UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

September 30, 2014 

Robert Moser, M.D. 

Secretary of Health and Environment 

State Health Officer 

Curtis State Office Building 

1000 SW Jackson, Suite 540 

Topeka, KS 66612-1368 

Dear Dr. Moser: 

On September 4, 2014, the Management Review Board (MRB) met to consider the proposed final 

Integrated Materials Performance Evaluation Program (IMPEP) report on the Kansas Agreement 

State Program. The MRB found the Kansas program adequate to protect public health and safety 

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

Section 5.0, page 11 of the enclosed final report contains a summary of the IMPEP team’s findings 

and one performance recommendation concerning materials licensing. Prior to the MRB meeting, 

the Kansas program submitted its root cause analysis and implemented corrective actions to 

address the recommendation. Therefore, no additional response needs to be submitted to the 

MRB. 

In our deliberation, the MRB thoroughly discussed the significant well logging event that occurred in 

March 2014 that was not sufficiently responded to by the State. The State was aware of the 

incident but did not prioritize an investigation. Following discussions with the IMPEP team, the 

State took aggressive actions to investigate the event. Prior to the MRB, the State had completed a 

root cause analysis on its failure to respond and implemented changes in procedures and 

managerial oversight to prevent recurrence. The State’s prompt action, once the error was 

realized, demonstrated to the MRB, the State’s commitment to protecting public health and safety. 

Based on the results of the current IMPEP review, the next full review of the Kansas Agreement 

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

scheduled for June 2016. 
R. Moser -2- 

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

I commend the Kansas program for the swift actions taken to proactively address a few program 

weaknesses identified by the IMPEP process. 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/ 

 Roy P. Zimmerman 

 Acting Deputy Executive Director for 

 Materials, Waste, Research, State, Tribal and 

 Compliance Programs 

 Office of the Executive Director for Operations 

Enclosure: 

Kansas Final IMPEP Report 

cc: Michael Ortiz, NM 

 Organization of Agreement States 

 Liaison to the MRB 

Thomas Langer, Director 

Bureau of Environmental Health 

Thomas Conley, CHP, RRPT, Chief 

Radiation & Asbestos Control Section 
R. Moser -2- 

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

I commend the Kansas program for the swift actions taken to proactively address a few program 

weaknesses identified by the IMPEP process. 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/ 

 Roy P. Zimmerman 

 Acting Deputy Executive Director for 

 Materials, Waste, Research, State, Tribal and 

 Compliance Programs 

 Office of the Executive Director for Operations 

Enclosure: 

Kansas Final IMPEP Report 

cc: Michael Ortiz, NM 

 Organization of Agreement States 

 Liaison to the MRB 

Thomas Langer, Director 

Bureau of Environmental Health 

Thomas Conley, CHP, RRPT, Chief 

Radiation & Asbestos Control Section 

Distribution: (See Attached) 

ML14259A357 

OFC RIV/RSAO:T

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MSSA MSSA MSSA:D TechEd FSME:D EDO:Acting 

DEDMRT 

NAME BTharakan 

via email 

w/edits 

LDimmick 

via email 

w/edits 

DWhite SAbraham for 

LDudes 

CPoland 

CP 

RLorson 

for 

BHolian 

RZimmerman 

DATE 09/18/14 09/19/14 09/22/14 09/23/14 09/24/14 09/26/14 09/30/14 

OFFICIAL RECORD COPY
Letter to Dr. Moser from Roy P. Zimmerman dated: September 30, 2014 

SUBJECT: KANSAS FY2014 FINAL IMPEP REPORT 

DISTRIBUTION: (SP08) 

RidsEdoMailCenter 

JFoster, OEDO 

RidsFsmeOd 

RidsOgcMailCenter 

JOlmstead, OGC 

RidsRgn3MailCenter 

DRoberts, RIII 

RidsRgn4MailCenter 

MShaffer, RIV 

LHowell, RIV 

RErickson, RIV 

RidsSecyCorrespondenceMailCenter Chairman Macfarlane 

RidsFsmeMssa Commissioner Svinicki 

SAbraham, MSSA Commissioner Ostendorff 

PHenderson, MSSA SECY 

MBeardsley, MSSA 

JLynch, RIII 

SXu, FSME 

MLight, OH 

JWeil, OCA (2 copies) 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE KANSAS AGREEMENT STATE PROGRAM 

JUNE 9–13, 2014 

FINAL REPORT
EXECUTIVE SUMMARY 

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

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

the period of June 9–13, 2014, by a review team composed of technical staff members from the 

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

Based on the results of this review, Kansas’ performance was found satisfactory for four of the 

six performance indicators reviewed: Technical Staffing and Training, Status of Materials 

Inspection Program, Technical Quality of Inspections, and Compatibility Requirements. The 

other two performance indicators, Technical Quality of Licensing Actions and Technical Quality 

of Incident and Allegation Activities, were found satisfactory, but needs improvement. 

The cause of the satisfactory, but needs improvement, finding for Technical Quality of Licensing 

Actions was due to the number of deficiencies identified by the team during a sampling of 

medical licensing actions. The details of these deficiencies are described in Section 3.4 of this 

report. The review team made a recommendation to review all active medical licenses and 

develop a process that ensures authorized users on the license are adequately qualified to 

perform the licensed activities. Prior to the Management Review Board (MRB) meeting, Kansas 

took a proactive approach to addressing the issues identified by the IMPEP team. Kansas 

conducted a root cause analysis for the medical licensing concerns and took corrective actions 

to address the issues and prevent recurrence. These actions included an audit of all license 

files, database updates, procedural changes, and issuance of amendments as necessary. 

The cause of the satisfactory, but needs improvement, finding for Technical Quality of Incident 

and Allegation Activities was due to an insufficient response by the Program to an overexposure 

event at a well logging licensee facility. The details of the event and the Kansas Program’s 

response are described in Section 3.5 of this report. The review team did not make a 

recommendation for this indicator because the insufficient response was isolated to this 

singular, albeit significant event, and the Program has previously demonstrated satisfactory 

performance when responding to similar types of events. Prior to the MRB meeting, Kansas 

took a proactive approach to address performance deficiencies related to its handling of the well 

logging event. Specifically, Kansas conducted a root cause analysis and implemented changes 

in procedures and management oversight of incidents to prevent recurrence. 

The review team determined, and the MRB agreed, that the two recommendations from the 

2010 IMPEP review, described in Section 2.0 of this report, regarding training to increase 

familiarity with the regulations in 10 CFR Part 35 during inspections, and to develop a process 

for handling and marking sensitive documents, should be closed. 

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

State Program is adequate to protect public health and safety and is compatible with the NRC's 

program. The review team recommended, and the MRB agreed, that the next IMPEP review 

take place in approximately 4 years. The MRB commended the Kansas program for its swift 

actions taken to proactively address a few program weaknesses identified in the IMPEP 

process. 
Kansas Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

review was conducted during the period of June 9–13, 2014, by a review team composed of 

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

Ohio. Team members are identified in Appendix A. The review was conducted in accordance 

with the “Implementation of the Integrated Materials Performance Evaluation Program and 

Rescission of Final General Statement of Policy,” published in the Federal Register on 

October 16, 1997, and NRC Management Directive 5.6, “Integrated Materials Performance 

Evaluation Program (IMPEP),” dated February 26, 2004. Preliminary results of the review, 

which covered the period of June 19, 2010, to June 13, 2014, were discussed with the Kansas 

Secretary of Health and Environment, and other managers, on the last day of the review. 

A draft of this report was issued to Kansas on July 17, 2014, for factual comment. Kansas 

responded to the findings and conclusions of the review by letter dated August 12, 2014. 

Copies of the State’s responses are included as an attachment to this report. The Management 

Review Board (MRB) met on September 4, 2014, to consider the proposed final report. The 

MRB found the Kansas Agreement State Program adequate to protect public health and safety, 

and compatible with the NRC’s program. 

The Kansas Agreement State Program is administered by the Radiation and Asbestos Control 

Section (the Section), which is located within the Bureau of Environmental Health (the Bureau). 

The Bureau is part of the Kansas Department of Health and Environment (the Department). 

Organization charts for the Department, Bureau, and Section are included as Appendix B. 

At the time of the review, the Kansas Agreement State Program regulated 283 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 Kansas. 

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

non-common performance indicators was sent to the Section on March 8, 2014. The Section 

provided its response to the questionnaire on May 14, 2014. A copy of the questionnaire 

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

(ADAMS) using Accession Number ML14136A370. 

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

the Section’s response to the questionnaire, (2) review of applicable Kansas statutes and 

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

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

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

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

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

performance. 

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

during previous reviews. 
Kansas Final IMPEP Report Page 2 

Results of the current review of the common performance indicators are presented in 

Section 3.0. Section 4.0 details the results of the review of the applicable non-common 

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

2.0 STATUS OF ITEMS IDENTIFIED IN PREVIOUS REVIEWS 

During the previous IMPEP review, which concluded on June 18, 2010, the review team made 

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

statuses of the recommendations are as follows: 

1. “The review team recommends that the State ensure that inspectors gain increased 

familiarity with the regulations in 10 CFR Part 35, as well as be provided appropriate 

formal training in addition to mentoring and/or on-the-job training to ensure familiarity 

with various therapeutic modalities involving byproduct materials such that these areas 

will be appropriately reviewed during inspections. (Section 3.1)” 

Status: During the review period, the State completed a number of actions to address 

this recommendation. The State completed formal training of all radioactive materials 

inspection staff by attending the NRC brachytherapy course. The State implemented a 

policy to have at least a two-person team inspect complex medical licenses to further 

enhance on-the-job training and mentoring of newer staff. The State developed training 

material on brachytherapy requirements which was presented at the 2011 Kansas 

Regulatory Conference; staff observed the NRC brachytherapy webinar in 2012, and 

conducted in-house refresher training on 10 CFR Part 35 in 2014. The review team 

determined the actions taken by the State addressed the recommendation. This 

recommendation is closed. 

2. “The review team recommends that the State further develop the policy that was 

instituted during the onsite review and provide additional guidance for identifying, 

marking, handling, transmitting, and storing documents containing sensitive information. 

(Section 3.3)” 

Status: The State developed and has guidance for identifying, marking, handling, 

transmitting, and storing documents containing sensitive information. Documents 

containing sensitive material are clearly marked and safeguarded as appropriate. These 

documents are stored in a locked storage area and have folders that are conspicuously 

marked “Controlled File.” The review team determined the actions taken by the State 

addressed the recommendation. This recommendation is closed. 

3.0 COMMON PERFORMANCE INDICATORS 

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

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

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

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

 
Kansas Final IMPEP Report Page 3 

3.1 Technical Staffing and Training

Considerations central to the evaluation of this indicator include the Section’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 Section’s questionnaire response relative 

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

and considered workload backlogs. 

The Section is responsible for materials inspection, licensing and compliance activities, and 

emergency response activities. The Section is composed of one manager, one radioactive 

materials supervisor, one program support staff member, and five technical staff members. 

At the time of the review, five technical staff members, plus the supervisor, totaling 5.5 

full-time equivalents (FTE) had direct involvement in the daily operations of the radioactive 

materials program. All of the technical staff members are allocated 5 percent of their FTE for 

nuclear power plant emergency response with one staff member allocated an additional 20 

percent of his FTE to perform asbestos program activities. No positions were vacant at the 

time of the review. One technical staff person resigned at the end of 2011 for personal 

reasons. The position was filled within three months by an internal candidate from the 

Bureau. The review team determined that staffing levels were adequate for the Kansas 

Agreement State program. 

The Section has a documented training plan for technical staff that is consistent with the 

requirements of the NRC/Organization of Agreement States Training Working Group Report and 

NRC Inspection Manual Chapter (IMC) 1248, “Qualification Programs for Federal and State 

Materials and Environmental Programs.” Staff members are assigned increasingly complex 

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

Section’s training program is adequate to carry out its regulatory duties and noted that Kansas 

management supports the Section’s training program. 

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

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

found satisfactory. 

3.2 Status of Materials Inspection Program

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

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

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

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

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

management and staff. 

The review team verified that Kansas' inspection frequencies for all types of radioactive material 

licenses are usually more frequent than the NRC’s frequency for similar license types listed in 

NRC IMC 2800, “Materials Inspection Program.” The only exception is industrial radiography 

which is routinely inspected annually at the same frequency as the NRC. However, the Section 

does increase the inspection frequency if there are performance issues with any of its licensees, 
Kansas Final IMPEP Report Page 4 

including radiography licensees. Frequencies have been adjusted to quarterly inspections in 

some instances where poor performance has warranted this additional oversight. 

The Section conducted 145 Priority 1, 2, and 3 inspections during the review period. One of 

these Priority 1 inspections was conducted overdue by more than 25 percent of the inspection 

frequency prescribed in IMC 2800. In addition, the Section performed 33 initial inspections 

during the review period, one of which was conducted overdue by 105 days. Section 

procedures, in agreement with IMC 2800, state initial inspections should be conducted within 12 

months of license issuance. The initial inspection was conducted late due to scheduling 

conflicts for the inspector. Overall, the review team calculated that the Section performed 1.1 

percent of its inspections overdue during the review period. 

The review team evaluated the Section’s timeliness in providing inspection findings to licensees. 

A sampling of 15 inspection letters indicated that 6 of the inspection findings letters were 

transmitted to the licensees beyond the Section’s goal of 30 days after the inspection. Out of 

the 178 initial and higher priority inspections conducted during the review period, the review 

team determined that approximately 26 percent (47) of the inspection findings letters were 

transmitted to licensees between 31 and 105 days after the inspection. The review team noted 

that the majority of the delayed inspection findings letters did not have violations. The primary 

reason for the delay in issuing the letters was due to the Section staff addressing other issues 

when returning to the office after the inspection. The Section does inform the licensee of the 

preliminary results of the inspection at the exit interview. A delay in transmitting inspection 

findings letters does not impact the licensee’s ability to implement corrective actions to address 

any violations that may have been identified during the inspection. The review team discussed 

this issue with the Section manager and supervisor. Section management determined that 

computer generated reports used by the Section to monitor the timeliness of inspection activities 

were not providing sufficient detail to monitor the transmittal of inspection findings. Section 

management addressed this issue by modifying the computer generated reports and more 

closely monitoring the timely transmittal of inspection findings. 

During the review period, the Section granted 303 reciprocity permits, of which, 118 were 

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

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

determined that the Section did not meet the NRC’s criteria of inspecting 20 percent of 

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

period. In 2010, the Section inspected 20 percent of candidates, but for the other years during 

the review period the reciprocity inspection rate has been 10 - 13 percent. Prior to the onsite 

IMPEP review, the Section had identified this declining trend, which appears to be due to the 

geographical challenges associated with the size of Kansas and the location of reciprocity 

activities. The number of reciprocity candidates has increased due to the increased radiography 

and well logging activities in western Kansas. The large geographical area of western Kansas 

poses a challenge to Section inspectors because when inspectors travel to western Kansas to 

perform a reciprocity inspection, they usually find the licensee has either completed work and 

moved on, or has yet to arrive at the site. To resolve these challenges, the Section 

implemented new requirements for each inspector to identify and track reciprocity candidates at 

the beginning of each year. The Section determined that it becomes aware of approximately 

15 to 20 candidates licensees by the end of January each year, and the rest of the candidates 

come in throughout the remainder of the year. The Section plans to require each inspector 
Kansas Final IMPEP Report Page 5 

select two candidates to inspect each year to ensure the Section meets the criteria of inspecting 

20 percent of the candidates. The team determined that the Section’s plans and action taken to 

address its reciprocity challenges were sufficient, and therefore did not offer a specific 

performance recommendation. The MRB agreed and commended the Section on identifying 

and taking prompt corrective action. The MRB noted that issues with reciprocity are currently 

under review by NRC and Agreement State staff working on revisions to the applicable 

procedures. 

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

that Kansas’ performance with respect to the indicator, Status of Materials Inspection Program, 

be found satisfactory. 

3.3 Technical Quality of Inspections

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

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

review period. The casework reviewed included inspections conducted by one former and five 

current Section inspectors and covered inspections of various license types: academic and 

medical broad scope, diagnostic nuclear medicine, medical license distribution, high dose-rate 

remote afterloaders, industrial radiography, veterinary, nuclear pharmacy, and well logging 

licensees. The review also included both initial and follow-up Increased Controls inspections. 

Appendix C lists the inspection casework files reviewed; as well as the results of the inspector 

accompaniments. 

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

aspects of the licensee’s radiation safety programs. The review team found that inspection 

reports were thorough, complete, consistent, and of high quality, with sufficient documentation 

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

documentation supported violations, unresolved safety issues, the effectiveness of corrective 

actions taken to resolve previous violations and discussions held with licensees during exit 

interviews. In addition, all inspection documentation is entered into the Section’s database, 

which is accessible to all staff members. 

The review team determined that documents involving Increased Controls inspections were 

protected, segregated from other files, and maintained in a manner to limit access. Inspection 

report files for Increased Controls were in color coded folders and kept separate from the 

routine inspection reports. Documents that were released to the public in information requests 

were sufficiently marked as sensitive information, as appropriate. 

The inspection procedures utilized by the Section are consistent with the inspection guidance 

outlined in IMC 2800. The Section has a policy to accompany all staff performing radioactive 

materials inspections on an annual basis. Supervisory accompaniments were conducted 

annually for all inspectors. 

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

regulatory actions were taken, as necessary. Inspection findings were clearly stated and 

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

results of the inspection. The review team noted that the computer generated inspection reports 
Kansas Final IMPEP Report Page 6 

provided a good format for a narrative of the inspectors’ observations and findings. Examples of 

these reports were taken by the review team for future training and demonstration purposes. 

The review team verified that the Section maintains an adequate supply of appropriately 

calibrated survey instruments to support the inspection program, as well as to respond to 

radioactive materials incidents and emergency conditions. Instruments used to support the 

radioactive materials inspection program are calibrated by the manufacturer. 

Accompaniments of four inspectors were conducted by an IMPEP team member during the 

week of May 5, 2014. The inspectors were accompanied during health, safety and security 

inspections of two industrial radiography licensees and a medical therapy licensee. The 

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

demonstrated appropriate inspection techniques, knowledge of the regulations, and conducted 

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

and thorough in their audits of the licensees’ radiation safety programs. The inspectors 

conducted interviews with appropriate personnel, observed licensed operations, conducted 

confirmatory measurements, and utilized good health physics practices. The inspections were 

adequate to assess radiological health and safety and security at the licensed facilities. 

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

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

found satisfactory. 

3.4 Technical Quality of Licensing Actions

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

licensing actions covering specific licenses. A total of 20 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, security requirements, operating and emergency procedures, 

appropriateness of license conditions, and overall technical quality. The casework was also 

reviewed for timeliness, use of appropriate correspondence, reference to appropriate 

regulations, supporting documentation, consideration of enforcement history, pre-licensing 

visits, peer and supervisory review, and proper signatures. 

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

during the review period. Licensing actions selected for evaluation included 2 new licenses, 

5 renewals, 11 amendments, and 2 license terminations. Casework reviewed included a 

cross-section of license types such as industrial, broad scope medical and academic, nuclear 

medicine diagnostic and therapeutic, research and development, portable gauge, fixed gauge, 

nuclear pharmacy, and veterinary. A listing of the licensing casework reviewed, with case 

specific comments, can be found in Appendix D. 

The review team concluded that actions taken in terminating licenses were appropriately 

documented, which included suitable material survey records, and contained documentation of 

proper disposal or transfer of radioactive material. 
Kansas Final IMPEP Report Page 7 

Licenses are created and tracked using a local database. Once completed, all licensing actions 

are reviewed by the Section Supervisor, and then reviewed and signed by the Section Manager. 

The Section has Kansas specific guidance documents for the common types of licenses issued 

but also uses the NRC’s NUREG-1556 series for additional licensing guidance. 

Kansas adopts 10 CFR Part 35 – “Medical Use of Byproduct Material,” by reference. The 

equivalent Part 35 regulations are found in Kansas Administrative Regulations 

(KAR 28-35-264). The review team identified five licenses where authorized users were added 

to radioactive material licenses for medical use without the proper documentation to verify the 

training, experience, and preceptor attestation. In four cases, the Section approved users who 

were neither qualified for, nor who applied for, all of the authorized uses in 10 CFR 35.300. 

However, the authorized users were granted full authorization to use 10 CFR 35.300 materials. 

The review team brought these issues to the attention of the Section supervisor, who 

immediately contacted the licensees and determined these physicians had not used the 

radioactive materials for applications that they were not qualified to administer. The Section will 

re-issue these licenses with appropriate authorizations for these physicians. In one amended 

license issued for a facility, the Section included an authorized physician who was added to the 

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

attestation. Specifically, the documentation submitted only contained continuing education 

certificates. The review team brought this to the attention of the Section supervisor, who 

contacted the licensee and reviewed all previously archived submissions of the user’s 

qualification documents. The Section determined this specific authorized user was approved in 

1992, and had inadvertently been removed from a recent amendment to the license. The 

Section added the appropriate documentation to the file for this amendment to show the 

authorized user meets the requirements. 

The review team identified repeated examples of problems authorizing physician users for 

10 CFR 35.300 (KAR 28-35-264) uses with respect to thoroughness, completeness, 

consistency, and adherence to existing guidance for medical licensing actions. The review 

team recommends that the State review all active medical licenses and verify that previously 

approved authorized physician users have the proper board certification or training 

requirements, and preceptor attestation, and develop and implement a process that will ensure 

proper verification and documentation of user qualifications for 10 CFR 35.300 (KAR 28-35-264) 

uses of byproduct material. While no problems were identified by the review team with respect 

to authorized medical physicists, radiation safety officers, and authorized nuclear pharmacists, 

as a result of subsequent discussions, Section management decided to review a sampling of 

the training and experience of these individuals, in addition to the team’s recommendation. 

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

that Kansas’ 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 Section’s actions in responding to incidents and 

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

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

Database (NMED) against those contained in the Section’s files, and evaluated the casework 
Kansas Final IMPEP Report Page 8 

for 14 radioactive materials incidents. A list of the incident casework examined, with a case 

specific comment, may be found in Appendix E. The review team also evaluated the Section’s 

response to three allegations involving radioactive materials received by the State during the 

review period. 

The incidents selected for review included the following categories: lost radioactive material, 

overexposures, damaged equipment, equipment failure and transportation. The review team 

determined that the Section’s response to incidents was adequate for 13 of the 14 evaluated 

incidents. The Section performed a complex investigation for one of the incidents, a licensee 

employee radiation overexposure case. That investigation was thorough and comprehensive 

and suitable enforcement and follow-up actions were taken. Section staff employ a procedure 

entitled, “Investigation of Accidents, Incidents or Overexposures” when responding to an 

incident. The procedure has a good discussion of considerations for inspectors to think about 

during their investigation. The Section supervisor stated that, based on feedback from the 

review team, the procedure would be enhanced to provide more specific direction with respect 

to on-site investigation of incidents. 

One incident, in particular, with the potential for significant health and safety consequences to 

licensee personnel, as well as the public, was not sufficiently responded to by the Section. A 

well logging licensee reported in March 2014 that a licensee employee received a whole body 

overexposure for calendar year 2013. The licensee stated that the individual, a well logging 

assistant, was overexposed because he handled gamma (Cs-137) and neutron-emitting 

(Am-Be) well logging sources with his bare hands, instead of the standard industry practice of 

using remote handling tools. The Section responded to the licensee via email with a significant 

number of questions regarding the overexposure, including a request for the results of the 

licensee’s incident reenactment and the training history of the employee. In early April 2014, 

the licensee responded to the Section with the results of its reenactment showing a whole body 

overexposure and a considerable extremity exposure, without sufficient discussion of the 

potential neutron dose. The licensee also indicated that the employee had not received formal 

training prior to handling the radioactive sources. The team observed and discussed with the 

Section that the licensee’s response did not address possible radiation exposures to other 

workers at the well site who could be considered members of the public, nor did the licensee 

adequately discuss how it failed to exercise proper supervision of this untrained worker. 

A Section senior inspector was assigned to the case, but routine inspections and licensing 

actions took priority so that quarterly assignments would not come overdue. Section managers 

were aware of the incident but did not prioritize an investigation. After the review team’s 

discussion with Section and Bureau managers during this review, the managers agreed that an 

aggressive response was warranted in this case and stated that such an on-site investigation 

would be launched promptly, including an independent reenactment of the incident. 

Section managers were aware of incident reportability thresholds, as established in the Office of 

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

SA-300 “Reporting Material Events.” All applicable incidents were reported to the NRC 

Headquarters Operations Center and entered into NMED, in a timely manner. It should be 

noted that the well logging incident discussed above was also reported to NMED in a timely 

manner. The Section was not required to report the well logging incident to the NRC 

Headquarters Operations Center based on the event description and dose information received 
Kansas Final IMPEP Report Page 9 

from the licensee. The Section’s reenactment may result in different dose assignments to the 

well logging assistant or other workers (members of the public) which may require additional 

notifications. On August 12, 2014, the Section provided an update to the investigation of the 

well logging incident described above and indicated that no members of the public were 

exposed to radiation from this incident. Two radiation workers received doses in excess of 

regulatory limits. One worker received a whole body dose of 5.122 rem and the other worker 

received an extremity dose of 50.14 rem. No other individuals received doses which exceeded 

regulatory limits. Prior to the MRB meeting, the Section conducted a root cause analysis for the 

Section’s insufficient response to the well logging event. The root causes were determined to 

be insufficient management oversight of this particular investigation, and the Section’s 

procedures did not have specific guidance on when an onsite investigation should be 

conducted. The Section implemented procedural and management oversight changes to 

prevent recurrence. 

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

evaluated the completed casework for three allegations received by the State during the review 

period. The review team concluded that the Section took prompt and appropriate actions in 

response to concerns raised. The review team noted that the Section documented the 

investigations of concerns and retained all necessary documentation to appropriately close the 

allegations. The Section notified the concerned individuals of the conclusion of its 

investigations. The review team determined that the Section adequately protected the identity 

of concerned individuals. 

The review team considered recommending a finding of “unsatisfactory” for this indicator. 

However, the review team concluded that, despite the Section’s failure to properly respond to 

the potentially significant health and safety consequences from the well logging incident, the 

Section had responded to another overexposure incident and to allegations in a prompt, 

comprehensive manner. Therefore, the Section’s performance was not indicative of frequent 

examples of incomplete or inappropriate responses to incidents. 

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

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

Allegation Activities, be found satisfactory, but needs improvement. 

4.0 NON-COMMON PERFORMANCE INDICATORS 

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

(1) Compatibility Requirements, (2) Sealed Source and Device Evaluation Program, 

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

NRC’s Agreement with Kansas does not relinquish regulatory authority for a uranium recovery 

program; therefore, only the first three non-common performance indicators applied to this 

review. 

4.1 Compatibility Requirements

4.1.1 Legislation
Kansas Final IMPEP Report Page 10 

Kansas became an Agreement State on January 1, 1965. Legislative authority to create an 

agency and enter into an Agreement with the NRC is granted in Article 16 - Nuclear Energy 

Development and Radiation Control Act, Kansas Statutes, K.S.A. 48-1601 to 48-1619. The 

Department Secretary is responsible by law for radiation control. The Department is designated 

as the State's radiation control agency. There were no legislative changes affecting the 

program during the review period. 

4.1.2 Program Elements Required for Compatibility 

The Kansas regulations governing radiation protection requirements are found in 

KAR 28-35-133 through KAR 28-35-505, apply to all ionizing radiation, whether emitted from 

radionuclides or produced by machines. Kansas requires a license for the possession and use 

of all radioactive material, including naturally occurring materials and accelerator-produced 

radionuclides. Kansas also requires registration of all machines designed to produce x-rays or 

other ionizing radiation. Kansas’ regulations are not subject to sunset laws. The State has the 

ability to adopt certain rules by license condition. 

The review team verified that the State’s rulemaking process offers the public and other 

interested parties an opportunity to comment on proposed regulation changes. Proposed 

rulemaking packages are initially reviewed by the Secretary of Administration and then by the 

Attorney General for legality. The Department then offers the public and other interested parties 

an opportunity to comment on the proposed regulation changes when it is published in the 

Kansas Register. The Department sends the proposed regulation changes to NRC for a 

compatibility review during the public comment period. The Joint Committee on Administrative 

Rules and Regulations is responsible for legislative oversight of regulations and also reviews the 

proposed regulatory package during the public comment period. Once the proposed regulation 

is adopted, it is then published in the Kansas Register and typically takes effect within 15 days. 

The review team determined that the regulation promulgation process takes approximately 6-10 

months. 

Current NRC policy requires that Agreement States adopt certain equivalent regulations or 

legally binding requirements no later than 3 years after the effective date of NRC’s 

regulations. Kansas is up to date on the adoption of regulation packages, which the review 

team noted was a strength of the Kansas program. At the time of this review, the following 

three promulgated regulations had outstanding comments, from the NRC, which need to be 

resolved: 

• “Requirements for Certain Generally Licensed Industrial Devices Containing Byproduct 

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

Agreement State adoption by February 16, 2004. 

• “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, and 150 amendment (72 FR 55864), that was due for Agreement State 

adoption by November 30, 2010. 
Kansas Final IMPEP Report Page 11 

A complete list of regulation amendments may be found on the NRC website at the following 

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

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

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

satisfactory. 

4.2 Sealed Source and Device Evaluation Program

The Kansas Agreement State Program has authority to conduct sealed source and device 

(SS&D) evaluations for byproduct, source, and certain special nuclear materials; however, the 

Section did not conduct any SS&D evaluations during the review period. There are currently no 

SS&D manufacturers in Kansas. If the Section receives an application for an SS&D action, the 

Section has a procedure in place to outsource or contract the action. Accordingly, the review 

team did not review this indicator. 

4.3 Low-Level Radioactive Waste Disposal Program

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

Discontinuance of NRC Regulatory Authority and Assumption Thereof by States Through 

Agreement," to allow a State to seek an amendment for the regulation of Low-Level Radioactive 

Waste (LLRW) as a separate category. Although the Kansas Agreement State Program has 

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

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

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

regulate a LLRW disposal facility, 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 Kansas. Accordingly, the review team did not review this 

indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0 above, Kansas’ performance was found satisfactory for four of 

the six performance indicators reviewed and satisfactory, but needs improvement, for the 

indicators: Technical Quality of Licensing Actions and Technical Quality of Incident and 

Allegation Activities. The review team made one recommendation regarding program 

performance by the State and determined that the two recommendations from the 2010 IMPEP 

review should be closed. 

The review team considered additional NRC oversight including a period of monitoring and 

decreasing the time until the next periodic meeting because two performance indicators were 

less than fully satisfactory. However, given that the deficiencies identified by the review team 

were limited to a specific area of licensing, and the response to a singular, albeit significant 

event, for which past performance to a similar event was sufficient, the review team determined 

additional NRC oversight was not necessary. 

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

State Program be found adequate to protect public health and safety and compatible with the 
Kansas Final IMPEP Report Page 12 

NRC's program. Based on the results of the current IMPEP review, the review team 

recommends that the next full IMPEP review take place in approximately 4 years. The MRB 

commended Kansas for its swift actions taken to address a few program weaknesses: 

reciprocity inspections, medical licensing, and incident investigation. The Section updated its 

procedures and databases to ensure effective implementation of corrective actions. 

Below is the review team’s recommendation, as mentioned in the report, for evaluation and 

implementation by the State: 

RECOMMENDATION 

The review team recommends that the State review all active medical licenses and verify that 

previously approved authorized physician users have the proper board certification or training 

requirements, and preceptor attestation, and develop and implement a process that will ensure 

proper verification and documentation of user qualifications for 10 CFR 35.300 (KAR 28-35-264) 

uses of byproduct material.(Section 3.4) 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B KANSAS Organization Charts 

Appendix C Inspection Casework Reviews 

Appendix D License Casework Reviews 

Appendix E Incident Casework Reviews 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Jim Lynch, Region III Team Leader 

Technical Quality of Incident and Allegation 

Activities 

Inspector Accompaniments 

Compatibility Requirements 

Binesh Tharakan, Region IV Team Leader in Training 

 Technical Staffing and Training 

 Status of Materials Inspection Program 

Shirley Xu, FSME Technical Quality of Licensing Actions 

Mark Light, Ohio Technical Quality of Inspections 
APPENDIX B 

KANSAS ORGANIZATION CHARTS 

ADAMS ACCESSION NO.: ML14141A348 
 APPENDIX C 

INSPECTION CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Cardinal Health, LLC License No.: 10-C956 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 12/9/11 Inspectors: TC/JB 

File No.: 2 

Licensee: VCA Mission Animal Referral License No.: 33-B965 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 2/19/13 Inspector: JW 

File No.: 3 

Licensee: IRIS NDT, Inc. License No.: 21-B982 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 4/2/14 Inspector: DL 

File No.: 4 

Licensee: Coffey County Hospital License No.: 12-B970 

Inspection Type: Initial, Announced Priority: 5 

Inspection Date: 7/11/13 Inspector: JW 

File No.: 5 

Licensee: XCEL NDT, Inc. License No.: 21-B982 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 12/19/13 Inspector: AS 

File No.: 6 

Licensee: West Central Kansas Association License No.: 12-B975 

DBA Russell Regional Hosp. 

Inspection Type: Initial, Announced Priority: 1 

Inspection Date: 2/12/14 Inspector: JB 

File No.: 7 

Licensee: Menorah Medical Center. License No.: 19-B703-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 8/9/11 Inspector: JH 

File No.: 8 

Licensee: Chanute Manufacturing Company License No.: 21-B189-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 8/1/11 Inspector: JS 

 
Kansas Final IMPEP Report Page C. 2 

Inspection Casework Reviews 

File No.: 9 

Licensee: Bradken, Atchison/St. Joseph, Inc. License No.: 21-B092-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 5/5/14 Inspector: DL 

File No.: 10 

Licensee: Anderson County Hospital License No.: 19-B466-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 1/28/14 Inspector: JW 

File No.: 11 

Licensee: Coder X-ray Service License No.: 21-B165-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 1/28/14 Inspector: AS 

File No.: 12 

Licensee: Kansas State University License No.: 38-C011-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 1/28/14 Inspector: JB 

File No.: 13 

Licensee: Sauder Custom Fabrication, Inc. License No.: 21-B149-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 1/10/14 Inspector: JH 

File No.: 14 

Licensee: Quality Nuclear Services License No.: 34-C925-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 1/28/14 Inspector: AS 

File No.: 15 

Licensee: Nuclear Enterprises, LLC License No.: 20-B892 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 5/14/13 Inspector: JB 

File No.: 16 

Licensee: Great Bend Regional Hospital License No.: 19-B936 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 3/25/13 Inspector: AS 

File No.: 17 

Licensee: Dodge City Healthcare Group, LLC License No.: 19-B343-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 3/26/13 Inspector: AS 
Kansas Final IMPEP Report Page C. 3 

Inspection Casework Reviews 

File No.: 18 

Licensee: Cornish Wireline Services License No.: 27-B128-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 1/28/14 Inspector: JW 

File No.: 19 

Licensee: DBI, Inc. License No.: 21-B805 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 5/8/14 Inspector: AS 

File No.: 20 

Licensee: Via Christi Hospitals Witchita, Inc. License No.: 18-C753-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 12/3/13 Inspector: JH 

File No.: 21 

Licensee: University of Kansas Medical Center License No.: 18-C800 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/14/13 Inspector: JH 

File No.: 22 

Licensee: University of Kansas Hospital Authority License No.: 18-C801 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 3/11/13 Inspector: JW 

File No.: 23 

Licensee: Perf-Tech Wireline Services License No.: 27-B779 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 11/21/13 Inspector: DL 

File No.: 24 

Licensee: Gemini Wireline, LLC License No.: 27-B928 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 11/20/13 Inspector: DL 

File No.: 25 

Licensee: L-K Wireline, Inc. License No.: 27-C339-01 

Inspection Type: Routine, Announced Priority: 3 

Inspection Date: 2/6/14 Inspector: DL 

 
Kansas Final IMPEP Report Page C. 4 

Inspection Casework Reviews 

INSPECTOR ACCOMPANIMENTS 

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

Accompaniment No.: 1 

Licensee: Bradken, Atchison/St. Joseph, Inc. License No.: 21-B092-01 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 5/5/14 Inspector: DL 

Accompaniment No.: 2 

Licensee: DBI, Inc. License No.: 21-B805 

Inspection Type: Routine, Announced Priority: 1 

Inspection Date: 5/6/14 Inspector: AS 

Accompaniment No.: 3 

Licensee: Shawnee Mission Medical Center License No.: 19-C264-01 

Inspection Type: Routine, Announced Priority: 2 

Inspection Date: 5/7/14 Inspectors: JB, JW 
APPENDIX D 

LICENSE CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Cardinal Health 414 LLC License No.: 10-C956 

Type of Action: New Amendment No.: 0 

Date Issued: 12/5/11 License Reviewer: JH 

File No.: 2 

Licensee: Acuren Inspection Inc. License No: 21-B126-01 

Type of Action: Renewal Amendment No.: 45 

Date Issued: 4/22/14 License Reviewer: JW 

File No.: 3 

Licensee: Cushing Memorial hospital St Luke's Health System License No.: 19-B374-01 

Type of Action: Amendment Amendment No.: 29 

Date Issued: 11/7/13 License Reviewer: AS 

Comment: An authorized radiologist was added to the license without proper documentation 

regarding training, experience, and preceptor attestation. 

File No.: 4 

Licensee: Coffeyville Resources Refining License No.: 22-B097-01 

Type of Action: Amendment Amendment No.: 33 

Date Issued: 5/15/12 License Reviewer: JH 

File No.: 5 

Licensee: Como Tech Inspection Inc. License No.: 21-B629-01 

Type of Action: Renewal Amendment No.: 19 

Date Issued: 2/19/13 License Reviewer: JW 

File No.: 6 

Licensee: Cotton O'Neil Clinic License No.: 19-B550-01 

Type of Action: Termination Amendment No.: NA 

Date Issued: 11/22/12 License Reviewer: JW 

File No.: 7 

Licensee: Hays Medical Center St Anthony Campus License No.: 19-B261-01 

Type of Action: Amendment Amendment No.: 62 

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

File No.: 8 

Licensee: Kansas State University License No.: 38-C011-01 

Type of Action: Amendment Amendment No.: 76 

Date Issued: 1/21/14 License Reviewer: JB 
Kansas Final IMPEP Report Page D. 2 

License Casework Reviews 

File No.: 9 

Licensee: Lawrence Memorial Hospital License No.: 12-B161-01 

Type of Action: Amendment Amendment No.: 54 

Date Issued: 8/28/13 License Reviewer: JW 

Comment: An authorized radiologist was added to the license without proper documentation 

regarding training, experience, and preceptor attestation. 

File No.: 10 

Licensee: Lead Testers, LLC License No.: 22‐B948 

Type of Action: Amendment Amendment No.: 1 

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

File No.: 11 

Licensee: Mercy Regional Health Center, Inc. License No.: 19-B528-01 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 2/8/13 License Reviewer: JW 

Comment: An authorized radiologist was added to the license without proper documentation 

regarding training, experience, and preceptor attestation. 

File No.: 12 

Licensee: Mission Medvet License No.: 33‐B729‐01 

Type of Action: Termination Amendment No.: NA 

Date Issued: 1/29/13 License Reviewer: JB 

File No.: 13 

Licensee: Mitchell County Hospital License No.: 19-B355-01 

Type of Action: Renewal Amendment No.: 28 

Date Issued: 9/5/13 License Reviewer: JB 

File No.: 14 

Licensee: Quintiles Phase I Service, Inc. License No.: 16-B678-01 

Type of Action: Renewal Amendment No.: 13 

Date Issued: 6/20/11 License Reviewer: JB 

File No.: 15 

Licensee: Saint Luke's South Hospital License No.: 19-B775 

Type of Action: Amendment Amendment No.: 24 

Date Issued: 7/12/13 License Reviewer: JW 

Comment: An authorized radiologist was added to the license without proper documentation 

regarding training, experience, and preceptor attestation. 

 
Kansas Final IMPEP Report Page D. 3 

License Casework Reviews 

File No.: 16 

Licensee: VCA Mission Animal Referral License No.: 33-B965 

Type of Action: Amendment Amendment No.: 1 

Date Issued: 4/11/14 License Reviewer: JH 

File No.: 17 

Licensee: West Central Kansas Association License No.: 12-B975 

Type of Action: New Amendment No.: 0 

Date Issued: 7/1/13 License Reviewer: JB 

File No.: 18 

Licensee: XCEL NDT LLC License No.: 21-B980 

Type of Action: Amendment Amendment No.: 2 

Date Issued: 5/15/14 License Reviewer: DL 

File No.: 19 

Licensee: Fort Hays State University License No.: 31-B049-01 

Type of Action: Amendment Amendment No.: 30 

Date Issued: 9/5/13 License Reviewer: JB 

File No.: 20 

Licensee: Wesley Medical Center LLC License No.: 19-C041 

Type of Action: Renewal Amendment No.: 76 

Date Issued: 8/8/13 License Reviewer: JH 
APPENDIX E 

INCIDENT CASEWORK REVIEWS 

NOTE: CASEWORK LISTED WITHOUT COMMENT IS INCLUDED FOR COMPLETENESS. 

File No.: 1 

Licensee: Kansas Department of Transportation License No.: 22-B315-01 

Date of Incident: 9/23/10 NMED No.: 100509 

Investigation Date: 10/12/10 Type of Incident: Lost RAM 

 Type of Investigation: Telephone 

File No.: 2 

Licensee: Frontier El Dorado Refining, LLC License No.: 22-B145-01 

Date of Incident: 2/25/11 NMED No.: 110161 

Investigation Date: 2/25/11 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 3 

Licensee: Frontier El Dorado Refining, LLC License No.: 22-B145-01 

Date of Incident: 10/4/11 NMED No.: 110529 

Investigation Date: 10/5/11 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 4 

Licensee: PFI, LLC License No.: 10-C842-01 

Date of Incident: 9/30/11 NMED No.: 110616 

Investigation Date: 12/9/11 Type of Incident: Overexposure 

 Type of Investigation: Site 

File No.: 5 

Licensee: PETNET Solutions License No.: 10-C814-01 

Date of Incident: 2/22/12 NMED No.: N/A 

Investigation Date: 3/21/12 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 6 

Licensee: St. Francis Health Center License No.: 19-B272-04 

Date of Incident: 1/23/13 NMED No.: 130067 

Investigation Date: 1/23/13 Type of Incident: Transportation 

 Type of Investigation: Telephone 

File No.: 7 

Licensee: Frontier El Dorado Refining, LLC License No.: 22-B145-01 

Date of Incident: 4/3/13 NMED No.: 130167 

Investigation Date: 4/3/13 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

 
Kansas Final IMPEP Report Page E. 2 

Incident Casework Reviews 

File No.: 8 

Licensee: Frontier El Dorado Refining, LLC License No.: 22-B145-01 

Date of Incident: 4/20/13 NMED No.: 130184 

Investigation Date: 4/22/13 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 9 

Licensee: Coder X-ray Service License No.: 21-B165-01 

Date of Incident: 4/23/13 NMED No.: 130275 

Investigation Date: 6/9/13 Type of Incident: Overexposure 

 Type of Investigation: Telephone 

File No.: 10 

Licensee: Coder X-ray Service License No.: 21-B165-01 

Date of Incident: 8/5/13 NMED No.: 130400 

Investigation Date: 9/4/13 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 11 

Licensee: J and R Sand Company, Inc. License No.: 22-B623-01 

Date of Incident: 9/30/13 NMED No.: 130494 

Investigation Date: 10/21/13 Type of Incident: Damaged Equipment 

 Type of Investigation: Telephone 

File No.: 12 

Licensee: St. Francis Health Center License No.: 19-B272-04 

Date of Incident: 10/31/13 NMED No.: 130521 

Investigation Date: 11/1/13 Type of Incident: Overexposure 

 Type of Investigation: Telephone 

File No.: 13 

Licensee: DBI, Inc. License No.: 21-B805-01 

Date of Incident: 2/17/14 NMED No.: 140110 

Investigation Date: 2/17/14 Type of Incident: Equipment Failure 

 Type of Investigation: Telephone 

File No.: 14 

Licensee: Pioneer Wireline Services License No.: 27-B565-01 

Date of Incident: 12/31/13 NMED No.: 140225 

Investigation Date: 3/26/14 Type of Incident: Overexposure 

 Type of Investigation: Email 

Comment: At the time of the review, an on-site investigation had not yet been performed by the 

State, in spite of evidence of a significant exposure to an untrained individual, and 

potential overexposures to members of the public. 
 

ATTACHMENT 

August 12, 2014 Letter from Thomas Conley 

Kansas Response to the Draft Report 

ADAMS Accession No.: ML14230A753