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Category:Inspection Report
MONTHYEARIR 05000483/20230042024-01-19019 January 2024 Integrated Inspection Report 05000483/2023004 IR 05000483/20230102023-11-15015 November 2023 NRC License Renewal Phase 1 Inspection Report 05000483 2023010 IR 05000483/20233012023-11-0909 November 2023 NRC Examination Report 05000483-2023301 ML23293A2652023-10-24024 October 2023 3rd Quarter 2023 Integrated Inspection Report IR 05000483/20240122023-10-24024 October 2023 Information Request for the Cybersecurity Baseline Inspection, Notification to Perform Inspection (05000483/2024012) IR 05000483/20234012023-09-13013 September 2023 NRC Security Baseline Inspection Report 05000483/2023401 IR 05000483/20230052023-08-23023 August 2023 Updated Inspection Plan for Callaway Nuclear Power Plant, Unit 1 (Report 05000483/2023005) - Mid Cycle Letter 2023 IR 05000483/20230022023-07-10010 July 2023 Integrated Inspection Report 05000483/2023002 IR 05000483/20230112023-06-15015 June 2023 Comprehensive Engineering Team Inspection (CETI) Inspection Report 05000483/2023011 ML23122A3172023-05-0808 May 2023 Review of the Spring 2022 Steam Generator Tube Inservice Inspections IR 05000483/20230012023-04-12012 April 2023 Integrated Inspection Report 05000483/2023001 IR 05000483/20234022023-03-29029 March 2023 NRC Security Baseline Inspection Report 05000483/2023402 IR 05000483/20220062023-03-0101 March 2023 Annual Assessment Letter for Callaway Plant (Report 05000483/2022006) ML23019A0802023-01-19019 January 2023 Notification of Comprehensive Engineering Team Inspection (05000483/2023011) and Request for Information IR 05000483/20220042023-01-12012 January 2023 Integrated Inspection Report 05000483/2022004 IR 05000483/20220132022-11-15015 November 2022 Design Basis Assurance Inspection (Programs) Inspection Report 05000483/2022013 IR 05000483/20220032022-10-17017 October 2022 Integrated Inspection Report 05000483/2022003 IR 05000483/20220102022-10-12012 October 2022 Biennial Problem Identification and Resolution Inspection Report 05000483-2022010 - Draft IR 05000483/20224032022-09-27027 September 2022 Security Baseline Inspection Report 05000483/2022403 IR 05000483/20220052022-08-23023 August 2022 Updated Inspection Plan for Callaway Plant (Report 05000483/2022005) IR 05000483/20224022022-08-11011 August 2022 NRC Security Inspection Report 05000483/2022402 (Cover Letter Only) IR 05000483/20220112022-08-0202 August 2022 Triennial Fire Protection Inspection Report 05000483 2022011 IR 05000483/20220022022-07-27027 July 2022 Integrated Inspection Report 05000483/2022002 ML22157A0572022-06-0606 June 2022 Notification of NRC Design Bases Assurance Inspection (Programs) (05000483/2022013) and Request for Information IR 05000483/20220402022-05-0606 May 2022 95001 Supplemental Inspection Report 05000483/2022040 and Follow-Up Assessment Letter IR 05000483/20224012022-05-0505 May 2022 Cyber Security Inspection Report 05000483/2022401 IR 05000483/20220012022-04-26026 April 2022 Integrated Inspection Report 05000483/2022001 IR 05000483/20223012022-04-12012 April 2022 NRC Examination Report 05000483/2022301 ML22082A2012022-03-28028 March 2022 Notification of an NRC Fire Protection Baseline Inspection (NRC Inspection Report 05000483/2022011) and Request for Information IR 05000483/20224042022-03-24024 March 2022 Final Security Baseline Inspection Report 05000483/2022404 (Letter) IR 05000483/20210062022-03-0202 March 2022 Annual Assessment Letter for Callaway Plant (Report 05000483/2021006) IR 05000483/20210042022-01-0707 January 2022 Integrated Inspection Report - 05000483/2021004 IR 05000483/20210032021-11-0808 November 2021 Integrated Inspection Report 05000483/2021003 IR 05000483/20214202021-10-29029 October 2021 NRC Security Baseline Inspection Cover Letter 050004832021420 IR 05000483/20214022021-10-26026 October 2021 Security Baseline Inspection Report 05000483/2021402 IR 05000483/20210052021-09-0101 September 2021 Mid-Cycle Inspection Plan Transmittal Letter for Callaway Plant (Report 05000483/2021005) IR 05000483/20210022021-08-0505 August 2021 Integrated Inspection Report 05000483/2021002 and Independent Spent Fuel Storage Installation Report 07201045/2021001 IR 05000483/20214012021-05-26026 May 2021 Security Baseline Inspection Report 05000483/2021401 IR 05000483/20210012021-05-11011 May 2021 Integrated Inspection Report 05000483/2021001 IR 05000483/20214032021-04-15015 April 2021 Material Control and Accounting Program Inspection Report 05000483-2021403 (Public) IR 05000483/20200042021-02-0909 February 2021 CWY2020004-RP-DSB, Callaway Plant - Integrated Inspection Report and Assessment Follow-Up Letter (05000483/2020004) IR 05000483/20200032020-11-0202 November 2020 Integrated Inspection Report 05000483/2020003 IR 05000483/20204112020-10-27027 October 2020 Security Baseline Inspection Report 05000483/2020411 IR 05000483/20203012020-10-13013 October 2020 NRC Examination Report 05000483/2020301 IR 05000483/20200052020-09-0101 September 2020 Updated Inspection Plan for Callaway Plant (Report 05000483/2020005) IR 05000483/20200022020-07-29029 July 2020 Integrated Inspection Report 05000483/2020002 IR 05000483/20200102020-06-12012 June 2020 Biennial Problem Identification and Resolution Inspection Report 05000483/2020010 IR 05000483/20204102020-04-24024 April 2020 NRC Security Inspection Report 05000483/2020410 IR 05000483/20200012020-04-20020 April 2020 Integrated Inspection Report 05000483/2020001 IR 05000483/20200112020-04-15015 April 2020 Design Basis Assurance Inspection (Teams) Inspection Report 05000483/2020011 2024-01-19
[Table view] Category:Letter
MONTHYEARULNRC-06853, Submittal of 2023 Fitness for Duty Performance Data Per Per 10 CFR 26.7172024-01-29029 January 2024 Submittal of 2023 Fitness for Duty Performance Data Per Per 10 CFR 26.717 IR 05000483/20230042024-01-19019 January 2024 Integrated Inspection Report 05000483/2023004 ML24008A0552024-01-19019 January 2024 Acceptance of Requested Licensing Action - Proposed Alternative to the Requirements of the ASME Code (EPID L-2023-LLR- 0061) ML23353A1712024-01-18018 January 2024 Issuance of Amendment No. 237 to Clarify Support System Requirements for the Residual Heat Removal System and Control Room Air Conditioning System Under Technical Specifications 3.4.8, 3.7.11, and 3.9.6 ML23317A0012024-01-12012 January 2024 Audit Summary Regarding LAR to Clarify Support System Requirements for the Residual Heat Removal and Control Room Air Conditioning System Under Technical Specifications 3.4.8, 3.7.11, and 3.9.6 ML23347A1212024-01-11011 January 2024 Issuance of Amendment No. 236 to Adopt TSTF-501, Revision 1, Relocate Stored Fuel Oil and Lube Volume Values to Licensee Control EPID L-2023-LLA-0046) ML24011A1492024-01-11011 January 2024 Notification of Post-Approval Site Inspection for License Renewal and Request for Information (05000483/2024011) ULNRC-06847, Supplement to Relief Request from Requirements of ASME BPV Code, Section XI, Subsection Iwl Regarding Examination and Testing of the Unbonded Post-Tensioning System (Relief Request C3R-01)2023-12-21021 December 2023 Supplement to Relief Request from Requirements of ASME BPV Code, Section XI, Subsection Iwl Regarding Examination and Testing of the Unbonded Post-Tensioning System (Relief Request C3R-01) ULNRC-06849, License Renewal Resolution for Commitments 34 and 35 Perform Evaluation of Crack Initiation and Propagation in Steam Generator Divider Plate and Tube-To-Tubesheet Welds2023-12-20020 December 2023 License Renewal Resolution for Commitments 34 and 35 Perform Evaluation of Crack Initiation and Propagation in Steam Generator Divider Plate and Tube-To-Tubesheet Welds ML23346A0392023-12-14014 December 2023 Supplemental Information Needed for Acceptance of Requested Licensing Action Request for Relief from Requirements of ASME Code, Section Xl, Examination and Testing Unbonded Post-Tensioning System ULNRC-06844, Request for Exemption from Specific Requirements in 2023 Security Rule, Enhanced Weapons, Firearms Background Checks, and Security Event Notification2023-12-0707 December 2023 Request for Exemption from Specific Requirements in 2023 Security Rule, Enhanced Weapons, Firearms Background Checks, and Security Event Notification 05000483/LER-2023-001, Submittal of LER 2023-001-00 for Callaway, Unit 1, Inoperable Instrument Tunnel Sump Level Indication Resulted in Condition Prohibited by Technical Specifications2023-11-29029 November 2023 Submittal of LER 2023-001-00 for Callaway, Unit 1, Inoperable Instrument Tunnel Sump Level Indication Resulted in Condition Prohibited by Technical Specifications ULNRC-06827, Supplement to License Amendment Request Regarding Support System Requirements for Residual Heat Removal and Control Room Air Conditioning Systems Under Technical Specifications 3.4.8, 3.7.11, and 3.9.6 (LDCN 22-0029)2023-11-20020 November 2023 Supplement to License Amendment Request Regarding Support System Requirements for Residual Heat Removal and Control Room Air Conditioning Systems Under Technical Specifications 3.4.8, 3.7.11, and 3.9.6 (LDCN 22-0029) IR 05000483/20230102023-11-15015 November 2023 NRC License Renewal Phase 1 Inspection Report 05000483 2023010 IR 05000483/20233012023-11-0909 November 2023 NRC Examination Report 05000483-2023301 ML23311A2082023-11-0909 November 2023 Reassignment of U.S. Nuclear Regulatory Commission Branch Chief in the Division of Operating Reactor Licensing for Plant Licensing Branch IV ML23297A2502023-11-0606 November 2023 Individual Notice of Consideration of Issuance of Amendment to Renewed Facility Operating License, Proposed No Significant Hazards Consideration Determination and Opportunity for a Hearing (EPID L-2022-LLA-0176) - Letter IR 05000483/20240122023-10-24024 October 2023 Information Request for the Cybersecurity Baseline Inspection, Notification to Perform Inspection (05000483/2024012) ML23293A2652023-10-24024 October 2023 3rd Quarter 2023 Integrated Inspection Report ML23240A3692023-10-0505 October 2023 Issuance of Amendment No. 235 to Revise Technical Specifications to Use of Framatome Gaia Fuel (EPID L-2022-LLA-0150) (Non-Proprietary) ML23234A1522023-10-0505 October 2023 Exemption from the Requirements of 10 CFR Part 50, Section 50.46, and Appendix K Regarding Use of M5 Cladding Material (EPID L-2022-LLE-0030) (Letter) ML23305A0942023-10-0202 October 2023 10-CW-2023-09 Post-Exam Submittal ML23270B9662023-09-27027 September 2023 10 CFR 50.55a(z)(I) Request for Relief from ASME OM Code Pump and Valve Testing Requirements for Fifth 120-Month Inservice Testing Interval ML23228A0252023-09-25025 September 2023 Issuance of Amendment No. 234 to Revise Technical Specification 5.5.16, Containment Leakage Rate Testing Program, for Permanent Extension of Type a and Type C Leak Rate Test Frequencies ML23261C3852023-09-25025 September 2023 Safety Evaluation for Operating Quality Assurance Manual Revision 36A ML23166B0882023-09-20020 September 2023 Issuance of Amendment No. 233 for Adoption of Alternative Source Term and Revision of Technical Specifications ML23206A1992023-09-15015 September 2023 Regulatory Audit Summary Regarding License Amendment and Regulatory Exemptions Request for Fuel Transition to Framatome Gaia Fuel (Epids L-2022-LLA-0150 and L-2022-LLE-0030) IR 05000483/20234012023-09-13013 September 2023 NRC Security Baseline Inspection Report 05000483/2023401 ML23240A7572023-08-31031 August 2023 NRC Initial Operator Licensing Examination Approval 05000483/2023301 IR 05000483/20230052023-08-23023 August 2023 Updated Inspection Plan for Callaway Nuclear Power Plant, Unit 1 (Report 05000483/2023005) - Mid Cycle Letter 2023 ULNRC-06824, Response to Request for Additional Information Regarding Operating Quality Assurance Manual (Oqam) Revision 36A2023-08-17017 August 2023 Response to Request for Additional Information Regarding Operating Quality Assurance Manual (Oqam) Revision 36A ML23219A1392023-08-15015 August 2023 Request for Withholding Information from Public Disclosure ULNRC-06830, Transmittal of Updated Technical Specification Markup and Clean Pages for License Amendment Request to Revise Technical Specification 5.5.16, Containment Leakage Rate Testing Program, for Permanent Extension of Type a and Type C Leak2023-08-15015 August 2023 Transmittal of Updated Technical Specification Markup and Clean Pages for License Amendment Request to Revise Technical Specification 5.5.16, Containment Leakage Rate Testing Program, for Permanent Extension of Type a and Type C Leak ML23215A1972023-08-0303 August 2023 Supplement to License Amendment and Exemption Request Regarding Use of Framatome Gaia Fuel (LDCN 22-0002) ULNRC-06223, Minor Correction to License Amendment Request to Revise Technical Specification 5.5.16, Containment Leakage Rate Testing Program, for Permanent Extension of Type a and Type C Leak Rate Test Frequencies (LDCN 2020-0004)2023-07-25025 July 2023 Minor Correction to License Amendment Request to Revise Technical Specification 5.5.16, Containment Leakage Rate Testing Program, for Permanent Extension of Type a and Type C Leak Rate Test Frequencies (LDCN 2020-0004) ULNRC-06799, Submittal of Licensee Event Report 2022-003-01, Class 1E Electrical Air Conditioning System Thermal Expansion Valve Failure Resulted in Condition Prohibited by Technical Specifications2023-07-13013 July 2023 Submittal of Licensee Event Report 2022-003-01, Class 1E Electrical Air Conditioning System Thermal Expansion Valve Failure Resulted in Condition Prohibited by Technical Specifications IR 05000483/20230022023-07-10010 July 2023 Integrated Inspection Report 05000483/2023002 ML23174A1272023-06-23023 June 2023 Cw FFD Document Request List 2023 ML23171A9942023-06-22022 June 2023 Acceptance of Request for Approval of Operating Quality Assurance Manual Revision 36a ULNRC-06821, Post-Audit Follow-Up Information in Support of Callaway'S License Amendment Request and Proposed Exemption to Allow Use of Framatome Gaia Fuel (LDCN 22-0002) (EPID L-2022-LLA-0150 and EPID L-2022-LLE-00301)2023-06-21021 June 2023 Post-Audit Follow-Up Information in Support of Callaway'S License Amendment Request and Proposed Exemption to Allow Use of Framatome Gaia Fuel (LDCN 22-0002) (EPID L-2022-LLA-0150 and EPID L-2022-LLE-00301) IR 05000483/20230112023-06-15015 June 2023 Comprehensive Engineering Team Inspection (CETI) Inspection Report 05000483/2023011 ULNRC-06822, Additional Information Regarding Request for NRC Approval of Operating Quality Assurance Manual (Oqam) Revision 36a2023-06-14014 June 2023 Additional Information Regarding Request for NRC Approval of Operating Quality Assurance Manual (Oqam) Revision 36a ML23158A1462023-06-13013 June 2023 Notification of Post-Approval Site Inspection for License Renewal and Request for Information Inspection (05000483/2023010) ULNRC-06815, Request for NRC Approval of Operating Quality Assurance Manual, Revision 36a2023-06-0505 June 2023 Request for NRC Approval of Operating Quality Assurance Manual, Revision 36a ULNRC-06818, Response to Request for Additional Information Regarding License Amendment Request to Revise Technical Specification 5.5.16, Containment Leakage Rate Testing Program, for Permanent Extension of Type a and Type C Leak Rate .2023-06-0505 June 2023 Response to Request for Additional Information Regarding License Amendment Request to Revise Technical Specification 5.5.16, Containment Leakage Rate Testing Program, for Permanent Extension of Type a and Type C Leak Rate . ML23093A0952023-05-10010 May 2023 Issuance of Amendment No. 232 Regarding Technical Specification Changes for Spent Fuel Storage ULNRC-06816, Withdrawal of Previously Submitted Enclosures Regarding License Amendment Request for Adoption of Alternative Source Term and Revision of Technical Specifications (LDCN 21-0015)2023-05-0909 May 2023 Withdrawal of Previously Submitted Enclosures Regarding License Amendment Request for Adoption of Alternative Source Term and Revision of Technical Specifications (LDCN 21-0015) ML23129A7942023-05-0909 May 2023 Post-Audit Supplement to License Amendment Request and Exemption to Allow Use of Framatome Gaia Fuel (LDCN 22-0002) (Iepid L-2022-LLA-0150 and EPID L-2022-LLE-0030) ML23122A3172023-05-0808 May 2023 Review of the Spring 2022 Steam Generator Tube Inservice Inspections ML23118A3492023-05-0808 May 2023 Request for Withholding Information from Public Disclosure 2024-01-29
[Table view] |
Text
September 13, 2023
SUBJECT:
CALLAWAY PLANT - SECURITY BASELINE INSPECTION REPORT 05000483/2023401
Dear Fadi Diya:
On August 21, 2023, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at Callaway Plant and discussed the results of this inspection with B. Brown, Security Manager, and other members of your staff. The results of this inspection are documented in the enclosed report.
One finding of very low security significance (Green) is documented in this report. This finding involved a violation of NRC requirements. We are treating this violation as a non-cited violation (NCV) consistent with Section 2.3.2 of the Enforcement Policy.
A licensee-identified violation which was determined to be of very low security significance is documented in this report. We are treating this violation as an NCV consistent with Section 2.3.2 of the Enforcement Policy.
If you contest the violations or the significance or severity of the violations 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 Callaway Plant.
The following cross cutting aspect was assigned to a finding using Inspection Manual Chapter 0310 Aspects Within Cross Cutting Areas: [P.6] - Self-Assessment.
If you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, 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 Nuclear Security and Incident Response; and the NRC Resident Inspector at Callaway Plant. 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, Signed by Kellar, Ray on 09/13/23 Ray L. Kellar, P.E., Chief Physical Security Branch Division of Radiological Safety & Security Docket No. 05000483 License No. NPF-30
Enclosure:
As stated
Inspection Report
Docket Number: 05000483 License Number: NPF-30 Report Number: 05000483/2023401 Enterprise Identifier: I-2023-401-0008 Licensee: Ameren Facility: Callaway Plant Location: Missouri Inspection Dates: August 14, 2023, to August 21, 2023 Inspectors: D. Holman, Sr Physical Security Inspector Approved By: Ray L. Kellar, P.E., Chief Physical Security Branch Division of Radiological Safety & Security Enclosure
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a security baseline inspection at Callaway Plant, 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. A licensee-identified non-cited violation is documented in report section: 71130.0
List of Findings and Violations
Failure to establish policies and procedures that implement 10 CFR Part 26 Cornerstone Significance Cross-Cutting Report Aspect Section Security Green [P.6] - Self- 71130.08 NCV 05000483/2023401-01 Assessment Open/Closed The inspector identified two examples of one non-cited violation (NCV) of 26.27(a) for failure to establish, implement, and maintain written policies and procedures to meet the general performance objectives and applicable requirements of this part.
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.
SAFEGUARDS
The inspector evaluated the fitness for duty program by completing the following nominal range
Main article: IP 71130.08
- (1) Tier I: All Requirements Tier II: All Requirements (except questionnaires/interviews associated with 02.07 and 02.08)
Tier III: All Requirements (except 02.13d, 02.14a/b/c)
INSPECTION RESULTS
Failure to establish policies and procedures that implement 10 CFR Part 26 Cornerstone Significance Cross-Cutting Report Aspect Section Security Green [P.6] - Self- 71130.08 NCV 05000483/2023401-01 Assessment Open/Closed The inspector identified two examples of one NCV of 10 CFR 26.27(a) for failure to establish, implement, and maintain written policies and procedures to meet the general performance objectives and applicable requirements of this part.
Description:
While reviewing policies and procedures on July 31, 2023, the inspector identified two examples of one NCV of 10 CFR 26.27(a) in which a licensee policy or procedure did not meet applicable requirements of 10 CFR Part 26.
First Example. While reviewing FFD Policy, POL0044, revision 010, the inspector noted section 3.18, states, "Misuse of over-the-counter drugs, prescription drugs, abuse of alcohol or legal drugs is considered a fitness for duty violation. If it is determined by the Medical Review Officer (MRO) that misuse or abuse is occurring, the individual's unescorted access will be revoked pending an investigation. A determination of fitness will be required and disciplinary action may be taken."
The inspector noted that 10 CFR 26.185(j)(3) states, "If the MRO determines that the donor has used another individual's prescription medication and clinical evidence of drug abuse is found, the MRO shall report to the licensee the donor has violated the FFD policy." This section established the legal drugs under consideration are prescription medications and that the prescription does not belong to the donor.
The inspector further noted that 10 CFR 26.75(e)(1) established the licensee's required minimum sanction response to a first violation of the FFD policy involving a confirmed positive drug or alcohol test result must, as minimum, result in immediate unfavorable termination of the individual's authorization for at least 14 days from the date of the unfavorable termination.
Therefore, the FFD Policy, section 3.18 does not implement applicable requirements of 10 CFR 26.75(e)(1) because revoking an individuals unescorted access pending an investigation that may result in disciplinary action after the MRO has determined a drug abuse related FFD policy violation does not meet NRC required minimum sanctions.
Second Example. While reviewing procedure XPD-PD-00005, revision 008, section 4.4.9.c.,
the inspector noted it states, "MRO, if it is determined the donor has used another individual's prescription medication, including a medication containing opiates, and no clinical evidence of abuse is found, IMMEDIATELY REPORT to AA/FFD Management the donor has misused prescription medication." The inspector recalled FFD Policy, POL0044, revision 010, section 3.18, states, in part, "misuse of over-the-counter drugs, prescription drugs ... is considered a fitness for duty violation." This is relevant because 10 CFR 26.185(c) states, in part, "If the MRO determines that a positive ... test result or other occurrence is an FFD policy violation, the MRO shall immediately notify the licensee's ... designated representative." Therefore, the inspector determined procedure XPD-PD-00005, revision 008, section 4.4.9. did not implement applicable requirements of 10 CFR 26.185(c) because it did not instruct the MRO to notify the licensee that a policy violation had occurred.
Corrective Actions: The FFD manager immediately notified the staff of the deficient language to ensure it was not improperly acted on until permanent corrective actions could be made.
The licensee stated both documents would be revised to align with 10 CFR Part 26.
Corrective Action References: CR 202305573
Performance Assessment:
Performance Deficiency: The failure to establish, implement, and maintain written policies and procedures to meet the general performance objectives and applicable requirements of 10 CFR Part 26 is a performance deficiency. It is a performance deficiency because it was within the licensees ability to foresee and correct.
Screening: The inspector determined the performance deficiency was more than minor because it was associated with the Access Authorization attribute of the Security cornerstone and adversely affected the cornerstone objective to provide assurance that the licensees security system and material control and accountability program use a defense-in-depth approach and can protect against
- (1) the design basis threat of radiological sabotage from external and internal threats, and
- (2) the theft or loss of radiological materials. It is more than minor because it could have resulted in a donor determined to have committed an FFD policy violation by the MRO being disciplined and returned to unescorted access authorization which would be contrary to the minimum sanctions required by 10 CFR 26.75 for policy violation sanctions involving confirmed positive drug tests.
Significance: The inspector assessed the significance of the finding using IMC 0609 Appendix E, Part I, Baseline Security SDP for Power. The inspector determined the cumulative total for the finding is one
- (1) point. This was calculated by factoring the impact area (Vital Area)against Tier II, Inspection Procedure element 71130.08-02.05d/e. Because the calculated point total did not exceed the range for a Green determination (0 to 6 points), the inspector determined the finding to be of very low security significance.
Cross-Cutting Aspect: P.6 - Self-Assessment: The organization routinely conducts self-critical and objective assessments of its programs and practices. The licensees self-assessment and audit programs should have been able to detect these language mismatches with 10 CFR Part 26.
Enforcement:
Violation: Title 10 CFR 26.27(a) states, "Each licensee and other entity shall establish, implement, and maintain written policies and procedures to meet the general performance objectives and applicable requirements of this part."
Contrary to the above, the licensee failed to establish, implement, and maintain written policies and procedures to meet the general performance objectives and applicable requirements of this part. Specifically in the first example, FFD Policy, POL0044, revision 010, section 3.18, prescribed management actions following a FFD policy violation related to abuse of legal drugs that did not meet the applicable minimum management actions required in 10 CFR 26.75(c)(1) following a first violation of the FFD policy involving a confirmed positive drug test. Specifically in the second example, procedure XPD-PD-00005, revision 008, section 4.4.9.c, did not require the MRO to notify the licensee that a FFD policy violation had occurred if the MRO determined the donor had misused a prescription medication. Not requiring the MRO to notify the licensee that a FFD policy violation had occurred related to misuse of prescription medication did not meet applicable requirements in 10 CFR 26.185(c).
Enforcement Action: This violation is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Licensee-Identified Non-Cited Violation 71130.08 This violation of very low safety significance was identified by the licensee, has been entered into the licensee's corrective action program and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.
Violation: While reviewing CR 202207911 the inspector became aware that a trained FFD notifier called an individual who had been selected for random drug and alcohol testing thinking the individual was working at home. In reality, the individual was working remotely out of state, but because the notifier did not ask where the individual was, the notifier told the individual that they had been selected for a random collection when the individual was not available for testing. This inadvertently provided prior notification to the selected individual that they had been selected. Due to geographic separation, the FFD collection staff was unable to collect samples from the individual until 14 days after the individual became aware of the impending drug and alcohol test. This was a violation of 10 CFR 26.31(d)(2)(v)because an individual who was off site and not reasonably available was not tested at the earliest and practical opportunity without prior notification to the individual.
Significance/Severity: Green. When processed through the Baseline Security Significance Determination Process for Power Reactors, this issue screened out as zero points, Green.
Corrective Action References: CR 202207911 (Z170.0007)
EXIT MEETINGS AND DEBRIEFS
The inspectors verified no proprietary information was retained or documented in this report.
On August 21, 2023, the inspectors presented the security baseline inspection results to B. Brown, Security Manager, and other members of the licensee staff.
DOCUMENTS REVIEWED
Inspection Type Designation Description or Title Revision or
Procedure Date
71130.08 Corrective Action 202102630, Condition Report
Documents 202202395,
2202410,
2202396,
2207911,
2303885,
2304667,
2201942,
2207865,
2205100,
2201155,
2200867
71130.08 Corrective Action 202207911, Condition Report
Documents 202305561,
Resulting from 202305573
Inspection
71130.08 Miscellaneous CA1943 Drug and Alcohol Test Notification Revision 003
71130.08 Miscellaneous CA3086 Notifier Instructions for Random Selections Revision 002
71130.08 Miscellaneous POL0044 Fitness For Duty Policy Revision 010
71130.08 Procedures APA-ZZ-00542 Event Review and Post Transient Evaluation Revision 025
71130.08 Procedures APA-ZZ-00906 Behavioral Observation Program Revision 032
71130.08 Procedures APA-ZZ00908 Fitness For Duty Program Revision 040
71130.08 Procedures XDP-PD-00001 General Administration of Drug/Alcohol Testing Revision 036
71130.08 Procedures XDP-PD-00005 Medical Review Officer/Substance Abuse Expert Revision 008
71130.08 Procedures XPD-PD-00004 Operation, Maintenance, and Quality Control of The Revision 014
Intoxilyzer 8000
7