ML20211N435
| ML20211N435 | |
| Person / Time | |
|---|---|
| Issue date: | 09/02/1999 |
| From: | Spector A NRC (Affiliation Not Assigned) |
| To: | NRC (Affiliation Not Assigned) |
| References | |
| NUDOCS 9909100193 | |
| Download: ML20211N435 (18) | |
Text
,;
September 2, 1999 MEMORANDUM TO:
File FROM:
August K. Spector, Communication Task Leader inspection Program Branch Division ofInspection Progranbci inal si ned by:)
abagemen0 Office of Nuclear Reactor Regulation
SUBJECT:
PUBLIC MEETING REACTOR OVERSIGHT PROGRAM FIRE PROTECTION ISSUES MAY 6,1999 On July 15,1999, a public meeting was held between the NRC and the NEl to continue exchanging information on the reactor oversight program. The meeting agenda, a meeting summary, a list of attendees and a copy of written information exchanged at the meeting are attached.
Attachments: As stated
Contact:
August K. Spector 301-415-2140
'/
Distribution:
b Central Files X0 PUBLIC T/
llPB R/F K-6 y /gy +{S fed
- See previous concurrence.
DOCUMENT NAME: A:\\MAY6MTG g4jf M To rrceive a copy of this document, indicate in the box: "C" = Copy without enclosures "E" = Copy with enclosures "N" = No copy OFFICE IIPB:DIPM l0f IIPB:DIPM f l
l l
NAME AKSpector WMD g DATE 09/ 1/ l99 7
l99 OFFICIAL RECORD COPY 9909100193 990902 pp.ffp PM hIhhy J
. pR *E4g p%
4 UNITED STATES g
j NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20565-0001
'+9 * * * * *,o September 2, 1999 i
MEMORANDUM TO:
File
\\'
2 FROM:
August K. Spector, Communication Task Leader inspection Program Branch Division of Inspection Program Management Office of Nuclear Reactor Regulation
SUBJECT:
PUBLIC MEETING REACTOR OVERSIGHT PROGRAM FIRE PROTECTION ISSUES JULY 15,1999 On July 15,1999, a public meeting was held between the NRC and the NEl to continue exchanging information on the reactor oversight program. The meeting agenda, a meeting summary, a list of attendees and a copy of written information exchanged at the meeting are attached.
Attachments: As stated
Contact:
August K. Spector 301-415-2140
j(
ATTENDEES Public Meeting July 15,1999 NBG Morris Branch Cornelius Holden Jeff Jacobson Alan Madison August Spector Mohan Thadani
{
Tim Frye i
Michael Johnson William M Dean OTHERS Dennis Hassler, PSEG Nuclear Kevin Borton, PECO Energy Mark Burzynski, TVA i
Jim Sumpter, NPPD David Perkey, NUS Information Systems.
l Jim Long, NPPD i
Cary Gradle, BGE Dennis Zannoni, NJ BNE Ray Lewis, Lewis Group Jeff Reinhart,INPO Wally Beck, Com Ed. - Quad Cities Robert C. Evans, NEl
's 1
i I
r
Public Meeting -- Working Session i
' July 15,1999
)
Agenda
- 1. Discuss definitions of unavailability
- 2. Fire Protection issues related to SDP
- 3. Security issues update i
- 4. Training needs
- 5. NEl/ Industry inspection Feedback Form
- 6. Initial ideas related to full program implementation strategy
- 7. Update of Pilot Program Evalustion Panel
- 8. Supplemental inspection program update
- 9. Open feedback discussion by industry of program progress Public Meeting -Working Session July 15,1999 Summary
- 1. Unavailability: NRC distributed the draft " Definition of Unavailability" (see attachment) At an INPO meeting to be held week of July 19,1999 the draft definition will be discussed with industry and NRC. NRC indicated that unavailability can simply be defined as "the capability of a system to perform its mission when demanded." The attached definition represents the coordinated approach by NRC. Industry representatives indicated concern as to recording data to NRC, questioning the " ownership and reliability" of the data as submitted and how NRC will handle timeliness and quality issues. These issues will be discussed at INPO meeting
- 2. Fire Protection: NRC indicated it has tried several examples of fire protection SDP's.
Findings of NRC and industry correspond. Agreed that future meeting should be held on fire protection to discuss inspection procedures. Consider this topic for the August 11,1999 working public meeting.
- 3. Security: Security inspection during the pilot will go forward without " force on force" aspects.
The NRC staff will be going forward with rule making regarding security issues.
- 4. Training: NEl/ industry suggested that NRC support its efforts in training pilot plant industry representatives on the SDP process. Such training would probably be two days, held for about 30 people in mid August 1999. NEl will secure space and arrange time frame. NRC will announce as a public meeting.
NRC indicated that it was planning to hold a public workshop early in 2000 at which time NRC, industry and public would discuss lessons learned during the pilot.
h NEl suggested that it would consider holding a series of training sessions in the Spring of 2000 to train industry on new processes prior to formal implementation in April 2000.- Requested l
assistance of NRC experts in this effort.
5.' Feedback Form: NRC suggested modifications to the NEl inspection Feedback form which
.was distributed at the last public meeting. Industry indicated that they will provide NRC both general and specific data which applies to the program at future public meetings. This will help l
both industry and NRC to make necessary modifications during the pilot process. Data related l~
to concems with specific inspections will be processed through Regional Branch Chief l
management.
l l
- 6. Fullimplementation strategy: Brief discussion held conceming relationship between NRC and industry during the first few years of full program implementation. Agreed that there would.
be a continuing need for public meeting working sessions held on a regular basis. Agreed that the development of success criteria and milestones should be discussed at future working public meetings in order to begin establishing a plan for full implementation. Agreed to begin milestone development at the July 29,1999 public meeting working session.
- 7. Pilot Program Evaluation Panet: NRC presented the PPEP Charter (see attached) and
. indicated that the first meeting of the group would be held on July 28,1999. A Federal Register notice has been issued. Charter approved by GSA.
- 8. Supplemental program: NRC distributed a draft supplemental inspection for issues categorized as white and contained in column two of the Action Matrix pro 0 ram inspection l'
. manual chapter (see attached). This manual chapter will be discussed at the next public l
meeting working session to be held on July 29,1999.
- 9. Open Feedback: Industry and NEl provided suggestions that NRC inspectors should be consistent in their inspection approach and in their implementation of the SDP. Industry and NEl gave positive feedback to NRC indicating that the NRC inspectors do have knowledge of the new processes, have kept to inspection module requirements, and have done an exceptional job during inspections of occupational radiation, liquid and gaseous effluent, and operator requal program inspection.- Inspectors have worked with !!censees on exchange of information during the process, providing useful feedback to licensees related to safety.
Industry indicated that the new program will impact the organizational culture of licensees as well as NRC. Suggestion was made that organizational culturalissues be considered during program implementation.
Next meeting to be held July 29,1999 8:00 am to 3:30 pm l
Topics to be included:
- a. Update status of PPEP
- b. Update discussion of containment issues by industry /NEl
- c. Discussion of Draft Supplementalinspection program manual
- d. Discussion of fullimplementation milestones Submitted by:
August K. Spector, NRR 7/15/99
9/
DEFINITION OF UNAVAILABILITY Causes of planned unavailable hours include, but are not' limited to, the following:
preventive maintenance, corrective maintenance on non-failed trains, or inspection requiring
. a train to be mechanically and/or electrically removed from service planned support system unavailability causing a train of a monitored system to be a
unavailable (e.g., ac or de power, instrument air, service water, component cooling water, or room cooling)
. surveillance testing, unless the test configuration is automatically overridden by a valid starting signal, or the function can be immediately restored either by an operator in the control room or by a dedicated operator stationed locally for that purpose. Restoration.
actions must be contained in a written procedure, must be uncomplicated (generally, a single action), and must not require diagnosis or repair. Credit for a dedicated local operator can be taken only if (s)he is positioned at the proper location throughout the duration of the test for the purpose of restoration of the train should a valid demand occur. The intent of this paragraph is to allow licensees to take credit for restoration actions that are virtually certain to be successful (i.e., probability nearly equal to 1) during accident conditions.
. any modification that requires the train to be mechanically and/or electrically removed from service The following note is for explanatory purposes and is not to be included in the Guidelines:
Note: Most Pis, including the SSU, monitor events or conditions that represent varying degrees
- of increased risk to public health and safety. The NRC has determined that the increase in risk is not safety significant (excluding exceptional events, which are promptly identified and handled outside the Pl and baseline inspection programs) unless the white-yellow threshold is exceeded.
The NRC investigates events or conditions for safety significance, root cause, and corrective actions when the green-white threshold has been exceeded. There are situations in which a safety system is unable to respond automatically to a valid demand signal, yet there is virtually no increase in risk to public health and safety. These situations occur in some surveillance test
- configurations where the operator is able to immediately restore system availability. Therefore, conditions in which the probability of restoration is essentially 1.0 need not be reported because the increase in risk is negligible. Any other condition would be captured by the SSU because it represents some increased risk to public health and safety, which is what this Pl is intended to monitor.
i I
UNITED STATES NUCLEAR REGULATORY COMMISSION CHARTER PILOT PROGRAM EVALUATION PANEL 1.
The Committee's official designation:
Pilot Program Evaluation Panel (PPEP) 2.
The Committees objectives and the scope of its activity:
The NRC has developed a revised regulatory oversight process for commercial nuclear power plant licensees as described in Commission paper SECY 99-007, e
"Recornmendations For Reactor Oversight Process Improvements," dated January 8, 1999, and SECY-99-007A. " Recommendations For Reactor Oversight Process Improvements (Follow-up to SECY-99-007)," dated March 22,1999. These Commission papers describe the scope and contents for performance indicator reporting, a new risk-informed baseline inspection program, a new streamlined assessment process, and a new enforcement policy. Commission paper SECY 007A also described a pilot program that would be performed at two sites per region to exercise these new oversight processes prior to full implementation.
The PPEP will function as a management-level, cross-disciplinary oversight group to independently monitor and evaluate the results of the pilot effort. The PPEP will meet periodically during the pilot program to review the implementation of the oversight processes and the results generated by the PI reporting, baseline inspection, assessment, and enforcement activities. These meetings will be publically announced in advance, open to the public, and all material reviewed placed in the public document room. A meeting summary will be prepared following each meeting to document the results of the meeting The PPEP will evaluate the pilot program results against established success criteria.
For those success criteria that are intended to measure the effectiveness of the processes, and that generally do not have a quantifiable performance measure, the PPEP will serve as an " expert panel" to review the results and evaluate how well the success criteria were met. At the end of the pilot program, the PPEP members will provide an evaluation as to whether each of the success criteria have been met. This report willinclude both the consensus view of the panel, along with the dissenting 'ticws of any of the panel members. The staff will use the PPEP evaluation to determine the need for any additional process development or improvements prior to full implementation.
I 3.
The period of time necessary for the Committee to carry out its purpose:
Nine months l
l1
- 1
. 4.-
The NRC official to whom this Committee will report:
Frank Gillespie Deputy Director, Division of Inspection Program Management Office of Nuclear Reactor Regulation
- 5. -
The NRC office responsible for providing support for the Committee:
The Office of Nuclear Reactor Regulation 6.
A description of the duties for which the Committee is responsible, and if such duties are not solely advisory, a specification of the authority for such functions:
The duties of the Committee are set forth in item 2.
7,-
The estimated annual operating costs, in dollars and staff years, for the Committee *-
- a. $120,000 I
- b. 0.50 FTE
- Includes travel and per diem 8.
The estimated number and frequency of the Committee meetings:
Approximately 4 meetings held bi-monthly
' 9.
The Committee's termination date, if less than two years, from the da'a of establishment:
March 31,2000 10.
Filing date:
June 30.1999 b k-h Andrew L. Dates Advisory Committee Management Officer Office of the Secretary of the Commission i
l l
NRC INSPECTION MANUAL AAAA Inspection Procedure XXXXX SUPPLEMENTAL INSPECTION FOR ISSUES CATEGORIZED AS WHITE AND CONTAINED IN COLUMN TWO 0F THE ASSESSMENT ACTION MATRIX PROGRAM APPLICABILITY:
2515 FUNCTIONAL AREA:
Initiating Events Mitigating Systems Barrier Integrity Emergency Preparedness Occupational Radiation Safety Public Radiation Safety Physical Protection INSPECTION BASIS:
The NRC's revised inspection program includes three parts: baseline inspections:
generic safety issues and special inspections; and supplemental inspections performed as a result of risk significant performance issues. The inspection program is designed to apply NRC inspection assets in an increasing manner when risk significant performance issues are identified, either by inspection findings evaluated using the significance determination process (SDP) or when performance indicator thresholds are exceeded. Accordingly, following the identification of an inspection finding categorized as risk significant (i.e., white, yellow, or red) via Table 2 of the SDP, or when a performance indicator exceeds the
" licensee response band" threshold, the NRC regional office will perform supplemental inspection (s). The scope and breadth of these inspections will be based upon the guidance provided in the NRC's " Assessment Action Matrix" and the Supplemental Inspection Selection Table (included in'2515 xxxxxxx).
This procedure provides the supplemental response for performance indicators or inspection issues categorized as White and included in Column Two of the Assessment Action Matrix. The guidance provided in this procedure was developed with consideration of the following boundary conditions:
supplemental inspection will not be done for single or multiple green e
issues; i
the baseline inspection procedure for identification and resolution of e
problems is independent of the supplemental response:
- however, information previously obtained during the baseline inspection can be Issue Date: 07/09/99 Draft XXXXX I
p used to address the inspection requirements contained within this procedure:
the inspection requirements contained in this procedure will be completed e
for all issues categorized as' White and contained in Column Two of the agency's Assessment Action Matrix; the inspection' requirements are the same for any White issue regardless e
of whether the issue emanated from a performance indicator or from an L
inspection finding:
e new inspection issues (other than programmatic) resulting from supplemental inspections will be evaluated and categorized in a similar manner to that of the baseline inspection program using the significance l
determination process; and, l
programmatic issues resulting from this supplemental inspection will not e
be evaluated using the significance determination process, but will be i
l addressed via appropriate enforcement actions or additional supplemental inspection.
l The supplemental inspection program is designed to support the NRC's goals of maintaining safety, enhancing public confidence, improving the effectiveness and efficiency of the regulatory process, and reducing unnecessary regulatory burden.
XXXXX-01 INSPECTION OBJECTIVE (S) 01.01 To provide assurance that the root causes and contributing causes of risk h
significant performance issues are understood.
01.02 To provide assurance that the generic implications and extent of condition of risk significant performance issues are identified.
01.03 To provide assurance that licensee corrective actions to risk significant performance issues are sufficient to address the root causes, the contributing causes, and prevent recurrence.
XXXXX-02 INSPECTION REQUIREMENTS The intent of this inspection procedure is to review the licensee's evaluation of each issue categorized as White and included in Column Two of the Assessment Action Matrix.
It is expected that the licensee's evaluation should generally address each attribute contained in the inspection requirements section: however, the depth of the licensee's analysis may vary depending on the significance and complexity of the issue.
In some cases, the answers to specific inspection requirements will be self-evident with little additional review or analysis required.
1 l
XXXXX Issue Date:
XX/XX/XX t
02.01 Problem fdentification t
i a.
Determine that the evaluation identifies who (i.e. licensee or NRC), and under what conditions the issue was identified.
b.
Determine that the evaluation documents how long the issue existed, and prior opportunities for identification.
j c.
Determine that the evaluation documents the plant specific risk consequences and compliance concerns associated with the issue.
02.02 Root Cause and Extent of Condition Evaluation a.
Determine that the problem was evaluated using a systematic method (s) to identify root cause(s) and contributing cause(s).
4 i
b.
Determine that the root cause evaluation was conducted to a level of detail commensurate with the significance of the problem.
c.
Determine that the root cause evaluation included a consideration of prior occurrences of the problem and knowledge of prior operating experience.
d.
Determine that the root cause evaluation included consideration of potential common cause(s) or generic impacts (extent of condition) of the problem.
02.03 Corrective Actions a.
Determine that corrective action (s) are specified for each root / contributing cause or that there is an evaluation that no actions are necessary, b.
Determine that the corrective actions have been prioritized with consideration of the risk significance and regulatory compliance.
c.
Determine that a schedule has been established for implementing and completing the corrective actions.
d.
Determine that quantitative or qualitative measures of success have been developed for determining the effectiveness of the corrective actions to prevent recurrence.
XXX-03 INSPECTION GUIDANCE General Guidance j
}
This inspection procedure is designed to be used to assess the adequacy of the
[
licensee's evaluation of issues categorized as White and entered into Column Two of the agency's Assessment Action Matrix. As such, a reasonable time (generally Issue Date: 07/09/99 Draft XXXXX j
i i
n.
with'in 30-60 days) should be allowed for.the licensee to complete their evaluation; however, all corrective actions may not be fully completed upon implementation of this procedure.
The adequacy of the completed corrective ~
actions will be assessed in the baseline inspection portion of the program. The inspection report associated with this inspection will contain the NRC's assessment. for each inspection requirement. whether positive or negative.
Weaknesses in the licensee's evaluation will be considered for enforcement action.
In addition, weaknesses in the licensee's evaluation may require additional NRC supplemental inspections, as necessary for the NRC to
. independently identify the generic implications and' ensure that adequate corrective actions are specified.
The following sections of the procedure are provided as guidance to help the inspector fulfill the specific inspection requirements contained in paragraph
- 02. It is not intended that the inspector verify that the licensee's evaluation of the White issue contains every attribute contained in the inspection guidance section.
The intent is that the inspector use the guidance sections of the procedure to look for weaknesses in the licensee's evaluation that might indicate an issue associated with one of the inspection requirements.
Definitions Root-Cause(s) are defined as the basic reason (s) (i.e.. hardware, process, human performance), for a problem, which if corrected, will prevent recurrence of that problem.
Contributing Cause(s) are defined as causes that by themselves would not create the problem, but which are important enough to be recognized as needing corrective action.
Contributing causes are sometimes referred to as causal factors.
Causal factors are those actions, conditions, or events which directly or indirectly influence the outcome of a situation or problem.
Repeat occurrences are. defined as two or more independent conditions which are the result of the same~ basic causes.
Common Cause is defined as multiple failures (i.e., two or more) of plant equipment or' processes attributable to a shared cause.
Generic Impact is defined as the extent to which an identified problem has the potential to impact other plant equipment or processes in the same manner identified in the root cause analysis. Generic impact is sometimes referred to as extent of condition.
Consequences are defined as the actual or potential outcome of an identified problem or condition.
Soecific Guidance 03.01 Problem Identification a.
The evaluation should state how and by whom the issue was identified.
When appropriate, failure of the licensee to identify the problem at a precursor level should be evaluated.
Specifically, the failure of the XXXXX Issue Date:
XX/XX/XX
m licensee to identify a problem at an early stage may be indicative of a more. substantial problem.
Examples would include a failure of the licensee's staff to enter a recognized non-compliance into the corrective action program, or raise safety concerns to management. or the failure to complete corrective actions for a previous problem resulting in further degradation. If the NRC identified the White issue, the evaluation should address why licensee processes such as peer review, supervisory over' sight, inspection, testing or quality activities did not identify the problem.
b.
The evaluation should state when the problem was identified. how long the 4
condition (s) existed, and whether there were prior opportunities for 1
correction.
For example, if a maintenance activity resulted in an inoperable system that was not detected by post-maintenance testing or by quality assurance oversight. the reasons that the testing and quality oversight did not detect the error should be included in the problem identification statement and addressed in the root cause evaluation.
c.
The evaluation should address the plant specific risk consequences of the issue.
A plant specific assessment may better characterize the risk associated with the White issue due to the generic nature of the performance indicators and the significance determination process.
For conditions that are not easily assessed quantitatively, such as the unavailable of security equipment, a qualitative assessment should be completed.
The evaluation should also include an assessment of compliance.
As applicable, some events may be more appropriately assessed as hazards to plant personnel or the environment.
The inspector's review of the risk assessment should be coordinated with the Senior Reactor Analyst.
03.02 Root Cause Evaluation a.
The licensee's evaluation shoul.d generally make use of a systematic method (s) to identify root cause(s) and contributing cause(s)
The root cause evaluation methods that are commonly used in nuclear facilities are:
Events and causal factors analysis -- to identify the events and conditions that led up to an event:
Fault tree analysis -- to identify relationships among events and e
l the probability of event occurrence:
Barrier analysis -- to identify the barriers that. if present or e
strengthened, would have prevented the event from occurring:
I Change analysis -- to identify changes in the work environment since e
the activity was last performed successfully that may have caused or contributed to the event:
Management Oversight and Risk Tree (MORT) analysis to systematically check that all possible causes of problems have been considered; and Issue Date: 07/09/99 Draft XXXXX
r-Critical incident techniques --- to identify critical actions that, C
if performed correctly, would have prevented the event from occurring or would have significantly reduced its consequences.
The'. licensee may use other methods to conduct the root cause evaluations.
A systematic evaluation of a problem using one of the above methods should normally include:
A clear identification of the problem and the assumptions made as a part of the root cause evaluation.
For example, the evaluation should describe the initial operating conditions of the system / component identified, staffing levels, and training requirements as applicable.
A timely collection of data, verification of data, and preservation of evidence to ensure that the information and circumstances surrounding the problem are fully understood.
The analysis should i
be documented such that the progression of the problem is clearly understood, any missing information or inconsistencies are identified, and the problem can be easily explained / understood by others.
A determination of cause and effect relat onships resulting in an i
identification of root and contributory causes which consider potential hardware, process, and human performance issues.
For l
example:
- hardware issues could include design, materials, systems aging, and environmental conditions:
- process issues could include procedures, work practices, operational policies, supervision and oversight, preventive l
and corrective maintenance programs, and quality control i
methods; and human performance issues could include
- training, communications, human system interface, and fitness for duty.
- b. The root cause evaluation should be conducted to an adequate level of l
detail, considering the significance of the problem.
Different root cause evaluation methods provide different
- perspectives on the problem. In some instances, using a combination of methods helps to ensure the analysis is thorough. Therefore, the root cause evaluation should consider evaluating complex problems which could result in significant consequences using multi-disciplinary teams and/or different and complimentary methods appropriate to the circumstances.
For example, problems that involve hardware issues may be evaluated using barrier analysis, change analysis, or fault trees.
XXXXX Issue Date:
XX/XX/XX l
n.
The_ depth of a root cause evaluation is normally rchieved by repeatedly L
asking the question "Why?" about the occurrences and circumstances that caused or contributed to the problem. Once the analysis has developed all L
of the causes for the problem (i.e.
root. contributory. programmatic).
I the evaluation should also look for any relationships among the different causes.
l The depth of the root cause evaluation may be assessed by:
Determining that the questioning process appeared to have been l
conducted until the causes were beyond the licensee's control.
For example, problems that were initiated by an act of nature, such as a lightning strike or tornado. could have the act of nature as one of the causes of the problem. However, the act of nature would not be a candidate root cause. in part. because the licensee could not prevent.it from happening again. However, a licensee's failure l
to plan for or respond properly to acts of nature would be under management control and could be root causes for the problem.
Determining that the problem was evaluated to ensure that other root l
e l
and contributing causes were not inappropriately ruled out due to assumptions made as a part of the analysis.
l For example, a root cause evaluation may not consider the adequacy I
of the design or process controls for a system if the problem I
a] pears to be primarily human performance focused. Consideration of l
t1e technical appropriateness of the evaluation assumptions and their impact on the root causes would also be appropriate.
Determining that the evaluation collectively reviewed all root and contributory causes, for indications of higher level problems with a process or system.
For example, a problem that involved a number of ~ procedural inadequacies or errors may indicate a more fundamental or higher level problem in the processes for procedural development, control.
review. and approval.
Issues associated with personnel failing to follow procedures may also be indicative of a problem with supervisory oversight and communication of standards.
Determining that the root cause evaluation properly ensures that correcting the causes would prevent the same and similar problems from happening again or sufficiently minimizes the chances of re-occurrence. Complex problems may have more than one root cause as well as several contributory causes. The evaluation should include checks to ensure that corrections for the identified root causes do not rely on unstated assumptions or conditions which are not controlled or ensured.
For example, root causes based upori normal modes of operation may not be valid for accident modes or other "off normal" modes of operation.
Issue Date: 07/09/99 Draft XXXXX
r-
~
~
Determining that the evaluation includes an explanation for o
rejecting possible root causes.
Providing a rationale for ruling out alternative possible root cause(s) helps to ensure the validity of the specific root cause(s) that are identified.
- c. The root cause evaluation should include a proper consideration of repeat occurrences of the same or similar problems at the facility and knowledge of prior operating experience.
This review is necessary to help in developing the specific root and ;ontributing causes and also to provide indication as to whether the White issue is do to a higher level concern involving weaknesses in the licensee's corrective action program.
The evaluation should:
Broadly question the applicability of other similar events or issues with related root or contributory causes.
i For example, root cause evaluations associated with outage activities and safety related systems could include a review of prior operating experience involving off-normal operation of systems, unusual system alignments, and infrequently performed
{
evolutions.
Assess whether previous root cause evaluations and/or corrective actions identified what root causes were missed or inappropriate and what aspects of the prior corrective actions did not preclude reoccurrence of the problem.
For example, an adequate evaluation would include a more detailed validation of the implementation of the previously specified corrective actions and a reassessment of the identified root causes i
to determine process or performance errors which may have contributed to the repeat occurrence.
Determine if the root cause evaluation for the current problem specifically addresses those aspects of the prior root cause evaluation or corrective actions that were not successfully addressed.
For example, if during the review of a tagging error that resulted in a mis-positioned valve the licensee determines that a previous similar problem occurred and the corrective actions only focused on individual training, then the root cause for the repeat occurrence should evaluate why the previous corrective actions were inadequate.
Include a review of prior documentation of problems and their associated corrective actions to determine if similar incidents have occurred in the past.
For example, the licensee should consider in its review of prior operating experience internal self-assessments, maintenance history, adverse problem reports, and external data bases developed to identify and track operating experience issuec.
Examples of XXXXX Issue Date:
XX/XX/XX
external data bases may include Information Notices. Generic Letters, and vendor / industry generic communications.
The. inspectorr should discuss ~ the problem with other resident or regional inspectors associated with the facility to assess whether
.other similar problems or root causes for dissimilar. problems have coccurred at the facility that should have been considered.
- d. The root cause evaluation should include a proper consideration of generic impacts (extent of condition) of the problem including whether other systems, equipment, programs or conditions could be effected.
The evaluation should:
Assess the applicability of the root causes across disciplines or departments. for different programmatic activities, for human performance, or for different types of equipment.
For example, the Fire-Protection Organization considered that the root causes identified for the mis-alignment associated with the safety injection system could potentially affect their systems since they shared a common tagging and alignment method with operations.
As a result, feedback was provided to the incident review committee j
to include modification of the Fire-Protection control procedure,
)
and provide formal training to all Fire-Protection personnel.
03.03 Corrective Action The proposed corrective actions to the root and contributing causes should:
-a.
Address each of the root and contributing causes to the White issue and the generic impact of the issue. The corrective actions should be clearly defined. Examples of corrective actions may include, but are not limited to, modifications, inspections, testing, process or procedure changes, training, and notification of involved individuals.
The proposed corrective actions should not create new or different problems as a result of the corrective action. If the licensee determines that no corrective actions are necessary, the basis for this decision should be documented in the evaluation.
b.
Include consideration of the results of the licensee's risk assessment of the issue in prioritizing the type of corrective action chosen. Solutions that involve only changing procedures or providing training are sometimes over-utilized when more comprehensive corrective actions such as a design
)
modification would be more appropriate.
The corrective action plan j
should also -include a review of the regulations to ensure that if
~
compliance issues exist, the plan achieves compliance.
Also, the-licensee should ensure that:
c.
The corrective actions are assigned to individuals or >rganizations that are appropriate to ensure that the actions are taken in timely manner.
Issue Date: 07/09/99 Draft XXXXX
Also, the licensee should ensure that there is a formal tracking mechanism established for each of the specific corrective actions?
d.
A mechanism exists to validate the effectiveness of the overall corrective action plan. Specifically, a feedback loop and data acquisition / validation techniques should be established to measure, either quantitatively or qualitatively, the effectiveness of the corrective actions.
Effective mechanisms would include, but are not limited to, assessments, audits, inspections, tests, and trending of plant data, or follow-up discussions with plant staff.
XXXXX-04 RESOURCE ESTIMATE It is estimated that-this procedure will take between 16 and 40 man-hours to complete for each White issue. The inspector or inspectors assigned should be familiar with the discipline associated with. the subject of the licensee's evaluation. For planning purposn. a resource estimate near the lower end of the scale should be used for licensees with corrective actions programs that have been determined to be thorough during the annual inspection for the identification and resolution of problems.
For licensees with weak corrective action programs, a resource estimate near the higher end of the scale should be used.
XXXXX-05 REFERENCES None END i
r XXXXX Issue Date:
XX/XX/XX