UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

August 18, 2016 

Lourdes Iturralde, Assistant Secretary 

Department Environmental Quality 

Office of Environmental Compliance 

P.O. Box 4312 

Baton Rouge, LA 70821 

Dear Ms. Iturralde: 

On July 21, 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 Louisiana Agreement State Program. The MRB 

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

the NRC’s program. 

Section 5.0, page 15, of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. Based on the results of the current IMPEP review, the next full 

review of the Louisiana Agreement State Program will take place in approximately 4 years, with 

a periodic meeting tentatively scheduled for April 2018. 

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 

Enclosure: 

Louisiana IMPEP Final Report 

cc: See next page
L. Iturralde -2- 

cc: Bryan Riche, Administrator 

Assessment Division Radiation Section 

Office of Environmental Compliance 

David Howe, OR 

Organization of Agreement States 

 Liaison to the MRB 

 
Lourdes Iturralde, Assistant Secretary 

Department Environmental Quality 

Office of Environmental Compliance 

P.O. Box 4312 

Baton Rouge, LA 70821 

Dear Ms. Iturralde: 

On July 21, 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 Louisiana Agreement State Program. The MRB 

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

the NRC’s program. 

Section 5.0, page 15, of the enclosed final report contains a summary of the IMPEP team’s 

findings and recommendations. Based on the results of the current IMPEP review, the next full 

review of the Louisiana Agreement State Program will take place in approximately 4 years, with 

a periodic meeting tentatively scheduled for April 2018. 

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 

Enclosure: 

Louisiana IMPEP Final Report 

cc: See next page 

DISTRIBUTION: (SP08) 

See next page 

ADAMS Accession Number: ML16211A049 *via email 

OFFICE RIII:TL MSTR/ASPB MSTR/ASPB NMSS/MSTR NMSS/Tech 

Editor 

NMSS/OD OEDO 

NAME OMasnykBaiely* 

LDimmick PMichalak DCollins WMoore SMoore GTracy 

DATE 08/01/16 07/29/16 08/01/16 08/04/16 08/05/16 08/05/16 08/18/16 

OFFICIAL RECORD COPY
Letter to L. Iturralde from G. Tracy Dated: August 18, 2016 

SUBJECT: LOUISIANA FY2016 FINAL IMPEP REPORT 

DISTRIBUTION: (SP08) 

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OAS Board 

State of LA 
 Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE LOUISIANA AGREEMENT STATE PROGRAM 

APRIL 25–29, 2016 

FINAL REPORT
EXECUTIVE SUMMARY 

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

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

the period of April 25–29, 2016, by a review team composed of technical staff members from 

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

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

of seven indicators: Technical Staffing and Training, Status of Materials Inspection Program, 

Technical Quality of Inspections, Technical Quality of Licensing Actions, Sealed Source and 

Device Evaluation Program, and Compatibility Requirements. One of the performance 

indicators, Technical Quality of Incident and Allegation Activities, was found to be satisfactory, 

but needs improvement. 

The review team made three recommendations: (1) The review team recommends that the 

Assessment Division (the Division) perform an evaluation to determine the causes for the low 

staff retention rate and implement corrective actions to mitigate the causes; (2) The review team 

recommends that the Division implement a procedure that addresses at a minimum, the means 

for controlling access to documents that contain sensitive information, within the limits of 

Louisiana regulations; and (3) The review team recommends that the Division develop and 

implement a comprehensive incident and allegation procedure, provide incident and allegations 

training to the staff, and ensure management oversight of the incident and allegation program. 

The review team recommended, and the Management Review Board (MRB) agreed, that the 

recommendations from the 2012 IMPEP review should be closed. (Section 2.0) 

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

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 and that a periodic meeting be held in 2 

years to assess the State’s actions on the recommendations.
Louisiana Final IMPEP Report Page 1 

1.0 INTRODUCTION 

This report presents the results of the review of the Louisiana Agreement State Program 

radioactive materials safety program. The review was conducted during the period of 

April 25–29, 2016, by a review team composed of technical staff members from the U.S. 

Nuclear Regulatory Commission (NRC) and the State of Washington. 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 April 28, 2012, to April 29, 2016, were 

discussed with Louisiana 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 the Louisiana on February 9, 2016. 

Louisiana provided its response to the questionnaire on April 1, 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 ML16095A113. 

The team issued a draft report to Louisiana on May 27, 2016, for factual comment. 

Louisiana responded to the findings and conclusions of the review by letter dated July 6, 

2016. A copy may be found in ADAMS using Accession Number ML16189A000. In its 

response, Louisiana offered its plans to address the review team’s proposed 

recommendations. The team’s resolution of Louisiana’s comments are provided in a 

comment resolution document (ML16189A222). The Management Review Board 

(MRB), which consisted of NRC senior managers and an Organization of Agreement 

States liaison to the MRB, met on July 21, 2016, to consider the proposed final report. 

The MRB found the Louisiana Agreement State Program adequate to protect public 

health and safety, and compatible with the NRC’s program. Additional information on 

the status of actions taken by Louisiana to address the recommendations was provided 

by representatives from the State attending the MRB (Accession Number 

ML16211A044). 

The Louisiana Agreement State Program is administered by the Assessment Division 

(the Division), which is one of four divisions under the Office of Environmental 

Compliance (the Office) located within the Department of Environmental Quality (the 

Department). Organization charts for Louisiana can be found in ADAMS using the 

Accession Number ML16095A111. 

At the time of the review, the Louisiana Agreement State Program regulated 460 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 

Louisiana. 

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 Louisiana Agreement State Program’s performance. 

 
Louisiana Final IMPEP Report Page 2 

2.0 PREVIOUS IMPEP REVIEW AND STATUS OF RECOMMENDATIONS 

The previous IMPEP review concluded on April 27, 2012. The final report is available in 

ADAMS (Accession Number ML12199A224). The results of the review and the status of 

the recommendations are as follows: 

Technical Staffing and Training: Satisfactory 

Recommendation: None 

Status of Materials Inspection Program: Satisfactory 

Recommendation: None 

Technical Quality of Inspections: Satisfactory 

Recommendation: None 

Technical Quality of Licensing Actions: Satisfactory 

Recommendation: The review team recommends that the Department evaluate its 

review processes and develop and implement appropriate actions to ensure that 

products issued are of high technical quality and meet the standard expectations of the 

Department. (Section 3.4 and 4.2.2 of the 2012 IMPEP Report) 

Status: The Division has provided training to staff and has reemphasized the use of 

standard operating procedures to ensure products issued by the Division are of high 

technical quality. Prior to issuance of licensing documents and sealed source and 

device evaluations, the Division performs several reviews to ensure the product is of 

high quality. The review process includes peer reviews, subject matter expert technical 

reviews, as well as supervisory and management reviews prior to issuance. The end 

product meets the standard expectations of the Division and is of high technical quality. 

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

be closed. 

Technical Quality of Incident and Allegation Activities: Satisfactory 

Recommendation: None 

Sealed Source and Device Evaluation Program: Satisfactory 

Recommendations: 

1. The review team recommends that the Division adhere to the document format and 

content guidance in the current version of NUREG-1556, Volume 3 (Section 4.2.2 of 

the 2008 and 2012 IMPEP Report); and 

 

2. The review team recommends that all of the active sealed source and device 

registration commitments be located and made readily accessible by the Division. 

(Section 4.2.2 of the 2012 IMPEP Report) 

Status: 

1. Prior to issuance of licensing documents and sealed source device evaluations, the 

Division performs several reviews to ensure the product is of high quality. The 

review process includes peer reviews, subject matter expert technical reviews, as 

well as, supervisory and management reviews prior to issuance. The Division 

currently uses a peer review process to ensure that the supporting documentation is 

contained in the individual Sealed Source and Device (SS&D) registry folder before 
Louisiana Final IMPEP Report Page 3 

issuing the registration in accordance with the guidance in NUREG-1556, Volume 3, 

“Application for Sealed Source Device Evaluation and Registration.” 

2. The Division reviewed and updated all 61 SS&D registries dating back to 1972, 

obtained missing documents to the extent possible, and identified what documents 

could not be located. The SS&D registries for devices and sealed sources no longer 

being manufactured and distributed have been reviewed, updated, and inactivated. 

The Division is currently using the format and content guidance in the current version 

of NUREG-1556, Volume 3, “Application for Sealed Source Device Evaluation and 

Registration.” 

The review team recommended, and the MRB agreed, that these recommendations 

should be closed. 

Compatibility Requirements: Satisfactory but needs improvement 

Recommendation: None 

 

Overall finding from the 2012 IMPEP review: Adequate to protect public health and 

safety and compatible with the NRC’s program. 

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 

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

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

the review period. 

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

Inspection Manual Chapter (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. 
Louisiana Final IMPEP Report Page 4 

• 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 Louisiana Agreement State Program is composed of 19 technical staff members, 

2 supervisors, 1 manager, and 1 administrative assistant which equals 12 full-time 

equivalent (FTE) staff for the radioactive materials program including current vacancies 

in the Division. In addition to implementing the radioactive materials program, the 

Division staff also performs X-ray, mammography, and emergency preparedness 

activities which account for the rest of the FTE allocation. At the time of the IMPEP 

review, there was one vacancy. During the review period, 14 staff members left the 

program, 12 staff members were hired, and 1 technical staff position was moved to a 

different division. The positions were vacant from 1 to 3 months. 

c. Evaluation 

The review team interviewed Division staff and managers, reviewed the questionnaire 

response, and evaluated the Division’s hiring and training data. During the current 

IMPEP review period 14 staff members left the Division. During the previous IMPEP 

review period from 2008–2012, 10 staff members left the Division. During this review 

period, 6 of the12 current inspection staff members and 2 of the 5 current licensing staff 

members are new to the Division and undergoing training and qualification. Although 

the Division’s management was able to fill each vacancy in about 1 to 3 months, the 

Division has been challenged with keeping the positions filled. The low staff retention 

rate has caused an increased workload for the fully qualified materials inspectors and 

license reviewers. Based on interviews with the Division’s staff and management, the 

review team concluded that the most significant factor contributing to the low staff 

retention rate is the compensation offered by the Division; however, additional factors 

may also be contributing to the low retention rates. The review team recommends that 

the Division perform an evaluation of its staff turnover to determine the causes for the 

low staff retention rate and implement corrective actions to mitigate the causes. 

The Division has implemented a training and qualification manual compatible to the 

NRC’s IMC 1248. On average it takes about 3 years for a new staff member to become 

qualified in one area of the radioactive materials program (e.g., industrial or medical 

licensing and inspection). The qualification process begins with staff attending NRC 

training courses; however, the staff is initially qualified in the X-ray and mammography 

programs for the first year or two before progressing to complete the radioactive 

materials training and qualification. Due to the staff turnover mentioned above, only a 

few of the staff that completed the NRC training stayed in the Division and completed the 

radioactive materials qualification. The Division’s management indicated that the 

training and qualification program has the flexibility to expedite radioactive material 

qualifications and that additional strategies could be explored to reduce the average 

radioactive material program qualification time. 

 
Louisiana Final IMPEP Report Page 5 

d. Results 

The review team determined that the amount of staff turnover, lack of management 

attention to the high rates of attrition, and the length of time that it takes for individuals to 

complete all of the training and qualification requirements was indicative of less than 

satisfactory performance for this indicator. Immediately following the onsite review, 

Division management worked to develop and implement actions to address these issues 

and was able to report the progress made to the MRB. The Division has adjusted its 

training program to expedite the qualification process by having new inspectors 

accompany experienced inspectors earlier in the training process, decreasing the 

number of inspections needed to become qualified, and allowing inspectors to become 

incrementally qualified to perform lesser to more complex materials inspections and 

licensing reviews. The Division is also working to increase Louisiana’s compensation 

comparable to adjacent states with similar costs of living.

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

Louisiana’s performance with respect to the indicator, Technical Staffing and Training, 

be found satisfactory but needs improvement. The MRB acknowledged the IMPEP 

team’s finding, but concluded that the Louisiana’s performance with respect to the 

indicator, Technical Staffing and Training be found satisfactory because the issues in 

this indicator did not impact Louisiana’s performance in inspection, licensing, or incident 

response. 

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 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 Louisiana’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. 
Louisiana Final IMPEP Report Page 6 

• 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 Division performed a total of 730 Priority 1, 2, and 3, and initial inspections over the 

review period. The Division conducted 1.4 percent of these inspections overdue. Nine 

of 699 Priority 1, 2, or 3 and one of 31 initial inspections were conducted overdue. No 

inspections were overdue at the time of the review. A sampling of 23 inspection reports 

indicated that none of the inspection findings were communicated to the licensees 

beyond the Division’s goal of 30 days following the inspection exit. Each year of the 

review period, the Division performed greater than 20 percent of candidate reciprocity 

inspections. Louisiana’s inspection frequency is the same or more frequent for similar 

license types in IMC 2800. 

c. Evaluation 

The team determined that during the review period Louisiana met the performance 

indicator objectives listed in Section 3.2.a. 

d. Results 

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

the MRB agreed, that Louisiana’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 

Louisiana’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. 

 
Louisiana Final IMPEP Report Page 7 

• 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 23 materials inspections conducted during the review period. 

The casework reviewed included inspections conducted by 13 of the Division’s 

inspectors and covered therapeutic medicine, industrial radiography, well logging, 

manufacturing and distribution, nuclear pharmacy, academic research and development, 

and reciprocity licenses. 

Review team members accompanied five Division inspectors on seven inspections from 

March 21 through 24, 2016. The inspector accompaniments are identified in Appendix 

B. 

c. Evaluation 

The team determined that during the review period Louisiana met the performance 

indicator objectives listed in Section 3.3.a. 

d. Results 

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

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

Quality of Inspections, be found satisfactory. 

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 Louisiana 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 Louisiana’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. 
Louisiana Final IMPEP Report Page 8 

• 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 Division performed 2000 radioactive materials licensing 

actions. The review team evaluated 25 radioactive materials licensing actions. The 

licensing actions selected for review included 5 new applications, 15 amendments, 

4 renewals, and 1 termination. The review team evaluated casework for the following 

license types and actions: broad scope, medical diagnostic and therapy, veterinary, 

research and development, industrial radiography, nuclear pharmacy, well logging, 

academic, gauges, service providers, and financial assurance. 

c. Evaluation 

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

performance indicator objectives listed in Section 3.4.a., with one exception. The 

exception is noted for the security of licensing documents containing sensitive 

information. The Division’s licensing system is entirely electronic. Radioactive material 

licenses marked “Security Related Information” are stored in the State’s Electronic 

Document Management Database. Any Department employee has access to the 

database and a member of the public can submit a request to the State and receive a 

copy of a radioactive materials license within 3 to 4 business days. A similar issue of 

marking licenses containing sensitive security-related information was described in the 

2012 review. At that time, the Department received approval from its legal counsel that 

the increased control licenses, which are maintained on the electronic system, may be 

marked (under the State’s Public Records Act) to indicate they are security-related. 

Currently, licensing documents with security-related information are marked. However, 

the marking does not prevent disclosure of licensing information with a security marking 

to those without a need to know the information. 

At the time of the onsite review, the Division indicated it had an informal unwritten 

process for handling security-related information which includes the review of public 

requests for information before authorizing the release of licensing documents 

containing security-related information. Subsequent to the onsite review, the Division 

indicated that it has limited access to radiation security sensitive information to only 

pre-approved Department radiation staff. The review team recommends that the 

Division implement a procedure that addresses at a minimum, the means for controlling 

access to documents that contain sensitive information, within the limits of Louisiana 

regulations. 

 
Louisiana Final IMPEP Report Page 9 

d. Results 

The review team considered if the finding for the indicator was satisfactory, but needs 

improvement. Because the team did not identify any inadvertent releases of securityrelated information and because the Division has an informal process for reviewing 

document requests, the team supports a satisfactory finding. 

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

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

Quality of Licensing Actions, be found satisfactory. 

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 Louisiana’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. 

• On-site 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 (NMED). 

• Allegations are investigated in a prompt, appropriate manner. 

• Concerned individuals are notified of investigation conclusions. 

• Concerned individuals’ identities are protected, as allowed by law. 

b. Discussion 

During the review period, 235 incidents were reported to Louisiana, 56 of these were 

related to radioactive materials versus issues dealing with X-ray or naturally occurring 

radioactive material. The review team evaluated 20 radioactive materials incidents 

which included 5 lost/stolen/abandoned radioactive sources, 4 potential overexposures, 

3 medical events, and 8 related to damaged equipment. Louisiana dispatched 

inspectors for onsite follow-up for 12 of the cases reviewed. 
Louisiana Final IMPEP Report Page 10 

During the review period, two allegations were received by Louisiana. The review team 

evaluated both allegations, including the allegation that the NRC referred to the State, 

during the review period. 

The review team evaluated Louisiana’s “Standard Operating Procedure for Radiation 

Incidents and Allegations,” and interviewed Division staff as to their familiarity and 

involvement with incidents and allegations. 

c. Evaluation 

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

the performance indicator objectives listed in Section 3.5.a. The team determined that 

the Division’s incident and allegation procedure lacked guidance for the handling of 

allegations and had limited guidance for the handling of incidents. The applicable 

portions of the Division’s procedure regarding management review and coordination are 

not being followed. Most of the Division’s procedure is taken from the SA-105 

“Reviewing the Common Performance Indicator, Technical Quality of Incident and 

Allegation Activities,” procedure used by IMPEP teams to evaluate this indicator, and 

has not been edited to provide guidance to Division staff. For example, the Division’s 

procedure makes reference to Appendices A and B to be used for incident and 

allegation intake; however, the forms appended to the procedure are those contained in 

SA-105 for casework reviews, rather than meaningful tools for managing the intake of 

information for incidents and allegations. 

Despite the lack of written guidance, the review team found, after review of gathered 

documentation and discussion with Division personnel, that Louisiana’s response to 

incidents was complete and comprehensive, albeit poorly documented. Initial responses 

were prompt and well-coordinated, and the level of effort commensurate with the health 

and safety significance. Response to incidents was timely and prompt inquiries were 

made to evaluate the need for an on-site investigation. The Division dispatched 

inspectors to 12 of the incidents reviewed and took suitable enforcement and follow up 

actions. If the incident met the reportability thresholds, established in SA-300 “Reporting 

Material Events,” the Division notified the NRC Headquarters Operations Center (HOO) 

in a prompt manner. However, in most cases, the Division relied on the HOO to ensure 

that the information got into NMED, and 10 of the 56 events were still marked as “open” 

in NMED even though all follow-up actions had been completed. The strength of the 

incident response actions can be attributed to the Division’s senior staff supporting 

NMED. 

There is limited discussion of allegations in the Division’s procedure and none of the 

staff have received allegations training. The allegation that was referred to Louisiana by 

the NRC was appropriately investigated and closed. However, another potential 

allegation was referred to Louisiana via the 24 hour “hot line” in July 2015. A 

radiography company’s radiation safety officer (RSO) called to advise Louisiana that 

some of the company’s radiographers were performing work in North Dakota outside the 

scope of the license. Later, one of these radiographers called Louisiana to report wrong 

doing on the part of the RSO. The State of North Dakota issued escalated enforcement 

against the Louisiana licensee as a result of these activities. At the time of the IMPEP 

review, the Division had not responded to these concerns or performed an inspection of 

the licensee. 

The review team recommends that the Division develop and implement a 

comprehensive incident and allegation procedure, provide incident and allegations 
Louisiana Final IMPEP Report Page 11 

training to the staff, and ensure adequate management supervision in the incident and 

allegation program. 

d. Results 

The review team determined that the Division lacked procedures for responding to 

significant incidents and allegations, lacked allegations training for the staff, and lacked 

management coordination in the incidents and allegations processes. Despite the lack 

of adequate procedures, there were timely responses and resolutions to incidents. The 

lack of procedures and management coordination was more evident in the area of 

allegations. There were only two allegations for the review period, with one allegation 

not addressed at all. 

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

the MRB agreed, that Louisiana’s 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 

(SS&D) Program, (3) Low-Level Radioactive Waste Disposal (LLRW) Program, and (4) 

Uranium Recovery Program. The NRC’s Agreement with Louisiana does not relinquish 

regulatory authority for uranium recovery program; therefore, only the first three 

non-common performance indicators applied 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 

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 

Louisiana’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. 
Louisiana Final IMPEP Report Page 12 

• 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 

Louisiana became an Agreement State on May 1, 1967. The Louisiana Agreement 

State Program‘s current effective statutory authority is contained in Title 33, 

“Environmental Quality,” Part XV, “Radiation Protection,” of the Louisiana Administrative 

Code. The Department is designated as Louisiana’s radiation control agency. No 

legislation affecting the radiation control program was passed during the review period. 

Louisiana’s administrative rulemaking process takes approximately 6 months 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 Legislative Oversight Committee. The 

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

laws. 

During the review period, Louisiana submitted 23 final regulation amendments to the 

NRC for a compatibility review. Thirteen of the 23 regulation amendments were adopted 

overdue during the review period. Twelve of the 13 overdue regulation amendments 

were identified as overdue during the 2012 IMPEP review and were finalized during the 

2016 IMPEP review period. Eight of the 23 regulation amendments were due for 

adoption by Louisiana during the current review period and 3 are not due yet for 

adoption. Louisiana submitted 10 of the 11 amendments for a compatibility review in a 

timely manner and adopted the regulations before the due date. One regulation 

amendment that was due for adoption on September 28, 2012, was adopted by 

Louisiana on November 20, 2012. 

No regulation amendments were overdue for adoption at the time of this IMPEP review. 

c. Evaluation 

The 2012 IMPEP review team found Louisiana to be Satisfactory but needs 

improvement for this performance indicator. For the 2012 review period, there were 14 

regulation amendments that were overdue for adoption. Twelve of those regulation 

amendments were carried over into this current review period. During the current 
Louisiana Final IMPEP Report Page 13 

IMPEP review period, the Division’s staff cleared the backlog of overdue regulation 

amendments and ensured that new regulations were adopted by the due date. 

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

performance indicator objectives listed in Section 4.1.a. 

d. Results 

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

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

Compatibility Requirements, be found satisfactory. 

4.2 Sealed Source and Device Evaluation Program 

Adequate technical evaluations of SS&D designs are essential to ensure that SS&Ds will 

maintain their integrity and that the design is adequate to protect public health and 

safety. NUREG-1556, Volume 3, “Consolidated Guidance about Materials Licenses: 

Applications for Sealed Source and Device Evaluation and Registration,” provides 

information on conducting SS&D reviews and establishes useful guidance for review 

teams. Three sub elements: technical staffing and training, technical quality of the 

product evaluation program, and evaluation of defects and incidents regarding SS&D’s, 

will be evaluated to determine if the SS&D program is satisfactory. Agreement States 

with authority for SS&D evaluation programs who are not performing SS&D reviews are 

required to commit in writing to having an SS&D evaluation program in place before 

performing evaluations. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-108, “Reviewing 

the Non-Common Performance Indicator: Sealed Source and Device Evaluation 

Program,” and evaluated Louisiana’s performance with respect to the following 

performance indicator objectives: 

Technical Staffing and Training 

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

the review period. 

• 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 are filled in a timely manner. 

• Management is committed to training and staff qualification. 

• Individuals performing SS&D evaluation activities are adequately qualified and 

trained to perform their duties. 

• SS&D reviewers are trained and qualified in a reasonable period of time. 

Technical Quality of the Product Evaluation Program 

• SS&D evaluations are adequate, accurate, complete, clear, specific, and consistent 

with NUREG 1556, Volume 3. 

 
Louisiana Final IMPEP Report Page 14 

Evaluation of Defects and Incidents 

• SS&D incidents are reviewed to detect possible manufacturing defects and the root 

causes of these incidents. 

• Incidents are evaluated to determine if other products may be affected by similar 

problems. Appropriate action and notifications to the NRC, Agreement States, and 

others, as appropriate, should occur in a timely manner. 

b. Discussion 

Technical Staffing and Training 

The Division had four qualified SS&D reviewers over the review period. Two reviewers 

left the Division. The Division currently has two qualified individuals. The review team 

determined that current staffing levels are sufficient for the Division’s SS&D program. 

The Division’s training program is compatible with the training requirements identified in 

Appendix D to IMC 1248. 

Technical Quality of the Product Evaluation 

Louisiana has 13 SS&D licensees. Over the review period, the Division issued 74 SS&D 

actions of which 7 were new applications and 6 were amendments to existing device 

sheets. In response to recommendations from the 2012 IMPEP review, the Division 

processed 61 SS&D actions. In the 2012 IMPEP review, the review team found 

amendments to registries originally written as far in the past as 1972 lacked supporting 

documentation. Several SS&D registries had not been updated for safety considerations 

or transferred to inactive status as required. Some required either reactivation or a 

change of vendor number due to a change in company ownership. Division staff 

reviewed and updated all historical SS&D registries in addition to their new applications, 

to research, acquire, and document old and no longer existing paperwork. In this effort, 

eight SS&D registries were transferred to inactive status, and six supersession 

amendments were issued with all safety updates and documentation for reactivation or 

change of vendor number due to change of ownership. In addition the System 

International units were also added to amended registries. All SS&D registries were 

updated to current NUREG 1556, Volume 3 standards to the extent possible. 

 

The review team evaluated 15 SS&D actions processed during the review period 

including 6 of the new applications and 9 amendments. The review team determined 

that the SS&D reviewers evaluated the cases against applicable guidance and 

standards. The work performed was found to be comprehensive and of high quality. 

Evaluation of Defects and Incidents Regarding SS&Ds 

The review team evaluated three incidents involving SS&D registered products during 

the review period. Two of the incidents involved equipment failures and one, a source 

leakage. Senior technical staff evaluated the incidents to determine if the incidents 

require any amendment to the SS&D registry. 

c. Evaluation 

The team determined that during the review period Louisiana met the performance 

indicator objectives listed in Section 4.2.a. 
Louisiana Final IMPEP Report Page 15 

d. Results 

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

the MRB agreed, that Louisiana’s performance with respect to the indicator, Sealed 

Source and Device Evaluation Program, be found satisfactory. 

4.3 Low-level Radioactive Waste Disposal Program 

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

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 Louisiana Agreement State Program has LLRW 

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

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

for a LLRW disposal facility. When an Agreement State has been notified or becomes 

aware of the need to regulate a LLRW disposal facility, they are expected to put in place 

a regulatory program which will meet the criteria for an adequate and compatible LLRW 

disposal program. There are no plans for a LLRW disposal facility in Louisiana. 

Accordingly, the review team did not review this indicator. 

5.0 SUMMARY 

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

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

improvement, for Technical Quality of Incidents and Allegation Activities indicator. The 

review team made three recommendations regarding program performance by Louisiana 

and determined that the recommendations from the 2012 IMPEP review should be 

closed. 

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

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 IMPEP review take 

place in approximately 4 years and that a periodic meeting be held in 2 years. 

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

evaluation and implementation by Louisiana: 

1. The review team recommends that the Division perform an evaluation to determine 

the causes for the low staff retention rate and implement corrective actions to 

mitigate the causes. (Section 3.1) 

2. The review team recommends that the Division implement a procedure that 

addresses at a minimum, the means for controlling access to documents that contain 

sensitive information, within the limits of Louisiana regulations. (Section 3.4) 

3. The review team recommends that the Division develop and implement a 

comprehensive incident and allegation procedure, provide incident and allegations 

training to the staff, and ensure adequate management supervision in the incident 

and allegation program. (Section 3.5) 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Inspection Accompaniments 
APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Orysia Masnyk Bailey, Region I Review Team Leader 

 Technical Quality of Incident and Allegation Activities 

 Inspector Accompaniments 

Binesh Tharakan, Region IV Technical Staffing and Training 

 Compatibility Requirements 

Michelle Simmons, Region IV Technical Quality of Licensing 

Geoffrey Warren, Region III Status of Materials Inspection 

 Technical Quality of Inspections 

 

Anine Grumbles, Washington Sealed Source and Device Evaluation Program 
APPENDIX B 

INSPECTION ACCOMPANIMENTS 

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

Accompaniment No.: 1 License No.: LA-7072-L01 

License Type: Industrial Radiography Priority: 1 

Inspection Date: 03/21/2016 Inspector: MC 

Accompaniment No.: 2 License No.: LA-7985-L01 

License Type: Industrial Radiography Priority: 1 

Inspection Date: 03/21/2016 Inspector: MC 

Accompaniment No.: 3 License No.: LA-3773-L01A 

License Type: Industrial Radiography Priority: 1 

Inspection Date: 03/21/2016 Inspector: MC 

Accompaniment No.: 4 License No.: LA-11296-L01A 

License Type: Nuclear Pharmacy Priority: 2 

Inspection Date: 03/22/2016 Inspector: JE 

Accompaniment No.: 5 License No.: LA-10950-L01 

License Type: Well Logging Priority: 1 

Inspection Date: 03/23/2016 Inspector: JF 

Accompaniment No.: 6 License No.: LA-2966-L01 

License Type: Manufacturing and Distribution Priority: 1 

Inspection Date: 03/24/2016 Inspector: TB 

Accompaniment No.: 7 License No.: LA-4266-L01 

License Type: Industrial Radiography Priority: 1 

Inspection Date: 03/24/2016 Inspector: RC