ML23222A168

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IMC 0611 Appendix D Guidance for Problem Identification and Resolution Inspection Reports
ML23222A168
Person / Time
Issue date: 10/31/2023
From: Sarah Obadina
NRC/NRR/DRO/IRIB
To:
References
DC 23-012, CN 23-032
Download: ML23222A168 (1)


Text

NRC INSPECTION MANUAL IRIB

INSPECTION MANUAL CHAPTER 0611 APPENDIX D

GUIDANCE FOR PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORTS

Effective Date: 01/01/2024

Document assessment of the licensees Problem Identification and Resolution (PI&R) programs in the team inspection report in accordance with IMC 0611 section 12.02. Consider activities that were not only observed during this inspection but also previously documented inspection activities that occurred since the last biennial team assessment as they relate current licensee performance.

Document an assessment of the licensees performance in the following areas:

1. The effectiveness of the corrective action program which includes problem identification, problem evaluation and prioritization, and corrective actions.
2. The use of operating experience.
3. Completed self-assessments and audits.
4. The health of the licensees Safety Conscious Working Environment (SCWE) which includes any underlying factors that would produce a reluctance to raise nuclear safety concerns or prohibit the free flow of information. [C1]

Unlike other b aseline inspection procedures, (IP) 71152 biennial team inspections seek to assess elements of the PI&R programs that may not rise to the level of ROP findings.

Consequently, these inspections may, in some instances, document qualitative observations, minor performance deficiencies, and minor violations. The following guidance supplements that the guidance contained in IMC 0611.

1. The inspection report should describe the observations and basis for each assessment conclusion. The inspection scope for each assessment area should include documentation of the non-cited violations (NCVs), findings (FINs), licensee-identified violations (LIVs), or minor violations (MVs) that were reviewed for verification of corrective actions as well as open corrective actions to prevent recurrence (CAPR s) that were reviewed resulting from supplemental inspections. T he report outline below contains the inspection requirements for each assessment area in a logically organized format.

Negative assessment conclusions should be supported by examples of performance deficiencies. When documenting such performance deficiencies, the discussion must include a disposition of the performance deficiency consistent with IMC 0612 and the Agencys enforcement process. Other conclusions should be supported by a brief basis statement and should include the scope of material reviewed in reaching the conclusion.

To document the review of open CAPRs associated with prior supplemental inspection in RPS, add the inspection report number in the description field. To document the closure of open CAPRs in RPS, select closed under Tracking Data for the specific CAPR and add the associated inspection report number in the description field.

2. Report Cover Letters

Inspection report cover letter guidance is contained in IMC 0611 Exhibit 4, Cover Letter Templates. IMC 0611 Exhibit 4 contains a report cover letter template that can be modified to create a biennial PI&R inspection report cover letter.

Issue Date: 10/31/23 1 0611 App D REPORT OUTLINE:

1. Corrective Action Program Effectiveness

(a) Inspection Scope

Problem Identification 1 - Identify the documents that were reviewed, the standards that the licensee was evaluated against, and if applicable, the other activities that were competed to determine whether the licensee is identifying problems at the proper threshold and entering them into the corrective action system.

Problem Prioritization and Evaluation1 - Identify the documents that were reviewed, the standards that the licensee was evaluated against, and if applicable, the other activities that were competed to determine whether the licensee is adequately prioritizing and evaluating problems. Identify the prioritizations and evaluations which were reviewed and were associated with previous ly documented NRC findings, minor violations, or other inspection activities. Include pertinent reference numbers (e.g., condition report numbers, NRC finding numbers, NRC inspection reports ).

Corrective Actions1 - Identify the documents that were reviewed, the standards that the licensee was evaluated against, and if applicable, the other activities that were competed to determine whether corrective actions are effective, timely, and in the case of significant conditions adverse to quality, prevent recurrence. Identify the corrective actions which were reviewed and were associated with previous documented NRC findings, minor violations, supplemental inspections, or other inspection activities. Include pertinent reference numbers (e.g., condition report numbers, NRC finding numbers, NRC inspection reports).

The inspection scope should include those issues that were designated as part of the five-year review. In addition, the specific NCVs, FINs, LIVs, MVs, and open CAPRs that were reviewed should be documented.

(b) Assessment

Problem Identification1 - Document a conclusion regarding the licensee s effectiveness in problem identification. Include the bases for the conclusion. Discuss issues and relevant observations regarding problem identification.

Problem Prioritization and Evaluation1 - Document a conclusion regarding the licensees effectiveness in prioritizing and evaluating problems. I nclude the bases for that conclusion. Discuss issues relative to:

  • the effectiveness of the licensee s process for prioritizing problems for resolution,
  • technical adequacy and depth of evaluations (including root cause analysis where appropriate),
  • adequate consideration of operability and reportability requirements, and
  • appropriate consideration of risk in prioritizing or evaluating problems for resolution

1 These three areas may be combined into a single write-up

Issue Date: 10/31/23 2 0611 App D Corrective Actions1 - Document a conclusion regarding the licensee s ability to develop and implement effective corrective actions. Include the bases for the conclusion. Discuss issues and relevant observations regarding corrective actions,

including, for significant conditions adverse to quality, issues associated with corrective actions taken to prevent recurrence.

2. Use of Operating Experience

(a) Inspection Scope - Identify documents critically reviewed and if applicable, the other activities that were completed to determine whether the licensee appropriately used operating experience information. If applicable, document NCVs, FINs, LIVs, MVs, or open CAPRs that were reviewed.

(b) Assessment - Document a conclusion regarding the licensee s use of operating experience information. Include the bases for the conclusion.

3. Self-Assessments and Audits

(a) Inspection Scope - Identify documents critically reviewed and if applicable, the other activities that were completed to determine whether conducted licensee self-assessments and audits of their corrective action and quality assurance programs appropriately assessed performance and identify areas for improvement. If applicable, document NCVs, FINs, LIVs, MVs, or open CAPRs that were reviewed.

(b) Assessment - Document a conclusion regarding the licensee s self-assessments and audits. Include in the conclusion if issues identified by those self-assessments and audits were addressed. Include the bases for the conclusion.

4. Safety Conscious Work Environment

(a) Inspection Scope - Identify the documents reviewed and as applicable, other activities that were completed such as Employee Concerns Program reviews and employee interviews to assess whether issues exist that may represent challenges to the free flow of information, and to determine whether underlying factors exist that would produce a reluctance to raise nuclear safety concerns. [C1]

(b) Assessment - Document the existence of issues that may represent challenges to the free flow of information, and underlying factors that could produce a reluctance to raise nuclear safety concerns. [C1] Based on inspection interviews and insights obtained from safety culture and other relevant assessments, document a conclusion as to whether the conditions at the site were conducive to a Safety Conscious Working Environment.

Issue Date: 10/31/23 3 0611 App D Attachment 1: Revision History for IMC 0611 Appendix D

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

ML031610702 Initial Issuance 06/24/03 CN 03-021

C1 ML061560471 PI&R Team Inspection Report format revised to Yes ML061570081 06/22/06 accommodate the safety culture initiative described 07/01/2006 CN 06-015 in Staff Requirements - SECY-04-0111 -

Recommended Staff Actions Regarding Agency Guidance in the Areas of Safety Conscious Work Environment and Safety Culture, dated August 30, 2004 ML111881201 Relocated example cover letter guidance to 10/28/11 IMC 0612 Exhibit 4.

CN 11-024 ML12345A022 Revised to address regional reliability effort change ML13052A347 08/13/13 recommendations. Removed sample inspection FF 0612D-1785, CN 13-017 report for future incorporation into IMC 0612 Exhibit 1827, 1843, 1844,

3. 1845, 1846, 1847 ML17130A997 Editorial update made to reflect the splitting 12/13/17 IMC 0612 into IMC 0611 for documentation and CN 17-029 IMC 0612 for issue screening.

ML22339A153 Completed five-year review. IMC 0611 App D. N/A 12/29/22 FBFs 1616 & 2470 remain open.

CN 22-029

Issue Date: 10/31/23 Att1-1 0611 App D Commitment Accession Description of Change Description of Comment Tracking Number Training Resolution and Number Issue Date Required and Closed Feedback Change Completion Form Accession Notice Date Number (Pre-Decisional, Non-Public Information)

ML23222A168 Revised to incorporate changes to IP 71152 as a ML23222A180 10/31/23 result of recommendations from the Problem CN 23-032 Identification and Resolution Comprehensive Review (ML20247J602).

Issue Date: 10/31/23 Att1-2 0611 App D