ML18207A135

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

ML18207A135
Person / Time
Issue date:	07/26/2018
From:	Keefe M NRC/NRR/DIRS/IRAB
To:
Keefe, MJ
Shared Package
ML18207A128	List: Inspection Manual Change Notice 18-022, Table of Contents for Inspection Manual Change Notice 18-022 ML18207A132 ML18207A135 ML18208A487
References
CN 18-022
Download: ML18207A135 (9)

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NRC INSPECTION MANUAL IRAB INSPECTION PROCEDURE 93100 SAFETY-CONCIOUS WORK ENVIROMENT ISSUE OF CONCERN FOLLOWUP PROGRAM APPLICABILITY: IMC 2515 C CORNERSTONES: ALL INSPECTION BASIS: This procedure inspects the safety-conscious work environment (SCWE) attribute of a licensees safety culture.

This procedure can also be used to follow-up on a SCWE cross cutting issue (CCI) or SCWE theme. Insights gathered during this inspection would be considered during the mid- or end-of-cycle assessment meetings conducted in accordance with Inspection Manual Chapter (IMC) 0305, Operating Reactor Assessment Program. The SCWE safety culture attribute is sampled during the biennial problem identification and resolution team inspection conducted in accordance with Inspection Procedure (IP) 71152, Problem Identification and Resolution. When directed by management, SCWE-related issues of concern identified during IP 71152 can be examined in more depth using this procedure to gain additional insights.

A SCWE is defined as an environment in which employees are encouraged to raise safety concerns, are free to raise concerns both to their own management and to the NRC without fear of retaliation, where concerns are promptly reviewed, given the proper priority, and appropriately resolved, and timely feedback is provided to those raising concerns. In contrast, a chilled work environment is one in which employees perceive that raising safety concerns to their employer or to the NRC is being suppressed or is discouraged and can occur because of an event, interaction, decision, or policy change.

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

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

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

Issue Date: 07/26/18 1 93100

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

93100-02 INSPECTION REQUIREMENTS To determine if indications of a chilled work environment exist, inspectors should review the following with respect to identified SCWE issues of concern:

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

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

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

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

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

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

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

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

Issue Date: 07/26/18 2 93100

93100-03 INSPECTION GUIDANCE The inspection team leader and regional management should decide during the inspection planning stages if any observations will be conducted. Similarly, the team leader and regional management should decide if focus groups, in addition to individual interviews, will be used to obtain general SCWE insights. The team leader and regional management should also decide whether qualified safety culture assessors from NRC Headquarters or other regions may be necessary. These decisions may be based on factors such as, but not limited to, the team members knowledge of and experience with conducting focus groups, prior success using focus groups at the site, available resources, or knowledge of potential SCWE issues at the site (for example, an increase in the number of allegations may indicate a negative trend in the SCWE). Before conducting focus group interviews per this procedure, inspectors must have completed focus group moderation training. For guidance on conducting individual interviews, focus groups, behavioral observations, and evaluations of safety culture surveys or licensee SCWE assessments, refer to Enclosures B, C, D, and F of IP 95003.02, Guidance for Conducting an Independent NRC Safety Culture Assessment.

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

For each SCWE-related issue, the inspectors should note the circumstances that contributed to the inspectors awareness, such as what types of concerns employees have indicated they are hesitant to raise and their safety significance, which avenues they are hesitant to use (e.g.,

supervisor, chain of command, CAP, ECP, NRC), which employees and work groups are impacted and for how long, and who and what behaviors contributed to the chilling effect. If the staff decides to conduct focus groups, more than one inspector would typically be neededone inspector to take notes while the other inspector facilitates the focus groups. For inspection activities involving interviews on sensitive topics or focus groups, it is beneficial to have multiple inspectors to discuss interview results and share viewpoints before developing conclusions.

With approval from regional management, the inspectors should develop and implement a site-specific inspection plan using the guidance below.

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

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

Issue Date: 07/26/18 3 93100

03.02 Employee Concerns and Corrective Action.

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

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

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

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

03.03 Interviews and Focus Groups.

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

a. Inspectors should individually interview (1) a few randomly-selected individuals from the same work groups as the involved individuals, (2) the individuals involved in the original SCWE concern, (3) a few randomly-selected individuals from other work groups, (4) one or more key supervisors or managers through whom the involved individuals report, and (5) the ECP Manager.

Issue Date: 07/26/18 4 93100

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

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

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

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

During these interviews, the inspectors may use the guidance in Appendix 1 to IP 71152 and should ask interviewees to describe the following:

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

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

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

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

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

Issue Date: 07/26/18 5 93100

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

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

(a) Are you aware of any event or change in circumstances within the last 18 months that could have discouraged any staff member from identifying a safety concern? If so, please describe the situation.

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

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

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

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

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

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

(a) their confidence (and the basis for that confidence) that concerns identified in the ECP will be adequately addressed (b) their confidence (and the basis for that confidence) in the ECPs ability to protect their identity (c) how site management promotes use of the ECP

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

Issue Date: 07/26/18 6 93100

(a) How do you define the term Safety Conscious Work Environment? (Note:

if the interviewees do not clearly understand the term, thank them and explain how the NRC defines SCWE before continuing.)

(b) In what ways does your management support a SCWE?

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

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

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

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

93100-04 RESOURCE ESTIMATE It is estimated that this procedure will take 60-80 hours to complete.

93100-05 PROCEDURE COMPLETION Meeting the inspection objectives defined in Section 93100-01 of this IP will constitute competition.

93100-06 REFERENCES IMC 0305, Operating Reactor Assessment Program IP 40001, Resolution of Employee Concerns IP 40100, Independent Safety Culture Assessment Follow-up IP 71152, Problem Identification and Resolution Issue Date: 07/26/18 7 93100

IP 95003.02, Guidance for Conducting an Independent NRC Safety Culture Assessment MD 8.8, Management of Allegations NRC Enforcement Policy END : Revision History Issue Date: 07/26/18 8 93100

Attachment 1 - Revision History for IP 93100 Commitment Accession Description of Change Description of Comment Resolution Tracking Number Training Requires and Closed Feedback Number Issue Date and Completion Form Accession Change Notice Number (Pre-Decisional, Non-Public Information N/A 08/18/11 Initial issue. Researched commitments for 4 Focus group ML110410424 CN 11-013 years and found none. Issued to provide facilitation training ML110100229 guidance to inspectors for the follow-up of will be complete safety-conscious work environment issues. before use of this procedure.

On-going N/A ML15090A433 Editorial changes for consistency with N/A N/A 04/09/15 terminology and changes to the original SCCIs CN 15-005 N/A ML18207A135 Editorial updates to meet 5 year metric N/A N/A 07/26/18 CN 18-022 Issue Date: 07/26/18 Att 1-1 93100