The Role of Inspection FindingsThe Role of Inspection Findingsand Crossand Cross--Cutting Issues in theCutting Issues in the

Enhanced Reactor Oversight ProcessEnhanced Reactor Oversight Process

John W. ThompsonJohn W. ThompsonSenior Reactor Operations EngineerSenior Reactor Operations Engineer

Performance Assessment BranchPerformance Assessment BranchDivision of Inspection & Regional Support, NRRDivision of Inspection & Regional Support, NRR

INITIATINGEVENTS

MITIGATINGSYSTEMS

BARRIERINTEGRITY

EMERGENCYPREPAREDNESS

CornerstonesPUBLIC

RADIATIONSAFETY

OCCUPATIONALRADIATION

SAFETY

PHYSICALPROTECTION

StrategicPerformance

Areas

REACTORSAFETY

RADIATIONSAFETY SAFEGUARDS

HUMANPERFORMANCE

SAFETY CONSCIOUS WORKENVIRONMENT

PROBLEMIDENTIFICATION AND

RESOLUTION

PUBLIC HEALTH AND SAFETYAS A RESULT OF CIVILIAN

NUCLEAR REACTOROPERATION

NRC’s OverallSafety Mission

REGULATORY FRAMEWORK

Cross-Cutting Areas

2

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Inspections in the Reactor Oversight Inspections in the Reactor Oversight Process Process -- ReviewReview

P erfo rm an c e In d ica tor s

P erform ance Ind icators

S ign ific a nc e E v alu a tion s

M an a ge m e n t C o nfe re nc e

M o nito r L ic en se e A ctio n sN R C In sp ec tion s

A d d ition a l R e gu lato ry A c tion s

A ssessm ent P rocess

(A ction M atrix )

E nforcem en t

Sign ifica n ce D e term in atio n P ro ce ss

S up p lem e nta lIn spe c tion s

R EA CT O R O V ER SIG H T PR O CE SS

A gency R esp onse

P ub lic M ee tin gs

C om m unications

A sses sm e n t R e po rtsIn spe c tion P la ns

In spe c tion F ind in gsP erfo rm an c e In d ica tor s

In spection s

S ign ific a nc e E v alu a tions

P erf orm ance R esults in all 7 C ornerstones of Safety

C ornerstones o f Sa fe ty

P erfo rm an c e In d ica tor T h res ho ld s

E v en t R e sp on se(S I/A IT /IIT )

R isk In fo rm e dB a se line In sp ec tion s

G e n eric S afe tyIn spe c tion s

Press Re lea sesNR C W eb SitePD R/A DA M S

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ROP Enhanced Areas Based on DavisROP Enhanced Areas Based on Davis--BesseBesse

Commission direction in the form of staff requirements Commission direction in the form of staff requirements memoranda, included:memoranda, included:

•• Enhance the Reactor Oversight Process (ROP) Enhance the Reactor Oversight Process (ROP) treatment of crosstreatment of cross--cutting issues to more fully address cutting issues to more fully address Safety Culture;Safety Culture;

•• Develop a process for determining the need for a Develop a process for determining the need for a specific safety culture evaluation of plants in a specific safety culture evaluation of plants in a degraded cornerstone; anddegraded cornerstone; and

• Ensure modifications to the ROP are consistent with the ROP development principles.

•• Ensure inspectors are properly trained;Ensure inspectors are properly trained;

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The Development of anThe Development of anInspection FindingInspection Finding

•• Screen to determine if there is a Screen to determine if there is a performance deficiencyperformance deficiency

•• Screen for greater than minor issueScreen for greater than minor issue

•• Screen for significance using the SDPScreen for significance using the SDP

•• Screen for traditional enforcementScreen for traditional enforcement

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Revised Definition of aRevised Definition of aPerformance DeficiencyPerformance Deficiency

An issue that is the result of a licensee not An issue that is the result of a licensee not meeting a requirement or standard where the meeting a requirement or standard where the cause was reasonably within the licensee’s ability cause was reasonably within the licensee’s ability to foresee and correct, and that should have to foresee and correct, and that should have been prevented. been prevented. A PD can exist if a licensee fails A PD can exist if a licensee fails to meet a selfto meet a self--imposed standard or a standard imposed standard or a standard required by regulationrequired by regulation. If the PD has related CC . If the PD has related CC aspects, the CC aspects are generally aspects, the CC aspects are generally considered an underlying cause of the PD, rather considered an underlying cause of the PD, rather than an independent issue.than an independent issue.

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Everything Starts With aEverything Starts With aPerformance DeficiencyPerformance Deficiency

•• A finding is defined as a performance deficiency A finding is defined as a performance deficiency that is more than minor.that is more than minor.

•• Is reflected of current licensee performance.Is reflected of current licensee performance.

•• May have a significant contributing cause in one of May have a significant contributing cause in one of the three CC areas of human performance, PI&R, the three CC areas of human performance, PI&R, or safetyor safety--conscious work environment.conscious work environment.

•• Is documented in the inspection report.Is documented in the inspection report.

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Minor Violations/FindingsMinor Violations/Findings

Minor Violations/Findings are less significant Minor Violations/Findings are less significant than a Severity Level IV violation or less than a Severity Level IV violation or less significant than what the SDP characterizes as significant than what the SDP characterizes as Green and is of such low significance that Green and is of such low significance that documentation in an NRC inspection report is documentation in an NRC inspection report is not normally warranted, although the not normally warranted, although the issue/violation must be correctedissue/violation must be corrected..

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A Simple Model of the NRC Inspection A Simple Model of the NRC Inspection ProcessProcess

REGULATORYREQUIREMENTS

INDUSTRY STANDARDS

INSPECTION PROCEDURES

NRC INSPECTS

INSPECTION RESULTS

PERSONNEL ARE

SELECTED

PERSONNEL ARE TRAINED

PERSONNEL PERFORM

TASKSRESULTS

DESIRED ATTRIBUTES OF TASKS

HUMAN PERFORMANCE

TOOLS

Performance DeficiencyPerformance Deficiency

Mitigating Systems

Procedure Quality Human PerformanceEquipment PerformanceConfiguration ControlDesign

DesignModifications

RII

EquipmentLineup (at power)

PI = SSUMRV

Availability

PI = SSUMRV

Operating Procedures(Post-event)

- AOP - SOP - EOP

RII (Init, Requal)

Human Error(Pre-events)

PI = SSU

Key:

Human Error(Post-events)

RII (Init,Requal)

Reliability

SSFFMRV

Equipment Lineup(Shutdown)

RII

FloodWeatherToxic HazardFireLoss of heat sinkSeismic

RII

January 30, 2001

ProtectionAgainstExternalEvents

Maint & testingProcedures(Pre-event)

PI = SSFF, RII

Initial Design

PI = none

INSPECTABLE AREAS: PI&R Operator Work Arounds Permanent Plant Mods. Eval of Changes, Tests, Exper. SS Design & Perf. Capability Temporay Plant Mods

INSPECTABLE AREAS: PI&R Flood Protection Measures Adverse Weather Protec. Fire Protection Heat Sink Performance Permanent Plant Mods. Temporary Plant Mods.

INSPECTABLE AREAS: PI&R Equipment Alignment Maint. Risk & Emergent Work Refueling Activities Temporary Plant Mods.

INSPECTABLE AREAS: PI&R Equipment Alignment MR Implementation Operability Evalauation Surveillance Testing

INSPECTABLE AREAS: PI&R Licensed Oper. Requal Eval of Changes, Tests, Exper

INSPECTABLE AREAS: PI&R Licensed Oper. Requal Personnel Perf. in Non- Routine Evols.

Verify PI

INSPECTABLE AREAS: PI&R Equipment Alignment Maint. Risk & Emergent Work Temporary Plant Mods. MR Implementation

Verify PIINSPECTABLE AREA:MR Implemenation

Verify PIINSPECTABLE AREAS: Post Maintenance Testing Surveillance Testing

Verify PI

INSPECTABLE AREAS: PI&R Personnel Perf. in Non- Routine Evols.

PI = Performance IndicatorSSFF = Safety System Functional FailuresSSU = Safety System UnavailabilitySD = Shutdown Margin (Future)

RII = Risk Informed InspectionsInit = Initial Operator ExamRequal = Operator RequalificationPI&R = Problem Identification & ResolutionMR = Maintenance RuleV = Verification and Validation

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1111

In the Industry, Human Performance In the Industry, Human Performance Errors Are Identified in HFIS RecordsErrors Are Identified in HFIS Records

Industry Hits vs. Category, 2005-2005

0 500 1000 1500 2000

Action not yetstarted or untimely

Individual correctiveaction LTA

Non-conservativedecisionmaking

Document technicalcontent LTA

Work practice orcraft skill LTA

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Safety Culture and the CrossSafety Culture and the Cross--Cutting AreasCutting Areas

-- Environment for Raising Environment for Raising

Concerns Concerns

-- Preventing, Detecting, andPreventing, Detecting, and

Mitigating Perceptions ofMitigating Perceptions of

Retaliation Retaliation

-- NoneNoneSafety Conscious Safety Conscious Work Environment Work Environment (SCWE)(SCWE)

-- Corrective Action ProgramCorrective Action Program

-- AssessmentsAssessments

-- Operating ExperienceOperating Experience

-- IdentificationIdentification

-- EvaluationEvaluation

-- Corrective ActionCorrective Action

Problem Identification Problem Identification & Resolution& Resolution

-- Decision Making (3)Decision Making (3)

-- Resources (4)Resources (4)

-- Work Control (2)Work Control (2)

-- Work Practices ((3)Work Practices ((3)

--PersonnelPersonnel

-- ResourcesResources

-- OrganizationOrganization

Human PerformanceHuman Performance

New: ComponentsNew: ComponentsPrevious: BinsPrevious: BinsCrossCross--cutting Areacutting Area

Cross Cutting Components and Cross Cutting Components and Supplemental Inspection EnhancementsSupplemental Inspection Enhancements

•• Decision MakingDecision Making•• Resources Resources (Human Performance)(Human Performance)•• Work PracticesWork Practices•• Work ControlWork Control

•• Corrective Action ProgramCorrective Action Program•• Operating Experience Operating Experience (PI&R)(PI&R)•• Self and Independent AssessmentsSelf and Independent Assessments

•• Preventing, Detecting, and Mitigating Preventing, Detecting, and Mitigating Perceptions of Perceptions of Retaliation Perceptions of Perceptions of Retaliation (SCWE) (SCWE)

•• Environment for Raising ConcernsEnvironment for Raising Concerns

•• Safety PoliciesSafety Policies•• Organizational Change Management (Supplemental Organizational Change Management (Supplemental + Reactive)+ Reactive)•• AccountabilityAccountability•• Continuous Learning EnvironmentContinuous Learning Environment

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Inspection Findings Related to Inspection Findings Related to CrossCross--Cutting AreasCutting Areas

•• The crossThe cross--cutting aspect of a finding is not cutting aspect of a finding is not considered a separate finding, but rather as considered a separate finding, but rather as a significant contributing cause of the a significant contributing cause of the finding.finding.

•• This is important because the inspection This is important because the inspection finding w/CC aspect is entered into the PIM finding w/CC aspect is entered into the PIM and coded in order to support the and coded in order to support the assessment process.assessment process.

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How a CrossHow a Cross--Cutting Aspect (e.g., Human Cutting Aspect (e.g., Human Performance) Relates to the Assessment Performance) Relates to the Assessment

ProcessProcess

The NRC may request an The NRC may request an independent assessment of safety independent assessment of safety cultureculture

The same Substantive CrossThe same Substantive Cross--Cutting Cutting Issue" is identified in three Issue" is identified in three consecutive assessment cyclesconsecutive assessment cycles

The NRC may determine that a The NRC may determine that a "Substantive Cross"Substantive Cross--Cutting Issue" Cutting Issue" existsexists

During an assessment period, four During an assessment period, four or more performance deficiencies or more performance deficiencies had the same crosshad the same cross--cutting aspectcutting aspect

The weakness would be designated The weakness would be designated as a HP crossas a HP cross--cutting aspect and the cutting aspect and the contributing cause of the contributing cause of the performance deficiencyperformance deficiency

A weakness in a human A weakness in a human performance component caused a performance component caused a moremore--thanthan--minor performance minor performance deficiencydeficiency

then...then...If...If...

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Human Performance Could Become A Human Performance Could Become A Regulatory Issue Through the Action MatrixRegulatory Issue Through the Action MatrixIf: Licensee performance enters Column 3 of the NRC’s Action MatIf: Licensee performance enters Column 3 of the NRC’s Action Matrix,rix,

Then the NRC:Then the NRC:•• would conduct an IP 95002 inspection, andwould conduct an IP 95002 inspection, and•• could request an independent licensee selfcould request an independent licensee self--assessment of safety assessment of safety

culture.culture.

If: Licensee performance enters Column 4 of the NRC's Action MatIf: Licensee performance enters Column 4 of the NRC's Action Matrix, rix,

Then the NRC:Then the NRC:•• would conduct an IP 95003 inspection, and would conduct an IP 95003 inspection, and •• the licensee the licensee would be expected to conduct an independent licensee to conduct an independent licensee

assessment of safety culture, andassessment of safety culture, and•• would document the key elements of that assessment in a would document the key elements of that assessment in a

Confirmatory Action Letter (CAL).Confirmatory Action Letter (CAL).

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When The NRC Inspects Attributes Of When The NRC Inspects Attributes Of Task Activities, an Inspection Finding May Task Activities, an Inspection Finding May

Relate Directly To a CrossRelate Directly To a Cross--Cutting Area Cutting Area (e.g., Human Performance)(e.g., Human Performance)

Example of Findings and their associated CC aspectsExample of Findings and their associated CC aspects::

•• Failure to define and effectively communicate expectations Failure to define and effectively communicate expectations regarding procedural complianceregarding procedural compliance

•• Failure to use a systematic decisionFailure to use a systematic decision--making processmaking process

•• Failure provide complete, accurate and upFailure provide complete, accurate and up--toto--date design date design documentation to plant personnel.documentation to plant personnel.

•• Failure to effectively plan work activities (work control)Failure to effectively plan work activities (work control)

Substantive CrossSubstantive Cross--Cutting IssuesCutting Issues

•• A common performance theme as evidenced by a A common performance theme as evidenced by a significant number of current inspection findings in the significant number of current inspection findings in the crosscross--cutting areas of human performance, problem cutting areas of human performance, problem identification and resolution, and safetyidentification and resolution, and safety--conscious work conscious work environment.environment.

•• The NRC will The NRC will determinedetermine if it has a concern with the if it has a concern with the licensee's scope of efforts or progress in addressing the licensee's scope of efforts or progress in addressing the crosscross--cutting theme.cutting theme.

•• Not specifically used to determine standing in the Action Not specifically used to determine standing in the Action Matrix, although increased focus can result.Matrix, although increased focus can result.

•• Discussed in the midDiscussed in the mid--cycle and endcycle and end--ofof--cycle plant cycle plant

assessment letters. assessment letters. 1818

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Criteria for SubstantiveCriteria for SubstantiveHuman Performance and PI&RHuman Performance and PI&RCrossCross-- Cutting Issues (SCCI)Cutting Issues (SCCI)

A substantive crossA substantive cross--cutting issue in Human Performance and PI&R cutting issue in Human Performance and PI&R would exist if allwould exist if all of the following criteria are met:of the following criteria are met:

1.1. There are more than 3 inspection findings in the current 12There are more than 3 inspection findings in the current 12--month assessment period with documented crossmonth assessment period with documented cross--cutting cutting aspectsaspects in the areas of Human PI&R; in the areas of Human PI&R;

2.2. There is a crossThere is a cross--cutting cutting themetheme that ties the >3 finding that ties the >3 finding aspectsaspectstogether; and together; and

3.3. The NRC has a concern with the licensee’s scope of efforts or The NRC has a concern with the licensee’s scope of efforts or progress in addressing the crossprogress in addressing the cross--cutting theme: cutting theme: NRC JudgmentNRC Judgment

2020

Assessment of Open SCCIs Assessment of Open SCCIs

•• During mid and endDuring mid and end--ofof--cycle assessments, the NRC determines (or cycle assessments, the NRC determines (or reassesses) if a substantive cross cutting issue still exists.reassesses) if a substantive cross cutting issue still exists.

•• Staff will determine if there continues to be greater than 3 curStaff will determine if there continues to be greater than 3 current rent inspection findings w/CC aspects with the same common theme. inspection findings w/CC aspects with the same common theme.

•• A licensee should address the common theme, take effective correA licensee should address the common theme, take effective corrective ctive action, implement those actions, and show improving performance action, implement those actions, and show improving performance in in that area.that area.

•• Licensee actions must address the issues and concerns in the mosLicensee actions must address the issues and concerns in the most t recent performance assessment letter.recent performance assessment letter.

•• Staff will assess effectiveness through baseline inspections sucStaff will assess effectiveness through baseline inspections such as h as PI&R inspections. Staff will look at areas such as effectivenesPI&R inspections. Staff will look at areas such as effectiveness of s of problem identification, resolution of issues, and recent trendinproblem identification, resolution of issues, and recent trending of g of inspection findings w/crossinspection findings w/cross--cutting aspects.cutting aspects.

ROP Assessment ProcessROP Assessment Process

•• Performance Indicators and Inspection Findings Are Performance Indicators and Inspection Findings Are Equally Weighted to Arrive at an Overall Assessment of Equally Weighted to Arrive at an Overall Assessment of Plant Performance.Plant Performance.

•• Action Matrix Is Used to Assess Performance and Action Matrix Is Used to Assess Performance and Determine Regulatory Actions. Determine Regulatory Actions.

•• Quarterly, MidQuarterly, Mid--Cycle and End of Cycle Assessments Are Cycle and End of Cycle Assessments Are Performed for Each Licensee. Performed for Each Licensee.

•• Independent Assessment of Safety Culture May be Independent Assessment of Safety Culture May be Requested (or expected) of the Licensee, Depending on Requested (or expected) of the Licensee, Depending on Assessed Performance.Assessed Performance.

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Action Matrix ConceptAction Matrix Concept

LicenseeResponse

RegulatoryResponse

DegradedCornerstone

Multiple/Rep.DegradedCornerstone

UnacceptablePerformance

Increasing Safety Significance

Increasing NRC Inspection Efforts

Increasing NRC/Licensee Management Involvement

Increasing Regulatory Actions and Requests for Self-Assessments

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Communication is Key to Communication is Key to Understanding Performance IssuesUnderstanding Performance Issues

•• Licensees can provide or clarify PI inputs through the FAQ proceLicensees can provide or clarify PI inputs through the FAQ process.ss.

•• Licensees may provide risk insights (phase III SDP analysis) to Licensees may provide risk insights (phase III SDP analysis) to assist assist the staff in the risk characterization of a performance deficienthe staff in the risk characterization of a performance deficiency. cy.

•• Licensees may provide results of root cause analysis and other fLicensees may provide results of root cause analysis and other factual actual information to supplement information on the cause of the perforinformation to supplement information on the cause of the performance mance deficiency with possible crossdeficiency with possible cross--cutting aspect. cutting aspect.

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ROP Safety Culture Focus TeamROP Safety Culture Focus TeamPurposePurpose

To promote the implementation of the ROP safety culture changes (CN 06-015 and the CN for IP95003) in an effective and consistent manner across the regions during the initial 18-month implementation period. To resolve implementation issues and act on lessons learned information.

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ROP SCFT FunctionsROP SCFT Functions• Serve as a clearinghouse to resolve ROP safety culture implementation issues and

questions in a timely manner. This includes issues detected by the focus team, raised by regional staff (through the ROP feedback process), and identified by industry (primarily through ROP monthly meetings).

• Develop and coordinate the implementation of effective ROP safety culture change monitoring/assessment techniques. Compile lessons learned results and evaluate/act on resultant information.

• Assist in the development of IP95003 just-in-time training and review inspector training material related to safety culture including IP95003 just-in-time training.

• Interface with external and internal stakeholders on ROP safety culture topics through various forums (e.g. RUG meetings, public monthly ROP meetings, NRC Safety Culture Working Group).

• Coordinate safety culture assessor staffing and deployment of just-in-time training for IP95003 inspections.

• Provide input to regional and headquarters management briefings, responses to ticketed items, and Commission papers as needed.

• Propose program changes and provide input for annual ROP assessment Commission

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SummarySummary

•• Before any human performance or other crossBefore any human performance or other cross--cutting cutting aspect can be documented, a performance deficiency must aspect can be documented, a performance deficiency must exist.exist.

•• The crossThe cross--cutting cutting aspectaspect of a finding is not considered a of a finding is not considered a separate performance issue, but rather a significant separate performance issue, but rather a significant contributing cause of the performance deficiency.contributing cause of the performance deficiency.

•• Human performance, PI&R, and SCWE are areas that can Human performance, PI&R, and SCWE are areas that can be developed into substantive crossbe developed into substantive cross--cutting issues where cutting issues where the NRC has a concern with the licensee's effort to address the NRC has a concern with the licensee's effort to address current performance issue(s).current performance issue(s).

•• SCCIs are not inputs into the Action Matrix performance SCCIs are not inputs into the Action Matrix performance assessment, but can result in increased NRC focus and assessment, but can result in increased NRC focus and attention.attention.