Oklahoma IMPEP Question Responses Text (2014)

A.1 There were four findings on the last IMPEP. The reviewers recommended that we continue to implement our program for ensuring that we did not miss required radioactive materials inspections due to glitches in our RADMAN tracking software, failures by inspectors to update inspections, and other causes. Our tracking system for verifying inspections has been very successful, and we feel we are in good shape on our routine radioactive materials inspections. We were late on three IP 1-3 inspections during the period of this review. We did have a short-term problem with reciprocity inspections in 2012. Ideally, we should have done 1.8 reciprocity inspections. We did not do any “pure” reciprocity inspections that year, but we did two inspections of reciprocity licensees after they applied for and received Oklahoma licenses. In the subsequent years of 2013 and 2014, we exceeded the guideline (2 needed, 3 completed for each year). We have a history of excellent performance on reciprocity inspections on previous IMPEPS (met or exceeded the reciprocity criteria for all other IMPEPs since becoming an Agreement State in 2000), and we do not believe this indicates an ongoing problem with our program for reciprocity inspections. The reviewers recommended that we improve training to increase familiarity with Part 35, especially the new requirements for preceptor statements. An NRC staff member from Region IV came to Oklahoma and provided our staff with specialized training that was very helpful in this. Staff were reminded of the new requirements during staff meetings. A self-audit of medical licenses was later done by senior staff which found no problems. We believe we have resolved this issue. The reviewers left open a recommendation regarding improved recordkeeping on inspection and licensing issues. We have had some turnover in our clerical staff, but we have not had internal problems with reviewing records, and the system established by the experienced secretary with a strong record who was transferred from another part of the agency is still in use and appears to be functioning well. We believe we have resolved this issue. The reviewers recommended the state take measures to ensure proper recordkeeping, tracking, and closure of allegations. We prepared a radiation-specific SOP on this issue, and training on it was conducted in-house during the last IMPEP. Further reinforcement and training has occurred during Section staff meetings. A specific staff member was assigned to be a central point of contact to help staff in interpreting the SOP. During our review of records in preparing to implement document control, we identified some allegation records that had been maintained by our Section secretary and moved them into secure storage by combining them with facility files in Central Records. B.1.2 (a) See document “Organizational Chart Env Quality Board” The organizational charts attached are the only ones available. The members of the Environmental Quality Board are appointed by the Governor, though they do not report to her. The Environmental Quality Board does not manage the day-to-day affairs of the agency, though they approve all rules of the agency, and appoint the agency Executive Director. B.1.2 (b) See document “Organizational Chart LPD”

B.1.2 (c) Oklahoma DEQ did not receive jurisdiction for sealed source and device evaluation, nor for Uranium recovery. We do have jurisdiction over low level radioactive waste, but the program is inactive until an application for a facility is received. B.1.3 ______________Area of Effort_____________

Name Position Admin Ram Other

Broderick Pgm Mgr .40 .40 .20 Sampson EPS IV .10 .75 .15 Cornelius EPS IV .05 .50 .45 Brewer EPS IV 0 .60 .40 McAllister EPS III .15 .55 .30 McCaskill EPS III .05 .55 .40 Deaton EPS II .40 .10 .50 Reid EPS II 0 .15 .85 Flynn Prof Engr .10 .80 .10

---Admin includes rulemaking, fee work, supervisory duties, database work, etc. ---RAM includes licensing and inspection of radioactive materials ---Other includes radon, X-ray, complaint/incident investigation, training, radiography

certification, etc. B.I.4 See document “New Professional Personnel Hired” B.I.5

Name Inspection Type Estimated Date Reid X-ray inspector October 2014

Basic AEA December 2014 Diagnostic nuclear medicine April 2015

Deaton Basic AEA July 2014

Diagnostic nuclear medicine November 2014 Industrial Radiography Mid 2015

Cornelius Industrial Radiography November 2014

Well logging Mid 2015

Brewer Brachytherapy Late 2014/early 2015 Nuclear pharmacy Mid 2015 Broad Scope Late 2015

McAllister Brachytherapy Late 2014/early 2015 Well logging Mid 2015 Broad Scope or nuclear pharmacy Early 2016

McCaskill Well logging Late 2014 Brachytherapy Mid/Late 2015

Nuclear Pharmacy Mid 2016 B.I.6 The DEQ sponsored Five Week HP course was replaced with Three Weeks of HP courses provided by NRC.

B.I.7

Name Position Hired in Radiation Left Radiation Nolan Newkirk EPS 05/22/2006 01/24/2012 Michele Woods Secretary 09/04/2007 12/01/2010 Mohammed Idrissa EPS 09/20/2000 03/01/2011 Morgan Buckner EPS 11/03/2008 10/08/2010

B.I.8 There are currently no vacant positions in Radiation. At the time of the last IMPEP, we had two vacant positions because of funding shortages. Inflation had caused our costs to exceed our fee income. This did impact our operations for a time. Eventually a fee increase was passed that included an annual CPI adjustment to help account for increased costs as time went on. In 2011, McAllister, McCaskill, and Deaton were hired. The first CPI increase went into effect on July 1, 2014. The agency suffered a significant cut in appropriations after the 2014 legislative session. As of now, those have not affected staffing or the functions of the Section. Fortunately, turnover among technical staff in the Section has been low for the last several years. B.I.9 The program works with the Radiation Management Advisory Council (RMAC). The RMAC is strictly an advisory body, established by statute, for rule development, review and recommendation to the Environmental Quality Board, and for such other purposes specified by law. The composition is established by statute, and members represent various groups, including the engineering profession, Industrial Radiography, General Public, etc. The members are appointed by the Governor and Legislative leaders. The appointing authorities generally pay close attention to the recommendations of the Section in selecting who should be on the RMAC, but are not bound by the recommendations. The RMAC is a channel for communication between the Section and affected facilities and the public. It has no authority over the program, including no input on hiring or setting policy. RMAC members are governed by state ethics laws and rules. The Section believes that the RMAC is functioning effectively and as intended, and that there are no significant effects from any real or perceived conflicts of interest. A chart listing the positions, their affiliation, and the names of current members is attached. See document “RMAC Public Distribution Chart”

B.II.10 None

B.II.11 See “IMPEP 2014 Statistics” tab # 11 Inspection Totals B.II.12 See “IMPEP 2014 Statistics” tab #12 Overdue Insp. Completed B.II.13 None

B.II.14 See “IMPEP 2014 Statistics” tab #14 Reciprocity B.III.15 No changes to DEQ written inspection procedures. We generally adopt NRC

guidance for new technologies, and similar issues. B.III.16 See “IMPEP 2014 Statistics” tab #16 Accompaniments B.III.17 See “IMPEP 2014 Statistics” tab #17 Instrumentation B.IV.18 Specific Radioactive Materials Licenses = 224 Total B.IV.19 In previous IMPEPs, I’ve used this question to advise of any licensees that have had unusual problems or we feel are of interest (not limiting myself to license issues), and this has been well-received, so I’m doing it again this IMPEP.--MB In response to the issue with financial assurance and Ge-68 identified during OAS conference calls, our investigation found only one licensee that had Ge-68 generators in Oklahoma. The University of Oklahoma Health Sciences Center, OK license OK-03176-01, a broad scope license, had one generator. The RSO informs us that although when new, this model of generators contains 10 milliCuries of Ge-68, the generator they currently have on hand has only (approx.) 6 milliCuries. OU already has financial assurance for other isotopes. The RSO tells us his calculations indicate that 10 milliCuries of Ge-68 would raise OU to needing not just financial assurance, but a decommissioning funding plan. The RSO committed not to order further Ge-68 until some clarification of this situation is received. He indicated he will submit a license amendment limiting the facility to 6 milliCuries of Ge-68. RCOA Imaging Services, OK license OK-31048-01, declared bankruptcy and ceased operations. RCOA was a mobile medical imaging company with no permanent operations in Oklahoma. We were informed they had two PET/CT coaches, but neither was in Oklahoma after the bankruptcy, and the company had no licensed materials in the state. The license was terminated. E+Pet Imaging, OK license OK-31058-01, requested approval to use F-18 in a form not approved by FDA. This was part of a clinical trial. Their license was amended to allow the use.

Oklahoma State University, OK license OK-00237-03, a broad scope license, had been identified as a concern before our previous IMPEP because of turnover in the RSO position, and repeated problems. The RCP director and another staff member visited OSU and met with the Radiation Safety Committee, explaining the past problems and our concerns about OSU having repeated problems. We renewed their license for a shorter term than normal, and explained that if improvements were not seen, our ability to renew their license as a broad scope was in doubt. We met separately with a University Vice President (who also attended the RSC meeting), and reiterated this. There have been no major problems since this time. The new RSO has remained in his position for several years, and OSU did well on an inspection accompanied by NRC as part of this IMPEP. Unless there is an adverse change, we expect to be able to renew their license as a broad scope. TEAM Industrial Services, OK license OK-31066-01, an industrial radiography license, has had repeated incidents where an unauthorized person was able to enter the 2 mrem/hour line while radiography was being performed. We have scheduled an enforcement meeting with them to discuss what may be causing the problem, and if there are systemic issues that they need to address. Core Oncology, OK license OK-27502-01, formerly a manufacturing operation, requested conversion to storage-only after they ceased manufacturing operations. They were approved to store I-125 and Pd-103 pending decay and decommissioning. We have had repeated problems with difficulty contacting a company representative and fee payments. Core Laboratories, OK license OK-26928-02 (a division of ProTechnics), a well logging and tracer study licensee, improperly disposed of Ir-192 in the trash dumpster of an unrelated business. The radioactive material was detected when it set off a gate alarm at a local landfill. DEQ investigated, and traced the material back to Core. The material was recovered by Core, our enforcement policy was followed, and a Consent Order including a financial penalty was issued. Geodata, OK license OK-31069-01, a well logging license (not approved for tracer) is a well logging licensee that had ceased active operations due to health problems of the owner. DEQ has had trouble getting the owner to properly transfer or dispose of his sources. We have recently been told that he had sold his operation, including the sources, to a licensed owner out of state, but he has not (as of this writing) provided us with the expected information to document the transfer. Hi-Tech Testing Service, OK license OK-32150-01, an industrial radiography company, identified a leaking Ir-192 radiography source. They contacted DEQ, and we found minor contamination in the guide tube and vehicle. The source, camera, and all associated equipment were almost brand-new and had only been used together. The manufacturer was contacted, and came to recover the source. Surveys of the homes of the radiographers and the location where the radiographers had been working found only minor contamination on a shirt that had been worn by one of the radiographers. The manufacturer agreed that the source had apparently been contaminated during manufacture, but no definitive conclusion was ever reached.

Norman Regional Health System, OK license OK-14145-01, a medical licensee, suffered a tornado strike on one of its locations at Moore Medical Center. The building was heavily damaged. The technicians reported that all radioactive material was left in the locked hot lab when the building was evacuated. Representatives of their pharmacy recovered the radioactive material from the damaged building without incident. B.IV.20 No variances or exemptions during the review period. B.IV.21 No written changes to policy made during the period of this review. We have adopted most or all updates to NRC procedures, notably those regarding licensing Ra-223 under Part 35. Note that, as mentioned in the Agreement States Letter dated March 14, 2014, Oklahoma DEQ is conducting pre-licensing visits (one management accompaniment during the period under review was of such a pre-licensing visit), and we have sought to implement the 2008 changes to preceptor approval as identified in the same letter, and during the 2010 Oklahoma IMPEP. B.IV.22 See “IMPEP 2014 Statistics” – tab #22 Renewal Applications B.V.23 None B.V.24 See document “Environmental Complaints Program”, “AIW flow chart A”,

“Complaint characterization flow chart B”, and “Complaint investigation flow chart C”)

Written formal procedures for the Radiation Management Section were established to supplement the Environmental Complaints Program SOP. C.I.25 27A O.S. § 2-9-101 et seq. is the Radiation Management Act. One section of the Act, 27A O.S. § 2-9-104 B, was amended in 2011 and again in 2012. The amendments exempt electronic products used for bomb detection by public safety bomb squads within Oklahoma law enforcement agencies and law enforcement agencies of political subdivisions. 51 O.S. § 24A.1. et seq. is the Open Records Act. One section of the Act, 51. O.S. § 24A.28 was amended by the addition of subsection A.9. in 2013. The addition provides that the following information may be kept confidential: 9. Records received, maintained or generated by the Department of Environmental Quality that contain information regarding sources of radiation in quantities determined by the United States Nuclear Regulatory Commission to be significant to public health and safety, by whomever possessed, whether in transit or at fixed sites, when the information could reasonably be expected to have an adverse effect on the health and safety of the public by increasing the likelihood of theft,

diversion or sabotage of the radiation sources or facilities. The information may include but is not limited to information: a. from or relating to radioactive material licensees identifying the exact location of the radioactive material, b. describing how the radioactive material is secured from unauthorized removal or access when it is in storage, c. describing the control and maintenance of constant surveillance of the radioactive material when it is not in storage,

d. describing specific policies and procedures for actions to physically protect the radioactive material, e. identifying possession limits or actual inventories of radionuclides, f. containing or describing assessments or analyses that could reveal vulnerabilities, g. identifying specific locations of safety and security equipment, h. describing emergency planning, emergency response and fire protection, and i. containing or describing other information that could reasonably be expected to be useful to persons with malevolent intent.

B. The following information shall not be kept confidential: 1. Records related to federal grants administered by the Oklahoma Office of Homeland Security or the Department of Environmental Quality; 2. Records related to the receipt and expenditure of public funds; or 3. Records related to the financial performance or financial administration of the Oklahoma Office of Homeland Security or the Department of Environmental Quality. C. For the purposes of this section, the term "terrorism" means any act encompassed by the definitions set forth in Section 1268.1 of Title 21 of the Oklahoma Statutes.

C.I.26 No “sunset” provisions.

C.I.27 Based on the current SRS listing, Oklahoma has adopted all regulations except RATS ID# 2013-1 (due by March 19, 2016) and 2013-2 (due by August 27, 2016). Oklahoma will propose these rule changes in the next rulemaking session that begins this fall of 2014, and anticipate they will go into effect in fall 2015. RATS ID # 2011-1, 2011-2, 2012-2, 2012-3, and 2012-4 have been approved by the state rulemaking process and will be effective on September 12, 2014. C.I.28 Oklahoma has adopted all amendments within the 3 year timeframe from the date of NRC rule promulgation. Oklahoma has adopted all amendments within three years. Changes to the State’s procedures for promulgating rules have been amended in 2014. As a result, the rulemaking process may take longer, by up to several months, such that from beginning to end the rulemaking process may take up to 18 months.

1) Publication of Rulemaking Notice in Oklahoma Register. (Text of Notice must be submitted approximately one month before publication. The publication date must be at least one month before the Council meeting.

2) Radiation Management Advisory Council recommends rule to Environmental Quality Board.

3) Environmental Quality Board approves rule. 4) Legislature approves rule. Legislature is in session February through end of May. If

legislature does not approve the rule before sine die, the Governor may approve. 5) Governor signs rule.

The practical effect of this is that rules generally go before the Radiation Management Advisory Council in the summer or fall of the year, and then to the Environmental Quality Board during the Winter. Legislative review and approval is by end of May. Gubernatorial review and approval will be in June or July. Effective date for the agency’s rules will be in early to mid-September. C.II.29 None. Do not have a program C.II.30 None. Do not have a program C.III.31 None C.IV.32 None

Name Degree Hire Date NRC completed courses HP Course

McAllister, Jennifer

B.S. Zoology M.S. Environmental Sciences

January 2011 *Fundamental Health Physics I & II (H-122) *Fundamental Health Physics III (H-123) Environmental Monitoring (H-111) Inspection Procedures (G-108) Licensing Practices and Procedures (G-109) Industrial Radiography (H-305) Increased Controls (S-201) Nuclear Medicine (H-304) Brachytherapy (H-313) Well Logging (H-314) MARSSIM (H-121) Root Cause (G-205)

* ORAU 2 week and 1 week (HP course provided by NRC)

McCaskill, Elizabeth (Libby)

B.S. Biology

January 2011 *Fundamental Health Physics I & II (H-122) *Fundamental Health Physics III (H-123) Inspection Procedures (G-108) Licensing Practices and Procedures (G-109) Industrial Radiography (H-305) Nuclear Medicine (H-304) Increased Controls (S-201) Environmental Monitoring (H-111) Air Sampling (H-119) Well Logging (H-314) MARSSIM (H-121) Root Cause (G-205)

* ORAU 2 week and 1 week (HP course provided by NRC)

Deaton, Kate B.S. Geology September 2011 *Fundamental Health Physics I & II (H-122) *Fundamental Health Physics III (H-123) Inspection Procedures (G-108) Licensing Practices and Procedures (G-109) Air Sampling (H-119) MARSSIM (H-121) Nuclear Medicine (H-304) Brachytherapy (H-313) Well Logging (H-314) Root Cause (G-205)

* ORAU 2 week and 1 week (HP course provided by NRC)

Reid, Michael B.S. Biology May 2012 *Fundamental Health Physics I & II (H-122) *Fundamental Health Physics III (H-123) Inspection Procedures (G-108) Licensing Practices and Procedures (G-109) Industrial Radiography (H-305) Nuclear Medicine (H-304) Increased Controls (S-201)

* ORAU 2 week and 1 week (HP course provided by NRC)

FOR PUBLIC DISTRIBUTION

DEPARTMENT OF ENVIRONMENTAL QUALITY

RADIATION MANAGEMENT ADVISORY COUNCIL Address Correspondence to: (Council Member)

c/o Quiana Fields, Board and Council Secretary Department of Environmental Quality P. O. Box 1677 Oklahoma City, OK 73101-1677

Visit our website at: http://www.deq.state.ok.us/LPDnew/Rad/radmac.html FY14

MEMBER PROFESSIONAL REALM APPOINTING OFFICIAL TERM EXPIRES

Christopher Honigsberg

Industry which uses sources of radiation in

its manufacturing or processing business Governor 7/1/2013

Karen Jennings

Environmental Organization Governor 7/1/2015

Steve Woods Vice -Chair

Engineering Profession Governor 7/1/2017

Nadine Barton

General Public Pro Tempore 1/3/2014

Wayne Conway

Industrial Radiography Pro Tempore 3/3/2016

George MacDurmon Chair

Faculty of institute of higher learning of university status

Pro Tempore 1/4/2015

Chad Mashburn

Petroleum Industry Speaker of the House 6/30/2014

Eric Mitchell

Transportation Industry Speaker of the House 6/30/2016

Shawn Heldebrandt

Medical Industry Speaker of the House 6/30/2015

Radiation Management Advisory Council

The Radiation Management Advisory Council (RMAC) serves as the initial rulemaking body for the LPD and operates under the authority of the Oklahoma Radiation Management Act. The RMAC holds public hearings, reviews radiation management issues, and provides expertise about various radiation management issues. All radiation management rules and regulations must first be reviewed and approved by the RMAC before being recommended to the Environmental Quality Board. Once approved by the Environmental Quality Board, the rules proceed to the State Legislature and the Governor for final approval. The Council is composed of nine members who represent specific areas of expertise as described by 27A O.S. § 2-2-201(F), the Oklahoma Environmental Quality Code.

Enter basic data In RadMan

AIW

Go to flow chart C

E-mail Kevin with description to determine if NMED reportable

(Kevin / Alt)

NMED data entry and reports

(Kevin/Alt)

Complete RadMan data entry in licensee Inspection & Enforcement tabs, and AIW

Does it meet DEQ Complaint criteria?

See flow chart B

Information Received by DEQ

(Hotline, ECLS, Rad Staff)

Yes

No

Send complainant closure letter. Is this one of our

licensees?

Yes

No Complete RadMan data entry in AIW

Create paper incident file and send to Central Records. File notice in

inspections section of license file, if applicable

(Secretary)

Assemble paper documents and complete licensee file notice

Yes

No

Incident / Allegation flow chart A

Contact complainant within 24 Hrs and collect Information

Action Assigned to Inspector

(Program Manager / Alt)

Conduct reactive inspection. Violations found?

Monitor/evaluate response to enforcement

Close complaint?

Prepare enforcement documents as required

No

Yes

End

Yes No

Return from flow

chart C

Complaint characterization flow chart B

Was the incident / event / situation self reported?

Are we aware of the situation / non-compliance

because of a routine or reactive inspection?

Is the contact actually alleging anything against

another party?

Is this just a request for technical assistance (i.e.

NORM, cell phone towers, power lines, lasers, tanning

booths, etc.)?

Does not meet DEQ complaint criteria

NO

YES

YES

NO

NO

YES / NOT SURE

YES

Meets DEQ complaint criteria

NO

Enter From Flowchart A

Complaint investigation flow chart C

Send letter to complainant with inspector’s contact information

(day 7)

Conduct on-site inspection within 3 days of receiving complaint

Update complaint status with Al Coulter weekly Close complaint?

If complaint not closed by day 90, justify “extraordinary circumstances”

with Division Director and Deputy Exec. Director

(Program Manager, Inspector)

Enter from Flowchart A

Assemble documents and provide to Al Coulter. All documents must be in electronic format, paper documents

will need to be scanned. *

Contact Al Coulter to determine if incident is already in the DEQ

Complaints system.

Initiate new complaint, give complaint no. to Secretary

Yes

No

Violations found? Contact complainant to solicit

comment on enforcement. Allow 14 days for response

Yes

Monitor/evaluate response to enforcement

No

Yes

No

* All documents submitted pursuant to a DEQ complaint will be scanned into Edoctus. The inspector assigned to the complaint is responsible for ensuring that all information which would compromise materials security or individual privacy is removed prior to scanning.

Return to flow chart A “Send complainant closure letter. Is this one of

our licensees?”

Contact complainant within 2 days of receiving complaint

Prepare enforcement documents as required