ML21089A011

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OIG-21-A-07-Audit of Nrc'S Nuclear Power Reactor Inspection Issue Screening Dated March 29th, 2021
ML21089A011
Person / Time
Issue date: 03/29/2021
From: Baker B
NRC/OIG/AIGA
To: Margaret Doane
NRC/EDO
References
OIG-21-A-07
Download: ML21089A011 (21)
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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening OIG-21-A-07 March 29, 2021 All publicly available OIG reports (including this report) are accessible through the NRCs website at http://www.nrc.gov/reading-rm/doc-collections/insp-gen

UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20555-0001 OFFICE OF THE INSPECTOR GENERAL March 29, 2021 MEMORANDUM TO: Margaret M. Doane Executive Director for Operations FROM: Dr. Brett M. Baker /RA/

Assistant Inspector General for Audit

SUBJECT:

AUDIT OF THE NRCS NUCLEAR POWER REACTOR INSPECTION ISSUE SCREENING (OIG-21-A-07)

Attached is the Office of the Inspector Generals (OIG) audit report titled Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening.

The report presents the results of the subject audit. Following the March 23, 2021, exit conference, agency staff indicated that they had no formal comments for inclusion in this report.

Please provide information on actions taken or planned on each of the recommendation(s) within 30 days of the date of this memorandum. Actions taken or planned are subject to OIG followup as stated in Management Directive 6.1.

We appreciate the cooperation extended to us by members of your staff during the audit. If you have any questions or comments about our report, please contact me at (301) 415-5915 or Paul Rades, Team Leader, at (301) 415-6228.

Attachment:

As stated

Office of the Inspector General U.S. Nuclear Regulatory Commission Defense Nuclear Facilities Safety Board OIG-21-A-07 March 29, 2021 Results in Brief Audit of the NRCs Nuclear Power Reactor Inspection Why We Did This Review The U.S. Nuclear Regulatory Issue Screening Commissions (NRC) internal What We Found guidance requires inspectors to screen issues of concern NRC staff screen issues of concern in accordance with agency identified during nuclear power reactor inspections to determine guidance.

whether the issues in question fall under the agencys However, the NRC could benefit from clarifying guidance to traditional enforcement (TE) periodically review the consistency with which staff document program and Reactor Oversight Process (ROP). inspection results in the agencys RPS as well as in inspection reports.

Under the ROP, if an issue of concern screens positive for a This occurs because the NRC has multiple guidance documents performance deficiency, inspectors must determine if it that address inspection result data entry into the RPS and has minor or more-than-minor management review of inspection result documentation. In safety or security significance. addition, the NRC needs to continue implementing quality assurance checks introduced in early 2021 to further identify and When screening issues of concern under the TE pathway, fix RPS data entry and report generation errors.

inspectors do not use the ROP screening process to screen TE violations, but rather, use that What We Recommend process to screen for performance deficiencies. The report contains recommendations to clarify guidance for inputting inspection results into RPS, to review the RPS data The audit objective was to assess entries for accuracy and completeness, to improve quality the consistency with which NRC assurance processes, and to conduct training regarding the RPS staff screen issues of concern for TE and ROP in accordance with data input.

agency guidance.

Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening TABLE OF CONTENTS ABBREVIATIONS AND ACRONYMS .......................................................... i I. BACKGROUND ................................................................................ 1 II. OBJECTIVE ...................................................................................... 5 III. FINDING ........................................................................................... 6 NRC Inspection Results Need Periodic Quality Assurance Checks ........................................................................................ 6 Recommendations .................................................................... 12 IV. AGENCY COMMENTS ................................................................... 13 APPENDIXES A. OBJECTIVE, SCOPE, AND METHODOLOGY ............................... 14 TO REPORT FRAUD, WASTE, OR ABUSE ............................................. 17 COMMENTS AND SUGGESTIONS .......................................................... 17

Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening ABBREVIATIONS AND ACRONYMS COVID-19 Coronavirus Disease-2019 GAO U.S. Government Accountability Office IMC Inspection Manual Chapter NRC U.S. Nuclear Regulatory Commission OIG Office of the Inspector General ROP Reactor Oversight Process RPS Reactor Program System SL Severity Level SDP Significance Determination Process TE Traditional Enforcement i

Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening I. BACKGROUND Issues of Concern Screening The U.S. Nuclear Regulatory Commissions (NRC) internal guidance requires inspectors to screen issues of concern identified during nuclear power reactor inspections to determine whether the issues in question fall under the agencys traditional enforcement (TE) program and Reactor Oversight Process (ROP).1 The NRC defines an issue of concern as a well-defined observation or collection of observations potentially impacting safety or security which may warrant further inspection, screening, evaluation, or regulatory action. The NRC can screen issues of concern for both the ROP and TE pathways.

The ROP Pathway Under the ROP, if an issue of concern screens positive for a performance deficiency,2 inspectors must determine if it has minor or more-than-minor safety or security significance. The NRC generally does not document issues that screen minor, while more-than-minor issues become potential findings to be assessed through the agencys Significance Determination Process3 (e.g., Green, White, Yellow, and Red). Figure 1 shows the total number of ROP findings by significance between January 1, 2017 and December 31, 2020.4 1

Inspection Manual Chapter (IMC) 0612, Issue Screening.

2 The NRC defines a performance deficiency as the licensees failure to satisfy one or more regulatory requirements or self-imposed standards where such failure was reasonably foreseeable and preventable.

3 The Significance Determination Process uses risk insights and other relevant information as appropriate to assess the safety or security significance of inspection findings identified at operating reactors. The safety significance of inspection findings are expressed through colors: Green - very low safety significance, White - low to moderate safety significance, Yellow - substantial safety significance, and Red - high safety significance.

4 There were no yellow or red ROP findings between January 1, 2017 and December 31, 2020. This table is based on raw data extracted from the IR4 Advanced Finding_Violations Search report in the RPS, and is intended to show general reactor inspection finding totals. Raw RPS data is subject to revision based on future quality assurance checks.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening Figure 1: Reactor Oversight Process Findings5 525 500 475 450 425 400 375 350 325 300 275 250 2017 2018 2019 2020 Green White Yellow Red Source: OIGs analysis of the Reactor Program System (RPS) 6 data.

The TE Pathway When screening issues of concern under the TE pathway, inspectors do not use the ROP screening process to screen TE violations, but rather, use that process to screen for performance deficiencies. If an issue of concern screens positive for TE, the NRC may cite the reactor licensee for a violation. Violations can involve actual safety or security consequences, willful misconduct, and licensee actions that impede the regulatory process. Additionally, if an issue screens positive for a performance deficiency under the ROP, inspectors must assess whether the issue is minor or more-than-minor, and whether it is associated with any cross-5 In response to Coronavirus Disease-2019 (COVID-19), the NRC suspended some regulatory requirements and deferred some inspection activities. In addition, the agencys COVID-19 response resulted in inspection data reporting delays. Together, these factors may have contributed to the significant decline in ROP findings documented in 2020 compared to the preceding 3 years.

6 RPS is a web-based application that is designed to capture information about reactor inspection and licensing activities.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening cutting areas.7 If the issue is associated with any cross-cutting areas, the agency must decide what action to take in response to signs of declining licensee performance.

The agency assigns TE violations severity levels (SL), ranging from SL IV for those of more-than-minor concern to SL I for the most significant, that are associated with findings assessed through the ROPs Significance Determination Process. Figure 2 shows the total number of TE violations between January 1, 2017 and December 31, 2020. Most TE violations were SL IV.

Figure 2: Traditional Enforcement Violations8 60 50 40 30 20 10 0

2017 2018 2019 2020 SL IV SL III SL II SL I other Source: OIGs analysis of RPS data.

7 Cross-cutting areas are the fundamental performance characteristics that extend across all of the ROP cornerstones of safety. These areas are human performance, problem identification and resolution, and safety conscious work environment.

8 Other TE violations include items marked within the RPS as TE without a SL, for example: observations, assessments, apparent violations, minor violations, licensee event reports, notices of violation, and enforcement discretion. This table is based on raw data extracted from the IR4 Advanced Finding_Violations Search report in the RPS, and is intended to show general totals of TE actions resulting from operating reactor inspections. Raw RPS data is subject to revision based on future quality assurance checks.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening Furthermore, the NRC documents inspection results with ROP findings and TE violations in the agencys RPS and inspection reports. NRC policies require ROP findings and TE violations to be consistent and accurately documented.

The NRC Organizations Responsible for Screening Issues of Concern The NRCs Office of Nuclear Reactor Regulation is responsible for the overall management, support, and oversight of issue screenings including updates of regulatory requirements. The Division of Reactor Oversight within the Office of Nuclear Reactor Regulation revises reactor inspection guidance and oversees regional implementation. NRC inspectors are responsible for screening issues of concern, while regional managers are responsible for ensuring issue of concern screenings are completed in accordance with agency guidance.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening II. OBJECTIVE The audit objective was to assess the consistency with which NRC staff screen issues of concern for TE and ROP in accordance with agency guidance. Appendix A contains information on the audit scope and methodology.

III. FINDING NRC staff screen issues of concern in accordance with agency guidance.

However, the NRC could benefit from clarifying guidance to periodically review the consistency with which staff document inspection results in the agencys RPS, as well as, in inspection reports.

A. NRC Inspection Results Need Periodic Quality Assurance Checks The NRC should ensure inspection results entered in the agencys RPS are consistent, complete, and accurate. Additionally, the agency should ensure that staff clearly communicate inspection results to the licensee, NRC staff, and the public in a consistent manner. However, the NRC does not consistently document inspection results within the RPS and in accordance with agency guidance. This occurs because the NRC does not have clear guidance and application controls on documenting inspection results. This inconsistent documentation of inspection results merits attention because NRC management needs reliable inspection data for effective management and oversight of its reactor inspection programs.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening What Is Required Ensure Inspection Results are Consistently Documented in Accordance with Federal and Agency Guidance Federal Standards The U.S. Government Accountability Office, What is internal control?

Standards for Internal Control in the Federal Internal control is a process used Government,9 (GAO Green Book) states by management to help an entity management should use quality information achieve its objectives.

to achieve the entitys objectives.

Therefore, agency managers are How does internal control work?

responsible for ensuring processed data is Internal control helps an entity:

accurate, complete, accessible, and timely.

  • Run its operations efficiently Agencies use such information to make and effectively, informed decisions regarding the use and
  • Report reliable information about its operations and, prioritization of resources, as well as
  • Comply with applicable laws evaluating agency performance and and regulations.

potential risk areas that could affect efficiency and effectiveness.

The GAO Green Book also states that management should design the entitys information system and related control activities to achieve objectives and respond to risks. This includes application controls, which are those controls that are incorporated directly into computer applications to achieve validity, completeness, accuracy, and confidentiality of transactions and data during application processing. Application controls include controls over input, processing, output, master file, interface, and data management system controls.

9 Government Accountability Office, Standards for Internal Control in the Federal Government, GAO-14-704G, September 2014.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening Agency Policies The NRCs IMC 0306, Planning, Scheduling, Tracking, and Reporting of the Reactor Oversight Process, requires staff to enter consistent, complete, accurate, and timely inspection results in the agencys RPS to support plant and ROP self-assessment activities.

Additionally, the NRCs IMC 0611, Power Reactor Inspection Reports, requires the NRC staff to clearly communicate significant inspection results in a consistent manner to licensees, NRC staff, and the public.

What We Found Inspection Results not Consistently Documented in Accordance with Guidance The NRC does not consistently document inspection results within the agencys RPS and in accordance with agency and federal guidance.

The OIG reviewed 142 TE violations associated with operating reactor inspections documented in the RPS between January 1, 2017 and September 1, 2020. The OIG analyzed the inspection reports for all the TE violations in this period for documentation consistency within the RPS and in accordance with IMC 0611 requirements.

RPS Documentation Inconsistency Regarding TE violation entry into the RPS, there were inconsistencies with inspection result documentation. For example, there were 50 incorrectly documented TE violations10 in the RPS. Figure 3 shows RPS documentation errors and the number of inspection results with each error.

10 The sum of errors in Figure 3 and Figure 4 is greater than the 50 TE violations that were incorrectly documented in RPS and the 12 TE violations that were not documented in accordance with IMC 0611 because some TE violations had multiple errors.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening Figure 3: RPS Documentation Errors Errors Count Should not have been documented as TE 13 Missing Source 9 Should not have included Cornerstone 9 Incorrect Inspection Procedure 5 Incorrect Significance Determination 5 Missing ID Numbers 4 Old System Conversion Error 2 Missing Case Number 1 Should not have included Cross-cutting 1 Aspect not have been in the RPS Should 1 Source: OIGs analysis of RPS data and inspection reports.

IMC 0611 Non-compliance Regarding the documentation of TE violations, there were 12 TE violations incorrectly documented in accordance with IMC 0611 requirements.

Figure 4 shows the inspection report IMC 0611 noncompliance errors and the number of affected inspection results.

Figure 4: IMC 0611 Non-compliance Errors Errors Count Incorrect Performance Assessment 8 Should not have included Cornerstone 3 Missing Enforcement Severity 2 Missing Inspection Procedure 2 Significance did not match detailed results 1 Incorrect report format 1 Source: OIGs analysis of RPS data and inspection reports.

Other Inconsistencies This audit identified other inconsistencies with how data was documented in the RPS. In general, the cornerstone, cross-cutting area, and significance determination columns were blank; however, there were instances where inspection reports inconsistently included additional data.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening The OIG did not count these inconsistencies as documentation or IMC 0611 compliance errors:

  • 13 significance determinations were marked No Performance Deficiency and 7 were marked Minor Performance Deficiency;
  • 7 ROP cornerstones were marked Not Applicable; and
  • 2 cross-cutting areas were marked NA.

Why This Occurred Unclear Guidance and Application Controls Impact Documentation of Inspection Results The NRC has multiple guidance documents that address inspection result data entry into the RPS and management review of inspection result documentation. However, staff do not clearly understand the relationship among these documents, which has contributed to the RPS documentation errors and IMC 0611 non-compliance. In addition, staff acknowledge an RPS programming flaw that has led to erroneous data outputs.

Guidance Both IMC 0306, Planning, Scheduling, Tracking, and Reporting of the Reactor Oversight Process, and the RPS Desktop Guide do not provide sufficient details as to how staff should enter inspection results in the RPS.

For example, the NRC has no specific guidance on how to enter escalated enforcement actions, notices of violation, and licensee identified violations into the RPS, which resulted in improper RPS data entries.

Application Controls In addition to insufficient guidance in documenting inspection results, the NRC needs to continue implementing quality assurance checks introduced in early 2021 to further identify and fix RPS data entry and report 9

Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening generation errors. Notably, staff told the OIG that the RPS has a known programming flaw that can cause correctly entered data to be displayed or outputted incorrectly in a report known as IR4. Consequently, a RPS user may extract data from the RPS and see erroneous data elements in IR4 even if those elements have been corrected in the system.

Together, clearer and better understood guidance, along with adequate management review, quality assurance checks, and correction of RPS programming flaws, can help prevent and detect RPS documentation errors, IMC 0611 non-compliances, and data entry inconsistencies identified by the OIG.

Why This Is Important Quality Information Supports Program Management and Transparency NRC management relies on quality information to conduct accurate end of cycle assessments of licensees, track findings and violations, ensure consistency among inspectors, charge licensees for inspection hours, and determine effectiveness and where to devote more time. Additionally, Congress and licensees rely on quality information when making decisions. When the NRC releases inaccurate data:

  • poor decisions could be made by Congress, the licensees, and the NRC;
  • licensees could easily dispute violations;
  • it could confuse the public, licensees, and stakeholders; and,
  • it could reduce public confidence in the NRC.

Recommendations The OIG recommends that the Executive Director for Operations:

1. Clarify guidance for inputting inspection results into the RPS that involve TE actions, such as escalated enforcement actions, notices of violation, and licensee identified violations, etc.;

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening

2. Periodically review RPS data and test RPS controls for accuracy and completeness;
3. Improve quality assurance processes implemented in 2021 to identify and fix RPS data entry reporting errors; and,
4. Conduct periodic training regarding RPS data input.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening IV. AGENCY COMMENTS An exit conference was held with the agency on March 23, 2021. Prior to this meeting, after reviewing a discussion draft, agency management provided comments that have been incorporated into this report, as appropriate. As a result, agency management stated their general agreement with the finding and recommendations in this report and opted not to provide formal comments for inclusion in this report.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening Appendix A OBJECTIVE, SCOPE, AND METHODOLOGY Objective The audit objective was to assess the consistency with which staff screen issues of concern for TE and ROP in accordance with agency guidance.

Scope This audit focuses on how the NRC screens issues of concern for both TE and ROP pathways and documents inspection results in the RPS and inspection reports. We analyzed inspection results for the period of January 1, 2017 through December 31, 2020. The OIG conducted this performance audit from August 5, 2020 through February 3, 2021 at NRC headquarters in Rockville, Maryland. The OIG used RPS data as the basis for its audit finding. The OIG performed a data reliability test of the RPS and determined that the data were sufficiently reliable for assessing the consistency with which staff screen issues of concern.

Internal controls related to the audit objective were reviewed and analyzed. Specifically, the OIG reviewed the components of control environment, risk assessments, control activities, information and communication, and monitoring. Within those components, the OIG reviewed the principles of exercising oversight responsibility; identifying, analyzing, and responding to risk; assessing fraud risk; identifying, analyzing, and responding to change; designing control activities; designing activities for the information system; implementing control activities through policies; using quality information; communicating internally; performing monitoring activities; and evaluating issues and remediating deficiencies.

Methodology To accomplish the audit objective, the OIG analyzed relevant criteria for this audit including:

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening

  • Government Accountability Office, Standards for Internal Control in the Federal Government, GAO-14-704G, September 2014;
  • IMC 0306, Planning, Scheduling, Tracking, and Reporting of the Reactor Oversight Process, November 4, 2019;
  • IMC 0611, Power Reactor Inspection Reports, January 7, 2020;
  • The NRCs Enforcement Manual, October 1, 2019.

The OIG conducted analyses to determine whether the agency consistently screens issues of concern for TE and the ROP. The OIG reviewed the trend of TE and ROP violations from calendar year 2017 through 2020. The OIG also reviewed 114 inspection results from January 1, 2019 through June 1, 2020 for compliance with IMC 0611 and ensured their proper documentation in the RPS. The OIG analyzed 142 TE violations between January 1, 2017 and September 1, 2020 for compliance with IMC 0611 and ensured their proper documentation through a review of the IR 4 Advanced Findings search report in the RPS.

Additionally, the OIG interviewed NRC staff and management from the regions and headquarters.

We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Throughout the audit, auditors considered the possibility of fraud, waste, and abuse in the program.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening The audit was conducted by Paul Rades, Team Leader; Avinash Jaigobind, Audit Manager; John Thorp, Senior Technical Advisor; Chanel Stridiron, Senior Auditor; Brigit Larsen, Senior Auditor; and Melissa Chui, Auditor.

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Audit of the NRCs Nuclear Power Reactor Inspection Issue Screening TO REPORT FRAUD, WASTE, OR ABUSE Please

Contact:

Email: Online Form Telephone: 1-800-233-3497 TDD: 7-1-1, or 1-800-201-7165 Address: U.S. Nuclear Regulatory Commission Office of the Inspector General Hotline Program Mail Stop O5-E13 11555 Rockville Pike Rockville, MD 20852 COMMENTS AND SUGGESTIONS If you wish to provide comments on this report, please email the OIG using this link.

In addition, if you have suggestions for future OIG audits, please provide them using this link.

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