ULNRC-06046, Investigation of Lab Accessioning Error

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Investigation of Lab Accessioning Error
ML13277A114
Person / Time
Site: Callaway 
Issue date: 10/03/2013
From: Maglio S
Ameren Missouri
To:
Document Control Desk, Office of Nuclear Reactor Regulation
References
ULNRC-06046
Download: ML13277A114 (6)


Text

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WAmeren MISSOURI Callaway Plant October 03,2013 ULNRC-06046 U.S. Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555-0001 Ladies and Gentlemen:

10CFR26.719(c)

DOCKET NUMBER 50-483 CALLAWAY PLANT UNIT 1 UNION ELECTRIC CO.

FACILITY OPERATING LICENSE NPF-30 INVESTIGATION OF LAB ACCESSIONING ERROR In accordance with 1 OCFR26. 719( c), enclosed is the documentation of investigative findings and the corrective actions taken for a lab accessioning error. A report from MU Health Care, Toxicology &

Drug Monitoring Laboratory is included in the enclosed documentation of investigative findings.

Please contact Anna Lee at 573/676-4435 if any additional action is needed as a result of this information.

This letter does not contain new commitments.

SAM/ AML/gld/rjb Enclosure Sincerely,

/:\\eot1A. 9 Scott A. Maglio Regulatory Affairs Manager PO Box 620 Fulton, MD 65251 AmerenMissouri.com

ULNRC-06046 October 03, 2013 Page 2 cc:

Mr. Steven A. Reynolds Acting Regional Administrator U.S. Nuclear Regulatory Commission Region IV 1600 East Lamar Boulevard Arlington, TX 76011-4511 Senior Resident Inspector Callaway Resident Office U.S. Nuclear Regulatory Commission 8201 NRC Road Steedman, MO 65077 Mr. Fred Lyon Project Manager, Callaway Plant Office of Nuclear Reactor Regulation U.S. Nuclear Regulatory Commission Mail Stop 0-8 B 1 Washington, DC 20555-2738

ULNRC-06046 October 03, 2013 Page 3 Index and send hardcopy to QA File A160.0761 Hardcopy:

Certrec Corporation 4150 International Plaza Suite 820 Fort Worth, TX 76109 (Certrec receives ALL attachments as long as they are non-safeguards and may be publicly disclosed.)

Electronic distribution for the following can be made via Other Situations ULNRC Distribution:

A. C. Heflin F. M. Diya D. W. Neterer C. 0. Reasoner III L. H. Graessle B.L.Cox S. A. Maglio Corporate Communications Corporate Oversight NSRB Secretary T. B. Elwood Performance Improvement Coordinator Resident Inspectors (NRC)

STARS Regulatory Affairs Mr. John O'Neill (Pillsbury Winthrop Shaw Pittman LLP)

Missouri Public Service Commission

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WAmeren MISSOURI AAFFD 13-0009 October 01, 2013 Mrs. Anna Lee Supervisor Access Authorization/Fitness for Duty Ameren Missouri Callaway Energy Center P.O. Box 620 Fulton, MO 65251 RE: Investigation of Lab Accessioning Error at DHHS Laboratory Enclosure to ULNRC-06046 Callaway Plant Attached is the investigative report and corrective actions regarding an accessioning error received from Toxicology Laboratories. In addition to the lab actions, the specimens involved were recollected and tested. All results were negative.

As MRO, I am satisfied that the appropriate actions have been taken to resolve the issue. If any further questions arise, please do not hesitate to give me a call at 573/676-430 I.

William P. Cravens, M.D.

Medical Review Officer, Callaway Energy Center cc:

Al60.0001 PO Box 620 Fulton, MO 65251 AmerenMissouri.com

W Health Care University of Missouri Health System TOXICOLOGY & DRUG MONITORING LABORATORY September 30, 2012 Ms. Anna M. Lee Supervisor Access Authorlzation/FFD Callaway Plant P.O. Box 620 Fulton, MO 65251 RE: CARS Number 201307428

Dear Ms. Lee:

Enclosure to ULNRC-06046 I am In receipt of the Callaway Action Request document (CARS Number 201307428) submitted to the laboratory on September 26, 2013. Thts document details a laboratory error that occurred on September 10, 2013 In which a laboratory technologist failed to provide required signatures on the Specimen Receiving Section (Step 4) of the Federal Custody and Control Form (CCF).

After a thorough review of this matter, l have determined that the laboratory technologist who received/accessioned the specimens failed to follow the standard operating procedures for the handling of Callaway (Ameren} samples. As soon as the error was identified, during the revie~ process, steps were taken to remedy the omissions. But, since the technologist had already left for the day, the annotations could not occur until the following day-September 11. Testing results and the CCFs (with the CCF receiving omissions) were nonetheless transmitted via secure email on September 10.

Corrections to the CCFs were made the following day on September 11. However, the laboratory failed to re-submit the correctly annotated CCFs to Callaway.

Let me be clear, this is an error of omission associated with the annotation of custody &

control documents. Security seals on the specimens were intact. Specimens were placed Into secure storage. This error In no way affected the proper analysis or results reported for the submitted samples and there were no additional areas of concern identified regarding the specimen handling or processing. In other words, this Is a custody paperwork omission only. Results reported to Ameren were correct.

It should be noted that our laboratory just completed its annual Ameren audit (September 17 & 18. 2013}. During that inspection, a member of the audit team observed the technologist involved in this event receive/accession Callaway samples and no policy or practice prob,ems were detected.

The laboratory unequivocally accepts responsibility for this oversight. The laboratory takes this event very seriously and we regret this error. That said, on occasion, even the most perfunctory/routine tasks (the signing of a receiving statement, that has been performed by this technologist countless times over the last four years) can inexplicably become problematic.

301 Business Loop 70 West Suite 208 Columbia, MO 65'203 Phone: 573-882-1273 Fa.1:: 573-884-4917

Ms. Anna M. Lee September 30, 2013 Page2 Enclosure to ULNRC-06046 As remediation, the technologist was required to re-read the standard operating procedures for specimen recelvlng/accesslonlng and sign a document that attests to its understanding and compliance. In addition, supervisory staff will oversee the receiving/accessionlng steps performed by this technologist for five working days commencing with the next shipment of Ameren specimens.

I trust that these remediation measures will demonstrate the laboratory's commitment to correcting this mistake as we work toward "error-free" procedures (with the acknowledgment that perfection is an unattainable goal). You should know that we also utilize these types of events as a valuable staff development tool. Identifying and addressing errors provides us with the opportunity to re-examine our responsibilities and re-enforce the vigilance necessary to properly perform our required tasks.

If you have additional concerns. please contact me.

_;;p)yfhours.

PaulL. Cary, M.S.

Responsible Person Toxicology Laboratory