IMC 0305, Operating Reactor Assessment Program
Operating Reactor Assessment Program
- 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
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,
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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.
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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
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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
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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
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
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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.
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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
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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
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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
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
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.
Issue Date: 05/04/23 38 0305
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.”
Issue Date: 05/04/23 39 0305
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.
Issue Date: 05/04/23 41 0305
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”
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 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
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
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
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
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
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
DRS/DRP/DORS/DRSS
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
N/A ML063120182
01/25/07
CN 07-003
Incorporate feedback from stakeholders None
N/A
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
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
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
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
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
N/A ML12089A066
06/13/12
CN 12-009
Incorporated the Security Cornerstone into the
assessment process governed by IMC 0305.
None
N/A
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)
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
ML12198A252
ML14204A360
ML12284A157
ML13070A100
ML14204A093
ML13183A043
ML14204A479
ML14204A654
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
ML15091A333
ML15091A347
ML15091A355
ML15091A109
ML15091A113
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
ML15355A032
ML15355A040
ML15299A208
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
ML16098A167
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
0305-2253
0305-2298
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
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