Issue Date: 1/17/02
NRC Inspection Manual IIPB
PROGRAM APPLICABILITY: | 2515 |
CORNERSTONES: | ALL |
INSPECTION BASIS: | The NRC's revised inspection program includes three parts: baseline inspections; generic safety
issues and special inspections; and supplemental inspections performed as a result of risk
significant performance issues. The inspection program is designed to apply NRC inspection
assets in an increasing manner when risk significant performance issues are identified, either by
inspection findings evaluated using the significance determination process (SDP) or when
performance indicator thresholds are exceeded. Accordingly, following the identification of an
inspection finding categorized as risk significant (i.e., white, yellow, or red) via the SDP, or when
a performance indicator exceeds the "licensee response band" threshold, the NRC regional office
will perform supplemental inspection(s). The scope and breadth of these inspections will be based
upon the guidance provided in the NRC's assessment "Action Matrix" and the Supplemental
Inspection Table (included in 2515 Appendix B). The supplemental inspection program is
designed to support the NRC's goals of maintaining safety, enhancing public confidence,
improving the effectiveness and efficiency of the regulatory process, and reducing unnecessary
regulatory burden. This procedure provides the supplemental response for one degraded cornerstone or three White inputs in a strategic performance area. The guidance provided in this procedure was developed with consideration of the following boundary conditions:
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01.01 | To provide assurance that the root causes and contributing causes are understood for individual and collective (multiple white inputs) risk significant performance issues. |
01.02 | To independently assess the extent of condition for individual and collective (multiple white inputs) risk significant performance issues. |
01.03 | To provide assurance that licensee corrective actions to risk significant performance issues are sufficient to address the root causes and contributing causes, and to prevent recurrence. |
The following inspection requirements relate to the minimum set of information that the NRC will generally need to acquire in order to assure that the causes of risk significant performance issues are identified and that appropriate corrective actions are taken to prevent recurrence. While the inspection requirements are generally written to address individual performance issues, the procedure may also be utilized to assess the adequacy of licensee's evaluations associated with multiple performance issues. While these inspection requirements do not necessarily represent NRC requirements for the licensee, significant weaknesses in the licensee's evaluation may require that the NRC conduct additional inspections to acquire the information independently. It is recognized that the depth of the licensee's evaluation may vary depending on the significance and complexity of the issues. In some cases, the answers to specific inspection requirements will be self-evident with little additional review or analysis required by the inspectors. This procedure also requires an independent NRC inspection to inspect the adequacy of the licensee's extent of condition determination. The inspection report associated with this inspection should contain the NRC's assessment of the licensee's evaluation for each inspection requirement.
Significant weaknesses in the licensee's evaluation of the performance issue may be subject to additional agency actions, including additional enforcement actions or an expansion of this procedure as necessary to independently acquire the information necessary to satisfy the inspection requirements. In general, licensee's should be given an opportunity to correct any identified deficiencies prior to re-inspection. Also, for inspection findings, the original performance issue will remain open and will not be removed from the action matrix until the weaknesses in the evaluation are addressed and corrected. For significant weaknesses in the licensee's evaluation of a performance issue that is associated with a performance indicator, a parallel inspection finding will be opened and given the same color as the PI; however, the finding will not be double counted in the action matrix. Also, for those performance indicators that include fault exposure hours, the provision contained in NEI 99-02 to remove the fault exposure hours after four quarters requires successful closure of any open items identified during this inspection. Programmatic weaknesses associated with the licensee's evaluation of the performance issue will also be documented in the inspection report and additional focus will be given to those areas during the next annual problem identification and resolution baseline inspection.
Should new or additional examples of performance issues (non-programmatic) be identified by this inspection or by the licensee during their evaluation, the new issues will be categorized using the SDP and the corresponding supplemental inspection procedure will be performed. Supplemental inspections will also be performed if additional examples of performance issues are reported via performance indicators (PIs) that result in crossing a new PI threshold. Additional supplemental inspections will generally not be performed if the new or additional examples of performance issues reported via PIs do not result in crossing a new PI threshold.
The following inspection requirements are generally applicable for single inspection findings, multiple inspection findings, and for performance issues reported by PIs that might represent more than one independent event (e.g. multiple scrams). The scope of this inspection should include all white or yellow performance issues (inspection findings or PIs) in the associated degraded cornerstone or strategic performance area. For example, if this procedure is being performed due to a yellow PI in the mitigating systems cornerstone, the inspection scope should also include any white PIs or inspection findings in that cornerstone. If the procedure is being performed due to three white PIs in the reactor safety strategic performance area, the inspection scope should include all white PIs in the reactor safety strategic performance area.
In the case where a performance indicator is associated with multiple events or occurrences, or for evaluations of multiple performance issues, it is expected that the licensee's evaluation would address each of the events or occurrences collectively, as well as individually. In those instances where the licensee's evaluation was previously reviewed as part of Inspection Procedure 95001, a re-review of the evaluation during this procedure is not required; however, a review of the licensee's collective evaluation for multiple performance issues would generally need to be performed.
02.01 | Problem Identification |
a. Determine that the evaluation identifies who (i.e. licensee, self revealing, or NRC), and under what conditions the issue was identified. | |
b. Determine that the evaluation documents how long the issue existed, and prior opportunities for identification. | |
c. Determine that the evaluation documents the plant specific risk consequences (as applicable) and compliance concerns associated with the issue(s) both individually and collectively. | |
02.02 | Root Cause and Extent of Condition Evaluation |
a. Determine that the problem was evaluated using a systematic method(s) to identify root cause(s) and contributing cause(s). | |
b. Determine that the root cause evaluation was conducted to a level of detail commensurate with the significance of the problem. | |
c. Determine that the root cause evaluation included a consideration of prior occurrences of the problem and knowledge of prior operating experience. | |
d. Determine that the root cause evaluation included consideration of potential common cause(s) and extent of condition of the problem. | |
02.03 | Corrective Actions |
a. Determine that appropriate corrective action(s) are specified for each root/contributing cause or that there is an evaluation that no actions are necessary. | |
b. Determine that the corrective actions have been prioritized with consideration of the risk significance and regulatory compliance. | |
c. Determine that a schedule has been established for implementing and completing the corrective actions. | |
d. Determine that quantitative or qualitative measures of success have been developed for determining the effectiveness of the corrective actions to prevent recurrence. | |
02.04 | Independent Assessment of Extent of Condition and Generic Implications. Perform a focused inspection(s) to independently assess the validity of the licensee's conclusions regarding the extent of condition of the issues. In order to accomplish this objective, the inspection team leader should develop a customized inspection plan using the applicable portions of the inspection procedure(s) listed in Appendix B to Inspection Manual 2515. The objective should be to independently sample performance, as necessary to provide assurance that the licensee's evaluation regarding extent of condition is sufficiently comprehensive. The intent is not to re-perform the licensee's evaluation, but is to assess the validity of the licensee's evaluation by independently sampling performance within the key attributes of the cornerstone(s) that are related to the subject performance issue. The results of the NRC's review of extent of condition should be documented in this inspection report, including the NRC's assessment of the licensee's evaluation in this area. |
General Guidance
This inspection procedure is designed to be used to assess the adequacy of the licensee's evaluation of risk significant performance issues. As such, a reasonable time (generally within 30-60 days) should be allowed for the licensee to complete their evaluation (or self assessment for multiple performance issues); however, all corrective actions may not be fully completed upon commencement of this procedure. Implementation of these corrective actions may be verified during subsequent baseline inspections such as the annual problem identification and resolution.
The following sections of this procedure are provided as guidance to help the inspector fulfill the specific inspection requirements contained in section 02. It is not intended that the inspector verify that the licensee's evaluation of the performance issues address every attribute contained in the inspection guidance section. The intent is that the inspector use the guidance sections of the procedure to look for weaknesses in the licensee's evaluation that might indicate an issue associated with one of the inspection requirements.
Definitions
Root Cause(s) are defined as the basic reason(s) (i.e., hardware, process, human performance), for a problem, which if corrected, will prevent recurrence of that problem.
Contributing Cause(s) are defined as causes that by themselves would not create the problem, but are important enough to be recognized as needing corrective action. Contributing causes are sometimes referred to as causal factors. Causal factors are those actions, conditions, or events which directly or indirectly influence the outcome of a situation or problem.
Repeat occurrences are defined as two or more independent conditions which are the result of the same basic cause(s).
Common Cause is defined as multiple failures (i.e., two or more) of plant equipment or processes attributable to a shared cause.
Extent of Condition is defined the extent to which the root causes of an identified problem have impacted other plant processes, equipment, or human performance.
Consequences are defined as the actual or potential outcome of an identified problem or condition.
Specific Guidance
Sections 03.01 through 03.03 apply to the licensee's evaluation of both individual and collective issues.
03.01 | Problem Identification |
a. The evaluation should state how and by whom the issue was identified. When appropriate, failure of the licensee to identify the problem at a precursor level should be evaluated. Specifically, the failure of the licensee to identify a problem before it becomes risk significant may be indicative of a more substantial problem. Examples would include a failure of the licensee's staff to enter a recognized non-compliance into the corrective action program, or raise safety concerns to management, or the failure to complete corrective actions for a previous problem resulting in further degradation. If the NRC identified the performance issue, the evaluation should address why licensee processes such as peer review, supervisory oversight, inspection, testing, self assessments, or quality activities did not identify the problem. | |
b. The evaluation should state when the problem was identified, how long the condition(s) existed, and whether there were prior opportunities for correction. For example, if a maintenance activity resulted in an inoperable system that was not detected by post-maintenance testing or by quality assurance oversight, the reasons that the testing and quality oversight did not detect the error should be included in the problem identification statement and addressed in the root cause evaluation. | |
c. The evaluation should address the plant specific risk consequences of the issues, both individually and collectively. A plant specific assessment may better characterize the risk associated with the White issue due to the generic nature of the performance indicators. For conditions that are not easily assessed quantitatively, such as the unavailability of security equipment, a qualitative assessment should be completed. The evaluation should also include an assessment of compliance. As applicable, some events may be more appropriately assessed as hazards to plant personnel or the environment. The inspector's review of the risk assessment should be coordinated with the Senior Reactor Analyst. | |
03.02 | Root Cause Evaluation |
a. The licensee's evaluation should generally make use of a
systematic method(s) to identify root cause(s) and contributing
cause(s). The root cause evaluation methods that are commonly
used in nuclear facilities are:
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The licensee may use other methods to conduct the root cause
evaluations. A systematic evaluation of a problem using one of
the above methods should normally include:
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b. The root cause evaluation should be conducted to an adequate
level of detail, considering the significance of the problem.
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The depth of the root cause evaluation may be assessed by:
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c. The root cause evaluation should include a proper consideration of repeat occurrences of the same or similar problems at the facility and knowledge of prior operating experience. This review is necessary to help in developing the specific root and contributing causes and also to provide indication as to whether the White issue is due to a more fundamental concern involving weaknesses in the licensee's corrective action program. | |
The evaluation should:
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d. The root cause evaluation should include a proper
consideration of the extent of condition of the problem
including whether other systems, equipment, programs or
conditions could be effected. The evaluation should:
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03.03 | Corrective Action |
The proposed corrective actions to the root and contributing causes should: | |
a. Address each of the root and contributing causes to the White
issue and the extent of condition of the issue. The corrective
actions should be clearly defined. Examples of corrective
actions may include, but are not limited to, modifications,
inspections, testing, process or procedure changes, and training. The proposed corrective actions should not create new or different problems as a result of the corrective action. If the licensee determines that no corrective actions are necessary, the basis for this decision should be documented in the evaluation. | |
b. Include consideration of the results of the licensee's risk assessment of the issue in prioritizing the type of corrective action chosen. Attention should be given to solutions that involve only changing procedures or providing training as they are sometimes over-utilized. In such cases, consideration should be given to more comprehensive corrective actions such as design modifications. The corrective action plan should also include a review of the regulations to ensure that if compliance issues exist, the plan achieves compliance. | |
Also, the licensee should ensure that:
c. The corrective actions are assigned to individuals or organizations that are appropriate to ensure that the actions are taken in a timely manner. Also, the licensee should ensure that there is a formal tracking mechanism established for each of the specific corrective actions. d. A method exists to validate the effectiveness of the overall corrective action plan. Specifically, a method should be established to measure, either quantitatively or qualitatively, the effectiveness of the corrective actions. Effective methods would include, but are not limited to, assessments, audits, inspections, tests, and trending of plant data, or follow-up discussions with plant staff. | |
03.04 | Independent Assessment of Extent of Condition |
a. In choosing the inspection procedure(s) to assess the validity
of the licensee's conclusions regarding extent of condition,
consideration should be given to whether multiple risk
significant performance issues have been identified. For those
instances where multiple issues have been documented, a broad
based inspection(s) which would assess performance across the
associated strategic performance area should be considered. If
this procedure is being performed due to a single yellow issue, a
more focused inspection would likely be appropriate.
Consideration should also be given to the comprehensiveness of the licensee's evaluation(s). In those cases where significant weaknesses are identified in the licensee's evaluation(s) during implementation of paragraphs 02.01 through 02.03 of this procedure, consideration should be given to performing a more in-depth programmatic review of the licensee's corrective action program. |
The resources required to complete this procedure will vary greatly depending upon the specific procedure(s) chosen to independently assess the validity of the licensee's evaluation of extent of condition and generic implications. Generally it would be expected that the procedure could be completed within 40-240 hours.
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