View source for IP 71152, Problem Identification and Resolution (PI&R)

{{IP-Nav}}


=Text=
{{#Wiki_filter:
Issue Date: 02/26/15 1 71152
NRC INSPECTION MANUAL IRIB
INSPECTION PROCEDURE 71152
PROBLEM IDENTIFICATION AND RESOLUTION
PROGRAM APPLICABILITY: 2515 Appendix A
CORNERSTONES: ALL
EFFECTIVE DATE: January 01, 2015

==INSPECTION BASIS:==
A fundamental goal of the U.S. Nuclear Regulatory
Commission’s (NRC’s) Reactor Oversight Process (ROP) is to
establish confidence that each licensee is effectively detecting,
correcting, and preventing problems which could impact
cornerstone objectives. A key premise of the ROP is that
weaknesses in licensees’ problem identification and resolution
(PI&R) programs will manifest themselves as performance
issues which will be identified during the baseline inspection
program or performance indicators (PIs) crossing
predetermined thresholds. However, several aspects of PI&R
are not specifically addressed by either the individual
cornerstone performance indicators or other baseline
inspections. These aspects are described in Section 71152-01
of this inspection procedure (IP).
LEVEL OF EFFORT: Completion of this IP is accomplished by conducting routine
PI&R reviews, semiannual trend reviews, annual follow-up of
selected issues, and biennial team inspections, as described
in Section 71152-02 of this IP.

==71152-01 INSPECTION OBJECTIVES==
01.01 To evaluate the effectiveness of the licensee’s corrective action program in identifying,
prioritizing evaluating, and correcting problems.
01.02 To confirm that licensees are complying with NRC regulations regarding corrective
action programs.
01.03 To help the NRC gauge supplemental response when ROP Action Matrix thresholds
are crossed.
Issue Date: 02/26/15 2 71152
01.04 To confirm the licensee’s appropriate use of industry and NRC operating experience.
01.05 To evaluate the effectiveness of licensee audits and self-assessments.
01.06 To confirm licensees have established a safety conscious work environment.
01.07 To follow-up on corrective actions for selected previously identified compliance issues
(e.g., non-cited violations (NCVs)).
01.08 To verify that licensees are identifying and placing potential 10 CFR 21—REPORTING
OF DEFECTS AND NON-COMPLIANCE issues into the Corrective Action Program (CAP) and
appropriately evaluating them. [C3]

==71152-02 INSPECTION REQUIREMENTS==
PI&R activities are reviewed in four locations within the baseline inspection program: routine
reviews; semiannual trend reviews; follow-up of selected issues; and biennial team inspections
as discussed in the following sections. Section 71152-02 provides the minimum inspection
requirements. Section 71152-03 describes these requirements and their bases in more detail.
02.01 Routine Review.
The routine review of PI&R activities includes the following:
a. Resident inspectors should screen each item entered into the corrective action program
to select the best samples for follow-up. This review can be accomplished by attending
daily corrective action program review board meetings; reviewing computerized
corrective action program entries, or reading hard copies of corrective action program
documents. The intent of this review is for inspectors to be alert to conditions such as
repetitive, long-term, or latent equipment failures or cross-cutting aspect breakdowns
that might warrant additional follow-up through the semiannual trend review, annual
follow-up of selected issues, biennial team inspections, or other baseline inspections.
Inspectors must be alert for adverse performance trends and risk-significant or
repetitive equipment failures. Repeated failures to meet a technical specification
limiting condition of operation or its associated action(s) may be an example of an
adverse performance trend. [C1]
b. Verify that corrective actions commensurate with the significance of the issue have
been identified and implemented by the licensee. An in-depth review of selected issues
may be conducted in accordance with Section 02.03 of this IP.
c. Verify that equipment, human performance, and program issues are being identified by
the licensee at an appropriate threshold and entered into the PI&R program.
d. Review a sample of issues to verify that the licensee has appropriately classified the
issue and has taken appropriate short-term corrective actions. [C1]
Issue Date: 02/26/15 3 71152
e. Additionally, inspectors are expected to conduct reviews of PI&R activities during the
conduct of other baseline inspection procedures.
f. In completing a. through e., above, evaluate whether the licensee should perform an
evaluation in accordance with 10 CFR Part 21—REPORTING OF DEFECTS AND
NONCOMPLIANCE of any defect or non-conformance that has been identified. [C3]
02.02 Semiannual Trend Review.
Perform a semiannual review to identify trends (either NRC- or licensee-identified) that might
indicate the existence of a more significant safety issue. The scope of this review should
include repetitive or closely-related issues that may have been documented by the licensee
outside the normal corrective action program, such as: trend reports or PIs, major equipment
problem lists, repetitive and/or rework maintenance lists, departmental problem/challenge lists,
issues that challenge operators in performing duties (e.g., workarounds), system health reports,
quality assurance audit/surveillance reports, self-assessment reports, maintenance rule
assessments, or corrective action backlog lists. [C1] Additionally, consider a review of
corrective action documents which have been dispositioned to identify potential adverse trends
in structures, systems, and components (SSCs) as evidenced by acceptance of long-standing
non-conforming or degraded conditions. Such indicators could include “use-as-is”
determinations, revision of engineering or operational acceptance criteria, reductions in design
or operational margin, and repetitive work orders.
02.03 Annual Follow-up of Selected Issues.
The annual follow-up of selected issues ensures that the licensee has planned and/or
implemented corrective actions commensurate with the significance of identified issues. Select
four to eight issues (i.e., samples) per year for an in-depth review. These samples may be
reviewed throughout the annual assessment cycle. Inspectors should use the guidance
contained in Section 71152-03.04 as an aid in selecting samples for review. Inspectors should
review the selected samples against the performance attributes contained in Section 03.06 of
this IP. [C1] The samples should generally be representative of multiple cornerstones of safety.
Inspectors may select issues associated with cross-cutting areas as samples.
02.04 Biennial Team Inspection.
Perform a biennial team inspection of PI&R program as described below. Note any contribution
that cross-cutting aspects make to performance deficiencies and consider insights that these
issues may provide into the licensee’s progress in addressing any developing or existing crosscutting themes.
a. Use risk insights to select issues that have been processed through the licensee’s
corrective action program since the last biennial team inspection. For a subset of the
chosen samples, the scope of the review should be expanded to at least five years.
Inspectors should use the guidance contained in Sections 71152-03.04b and 03.05 to
select samples. To the extent available, the samples selected should include:
Issue Date: 02/26/15 4 71152
• Significant conditions adverse to quality (SCAQ) and conditions adverse to quality
(CAQ) that are documented in the licensee’s corrective action program
• cited or non-cited violations of regulatory requirements and other documented
findings,
• issues identified through NRC operating experience,
• issues identified through industry operating experience that are documented in the
licensee’s corrective action program, and
• licensee audits and assessments. [C1]
b. Inspectors should review each selected issue using the performance attributes
contained in Section 03.06 of this IP.
c. Inspectors should review the results of recent audits and self-assessments related to
the licensee’s corrective action and quality assurance programs. Inspectors should
compare and contrast the identified problems and corrective actions being taken as a
result of these audits and self-assessments with the results of this inspection.
d. Inspectors should review issues that pose challenges to the free flow of information for
adequate resolution. [C2] Employees should feel free to raise safety concerns, both to
their management and to the NRC, without fear of retaliation.
e. Inspectors must review corrective actions related to greater-than-green findings that
were not completed by the end of the associated supplemental inspection, and were not
otherwise reviewed.
f. Inspectors should perform assessments of the following items using the results
developed from steps a through d:
• the effectiveness of the licensee’s corrective action program in identifying,
evaluating, and correcting problems,
• the licensee’s use of operating experience information,
• completed licensee audits and self-assessments, and
• the licensee’s SCWE in order to identify any indications of reluctance to report
safety issues by licensee personnel. [C2]
Issue Date: 02/26/15 5 71152
71152-03 INSPECTION GUIDANCE
The PI&R inspections should follow a performance-based approach to the extent possible.
Inspectors should evaluate products and results of the licensee’s corrective action program,
including the use of operating experience, assessments, and audits. Inspectors should focus on
the results associated with risk-significant issues. For the issues that are determined to be
performance deficiencies, inspectors should evaluate the causes that relate to cross-cutting
aspects for insights on performance. Inspections performed in accordance with this procedure
should focus on the identification of problems and the effectiveness of corrective actions for risksignificant issues rather than the administrative aspects of the corrective action program and
associated procedures. This section provides detailed guidance for the routine, semiannual,
annual, and biennial PI&R reviews in addition to detailed guidance on sample selection,
performance attributes, and documentation.
Notify the NRC’s Vendor Inspection Center of Expertise in the Office of New Reactors, Division
of Construction Inspection and Operational Programs, via email to the branch chiefs of the
Electrical, Mechanical, and Quality Vendor Inspection Branches, when issues related to
potential vendor or supplier deficiencies are reviewed. Include the vendor’s name and provide a
brief description of the deficiency and/or component, as appropriate
.
Consider the following guidance when reviewing a licensee’s PI&R activities.
03.01 Routine Review.
One of the primary goals of the routine reviews is to verify that licensees are identifying issues
at an appropriate threshold and entering issues into the corrective action program. This can be
accomplished by having inspectors compare issues identified by the NRC during the conduct of
the plant status and inspectable area portions of the baseline inspection program IPs with those
issues identified by the licensee. The routine reviews allow for follow-up of selected issues and
operational occurrences to ensure that corrective actions commensurate with the significance of
the issues have been identified and implemented by the licensee.
During inspections and plant status reviews, inspectors should be alert for potential
performance deficiencies as may be associated with equipment failures, inadequate
maintenance work practices, personnel errors, inadequate risk assessments, management and
emergent work control problems, procedure deficiencies, or non-compliances with procedures
or regulatory requirements. When inspectors identify such conditions, they should examine the
licensee’s corrective action program records and/or attend licensee corrective action program
meetings to verify that the licensee either previously identified and documented the conditions
noted by the inspector or acknowledged the inspector’s observations and entered those
conditions into the corrective action program. Inspectors should be aware of any contribution
that cross-cutting aspects make to these performance deficiencies and consider insights that
these issues may provide into the licensee’s progress in addressing any developing or existing
cross-cutting themes. Inspectors should review and be aware of applicable 10 CFR 21
notifications and verify that the issues have been entered into the licensee’s corrective action
program for evaluation and disposition. The inspectors should also confirm on a sampling basis
that for defects or non-conformances that the licensee identifies the licensee performs an 
Issue Date: 02/26/15 6 71152
evaluation in accordance with 10 CFR Part 21—REPORTING OF DEFECTS AND
NONCOMPLIANCE. [C3]
Degradation and failures due to aging effects, such as loss of material, loss of preload, or
cracking, can occur. Plants with renewed licenses have established aging management
programs (AMPs) to identify, address, and/or prevent aging effects prior to loss of intended
function for those SSCs within the scope of the AMP. When degradation or failures occur that
appear to be age-related, inspectors should, in addition to other routine review activities,
determine whether the SSC is being managed by an AMP. If so, the inspector should also
determine whether the activities in the AMP are adequate to identify the aging effect prior to loss
of SSC intended function, and whether the licensee’s corrective actions address the adequacy
of the AMP. Consult with the regional license renewal point of contact for support in evaluating
the adequacy of the AMP.
Inspectors should remain alert to problems or conditions that could have more than minor safety
significance and for which the licensee’s investigation, conclusions, and/or corrective actions
appear to be inadequate. Inspectors should also review the circumstances associated with the
licensee’s investigation and disposition of the problem or condition to determine the reason(s)
why the licensee’s analysis and corrective actions were not adequate. Inspectors should review
selected samples against the performance attributes listed in Section 71152-03.06, as
applicable. Inspectors should determine if the licensee’s identification, classification, or
immediate and/or final disposition of a (significant) condition adverse to quality are in
compliance with the licensee’s procedures and/or regulatory requirements. The final disposition
of conditions adverse to quality could reveal acceptance of long-standing non-conforming or
degraded conditions as evidenced by “use-as-is” determinations, revision of engineering or
operational acceptance criteria, reductions in design or operational margin, and repetitive work
orders.
Most of the baseline IPs contain a requirement to inspect PI&R performance within the IP’s
subject area. The inspection of PI&R performance as part of baseline IPs is intended to ensure
that over the course of an assessment cycle, a sample of PI&R performance in all cornerstones
is obtained. As stated above, the primary focus of this portion of the PI&R review should be on
verifying that licensees are identifying issues at an appropriate threshold and entering them into
their corrective action program. However, inspectors are not precluded from routine review of
corrective action documents once they have been dispositioned to identify potential areas for
further inspection. Inspectors should consider PI&R insights when selecting baseline inspection
samples and may follow-up on PI&R issues as part of a baseline inspection procedure’s PI&R
review.
03.02 Semiannual Trend Review.
Inspectors should consider emerging or existing cross-cutting themes during the semi-annual
trend review to develop insights into the licensee’s progress in addressing the themes.
Inspectors can perform this review by summarizing the results of the licensee’s reviews and
comparing those results to those identified by the NRC through the baseline or supplemental
inspection program, including issues identified as a result of the daily review of corrective action
program items discussed above. If a biennial team inspection is scheduled within six months of
the semiannual review, the senior resident inspector could forward any concerns to the PI&R
team. This information should be incorporated into the scope of the team inspection. [C1]
Issue Date: 02/26/15 7 71152
03.03 Annual Follow-up of Selected Issues.
Inspectors should choose a sample of four to eight issues per year for an in-depth review, as
necessary, to verify that the licensee has taken corrective actions commensurate with the
significance of the issue. These issues can be chosen from, but not limited to, information
obtained from condition report reviews and reviews conducted as part of the baseline IPs.
Samples may also be chosen from the guidance contained in Section 71152-03.05 of this IP.
Inspectors may also select an issue that is tracked by a PI for which a threshold level change
has yet to occur.
Issues Associated with Safety Culture. Following the issuance of a second assessment letter
identifying a repetitive substantive cross-cutting issue (SCCI), the licensee’s progress in
addressing the issue should be evaluated as an annual sample. Inspectors should also
consider one of the annual samples to be a follow-up on emerging or existing cross-cutting
themes to develop insights into the licensee’s progress in addressing the themes. The review
should be scheduled at a time that will provide meaningful input to the assessment process.
Defects and Non-conformance. Defects and non-conforming materials, parts, or components
may present a substantial safety hazard. Inspectors should consider using an annual follow-up
sample to inspect defects or non-conforming conditions for compliance with 10 CFR 50,
Appendix B and 10 CFR 21. Inspectors may refer to IP 36100, “10 CFR Part 21 Inspections at
Nuclear Power Reactors” and IP 42004, “Inspection of Commercial-Grade Dedication
Programs” for additional guidance. [C3]
Maintenance Rule Issues. IP 71111.12, “Maintenance Effectiveness,” instructs inspectors to
evaluate corrective actions associated with equipment subject to the Maintenance Rule
(10 CFR 50.65). This IP also instructs inspectors to consider applicability of 10 CFR 50,
Appendix B, Criterion XVI for equipment subject to the requirements of 10 CFR 50, Appendix B,
especially when the corrective action-related requirements of 10 CFR 50.65(a)(1) may not be
applicable. If inspectors identify potential corrective action program weaknesses during
implementation of IP 71111.12 that require additional focus beyond the expectations of
IP 71111.12, inspectors may select the issue as a sample for PI&R annual follow-up.
Operator workarounds (OWAs). Action(s) taken to compensate for a degraded or nonconforming condition are considered OWAs. OWAs that cannot be implemented effectively can
increase the baseline core damage or large early release frequency. This review should verify
that the licensee is identifying OWA problems at an appropriate threshold, entering them in the
corrective action program, and planning or taking appropriate corrective actions. OWA samples
should be evaluated considering all existing plant conditions including the cumulative effects of
other OWAs.
03.04 Biennial Team Inspection.
The biennial team inspection is intended to complement and expand upon the reviews
described in Sections 03.01, 03.02, and 03.03 of this IP by:
• evaluating additional examples of licensee PI&R,
Issue Date: 02/26/15 8 71152
• reviewing the resolution of issues that earlier had been assessed for the licensee’s
identification efforts only,
• comparing the NRC’s results against the licensee’s assessment of performance in the
PI&R area, and
• assessing whether PI&R deficiencies may indicate potential programmatic issues.
a. Planning. Inspectors should obtain licensee administrative procedures that control the
identification, evaluation, and resolution of problems. Selected licensee documents
needed to support the inspection may be obtained prior to the inspection. These
documents should only be reviewed to provide the inspectors with sufficient knowledge
of the licensee’s programs and processes, as necessary, to conduct an effective and
efficient inspection.
Inspectors should obtain and review documents for the in-office review, such as a list of
corrective action documents issued from the time of the last biennial team inspection
(e.g., a list of work orders, work requests, temporary modifications, calibration failures,
condition/problem identification reports, operability evaluations and determinations,
etc.). In addition, inspectors should obtain relevant licensee corrective action program
assessments, program performance information, trend reports, and licensee safety
culture assessments. Refer to IMC 0620, “Inspection Documents and Records” for
more information on requesting documents for inspection preparation.
Inspectors should obtain and review all NRC inspection reports issued since the last
biennial team inspection to determine:
• the extent to which licensee actions in response to NCVs and findings have been
sampled by routine reviews of licensee PI&R activities, and
• if any trends or patterns in corrective action program or performance issues 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 licensee’s 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. Consider the need to follow-up on performance trends
documented as a result of the semiannual trend review.
b. Sample Selection. Based on the planning review, inspectors should identify a sample
of licensee corrective actions for review. The biennial inspection team leader should
choose as many issues for review as warranted to complement the routine PI&R
reviews and ensure a sufficient basis for evaluating the effectiveness of the licensee’s
PI&R program. Inspectors can review Institute of Nuclear Power Operations (INPO)
findings, recommendations, corrective actions, and operating experience that are
documented in the licensee’s corrective action program. Inspectors may refer to the 
Issue Date: 02/26/15 9 71152
NRC/INPO Memorandum of Agreement, dated November 14, 2005 (ML060060035), for
guidance prior to reviewing any INPO documents. [C1]
1. The samples chosen for review should include a range of issues selected from
the list in Section 71152-03.05, including those sample types that are designated
as requiring a mandatory review. For a subset of the samples chosen for review,
the scope of the review should be expanded to at least five years. Among the
samples chosen for this extended review should be those issues whose
significance might be age-dependent, such as issues associated with erosion of
piping, degradation of safety-related raw water systems, boric acid
accumulations, aging of electronic components, environmental qualification, etc.
This review can be performed by requesting the licensee to perform a corrective
action program search (computerized or other) for those items designated by the
team for the five-year review. [C1]
2. If the licensee conducted any periodic self-initiated assessments of safety culture
during the review period, this assessment shall be included along with other nonsafety 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 licensee’s evaluation and actions
to address the issues identified by the safety culture assessment. Not all actions
necessarily need to be handled within the licensee’s corrective action program
under 10 CFR 50, Appendix B, Criterion XVI. It may be more appropriate for
some issues that are not conditions adverse to quality to be tracked to resolution
through an alternate licensee program such as an employee concerns program.
The inspectors review should focus mainly on the licensee’s response to the
assessment results or actions taken to address identified issues instead of the
assessment methodology or an evaluation the assessment’s adequacy.
Section 03.04.c provides more guidance on reviewing the licensee’s safety
culture assessment from the SCWE perspective.
3. When the licensee has been requested by the NRC to perform an independent
safety culture assessment, inspectors shall evaluate the licensee’s assessment.
4. Inspectors should consider emerging or existing cross-cutting themes for review
during the biennial team inspection to develop insights into the licensee’s
progress in addressing the themes.
5. Inspectors may select one or more risk-significant systems on which to focus
sample selections. Performing a walkdown of selected systems in accordance
with the guidance provided in IP 71111.04, Equipment Alignment, Section 02.02,
Complete Walkdown will provide insight into the adequacy of the licensee’s
implementation of all aspects of the corrective action program (identification,
prioritization, evaluation and implementation). However, in cases where this
method for sample selection is used, additional issues may be required to be
reviewed to ensure adequate coverage in the Emergency Planning Cornerstone
and the Radiation Safety or Safeguards Strategic Performance Areas.
Issue Date: 02/26/15 10 71152
c. Assessment of Safety Conscious Work Environment. When conducting interviews with
or observing other activities involving licensee personnel and/or long-term contractors
(i.e., those that have been working at the site for at least six 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 corrective action 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 licensee’s 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
licensee’s safety culture and other relevant assessments.
Although the licensee may be implementing an employee concerns or similar program
regarding the identification of safety issues, the possibility of existing underlying factors
that would 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.
Appendix A to this procedure provides a list of questions that can be used when
discussing PI&R issues with licensee personnel to help assess whether impediments to
the establishment of a SCWE exist. It is not intended that inspectors conduct formal
interviews solely for the purpose of assessing the work environment; rather, inspectors
may use the questions in Appendix A during discussions with licensee individuals
concerning other attributes of the inspection. It is expected that during this inspection,
discussions or interviews will be held with both licensee management and staff.
If inspectors become aware of (1) instances of employees being discouraged from
raising safety or regulatory issues within the licensee’s or contractor’s organization or to
the NRC, (2) a “chilling” effect, or (3) other general reluctance of employees to raise
safety or regulatory issues unrelated to a specific event or incident, they should refer to
IP 93100, “Safety Conscious Work Environment Issue Follow-up” and consult with
regional management to determine appropriate follow-up actions.
d. Development of PI&R Program Performance Insights. By reviewing a sufficient number
and breadth of samples, the inspection team should be able to develop insights into the
licensee’s ability to identify, evaluate, and resolve problems using the corrective action
program, operating experience, and results of self-assessments/audits. Inspectors
should compare these results with the licensee’s performance reviews, including
reviews of PI&R programs. Inspectors should determine whether licensee reviews are
consistent with the NRC review of PI&R issues.
Issue Date: 02/26/15 11 71152
The intent of this IP (both the routine and biennial inspection effort) is to provide insights
into licensee performance in the PI&R area based upon a performance-based review of
corrective action issues, operating experience, and self-assessments/audits. More
detailed programmatic reviews of licensee performance in the PI&R area will be
conducted during supplemental inspections if established performance thresholds are
crossed.
03.05 Sample Selection Guidance.
Inspectors should seek the broadest range of examples from the cornerstones of safety when
selecting inspection samples. Inspectors can obtain insights for determining appropriate
samples from discussion with resident or regional inspectors who are familiar with the site’s
issues, PI&R process, and previously inspected areas. In selecting issues for review,
inspectors should also use relevant risk insights, such as maintenance rule program basis
documents, current licensee risk analysis results or insights, licensee system health reports,
and significance determination process (SDP) Phase 2 worksheets for the plant
Inspectors should consider including samples from the sources listed below (♠ – indicates
mandatory samples only for biennial team inspections). Other than for the mandatory samples,
inspectors are not required to select from each type of source listed. The sample-selection
guidance is intended to help ensure that the NRC can obtain insights into a licensee’s corrective
action program throughout an assessment cycle
a. ♠Licensee-identified issues, including issues identified during audits or selfassessments, and licensee event reports. The review of licensee event reports should
be coordinated with the resident inspectors to effectively utilize inspection resources
during the biennial team inspection. Include a sample of corrective actions that were
considered having the highest priority including those constituting SCAQs. The
licensee’s root cause analyses associated with these items should be assessed using
the inspection guidance contained in IP 95001, “Supplemental Inspection for One or Two
White Inputs in a Strategic Performance Area,” as an aid.
b. ♠Completed self-assessments/audits, including quality assurance program audits
performed to satisfy 10 CFR 50, Appendix B, Criterion XVIII. Determine if the results are
consistent with the data collected during this inspection and whether the audits and selfassessments are effectively identifying problems. Verify that any substantial differences
that exist between results from the subject assessment/audit and the results of previous
assessments/audits are reasonable. Review the licensee’s response to the
assessments/audits to determine if corrective actions were tracked, timely, and
appropriate for resolving identified issues.
c. ♠Quality assurance audits can be an important source of problem identification. When
reviewing quality assurance audits inspectors should be familiar with the licensee's
quality assurance topical report/ Quality Assurance Plan and the associated industry
standards that the Quality Assurance Plan commits to in order to determine if the audits
are appropriately identifying problems in the Appendix B area the audit is focused on. If
the inspector finds inconsistencies between the conclusions of the audit and the 
Issue Date: 02/26/15 12 71152
conclusions of the PI&R team, several cycles of audits for that area should be reviewed
to determine if the audits were of sufficient depth and scope to adequately assess the
appropriate Appendix B audit area. The collective result of all the Appendix B,
Criterion XVIII, quality assurance audits for the two year cycle should be to "verify
compliance with all aspects of the quality assurance program and to determine the
effectiveness of the quality assurance program." The PI&R team should assess the
identified inconsistencies to determine if the quality assurance audits are appropriately
indentifying problems.
d. ♠Safety culture assessments. A licensee's evaluation of specific cross-cutting aspects,
cross-cutting areas, functional departments, or levels (e.g., supervisors or nonsupervisory workers) may constitute a safety culture assessment review. Licensee
safety culture self-assessments may also be reviewed in accordance with Section 02.03
of this IP as an annual follow sample [C2]
e. ♠A sample of NRC-identified issues during baseline, supplemental, and reactive
inspections. Discuss such issues with respective NRC inspectors and management as
part of inspection preparations. The biennial team inspection shall review all licensee
corrective actions associated with greater than green inspection findings that were not
completed by the conclusion of the associated supplemental inspection and which have
not been previously completed and subsequently reviewed. A review of all licensee
completed corrective actions for greater than green findings provides additional
assurance that the licensee’s completed corrective actions for risk- significant
performance issues are sufficient to address the root and contributing causes and
prevent recurrence.
f. ♠Issues related to cited and non-cited violations and documented findings. During the
biennial inspection, it is mandatory to review the licensee’s response to a sample of
NCVs in each cornerstone unless no NCVs were identified in the cornerstone.
g. ♠Issues identified through NRC and industry operating experience exchange
mechanisms (e.g., NRC generic communications, reports associated with 10 CFR 21,
nuclear steam system supplier vendor reports, Electric Power Research Institute reports,
and operating experience reports from similar facilities, NRC Operating experience
smart samples).
h. Issues captured in databases operated and/or maintained by the site’s corporate office.
A site’s corporate office may track such issues in a database(s) separate from the site’s
corrective action program. Inspectors may choose to view the contents of such a
database(s) to ensure that issues and operating experience are communicated to
affected sites owned or operated by or associated with the corporate entity. Should an
issue be identified on site that warrants follow-up and that issue is captured in the
corporate corrective action program, then that issue and the licensee’s handling of it
should be reviewed, even though it is a corporate corrective action program issue. A
review of corporate corrective actions programs can identify important information
affecting multiple sites, such as those identified with bio-diesel fuel for which NRR issued
Information Notice (IN 2009-02) for example.
Issue Date: 02/26/15 13 71152
i. Cause analyses and corrective action documentation associated with SSCs or functions
classified as (a)(1) status in accordance with the Maintenance Rule (10 CFR 50.65).
Review the licensee’s trending analysis associated with these SSCs/functions to
determine whether the licensee’s corrective action program should have enabled the
identification and correction of the adverse trend prior to the SSC/function obtaining
(a)(1) status.
j. Cross-cutting issues and other issues identified by safety review committees or other
management oversight mechanisms.
k. Issues identified through alternative avenues, such as employee concerns or similar
programs. [C2] Note that some members of the licensee staff may not have authorized
access to information about issues that are captured in these programs. Inspectors
should accordingly protect this information from disclosure to any unauthorized
personnel. In particular, inspectors should limit any verbal and/or written discussions to
only those licensee staff that have access rights to the subject records and to inspection
team members that have a need-to-know. Inspectors may need to restrict access to
portions of the exit or debrief meetings as appropriate.
l. Issues that challenge operator performance including but not limited to: operator work
arounds, Main Control Room deficiencies, operator burdens and challenges, night
orders/standing orders, temporary logs, control room and/or equipment operator logs,
and work requests/work orders dealing with long standing issues. Inspectors should
also review the corrective actions associated with failed SSCs that resulted in prompt
and final operability evaluations..
m. Issues that may be age-related (e.g. due to aging effects such as loss of material, loss of
preload, or cracking). Plants with renewed licenses have established aging
management programs (AMPs) to identify, address, and/or prevent aging effects prior to
loss of intended function for those SSCs within the scope of the AMP. When inspecting
degradation or failures that appear to be age-related, inspectors should, in addition to
other inspection activities, determine whether the SSC is being managed by an AMP.
If so, the inspector should also determine whether the activities in the AMP are adequate
to identify the aging effect prior to loss of SSC intended function, and whether the
licensee’s corrective actions address the adequacy of the AMP. Consult with the
regional license renewal point of contact for support in evaluating the adequacy of the
AMP.
n. Fatigue-related issues identified through fitness for duty effectiveness reviews or
licensee assessments reports, see 10 CFR 26.717(9). Refer to IP 93002, “Managing
Fatigue” for additional guidance.
03.06 Performance Attributes.
When evaluating the effectiveness of a licensee’s corrective actions for a particular issue, the
nature and (potential) significance of the identified problem must be considered. While
licensees may appropriately consider monetary, plant availability, and other factors when 
Issue Date: 02/26/15 14 71152
determining significance, the potential impact on nuclear safety and risk should be the primary
factors in the licensee’s classification and prioritization of corrective actions. Attributes to
consider during the routine review, semiannual trend review, annual follow-up of selected
issues, and biennial team inspection are listed in the table below. Inspectors are not expected
to assess each attribute for every issue selected for follow-up during routine reviews,
semiannual trend reviews, or during the annual follow-up of selected issues. Instead, inspectors
may choose to assess licensee performance against selected attributes, as necessary, to be
most effective. Inspectors can also refer to IP 95001 for additional guidance on assessing
licensee evaluations of significant performance issues.
Issue Date: 02/26/15 15 71152
Table 1 – Performance Attributes
Performance Attributes See Legend Below
Complete, accurate, and timely documentation of the identified problem in
the corrective action program.
R S A B
Evaluation and timely disposition of operability and reportability issues.
Refer to Section 4.6 of the Attachment to NRC Regulatory Issue Summary
(RIS) 2005-20, Revision 1 for additional guidance related to the timing of
operability determinations.
R S A B
Consideration of extent of condition and cause, generic implications,
common cause, and previous occurrences. R S A B
Classification and prioritization of the problem’s resolution commensurate
with the safety significance. R S A B
Identification of root and contributing causes of the problem. The
identification of the significant condition adverse to quality, the cause of the
condition, and the corrective action taken shall be documented and reported
to appropriate levels of management. Inspectors may use guidance
contained in IP 95001 as an aid in assessing the adequacy of licensee root
cause analyses.
R♣ S♣ A B
Identification of corrective actions that are appropriately focused to correct
the problem (and to address the root and contributing causes for significant
conditions adverse to quality).
R♣ S♣ A B
Completion of corrective actions in a timely manner commensurate with the
safety significance of the issue. Included within this attribute would be
justifications for extending corrective action due dates. If permanent
corrective actions require significant time to implement, then inspectors
should verify that interim corrective actions and/or compensatory actions
have been identified and implemented to minimize the problem and/or
mitigate its effects until the permanent action could be implemented. Refer
to Section 7.2 of the Attachment to NRC RIS 2005-20, Revision 1 for
additional guidance related to the timing of corrective actions.
R♣ S♣ A B
Action taken results in the correction of the identified problem. In the case of
significant conditions adverse to quality, the corrective action taken shall
preclude repetition.
R♣ S♣ A B
Identification of negative trends associated with human or equipment
performance that can potentially impact nuclear safety. S B
Operating experience is adequately evaluated for applicability, and
applicable lessons learned are communicated to appropriate organizations
and implemented.
R S A B
Self assessments and audits are effective at identifying issues, which are
evaluated and resolved commensurate with their significance. B
For NRC-identified issue(s), evaluate whether opportunities to identify the
problem(s) by the licensee were missed in the past and if prior attempts by
the licensee to remedy the problems were adequate.
B
R – Routine Review S – Semi Annual Trend Review
A – Annual Follow-up of Selected Issues B – Biennial Team Inspection
♣ – Identified issues may be deferred and addressed with the annual follow-up of selected
issues or the biennial team inspection.
Issue Date: 02/26/15 16 71152
03.07 Documentation Guidance.
The level of documentation for PI&R inspection activities differs from that used for other
baseline inspection activities by allowing the documentation of observations and assessments.
a. Routine Review. Document the completion of routine plant status reviews and the daily
screening of items entered into the corrective action program performed under Sections
02.01 and 03.01 of this inspection procedure. Typically this is documented in Section
4OA2 of the quarterly integrated inspection report.
b. Semiannual Trend Review. On a semiannual basis, a section should be added to the
quarterly integrated inspection report to document the inspectors’ observations and
assessments of trends that might indicate the existence of a more significant safety
issue as they relate to the performance attributes discussed in Section 03.06. Unlike
the level of documentation for the routine reviews above, the level of documentation for
the trend review should include trends that might not rise to the level of an inspection
finding.
c. Annual Follow-up of Selected Issues. The basis for the selection and the scope of
review of each sample should be documented in the integrated inspection report. In
general, issues associated with PI&R programs should also be documented in the
report. This documentation should include factual information that relates to the
performance attributes discussed in Section 03.06 if that information indicates licensee
performance weaknesses. This documentation standard is different from the standard
used to document issues elsewhere in the quarterly integrated inspection reports.
Assessments of PI&R program effectiveness will not be performed during these
inspections – such assessments will be performed only during the biennial team
inspection. Technical issues associated with other inspectable areas and cornerstones
should also be documented in those sections of the report.
d. Biennial Team Inspection. At the completion of inspection activities, the team should
develop a clear and concise discussion of the results of their review. This discussion
should also be supported by the inspection activities, including those activities from the
routine reviews, semiannual trend reviews, and annual follow-up of selected issues,
conducted since the last biennial assessment of the licensee’s PI&R program. The
discussion should be documented in the inspection report for the biennial team
inspection. IMC 0612, Appendix D provides additional specific and unique guidance
beyond that contained in IMC 0612 for documenting the biennial PI&R inspections.
71152-04 RESOURCE ESTIMATE
04.01 Routine Review.
The effort for daily review of corrective action items is estimated at just over 30, 40, and
50 minutes for single-, dual-, and triple-unit sites, respectively. This equates to an annual effort
of 129 hours, 178 hours, and 225 hours for single-, dual-, and triple-unit sites, respectively.
Time spent performing these daily reviews should be charged to IP 71152.
Issue Date: 02/26/15 17 71152
It is expected that routine reviews of PI&R activities should equate to approximately 10 to
15 percent of the resources estimated for the associated baseline cornerstone procedures, this
is a general estimate only based on the overall effort expected to be expended in each strategic
performance area. It is anticipated that the actual hours required to be expended may vary
significantly from attachment to attachment, depending on the nature and complexity of the
issues that arise at the particular facility. Overall, an effort should be made to remain within the
10 to 15 percent estimate on a strategic performance area basis. Inspection time spent
assessing PI&R as part of the baseline procedure attachments should be charged to the
corresponding baseline procedure.
04.02 Semiannual Trend Review.
The effort for the semiannual trend reviews is estimated to take an average of 16 to 24 hours
per year, regardless of the number of units on site. The time spent performing these reviews
should be charged to IP 71152.
04.03 Annual Follow-up of Selected Issues.
The annual effort for review of the four to eight samples per Section 02.02 is estimated to take
an average of 61 to 81 hours for a single-unit site, 64 to84 hours for a dual-unit site, and 67 to
87 hours for a triple-unit site. The time spent reviewing the four to eight samples should be
charged to IP 71152.
04.04 Biennial Team Inspection.
The biennial team inspection is estimated to take an average of 212 to 288 hours of direct
inspection effort. Resident inspector staff participation (either full or part time) on the inspection
team is highly recommended. The time spent performing the biennial team inspection should
be charged to IP 71152B.
Resources used to perform IP 93100, “Safety Conscious Work Environment Issue Follow-up”
inspection should be charged to IP 93100.
71152-05 PROCEDURE COMPLETION
Inspection of the minimum sample size will constitute completion of this procedure in the
Reactor Program System (RPS). The minimum sample size for the annual completion of the
baseline inspection consists of 2 semiannual trend reviews per Section 02.02 of this IP and
4 issues selected for follow-up per Section 02.03 of this IP for a total of 6 samples in RPS. The
minimum sample size for the biennial team inspection is 1 and is defined as the biennial team
inspection. These minimum sample sizes apply regardless of the number of reactor units at the
site. See IMC 2515 for further guidance on procedure completion.
Issue Date: 02/26/15 18 71152
71152-06 REFERENCES
Audit of NRC’s Implementation of 10 CFR Part 21, Reporting of Defects and Noncompliance
(OIG-11-A-08, March 23, 2011, ML110820426)
IMC 0326, “Operability Determinations and Functionality Assessments for Conditions Adverse
to Quality or Safety” (Link to external directory containing links to the latest version of this IMC
and to other IMCs including the following. Note: This directory also contains links to public
versions of Operating Experience Smart Samples [OpESSs] by IP)
IMC 0305, “Operating Reactor Assessment Program”
IMC 0308 Attachment 2 “Technical Basis for Inspection Program”
IMC 0612, “Power Reactor Inspection Reports”
IMC 0620, “Inspection Documents and Records”
IMC 2515, “Light-Water Reactor Inspection Program – Operations Phase”
IP 36100, “10 CFR Part 21 Inspections at Nuclear Power Reactors”
IP 43004, “Inspection of Commercial-Grade Dedication Programs”
IP 93002, “Managing Fatigue”
IP 93100, “Safety Conscious Working Environment Issue Follow-up”
IP 71111.12, “Maintenance Effectiveness”
IP 95001, “Supplemental Inspection for One or Two White Inputs in a Strategic Performance
Area”
Nuclear Regulatory Commission Enforcement Manual
Title 10 of the Code of Federal Regulations
NRC/INPO Memorandum of Agreement, dated November 14, 2005 (ADAMS ML060060035)
See the following web links for reference documents:
http://nrr10.nrc.gov/rorp/ip71152.html
END
Appendix A: Guidance for Gathering SCWE and PI&R Insights
Attachment 1: Revision History
Issue Date: 02/26/15 App A-1 71152
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 Work Environment Issue Follow-up” to gain
additional SCWE insights.
Suggested Questions
1. a. Are you willing to raise a safety concern?
b. Are there any conditions under which you would be hesitant to raise a safety concern?
c. If yes, does that condition exist here at {Insert Plant Name}? Please elaborate.
2. a. Are you aware of situations where any employee or contractor may be hesitant to raise
concerns, internally or externally?
b. If yes, please explain. (If an NRC inspector is aware of a specific incident that may have
caused such hesitation, then ask about it. Focus on whether or not the interviewee or
others may be less likely to report concerns because of that incident).
3. a. Where would you go to raise a safety issue? [The NRC inspector should be aware of
the following avenues for raising concerns, but should not prompt the interviewee by
listing them as potential answers to the question: supervisor, corrective action program,
alternative program (Employee Concerns Program (ECP)/Ombudsman), NRC, or other
avenue.]
b. Why would you pick this avenue? Have you or others had any experiences, or know of
any situations, that have influenced your decision to pick this avenue? If so, please
describe.
4. Are there other avenues available to you for raising safety issues (i.e., supervisor,
corrective action program, ECP/ombudsman, NRC, or other avenues)? Ask each of the
questions listed below for each avenue available.
a. Have you ever submitted a safety issue to {insert method}? If not, why not?
b. If yes, was the issue adequately addressed? Why or why not?
c. If not adequately addressed, did you further pursue the issue? If not, why not?
d. Given the nuclear safety importance of the issue, did you receive timely feedback?
Issue Date: 02/26/15 App A-2 71152
e. Describe any instances in which you know of another employee who submitted an issue
to {insert method} and you considered the response unacceptable.
5. Would you say that your management is supportive of the ECP/Ombudsman program?
a. If yes, how is such support demonstrated?
b. If no, please describe what has led you to believe that they are not supportive.
6. Are you aware of any actions taken by your management to prevent and detect
retaliation and/or chilling effect?
a. Are their actions effective?
b. Has management’s handling of any chilling effect issues been consistent?
7. Are you aware of any instances in which another individual experienced a negative
reaction for raising a safety issue? If yes, please describe the incident, including any
information conveyed by management concerning the incident.
8. a. What does SCWE mean to you?
b. Do you know if {Insert Plant Name} has a SCWE policy? If yes, can you briefly explain
what the established policy requires?
9. Would you say that your management is supportive of the SCWE policy?
a. If yes, how is such support demonstrated?
b. If no, please describe what has led you to believe they are not supportive.
10. Have events or circumstances occurred in the past six months that have reduced:
a. Your willingness to identify or raise safety issues?
b. Your confidence in the corrective action program?
c. Your willingness to challenge actions or decisions you believe are unsafe?
END
Issue Date: 02/26/15 Att 1-1 71152
Attachment 1 – Revision History for IP 71152
Commitment
Tracking
Number
Accession
Number
Issue Date
Change Notice
Description of Change Description of
Training Required
and Completion Date
Comment and
Feedback
Resolution
Accession Number
(Pre-Decisional,
Non-Public)
N/A 03/06/2001
CN 01-006
Revised to delete certain inspection requirements
(collective risk of maintenance backlog and
equipment unavailability accounting), eliminate
duplication within the procedure, and provide
additional guidance concerning the review of a safety
conscious work environment.
N/A N/A
N/A 01/17/2002
CN 02-001
Revised to include changing the inspection frequency
to biennial and add guidance on the conduct of
inspections of 3 to 6 samples per year outside of the
team inspections.
N/A N/A
C1 09/08/2003
CN 03-032
Revised to incorporate 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 longstanding issues,
and biennial reviews of operating experience issues.
Yes
09/24/2003
N/A
N/A ML053490187
01/05/2006
CN 06-001
A requirement to inspect for cumulative effects of
operator workarounds to IP 71152 as one of its
annual samples was added. Also, the annual sample
size and the estimate inspection resources required to
complete this IP were increased to support review of
operator work-arounds. Completed historical CN
search.
N/A N/A
Issue Date: 02/26/15 Att 1-2 71152
Commitment
Tracking
Number
Accession
Number
Issue Date
Change Notice
Description of Change Description of
Training Required
and Completion Date
Comment and
Feedback
Resolution
Accession Number
(Pre-Decisional,
Non-Public)
N/A
C2
ML061560498
06/22/06
CN 06-015
Guidance added for procedure completion regarding
annual sample size.
Procedure now requires that the time spent to review
condition reports to be charged to IP71152 instead of
the plant status procedure.
Hours have been increased for condition report
reviews.
Incorporate safety culture initiatives described in Staff
Requirements - SECY-04-0111, ARecommended Staff
Actions Regarding Agency Guidance in the Areas of
Safety Conscious Work Environment and Safety
Culture," dated August 30, 2004.
N/A
Yes
1/7/2006
ML061570086
N/A ML070720179
09/20/07
CN 07-029
IP 71152 has been revised to add guidance on NRC
use of INPO documents.
N/A ML071560246
N/A ML073540265
01/10/08
CN 08-001
IP revised to address ROP Feedback Form 95001-
1125 and some enhancements identified by the
Problem Identification and Resolution Best Practices
draft report.
N/A ML073540274
Issue Date: 02/26/15 Att 1-3 71152
Commitment
Tracking
Number
Accession
Number
Issue Date
Change Notice
Description of Change Description of
Training Required
and Completion Date
Comment and
Feedback
Resolution
Accession Number
(Pre-Decisional,
Non-Public)
N/A ML093270053
02/26/10
CN 10-008
This revision incorporates:
Resolution of ROP feedback forms: 71152-1314
(increased sensitivity to handling of confidential ECP
information), -1322 (optional review of corporate
databases to select samples), -1381 (interviewing
long-term contractors for SCWE insights) and -1474
(budget hour correction). An additional inspection
attribute for the Biennial Team Inspection to address
a 2007 External Survey Comment. Added an
additional 4 hours of inspection resources per the
2009 ROP Realignment Results (ML092090312).
N/A ML100050386
N/A ML101090438
08/18/11
CN 11-013
Added an inspection requirement to inspect
completed corrective actions for greater than green
inspection findings (feedback form 71152-1449), and
added additional guidance related to the review of
quality assurance audits (feedback form 71152-1400).
Added reference to IP 93100, “Safety Conscious
Working Environment Issue Follow-up” and provided
additional guidance for follow-up (FF 71152-1561),
provided additional guidance for inspectors in the
selection of condition reports for the routine and semiannual reviews (FF 71152-1626).
N/A ML111870499
Issue Date: 02/26/15 Att 1-4 71152
Commitment
Tracking
Number
Accession
Number
Issue Date
Change Notice
Description of Change Description of
Training Required
and Completion Date
Comment and
Feedback
Resolution
Accession Number
(Pre-Decisional,
Non-Public)
N/A ML112360542
12/05/2011
CN 11-039
Added guidance for license renewal age management
programs. Add requirement to verify applicable10
CFR 21 notifications entered into the licensee’s CAP.
Added sample selection guidance and references
related to inspecting defects and nonconforming
materials, part, or components. Resources changed
to reflect the 2011 ROP Realignment
(ML11178A329).
N/A ML11332A016
C3 ML13030A098
01/31/13
CN 13-004
Added guidance ensures that potential Part 21 issues
are evaluated on a continual basis. This and CN 11-
039 guidance and an associated objective pertaining
to 10 CFR 21 are established as commitment C3.
N/A
ML13179A365
08/13/13
CN 13-017
Relocated some of documentation guidance related to
the biennial PI&R inspection contained in Section
03.07 of this IP to IMC 0612 App D to eliminate
redundancy and possible guidance conflicts.
N/A
Issue Date: 02/26/15 Att 1-5 71152
Commitment
Tracking
Number
Accession
Number
Issue Date
Change Notice
Description of Change Description of
Training Required
and Completion Date
Comment and
Feedback
Resolution
Accession Number
(Pre-Decisional,
Non-Public)
ML14316A042
02/26/15
CN 15-003
Relocated Operator Work-around inspection
requirement to IP 71111.15; enhanced alignment of
71152-01 INSPECTION OBJECTIVES with IMC 0308
Att. 2 Fig. 37; enhanced IP organization; aligned
language to updated IMC 0310 nomenclature;
enhanced communications with the NRC Vendor
Inspection Center of Expertise for vendor or supplier
deficiencies; updated references to external IP’s and
IMC’s and eliminated reference to retired RIS 2005-
20; eliminated use of undefined terminology; and
enhanced integration of OpE Smart Samples into
inspection sample population. This revision
addresses or partially addressed FBF’s 71152-1787, -
1836, -1946, -1964, -2012, -2013, and -2022.
ML14287A039
ML15027A203
ML15027A208
ML15027A211
ML15027A215
ML15027A219
ML15027A222
ML15027A228
}}