February 5, 2013 

Judson H. Turner, Director 

Georgia Department of Natural Resources 

Environmental Protection Division, Air Protection Branch 

4244 International Parkway 

Suite 120 

Atlanta, GA 30354 

Dear Mr. Turner 

On January 17, 2013, the Management Review Board (MRB) met to consider the proposed final 

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

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

health and safety, but needs improvement, and compatible with the U.S. Nuclear Regulatory 

Commission’s (NRC) program. 

The IMPEP team identified an overall declining performance by Georgia. Significant 

deficiencies were noted throughout the program and have the potential to impact public health 

and safety, if left uncorrected. Because of the significance of the findings, the MRB will 

recommend to the Commission that Georgia be placed on probation. Probation is a formal 

process that requires Commission approval. If approved, a press release and notifications to 

the Governor and Congressional delegation will be made. Probation requires an increased level 

of communication between the NRC staff and the State program office. Pending the 

Commission’s review, the Georgia Agreement State Program is on Heightened Oversight. 

Heightened Oversight involves increased interaction with the NRC staff, the State’s preparation 

of a program improvement plan, bimonthly conference calls, and submission of status reports.

Section 5.0, page 18, of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. The State was found unsatisfactory for two performance 

indicators and satisfactory, but needs improvement, for three performance indicators. The 

review team made 11 new recommendations regarding program performance by Georgia and 

kept open a recommendation from the 2008 review. Based on the results of the current IMPEP 

review, the MRB directed that the next full review of the Georgia Agreement State Program will 

take place in approximately one year (January 2014). 

I request that you prepare and submit a program improvement plan as part of your response to 

the review team’s recommendations and to further support the response you provided on 

December 27, 2012, to the draft IMPEP report. A program improvement plan is necessary 

whether or not the Commission approves placing your State on probation. I ask that you have 

your staff discuss the required elements of this plan with Mr. Brian McDermott, Director, Division 

of Materials Safety and State Agreements, Office of Federal and State Materials and 

Environmental Management Programs, before you submit it, to ensure that the planned actions 

and measures of success are clearly identified. 
J. Turner -2- 

The plan should be submitted within 30 days of receipt of this letter. Upon review of your 

program improvement plan, the NRC staff will schedule the first conference call. 

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: 

Georgia Final IMPEP Report 

cc w/ encl: Alice Rogers, TX 

 Organization of Agreement States 

 Liaison to the MRB 

 Jim Ussery, Assistant Director 

 Environmental Protection Division 

 

 Jac Capp, Chief 

 Air Protection Branch 

 

 Chuck Mueller, Senior Policy Analyst 

 Air Protection Branch 

 

 James Hardeman, Manager 

 Radioactive Materials Program 
J. Turner -2- 

The plan should be submitted within 30 days of receipt of this letter. Upon review of your 

program improvement plan, the NRC staff will schedule the first conference call. 

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: 

Georgia Final IMPEP Report 

cc w/ encl: Alice Rogers, TX 

 Organization of Agreement States 

 Liaison to the MRB 

 Jim Ussery, Assistant Director 

 Environmental Protection Division 

 

 Jac Capp, Chief 

 Air Protection Branch 

 

 Chuck Mueller, Senior Policy Analyst 

 Air Protection Branch 

 

 James Hardeman, Manager 

 Radioactive Materials Program 

DISTRIBUTION: 

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 ML13023A219 

OFC Rgn III:TL MSSA MSSA MSSA MSSA:D TechEd FSME:D EDO/DEDMRT 

NAME JLynch 

(via email) 

LDimmick DWhite PHenderson BMcDermott CPoland MSatorius MWeber 

DATE 02/04/13 01/24/13 01/24/13 01/31/13 02/04/13 02/04/13 02/04/13 02/05/13 

OFFICIAL RECORD COPY 
Letter to J. Turner, M.D. from Michael F. Weber dated February 5, 2013 

SUBJECT: GEORGIA FY2013 FINAL IMPEP REPORT 

DISTRIBUTION: 

RidsEdoMailCenter DCD (SP01) 

RidsFsmeOd 

RidsOgcMailCenter 

RidsRgn1MailCenter 

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RidsFsmeDmssa 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

MOrendi, RI/RSAO Commissioner Svinicki 

JThompson, RIV Commissioner Apostolakis 

JKatanic, FSME Commissioner Magwood 

DSulas, NC Commissioner Ostendorff 

MStephens, FL SECY 

RLorson, RI 

DLew, RI 

JFoster, OEDO 

JWeil, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE GEORGIA AGREEMENT STATE PROGRAM 

October 22-26, 2012 

FINAL REPORT
EXECUTIVE SUMMARY 

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

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

the period of October 22-26, 2012, by a review team composed of technical staff members from 

the U.S. Nuclear Regulatory Commission (NRC) and the States of North Carolina and Florida.

In 2008, the Georgia Agreement State Program was found to be adequate to protect public 

health and safety, but needs improvement, and compatible with the NRC’s program. A period of 

Monitoring was initiated to monitor the effects of a State-wide hiring freeze, staff attrition and 

weaknesses in the Georgia Agreement State Program training and qualification programs. 

The review team identified an overall declining performance by the Georgia Agreement State 

Program. Significant deficiencies were noted throughout the program and have the potential to 

impact public health and safety, if left uncorrected. The review team observed a basic 

misunderstanding of several important safety and security parameters by staff and 

management. The review team also observed significant communication issues between staff 

and management which affected the safety culture of the program. 

Agreements between the NRC and a State assume that certain tasks be prioritized and 

performed in an efficient manner. Prominent among these tasks is the response to incidents 

involving radioactive materials. When a program becomes aware of a potentially significant 

incident, the program is obligated, under the Agreement, to promptly respond to ensure that 

public health and safety are protected. Additionally, prioritizing inspections of high priority 

licensees, such as industrial radiographers, is important because of the significant potential for 

harm if the radioactive material is not controlled properly. The review team’s evaluation of the 

Georgia program identified numerous examples where appropriate tasks were not prioritized 

and thus, potentially affecting public health and safety. 

For the 2012 IMPEP review, the review team recommended, and the Management Review 

Board (MRB) agreed, that the Georgia Agreement State Program be found adequate to protect 

public health and safety, but needs improvement, and compatible with the NRC’s program. Due 

to the prioritization problems noted during the review, the review team considered whether to 

recommend that the Georgia program was compatible, or not, with the NRC's program. After 

some discussion and examination of the NRC’s policy statements on the subject, the review 

team recommended to the MRB that, despite the problems noted, Georgia be found compatible 

with the NRC’s program. 

The review team recommended, and the MRB agreed, that Georgia’s performance be found 

unsatisfactory for the performance indicators: Technical Quality of Inspections and Technical 

Quality of Incident and Allegation Activities. The review team recommended, and the MRB 

agreed, that Georgia’s performance be found satisfactory, but needs improvement, for the 

performance indicators: Technical Staffing and Training, Status of Materials Inspection 

Program, and Technical Quality of Licensing Actions. The review team found Georgia’s 

performance to be satisfactory for the two non-common performance indicators reviewed. The 

review team made 11 new recommendations regarding the performance of the State and kept 

open a recommendation from the 2008 IMPEP review. 

 
Executive Summary Page 2 

Based on the results of the current IMPEP review, and in accordance with the criteria in the 

NRC Management Directive 5.6, the review team recommended, and the MRB agreed, that the 

period of Monitoring be discontinued and that the Georgia Agreement State Program be placed 

on Probation. In cases where program weaknesses exist regarding the adequacy and/or 

compatibility of an Agreement State’s program yet the weaknesses are not so serious as to find 

the program inadequate to protect public health and safety, one of the options available to 

ensure continued protection of public health and safety, is to place the Agreement State on 

Probation. 

The review team further recommended, and the MRB agreed, that a full IMPEP review be 

conducted within one year of the MRB meeting to assess the State’s progress in addressing the 

open recommendations and the programmatic issues identified during this review. 
Georgia Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of October 22-26, 2012, by a review team composed of 

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

North Carolina and 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 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 September 27, 2008, to October 26, 2012, 

were discussed with Georgia managers on the last day of the review. A second exit meeting 

was conducted by telephone with Georgia managers on November 2, 2012. 

A draft of this report was provided to Georgia for factual comment on November 27, 2012. The 

State responded by letter dated December 27, 2012. A copy of the State’s response is included 

as an Attachment to this report. A Management Review Board (MRB) met on January 17, 2013, 

to consider the proposed final report. The MRB found the Georgia Agreement State Program 

adequate to protect public health and safety, but needs improvement and compatible with the 

NRC’s program. The MRB will recommend to the Commission that the State be placed on 

Probation. 

The Georgia Agreement State Program (the Program) is administered by the Air Protection 

Branch (the Branch), which is located within the Environmental Protection Division (the 

Division). The Division is part of the Department of Natural Resources (the Department). 

Organization charts for the Department, Division, and the Branch are included as Appendix B. 

At the time of the review, the Program regulated 490 specific licenses authorizing possession 

and use of radioactive materials. The review focused on the radioactive materials program as it 

is carried out under the Section 274b. (of the Atomic Energy Act of 1954, as amended) 

Agreement between the NRC and the State of Georgia. 

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

non-common performance indicators was sent to the Branch on June 19, 2012. The Branch 

provided its response to the questionnaire on October 4, 2012. A copy of the questionnaire 

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

(ADAMS) using the Accession Number ML12278A182. 

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

the Branch’s response to the questionnaire, (2) review of applicable Georgia statutes and 

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

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

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

against the established criteria for each common and the applicable non-common performance 

indicator and made a preliminary assessment of the Georgia Agreement State Program’s 

performance. 
Georgia Final IMPEP Report Page 2 

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

during previous reviews. 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 September 26, 2008, the review team 

made four recommendations regarding the Georgia Agreement State Program’s performance. 

The status of the recommendations is as follows: 

1. “The review team recommends that the State develop, document, and implement a formal 

qualification program for licensing and inspection activities that includes written 

documentation and supervisor endorsement of competency in each program area. (Section 

3.1 of the 2008 IMPEP report)” 

Status: The State developed, documented and implemented a formal qualification program 

for licensing and inspection activities in October 2009. This qualification program was 

applied to new staff currently going through the qualification process. The qualification 

program includes written documentation and supervisor endorsement of competency in 

each area. The Program manager also reviewed select licensing and inspection casework 

of fully qualified employees to assess their competency in each area. This recommendation 

is closed. 

2. “The review team recommends that the State update its inspection procedures and 

enforcement guidance to include the requirements for timely follow-up of Increased Controls 

violations. (Section 3.3 of the 2008 IMPEP report)” 

Status: Following the 2008 IMPEP review, the State updated its inspection procedures and 

enforcement guidance; these updates incorporated guidance on the performance of 

Increased Controls inspections, and associated follow-up for any violations identified. This 

recommendation is closed. 

3. “The review team recommends that the State develop and implement a process for 

conducting annual accompaniments of all radiation compliance inspectors by a supervisor. 

(Section 3.3 of the 2004 IMPEP report)” 

Status: Following the 2008 IMPEP review, the State developed requirements for an annual 

supervisory accompaniment of each radiation compliance inspector. This recommendation 

is closed. 

4. “The review team recommends that the State qualify one additional reviewer in SS&D 

evaluations to provide backup for the principal reviewer. This is in addition to a qualified 

reviewer or supervisor performing concurrence reviews. (Section 4.2 of the 2004 IMPEP 

report and 2013 IMPEP MRB).” 

Status: Although the State provided some SS&D training to two staff members, no 

additional SS&D reviewers were qualified to provide backup for the principal reviewer. This 

recommendation remains open. 
Georgia Final IMPEP Report Page 3 

3.0 COMMON PERFORMANCE INDICATORS 

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

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

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

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

3.1 Technical Staffing and Training

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 Branch’s questionnaire response relative to this 

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

considered workload backlogs. 

At the time of the review, there were six technical staff members and a program manager in 

the Branch, totaling approximately seven full-time equivalents (FTE). Five of the six technical 

staff members are fully qualified to perform inspection and licensing (with the exception of 

Sealed Source and Device (SS&D) work) activities. Only one staff member is fully qualified to 

perform SS&D reviews as the primary reviewer. Each technical staff member has at least a 

Bachelor of Science degree in a physical science and has between 4 and 16 years experience 

with the Program. There were no new hires during the review period and two technical staff 

members left the Program. According to the staffing plan, two positions were vacant at the 

time of this review. A third vacant position was removed from the staffing plan during the 

review period. Branch management stated that this position could be reinstated if funding for 

the position was made available. 

In October 2009, the Program implemented a newly documented training plan for technical staff 

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

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

Qualification Programs in the Nuclear Material Safety and Safeguards Program Area.” This 

documented training plan was in response to a recommendation made during the 2008 IMPEP 

review. Staff members are assigned increasingly complex duties as they progress through the 

qualification process. The review team concluded that the Program’s documented training 

program is adequate to carry out its regulatory duties and noted that Georgia management 

supports the training program. 

While the review team concluded that the training program is adequate if implemented properly, 

it was noted by the team that correct knowledge of current licensing and inspection activities 

was lacking amongst management and senior staff. Therefore, training of new staff using these 

criteria, which includes in-house training and mentoring by management and senior staff, could 

lead to insufficient knowledge by the new staff members thereby impacting each of the other 

indicators reviewed. Examples of incorrect knowledge were identified by the review team in 

program components such as pre-licensing visits, inspection security requirements and 

response to incidents and allegations. These deficiencies are described in later sections of this 

report. 
Georgia Final IMPEP Report Page 4 

The review team also observed significant communication issues between staff and 

management which affected the safety culture of the program. These issues were evident 

during interviews with both the Program manager and with inspection/licensing staff members. 

As a result, key information was not communicated to the Program manager, including the 

awareness of significant incidents which occurred at licensee facilities. Work priorities were not 

effectively communicated to staff members, resulting in a failure to emphasize safety and 

security inspections of high risk licensees, such as industrial radiographers. This lack of 

communication affected the ability of the Georgia program to manage its health and safety 

responsibilities. 

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

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

found satisfactory, but needs improvement. 

3.2 Status of Materials Inspection Program

The review team focused on five factors 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 Branch’s questionnaire response relative to this indicator, data gathered from the 

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

management and staff. 

The review team evaluated Georgia's inspection frequencies for all types of radioactive material 

licenses to determine if they are at least as frequent as similar license types listed in IMC 2800, 

“Materials Inspection Program.” Several lower priority license categories established by the 

Program were assigned inspection priority codes that prescribe a less frequent inspection 

schedule than those established in IMC 2800 for similar license types. Specifically, small 

academic research programs have a Georgia inspection priority of six years. Currently, six 

Georgia academic institutions are in this category. Similar NRC licensees are inspected on a 

five-year frequency. The State also assigns several priority code 7 frequencies, which 

correlates to the NRC’s five-year contacts. A total of 12 Georgia licensees have priority code 7 

inspection frequencies. The Program manager stated that this was an oversight and that the 

Program intended to have the same inspection frequencies as the NRC. The Program manager 

indicated that they would adjust the inspection priorities as appropriate, if license fees 

associated with the license categories were not adversely affected. 

The Program reported that it conducted approximately 247 high priority (Priority 1, 2, and 3) 

inspections during the review period, based on the inspection frequencies established in IMC 

2800. Thirty-six of these inspections were conducted overdue by more than 25 percent of the 

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

approximately 20 initial inspections during the review period, four of which were conducted 

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

license issuance. Approximately 15 inspections, both high priority and initial, were overdue at 

the time of the review. The Program manager stated that inspections were conducted late due 

to the loss of inspection personnel and exacerbated by errors in the inspection database. 

Overall, the review team calculated that the Program performed 19.5 percent of its inspections 

overdue during the review period, an increase from the 15 percent overdue percentage 
Georgia Final IMPEP Report Page 5 

identified during the 2008 IMPEP review. Of the six Priority 1 (high safety significance) 

licensees in the State, four (67 percent) were inspected overdue. The review team 

recommends that the State develop and implement a plan to complete the higher priority and 

initial inspections in accordance with the inspection frequencies specified in IMC 2800. 

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

licensees. A sampling of inspection reports indicated that inspection findings were 

communicated to the licensees within the Program’s goal of 30 days after the inspection. 

During the review period, the Program granted 252 reciprocity permits, of which approximately 

35 were Priority 1–3 licenses. The Program does not categorize reciprocity inspections as 

candidates or non-candidates as is outlined in the IMC 1220 “Processing of NRC Form 241 and 

Inspection of Agreement State Licensees Operating under 10 CFR 150.20” procedure. The 

review team determined that the Program inspected approximately 17 percent of Priority 1–3 

licensees requesting reciprocity from Georgia during the entire review period. The Program 

manager stated that she prioritized inspections of Georgia specific licenses over the reciprocity 

licenses due to the limited staff available to do such inspections. The review team identified 

only one Priority 1 and five Priority 3 reciprocity license inspections that were completed during 

the review period. This issue is discussed further in Section 3.3. 

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

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

Program, be found satisfactory, but needs improvement. 

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 six Program 

inspectors and covered inspections of various license types: medical institutions-therapy, 

medical-diagnostic, portable nuclear gauges, industrial radiography, self-shielded irradiators, 

industrial manufacturers and distributors, and Increased Security Controls for large quantities of 

radioactive materials (Increased Controls). Appendix C lists the inspection casework files 

reviewed, with case-specific comments, as well as the results of the inspector accompaniments. 

The inspection procedures utilized by the Program are not consistent with the inspection 

guidance outlined in IMC 2800. In December 2010, changes to IMC 2800 were announced to 

Agreement States, who had 6 months to implement the changes. The changes included 

revised security inspection frequency, requirements for initial security inspections, and prelicensing visits. Additionally, the inspection guidance addressed the use of the National Source 

Tracking System (NSTS) which is to be reviewed during each inspection of those licensees 

authorized to possess greater than or equal to Category 2 quantities of radioactive material. 

The Program did not update its inspection guidance and inspectors were not aware of the 

changes, including the required NSTS reviews. Further, most of the Program inspectors did not 

have access to the NSTS database, because their NSTS digital certificates had expired, and 

had not been renewed. The review team recommends that the State update its inspection 

procedures to include the most recent revisions to Inspection Manual Chapter 2800, including 

the implementation of inspection guidance for NSTS reviews. 
Georgia Final IMPEP Report Page 6 

Inspection field notes were completed by the inspector for each safety and security inspection 

and maintained in the licensee file, and an inspection report was sent to the licensee. For 

inspections that did not identify violations, the inspection reports were sent to the licensee by 

the inspector without supervisory review. Inspection reports that identified violations were sent 

to the licensee by the supervisor, after review and approval. During the review period, 

supervisory accompaniments were conducted annually for all but one of the inspectors; this 

inspector was accompanied in three of the four years by the supervisor. 

Based on the evaluation of casework, the review team noted that Increased Controls security 

inspections of licensees were not always performed during the same visit as the health and 

safety inspections. In some cases, Increased Controls security inspections were not performed 

at all. For one of Georgia’s industrial radiography licensees, a Priority 1 licensee, neither a 

safety nor a security inspection had been performed in over three years. For another industrial 

radiography licensee, safety inspections were performed in 2009 and 2012, but during neither 

visit was a security inspection performed. The review team recommends that the State perform 

Increased Controls security inspections at least as frequently as the priority of the license being 

inspected. 

The review team determined that inspection documentation reviewed supported violations; 

however, the effectiveness of corrective actions taken to resolve these violations were not 

always documented or reviewed. During one of the security inspections performed in 

January 2011, a security violation was identified involving the failure to perform a 

trustworthiness and reliability determination of an employee granted unescorted access to 

licensed material. The licensee never responded to this violation, and the Program did not 

follow up with the licensee to ensure that corrective actions had been taken. It should be noted 

that the Program’s failure to follow up on Increased Controls security violations was identified 

during the previous IMPEP review in 2008. 

The review team found that the Program has a useful method of collecting data for both 

reciprocity work in the State, as well as licensed industrial radiography work at temporary job 

sites. Georgia licensees that perform industrial radiography at temporary job sites are required 

by license condition to notify the Program at least three days in advance prior to performing this 

work, affording the Program the opportunity to inspect licensee work. Reciprocity licensees are 

also required to provide at least three days notice of work performed in Georgia. Although the 

Program performed various inspections of reciprocity licensees during the review period, the 

review team identified only one Priority 1 licensee that had been inspected. Most of the 

reciprocity inspections were of Priority 5 licensees. Additionally, the review team only identified 

one industrial radiography licensee that had been inspected at a temporary job site during the 

review period, even though there were dozens of opportunities during the review period to 

perform these radiography inspections. The Program receives daily notifications via facsimile 

from Georgia licensees performing radiography within the State. The review team found that 

many of these notifications were placed into a former employee’s mailbox and were not being 

reviewed by the Program. During interviews with staff members, the review team noted that 

other factors, such as distance to the licensed operations from the Program office, took priority 

over the safety significance of the licensed activities being performed. 
Georgia Final IMPEP Report Page 7 

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

support its inspection program. Appropriate, calibrated survey instrumentation, such as GeigerMueller (GM) meters, scintillation detectors, ion chambers, micro-R meters, and neutron 

detectors, was observed to be available. The Program also has portable multi-channel 

analyzers available for investigations. Instruments are calibrated at least annually, or as 

needed, by a service provider with National Institute of Standards and Technology traceable 

sources. The Program uses a database to track each instrument, its current location, and next 

calibration date. The responsibilities for the calibration program are rotated amongst Program 

inspectors annually. 

Accompaniments of six Program inspectors were conducted by two IMPEP team members 

during the weeks of September 10 and 24, 2012. The inspectors were accompanied during 

health and safety inspections of medical institutions with therapy, medical-diagnostic, portable 

nuclear gauges, industrial radiography, self-shielded irradiators, and industrial manufacturers 

and distributors. The accompaniments are identified in Appendix C. During the 

accompaniments, four of the six inspectors demonstrated appropriate inspection techniques, 

knowledge of the regulations, and conducted performance-based inspections. On one of the 

accompaniments, however, the inspector was unprepared for the inspection, stating to the 

licensee’s RSO that he was unfamiliar with the licensee’s program and license. This licensee 

had an extensive calibration program that was used to calibrate its own radiation detection 

instruments, pocket dosimeters, and alarming rate meters; however, none of the licensee’s 

calibration program was reviewed by the Program inspector. Further, NSTS data was not 

reviewed during this inspection, nor were the licensee’s increased controls requirements, such 

as trustworthy and reliability determinations. At one point during the accompaniment, the 

Program inspector told the licensee that they were not allowed to transfer a radiography camera 

to its Kentucky field office because the Kentucky field office was not on its Georgia license, 

indicating that the inspector was unfamiliar with licensing and jurisdictional boundaries. The 

inspector also told the licensee that a leak test needed to be performed each time that the 

radiography cameras were transferred to another location, which indicated that the inspector 

was unfamiliar with industrial radiography requirements. This is especially important, because 

this particular inspector performed four out of the seven industrial radiography inspections 

during this review period. Finally, the Program inspector only interviewed the RSO, and did not 

perform interviews of any of the radiographers or radiographer’s assistants present at the 

facility. 

During another of the inspector accompaniments, the inspector was not cognizant of the 

requirements for the two independent physical controls necessary to prevent unauthorized 

removal of a nuclear gauge when left unattended. The review team recommends that the State 

perform a causal analysis regarding the deficiencies identified during the NRC accompaniments 

of the Program inspectors, as documented in this section as well as Appendix C of this report, 

and formulate corrective actions for the causes identified during this analysis. 

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

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

found unsatisfactory. 
Georgia Final IMPEP Report Page 8 

3.4 Technical Quality of Licensing Actions

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

36 specific licensing actions involving 27 specific licenses. Licensing actions were reviewed for 

completeness, consistency, proper radioisotopes and quantities, qualifications of authorized 

users, adequacy of facilities and equipment, adherence to good health physics practices, 

financial assurance, operating and emergency procedures, appropriateness of license 

conditions, and overall technical quality. The casework was also reviewed for timeliness, use of 

appropriate deficiency letters and cover letters, reference to appropriate regulations, supporting 

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

review, and proper signatures. 

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

completed during the review period. Licensing actions selected for evaluation included 8 new 

licenses, 3 renewals, 6 termination actions, and 19 amendments. Files reviewed included a 

cross-section of license types: broad scope, medical diagnostic and therapy, industrial 

radiography, research and development, nuclear pharmacy, gauges, manufacturers, and selfshielded irradiators. The casework sample represented work from all current license reviewers. 

A list of the licensing casework evaluated, with case-specific comments, is provided in 

Appendix D. 

The Program has five license reviewers responsible for licensing in six geographical regions. 

One of the staff is currently only trained to do portable nuclear gauge licenses and 

amendments. This reviewer is being trained to write licenses for diagnostic nuclear medicine 

licensees. Each of the remaining four license reviewers has a specific region assigned to them, 

and they are responsible for the licensing in that region. Licensing actions are assigned by 

administrative staff directly to the license reviewer who is responsible for the region from which 

the licensing request originated. The workload for the remaining two unstaffed regions is 

shared by the license reviewers. Tracking numbers are assigned and logged into a computer 

tracking system. 

After the technical review is completed, a license reviewer will place his or her action on a 

review table. The Program manager will then assign a secondary review to a peer license 

reviewer, or performs the secondary review herself. Documentation of the secondary review 

and the dates of discussions with the licensee and peer reviewer are documented on a routing 

form. If a license reviewer has authority to sign for a particular type of licensing action, the 

action is then processed and logged in an electronic tracking system. The Program manager 

authorizes license reviewers to sign licensing actions. Each license reviewer has a form 

documenting what licensing actions he or she is authorized to sign. If a license reviewer is not 

yet authorized to sign a type of license, the Program manager will sign the license document 

after the secondary peer review. 

License tie-down conditions, including previously omitted security requirements, were stated 

clearly and inspectable. Deficiency letters were usually sent via email and follow-up telephone 

calls were documented in the licensee file. Both deficiency letters and follow-up telephone calls 

clearly stated regulatory positions, were used at the proper time, and identified substantive 

deficiencies in the licensees’ documents. Licenses are issued for a five-year period under a 

timely renewal system. 
Georgia Final IMPEP Report Page 9 

License reviewers use the Program’s licensing guides that are similar to the NUREG-1556 

series. Several of the Program’s licensing guidance documents had not been updated since 

new regulations were adopted in 2008. Specifically, the Program’s medical guidance had not 

been updated to include new regulatory requirements regarding authorized user training and 

experience, including the need for preceptor attestation. The review team recommends that the 

State update its medical licensing guidance documents to be consistent with Georgia 

regulations. 

The review team identified five medical licenses that included authorized users that were added 

to the license without proper documentation to verify the training, experience, and preceptor 

attestation. The review team brought this to the attention of the Program. The Program 

manager and license reviewers indicated a misunderstanding regarding preceptor attestation 

requirements, as stated in the Georgia regulations, in situations where a potential authorized 

user is board certified. Due to this misunderstanding, the Program did not request preceptor 

attestation information for potential authorized users who submitted board certification 

documentation. The review team recommends that the State verify that all previously approved 

medical authorized users have proper documentation of their qualifications, since the new 

requirements were initiated in 2008. 

The review team analyzed the Program’s methodology for identifying Increased Controls 

licenses. The review team confirmed that license reviewers evaluated new license applications 

and license amendments using a three-step program. The Program’s pre-licensing review 

forms incorporate the essential elements of the NRC’s revised pre-licensing guidance to verify 

that the applicant will use requested radioactive materials as intended. Eight new licenses were 

reviewed but only one of those reviewed received a pre-licensing visit. Review of the form and 

interviews with the Program manager and license reviewers indicate that the intent of the prelicensing form was misunderstood. New licenses issued to previously unlicensed entities did 

not prompt further investigation into whether a pre-licensing visit was required. Examples of 

failures in the pre-licensing process include a new nuclear pharmacy license that was not 

reviewed using the Program’s guidance, and a new industrial radiography license which was 

properly identified as needing Increased Controls but did not receive a pre-licensing visit to 

ensure that the radioactive material would be used as intended and that security measures were 

implemented prior to obtaining material. The industrial radiography licensee was inspected for 

the first time, 11 months after issuance. The review team referred the Program to pre-licensing 

guidance in Radiation Control Program Directors (RCPD) letter RCPD-08-020 “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.” 

The review team recommends that the State implement pre-licensing guidance for all licensing 

actions to provide assurance that radioactive material will be used as specified on the license. 

As stated above, the review team noted repeated examples of issues with thoroughness, 

completeness, consistency, clarity, technical quality, and adherence to existing licensing 

guidance. The instance of not performing a pre-licensing visit for an industrial radiography 

license posed a potential security threat. 

The Program manager indicated that State open records laws prohibit the Program from 

routinely marking licenses or documents containing security-related information as 

recommended in RCPD-11-005 “Additional Guidance and Clarification Regarding the Review of 
Georgia Final IMPEP Report Page 10 

the Control of Sensitive Information during Integrated Materials Performance Evaluation 

Program Reviews.” License reviewers indicated that they encourage licensees to mark 

documents as “sensitive” if they want information withheld. If a licensee indicates in a document 

that any information is sensitive or a trade secret, the marked documentation is put in a 

separate locked file cabinet. If records are requested by a member of the public, the documents 

are reviewed and potentially withheld, as appropriate. 

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

that Georgia’s 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 Branch’s response to the questionnaire relative to 

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

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

for 13 radioactive materials incidents. A list of the incident casework examined, with casespecific comments, may be found in Appendix E. The review team also evaluated the 

Program’s response to nine allegations involving radioactive materials, including five allegations 

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

The incidents selected for review included the following categories: medical event, leaking 

source, damaged equipment, contamination, transportation, lost/stolen radioactive material, and 

dose to embryo/fetus. Of the 13 incidents reviewed, 7 were reportable to the NRC. There were 

two additional incidents whose reportability was unclear due to a lack of supporting information. 

Two of the seven incidents determined to be reportable within 24 hours had not been reported 

by the State to the NRC Headquarters Operations Center. These incidents were reported 

subsequent to the IMPEP review. For two incidents, there was insufficient information in the 

Program’s incident file to determine whether or not they were reportable to the NRC within 

24 hours. Specifically, the licensee’s reports indicate that the dose to the embryo/fetus for both 

incidents is “greater than 500 millirem,” but the final dose determination was not available in the 

Program’s incident files. Depending on the final dose, these incidents could be a 24-hour 

reportable event to the NRC and could meet the Abnormal Occurrence reporting criteria. Both 

of the incidents were reported in NMED as 30-day reports. These incidents were reported to 

the NRC Headquarters Operations Center following the IMPEP review. In addition, two of the 

seven reportable incidents were not promptly reported to NMED. 

The review team found that although the Program understands “how” to report incidents to the 

NRC, some Program members did not know which types of incidents were reportable or how to 

determine whether or not an incident was reportable. The review team identified many items in 

NMED, including several for reportable incidents, which were identified in NMED as incomplete, 

resulting in the NMED contractor requesting additional information from the Program about the 

incidents. Those requests for additional information remain unanswered. The review team 

recommends that the State develop, document, provide training to the Program staff on, and 

implement a procedure to notify the NRC of reportable incidents in a complete, timely, and 

accurate manner in accordance with Office of Federal and State Materials and Environmental 

Management Programs Procedure SA-300 “Reporting Material Events.” 
Georgia Final IMPEP Report Page 11 

The review team’s evaluation of selected incident case files found that the Program’s responses 

to reported incidents were not well coordinated, not consistent, and in several cases, not 

thorough. The Program’s level of effort was often not commensurate with the potential health 

and safety significance of the incident. Based on a review of Program procedures and 

discussions with the Program manager and technical staff, it was revealed that the Program did 

not have either formal or informal procedures to respond to radioactive materials incidents. 

Incidents reported by licensees were typically reported directly to Program inspectors. Due to 

the lack of incident evaluation and response processes or procedures, when the Program 

inspectors received notification of an incident, there was no consistent approach to perform an 

initial evaluation of the safety or security significance of an incident. Furthermore, there was no 

clear expectation that the Program manager be informed of reported incidents, and as a result, 

the Program manager was unaware of several reported incidents until they were discussed by 

the review team. Because the Program manager was unaware of many reported incidents 

along with the lack of procedures for incident response, the review team determined that there 

was no consistent approach to determine the type, level, or timeliness of Program response. 

On-site incident evaluation was performed for 2 of the 13 incident case files reviewed. For the 

first incident, a Program inspector performed an on-site inspection to evaluate the 

circumstances that led to the loss of a package containing sealed sources for therapy. For the 

second incident, the Environmental Radiation Protection Branch responded to the scene of a 

transportation incident involving several damaged portable nuclear gauges. For the remainder 

of the 13 case files, on-site inspections or evaluation of incidents were not performed by the 

Program. Although on-site inspections might not be warranted in all cases, there was no 

systematic approach by the Program to evaluate which incidents were of actual or potential 

safety consequence and warranted on-site inspection. The Program inspectors waited for the 

licensee’s written report rather than perform an on-site review. The review team found that the 

Program’s review of licensee written reports was not thorough. In several cases, the Program’s 

review of licensee written reports did not identify missing information required by regulation to 

be contained in written reports. In some cases, the Program did not identify that licensee 

written reports were missing corrective actions to prevent recurrence or did not recognize that 

the licensee’s identified actions were inadequate to prevent recurrence. 

Several of the reported incidents that the Program did not respond to with an on-site inspection 

warranted a more detailed review by the Program, including an on-site presence to review 

licensee actions and perform an independent evaluation of the circumstances of the incident. 

During the review period, licensees reported three medical events, although only one was 

considered a medical event by the Program. In one case involving permanent implant prostate 

brachytherapy, the Program inspector did not recognize that it was a probable medical event 

even though the licensee reported that the administered dose to the prostate gland met the 

requirement for a medical event (i.e., was less than 80 percent of the prescribed dose). Another 

medical event involved yttrium-90 microspheres that leaked between the vial and the catheter 

during infusion. The inspector considered this a spill or contamination incident, not recognizing 

the potential medical event. The inspector indicated that he relied on the licensee’s conclusion 

that no harm or medical event occurred. In this case, the leakage of the microspheres could 

indicate a potential generic problem with equipment and warranted follow-up. 

Another incident that warranted additional review, including an on-site inspection by the 

Program, was a contamination incident involving nickel-63. The incident involved a researcher 
Georgia Final IMPEP Report Page 12 

who was using 25 millicuries of nickel-63 in aqueous solution. A licensee survey of the 

laboratory indicated levels of nickel-63 that were up to 220 times the licensee’s action level. 

This resulted in the closure of the laboratory and additional surveys of adjacent areas, including 

hallways and a restroom. Two days later, when additional contamination was detected, the 

licensee notified the Program and took actions to restrict access to the entire building for almost 

three days. Licensee efforts to contain and decontaminate affected areas took over a week but 

the Program did not respond to the incident. The licensee’s written report identified potential 

violations but the Branch did not issue any enforcement action. The review team found that the 

Program’s response to the incident was not commensurate with the potential consequences. 

The review team questioned the Program manager regarding this incident and the lack of an 

appropriate response. The Program manager stated that it was the first time she had heard of 

the incident. 

The review team recommends that the State strengthen its incident response program and take 

measures to (1) develop, document, implement, and provide training to the Program on the 

incident response procedure; (2) ensure that reported incidents are promptly evaluated to 

determine the appropriate type and level of Program response, including providing for Program 

management notification and review; (3) ensure that incidents are responded to with an 

appropriate level of effort and in a timeframe commensurate with the potential health and safety 

and/or security consequences of the incident; (4) ensure that licensee written reports are 

reviewed for completeness and appropriate corrective actions; and (5) ensure that the 

Program’s evaluation of licensee incidents, whether based on a review of licensee reports, 

on-site reviews, or inspection follow-up, is properly documented to facilitate future follow-up. 

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

evaluated the completed casework for nine allegations, including five that the NRC referred to 

the State during the review period. The review team concluded that the Program’s actions in 

response to allegations were not well coordinated, not consistent, and not well documented. 

The review team found that the Program often failed to take prompt and appropriate actions in 

response to concerns raised. 

The five allegations that were referred to the State by the NRC during the review period were 

discussed with the Program manager and appropriate technical staff. The first allegation, which 

was forwarded to the State in December 2009, was related to prostate brachytherapy 

procedures and had been put on hold by the Program manager. The stated reason it was put 

on hold was because the inspector was having difficulty understanding and addressing the 

concern. No documentation of the Program’s actions in this case was available for review and 

the allegation continues to be on hold since December 2009. The second allegation referred to 

the State by the NRC related to scrap metal and nuclear laundry activities. The Program 

manager was unable to identify what actions were taken to address the allegation. The third 

allegation referred to the State by the NRC regarded an alleged impropriety by licensee 

personnel that was not related to regulatory requirements. The fourth allegation referred to the 

State by the NRC involved radiation levels in a public area. The Program manager stated that 

this allegation was reviewed by a former Program member; however, documentation regarding 

the results of the allegation evaluation was not available for review. The fifth allegation, which 

was forwarded to the State by the NRC in September 2012, involved a medical licensee and as 

of the date of the IMPEP review, had not yet been assigned to a staff member for evaluation. 
Georgia Final IMPEP Report Page 13 

The review team examined the Program’s response to four allegations that were directly 

received by the Program. The first allegation regarded the alleged use of improper radiological 

boundaries by a radiography licensee. The inspector’s evaluation appeared appropriate, was 

documented, and a verbal discussion of the outcome of the evaluation was provided to the 

alleger. The second allegation received by the State was related to a spill of radioactive 

material. The inspector who received the allegation concluded that the short half-life did not 

warrant that the State take any action, and the allegation was closed. The third allegation was 

received a few days after the second allegation. This allegation was from a different individual 

regarding the same facility from the second allegation, and also related to an alleged spill of 

radioactive material in addition to other radiation safety concerns. An inspector was dispatched 

to the licensee facility, documented the results of his evaluation, and provided verbal follow-up 

to the alleger. 

The fourth allegation was received in December 2010, from a member of the public that 

purchased an abandoned storage unit and had inadvertently acquired an abandoned device 

containing an americium-241 sealed source. The individual stated that he would store the 

device and requested the Program’s assistance in disposing of the device. The Program 

inspector who received the allegation made an attempt to locate the original owner of the device 

but took no further action when the attempt was unsuccessful. The review team discussed this 

allegation with the inspector during the review. The inspector said that no action had been 

taken since receipt of the allegation and that he was unaware of the status of the device. The 

review team discussed this with the Program manager, who expressed that she was unaware of 

the allegation and that had she been aware she would have taken action to recover the device 

or arrange for its disposal. Following this discussion, the Program manager took immediate 

action and contacted the member of the public. Fortunately, after almost two years, the 

individual still possessed the device, which he had wrapped in plastic and stored under an 

out-building on his property. The Program manager made arrangements for an inspector to 

recover the device from the member of the public later in the week. 

The Program has a procedure to address allegations, entitled “Allegation Procedure,” dated 

October 2004. The procedure includes guidance on allegation receipt, timeliness of allegation 

evaluation, and expectations for providing written follow-up to allegers. An allegation receipt 

form and a sample close-out letter to allegers are included in the procedure. The review team 

determined that the Program was not consistently implementing the Program’s allegation 

procedure. As a result, allegations were not being tracked to ensure timely and thorough 

review, completion, and response to allegers. Furthermore, Program management was not 

aware of all received allegations. The review team noted that in several cases, the Program did 

not document the results of investigations of allegations and did not retain all necessary 

documentation to appropriately close allegations. The review team was informed that the 

Program is unable to protect the identity of allegers but makes every attempt to avoid disclosure 

of such information. 

The review team recommends that the State revise, enhance, implement, and provide training 

to the staff on its allegation procedure, including providing additional written guidance and 

training on (1) recognizing and identifying allegations; (2) notifying Program management of all 

received allegations; (3) promptly evaluating allegations for safety and security significance; 
Georgia Final IMPEP Report Page 14 

(4) ensuring that the level of effort and timeliness in responding to allegations is commensurate 

with the potential significance of the allegation; and (5) tracking all allegations to ensure timely 

review and closure of allegations and timely feedback to allegers. 

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

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

Allegation Activities, be found unsatisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS 

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

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

Agreement with Georgia 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

Georgia became an Agreement State on December 15, 1969. The current effective statutory 

authority is contained in the Official Code of Georgia Annotated, Title 31 Chapter 13. The 

Department is designated as the State’s radiation control agency. The Branch implements the 

radiation control program. 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 Georgia regulations governing radiation protection requirements are located in Chapter 

391 of the Georgia Administrative Code and apply to all ionizing radiation. Georgia requires a 

license for possession and use of all radioactive material. Georgia also requires registration of 

all equipment designed to produce ionizing radiation. 

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

process takes approximately one year from the development stage to the final approval by the 

Board of Natural Resources, after which the rule becomes effective in 20 days. The public, the 

NRC, other agencies, and potentially impacted licensees and registrants are offered an 

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

appropriate, before the regulations are finalized and approved. The review team noted that the 

State’s rules and regulations are not subject to sunset laws. 

The review team evaluated Georgia’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. 
Georgia Final IMPEP Report Page 15 

During the review period, Georgia submitted one final regulation amendment and no proposed 

regulation amendments or legally binding license conditions to the NRC for a compatibility 

review. Current NRC policy requires that Agreement States adopt certain equivalent regulations 

or legally-binding requirements no later than three years after they become effective. 

At the time of this review, the following four amendments were overdue: 

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

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

(72 FR 58473), that was due for Agreement State adoption by December 17, 2010. 

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

32, 33, 35, 61, 150 amendment (72 FR 55864), that 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 amendment (72 FR 68043), that was due for Agreement State 

adoption by February 15, 2011. 

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

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

28, 2012. 

The Branch has drafted proposed regulations for these four amendments and plans to submit 

them to the NRC for review in the spring of 2013. As noted in the 2008 IMPEP report, which 

covered a review period from August 27, 2004, through September 26, 2008, the Board 

approved nine regulation amendments in final on September 24, 2008. These nine regulation 

amendments became effective on November 6, 2008. Six of the nine regulation amendments 

adopted were overdue for adoption. A list of regulations that are due for adoption can be found 

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

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

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

satisfactory. 

4.2 Sealed Source and Device Evaluation Program

In reviewing this indicator, the review team used three subelements to evaluate the Program’s 

performance regarding the Sealed Source and Device (SS&D) Evaluation Program. These 

subelements are (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 Georgia SS&D evaluation activities, the review team examined the Branch’s 

response to the IMPEP questionnaire on this indicator, performed a search of the SS&D 

Registry for registrations issued by Georgia, and performed NMED searches of manufacturers 

and distributors identified on SS&D registrations issued by Georgia. A review of new and 

amended SS&D registration evaluations and supporting documents covering the review period 
Georgia Final IMPEP Report Page 16 

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

SS&D registry evaluation responsibilities currently are performed by two qualified reviewers 

where one of the reviewers (the Program manager) only performs the concurrence review. The 

Program has two reviewers in training to become full reviewers, but they are not currently active 

in the SS&D program. The review team was informed that the Program’s vacant Environmental 

Planning Specialist position that has SS&D review job descriptions has been reclassified as an 

Environmental Compliance Specialist. There has been no change in SS&D staffing levels since 

the 2008 review. Due to the time delays in processing current SS&D requests and related 

licensing actions and the existing backlog of registry inactivations, as outlined below, the review 

team has concerns that the current SS&D staffing level may be insufficient to maintain the 

program. A recommendation was made to the State in 2004 to qualify one additional reviewer 

in SS&D evaluations to provide backup for the principal reviewers. That recommendation 

remains open, as discussed in Section 2.0. 

The Program has a documented qualification program for SS&D reviewers as a subsection of its 

overall Licensing Evaluator Qualification Procedures. The SS&D qualification procedures 

require that reviewers in training be trained in-house with oversight from the senior SS&D 

reviewers. 

4.2.2 Technical Quality of the Product Evaluation Program

During the review period, the Program processed 13 SS&D actions from seven different 

distributors. Only one of these distributors actually possesses radioactive materials related to 

the manufacturing, assembly and distribution under a SS&D registration. The other six 

distributors either do not possess radioactive materials used in the SS&D registration or are for 

foreign vendors where the product is manufactured overseas and dropped shipped to the 

customer. All six of these distributors are authorized to provide servicing of their products 

(installation, surveys, relocations, repair, leak testing, etc.) at customer sites. Of the 13 SS&D 

actions, six were amendments in their entirety and seven were new applications. Four of the 

seven new applications were transferred from Arizona and one of the new applications was 

transferred from Georgia to Virginia. There were no inactivations of SS&D registrations or 

emerging technology evaluations processed during the review period. 

The review team evaluated six actions completed during the review period consisting of four 

new applications and two amendments in their entirety. The actions selected for review 

included the one distributor who actually possesses radioactive materials. The casework 

selected for review was representative of two qualified reviewers, one of whom while qualified 

for a full review, only performed concurrence reviews during the review period. A list of the 

SS&D registrations evaluated by the review team, with case-specific comments, may be found 

in Appendix F. 

The Program performed evaluations based on sound conservative assumptions to ensure public 

health and safety is adequately protected. Good health physics practices were implemented 
Georgia Final IMPEP Report Page 17 

throughout this review period. As a means to legally enforce the commitments made for the 

SS&D actions, the Program incorporates these commitments into the radioactive materials 

license authorizing the distribution as a unique license condition listing the SS&D registry 

number in the tie-down condition. It is the policy of the Program to issue the radioactive 

materials license amendments with the issuance of the registration sheets. During the on-site 

visit, the review team identified one instance where the Program omitted these license 

conditions and therefore did not provide a means to legally enforce these commitments. 

Subsequent to the on-site review, an amendment was issued to correct this license. 

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

contained in the questionnaire response and interviewed program staff and managers. The 

review team confirmed that the Program follows the recommended guidance from the NRC 

SS&D Workshop, NUREG-1556, Volume 3, applicable and pertinent American National 

Standards Institute (ANSI) and Military standards, ISO-9001 and Georgia regulations, statutes, 

policies and procedures. The review team verified that these documents were available and 

were used appropriately in performing SS&D reviews. Deficiency correspondence clearly stated 

regulatory positions and all health and safety issues were addressed. 

While the review team determined that product evaluations were complete and adequately 

addressed the integrity of the products during use and in the event of accidents, a few items 

were noted. The review team identified that one registration was missing the radiation dose rate 

profile at one meter as required in NUREG-1556, Volume 3 and that three of the registrations 

did not follow the format and content recommended in NUREG-1556, Volume 3 where the date 

on the registration’s page one 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 page one information), the documents 

should be consistent with national standards. 

The review team noted that there were occasionally a significant time lag between receiving 

SS&D action requests and when work began on these requests. Two actions were more than a 

year between application date and issuance and one action appeared to be reviewed only in 

conjunction with the license renewal that was submitted more than five years earlier. Another 

registry action took more than five months for a minor amendment and the corresponding 

license amendment authorizing its distribution was not completed until more than 14 months 

from that date. The review team also noted that the Program has in excess of 40 registry 

sheets that are no longer active due to licensees’ discontinuation of product lines, license 

terminations, or have requested SS&D inactivations and license terminations that have not been 

processed. This issue was also noted during the 2008 review. SS&D registrations need to be 

inactivated to let other regulatory agencies know that that product line is no longer in production 

and additional care needs to be taken regarding obtaining servicing for or disposal of these 

products containing radioactive material. The review team recommends that the State develop 

and implement a plan to inactivate SS&D registrations for devices and sources that are no 

longer being made or distributed. 

The review team determined the Program has not started reviewing two of the three SS&D 

actions indentified in the questionnaire as “under review”. These actions were received in 

March and May, 2012. Also, the Program is aware that a Georgia licensee, Elekta, Inc. has 

acquired Nucletron, currently located in Maryland, and that in May 2012 the Program received 
Georgia Final IMPEP Report Page 18 

an application from Elekta for a radioactive materials distribution license and up to seven new 

SS&D applications for the current HDR devices authorized under the Maryland license. While 

the Program has not started reviewing these applications at the time of the review, they have 

been in contact with Elekta regarding licensing and SS&D requirements needed to obtain a 

Georgia license. 

4.2.3 Evaluation of Defects and Incidents Regarding SS&Ds

Based upon the Branch’s response to the questionnaire, interview of Program personnel, and 

the review team’s searches of NMED, the review team selected a suspect incident reported 

during the review period involving SS&D products registered in Georgia. NMED No. 120591 

was reviewed because the event description described a potential product defect. After 

reviewing the incident with the SS&D reviewer, the review team determined this incident was 

not related to a SS&D product defect but due to an implementation issue regarding the 

licensee’s other QA/QC processes. The Program manager stated that they confirmed with the 

SS&D distributor that the QA/QC program related to the SS&D is being implemented. 

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

that Georgia’s performance with respect to the indicator, Sealed Source and Device Evaluation 

Program, be found satisfactory. 

4.3 Low-level Radioactive Waste Disposal Program

In 1981, the NRC amended its Policy Statement, "Criteria for Guidance of States and the 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 Georgia 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 

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

5.0 SUMMARY 

The review team identified an overall declining performance by the Georgia Agreement State 

Program. Significant deficiencies were noted throughout the program and have the potential to 

impact public health and safety, if left uncorrected. The review team observed a basic 

misunderstanding of several important safety and security parameters by staff and 

management. The review team also observed significant communication issues between staff 

and management which affected the safety culture of the program. 

As noted in Sections 3.0, and 4.0 above, the review team recommended, and the MRB agreed, 

that Georgia’s performance be found unsatisfactory for the performance indicators: Technical 

Quality of Inspections and Technical Quality of Incident and Allegation Activities. The review 

team recommended, and the MRB agreed, that Georgia’s performance be found satisfactory, 

but needs improvement for the performance indicators: Technical Staffing and Training, Status 
Georgia Final IMPEP Report Page 19 

of Materials Inspection Program, and Technical Quality of Licensing Actions. The review team 

found Georgia’s performance to be satisfactory for the two non-common performance indicators 

reviewed. The review team made 11 new recommendations regarding the performance of the 

State and kept open a recommendation from the 2008 IMPEP review. 

Accordingly, the review team recommended, and the MRB agreed, that the Georgia Agreement 

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

and compatible with the NRC’s program. Agreements between the NRC and a State assume 

that certain tasks be prioritized and performed in an effective and efficient manner. Prominent 

among these tasks is the response to incidents involving radioactive materials. When a 

Program becomes aware of a significant incident, the Program is obligated, under the 

Agreement, to promptly respond to ensure that public health and safety is protected. 

Additionally, prioritizing inspections of high priority licensees, such as industrial radiographers, is 

important because of the significant potential for harm if the radioactive material is not controlled 

properly. Due to the prioritization problems noted during the review, the review team 

considered whether to recommend that the Georgia program was compatible, or not, with the 

NRC's program. After some discussion and examination of the NRC’s policy statements on the 

subject, the review team decided to recommend that, despite the problems noted, Georgia be 

found compatible with the NRC’s program. 

Based on the results of the current IMPEP review, and in accordance with the criteria in the 

NRC Management Directive 5.6, the review team recommended, and the MRB agreed, that the 

period of Monitoring be discontinued and that the Georgia Agreement State Program be 

recommended to be placed on Probation. Specifically, the review team notes that Management 

Directive 5.6 states that in cases where program weaknesses exist regarding the adequacy 

and/or compatibility of an Agreement State’s program yet the weaknesses are not so serious as 

to find the program inadequate to protect public health and safety, one of the options available 

to ensure continued protection of public health and safety, is to place the Agreement State on 

Probation. Probation is a formalized process that requires Commission approval. If approved, a 

press release and notifications to the Governor and Congressional delegation will be made. 

Probation also requires a program improvement plan and an increased level of communication 

between the NRC staff and the State program office. 

The review team further recommended, and the MRB agreed, that a full IMPEP review be 

conducted within one year of the Management Review Board meeting to assess the State’s 

progress in addressing the open recommendations and the programmatic issues identified 

during this review. 

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 State develop and implement a plan to complete 

higher priority and initial inspections in accordance with the inspection frequencies 

specified in IMC 2800. (Section 3.2) 

 
Georgia Final IMPEP Report Page 20 

2. The review team recommends that the State update its inspection procedures to include 

the most recent revisions to Inspection Manual Chapter 2800, including the 

implementation of inspection guidance for NSTS reviews. (Section 3.3) 

3. The review team recommends that the State perform Increased Controls security 

inspections at least as frequently as the priority of the license being inspected. (Section 

3.3) 

4. The review team recommends that the State perform a causal analysis regarding the 

deficiencies identified during the NRC accompaniments of the Program inspectors, as 

documented in this section as well as Appendix C of this report, and formulate corrective 

actions for the causes identified during this analysis. (Section 3.3) 

5. The review team recommends that the State update its medical licensing guidance 

documents to be consistent with Georgia regulations. (Section 3.4) 

6. The review team recommends that the State verify that all previously approved medical 

authorized users have proper documentation of their qualifications, since the new 

requirements were initiated in 2008. (Section 3.4) 

7. The review team recommends that the State implement pre-licensing guidance for all 

licensing actions to provide assurance that radioactive material will be used as specified 

on the license. (Section 3.4) 

8. The review team recommends that the State develop, document, provide training to the 

Program staff on, and implement a procedure to notify the NRC of reportable incidents in 

a complete, timely and accurate manner in accordance with Office of Federal and State 

Materials and Environmental Management Programs Procedure SA-300 “Reporting 

Material Events.” (Section 3.5) 

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

and take measures to (1) develop, document, implement, and provide training to the 

Program on the incident response procedure; (2) ensure that reported incidents are 

promptly evaluated to determine the appropriate type and level of Program response, 

including providing for Program management notification and review; (3) ensure that 

incidents are responded to with an appropriate level of effort and in a timeframe 

commensurate with the potential health and safety and/or security consequences of the 

incident; (4) ensure that licensee written reports are reviewed for completeness and 

appropriate corrective actions; and (5) ensure that the Program’s evaluation of licensee 

incidents, whether based on a review of licensee reports, on-site reviews, or inspection 

followup, is properly documented to facilitate future followup. (Section 3.5) 

10. The review team recommends that the State revise, enhance, implement, and provide 

training to the staff on its Allegation Procedure, including providing additional written 

guidance on (1) recognizing and identifying allegations; (2) notifying Program 

management of all received allegations; (3) promptly evaluating allegations for safety 

and security significance; (4) ensuring that the level of effort and timeliness in 
Georgia Final IMPEP Report Page 21 

responding to allegations is commensurate with the potential significance of the 

allegation; and (5) tracking all allegations to ensure timely review and closure and timely 

feedback to allegers. (Section 3.5) 

11. The review team recommends that the State qualify one additional reviewer in SS&D 

evaluations to provide backup for the principal reviewer. This is in addition to a qualified 

reviewer or supervisor performing concurrence reviews. (Section 4.2 of the 2004 IMPEP 

report and 2013 IMPEP MRB). 

12. The review team recommends that the State develop and implement a plan to inactivate 

SS&D registrations for devices and sources that are no longer being made or distributed. 

(Section 4.2.2) 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Georgia 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

Jim Lynch, Region III Team Leader 

 Status of Materials Inspection Program 

 Inspector Accompaniments 

Monica Orendi, Region I Technical Staffing and Training 

 Compatibility Requirements 

James Thompson, Region IV Technical Quality of Inspections 

 Inspector Accompaniments 

Diana Sulas, North Carolina Technical Quality of Licensing Actions 

Janine Katanic, FSME Technical Quality of Incident & Allegation Activities 

Mike Stephens, Florida Sealed Source and Device Evaluation Program 

 Technical Quality of Licensing Actions 
APPENDIX B 

GEORGIA ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML12278A179 
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Robert T. Hart License No.: 1189-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 4/20/11 Inspector: EJ 

Comments: 

a) This inspection performed overdue; last inspection was 7/16/09. 

b) NSTS review not performed. 

File No.: 2 

Licensee: Hurst Boiler and Welding License No.: 0918-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 1/27/11 Inspector: KR 

Comments: 

a) This inspection performed overdue; last inspection was 6/23/08. 

b) NSTS review not performed. 

c) Security violation for this inspection issued on 5/6/11; however, 

no licensee response was received nor Program followup performed. 

File No.: 3 

Licensee: Mistras Group License No.: 1615-1 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 3/8/12 Inspector: JM 

Comment: NSTS review not performed 

File No.: 4 

Licensee: Acuren Inspection License No.: 1115-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 7/7/11 Inspector: KR 

Comments: 

a) This inspection performed overdue; last inspection was 7/29/09. 

b) NSTS review not performed. 

 
Georgia Final IMPEP Report Page C.2 

Inspection Casework Reviews 

File No.: 5 

Licensee: Applied Technical Services License No.: 0896-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 9/26/12 Inspector: KR 

Comments: 

a) No security review performed during this inspection. 

b) NSTS review not performed. 

File No.: 6 

Licensee: Jan-X Integrity License No.: 1369-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 7/21/11 Inspector: JM 

Comments: 

a) This inspection performed overdue; last inspection was 5/8/08. 

b) NSTS review not performed. 

File No.: 7 

Licensee: Sowega Testing Services License No.: 0923-1 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 10/8/09 Inspector: KR 

Comment: This licensee is currently overdue for inspection, as of 10/26/12. 

File No.: 8 

Licensee: John D. Archbold Hospital License No.: 0078-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 7/29/10 Inspector: KR 

File No.: 9 

Licensee: Arch Chemicals License No.: 1619-1 

Inspection Type: Initial, Announced Priority: 3 

Inspection Date: 12/13/11 Inspector: IB 

File No.: 10 

Licensee: Cardinal Health License No.: 1609-1 

Inspection Type: Initial, Announced Priority: 2 

Inspection Date: 10/27/11 Inspector: KC 

File No.: 11 

Licensee: Emory University License No.: 0153-1 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 6/12/12 Inspector: JM 

Comment: This inspection performed overdue; last inspection was 6/10/06. 
Georgia Final IMPEP Report Page C.3 

Inspection Casework Reviews 

File No.: 12 

Licensee: Theragenics Corporation License No.: 0881-5 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 6/21/12 Inspector: EJ 

Comment: This inspection performed overdue; last inspection was 9/18/08. 

File No.: 13 

Licensee: Savannah Oncology Center License No.: 1119-1 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 1/6/11 Inspector: TC 

Comment: This inspection performed overdue; last inspection was 6/5/08. 

File No.: 14 

Licensee: Redmond Regional Medical License No.: 0165-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 5/26/11 Inspector: JM 

Comment: This inspection performed overdue; last inspection was 5/14/07. 

File No.: 15 

Licensee: Harbin Clinic License No.: 1278-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 12/9/10 Inspector: JM 

File No.: 16 

Licensee: Shashikant A. Daya License No.: 1545-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 9/16/10 Inspector: TC 

File No.: 17 

Licensee: Clark Holder Clinic License No.: 1358-1 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 12/16/10 Inspector: TC 

File No.: 18 

Licensee: Georgia Urology License No.: 1510-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 7/26/11 Inspector: KC 

File No.: 19 

Licensee: Dalton Imaging Center License No.: 1222-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 12/7/11 Inspector: JM 

 
Georgia Final IMPEP Report Page C.4 

Inspection Casework Reviews 

File No.: 20 

Licensee: Central Georgia Diagnostic License No.: 1093-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 7/21/11 Inspector: KR 

File No.: 21 

Licensee: Atlanta Outpatient Surgery License No.: 1325-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 11/2/10 Inspector: TC 

File No.: 22 

Licensee: Georgia Cardiology Center License No.: 1341-1 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 8/2/12 Inspector: KR 

File No.: 23 

Licensee: Morpho Detection License No.: Reciprocity 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 5/29/12 Inspector: IB 

File No.: 24 

Licensee: Ameriphysics License No.: Reciprocity 

Inspection Type: Reciprocity, Unannounced Priority: 5 

Inspection Date: 2/17/12 Inspector: JM 

File No.: 25 

Licensee: Best Theratronics License No.: Reciprocity 

Inspection Type: Reciprocity, Unannounced Priority: 3 

Inspection Date: 4/4/12 Inspector: JM 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: American Red Cross Blood Services License No.: 0096-2 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 9/11/12 Inspector: JM 

Comment: Inspector was not prepared to perform an NSTS review. 

Accompaniment No.: 2 

Licensee: Doctors Hospital License No.: 0615-1 

Inspection Type: Routine, Unannounced Priority: 2 

Inspection Date: 9/12/12 Inspector: TC 
Georgia Final IMPEP Report Page C.5 

Inspection Casework Reviews 

Accompaniment No.: 3 

Licensee: Hopewell Designs, Inc. License No.: 1434-1 

Inspection Type: Routine, Unannounced Priority: 3 

Inspection Date: 9/13/12 Inspector: EJ 

Accompaniment No.: 4 

Licensee: Stewart Brothers, Inc. License No.: 1025-1 

Inspection Type: Routine, Unannounced Priority: 5 

Inspection Date: 9/14/12 Inspector: QT 

Comment: The inspector was unaware of the two barrier portable gauge security rule. 

Accompaniment No.: 5 

Licensee: Northeast Georgia Medical Center License No.: 0199-1 

Inspection Type: HDR/nuclear medicine Priority: 2 

Inspection Date: 9/25/12 Inspector: IB 

Accompaniment No.: 6 

Licensee: Applied Technical Services License No.: 0896-1 

Inspection Type: Industrial Radiography Priority: 1 

Inspection Date: 9/26/12 Inspector: KR 

Comments: 

a) Security not reviewed. 

b) NSTS not reviewed. 

c) Inspector not well prepared for inspection. 

d) Licensee’s calibration program not reviewed during inspection. 

e) Inspector unaware of some industrial radiography requirements. 

f) Inspector unaware of licensed operations with respect to Georgia’s jurisdictional 

boundaries. 

.
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Liberty Regional Medical Center License No.: 1131-1 

Type of Action: Termination Amendment No.: 02 

Date Issued: 4/18/11 License Reviewer: JM 

File No.: 2 

Licensee: Southern Company Services, Inc. License No.: 0040-4 

Type of Action: Termination Amendment No.: 34 

Date Issued: 1/24/11 License Reviewer: TC 

File No.: 3 

Licensee: RIS Mobile License No.: 1527-1 

Type of Action: Termination Amendment No.: 02 

Date Issued: 8/7/09 License Reviewer: IB 

File No.: 4 

Licensee: Cytyc Surgical Products II License No.: 1433-1 

Type of Action: Termination Amendment No.: 07 

Date Issued: 1/18/12 License Reviewer: EJ 

File No.: 5 

Licensee: Tri County Medical Center License No.: 1484-1 

Type of Action: Termination Amendment No.: 02 

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

File No.: 6 

Licensee: Memorial Hospital of Adel License No.: 0571-1 

Type of Action: Termination Amendment No.: 25 

Date Issued: 9/6/12 License Reviewer: KR 

File No.: 7 

Licensee: Bryan County Health Department License No.: 1612-1 

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

Date Issued: 11/2/10 License Reviewer: QT 

File No.: 8 

Licensee: Accura Engineering and Consulting Services, Inc. License No.: 1511-1 

Type of Action: Amendment Amendment No.: 02 

Date Issued: 11/1/10 License Reviewer: QT 

 
Georgia Final IMPEP Report Page D.2 

License Casework Reviews 

 

File No.: 9 

Licensee: Theragenics Corporation License No.: 0881-5 

Type of Action: Renewal Amendment No.: 10 

Date Issued: 7/25/12 License Reviewer: EJ 

File No.: 10 

Licensee: Hopewell Designs, Inc. License No.: 1434-1 

Type of Action: Renewal, Amendments Amendment Nos.: 12, 13, 14 

Dates Issued: 1/7/11, 10/26/11, 12/12/11 License Reviewer: EJ 

File No.: 11 

Licensee: Yokogawa Corporation of America License No.: 1635-1 

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

Date Issued: 7/31/12 License Reviewer: EJ 

File No.: 12 

Licensee: Emory University License No.: 0153-1 

Type of Action: Renewal, Amendment Amendment No.: 64 

Date Issued: 3/19/12 License Reviewer: JM 

File No.: 13 

Licensee: Phoenix Technology Consulting, LLC License No.: 1616-1 

Type of Action: New Amendment Nos.: 00, 01, 02 

Date Issued: 7/22/11 License Reviewer: IB 

Comment: Improper use of pre-licensing guidance. 

File No.: 14 

Licensee: Northeast Georgia Imaging Center License No.: 1587-1 

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

Date Issued: 1/23/09 License Reviewer: IB 

Comment: Improper use of pre-licensing guidance. 

File No.: 15 

Licensee: Mercer Medicine, Mercer University License No.: 1628-1 

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

Date Issued: 3/6/12 License Reviewer: KR 

Comments: 

a) Improper use of pre-licensing guidance. 

b) Authorized user added to the license without proper documentation regarding training, 

experience, and preceptor attestation. 

 
Georgia Final IMPEP Report Page D.3 

License Casework Reviews 

 

File No.: 16 

Licensee: Applied Technical Services License No.: 0896-1 

Type of Action: Amendments Amendment Nos.: 49, 50 

Dates Issued: 10/14/09, 6/4/12 License Reviewer: JM 

File No.: 17 

Licensee: Honeywell International, Inc. License No.: 0832-1 

Type of Action: Amendment Amendment Nos.: 44, 45 

Dates Issued: 4/3/12, 8/23/12 License Reviewer: EJ 

File No.: 18 

Licensee: Atlanta Heart Associates, PC License No.: 1271-1 

Type of Action: Amendment Amendment No.: 15 

Date Issued: 4/6/11 License Reviewer: TC 

Comment: Authorized user added to the license without proper documentation regarding 

 training, experience, and preceptor attestation. 

File No.: 19 

Licensee: Redmond Regional Medical Center License No.: 0165-1 

Type of Action: Amendment Amendment No.: 44 

Date Issued: 9/4/12 License Reviewer: JM 

Comment: Authorized user added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 

File No.: 20 

Licensee: John D. Archbold Memorial Hospital License No.: 0078-1 

Type of Action: Amendment Amendment No.: 46 

Date Issued: 8/31/12 License Reviewer: KR 

Comment: Authorized user added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 

File No.: 21 

Licensee: Savannah Oncology Center License No.: 1119-1 

Type of Action: Amendment Amendment No.: 05 

Date Issued: 6/3/11 License Reviewer: IB 

File No.: 22 

Licensee: Harbin Clinic License No.: 1278-1 

Type of Action: Amendment, Renewal Amendment Nos.: 15, 16 

Dates Issued: 9/8/10, 6/1/12 License Reviewer: JM 

Comment: Authorized user added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 
Georgia Final IMPEP Report Page D.4 

License Casework Reviews 

 

File No.: 23 

Licensee: ROSA of Georgia License No.: 1178-1 

Type of Action: Amendment Amendment No.: 25 

Date Issued: 8/16/12 License Reviewer: TC 

Comment: Authorized users added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 

File No.: 24 

Licensee: Northside Hospital- Cherokee, Inc. License No.: 0798-1 

Type of Action: Amendment Amendment No.: 24 

Date Issued: 5/1/12 License Reviewer: IB 

Comment: Authorized users added to the license without proper documentation regarding 

training, experience, and preceptor attestation. 

File No.: 25 

Licensee: Cardinal Health License No.: 1178-1 

Type of Action: New, Amendments Amendment Nos.: 00, 01, 02, 03 

Dates Issued: 2/22/11, 7/15/11, 11/7/11, 7/10/12 License Reviewer: KC 

Comment: Pre-licensing guidance not used. 

File No.: 26 

Licensee: Mistras Group, Inc. License No.: 1615-1 

Type of Action: New, Amendment Amendment Nos.: 00, 01 

Dates Issued: 4/19/2011, 3/7/2012 License Reviewers: JM, CS 

Comment: No pre-licensing visit conducted. 

File No.: 27 

Licensee: South East Veterinary Oncology License No.: 1622-1 

Type of Action: New Amendment No.: 00 

Date Issued: 10/12/11 License Reviewer: KS 
 

APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Piedmont Fayette Hospital License No.: 1340-1 

Date of Incident: 7/6/10 NMED No.: 120675 

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

 Type of Investigation: Review licensee report 

Comments: 

a) On-site investigation not conducted. 

b) Incident not reported to the NRC Headquarters Operations Center or NMED (reported to 

the HOO post-review on 11/7/12). 

c) Licensee’s written report did not contain all of the information required by regulation, 

such as corrective actions to prevent recurrence. 

File No.: 2 

Licensee: PennTeck Diagnostics License No.: 0975-1 

Date of Incident: 1/7/12 NMED No.: N/A 

Investigation Date: 1/17/12 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Review licensee report 

File No.: 3 

Licensee: Georgia Institute of Technology License No.: 0147-1 

Date of Incident: 1/21/11 NMED No.: N/A 

Investigation Date: 1/25/11 Type of Incident: Leaking Source 

 Type of Investigation: Review licensee report 

File No.: 4 

Licensee: Building & Earth Sciences, Inc. License No.: 1136-1 

Date of Incident: 9/14/12 NMED No.: 120618 

Investigation Date: 9/14/12 Type of Incident: Damaged Equipment 

 Type of Investigation: Review licensee report 

File No.: 5 

Licensee: Emory University License No.: 0153-1 

Date of Incident: 8/5/09 NMED No.: 090656 

Investigation Date: 8/14/09 Type of Incident: Medical Event/Contamination 

 Type of Investigation: Review licensee report 

Comments: 

a) On-site investigation not conducted. 

b) The inspector did not believe that an on-site investigation was warranted because the 

medical event was the result of an underdose rather than an overdose. 

c) License’s written report did not contain corrective actions to prevent recurrence. 

 
Georgia Final IMPEP Report Page E.2 

Incident Casework Reviews 

File No.: 6 

Licensee: Northeast Georgia Medical Center License No.: 1479-1 

Date of Incident: 10/13/08 NMED No.: 080710 

Investigation Date: 10/27/08 Type of Incident: Dose to Embryo/Fetus 

 Type of Investigation: Review licensee report 

File No.: 7 

Licensee: Atlanta Heart Associates, PC License No.: 1271-1 

Date of Incident: 8/3/09 NMED No.: 090811 

Investigation Date: 8/12/09 Type of Incident: Dose to Embryo/Fetus 

 Type of Investigation: Review licensee report 

Comments: 

a) On-site investigation not conducted. 

b) The Program’s incident file did not contain the licensee’s fetal dose calculation, only that 

the dose was “greater than 500 mrem.” The inspector could not locate the fetal dose 

calculation. The dose information is necessary to determine whether the incident is an 

Abnormal Occurrence. 

c) The Program did not identify that the license’s corrective actions would not be effective 

to prevent recurrence. 

File No.: 8 

Licensee: Atlanta Heart Associates, PC License No.: 1271-1 

Date of Incident: 8/17/09 NMED No.: 090812 

Investigation Date: 8/28/09 Type of Incident: Dose to Embryo/Fetus 

 Type of Investigation: Review licensee report 

Comments: 

a) On-site investigation not conducted. 

b) The Program’s incident file did not contain the licensee’s fetal dose calculation, only that 

the dose was “greater than 500 mrem.” The inspector could not locate the fetal dose 

calculation. The dose information is necessary to determine whether the incident is an 

Abnormal Occurrence. 

c) The Program did not identify that the license’s corrective actions would not be effective 

to prevent recurrence. 

File No.: 9 

Licensee: R&L Carriers License No.: Non-licensee 

Date of Incident: 9/12/11 NMED No.: 110480 

Investigation Dates: 9/12-14/11 Type of Incident: Transportation 

 Type of Investigation: Site 

File No.: 10 

Licensee: Medical Center of Central Georgia License No.: 0364-1 

Date of Incident: 8/2/11 NMED No.: 120635 

Investigation Date: 9/6/11 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Site 

Comment: Incident reported to NMED over a year late. 

 
Georgia Final IMPEP Report Page E.3 

Incident Casework Reviews 

File No.: 11 

Licensee: Georgia Institute of Technology License No.: 0147-1 

Date of Incident: 4/13/10 NMED No.: 100198 

Investigation Date: 4/26/10 Type of Incident: Contamination 

 Type of Investigation: Review licensee report 

Comments: 

a) On-site investigation not conducted. 

b) The Program did not identify the potential consequences of the incident with respect to 

occupational safety, environmental safety, as well as public health and safety. The 

incident involved extensive contamination of a lab and adjacent areas, and resulted in a 

campus building being temporarily shut down for decontamination. 

c) The Program did not recognize that the licensee’s written report identified violations of 

regulatory requirements. No violations were issued to the licensee. 

File No.: 12 

Licensee: Emory University License No.: 0153-1 

Date of Incident: 5/24/11 NMED No.: 120641 

Investigation Date: 6/7/11 Type of Incident: Medical Event/Contamination 

 Type of Investigation: Review licensee report 

Comments: 

a) On-site investigation not conducted. 

b) This incident was reported by the licensee to the Program, including a written report, but 

the Program did not identify it as a reportable incident to the NRC nor did the Program 

capture the incident in its incident log. 

c) The Program inspector considered the incident to be a spill of radioactive material and 

did not recognize the underlying associated medical event. 

d) After the IMPEP review team identified the reportability of the incident, the Program 

reported the incident to the HOO on 10/25/12. 

e) Licensee’s written report did not contain some information required by regulation, such 

as actions to prevent recurrence and patient notification information. 

File No.: 13 

Licensee: Weyerhaeuser Company License No.: 1109-1 

Date of Incident: 8/17/11 NMED No.: 110416 

Investigation Date: 8/18/11 Type of Incident: Lost/Stolen RAM 

 Type of Investigation: Telephone 

Comments: 

a) Reported to NMED on 10/18/12, fourteen months after the incident. 

b) Licensee did not submit a written incident report, as required by regulation. 
APPENDIX F 

SEALED SOURCE AND DEVICE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Registry No.: GA-0678-D-103-G SS&D Type: (E) Beta Gauge 

Applicant Name: Yokogawa Corporation of America Type of Action: New 

Date Issued: 8/22/12 SS&D Reviewers: EJ/CL 

Comments: 

a) Nineteen months to issue SS&D registration with no deficiency noted, and thirteen 

months to issue distribution license which authorized distribution a month before the 

SS&D was issued. 

b) Applicant submitted design changes that included new drawings. A reviewer’s note 

dated 8/14/12 indicating to include correspondence in next SSR certificate amendment. 

The distribution license did not include this correspondence in the tie-down. 

File No.: 2 

Registry No.: GA-0645-S-102-S SS&D Type: (AA) Manual Brachytherapy 

Applicant Name: Theragenics Corporation Type of Action: Amendment in Entirety 

Date Issued: 3/17/11 SS&D Reviewers: EJ/CL 

Comments: 

a) License renewal submitted in 2007 and this SS&D amendment is one of many changes 

requested since that time. The license was renewed authorizing this product distribution 

14 months after the SS&D issuance. 

b) SS&D registry commitments are not legally binding to the radioactive materials license. 

File No.: 3 

Registry No.: GA-0571-D-106-B SS&D Type: (E) Beta Gauge 

Applicant Name: Honeywell International Type of Action: New 

Date Issued: 8/22/12 SS&D Reviewers: EJ/CL 

File No.: 4 

Registry No.: GA-1077-D-102-S SS&D Type: (H) General Neutron Source Applications 

Applicant Name: EADS SODERN North America Type of Action: New 

Date Issued: 2/4/10 SS&D Reviewers: EJ/CL 

Comments: 

a) Concurrence date 2/9/10 does not agree with Page 1 date of 2/4/10. 

b) License amended authorizing distribution 54 days after SS&D sheet issuance. 

c) Licensee moved to Virginia and the NRC issued NR-1077-D-101-S that supersedes the 

Georgia SS&D registration. The Georgia registration was not inactivated or distribution 

license amended to show move. 

 
Georgia Final IMPEP Report Page F.2 

Sealed Source and Device Casework Reviews 

File No.: 5 

Registry No.: GA-1138-D-104-S SS&D Type: (J) Gamma Irradiation Category I 

Applicant Name: Hopewell Design. Inc. Type of Action: Amendment in its Entirety 

Date Issued: 12/12/11 SS&D Reviewers: EJ/CL 

Comments: 

a) Concurrence date 12/13/12 does not agree with Page 1 date 12/12/11. 

b) SS&D issued 12 months after updated information provided. 

File No.: 6 

Registry No.: GA-1138-D-106-S SS&D Type: (K) Gamma Irradiation Category II 

 (H) General Neutron Source Applications 

Applicant Name: Hopewell Designs, Inc. Type of Action: New 

Date Issued: 12/20/10 SS&D Reviewers: EJ/CL 

Comments: 

a) Concurrence date 12/21/10 does not agree with Page 1 date 12/20/10. 

b) Dose rate at one meter not listed in “External Radiation Levels” section. 
ATTACHMENT 

December 27, 2012 letter from Judson H. Turner 

Georgia’s Response to the Draft Report 

ADAMS Accession No.: ML12363A71