IMC 0305, Operating Reactor Assessment Program

Operating Reactor Assessment Program

• 05/04/23 - https://www.nrc.gov/docs/ML2309/ML23093A184.pdf

• See also Inspection Manual Chapter (IMC)

text

0305-01 PURPOSE

01.01 The Operating Reactor Assessment Program evaluates the overall performance of

operating commercial nuclear reactors and communicates this information to licensee

management, members of the public, and other stakeholders. The Assessment Program

is part of the Reactor Oversight Process (ROP), which integrates the U.S. Nuclear

Regulatory Commission’s (NRC’s) inspection, performance indicator, assessment, and

enforcement programs applicable to operating reactors.

01.02 The Operating Reactor Assessment Program collects information from inspections and

performance indicators (PIs) to enable the NRC to develop objective conclusions about

a licensee’s safety performance. Based on this assessment information, the NRC

determines the appropriate level of its response, such as performing supplemental

inspections, conducting meetings with NRC and licensee management, or issuing orders

to shutdown plants. The assessment information and NRC response are then

communicated to the public, except for certain security-related information associated

with the Security Cornerstone that the Commission has determined to withhold from

public disclosure. The NRC conducts follow-up actions, as applicable, to ensure that the

corrective actions designed to address performance issues were effective.

0305-02 OBJECTIVES

02.01 To collect information from inspection findings and PIs.

02.02 To arrive at an objective assessment of licensee safety performance using inspection findings and PIs.

02.03 To assist NRC management in making timely and predictable decisions regarding appropriate NRC actions used to oversee, inspect, and assess licensee performance.

02.04 To provide a method for informing the public and soliciting stakeholder feedback on NRC’s assessment of licensee performance.

02.05 To provide a process to follow up on areas of concern.

0305-03 APPLICABILITY

This inspection manual chapter (IMC) applies to all operating commercial nuclear reactors except those sites that are under IMC 0350, “Oversight of Reactor Facilities in a Shutdown Condition Due to Significant Performance and/or Operational Concerns.” The contents of this IMC do not restrict the NRC from taking any necessary actions to fulfill its responsibilities under the Atomic Energy Act of 1954, as amended. A power reactor is no longer subject to this manual chapter after a licensee submits a written certification to cease operation in accordance with 10 CFR 50.82(a).

0305-04 DEFINITIONS

04.01 Action Matrix. A table (i.e., Figure 1) that categorizes various levels of plant performance

and identifies the range of NRC and licensee actions and the appropriate level of

communication for these various levels of performance.

04.02 Action Matrix Deviation. Any regulatory action taken that is inconsistent with the range of

actions described in the pertinent column of the Action Matrix, as described in detail in

section 11.06.

04.03 Action Matrix Inputs. Inspection findings and parallel PI findings that are used to

determine a plant’s Action Matrix column.

04.04 Annual Assessment Cycle. The assessment period from January 1st through

December 31st of each year.

04.05 Assessment Inputs. Information considered in the assessment process to determine

appropriate NRC actions.

04.06 Assessment Letter. A letter from the NRC to a licensee that communicates assessmentrelated information. Assessment letters include assessment follow-up letters, and annual

assessment letters.

04.07 Assessment Period. A period that contains four full consecutive calendar quarters. An

end-of-cycle assessment period is the annual assessment cycle from January 1st to

December 31st.

04.08 Cross-Cutting Area. Defined in IMC 0310, “Aspects within the Cross-Cutting Areas.”

04.09 Cross-Cutting Aspect (CCA). Defined in IMC 0310.

04.10 Cross-Cutting Issue (CCI). A CCI is a cross-cutting theme which has been identified in at

least three consecutive assessment letters.

04.11 Cross-Cutting Theme. For the cross-cutting areas of problem identification and

resolution (PI&R) and human performance (HU), a cross-cutting theme is reached when

six findings with the same CCA exist in the four quarters assessed during the second

quarter review and end-of cycle assessment period. For the Safety Conscious Work

Environment (SCWE) area, a theme exists with one finding in an 18-month assessment

period, or under circumstances described in section 14. A cross-cutting theme also

exists when there are at least 20 findings in the Human Performance area or at least 12

findings in the PI&R area during the second quarterly assessment review or end-of-cycle

assessment period.

04.12 Degraded Cornerstone. A cornerstone that has three or more White inputs concurrently

or one Yellow input.

04.13 IMC 0350 Process. An oversight process that oversees licensee performance,

inspections, and restart efforts for plants in shutdown conditions with significant

performance and/or operational concerns.

04.14 IMC 0375 Process. Provides guidance for implementation of the ROP for plants in an

extended shutdown condition for reasons not related to performance.

Issue Date: 05/04/23 3 0305

04.15 Multiple Degraded Cornerstones. Two or more cornerstones that are degraded

concurrently for any period of time.

04.16 Nuclear Safety Culture. Defined in NUREG-2165, “Safety Culture Common Language.”

04.17 Old Design Issue. An inspection finding involving a past design-related problem in the

engineering calculations or analyses, the associated operating procedure, or installation

of plant equipment that does not reflect a performance deficiency associated with

existing licensee programs, policy, or procedures.

04.18 Parallel PI Finding. A finding issued at the same significance level of a safety-significant

PI that acts as the Action Matrix input. This would be captured as an FIN within RPS with

no violation, SDP, or enforcement fields.

04.19 Plant Performance Summary (PPS). A document prepared by the regional offices and

used during the end-of-cycle meeting and Agency Action Review Meeting (AARM) (if

applicable) that describes assessment inputs and other pertinent information used to

develop a conclusion about a plant’s safety performance.

04.20 Regulatory Performance Meeting. A meeting held between a licensee and the NRC to

discuss corrective actions associated with safety-significant Action Matrix inputs.

04.21 Repetitive Degraded Cornerstone. A cornerstone that is degraded (three open White

inputs or one open Yellow input in a single cornerstone) for more than five consecutive

quarters with: (1) four or more concurrent White inputs (the additional White input(s) can

be from any cornerstone), or (2) one Yellow and one concurrent White input (the

additional White input can be from any cornerstone).

04.22 Safety-Conscious Work Environment. A work environment where employees feel free to

raise safety concerns and where concerns are promptly reviewed, given the proper

priority based on their potential safety significance, and appropriately resolved with

timely feedback to the originator of the concerns and to other employees."

04.23 Safety Culture. Refer to “Nuclear Safety Culture.”

04.24 Safety Culture Assessment. A comprehensive evaluation of the assembly of

characteristics and attitudes related to all of the safety culture attributes described in

NUREG-2165. Individuals performing the evaluation can be qualified through experience

and formal training.

a. An independent safety culture assessment is one performed by qualified individuals that

have no direct authority and have not been responsible for any of the areas being

evaluated (for example, staff from another of the licensee’s facilities, or corporate staff

who have no direct authority or direct responsibility for the areas being evaluated).

b. A third-party safety culture assessment is one performed by qualified individuals who are

not members of the licensee’s organization or utility operators of the plant (licensee team

liaison and support activities are not team membership).

04.25 Safety-Significant. Having greater than very low (i.e., Green) safety significance.

04.26 Significance Determination Process (SDP). The process described in IMC 0609 and

associated appendices that is applied to an inspection finding to determine its safety or

security significance as either Green (very low), White (low-to-moderate), Yellow

(substantial), or Red (high).

0305-05 RESPONSIBILITIES AND AUTHORITIES

05.01 Executive Director for Operations (EDO)

a. Oversees the activities described in this IMC.

b. Approves all Action Matrix deviations. [C1]

c. Informs the Commission of all approved Action Matrix deviations. [C1]

05.02 Director, Office of Nuclear Reactor Regulation (NRR)

a. Implements the requirements of this IMC within NRR.

b. Develops assessment program policies and procedures.

c. Ensures uniform program implementation and effectiveness.

d. Concurs on regional requests for Action Matrix deviations.

05.03 Regional Administrator (RA)

a. Implements the requirements of this IMC within its respective region.

b. Develops and issues assessment letters to each licensee.

c. Conducts assessment reviews and directs allocation of inspection resources within the

regional office based on the Action Matrix.

d. Establishes a schedule and determines a suitable location for involvement of the public

in the discussion of the results of the NRC’s annual assessment of the licensee’s

performance to ensure a mutual understanding of the issues discussed in the annual

assessment letter.

e. Suspends the end-of-cycle performance review for those plants that have been

transferred to the IMC 0350 process.

f. Chairs the end-of-cycle review meetings.

g. Initiates requests for Action Matrix deviations.

05.04 Director, Office of Public Affairs (OPA)

Issues press releases following the completion of the end-of-cycle reviews.

=== 05.05 Deputy Director, Division of Reactor Oversight (DRO)

a. Develops assessment program guidance.

b. Collects feedback from the regional offices and assesses execution of the Operating

Reactor Assessment Program to ensure consistent application.

c. Recommends, develops, and implements improvements to the Operating Reactor

Assessment Program.

d. Provides oversight of the end-of-cycle review meetings.

e. Confers with regional offices to align on proposals to not count old design issues in the

assessment process.

f. Confers with the regional offices to align on the supplemental inspection plans for plants

in Column 4 of the Action Matrix.

05.06 Regional Director, Division of Reactor Projects (DRP), Division of Reactor Safety (DRS), Division of Operating Reactor Safety (DORS), or Division of Radiological Safety and Security (DRSS)

a. Approves proposals by the regional offices to not count an old design issue in the

assessment process.

b. Approves the supplemental inspection plans for plants in Column 4 of the Action Matrix.

05.07 Director, Office of Enforcement (OE)

a. Provides any significant insights from the enforcement program to the regional offices

during the end-of-cycle review meetings.

b. Provides any significant insights from the NRC’s allegation program to the regional

offices in preparation for the end-of-cycle review meetings for discussions related to the

SCWE cross-cutting area.

05.08 Director, Office of Investigations (OI)

Provides any significant insights from OI to the regional offices during the end-of-cycle

review meetings.

05.09 Director, Office of Research (RES)

Provides any significant insights from RES to the regional offices during the end-of-cycle

review meetings.

05.10 Director, Office of Nuclear Security and Incident Response (NSIR)

Provides any significant licensee performance insights to the regional offices during the

end-of-cycle review meetings, and as needed to ensure regulatory responses are

appropriate.

05.11 Director, Office of Nuclear Material Safety and Safeguards (NMSS)

Provides any significant insights from NMSS to the regional offices during the end-ofcycle review meetings, and as needed to ensure regulatory responses are appropriate.

Issue Date: 05/04/23 6 0305

05.12 Director, Division of Operating Reactor Licensing (DORL)

Ensures operating reactor Project Managers provide significant insights from DORL to

the regional offices during the end-of-cycle review meetings.

05.13 Chief, Reactor Assessment Branch (IRAB), NRR/DRO

For a period of up to two years after plants have exited Column 4 or the IMC 0350

process, concurs on all assessment letters describing NRC actions beyond those

specified by the Action Matrix.

05.14 Regional Branch Chief

Responsible for continuously monitoring the performance of their assigned plants and

discussing that performance at annual assessment meetings, reviewing performance

indicator data, meeting with licensee management in regulatory performance meetings,

and developing inspection plans consistent with plant performance in the Action Matrix.

0305-06 ASSESSMENT PROCESS OVERVIEW

Licensee performance is reviewed over a 12-month period as part of the Operating Reactor

Assessment Program (Figure 2). The continuous assessment process includes the

determination of a plant’s Action Matrix column, as described in sections 10, 11, and 12. The

assessment process also includes performance reviews, as described in section 7, program

reviews, as described in section 8, and public stakeholder involvement, as described in

section 9. The performance reviews include traditional enforcement reviews, as described in

section 13, and cross-cutting area reviews, as described in section 14. Figures 3 and 4 further

illustrate how the assessment process is part of the ROP.

0305-07 PERFORMANCE REVIEWS

The assessment process consists of a series of reviews that are described below.

07.01 Continuous Review.

The resident inspectors and branch chiefs in each regional office continuously monitor

the performance of their assigned plants using the results of inspection findings and PIs.

Inspections are conducted on a continuous basis in accordance with IMC 2515, “LightWater Reactor Inspection Program – Operations Phase,” and IMC 2201, “Security

Inspection Program for Operating Commercial Nuclear Power Reactors,” and PIs are

reported quarterly by licensees.

Between the normal quarterly assessments, the region may issue an assessment followup letter and address an issue in accordance with the Action Matrix if:

a. A safety-significant inspection finding is finalized (in this case, the assessment follow-up

letter may be combined with the final SDP letter; Security Cornerstone findings are

discussed below). The assessment follow-up letter should be issued within 2 weeks of

issuance of the final SDP letter. The assessment follow-up letter need not be issued if a

periodic (quarterly or annual) assessment letter including discussion of the issue will be

issued within 4 weeks of final SDP letter issuance.

Issue Date: 05/04/23 7 0305

b. A finding will be closed after the appropriate supplemental inspection has been

satisfactorily completed (in this case, the assessment follow-up letter may be combined

with the inspection report cover letter).

For Security Cornerstone findings the assessment follow-up letter may be combined with

the publicly available Security Cornerstone SDP letters or supplemental inspection

reports. If the assessment follow-up letter is not combined with the Security Cornerstone

SDP letters or supplemental inspection reports, then a separate publicly available

assessment follow-up letter shall be issued. If the assessment follow-up letter is

combined with another document as described above, ensure the document title

includes “assessment follow-up letter,” to clearly communicate the assessment follow-up

letter being combined with the other document.

An assessment follow-up letter shall also be issued to communicate that an Action

Matrix deviation was issued or closed if not communicated in the annual assessment

letter. The assessment follow-up letter should discuss planned actions and note

applicable changes to the plant’s designation in the Action Matrix.

An assessment follow-up letter may also be issued after the second quarter to notify a

licensee that a cross-cutting theme or cross-cutting issue (CCI) was identified. This letter

can be combined with the inspection plan transmittal letter issued.

The assessment follow-up letter should be emailed to

ROPassessment.Resource@nrc.gov. The ROP website will be updated as necessary to

reflect the Action Matrix information discussed in the most recent assessment follow-up

letter. Example assessment follow-up language can be found in Exhibit 4 (not publicly

available). If security-related information, which is a type of Sensitive Unclassified NonSafeguards Information (SUNSI), must be discussed in the assessment follow-up letter,

it shall be provided to the licensee in a separate non-publicly available correspondence.

Agency policy regarding SUNSI is provided in Management Directive 12.6, “NRC

Controlled Unclassified Information (CUI) Program.”

07.02 Quarterly Review

a. Requirements. Each region conducts a quarterly review for each plant using PI data

submitted by licensees and inspection findings compiled over the previous assessment

period. This review is conducted within five weeks following the conclusion of the first

and third quarters of the annual assessment cycle and within seven weeks following the

conclusion of the second quarter of the assessment period. The most recent quarter of

PIs and applicable inspection findings shall be considered in determining NRC actions in

accordance with the Action Matrix.

b. Preparation. The responsible regional DRP or DORS branch chief reviews the most

recently submitted PIs, which should be submitted by the licensee 21 days after the end

of the quarter, and the inspection findings contained in the plant issues matrix (PIM) to

identify any performance trends. The branch chief shall use the Action Matrix to help

identify if there are NRC actions that should be considered that are not already included

in the existing inspection plan.

c. Conducting the quarterly review. The region determines the appropriate Action Matrix

column for each plant and communicates the results to headquarters. The staff may

Issue Date: 05/04/23 8 0305

become aware that a plant will reach a repetitive degraded cornerstone categorization

prior to five consecutive quarters being exceeded. When the regional office determines

that a plant will reach a repetitive degraded cornerstone, an assessment letter shall be

issued after entering the sixth quarter stating that the changes to the planned actions are

consistent with Column 4 in the Action Matrix unless a deviation is requested.

During the second quarter review, the staff shall review the PIM or Reactor Program

System-Inspections (RPS-Inspections)/RRPS Reports/IR 12 Cross Cutting Aspect to

determine if a cross-cutting theme or a CCI exists. The period of review should include

the third and fourth quarters of the previous assessment year, and the first and second

quarter of the current assessment year.

Additionally, for plants whose performance is in Column 4 of the Action Matrix,

consideration shall be given at each quarterly review to engaging senior licensee and

NRC management in discussions associated with (1) transferring the plant to the

IMC 0350 process, (2) declaring licensee performance to be unacceptable in

accordance with this IMC, and (3) taking additional regulatory actions (as appropriate). A

discussion of this decision shall be documented in a quarterly assessment follow-up

letter, annual assessment letter, or quarterly inspection report, as applicable.

d. Quarterly review output. The output of the quarterly review is a quarterly assessment

follow-up letter, if applicable. Assessment follow-up letters are normally issued within two

weeks after the quarterly review (a total of seven weeks after completion of the quarter,

or nine weeks after completion of the second quarter) for any new safety-significant PIs

or inspection findings. The licensee does not have to change Action Matrix columns for

an assessment follow-up letter to be issued. New inputs, such as a White PI reported

during the quarterly review, should be documented in an assessment follow-up letter

even if the licensee does not change columns because they are already in a higher

column due to an existing open Action Matrix input. Assessment follow-up letters should

also be issued to communicate that a licensee has a cross-cutting theme or crosscutting issue. If, based on the continuous review, as discussed above, the region issued

an assessment follow-up letter for inspection findings, PIs, or Action Matrix deviations

during the past quarter, then a subsequent quarterly assessment follow-up letter is not

needed if its only purpose is to reiterate issues that had been previously communicated

to the licensee. If there are significant changes in the inspection plan for a plant in

Column 4 of the Action Matrix, the regions should issue a separate assessment followup letter to ensure the licensee is aware of these changes. A quarterly assessment

follow-up letter is not required unless for the reasons described above or to

communicate the opening or closing of an Action Matrix deviation. The quarterly

assessment follow-up letter should be emailed to ROPassessment.Resource@nrc.gov.

If security-related information, which is a type of SUNSI, must be discussed in the

quarterly assessment follow-up letter, it shall be provided to the licensee in a separate

non-publicly available correspondence. For example, regions can reference a final SDP

letter previously issued that explains any greater-than-Green security issues.

If during the second quarter review it is determined that the licensee has met the criteria

for a cross-cutting theme, a continuing cross-cutting theme, or a CCI, the theme or CCI

will be documented in an assessment follow-up letter. Refer to section 07.03.d.5 when

documenting a cross-cutting theme or CCI.

After the second quarter review, an updated inspection plan consisting of approximately

24 months (from the end of the second quarter) of inspection activities should be issued

to licensees within nine weeks of the end of the second quarter as a separate

correspondence utilizing the inspection report numbering as described in IMC 0306 (See

Exhibit 12, Inspection Plan Transmittal Letter). The inspection plan consists of RPSInspections/RRPS Reports/IP 22 Inspection Activity Plan Report. Updated security

inspection plans should be included in the Report 22 and need not be transmitted via

separate correspondence.

For a plant in Column 4 of the Action Matrix, documentation of the date of NRC’s

quarterly review and discussion of NRC decision regarding transferring the plant to the

0350 process, for the unacceptable performance column, or taking any additional

regulatory actions is required. The documentation can be in a quarterly assessment

follow-up letter, annual assessment letter, or quarterly inspection report, as applicable.

07.03 End-of-Cycle Reviews

a. Requirements. Each regional office conducts an end-of-cycle review for each plant using

PIs (including those applicable to the last quarter of the assessment period), inspection

results, and enforcement actions compiled over the assessment period. The end-ofcycle review should also include a discussion of any open items (e.g., Licensee Event

Reports (LERs), etc.). The regional office may also consider insights documented in the

most recently issued biennial problem identification and resolution inspection report. The

review meeting will be completed within seven weeks after the end of the last quarter of

the assessment period. Additional activities include planning inspection activities for

approximately 24 months following the end of the assessment period, discussing site

performance in the cross-cutting areas, and determining if any traditional enforcement

follow-up inspections are necessary. The end-of-cycle review also serves as input to

support the End-of-Cycle Summary Meeting and the AARM. See sections 07.04 and

08.01 respectively for more information.

The review shall consider the conclusions of any independent assessments of a

licensee, such as Institute of Nuclear Power Operations (INPO) and International Atomic

Energy Agency (IAEA) Operational Safety Review Team (OSART) inspections. The

purpose of considering independent assessments is to provide a means of selfassessing the NRC inspection and assessment process. References to INPO

conclusions will not be included in the assessment letters. [C3]

The Action Matrix and assessment inputs will be used to determine the scope of NRC

actions. The review and subsequent assessment letters should only discuss issues from

inspections that were completed during the applicable assessment period.

b. Preparation. In preparation for the assessment review meetings, the regional offices

shall:

1. Develop a meeting agenda. The meeting agenda shall identify the areas that should

be addressed by the regional offices for all plants except those for which a PPS is

required. A single written agenda outlining planned discussion topics is sufficient to

conduct the meeting. Exhibit 2 provides a sample agenda for Column 1 and 2 plants.

Treat the meeting agendas as draft and pre-decisional, and apply the NRC’s SUNSI

handling requirements, as necessary. At the conclusion of the assessment meetings,

the regional office shall add the end-of-cycle agendas and plant performance

summaries for all plants to the NRCs Agencywide Documents Access and

Management System (ADAMS) to save them as agency records. They should be

treated as internal documents and profiled as non-publicly available.

2. Compile the PIM (RPS-Inspections/RRPS Reports/IR 3 PIM), the results of the PIs,

and the proposed inspection plan (RPS-Inspections/RRPS Reports/IP 22 Inspection

Activity Plan Report) for each plant. Regions are not required to email this

information to ROPassessment.Resource@nrc.gov

In reviewing the PIM, staff shall review findings for the past two years to determine if

there are any programmatic trends that should be considered during the assessment

meeting. Suggested areas of consideration are engineering areas (i.e., Criterion III,

50.59, 50.65), the corrective action program (Criterion XVI), procedures (Criterion V

or Technical Specifications), and security. If there are an abnormally high number of

findings in a given area, staff should consider using the information to inform the

inspection sample selection for the next inspection cycle. The staff should document

in the plant assessment package that the review was completed and whether or not

a programmatic trend was identified. If a trend is identified, document if the trend

warrants a focused inspection, e.g., a semi-annual PI&R trend review sample.

3. Develop a PPS for those plants whose performance has been in Column 3, 4, or 5 of

the Action Matrix during any quarter of the applicable assessment period. Also

develop a PPS for those plants that may or will have new or continuing CCIs.

The PPSs will assist the regional offices in conducting the meeting and form the

basis for the assessment letters. The final revision of these summaries will also be

used at the End-of-Cycle Summary Meeting and serve as input to the AARM.

Treat the summaries as draft and pre-decisional, and apply the NRC’s SUNSI

handling requirements, as necessary.

The PPS should include (an example template can be found in non-publicly available

Exhibit 3):

(a) an operating summary

(b) a performance overview (current overall assessment and previous assessment

results)

(c) inspection and PI results by cornerstones

(d) other issues (e.g., cross-cutting issues, PI verification, and enforcement actions

of any SL over the assessment period)

(e) a proposed inspection plan

Prepare a plant-specific action matrix as an attachment to the PPS. The plantspecific action matrix should show the timeline and consideration of PIs and

inspection findings in the assessment program and display the quarterly status of

safety-significant inspection findings and PIs and the associated Action Matrix

column over a sufficient timeline. The plant-specific action matrix does not need to

be included in a PPS that is developed only for the purpose of discussing a CCI.

Issue Date: 05/04/23 11 0305

4. Consider operating experience insights. Additional guidance is provided in IMC 2523,

“NRC Application of the Reactor Operating Experience Program in NRC Oversight

Process.”

c. Conducting the assessment review.

The end-of-cycle review meeting is chaired by the RA or designee. The regional division

directors and/or branch chiefs present the results of the annual review to the RA or

designee.

The regional DRP or DORS branch chiefs shall coordinate with the appropriate branch

chiefs to provide adequate support for the presentation and the development of the

inspection plan. Because some infrequently performed inspections require advance

planning and preparation, the presentation and development of the inspection plan shall

include consideration of any upcoming activities planned for the next two years that need

to be inspected using the inspection procedures identified in IMC 2515, Appendix C,

“Special and Infrequently Performed Inspections.” Examples of activities that should be

considered include extended power uprates, steam generator replacements, reactor

vessel head replacements, and significant digital upgrades. The station’s intent to

perform these activities should be ascertained through discussion with the NRR PM or

the resident inspectors.

Other participants should include applicable regional and resident inspectors, a

representative from NRR/DRO, the regional allegations coordinator or the agency

allegations advisor, and any other additional participants deemed necessary by the

regional offices. The agency allegations advisor will provide any significant insights to

the regional offices in advance of the assessment meeting to support meeting

preparation. The DRO observer should complete Exhibit 10, “DRO End-of-Cycle

Observation Form,” during the meetings to gather lessons learned.

Representatives from the Division of Operating Reactor Licensing (NRR/DORL) are

expected to participate in the semi-annual assessment reviews. Representatives from

OI, OE, NSIR, and RES should also participate if there are pertinent performance issues

that should be factored into the performance for a particular plant. The role of the various

headquarters participants during the assessment meeting is to provide: (1) an

opportunity for these offices to share any significant insights into licensee performance

over the course of the annual assessment period, (2) an independent validation of the

regional office’s assessment of licensee performance from their office’s perspective, and

(3) clarifying or ancillary remarks regarding ongoing or current issues under their

cognizance. The licensing Project Manager, with the support of the technical staff,

should be prepared to discuss significant performance concerns that may come to light

through 10 CFR 2.206 petitions, licensing issues, or financial issues that are within the

scope of NRC regulations. Inspectors should consider using the insights provided to

develop the scope of inspections in areas of potential concern, balanced with risk

insights, e.g., weak engineering support could be considered in Comprehensive

Engineering Team Inspections (CETIs).

A senior reactor analyst (SRA) is not required to attend the meeting if the SRA’s insights

on safety-significant performance issues have been provided before the meeting.

Issue Date: 05/04/23 12 0305

The average time allocated for each plant review is intended to be between 20 minutes

and one hour. The time allotted per review should be consistent with the number and

significance of plant issues.

For plants with several violations dispositioned through traditional enforcement during

the assessment period, consideration should be given for conducting follow-up

inspections utilizing IP 92722, “Follow Up Inspection For Any Severity Level I or II

Traditional Enforcement Violation or for Two or More Severity Level III Traditional

Enforcement Violations in a 12 Month Period,” or IP 92723, “Follow-Up Inspection for

One Severity Level III and Two Severity Level IV Traditional Enforcement Violations or

for Three or More Severity Level IV Traditional Enforcement Violations in the Same Area

in a 12-Month Period,” if the licensee meets the criteria discussed in section 0305-13 of

this manual chapter. Regions should consider only TE violations that involve willfulness,

impeding the regulatory process, or which involve actual safety consequences when

determining whether to discuss the need to perform a TE follow-up inspection. The

decision to conduct one of these follow-up inspections should be made at the time a

licensee meets the criteria. The decision to conduct one of these follow-up inspections

should be made at the time a licensee meets the criteria. This decision should be

discussed at the assessment meeting as part of the inspection plan and under licensee

performance. The decision to conduct or not conduct one of these follow-up inspections

should be documented in accordance with section 13.02 of this manual chapter.

When reviewing allegations, staff should be alert for trends that might be indicative of

declining confidence in a licensee’s Employee Concerns Program (ECP). That

information should be communicated to the biennial PI&R team for review.

d. End-of cycle review output.

The output of the end-of-cycle review is an annual assessment letter. The annual

assessment letter shall be issued within nine weeks after the end of the end-of-cycle

assessment period. Signature authority for the annual assessment letter is determined

by the most significant column of the Action Matrix that the plant has been in during the

end-of-cycle assessment period. A four-quarter look-back to determine signature

authority is warranted because these letters support the EOC Summary Meeting and the

AARM. If a plant has an open deviation memo, the RA or designee should have

signature authority for the end-of-cycle letter.

If security-related information, which is a type of SUNSI, must be discussed in the

annual assessment letter, it shall be provided to the licensee in a separate non-publicly

available correspondence. For example, regions can reference a final SDP letter

previously issued that explains any greater-than-Green security issues.

The assessment letters shall contain:

Note: Publicly available discussion of Security Cornerstone issues will consist of

indicating the existence of one or more greater-than-Green security inputs. Do not list

the specific number, safety significance (i.e. White, Yellow or Red) or other more

detailed information regarding Security Cornerstone Action Matrix inputs in publicly

available assessment letters.

1. A summary of safety-significant PIs and inspection findings for the applicable

assessment period as well as discussion of previous action taken by the licensee

and the NRC relative to these issues. Also discuss any actions to be taken by the

NRC in response to safety-significant issues. The assessment letter shall note any

changes in Action Matrix column status since the end of the previous assessment

period.

Performance issues from previous quarters may be discussed if:

(a) The NRC’s response to an issue had not been adequately captured in previous

correspondence to the licensee.

(b) These issues, when considered with assessment inputs from the most recent

quarter, result in increased regulatory action per the Action Matrix that would not

be apparent from reviewing only the most recent quarter’s results.

2. A discussion of any Action Matrix deviations during the assessment period.

3. For plants that have remained in Column 3 for three years or more, a discussion on

why the plant has remained in this column for such a period of time and how the

licensee plans to address the performance issues.

4. For plants that are in Column 4, a discussion of the performance issues contributing

to the plant being placed in this column and the licensee’s actions being taken to

address the performance problems. The end-of-cycle letter should also document

NRC’s decision regarding the need to transfer the plant to the 0350 process, or the

unacceptable performance column, or to take additional regulatory actions.

5. A qualitative discussion of CCIs, if applicable. The assessment letter shall document

any cross-cutting themes and CCIs that are new, remaining open, or being closed.

(a) The assessment letter shall include the following information for new CCIs:

(1) the alpha-numeric identifier of the new CCI or the cross-cutting area (HU,

PI&R, SCWE), if applicable, (2) the basis for the cross-cutting theme and CCI

criteria being met, (3) the purpose of identifying a CCI, (4) the CCI closure

criteria, and (5) a brief description of the region’s plans to follow-up on the CCI.

(b) If a CCI is remaining open, the assessment letter shall include the following

information: (1) the alpha-numeric identifier of the CCI or the cross-cutting area

(HU, PI&R, SCWE), if applicable, (2) the date of the assessment letter(s) that

opened and/or discussed the CCI, (3) the region’s basis for continuing the CCI,

including a summary of the licensee’s progress in addressing the CCI, (4) the

CCI closure criteria, (5) a brief description of the region’s plans to follow-up on

the CCI, and (6) any requests for additional meetings with the licensee or safety

culture assessments to be performed.

(c) If a CCI is being closed, the assessment letter shall include the following

information: (1) the alpha-numeric identifier of the CCI or the cross-cutting area

(HU, PI&R, SCWE), if applicable, (2) the date of the assessment letter(s) that

opened and/or discussed the CCI, and (3) the region’s basis for closing the CCI,

including a summary of the licensee’s actions to address the CCI.

(d) A statement that a cross-cutting theme exists if the licensee meets the criteria for

a theme and has not yet met the criteria to be documented as a CCI. The letter

Issue Date: 05/04/23 14 0305

should include a detailed discussion of any insights, NRC concerns with licensee

performance in the area, if applicable, and any NRC decisions, with a basis for

any decisions being made, and a brief description of cross-cutting theme

follow-up actions taken or planned. See additional guidance for documentation in

Exhibit 7.

6. A discussion of any traditional enforcement follow-up inspection (i.e., IP 92702,

92722, or 92723) to be performed as an Appendix C type inspection, if applicable.

7. A discussion of potentially safety-significant findings that are currently being

evaluated by the SDP that may affect the inspection plan.

8. An inspection plan consisting of approximately 24 months (from the end of the

applicable assessment period) of activities. The inspection plan consists of

RPS-Inspections/RRPS Reports/IP 22 Inspection Activity Plan Report. The Report

22 shall also include the updated plan for security inspections.

9. If applicable, the letter should describe any impact to the inspection plan for plants

subject to IMC 0375, “Implementation of the Reactor Oversight Process at Reactor

Facilities in an Extended Shutdown Condition for Reasons Not Related to

Performance.”

07.04 End-of-Cycle Summary Meeting

The End-of-Cycle Summary Meeting is conducted following the conclusion of the end-ofcycle review meetings to summarize the results of the end-of-cycle review with the

Director, NRR, or another member of the NRR Executive Team.

a. Requirements. The End-of-Cycle Summary Meeting is an informational meeting whose

purpose is for regional management to engage headquarters management to ensure

awareness of:

1. plants to be discussed at the AARM

2. plants with significant performance issues

3. plants with open Action Matrix deviations

4. plants with a CCI for more than two consecutive assessment letters

5. NRC actions already taken in response to plant performance

The End-of-Cycle Summary Meeting will be scheduled after the completion of the last

regional end-of-cycle review. This meeting should occur after the completion of all the

end-of-cycle meetings but before the issuance of the annual assessment letters, if

possible.

b. Preparation. NRR/DRO/IRAB will start coordinating with the regional offices upon

completion of the end-of-cycle meetings to identify plants that will be discussed at the

End-of-Cycle Summary Meeting and draft an agenda.

c. Conducting the End-of-Cycle Summary Meeting. Each RA will lead the discussion for

their region. The regional presentation should:

Issue Date: 05/04/23 15 0305

1. Summarize the results of the end-of-cycle review for those plants whose

performance in one or more quarters in the past twelve months has been in

Column 3, 4, or 5 of the Action Matrix. RAs may discuss plants with performance

issues considered to be at the threshold for more significant regulatory action (i.e., at

risk of moving to Columns 3 or 4 of the Action Matrix.)

2. Discuss plants that are in the IMC 0350 process.

3. Present the results for those plants that have new or continuing CCIs.

4. Discuss any open Action Matrix deviations, including their bases and actions

required to close.

0305-08 PROGRAM REVIEWS

08.01 Agency Action Review Meeting

An AARM is conducted several weeks after issuance of the annual assessment letters.

This meeting is attended by appropriate senior NRC managers and is chaired by the

EDO or designee.

This meeting is a collegial review by senior NRC managers of:

a. the appropriateness of NRC actions for plants with significant performance issues based

on data compiled during the end-of-cycle review and those that have moved into

Column 4 or 5 of the Action Matrix during the first quarter of the year in which the AARM

is held

b. the appropriateness of NRC actions concerning fuel cycle facilities and other materials

licensees with significant performance problems

c. the results of the ROP self-assessment, including a review of approved Action Matrix

deviations [C2]

Management Directive (MD) 8.14, “Agency Action Review Meeting,” includes a complete

description of the meeting.

08.02 AARM Commission Meeting

The EDO will brief the Commission annually to convey the results of the AARM,

including a discussion of any ROP Action Matrix deviations. [C2] The Commission

should be briefed within approximately four weeks of the AARM, consistent with

Commission availability, to ensure that the information presented is as current as

possible.

0305-09 PUBLIC STAKEHOLDER INVOLVEMENT

09.01 Scheduling

Involvement of the public in the discussion of the results of the NRC’s annual

assessment of the licensee’s performance can occur in various ways. The regional

offices should use this opportunity to engage interested stakeholders on the

performance of the plant and the role of the NRC in ensuring safe plant operations.

Although the Security Cornerstone is included in the assessment process, the

Commission has decided that specific information related to findings pertaining to the

Security Cornerstone will not be publicly available to ensure that security information is

not provided to a possible adversary. Therefore, security-related information other than

what is publicly available in assessment letters, final significance determination letters

and security inspection report cover letters will not be discussed during public meetings.

If security-related information, which is a type of SUNSI, must be discussed during the

meeting, it shall be discussed during a closed meeting, or during a closed session

following a public meeting.

For plants that have been in Column 3, 4, or 5 of the Action Matrix, involvement of the

public in a meeting or some other appropriate venue should be scheduled within

16 weeks of the end of the assessment period. The 16-week guideline may occasionally

be exceeded to accommodate the regional office or licensee’s schedule. For these

plants, public involvement should include a formal public meeting with the licensee if one

has not already been held to close out the performance issues.

For plants that have been in Column 1 or 2 of the Action Matrix during the entire

assessment period, public stakeholder involvement should be scheduled during the year

at a time that presents the best opportunity to effectively engage public stakeholders.

Public stakeholder involvement can be a meeting tailored to the public, an open house

for the public, poster sessions, virtual meetings, or other similar activities that allow the

NRC to effectively engage public stakeholders. Participating in an event sponsored by

another organization can be considered if such an event would maximize public

engagement.

The region may decide whether the outreach activity should be conducted onsite or in

the vicinity of the site. The outreach effort should be scheduled to ensure that it is

accessible to members of the public. Two separate venues/events can be considered,

such as a public assessment meeting with the licensee and a public event to discuss

topics of local interest. In determining what type of event or forum to conduct, the

regions should consider, among other things, plant performance, public interest in plant

performance, any discussion the regions need to have with the licensee, and any other

areas of public interest.

09.02 Preparation

The region shall notify: (1) those on distribution for the annual assessment letters of the

opportunity for public involvement in the discussion of the results of the NRC’s annual

assessment and (2) the media and state and local government officials of the event with

the licensee and the issuance of the annual assessment letter. A meeting notice shall be

posted at least 10 calendar days prior to any public meeting to discuss the annual

assessment of licensee performance.

The region should consider the level of historical interest and performance issues, and

should use the following additional tools, as appropriate, to inform members of the public

of the event: press releases, advertisements in local newspapers, or letters soliciting

attendance and/or interest to known parties.

The regions should also consider:

a. practice sessions before meetings/events. (Prior to the annual meeting(s), the region

should map out a strategy for the public meetings for all the plants in the region and

conduct preparation sessions for higher-profile meetings, as needed.)

b. using the sample assessment event slides available from the Assessment Program

Sharepoint site (internal website not available to external stakeholders).

c. using the same NRC spokesperson(s) at more than one site to give a consistent

message and developing standard responses to repeated questions.

The regions should also consult with the regional public affairs staff in determining the

end-of-cycle meetings and/or events at each site. NRC management, as specified in the

Action Matrix and determined by the most significant column that the plant has been in

over the assessment cycle, should normally be involved at the event. For plants with

heightened stakeholder interest, media inquiry, or contentious issues, regions should

consider sending an appropriate level of management needed to respond to stakeholder

interest and effectively conduct the meeting. For plants that have been in the Column 3,

4, or 5 of the Action Matrix and a formal public meeting has not been conducted (e.g.,

regulatory performance meeting after completion of a 95001, 95002, or 95003), a formal

public meeting with the licensee is required, at a minimum.

Because security-related information is not discussed in public meetings as outlined in

the preceding section, a formal public meeting is not necessary for plants that have been

in Column 3, 4 or 5 solely as a result of security issues. These plants may also be

required to meet with the Commission depending on the circumstances as discussed in

section 10.02.

09.03 Conduct

The annual involvement of the public in the results of the NRC’s assessment of licensee

performance is intended to provide an opportunity for the NRC to engage interested

stakeholders on the performance of the plant and the role of the NRC in ensuring safe

plant operations. Public involvement in the results of the NRC’s assessment of licensee

performance should focus on topics of interest to the public. The format for the public

involvement should not be limited to a formal type public meeting; it could be in an open

house, a webinar, a round table discussion, or a poster board session. For higher-profile

events, consideration should include NRC or non-NRC facilitators.

The annual assessment letters provide the minimum performance information that

should be conveyed to interested stakeholders in a public meeting, if conducted.

However, this does not preclude the presentation of additional plant performance

information when placed in the proper context. The licensee, if present, should be given

the opportunity to respond at the meeting to any information contained in the annual

assessment letter. The licensee, if present, should also be given the opportunity to

present to the NRC any new or existing programs that are designed to maintain or

improve their current performance.

If the staff uses a formal public meeting format for public involvement, the meeting

should be conducted as an observation meeting with the licensee. An important

exception is that the meeting must be closed for such portions which may involve

matters that should not be publicly disclosed under section 2.390 of Title 10 of the Code

of Federal Regulations (10 CFR 2.390). Members of the public, the press, and

government officials from other agencies are considered observers during the conduct of

these public meetings.

If the licensee will not be formally represented at the meeting, the meeting should be

conducted as an information meeting with a question-and-answer session. A comment gathering meeting may also be used, but this is expected to be rare for formal public

meetings conducted in accordance with this manual chapter.

In any of these formal public meeting formats, a designated opportunity for the public to

ask questions of the NRC representatives should be made available. The NRC staff

should strive to ensure sufficient time is allotted to ensure that the public can pose

questions and have them answered during the meeting. Whether all questions are

addressed or not, the NRC staff should emphasize ways members of the public can ask

questions outside the meeting.

Upon completion of the annual public engagement to discuss the assessment of

licensee performance, a meeting summary shall be completed for all formal public

observation meetings, information meetings with question-and-answer sessions, and

comment-gathering meetings. If a more informal format was used, a meeting summary is

not required if the assessment letter was attached to the meeting notice.

0305-10 ROP ACTION MATRIX

10.01 Description of the Action Matrix

The Action Matrix (Figure 1) identifies the range of NRC and licensee actions and the

appropriate level of communication for different levels of licensee performance. The

Action Matrix describes a graded approach for addressing performance issues and was

developed with the philosophy that within a certain level of safety performance (e.g., the

licensee response band), licensees would address their performance issues without

additional NRC engagement beyond the baseline inspection program. NRC actions

beyond the baseline inspection program will normally occur only if assessment input

thresholds are exceeded. The NRC’s public “ROP Action Matrix Summary and Current

Regulatory Oversight” website is updated in accordance with IMC 0306.

The following terms are used throughout the discussion of the Action Matrix.

a. Regulatory Performance Meetings. Regulatory performance meetings are held between

licensees and the NRC to discuss corrective actions associated with safety-significant

Action Matrix inputs. The purpose of the meeting is to provide a forum in which to

develop a shared understanding of the performance issues, underlying causes, and

planned licensee actions for each safety-significant Action Matrix input.

These meetings may take place during periodic inspection exit meetings between the

NRC and the licensee, a periodic NRC management visit, conference calls, a public

supplemental inspection exit meeting, or public meetings after completion of the

supplemental inspection. These meetings are documented in either an inspection report

or a public meeting summary, as appropriate.

If security-related information, which is a type of SUNSI, must be discussed during the

regulatory performance meeting, it shall be discussed during a closed meeting, or during

a closed session following a public meeting to discuss inputs in other cornerstones.

b. Licensee Actions. Anticipated licensee actions in response to overall performance are

identified for each column of the Action Matrix. If these actions are not being taken by

the licensee, then the NRC may consider expanding the scope of the applicable

supplemental inspection to appropriately address the area(s) of concern. This would not

be considered an Action Matrix deviation.

c. NRC Inspections. The range of NRC inspection activities to be conducted in response to

licensee performance is identified for each column of the Action Matrix.

d. Regulatory Actions. The range of actions that may be taken by the NRC in response to

licensee performance is identified for each column of the Action Matrix.

e. Communications. Communication between the licensee and the NRC is based on a

graded approach. Normally, declining licensee performance will result in higher levels of

NRC management reviewing and signing the assessment letters and conducting the

annual public stakeholder involvement.

10.02 Expected Responses for Performance in Each Action Matrix Column

The Action Matrix lists expected NRC and licensee actions based on the Action Matrix

inputs. Actions are graded such that the NRC becomes more engaged as licensee

performance declines. Listed below are the ranges of expected NRC and licensee

actions for each column of the Action Matrix:

a. Licensee Response Column (Column 1)

1. All Action Matrix inputs are Green.

2. The licensee will receive the complete risk-informed baseline inspection program,

and any identified deficiencies are expected to be addressed through the licensee’s

corrective action program.

b. Regulatory Response Column (Column 2)

1. Action Matrix inputs result in one or two White inputs in a strategic performance area.

2. The licensee is expected to place the identified deficiencies in its corrective action

program and perform a causal evaluation. When two White inputs correspond to the

same cornerstone, the licensee is expected to also perform a causal evaluation for

the collective issues.

3. The licensee’s evaluation will be reviewed using IP 95001, “Supplemental Inspection

Response to Action Matrix Column 2 (Regulatory Response) Inputs.”

4. Following completion of the inspection, the branch chief or division director should

discuss the performance deficiencies and the licensee’s proposed corrective actions

with the licensee. The regulatory performance meeting can occur at an inspection

exit meeting, a periodic NRC management visit, or a conference call between the

licensee and the appropriate branch chief (or division director). If security-related

Issue Date: 05/04/23 20 0305

information, which is a type of SUNSI, must be discussed during the regulatory

performance meeting, it shall be discussed during a closed meeting, or during a

closed session following a public meeting to discuss inputs in other cornerstones.

Agency policy regarding SUNSI is provided in Management Directive 12.6.

c. Degraded Performance Column (Column 3)

1. Action Matrix inputs result in a degraded cornerstone (three or more concurrent,

i.e., existing at the same time) White inputs or one Yellow input in any cornerstone)

or three concurrent White inputs in any strategic performance area.

2. The licensee is expected to place the identified deficiencies in its corrective action

program and perform a causal evaluation for both the individual and the collective

issues. This evaluation should also determine whether deficiencies in the licensee’s

nuclear safety culture caused or significantly contributed to the risk-significant

performance issues. If so, then the licensee should address these deficiencies.

3. The licensee’s evaluation will be reviewed using IP 95002, “Supplemental Inspection

Response to Action Matrix Column 3 (Degraded Performance) Inputs.” The region

will also perform an independent assessment of the extent of condition using

appropriate inspection procedures chosen from the tables contained in Appendix B

to IMC 2515.

Additionally, the NRC may request that the licensee complete an independent safety

culture assessment, if the NRC identified through the IP 95002 inspection and the

licensee did not recognize, that one or more safety culture deficiencies caused or

significantly contributed to the risk-significant performance issues. [C4]

The guidance in IP 40100, “Independent Safety Culture Assessment Follow-up,”

shall be used to follow up when the NRC requests the licensee to perform an

independent safety culture assessment. The regional office shall treat the use of this

guidance as an expansion of the IP 95002 inspection and should still charge time to

IP 95002. The focus of the follow-up effort will be to confirm that the licensee is

appropriately dealing with the weaknesses identified by its safety culture

assessment. Regional staff can contact the Chief, Reactor Assessment Branch,

NRR/DRO, for additional assistance and guidance.

4. Following completion of the IP 95002 inspection, the RA or designee should discuss

the performance deficiencies and the licensee’s proposed corrective actions with the

licensee. The regulatory performance meeting should be a public meeting between

the licensee and the appropriate RA or designee. If security-related information,

which is a type of SUNSI, must be discussed during the regulatory performance

meeting, it shall be discussed during a closed meeting, or during a closed session

following a public meeting to discuss inputs in other cornerstones.

5. Each time a plant enters Column 3 of the Action Matrix, the region should assess the

benefit of performing an additional PI&R team inspection in accordance with

IP 71152, “Problem Identification and Resolution.” A maximum of one additional

inspection should be considered for the two-year period following the quarter in

which the plant entered Column 3 of the Action Matrix. In those instances where an

additional inspection is deemed appropriate, the region should provide the basis for

Issue Date: 05/04/23 21 0305

its decision to conduct the inspection in the appropriate assessment letter to the

licensee.

6. Any licensee remaining in Column 3 for three years or more may be invited to meet

with the Commission to discuss performance issues and its plan for addressing

those issues. [C5]

d. Multiple/Repetitive Degraded Cornerstone Column (Column 4)

1. Action Matrix inputs result in a repetitive degraded cornerstone, multiple degraded

cornerstones, multiple Yellow inputs, or one Red input.

2. The licensee is expected to place the identified deficiencies in its corrective action

program and perform a causal evaluation for both the individual and the collective

issues. This evaluation may consist of a third-party assessment.

In addition, a licensee is expected to meet with the Commission within six months of

entering Column 4 to discuss its plans for addressing the performance deficiencies

and its plans for improvement. The timing of the meeting shall be based on a

collegial determination by the Commission informed by a recommendation from the

EDO, and may exceed six months. [C5]

The licensee is also expected to have a third-party safety culture assessment

performed. [C4]

3. IP 95003, “Supplemental Inspection Response to Action Matrix Column 4

(Multiple/Repetitive Degraded Cornerstone) Inputs,” will be performed to review the

breadth and depth of the performance deficiencies, assess the licensee’s evaluation

of its safety culture, and independently perform a graded assessment of the

licensee’s safety culture. A decision to not independently perform an assessment of

the licensee’s safety culture would be an Action Matrix deviation. However, the staff

can use the results from a licensee’s third-party safety culture assessment and the

licensee’s causal evaluation to satisfy the inspection requirements if the staff has

completed a validation of the third-party safety culture assessment methodology,

assessment effort, and causal evaluation. This situation would not be an Action

Matrix deviation. The supplemental inspection plan must be approved by the

appropriate regional division director after conferring with the Director or Deputy

Director, NRR/DRO.

When the objectives of the IP 95003 supplemental inspection have been

satisfactorily met, the findings may be closed. However, the licensee will remain in

the higher column until the requirements to transfer out of Column 4 described in the

CAL have been inspected and met. When that is accomplished, the Region will issue

an assessment follow-up letter moving the licensee out of Column 4.

4. Each time a plant enters Column 4 of the Action Matrix, the region should assess the

benefit of performing an additional PI&R team inspection in accordance with

IP 71152. In those instances where an additional inspection is deemed appropriate,

the region should provide the basis for its decision to conduct the inspection in the

associated communication to the licensee.

Issue Date: 05/04/23 22 0305

5. Following the completion of the inspection, the EDO or designee, in conjunction with

the RA and the Director, NRR, will decide whether additional NRC actions are

warranted. At a minimum, the regional office will issue a Confirmatory Action Letter

(CAL) to document the licensee’s commitments, as discussed in its performance

improvement plan, and any other written or verbal commitments. The CAL should

explicitly identify licensee actions, which, when effectively implemented and validated

by the NRC, will provide the necessary bases to transition the plant out of Column 4

when an assessment follow-up letter is issued. These actions need to be as clear

and objective as possible. The licensee will remain in Column 4 until meeting the

criteria specified in the CAL, even though there may be no open Action Matrix inputs.

This will be annotated on the public website. Normally CAL follow-up inspections are

conducted to conclude licensee actions have been effectively implemented.

Other actions will also be considered, including performing additional supplemental

inspections, issuing a demand for information, or issuing an order, up to and

including a plant shutdown. The RA should document the results of the staff’s

decision in a letter to the licensee. These regulatory actions may also be considered

prior to the completion of IP 95003, if warranted.

Note: Other than the CAL, the regulatory actions listed in this column of the Action

Matrix are not mandatory. However, the regional office should consider each of these

regulatory actions when significant new information about licensee performance

becomes available.

6. The regulatory performance meeting should be a public meeting between the

licensee and the EDO or designee. The regions should consider the following as

indicative of actual performance improvements:

(a) New plant events or findings do not reveal similar significant performance

weaknesses.

(b) NRC findings and licensee PIs do not indicate similar significant performance

weaknesses that have not been adequately addressed.

(c) The licensee’s performance improvement program has demonstrated sustained

improvement.

(d) NRC supplemental inspections show licensee progress in the principal areas of

weakness.

(e) There were no issues that led the NRC to take additional regulatory actions

beyond those listed in Column 4 of the Action Matrix.

(f) Additionally, the licensee has made significant progress on any regulatory

actions imposed (e.g., orders, or 50.54 (f) letters) because of the performance

deficiencies leading to the Column 4 designation.

If security-related information, which is a type of SUNSI, must be discussed

during the regulatory performance meeting, it shall be discussed during a closed

meeting, or during a closed session following a public meeting to discuss inputs

in other cornerstones.

Due to the depth and/or breadth of performance issues reflected by a plant being

in Column 4 of the Action Matrix, it is prudent to ensure that actual performance

improvements, which typically take longer than several quarters to achieve, have

been made prior to closing out the inspection findings and allowing the plant to

exit Column 4 of the Action Matrix. [C2]

7. After the original findings and required CAL items have been closed, an assessment

follow-up letter is issued, and the licensee will return to the Action Matrix column that

is represented by applicable Action Matrix inputs.

Additionally, for a period of up to two years after the initial findings have been closed

out, the regional offices may use some actions that are consistent with Column 3 or 4

of the Action Matrix in order to ensure the appropriate level of NRC oversight of

licensee improvement initiatives. [C2]

These actions, which do not constitute Action Matrix deviations, include:

(a) senior management participation at periodic meetings or site visits focused on

reviewing the results of improvement initiatives (such as efforts to reduce

corrective action backlogs and progress in completing a performance

improvement plan)

(b) conducting supplemental IP 95003 and follow-up inspections (not to exceed

200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> of direct inspection over a maximum two-year period) after conferring

with the Deputy Director, NRR/DRO

(c) annual public meetings and authorization of the contents of the subsequent

assessment letters

The actions taken beyond those required by the Action Matrix shall be discussed at

the following end-of-cycle review meetings to ensure an appropriate basis for

needing the additional actions to oversee the licensee improvement initiatives. These

actions will also be described in the following annual assessment letters until the end

of the extended period of time. All assessment letters that address these additional

actions shall include the NRR/DRO/IRAB branch chief on concurrence.

e. Unacceptable Performance Column (Column 5)

1. Licensee performance is unacceptable, and continued plant operation is not

permitted within this column. Unacceptable performance represents situations in

which the NRC lacks reasonable assurance that the licensee can or will conduct its

activities to ensure protection of public health and safety. Examples of unacceptable

performance may include:

(a) Multiple escalated violations of the facility’s license, technical specifications,

regulations, or orders.

(b) Loss of confidence in the licensee’s ability to maintain and operate the facility in

accordance with the design basis (e.g., multiple safety-significant examples

where the facility was determined to be outside of its design basis, either

because of inappropriate modifications, the unavailability of design basis

Issue Date: 05/04/23 24 0305

information, inadequate configuration management, or the demonstrated lack of

an effective Corrective Action Program).

(c) A pattern of failure of licensee management controls to effectively address

previous significant concerns to prevent recurrence. In general, it is expected, but

not required, that entry into Column 4 of the Action Matrix and completion of

IP 95003 will precede consideration of whether a plant is in Column 5.

2. The licensee is expected to have a third-party safety culture assessment performed.

[C4]

3. If the NRC determines that a licensee’s performance is unacceptable, then a

shutdown order will be issued.

4. The NRC will assess the licensee’s evaluation of its safety culture and independently

perform a graded assessment of the licensee’s safety culture using the guidance in

IP 95003. A decision not to independently perform an assessment of the licensee’s

safety culture would be an Action Matrix deviation. However, the staff can use the

results from a licensee’s third-party safety culture assessment and the licensee’s

causal evaluation to satisfy the inspection requirements if the staff has completed a

validation of the third-party assessment methodology, assessment effort, and causal

evaluation.

5. The EDO or designee will meet with senior licensee management in a regulatory

performance meeting to discuss the licensee’s degraded performance and corrective

actions. The Commission will also meet with senior licensee management to discuss

the issues which will need to be taken before operation of the facility can be

resumed. If security-related information, which is a type of SUNSI, must be

discussed during the regulatory performance meeting, it shall be discussed during a

closed meeting, or during a closed session following a public meeting to discuss

inputs in other cornerstones.

6. The NRC oversight of plant performance will be conducted in accordance with

IMC 0350.

f. IMC 0350 Process Column

1. The criteria for entrance into the IMC 0350 process, as discussed in section 12.01 of

this IMC, have been met, and subsequent management review of licensee

performance has determined that entrance into Column 5 is not warranted at this

time. Plants that meet these criteria are considered to be outside of the normal

assessment process and under the control of IMC 0350. However, this column has

been added to the Action Matrix for illustrative purposes to demonstrate comparable

NRC response and communications and is not necessarily representative of the

worst level of licensee performance.

2. NRC management will review licensee performance on a quarterly basis to

determine if entrance into Column 5 is warranted.

3. The licensee is expected to place the identified deficiencies into its performance

improvement plan and perform a causal evaluation for both the individual and

collective causes.

Issue Date: 05/04/23 25 0305

4. As discussed in IMC 0350, the regional offices will conduct baseline and

supplemental inspections as appropriate, as well as special inspections per the

restart checklist. PI data should continue to be gathered in accordance with

IMC 0608, “Performance Indicator Program,” to the extent that it is applicable to

shutdown conditions. Plants under the IMC 0350 process should be discussed at the

end-of-cycle review to integrate inspection planning efforts across the regional office

and to keep internal stakeholders informed of ongoing inspection and oversight

activities. Annual assessment letters are generally not issued for these plants.

Annual public meetings will not be conducted for these plants as the regional office

conducts periodic public meetings to discuss licensee performance.

As discussed in section 12.02, the regional offices may use some actions that are

consistent with the Column 3 or 4 of the Action Matrix in order to ensure the

appropriate level of NRC oversight of licensee improvement initiatives as the

licensee exits the IMC 0350 Process. [C2]

0305-11 ADDITIONAL ACTION MATRIX GUIDANCE

The determination of a plant’s Action Matrix column considers inspection findings, PIs, the

timing of inputs, and the status of supplemental inspections and reports. Action Matrix inputs are

monitored continuously and plants can change Action Matrix column designation throughout the

quarter in accordance with section 07.01. The first calendar quarter is from January 1st through

March 31st. The second quarter is from April 1st through June 30th. The third quarter is from

July 1st through September 30th. The fourth quarter is from October 1st through December 31st.

11.01 Inspection Findings

a. Use of Safety-Significant Inspection Findings. Safety-significant inspection findings are

considered in the assessment process when (1) the NRC determines the final

significance in accordance with IMC 0609, “Significance Determination Process,” and

(2) the licensee has been informed of the decision. The start date of the finding and the

timeframe for consideration of the finding as an Action Matrix input are described below.

b. Start Date of Findings. The start date used for consideration of inspection findings in the

assessment process and Action Matrix, also known as the PIM date, is the end of the

inspection activities that designate the issue as an apparent violation (AV), violation

(NOV), finding (FIN), or non-cited violation (NCV) in the RPS-Inspections. For quarterly

integrated inspection reports, the last day of the quarter being assessed is the start date

or the date of a re-exit if the finding disposition has changed since the original exit

meeting. For all other inspection reports, the start date is the exit meeting or the date of

a re-exit if the disposition of the finding or violation changed since the original exit

meeting. The finding’s start date is used to determine the first quarter in which the

finding becomes an Action Matrix input. A safety-significant finding is considered an

Action Matrix input beginning on the first day of the quarter that includes the finding’s

start date until satisfaction of all supplemental inspection objectives.

Example 11.01-1: A preliminary White inspection finding is identified and communicated

to the licensee in an exit meeting in the second quarter. The NRC makes its final

determination that the finding had low to moderate (i.e., White) safety significance during

the third quarter. Because the exit meeting date, or start date, was in the second quarter,

Issue Date: 05/04/23 26 0305

the finding would be considered a White input to the Action Matrix beginning on the first

day of the second quarter.

c. Closure Date of Findings

A finding is closed and no longer considered an Action Matrix input after the licensee

satisfies all the objectives of the appropriate supplemental inspection. The closure date

will be the date of the exit meeting for the appropriate supplemental inspection. While

the finding is no longer considered an input into the Action Matrix as of the exit meeting

date for a satisfactory supplemental inspection, it can’t officially be closed until the

inspection report and assessment follow-up letter are issued. The assessment follow-up

letter will state that the finding is closed and no longer considered an Action Matrix input

as of the exit meeting date. The assessment follow-up letter will also notify the licensee

of any changes to the Action Matrix assignment. A region may close a finding if external

agencies have not completed their investigations.

A finding is only considered an Action Matrix input during the time it was open. Once the

finding is closed, it is no longer an Action Matrix input.

d. Concurrent inputs. After a safety-significant finding’s final significance determination is

made and the regional office determines the finding’s start date, as discussed above, the

regional office shall determine (1) how the plant’s Action Matrix column designation is

affected by other concurrent inputs (including those that are closed) that are applicable

during the time in which the finding is applicable and (2) if any additional action needs to

be taken as a result.

Example 11.01-2: A licensee is in Column 2 because a White parallel PI finding exists

for the first quarter and a White inspection finding in the same cornerstone is open. The

inspection finding closes in the middle of the first quarter due to satisfying all the

objectives of the appropriate supplemental inspection. Inspectors complete a team

inspection in March of that year, and in the exit meeting they identify an AV in the same

strategic performance area that is potentially greater-than-Green. The finding is finalized

White near the end of the second quarter. The start date of the new finding is the same

date as the exit meeting in which it was identified as an AV, held during the first quarter.

Therefore, the new finding counts as an Action Matrix input as of January 1st. Because

on January 1st the licensee had two White findings open and a White PI in the same

strategic performance area, three White Action Matrix inputs are open concurrently,

tripping the criteria for Column 3, the Degraded Performance Column, as of the

beginning of the first quarter, even though one of the inputs was closed before that

determination was made. Therefore, a 95002 supplemental inspection would have to be

scheduled.

e. Unresolved Items (URIs). URIs should be dispositioned in accordance with IMC 0612,

“Issue Screening,” and updated in RPS-Inspections when additional information

becomes available.

f. Significance Determinations under Appeal. The process by which a licensee may appeal

the staff’s final significance determination of an inspection finding documented in an

NRC inspection report or final significance determination letter is described in IMC 0609,

Attachment 2, “Process for Appealing NRC Characterization of Inspection Findings (SDP

Appeal Process).” If a licensee appeals the significance determination of a finding, that

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finding is counted in the Action Matrix until the staff notifies the licensee in writing of a

change in the final significance determination.

11.02 Performance Indicators

a. Licensees submit PI data on a quarterly basis. The PI data for a quarter are submitted to

the NRC approximately 21 days after the end of that quarter. If a greater-than-Green PI

is reported, a parallel PI finding will be issued with the same color as the PI. This parallel

PI finding becomes the Action Matrix input, with a start date being the first date of the

quarter for which the data were collected.

Example 11.02-1: A licensee submits its PI results for the first quarter to the NRC on

April 21st. For PIs that exceed a safety-significant threshold, a parallel PI finding will be

issued with a start date of January 1st.

When new PI data are received and become Action Matrix inputs for the applicable

quarter, the PI inputs should be considered with any other Action Matrix inputs that are

applicable during that quarter to determine the appropriate Action Matrix column and

associated actions.

Example 11.02-2: A White Mitigating Systems Cornerstone finding was closed after

1Q20YY. The licensee submits a White Mitigating Systems Cornerstone PI on April 21,

20YY. Because the parallel White PI finding would have a start date of January 1st and

the White finding is still an Action Matrix input for that quarter, the plant would remain in

Column 2 for two White inputs in the same cornerstone. If there were an additional White

finding or parallel PI finding in 1Q20YY, then the plant would transition to Column 3 in

1Q20YY, and an IP 95002 supplemental inspection would have to be performed.

b. PIs are not intended to be monitored on a real time basis. However, the regional office

may take the appropriate action if, based on current inputs, a PI will cross a performance

threshold at the end of the quarter. Appropriate actions can include supplemental

inspection planning, scheduling and informal communication with the licensee. However,

the plant does not change columns in the Action Matrix until the final PI data are

submitted, reviewed and posted following the end of the quarter, and any formal

communication with the licensee should not indicate the future Action Matrix column

designation except in an assessment follow-up letter.

c. If a safety-significant PI returns to the Green performance band in a subsequent quarter,

the PI is reported as Green on the ROP public website, the parallel PI finding remains

open and the licensee remains in the higher column of the Action Matrix until the

licensee satisfies the objectives of the appropriate supplemental inspection.

d. When a licensee satisfies the objectives of the appropriate supplemental inspection, the

parallel PI finding will be closed and no longer count as an Action Matrix input as of the

date of the exit meeting, or re-exit meeting, if applicable, after the final inspection report

and assessment follow-up letter are issued, similar to the closure of safety-significant

inspection findings. If the PI continues to be safety significant, e.g., White, the PI will be

reported as such on the ROP public website, but the plant will still transition to a lower

column of the Action Matrix based on closure of the parallel PI finding if there are no

other Action Matrix inputs.

Issue Date: 05/04/23 28 0305

e. If a parallel PI finding is closed because of satisfactory completion of the appropriate

supplemental inspection, and the licensee continues to accumulate additional

occurrences to the same PI, the region has several options. First, if the supplemental

inspection was completed before the licensee implemented the corrective actions

reviewed, then additional occurrences to the PI may not be unexpected until those

corrective actions have been implemented or have had time to become effective. In this

case, the region may take no action pending implementation of those corrective actions.

If corrective actions have been implemented and there are additional hits to the PI,

inspectors could perform a PI&R semi-annual trend review or focused PI&R sample to

determine if the corrective actions to prevent recurrence have been effective or not,

depending on the causes. The regional office should consider issuing a violation of

10 CFR Part 50, Appendix B, Criterion XVI, “Corrective Action,” if appropriate. If a

licensee reports the PI in a subsequent quarter as having crossed the next higher

significance threshold, e.g., Yellow, then a Yellow parallel PI finding will be opened, the

original White parallel PI finding will be closed, and an assessment follow-up letter will

be issued moving the plant to the appropriate Action Matrix column, in this case

Column 3.

f. If the licensee does not satisfy all the objectives of the appropriate supplemental

inspection, the region should follow the guidance described above in sections 11.01.d

and 11.01.e.

11.03 Other Action Matrix Input Considerations

a. Double-Counting PIs and Inspection Findings. Some issues may result in a

simultaneous safety-significant PI and safety-significant inspection finding. For example,

a single performance issue in the Mitigating Systems Cornerstone could result in an

inspection finding and count toward the PI as a failure with unavailability. In accordance

with the Action Matrix, this would result in two or more assessment inputs causing

increased regulatory action.

However, when safety-significant inspection findings and PIs have the same underlying

cause, they should not be “double-counted” in the Action Matrix in any given quarter.

The double counting principle should be applied each quarter in order to reassess Action

Matrix inputs using the available current PIs and inspection findings. The Action Matrix

column representing the highest degree of safety significance should be used when

there is flexibility in deciding which inputs should be used or excluded from the Action

Matrix.

The double-counting principle is not applied across PIs. For example, a system failure

could be counted in two PIs with both crossing performance thresholds into the White

performance band. In this situation, the plant would remain in Column 2 assuming no

other safety-significant Action Matrix inputs. However, if the failure resulted in only one

PI crossing a performance threshold, and the system failure was assessed by the SDP

as a White finding, the double-counting rule would need to be considered.

When applying the double-counting criteria and the most conservative outcome, the

inspection finding input should be calculated out (removed) from the PI calculation, and

the remaining inputs should be evaluated and used in the Action Matrix. The PI does not

actually change color. If there is a safety-significant PI and an inspection finding with the

same underlying cause and if it was determined that the PI would remain White even

Issue Date: 05/04/23 29 0305

with the failure removed from the PI calculation, then both the PI input and the inspection

finding would count.

Example 11.03-1: A licensee accrues three PI occurrences in occupational radiological

health in the first quarter resulting in a White PI. In the third quarter, two of the

occurrences roll off and the PI returns to Green. In the fourth quarter, the licensee

accrues two additional PI occurrences. The NRC conducts a supplemental inspection in

the fourth quarter that reviews the first three occurrences and concludes that the parallel

PI finding remains open. In the first quarter of the following year, one occurrence rolls off

but the licensee accrues a third additional PI occurrence.

In the fourth quarter, the PI again goes White, but because one of the PI occurrences is

already covered by the parallel finding, the White PI is not considered in determining the

Action Matrix column. However, in the first quarter of the following year, the third

additional PI occurrence results in a White PI based solely on new PI occurrences, so

the plant would remain in Column 2 because of two White inputs in the Action Matrix. If

there were an additional White finding or PI in the same cornerstone, the plant would

move to Column 3 due to the three White inputs.

When processing an inspection finding that is being considered under the double

counting rule, the Region may consider delaying the performance of the supplemental

inspection for the greater-than-Green PI until the final significance determination has

been completed to ensure the appropriate supplemental inspection is conducted.

b. Repetitive Degraded Cornerstone. A repetitive degraded cornerstone is defined in

section 04.

If multiple safety-significant findings are concurrent Action Matrix inputs, a supplemental

inspection can close one or more findings to prevent entry into Column 4. For example,

suppose three White findings, which meet the Column 3 entry criteria, all start in the

same quarter. If the IP 95002 supplemental inspection results in two of the findings

being closed but the other White finding remaining open, the plant would not transition to

Column 4. Although the plant would remain in Column 3 until the IP 95002 could be

completed successfully, a degraded cornerstone would not exist for more than five

quarters.

11.04 Supplemental Inspections

a. Until the supplemental inspection is satisfactorily completed for the highest column of the

Action Matrix assigned, the licensee shall remain in the higher column of the Action

Matrix, even though subsequent quarters might indicate that one or more greater-thanGreen inspection findings or PIs are no longer present in the Action Matrix.

b. When the assessment program was being developed, the Commission directed the staff

to improve the timeliness of the NRC assessment program in order to enhance the

ability to identify declining performance early. To support this objective, the NRC’s

supplemental inspections should be completed in a timely manner.

c. If a supplemental inspection is performed for a safety-significant inspection finding, and

the region concludes that the licensee adequately addressed the finding and exits the

inspection, then the finding will be closed, and the plant can change Action Matrix

columns. While the closure date of the finding will be the date of the exit meeting for the

Issue Date: 05/04/23 30 0305

satisfactorily completed supplemental inspection, no finding may be closed without the

closure being documented in an inspection report, and no licensee may change Action

Matrix columns without the movement being documented in an assessment follow-up

letter. When the supplemental inspection report and assessment follow-up letter are

issued, the cover letter will state that the finding is closed and no longer an Action Matrix

input as of the date of the exit meeting. If no other safety-significant Action Matrix inputs

exist, then the letter will state the licensee moved back to Column 1 as of the date of the

exit meeting. An assessment follow-up letter would be issued in accordance with section

07.01, and the NRC’s public Action Matrix website would be updated in accordance with

IMC 0306.

d. The regional office shall still perform a supplemental inspection if a safety-significant PI

returns to the Green performance band before the supplemental inspection is completed

because the parallel PI finding remains open. This includes the situation where a PI

reverts to Green because of the time dependence of the PI calculation, plant

modifications, and/or changes to the probabilistic risk assessment before the

supplemental inspection has been conducted. The plant remains in the higher column

until all objectives of the supplemental inspection have been met.

Example 11.04-1: A PI turns White in the second quarter and returns to Green in the

third quarter. The region exits an IP 95001 inspection in the fourth quarter, and issues

the inspection report and assessment follow-up letter late in the fourth quarter. All other

Action Matrix inputs are currently Green in the fourth quarter. The plant would transition

to Column 1 in the fourth quarter on the date of the exit meeting for the supplemental

inspection upon issuance of the assessment follow-up letter.

e. The scope of supplemental inspections could include all currently open safety-significant

performance issues in all cornerstones and strategic performance areas.

Example 11.04-2: If an IP 95002 inspection is being performed because of a Yellow PI in

the Mitigating Systems Cornerstone, the scope could also include any White inspection

findings and PIs in that cornerstone or any other cornerstone.

Example 11.04-3: If an IP 95002 inspection is being performed because of three White

findings in the Reactor Safety Strategic Performance Area, the scope could include

White PIs and inspection findings in all strategic performance areas and cornerstones.

f. If a White inspection finding or PI subsequently occurs in an unrelated cornerstone or

strategic performance area, the associated supplemental inspection should be

conducted at the appropriate level.

Example 11.04-4: A regional office is performing an IP 95002 for three White findings in

the Initiating Events Cornerstone. If an additional White inspection finding is identified in

the Occupational Radiation Safety Cornerstone, then the regional office should inspect

this finding using IP 95001.

g. If a plant moves to the right in the Action Matrix (i.e., has a higher column number)

because a safety-significant input starts while other safety-significant inputs are open,

then the applicable supplemental inspection for the higher column shall be performed

even if the lower column’s supplemental inspection was already performed or scheduled

to be performed for the first input. The plant will remain in the higher column until the

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supplemental inspection for the higher column is completed and the conditions in

section 11.04.b or 11.04.c are met.

The regional office can perform the first supplemental inspection before performing the

supplemental inspection for the higher column. If the first supplemental inspection

objectives are met, then the applicable input would no longer be considered with other

Action Matrix inputs in accordance with the guidance in section 11.

Likewise, any inspection finding, which is satisfactorily inspected and resolved through

an IP 95001 inspection and considered isolated from the other findings or PIs inspected,

can be closed once the supplemental inspection has been satisfactorily completed. The

basis for the NRC’s actions should be stated in the inspection report cover letter. The

cover letter should also include the licensee actions necessary to close any open

findings or parallel PI findings. However, the licensee shall not move across the Action

Matrix column in accordance with section 11.04.a.

Example 11.04-5: A plant has a White finding starting in the first quarter, the NRC

completes an IP 95001 inspection in the third quarter, and the plant has two additional

White inputs in the same cornerstone starting in the third quarter. Because the plant

would enter Column 3 in the third quarter, the licensee would stay in Column 3 until the

IP 95002 inspection results in the determination that the licensee adequately evaluated

and addressed the issues. Even though the initial White finding would no longer be

active in the Action Matrix because it was closed upon satisfactory completion of the

supplemental inspection, the plant remains in Column 3 until the IP 95002 is completed

as just described.

h. The regional offices should coordinate with NSIR to close greater-than-Green security

findings related to force-on-force exercise deficiencies because closure of these types of

findings may require a force-on-force exercise re-inspection performed by NSIR.

i. For licensees transitioning to Column 4, the Region should consider a phased approach

for conducting the IP 95003 supplemental inspection to inform whether continued

operation of the facility is acceptable and to decide whether additional regulatory actions

are necessary to arrest declining plant performance. This could entail conducting some

sample reviews of key attributes of the affected Strategic Performance Area before the

licensee completes its evaluations to provide NRC decision-makers with timely

information.

11.05 Treatment of Items Associated with Enforcement Discretion

A finding that includes a violation that meets the criteria discussed below will be

processed as specified in this section. The intent of this section is to establish ROP

guidance that supports the objective of enforcement discretion, which is to encourage

licensee initiatives to identify and resolve problems, especially those subtle issues that

are not likely to be identified by routine efforts.

The purpose of this approach is to place a premium on licensees initiating efforts to

identify and correct safety-significant issues, which are not likely to be identified by

routine efforts, before degraded safety systems are called upon to work. The

assessment program evaluates present performance issues, and this approach excludes

old design issues from consideration of overall licensee performance in the Action

Matrix. The DRP or DRS division director will authorize the treatment of findings as old

Issue Date: 05/04/23 32 0305

design issues after conferring with the Deputy Director, NRR/DRO. This is not an Action

Matrix deviation.

A finding that includes a violation subject to enforcement discretion must be

dispositioned under one of the following categories:

a. Treatment of Old Design Issues in the Assessment Process. A finding associated with

engineering calculations or analysis, associated operating procedure, or installation of

plant equipment is considered an Old Design Issue if it meets all of the following criteria:

1. It was licensee-identified as a result of a voluntary initiative, such as a design basis

reconstitution. For the purposes of this IMC, self-revealing findings, which are

defined in IMC 0612, are not considered to be licensee-identified.

2. It was or will be corrected, including immediate corrective actions and long-term

comprehensive corrective actions to prevent recurrence, within a reasonable time

following identification (this action should involve expanding the initiative, as

necessary, to identify other failures resulting from similar causes). For the purpose of

this criterion, identification is defined as the time when the significance of the finding

is first discussed between the NRC and the licensee. Accordingly, issues being cited

by the NRC for inadequate or untimely corrective action are not eligible for treatment

as old design issues.

3. It was not likely to be previously identified by recent ongoing licensee efforts, such as

normal surveillance, quality assurance activities, or evaluation of industry

information.

4. It does not reflect a current performance deficiency associated with existing licensee

programs, policy, or procedure.

If all the old design issue criteria are met, then the finding would not aggregate in the

Action Matrix with other PIs and inspection findings.

If the old design issue criteria are not met, then the finding would be treated similar to

any other inspection finding and additional NRC actions would be taken in accordance

with the Action Matrix.

Overall Inspection Approach

The finding considered for treatment as an old design issue shall be brought to a SERP

and a Regulatory Conference, if applicable. The finding shall be discussed in the

appropriate inspection report cover letter and displayed on the NRC’s website with its

actual safety significance after the final safety significance is determined.

If enough information is known to determine that the finding meets the old design issue

criteria, then the licensee shall be notified in the inspection report cover letter that the

finding was determined to be an old design issue. The regional office shall perform an

IP 95001 supplemental inspection for a White finding or an IP 95002 supplemental

inspection for a Yellow or Red finding to review the licensee’s causal evaluation and

corrective action plan for that particular issue. Because old design issues often predate

current licensee policies and practices, performing a review of the licensee’s safety

culture as part of an IP 95002 inspection may not be necessary. If the region determines

Issue Date: 05/04/23 33 0305

that a safety culture review is not required as part of an IP 95002 inspection for an old

design issue, the region should document that the review was not performed and include

justification in the inspection report.

Example 11.05-1: The NRC concluded that a White finding in the Mitigating Systems

Cornerstone meets the criteria for an old design issue for a plant. The plant also has a

White PI in the Mitigating Systems Cornerstone. This plant would be placed in Column 2

of the Action Matrix because of the White PI, and NRC actions would be taken in

accordance with that column, including an IP 95001 supplemental inspection for the

White PI. The old design issue does not aggregate with other inputs in determining the

Action Matrix column or required NRC response. Therefore, the White old design issue

would be considered independently, and an IP 95001 supplemental inspection for that

issue would be conducted.

If additional information is needed to determine whether the finding meets the old design

issue criteria, the inspection report cover letter should state that the finding is being

considered for treatment as an old design issue. The regional offices should then

perform an IP 95001 supplemental inspection for a White finding or an IP 95002

supplemental inspection for a Yellow or Red finding to review the licensee’s causal

evaluation of that particular issue and to gather the additional information required to

determine whether the finding meets the old design issue criteria.

Example 11.05-2: The regional office does not have enough information to determine if a

Red finding meets the criteria for an old design issue. The regional office would perform

an IP 95002 inspection to review the causal evaluation and gather additional information

on whether the finding meets the criteria for an old design issue. As a result of the

inspection, if the regional office determines that the criteria have not been met, the

regional office would perform the additional inspection activities to complete

supplemental inspection requirements for an IP 95003 inspection.

b. Violations in Specified Areas of Interest Qualifying for Enforcement Discretion. Findings

that include violations subject to the following enforcement discretion may be

dispositioned as described below:

• Enforcement discretion in accordance with the Interim Enforcement Policy Regarding

Enforcement Discretion for Certain Fire Protection Issues (10 CFR 50.48(c)) included

in the Commission’s Enforcement Policy.

The NRC will normally refrain from processing the related inspection finding through the

SDP and into the Action Matrix, if applicable. The finding must be documented in an

inspection report noting that the related violation meets all applicable requirements for

enforcement discretion as explicitly provided for in the associated authorizing document,

and further meets the criteria listed below.

1. The licensee places the finding into its corrective action program. Licensees may

track pre-existing performance deficiencies/violations and findings identified during

the National Fire Protection Association (NFPA) 805, “Performance-Based Standard

for Fire Protection for Light-Water Reactor Electric Generating Plants,” transition

period, through the Licensee Event Report (LER) process. It is recommended that an

LER be developed for each fire area or each area of assessment.

Issue Date: 05/04/23 34 0305

2. In cases where the finding is being given discretion, the staff may perform the most

expeditious of either an SDP evaluation using IMC 0609 Appendix F, “Fire Protection

Significance Determination Process,” or a qualitative evaluation using IMC 0609

Appendix M, “Significance Determination Process Using Qualitative Criteria,” to

ensure the finding is not of high safety significance (red).

3. The licensee performs an operability evaluation (when applicable) using the

guidelines in IMC 0326, “Operability Determinations”,” to demonstrate that safety will

be maintained during operation (both power operation and shutdown, as applicable)

with compensatory measures as appropriate.

4. Licensees will implement appropriate compensatory measures for each finding

immediately upon identification. Such compensatory measures will be maintained

while the licensee completes their NFPA 805 evaluation and (1) determines whether

the existing configuration is acceptable based on risk analysis, or (2) there is a need

for permanent corrective action if the existing configuration is not acceptable, and the

corrective action is completed.

If the above criteria are not met, the staff may take whatever action is deemed

necessary and appropriate, including the issuance of enforcement action, entry into the

SDP, and, if applicable, the Action Matrix, and implementation of supplemental

inspections.

The cover letter that informs the licensee of the staff’s exercise of enforcement discretion

should include a clear explanation of the staff’s basis for exercising enforcement

discretion, including a reference to the applicable authorizing document(s) and this

section. Cover letters should also be consistent with the guidance provided in the

Enforcement Manual.

If a single finding has multiple related violations of which only a subset are eligible to be

granted enforcement discretion, then the finding will be dispositioned in accordance with

the normal SDP and Action Matrix process using the assumption that only the violations

not subject to enforcement discretion existed. The violations subject to enforcement

discretion will be processed and documented as findings in accordance with the

provisions of this section.

PI inputs received as a result of issues receiving enforcement discretion during transition

to NFPA 805 should be evaluated for exclusion from consideration of overall licensee

performance in the Action Matrix on a case-by-case basis. The DRP, DRS, DORS, or

DRSS division director will authorize the exclusion of inputs after conferring with the

Deputy Director, NRR/DRO. This is not an Action Matrix deviation.

11.06 Action Matrix Deviations

The regulatory actions dictated by the Action Matrix may not be appropriate in rare

instances. In these instances, the NRC may deviate from the Action Matrix to either

increase or decrease NRC action. The application of additional resources to evaluate

issues not related to licensee performance is not considered a deviation from the Action

Matrix. Guidance for applying additional resources can be found in section 07.03 of

IMC 2515.

Issue Date: 05/04/23 35 0305

a. An Action Matrix deviation is defined in section 04.02. An Action Matrix deviation may be

considered for a situation such as a type of finding unanticipated by the SDP that results

in an inappropriate level of regulatory attention when entered into the Action Matrix.

Examples of approved deviations can be found on the NRC’s public “ROP Action Matrix

Deviations” website.

b. A memorandum requesting an Action Matrix deviation shall be initiated by the applicable

regional office. The memorandum shall include a synopsis of the licensee’s performance

issues, the required NRC actions per the Action Matrix for these issues, the proposed

alternative actions, and the region’s basis for requesting the deviation. The draft

memorandum should be emailed to NRR/DRO/IRAB via

ROPassessment.Resource@nrc.gov for awareness. Comments may be offered for

regional consideration. The region should then place the document in the NRC’s

ADAMS, create a concurrence package, and the RA should send the memorandum to

the Office Director of NRR for concurrence. NRR will then forward the memorandum to

the EDO for approval.

c. The EDO shall approve all deviations from the Action Matrix and inform the Commission

when deviations are approved and at the annual AARM Commission Meeting. [C1] After

the EDO approves the deviation, the document shall remain draft in ADAMS until the

licensee is notified via publicly available docketed correspondence, which is described

below.

d. Deviations from the Action Matrix shall be communicated to the licensee in an

assessment follow-up letter or annual assessment letter. This letter shall contain the

EDO-signed memorandum as an enclosure and shall also be emailed to

ROPassessment.Resource@nrc.gov. Both the letter and memorandum shall be made

publicly available after the licensee is notified of the deviation. The NRC’s public “ROP

Action Matrix Deviations” website will be updated in accordance with IMC 0306.

e. MD 8.14 requires NRR to ensure that the causes for deviations are understood and to

identify any necessary changes to the ROP guidance. To ensure that this requirement is

met, NRR/DRO/IRAB shall coordinate with the regional office that requested the

deviation to generate an ROP Feedback Form in accordance with IMC 0801, “Inspection

Program Feedback Process,” that describes the causes for the deviation,

recommendations for changes, if any, to ROP guidance, and the basis for the

recommendations to change or not change ROP guidance. In the ROP Feedback Form,

the regions should request that any recommended changes to ROP guidance be shared

with the other regional offices to ensure that all perspectives are considered.

f. Ensure that deviation documents containing SUNSI information are marked and handled

in accordance with Management Directive 12.6.

0305-12 TRANSITIONS BETWEEN OVERSIGHT PROCESSES

12.01 Transitioning to the IMC 0350 Process

The criteria for considering a plant for the IMC 0350 process include: (1) plant

performance is in Column 4 or 5 of the Action Matrix, or a significant operational event

has occurred as defined by MD 8.3, “NRC Incident Investigation Program;” (2) the plant

is shutdown or the licensee has committed to shut down the plant to address these

performance issues (whether voluntary or via an NRC order to shutdown); (3) a

regulatory hold is in effect, such as an NRC order; and (4) an NRC management

decision is made to place the plant in the IMC 0350 process.

Management considerations in placing a plant under the IMC 0350 process are

discussed in IMC 0350. At this point, periodic assessments (quarterly and end-of-cycle)

of licensee performance are no longer under the auspices of this IMC; rather, they are

now under the IMC 0350 process. This process is more completely described in

IMC 0350.

The following are examples of the appropriate level of regulatory engagement between

the NRC and a licensee once a plant has entered Column 4 of the Action Matrix and

how IMC 0350 may be applied:

a. Plant A continues to operate, and regulatory engagement is dictated by Column 4 of the

Action Matrix. The NRC performs an IP 95003 supplemental inspection (if not already

performed), issues a CAL to document licensee commitments, and the plant remains

under the level of oversight dictated by this IMC and is not transferred to the IMC 0350

process.

b. Plant B performs a voluntary shutdown to address performance issues. The NRC

performs an IP 95003 supplemental inspection (if not already performed) and issues a

CAL to document licensee commitments to the NRC. The plant remains under the level

of oversight dictated by this IMC and is not transferred to IMC 0350 process.

c. Plant C performs a voluntary shutdown to address performance issues. The NRC issues

a CAL to ensure a common understanding of licensee commitments to address the

underlying performance deficiencies. The entry conditions for IMC 0350 have been met

and NRC management determines that this process should be implemented using the

criteria in IMC 0350. At this point, periodic assessment of licensee performance is no

longer dictated by this IMC and is transferred to the IMC 0350 process. Plant

performance is not determined to be unacceptable.

d. Plant D voluntarily shuts down to address performance issues. The NRC determines that

one of the criteria in section 10.02.e. for unacceptable performance is met. The plant is

considered to be in the Unacceptable Performance Column of the Action Matrix, and a

shutdown order is issued by the NRC. The plant is transferred to the IMC 0350 process.

e. Plant E, which is operating, is issued an order by the NRC to shut down because it is

considered to have met one of the criteria in section 10.02.e. The licensee’s

performance is declared to be unacceptable, and the plant will be transferred to

IMC 0350.

12.02 Transitioning out of the IMC 0350 Process

Once the conditions for restart have been completed, as discussed in IMC 0350, the RA

will issue a restart authorization letter. If preexisting orders are involved, Commission or

EDO approval may be required. The restart authorization letter will include the basis for

restart and the extent of continued Restart Oversight Panel engagement. The panel will

determine the duration of its oversight activities and the date that the plant will be

assessed in accordance with IMC 0305.

Issue Date: 05/04/23 37 0305

Additionally, for a period of up to two years after the plant has exited the IMC 0350

process, the regional offices may use some actions that are consistent with the

Column 3 or 4 of the Action Matrix in order to ensure the appropriate level of NRC

oversight of licensee improvement initiatives. [C2]

These actions do not constitute a deviation from the Action Matrix. Actions can include

senior management participation at periodic meetings/site visits focused on reviewing

the results of improvement initiatives (such as efforts to reduce corrective action

backlogs and progress in completing the Performance Improvement Plan), the annual

public meetings, authorization of the contents of the subsequent assessment letters, and

non-baseline Order and follow-up inspections (not to exceed 200 hours0.00231 days <br />0.0556 hours <br />3.306878e-4 weeks <br />7.61e-5 months <br /> of direct

inspection over a maximum two-year period without concurrence from the Deputy

Director, NRR/DRO). The actions taken above those required by the Action Matrix shall

be discussed at the following end-of-cycle review meetings. These actions will also be

described in the following annual assessment letters until the end of the extended period

of time. All assessment letters that address these additional actions shall include the

Chief, NRR/DRO/IRAB on concurrence.

12.03 Transitioning out of the ROP for Decommissioning Units

Once licensees have submitted the 10 CFR 50.82 certifications for cessation of power

operations and permanent removal of fuel from the reactor vessel, the Region shall

notify the licensee, via letter, of their removal from oversight in accordance with the

operating power reactor inspection program. The licensee will then be subject to

oversight under IMC 2561, “Decommissioning Power Reactor Inspection Program.” A

template for the decommissioning oversight letter is provided in Exhibit 11.

The Region shall document the final assessment of licensee performance under the

ROP based on active Action Matrix inputs in the final resident inspection report cover

letter.

12.04 Transitioning from New Construction to the ROP

After the 10 CFR 52.103(g) determination (henceforth referred to as the 103(g)), the staff

will use this IMC to assess licensee performance and will consider results of all

inspection activities conducted onsite (i.e., ROP baseline, Operational Program, Startup

Testing, etc.). The staff will issue a single assessment letter that will focus on the ROP

assessment and status after the 103(g) finding. The letter will also note any open

operational program findings or construction ROP (cROP)-related issues.

When licensees transition to oversight under the ROP from a construction status, there

may be greater-than-Green operational program inspection findings identified under

construction oversight that remain open after the 103(g) determination is made.

If there are greater-than-Green findings associated with an operational program for

which the supplemental inspections were not successfully completed before the 103(g)

determination was made, the findings will remain open and will be assigned to the ROP

cornerstone that is most closely related to the finding. These findings will be considered

as inputs to the ROP Action Matrix upon initial implementation of the ROP. These

findings will remain open until the appropriate supplemental inspection is completed.

Greater-than-Green inspection findings mapped to a cornerstone that is more reliant on

a probabilistic risk assessment (PRA) (i.e., initiating events, mitigating systems, barrier

integrity), will not count in the ROP Action Matrix, but the licensee will be required to

have the appropriate supplemental inspection completed in order to close the finding.

Additional details on this topic can be found in the memo, “Transition to Reactor

Oversight Process for Vogtle Electric Generating Plant, Units 3&4” (ML20191A383).

0305-13 TRADITIONAL ENFORCEMENT FOLLOW-UP

13.01 Traditional Enforcement in the Assessment Process

Violations involving willfulness, impacting the regulatory process, or having actual safety

consequences are not adequately characterized by the SDP alone. For this reason, such

violations are referred to in this IMC as traditional enforcement violations. These

violations are processed in accordance with the NRC’s Enforcement Policy and

Enforcement Manual. Traditional enforcement violations may have underlying findings

that are assessed for significance using the SDP, and these findings shall be considered

in the assessment program and the Action Matrix.

Traditional enforcement violations shall be considered during the end-of-cycle review

when determining: (1) the range of NRC actions within the appropriate column of the

Action Matrix when various actions are possible within a column, (2) whether a crosscutting theme exists in the SCWE cross-cutting area (see section 14), and (3) the need

for more detailed follow-up in response to escalated enforcement actions or a series of

violations in one of the traditional enforcement areas of willfulness, impacting the

regulatory process, or actual consequences.

13.02 Traditional Enforcement Follow-up Inspections

Traditional enforcement violations without an underlying performance deficiency do not

influence the findings that result in a plant being assigned to a specific column of the

Action Matrix. However, traditional enforcement violations normally receive some level of

follow-up. If follow-up of traditional enforcement violations is planned, then it should be

coordinated with any other follow-up or supplemental inspections to avoid duplication of

effort. Follow-up of traditional enforcement violations is not considered an Action Matrix

deviation because traditional enforcement violations are outside of the ROP.

a. If a traditional enforcement violation was resolved using corrective actions negotiated

through the NRC’s Alternative Dispute Resolution (ADR) program, then the regional

office must follow up on items identified in the ADR confirmatory order. The unique

nature of each ADR settlement agreement should be used as a guide when selecting the

most appropriate inspection follow-up procedure. ADR follow-up may be performed

using IP 92702, “Follow up on Traditional Enforcement Actions Including Violations,

Deviations, Confirmatory Action Letters, Confirmatory Orders, And Alternative Dispute

Resolution Confirmatory Orders,” IP 92722, “Follow Up Inspection For Any Severity

Level I or II Traditional Enforcement Violation or for Two or More Severity Level III

Traditional Enforcement Violations in a 12-Month Period,” or IP 92723, “Follow-Up

Inspection for One Severity Level III and Two Severity Level IV Traditional Enforcement

Violations or for Three or More Severity Level IV Traditional Enforcement Violations in

the Same Area in a 12-Month Period.”

b. Traditional enforcement actions incurred by the licensee shall be continuously monitored

to determine if follow up inspection is needed. At the time a traditional enforcement

action is issued, the staff shall determine if the licensee meets the criteria for a follow-up

inspection under IP 92723 or IP 92722 by determining if any additional traditional

enforcement actions were issued during the previous 12 months within the same area of

willfulness, impeding the regulatory process, or actual consequences. If the region

determines that follow up inspection is appropriate, this will be documented in the cover

letter accompanying the enforcement action. If the region determines that follow up

inspection is not warranted, this should also be documented. The basis for either

decision should be described. Regions should consider only TE violations that involve

willfulness, impeding the regulatory process, or which involve actual safety

consequences when determining whether to discuss the need to perform a TE follow-up

inspection. The staff may also consider if additional follow-up inspection is warranted for

the traditional enforcement action under IP 92702; however, because individual TE

violations are outside of the ROP and follow-up may be conducted under a baseline

inspection procedure, documentation of the decision to implement or not implement IP 92702 is not required.

Individual traditional enforcement violations not involving ADR normally receive limited

follow-up using IP 92702 to ensure they have been captured in the licensee’s corrective

action program. If more detailed follow-up is planned using other inspection procedures,

performing the limited follow-up using IP 92702 is not required.

The regional office may perform IP 92722 to follow up on any SL I or II traditional

enforcement violation or two or more SL III violations incurred by the licensee during any

12-month period. The purpose of this inspection is to ensure that the causes of the

violations are understood and that the licensee has adequately evaluated the extent of

cause and the impact of the violations on safety culture. The regional office may perform

IP 92723 to follow up on three or more SL IV violations or one SL III and two SL IV

violations in one of the traditional enforcement areas of willfulness, impacting the

regulatory process, or actual consequences incurred by the licensee during any 12-

month period. Non-cited violations (NCVs) should be counted. The purpose of this

inspection is to ensure that the causes of the group of violations are understood, and

that licensee has adequately evaluated the extent of condition.

0305-14 CROSS-CUTTING ISSUES

The NRC identifies a cross-cutting issue (CCI) to inform the licensee that the NRC has a

concern with the licensee’s performance in the cross-cutting area and to encourage the licensee

to take appropriate actions before more significant performance issues emerge. The CCAs are

described in IMC 0310. CCAs are assigned, themes are monitored, and CCIs are identified on a

“per site” basis, not on a “per unit” basis. In order to determine whether CCIs exist at a site, an

assessment must be performed during the preparation for the second quarter assessment

review (four quarters from July – June) and end-of-cycle assessment meetings (four quarters

from January – December), as described below.

14.01 Cross-Cutting Themes

To determine if a cross-cutting theme exists at a site, the regional offices shall gather

inspection results related to CCAs, as described below.

a. Human Performance and Problem Identification and Resolution Themes. A search of

PIM entries should be conducted for findings having CCAs in the cross-cutting areas of

HU and/or PI&R. This should be completed based on two, overlapping, 12-month

assessment periods: January-December and July-June. A cross-cutting theme in the

area of HU or PI&R exists if six or more of these findings were assigned the same CCA.

The findings should be representative of more than one cornerstone; however, given the

significant inspection effort applied to the Mitigating Systems Cornerstone, a crosscutting theme can exist consisting of inspection findings associated with only this one

cornerstone.

A cross-cutting theme also exists if during the assessment period, a licensee has at least

20 findings with CCAs in the Human Performance cross-cutting area, or 12 findings with

CCAs in the Problem Identification and Resolution cross-cutting area.

b. Safety Conscious Work Environment Themes. SCWE-related issues from an 18-month

period (i.e., the second quarter assessment review or the end-of-cycle assessment

period and the two quarters preceding that period) shall be considered. Declining SCWE

trends take time to manifest; similarly, they also require time to correct and improve. For

this reason, an 18-month period after a SCWE theme is identified is warranted to assess

the effectiveness of SCWE-related corrective actions. The start date is the beginning of

the quarter in which the input counted, i.e., the same quarter as the start date of the

finding, or the date of the chilling effect letter or correspondence documenting potential

discrimination. A cross-cutting theme in the area of SCWE exists if at least one of the

following three conditions exists:

1. There is a finding in the PIM with a documented CCA in the area of SCWE, and the

impact on SCWE was not isolated.

For the purpose of this IMC, “not isolated” means more than one individual is

impacted (e.g., multiple individuals, functional groups, shift crews, or levels within the

organization are affected). Consideration should be given to: the roles,

responsibilities, and job functions of the impacted individuals; insights from the most

recent PI&R inspection; and the number and nature of allegations received during

the review period.

2. The licensee has received a chilling effect letter during the assessment period, or

one remains open.

3. The licensee has received correspondence from the NRC that transmitted (1) a SL I,

II, or III enforcement action that involved discrimination or (2) a confirmatory order

that involved discrimination. The theme applies only to the sites(s) where the

discrimination occurred.

If the Region documents that the licensee has adequately addressed the SCWE concern

identified in the chilling effect letter or enforcement correspondence and concludes it is

no longer indicative of current licensee performance during the 18-month review, then

the cross-cutting theme no longer exists and does not require documentation as a crosscutting theme in subsequent assessment letters.

14.02 Opening Cross-Cutting Issues

The first time that a licensee meets the criteria for a cross-cutting theme, the region will

document the theme in the assessment letter. The region should review licensee actions

with regards to a causal analysis and/or corrective actions for that theme.

For the second consecutive assessment period with the same cross-cutting theme, the

region will document the theme in the assessment letter again. If not already done, the

region should consider the effectiveness of licensee actions (e.g., additional findings with

the same aspect during the last six months of the assessment cycle) in determining

whether or not to perform additional follow-up of licensee corrective actions. Regional

follow-up of licensee corrective actions could be accomplished through a PI&R

inspection sample, a semi-annual trend review focused on the theme, or including it

within the scope of a biennial PI&R inspection, if one is scheduled during the period.

For the third consecutive assessment period with the same cross-cutting theme, the

region will open and document a cross-cutting issue (CCI) in the assessment letter,

except if the theme is in SCWE. Because SCWE-related issues take time to correct, an

18-month period after a SCWE theme is identified is warranted to assess the

effectiveness of SCWE-related corrective actions. Therefore, upon the fourth

consecutive assessment cycle with the same theme in SCWE, the Region should open a

CCI. However, if the Region concludes that the licensee has made sufficient progress in

addressing the SCWE concern, they may choose not to open a CCI, but continue to

document the cross-cutting theme until the licensee no longer meets the criteria.

If a licensee meets the criteria for a cross-cutting theme in more than one CCA and/or a

cross-cutting area, each theme will be documented separately in the assessment letter.

Multiple CCIs shall also be documented separately, if appropriate.

14.03 Closing Cross-Cutting Issues

a. CCIs can be closed only in assessment follow-up letters and annual assessment letters.

If applicable, CAL closure could serve as a basis for closing a CCI in the following

annual assessment letter. CAL closure for licensees exiting Column 4 of the Action

Matrix will serve as the basis for closing out any existing CCIs.

b. The regional office shall establish the criteria for closing the CCI, and that criteria should

be clearly described in the assessment letter. The CCI should be closed out through a

follow-up inspection. IP 71152 can be used to close out CCIs in the Human Performance

and PI&R cross-cutting areas. IP 93100 can be used to close out SCWE-related CCIs;

however, it would not typically be used to follow-up on licensee actions when a SCWE

theme is initially identified in order to give the licensee time to correct the concern.

Additional examples of closure criteria include, but are not limited to, the following or any

combination of the following:

1. Fewer findings with the same CCA as the CCI. In this case, if the number of findings

with the same CCA as the CCI in the current assessment period is less than the

number of findings when the CCI was opened, then the CCI could be closed.

2. Increased confidence in the licensee’s ability to address the CCI. In this case, if the

staff has confidence in the licensee’s scope of efforts or progress in addressing the

Issue Date: 05/04/23 42 0305

CCI, even though the cross-cutting theme criteria continue to be met, then the CCI

would be closed.

3. An improving trend in the number of findings with the same CCA as the CCI during

the most recent half of the assessment period. In this case, if the licensee made

significant improvements in the last half of the assessment period but still meets the

cross-cutting theme criteria, then the CCI could be closed.

c. The decision to continue to identify a CCI in the next assessment letter will be based on

whether the closure criteria were met.

14.04 Follow-up Actions for Cross-Cutting Issues

a. If the NRC issues a CAL to a licensee that confirms a licensee’s agreement to make

improvements and if the improvements would provide a basis for the region to close a

CCI, then the NRC’s follow-up and closure actions for the CAL can serve as CCI followup. The CCI closure criteria defined in the assessment letter can reference the CAL

actions.

b. After identifying a CCI to a licensee in an assessment letter, the staff shall follow-up on

the CCI. Examples of how the staff may follow-up on a CCI include: (1) semi-annual

evaluations conducted during the second quarter assessment and end-of-cycle

performance reviews, and (2) inspections performed in accordance with IP 71152. ADR

follow-up actions, as described in section 13.02.a, may also provide an additional

mechanism for CCI follow-up, if applicable.

c. In the second consecutive assessment letter identifying the same CCI, the regional

office may consider requesting: (1) the licensee to provide a response at an annual or

other public meeting; (2) the licensee to provide a written response to the CCI(s)

identified in the assessment letters, or (3) a separate meeting be held with the licensee.

If the NRC requests a meeting with the licensee, the plant’s Action Matrix column will be

used to determine the appropriate level of management to chair the meeting and

whether a public meeting is required. The regional branch chief or division director

should chair the meeting for plants in Column 1.

The regional office should use IP 71152 to evaluate the licensee’s progress in

addressing the CCI.

The regional office may request the licensee to perform an assessment of safety culture.

[C4] The regional office would typically request the licensee to perform an independent

safety culture assessment. The regional office could decide that a safety culture

assessment request is not necessary if the licensee has made reasonable progress in

addressing the issue but has not yet met the specific CCI closure criteria.

The regional office should review the licensee’s safety culture assessment using the

IMC 2515, Appendix C, infrequently performed inspection procedure, IP 40100. The

purpose of this inspection will be to confirm that the licensee is appropriately addressing

any weaknesses identified by the safety culture assessment. The inspection results

should be documented in an inspection report and can serve as a basis for closing the

CCI in the next assessment letter.

Issue Date: 05/04/23 43 0305

Because SCWE-related CCIs may be more difficult for licensees to address and that

corrective actions require more time to take effect, the regional office can defer

requesting the licensee to conduct a safety culture assessment and deciding to perform

the IP 40100 inspection until the third consecutive assessment letter identifying the

same SCWE-related CCI.

d. If the same CCI is identified beyond the second consecutive assessment letter, and all of

the options proposed above have been exhausted, the regional office may consider

additional actions (e.g., actions not prescribed by the Action Matrix) to address the issue.

One option is either the Regional Administrator, the Director of NRR, or both may

choose to meet with the licensee’s Board of Directors to discuss licensee performance.

Additional actions should be developed in consultation with the Director of NRR and the

EDO.

0305-15 REFERENCES

Atomic Energy Act of 1954 as amended

IMC 0306, “Planning, Scheduling, Tracking and Reporting of the Reactor Oversight Process

(ROP)”

IMC 0310, “Aspects within the Cross-Cutting Areas”

IMC 0326, “Operability Determinations”

IMC 0350, “Oversight of Reactor Facilities in Shutdown Condition Due To Significant

Performance and/or Operational Concerns”

IMC 0375, “Implementation of the Reactor Oversight Process at Reactor Facilities in an

Extended Shutdown Condition for Reasons Not Related to Performance”

IMC 0608, “Performance Indicator Program”

IMC 0609, “Significance Determination Process”

IMC 0609, Attachment 2, “Process for Appealing NRC Characterization of Inspection Findings

(SDP Appeal Process)”

IMC 0612, “Issue Screening”

IMC 0801, “Inspection Program Feedback Program”

IMC 2201, “Security Inspection Program for Operational Commercial Power Reactors”

IMC 2515, “Light-Water Reactor Inspection Program – Operations Phase”

IMC 2515, Appendix B, “Supplemental Inspection Program”

IMC 2515, Appendix C, “Special and Infrequently Performed Inspections”

IP 40100, “Independent Safety Culture Assessment Follow-up”

Issue Date: 05/04/23 44 0305

IP 71152, “Problem Identification and Resolution”

IP 92702, “Follow up on Traditional Enforcement Actions Including Violations, Deviations,

Confirmatory Action Letters, Confirmatory Orders, And Alternative Dispute Resolution

Confirmatory Orders”

IP 92722, “Follow Up Inspection for Any Severity Level I or II Traditional Enforcement Violation

or for Two or More Severity Level III Traditional Enforcement Violations in a 12 Month

Period”

IP 92723, “Follow-Up Inspection for One Severity Level III and Two Severity Level IV Traditional

Enforcement Violations or for Three or More Severity Level IV Traditional Enforcement

Violations in the Same Area in a 12-Month Period”

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

IP 95001, “Supplemental Inspection Response to Action Matrix Column 2 (Regulatory

Response) Inputs”

IP 95002, “Supplemental Inspection Response to Action Matrix Column 3 (Degraded Performance)

Inputs”

IP 95003, “Supplemental Inspection Response to Action Matrix Column 4 (Multiple/Repetitive

Degraded Cornerstone) Inputs”

MD 8.3, “NRC Incident Investigation Program”

MD 8.14, “Agency Action Review Meeting”

NFPA 805, “Performance-Based Standard for Fire Protection for Light-Water Reactor Electric

Generating Plants”

NRC Enforcement Manual

NRC Enforcement Policy

NUREG-2165, “Safety Culture Common Language”

END

Issue Date: 05/04/23 F1-1 0305

Figure 1: Reactor Oversight Process Action Matrix

Licensee Response

Column (Column 1)

Regulatory Response

Column (Column 2)

Degraded Performance

Column (Column 3)

Multiple/Repetitive

Degraded Cornerstone

Column (Column 4)

Unacceptable

Performance Column

(Column 5)

IMC 0350 Process1

RESULTS

All assessment inputs

(performance indicators

and inspection findings)

Green;

Cornerstone objectives

fully met

One or

Two White inputs in a

strategic performance

area;

Cornerstone objectives

met with minimal

degradation in safety

performance

One degraded cornerstone

(3 or more White inputs or

1 Yellow input), or

3 White inputs in any

strategic performance

area;

Cornerstone objectives

met with moderate

degradation in safety

performance

Repetitive degraded

cornerstone,

Multiple degraded

cornerstones,

Multiple Yellow inputs, or

One Red input;

Cornerstone objectives met

with longstanding issues or

significant degradation in

safety performance

Overall unacceptable

performance;

Plants not permitted to

operate within this band;

Unacceptable margin to

safety

Plants in a shutdown

condition with

performance problems

are placed in the

IMC 0350 process

RESPONSE

Regulatory

Performance

Meeting

None Branch Chief or Division

Director meets with

licensee

Regional Administrator or

designee meets with senior

licensee management.

EDO/DEDO or designee

meets with senior licensee

management

EDO/DEDO or designee

meets with senior

licensee management

RA/EDO or designee

meets with senior

licensee management

Licensee Action Licensee corrective

action

Licensee causal

evaluation and

corrective action with

NRC oversight

Licensee cumulative

causal evaluation with

NRC oversight

Licensee performance

improvement plan with NRC

oversight

Licensee performance

improvement & restart

plan with NRC

oversight

NRC Inspection Risk-informed baseline

inspection program

Baseline and

supplemental inspection

(IP 95001)

Baseline and supplemental

inspection (IP 95002)

Baseline and supplemental

inspection (IP 95003)

Baseline and

supplemental as

practicable;

Special inspections per

restart checklist.

Regulatory

Actions2

None Supplemental

inspection only

Supplemental inspection

only;

Plant discussed at AARM if

conditions met

10 CFR 2.204 DFI;

10 CFR 50.54(f) letter;

CAL/Order;

Plant Discussed at AARM

Order to modify, suspend,

or revoke license;

Plant discussed at AARM

CAL/Order requiring

NRC approval for

restart;

Plant discussed at

AARM

COMMUNICATION

Assessment

Letters

Branch Chief or Division

Director reviews and

signs assessment letter

w/ inspection plan

Division Director

reviews/signs

assessment letter w/

inspection plan

Regional Administrator

reviews/signs assessment

letter w/ inspection plan

Regional Administrator

reviews/signs assessment

letter w/ inspection plan

N/A. RA or 0350 Panel

Chairman review/ sign

0350-related

correspondence

Annual

Involvement of

Public

Stakeholders

Various public

stakeholder options

involving the senior

resident inspector or

Branch Chief

Various public

stakeholder options

involving the BC or DD

Regional Administrator or

designee discusses

performance with senior

licensee management

EDO/DEDO or designee

discuss performance with

senior licensee

management

N/A. 0350 Panel

Chairman conducts

periodic public status

meetings

External

Stakeholders3

None State Governors State Governors, DHS,

Congress

State Governors, DHS,

Congress

State Governors, DHS,

Congress

Commission

Involvement

None None Possible Commission

meeting if licensee remains

for 3 years

Commission meeting with

senior licensee

management within

6 months.4

Commission meeting with

senior licensee

management

Commission meetings

as requested;

Restart approval in

some cases.

INCREASING SAFETY SIGNIFICANCE 

Issue Date: 05/04/23 F1-2 0305

1 The IMC 0350 Process column is included for illustrative purposes only and is not necessarily representative of the worst level of

licensee performance. Plants in the IMC 0350 oversight process are considered outside the auspices of the ROP Action Matrix. See

IMC 0350, “Oversight of Reactor Facilities in a Shutdown Condition due to Significant Performance and/or Operational Concerns,” for

more information.

2 Other than the CAL, the regulatory actions for plants in the Multiple/Repetitive Degraded Cornerstone and IMC 0350 columns are

not mandatory NRC actions. However, the regional office should consider each of these regulatory actions when significant new

information regarding licensee performance becomes available.

3 These specific stakeholders shall be notified if a plant is moving to the specified column because of security-related issues.

4 The timing of the meeting shall be based on a collegial determination by the Commission informed by a recommendation from the

EDO, and may exceed the six-month requirement.

Issue Date: 05/04/23 F2-1 0305

Figure 2: Assessment Activities

Level of

Review Frequency/Timing

Participants

(* indicates

chairperson)

Desired Outcome Communication

Continuous Continuous SRI, RI, regional

inspectors, SRAs, DRO

Performance

awareness

None required;

Notify licensee by

an assessment

follow-up letter

only if thresholds

crossed

Quarterly Once per quarter;

Five weeks after

end of quarter

Division of Reactor

Projects (DRP) or

Division of Operating

Reactor Safety

(DORS): BC*, PE, SRI,

RI; DRO

Input/verify

PI/PIM data;

Detect early

trends

Update data set;

notify licensee by

an assessment

follow-up letter

only if Action

Matrix or crosscutting theme

thresholds

crossed. After

second quarter,

updated

inspection plans

provided to

licensees via

separate

transmittal letter.

End-ofCycle

At end-of-cycle;

Seven weeks after

end of assessment

cycle

DRS, DRP, DORS and

DRSS DD, RAs*, BCs,

principal inspectors,

SRAs, DRO, HQ offices

as appropriate

Assessment of

plant

performance,

oversight and

coordination of

regional actions

Annual

assessment letter

with an inspection

plan of

approximately

24 months

End-ofCycle

Summary

Meeting

Scheduled within

one week after the

completion of the

last regional end-ofcycle review

NRR OD, RAs, DRO,

OE, OI, other HQ

offices as appropriate

Summarize

results of the endof-cycle review

Information to be

discussed at

Agency Action

Review Meeting.

Agency

Action

Review

Meeting

Annually;

Several weeks after

issuance of the

annual assessment

letters

EDO*, NRR OD, RAs,

DRS/DRP/DORS/DRSS

DDs, DRO, OE, OI,

other HQ offices as

appropriate

Review of the

appropriateness

of NRC actions

Commission

briefing, followed

by public

meetings with

individual

licensees to

discuss

assessment

results, as

appropriate

Issue Date: 05/04/23 F3-1 0305

Figure 3: Reactor Oversight Process

• The Commission has decided that certain information related to findings and performance indicators pertaining to the Security

Cornerstone will not be publicly available to ensure that security information is not provided to a possible adversary. Therefore,

security-related information will not be discussed during public meetings.

Issue Date: 05/04/23 F4-1 0305

Figure 4: Regulatory Framework

Issue Date: 05/04/23 Att1-1 0305

Attachment 1: Revision History for IMC 0305

Commitment

Tracking

Number

Accession

Number

Issue Date

Change Notice

Description of Change Description of

Training Required

and Completion

Date

Comment Resolution

and Closed

Feedback Form

Accession Number

(Pre-Decisional, NonPublic Information)

N/A 04/24/2000

CN 00-009

Provide guidance on the assessment program that is

consistent with the Revised ROP

None

N/A

C1 03/23/2001

CN 01-009

Incorporated feedback from stakeholders and added

guidance on approval and notification of deviation

requests (Staff Requirements memo dated 5/17/00)

None

N/A

N/A 02/11/2002

CN 02-005

Incorporate lessons learned since ROP issuance None

N/A

N/A ML030520611

02/19/2003

CN 03-005

Incorporated feedback from stakeholders None

N/A

N/A ML040620054

01/29/04

CN 04-002

Incorporated feedback from stakeholders None

N/A

C2 ML043560249

12/21/2004

CN 04-028

Incorporated feedback from stakeholders. Review

deviations for possible changes to ROP guidance

and discussion of the deviations (Staff Requirements

memo dated 5/27/04)

None

N/A

C3 ML043560249

12/21/2004

CN 04-028

Utilizing independent assessments of licensee

performance (DBLLTF 3.3.3(1))

None

N/A

N/A ML052770021

11/15/2005

CN 05-029

Incorporated feedback from stakeholders Yes, computerbased training

08/30/2005

Issue Date: 05/04/23 Att1-2 0305

Commitment

Tracking

Number

Accession

Number

Issue Date

Change Notice

Description of Change Description of

Training Required

and Completion

Date

Comment Resolution

and Closed

Feedback Form

Accession Number

(Pre-Decisional, NonPublic Information)

C4 ML061520397

06/22/06

CN 06-015

Enhancing the ROP to more fully address safety

culture (SRM 04-0111)

Yes, computerbased training

and counterpart

meeting training

07/01/2006

ML061520403

N/A ML063120182

01/25/07

CN 07-003

Incorporate feedback from stakeholders None

N/A

ML070080358

N/A ML070870483

04/04/07

CN 07-012

Incorporated feedback from stakeholders to number

cross-cutting aspects.

None.

N/A

N/A (administrative

change)

C5 ML072770496

11/27/07

CN 07-036

Revised the Action Matrix for plants in Column 3 and

4 (SRM COMSECY-07-0005)

06/29/07

None.

N/A

ML073230132

N/A ML082770835

01/08/09

CN 09-001

Revised numerous guidance elements to address

implementation issues. Revised some safety culture

related elements as a result of the lessons learned

evaluations. Addressed ROP feedback forms 0305-

1190, 0305-1232, 0305-1202, 0305-1268, 0305-

1269, 0305-1295, and 0612-1231.

None.

N/A

ML083181119

N/A ML090700528

04/09/09

CN 09-011

Reformatted to improve usability. No changes to the

content.

None

N/A

N/A

N/A ML091490387

08/11/09

CN 09-020

Content added to incorporate the use of traditional

enforcement actions in the mid- and end-of-cycle

reviews

None

N/A

ML091940214

Issue Date: 05/04/23 Att1-3 0305

Commitment

Tracking

Number

Accession

Number

Issue Date

Change Notice

Description of Change Description of

Training Required

and Completion

Date

Comment Resolution

and Closed

Feedback Form

Accession Number

(Pre-Decisional, NonPublic Information)

N/A ML093421300

12/24/09

CN 09-032

Incorporated feedback. Revised to incorporate

program clarifications. Revised to clarify movement

in the Action Matrix. Revised to define the SCWE

cross-cutting theme. Revised to relocate guidance on

cross-cutting aspects.

None

N/A

ML093350363

N/A ML102730571

07/06/11

CN 11-011

Incorporated FBFs: 0305-1471, 0305-1514, 0305-

1518, 0305-1536, 0305-1560, 0305-1633, and 0105-

1640. Revised method Substantive Cross-Cutting

Issue documentation. Re-numbered various

sections, provided additional examples to others and

incorporated program clarifications.

None

N/A

ML11173A054

N/A ML12089A066

06/13/12

CN 12-009

Incorporated the Security Cornerstone into the

assessment process governed by IMC 0305.

None

N/A

ML12152A141

Issue Date: 05/04/23 Att1-4 0305

Commitment

Tracking

Number

Accession

Number

Issue Date

Change Notice

Description of Change Description of

Training Required

and Completion

Date

Comment Resolution

and Closed

Feedback Form

Accession Number

(Pre-Decisional, NonPublic Information)

ML14198A117

11/20/14

CN14-028

Revised definition of repetitive degraded

cornerstone. Revised to incorporate program

clarifications. Incorporated FBFs: 0305-1632, 1659,

1660, 1675, 1761, 1775, 1819, 1852, 1858, 1866,

1871, 1903, 1953, 1977, 1983, 1986, 1993, 2007.

None

N/A

ML14198A129

ML12198A252

ML12226A321

ML14204A360

ML12284A142

ML12284A157

ML14204A085

ML13070A100

ML14204A366

ML14204A093

ML13058A186

ML13183A043

ML14204A398

ML14204A479

ML14204A541

ML14204A654

ML14204A704

ML14204A719

N/A ML15089A315

04/09/15

CN 15-005

Revised to implement changes to the SCCI process,

henceforth referred to as the CCI process, to include

changes to thresholds for cross-cutting themes and

guidance on opening and closing CCIs. Revised to

address recommendations and suggestions from the

ROP Independent Assessment Report. Incorporated

FBFs: 0305-1646, 1647, 1919, 1971, 2004, 2005,

2113.

None

N/A

ML15084A111

ML15091A333

ML15091A336

ML15091A347

ML15091A349

ML15091A355

ML15091A357

ML15091A109

ML15091A210

ML15091A113

ML15091A366

Issue Date: 05/04/23 Att1-5 0305

Commitment

Tracking

Number

Accession

Number

Issue Date

Change Notice

Description of Change Description of

Training Required

and Completion

Date

Comment Resolution

and Closed

Feedback Form

Accession Number

(Pre-Decisional, NonPublic Information)

N/A ML15317A147

12/23/15

CN 15-032

Revised to change the definition of Degraded

Cornerstone (SRM SECY 15-0108, December 2,

2015), to make conforming changes resulting from

the revised definition, and to change the title of

Column 3 of the Action Matrix. Incorporated FBFs:

0305-1853, 1953, 2136, 2137, 2170.

None

N/A

ML15337A031

ML15355A032

ML15355A036

ML15355A040

ML15355A043

ML15299A208

ML15344A307

N/A ML16257A522

11/17/16

CN 16-031

Revised to remove requirement to hold formal midcycle assessment meetings. Requires a review of

cross-cutting aspects during the second quarter

assessment review, and to maintain issuance of

inspection plans semi-annually. Incorporated FBFs:

0305-2175, 2176, 2177, 2209

N/A ML16312A160

ML16098A171

ML16301A060

ML16098A167

ML16313A361

N/A ML18059A337

06/12/18

CN 18-016

Revised to update the language in section 07.03.c

regarding IMC 2515, App C inspections. Revision

also includes updates to clarify language in sections

0703.d and 13.02 regarding TE violations. A revision

to section 0305-14 was also made to provide

flexibility in determining if a CCI should be opened or

not. Section 07.03 was updated to include a

requirement to look at ‘open items’ at end-of-cycle

meetings.

N/A ML18059A373

0305-2245

ML18072A152

0305-2253

ML18072A148

0305-2298

ML18072A143

N/A ML19256A191

11/25/19

CN 19-037

Revised to clarify timing for opening a cross-cutting

issue, and to change references to inspecting

licensee root cause analyses to inspecting licensee

causal analyses for safety-significant findings.

Incorporated FBF 0305-2286.

N/A ML19225B958

0305-2286

ML19225B958

Issue Date: 05/04/23 Att1-6 0305

Commitment

Tracking

Number

Accession

Number

Issue Date

Change Notice

Description of Change Description of

Training Required

and Completion

Date

Comment Resolution

and Closed

Feedback Form

Accession Number

(Pre-Decisional, NonPublic Information)

N/A ML20273A317

11/04/20

CN 20-058

Revised to clarify start date of findings, to provide

additional guidance for issuing meeting notices and

meeting summaries for annual assessment public

meetings, and to provide clarifying guidance on

SCWE cross-cutting concerns. Additional guidance

was added for assessment of plants transitioning

from construction to operational oversight.

N/A ML20273A325

N/A ML21092A111

06/28/21

CN 21-022

Revised to address new Commission policy on public

meetings, to provide additional guidance on the twoyear PIM review for annual assessment meetings,

and to provide additional guidance on documenting

SCWE cross-cutting themes. Incorporated FBF

95002-2112.

N/A ML21092A112

N/A ML23093A184

05/04/23

CN 23-012

Incorporated new Commission policy from SRMSECY-22-0086. Revised to eliminate four-quarter

requirement for inspection findings to remain as

Action Matrix inputs, and revise treatment of greaterthan-Green Performance Indicators to remain as

Action Matrix inputs until satisfactory completion of

the appropriate supplemental inspection. Additional

guidance added to documenting cross-cutting

themes from cross-cutting issues effectiveness

review. Incorporated FBF 0303-2481.

N/A ML23090A156

ML23093A186

FBF 0305-2481

ML23090A156