ML20236W160
| ML20236W160 | |
| Person / Time | |
|---|---|
| Issue date: | 07/27/1998 |
| From: | Lieberman J NRC OFFICE OF ENFORCEMENT (OE) |
| To: | Miller H, Paperiello C, Reyes L NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I), NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION II), NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| References | |
| EGM-98-006, EGM-98-6, FACA, NUDOCS 9808050119 | |
| Download: ML20236W160 (12) | |
Text
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July 27, 1998 EGM 98-006 MEMORANDUM TO: Hubert J. Miller, Regional Administrator Region i Luis A. Reyes, Regional Administrator ,
Region ll Carl J. Paperiello, Acting Regional Administrator .
Region lil Ellis W. Merschoff, Regional Administrator Region IV Bruce Boger, Acting Associate Director for Projects, NRR Brian W. Sheron, Acting Associate Director for Technical Review, NRR Elizabeth O. Ten Eyck, Director, Division of Fuel Cycle Srafety and Safeguards, NMSS Donald A. Cool, Director, Division of Industrial and Medical Nuclear Safety, NMSS John T. Greeves, Director, Division of Waste Management, NMSS i
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FROM: James Lieberman, Director Office of Enforcement /
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SUBJECT:
V ENFORCEMENT GUIDANCE MEMORANDUM - INTERIM GUIDANCE FOR SEVERITY LEVEL IV VIOLATIONS BACKGROUND in light of the high number of non-escalated violations that has been recently issued and the need to provide better oversight of non-escalated actions, this EGM is being issued as a short term measure to clarify guidance under the existing Enforcement Policy for Part 50 licensees, Part 76 certificate holders, and Part 70 licensees with resident inspectors. The staff intends to consider additional guidance in the future including possible changes in the Enforcement Policy l and the need for similar guidance for other materiallicensees.
A major tenet of the NRC Enforcement Policy is that licensees should be encouraged to identify and correct violations of NRC requirements. Accordingly, incentives for self-identification and corrective actions are provided in the policy for both escalated and non-escalated enforcement that provide for licensees to avoid civil penalties and notices of violation. In addition to providing incentives to avoid or lessen enforcement actions, the Enforcement Policy provides for the staff to waive formal responses to cited violations when all aspects of the licensee's i
actions as a result of the violations are already known and documented on the docket, thus reliving unnecessary burden.
Consistent with this philosophy, NRC enforcement decisions must consider licensee actions in identifying and correcting the subject violations. When cited violations result, consideration should be given to what value to the NRC process might be gained from the additional
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. 1 information contained in a formal response from the licensee.
The staff should not be focusing its resources and enforcement attention on licensee I
identified and corrected violations, rather inspectors should focus their attention.on potential safety and risk significant issues and subsequently determine appropriate enforcement . t including whether associated violetions should be cited or treated as NCVs. Consistent with this approach, the staff should not Interpret this EGM as guidance to not document licensee
- identified Severity LevelIV violations, or to not follow up on significant issues that a licensee identifies.
i IMPLEMENTATION The purpose of this EGM is to (1) emphasize existing guidance to ensure that NRC resources are not used to develop, review, track, and close out, and licensee resources are not used to respond to, SL IV violations that do not warrant being formally cited; (2) emphasize existing guidance to ensure that licensees are not directed to provide responses when necessary information is already docketed; and (3) clarify guidance regarding the handling of multiple violations vs multiple examples of the same violation.
Therefore, in order to ensure a consistent approach is achieved during the conduct of inspections, the following general guidance is provided:
- 1. Utilize guidance in section Vil.B.1 of the Enforcement Policy to not cite licensees for non-repetitive, non-willful SL IV violations that were licensee identified and are or will be corrected within a reasonable time.
- 2. Use Enforcement Discretion per Sections Vll.B.2, Vll.B.3, Vll.B.4, and Vll.B.6 of the Enforcement Policy where warranted for Severity Level IV violations.
- 3. Licensee responses to cited Severity Level IV violations should not be required when information needed to be included in a response is already on the docket in an inspection report, LER, or other correspondence, i
- 4. Licensee corrective action program records should not be " mined" solely for the purpose of identifying violations.
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- 5. Multiple examples of the same violation should be included in a single citation l when appropriate.
- 6. In considering whethe.' corrective action is prompt and comprehensive the standard is reasonableness, i.e., licensees' actions should be commensurate with safety significance. '
This guidance is more fully discussed below.
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- 1. Non-cited Violations
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Utilize guidance in section Vll.B.1 of the Enforcement Policy to not cite licensees for non-repetitive, non-wlliful SL IV violations that were licensee identified and are or will be corrected within a reasonable time:
Section Vll.B.1 of the Enforcement Policy describes the enforcement discretion available for ,
licensee-identified SL IV violations. Generally, non-repetitive, non-willful SL IV violations that are or will be corrected within a reasonable time should be dispositioned as NCVs. This .
discretion specifically applies to licensee identified issues that are formally reported in Licensee '
Event Reports (LERs) as well as issues identified through other means. As a reminder, -
violations revealed in LERs, other than minor violations, must be described as such in the LER closeout in an inspection report. {
A. NCV Identification Credit for Event Revealed Violations:
Generally, for the purposes of determining NCV applicability to a violation, Enforcement Policy section Vll.B.1 states:
Licensee identification credit is not warranted when a licensee identifies a violation as a result of an event where the root cause of the event is obvious or the licensee had prior. )
j opportunity to identify the problem but failed to take action that would have prevented the event.
In application of this provision, consideration should also be given to the policy discussion in section VI.B.2.b, Credit for Actions Related to identification, associated with civil penalty assessment:
When a problem requiring corrective action is identified through an event, the decision on whether to give the licensee credit for actions related to identification normally should consider the ease of discovery, whether the event occurred as the result of a licensee self-monitoring effort (i.e., whether the licensee was "looking for the problem"), the degree of licensee initiative in identifying the problem or problems requiring corrective action, and whether prior opportunities existed to identify the problem.
Any of these considerations may be overriding if particularly noteworthy or particularly egregious. For example, if the event occurred as the result of conducting a surveillance or similar self-monitoring effort (i.e., the licensee was looking for the problem), the
- licensee should normally be given credit for identification. As a secondinstance, even if the problem was easily discovered (e.g., revealed by a large spill ofliquid), the NRC
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may choose to give credit because noteworthy licensee effort was exertedin ferreting l
out the root cause and associated violations, or simply because no prior opportunities (e.g., procedural cautions, post-maintenance testing, quality control failures, readily observable parameter trends, or repeated or locked-in annunciator wamings) existed to
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. 4 Jdentify the problem (Emphasis added).
Typically, the identifiable event is the result of the underlying violation and not a violation itself.
ID credit should be considered when licensee follow-up of the event demonstrates thoroughness in assessing contributing factors as well as any obvious, direct cause. The standard for the thoroughness of the licensees' actions is reasonableness based on safety significance. See discussion under item 1.C. " NCV Corrective Actions." '
' Cases where ID credit is denied should be limited to superficial investigations when corrective actions or root causes default to " easy fixes" and the inspectors can demonstrate that significant, credible, differing causes existed that were not identified by the licensee. In regard
[ to " easy fixes," there are cases where an event is caused simply by an isolated human error l
with minimal opportunity for prevention or without contributing causes (e.g., inadequate i
procedures, labeling errors, lack of resources or supervision, and prior opportunities) - the most l
obvious cause turns out to be the correct one. Granting of ID credit should be considered for these cases when licensee efforts are thorough enough to rule out the potential for more subtle contributing factors.
In regard to issues identified by the licensee that NRC is following, the licensee should not be denied credit for identification if it is reasonably pursuing an issue'it identified even though NRC l may have identified the violation first. This assumes the licensee's plans and intent were such j that it is likely the licensee would have identified the vloistion within a reasonable time.
In sum, credit for identification is warranted for non-escalated violations associated with events l unless the staff can show credible actions that clearly should of been taken by the licensee in
! identifying event causes. In all non-escalated cases involving events where ID credit is being denied, the regional Division Director must agree with the denial after consultation with the regional enforcement coordinator.
l B. Determining Repetitiveness:
l in determining repetitiveness for NCV discretion, the Enforcement Policy states:
It was not a violation that could reasonably be expected to have been prevented by the licensee's corrective action for a previous violation or a previous licensee finding that occurred within the past 2 years of the inspection at issue, or the period within the last two inspections, whichever is longer; EGM 97-012, dated June 9,1997, contained guidance for the determination of repetitiveness:
Reviews must be performed to ensure that the current violation is not a repetitive issue before exercising this discretion. The expectation for these reviews would include a review of NRC inspection findings, such as inspection reports, plant issues matrixes, and the inspection follow-up system (IFS) for previous NCVs and NOVs. This review should also include a review of the licensee's records if the insoector has actual 1
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knowledae of a orevious licensee findina. It should be emcheshed that inscectors are not expected to nerform a review of every condition report or other corrective action document for the past 2 years to determine if similar find lncs were identified bv the licensee. Only to the extent that the insoector or reolonal staff had orior knewbdos of such issues that were obtained throuah implementation of the inscection orocram. must they be considered in makina a repetitiveness determination. (Emphasis added)
This guidance is being modified. The underlined words are no longer operative. In considering previous NRC violations or licensee findings, use oely docketed information so that the licensee will have been put on notice of the need to take corrective action for a violation. For determining a violation's repetitiveness, use of licensee corrective action program records is appropriate only to the extent that the inspector or regional staff had previously described the issue in inspection reports or it was described in other docketed information. Generally, the Plant issues Matrix (PIM) should serve as the reference for determining repetitiveness as it should provide notice to the licensee of NRC findings or violations. It is noted that this may result in the inspector not being able to issue a NOV for a licensee identified recurring violation because it was not in the PlM. However, it would be treated at least as a NCV so that if the corrective action was not effective, a citation would be warranted the next time it repeats.
In determining whether a violation is repetitive, the test is not just whether the violation repeats.
The fact that a violation recurs does not necessarily mean that past corrective action was not reasonable or effective. The test is whether the licensee had developed and implemented l
reasonable corrective actions for the previous violation commensurate with its safety l significance such that at the time the actions were developed it was reasonably expected that i
the root causes of the violation were corrected. See item C. "NCV Corrective Action Credit."
C. NCV Corrective Action Credit:
To warrant NCV corrective action credit for a St. IV violation, the Enforcement Policy states:
it was or will be corrected within a reasonable time, by specific corrective action l committed to by the licensee by the end of the inspection, including immediate i
! corrective action and comprehensive corrective action to prevent recurrence. I
' In evaluating the scope and comprehensiveness of corrective actions, ins'pectors and their !
management should judge licensee response commensurate with the significance of the issue.
Inspectors frequently can formulate additional actions that a licensee might omit. However, the standard is reasonableness. Unless the inspector, in consultation with regional management, determines that there were significant, credible, differing causes that were not reasonably addressed in the corrective actions, the licensee's actions should be considered adequate for credit. If there is a dispute with the licensee on the reasonableness of its corrective l
actions, the Division Director must concur on any cited violation. !
One aspect of the NCV criteria of Section Vll.B.1 of the Enforcement Policy that frequently
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raises questions concems the criteria for "... corrective action committed to by the licensee by '
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the end of the inspection..? The licensee's discovery of an issue realistically may be near the end of an inspection, creating an artificial constraint for assigning an NCV instead of a cited SL IV if insufficient time is available for the licensee to formulate corrective actions. Judgement is required and is appropriate for these situations to reasonably accommodate the timing of events and in no case should denial of an NCV in favor of a cited SL IV violation be based -
solely on undeveloped correctiv6 actions due to the close proximity to the end of the inspection.
For region based inspectors, who may be on site for only a short time, follow-up discussions via phone with licensees or resident staffs should be made prior to completing the inspection report, if necessary, to gain the information needed to maks decisions regarding corrsctive action credit for licensee identified violations. If the report has to be issued and there has.not been a reasonable time for the licensee to have developed its corrective action approach (but no longer than 30 days from licensee discovery), a potential violation that otherwise meets the criteria for an NCV may be left open as an Apparent Violation (EEI)' to apply the corrective action criterion. Treatment of Eels including those involving potential LERs or other required reports are addressed in item 3, below.
In sum, the NRC is interested in development of adequate corrective actions which reasonably may require more time than the remaining inspection period. An Enforcement Policy change is planned to remove the "by the end of the inspections criteria for NCVs.
D. NCVs involving Programmatic lasues:
EGMs97-012 and 12a, dated June 9 and June 26,1997, respectively, previously provided guidance regarding NCVs including guidance pertaining to programmatic 8 issues. That guidance stated that in the case of Severity Level IV programmatic issues, a formal citation is warranted for deterrence and to obtain a more detailed discussion on the docket of the licensee's comprehensive correction action rather than the brief discussion of corrective action typically included in the inspection report for an NCV. This EGM revises that guidance as follows. Notwithstanding that somewhat broader corrective action may be warranted for Severity Level IV programmatic issues, an NCV should normally be assigned for SL IV violations meeting the NCV criteria in Section Vil.B.1 of the Enforcement Policy, including non-repetitiveness, provided the documented description of corrective actions taken or planned are sufficient to cover the programmatic nature of the issue. This is because of the safety significance of the level IV issues and the lack of prior ocurrence. If NCV treatment is not warranted, the regional enforcement coordinator should be consulted and the cover letter transmitting Severity Level IV citations involving programmatic issues meeting NCV criteria must be signed by the Regional Administrator and must explain the basis An eel designation is being used because an apparent violation has been identified and not because escalated action is being considered.
2 Programmatic is used here to mean that broad corrective actions (e.g., substar:tial retraining, procedure revisions, or additional resources) are needed to address root cause, i.e.,
the issue is more than a failure of a person to implement a reasonable program requirement.
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- 7 for the NRC concern. The same guidance applies if there are other reasons why a violation meeting the NCV guidance should be cited. The enforcement coordinator should consult with the OE for consistency.
- 2. Enforcement Discretion per Sections Vll.B.2, Vll.B.3, Vll.B.4, and VILB.6 of the .
Enforcement Policy:
l Enforcement Policy Sections Vll.B.2, Violations identified During Extended Shutdowns or Work Stoppages; Vll.B.3, Violations invoMng Old Design lasues; Vll.B.4, Violations identified Due to Previous Enforcement Action, and Vll.B.6, Violations involving Special Circumstances, may all apply at the SL IV level to grant enforcement discretion for not citing violations. Regional
[ Management should seek guidance on specific cases from the regional enforcement staff who l will coordinate with OE for application of these discretion options and obtain an EA number.
Note: The term NCV is reserved for SL IV violations using discretion per Vll.B.1.
Violations not cited per Vll.B.2,3,4, or 6 should include a description as follows: "The NRC is exercising discretion in accordance with Section Vll.B.x of the Enforcement Policy and refraining from issuing a citation for this Severity Level IV violation." Until the IFS and the PIM processes are modified to reflect the different types of discretion and severity levels, the Vll.B.
2 -6 discretion cases for PIM and IFS are to be isbeled NCVs with the text explaining the particular type of discretion and severity level. However, the inspection reports should not use :
NCV language as noted above.
- 3. Licensee responses to cited Severity Level IV violations should not be required when information needed to be included in a response is already on the docket in an inspection report, LER, or other correspondence.
When citing a SL IV violation, the Enforcement Policy provides for not requiring a written response from the licensee. Typically, this is appropriate when the information needed for a response to a Notice of Violation is already'on the docket in one or more publicly available correspondences, usually the inspection Report describing the violation, an LER, or other required report. Cover letter and NOV forms in Appendix B of the Enforcement Manualinclude the appropriate text for these situations:
The NRC has concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence is
' already adequately addressed on the docket in [ indicate correspondence, e.g.,
Inspection Report No. XX-XXX/YY-NN, LER YY-NNN, or letter from Licensee] dated i
. Therefore, you are not required to respond to this letter unless the "
description therein does not accurately reflect your corrective actions or your position. In that case, or if you choose to provide additional information, you should follow the instructions specified in the enclosed Notice. '
1 This option should be utilized whenever the information known about the licensee's corrective I actions supports it - where applicable, this should be the usual approach instead of the l
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i exception.
In cases involving a potential SL IV for which an LER is required to be submitted for a reportable occurrence, the enforcement decision, i.e., issuance of either a NOV or NCV, should be deferred until the report is submitted assuming it is provided within the required time frame.
At that time, if the information in the LER confirms the existence of the violation, reasonably i
addresses the reason for the violation, the conective actions taken and planned to correct the L
I violation and prevent recurrence, NCVs can be issued if the criteria is met or citations should be issued as "no response required," indicating the LER as the source of the docketed I
correspondence. It is appropriate to hold an item open until after receipt of an LER in order for the issue to qualify as a "no response required" violation or NCV. Based on the delay of up to 30 days for issuance of an LER, the likely sequence of actions is that the inspection period including the event will have ended, the exit interview will have occurred, and the inspection report will be in final preparation prior to receipt of the LER. This will create the need for an open item designator in order to track the suspected violation in IFS. If needed, an Apparent Violation (EEI) should be opened for this purpose since a potential violation is involved. If an l
eel is opened, the reason for leaving the item open should be similar to the following:
l This issue, which may represent a violation of NRC requirements will remain open
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[pending receipt and analysis of the LER required to be submitted to the NRC by 10 i CFR 50.73) or [for a reasonable time to allow the licensee to develop its corrective actions).
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l The same approach is warranted for other required reports such as radiation and safeguards !
l reports.
' 4. Licensee corrective action program records should not be " mined" solely for the purpose of identifying violations.
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The Enforcement Policy places great emphasis on and provides much incentive for licensees to self identify and correct violations. The staff should not be focusing its enforcement attention on licensee identified and corrected violations, rather inspectors should focus their attention on uncorrected potential safety issues and then determine whether associated violations should be cited or treated as NCVs.
l Consistent with this, inspectors should not be revisiting issues within licensee corrective action i
programs for which adequate corrective actions have been taken solely for the purpose of identifying violations. This direction applies to after-the-fact reviews of records in which the l
' corrective action process worked to correct deficiencies or violations. It is acceptable to review records to judge the quality of the corrective action program and to identify examples of inadequate corrective actions and take enforcement action. ,
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l' The overall assessment of the corrective action programs is accomplished by inspection Procedure 40500, Effectiveness of Licensee Controls in Identifying, Resolving, and Preventing ;
Problems. . Inspection Manual Chapter 0610 contains the following discussion in this regard:
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. 9 Violations identified as Part of Lkensee Self-Assessments. Under certain circumstances, even a violation that could be classified as SL IV ('more-than-minor")
need not be documented. This is generally justified when the violation has been i
identified and corrected as part of a licensee self-assessment effort. As a matter pf policy, NRC enforcement seeks to encourage licensee self-assessment efforts, and seeks to avoid the negative impact that can result from a redundant NRC emphasis on problems which the licensee's responsible action has already identified and corrected.
Thus, in general, licensee corrective action program records should not be " mined" for the purpose of identifying violations. This does not mean that an emerging issue revealed to an inspector through day-to-day inspection sampling activities to determine current performance, including attendance at licensee status meetings or conversations with licensee personnel, that is concurrently or subsequently entered into the corrective action process is immune from enforcement. For example, if an inspector reads a control room log entry (as a result of follow-up from a morning meeting discussion) describing a situation revealing a SL IV violation, an NCV or cited SL IV violation would be appropriate even if the log entry initially stated, fc-example, that Adverse Condition Report 98-xxx was opened. In this case, the inspector became aware of the issue through routine inspection sampling activities, not by searching through corrective action program files. For these emerging issues inspectors should allow the licensee to develop its approach to corrective action ( the schedule for implementation of the corrective actions should be commensurate with safety significance and NRC requirements, See Generic Letter 91-18) before making a decision on enforcement in order to minimize NRC influence on the licensee's results. In regard to issues identified by the licensee that NRC is following, the licensee should not be denied credit for identification if it is reasonably pursuing an issue it identified even though NRC may have identified the violation first. This assumes the licensee's plans and intent were such that it is likely the licensee would have identified the violation within a reasonable time. During the corrective action process, inspectors should promptly inform the licensee of known pertinent safety significant information that the licensee may be unaware of.
This guidance should not be interpreted to prohibit challenges to corrective action program j resolutions. Since licensee corrective action programs may arrive at incorrect or incomplete {
! resolutions, inspectors should continue to review and question licensee conclusions including i i reviews of program records. If the inspector can show that the licensee corrective action
! program reached the wrong conclusion (s), enforcement action may be appropriate, if SL IV violations are identified through the course of corrective action program reviews, e.g., inspection Procedure 40500, the regional Division Director must agree with the enforcement action after consultation with the regional enforcement coordinator.
- 5. Multiple examples of the same violation should be included in a single citation when appropriate.
Enforcement Manual section 4.2.1, NOV Preparation, states:
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l As a general rule, multiple examples of the same violation during the period covered by an inspection should be included in one citation. However, if the violations were committed by different disciplines, on different systems, or in different areas of the facility, it may be appropriate to issue separate citations, even if the same basic .
requirement was violated.... Consider also whether different root causes are involved and different corrective actions are needed for the different examples.
- The test of whether or not multiple examples should be cited in a single violation is whether or not the corrective actions necessary to prevent recurrence for och example is similar to all the examples, if the corrective action is similar for multiple examples of v!olations of the same requirement (s) they should normally be cited in a single citation. For then situations, the following guidance is provided:
An Unresolved item from a previous inspection report period that is subsequently r resolved to be a violation may be included with additional examples in a cur. ent report period if, in the judgement of the inspector and his/her management, the similarities of the viola tions reasonably constitute " examples" of the same underlying violafon.
Absent the multiple examples, each example must be able to stand alone is a separate SL IV violation, i.e., multiple minor violations must not be aggregated to Juttify a SL IV violation.
The number of examples cited should be limited to the number necest ary to make the case for any corrective actions beyond the specific details of each enmple such that
- the scope and depth of needed corrective actions is illustrated if tw nerous examples were identified during the inspection, the NOV should cite represer rative examples of the highest safety / regulatory significance.
OE will be working with NRR to address inspection guidance relative ta topics with multiple examples from the standpoint of how much inspection and how much documentation is optimal to capture broader issues, inspection report details of individual examplet should be limited to that necessary to support the examples cited in the violation. It should not be necessary to discuss examples that are not being used in the cited violation.
t This guidance presumes that licensees will assess any needed corrective actions broadly enough to encompass any broader issues illustrated by the multiple examples. As such, an l
l increased burden is placed on the inspectioq staff to ensure the comprehensiveness of I corrective actions when performing follow-up inspection of the violation.
Other cases frequently arise in which additional examples of violations are identified that have already been cited as NOVs or dispositionec' cs NCVs. In such cases, if corrective actions from the earlier issues have not been completed at the time of the violation and no broad additional corrective actions are warranted (i.e., the examples, if known at the time of the original inspection, would not have been necesarry in the initial citation to establish the scope and depth of the needed corrective actions), the additional examples need not be cited. In these cases,
, 11 any inspection report description of the additional example (s) should include text similar to the following:
This violation constitutes an additional example of [ violation][NCV] 50 333/98-15-01 and is not being cited individually. No additional response to violation 50-333/98-15-01 is required. Further corrective actions for this additional example are expected to be taken in conjunction with corrective actions for the previously cited violation. '
Administration This EGM is effective upon issuance. Questions regarding implementation should be directed to the corresponding regional Enforcement Coordinator who will coordinate with OE as necessary. Inspection staff in NRR and NMSS should consult with OE.
cc:
The Chairman The Commissioners L. Callan, EDO H. Thompson, DEDR W. Travers, DEDE S. Collins, NRR R. Zimmerman. NRR A. B. Beach, NRR M. Knapp, NMSS J. Goldberg, OGC SECY l
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