05000354/LER-2007-005
| Docket Number Sequential Revmonth Day Year Year Month Day Yearnumber No. Salem Generating Station Unit 1 50-272 | |
| Event date: | 10-09-2007 |
|---|---|
| Report date: | 12-07-2007 |
| Initial Reporting | |
| 3542007005R00 - NRC Website | |
PLANT AND SYSTEM IDENTIFICATION
Hope Creek - General Electric — Boiling Water Reactor (BWR/4) Salem 1 and 2 — Westinghouse — Pressurized Water Reactor (PWR/4)
IDENTIFICATION OF OCCURRENCE
Event Date: October 09, 2007 Discovery Date: October 11, 2007
CONDITIONS PRIOR TO EVENT
Hope Creek was in Mode 1 with reactor power at approximately 88% Salem Units 1 and 2 were in Mode 1 with reactor power at approximately 100%.
DESCRIPTION OF EVENT
On October 4, 2007 a pre-access Fitness for Duty (FFD) specimen collection was performed on a supplemental person. The sample presented was within normal limits for color, odor, temperature and specific gravity. The specimen was tested on site for cannabinoids (THC) at 50 ng/ml. The test yielded results higher than the 50 ng/ml calibrator for THC. Per procedure, the sample was deemed a "presumptive positive" test result. The specimen was forwarded to an offsite laboratory for additional testing. The supplemental person's access was placed on temporary hold pending confirmatory testing results.
On October 6, 2007 the onsite FFD analyst received the laboratory's report for the above-mentioned specimen.
The specimen identification was verified as matching the original sample. The report for the confirmatory test documented negative for THC; however, the report indicated that the test cut-off level for THC was 100 ng/ml.
The section of the report that identifies the cut-off levels for each drug tested was not reviewed, rather the results section for the drug screening was reviewed. The report was initialed by the FFD analyst and entered into the Integrated Nuclear Security System (INSS) database currently used at Salem/Hope Creek. Based on the report results, the individual was granted unescorted access on October 9, 2007.
An "amended" report was received on October 11, 2007 (for this same individual). The FFD analyst verified the specimen number was the same as the report from October 6, 2007. This report indicated different test results for THC, (i.e. the report documented the results were positive for THC (using 50 ng/ml as the cut-off level)).
The Manager of Access Authorization was notified. The individual's badging status was placed on hold and the individual was removed from the site. The Medical Review Officer (MRO) interviewed the individual. The MRO declared the result "positive" and the individual's access was immediately denied. A one-hour report was made to the NRC in accordance with 73.71(b)(1).
A work performance investigation determined that the individual did not perform any safety related work during the period granted unescorted access.
The laboratory performed a review of all samples submitted since September 1, 2007. No other specimens were identified as being processed with the incorrect cut-off level. PSEG reviewed THC cases from January 1, 2007 to October 11, 2007. All cases were tested at the 50 ng/ml cut-off.
CAUSE OF EVENT
A lab error caused the individual's sample to be initially tested at a THC cut-off level of 100 ng/ml instead of the 50 ng/ml cut-off level required by PSEG Nuclear procedures. The lab discovered the error on October 6, 2007 and a second test was ordered at the correct level of 50 ng/ml; however, the original test results were forwarded to PSEG without noting the error.
CORRECTIVE ACTIONS
The individual was removed from the protected area; the Medical Review Officer (MRO) performed a review; and the individual was denied unescorted access.
The laboratory has been replaced by another certified lab.
PSEG Nuclear procedures have been revised to assure cut-off levels are reviewed for each reported result.
PREVIOUS SIMILAR EVENTS
No similar occurrences have been identified.
COMMITMENTS
This report contains no commitments.
Nuclear Licensing and Safety - Quality of Work Check list/ Scorecards� 11/18/05
LER
Identification (item being reviewed) Content (peer reviewer) NA or Y/N o A brief abstract describing the major occurrences during the event, including all component or system failures that contributed to the event and significant corrective action taken or planned to prevent recurrence.
o A clear, specific, narrative description of what occurred so that knowledgeable readers conversant with the design of commercial nuclear power plants, but not familiar with the details of a particular plant, can understand the complete event.
o Plant operating conditions before the event.
o Status of structures, components, or systems that were inoperable at the start of the event and that contributed to the event.
o Dates and approximate times of occurrences.
o The cause of each component or system failure or personnel error, if known.
o The failure mode, mechanism, and effect of each failed component, if known.
o The Energy Industry Identification System component function identifier and system name of each system referred to in the LER.
o The Energy Industry Identification System component function identifier and system name of each component referred to in the LER.
o For failures of components with multiple functions, include a list of systems or secondary functions that were also affected.
o For failure that rendered a train of a safety system inoperable, an estimate of the elapsed time from the discovery of the failure until the train was returned to service.
o The method of discovery of each component or system failure or procedural error.
o Operator actions that affected the course of the event, including operator errors, procedural deficiencies, or both, that contributed to the event.
o For each personnel error, the licensee shall discuss: (i) Whether the error was a cognitive error (e.g., failure to recognize the actual plant condition, failure to realize which systems should be functioning, failure to recognize the true nature of the event) or a procedural error; o Whether the error was contrary to an approved procedure, was a direct result of an error in an approved procedure, or was associated with an activity or task that was not covered by an approved procedure; o Any unusual characteristics of the work location (e.g., heat, noise) _ that directly contributed to the error; and o The type of personnel involved (i.e., contractor personnel, licensed operator, nonlicensed operator, other licensee personnel).
o Automatically and manually initiated safety system responses.
o The manufacturer and model number (or other identification) of each component that failed during the event.
o An assessment of the safety consequences and implications of the event.
This assessment must include the availability of other systems or components that could have performed the same function as the components and systems that failed during the event.
o A description of any corrective actions planned as a result of the event, including those to reduce the probability of similar events occurring in the future.
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