ML22243A266
| ML22243A266 | |
| Person / Time | |
|---|---|
| Site: | Palo Verde  |
| Issue date: | 08/30/2022 |
| From: | Harbor C Arizona Public Service Co |
| To: | Document Control Desk, Office of Nuclear Security and Incident Response |
| References | |
| 102-08489-CDH/LMW | |
| Download: ML22243A266 (3) | |
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ENCLOSURE Unanticipated Result for FFD Performance Test Sample
ENCLOSURE Unanticipated Result for a FFD Performance Test Sample Description In accordance with 10 CFR 26.168, Arizona Public Service Company (APS) provides performance test samples which are submitted to the two contracted Department of Health and Human Services (HHS) certified laboratories for Fitness for Duty (FFD) specimen analysis for the Palo Verde Generating Station (PVGS) FFD program. The two laboratories are MedTox Laboratories Incorporated (MedTox) and Laboratory Corporation of America Holdings (LabCorp).
On Thursday, April 14, 2022, APS Fitness for Duty (FFD) sent specimen Y42603645 to MedTox for expanded panel testing (42023). On Friday, April 15, 2022, Palo Verde received an unanticipated negative test result back for blind performance test specimen, as opposed to receiving a positive test result back for the specimen. Palo Verde found that MedTox performed a five-panel test (42021) as opposed to the requested expanded panel test (42023). Palo Verde immediately contacted MedTox on Friday April 15, 2022, inquiring why the laboratory did not test the specimen as requested on the Custody and Control (CCF). The blind performance test specimen sent to the laboratory for testing was a synthetic opioid and was not part of the five-panel test. Therefore, MedTox did not perform the test that PVGS had requested them to perform resulting in the unanticipated test result. This is considered a testing error requiring an investigation be conducted and be reported to the NRC in accordance with the requirement contained in 10CFR 26.719(c)(1).
Investigation Results Vendor Corrective Action Report (VCAR) #VC-MAE1-22-001 was issued to MedTox on May 06, 2022 to initiate an internal investigation as to the reason for the testing error of entering the incorrect testing code and provide a cause and a corrective action(s) either taken or planned to mitigate and prevent re-occurrence.
0n June 07, 2022, MedTox concluded their internal investigation stating that the data entry operator mistakenly entered 42021 into their system versus the requested expanded panel 42023.
A review of this response by both NAD and FFD management noted that MedToxs initial response identified an individual human performance error and no programmatic gaps either in their training or procedures. MedToxs response was accepted by NAD and signed on June 28, 2022.
Actions Taken The corrective action(s) provided by MedTox stated that the data entry operator was coached to contact a team lead when unsure which test number to enter into their system. Additionally, MedTox provided additional training to the operator that entered the incorrect test number into the system for testing.