ML18207A132
| ML18207A132 | |
| Person / Time | |
|---|---|
| Issue date: | 07/26/2018 |
| From: | Keefe M J NRC/NRR/DIRS/IRAB |
| To: | |
| Keefe MJ | |
| Shared Package | |
| ML18207A128 | List: |
| References | |
| CN 18-022 | |
| Download: ML18207A132 (8) | |
Text
Issue Date: 07/26/18 1 40100 NRC INSPECTION MANUAL IRAB INSPECTION PROCEDURE 40100 INDEPENDENT SAFETY CULTURE ASSESSMENT FOLLOWUP PROGRAM APPLICABILITY: IMC 2506, IMC 2515 C CORNERSTONES: ALL INSPECTION BASIS: This inspection procedure provides guidance for following up on a U.S. Nuclear Regulatory Commission (NRC) request for a licensee to perform an independent safety culture assessment. The NRC can ask a licensee to perform an independent safety culture assessment for the following situations: (1) a conclusion is reached during an inspection under Inspection Procedure (IP) Cornerstone or Any Three White Inputs in a Strategic evaluate the contribution of a safety culture trait to the performance issue, or (2) a licensee has not adequately addressed a repetitive cross-cutting issue (CCI), which may be indicative of underlying organizational issues with safety culture implications. Inspection Manual Chapter (IMC) 0305, guidance related to these situations. Some of the guidance in this inspection procedure could be applied to other unique situations (e.g., when reviewing a safety culture assessment performed as part of an alternative dispute resolution agreement). Chapter 6.4 of the Nuclear Regulatory Commission Enforcement Manual contains additional guidance related to alternative dispute resolution. As mentioned in the guidance, it is important that the inspector engage on a limited basis with the licensee early in the planning phase for the independent safety culture assessment. 40100-01 INSPECTION OBJECTIVES 01.01 To provide assurance that the licensee recognizes the safety culture cross-cutting trait deficiencies that caused or significantly contributed to risk-significant performance issues or repetitive CCIs.
Issue Date: 07/26/18 2 40100 01.02 To assess whether completed and proposed corrective actions should be considered sufficient and appropriate to address recognized cross-cutting traits deficiencies identified independent safety culture assessment. More guidance on conducting safety culture assessments can be found in IP 40100-02 INSPECTION REQUIREMENTS 02.01 Inspectors must have completed focus group moderation training before conducting focus group interviews. For guidance on conducting individual interviews, refer to IP 95003.02-B and C. 02.02 Inspectors should review potential safety-conscious work environment (SCWE) issues at the site (e.g., allegations, chilled work environments). 02.03 safety culture assessment to provide the following assurances: a. culture trait deficiencies that caused or significantly contributed to risk-significant performance issues or a repetitive CCI. b. uate to address recognized cross-cutting trait deficiencies that caused or significantly contributed to risk-significant performance issues or a repetitive CCI. The proposed corrective actions should provide reasonable assurance that risk-significant performance issues stemming from contributing and identified cross-cutting trait deficiencies will not recur. 02.04 assessment, data, communications, evaluation, implementation, and effectiveness assessment to be germane to IP 95002 objectives and feels that the results of IP 40100 would result in holding open a finding, then the assessment belongs in the supplemental inspection report. Otherwise, the assessment could usually be relegated to the quarterly integrated inspection report. 40100-03 INSPECTION GUIDANCE Some of the recommended followup activities, such as possible interviews or focus groups, can be more effectively performed by more than one inspector. This allows inspectors to collaborate as they interview, take notes, and confer on gathered insights.
Issue Date: 07/26/18 3 40100 The inspection can be accomplished by conducting discussions with site personnel in individual interviews or during focus groups. Discussions with focus groups would allow input from a broader number of individuals. In preparing for interviews and focus group discussions, inspectors should also review documentation associated with the assessment and the discussions is for the inspectors to gain a direct understanding of the views of site personnel. IP 95003.02-C (Agencywide Documents Access and Management System (ADAMS) Accession No. ML082630691;http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html) provides guidance for conducting focus groups. 03.01 Methodology Review. Inspectors should evaluate whether the safety culture assessment scope and methodology are consisthave an independent safety culture assessment performed. The inspection focus in this area should be applied with less depth than an inspection effort under IP Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple of the assessment tools and methodology. IP 95003.02 contains guidance on what methodologies the NRC considers to be acceptable. The inspector would use this information to conduct an independent safety culture assessment, if necessary. Therefore, when evaluating an assessment done by another entity, the inspector should apply the same standards as those in IP 95003.02. It is recommended that the inspector engage on a limited basis with the licensee early in the planning phase for the independent safety culture assessment. This provides the opportunity for the inspector to gain an understanding of thsafety culture assessment on a limited or sampling basis. However, when doing so, the inspector should be careful not to take any actions that could potentially affect the conduct or protocol to guide the conduct of licensee focus groups, but the inspector should not observe the focus groups because his or her presence may affect the conduct of the focus group (e.g., Inspectors should take care to ensure that their presence and activities do not bias the outcome 03.02 Independence of Assessment Team Members. Evaluate the degree of independence of the persons performing the assessment on behalf of the licensee. For an independent assessment, assessor personnel should not have direct authority or responsibility for any of the areas being evaluated. In this case, corporate licensee staff or utility staff from another site potentially could fulfill the assessor role. 03.03 Data Review. Inspectors should evaluate the licensee safety culture assessment data to determine if they support the assessment findings. The inspectors should briefly review the safety culture assessment data to look for trends or outlier groups (e.g., low response rates or deviations from the averages) and evaluate if the licensee took any followup actions to compensate or further investigate the reasons for the differences. Conducting a review of a sample of the data is important because sitewide averaging of the data could mask response rates from certain groups or specific negative inputs.
Issue Date: 07/26/18 4 40100 03.04 Effectiveness of Licensee Communications. Inspectors should evaluate a sample of the the assessment results, and the site response. Inspectors should determine if the licensee communicated the results of the safety culture assessment to plant staff using methods such as meetings in the field with plant staff and their supervisors, management presentations, or Internet postings. Inspectors should review the communication materials and message. During discussions (individual and/or focus group interviews) with site personnel, inspectors should gain an understanding of their interpretation communication materials and intended messages with the message the site personnel received. needed because it is important for the inspectors to understand the level of effort, emphasis, and consideration the licensee gives to its safety culture assessment and how it communicates the results and corrective actions to its line organization. 03.05 Licensee Evaluation of the Safety Culture Assessment Results and Implementation of Actions in Response to the Assessment (Primary Followup Emphasis). a. Inspectors should determine if the weaknesses identified by the safety culture assessment were tracked by the licensee using a formal program, such as a corrective action program, or an appropriate alternative, such as the employee concerns program (ECP). In some cases, corrective actions may involve sensitive areas, such as personnel actions or other matters that warrant confidentiality. This type of information may not be documented in any corrective action or ECP files and must be solicited or inferred from discussions with licensee officials (such as human resource personnel or senior management). The inspector should evaluate these circumstances and conduct activities to gather this information as needed. The inspector should determine the need-to-know basis. b. the safety culture assessment were appropriate based on the assessment results. c. actions for addressing the weaknesses identified by the safety culture assessment. Inspectors should ensure that the licensee addresses both sitewide issues and any specific issues (for example, targeted at a specific part of the organization). Inspectors should look for differences between sitewide versus unique organizational or departmental issues and evaluate how those differences are being treated by the Inspectors should evaluate whether licensee actions appear to be appropriate for the circumstances of the issue being targeted. For example, if the safety culture assessment detected deeper organizational problems, such as potential departmental SCWE issues, the licensee should typically take more substantial actions in response to the concern than simply providing a short training session on SCWE. Although short-term or limited-scope actions such as training or personnel changes can have positive impacts, effective corrective actions for producing lasting changes in organizational Issue Date: 07/26/18 5 40100 culture require a long-term focus. Discrete activities, such as communications (e.g., stand-downs and publication of policies) and training sessions, should be reinforced and evaluated for effectiveness. The licensee should have plans to monitor long-term progress and the capability and flexibility to make adjustments to corrective action plans as needed. d. If the licensee is crediting existing or previously-planned action plans to resolve any weaknesses identified by the safety culture assessment, inspectors should ensure the appropriateness of this credit given the scope and depth of the safety culture assessment issues. Although the issues may appear to be similar on the surface, insights from the safety culture assessment could indicate the need to expand or modify the preexisting action plans to thoroughly envelop the full scope and depth of the issues identified by the safety culture assessment, particularly because preexisting action plans could have contributed to the existing conditions. e. progress based on the types of corrective actions and their intended effects. The licensee may implement actions aimed at creating immediate changes or near-term improvements and other actions focused on long-term changes. It is important to note that some cultural changes may require several years or longer to develop, depending on the circumstances. However, short-term progress can be made and should be monitored. f. Inspectors should conduct discussions with licensee personnel, either through individual or focus group interviews (IP 95003.2-C contains guidance on conducting interviews and focus groups, as well as the strengths and weakness of each), to gain an understanding of their views on the conduct of the safety culture assessment, the personnel perceptions about the independence of the assessment. Inspectors should consider asking the questions listed below and evaluate if there appear to be any differences in the views of different levels of personnel or between groups. If there are differences, inspectors should investigate if site management has an understanding of the differences and is taking appropriate actions to address them. Inspectors should be prepared for discussion of other safety culture issues, SCWE issues, or allegations. (IP 95003.02 provides guidance for discussing safety culture issues, and IP 71152, issues.) 1. What do you remember about the safety culture assessment? 2. What are your thoughts on the quality of the assessment tool(s) (e.g., the survey, if one was used)? 3. What are your thoughts on the independence of the assessment tool(s) (e.g., the survey, if one was used)?
Issue Date: 07/26/18 6 40100 4. What communication or changes have you received from your management about to the safety culture assessment (e.g., before the assessment was conducted, during the assessment, and concerning the results of the assessment)? 5. Have you been provided feedback on planned corrective actions for the issues identified by the assessment? What are your views on the probable effectiveness of the corrective actions (both in progress and planned)? 6. trending in a positive or negative direction)? g. Inspectors should evaluate whether the licensee has established appropriate means to monitor or measure the effectiveness of the planned actions to address the weaknesses identified by the safety culture assessment. 03.06 Documentation and Expected Licensee Followup. The inspection report should assessment to be germane to IP 95002 objectives and feels that the results of IP 40100 would result in holding open a finding, then the assessment belongs in the supplemental inspection report. Otherwise, the assessment could usually be relegated to the quarterly integrated inspection report. The licensee is expected to address NRC-identified issues and weaknesses. These actions can include a request to perform additional independent safety culture assessments, evaluations, or corrective actions. 40100-04 RESOURCE ESTIMATE An independent safety culture assessment followup inspection is estimated to take 50 to 60 hours6.944444e-4 days <br />0.0167 hours <br />9.920635e-5 weeks <br />2.283e-5 months <br />. 40100-05 PROCEDURE COMPLETION Meeting the inspection objectives defined in Section 40100-01 of this IP will constitute completion. 40100-06 REFERENCES IMC IMC 0611 IIssue Screening IMC -Water Reactor Inspection Program Issue Date: 07/26/18 7 40100 IP Performance Area IP Nuclear Regulatory Commission Enforcement Manual END Attachment 1: Revision History Issue Date: 07/26/18 Att 1-1 40100 ATTACHMENT 1 Revision History for IP 40100 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, Non-Public Information) N/A ML080040273 04/05/11 CN 11-005 Initial Issue: searched commitments for 4 years and found none. This inspection procedure provides guidance for following up on an NRC request for a licensee to perform an independent safety culture assessment. N/A ML092520312 ML14072A073 03/14/14 CN 14-008 Revised administratively to align with the current version of IMC 0310, which was issued with Change Notice 13-029 FBF 0310-1945 N/A ML15090A437 04/09/15 CN 15-005 Editorial changes for consistency with terminology and changes to the original SCCIs N/A N/A N/A ML18207A132 07/26/18 CN 18-022 Editorial updates to meet 5 year metric. N/A N/A