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NSP000031 NRC INSPECTION MANUAL IRIB MANUAL CHAPTER 0612 POWER REACTOR INSPECTION REPORTS i
CONTENTS Page 0612-01 PURPOSE ................................................................................................. 1 0612-02 OBJECTIVES............................................................................................. 1 0612-03 DEFINITIONS ............................................................................................ 1 0612-04 RESPONSIBILITIES .................................................................................. 4 04.01 General Responsibilities. ........................................................................... 4 04.02 Inspectors .................................................................................................. 4 04.03 Branch Chiefs and Division Directors......................................................... 4 04.04 Division of Inspection and Regional Support.............................................. 4 0612-05 SCREENING INSPECTION RESULTS ..................................................... 5 05.01 Screen for Performance Deficiency............................................................ 5 05.02 Screen for Enforcement. ............................................................................ 5 05.03 Screen for More than Minor ....................................................................... 5 05.04 Screen for Significance (Color or Severity Level)....................................... 6 05.05 Analyze for Cross-Cutting Aspects............................................................. 6 05.06 Screening for Applicable Enforcement Action ............................................ 7
- a. For findings assessed in the SDP .............................................................. 7
- b. For findings with enforcement .................................................................... 7
- c. For violations with no performance deficiencies......................................... 8 0612-06 DOCUMENTING FINDINGS ...................................................................... 8 06.01 Introduction. ............................................................................................... 9 06.02 Description. ................................................................................................ 9 06.03 Analysis...................................................................................................... 9
- a. First Part Attributes. ................................................................................... 9
- b. Second Part Attributes. .............................................................................. 9
- 1. Risk-Informed SDP Results - Results from IMC 0609 Appendices A, F, G, H and K. .......................................................... 9
- 2. Deterministic SDP Results - Results from IMC 0609 Appendices B, C, D, E, I, J and M................................................... 10
- 3. Enforcement.................................................................................... 11
- c. Third Part Attributes. ................................................................................ 11 06.04 Enforcement. ........................................................................................... 11
- a. Finding without a violation........................................................................ 12
- b. Finding with a violation............................................................................. 12
- c. Finding with a violation with Enforcement Discretion ............................... 13 0612-07 DOCUMENTING VIOLATIONS WITHOUT PERFORMANCE DEFICIENCIES ........................................................................................ 13 0612-08 DOCUMENTING UNRESOLVED ITEMS ............................................... 14 08.01 Opening ................................................................................................... 14 08.02 Follow-up and Closure ............................................................................. 14 Issue Date: 12/04/08 i0612
0612-09 DOCUMENTING CLOSURE OF LERs AND CITED VIOLATIONS ......... 15 09.01 Licensee Event Reports (LERs) ............................................................... 15 09.02 Cited Violations ........................................................................................ 16 0612-10 DOCUMENTING LICENSEE-IDENTIFIED VIOLATIONS ....................... 16
- a. Potentially greater than Green. ................................................................ 16
- b. Violation ................................................................................................... 16
- c. Not a violation .......................................................................................... 16
- d. NRC added value..................................................................................... 17 0612-11 DOCUMENTING MINOR ISSUES AND MINOR VIOLATIONS ............... 17 0612-12 DOCUMENTING PERFORMANCE INDICATOR VERIFICATION RESULTS ................................................................................................ 17 12.01 Scope....................................................................................................... 17 12.02 Findings ................................................................................................... 17 0612-13 OTHER GUIDANCE................................................................................. 18 13.01 Treatment of Third Party Reviews............................................................ 18 13.02 Non-Routine Inspections.......................................................................... 18 13.03 Documenting Backfit Items ...................................................................... 19 0612-14 COMPILING AN INSPECTION REPORT ................................................ 19 14.01 Cover Letter ............................................................................................. 19
- a. Date ......................................................................................................... 19
- b. Enforcement Action.................................................................................. 20
- c. Addressee................................................................................................ 20
- d. Subject Line ............................................................................................. 20
- e. Salutation ................................................................................................. 20
- f. Introductory Paragraphs........................................................................... 20
- g. Body......................................................................................................... 20
- h. Closing ..................................................................................................... 21
- i. Security Inspection Reports ..................................................................... 21 14.02 Cover Page .............................................................................................. 22 14.03 Table of Contents..................................................................................... 22 14.04 Summary of Findings ............................................................................... 22 14.05 Plant Status.............................................................................................. 24 14.06 Report Details .......................................................................................... 24 14.07 Exit Meeting Summary ............................................................................. 27 14.08 Report Attachments ................................................................................. 28 0612-15 ISSUING INSPECTION REPORTS ......................................................... 29 15.01 Report Timeliness .................................................................................... 29 15.02 Release and Disclosure of Inspection Reports ........................................ 30 Issue Date: 12/04/08 ii0612
0612-01 PURPOSES To provide guidance for screening inspection results and to define the content and format for reports of power reactor inspections.
0612-02 OBJECTIVES 02.01 To screen inspection results to determine if issues warrant documentation in inspection reports.
02.02 To ensure inspection reports clearly communicate significant inspection results in a consistent manner to licensees, NRC staff, and, where applicable, the public.
02.03 To document the basis for significance determination and enforcement action.
02.04 To provide inspection results as input into the Operating Reactor Assessment Program (IMC 0305) of the Reactor Oversight Process (ROP) and the Operating Security Assessment Program (IMC 0320).
0612-03 DEFINITIONS The following terms are applicable for the purposes of screening and documentation:
Apparent Violation (AV): A violation of regulatory requirements that is being considered for potential escalated enforcement action.
Closed Item: A matter previously reported as a noncompliance, an inspection finding, a licensee event report, or an unresolved item, that the inspector concludes has been satisfactorily addressed based on information obtained during the current inspection.
Cross-Cutting Aspect: The cross-cutting aspects which can be ascribed to an inspection finding are fully described in IMC 0305, AOperating Reactor Assessment Program.@
Escalated Enforcement Action: A notice of violation or civil penalty for any Severity Level I, II, or III violation; a notice of violation associated with an inspection finding that the significance determination process characterizes as having low to moderate, or greater safety significance (White, Yellow or Red finding); or any order based upon a violation.
Finding (FIN): A performance deficiency of greater than minor significance. Findings may or may not be associated with regulatory requirements and, therefore, may or may not result in a violation.
Green Finding: A finding of very low safety significance.
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Independent Item: An item used to track information that does not originate in or is typically not documented as a finding in an inspection report but may be referenced in an inspection report to assess plant performance such as an Office of Investigation harassment and intimidation case.
Integrated or Independent Inspection Report: A reactor inspection report that documents the results of inspection(s) conducted by NRC inspectors within a specified period.
Issue of Concern: A well-defined observation or collection of observations that is of concern and may or may not involve a performance deficiency.
Licensee-Identified: For the purpose of this inspection manual chapter (IMC), Alicensee-identified@ findings are those findings that are not NRC-identified or self-revealing. Most, but not all, licensee-identified findings are discovered through a licensee program or process.
Some examples of licensee programs that likely result in such findings are post maintenance testing, surveillance testing, ASME Section XI testing, drills, critiques, event assessments, evaluations, or audits conducted by or for the licensee. Other examples of licensee-identified findings are those findings that are identified by the licensee as a result of their deliberate and focused observation during the course of performing their normal duties (e.g., plant operator or other licensee personnel identifying a packing leak on a valve or identifying a valve out-of-position during a routine tour of the facility would be considered licensee-identified, although the individual=s duties at the time may not have been to identify these types of deficiencies).
Minor Violation: A violation that is of such low significance that documentation in an NRC inspection report is not normally warranted (See screening criteria in Section 1-3 of Appendix B to this chapter). Although minor violations must be corrected, they are not usually described in inspection reports (see exceptions in Section 0612-11).
Non-Cited Violation (NCV): A method for dispositioning a Severity Level IV violation or a violation associated with a finding that is characterized as Green (very low safety significance). Provided applicable criteria in the Enforcement Policy are met, such findings are documented as violations, but are not cited in notices of violation, which normally require written responses from licensees.
Notice of Deviation: A licensee's failure to satisfy a written commitment, such as a commitment to conform to the provisions of applicable codes, standards, guides, or accepted industry practices when the commitment, code, standard, guide, or practice involved has not been made a requirement by the Commission.
Notice of Violation (NOV): A formal, written citation in accordance with 10 CFR 2.201 that sets forth one or more violations of a legally binding regulatory requirement.
NRC-Identified: Findings or violations, found by NRC inspectors, of which the licensee was not previously aware or had not been previously documented in the licensee=s corrective action program. NRC-identified findings also include previously documented licensee findings to which the inspector has significantly added value. Added value means that the Issue Date: 12/04/08 2 0612
inspector has identified a previously unknown weakness in the licensees classification, evaluation, or corrective actions associated with the licensee=s correction of a finding.
Observation: A factual detail noted during an inspection. Relevant observations are documented to support inspection findings or unresolved items. Additionally, observations not directly related to a finding may be documented if allowed by an appendix to this chapter or by the specific inspection procedure or temporary instruction.
Performance Deficiency: An issue that is the result of a licensee not meeting a requirement or standard where the cause was reasonably within the licensee=s ability to foresee and correct, and that should have been prevented. A performance deficiency can exist if a licensee fails to meet a self-imposed standard or a standard required by regulation.
Potentially Generic Issue: An inspection finding that may have implications for other licensees, certificate holders, or vendors whose facilities or activities are of the same or similar manufacture or style.
Red Finding: A finding of high safety significance as determined by IMC 0609, Significance Determination Process.
Self-Revealing: For the purpose of documentation in the ROP, self-revealing findings are those findings that become self-evident and require no active and deliberate observation by the licensee or NRC inspectors to determine whether a change in process or equipment capability or function has occurred. Self-revealing findings become readily apparent to either NRC or licensee personnel through a readily detectable degradation in the material condition, capability, or functionality of equipment or plant operations and require minimal analysis to detect. Self-revealing findings are treated the same as NRC-identified findings for the purposes of documenting them in inspection reports. Some examples of self-revealing findings include those resulting from: reactor trips and secondary plant transients; failure of emergency equipment to operate; unanticipated or unplanned relief valve actuations; obvious failures of fluid piping or plant equipment; identification of large quantities of water in areas where you would not normally expect such a condition; and non-compliance with high radiation area requirements that, in some cases, was identified through an electronic dosimeter alarm.
Significance Determination Process (SDP): The process used to determine the safety or security significance of an inspection finding as described in IMC 0609.
Unresolved Item (URI): An issue of concern about which more information is required to determine if a performance deficiency exists, if the performance deficiency is more than minor or if the issue of concern constitutes a violation. Such a matter may require additional information from the licensee or cannot be resolved without additional guidance or clarification/interpretation of the existing guidance (e.g., performance indicator reporting guidance).
Violation (VIO): The failure to comply with a legally binding regulatory requirement, such as a statute, regulation, order, license condition, or technical specification.
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Willfulness: An attitude toward noncompliance with requirements that ranges from careless disregard to a deliberate intent to violate or falsify.
White Finding: A finding of low to moderate safety significance as determined by IMC 0609, Significance Determination Process.
Yellow Finding: A finding of substantial safety significance as determined by IMC 0609, Significance Determination Process.
0612-04 RESPONSIBILITIES 04.01 General Responsibilities. Each inspection of a reactor facility shall be documented in a report consisting of a cover letter, a cover page, a summary of findings or summary of issues, inspection details, and supplemental information.
04.02 Inspectors.
- a. All NRC power reactor inspectors are required to prepare inspection reports in accordance with the guidance provided in this manual chapter.
- b. Inspectors have the primary responsibility for ensuring that inspection results are properly characterized, accurately reported, and that referenced material is correctly documented.
- c. Inspectors are responsible for ensuring that the content of the inspection report does not conflict with the information presented at the exit meeting.
04.03 Branch Chiefs and Division Directors.
- a. A manager familiar with NRC requirements in the inspected area shall review each inspection report to ensure that the report follows the format given in this chapter.
- b. The management reviewer shall ensure that inspection findings are consistent with NRC policies and technical requirements, and ensure that violations are addressed in accordance with the NRC Enforcement Policy and the NRC Enforcement Manual.
- c. The management reviewer shall ensure that significance determinations made in the inspection report are in accordance with Appendix B of this Chapter, IMC 0609 and the Enforcement Policy, as applicable.
- d. The applicable division director or designated branch chief is responsible for the content, tone, overall regulatory focus, and timeliness of regional inspection reports.
04.04 Division of Inspection and Regional Support. The Reactor Inspection Branch is responsible for providing interpretations of the information contained in this manual chapter, for answering questions related to the guidance, and for providing guidance for situations not covered in this manual chapter.
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0612-05 SCREENING INSPECTION RESULTS The evaluation of inspection results begins with screening to determine if an issue of concern will be documented for consideration in the ROP assessment process. The process for screening inspection results is described in the following sections. Detailed instructions are provided in Appendix B of this Chapter. For issues with multiple examples, each example should be screened separately. Guidance for documenting issues with multiple examples is provided in Section 0612-06.
05.01 Screen for Performance Deficiency.
An issue of concern must be a performance deficiency before it can be considered a finding.
Screen the issue of concern using section 1-1 of Appendix B to determine if it is a performance deficiency.
- If the issue of concern is a performance deficiency, it is screened to determine if it should be dispositioned under the enforcement process. See section 05.02 of this chapter; or
- If the issue of concern is not a performance deficiency but is associated with a violation, it must be evaluated under the guidance of the Enforcement Manual. Go to Section 0612-07; or
- If additional information is needed to determine if the issue of concern is a performance deficiency then the issue is an unresolved item and should be documented in accordance with Section 0612-08.
05.02 Screen for Enforcement This screen is used to determine if a performance deficiency, involving a violation of regulatory requirements, warrants consideration of enforcement action using severity levels and possible civil penalties by virtue of being in one of the prescribed categories for enforcement. Specifically, if a performance deficiency: had actual safety consequences; had the potential to impact the NRCs ability to perform its regulatory function; or involved willful aspects it must be dispositioned using the enforcement process. It is expected that only a small fraction of all performance deficiencies will be handled under the enforcement process.
Screen the performance deficiency using section 1-2 of Appendix B to determine if it should be dispositioned in accordance with the enforcement process.
05.03 Screen for More than Minor A performance deficiency must be more than minor to be considered a finding. For ROP, examples of minor performance deficiencies are provided in Appendix E to this chapter. If the performance deficiency is similar to a minor example, then the performance deficiency is Issue Date: 12/04/08 5 0612
minor. If the performance deficiency is not similar to the minor description, then the screen for more than minor questions in Appendix B Section 1-3 must be used to determine if the performance deficiency is more than minor and, therefore, a finding that warrants documentation.
For enforcement, examples of minor violations are provided in the supplements of the Enforcement Policy.
If the performance deficiency is minor, it is not a finding, will not be considered in the ROP assessment process, and in most cases will not be documented. See Section 0612-11 for the exceptions for documenting minor issues.
05.04 Screen for Significance (Color or Severity Level)
All findings (licensee-identified, NRC-identified or self-revealed) must be screened for significance to determine if they are potentially significant (greater than Green or SLIII or above). Findings that meet the criteria for enforcement are evaluated in accordance with the Enforcement Policy to determine the significance (severity level). Sections 1-4 and 2-1 of Appendix B, respectively, provide instructions for determining the significance of SDP and enforcement findings.
It should be noted that it is appropriate to state that the significance is TBD if the significance has not been finalized.
Licensee identified findings that are not potentially significant (greater than Green or SLIII or above) are not considered in the ROP assessment process and, therefore, no further evaluation is needed. These lower significant licensee identified findings are documented in accordance with Section 0612-10.
05.05 Analyze for Cross-Cutting Aspects All NRC-identified and self-revealing findings and all licensee-identified potentially greater than green findings shall be assessed for potential cross-cutting aspects. This includes findings assessed using SDPs or through enforcement.
For the specific case where a violation does not have a performance deficiency, the cause of the violation does not need to be evaluated for a cross-cutting aspect. This violation is not a finding, therefore will not have a cross-cutting aspect.
Assess the cause(s) of the performance deficiency to identify a potential cross-cutting aspect using the guidance and questions in section 1-5 of Appendix B. The cross-cutting aspect of a finding is not considered a separate finding but rather a performance characteristic that is the most significant contributor to the performance deficiency, if applicable. The intent of identifying the cross-cutting aspect of a finding is so that insight can be used in the assessment process. It should be noted that not all performance deficiencies have a cross-cutting aspect associated with them.
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The decision whether the cross-cutting aspect is reflective of current performance cannot be made solely based upon the time when the performance deficiency was identified or when the event occurred. The inspector should attempt to determine when the cause of the performance deficiency occurred.
It is necessary for the staff to make a sound decision based on available information on what causes are, and are not, reflective of current licensee performance. The inspectors decision is important so that the assessment process can focus on issues that are reflective of current licensee performance.
05.06 Screening for Applicable Enforcement Action This screen determines how a finding or a violation will be categorized (i.e., FIN, NCV, discretion, etc.) and whether a violation associated with a finding should be cited or non-cited as discussed in the NRC Enforcement Policy.
- a. For findings assessed in the SDP:
- If the finding did not involve a violation of requirements, then the finding is a FIN or TBD depending on its significance. There is no enforcement action.
Document the finding in accordance with Section 0612-06; or
- If the finding involves a violation and the significance is Green, then the violation must be evaluated to determine if it should be cited or non-cited in accordance with the NRC Enforcement Policy. The inspector must evaluate the immediate corrective actions performed by the licensee, and determine whether the licensee entered the issue into the corrective action program to address recurrence. (Note: For the guidance on to address recurrence see the NRC Enforcement Policy and Enforcement Manual.);
or
- If the finding involves a violation and the significance of the finding is potentially greater than Green, then the finding is an AV. The final significance and appropriate enforcement action will be determined in accordance with IMC 0609 and/or the Enforcement Policy. Document the finding in accordance with Section 0612-06.
- b. For findings with enforcement:
- If the finding involves a Severity Level IV violation, then the violation must be evaluated to determine if it should be cited or non-cited in accordance with the NRC Enforcement Policy. The inspector must evaluate the immediate corrective actions performed by the licensee to determine whether the licensee entered the issue into the corrective action program to address recurrence, and whether the violation was repetitive. (Note: For the guidance on to address recurrence see the NRC Enforcement Policy and Enforcement Manual.); or Issue Date: 12/04/08 7 0612
- If the finding involves a potentially greater than Severity Level IV violation, then the finding is an AV. Document the finding in accordance with Section 0612-06.
- c. For violations with no performance deficiencies:
- Work with the Office of Enforcement through the Regional Enforcement Coordinator to disposition these violations. Document the violation in accordance with Section 0612-07.
0612-06 DOCUMENTING FINDINGS This section provides instructions for documenting:
- NRC-identified or self-revealing findings that are Green or Severity Level IV; and
- Findings that are potentially greater than Green or greater than SL IV.
Guidance for documenting licensee-identified Green or Severity Level IV violations, violations without performance deficiencies, or minor violations is provided in Sections 0612-10, 0612-07, and 0612-11, respectively.
Additional guidance for documenting findings associated with Licensee Event Reports is provided in Section 0612-09.
Findings involving multiple examples may be documented as a single finding which will be entered as a single PIM entry, and will be assigned a single tracking number.
Old design issues that meet documentation screening criteria should be documented under the applicable inspectable area. See Section 06.06 of IMC 0305, Operating Reactor Assessment Program, for additional documentation requirements.
Use a four part format: an introduction, a description, an analysis, and an enforcement section for each of the findings. The sample inspection report provides examples on how to apply the principles described in the sections below.
06.01 Introduction.
The introduction should be one or two sentences that provide a brief discussion of the finding. This section does not need to stand alone because the description that follows will provide the supporting details.
The introduction must include the performance deficiency; the significance (color or severity level); identification credit; and the enforcement action and requirement violated, if applicable.
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06.02 Description.
Describe the finding in sufficient detail commensurate with the significance for the reader to understand the issue or event, evaluation of significance and cross-cutting and enforcement conclusions. Include a description of any positive licensee performance that mitigated a potential problem and influenced the significance of the finding. New information shall not be introduced in the Analysis and Enforcement Sections. Findings with generic concerns should include specific details to identify the item of concern.
06.03 Analysis.
Describe the logic used to determine the performance deficiency, the bases for more than minor, the significance or severity level of the finding and applicability of the cross-cutting aspects. The level of detail must allow a knowledgeable reader to reconstruct the decision logic used to arrive at the final conclusion.
- a. The first part shall include the following attributes:
- A concise restatement of the performance deficiency (i.e., the issue of concern that resulted from the standard or requirement not met);
- The traditional enforcement criterion that was met, if applicable; and
- The specific circumstances for a more than minor determination.
- b. The second part should include the specific basis for the determination of the significance (color or severity level) of the finding so the reader can independently arrive at the same conclusion. Specific guidance based on the method used for determination of significance is provided below:
(a) If SDP phase 1 screening assesses the finding as very low safety significance (Green), the analysis shall identify:
$ The affected cornerstone;
$ The SDP used in the determination including the reason why it applies;
$ The assumptions used in the determination; and,
$ The phase 1 question that was satisfied that caused the finding to be assessed as Green (e.g., AThe loss of function did not exceed the allowed out of service time@). (if applicable)
(b) If the SDP phase 1 screening results in a phase 2 or 3 evaluation, the analysis shall also include:
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$ The phase 1 criteria that was satisfied that caused the finding to be assessed through phase 2;
$ The most dominant core damage sequences, including the remaining mitigation capability that limited the significance; and
$ The resulting color (i.e., Green, etc.).
(c) For findings that are potentially greater than Green, in addition to (b) above, the analysis should use the risk characterization as determined by the Significance Determination Enforcement Review Panel (SERP) as its basis and should identify:
$ The exposure time;
$ Recovery credit;
$ Most dominant sequences greater than Green;
$ Why the finding does not present an immediate safety concern;
$ Compensatory measures in place while licensee long-term corrective measures are being implemented (if appropriate);
$ The significance attributed to the finding by the licensee (if available at the time of documentation). If the significance is different than that determined by the NRC, then describe the assumptions used by the licensee, and identify what the licensee considered applicable to its determination that the NRC did not consider; and
$ A statement designating the significance of the finding as ATo Be Determined (TBD).@ Emphasize that the safety characterization is not yet finalized. Do not make direct statements regarding safety significance in the inspection report when the agency has not yet reached a conclusion.
(a) The analysis shall include:
$ The affected cornerstone;
$ The SDP used in the determination including the reason why it applies;
$ Any assumptions used in the determination;
$ The table or flowchart used;
$ A description of the path on the flow chart used to arrive at the conclusion, if applicable; and
$ The resulting color.
(b) For findings that are Potentially Greater than Green, in addition to (a) above, the analysis shall describe the risk characterization or other basis as determined by the SERP and the following:
$ Why the finding does not present an immediate safety concern; Issue Date: 12/04/08 10 0612
$ Compensatory measures in place while licensee long-term corrective measures are being implemented (if appropriate);
$ The significance attributed to the finding by the licensee (if available at the time of documentation). If the significance is different than that determined by the NRC, then describe the assumptions used by the licensee, and identify what the licensee considered applicable to its determination that the NRC did not consider; and
$ A statement designating the significance of the finding as ATo Be Determined (TBD).@ Emphasize that the safety characterization is not yet finalized. Do not make direct statements regarding safety significance in the inspection report when the agency has not yet reached a conclusion.
- 3. Enforcement. If a finding is dispositioned using enforcement, the second part of the analysis section should describe the logic for determining the severity level, including reference to the Enforcement Policy supplement, as applicable. See the sample report for examples.
- c. The third part of the analysis section should include the basis for assigning, or not assigning, the cross-cutting aspect, if applicable. Specifically:
- If the finding has a cross-cutting aspect, inspectors shall restate the cross-cutting area, the component, and the cross-cutting aspect as described in section 06.07.c of IMC 0305. Additional information is necessary to explain how the selected cross-cutting aspect is applicable to the specific circumstances of the performance deficiency. The inspectors shall also include the corresponding alphanumeric identifier for the cross-cutting aspect;
- If it was determined the performance deficiency does not have a cross-cutting aspect, the analysis section must include a statement briefly stating the reason for not assigning a cross-cutting aspect; and
- If the licensee provides new information after the inspection report is issued, this information will be assessed to determine if a change in the original cross-cutting aspect of the finding is appropriate. Section 14.06 provides guidance on documentation if a change is warranted.
06.04 Enforcement.
Describe the applicable enforcement action for the finding. Findings found or reviewed during inspections that also include violations of regulatory requirements are documented in accordance with the NRC Enforcement Policy and the guidance provided below. The enforcement discussion and subsequent enforcement action must be consistent with the significance determination.
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Do not speculate or reach conclusions about the intent behind a violation. Conclusions about the willfulness of a violation are agency decisions, and are normally not made until after the Office of Investigations (OI) has completed an investigation. A premature or inaccurate discussion of the willfulness of a violation in the inspection report could result in later conflicts based on additional input and review. Inspection reports that include potentially willful violations or containing material that may be related to an ongoing investigation must be reviewed by OI and the Office of Enforcement (OE) prior to issuance.
In addition, 10 CFR 50, Appendix B, Criterion XVI violations for failure to Apreclude repetition@ can only be written for significant conditions adverse to quality (SCAQ). The inspection report details must clearly explain the basis for determining the previous condition was a SCAQ (e.g., the condition meets the definition of a SCAQ per the licensee's corrective action program), the relationship between the previous SCAQ and the current one, and the corrective actions from the previous SCAQ that failed to prevent recurrence.
Document the enforcement aspect of the finding as described below: (See Section 0612-14 for guidance on tracking number assignment.)
- a. For a finding without a violation, the enforcement section shall include the following:
- A statement similar to AEnforcement action does not apply because the performance deficiency did not involve a violation of a regulatory requirement; and
- If the finding is Green, Because this finding does not involve a violation of regulatory requirements and has very low safety significance, it is identified as FIN [Tracking Number], Title.@; or
- If the finding is potentially greater than Green, Because this finding does not involve a violation of regulatory requirements, but is potentially significant, it is identified as FIN [Tracking Number], Title.@
- b. For a finding with a violation, the enforcement section shall include the following (with exceptions noted below):
- What requirement was violated;
- When the violation occurred and how long it existed;
- Any actual or potential safety consequence (if not described earlier);
- Immediate corrective actions taken to restore compliance (if not described earlier);
- A reference to the licensee=s corrective action document number; Issue Date: 12/04/08 12 0612
- Specific enforcement actions; and
For SDP and management decision findings of very low safety significance, state:
ABecause this violation was of very low safety significance and it was entered into the licensee=s corrective action program, this violation is being treated as an NCV, consistent with the NRC Enforcement Policy.@
For Severity Level IV violations, state:
ABecause this violation was of very low safety significance, was not repetitive or willful, and was entered into the licensee=s corrective action program, this violation is being treated as an NCV, consistent with the NRC Enforcement Policy.@
For a NOV, the specific enforcement action should be stated as Because the licensee failed to (correct the violation, enter the condition into the corrective action program, prevent recurrence), this violation is being treated as a NOV, consistent with the NRC Enforcement Policy. In addition, see the Enforcement Manual for guidance on developing the notice and cover letter.
- c. For a finding with a violation in which enforcement discretion is applied, work with the Office of Enforcement through the Regional Enforcement Coordinator to develop appropriate wording for the Enforcement Section. See the Enforcement Manual for standard paragraphs to be included.
0612-07 DOCUMENTING VIOLATIONS WITHOUT PERFORMANCE DEFICIENCIES The Enforcement Policy states that the agency may exercise enforcement discretion. A violation that does not involve a performance deficiency may warrant discretion. As stated previously, this type of violation is not a finding and therefore, will not be documented using the four-part format.
If the violation is minor, no documentation is required. However, see the exceptions listed in Section 0612-11. If the violation is more than minor it must be dispositioned in an inspection report. Work with the Office of Enforcement through the Regional Enforcement Coordinator to determine the appropriate action. Also, see Enforcement Manual Chapter 5 for additional guidance. Consider the following two-part format:
The first part will describe the issue of concern, why there was no Performance Deficiency, and the safety significance. This part does not have to be lengthy, but contain sufficient detail including how significance was determined.
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The second part will describe the requirement violated and include the following statement:
However, because a performance deficiency was not identified, no enforcement action is warranted for this violation of NRC requirements in accordance with the NRCs Enforcement Policy. Further, because licensee actions did not contribute to this violation, it will not be considered in the assessment process or NRCs Action Matrix.
- No tracking number is assigned and no RPS/PIM entry for these violations is required. Also, these violations are not documented in the Summary of Findings.
The cover letter shall contain the required language used for exercising enforcement discretion. See Section 0612-14.01, Cover Letter, for additional guidance.
0612-08 DOCUMENTING UNRESOLVED ITEMS 08.01 Opening. An inspector should open an unresolved item (URI) when an issue of concern is identified but more information is required to determine, 1) if there is a performance deficiency, 2) if the performance deficiency is more than minor, or 3) if the issue of concern constitutes a violation. An URI cannot be used to obtain more information to determine the significance of a finding.
Such a concern may require additional information from the licensee or cannot be resolved without additional guidance or clarification/interpretation of the existing guidance (e.g.,
performance indicator reporting guidance, OI investigation in progress). An Unresolved Item may also be opened when a Notice of Enforcement Discretion is granted to obtain additional information concerning the cause or need for the discretion. The action of documenting an unresolved item is a commitment of future resources, and shall not be opened to track completion of licensees actions associated with a finding or an inspection question.
The URI should be documented using the Introduction and Description Sections of the Four Part Format discussed in Section 0612-06. Because URIs are not findings, the Analysis and Enforcement Sections are not required. The Introduction Section should clearly state that an URI was identified. The Description Section should describe the issue with sufficient detail to allow another inspector to complete the inspection effort, if necessary. Include details related to the Notice of Enforcement Discretion, if applicable. The report must clearly identify the specific licensee or NRC actions needed to resolve the issue. Include a tracking number for the URI in accordance with Section 0612-14.
Unresolved items are not documented in the summary of findings section or in the inspection report cover letter.
08.02 Follow-up and Closure. The level of detail devoted to closing URIs depends on the nature and significance of the additional information identified. The closure of an URI must summarize the topic, summarize the inspector's follow-up actions, evaluate the adequacy of any licensee actions, determine if a violation has occurred, and provide enough detail to justify closing the item. If resolution to an URI was based on discussions between Issue Date: 12/04/08 14 0612
inspector(s) and NRR technical staff(s), concisely document the details of these discussions as the basis for the regulatory decision. Additionally, branch chiefs of inspector(s) and technical staff(s) who were involved in these discussions should concur on the inspection report.
If a finding is identified, use the four part format and follow the guidance of section 0612-06.
The finding and/or associated violation should be documented in an inspectable area section, likely under the procedure in which the original URI was documented.
If no findings or violations were identified, document the resolution in Section 4OA5 of the report.
0612-09 DOCUMENTING CLOSURE OF LERs AND CITED VIOLATIONS 09.01 Document reviews and closures of LERs, including revisions to LERs, in the inspection report under Section 4OA3, AEvent Follow-up.@ If inspection documentation in another cornerstone area provides a description of the event in the LER (i.e., personnel performance during surveillances), then that section of the report should be referenced under Section 4OA3 with a very brief description.
In general, LER reviews should have a brief description of the event and reference the docketed LER. If an LER review is already documented in a separate NRC correspondence, then close the LER with a brief statement in an inspection report referencing the separate correspondence.
The event described in the LER needs to be evaluated for a potential violation and must be identified clearly in the inspection report as a cited violation, non-cited violation or as a minor violation, as appropriate, or warranting enforcement discretion if no performance deficiency occurred. Screen any violations in accordance with Section 0612-05. In addition to the information described above, document closure of the LER as follows:
- a. No Violations ,Licensee-identified Green Findings, or No Findings: State the LER was reviewed and that no findings of significance were identified and no violation of NRC requirements occurred.
- b. Minor Violations. Use guidance in Section 0612-11.
- c. NRC-Identified or Self-Revealed Findings or Violations or Significant Licensee-Identified Violations and Findings: The four part format in section 06 must be followed if not previously documented.
- d. Licensee-identified NCVs: The safety significance and enforcement should be discussed per Section 0612-10 of this manual chapter and not in the LER closeout section. A statement, such as The enforcement aspects of this finding are discussed is Section 4OA7, should be included in the LER closeout section.
Issue Date: 12/04/08 15 0612
09.02 Document the closure of cited violations in Section 4OA5. The level of detail required to document closure of cited violations depends on the extent of corrective actions conducted by the licensee. In general, the write-up must summarize the inspector's follow-up actions which evaluated the adequacy of any licensee actions and provide enough detail to justify closing the violation. The closure documentation should consist of a few paragraphs. Refer to IP 92702, Followup on Corrective Actions for Violations and Deviations, for further guidance.
0612-10 DOCUMENTING LICENSEE-IDENTIFIED VIOLATIONS NRC policy requires that all documented non-compliances be dispositioned in accordance with the Enforcement Policy, regardless of who identified them. However, licensee-identified violations that are of very low safety significance and incorporated into the licensee=s corrective action program should have minimal documentation. See Section 0612-03 for definitions of Alicensee-identified@ and Aself-revealing.@
- a. Potentially greater than Green - If the finding is potentially greater than Green or greater than Severity Level IV then the finding must be screened and documented in accordance with Section 0612-05 and 06. The finding should be documented in the appropriate inspectable area and Summary of Findings. Although the finding or violation may be potentially greater than Green the documentation should state that the licensee identified the finding or violation.
- b. Violation - If the finding is a violation, of very low safety significance or Severity Level IV, and the licensee has correctly evaluated the finding and has developed appropriate corrective actions, then briefly describe the violation in Section 4OA7.
Include the requirement(s) violated, describe how it was violated, identify the licensee=s corrective action tracking number(s), and provide a very brief justification why the violation is not greater than Green. A complete reconstruction of the SDP logic is not required. However, Section 4OA7 must include the following introductory paragraph:
AThe following violations of very low safety significance (Green) or Severity Level IV were identified by the licensee and are violations of NRC requirements which meet the criteria of the NRC Enforcement Policy, for being dispositioned as a Non-Cited Violation.@
NOTE: In accordance with the Enforcement Policy, the approval of the Director, Office of Enforcement, with consultation with the Deputy Executive Director as warranted, is required for dispositioning willful violations as NCVs.
- c. Not a violation - If the finding is not a violation, the finding is of very low safety significance, and the licensee has correctly evaluated the finding and has developed appropriate corrective actions, then the finding shall not be documented in the inspection report.
Issue Date: 12/04/08 16 0612
- d. NRC added value - If a problem exists with the licensee=s evaluation or corrective actions associated with the finding and if further inspection added significant value, then document the finding as a NRC-identified finding under the applicable cornerstone section of the report. Documentation should clearly emphasize that the licensee identified the finding but failed to recognize the problem identified by the inspector.
0612-11 DOCUMENTING MINOR ISSUES AND MINOR VIOLATIONS Minor violations are not routinely documented in inspection reports. However, as stated in the Enforcement Policy/Manual, there may be exceptions. Documenting a minor violation may be warranted as part of closing out a Licensee Event Report, Unresolved Item, or follow-up to an allegation. Licensees are required to correct minor violations. If it is necessary to document a minor violation then only minimal discussion is required. The write-up should briefly describe the issue of concern, state that the issue has been addressed by the licensee and should include the following:
AThis failure to comply with {requirement} constitutes a violation of minor significance that is not subject to enforcement action in accordance with the NRC=s Enforcement Policy.@
An issue of concern, regardless of whether it involves a violation of requirements, may be documented if related directly to an issue of agency-wide concern, if allowed by an appendix to this chapter, or by the specific inspection procedure or temporary instruction. In addition, limited documentation of the NRCs review of events associated with radioactive leaks and spills should be provided in the inspection report for those leaks and spills reported to State and local authorities even when there were no performance deficiencies identified or the finding is determined to be minor.
If it is necessary to document a minor issue then only minimal discussion is required. The write-up should briefly describe the issue and state that the issue has been addressed by the licensee, if applicable.
0612-12 DOCUMENTING PERFORMANCE INDICATOR VERIFICATION RESULTS All performance indicator (PI) verification baseline inspections shall be documented under Section 4OA1.
12.01 Scope. When writing the scope section, include the time period for which the PI data was verified. Include the criteria used to verify the PIs. List the PIs verified and the associated cornerstones. When there are findings to report, list the individual PI scope and findings separately.
12.02 Findings. When assessing PIs, if the inspector identifies an error that, upon correction by the licensee, resulted in the licensee crossing a PI threshold, the issue needs to be documented in the Findings section in accordance with Section 06 of this chapter.
Briefly describe the circumstances surrounding the finding in the write-up. Inaccurate and Issue Date: 12/04/08 17 0612
incomplete PI data violations should be dispositioned in accordance with the guidance in the Enforcement Policy/Manual.
If the inspector disagrees with the licensee=s data or the licensee=s interpretation of the reporting guidance, the issue will be resolved using the inspection feedback process and/or PI frequently asked questions (FAQs) process and should be identified as an URI in accordance with Section 0612-08 of this chapter. The region should contact the Performance Assessment Branch of NRR and submit a feedback form capturing their concerns and perspectives. Upon resolution of all interpretation issues and the FAQ, the issue should be closed in accordance with the closure guidance described in IMC 0608,
?Performance Indicator Program.@
0612-13 OTHER GUIDANCE 13.01 Treatment of Third Party Reviews. Detailed NRC reviews of Institute of Nuclear Power Operations (INPO) evaluations, accreditation reports, findings, recommendations, and corrective actions, or other third party reviews with similar information are not referenced in NRC inspection reports, tracking tools, or other agency documents unless the issue is of such safety significance that no other reasonable alternative is acceptable. INPO findings, recommendations and associated licensee corrective actions are not normally tracked by the NRC. If a finding warrants tracking, it should be independently evaluated, documented, and tracked as an NRC finding in Section 4OA5.
INPO findings, recommendations, corrective actions, and operating experience which are placed in the licensee=s corrective action program, can be considered appropriate for inspection. Additionally, when documenting review of these issues which originated from INPO, inspection reports should not refer to any proprietary INPO reports or documents, INPO reference numbers, or identify specific sites when referencing operating experience. If it is necessary to document review of an INPO document (i.e., an evaluation referring to the INPO document was an inspection sample or justification for a cross-cutting aspect), then state the reference number of the reviewed item (e.g., condition report or evaluation number) and provide general words for the title, if applicable. For example, ACondition Report No. 235235 concerning industry information on pumps.@
Include a short statement in the inspection report to document that a review of a specified INPO evaluation or accreditation report was completed. Do not include a recounting or listing of INPO findings or reference a final INPO rating when documenting an INPO evaluation or accreditation report review. Discuss the specifics of any significant differences between NRC and INPO perceptions with regional management.
13.02 Non-Routine Inspections. Document in Section 4OA4 activities related to Supplemental Inspections. Document in Section 4OA5 inspection results from IMC 2515 Appendix C, temporary instructions (TIs) and other non-routine inspection activities not addressed in this manual chapter. In some cases, factual observations may be documented. If it is necessary to document a minor issue or minor violation, follow the guidance in Section 0612-11 of this chapter.
Issue Date: 12/04/08 18 0612
13.03 Documenting Backfit Items. When a backfit is identified, it is necessary to track the completion of the licensee's actions to correct the identified condition. Document this tracking in Section 4OA5 and classify the backfit item as a VIO. When inputting into RPS, enter the following:
This issue is a compliance backfit. By definition, the licensee was put on notice that they are in violation. This item was created to ensure appropriate NRC inspection of the licensee's corrective actions required to ensure compliance -
similar to follow-up from an NOV. The inspection report issued this concern as a VIO.
0612-14 COMPILING AN INSPECTION REPORT Each inspection report will have a cover letter, cover page, summary of findings, report details, and attachments as described in this section. A table of contents and summary of plant status may be provided as discussed below. A standard inspection report outline is shown in Exhibit 1. The following additional guidance applies:
- Supplemental inspection results must also reflect the additional guidance provided in Appendix C;
- IP-71152, Identification and Resolution of Problems, results have varying thresholds for documentation and must reflect the guidance provided in Appendix D;
- Escalated enforcement actions and cited violations must reflect the guidance found in the Enforcement Manual, Appendix B, Standard Formats for Enforcement Packages; and
- Issues which are subject to enforcement discretion must reflect the guidance found in the Enforcement Manual and IMC 0305, Section 06.06.
14.01 Cover Letter. Write a cover letter to transmit the overall inspection results and convey the inspection findings to the licensee. Inspection reports are sent from the applicable NRC official (branch chief, division director, or regional administrator) to the designated licensee executive. See the inspection report documentation matrix in Exhibit 2 for what should and should not be documented in the inspection report cover letter.
Examples of inspection report cover letters can be found in Exhibit 4.
Guidance and cover letter formats for transmitting enforcement actions vary. Guidance and sample cover letters for enforcement-related correspondence are found in the Enforcement Manual, Appendix B, AStandard Formats for Enforcement Packages.@
Cover letter content varies somewhat depending on whether or not the inspection identified findings. In general, however, every cover letter has the same basic structure as follows:
- a. Date. The NRC seal and address are at the top of the first page and are followed by the date on which the report cover letter is signed and the report issued.
Issue Date: 12/04/08 19 0612
- b. Enforcement Action. If the report contains findings assigned an enforcement action (EA) number, then the EA number should be placed in the upper left-hand corner above the principal addressee=s name.
- c. Addressee. The name and title of the principal addressee are placed at least four lines below the letterhead, followed by the licensee=s name and address.
- d. Subject Line. The subject line of the letter shall state the plant name and inspection subject (e.g.,@XXXXX Generating Station - NRC Integrated Inspection Report@)
followed by the report number. The information presented in the subject line must be in the following sequence: plant name, type of inspection, report number. Use the official plant name and docket number as described in Section 0612-14.
The words "NOTICE OF VIOLATION" (AEXERCISE OF ENFORCEMENT DISCRETION@ or "NOTICE OF DEVIATION," etc.) must be included if an enforcement action accompanies the inspection report.
- e. Salutation. Ensure the salutation follows the subject line.
- f. Introductory Paragraphs. The first two paragraphs of the cover letter should give a brief introduction, including the type of report (e.g., license renewal report, integrated inspection report) and pertinent dates (i.e., date of final exit meeting with licensee, date NRC was informed of licensee readiness for supplemental inspections, date decision was made that a reactive inspection would be conducted in response to events).
- g. Body. The body of the letter shall discuss the most important topics first. The following identifies how different types of findings should be reflected in the cover letter to an inspection report.
IF: THEN:
If there are no Insert a separate paragraph stating:
findings identified "Based on the results of this inspection, no findings of significance were identified."
If Green findings are State the number of findings and a brief description of identified cross-cutting aspects, if applicable. Include the following statement:
AThere were [the number] findings of very low safety significance (Green) identified in the report."
If Severity Level IV Document in accordance with the guidance in Appendix violations or violations B, Form 2 of the Enforcement Manual.
associated with Green findings are Issue Date: 12/04/08 20 0612
IF: THEN:
being dispositioned as NCVs or in NOVs If a finding has the Briefly discuss the finding(s), in the order of potential to be greater significance if more than one finding. The cover letter than Green in should clearly state why the finding does not present an significance immediate safety concern, and (if appropriate) that licensee compensatory measures are in place while licensee long-term corrective measures are being implemented.
If a finding appears to Briefly discuss the finding(s), in the order of be greater than Green significance if more than one finding. The appropriate and if an apparent wording for the findings that are also violations of violation AV is requirements can be found in the Enforcement Manual.
involved for which a Notice of Violation is being considered If a violation appears Briefly discuss the finding(s)/violation(s), in the order of to be greater than significance if more than one finding. Discuss in Severity Level IV accordance with the guidance in the Enforcement Manual.
If a violation was Discuss in accordance with the guidance described in identified but was not the Enforcement Manual/Policy.
associated with a performance deficiency.
(See IMC 0305, section 06.06 and the Enforcement Manual)
- h. Closing. The final paragraph consists of standard legal language that varies depending on whether enforcement action is involved. See the example cover letter in Exhibit 4.
The signature of the appropriate NRC official is followed by the docket number(s),
license number(s), enclosures, and distribution list.
- i. Security Inspection Reports. The cover letters for security inspection reports will be similar in format to other inspection report cover letters, but will not include details or descriptions of any inspection findings. The cover letters shall state the number of Green findings identified and a brief description of cross-cutting aspects, if applicable. However, the letters will not state the number of greater than Green findings (if any were identified), only that findings with greater-than-green significance have been identified and a brief description of cross-cutting aspects, if Issue Date: 12/04/08 21 0612
applicable. See sample cover letter number 3 of Exhibit 4 for standard paragraphs to include in security report cover letters.
14.02 Cover Page. The report cover page gives a succinct summary of information about the inspection. It contains: the docket number(s), license number(s), report number, licensee name, facility name, facility location (city and state), dates of the inspection, names and titles of participating inspectors (and may include names of those inspectors who have achieved basic inspector certification but are not yet fully qualified), and name and title of the approving NRC manager. See Exhibit 3 for format.
The inspection report number is to be identified in the following form as required by IMC 0306:
Docket No./Year [sequential number of the report in that year]
(e.g., 05000410/2003001) 14.03 Table of Contents. If a report is considered complicated or of significant length, then develop a table of contents. If Report Details section is more than 20 pages long, a table of contents should be considered.
14.04 Summary of Findings. The summary should be an informative but concise overview of the significant inspection findings contained in the details of the report. It will also be used for entries to the Agency-wide Documents Access and Management System (ADAMS) and the RPS Plant Issues Matrix (PIM).
- a. The first paragraph of the summary of findings section is used to describe the inspection report in ADAMS (title value field in ADAMS).
The paragraph must include the following, in order:
$ The inspection report number (See IMC 0306 for format);
$ The dates of the inspection;
$ The name of the site; and
$ The titles of only the inspection procedures or attachments in which findings were identified (e.g., equipment alignment, fire protection, operability evaluations).
If no findings were identified, the general inspection area or title of inspection report should be listed (e.g., integrated report, or emergency preparedness report, or biennial problem identification and resolution report, or special inspection report).
For non-routine inspections, the same format should be followed to identify the report number, unit names, and dates of inspection. These are followed by the title of the inspection and a list of findings. (See Appendix D for examples.)
- b. Summary Paragraph. The summary paragraph follows the ADAMS template paragraph and describes who conducted the inspection (i.e., resident and/or specialist inspectors), the number of findings, and violations.
Issue Date: 12/04/08 22 0612
The summary also includes an explanation that the significance of most findings is indicated by their color (greater than Green, or Green, White, Yellow, Red); the significance was determined using IMC 0609, ASignificance Determination Process@
(SDP); the cross-cutting aspect was determined using IMC 0305, Operating Reactor Assessment Program; and that findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. This explanation is not included if no findings were identified.
- c. List of findings. Compile a list of findings by reviewing the details developed for each report section. Write a two paragraph summary for each issue that is designated a finding (FIN), violation (VIO), an apparent violation (AV), or non-cited violation (NCV). The text of the summaries must be consistent with the corresponding details in the inspection report.
Do not document the following in the summary of findings: licensee-identified NCVs, licensee-identified Green findings, minor violations, and unresolved items.
- 1. First Paragraph: Begin the summary for each finding with the significance (color or severity level). Use TBD for those violations where the significance or severity level has not yet been determined and for findings with a preliminary color greater than Green. Then, describe the finding including any enforcement action, the specific requirement violated, and identification credit for the finding. Include a brief description of the immediate corrective actions completed to restore compliance, planned by the licensee, if applicable, and a statement that the violation has been placed in the licensee corrective action program. If the planned corrective action is still being evaluated, a sentence stating such is sufficient.
Second Paragraph: The second paragraph should briefly summarize the finding=s significance from the analysis section. Briefly describe why the finding is greater than minor, provide effect on the cornerstone, and state why the finding is not greater than green (if applicable). If applicable, restate the cross-cutting area, the cross-cutting component, the cross-cutting aspects of the finding, and the alphanumeric identifier as described in the corresponding Analysis Section of the report. If no cross-cutting aspect was identified then make a statement to that effect. Each summary must end with a reference to the section of the report in which the finding is discussed.
- 2. Group the finding summaries by cornerstones in the order specified in Exhibit 1. Findings not associated with a cornerstone should be listed at the end under Other Findings (e.g., Enforcement).
- 3. If a Green or Severity Level IV licensee-identified finding resulted in a violation, include the following boilerplate paragraph as the last paragraph of the summary of findings:
Issue Date: 12/04/08 23 0612
AViolations of very low safety significance or severity level IV that were identified by the licensee have been reviewed by the inspectors. Corrective actions taken or planned by the licensee have been entered into the licensee=s corrective action program. These violations and corrective action tracking numbers are listed in Section 4OA7 of this report.@
14.05 Plant Status. If appropriate, write a Summary of Plant Status section. If used, briefly describe pertinent operational events, such as any plant shutdowns or significant changes in power. This summary is not needed for specialist inspections since plant operating status may not be relevant to a safeguards or emergency preparedness inspection.
14.06 Report Details. Arrange the report details in accordance with the standard report outline shown in Exhibit 1. Each outline topic (inspectable area) does not have to be covered in each report. When an inspection is performed in a particular area, the resulting details are placed in the corresponding section of the report.
In those cases where a standard format is not readily applied, the most important subject should be identified first, followed by a discussion of major topics identified in descending order of significance.
Exceptions to the standard format include:
- Supplemental Inspection (SI) reports;
- Augmented Inspection Team (AIT) reports;
- Special Inspection Team (SIT) reports, and;
- Other cases where the specifically directed focus of the inspection does not easily fit into the standardized report outline (i.e., license renewal inspections).
Findings, violations, and unresolved items are documented under the inspectable area in which the issue was discovered. Additionally:
- If a finding is unrelated to a specific inspectable area, then document the finding in Section 4OA5 of the inspection report;
- If a violation is not a performance deficiency, and does not involve willfulness, actual safety consequences, or impeding the regulatory process, then it is documented in Section 4OA5 of the inspection report;
- Issues or findings that may be of some value as a potential future Problem Identification and Resolution (PI&R) inspection sample may be listed as a cross-reference in Section 4OA2 of the inspection report. These findings must already be documented elsewhere in the report; Issue Date: 12/04/08 24 0612
- If new information becomes available after the inspection report is issued, which results in a change to the cross-cutting aspect of a finding, document the change and the basis for the revision in section 4OA5, Other Activities, in the integrated report that is open at the time of the revision. Also update the original PIM entry with the revised cross-cutting aspect;
- Observations not directly related to a finding or unresolved item may be documented if allowed by an appendix to this chapter or by the specific inspection procedure or temporary instruction; and
- If documenting a Backfit where the licensee is not in compliance, then document in Section 4OA5 as a VIO.
- a. Format of Each Inspectable Area: Each inspectable area shall include an Inspection Scope and Findings sections as described below:
- 1. Inspection Scope: For each inspectable area, describe the inspection scope.
Do not repeat any portion of the Scope in the Findings section. The scope should:
- Identify how the inspection was conducted (i.e., the methods of inspection.) Methods can include a walk-down, an in-office review, observation of test from the control room, discussion with specific personnel, or participation in an exercise;
- Identify what was inspected. Include sufficient detail on which and how many samples were completed. If more than six documents were reviewed, then list the items in an attachment and reference the attachment in the Scope section;
- Identify the inspection objectives and the criteria that were used to determine whether the licensee is in compliance; and
- Include inspection dates to clarify inspection scope context if it helps with understanding the scope. For example, inspection dates may be helpful when discussing event follow-up.
If a substantive portion of the inspection activity was conducted at a location other than the plant, (e.g., an in-office review), then identify where the inspection took place.
- 2. Findings. Document each finding in accordance with Section 0612-06 and each URI in accordance with Section 0612-08. Present the findings within each report section in order of importance. If no findings or only minor violations/findings that do not require documentation were identified within an inspectable area, then state ANo findings of significance were identified@ in the Findings section of the report.
Issue Date: 12/04/08 25 0612
- b. Miscellaneous Guidance:
- Graphics/visual aids - Use of graphics (drawings, diagrams, photographs, or photocopies) is permissible if their inclusion will simplify describing a complex condition that would otherwise require substantially more text. Including graphics may complicate report processing and result in excessive file sizes.
Also, these graphics must not be proprietary or violate the SUNSI guidelines.
When photographs of plant areas or equipment or photocopies of technical or vendor manual pages are used, permission shall be obtained in writing from the licensee or vendor. An e-mail from the licensee or vendor is acceptable provided it is placed in ADAMS as an official record or attached to the inspection report. It is allowable to develop a simplified drawing or diagram, however, it must be submitted to the licensee or vendor to determine if it is considered proprietary. All graphics shall adhere to the following guidelines:
All graphics shall be in a jpeg format and sized (height, width, and resolution) so as not to significantly increase overall file size; Keep each graphic to a reasonable size (e.g.: <1/2 page), or put in attachment; Centered on page and left/right indented from the text; and Each graphic shall have a unique identifier (Figure/Diagram/Photograph X) with a descriptive title (e.g.: Breaker Trip Latch Alignment).
- c. Tracking: As stated in IMC 0306, all NRC-identified and self-revealing findings (FINs), violations (VIOs), and non-cited violations (NCVs), as well as apparent violations (AV) and unresolved items (URIs) must be assigned a sequential tracking number. A brief title for the finding will be listed after the assigned tracking number. This title will be entered into the PIM and should describe the performance deficiency that is the basis for the finding.
- 1. Assign type codes as follows; (a) AV - an inspection finding associated with a violation which is being reviewed because it may be potentially greater than Green or higher than Severity Level IV.
(b) FIN - an inspection finding which does not have enforcement. It may be Green or have a preliminary determination of greater than Green or have a final determination of White, Yellow, or Red).
(c) VIO - an inspection finding which resulted in a cited violation. NOTE:
This may also be used when documenting a Backfit item since the licensee is in violation of requirements.
Issue Date: 12/04/08 26 0612
(d) NCV - an inspection finding which resulted in a non-cited Severity Level IV violation or a non-cited violation with Green significance.
(e) URI - an issue of concern in which more information is needed.
14.07 Exit Meeting Summary: Write a brief summary of the exit meeting in Section 4OA6.
This information will also be described in the first paragraph of the cover letter. The summary must identify the most senior licensee manager who attended the meeting and must include the following information:
- a. Absence of Proprietary Information: At the exit meeting, the inspectors will verify whether the licensee considers any materials provided to or reviewed by the inspectors to be proprietary. If the licensee did not identify any material as proprietary, include a sentence to that effect in the exit meeting summary. See IMC 0620, AInspection Documents and Records,@ for actions to take if the report includes proprietary material.
NOTE: When an inspection is likely to involve proprietary information (i.e., given the technical area or other considerations of inspection scope), handling of proprietary information should be discussed at the entrance meeting.
- b. Subsequent Contacts or Changes in NRC Position: If the NRC's position on an inspection finding changes after the exit meeting, conduct an additional exit meeting to discuss that change with the licensee. Also, document the additional exit meeting in the inspection report.
- c. Characterization of Licensee Response: Do not characterize a licensee=s exit meeting response. If the licensee disagrees with an inspection finding, this position may be characterized by the licensee in its formal response to the inspection report, if applicable.
- d. Oral Statements and Regulatory Commitments: Do not attempt to characterize or interpret any oral statements the licensee makes, at the exit meeting or at any other time during the inspection, as a commitment. Licensee commitments are documented by licensee correspondence, after which they may be referenced in the inspection report. Oral statements made or endorsed by a member of licensee management authorized to make commitments are not regulatory commitments unless they are documented as such by the licensee. For further guidance on licensee commitments, see ADAMS Accession Nos. ML003680088 (NEI 99-04),
ML003680078 (NEI Cover Letter), and ML003679799 (SECY 00-045 endorsing NEI 99-04 guidance).
Because regulatory commitments are a sensitive area, ensure that any reporting of licensee statements are paraphrased accurately and contain appropriate reference to the licensee=s document.
Issue Date: 12/04/08 27 0612
14.08 Report Attachments: The attachments discussed below are included at the end of the inspection report if applicable to the inspection. The attachments may be combined into a single attachment entitled "Supplementary Information."
- a. List of Items Opened, Closed, Discussed, and Updated: The report shall include a quick reference list of items opened, closed, and updated, including the item type, the tracking number for the item, and the item title (used in PIM headers describing the item). Open items that were discussed (but not closed) should also be included in this list, along with a reference to the sections in the report in which the items are discussed. NCVs will normally be opened and closed in the initiating inspection report.
- b. Key Points of
Contact:
List, by name and title, those individuals who furnished relevant information or were key points of contact during the inspection (except in cases where there is a need to protect the identity of an individual). The list should not be exhaustive but should identify those individuals who provided information related to developing and understanding findings. The list includes the most senior licensee manager present at the exit meeting and NRC technical personnel who were involved in the inspection if they are not listed as inspectors on the cover page.
- c. List of Documents Reviewed: A list of the documents and records reviewed during an inspection must be publicly available. Therefore, include a listing of all the documents and records reviewed during the inspection that are not identified in the body of the report. "Reviewed" in this context means to examine critically or deliberately (see IMC 0620). The list does not include records that were only superficially reviewed. Lists consisting of more than six documents reviewed should be removed from the body of the report and included as an attachment.
Documents and records reviewed for Security inspection reports will not be made publicly available.
The level of detail for listed documents must be sufficient to allow the NRC to retrieve the document from the licensee in the foreseeable future. Therefore, a unique identifier, which may include the tracking number, title, revision and/or date, must be provided for each document referenced.
If it is necessary to document review of an INPO document (i.e., an evaluation referring to the INPO document was an inspection sample or justification for a cross-cutting aspect), then state the reference number of the item reviewed (e.g.,
condition report or evaluation number) and provide general words for the title. For example, ACondition Report No. 235235 concerning industry information on pumps.@
- d. List of Acronyms: Recommend including a list of acronyms for any report whose Details section exceeds 20 pages. For reports in which a relatively small number of acronyms have been used, the list is optional. The list is also optional if more than 20 pages and the number of acronyms is relatively small. In all cases, however, acronyms should be spelled out when first used in inspection report text.
Issue Date: 12/04/08 28 0612
0612-15 ISSUING INSPECTION REPORTS 15.01 Report Timeliness.
- a. Most inspection reports, including Special Inspections, should be issued no later than 45 calendar days after inspection completion.
- b. Timeliness goals should be accelerated as necessary for inspection reports covering potential escalated enforcement actions and as specified in Management Directive 8.3 for reactive inspections; (e.g., AITs, and IITs.)
NOTE: For independent inspection reports, the inspection completion is normally defined as the day of the exit meeting. For integrated inspection reports the inspection completion is normally defined as the last day covered by the inspection report.
- c. Whenever an inspection reveals findings of significance (i.e., White or higher) or other significant or immediate public health and safety concern, an expedited inspection report that is limited in scope to the specific findings should be considered.
15.02 Release and Disclosure of Inspection Reports.
- a. General Public Disclosure and Exemptions. Except for report enclosures containing exempt information, all final inspection reports will be disclosed routinely to the public. IMC 0620 gives guidance on acquiring and controlling NRC records, including inspection-related documents. In general, safeguards information or related sensitive information should not be released except as specified by current agency policy. Any questions regarding this policy should be referred to the program office.
- b. Security Cornerstone Inspection Reports. Inspection reports for the security cornerstone will not be made publicly available. Security-related inspection reports will be sent to the respective State Liaison Officers and State Homeland Security Advisors, when they have been appointed, authorized, communicated a desire to receive the report, and have the resources to control the safeguards information.
These reports will be controlled and marked as safeguards information or official use only information (sensitive unclassified nonsafeguards information) based on the level of information contained in them. The cover letters to the reports will be made publicly available.
The cover letters for security inspection reports will be similar in format to other inspection report cover letters (see IMC 0612, Sections 14.01 a through i), but will not include details or descriptions of any inspection findings. The cover letters shall state the number of Green findings identified and a brief description of cross-cutting aspects, if applicable. The letters will not state the number of greater than Green findings (if any were identified), only that findings with greater-than-green Issue Date: 12/04/08 29 0612
significance have been identified and a brief description of cross-cutting aspects, if applicable. See sample cover letter number 3 of Exhibit 4 for standard paragraphs to include in security report cover letters.
The cover letters will be marked for the highest level of controlled information contained in the inspection report: official use only (SUNSI) or safeguards information. The marking requirements for safeguards information is in Management Directive 12.6, ANRC Sensitive Unclassified Information Security Program,@ and the requirements for marking security-related official use only documents is on the Web at: http://www.internal.nrc.gov/sunsi/, ASensitive Unclassified Non-Safeguards Information (SUNSI).@
- c. Release of Investigation-Related Information. When an inspector accompanies an investigator on an investigation, the inspector must not release either the investigation report or his or her individual input to the investigation report. This information is exempt from disclosure by 10 CFR 9.5, and must not be circulated outside the NRC without specific approval of the Chairman (refer to OI Policy Statement 23).
END EXHIBITS:
Exhibit 1: Standard Reactor Inspection Report Outline Exhibit 2: Inspection Report Documentation Matrix Exhibit 3: Sample Reactor Inspection Report Exhibit 4: Sample Cover Letters APPENDICES:
Appendix A: Acronyms Used in Inspection Manual Chapter 0612 Appendix B: Issue Screening Appendix C: Documentation Guidance for Supplemental Inspections Appendix D: Documentation Guidance AIdentification and Resolution of Problems@
Inspection Procedure (IP 71152)
Appendix E: Examples of Minor Issues Appendix F: Examples of Cross-Cutting Aspects Appendix G: Documentation Guidance for License Renewal Inspections Issue Date: 12/04/08 30 0612
ATTACHMENT 1 Revision History - IMC 0612 Commitment Issue Date Description of Change Training Training Comment Tracking Needed Completion Resolution Number Date Accession Number N/A 02/10/2006 Revision history reviewed for the last four NO N/A N/A years.
N/A 04/29/2002 Initial issue of IMC-0612. Revised from NO N/A N/A CN 02-021 IMC-0610* to address revised documentation requirements of the revised Reactor Oversight Process (ROP). This revision changed the manner in which findings are documented, deleted ""no color"" findings and the requirements to add licensee identified violations to the Plant Issue Matrix. Other Major changes involved re-formatting several sections for clarity; provided a sample inspection report (to be issued separately); re-structured and revised the thresholds for documentation (Appendix B); provided numerous new examples of minor violations in Appendix E; and provided a revised format for documenting findings.
N/A 02/21/2003 Made editorial changes to Appendix B NO N/A N/A CN 03-006 (Issue Dispositioning Screening) to reflect title changes to standard ROP terminology.
Issue Date: 12/04/08 Att 1-2 0612
N/A 05/23/2003 Exhibit 3 (Sample Reactor Inspection NO N/A N/A CN 03-016 Report) revised to not require licensee identified NCV's be put in the PIM.
N/A 06/24/2003C IMC 0612 Power Reactor Inspection NO N/A N/A N 03-021 Reports main body, app appendices and exhibits were revised to achieve the following:
- 1. Consistency with IMC-0306 (Information Technology Support for the Reactor Oversight Process)
- 2. Presented information in the order in which the activities will normally be performed in the process of developing and transmitting a reactor inspection report.
- 3. Removed specific enforcement guidance to ensure consistency between the guidance in IMCB0612 and the Enforcement Policy and Enforcement Manual.
- 4. Corrected incorrect or conflicting information.
N/A 01/14/2004 Changed the inspection report timeliness NO N/A N/A CN 04-001 to 45 calendar days for most inspection reports, including Special Inspections.
N/A 09/30/2005 Revised to clarify definitions for YES N/A N/A CN 05-028 NRC-identified, self-revealing and licensee identified; to provide additional guidance on how to document cross-cutting issues; to improve guidance on LER closure; to update the new report Issue Date: 12/04/08 Att 1-3 0612
timeliness requirement; and to reflect changes made to the document based on inspector feedback.
N/A 06/22/2006 Revised to provide additional guidance YES 07/01/2006 ML061510135 CN 06-015 and requirements for documenting cross-cutting aspects of inspection findings and to provide guidance on inspection report approval requirements when resolution to unresolved items are based on discussions between inspector(s) and NRR technical staff(s).
N/A 11/02/06 Revised definition of performance YES 09/06/2006 ML063000483 CN 06-033 deficiency to bring the definition in alignment with the basis for performance deficiency as described in ROP basis document, IMC-0308 Attachment 3, ASignificance Determination Process Basis Document.@
N/A 09/20/07 IMC 0612 has been revised to add No N/A ML071560246 CN 07-029 guidance on NRC use of INPO documents and on cover letters for security inspections. Also enhanced guidance on NCV=s and SCAQ=s.
N/A 12/04/08 IMC 0612 has undergone a major re- Yes N/A ML083220722 CN 08-034 write to incorporate numerous feedback forms and to add additional guidance for documenting inspection findings.
Issue Date: 12/04/08 Att 1-4 0612