ML24115A194

IP 93100 - Safety Culture/Safety-Conscious Work Environment Issue of Concern Follow-up

ML24115A194
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Issue date:	04/23/2024
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Issue Date: 07/14/21 1

93100 NRC INSPECTION MANUAL IRAB INSPECTION PROCEDURE 93100 SAFETY CULTURE/SAFETY-CONSCIOUS WORK ENVIROMENT ISSUE OF CONCERN FOLLOWUP PROGRAM APPLICABILITY:

IMC 2515 C, 2561, 2690, 2514, 2501-2504, and 2800 CORNERSTONES:

ALL INSPECTION BASIS:

This procedure provides guidance to inspects the safety-conscious work environment (SCWE) attribute of a licensees safety culturetrait at a facility to include one or more other traits of safety culture when appropriate. This procedure can also be used to follow-up on a SCWE cross cutting issue (CCI) or SCWE theme. Insights gathered during this inspection would be considered during the mid-or end-of-cycle assessment meetings conducted in accordance with Inspection Manual Chapter (IMC) 0305, Operating Reactor Assessment Program. The SCWE safety culture attribute is sampled during the biennial problem identification and resolution team inspection conducted in accordance with Inspection Procedure (IP) 71152, Problem Identification and Resolution. When directed by management, SCWE-related issues of concern identified during IP 71152 can be examined in more depth using this procedure to gain additional insights.This is a comprehensive inspection procedure that can be effectively and efficiently applied depending on the nature of the safety culture performance issue identified.

Safety culture is defined in the Commission Policy Statement as the core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals, to ensure protection of people and the environment.

A SCWE is defined in the Freedom of Employees in the Nuclear Industry to Raise Safety Concerns Without Fear of Retaliation Policy Statement issued in 1996, as an environment in which employees are encouraged to raise safety concerns, are free to raise concerns both to their own management and to the NRC without fear of retaliation, where concerns are promptly reviewed, given the proper priority, and appropriately resolved, and timely feedback is provided to those raising concerns. In contrast, a chilled work environment is one in which employees perceive that raising safety concerns to their employer or to the NRC is being

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93100 suppressed or is discouraged and can occur because of an event, interaction, decision, or policy change.

ENTRY CRITERIA: As an inspection listed in Inspection Manual Chapter (IMC) 2515 Appendix C, Special and Infrequently Performed Inspections, this IP is implemented at Regional Administrator (RA) discretion in response to events or situations described below. Regional Administrators (RAs) should use Appendix A, Safety Culture Traits, of this Inspection Procedure (IP) in conjunction with the data informing the decision to use this IP to develop a charter outlining the areas of concern that the inspection team should address.

A) To follow-up on a SCWE cross cutting issue (CCI) or SCWE theme, or safety culture or SCWE concern raised during the allegation process, as recommended by an Allegations Review Board (ARB) and approved by an RA or, for non-regional ARBs, an Office Director.

B) To conduct follow-up inspections, with RA approval, of facilities with a known issue in the environment for raising concerns trait (i.e. chilling effect or chilled environment) until the issue is resolved.

C) If an inspection identifies a safety culture issue of concern during implementation of IP 71152, Problem Identification and Resolution, IP 93800, Augmented Inspection Team,

IP 93812, Special Inspection, or IP 95001, Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response) Inputs, that was not identified by the licensee, and inspectors have concerns with the licensees associated corrective actions. The RA may authorize use of IP 93100 to further inspect the specific safety culture traits of concern.

93100-01 INSPECTION OBJECTIVES 01.01 Determine if indications of a chilled work environment exist.

01.02 Determine if employees are reluctant to raise safety or regulatory issues.

01.03 Determine if employees are being discouraged from raising safety or regulatory issues.

01.04 Determine if the selected safety culture traits identified in the charter are areas of concern and use the inspection procedure to validate those concerns.

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93100 Note: In general, information gathered by the NRC during this inspection will be used in the aggregate in such a manner as to not specifically identify any concerned individuals per the NRCs identity protection guidance. Concerned individuals looking for a specific response to their concern(s) that meet the definition of an allegation,1 should be handled within the Allegation Program in accordance with Management Directive (MD) 8.8, Management of Allegations, and the NRC Enforcement Policy, as applicable. Nonetheless, such information can also be used to inform this inspection effort. This procedure should not be used to investigate or inspect allegations unless specifically directed by an Allegation Review Board with Regional Administrator approval.

93100-02 INSPECTION REQUIREMENTS Note: The term safety culture in this section is intended to be limited to inspection activities focused on the safety culture traits specifically identified in the charter for inspection. If additional traits are developed during interviews, these should be discussed with RA and the charter updated if needed. The charter should specify which of the following inspection requirements are applicable.

To determine if indications of a chilled work environment exist, inspectors should review the following with respect to identified SCWE issues of concern:

02.01 Inspectors should review the recent (within the last 18 months) problem identification and resolution (PI&R) SCWE observations.

02.02 Inspectors should review recent (within the last 18 months) allegations.

02.03 Inspectors should review recent (within the last 18 months) employee concerns and relevant corrective action program records.

02.04 Inspectors should review licensee SCWE-related policies, communications, and training materials.

02.05 Inspectors should assess SCWE by interviewing and/or conducting focus groups with selected site personnel.

02.06 Inspectors should assess SCWE by observing interactions between licensee supervisors and employees, if applicable (e.g., pre-job briefs, site status meetings, review committees discussing corrective action related issues).

02.07 If available, inspectors should review recent licensee safety culture or SCWE assessments. Independent licensee safety culture assessments previously evaluated using IP 40100, Independent Safety Culture Assessment Follow-up, need not be reviewed as part of this inspection. However, inspectors should review the inspection report documenting the IP 40100 inspection activity.

1 An allegation is defined as a declaration, statement, or assertion of impropriety or inadequacy associated with NRC-regulated activities, the validity of which has not been established.

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93100 93100-03 INSPECTION GUIDANCE If IP 93100 is being conducted as a stand-alone inspection, the inspection team leader should be qualified a safety culture assessor. The inspection team leader should work withand regional management during the inspection planning stages to develop an inspection charter. The charter shall identify the specific safety culture traits to be inspected which are clearly linked to the issue of concern which prompted the entry criteria for the IP to be met. If a known issue of concern exists in one of these traits, there may be others that are closely interrelated, and the RA must approve the safety culture traits to be inspected and how to address any emergent traits identified during the course of the inspection. If the scope of the inspection is adjusted due to emergent issues, the charter should be updated to reflect the new scope.

The charter shall also identify the resource requirements for the inspection, including the number of inspectors and the length of the inspection. Factors to consider include:

Number of licensee staff potentially impacted by the issue(s) prompting the inspection Safety scope of the issue(s) under review Whether interviews or focus groups or a combination will be required Whether observations of plant activities will be needed The objectives and requirements for each inspection are tailored to the specific safety culture traits to be inspected and should be specified in the charter. The initial charter and any subsequent updates to it shall be provided to NRR DRO Director, IRAB Branch Chief and Safety Culture Program lead.should decide during the inspection planning stages if any observations will be conducted. Similarly, the team leader and regional management should decide if focus groups, in addition to individual interviews, will be used to obtain general SCWE insights. The team leader and regional management should also decide whether qualified safety culture assessors from NRC Headquarters or other regions may be necessary. These decisions may be based on factors such as, but not limited to, the team members knowledge of and experience with conducting focus groups, prior success using focus groups at the site, available resources, or knowledge of potential SCWE issues at the site (for example, an increase in the number of allegations may indicate a negative trend in the SCWE).

Before conducting focus group interviews per this procedure, inspectors who are not qualified as a safety culture assessor inspectors must have completed focus group moderation training.

For guidance on conducting individual interviews, focus groups, behavioral observations, and evaluations of safety culture surveys or licensee SCWE assessments, refer to Enclosures B, C, D, and F of IP 95003.02, Guidance for Conducting an Independent NRC Safety Culture Assessment.

Inspectors and regional management should consult with appropriate staff from the Offices of Enforcement and Investigations, as well as allegations and enforcement specialists in the region and Headquarters offices, for more specific guidance and applicable limitations that depend on the circumstances of the SCWE or safety culture issue. This guidance may include: (1) ensuring understanding of related allegations or trends in allegation data that provide insights into the SCWE; (2) guidance on what constitutes an NRC SCWE concern includingand, potentially, the issuance of a Chilling Effect Letter; (3) ADR related confirmatory orders involving safety culture/ SCWE; or (4) insights on SCWE-related Office of Investigations assistance activitiesOffice of Investigations assistance that may have a bearing on SCWE or safety culture issues at the site.

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93100 For each SCWE-related and/or safety culture issue, the inspectors should note the circumstances that contributed to the inspectors awareness, such as what types of concerns employees have indicated they are hesitant to raise and their safety significance, which avenues they are hesitant to use (e.g., supervisor, chain of command, Corrective Action Program (CAP), Employee Concerns Program (ECP), NRC), which employees and work groups are impacted and for how long, and who and what behaviors contributed to the chilling effect.

For each safety culture issue, the inspectors should note the circumstances that contributed to the inspectors observation, such as the level of staff that are involved, the organizations that are involved, and any other clarifying information.

If the staff decides to conduct focus groups, more than one inspector would typically be neededone inspector to take notes while the other inspector facilitates the focus groups. For inspection activities involving interviews on sensitive topics or focus groups, it is beneficial to have multiple inspectors to discuss interview results and share viewpoints before developing conclusions.

With approval from regional management, tThe inspectors should develop and implement a site-specific inspection plan based on the inspection charter using the guidance below. The applicable branch chief shall approve the inspection plan.

03.01 Allegations. Inspectors should review recent allegations associated with the site to determine whether any of the allegations (1) were similar to the noted examples; (2) suggested the possible existence of a chilled work environment in one or more work groups; or (3) suggested the possible existence of any factors (e.g., excessive overtime, perceived schedule or cost pressure, large backlogs, deferred corrective action, unresponsiveness to previously raised concerns, or discouraging behavior from supervisors) that could produce a reluctance to identify safety concerns.

If any of the reviewed allegations meet these criteria, then inspectors should also review the corresponding files to determine how the allegation was evaluated by the NRC and, if substantiated, how the allegation was resolved by the licensee.

03.02 Employee Concerns and Corrective Action.

a.

Inspectors should review recent employee concerns (refer to IP 40001, Resolution of Employee Concerns, for additional guidance) and corrective action program records to determine whether any reported concern (1) was similar to the raised issues; (2) suggested the possible existence of a chilled work environment in one or more work groups; or (3) suggested the possible existence of any factors (e.g., excessive overtime, perceived schedule or cost pressure, large backlogs, deferred corrective action, unresponsiveness to previously raised concerns, or discouraging behavior from supervisors) that could produce a reluctance to identify safety concerns.

If the reviewed records meet the criteria above, inspectors should also review the corresponding files to (1) determine how the licensee responded to those concerns and (2) ascertain the status of any corrective actions identified by the licensee.

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93100 Note:

Care should be taken to protect from disclosure (especially to licensee management and employees) the content of the ECP files and the identity of individuals raising concerns to the ECP. If copies of documents from the ECP files are necessary, they should be redacted of all information that could identify individuals and personal privacy information.

b.

Inspectors should also review ECP records to determine whether any recorded employee concern aligns with either (1) a specific response provided by an interviewee or (2) an observation developed by the inspector. If so, review ECP records further to determine how the licensee responded to the subject employee concern.

03.03 Interviews and Focus Groups.

Note: The inspectors should inform interviewees that the NRC is gathering information about the SCWE safety culture to address concerns identified and their potential to impact SCWE, and thatduring the biennial PI&R baseline inspection and our observations will be documented in a public inspection report. Information provided by the interviewees will be used in the aggregate in such a manner as to not specifically identify any participants per the NRCs identity protection guidance. Should someone in a focus group have a concern they wish the NRC staff to specifically address and respond to, they should contact the inspectors separately. Inspectors should provide a phone number or other contact information where they can be reached. Such issues should be handled as allegations, but can also be used to inform the ongoing inspection, current PI&R inspection samples, and related SCWE observations.

a.

This inspection may include a combination of focus groups and individual interviews.

The use of focus groups may not be necessary if the issue is narrowly focused and appears to affect only one or two individuals. However, even in these cases, additional interviews or targeted focus groups may help to clarify whether there are broader safety culture issues at the site that may challenge licensee response to the issue under review.

b.

Each focus group should be made up of between 8-12 randomly-selected individuals from the same work group. Focus groups should be concentrated in the department of any concerned individual, but also include other groups where safety culture issues and challenges to raising concerns would impact regulated activities. Each focus group nominally takes 60 minutes and takes two inspectors to complete. The inspection team should make the random selection of the individuals for the focus groups based on site organizational charts. Inspectors should consider conducting focus groups with individuals from the sites operations, maintenance, engineering, emergency planning, radiation protection, and security departments, but the actual selection should depend on the issue(s) involved, previous inspection observations, and information from initial interviews and focus groups. A total of 10-20% of individuals from each work group allows for sufficient representation of any group where there may be concerns or until the information reaches saturation of information. Discussions with groups of supervisor should be conducted separately.

c.

Inspectors should individually interview (1) key supervisors or managers associated with the identified issues, and a few randomly-selected individuals from the same work groups as the involved individuals, (2) the individuals involved in the original SCWE concern, (3) a few randomly-selected individuals from other work groups, (4) one or

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93100 more key supervisors or managers through whom the involved individuals report, and (5) the ECP Manager. Depending on the circumstances, inspectors should consider whether it is better to interview any concerned individual(s) or include them in focus groups. Interviews nominally take about 30 minutes and one inspector.

d.

Interactions with operations or security personnel may be complicated by shift scheduling. Inspectors may have to leverage a combination of small focus groups, control room/security station interactions, and individual backshift interviews to obtain adequate coverage if there are concerns in these areas.

During these interviews/focus groups, the inspector should ask about the general safety culture SCWE concern(s) that was/were raised and about similar circumstances or events to develop insights into the concern(s) and their extent of condition. If the it is a SCWE-related issue the inspector should determine if it is related to a potential chilling effect,. iInspectors should ask about the events, observations, circumstances, and behaviors that are the bases for the perceived chilling effect or safety culture issue.

Inspectors should also ask about similar events, observations, circumstances, and behaviors to develop insights into the nature and extent of the perceived chilled work environment or safety culture issue. Inspectors should be careful not to divulge information that could be used to identify the source of the concern.

a.

The use of focus groups may only be necessary in certain circumstances (e.g., if the individual interviews indicate that the scope of the chilling effect is greater than one or two individuals). Each focus group should be made up of between 8-12 randomly-selected individuals from the same work group as the involved individual and others.

Inspectors should ensure that these interviews include individuals from at least the sites operations, maintenance, engineering, emergency planning, and security departments. A total of 10-20% of individuals from each work group allows for sufficient representation. Supervisor groups discussions should be conducted separately.

During these interviews, the inspectors may use the guidance in Appendix 1 to IP 71152 or the guidance in IP 95003.02B to choose questions that will provide information and insight to each SCWE or safety culture issue of concern to be inspected. In addition to the questions associated with the specific safety culture issue, the inspectorsand should ask interviewees to describe the following:

1.

circumstances or similar events (without providing specific details about any particular example) to develop insights into the extent of condition across circumstances and work groups

2.

for inspection involving a perceived chilling effect, any events, observations, circumstances, and behaviors that are similar to the events, observations, circumstances, and behavior that are the basis for the perceived chilling effect (without providing specific details about the basis for the perceived chilling effect) to develop insights into the extent of the chilling effect across circumstances and work groups

3.

any indications of the possible existence of a chilled environment in their work groups, which can be obtained by asking the interviewees the following questions:

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93100 Are you aware of any current situation in which a staff member initiated a condition report and received negative feedback or an otherwise unacceptable response as a result? Please describe the incident and any information conveyed by management concerning the incident.

Are you aware of any current situation in which a staff member reported a concern to a supervisor or manager and received negative feedback or an otherwise unacceptable response as a result? Please describe the incident.

Are you aware of any statement made or action taken currently that could discourage people from identifying a safety concern? Please describe the incident.

4.

any indications of factors that could contribute to a chilled environment in specific work groups, which can be obtained by asking the interviewees the following questions:

Are you aware of any event or change in circumstances within the last 18 months that could have discouraged any staff member from identifying a safety concern?

If so, please describe the situation.

Are you aware of any concern that was identified in the corrective action program and was not adequately addressed? If so, please describe the concern.

Are you aware of any individual or work group that, during the last 18 months, worked relatively high amounts of overtime? If so, please describe which individuals or work groups were affected, approximately the amount of overtime, and why that overtime was required.

Are you aware of any action taken within the last 18 months to reduce the overtime worked by that individual or group? If so, please describe the nature of the work hours and overtime and any changes in work-hour levels and overtime for the group.

5.

the interviewees perceptions about the corrective action program, which can be obtained by asking them to describe the following:

their confidence (and basis for that confidence) that concerns identified in the corrective action program will be adequately addressed how site management promotes use of the corrective action program

6.

the interviewees perceptions about the ECP, which can be obtained by asking them to describe the following:

their confidence (and the basis for that confidence) that concerns identified in the ECP will be adequately addressed their confidence (and the basis for that confidence) in the ECPs ability to protect their identity

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93100 how site management promotes use of the ECP

7.

the interviewees perceptions about the SCWE at the site, which can be obtained by asking them the following questions:

How do you define the term Safety-Conscious Work Environment? (Note: if the interviewees do not clearly understand the term, thank them and explain how the NRC defines SCWE before continuing.)

In what ways does your management support a SCWE?

Are you aware of any management or supervisory action that did not support a SCWE? If so, please provide a description of the action.

03.04 Safety Culture Assessments. Inspectors should review recent licensee safety culture or SCWE assessments to determine whether results from those assessments are consistent with the interview responses. If actions were warranted by licensee management in response to the assessment findings, what isdetermine the status of the actions, and what indications are there that the actions were effective.?

03.05 Characterization and Documentation. Inspectors should characterize observations obtained through interviews, focus groups, allegation reviews, ECP reviews, and reviews of safety culture assessments to develop an overall characterization of the selected licensees safety culture traits and/or SCWE. The characterization should address the inspection objectives list in Section 93100-01 identified in the charter.

The inspection results and SCWE characterization, including supporting observations, would normally be documented either in the Section 4OA5 of a quarterly integrated inspection report or as a stand-alone inspection team report. The report should protect the identities of those interviewed by the NRC and those associated with reviewed ECP or allegation files.

93100-04 RESOURCE ESTIMATE The level of effort to perform sections of this IP is limited to that required to inspect the specific safety culture issue(s) specified in the charter. Appendix A outlines resource estimates for each of the safety culture traits. Resources required will be dependent on the safety culture issue as well as the number and size of organizations potentially affected. The nature of the SCWE/safety culture issue identified may require different inspection methods (i.e. focus groups, individual interviews, etc.). As such, the resources required to complete the inspection are dependent on the circumstances involved, although it is estimated that this procedure will take 40-80 hours to complete. The RA shall consult with the Director of NRR before authorizing an inspection scope of 120 hours0.00139 days <br />0.0333 hours <br />1.984127e-4 weeks <br />4.566e-5 months <br /> or more.

It is estimated that this procedure will take 60-80 hours to complete.

Issue Date: 07/14/21 10 93100 93100-05 PROCEDURE COMPLETION Meeting one or more of the inspection objectives defined in Section 93100-01 of this IP, as necessary for the associated entry criteria met, will constitute completition.

Insights gathered during this inspection should be considered during the quarterly reviews and assessment meetings conducted in accordance with Inspection Manual Chapter (IMC) 0305, Operating Reactor Assessment Program.

93100-06 REFERENCES IMC 0305, Operating Reactor Assessment Program IP 40100, Independent Safety Culture Assessment Follow-up IP 71152, Problem Identification and Resolution IP 93800, Augmented Inspection Team IP 93812, Special Inspection IP 95001, Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response) Inputs IP 95003.02, Guidance for Conducting an Independent NRC Safety Culture Assessment IP 95003.02, Guidance for Conducting an Independent NRC Safety Culture Assessment MD 8.8, Management of Allegations NRC Enforcement Policy END Appendix A: Safey Culture Traits : Revision History

Issue Date: 07/14/21 11 93100 Appendix A Safety Culture Traits This section provides a list of the safety culture traits from the Safety Culture Policy Statement, to be used for planning purposes. Historically, the inspection has been accomplished with a team lead and one or two team members for up to one week. Determining an appropriate size for the safety culture team depends on the scope of the safety culture assessment, the number potentially impacted organizations and the size of the facility. Historically, the inspection has been accomplished with a 3-person on-site team for up to 1 week (+/- 1 person depending on facility size and/or size and number of departments needed to be interviewed). A minimum of 2 people is needed to run a focus group with one facilitator and one note-take. A third team member provides for individual interviews or direct behavioral observations while focus groups are being conducted. Adding additional traits to the inspection scope is not expected to add significant additional hours into the overall inspection. The nature of the questions asked during already planned focus groups may change instead.

LEADERSHIP SAFETY VALUES AND ACTIONS (LA): Leaders demonstrate a commitment to safety in their decisions and behaviors.

PROBLEM IDENTIFICATION AND RESOLUTION (PI): Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance.

PERSONAL ACCOUNTABILITY (PA): All individuals take personal responsibility for safety.

WORK PROCESSES (WP): The process of planning and controlling work activities is implemented so that safety is maintained.

CONTINUOUS LEARNING (CL): Opportunities to learn about ways to ensure safety are sought out and implemented.

ENVIRONMENT FOR RAISING CONCERNS (RC): A safety conscious work environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination.

EFFECTIVE SAFETY COMMUNICATION (CO): Communications maintain a focus on safety.

RESPECTFUL WORK ENVIRONMENT (WE): Trust and respect permeate the organization.

QUESTIONING ATTITUDE (QA): Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action.

DECISION MAKING (DM): Decisions that support or affect nuclear safety are systematic, rigorous, and thorough.

Issue Date: 07/14/21 Att1-1 93100

- Revision History for IP 93100 Commitment Tracking Number Accession Number Issue Date Change Notice Description of Change Description of Training Requires and Completion Comment Resolution and Closed Feedback Form Accession Number (Pre-Decisional, Non-Public Information N/A 08/18/11 CN 11-013 ML110100229 Initial issue. Researched commitments for 4 years and found none. Issued to provide guidance to inspectors for the follow-up of safety-conscious work environment issues.

Focus group facilitation training will be complete before use of this procedure.

On-going ML110410424 N/A ML15090A433 04/09/15 CN 15-005 Editorial changes for consistency with terminology and changes to the original SCCIs N/A N/A N/A ML18207A135 07/26/18 CN 18-022 Editorial updates to meet 5 year metric N/A N/A N/A ML21179A608 07/14/21 CN 21-024 Addition of applicable IMCs and deletion of a retired IP, correction of document title N/A FBF 93100-2422 ML21188A158