UNITED STATES

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

September 1, 2016 

Richard E. Dunn, Director

Department of Natural Resources

Environmental Protection Division

2 Martin Luther King Jr. Drive, Suite 1456

Atlanta, GA 30334

Dear Mr. Dunn:

On August 4, 2016, a Management Review Board (MRB), which consisted of U.S. Nuclear 

Regulatory Commission (NRC) senior managers and an Organization of Agreement States 

liaison to the MRB, met to consider the proposed final Integrated Materials Performance 

Evaluation Program (IMPEP) report on the Georgia Agreement State Program. The MRB found 

the Georgia program adequate to protect public health and safety, and compatible with the 

NRC’s program.

The enclosed final report contains a summary of the IMPEP team’s findings and 

recommendations (Section 5.0). The review team identified performance issues in the 

indicators of Status of the Materials Inspection Program (Section 3.2), Technical Quality of 

Inspections (Section 3.3), and Technical Quality of Licensing actions (Section 3.4) that are 

attributed to staff turnover. The MRB recommends that the Georgia Agreement State Program 

management develop a strategy to address staff retention and implement corrective actions to 

mitigate the causes of the turnover to ensure satisfactory performance is sustained. The MRB 

acknowledges the performance improvements Georgia has made since 2012. As such, the 

MRB determined that the period of heightened oversight be discontinued and a period of 

monitoring be initiated until such time as the Georgia Agreement State Program has 

demonstrated a sustained period of satisfactory performance. Monitoring is an informal process 

that allows the NRC to maintain an increased level of communication with an Agreement State 

program. 

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

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

scheduled for May 2017, and a second periodic meeting in the November 2018 timeframe. 

These periodic meetings will include a focused discussion of Georgia’s actions taken to address 

the recommendations in the enclosed report. 

Enclosure: 

Georgia IMPEP Final Report 

cc: See next page
I appreciate the courtesy and cooperation extended to the IMPEP team during the review. I 

also wish to acknowledge your continued support for the Agreement State program. I look 

forward to our agencies continuing to work cooperatively in the future.

Sincerely, 

 /RA/ 

Glenn M. Tracy

Deputy Executive Director for Materials, Waste,

 Research, State, Tribal, Compliance, Administration,

 and Human Capital Programs 

Office of the Executive Director for Operations 

cc: Karen Hays, P.E., Chief 

 Air Protection Branch 

David Walter, AL 

Organization of Agreement States 

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

also wish to acknowledge your continued support for the Agreement State program. I look 

forward to our agencies continuing to work cooperatively in the future.

Sincerely, 

 /RA/ 

Glenn M. Tracy

Deputy Executive Director for Materials, Waste,

 Research, State, Tribal, Compliance, Administration,

 and Human Capital Programs 

Office of the Executive Director for Operations 

cc: Karen Hays, P.E., Chief 

 Air Protection Branch 

David Walter, AL 

Organization of Agreement States 

 Liaison to the MRB 

DISTRIBUTION: (SP05) 

See Next Page 

ADAMS Accession Number: ML16223A001 

OFFICE Team 

Leader:RIV 

MSTR/ASPB MSTR/ASPB NMSS/MSTR NMSS/Tech 

Editor 

NMSS DEDM 

NAME BTharakan 

LRO for via 

email 

LDimmick 

LD w/edits 

PMichalak 

PM w/edits 

DCollins WMoore SMoore GTracy 

DATE 08/ 11 /16 08/ 11/16 08/12 /16 08/17/16 08/18/16 08/22/16 09/01/16

OFFICIAL RECORD COPY
Letter to Richard Dunn from Glenn Tracy, dated September 1, 2016 

SUBJECT: GEORGIA FY2016 FINAL IMPEP REPORT 

DISTRIBUTION: (SP05) 

RidsEdoMailCenter 

MSampson, OEDO 

RidsSecyCorrespondenceMailCenter Chairman Burns 

RidsOgcMailCenter Commissioner Svinicki 

JOlmstead, OGC Commissioner Baran 

MFord, RSAO/RI SECY 

FGaskins, RI 

LRoldan-Otero, MSTR 

JGriffis, TTC 

VDanese, TX DSHS 

RidsNmssOd 

DCollins, MSTR 

PHenderson, MSTR 

OAS Board 

LRoldan, ASPB 

DWhite, ASPB 

State of GA 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE GEORGIA AGREEMENT STATE PROGRAM 

MAY 9–12, 2016 

FINAL REPORT
EXECUTIVE SUMMARY 

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

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

the period of May 9–12, 2016, by a review team composed of technical staff members from the 

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

Based on the results of this review, Georgia’s performance was found satisfactory for five out of 

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

Program, Technical Quality of Inspections, Technical Quality of Incidents and Allegation 

Activities, and Compatibility Requirements. The Technical Quality of Licensing Actions 

performance indicator was found satisfactory, but needs improvement. 

The review team made three new recommendations (see Section 5.0) and determined that the 

three recommendations from the 2014 IMPEP review should be closed (see Section 2.0). Upon 

its deliberations, the Management Review Board (MRB) issued two additional recommendations 

to Georgia to bolster performance in the areas of staff retention and reciprocity inspections 

(Sections 3.1 and 3.2). With respect to staffing, the Technical Staffing and Training indicator 

was found satisfactory in 2014 and 2016. Because staff turnover led to negative performance 

trends in some areas of licensing and inspection over the 2016 review period, the MRB issued a 

recommendation to the Georgia Agreement State Program management to develop a strategy 

to address staff retention and implement corrective actions to ensure satisfactory program 

performance is sustained. 

The review team recommended, and the MRB agreed, that the period of heightened oversight 

be discontinued and a period of monitoring be initiated until such time as the Georgia 

Agreement State Program has demonstrated a sustained period of satisfactory performance. 

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

State Program is adequate to protect public health and safety and 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 directed that a periodic meeting be held 1 year 

from this review with a second meeting approximately 18 months after the first periodic meeting. 

These periodic meetings will include a focused discussion of Georgia’s actions taken to address 

the recommendations in the enclosed report. 
Georgia Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

The review was conducted during the period of May 9–12, 2016, by a review team 

composed of technical members from the U.S. Nuclear Regulatory Commission (NRC) 

and the State of Texas. 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 (MD 5.6), “Integrated Materials Performance Evaluation Program (IMPEP),” dated 

February 26, 2004. Preliminary results of the review, which covered the period of 

February 11, 2014, through May 12, 2016, were discussed with Georgia managers on 

the last day of the review. 

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

non-common performance indicators was sent to Georgia on December 4, 2015. 

Georgia provided its response to the questionnaire on April 21, 2016. A copy of the 

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

Management System (ADAMS) using the Accession Number ML16140A116. 

A draft of this report was issued to Georgia on June 13, 2016, for factual comment. 

Georgia responded to the findings and conclusions of the review by letter dated 

June 29, 2016. A copy of Georgia’s response can be found in ADAMS using the 

Accession Number ML16194A001. A Management Review Board (MRB), which 

consisted of NRC senior managers and an Organization of Agreement States liaison to 

the MRB, met on August 4, 2016, to consider the proposed final report. The MRB found 

the Georgia Agreement State Program adequate to protect public health and safety, and 

compatible with the NRC’s program. 

The Georgia Agreement State Program is administered by the Radioactive Materials 

Program (the Program). The Program is located in the Air Protection Branch (the 

Branch) of the Environmental Protection Division of the Georgia Department of Natural 

Resources (the Department). Organization charts for the State can be found in ADAMS 

using the Accession Number ML16116A122. 

At the time of the review, the Program regulated 433 specific licenses authorizing 

possession and use of radioactive materials. The review focused on the radioactive 

materials program as it is carried out under the Section 274b. (of the Atomic Energy Act 

of 1954, as amended) Agreement between the NRC and the State of Georgia. 

The review team evaluated the information gathered against the established criteria for 

each common and the applicable non-common performance indicator and made a 

preliminary assessment of the Georgia Agreement State Program’s performance. 

2.0 PREVIOUS IMPEP REVIEW AND STATUS OF RECOMMENDATIONS 

The previous IMPEP review concluded on February 10, 2014. The final report is 

available in ADAMS (Accession Number ML14121A618). The results of the previous 

review and the status of the recommendations are as follows: 
Georgia Final IMPEP Report Page 2 

Technical Staffing and Training: Satisfactory 

Recommendation: None 

Status of Materials Inspection Program: Unsatisfactory 

Recommendation: None 

Technical Quality of Inspections: Satisfactory but Needs Improvement 

Recommendation 1: The review team recommends that the State: (1) implement its 

inspection procedures to ensure that inspectors document the reason for missing 

temporary job site inspections; document details and circumstances of violations in 

inspection reports and Notices of Violations (NOV); consider a reduction (or increase) in 

inspection frequency for serious violations and conduct performance based inspections; 

and (2) complete its enforcement procedure for assigning severity levels of violations. 

(Section 3.3 of the 2014 IMPEP Report) 

Status: For part one of this recommendation, the review team examined inspection 

reports for licensees that were authorized for temporary job sites. The review team 

determined that, if applicable, the reasons for missing temporary job site inspections, 

such as the sites were not available during the inspection, were documented in the 

inspection reports. The review team determined that violations were well documented in 

inspection reports and in the NOV’s issued to licensees. The NOV’s included 

statements of the regulation and provided the circumstances of the violations. In 

addition, the review team determined that the Program manager reviews all violations 

when the inspectors return to the office. Significant enforcement actions involving public 

health and safety are discussed by the Program manager and inspectors, and changes 

to the inspection frequencies are considered. Based on the inspector accompaniments 

and interviews with the inspectors and Program manager, the review team determined 

that the Program’s inspectors conduct performance based inspections. For part two of 

this recommendation, the review team determined that the Program has completed and 

implemented its enforcement procedure for assigning severity levels of violations. The 

review team recommended, and the MRB agreed, that this recommendation be closed. 

Technical Quality of Licensing Actions: Satisfactory 

Recommendation 2: The review team recommends that the State verify that all 

previously approved medical authorized users have proper documentation of their 

qualifications, since the new requirements were initiated in 2008. (Section 3.4 of the 

2012 and 2014 IMPEP Reports) 

Status: The Program contacted all authorized users/licensees and either obtained the 

necessary documentation or amended the licenses as needed for all but three 

authorized users, as of the date of the review. An amendment was pending to remove 

those users from the applicable license. To track its progress in obtaining the necessary 

documentation, the Program created a spreadsheet of all authorized users which is now 

used by staff to verify that training and experience have been documented prior to 

adding an authorized user to a license. The review team recommended, and the MRB 

agreed, that this recommendation be closed. 

 
Georgia Final IMPEP Report Page 3 

Recommendation 3: The review team recommends that the State finalize its procedure 

for pre-licensing requirements and provide training to the staff on the revised procedure. 

(Section 3.4 of the 2014 IMPEP Report) 

Status: The Program revised its licensing procedures in May 2014 to include 

pre-licensing requirements and held training for staff on this procedure in July 2014. 

The review team recommended, and the MRB agreed, that this recommendation be 

closed. 

Technical Quality of Incident and Allegation Activities: Satisfactory 

Recommendation: None 

Compatibility Requirements: Satisfactory 

Recommendation: None 

2014 Overall Finding: Adequate to protect public health and safety, but needs 

improvement, and Compatible with the NRC’s program. 

The Georgia Agreement State Program was removed from probation and placed on 

heightened oversight following the 2014 IMPEP review. 

3.0 COMMON PERFORMANCE INDICATORS 

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

Agreement State radioactive materials programs. These indicators are (1) Technical 

Staffing and Training, (2) Status of Materials Inspection Program, (3) Technical Quality 

of Inspections, (4) Technical Quality of Licensing Actions, and (5) Technical Quality of 

Incident and Allegation Activities. 

3.1 Technical Staffing and Training 

The ability to conduct effective licensing and inspection programs is largely dependent 

on having a sufficient number of experienced, knowledgeable, well-trained technical 

personnel. Under certain conditions, staff turnover could have an adverse effect on the 

implementation of these programs, and thus could affect public health and safety. 

Apparent trends in staffing must be explored. Review of staffing also requires a 

consideration and evaluation of the levels of training and qualification. The evaluation 

standard measures the overall quality of training available to, and taken by, materials 

program personnel. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-103, “Reviewing 

the Common Performance Indicator: Technical Staffing and Training,” and evaluated 

Georgia’s performance with respect to the following performance indicator objectives: 

• A well-conceived and balanced staffing strategy has been implemented throughout 

the review period. 
Georgia Final IMPEP Report Page 4 

• Agreement State training and qualification program is equivalent to NRC Inspection 

Manual Chapters (IMC) 1248, “Formal Qualifications Program for Federal and State 

Material and Environmental Management Programs.” 

• Qualification criteria for new technical staff are established and are being followed or 

that qualification criteria will be established if new staff members are hired. 

• Any vacancies, especially senior level positions, are filled in a timely manner. 

• There is a balance in staffing of the licensing and inspection programs. 

• Management is committed to training and staff qualification. 

• Individuals performing materials licensing and inspection activities are adequately 

qualified and trained to perform their duties. 

• License reviewers and inspectors are trained and qualified in a reasonable period of 

time. 

b. Discussion 

The Program is composed of 13 staff members, with approximately 10 full-time 

equivalents dedicated to the radioactive materials program. Of the 13 staff, 4 staff have 

primary duties associated with emergency response, so only a portion of their time is 

directed to the radioactive materials program. At the time of the review, there were no 

vacancies in the Program. However, during the review period, five staff members left 

the Program for various reasons. One staff member was released because of 

performance issues, three staff members found employment elsewhere, and one staff 

member left for personal reasons. The Program filled the resulting vacancies by hiring 

five new staff members. An additional emergency response position was also filled, with 

the intent that this staff member would seek qualification to support the radioactive 

materials program. All open positions were filled within the review period, with individual 

positions taking between 3–6 months to fill. Because of the turnover of staff during the 

review period, staff retention was discussed with the Branch chief and Program 

manager. The Branch chief indicated that pay increases were being considered for staff 

to aid in staff retention. In addition, the Program manager was attempting to reclassify 

staff positions as “Health Physicists,” to also help increase staff salaries. At the time of 

the MRB, the Branch chief confirmed that salary increases were made for the majority of 

the Branch. 

Georgia has a training and qualification manual compatible to the NRC’s IMC 1248. Due 

to the turnover in staff during the review period, the Program only had three fully 

qualified staff in the radioactive materials group at the time of review. However, one of 

the emergency response staff in the environmental group is qualified and is assisting 

with radioactive materials inspections and licensing. In addition, some of the new staff 

had received interim qualification to perform certain inspection and licensing activities. It 

was expected that all new staff will be fully qualified for all license types within 2 years of 

being hired. 

c. Evaluation 

The review team determined that during the review period the Program met the 

performance indicator objectives listed in Section 3.1.a. However, the MRB discussed 

Georgia’s turnover of staff and how this trend had impacted staff training and 

qualifications. The review team had identified performance issues in the indicators of 

Status of the Materials Inspection Program (Section 3.2), Technical Quality of 
Georgia Final IMPEP Report Page 5 

Inspections (Section 3.3) and Technical Quality of Licensing actions (Section 3.4) that 

are attributed to staff turnover. The MRB recommended that the Program management 

develop a strategy to address staff retention and implement corrective actions to mitigate 

the causes of the Program’s turnover to ensure satisfactory program performance is 

sustained. 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, the review team recommended, and 

the MRB agreed, that Georgia’s performance with respect to the indicator, Technical 

Staffing and Training, be found satisfactory. 

3.2 Status of the Materials Inspection Program 

Periodic inspections of licensed operations are essential to ensure that activities are 

being conducted in compliance with regulatory requirements and consistent with good 

safety practices. The frequency of inspections is specified in NRC IMC 2800, “Materials 

Inspection Program,” and is dependent on the amount and kind of material, the type of 

operation licensed, and the results of previous inspections. There must be a capability 

for maintaining and retrieving statistical data on the status of the inspection program. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-101, “Reviewing 

the Common Performance Indicator: Status of the Materials Inspection Program,” and 

evaluated Georgia’s performance with respect to the following performance indicator 

objectives: 

• Initial inspections and inspections of Priority 1, 2, and 3 licensees are performed at 

the frequency prescribed in IMC 2800. 

• Candidate licensees working under reciprocity are inspected in accordance with the 

criteria prescribed in IMC 1220, Processing of NRC Form 241, “Report of Proposed 

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

Offshore Waters, and Inspection of Agreement State Licensees Operating Under 10 

CFR 150.20.” 

• Deviations from inspection schedules are normally coordinated between technical 

staff and management. 

• There is a plan to perform any overdue inspections and reschedule any missed or 

deferred inspections, or a basis has been established for not performing any overdue 

inspections or rescheduling any missed or deferred inspections. 

• Inspection findings are communicated to licensees in a timely manner (30 calendar 

days, or 45 days for a team inspection, as specified in IMC 0610, “Nuclear Material 

Safety and Safeguards Inspection Reports”). 

b. Discussion 

The Program conducted a total of 143 Priority 1, 2, 3, and initial inspections during the 

review period. Eleven of 123 Priority 1, 2, or 3 inspections were conducted overdue. All 

initial inspections of new licenses were performed within 12 months of license issuance. 

Overall for the review period, the Program conducted 7.7 percent of Priority 1, 2, 3, and 
Georgia Final IMPEP Report Page 6 

initial inspections overdue. This was a significant improvement over the Program’s 

overdue rate of 53 percent during the 2014 IMPEP review period. In addition, as the 

Program has prioritized and conducted overdue inspections, 11 overdue inspections 

from the 2014 IMPEP review period were conducted during the current IMPEP review 

period. 

The Program’s inspectors are expected to issue inspection reports within 30 days from 

the end of an inspection. A review of the database records for Priority 1, 2, and 3 

inspections performed during the review period indicated that 16 inspection reports were 

issued anywhere from 1 to 34 days beyond the Program’s goal of 30 days. Of the 16 

inspection reports issued late, 8 were issued by former inspectors that are no longer with 

the Program. 

For each year of the review period, the Program did not perform greater than 20 percent 

of candidate reciprocity inspections. In 2014, the Program completed 14 percent (7 of 

48) of the reciprocity inspections available; in 2015, 9 percent (2 of 22); and in 2016, at 

the time of the IMPEP review, the Program had not performed any reciprocity 

inspections (0 of 26). 

c. Evaluation 

The review team determined that during the review period, the Program met the 

performance indicator objectives listed in Section 3.2.a, with the following exception. 

The loss of qualified inspection staff and the Program’s previous process which allowed 

inspectors to choose reciprocity inspections at their discretion without adequate 

management oversight contributed to the Georgia’s failure to conduct at least 20 percent 

of the candidate reciprocity inspections in each year of the review period. Georgia 

management acknowledged that the loss of qualified staff shifted additional workload 

onto the remaining qualified inspectors. As a result, Georgia management focused 

inspection work on completing inspections of higher risk significant radioactive materials 

used by Georgia licensees. The Program manager indicated to the review team that 

corrective actions were implemented just prior to the review team’s arrival. Some of the 

corrective actions implemented by the program manager include: (1) assigning specific 

reciprocity inspections to each qualified inspector; (2) a periodic review of the status of 

reciprocity inspections throughout the year; and (3) a review of reciprocity inspections 

completed by each inspector during the inspector’s performance evaluation each year. 

As new staff members become qualified inspectors, additional reciprocity inspections 

can be completed to ensure that at least 20 percent of candidate reciprocity inspections 

are performed. 

The review team did not make a recommendation for the low number of reciprocity 

inspections completed each year of the review period because the Program manager 

had implemented corrective actions noted above to address the issue. Despite 

completing five reciprocity inspections since the onsite review, the MRB discussed that 

Georgia has not had sufficient time to show sustained performance with regard to the 

corrective actions taken just prior to the onsite IMPEP review concerning reciprocity. 

The MRB recommended that Program management implement corrective actions and 

make necessary adjustments to ensure satisfactory program performance is sustained 

with regard to reciprocity inspections. 
Georgia Final IMPEP Report Page 7 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, the review team recommended, and 

the MRB agreed, that Georgia’s performance with respect to the indicator, Status of the 

Materials Inspection Program, be found satisfactory. 

3.3 Technical Quality of Inspections 

Inspections, both routine and reactive, provide assurance that licensee activities are 

carried out in a safe and secure manner. Accompaniments of inspectors performing 

inspections, and the critical evaluation of inspection records are used to assess the 

technical quality of a program’s inspection capability. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-102, “Reviewing 

the Common Performance Indicator: Technical Quality of Inspections,” and evaluated 

Georgia’s performance with respect to the following performance indicator objectives: 

• Inspections of licensed activities focus on health, safety, and security. 

• Inspection findings are well-founded and properly documented in reports. 

• Management promptly reviews inspection results. 

• Procedures are in place and used to help identify root causes and poor licensee 

performance. 

• Inspections address previously identified open items and violations. 

• Inspection findings lead to appropriate and prompt regulatory action. 

• Supervisors conduct annual accompaniments of each inspector to assess 

performance and assure consistent application of inspection policies. 

• For programs with separate licensing and inspection staffs, to verify that procedures 

are established and followed to provide feedback information to license reviewers. 

• For Agreement States, to determine if inspection guides are consistent with NRC 

guidance. 

• An adequate supply of calibrated survey instruments is available to support the 

inspection program. 

b. Discussion 

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

interviewed inspectors for 19 materials inspections conducted during the review period. 

The casework reviewed included inspections conducted by seven of the Program’s 

former and current inspectors and covered medical, industrial, commercial, academic, 

research, and service licenses. The inspection casework and inspector 

accompaniments were also assessed for implementation of security requirements for 

risk significant material, as applicable. 

Review team members accompanied five Program inspectors during the week of 

February 8-12, 2016. The Program inspectors were accompanied during health, safety, 

and security inspections of medical therapy institutions (high dose rate remote 

afterloader (HDR) and permanent brachytherapy), industrial radiography, manufacturer 
Georgia Final IMPEP Report Page 8 

and distribution, and portable gauges. The inspector accompaniments are identified in 

Appendix B. 

Supervisory accompaniments for all qualified inspectors were performed during the 

review period. 

c. Evaluation 

The review team determined that during the review period, the Program met the 

performance indicator objectives listed in Section 3.3.a, with the following exceptions. 

During the inspection accompaniments of the Program’s inspectors, the review team 

determined that four out of five inspectors demonstrated appropriate inspection 

techniques, conducted performance-based inspections, and focused on health, safety, 

and security issues. However, during the medical (HDR and permanent brachytherapy) 

inspection accompaniment, the review team determined that the inspector did not verify 

whether the licensee had any medical events through examination of the written 

directives (prescribed vs. administered dose). The review team member observed that 

the licensee’s authorized medical physicist (AMP) had dated and signed, in advance, 

several verification sections for proper implementation of a written directive. One of the 

verification sections that was already dated and signed was for the verification of a 

patient’s identity that had not yet been seen and was scheduled for treatment later that 

day. The review team member further observed that the licensee lacked the procedures 

for proper administration of a written directive. The review team member communicated 

these observations to the inspector; however, the inspector did not question the AMP 

regarding the pre-filled written directive form or the licensee’s lack of procedures. The 

inspector did not consider the lack of procedures to be an issue; however, this appeared 

to be a violation of Georgia’s regulation for requiring written directive procedures. 

Additionally, the review team determined that the inspector missed a performance-based 

inspection opportunity by concluding the inspection prior to observing a manual 

brachytherapy procedure scheduled for later that day. 

The 2014 IMPEP report identifies and discusses similar performance issues with 

brachytherapy inspections which were not corrected by the Program. The review team 

recommends that the Program develop and implement training for inspectors on the 

examination of the written directives, and NRC Inspection Procedure 87132, 

Brachytherapy Program. The Program demonstrated appropriate inspection technique 

for the other license types assessed by the IMPEP team on inspection accompaniments. 

Because the performance issues concerned the inspection of only one type of 

brachytherapy procedure, the review team determined the Program met a satisfactory 

level of performance overall for technical quality of inspections. The review team found 

that inspections are usually well founded and well documented. 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, the review team recommended, and 

the MRB agreed, that Georgia’s performance with respect to the indicator, Technical 

Quality of Inspections, be found satisfactory. 
Georgia Final IMPEP Report Page 9 

3.4 Technical Quality of Licensing Actions 

The quality, thoroughness, and timeliness of licensing actions can have a direct bearing 

on public health and safety, and security. An assessment of licensing procedures, 

actual implementation of these procedures, and documentation of communications and 

associated actions between the Georgia licensing staff and regulated community will be 

a significant indicator of the overall quality of the program. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-104, “Reviewing 

the Common Performance Indicator: Technical Quality of Licensing Actions,” and 

evaluated Georgia’s performance with respect to the following performance indicator 

objectives: 

• Licensing action reviews are thorough, complete, consistent, and of acceptable 

technical quality with health, safety, and security issues properly addressed. 

• Essential elements of license applications have been submitted and elements meet 

current regulatory guidance (e.g., financial assurance, increased controls, 

pre-licensing guidance). 

• License reviewers, if applicable, have the proper signature authority for the cases 

they review independently. 

• License conditions are stated clearly and are inspectable. 

• Deficiency letters clearly state regulatory positions and are used at the proper time. 

• Reviews of renewal applications demonstrate a thorough analysis of a licensee’s 

inspection and enforcement history. 

• Applicable guidance documents are available to reviewers and are followed (e.g., 

NUREG-1556 series, pre-licensing guidance, regulatory guides, etc.). 

• Licensing practices for risk significant radioactive materials are appropriately 

implemented including increased controls and fingerprinting orders (Part 37 

equivalent). 

• Documents containing sensitive security information are properly marked, handled, 

controlled and secured. 

b. Discussion 

During the review period, the Program performed 889 radioactive materials licensing 

actions. The review team evaluated 14 radioactive materials licensing actions, including 

5 new applications, 4 amendments, 1 renewal, and 2 terminations. The review team 

also reviewed a financial assurance action and a decommissioning action. The 

casework sampled represented work from a total of seven current and former license 

reviewers. 

The review team evaluated casework which included the following license types and 

actions: medical diagnostic and therapy, commercial manufacturing and distribution, 

industrial radiography, academic, nuclear pharmacy, gamma knife, decommissioning 

action and financial assurance. 

License reviewers perform license reviews following the Program’s licensing guidance 

which is comparable to the NRC’s NUREG-1556 series, “Consolidated Guidance About 
Georgia Final IMPEP Report Page 10 

Materials Licenses.” All actions are peer reviewed and licenses signed by a qualified 

license reviewer. Licenses are issued for a 5-year period under a timely renewal 

system. 

c. Evaluation 

The review team determined that during the review period, the Program did not fully 

meet the performance indicator objectives listed in Section 3.4.a. The team identified 

weakness with essential elements of license application, analysis of inspection history, 

and technical quality. 

The review team identified three licensing actions that designated an authorized user on 

a medical license as the Radiation Safety Officer (RSO) without the license reviewer 

obtaining a preceptor RSO attestation or documenting that the authorized user had 

training in the radiation safety, regulatory issues and emergency procedures appropriate 

for the license. Interviews with staff indicated they were not aware of all of the 

requirements for adding an RSO to a medical license. The Program staff did obtain 

RSO preceptor attestations for a few designated RSOs as part of their work to document 

training and experience for all authorized users but they discontinued this practice for 

unknown reasons. The review team recommends that the Program verify that all 

previously approved radiation safety officers for medical licenses have an attestation by 

a preceptor RSO, and that the individual has completed training in the radiation safety, 

regulatory issues and emergency procedures for the appropriate license type. 

The review team found that a new license application for the use of unsealed radioactive 

material requiring a written directive contained procedures for occupational monitoring, 

area surveys, safe use of unsealed radioactive material, and waste management that 

were accepted by the reviewer, but did not meet the Program’s regulatory guidance. 

Additionally, a license renewal action resulted in the removal of a strontium-90 sealed 

source and authorization for manual brachytherapy sealed sources from the license 

without documentation of transfer or disposal. The renewal action did not document a 

review of the licensee’s inspection or enforcement history. Interviews with staff indicated 

that a review of inspection and enforcement history is not always performed and is not 

documented. 

An amendment request by a medical limited scope licensee to add sealed sources for 

manual brachytherapy on a storage only basis resulted in the issuance of the license to 

authorize use of the sources; however, the license was issued without an authorized 

user. Another license amendment requested authorization for use of unsealed material 

that requires a written directive; however, the license was amended to authorize 

possession of sealed sources for this use. The review team also found this license was 

missing two standard license conditions. The Program’s peer review of this licensing 

action identified that the form of material should be changed from sealed sources to 

unsealed material but the correction was not made prior to license issuance. After being 

notified by the licensee about the error, the Program subsequently re-issued the license. 

Three new license applications were found to have a pre-licensing checklist that was 

either not completed in its entirety or had criterion that were not evaluated as intended 

by the checklist guidance. Interviews with staff indicated that they were not familiar with 

the questions and sources of information intended to be used to evaluate the 
Georgia Final IMPEP Report Page 11 

pre-licensing criteria. Two license reviewers who were hired subsequent to the 

Program’s July 2014 pre-licensing training were not provided the instructions for 

completing the pre-licensing checklist. The Program conducts quarterly reviews of 100 

percent of new license files to confirm that pre-licensing requirements are met and 

deficiencies are brought to the attention of the license reviewer for correction. However, 

the quarterly reviews did not identify as deficiencies the incomplete pre-licensing 

checklists, or the unevaluated pre-licensing criteria. Consequently, the issues were not 

brought to the attention of the license reviewer. The review team recommends that the 

Program management develop and implement training and guidance that provides the 

staff with the tools necessary to accurately complete the Program’s pre-licensing 

requirements for each new license. 

d. Results 

The review team determined that some licensing actions indicated repeated examples of 

problems with respect to thoroughness, completeness, consistency, technical quality, 

and adherence to existing guidance. Therefore, based on the IMPEP evaluation criteria 

in MD 5.6, the review team recommended, and MRB agreed, that Georgia’s 

performance with respect to the indicator, Technical Quality of Licensing Actions, be 

found satisfactory, but needs improvement. 

3.5 Technical Quality of Incident and Allegation Activities 

The quality, thoroughness, and timeliness of response to incidents and allegations of 

safety concerns can have a direct bearing on public health and safety. An assessment 

of incident response and allegation investigation procedures, actual implementation of 

these procedures, internal and external coordination, and investigative and follow-up 

procedures and actions will be a significant indicator of the overall quality of the 

program. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-105, “Reviewing 

the Common Performance Indicator: Technical Quality of Incident and Allegation 

Activities,” and evaluated Georgia’s performance with respect to the following 

performance indicator objectives: 

• Incident response, investigation, and allegation procedures are in place and 

followed. 

• Response actions are appropriate, well-coordinated, and timely. 

• Onsite responses are performed when incidents have potential health, safety or 

security significance. 

• Appropriate follow-up actions are taken to ensure prompt compliance by licensees. 

• Follow-up inspections are scheduled and completed, as necessary. 

• Notifications are made to the NRC Headquarters Operations Center for incidents 

requiring a 24-hour or immediate notification to the Agreement State or the NRC. 

• Incidents are reported to the Nuclear Material Events Database. 

• Allegations are investigated in a prompt, appropriate manner. 

• Concerned individuals are notified of investigation conclusions. 

• Concerned individuals’ identities are protected, as allowed by law. 
Georgia Final IMPEP Report Page 12 

b. Discussion 

During the review period, 24 incidents were reported to the Program. The review team 

evaluated 12 radioactive materials incidents which included 3 lost/stolen radioactive 

materials events, 4 medical events, 2 damaged equipment events, and 3 leaking 

sources events. The Program dispatched inspectors for immediate onsite 

assessment for four of the cases reviewed. The other eight cases were evaluated 

through phone and e-mail conversations. Additionally, the Program follows up on events 

at the next routine inspection. 

During the review period, six allegations were received by the Program. The review 

team evaluated all six allegations, including one allegation that the NRC referred to the 

Program, during the review period. 

c. Evaluation 

The team determined that during the review period, the Program met the performance 

indicator objectives listed in Section 3.5.a. 

d. Results 

Based on the IMPEP evaluation criteria in MD 5.6, the review team recommended, and 

the MRB agreed, that Georgia’s performance with respect to the indicator, Technical 

Quality of Incident and Allegation Activities, be found satisfactory. 

4.0 NON-COMMON PERFORMANCE INDICATORS 

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

programs: (1) Compatibility Requirements, (2) Sealed Source and Device (SS&D) 

Evaluation Program, (3) Low-Level Radioactive Waste (LLRW) Disposal Program, and 

(4) Uranium Recovery Program. The NRC’s Agreement with Georgia does not 

relinquish regulatory authority for a SS&D, or a uranium recovery program; therefore 

only two non-common performance indicators apply to this review. 

4.1 Compatibility Requirements 

State statutes should authorize the State to establish a program for the regulation of 

agreement material and provide authority for the assumption of regulatory responsibility 

under the agreement. The statutes must authorize the State to promulgate regulatory 

requirements necessary to provide reasonable assurance of protection of public health, 

safety, and security. The State must be authorized through its legal authority to license, 

inspect, and enforce legally binding requirements, such as regulations and licenses. 

The NRC regulations that should be adopted by an Agreement State for purposes of 

compatibility or health and safety should be adopted in a time frame so that the effective 

date of the State requirement is not later than 3 years after the effective date of the 

NRC's final rule. Other program elements, as defined in Appendix A of State 

Agreements procedure SA-200, “Compatibility Categories and Health and Safety 

Identification for NRC Regulations and Other Program Elements,” that have been 

designated as necessary for maintenance of an adequate and compatible program 
Georgia Final IMPEP Report Page 13 

should be adopted and implemented by an Agreement State within 6 months following 

NRC designation. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-107, “Reviewing 

the Non-Common Performance Indicator: Compatibility Requirements,” and evaluated 

Georgia’s performance with respect to the following performance indicator objectives. A 

complete list of regulation amendments can be found on the NRC website at the 

following address: https://scp.nrc.gov/rss_regamendents.html. 

• The Agreement State program does not create conflicts, duplications, gaps, or other 

conditions that jeopardize an orderly pattern in the regulation of radioactive materials 

under the Atomic Energy Act, as amended. 

• Regulations adopted by the Agreement State for purposes of compatibility or health 

and safety were adopted no later than 3 years after the effective date of the NRC 

regulation. 

• Other program elements, as defined in SA-200 that have been designated as 

necessary for maintenance of an adequate and compatible program have been 

adopted and implemented within 6 months of NRC designation. 

• The State statutes authorize the State to establish a program for the regulation of 

agreement material and provide authority for the assumption of regulatory 

responsibility under the agreement. 

• The State is authorized through its legal authority to license, inspect, and enforce 

legally binding requirements such as regulations and licenses. 

• Impact of sunset requirements, if any, on the State’s regulations. 

b. Discussion 

Georgia became an Agreement State on December 15, 1969. The Program‘s current 

effective statutory authority is contained in the Official Code of Georgia Annotated, Title 

31, Chapter 13, of the Georgia Statutes. The Department is designated as the State’s 

radiation control agency. No legislation affecting the radiation control program was 

passed during the review period. 

Georgia’s administrative rulemaking process takes approximately 1 year from drafting to 

finalizing a rule. The public, the NRC, other agencies, and potentially impacted 

licensees and registrants are offered an opportunity to comment during the process. 

Comments are considered and incorporated, as appropriate, before the regulations are 

finalized and approved by the Board of the Department of Natural Resources. The 

review team noted that Georgia’s rules and regulations are not subject to “sunset” laws. 

During the review period, the Program submitted four final regulation amendments, three 

proposed regulation amendments and one legally binding license condition to the NRC 

for a compatibility review. One of the amendments was overdue for adoption by Georgia 

at the time of submission. 

Two out of the three aforementioned proposed regulations (RATS ID’s 2011-2 and 

2012-1) have been promulgated in a timely manner. However, the Program has not 

submitted the final packages for NRC review. The third regulation package submitted as 
Georgia Final IMPEP Report Page 14 

proposed (RATS ID 2013-1) has been adopted by a legally binding license condition. 

The Program should submit the final package for NRC review if they plan to adopt the 

regulation and remove the license condition from the applicable licenses. 

The team noted that during the review period, the Program submitted three additional 

regulation packages addressing several comments that were generated during previous 

reviews. 

At the time of this review, no amendments were overdue. 

Evaluation 

The team determined that during the review period, the Program met the performance 

indicator objectives listed in Section 4.1.a. 

c. Results 

Based on the IMPEP evaluation criteria in MD 5.6, the review team recommended, and 

the MRB agreed, that Georgia’s performance with respect to the indicator, Compatibility 

Requirements, be found satisfactory. 

4.2 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 LLRW 

as a separate category. Although the 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 Georgia. Accordingly, the review team did 

not review this indicator. 

5.0 SUMMARY 

As noted in Sections 3.0 and 4.0 above, Georgia’s performance was found satisfactory 

for five out of six performance indicators reviewed and satisfactory, but needs 

improvement, for the indicator, Technical Quality of Licensing Actions. The review team 

identified performance issues in the indicators of Status of the Materials Inspection 

Program (Section 3.2), Technical Quality of Inspections (Section 3.3), and Technical 

Quality of Licensing actions (Section 3.4) that are attributed to staff turnover. 

The review team made three recommendations regarding performance by the Program 

in the areas of inspection technique for brachytherapy, licensing criteria for radiation 

safety officers, and pre-licensing guidance requirements. The review team determined 

that the recommendations from the 2014 IMPEP review should be closed (Section 2.0). 

The MRB issued two additional recommendations to the Program to bolster 

performance. One concerns staff retention and the second, reciprocity inspections. 
Georgia Final IMPEP Report Page 15 

With respect to staff retention, the Technical Staffing and Training indicator was found 

satisfactory in 2014 and 2016. Because staff turnover led to negative performance 

trends in some areas of licensing and inspection over the 2016 review period, the MRB 

issued a recommendation to the Program management to develop a strategy to address 

staff retention and implement corrective actions to ensure satisfactory program 

performance is sustained. 

The review team recommended, and the MRB agreed, that the period of heightened 

oversight be discontinued and a period of monitoring be initiated until such time as the 

Georgia Agreement State Program has demonstrated a sustained period of satisfactory 

performance. 

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

Agreement State Program be found adequate to protect public health and safety and 

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

the review team recommended, and the MRB agreed, that the next full IMPEP review 

take place in approximately 4 years. The MRB directed that a periodic meeting be held 

1 year from this review with a second meeting approximately 18 months after the first 

periodic meeting. These periodic meetings will include a focused discussion of 

Georgia’s actions taken to address the recommendations noted below. 

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

evaluation and implementation by Georgia: 

1. The MRB recommends that the Program management develop a strategy to 

address staff retention and implement corrective actions to mitigate the causes of 

the Program’s turnover to ensure satisfactory program performance is sustained. 

(Section 3.1) 

2. The MRB recommends that Program management implement corrective actions 

and make necessary adjustments to ensure satisfactory program performance is 

sustained with regard to reciprocity inspections. (Section 3.2) 

3. The review team recommends that the Program develop and implement training 

for inspectors on the examination of the written directives and NRC Inspection 

Procedure 87132, Brachytherapy Programs. (Section 3.3) 

4. The review team recommends that the Program verify that all previously 

approved radiation safety officers for medical licenses have an attestation by a 

preceptor RSO, including that the individual has completed training in the 

radiation safety, regulatory issues and emergency procedures for the appropriate 

license type. (Section 3.4) 

5. The review team recommends that the Program management develop and 

implement training and guidance that provides the staff with the tools necessary 

to accurately complete the Program’s pre-licensing requirements for each new 

license. (Section 3.4) 
Georgia Final IMPEP Report Page 2 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Inspection Accompaniments 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Binesh Tharakan, Region IV Team Leader 

 Status of the Materials Inspection Program 

Lizette Roldan-Otero, NMSS Team Leader in Training 

 Inspector Accompaniments 

 Compatibility Requirements 

Jeff Griffis, NRC Technical Staffing and Training 

Technical Training Center 

Farrah Gaskins, Region I Technical Quality of Inspections 

Vanessa Danese, State of Texas Technical Quality of Licensing Actions 

Monica Ford, Region I Technical Quality of Incident and Allegation 

Activities 
APPENDIX B 

INSPECTION ACCOMPANIMENTS 

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

Accompaniment No.: 1 License No.: GA 1369-1 

License Type: Industrial Radiography Temporary Job Site Priority: 1 

Inspection Date: 02/08/16 Inspector: IB 

Accompaniment No.: 2 License No.: GA 1635-1 

License Type: Generally Licensed Device Distribution Priority: 3 

Inspection Date: 02/09/16 Inspector: GR 

Accompaniment No.: 3 License No.: GA 1119-1 

License Type: Medical Institution Therapy Priority: 2 

Inspection Date: 02/10/16 Inspector: JM 

Accompaniment No.: 4 License No.: GA 488-1 

License Type: Portable Gauge Priority: 5 

Inspection Date: 02/11/16 Inspector: LS 

Accompaniment No.: 5 License No.: GA 1531-1 

License Type: Portable Gauge Priority: 5 

Inspection Date: 02/12/16 Inspector: SF