UNITED STATES

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

November 10, 2016 

Hiram C. Polk, Jr., MD 

Commissioner 

Department for Public Health 

Cabinet for Health and Family Services 

275 East Main Street, HS1C-A 

Frankfort, KY 40621-0001 

Dear Dr. Polk:

On October 20, 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 Kentucky Agreement State Program. The MRB 

found the Kentucky program adequate to protect public health and safety, but not 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 MRB acknowledges the significant improvement Kentucky 

has made since 2012 concerning the timely performance of inspections. Kentucky improved 

from an unsatisfactory rating to a satisfactory rating for this indicator. 

For the 2016 review, the review team identified some performance issues in the indicators of 

Compatibility Requirements and Low-Level Waste Disposal. With regard to Compatibility 

Requirements, the review team did not make a specific recommendation for Kentucky to 

implement because Kentucky is pursuing a process which would allow NRC regulations to be 

adopted by reference. If Kentucky is successful in this effort, the issue of timely adoption of 

regulations will be resolved. The review team did make a specific recommendation concerning 

the Maxey Flats Disposal Site (MFDS). The MRB noted that without timely issuance of 

inspection reports, public visibility of Kentucky’s oversight responsibilities for MFDS is lacking. 

To ensure openness and transparency with respect to Kentucky’s monitoring and oversight 

activities involving MFDS, the review team recommended that Kentucky’s Radiological Health 

Branch ensure timely and consistent issuance of licensing actions and inspection results for the 

MFDS.

Based on the results of the current IMPEP review, the next full review of the Kentucky 

Agreement State Program will take place, as regularly scheduled, in approximately 4 years with 

a periodic meeting in 2 years. 

 
H. Polk 2

 

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/ 

Marc L. Dapas, Director

Office of Nuclear Material Safety 

 and Safeguards 

Enclosure: 

Kentucky Final IMPEP Report 

cc: Matthew W. McKinley, Administrator 

 Radiation Health Program 

BJ Smith, MS 

Organization of Agreement States 

 Liaison to the MRB 
H. Polk 2 

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/ 

Marc L. Dapas, Director

Office of Nuclear Material Safety 

 and Safeguards 

Enclosure: 

Kentucky Final IMPEP Report 

cc: Matthew W. McKinley, Administrator 

 Radiation Health Program 

BJ Smith, MS 

Organization of Agreement States 

 Liaison to the MRB 

DISTRIBUTION: (SP05) 

See Next Page 

ADAMS Accession Number: ML16299A197 

OFFICE Team 

Leader:RIII 

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

Editor 

NMSS 

NAME JLynch 

via email

LDimmick 

w/edits 

PMichalak 

w/edits

PHenderson

w/edits

WMoore MDapas 

w/edits

DATE 10/25/16 10/27/16 11/01/16 11/01/16 11/03/16 11/10/16

OFFICIAL RECORD COPY
 

Letter to Hiram Polk from Marc Dapas, dated November 10, 2016 

SUBJECT: KENTUCK FY2016 FINAL IMPEP REPORT 

DISTRIBUTION: (SP05) 

RidsEdoMailCenter 

MSampson, OEDO 

RidsSecyCorrespondenceMailCenter Chairman Burns 

RidsOgcMailCenter Commissioner Svinicki 

JOlmstead, OGC Commissioner Baran 

MFord, RI/RSAO 

DJanda, RI 

JCook, RIV 

KModes, NMSS 

RParsons, TN 

DShearer, PA 

DCollins, NMSS 

JTrapp, RI 

JNick, RI 

OAS Board 

RidsNmssOd 

LRoldan, NMSS 

DWhite, NMSS 

State of KY 
Enclosure 

INTEGRATED MATERIALS PERFORMANCE EVALUATION PROGRAM 

REVIEW OF THE KENTUCKY AGREEMENT STATE PROGRAM 

July 25–29, 2016 

FINAL REPORT
EXECUTIVE SUMMARY 

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

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

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

U.S. Nuclear Regulatory Commission (NRC), the State of Tennessee, and the Commonwealth 

of Pennsylvania. 

Based on the results of this review, Kentucky’s performance was found satisfactory for seven of 

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

Inspection Program, Technical Quality of Inspections, Technical Quality of Licensing Actions, 

Technical Quality of Incident and Allegation Activities, Sealed Source and Device Evaluation 

Program, and Low-Level Radioactive Waste Disposal Program. Performance with respect to 

the Compatibility Requirements performance indicator was determined to be unsatisfactory. 

The finding for the Status of Materials Inspection Program indicator significantly improved from 

unsatisfactory to fully satisfactory since the previous IMPEP review. The finding for the 

Compatibility Requirements indicator was downgraded to an unsatisfactory rating as the 

backlog of required regulation adoptions increased since the last IMPEP review. Kentucky is 

pursuing a process which would allow NRC regulations to be adopted by reference. Several 

regulations, including Title 10 of the Code of Federal Regulations Part 37, were adopted in this 

manner. If Kentucky is successful in this effort, the issue of timely regulation adoption would be 

resolved. The unsatisfactory finding results in Kentucky being not compatible with the NRC’s 

program. 

The review team considered recommending that Kentucky be placed on monitoring until the 

regulation adoption problem is resolved, but since actions are currently underway to use the 

adoption by reference process, this action was deemed unnecessary. 

The review team made one recommendation, regarding the Low-Level Radioactive Waste 

Disposal Program, (see Section 5.0) and determined that the recommendation from the 2012 

IMPEP review, regarding a self-assessment of the inspection program, should be closed (see 

Section 2.0). 

Accordingly, the review team recommended, and the Management Review Board (MRB) 

agreed, that the Kentucky Agreement State Program is adequate to protect public health and 

safety, but is not compatible with the NRC's program. The review team recommended, and the 

MRB agreed, that the next IMPEP review take place, as regularly scheduled, in approximately 4 

years with a periodic meeting in 2 years.
Kentucky Final IMPEP Report Page 1 

1.0 INTRODUCTION 

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

The review was conducted during the period of July 25–29, 2016, by a review team 

comprised of technical staff members from the U.S. Nuclear Regulatory Commission 

(NRC), the State of Tennessee, and the Commonwealth of Pennsylvania. 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 June 16, 2012, to July 29, 2016, were 

discussed with Kentucky 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 Kentucky on December 10, 2015. 

Kentucky provided its response to the questionnaire on July 11, 2016. A copy of the 

questionnaire response is available in the NRC’s Agencywide Documents Access and 

Management System (ADAMS) using the Accession Number ML16194A002. 

A draft of this report was issued to Kentucky on August 31, 2016, for factual comment. 

Kentucky responded to the findings and conclusions of the review by electronic mail 

dated October 3, 2016. A copy of Kentucky’s response is available in ADAMS 

(Accession Number ML16281A199). The Management Review Board (MRB) met on, 

October 20, 2016, to consider the proposed final report. The MRB found the Kentucky 

Agreement State Program adequate to protect public health and safety, and compatible 

with the NRC’s program. 

The Kentucky Agreement State Program is administered by the Radiation Health Branch 

(Branch) which is located within the Department for Public Health (Department). The 

Department is part of the Cabinet for Health and Family Services (Cabinet). The Branch 

is comprised of three sections: the Radioactive Materials Section (Section), the 

Radiation Producing Machines Section, and the Radiation/Environmental Monitoring 

Section. The Radioactive Materials Section implements the elements of the Agreement 

State Program. Organization charts for Kentucky are available in ADAMS (Accession 

Number ML16194A003). 

At the time of the review, the Kentucky Agreement State Program regulated 364 specific 

licenses authorizing possession and use of radioactive materials. Kentucky also 

regulates the closed Maxey Flats low-level radioactive waste disposal site. 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 

Commonwealth of Kentucky. 

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

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

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

 
Kentucky Final IMPEP Report Page 2 

2.0 PREVIOUS IMPEP REVIEW AND STATUS OF RECOMMENDATIONS 

The previous IMPEP review concluded on June 15, 2012. The final report is available in 

ADAMS (Accession Number ML12264A598). The results of the 2012 review and the 

status of the recommendation are as follows: 

Technical Staffing and Training: Satisfactory 

Recommendation: None 

Status of Materials Inspection Program: Unsatisfactory 

Recommendation: The MRB recommended that the Branch perform a self-assessment 

to determine the effectiveness of its oversight of the inspection program and that the 

results of this self-assessment be reviewed as part of the IMPEP periodic meeting. 

Status: Kentucky submitted its self-assessment and the resulting programmatic 

changes to the NRC and these items were evaluated during the July 9, 2014, periodic 

meeting. The changes adopted by Kentucky allow managers to be aware of potential 

inspection backlogs. A new inspection tracking database allows for simplified tracking of 

inspection metrics. The review team determined that these efforts were effective in 

Kentucky’s oversight of the materials inspection program. The review team 

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

Technical Quality of Inspections: Satisfactory 

Recommendation: None 

Technical Quality of Licensing Actions: Satisfactory 

Recommendation: None 

Technical Quality of Incident and Allegation Activities: Satisfactory 

Recommendation: None 

Compatibility Requirements: Satisfactory, but needs improvement 

Recommendation: None 

Sealed Source and Device Evaluation Program: Satisfactory 

Recommendation: None 

Low-Level Radioactive Waste Disposal Program: Not reviewed during the 2012 IMPEP 

Overall finding in 2012: Adequate to protect public health and safety, but needs 

improvement, and compatible with the NRC’s program. 

The 2012 MRB directed that Kentucky remain on monitoring to provide continued 

assurance that the Agreement State Program maintained sustained performance in the 

area of timely inspections and promulgation of the required regulations. NOTE: The 

period of monitoring was discontinued after the July 2014 periodic meeting. At that time, 

Kentucky had no current overdue inspections and only one inspection was overdue in 

the 2 years since the last IMPEP review. Six regulations were overdue for adoption. 

 
Kentucky Final IMPEP Report Page 3 

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, and well-trained technical 

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

implementation of these programs, and 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 

Kentucky’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 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 

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 Branch is comprised of a manager, a supervisor, and seven staff members which 

equals approximately 8.2 full-time equivalents for the radioactive materials program. 

Additional technical assistance for oversight of the Maxey Flats Disposal Site (MFDS) is 

provided by a staff member from the Radiation/Environmental Monitoring Section. 

Currently, there are no vacancies, and the Branch is fully staffed. During the review 

period, one of the staff members left the program and three staff members were hired, 

filling vacant positions. One staff member was deployed on active duty for 

approximately 2 1⁄2 years during the review period. All of the staff members are fully 
Kentucky Final IMPEP Report Page 4 

qualified in licensing and inspection for either medical or industrial programs. Several 

staff members are undergoing qualifications for full qualification of all license types. 

Kentucky has a training and qualification manual compatible to IMC 1248. 

c. Evaluation 

The team determined that, during the review period, the Kentucky program met the 

performance indicator objectives listed in Section 3.1.a. 

d. Results 

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

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

Staffing and Training, be found satisfactory. 

3.2 Status of 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 Materials Inspection Program,” and 

evaluated Kentucky’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”). 

 
Kentucky Final IMPEP Report Page 5 

b. Discussion 

Kentucky performed 203 Priority 1, 2, 3, and initial inspections during the review period. 

Kentucky conducted two percent of Priority 1, 2, 3, and initial inspections overdue. 

Three priority 1, 2, or 3 inspections, and one initial inspection were conducted overdue. 

 

The team’s evaluation of 29 inspection reports indicated that one of the inspection 

reports was communicated to a licensee beyond Kentucky’s goal of 30 days after the 

inspection exit. 

In 2016, the Branch performed a self-assessment and determined that it was incorrectly 

prioritizing service providers requesting reciprocity. A recalculation of reciprocity 

frequencies indicated that Kentucky performed only 13 percent of candidate reciprocity 

inspections in 2012, but had an inspection percentage above 20 percent for each of the 

last 3 years. 

c. Evaluation 

The team determined that, during the review period, Kentucky 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 Kentucky’s performance with respect to the indicator, Status of 

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 

Kentucky’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. 

 
Kentucky Final IMPEP Report Page 6 

• For programs with separate licensing and inspection staffs, procedures are 

established and followed to provide feedback information to license reviewers. 

• For Agreement States, 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 29 materials inspections conducted during the review period. 

The casework reviewed included inspections conducted by nine current and former 

inspectors and covered medical, industrial, commercial, academic, research, and service 

provider licenses. 

Review team members accompanied eight program inspectors in April and June 2016. 

The inspectors were adequately prepared and conducted performance-based 

inspections. The inspector accompaniments are identified in Appendix B. The review 

team noted the Branch performed annual supervisory accompaniments for each of the 

inspectors throughout the review period. 

Over the past two IMPEP review periods, Kentucky developed a robust General License 

(GL) program for certain types of generally licensed devices, particularly fixed gauges. 

The GL program incorporates a tracking database, inspections, and fees. Inspections 

are performed at 5-year intervals. Kentucky has validated this program out of concern 

for lost and orphaned sources, particularly in the coal industry, and sees the GL program 

as a significant benefit to Kentucky. 

c. Evaluation 

The team determined that, during the review period, Kentucky 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 Kentucky’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 Kentucky 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 
Kentucky Final IMPEP Report Page 7 

evaluated Kentucky’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, Kentucky performed 2,856 radioactive materials licensing 

actions. The review team evaluated 27 of these actions. The licensing actions selected 

for review included six new applications, nine amendments, seven renewals 

(amendments in entirety), four terminations, and one bankruptcy filing. The review team 

evaluated casework which included the following license types and actions: broad 

scope academic, broad scope medical, medical diagnostic and therapy, other 

manufacturing and distribution, industrial radiography, research and development, 

academic, nuclear pharmacy, gauges, self-shielded irradiators, well-logging, service 

providers, and bankruptcy. The casework sample represented work from nine license 

reviewers, including one former license reviewer. Terminated licensing actions were 

well documented, showing transfer to authorized recipients and final status surveys, as 

appropriate. 

All licensing actions undergo a peer review and management review by the Section 

Supervisor. The Branch Manager subsequently signs all of the materials licenses. 

During the previous IMPEP review period, it was reported that due to staff turnover and 

license backlog issues, processing of amendments in entirety were delayed. During this 

review period, the team noted that the amendments in entirety were again being 

processed. Currently, no amendments in entirety are backlogged. 

The Branch performed a self-assessment of the pre-licensing program in response to 

the NRC’s publication of Radiation Control Program Directors (RCPD)-15-010 in October 

2015, entitled “The Importance of Using Pre-Licensing Guidance and Site Visits During 

 
Kentucky Final IMPEP Report Page 8 

the Licensing Process.” The RCPD letter requested that the Agreement States conduct 

a self-assessment or audit of those licenses in which pre-licensing guidance was used 

and required. 

The results of the self-assessment indicated that the pre-licensing forms were being 

utilized, but the section of the form related to the basis for making the determination that 

licensed materials would be used as intended was not complete, and the basis for 

making that determination was not thoroughly documented. It was noted that many of 

the staff had not thoroughly reviewed the directions at the end of the form nor 

understood completely what each question was asking. In addition, in those cases 

where a solid determination of material use as intended could not be made, the staff was 

not performing adequate assurance screening. Therefore, based on these results, the 

Section Supervisor held several training sessions with the staff to review the 

pre-licensing policy and the pre-licensing forms contained therein. After the 

self-assessment, Kentucky performed a retroactive review of all pre-licensing actions to 

ensure that appropriate determinations had been made, in spite of the weaknesses 

identified in the process. Kentucky’s pre-licensing review methods now incorporate the 

essential elements of the NRC’s pre-licensing guidance to verify that an applicant will 

use requested radioactive materials as intended. 

c. Evaluation 

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

indicator objectives listed in Section 3.4.a. 

d. Results 

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

the MRB agreed, that Kentucky’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 followup 

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 Kentucky’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. 
Kentucky Final IMPEP Report Page 9 

• On-site responses are performed when incidents have potential health, safety or 

security significance. 

• Appropriate followup actions are taken to ensure prompt compliance by licensees. 

• Followup 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, Kentucky reported 25 incidents to the NRC. The review team 

evaluated 17 radioactive materials incidents which included 11 medical events and 6 

damaged equipment events. The review team also evaluated one potential 

overexposure event which Kentucky determined not to be an overexposure. The review 

team determined that the potential overexposure was correctly categorized by the 

Branch as non-reportable. Kentucky dispatched inspectors for onsite followup for nine of 

the cases reviewed. For the incidents that did not receive an onsite followup inspection, 

the review team determined that Kentucky conducted appropriate followup activities via 

telephone and/or e-mail to ensure that public health and safety were protected. 

Kentucky received six allegations during the review period. The review team evaluated 

all six allegations, including two allegations that the NRC referred to Kentucky during the 

review period. The review team evaluated the completed casework and determined that 

the Branch took prompt and appropriate action in response to the concerns raised. The 

concerned individuals were notified of the findings. The team found that the Branch 

adequately protected the concerned individuals’ identity. 

c. Evaluation 

The team determined that, during the review period, Kentucky 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 Kentucky’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 Disposal (LLRW) Program, and 

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

relinquish regulatory authority for a UR program; therefore, only the remaining three noncommon performance indicators applied to this review. 

 
Kentucky Final IMPEP Report Page 10 

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. 

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 

Kentucky’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/regtoolbox.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 

Kentucky became an Agreement State on March 26, 1962. The Kentucky Agreement 

State Program‘s current effective statutory authority is contained in the Kentucky 

Revised Statutes 13B.170, 194A.050, 211.090, 211.842 to 211.852, 211.859, 

211.990(4), and 211.861 to 211.869. The Branch is designated as Kentucky’s radiation 

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

the review period. 
Kentucky Final IMPEP Report Page 11 

Kentucky’s administrative rulemaking process takes approximately 19 months from 

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

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

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

finalized and approved. The review team noted that Kentucky’s rules and regulations 

are not subject to “sunset” laws. 

During the review period, Kentucky submitted 2 final regulation amendments and 12 

revised final regulation amendments to the NRC for a compatibility review. One of the 

two final regulation amendments was overdue for adoption by Kentucky at the time of 

submission. 

At the time of this review, the following 12 amendments were overdue: 

• “Requirements for Certain Generally Licensed Industrial Devices Containing 

Byproduct Material,” Title 10 of the Code of Federal Regulations (10 CFR) Parts 30, 

31 and 32 amendment (65 FR 79162), that was due for Agreement State adoption by 

February 16, 2004 (10 CFR Parts 30 and 31 only). 

• “Medical Use of Byproduct Material – Minor Corrections and Clarifications,” 10 CFR 

Parts 32 and 35 amendment (72 FR 45147, 54207), that was due for Agreement 

State adoption by October 29, 2010. 

• “Exemptions From Licensing, General Licenses, and Distribution of Byproduct 

Material: Licensing and Reporting Requirements,” 10 CFR Parts 30, 31, 32, and 150 

amendment (72 FR 58473), that was due for Agreement State adoption by 

December 17, 2010. 

• “Requirements for Expanded Definition of Byproduct Material,” 10 CFR Parts 20, 30, 

31, 32, 33, 35, 61, and 150 amendment (72 FR 55864), that was due for Agreement 

State adoption by November 30, 2010. 

• “Occupational Dose Records, Labeling Containers, and Total Effective Dose 

Equivalent,” 10 CFR Parts 19 and 20 amendment (72 FR 68043), that was due for 

Agreement State adoption by February 15, 2011. 

• “Medical Use of Byproduct Material – Authorized User Clarification,” 10 CFR Part 35 

amendment (74 FR 33901), that was due for Agreement State adoption by 

September 28, 2012. 

• “Decommissioning Planning,” 10 CFR Parts 20, 30, 40, and 70 amendment (76 FR 

35512), that was due for Agreement State adoption by December 17, 2015. 

• “Licenses, Certifications, and Approvals for Materials Licensees,” 10 CFR Parts 30, 

36, 39, 40, 70, and 150 amendment (76 FR 56951), that was due for Agreement 

State adoption by November 14, 2014. 

• “Change of Compatibility of 10 CFR 31.5 and 31.6,” 10 CFR Part 31 amendment (77 

FR 3640), that was due for Agreement State adoption by January 25, 2015. 

 
Kentucky Final IMPEP Report Page 12 

• “Advance Notification to Native American Tribes of Transportation of Certain Types 

of Nuclear Waste,” 10 CFR Part 71 amendment (77 FR 34194), that was due for 

Agreement State adoption by August 10, 2015. 

• “Technical Corrections,” 10 CFR Parts 30, 34, 40, and 71 amendment (77 FR 

39899), that was due for Agreement State adoption by August 6, 2015. 

• “Requirements for Distribution of Byproduct Material,” 10 CFR Parts 30, 31, 32, 40, 

and 70 amendment (77 FR 43666), that was due for Agreement State adoption by 

October 23, 2015. 

The review team had several discussions with Kentucky management to determine their 

path forward in addressing the overdue regulation amendments. This included access 

to a dedicated Regulation Coordinator in the Cabinet and adoption of the NRC 

regulations by reference. Previously, regulations were drafted by Branch staff who were 

already tasked with other duties such as licensing and inspection activities. 

Kentucky started adoption by reference with 10 CFR Part 37 which was adopted timely 

and as a final regulation in February 2016. At the time of the team’s review, Kentucky 

was in the process of adopting by reference specific tables from 10 CFR Parts 20 and 

30. These regulations were finalized on August 17, 2016. The Branch intends to adopt 

all applicable NRC regulations by reference by June of 2018. The plan was shared with 

the review team at the time of their review. The Branch provided the plan in writing just 

prior to the October 20 MRB meeting. The MRB acknowledged the Branch’s significant 

action to address the regulation backlog that has been accruing over time. The Branch’s 

plan is available in ADAMS (Accession Number ML16298A199). 

c. Evaluation 

The review team determined that during the review period, Kentucky did not meet all of 

the performance indicator objectives listed in Section 4.1.a. Specifically, Kentucky had 

not adopted final regulations for 12 NRC amendments within the required 3-year 

timeframe. This represents an increase of seven overdue amendments since the 2012 

IMPEP review. The review team considered making a formal recommendation to 

Kentucky for addressing the overdue regulations; however, because Kentucky has 

already developed a written plan and implemented a path forward to adopt all applicable 

NRC regulations by reference, the review team did not make a recommendation for this 

indicator. 

d. Results 

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

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

Requirements, be found unsatisfactory. 
Kentucky Final IMPEP Report Page 13 

4.2 Sealed Source and Device (SS&D) 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. Under this guidance, three sub-elements: Technical Staffing and Training, 

Technical Quality of the Product Evaluation Program, and Evaluation of Defects and 

Incidents Regarding SS&D’s, are 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 Kentucky’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 

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 the guidance in NUREG-1556, Volume 3, Revision 2. 

Evaluation of Defects and Incidents Regarding SS&Ds 

• SS&D incidents are reviewed to identify 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 NRC, Agreement States, and 

others, as appropriate, occur in a timely manner. 

 
Kentucky Final IMPEP Report Page 14 

b. Discussion 

Technical Staffing and Training 

The Branch has two SS&D reviewers previously qualified and two new SS&D reviewers 

who are qualified to perform safety evaluations of SS&D registrations. Kentucky has a 

training program compatible with the NRC training requirements listed in IMC 1248, 

Appendix D. All reviewers have degrees in a physical science or engineering discipline 

and have attended the NRC’s SS&D Workshop or the Branch’s contracted training 

course. The reviewers also have attended the G-108 “Licensing and Inspection 

Course,” G-109 “Licensing Practice and Procedure Course,” or have equivalent training. 

The review team interviewed all of the SS&D reviewers and determined that they were 

familiar with the procedures used in the evaluation of a device or source and had access 

to applicable reference documents. 

Technical Quality of the Product Evaluation Program 

Kentucky currently has one device manufacturer who has 11 active SS&D registrations. 

Registrations clearly summarize the product evaluations and provide license reviewers 

with adequate information to license the possession and use of the products. Deficiency 

letters clearly stated regulatory positions and all health and safety issues were 

addressed. Overall, the review team determined that the product evaluations were 

thorough, complete, consistent, of acceptable quality, and adequately addressed the 

integrity of the product during use and under accident conditions. 

The review team evaluated the only two amendment actions issued during the review 

period, and discussed the one pending action in process at the time of the review. 

Analysis of the casework and interviews with the SS&D reviewers confirmed that the 

Branch follows the recommended guidance from the NRC SS&D Workshop and 

NUREG-1556, Volume 3, Revision 2. The review team confirmed that all applicable and 

pertinent American National Standards Institute NUREG-1556 Series guides, NRC 

Regulatory Guides, and applicable references were available and used appropriately in 

performing the SS&D reviews. The Branch follows a documented internal process when 

performing an SS&D review that includes communication via email with the licensee and 

the use of the evaluation checklist as recommended in NUREG-1556. 

Evaluation of Defects and Incidents Regarding Sealed Source and Devices 

Utilizing NMED, the review team examined reported incidents involving devices 

regulated by Kentucky. There were 31 events reported nationally over the review period 

for Kentucky's one device manufacturer. The review team determined that the Branch 

analyzed the events, reviewed the issues, and followed up on the incidents with the 

manufacturer, as appropriate. None of the events were related to manufacturing or 

design of the product. 

c. Evaluation 

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

indicator objectives listed in Section 4.2.a. 
Kentucky 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 Kentucky’s performance with respect to the indicator, Sealed 

Source and Device Evaluation Program, be found satisfactory. 

4.3 Low-Level Radioactive Waste (LLRW) Disposal Program 

The objective is to determine if Kentucky’s LLRW disposal program is adequate to 

protect public health and safety. Five sub-elements are used to make this 

determination: (1) Technical Staffing and Training, (2) Status of LLRW Inspection, (3) 

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

Technical Quality of Incident and Allegation Activities. This program was not evaluated 

during the 2012 IMPEP review. 

a. Scope 

The review team used the guidance in State Agreements procedure SA-109, “Reviewing 

the Non-Common Performance Indicator: Low-Level Radioactive Waste Disposal 

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

performance indicator objectives: 

Technical Staffing and Training 

• Qualified and trained technical staff are available to license, regulate, and inspect the 

operation and performance of the LLRW disposal facility. 

• Qualification criteria for new LLRW technical staff are established and are being 

followed or 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 the LLRW licensing and inspection programs. 

• Management is committed to training and staff qualification. 

• Individuals performing LLRW licensing and inspection activities are adequately 

qualified and trained to perform their duties. 

• LLRW license reviewers and inspectors are trained and qualified in a reasonable 

period of time. 

Status of LLRW Inspection 

• The LLRW facility is inspected at prescribed frequencies. 

• Statistical data on the status of the inspection program is maintained and can be 

retrieved. 

• Deviations from inspection schedules are coordinated between LLRW technical staff 

and management. 

• There is a plan to reschedule any missed or deferred inspections or a basis has 

been established for not rescheduling any missed inspections. 

• Inspection findings are communicated to licensees in a timely manner. 

 
Kentucky Final IMPEP Report Page 16 

Technical Quality of Inspections 

• Inspections of LLRW licensed activities focus on health, safety, and security for the 

public, as well as, the environment. 

• 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 LLRW inspector to assess 

performance and assure consistent application of inspection policies. 

• For Agreement States, inspection guides are consistent with NRC guidance. 

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

inspection (sampling and monitoring) program. 

Technical Quality of Licensing Actions 

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

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

• Applicable LLRW guidance documents are available to reviewers and are followed 

(e.g., pre-licensing guidance, regulatory guides, etc.). 

• LLRW license reviewers, if applicable, have the proper signature authority for the 

cases they review independently. 

• License tie-down conditions are stated clearly and are inspectable. 

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

• Reviews of amendments in their entirety demonstrate a thorough analysis of a 

licensee’s inspection and enforcement history. 

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

controlled, and secured. 

Technical Quality of Incident and Allegation Activities 

• LLRW 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 followup actions are taken to ensure prompt compliance by licensees. 

• Followup 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 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. 

 
Kentucky Final IMPEP Report Page 17 

b. Discussion 

The MFDS is a closed LLRW site in its Final Closure Period. The Cabinet for Health 

and Family Services is responsible for oversight for the protection of the public health, 

safety, and welfare. The Branch performs licensing and inspection functions at the 

MFDS. Kentucky’s Energy and Environment Cabinet is the licensee listed on the 

MFDS radioactive materials license. 

The MFDS operated as a commercial LLRW disposal facility authorized by Kentucky 

from 1963 through 1977. The waste was dumped into unlined trenches, resulting in 

some containers laying on their sides, upside-down, and in a variety of configurations. 

Approximately 4 to 6 million cubic feet of radioactive waste was received and buried at 

MFDS in 40 unlined trenches. 

Between 1977 and 1986, a vapor barrier was placed over approximately 30 acres of the 

trenched area for stabilization. However, water continued to collect in the trenches and 

leach radioactive material into the surrounding environment. Based on the chemicals 

and radioactive materials in the trenches, MFDS was listed on the National Priorities List 

in 1986, and a Record of Decision (ROD) was issued in September 1991, by the U.S. 

Environmental Protection Agency (EPA) under its Comprehensive Environmental 

Response, Compensation, and Liability Act authority. The ROD describes a remedy of 

natural stabilization, which also includes installing and monitoring a landfill cap made of 

a synthetic liner, replacing the landfill cap after 20 years, and installing a final landfill cap 

after 35 to 100 years. Construction of the interim cap was completed in 2003, and 

MFDS entered the "Interim Maintenance Period" of operation. The plan to replace the 

interim cap approximately every 25 years would have allowed the trenches to stabilize 

and allowed further decay of the shorter half-life radionuclides. Although natural 

stabilization was estimated to require 35 to 100 years, the EPA elected to proceed to the 

Final Closure Period, which would require a final cap. In 2012, EPA, in its Five Year 

Review, indicated that 35 years had passed since the termination of authorized disposal 

(1977-2012), and the Cabinet and EPA agreed to place a final cap in 2012. 

In November 2012, MFDS was placed into the Final Closure Period which includes an 

installation of a vegetative cap, surface water control features, and surface monuments 

to identify the location of buried waste. Once the Final Closure Period is completed, 

MFDS will enter into the Custodial Maintenance Period. The first 100 years of the 

Custodial Maintenance Period is defined as the Institutional Control Period which will 

include fencing and other activities to control access to the MFDS; periodic surveillance; 

custodial care; and filing of notices, survey plats, and deed restrictions with the 

appropriate authorities. This Institutional Control Period will accomplish the goal of 

preventing inadvertent intrusion onto the MFDS and providing of custodial care in 

perpetuity. 

Technical Staffing and Training 

LLRW activities are handled by Kentucky’s staff, under the direction of the Branch 

Manager. The basic qualifications for the LLRW program staff are the same as for the 

radioactive materials program staff, as described in Section 3.1, and are commensurate 

with IMC 1248. 

 
Kentucky Final IMPEP Report Page 18 

Status of LLRW Disposal Inspection 

The Branch conducts site visits at least once a month to acquire water samples from 

multiple locations, and performs inspections every 2 years. NRC guidance in IMC 2401 

“Near Surface Low-Level Radioactive Waste Disposal Facility Inspection Program,” IMC 

2602 “Decommissioning Oversight and Inspection Program for Fuel Cycle Facilities and 

Materials Licensees,” and IMC 2800, allows for inspections to be performed as needed 

based on the licensee’s activities at the site. 

There were not any areas of non-compliance identified as a result of inspections 

conducted in 2012. A finding from the 2014 inspection was verbally communicated to 

the licensee. A formal report was withheld at the direction of previous Cabinet 

management. A review of the documentation indicated that there was a non-compliance 

regarding failure to continue monitoring the trench sump levels, as the sumps had been 

removed. The 2016 inspection was not performed prior to the onsite IMPEP review. 

However, the Branch reported to the MRB that the 2016 inspection was conducted in 

October. 

Technical Quality of Inspections 

On June 22, 2016, the review team accompanied three representatives from the Branch 

at the MFDS. The inspectors were adequately prepared and performed performance 

based inspections. Site security, environmental monitoring stations, and facility postings 

were observed. 

The review team evaluated three inspections, an independent third party site 

assessment, and the Branch’s annual monitoring reports based on the water samples 

collected and analyzed. 

On July 27, 2016, the review team toured the Branch laboratory and observed 

equipment capable of analyzing the types of radionuclides that are present at the MFDS. 

The Branch collected and analyzed surface water and ground water samples. The 

review team evaluated the Branch’s MFDS monitoring reports and determined that all 

radionuclide measurements did not exceed the annual drinking water standards at any 

of the sample locations. However, the review team noted tritium mobility from the 

unlined trenches at MFDS based on measurements taken during the construction of the 

north wall cutoff drain and nearby creeks. The Branch has been compiling the water 

quality data and performing trend analysis. The Branch has identified an upward trend 

in uranium and plutonium concentrations and more recently, cesium-137, at one sample 

location inside the owner controlled area. This data will assist the Branch in identifying 

releases from the MFDS and allow the Branch to develop remedies to address potential 

issues. The Branch’s water sampling and analysis of water quality results support the 

conclusion that the public health and safety have been maintained. The reports were 

thorough, complete, consistent, and had sufficient documentation to ensure that licensee 

performance with respect to health and safety was acceptable. 

Technical Quality of Licensing Actions 

The review team examined two LLRW licensing actions which included one denial and 

one pending amendment to renew the MFDS license in its entirety. In December 2013, 

the licensee submitted an amendment to renew the license in its entirety. The action to 
Kentucky Final IMPEP Report Page 19 

renew the license was halted by Cabinet management. The licensee subsequently 

submitted a request to terminate the license. In July 2014, the Branch officially denied 

the licensee’s request to terminate the license. At the time of the onsite review, the 

license had not been amended in its entirety. 

Technical Quality of Incident and Allegation Activities 

There were no incidents or allegations pertaining to the LLRW program during the 

review period. 

c. Evaluation 

The review team noted that the MFDS is a closed radioactive waste burial facility and 

the Final Closure Period is nearing completion. This performance indicator is based on 

oversight of open and active disposal sites, so not all of the performance criteria are 

relevant for the MFDS. The review team determined that, during the review period, the 

Commonwealth met the relevant performance indicator objectives listed in Section 4.3.a. 

The review team discussed a rating of satisfactory versus satisfactory, but needs 

improvement for the indicator. The review team noted that the Branch has shared the 

July 2014 inspection findings with the licensee, but has delayed issuance of the 

inspection report. In addition the Branch has not issued the renewal (amendment in its 

entirely) for the MFDS license. The review team determined that this indicator should be 

found satisfactory with a recommendation. The Cabinet is responsible for regulatory 

oversight of MFDS and the oversight is implemented by the Branch. The MRB noted 

that without issuance of inspection reports, there is no public visibility with respect to the 

results of the Branch’s execution of its oversight responsibilities for MFDS in accordance 

with Kentucky’s requirements. To ensure openness and transparency regarding the 

Branch’s monitoring and oversight of MFDS, the team recommended, and the MRB 

agreed, that the Branch ensure timely and consistent issuance of licensing actions and 

inspection results for the MFDS. 

d. Results 

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

the MRB agreed that Kentucky’s performance with respect to the indicator, Low-Level 

Radioactive Waste Disposal Program, be found satisfactory. 

5.0 SUMMARY 

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

for seven out of eight performance indicators reviewed and unsatisfactory for the 

Compatibility Requirements performance indicator. The failure by Kentucky to adopt 

regulations, or other legally binding requirements, in a timely manner, creates a gap in 

the collective national effort to regulate radioactive materials, which led to the not 

compatible finding. The review team made one recommendation regarding program 

performance by Kentucky and determined that the recommendation from the 2012 

IMPEP review should be closed. 

With the unsatisfactory finding in the Compatibility Requirements indicator, the review 

team considered recommending that Kentucky be placed on monitoring until the 
Kentucky Final IMPEP Report Page 20 

regulation adoption problem is resolved, but since actions are currently underway to use 

the adoption by reference process, this action was deemed unnecessary. 

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

Agreement State Program is adequate to protect public health and safety, but is not 

compatible with the NRC's program. The review team recommended, and the MRB 

agreed, that the next IMPEP review take place, as regularly scheduled, in approximately 

4 years with a periodic meeting in 2 years. 

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

and implementation by Kentucky: 

To ensure openness and transparency regarding the Branch’s monitoring 

and oversight of the Maxey Flats Disposal Site (MFDS), the review team 

recommends that the Branch ensure timely and consistent issuance of 

licensing actions and inspection results for the MFDS. (Section 4.3.c.) 
LIST OF APPENDICES 

Appendix A IMPEP Review Team Members 

Appendix B Inspection Accompaniments 
 

APPENDIX A 

IMPEP REVIEW TEAM MEMBERS 

Name Area of Responsibility

Jim Lynch, Region III Team Leader 

 Technical Staffing and Training 

 Inspection Accompaniments 

Donna Janda, Region I Technical Quality of Incident and Allegation Activities 

 Compatibility Requirements 

Dwight Shearer, Pennsylvania Status of Materials Inspection Program 

 Technical Quality of Inspections 

Jackie Cook, Region IV Technical Quality of Licensing Actions 

Ron Parsons, Tennessee Sealed Source and Device Evaluation Program 

 Technical Quality of Licensing Actions 

Kathy Modes, NMSS Low-Level Radioactive Waste Disposal Program 

 Inspection Accompaniments 

 
APPENDIX B 

INSPECTION ACCOMPANIMENTS 

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

Accompaniment No.: 1 License No.: 201-168-05

License Type: Industrial Radiography Priority: 1

Inspection Date: 4/25/16 Inspector: EP

Accompaniment No.: 2 License No.: 201-798-05

License Type: Industrial Radiography Priority: 1

Inspection Date: 4/26/16 Inspector: CK

Accompaniment No.: 3 License No.: 201-768-96

License Type: Irradiators Priority: 5

Inspection Date: 4/27/16 Inspector: AB

Accompaniment No.: 4 License No.: 202-352-27

License Type: Medical Therapy Priority: 2

Inspection Date: 4/28/16 Inspector: MV

Accompaniment No.: 5 License No.: 202-433-25

License Type: Medical Priority: 3

Inspection Date: 6/23/16 Inspector: JM

Accompaniment No.: 6 License No.: 206-002-03

License Type: Low-Level Radioactive Waste Site Priority: 2

Inspection Date: 6/22/16 Inspectors: MM, AB, NG