ML20195H707

Draft NRC Inspection Manual,Inspection Procedure 71152, Identification & Resolution of Problems

ML20195H707
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Issue date:	05/14/1999
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71152, NUDOCS 9906170116
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NRC INSPECTION MANUAL IoMB

' Inspection Procedure 71152 IDENTIFICATION AND RESOLUTION OF PROBLEMS PROGRAM APPLICABILITY: 2515 CORNERSTONES: Initiating Events Mitigating Systems Barrier Integrity Emergency Preparedness Occupational Radiation Safety Public Radiation Safety Physical Protection INSPECTION BASIS:

I An effective problem identification and resolution program is an important means of maintaining a sufficiently low level of risk by correcting deficiencies involving people (i.e. , training, knowledge and skills), processes (i.e. ,

procedures and programs), and equipment (i.e., design and maintenance) before they manifest in a significant event affecting health and safety of workers or the public. This inspection is conducted because none of the established Performance Indicators (PIs) cover this area.

71152-01 INSPECTION OBJECTIVE (S)

L 01.01 To ensure that the licensee has effective programs for identifying, evaluating, and correcting problems which could impact the cornerstone objectives.

01.02 To ensure that the licensee has effective programs for correcting and l limiting non-compliance with NRC regulations.

71152-02 INSPF.CTION REQUIREMENTS 02.01 Problem Identification In Plant Status

a. Incorporate checks of problem identification in the Plant Status inspection procedure as described in inspection requirement 02.04, 9906170116 99o52o 5 PDR REVGP ERGNUMRC PDR ,

Issue Date: 05/14/99 71152 DRAFT a %DL, j 101/ L

Problem Identification" of that procedure. This is not direct inspection effort (DIE).

02.02 Problem Identification and Resolution In Other Insoectable Areas

a. Incorporate checks of problem identification and resolution in ongoing inspection activities for other inspectable areas for all cornerstones.

Within the scope of those inspections, inspect activities interview staff, and review documents to determine if the following activities are being conducted in an effective and timely manner commensurate with their importance to safety and risk:

1. Initial problem identification, characterization, and tracking.

2. Disposition of operability /reportability issues.

3. Evaluation of safety significance / risk and priority for resolution.

4. Identification of repetitive problems and extent of the condition.

5. Identification of root cause or contributing causes

6. Identification and implementation of corrective actions which will achieve lasting results. Does field verification show actions have been completed as stated by the licensee.

7. Resolution of non-cited violations (NCVs) tracked in corrective action system (s).

8. Implementation / consideration of risk significant operational experience feedback.

Emphasis should be placed on ensuring problems are identified, characterized, prioritized, entered into a corrective action program, and l resolved commensurate with their risk significance.

02.03 Annual Problem Identification and Resolution Insoection i a. Plan the inspection. Review a sampling of probleni identification and resolution documents to identify areas where insJection would be most beneficial. The inspection leader should meet wit 1 Region NRC staff and management to determine the appropriate areas in which to concentrate the inspection based on potential risk significance. Based on these reviews and meetings, select a sample of Non-cited Violations TNCVs) and licensee identified problems representing each of the cornerstones for detailed review. Also determine who will participate in the inspection and brief them on siw specific insights to further assist them in selection of specific items to inspect.

b. Review problem identification and resolution findings from the PIM. and from plant status and other inspectable reas for corrective action related issues (e.g. unresolved issues, repetitive issues, etc.). Look beyond the individual system or activity importance. Look at the potential impact on the plant as a whole. 'Look for any trends in corrective action issues and the basis for those trends.

c. Conduct detailed checks of problem identification and resolution activities for the Non-cited Violations (NCVs) and licensee identified problems selected during inspection planning. Inspect activities.

DRAFT 71152 Issue Date: 05/14/99

interview staff, and review documents to determine if the following activities are being conducted in an effective and timely manner  !

commensurate with their importance to safety:

1. Initial problem identification, characterization, and tracking. '

2. Disposition of operability /reportability issues.

3. Evaluation of risk significance and priority for resolution. l

4. Identification of repetitive problems and extent of the condition.

5. Identification of root cause or contributing causes. l

6. Identification and implementation of corrective actions which will achieve lasting results. Does field verification show actions have been completed as stated by the licensee.

7. Resolution of Non-Cited Violations tracked in corrective action system (s).

8, _ Implementation / consideration of risk significant operational experience feedback.

The focus of the detailed inspections should be a comprehensive review of the corrective actions being addressed for those issues. Emphasis is placed on identification of root.cause or contributing causes and other activities associated with resolving problems after they have been identified. If new or repeat problems are identified during the course )

of this inspection. they should be evaluated, documented, and assessed for risk significance using the Significance Determination Process. l Likewise, this inspection may be used as a means for evaluating the collective risk significance of concurrent safety issues,

d. Review the licensee's self-assessment activities across all cornerstones.

This includes management, QA organization, audit organization and safety review committee oversight of the problem identification and resolution process. Inspect activities, interview staff, and review documents to determine:

1. Is recent equipment / plant / activity performance consistent with licensee self-assessment findings and the scope of those assessments?

2. Are licensee self-assessment findings consistent with NRC inspection findings and third party audits?

3. Are self-assessment find 1ngs prioritized, tracked and effectively corrected in a timely fashion?

4. Is a trending / monitoring program for identifying recurring problems being effectively implemented?

5. Is the overall self-assessment program effectively reviewing areas as required by programs such as the licensee's quality assurance plan audit program and the maintenance rule program?

Emr.hasis should be placed on the effectiveness of licensee oversight activities at identifying, evaluating, and resolving risk significant issues. The level of effort in this inspection item may be adjusted based on findings from 02.03(b) and 02.03(c).

e. While conducting other inspection activities, and particularly during interviews, determine if- problems could exist in the licenee's safety issue identification environment. l Issue Date: 05/14/99 71152 DRAFT l

p 1

! If any indication of a " chilling"~effect is suspected, inform regional l

management for further review and follow-up.

71152-03 INSPECTION GUIDANCE l General Guidance ,

l This inspectable area will determine whether the licensee has an effective problem identification and resolution program. Inspection in this area supports all seven cornerstones. No PIs cover this area. However. PIs developed for each cornerstone may provide some insight which may reduce the overall inspection i effort in this area.

To the extent possible. this inspection should follow a performance based i approach. Emphasize the products and results, and work backwards through the i processes and activities, programs and policies and regulations and standards, if necessary. Therefore, this inspection will concentrate on the identification of problems and the effectiveness of corrective actions rather than on the .

corrective action _ program description and associated procedures. l Sampling performed during this inspection should determine whether: (1) the licensee's assessments of problems and issues were of sufficient scope to address the key attributes of the cornerstones: (2) the risk significance of the findings l was assessed: (3) root cause analyses and corrective actions were timely and l adequate to prevent recurrence: (4) industry and NRC generic issues were .

considerec (5) recurring issues were identified, and (6) required reports to the I Commission were made.

l When checking / sampling / selecting (systems, issues, problems, etc.) is called for in this procedure, use the following guidance. The inspector will make the selection using insights gained from: 1) high safety significant systems / functions identified by the Maintenance Rule. 2) site specific PRA results. 3) the Risk Information Matrix No. 2 in SECY 99-007, or 4) the potential to compromise the objectives of any cornerstone. Guidance from specialist and management can be sought, as needed.

Various licensee organizations may use individualized problem identification and resolution processes within each department, or they may use a common, plant-wide process. Include items from each 6f those processes in the inspection sample.

When multiple corrective action processes exist, determine whether the licensee's organizations adequately irxeract to ensure that all deficiencies required to be in the corrective action programs are captured, root cause or contributing causes are determined, and corrective actions are performed, tracked, monitored, and .

trended as needed. Regardless of the organization of the licensee's program, the l focus of the inspection is on the licensee's effectiveness in identifying. I resolving and preventing risk significant problems that could impact the  !

cornerstone objectives.

With limited exceptions. Severity Level IV violatioas will be identified as non- l cited violations (NCVs) and not require a response by the licensee or a formal j closure by the NRC. This policy is based on the assumption that corrective action programs developed by licensees have attained a level of proficiency sufficient to reliably evaluate and correct issues of this type. As a result of DRAFT 71152 Issue Date: 05/14/99 I

this policy, individual NCVs will be closed out based on evidence that the issue has been placed into the licensee's corrective action program. The corrective actions for each individual NCV will not be inspected. Instead, the focus will be on the overall effectiveness of the licensee's corrective action program. To this end, a sample of NCVs should be reviewed alongside similar licensee-identified problems to ensure that the licensee's disposition of these issues is adequate.

The general standards fo'r acceptable problem identification and resolution actions are:

. The problem is identified in a timely manner commensurate with its significance and ease of discovery.

. Identification of the problem is accurate and complete. and includes consideration of the generic implications and possible previous occurrences.

. Operability /reportability issues are dispositioned.

. The problem report is classified and prioritized for resolution commensurate with its safety significance.

. The root cause(s) of the problem (or all contributing causes, as appropriate), are identified when required. Corrective actions are appropriately focused to address the root causes or contributing causes and to prevent recurrence of the problem.

. Corrective actions are completed in a timely manner with respect to safety significance.

Irrespective of the above listing, the ultimate standard for evaluating corrective actions is the reasonableness and effectiveness of those actions as they pertain to the nature and significance of the identified problem. As long as the corrective actions acceptably address the identified causes and no other credible causes exist, the licensee's actions should be considered acceptable.

Findings should be documented in sufficient detail to allow management to assess the need for additional inspection in this area. The report should also provide l sufficient detail to explain the importance of findings for problems having importance beyond the individual system importance. All negative findings from the inspection requirements should be documented, regardless of their individual importance. They will be important in determining the overall effectiveness of the problem identification -and resolution process.

NRC personnel will not take possession of INP0 evaluation documents, make copies for distribution, identify any INP0 documents in inspection reports, or use these documents to form a basis for regulatory actions. Refer to Field Policy Manual No. 9. "NRC Review of INP0 Documents." for additional guidance.

The term " problem" in this procedure is synonymous with conditions adverse to quality and any other condition or defect that may be detrimental to plant, worker or public safety. The term " licensee controls" in this procedure includes all licensee activities associated with the resolution of problems. These Issue Date: 05/14/99 71152 DRAFT

I L

) activities include actions to identify, assess, and prevent problems related to l safety issues, regulatory issues, and substandard performance of personnel and l

equipment. Typical problem identification and resolution systems that could be reviewed include: Logs, Licensee Event Reports, non conformance reports. I deficiency reports, engineering work requests, corrective a,ction requests, safety l committee action items. and other self-assessment reports / audits.

Soecific Guidance l l 03.01 Problem Identification In Plant Status Procedure.

l Problem identification in the Plant Status procedure is reactive in nature. It is most focused on near-term problem identification activities as the problems ,

happen. Such activities include the initial identification, characterization and l classification of the problem. This should include initial disposition of l operability /reportability issues, evaluation of safety / risk significance and j priority for resolution. The Plant Status procedure is designed to allow the l resident inspector to maintain an awareness of plant conditions and maintain a 1 knowledge of planned and ongoing activities. It is not considered DIE. Section 02.01 is included here as a reminder of the role of the Plant Status procedure l in assuring problems are identified.  !

03.02 Problem Identification and Resolution In Other Insoectable Areas Periodic inspections of problem identification and resolution issues are part of l ongoing inspection efforts in the other inspectable areas. Those procedures will 1 l provide specific details beyond the general requirements of this procedure (e.g.  !

frequency and specific issues to review), as needed. The scope is normally limited to problem identification and resolution of issues within the scope of the inspection for those other inspectable area (s). Inspection requirement item 02.02(a) ensures that basic problem identification and resolution activities are being completed within this scope. Emphasis should be placed on ensuring problems are identified, characterized, prioritized, entered into a corrective action system, and resolved in a timely manner.

Within the scope of the inspection being conducted, identify any issues that should have been identified on corrective action documents but were not. Also look for adverse trends or patterns (e.g. recurring or longstanding problems) which were not identified as such, and any other issue showing a lack of effectiveness in identifying and correcting problems. Possible areas to review include:

a. Operational events, testing, or maintenance activities (such as temporary repairs or troubleshooting activities).

b. Deficiencies or modifications requiring safety evaluations or operability determinations.

c. Procedural adherence deficiencies and procedure change backlog.

d. 0A audits and self-assessments.

DRAFT 71152 Issue Date: 05/14/99

1 I

e. Maintenance history, significant equipment problems, age of equipment problems, rework repetitive equipment deficiencies.

f. Other corrective action documents or other events or issues that may indicate weaknesses.

g. Any other program that identifies issues or problems that are not considered as being adverse to quality (e.g., plant support areas. "fix-it-now" programs, work requests and work orders, test failure reports, etc.).

Emphasize problems which involve equipment or activities with a relatively high significance based on 1) high safety significant systems / functions identified by the Maintenance Rule. 2) site specific PRA results. 3) the Risk Information Matrix No. 2 in SECY 99-007. or 4) the potential to compromise the objectives of ,

any cornerstone. Do not neglect issues that if taken collectively could be risk l significant or precursors to risk iignificant problems. j 03.03 Annual Problem Identification and Resolution Insoection 03.03(a) Plannina i To plan for the inspection, collect and review problem identification and ]

resolution findings from periodic inspections in other inspectable areas since i the last annual inspection. Also obtain and review a listing of non-cited violations (NCVs) identified during the last year. Look for problems and trends in licensee controls identified during these reviews. Obtain, through discussion {

and inspection report or PIM review, the resident inspector's assessment of the overall effectiveness of the licensee's corrective action program.

If necessary compliment the above review by obtaining and briefly reviewing a sampling of other problem identification and resolution documentation to identify potential areas to address in the inspection. Try to gain an impression of overall licensee performance. Select documents of activities in those areas in which deficiencies are known or suspected to exist. Ensure all cornerstones are I included in the sample. l l

Consider the following:

a. Review problems in licensee controls identified in performance reviews (PPRs), enforcement history, the Plant Issues Matrix. performance indicators.11censee event reports (LERs), operating activities, licensee maintenance rule periodic evaluation reports. NRC management trip reports; and management meeting reports.

b. Review the results of a srple of licensee self-assessments. Select a sample of self-assessments where potentially risk significant issues are known or suspected to ex5t. Place special emphasis on the conclusions and corrective actions.

c. Obtain and review documentation on licensee efforts to identify. resolve and prevent structure, system and component (SSC) performance problems through performance monitoring, goal setting, root cause analysis, cause Issue Date: 05/14/99 71152 DRAFT

t determination and corrective action to meet the monitoring requirements of the maintenance rule (MR) (10CFR50.65),

d. Obtain and review other documents that would be valuable for the in-office review, such as a list of corrective action documents issued from the time of the last Identification and Resolution of Problems inspection l (e.g. a list of work orders, work requests, temporary modifications, calibration failures, condition / problem identification reports, operability evaluations and determinations, etc.).

f. Obcain licensee administrative procedures that control the l identification, evaluation, and resolution of problems. Selected lic insee documents needed to support the inspection may be obtained ouring a pre-inspection trip to the site or requested to be available when the inspectors arrive on site. 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 1

and efficient inspection.

At some point during or after this review, the inspection leader should meet with Region management and appropriate specialists. With management endorsement, determine the areas to concentrate the inspection on based on past observed performance and the potential safety / risk significance.

Select a sample of Non-cited Violations (NCVs) and licensee identified problems for detailed review. Although some cornerstones may be emphasized based on this brief review, ensure all cornerstones are still represented in the sample.

Emphasize systems or activities with a relatively high significance based on 1) high safety significant systems / functions identified by the Maintenance Rule, 2) site specific PRA results, 3) the Risk Information Matrix No. 2 in SECY 99-007, or 4) the potential to compromise the objectives of any cornerstone. However, do not neglect issues that if taken collectively coulri 5e risk significant or precursors to risk significant problems.

Guidance on the number and nature of NCV's and licen'see identified issues to include in the detailed review is:

Approximately 20 percent of the NCVs issued over the past two years should be reviewed, or at least two, whichever is greater. Select approximately 3 l licensee-identified issues for each NCV or a minimum of 15-20 issces.

Increase the sample size if necessary to ensure all cornerstones are represented. Selection should be based on maximizing the following:

. Items'that have not been previously reviewed in detail by the NRC 4

= Items that affect risk significant systems, functions and worker /public safety (though not necessarily excluding other systems and functions that are important to safety)

- Items that involve many functional disciplines or cornerstones

. Items that likely involve complex corrective actions l

Based on all of the above, determine the overall scope of the inspection, who will participate in the inspection, and the estimated inspection resources required. Typically two inspectors with part-time resident and specialist DRAFT 71152 Issue Date: 05/14/99

participation might be expected. Full-time, part-time, and brief consultation expertise should include a broad range of skills-(e.g. engineering, maintenance.

radiation protection, security, emergency preparedness). The inspection leader should brief those involved on the inspection scope and any site specific insights, as appropriate, to further aid in selection of specific items to inspect.

03.03(b) Review uf Plant Status and Other Insoectable Area Findinas Many inspection findings from other inspectable areas may have little impact on the cornerstones when taken individually. However, when the corrective actions for such findings are looked at collectively, potentially risk significant issues may emerge. Therefore, the inspector should not necessarily approach this inspection solely based on individual system or cornerstone importance. The potential impact of the root cause or contributing causes and collective impact of the corrective action' backlog on the plant as a whole should be sought.

Unidentified or' uncorrected root cause or contributing causes and improper identification of significance by the licensee for multiple corrective action items could lead to increasing common cause event rates, human event rates, and <

to breakdowns in multiple cornerstone areas. For example, an individual procedural adherence problem may have no risk significance. However, multiple procedural adherence problems in the Occupational Exposure. Initiating Events and Barrier Integrity cornerstones could. j Annual inspection requirement item 02.03(b) for the review of problem identification and resolution issues identified as part of other inspectable area inspections is not intended to duplicate those inspections. The findings from those inspections are reviewed here to look beyond their individual importance and to look at the potential impact on the plant as a whole. The review should look for root causes, common causes, contributing causes, unresolved issues, repetitive issues and other trends in corrective action issues. It should also look for cases where potentially risk significant combinations of problems could have existed during the same time frame, but were not identified as such by the licensee. Such issues may not always be apparent from individual inspection efforts in other inspectable areas.

1 03.03(c) Detailed Review of NCVs and Licensee Identified Problems I Conduct a comprehensive review of the corrective action issues for the NCVs and licensee identified problems selected during inspection planning. Emphasis is '

placed on identification of root cause or contributing causes, and other problem resolution activities for problems previously identified rather than identifying new problems. However. if new or repeat problems are identified during the course.of this inspection, they should also be noted, evaluated and documented.

This detailed analysis should be of sufficient depth to technically understand the problems, to evaluate why they occurred, and to determine the roles played by the quality verification organizations and line management in the identification and resolution of issues. In addition to the problem identification and resolution inspection requirements listed for 02.03(c) the analysis might also include:

• Determining the chain of events leading to the occurrence of the problem.

Issue Date: 05/14/99 71152 DRAFT

o Developing an understanding of the technical and work activities

! associated with the problem, o Determining the information that is needed for understanding the generic '

implications of the problem, and if such generic implications were identified by the licensee, o Determining the extent to which the licensee identified precursors and investigated the facts surrounding the problem, )

Root Cause or Contributina Causes Guidance:

While reviewing problems, be alert for cases where the licensee may have classified a significant problem as non-significant. Some aspects that can be considered when determining the significance of issues include the impact on plant system functionality, the consideration of whether regulatory requirements have not 'been fulfilled, and the scope of the adverse condition (1scicted vs.

generic).

Once a problem has been determined to be significant, determino if a root-cause analysis was conducted when it was required, and evaluate the effectiveness and validity of the evaluations. Also look for cases in which the corrective actions were insufficient, ineffective, or not timely. Consider the scope of the corrective actions to ensure that similar components and activities have not been l overlooked.

Do nct defer from pursuing problems in the balance of plant area when the analysis indicates the primary cause was in that area. Determine whether the licensee's maintenance rule monitoring program captures these balance of plant problems. If permanent action to correct the problem takes an excessive amount of time, as in the case of significant plant modifications, ensure that interim action was taken to control or minimize the problem until the permanent action

-l could be implemented. Effective problem resolution may involve several overlapping causes. For these complex problems, multiple corrective actions may be appropriate. For areas where all contributing causes are not addressed, reinspection for recurrence of similar problems should be conducted.

Doeratina Exoerience Feedback Guidance:

Consider any indicators of the adequacy of the licensee's implementation of operational experience feedback discovered during performance of other sections of this procedure to determine if additional evaluation is needed. Consider the following additional inspection activities:

a. Evaluate the adequacy of the licensee's implementation of corrective actions. for operational experience feedback. Focus on the licensee's effectiveness to assess, to inform appropriate personnel of the results, and to initiate corrective actions for information obtained both within and outside the licensee's organization. Consider the following sources of information: [D0 NOT EXPEND INSPECTION RESOURCES READING THESE DOCUMENTS IF CORRECTIVE ACTIONS ARE NOT INVOLVED)

1. 10 CFR Part 21 notifications.

-DRAFT 71152 Issue Date: 05/14/99

2. NRC bulletins, generic letters, and information notices.

3. Reports issued by NSSS vendors.

4. Reports from other facilities under the licensee's control or from similar facilities (with respect to design and vintage).

5. EPRI reports.

b. Identify any strengths or contributing conditions which reflect a lack of efiactiveness in licensee programs that implement operational experience feedback.

c. Review the implementation of tracking and trending programs utilized by the licensee for identifying and closing out action items associated with the operational experience program. Review the implementation of the more significant action items associated with training programs, procedures, and corrective action progcams to ensure the recommendations have been implemented and concerns have been add.ressed.

d. Select and evalur...e the most significant item (s) in each cornerstone area, or sample li depth operating experience in a specific area (e.g.

motor-operated valve performance, stress corrosion cracking, etc.), as appropriate. The evaluation will provide an overall assessment of the licensee's programs for implementing industry lessons learned. Since the industry information is usually provided to the licensee as recommendations, focus on the applicability of the recommendations to the licensee and how the recommendations were handled.

03.03(d) Self-assessment Activities Guidance:

The licensee's effectiveness in verifying the corrective action process itself is working is an integral part of the problem identification and resolution process. The level-of effort for this inspection area may be adjusted based on findings from 02.03(b) and 02.03(c). The more that basic problem identification and resolution problems are found or suspected, the more'that effort should be expended in determining if the licensee is also identifying and addressing these problems. On the other hand, if few or minor basic problem identification and resolution problems are found, then only a relatively limited review of self-assessment activities may be in order. Also consider additional sampling of the licensee's self-assessment process if: (1) recurrent isst. s or potential risk ,

significant findings are identified: or (2) adequate corrective actions were not taken in response to a declining trend or performance above a PI threshold. The amount of additional sampling should address whether or not licenece self-assessment efforts detected or should have detected the issues you identified and how they were handled. Consider the following inspection activities;

a. Evaluate the significance of a sample of self-assessment findings to determine the effectiveness of the self-assessment effort. If relatively few significant findings are identified, review the scope of the self-assessment and the qualification of the plant staff involved in the self assessment. Determine if the self-assessment findings are consistent Issue Date: 05/14/99 71152 DRAFT

with previous inspection findings, plant performance, and third-party l I

audits / reviews.

b. Review corrective actions associated with self-assessment reports, audits (including audits of both onsite and offsite safety committee activities), and evaluations. Determine if the licensee is correcting self-assessment findings. Determine whether the corrective actions are prioritized, tracked, adequate, and timely.

c. Determine if a trending program has been implemented and that it provides sufficient information for identifying recurring problems. Determine if it is being used in self-assessments.

d. Evaluate the overall self-assessment program to ensure that the major j functional areas are reviewed as required by the quality assurance audit program. The self-assessment program should also ensure that the maintenance rule program is adequately monitoring the effectiveness of maintenance and taking corrective actions when maintenance problems are found.

e. Interview selected individuals involved with the oversight function, as well as the audited organizations. Are the oversight and audited organizations both aware of the current status of corrective actions taken or planned to address the findings? Is there any apparent communication problem between the oversight and audited organizations regarding the findings?

f. Review licensee performance data and discuss anomalies and trends with management. Is management aware of those issues and any actions planned or taken to address them?

g. Does the quality organization meet with upper line management? What oversight issues were discussed? Have the issues been resolved? Are there any oversight findings or lack of response in correcting findings which should have been discussed with line management but were not? ,

h. Determine whether quality activity reports, assessments, and audits accurately reflect the findings and observations of the auditors, to ensure that management is receiving a complete and unbia:ed perspective of the plant's quality achievement and deficiencies. To assess organizational independence, determine whether reports have been revised by line management in a manner that has changed the substantive cor. tent of the report prior to exit meetings or final documentation.

i. If possible, witness the performance of and/or preparation for a self-assessment by the licensee's assessors or auditors..

1 Safety review committees comprise another area of licensee self-assessment activities. Consider the following if reviewing their activities:

a. Determine if the committees have been aggressive in seeking out areas needing improvement, rather than just responding to events and information from outside sources. The inspector's review must be of sufficient depth and detail to provide an overall assessment of the DRAFT 71152 Issue Date: 05/14/99

committee's ability to identify, assess, and resolve issues. Effective safety committees will emphasize technical achievement over programmatic conformance.

b. Review the safety comittees' trending programs for tracking and analyzing adverse conditions, which include the identification of L

repetitive problems that are not readily apparent. Evaluate the licensee's trending programs based on a review of the adequacy of trends developed for repetitive problems, analysis of trended data, and timeliness of improvements, replacements, and modifications to systems or equipment. In developing these trends, the licensee should have considered the occurrences of problems that are related as well as those that are identical. Additionally, trending should not be reserved for 4 systems and equipment: trends can also be invaluable to managers in identifying and correcting personnel performance issues. Consider the effectiveness of the safety committees to communicate the results of trending analyses to managers, Er.d the managers' subsequent involvement 1 in resolving related issues. Consider any other indicators of safety I committee effectiveness discovered during performance of other sections (

of this procedure to determine if additional evaluation is needed. '

c. Interview, at random, selected members of the safety committees to get {

their insights into. organizational buy-in and management commitment to  !

the comittee recommendations and decisions,

d. Evaluate the effectiveness of the safety comittees by reviewing comittee minutes, audits, or other actions initiated by the committees as they . relate to major corrective action successes or failures.

J Consider the following i

a. -Identify what issues are reviewed by the safety committees and j review the actions initiated by the safety committees to identify, )

assess, and correct areas of weakness.

l

b. Review safety committee activities and discuss specific activities with selected safety committee members or safety committee support staff to gain insights and to assess the committee's effectiveness, work load, and ability.

c. Select audits conducted under the cognizance of the offsite safety committee and determine if the audit findings were consistent with such external assessments as NRC and consultants.

d. Evaluate the licensee's follow-up to items identified by the safety committees, including committee-initiated audit findings and any recurring problems.

The exact organizational arrangement for safety review at each licensee will differ. Whatever the organizational arrangement, there must be serious management commitment to safety review, and safety review officials must have the requisite abilities, experience, and authority to produce high-quality technical work.

Issue Date: 05/14/99- 71152 WAFT  !

03.03(e) Safety Issue Identification Environment Guidance:

In conducting interviews or other activities with licensee personnel during the inspection, be sensitive to areas where employees may be reluctant to raise concerns. Although the licensee may be implementing an employee concerns 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 the inspector should be alert for such indications.

The inspectors should conduct interviews where the workers feel comfortable (e.g.

.in their work environment). Select personnel for the interviews at random and do not allow the licensee to select the interview candidates.

Appendix 1 to this procedure provides guidance on preparing for the inspection and provides a list of questions that will help an inspector prepare for any subsequent interviews. If, as a result of the interviews, the inspector becomes aware of specific examples of employees being discouraged from raising safety or regulatory issues within the licensee's or contractor's organization or to the NRC, the inspector should get as complete a set of facts as possible. If the inspector becomes aware of a reluctance of employees to raise safety or regulatory issues unrelated to a specific event or incident, continue pursuing the issue during the remaining interviews and try to determine the reason employees are reluctant to raise issues. However, if any indication of a

" chilling" effect is suspected, inform regional management for further review and follow-up.

71152-04 RESOURCE ESTIMATE Identification and Resolution of Problems inspection incorporated in inspection efforts in other inspectable areas will involve approximately 5% - 10% of the effort in those areas.

The annual inspection will involve approximately 100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br /> including part-time participation by the resident.

71152-05 REFERENCES SECY-99-007. " Recommendations for Reactor Oversight Process Improvements" Nuclear Management and Resource Council. NUMARC 93-01, " Industry Guideline for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants" U.S. Nuclear Regulatory Commission. Regulatory Guide 1.160, " Monitoring the Effectiveness of Maintenance at Nuclear Power Plants" END DRAFT 71152 Issue Date: 05/14/99 m

APPENDlX 1 - GUIDANCE FOR CONDUCTING INTERVIEWS In preparing to conduct the interviews, the inspector should review allegations received in the last 12 months to determine if the NRC has received or confirmed any allegations of discrimination or chilling effects. The inspector should also determine if the allegations are coming from specific portions of the licensee's or contractor's organization. To the extent the information is available, the inspector should determine if there been an unexplainable change in the number or nature of concerns raised by employees to the licensee's corrective action program or employee concern program or the NRC.

Suaaested Questions

1. How would the interviewee raise a safety or regulatcry issue (e.g. inform supervisor, corrective action program ECP, NRC)? i

2. Why would they pick that approach (e.g. supervisor's preference, trying to keep numbers down, system difficult to use)? ,

3. Has the person being interviewed ever submitted .an issue to the q corrective action program or the ECP? Was the issue adequately 1 addressed? If not, did he or she pursue the issue? If not, why not? )

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4. Does the interviewee know whether employee concerns are tracked to completion and whether employees are informed of the result?

5. Does the interviewee believe the licensee's corrective action programs are successful in addressing issues submitted?

6. Is the interviewee aware of any specific instances in which another employee submitted an issue to the corrective action program or ECP and considered the licensee's response incomplete or unacceptable or was retaliated against for pursuing the issue? (Try to get enough specific information to followup with the other employee.)

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7. Does the interviewee believe there has been a change in the amount of time necessary to resolve corrective action issues or employee concerns?

8. Is the interviewee aware of or have there been interactions with NRC personnel that suggest that some employees may be hesitant to raise concerns or present information to the NRC?

9. Is the interviewee aware of any events that would discourage employees from raising concerns (e.g. chastisement for submitting issues to .

corrective action program. ECP, or NRC: supervisors holding up submittal of concerns).

10. Has there been an unexplainable change in the number or nature of concerns raised by employees to the licensee's corrective action program or employee concern program or the NRC7

11. Are there any unofficial corrective actions or tracking systems that exist because the existing formal systems are thought to be ineffective?  !

Issue Date: 05/14/99 71152 DRAFT

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(Unofficial corrective actions that bypass the recognized corrective action program have been previously in engineering and health physics areas.)

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• Issue Date: 05/14/99 i

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IP# 71153 INSPECTION PROCEDURE: Event Follow-up CORNERSTONES: All  ;

INSPECTION BASES: The focus of this inspection is to appropriately assess the significance of the event based on the performance of mitigating systems and barriers.

l LEVEL OF EFFORT: Events should be assessed by the resident inspector as they l occur to determine the significance. (Estimated hours - 3/ event) l 1

-01' INSPECTION OBJECTIVE I Perform initial evaluation of licensee events to determine facility status, adequacy of initial l licensee actions to mitigate the event, and to provide input to regional determination of whether '

reactive inspection resources are needed.

02 INSPECTION REQUIREMENTS:

l 02.01 EVENT RESPONSE: Make an initial determination of facility status and licensee actions l to mitigate the event. l

a. Observe plant parameters and discuss with the licensee the current plant status including the status of the fission product barriers. l

b. Evaluate the performance of the mitigating systems and actions taken by the licensee in order to determine the significance of the event.  ;

c. Confirm that the licensee has properly classified the event in accordance with the Emergency Plan and made timely off-site notification of the event when required.

The licensee should notify the NRC of any significant new developments or l changes in plant conditions. Determine if the licensee has identified the root I cause(s) of the event and implemented appropriate corrective action (s) before starting the reactor. j

d. Discuss findings related to the event with regionel management so that a determination can be made of whether reactive inspection resources are needed.

02.02 EVENT REVIEW: Review and disposition written event reports.

03 INSPECTION GUIDANCE:

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r GENERAL The Event Follow-up procedure is intended to allow events to be evaluated so that the NRC can determine whether the event falls outside the baseline inspection program. Events that fall outside the baseline program are those that meet the criteria to be a Significant Operational Event as descnbed in Management Directive 8.3, NRC incident Investigation Program or those that activate NRC emergency response facilities under the NRC Emergency Response Plan.

All other events can be evaluated within the baseline program using the comerstone

' inspectable area procedures shown in the flow chart for the event follow-up process. The need for prompt follow-up using inspectable area procedures should be based on an issue being a

' potential Significance Determination Process (SDP) candidate; otherwise it should be saved for the identification and Resolution of Problems team inspection.

Events deserving prompt evaluation include those events reported to the NRC under the Code of Federal Regulations ( 10 CFR 50.72,10 CFR 20,10 CFR 50.9,10 CFR 73.71,etc.).

I Events deserving prompt follow-up are reactor trips during power operation including those with subsequent complications, reactor trips resulting from a manual trip signal; transients that ordinarily would, but fail to, result in an automatic trip signal; and transients that do not result in a reactor trip but result in plant conditions that deviate significantly from normal operating conditions. Also included are those events that significantly threaten the effectiveness of

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security systems; result in unplanned releases of radioactivity; and fires that affect containment integrity or disable safety functions provided by mitigating systems, .

03.01 EVENT RESPONSE

a. The inspector should independently observe plant parameters and plant conditions. The discussion with the licensee should focus on developing a full understanding of the event including those alarms or conditions that preceded or gave indication of the event. The inspector should not distract the licensee from responding to the event. The discussion can wait until the licensee has placed ,

the plant in a stable condition and the appropriate personnel are available. Many i I

licensees conduct debriefs immediately after the event which is an attemative way to gain the desired information.

b. Based on the description of the event, the inspector should have sufficient

' information to determine which mitigating systems should have been activated by the event. The inspector can then confirm that the mitigating equipment activated as required. Licensee actions may also be part of the mitigating '

strategy or may be the mitigating strategy. The inspector should confirm that those mitigating actions were taken. <

c. The licensee should impler:.ent the Emergency Plan through the Emergency Achon Level procedures which would provide the basis for the proper classification of the event. Notifications would include the NRC and State and l County govemments ( 10 CFR 50.72, 10 CFR 20,10 CFR 50.9, etc.)..

d. The inspector and Regional management should consider whether the plant is stable and whether Emergency Operating Procedure recovery actions are complete when deciding when to terminate event response. NRC Management 4/21/99 DRAFT 2 DRAFT

l should consider the risk significance when determining what, if any, further review is necessary on a non-prompt basis. The criteria for those issues should be whether they could be an SDP candidate. The inspector should pursue the issue (s) in the appropriate inspectable area.

The NRC response will be considered outside the baseline inspection program if the NRC Emergency Response Plan or the Incident investigation Program have been implemented.

03.02 EVENT REVIEW: The inspectors should review all written event reports. Reports which describe issues that are of low risk significance, as determined by the SDP process, should received a limited review. The review should determine if the cause of the event is accurate and if corrective actions will prevent recurrence. For issues which are not adequately addressed and the issue could be an SDP candidate the inspector should pursue the issue through the appropriate inspectable area.

-04 RESOURCE ESTIMATE Events should be assessed by the resident inspector as they occur to determine the significance. This is estimated to take approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> per event.

-05 REFERENCES NUREG-0728, "NRC incident Response Plan," (NUDOCS assession #8706240202)

NUREG-0845, " Agency Procedures for the NRC incident Response Plan," (NUDOCS assession #8303090505)

Management Directive 8.3, NRC incident investigation Program l

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