ML18095A221
| ML18095A221 | |
| Person / Time | |
|---|---|
| Site: | Salem, Hope Creek  |
| Issue date: | 05/18/1990 |
| From: | Albert R, Bush L, Della Ratta A, Keimig R, Pirtle G NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | |
| Shared Package | |
| ML18095A220 | List: |
| References | |
| 50-272-90-10, 50-311-90-10, 50-354-90-07, 50-354-90-7, NUDOCS 9005290023 | |
| Download: ML18095A221 (13) | |
See also: IR 05000272/1990010
Text
U. S. NUCLEAR REGULATORY COMMISSION
REGION I
50-272/90-10
50-311/90-10
Report Nos. 50-354/90-07
50-272
50-311
Docket Nos. 50-354
License Nos. NPF-57
Licensee:
Public Service Electric & Gas Company
Facility Name:
Artificial Island Nuclear Generating Station
Inspection At:
Hancocks Bridge, New Jersey
Inspection Conducted:
March 12-15, 1990
Type of Inspection:
Initial, Fitness-for-Duty
Inspectors:
Approved by:
Approved by:
Inspector
. L. Bush, Jr., Chief, Program Development
and Review Section, NRR/RSGB
G. L. Pirtle, Plant Protection
Analyst, RIII
R. R. Keimig, Chief, S~fe uards Section
Div"sion of Radiation Safety and Safeguards
and Review Section,
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Development
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date
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date
I
Inspection Summary:
Initial, Fitness-For-Duty Inspection (Combined Inspection
Report Nos. 50-272/90-10, 50-311/90-10, and 50-354/90-07)
Areas Inspected:
Written policies and procedures; program administration;
training, key program processes and onsite testing facility.
Findings:
Based upon selective examinations of key elements of PSE&G 1 s
fitness-for-duty program, the objectives of 10 CFR Part 26 are being met.
Management support for this program was evidenced by the quality of the
facilities and the staff who administered the program.
However, there were
some weaknesses in the implementation which can be expected for a new program.
The more significant of these are as follows:
1.
Although policies were included in staff procedures provided the individuals
affected by the FFD program, there was no written policy on drugs which
2.
met the requirements of 10 CFR 26.20(a).
By letter dated April 17, 1990,
PSE&G forwarded to the NRC a written policy statement that met the requirements.
(Reference paragraph 4.) This is a non-cited violation.
The licensee permitted flexibility in scheduling random tests, allowing a
supervisor to request postponement of the test until later in the day if
it would be a significant inconvenience or an interruption of important
work.
This program feature has the potential for abuse that could result
in a delay of 8-12 hours in testing.
(Reference paragraph 7a.) This is an
unresolved item.
3.
Several corporate and contractor personnel who have infrequent unescorted
access were not subject to random testing while not working at the site
and ~re not routinely rescreened after more than 60 days absence.
(Reference
paragraph 7a.) This is an unresolved item pending evaluation of corrective
action initiated by the licensee.
4.
The. licensee did not collect specimens over the weekends and between 7:00
5.
p.m. and 6:00 a.m. on weekdays.
This predictable gap in scheduling diminishes
the deterrent effect of random testing.
(Reference paragraph 7b.) This
is a non-cited violation.
Custody of blood specimens was not properly maintained.
immediate corrective action by changing the procedure.
7b.) This is a non-cited violation.
The licensee took
(Reference paragraph
DETAILS
1.
Key Persons Contacted
The following personnel attended the exit meeting on March 15, 1990:
Licensee
D. Coles, Medical Services Supervisor
G. Connor, General Manager-Nuclear Services
T. Crimmins, Vice President Nuclear Engineering
B. Espinosa, Manager-Nuclear Human Resources and
Administrative Services
R. Fisher, Screening Supervisor
J. Fleming, Senior Staff Engineer-QA
A. Giardino, Manager-QA Programs and Audits
W. Grau, Senior Staff Engineer-Licensing
E. Hall, Employee Relations Manager
M. Ivanick, Senior Security Regulatory Coordinator
L. Krajewski, Site Access Administrator
J. Lawrence, Legal Intern
R. Mack, Medical Director-Nuclear
R. McCarthy, Psychological Services Administrator
S. Miltenberger, Vice President CNO
P. Moeller, Manager-Site Protection
B. Preston, Manager-Licensing and Regulations
L. Reiter, Manager-Nuclear Engineering Projects
D. Renwick, Nuclear Security Manager
C. Rokes, Licensing Engineer
C. Sauder, Personnel Affairs Manager
B. Thomas, Associate Engineer
M. Walton, Medical Administrator-Nuclear
N. Wetterhahn, Attorney
J. Zupko, Jr., General Manager-QA/NSR
USN RC
T. Johnson, Senior Resident Inspector
R. Keimig, Chief, Safeguards Section-Region I
S. Pindale, Resident Inspector
G. Tracy, Resident Inspector
L
The inspectors also interviewed other licensee and contractor personnel
who did not attend the exit meeting.
The following Battelle personnel, who are under NRC contract, participated
in the inspection:
N. E. Durbin, Research Scientist
J. Olson, Senior Research Scientist
2.
4
Entrance and Exit Meetings
The inspectors met with the licensee representatives, as indicated above,
at the Salem/Hope Creek site on March 13, 1990, to summarize the scope and
purposes of the inspection and on March 15, 1990, to present the inspection
findings.
3.
Approach
The inspection team evaluated the licensee's Fitness-for-Duty (FFD) Program
using an NRC draft Temporary Instruction, Fitness-For-Duty:
Initial
Inspection of Program Implementation.
This evaluation included a review
of the licensee's written policies and procedures and program implementation,
as required by 10 CFR 26, in the areas of:
management support; selection
and notification for testing; collection and processing of specimens; chemical
testing for illegal drugs and alcohol; FFD training and worker awareness;
the employee assistance program; management actions including sanctions;
appeals; audits; and maintenance and protection* of records.
The review of
the program implementation involved interviews with key FFD program personnel
and a sampling of the licensee's employees and contractor employees with
unescorted plant access, a review of relevant program records, and observation
of key processes, such as specimen collection and onsite screening processes.
4.
Written Policies and Procedures
The licensee has recently undertaken significant changes in its Fitness-
for-Duty policy and programs in order to comply with the requirements under
The NRC was notified that the program had been fully implemented
by l~tter on January 3, 1990.
The inspection team compared the license.e's
written policies and procedures to those required under 10 CFR 26 to assure
that the required policies and procedures had been developed, that their
content was in compliance with the rule, and that their quality and level
of detail provided for an effective program.
The inspection team had the
following observations:
0
While the licensee had communicated its drug policy through training,
higher level management and implementing procedures, licensee staff
could not produce a copy of an official policy statement on the use
of illegal drugs.on the part of individuals covered by the rule, as
required by 10 CFR 26.20(a), "Written policy documents must be in
sufficient detail to provide affected individuals with information
on what is expected of them, and what consequences may result from a
lack of adherence to the policy.
11 The licensee issued a policy on
alcohol in November 1989, which made reference to a corporate policy
on drugs, as amended by the Nuclear Division.
The corporate policy
which had been issued in 1985, did not cover the policies that all
licensees committed to develop in response to the NRC's Policy Statement
published in the Federal Register on August 14, 1986.
The expected
0
0
0
0
5
written policies appeared to be included in written procedures developed
by the various staff elements administering the FFD program, however,
these documents are not provided to the affected individuals.
The
licensee agreed to develop a written policy statement that included
all applicable aspects of 10 CFR 26, which was forwarded to the NRC
by letter dated April 17, 1990.
Although this was a violation of 10
CFR 26.20(a), the violation is not being cited because the criteria
specified in Section V.A. of the Enforcement Policy were satisfied.
Procedures were not developed to a reasonably consistent level of
quality.
Specifically, higher order procedures (Vice President -
Nuclear ADP-12 and NC-NA-AP.ZZ-0042) assigned responsibilities and
established broad program objectives which covered the several areas
required by the rule.
However, detailed implementing procedures for
the appropriate departments, in some cases, were not available, as
required by Section 8.2.2 of Procedure VPN-ADP-12.
Examples include
elements of the selection and notification process, the appeals process
(in draft format), and the process for evaluating program performance.
Interviews disclosed that no specific procedures had been developed
by the Nuclear Employee Relations Manager to address the assigned FFD
program implementation functions, including those relative to the FFD
appeal process as described in Section 3.7 of Procedure NC-NA-AP.ZZ-0042.
Additionally, no specific procedure had been developed by the Personnel
Affairs Manager for the FFD appeal process, as described in Section
3.11 of the above procedures.
In some of these areas, the licensee
expressed an intention to develop detailed procedures in the near
future.
A detailed review appears warranted to assure that departmental
procedures have been prepared to assure responsibilities assigned by
the higher tier documents are addressed.
The licensee's procedure (NC-NA-AP.ZZ-0042) did not clearly reflect
the requirement that the licensee will notify the NRC of certain per-
formance problems in its Department of Health and Human Services
(HHS)-certified laboratory, as required by 10 CFR 26, Appendix A,
2.8.(e)(4) and (5).
The licensee stated that it would revise its
procedures to address this issue.
In some cases, existing procedures and current practices were not
clear.
These include the procedure to use security staff to conduct
11 for cause
11 testing during the back shift (generally limited to breath
analysis testing) and Section 5.14.1.3 of Procedure NC-NA-AP.ZZ-0042
which mandates that misuse of prescription and over-the-counter drugs
will result in the same sanctions as use of illegal drugs.
In practice,
the Medical Review Officer (MRO) uses judgement as to whether
11misuse 11
warrants imposition of a sanction.
While most staff members involved in the FFD program were found to be
performing their jobs at a high level of proficiency, the possibility
of inadvertent errors in the discharge of these duties is increased
6
by the lack of detailed procedures for some functions.
The inspectors
found that Section 8.2.2 of Vice President - Nuclear Procedure ADP-12,
Revision 1, requires that appropriate procedures for the FFD program
be developed and utilized by those departments with specific program
responsibilities.
5.
Program Administration
Following are the inspectors' findings with respect to the administration
of key elements of the licensee's FFD program.
a.
Delineated Responsibilities
Overall program responsibilities have been clearly delineated by the
licensee's primary FFD program procedures (NC-NA-AP.ZZ-0042).
In
general, major FFD program functions have been assigned to appropriate
staff elements.
b.
Management Awareness of Responsibilities
With the exception of the licensee's responsibility to report to the
NRC performance problems at the HHS-certified laboratory, managers of
the program functions appeared to be aware of their responsibilities,
as described in procedure NC-NA-AP.ZZ-0042.
c.
Program Resources
Program resources currently appear adequate.
FFD program staff with
assigned program functions report that upper management, both at the
site and corporate levels, have been very supportive in providing the
necessary program resources.
The licensee staff reported very little
additional impact because of th~ rule requirements.
The exception is
the Medical Department where both workload and staff have expanded
substantially.
While resources in the Medical Department appear to
be keeping up with demand, the occurrence of three scheduled outages
in 1990 and the resulting increase in the number of drug and alcohol
screens may place a strain on the staff.
The licensee plans to increase
its FFD staff to cope with the workload.
The physical facilities
available for the FFD program are new, spacious, well-maintained, and
excellent housekeeping practices were noted.
The onsite FFD testing
.area, the laboratory facility for preliminary screening tests, the
medical support area, the facilities for the Medical Review Officer
(MRO), the several classrooms, and security's access processing
operations are all located in one building.
This contributes to timely
and efficient coordination of operations among the various personnel
responsible for implementing most elements of the program.
The
facilities available to support the FFD program may well be a model
for other utilities .
d.
7
The laboratory facility was adequate in size, locked at all times,
and visitor access controlled and recorded on an access log.
Physical
security upgrades were planned to compensate for some structural
vulnerabilities identified during a February 1990 audit by the licensee.
The security upgrade project is scheduled to be completed by the end
of April 1990.
Management Monitoring of Program Performance
It appears that management monitoring of program performance will be
adequate, with the following:
0
0
The fitness-for-duty program administrator was also the manager
of Nuclear Human Resources and Administrative Services.
While
it is desirable to assign management responsibilities to someone
with the authority to take action to assure program success, the
inspectors had some concerns that the program administrator was
at a level with so many disparate responsibilities that the
administrator was not sufficiently aware of the day-to-day operation
of the program to be able to effectively monitor and coordinate
program performance and identify program weaknesses.
A strategy for assessing program performance and analyzing program
performance data has not yet been developed.
While the medical
department has begun to trend and analyze data from the chemical
testing program, workload pressures and other factors have inhibited
the staff from pursuing its plan to develop an approach designed
to identify program weaknesses, as required by 10 CFR 26.7l(d).
e.
Measures Undertaken to Meet Performance Objectives of the Rule
The licensee has provided more than adequate resources and personnel
to meet the performance objective of the FFD rule.
However, some
areas of concern were identified:
0
0
0
Although the searching of persons, packages, and vehicles entering
the protected area contributes to achieving the performance
objective of a drug-free workplace, as stated in 10 CFR 26.lO(c),
the licensee does not conduct searches of the workplace with
drug detection dogs which could contribute to achieving that
performance objective.
The licensee has not yet devised a method of random testing of
personnel granted unescorted access who are seldom onsite. (This
is discussed in more detail in paragraph 7a).
The licensee's practices did not include certain actions that
could be taken in response to confirmed positive test results.
These actions could include an attempt to identify the sources
of the drugs consumed, and a review of previous work .
8
f.
Sanctions
g.
The licensee's procedures establish sanctions as set forth by the FFD
rule, except for sanctions on misuse of legal drugs.
According to.
Section 5.14.1.3 of the licensee's nuclear administrative procedure
NC-NA-AP.ZZ-0042, the misuse of legal drugs shall be subject to the
same sanctions as those for illegal drugs.
However, the Medical Review
Officer stated that he exercises judgment as to what constitutes
enforceable misuse of legal drugs.
The
11 shall
11 in the procedure is
appropriately
11may
11 in practice; the licensee should make the
appropriate revision to that procedure.
As permitted by the FFD rule, PSE&G permits contractor employees who
have been denied access based upon the first confirmed positive test
to regain their unescorted access status on the condition that they
provide evidence of rehabilitation and abstinence, are free of substances,
and undergo follow-up testing for three years.
Employee Assistance Program
The licensee's implemented Employee Assistance Program (EAP) appeared
adequate in meeting the requirements of the rule.
In some cases, the
licensee has gone beyond normal expectations, in that insurance coverage
is provided for employees who lack the coverage and need rehabilitation
treatment; and EAP services are provided for
11 permanent
11 contractors.
The staff and adequate facilities were available on site to address
FFD ref erra 1 s.
6.
Training
The licensee's FFD training program did not achieve some of the desired
objectives.
The inspectors' evaluation was based on comments by resident
inspectors who attended the training, and on interviews with licensee and
contractor personnel, as follows:
a.
Program Awareness
While personnel interviewed were aware of FFD testing, they did not
appear to understand fully the scope of the program and its intended
positive impact on the workplace.
b.
Worker Perceptions
It appeared the licensee had not adequately allayed employees' ap-
prehension toward false positives.
Nor did it appear that the licensee
provided information to assure that test results would be valid and
reliable, and that any employee could be tested randomly at any time.
The workers conveyed to the inspectors:
7.
0
0
0
9
Strong convictions, particularly by contractor employees, that
employment would be terminated because of a false positive.
A perception that consumption of poppy seeds was a means of
circumventing the program.
A perception that the large volume of people tested reduces
the odds of being randomly selected for an immediate retest.
c.
Supervisor and Escort Understanding of Responsibilities
Supervisors and escorts appeared knowledgeable of their functions,
but there were concerns expressed that training on drug recognition
and behavioral observation needed to be more indepth.
Supervisors may not be sufficiently sensitive to various impa1r1ng
conditions of the workers and to the potential adverse impacts on the
work schedules when these conditions are ignored.
Some examples:
0
Although several workers had reported taking prescription or
over-the-counter medication which caused drowsiness (such as
codeine), these individuals apparently were put to work in
potentially hazardous situations .
Key Program Processes
a.
Selection and Notification for Testing
Selection for random testing was conducted by use of a computer
generated list .. The computer software is designed to prevent access
to or tampering with the random selection process and, once the
selection process is.initiated, the computer is not affected by
manipulation.
Additionally, names could not be added to or deleted
from the random selection process once it was initiated.
Notification of personnel selected for testing was accomplished by a
FFD staff member, a medical clerk who contacted FFD coordinators for
the appropriate department and advised them of the personnel scheduled
for chemical testing and made an appointment for the test.
The supervisor
is permitted to request postponement of the test until later in the
day if it would be a significant inconvenience or an interruption of
important work.
The FFD coordinators, supervisors and the Medical
Clerk coordinated to reschedule the test for later the same day.
However, abuse of this program feature could result in a delay of 8
to 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> in the test - sufficient time to avoid detection of the
abuse of some substances, particularly alcohol. In addition, the current
FFD program does not limit the time between when a person is advised
he or she was selected for testing and. his or her scheduled test time .
10
In practice, the staff attempts to limit the time between notification
and the test. However, the program, as currently administered, could
allow a person to be advised at 7 p.m. that he or she has been selected
for FFD testing and the actual testing could conceivably not occur
until 6 a.m. or later the following day.
This vulnerability has been
somewhat compensated for by attempting to test personnel on backshifts
either before going to work or after work.
This issue is considered
an unresolved item (272/90-10-01; 311/90-10-01; 354/90-07-01).
Approximately 1000 personnel authorized unescorted access (issued a
key card badge) are assigned to various categories of jobs or locations
that are not onsite and infrequently have access.
Collection of specimens
is generally limited to when they are onsite, and therefore these
individuals are seldom tested when randomly selected.
The
11predictability
11
of testing under this approach significantly reduces the deterrent
effect of random testing because it allows the personnel involved to
perceive a means to avoid random testing.
As the licensee's program
is implemented, personnel having, infrequent access could be chemically
tested at a lower frequency than the onsite workers.
In addition,
other categories of personnel may perceive that testing criteria is
inequitable.
The licensee's February 1990 Quality Assurance audit
issued a finding pertaining to this observation; corrective actions
were being considered and were scheduled for resolution by March 31,
1990.
Subsequent to the inspection, the inspectors were informed
that the licensee had taken corrective action.
This issue is considered
an unresolved item (272/90-10-02; 311/90-10-02; 354/90-07~02).
Provisions had been established to accomplish
11 for cause
11 testing of
.backshift personnel when needed.
Testing for alcohol abuse would be
performed by designated and trained security force personnel.
Laboratory
personnel would be called in to collect and test urine specimens and
to draw blood if requested by the individual for further confirmatory
testing for alcohol abuse.
Sufficient breath analysis equipment was
available onsite to perform initial and confirmatory tests.
The selection and notification process files contained, among other
things, copies of the random selection list, record of telephone calls
made for notification and scheduling purposes, and written verifications
pertaining to reasons for not testing a person who was randomly selected.
The files ~eviewed were generally complete, accurate, and well maintained.
However, in some cases, the form used to obtain written verification
from management of the reasons why a selected person was excused from
random testing was not received by the medical department until a
week or more after the scheduled test date.
More timely responses
appear warranted to allow followup on any problems encountered with
persons excused from testing situations.
11
b.
Collection and Processing of Specimens
c.
The inspectors evaluated collection and processing of specimens by
observing another inspector, who was subjected to the breathalyzer
and who actually gave a urine sample, go through the screening process.
Those specimens were properly identified, positively controlled, and
processed according to the licensee's procedures and the rule.
However, while processing the simulated blood specimen provided by
the inspector, the chain of custody was not properly maintained, in
that the onsite testing laboratory technician had temporary custody
without signing the chain-of-custody form.
The licensee took immediate
corrective action by changing the procedure to take the blood specimen
directly to secure storage pending shipment to the HHS-certified
laboratory.
Although this is a violation of Section 2.4(d) of Appendix
A to 10 CFR Part 26, the violation is not being cited because the
criteria specified in Section V.A. of the Enforcement Policy were
satisfied.
The licensee does not test between 7:00 pm and 6:00 am on weekdays
and over the weekends.
The licensee had explored the possibility of
testing during the off-hours, but the effort was not considered
productive for several reasons:
a.
It required three people to administer the testing, roughly
equivalent to the number of workers tested.
b.
The people on these shifts may be tested early or late during
their shift; plus they rotate shifts and are subject to behavioral
observation.
c.
No positives have resulted, to date, and there is a low-positive
rate for the entire workforce.
This predictable gap in scheduling diminishes the deterrent effect
of random testing. Although this is a violation of 10 CFR 26.24,
the violation is not cited because the criteria in Section V.A. of
the Enforcement Policy were satisfied.
Development, Use, and Storage of Records
A system of files and procedures to protect personal information
contained in FFD related records had been developed.
Such records
were used and stored in an appropriate manner.
Medical-related records
were routinely stored within a fire retardant storage room in the
medical services area which was routinely locked during non-working
hours~ Access to such records was limited to medical and clerical
staff members who had job-related "need to know" responsibilities.
Results of quality control and confirmatory tests from the HHS
laboratories were routinely delivered by express mail to the Laboratory
12
Supervisor or by electronic transmission to a terminal located within
the secured laboratory facility.
The Laboratory Supervisor collects
the results of the onsite testing and the laboratory report, which
are then provided to the MRO.
Adequate controls were also implemented
for computer related information.
Passwords were required for access
to the data, and personnel with access capabilities had a work-related*
need for such access.
Interviews disclosed that the computer programmer
had been subject to the same type of psychological evaluation and
background investigation as the FFD staff members.
The Quality Assurance department noted in its February 1990 audit
that some FFD related records (such as continuous behavioral observation
records) needed to be included and/or identified as part of the FFD
record files.
The audit findings were scheduled to be resolved by
March 31, 1990.
One practice noted during the inspection detracted from the generally
stringent controls for FFD-related records.
By practice, presumptive
positive test results noted during the initial onsite screening test
(pre-access) were given to a nurse for storage in her desk until the
confirmatory test results were received from the HHS laboratory.
A
clerk within the Medical Department was also advised of the presumptive
positive test results for applicants for unescorted access so an
administrative hold could be placed on issuing a security badge (the
reason for the administrative hold did not appear in the computer
data.) Since a presumptive positive is identified only as an
administrative hold and there are many other reasons for administrative
hold, the licensee 1s staff believed that individual rights were
protected.
Retaining presumptive positive test results within the
laboratory until confirmatory test results are received appears to be
a more appropriate control of access to the information, provides a
more secure storage location, and prevents subsequent administrative
action on such presumptive positive test results.
d.
Audit Program
The licensee had completed Quality Assurance (QA) audits of the FFD
program implementation and audits of the two HHS laboratories that
are used to perform testing services and redundant quality checks.
The scope and depth of the audits were excellent and addressed all
major elements of the FFD program.
Audit findings were technically
correct and well defined.
Initial responses to the audit findings
were scheduled to be completed by March 31, 1990.
The audit findings
were generally consistent with the observations of the NRC team
members.
w
-
8.
13
Onsite Testing Facility
The onsite testing facility was centrally located, modern, spacious,
well-equipped, and adequately staffed by persons who displayed a high
level of proficiency.
Aside from some minor concerns, such as a
considerable amount of personnel traffic, some of which criss-crossed
during the specimen collection process, the facility more than adequately
meets the intent of the FFD rule.
a.
Written Procedures
Written procedures had been developed for key functions and processes.
The testing facility procedures were not reviewed by the inspectors,
therefore no conclusions are made concerning their adequacy or
whether they meet regulatory requirements.
b.
Practices
Practices were in accordance with the general intent of the FFD rule.
c.
Quality Controls
The inspectors verified that the licensee followed the blind performance
test procedures.
The quality control measures met the intent of the
FFD rule.
To help assure that test results are valid, the licensee splits all
urine specimens and the licensee sends all presumptive positive
,preliminary tests and blind performance test specimens to two separate
HHS-certified laboratories for further testing.
d.
Security
The licensee self-identified a physical security weakness that exists
in the testing facility, and has initiated corrective action, as
described in paragraph Sc, above .