IR 05000416/2023402

Security Baseline Inspection Report 05000416/2023402

ML23136B259
Person / Time
Site:	Grand Gulf
Issue date:	05/17/2023
From:	Ray Kellar NRC/RGN-IV/DRSS/PSB
To:	Kepellas B Entergy Operations
Kellar R
References
IR 2023402
Download: ML23136B259 (10)

Text

May 17, 2023

SUBJECT:

GRAND GULF NUCLEAR STATION - SECURITY BASELINE INSPECTION REPORT 05000416/2023402

Dear Brad Kepellas:

On April 6, 2023, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at Grand Gulf Nuclear Station and discussed the results of this inspection with you and other members of your staff. The results of this inspection are documented in the enclosed report.

One Severity Level IV violation without an associated finding is documented in this report. We are treating this violation as a non-cited violation (NCV) consistent with Section 2.3.2 of the Enforcement Policy.

No NRC-identified or self-revealing findings were identified during this inspection.

If you contest the violation or the significance or severity of the violation documented in this inspection report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:

Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; the Director, Office of Nuclear Security and Incident Response; and the NRC Resident Inspector at Grand Gulf Nuclear Station.

This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely, Ray L. Kellar, P.E., Chief Physical Security Branch Division of Radiological Safety & Security Signed by Kellar, Ray on 05/17/23 Docket No.05000416 License No.NPF-29

Enclosure:

As stated

Inspection Report

Docket Number:

05000416

License Number:

NPF-29

Report Number:

05000416/2023402

Enterprise Identifier:

I-2023-402-0004

Licensee:

Entergy Operation, Inc.

Facility:

Grand Gulf Nuclear Station

Location:

Port Gibson, MS

Inspection Dates:

April 03, 2023 to April 06, 2023

Inspectors:

D. Holman, Sr Physical Security Inspector

Approved By:

Ray L. Kellar, P.E., Chief

Physical Security Branch

Division of Radiological Safety & Security

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a security baseline inspection at Grand Gulf Nuclear Station, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.

List of Findings and Violations

Failure to Retain Required Records according to 26.713(a)(2).

Cornerstone Severity Cross-Cutting Aspect Report Section Not Applicable Severity Level IV NCV 05000416/2023402-01 Open/Closed Not Applicable 71130.08 The inspector identified a SLIV non-cited violation of 26.713(a)(2) for failure to maintain a record of the MRO's review of a positive drug test result.

Additional Tracking Items

None.

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2201, Security Inspection Program for Commercial Nuclear Power Reactors. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.

71130.08 - Fitness For Duty Program

The inspectors evaluated the fitness for duty program by completing the following inspection

elements: Fitness For Duty Program

(1) Tier I: All Requirements.

Tier II: 13 Requirements; 02.05 a - k, 02.06 a. and e.

Tier III: 3 Requirements; 02.10, 02.11 a; 02.13 a.

INSPECTION RESULTS

Failure to Retain Required Records according to 26.713(a)(2).

Cornerstone Severity Cross-Cutting Aspect Report Section Not Applicable Severity Level IV NCV 05000416/2023402-01 Open/Closed Not Applicable 71130.08 The inspector identified a SLIV non-cited violation of 26.713(a)(2) for failure to maintain a record of the MRO's review of a positive drug test result.

Description:

While reviewing selected FFD records on April 3, 2023, the inspector reviewed a file that contained 3 separate positive drug test results, all derived from the same unique urine specimen number. The inspector noted that the Medical Review Officer (MRO) had recorded the date and time, and some medical facts and conclusions, related to the second and third positive test results, but not the first positive test result. The inspector then reviewed licensee procedure EN-NS-102-03, Processing of Fitness for Duty Test Results, revision 0, section 7.3, NOTE box. The NOTE states, in part, "The MRO shall review all positive... test results from the HHS-certified laboratory to determine whether the donor has violated the Entergy Fitness for Duty Policy Statement before reporting the results to Entergy's designated representative. The review shall be documented on MRO Test Result Review Checklist (FF-052 and MRO Confirmed Chemical Test Form (FF-053) as applicable."

The inspector could see there was a positive test result returned from an HHS-certified laboratory on October 4, 2021, but could not locate the FF-052 or FF-053 forms to gain understanding of the MRO's reasoning associated with review of the positive test result. The inspector also searched the entirety of the record to see if there were any freehand type notes regarding the October 4, 2021 positive test result, in lieu of forms FF-052 and FF-053, but there were not.

The inspector noted this particular urine specimen, and FFD file, was associated with the MRO's determination that an FFD Policy violation had occurred and it resulted in a denial of unescorted access authorization. In response to the inspector's questions about the missing forms, the licensee provided a memo for record signed by the MRO indicating the review had been completed on October 5, 2021, including a discussion with the donor for possible alternative medical explanations for the positive result. The inspector determined, in addition to being out of compliance, the missing MRO review forms FF-052 and FF-053 impacted the NRC's ability to perform its regulatory oversight function of the licensee's FFD Program.

Corrective Actions: When notified of this violation the licensee entered this issue into the corrective action program for further analysis.

Corrective Action References: CR GGN-2023-02210

Performance Assessment:

The ROPs significance determination process does not specifically consider the regulatory process impact in its assessment of licensee performance. Therefore, it is necessary to address this violation which impedes the NRCs ability to regulate using traditional enforcement to adequately deter non-compliance. The inspector determined the missing MRO review forms FF-052 and FF-053 impacted the NRC's ability to perform its regulatory oversight function of the licensee's FFD Program. Specifically, had the inspector failed to notice the missing information, and not asked about it, verifying regulatory compliance related to how the specimen was reviewed would have been difficult without the memorandum for record the licensee created after the fact.

Enforcement:

Violation: Title 10, 26.185(a) states, in part, "The Medical Review Officer shall review all positive... test results from the HHS-certified laboratory to determine whether the donor has violated the FFD policy before reporting the results to the licensee's or other entity's designated representative."

Title 10, 26.713(a)(2), states, "Each licensee and other entity who is subject to this subpart shall retain the following records for at least 5 years after the licensee or other entity terminates or denies an individual's authorization or until the completion of all related legal proceedings, whichever is later: Records pertaining to the determination of a violation of the FFD policy and related management actions."

Contrary to the above, on approximately October 5, 2021, the licensee failed to retain, for at least 5 years, a record of the Medical Review Officer's review of a positive drug test result returned from an HHS-certified laboratory on October 4, 2021. Specifically, a Medical Review Officer's record of review of a positive drug test that resulted in the denial of an individual's authorization was not retained for at least 5 years after the licensee denied an individuals authorization.

T Enforcement Action: SL IV. When compared to examples in the NRC Enforcement Policy, Section 6.11, this issue did not exceed the significance of examples in 6.11.d. This violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.

EXIT MEETINGS AND DEBRIEFS

The inspectors verified no proprietary information was retained or documented in this report.

On April 6, 2023, the inspectors presented the security baseline inspection results to Brad Kepellas and other members of the licensee staff.

DOCUMENTS REVIEWED

Inspection

Procedure

Type

Designation

Description or Title

Revision or

Date

Corrective Action

Documents

Condition Report

GGN-2022-07417, GGN-2022-07992, GGN-2022-10148,

GGN-2022-10456,

GGN-2022-00467, GGN-2022-01672

Corrective Action

Documents

Resulting from

Inspection

Condition Report

HQN-2023-00442, HQN-2023-00443, HQN-2023-00462,

HQN-2023-00463,

HQN-2023-00464, GGN-2023-02210, GGN-2023-02211,

GGN-2023-02212,

GGN-2023-02213, GGN-2023-02214, GGN-2023-02224,

GGN-2023-02225

COC

Federal Drug Testing Custody and Control Form

Multiple

years/files

Department of

Health and

Human Services

MRO Guidance Manual for Federal Workplace Drug Testing

Programs

2018/2020

FF-000

Entergy's Nuclear Fitness for Duty Program Statement of

Policy

Revision 01

Form Entergy,

FF-052.

Tied to EN-NS-

2-03

MRO Test Result Review Checklist

Multiple

years/files

Form Entergy,

FF-053.

Tied to EN-NS-

2-03

Confirmed Chemical Test Notification

Multiple

years/files

Miscellaneous

NEI 03-01

Nuclear Power Plant Access Authorization Program

Revision 3

EN-NS-101-04

Processing Potentially Disqualifying Information (PDI)

Revisions 05

and 07

EN-NS-101-06

Terminating, Denial and Appeal of Unescorted Access

Authorization/Unescorted Access

Revision 08

EN-NS-102

Fitness For Duty Program

Revisions

21/25/27

71130.08

Procedures

EN-NS-102-01

Fitness for Duty Random and Follow-Up Testing Selection

Revision 02

Inspection

Procedure

Type

Designation

Description or Title

Revision or

Date

and Notification

EN-NS-102-02

Fitness for Duty Specimen Collection and Shipment

Revision 03

EN-NS-102-03

Processing of Fitness for Duty Test Results

Revisions

00/04