ML20057A463
| ML20057A463 | |
| Person / Time | |
|---|---|
| Issue date: | 07/26/1993 |
| From: | Taylor J NRC OFFICE OF THE EXECUTIVE DIRECTOR FOR OPERATIONS (EDO) |
| To: | Rogers, Selin I, The Chairman NRC COMMISSION (OCM) |
| References | |
| NUDOCS 9309140250 | |
| Download: ML20057A463 (13) | |
Text
__ ___ _ _ _ _ ____ _ _____
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UNITED STATES e
[d*. D. j NUCLEAR REGULATORY COMMISSION j
WASHINGTON, D.C. 20666-0001 u
/
July 26, 1993 5,....+
MEMORANDUM FOR:
The Chairman Commissioner Rogers Commissioner Remick Commissioner de Planque FROM:
James M. Tay1or Executive Director for Operations
SUBJECT:
EXPANDED AE00 ACTIVITIES TO ADDRESS REACTOR AND NUCLEAR MATERIALS SAFETY ISSUES
Purpose:
To inform the Commission of the Office for Analysis and Evaluation of Operational Data's (AE0D) plans and actions to place additir,nal emphasis on the assessment of operatir.g experience to address the effectiveness of nuclear power plant safety programs and of prior safety issue resolution. The expanded role of risk and reliability analyses and AEOD's plans to expand review of operational experience in the nuclear medicine and materials areas are also included.
Backaround:
In the past, AEOD placed emphasis on the identification and analysis of reactor safety issues based on operating experience.
Importance was placed on the identification of new issues.
Since AE0D was formed in 1980, several hundred studies have been conducted concerning a broad range of primarily hardware and systems related issues. AEOD supplemented these activities with the human performance study program beginning in early 1990.
A review of past efforts shows a focus on front line and support system hardware needed to prevent or mitigate a reactor accident. The staff's recent experience with Thenno-Lag fire barriers indicates that some broad safety i
areas fa.g., fire protection program) may have not been given the same indepth analysis and formal followup that operational events have ree.eived.
l Similarly, medical and nuclear materials areas have received far less attention than reactor issues based on perceptions of limited overall public i) risk.
Discussion:
We believe that additional emphasis needs to be placed on what an expanded view of operating exper%nce can reveal about weaknesses in broad safety areas, and the effectiveness of prior imposed requirements. Similarly, based on recent operating experience, additional efforts are warranted in the I
nuclear medicine and mater 1 r
r 4.r g f. 7 ( A N D
Contact:
Jack E. Rosenthal, AEOD M,",[m. g lC y '
- i 492-4440 k'c
. c 3 ' 'N 93o914o230 93o726 PDR ORG NE ED
/
/
I The Commissioners July 26, 1993 f
i To accomplish this objective, AEOD will place new emphasis on broad based integrated technical issues, and the industry's followup to previously j
resolved issues. AEOD will continue its search for new safety issues based on cperating experience; continuing to base its studies, conclusions, and recommendations on observable, quantifiable performance. AE0D's traditional approach of identifying and analyzing safety issues based on reported npmting experience is being heavily supplemented with the application of reliability and risk methodology. At the same time, AE00 will place additional emphasis on nonevent related information (including allegations and issues nominated by other offices or staff members), that is, it will take an expansive view of operating experience. This approach will strengthen AEOD's l
independent means of identifying and studying the generic lessons from i
operating experience. The cognizant NRC offices will continue to be responsible for identifying and acting upon plant specific and generic safety issues including the resolution of issues from individual allegations, licensee reports, and other sources of information.
The goal of these efforts is to achieve a feedback system in which the lessons of operating experience are consistently used to achieve improved safety.
Figure 1 provides a visual representation of a system in which lessons from operating experience are consistently fed back to industry; either presented directly to industry for their action, or imposed as new regulatory requirements and the results of both industry and agency action are periodically reviewed to assess their effectiveness. Such-a system involves review of current operating information from all sources to evaluate the effectiveness of those actions.
It requires a willingness to learn from past experience, look forward, and make needed changes; these are important aspects to a healthy safety program.
To implement the system illustrated in Figure 1, AE0D will restructure several aspects of its operations. Within the Division of Safety Programs, increased emphasis will be placed on a more systematic process to identify, categorize, pricritize, and evaluate safety issues ensuring adequate attention to licensee i
broad based safety issues. Safety Issue Followup Studies will be undertaken following a systematic selection process.
Reliability and risk analysis i
techniques will be systematically applied to:
(1) identify and provide a quantitative context for new safety issues; (2) evaluate the effectiveness of current regulations, regulatory actions, and initiatives taken by licensees to resolve safety issue concerns; and, (3) help guide and focus follow on studies.
I This systematic process will complement AEOD's traditiond
~
in evaluating operating experience related to hardware and systems, ar inc1w the following three parts.
First, an expanded view of operating data will be taken. Although AEOD typically reviews Licensee Event Reports (LERs) (10 CFR Part 50.73), Immediate Notification Reports made under 10 CFR 50.72,10 CFR Part 21 reports, Nuclear Plant Reliability Data System (NPRDS) data, and regional inspection reports, an expanded view of operating experience will be taken to include allegations, vendor test data, plant test data, vendor inspection reports, and an increased level of review of regional inspection reports. AE0D will explicitly seek the identification of potential safety issues from other program offices, regions, and interested parties. A closer coordination with the Office of Nuclur
The Commissioners Jub 26, 1903 Reactor Regulation (NRR) Vendor Inspection Branch and more plant visits will be required. An issue nomination process will be developed and made widely known. AE0D will make greater use of PRA insights to identify components, systems, accident initiators, accident sequences, and safety regulatory issues as candidates for analyses. This expanded view, together with other changes discussed below, is intended to increase completeness in AEOD's issue selection and evaluation.
Second, a more systematic process to prioritize and select issues for further study will be used. While the current process for selecting issues for further study within AEOD has relied upon safety significance and operating experience, the process for selecting issues will be expanded to include additional factors (e.g., potential safety significance, operating Experience, issue complexity, previous NRC requirements and reviews, and industry initiatives). These factors are discussed in more detail in Enclosure I and shown in the form of a screening factor sheet in Enclosure 2.
The screening factors addressed in Enclosures 1 and 2 will be used on a pilot-project basis, and will be re-evaluated and revised as necessary. Potential issues will also be organized by category (e.g., critical safety function; plant functional areas such as operations, maintenance, procurement; and broad based integrated technical issues such as fire protection, equipment qualification, inservice testing; system, component, human performance, etc.). AE0D will maintain up-to-date safety data trends for selected high risk or high regulatory profile components, systems, accident initiators, accident sequences, and safety regulatory issues. This multifaceted approach will allow a search for issues that cut across multiple prioritization factors. An example is the identification of components or issues, such as commercial dedication of components, common to multiple systems and affecting multiple safety functions. Hence, the decision to pursue certain issues and not to pursue other issues will be more robust, well documented, and scrutable.
This process should improve communication between AEOD and the program offices, and ensure understanding of the AE00 process within these offices and among the public and industry. Understanding of the process that AE00 will be using to select issues for further study is expected to aid in improving acceptance of the AE0D studies and their insights.
Third, analysis guidelines will be developed and documented which will make several improvements in the current AE0D process. When an issue is selected for further study, the principal reviewer will develop a study plan to include a thorough review of the safety significance, available PRA studies, and prior NRC studies and agency actions. At the outset of a planned study, division level coordination will take place between AE0D and the program offices to ensure that there is general understanding of the planned direction and to eliminate duplication of effort. As the study progresses the potential regulatory implications will be considered. The issue's characterization as either an adequate safety issue or a safety enhancement will guide the substance, content, priority, and resources applied to an issue. AEOD will also make greater use of PRA insights and perform limited probabilistic safety assessments to evaluate the safety significance of qualitative results.
Throughout the study of an issue, coordination with other offices will continue to ensure that developing issues are understood by all involved parties and that management of the offices involved is kept informed. The
i
- T'he Commissicners results of the Safety Issue Followup Studies will normally be documented in AE0D case studies, with summaries included in the AEOD Annual Report.
AE00 also plans substantive expansion of its efforts in the nuclear medicine and materials areas. These efforts parallel initiatives described above for reactors. Specifically, in recent weeks, AE0D has increased resource commitments in the Nonreactor Assessment Staff.
In the near-term, concerted effort will be focused in developing the means for improved information collection, storage and retrieval, as well as enhancing analytical capabilities in these areas.
For events at medical institutions, nonpower reactors, and fuel facilities, AE00 plans to develop a data collection and processing system that is as sophisticated as the one for power reactors, and which will serve the information needs of the entire agency. These future efforts will include:
improved information collection; staff review and screening; ranking of reported events by severity and frequency of occurrence; and, coding, storage and retrieval of information.
Planned activities include root cause analyses, trends analyses, and ultimately, feeding back the lessons l
learned to enhance licensee awareness and minimize recurrences.
i Finally, AE0D management continues to meet with NRR, RES, and NMSS and OSP management to discuss the AE0D studies, and the plans and actions of the various offices.
Resources:
i The reductions in staff levels make it necessary to refocus existing resources on the most important issues. The systematic processes of issue identifi-cation, prioritization, and selection will assist in focusing study resources and will be done in AE00 with existing resources. Two staff members have been detailed to the nuclear medicine and materials area from the AE0D reactor program. Some AEOD studies and data collection and analysis will be performed under contract. As in the past, the NRC Program Offices will be requested to provide resources in responding to each AE00 study and may be expected, in some cases, to undertake followup actions to address the technical l
recommendation or to identify the need for programmatic improvement.
Initial FY 1993 funding for reactor issue studies, reliability and risk studies, and medical and nuclear material issues has been reprogrammed within AE0D.
If additional funds are needed in FY 1994, they will be addressed during the midyear review process. FY 1995 through FY 1998 resources to support these efforts are included in the FY 1994-1998 Internal Program / Budget Review document.
gggy James M. Tay1or Am Ma$
Executive Director for Operations i
Enclosures:
t As stated l
1 cc w/ enclosures:
See attached list
- See previous concurrence:
ROAB C:ROAB TPAB C:TPAB DSP D:DSP WJones:mmk JRosenthal RTripathi PBaranowsky VBenaroya GHolahan j
7/07/93*
7/07/93*
7/14/93*
7/14/93*
7/14/93*
7/15/93*
h EDO /
EDO ODO[ lor DD:
D:AE0D 0
ss EJordan R
v tins JSyrizek HT mpson GTay
/93 7/15/93*
7/g93 F/ /93
. / /93 7/y/93 l
L The Commissioners !
2 reactors. Specifically, in recent weeks, AE0D has increased resource commitments in the Nonreactor Assessment Staff.
In the near-term, concerted effort will be focused in developing the means for improved information For events at medical institut] ions, nonpower ana ytical i
i collection, storage and retrieval, as well as enhancing i
j capabilities in these areas.
reactors, and fuel facilities, AE0D plans to develop a data collection and l
processing system that is as sophisticated as the one fop / power reactors, and ency. These future which will serve the information needs of the-entire _ag/ staff review and efforts will include:
improved information collection screening;rankingofreportedeventsbyseverityand/frequencyofoccurrence; and, coding, storage and retrieval of information. flanned activities include 4
root cause analyses, trends analyses, and ultimatelf, feeding back the lessons l
learned to enhance licensee awareness and minimize / recurrences..
/
i Finally, AE00 management continues to meet with plRR, RES, and NMSS and OSP management to discuss the AE00 studies, and thejplans and actions of the various offices.
./
l, Resources:
/
The reductions in staff levels make it necessary to refocus existing resources on the most important issues. The systemat!ic processes of issue identifi-cation, prioritization, and selection will assi',c in focusing study resources and will be done in AE0D with existing re' sources. Two staff members have'been detailed to the nuclear medicine and mat'erials area from the AE0D reactor program. Some AE0D studies and data cgilection and analysis will'be performed under contract. As in the past, the NftC Program Offices will be requested to provide resources in responding to eagh AE0D study and may be~ expected, in some cases, to undertake followup act/ ions to address the technical i
recommendation or to identify the need for programmatic improvement.
Additional technical resources and,e/
xpertise will be obtained through l
Technical Assistance Contract Support.
Initial FY 1993 funding of $250K for l
medical and special nuclear materj% liability and risk studies, and $180K fo reactor issue studies, $250K for r al issues will be obtained by reprogramming TU..d5 within AEOD.
Increased FY J994 funding for reactor issues, for reactor issue studies, and for risk and reliability analysis) and for medical and materials issues is being considered. Future funding in out years will be requested through proposed changes to the NRC 5-year plan.
James M. Taylor i
Executive Director for Operations
Enclosures:
As stated cc w/ enclosures:
See attached. list
- See previous concurrence:
4 ROAB C:ROAB TPAB C:TPAB DSP D:DSP WJones:mmk JRosenthal RTripathi FBaranowsky VBenaroya GHolahan 7/07/93*
7/07/93*
7/14/93*
7/14/93*
7/14/93*
7/15/93*
AE00 D:AE00 EDO ED0 EDO DR EJordan JSniezek HThompson JTaylor 7/
S{
7/15/93*
7/ /93 7/ /93 7/ /93 i
The Commissioners for reactor. issue studies and $500K for risk and reliability analysis) and l
$200K for medical and materials issues will be requested.
Future funding in l
out years will be requested throu9h proposed changes to the-NRC 5-year plan.
l 1
i James M. Taylor Executive Director for Operations
Enclosures:
As stated cc w/ enclosures
ACRS ACNW SDBU/CR ASLBP Distribution:
PDR JKnubel, EDO JRaines, AE0D 93-38 Central File EJordan, AE0D SRohrer, AE0D 93-38 AEOD R/F Dross, AE00 DSP R/F GHolahan, A D ROAB R/F VBenaroya, E0D OEDO R/F (WITS 9300071)
JRosenthal AE0D MTaylor, ED0
- WJones, OD JBlaha, EDO PBaranow ky, AE00 JSniezek, EDO RTripat i, AE0D HThompson, ED0 P0'Rei ly, AEOD-1
- *See previous concurrenc :
ROAB C:ROAB TPAB C:TPAB DSP iSP WJones:rgz JRosenth RTripathi PBaranowsky VBenar a Holahan 7/07/93*
7/07/9 7/14/93*
7/14/93*
7/14/9 7/gf/93 l
l DD:AE0D EDO.
EDO ED0 l
Dross or-n JSniezek HThompson JTaylor 7/ /93 7/p/93 7/ /93 7/~/93 7/ /93
)
,W
The Commissioners /
/
reactors. Specifically, in recent weeks, AEOD has increased resource
/
commitments in the Nonreactor Assessment Staff.
In the near-term, concerted 4
effort will be focused in developing the means for improved information collection, storage and retrieval, as well as enhancing analytical capabilit%s in these areas.
For events at medical institutions, nonpower reactors, and fuel facilities, AE0D plans to develop a data collection and processing system that is as sophisticated as the one for power reactors, and which will serve the information needs of the entire agency. These future efforts will include:
improved information collection; staff review and/
screening; ranking of reported events by severity and frequency of occurrence; and, coding, storage and retrieval of information.
Planned activities' include root cause analyses, trends analyses, and ultimately, feeding back the lessons learned to enhance licensee awareness and minimize recurrences.
Finally, AE00 management continues to meet with NRR, RES, and NMSS and OSP management to discuss the AE0D studies, and the plans and actions of the various offices.
Resources:
The reductions in staff levels make it necessary to refocus existing resources on the most important issues. The systematic processes of issue identifi-I cation, prioritization, and selection will be done in AE0D with existing resources.
Some studies and data collection and analysis will be performed under contract.
Additional technical resources and expertise' ill be obtained through Technical Assistance Contract Support.
Initial FY 1993 fundin. of $250K for reactor issue studies, $250K for reliab.ility and risk studies, and $180K for medical and special nuclear material js' sues will be obtained by reprogramming funds within AEOD.
Increased FY 1994 funding of $1H for reactor issues ($500K for reactor issue studies and $500K'for risk and reliability analysis) and
$200K for medical and materials.is' sues will be requested.
Future funding in out years will be requested through proposed changes to the NRC 5-year plan.
/
/
James M. Taylor Executive Director for Operations
/
Enclosures:
j/
As stated f
/
cc w/ enclosures:
/
OP OCA SDBU/CR OIG ASLBP Office irectors, Regions Dist ibution:
See attached
/
- See previous concurrence:
ROAB C:ROAB TPAyf' C:TPApM.
DSPvg D:DSP WJones:mmk JRosenthal RTripathi PBarahowsky VBenatoya GHolahan 7/07/93*
7/07/93*
7//u/93 7//[/93 7/g/93 7/ /93 i
DD:AEOD D:AE0D EDO ED0 EDO Dross EJordan JSniezek HThompson JTaylor 7/ /93 7/ /93 7/ /93 7/ /93 7/ /93 j
l
. ~,
The Commissioners l Additional technical resources and expertise will be obtained through Technical Assistance Contract Support.
Initial funding of $250K will be obtained by reprogramming funds within AE00.
Fiscal year 1994 funding is y
estimated at $500K. Future funding in out years will be requested through 'p proposed changes to the NRC 5-year plan.
~
j i
James M. Taylor Executive Director for Operations t
i
Enclosures:
As stated cc w/ enclosures:
i SECY l
i OGC OPA OCA OIG Office Directors, Regions i
ACRS l
ACNW l
OP SDBU/CR ASLBP Distribution:
PDR.
JKnubel, EDO Central File WJones, AE00 AE0D R/F JRosenthal, AE0D DSP R/F VBenaroya, AE0D ROAB R/F GHolahan, AE0D DEDO R/F (WITS 9300071) Dross, AEOD MTaylor, ED0 EJordan, AE0D JSniezek, ED0 PBaranowsky, AE0D HThompson, EDO JRaines, AE0D 93-38 JBlaha, EDO SRohrer, AEOD 93-38
/
l l
,I.
l
- See previous con'currence:
- 'I ROAB CiROAB DSP_
- DSP-DD:AE00 0:AE0D WJones:mmk
/JRosenthal VBenaroya GHolahan Dross EJordan 7/07/93*
/ 7/07/93*
7/07/93*
7/ 7 /93 7/ /93_
7/- /93
/
JSniezek.j/
.JTaylor 7/ /93' 7/ /93 7/ /93
/.
-/
\\
The Commissioners i Additional technical resources and expertise will be obtained through Technical Assistance Contract Support.
Initial funding of $250K will be obtained by reprogramming funds within AE00.
Fiscal year 1994 funding is estimated at $500K.
Future funding in out years will be requested through proposed changes to the NRC 5-year plan.
e James M. Taylor Executive Director for Operations
Enclosures:
As stated cc w/ enclosures:
SECY OGC OPA OCA OIG Office Directors, Regions 1
ACRS ACNW OP SDBU/CR ASLBP Distribution:
PDR JKnubel, E00 Central File WJones, AE0D AEOD R/F JRosenthal. AE0D DSP R/F VBenaroya, AEOD ROAB R/F GHolahan, AE0D OED0 R/F (WITS 9300071) Dross, AE0D MTaylor, EDO EJordan, AE0D JSniezek, EDO PBaranowsky, AE00 HThompson, ED0 JRaines, AE0D 93-38 JBlaha, EDO SRohrer, AEOD 93-38 l
1 ROAB pJ6 C
DSP D:DSP DD:AE0D D:AE0D WJones:..k' JRo enthal VBenaroya GHolahan Dross EJordan 7> /93 7/f/93 7/ /93 7/ /93 7/ /93 7/7/93 j EDO
/
ED0 ED0 JSnieiek HThompson JTaylor 7/ //93 7/ /93 7/ /93
The Comissien:rs -
1 I
cc w/ enclosure:
l SECY OGC OPA OCA OIG Office Directors, Regions l
ACRS l
ACNW OP SDBU/CR ASLBP Distribution:
PDR.
4
. Central File s AE0D P/F DSP R/F ROAB R/F OEDO R/F (WITS 9300071) l MTaylor, E00 l
JBlaha, ED0 JSniezek, ED0 HThompson, EDO JKnubel, ED0 RScroggins, OC EJordan, AE00 Dross, AE00 GHolahan, AE0D VBenaroya, AEOD JRosenthal, AE0D WJones, AE0D PBaranowsky, AEOD RTripathi, AE0D P0'Reilly, AE00 l
JRaines, AE0D 93-38 l
SRohrer, AE0D 93-38 l
l 1
l l
1 1
i
i FACTORS FOR EVALUATING POTENTIAL AEOD STUDY ISSUES
}
- 1. Safety Sionificance. Safety significance is based on several attributes.
First, there are several systems in light water reactors which are generally t
accepted as risk significant.
Issues connected with problems with these i
systems will be assigned a relative risk significance (i.e., high, medium, low) in a manner appropriate to the issue.
For issues for which the safety j
significance is less obvious, available Probabilistic Risk Assessment (PRA) methods, appropriate to the issue, will be used to determine a relative safety l
significance.
j In addition, the safety significance for issues is related to the associated potential for common-cause failure; containment bypass potential; containment i
failure potential; potential or actual interaction between two or more systems; E potential for emergency preparedness degradation.
t
- 2. Operatino Experience. There are several sources of information about the prevalence of issues. The number of repetitive problems associated with the issue (derived from operating experience) provides a measure of the l
significance of an issue. Sources for this information include but are not limited to LERs, Immediate Notifications, inspection reports, and 10 CFR 21 reports.
In addition, the number of credible allegations is indicative of the severity of problems associated with the issue.
Plant visits are an 1
invaluable source of information about the prevalence of issues and AE0D will be doing more site visits.
- 3. Issue Complexity. The issue's complexity will be used as a screening factor category. The complexity of the issue itself including the level of development of the associated technology will be considered in evaluating is:ues.
If the issue is representative of a new phenomenon, the issue will have a higher priority than issues involving well understood conditions.
- 4. Recuirements and Reviews.
Issues will be reviewed with respect to the type of NRC requirements which exist related to the issue. Where the NRC recuirements are well publicized and well understood, there may be less reason to pursue issues than when NRC requirements have been considered vague or ambiguous and have been interpreted dissimilarly by several entities. Also, where there is a strong industry consensus code or standard (e.g., ASME),
i there would be less reason to pursue an issue. Likewise where the NRC applies substantial resources for the review, examination, and inspection related to the issue, there may be less reason for AE00 to pursue the issue then when the NRC has not devoted extensive resources.
- 5. Industry Initiatives. Where there is a strong nuclear industry or specific 4
licensee initiative associated with an issue, there may be less reason to pursue it than in cases where the industry has done relatively little.
However, if operating experience indicates that such initiatives have not been effective, then there is reason to pursue the issue further. Where there is a strong incentive on the licensee's part to make safety improvements (e.g.,
where cost and power production factors are closely coupled to a safety improvement), there is less need for follow-up studies.
- PRELIMINARY SCREENING FACTORS **
SUMMARY
FACTOR RATINGS RATINGS SAFETY SIGNIFICANCE FACTORS RISK MEASURE /PRA INSIGHT (CORE LOW HIGH DAMAGE PROB.)
COMMON-CAUSE POTENTIAL LOW HIGH SYSTEM INTERACTION POTENTIAL LOW HIGH CONTAINMENT FAILURE POTENTIAL LOW HIGH CONTAINMENT BYPASS POTENTIAL LOW HIGH EMERGENCY PREPAREDNESS DEGRADATION LOW HIGH EXPERIENCE FACTORS RECENT EXAMPLES OF PROBLEMS FEW MANY ALLEGATIONS FEW MANY ISSUE COMPLEXITY FACTORS NEW PHENOMENON NO YES COMPLEXITY OF ISSUE LOW HIGH ESTABLISHED TECHNOLOGY YES NO RE0VIREMENTS/ REVIEW FACTORS CLARITY OF NRC REQUIREMENTS GOOD POOR APPLICABLE INDUSTRY STRONG WEAK CODES / STANDARDS FREQUENCY OF INSPECTIONS HIGH LOW I
DEPTH OF NRC REVIEW GOOD POOR DEPTH OF NRC INSPECTION PROGRAM GOOD POOR CURRENT /RECENT NRC ACTIONS YES N0 ON ISSUE CURRENT /RECENT NRC STUDIES ON ISSUE YES N0 l
INDUSTRY INITIATIVE FACTORS l
LICENSEE / INDUSTRY INITIATIVES MANY FEW i
ON ISSUE i
EFFECTIVENESS OF INITIATIVES GOOD POOR LICENSEE INCENTIVE FOR STRONG WEAK IMPROVEMENTS l
AEOD NEW DIRECTIONS SYSTEMATIC FOLLOW-UP REVIEWS 1
ISSUE IDENTIFICATION
> DISSEMINATION (ALL) 0F EXPERIENCE AND GOOD PRACTICES ISAFETY ISSUE I ISSUE (AEOD, NRR) s i FOLLOW-UP I<
[NO ACTION 3 RESOLUTION E
l STUDIES I
I V
VOLUNTARY A
[ ACTION 3 ACTION (LICENSEES) e V
i INSPECTION IMPOSITION i
(NRR, REG's)
(NRR)
IMPLEMENTATION *'
REVIEW (LICENSEE)
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