UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

REGION I 

2100 RENAISSANCE BLVD., SUITE 100 

KING OF PRUSSIA, PA 19406-2713 

June 2, 2015 

W. Lee Cox, Chief 

Radiation Protection Section 

Division of Health Service Regulation 

5505 Creedmoor Road 

1st Floor 

Raleigh, NC 27612 

Dear Mr. Cox: 

A periodic meeting with you and your staff was held on April 16, 2015. The purpose of this 

meeting was to review and discuss the status of the North Carolina Agreement State Program. 

The U.S. Nuclear Regulatory Commission (NRC) was represented by Daniel Collins, 

Lisa Dimmick, and me. 

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

resulting from the discussions. A Management Review Board (MRB) meeting to discuss the 

outcome of the periodic meeting has been scheduled for June 23, 2015 at 1:00pm. Call in 

information for the MRB will be provided in a separate transmission. 

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) 337-5214 or 

via e-mail at Monica.Ford@nrc.gov to discuss your concerns. 

 Sincerely, 

 /RA/ 

 Monica Lynn Ford 

 Regional State Agreements Officer 

 Division of Nuclear Materials Safety 

 U.S. NRC Region I 

Enclosure: 

Periodic Meeting Summary for North Carolina 

cc w/encl.: David Crowley, Manager 

 
June 2, 2015 

W. Lee Cox, Chief 

Radiation Protection Section 

Division of Health Service Regulation 

5505 Creedmoor Road 

1st Floor 

Raleigh, NC 27612 

Dear Mr. Cox: 

A periodic meeting with you and your staff was held on April 16, 2015. The purpose of this 

meeting was to review and discuss the status of the North Carolina Agreement State Program. 

The U.S. Nuclear Regulatory Commission (NRC) was represented by Daniel Collins, 

Lisa Dimmick, and me. 

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

resulting from the discussions. A Management Review Board (MRB) meeting to discuss the 

outcome of the periodic meeting has been scheduled for June 23, 2015 at 1:00pm. Call in 

information for the MRB will be provided in a separate transmission. 

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) 337-5214 or 

via e-mail at Monica.Ford@nrc.gov to discuss your concerns. 

 Sincerely, 

 /RA/ 

 Monica Lynn Ford 

 Regional State Agreements Officer 

 Division of Nuclear Materials Safety 

 U.S. NRC Region I 

Enclosure: 

Periodic Meeting Summary for North Carolina 

cc w/encl.: David Crowley, Manager 

Distribution: 

L. Dimmick, NMSS J. Piccone, NMSS C. Einberg, NMSS 

K. Meyer, NMSS P. Henderson, NMSS M. Ford, RI DNMS 

D. Collins, RI DNMS J. Nick, RI DNMS D. Janda, RI DNMS 

SUNSI Review Complete: MLF (Reviewer’s Initials) 

\\nrc.gov\nrc\R1\Shared\State Agreement Files\North Carolina\NC April 2015 Periodic Meeting Summary and 

Transmittal Letter.docx ML15153A624 

After declaring this document “An Official Agency Record” it will be released to the Public. 

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

with attachment/enclosure "N" = No copy 

OFFICE DNMS/RI 

NAME MFord/mlf 

DATE 06/02/15 
 

AGREEMENT STATE PERIODIC MEETING SUMMARY FOR 

NORTH CAROLINA’S DIVISION OF HEALTH SERVICE REGULATION 

RADIATION PROTECTION SECTION 

DATE OF MEETING: April 16, 2015 

U.S. Nuclear Regulatory Commission 

(NRC) Attendees 

North Carolina Division of Health Service 

Regulation Attendees 

Monica Ford, State Agreements Officer, 

Region I 

W. Lee Cox, Chief, Radiation Protection Section 

Daniel Collins, Director, Division of 

Nuclear Materials Safety, Region I 

David Crowley, Manager, Radioactive Materials 

Branch 

Lisa Dimmick, Senior Health Physicist, 

Agreement State Programs Branch, 

Office of Nuclear Material Safety and 

Safeguards 

Talytha Moore, Technology Support Specialist 

DISCUSSION: 

During the 2014 Integrated Materials Performance Evaluation Program (IMPEP) review of the 

North Carolina Agreement State Program (Program), the review team found the State’s 

performance satisfactory for the indicators Technical Quality of Inspections, Technical Quality of 

Licensing Actions, Technical Quality of Incidents and Allegations, and Compatibility 

Requirements and satisfactory but needs improvement for the indicators Technical Staffing and 

training, Status of the Materials Inspection Program, and Sealed Source and Device Evaluation 

Program. The review team made three recommendations regarding program performance. The 

review team recommended that the Program be found adequate to protect public health and 

safety but needs improvement and compatible with the NRC’s program. The review team also 

recommended that the State enter into a period of Monitoring. On June 5, 2014, the 

Management Review Board (MRB) met to consider the proposed final IMPEP report on the 

Program. The MRB disagreed with the review team’s finding for the indicator Status of the 

Materials Inspection Program and directed that the indicator be found satisfactory. The MRB 

agreed with the findings for the other indicators. The MRB also disagreed with the 

recommendation to place the State on Monitoring, stating that the team did not identify any 

performance issues which impacted public health, safety, and security. Overall, the MRB found 

the Program adequate to protect public health and safety but needs improvement and 

compatible with the NRC’s program. The MRB directed that a periodic meeting should be held 

in one year and that the next IMPEP review should take place in approximately four years. This 

summary is a reflection of that periodic meeting. 

TOPICS COVERED DURING THE MEETING INCLUDED:

Program Strengths

1. Experienced Radiation Control Program Director 

• The radiation control program director came up through the Program and has 22 

years of experience with North Carolina State government. 
North Carolina Periodic Meeting Summary 2 

 

2. Well trained staff 

• Program management also stated that program staff is the most well trained staff 

in North Carolina State government thanks to the training resources available to 

the staff. 

3. Dedicated Information Technology (IT) Staff 

• The Program has its own IT department which can make changes quickly and 

deal with IT issues that arise. 

4. ~51 years as an Agreement State 

• North Carolina became an Agreement State on August 1, 1964. The 

experiences and knowledge the Program has gained over the years have helped 

shape the Program. 

Program Challenge(s)

1. An underperforming legacy database. 

• The Program has dealt with this challenge by transitioning to the distributed 

version of Web Based Licensing (WBL). While the transition hasn’t solved every 

database tracking issue, the Program has a plan in place and hopes that 

eventually modifications to WBL will allow them to track the data they need. 

2. Staff morale 

• Staff morale was low at the time of the last IMPEP review due to poor managerial 

oversight of the program. Since the last IMPEP review the Program has hired a 

new Branch manager and has implemented monthly staff meetings that the 

home based inspectors come to the main office to attend. 

3. Some licensees being inspected by the same inspector for several inspections 

• Since the Program’s inspectors are home based, inspections are variably 

regionalized based on the work load for that year. This can lead to an inspector 

performing the same licensee’s inspection several times in a row. The Program 

has decided that it will implement a policy that at least every third inspection will 

be done by a different inspector from the previous inspection. 

Feedback on the NRC’s Program

The Program was very complimentary of the IMPEP process. However, the Program 

mentioned that it would be preferential if the IMPEP report could contain language that would 

help a program get the resources it deemed necessary to have a successful program (in North 

Carolina’s case the discussion specifically revolved around staffing issues from the 2014 IMPEP 

review). A discussion on this topic during the periodic meeting brought to light other resources 

that could be used to achieve the same goal, for example a letter of support. The Program also 

mentioned that it would be helpful if the IMPEP reports tied in information from the State’s 

previous IMPEP reports in order to look for trending. 

Organization

The Program is administered by the Radiation Protection Section, which includes the 

Radioactive Materials Branch, within the Division of Health Service Regulation (the Division). 
North Carolina Periodic Meeting Summary 3 

The Division is part of the Department of Health and Human Services. There have been no 

reorganizations since the 2014 IMPEP review. 

Program Budget/Funding

The program is 100 percent fee funded. The money goes into a dedicated fund specific for 

agency use. Surplus money is maintained in a non-reverting fund and can be used for future 

decommissioning or clean-up projects as needed. 

Technical Staffing and Training (2014 IMPEP: Satisfactory but needs improvement)

At the time of the periodic meeting, the Program consisted of 11 technical staff positions totaling 

10.5 full time equivalents (FTE), one Branch manager, and one administrative support staff. 

During the month following the periodic meeting the Program stated that two FTE were 

reallocated to the branch. This reallocation creates an increase of two technical staff positions 

from number identified in the 2014 IMPEP review. 

It was noted in the 2014 IMPEP report that at the time of the review there were two vacant staff 

positions in the Program. Since the IMPEP review both of these positions have been filled. 

This includes the vacant Branch Manager position that was discussed in the IMPEP report. The 

Program hired a new Branch Manager in December 2014. At the time of the periodic meeting 

there were another two vacancies in the Program. One resulted from an individual who left the 

Program shortly after the IMPEP review and the other is a new position for the Program which 

came about from the reallocation mentioned above. One of the two vacancies has been posted 

and is expected to be filled in the three to four weeks following the periodic meeting. The 

Program hopes to have the other vacancy filled within four months. The Program also utilizes 

two contract employees when needed. One contract employee helps with engineering reviews 

for sealed source and device applications and the other contract employee helps with regulation 

promulgation. 

The Program has a documented training plan for technical staff. However, as noted in the 2014 

IMPEP report, the training plan had not been updated since 2004 and was not consistent with 

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

and NRC’s Inspection Manual Chapter (IMC) 1248, “Formal Qualification Program for Federal 

and State Material and Environmental Management Programs.” The review team made one 

recommendation for this indicator. The recommendation is listed below along with its status. 

Recommendation 1: The review team recommends that the State update its training 

qualification program to be consistent with IMC 1248, “Formal Qualification Program for Federal 

and State Material and Environmental Management Programs” and the State apply this program 

to all technical staff currently going through the qualification process and all new staff that are 

hired. 

Status: The Program revised its procedure to make it consistent with IMC 1248 following the 

2014 IMPEP review. The revised procedure is currently undergoing a second revision and the 

Program hopes to have the revisions completed within the next four to six weeks. The revised 

procedure is being used by all staff currently going through the qualification process and will be 

applied to new staff hired by the Program. 
North Carolina Periodic Meeting Summary 4 

Status of Materials Inspection Program (2014 IMPEP: Satisfactory); Technical Quality of 

Inspections (2014 IMPEP: Satisfactory)

The Program has conducted 130 Priority 1, 2, and 3 inspections since the last IMPEP review. 

Of those, five have been completed overdue. Two inspections are currently overdue. The 

Program performs its health and safety inspections separate from its security inspections. No 

security inspections have been completed overdue since the last IMPEP review. The Program 

has completed 16 initial inspections of which it is believed 10 were completed overdue. These 

inspections were completed overdue because of data tracking errors associated with the 

distributed version of WBL. The Program is unsure of the reported numbers since they 

discovered inconsistencies in the way initial inspection data was being populated by the 

software in WBL. The Program demonstrated the database issues during the periodic meeting. 

The Program is working with the NRC WBL contractors to correct for these database issues and 

to ensure proper tracking of inspection due dates (for both routine and initial inspections) and 

database population. The review team made one recommendation for the indicator Status of 

the Materials Inspection Program. The recommendation and its status are listed below. 

Recommendation 2: The review team recommends that the State implement procedures and 

a new tracking system to ensure that less than 10 percent of Priority 1, 2, and 3 and initial 

inspections are completed overdue. 

Status: In the 2014 IMPEP report it was noted that the Program faced many challenges with the 

database that was in place at the time of the review. Shortly after the review was complete the 

Program did a large data dump into the distributed version of WBL in order to close down the 

legacy database that was causing so many tracking issues. In implementing the new database 

issues with data population and with inspection tracking were again identified. The Program is 

working with the NRC contractors for WBL to fix the problems found and to ensure that data for 

initial and routine inspections is populated correctly, based off of what is initially entered by staff, 

so that the next inspection date is correct. 

 

The Program uses inspection procedures that are consistent with the inspection guidance 

outlined in IMC 2800. The Program does not issue any inspection findings in the field. All 

inspection data is reviewed and signed by the Inspection Coordinator (or if the Inspection 

Coordinator performs the inspection the review and signature is completed by the Branch 

Manager). Inspection findings are routinely sent to licensees within 30 days of completing an 

inspection. 

The Program issued 36 reciprocity approvals in calendar year (CY) 2014. Sixteen of those 

reciprocity candidates provided notification of work to be performed. The Program inspected 

eight of those 16 reciprocity candidate licensees. In CY 2015 the Program received 36 

applications for reciprocity. Eleven of those licensees have sent in notifications of work. The 

Program has performed zero reciprocity inspections as of the periodic meeting. 

The Program has a policy to accompany all staff performing radioactive materials inspections on 

an annual basis. All inspector accompaniments were performed in CY 2014. Two of those 

accompaniments were performed by the Inspection coordinator since the Branch Manager 

position was not filled until December 2014. 
North Carolina Periodic Meeting Summary 5 

Technical Quality of Licensing Actions (2014 IMPEP: Satisfactory)

The Program has approximately 600 specific licensees. All licensing actions are worked on in a 

timely manner. Since the last IMPEP review the Program has implemented a peer review 

system for licensing actions and holds weekly licensing meetings in order to discuss any issues 

that arise during the processing of licensing actions. The Program has received 540 licensing 

actions since the last IMPEP review. One hundred and seventy eight actions are currently in 

house. The longest licensing action has been with the Program for approximately 271 days and 

is a renewal. Staff has signature authority for licensing actions that they have been qualified to 

perform. The guidance used by the Program is equivalent to the NRC’s NUREG 1556 Series 

guidance. 

Technical Quality of Incidents and Allegations (2014 IMPEP: Satisfactory)

The Program is aware of the need to maintain an effective response to incidents and 

allegations. At the time of the periodic meeting the Program had reported eight events since the 

last IMPEP review. All reportable events were conveyed to the NRC in the correct manner. 

The Program is aware that five of the reported events require additional information and that 

seven of the events have not yet been closed by the State in NMED. The Program is working 

with Idaho National Laboratory to address these items. The Program uses procedures 

equivalent to the NRC’s allegation procedures for processing allegations. The Program updated 

these procedures following the 2014 IMPEP review. The Program received and responded to 

six allegations since the last IMPEP review two of which pertained to material regulated by the 

Program. 

Regulations and Legislative Changes (2014 IMPEP: Satisfactory)

The current effective statutory authority is contained in Chapter 104E of the North Carolina 

General Statutes. In Section 104E-6, the Department is designated as the State’s radiation 

control agency. No legislative changes affecting the Program have occurred since the last 

IMPEP review. The Program has one regulation amendment overdue for adoption. The 

overdue regulation is associated with Regulation Amendment Tracking System Identification 

Number 2011-2 “Licenses, Certifications, and Approvals for Materials Licensees; Parts 30, 36, 

39, 40, 70, and 150.” The Program is working on addressing this overdue regulation along with 

other regulations that are coming due later this year. The Program plans to have final 

regulations in place by the end of CY 2015. 

North Carolina regulations are subject to sunset provisions which require a review of all 

regulations promulgated by the State every 10 years. Regulations that are not reviewed and 

approved prior to the end of the review period automatically expire. The Branch will be required 

to review all radiation protection rules in July 2018 and then report to the Rules Review 

Committee as to whether the rules are necessary or not necessary and what if any public 

impact the rule has. 

The Program has not yet implemented regulations equivalent to the NRC’s Part 37 regulations. 

The Program plans to have equivalent regulations implemented by the due date in March 2016. 

If the Program determines that they are unable to meet this deadline they will use a license 

condition to adopt the NRC’s Part 37 regulations by reference. This license condition would 

then need to be administratively added to approximately 40 licenses. 
North Carolina Periodic Meeting Summary 6 

The Program’s administrative rulemaking process takes approximately two years from the 

development stage to the final approval by the Rules Review Commission, after which the rule 

becomes effective. The public, 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. 

Sealed Source and Device (SS&D) Evaluation Program (2014 IMPEP: Satisfactory but needs 

improvement)

• Technical Staffing and Training 

SS&D evaluation responsibilities are distributed between two qualified reviewers. The 

Program is working to qualify one additional reviewer in the near future. Both qualified 

reviewers have degrees in a physical science and have attended the NRC’s SS&D 

Workshop. 

• Technical Quality of the Product Evaluation Program 

Since the last IMPEP review, The Program has processed two SS&D actions. Both 

actions were amendments to an existing registry. 

The review team made one recommendation for this indicator. The recommendation is listed 

below along with its status. 

Recommendation 3: The review team recommends that the State identify, develop, and 

implement processes to ensure official sealed source and device registry documents are 

complete, legible, accounted for, and are readily accessible to those who are determined to 

have a need to know the information. 

Status: The Program rewrote their SS&D procedures following the 2014 IMPEP review. The 

revisions included changes to the SS&D review process that will help ensure the Program has 

complete and legible SS&D information that is accounted for. The Program has also moved into 

a new office space since the last IMPEP review. This move allowed the Program to consolidate 

all of the Program’s files (Licensing, SS&D, Financial Assurance ...) into one location so that 

they are readily accessible for those that have a need to know. 

CONCLUSIONS: 

The Program continues to be an effective, well maintained Agreement State program. There 

are two staff level vacancies at this time. The Program is working on addressing the three 

recommendations from the previous IMPEP review. Use of the distributed version of WBL has 

provided some challenges for the Program, specifically in the area of data tracking, which the 

Program is aware of and is working with the NRC contractors to resolve. The Program is 

effectively managing its licensing and inspection activities. The Program is responding to 

incidents and allegations as appropriate and has one regulation amendment overdue for 

adoption. There are two qualified SS&D reviewers in the Program and two SS&D actions have 

been processed since the last IMPEP review. 

NRC staff recommends that a periodic meeting be held in 18 months and that the next IMPEP 

review be conducted as scheduled in March 2018.