ML25314A002

Draft Inspection Procedures (IP) 93816 Problem Identification and Resolution (Pi&R) Team Inspection

ML25314A002
Person / Time
Issue date:	11/12/2025
From:	Sarah Obadina NRC/NRR/DRO/IRIB
To:
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Download: ML25314A002 (18)

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Issue Date: xx/xx/xx 1

93816 NRC INSPECTION MANUAL IRIB INSPECTION PROCEDURE 93816 DRAFT PROBLEM IDENTIFICATION AND RESOLUTION (PI&R) TEAM INSPECTION Effective Date: January 1, 2026 PROGRAM APPLICABILITY: IMC 2515 C CORNERSTONES:

ALL INSPECTION BASIS:

See IMC 0308, Attachment 2 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 should use 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) Two or more Greater-then-Green (GTG) findings in the area of PI&R or performance deficiencies related to PI&R in any 12-month period B) Five or more cumulative findings in the area of PI&R or performance deficiencies related to PI&R in any 12-month period that the regional office has concerns about the adequacy of the licensee corrective actions.

C) Supplemental inspection identifies and documents a significant weakness in the PI&R program which the licensee did not identify D) Results of a supplemental inspection or IMC 0350 inspection document a Safety Conscious Work Environment (SCWE) concern 93816-01 INSPECTION OBJECTIVES 01.01 To confirm that licensees implementation of problem identification and resolution (PI&R) programs complies with NRC regulations and applicable industry standards.

01.02 To evaluate the effectiveness of the licensees PI&R program in identifying, prioritizing, evaluating, and correcting problems 01.03 To confirm the licensees appropriate use of industry and NRC operating experience.

01.04 To evaluate the effectiveness of licensee audits and self-assessments.

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93816 01.06 To confirm licensees have established a safety conscious work environment.

93816-02 INSPECTION REQUIREMENTS 02.01 General Requirements

a. Scope The scope of the inspection is defined by the inspection charter which requires approval from the regional administrator. The charter should include a background discussion, delineate the applicable inspection objectives and requirements, include a basis for the selected scope, and the expected team staffing and resources (e.g., 1-or 2-person team). The charter should also include the evaluation period (e.g., 3 years or 5 years).

b. Sample Selection and Inspection Planning Use risk insights to select issues that have been processed through the licensees PI&R program that encompass an evaluation period as defined in the charter. [C1] The PI&R team leader should choose as many issues for review as warranted to complement PI&R samples already completed during the evaluation period and ensure a sufficient basis for evaluating the effectiveness of the licensees PI&R program.

The samples chosen for review should include a range of issues selected from the list in IP 71152 and meet the requirements of sections 03.02-03.05 of this IP, as applicable.

For a subset of the samples chosen for review, the scope of the review should be expanded to at least 5 years to detect and evaluate long term trends. [C1]

Based on the samples selected and the requirements of the charter, the team leader should develop an inspection plan that contains the technical and logistical details of the inspection. IMC 2901, Team Inspections, provides additional information on the conduct of team inspections.

02.02 PI&R program compliance and effectiveness

a. Confirm that the licensees implementation of the PI&R program complies with NRC regulations and any self-imposed or other standards necessary for continued participation in the Reactor Oversight Process.

b. Evaluate the effectiveness of the licensees PI&R program.

02.03 Operating Experience Confirm the licensee appropriately uses industry and NRC operating experience.

02.04 Licensee Audits and Self-Assessments Evaluate the effectiveness of licensee audits and self-assessments.

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93816 02.05 Safety Conscious Work Environment Review issues that pose challenges to the free flow of information for adequate resolution. Employees should feel free to raise safety concerns, both to their management and to the NRC, without fear of retaliation. [C2]

93816-03 INSPECTION GUIDANCE 03.01 General Guidance

a. Scope The charter objectives and requirements will depend on the specific circumstances that led to the implementation of this IP. For example, if a a greater than green finding had a performance deficiency associated with PI&R effectiveness, the charter objectives and requirements should typically focus the specific area documented in the greater than green finding.

For team staffing, consider team composition, background, and experience during charter development. PI&R team inspections can either benefit from a diverse team make-up or the inclusion of subject matter experts to focus on specific performance issues. Regional or headquarters specialists and subject matter experts (e.g., safety culture assessors, security, emergency preparedness, and radiation protection inspectors) can participate on the team in a full-or part-time capacity.

Licensee PI&R programs include all methods of identifying, prioritizing, evaluating, and correcting deficiencies. These programs commonly include but are not limited to the licensee corrective action and work management programs. However, any other licensee program or process that addresses deficiencies with risk significant systems, structures and components (SSCs), compliance with regulatory requirements, or adherence to licensee commitments and standards is within the scope of the PI&R program.

b. Sample Selection and Inspection Planning Inspectors may select one or more risk-significant systems on which to focus sample selections. Performing a walkdown of selected systems will provide insight into the adequacy of the licensees implementation of all aspects of the PI&R program (identification, evaluation, and corrective action). Team leaders are reminded to ensure adequate coverage of the Emergency Preparedness, Radiation Safety, and Security cornerstones, if the charter includes those cornerstones.

Selected licensee documents needed to support the inspection may be obtained in advance. Inspectors should obtain and review documents necessary to address the requirements specified in the charter. Refer to IMC 0620, Inspection Documents and Records, for more information on requesting documents for inspection preparation.

Consider the following when developing information requests:

1. Procedures that govern PI&R, audits and assessments, operating experience, operability determinations, safety culture, employee concerns, work requests, maintenance programs, etc., related to specific samples.

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2. Lists of PI&R documents issued for the time period delineated in the charter (e.g.,

work orders, work requests, temporary modifications, calibration failures, condition/problem identification reports, operability evaluations and determinations, operating experience, etc.).

3. Specific PI&R documents related to:

(a) risk significant causal evaluations (b) LERs (c) NCVs (d) FINs (e) specific issues identified by the team during inspection planning (f) relevant licensee PI&R program assessments, program performance information, metrics, trend reports, and licensee safety culture assessments Inspectors should review NRC inspection reports for the period specified in the charter.

Observations, assessments, and inspection results from IP 71152 PI&R samples or other team inspection samples during the evaluation period should be reviewed for themes or trends to consider during the PI&R team inspection and evaluation of the licensees PI&R program. The inspection plan should deconflict samples with any previously completed during the cycle. Issues can be inspected if the scope of the inspection is different than previous inspection samples and supports objectives (i.e.,

resident inspectors reviewed the root cause of an issue, but the team is reviewing the completion of the corrective actions).

Review PI&R related observations, performance trends documented as a result of the semiannual trend review, and end of cycle discussions for any trends or patterns in PI&R program or performance issues that warrant additional sampling to confirm. For example, a series of issues associated with failure to follow procedures within one cornerstone may indicate a corrective action performance deficiency within a portion of the licensees organization; a series of issues associated with failure to follow procedures in multiple cornerstones may indicate a broader concern. Also, a lack of licensee-identified corrective action issues within a particular organization may be indicative of a problem with the identification threshold.

03.02 PI&R program compliance and effectiveness

a. Inspectors should verify that the licensee has established PI&R programs intended to meet applicable standards. PI&R programs may be required to comply with the following NRC regulations, industry standards and self-imposed standards:

The following NRC regulations may apply to aspects of the licensees PI&R programs under the various cornerstones o 10 CFR Part 21, Reporting of Defects and Noncompliance o 10 CFR Part 26.717, Fitness-for-duty program performance data o 10 CFR Part 50 Appendix B, Quality Assurance Criteria for Nuclear Power Plants and Fuel Reprocessing Plants o 10 CFR Part 50 Appendix E, Emergency Planning and Preparedness for Production and Utilization Facilities

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93816 o 10 CFR Part 50 Appendix R, Fire Protection Program for Nuclear Power Facilities Operating Prior to January 1, 1979 o 10 CFR 50.48, Fire Protection o 10 CFR Part 50.55a, Codes and standards o 10 CFR Part 50.65, Requirements for monitoring the effectiveness of maintenance at nuclear power plants o 10 CFR 50.69, Risk-informed categorization and treatment of structures, systems and components for nuclear power reactors o 10 CFR Part 71, Packaging and Transportation of Radioactive Material, Subpart H, Qualify Assurance o 10 CFR Part 73, Subpart F, Physical Protection Requirements at Fixed Sites o 10CFR Part 20, Standards for Protection Against Radiation Regulatory Guide 1.33, Quality Assurance Program Requirements (Operation),

contains guidance and endorsements for American National Standards Institute (ANSI) and American Society of Mechanical Engineers (ASME) standards related to Quality Assurance Programs (i.e., ASME NQA-1, Quality Assurance Program Requirements for Nuclear Power Plants).

The following licensee documents may contain additional commitments and/or requirements:

o quality assurance manual o emergency plan o radiation protection plan o fire protection plan o security plan o aging management program Licensees may also commit to industry documents not endorsed by the NRC such as:

o NEI 09-07, Fostering a Healthy Nuclear Safety Culture o NEI 16-07, Improving the Effectiveness of Issue Resolution to Enhance Safety and Efficiency o NEI 18-03, Operability Determination o NEI 18-10, Monitoring the Effectiveness of Nuclear Power Plant Maintenance This requirement ensures the licensees PI&R program meets the minimum expectations necessary for continued implementation of the ROP. IMC 0308 Attachment 2, Technical Basis for Inspection Program, Section 03.02, discusses the importance of licensees PI&R programs to the ROP, the necessity of inspection of PI&R across the cornerstones, and what is required to determine that a licensees PI&R program does not comply with NRC regulations or applicable standards. Document the result of this requirement in the report cover letter in accordance with IMC 0611, Exhibit 4.

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b. To evaluate the effectiveness of the licensees PI&R program, the team should develop insights into the licensees effectiveness at identifying, evaluating, and correcting problems using the PI&R program by reviewing a sufficient number and breadth of samples conducted both during the evaluation period and the team inspection.

Inspectors should compare these results with the licensees performance reviews, including reviews of PI&R programs. Inspectors should determine whether licensee reviews are consistent with the NRC review of PI&R issues.

Utilizing the below criteria, the team should develop a clear and concise assessment of the results of their review. This assessment can be supported by observations uncovered during the inspection activities, including those activities from IP 71152 inspections or other team inspections, conducted during the evaluation period. The discussion should be documented in the inspection report for the team inspection.

IMC 0611, Appendix D, provides additional specific and unique guidance beyond that contained in IMC 0611 for documenting the PI&R team inspections.

1. Identification From the samples chosen and a review of PI&R samples completed during the evaluation period, assess the licensees ability to identify and enter issues into their PI&R program against the success criteria listed below. Utilize the examples and IMC 0611, Appendix D, guidance to document an assessment.

(a) Success Criteria (1) Licensee staff enter conditions into the licensees PI&R program at a low threshold.

(2) Deficient conditions associated with safety system performance or regulatory compliance are promptly brought to the attention of main control room operators so operability and functionality can be assessed. When appropriate, technical specification action statements or compensatory measures are initiated.

(3) The licensee has an effective trending program which uses PI&R program data and other applicable insights (e.g., Maintenance Rule program, system health reports, etc.) to identify low level trends with equipment and human performance. The licensee addresses identified issues prior to the issues becoming more significant problems.

(4) The licensee has no adverse or reoccurring trends in identification or trending over an 18-month period (5) For NRC-identified issue(s), the licensee did not miss opportunities to identify the problem(s).

(b) Issues of Concern (1) A failure to identify or enter a significant condition adverse to quality (SCAQ) into the PI&R program.

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93816 (2) An adverse trend that affects the success criteria exists An adverse trend should be supported by several examples which indicate a performance or programmatic weakness that affects the success criteria.

(3) Repetitive examples of licensee staff being aware of conditions adverse to quality (CAQs) and failing to document them in the PI&R program.

(4) CAQs affecting operability are not promptly brought to the main control room operators so operability can be determined, and applicable technical specifications entered when appropriate.

(5) Repetitive examples of issues not being documented with enough relevant detail, such that operators cannot make conservative decisions for identified CAQs or conditions adverse to regulatory compliance (CARCs).

(6) Multiple NRC-identified trends during the evaluation period not previously identified by the licensee.

(7) A greater-than-green finding during the evaluation period with a documented performance deficiency of failing to identify a significant adverse condition.

(8) A significant programmatic weakness exists which results in widespread failure to enter SCAQ, CAQ, or CARC into the corrective action program.

(9) Identification of negative trends associated with human or equipment performance that can potentially impact nuclear safety.

(10) Area documented as a significant or general weakness during a Supplemental Inspection (IP 95001, IP 95002, or IP 95003) or IMC 0350 inspection.

2. Evaluation From the samples chosen, and a review of IP 71152 PI&R samples as well as other team inspection samples completed during the evaluation period, assess the licensees ability to evaluate and prioritize issues entered into their PI&R program against the success criteria listed below. Utilize the examples and IMC 0611, Appendix D, guidance to document an assessment.

(a) Success Criteria (1) The licensee appropriately prioritizes issues in accordance with safety, security, or radiological significance so that licensee resources and oversight are assigned commensurate with the actual or potential consequences of the issue in accordance with their PI&R program.

(2) The licensee thoroughly evaluates issues to ensure that resolutions address causes and extent of conditions are commensurate with their safety, security, and radiological significance in accordance with their corrective action program procedure and quality assurance plan.

(b) Issues of Concern

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93816 (1) Inappropriate assessment of the priority of an SCAQ (e.g., wrong significance assigned).

(2) Failure to evaluate the root cause of an identified SCAQ.

(3) Repetitive examples of licensee staff failing to accurately prioritize issues in accordance with their safety or security significance, and as a result CAQs and CARCs are not corrected commensurate with their safety significance.

(4) Repetitive examples of licensee staff failing to perform an adequate evaluation as assigned in their corrective action program which either:

(1) does not identify the correct cause, or (2) does not conduct an extent of cause or extent of condition issues (when required) due to lack of rigor.

(5) Repetitive examples of the licensee failing to follow the corrective action program requirements when an evaluation is unable to determine a cause for a more significant event.

(6) A finding of yellow or red significance with a documented performance deficiency of failing to evaluate a significant adverse condition or develop corrective actions to preclude repetition (CAPRs).

(7) A significant programmatic weakness exists which results in widespread failure to adequately evaluate an SCAQ, CAQ, and CARC, and develop corrective actions to correct the conditions.

(8) A repetitive adverse trend in the evaluation documented in the semiannual trend reviews or consecutive PI&R area inspections and licensee corrective actions have been ineffective based upon follow up inspection.

(9) Area documented as a significant or general weakness during a Supplemental Inspection (IP 95001, IP 95002, or IP 95003) or IMC 0350 inspection.

3. Corrective Action From the samples chosen, and a review of IP 71152 PI&R samples as well as other team inspection samples completed during the evaluation period, assess the licensees ability to determine, track, implement, and evaluate timely corrective action issues entered into their PI&R program against the success criteria listed below. Utilize the examples and IMC 0611, Appendix D, guidance to document an assessment.

(a) Success Criteria (1) The licensee effectively schedules and completes corrective action implementation commensurate with their safety significance using the work control process.

(2) The licensee appropriately performs an evaluation in the event that corrective actions placed in the work control process are deferred or cancelled. This evaluation would include compensatory actions, bridging

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93816 strategies, or alternative corrective actions to ensure the CAQ or CARC is corrected commensurate with its risk significance.

(3) The licensee ensures that the final corrective actions completed adequately address the original CAQ or CARC observed.

(4) The licensee tracks CAPRs for SCAQ to completion in the corrective action program.

(5) The licensee conducts effectiveness reviews for CAPRs associated with an SCAQ and develops new corrective actions when appropriate.

(b) Issues of Concern (1) An example of a failure to implement CAPRs in a timely manner and prevent repetition of an identified SCAQ, resulting in a safety-or security-significant finding with a documented performance deficiency of failing to correct a significant adverse condition.

(2) Examples where CAPRs for SCAQ are not being tracked or completed under the corrective action program.

(3) Examples of effectiveness reviews for CAPRs of SCAQ not being completed or actions taken if the review identified an issue.

(4) Repetitive examples of licensee staff failing to schedule corrective action assignments in a timely manner commensurate with the CAQs or CARCs safety or security significance as evidenced by repetitive failures of equipment or corrective actions not accurately being completed due to errors in the work management process.

(5) Repetitive examples of licensee staff failing to complete corrective actions assigned due to work orders or engineering change packages being deferred and the deferrals not being evaluated and results in unnecessary or uncompensated safety or security risk until the underlying CAQ or CARC is corrected.

(6) Repetitive examples of the licensee failing to identify that the actions completed did not actually correct the CAQ or CARC or restore compliance commensurate with its safety or security significance.

(7) A significant programmatic weakness exists which results in widespread failure to correct an SCAQ, CAQ, or CARC commensurate with their safety or security significance.

(8) A repetitive adverse trend in resolution documented by a semi-annual trend review or PI&R area inspection, and licensee corrective actions have been ineffective based upon follow up inspection.

(9) Area documented as a significant or general weakness during a Supplemental Inspection (IP 95001, IP 95002, IP 95003) or IMC 0350 inspection.

Issue Date: xx/xx/xx 10 93816 (10) For NRC-identified issue(s), prior attempts by the licensee to remedy the problems were inadequate.

03.03 Operating Experience

a. To confirm the licensees appropriate use of industry and NRC operating experience, inspectors should review a risk-informed selection of NRC, industry, and corporate (if applicable) operating experience issued or dispositioned during the evaluation period defined in the charter. These may include:

NRC Information Notices NRC Generic Letters Part 21 Reports INPO IERs Corporate or Fleet Operating Experience Review the licensees process for receiving and dispositioning operating experience, and how applicable operating experience is determined.

Utilizing the success criteria and observation guidance below, evaluate the licensees use of operating experience; document an assessment in accordance with IMC 0611, Appendix D.

(1) Success Criteria: Licensee implements a process for gathering, evaluating, and entering issues identified at other facilities into their PI&R program such that potential licensee vulnerabilities or weaknesses are addressed and resolved in a timely manner. Applicable operating experience includes NRC Generic Communications, Part 21 reports, industry wide communications, and fleet and owners group reports and recommendations.

(2) Issues of Concern:

(a) programmatic weaknesses (e.g., lack of procedural guidance, unidentified leads for the operating experience program, or failure to follow self-imposed standards for operating experience monitoring and tracking)

(b) repetitive examples of licensee failure to capture applicable operating experience (c) repetitive examples of licensee failure to screen operating experience as applicable (d) failure to act on applicable Part 21 reports (e) inadequate actions in response to operating experience (f) failure to track completion of actions related to operating experience

Issue Date: xx/xx/xx 11 93816 03.04 Licensee Audits and Self-Assessments

a. To evaluate the effectiveness of licensee audits and self-assessments, inspectors should review a sample of licensee audits and self-assessments conducted during the period of evaluation defined in the charter. [C1]

When the licensee has performed an independent safety culture assessment, inspectors should evaluate the licensees assessment.

If the licensee conducted any periodic self-initiated assessments of safety culture during the evaluation period, this assessment should be included along with other non-safety culture self-assessments selected to review. If the licensee performed several assessments that collectively addressed safety culture issues, then those assessments combined should be considered as one assessment. [C2]

Inspectors should review the adequacy of the licensees evaluation and actions to address the issues identified by the safety culture assessment. Not all actions necessarily need to be handled within the licensees corrective action program under 10 CFR 50, Appendix B, Criterion XVI. It may be more appropriate for some issues that are not CAQs to be tracked to resolution through an alternate licensee program such as an employee concerns program (ECP). The inspectors review should focus mainly on the licensees response to the assessment results or actions taken to address identified issues instead of the assessment methodology or an evaluation of the assessments adequacy. Section 03.05 provides more guidance on reviewing the licensees safety culture assessment from the SCWE perspective.

Utilizing the success criteria and observation guidance below, evaluate the licensees ability to conduct audits and self-assessments; document an assessment in accordance with IMC 0611, Appendix D.

1. Success Criteria:

(a) Licensee has an effective quality assurance audit and self-assessment program which identifies weaknesses and places those deficiencies and observations into the PI&R program for resolution.

(b) Licensees quality assurance audits are appropriately identifying problems in the 10 CFR Part 50, Appendix B, area the audit is focused on.

(c) Licensee's audits are in accordance with the quality assurance topical report/

Quality Assurance Plan and the associated industry standards that the Quality Assurance Plan commits to.

2. Issues of Concern:

(a) Examples of audit results that are not consistent with the inspectors observations or previous NRC findings and/or observations.

(b) Licensee failure to identify, implement and track corrective actions resulting from audits and assessments

Issue Date: xx/xx/xx 12 93816 03.05 Safety Conscious Work Environment

a. To assess the licensees environment for raising concerns, and to determine whether impediments exist to the establishment of a SCWE, inspectors should interview a number of licensee personnel and, if applicable, long-term contractors. These interviews should focus on the willingness of these personnel to raise safety concerns to supervisors/management or through the PI&R program, their knowledge of alternative avenues for raising concerns, and whether they have experienced or heard of anything perceived as retaliation for raising concerns.

Inspectors may conduct these interviews by one of several methods: as a supplement to other discussions with personnel about PI&R issues, as standalone interviews with select personnel, or by conducting focus group interviews. Focus group interviews are permissible only when the inspector facilitating the focus group has received training in conducting focus groups; it is strongly preferred that the facilitator be qualified as a Safety Culture Assessor per IMC 1245, Appendix C12.

When conducting interviews with or observing other activities involving licensee personnel and/or long-term contractors (i.e., those who have been working at the site for at least 6 months) during the inspection, inspectors should be sensitive to areas and issues that may represent challenges to the free flow of information, such as areas where employees may be reluctant to raise concerns or report issues in the PI&R program. [C2]

Interviewing long-term contractors would allow inspectors to assess the SCWE of a group of individuals that have worked at the site for extended periods of time and impacted plant operations and safety. Inspectors should also obtain insights about the SCWE during their review of the licensees most recent safety culture and other relevant assessments. Inspectors should be sensitive to similarities and differences between the results of their SCWE interviews with plant staff and the results of the licensees safety culture and other relevant assessments.

During inspection preparation and performance, readily available indications of licensee SCWE (e.g., licensee SCWE survey results, NRC allegation data, licensee ECP records, Nuclear Safety Culture Monitoring Panel inputs, and resident input) should be reviewed to determine an appropriate scope for assessing the SCWE via onsite interviews and/or focus groups. To the extent practicable, personnel interviewed should be mostly nonsupervisory and should represent a cross-section of the licensees organizational departments (e.g., operations, maintenance, engineering, security, etc.). If possible, the experience levels of the personnel should vary; both newer and mid-career individuals should be included. Focus group interviews should similarly cover a cross-section of the licensees organizational departments and should include people with a variety of experience levels, where a focus group consists of 8-10 or more individuals. Each focus group should only include personnel at the same supervisory level and may be supplemented by individual discussions with managers or supervisors.

Appendix A to this procedure provides a list of questions that may be used to assess SCWE in interviews or focus groups. IP 95003.02 may also be references as a source for additional questions that can be used during SCWE interviews and/or focus groups.

Although the licensee may be implementing an ECP or similar program regarding the identification of safety issues, the possibility of existing underlying factors that would

Issue Date: xx/xx/xx 13 93816 produce a "chilling" effect or reluctance to report such issues could exist, and inspectors should be alert for such indications. Such factors could include but not be limited to direct retaliation, inadequate staffing that results in excessive overtime, an unwillingness to raise issues that might result in further increases to an already high workload, or inadequate corrective actions for previously identified issues causing personnel to be reluctant to identify additional related issues.

Utilizing the success criteria and observation guidance below, evaluate the licensees safety conscious work environment, and document an assessment in accordance with IMC 0611, Appendix D.

1. Success Criteria:

(a) The licensee has an established SCWE program verified by a review of programmatic documents.

(b) The licensee monitors for a SCWE through self-assessment using their proceduralized nuclear safety culture monitoring programs, ECP, and site-specific review boards to screen disciplinary actions for potential chilling implications.

(c) The licensee maintains a SCWE as is evidenced through discussions and interviews with licensee staff. Site employees appear willing to raise nuclear safety concerns through available avenues.

2. Issue of Concern (a) Results of SCWE interviews that indicate multiple employees in a work group are hesitant or unwilling to raise concerns to certain managers or at all.

(b) The licensee or third-party safety culture review/assessment identifies work groups of concern with respect to SCWE.

(c) There is a step-increase in the number of allegations received compared to the previous assessment period. An example could be a step change that results in the total number of allegations being at least double the industry average for that year.

(d) There is a high-volume of allegations where total allegations are substantially higher than the industry average for at least 2 consecutive years. An example could be where the total allegations are greater than 3 times the industry average.

(e) The licensee has received a chilling effect letter during the assessment period, or one remains open.

(f) The licensee has received correspondence from the NRC that transmitted a severity level I, II, or III enforcement action that involved discrimination or a confirmatory order that involved discrimination. The theme applies only to the sites(s) where the discrimination occurred.

Issue Date: xx/xx/xx 14 93816 (g) Results of a supplemental inspection or IMC 0350 inspection document a SCWE concern.

(h) Results of SCWE interviews (from IP 71152 PI&R samples) documented in 3 consecutive reports show no improvement, declining SCWE, or indications that the concern is impacting multiple site organizations and NRC management has concerns about the effectiveness of their corrective actions taken to date and this concern is documented in an Annual Assessment letter.

93816-04 RESOURCE ESTIMATES Completion of this procedure is estimated to require between 60 and 80 hours9.259259e-4 days <br />0.0222 hours <br />1.322751e-4 weeks <br />3.044e-5 months <br /> depending on the requirements of the charter. IMC 2515-08.04, Completion of Inspection Procedures, discusses the intent of the inspection hours estimate.

93816-05 PROCEDURE COMPLETION This procedure is considered complete when charter objectives and requirements have been met and the final inspection report has been issued. Document PI&R team inspection results using the governance contained in IMC 0611, Appendix D, Guidance for Problem Identification and Resolution Inspection Reports.

93816-06 REFERENCES Audit of NRCs Implementation of 10 CFR Part 21, Reporting of Defects and Noncompliance (OIG-11-A-08, March 23, 2011, ML110820426)

IMC 0308 Attachment 2 Technical Basis for Inspection Program IMC 0350, Oversight of Reactor Facilities in a Shutdown Condition Due to Significant Performance and/or Operational Concerns IMC 0611, Power Reactor Inspection Reports IMC 0611, Appendix D, Guidance for Problem Identification and Resolution Inspection Reports IMC 0620, Inspection Documents and Records IMC 2515, Appendix B, Supplemental Inspection Program IMC 2901, Team Inspections IP 36100, Inspection of 10 CFR Part 21 and Programs for Reporting Defects and Noncompliance IP 43004, Inspection of Commercial-Grade Dedication Programs IP 93002, Managing Fatigue IP 93100, Safety Conscious Working Environment Issue of Concern Follow-up

Issue Date: xx/xx/xx 15 93816 IP 95001, Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response) Inputs IP 95002, Supplemental Inspection Response to Action Matrix Column 3 (Degraded Performance) Inputs IP 95003, Supplemental Inspection Response to Action Matrix Column 4 (Multiple/Repetitive Degraded Cornerstone) Inputs NEI 09-07, Fostering a Healthy Nuclear Safety Culture NEI 16-07, Improving the Effectiveness of Issue Resolution to Enhance Safety and Efficiency NEI 18-03, Operability Determination NEI 18-10, Monitoring the Effectiveness of Nuclear Power Plant Maintenance NRC Enforcement Manual NRC Enforcement Policy NRC/INPO Memorandum of Agreement, dated December 1, 2022 (ML23026A093)

Regulatory Guide 1.33, Quality Assurance Program Requirements (Operation)

END List of Appendices:

Appendix A: Guidance for Gathering SCWE and PI&R Insights List of Attachments : Revision History for IP 93816

Issue Date: xx/xx/xx AppA-1 93816 Appendix A: Guidance for Gathering SCWE and PI&R Insights The following are suggested questions that may be used when discussing PI&R issues with licensee individuals. It is not intended that these questions are asked verbatim, but rather, that they form the basis for gathering insights regarding whether there are impediments to the formation of a SCWE.

In cases where a potential problem with SCWE is identified in response to these questions, inspectors should consult with regional management to determine if inspection resources should be applied using IP 93100, Safety Conscious Working Environment Issue of Concern Follow-up, to gain additional SCWE insights.

SUGGESTED QUESTIONS Problem Identification and Resolution Program (PI&R):

How effective is the PI&R program in addressing problems?

Do you think its worth taking time to place problems found into the PI&R program?

Why or why not?

When you enter an issue into the process, do you receive any feedback when its been discussed or addressed? Are you satisfied with this level of feedback?

Are there informal means you would use to address issues found, other than the official PI&R program? If so, please provide some examples.

Can anyone at the site (contractor, security officer, etc.) enter an issue into the PI&R program? When someone enters an issue into the PI&R program, does the entry have to be approved by a supervisor? (If yes, does this affect what gets put in the PI&R program?)

Environment for Raising Concerns (SCWE):

Do you feel free to raise concerns without fear of retaliation?

Are you aware of any situations where any employee or contractor may have been hesitant to raise concerns or feared a negative consequence for raising a concern?

What kind of concerns? Can you give some examples?

How do you and your colleagues feel about expressing your opinions? How do you think management receives and addresses opinions and viewpoints?

In your opinion, if employees dont receive a response that they are satisfied with, are they able to escalate their concern to a higher level of management? If no, why not? Is escalation of concerns encouraged by management? If so, how?

Have there been any issues recently (2 years) that would affect your willingness to raise safety issues or your confidence in the PI&R program? Please provide examples.

How do you feel about using ECP? Are you confident about confidentiality?

Issue Date: xx/xx/xx AppA-2 93816 Do you feel free to bring concerns to the NRC without fear of retaliation?

How does your management encourage the use of alternate avenues (ECP) for raising safety concerns?

Does your management seem to put what you believe to be the appropriate emphasis on safety (nuclear, radiological, and industrial)? Please provide examples.

When production goals (schedules) are set, how are they communicated to you?

What is managements reaction when a safety concern is raised that affects the schedule and thus the production goal is not met?

Preventing, Detecting and Mitigating Perceptions of Retaliation (SCWE):

Does the station have a policy concerning maintaining a work environment where workers can raise safety concerns without fear of retaliation? What does it say, in general? Would you say that your management is supportive of the policy?

Are you aware of any actions taken by your management to prevent and detect retaliation and/or other behaviors that could cause workers to be hesitant to raise safety concerns, that is, behaviors that could cause a chilling effect? If so, please provide examples.

Have your perceptions about this issue changed over time particularly over the last 1 to 2 years?

Are you aware of any instance in which someone on site has experienced a negative reaction from a supervisor or manager for raising a safety issue? If so, please provide examples.

END

Issue Date: xx/xx/xx Att1-1 93816 : Revision History for IP 93816 Commitment Tracking Number Accession Number Issue Date Change Notice Description of Change Description of Training Required and Completion Date Comment Resolution Closed Feedback Form Accession Number (Pre-Decisional, Non-Public Information)

[C1]

[C2]

ML#

DRAFT Initial issuance to move PI&R team inspection from IP 71152 to IMC 2515 App C, Special and Infrequently Performed Inspections. These revisions were recommended as a result of the ADVANCE Act 507 Report to Congress that discussed the revision of the ROP Baseline Inspection Program.

Incorporating recommendations made by the PI&R focus group to address several items from the Davis Besse Lessons Learned Task Force. The changes include enhanced requirements regarding the routine PI&R reviews conducted by resident inspectors, biennial reviews of long-standing issues, and biennial reviews of operating experience issues. The recommendations are documented in ML101060482, Status of Davis-Besse Lessons Learned Task Force Recommendations (Final Update): December 2009.

Incorporate safety culture initiatives described in Staff Requirements - SECY-04-0111, Recommended Staff Actions Regarding Agency Guidance in the Areas of Safety Conscious Work Environment and Safety Culture, dated August 30, 2004.

ML25274A088