August 14, 2012 

Cheryl Nolan 

Assistant Secretary 

Department Environmental Quality 

Office of Environmental Compliance 

P.O. Box 4312 

Baton Rouge, LA 70821 

Dear Ms. Nolan: 

On July 12, 2012, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Louisiana Agreement State Program adequate 

to protect public health and safety and compatible with the Nuclear Regulatory Commission’s 

program. 

Section 5.0, page 16 of the enclosed final report contains a summary of the IMPEP team’s 

findings. Based on the results of the current IMPEP review, the next full review of the Louisiana 

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

in 18 to 24 months. The corrective actions taken to address the open recommendations will be 

reviewed during the periodic meeting and subsequently verified for closure at the next IMPEP. 

No additional written response is required at this time to address the open recommendations. 

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: 

Louisiana Final IMPEP Report 

cc w/ encl: Tim Knight, Administrator 

 Department of Environmental Quality 

 

 Earl Fordham 

 Organization of Agreement States 

 Liaison to the MRB
August 14, 2012 

Cheryl Nolan 

Assistant Secretary 

Department Environmental Quality 

Office of Environmental Compliance 

P.O. Box 4312 

Baton Rouge, LA 70821 

Dear Ms. Nolan: 

On July 10, 2012, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Louisiana Agreement State Program adequate 

to protect public health and safety and compatible with the Nuclear Regulatory Commission’s 

program. 

Section 5.0, page 16 of the enclosed final report contains a summary of the IMPEP team’s 

findings. Based on the results of the current IMPEP review, the next full review of the Louisiana 

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

in 18 to 24 months. The corrective actions taken to address the open recommendations will be 

reviewed during the periodic meeting and subsequently verified for closure at the next IMPEP. 

No additional written response is required at this time to address the open recommendations. 

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: 

Louisiana Final IMPEP Report 

cc w/ encl: Tim Knight, Administrator 

 Department of Environmental Quality 

 Earl Fordham 

 Organization of Agreement States 

 Liaison to the MRB 

DISTRIBUTION: EDATS: FSME-2012-0022 

See next page 

ADAMS Accession Number: ML12199A224 

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

NAME LDimmick DWhite CEinberg / BJM for BMcDermott 

DATE 07/19/12 07/19/12 07/25/12 07/25/12 

OFFICE Tech Editor FSME DEDMRT 

NAME CPoland / PMT for MSatorius / KSW for MWeber 

DATE 07/30/12 08/01/12 08/14 /12 

OFFICIAL RECORD COPY 
Letter to C. Nolan from Michael F. Weber dated August 14, 2012 

SUBJECT: Louisiana 2012 FINAL IMPEP REPORT 

DISTRIBUTION: EDATS: FSME-2012-0022 

MSSA_Technical_Asst_Resource DCD (SP01) 

RidsEdoMailCenter 

RidsFsmeOd 

RidsOgcMailCenter 

RidsRgn1MailCenter 

RidsRgn4MailCenter 

RidsFsmeDmssa 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

BParker, RIII Commissioner Svinicki 

RHays, RIII Commissioner Apostolakis 

RBrowder, RIV/RSAO Commissioner Magwood 

MStephens, FL Commissioner Ostendorff 

MBeardsley, FSME SECY 

AVegel, RIV 

VCampbell, RIV 

RLorson, RI 

JSchuerman, LA 

MKotzalas, OEDO 

JWeil, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE LOUISIANA AGREEMENT STATE PROGRAM 

APRIL 23-27, 2012 

FINAL REPORT
EXECUTIVE SUMMARY 

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

(IMPEP) review of the Louisiana Agreement State Program. The review was conducted during 

the period of April 23-27, 2012, by a team composed of technical staff members from the 

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

Based on the results of this review, Louisiana’s performance was found satisfactory for the 

indicators Technical Staffing and Training, Status of Materials Inspection Program, Technical 

Quality of Inspections, Technical Quality of Licensing Actions, and Technical Quality of Incident 

and Allegation Activities. Louisiana’s performance was found to be satisfactory, but needs 

improvement for the Compatibility Requirements, and Sealed Source and Device Evaluation 

Program performance indicators. 

The review team made two recommendations: (1) the State should review its processes and 

develop and implement appropriate actions to ensure that products issued are of high 

technical quality and meet the standard expectations, and (2) the State should locate and 

make readily accessible all of the active sealed source and device registration commitments. 

Also, a recommendation from the 2008 IMPEP review remains open based on similar issues 

identified in the Sealed Source and Device Evaluation Program indicator. 

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

agreed, that the Louisiana Agreement State Program is adequate to protect public health and 

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

agreed, that the next IMPEP review will take place in approximately 4 years and that a periodic 

meeting held in 18 to 24 months. 
Louisiana Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of April 23-27, 2012, by a review team composed of 

technical staff members from the NRC and the State of Florida. Team members are identified in 

Appendix A. The review was conducted in accordance with the “Implementation of the 

Integrated Materials Performance Evaluation Program and Rescission of Final General 

Statement of Policy,” published in the Federal Register on October 16, 1997, and NRC 

Management Directive 5.6, “Integrated Materials Performance Evaluation Program (IMPEP),” 

dated February 26, 2004. Preliminary results of the review, which covered the period of May 

17, 2008, to April 27, 2012, were discussed with Louisiana managers on the last day of the 

review. 

A draft of this report was provided to Louisiana for factual comment on May 23, 2012. Louisiana 

responded to the findings and conclusions of the review by letter dated June 25, 2012. A copy 

of the State’s response is included as an attachment to this report. An MRB met on July 12, 

2012, to consider the proposed final report. The MRB found the Louisiana Agreement State 

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

The Louisiana Agreement State Program is administered by the Assessment Division–Radiation 

(the Division), which is located under the Office of Environmental Compliance within the 

Department of Environmental Quality (the Department). Organization charts for the Department 

and the Division are included as Appendix B. 

At the time of the review, the Louisiana Agreement State Program regulated 504 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 NRC and the State of Louisiana. 

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

non-common performance indicators was sent to the Department on December 13, 2012. The 

Department provided its response to the questionnaire on April 5, 2012. A copy of the 

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

Management System (ADAMS) using the Accession Number ML12129A058. 

The review team's general approach for conducting the review consisted of (1) an examination 

of the Department’s response to the questionnaire, (2) review of applicable Louisiana statutes 

and regulations, (3) analysis of quantitative information from the Department’s database, 

(4) technical review of selected regulatory actions, (5) field accompaniments of five 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 indicators and made a preliminary assessment of the Louisiana Agreement State 

Program’s performance. 

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

during previous reviews. 
Louisiana 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 May 16, 2008, the review team made 

two recommendations regarding the Louisiana Agreement State Program’s performance. The 

status of each recommendation is as follows: 

1. The review team recommends that the State take measures to evaluate corrective 

actions of all radioactive material incidents, ensure proper documentation of the review, 

and appropriately follow up on the corrective actions at subsequent inspections. 

(Section 3.5 of the 2008 IMPEP Report) 

Status: The State has taken measures including revision of the inspection checklist 

procedure, to evaluate and followup on corrective actions and document review of 

incidents in subsequent inspection reports. This recommendation is closed. 

2. The review team recommends that the State adhere to the document format and content 

guidance in current version of NUREG-1556, Volume 3. (Section 4.2.2 of the 2008 

IMPEP Report) 

Status: Similar issues regarding format and content errors were identified during the 

2012 review of the Sealed Source and Device Evaluation Program. This 

recommendation remains open. 

 

3.0 COMMON PERFORMANCE INDICATORS 

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

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

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

Quality of Licensing Actions, and (5) Technical Quality of Incident and Allegation Activities. 

3.1 Technical Staffing and Training

Issues central to the evaluation of this indicator include the Department’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 Department’s questionnaire response relative to 

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

and considered workload backlogs. 

The Department manages the Office of Environmental Compliance which oversees the 

Division. The Division is composed of the Licensing and Registration Section and the 

Surveillance and Enforcement Section which are responsible for materials inspection, 

licensing and compliance activities, and emergency response activities. 
Louisiana Final IMPEP Report Page 3 

At the time of the review, there were 26 technical staff members with various degrees of 

involvement in the radioactive materials program, totaling approximately 19 full-time 

equivalents (FTE). Ten staff members left the Department since the last review and nine staff 

were hired. The Department was recently informed that the position of Senior Technical Staff, 

vacated November 2011, was eliminated. Department managers are in the process of 

identifying, assigning, and performing the duties of this position. No positions were vacant at 

the time of this review. The review team determined that staffing levels were adequate for the 

Agreement State program. 

The Department had developed a documented training plan for technical staff in response to a 

recommendation from the 2003 IMPEP. Department management could not provide the actual 

procedure to the team for review; however, the team determined that it was being implemented. 

The team discussed the need for a documented procedure for knowledge management. The 

Department managers immediately developed one for the team to review that appeared 

consistent with the requirements in the NRC/Organization of Agreement States Training 

Working Group Report and NRC’s Inspection Manual Chapter (IMC) 1246, “Formal Qualification 

Programs in the Nuclear Material Safety and Safeguards Program Area.” Staff members are 

assigned increasingly complex duties as they progress through the qualification process. The 

review team concluded that the Department’s training program is adequate to carry out its 

regulatory duties and noted that Louisiana management supports the Department training 

program. 

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

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

found satisfactory. 

3.2 Status of Materials Inspection Program

The review team focused on five factors while reviewing this indicator: (1) inspection frequency, 

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

findings to licensees, and (5) performance of reciprocity inspections. The review team’s 

evaluation was based on the Department’s questionnaire response relative to this indicator, 

data gathered from the Department’s database, examination of completed inspection casework, 

and interviews with management and staff. 

The review team verified that Louisiana's inspection frequencies for all types of radioactive 

material licenses are at least as frequent as similar license types listed in IMC 2800, “Materials 

Inspection Program.” Many of the Department’s license categories are inspected at a more 

frequent inspection schedule than those established in IMC 2800 for similar license types, 

including nuclear medicine, gauges, and manufacturer/distribution licensees. 

The Department conducted approximately 660 higher priority (Priority 1, 2, and 3) inspections 

during the review period based on the inspection frequencies established in IMC 2800. 

Nineteen of these inspections were conducted overdue by more than 25 percent of the 

inspection frequency prescribed in IMC 2800. In addition, the Department performed 

approximately 77 initial inspections during the review period, 6 of which were conducted 

overdue. As required by IMC 2800, initial inspections should be conducted within 12 months of 

license issuance. The inspections were conducted late due to the military deployment of one 
Louisiana Final IMPEP Report Page 4 

inspector for over one year; he has since returned. There were no overdue inspections at the 

time of the review. Overall, the review team calculated that the Department performed 

approximately three percent of its inspections overdue during the review period. 

The review team evaluated the Department’s timeliness in providing inspection findings to 

licensees. A sampling of 25 inspection reports indicated that none of the inspection findings 

were communicated to the licensees beyond the Department’s goal of 30 days after the 

inspection. 

During the review period, the Department granted 205 reciprocity permits, all of which were 

candidate licensees based upon the criteria in IMC 1220, “Processing of NRC Form 241 and 

Inspection of Agreement State Licensees Operating Under 10 CFR 150.20.” The review team 

determined that the Department exceeded the NRC’s criteria of inspecting 20 percent of 

candidate licensees operating under reciprocity in each of the four years covered by the review 

period. 

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

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

Program, be found satisfactory. 

3.3 Technical Quality of Inspections

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

notes, and interviewed inspectors for 25 radioactive materials inspections conducted during the 

review period. The casework reviewed included inspections conducted by 11 Department 

inspectors and covered inspections of various license types, including academic broad scope, 

medical institutions with high dose rate remote afterloaders, unsealed radioiodine therapy, 

permanent or temporary implant brachytherapy, radionuclide production (cyclotron), medicaldiagnostic, portable gauges, industrial radiography, self-shielded irradiators, nuclear pharmacy, 

mobile nuclear medicine, well-logging, and Increased Security Controls for Large Quantities of 

Radioactive Materials (Increased Controls). Appendix C lists the inspection casework files 

reviewed as well as the results of the inspector accompaniments. 

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

aspects of licensed radiation programs. The review team found that inspection reports were 

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

ensure that a licensee’s performance with respect to health and safety was acceptable. The 

majority of the documentation supported violations, recommendations made to licensees, 

unresolved safety issues, and discussions held with licensees during exit interviews. 

The inspection procedures utilized by the Department are consistent with the inspection 

guidance outlined in IMC 2800, including a compliance checklist used by inspectors. An 

inspection report is completed by the inspector which is then peer reviewed by a second 

inspector and subsequently emailed to the inspector’s supervisor for final review and signature. 

Supervisory accompaniments were conducted at least annually for all inspectors. 

The review team determined that the inspection findings were appropriate and prompt 

regulatory actions were taken, as necessary. All inspection findings were clearly stated and 
Louisiana Final IMPEP Report Page 5 

documented in the reports and sent to the licensees with the appropriate letter detailing the 

results of the inspection. The Department issues to the licensee a Field Interview Form at the 

exit meeting of the inspection and, when required, a letter indicating a Notice of Deficiency 

(NOD), in letter format, which details the results of the inspection. When the Department issues 

a NOD, the licensee is required to provide a written corrective action plan, based on the 

deficiencies cited, within 30 days. All findings are reviewed by the Enforcement Coordinator 

and inspection staff. 

The review team noted that the Department has an adequate supply of survey instruments to 

support their inspection program. Appropriate, calibrated survey instrumentation, such as 

Geiger-Mueller meters, scintillation detectors, ion chambers, micro-R meters, and neutron 

detectors, were observed to be available. The Department also has a portable multi-channel 

analyzer for isotope determination of unknown or unidentified radioactive material. Survey 

instruments are calibrated at least annually, or as needed, by state-licensed calibration services 

with National Institute of Standards and Technology traceable sources, in the geographic area 

of each regional office. The Department uses a database to track each instrument, its current 

location, and next calibration date. 

Accompaniments of five Department inspectors were conducted by one IMPEP team member 

during the week of March 19-23, 2012. The inspectors were accompanied during health and 

safety inspections of industrial radiography source manufacturing, industrial radiography, 

medical broad scope including high dose rate remote afterloader therapy, unsealed radioiodine 

therapy, permanent/ temporary implant brachytherapy, and self-shielded irradiators, PET 

medical-diagnostic, well-logging, and Increased Controls. The accompaniments are identified in 

Appendix C. During the accompaniments, the inspectors demonstrated appropriate inspection 

techniques, knowledge of the regulations, and conducted performance-based inspections. In 

response to the recommendation from the previous IMPEP review, the inspection checklist was 

revised to address incident followup. The inspectors were trained, well-prepared for the 

inspections, and thorough in their audits 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 Louisiana’s performance with respect to the indicator, Technical Quality of Inspections, be 

found satisfactory. 

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, operating and 

emergency procedures, 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. 
Louisiana Final IMPEP Report Page 6 

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

completed during the review period. Licensing actions selected for evaluation included 3 new 

licenses, 7 renewals, 2 termination actions, and 12 amendments. Files reviewed included a 

cross-section of license types, including broadscope, medical diagnostic and therapy, gamma 

knife, industrial radiography, research and development, nuclear pharmacy, gauges, 

manufacturers, pool and self-shielded irradiators. The casework sample represented work from 

four license reviewers. A listing of the licensing casework examined, with case-specific 

comments is provided in Appendix D. 

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

and properly addressed health, safety, and security issues. License reviewers use the NRC 

NUREG-1556 series guidance documents, policies, checklists, and standard license conditions 

specific to the type of licensing actions to ensure consistency in licenses. Of the actions 

reviewed, there were approximately five actions that had deficiencies. The licensing staff 

addressed and corrected most of the deficiencies prior to the preliminary exit meeting with 

management. Some of the deficiencies identified included (1) not reviewing a historical 

authorization of U-235 for shielding in lieu of depleted uranium as part of a license renewal 

action, (2) using the American Board of Radiology computer generated results for oral exams 

only, in lieu of the actual board certificate to document the oral and written exams of a physician 

authorized user, (3) not listing the Radiation Safety Committee Chair on a broad scope license, 

and (4) not requiring that the processes used by the Radiation Safety Committee to approve 

authorized users and designated rooms be submitted during a broad scope license renewal 

action. The review team determined there was no consistent pattern to the deficiencies 

identified; however, these deficiencies either did not meet the required technical quality for the 

review or there was incomplete supporting documentation for the licensing action. 

In addition, the review team identified that three medical attestations were not provided as part 

of the supporting documentation for authorizing a radiation safety officer and two medical 

physicists. However, the review team determined that the requirements for written attestations 

are not captured in the current medical regulations for the State of Louisiana, and therefore is 

not required documentation to support the respective licensing actions. The final medical 

regulations that were adopted under RATS ID 2007-1 have been submitted to the NRC and are 

under review at this time. 

On June 13, 2003, the NRC issued Orders to all panoramic and underwater irradiator licensees 

authorized to possess greater than 10,000 curies of byproduct material. One of the licenses 

issued by the Department authorized an amount of radioactive material in a pool irradiator 

greater than 10,000 curies and the licensee had received the aforementioned Order. The NRC 

received information from the licensee in 2003 indicating that, although authorized for greater 

than 10,000 curies, they possessed quantities significantly below 10,000 curies and, therefore, 

the specific Order was not applicable. During the review, the Department contacted the 

licensee and requested a current level of activity in the pool. The review team noted that the 

current activity corresponded with previous documentation of the activity from 2002 and 2003, 

with calculated decay correction. Therefore, the pool did not meet the 500 rad/hr at one meter 

requirement as specified in Chapter 17, "Licensing and Radiation Safety Requirements for 

Irradiators" under Title 33, Part XV of the Louisiana Code, which is equivalent to Title 10 of the 

Code of Federal Regulations (CFR) Part 36 requirement. The licensee was implementing the 

Increased Controls and Fingerprinting Orders as required, for the facility. The Department 
Louisiana Final IMPEP Report Page 7 

amended the license during the IMPEP review to reflect an authorized activity well below the 

10,000 curie level in order to show that the underwater irradiator Order is not applicable. 

Deficiency letters reviewed clearly stated regulatory positions and were used appropriately. In 

addition to using formal written requests, the staff frequently used telephone or email requests 

for clarification or to obtain additional information from the licensee or applicant. However, the 

review team also identified that some of the requests for additional information were not always 

documented, which resulted in not being able to ascertain what was authorized in the licensing 

action. This was especially evident for those requests that were partially authorized or for 

requests to authorize specific individuals for certain high-risk activities, such as source retrieval. 

In addition, the Department does not use cover letters for its licensing actions, so there is no 

formal correspondence to accompany the approved authorization. The Department 

incorporates the licensee's application date and includes the language "and all subsequent 

correspondence" as part of the license tie-down condition. The review team discussed the 

consideration to specifically list documents as part of the tie-down conditions, in order to 

ascertain what was specifically authorized and in some cases to identify certain individuals that 

are specifically authorized for high-risk activities, such as source retrieval. Based on 

discussions with the staff and management, the review team understood that all 

correspondence from the licensee to the Department is tied-down by the particular license 

condition. Based on the enforcement actions taken by the Department, it appears that the 

license and all tie-down conditions are enforceable. 

All license evaluators were qualified for the respective licensing actions reviewed. The 

Department performs a peer review, technical review and a supervisory review for all licensing 

actions. All licensing actions are then routed to the Program Manager and Administrator and 

are subsequently signed by the Assistant Secretary, Office of Environmental Compliance under 

the Department of Environmental Quality. Based on the review team's discussions with the staff 

and management, it was determined that the peer review is primarily administrative in nature to 

ensure that the license format, amendment number, and dates are correct, whereas the 

technical review primarily focuses on the specific request and corresponding authorization. 

Since the review team identified several deficiencies regarding the technical quality and 

supporting documentation of the licensing actions in addition to identified deficiencies in other 

products issued by the Department, including sealed source and device registries (see 

Section 4.2.2), the review team recommends that the Department evaluate its review processes 

and develop and implement appropriate actions to ensure that products issued are of high 

technical quality and meet the standard expectations of the Department. 

Once all of the supporting documentation is received for a licensing action, then the Department 

typically issues the action within 30-days. The results of this metric are provided to the 

Louisiana legislature on a quarterly basis. 

Licenses are initially issued for a five-year period. Prior to the expiration date, the licensee is 

required to submit a "partial" renewal and attest that their program has not changed or the 

licensee is required to submit any changes to the program at this time. The license is then 

issued for a four-year period. Prior to the four-year expiration date, the licensee is required to 

submit a full license renewal application. In this manner, the license renewals are completed 

within 10 years and there is an attestation given during the middle of the 10-year period. 
Louisiana Final IMPEP Report Page 8 

On June 21, 2010, the NRC issued RCPD letter RCPD-10-007, "Requesting Implementation of 

a Policy on Maximum Possession Limits for Radioactive Material Licenses" to all Agreement 

States and Michigan. The Department has completed the requested action for all increased 

control licenses and has completed approximately 95 percent of the remaining material 

licenses. The Department anticipates that all licenses will be completed by the end of 2013. 

The Department has access to the National Source Tracking System (NSTS) and utilizes 

and updates the database, as necessary, when completing certain licensing actions. The 

Department did not have any licensees with outstanding NSTS reconciliations for 2011. 

The Department performs pre-licensing checks of all new applicants. The Department's prelicensing review methods incorporate the essential elements of NRC’s revised pre-licensing 

guidance to verify that the applicant will use requested radioactive materials as intended. All 

new licensees receive a pre-licensing site visit which includes an evaluation of the applicant’s 

radiation safety and security programs prior to receipt of the initial license. 

The review team examined the Department's licensing practices regarding the Increased 

Controls and Fingerprinting Orders. The review team noted that the State uses legally binding 

license conditions that meet the criteria for implementing the Increased Controls and Fingerprint 

Orders, as appropriate. The review team analyzed the Department'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 Department requires 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 Department's processes for the control of sensitive information. 

The Department's licensing system is entirely electronic, except for the increased controls 

supporting documentation. The increased controls license itself is maintained in the electronic 

system; however, there are no markings on the license to indicate it is considered sensitive 

information. Access to the electronic radiation records is limited to the Radiation Division and 

those with a need to know. The increased controls sensitive information that is maintained 

separately from the electronic system is placed in an Increased Controls marked envelope and 

secured from inadvertent disclosure in a locked file cabinet. The Department recently received 

approval from their legal counsel that the increased control licenses, which are maintained on 

the electronic system, may be marked to indicate they are security-related. The Department's 

legal counsel determined that this action would not alter the State's obligations under the Public 

Records Act or other applicable rules. The Department indicated that they would be marking 

the electronic increased control licenses during future amendments and renewals. 

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

that Louisiana’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 Department’s actions in responding to incidents and 

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

to this indicator, evaluated selected incidents reported for Louisiana in the Nuclear Material 

Events Database (NMED) against those contained in the Department’s files, and evaluated the 
Louisiana Final IMPEP Report Page 9 

casework for eight radioactive materials incidents. A listing of the incident casework examined, 

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

Department’s response to eight allegations involving radioactive materials. There were no 

allegations referred to the State by the NRC during the review period. 

The review team examined the Department’s incident and allegation processes, including 

written procedures for handling allegations and incident response, file documentation, 

notification of incidents to the NRC Headquarters Operations Center, and the use of NMED 

software. When notification of an incident or an allegation is received, the Staff Technical 

Advisor and the Surveillance Supervisor or Program Manager determine the appropriate level of 

initial response. 

The review team identified 64 radioactive material incidents in NMED for Louisiana during the 

review period. As a policy, the State chose to report all incidents to the NRC through NMED 

regardless of reportability. The review team selected eight radioactive material incidents for 

evaluation. The incidents selected for review included the following categories: potential 

overexposure, medical event, damaged equipment, equipment or procedural failure, and a fire. 

The review team determined that the Department’s response to incidents was complete and 

comprehensive. Initial responses were prompt and well-coordinated, and the level of effort was 

commensurate with the health and safety significance. The Department dispatched inspectors 

for on-site investigations in all of the cases reviewed and took suitable enforcement and 

followup actions. If the incident met the reportability thresholds, as established in the Office of 

Federal and State Materials and Environmental Management Programs (FSME) Procedure 

SA-300 “Reporting Material Events,” the State notified the NRC Headquarters Operations 

Center and entered the information into NMED, in a prompt manner. The actions taken in 

response to incidents were documented and filed, and the data were submitted to the NRC’s 

contractor responsible for maintaining NMED for inclusion in the database. 

Incidents were addressed in subsequent inspections as recommended from the 2008 IMPEP 

review. Interviews of inspectors and a sampling of reports for those inspections showed that 

followup and corrective actions are evaluated and documented. However, the review team 

noted that the documentation did not give details as to the effectiveness of the corrective 

actions. 

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

evaluated the completed casework for eight allegations. The review team concluded that the 

Department consistently took prompt and appropriate actions in response to concerns raised. 

The review team noted that the Department documented the investigations of concerns and 

retained all necessary documentation to appropriately close the allegations. When appropriate, 

the Department notified the concerned individuals of the conclusion of its investigations. The 

review team determined that the Department adequately protected the identity of concerned 

individuals. 

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

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

Allegation Activities, be found satisfactory. 
Louisiana Final IMPEP Report Page 10 

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 (SS&D) Program, 

(3) Low-Level Radioactive Waste (LLRW) Disposal Program, and (4) Uranium Recovery 

Program. The NRC’s Agreement with Louisiana does not relinquish regulatory authority for a 

low level radioactive waste disposal or uranium recovery program; therefore, only the first two 

non-common performance indicators applied to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Louisiana became an Agreement State in 1967. The statutory authority for the Louisiana 

program is found in Louisiana Administrative Code, Title 33, Part XV, Radiation Protection, and 

apply to all ionizing radiation. The Department 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 review team evaluated Louisiana’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. Louisiana’s regulation process 

normally takes approximately two to three months, if the proposed State regulations are 

identical to Federal regulations, and six months maximum if they are not identical. 

During the review period, Louisiana submitted six final regulation amendments, no proposed 

regulation amendments and one legally binding license condition to the NRC for a compatibility 

review. Two of the amendments were overdue for State adoption at the time of submission. 

The NRC’s compatibility review resulted in six comments, which will need to be addressed by 

the State in upcoming rulemaking activities. Current NRC policy requires that Agreement States 

adopt certain equivalent regulations or legally binding requirements no later than three years 

after the effective date of NRC’s regulations. 

The following four amendments have not been submitted as of the time of this review and are 

overdue: 

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

10 CFR Parts 32 and 35 amendments (72 FR 45147, 72 FR 54207) that became 

effective on October 29, 2007, and were due for Agreement State adoption on 

October 29, 2010. 

• “Exemptions From Licensing, General Licenses, and Distribution of Byproduct Material: 

Licensing and Reporting Requirements,” 10 CFR Parts 30, 31, 32, and 150 amendments 

(72 FR 58473) that became effective on December 17, 2007, and was due for 

Agreement State adoption by December 17, 2010. 
Louisiana Final IMPEP Report Page 11 

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

32, 33, 35, 61, and 150 amendments (72 FR 55864) that became effective on November 

30, 2007, and was due for Agreement State adoption by November 30, 2010. 

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

10 CFR Parts 19 and 20 amendments (72 FR 68043) that became effective 

February 15, 2008, and was due for Agreement State adoption by February 15, 2011. 

The following two amendments were submitted overdue during this review period: 

• “Energy Compensation Sources for Well Logging and Other Regulatory Clarifications”, 

10 CFR Part 39 amendment (65 FR 20337) that was due for Agreement State adoption 

on May 17, 2003. 

• “Minor Amendments,” 10 CFR Parts 20, 32, 35, 40 and 70 amendment (71 FR 15005) 

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

At the time of this review, the following eight amendments have not been reviewed as final 

regulations and were overdue: 

• “Standards for Protection Against Radiation”, 10 CFR Part 20 amendment (56 FR 

23360) (56 FR 61352) (57 FR 38588) (57 FR 57877) (58 FR 67657) (59 FR 41641) 

(60 FR 20183) that became effective on January 1, 1991, and was due for Agreement 

State adoption by January 1, 1994. The review team noted that this amendment had 

been reviewed as a proposed regulation, but not submitted as a final regulation for NRC 

review. 

• “Notification of Incidents,” 10 CFR Parts 20, 30, 31, 34, 39, 40, and 70 amendments 

(56 FR 64980) that became effective on October 15, 1991, and was due for Agreement 

State adoption by October 15, 1994. 

• “Decommissioning Recordkeeping and License Termination: Documentation Additions,” 

10 CFR Parts 30 and 40 amendments (58 FR 39628) that became effective on 

October 25, 1993, and was due for Agreement State adoption by October 25, 1996. 

• “Termination or Transfer of Licensed Activities: Recordkeeping Requirements,” 

10 CFR Parts 20, 30, 40, 61, and 70 amendments (61 FR 24669) that became effective 

on June 17, 1996, and was due for Agreement State adoption by June 17, 1999. 

• “Licenses for Industrial Radiography and Radiation Safety Requirements for Industrial 

Radiography Operations,” Parts 30, 34, 71, and 150 amendments (62 FR 28947) that 

became effective on June 27, 1997, and was due for Agreement State adoption by 

June 27, 2000. 

• “Minor Corrections, Clarifying Changes, and a Minor Policy Change,” 10 CFR Parts 20, 

35, and 36 amendments (63 FR 39477, 63 FR 45393) that became effective on 

October 26, 1998, and was due for Agreement State adoption by October 26, 2001. 
Louisiana Final IMPEP Report Page 12 

• “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct 

Material,” 10 CFR Parts 30, 31, and 32 amendments (65 FR 79162) that became 

effective on February 16, 2001, and was due for Agreement State adoption on February 

16, 2004. 

• “Minor Amendments”, 10 CFR Parts 20, 30, 32, 35, 40 and 70 amendments 

(71 FR 15005) that became effective on March 27, 2006, and was due for Agreement 

State adoption on March 27, 2009. 

The following NRC amendments will need to be addressed in upcoming rulemakings or by 

adopting alternate legally binding requirements: 

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

amendment (74 FR 33901) that became effective on September 28, 2009, and is due for 

Agreement State adoption by September 28, 2012. 

• “Decommissioning Planning”, 10 CFR Parts 20, 30, 40 and 70 (76 FR 35512) that 

became effective on December 17, 2012, and is due for Agreement State adoption by 

December 17, 2015. 

• “Licenses, Certifications, and Approvals for Materials Licensees”, 10 CFR Parts 30, 36, 

39, 40, 70 and 150 (76 FR 56951) that became effective on November 14, 2011, and is 

due for Agreement State adoption by November 14, 2014. 

• “Change of Compatibility of 10 CFR 31.5 and 31.6”, (77 FR 3640) that became effective 

on January 25, 2012, and is due for Agreement State adoption by January 25, 2015. 

As reported in Section 3.1, one of the duties of the vacated Senior Technical Staff position 

included the development of regulations. The Program Manager is in the process of identifying 

overdue regulation amendments, submitting them for NRC review, reviewing the NRC 

comments on the final regulation amendments submitted during this review period, and planning 

to address the comments in upcoming rulemaking. 

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

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

satisfactory, but needs improvement. 

4.2 Sealed Source and Device Evaluation Program

In evaluating this indicator, the review team used three sub elements to evaluate the 

Department’s performance regarding the SS&D Evaluation Program. These subelements 

include the following: (1) Technical Staffing and Training, (2) Technical Quality of the Product 

Evaluation Program, and (3) Evaluation of Defects and Incidents Regarding SS&Ds. 

In assessing the Department’s SS&D evaluation activities, the review team examined the 

Department’s response to the IMPEP questionnaire on this indicator, performed a search of the 

SS&D Registry for registrations issued by Louisiana, and performed NMED searches of 
Louisiana Final IMPEP Report Page 13 

manufacturers and distributors identified on SS&D registrations issued by Louisiana. A review 

of new, amended, and corrected SS&D evaluations and supporting documents covering the 

review period was conducted. The review team noted the staff’s use of guidance documents 

and procedures, interviewed managers and staff, and verified the use of regulations, license 

conditions, and inspections to enforce commitments made in the applications. 

4.2.1 Technical Staffing and Training 

During the review period, one qualified SS&D reviewer left the Department. At the time of the 

review, the Department had four qualified SS&D reviewers with full signature authority. Two of 

the qualified reviewers did not perform any reviews during the review period. 

The Department completed one new SS&D registration, five SS&D registrations were amended 

in entirety, and eight SS&D registration inactivations during the review period. Three of the 

four qualified reviewers with full signature authority each have over 10 years of experience with 

the Department and the fourth reviewer has five years experience. Each reviewer has obtained 

either a bachelor's or master's degree in science. All of the reviewers have attended the NRC 

SS&D workshop. The Department had two pending SS&D evaluations. The review team 

determined that the staffing level is adequate for the Department’s SS&D workload. 

4.2.2 Technical Quality of the Product Evaluation Program 

During the review period, the Department processed 14 SS&D actions. These actions 

consist of one new SS&D registration, five SS&D registrations amended in entirety, and eight 

SS&D registration inactivations. The casework review included one new, five were amended 

in entirety, and three inactivations to include reviewing all supporting documentation, 

licensing actions, and inspections. The review team evaluated 9 of these 14 registrations. A 

listing of the SS&D registrations evaluated, with case-specific comments, can be found in 

Appendix F. 

The review team confirmed that the Department’s policy is to follow the recommended 

guidance from the NRC SS&D training workshops and NUREG-1556, Volume 3, Revision 1, 

“Consolidated Guidance About Materials Licenses - Applications for Sealed Source and Device 

Evaluation and Registration.” The review team verified that appropriate review checklists were 

used to ensure that all relevant materials had been submitted and reviewed. The checklists 

were retained in the SS&D files that identified the responsible reviewer. The review team 

verified that pertinent American National Standards Institute standards, NRC Regulatory 

Guides, and applicable references were available and used when performing SS&D reviews. 

The review team noted that all nine of the reviewed registrations did not follow the format and 

content recommended in NUREG-1556, Volume 3. In cases where the format and content 

were not followed, the Department relied upon the format and content from the previously 

issued registration without checking the NUREG. For example, in four registrations reviewed, 

each applicant submitted the incorrect use code identified in Appendix C of the NUREG. (This 

issue was identified during the 2008 IMPEP review.) Also for six registrations reviewed, the 

date on the registration’s first page did not match the dates on the signature page. These 

formatting issues did not adversely impact the technical quality or content of the reviews; 

however, because the registrations are used nationally (especially first page information), the 
Louisiana Final IMPEP Report Page 14 

documents should be consistent with national standards. The review team recommends that 

the State adhere to the document format and content guidance in the current version of 

NUREG-1556, Volume 3. 

The registration files do not contain all correspondence, engineering drawings, photographs, 

radiation profiles, and details of the applicant’s quality assurance and quality control program 

and other commitments made that are incorporated by reference into the registration. For 

example, the “Reference Section” of three registrations did not include the standard language 

indicating that the documents and commitments are incorporated by reference into the 

registration. Five registrations contain documents that could not be found at the time of the 

onsite review or documents with incorrect dates. One initial application was superseded by a 

more recent revision that resulted in deficiency items responses, none of which were 

incorporated into the registration’s reference section. The SS&D reviewers indicated that they 

do not review previous documents in the reference section to verify that they are appropriate, 

need to be changed, or accessible during amendment in its entirety reviews. The Department 

enforces the requirements of SS&D registrations through conditions made part of specific 

licenses issued to the manufacturers or distributors of SS&D products by listing the SS&D 

registrations numbers in a license condition. The license tie-down condition requires the 

licensee to follow the commitments made in the registration numbers listed in the license 

condition. None of the SS&D registration commitments listed in the SS&D “Reference Section” 

are uniquely identified on the license except by the SS&D registration number. The Department 

may have difficulty enforcing registration commitments or evaluate any product defect issues 

that may arise if it does not actually possess the commitment documents. 

The majority of the documents not available at the time of the review appear to be part of an 

initial upload into the document imaging system during 2002-2003 when the Department moved 

to a paperless record keeping system. The recently received documents were located in the 

document imaging system and the SS&D “Reference Section” did contain a few errors. For 

example, the reference section indicated a document date, but a review of the document 

indicated that this date was actually the received date and not the document date. 

While most of the registrations clearly summarized the product evaluation to provide license 

reviewers with adequate information to license the products, two of the registrations did not list 

external radiation limits at the specified distances as required in NUREG-1556, Volume 3. In 

addition, a new registration did not provide critical information that the brachytherapy sources 

are delivered non-sterile and provide the maximum temperatures and pressures for sterilization. 

While a detailed review of this issue showed the source could withstand these temperature and 

pressures and no health and safety issue existed, this information is important to regulatory 

agencies in licensing these sources. The review team found that deficiency letters clearly 

stated regulatory positions and health and safety issues were properly addressed. With the 

exception of the formatting issues and reference documents missing, the review team found that 

the majority evaluations were of good quality. 

During the onsite review, the team also discovered one registration amended on 

January 11, 2011, was not transmitted to NRC. This registration was also not included in the 

Department’s initial response to the questionnaire. A revised questionnaire response was 

provided to include this registration. 
Louisiana Final IMPEP Report Page 15 

The review team noted that the Department had terminated a specific license associated with 

multiple SS&D registrations and did not address inactivation of the registrations. The review 

team also identified that the Department did not address inactivation of one additional SS&D 

registration. The review team concluded that no adverse health and safety issues resulted and 

discussed the benefits of performing inactivation of registrations prior to or concurrent with 

performing license terminations. The SS&D reviewer agreed to evaluate the need to inactivate 

the registrations in question and to inactivate the registrations consistent with the guidance in 

NUREG-1556, as applicable. At the time of the onsite review, the Department had two 

registration amendments currently under review. 

The review team found that while the Department has multiple levels of peer, technical, and 

management review of documents that are part of their processes in issuing SS&D registrations 

and the associated license amendments, these reviews did not identify these issues prior to the 

SS&D registration being issued. (See recommendation discussed in Section 3.4, Technical 

Quality of Licensing Actions.) 

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds 

Based upon the Department’s response to the questionnaire, interview of Department 

managers, and the review team’s searches of NMED, the review team selected a suspect 

incident (NMED No. 100251 reported during the review period involving SS&D products 

registered in Louisiana). NMED No. 100251 was reviewed because the event description 

described a potential product defect. After reviewing the event with the SS&D reviewer, the 

review team determined this was event was not related to a product defect. While an NMED 

text search indicated several industrial radiography events, none was related to a 

product/equipment defect. 

The Department staff indicated that SS&D incidents were reviewed and followed up by the 

Senior Technical Advisor (DCLB). This individual left the Department in November 2011 and 

the person who is to assume these duties has not been identified at the time of the onsite 

review. The Department reported that there were no allegations received by the Department 

related to SS&D products registered in Louisiana during the review period. 

The review team recommends that all of the active sealed source and device registration 

commitments be located and made readily accessible by the State. 

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

agreed, that Louisiana’s performance with respect to the indicator, SS&D Evaluation Program, 

be found satisfactory, but needs improvement. 

4.3 Low-level Radioactive Waste Disposal Program

In 1981, the 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 LLRW as a separate 

category. Although the Louisiana Agreement State Program has LLRW disposal authority, the 

NRC has not required States to have a program for licensing a LLRW disposal facility until such 
Louisiana Final IMPEP Report Page 16 

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, they are expected to put in place a regulatory program which will meet the criteria for an 

adequate and compatible LLRW disposal program. There are no plans for a LLRW disposal 

facility in Louisiana. Accordingly, the review team did not review this indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0 above, Louisiana’s performance was found satisfactory for five 

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

the indicators, Compatibility Requirements, and the SS&D Evaluation Program. The review 

team made two recommendations regarding program performance by the State and determined 

that one recommendation from the 2008 IMPEP review should be closed and another should be 

kept open. Accordingly, the review team recommended, and the MRB agreed, that the 

Louisiana 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 4 years and that a periodic meeting be held in 18 to 24 months. 

Below are the review team’s recommendations, as mentioned in the report, for evaluation and 

implementation by the State: 

RECOMMENDATIONS 

1. The review team recommends that the Department evaluate its review processes and 

develop appropriate actions to ensure that products issued are of high technical quality 

and meet the standard expectations of the Department. (Section 3.4 and 4.2.2) 

2. The review team recommends that all of the active sealed source and device 

registration commitments be located and made readily accessible by the State. 

(Section 4.2.2)

3. The review team recommends that the State adhere to the document format and 

content guidance in current version NUREG-1556, Volume 3. (Section 4.2.2) (Kept 

open from the 2008 IMPEP review). 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Louisiana Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

Appendix F Sealed Source and Device Casework Reviews 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Bryan Parker, Region III Team Leader 

Technical Quality of Incident and Allegation 

Activities 

Michelle Beardsley, FSME Technical Staffing and Training 

 Status of Materials Inspection Program 

 Compatibility Requirements 

Robert Hays, Region III Technical Quality of Inspections 

 Inspector Accompaniments 

Rachel Browder, Region IV Technical Quality of Licensing Actions 

Michael Stephens, Florida Sealed Source and Device Evaluation Program 
APPENDIX B 

LOUISIANA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML120960347 
APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Cardinal Health 414, LLC License No.: LA-5115-L01 (AI# 128228) 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 11/17/11 Inspector: JF 

File No.: 2 

Licensee: Lafayette General Medical Center License No.: LA-5330-L01 (AI# 35788) 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 5/15/08 Inspector: JF 

File No.: 3 

Licensee: Qualitech Services, Inc. License No.: LA-6346-L01 (AI# 102655) 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 9/24/10 Inspector: JB 

File No.: 4 

Licensee: Southern Isotopes License No.: LA-10477-L01 (AI# 91705) 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 3/29/11 Inspector: JB 

File No.: 5 

Licensee: Savoy Technical Services, Inc. License No.: LA-11235-L01 (AI# 23431) 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 03/27/12 Inspector: JR 

File No.: 6 

Licensee: Abbeville General Hospital License No.: LA-0222-L01 (AI# 1586) 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/26/11 Inspector: AH 

File No.: 7 

Licensee: Christus St. Francis Cabrini Hospital License No.: LA-1121-L01 (AI# 55) 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 2/12/09 Inspector: JE 

File No.: 8 

Licensee: Louisiana State University License No.: LA-0001-L01 (AI# 5540) 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 2/17/12 Inspectors: MC, JN 

 
Louisiana Final IMPEP Report Page C.2 

Inspection Casework Reviews 

File No.: 9 

Licensee: H & H X-Ray License No.: LA-2970-L01 (AI# 30909) 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 2/29/12 Inspector: MC 

File No.: 10 

Licensee: Rapides Regional Medical Center License No.: LA-0350-L01 (AI# 2971) 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/16/09 Inspector: JE 

File No.: 11 

Licensee: Shiloh Contractors, Inc. License No.: LA-10254-L01 (AI# 128921) 

Inspection Type: Routine, Announced Priority: 4 

Inspection Date: 6/22/09 Inspector: JB 

File No.: 12 

Licensee: ICON-Industrial Control License No.: LA-10631-L01 (AI# 100040) 

Inspection Type: Routine, Announced Priority: 4 

Inspection Date: 7/23/09 Inspector: JG 

File No.: 13 

Licensee: Women’s and Children’s Hospital License No.: LA-10698-L01 (AI# 12296) 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 12/08/11 Inspector: AH 

File No.: 14 

Licensee: Pioneer Pharmacy License No.: LA-11301-L01 (AI# 174653) 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 05/12/11 Inspectors: MM, JR 

File No.: 15 

Licensee: Scientific Drilling International Inc. License No.: LA-10950-L01 (AI# 11373) 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/23/10 Inspector: JR 

File No.: 16 

Licensee: Northeast Louisiana Cancer Center License No.: LA-10206-L01 (AI# 36565) 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 4/13/11 Inspector: JG 

File No.: 17 

Licensee: Teche Regional Medical Center License No.: LA-0571-L01 (AI# 34247) 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 5/18/10 Inspector: JB 

 
Louisiana Final IMPEP Report Page C.3 

Inspection Casework Reviews 

File No.: 18 

Licensee: Acuren Inspection, Inc. License No.: LA- 7072-L01 (AI# 126755) 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 3/08/12 Inspector: JR 

File No.: 19 

Licensee: Combined Technical Services License No.: LA-7125-L01A (AI# 39006) 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 9/15/10 Inspector: KJ 

File No.: 20 

Licensee: Slidell Memorial Hospital License No.: LA-0783-L02 (AI# 2970) 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 2/24/10 Inspector: MM 

File No.: 21 

Licensee: Southern Valve Service, Inc. License No.: LA-10608-L01 (AI # 12340) 

Inspection Type: Routine, Unannounced Priority: 4 

Inspection Date: 11/29/11 Inspector: JR 

File No.: 22 

Licensee: Alliance Imaging, Inc. License No.: LA-10598-L01 (AI# 86657) 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 5/15/09 Inspector: KJ 

File No.: 23 

Licensee: Southeastern Louisiana University License No.: LA-2574-L01 (AI# 5101) 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 1/06/11 Inspector: MM 

File No.: 24 

Licensee: Gamma-Tron Services, Inc. License No.: LA-4895-L01 (AI# 38912) 

Inspection Type: Initial, Unannounced Priority: 2 

Inspection Date: 10/31/08 Inspector: RC 

File No.: 25 

Licensee: Louisiana State University License No.: LA-0001-L01 (AI# 5540) 

Inspection Type: Special, Announced Priority: 1 

Inspection Date: 2/14/12 Inspectors: MC, JN 

 
Louisiana Final IMPEP Report Page C.4 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Ochsner Clinic Foundation License No.: LA-0002-L01 (AI # 3043) 

Inspection Type: Routine, Announced/Special Priority: 1 

Inspection Date: 3/19/12 Inspector: GM 

Accompaniment No.: 2 

Licensee: Source Production and Equipment Co. License No.: LA-2966-L01 (AI# 38844) 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 3/20/12 Inspector: KJ 

Accompaniment No.: 3 

Licensee: Open Air MRI of Cen-LA License No.: LA-10218-L01 (AI# 156084) 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 3/21/12 Inspector: JE 

Accompaniment No.: 4 

Licensee: Capitol Ultrasonics License No.: LA-5838-L01 (AI# 12540) 

Inspection Type: Routine, Unannounced/Special Priority: 1 

Inspection Date: 3/22/12 Inspector: RC 

Accompaniment No.: 5 

Licensee: Weatherford License No.: LA-4413-L01 (AI# 127801) 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 3/23/12 Inspector: JF 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Code Inspection & Testing Co. South License No.: LA-12071-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 2/13/09 License Reviewer: JR 

File No.: 2 

Licensee: Desert Industrial X-Ray, LP License No.: LA-12285-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 4/26/10 License Reviewer: MB 

File No.: 3 

Licensee: Waggoner Services, Inc. License No.: LA-11860-L01 

Type of Action: New Amendment No.: 0 

Date Issued: 3/5/09 License Reviewer: BS 

File No.: 4 

Licensee: Louisiana State University License No.: LA-0001-L01 

Type of Action: Amendment Amendment No.: 37 

Date Issued: 4/14/10 License Reviewer: MB 

File No.: 5 

Licensee: Tulane University Health Sciences Center License No.: LA-0004-L01 

Type of Action: Renewal Amendment No.: 53 

Date Issued: 12/16/11 License Reviewer: KR 

Comment: 

 File contained insufficient information to follow reviewer’s determination process for 

 authorizing the licensing action. 

File No.: 6 

Licensee: LSU Health Sciences Center/Shreveport License No.: LA-0005-L01 

Type of Action: Renewal Amendment No.: 120 

Date Issued: 12/6/11 License Reviewer: KR 

Comment: 

 Radiation Safety Committee Chair was not authorized. 

 
Louisiana Final IMPEP Report Page D.2 

License Casework Reviews 

File No.: 7 

Licensee: Cardinal Health 414, Inc. License No.: LA-10217-L01 

Type of Action: Renewal Amendment No.: 24 

Date Issued: 4/24/08 License Reviewer: BS 

Comment: 

 Authorized U-235 in lieu of depleted uranium for shielding. 

File No.: 8 

Licensee: PETNET Solutions, Inc. License No.: LA-10505-L01 

Type of Action: Renewal Amendment No.: 22 

Date Issued: 10/22/09 License Reviewer: KR 

File No.: 9 

Licensee: Touro Infirmary License No.: LA-1198-L01 

Type of Action: Amendment Amendment No.: 36 

Date Issued: 8/5/11 License Reviewer: KR 

File No.: 10 

Licensee: Terrebonne General Medical Center License No.: LA-2762-L01 

Type of Action: Amendment Amendment No.: 52 

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

File No.: 11 

Licensee: Loyola University License No.: LA-0014-L01 

Type of Action: Termination Amendment No.: 26 

Date Issued: 10/16/08 License Reviewer: BS 

File No.: 12 

Licensee: Source Production & Equipment Company, Inc. License No.: LA-2966-L01 

Type of Action: Amendment Amendment No.: 59 

Date Issued: 2/8/11 License Reviewer: JR 

Comment: 

 File contained insufficient information to follow reviewer's determination process for 

 authorizing the licensing action. 

File No.: 13 

Licensee: Source Production & Equipment Company, Inc. License No.: LA-2966-L01 

Type of Action: Amendment Amendment No.: 61 

Date Issued: 3/11/11 License Reviewer: JR 

File No.: 14 

Licensee: Ochsner Medical Center Baton Rouge License No.: LA-5088-L01 

Type of Action: Amendment Amendment No.: 29 

Date Issued: 10/14/10 License Reviewer: KR 
Louisiana Final IMPEP Report Page D.3 

License Casework Reviews 

File No.: 15 

Licensee: Ochsner Medical Center - Kenner, LLC License No.: LA-5162-L01 

Type of Action: Amendment Amendment No.: 35 

Date Issued: 3/9/10 License Reviewer: KR 

File No.: 16 

Licensee: Sterling Sugars, Inc. License No.: LA-4665-L01 

Type of Action: Amendment Amendment No.: 11 

Date Issued: 5/20/10 License Reviewer: BS 

File No.: 17 

Licensee: Mary Bird Perkins Cancer Center License No.: LA-2651-L01 

Type of Action: Amendment Amendment No.: 89 

Date Issued: 7/5/11 License Reviewer: KR 

Comment: 

 Authorized two medical physicists based on ABR computer generated oral board results 

in lieu of the ABR board certificate. 

File No.: 18 

Licensee: Women's Hospital Foundation License No.: LA-2338-L01 

Type of Action: Amendment Amendment No.: 27 

Date Issued: 8/16/10 License Reviewer: MB 

File No.: 19 

Licensee: Mary Bird Perkins Cancer Center License No.: LA-2651-L01 

Type of Action: Amendment Amendment No.: 90 

Date Issued: 11/1/11 License Reviewer: KR 

File No.: 20 

Licensee: Lake Charles Memorial Hospital License No.: LA-0575-L01 

Type of Action: Renewal Amendment No.: 68 

Date Issued: 6/24/10 License Reviewer: MB 

File No.: 21 

Licensee: Warrior Energy Services Corp. License No.: LA-10011-L01 

Type of Action: Renewal Amendment No.: 16 

Date Issued: 3/31/10 License Reviewer: BS 

File No.: 22 

Licensee: BioLab Facility License No.: LA-10387-L01 

Type of Action: Renewal Amendment No.: 4 

Date Issued: 3/4/09 License Reviewer: BS 

 
Louisiana Final IMPEP Report Page D.4 

License Casework Reviews 

File No.: 23 

Licensee: Kiewit Louisiana Company License No.: LA-12214-L01 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 11/4/10 License Reviewer: MB 

File No.: 24 

Licensee: Seaboard Wireline, Inc. License No.: LA-11728-L01 

Type of Action: Termination Amendment No.: 3 

Date Issued: 2/20/09 License Reviewer: BS 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Mary Bird Perkins Cancer Center License No.: LA-2651-L01 

Date of Incident: 12/23/08 NMED No.: 090094 

Investigation Date: 1/15/09 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 2 

Licensee: Hill Brothers Construction License No.: MS-520-01 

Date of Incident: 3/26/09 NMED No.: 090407 

Investigation Date: 3/31/09 Type of Incident: Damaged Portable Gauge 

 Type of Investigation: Site 

File No.: 3 

Licensee: Cameron Valves & Measurement License No.: LA-7095-L01 

Date of Incident: 7/28/09 NMED No.: 090689 

Investigation Date: 7/31/09 Type of Incident: Radiography Source Disconnect 

 Type of Investigation: Site 

File No.: 4 

Licensee: Accurate NDE & Inspection License No.: LA-10207-L01 

Date of Incident: 7/31/09 NMED No.: 090751 

Investigation Date: 9/25/09 Type of Incident: Personnel Overexposure 

 Type of Investigation: Site 

File No.: 5 

Licensee: Westlake Polymers, LLC License No.: LA-5404-L01 

Date of Incident: 12/07/09 NMED No.: 100043 

Investigation Date: 12/10/09 Type of Incident: Fixed Gauge Shutter Failure 

 Type of Investigation: Site 

File No.: 6 

Licensee: Mary Bird Perkins Cancer Center License No.: LA-2651-L01 

Date of Incident: 3/12/10 NMED No.: 100219 

Investigation Date: 5/28/10 Type of Incident: Medical Event 

 Type of Investigation: Site 

File No.: 7 

Licensee: Accurate NDE & Inspection License No.: LA-10207-L01 

Date of Incident: 12/01/11 NMED No.: 120154 

Investigation Date: 3/05/12 Type of Incident: High Dosimeter Result 

 Type of Investigation: Site 

File No.: 8 

Licensee: Shaw Sunland Fabricators, Inc. License No.: LA-3462-L01 

Date of Incident: 3/15/12 NMED No.: 120184 

Investigation Date: 3/16/12 Type of Incident: Facility Fire 

 Type of Investigation: Site 
 

APPENDIX F 

SEALED SOURCE AND DEVICE CASEWORK REVIEWS 

File No: 1 

Registry No: LA-612-D-114-S SS&D Type: (A) Industrial Radiography 

Date Issued: 11/25/09 Type of Action: Amendment 

Distributor: Source Production & Equipment Company, Inc. Reviewers: JP, JR 

Type of Device: Industrial Radiography Source Assembly 

Model Number: G-80 Series, G-80 548 Series, G-80 741 Series 

Comments: 

a) Review and concurrence date 11/25/09 does not agree with Page 1 date of 10/26/09 as 

the format described in NUREG 1556 Vol 3 Rev.1 Appendix D. 

b) Leak test frequency on Page 1 indicates testing “During fabrication final inspection, then 

every six months” instead of “Six months.” Does not follow format described in 

NUREG 1556 Vol 3 and comments regarding leak testing during the manufacturing 

process belong in the Quality Control and Quality Assurance Section. 

c) Document dated 1/24/2000 in reference section could not be located. 

d) Document listed in the reference section as “letter dated September 29, 2009” is actually 

dated 9/28/09. The document was received on 9/29/09. 

File No: 2 

Registry No: LA-0612-D-111-S SS&D Type: (A) Industrial Radiography 

Date Issued: 1/11/11 Type of Action: Amendment 

Distributor: Source Production & Equipment Company, Inc. Reviewers: JP, AT 

Type of Source: Radiographic Exposure Device. 

Model Number: SPEC 150 

Comments: 

a) Issuance date of 1/18/11 on signature page 10 does not agree with the page 1 date of 

1/11/11 as described in NUREG 1556 Vol 3 Rev.1 Appendix D. 

b) Document listed in the reference section as “letter dated November 04, 2010” is actually 

dated 10/4/10. The document was received on 11/4/10. 

c) NRC SS&D website does not list this 1/11/11 revision. This revision was not identified 

on the IMPEP questionnaire. 

 
Louisiana Final IMPEP Report Page F.2 

Sealed Source and Device Casework Reviews 

File No: 3 

Registry No: LA-0612-S-116-S SS&D Type: (AA) Manual Brachytherapy 

Date Issued: 6/25/09 Type of Action: NEW 

Applicants Name: Source Production & Equipment Company, Inc. Reviewers: JR, JP 

Type of Device: Brachytherapy Source 

Model Number: SPEC Model M-31 

Comments: 

a) Issuance and concurrence date 6/29/09 does not agree with Page 1 date of 6/25/09 as 

the format described in NUREG 1556 Vol 3 Rev.1 Appendix D. 

b) Limitations section use uses the word “should” in items 3, 5, 6, and 7 instead of “shall” 

which places the limitation on the use. 

c) A statement that the sources are sent as non-sterile needs to be added to the 

“Limitations” section along with a statement to that they shall follow the manufacturer’s 

instructions for sterilization and list with the maximum temperature and pressure. 

d) The reference section does not include the phrase that “The following supportive 

documents are hereby incorporated by reference and are made part of this registry 

document.” As described in NUREG 1556 Vol 3 Rev.1 Appendix D. 

e) Details not provided on the manufacturer’s instrumentation used, its calibration or 

procedures followed to determine the activity of Ytterbium 169. 

File No: 4 

Registry No: LA-1281-D-801-S SS&D Type: (AC) Photon-emitting Remote Afterloader 

Date Issued: 7/21/09 Type of Action: Inactive Amendment 

Distributor: Oncology Systems Reviewers: JR, AT 

Type of Device: Remote Afterloading Brachytherapy Unit 

Model Number: AccuSource 1000 

Comment: 

The first page information section of the registration incorrectly indicates the use as “(V) 

General Medical” instead of “(AC) Photon-emitting Remote Afterloaders” and the FDA 

Approval Summary was not included in the registration. 

File No: 5 

Registry No: LA-612-D-106-S SS&D Type: (A) Industrial Radiography 

Date Issued: 10/21/10 Type of Action: Amendment 

Distributor: Source Production & Equipment Company, Inc. Reviewers: JR, JP 

Type of Device: Industrial Radiography Source Assembly 

Model Number: “T” Series 

Comments: 

a) Concurrence date 11/16/10 is past the 10/21/09 date identified on Page 1 and the 

signature page. 
Louisiana Final IMPEP Report Page F.3 

Sealed Source and Device Casework Reviews 

b) The first page information section of the registration incorrectly indicates the use as 

Industrial Radiography” instead of “(A) Industrial Radiography” as required by NUREG 

1556 Vol 3 Rev. 1. 

c) The External Radiation Level Section does not provide measured or calculated radiation 

levels of a for each isotope with the maximum activity allowed at distances of 0, 5, 30 

and 100 centimeters as described in NUREG 1556 Vol 3 Rev.1. 

d) Multiple documents between 1988 and 1994 listed in the reference section that are 

incorporated by reference could not be located. 

File No: 6 

Registry No: LA-612-D-105-S SS&D Type: (A) Industrial Radiography 

Date Issued: 10/21/10 Type of Action: Amendment 

Distributor: Source Production & Equipment Company, Inc. Reviewers: JR, JP 

Type of Device: Industrial Radiography Source Assembly 

Model Number: “G” Series 

Comments: 

a) Issuance date of 10/21/10 on signature page 6 does not agree with the page 1 date of 

10/18/10 as described in NUREG 1556 Vol 3 Rev.1 Appendix D. 

b) The concurrence date 11/16/10 is past the issuance date 10/21/10 on page 1. 

c) The External Radiation Level Section does not provide measured or calculated radiation 

levels of a for each isotope with the maximum activity allowed at distances of 0, 5, 30 

and 100 centimeters as described in NUREG 1556 Vol 3 Rev.1. 

d) Multiple documents between 1979 and 1995 listed in the reference section that are 

incorporated by reference, to include the original application and deficiency replies could 

not be located. 

e) Applicant submitted the following revisions that were reviewed and approved but were 

not added to the Reference Section. Registration Application Revision (1) dated 

10/1/96, letter dated 3/25/97. The amendment in its entirety did not incorporate changes 

and remove outdated procedures as required by NUREG 1556 Vol 3 Rev. 1. 

File No: 7 

Registry No: LA-0577-S-802-S SS&D Type: (AA) Manual Brachytherapy 

Date Issued: 6/10/08 Type of Action: Inactivation Amendment 

Distributor: RADS S.L., Inc. Reviewers: JP, AT 

Type of Source: Brachytherapy Source 

Model Number: SL-77HS 

Comment: 

a) The first page information section of the registration still incorrectly indicates the use as 

“(V) General Medical” instead of “(AA) Manual Brachytherapy.” While this is an 

inactivation, NUREG 1556 Vol 3 Rev.1 requires inactivation to formatted to standards 

and contain the most current and correct information. 

b) Page 1 list the isotope as “Iridium-I 92” instead “Iridium-192.” 
Louisiana Final IMPEP Report Page F.4 

Sealed Source and Device Casework Reviews 

c) The incorporated by reference letter dated 5/25/88 in the Reference Section could not be 

found. 

File No: 8 

Registry No: LA-612-D-102-U SS&D Type: (A) Industrial Radiography 

Date Issued: 5/5/08 Type of Action: Amendment 

Distributor: Source Production & Equipment Company, Inc. Reviewers: JP, AT 

Type of Device: Industrial Radiography Source Changer 

Model Number: C-1 

Comments: 

a) The SS&D number in the header section contains the designation “U” for unknown 

license type. This designation should have been changed to “S” for specific license 

when the registry was amended in its entirety. 

b) The first page information section of the registration incorrectly indicates the use as 

Industrial Radiography” instead of “(A) Industrial Radiography” as required by NUREG 

1556 Vol 3 Rev. 1 

c) The reference section does not include the phrase that “The following supportive 

documents are hereby incorporated by reference and are made part of this registry 

document.” as described in NUREG 1556 Vol 3 Rev.1 Appendix D. 

 File No: 9 

Registry No: LA-612-S-806-S SS&D Type: (AC) Photon-emitting Remote Afterloader 

Date Issued: 10/7/08 Type of Action: Inactive Amendment 

Distributor: Source Production & Equipment Company, Inc. Reviewers: JP, AT 

Type of Device: Brachytherapy Source 

Model Number: SPEC Model M-19 Source Assembly 

Comment: 

a) The issuance and concurrence date 10/7/08 does not agree with Page 1 date of 8/7/09 

as the format described in NUREG 1556 Vol 3 Rev.1 Appendix D. 

b) The reference section does not include the phrase that “The following supportive 

documents are hereby incorporated by reference and are made part of this registry 

document.” as described in NUREG 1556 Vol 3 Rev.1 Appendix D. 
 

ATTACHMENT(S) 

June 25, 2012 Letter from Tim B. Knight 

Louisiana Response to the Draft Report 

ADAMS Accession No.: ML12178A015