October 31, 2009 

Jon Goldstein, Deputy Secretary 

New Mexico State 

 Environment Department 

1190 St. Francis Drive 

Santa Fe, NM 87505 

Dear Mr. Goldstein: 

On October 7, 2009, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the New Mexico 

Agreement State Program. The MRB found the New Mexico Agreement State Program 

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

Commission=s program. 

Section 5.0, page 11, of the enclosed final report summarizes the IMPEP review team=s findings 

and one recommendation regarding program performance by the State. We request your 

evaluation and response to the recommendation within 30 days from receipt of this letter. 

Based on the results of the current IMPEP review, the next full review of the New Mexico 

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

tentatively scheduled for July 2011. 

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

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

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

Sincerely, 

 /RA/ 

Martin J. Virgilio 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

New Mexico Final IMPEP Report 

cc w/encl.: See next page 
J. Goldstein - 2 - 

cc w/encl: Carlos Romero, Director 

 Environmental Health Division 

 John Parker, Chief 

 Radiation Control Bureau 

 Michael Snee, Ohio 

 Organization of Agreement States 

 Liaison to the MRB 
October 31, 2009 

Jon Goldstein, Deputy Secretary 

New Mexico State 

 Environment Department 

1190 St. Francis Drive 

Santa Fe, NM 87505 

Dear Mr. Goldstein: 

On October 7, 2009, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the New Mexico 

Agreement State Program. The MRB found the New Mexico Agreement State Program 

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

Commission=s program. 

Section 5.0, page 11, of the enclosed final report summarizes the IMPEP review team=s findings 

and one recommendation regarding program performance by the State. We request your 

evaluation and response to the recommendation within 30 days from receipt of this letter. 

Based on the results of the current IMPEP review, the next full review of the New Mexico 

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

tentatively scheduled for July 2011. 

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

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

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

Sincerely, 

 /RA/ 

Martin J. Virgilio 

Deputy Executive Director for Materials, Waste, 

Research, State, Tribal, and Compliance Programs 

Office of the Executive Director for Operations 

Enclosure: 

New Mexico Final IMPEP Report 

cc w/encl.: See next page 

Distribution: See next page.

 ML092870666 EDATS: FSME-2009-0040 

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

NAME ATMcCraw:knm1 ADWhite TReis RJLewis 

DATE 10/14/09 10/14/09 10/16/09 10/19/09 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland (PTressler for) GCPangburn MJVirgilio 

DATE 10/21/09 10/22/09 10/31/09 

OFFICIAL RECORD COPY
Letter to Jon Goldstein from Martin J. Virgilio dated: October 31, 2009 

DISTRIBUTION: FSME-2009-0040

MSSA RF DCD (SP01) 

EDO RF 

RidsFsmeOd Chairman Jaczko 

RidsSecyCorrespondenceMailCenter Commissioner Klein 

MBeardsley, FSME/MSSA Commissioner Svinicki 

LMcLean, RIV/RSAO SECY 

JThompson, RIV 

Matthew McKinley, Kentucky 

JKatanic, FSME/MSSA 

WRautzen, FSME/MSSA 

MFranovich, OEDO 

APowell, OCA (2 copies) 

JGray, OGC 

BJones, OGC 

TReis, FSME/MSSA 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE NEW MEXICO AGREEMENT STATE PROGRAM 

July 20-24, 2009 

FINAL REPORT
New Mexico Final Report Page 1 

1.0 INTRODUCTION 

This report presents the results of the review of the New Mexico Agreement State Program. 

The review was conducted during the period of July 20-24, 2009, by a review team composed of 

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

Commonwealth of Kentucky. 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 June 11, 2005, to July 24, 2009, were 

discussed with New Mexico managers on the last day of the review. 

A draft of this report was issued to New Mexico for factual comment on August 19, 2009. The 

State responded by letter dated September 15, 2009, from Jon Goldstein, Deputy Secretary, 

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

Attachment to this report. The Management Review Board (MRB) met on October 7, 2009, to 

consider the proposed final report. The MRB found the New Mexico Agreement State Program 

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

The New Mexico Agreement State Program is administered by the Radiation Control Bureau 

(the Bureau) in the Environmental Health Division (the Division) of the Department. 

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

At the time of the review, the New Mexico Agreement State Program regulated 189 specific 

licenses authorizing byproduct, source, and certain special nuclear materials. The review 

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

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

Mexico. 

In preparation for the review, a questionnaire addressing the common and applicable noncommon performance indicators was sent to the Bureau on March 31, 2009. The Bureau 

provided its response to the questionnaire on June 30, 2009. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML092110656. 

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

the Bureau’s response to the questionnaire; (2) review of applicable New Mexico statutes and 

regulations; (3) analysis of quantitative information from the Bureau’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 New Mexico Agreement State Program’s 

performance. 

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

made during the previous review. Results of the current review of the common performance 

indicators are presented in Section 3.0. Section 4.0 details the results of the review of the 
New Mexico Final Report Page 2 

applicable non-common performance indicators, and Section 5.0 summarizes the review team's 

findings and recommendations. The review team’s recommendations are comments that relate 

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

recommendations in the final report. 

2.0 STATUS OF ITEMS IDENTIFIED IN THE PREVIOUS REVIEW 

During the previous IMPEP review, covering the period of June 23, 2001, to June 10, 2005, the 

review team made two recommendations regarding to program performance. The status of the 

recommendations is as follows: 

1. The review team recommends that the Program retrain its staff with regard to following 

its established procedure for termination of radioactive material licenses and followup 

actions by the inspectors regarding closeout surveys or additional documentation to 

support the termination request. (Section 3.4 of the 2005 IMPEP Report) 

Status: The Bureau revised its procedure regarding license termination to put more 

responsibility on Bureau management to ensure that the proper documentation of 

radioactive material disposition and closeout survey records are in the license file prior 

to termination. The review team found that actions terminating licenses were well 

documented. Terminated licenses contained documentation of proper disposal or 

transfer of the radioactive material and records of closeout surveys by the inspectors. 

This recommendation is closed. 

2. The review team recommends that the Program develop and implement a process that 

ensures an adequate evaluation of license renewal information. (Section 3.4 of the 

2005 IMPEP Report) 

Status: Following the 2005 review, the Bureau revised its procedure to require 

licensees to submit a complete application for renewal requests at least 30 days in 

advance of the expiration of their existing licenses. The procedure requires the license 

reviewer to complete a checklist that helps determine whether a complete review is 

warranted (as with an application for a new license) or a limited review will suffice. 

The determination is based on the complexity of the license, as well as the number 

and magnitude of changes to the licensee’s program since the last review of the 

license. The review team verified that staff was aware of the procedural revision and 

followed the procedure in the renewals evaluated by the review team. This 

recommendation is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

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

radioactive materials programs. These indicators are: (1) Technical Staffing and Training, 

(2) Status of Materials Inspection Program, (3) Technical Quality of Inspections, (4) Technical 

Quality of Licensing Actions, and (5) Technical Quality of Incident and Allegation Activities. 
New Mexico Final Report Page 3 

3.1 Technical Staffing and Training

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

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

this indicator, the review team examined the Bureau’s questionnaire response relative to this 

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

considered any workload backlogs. 

The day-to-day operations of the New Mexico Agreement State Program are executed by the 

Licensing, Registration, and Inspection Section (the Section). Staff members in the Section 

perform licensing, registration, inspection, and incident response activities for radioactive 

material and x-ray facilities. When fully staffed, the Section is composed of eight technical staff 

members and the Section Supervisor. At the time of the review, the Section employed seven 

technical staff members. One staff member was primarily assigned to licensing activities. The 

inspection workload was split among the other six staff members. The license reviewer and four 

inspectors are located in the Santa Fe office; the other two inspectors are located in the 

Albuquerque field office. 

Four staff members left the Section during the review period, including the Section Supervisor 

who was hired during the review period. Two technical staff members were hired during the 

review period. At the time of the review, the Section Supervisor position and one inspector 

position were vacant. The Bureau was seeking an exemption to the State-wide hiring freeze to 

fill the vacant inspector position. There were no efforts to fill the Section Supervisor position, 

which had only been vacant since June 2009. The review team concluded that, when fully 

staffed, the Section’s staffing level is adequate to carry out its regulatory duties. The review 

team noted that the Bureau has a successful strategy for performing its regulatory duties in a 

timely manner with the existing staffing level until the vacancies are filled. 

Staff members are required to have a Bachelor’s degree or equivalent experience in a physical 

or biological science or engineering. All technical staff members are called Environmental 

Scientists/Specialists and can be classified as Basic, Operational, or Advanced depending on 

experience and time in the program. At the time of the review, five of the staff members were 

classified as Advanced, and two were classified as Operational. 

The Bureau has a documented training and qualification program for technical staff that is 

consistent with NRC Inspection Manual Chapter (IMC) 1246, “Formal Qualification Programs in 

the Nuclear Material Safety and Safeguards Program Area.” Qualification is achieved through a 

combination of education and experience, formal classroom training, and on-the-job training. 

The Bureau maintains training and qualification records for each staff member. The review 

team noted that Bureau management encourages and supports training opportunities, based on 

program needs and funding. The review team concluded that the Section staff’s qualifications 

and training are adequate to carry out its regulatory duties. 

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

that New Mexico's performance with respect to the indicator, Technical Staffing and Training, 

was satisfactory. 
New Mexico Final Report Page 4 

3.2 Status of Materials Inspection Program

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

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

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

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

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

conducted with the Bureau Chief and staff. 

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

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

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

of licenses are inspected more frequently, including nuclear pharmacy, research and 

development, and both fixed and portable nuclear gauge licenses. The Bureau does not have 

any inspection intervals longer than 3 years, whereas IMC 2800 prescribes inspection intervals 

of up to 5 years for several license types. 

During the review period, the Bureau conducted 259 inspections of high priority (Priority 1, 2, 

and 3) licensees, as well as 7 initial inspections. All of the initial inspections reviewed were 

performed within 12 months of license issuance in accordance with the requirements in IMC 

2800. The review team identified five Priority 1 and 2 inspections that were performed overdue, 

due to staff turnover during the beginning of the review period. The review team verified that 

there were no Priority 1, 2, or 3 inspections overdue at the time of the review. Overall the 

review team calculated that the Bureau performed less than 2 percent of its high priority and 

initial inspections overdue during the review period. 

The review team also evaluated the timeliness of the issuance of inspection findings to 

licensees. Of the 17 inspection reports reviewed, only 1 inspection report was issued to the 

licensee greater than 30 days after the inspection. In this case, the letter to the licensee was 

not sent until the next inspection approximately 6 months later. All other inspection reports 

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

The Bureau stated in its response to the questionnaire that it issued 152 reciprocity licenses 

during Calendar Years 2005 through 2008. The Bureau does not specifically identify which 

licensees are candidates for inspection based on the criteria in IMC 1220 “Processing of NRC 

Form 241 and Inspection of Agreement State Licensees Operating Under 10 CFR 150.20.” 

Instead, the Bureau considers all reciprocity licensees as candidates for inspection. The 

Bureau places emphasis on high priority (Priority 1, 2, and 3) reciprocity licenses and performs 

periodic checks to ensure that inspection goals are reached or are on track to being reached. 

Using the Bureau’s records, the review team determined that the Bureau conducted reciprocity 

inspections of at least 20 percent of all reciprocity licensees, including all candidate reciprocity 

licensees per the criteria in IMC 1220, during each of the years covered by the review period. 

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

Controls inspections of affected licensees. The Bureau identified 26 licensees that were subject 

to the Increased Controls and performed all of the first-year inspections in a timely manner. 

Subsequent inspections of Increased Controls licensees evaluated the pertinent aspects of the 

security measures, as documented in each inspection report’s field notes. 
New Mexico Final Report Page 5 

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

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

Program, was satisfactory. 

3.3 Technical Quality of Inspections

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

and interviewed the responsible inspectors for 17 radioactive materials inspections conducted 

during the review period. The casework consisted of a cross-section of inspections conducted 

by the six qualified inspectors. The casework included inspections of various license types, 

including: nuclear medicine, high dose-rate remote afterloader, medical broad scope, industrial 

radiography, well logging, self-shielded irradiator, nuclear pharmacy, portable gauge, and 

research/development licensees. Appendix C lists the inspection casework files reviewed and 

includes case-specific comments. The review also included an examination of inspection 

casework for seven Increased Controls inspections that the Bureau performed. 

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

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

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

Inspection records sufficiently documented observations of licensed activities, discussions held 

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

radiation safety program, as applicable. The review team found that, in some cases including 

Increased Controls inspections, the letters sent to the licensees describing the violations 

identified by the inspector were not always clear. The letters vaguely stated the regulatory 

requirements and did not specify which portion of the requirement was violated by the licensee. 

In most cases, the “contrary to” statement did not provide a factual basis for the violation. 

Despite, the limited documentation in the notices of violation, the review team did not identify 

any cases where the licensee did not take prompt corrective actions. The review team 

discussed with the Bureau the benefits of clearly documenting the specific violation of the 

State’s regulatory requirements to help the licensee determine the necessary actions to resolve 

the violations, as well as to provide the next inspector sufficient detail to follow up on the 

violation during a future inspection. The Bureau Chief committed to ensuring that future letters 

to licensees clearly describe the regulatory requirement that was violated and the specific 

details of how it was violated. 

The Bureau has detailed checklists/inspection forms for inspections of various license types, 

each color-coded for the specific license type. Following the inspection, these 

checklists/inspection forms are retained in the license file as the inspection record. The review 

team determined that the inspectors’ use of the checklists aided in performing thorough 

performance-based inspections. The Bureau also has a written inspection procedure for 

general conduct of inspections, as well as supplemental guidance for inspections of various 

license types. 

While on site, the review team evaluated the Bureau’s control and handling of sensitive 

information. The review team found that information determined to be “security-related 

information” was adequately controlled to prevent inadvertent release and was maintained in a 

separate color-coded folder. 
New Mexico Final Report Page 6 

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

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

each year of the review period, as presented in the questionnaire and through interviews with 

the inspectors. The review team noted that the accompaniments were not documented on the 

Supervisor Accompaniment Forms, as required by the Bureau’s procedures. Because of this, 

the review team was not able to evaluate the depth and scope of the accompaniments 

performed. The Bureau Chief committed to document supervisory accompaniments using the 

Supervisor Accompaniment Form for future accompaniments. 

The review team observed that the Bureau maintains an adequate supply of appropriately 

calibrated radiation detection and measurement instrumentation to support the inspection 

program, as well as for response to radioactive materials incidents and emergency conditions. 

The instruments are sent to the instrument manufacturer annually for calibration. The Bureau 

also has access to the New Mexico Department of Health’s Scientific Laboratory Division for 

additional support, including alpha/beta spectroscopy, radiochemical analysis, and liquid 

scintillation counting. 

A member of the review team accompanied three qualified radioactive materials inspectors on 

inspections during the week of June 29, 2009. The licensees inspected were an industrial 

radiography facility and two medical institutions with written directives required. Appendix C 

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

inspectors demonstrated performance-based inspection techniques and knowledge of the 

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

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

interviews with appropriate personnel, observed licensed operations, conducted confirmatory 

measurements, and utilized good health physics practices. Overall, the review team determined 

that the inspections were adequate to assess radiological health, safety, and security at the 

licensed facilities. 

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

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

was satisfactory. 

3.4 Technical Quality of Licensing Actions

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

23 specific licenses. Licensing actions were reviewed for completeness, consistency, proper 

radioisotopes and quantities, qualifications of authorized users, adequacy of facilities and 

equipment, adherence to good health physics practices, financial assurance, operating and 

emergency procedures, appropriateness of license conditions, and overall technical quality. 

The casework was also reviewed for timeliness, use of appropriate correspondence, reference 

to appropriate regulations, supporting documentation, consideration of enforcement history, prelicensing visits, peer or supervisory review, and proper signatures. 

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

completed during the review period. Licensing actions selected for evaluation included 5 new 

licenses, 4 amendments, 8 renewals (including 3 for expired licenses), 5 terminations, and 1 

facility undergoing decommissioning. Files reviewed included a cross-section of license types, 
New Mexico Final Report Page 7 

including: medical private practice, medical institution, medical broadscope, research and 

development, portable gauge, fixed gauge, irradiator, cyclotron, industrial radiography, and well 

logging. A listing of the licensing casework reviewed can be found in Appendix D. 

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

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

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

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

obtain additional information from the applicant or licensee. Prior to issuance of a license, the 

document goes through a peer and supervisory reviews. The review team determined that the 

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

quality of licensing documents. All licenses are signed out by the Bureau Chief. 

The review team found that the Bureau implemented the pre-licensing guidance from NRC’s 

Office of Federal and State Materials and Environmental Management Programs (FSME) Letter 

RCPD-07-026; dated March 20, 2007; prior to the deadline for implementation; however, at the 

time of the review, the revised guidance that was sent out via FSME Letter RCPD 08-020 had 

not yet been officially implemented. The review team discussed this with the Bureau Chief who 

indicated that it was an oversight on their part and would be corrected immediately. Based on a 

review of new licenses issued since the revised guidance was supposed to be implemented, the 

review team determined that the Bureau was still able to meet all of the essential objectives of 

the revised guidance for the new licenses. 

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

fingerprinting requirements, and the National Source Tracking System. The review team noted 

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

implementing these requirements in a timely manner. The Bureau has a practice of 

administratively inactivating the Increased Controls requirements when a licensee that is 

authorized to possess quantities of concern does not physically possess those quantities of 

material. By not capping the possession limit to reflect the actual inventory, the Bureau is 

dependent on the licensee to notify them of any changes to its inventory that would require 

implementation of the Increased Controls. The review team noted that there is not a 

performance issue with the Bureau’s practice of administratively inactivating the Increased 

Controls requirements; however, the review team discussed with the Bureau the benefits of 

capping the possession limits below the quantities of concern when a licensee does not 

physically possess the materials. By doing so, the Bureau would have sufficient notification that 

the licensee intends to possess materials in quantities of concern and could perform an 

inspection to ensure the Increased Controls have been successfully implemented prior to 

authorizing the licensee to possess quantities of concern. The review team verified that the 

Bureau has a sufficient method to ensure that new license applications and license 

amendments are evaluated to determine the applicability of enhanced security requirements. 

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

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

Actions, was satisfactory. 
New Mexico Final Report Page 8 

3.5 Technical Quality of Incident and Allegation Activities

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

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

this indicator, evaluated selected incidents reported for New Mexico in the Nuclear Material 

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

casework for nine radioactive materials incidents. A listing of the casework examined, with 

case-specific comments, can be found in Appendix E. The review team also evaluated the 

Bureau’s response to six allegations involving radioactive materials, including two allegations 

that NRC forwarded to the State during the review period. 

The Bureau has written procedures for responding to incidents and allegations. The procedures 

address the actions to be taken upon the notification of an incident or allegation, an event 

tracking system, the method for conducting an event evaluation or investigation, the 

requirements for documentation, the process for notifying the NRC Headquarters Operations 

Center of reportable events, and the process for submitting event information to NMED. The 

review team found that the procedures provided thorough information to technical staff; 

however, the procedures were not always followed. 

The review team determined that the weaknesses that resulted from not following the 

established procedures were primarily administrative. For all incidents evaluated, the review 

team found that the Bureau’s responses were thorough, complete, and comprehensive. The 

incidents selected for review included lost or stolen radioactive material, a leaking source, and 

an equipment failure. Initial responses were prompt and well coordinated, and the level of effort 

was commensurate with the health and safety significance. The Bureau dispatched inspectors 

to the site when the possibility of an immediate threat to public health and safety existed. When 

no immediate threat was present and the Section determined that the licensee had qualified, 

competent individuals investigating the incident, the Bureau generally responded telephonically 

or with an on-site followup at the next inspection. 

Although the procedures describe an event tracking system, the Bureau does not have a 

reliable system for tracking the number or status of radioactive material incidents. The review 

team identified information for incidents that occurred during the review period in four different 

places: the license files, the Bureau’s chronology files, NMED, and the Bureau’s response to 

the questionnaire. 

For the majority of incidents evaluated, the review team had to review documentation in at least 

two of the sources of information in order to piece together sufficient documentation to review 

the Bureau’s response. Even then, the documentation was often still incomplete and had to be 

supplemented by information from individual inspector’s personal files. The individual 

inspectors are responsible for ensuring that the documentation for the incidents they are 

investigating gets into the appropriate files. 

According to the Bureau’s procedures, if an incident meets the reportability thresholds, as 

established in FSME Procedure SA-300 “Reporting Material Events,” the Bureau should notify 

the NRC Headquarters Operations Center in the appropriate timeframe. In three out of the nine 

incidents reviewed, the Bureau did not report the incidents to the NRC Headquarters Operations 

Center in a timely manner. The Bureau failed to report two of the nine incidents at all. The 
New Mexico Final Report Page 9 

review team discovered that a misunderstanding of the reporting requirements was the 

underlying cause for the Bureau’s not reporting the two incidents. The review team clarified the 

reporting requirements for the Bureau. Because the Bureau does not use the NMED Software, 

these two incidents were also not submitted for inclusion in NMED. The Bureau committed to 

submitting the events to NRC Headquarters Operations Center and NRC’s contractor 

responsible for maintaining NMED. 

Through the review of the information for those events in NMED, the review team noted that in 

all cases the Bureau had not closed the events although the Bureau’s investigation or followup 

had concluded. The review team also identified three event entries where NRC’s contractor 

responsible for maintaining NMED had requested additional information regarding the event; 

however, there was no evidence indicating that the Bureau ever provided that information. The 

review team recommends that the State develop and implement a process to ensure 

appropriate notification to the NRC Headquarters Operations Center for reportable events, to 

ensure all required information is submitted to NMED, and to promote timely closure of NMED 

entries. 

As detailed in the preceding paragraphs, the review team identified administrative weaknesses 

in the areas of tracking, documenting, and reporting incidents. The review team attributed these 

weaknesses to a lack of adherence to established procedures and a lack of management 

oversight in these areas. During the review period, the Section Supervisor position experienced 

some turnover and was also vacant at times, bestowing the responsibility on the inspectors to 

ensure that the incidents were appropriately reported, the investigations were documented, and 

the incidents were closed out upon completion. The Bureau Chief indicated that he intends to 

appoint a technical staff member to serve as the point of contact for ensuring that incidents are 

tracked, documented, and reported as appropriate while the Section Supervisor position is 

vacant. 

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

evaluated the casework for six allegations. The review team concluded that the Section 

consistently took prompt and appropriate action in response to concerns raised. The Bureau 

notified the allegers of the conclusion of the investigations. The review team identified the same 

tracking and documentation weaknesses described above for allegations as well. 

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

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

Allegation Activities, was satisfactory, but needs improvement. 

4.0 NON-COMMON PERFORMANCE INDICATORS 

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

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

Agreement with the State of New Mexico does not relinquish the authority for a sealed source 

and device evaluation program or uranium recovery program; therefore, only the non-common 

performance indicators Compatibility Requirements and Low-level Radioactive Waste Disposal 

Program were applicable to this review. 
New Mexico Final Report Page 10 

4.1 Compatibility Requirements

4.1.1 Legislation

New Mexico became an Agreement State in 1974. The statutory authority for the New Mexico 

program is found in the Radiation Protection Act. The Bureau is designated as the State's 

radiation control agency. The review team noted that no legislation affecting the radiation 

control program was passed during the review period. 

4.1.2 Program Elements Required for Compatibility

The New Mexico regulations pertaining to radiation control apply to all ionizing radiation, 

whether emitted from radionuclides or devices. New Mexico requires a license for possession, 

and use, of all radioactive material. 

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

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

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

obtains approval from the Radiation Technical Advisory Council. The Council must approve all 

rule changes before the process for rule promulgation can proceed. The public, NRC, other 

agencies, and all potentially affected licensees and registrants are offered an opportunity to 

comment during the rulemaking process. Comments are considered and incorporated, as 

appropriate, before the regulations are finalized, approved, and filed. The Environmental 

Improvement Board is the rule promulgating authority for radiation and all other Department 

programs. New Mexico’s rules and regulations are not subject to sunset laws. The Bureau has 

the authority to issue alternate legally binding requirements, such as license conditions, in lieu 

of regulations. 

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

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

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

from the State Regulation Status sheet that FSME maintains. 

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

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

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

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

package that became effective on May 30, 2009, six of which were adopted beyond the 3-year 

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

that are required through February 2011. 

The following amendment will need to be addressed by the Bureau in future rulemakings or by 

adopting alternate generic legally binding requirements: 

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

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

adoption by February 15, 2011. 
New Mexico Final Report Page 11 

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

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

satisfactory. 

4.2 Low-level Radioactive Waste Disposal Program

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

Discontinuance of NRC Regulatory Authority and Assumption Thereof by States Through 

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

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

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

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

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

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

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

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

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

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

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0, Mexico’s performance was found satisfactory for five of the six 

performance indicators reviewed and satisfactory, but needs improvement, for the performance 

indicator, Technical Quality of Incident and Allegation Activities. The review team made one 

recommendation regarding program performance. Overall, the review team recommended, and 

the MRB agreed, that the New Mexico Agreement State Program is adequate to protect public 

health and safety and compatible with NRC's program. Based on the results of this review, the 

review team recommended, and the MRB agreed, that the next full IMPEP review of the New 

Mexico Agreement State Program take place in approximately 4 years. 

Below is the recommendation, as mentioned earlier in the report, for evaluation and 

implementation by the State: 

 The review team recommends that the State develop and implement a process to 

ensure appropriate notification to the NRC Headquarters Operations Center for 

reportable events, to ensure all required information is submitted to NMED, and to 

promote timely closure of NMED entries. (Section 3.5) 
LIST OF APPENDIXES AND ATTACHMENT 

Appendix A IMPEP Review Team Members 

Appendix B New Mexico Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Attachment September 15, 2009 Letter from Jon Goldstein 

 New Mexico’s Response to Draft IMPEP Report 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Aaron McCraw, FSME Team Leader 

 Technical Quality of Incident and Allegation 

 Activities 

Linda McLean, Region IV Technical Staffing and Training 

 Compatibility Requirements 

James Thompson, Region IV Status of Materials Inspection Program 

 Technical Quality of Inspections 

 Inspector Accompaniments 

Matthew McKinley, KY Technical Quality of Licensing Actions 
APPENDIX B 

NEW MEXICO ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML092110695 
APPENDIX C 

 INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Permian NDT License No.: IR 426 

Inspection Type: Field, Unannounced Priority: 1 

Inspection Date: 4/28/09 Inspector: CS 

File No.: 2 

Licensee: Desert Industrial X-Ray License No.: IR 362 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 4/28/09 Inspector: CS 

File No.: 3 

Licensee: Integrity Testing License No.: IR 451 

Inspection Type: Initial, Unannounced Priority: 1 

Inspection Date: 4/20/09 Inspector: SR 

File No.: 4 

Licensee: Permian NDT License No.: IR 426 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 4/17/07 Inspector: EV 

File No.: 5 

Licensee: Black Warrior Wireline License No.: WL 032 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 5/12/08 Inspector: DB 

File No.: 6 

Licensee: Conam Inspection License No.: IR 268 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 12/4/07 Inspector: DB 

Comment: 

Inspection findings, including a Notice of Violation, were sent to licensee greater than 30 

days after inspection. 

File No.: 7 

Licensee: Premier NDT License No.: IR 399 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 8/21/08 Inspector: DB 
New Mexico Final Report Page C.2 

Inspection Casework Reviews

File No.: 8 

Licensee: Blue Jet, Inc. License No.: WL 034 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 3/20/07 Inspector: DB 

Comment: 

Violations were not clearly stated. The “contrary-to” statement was not adequately 

supported with facts. 

File No.: 9 

Licensee: EMCC License No.: RD 449 

Inspection Type: Initial, Unannounced Priority: 5 

Inspection Date: 10/31/08 Inspector: WM 

File No.: 10 

Licensee: Biotech License No.: RP 301 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 1/20/09 Inspector: SR 

File No.: 11 

Licensee: Associated Technology License No.: DM 311 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 10/8/08 Inspector: EV 

File No.: 12 

Licensee: PHC Las Cruces License No.: MI 410 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/27/09 Inspector: CS 

File No.: 13 

Licensee: Eagle NDT License No.: TX L06176 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 5/20/09 Inspector: CS 

File No.: 14 

Licensee: Pathfinder Energy Services License No.: TX L05236 

Inspection Type: Reciprocity, Announced Priority: 3 

Inspection Date: 5/19/09 Inspector: CS 

File No.: 15 

Licensee: American X-Ray License No.: TX L05974 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 3/28/08 Inspector: CS 
New Mexico Final Report Page C.3 

Inspection Casework Reviews

File No.: 16 

Licensee: APEX Geoscience License No.: TX L04929 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 2/6/08 Inspector: SR 

File No.: 17 

Licensee: Kimball & Associates License No.: NRC 37-17717-02 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 8/22/07 Inspector: DB 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: New Mexico Oncology License No.: MI 383-09 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 7/1/09 Inspector: DB 

Comment: 

Entrance and exit meetings were held with only the Radiation Safety Officer present. 

Accompaniment No.: 2 

Licensee: Christus Saint Vincent License No.: MI 213-52 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/30/09 Inspector: SR 

Accompaniment No.: 3 

Licensee: Atomic Inspection, Inc. License No.: MI 383-09 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 6/29/09 Inspector: CS 

Comment: 

A contamination probe was used to measure ambient radiation levels. 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: IBA Molecular North America, Inc. License No.: AP 404 

Types of Action: Decommissioning Amendment No.: 15 

Date Issued: Pending License Reviewer: MR 

File No.: 2 

Licensee: Linac Systems, LLC License No.: AP 453 

Type of Action: New Amendment No.: 00 

Date Issued: 5/04/09 License Reviewer: DB 

File No.: 3 

Licensee: UNM Radiation Safety License No.: BM 233 

Types of Action: Renewal Amendment No.: 77 

Date Issued: Pending License Reviewer: N/A 

File No.: 4 

Licensee: Albuquerque, City of License No.: DM 006 

Type of Action: Termination Amendment No.: 13 

Dates Issued: 7/1/09 License Reviewer: JP 

File No.: 5 

Licensee: Armstrong Construction Co., Inc. License No.: DM 017 

Type of Action: Termination Amendment No.: 11 

Date Issued: 7/14/09 License Reviewer: JP 

File No.: 6 

Licensee: Santa Fe, City of License No.: DM 193 

Type of Action: Termination Amendment No.: 09 

Date Issued: 10/9/08 License Reviewer: DH 

File No.: 7 

Licensee: Marvin Brandstetter, Engineer License No.: DM 285 

Type of Action: Renewal Amendment No.: 04 

Date Issued: 5/31/09 License Reviewer: DB 
New Mexico Final Report Page D.2 

Licensing Casework Reviews

File No.: 8 

Licensee: Taos Gravel Products License No.: DM 289 

Type of Action: Renewal Amendment No.: 04 

Date Issued: Pending License Reviewer: N/A 

File No.: 9 

Licensee: William M. Serazio Company License No.: DM 361 

Type of Action: Renewal Amendment No.: 02 

Date Issued: Pending License Reviewer: N/A 

File No.: 10 

Licensee: Gordon Environmental, Inc. License No.: DM 371 

Type of Action: Renewal Amendment No.: 03 

Date Issued: Pending License Reviewer: N/A 

File No.: 11 

Licensee: Bohannon Huston, Inc License No.: DM 456 

Type of Action: New Amendment No.: 00 

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

File No.: 12 

Licensee: Arizona Public Service Company License No.: GA 016 

Type of Action: Termination Amendment No.: 44 

Date Issued: 4/7/09 License Reviewer: DH 

File No.: 13 

Licensee: Caprock Pipe & Supply, LP License No.: GA 058 

Type of Action: Renewal Amendment No.: 13 

Date Issued: 4/18/06 License Reviewer: DB 

File No.: 14 

Licensee: Ethicon Endo Surgery License No.: GI 316 

Type of Action: Amendments Amendment No.: 06 

Dates Issued: Various License Reviewers: Various 

File No.: 15 

Licensee: American X-Ray & Inspection Services License No.: IR 448 

Type of Action: New Amendment No.: 00 

Date Issued: 5/19/08 License Reviewer: DB 
New Mexico Final Report Page D.3 

Licensing Casework Reviews

File No.: 16 

Licensee: Permian NDT License No.: IR 426 

Type of Action: Amendments Amendment No.: 08 

Dates Issued: Various License Reviewers: Various 

File No.: 17 

Licensee: Robert A. Graor, M.D., P.A. License No.: MD 457 

Type of Action: New Amendment No.: 00 

Date Issued: 6/25/09 License Reviewer: DB 

File No.: 18 

Licensee: Lea Regional Medical Center License No.: MI 122 

Type of Action: Renewal Amendment No.: 47 

Date Issued: 11/15/05 License Reviewer: DB 

File No.: 19 

Licensee: Miner’s Colfax Medical Center License No.: MI 135 

Type of Action: Termination Amendment No.: 27 

Date Issued: 3/27/09 License Reviewer: MR 

File No.: 20 

Licensee: Energy Matter Conservation Corporation License No.: RD 449 

Type of Action: New Amendment No.: 00 

Date Issued: 5/1/08 License Reviewer: DB 

File No.: 21 

Licensee: Warrior Energy Services Corp. License No.: WL 032 

Type of Action: Amendments Amendment No.: 17 

Dates Issued: Various License Reviewers: Various 

File No.: 22 

Licensee: Baker Hughes Oilfield Operations, Inc. License No.: WL 241 

Type of Action: Renewal Amendment No.: 35 

Date Issued: Pending License Reviewer: N/A 

File No.: 23 

Licensee: Gray Wireline Services, Inc. License No.: WL 414 

Type of Action: Amendments Amendment No.: 08 

Dates Issued: Various License Reviewers: Various 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: BJ Services Co. License No: GA 023 

Date of Incident: 12/9/08 NMED No.: 090099 

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

 Type of Investigation: None 

Comments: 

a) Event was not reported in a timely manner, per FSME SA-300. 

b) File did not contain a record for investigation or followup at next inspection. 

File No.: 2 

Licensee: Public Service of New Mexico License No: GL 

Date of Incident: 4/18/08 NMED No.: 080267 

Investigation Date: 4/23-34/08 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Site 

Comment: 

 Event was not reported in a timely manner, per FSME SA-300. 

File No.: 3 

Licensee: Permian NDT License No: IR 426 

Date of Incident: 12/15/07 NMED No.: N/A 

Investigation Date: 4/28/08 Type of Incident: Equipment Failure 

 Type of Investigation: Next Inspection 

Comment: 

 Event was not reported to NRC Headquarters Operations Center. 

File No.: 4 

Licensee: New Mexico Radiation Control Program License No: CS 069 

Date of Incident: 4/1/07 NMED No.: 070203 

Investigation Date: 4/1/07 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Site 

File No.: 5 

Licensee: Rio Grande Radiological Physics License No: RS 433 

 Group, LLC 

Date of Incident: 11/17/06 NMED No.: 060710 

Investigation Date: 11/20/08 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Site 
New Mexico Final Report Page E.2 

Incident Casework Reviews

File No.: 6 

Licensee: A.S. Horner, Inc. License No: DM 375 

Date of Incident: 8/19/06 NMED No.: 060533 

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

 Type of Investigation: None 

Comment: 

 Event was not reported in a timely manner, per FSME SA-300. 

File No.: 7 

Licensee: Presbyterian Kaseman Hospital License No: BR 423 

 Cancer Treatment Center 

Date of Incident: 7/14/06 NMED No.: N/A 

Investigation Date: N/A Type of Incident: Leaking Source 

 Type of Investigation: None 

Comment: 

 Event was not reported to NRC Headquarters Operations Center. 

File No.: 8 

Licensee: Baker Hughes Oilfield Operations, Inc. License No: WL 241 

Date of Incident: 1/31/06 NMED No.: 060083 

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

 Type of Investigation: None 

Comment: 

File did not contain a record for investigation or followup at next inspection. 

File No.: 9 

Licensee: AMEC Earth & Environmental License No: DM 201 

Date of Incident: 8/5/05 NMED No.: 050521 

Investigation Date: 8/15/05 Type of Incident: Lost/Stolen Material 

 Type of Investigation: Next Inspection 
ATTACHMENT 

September 15, 2009 Letter from Jon Goldstein 

New Mexico’s Response to Draft IMPEP Report 

ADAMS Accession No.: ML092650384