UNITED STATES

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

April 23, 2014 

Nathaniel Smith, M.D., MPH 

Director and State Health Officer

Arkansas Department of Health 

4815 West Market Street 

Little Rock, AR 72205-3867 

Dear Dr. Smith: 

On April 1, 2014, the Management Review Board (MRB) met to consider the proposed final 

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

Agreement State Program. The MRB found the Arkansas program adequate to protect public 

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

program. 

Section 5.0, page 15 of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. The review team made three recommendations regarding the 

performance of the State. The review team determined that the recommendation from the 2011 

follow-up IMPEP regarding tracking the status of license actions reviews was addressed by the 

Program and should be closed. Based on the results of the current IMPEP review, the next full 

review of the Arkansas Agreement State Program will take place in approximately 4 years, with 

a periodic meeting tentatively scheduled for October 2015. 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. 
Dr. Smith -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: 

Arkansas Final IMPEP Report 

cc: Earl Fordham, Washington 

 Organization of Agreement States 

 Liaison to the MRB 

 Jared Thompson, Program Manager 

 Radiation Control Section 
Dr. Smith -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: 

Arkansas Final IMPEP Report 

cc: Earl Fordham, Washington 

 Organization of Agreement States 

 Liaison to the MRB 

 Jared Thompson, Program Manager 

 Radiation Control Section 

DISTRIBUTION: (SP08) 

See next page 

ML14097A167 

OFC ASPB/MSSA

: TL ASPB/MSSA ASPB:BC MSSA: D TechEd FSME:D EDO/DEDMRT 

NAME JKatanic via 

email 

LDimmick 

w/edits 

DWhite LDudes CPoland BHolian 

(MShaffer for) 

MWeber 

DATE 04/08/14 04/09/14 04/10/14 04/21/14 04/21/14 04/21/14 04/23/14

OFFICIAL RECORD COPY 
Letter to Dr. Smith from Michael F. Weber dated: April 23, 2014 

SUBJECT: ARKANSAS FY2014 FINAL IMPEP REPORT 

DISTRIBUTION: (SP08) 

RidsEdoMailCenter 

JFoster, OEDO 

RidsFsmeOd 

RidsOgcMailCenter 

PMoulding, OGC 

RidsRgn1MailCenter 

DLew, RI 

RidsRgn4MailCenter 

LHowell, RIV 

AVegel, RIV 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

RidsFsmeMssa Commissioner Svinicki 

JMoses, MSSA Commissioner Apostolakis 

RErickson, RIV/RSAO Commissioner Magwood 

BTharakan, RIV Commissioner Ostendorff 

MHammond, RIV SECY 

SRodriguez, NM 

MBeardsley, MSSA 

BBevill, AR 

DSmith, AR 

RMallory, AR 

JWeil, OCA (2 copies)
Enclosure 1 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE ARKANSAS AGREEMENT STATE PROGRAM 

OCTOBER 28–NOVEMBER 1, 2013 

FINAL REPORT 
EXECUTIVE SUMMARY 

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

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

the period of October 28–November 1, 2013, by a review team composed of technical staff 

members from the U.S. Nuclear Regulatory Commission (NRC) and the State of New Mexico. 

Based on the results of this review, the review team recommended, and the Management 

Review Board (MRB) agreed, that Arkansas’ performance be found satisfactory, but needs 

improvement for the indicator Technical Quality of Licensing Actions, and satisfactory for the 

remaining indicators reviewed. 

The review team found that the recommendation from the 2011 follow-up IMPEP review 

regarding tracking the status of license actions reviews to ensure timely completion was 

addressed by the Program and can be closed. 

Based on this review, the review team made three recommendations regarding the performance 

of the Arkansas Agreement State Program. These recommendations, which are briefly 

described below, included areas for improvement to correct identified performance deficiencies 

and weaknesses in Arkansas’ Agreement State Program. The review team recommends that 

the State: (1) provide refresher training to the inspection staff on the inspection procedures and 

incorporate the inspection procedures into the training and qualification program for inspectors 

to ensure consistent implementation during inspections; (2) revise its licensing procedures to 

include current guidance to determine and document the basis of confidence for all new 

applications and transfers of control that radioactive materials will be used as intended, prior to 

authorizing the material on the license; and provide staff with training on the process and 

changes to the Program’s licensing procedures; and (3) strengthen its incident response 

program by developing guidance and providing training to the staff on evaluating and 

responding to reported medical events. 

The review team recommended, and the MRB agreed, that the Arkansas 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 a Periodic Meeting be 

held in 2 years and that the next IMPEP review take place in approximately 4 years. 
Arkansas Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

onsite portion of the review was conducted during the period of October 28–November 1, 2013, 

by a review team composed of technical staff members from the U.S. Nuclear Regulatory 

Commission (NRC) and the State of New Mexico. 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 the 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 October 31, 2009, to October 27, 

2013, were discussed with Arkansas managers on the last day of the review. Subsequent to 

the exit meeting, the review team reconvened to discuss and reconsider the preliminary results 

of the review. The review team’s revised recommendations were discussed with the 

Radioactive Materials Program Manager on December 12, 2013. 

A draft of this report was provided to Arkansas for factual comment on February 21, 2014. The 

State responded to the findings and conclusions by email dated March 21, 2014. A copy of the 

State’s response is included as an Attachment to this report along with a comment resolution 

document. A Management Review Board (MRB) met on April 1, 2014, to consider the proposed 

final report. The MRB found the Arkansas Agreement State Program adequate to protect public 

health and safety, and compatible with the NRC’s program. 

The Arkansas Agreement State Program is administered by the Radioactive Materials Program 

(the Program). The Program is one of three organizations within the Radiation Control Section, 

which is part of the Health Systems Licensing and Regulation Branch. The Health Systems 

Licensing and Regulation Branch is part of the Center for Health Protection, which is within the 

Arkansas Department of Health (the Department). The Director of the Department is the State 

Health Officer, who reports to the Governor. Organizational charts from the Governor’s office 

down to the Program office are included as Appendix B. 

At the time of the review, the Arkansas Agreement State Program regulated 198 specific 

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

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

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

Arkansas. 

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

non-common performance indicators was sent to the Program on June 26, 2013. The Program 

provided its response to the questionnaire, which was received by the NRC via mail on 

October 3, 2013, with supplemental information provided by the Program to the NRC in an 

October 24, 2013 email. Publicly available versions of the questionnaire response and 

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

Management System (ADAMS) using the Accession Numbers ML13276A186 and 

ML13301A002, respectively. 

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

the Program’s response to the questionnaire, (2) review of applicable Arkansas statutes and 
Arkansas Final IMPEP Report Page 2 

regulations, (3) analysis of quantitative information from the Program’s databases, (4) technical 

review of selected regulatory actions, (5) field accompaniments of five inspectors; and 

(6) interviews with Program 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 Arkansas Agreement State 

Program’s performance. 

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

during previous reviews. Results of the review for 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 

and recommendations. 

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on October 30, 2009, the review team 

made four recommendations regarding Program performance. All four of the recommendations 

were reviewed and closed during the follow-up IMPEP, which concluded on April 8, 2011. The 

review team for the follow-up IMPEP made one recommendation regarding Program 

performance. The status of the recommendation is as follows. 

Recommendation: “The review team recommends the State develop and implement a method 

for tracking the status of license actions reviews to ensure timely completion. (Section 2.3 of 

the 2011 follow-up IMPEP Report)” 

Status: The Program developed databases and procedures to track the status of licensing 

actions and have successfully eliminated the licensing action backlog. Incoming licensing 

actions for license amendment requests are entered in a database by the Program’s 

Administrative Specialist. Amendment requests are tracked by licensee, receipt date, assigned 

Program staff, and other pertinent information. Applications for new licenses and license 

renewals are also tracked by the Program Manager in a database that includes licensee, receipt 

date, assigned Program staff, and other pertinent information. The review team evaluated the 

Program’s actions to implement a tracking method and found it to be effective in preventing a 

recurrence of a backlog in licensing actions, including amendment requests and renewals. At 

the time of the review, there were seven pending renewals, five of which were received during 

2013. The remaining two pending licensing renewals were received in 2008 and the Program 

was actively taking measures to process these renewals. The review team verified the 

Program’s database capabilities, staff responsibilities, and procedures to track the status of 

licensing actions to prevent a reoccurrence of a backlog in licensing. This recommendation is 

closed. 

3.0 COMMON PERFORMANCE INDICATORS 

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

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

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

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

3.1 Technical Staffing and Training

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

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

considered any workload backlogs. 

Full staffing of the Program consists of the Program Manager, six Health Physicists, and one 

administrative staff member. Five of the Health Physicists perform licensing, inspection, and 

incident response duties, as well as emergency response activities related to the nuclear power 

plant in the State. The sixth Health Physicist works primarily on regulations but also drafts 

information notices, issues Department of Transportation permits, responds to certain events, 

and works on radon issues. At the time of the review, the Program had caught up on its 

long-existing backlog of licensing renewals, so the two part-time consultants previously used to 

assist with licensing actions and special projects are rarely called upon to assist the Program. 

The review team determined that the number of staff in the Program is sufficient based on the 

Program’s current and projected workloads. 

The Program 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 

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

Material Safety and Safeguards Program Area.” All Program Health Physicists have Bachelor’s 

degrees or equivalent work experience. Qualification is achieved through a combination of 

education and experience, formal classroom training, 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 Program’s training program is adequate to carry out its 

regulatory duties and noted that Program management strongly supports training opportunities. 

The review team also discussed with the Program manager the April 19, 2013, publication of 

NRC’s IMC 1248, “Qualification Programs for Federal and State Materials and Environmental 

Management Programs.” The Program’s implementation of the training and qualification 

requirements described in IMC 1248 will be reviewed during the next IMPEP review. 

While all but one of the Health Physicists are considered fully qualified, as described in 

subsequent sections of this report, the review team identified an area for improvement regarding 

the familiarity of the Program staff with the inspection procedures when performing inspections. 

The review team recommends that the State provide refresher training to the inspection staff on 

the inspection procedures and incorporate the inspection procedures into the training and 

qualification program for inspectors to ensure consistent implementation during inspections. 

In addition to core training courses, the Department implemented an increased salary grid 

consisting of three tiers. To progress through the salary grid, staff members are required to be 

in service to the Department for a specific number of years, must take additional advanced NRC 

and FEMA training, and have satisfactory performance evaluations. The effectiveness of the 

salary grid was reviewed in June 2012 by the Committee on Uniform Personnel Classification 

and Compensation of the Department’s Office of Personnel Management and has been 

approved to continue. 
Arkansas Final IMPEP Report Page 4 

During the previous review period, the Program experienced a high attrition rate with six staff 

leaving and six others being hired to fill those positions. The Program also had one vacancy at 

the time of the previous review. During the current review period, staffing had stabilized. The 

vacancy during the previous review was filled and the Program has not experienced any 

additional staff losses. Since the last review, the program implemented a general increase in 

salary, provided staff with new opportunities through an advanced training plan, and senior 

management is directly involved with the staff in the general day-to-day operations of the 

Program. 

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

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

found satisfactory.

3.2 Status of Materials Inspection Program

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

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

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

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

Program’s database, examination of completed inspection casework, and interviews with the 

Program Manager and staff. 

The review team verified that Arkansas’ 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.” 

During the review period, the Program conducted a total of 137 routine inspections of Priority 1, 

2, and 3 licensees. Of these 137 inspections, the review team identified two inspections that 

were conducted overdue by more than 25 percent of the inspection frequency prescribed by IMC 

2800. The two overdue inspections were conducted 13 days and 133 days beyond the required 

timeframe. The review team did not identify any Priority 1, 2, or 3 inspections that were overdue 

for inspection at the time of the review. The review team also evaluated the Program’s 

timeliness for conducting initial inspections. As required by IMC 2800, initial inspections shall be 

completed within 12 months of license issuance. The Program conducted 20 initial inspections 

during the review period. The review team verified that the Program performed all 20 initial 

inspections within 12 months, and there were no overdue initial inspections at the time of the

review. Overall, the review team calculated that the Program performed 1.3 percent of all Priority 

1, 2, and 3, and initial inspections overdue during the review period. 

The review team evaluated the Program’s timeliness of issuance of inspection findings. The 

Program’s policy is that licensees are made aware of the inspectors’ preliminary findings at the 

conclusion of the inspection. The Program has a goal of issuing inspection findings letters to 

licensees within 30 days of the final date of the inspection. Of the 25 inspection reports 

reviewed, four reports were issued greater than 30 days after the inspection. These letters were 

issued within 18 days beyond the 30-day goal. 

During the review period, the Program granted 65 reciprocity licenses that were candidates for 

inspection based upon the criteria in IMC 1220, “Processing of NRC Form 241 “Report of 
Arkansas Final IMPEP Report Page 5 

Proposed Activities in Non-Agreement States, Areas of Exclusive Federal Jurisdiction, and 

Offshore Waters,” and Inspection of Agreement State Licensees Operating under 10 CFR 

150.20.” In accordance with IMC 1220, onsite inspection is required of 20 percent of candidate 

licensees operating under reciprocity. The review team determined that the Program 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 Arkansas’ performance with respect to the indicator, Status of Materials Inspection 

Program, be found satisfactory. 

3.3 Technical Quality of Inspections

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

notes, and interviewed inspectors for 26 radioactive materials inspections conducted during the 

review period. The casework examined included a representative sample of inspections 

conducted by five current inspectors and covered a wide variety of inspection types involving 

initial and routine inspections. The casework reviewed included the following license types: 

industrial radiography, self-shielded irradiator, service provider, positron emission tomography, 

high dose-rate remote after loader, nuclear pharmacy, diagnostic nuclear medicine, portable 

gauge, panoramic irradiator, and reciprocity licensees. The review also included initial and 

follow-up Increased Controls inspections. Appendix C lists the inspection casework files 

reviewed. 

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

covered all aspects of the licensees’ radiation safety and security programs. The review team 

noted that inspection records were thorough, complete, consistent, and of sound quality with 

sufficient documentation to ensure that licensees’ performances with respect to health, safety, 

and security were acceptable. The review team noted that inspectors were conducting 

confirmatory reviews of source inventories in the National Source Tracking System for affected 

licensees. Inspection record documentation supported identified violations and 

recommendations made to licensees, and also described unresolved safety issues. 

The review team evaluated the Program’s handling and storing of sensitive documents. The 

review team determined that documents containing sensitive information were maintained and 

secured in a locked file cabinet, segregated from non-sensitive document files, with access 

limited to staff with a need to know. The review team determined that these files were not 

subject to Freedom of Information Act-equivalent State law and verified that staff handling the 

files was aware of the sensitive information and its special handling requirements associated 

with these licensees. 

The Program has a policy and associated procedure for performing supervisory 

accompaniments of inspectors. The review team verified that the Program Manager 

conducted supervisory accompaniments of all of the staff at least annually for two of the 

years covered by the review period. The review team noted that for the other two years 

covered by the review period, one inspector was not accompanied during 2011 and one 

inspector was not accompanied during 2012. 
Arkansas Final IMPEP Report Page 6 

The Program possesses a variety of calibrated survey instruments used to support the 

inspection program and to respond to radioactive materials incidents and allegations. The 

Program sends all survey instruments to the manufacturer for calibration on an annual basis. 

At the time of the review, instruments that were out of calibration were segregated from 

calibrated survey equipment. The Program’s policy states that the Arkansas Radioactive 

Materials Program utilizes the Arkansas Department of Health Radiochemistry Laboratory to 

perform sample counting and assay services, as needed. 

Accompaniments of five Program inspectors were conducted during the weeks of August 19, 

2013, and September 9, 2013. The inspectors were accompanied during health and safety 

inspections of the following types of licensees: nuclear pharmacy; well logging; panoramic 

irradiator; industrial radiography; medical-written directives required; and broad scope, which 

included high dose rate remote afterloader, stereotactic radiosurgery, and unsealed radioactive 

material therapy. Three of the inspections included a review of the licensee’s implementation of 

the Increased Controls and Fingerprinting requirements. The inspections selected were for 

licensed activities that each respective inspector was fully qualified to inspect. The 

accompaniments and associated comments are identified in Appendix C. 

With one exception, the inspectors were well-prepared for the inspections, demonstrated 

knowledge of the licensed activities, and were familiar with the applicable regulations. During 

one accompaniment inspection, the inspector was not adequately prepared for the inspection, 

was not sufficiently familiar with the licensed activity, and was not sufficiently familiar with the 

regulatory requirements for the licensed activity. The inspector demonstrated poor health 

physics practices by entering the cell of a panoramic irradiator without performing a radiation 

survey but instead relying on an alarming dose rate meter. It was observed during the 

inspection that the inspector did not have an appropriate focus on risk-significant health and 

safety matters. It was further observed that the inspector was not following an inspection 

procedure for this type of inspection and was relying on the inspection notes from the previous 

inspection of the facility as a guide to conduct the current inspection, resulting in items important 

to health and safety not being addressed. The Program took swift action and removed the 

individual from performing inspections independently until performance is further evaluated. 

The Program has inspection report forms for several inspection activities (i.e. medical, portable 

and fixed gauge, radiography, etc.), but not for all of the activities that the Program regulates 

(i.e. panoramic irradiators, specific therapeutic modalities). The forms do not contain specific 

inspection guidance for the conduct of inspections. This was discussed with the Program 

Manager, who stated that the expectation was that Program staff use NRC’s inspection 

procedures, but staff did not demonstrate knowledge of this expectation. The Program’s 

procedure RAM-01.10, “Inspection of Radioactive Materials,” provides a general overview of the 

Arkansas inspection program and the general conduct of inspections. However, the procedure 

did not document the Program Manager’s expectations that the NRC inspection procedures be 

used for the conduct of inspections. During the IMPEP, the Program Manager addressed this 

concern and revised procedure RAM-01.10 to clearly articulate that the NRC inspection 

procedures should be used as guidance to perform inspections and also included a link to the 

NRC’s web page for inspection procedures. Language was also added to RAM-01.10 regarding 

the NRC’s inspection procedure for the performance of Increased Controls inspections. 
Arkansas Final IMPEP Report Page 7 

During the exit meeting at the conclusion of the onsite IMPEP review, the team recommended 

that Arkansas’ performance with respect to this indicator, be found satisfactory, but needs 

improvement. The team also recommended that the State provide additional training to the 

inspection staff on the inspection procedures and incorporate them into their training and 

qualification program to ensure consistent implementation during inspections. The team 

discussed and agreed that this finding was appropriate based on several considerations, 

including: staff lack of awareness of the Program’s expectations with respect to the use of 

inspection procedures; observations made during an IMPEP accompaniment inspection at a 

high risk significance licensed activity, when items important to health and safety were not 

adequately addressed; an observed misunderstanding of the role of the regulatory authority in 

inspecting broad scope licensees; and during two years of the review, not all inspectors were 

accompanied by the Program Manager. At the exit meeting, the State disagreed with the 

team’s finding. 

Subsequent to the exit meeting, the team reconsidered the initial finding and it was determined 

that a finding of satisfactory was more appropriate for this indicator. In revising its finding, the 

team considered that the observations made during one inspector accompaniment that 

demonstrated poor performance was indicative of one inspector’s performance, and the 

Program subsequently took actions to address these performance issues. Although some 

performance issues were observed during other accompaniment inspections, the inspector 

performance was of generally acceptable quality. Furthermore, the Program revised its policies 

to document its expectations regarding the use of inspection procedures. After additional 

discussion amongst the team, it was concluded that the finding should be changed to 

satisfactory. The team agreed that the recommendation regarding additional training on the 

inspection procedures should remain, but that the recommendation would be more appropriate 

if included under the indicator, Technical Staffing and Training. These changes were discussed 

with the Radioactive Materials Program Manager on December 12, 2013. 

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

that Arkansas’ performance with respect to the indicator, Technical Quality of Inspections, be 

found satisfactory. 

3.4 Technical Quality of Licensing Actions

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

for 18 specific licensing actions. Licensing actions were reviewed for completeness, 

consistency, proper radioisotopes and quantities, security basis for confidence that radioactive 

material will be used as appropriate, qualifications of authorized users, adequacy of facilities 

and equipment, marking of security related documents, financial assurance, operating and 

emergency procedures, appropriateness and consistency of license conditions, and overall 

technical quality. The casework was also reviewed for timeliness, use of appropriate 

correspondence, references to appropriate regulations, application of the most recent licensing 

guidance, supporting documentation, pre-licensing visits, peer or supervisory review, and proper 

signatures. 

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

completed during the review period. Licensing actions selected for evaluation included: four 

new licenses; three renewals; nine amendments; and two terminations. Files reviewed included 
Arkansas Final IMPEP Report Page 8 

a cross-section of license types: industrial radiography, medical diagnostic, medical therapy 

including permanent implant brachytherapy and stereotactic radiosurgery, nuclear pharmacy, 

broad scope, and industrial gauging licensees. The casework sample included technical 

reviews performed by each of the license reviewers, including licensing work performed by the 

two contract employees. A listing of the licensing casework reviewed, with case-specific 

comments, is provided in Appendix D. 

Licensing actions are all tracked via two databases. The information is entered into a primary 

database by the administrative staff upon receipt, and then the Program Manager enters the 

same information in a separate database and assigns the licensing action. This provides the 

Program Manager with a way to separately track and confirm that licensing actions are being 

completed in a timely manner by the reviewer. There was no backlog of amendment requests 

or new applications at the time of the review. The staff responds to new applications, 

amendment requests, and renewals within 10 business days, and issues completed licensing 

actions within 30 to 45 days. Three license evaluators have signature authority for licensing 

actions. The Program Manager performs a technical and supervisory review on all licensing 

actions before issuance to the licensee. Licenses are issued for a 7 year period under a timely 

renewal system. 

The review team evaluated the Program’s application of the State’s financial assurance 

requirements. At the time of the review, the Program had one licensee that was authorized for 

possession of radioactive material in excess of the quantities requiring financial assurance, and 

one licensee with a pending renewal that still needed to submit financial assurance. The review 

team verified that the proper financial assurance documentation was on file and that the 

information was appropriately protected. 

With some exceptions, the review team found that licensing actions were complete with health 

and safety issues properly addressed. During the review period, the license reviewers were 

thorough in identifying deficiencies in licensing action requests and preparing requests for 

additional information from licensees; however, the review team found instances where the 

responses received from the licensees were not adequately reviewed for accuracy and 

completeness and licensing actions were subsequently issued. In one case, a licensee 

submitted operating and emergency procedures that included operating and emergency 

procedures for off-shore operations, and these procedures were approved by the Program as 

tie-down conditions without being reviewed. In another case, a licensee submitted sealed 

source information to be added to the license, but the model and manufacturer number were not 

included in the possession authorization, and the license was issued without a model 

designation. In another case file reviewed, a license was amended to remove a permanent 

storage location; however, the licensing case file did not include justification for removing the 

location from the license, such as radiation surveys or leak test records. In another case, the 

Operating and Emergency procedures tied-down as a license condition did not reflect the 

correct model number of the device authorized by the license. In discussing the issues with the 

Program, the Program and team attributed the quality issues to the Program’s extensive effort to 

eliminate the licensing backlog initiative. 

The review team assessed the program’s implementation of pre-licensing guidance. The 

Program’s practice is to prepare the license and subsequently hand-deliver the license during 

an onsite visit. The review found that several case files including four new licenses and one 
Arkansas Final IMPEP Report Page 9 

change of ownership did not have the documentation to support a basis of confidence that the 

radioactive material would be used as requested. In addition, the Program’s procedure for 

conducting such reviews predates RCPD-08-20, “Requesting Implementation of the Checklist to 

Provide a Basis for Confidence that Radioactive Material will be Used as Specified on a License 

and the Checklist for Risk-Significant Radioactive Material (RSRM),” issued on September 22, 

2008, and the onsite visits alone do not meet the objective of establishing if an entity is 

“unknown” and do not support a basis of confidence that the radioactive material will be used as 

requested. The license reviewers were not following the Program’s procedures on pre-licensing 

guidance and were unaware of the most current guidance (RCPD-08-020). Therefore, the 

review team recommends the Program revise its licensing procedures to include the current 

guidance to determine and document the basis of confidence for all new applications and 

transfers of control that radioactive materials will be used as intended, prior to authorizing the 

material on the license; and provide staff with training on the process and changes to the 

Program’s licensing procedures. 

The review team examined the Program’s licensing practices in regard to requests for RSRM 

(i.e. Increased Controls and Fingerprinting Orders). The review team determined that the 

Program has a licensing procedure to identify new and amended licenses that should be subject 

to additional security measures. While the Program did not always document this process, the 

team did not identify any new or amended licenses that were missing the required license 

conditions and concluded that the Program added legally binding license conditions to the 

licenses that met the criteria for Increased Controls, including fingerprinting, as appropriate. 

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

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

be found satisfactory, but needs improvement. 

3.5 Technical Quality of Incident and Allegation Activities

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

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

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

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

for 10 radioactive materials incidents. A list of the incident casework examined, with 

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

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

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

The incidents/events selected for review included the several categories: equipment failure, lost 

radioactive material, damage to equipment/equipment failure, damage to radioactive sources, 

contamination, medical event, overexposure, and abandoned radioactive material. The review 

team compared the Program’s reporting of events to NRC with those established in the Office of 

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

SA-300 “Reporting Material Events.” The Program has procedures in place for reporting events 

to the NRC Headquarters Operations Officer, and into the NMED system. Of the 10 events 

reviewed, 5 were reportable to NRC. Three of the five reportable events were reported to NRC 

in a time frame consistent with the reporting category. Of the five events that were not 

 
Arkansas Final IMPEP Report Page 10 

reportable to the NRC, the review team confirmed that these events did not meet the 

reportability thresholds. 

The Program Manager explained that the Program’s goal is to respond onsite to all reported 

events. Of the 10 events reviewed, 1 was identified during a routine inspection, 7 resulted in an 

onsite visit by the Program, and 2 did not result in onsite visits by the Program. Of the seven 

that resulted in a site visit by the Program, the Program’s response was prompt. In some cases, 

the Program responded the same day as the reported event. The Program’s onsite event 

response was documented in a memo to file that was placed in the Program’s event files along 

with other supporting documentation. In general, the Program’s onsite event response memos 

to file contained information about the event, such as the circumstances leading up to the event; 

synopses of interviews with licensee employees; results of radiation surveys when applicable; 

and the timeline of the event. The Program Manager did not routinely review these memos to 

file although response activities were discussed during routine staff meetings. The Program’s 

event files did not routinely document an independent evaluation of the event that included a 

determination of the contributing factors and root causes of the event rather than relying on the 

licensee’s conclusions. 

For the two reported events that did not result in an onsite inspection, the Program reviewed the 

licensee’s written reports and followed up during the next routine inspection. Both of these 

events occurred at the same broad scope licensee facility. One event involved the loss of an 

iodine-125 sealed brachytherapy source during a source disposal procedure, and in this event, 

the Program did not identify that the licensee’s written report did not contain all of the 

information required by regulation, including corrective actions to prevent recurrence. Three 

weeks later, a related event, involving the same type of source disposal procedure, equipment, 

and iodine-125 sealed brachytherapy sources occurred at the same broad scope licensee 

facility. The Program performed an onsite response for the second event and the licensee 

subsequently provided a written report that contained corrective actions to address both events. 

The other event reviewed for which the Program did not respond onsite was a reported medical 

event involving brachytherapy with yttrium-90 microspheres in which a problem was 

encountered with the administration of the radioactive material, resulting in a dose to the patient 

that was less than the prescribed dose. Although it is the Program Manager’s expectation that 

all reported events result in an onsite response, the Program did not respond onsite to this 

medical event at the broad scope licensee facility. Another contributing factor was that the 

Program does not have criteria for evaluating reported medical events in order to identify which 

ones may warrant an onsite response. The Program indicated that staff was not as familiar with 

yttrium-90 microspheres and the associated treatment administration equipment as the 

licensee. A search of the Program’s event records in NMED indicated that this event was the 

only medical event reported by the Program during the review period. Interviews with Program 

staff and a review of Program files did not reveal any additional medical events. 

The Program’s procedure RAM-04.4, dated September 3, 2013, “Responding to Events 

Involving Radioactive Material,” references “Emergency Response Procedures for 

non-Arkansas Nuclear One Incidents,” issued on September 4, 2013. These referenced 

procedures contain Radiation Control Section Staff guidance for the receipt of notifications 

involving the following types of events: transportation, licensee work-site incident, missing 

radioactive material, recovered radioactive material, irretrievable down-hole radioactive source, 
Arkansas Final IMPEP Report Page 11 

and stuck radiography source. These procedures do not address how to respond to events but 

rather how to collect information when an event notification is received by Radiation Control 

Program staff. 

The review team inquired regarding commensurate procedures for receiving notifications of 

medical events or for responding to medical events. The Program Manager indicated that 

procedures for receiving medical event notifications were not developed because the Radiation 

Control Section Staff does not receive many medical event reports. The review team found that 

the Radioactive Materials Program procedure RAM-04.4 “Responding to Events Involving 

Radioactive Material” describes general event response procedures and does not contain 

specific guidance associated with responding to or evaluating medical events. Given the 

infrequency of reported or identified medical events and the Program’s inexperience in 

responding to medical events, the team determined the Program would benefit from procedures 

addressing medical events. The review team recommends that the State strengthen its incident 

response program by developing guidance and providing training to the staff on evaluating and 

responding to reported medical events. 

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

evaluated the completed casework for six allegations, including two that were referred to the 

Program by NRC during the review period, and one that was referred to the Program from 

another Agreement State during the review period. The Program’s incident and allegation log 

indicated that the Program received 16 allegations during the review period. Of the casework 

files evaluated, the review team concluded that the Program’s actions in response to allegations 

were prompt, well-coordinated, and commensurate with the potential health and safety or 

security consequences of the identified concerns. In some cases, the Program responded 

onsite the same day as the allegation. 

It was noted by the Program Manager and documented in Program procedure AD-06.9, 

“Investigation of Allegations,” dated August 16, 2009, that during all phases of an investigation 

into an allegation, any and all memoranda, letters, reports, emails, photographs, electronic 

images, telephone messages and notes, regardless of form, are subject to release under the 

Arkansas Freedom of Information Act. This includes the concerned individual’s identity as well 

as any information that is related to concerns that is forwarded to the Program by NRC. 

During the exit meeting at the conclusion of the onsite IMPEP review, the team recommended 

that Arkansas’ performance with respect to this indicator, be found satisfactory, but needs 

improvement. The team also recommended that the State develop, implement, and provide 

training to the staff for responding to medical events. In making this recommendation, the team 

considered the Program’s lack of a procedure for responding to medical events; the Program’s 

lack of an onsite response to the one medical event that was reported during the review period, 

for which a reason offered was that the Program staff was not as familiar with the particular 

equipment as the licensee; for another event, corrective actions were not identified in the 

licensee’s report and this was not recognized by the Program; and there were a few instances 

where event reports to NRC were not made within the required time frame. At the exit meeting, 

the State disagreed with the team’s finding. 

Subsequent to the exit meeting, the team reconsidered the initial finding and it was determined 

that a finding of satisfactory was more appropriate for this indicator. Consideration was given 
Arkansas Final IMPEP Report Page 12 

that with the exception of the medical event and one other event, the State performed onsite 

reviews for other reported events, demonstrating a strong commitment by the Program to review 

events. The team agreed that the recommendation regarding developing a procedure to 

respond to medical events should remain. These changes were discussed with the Radioactive 

Materials Program Manager on December 12, 2013. 

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

that Arkansas’ 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 the State of Arkansas does not relinquish authority to regulate a sealed 

source and device evaluation program, or a uranium recovery program, so only the first and 

third non-common performance indicators were applicable to this review. 

4.1 Compatibility Requirements

4.1.1 Legislation

Arkansas became an Agreement State on July 1, 1963. Legislative authority to create a 

radiation control agency and enter into an Agreement with NRC was granted in the “Arkansas 

Code of 1987 Annotated, Volume 20A, Title 20, Subtitle 2, Chapter 21.” The Department is 

designated as the State’s radiation control agency. 

The review team noted one new piece of legislation adopted during the review period. Act 596, 

approved on March 23, 2011, transferred the authority for radioactive material licensing fee 

increases from the Arkansas Legislature to the Arkansas State Board of Health (the Board). 

Under this Act, the Board was given the authority to establish radioactive material license fees 

not to exceed 25 percent of NRC’s comparable annual fees. At the time of the review, the 

Program’s fees for radioactive materials licenses were 15 percent of NRC’s comparable annual 

fees. 

4.1.2 Program Elements Required for Compatibility 

Arkansas’s regulations for the control of radiation are found in the Rules and Regulations for 

Control of Sources of Ionizing Radiation of the Arkansas State Board of Health and apply to all 

sources of ionizing radiation used within the State. Arkansas requires a license for possession 

and use of all radioactive materials and requires registration of all machines specifically 

designed to produce x-rays including accelerators, cyclotrons and other ionizing radiation. 

The review team examined the State’s rulemaking process and found that draft regulations are 

sent to NRC for review and comment and those comments are incorporated prior to final 

adoption. Rule packages prepared by the Program require an appearance before the Executive 

Committee of the Arkansas Department of Health Administration to seek approval to proceed to 
Arkansas Final IMPEP Report Page 13 

the Arkansas Board of Health. After an appearance in front of, and approval by, the Arkansas 

State Board of Health, rule packages move to public hearings and then on to the State House 

and Senate Interim Committees on Public Health, Welfare, and Labor of the Arkansas General 

Assembly. The rules then undergo a review by the Arkansas Administrative Rules and 

Regulations Subcommittee of the Arkansas Legislative Council. Afterward they proceed to the 

Arkansas State Board of Health to receive final approval and, once approved, they are sent for 

signature by the Director of the Arkansas Department of Health. During this final step, they are 

also sent to the NRC for a final review. This entire process takes approximately nine months to 

complete. 

The review team noted that the State has emergency rule capability for situations where public 

health and safety are at risk. The Arkansas State Board of Health Rules and Regulations for 

Control of Sources of Ionizing Radiation are not subject to "sunset" laws, and the Program has 

the authority to issue legally binding requirements (e.g., license conditions) in lieu of regulations 

until compatible regulations become effective. 

The review team noted that the Program does not have an advisory board; however, if needed a 

Medical Advisory Committee can be convened to approve alternative uses of radioactive 

materials. 

The review team evaluated the Program’s response to the questionnaire relative to this 

indicator, reviewed the status of regulations required to be adopted by the Program 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. 

During the review period, Arkansas submitted 5 regulation packages to NRC for a compatibility 

review, which addressed 17 final regulation amendments, including 10 proposed regulation 

amendments and 10 revisions to final regulations addressing all previous NRC comments. The 

following eight amendments were submitted overdue during this review period. For the first 

three listed, Arkansas had submitted proposed regulations for NRC review and NRC provided 

comments in 2008; however, Arkansas had not submitted the final regulations for review prior to 

the 2009 IMPEP, but provided the revised final regulation addressing NRC’s comments in 2012. 

• “Compatibility with IAEA Transportation Safety Standards and Other Transportation 

Safety Amendments,” 10 CFR Part 71 amendment (69 FR 3697) that was due for 

Agreement State adoption on October 1, 2007. 

• “Medical Use of Byproduct Material – Recognition of Specialty Boards,” 10 CFR Part 35 

amendment (70 FR 16336, 71 FR 1926) that was due for Agreement State adoption on 

April 29, 2008. 

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

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

• “Medical Use of Byproduct Material - Minor Corrections and Clarifications," 10 CFR Parts 

32 and 35 amendments (72 FR 45147; 72 FR 54207) that was due for Agreement State 

adoption on October 29, 2010. 
Arkansas Final IMPEP Report Page 14 

• “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 was due for Agreement State adoption on December 17, 2010. 

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

32, 33, 35, 61, and 150 amendments (72 FR 55864) that was due for Agreement State 

adoption on November 30, 2010. 

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

10 CFR Parts 19 and 20 amendments (72 FR 68043) that was due for Agreement State 

adoption on February 15, 2011. 

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

amendment (74 FR 33901), that was due for Agreement State adoption on September 

28, 2012. 

In addition, in the 2009 IMPEP review, the following two amendments were erroneously listed 

as overdue. The correct status is as follows: 

• “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct 

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

Agreement State adoption February 16, 2004. 

Arkansas provided final regulations in 2008, addressing comments previously provided by 

NRC in 2006. Additional comments on the final regulations and proposed revisions were 

provided by NRC in 2008. This amendment was not considered overdue; however the 

outstanding comments needed to be addressed. All comments were resolved with the 

review and promulgation of Arkansas’ October 1, 2012, final regulations. 

• “National Source Tracking System,” 10 CFR Part 20 amendments (71 FR 65685) that was 

due for Agreement State adoption January 31, 2009. 

Arkansas’ license condition to implement this requirement was reviewed by NRC and had 

no comments as noted in the letter dated January 22, 2009. Arkansas has since adopted 

these legally binding requirements in their regulations as of October 1, 2012. This 

amendment was not considered overdue, since Arkansas was implementing the 

requirement by license conditions prior to the adoption of final regulations. 

Arkansas’ regulations were published as final and became effective on October 1, 2012. 

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. Since the 2009 IMPEP review, the State has adopted all regulation amendments 

that were overdue and addressed all outstanding comments on final regulations that were 

previously reviewed by the NRC. At the time of the review, there were no amendments overdue 

for State adoption. 
Arkansas Final IMPEP Report Page 15 

Prior to this review period, the Program had frequently experienced issues with overdue 

regulatory amendments. This was primarily because regulation development had been 

assigned to the Section Chief as a secondary responsibility. To remain timely in rule 

development, the Program reassigned one Health Physicist to work on rulemaking. As a result 

of the reassignment, the Program has caught up the backlog of overdue amendments. With the 

upcoming amendments scheduled for adoption over the next review period, the Program plans 

to continue the assignment of a Health Physicist in order to maintain regulations that are current 

with the NRC’s regulations. 

A complete list of upcoming regulation amendments that will need to be addressed in the future 

may 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 Arkansas’ performance with respect to the indicator, Compatibility Requirements, be found 

satisfactory. 

4.2 Low-Level Radioactive Waste (LLRW) Disposal Program

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

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

allow a State to seek an amendment for the regulation of LLRW as a separate category. Those 

States with existing Agreements prior to 1981 were determined to have continued LLRW 

disposal authority without the need of an amendment. Although Arkansas has such authority to 

regulate a LLRW disposal facility, NRC has not required States to have a program for licensing 

a disposal facility until such time as the State has been designated as a host State for a LLRW 

disposal facility. When an Agreement State has been notified or becomes aware of the need to 

regulate a LLRW disposal facility, it is expected to put in place a regulatory program that will 

meet the criteria for an adequate and compatibility LLRW program. There are no plans for a 

commercial LLRW disposal facility in Arkansas. Accordingly, the review team did not review 

this indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0 above, the team initially recommended that Arkansas’ 

performance, with respect to the indicators Technical Quality of Inspection, Technical Quality of 

Licensing, and Technical Quality of Incident and Allegation Activities, be found satisfactory, but 

needs improvement, and that the other indicators reviewed be found satisfactory. Based on its 

initial recommendation of three satisfactory, but needs improvement, indicators, and in 

accordance with NRC Management Directive 5.6, the team recommended that the Arkansas 

program be found adequate, but needs improvement, to protect public health and safety and 

compatible with NRC’s program. Furthermore, the team recommended that Monitoring should 

be considered for the Program. 

After the exit meeting, the team reconsidered its findings and revised its recommendations, 

resulting in the team recommending that Arkansas’ performance be found satisfactory, but 

needs improvement, for the indicator Technical Quality of Licensing Actions, and satisfactory for 

the other indicators reviewed. Accordingly, the team revised its adequacy finding, resulting in 
Arkansas Final IMPEP Report Page 16 

the team recommending, and the MRB agreed, that the Arkansas Agreement State Program be 

found adequate to protect public health and safety, and compatible with NRC's program. The 

review team recommended, and the MRB agreed that a Periodic Meeting be held in 2 years, 

and that the next IMPEP review take place in approximately 4 years. The revised 

recommendations were provided to the Radioactive Materials Program Manager on December 

12, 2013. 

The review team made three recommendations regarding the performance of the State. As 

noted in Section 2.0, the review team determined that the recommendation from the 2011 

Follow-up IMPEP regarding tracking the status of license actions reviews to ensure timely 

completion was addressed by the Program and should be closed. 

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

implementation by the State: 

1. The review team recommends that the State provide refresher training to the inspection 

staff on the inspection procedures and incorporate the inspection procedures into the 

training and qualification program for inspectors to ensure consistent implementation 

during inspections. (Section 3.1) 

2. The review team recommends that the State revise its licensing procedures to include 

current guidance to determine and document the basis of confidence for all new 

applications and transfers of control that radioactive materials will be used as intended, 

prior to authorizing the material on the license; and provide staff with training on the 

process and changes to the Program’s licensing procedures. (Section 3.4) 

3. The review team recommends that the State strengthen its incident response program 

by developing guidance and providing training to the staff on evaluating and responding 

to reported medical events. (Section 3.5) 
 

LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Arkansas Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 

 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Janine Katanic, FSME Team Leader 

 Inspector Accompaniments 

Technical Quality of Incident and 

 Allegation Activities 

 

Randy Erickson, Region IV Technical Staffing and Training 

 Compatibility Requirements 

Binesh Tharakan, Region IV Status of Materials Inspection Program 

 

Michelle Hammond, Region IV Technical Quality of Licensing Actions 

Santiago Rodriguez, New Mexico Technical Quality of Inspections 
APPENDIX B 

ARKANSAS ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML13276A239
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Team Industrial Services, Inc. License No.: ARK-0344-03310 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 3/13/13 Inspectors: AH, RP 

File No.: 2 

Licensee: Huber Specialty Hydrates, LLC License No.: ARK-1029-03120 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 12/14/12 Inspectors: AH, KA 

File No.: 3 

Licensee: Schultz Surveying & Engineering License No.: ARK-1032-03121 

Inspection Type: Initial Priority: 5 

Inspection Date: 8/13/13 Inspector: RP 

File No.: 4 

Licensee: University Nuclear & Diagnostic License No.: ARK-1019-02201 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 5/21/10 Inspectors: RP, JT 

 

File No.: 5 

Licensee: U.S. Cardiovascular Radiopharmacy License No.: ARK-1024-02500 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 3/13/13 Inspectors: AH, RP 

File No.: 6 

Licensee: MISTRAS Group License No.: ARK-1034-03310 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 6/10/13 Inspector: SM 

File No.: 7 

Licensee: MISTRAS Group License No.: REC-372-03310 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 6/21/12 Inspectors: KA, RP 

File No.: 8 

Licensee: Red River Pharmacy Services License No.: ARK-1033-02500 

Inspection Type: Initial, Unannounced Priority: 2 

Inspection Date: 10/24/12 Inspectors: AH, RP 
Arkansas Final IMPEP Report Page C. 2 

Inspection Casework Reviews 

File No.: 9 

Licensee: Subsurface Xplorations, LLC License No.: ARK-1018-03121 

Inspection Type: Initial, Unannounced Priority: 5 

Inspection Date: 5/6/10 Inspector: KA 

File No.: 10 

Licensee: National Inspection Services, LLC License No.: ARK-1026-03310 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 10/3/11 Inspector: RP 

File No.: 11 

Licensee: National Inspection Services, LLC License No.: REC-376-03310 

Inspection Type: Reciprocity, Unannounced Priority: 1 

Inspection Date: 4/14/10 Inspector: TK 

File No.: 12 

Licensee: URS Energy & Construction License No.: ARK-0837-03310 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 10/2/13 Inspector: TK 

File No.: 13 

Licensee: University of Arkansas at Little Rock License No.: ARK-0421-03620 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 2/4/10 Inspector: TK 

File No.: 14 

Licensee: Arkansas Children’s Hospital License No.: ARK-0572-02110 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/12-13/12 Inspectors: SM, AH 

File No.: 15 

Licensee: Sterigenics US, LLC License No.: ARK-0903-03521 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 9/17/10 Inspector: RP 

File No.: 16 

Licensee: Applied Inspection Systems, Inc. License No.: ARK-0576-03310 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 5/29/13 Inspectors: AH, SM 

File No.: 17 

Licensee: H & H X-Ray Services, Inc. License No.: ARK-0650-03310 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 10/3/13 Inspector: AH 
Arkansas Final IMPEP Report Page C. 3 

Inspection Casework Reviews 

File No.: 18 

Licensee: International Testing & Inspection Services License No.: ARK-0773-03310 

Inspection Type: Routine, Unannounced Priority: 1 

Inspection Date: 7/12-13,15/10 Inspector: TK 

File No.: 19 

Licensee: University of Arkansas License No.: ARK-0711-03222 

Inspection Type: Routine, Announced Priority: 5 

Inspection Date: 3/12-14/13 Inspectors: SM, TK 

File No.: 20 

Licensee: Costal Wireline Services License No.: REC-238-03110 

Inspection Type: Reciprocity, Unannounced Priority: 3 

Inspection Date: 4/27/10 Inspectors: AM, RP 

. 

File No.: 21 

Licensee: CARTI-UAMS License No.: ARK-0930-2230 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 6/10/10 Inspector: KA 

. 

File No.: 22 

Licensee: Drew Memorial Hospital License No.: ARK-0482-02120 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/13/13 Inspector: SM 

File No.: 23 

Licensee: Arkansas Methodist Hospital License No.: ARK-0355-02120 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 4/25/12 Inspector: RP 

File No.: 24 

Licensee: PETNET Solutions, Inc. License No.: ARK-0953-02500 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 4/22/13 Inspectors: TK, AH 

File No.: 25 

Licensee: Schlumberger Technology Corp. License No.: ARK-0657-03110 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 6/6/12 Inspectors: SM, AH 

File No.: 26 

Licensee: Ouachita County Medical Center License No.: ARK-208-02121 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 9/7/11 Inspector: AH 

. 
Arkansas Final IMPEP Report Page C. 4 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

The following inspector accompaniments were performed prior to the onsite IMPEP review: 

Accompaniment No.: 1 

Licensee: Cardinal Health License No.: ARK-0642-02500 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 8/19/13 Inspector: AH 

Accompaniment No.: 2 

Licensee: Halliburton Energy Services, Inc. License No.: ARK-0319-03110 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 8/20/13 Inspector: SM 

Accompaniment No.: 3 

Licensee: Sterigenics US, LLC License No.: ARK-903-03521 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 8/21/13 Inspector: RP 

Comment: 

The inspector was not adequately prepared for the inspection, was not familiar with 

the regulatory requirements for this type of licensed activity, and was not familiar with 

the facility and health and safety information contained in the license. The inspector 

demonstrated poor health physics practices and did not have due attention to 

radiation safety and the risk significance of this type of licensed activity. 

Accompaniment No.: 4 

Licensee: H&H X-Ray Services, Inc. License No.: ARK-0650-03310 

Inspection Type: Temporary Job Site, Unannounced Priority: 1 

Inspection Date: 8/22/13 Inspector: AH 

Accompaniment No.: 5 

Licensee: Saint Vincent Infirmary Medical Center License No.: ARK-0394-02120 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 9/9-10/13 Inspector: KA 

Accompaniment No.: 6 

Licensee: University of Arkansas for Medical Sciences License No.: ARK-0001-02110 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 9/11-13/13 Inspector: TK, KA 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Red River Pharmacy License No.: ARK-1033-02500 

Type of Action: New Amendment No.: 0 

Date Issued: 10/24/12 License Reviewers: AH, SM 

Comment: 

Pre-licensing guidance was not used. 

File No.: 2 

Licensee: National Inspection Services, LLC License No.: ARK-1026-03310 

Type of Action: New Amendment No.: 0 

Date Issued: 5/3/11 License Reviewers: RP, SM 

Comment: 

Pre-licensing guidance was not used. 

File No.: 3 

Licensee: Subsurface Xplorations License No.: ARK-1018-03121 

Type of Action: Termination Amendment No.: 3 

Date Issued: 4/29/13 License Reviewers: KA, JT 

File No.: 4 

Licensee: Mistras Group License No.: ARK-1034-03310 

Type of Action: New Amendment No.: 0 

Date Issued: 12/20/12 License Reviewers: KA, JT 

Comments: 

1) Pre-licensing guidance was not used. 

2) Off-shore operating and emergency procedures for conducting radiographic 

operations in exclusive federal jurisdiction were tied down to the license. 

File No.: 5 

Licensee: Mistras Group License No.: ARK-1034-03310 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 3/20/13 License Reviewers: RP, JT 

Comment: 

The license was amended to remove a permanent storage location; however, the 

licensing case file did not include justification for removing the location from the 

license, such as radiation surveys or leak test records. 
Arkansas Final IMPEP Report Page D. 2 

License Casework Reviews 

File No.: 6 

Licensee: University Nuclear and Diagnostics License No.: ARK-1019-02201 

Type of Action: Termination Amendment No.: 4 

Date Issued: 3/11/13 License Reviewers: KA, JT 

File No.: 7 

Licensee: University of Arkansas for Medical Sciences License No.: ARK-0001-02110 

Type of Action: Renewal Amendment No.: 31 

Date Issued: 12/18/12 License Reviewers: KA, JT 

File No.: 8 

Licensee: Construction Materials Testing Services License No.: ARK-0750-03121 

Type of Action: Renewal Amendment No.: 49 

Date Issued: 7/28/10 License Reviewers: DS, JT 

File No.: 9 

Licensee: Insight Health Corporation License No.: ARK-0994-02231 

Type of Action: Amendment Amendment No.: 4 

Date Issued: 10/13/10 License Reviewers: AM, JT 

File No.: 10 

Licensee: St. Vincent Infirmary Medical Center License No.: ARK-0394-02120 

Type of Action: Amendment Amendment No.: 143 

Date Issued: 8/27/13 License Reviewers: AH, JT 

Comments: 

1) Sealed Sources for manual brachytherapy therapy authorized as “Seeds” on the 

license and did not specify manufacturer or model number. 

2) Sealed Sources for manual brachytherapy and calibration sources did not specify 

manufacturer or model number. 

3) Sealed sources listed in sections 8.H., 8.O., and 8.P did not list the maximum 

activity authorized per single source as directed in Requesting Implementation of 

a Policy on Maximum Possession Limits for Radioactive Licenses (RCPD-10-

007). 

4) Cover letter mailed with license amendment did not include the standard language 

for releasing a specific authorized use location for unrestricted use in accordance 

with Program procedures. 

File No.: 11 

Licensee: NEA Baptist Clinic License No.: ARK-0925-02201 

Type of Action: Amendment Amendment No.: 11 

Date Issued: 3/1/10 License Reviewers: RP, JT 

Comment: 

Pre-licensing guidance was not used. 

 
Arkansas Final IMPEP Report Page D. 3 

License Casework Reviews 

File No.: 12 

Licensee: Southwestern Electric Power Company License No.: ARK-1025-03120 

Type of Action: Amendment Amendment No.: 2 

Date Issued: 5/11/12 License Reviewers: RP, SM 

File No.: 13 

Licensee: Huber Specialty Hydrates, LLC License No.: ARK-1029-03120 

Type of Action: New Amendment No.: 0 

Date Issued: 6/27/12 License Reviewers: KA, SM 

Comment: 

Pre-licensing guidance was not used. 

File No.: 14 

Licensee: Apex Geoscience, Inc. License No.: ARK-1027-03121 

Type of Action: Amendment Amendment No.: 5 

Date Issued: 12/20/12 License Reviewers: RP, JT 

File No.: 15 

Licensee: CARTI License No.: ARK-0654-02200 

Type of Action: Renewal Amendment No.: 56 

Date Issued: 4/9/12 License Reviewers: KA, KW 

Comment: 

Licensee upgraded the high dose rate remote afterloader (HDR) unit to a new model 

with pulsed dose mode (PDR) capabilities, as well as interlock, and software 

updates. The Operating and Emergency procedure that was a tie-down condition to 

the license did not reflect the change in the model number of the HDR unit, the 

changes associated with its operation, and additional training on the upgraded HDR 

unit. 

File No.: 16 

Licensee: CARTI License No.: ARK-0654-02200 

Type of Action: Amendment Amendment No.: 58 

Date Issued: 7/9/12 License Reviewers: RP, JT 

File No.: 17 

Licensee: Mercy Health Center License No.: ARK-0880-02120 

Type of Action: Amendment Amendment No.: 13 

Date Issued: 9/27/12 License Reviewers: AH, JT 

File No.: 18 

Licensee: Mercy Health Center License No.: ARK-0880-02120 

Type of Action: Amendment Amendment No.: 14 

Date Issued: 10/5/12 License Reviewers: TK, JT
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS 

ONLY. 

File No.: 1 

Licensee: Flakeboard America License No.: ARK-0664-03120 

Date of Incident: 2/2/11 NMED No.: 130354 

Investigation Date: 8/8/13 Type of Incident: Equipment Failure 

 Type of Investigation: Inspection 

Comment: 

This event was not reported by the licensee but was instead identified during a 

routine inspection on 8/8/13 and subsequently reported to NRC. 

File No.: 2 

Licensee: Applied Inspection Systems License No.: ARK-0576-03320 

Date of Incident: 7/26/10 NMED No.: 10038 

Investigation Date: 7/27/10 Type of Incident: Equipment Failure 

 Type of Investigation: Site 

File No.: 3 

Licensee: University of Arkansas for Medical Sciences License No.: ARK-001-02110 

Date of Incident: 8/27/10 NMED No.: 100496 

Investigation Date: 9/13/10 Type of Incident: Lost RAM 

 Type of Investigation: Review licensee report 

Comment: 

The licensee’s written report did not contain all of the information required by 

regulation, including information regarding corrective actions to prevent recurrence. 

File No.: 4 

Licensee: University of Arkansas for Medical Sciences License No.: ARK-001-02110 

Date of Incident: 9/17/10 NMED No.: 100551 

Investigation Date: 9/20/10 Type of Incident: Damage to Equipment/Source 

 Type of Investigation: Site 

File No.: 5 

Licensee: Johnson Regional Medical Center License No.: ARK-0523-02120 

Date of Incident: 11/9/10 NMED No.: N/A 

Investigation Date: 11/17/10 Type of Incident: Contamination 

 Type of Investigation: Site 

 
Arkansas Final IMPEP Report Page E. 2 

Incident Casework Reviews 

File No.: 6 

Licensee: University of Arkansas for Medical Sciences License No.: ARK-001-02110 

Date of Incident: 3/16/11 NMED No.: 110154 

Investigation Date: 8/2/11 Type of Incident: Medical Event 

 Type of Investigation: Review licensee report 

Comment: 

The State did not report the event to NRC within the required timeframe. The 

reporting category is 24 hours. The licensee informed the Program on 3/17/11 and 

the Program reported the event to NRC on 4/1/11. 

File No.: 7 

Licensee: Protechnics License No.: REC-084 

Date of Incident: 10/25/12 NMED No.: N/A 

Investigation Date: 10/26/12 Type of Incident: Contamination 

 Type of Investigation: Site 

File No.: 8 

Licensee: Pathfinder Energy Services License No.: Reciprocity 336 

Date of Incident: 3/15/11 NMED No.: 120038 

Investigation Date: 3/18/11 Type of Incident: Abandoned RAM 

 Type of Investigation: Review licensee report/Site 

File No.: 9 

Licensee: International Testing & Inspection License No.: ARK-773-03320 

Date of Incident: 4/29/12 NMED No.: N/A 

Investigation Date: 5/22/12 Type of Incident: Overexposure 

 Type of Investigation: Site 

File No.: 10 

Licensee: Team Industrial Services, Inc. License No.: ARK-0344-03320 

Date of Incident: 10/3/10 NMED No.: 100503 

Investigation Date: 10/18/10 Type of Incident: Equipment failure 

 Type of Investigation: Site 

Comment: 

The State did not report the event to NRC within the required timeframe. The 

reporting category is 24 hours. The licensee informed the Program on 10/4/10 and 

the Program reported the event to NRC on 10/7/10. 
ATTACHMENTS 

March 21, 2014 Letter from Nathaniel Smith 

Arkansas’ Response to the Draft Report 

ADAMS Accession No.: ML14083A332 

NRC Comment Resolution to March 21, 2014 Letter 

ADAMS Accession No.: ML14084A017