IR 05000397/1991032
| ML17286B240 | |
| Person / Time | |
|---|---|
| Site: | Columbia  |
| Issue date: | 12/27/1991 |
| From: | Norderhaug L, Reese J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | |
| Shared Package | |
| ML17286B239 | List: |
| References | |
| 50-397-91-32, NUDOCS 9201140021 | |
| Download: ML17286B240 (21) | |
Text
U. S.
NUCLEAR REGULATORY COMMISSION
REGION V
Report No:
50-397/91-32 License No:
NPF-21 Licensee:
'Washington Public Power Supply System P.
0.
Box 968 Richland, WA 99352 I
1991 nspectson Conduct
December 2 - 6, Facility Name:
Washington Nuclear Project, Number 2 (WNP-2)
Inspection at:
Richland, Washington Inspectors:
or er aug en'aterials Cont ol Analyst l2~7 g/
a e
gne Approved by:
am eese, ie Sa eg ds, Emergency Preparedness and Nonpower Reactor Branch
/zz7 Q a
e cygne Ins ection Summar
Areas Ins ected:
This announced inspection reviewed the licensee's Fitness or u y program in accordance with Temporary Instruction 2515/106.
The inspection included a review of the licensee's written policies and procedures; program administration and management support; employee awareness and understanding of the FFD program; training program; and key program processes.
Results:
Based upon selective examination of key elements of the licensee's FFD program, it has been concluded that the licensee is satisfying the general objectives of 10 CFR 26.
The licensee was found to be in compliance with NRC requirements within the areas examined.
Three strengths were identified in the licensee's FFD program:
the professionalism and technical expertise exhibited by personnel involved in administering the program, employee awareness and use of the Employee Assistance Program and the strong quality assurance program (Inspection Report Details, paragraphs 4. a, 4. h and 7, respectively).
However, two weaknesses were also identified in the areas of program direction and implementing procedures (Inspection Report Details, paragraphs 3 and 4.b, respectively).
9201140021 911227 PDR ADOCK 05000397
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REPORT DETAILS Ke Persons Contacted
- J. Bell, Manager, Plant Services
"D. Coody, Fitness for Duty Supervisor G. Denniston, Director, Human Resources
"L. Garvin, Manager, Programs and Audits
"J. Garza, Manager Safeguards 8 Compliance D.
Lowe, Hanford environmental Health Foundation D. Mazur, Managing Director
"M. Monopoli, Manager, Support Services
- T. Northstrom, Supervisor, Environmental Sciences
- A. Oxsen, Deputy Managing Director J.
Spencer, Supervisor, Data Entry, Hanford Environmental Health Foundation
- R. Steiner, Manager, Project Human Resources
"S. Telander, Manager, General Services
- A. Witt, Fitness for Duty Coordinator V. Yates, Medical Review Officer, Hanford Environmental Health Foundation
" Denotes those in attendance at the exit interview.
The inspector also interviewed other members of the licensee and contractor staffs, both supervisors and staff, during the course of this inspection.
Ins ection A
roach By letter dated August 19, 1991, the licensee was notified of the dates and scope of this inspection.
The licensee was requested to provide copies of policies, procedures, audits and reviews, and training material pertaining to the FFD program, which were reviewed in-office prior to the onsite inspection; Onsite inspection activities included interviews of the key individuals responsible for program implementation:
the Managing Director, the Deputy Managing Director, the Support Services Manager, the General Services Manager, the Human Resources Director, the Medical Review Officer (MRO), the FFD Supervisor, the FFD Coordinator, the Employee Assistance Program Coordinator, the Security Investigations Supervisor and members of the staff of the FFD Program, Employee Assistance Program, equality Assurance, and General Employee Training.
Additionally, the inspector interviewed 16 licensee and contractor employees and supervisors (approximately 3X of the persons in the random selection pool).
Written Policies and Procedures The licensee's written Fitness for Duty Policy is specified in the General Information Handbook, Procedure No. 4.2.4 as well as in summary booklets and pamphlets given to all employees.
The policy directive includes individual responsibilities and sanctions for use of drugs and
alcohol.
Interviews with employees indicated that the policy was understood.
The licensee's Supply System Directive No. 4.6 "Fitness for Duty", most recently revised May 8, 1991, is the basic procedure that addresses the organization and operation of the FFD program.
Additionally, the licensee has published supplements and implementing procedures related to the following individual program areas:
FFD responsibilities; Employee assistance; Continued behavioral observation; Unescorted access authorization; Appeals process; Records management and retention; Applicants, employees, and contractor drug and alcohol, screening; Specimen collection, handling and attempted tampering or refusing to cooperate; Selection, notification and backlog Tracking for random chemical testing; Procurement of Standard Solutions for BAC (Blood Alcohol Content) Datamaster; HRO notification of chemical. test results (including inquiry for 0.01 to 0.04 I BAC);
Preparation of blind samples for laboratory testing; and Although some shortcomings were noted, these written procedures generally provide adequate guidance to fulfill basic program requirements.
As noted in a recent program audit, the implementing procedures warrant additional attention.
Differences in organization and format, and the use of different terminology to represent the same concept or application could lead to misunderstandings and improper implementation.
The licensee s future actions to remedy this problem will be reviewed as a part of followup item 91-32-02 (See paragraph 7.d.(3) of this inspection report).
4.
Pro ram Administration and Hang ement Su ort Following are the inspector findings with respect to the administration of key elements of the licensee's FFD program.
a.
Delineated Res onsibilities The FFD program is organized to facilitate coordination among the various program elements.
Formerly located within the Human Resources Directorate, the program has recently been transferred to the Site Support Services organization.
The program includes the active involvement of the FFD Supervisor who is responsible for the key program elements of:
training, random selection, specimen collect>on, disciplinary actions, drug rehabilitation and FFD record ~'
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The FFD Supervisor reports directly to the Manager, Plant Services.
who, in turn, reports to the Manager General Services, the Manager, Support Services, and the Deputy Managing Director.
Interviews with these individuals confirmed that they are cognizant of their responsibilities.
The FFD Supervisor is provided assistance by the following support organizations:
o Training Department -- maintain training records for this and other plant programs, o
Security Department -- conduct the "suitable inquiries" of past FFD incidents required by 10 CFR 26, o
Medical Review Officer (MRO) and alternate MRO (members of the medical'staff of Hanford Health Services)--
evaluate testing results and prescribe medical treatment as appropriate, o
Human Resources Directorate administers the Employee Assistance Program, o
Corporate Licensing and Assurance -- conducts independent.
audits of the program.
A notable program strength was the professionalism and technical expertise of the staff )nvolved in operating the program.
b.
Mana ement Awareness of Res onsibilities Interviews with FFD program staff and selected supervisors employed by the licensee and by licensee contractors, reviews of implementing procedures, and discussions with licensee management, indicated that management at all levels is aware of its responsibilities under
CFR 26.
i Management's involvement in the FFD program is documented from early 1988.
A Fitness for Duty Employee Advisory Committed which included union stewards from both the International Brotherhood of Electrical Workers and the Oil, Chemical and Atomic Workers met at least monthly throughout much of 1988 and 1989 to resolve implementation issues prior, to the licensee's full compliance with
CFR 26 in January of 1990.
This "up front" confrontation of labor concerns appears to have been instrumental in generating the high degree of employee acceptance of the program observed by the inspector.
However, the unacceptably high turnover of program supervision was identified in a recent audit as warranting increased management attention.
The licensee's future actions to remedy this problem will be reviewed as a part of followup item 91-32-02 (See paragraph 7.d.(3) of this inspection report).
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Pro ram Resources The licensee has contracted the operation and supervision of their two collection facilities to Kadlec Hospital.
The facility onsite (but outside the protected area) is provided by the licensee and staffed with Kadlec Hospital personnel.
The second facility is collocated at a medical facility operated by the Kadlec Hospital in the city of Richland.
While both facilities are used for random test co1lections, the Richland facility is used primarily for pre-employment collections.
The onsite collection facility, used for the bulk of the random tests, is operated on an unannounced, random schedule encompassing all shifts, weekends, and holidays.
All collection personnel are employees of Kadlec Hospital and are organizationally independent of FFD program management.
Mana ement Monitorin of Pro ram Performance The FFD Supervisor exercises effective daily oversight of the program and maintains effective communications with the FFD program staff.
The licensee's six-month reports on program performance, indicate little substance abuse among its employees and those of its contractors.
Measures Undertaken to Meet Performance Ob 'ectives of the Rule The licensee has aggressively monitored and evaluated information concerning techniques that individuals may use to adulterate or otherwise subvert the chemical testing process.
The FFD supervisor coordinates the activities of the MRO (with respect to samples suspected of dilution) and the licensee's onsite analysis laboratory (for Enzyme Multiplied Immunoassay Technique (EMIT))
screening and the preparation of "blind" samples for monitoring the performance of the EMIT screening tests and the Mass Spectroscopy
-- Gas Chromatography (MS/GC) confirmatory analyses conducted by the HHS-certified laboratories.
Pro ram Testin Standards As negotiated between the licensee and local unions, the licensee's FFD program includes pre-access testing, for-cause testing, random testing, and follow-up testing as well as pre-employment testing.
The specific drugs tested for, and their cut-off levels, are identical to those described in 10 CFR 26.
Sanctions and A
eals The licensee's FFD program has established sanctions consistent with 10 CFR 26.27(b).
The sanctions apply to licensee and contract employee (1). On-Dut Alcohol Intoxication or Use of Ille al Dru s.
The
>rs con horme pos)
ive es resu s
sn a suspens>on of site access or other duties as defined in the Rule for a minimum of 14 days, referral to a Employee Assistance Program, subsequent review and evaluation by the Medical Review Officer (MRO), and follow-up testing for a minimum period of three years.
A second confirmed positive test for illegal drugs results in revocation of site access and removal from emergency operations activities covered by the Rule for a minimum of three years.
Any sale, offer of sale, and/or possession of illegal drugs for sale, either on-duty or off-duty, results in removal for a minimum of five years.
Persons removed for a period of three years or more may be granted unescorted access only if there is satisfactory medical assurance that the person has abstained from drugs for at least three years.
(2)
Off-dut Use of Alcohol.
Persons within the scope of 10 CFR
,
w o are summone o perform unscheduled work, must inform their supervisor if they have consumed alcohol w>thin the preceding five-hour period.
If so, a determination must be made of the person's fitness for duty by that person'
supervisor or manager.
Consumption of alcohol during the abstinence period does not, by itself, preclude use of individuals needed to respond to an emergency.
The MRO notifies the individual of a confirmed positive test result and offers an opportunity to discuss the results prior to notifying the FFD supervisor.
The licensee's HHS-certified laboratories are instructed by procedure, to hold an archive sample for later repeat analysis if the initial results are challenged.
h.
Em lo ee Assistance Pro ram (EAP)
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The licensee maintains an EAP that offers assessment, counseling, and referral services through both a 24-hour 800 telephone hotline and locally contracted counseling professionals.
The EAP services are available to employees and their immediate family.
Three free consultation visits are provided by the EAP; if additional counselling is needed, the initial series of visits can serve as the basis for documentinq the existence of a medical or emotional problem covered by the licensee's health insurance plan.
While the licensee's program is not available to contractor employees, contractors are strongly urged to establish their own EAP.
The inspector interviewed the company EAP coordinator and one of the local counselors and found both to be knowledgeable of the Rule FFD procedures and with the numerous local EAP services available to employees.
The inspector determined that the licensee would be informed of an employee whose condition constitutes a hazard to the plant, themselves or others, when the EAP counselor identifies such a situatio The inspector determined through interviews with randomly selected employees and contractors that the EAP is well accepted, highly utilized and strictly confidential.
The scope and utilszatlon of the program is considered a strength.
Trainin and Em lo ee Awareness/Acce tance of the.FFD Pro ram The inspector selectively reviewed the licensee's lesson plans, records of supervisor training, and videotape training programs used for both initial as well as annual refresher training, Although continued behavioral observation (CBO) training is required only for supervisors, the licensee recently expanded the general employee training to include CBO as well.
The inspector interviewed 16 individuals subject to the licensee's FFD program.
These personnel were randomly selected by the inspector from the licensee's computer list of individuals in the random selection pool and included licensee and contractor, permanent and temporary, male and female, supervisors and staff.
Several of the individuals.had been randomly selected for testing more than once but some had yet to be selected for a first time.
None of the individuals interviewed had themselves perceived nor heard of others speculating about "safe haven" times, jobs or associations.
Employees and contractor personnel interviewed were knowledgeable of the FFD program and the sanctions that would be taken in the event of a positive test result.
All expressed the opinion that the FFD program was acting as a deterrent for drug abuse and that management was serious about maintaining a drug-free work place.
The employees awareness and acceptance of the FFD program is a notable strength.
Re orted Fitness for Dut Events The inspector reviewed and identified no discrepancies in the FFD records for individuals that had previously been confirmed positive by the HRO for illegal use of drugs, and were presently enrolled in the licensee's FFD follow-up testing program.
The licensee is currently investigating an inconsistency between two HHS-certified laboratories for the analysis of a blind sample.
In April 1991, blind samples (originally thought to be free of opiates)
were sent to Lab of Pathology and Hedpath, the two HHS-certified laboratories being used at the time.
Hedpath reported opiates in the samples while Lab of Pathology apparently correctly reported the sample to be opiate-free.
Mien the licensee's onsite ENIT analysis similarly indicated opiate presence, an investigation into the manner of preparing the sample was initiate ) I'
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The licensee prepares their own blind samples using as a source of
"clean urine" the stored samples for which the EMIT screening analytical results were negative and no referral to the HHS-certified laboratories was warranted.
In this case, the investigation disclosed that the sample, used as the supposedly opiate-free blind, had been declared
"negative" on the basis that the results did not exceed the threshold concentration established by procedure (See paragraph 4.f of this inspection report).
The sample actually contained opiates; albeit, in concentrations less than the EMIT threshold concentrations, which could precipitate a positive MS/GC result dependinq on specific procedure variations in use at HHS-certified laboratories.
Dr. Larry Howard of Bensinger, DuPont and Associates, under contract to the licensee, and the two HHS-certified laboratories involved are reviewing the analytical records and laboratory procedures to explain the discrepancy.
Inadequate mixing of what was thought to be a clean sample, or low efficiency in either the hydrolysis or extraction steps in Lab of Pathology's analytical procedure have been identified as possible contributors to the discrepancy.
Until the matter is resolved, the licensee is routinely sending all samples identified as positive by the onsite EMIT laboratory to two HHS-certified laboratories and is monitoring the results for any disparity between the results.
The licensee's further actions to resoive this discrepancy will be reviewed in the course of a future inspection.
(91-32-01)
7.
Ke Pro ram Processes a.
Selection and Notification for Testin The licensee's selection and notification process appears to be carried out in a manner that meets the objectives of 10 CFR 26.
A list of individuals for random testing is generated by a computer on an unannounced basis, from a pool of all individuals with unescorted access to the site or emergency related jobs as outlined in 10 CFR 26.
Approximately 2X of the pool population is selected per week for 104K per year (less the end-of-year backlog discussed below).
The schedule of testing is also randomly determ)ned but occasionally modified to assure adequate coverage of all shifts, weekends, Holidays and the day following Holidays.
The random pools are updated daily from personnel action records and site unescorted access authorization changes.
No category of personnel, are routinely excluded from being tested when selected.
Individuals selected for random testing, who are not at the site or corporate office or are otherwise unavailable for a legitimate reason, are placed on a backlog list to be tested during the next occasion for random testing.
If a person on the backlog list is randomly selected a second time, prior to having been tested, his name is tallied again -- to be subsequently removed from the list, one test at a time.
For example, a person whose name had been randomly, selected three times since he was last available for test would, on this basis, be tested on each of the next three available dates for random testing.
If needed a special collection date is established, primarily to "work off" the backlog and to assure that
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the testing rate is consistent with the required lOOX per year.
By virtue of the fact that the schedule for random testing is unannounced, and purposely scheduled to reduce the backlog or otherwise assure no
'safe haven" shifts, the scheduling of special collection dates does not appear to effect the credibility of the program.
Notification of employees selected for random testing is conducted by a member of the FFD staff directly to the selected employee's supervisor who, in turn, notifies the employee.
The notification is documented by an appointment slip directing the individual to report to the collection facility at a preset time (within 1 to
hours).
b.
Collection and Processin of S ecimens (j.)
Collection of S ecimens For Plant Em lo ees.
The inspector con uc e
a wa roug o
e proce ures for collection and processing of,a specimen.
The licensee has two collection facilities in operation.
Mhile the facility onsite normally processes only one person at a time, it is sufficiently spacious to allow processing two individuals with augmented collection staff.
This facility is primarily utilized to conduct tests of employees that were randomly selected.
The second facility located in the. city of Richland is primarily used for pre-employment testing and is similarly capable of processing more than one individual at a time if necessary.
The layout of both facilities is conducive to monitoring individuals as they proceed through the collection process.
Access to the facilities is well controlled by collection personnel.
Both facilities provide adequate security for specimens, collection equipment, and records.
Both facilities have implemented effective measures to prevent subversion of specimens.
No sources of clear water are available in the collection booth (blue dye is manually added to the toilet bowl prior to each use)
and the sink area, used for hand washing, is easily visible to the technician performing the specimen examination, sealing, and documentation function.
Despite the temporary quarters for the Richland facility (which is also used for storage of Kadlec Hospital supplies),
both facilities were well stocked with necessary supplies and maintained excellent housekeeping practices.
The collection site personnel appeared to have a
thorough knowledge of specimen collection procedures, (2)
Processin of S ecimens.
Upon collection of specimens, the icensee orwar s one of the three individually sealed aliquots to the onsite screening laboratory for EMIT analysis.
If positive a second sample (referred to as a "presumptive positive") is normally sent, via air-express, to their primary HHS-certified laboratory.
Upon testing, the laboratory
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notifies the MRO of the results of all tests.
If positive, the MRO then requests that the third specimen be sent to a second different HHS-certified laboratory for confirmation.
By procedure, both HHS-certified laboratories hold a portion of the specimen as an archived sample for later use if the analysis is challenged.
Pending resolution of the investigation discussed in paragraph 6, all presumptive ositives are routinely sent to both HHS-certified aboratories for confirmation.
(3)
Collection of S ecimens for FFD Staff.
Since the collection aci
> res are ou s)
e e pro ec e
area, the contracted Kadlec persons who staff and supervise the collection facility do not have unescorted PA access.
These personnel are also organizationally independent (neither subordinates nor co-workers) of the licensee's FFD staff.
However, since the onsite EMIT screening laboratory is operated by the licensee and could potentially be subject performance abuses, all samples collected from FFD staff are, by procedure, declared to be presumptive positives and are immediately sent for confirmation.
c.
Develo ment Use and Stora e of Records A system of files and procedures to document the program and to protect personal information has been developed.
The inspector examined the security and contents of the fHes and found them to be adequately secure and current.
Access to sensitive information is limited to individuals with a need-to-know.
Additionally, chain-of-custody procedures appear to be followed at all times.
d.
A~dit d
In addition to the pre-award audits of the HHS-certified laboratories, the licensee has completed the following program audits.
In all cases, the audit findings had been reported and acknowledged by appropriate levels of management.
(1)
The licensee conducted an initial audit of the FFD program in December 1989, prior to formal program implementation.
This audit included a review of 10 CFR 26, assuring that their procedures complied with the requirements of the rule, then verifying the implementation of these requirements in the FFD program.
(2)
In September 1990, the licensee contracted with Bensinger, DuPont and Associates to conduct an audit of the FFD program.
This audit consisted of a review of Corporate policies and procedures, training, chemical testing and medical review rograms and contractor FFD programs as they relate to the icensee's site.
During this audit, the two HHS-certified laboratories being used at the time (Lab of Pathology, Seattle, Washington and Medpath, Teterboro, New Jersey)
were
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also evaluated.
Medpath was subsequently replaced by MedTox, St.
Paul, Minnesota because of slow turnaround times for the
.
New Jersey laboratory.
(3)
The most recent licensee audit, Corporate Licensing and Assurance Audit 91-553, was conducted in two phases; the first phase, in May 1991, again by Bensinger, DuPont and Associates, reviewed specifically, the onsite EMIT Laboratory, the Medical Review Officer function and the operation of the collection facilities.
Phase 2 which concentrated on remaining program activities and procedures was completed in November 1991.
The inspector discussed with the audit team leader, the several problem areas identified in the course of this audit and the corrective actions taken to date.
They had issued 23 equality Finding Reports, attributed by the audit team to:
a lack of training, a lack of supervisory review and inadequate procedures.
While the licensee's corrective actions appeared appropriate, the effectiveness of those implemented as a result of the most recent audit and the planned review of the FFD procedures will be evaluated in the course of a future inspection.
(91-32-02)
8.
Entrance and Exit Interviews The inspector met with the licensee representatives on December 2, 1991, to review the scope and schedule of the inspection.
On December 6,
1991, at the conclusion of the site visit, the inspector met with the licensee representatives identified in paragraph 1 above to summarize the scope and the preliminary results of thss inspection.
The inspector concluded that the FFD program had been effectively developed, implemented, and monitored, and was meeting the general performance objectives of 10 CFR 26. 10.
The inspector summarized the strengths and weaknesses identified in the preceding paragraphs.
He noted that these and the several findings of Corporate Licensing and Assurance Audit 91-553 would be reviewed in the course of a future inspection to assess the effectiveness of corrective actions currently underwa i)
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