October 8, 2013 

Butch Tongate, Deputy Secretary 

Office of the Secretary 

New Mexico Environment Department 

1190 Saint Francis Drive 

Harold Runnels Building 

P.O. Box 5469 

Santa Fe, NM 87502-5469 

Dear Mr. Tongate: 

On September 5, 2013, 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 program adequate to protect 

public health and safety, and compatible with the U.S. Nuclear Regulatory Commission’s (NRC) 

program. 

Section 5.0, page 10 of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. The review team made one recommendation for improvement 

regarding staff vacancies. The review team also determined that the recommendation from the 

2009 IMPEP review, regarding developing and implementing a process to ensure appropriate 

notification of reportable events can be closed. 

Accordingly, the review team recommended, and the MRB agreed, that the New Mexico 

Agreement State Program be found adequate to protect public health and safety and compatible 

with the NRC's program. 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 June 2015. 

 
B. Tongate -2- 

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

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

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

Sincerely, 

/RA/ 

Michael F. Weber 

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: Michael Vonderheide, Director 

 Environmental Protection Division 

 Michael Ortiz, Bureau Chief 

 Environmental Protection Division 

 Radiation Control Bureau 

Bill Dundulis, Rhode Island 

 Organization of Agreement States 

 Liaison to the MRB 
B. Tongate -2- 

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

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

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

Sincerely, 

/RA/ 

Michael F. Weber 

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: Michael Vonderheide, Director 

 Environmental Protection Division 

 Michael Ortiz, Bureau Chief 

 Environmental Protection Division 

 Radiation Control Bureau 

Bill Dundulis, Rhode Island 

 Organization of Agreement States 

 Liaison to the MRB 

DISTRIBUTION: 

See next page 

 ML13255A201 

OFC

MSSA/ 

SMPB: TL MSSA MSSA MSSA:DD TechEd FSME:D EDO/DEDMRT 

NAME JDeCicco LDimmick DWhite 

(LDimmick for) 

PHenderson CPoland 

(PTressler for) 

BHolian MWeber 

DATE 9/12/13 9/12/13 9/13 /13 9/20/13 9/23/13 9/24/13 10/08/13 

OFFICIAL RECORD COPY 
Letter to B. Tongate from Michael F. Weber dated October 8, 2013 

SUBJECT: NEW MEXICO FY2013 FINAL IMPEP REPORT 

DISTRIBUTION: (SP08) 

RidsEdoMailCenter 

JFoster, OEDO 

RidsFsmeOd 

LDudes, FSME 

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TCampbell, OGC 

ABoland, RIII 

JLynch, RIII 

RidsRgn4MailCenter 

AVegel, RIV 

RTorres, RIV 

RidsFsmeMssa 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

RErickson, RIV/RSAO Commissioner Svinicki 

Randolph Ragland, RI Commissioner Apostolakis 

Chris Timmerman, WI Commissioner Magwood 

LHanson, RIV Commissioner Ostendorff 

MBeardsley, FSME SECY 

BTharakan, RIV 

SRodriguez, NM 

JWeil, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE NEW MEXICO AGREEMENT STATE PROGRAM 

June 24–28, 2013 

FINAL REPORT
EXECUTIVE SUMMARY 

This report presents the results of the Integrated Materials Performance Evaluation Program 

(IMPEP) review of the New Mexico Agreement State Program. The review was conducted 

during the period of June 24–28, 2013, by a review team composed of technical staff members 

from the U.S. Nuclear Regulatory Commission (NRC) and the State of Wisconsin.

Based on the results of this review, New Mexico’s performance was found satisfactory, but 

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

remaining indicators reviewed. 

The review team made one recommendation regarding program performance by the State 

regarding staff vacancies. The review team also determined that the recommendation from the 

2009 IMPEP review, regarding developing and implementing a process to ensure appropriate 

notification of reportable events, to ensure submitting information to the Nuclear Material Events 

Database (NMED), and to promote timely closure of NMED entries, should be closed. 

Accordingly, the review team recommended, and the Management Review Board (MRB) 

agreed, that the New Mexico Agreement State Program be found adequate to protect public 

health and safety and compatible with the NRC's program. The review team recommended, 

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

. 
New Mexico Final IMPEP 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 June 24–28, 2013, by a review team composed 

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

of Wisconsin. 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 July 25, 2009 to June 28, 2013, were discussed with New 

Mexico managers on the last day of the review. 

A draft of this report was provided to New Mexico for factual comment on July 25, 2013. The 

State responded by letter dated August 19, 2013. A copy of the State’s response is included as 

an Attachment to this report. A Management Review Board (MRB) met on September 5, 2013 

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 the NRC’s program. 

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

(the Bureau) which is located within the Environmental Protection Division (the Division). The 

Division is part of the New Mexico Environmental Department (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 197 specific 

licenses authorizing possession and use of radioactive 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 the NRC and the State of New Mexico. 

In preparation for the review, a questionnaire addressing the common and applicable 

non-common performance indicators was sent to the Bureau on March 26, 2013. The Bureau 

provided its response to the questionnaire on June 4, 2013. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML13156A047. 

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 four inspectors, and (6) 

interviews with staff and managers. The review team evaluated the information gathered 

against the established criteria for each common and the 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 a recommendation made 

during the previous review. 
New Mexico Final IMPEP Report Page 2 

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 applicable non-common performance 

indicators, and Section 5.0 summarizes the review team's findings. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on July 24, 2009, the review team made 

one recommendation regarding the New Mexico Agreement State Program’s performance. The 

status of the recommendation is as follows: 

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

ensure appropriate notification to the NRC Headquarters Operations Officer (HOO) for 

reportable events, to ensure all required information is submitted to Nuclear Material 

Events Database (NMED), and to promote timely closure of NMED entries. (Section 3.5 

of the 2009 IMPEP Report) 

Status: The Bureau utilizes a database it created to track all NRC reportable and nonreportable events in response to the recommendation. The database is also being used 

to ensure HOO reportable and NMED entries are closed in a timely manner. A staff 

member has been designated as the primary point of contact for the database. In 

reviewing NMED as part of this IMPEP review, the team found that the State is updating 

the information appropriately in NMED. This recommendation is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

Five common performance indicators are used to review the 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

Considerations 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 these issues, 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 workload backlogs. 

During this review period, the Department reorganized, resulting in the Bureau being placed 

under a newly organized Environmental Protection Division. The Radiation Protection 

Program within the Bureau executes the daily operations of the radioactive materials program 

inspection, licensing, incident response, and reporting activities. The Radiation Protection 

Program also has responsibility for the State’s x-ray generation program. 

Technical staff is required to have a Bachelor’s Degree in a physical, natural, or environmental 

science, and two years of work experience in public/environmental health or related technical 

field. At the time of the review, there were four technical staff members with various degrees 

and involvement in the radioactive materials program, and a contractor, totaling approximately 
New Mexico Final IMPEP Report Page 3 

3.0 full-time equivalents (FTE). Of the four technical staff, three staff are fully qualified and one 

is midway through the qualification process. In addition, both the Bureau Chief and Program 

Manager are fully qualified and support the program technically on licensing and inspections. 

The contractor, whose efforts are concentrated in the area of licensing review, provides 

approximately 0.9 FTE for the program. 

The review team noted that a significant turnover and position vacancy issue existed during 

the review period. Four staff members left the materials program, while four staff members 

were hired. The Bureau Chief and Program Manager positions were vacant for 10 months 

and 9 months, respectively, in the 2010–2011 timeframe. Four technical positions were 

unfilled at the time of this review, vacant for various lengths of time. Bureau management is 

currently taking steps to fill the existing vacancies. The Bureau expects to fill one vacancy 

with an eligible individual in August 2013. The Bureau had a second position posted with a 

posting closure date of June 27, 2013. This position is expected to be filled in September 

2013. The third position is being reclassified; the expected fill-date is December 2013. The 

fourth staff position is in a hold status, pending a budget analysis. The review team also 

noted that currently there is no backlog in either inspections or licensing actions. However, 

the review team recommends, and the MRB agreed, that the Bureau continue to aggressively 

pursue the hiring of new staff to fill the vacancies in order to ensure the program’s continued 

adequacy and compatibility. 

On September 5th, the Bureau updated the MRB on the status of the vacancies. The Bureau 

reported that one vacancy was filled on August 17, 2013. A second position can be filled in 

September. The third and fourth positions are on hold pending budget, funding, and 

reclassification reviews. 

The Bureau 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 

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

Nuclear Material Safety and Safeguards Program Area.” Current documentation contains dates 

of training courses and on-the-job training. Staff members are assigned increasingly complex 

duties as they progress through the qualification process. The review team concluded that the 

Bureau’s training program is adequate to carry out its regulatory duties and noted that New 

Mexico management supports the Bureau training program. This support will be important in 

the near future as vacancies are filled by new staff, and to provide refresher training for 

current staff. 

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, be 

found satisfactory, but needs improvement. 

3.2 Status of Materials Inspection Program

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

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

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

on the Bureau’s questionnaire response relative to this indicator, data gathered from the 
New Mexico Final IMPEP Report Page 4 

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 the NRC’s IMC 2800, “Materials Inspection Program.” The Bureau’s 

license categories are similar to those prescribed in IMC 2800; however, most categories of 

licenses are inspected more frequently, including nuclear pharmacy, mobile Positron Emission 

Tomography, medical facilities, research and development, and both fixed and portable nuclear 

gauge licenses. The Bureau does not have any inspection intervals longer than three years, 

whereas IMC 2800 prescribes inspection intervals of up to five years for several license types. 

During the review period, the Bureau conducted 400 inspections, of which 49 were high priority 

(Priority 1, 2, and 3) licensees, as well as 6 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 verified that there were no Priority 1, 2, or 3 

inspections overdue during the review period or at the time of the review. 

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

licensees. Of the 30 inspection reports reviewed, only 3 inspection reports were issued to 

the licensee greater than 30 days after the inspection. In these instances, the letters to the 

licensee were sent within 23 days after the 30-day requirement. All other inspection reports 

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

The Bureau’s questionnaire response indicated that the Bureau issued 200 reciprocity 

licenses during the calendar years 2009 through 2012. 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 greater than 20 

percent of all candidate licensees per the criteria in IMC 1220, “Processing of NRC Form 241 

and Inspection of Agreement State Licensees Operating Under 10 CFR 150.20,” for calendar 

years 2009, 2010, and 2011. During 2012, the Bureau reported conducting 17.65% 

reciprocity inspections of the candidates for inspection. 

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, be found satisfactory. 

3.3 Technical Quality of Inspections

The review team interviewed Bureau inspectors and evaluated inspection reports, enforcement 

documentation, and inspection field notes for 17 radioactive materials inspections conducted 

during the review period. The examined casework included a cross-section of inspections and 

covered a wide variety of inspection types. These included radiation therapy, nuclear medicine, 

veterinary nuclear medicine, industrial radiography, portable gauges, fixed gauges, a panoramic 

irradiator, and a manufacturer and distributor. The casework included routine, reciprocity, and 

security inspections. Appendix C lists the inspection casework files reviewed. 
New Mexico Final IMPEP Report Page 5 

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

aspects of the licensees’ radiation safety and security programs. The review team noted that 

the inspections covered the security requirements, and the National Source Tracking System 

reporting requirements when appropriate. The review team found that inspection reports were 

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

licensees’ performances with respect to health, safety, and security were acceptable. 

Inspections identified problems that resulted in timely and appropriate corrective actions. 

Inspection report documentation supported violations, recommendations made to licensees, and 

unresolved safety issues. All inspection reports were approved and signed by a supervisor. 

The review team did note a repeat of an observation from the 2009 New Mexico IMPEP review. 

The 2009 New Mexico IMPEP team observed that the text of the violations that were issued 

were not always clear. The letters vaguely stated the regulatory requirements and did not 

always specify which portion of the requirement was violated by the licensee. The current 

review team made the same observation. The review team provided the Bureau Chief with a 

standard set of citations, and the Bureau Chief stated that he would review these for program 

enhancement. 

The Bureau has a policy to accompany all staff performing radioactive materials inspections on 

an annual basis and to document the accompaniments on Supervisory Accompaniment forms. 

The team noted that three supervisory accompaniments were missed (one in 2011 and two in 

2012) during this review period and not all accompaniments were documented on Supervisory 

Accompaniment forms. The Bureau Chief reported that due to the loss of several inspectors, 

supervisors had an increased inspection load, and as a result, missed several accompaniments. 

The Bureau Chief committed to consistently perform and document inspector accompaniments 

of all inspectors annually. 

The review team noted that the Bureau has an adequate supply of appropriately calibrated 

survey instruments to support its inspection program, as well as to respond to incidents and 

emergency conditions. Instruments are calibrated annually by an authorized laboratory, and the 

calibration is traceable to the National Institute of Standards and Technology. 

An IMPEP team member conducted accompaniments of four Bureau inspectors during the 

period June 11–13, 2013. The accompaniments included health and safety and security 

inspections of a gamma knife, a diagnostic nuclear medicine department, a high dose rate 

remote after-loader device (HDR), and industrial radiography. The accompaniments are 

identified in Appendix C. During the accompaniments, the inspectors demonstrated 

appropriate inspection techniques and knowledge of the regulations, and conducted 

performance-based inspections. The inspectors were trained and well-prepared for the 

inspections, and were thorough in their inspections of the licensees’ radiation safety 

programs. The inspectors conducted interviews with appropriate personnel, observed 

licensed operations, conducted confirmatory measurements, and utilized good health 

physics practices. The inspections were adequate to assess radiological health and 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, 

be found satisfactory. 
New Mexico Final IMPEP Report Page 6 

3.4 Technical Quality of Licensing Actions

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

24 specific licensing actions. 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, appropriateness of 

license conditions, and overall technical quality. The casework was also reviewed for 

timeliness, use of appropriate deficiency letters, reference to appropriate regulations, supporting 

documentation, consideration of enforcement history, pre-licensing visits, peer/supervisory 

review, and proper signatures. 

The team selected casework to provide a representative sample of licensing actions completed 

during the review period. Licensing actions included five new licenses, eight renewals, three 

decommissioning or termination actions, and eight amendments. Files reviewed included a 

cross-section of license types: broadscope medical, academic broadscope type B, medical 

diagnostic and therapy (which included HDR, unsealed radioiodine therapy, 

temporary/permanent implant brachytherapy, and gamma knife), industrial radiography, 

research and development, accelerator production, nuclear pharmacy, gauges, well logging, 

panoramic and self-shielded irradiators, and a nuclear laundry. The casework sample 

represented work from six license reviewers. A list of the licensing casework evaluated with 

case-specific comments is provided in Appendix D. 

Based on the casework evaluated, the review team found that the licensing actions were of a

thorough, complete, consistent manner, and good quality with health, safety, and security issues 

properly addressed. License tie-down conditions were stated clearly and were supported by 

information contained in the file. Deficiency letters clearly stated regulatory positions, were 

used at the proper time, and identified substantive deficiencies in the licensees’ documents. 

Terminated licensing actions were well documented, showing appropriate transfer and survey 

records. License reviewers use the Bureau’s licensing guides and/or NRC NUREG-1556 series 

guidance documents, policies, checklists, and standard license conditions specific to the type of 

licensing actions to ensure consistency in application and license reviews. 

However, the review team identified a weakness concerning the licensing actions for selected 

HDR license authorizations. The review team noted that the Bureau licensed HDR units with 

possession limits that exceeded medical use limitations on respective Sealed Source and 

Device Registry sheets and also existing licensing guidance. The team discussed this matter 

with the Program Manager who directed staff to promptly amend all of the medical licenses that 

authorized HDR use, to ensure a high technical quality and adherence to existing licensing 

guidance. 

The Program Manager and the Bureau Chief have signature authority for licensing actions. The 

Program Manager or the Bureau Chief performs a technical and supervisory review on all 

licensing actions before issuance to the licensee. Licenses are issued for a five-year period 

under a timely renewal system. 

The documentation of correspondence on some of the selected licensing actions was consistent 

with few exceptions. The review team concluded from the casework evaluated that the 

licensing actions incorporated good health physics practices. The review team attributed the 
New Mexico Final IMPEP Report Page 7 

consistent use of templates and quality assurance reviews to the overall quality noted in the 

casework reviews. 

The Bureau’s pre-licensing review methods incorporated the essential elements of the NRC’s 

revised pre-licensing guidance to verify that the applicant will use requested radioactive 

materials as intended. All new licensees received an evaluation of the applicant’s radiation 

safety and security programs by a license reviewer and the Program Manager or the Bureau 

Chief. Either staff or management then hand-delivered the new license to the applicant. 

 

The review team examined the Bureau’s licensing practices regarding the Increased Controls 

and Fingerprinting Orders. The review team noted that the Bureau used legally binding license 

conditions that meet the criteria for implementing the Increased Controls Orders, including 

fingerprinting, as appropriate. The review team analyzed the Bureau’s methodology for 

identifying those licenses and found the rationale was thorough and accurate. The review team 

confirmed that license reviewers evaluated new license applications and license amendments 

using the same criteria. The Bureau required full implementation of the Increased Controls prior 

to issuance of a new license or license amendment that meets the established criteria. 

The review team examined the Bureau’s implementation of its procedure for the control of 

sensitive information. The Bureau procedure addressed the identification, marking, control, 

handling, preparation, transportation, transmission, and destruction of documents that contain 

sensitive information related to the Increased Controls. The review team noted that the Bureau 

controls access to all of their licensing and inspection files via keycard access to the office suite 

of the Bureau, and the file room is locked during non-office hours. 

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, be found satisfactory. 

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, 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 eight radioactive 

materials incidents. A listing of the incident casework examined may be found in Appendix E. 

The review team also evaluated the Bureau’s response to one allegation involving radioactive 

materials received directly by the Bureau. No allegations were referred to the State by the NRC 

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 incident evaluation or investigation, the 

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

Officer (HOO) of reportable incidents, and the process for submitting event information to 

NMED. 
New Mexico Final IMPEP Report Page 8 

For all of the incidents evaluated, the review team found that the Bureau’s responses were 

thorough, complete, and comprehensive. The incidents selected for review included medical 

events, radiography source disconnect, gauge shutter malfunction, leaking source and a lost 

source. 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 Bureau determined that the licensee had qualified, 

competent individuals investigating the incident, the Bureau generally responded telephonically 

or with an on-site follow-up at the next inspection. 

During the previous review, the team noted administrative weaknesses in the incident and 

allegation program, primarily because the Bureau did not have a reliable system for tracking the 

number or status of radioactive materials incidents. The previous IMPEP review team also 

recommended that the Bureau develop a process that would ensure in part, that the HOO and 

NMED received timely reports of incidents, and that those incidents reported to NMED be 

closed in a timely manner. 

In response to the recommendation, the Bureau developed a tracking database and assigned 

an individual to manage it. Incidents are now tracked, helping to ensure that HOO reportable 

incidents and NMED entries are closed in a timely manner. The review team noted there was 

an apparent misunderstanding of the function of the NMED database. Over the review period 

the Bureau only populated the NMED database with those incidents that were concurrently 

reported to the HOO. The team discussed the issue with staff and management, who agreed to 

begin reporting other than HOO reportable events to NMED, and to go back over the incidents 

and place those they believe are appropriate into NMED. 

In evaluating the effectiveness of New Mexico’s actions responding to allegations, the review 

team evaluated the casework for one allegation reported directly to the Bureau. The Bureau 

evaluated the allegation and determined the proper level of response. The casework review 

indicated that the Bureau took prompt and appropriate action in response to all concerns raised. 

The allegation was appropriately closed, and appropriate parties were notified of the actions 

taken. The review team identified no performance issues from the review of the allegation 

casework. The review team determined that the Program adequately protected the identity of 

concerned individuals. 

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

NRC’s Agreement with New Mexico does not relinquish regulatory 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 applied to this review. 
New Mexico Final IMPEP Report Page 9 

4.1 Compatibility Requirements

4.1.1 Legislation

New Mexico became an Agreement State on May 1, 1974. The statutory authority for the New 

Mexico program is contained in the Radiation Protection Act, Title 20 Environmental Protection, 

Chapter 3, Radiation Protection. The Bureau is designated as the State’s radiation control 

agency. The review team noted that no new 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 to complete. 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 the Office of Federal and State 

Materials and Environmental Management Programs 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 the NRC’s 

regulations. The review team noted one amendment as being overdue. While the Bureau had 

previously adopted the regulations, they had not submitted them to the NRC for review. This 

was brought to the Bureau’s attention prior to the review team’s arrival and the Bureau 

immediately submitted the regulation package to the NRC. It is currently undergoing the NRC 

review. 

The following amendment was submitted overdue during the review period: 

• “Licensing and Radiation Safety Requirements for Irradiators,” 10 CFR Part 36 

amendment (58 FR 7715), that was due for Agreement State adoption on July 1, 1996. 
New Mexico Final IMPEP Report Page 10 

A complete list of upcoming regulation amendments that will need to be addressed can be 

found on the NRC website at the following address: 

http://nrc-stp.ornl.gov/rss_regamendents.html 

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, be 

found 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 above, New Mexico’s performance was found satisfactory for 

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

indicator Technical Staffing and Training with one recommendation regarding program 

performance by the State. The MRB determined that the recommendation from the 2009 

IMPEP review should be closed. 

Accordingly, the review team recommended, and the MRB agreed, that the New Mexico 

Agreement State Program be found adequate to protect public health and safety and compatible 

with the 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 four years. 

Below is the review team’s recommendation, as mentioned in the report, Section 3.1, for 

evaluation and implementation by the State: 

The review team recommends that the Bureau management continue to aggressively 

pursue the filling of the current vacancies in order to ensure the program’s continued 

adequacy and compatibility. 
LIST OF APPENDICES 

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 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Joseph DeCicco, FSME Team Leader 

 Technical Staffing and Training 

 Status of Materials Inspection Program 

Randy Erickson, Region IV Technical Quality of Incident and Allegation 

 Activities 

 Compatibility Requirements 

 Inspection Accompaniments 

 

Randolph Ragland, Region I Technical Quality of Inspections 

Chris Timmerman, WI Technical Quality of Licensing Actions 

Latischa Hanson, Region IV, assisted the team in the review of Status of Materials 

Inspection Program 
APPENDIX B 

NEW MEXICO ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML13156A034 
 

APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Mistras Group, Inc. License No.: IR268-32 

Inspection Type: Special Priority: 1 

Inspection Date: 8/9-12/2011 Inspector: CS 

File No.: 2 

Licensee: New Mexico Pipe & Supply License No.: GA058-13 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 6/18/2010 Inspector: CS 

File No.: 3 

Licensee: Advanced Testing & Materials License No.: DM391-04 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 3/22/2010 Inspector: EV 

File No.: 4 

Licensee: Robert A. Graor, M.D. License No.: MD457-02 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 9/27/11 Inspector: EV 

File No.: 5 

Licensee: Premier NDT Services, Inc. License No.: IR426-10 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 5/10/2012 Inspector: CS 

File No.: 6 

Licensee: American X-Ray License No.: IR448-07 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 10/26/2012 Inspector: DB 

 

File No.: 7 

Licensee: CHRISTUS St. Vincent Regional Medical Center License No.: MI213-53 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 6/9/11 Inspector: MO 

File No.: 8 

Licensee: New Mexico Cancer Center License No.: MI383-01 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 6/20-21/2011 Inspector: MO 
New Mexico Final IMPEP Report C.2 

Inspection Casework Reviews 

File No.: 9 

Licensee: High Resolution License No.: MD435-02 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 12/30/2011 Inspectors: SR, RL 

File No.: 10 

Licensee: Ethicon Endo-Surgery License No.: GI316-08 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 9/28/2012 Inspectors: SR, JM 

File No.: 11 

Licensee: University of New Mexico License No.: RP479-01 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 3/7/2013 Inspectors: MO, JM 

File No.: 12 

Licensee: Arroyo Pet Care Center License No.: VT315-05 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 9/01/2010 Inspector: CS 

File No.: 13 

Licensee: Presbyterian Hospital Center License No.: MI170-73 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 6/07/12 Inspector: CS 

File No.: 14 

Licensee: Best Theratronics, Ltd. License No.: NRC 45-31299-01 

Inspection Type: Reciprocity Priority: 1 

Inspection Date: 2/3/2011 Inspector: EV 

File No.: 15 

Licensee: Diamond Technical Services License No.: PA1077 

Inspection Type: Reciprocity Priority: 1 

Inspection Date: 3/28/2013 Inspector: WM 

File No.: 16 

Licensee: New Mexico Cancer Center License No.: MI383-29 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 7/20-21/2011 Inspector: MO 

File No.: 17 

Licensee: Lovelace Medical Center License No.: MI210-103 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 8/22/2012 Inspector: EV 

 
New Mexico Final IMPEP Report C.3 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Lovelace Medical Center License No.: MI210-104 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 6/11/13 Inspector: WM 

Accompaniment No.: 2 

Licensee: Women’s Hospital License No.: MI211-18 

Inspection Type: Routine/Unannounced Priority: 3 

Inspection Date: 6/12/13 Inspector: JM 

Accompaniment No.: 3 

Licensee: Atomic Inspection Labs, Inc. License No.: IR022-28 

Inspection Type: Routine/Unannounced Priority: 1 

Inspection Date: 6/12/13 Inspector: CS 

Accompaniment No.: 4 

Licensee: MD Anderson Cancer Center License No.: MI423-13 

Inspection Type: Routine/Unannounced Priority: 2 

Inspection Date: 6/13/13 Inspector: EV 
 

APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: PETNET Solutions Inc. License No.: AP463-00 

Type of Action: New Amendment No.: 0 

Date Issued: 1/29/10 License Reviewer: MR 

File No.: 2 

Licensee: Wilco NDT, LLC License No.: IR470-00 

Type of Action: New Amendment No.: 0 

Date Issued: 7/20/11 License Reviewer: MR 

File No.: 3 

Licensee: E & P Wireline Services, LLC License No.: WL411-11 

Type of Action: Termination Amendment No.: 11 

Date Issued: 9/1/11 License Reviewer: MR 

File No.: 4 

Licensee: Rokkon Engineering & Inspection, LLC License No.: IR476-00 

Type of Action: New Amendment No.: 0 

Date Issued: 1/12/12 License Reviewer: MR 

File No.: 5 

Licensee: Rokkon Engineering & Inspection, LLC License No.: IR476-03 

Type of Action: Termination Amendment No.: 3 

Date Issued: 10/16/12 License Reviewer: VRB 

File No.: 6 

Licensee: URS – Washington Division License No.: IR367-12 

Type of Action: Termination Amendment No.: 12 

Date Issued: 2/24/11 License Reviewer: DKB 

File No.: 7 

Licensee: Premier NDT Services, LLC License No.: IR399-28 

Type of Action: Amendment Amendment No.: 28 

Date Issued: 10/16/12 License Reviewer: VRB 

File No.: 8 

Licensee: New Mexico State University License No.: AB151-41 

Type of Action: Amendment Amendment No.: 41 

Date Issued: 7/16/10 License Reviewer: MR 

 
New Mexico Final IMPEP Report D.2 

License Casework Reviews 

File No.: 9 

Licensee: X-Ray Associates - Farmington License No.: MD481-00 

Type of Action: New Amendment No.: 0 

Date Issued: 9/18/12 License Reviewer: VRB 

File No.: 10 

Licensee: Christus St. Vincent Regional Medical Center License No.: MI485-00 

Type of Action: New Amendment No.: 0 

Date Issued: 2/21/13 License Reviewer: VRB 

Comment: HDR possession limit authorization exceeds SSDR maximum possession limit 

File No.: 11 

Licensee: City of Las Vegas License No.: DM119-07 

Type of Action: Renewal Amendment No.: 7 

Date Issued: 4/7/11 License Reviewer: SJM 

File No.: 12 

Licensee: K. Barnett & Sons, Inc. License No.: DM025-09 

Type of Action: Renewal Amendment No.: 9 

Date Issued: 5/31/11 License Reviewer: SR 

File No.: 13 

Licensee: UNM Radiation Safety License No.: BM233-85 

Type of Action: Amendment Amendment No.: 85 

Date Issued: 5/15/13 License Reviewer: VMD 

Comment: HDR possession limit authorization exceeds SSDR maximum possession limit 

File No.: 14 

Licensee: Atomic Inspection Labs License No.: IR022-28 

Type of Action: Renewal Amendment No.: 28 

Date Issued: 2/29/12 License Reviewer: VRB 

File No.: 15 

Licensee: Unitech Services Group, Inc. License No.: LA110-25 

Type of Action: Renewal (including Financial Assurance evaluation) Amendment No.: 25 

Date Issued: 3/6/13 License Reviewer: VRB 

File No.: 16 

Licensee: High Resolution License No.: MD435-03 

Type of Action: Renewal Amendment No.: 3 

Date Issued: 10/6/11 License Reviewer: MR 

 
New Mexico Final IMPEP Report D.3 

License Casework Reviews 

File No.: 17 

Licensee: Ethicon Enco - Surgery License No.: GI316-08 

Type of Action: Renewal Amendment No.: 8 

Date Issued: 2/24/11 License Reviewer: DKB 

File No.: 18 

Licensee: Carlsbad Medical Center License No.: MI083-31 

Type of Action: Renewal Amendment No.: 31 

Date Issued: ending License Reviewer: VMD 

File No.: 19 

Licensee: TriCore Reference Laboratories License No.: IV181-13 

Type of Action: Renewal Amendment No.: 13 

Date Issued: 3/10/10 License Reviewer: MR 

File No.: 20 

Licensee: Schlumberger Technology Corporation License No.: WL197-55 

Type of Action: Amendment Amendment No.: 55 

Date Issued: 5/21/12 License Reviewer: VRB 

File No.: 21 

Licensee: San Juan Regional Medical Center License No.: MI188-50 

Type of Action: Amendment Amendment No.: 5 0 

Date Issued: 5/16/13 License Reviewer: VMD 

File No.: 22 

Licensee: Energy Matter Conversion Corporation License No.: RD449-01 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 2/28/12 License Reviewer: VRB 

File No.: 23 

Licensee: New Mexico Oncology License No.: MI383-33 

Type of Action: Amendment Amendment No.: 33 

Date Issued: 5/14/13 License Reviewer: VMD 

File No.: 24 

Licensee: Christus St. Vincent Regional Medical Center License No.: MI213-56 

Type of Action: Amendment Amendment No.: 56 

Date Issued: 3/13/13 License Reviewer: VRB 

Comment: HDR possession limit authorization exceeds SSDR maximum possession limit 
 

APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: University of New Mexico Hospital License No.: BM233-79 

Date of Incident: 7/21/10 NMED No.: 100386 

Investigation Date: 7/23/10 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 2 

Licensee: Nor-Lea General Hospital License No.: MI466-04 

Date of Incident: 5/15/13 NMED No.: 130001 

Investigation Date: 5/30/13 Type of Incident: Medical Event 

 Type of Investigation: Phone 

File No.: 3 

Licensee: Lovelace Medical Center License No.: MI210-94 

Date of Incident: 5/4/10 NMED No.: 100294 

Investigation Date: 7/12-7/14/10 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 4 

Licensee: Mistras Group License No.: IR268-30 

Date of Incident: 6/14/11 NMED No.: 110315 

Investigation Date: 8/9/11 Type of Incident: Source Disconnect 

 Type of Investigation: Site 

File No.: 5 

Licensee: Intrepid Potash License No.: GA417-05 

Date of Incident: 8/2/12 NMED No.: 120536 

Investigation Date: 8/22/12 Type of Incident: Gauge Shutter Malfunction 

 Type of Investigation: Site 

File No.: 6 

Licensee: St. Vincent Regional Medical Center License No.: MI213-53 

Date of Incident: 4/22/10 NMED No.: N/A 

Investigation Date: 7/7-9/10 Type of Incident: Other 

 Type of Investigation: Site 

File No.: 7 

Licensee: C.R. Sergeant License No.: N/A 

Date of Incident: 5/23/11 NMED No.: N/A 

Investigation Date: 5/23/11 Type of Incident: Leaking Source 

 Type of Investigation: Site 

 
New Mexico Final IMPEP Report E.2 

Incident Casework Reviews 

File No.: 8 

Licensee: Eastern New Mexico Medical Center License No.: MI065-31 

Date of Incident: 9/15/09 NMED No.: N/A 

Investigation Date: 9/16/09 Type of Incident: Lost Source 

 Type of Investigation: Phone 
ATTACHMENT 

August 19, 2013 Letter from Butch Tongate 

New Mexico’s Response to the Draft Report 

ADAMS Accession No.: ML13238A056