**NRC INSPECTION MANUAL** IPAB

INSPECTION PROCEDURE 92702

FOLLOWUP ON TRADITIONAL ENFORCEMENT ACTIONS INCLUDING VIOLATIONS,
DEVIATIONS, CONFIRMATORY ACTION LETTERS, CONFIRMATORY ORDERS, AND
ALTERNATIVE DISPUTE RESOLUTION CONFIRMATORY ORDERS

PROGRAM APPLICABILITY: 2201, 2515, 2517, 2561, 2600, 2602

92702-01 INSPECTION OBJECTIVES

To determine that adequate corrective actions have been implemented for
traditional enforcement actions including violations, deviations,
Confirmatory Action Letters (CALs), Confirmatory Orders, and
Confirmatory Orders associated with the Alternative Dispute Resolution
(ADR) process. To verify that the root causes of these enforcement
actions have been identified, that their generic implications have been
addressed, and that the licensee\'s programs and practices have been
appropriately enhanced to prevent recurrence.

Note that for construction inspection activities, licensee programs
referenced throughout this procedure include the licensee Quality
Assurance (QA) program.

92702-02 INSPECTION REQUIREMENTS AND GUIDANCE

[General Guidance]{.underline}. This inspection procedure provides a
mechanism to perform in-office and on-site follow-up inspection of
traditional enforcement actions as deemed necessary by the regional
office.

10 CFR 50, Appendix B, may form the regulatory basis for many
enforcement actions. Licensee commitments that form the basis for
deviations may have been made during the licensing process or may have
been made in written correspondence to the NRC after receipt of the
plant operating license.

In accordance with 10 CFR 2.201, ANotice of Violation@, enforcement
sanctions typically require written explanations and statements of reply
concerning corrective actions, steps taken to prevent recurrence, and a
schedule for completion of corrective and preventive actions.

Specific responses or actions may be required in other enforcement
sanctions. The inspector should carefully review the enforcement actions
and inspection report transmittal letters which may contain NRC
perceptions of, and concerns with, licensee performance. Such statements
are valuable background information.

The NRC inspection program places strong emphasis on the inspection of
licensee performance as the basis for determining the overall adequacy
of the implementation of licensee programs. Thus, when a deficiency in
the licensee performance is identified, and especially when repetitive
conditions occur, a key element to be reviewed is the failure of the
licensee program to identify and correct the deficiency. Where licensee
corrective actions for NRC identified deficiencies are not adequate,
additional inspections (such as IP71152, Problem Identification and
Resolution for power reactors and selected portions of IP88005,
Management Organization and Controls, for fuel facilities) may be
warranted to assess the adequacy of the licensee corrective actions for
internally identified problems.

Confirmatory Orders issued as a result of the ADR process require
followup to ensure required actions are completed. Inspection followup
should be completed as described below; however, inspectors should note
that unlike commitments made by licensees in response to violations,
Confirmatory Order requirements are legally binding obligations.

02.01 [Documentation Review]{.underline}. Conduct a review of licensee
responses to traditional enforcement actions to ascertain that the
licensee responses and stated corrective and preventive actions were
timely and appropriate. Evaluate whether the responses describe the
conduct of a root cause analysis and implementation of any appropriate
changes in training or procedures. Assess whether generic implications
were addressed and whether the licensee programs and practices have been
enhanced where appropriate to prevent recurrence.

Determine which responses are to receive onsite followup inspection
based on their safety or security significance and complexity, inherent
inadequacy, or apparent weaknesses in licensee administrative or
management controls. Because of their importance, follow-up will be
performed for all traditional enforcement for willful violations and for
all ADR Confirmatory Orders.

[Guidance:]{.underline} The timing of NRC followup to a routine
inspection would depend on the relative qualitative safety or security
significance of a deficient licensee program in the area of the
traditional enforcement action. Typically, the inspection staff will
have information about the probable root cause of traditional
enforcement actions as a result of their normal inspection activity. In
addition, as part of the enforcement process, the licensee would make
their own determination of their program adequacy. The available
information can then be used to make a determination on the timing of
NRC follow-up, along with the scope and depth of follow-up that is
warranted. Followup to ADR Confirmatory Orders should generally be
completed after notification by the licensee, or party subject to the
order, that the required actions are complete. Some actions are
recurring over a long period, as such, followup is not required to wait
pending completion of all confirmatory order actions.

The documentation review should include relevant inspection reports,
inspection report transmittal letters, Notices of Violations or
Deviations, CALs, Confirmatory Orders, ADR Confirmatory Orders, licensee
response letters to enforcement correspondence, minutes of related
enforcement meetings with the licensee, and any other agency records of
communication on the issue with the licensee.

Depending on the relative safety or security significance of the issue,
the inspector and their management may conclude that an in-office review
of the licensee docketed evaluation and corrective actions may suffice
to close out the finding, rather than performing an onsite follow-up
inspection.

Because of their unique nature, the regional office should closely
coordinate with the Office of Enforcement (OE) for follow-up of ADR
Confirmatory Orders related to discrimination cases. Typically, the OE
staff will take the lead to perform the follow-up review of
discrimination cases. The review will initially take place in-office.
The OE reviewer will determine any necessary on-site follow-up activity
and coordinate on-site follow-up with the region. The OE reviewer will
also provide a feeder inspection report input to document the results of
their review.

02.02 [Onsite Inspection.]{.underline} As necessary, conduct an onsite
inspection of the selected traditional violations, deviations, CALs,
Confirmatory Orders, and ADR Confirmatory Orders with respect to
timeliness, completeness, and adequacy of licensee actions in the
following areas. Where appropriate, these inspections are to be actual
physical verifications of equipment and processes.

a.  [Corrective Actions]{.underline}. Determine whether:

    1.  Licensee management has assigned responsibility for implementing
        corrective actions, including any necessary changes in
        procedures and practices.

    2.  Corrective actions have been fully implemented.

    3.  The licensee has posted copies of enforcement correspondence for
        radiological working conditions as required by 10 CFR 19.11.

    4.  Followup actions were initiated for deviations noted in any
        recent Quality Assurance (QA) audits conducted by the licensee
        of the inspection area in which traditional enforcement actions
        were identified.

b.  [Root Cause Analysis]{.underline}. Review adequacy of licensee
    analysis.

c.  [Generic Implications Analysis]{.underline}. Review adequacy of
    licensee analysis.

d.  [QA Program Procedures and Practices Changes.]{.underline} For
    activities performed to satisfy a construction inspection program
    (IMC 2517), determine that the licensee\'s review of the QA program
    evaluated the program\'s scope and effectiveness.

[Guidance:]{.underline} The onsite inspection, if necessary, is to both
determine the adequacy of the licensee actions to correct the
deficiencies associated with the traditional enforcement action, and to
examine whether the licensee evaluations included a review of items from
their internal self-assessment activities when assessing the repetitive
and generic nature of an NRC action and the effectiveness of the related
licensee programs. Where an item is identified as repetitive in nature,
the licensee should have conducted an in-depth analysis of the
effectiveness of their management control systems. This analysis entails
the determination of the root cause(s) of deficient management controls
and their potential generic implications. Note that this is considered
to be the most important part of this inspection procedure. The OE
reviewer will identify any necessary on-site verification of selected
aspects of a licensee\'s commitments that are part of the ADR
Confirmatory Order related to discrimination that shall be performed to
ensure the adequacy of implementation. Confirm that the licensee has
instituted appropriate corrective and preventive measures. Refer to
IPs71152, 95001, and 88005 for further guidance on root cause
evaluations and corrective action reviews.

The inspector should use their discretion to perform field verification
activities to supplement their review of licensee programs to gain
assurance that the corrective and preventive measures have been
appropriately implemented in the field.

02.03 [Documentation.]{.underline} The results of the follow-up ROP
inspection activity should be documented in section 4OA5 (Other
Activities) of the associated power reactor inspection report. The Plant
Issue Matrix for the item should be updated appropriately. It is noted
that Confirmatory Orders can be tracked to closure in RPS/IR module
(Reactor Protection System/Item Reporting) under independent items (see
IMC0306, section 05.06.b.8). Similarly, the results of the follow-up
construction inspection activity (IMC2517) should be documented in
section IV (other activities).

92702-03 RESOURCE ESTIMATE

This inspection procedure supports the review of the adequacy of a
licensee corrective and preventive measures in response to a traditional
enforcement violation or deviation, CAL, Confirmatory Order, or ADR
Confirmatory Order. The inspector should obtain confidence through an
in-office review of the licensee actions, supplemented with onsite
reviews and field verifications when appropriate. The amount of time to
perform the inspection is a function of the number of findings followed
up, as well as the scope and depth of the follow-up activity. This
procedure is implemented on an as-needed basis, and can serve as a
vehicle to perform follow-up on a single to multiple traditional
enforcement actions. For power reactor licensees, this procedure will be
performed on an as needed basis as part of IMC2515 Appendix C and
IMC2201 Appendix C.

92702-04 REFERENCES

10 CFR 2.201, \"Notice of Violation\"

10 CFR 19.11, \"Posting of Notices to Workers\"

NRC Enforcement Manual (on-line only)

NRC Enforcement Policy (on-line only)

IMC2561, \"Decommissioning Power Reactor Inspection Program\"
(ML031270502)

IMC2201 Appendix C, \"General Special and Infrequent Inspections\"

IP71152, \"Problem Identification and Resolution\"

IP95001, \"Inspection for One or Two White Inputs in a Strategic
Performance Area\"

EGM 04-004, Enforcement Guidance memorandum - Alternative Dispute
Resolution Pilot Program Subsequent to Completion of an Investigation
(October 20, 2004)

Interim Enforcement Policy Regarding Alternative Dispute Resolution
(Federal Register Notice Vol. 69, No. 156, page 50219, August 13, 2004)

10 CFR Part 50, Appendix B, \"Quality Assurance Criteria for Nuclear
Power Plants and Fuel Reprocessing Plants\"

IMC2517, \" Watts Bar Unit 2 Construction Inspection Program\"

END

ATTACHMENT 1

Revision History for Inspection Procedure 92702

+--------+------+--------------------------+-----+-------+------------+
| Comm   | I    | Description of Change    | Tr  | Tra   | Comment    |
| itment | ssue |                          | ain | ining | Resolution |
| Tr     | Date |                          | ing | Compl | Accession  |
| acking |      |                          | Nee | etion | Number     |
| Number |      |                          | ded | Date  |            |
+--------+------+--------------------------+-----+-------+------------+
| N/A    | 01/1 | Re-issuance of procedure | N   | N/A   | M          |
|        | 0/08 | to resolve ROP Feedback  | one |       | L080020045 |
|        |      | Form 2515B-1104          |     |       |            |
|        | CN   | regarding follow-up for  |     |       |            |
|        | 08   | traditional enforcement  |     |       |            |
|        | -001 | and ADR Confirmatory     |     |       |            |
|        |      | Orders, and ROP Feedback |     |       |            |
|        |      | Form 92702-1216          |     |       |            |
|        |      | regarding the interface  |     |       |            |
|        |      | with security inspection |     |       |            |
|        |      | program IMC2201.         |     |       |            |
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|        |      |                          |     |       |            |
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|        |      |                          |     |       |            |
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|        |      |                          |     |       |            |
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