IR 05000483/2023401
| ML23242A336 | |
| Person / Time | |
|---|---|
| Site: | Callaway  |
| Issue date: | 09/13/2023 |
| From: | Ray Kellar NRC/RGN-IV/DRSS/PSB |
| To: | Diya F Ameren Missouri |
| Holman D | |
| References | |
| IR 2023401 | |
| Download: ML23242A336 (7) | |
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, 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:
Report Number:
Enterprise Identifier:
I-2023-401-0008
Licensee:
Ameren
Facility:
Callaway Plant
Location:
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
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 Aspect Report Section Security Green NCV 05000483/2023401-01 Open/Closed
[P.6] - Self-Assessment 71130.08 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
71130.08 - Fitness For Duty Program
The inspector evaluated the fitness for duty program by completing the following nominal range
of inspection elements: Fitness For Duty Program
- (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 Aspect Report Section Security Green NCV 05000483/2023401-01 Open/Closed
[P.6] - Self-Assessment 71130.08 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
Procedure
Type
Designation
Description or Title
Revision or
Date
Corrective Action
Documents
2102630,
2202395,
2202410,
2202396,
2207911,
2303885,
2304667,
2201942,
2207865,
2205100,
2201155,
2200867
Condition Report
Corrective Action
Documents
Resulting from
Inspection
2207911,
2305561,
2305573
Condition Report
Miscellaneous
CA1943
Drug and Alcohol Test Notification
Revision 003
Miscellaneous
CA3086
Notifier Instructions for Random Selections
Revision 002
Miscellaneous
POL0044
Fitness For Duty Policy
Revision 010
Procedures
APA-ZZ-00542
Event Review and Post Transient Evaluation
Revision 025
Procedures
APA-ZZ-00906
Behavioral Observation Program
Revision 032
Procedures
APA-ZZ00908
Fitness For Duty Program
Revision 040
Procedures
XDP-PD-00001
General Administration of Drug/Alcohol Testing
Revision 036
Procedures
XDP-PD-00005
Medical Review Officer/Substance Abuse Expert
Revision 008
Procedures
XPD-PD-00004
Operation, Maintenance, and Quality Control of The
Intoxilyzer 8000
Revision 014