ML22189A179

IMC 2515 Appendix B, Supplemental Inspection Program

ML22189A179
Person / Time
Issue date:	09/28/2022
From:	Jeffrey Bream NRC/NRR/DRO/IRIB
To:
Jeffrey.Bream@nrc.gov
Shared Package
ML22269A545, ML22173A265	List:
References
CN 22-019, DC 22-016
Download: ML22189A179 (23)

Text

NRC INSPECTION MANUAL IRIB INSPECTION MANUAL CHAPTER 2515 APPENDIX B SUPPLEMENTAL INSPECTION PROGRAM Effective Date: 09/28/2022 2515B-01 PURPOSE 01.01 To facilitate timely graduated inspections of increasing breadth, depth, and diagnostic rigor when, due to declining licensee performance 1, baseline inspection or lower-tiered supplemental inspections alone are no longer adequate to provide the necessary information and analysis to ensure adequate protection of public health and safety and promote common defense.

01.02 To ensure that licensees with declining performance complete timely effective problem identification, analysis, corrective action planning and execution 2 to preclude repetition of significant performance issues.

01.03 To ensure the capture of risk-weighted insights into licensee Problem Identification and Resolution (PI&R) performance during infrequent instances when it is most important -

when addressing and seeking to preclude repetition of significant licensee performance issues. These risk-weighted insights support periodic NRC assessments of licensee performance.

2515B-02 OBJECTIVE In addition to supporting Inspection Manual Chapter (IMC) 2515 objectives 02.01 and 02.02 and supplemental inspection procedures (IPs) 95001, -02, and -03 objectives, the objective of this appendix is to add clarity to supplemental inspection fundamentals common to multiple supplemental IPs including (a) differentiating between inspector requirements, regulatory obligations (e.g. regulations, license conditions, and orders), NRC expectations (e.g. licensee self-imposed standards) requisite to voluntary ROP participation and associated benefits, and, (b) scheduling considerations, (c) the relationship between general weaknesses and omissions, significant weaknesses and omissions, and findings, (d) the importance of enhanced inspection, assessment, and documentation rigor in supplemental inspections, (e) the role of supplemental inspection in facilitating follow-up baseline inspection of planned corrective actions to preclude repetition of significant issues, and (f) the role of supplemental inspection in capturing risk-important licensee PI&R performance insights for future periodic operating reactor assessment program efforts.

1 Declining licensee performance is reflected by significant (i.e., white, yellow, or red) inspection findings and/or by Performance Indicator (PI) data exceeding response thresholds - either resulting in the licensee transitioning to the right across Action Matrix columns.

2 Execution of corrective actions to preclude repetition of significant performance issues will be ensured during supplemental inspection when possible; during subsequent baseline inspection otherwise.

Issue Date: 09/28/22 1 2515 App B

2515B-03 APPLICABILITY This Appendix applies exclusively to supplemental IPs 95001, -02, and -03 which address all strategic performance areas and associated cornerstones of safety. It applies to all NRC managers, team leads, inspectors, and staff engaged in the supplemental inspection and follow-up inspection processes conducted in accordance with (IAW) the Action Matrix in IMC 0305.

Supplemental inspection shall be initiated for greater-than-green (GTG) findings and PIs IAW IMC 0305. The inspection objectives and requirements are independent of (a) whether the issue(s) originated from a finding or PI or (b) the evaluation methodology chosen by the licensee.

2515B-04 DEFINITIONS This appendix defines language used in the context of ROP supplemental IPs 95001, -02, and -03 to promote common understanding and uniform supplemental inspection implementation. Licensees may use differing nomenclature. Inspectors implementing- and managers overseeing supplemental inspection will focus on the effectiveness of licensee analyses, actions, and documentation (licensee performance) - not on licensee nomenclature.

04.01 Apparent Cause Evaluation (ACE)

A causal analysis type that is based on the evaluators judgment and experience where a reasonable effort is made to determine why a performance issue occurred. This might include fact finding, analysis, interviewing, benchmarking, reviewing data or maintenance history, or other methods. See subsections 01.02, 01.03, 02.01, 04.18, 04.20, 07.01, 08.01, 08.02, 09, 10.01, 10.02, 11.01, and 11.02 of this Appendix for discussion related to precluding repetition.

04.02 Cause (Causal) Analysis or Evaluation A process or method of trying to determine what may be responsible for a performance issue, problem, or condition. Two primary causal analysis types into which most methods fall are the ACE and the Root Cause Analysis (RCA).

04.03 Cause (Causal Factor)

An action, condition, or event that directly or indirectly shapes or influences the outcome of a performance issue, problem, or condition.

04.04 Common Cause Failures When two or more failures of plant processes, programs, equipment, or human performance, are attributable to a shared cause.

04.05 Completed CAPR A CAPR (see definition of CAPR below) is Completed when it has been fully implemented and inspected by NRC inspectors to confirm the implementation was IAW an NRC-accepted plan. [C2]

Issue Date: 09/28/22 2 2515 App B

04.06 Contributing Cause A cause that contributed to an occurrence but, by itself, would not create the occurrence.

04.07 Consequence The actual or potential outcome of an identified performance issue, problem or condition.

04.08 Corrective Action to Preclude Repetition (CAPR)

As used in this appendix or in connection with IPs 95001, -02, and -03 supplemental-and follow-up inspection, CAPR refers to licensee corrective actions necessary to preclude repetition of significant (i.e., Greater-than-Green) performance issue(s). [C2]

04.09 Extent of Condition The extent to which the actual condition exists with other plant processes, programs, equipment, or human performance.

04.10 Extent of Cause The potential for the root cause(s) of an identified performance issue, condition, or problem to exist in other plant processes, programs, equipment, or human performance.

04.11 General Weakness or Omission A weakness or omission associated with licensee actions to identify the causes of a GTG performance issue and to preclude repetition. A general weakness or omission is of enough importance to (a) warrant licensee engagement by inspectors, (b) be screened as an issue of concern IAW IMC 0612, (c) be documented IAW IMC 0611, and (d) inform NRC periodic licensee PI&R assessments. A general weakness or omission cannot preclude satisfaction of supplemental inspection objectives and requirements. A general weakness may constitute an ROP finding, a violation, a failure to satisfy an ROP fundamental expectation, or some combination thereof, and should be characterized and documented accordingly. General weaknesses shall be documented IAW IMC 0611.

04.12 Minor Weakness or Omission A weakness or omission that may warrant informal licensee engagement by inspectors but screens as a non-finding and non-violation IAW IMC 0612 that does not warrant documentation IAW IMC 0611 nor further consideration in periodic licensee PI&R assessments.

04.13 Planned (Open) CAPR A licensee-planned NRC-accepted CAPR that could not be Completed (Closed) (see definition above) prior to satisfactory completion of an IP 95001 or -02 supplemental inspection. [C2]

Issue Date: 09/28/22 3 2515 App B

04.14 Planned CAPR Deviation Occurs when a licensee deviates from a previously inspected and accepted CAPR analysis or plan before the CAPR has been NRC-inspected as complete. See subsection 11.01 of this Appendix for further discussion.

04.15 CAPR Tracking Methods established in ROP governance and software to support documentation of significant planned corrective actions associated with 95001 and 95002 supplemental inspections and to Implement an efficient means for inspectors to readily identify and retrieve information about completed and planned corrective actions associated with 95001 and 95002 supplemental inspections. [C2]

04.16 Repeat occurrences Two or more independent conditions resulting from the same basic cause(s).

04.17 Root Cause The basic reason (e.g., plant processes, programs, equipment, or human performance) for a performance issue, problem, or condition, which if corrected, will preclude repetition. Valid Root Causes generally satisfy the following four criteria: (1) The performance issue, problem, or condition would not have occurred had the root cause not been present; (2) The performance issue, problem, or condition will not recur if the root cause is corrected or eliminated; (3) Correction or elimination of the root cause will preclude repetition of similar performance issues, problems, or conditions, and (4) The root cause is sufficiently specific that it is realistically correctable by the licensee.

04.18 Root Cause Analysis A systematic evidence-based causal analysis designed to reliably and scrutably determine the root- and contributing cause(s) of a performance issue, problem, or condition.

04.19 Significant Performance Issue A GTG finding as determined by IMC 0609, Significance Determination Process or a PI that exceeds the green-to-white performance threshold.

04.20 Significant Weakness or Omission A weakness or omission associated with licensee actions to identify the causes of a GTG performance issue and to preclude repetition which does not provide the level of assurance required to meet supplemental inspection objectives and requirements. Until resolved or sufficiently mitigated, it precludes satisfactory completion of a supplemental inspection. Significant weaknesses warrant prompt licensee and NRC management engagement. If identified during an IP 95003 supplemental inspection, the NRC will further assess a significant weakness to determine whether the facility should be ordered to shut down and placed under IMC 0350 and/or if other agency actions are warranted. Significant weaknesses or omissions should be dispositioned, communicated, and documented with enough detail to assure that informed readers will Issue Date: 09/28/22 4 2515 App B

understand why the significant weakness or omission prevented satisfactory completion of the supplemental inspection and the licensee actions necessary to meet all pending supplemental inspection objectives prior to completing the inspection. A significant performance issue that cannot be resolved or mitigated during the supplemental inspection requires an interim inspection report (IR) and may demonstrate the need to open a parallel PI finding. Refer to IMC 0305 for additional guidance on parallel PI findings and holding open findings in the Action Matrix.

04.21 Supplemental IP IPs that supplement baseline inspections at a licensee when that licensee is in ROP Action Matrix Column 2, 3, or 4, conducted prior to the licensee returning to ROP Action Matrix Column 1. IPs 95001, -02, and -03 are the only supplemental inspection procedures recognized or authorized by the Action Matrix and this Appendix.

04.22 Weakness or Omission A deficiency associated with licensee actions to identify the causes of a GTG performance issue and to preclude repetition. A weakness or omission can be associated with established or omitted facts, assumptions, analysis, or documentation associated with (a) identifying the GTG performance issue(s), (b) determining the root-and contributing cause(s), extent of condition, and/or extent of cause, (c) identifying, planning, or implementing corrective actions to preclude repetition, and/or (d) identifying, planning, or implementing an effectiveness review. Weaknesses and omissions may be categorized and dispositioned as (a) minor, (b) general, or (c) significant. See General-and Significant Weakness or Omission for additional discussion.

2515B-05 RESPONSIBILITIES AND AUTHORITIES See IMC 2515, Light-Water Reactor Inspection Program - Operations Phase.

2515B-06 OVERVIEW The supplemental inspection program is detailed further in this appendix and in IPs 95001, -02, and -03. Combined, these documents facilitate graded regulatory oversight increasing in depth and breadth and becoming more intrusive and diagnostic with the significance and breadth of licensee performance issues that move licensees to the right across the Action Matrix.

Supplemental inspection requirements apply to both single inspection findings and to PIs that might represent more than one independent event (e.g., multiple scrams). Unless a second White input occurs in the same cornerstone, the inspection must be accomplished either by independently evaluating each occurrence or by collective evaluation as appropriate. The licensees evaluation is expected to address each of the occurrences when multiple occurrences exist and the potential for programmatic weaknesses when a second white input occurs in the same cornerstone. [C3]

To reduce unnecessary regulatory burden, supplemental inspection effort and scope are managed to the minimum necessary to satisfy inspection objectives and requirements which, in turn, are necessary to restore reasonable assurance of public safety following significant (i.e.,

GTG) licensee performance issues. IMC 0305 Figure 1: Reactor Oversight Process (ROP)

Issue Date: 09/28/22 5 2515 App B

Action Matrix summarizes conditions warranting column placement and associated expectations regarding regulatory and licensee response and communications. The following table further highlights the similarities and differences between supplemental IPs 95001, -02, and -03:

Supplemental Inspection Selection Table Supplemental Scope Assessment of Supplemental IP Inspection Findings IP 95001, Intent is to review and selectively These two supplemental Supplemental challenge aspects of the licensees inspections are intended to provide Inspection causal evaluation (e.g., problem the information the NRC needs in Response to identification, causal analysis, operating order to assess safety. The NRC Action Matrix experience, extent of cause, extent of can acquire this information by Column 2 condition, safety culture, corrective performing independent (Regulatory actions to preclude repetition, and inspections or reviewing the Response effectiveness review) for the individual licensees efforts to assess the root Column) and collective risk significant cause of the issue.

Inputs performance issues that warranted Significant weaknesses in the supplemental inspection, but not to licensees evaluation or corrective perform an independent assessment of action plans, until resolved, the performance issue. preclude satisfactory completion of supplemental inspection and may IP 95002, Objective is to review and selectively result in the expansion of the Supplemental challenge aspects of the licensees root inspection as necessary to Inspection cause evaluation for the individual and independently complete the Response to collective risk significant performance inspection requirements. (Refer to Action Matrix issues that warranted this supplemental IMC 0305 for additional Column 3 inspection. Also requires an governance.)

(Degraded independent NRC inspection to NRC assessment of licensee PI&R Performance determine adequacy of the licensees performance in resolving GTG Column) extent of condition determination.

issues is also a risk-informed input Inputs It determines if safety culture to the IMC 0305 Operating Reactor components caused or significantly Assessment Program.

contributed to significant performance Weaknesses must be identified, issues and independently assesses the dispositioned, and documented adequacy of the licensees extent of accordingly.

condition and extent of cause using IPs selected from Attachment 1.

Issue Date: 09/28/22 6 2515 App B

Supplemental Inspection Selection Table Supplemental Scope Assessment of Supplemental IP Inspection Findings IP 95003, Intended to determine the breadth and Results assessed to determine Supplemental depth of safety, organizational, and whether the facility warrants a Inspection programmatic issues; is more diagnostic shutdown order and subsequent Response to than indicative and includes reviews of inspection under IMC 0350 or if Action Matrix programs and processes not inspected other agency actions are Column 4 as part of the baseline inspection warranted.

(Multiple/ program. NRC assessment of licensee PI&R Repetitive Allows focus to be applied to areas performance in resolving GTG Degraded where performance issues have been issues is also a risk-informed input Cornerstone, previously identified but requires that to the IMC 0305 Operating Reactor Column) some sample reviews be performed for Assessment Program.

Inputs all key attributes of the effected strategic Weaknesses must be identified, performance areas. dispositioned, and documented Incorporates ROP self-assessment. accordingly.

2515B-07 ENHANCED INSPECTION, ASSESSMENT, AND SUCCESSFUL COMPLETION 07.01 Enhanced Inspection - Challenging Aspects of Licensee PI&R Performance Once a significant (i.e., GTG) performance issue has occurred, inspectors need to ensure the licensee takes actions to identify the causes of the performance issue(s) and to preclude repetition. It is expected that the licensees evaluation of the issue(s) triggering supplemental inspection will generally need to address each of the inspection requirements; however, the depth of licensee analysis may vary depending on the significance and complexity of the issue(s).

Supplemental IPs examine licensee performance relative to regulatory requirements and obligations and self-imposed standards. Absent non-compliance with a regulatory obligation or failure to satisfy a self-imposed standard, a licensee failure to satisfy a fundamental ROP expectation will not generally prompt an enforcement action or the documentation of an ROP finding. It can, however, alter the outcome of a supplemental inspection. A significant weakness in licensee actions to identify the causes of the performance issue(s) and to preclude repetition, until resolved or sufficiently mitigated, will preclude satisfactory completion of a supplemental inspection.

The depth of the NRC evaluation may vary depending on the complexity of the performance issue(s). In some instances, the satisfaction of specific inspection requirements will be self-evident with little additional review or analysis required by the inspectors.

NRC inspectors are generally not required to perform an independent evaluation of the performance issue(s) but shall verify licensee performance of issue identification, evaluation, and corrective plans and activities, sufficiently challenging aspects and assessing the adequacy of licensee performance in each of these areas to ensure that the GTG performance issues and their cause(s) have been properly identified and that Issue Date: 09/28/22 7 2515 App B

corrective plans and actions are in place to promptly and effectively address and preclude repetition.

Supplemental inspection is required to provide increasingly rigorous, diagnostic and programmatic assessments of expanded breadth and depth as the significance of licensee performance issues increases beyond the regulatory response band (Green) to White, to Yellow, or to Red and result in crossing increasing Action Matrix thresholds.

These changes are factored into the supplemental inspection program through the assessment process, as further discussed in Sections 07 and 08 of IMC 2515 Light-Water Reactor Inspection ProgramOperations Phase.

Unless flexibility is explicitly stated, inspectors, staff, and managers engaged in the inspection, in dispositioning, and in documenting the inspection shall satisfy all applicable inspection requirements. The IR should clearly communicate the outcomes to an independent reader. [C1]

07.02 Assessment of Extent of Condition during IP 95002 and -03 Inspection In addition to the above, during IP 95002 and IP 95003 inspections, inspectors shall independently assess the extent of condition with the aid of IPs referenced in Attachment 1 to this Appendix. However, these reference IPs shall not be substituted for completing and documenting the NRCs assessment regarding each applicable IP 95002 or -03 supplemental IP requirement.

Attachment 1 IPs include baseline IPs (portions of which can be repeated with additional samples); procedures that were part of the old inspection program core, regional initiative, and temporary instructions; and new IPs written solely for augmenting supplemental inspection. A combination of procedures or portions of procedures can also be used as appropriate.

The objective of the independent extent of condition review is to ensure that the licensee has properly identified the scope (extent) of the significant issues and that the proposed and completed corrective actions are sufficiently comprehensive. Inspection hours utilized in fulfilling this inspection requirement shall be charged to IP 95002 or IP 95003 as appropriate, regardless of the specific Attachment 1 procedure(s) chosen.

07.03 Multiple GTG Action Matrix Inputs While the inspection requirements are generally written to address individual performance issues, supplemental IPs may also be used to assess the adequacy of the licensees evaluations associated with multiple performance issues associated with transition to Action Matrix Column 2. When performed in connection with a second White input in the same cornerstone as the first, the inspection must evaluate the adequacy of the licensees common cause analyses to consider the potential for programmatic weaknesses in the licensees performance. [C3]

07.04 NRC Assessment of Each Applicable Inspection Requirement Each IR produced to document a supplemental inspection will contain the NRCs assessment for each applicable inspection requirement. These inspection requirements are independent of whether the performance issues were the result of PIs or inspection findings and the licensees causal analysis method. The resource estimates provided in Issue Date: 09/28/22 8 2515 App B

each supplemental IP are estimates only. Inspection effort may vary considerably due to the complexity of the issue(s) and the thoroughness of the licensees own evaluations and proposed corrective actions.

07.05 Cross-Cutting Issue Follow-up Activities taken to follow-up and close cross-cutting issues may be performed in conjunction with a supplemental inspection in the event a supplemental inspection is scheduled within an appropriate timeframe for cross-cutting issue follow-up. See IMC 0305, Operating Reactor Assessment Program, for additional guidance.

07.06 Successful Supplemental Inspection Completion Once an Action Matrix input is identified that causes a licensee to be moved out of Action Matrix Column 1, the Licensee Response Column, the applicable supplemental IP requirements and objectives must be satisfied to return the licensee to Column 1 of the action matrix. The return of a triggering PI to green is insufficient to return the licensee to Action Matrix Column 1. A successfully completed and documented supplemental inspection is necessary.

2515B-08 INITIATING, DELAYING, SUSPENDING OR EXPANDING INSPECTION 08.01 Scheduling and Initiating Supplemental Inspection IP 95001 and -02 supplemental inspections should be scheduled and initiated in a timely manner in response to a licensee request following a licensee transition out of the licensee response column of the Action Matrix. Prior to requesting one of these supplemental inspections, the licensee is expected to have completed thorough problem identification, causal analysis, and corrective action plans to preclude repetition of the associated significant (i.e., GTG) action matrix input(s) and to have implemented any prompt risk-mitigation measures, as appropriate. The evaluation should be documented with enough rigor and detail to enable inspectors to satisfy supplemental IP objectives and requirements. Effective licensee preparation will promote timely and efficient supplemental inspection, closure of associated findings and violations, and a prompt return to the licensee response column of the Action Matrix with minimal regulatory burden.

Planned CAPRs need not be fully implemented prior to supplemental inspection but those CAPRs that are not implemented and inspected during the supplemental inspection will be verified during a future follow-up inspection - typically a baseline inspection sample - to have been promptly and satisfactorily implemented IAW the NRC-inspected and accepted CAPR plan, as further discussed in section 2515B-11.

With the exception of the first phase of IP 95003 supplemental inspection, no licensee should be subject to supplemental inspection until it has signaled readiness. Unlike IP 95001 and -02 supplemental inspections, IP 95003 supplemental inspections may be conducted in two parts. The first phase of IP 95003 is conducted to obtain timely additional information necessary for the NRC to conduct an independent interim assessment of the associated risk significant issues. This interim assessment is used in determining whether the continued operation of the facility is acceptable, whether interim licensee and/or NRC actions are necessary pending completion of licensee assessment Issue Date: 09/28/22 9 2515 App B

and corrective actions and pending satisfaction of remaining IP 95003 supplemental inspection objectives. For this reason, the first phase of IP 95003 supplemental inspection is not contingent on licensee readiness. However, the licensee should signal readiness before the second phase of IP 95003 supplemental inspection is scheduled.

08.02 Delaying Supplemental Inspection A reasonable time is expected for the licensee staff to complete an evaluation, develop, and begin implementation of corrective action plans in preparation for a supplemental inspection. This period is generally proportional to the significance and complexity of the GTG issue(s) prompting the supplemental inspection. If the licensee does not complete preparations and request supplemental inspection within a reasonable time following a GTG performance issue, regional management should (a) prompt the licensee to provide the basis for the delay including significance insights, (b) encourage the licensee to promptly complete analysis and corrective action plan to preclude repetition, and (c) coordinate with the licensee to schedule a timely supplemental inspection.

Should a significant 3 concern regarding licensee readiness arise during inspection preparation or prior to the start of the direct inspection period, the inspectors will promptly inform NRC management and the licensee regarding the concern, its basis, and recommended remedial actions to prepare for a successful supplemental inspection.

The licensee may be offered the opportunity to defer 4 or reschedule the supplemental inspection 5 but shall be made to understand that, in the event the inspection is deferred:

a. A second inspection preparation effort will be necessary

b. In the subsequent IR, inspectors will follow-up, disposition, and document:

1. the weakness prompting the deferral of the supplemental inspection,

2. the duration of the delay,

3. the cause of the weakness, and

4. the effectiveness of corrective actions to address the weakness.

The decision to defer, reschedule, or continued as planned the supplemental inspection should be determined by NRC management after discussion of the potential concerns with licensee management. The NRC decision should account for the need of the inspectors to perform adequate inspection preparation and review any licensee changes prior to the start of the direct inspection period.

08.03 Suspending Supplemental Inspection If, at any time after the start of direct inspection, the inspection team lead is given reason to anticipate the satisfactory completion of the ongoing supplemental inspection will be delayed or will require an additional site visit due to a significant weakness or omission, they shall inform regional management, the program office (e.g., NRR/DRO/IRIB), and 3A significant concern would be a concern sufficient to anticipate an unsatisfactory or delayed completion.

4 Moving the direct inspection period back from the scheduled date for a short period (e.g., a week) should be considered a rescheduled inspection and is not considered a deferred inspection.

5 Note IP 95003 phase-one inspection exception above.

Issue Date: 09/28/22 10 2515 App B

the licensee. A coordinated decision will be made either to suspend the inspection pending licensee resolution of the significant weaknesses or omissions or to continue the inspection in parallel with licensee efforts to resolve the significant weakness. The NRC will communicate to the licensee that continuing the inspection in parallel with licensee efforts to resolve a significant weakness can result in additional onsite or offsite inspection effort.

Should the supplemental inspection proceed in parallel with licensee efforts to resolve the significant weakness, the inspection shall disposition and document the issues both as found and, if applicable, as resolved. Should the inspection be suspended, an interim IR shall be issued that dispositions and documents the significant weakness or omission and addresses licensee actions necessary prior to scheduling a return inspection to resolve the significant weakness or omission. The final IR must confirm and document the resolution of the significant weakness or omission.

08.04 Expanding Supplemental Inspection Expansion of a supplemental inspection may become necessary for inspectors to independently acquire, evaluate, and document additional information necessary to satisfy inspection objectives and requirements. This may occur (a) if a licensee has not thoroughly completed and documented an adequate and scrutable causal analysis and planned CAPRs to enable inspectors to satisfy supplemental IP objectives and requirements, (b) due to other significant weaknesses or omissions in licensee PI&R efforts, (c) as a result of an unusually complex licensee performance issue, or some combination thereof. Such an expansion would constitute a continuation or expansion of the supplemental inspection - not a separate inspection.

If, at any time, regional management or the inspection team lead anticipates that inspection expansion will exceed 130 percent of the maximum IP resource estimate (e.g., exceeding 52 hours6.018519e-4 days <br />0.0144 hours <br />8.597884e-5 weeks <br />1.9786e-5 months <br /> for one white input, 156 hours0.00181 days <br />0.0433 hours <br />2.579365e-4 weeks <br />5.9358e-5 months <br /> for two white inputs in an IP 95001 supplemental inspection), the program office (e.g., NRR/DRO/IRIB) shall be promptly consulted and the licensee shall be informed. An explanation should be provided along with a revised estimate of the resources required to complete the inspection.

When licensee performance indicates the need to open a parallel PI finding or to hold a finding open in the Action Matrix past four quarters, an inspection report shall be issued that describes specific licensee deficiencies and clearly states the necessary licensee actions required to meet all supplemental inspection objectives.

When continued or additional supplemental inspections are conducted, the inspection scope is normally limited to verifying those licensee actions necessary to meet previously unmet supplemental inspections objectives and requirements. Licensees shall be afforded reasonable opportunity to correct identified deficiencies or weaknesses prior to scheduling continued or additional inspection. A final supplemental inspection report must be issued when all inspection objectives and requirements are met.

2515B-09 FINDINGS, VIOLATIONS, GENERAL- AND SIGNIFICANT WEAKNESSES New or additional licensee performance issues identified during supplemental inspection including those identified by the licensee during their evaluation, must be inspected, screened, Issue Date: 09/28/22 11 2515 App B

and dispositioned IAW IMC 0612 to determine whether the issues constitute findings or violations, and documented IAW IMC 0611 Appendix C. Issues that constitute violations must be dispositioned IAW the Enforcement Policy. Additionally, these issues must be assessed to determine whether they constitute general- or significant weaknesses as defined and discussed in Section 04.

Any identified weakness or omission associated with licensee actions to identify the causes of a GTG performance issue and to preclude repetition should be assessed by the supplemental inspection team to determine whether it constitutes a minor-, general-, or significant weakness.

Minor weaknesses, unless they also constitute findings or violations, do not generally warrant documentation and may be resolved informally. General and significant weaknesses must be dispositioned, communicated, and documented IAW IMC 0611 and their respective definitions and discussion in Section 04 of this appendix.

Findings, violations, weaknesses, and planned corrective actions identified during supplemental inspections may warrant follow-up inspection.

2515B-10 INSPECTION REQUIREMENTS, LICENSEE REGULATORY OBLIGATIONS, AND ROP EXPECTATIONS 10.01 Inspection Requirements vs. Licensee Regulatory Obligations Supplemental IP requirements communicate must-do inspector activities and criteria generally necessary for inspectors to satisfy inspection objectives and to complete the inspection, address the associated GTG action matrix inputs, close associated findings and violations, and return the licensee to Column 1 of the Action Matrix. Portions of other recently completed inspections may be credited to the extent that they documented satisfaction of requirements and objectives equivalent or superior to the supplemental IP requirements and objectives.

Supplemental inspection reports must document the NRCs assessment of the licensees evaluation for each inspection requirement IAW IMC 0611, Power Reactor Inspection Reports, Appendix C, Guidance for Supplemental Inspection Reports.

If a supplemental inspection is suspended after the entrance meeting, an interim inspection debrief shall be held with the licensee and an interim inspection report must be issued to document the circumstances of the suspension including those inspection requirements and objectives satisfied, those not satisfied, and the licensee actions necessary to satisfy the requirements and objectives.

Regulatory Obligations are conditions or actions that are legally binding requirements imposed on licensees through applicable rules, regulations, orders, and licenses (including technical specifications and license conditions). They are addressed further in LIC-100, Revision 1, Control of Licensing Bases for Operating Reactors (ADAMS Accession No. ML033530249 (non-publicly available)). IPs may reference obligations, but they may never establish them. A licensee cannot be cited for failure to meet supplemental IP requirements and objectives but would rather be cited for the failure to meet a related obligation revealed by the inspection.

Consequently, while a supplemental IP cannot establish a regulatory obligation compelling a licensee to complete thorough problem identification, causal analysis, and Issue Date: 09/28/22 12 2515 App B

corrective action plans to preclude repetition of the significant (i.e., GTG) action matrix input(s) or compel the licensee to document the evaluation with rigor and detail, the licensee benefits from doing so as this will enable inspectors to satisfy supplemental IP requirements and objectives and thus complete a more timely and efficient supplemental inspection, closure of associated findings and violations, and facilitate the prompt return to Column 1 of the Action Matrix with minimal licensee burden.

New performance issues and new examples of previously identified performance issues revealed within the scope of the supplemental inspection shall be dispositioned and documented IAW IMCs 0612 and 0611, as in the baseline inspection program, allowing for differences specified in this appendix. Unresolved performance issues that rise to the level of findings but do not preclude satisfaction of supplemental IP requirements and objectives shall be characterized as general weaknesses while those that preclude satisfaction of requirements and objectives shall be characterized as significant weaknesses. Significant weaknesses that are not resolved prior to the completion of the scheduled supplemental inspection period are sufficient cause to expand or continue the inspection.

10.02 ROP Expectations of Licensee Performance Participation in the ROP is voluntary and beneficial to all parties but is preconditioned upon the ongoing satisfaction of requisite self-imposed standards. A lapse in satisfaction of a requisite self-imposed standard cannot, in and of itself, trigger enforcement action but it could lead to reductions in one or more benefits of voluntary ROP participation.

As with other expectations requisite to full voluntary ROP participation, supplemental IP requirements and objectives are not contingent on whether significant performance issues are subject to Title 10 of the Code of Federal Regulations Part 50 Appendix B or other regulatory obligations. ROP inspection requirements and objectives are primarily predicated on risk and licensee performance. A licensee preparing for a successful supplemental inspection outcome will generally complete a systematic evidence-based causal analysis designed to reliably and scrutably determine the root- and contributing cause(s) of a performance issue, problem, or condition; complete or plan prompt analysis-driven CAPRs; and provide inspectors with sufficient objective evidence for the inspectors to conclude that the supplemental IP requirements and objectives have been satisfied without significant weaknesses.

The NRCs expectations increase with findings of increasing significance. The significance determination process, action matrix, and the supplemental inspection program determine and respond to a performance issues significance without consideration of the issues enforcement status. The ROP supplemental inspection program expects licensees to conduct the same rigorous causal analysis and corrective action for a given issue significance (i.e., white, yellow, or red) regardless of whether the issue is in the form of a PI, non-violation finding, or cited violation.

2515B-11 FOLLOW-UP INSPECTION OF PLANNED CORRECTIVE ACTIONS 11.01 General Discussion Regarding Follow-up Inspection In order to provide for adequate protection of public health and safety, once a risk significant (i.e. GTG) performance issue is identified, the NRC needs to ensure that Issue Date: 09/28/22 13 2515 App B

licensees take actions to (a) identify the causes of the performance issue and (b) preclude repetition. A satisfactory supplemental inspection completion ensures identification of the causes, item (a). It can also ensure that repetition is precluded, item (b), but only if the licensee has completed- and inspectors were able to verify satisfactory implementation of all CAPRs IAW the inspected plan. Otherwise, follow-up inspection, generally scheduled consistent with the NRC-accepted CAPR completion date as part of a baseline inspection sample, is necessary and sufficient to ensure the licensee has implemented CAPRs IAW the previously inspected plan. The inspection shall be executed IAW the selected IP requirements and documented IAW IMC 0611.

11.02 Documenting CAPR Plans & Implementation Supplemental- and follow-up inspection of licensee completed and planned CAPRs associated with IP 95001 and 95002 supplemental inspections shall be appropriately centralized to ensure inspectors are able to readily and efficiently identify and retrieve information about these CAPRs. [C2]

END Issue Date: 09/28/22 14 2515 App B

Attachment 1: Suggested IPs for Reference Use In Assessing Extent of Condition in IPs 95002 and 95003 Publicly available IPs, including IPs not listed in Attachment 1, are available at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html.

A complete listing of non-publicly available IPs regarding security inspection are internally available at the NRR/DRO internal SharePoint pages.

Any IP may be referenced as needed within the scope of the supplemental inspection.

INITIATING EVENTS Protection Human Procedure Equipment Design Configuration Against Performance Quality Performance Control External Events 71111.01 41500 42700 50002 50002 62709 71111.05 71715 72701 55050 52003 71111.04 71111.06 71841 55100 93803 71111.13 56700 93807 71111.20 61726 93811 62700 62706 62709 71111.07 71111.08 71111.12 71111.13 93805 IPs related to this table that may not be uniquely specific to one of the attributes above 90700 93801 90712 93802 92700 93806 Issue Date: 09/28/22 Att1-1 2515 App B

MITIGATING SYSTEMS Design Protection Configuration Equipment Procedure Human Against Control Performance Quality Performance External Events 52003 71111.01 62709 49001 42001 41500 56700 71111.05 71111.04 55050 42700 71111.11 62710 71111.06 71111.13 55100 72701 71715 71111.18 71111.20 56700 73052 71841 71111.21 57050 93803 57060 93807 57070 93810 57080 93811 57090 61726 62002 62700 62706 62708 62709 62710 71111.07 71111.12 71111.13 71111.15 71111.17 71111.18 71111.21 71111.24 73756 93805 93810 93811 IPs related to this table that may not be uniquely specific to one of the attributes above 90700 93802 90712 93803 92700 93804 93801 93806 Issue Date: 09/28/22 Att1-2 2515 App B

BARRIER INTEGRITY Fuel RCS Equip. Containment Human Procedure Design Con-Cladding & Barrier System, Per- Quality Control figuration Per- Per- Structure and formance Control formance formance Component

& Barrier Performance 61705 55050 38703 41500 42700 50002 62709 61706 55100 49001 71111.11 70307 71111.17 71111.04 61707 56700 50002 71715 72701 71111.18 71111.13 61708 57050 55050 71841 73052 93803 71111.20 61709 57060 55100 93811 61710 57070 56700 57080 57050 57090 57060 61728 57070 62700 57080 62706 57090 62709 61715 71111.08 61720 71111.12 62002 71111.13 62003 71111.17 62700 71111.18 62706 71111.24 62709 73051 70313 73753 70323 73755 71111.12 73756 71111.13 93805 71111.17 71111.18 71111.24 93805 IPs related to this table that may not be uniquely specific to one of the attributes above 90700 90712 92700 93801 Issue Date: 09/28/22 Att1-3 2515 App B

EMERGENCY PREPAREDNESS Emergency Facilities and Procedure ERO Offsite EP Response Equipment Quality Performance Organization (ERO)

Readiness 71114 71114 71114 82001 No NRC inspec-82001 82001 82001 tion of this key 82201 82201 82201 attribute. - Eval-82202 82202 82202 uation per-formed by FEMA PUBLIC RADIATION SAFETY Facilities/Equipment Program/Process Human Performance 71124 84522 71124 84522 41500 83502.03 83502 84750 83502 84750 71124 83523 83502.01 86750 83502.01 86740 71841 83723 83502.02 83502.02 86750 83502 84750 83502.03 83502.01 86740 83502.02 86750 OCCUPATIONAL RADIATION SAFETY Facilities and Equipment Program/Process Human Performance 71124 83724 71124 83724 41500 83723 83725 79702 83725 71124 83724 83501 83728 71841 83750 83750 83501 SECURITY Physical Protection Access Authorization Access Control Response to System System System Contingency Events 71130.01 71130.01 71130.02 71130.01 71130.02 71130.02 71130.04 71130.02 71130.03 71130.04 71130.05 71130.03 71130.04 71130.05 71130.07 71130.04 71130.05 71130.07 65001.17 71130.05 71130.06 71130.08 71130.06 71130.07 65001.17 71130.07 71130.08 71130.08 71130.14 71130.14 65001.17 65001.17 END Issue Date: 09/28/22 Att1-4 2515 App B

Attachment 2: Supplemental Inspection Best Practices ROP Feedback Referenced

1. and Title Best Practice IP Form in IP

1. Inspection Due to the extremely large volume of information for the inspection 95003-1976 95002 Yes Preparation team to review and the significant degree of overlap in the areas to 95003 be inspected, a great deal of emphasis was placed on inspection preparation. This included a week of just-in-time training that pro-vided the NRCs perspective of the licensee and the history of issues to be inspected, and the expectations of how the team should interact to ensure an effective and thorough inspection. In addition, due to the large number of root cause analyses to be reviewed, the team was provided root cause refresher training with a focus on the Browns Ferry process. The preparation also included an onsite orientation week, during which the licensee explained their recovery process, and their perspectives of the significant issues related to the inspection. During the site orientation badging and site tours were completed as well as establishing the point of contact for each inspection area.

2. Emphasis on Based on the licensees history of being able to develop processes 95003-1976 95002 Yes Observations that were on par with the rest of the industry but having difficulties 95003 of In-Plant implementing these processes and sustaining improvement, the Activities team focused on observations of in-plant activities. To allow this to happen, the team completed most of the document reviews during the preparation weeks. Also, all observations, whether positive, negative or neutral, were collected and tracked in a database to allow the development of trends. In addition, due to the concerns regarding safety culture, coordination between the technical in-spectors and the safety culture assessors was vital to the success of the inspection, so, the two groups worked together in the field and during interviews as well as in the team discussion to ensure both the technical aspects and the safety culture aspects were captured.

Issue Date: 09/28/22 Att2-1 2515 App B

Attachment 3: Revision History for IMC 2515 Appendix B Commitment Accession Description of Change Description of Comment Resolution Tracking Number Training and Closed Feedback Number Issue Date Required and Form Accession Change Notice Completion Number Date (Pre-Decisional, Non-Public Information)

N/A 04/03/00 Updated for ROP to include list of procedures that can CN 00-003 be used to follow up on risk significant inspection activities.

N/A 09/12/00 Revised to include newly issued IP 62708, "Motor-CN 00-018 Operated Valve Capability, and to delete IP 50001, "Steam Generator Replacement Inspection." IP 50001 has been moved to IMC 2515, Appendix C, Special and Infrequently Performed Inspections.

N/A 03/06/01 Revised to include new IP 62710, "Power-Operated N/A CN 01-006 Gate Valve Pressure Locking and Thermal Binding."

N/A 1/17/2002 Revised to include new IP 62710. N/A N/A CN 02-001 N/A ML050770156 Revised to add IP 56700, Calibration, IP 82201, N/A N/A 3/23/2005 Emergency Detection and Classification , IP 82202, CN 05-008 Protective Action Decision Making, and IP 90700, Feedback of Operational Experience Information at Operating Power Reactors, to Attachment 1.

N/A ML061580281 Added IP 61726, Surveillance Observations, to list of N/A ML063460228 01/26/07 IPs to be used for assessing extent of condition (FF CN 07-004 IMC2515B-919). Completed 4-year historical change notice search.

N/A ML092300213 Revised to add IP 52003, Digital Instrumentation And N/A N/A 10/29/09 Control Modification Inspection, and remove CN 09-025 references to previously deleted procedures.

Issue Date: 09/28/22 Att3-1 2515 App B

Commitment Accession Description of Change Description of Comment Resolution Tracking Number Training and Closed Feedback Number Issue Date Required and Form Accession Change Notice Completion Number Date (Pre-Decisional, Non-Public Information)

N/A ML102090718 Revised to remove redundant and contradicting N/A ML110130130 02/09/11 assessment guidance since this guidance resided in CN 11-001 IMC 0305. Updated Attachment 1 to reflect currently available procedures. Deleted the old Attachment 2 and since it is redundant to the information maintain on the web. Renamed Attachment 3 to Attachment 2.

N/A ML111870266 Updated Attachment 1 to reflect the current security and N/A N/A 08/18/11 radiation safety procedures.

CN 11-013 N/A ML15204A007 Partially addressed ROPFF 95003-1976 (Include the N/A ML15204A516 12/18/15 best practices as guidance in the Inspection Procedures CN 15-031 95003 and 95002). The ROPFF will be closed upon subsequent revisions to both IP 95003 and IP 95002 to reference Attachment 2. Terminology enhancements and clarifications associated with should vs. shall and governance vs. requirement vs. guidance were incorporated. Grammatical, typographical, formatting, and code transfer issues were also corrected.

C1 ML20052E649 This is a major revision. Commitment C1 is established IP Lead to ML20157A018 10/21/20 in response to the EDO ASSESSMENT and Decision partner with CN 20-054 on Pages 8 and 9 of DPO-2018-001 Case File [OUO - regional FBF 2515B-2331 Sensitive Internal Information - Limited Distribution supplemental ML20157A063 (ML19214A199)] to enhance direction regarding inspection POC supplemental inspections as follows: to conduct training (in

a. Highly qualified inspectors are entrusted with the person or via responsibility to inspect to the requirements of the webinar) during procedure; Spring 2020 Issue Date: 09/28/22 Att3-2 2515 App B

Commitment Accession Description of Change Description of Comment Resolution Tracking Number Training and Closed Feedback Number Issue Date Required and Form Accession Change Notice Completion Number Date (Pre-Decisional, Non-Public Information)

b. Inspectors should document their assessment of regional how the licensee met the inspections objectives; counterpart

c. The inspection report should clearly communicate meetings.

the outcomes to an independent reader; and

d. The inspection reports conclusions should be explicit regarding additional actions required by the inspectors.

C2 C2 addresses agency actions (ML19325C330) in response to OIG-19-A-19 Audit of the NRC Oversight of Supplemental Inspection Corrective Actions and Agency Response, dated October 10, 2019 (ML19256A776).

C3 C3 addresses migrated IP 95001 content related to Staff Requirements Memorandum, SECY-15-0108 Recommendation to Revise the Definition of Degraded Cornerstone as used in the Reactor Oversight Process (ML15335A559) (See C2 in IP 95001).

In addition, content that is common to multiple supplemental IPs is being relocated from individual supplemental IPs to this appendix and is referenced as appropriate rather than replicated in those IPs.

Finally, this revision brings this appendix into alignment with current IMC 0040 structure requirements.

Issue Date: 09/28/22 Att3-3 2515 App B

Commitment Accession Description of Change Description of Comment Resolution Tracking Number Training and Closed Feedback Number Issue Date Required and Form Accession Change Notice Completion Number Date (Pre-Decisional, Non-Public Information)

N/A ML22189A179 Expanded definitions of terms and clarified None ML22189A180 09/28/22 supplemental inspection flexibilities given significant CN 22-019 concerns under sections 08.02, 08.03, and 08.04. FBF 2515B-2456 ML22110A173 Section 07.05 added based on corresponding change to IMC 0305 related to cross-cutting issue follow-up from cross-cutting issue effectiveness review Issue Date: 09/28/22 Att3-4 2515 App B