ML24059A170
| ML24059A170 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 02/28/2024 |
| From: | Hamman D Wolf Creek |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation, Office of Nuclear Security and Incident Response |
| References | |
| 000335 | |
| Download: ML24059A170 (17) | |
Text
P.O. Box 411 l Burlington, KS 66839 l 620-364-8831 Dustin T. Hamman Director Nuclear Regulatory Affairs February 28, 2024 000335 U.S. Nuclear Regulatory Commission Attn: NRC Document Control Desk Washington, DC 20555-0001
Subject:
Docket No. 50-482: Electronic Submittal of Annual Fitness for Duty Program Performance Report and Annual Fatigue Report for 2023 Commissioners and Staff:
The enclosed documents contain Wolf Creek Nuclear Operating Corporations (WCNOC) 2023 Annual Fitness for Duty (FFD) program performance data and Annual Fatigue Report. This submittal meets the requirements of 10 CFR 26.203, 10 CFR 26.717 and 10 CFR 26.719. In accordance with 10 CFR 26.11, copies of the reported information are also enclosed with this report for the appropriate regional office and Senior Resident Inspector.
This letter contains no commitments. If you have any questions concerning this matter, please contact me at (620) 364-4204.
Sincerely, Dustin T. Hamman DTH/nwl Enclosure I: 2023 Fatigue Assessment and Report (2 pages)
Enclosure II: 2023 FFD Report and Attachment (12 pages)
CC: S. S. Lee (NRC), w/e J. D. Monninger (NRC), w/e G. E. Werner (NRC), w/e Senior Resident Inspector (NRC), w/e Licensing Correspondence - RA 24-000335, w/e
Enclosure I to 000335 2023 Fatigue Assessment and Report (This enclosure contains 2 pages)
NRC FFD Program Performance Data Reporting System 10 CFR Part 26, Subpart I -
Managing Fatigue Attachment This attachment provides the entire narrative as the NRC form has been created with boxes that scroll down, and when printed, the information prints very small due to the way the NRC has built the electronic Fatigue Management form.
Analysis of Waiver Assessment Data:
One work hour waiver completed for 2023.
Waiver 11/2/2023 ONLINE Waiver issued to ensure minimum NSO and fire brigade staffing due to sick callout.
Waiver request initiated for an operator to extend shift for 1 additional hour until relief could report. This extension would exceed work hours by 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> in regards to greater than 16 work hours in any 24-hour period and greater than 26 work hours in any 48-hour period. Waiver for individual was initiated and approved by management.
Individual performed work satisfactory and relieved in 1-hour time frame when relief arrived. No concerns noted in review of the waiver documentation or fatigue assessment documentation.
Analysis of Fatigue Assessment Data:
Six fatigue assessments were completed in 2023.
- 1 Post event 1/23/2023 ONLINE
- 2 For cause 6/8/2023 ONLINE
- 3 For cause 7/10/2023 ONLINE
- 4 Post event 7/16/2023 ONLINE
- 5 For cause 8/8/2023 ONLINE
- 6 Waiver 11/2/2023 ONLINE Condition reports were validated to be initiated for fatigue assessments within the corrective action program. In review of responses within fatigue assessments individuals involved did not describe or document any issues with fatigue or work hours that could have contributed to the event. The waiver initiated in operations for minimum staffing met regulatory and procedure requirements. No issues were identified from operations management for individual working additional work hours to maintain staffing.
==
Conclusions:==
The results of the annual fatigue management program effectiveness review determined Wolf Creek is effective in controlling the work hours of individuals subject to work hour controls.
Summary and Status of Corrective Actions:
The Corrective Action Program is adequately used to identify and correct concerns with compliance to the fatigue rule requirements
Enclosure II to 000335 2023 FFD Report and Attachment (This enclosure contains 12 pages)
Special Analyses Testing Results
- 26.163(a)(2) and 26.717(b)(2)
Total Number of "Dilute" Specimen Test Results (Optional)
Total Number of Specimens (Special Analyses Testing Conducted) 1 FFD Program Performance Data Reporting System NRC Form 891, Annual Reporting Form for Drug and Alcohol Tests (submit using the NRC EIE General Submission portal)
APPROVED BY OMB: CLEARANCE NO. 3150-0146 EXPIRES: 09/30/2024 Estimated burden per response to comply with this collection request is 106 hours0.00123 days <br />0.0294 hours <br />1.752645e-4 weeks <br />4.0333e-5 months <br />. This form is a voluntary means of reporting the information required under 10 CFR 26.417(b)(2) and 26.717. The information is required by the NRC to obtain on an annual basis site specific fitness-for-duty (FFD) program performance data on drug and alcohol programs from licensees and other entities. Send comments regarding burden estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001, or by e-mail to Infocollects.Resource@NRC.gov, and the OMB reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0146), Attn: Desk Officer for the Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; e-mail: oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the document requesting or requiring the collection displays a currently valid OMB control number.
- 1) All fields required unless marked 'optional'
- 2) Use of Adobe Reader 8 or later is required
- 3) Mouse over fields for additional information Facility Wolf Creek [50-482]
Submission Update Period of Report 2023 Tests Conducted in the Calendar Year Reason For Testing Total Number of Tests Conducted Total Number of Positive, Adulterated, Substituted, and Refusal to Test Results Licensee Employees Contractors/Vendors Pre-Access 83 217 3
Random 420 79 1
For Cause 2
2 1
Post-Event 2
0 0
Followup 21 3
1 Total (Calculated) 528 301 6
FFD Program Random Testing Population and Rate Average number of licensee employees 730 Average number of contractors/vendors 215 Total size of the random testing pool throughout the period (Calculated) 945 Annual random testing percentage achieved for the testing pool 52.8 Laboratory Testing Does your program use a Licensee Testing Facility? No HHS-Certified Laboratory Clinical Reference Laboratory (Primary)
Blind Performance Test Sample Supplier(s) ElSohly Laboratory HHS-Certified Laboratory Quest Laboratory (Lenexa, KS)
(Backup)
Substances Tested Did your program only test for NRC-required substances AND at the NRC-specified minimum cutoff levels? Yes Annual Report Form (version 1.11.0 - November 2022)
- Page 1 of 2 -
Additional Substances Tested Summary of Management Actions - 26.717(b)(8)
Summarize actions implemented to improve FFD program performance. As applicable, reference in the topic description audit reports, 30-day reports, and/or corrective action reports. If reporting information on more than three topics, select "Others" for Topic 3 to report any additional topics.
Topic 1 Policies and Procedures Add an additional Topic Topic 2 Blind Performance Test Samples Add an additional Topic Topic 3 Other(s)
Please elaborate:
CR # 10024692 - 2023 NRC FFD Inspection Minor Violation Training. Collector training contained incorrect information regarding the use of temperature strips.
The NRC Inspection Report 2023-401 proposed an NRC-Identified Minor Violation of 10 CFR 26.85(a)(1), which requires each Topic 1 Description CR # 10024690 NRC Green NCV - Fitness For Duty Policy did not provide specific guidance for employees to report directly to FFD testing as soon as reasonably practicable once notified of a random test.
NRC Inspection Report 2023-401 issued violation to Access Screening for 10 CFR 26.27(b) which requires the FFD policy be written 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.
Actions taken to correct this deficiency and strengthen the FFD program -
Compliance was restored on June 07, 2023, when Wolf Creeks FFD / FM Policy was updated to include as soon as reasonably practicable verbiage, so individuals are aware of 10 CFR Part 26 requirements when reporting for FFD tests once notified. There was no reportability.
1)The FFD / FM Policy was updated on June 06, 2023, by Access Screening. The new revision was signed off by the Access Screening Supervisor and the Director of Nuclear Maintenance on June 07, 2023. All FFD / FM Policy hard copy documents were replaced with the new FFD / FM Policy revision on June 07, 2023. A site wide communication was published in the Wolf Creek News on June 21, 2023 Topic 2 Description CR # 10023241 - Test Result Received for Blind Test Sample Not as Expected. On March 20, 2023, Wolf Creek Access Screening was notified a blind performance test provided by ElSohly and submitted to Clinical Reference Laboratory tested Substituted instead of PCP as expected. In discussion with the MRO staff at Coffey County Hospital it is believed the vials for PCP and Substituted were placed in bags with the incorrect Chain of Custody form. The Chain of Custody forms tie the vials to the expected result.
Actions taken - Access Screening conducted an extensive investigation and found the unexpected Blind Result was a result of human error. We found substantial evidence the lab did not make a mistake in testing and Elsohly, our blind manufacturer, did not make a mistake in what they sent us. With these findings, it was also determined this event does not require a 30-day report.
After reviewing the blind packaging process, Access Screening determined an improvement could be made to streamline and mitigate the possibility of human error in the future. The improvement suggestion was presented by Access Screening to CCH MRO Staff to change the ownership of packaging the blinds for shipment to Access Screening. CCH MRO Staff will continue to order the blind Topic 3 Description CR # 10022895 - Shy Bladder Individual Not Properly Sanctioned. On 3/7/2023, during an external peer review a shy bladder concern was identified when a review of the individuals file was performed.
Upon investigation it was confirmed the MRO did not follow 10 CFR 26.119. 10 CFR 26.119(c) states "The physician who conducts this evaluation shall make one of the following determinations:
(1) A medical condition has, or with a high degree of probability could have, precluded the donor from providing a sufficient amount of urine; or (2) There is an inadequate basis for determining that a medical condition has, or with a high degree of probability could have, precluded the donor from providing a sufficient quantity of urine."
Actions taken - Access Screening conducted a meeting with the Coffey County Hospital MRO Chief of Staff, Coffey County Hospital MRO Staff, and Supplier Quality auditor on March 21, 2023. We discussed 10 CFR 26.119(c). Since this individual did not have a medical condition which precluded them to provide a sample the determination by the MRO should have been considered a refusal to test as per 10 CFR 119(g)(2). The MRO stated he understood the mistake that was made, and he would ensure his MROs understand the expectations moving forward. Access Screening provided copies of Person(s) Responsible for Information Provided Person 1 (required):
Mallory First Name Rosales Last Name Senior Access Specialist Position Title mallory.rosales@evergy.com Company Email Address Person 2 (optional):
Sonya First Name Jones Last Name Supervisor of Access Screening Position Title sonya.jones@evergy.com Company Email Address Final Step (Required) - NRC will consider this form authentic in accordance with 10 CFR 26.11 only when the Validate & Lock button has been selected and all errors (i.e., those highlighted in red) have been corrected. The Validate & Lock button will change to Locked after the data validation process has been successfully completed and the form is ready for submission.
Form Locked On: Feb 26, 2024 at 2:52:03 PM Annual Report Form (version 1.11.0 - November 2022)
- Page 2 of 2 -
NRC Form 891 Print this Report Save to Local PC Locked
NRC FFD Program Performance Data Reporting 10CFR Part 26 - FFD This attachment provides the entire narrative as the NRC form has been created with boxes that scroll down, and when printed, the information prints very small due to the way the NRC has built the electronic form.
FFD Summary of Management Actions Summarize actions implemented to improve FFD program performance Topic 1: Policies and Procedure CR # 10024690 NRC Green NCV - Fitness For Duty Policy did not provide specific guidance for employees to report directly to FFD testing as soon as reasonably practicable once notified of a random test.
NRC Inspection Report 2023-401 issued violation to Access Screening for 10 CFR 26.27(b) which requires the FFD policy be written 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.
Actions taken to correct this deficiency and strengthen the FFD program -
Compliance was restored on June 07, 2023, when Wolf Creeks FFD / FM Policy was updated to include as soon as reasonably practicable verbiage, so individuals are aware of 10 CFR Part 26 requirements when reporting for FFD tests once notified.
There was no reportability.
1)The FFD / FM Policy was updated on June 06, 2023, by Access Screening. The new revision was signed off by the Access Screening Supervisor and the Director of Nuclear Maintenance on June 07, 2023. All FFD / FM Policy hard copy documents were replaced with the new FFD / FM Policy revision on June 07, 2023. A site wide communication was published in the Wolf Creek News on June 21, 2023 to inform site personnel the changes made to the FFD / FM Policy when reporting for Fitness for Duty (FFD) testing. The Access Screening share point was updated with the new FFD / FM Policy on June 07, 2023.
2)Procedure AP 01A-001 (Fitness for Duty Program) was revised to align with 10 CFR 26.31(d)(2)(iii) requirements of reporting to the collection site as soon as reasonably practicable within the time specified in the FFD policy.
3)An article was published in the Wolf Creek News to communicate the changes made to the FFD / FM Policy when reporting for Fitness for Duty (FFD) testing.
4)The FFD Program Owner JFG was updated to include this CR to enhance knowledge of the 10 CFR Part 26 Regulation.
Topic 2: Blind Performance Test Samples CR # 10023241 - Test Result Received for Blind Test Sample Not as Expected. On March 20, 2023, Wolf Creek Access Screening was notified a blind performance test provided by ElSohly and submitted to Clinical Reference Laboratory tested Substituted instead of PCP as expected. In discussion with the MRO staff at Coffey County Hospital it is believed the vials for PCP and Substituted were placed in bags with the incorrect Chain of Custody form. The Chain of Custody forms tie the vials to the expected result.
Actions taken - Access Screening conducted an extensive investigation and found the unexpected Blind Result was a result of human error. We found substantial evidence the lab did not make a mistake in testing and Elsohly, our blind manufacturer, did not make a mistake in what they sent us. With these findings, it was also determined this event does not require a 30-day report.
After reviewing the blind packaging process, Access Screening determined an improvement could be made to streamline and mitigate the possibility of human error in the future. The improvement suggestion was presented by Access Screening to CCH MRO Staff to change the ownership of packaging the blinds for shipment to Access Screening. CCH MRO Staff will continue to order the blind specimens through ElSohly, they will contact Access Screening to pick up the unpackaged blind specimens and then review the test results when theyre returned from CRL. Access Screening will be responsible for preparing the blind specimen for shipment. The strength gained in this change is only 1 blind specimen will be packaged on the designated day the blind is scheduled to be sent which can mitigate the possibility of human error and eliminates the packaging all the blinds at one time as the MRO Staff was doing. This improvement in the process cuts down on the multiple steps used in the past between MRO Staff and Access Screening.
Topic 3: Policies and Procedure CR # 10022895 - Shy Bladder Individual Not Properly Sanctioned. On 3/7/2023, during an external peer review a shy bladder concern was identified when a review of the individuals file was performed. Upon investigation it was confirmed the MRO did not
follow 10 CFR 26.119. 10 CFR 26.119(c) states "The physician who conducts this evaluation shall make one of the following determinations:
(1) A medical condition has, or with a high degree of probability could have, precluded the donor from providing a sufficient amount of urine; or (2) There is an inadequate basis for determining that a medical condition has, or with a high degree of probability could have, precluded the donor from providing a sufficient quantity of urine."
Actions taken - Access Screening conducted a meeting with the Coffey County Hospital MRO Chief of Staff, Coffey County Hospital MRO Staff, and Supplier Quality auditor on March 21, 2023. We discussed 10 CFR 26.119(c). Since this individual did not have a medical condition which precluded them to provide a sample the determination by the MRO should have been considered a refusal to test as per 10 CFR 119(g)(2). The MRO stated he understood the mistake that was made, and he would ensure his MROs understand the expectations moving forward. Access Screening provided copies of 10 CFR 26 handouts (26.119, 26.183, 26.185, & 26.187) for the MRO Chief of Staff to use for communicating the expectations going forward to our other MROs. Ensuring communication occurred to the other MROs was verified by calling the Director of Clinical Operations. All MROs have the documentation to understand the expectations.
During this meeting it was discovered the dictation system has been significantly upgraded since this issue occurred. The MROs dictation is now immediate as opposed to previously having a 24-hr. delay, closing the gap between when the evaluation occurs and Access Screening receiving the MRO determination. The MROs full dictation notes from 2021 to current were provided to Access Screening for review. The review did not identify any issues. Supplier Quality auditor initiated a Report of Non-Compliance (RON
- 25471-01) to Coffey County Hospital. The individual has now been correctly sanctioned. Access Screening also incorporated into the Water Intake process an informational sheet detailing the Water Intake and Shy Bladder Processes and the possible consequences. When the Water Intake process is needed the collector will get out informational sheet have the donor read the sheet, ensure they have no questions, and have them sign the Water Intake form they understand the process and possible consequences.
Topic 4: Training CR # 10024692 - 2023 NRC FFD Inspection Minor Violation Training. Collector training contained incorrect information regarding the use of temperature strips.
The NRC Inspection Report 2023-401 proposed an NRC-Identified Minor Violation of 10 CFR 26.85(a)(1), which requires each collector shall be knowledgeable of the
requirements of this part and the FFD policy and procedures of the licensee or other entity for whom collections are performed and shall keep current on any changes to the collection procedures for each specimen the individual is qualified to collect under this part. Specifically, the Licensee did not provide the correct training for measuring temperature of collections using the temperature strips used at the station.
Actions Taken - Access Screening reviewed the collector training material and removed the incorrect temperature strip training aide. The Fitness for Duty collector training material is now correct and in compliance with 10 CFR 26.85(a)(1). FFD / Access Screening verified procedure AI 01A-002, Fitness For Duty Screenings, aligns with the Fitness for Duty collector training material and they both align with the manufacturers recommendation on how to use and read the temperature strips.