ML24101A105

IMC 0615 Non-Power Production and Utilization Facility Inspection Reports

ML24101A105
Person / Time
Issue date:	10/17/2024
From:	Arellano J NRC/NRR/DANU/UNPO
To:
Juan Arellano, NRR/DANU
References
DC 24-010, CN 24-029
Download: ML24101A105 (1)

Text

NRC INSPECTION MANUAL UNPO

INSPECTION MANUAL CHAPTER 0615

NON-POWER PRODUCTION AND UTILIZATION FACILITY INSPECTION REPORTS

TABLE OF CONTENTS

0615-01 PURPOSE.................................................................................................................. 1 0615-02 OBJECTIVES.............................................................................................................. 1 0615-03 DEFINITIONS............................................................................................................. 1 0615-04 RESPONSIBILITIES................................................................................................... 2 0615-05 INSPECTION RESULTS............................................................................................ 3 0615-06 DOCUMENTING VIOLATIONS USING THE FOUR-PART FORMAT........................ 5 0615-07 UNRESOLVED ITEMS (URIs).................................................................................... 8 0615-08 DISCUSSED OPEN ITEMS...................................................................................... 10 0615-09 CLOSURE OF EVENT NOTIFICATIONS................................................................. 11 0615-10 CLOSURE OF CITED VIOLATIONS........................................................................ 11 0615-11 VIOLATIONS WARANTING ENFORCEMENT DISCRETION.................................. 12 0615-12 NON-CITED VIOLATIONS (NCVs)........................................................................... 13 0615-13 MINOR VIOLATIONS............................................................................................... 13 0615-14 OTHER GUIDANCE................................................................................................. 15 0615-15 COMPILING INSPECTION REPORTS.................................................................... 17 15.01 Cover Letter.............................................................................................................. 18 15.02 Cover Page............................................................................................................... 20 15.03 Summary................................................................................................................... 20 15.04 Table of Contents...................................................................................................... 20 15.05 Plant Status............................................................................................................... 21 15.06 Inspection Scopes..................................................................................................... 21 15.07 Inspection Results..................................................................................................... 22 15.08 Exit Meetings and Debriefs....................................................................................... 22 15.09 Third-Party Reviews.................................................................................................. 23 15.10 Documents Reviewed............................................................................................... 23 15.11 Report Attachments.................................................................................................. 23 15.12 List of Acronyms....................................................................................................... 23 15.13 Cover Letter Enclosures........................................................................................... 23 0615-16 INSPECTION REPORT ADMINISTRATION............................................................ 23 0615-17 RELEASE AND DISCLOSURE OF INSPECTION REPORTS................................. 24 : Revision History for IMC 0615....................................................................... Att1-1

Issue Date: 10/17/24 i 0615 0615-01 PURPOSE

01.01 To provide guidance on non-power production and utilization facility (NPUF) inspection report content, format, and style.

01.02 To provide guidance for documenting and dispositioning NPUF inspection conclusions and noncompliances.

0615-02 OBJECTIVES

02.01 Clearly and precisely document significant NRC inspection results in a consistent manner to licensees, NRC staff, and the public.

02.02 Provide conclusions about the inspected pro grams or activities regarding their compliance with regulatory requirements. The depth and scope of the conclusions should be commensurate with the depth and scope of the inspection.

02.03 Document the basis for the determination of any significant enforcement action (EA), as appropriate.

0615-03 DEFINITIONS

03.01 Closed Item

A matter documented in an inspection report as an open item associated with a violation, an event notification, an unresolved item, or a 10 CFR Part 21 reportfor which the matter has been satisfactorily corrected and resolved, based on an assessment of the matter during inspection.

03.02 Conclusion

An assessment that relates inspection results to the broader context of a licensee program or activities.

03.03 Open Item

A matter that requires further inspection. The reason for requiring further inspection may be that corrective actions are not completed, or the matter has been identified as a noncompliance, unresolved item, event notification, violation, or 10 CFR Part 21 report.

03.04 Unresolved Item

An issue of concern associated with an inspection activity that requires more information to determine if it is acceptable, constitutes a noncompliance, or violation. The issue may require additional information from the licensee or cannot be resolved without additional guidance or clarification/interpretation of the existing guidance.

Issue Date: 10/17/24 1 0615 0615-04 RESPONSIBILITIES

04.01 General Responsibilities

Each inspection shall be documented in a report consisting of a cover letter, inspection report enclosure, and attachments.

04.02 Division Director or responsible NPUF Branch Chief

a. Review each inspection report to ensure that it follows the guidance given in this document.

b. Ensure inspection noncompliances are consistent with NRC policies and technical requirements, enforcement-related violations are addressed in accordance with the NRC Enforcement Policy and the NRC Enforcement Manual, and conclusions are logically drawn and sufficiently supported by observations and noncompliances.

c. Ensure that inspectors and reviewers concurrences are maintained on record. Ensure continued inspector concurrence when substantive changes are made to the report as originally submitted, and mediate disagreements that occur during the review process.

As a minimum, substantial changes should be discussed with the i nspector or inspectors involved to ensure continued concurrence, and disagreements that cannot be adequately resolved should be documented using the process described in Management Directive 10.158, NRC Non-Concurrence Process.

d. Ensur e the report is issued to the licensee in a timely manner.

e. Provide interpretations of the information contained in this document and for answering questions related to the guidance.

04.03 Inspectors

a. Prepare NPUF inspection reports in accordance with the guidance provided in this document, including report timeliness.

b. Ensure that the inspection report is accurate, that referenced material is correctly characterized, and that the scope and depth of conclusions are adequately supported by documented observations and noncompliances.

c. Ensure that inspection reports communicate regulatory determinations or actions established in accordance with approved processes (section 0615-14.06).

d. Ensure that the content, tone and focus of the inspection report, as issued, is consistent with the content and tone of the exit meeting presentation or that the licensee is appropriately informed of changes after the exit meeting.

e. Ensure inspection noncompliances are documented in accordance with NRC policies and technical requirements, enforcement-related violations are documented in accordance with the NRC Enforcement Policy and the NRC Enforcement Manual, and conclusions are logically drawn and sufficiently supported by observations and noncompliances.

Issue Date: 10/17/24 2 0615 0615-05 INSPEC TION RESULTS

05.01 Types of Noncompliance

The manner of documenting a noncompliance in the inspection report depends on how that noncompliance will be dispositioned. A noncompliance may be addressed as a minor violation, a non-escalated enforcement action (i.e., a cited Severity Level ( SL)-IV violation or NCV, a deviation, or a nonconformance), an apparent violation (AV), or as an escalated enforcement action (i.e., a SL-I, II, or III violation).

Note: I f an issue is described in an inspection report in sufficient detail to conclude that a noncompliance has occurred, then that issue must be dispositioned as a violation, an apparent violation, or an NCV (for violations); or a Notice of Deviation or Nonconformance may be issued (for deviations and nonconformances). D ocumenting a noncompliance as a weakness, licensee failure, observed discrepancy, or similar characterization without dispositioning it, is inappropriate. If a violation has not occurred, to avoid any confusion, it may be appropriate in certain situations to include a statement such as, this issue does not constitute a violation of NRC requirements. If it cannot be determined if a noncompliance exists due to insufficient information from either the licensee or NRC, it may be treated as a URI.

Note: M inor violations are not normally documented in inspection reports (See 0615-13, Minor Violations).

a. Non-Escalated Enforcement Actions

Most violations of low significance (i.e., more than minor concerns) fall into the SL-IV category. If at the time of issuing the inspection report a violation has been categorized at SL-IV, then an NOV is generally sent out with the inspection report, as a non-escalated EA. The cover letter for reports that include non-escalated EAs should follow the appropriate NRC Enforcement Manual guidance.

Whether an NOV accompanies the report or is issued later, the designation of SL is made in the NOV itself. However, to substantiate the significance of the violation, the four-part format (s ection 0615-06, Documenting Violations Using the Four -Part Format )

should contain the logic for determining the significance with possible reference to a specific NRC Enforcement Policy violation example, if applicable.

Deviations and nonconformances are also considered non-escalated enforcement actions. When a licensee fails to meet a regulatory commitment or to conform to the provisions of an applicable code or industry standard, the failure may result in a Notice of Deviation. When a vendor or certificate holder fails to meet a contract requirement related to NRC activities, the failure may result in a Notice of Nonconformance. For specific guidance on documenting deviations and nonconformances, see the NRC Enforcement Manual.

b. Non-Cited Violations

The criteria for dispositioning a violation as an NCV is laid out in the NRC Enforcement Policy. SL-IV violations at facilities that meet the NCV criteria should be dispositioned

Issue Date: 10/17/24 3 0615 with minimal documentation, as described in s ection 0615-12, Non-Cited Violations (NCVs).

c. Potential Escalated Enforcement Actions

When an issue is being considered for escalated EA, the inspection report should refer to the potential violation as an apparent violation. The report should not include any speculation on the SL of such violations nor on expected NRC enforcement sanctions.

Potential EAs, by their nature, require further agency deliberation (and, usually, additional licensee input at an enforcement panel) to determine the appropriate SL and NRC action.

Similarly, reports that discuss apparent violations should be carefully constructed to avoid making explicit conclusions (i.e., final judgments) about the safety or safeguards significance of the issue. The report should include any available details that demonstrate safety or safeguards significance, or that would help in making such a decision and should also describe any corrective actions taken or planned by the licensee. However, because a potential escalated enforcement action automatically entails further evaluative steps, neither the inspection report details nor the accompanying cover letter should present a final judgment on the issue.

05.02 Supporting Details and Discussions of Safety or Safeguards Significance

The discussion of violations must be sufficiently detailed to substantiate any NRC safety, safeguards, and regulatory concerns and to support any EA the NRC may choose to issue. The degree of detail necessary to support an EA is a function of the significance and complexity of the violation. At a minimum, for a violation, the report should state:

• What requirement was violated.

• How the violation occurred.

• When the violation occurred and how long it existed.

• Who identified it, and when.

• Any actual or potential safety consequence.

• The root cause (if identified); Whether the violation is isolated or programmatic.

• What corrective actions have been taken or planned.

• Who was involved with the violation (i.e., management, operators, technicians).

Although supporting details clearly assist in determining the safety or safeguards significance of violations, inspectors should be cautious in making direct statements regarding safety or safeguards significance in the inspection report details. Violation SLs, as described in the NRC Enforcement Policy, are based on the degree of safety or safeguards significance involved. In assessing the significance of a violation, the NRC considers four specific issues: (1) actual safety or safeguards consequences; (2) potential safety or safeguards consequences, including the consideration of risk information; (3) potential for impacting the NRCs ability to perform its regulatory

Issue Date: 10/17/24 4 0615 function; and (4) any willful aspects of the violation. As a result, if an inspection report refers to a violation as being of low safety or safeguards significance (the meaning of which could be interpreted as implying that the violation did not result in any actual adverse impact on equipment or personnel), the writer may have inadvertently made it difficult for the NRC to subsequently decide that the potential for an adverse impact or the regulatory significance of the violation warrants issuance of a SL-III violation.

Therefore, when characterizing the safety or safeguards significance of a violation, the inspector should address both the actual and potential safety or safeguards and regulatory consequences.

05.03 Violations Involving Willfulness

Inspection reports should neither speculate nor reach conclusions about the intent behind a violation, such as whether it was deliberate, willful, or due to careless disregard. As with any observation, the report discussion should include relevant details on the circumstances of the violation without making a conclusion about the intent of the violator.

For example, The technician failed to follow established sampling procedures, although he had informed the inspectors earlier that he had been properly trained on the use of the proper tools and technique; not, The technician deliberately failed to take quality assurance (QA) samples using established procedures.

Conclusions about the willfulness of a violation are agency decisions and are normally not made until after the Office of Investigation (OI) has completed an investigation. A premature or inaccurate discussion of the willfulness of an apparent violation in the inspection report could result in later conflicts based on additional input and review.

Inspection reports that include potentially willful violations are to be coordinated with OI and the Office of Enforcement (OE).

0615-06 DOCUMENTING VIOLATIONS USING THE FOUR-PART FORMAT

The four-part format should be used for documenting more than minor violations and is organized as follows:

a. Introduction

b. Description

c. Analysis

d. Enforcement

The following table should be used to document traditional enforcement violations, including Severity Level I through IV NOVs and apparent violations. Note: T he table for NCVs is covered in section 0615-12, Non-Cited Violations (NCVs).

Issue Date: 10/17/24 5 0615 Table 1: Traditional Enforcement Violation

[06.01a - Violation Title]

Severity Report Section

Severity Level [X] [IP Number]

NCV/NOV [Tracking Number]

Open/Closed

EA-YY-XXX

[06.01b - Introduction]

Description:

[06.02a - Description]

Corrective Actions: [06.02b - Corrective Actions]

Analysis: [06.03 - Analysis]

Enforcement:

Severity: [06.04 a - Severity Level]

Violation: [06.04 b - Violation]

Enforcement Action: [06.04c - Enforcement Action]

[06.05 - Unresolved Item Closure]

06.01 Title and Introduction

a. Title

Provide a title that describes the violation.

b. Introduction

The introduction should be one or two sentences that provide a brief discussion of the violation. This section does not need to stand alone because the description that follows will provide the supporting details. The introduction should include:

1. The SL (or identification as an AV).

Issue Date: 10/17/24 6 0615

2. The identification credit (self-revealing, NRC -identified, or licensee-identified). Note:

This is not appropriate for AVs.

3. The violation and whether it is an NOV or AV.

06.02 Description and Corrective Actions

a. Describe the circumstances associated with the violation and include the information that is both necessary and sufficient to support the determinations describe d in the enforcement section and to enable an informed, independent reader to understand the actual or potential impact to safety or security. Most violation s can be described in less tha n one page and should rarely exceed two pages. Violations based on more-complex circumstances may merit more discussion.

Include the approximate dates the NRC and licensee became aware of the problem.

Also include references to any other documented inspection activities or docketed correspondence associated with the violation.

For violations determined to be NRC-identified because the inspector identified a previously unknown weakness in the licensees classification, evaluation, or corrective actions, include evidence that the licensee had identified the issue but failed to properly classify, evaluate, or correct the problem.

b. Corrective actions taken to restore compliance or ensure adequate safety. If the planned corrective action is still being evaluated, a sentence stating why continued noncompliance does not present an immediate safety or security concern.

06.03 Analysis

The level of detail must allow a knowledgeable reader to reconstruct the decision logic used to arrive at the conclusion. The analysis must include the following as applicable:

a. Examples in NRC Enforcement Policy s ection 6.0, Violation Examples, aligning with SL-I through SL-IV violations, if applicable.

b. Actual and potential safety or security significance, including a discussion of the safety margin and duration of the violation, as well as the regulatory consequences.

06.04 Enforcement

Violations are documented in accordance with the NRC Enforcement Policy. The enforcement section must inc lude the following for violations which do not receive enforcement discretion (except as noted below).

a. Describe the logic used to determine the SL of the violation and the resulting SL. Include reference to Enforcement Policy examples. For AVs, indicate the NRC has not made an enforcement decision.

b. Document the disposition of violations as follows:

1. Describe what requirement was violated and how it was violated (this requires a contrary to statement consistent with guidance in the Enforcement Manual, using language that is parallel to that of the requirement).

Issue Date: 10/17/24 7 0615

2. Describe when the violation occurred and how long it existed (Use bracketing dates or date and duration. Indicate when estimated or ongoing at time of the exit meeting).

Use the following format, unless directed otherwise by the Enforcement Manual:

[Requirement violated] requires [Requirement].

Contrary to the above, [When the violation occurred and how long it existed. (e.g.,

from January 1, 1234, to December 31, 1234)], the licensee [what the licensee did contrary to the requirement].

c. For AVs, and NOVs, provide a statement similar to:

1. AVs: This violation is being treated as an apparent violation (AV) pending a final significance (enforcement) determination.

2. NOVs: This violation is being cited because [reason], consistent with section 2.3.2 of the Enforcement Policy.

06.05 Unresolved Item Closure

If the assessment of a violation results in a URI closure, include a reference to URI

[Docket Number(s)] /[Report Number]-[Unique Sequential Integer] being closed. (e.g.,

This closes URI 0 5001234/2022001-01.).

0615-07 UNRESOLVED ITEMS (URIS)

07.01 Opening

An inspector should open a URI when an issue of concern is identified but more information is required to determine if the issue of concern is a noncompliance.

A URI cannot be used to determine the significance of a violation (except when more information is needed to determine if a violation is minor or more than minor), to track completion of licensees actions associated with a violation or an inspection question, or to determine if enforcement discretion should be granted for a violation. The action of documenting URIs is a commitment of future resources. Do not document URIs in the List of v iolations section or in the inspection report cover letter.

The URI should be documented using the format shown in the table below.

Issue Date: 10/17/24 8 0615 Table 2: Open Unresolved Item

Unresolved Item [07.02a - Title and Tracking Number] [IP Number]

(Open)

Description:

[07.02b - Description]

Planned Closure Actions: [07.02c - Planned Closure Actions]

Licensee Actions: [07.02d - Licensee Actions]

Use the following table to document URI closures associated with no violation determination. Do not use the table to document other outcomes of the URI because the URIs closure basis will be captured in the respective write-up. Document the URI closure in the results section of the report under the inspectable area associated with the sample or inspection activity that resulted in the opening of the URI. Otherwise, such as in cases where the URI was opened during a reactive inspection, document the closure under the inspectable area associated with the sample or inspection activity used to inspect the URI.

Table 3: Closed Unresolved Item

Unresolved Item [0 7.0 2 a - Title and Tracking] [IP Number ]

(Closed)

Description : [0 7.0 2 b - Description]

07.02 Unresolved Item

a. Title and Tracking

Provide a title for the URI. The title should describe the issue of concer n on line one. On line two, enter URI followed by the [Docket Number(s)]/[Report Number] -[Unique Sequential Integer].

b. Description

1. When opening a URI, clearly state that an URI was identified, and describe the issue with sufficient detail so that another inspector could complete the inspection and documentation effort. Indicate whether the issue of concern was, in part, determined to be a violation and indicate what additional information is needed to make the violation.

Issue Date: 10/17/24 9 0615

2. When closing a URI, the level of detail devoted to closing URIs depends on the nature and significance of the additional information identified.

In the first paragraph, summarize the topic, inspector follow-up actions, and describe any licensee actions.

In the second paragraph, include why the issue was or was not a violation (e.g., not reasonably within the licensee ability to foresee and correct or not a violation or licensee standard). Caution should be used when describing why a violation did not exist.

If resolution to a URI was based on discussions between inspector(s) and Nuclear Reactor Regulation (NRR) technical staff, concisely document the details of these discussions. Additionally, branch chiefs of the inspector(s) and technical staff who were involved in these discussions should concur on the inspection report.

c. Planned Closure Actions

Identify the specific licensee or NRC actions needed to determine whether the issue of concern is a violation.

d. Licensee Actions

Describe any corrective actions taken to eliminate any perceived immediate safety or security concerns.

0615-08 DISCUSSED OPEN ITEMS

Use the following table to document open items being discussed.

Table 4: Discussed Item

[08a - Item Type] [08b - Title and Tracking] [IP Number]

(Discussed)

Discussion: [08c - Discussion]

Open items such as unresolved items, apparent violations, and notices of violations requiring a response were assigned an open tracking status in a previously issued inspection report.

Document discussed open items in the results section of the report under the inspection procedure associated with the sample or inspection activity that resulted in the opening of the item.

a. Item Type

Describe the item type (e.g., Unresolved Item).

Issue Date: 10/17/24 10 0615

b. Title and Tracking

Enter the previously used title and tracking number assigned when the item was opened in a prior report.

c. Discussion

Capture follow up actions, pertinent facts gathered, and observations which may support a future disposition of the item.

0615-09 CLOSURE OF EVENT NOTIFICATIONS

Licensee events are submitted by the licensee and reviewed and inspected using IP 92701, Followup, or by an associated inspection procedure. Inspectors review these reported events and document their review and closure.

In general, event reviews should have a brief description of the event and reference the docketed notification number. If a review is already documented in a separate NRC correspondence, then close the event with a brief statement in an inspection report referencing the separate correspondence. In addition, document closure of the event as follows:

a. No Violations

Include a statement similar to The Event Report was reviewed. No violations of NRC requirements were identified."

b. Minor Violations

Document as specified in s ection 0615-13, Minor Violations, in accordance with the NRC Enforcement Policy.

c. Non-Cited Violations

The safety significance and enforcement should be discussed per s ection 0615-12, Non -Cited Violations (NCVs).

d. Violations

NRC-Identified or Identified Through an Event Violations should us e section 0615-06, Documenting Violations Using the Four-Part Format, if not previously documented.

0615-10 C LOSURE OF CITED VIOLATIONS

After receipt of the licensees response to an NOV and completion of any necessary inspections, document the closure of cited violations under the inspection procedure used to review and close the NOV. The level of detail required to document closure of cited violations depends on the extent of corrective actions conducted by the licensee. In general, the write-up must summarize the inspector's follow-up actions to evaluate the adequacy of any licensee actions and provide enough detail to justify closing the violation.

Issue Date: 10/17/24 11 0615 For example: The inspectors reviewed the licensees response to NOV [Docket Number(s)]/[Report Number]-[Unique Sequential Integer] and determined that the reason, corrective actions taken and planned to address recurrence, and the date when full compliance will be/was achieved for this violation is adequately addressed and captured on the docket.

0615-11 VIOLATIONS WARANTING ENFORCEMENT DISCRETION

Bring violations that may warrant enforcement discretion to the attention of the NRR Enforcement Coordinator. Default to any overriding directions found in an Interim Enforcement Policy, an Enforcement Guidance Memorandum, or the Enforcement Manual. Use of enforcement discretion also requires coordination with the Office of Enforcement. This includes the pathway to reach the decision and concurrence review on the final report. Unless otherwise directed, document violations receiving enforcement discretion in the results section of the report under the applicable inspectable area. Use the following table to document violations receiving enforcement discretion.

Table 5: Enforcement Discretion

Enforcement [11.01 - Enforcement Action] [IP Number]

Discretion

Description:

[06.02a - Description]

Corrective Actions: [06.02b - Corrective Actions]

Enforcement:

Severity/Significance: [06.04a - Severity]

Violation: [06.04b - Violation]

Discretion Basis: [11.02 - Discretion]

[11.03 - Unresolved Item Closure]

11.01 Enforcement Action

Identify the Enforcement Action Number and provide a title with a reference to any applicable Enforcement Guidance Memorandum (EGM).

Issue Date: 10/17/24 12 0615 11.02 Discretion

State why enforcement discretion is being granted. Include an appropriate statement such as:

The NRC exercised enforcement discretion in accordance with s ection [#.#] of the Enforcement Policy because [reason].

Note: Violations must be assigned an EA number, which can be obtained through the NRR Enforcement Coordinator. The cover letter must contain the required language for exercising enforcement discretion.

11.03 Unresolved Item Closure

If the granting of enforcement discretion results in a URI closure, include a reference to URI [Docket Number(s)]/[Report Number]-[Unique Sequential Integer] being closed.

(e.g., This closes URI 050000123/2014007-01.).

0615-12 NON-CITED VIOLATIONS (NCVS)

Violations which meet the requirements for an NCV in accordance with the NRC Enforcement Policy and the NRC Enforcement Manual should receive minimal documentation.

All other non-minor violations must be documented in accordance with the appropriate s ection.

Document non-cited violations in the results section of the report under the inspectable area associated with the sample or inspection activity. Use the following table to document NCVs.

Table 6: Non-Cited Violation

Non-Cited Violation [IP Number]

This violation of very low safety significance was identified by the licensee and [has been corrected or committed to being corrected within a reasonable period of time] and is being treated as a non-cited violation, consistent with section 2.3.2(b) of the Enforcement Policy.

Violation: [06.04b - Violation]

[06.05 - Unresolved Item Closure]

0615-13 MINOR VIOLATIONS

Minor violations should only be documented when it becomes necessary to capture a required inspection activity or conclusion for the record where it would be obvious to a member of the public that a violation is involved, such as closing out a written event notification or URI.

Documentation, in this case, helps to provide public confidence that the agency has

Issue Date: 10/17/24 13 0615 dispositioned the violation. When a minor violation is documented, sufficient detail must be provided to allow an informed, independent reader to understand the basis for the minor determination (see the NRC Enforcement Manual s ection for more information). Minor violations should not be included in the List of Violations section or Additional Tracking Items section of the report. Document minor violations in the results section of the report under the applicable inspectable area, when necessary. For minor violations, document using the following table:

Table 7: Minor Violation

Minor Violation [IP Number]

Minor Violation: [13.a - Minor Issue Description]

Screening: [13.b - Minor/More than Minor Screening Text]

Enforcement: [13.c - Enforcement]

[13.d - Unresolved Item Closure]

a. Minor Issue Description

Briefly describe the minor violation.

b. Minor/More than Minor Screening

State the reason why the violation is minor in accordance the NRC Enforcement Policy as applicable.

c. Enforcement

State that the licensee has taken actions to restore compliance and include a statement similar to the following: This failure to comply with [requirement] constitutes a minor violation that is not subject to enforcement action in accordance with the NRC Enforcement Policy.

d. Unresolved Item Closure

If the minor violation results in a URI closure, include a reference to URI [Docket Number(s)]/[Report Number]-[Unique Sequential Integer] being closed. (e.g., This closes URI 07001234/2020001-01.).

Issue Date: 10/17/24 14 0615 0615-14 OTHER GUIDANCE

14.01 Treatment of Third-Party Reviews

Detailed NRC reviews of National Organization of Test, Research and Training Reactor (TRTR) evaluations, reports, issues of concern, recommendations, and corrective actions, or other third-party reviews with similar information are not referenced in NRC inspection reports, tracking tools, or other Agency documents unless the issue is of such safety significance that no other reasonable alternative is acceptable. TRTR observations, recommendations and associated licensee corrective actions are not normally tracked by the NRC. If an observation warrants tracking, it should be independently evaluated, documented, and tracked as an NRC observation. Include a short statement in the inspection report to document that a review of a specified TRTR evaluation or report was completed. Do not include a recounting or listing of TRTR findings or reference a final TRTR conclusions when documenting an TRTR ev aluation or accreditation report review. Discuss the specifics of any significant differences between NRC and TRTR perceptions with management.

14.02 Treatment of Sensitive Unclassified Non-Safeguards Information (SUNSI)

SUNSI must not be made publicly available and must be segregated from other portions of the report, which are to be made publicly available. This can typically be accomplished by creating and referencing a separate report enclosure, which can be profiled in Agencywide Documents Access and Manage ment System (ADAMS) as Non-Publicly Available. The documents containing SUNSI must be marked in accordance with Management Directive 12.6, NRC Sensitive Unclassified Information Security Program.

14.03 Amending Inspection Reports

When it becomes necessary to correct an issued report, the previously issued report should generally be revised and reissued in its entirety under the same inspection report number. The revised report would receive a new and unique ADAMS accession number and should include an appropriate cover letter explaining why the report is being reissued.

Note: A revised inspection report must not be used to document new violations or inspection activities which occurred after the initial report was issued. D epending on the nature of the correction, it may be more appropriate to discuss the change in a future report, rather than to reissue a complete report.

14.04 Plain Language

Use plain language in inspection reports. For additional direction, refer to NUREG -1379, NRC Editorial Style Guide.

a. Grammatical Person, Tense, and Voice

Always write in the third person. For example, The inspector watched the operator startup the reactor.

Issue Date: 10/17/24 15 0615 In general, use the past or past perfect tense. For example, The facility director stated that the safety review committee met quarterly. As a rule of thumb, use the past tense (e.g., the pump cavitated OR the pump was cavitating ) when writing about events that occurred during the inspection. Use the past perfect tense (e.g., the pump had cavitated OR the pump had been cavitating) when writing about events that occurred before the inspection. However, when quoting or paraphrasing existing documents, the present tense may be used (e.g., 10 CFR 50.71 states ). When quoting a licensee document, give the date and/or revision number of the document from which the quote was taken).

Use predominately active voice (subject-verb-object). For example, The operator reported that pool water level was rising. The inspection report should clearly identify the subject, or the performer of the action, which could be important in evaluating the significance of the observation.

b. Words or Phrases with Unspecific Connotations or Hidden Implications

Avoid words or phrases that have unspecific connotations or hidden implications, such that a reader might misconstrue the meaning. Avoid words and phrases which are imprecise, e.g., wonderful or awful. These words and others are imprecise and unsupported. A more concrete description, detailing those aspects and attributes of the issue are more appropriate. For example, a program exceeded or failed to meet requirements or standards on timeliness.

c. Technical, Legal, and Local Jargon

Because of the specialized technical and legal aspects of NRC regulation, inspectors must maintain sensitivity to the use of specialized vocabulary in inspection reports. The use of technical and legal jargon is expected and necessary; however, inspectors should avoid the use of local jargon, terms or phrases that have specific meaning for a particular facility or are not widely understood. Examples include terms and phrases such as tailgate (when used to refer to an informal meeting), work -around, and command and control. Because these labels are used routinely by a localized group, inspectors may become accustomed to their use and assume that they have a consistent, widely understood meaning. To reduce the potential for miscommunication, inspectors should define such terms and phrases whenever used or, if possible, use an alternate word that has a clear, dictionary -defined meaning. For example, consider the following usage of the term work -around: The licensee s failure to resolve longstanding concerns has contributed to an excessive reliance on an operator work -

around. The term work -around, as used in this report, refers to non-routine actions performed by the operating crew to compensate for equipment not functioning as designed. In this case, the inspector chose to use local jargon by including the term work -around. By defining the term immediately after its initial use in the report, however, the inspector avoided the possibility of vagueness or an incorrect interpretation for a reader not familiar with the term. As an alternative, the inspector may choose not to use the term at all: T he licensee s failure to resolve longstanding concerns has contributed to an excessive reliance on the performance of non-routine actions by the operators, to bypass or compensate for equipment not functioning as designed.

Issue Date: 10/17/24 16 0615 14.05 Graphics/Visual Aids

Use graphics (drawings, diagrams, photographs, or photocopies) if their inclusion will simplify describing a complex condition that would otherwise require substantially more text. Photographs of plant areas or equipment or photocopies of technical or vendor manual pages must be handled in accordance with IMC 0620, Inspection Documents and Records. When including graphics, the following should be considered:

a. Format as a jpeg and adjust size (height, width, and resolution) so as not to significantly increase overall file size.

b. Locate on less than 1/2 page or put in an attachment.

c. Center on page and left/right indented from the text.

d. Include a unique identifier (Figure/Diagram/Photograph X) with a descriptive title (e.g.,

Breaker Trip Latch Alignment).

14.06 Caution Regarding the Creation of Staff Positions

The statement No violations of more than minor significance were identified, does not create a staff position. This language acknowledges the possibility that noncompliances existed but were not documented in the report (e.g., because the inspectors did not discover them or because any identified noncompliances were found to be minor).

However, if the inspection report states, The licensee complied with [Requirement X],

as related to an issue of concern, that language would constitute a staff position. If the NRC subsequently determined there is a noncompliance with Requirement X related to the issue of concern, then the NRC may need to consider that discovery a change in staff position subject to the backfitting provisions.

As such, the staff must exercise caution and avoid creating staff positions by not documenting statements about the adequacy of the licensing basis or statements about licensee compliance (some exceptions may apply depending on the type of inspection).

0615-1 5 COMPILING INSPECTION REPORTS

Inspection results shall be reported to the licensee by issuance of an inspection report consisting of a cover letter signed by the cognizant branch chief, Division Director, or other designee, depending on the significance of any violations, an NOV if applicable, an inspection cover sheet, and report details.

The NRC Inspection Report is the document that states the official Agency position on the inspection scope, any noncompliances, and/or URIs noted by the inspectors, and any conclusions that were reached relating to the inspection. All enforcement, routine and escalated, and all other Agency actions that may result from an inspection (such as Orders), will be based upon the associated inspection report. Inspection reports must be clear, accurate, consistent, and complete. Inspectors may use previously issued NPUF inspection reports for examples and guidance.

Issue Date: 10/17/24 17 0615 15.01 Cover Letter

Inspection reports are transmitted using a cover letter to communicate the overall inspection results to the licensee. Cover letter content varies somewhat depending on whether or not the inspection identified a noncompliance. In general, however, every cover letter uses the same basic structure.

a. Cover Letter Content

In general, every cover letter is based on a standard letter from Appendix B of the NRC Enforcement Manual and has the same basic structure as follows:

Addresses, Date, and Salutation. At the top of the first page, the cover letter begins with the NRC seal and address followed by the date on which the report cover letter is signed and the report is issued.

For cover letters transmitting report details with violations assigned an EA number, the EA number should be placed in the upper left-hand corner above the principal addressees name. T he EA number should be placed into the ADAMS profile of the document for the case/reference number.

The name and title of the principal addressee is placed at least four lines below the letterhead, followed by the licensees name and address. Note that the salutation is placed after the subject line.

b. Subject Line

The subject line of the letter should state the facility name, the inspection subject, the docket, and report number (e.g., UNIVERSITY OF ABC - U.S. NUCLEAR REGULATORY COMMISSION SAFETY INSPECTION REPORT NO.

012345678/209901). The words NOTICE OF VIOLATION (or NOTICE OF DEVIATION, etc.) should be included if such a notice accompanies the inspection report. The entire subject line shall be capitalized.

c. Body Paragraphs

The first two paragraphs of the cover letter should give a brief introduction, including the type of inspection report. The cover letter is written to transmit the inspection report to the licensees management, and to deliver the big picture message regarding the inspection. Because it is the highest-level document, it does not need to (and normally will not) detail all the items inspected, and the inspection procedures used. It will note the areas covered by the inspection. The cover letter must never contain any significant information which is not also contained in the summary and supported in the report details.

The cover letter must always be consistent with the inspection report. In addition, it must be consistent with the information which the inspector conveyed to licensee managers at the exit meeting. If the inspectors understanding of the facts or the significance of the violations changes after the exit meeting, the NRC shall call the licensee and re-exit. The re-exit should be documented in the cover letter. There should never be any surprises in a cover letter to anyone who was present at the exit meeting.

Issue Date: 10/17/24 18 0615 The cover letter usually should not contain recommendations. There should not be any statements to the effect, The licensee needs to... or, The licensee should.... If the licensee is not meeting safety or regulatory requirements, the statements should c learly show those facts. If the NRC believes that a licensee cannot ensure the safety of its activities, then an Order or some similar official action may be appropriate. Guiding licensee decision-making using a cover letter to an inspection report is not the appropriate method for accomplishing this type of action.

The content of a publicly-available cover letter to a non-public inspection report and NOV should be limited. The cover letter should closely follow the template provided in the Enforcement Manual. The number and SL of the violations identified should be stated, if the violations are NCVs or SL-IV violations. The number of violations pertaining to escalated enforcement should also be stated; however, the specific severity level should not be given. In all cases, the content of the violations shall be withheld, and the NOV shall not be included on the public docket. The specific regulation that the licensee was in violation of should not be specified. The type of inspection (Material Control and Accounting (MC&A), physical security, etc.) should not be specified in the publicly -

available cover letter.

A publicly-available cover letter should accompany all security and safeguards related inspection reports that include enforcement information, including but not limited to:

choice letters, conference letters, predecisional enforcement letters, and final determination letters. In the instance that a security or safeguards related inspection report does not contain a NOV, the publicly -available cover letter should clearly state this.

However, in rare and exceptional instances, the NRC may choose not to release a cover letter or enforcement document with security -related violations when the information could potentially increase the security risk of a licensee or when another Federal agency requests the NRC not to issue any public notifications regarding a specific event. On a case-by -case basis, NRC senior management from the office issuing the cover letter of an enforcement document, the Office of Nuclear Security and Incident Response (NSIR), OE, the Office of the General Counsel (OGC) and OI (for cases involving OI reports) will determine when withholding a cover letter of an enforcement document is appropriate after reviewing specific circumstances of the case.

d. Closing

The final paragraph consists of standard legal language that varies depending on whether enforcement action is involved. The final paragraph is followed by the signature of the appropriate NRC official followed by the docket number(s), licensee number(s),

enclosure(s), and cc: list. The distribution list is then on the concurrence page.

e. NOV (If Applicable)

Licensees are officially notified that they have failed to meet regulatory requirements when NRC issues an NOV. An NOV may be sent to licensees as part of a package of documents which also includes a cover letter and associated inspection report. An NOV may be sent with a cover letter which refers to an inspection report that was distributed previously. An NOV should not be sent to the licensee in advance of the inspection report.

Issue Date: 10/17/24 19 0615 Every NOV must be clear, so that there is little doubt that the licensee (or other interested reader) can understand the basis for the violation. The licensee may not agree with the NRC basis, but they must understand the NRC position.

Every NOV must clearly state what requirement was not met. That may mean that the date and revision number of the applicable document will need to be provided. Then, a clear statement of what happened (including when and for how long, if the timing is important) will be provided. The intention is that any interested reader will be able to clearly see and understand what the requirement was and how it was not met. For additional guidance on documenting violations, refer to the NRC Enforcement Manual.

The NOV should be an enclosure to the cover letter.

15.02 Cover Page

The report cover page provides a quick glance summary of information about the inspection. It contains the docket number, license number, report number, licensee, facility name, location, dates of inspection, names of inspectors and accompaniments, and name and title of approving NRC manager.

15.03 Summary

The summary should include a paragraph that covers the type of inspection, and a summary sentence of the overall regulatory conclusion on facility safety and compliance.

Include a paragraph similar to the following:

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a(n) [ integrated] inspection at [Site Name], in accordance with the research and test reactor inspection program. this is the NRCs program for overseeing the safe operation of research and test reactor facilities. For more information refer to https://www.nrc.gov/reactors/non-power.html.

a. List of Violations

Copy the violation headers from the writeups done for s ection 0615-06, Documenting Violations Using the Four-Part Format, and s ection 0615-12, Non -Cited Violations (NCVs). Organize the violation headers by the order the y appear in the report. If no violations were identified, include a statement similar to No violations of more than minor significance were identified.

b. Additional Tracking Items

Include a list of items opened, closed, and discussed which are not directly covered in the list of violations above. For each listed item, include the item type, tracking number, title, status (i.e., Open, Closed, or Discussed), and a reference to the appropriate section.

15.04 Table of Contents

For reports of significant length (i.e., in which the report details section exceeds 20 pages), the inspector should consider including a table of contents as an aid to clarity.

Issue Date: 10/17/24 20 0615 15.05 Facility Status

Include a Summary of Facility Status section, if appropriate. Briefly describe the overall operations at the facility and plant status for the report period. An example of plant status would be the normal ongoing activities or a list of degraded conditions which significantly affected operations. Describe any shutdowns or significant changes if applicable.

15.06 Inspection Scopes

This section details the specific items such as equipment or programs that were inspected and the regulatory standards that were used to determine if the licensee was in compliance. In most cases, the approach that should be used in writing the s cope should be consistent with the i nspection procedure used in performing the inspection.

When describing the s cope, it is acceptable to state either what the inspector(s) did, or what the inspection accomplished. That is, a scope section could be phrased, This inspection included a review (or observation, or evaluation, etc.) of.... or it could be written as, The inspectors reviewed (observed, evaluated) the.... The s cope statements should also describe why certain items were inspected. For example,...to determine compliance with....

There should always be a readily identifiable connection between the stated s cope and the items that the inspector reviewed. Thus, if the s cope was to review personnel dosimetry records, the inspector should not include issues associated with packaging and shipping problems. The scope may, when germane to the inspection, include (1) how the inspection was conducted (i.e., the methods of inspection), (2) what was inspected, (3) approximately when each activity was performed, (4) where the inspection took place (i.e., what room(s) or buildings) and (5) the inspection objectives and/or criteria for determining whether the licensee is in compliance.

a. Scope Paragraph

Include a paragraph similar to the following once at the beginning of the scope section.

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at https://www.nrc.gov/reading-rm/doc -collections/insp-manual/inspection-procedure/index.html. Ins pections were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2545, Research and Test Reactor Inspection Program. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, licensee conditions, site procedures, and standards.

b. Individual Inspection Scopes

Following the general scope paragraph, for inspection activities performed, identify the inspection procedure and title, then include a scope section about the specific inspection procedure section. An example is shown below.

69001 - Class II Research and Test Reactors

Issue Date: 10/17/24 21 0615 This is the scope text for IP 69001. Note: When the inspector is present during a significant facility event or an unusual evolution, more detail may be appropriate concerning which portions of the event or evolution were actually observed. For inspections of significant facility modifications, strong emphasis is generally given to quality verification of newly installed or re-worked components or systems. In such cases, the description of inspection activities should be very detailed about what the inspector actually examined (e.g., a listing of welds observed or radiographs reviewed).

Organization and Staffing (IP Section 02.01)

This is the scope text for the respective IP se ction. Specifically, the inspection included a review of the following:

• [list of observations, logs, etc.]

All inspection scopes shall be listed under the IP that was used to conduct the review.

The scope should focus on activities conducted to follow up on the issue, but it should not mention any opinions about the adequacy of licensee actions. For follow-up on previously identified issues, inspectors should typically use the IP in which the item was originally opened. For event follow -up, the inspectors should use the IP most closely related to the event or IP 92701 Followup.

If the inspection activities were conducted at a location other than the facility, (e.g., an evaluation of emergency or security services), then identify where the inspection took place.

15.07 Inspection Results

Organize the inspection results grouped by IP, applicable IP section, and finally by the order of the table used in this IMC to document the results. When there are no inspection results in the report, include a statement similar to, No violations of more than minor significance were identified.

15.08 Exit Meetings and Debriefs

This section briefly summarizes the exit meeting(s), which is/are also described in the first paragraph of the cover letter and identifies the most senior principal manager who attended the meeting(s).

At the exit meeting, the inspectors should verify that the information the inspector reviewed during the inspection, if intended to be included in the report, is not proprietary.

If the licensee does not identify any material as being proprietary the Exit Meetings and Debriefs section should include a sentence to that effect.

If the NRCs position on an inspection issue changes after the exit meeting, conduct an additional exit meeting to discuss the change with the licensee. Do not accept any oral statements made by the licensee as commitments. If the licensee disagrees with a violation, this position may be characterized by the licensee in its formal response to the inspection report.

Issue Date: 10/17/24 22 0615 15.09 Third-Party Reviews

In rare circumstances, it may be necessary to document the completion of third-party reviews in this section of a report. Omit this report section when there are no reviews.

15.10 Documents Reviewed

List critically reviewed documents in support of future inspection activities or that support NRC determinations. The list need not include thos e reviewed documents and records already identified in the body of the report. The level of detail for listed documents must be sufficient to allow the NRC to retrieve the document for the licensee in the foreseeable future. Therefore, a unique identifier, which may include the tracking number, title, revision, and/or date, must be provided for each document referenced.

15.11 Report Attachments

If applicable, attachments (e.g, escalated enforcement supporting details) may be references and added to the end of the inspection report. The attachments may be combined into a single attachment entitled Supplemental Information if desired.

15.12 List of Acronyms

If applicable, acronyms should be spelled out when first used in inspection report text. A list of acronyms should be included in the inspection report referenced, when the report section is 20 pages or longer. When referenced, the list of acronyms should be made publicly available for publicly available reports.

15.13 Cover Letter Enclosures

The inspection report, starting with t he cover page, is typically cover letter Enclosure 1.

An additional cover letter enclosure may be necessary to communicate an NOV.

0615-16 INSPECTION REPORT ADMINISTRATION

16.01 Report Timeliness

a. Timeliness

Routine inspection reports should be issued no later than 45 calendar days after inspection completion. Reactive and supplemental inspection reports should be issued no later than 30 calendar days after inspection completion. Inspection completion is the day of the exit meeting. Timeliness goals should be accelerated for inspection reports covering potential escalated enforcement actions. For specific enforcement timeliness goals, see the NRC Enforcement Manual.

Note: Certain situations may arise where multiple inspections may compile into a single inspection report over a predetermined time frame. Ifthere is a significant or immediate health and safety issue, the need for an expedited inspection report may be considered.

Issue Date: 10/17/24 23 0615

b. Submitting to Document Processing Center

Submit approved and finalized inspection reports in their native application to the Document Processing Center to be declared as an Official Agency Record and be routed through concurrence appropriately.

0615-17 RELEASE AND DISCLOSURE OF INSPECTION REPORTS

17.01 General Public Disclosure and Exemptions

Except for report enclosures containing exempt information, all final inspection reports will be disclosed routinely to the public. Information that should not appear in an inspection report is described in 10 CFR 2.390 and 9.17. MD 8.8. Management of Allegations, addresses the manner in which an inspection report may be used to document allegation follow up activities. IMC 0620, "Inspection Documents and Records," gives guidance on acquiring and controlling NRC records, including inspection-related documents. Safeguards information or related sensitive information should not be released per current Agency policy. Any questions regarding this policy should be referred to the program office.

Inspection reports containing Official Use Only - Security Related Information will not be disclosed to the public. The number and severity of violations contained within these reports, however, will be stated in a publicly -available cover letter. If the severity level of the violation is an NCV or Severity Level IV violation, then the specific level should be listed. If the severity level of the violation is Severity Level I - III, then the publicly-available cover let ter should only state that the violation is escalated enforcement. The content behind these violations shall not be discussed on the public docket or in public meetings.

17.02 Release of Investigation-Related Information

When an inspector accompanies an investigator on an investigation, the inspector must not release either the investigation report n or their individual input to the investigation report. This information is exempt from disclosure by 10 CFR 9.17 and must not be circulated outside the NRC without specific approval of the Chairman (refer to OI Policy Statement 23).

END

Issue Date: 10/17/24 24 0615 Attachment 1: Revision History for IMC 0615

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 Date Number (Pre-Decisional Non-Public Information)

ML041810390 Issued to provide appropriate guidance for research and N/A N/A 06/23/04 test reactor inspection reports.

CN 04-018 ML24101A105 Revised to update organization changes, include N/A ML24120A186 10/17/24 additional definitions, and to reflect new streamlined CN 24-029 report format.

Issue Date: 10/17/24 Att1-1 0615