UNITED STATES 

 NUCLEAR REGULATORY COMMISSION 

 REGION I 

 475 ALLENDALE ROAD 

 KING OF PRUSSIA, PENNSYLVANIA 19406-1415

September 21, 2011 

Robert L. Gallaghar, Acting Director 

Radiation Control Program 

Massachusetts Department of Public Health 

Schrafft Center, Suite 1M2A 

529 Main Street 

Charlestown, MA 02129 

Dear Mr. Gallaghar: 

A periodic meeting was held with you on August 1, 2011. The purpose of the meeting was to 

review and discuss the status of the Commonwealth of Massachusetts Department of Public 

Health’s Radioactive Materials Program. The NRC was represented by Michelle Beardsley, 

Michelle Killian, and me. Topics and issues of importance discussed at the meeting included a 

detailed discussion of recommendations from the 2010 IMPEP review. 

I have completed and enclosed a general meeting summary, including any specific actions that 

will be taken as a result of this meeting. If you feel that our conclusions do not accurately 

summarize the meeting discussion, or have any additional remarks about the meeting in 

general, please contact me at (610) 337-5371, or email to Donna.Janda@nrc.gov to discuss 

your comments. 

Sincerely, 

 /RA/ 

Donna M. Janda 

Regional State Agreements Officer 

Division of Nuclear Materials Safety 

Enclosure: As stated 

 
 

September 21, 2011 

Robert L. Gallaghar, Acting Director 

Radiation Control Program 

Massachusetts Department of Public Health 

Schrafft Center, Suite 1M2A 

529 Main Street 

Charlestown, MA 02129 

Dear Mr. Gallaghar: 

A periodic meeting was held with you on August 1, 2011. The purpose of the meeting was to 

review and discuss the status of the Commonwealth of Massachusetts Department of Public 

Health’s Radioactive Materials Program. The NRC was represented by Michelle Beardsley, 

Michelle Killian, and me. Topics and issues of importance discussed at the meeting included a 

detailed discussion of recommendations from the 2010 IMPEP review. 

I have completed and enclosed a general meeting summary, including any specific actions that 

will be taken as a result of this meeting. If you feel that our conclusions do not accurately 

summarize the meeting discussion, or have any additional remarks about the meeting in 

general, please contact me at (610) 337-5371, or email to Donna.Janda@nrc.gov to discuss 

your comments. 

Sincerely, 

 /RA/ 

Donna M. Janda 

Regional State Agreements Officer 

Division of Nuclear Materials Safety 

Enclosure: As stated 

Distribution: 

M. Beardsley, FSME 

M. Killian, FSME 

L. Dimmick, FSME 

K. Meyer, FSME 

R. Lorson, RI 

D. Collins, RI 

SUNSI Review Complete: DMJ (Reviewer=s Initials) 

DOCUMENT NAME: S:\State Agreement Files\Massachusetts\PERIODIC MEETING SUMMARY FOR MA 08-01-11.doc 

After declaring this document AAn Official Agency Record@ it will be released to the Public. Ml112640241 

To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy with 

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OFFICE DNMS/RI E 

NAME DJanda/dmj 

DATE 09/21/11 

OFFICIAL RECORD COPY
Enclosure 

AGREEMENT STATE PERIODIC MEETING SUMMARY FOR MASSACHUSETTS 

DEPARTMENT OF PUBLIC HEALTH (DPH) 

DATE OF MEETING: August 1, 2011 

NRC Attendees Massachusetts DPH

Donna Janda, Region I RSAO Robert Gallaghar, Acting Director, Radiation 

Control Program (RCP) 

Michelle Beardsley, FSME Beverly Anderson, Supervisor, RCP 

Michelle Killian, FSME Michael Whalen, RCP 

 Kenath Traegde, RCP 

DISCUSSION: 

During the 2010 Integrated Materials Performance Evaluation Program (IMPEP) review of the 

Massachusetts Agreement State Program (the Program), the review team found the 

Commonwealth’s performance satisfactory for four performance indicators: Technical Quality of 

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

Allegations, and Sealed Source and Device Evaluation Program; and satisfactory, but needs 

improvement, for three performance indicators: Technical Staffing and Training, Status of 

Materials Inspection Program, and Compatibility Requirements. Three recommendations were 

made by the IMPEP review team, and five recommendations were carried over from the 2002 

and 2006 IMPEP reviews. On September 20, 2010, the Management Review Board (MRB) met 

to consider the proposed final IMPEP report on the Massachusetts Agreement State Program. 

The MRB found the Program adequate to protect public health and safety, but needs 

improvement, and compatible with NRC’s program. The MRB directed NRC staff to initiate a 

period of monitoring, requested that calls between the Massachusetts DPH and NRC staffs be 

conducted quarterly, and directed that a periodic meeting take place approximately one year 

from the 2010 IMPEP review. 

The following is a status summary of the eight recommendations that were identified in the 2010 

Massachusetts final IMPEP report: 

1. The review team recommended that the Commonwealth pursue adequate funding to 

support and implement the staffing plan which is needed to meet current program 

demands as well as the projected increase in workload. (Carryover from the 2006 

IMPEP review) 

Status: During Fiscal Year (FY) 2012, the Radiation Control Program (RCP) 

received slightly more funding (approximately $13,000 in additional funds) than FY 

2011. Since the 2010 IMPEP review, one new technical staff member, one senior 

supervisor, and one clerical staff member joined the Program. One senior supervisor 

recently retired from the Program and the clerical staff member left the Program. 

According to the Acting Director, the staffing plan includes filling the Director’s post 

as a permanent position and hiring one additional technical staff member and a 

replacement for the clerical position (which has been approved for posting the 

vacancy.)

 
2

Enclosure 

2. The review team recommended that the Commonwealth monitor and maintain 

accurate information in its database so it can be used by Program management and 

staff as a reliable planning and tracking tool to ensure that inspections are completed 

within the required timeframe. 

Status: The Program has completed modifications to its database to more effectively 

monitor and track inspections as well as licensing actions. In addition, the Program 

modified the database to track assigned and unassigned inspections, flag 

inspections approaching their due dates, and identify potential data entry errors. 

Tickler reports of outstanding actions are sent to managers. Individual inspectors 

and license reviewers receive weekly tickler reports listing their respective 

outstanding actions. 

3. The review team recommended that the Commonwealth routinely perform 

accompaniments of each inspector, at least annually, to ensure quality and 

consistency in the inspection program. 

Status: The Program now uses their database as a tool to schedule and track 

inspections and supervisory accompaniments. These accompaniments are 

documented on a supervisor accompaniment form which is monitored quarterly. The 

Program has performed two supervisor accompaniments in calendar year 2011 and 

is on track to complete the remaining six accompaniments by the end of the calendar 

year. 

4. The review team recommended that the Commonwealth take necessary steps to 

ensure that all reportable events are submitted and updated to NRC in accordance 

with FSME Procedure SA-300. (Carryover recommendation from the 2002 IMPEP 

review.) 

Status: The 2010 IMPEP review team determined that five out of 51 events were not 

reported to NRC in a timely manner and timely follow up information was not 

provided for nine events which were still open in the Nuclear Material Events 

Database (NMED). Since the IMPEP review, the Program has addressed the open 

events in NMED and has reported seven new events, six of which were reported in a 

timely manner. The event which was reported to NRC late occurred during the 

timeframe that the Program staff was preparing for the 2010 IMPEP and the 

reporting requirement was inadvertently overlooked. 

5. The review team recommended that the Commonwealth adopt regulations 

necessary for compatibility within the required 3-year period. (Carryover from the 

2006 IMPEP review; modified in the 2010 IMPEP review.) 

Status: The Program has developed and now uses a written procedure for the 

regulation adoption process. According to the Acting Director, a comprehensive 

rulemaking package was presented to the Commonwealth’s Public Health Council 

(PHC) on July 13, 2011. The PHC gave its approval for the regulatory changes to be 

published for public comment. This rulemaking package included all of the 

amendments identified in the 2010 IMPEP report. 
3

Enclosure 

6. The review team recommended that the Commonwealth reissue the certificate MA0555-S-102-S to contain a table indicating radiation levels under maximum loading 

conditions. 

Status: Registration certificate MA-0555-S-102-S has been revised to include a table 

of radiation levels under maximum loading conditions. The revised certificate has 

been posted in the SS&D Registry. 

7. The review team recommended that the Commonwealth make corrections to 

registration certificate MA-0166-D-102-B. (Carryover recommendation from the 2002 

and 2006 IMPEP reviews.) 

Status: The new registration certificate with the proper model number (HUB-77A) 

was completed on July 23, 2010. This certificate was posted in the SS&D Registry 

with the new registration number MA-1287-D-103-B and subsequently inactivated on 

September 2, 2010 and posted as MA-1287-D-801-B. 

 

8. The review team recommended that the Commonwealth reissue registration 

certificate MA-8154-D-803-B with the complete text or equivalent form. (Carryover 

recommendation from the 2006 IMPEP review; modified in the 2010 IMPEP review.) 

Status: The Commonwealth provided a copy of the cover page of the registration 

certificate NR-143-D-103-B and the inactivated certificate MA-8154-D-803-B for 

posting in the SS&D Registry. As of July 31, 2011, this change had not yet been 

posted. RCP has contacted the SS&D staff at NRC to resolve the issue. 

OTHER TOPICS COVERED DURING THE MEETING INCLUDED:

Program Strengths

The Program has an experienced and well-trained staff. Both senior management and Program 

management support staff training. The Program has been responsive to the recommendations 

from the 2010 IMPEP review. 

Program Weaknesses

The Commonwealth’s fiscal constraints continue to be a challenge for the Program, although 

the Program did receive a slight increase in funding this fiscal year. 

Feedback on the NRC’s Program

The Program commented that both the overall relationship and communications with the NRC 

are good. The Program expressed appreciation for the NRC funding of training. The Acting 

Director noted that, because it can take approximately six weeks to receive State approval for 

travel, it can be challenging to support NRC’s requests to participate on short notice on an 

IMPEP team or working groups. The Acting Director suggested that NRC consider conducting 

working group meetings in conjunction with regional or national meetings, such as OAS or 

CRCPD annual meetings, to gain more Agreement State participation/support. 
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Enclosure 

The Program also suggested that it would be beneficial to have a unified licensing approach 

between NRC and the Agreement States for licensees with facilities throughout the United 

States. 

Agreement State Program Staffing and Training

The Program staff currently consists of eight technical staff members and two managers, 

including the Acting Director. There are two staff vacancies, one technical position and one 

administrative position. No technical staff members have left the Program since the 2010 

IMPEP. The materials supervisor position has been permanently removed from the Program 

after the individual retired in May 2011. However, the senior supervisor who initially transferred 

to the Program on a temporary basis after the 2010 IMPEP is now permanently assigned to the 

Program. 

Support for staff training exists in the Program. Two technical staff members are progressing 

through the Program’s qualification process. Program staff has attended NRC and other 

training courses, including the NRC’s Security Systems and Principles Course. The Acting 

Director noted that other activities that are not specifically training, such as attendance at 

meetings, also provide valuable opportunities for knowledge sharing. 

Organization

The Massachusetts Agreement State Program is administered by the Radiation Control 

Program which is located in the Department of Public Health. No senior management changes 

have occurred since the most recent IMPEP review. 

Program Budget/Funding

The Program received a slight increase in funding in the current fiscal year and is adequately 

funded by licensing and registration fees. The funds are placed into a retained revenue account 

and the Program is allowed to retain a certain percentage of the revenue from its annual fees 

and is capped at that point. The remainder of the revenue is placed into the Commonwealth’s 

General Fund. Despite fiscal constraints, the Program has hired additional staff since the 2010 

IMPEP and has received approval to hire an administrative staff member and permanently fill 

the Director’s position. 

Inspection and Licensing Programs

The Program’s inspection frequencies are at least as frequent as NRC’s. Since the 2010 

IMPEP, five of 44 Priority 1, 2, and 3 (high priority) inspections were conducted overdue by 

more than 25 percent of the inspection frequency prescribed by Inspection Manual Chapter 

2800. Two of these inspections were completed overdue because the inspection priority for 

each of these licensees was not changed to a higher frequency in conjunction with a program 

code change based on new licensed activities. The Program identified and corrected this error. 

No high priority inspections were overdue at the time of the periodic meeting. Since the 2010 

IMPEP, one initial inspection was conducted overdue (greater than 12 months of license 

issuance) and no initial inspections were overdue at the time of the periodic meeting. 
5

Enclosure 

The Program currently has approximately 500 specific licenses. Massachusetts licensees are 

subject to a five-year license renewal term. The Acting Director continues to conduct secondary 

technical reviews of licensing actions and provides feedback to the license reviewers. 

Regulations and Legislative Changes

There have not been any legislative changes or proposals that have affected the Program. 

Since the 2010 IMPEP, the Program submitted a comprehensive rulemaking package to the 

Commonwealth’s Public Health Council (PHC) on July 13, 2011. The PHC gave its approval for 

the regulatory changes to be published for public comment. This rulemaking package included 

all of the amendments identified in the 2010 IMPEP report as overdue for adoption or as 

upcoming rulemaking through September 2012. 

Event Reporting

This topic is discussed in Recommendation 4 above. 

Response to Incidents and Allegations

The Program continues to be sensitive to notifications of incidents and allegations. Incidents 

are quickly reviewed for their effect on public health and safety. Staff is dispatched to perform 

onsite investigations when necessary. The Program is aware of the need to maintain an 

effective response to incidents and allegations. 

Program staff responded in a prompt and effective manner to reports of the possible presence 

of depleted uranium contamination at multiple locations at the site of the former Springfield 

Armory. This large-scale investigation received high media interest and support from other 

Commonwealth offices. 

Sealed Source and Device (SS&D) Evaluation Program

Since the 2010 IMPEP review the Program has addressed the three recommendations 

associated with this indicator. This topic is discussed in Recommendations 6, 7, and 8 above. 

Large, Complicated, or Unusual Authorizations for Use of Radioactive Material

The Program received a request for a new cyclotron from a medical broad scope licensee. 

Commonwealth’s Mechanisms to Evaluate Performance

Inspection reports and licensing actions receive secondary technical reviews. Staff members 

are provided with weekly tickler reports of due dates for inspections and licensing actions. 

Managers conduct periodic audits of licensing actions and inspection due dates and perform 

supervisory accompaniments of inspectors on an annual basis. After the 2010 IMPEP, the 

Program conducted a thorough review of their database to correct any issues which were 

identified. The Program also holds monthly staff meetings. 

 
6

Enclosure 

CONCLUSIONS: 

Massachusetts has been responsive to the recommendations that were made during the 2010 

IMPEP review and to the open recommendations from previous IMPEP reviews. The Program 

has received additional funds and has made significant progress to address staffing vacancies, 

correct database errors which led to overdue inspections, and improve management oversight 

and direction for the licensing and inspection staff. 

Based on the significant progress the Commonwealth has made in addressing the IMPEP 

recommendations and the information reviewed during this periodic meeting, NRC staff 

recommends that the period of monitoring be discontinued. In addition, NRC staff recommends 

that a periodic meeting should be conducted approximately 18 months from the date of this 

meeting and that the next IMPEP review should be conducted as scheduled in FY 2014 

(tentatively July 2014).