ML17262A398
| ML17262A398 | |
| Person / Time | |
|---|---|
| Site: | Ginna  |
| Issue date: | 02/25/1991 |
| From: | Keimig R, King E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML17262A396 | List: |
| References | |
| 50-244-91-04, 50-244-91-4, NUDOCS 9103050018 | |
| Download: ML17262A398 (22) | |
See also: IR 05000244/1991004
Text
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U.
S
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NUCLEAR REGULATORY COMMISSION
REGION I
d
Report
No.
50-244/91-04
Docket No.
50-244
License
No.
Licensee:
Rochester
Gas
and Electric Cor oration
89 East
Avenue
Rochester
14649
Facility'ame:
R.
E. Ginna Nuclear
Power Plant
Inspection At:
Ontario
Inspection
Conducted:
Januar
23-25,
1991
Type of Inspection:
Initial Fitness-For-Dut
Inspector
&m~r/
xf.
E.
B. King, Physical
e urity Inspector
Division of Radiat
Safety
and Safeguards
Approved by:
R. Keimig, Chi
Safeguards
Section
Division of Radi
on Safety
and Safeguards
da
e
date
I'ns ection
Summar
Initial Fitness-For-Dut
Ins ection
Ins ection
Re ort
No. 50-244/91-04
d: lll
lid
d
training,
key program processes
and on-site collection and testing facilities
~Findin s:
Based
upon selective
examinations of key elements
of the Rochester
Gas
and Electric Fitness-For-Duty
(FFD) program,
the objectives of 10 CFR 26
are generally being met.
One apparent violation was identified relative to the
manner in which the permanent
record
book was being maintained at the collection
site.
One non-cited violation was self-identified by the licensee
concerning
the failure to conduct
a pre-award audit of the
HHS laboratory
and one unresolved
item was identified concerning
the lack of a policy to deal with individuals
with infrequent access
to the site.
The following program strengths
and
potential
weaknesses
were identified.
9103050018
910225
ADOCK 05000244
G
'
~Stren the:
e
gf
1.
the professionalism,
competency
and dedication of the staff who were
involved in administering
the program
2. 'he excellent computer
program for random selection
3.
the strong
support exhibited by management
for the program
4.
the awareness
of and utilization by employees
of the Employee Assistance
Program
(EAP)
5.
the effective and comprehensive
audit program
6.
the inclusion of all company
employees
in the
FFD program
Potential
Weaknesses:
1.
the manner in which the permanent
record
book is maintained at the collection
site
2.
the lack of an official policy and implementing procedure
for individuals
with infrequent unescorted
access
3.
the lack of a formal policy and'procedure
for the Medical
Review Officer
r
4.
the lack of consistency
among
some
program policies
and procedures
5.
unfamiliarity of the employees
with the
FFD program appeals
process
DETAILS
1.0
Ke
Personnel
Contacted
Licensee
- "R. Mecredy,
Vice President,
Ginna Nuclear Production
- S. Spector,
Plant Manager - Ginna
- R. Smith, Senior Vice President,
Production
and Engineering
- "J. Peters,
Department
Manager - Employee Relations (Fitness-for-Duty
Program
Manager)
- L. Houck, Fitness-For-Duty
Coordinator
- 'B. Mesher, Director,
Human
Resource
Research,
Planning
and
EEO
"*A. Fraser,
Manager,
Safety
and Health Service
- B. Stanfield,
QA Engineer,
Operations
"*D. Fredericksen,
Industrial Hygenist
""*E. Doty, Technical Writer
- S. Eckert,
Nuclear Access Authorization Administrator
""W. Dillon, Director of Security
- R.'oods, Supervisor
Nuclear Security
- A. Plummer,
Coordinator Medical Services
- A. Kurchin, Medical
Review Officer
"G. Meier, Department
Manager,
Production Division Training
- G. Taylor, Director Employment
H.
Bush-, Contract
Employee Assistance
Program Coordinator
United States
Nuclear
Re ulatory Commission
T. Moslak, Senior Resident
Inspector
"Denotes
those
personnel
who attended
the entrance
meeting only.
- Denotes those
personnel
who attended
both the entrance
and exit meeting.
- Denotes those
personnel
who attended
the exit meeting only.
The inspectors
also interviewed other licensee
and contractor
personnel
during the course of the inspection.
2.0
Pur ose
and
Sco
e of Ins ection
The inspector
met with the licensee's
representatives,
as indicated in
Section
1.0, at the Rochester
Gas
and Electric Corporate office in Rochester,
New York on January
23,
1991, to summarize
the purpose
and
scope of the
inspection
and
on January
25,
1991, to present
the inspection findings.
The licensee's
commitments,
as documented
in this report,
were reviewed
and confirmed with the licensee
during the exit meeting.
3.0
A
roach to
NRC Review of the Fitness-For-Dut
Pro
ram
The inspector
evaluated
the licensee's
Fitness-For-Duty
(FFD) Program
using
NRC Temporary Instruction 2515/106:
Fitness-For-Dut:
Initial
Ins ection of Pro
ram
Im lementation.
This evaluation
included
a review
of the licensee
s written policies
and procedures,
and program
implementation,
as required by,10 CFR Part 26, in the areas of:
management
support;
selection
and notification for testing; collecting and
processing
specimens;
chemical testing for illegal drugs
and alcohol;
FFD training and worker awareness;
the employee
assistance
program;
manage'ment
actions,
including sanctions,
appeals,
and audits;
and
maintenance
and protection of records.
The e'valuation of program
implementation
also included interviews with key
FFD program personnel
and
a sampling of licensee
and contractor
employees with unescorted
plant
access;
a review of relevant
program records;
and observation
of key
processes,
such
as
specimen collection, on-site notification/documentation
procedure for random testing,
and the
random selection
process.
4.C
Written Policies
and Procedures
The inspector determined,
through in-office review of Rochester
Gas
and
Electric's Fitness-For-Duty policy dated
December
1,
1989,
and
discussions
with the licensee,
that the licensee's
written
FFD policies
and procedures
generally
met regulatory requirements.
However,
several
areas
where
improvements
could enhance
the effectiveness
of the program were identified as follows:
4. 1
Prescri tion Dru
Procedures
Several
procedures
require
employees
to report to the medical office
any prescribed
medication determined
by their physician to have
an
adverse effect
upon his/her job performance.
However, the procedures
do not address
over-the- counter
(OTC) drugs that
may also
have
adverse
side affects.
The licensee
agreed to revise the procedures
to include
OTC drugs,
as applicable.
4.2
Medical
Review Officer Procedures
The licensee
has not developed
a formal policy and procedure delineating
the responsibilities
of the Medical
Review Officer.. Presently,
the
MRO is following the guidance of the National Institute
on Drug Abuse
(NIDA) Medical
Review Officer Manual,
as well as informal guidance
provided by the licensee
in discussions.
The licensee, agreed to develop
and implement
an
MRO policy and procedure
by March 1,
1991.
45
U
4.3
A
eal s Process
Procedure
Several
procedures
addressing
the appeals
process
have contradictory
time periods for when
an employee
may appeal
a confirmed positive
drug and/or alcohol test
by submitting
a written request.
The licensee
has
agreed to review and revise the procedures
to be consistent with
the
NRC rule.
4.4
Oru
and Alcohol Rehabilitation
Several
procedures
addressing
the licensee's
Drug and/or Alcohol
Rehabilitation
Program state that after successful
completion of the
rehabilitation
program the employee will be subject to an unannounced
testing
program.
In addition, while participating in the unannounced
testing
program,
they would be
removed
from the
random drug/alcohol
testing pool.,
However,
10 CFR 26.2 states,
in part, that the provisions of the
Fitness-For-Duty
program must apply to all persons
granted
unescorted
access
to protected
areas.
The inspector advised
the licensee that,
even
though
unannounced
testing for those individuals who have completed
a rehabilitation
program generally will ensure testing
on
a more frequent basis,
in
accordance
with the
NRC rule, those individuals must
be subjected
to
the
random testing requirement,
in addition to the
unannounced
testing
program.
The licensee
has
agreed to review and revise the procedures
as
needed.
4.5
Collection Site Procedures
The collection site procedures
do not contain step-by-step
instructions
for carrying out the collection process;
rather,
the procedures
are
written in narrative
format.
However,
based
upon interviews with the
collection site staff, it was apparent
that they were knowledgeable
of their duties
and responsibilities.
The inspector stated that the
lack of detailed
procedures
created
the potential for inconsistencies
in carrying out the processes
and the opportunity for employees
to
deviate
from acceptable
practices.
The licensee
agreed to review and
revise the procedures
as
needed.
5.0
Pro
ram Administration
Following are the inspector's
findings with respect
to the administration
of key program elements
in the licensee's
FFD program.
'J
5.1
Delineated
Res onsibi1ities
5.2
The program is organized to facilitate coordination
among the various
program elements.
This includes the active involvement of the Vice
President,
Employee Relations
and Public Affairs, who is responsible
for all of the
key line program elements (e.g.,
health
and safety,
training,
EAP (Human Resources),
Fitness-For-Duty.
The
FFD program
manager,
reports directly to the Vice President,
Employee
Relations'nd
Public Affairs, who reports directly to the President
and Chief,
Operating Officer.
Except
as noted in Details,
Section 4.0 of this
report,
the licensee's
procedures
clearly delineate
the responsi-
bilitiess
and duties of each
member of the
FFD program staff.
Mana
ement Awareness
of Res onsibilities
Interviews with FFD program staff and selected
supervisors,
reviews
of procedures
and contracts,
and discussions
'with licensee
management
by the inspector indicated that management,
at all levels, is not
only aware of its responsibilities
under the rul.e,
and its particular
responsibilities within the program,
but is also fully commi tted to
the goal of the rule:
a work place free of drugs
and alcohol
and
their effects.
5.3
Pro
ram Resources
The licensee
appears
to be providing adequate
resources
for effective
program implementation.
Interviews with FFD program personnel
indicated
that
u'pper management
has
been very supportive in providing tbe facilities
and staff that are necessary
for them to carry out their jobs.
This
was evident
by the manner in which'oth collection sites,
one located
at the corporate office and the other located outside
the protected
area at the Ginna Station were observed
to be equipped,
staffed
and
utilized.
5.4
Mana ement Monitorin
of Pro
ram Performance
The
FFD program manager
exercises
effective daily oversight of the
program
and maintains
open communications'ith
FFD program staff.
The licensee
completed its six-month report
on program performance,
which indicated very little substance
abuse
among its employees
and
those of its contractors.
A licensee
internal audit was determined
by the inspector to be in-depth
and thorough.
Through its audit
program,
the licensee identified several
weaknesses,
including: lack
of procedures
for the operation; calibration,
and maintenance
of
breathalyzer
equipment;
lack of procedures
for collection site tasks,
including collection, chain-of-custody
and security measures;
and the
lack of a procedure outlining the frequency/rate
of blind performance
'
tests
submitted
and subsequent
actions
in case of unsatisfactory
HHS-certified laboratory performance.
The licensee
implemented
measures
to correct the audit findings.
The corrective
measures
were
reviewed
by the inspector
and determined to be adequate
except for
those
weaknesses
discussed
in Details,
Section
4.0 of this report.
Measures
Undertaken to Meet Performance
Objective of the Rule
The licensee
has provided adequate
resources
and personnel
to meet
the performance
objectives of the NRC's
FFD rule.
In regard to
achieving
a drug-free work place,
as stated
in 10 CFR 26.10(c),
the
licensee
reserved
the right to search
the work place if it had
".reasonable
suspicion" that there
was
a violation of company policy
and procedures.,
The licensee
has also trained all of its security
officers in behavioral
observation.
Those officers act as the first
line of defense
against
employees
who are
impaired
due to drug or
alcohol
use
from gaining station access.
Although not required
by "NRC regulation,
the licensee
requires all
contractors
and vendors to make
an
EAP program available to their
employees.
The inspectors
also
found that the licensee
had adequate
mechanisms
in p'lace to receive
and provide "suitable inquiry" information
relative to an employee's
or applicant's
drug or alcohol history.
Sanctions
The licensee's
FFD policy establishes
sanctions
consistent with 10 CFR 26.27(b).
As stated
in the licensee's
FFD policy, company
employees
who have confirmed positive test results for illegal drugs will be
suspended
for 14 consecutive
days without pay, referred to the
program
as
a condition of employment,
and are subject to followup
testing for a minimum period of three years.
Any subsequent
confirmed
positive test for illegal drugs will result in termination with no
rehire consideration.
Contractor
employees
who have confirmed positive
test results for drugs will have their unescorted
access
revoked
and
will'not be eligible to work at any Rochester
Gas
and Electric
facility, or job site,
in the future.
Employees
who have
a confirmed positive alcohol test result will be
suspended
without pay for one week,
given
a written warning,
and will
be subject to unannounced
testing.
An employee with a second
offense
wi 11
be
suspended
for two weeks
and
as
a condition of employment receive
counseling at the
EAP and will be subject to unannounced
testings
An employee with a third offense will be terminated with no rehire
considerations
Contractor
employees will be
removed
from site
and
will no longer
be eligible to work at any Rochester
Gas
and Electric
facility, or job site, for a first offense.
S.7
Em lo ee Assistance
Pro
ram
The licensee's
EAP has
been in existence
for many years.
The
program offers assessment,
counseling,
and referral
services
through
a contract with qualified counseling professionals.
The inspectors
interviewed the
EAP Coordinator
and found that
he was not only
knowledgeable
of the duties
and responsibilities
of his position in
accordance
with the Rule, but also with the facilities and
numerous
'AP services
available to Rochester
Gas
and Electric employees.
Participation in the
EAP is treated
on
a confidential basis.
The
inspector determined that the licensee
would be informed of an
employee
whose condition constitutes
a hazard to the plant, himself,
or others,
when the
EAP counselor identifies
such
a situation.
The inspector determined
through interviews with randomly selected
station
employees
that the
EAP is well accepted
and is utilized by
the employees.
The
EAP Director provided documentation
that
indicated that the majority of individuals enrolled ir the program
are self-refe'rrals.
This demonstrates
that the licensee
has
encouraged its employees
to use the .service
and that the employees
have confidence
in the program.
An additional benefit provided to licensee
employees
is the availability
of a one-time monetary grant to defray any expenses
incurred
by an
employee participating in
a rehabilitation
program that is not be
covered
by the employee's
medical
insurance
benefits.
6. 0
~Tra 1 n 1 n
The licensee's
FFD training program appears
to be adequate
in most
respects.
Interviews with plant employees,
consisting of licensee
and
contractor supervisory
and non-supervisory
personnel,
revealed that plant
employees
were generally
knowledgeable
of the program
and the actions
and
responsibilities that were assigned
to them.
However,
the interviews revealed that the employees
were not familiar with
the appeals process'he
licensee
agreed to enhance
the training lesson
plans addressing
the appeals
procedure to ensure
employee
understanding.
The inspector
reviewed the licensee's'esson
plans, training records,
and
observed
a film presentation
utilized for supervisor
FFD training.
It was
apparent that the licensee
has
expended
considerable
efforts to ensure
the
effectiveness
of the training.
No deficiencies
were noted.
7.0
Ke
Pro
ram Processes
7.1
Selection
and Notification for~Teatin
The selection
and notification process
appears
to be carried out in
a manner that meets the objectives of the
NRC rule.
A list of
individuals for random testing is generated
by a computer
on
a
'
~
\\
0
weekly basis
from separate
pools
composed of all individuals with
unescorted
station
access.
The pools are updated
on
a daily basis.
Separate
pools
have
been established
for licensee
employees
and
contractor personnel.
Data compiled for the first twelve months of program implementation
indicated that the goal of testing
100 percent of station personnel
with unescorted
access
was achieved.
The inspector
noted that the
licensee
conducts
random testing
on backshifts
and weekends.
Employees
who are not at the station
when their names
are selected
for random testing
(due to travel out of the area,
illness or vacation)
are
excused for that day.
The
names of those individuals are returned
to the selection
pool.
Licensee
employees
working in corporate
head-
quarters
who have unescorted
station
access
are required to report
to the corporate collection facility if their names
are
randomly
selected.
However,
the licensee
does
not have
a policy to deal with
personnel
with infrequent unescorted
access
to the Station.
The
inspector
advised the licensee
of the
need to develop
such
a policy
along with implementing procedures.
Testing of personnel
with
infrequent unescorted
access
is considered
an Unresolved
Item (UNR
50-244/91-04-01),
and wi 11
be reviewed during
a subsequent
inspection.
The selection
process
appears
to have adequate
safeguards
to protect
sensitive
information.
Only two individuals have
access
to the
computer
program that generates
the lists,
and all uses
and
modifications of the program are automatically recorded.
The
physical
location of the computer
and the computer
generated lists
allows for adequate
security.
Notification of employees
selected
for random testing is conducted
by the Collection Site Supervisor,
or designee,
by informing their
supervisors
to have the individual report for testing within a
designated
time period.
The licensee
has
a very aggressive
program
which requires actions to be taken to locate
any individual who is
more than
5 minutes late for a pre-scheduled
appointment.
However,
'he
collection site procedures
do not contain the followup actions
to be
implemented
by the collection site staff if such actions
are
required.
As stated
in Details,
Section 4.5, the licensee
agreed to
review and revise the procedure,
as
needed.
Procedures,and
program support in cases
of for-cause testing appear
to be adequate.
The licensee
has coordinated
specimen collection
procedures
with a local
area
hospital to ensure that proper actions
are taken if for-cause testing is required
and on-site
support is
unavailable
to conduct the testing.
10
17
2
Collection and Processin
of
S ecimens
7.3
The inspector
conducted
a walkthrough of the procedures
for collection
and processing
of a specimen.
Each collection site
was adequate
to
process
one person at
a time.
The design of the facilities is conducive
to tracking individuals as they proceed
through the process.
The
facilities provide adequate
security for specimens,
collection equipment,
and records.
The collection
rooms
have
no source of water that have
not had
a bluing agent
added.
In addition,
the licensee
has
a backup
power supply in place to assure
that the storage refrigerator would
not be without power for extended
periods.
During the walkthrough,
no weaknesses
were observed
in the way the collection site personnel
process either individuals undergoing testing or the specimens.
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 inspectors
examined
the security
and ccntents
of the files and found them to be
adequately
secure
and current.
Access to sensitive
information is
limited to individuals with a need-to-know.
Additionally, review of
records
by the inspector indicated that chain of custody procedures
were being followed at all times.
However,
on January
24,
1991, while reviewing the "Permanent
Record
Book" maintained
by the collection site staff at the Ginna Plant, it
was determined
by the inspector
that
a "Permanent
Record
Book" was
not being maintained
in accordance
with the requirements
of the
NRC
rule.
Appendix A, Subpart
8, Paragraph
2.4,
"Specimen Collection Procedures,"
Subparagraph
(g)(24) states
that the collection site person
shall
enter in the permanent
record
book all information identifying the
specimens.
The collection site person
shall
sign the permanent
record
book next to the identifying information.
Appendix
A ( 1.2) of 10 CFR 26 defines
the permanent
record book as
a permanently
bound
book in
which identifying data
on each
specimen collected at
a collection
site are permanently
recorded
in the sequence
of collection.
The licensee
stated that the only documentation
contained
in the record
book were the
names of contractor
employees- who have
been tested
because
the collection services
are being provided by a contractor
and the
record
book was being utilized to bill the contractor for the services
However,. the licensee
had developed
a computerized
system to track
and print a list of all individuals tested (including the contractor
employees),
in chronological
order,
and
had retained
a copy of each
chain-of-custody
form to use
as
a record
signed
by the employee being
tested.
Therefore,
although all of the required data
were available,
the data were not being entered into
a permanently
bound record book,
with the signature of the collection site person,
for use
as
a legal
record.
After discussions
with the inspector,
the licensee
agreed to log all
testing in the permanent
record book and revise the applicable
procedures
accordingly.
The licensee's
failure to maintain the permanent
record
book in ac-
cordance with the
NRC rule is an apparent violation of 10 CFR 26.
( VIO 50-244/91-04-01)
Additionally, Appendix
A (2.4)(j) of 10 CFR 26 states,
in part, that
if an individual refuses
to cooperate
with the urine collection or
breath analysis
process,
then the collection site person
shall
inform
the Medical
Review Officer and shall
document
the non-cooperation
in
the permanent
record book.
The collection site staff were apparently
not aware of this requirement.
However,
no such instance
had yet
occurred
and the licensee
agreed
to include this requirement
in the
collection site procedure.
This matter will be reviewed during
a
subsequent
inspection.
The licensee
had completed
a Quality Assurance
Audit (No. 90-37 dated
September
11-18,
1990) of its
FFD program.
The inspector
found the
licensee's
audit to be timely, in-depth,
and thorough.
This audit
provided identification of several
weaknesses
in the licensee's
program,
and these either
had been'orrected
or were in the process
of being corrected
at the time of the inspection.
During this inspection it was brought to the attention of the inspector
that the licensee
failed to conduct
a pre-award audit of the
Laboratory prior to awarding the laboratory
a contract for services.
The licensee's
failure to conduct
a pre-award
inspection
and evaluation
of the procedural
aspects
of the laboratory's
drug testing operation
is an apparent violation of 10 CFR 26 Appendix A, Subsection
A,
Paragraph
2.7(m).
However, the inspector determined that once identified, the licensee
took immediate corrective actions
by having the
HHS Laboratory audited
by a creditable firm independent
of Rochester
Gas
and Electric
Corporation.
The audit was reviewed
by the inspector
and found to be
satisfactory.
The inspector also determined that the criteria of the
NRC's Enforcement
Policy (10 CFR 2, Appendix C, Section
VS G.) for a non-cited violation
had been met,
as follows:
the violation was identified by the licensee;
the violation would be classified at Severity
Level IV; it was not
r
>1
'k
I*
'I
12
required to be reported; it was corrected
by conducting
an audit of
the
HHS Laboratory within a reasonable
time; and, it was not
a willful
violation nor could it have
been
reasonably
expected
to have
been
prevented
by corrective action for a previous violation.
Non-cited
Violation (NCV) 50-244/91-04-02.
8.0
Onsite Testin
Faci lit
The licensee
does
not conduct on-site
screening for drugs.
However, testing
capabilities for breath alcohol
are provided and are consistent with the
expectations
of the rule.
Approved breath-testing
devices
are
used.
Procedures
for their use
are appropriate
and personnel
have
been trained
in the
use of the devices.
S