ML24166A198

NIST - Independent Third-Party Second Nuclear Safety Culture Assessment, Revision 1

ML24166A198
Person / Time
Site:	National Bureau of Standards Reactor
Issue date:	06/07/2024
From:	US Dept of Commerce, National Institute of Standards & Technology (NIST)
To:	Office of Nuclear Reactor Regulation
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ML24166A197	List: ML24166A198 ML24166A199
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Download: ML24166A198 (1)

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Page 1 of 170 Independent Third-Party Second Nuclear Safety Culture Assessment of the NIST Center for Neutron Research (Task 12)

Revision 1 Conduct of Assessment: March 27 Through June 3, 2024 Report Approval: June 7, 2024

Page 2 of 170 Contents EXECUTIVE

SUMMARY

............................................................................................................ 4 Purpose.................................................................................................................................. 4 Scope and Approach.............................................................................................................. 4 Summary of Results............................................................................................................... 4 Overall Conclusion................................................................................................................10 REPORT................................................................................................................................... 11 Methods of Analysis.................................................................................................................. 11 Analysis Results........................................................................................................................13 Objective 1: Personal Accountability......................................................................................13 Objective 2: Questioning Attitude...........................................................................................14 Objective 3: Effective Safety Communications.......................................................................15 Objective 4: Leadership Safety Values and Actions...............................................................17 Objective 5: Decision Making................................................................................................20 Objective 6: Respectful Work Environment............................................................................22 Objective 7: Continuous Learning..........................................................................................24 Objective 8: Problem Identification and Resolution................................................................27 Objective 9: Environment for Raising Concerns.....................................................................29 Objective 10: Work Processes...............................................................................................30 Safety Culture Performance Improvement.............................................................................33 Traits by OU Group...............................................................................................................33 Review of Internal Events......................................................................................................33 Review of External Information..............................................................................................35 Matrix of Initiatives to Recommendations..................................................................................37 Effectiveness Review............................................................................................................39 Attachments..............................................................................................................................40 : Survey Data Personal Accountability..............................................................41 : Survey Data Questioning Attitude...................................................................44 : Survey Data Effective Safey Communications................................................47 : Survey Data Leadership Safety Values and Actions........................................50 : Survey Data Decision-Making.........................................................................53 : Survey Data Respectful Work Environment....................................................56 : Survey Data Continuous Learning..................................................................59 : Survey Data Problem Identification and Resolution........................................62 : Survey Data Environment for Raising Concerns.............................................65

Page 3 of 170 0: Survey Data Work Processes.......................................................................68 1: Survey Data Status of NSC Improvement.....................................................71 2: Survey Data for Operations..........................................................................73 3: Survey Data for Reactor Engineering............................................................82 4: Survey Data for Health Physics....................................................................91 5: Survey Data for Aging Reactor Management................................................99 6: Survey Data for Other Groups.................................................................... 109 7: Survey Data Comparison 2023 to 2024...................................................... 117 8: Survey Question List................................................................................... 125 9: Review of Internal Events........................................................................... 130 0: Review of External Information................................................................... 132 1: Status of 2023 INSCA Recommendations................................................... 135 2: Status of 2023 INSCA Program Limiting Weaknesses................................ 145 3: Focus Group/Interviews Form..................................................................... 151 4: Meeting Observation Form......................................................................... 156 5: Behavioral Observation Form..................................................................... 158 6: INSCA Team Members, Assignments, and Bios.......................................... 161 7: INSCA Background Detail........................................................................... 164 8: NRC Inspection Report - Confirmatory Order Excerpt................................ 165 9: Definitions................................................................................................... 167 0: References................................................................................................. 170

Page 4 of 170 EXECUTIVE

SUMMARY

Purpose The Independent Nuclear Safety Culture Assessment (INSCA) Team conducted a second independent and comprehensive assessment of the existing Organizational Nuclear Safety Culture (NSC), including the Safety Conscious Work Environment (SCWE), at the NIST Center for Neutron Research. The assessment was performed in accordance with the requirements of the August 1, 2022, Confirmatory Order Modifying License No. TR-5 (Reference Attachment 27 and Attachment 28 for more detail). The Order required a second Nuclear Safety Culture Assessment, within 12 months of completing the initial assessment, to ensure sustainability and effectiveness of the identified recommended corrective actions within the identified areas.

Scope and Approach A highly experienced INSCA team evaluated the current NCNR 10 Traits of a Healthy Safety Culture that included SCWE, using a survey, focus group/interviews, meeting observations, and other data collection methods. The survey data supported what personnel believe and the focus group/interviews and observations demonstrated what personnel do to support a healthy NSC. The results were analyzed to identify Integrated Safety Culture (ISC) strengths and weaknesses. The strengths and weaknesses were then compared to the status of the existing seven initiatives, and twelve recommendations out of the 2023 INSCA, and formulated into recommendations to support continuing improvement and close any substantive gaps.

Summary of Results The overall results for each of the 10 Traits are provided below, with the supporting data and analyses being contained within the body of the report and attachments.

Trait 1: Personal Accountability (PA) - Individuals take personal responsibility for safety. The underlying Attributes include Standards (PA.1), Job Ownership (PA.2), and Teamwork (PA.3).

Positive Observation (PA.1): Understanding Standards and Responsibilities.

There is survey consensus on individuals understanding the importance of adherence to standards, encouraging teamwork, and responsibilities of raising safety concerns.

Recommendation:

1)

Initiative - Safety Culture: Stay the course.

Trait 2: Questioning Attitude (QA) - Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. The underlying Attributes include Nuclear is Recognized as Special and Unique (QA.1), Challenge the Unknown (QA.2), Challenge Assumptions (QA.3), and Avoid Complacency (QA.4).

Positive Observation (QA.2): Challenge the Unknown.

Personnel are questioning work practices, procedures, and equipment as evident in the increasing CAP inventory.

Page 5 of 170 Recommendation:

1)

Initiative - Safety Culture: Stay the course.

Trait 3: Effective Safety Communication (CO) - Communications maintain a focus on safety.

The underlying Attributes include Work Process Communications (CO.1), Bases for Decisions (CO.2), Free Flow of Information (CO.3), and Expectations (CO.4).

Positive Observation (CO.4): Communication Methods.

NCNR has increased the forms and frequency of communications since the 2023 INSCA. Examples include K-Wing newsletter, Plan of the Day Meeting, All-Hands Meeting, and Integrated Plant Schedule and Meeting.

Area in Need of Attention (CO.4): Communication Strategy Plan and Execution.

The communications strategy lacks a full plan and implementation. Communications are not always timely and with enough context to support full understanding. There is limited confirmation that messages sent are being received and understood by those with a need to know.

Recommendations:

1)

Initiative - Communications: Strengthen interim communication initiative and develop a strategy to support continuing communication improvement.

2)

Initiative - Communications: As a part of the planned strategy, take action to improve engagement to obtain feedback/confirmation on the quality, dissemination, and understanding of communications.

Trait 4: Leadership Safety Values and Actions (LA) - Leaders demonstrate a commitment to safety in their decisions and behaviors. The underlying Attributes include Resources (LA.1);

Field Presence LA.2); Incentives, Sanctions, and Rewards (LA.3); Strategic Commitment to Safety (LA.4); Change Management (LA.5); Roles, Responsibilities, and Authorities (LA.6);

Constant Examination (LA.7); and Leader Behaviors (LA.8).

Positive Observation (LA.4): Leader Engagement.

Leaders are engaged in working towards improvement, accepting of understanding of performance shortfalls, and development of improvement plans.

Positive Observation (LA.7): Integrated Safety Culture Monitoring Panel (ISCMP).

ISCMP has been established for the monitoring of safety culture traits and the identification of performance issues and actions to achieve and then maintain a healthy safety culture. This is a leading initiative within the Research and Test Reactor (RTR) industry. This is not an Area of Strength at this time in that there have been only two meetings and effective implementation is pending.

Area for Improvement (LA.1): Resource Management.

The availability of personnel and funds is inadequate to support procedure quality, engineering drawing quality, training to close gaps in skills and knowledge, and necessary Corrective Action Program (CAP) improvements. The procedure and drawing elements are a part of configuration management that over the years has resulted in discrepancies between procedures, drawings, and equipment.

Page 6 of 170 Area in Need of Attention (LA.2): Observation Program.

The Observation Program is being used by leaders but is not fully leveraged to improve performance and specifically field presence to communicate, model, and reinforce the behaviors.

Area For Improvement (LA.8): Reinforcement of Standards and Expectations.

Leaders are not consistent in their coaching and are missing opportunities for reinforcement of standards and expectations that are important to the NSC.

Recommendations

1)

Initiative - Resource Strategy: Conduct a review of the current levels of personnel and funds to identify critical underfunded area that comprise NSC and seek additional funding from NIST and Department of Commence (DOC).

Examples include procedure quality, drawing quality, training, and necessary CAP improvements.

2)

Initiative - Communications: Communicate and reinforce to NCNR personnel the expectation to, and importance of, promptly identifying deltas in procedures and drawings in comparison to actual plant configuration into the CAP for collective review of priority and level of resolution.

3)

Initiative - Safety Culture: Implement the following actions to improve the Behavioral Observation Program and Leader reinforcement of standards and expectations.

Educate leaders on using the ABC Model (Aubrey Daniels - Antecedent, Behavior, and Consequence) to influence leader and worker behaviors.

Develop and provide leaders observation forms/criteria that reflect desired behaviors.

Mentor of leaders in observing and coaching behaviors in addition to the Observation Program expectations, to ensure expectations are met and deviations in expectations are promptly identified and corrected on the spot or within the CAP.

4)

Initiative - Safety Culture: Roll out the ISC booklet and associated training for all workers.

Trait 5: Decision Making (DM) - Decisions that support or affect nuclear safety are systematic, rigorous, and thorough. The underlying Attributes include Consistent Process (DM.1),

Conservative Bias (DM.2), and Accountability for Decisions (DM.3).

Positive Observation (DM.2): Decision Making and Safety Margin.

NCNR staff are making informed, conservatively biased decisions with overt consideration of maintaining higher levels of safety margin.

Area in Need of Attention (DM.1): Stakeholder Participation in Decision Making.

Some safety decisions are made without engagement of some NCNR and NIST stakeholders. The communication of decisions by participants is not always timely and with adequate context/clarity as to why the decision was made, as to support personnel in the planning and scheduling of work functions.

Page 7 of 170 Recommendation

1)

Initiative - Communications: Update the Communications Strategy Initiative to include the element of decision-making. Specifically, updates to include more timely and complete communications on important decisions to increase awareness, understanding, and ability of personnel to contribute and provide feedback.

Trait 6: Respectful Work Environment (WE) - Trust and respect permeate the organization.

The underlying Attributes include Respect is Evident (WE.1), Opinions are Valued (We.2), High Level of Trust (WE.3), and WE.4 (Conflict Resolution).

Positive Observation (WE.2): Willingness to Raise Concerns.

Personnel are confident in their ability to raise safety concerns and will raise safety concerns.

Positive Observation (WE.3): Teamwork.

People are open, engaged, and willing to ask for help due to a respectful work environment and the level of teamwork.

Area in Need of Attention (WE.2): Engagement of Stakeholders.

NCNR is not consistent in engaging key NCNR personnel in plans and decisions.

Area in Need of Attention (WE.3): Feedback when Raising Concerns.

The behavior of raising concerns is not always consistently reinforced in a positive manner.

Recommendations

1)

Initiative - Safety Culture: Develop and incorporate actions within the Safety Culture Initiative with regard to providing positive reinforcement to individuals willing to raise concerns.

2)

Initiative - Safety Culture: Consider incorporating a question regarding key NCNR stakeholder participation (Organizational Groups (OU) and Integrated Safety) into NCNR decision-making guidance. Suggest placing in Integrated Management Model, Integrated Safety Culture Traits and Attributes Book, or procedure.

Trait 7: Continuous Learning (CL) - Opportunities to learn about ways to ensure safety are sought out and implemented. The underlying Attributes include Operating Experience (CL.1),

Self-Assessment (CL.2), Benchmarking (CL.3), and Training (CL.4).

Positive Observations (CL.4): Informal Training.

Health Physics group has bi-weekly training on selected topics.

Engineering group provides new hire indoctrination activities and monthly safety meetings.

Page 8 of 170 Area in Need of Attention (CL.1): Operating Experience.

NCNR is not consistently using internal and external Operating Experience (OE) and communicating the results, with recognition that external OE (other test reactors) is somewhat limited by the lack of industry communication methods. (Survey data driven ANA).

Area in Need of Attention (CL.4): Training Program Descriptions.

There is a lack of a consistent framework outside of Operations under which all groups in the OU can develop and implement consistent initial and continuing training programs.

Area for Improvement (CL.4): Training.

NCNR is not making progress fast enough, and in an integrated manner, to support OU groups and job performance across OU groups and job functions (i.e., Continuing Training, Supervisor Training, and General Employee Indoctrination).

Recommendations

1)

Initiative - Resource Strategy: Provide augmented resources to allow a systematic approach to implementing the Operations Training Program.

2)

Initiative - Training: Develop an overall strategy to improve training implementation across OU group functions and leader functions including the establishment of initial and continuing Training Program Descriptions.

3)

Initiative - Communications: Communicate to NCNR personnel expectations for the use of internal and external operating experience, and successes in the use of OE in improving performance.

Trait 8: Problem Identification and Resolution (PI) - Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. The underlying Attributes include Identification (PI.1), Evaluation (PI.2),

Resolution (PI.3), and Trending (PI.4).

Area of Strength (PI.1): Non-Conformance Process A Non-Conformance process has been added to the CAP and personnel identify and enter material, part, and component non-conformances for disposition and resolution.

This is a leading initiative within the Research and Test Reactor (RTR) industry.

Area of Strength (PI.1, PI.2, & PI.3): Establishment of the CAP Dashboard.

CAP Management has developed a CAP dashboard where groups and individuals can quickly access the status of CAP, Equipment Deficiencies, Observation Program, Drawing Deficiencies, ECNs, and Procedure Deficiencies items. This strength is a leading initiative within the Research and Test Reactor (RTR) industry.

Positive Observation (PI.1): Use of CAP.

There has been an overall increase in the use of the CAP since the 2023 INSCA.

Page 9 of 170 Area for Improvement (PI.1, PI.2 & PI.3): Leveraging CAP to Improve Performance.

Some personnel do not understand the scope and threshold for the entry of events, problems, and other issues in the CAP or which other programs should be used to identify and document issues.

Cause Analysts lack knowledge and proficiency in analysis tools and techniques.

There is limited use of the CAP dashboard due to a lack of reinforcement by management for personnel to use the dashboard.

CAP successes are not being communicated to promote and reinforce the use of CAP.

Recommendations

1)

Initiative - Performance Improvement - Finish building out the new CAP platforms (i.e., CAP dashboard, etc.) to improve the user interface, functionality, and visibility in problem identification, evaluation, and resolution.

2)

Initiative - Performance Improvement - Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.

3)

Initiative - Communications - Develop and implement a communication strategy to educate NCNR personnel on 1) the threshold for CAP entry, 2) their accountability for using CAP, 3) the importance of, promptly identifying nonconformances in procedures and drawings in comparison to actual plant configuration, and 4) reinforcement of CAP successes.

4)

Initiative - Training - Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.

5)

Initiative - Resources - Augment CAP resources and provide mentoring to support OU groups in problem identification, evaluation, and resolution.

Trait 9: Environment for Raising Concerns (RC) - A safety-conscious work environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. The underlying Attributes include SCWE Policy (RC.1) and Alternate Process for Raising Concerns (RC.2).

Positive Observation (RC.1): Raising Concerns.

Personnel, with a few exceptions, freely raise integrated safety concerns without fear of retribution and with confidence that their concerns will be addressed.

Area in Need of Attention (RC.2): Issue Employee Concerns Procedure.

The ECP has a designated office area and a program manager but lacks timeliness in issuance of the ECP procedure. The procedure has been developed and submitted to the NRC. Issuance has been delayed awaiting NRC concurrence.

Recommendation

1)

Initiative - Safety Culture: Develop and implement a change management plan to issue the ECP procedure.

Page 10 of 170 Trait 10: Work Processes (WP) - The process of planning and controlling work activities is implemented so that safety is maintained. The underlying Attributes include Work Management (WP.1), Design Margins (WP.2), Documentation (WP.3), and Procedure Adherence (WP.4).

Positive Observation (WP.1): Aligning Work and Priorities.

Use of the Plan of the Day (POD) and the 08:00 Meeting to align OU groups and personnel on work and priorities.

Positive Observation (WP.3): Finding and Fixing Procedures.

Personnel are finding and fixing procedure issues and the quality of procedures is generally improving.

Area in Need of Attention (WP.3): Procedure Quality.

Although there has been improvement, there are still issues with procedure quality involving errors and inconsistencies in content, and the process for changing procedures is slow.

Recommendations

1)

Initiative - Resource Strategy: Conduct a review of the current levels of personnel supporting procedures, drawings, and configuration management, and acquire and allocate resources as necessary to support integrated safety.

2)

Initiative - Procedures: Continue in the implementation of planned actions from the Procedure Initiative.

Overall Conclusion There has been a positive change in the NSC with the establishment of some foundational elements and changes in behaviors. A questioning attitude, coupled with the startup of a Corrective Action Program, is supporting the identification and correction of non-conformances, procedure deficiencies, and behavioral issues. Leaders are also making progress toward more informed and prudent decisions, and there is a more collaborative effort in the planning and scheduling of activities.

Areas for increased attention and improvement include procedure quality, personnel training, and leaders communicating and reinforcing standards and expectations. Behavioral areas for focus include ensuring the receipt and understanding of communications, leader field presence in observing behaviors, reinforcing expectations, and responding to the concerns for the workforce. An underlying cross-cutting issue is challenges in the number of personnel and adequacy of funding to support the improvement initiatives. The level of resources is currently significantly impacting the rate of necessary positive change in achieving a healthy and sustained integrated safety culture.

Page 11 of 170 REPORT Methods of Analysis This INSCA was conducted by a team of independent consultants with over 235 years of aggregate experience in nuclear leadership, operations, maintenance, engineering, work management, licensing, training, safety culture and the safety conscious work environments, problem identification and resolution (equipment, human performance, process, organizational effectiveness), and recovery at power reactors following events of industry significance (Reference Attachment 26).

The Team evaluated the current NCNR Traits of a Healthy Safety Culture including SCWE, using a survey with 94 questions followed by 16 focus group/interviews, observations of meetings and training, and other data collection methods, and identified strengths and weaknesses. (Reference Attachment 18, 23, 24, 25). There was the intent to observe work activities but due to limited activities during the on-site week there were no substantive observations.

The survey data supported what personnel believe and the focus group/interviews and observations supported what personnel do to support a healthy NSC. The results were used to identify Areas of Strength (AOS), Positive Observations (PO), Areas in Need of Attention (ANA),

and Areas for Improvement (AFI).

The Areas of Strength, Positive Observations, Areas in Need of Attention, and Areas for Improvement were then compared to the status of the Twelve Recommendations out of the 2023 INSCA, and subsequently NCNR established Seven Initiatives to improve overall the NSC.

The overall conclusions are presented in the Executive Summary.

The scope of the NSC Traits, Data Collection Methods, Survey, NSC Recovery Initiatives, and Interviews and Observations are briefly summarized below as a primer to the Analysis Results section of this report.

The NSC Traits The Traits included Personal Accountability (PA), Questioning Attitude (QA), Effective Safety Communication (CO), Leadership Safety Values and Actions (LA), Decision Making (DM), Respectful Work Environment (WE), Continuous Learning (CL), Problem Identification and Resolution (PI), Environment for Raising Concerns (RC), and Work Processes (WP).

The Data Collection Methods The methods included the Safety Culture Survey, Functional Analysis, Structured Focus Groups, Interviews, Observations of Meetings, Archived Data Review, Behavioral Anchored Rating Scales (BARS), and a Behavioral Checklist.

The Survey The survey consisted of 94 Questions across the NSC Traits, and was given across NCNR groups, with 65 respondents from Operations, Reactor Engineering, Health Physics, Aging Reactor Management, and Others. The data was broken down by All Respondents, Individual Contributors, Supervisors and Above, and OU groups.

Page 12 of 170 NSC Recovery Initiatives The Seven Initiatives included Communications, Safety Culture, Performance Improvement, Training, Procedures, Work Management, and Resource Strategy, as based on the previous 2023 INSCA Report Recommendations and Limiting Program Weaknesses (Reference Attachments 21 and 22 for status).

Interviews and Focus Groups There were multiple interviews and 16 focus groups comprised of personnel across OU groups at both the individual contributor and supervisor and above levels. The OU groups included Operations, Reactor Engineering, Health Physics, Aging Reactor Management, and Others. The NCNR Senior Leadership Team (SLT) was also interviewed as a part of data and insight collection, and there was a subsequent collegial review with the broader NCNR leadership team. The SLT and collegial reviews were only to gain additional insights and reduce the potential for any miss-characterization of performance. To clarify, the review with the leadership teams was not intended to, and did not, alter the independence of the NSC team or its conclusions.

Note: This report uses the term Nuclear Safety Culture (NSC) aligned with the Confirmatory Letter requirement to conduct a Nuclear Safety Culture Assessment. NCNR uses the term Integrated Safety Culture (ISC) that encompasses nuclear safety, occupational safety, radiological safety, security, and environmental safety, as defined in Attachment 29.

Page 13 of 170 Analysis Results Objective 1: Personal Accountability Trait: Personal Accountability (PA) - individuals take personal responsibility for safety. The underlying Attributes include Standards (PA.1), Job Ownership (PA.2), and Teamwork (PA.3).

The survey included 6 questions related to PA to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 1, to provide additional insights for leaders and others with a need or desire to know.

Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait PA identified the following:

The Assessment Category Area of Strength: None Area in Need of Attention: None Area for Improvement: None Positive Observation (PA.1): Understanding Standards and Responsibilities.

There is survey consensus on individuals understanding the importance of adherence to standards, encouraging teamwork, and responsibilities of raising safety concerns.

Page 14 of 170 Comparison of the Trait 2023 to 2024 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait PA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations

1)

Initiative - Safety Culture: Stay the course.

Objective 2: Questioning Attitude Trait: Questioning Attitude (QA) - Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. The underlying Attributes include Nuclear is Recognized as Special and Unique (QA.1), Challenge the Unknown (QA.2), Challenge Assumptions (QA.3), and Avoid Complacency (QA.4).

The survey included 9 questions related to QA to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 2, to provide additional insights for leaders and others with a need or desire to know.

Page 15 of 170 Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait QA identified the following:

The Assessment Category Area of Strength: None Area in Need of Attention: None Area for Improvement: None Positive Observation (QA.2): Challenge the Unknown.

Personnel are questioning work practices, procedures, and equipment as evident in the increasing CAP inventory. The inventory was 58 at the time of the 2023 INSCA and is currently at 363. Status as follows:

344 CAPs 88 Fully Closed 254 CAP Items with actions being worked to closure.

~100 CAP Items less than 120 days old. 92 Level 0 and 1.

107 CAP Items greater than 120 days old.

Comparison of the Trait 2023 to 2024 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations

1)

Initiative - Communications: Stay the course Objective 3: Effective Safety Communications Trait: Effective Safety Communication (CO) - Communications maintain a focus on safety. The underlying Attributes include Work Process Communications (CO.1), Bases for Decisions (CO.2), Free Flow of Information (CO.3), and Expectations (CO.4).

The survey included 7 questions related to CO to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 3, to provide additional insights for leaders and others with a need or desire to know.

Page 16 of 170 Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait CO identified the following:

The Assessment Category Area of Strength: None Area for Improvement: None Positive Observation (CO.4): Communication Methods.

NCNR has increased the forms and frequency of communications since the 2023 INSCA.

Examples include K-Wing newsletter, Plan of the Day Meeting, and Integrated Plant Schedule and Meeting.

Area in Need of Attention (CO.4): Communication Strategy Plan and Execution.

The communications strategy lacks a full plan and implementation. Communications are not always timely and with enough context to support full understanding. There is limited confirmation that messages sent are being received and understood by those with a need to know.

Supporting information includes:

Emergent issues sometimes dont contain context - Confinement Entry Issues.

Communications - there has been an effort to improve but there are still surprises with no consequence. i.e., I&C Flow and Level Calibrations - radios ineffective in basement -

moved to level calibrations and inadvertently tripped LOCA protection.

Decisions about what we're doing next are often right before we do it. The "why" isn't always part of the explanation.

Communications continues to be a weak area for the management team. Even when products have been requested that explain the basis of decisions, dissemination of these

Page 17 of 170 products to interested parties (the staff and non-management chain stakeholders) is non-existent.

It doesn't matter how much we attempt to communicate, emails are ignored, or things are forgotten, to where an activity always surprises someone that should have known.

Comparison of the Trait 2023 to 2024 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations

1)

Initiative - Communications: Strengthen the follow up on the interim actions and develop strategy to support continuing improvement.

2)

Initiative - Communications: As a part of the planned strategy, take action to improve engagement to obtain feedback/confirmation on the quality, dissemination, and understanding of communications.

Objective 4: Leadership Safety Values and Actions Trait: Leadership Safety Values and Actions (LA) - Leaders demonstrate a commitment to safety in their decisions and behaviors. The underlying Attributes include Resources (LA.1); Field Presence LA.2); Incentives, Sanctions, and Rewards (LA.3); Strategic Commitment to Safety (LA.4); Change Management (LA.5); Roles, Responsibilities, and Authorities (LA.6); Constant Examination (LA.7); and Leader Behaviors (LA.8).

The survey included 16 questions related to LA to understand what people believe. The graph below is based on All Respondents. Individual Contributors, and Supervisors and Above, Survey results are provided in Attachment 4, to provide additional insights for leaders and others with a need or desire to know.

Page 18 of 170 Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait LA identified the following:

The Assessment Category Area of Strength: None Positive Observation (LA.4): Leader Engagement.

Leaders are engaged in working towards improvement, accepting of understanding of performance shortfalls, and development of improvement plans.

Positive Observation (LA.7): Integrated Safety Culture Monitoring Panel (ISCMP).

The ISCMP has been established for the monthly monitoring of safety culture traits and the identification of performance issues and actions to achieve and then maintain a health safety culture. This is a leading initiative within the Research and Test Reactor (RTR) industry. This is not a strength at this time in that there have only been two meetings and effective implementation is pending.

Area for Improvement (LA.1): Resource Management.

The availability of personnel and funds is insufficient to support procedure, drawing, training, and Corrective Action Program (CAP) improvements. The procedure and drawing elements are a part of configuration management that over the years has resulted in discrepancies between procedures, drawings, and equipment.

Page 19 of 170 Supporting information includes:

The procedure Change Process is not well defined or efficient in its present state.

Changes to procedures are pushed and sometimes made only available just prior to the work activity.

The backlog in the CAP is increasing as personnel are demonstrating a questioning attitude and using CAP. Resources to support the level of problem identification and resolution are not sufficient to manage day-to-day activities and the backlog.

Self-Identified. (June 2023) NCNR does not have a documented approved process for issue, revision, and control of drawings. (Findings 2 & 16) CAP Item 102. Some drawings do not reflect as built configuration.

Training support is a one-man show and focused on Operations Training. The CAP Program Owner is providing a level of training, but is resource limited.

Area in Need of Attention (LA.2): Observation Program.

The Observation Program is being used by leaders but is not fully leveraged to improve performance and specifically field presence to communicate, model, and reinforce the behaviors.

Supporting information includes:

Surveys and interviews stated leader involvement and observations are less frequent than expected by the workforce.

Schedule immaturity (predictability) has limited the accomplishment of observations.

Area For Improvement (LA.8): Reinforcement of Standards and Expectations.

Leaders are not consistent in their coaching and are missing opportunities for reinforcement of standards and expectations that are important to the NSC.

Supporting information includes:

Both Survey and Interviews indicate that: Vertical and horizontal alignment at NCNR is not yet consistent. Sr. Leaders appear aligned. However, NCNR Supervisors were noted not to be aligned across the Organizational Unit (OU).

NIST Leadership is sometimes perceived to not be aligned to NCNR needs and goals.

There are pockets of siloed operations across the OU.

There is a perception that there is still a level of rationalization at the Sr. Leadership Level.

o Not reinforcing present standards and expectations (PPE, use of CAP, follow through on commitments (procedure reviews), control room standards, and conduct of meeting standards)

There is limited use of the CAP dashboard due to a lack of reinforcement by management for personnel to use the dashboard.

Comparison of the Trait 2023 to 2024 A comparison of the survey results for the LA Trait from 2023 to 2024 indicated a decline with respect to LA.1 Resources, as follows:

LA.1 Resources - Decline - NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.

Page 20 of 170 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations

1. Initiative - Resource Strategy: Conduct a review of the current levels of personnel and funds to identify critical underfunded area that comprise NSC and seek additional funding from NIST and Department of Commence (DOC). Examples include procedure quality, drawing quality, training, and necessary CAP improvements.

2. Initiative - Communications: Communicate and reinforce to NCNR personnel the expectation to, and importance of, promptly identifying deltas in procedures and drawings in comparison to actual plant configuration into the CAP for collective review of priority and level of resolution.

3. Initiative - Safety Culture: Implement the following actions (#4, 5, and 6) to improve the Behavioral Observation Program and Leader reinforcement of standards and expectations.

4. Initiative - Training: Educate leaders on using the ABC Model (Aubrey Daniels - Antecedent, Behavior, and Consequence) to influence leader and worker behaviors.

5. Initiative - Safety Culture: Develop and provide leaders observation forms/criteria that reflect desired behaviors.

Mentor leaders in observing and coaching behaviors in addition to the Observation Program expectations, to ensure expectations are met and deviations in expectations are promptly identified and corrected on the spot or within the CAP.

6. Initiative - Safety Culture: Roll out the ISC booklet and associated training for all workers.

Objective 5: Decision Making Trait: Decision Making (DM) - Decisions that support or affect nuclear safety are systematic, rigorous, and thorough. The underlying Attributes include Consistent Process (DM.1),

Conservative Bias (DM.2), and Accountability for Decisions (DM.3).

The survey included 5 questions related to DM to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 5, to provide additional insights for leaders and others with a need or desire to know.

Page 21 of 170 Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait DM identified the following:

The Assessment Category Area of Strength: None Area for Improvement: None Positive Observation (DM.2): Decision Making and Safety Margin.

NCNR staff are making informed, conservatively biased decisions with overt consideration of maintaining higher levels of safety margin.

Area in Need of Attention (DM.1): Stakeholder Participation in Decision Making.

Some safety decisions are made without engagement of some NCNR and NIST stakeholders.

The communication of decisions by participants is not always timely and with adequate context/clarity as to why the decision was made, as to support personnel in the planning and scheduling of work functions.

Supporting information includes:

The primary driver in this area is the timely communications of the whys behind decisions which appears to result in a perspective that either not all the inputs to a decision are being considered or just a lack of information necessary to support understanding of decisions.

Page 22 of 170 Decision Making o Indecision results in opportunity cost and impacts.

o We are not managing the risk of not running.

o Decisions being made outside of NCNR by NIST for appearances/political reasons with no technical basis.

Is there a minimization of issues? Rationalizing based on actual technical facts and not recognizing the significance of the event.

There is non-collective decision-making.

Still working on getting the actual decisions made and communicated uniformly across all of management. Maybe then we can also bring in the basis for decisions.

Rarely do we get into any detail for the basis of decisions.

Decisions about what we're doing next is often right before we do it. The "why" isn't always part of the explanation.

NCNR and NIST communications/coordination o External communication issues need to be resolved/formalized.

o Includes duties performed by outside organizations.

Comparison of the Trait 2023 to 2024 A comparison of the survey results for the DM Trait from 2023 to 2024 indicated improvement with respect to DM.3, as follows:

DM.3 - Improvement - Chiefs and Crew Chiefs maintain single-point accountability for important safety decisions.

Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendation

1)

Initiative - Communications: Update the Communications Strategy Initiative to include the element of decision-making. Specifically, include more timely and complete communications on important decisions to increase awareness, understanding, and ability of personnel to contribute and provide feedback.

Objective 6: Respectful Work Environment Trait: Respectful Work Environment (WE) - Trust and respect permeate the organization. The underlying Attributes include Respect is Evident (WE.1), Opinions are Valued (We.2), High Level of Trust (WE.3), and WE.4 (Conflict Resolution).

The survey included 9 questions related to WE to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 6, to provide additional insights for leaders and others with a need or desire to know.

Page 23 of 170 Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait WE identified the following:

The Assessment Category Area of Strength: None Area for Improvement: None Positive Observation (WE.2): Willingness to Raise Concerns.

Personnel are confident in their ability to raise safety concerns and will raise safety concerns.

Positive Observation (WE.3): Teamwork.

People are open, engaged, and willing to ask for help because of the respectful work environment and the level of teamwork.

Area in Need of Attention (WE.2): Engagement of Stakeholders.

NCNR is not consistent in engaging key NCNR personnel in plans and decisions.

Supporting information includes:

This is a very emotional issue both in the survey and interviews.

o Not treated as a peer.

Page 24 of 170 o Frequently left out of discussions and meetings.

o Quoted gender influence.

o Management may not be equipped to deal with softer issues.

o What happens depends on who brings up the issue.

o Treating everyone as being on the team.

o Dismissing violations.

o Soft pedaling issues.

NCNR personnel perceive that they are not included in decision-making which is leading to a limited perception of a lack of respect. (examples include junior but experienced personnel and supporting organizations outside Ops and engineering)

Area in Need of Attention (WE.3): Feedback when Raising Concerns.

The behavior of raising concerns is not always consistently reinforced in a positive manner.

Supporting Information Includes:

People feel disrespect, when people are invited to a meeting and choose not to dont show up, and then result in delays in getting work done.

Employees opinions and ideas are often not taken into serious consideration, especially from the junior employees, unless specifically asked for.

Professional capability is often respected and acknowledged, however certain interactions between leadership and others can come across as condescending.

Comparison of the Trait 2023 to 2024 No change or areas of interest.

Recommendations

1)

Initiative - Safety Culture: Strengthen actions within the Safety Culture Initiative with regard to providing positive reinforcement to individuals willing to raise concerns.

2)

3)

Initiative - Safety Culture: Consider incorporating a question regarding key NCNR stakeholder participation (OU Groups and Integrated Safety) into NCNR decision-making guidance. Suggest placing in Integrated Management Model, Integrated Safety Culture Traits and Attributes Book, or procedure.

Objective 7: Continuous Learning Trait: Continuous Learning (CL) - Opportunities to learn about ways to ensure safety are sought out and implemented. The underlying Attributes include Operating Experience (CL.1), Self-Assessment (CL.2), Benchmarking (CL.3), and Training (CL.4).

The survey included 7 questions related to CL to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 7, to provide additional insights for leaders and others with a need or desire to know.

Page 25 of 170 Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait CL identified the following:

The Assessment Category Area of Strength: None Positive Observations (CL.4): Informal Training.

Health Physics group has bi-weekly training on selected topics.

Engineering group provides new hire indoctrination activities and monthly safety meetings.

Area in Need of Attention (CL.1): Operating Experience.

NCNR is not consistently using internal and external Operating Experience (OE) and communicating the results, with recognition that external OE (other test reactors) is somewhat limited by the lack of industry communication methods. (Survey data driven ANA).

Supporting information includes:

Survey data indicates a desire for a more useful Operating Experience program using both within and outside NCNR information.

Page 26 of 170 Area in Need of Attention (CL.4): Training Program Descriptions.

There is a lack of a consistent framework outside of Operations under which all groups in the OU can develop and implement consistent initial and continuing training programs.

Supporting information includes:

From both the survey and interviews there is a significant desire for more training and more effective training. Some of the elements and observations from the staff include:

Only Ops has a strategy for improving training using the Systematic Approach to Training.

Groups within NCNR have completely different approaches to training and no formal programs yet are distinctly different and therefore difficult to determine effectiveness.

Area for Improvement (CL.4): Training.

NCNR is not making progress fast enough, and in an integrated manner, to support NCNR job performance across OU groups and job functions (i.e., Continuing Training, Supervisor Training, and General Employee Indoctrination).

Supporting information includes:

Training is in flux and the current state has a negative impact on the Operators and staffing the Operations organization. Concerned about training being a one man show.

Todays training program is not adequate. Framework is not there.

We are getting better at this, but the training and knowledge transfer infrastructure.

(particularly within Engineering) is still in its infancy, and it is still being developed.

Training programs are still under development and need to be formalized. Much of the training is informal at this time. Work is in progress to improve though.

This area had a significant decline since 2023 based on survey statistical data.

Comparison of the Trait 2023 to 2024 A comparison of the survey results for the CL Trait from 2023 to 2024 indicated decline in CL.1 and CL.4, as follows:

CL.1 Operating Experience - Decline - Operating experience is effectively implemented and institutionalized through changes to NCNR processes, procedures, equipment, and training programs.

CL.4 Training - Decline - NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.

Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations

1)

Initiatives - Resource Strategy: Provide augmented resources to allow a systematic approach to implementing the Operations Training Program.

2)

Initiative - Training: Develop an overall strategy to improve training implementation across OU group functions and leader functions including the establishment of initial and continuing Training Program Descriptions.

Page 27 of 170

3)

Initiative - Communications: Communicate to NCNR personnel expectations for the use of internal and external operating experience, and successes in the use of OE in improving performance.

Objective 8: Problem Identification and Resolution Trait: Problem Identification and Resolution (PI) - Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. The underlying Attributes include Identification (PI.1), Evaluation (PI.2),

Resolution (PI.3), and Trending (PI.4).

The survey included 6 questions related to PI to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 8, to provide additional insights for leaders and others with a need or desire to know.

Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait PI identified the following:

The Assessment Category Area of Strength (PI.1): Non-Conformance Process A Non-Conformance process has been added to the CAP and personnel identify and enter material, part, and component non-conformances for disposition and resolution. This is a leading initiative within the Research and Test Reactor (RTR) industry.

Area of Strength (PI.1, PI.2, & PI.3): Establishment of the CAP Dashboard CAP Management has developed a CAP dashboard where groups and individuals can quickly access the status of CAP items. This strength is a leading initiative within the Research and Test Reactor (RTR) industry.

Page 28 of 170 Positive Observation (PI.1): Use of CAP.

There has been an overall increase in the use of the CAP since the 2023 INSCA. The inventory was 58 at the time of the 2023 INSCA and is currently at 363. Status as follows:

344 CAPs 88 Fully Closed 254 CAP Items with actions being worked to closure.

~100 CAP Items less than 120 days old. 92 Level 0 and 1.

107 CAP Items greater than 120 days old.

Area for Improvement (PI.1, PI.2 & PI.3): Leveraging CAP to Improve Performance.

Some personnel do not understand the scope and threshold for the entry of events, problems, and other issues in the CAP or which other programs should be used to identify and document issues.

Cause Analysts lack knowledge and proficiency in analysis tools and techniques.

There is limited use of the CAP dashboard due to a lack of reinforcement by management for personnel to use the dashboard.

CAP successes are not being communicated to promote and reinforce the use of CAP.

Supporting information includes:

There are pockets across the organization that are perceived to not value the CAP Process and therefore are not using it to its best advantage.

There is a wide perception that a feedback loop to support understanding of CAP successes and dispositions would be helpful.

Survey results and interviews indicate there is not a consistent standard or understanding of what goes into CAP and what goes into other systems.

Resource limitations were stated as a barrier to timeliness of disposition and corrective actions.

Comparison of the Trait 2023 to 2024 A comparison of the survey results for PI Trait from 2023 to 2024 indicated improvement with respect to PI.2, as follows:

PI.2 Evaluation - Improvement - NCNR thoroughly evaluates problems underlying organizational and safety culture contributors.

Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations Initiative - Performance Improvement

1)

Initiative - Performance Improvement - Finish building out the new CAP platforms (i.e.,

CAP dashboard, etc.) to improve the user interface, functionality, and visibility in problem identification, evaluation, and resolution.

Page 29 of 170

2)

Initiative - Performance Improvement - Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.

3)

Initiative - Communications - Develop and implement a communication strategy to educate NCNR personnel on 1) the threshold for CAP entry, 2) their accountability for using CAP, 3) the importance of, promptly identifying nonconformances in procedures and drawings in comparison to actual plant configuration, and 4) reinforcement of CAP successes.

4)

Initiative - Training - Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.

5)

Initiative - Resources - Augment CAP resources and provide mentoring to support OU groups in problem identification, evaluation, and resolution.

Objective 9: Environment for Raising Concerns Trait: Environment for Raising Concerns (RC) - A safety-conscious work environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. The underlying Attributes include SCWE Policy (RC.1) and Alternate Process for Raising Concerns (RC.2).

The survey included 4 questions related to RC to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 9, to provide additional insights for leaders and others with a need or desire to know.

Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait RC identified the following:

Page 30 of 170 The Assessment Category Area of Strength: None Area for Improvement: None Positive Observation (RC.1): Raising Concerns.

The survey and interviews indicated that personnel, with a few exceptions, freely raise integrated safety concerns without fear of retribution and with confidence that their concerns will be addressed.

Area in Need of Attention (RC.2): Issue Employee Concerns Procedure.

The ECP has a designated office area and a program manager but lacks timeliness in issuance of the ECP procedure. The procedure has been developed and submitted to the NRC. Issuance has been delayed awaiting NRC concurrence.

Supporting information includes:

Both in Interviews and the survey comments:

There is no ECP Procedure/Program (at least that personnel are aware of)

Generally, issues and concerns are received well, however positive reinforcement of reporting concerns is not consistent.

Comparison of the Trait 2023 to 2024 A comparison of the survey results for the RC Trait from 2023 to 2024 indicated improvement in RC.1, as follows:

RC.1 SCWE Policy - Improvement - Leaders take ownership when receiving and responding to concerns, recognizing confidentiality if appropriate and ensuring the concerns are adequately addressed in a timely manner.

Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations

1)

Initiative - Safety Culture: Develop and implement a change management plan to issue the ECP procedure.

Objective 10: Work Processes Trait: Work Processes (WP) - The process of planning and controlling work activities is implemented so that safety is maintained. The underlying Attributes include Work Management (WP.1), Design Margins (WP.2), Documentation (WP.3), and Procedure Adherence (WP.4).

The survey included 8 questions related to WP to understand what people believe. The graph below is based on All Respondents. Individual Contributors and Supervisors and Above survey results are provided in Attachment 10, to provide additional insights for leaders and others with a need or desire to know.

Page 31 of 170 Subsequently, the team used focus group/interviews, observations, and cognitive analysis to substantiate survey responses and gain further insights into what people believe and what people do. The analysis of data for the Trait WP identified the following:

The Assessment Category Area of Strength: None Area for Improvement: None Positive Observation (WP.1): Aligning Work and Priorities.

Use of the Plan of the Day (POD) and the 08:00 Meeting to align OU groups and personnel on work and priorities.

Positive Observation (WP.3): Finding and Fixing Procedures.

Personnel are finding and fixing procedure issues and the quality of procedures is generally improving.

Area in Need of Attention (WP.3): Procedure Quality.

Page 32 of 170 Although there has been improvement, there are still issues with procedure quality involving errors and inconsistencies in content, and the process for changing procedures is slow.

Supporting information includes:

o Procedure/Drawing issues identified in both survey comments and interviews:

o Some are still on the R Drive.

o Physical Versions arent always available.

o Not all versions are on SharePoint.

o Revisions arent always sequential.

o Drawings and Diagram availability.

o Too many hands write procedures to varying levels of details and conflicts between procedures exist (quality) o The routing process can get things stuck and newer changes may be made without benefit of changes in process.

o The review process is not effectively used as a quality check.

Comparison of the Trait 2023 to 2024 Reference Attachment 17, Survey Data Comparison 2023 to 2024, and Trait LA for additional Areas of Interest that may need management attention to achieve full effectiveness and consistency.

Recommendations

1)

Initiative - Resource Strategy: Conduct a review of the current levels of personnel supporting procedures, drawings, and configuration management, and acquire and allocate resources as necessary to support integrated safety.

2)

Initiative - Procedures: Continue in the implementation of planned actions under the Procedure Initiative.

Page 33 of 170 Safety Culture Performance Improvement The survey results for all respondents revealed that personnel believe the NSC is improving based on the below chart. The question The NCNRs Nuclear Safety Culture has improved since the last survey in 2023 was not asked in the 2023 survey so there is no comparison data.

A more detailed comparison of the 10 traits from the 2023 survey to the 2024 survey is available in Attachment 11. Some of the more noteworthy changes were factored into the overall analyses within the report.

Traits by OU Group The survey results for each of the 10 Traits are presented in Attachments by the Operations, Reactor Engineering, Health Physics, Aging Reactor Management, and Others are in Attachments 12, 13, 14, 15, and 16, for those with a need or desire to know. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.

Review of Internal Events The Team reviewed two significant events since the last INSCA and identified the following Positive and Negative Observations. The results of the review are further discussed in 9.

Event: August 9, 2023, a loss of ventilation event occurred, resulting in minor contamination of fifteen NCNR staff members.

Positive Observations:

Page 34 of 170

1) The timeliness of the NCNR internal technical evaluation.

2) Developing a comprehensive timeline of the events leading up to the event.

3) Very detailed examination of the factors that drove the event with corrective actions to address each of the factors.

Negative Observations:

1) The IRIS evaluation has been drafted but is not yet approved. The organization is not currently aligned on the drivers for the event or the actions to prevent recurrence.

2) The CAP 172 analysis has structural issues, including:

i. Clear identification of a Problem Statement ii. Systematic evaluation of the extent of condition.

iii. Use of diverse and sufficient tools to determine causal factors.

iv. A systematic examination of organizational factors that allowed this event to occur and drove NIST response.

3) The root cause statement is a renaming of the effect (i.e., escape of FP inventory into confinement resulting in low-level contamination) and lacks sufficient depth to drive effective actions to prevent recurrence.

4) The evaluation does not adequately aggregate the contributing causes to understand if there is a deeper underlying causal factor that may be caused by deeper organizational drivers.

Event: On November 30, 2023, during installation of a shim shaft seal on a Shim Arm, the team misidentified their current work step causing a worker to apply 40 ft-lbs. to the incorrect bolt. The incorrect amount of torque caused the bolt to fail.

Positive Observations:

1) The decision by management to upgrade to a higher level of effort (root cause) to understand the underlying causes of the event.

2) Developing a comprehensive timeline of the events leading up to the event.

3) Tying each identified root cause to a safety culture attribute shows an organizational effort to tie significant events into gaps in Integrated Safety Culture.

Negative Observations:

1) The analysis has structural issues, including:

a. Clear identification of a Problem Statement

b. Systematic evaluation of the extent of condition.

c. Use of diverse and sufficient tools to determine causal factors.

d. Identification of the inappropriate action(s) or condition(s) that directly led to the event.

e. A systematic examination of organizational factors that allowed this event to occur at NCNR.

2) The root cause does not adequately aggregate the 18 root causes to understand organizational drivers. For example, examining the multiple issues related to procedures to determine if there are underlying organizational drivers.

Page 35 of 170 Review of External Information NRC Inspection Activities and Reports:

On January 25, 2024, the NRC issued the 1st and 2nd Quarter 2023 Supplemental Inspection Report for NIST. No violations were identified in this report. The report provided a status of the Supplemental Inspection Objectives. The following objectives remain open:

Emergency Plan and Event Response o Observe implementation of emergency plan procedures Operator Licensing o Evaluate adequacy of licensed operator proficiency training o Observe implementation of licensed operator proficiency training Corrective Actions o Evaluate program to ensure expectations, processes, and procedures are in place to identify and implement safety improvements.

o Evaluate the adequacy of corrective actions for re-evaluated root cause analysis performed with emphasis on nuclear safety culture.

o Confirm consideration of CO2 build up potential in safety documentation and emergency plan.

Safety Committee Oversight o Review disposition of SAC recommendations Procedures o Evaluate program and processes in place to ensure quality of written procedures, to ensure procedures can be effectively executed, and to ensure procedures are periodically evaluated to implement improvements.

Design Change Process o Review change process program and procedures for compliance with Title 10 of the Code of Federal Regulations (10 CFR) 50.59 o Evaluate effectiveness of Engineering Change Management Program for ensuring changes are made consistent with 10 CFR 50.59 Safety Culture o Follow-up Safety Culture Inspections The NRC documented the following observations and findings:

1. The inspectors observed several fuel operations and based on their observations determined that the appropriate corrective actions have been implemented to prevent recurrence and the associated IFI is now closed.

2. The inspectors observed several shifts and sessions of fuel handling training and noted adherence to procedure use and adherence guidance and concluded that all workers were trained on fuel movement operations.

3. The inspectors observed operations staff performing pre-evolution briefs and operations and observed consistent referring to procedures and place keeping. During training of operators at the console good coaching methods and challenges were observed.

4. The inspectors observed that NCNR staff conservatively limited power and staff working as a team to work through issues associated with power ascent.

5. The inspectors noted that operations personnel were not sure which process to use when they encountered problems; however, after discussions did enter the issue into CAP.

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6. The inspectors observed several evolutions and identified that while the licensee made numerous procedure changes, they still need to update procedures as they return to operations and use them.

NCNR Staff is aware of and has reviewed the NRC OIG Report Special Inquiry onto the US Nuclear Regulatory Commissions Oversight of Research and Test Reactors findings and the NRC Staff response. Discussions with senior NCNR staff show that they are aware of the concerns raised in the report and responses and are engaged with potential regulatory issues that may arise concerning the operation and inspection of RTRs.

Research and Test Reactor Interfaces The staff at NCNR has been actively involved with other RTRs as part of a group working to define the appropriate program controls and activities related to Problem Identification and Resolution at RTRs.

The senior staff at NCNR are engaged with their counterparts at similar facilities and are using that engagement to benchmark and interface on important external issues facing the RTR community.

==

Conclusion:==

1. NRC Inspection activities show an improvement in the behaviors observed by the NRC Inspectors in the areas of safety committee oversight, procedure quality and adherence behaviors, corrective action program use, and conduct of operations.

2. The NCNR staff is aware of regulatory challenges, and are interacting with counterparts in the RTR community, to understand and address challenges.

Page 37 of 170 Matrix of Initiatives to Recommendations Initiative Trait Recommendation Communications Effective Safety Communications (CO)

Strengthen the follow up on the interim actions and develop strategy to support continuing improvement.

Effective Safety Communications (CO)

As a part of the pending strategy, take action to improve engagement to obtain feedback/confirmation on the quality, dissemination, and understanding of communications to support implementation of tactical check/adjust actions.

Leadership Safety Values and Actions (LA)

Communicate and reinforce to NCNR personnel the expectation to, and importance of, promptly identifying deltas in procedures and drawings in comparison to actual plant configuration into the CAP for collective review of priority and level of resolution.

Decision-Making (DM)

Update the Communications Strategy Initiative to include the element of decision-making in the Communications Strategy Initiative. Specifically, updates to include more timely and complete communications on important decisions to increase awareness, understanding, and ability of personnel to contribute and provide feedback.

Continuous Learning (CL)

Communicate to NCNR personnel expectations for the use of internal and external operating experience, and successes in the use of OE in improving performance.

PI&R (PI)

Develop and implement a communication strategy to educate NCNR personnel on 1) the threshold for CAP entry, 2) their accountability for using CAP, 3) the importance of, promptly identifying nonconformances in procedures and drawings in comparison to actual plant configuration, and 4) reinforcement of CAP successes.

Safety Culture Personal Accountability (PA)

Stay the course.

Questioning Attitude (QA)

Stay the course.

Leadership Safety Values and Actions (LA)

Implement the following actions to improve the Behavioral Observation Program and Leader reinforcement of standards and expectations.

Page 38 of 170 Initiative Trait Recommendation Leadership Safety Values and Actions (LA)

Implement the following actions to improve the Behavioral Observation Program and Leader reinforcement of standards and expectations.

• Educate leaders on using the ABC Model (Aubrey Daniels - Antecedent, Behavior, and Consequence) to influence leader and worker behaviors.

• Develop and provide leaders observation forms/criteria that reflect desired behaviors.

• Mentor of leaders in observing and coaching behaviors in addition to the Observation Program expectations, to ensure expectations are met and deviations in expectations are promptly identified and corrected on the spot or within the CAP.

Leadership Safety Values and Actions (LA)

Roll out the ISC booklet and associated training for all workers.

Work Environment (WE)

Develop and incorporate actions within the Safety Culture Initiative with regard to providing positive reinforcement to individuals willing to raise concerns.

Work Environment (WE)

Consider incorporating a question regarding key NCNR stakeholder participation (OU Groups and Integrated Safety) into NCNR decision-making guidance. Suggest placing in Integrated Management Model, Integrated Safety Culture Traits and Attributes Book, or procedure.

Environment for Raising Concerns (RC)

Develop and implement a change management plan to issue the ECP procedure in a timelier manner - prior to NRC approval if necessary.

Performance Improvement PI&R (PI)

Finish building out the new CAP platforms (i.e., CAP dashboard, etc.) to improve the user interface, functionality, and visibility in problem identification, evaluation, and resolution.

PI&R (PI)

Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.

Training Continuous Learning (CL)

Develop an overall strategy to improve training implementation across OU group functions and leader functions including the establishment of initial and continuing Training Program Descriptions.

PI&R (PI)

Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.

Resource Leadership Safety Values and Actions (LA)

Conduct a review of the current levels of personnel and funds to identify critical underfunded area that comprise NSC and seek additional funding from NIST and Department of Commence

Page 39 of 170 Initiative Trait Recommendation (DOC). Examples include procedure quality, drawing quality, training, and necessary CAP improvements.

Continuous Learning (CL)

Provide augmented resources to allow a systematic approach to implementing the Operations Training Program PI&R (PI)

Augment CAP resources and provide mentoring to support OU groups in problem identification, evaluation, and resolution.

Work Processes (WP)

Conduct a review of the current levels of personnel supporting procedures, drawings, and configuration management, and acquire and allocate resources as necessary to support integrated safety.

Performance Improvement PI&R (PI)

Finish building out the new CAP platforms (i.e., CAP dashboard, etc.) to improve the user interface, functionality, and visibility in problem identification, evaluation, and resolution.

PI&R (PI)

Identify OU groups not actively using CAP and the CAP Dashboard and provide some indoctrination into the mechanics of the system, the value added to performance improvement, and senior leader expectations for when and how to use.

Training Continuous Learning (CL)

Develop an overall strategy to improve training implementation across OU group functions and leader functions including the establishment of initial and continuing Training Program Descriptions.

PI&R (PI)

Educate evaluators on the analytical tools and techniques necessary for successful conduct and documentation of causal analysis.

Procedures Work Processes (WP)

Continue in the implementation of planned actions for procedure initiative.

Effectiveness Review The effectiveness of the recommendations will be measured by the Quarterly ISCMP, and the 2025 INSCA as defined in the Confirmatory Order.

Page 40 of 170 Attachments

Survey Data Personal Accountability : Survey Data Questioning Attitude : Survey Data Effective Safey Communications : Survey Data Leadership Safety Values and Actions : Survey Data Decision-Making : Survey Data Respectful Work Environment : Survey Data Continuous Learning : Survey Data Problem Identification and Resolution : Survey Data Environment for Raising Concerns 0: Survey Data Work Processes 1: Survey Data Status of NSC Improvement 2: Survey Data for Operations 3: Survey Data for Reactor Engineering 4: Survey Data for Health Physics 5: Survey Data for Aging Reactor Management 6: Survey Data for Other Groups 7: Survey Data Comparison 2023 to 2024 8: Survey Question List 9: Review of Internal Events 0: Review of External Events and Guidance 1: Status of 2023 INSCA Recommendations 2: Status of 2023 INSCA Program Limiting Weaknesses 3: Focus Group/Interviews Form 4: Meeting Observation Form 5: Behavioral Observation Form 6: INSCA Team Members, Assignments, and Bios 7: INSCA Background Detail 8: NRC Inspection Report - Confirmatory Order Excerpt 9: Definitions

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Survey Data Personal Accountability Trait: Personal Accountability (PA) - individuals take personal responsibility for safety. The underlying Attributes include Standards (PA.1), Job Ownership (PA.2), and Teamwork (PA.3).

The survey included 6 questions related to PA to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 42 of 170 Graph of Individual Contributors

Page 43 of 170 Graph of Supervisors and Above

Page 44 of 170

Survey Data Questioning Attitude Trait: Questioning Attitude (QA) - Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action. The underlying Attributes include Nuclear is Recognized as Special and Unique (QA.1), Challenge the Unknown (QA.2), Challenge Assumptions (QA.9), and Avoid Complacency (QA.4).

The survey included 8 questions related to QA to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 45 of 170 Graph of Individual Contributors

Page 46 of 170 Graph of Supervisors and Above

Page 47 of 170

Survey Data Effective Safey Communications Trait: Effective Safety Communication (CO) - Communications maintain a focus on safety. The underlying Attributes include Work Process Communications (CO.1), Bases for Decisions (CO.2), Free Flow of Information (CO.3), and Expectations (CO.4).

The survey included 7 questions related to CO to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 48 of 170 Graph of Individual Contributors

Page 49 of 170 Graph of Supervisors and Above

Page 50 of 170

Survey Data Leadership Safety Values and Actions Trait: Leaders demonstrate a commitment to safety in their decisions and behaviors. The underlying Attributes include Resources (LA.1); Field Presence LA.2); Incentives, Sanctions, and Rewards (LA.3); Strategic Commitment to Safety (LA.4); Change Management (LA.5);

Roles, Responsibilities, and Authorities (LA.6); Constant Examination (LA.7); and Leader Behaviors (LA.8).

The survey included 16 questions related to LA to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 51 of 170 Graph of Individual Contributors

Page 52 of 170 Graph of Supervisors and Above

Page 53 of 170

Survey Data Decision-Making Trait: Decision Making (DM) - Decisions that support or affect nuclear safety are systematic, rigorous, and thorough. The underlying Attributes include Consistent Process (DM.1),

Conservative Bias (DM.2), and Accountability for Decisions (DM.3).

The survey included 5 questions related to DM to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 54 of 170 Graph of Individual Contributors

Page 55 of 170 Graph of Supervisors and Above

Page 56 of 170

Survey Data Respectful Work Environment Trait: Respectful Work Environment (WE) - Trust and respect permeate the organization. The underlying Attributes include Respect is Evident (WE.1), Opinions are Valued (We.2), High Level of Trust (WE.3), and WE.4 (Conflict Resolution).

The survey included 9 questions related to WE to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 57 of 170 Graph of Individual Contributors

Page 58 of 170 Graph of Supervisors and Above

Page 59 of 170

Survey Data Continuous Learning Trait: Continuous Learning (CL) - Opportunities to learn about ways to ensure safety are sought out and implemented. The underlying Attributes include Operating Experience (CL.1), Self-Assessment (CL.2), Benchmarking (CL.3), and Training (CL.4).

The survey included 7 questions related to CL to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 60 of 170 Graph of Individual Contributors

Page 61 of 170 Graph of Supervisors and Above

Page 62 of 170

Survey Data Problem Identification and Resolution Trait: Problem Identification and Resolution (PI) - Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance. The underlying Attributes include Identification (PI.1), Evaluation (PI.2),

Resolution (PI.3), and Trending (PI.4).

The survey included 6 questions related to PI to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 63 of 170 Graph of Individual Contributors

Page 64 of 170 Graph of Supervisors and Above

Page 65 of 170

Survey Data Environment for Raising Concerns Trait: Environment for Raising Concerns (RC) - A safety-conscious work environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. The underlying Attributes include SCWE Policy (RC.1) and Alternate Process for Raising Concerns (RC.2).

The survey included 4 questions related to RC to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 66 of 170 Graph of Individual Contributors

Page 67 of 170 Graph of Supervisors and Above

Page 68 of 170 0: Survey Data Work Processes Trait: Work Processes (WP) - The process of planning and controlling work activities is implemented so that safety is maintained. The underlying Attributes include Work Management (WP.1), Design Margins (WP.2), Documentation (WP.3), and Procedure Adherence (WP.4).

The survey included 8 questions related to WP to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above. The survey results were reviewed to understand what people believe and focus group/interviews were then held to obtain insights into their beliefs and then followed by observations to gain insights into what people do with key insights provided in the below tables. The results are provided in the Analysis Results section of this Report.

Graph of All Respondents

Page 69 of 170 Graph of Individual Contributors

Page 70 of 170 Graph of Supervisors and Above

Page 71 of 170 1: Survey Data Status of NSC Improvement The survey included one question related to has NSC improved since the last survey in 2023 to understand what people believe about NCNR ROE NSC. The graphs below represent survey results based on All Respondents, Individual Contributors, and Supervisors and Above.

Graph of All Respondents Graph of Individual Contributors

Page 72 of 170 Graph of Supervisor and Above

Page 73 of 170 2: Survey Data for Operations The survey results for what Operations personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.

Personal Accountability (PA)

Page 74 of 170 Questioning Attitude (QA)

Page 75 of 170 Effective Safety Communications (CO)

Page 76 of 170 Leadership Safety Value and Actions (LA)

Page 77 of 170 Decision-Making (DM)

Page 78 of 170 Respectful Work Environment (WE)

Page 79 of 170 Continuous Learning (CL)

Problem Identification and Resolution (PI)

Page 80 of 170 Environment for Raising Concerns (RC)

Work Processes (WP)

Page 81 of 170

Page 82 of 170 3: Survey Data for Reactor Engineering The survey results for what Reactor Engineering personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.

Personal Accountability (PA)

Page 83 of 170 Questioning Attitude (QA)

Effective Safety Communications (CO)

Page 84 of 170 Leadership Safety Value and Actions (LA)

Page 85 of 170 Decision-Making (DM)

Page 86 of 170 Respectful Work Environment (WE)

Page 87 of 170 Continuous Learning (CL)

Page 88 of 170 Problem Identification and Resolution (PI)

Page 89 of 170 Environment for Raising Concerns (RC)

Page 90 of 170 Work Processes (WP)

Page 91 of 170 4: Survey Data for Health Physics The survey results for what Health Physics personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.

Personal Accountability (PA)

Page 92 of 170 Questioning Attitude (QA)

Page 93 of 170 Effective Safety Communications (CO)

Page 94 of 170 Leadership Safety Value and Actions (LA)

Page 95 of 170 Decision-Making (DM)

Respectful Work Environment (WE)

Page 96 of 170 Continuous Learning (CL)

Problem Identification and Resolution (PI)

Page 97 of 170 Environment for Raising Concerns (RC)

Work Processes (WP)

Page 98 of 170

Page 99 of 170 5: Survey Data for Aging Reactor Management The survey results for what Aging Reactor Management personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.

Personal Accountability (PA)

Page 100 of 170 Questioning Attitude (QA)

Page 101 of 170 Effective Safety Communications (CO)

Page 102 of 170 Leadership Safety Value and Actions (LA)

Page 103 of 170 Decision-Making (DM) 1 1

1 1

1 5

4 3

3 4

3 4

6 7

6 4.00 4.10 4.50 4.70 4.60 (DM.3) 44. Chiefs and Crew Chiefs maintain single-point accountability for important safety decisions.

(DM.2) 46. I use decision-making practices that emphasize prudent choices over those that are simply allowable.

(DM.2) 3. Leaders apply a conservative approach to decision making, particularly when information is incomplete or conditions are unusual.

(DM.1) 47. When previous operational decisions are called into question by new facts, leaders re-evaluate these decisions to ensure they remain appropriate and adjust as needed.

(DM.1) 43. I use a consistent, systematic approach to making decisions.

Decision-Making ARM Strongly Disagree Disagree Neither Agree or Disagree Agree Strongly Agree Average

Page 104 of 170 Respectful Work Environment (WE)

Page 105 of 170 Continuous Learning (CL)

Page 106 of 170 Problem Identification and Resolution (PI)

Environment for Raising Concerns (RC)

Page 107 of 170 Work Processes (WP)

Page 108 of 170

Page 109 of 170 6: Survey Data for Other Groups The survey results for what Other Groups personnel believe about performance for each of the 10 NSC traits are provided in the below charts. The charts are broken-down by All Respondents, Individual Contributors, and Supervisors and Above. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results by OU group provide leaders with additional more subtle information for group leaders to review and act as they deemed appropriate.

Personal Accountability (PA)

Questioning Attitude (QA)

Page 110 of 170 Effective Safety Communications (CO)

Page 111 of 170 Leadership Safety Value and Actions (LA)

Page 112 of 170 Decision-Making (DM)

Page 113 of 170 Respectful Work Environment (WE)

Continuous Learning (CL)

Page 114 of 170 Problem Identification and Resolution (PI)

Environment for Raising Concerns (RC)

Page 115 of 170 Work Processes (WP)

Page 116 of 170

Page 117 of 170 7: Survey Data Comparison 2023 to 2024 The survey questions and changes in All Respondents responses from 2023 to 2024 are provided in the below table. While this INSCA Report identifies Areas in Need of Attention (ANA) and Areas for Improvement (AFIs) with recommendations for improvement, the survey results from 2023 to 2024 are provided to leaders with additional more subtle information for review and act as they deemed appropriate.

Leadership Safety Value and Actions ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 LA.6 Q44 Leaders assign single-point accountability for nuclear safety decisions.

3.25

44. Chiefs and Crew Chiefs maintain single-point accountability for important safety decisions.

3.80 Q23 Team Leaders are selected based upon fostering a strong nuclear safety environment that promotes accountability.

3.38 Not Used Not Used LA.3 Q12 Leaders provide incentives and rewards that are aligned with nuclear safety policies.

3.44 Q12. Leaders provide incentives, sanctions, and rewards that are aligned with NCNR integrated safety policies and reinforce behaviors and outcomes that reflect safety as the overriding priority.

3.40 LA.5 Q33. Leaders implement change in a way that builds organizational trust.

3.56 Q33. Leaders use a systematic process for evaluating and implement change so that integrated safety remains the overriding priority.

3.66 LA.8 Q21. Leaders at all levels ensure that the basis for operational and organizational decisions is communicated to staff in a timely manner.

3.58 Q21. Leaders ensure that the basis for operational and organizational decisions is communicated in a timely manner.

3.62 Q59. Leaders develop contingencies to deal with the possibility of emergent problems.

3.70 Not Used Not Used LA.1 Q41. Leaders provide training and knowledge transfer to establish and maintain technical competence.

3.71 Q41. NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.

3.29 LA.1 Q71. Leaders foster an environment in which individuals value and seek continuous learning opportunities.

3.71

71. Leaders foster an environment in which individuals value and seek continuous learning opportunities.

3.97 LA.2 Q17. Leaders from all levels in the organization are involved in oversight of work activities.

3.83

17. Leaders from all levels in the organization are involved in oversight of work activities.

3.95 LA.8 Q24. Leaders 'walk the talk modeling behaviors when resolving conflicts between nuclear safety and production.

3.8 Q24. Leaders walk the talk, modeling correct behaviors when resolving apparent conflicts between Integrated safety and facility availability.

3.97 LA.2 Q8. Leaders reinforce the focus on nuclear safety through site visits.

3.90 Q8. Leaders exhibit behaviors that set the standard for integrated safety.

3.92

Page 118 of 170 LA.4 Q20. Leaders provide goals for production of neutrons that are aligned to reflect nuclear safety as the overriding priority.

3.92 Q20. Chiefs and Crew Chiefs develop and implement cost and schedule goals in a manner that reinforces the importance of integrated safety.

3.62 Q16. Team Leaders are visible in the plant reinforcing Nuclear Safety Culture behaviors.

3.92 Not Used Not Used LA.7 Q63. Leaders apply conservative decision making to mitigate unpredicted failures.

3.94 Q63. Leaders apply a conservative approach to decision making, particularly when information is incomplete or conditions are unusual.

4.35 LA.6 Q6. Leaders clearly define roles, responsibilities, authorities, and accountabilities to ensure nuclear safety.

4.00 Q6. Leaders ensure roles, responsibilities, and authorities are clearly defined, understood and documented to promote integrated safety.

3.87 Q26. Our Team Leaders are frequently present in the field.

4.00 Not Used Not Used Q14. Leaders exhibit behaviors that set the standard for nuclear safety.

4.02 Not Used Not Used LA.8 Q45. Leaders ask for input when evaluating nuclear safety issues.

4.02 Q45. Leaders solicit challenges to assumptions when evaluating integrated safety issues.

4.02 LA.4 Q36. Leaders enhance trust and nuclear safety through communications.

4.08 Q36. Leaders share important information in an open, honest and timely manner such that trust is maintained.

4.22 Q72. Leadership enforces management standards and expectations that reflect nuclear safety values.

4.08 Not Used Not Used LA.8 Q47. When previous operational decisions are called into question by emerging facts, leaders re-evaluate and adjust as needed.

4.08 Q47. When previous operational decisions are called into question by new facts, leaders re-evaluate these decisions to ensure they remain appropriate and adjust as needed.

4.39 Environment for Raising Concerns ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 RC2 Q16. Team Leaders are visible in the plant reinforcing nuclear safety culture behaviors.

3.93 Q16. NCNR has a process for raising and resolving concerns that is independent of line-management influence.

3.86 RC1 Q29. I freely raise nuclear safety concerns without fear of retribution.

4.64 Q 29. I freely raise integrated safety concerns without fear of retribution and with confidence that their concerns will be addressed.

4.43 RC1 Q23. Team Leaders are selected based upon fostering a strong nuclear safety environment that promotes accountability.

3.45 Q 23. Leaders take ownership when receiving and responding to concerns, recognizing confidentiality if appropriate and ensuring the concerns are adequately addressed in a timely manner.

4.08

Page 119 of 170 Q15. My First-level Supervisor has personally recognized me for supporting nuclear safety.

3.91 Not Used in 2024 RC.1 Not Used Q 15. Claims of harassment, intimidation, retaliation, and discrimination are investigated.

4.09 Work Processes ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 Question SCORE 2024 WP.4 Q38. I follow processes, procedures, and work instructions.

4.67 Q 38. I follow processes, procedures, and work instructions.

4.65 Q25. My supervisor periodically observes me working and gives me useful feedback.

4.02 Not Used WP.3 Q55. Plant activities are governed by comprehensive high-quality programs, processes, and procedures.

3.51 Q 55. NCNR creates and maintains complete, accurate and up-to-date documentation.

3.25 WP.3 Q49. Plant activities are governed by comprehensive high-quality programs, processes, and procedures.

3.46

49. NCNR facility activities are governed by comprehensive high-quality programs, processes, and procedures.

3.26 WP.2 Q53. Safety-related equipment is operated and maintained within design requirements.

4.28 Q 53. Safety-related equipment is operated and maintained within design requirements.

4.37 WP.2 Q52. Design and operating margins are carefully guarded and changed as defined by procedures.

4.21 Q 52. Design and operating margins are carefully guarded and changed only with great thought and care.

4.39 Q72. Leadership enforces management standards and expectations that reflect nuclear safety values.

4.11 Not Used WP.1 Q54. Work is effectively planned and executed by incorporating risk-informed insights.

3.69 Q 54. Work is effectively planned and executed by incorporating risk-informed insights.

3.65 WP.4 Not Used Q 25. I understand and use human error reduction techniques, such as self-check, STAR, and pre-job briefs.

4.34 WP.2 Not Used Q 72. NCNR implements the work management process (planning, controlling and executing work activities) such that integrated safety is the overriding priority.

3.98 Personal Accountability ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 PA.3 Not Used Q73. I communicate and coordinate my activities within and across organizational boundaries to ensure integrated safety is maintained.

4.41

Page 120 of 170 PA.2 Q39. My supervisor discusses nuclear safety with me regarding my job responsibilities.

4.25 Q 39. I actively participate in pre-job briefings, understanding my responsibilities to raise integrated safety concerns before work begins.

4.51 PA.2 Q14. Leaders exhibit behaviors that set the standard for nuclear safety.

4.05 Not Used PA.2 Q11. The line of responsibility for nuclear safety is clear and not confused by research-related priorities.

4.04 Not Used PA.1 Q10. Employees adhere to nuclear safety culture behaviors.

4.04 Q 10. I am accountable for shortfalls in meeting integrated safety standards/behaviors.

4.17 PA.1 Q5. I am personally accountable for my nuclear safety culture behaviors.

4.68 Q 5. I clearly understand the importance of adherence to integrated safety standards.

4.79 PA.2 Not Used Q 14. I ensure that I am trained and qualified to perform assigned work.

4.39 PA.2 Not Used Q 11. I understand my personal responsibility to foster a professional environment, encourage teamwork and identify challenges to integrated safety.

4.61 Questioning Attitude ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 QA.4 Not Used Q65. I avoid complacency and plan for the possibility of mistakes.

4.38 QA.4 Not Used Q 37. I perform a thorough review of the work site and planned activity every time work is performed.

4.16 QA.3 Q45. Leaders ask for input when evaluating nuclear safety issues.

4.05 Q 45. Leaders solicit challenges to assumptions when evaluating integrated safety issues.

4.02 QA.3 Q64. I challenge assumptions/offer opposing views when I think something is not correct.

4.54 Q 64. I challenge assumptions/offer opposing views when I think something is not correct.

4.48 QA.2 Not Used Q 81.I stop work activities when confronted with an unexpected condition.

4.63 QA.2 Q60. I promptly challenge unanticipated test results or unexpected system response.

4.44 Q 60. I promptly challenge unanticipated test results or unexpected system response rather than rationalize them.

4.41 QA.2 Q58. I maintain a questioning attitude during pre-job briefs/job-site reviews to address changed conditions.

4.61 Q 58. I maintain a questioning attitude during pre-job briefs/job-site reviews to Identify and resolve unexpected conditions.

4.48 QA.1 Q57. I recognize the unique hazards of nuclear technology.

4.64 Q 57. I recognize the special characteristics and unique hazards of nuclear technology.

4.80

Page 121 of 170 QA.1 Q51. The organization conducts activities that could affect reactivity with caution, in accordance with procedures.

4.36 Q 51. Leaders ensures that activities that could affect reactivity are conducted with particular care, caution, oversight, and in accordance with procedures.

4.57 Problem Identification and Resolution ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 PI.4 Q77. A broad set of performance indicators is utilized with a focus on early detection of problems.

3.49 Q 77. NCNR uses performance indicators to monitor both equipment and organizational performance, including integrated safety culture.

3.47 Q18. Employees have input into resolving issues.

4.25 Not Used PI.2 Q70. We have processes to identify and resolve existing organizational weaknesses.

3.50 Q 70. NCNR thoroughly evaluates problems for underlying organizational and safety culture contributors.

3.98 PI.2 Q69. Root cause analysis is rigorously applied to identify and correct the fundamental causes of significant events.

3.80 Q 69. NCNR thoroughly evaluates problems to ensure that resolutions address causes and extent of conditions.

3.89 PI.1 Q62. I recognize and act upon deviations from standards.

4.42 Q 62. I recognize deviations from standards.

4.22 Q50. I understand the importance of processes designed to maintain critical nuclear safety functions.

4.45 Not Used PI.1 Q 50. I ensure issues, problems, degraded conditions and near misses are promptly reported and documented in the corrective action program.

4.27 PI.3 Q18. NCNR takes effective corrective actions to address issues in a timely manner, commensurate with their safety significance.

3.71 Respectful Work Environment ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 WE.3 Q36. Leaders enhance trust and nuclear safety through communications.

4.05 Q 36. Leaders share important information in an open, honest and timely manner such that trust is maintained.

4.22

Page 122 of 170 WE.3 Q32. Supervisors respond to questions and concerns.

4.27 Q 32. Chiefs, Crew Chiefs, Leads and Supervisors respond to questions and concerns in an open and honest manner.

4.20 Q27. My supervisor responds to questions and concerns in an open and honest manner.

4.52 Not Used WE.2 Q78. We value insights provided by operational support or oversight groups.

4.08 Q 78. I value the insights and perspectives provided by quality assurance, the employee concerns programs and independent oversight organizations.

4.23 WE.2 Q31. Differing opinions are welcomed and respected.

3.98 Q 31. Differing opinions are welcomed and respected.

4.09 WE.2 Q30. Leadership encourages individuals to seek ways to improve nuclear safety processes.

4.31 Q 30. I am encouraged to offer ideas, concerns, suggestions, differing opinions and questions to help identify and solve problems.

4.26 WE.1 Q42. I treat decision-makers with respect, even when I disagree with a decision.

4.55 Q 42. I treat decision-makers with respect, even when I disagree with a decision.

4.72 WE.1 Q28. I treat other employees with dignity and respect.

4.68 Q 28. I treat other employees with dignity and respect.

4.77 WE.1 Q7. Management regards individuals as its most valuable asset.

3.87 Q 7. Leaders regard individuals and their professional capabilities and experiences as its most valuable asset.

3.89 WE.3 Not Used Q 27. Leaders promote collaboration among work groups.

3.88 Effective Safety Communications ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 CO.4 Q61. I stop when I identify unexpected or uncertain conditions.

4.60 Not Used CO.4 Not Used Q 40. Leaders frequently communicate and reinforce the expectation that integrated safety is the organizations overriding priority.

4.27 CO.3 Q74. I believe the Center for Neutron Research (NCNR) Director, and Deputy Director are regularly informed about Reactor Safety Performance.

4.45 Not Used CO.3 Q35. I communicate candidly with oversight, audit, and regulatory organizations.

4.63 Q 35. I communicate openly and candidly with oversight, audit, and regulatory organizations.

4.48 CO.2 Q59. Leaders develop contingencies to deal with the possibility of emergent problems.

3.72 Not Used CO.2 Q21. Leaders at all levels ensure that the basis for operational and organizational decisions is communicated to staff in a timely manner.

3.64 Q 21. Leaders ensure that the basis for operational and organizational decisions is communicated in a timely manner.

3.62 CO.1 Q4. Safety is discussed at every meeting where plant work activities are planned and reviewed.

4.43 Q4. Integrated safety is discussed at every meeting where plant work activities are planned and reviewed.

4.11

Page 123 of 170 CO.2 Not Used Q59. Leaders encourage individuals to ask questions if they do not understand the basis of operational and management decisions.

4.40 CO.4 Not Used Q 61. Leaders ensure supplemental personnel understand expected behaviors and actions necessary to maintain integrated safety.

4.16 CO.3 Not Used Q 74. Leaders respond to me in an open, honest and non-defensive manner.

4.34 Continuous Learning ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024 CL.4 Q71. Leaders foster an environment in which individuals value and seek continuous learning opportunities.

3.75 Q 71. Leaders foster an environment in which individuals value and seek continuous learning opportunities.

3.97 CL.4 Q56. ROE employees master reactor operations to establish a solid foundation for decisions and behaviors.

3.97 Q 56. I understand reactor operations to establish a solid foundation for decisions and behaviors.

3.97 CL.4 Q41. Leaders provide training and knowledge transfer to establish and maintain technical competence.

3.77 Q 41. NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.

3.29 CL.3 Q76. Periodic nuclear safety culture assessments are used as a basis for improvement.

3.91 CL.2 Q75. The organization uses both self-assessments and independent oversight.

4.30 Q 75. Leaders value the insight and perspective provided through assessments.

4.21 CL.2 Q68. Employees are well informed of lessons learned from industry events.

4.14 Q 68. I use operating experience to understand equipment, operational and industry challenges and adopt new ideas.

4.17 CL.1 Q67. Leaders evaluate serious events and implement actions to learn from the experience.

4.18 Q 67. Operating experience is effectively implemented and institutionalized through changes to facility processes, procedures, equipment, and training programs.

3.50 CL.3 Not Used Q 76. NCNR uses benchmarking as an avenue to acquire innovative ideas to improve integrated safety.

3.61 Decision-Making ATTRIBUTE 2023 QUESTIONS SCORE 2023 2024 QUESTIONS SCORE 2024

Page 124 of 170 DM.3 Q44. Leaders assign single-point accountability for nuclear safety decisions.

3.35 Q 44. Chiefs and Crew Chiefs maintain single-point accountability for important safety decisions.

3.80 DM.2 Q63. Leaders apply conservative decision making to mitigate unpredicted failures.

4 Q63. Leaders apply a conservative approach to decision making, particularly when information is incomplete or conditions are unusual.

4.35 DM.2 Q46. I use a conservative approach to nuclear safety when making decisions.

4.47 Q 46. I use decision-making practices that emphasize prudent choices over those that are simply allowable.

4.35 DM.1 Q47. When previous operational decisions are called into question by emerging facts, leaders re-evaluate and adjust as needed.

4.07 Q 47. When previous operational decisions are called into question by new facts, leaders re-evaluate these decisions to ensure they remain appropriate and adjust as needed.

4.39 DM.1 Q43. I apply a rigorous approach to problem solving in accordance with procedures.

4.24 Q 43. I use a consistent, systematic approach to making decisions.

4.37

Page 125 of 170 8: Survey Question List

Page 126 of 170 Trait Question

1. How long have you worked at the NCNR?

2. What is your level in the organization (i.e., individual contributor, lead, supervisor, crew chief, chief, director)?

3. Within the NCNR, where do you work?

CO1

4. Integrated safety is discussed at every meeting where plant work activities are planned and reviewed.

PA1

5. I clearly understand the importance of adherence to integrated safety standards.

LA6

6. Leaders ensure roles, responsibilities, and authorities are clearly defined, understood and documented to promote integrated safety.

WE1

7. Leaders regard individuals and their professional capabilities and experiences as its most valuable asset.

LA8

8. Leaders exhibit behaviors that set the standard for integrated safety.

LA4

9. Leaders ensure NCNR facility priorities are aligned to reflect integrated safety as the overriding priority.

PA1

10. I am accountable for shortfalls in meeting integrated safety standards/behaviors.

PA2

11. I understand my personal responsibility to foster a professional environment, encourage teamwork and identify challenges to integrated safety.

LA3

12. Leaders provide incentives, sanctions, and rewards that are aligned with NCNR integrated safety policies and reinforce behaviors and outcomes that reflect safety as the overriding priority.

LA1

13. Leaders ensure that personnel, tools, equipment, procedures and other resource materials are available and adequate to support integrated safety.

PA2

14. I ensure that I am trained and qualified to perform assigned work.

RC1

15. Claims of harassment, intimidation, retaliation, and discrimination are investigated.

RC2

16. NCNR has a process for raising and resolving concerns that is independent of line-management influence.

LA2

17. Leaders from all levels in the organization are involved in oversight of work activities.

PI3

18. NCNR takes effective corrective actions to address issues in a timely manner, commensurate with their safety significance.

LA2

19. Chiefs, Crew Chiefs, Leads and Supervisors ensure supervisory and management oversight of contractors and supplemental personnel work activities, such that integrated safety is supported.

LA4

20. Chiefs and Crew Chiefs develop and implement cost and schedule goals in a manner that reinforces the importance of integrated safety.

CO2

21. Leaders ensure that the basis for operational and organizational decisions is communicated in a timely manner.

LA2

22. Chiefs and Crew Chiefs encourage informal leaders (non-supervisors) to model safe behaviors and high standards of accountability.

RC1

23. Leaders take ownership when receiving and responding to concerns, recognizing confidentiality if appropriate and ensuring the concerns are adequately addressed in a timely manner.

Page 127 of 170 Trait Question LA8

24. Leaders walk the talk, modeling correct behaviors when resolving apparent conflicts between Integrated safety and facility availability.

WP4

25. I understand and use human error reduction techniques, such as self-check, STAR, and pre-job briefs.

LA5

26. Chiefs and Crew Chiefs anticipate, manage and communicate the effects of impending changes.

WE3

27. Leaders promote collaboration among work groups.

WE1

28. I treat other employees with dignity and respect.

RC1

29. I freely raise integrated safety concerns without fear of retribution and with confidence that their concerns will be addressed.

WE2

30. I am encouraged to offer ideas, concerns, suggestions, differing opinions and questions to help identify and solve problems.

WE2

31. Differing opinions are welcomed and respected.

WE3

32. Chiefs, Crew Chiefs, Leads and Supervisors respond to questions and concerns in an open and honest manner.

LA5

33. Leaders use a systematic process for evaluating and implement change so that integrated safety remains the overriding priority.

LA3

34. Chiefs and Crew Chiefs reward individuals who identify and raise issues affecting the integrated safety policy.

CO3

35. I communicate openly and candidly with oversight, audit, and regulatory organizations.

WE3

36. Leaders share important information in an open, honest and timely manner such that trust is maintained.

QA4

37. I perform a thorough review of the work site and planned activity every time work is performed.

WP4

38. I follow processes, procedures, and work instructions.

PA2

39. I actively participate in pre-job briefings, understanding my responsibilities to raise integrated safety concerns before work begins.

CO4

40. Leaders frequently communicate and reinforce the expectation that integrated safety is the organizations overriding priority.

CL4

41. NCNR provides training and ensures knowledge transfer to maintain a knowledgeable, technical competent workforce.

WE1

42. I treat decision-makers with respect, even when I disagree with a decision.

DM1

43. I use a consistent, systematic approach to making decisions.

DM3

44. Chiefs and Crew Chiefs maintain single-point accountability for important safety decisions.

QA3

45. Leaders solicit challenges to assumptions when evaluating integrated safety issues.

DM2

46. I use decision-making practices that emphasize prudent choices over those that are simply allowable.

DM1

47. When previous operational decisions are called into question by new facts, leaders re-evaluate these decisions to ensure they remain appropriate and adjust as needed.

LA6

48. Corporate governance, review boards, and independent oversight organizations support the Director's ultimate responsibility for decisions affecting nuclear safety.

WP3

49. NCNR facility activities are governed by comprehensive high-quality programs, processes, and procedures.

Page 128 of 170 Trait Question PI1

50. I ensure issues, problems, degraded conditions and near misses are promptly reported and documented in the corrective action program.

QA1

51. Leaders ensures that activities that could affect reactivity are conducted with particular care, caution, oversight, and in accordance with procedures.

WP2

52. Design and operating margins are carefully guarded and changed only with great thought and care.

WP2

53. Safety-related equipment is operated and maintained within design requirements.

WP1

54. Work is effectively planned and executed by incorporating risk-informed insights.

WP3

55. NCNR creates and maintains complete, accurate and up-to-date documentation.

CL4

56. I understand reactor operations to establish a solid foundation for decisions and behaviors.

QA1

57. I recognize the special characteristics and unique hazards of nuclear technology.

QA2

58. I maintain a questioning attitude during pre-job briefs/job-site reviews to Identify and resolve unexpected conditions.

CO2

59. Leaders encourage individuals to ask questions if they do not understand the basis of operational and management decisions.

QA2

60. I promptly challenge unanticipated test results or unexpected system response rather than rationalize them.

CO4

61. Leaders ensure supplemental personnel understand expected behaviors and actions necessary to maintain integrated safety.

PI1

62. I recognize deviations from standards.

DM2

63. Leaders apply a conservative approach to decision making, particularly when information is incomplete or conditions are unusual.

QA3

64. I challenge assumptions/offer opposing views when I think something is not correct.

QA4

65. I avoid complacency and plan for the possibility of mistakes.

LA1

66. Chiefs and Crew Chiefs ensure staffing levels are consistent with the demands related to maintaining safety and reliability.

CL1

67. Operating experience is effectively implemented and institutionalized through changes to facility processes, procedures, equipment, and training programs.

CL1

68. I use operating experience to understand equipment, operational and industry challenges and adopt new ideas.

PI2

69. NCNR thoroughly evaluates problems to ensure that resolutions address causes and extent of conditions.

PI2

70. NCNR thoroughly evaluates problems for underlying organizational and safety culture contributors.

CL4

71. Leaders foster an environment in which individuals value and seek continuous learning opportunities.

WP1

72. NCNR implements the work management process (planning, controlling and executing work activities) such that integrated safety is the overriding priority.

PA3

73. I communicate and coordinate my activities within and across organizational boundaries to ensure integrated safety is maintained.

CO3

74. Leaders respond to me in an open, honest and non-defensive manner.

CL2

75. Leaders value the insight and perspective provided through assessments.

Page 129 of 170 Trait Question CL3

76. NCNR uses benchmarking as an avenue to acquire innovative ideas to improve integrated safety.

PI4

77. NCNR uses performance indicators to monitor both equipment and organizational performance, including integrated safety culture.

WE2

78. I value the insights and perspectives provided by quality assurance, the employee concerns programs and independent oversight organizations.

79

79. The NCNRs Nuclear Safety Culture has improved since the last survey in 2023.

LA7

80. Leaders constantly scrutinize nuclear safety through a variety of monitoring techniques, including assessments of nuclear safety culture.

QA2 81.I stop work activities when confronted with an unexpected condition.

ml

82. When you know that your immediate supervisor is responsible, do you put any extra efforts into his/her initiatives?

ml

83. Do you respond quickly when your immediate supervisor ask you to do something?

ml

84. Are you working now on his/her top priority issues?

ml

85. Do you see the connection between your daily efforts and the organization's vision?

ml

86. Can you cite an example of someone living the organization's values?

ml

87. Do you invest as much energy and enthusiasm as the leader invests into his/her initiatives?

ml

88. Can you give a recent example where a peer has helped you with your work?

ml

89. Do other departments and work units cooperate and assist your unit?

ml

90. Have you made any suggestions for improvement in the past 3 months?

ml

91. Is it safe to admit that you have made a mistake or failed at something?

ml

92. Is your immediate supervisor someone you feel you would respect for counsel and advice?

ml

93. Are you actively encouraged to improve your skills and personal growth here?

94. If there is any additional information you would like us to know, please add here.

Page 130 of 170 9: Review of Internal Events The assessment team reviewed the Corrective Action Program (CAP) database from June 2023 to present for events that would rise to a significance requiring an upper-level causal evaluation. The following two events were viewed as significant:

1. On August 9, 2023, a loss of ventilation event occurred, resulting in minor contamination of fifteen NCNR staff members. On the following day, CAP 172 in the NCNR Corrective Action Program was initiated to investigate the event and root causes. In accordance with Administrative Rule 7.2, this CAP was classified as a level 2 CAP which requires review by the NCNR Chief of Operations and Engineering. A narrative of the details of this event, including root causes and corrective actions was presented to the SEC and discussed during SEC meeting 413, held on August 24, 2023. Significant effort has been undertaken by the organization to understand the drivers of the scram and take corrective actions to prevent of minimize recurrence.

The Team reviewed CAP 172, which concluded the following root and contributing causes:

Root Cause: High fission-product inventory in the reactor primary system, originating from residual fuel debris, escaped into reactor confinement that resulted in low-level personal contamination upon reactor scram.

Contributing Cause 1: The reactor refueling plug and other penetrations around the reactor vessel leak helium (and therefore fission products) from the helium sweep system.

Contributing Cause 2: Loss of facility power resulting from maintenance being performed on building main electrical feeder lines at time of start-up without coordination between the maintenance component and NCNR.

Contributing Cause 3: Loss or reduction of reactor ventilation is lost or reduced upon loss of power to the confinement building.

Contributing Cause 4: Loss of helium sweep flow due to loss of power.

Contributing Cause 5: Messaging regarding the event was passed to the Department was not properly controlled and coordinated.

Contributing Causes 6 and 7: Relevant operating procedures were not written to cover the prevailing conditions resulting in somewhat slower operator response, and previously unanticipated conditions.

Page 131 of 170 Contributing Cause 8: The consequences of ventilation failure on effluent detectors (i.e., the effect of conservative setpoints) were not fully understood.

The assessment team determined the following observations:

Positive Observations:

1) The timeliness of the NCNR internal technical evaluation.

2) Developing a comprehensive timeline of the events leading up to the event.

3) Very detailed examination of the factors that drove the event with corrective actions to address each of the factors.

Negative Observations:

1) The IRIS evaluation has been drafted but is not yet approved. The organization is not currently aligned on the drivers for the event or the actions to prevent recurrence.

2) The analysis has structural issues, including:

i. Clear identification of a Problem Statement ii. Systematic evaluation of the extent of condition.

iii. Use of diverse and sufficient tools to determine causal factors.

iv. A systematic examination of organizational factors that allowed this event to occur and drove NIST response.

3) The root cause statement is a renaming of the effect (i.e., escape of FP inventory into confinement resulting in low-level contamination) and lacks sufficient depth to drive effective actions to prevent recurrence.

4) The evaluation does not adequately aggregate the contributing causes to understand if there is a deeper underlying causal factor that may be caused by deeper organizational drivers.

2. On November 30, 2023, during installation of the shim shaft seal on #4 Shim Arm, the team misidentified their current work step causing a worker to apply 40 ft-lbs. to the incorrect bolt. The incorrect amount of torque caused the bolt to fail. Work was halted, the area was placed in a safe condition, and a team investigation utilizing both operations and engineering commenced. The event was input into the Corrective Action Program and upgraded to a Level 3 by management decision.

After some fact-finding meetings the root cause team was assembled. The consequences of the event were Increased regulatory scrutiny, damage to trust in the organization, concern over the technical basis for several torque related items across multiple procedures, and rework and extent of condition review resulting in a schedule delay of a minimum three months.

The Assessment Team reviewed the final report dated January 31. 2024. NCNR conducted the root cause analysis using the TapRoot methodology and determined 18 root causes that they categorized into seven (7) categories:

Page 132 of 170 The procedure was not fully Administrative Rule (AR) 5.1 compliant which created several possible error precursors.

The review process outlined in Administrative Rule (AR) 5.2 did not catch the non-compliance with AR 5.1 or address the error precursors.

Communication needs improvement as the turnover process allowed misunderstandings to persist.

Procedure adherence standards, and policies were confusing and not strict enough notably when marking steps not applicable (N/A) within a procedure when not directed to do so by that procedure.

Procedure adherence standards and policies were not known or adequately enforced for step tracking across multiple copies and across multiple shifts.

Continuous Training needs improvement regarding both technical skills as well and policy understanding and adherence.

Work planning, general oversight, and job support need improvement when planning and performing high impact / risk work.

The assessment team was not able to determine a timeline for when the root cause analysis will be completed.

Positive Observations:

1) The decision by management to upgrade to a higher level of effort (root cause) to understand the underlying causes of the event.

2) Developing a comprehensive timeline of the events leading up to the event.

3) Tying each identified root cause to a safety culture attribute shows an organizational effort to tie significant events into gaps in Integrated Safety Culture.

Negative Observations:

1) The analysis has structural issues, including:

a. Clear identification of a Problem Statement

b. Systematic evaluation of the extent of condition.

c. Use of diverse and sufficient tools to determine causal factors.

d. Identification of the inappropriate action(s) or condition(s) that directly led to the event.

e. A systematic examination of organizational factors that allowed this event to occur at NCNR.

2) The root cause does not adequately aggregate the 18 root causes to understand organizational drivers. For example, examining the multiple issues related to procedures to determine if there are underlying organizational drivers. 0: Review of External Information

Page 133 of 170 0: Review of External Information NRC Inspection Activities and Reports:

On January 25, 2024, the NRC issued the 1st and 2nd Quarter 2023 Supplemental Inspection Report for NIST. No violations were identified in this report. The report provided a status of the Supplemental Inspection Objectives. The following objective remain open:

Emergency Plan and Event Response Observe implementation of emergency plan procedures Operator Licensing Evaluate adequacy of licensed operator proficiency training Observe implementation of licensed operator proficiency training Corrective Actions Evaluate program to ensure expectations, processes, and procedures are in place to identify and implement safety improvements.

Evaluate the adequacy of corrective actions for re-evaluated root cause analysis performed with emphasis on nuclear safety culture.

Confirm consideration of CO2 build up potential in safety documentation and emergency plan.

Safety Committee Oversight Review disposition of SAC recommendations Procedures Evaluate program and processes in place to ensure quality of written procedures, to ensure procedures can be effectively executed, and to ensure procedures are periodically evaluated to implement improvements.

Design Change Process Review change process program and procedures for compliance with Title 10 of the Code of Federal Regulations (10 CFR) 50.59 Evaluate effectiveness of Engineering Change Management Program for ensuring changes are made consistent with 10 CFR 50.59 Safety Culture Follow-up Safety Culture Inspections The NRC documented the following observations and findings:

1. The inspectors observed several fuel operations and based on their observations determined that the appropriate corrective actions have been implemented to prevent recurrence and the associated IFI is now closed.

Page 134 of 170

2. The inspectors observed several shifts and sessions of fuel handling training and noted adherence to procedure use and adherence guidance and concluded that all workers were trained on fuel movement operations.

3. The inspectors observed operations staff performing pre-evolution briefs and operations and observed consistent referring to procedures and place keeping. During training of operators at the console good coaching methods and challenges were observed.

4. The inspectors observed that NCNR staff conservatively limited power and staff working as a team to work through issues associated with power ascent.

5. The inspectors noted that operations personnel were not sure which process to use when they encountered problems; however, after discussions did enter the issue into CAP.

6. The inspectors observed several evolutions and identified that while the licensee made numerous procedure changes, they still need to update procedures as they return to operations and use them.

NCNR Staff is aware of and has reviewed the NRC OIG Report Special Inquiry onto the US Nuclear Regulatory Commissions Oversight of Research and Test Reactors findings and the NRC Staff response. Discussions with senior NCNR staff show that they are aware of the concerns raised in the report and responses and are engaged with potential regulatory issues that may arise concerning the operation and inspection of RTRs.

Research and Test Reactor Interfaces The staff at NCNR has been actively involved with other RTRs as part of a group working to define the appropriate program controls and activities related to Problem Identification and Resolution at RTRs.

The senior staff at NCNR are engaged with their counterparts at similar facilities and are using that engagement to benchmark and interface on important external issues facing the RTR community.

==

Conclusion:==

1) NRC Inspection activities show an improvement in the behaviors observed by the NRC Inspectors in the areas of safety committee oversight, procedure quality and adherence behaviors, corrective action program use, and conduct of operations.

2) The NCNR staff is aware of regulatory challenges, and are interacting with counterparts in the RTR community, to understand and address challenges.

Page 135 of 170 1: Status of 2023 INSCA Recommendations Source Recommendation May 2024 Status Update 1

INSCA#1 Jun 2023 RECOMMENDATION 1: Designate Operations and the I & C portion of the Aging Reactor Management section as priority groups and develop communications and team building strategies to better clarify and address the quality of the safety culture environment and implement corrective actions.

o Develop Communication and Team Building Plan to address toxic work environment between Operations and I&C groups Engaged the NIST OmBuds, and HR to aid in development of corrective actions.

Developed and implemented coaching and addition to performance evaluation for discrete individuals. Follow-ups. Behavior observations validate behavior change and anecdotal information from other portions of ARM and Ops reflect improvement. Code of ethics refreshed from NIST. Code of conduct for interpersonal behaviors is in development.

Page 136 of 170 Source Recommendation May 2024 Status Update 2

INSCA#1 Jun 2023 RECOMMENDATION 2: Develop and deliver a competence-based understanding of Nuclear Safety Culture.

Develop and implement a formal NCNR-ROE Nuclear Safety Culture Program based upon INPO 12-012 Traits of a Healthy Nuclear Safety Culture / NUREG 2165 to understand Nuclear Safety Culture (including SCWE),

Industrial Safety Culture, and the difference.

Develop and implement the vision, values, principles, and objectives that define the expected behaviors and attitudes needed to achieve and sustain a high-reliability Nuclear Safety Culture.

Enabling objectives need to focus on all NCNR-ROE leadership and staff owning and living nuclear safety culture attributes and role-modeling behaviors to: Build trust, Breakdown silos, and Improve daily communication behaviors.

Develop and implement NSC Training, and socialize expected NSC behaviors, teamwork and interactions amongst departments and between people.

Engage external resources to assist in developing, delivering, implementing, and coaching sustainable actions.

Interim: Re-implement daily use of the Gray Book INPO 12-012, Traits of a Healthy Nuclear Safety Culture.

Based on Budget Limitations and timing this recommendation was broken up into three pieces (not from the 2023 report). 1. To answer the CO, SC Training in this area, for the ROE Leadership, was developed and implemented. (Nov 2023). 2. As an outcome of that training the Safety Culture Monitoring Panel Guidance was tested with accomplishment of the initial SCMP was completed and continuing on a regular basis. 3. Modification of the INPO 12-012 SC Traits to match the NCNR Organization and Verbiage was completed published electronically and is in printing. 4.

Conducted a Baldrige Organizational Profile Exercise to define baseline Mission, Vision, Values and Culture for integration into a master reference for Behaviors, teamwork, and interactions as 5 Develop an Integrated Management Model as a frequently referenced tool for indoctrination, alignment and improvement.

Page 137 of 170 Source Recommendation May 2024 Status Update 3

INSCA#1 Jun 2023 RECOMMENDATION 3: Mitigate the staffing and resource shortage in the Operations Department.

Obtain and prioritize external resources (including funding) who can take on the Operations Department administrative workload (see LA.1, Section 7.4.1.2.2, last table entry).

Prioritize the engagement of external resources to coach Operations Crew Chiefs, SROs, and non-licensed operators regarding shift Operational Focus.

Complete the planned selection and appointment of a Deputy Chief Reactor Operations.

New entry level hires have been added to Operations. Due to reactor conditions and primarily shutdown operations, the application of resources has somewhat been mitigated in the area of administrative workload. Fed Government Continuing Resolutions and delay of 2024 funding made the application of coaching in a shutdown environment a lower priority for the time being. Applications for Deputy Chief of Operations has yet to be posted.

4 INSCA#1 Jun 2023 RECOMMENDATION 4: Develop, with Human Resources:

An effective and timely policy to attract and retain Operations staff.

Build Operator ranks with full support to stand up a fifth shift with a prescribed minimum reserve bench metric.

Aggressively pursue increasing the number of licensed individuals.

Mitigate the resource shortage in the Aging Reactor Management (ARM) Group with external resources to:

o Take on the administrative tasks.

o Develop and implement organization-wide programs (e.g., CAP, Observation Program, et.al.).

o Coach and mentor ARM staff with regards to programmatic responsibilities.

New entry level hires have been added to ARM. Due to reactor conditions and primarily shutdown operations, the application of resources has somewhat been mitigated in the area of administrative workload. The CAP, Observation Program, etc. have been reassigned outside ARM to strengthen focus of ARM on Maintenance, Surveillances and Trouble shooting.

Page 138 of 170 Source Recommendation May 2024 Status Update 5

INSCA#1 Jun 2023 RECOMMENDATION 5: Corrective Action Program:

Complete the PI&R Assessment as soon as practicable.

Continue with plans to implement a right-sized PI&R process. In the interim, prioritize the following immediate actions:

Establish and enforce an expectation for a reporting threshold across NCNR-ROE.

Select external resources to assist with program implementation, administration, and coaching.

Develop and implement an easy and personal input method for CAP.

Establish a Corrective Action Review Board (CARB) /

Management Operations Review Group utilizing external resources to assist with development, charter, startup, administration, and member coaching.

The PI&R Assessment was completed with 12 recommendations. In parallel to development of follow-on scopes of work, strengthening of reporting, prioritization, application of CAP Screening, and disposition reviews (CARB/MRG) has been effective at identification and proper classification of issues, correction and closure of issues lag initiations are slowly being address. Additional resources have been delayed due to Government Funding Issues. Changes in input screens, metrics, etc. are in progress. Reverse benchmarking CAP was conducted in February with MURR.

The RTR high powered reactors have entered into a collaborative agreement to share and optimize RTR CAP and a consortium.

Page 139 of 170 Source Recommendation May 2024 Status Update 6

INSCA#1 Jun 2023 RECOMMENDATION 6: Conduct behavioral assessments of the Operations Crew Chiefs to assess attitudes, alignment, leadership capabilities, and provide targeted development feedback.

Behavioral assessments, feedback and coaching have been shown to be critical to aligning leadership behavior to obtain consistent performance improvements.

Consider extending these assessments to other key leaders as priorities allow.

A minor level of personality and behavior assessments have been performed by NIST and others to provide input into changes in performance evaluations. Based on plant condition the facility decided that additional assessment would be more appropriate once the base programs and processes were fledged out and near normal operations are achieved.

The priority was also adjusted based on Fed Government Continuing Resolutions and delay of 2024 funding and make the application of coaching in a shutdown environment a lower priority for the time being. Applications for Deputy Chief of Operations have been non-existent.

Page 140 of 170 Source Recommendation May 2024 Status Update 7

INSCA#1 Jun 2023 RECOMMENDATION 7: Develop a behavior-based mentoring/coaching program focused on safety culture attributes, leadership, and process improvements.

Provide the top leadership team with a team coach at the Director/Chief level to promote organizational alignment and teamwork.

Identify key leaders in ROE and establish individual mentors to develop manager behaviors and their interface to the organizational recovery processes.

Conduct behavioral assessments of current organizational leadership starting at Crew Chiefs level and going to top level management (Director/Chiefs).

Part of this action is a repeat of the above.

(Conducting Behavioral Assessments)

Identifying Key Leaders is a work in process as the staffing of the team is gelling. With changes in alignment (Safety, SEC, QA/Programs, Engineering) some stability is needed to determine assessment needs and define the strategy (Resources Strategy)

Task 10 is providing the services of team coach for the top team leadership. The areas of present engagement are alignment, teamwork and R2A2, Baldrige, Aubrey Daniels basis for reinforcement of behaviors and communication interim actions

Page 141 of 170 Source Recommendation May 2024 Status Update 8

INSCA#1 Jun 2023 RECOMMENDATION 8: Training and Procedures Programs:

Complete the Training and Procedures Assessments as soon as practical.

Implement the Systematic Approach to Training (SAT).

Fully implement the PPA / INPO 11-003 requirements for procedures.

Training and Procedures assessments are complete with a total of 25 recommendations. Each of these assessments were deemed to be separate Improvement initiatives.

Page 142 of 170 Source Recommendation May 2024 Status Update 9

INSCA#1 Jun 2023 RECOMMENDATION 9: Establish and maintain housekeeping/combustibles and gas cylinder loading that reflect OSHA standards in: Guide Hall, Confinement Building, Laboratories, and other spaces.

Recommendation has been being addressed Level of Effort by the facility.

Recently $80K has been allotted to continue improvement. A significant reduction in fire loading in C100 and the Guide Hall has been achieved even in parallel to Instrument installation work. Much work to do in B1. Two labs have been emptied of equipment and risk.

10 INSCA#1 Jun 2023 RECOMMENDATION 10: Complete the planned development and implementation of an Employee Concerns Program (ECP).

Strongly recommend for the foreseeable future, establish and maintain a regular and consistent onsite presence.

Include within the scope of follow-on Nuclear Safety Culture Assessments.

The ECP Coordinator was named and assigned at the beginning of 2024. The ECP Procedure is in NRC Review. There is an ECP SharePoint site. The Facility is highly considering activating that procedure and program without NRC Approval. A decision is expected in June.

Page 143 of 170 Source Recommendation May 2024 Status Update 11 INSCA#1 Jun 2023 RECOMMENDATION 11:Develop and implement a problem-solving approach for emergent issues to include:

Define the Problem Statement.

Conduct significance assessment.

Identify known consequences.

Perform extent of condition evaluation.

Pre-establish a Command-and-Control NCNR-ROE response structure.

Establish response teams with issue-specific roles &

responsibilities.

Develop a written response plan.

Implement and revise response plan as necessary.

The methodology has been piloted and applied in several circumstances. In concert with the development of the Integrated Project Schedule across NCNR this is maturing.

Page 144 of 170 Source Recommendation May 2024 Status Update 12 INSCA#1 Jun 2023 RECOMMENDATION 12: As a function of development of the comprehensive improvement plan that results from planned assessments and the collective evaluation process, consider the following elements to address Cross-Cutting, Distributed Function Programs.

Every line manager owns a piece of distributed functions; examples of distributed functions include, but are not limited to:

o Nuclear Safety Culture and Roles, Responsibilities, Authorities, and Accountabilities o Emergent Issue Management Process o Conduct of Operations o Operational Focus o PI&R/Corrective Action Program o Employee Concerns Program o Training o Management Observation Program o Work Planning, Management and Control o Management of Change o QA and Oversight Function o Risk Management Obtain and prioritize external resources (including funding) to support development and implementation of the programs listed above.

Interim: Establish a daily framework: Morning meetings, daily schedule reviews, CAP Screening, Management Reviews, Plan of the Day, Break-out groups as needed.

Collective Eval 1 was completed, 61 recommendations from the assessments and 11 recommendations from the first SCMP (All from both data sets) were risk ranked and prioritized for implementation.

The IMM is intended to address, in some fashion, the list in this recommendation.

Page 145 of 170 2: Status of 2023 INSCA Program Limiting Weaknesses Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Management Observation Program Marginally Effective AFI Flat The existing management observation program is limited to procedural observations.

Many observations, including some from senior management, are not consistently documented in a timely manner by NCNR observers; some managers meet minimum requirements for 2 per quarter.

CAPs are not consistently being written by observers when observations document problems.

From the Observation Dashboard - 5/13/24 Observation goals are being met or exceeded.

In the 1st Quarter 24, 23 observations were conducted for a goal of

18. This performance was improved based on actions taken in Oct 23 per CAP 199.

While the observation form hasnt been revised, approximately 25% of the observations were beyond procedure based. All observations had at least one element of behavioral observation beyond the procedure quality aspects.

Procedure issues found during observations are being entered into CAP Based on Observation data review the process is being implemented as designed. Interviews indicate some leaders are using the process for teaching moments.

Rating: Marginally Effective ANA.

Trend: Improving Corrective Action Program Not Effective AFI Flat Less than adequate staffing to develop CAP.

CAP is being utilized to address deficiencies and events.

Rating: Marginally Effective AFI P.1, P.2, P.3

Page 146 of 170 Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Less than adequate training re:

CAP.

Program exists, recently revised.

Threshold not well understood by staff.

Lack of management engagement.

The CAP volume was 363, up from 58 at the time of the last assessment.

CAP Screening is mature. The backlog of unscreened items is at a minimum.

The AR 7.0 series needs to be updated to reflect the details being currently implemented.

The CAP process is being transitioned to a new platform with much more mature functionality.

There is still some misunderstanding of what goes into CAP or other systems that need to be addressed.

Documentation of actions taken are entered into CAP Cause Analysis is not consistently attached to the CAP Item.

Trend: Improving

Page 147 of 170 Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Audit/Surveillance/QA Program Not Effective AFI Flat QA Program applies to only Engineering.

Program does not identify important programs needed for safe and effective nuclear plant facility operation.

Of those programs that are identified, most have short runtimes and are in very early stages.

Program definition is fragmented among several documents, causing confusion and lack of use/compliance.

21 Audits and Self Assessments have been conducted in the last year. The findings of audits are entered and resolved in CAP.

Development of a full QA program based on ANSI 15.8/ISO 9000 is planned as a part of the Procedures and PI&R Initiative Strategies Rating: Marginally Effective Trend: Improving Document Control Program Not Effective AFI Flat No Records/Document Control Manager No plan to meet Federal Document Control requirements (36 CFR 1200 Att. B).

Lack of a Records Management Program that meets federal government requirements (36 CFR 1200 Att B)

A Document Librarian has been hired and is actively resurrecting the Document Control Process.

Rating: Marginally Effective Trend: Improving

Page 148 of 170 Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Conduct of Operations Program Marginally Effective AFI Positive Critical elements of CONOPs are insufficiently addressed in NBSR Conduct of Operations guidance. (See Section 7.3.5)

Operations staffing shortages, limited currently to two shifts.

Ops Training weaknesses (see Training program)

Lack of Ops staff understanding of NSC and how it applies to CONOPs AR 5.0, Procedure Use and Adherence and AR 1.1 Human Performance Tools address the majority of weaknesses in CONOPs as listed in section 7.3.5 of the 23 INSCA Report.

Three Shift Coverage is in effect.

Staffing levels continue to be a significant weakness.

Rating: Marginally Effective Trend: Improving Training Program Marginally Effective AFI Positive Current training program does not support a continuing Operator Training program.

Training that has been developed was not done using the Systematic Approach to Training.

Operator training is limited in scope and does not address full spectrum of Operations Department needs.

The facility has named Training as an Initiative for improvement.

The training Supervisor has been names, Postings for 2 additional resources are posted.

Resources have been applied to SAT Application of the Ops Training Program Rating: Marginally Effective AFI CL.4 Trend: Improving

Page 149 of 170 Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Procedures Marginally Effective AFI Positive Procedures are inadequate for rule-based operations required by operators with less experience.

Some revised procedures are overly complex and cumbersome.

Pen and ink changes to important procedures (i.e., reactor startup) did not receive 10CFR50.59 review.

Inexperienced (rather than experienced) operators are writing procedures.

Procedures was named as an Initiative for Improvement. AR 5.0 was revised to meet industry guidance. Pen and Ink changes are now categorized as Major and Minor and receive the appropriate 50.59 screening and reviews.

The facility is applying outside resources to revising AR 5.1 Procedures Writers Guide and plans to revise the ~300 procedures that were revised earlier in 2021/2022 to be more user friendly, at the correct level of detail of consistent structure and format.

Rating: Marginally Effective ANA Trend: Improving Causal Analysis Not Effective AFI Flat Program has not been implemented

& is under development with no written plans.

Few trained causal analysts.

The few trained causal analysts have limited experience.

There are 3 trained cause analysts (Tap Root and other techniques).

Experience is widely varied.

The facility would benefit greatly with a Rating: Marginally Effective ANA Trend: Improving

Page 150 of 170 Program 2023 Rating Trend Limiting Weaknesses Program Status 2024 Rating and Trend Cause Analysis Manual and training. This is planned as a part of the PI&R Initiative Employee Concerns Not Effective AFI Flat Program has not been implemented.

ECP Coordinator has not yet been trained or started in the position.

The ECP Coordinator has been hired, The ECP Website Developed. The ECP Program has been written and has been in NRC review for over a year. The facility has recently decided to implement the program in advance of NRC Review and approval.

Rating: Not Effective

Page 151 of 170 3: Focus Group/Interviews Form Note: The below form is a facsimile. While the content remains the same, there have been minor format changes to reduce the overall size of the form - removal of the number of spaces for written comments.

Focus Group Record: 2024 Independent Integrated Safety Culture Assessment:

ASSESSMENT CONFIDENTIAL: Do NOT Share beyond Assessment Team Focus Group FG-Template CONTAINS PRE-DECISIONAL INFORMATION: NOT TO BE DISTRIBUTED BEYOND THE INDEPENDENT ASSESSMENT TEAM WITHOUT THE EXPRESS AUTHORIZATION OF TASK LEADER FOCUS GROUP NUMBER:

GROUP MEMBERS/POSITIONS:

GROUP FACILITATORS:

DATE:

START: END:

DISCUSSION FOCUS:

NOTES:

This document summarizes a Focus Group conducted in support of an Independent Integrated Safety Culture Assessment of the NCNR.

This Focus Group was conducted for the sole purpose of evaluating the Integrated Safety Culture and is but one of a large number of data inputs. Readers are STRONGLY CAUTIONED against drawing conclusions or making decisions on the basis of this Focus Group alone.

Focus Group content is summarized below. This is not a verbatim transcript. Except where indicated by quotation marks; statements without quotation marks are either paraphrased or summarized. The order in which aspects of the Focus Group are documented may differ from the order in which they were discussed.

The Group Facilitators explained:

We are part of an independent team that was requested to conduct a comprehensive Integrated Safety Culture assessment of the NCNR.

The assessment will include: The Integrated Safety Culture survey administered in April 2024.

Individual interviews of approximately half of the NCNR staff and management.

Facilitated Focus Groups of NCNR staff.

Workplace and work observations.

Meeting observations; and Facility inspections.

No one at NCNR, and no one beyond the independent team itself will see the Focus Group summary, and we will protect your anonymity by not linking any

Page 152 of 170 comments or responses to any results report. Your name will appear on a list of People Contacted in the final report, along with other individuals who may or may not have participated in Focus Groups or have been interviewed.

At the end of this assessment, we will publish a report that includes our observations, conclusions, findings, and recommendations for specific actions to be taken, and details and elaboration the team believes to be vital to NCNRs understanding of the conclusions.

Focus Group Record: 2024 Independent Integrated Safety Culture Assessment:

ASSESSMENT CONFIDENTIAL: Do NOT Share beyond Assessment Team Focus Group FG-Template CONTAINS PRE-DECISIONAL INFORMATION: NOT TO BE DISTRIBUTED BEYOND THE INDEPENDENT ASSESSMENT TEAM WITHOUT THE EXPRESS AUTHORIZATION OF TASK LEADER Please do not share the content of, or questions from this Focus Group until the final report has been published.

Q: IF ANYONE WOULD LIKE TO TALK WITH US PRIVATELY FOLLOWING THIS FOCUS GROUP, WE WILL MAKE THE TIME AVAILABLE TO DO SO. PLEASE LET US KNOW BY CALLING OR EMAILING WITH A WAY TO CONTACT YOU. WE WILL RESPECT YOUR PRIVACY AND CONFIDENTIALITY.

Q: FGQ1: What does the term Integrated Safety Culture mean?

A:

SC Trait(s):

What examples of overall Integrated Safety Culture changes can you provide?

Prompts: Communications [CO]

Conduct of Operations [WP]

Employee Concerns [RC]

Performance Improvement [PI] Corrective Action Program Causal Analysis Benchmarking Management Observations Audit Surveillance Training Program [CL]

Procedures [WP]

Document Control Procedures in general Work Management [WP]

Resources [LA]

Q: FGQ2: How has the Integrated Safety Culture changed at NCNR overall since the 2023 Assessment?

A:

Page 153 of 170 SC Trait(s):

Q: FGQ3: Where would you rate the NCNR Integrated Safety Culture on a scale of 1 to 10, with 10 being outstanding and 1 being poor?

A:

SC Trait(s):

Q: FGQ4: What are the top three issues at NCNR that impact the Integrated Safety Culture?

A:

SC Trait (s):

Q: FGQ5: What are some examples of you stopping work when you identified unexpected or uncertain conditions? [DM, QA]

A:

SC Trait(s):

Q: FGQ6: What examples can you provide of managers/supervisors encouraging identification and reporting of nuclear safety issues or concerns? [RC, LA]

A:

SC Trait(s):

a. Can you give an example where the Corrective Action Program was effectively used to resolve an issue. [PI]

b. Have you entered an issue into the NCNR Corrective Action Program? If so, what issue(s) did you identify? [PI, PA]

Q: FGQ7: Corrective Action Program (CAP) Effectiveness:

a. Who owns the Corrective Action Program? [PI] How are you using the CAP? [PA]

A:

SC Trait(s):

Q: FGQ8: What is NCNRs greatest risk of failure to complete a successful restart and return to 127 full power operations?

A:

SC Trait(s):

Q: FGQ9: To what extent is reinforcement of standards and expectations (personal accountability) consistently carried out throughout the organization? [WE, LA] Examples?

A:

SC Trait(s):

Page 154 of 170 Q: FGQ10: To what extent do your peers question assumptions, decisions, or justifications that do not appear to sufficiently consider impacts to integrated safety? [QA]

A:

SC Trait(s):

Leaders 153 Walk the talk? [LA]

Communicate effectively? (NIST vs. NCNR? For Director and Chiefs) [CO]

Respect and respond effectively to differing opinions? [WE]

Respond to employees and the concerns they raise without defensiveness to questions, problems, issues, and concerns? [RC]

Workers Stop when unexpected or uncertain conditions exist? [DM]

Challenge assumptions and/or offer opposing views? [QA]

Are actively engaged in changes to processes and procedures? [WP]

Organization You receive feedback? [CL]

You give feedback? [LA]

Effective organizational communications? [CO]

Individuals taking ownership of issues, problems, and processes? [PA]

Clearly and unambiguously defined roles and responsibilities? [LA]

Processes Effective use of the problem reporting and resolution process? ID vs. Resolution?

[PI]

Effective resolution of employee concerns? [RC]

Q: FGQ11: On a scale of 1 to 10, with 10 being always and 1 being never, how frequently do you see:

A:

Page 155 of 170 SC Trait(s):

Q: FGQ12: To what extent is respect demonstrated for each other and others in the organization? Can you provide examples? [WE]

A:

Q: FGQ13: What else should we have asked to get a better feel for the current Integrated Safety Culture at NCNR? [Alternatively, What else can you tell us that you think we need to know?]

A:

SC Trait(s):

END OF FOCUS GROUP

Page 156 of 170 4: Meeting Observation Form NIST/NCNR INSCA Meeting - NSC Behavioral Observation Checklist Title of Meeting:

Date and Time:

Location:

Observer:

Point of

Contact:

• Prior to an Observation, Observers are expected to clearly communicate their presence to the Point of Contact and the purpose of the observation - learning and performance improvement - mitigating the potential of future events.

• During Observations, Observers are expected to coach on the spot if during an Observation there is a significant gap in NSC behaviors or other performance issue with likely unacceptable consequences.

• After the Observation, Observers are expected to verbally communicate observed positive behaviors and areas for improvement to affected stakeholders to gain additional insights - the underlying drivers for performance.

• For each noteworthy weakness, the Observer should provide a brief comment on the weaknesses including if known the stated underlying driver for the behavior or performance weakness.

Item Observable Behaviors Score Scoring is 1 for Strength, 2 for Satisfactory, 3 for Weakness, or N/A for Not Applicable).

1.0 Start of Meeting 1.1 Attendance (quorum is met and stakeholders are present) 1.2 Start Time (meeting starts on time with materials and audio/visual aids in place) 1.3 Stakeholders Preparations (materials have been reviewed and ready to comment) 2.0 Conduct of Meeting 2.1 Agenda (clearly stated purpose, objectives, and expected outcomes) 2.2 NSC Topic (review of a Trait and/or Behaviors related to an agenda item) 2.3 In-Process (adherence to protocols, work d processes, and corrective action program) 2.4 Pacing (length of discussions are commensurate with complexity and risk) 2.5 Risk Awareness (decisions factor risk/mitigation using probability/consequences)

Page 157 of 170 Item Observable Behaviors Score 2.6 Leadership (solicits stakeholders for input, concurrence, and/or concerns) 2.7 Respect is Evident (Opinions are valued and support fully informed decisions) 2.8 Supportive (no tolerance for elitism or bullying via words, expressions, or body language) 3.0 Conclusion 3.1 Objectives Met (Leader summarizes objectives and conclusions) 3.2 Clear Follow-up Actions (Actions to be taken, owners, timing, and resolution) 3.3 NSC Critique (Discuss positives and areas for improvement for awareness and learning) 3.4 End Time (Meeting finishes on time so stakeholder can make it to their next commitment) 4.0 Other NSC Behaviors 4.1 Leadership Safety Values and Actions (LA) 4.2 Problem Identification and Resolution (PI) 4.3 Personal Accountability (PA) 4.4 Work Processes (WP) 4.5 Continuous Learning (CL) 4.6 Environment for Raising Concerns (RC) 4.7 Effective Safety Communication (CO) 4.8 Respectful Work Environment (WE) 4.9 Questioning Attitude (QA) 4.10 Decision making (DM)

Comments:

Page 158 of 170 5: Behavioral Observation Form NIST/NCNR INSCA Work Activity - NSC Behavioral Observation Checklist Scope of Work:

Date and Time:

Location:

Observer:

Point of

Contact:

• Prior to an Observation, Observers are expected to clearly communicate their presence to the Point of Contact and the purpose of the observation - learning and performance improvement - mitigating the potential of future events.

• During Observations, Observers are expected to coach on the spot if during an Observation there is a significant gap in NSC behaviors or other performance issue with likely unacceptable consequences.

• After the Observation, Observers are expected to verbally communicate observed positive behaviors and areas for improvement to affected stakeholders to gain additional insights - the underlying drivers for performance.

• For each noteworthy weakness, the Observer should provide a brief comment on the weaknesses including if known the stated underlying driver for the behavior or performance weakness.

Item Observable Behaviors Score Scoring is 1 for Strength, 2 for Satisfactory, 3 for Weakness, or N/A for Not Applicable 1.0 Preparation for Work 1.1 Work Package (complete and accurate) 1.2 Stakeholder Awareness/Involvement (Operations, Engineering, Health Physics, etc., as applicable) 1.3 Pre-Job Brief (supervisor present, job scope/details, risk awareness/mitigation, and backout criteria) 1.4 Supervisor (solicits stakeholders/workers for input, concurrence, and/or concerns) 1.5 Qualifications (supervisors/workers are trained, qualified, experienced, and comfortable with the job) 1.6 Radiological Controls (RWP in place and workers aware, and surveys complete with postings in place) 1.7 Job Walkdown (clearance ready, Lockout/Tagout, and tags hung and verified) 1.8 Tools, Equipment, and Materials (staged, ready to go, and in good condition) 2.0 Conduct of Work

Page 159 of 170 Item Observable Behaviors Score 2.1 Take Two for Safety (verify system configuration and condition matches the work and in a safe manner) 2.2 Positive Component Verification (Independent Verification, Concurrent Verification, Peer Checking, etc.)

2.3 Self-Check STAR (Stop, Think, Act, and Review for critical and other important steps) 2.4 Stop When Unsure (use a questing attitude to stop, put job in safe condition, and notify supervision) 2.5 Procedure/Plan Quality (complete and accurate with detail commensurate with the job and risk) 2.6 Procedure Use (continuous use, reference use, information use, or multiple use) 2.7 Procedure Adherence (steps followed in sequence with up-to-date documentation and signoffs/initials 2.8 RWP Adherence (adherence to radiological safety protocols, procedures, and behaviors) 2.9 Industrial Safety Adherence (adherence to IS work practices with satisfactory IS equip/tool inspections) 2.10 Conservative Bias (a focus on prudent behaviors over simply allowable and no cutting of corners) 2.11 Safety Bias (safety takes priority when competing priorities exist, such as schedule and production) 2.12 Verbal Communications (3-part communication, phonetic alphabet, and clarifying questions) 2.13 Respect is Evident (Opinions are valued and support fully informed decisions) 2.14 Supportive (no tolerance for elitism or bullying via words, expressions, or body language) 3.0 Post-Job Review/Critique 3.1 Job Performance (what went right, what went wrong, and what can be done better) 3.2 Obstacles to Performance (any substantive barriers to doing work safely, correctly, and efficiently) 3.3 NSC Behaviors (what behaviors prevented a problem/event or removed a latent or active error precursor) 3.4 Determine approach to address successes and barriers/problems (Good Catches, CAP, etc.)

4.0 NSC Behaviors 4.1 Leadership Safety Values and Actions (LA) 4.2 Problem Identification and Resolution (PI) 4.3 Personal Accountability (PA) 4.4 Work Processes (WP)

Page 160 of 170 Item Observable Behaviors Score 4.5 Continuous Learning (CL) 4.6 Environment for Raising Concerns (RC) 4.7 Effective Safety Communication (CO) 4.8 Respectful Work Environment (WE) 4.9 Questioning Attitude (QA) 4.10 Decision making (DM)

Comments:

Page 161 of 170 6: INSCA Team Members, Assignments, and Bios Independent TPNSCA Team Membership Frederic Lake, Task Leader, and Analyst Karen Hutchings, Analyst and Assessment Report Leader John Osborne, Analyst and Assessment Report Author Dr. Mary Jo Rogers, Behavioral Scientist, Analyst**

Steven K. Crowe, CAPT, USNR (ret.), Analyst**

Bruce OBrien, Analyst**

John Ettien, TFE Oversight**

• • Team members that are designated with stars were involved in the 2023 INSCA as either team members or oversight activities. These members will provide continuity and insights from the previous INSCA.

Frederic Lake (President WD Associates, Inc.)

Over 40 years of experience root cause analysis and leadership experience covering operations, maintenance, engineering, licensing, and performance improvement. NRC recovery experience at numerous nuclear plants; Senior organizational leader guiding implementation of 95003 recovery at the Palo Verde Nuclear Station. Developed and implemented training activities to improve worker and leader behaviors, and to improve safety culture at several nuclear power plants as part of regulatory recovery efforts.

Karen Hutchings (Consultant/Contractor WD Associates, Inc.)

Over 35 years of experience in commercial nuclear power plants. Development and implementation of safety culture and leadership training for nuclear power plants; Conduct of cause analyses for Chilled Work Environment, SCWE, and safety culture issues; Leadership for assessments, problem identification, and investigation, and resolution. Workforce and staffing planning, succession planning, knowledge transfer and retention process; Implementation of NSC assessments and surveys; Champion of Human Performance (HU) initiatives and mentoring to change behaviors.

John Osborne (Consultant/Contractor WD Associates, Inc.)

Over 40 years of experience in commercial nuclear power plants. Corrective action program management, implementation, and oversight; evaluating programmatic, organizational, and cultural performance issues; analysis and resolution of NRC 95001/95002/95003 Issues including Safety Culture (Organizational Weaknesses), Safety Conscious Work Environment, Human Performance/Decision Making, Significant Equipment/Human Events (Plant Trips, EDGs, Refueling Activities, etc.), Organizational Performance / Leadership Fundamentals (Culture/Behaviors), Willful Events (Confirmatory Action Order), and Problem Identification &

Resolution (Cross-Cutting Issues).

Dr. Mary Jo Rogers (President of Rogers Leadership Group)

Authored the book Nuclear Energy Leadership: Lessons Learned from U.S. Operators (PennWell) and several published articles in HazardEx and Power Engineering magazines. Dr.

Page 162 of 170 Rogers has 25 years of experience consulting to commercial nuclear power, electric and gas utility companies, the U.S. Department of Energy, DOE contractors, and the National Institute of Standards and Technology (NCNR), among others. She has conducted board-requested effectiveness assessments of risk reduction programs and multiple safety culture assessments.

Her extensive background and education enable her to apply psychological and behavioral science principles, combined with real-world utility and business experience, to help individuals and organizations uncover the values, beliefs, and behaviors that may be limiting their performance.

Steven K. Crowe (Consultant)

Mr. Crowe has 45 years of experience in the operation and licensing of nuclear facilities, safe management of nuclear materials, decommissioning and demolition of nuclear facilities, and disposal of hazardous chemicals. He is a recognized subject matter expert (SME) in operational readiness and Conduct of Operations (CONOPS) and has mentored the recovery of troubled facilities prior to Operational Readiness Review (ORR) resumption. His relevant experience includes leading multiple root cause investigations and serving as a qualified team leader/advisor for numerous U.S. Department of Energy (DOE) ORRs and other assessments, including the Waste Isolation Pilot Plant (WIPP) restart. He is trained in MORT, Kepner-Tragoe, PII, and INPO Human Performance Evaluation/Root Cause Methodology. He provided specialty nuclear engineering, operations support, and consulting for the Depleted Uranium Hexafluoride (DUF6) facilities startup at the Portsmouth Gaseous Diffusion Plant (PORTS) and the Paducah Gaseous Diffusion Plant (PGDP). He served as a member of the Nuclear Safety Basis Review Board that reviewed and approved for submittal over 20 Documented Safety Analysis (DSA) documents for Bechtel Jacobs Company LLC (BJC). At the Rocky Flats Environmental Technology Site (RFETS), he managed all safety, health, and quality aspects for nuclear material-handling and rule and order compliance for the quality assurance (QA), nuclear safety, fire protection, waste management, and construction programs. He also managed the Westinghouse Government Services Quality Assurance Manual (QAM) Review and Gap Analysis. Mr. Crowe retired from TVA in 1995. While at TVA he served in a variety of positions including being a charter member of the nuclear oversight group, a shift outage manager, Human Performance Enhancement System coordinator, and the coordinator of the off-site (Nuclear Safety Review Board) activities. Mr. Crowe graduated from the United States Naval Academy in 1977 with Bachelor of Science (with merit) in Operations Analysis.

Bruce OBrien (ATL International Director of Reactor Safety and Performance Improvement)

Over 50 years of experience in commercial nuclear power production, naval submarine operations and shipyard work. Engagements include direct Management and Consulting assignments at an array of stations across North America and Africa. Bruce has had Senior Manager assignments in Operations, Maintenance, Training, Work Management/Outage Management, in addition to having held and exercised an SRO License. Bruce joined Marathon Consulting Group in 2000 and has held positions of increasing responsibility. His assumption of duties as President and CEO became effective in January 2016. Bruce has been a principal participant and driver in the support of several stations exiting the Degraded Cornerstone and Multiple/Repetitive Degraded Cornerstone columns of the NRCs ROP Action Matrix, including the writing and implementation of the procedures supporting those efforts, overall project management, and Senior Manager review of NRC Inspection preparation activities. Activities in this area include development or oversight of recovery project governance, project controls, subcontractor control and staffing, leadership indoctrination, conduct and oversight of assessment activities, cause analysis oversight, action plan development, implementation

Page 163 of 170 oversight, regulatory interface, and senior leadership mentoring through the process. Note:

Multiple/Repetitive Degraded Cornerstone (Column 4) recoveries involve deep diagnostic assessments to determine if the station operations are acceptable and if additional actions are required to arrest declining performance. These assessments include but are not limited to:

Program/Process (Governance) for all management processes, engineering programs, and cross organizational processes such as Problem Identification and Resolution, Work Management, etc., Equipment Reliability, Human Performance, Nuclear Safety Culture (including independent or third-party Safety Culture Assessments), Training, and Leadership. In earlier Marathon engagements, Bruce served as: Project Team Lead, to implement a system team for the Emergency Diesel Systems, including framework, performance metrics and industry wide benchmarking to identify vulnerabilities and provide mitigating strategies improving diesel system reliability. Project Manager of a CANDU Outage benchmark and improvement plan at Pickering Nuclear Generating Station. Also, implemented a standard Outage Control Center process and design. Liaison for the Chief Information Officer of Ontario Power Generation for Work Management Integration across all OPG sites. Project Manager for the Maintenance Improvement Project, Nine Mile Point. Maintenance Director, (seconded assignment) responsible for management of all maintenance activities during power operations, refueling, and several short outages. Nine Mile Point Unit 1; Work Control and Outage Manager (second assignment). Nine Mile Point Unit 2; Developed and lead human performance improvement program for the Operations Department, Nine Mile Point Unit 2. Acting General Manager, Operations Support, (second assignment) Nine Mile Point Unit 2. Lead the plant team in the NEI/EUCG management effectiveness review of overall station performance, responsible for assessment in areas of Operations, Maintenance, Work Planning, and Work Management, Outage, Radiation Protection, Chemistry, and Corrective Action and Self-Assessment, Koeberg Station in South Africa.

John Ettien (TFE Inc. Director of Operations & Technical Services)

More than 43 years of experience in program/project/facility management, procedure development and implementation, training, and qualification, conduct of operations (CONOPS),

and regulatory compliance to include over 21 years of experience directly supporting the U.S.

Department of Energy (DOE) and its prime contractors. His relevant experience includes Waste Disposition Operations Manager; Oak Ridge Reservation Landfill (ORRLF) Operations Manager; Operations Manager for the K-25 Decontamination and Decommissioning (D&D)

Project; and Deputy Project Manager (DPM) for the Molten Salt Reactor Experiment (MSRE) chemical defueling project. He served as the Program Manager for URS l CH2M Oak Ridge LLC (UCOR) Facility Management, training all UCOR Facility Managers (FMs) and implementing CONOPS organization wide for UCOR. Mr. Ettien also served as the Lockout/Tagout Subject Matter Expert (SME) and the Hazardous Energy Program Manager for UCOR. He was also the DPM for the U.S. Spent Fuel Team in the DPRK and mentor to the Operations Managers at the Comanche Peak, Point Beach, and Sizewell B Nuclear Plants. Mr.

Ettien is trained in Tap Root Cause Analysis and has participated in performing Root Cause Analysis utilizing other methodologies. Mr. Ettien has an active DOE "Q" clearance.

Page 164 of 170 7: INSCA Background Detail The National Institute of Standards and Technology (NIST) Center for Neutron Research (NCNR) owns and operates a heavy water-moderated nuclear test reactor and associated neutron beam research facility. The NCNRs reactor is licensed by the Nuclear Regulatory Commission (NRC) under the name National Bureau of Standards Reactor (NBSR).

On February 3, 2021, the chief of NCNR Reactor Operations and Engineering notified the NRC (event notification EN 55094) of an alert concerning elevated radiation levels at the NIST Reactor. Pursuant to the event notification received from NCNR staff on February 3, 2021, the NRC initiated a special inspection at the NCNR. On April 14, 2021, the NRC staff issued an interim special inspection report to provide an initial assessment of their understanding of the event sequence, consequences, and the NCNRs response to the event (ADAMS Accession No. ML21077A094).

On March 16, 2022, the NRC released a final report of its initial conclusion from its special inspection report. The NRCs final report confirms and expands on many aspects of NISTs analysis of the incident, pointing to deficiencies in policies, procedures, training, and safety culture as contributing to the incident.

On August 1, 2022, a Confirmatory Order Modifying License No. TR-5 was issued by the NRC.

The issued Confirmatory Order documents the NIST NCNR completed and planned actions, as well as the commitments made by NIST to enable the safe operation of the research reactor in the NCNR.

On June 2, 2023, the Final Report for the baseline Independent Third-Party Nuclear Safety Culture Assessment of the NIST Center For Neutron Research was issued. This report was an independent and critical assessment of NCNR-ROEs performance compared to INPO 12-012 /

NUREG 2165 Nuclear Safety Culture Traits. This assessment established the state of NCNR-ROEs Nuclear Safety Culture and described it by NSC traits and attributes. This report identified gaps and made recommendations for improvement in several organizational areas.

This task (Task 12) provides a second independent and comprehensive assessment of the existing Organizational Nuclear Safety Culture, including the Safety Conscious Work Environment (SCWE) at the NIST Center for Neutron Research. The assessment will be performed in accordance with the requirements of the August 1, 2022, Confirmatory Order Modifying License No. TR-5, which required a second Nuclear Safety Culture Assessment, within 12 months of completing the initial assessment, to ensure sustainability and effectiveness of the identified recommendation corrective actions within the identified areas.

Page 165 of 170 8: NRC Inspection Report - Confirmatory Order Excerpt

Reference:

NRC Inspection Report,

Subject:

National Institute of Standards and Technology, Center for Neutron Research - Confirmatory Order, Dated August 1, 2022

2. Nuclear safety program assessments

a. Nuclear safety culture assessment

i. Within 6 months of issuance of the CO, NCNR will hire a third-party, independent nuclear consultant (consultant) to conduct an independent third-party nuclear safety culture assessment. The contract will specify that the consultant will assist NCNR in the implementation of the recommendations and corrective actions identified in the assessment to prevent recurrence of the February 3, 2021, event or similar events at the NBSR.

ii. Prior to issuance of the Request for Quotations, NCNR will include criteria equivalent to the those described in Section 03.02.c.1, c.2, and c.3 of Inspection Procedure 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input, dated June 7, 2022, to ensure a consultant with the appropriate qualifications is identified.

iii. Within 6 months of contract award to the consultant, NCNR will submit a copy of the safety assessment report and NCNRs written response to the assessment report to the NRC. NCNRs written response will either address how it will implement the recommendations and corrective actions of the assessment report, including a proposed timeline; or provide an explanation and justification for why the recommendation(s) and corrective action(s) will not be implemented.

iv. Within 2 months of submitting the assessment report to the NRC, the NCNR Director shall issue written and verbal communications providing the results of the assessment, recommendations, and corrective actions to the NCNR staff. At least 30 days prior to issuing the written communication, NCNR will provide the statement for NRC staff review. Within 15 days of receiving the statement, the NRC staff will provide feedback to NCNR staff. NCNR will notify the NRC when the statement is issued.

v. The assessment will include employee surveys, the review of anonymous reports, and contractor-conducted interviews and focus groups to assess the effectiveness of the programs.

vi. NCNR will ensure this consultant is provided with all necessary materials, reports, and access to personnel to complete its assessment. The reports shall include the NRC special inspection report dated March 16, 2022, future NRC inspections reports regarding the February 3, 2021, event, and NCNR safety evaluation committee and safety assessment committee (SEC/SAC) reports.

vii. Within 12 months of completing the initial assessment, the consultant will perform a second assessment to ensure the sustainability and effectiveness of the corrective actions within the identified areas. Within 30 days of receiving the report, NCNR will submit a copy of the second assessment report to the NRC.

viii. Within 12 months of completing the second assessment, the consultant will conduct a third assessment to ensure long term sustainability and effectiveness of the identified

Page 166 of 170 recommendations and corrective actions. Within 30 days of receiving the report, NCNR will submit a copy of the third assessment report to the NRC.

Excerpt from NRC Inspection Manual, Inspection Procedure IP 95003: Supplemental Inspection Response to Action Matrix Column 4 (Multiple/Repetitive Degraded Cornerstone) Inputs, Effective Date: June 7, 2022

c. Qualification Requirements for SCAs

1. The team leader should coordinate with the program office to select the lead SCA.

The lead SCA will determine the size of the SCA team and members.

2. The lead SCA, in coordination with the team leader, should verify that the SCAs collectively possess the needed education and experience in the following areas:

Knowledge of methods for gathering safety culture data through: (1) individual and group interviews, (2) structured and unstructured interviews, (3) surveys, (4) behavioral observations and checklists, and (5) case studies; Ability to determine the applicability and likely usefulness of various data-gathering methods under different circumstances; Ability to implement the different methods correctly, including, but not limited to (1) conducting focus groups and interviews in a manner that elicits the desired Issue Date:

06/07/22 22 95003 information while reducing potential biases in the responses, (2) conducting reliable (i.e., repeatable) structured behavioral observations, and (3) collecting insights from written documentation and verbal communications; Knowledge of the requirements for developing, administering, and analyzing the results of surveys and questionnaires, including knowledge of: (1) the strengths and weaknesses of different item types (Likert, BARS, forced-choice, etc.); (2) the requirements for administering a survey to reduce potential biases in the responses; (3) behavioral statistics and the appropriate methods, and their constraints, for analyzing survey data; and (4) statistical requirements for the different types of validity and reliability, and appropriate techniques to assess, measure, and establish them; Knowledge of the rationale for a multiple-measures approach and an ability to assess the limitations of a single-method safety culture assessment; Knowledge of statistical and conceptual constraints on determining appropriate sample sizes for each method; Knowledge of the alternatives for selecting samples for the assessment and the biases introduced by different sample selection strategies; Knowledge of theories and research in organizational and human behavior; Ability to integrate results from applying the different methods to arrive at defensible conclusions; Knowledge of the ROP and applicable inspection requirements and techniques; and Knowledge of theory and research in safety culture.

3. The knowledge and experience of the selected SCAs should be evaluated promptly by the lead SCA to identify any training needs. The selected SCAs should complete the identified training before participating in IP 95003 inspection activities.

Page 167 of 170 9: Definitions Safety Culture: The set of core values and behaviors resulting from a collective commitment by leaders and individuals to emphasize safety over competing goals to ensure protection of people and the environment. (NUREG 2165, Safety Culture Common Language, INPO 12-012, Traits of a healthy Nuclear Safety Culture.

Safety Conscious Work Environment (SCWE): A working environment where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination because they raised the issue.

Integrated Safety Culture: The term integrated safety culture includes the values and beliefs associated with nuclear safety, occupational safety, radiological safety, security, and environmental safety.

Nuclear Safety: The achievement of proper operating conditions and the prevention or mitigation of accident consequences, resulting in the protection of workers, the public, and the environment from undue radiation hazards.

Radiation Safety: The protection of people from the harmful effects of exposure to ionizing radiation, and the means for achieving this.

Occupational Safety: The reduction of the risk of injury, loss, and danger to persons, property, or the environment in any facility or place involving the manufacturing, producing, and processing of goods or merchandise.

Nuclear Security: The prevention, or detection and response, to intentional malicious acts involving radioactive substances or directed against facilities or activities where such substances are used.

Environmental Safety: The guidance, policies, and practices enforced to ensure that the surrounding environment is free from hazards that will warrant the safety and well-being of workers, employees, and residents near industrial operations, as well as the prevention of accidental environmental damage.

Organization Structure: The collective group of all individuals, the reporting structure, and the procedures, policies, and practices that individuals use to set goals and make decisions, to accomplish tasks, and to implement and maintain a healthy integrated safety culture.

NIST Senior Leadership: NIST decision makers who are responsible for setting the long-term strategic goals for the NCNR organization; in addition, develop and implement NIST policies.

Director / Deputy Director: Individuals who are responsible for the execution of business activities, including setting priorities for and monitoring the performance of the organization.

Page 168 of 170 Leaders: Individuals who influence, coach, or lead others within the organization and determine the vision, goals, or objectives of their teams; leaders include NIST Senior Leadership, Directors, Chiefs, Supervisors, and others who influence individuals in the organization.

Chiefs and Leads: Individuals assigned to managerial positions who control, direct, guide, and advise.

Supervisors: Individuals who provide direction of the day-to-day activities of individual contributors; supervisors may include reactor supervisors, engineering supervisors, team leaders or work leaders.

Individual Contributors: Individuals who operate individually or as members of work groups to accomplish tasks; individual contributors may include leaders when leaders are acting in a nonsupervisory capacity or are accomplishing tasks as members of a work group.

Individuals: All people at all levels of the organization; individuals include all leaders, individual contributors, and supplemental personnel.

Supplemental Personnel: Individuals who accomplish work for but are not employees of the NCNR organization. Supplemental personnel include short-and long-term contractors, vendors, OFPM Office of Facilities and Property Management, research and science personnel and any other individuals who are not employed by the organization but occasionally perform work at NCNR.

Work Groups: Groups of individuals who work collaboratively to accomplish tasks; work groups may exist at any level of the organization.

Independent Oversight Organizations: Groups that independently review the performance and direction of the NCNR organization. This includes the NCNR Safety Evaluation Committee (SEC) and the NCNR Safety Assessment Committee (SAC), as well as independent reviews from groups outside of the NCNR organization.

Assessment Categories for Traits and Initiatives Area of Strength (AOS): Performance that is exceptionally effective in achieving its desired results; a program, process, or activity of such high quality that it could serve as an example for other similar elements.

Positive Observation (PO) - A performance, program, or element that is sufficient to meet its basic intent and does not require additional management attention to achieve full effectiveness and consistency.

Area in Need of Attention (ANA): A performance, program, or process element that is sufficient to meet its basic intent, but that requires management attention to achieve full effectiveness and consistency.

Area for Improvement (AFI): A performance, program, or process element that requires significant improvement to obtain the desired results in a consistent and effective manner.

Page 169 of 170 Area of Interest (AOI): A performance, program, or process element that is sufficient to meet its basic intent but would benefit from management attention to achieve full effectiveness and consistency.

Page 170 of 170 0: References US DOE G 414.1-1C, Management and Independent Assessments Guide US NRC Inspection Procedure 95003 US NRC Inspection Procedure 95003 Attachment 02 US NRC Inspection Manual Chapter 0350, Oversight of Reactor Facilities in a Shutdown Condition NUREG 2165, Safety Culture Common Language INPO 12-012, Traits of a Healthy Nuclear Safety Culture, dated March 2014 Research Report RSP-0060, Development of a Regulatory Organizational and Management Review Method. Haber, S.B. and Barriere, M.T., dated June 7, 2022 Task Order 01 dated January 31, 2023 (and additional documents referenced therein)

Safety Culture Policy Statement (76 FR 34773; dated June 14, 2011)

Special Inquiry into Oversight of Research and Test Reactors, OIG Case NO. I2100162 Technical Specifications for the NIST Test Reactor (NBSR) License No. TR-5 Appendix A Safety Analysis Report for the National Institute of Standards and Technology Reactor NBSR-14 NEA, No. 7673, OECD, 2024, Practice for Enhancing Leadership for Safety in Nuclear Regulatory Bodies Measure of A Leader, Aubrey Daniels, published 2007.

Note: Various references were reviewed, verbalized, and/or presented during interviews, focus groups, and/or subsequent discussions with NCNR and INSCA team personnel. The results of the reviews, verbalizations, and/or presentations, were factored into the conclusions within this report.