IR 05000295/1997017

Insp Repts 50-295/97-17 & 50-304/97-17 on 970619-0922.No Violations Noted But pre-decisional Enforcement Conference Will Be Scheduled to Discuss Violations Cited.Major Areas inspected:fitness-for-duty Related Events

ML20211P256
Person / Time
Site:	Zion  File:ZionSolutions icon.png
Issue date:	10/10/1997
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:
Shared Package
ML20211P216	List: IR 05000295/1997017 ML20211P211
References
50-295-97-17, 50-304-97-17, NUDOCS 9710200114
Download: ML20211P256 (12)

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U.S. NUCLEAR REGULATORY COMMISSION REGION lli Docket Nos: 50 295; 50 304 License Nos: DPR 39; DPR 48 Report Nos: 50-295/97017(DRS); 50-304/97017(DRS)

Licensee: Commonwealth Edison Company

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Facility: Zion Station, Units 1 and 2 Location: 105 Shiloh Boulevard Zion,IL 60099 Dates: June 19 September 22,1997 Inspectors: J. Belanger, Senior Physical Security inspector J Creed, Chief. Plant Support Branch i Approved by: John A. Grobe, Acting Director Division of Reactor Safety fDR Db 0295 0 PDR a

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EXECUTIVE SUMMARY Zion Generating Station, linits 1 and 2 NRC inspection Reports 50 295/97017; 50 304/97017 j

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The initial purpose of the inspection was to evaluate two fitnew for-duty related events. The first occurred on February 1,1997. During the process of finalizing NRC review of that event the second event occurred on June 12,1997. Both events related to the apparent failures to take appropriate actions to ensure that required for-cause drug and alcohol tests on Individuals when the odor of alcohol was detected. These two events were reported to the NRC as required by 10 CFR Part 26. The inspection was expanded when additional examples of failures to follow fitness for-duty procedures were identified through the licensee's investigations and audit progra The inspectors concluded that the failure to conduct fitness for duty related evaluations and for cause tests occurred due to significant weaknesses in the licensee's fitness for-duty progra The following is a summary of the significant inspection findings and conclusion * The overall level of knowledge and comn.ltment to imp!oment the fitness for duty among several plant employees and managers were deficien * Due to ineffective corrective actions in response to CAR 22 06 006, the underlying problem of controlling and implementing the unscheduled call out process which contributed to the February 1,1997 event was not correcte (suction 7.1)

• Zion Administrative Procedure ZAP 1130-00, Revision 3 dated April 17,1995 did not provide clear direction to employees regarding their responsibilities and actions upon the detection of the odor of alcohol. (Section S3.1)

• Employees failed on four occasions to advise their supervisors of violations of the fitness for duty pobey and/or procedures. (Section 01.3)

• Two supervisors failed to require a for-cause test for an employee who smelled of alcohol within the protected area. (Section Si.2)

- * A supervisor failed to ask an employos if they had consumed alcohol within the five hour abstinence period prior to directing them to report to the station. The employee likewise failed tc Inform the supervisor that they had consumed alcohol within the abstinence period. The individual was later observed to smell of alcohol within the protected area. (Section S1.2)

• An employee who volunts rily came to work at a time outside of their normal work hours, and who had consumed alcohol within the five hour abstinence period, did not request an alcohol test upon site arrival as required, entered the protected area, and was later observed to smell of alcohol. (Section S1.4)

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Report Detalls IV. Plant Support 51 Conduct of Security nd Safeguarde Activities S1.1 General Commer.jn Some licensee and c6r. tract employees granted unescorted access to the protected area failed to demonstrate an adequate understandbg of the licensee's fitness for-duty (FFD) policy and procedures to onen trat the general performance objectives stated in 10 CcR Part 26.10 were met. Onntribuitna to the causes of several FFD events was an apparent lack of commitment on the par + of some employees and sorr.e superviso:3. :o following the licensee's FFD policy sad procedures aM weak procedural guldance for implementing the corporate nucleaf security guidelines (CNSG).

During the course of the NRC Inspection, the following relevant circumstances were identified and are outlined here for clarity:

• In March and April 1996 a Comed audit identified several Instances in which procedures relating to the FFD aspv n of unscheduled worker call outs that appeared were not being followe e In late 1906 (specific date uncertain) an employee (Employee A) smelled alcohol on a contractor and no one was informed, e in January 1997 auditors escalsted the significance of the previous FFD findings because corrective actions appeared ineffective, o On February 1,1997, the Director of Fire Prevention (DFP), who consumed alcohol within the previous five hours, was called and entered the protected are The odor of alcohol was confirmed on the DFP, and no for cause FFD test was 9ve * During an aud' conducted February 319,19?", the licensee identified additional failures to properly implement the FFD procedures relating to unscheduled worker call-out e On March 1,1997, the Emergency Response Coordinator (ERC) consumed alcohol within the previous five hours, entered the protected area and did not request a FFD test nor notify a supervisor. The odor was detected by another employee (Employee A), who also did not notify a supervisor, e On June 12,1997, the odor of alcohol was detacted on an individual and no supervisor was notifie __ __-

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S1.2 Eailute_to Conduct For-Cause Test on February 1.1997 Insoection Scope (81502)

The inspectors reviewed corporate security Investigative Report No. 97 0080 dated March 6,1997 concoming a FFD event that occurred on February 1,1997. The licensee initiated the investigation on Februsry 12,1997, bcsed on a credible concern received by the Station Security Administrator on February 11,1997. The concem was raised by a non-supervisory contractor. The purpose of the inspector's review of the investigation report was to evaluate the safety and regulatory significance of the even Interviews with licensae investigators and managers were also conducte Qhsgrvation and Findinas On the evening of February 1,1997, the contract Director of Fire Protection (DFP) was called at home by a subordinate and notified that a fire watch person had been injured at the site. The DFP informed the caller that she had been drinking. The DFP then called a Fire Prevention Supervisor (FPS) at home and directed her to go to the site because the DFP had been drinking. The DFP later called the Comed Fire Marshall at home. The DFP was requested by the Comed Fire Marshall to report to the site to evaluate the situation. During that call the DFP apparently did not tell the Fire Marshall that alcohol was consumed within the previous five hours and the Fire Marshall did not ask. The 1.'FP drove to the site and entered the protected area (PA) at 9:29 p.m. Within about fifteen minutes after entry, several individuals observed that the DFP smelled of alcohol. They escorted the DFP to the access control facility and ensured that she exited at 10:00 p.m. They notified no one while the DFP was on site and failed to ensure that a for cause test was conducted when credible information that an individual may be under the influence of alcohol was know Zion Administrative Procedure 1130-00, Revision 3 dated April 17,1997 states that for-cause urinalysis and breath alcohol testing may be required for Commonwealth Edison or contractor employees, following any observed behavior indicatng possible substance abuse, including detection of the odor of alcohd per Corporate Nuclear Security Guide (CNSG 207) Testing For Cause. CNSG 207. Revision 9 dated November 1996 rer'uires a for-cause test when the odor of alcohol has been detected and a supervisor haa confirmed the odor of alcoho The failure of shift fire watch supervisors to ensure that a for-cause test was conducted when the smell of alcohol was confirmed on the DFP is considered an apparent violation of 10 CFR Part 26.24(a)(3) (Escalated Enforcement item (EEI) 50 295/97017-01; 50-304/97017 01).

Corporate Nuclear Guideline No. 200, Revision 0, dated June 1996, Paragraph requires that supervisors and others performing call-outs inquire and document if the person called to work unscheduled overtime has consumed alcohol within the five hour abstinence prior to reporting. The failure of the Fire Marshall when he directed the DFP

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to report to the site to ask if she had consumed alcohol within the five hour abstinence period is conaldered an example of an apparent violation of this procedure (eel 50 295/97017 02; 50 304/97017 02).

Corporate Nuclear Guideline 200, Revision 6 dated Fr,bruary 1996, Paragraph 5. requires that if an Individual is called to work unscheduled overtime, they must inform the person calling if they have consumed alcohol within the five hours prior to reporting to work. The failure of the DFW to inform the Fire Marshall that she had been drinking alcohol when he told her to go in is an example of an apparent violation of this procedure (eel 50 295/97017-03; 50 304/97017 03). Conclusions Three apparent violations were identified. The Director of Fire Protection was not for-cause tested after being observed and confirmed to smell of alcohol inside the PA. The Fire Marshall failed to ask the Director of Fire Protection whether alcohol had been consumed within the previous five hours. The Director of Fire Protection failed to inform the Fire Marshall that alcohol had been concumed within five hours. These violations collectively demonstrate a lack of supervisory implementation of the FFD program which caused an individual who was admittedly drinking to enter the protected area. Although the direct safety impact of this Incident was small, the potential consequences were significan S1.3 Emolovee Performance - Communication of FFD ViQlallQas to Suoervisors

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On June 13,1997, the licensee made a required twenty-four hour FFD report to the NRC relating to the failure to conduct a required for cause test on June 12,1997. The inspectors conducted an onsite review of this incident which included interviews and a review of records. The inspectors also reviewed the licensee's corporate security investigation report related to the even b.- Qbservations and Findinos On June 12,1997, at approximately 3:30 p.m., a licensee employee (Employee A)

detected the odor of alcohol on the breath of a contract employee (Contractor B).

Employee A left Contractor B and rel.ited this observation to another licensee employee (Employee C) who told him that "he should do something about It". Employee A then sought out and found Contractor B and told him that he should call Security and get FFD tested and left. Contractor B thought Employee A was joking because he did not escort

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him nor notify a supervisor. Within a few minutes, Contractor B left the site at his nonnal quitting time without being tested. The licensee discovered this event later when Employee A called a security supervisor to inquire about the results of the FFD tes The security supervisor realized that a problem had occurred, because no one had been tested, and reported i __ _ _________ _____-

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Corporate Nuclear Guideline No. 200, Revision 0 dated June 1990, paragraph 5. requires that individuals report to their supervisor instances of violation of the Fitness For Duty policy and/or procedures which might adversely impact safe operation and maintenance of the station. Employee A did not advise his supervisor of his observation concerning the odor of alcohol on Contractor Additional examples of this type were identifie During the licensee's follow-up investigation of the June 12th incident, Employee A stated that on two other occasions he smelled the odot cf alcohol on coworkers and had not advised his supervisor of those observations. The first occurrence happened sometime between September 15 and Christmas 1990. Employee A was not cerialn of the exact date of the first occurrence but only recalled that it was sometime between September 15 and Christmas 1996 and involved a work controller. Employee A stated that he smelled what he believed to be alcohol on the person and spoke to the worker about the odor but did not discuss it with anyone els Employee A stated that the second incident occurred on March 11,1997 during a General Station Emergency Plan (GSEP) activation. While in the onsite Technical Support Center (TSC) he smelled, what he described as a significant amount of alcohol on the breath of the Emergency Response Coordinator (ERC). In this Instance, Employee A told the ERC that he smelled alcohol and the ERC responded that he would go for testing. Employee A did not advise his supervisor of this observation. (See paragraph S1.4 for details).

The employee's (employee A and C) failure to notify their supervisors of violations of the licensee's FFD policy are considered examples of apparent violations of Corporate Nuclear Guideline 200, Paragraph 5.6.1 (eel 50-295/97017-04; 50 004/97017 04). The failure to report the violations precluded supervisors from acting in a timely manor when the concerns were identified. Those actions would include escorting the individual until the concern was sat lsfactorily resolved or until the individual left the protected area and removing the individual from work activities if their fitness was questionable, Conclusions Examples of violations of the FFD program were identified when the odor of alcohol was identified on a person in the PA and a supervisor was not notified. The ERC failed to report a violation of the FFD Program. An appropriate for-cause test was not completed. These violations demonstrate the cascadir? affect of individuals failure to properly implement the FFD procedures. A comprehensive for cause test was not conducted, for example, because an individual failed to notify his superviso Collectively, these events also represent a programmatic failure of the FFD program to provide reasonable assurance that those entering the PA unescorted are fi __ -.- - - .... _

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S1.4 Protected Area Entrv Without FFD Test Followina CQatumDtion of Alcohol

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insoection Scooe (81502)

, The inspectors followed up on a FFD incident which occurred on March 11,1997 This

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incident was first identified by the licen6ee during the investigation of the June *,0,199 This was the second FFD incident noted in the previous section (S1.3.b.). The

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l Inspectors reviewed the licensee's investigation report and interviewed the key individuals involved. During the licensee's interview with Employee A relating to the

. June 12,1997 FFD incident, he stated that he had handled the smell of alcoholin the PA in a similar manner on March 11,1997.

! Observat!ons and Findinas l On March 11,1997, the loss of off sMe power for Unit 1 and a loss of telephone communications prompted a Work Week Planner (WWP) to telephone the Emergency j Response Coordinator (ERC) at home at approximately 5:25 p.m. They were surprised to discover that the ERC had not yet been informed that the plant had initiated an

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emergency response. Additionally, they discussed the need to solve the problem of the

, telephone system being degraded. The ERC stated that he knew how to correct the proble .'

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In discussions with the inspectors, the WWP stated that he did not specifically request the ERC to come in and did not consider the telephone call to be a ' call out." He did

, not direct the ERC to report to the site, but did state that he was surprised that the ERC l was not called in because of his knowledge of the communication syste '

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The ERC stated that the loss of communications was on his mind and he decided to go to the site to make sure the phones were working and was onsite within forty five minutes. The ERC said that he entered the PA knowing that he had consumed alcohol

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within the past five hours. He stated that he proceeded to the phone room and then

went to the Technical Support Center (TSC), He estimated that he was in the protected area for approximately twenty minutes. While in the TSC, he stated that it came to his

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mind that he should be FFD tested because he had several beers at home prior to (within five hours) the phone call from the WWP, and was planning to do that. While he

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was in the TSC the ERC met Employee A (Paragraph S1.3) who stated that he smelled alcohol on the ERC's breath and that he should go and get teste The ERC stated that after completing the TSC activities, he left the protected area and requested a test for alcohol. He told the security guards in the gatehouse that he needed an alcohol test because he had a few drinks. (The Security Shift Supervisor told the inspectors that he documented that WWP had called and requested a FFD test for the ERC.) The security staff, who administered the breath analyzer test, believed this to

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be a voluntary test for a person entering the PA. Consequently, no drug urinalysis was conducted, as would be required during a for cause test. The SSS stated that he escorted the ERC to the in processing center, which is outside the PA, where a breath

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alcohol test was conducted. The test results of .036% blood alcohol concentiation

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. (BAC) were slightly below the licensee's cutoff level of .04% BAC. This fact was communicated to management and the individual re-entered the protected area. During their review of this incident, the licensee completed an informal test results extrapolation from the time the individual entered and protected area until he was tested and determined that he would have probably excoeded the cutoff level for alcohol had the test been done upon site arrival as required by procedur Corporate Nuclear Guideline No. 200, Revision 6 dated June 1996, Paragraph requires that each Individual who volun'arily comes to work at a time outside of his/her normal work hours should not have consumed alcohol within '.he five hour period prior to coming to work, and if alcohol has been consumed, the Individual must request an alcohol test upon site arrival. This matter will be reviewed furthe Conclusions The ERC entered the PA after consuming alcohol within the fi"o hour abstinence period without being tested as require *

S3 Fitness for Duty Procedures and Documentation S Evaluation of Procedures Insoection Scoce f81502)

The inspectors reviewed Zion Administrative Procedure (ZAP) 1130-00,* Commonwealth Edison Fitness for Duty Program", Revision 3 dated April 1995 and the Corporate Nuclear Security Guldelines" both of which implement the licensee's FFD Policy to determine if any procedure adherence or adequacy problems existe Observations and Findings On March 14,1997, the security staff wrote PIF 97-1414 documenting that in the previous six weeks there had been three separate incidents (one of which was the February 1,1997 fire watch incidein)in which management personnel had not followed

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the requirements of ZAP 1130-00. A " root cause" investigation responding to the PIF identified that the ZAP 1130-00 was " lacking in substance and content", was not " user friendly", and that the procedure as a whole left one with "more questions than answers". The root cause investigation also noted that relevant information contained in the applicable CNSGs was not included in the procedure. Most departments did not have these procedures available for us The inspectors identified deficiencies with procedural adequacy relative to the FFD events described in this report. ZAP 1130-00 did not address acticas upon the detection of the odor of alcohol, call / outs for unscheduled work, or voluntary reporting to work after having consumed alcoho: within the five hour abstinence period. These subjects were adequately addressed in the CSNGs but as noted in the root cause

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investigation, CNSGs were not readily available to most employees, inspector interviews with the employees involved in the March and June 1997 FFD events indicated that the guidance in ZAP 1130 was not adequate to addre;s the issue of detection of odor of alcoho Conclusions The inspectors concluded that the FFD guidance in ZAP 1130 was ineffective and may have caused the failure of an employee to take appropriate action, contributing to the March 11 and June 12 event S7 Quality Assurance in FFD Activities S7.1 Event Precursors and Previous Corrective Actions Insoection Scoce (81502)

The Inspectors rev!ewed the licensee's quality assurance audits to determine if there were precursor events and if management had corrected the underlying problems which contributed to these events, Observations and Findings Site Quality Verification (SQV) audit (QAA 22-96-02) conducted during the period of March 18,1996 through April 2,1996, identified that the requirements for unscheduled worker call outs were not met and issued a Level ll finding ' CAR 22 96-006). This finding related to the discovery that several' call-out" forms had not been annotated to indicated that the required FFD questions regarding alcohol use during the preceding five hours were asked or answered. The audit seemed to focus on the failure to complete the forms rather than on the implementation of the FFD program. The finding could have resulted in further questioning relating to the actual determination of the fitness of those being called in. A Corrective Action Request (CAR) was issued to cause corrective actions to be completed, in January 1997, the status of the CAR was elevated to a level B because of ineffective corrective actions taken to resolve this issue. The licensee's staff identified that corrective action had been ineffective because the problem was continuing to be identifie Later, SQV conducted the next regular annual aud;t February 319,1997 (QAA 97-01).

They found that the document problem appeared to be continuing, but further determined that the actual call outs for unscheduled work were not being performed in accordance with FFD procedures. Their interviews showed cases in which employees were called in but not asked the FFD questions. (Note: The FFD event involving the Director of Fire Protection (DFP) discussed in Section S1.a occurred on Februari 1, 1997).

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c, Gooclusions

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Due to ineffective actions and weak analysis of the evidence available, the licensee

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failed to correct the underlying problem which contributed to several FFD events. The licensee appeared to have indications of the potential problems that occurred, but did not recognize them and did not effectively correct them.

X1 Exit Meeting Summary

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l The inspectors presented the results of the inspection to members of licensee management at

, the conclusion of the inspection on September 22,1997. The licensee acknowledged the findings presented.

_ The inspectors acknowledged the licensee's request to withhold documents associated with the j conduct of this inspection as identified by Comed istters dated June 19 and June 26,1997,

, under the provisions of 10 CFR 2.790.

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PARTIAL LIST OF PERSONS CONTACTED Commonwgalth Edison Comoany S. DellaFave, Station Security Administrator R. Godley, Regulatory Assurance Manager

K. Hansing, Technical Specification Improvement Program Supervisor (Telephone)

J. Mueller, Site Vice President R. Starkey, Plant General Manager G. Vanderheyden, Operations Manager (Telephone)

M. Weis, Station Services Director U.S. NorJear Regulatorv Commistdga E. Cobey, Resident inspector, Zion Station A. Vegel, Senior Resident inspector, Zion Station INSPECTION PROCEDURES USED IP 81502 Fitness For Duty ITEMS OPENED, CLOSED, AND DISCUSSED ORfta 50 295/304 97017-01 eel Failure to perform for cause FFD tes /304 97017-02 eel Failure to ask FFD questions when unscheduled work call out was conducte /304 97017-03 eel Failure to advise supervisor of consumption of alcohol within abstinence perio /304 97017-04 eel Multiple instances of employees falling to advise supervisors of FFD violation Discussed or Clgted None

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LIST OF ACRONYMS USED BAC Blood Alcohol Concentration CAR Corrective Action Request CFR Code of Federal Regulations CNSG Corporate Nuclear Security Guideline Comed Commonwealth Edison DFP Director of Fire Prevention eel Escalated Enforcement item ERC Emergency Response Coordinator FFD Fitness For Duty FPS Fire Prevention Supervisor GS Generating Station Emergency Plan PA Protected Area

PlF Problem identification Form QAA Quality Assurance Audit SOV Site Quality Verification SSS Security Shift Supervisor TSC Technical Support Center WWP Work Week Planner ZAP Zion Administrative Procedure

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