amendment had not been reviewed for compatibility by 

NRC and was considered overdue: 

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

15005), that was due for Agreement State adoption on March 27, 2009. 

The review team identified the following regulation amendments that the State will need to 

address in the future: 
Kansas Final Report Page 14

• “Medical Use of Byproduct Material – Minor Corrections and Clarifications,” 10 CFR 

Parts 32 and 35 amendment (72 FR 45147, 54207), that is due for Agreement State 

adoption by October 29, 2010. 

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

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

by November 30, 2010. 

• “Exemptions from Licensing, General Licenses, and Distribution of Byproduct Material; 

Licensing and Reporting Requirements,” 10 CFR Parts 30, 31, 32, 150 amendment (72 

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

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

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

adoption by February 15, 2011. 

• “Medical Use of Byproduct Material – Authorized User Clarification,” 10 CFR Part 35 

amendment (74 FR 33901), that is due for Agreement State adoption by September 28, 

2012. 

At the time of the onsite IMPEP review, the review team found that the Section had prepared a 

regulatory package that included the single overdue regulation amendment (minor changes not 

resulting in a significant compatibility issue as a result of the delay in adoption) as well as the 

five regulatory amendments that are coming due for adoption. The Section submitted the 

regulatory package to the Kansas Attorney General’s office for legal review. On May 28, 2010, 

the Section received the Kansas Attorney General’s legal review and began the process of 

publishing the proposed notice in the Kansas Register for public comment. Following the 

IMPEP review, on August 16, 2010, a hearing was held before the Kansas Joint Committee on 

Administrative Rules and Regulations. The regulatory package was submitted to the NRC, and 

on August 19, 2010, was assigned to an NRC staff member for compatibility review. In 

accordance with its processes and procedures, Kansas has scheduled a public hearing to be 

held on October 7, 2010, after the public comment period has ended. 

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

that Kansas’ performance with respect to the indicator, Compatibility Requirements, be found 

satisfactory. 

4.2 Sealed Source and Device Evaluation Program 

Although the Kansas Agreement State Program has authority to conduct sealed source and 

device (SS&D) evaluations for byproduct, source, and certain special nuclear materials; the 

Section did not conduct any SS&D evaluations during the review period. Accordingly, the 

review team did not review this indicator. 
Kansas Final Report Page 15

4.3 Low-level Radioactive Waste Disposal Program 

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

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

allow a State to seek an amendment for the regulation of low-level radioactive waste (LLRW) as 

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

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

Kansas Agreement State Program has authority to regulate a LLRW disposal facility, NRC has 

not required States to have a program for licensing a disposal facility until such time as the 

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

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

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

compatibility LLRW program. There are no plans for a commercial LLRW disposal facility in 

Kansas. Accordingly, the review team did not review this indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, the review team found Kansas’ performance to be satisfactory 

for five of the six performance indicators reviewed and satisfactory but need improvement for 

the following indicator: Technical Quality of Inspections. The MRB disagreed with the review 

team and found Kansas’ performance to be satisfactory for all six performance indicators. The 

review team made two recommendations regarding program performance by the State. Overall, 

the review team recommended, and the MRB agreed, that the Kansas Agreement State 

Program be found adequate to protect public health and safety and compatible with NRC's 

program. Based on the results of the current IMPEP review, the review team recommended, 

and the MRB agreed, that the next full IMPEP review take place in approximately 4 years. 

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

implementation, as appropriate, by the State: 

1. The review team recommends that the State ensure that inspectors gain increased 

familiarity with the regulations in 10 CFR Part 35, as well as be provided appropriate 

formal training in addition to mentoring and/or on-the-job training to ensure familiarity 

with various therapeutic modalities involving byproduct materials such that these areas 

will be appropriately reviewed during inspections. (Section 3.1) 

2. The review team recommends that the State further develop the policy that was 

instituted during the onsite review and provide additional guidance for identifying, 

marking, handling, transmitting, and storing documents containing sensitive information. 

(Section 3.3) 
LIST OF APPENDIXES 

Appendix A IMPEP Review Team Members 

Appendix B Kansas Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility 

Janine F. Katanic, FSME Team Leader 

 Technical Staffing and Training 

Shirley Xu, FSME Status of Materials Inspection Program 

 Technical Quality of Inspections 

Charles W. Hamilton, Florida Technical Quality of Licensing Actions 

Rachel S. Browder, Region IV Technical Quality of Incident and Allegation 

 Activities 

 Compatibility Requirements 

Michelle Beardsley, FSME Inspector Accompaniments 
APPENDIX B 

KANSAS ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML101880168
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: University of Kansas Hospital Authority License No.: 18-C800 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 9/10/07 Inspectors: JW, JS, DW, JH 

File No.: 2 

Licensee: Via Christi Medical Center License No.: 18-C753-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 4/19/10 Inspector: JB 

Comment: 

The inspection did not cover relevant requirements related to 10 CFR Part 35 for various 

therapeutic modalities. 

File No.: 3 

Licensee: TEAM Industrial Svcs., Inc. License No.: 21-B875 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 4/20/10 Inspector: JW 

File No.: 4 

Licensee: University of Kansas Hospital Authority License No.: 10-C787 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 4/21/10 Inspector: JH 

File No.: 5 

Licensee: Chanute Manufacturing Company License No.: 21-B189-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 4/6/09 Inspector: JS 

File No.: 6 

Licensee: Acuren Inspection, Inc. License No.: 21-B126-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 11/20/07 Inspector: JJ 

File No.: 7 

Licensee: Coder X-Ray Service License No.: 21-B165-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 8/4/09 Inspectors: AS, JW 

 
Kansas Final Report Page C.2 

Inspection Casework Reviews 

File No.: 8 

Licensee: DBI, Inc. License No.: 21-B805 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 1/19/10 Inspector: JS 

File No.: 9 

Licensee: Sauder Custom Fabrication, Inc. License No.: 21-B149-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 8/24/09 Inspector: JH 

File No.: 10 

Licensee: Taylor Forge Engineered License No.: 21-B108-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 6/25/06 Inspector: JS 

File No.: 11 

Licensee: Wolf Creek Nuclear Operating License No.: 21-B690-01 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 6/18/09 Inspector: JH 

File No.: 12 

Licensee: Cardinal Health License No.: 20-B708-01 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 9/10/08 Inspector: JJ 

File No.: 13 

Licensee: Hays Medical Center License No.: 19-B261-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/18/09 Inspector: JB 

File No.: 14 

Licensee: Kansas City Cancer Center License No.: 19-C818 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/5/09 Inspector: JB 

File No.: 15 

Licensee: Olathe Medical Center License No.: 19-B296-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/30/09 Inspector: JB 

File No.: 16 

Licensee: Providence Medical Center License No.: 19-C182-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/26/09 Inspector: JB 

 
Kansas Final Report Page C.3 

Inspection Casework Reviews 

File No.: 17 

Licensee: Salina Regional Health License No.: 19-B112-02 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/26/10 Inspector: JB 

File No.: 18 

Licensee: St. Francis Health Center License No.: 19-B272-04 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 4/8/10 Inspector: JW 

File No.: 19 

Licensee: University of Kansas Hospital License No.: 18-C801 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 5/12/08 Inspectors: JB, JH, JJ 

File No.: 20 

Licensee: University of Kansas License No.: 38-C019-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 4/24/07 Inspectors: JB, JS 

File No.: 21 

Licensee: Midwest Inspection Service License No.: OK-27005-01 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 2/18/10 Inspector: AS 

File No.: 22 

Licensee: Wesley Medical Center, LLC License No.: 19-C041-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/14/07 Inspectors: JW, JH 

Comments: 

a) The Section dispatched the inspection report to the licensee approximately 75 days 

after the inspection. The 75-day delay was due to the processing of enforcement 

action. 

b) The Section used an incorrect citation to licensee in the notice of violation regarding a 

failure to report a lost source. 

c) The inspectors did not identify a potential medical event. 

File No.: 23 

Licensee: Halliburton Energy Services, Inc. License No.: 27-C048-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 9/19/07 Inspector: JJ 

File No.: 24 

Licensee: Kansas State University License No.: 38-C011-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/10/10 Inspector: JS 
Kansas Final Report Page C.4 

Inspection Casework Reviews 

File No.: 25 

Licensee: Mt. Carmel Regional Medical Center License No.: 19-C243-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 11/20/08 Inspector: JW 

File No.: 26 

Licensee: Pioneer Wireline Services License No.: 27-B565-01 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 4/7/10 Inspector: JW 

File No.: 27 

Licensee: Platte Valley Medical Group, P.C. License No.: 12-B887 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 4/28/09 Inspector: JB 

File No.: 28 

Licensee: Protechnics License No.: 27-B909 

Inspection Type: Routine, Telephone Priority: 3 

Inspection Date: 6/4/09 Inspector: JS 

Comment: 

The Section conducted a telephonic inspection because the licensee had not begun 

conducting licensed activities in Kansas. 

File No.: 29 

Licensee: Saint Luke’s South Hospital License No.: 19-B775 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 5/16/07 Inspector: JJ 

File No.: 30 

Licensee: St. Catherine Hospital License No.: 19-B300-03 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 3/23/10 Inspector: JB 

File No.: 31 

Licensee: Kansas City Testing & Engineering License No.: 22-C250-01 

Inspection Type: Routine, Announced Priority: 4 

Inspection Date: 10/31/07 Inspector: JS 

 
Kansas Final Report Page C.5 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Via Christi Medical Center License No.: 18-C753-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/19/10 Inspector: JB 

Accompaniment No.: 2 

Licensee: TEAM Industrial Svcs., Inc. License No.: 21-B875 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 4/20/10 Inspector: JW 

Accompaniment No.: 3 

Licensee: University of Kansas License No.: 10-C787 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 4/21/10 Inspector: JH 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Stevens County Hospital, Inc. License No.: 12-B923 

Type of Action: New Amendment No.: 0 

Date Issued: 2/12/08 License Reviewer: JW 

File No.: 2 

Licensee: Nuclear Enterprises, LLC License No.: 20-B892 

Type of Action: New Amendment No.: 0 

Date Issued: 9/29/06 License Reviewer: JH 

File No.: 3 

Licensee: SE Kansas Regional Planning Commission License No.: 22-B902 

Type of Action: New Amendment No.: 0 

Date Issued: 3/2/07 License Reviewer: JB 

File No.: 4 

Licensee: TL Enterprises, Inc. License No.: 22-B938 

Type of Action: New Amendment No.: 0 

Date Issued: 11/4/09 License Reviewer: JS 

File No.: 5 

Licensee: Line Medical, Inc. License No.: 19-B894 

Type of Action: New Amendment No.: 0 

Date Issued: 9/21/06 License Reviewer: JH 

File No.: 6 

Licensee: Sumner Regional Medical Center, Inc. License No.: 19-B942 

Type of Action: New Amendment No.: 0 

Date Issued: 10/7/09 License Reviewer: JW 

File No.: 7 

Licensee: Xenometrics, Inc. License No.: 26-B937 

Type of Action: New Amendment No.: 0 

Date Issued: 4/13/10 License Reviewer: JH 

File No.: 8 

Licensee: G.E. Engineering, P.A. License No.: 22-B762 

Type of Action: Renewal Amendment No.: 5 

Date Issued: 7/18/06 License Reviewer: JB 

 
Kansas Final Report Page D.2 

License Casework Reviews 

File No.: 9 

Licensee: William Newton Memorial Hospital, Inc. License No.: 19-B298-01 

Type of Action: Renewal Amendment No.: 35 

Date Issued: 4/25/07 License Reviewer: JS 

File No.: 10 

Licensee: Kansas Department of Health and Environment License No.: 22-B707-01 

Type of Action: Renewal Amendment No.: 10 

Date Issued: 2/25/10 License Reviewer: AS 

File No.: 11 

Licensee: Cornish Wireline Services, Inc. License No.: 27-B128-01 

Type of Action: Renewal Amendment No.: 40 

Date Issued: 2/19/08 License Reviewer: JJ 

File No.: 12 

Licensee: American Red Cross License No.: 24-B638-01 

Type of Action: Renewal Amendment No.: 10 

Date Issued: 10/16/09 License Reviewer: JS 

File No.: 13 

Licensee: Superior Bowen Asphalt Company License No.: 22-B649-01 

Type of Action: Renewal Amendment No.: 9 

Date Issued: 9/13/06 License Reviewer: JJ 

File No.: 14 

Licensee: Atchison Steel Casting and Machining, Inc. License No.: 21-B092-01 

Type of Action: Renewal Amendment No.: 43 

Date Issued: 11/30/07 License Reviewer: JH 

File No.: 15 

Licensee: Century Instrument Corporation License No.: 25-R494-01 

Type of Action: Renewal Amendment No.: 15 

Date Issued: 12/11/08 License Reviewer: JS 

File No.: 16 

Licensee: Cypress Women’s Imaging, Inc. License No.: 11-B853 

Type of Action: Renewal Amendment No.: 4 

Date Issued: 6/23/09 License Reviewer: JB 

 
Kansas Final Report Page D.3 

License Casework Reviews 

File No.: 17 

Licensee: Via Christi Regional Medical Center, Inc. License No.: 18-C753-01 

Type of Action: Renewal Amendment No.: 15 

Date Issued: 6/12/09 License Reviewer: JH 

Comment: 

The Section authorized a higher than intended maximum possession limit for the HDR 

unit on the license. The Section issued an amendment with lower possession limits 

during the on-site review. 

File No.: 18 

Licensee: Siemens Medical Solutions, USA, Inc. License No.: 29-C135-01 

Type of Action: Amendment Amendment No.: 28 

Date Issued: 6/7/10 License Reviewer: JB 

File No.: 19 

Licensee: PETNET Solutions, Inc. License No.: 10-C814 

Type of Action: Amendment Amendment No.: 16 

Date Issued: 1/25/10 License Reviewer: JH 

File No.: 20 

Licensee: Mowery Clinic, LLC License No.: 19-B795 

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

Date Issued: 3/11/08 License Reviewer: JW 

File No.: 21 

Licensee: Halliburton Energy Services, Inc. License No.: 27-C048-01 

Type of Action: Amendment Amendment No.: 47 

Date Issued: 11/7/08 License Reviewer: JJ 

File No.: 22 

Licensee: University of Kansas License No.: 38-C019-01 

Type of Action: Amendment Amendment No.: 63 

Date Issued: 8/26/08 License Reviewer: JH 

File No.: 23 

Licensee: Acuren Inspection, Inc. License No.: 21-B126-01 

Type of Action: Amendment Amendment No.: 40 

Date Issued: 3/1/10 License Reviewer: JW 

File No.: 24 

Licensee: Wichita State University License No.: 31-C155-01 

Type of Action: Amendment Amendment No.: 28 

Date Issued: 9/16/09 License Reviewer: JB 

 
Kansas Final Report Page D.4 

License Casework Reviews 

File No.: 25 

Licensee: Line Diagnostics, Inc. License No.: 19-B894 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 9/10/07 License Reviewer: JH 

File No.: 26 

Licensee: Xenotech, LLC License No.: 16-B808 

Type of Action: Amendment Amendment No.: 6 

Date Issued: 10/9/09 License Reviewer: JB 

File No.: 27 

Licensee: Wesley Medical Center, LLC License No.: 19-C041-01 

Type of Action: Amendment Amendment No.: 74 

Date Issued: 7/14/08 License Reviewer: JH 

Comment: 

The Section authorized a higher than intended maximum possession limit for the HDR 

unit on the license. The Section issued an amendment with lower possession limits 

during the on-site review. 

File No.: 28 

Licensee: Team Industrial Services, Inc. License No.: 21-B875 

Type of Action: Amendment Amendment No.: 3 

Date Issued: 7/16/07 License Reviewer: JH 

File No.: 29 

Licensee: Midwest Division – ACH, LLC License No.: 19-B366-01 

Type of Action: Termination Amendment No.: 28 

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

File No.: 30 

Licensee: New Eagle – Picher Pharma Services, Inc. License No.: 25-B561-01 

Type of Action: Termination Amendment No.: 24 

Date Issued: 5/10/10 License Reviewer: JH 

File No.: 31 

Licensee: Gressel Oil Field Services, Inc. License No.: 27-B781 

Type of Action: Termination Amendment No.: 5 

Date Issued: 4/30/09 License Reviewer: JB 

File No.: 32 

Licensee: Aptuit, Inc. License No.: 26-B904 

Type of Action: Termination Amendment No.: 2 

Date Issued: 5/10/10 License Reviewer: JH 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Boeing Commercial Airplane Group License No.: 29-C064-01 

Date of Incident: 12/1/06 NMED No.: 060727 

Investigation Date: 12/21/06 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Licensee Report 

File No.: 2 

Licensee: Acuren Inspection Inc. License No.: 21-B126-01 

Date of Incident: 9/4/06 NMED No.: N/A 

Investigation Date: 9/7/06 Type of Incident: Attempted Theft 

Type of Investigation: Law Enforcement 

Report 

File No.: 3 

Licensee: Honeywell License No.: GL-506 

Date of Incident: 7/27/06 NMED No.: 100318 

Investigation Date: 7/27/06 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Licensee Report 

Comment: 

The review team discovered this event had not been reported to NRC as required. The 

Section reported it to the NRC Headquarters Operations Center on June 18, 2010. 

File No.: 4 

Licensee: Geotechnology, Inc. License No.: 22-B845-01 

Date of Incident: 8/9/06 NMED No.: 080357 

Investigation Date: 8/9/06 Type of Incident: Damaged Equipment 

 Type of Investigation: Site 

File No.: 5 

Licensee: Kantest Incorporated License No.: 21-B702-01 

Date of Incident: 8/14/06 NMED No.: 080354 

Investigation Date: 8/14/06 Type of Incident: Lost/Abandoned Material 

 Type of Investigation: Site 

File No.: 6 

Licensee: Log-Tech, Inc. License No.: 27-B565-01 

Date of Incident: 6/13/06 NMED No.: 080353 

Investigation Date: 7/23/06 Type of Incident: Lost/Abandoned Material 

 Type of Investigation: Licensee Report
Kansas Final Report Page E.2 

Incident Casework Reviews 

File No.: 7 

Licensee: Tetra Tech License No.: 22-C250-01 

Date of Incident: 8/14/07 NMED No.: N/A 

Investigation Date: 10/31/07 Type of Incident: Damaged Equipment 

Types of Investigation: Site, Licensee 

Report 

File No.: 8 

Licensee: Tulsa Gamma Ray License No.: Reciprocity 

Date of Incident: 10/23/07 NMED No.: 070665 

Investigation Date: 10/25/07 Type of Incident: Equipment Failure 

 Type of Investigation: Licensee Report 

File No.: 9 

Licensee: Chanute Manufacturing License No.: 21-B189-01 

Date of Incident: 8/25/07 NMED No.: 070544 

Investigation Date: 8/25/07 Type of Incident: Equipment Failure 

 Type of Investigation: Site, Licensee Report 

File No.: 10 

Licensee: ELI Wireline Service License No.: 29-C064-01 

Date of Incident: 3/5/07 NMED No.: N/A 

Investigation Date: N/A Type of Incident: Lost/Abandoned Material 

 Type of Investigation: None 

File No.: 11 

Licensee: Aptuit, Inc. License No.: 26-B904 

Date of Incident: 4/22/08 NMED No.: 080640 

Investigation Date: 4/23/08 Type of Incident: Release of Material 

 Type of Investigation: Licensee Report 

File No.: 12 

Licensee: Aptuit, Inc. License No.: 26-B904 

Date of Incident: 8/20/08 NMED No.: 080652 

Investigation Date: 8/27/08 Type of Incident: Release of Material 

 Type of Investigation: Licensee Report 

File No.: 13 

Licensee: IPS, Inc. License No.: 27-C057-01 

Date of Incident: 11/12/06 NMED No.: 080448 

Investigation Dates: 7/18/08, 9/17/08, 11/4/08 Type of Incident: Lost/Abandoned Material 

 Type of Investigation: Licensee Report 

 
Kansas Final Report Page E.3 

Incident Casework Reviews 

File No.: 14 

Licensee: Hawker Beechcraft License No.: GL-185 

Date of Incident: 3/20/08 NMED No.: 060701 

Investigation Date: 4/21/08 Type of Incident: Lost/Abandoned Material 

 Type of Investigation: Licensee Report 

File No.: 15 

Licensee: Kleinfelder Central, Inc. License No.: 22-B632-01 

Date of Incident: 6/6/09 NMED No.: 090357 

Investigation Date: 7/9/09 Type of Incident: Lost/Abandoned Material 

 Type of Investigation: Licensee Report 

File No.: 16 

Licensee: Integrated Nuclear Enterprises License No.: 19-B272-01 

Date of Incident: 2/11/09 NMED No.: 090356 

Investigation Date: 2/11/09 Type of Incident: Transportation 

 Type of Investigation: Licensee Report 

File No.: 17 

Licensee: Hawker Beechcraft License No.: GL-185 

Date of Incident: 1/29/09 NMED No.: 090355 

Investigation Date: 2/3/09 Type of Incident: Lost/Abandoned Material 

 Type of Investigation: Licensee Report 

File No.: 18 

Licensee: Wesley Medical Center License No.: 19-C041-01 

Date of Incident: 10/1/06 NMED No.: 100315 

Investigation date: 2/14/07 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Site 

Comments: 

a) The review team discovered the lost source event had not been reported to NRC as 

required. The Section reported it to the NRC Headquarters Operations Center on June 

18, 2010. 

b) The review team found that the event report provided additional information that 

suggested that a medical event per 10 CFR 35.3045 may have occurred due to the 

source not being inside of the patient, as intended. The Section did not identify this as a 

potential medical event and, therefore, did not review this aspect of the incident. 
ATTACHMENT 

September 8, 2010 Letter from Thomas Conley 

Kansas’ Response to the Draft IMPEP Report 

and 

NRC’s comment resolution document 

ADAMS ACCESSION NO.: ML102520075