ML20058L741
| ML20058L741 | |
| Person / Time | |
|---|---|
| Site: | Millstone, Haddam Neck File:Connecticut Yankee Atomic Power Co icon.png |
| Issue date: | 07/15/1993 |
| From: | Kaufman B NORTHEAST UTILITIES |
| To: | |
| Shared Package | |
| ML20058L710 | List: |
| References | |
| SS-169, NUDOCS 9312170167 | |
| Download: ML20058L741 (14) | |
Text
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4 Quality Services Department Surveillance Report TO: R.J. Factora, M.D. Quinn, D,.J. Heritage REPORT NUMBER:
SS-169 FROM: B.S. Kaufman 3 4 DATFg g 15-93 UNIT: All RESPONSE REQUIRED: YES XX DATE[ 9-3-93 NO DEPARTMENT: OHU ACTIVITY OBSERVED:
The Internal Audits (IAD) and Quality Services (QSD) Departments were requested to perform a series of investigations of various aspects of the Fitness For Duty (FFD) Program.
This assessment evaluated the FFD users concerns.
EXECUTIVE
SUMMARY
T This assessment determined that an ineffective communication process between FFD users and FFD administrators resulted in a series of unresolved concerns.
These concerns were compiled into 16 items that are the subject of this surveillance.
Some of these concerns were addressed but are not finalized and have not been effectively communicated to the users.
The results of this surveillance indicate that there are no
'significant concerns with the effectiveness of'the FFD program.
Certain deficiencies of the random list process still exist that may impact the performance of the program.
Some implications pertain to the system usability and efficiency.
They are as follows:
1.
Lack of a contingency plan to generate a random list, 2.
Handling of a rejected specimen is not clearly. defined in the users guide, 3.
Lack of a process to collect FFD computer program users comments and/or suggestions (this item will be addressed in -
detail by the IAD at a later date),
These deficiencies are of significance category D.
A response from the FFD program administrators is required within 45 days of-the receipt of this report (approximately September 3, 1993).
At this time no response is required for item 3 above.
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9312170167 931207
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i Page 2 of 9 SS-169 In addition, there are two recommendations:
1.
recommendation to include the FFD users in a review of the new/
proposed Program Users Manual.
2.
recommendation to adapt a formalized process to handle user concerns.
This would be similar to the Issues Management System 1
proposed by the revised PEP Action Plan 3.3.1.
CORRECTIVE ACTION:
1.
Concern #1 (see item #16 of the Details of Observations) is a.
significance level D.
A written response from the FFD program administrators is requested to describe a contingency method to generate random lists.
(See NEO 3.07 for the response requirements for a level D concern).
2.
Concern #2 (see item #10 of the Details of Observations) is a significance level D.
A written response from the FFD program administrators is requested to describe actions taken'to correct i
this concern.
Clear instructions should be provided to the FFD users on handling of rejected specimen.
(See NEO 3.07 for the response requirements for a level D concern).
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3.
The weakness discussed in item #13 of the Details of Observati as j
will be presented later by a memorandum from IAD.
Although no i
response is required at this time, the FFD program administrators i
should consider a formal process to collect FFD computer program users comments.
Responses to concerns.#1 and #2 are required by September 3, 1993.
Please address it to Brian S. Kaufman, QSD Supervisor, Berlin NUS 129.
cc.: R.V. Ahlstrand - NU East A.P.. Anderson G.H. Bouchard - NUS129 G.J. Closius - MP R.
Ciurylo - NU East #
C.W. Griss - NU East G.R. Hallberg - E109 C.V. Marien - MP S.S. Mirabella - NU East M.W. Nericcio - CY D. Welch - NU East PERFORMED BY:
Kristoff J. Meller (ext. 3506) h ju,
DATE: 7/15/93 v
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- DETAILS OF OBSERVATIONS:
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The QSD and IAD-auditors were requested.to assessia' I
l resolution to thirteen concerns raised by.the FFD users..
Thel original concerns list. included sixteen items.
In1a seperate-j meeting between QSD and FFD users it was:decidedithat items?
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- 4,.#5, and #14 were not needed:to be.' addressed at this-time.
A scope of this surveillance wasEdiscussed with: MP Station j
and QSD management.
These: concerns were-brought;to the?
attention of the FFD' administrators (Health-Unit. Department).
J The auditors met-with tihe FFD users - (meeting off 06/01'/93,.-
I 04/29/93,.06/07/93), FFD administratiors s (meeting of. 5/11/93, -
.l 6/15/93,.7/1/93, 7/14/93),
Millstone: FFD Management" (meeting of 7/9/93).-
In'the. month of June, the~IAD and-QSD: performed i
an assessment of the security software protection.of thelFFD,
<l data base program.
This investigation revealed;thatitheL A
access to the program is well protected and controlled.
A memorandum presenting details of this.'part of the assessment; j
will b.e issued at a-later date by-the:IAD.-
The following are the thirteen concerns'and the current' h
status of their resolution, as presented by the FFD: program administrators.
The results of this part-oflthe assessment-are not conclusive because-the FFD enhancement process is ongoing and incomplete.
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t ltem #1. This is a random' list process / downtime wimpact. :
Concern:
a)
FFD computier printouts do 'not include time and date.
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b)
Does the CICS routine maintenance and down1 i
periods impact the-FFD obligation for' random.testout-generation?
(This appears to be a: routine practice-
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on Tuesday evenings andLon Sunday in late j
afternoons).
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.q Resolution:
a)
Verified sample printout of a random testouttlist.4 The date and time have been added as shown inia"
- l printout generated on 7/2/93 at 08
- 57:20'.-
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The FFD. program administrators-stated thatsthe-
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CICS downtime does not impact the program's performance.
The random-generated testout list is usually generated in the mornings (this;is the-i
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i Page 4 of 9 SS-169 pract' ice but is not required to_be; it can be done anytime at different frequencies, even once a week).
Employees who get selected are not notified about testing until a short time before being required to report to the FFD collection facility.
OSD Proposed Corrective Actions:
Recommendation # 1 QSD recommends adaptation of a formalized process to handle user concerns.
This would be similar to the Issues Management System proposed by the revised PEP Action Plan 3.3.1.
It would prevent the' risk of having inconsistent and fragmented methods for the control of issues which require follow-up actions.
Itenis #2, #9. This. is a design application / system usability.
issue.
Concern:
a) It is difficult to make timely revisions to names of supervisors in the FFD computer data base.
b) It is difficult to contact new supervisors whose names do not appear on a current Organizational Chart, NUCHRIS or VAX.
What is the expected process-to contact these supervisors in a timely manner?
Resolu tion :
a, b) The FFD program administrators stated that the process to revise a supervisor's name in the current.
FFD data base does not differ from the previous one.
They realize that the update process is not timely.
The NUCHRIS program has a lag time but it is the best tool that is now available.
When contacting a new supervisor is ineffective, they suggest contacting the department's upper management or the Human Resources Group.
This process is not formalized and according to the FFD program administrators does not need to be.
OSD Proposed Corrective Action:
See Recommendation #1 (page 4 of this report).
1 Page 5 of 9 SS-169 lten1 #3. This is a random list process / printing options.
Concern:
a) What is the design specification for printing random lists?
b) Is the " Printing a Random List" in the Users Guide the only QI preferred way to obtain random list
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printouts?
c) Should the Users Guide offer all other options to obtain a printout of a random list?
Resolution:
a, b, c) The FFD program administrators stated that
" Printing a Random List" is shown in the Users Guide as a model.
Therefore it is not intended as the only means to obtain a random list printout.
The FFD program administrators stated that they will discuss this further with the Information Resources Group (IRG) to clarify the printing options.
IRG is developing a new Users Manual which will, provide a proceduralized method to access and exit the FFD computer system.
The FFD program administrators stated that it includes enhancements which will address many Users concerno.
Currently the issuance of this manual is on hold.
The FFD program administrators explained that additional FFD program modifications need to be worked out with the Millstone Station FFD management.
OSD ProDosed Corrective Actions:
= Options for printing a random list should be resolved between the FFD program administrators and IRG.
This should then be communicated to the FFD Users.
Itenas #6i,7,8. This is a data entry / "need to know" issue.
Concern:
Is "the need to know" practice (defined in 10CFR20) in line with the department work practices.
Resolu tion :
The enhancement to the FFD program is in process.
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SS-169 l
FFD program administrators stated that it is.being changed to separate all sites.
This will limit the "the need to know" to a single site only (Berlin, CY, or Millstone).
OSD Prooosed C6rrective Actions:
Assure that this enhancement is implemented and
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communicated to the FFD Users via appropriate means (eg.: FFD program training)-.
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Item #10. This is a data entry / handling of rejected specimen issue.
C6ncern:
The Users Guide does not clearly explain-the rejected specimen process.
Resolution:
i This item still is not resolved and needs to be addressed.
OSD Proposed C6trective Action:
A written response from the FFD program administrators-a is required to. describe actions taken to correct this concern.
Provide clear instructions to the FFD users on th'e handling of rejected specimens.
See Recomr.iendation #1 (page 4 of this report).
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Iten1 #11. This is a data entry / input of test results issue.
b Concern:
What is the assurance that the' positive and the negative test results information is inputed without an error to-the FFD data base.
Resolution:
The FFD program administrator stated that he performs the input of positive test results.
This process will be improved by the IRG Program Manual.
Memo BWC-93-18, from B.W.
Cook to R.J. Factora, D.J.
Heritage, and.M.D.
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Page 7 of 9 SS-169 Quinn, da'ted on June 3, 1993 explains the integrity of entering test results.
OSD Proposed Corrective Acti2D1 The proposed action discussed in the above memo appears to be satisfactory.
Iteni #12. This is a data entry / SSN generation and input for
" blind tests" issue.
Concern:
What are the chances of issuing a real/ existing SSN for a " blind test."
Resolu tion :
The FFD program administrator stated that the " blind tests" are purchased from a outside company that already have been issued a false SSN.
This is an industry practice and it is considered to be effective.
All
" blind test" results are inputed into the FFD data base as "B"
(blind) category.
If the SSN already exists in a data base, then the program will reject that number.
OSD ProDosed Corrective Actions:
s See Recommendation #1 (page 4 of this report).
Item #13. This is a system usability / user feedback process issue.
Concern:
Is there a process to collect FFD computer program users comments and/or suggestions?
Resolu tion :
None.
Prooosed Corrective Action:
This will be presented in a later memorandum by the IAD.
Although no response is required at this time, the FFD l
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Page 8 of 9 SS-169 i
program administrators should consider a formal method-to collect FFD computer program users comments and ideas for software improvement.
Itena #15. This is a random list generation process issue.
Concern:
l Is the " randomness" process acceptable from the j
statistical perspective.
l Resolu tion :
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The FFD program administrators initiated statistical l
tests to assure that the random generation process is effective.
Memo from Ernest Lorda to Brian Cook, dated on March 22, 1993 documents the final results of these tests.
In this memo, Mr. Lorda states that "it appears that the new computer program will provide valid random l
selections of employees."
He also states that he intends to further analyze the process once the program has been in use for a few months.
Additional statistical tests utilizing actual selections data were performed-in June 1993.
This information was provided i
by the FFD program administrator.
OSD Prooosed Corrective Actione:
The FFD program administrator is requested to provide the latest results of the additional statistical tests.
These were discussed in a memo from Ernest Lorda to l
Brian Cook, dated on July 12, 1993'and will complete analysis of all the pools corresponding to the period ending on June 30th.
Iten1 #16. This is a random list process / contingency plans issue.
Concern:
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What is the contingency plan for a case when the CICS l
program is not available.
How would the random l
generating list be generated?
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SS-169 1
I ResolutioIn:
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-The FFD program administrators stated that.the FFD program is includedLin'the' Disaster Recovery System. ~In
'j a case where the system would become inoperative, the recovery time would not exceed'8 days..
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It appears'that the process relies on-computer support l
only.
There is no other plan to.' generate.a random list.
i OSD:Provosed Corrective Actions:
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= The FFD program administrator made a commitment to add-
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this. issue to the agenda.of-the'next:FFD task meeting.
= A written response-from the~FFD program administrators 1
is required to describe a contingency method to generate random lists.
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= See Recommendation #1--(page 3 of this' report),
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.mem.westa scor co-w August 17, 1993 MOH-93-147 TO:
B.
S.
Kaufman FROM:
D.
J. Heritage #
Berlin, (Ext. 2306)
SUBJECT:
Response to Surveillance Report SS-169 l
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The purpose of this memo is to reply to QSD Surveillance Report SS-169, dated July 15, 1993 which has a response date of September 3, 1993.
The details of observations and responses are as follows:
1.
Lack of contingency plan to generate a random list.
Response
Under 10CFR26.24(a)(2), it states that "... tests must be administered on a nominal weekly frequency...".
Th' FFD computer program which generates the random list, is covered by the IRG Disaster Recovery plan which assures that in the unlikely event that the mainframe computers in Wethersfield are disabled due to a disaster, the FFD computer program would be restored within 5-8 days.
Since the issuance of the surveillance report, Bryan Cook, FFD Program Administrator, spoke with Mr. Loren Bush, Chief, Program Development and Review Section, of the NRC for an interpretation of " nominal weekly" as referenced in 10Crn26.24(a)(2).
Mr. Bush was instrumental in the development and implementation of 10CFR26, Fitness For Duty Programs.
Mr. Bush explained that nominally means plus 25%, which in this case equates to 8.75 days.
Since our Disaster Recovery plan assures restoration within 8 days, he said that we are in compliance with the regulation.
Mr. Cook also stated that if this scenario were to occur, management would be instructed to increase their behavioral observation program to ensure that personnel granted unescorted access would not be abusing alcohol and/or drugs.
Mr. Bush concurred that with the combination of the Disaster Recovery plan and the increased behavioral observation awareness, we meet the intent of the FFD Program.
I trust that this satisfies the concerns regarding a
t contingency plan and no further action is required.
l 2.
Handling of a rejected specimen is not clearly defined in the users guide.
Response
i The handling of a rejected specimen was covered under
" Inputting Invalid Test Results" in the users guide.
This section heading has been changed to " Inputting Rejected i
specimens" and issued in Revision 3 of the FFD Users Guide-EZ (attached) on August 16, 1993.
l 3.
Lack of a process to collect FFD computer program users comments and/or suggestions.
Response
As explained in the surveillance report, this item will be addressed in detail by the IAD at a later date.
If you have any questions, comments, or requests for: additional l
information, please call Bryan Cook at extension 2153 in Berlin.
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DJH:BWC/mdw-cc: R. V. Ahlstrand A. P. Anderson l
G. H. Bouchard G. J. Closius i
B. W.
Cook i
R.
Ciurylo l
R.
J.
Factora f
C. W.
Grise' G. R. Hallberg C. V. Marien S.
S. Mirabella M. W. Nericcio M. D. Quinn D. E. Welch
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i CORRECTING A RECORD l
t Type in 10 and enter.
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Type in test pool, SSN, test reason and selection 'date. Hit enter.
i Scroll down to the left of the name and type in the appropriate number from the menu ( 1 for Random collected,2 for Random notest,3 for Random notified, or 4 for Non random). Hit enter.
t Change the disposition to G and enter. Hit PF3 (the record will be reset to G status).
l Hit PF3 to back out.
Proceed under option 2 to make the necessary correction.
INPUTTING RETECTED SPECIMENS i
Type in 4 and enter.
Type a C in the disposition field and the appropriate collection site (BE, CY or MP) and type in the specimen number and hit enter.
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Scroll down to the left of the name and type in 2 to the left of the name and enter.
Type in Invalid in the Lab result-1 line and Invalid in the MRO result-1 line and f
hit F3.
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Hit PF3 to back out.
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August 17, 1993 l
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QSD-93-5274 TO:
R.J.
- Factora, MP Unit Services Director M.D. Quinn, CY Nuclear Services Director 1
D.J. Heritage, Berlin OS&H Manager 1
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)et/e FROM:
B.S. Kaufman l
QSD Supervisor, Assessment & Staff Services Berlin, Extension 3060
SUBJECT:
OSD Surveillance Report SS-169, Assessment of the Fitness for Duty Procram.
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REFERENCES:
- 1. QSD Surveillance Report SS-169, dated on 7-15-93, from B.S. Kaufman to R.J. Factora, M.D. Quinn, and D.J. Heritage.
- 2. Memo MOH-93-147, dated on 8-17-93, from D.J.
Heritage to B.S. Kaufman.
We reviewed your referenced response to the subject surveillance.
The following is our evaluation:
COncent #1 (item #16 of the Details of Observations, see reference #1).
Your response is satisfactory.
Please assure that Mr. Bush's (NRC) concurrence, the IRG Disaster Recovery plan, and the need for increased behavioral observation program will be communicated to the FFD program employees.
l Cbncent #2 (item #10 of the Details of Observations, see I
reference #1).
Your response is satisfactory.
We verified the revision l
(Rev.3) of the section heading "Inputing Rejected Specimens" i
i 70 rcd S-GD l
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Page 2 of 2 F
QSD-93-5274 of the FFD Users Guide.
This clarification appears to be acceptable.
No further response is required.
The QSD surveillance SS-169 is closed.
cc.:
R.V. Ahlstrand - NU East A.P. Anderson G.H. Bouchard - NUS129 G.J. Closius - MP R. Ciurylo - NU East' C.W. Griss - NU East G.R. Hallberg - E109 C.V. Marien - MP S.S. Mirabella - NU East M.W. Nericcio - CY D. Welch - NU East L
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