**ATTACHMENT 71111.EP**

Inspectable Areas: Equipment Availability, Reliability, and Functional
Capability - Pilot

Cornerstone: Initiating Events (5%)

> Mitigating Systems (85%)

Barrier Integrity (10%)

Inspection Bases: The availability, reliability and functional
capability of structures, systems, and components (SSCs) can have a
direct impact on plant risk. The determination of the functional
failure(s), and the monitoring and documenting of availability and
reliability for these SSCs is performed under the Maintenance Rule (MR).
Temporary modifications to risk-significant SSCs may adversely affect
their availability, reliability or functional capability. Improperly
evaluated degraded and/or non-conforming conditions may result in
continued operation with a SSC that is not capable of performing its
design function. Operator work-arounds due to SSC unavailability can
impact human performance during event response, due to increasing
complexity of tasks and more limiting time to perform required actions.

> This inspectable area verifies aspects of the Initiating Events,
> Mitigating Systems and Barrier Integrity cornerstones for which there
> are no performance indicators.
>
> Level of Effort: [Quarterly Evaluation]{.underline}. This procedure
> shall be conducted quarterly as needed when an equipment performance
> issue affecting availability, reliability and/or functional capability
> of risk-significant SSCs is identified. It is expected that the
> inspector review maintenance rule implications, operability
> evaluations, temporary modifications, and operator work-arounds as
> they apply to each issue selected for review by the inspector. It is
> also expected that the inspector determine whether or not a licensee
> performance deficiency occurred which contributed to the equipment
> performance issue.
>
> [Periodic Evaluation]{.underline}. Every 2 years, review licensee
> \'50.65(a)(3) periodic evaluations and resulting adjustments or
> corrective action performed since the last inspection. As part of this
> inspection, review 4-6 scoped SSCs and/or functions (preferably
> high-risk-significant) that have suffered degraded performance or
> condition to aid in determining the effectiveness of the licensee\'s
> (a)(3) activities. When deemed necessary or appropriate, regional risk
> experts (with support from other agency risk analysis staff as
> necessary and available) review licensee probabilistic safety
> assessment (PSA) activities related to maintenance effectiveness in
> conjunction with the (a)(3) inspection.
>
> [Identification and Resolution of Problems]{.underline}. Effort for
> this procedure will include a review of the licensee\'s problem
> identification and resolution of equipment performance issues
> affecting availability, reliability and/or functional capability of
> risk-significant SSCs.

71111.EP-01 [Inspection Objective]{.underline}

01.01 The objective of this inspection is to assess the availability,
reliability, and functional capability of SSCs. Flexibility is provided
in the procedure such that once an equipment performance and/or
reliability issue is identified, the inspectors can use the guidance in
this procedure to review operability evaluations for the issue, operator
work-arounds caused by the situation, temporary modifications installed
to remedy the situation, and maintenance rule implications of the issue.
It is also intended for inspectors to review the circumstances
surrounding the equipment performance and reliability issue so that a
determination can be made as to whether or not there is a licensee
performance deficiency associated with the condition.

71111.EP-02 [Inspection Requirements]{.underline}

02.01 When a risk-significant SSC equipment availability or reliability
issue is identified, the inspector should review the operability
evaluation, and any compensatory measures taken for the situation such
as operator work-arounds and/or temporary modifications. The issue
should also be evaluated for maintenance rule applicability (there may
be a time lag of several months between the equipment performance and/or
reliability issue and its disposition under the maintenance rule). For
each issue, the inspector shall determine if a licensee performance
deficiency contributed to the equipment availability/reliability issue.

02.02 [Quarterly Evaluation]{.underline}

> a\. [SSC Availability, Reliability and/or Functional Capability Issue
> Review]{.underline}. Select equipment availability, reliability and/or
> functional capability issues involving risk significant SSCs.
> Selection of these issues can emerge from the inspector\'s review of
> plant status documents such as operator shift logs, emergent work
> documentation, and standing orders.
>
> As applicable, review the technical adequacy of the licensee\'s
> operability evaluation, and verify if operability is justified. Verify
> that the licensee considered other degraded conditions and their
> impact on compensatory measures for the condition being evaluated.
> Refer to the FSAR and other design basis documents during the review.
> If operability is justified, no further review of the operability
> evaluation is required. If operability is not justified, determine the
> impact on any Technical Specification LCOs, determine if there was a
> performance deficiency associated with the issue, and use the
> Significance Determination Process to evaluate the risk significance
> of the equipment inoperability.
>
> If the equipment availability or reliability issue involves
> compensatory measures (eg. operator work-arounds, temporary
> modifications, etc), determine if the measures are in place, will work
> as intended, and are appropriately controlled.
>
> For operator work-arounds, review the work-around to determine if the
> functional capability of the system or human reliability in responding
> to an initiating event is affected. Specifically, evaluate the affect
> of the work-around on the operator\'s ability to implement abnormal or
> emergency operating procedures. Also, consider the cumulative effects
> of operator work-arounds on the reliability, availability, and,
> potential for misoperation of a system; the cumulative effects of
> operator work-arounds that could affect multiple mitigating systems;
> and, the cumulative effects of operator work-arounds on the ability of
> operators to respond in a correct and timely manner to plant
> transients and accidents.
>
> For temporary modifications, review jumpers, lifted leads, temporary
> systems, repairs, design modifications and/or procedure changes to
> determine if changes to the plant design or operations have been
> introduced.
>
> For each equipment performance and/or reliability issue selected for
> review, the inspector shall determine if a licensee performance
> deficiency contributed to the issue.
>
> b\. [Routine Maintenance Effectiveness Inspection]{.underline}.
> Independently verify the licensee=s appropriate handling of SSC
> performance or condition problems in terms of:

1\. Appropriate work practices;

> 2\. Identifying and addressing common cause failures;
>
> 3\. Scoping in accordance with 10 CFR 50.65(b);
>
> 4\. Characterizing reliability issues (performance);
>
> 5\. Charging unavailability (performance);
>
> 6\. Trending key parameters (condition monitoring)
>
> 7\. 10 CFR 50.65(a)(1) or (a)(2) classification and reclassification;
>
> 8\. Appropriateness of performance criteria for SSCs/functions
> classified (a)(2) and/or appropriateness and adequacy of goals and
> corrective actions for SSCs/functions classified (a)(1)
>
> c\. For the maintenance effectiveness attributes specified in Section
> b above, verify the licensee=s appropriate handling of degraded
> SSC/function performance or condition as follows:
>
> 1\. Identify and screen equipment problems for review using an
> issue/problem-oriented approach and/or an SSC/function performance
> history-oriented approach. Problems can relate to reliability,
> availability, condition monitoring, work practices, work control, or
> common cause failures. Concentrate on high-safety-significant
> issues/problems or SSCs/functions, especially those not covered by
> performance indicators, those with declining performance or condition
> trends, and those with known equipment problems.
>
> 2\. Based on the review of paragraph c.1, select potentially
> risk-significant issues from either the issue/problem approach
> category or the SSC/function approach category or both and perform
> detailed reviews.
>
> 3\. In conjunction with the detailed review, assess the extent to
> which the problem(s) may affect other trains, systems, units, or
> similar components in other applications. For those problems
> recognized by the licensee, assess the accuracy with which the
> licensee has identified the extent of condition.
>
> d\. After the detailed review of the problem history and surrounding
> circumstances, evaluate the role of work practices and common cause
> problems as follows:
>
> 1\. Determine if deficient work controls or work practices contributed
> to the degraded performance or condition of the affected SSC(s).
> Having learned the extent of condition, if work practices are
> implicated, observe affected and/or related work activities, as
> appropriate. As necessary, discuss the issue with licensee personnel
> at the appropriate level, and evaluate licensee corrective actions.
>
> 2\. Determine the extent of condition for those issues with common
> cause or generic implications if the issues have the potential to
> result in, for example, failures of multiple or diverse trains of
> SSCs. Evaluate adequacy of licensee corrective actions.
>
> e\. Evaluate the licensee\'s handling of the SSCs/issues being
> reviewed under the requirements of the MR and, where applicable, 10
> CFR Part 50, Appendix B, and the technical specifications (TS) as
> follows:
>
> 1\. Determine whether the SSCs/functions of interest are within the
> licensee\'s MR scope. If they are, evaluate the licensee\'s handling
> of the issues under the MR. If not, determine whether they should be
> in scope and conduct regulatory review if they should. If they are not
> required to be in scope, there will be no MR issues.
>
> 2\. Independently evaluate SSC/function performance in terms of
> reliability and availability. Compare documented functional failures
> with those being tracked by the licensee under the MR. Compare
> unavailable hours (when required) to those being charged by the
> licensee. For SSCs under condition monitoring, evaluate the
> effectiveness of the licensee\'s condition monitoring at tracking and
> trending SSC condition and recognizing declining trends.
>
> 3\. Evaluate licensee corrective action that may be required by the MR
> for degraded SSC/function performance or condition, as well as any
> corrective action that may be required by 10 CFR Part 50, Appendix B;
> license technical specifications (TS); plant or site procedures. Also
> evaluate use of industry standards, guidance, and operating experience
> (important, but not regulatory requirements, except operating
> experience where its use is required by the MR).
>
> 4\. Evaluate functional failures and unavailable hours against the
> licensee\'s goals or performance criteria as applicable. Determine, as
> applicable, if goals are being met or if SSC/function performance or
> condition is being effectively controlled through the performance of
> appropriate preventive maintenance.
>
> 5\. Based on the performance and condition review above, determine if
> the affected SSC(s)/function(s) has/have been properly classified in
> terms of monitoring under 50.65(a)(1) or effectively controlling
> performance by appropriate preventive maintenance under (a)(2).
>
> 6\. Determine if (a)(1) goals are commensurate with safety, are
> reasonable, and where practicable, take industry operating experience
> into account. Similarly evaluate (a)(2) performance criteria for SSCs
> in (a)(2). Determine if effective preventive maintenance can be
> reasonably demonstrated or degraded performance detected.
>
> f\. If the results of any of the above determinations are
> unsatisfactory, conduct licensee engagement and regulatory review. See
> Appendix A for guidance.

02.03 [Periodic Evaluation (PE)]{.underline}. Once every 2 years, assess
the effectiveness of the licensee=s PE(s) and the resulting adjustments
performed pursuant to 10 CFR 50.65(a)(3) since the last PE inspection.
When deemed necessary and appropriate, regional risk experts (i.e.,
regional staff/inspectors with sufficient risk knowledge), with support
as necessary and as available from other agency risk analysis staff, may
review maintenance effectiveness activities related to the plant\'s
probabilistic safety assessment (PSA) or probabilistic risk analysis
(PRA), if any, in conjunction with the PE inspection.

02.04 [Identification and Resolution of Problems]{.underline}.
Inspection activities under this procedure include independent
verification that the licensee is identifying problems related to this
inspection area and entering them in the corrective action program. For
a sample of selected problems documented in the corrective action
program, verify that the corrective actions and resolutions are
appropriate and adequate. Problem identification and resolution (PI&R)
activities inspected per this procedure can count toward satisfaction of
the PI&R inspection requirements of Inspection Procedure 71152,
AIdentification and Resolution of Problems.@

71111.EP-03 [Inspection Guidance]{.underline}

03.01 [Operability Evaluations]{.underline}. The licensee\'s process of
ensuring operability is continuous and consists of the verification of
operability by surveillances and continuous monitoring of plant systems.
Formal determinations of operability are performed whenever a
verification or other indication calls into question the SSC\'s ability
to perform its specified function. Licensees are obligated to ensure the
continued operability of SSCs as specified by TS, or to take the
remedial actions addressed in the TS. The intent of this inspection is
to sample licensee\'s operability evaluations for risk significant SSCs
to verify if operability is justified, such that availability is
assured, and no unrecognized increase in risk has occurred. Also, the
inspections should verify that operability concerns associated with
plant issues and events are being identified.

Where there is a reason to suspect that the licensee\'s operability
determination is not, or was not correct based on the information
reviewed, the inspector should discuss the issue with regional
management for resolution. Depending on the complexity and risk
significance of the issue, in some cases, the inspector may need to
consult with regional specialists to complete verification of
licensee\'s operability evaluation. The regional specialist\'s time
spent on reviewing the issue should be charged to this procedure. The
inspectors are not required to spend additional time in reviewing an
issue if the discrepancies identified do not change the outcome of the
operability evaluation.

Generic Letter 91-18, \"Resolution of Degraded and Non-Conforming
Conditions\" and NRC Inspection Manual Part 9900
\"Operable/Operability - Ensuring the Functional Capability of a System
or Component\" provides additional guidance in this area. In particular,
as stated in section 4.5.4 of Generic Letter 91-18, some licensees may
refer to documents or processes that establish operability of SSCs as
JCOs or Justification for Continued Operation. The NRC has defined a JCO
as the licensee\'s technical basis for requesting authorization to
operate in a manner that is prohibited absent such authorization. This
procedure is not intended to review formal JCOs as defined by the NRC
but does cover evaluations referred to by licensees as JCOs which
establish operability of structures, systems or components.

03.02 [Operator Work-arounds]{.underline}

[General Guidance]{.underline}

An operator work-around is defined as operator action(s) taken to
compensate for a degraded or non-conforming condition that complicates
the operation of plant equipment.

A risk significant operator work-around is defined as operator action(s)
taken to compensate for a degraded or non-conforming condition which
could result in an increase in the baseline core damage or large early
release frequency and, if such actions could not be implemented
effectively, would be a finding with potentially greater than green
significance.

[Specific Guidance]{.underline}

The intention is to evaluate operator work-arounds for mitigating
systems as required to determine if the mitigating system function is
affected or the operator\'s ability to implement abnormal and emergency
operating procedures is affected. The inspector should be cognizant of:
(1) operator work-arounds that have not been evaluated by the licensee,
(2) operator work-arounds that have been formalized as the long-term
corrective action for a degraded or non-conforming condition (and
therefore may not be tracked by the licensee as an operator
work-around), and (3) operator work-arounds that increase the potential
for personnel error, including operator work-arounds that:

> a\. Require operations contrary to past training or require more
> detailed knowledge of the system than routinely provided.
>
> b\. Require a change from longstanding operational practices.
>
> c\. Require operation of system or component in a manner dissimilar
> from similar systems or components.
>
> d\. Create the potential for the compensatory action to be performed
> on equipment or under conditions for which it is not appropriate.
>
> e\. Impair access to required indications, increase dependence on oral
> communications, or require actions under adverse environmental
> conditions.
>
> f\. Require the use of equipment and interfaces that had not been
> designed with consideration of the task being performed.

03.03 [Temporary Modifications]{.underline}

[General Guidance]{.underline}

> a\. Review temporary modifications and associated 10 CFR 50.59
> screening against the system design bases documentation, including
> Updated Final Safety Analysis Report (UFSAR) and Technical
> Specifications (TS). Verify that the modifications have not affected
> system operability/availability. See Inspection Procedure 71111.17,
> \"Permanent Plant Modifications,\" for additional attributes which may
> be considered for review. Inspect only those attributes which are
> significant for the particular modification being reviewed.
>
> b\. Verify that the installation of the temporary modification (if
> accessible) is consistent with the modification documents. Verify
> configuration control of the modification is adequate by verifying
> that the plant documents, such as drawings and procedures, are
> updated, and verify the adequacy of operating and maintenance
> procedures.
>
> c\. Review post-installation test results to confirm that the tests
> are satisfactory and the actual impact of the temporary modifications
> on the permanent systems and interfacing systems have been adequately
> verified by test. Also, review planned testing after removal of the
> temporary modifications.
>
> d\. Verify that temporary modifications are identified on Control Room
> drawings and that appropriate tags are placed on equipment being
> affected by the temporary modifications.
>
> e\. Verify that the licensee has evaluated the combined effects of the
> outstanding temporary modifications in regard to mitigating systems
> and the integrity of radiological barriers.
>
> f\. Examine drawings, design and operating procedures, and operations
> logs for evidence of temporary modifications that have not been so
> evaluated or categorized.

[Specific Guidance]{.underline}

> a\. The review of the design aspects of a temporary modifications
> should focus on conformance to relevant design criteria not the
> programmatic elements of licensee programs.
>
> b\. The review of both the installation of a temporary modification
> and its retirement is necessary to ensure that the impact on the
> operation of other equipment is what is expected and previously
> analyzed, and to verify all other unexpected effects were subsequently
> evaluated with the results being there is no significant impact on the
> safe operation of plant or equipment.
>
> c\. The review of the post-installation test results is to ensure that
> the parent system remains operable and that its safety function has
> not been impaired.
>
> d\. Identification of temporary modifications on drawings and the
> placement of appropriate tags on equipment being affected by the
> temporary modification should make operators aware of their impact on
> the operation of plant equipment and components.
>
> e\. The synergistic effects of outstanding temporary modifications is
> best judged based on whether there are new impediments to the safety
> functions of mitigating safety systems, degradation of radiological
> barriers, and an increase in the consequences of pertinent analyses in
> Chapter 15 of the FSAR.
>
> f\. Focus more attention on identifying temporary modifications not
> previously identified by the licensee if there is no existing program
> tasked with making interested parties aware of the existence of all
> temporary modifications.

03.04 [Maintenance Effectiveness]{.underline}. See Appendix A to this
procedure for routine guidance. See Appendix B to this procedure for
Periodic Evaluation Guidance.

03.05 [Licensee Performance Deficiency Review]{.underline}. Inspection
activities under this procedure include an evaluation of whether or not
a licensee performance deficiency contributed to an equipment
performance issue affecting availability, reliability and/or the
functional capability of risk-significant SSCs. See Manual Chapter 0612,
APower Reactor Inspection Reports,@ for guidance.

03.06 [Identification and Resolution of Problems]{.underline}.
Inspection activities under this procedure include independent
verification that the licensee is identifying problems related to this
inspection area and entering them in the corrective action program. For
a sample of selected problems documented in the corrective action
program, verify that the corrective actions and resolutions are
appropriate and adequate. See Inspection Procedure 71152, \"Problem
Identification and Resolution of Problems,\" for additional guidance.

71111.EP-04 [Resource Estimate]{.underline}

The annual resource expenditure for this inspection procedure is
estimated to be 184 to 246 hours a year for sites with one reactor unit;
200 to 268 hours for sites with two reactor units; and 222 to 300 hours
for sites with three reactor units.

In addition, this inspection procedure is estimated to take 34 to 46
hours every 2 years for the biennial periodic evaluation inspection
regardless of the number of reactor units at the site. The PSA review,
if conducted, can be accommodated within the hours allotted to the
biennial inspection.

71111.EP-05 [Completion Status]{.underline}

Inspection of the minimum sample size will constitute completion of this
procedure in the Reactor Programs System (RPS). The minimum sample size
for routine inspection will consist of eight maintenance effectiveness
issues (of high risk significance to the extent available) in a year.
During the pilot program, these samples will be recorded under 71111.12Q
in RPS. The minimum sample size for the biennial inspection will consist
of four SSCs/functions (of high risk significance to extent available)
that have suffered degraded performance or condition regardless of the
number of reactor units at that site. During the pilot program, these
samples will be recorded under 71111.12B in RPS. The minimum sample size
for temporary modifications will consist of the review of 4 temporary
modifications for one unit; 5 temporary modifications for two units; and
6 temporary modifications for three units. During the pilot program,
these samples will be recorded under 71111.23 in RPS. The minimum sample
size for operability evaluations will consist of 15, 19, and 22
operability evaluations of degraded and non-conforming conditions in a
year at 1-unit, 2-unit, and 3-unit sites respectively. During the pilot
program, these samples will be recorded under 71111.15 in RPS. There is
no minimum sample size for operator workarounds, which will be reviewed
as they occur. However, an operator workaround is identified and
reviewed, 1 sample will be recorded under 71111.16 in RPS.

As an example, when a risk-significant SSC equipment availability or
reliability issue is identified, and the inspector reviews an
operability evaluation, a temporary modification, and the maintenance
effectiveness aspects for the issue, while the documentation will occur
in one section of the report, 1 sample will be recorded for the issue
under each of 71111.12A, 71111.15, and 71111.23 in RPS.

71111.EP-06 [References]{.underline}

Section 50.65, ARequirements for monitoring the effectiveness of
maintenance at nuclear power plants,@ of Title 10 of Part 50 of the Code
of Federal Regulations (10 CFR 50.65)

Statement of Considerations for the Maintenance Rule (three sections)

Inspection Procedure (IP) 62706, AMaintenance Rule@

NRC Regulatory Guide (RG) 1.160, AMonitoring the Effectiveness of
Maintenance at Nuclear Power Plants@

Nuclear Energy Institute (NEI) (formerly Nuclear Management and
Resources Council (NUMARC)), NUMARC 93-01, AIndustry Guideline for
Monitoring the Effectiveness of Maintenance at Nuclear Power Plants@

NRC Inspection Manual, Chapter 0609, AReactor Safety Significance
Determination Process@

NRC Inspection Manual, Chapter 0612, AInspection Reports@

IP 97201, ALicensee disposition of NRC Generic Communications@

IP 71152, AIdentification and Resolution of Problems@

NRC Generic Letter 90-03, June 15, 1990, ARelaxation of Staff Position
on Generic Letter 83-28, Item 2.2, Part 2, Vendor Interface for
Safety-Related Components@

NRC Enforcement Manual, Section 8.1.11, AActions Involving the
Maintenance Rule@ (Go to
[http://www.nrc.gov/what‑we‑do/regulatory/enforcement/guidance.html#manual]{.underline}
, click on Chapters 1-8)

IP 88025, AMaintenance and Surveillance Testing@

NRC Inspection Manual, Part 9900, Technical Guidance, APreconditioning
of Structures, Systems, and Components (SSCs) Before Determining
Operability@

NUREG -1648, ALessons Learned from Maintenance Rule Implementation@

Generic Letter 91-18, \"Resolution of Degraded and Nonconforming
Conditions\"

Inspection Manual Part 9900, \"Operable/Operability - Ensuring the
Function Capability of a System or Component\"

Information Notice 97-78, \"Crediting of Operator Actions in Place of
Automatic Actions and Modification of Operator Actions, including
Response Times\"

NRC Inspection Manual Part 9900 \"Resolution of Degraded and
Non-Conforming Conditions\"

Inspection Procedure 71111, Attachment 17, \"Permanent Plant
Modifications\"

NRC Manual Chapter 0612, APower Reactor Inspection Reports@

Appendices:

A. Routine Maintenance Effectiveness Inspection Detailed Guidance

B. Maintenance Effectiveness Periodic Evaluation Inspection Guidance

**APPENDIX A**

ROUTINE MAINTENANCE EFFECTIVENESS INSPECTION DETAILED GUIDANCE

This appendix provides additional information and guidance for the
performance of the maintenance effectiveness portion of the procedure.
The steps referenced in this appendix provide guidance for completing
the corresponding blocks in Flowchart 1. Comprehensive and detailed
review of the licensee\'s maintenance rule program is not within the
scope of this, performance-based baseline inspection, but inspection of
maintenance effectiveness performance may reveal programmatic weaknesses
requiring program improvements in addition to corrective action for the
performance issues themselves.

Start - There are concerns involving degraded performance or condition
of SSCs/functions or the handling thereof (concerns may be inspector or
licensee identified).

Blocks 1 & 2 - Routine Inspection, Screening

Identify and screen equipment problems for review. Problems to be
selected involve concerns with reliability, availability, work
practices, or common cause failures. Note that these reviews are similar
to and can be completed during performance of Inspection Manual Chapter
2515, Appendix D, APlant Status.@ The intent of this section is to
highlight inspection activities necessary to understand day-to-day
equipment performance problems.

Block 1 - Issue/Problem-Oriented Approach: Routinely review logs,
condition reports (or equivalents), etc., and monitor plant status to
identify problems with the performance (reliability and/or availability)
or condition of SSCs within the scope of the MR with emphasis on those
of high risk or safety significance. Using the sources of information
listed below (or others as available), review those instances that
appear to have maintenance effectiveness implications, warrant further
assessment of work practices, and/or may be related to common cause
failures, independent of whether the licensee has identified them as
such. The more significant issues should be considered for further
review.

Block 2 - SSC/Function-Oriented Approach: As an alternative,
complementary approach, review the performance or condition history of
selected, preferably high-safety-significant, SSCs/functions to identify
degraded or declining performance or condition independent of licensee
recognition. Review instances that have maintenance effectiveness
implications, warrant further assessment of work practices, and/or may
be related to common cause failures, independent of whether the licensee
has identified them as such. The SSCs/ functions may be selected and
even scheduled for review such that the most safety-significant are
covered periodically. The more significant maintenance effectiveness
issues involving these SSCs should be considered for further review,
particularly those that may not have been recognized or appropriately
dispositioned by the licensee.

[Sources of Information]{.underline}

The following list is not meant to be all-inclusive, but is intended to
provide the inspector with potential sources of information regarding
equipment problems for evaluation:

-   Operating logs (manual and automated)

-   Plant event reports/condition reports

-   Technical specification action statement logs

-   System or component work order history

-   Safety system unavailability and unreliability performance indicator
    data

-   Other reliability and availability data (MR, PRA, INPO/WANO)

-   Corrective action program documents

-   Operability evaluations or non-conformance reports

-   Temporary system modification documents

-   Maintenance (or component) history databases

-   System Ahealth@ reports

-   Predictive maintenance test or condition monitoring results (e.g.
    thermography, lubricating oil analysis, vibration analysis, other
    in-service test results)

-   Maintenance Rule program documents

-   Plant walkdown observations and plant status information

-   Licensee personnel interviews

-   Information discussed at licensee meetings

-   Industry operating experience (IOE) information

The following are some sources of IOE information:

-   NRC generic communications

-   10 CFR Part 21 notifications (and those posted on the NRC external
    website)

-   Notifications from the Institute for Nuclear Power Operations (INPO)

-   INPO=s Equipment Performance Information Exchange (EPIX)

-   Nuc Net

-   Vendor technical bulletins or other correspondence (Vendor Equipment
    Technical Information Program (VETIP) - see also NRC Generic Letter
    90-03)

-   Owners and users group information

-   IOE information published by the Electric Power Research Institute
    (EPRI)

From among the problems/issues (first approach category) or
SSCs/functions (alternative approach category) screened above, select
potentially risk-significant issues for detailed review from either or
both categories. Consider the following when selecting samples: (1) the
risk significance of the problems/issues or of the affected
SSC(s)/function(s), (2) the duration and frequency of the problem, (3)
the impact of the problem on the SSC performance (i.e., reliability and
unavailability) or condition, (4) whether the problem results in
frequent or repeated technical specification limiting condition for
operations entries, (5) the impact of the problem on the licensee=s
organization (i.e., are operators and maintenance personnel challenged
by frequent emergent work activities to resolve the issue?), (6) whether
the apparent cause of the problem could result in a common cause
failure, and (7) the extent to which the problem has been previously
inspected.

Block 3 - Detailed Review. Detailed review includes examining work
orders and associated records for corrective and preventive maintenance
and related corrective action documents. Obtaining an adequate
understanding of the problem may require review of those applicable work
orders and/or corrective action documents generated in at least the past
2 years. Reviews of up to 5 years may be considered for SSCs that are
rarely operated or tested.

Following the detailed, historical review, the inspector should
understand the duration and extent of the problem(s) being evaluated and
the effectiveness of the licensee=s corrective actions to improve SSC
performance or to correct the identified problem.

Block 4 - Extent of Condition. In conjunction with the detailed review,
independent determination of the extent to which the problem(s) may
affect other trains, systems, units or plants, or similar components in
other applications will enable the inspector to judge the accuracy with
which the licensee has assessed the extent of condition.

Block 5 - Work Practices Implicated. Deficient work practices can cause
or contribute to an SSC performance or condition problem. The term Awork
practices@ refers to the broad range of activities performed to maintain
SSCs, including (but not limited to) preventive maintenance program
requirements, maintenance procedures, field activities, system isolation
and restoration procedures and practices, and post-maintenance testing.
Note that the licensee\'s maintenance preventable functional failure
(MPFF) evaluations and/or root cause analyses, if any, may contain
insights in this area. If work practices are not implicated, continue
inspecting for common cause implications.

Block 6 - Observation of Work Activities. If work practices are
implicated, observation of affected and/or similar activities (as
necessary) will enable the inspector to assess the extent and/or the
impact of the maintenance problem. For instance, the inspector may
determine that it is necessary to review a specific activity such as
motor alignments, or perhaps it is necessary to look more broadly at
electrical maintenance activities to ensure that the nature and extent
of the maintenance problem is fully understood.

Block 7 - Work Practices OK? If work practices are found to be
acceptable, continue inspecting for common cause implications. If not,
go to Regulatory Review for this issue, but continue inspection in other
paths as appropriate.

Block 8 - Common Cause. For those issues with common cause or generic
implications, determination of the extent of condition will reveal the
issues= potential to result in, for example, failures of multiple or
diverse trains of SSCs. Note that common cause problems may be related
to maintenance support activities, including plant design, application
engineering, procurement and acceptance, material control, and
commercial-grade dedication. However, problems may occur that are
ultimately determined to be related to latent component design and
manufacturing deficiencies that were not or would not reasonably
expected to be identified by the licensee. This distinction may become
important in determining if any resultant functional failures were
maintenance preventable. If there are no apparent common cause
implications, continue the inspection in the MR implementation area. If
there are, proceed in this path.

Block 9 - Corrective Actions. Detailed review includes evaluation of the
licensee\'s corrective actions for the common cause problem(s). The
licensee should ensure that the entire extent of condition is identified
and adequately addressed. In addition, overall maintenance effectiveness
is in part dependent upon feeding the insights gained in dealing with
common cause issues back into other maintenance-related or support
areas. If corrective actions are adequate, continue the inspection in
the MR implementation area. If not, go to Regulatory Review for the
issue(s) in question, but then continue inspecting MR implementation.

[MR Implementation]{.underline}

Block 10 - MR Scope Determination. Is/are the SSC(s)/function(s) being
reviewed classified by the licensee as being within the scope of the MR?
If so, continue inspecting and evaluating SSC/function performance
(i.e., reliability and availability) or degraded condition issues if
any.

Block 11 - If not, determine if the SSCs/functions in question should be
in scope. If they should, regulatory review and licensee engagement will
facilitate development of a regulatory position. Continue evaluating
SSC/function performance and/or condition. If the SSC(s)/function(s) in
question are not required to be in scope, MR compliance is not a
regulatory issue. Go to Block 25.

SSCs/functions that have one or more of the following attributes must be
scoped into the maintenance rule program:

> 1\. Safety-related SSCs/functions \[50.65(b)(1)\]
>
> 2\. Non-safety-related SSCs that perform an accident or transient
> mitigation function \[50.65(b)(2)(i)\] (as defined in the Final Safety
> Analysis Report)\*
>
> 3\. Non-safety-related SSCs that are used in the emergency operating
> procedures (EOPs) \[50.65(b)(2)(i)\]\*
>
> 4\. Non-safety-related SSCs that could prevent the fulfillment of a
> safety-related function \[50.65(b)(2)(ii)\]
>
> 5\. Non-safety-related SSCs that could cause an unwanted reactor trip
> or engineered safety feature (ESF) activation \[50.65(b)(2)(iii)\]

\*Note: NUMARC 93-01 (Rev. 3) states that an SSC needs to be in scope
under (b)(2)(i) only if it Aprovides a significant fraction of the
mitigating function@; whereas, paragraph 1.1.2 of RG 1.160 (Rev. 2)
states that SSCs that are Adirectly used to address the accident or
transient or explicitly used in the EOPs are within the scope of the
rule, as are SSCs whose use is implied and that provide a significant
fraction of the mitigating function.@ NRR (MR group) should be consulted
for scoping issues of this type.

Block 12 - Reliability. SSC/function reliability may be evaluated by
reviewing failure history independent of the licensee\'s recognition of
failures as MR functional failures (MRFFs) (i.e., failures of one or
more functions for which the SSC was included in the MR scope). Compare
documented failures with those being tracked by the licensee under the
MR. Evaluate these failures against the licensee=s reliability
performance criteria for SSCs in (a)(2), or goals for SSCs in (a)(1),
and evaluate licensee corrective actions.

In view of varying inspector experience and widely varying licensee
practices, the following discussions address some of the more complex
(and historically contentious) MR issues based on the collective
inspection and enforcement experience of resident and regional
inspectors and headquarters staff:

MR reliability performance criteria may be defined in various ways by
the licensee, most of which are acceptable under the endorsed guidance.
However, the inspector should be aware of limitations. For example, a
licensee who defines reliability (or unreliability) in terms of
Maintenance Rule functional failures (MRFFs), i.e., loss of one or more
of the functions for which the affected SSC was included within the
scope of the MR program, may only consider a total loss of those
functions to be an MRFF. The licensee=s program may not recognize
certain degraded performance as an MRFF (e.g., reduction in capacity
below the nominal value). Nevertheless, it may be reasonable to
consider, for example, that an affected SSC which still retained its
minimum design-basis capability did not suffer an MRFF, particularly if
there were no condition monitoring being done on the SSC in question.
Further, it may also be reasonable to consider some degraded performance
not to be a MRFF when the minimum capability assumed in the PRA (upon
which performance criteria are based in part) was maintained (i.e., PRA
functional success criteria met) even if design-basis capability was
not. However, such rationalization to avoid declaring MRFFs (or to avoid
charging unavailability) may be counterproductive to maintenance
effectiveness because the practice may mask declining performance trends
that otherwise might be more promptly addressed, preferably before
complete failures occur. In addition, the inspector should consider not
only the design basis and/or PRA success criteria for the function(s) in
question, but also the success criteria for all the functions for which
the SSC was scoped (e.g., use in the EOPs). If the affected SSC cannot
meet the appropriate functional success criteria for one or more of the
functions for which it was scoped, the reduced capability should ideally
be considered a MRFF. If it is not, then the inspector would be
justified in questioning the licensee=s basis for this determination,
whether or not counting the degraded performance as an MRFF would result
in the need to consider putting the affected SSC in (a)(1). While this
situation may not result in an MR violation per se, there may be PI&R
and/or corrective action implications, not to mention some risk or
safety significance that could possibly be assessed through the
significance determination process (SDP).

Some licensees define their reliability performance criteria in terms of
maintenance-preventable functional failures (MPFFs) in a given number of
valid demands or within some time period, as opposed to merely MRFFs.
This further distinction can become very subjective. In evaluating the
licensee\'s characterization of MRFFs as MPFFs (or not), where
circumstances warrant, the inspector should consider maintenance-related
contributing factors in a broad sense, not limited to work practices or
other activities of maintenance staff alone. For example, deficiencies
in certain direct maintenance support activities may cause or
substantially contribute to failures, allow failures to occur or fail to
prevent them, or allow unsatisfactory conditions to persist. These
activities can include (but are not limited to) procurement; acceptance
(including receiving and commercial-grade dedication); material control
and issue; engineering (including design control, specifications,
procedures and drawings, and poorly designed post-maintenance tests),
work controls (including clearances, equipment lineups, etc.); operators
(reconfiguring systems and equipment in support of maintenance); and use
of vendor information and industry operating experience to keep
instructions and procedures up to date. See the definition of
maintenance in Section 1.2 of RG 1.160 and Appendix B of NUMARC 93-01.

Even certain common cause problems related to design and/or
manufacturing deficiencies in replacement parts, component, or materials
(e.g., sealants, adhesives, lubricants, etc.) may be legitimately
considered to render an MRFF maintenance-preventable (i.e., the MRFF
would become an MPFF) if the deficiency(ies) could or should reasonably
have been detected and screened out (or contained) by the licensee
applying generally acceptable industry standard practices in
procurement, acceptance, and comprehensive corrective action. These
maintenance support activities can be viewed as part of a more
comprehensive concept of maintenance, and preventive maintenance in
particular.

However, the inspector should also recognize that while such factors may
indicate the need for improvements in maintenance and/or its support
activities (e.g., re-training, improved work practices, etc.), they may
not necessarily reflect degraded health of the affected SSC that would
warrant monitoring. Such contributing factors as certain operator
errors, for example, committed in direct support of maintenance (e.g.,
clearances, valve or equipment lineups, etc.), may require a failure to
be deemed an MPFF by the licensee=s program. However, absent any
indications of actual degraded performance or condition of the SSC(s)
involved, the licensee (typically an expert panel) may be justified in
not placing or retaining the affected SSC(s) in (a)(1), even if that
operator error-related MPFF caused the applicable performance criterion
to be exceeded. It would be reasonable in such a situation for the
licensee to prescribe corrective action more appropriate to the
circumstances, such as remedial operator training or requalification.
The licensee should be expected to be able to defend such decisions.
Although not required by the MR to be documented, this sort of rationale
may often be found recorded in expert panel meeting minutes or similar
documents.

Note that for MR purposes, reliability or unreliability is tracked under
all plant conditions for which the scoped SSC(s) or function(s) are
expected to start and run, or remain running while meeting the
appropriate success criteria for their required mission time. Valid
demands may include automatic or manual operation in-service or during
testing. When in doubt with regard to licensee recognition or
categorization of functional failures, inspectors are encouraged to
consult with MR experts in the region and/or NRR. If reliability is not
an issue, review availability/unavailability. If reliability is an
issue, continue in this flowchart path.

Block 13 - Comparison of the identified failures with the licensee=s
(a)(1) reliability goals and/or (a)(2) reliability performance criteria
will enable the inspector to determine whether the given failures
exceeded or did not meet them as applicable. If reliability goals are
not met or unreliability goals exceeded for SSCs in (a)(1), the licensee
must take corrective actions under the MR. Note that prompt corrective
actions may also be required for SSCs in (a)(2) by other regulations
(e.g., Criterion XVI of 10 CFR Part 50, Appendix B, or technical
specifications). If there are MRFFs or MPFFs of SSCs in (a)(2) status,
particularly if unreliability performance criteria are exceeded, the
licensee must determine whether effective control of SSC performance is
being demonstrated. If not, the licensee must at least consider placing
(a)(2) SSCs into (a)(1). If reliability goals or performance criteria
are appropriate and are being met as applicable, reliability is not
normally an issue unless the performance criteria are inappropriate and
cannot be relied upon to identify degraded performance. In this case,
the validity of the (a)(2) demonstration may be in doubt even when
performance criteria are met and regulatory review must include
consultation with NRR and OE. If reliability is not an issue, go to
Block 25; otherwise continue.

Block 14 - Licensee Aware? When the licensee miscounts failures and is
unaware of exceeding unreliability goals or performance criteria as
applicable, or when the licensee counts correctly, but still fails to
recognize that goals or performance criteria have been exceeded, go to
Regulatory Review for this issue, but continue inspecting in this path.

Block 15 - Licensee Actions. If the SSC performance trend is poor and
not improving, the licensee=s corrective actions for this problem likely
have not been timely and adequate. In cases where an SSC has experienced
an apparently high number of failures, consult with a regional senior
reactor analyst (SRA) to determine whether the SSC reliability problems
are likely to result in a significant risk increase. If licensee actions
are acceptable, proceed to assess availability. If not, go to Regulatory
Review for this issue, but continue to review SSC availability.

Block 16 - Availability. Availability is often tracked by its numerical
complement, unavailability, and typically only for
high-safety-significance (HSS) SSCs as provided for in the endorsed
industry guidance. Unavailability is the time an SSC is unavailable
during periods when the SSC was required to be available. Unavailability
may also be expressed as a fraction of the total time the SCC was
required to be available. Refer to the definition and discussion of
unavailability in Appendix B to NUMARC 93-01. Under the MR,
unavailability is customarily charged from the time of a demand failure
or discovery of a degraded or failed condition until restoration. For
the period prior to a demand failure or discovery of a failed or
degraded condition, additional unavailability may be charged from when
the condition first existed (i.e., fault exposure time) if the fault
exposure time can be determined. However, for MR purposes, if the fault
exposure time cannot be determined, additional unavailability need not
be charged. Nevertheless, as an alternative to charging unavailability
for fault exposure time, the licensee may impute a demand failure and
count it against the unreliability performance criterion. Treatment of
very long fault exposure time resulting from long-standing latent
deficiencies (e.g., design deficiencies) depends on the circumstances.
While the condition should be promptly corrected (and extent of
condition addressed), it may legitimately be judged not to reflect
adversely on current maintenance effectiveness or on other aspects of
the Ahealth@ of the affected SSC(s); hence, not be charged as
unavailability. Consultation with cognizant NRC staff in such instances
is encouraged.

An SSC may be considered unavailable, even if deemed operable under
technical specifications, when it cannot meet the appropriate success
criteria for one or more of its MR-scoped functions. On the other hand,
if the performance of the scoped function is tracked at the system
level, and not all trains of the system are unavailable (such that the
system can still meet scoped functional success criteria), then the
licensee may legitimately consider the system available. For MR
purposes, support system unavailability is not normally cascaded onto
supported system(s) because it is indicative only of the performance or
condition (Ahealth@) of the support system, not that of the supported
system.

NUMARC 93-01 contains guidance on the restrictions for crediting
operator recovery actions. Note that required availability may vary
widely under different plant conditions. It may depend upon the
licensee\'s relying on the SSC for alternate success paths to preserve
key safety functions.

With the assistance of regional and headquarters staff cognizant of the
MR, the inspector should be able to keep abreast of changes to industry
guidance related to maintenance effectiveness and the NRC positions with
respect to that guidance. For example, it is current industry practice
to track unavailability of HSS SSCs or functions for MR purposes under
all plant conditions in which they are required. However, this may not
always be the case during shutdown. Also, there may be changes in the
way fault exposure time and discovered conditions are treated for MR
purposes in the interest of improved consistency with unavailability
tracking for ROP performance indicators and other reporting programs.

If availability is affected, continue in this path. If not, proceed to
assessment of MR (a)(1)/(a)(2) classification, i.e., MR monitoring
category. If neither availability nor reliability is affected, go to
Block 25.

Block 17 - Goals or Performance Criteria Exceeded? If unavailability
goals are exceeded, the licensee must take corrective actions under the
MR for SSCs in (a)(1). Note that prompt corrective actions may also be
required for SSCs in (a)(2) by other regulations (e.g., Criterion XVI of
10 CFR Part 50, Appendix B, or technical specifications). If there is
unavailability incurred by SSCs in (a)(2) status, particularly if
performance criteria are exceeded, the licensee must determine whether
effective control of SSC performance is being demonstrated. If not, the
licensee must at least consider placing (a)(2) SSCs into (a)(1). If
availability goals or performance criteria are appropriate and are being
met as applicable and the inspector is satisfied that effective
preventive maintenance is being demonstrated for SSCs in (a)(2), or if
availability is not an issue, go to Block 25; otherwise continue.

Block 18 - Licensee Aware? Actual unavailable hours (or as determined by
the inspector from records and applying applicable criteria) may not be
consistent with those being tracked and counted by the licensee. When
the licensee incorrectly tracks unavailability, but is unaware that
goals or performance criteria have been exceeded or when the accounting
is correct, but the licensee still fails to recognize that goals or
performance criteria have been exceeded, go to Regulatory Review for
this issue, but continue inspecting in this path.

Block 19 - Licensee Actions OK? Unavailability trend data should show
whether system performance is improving. If performance is not
improving, ideally, the licensee should take timely and reasonable
corrective actions for this problem. Depending on the circumstances,
this situation may or may not amount to an MR violation, but it reflects
negatively upon maintenance effectiveness and should be pursued through
regulatory review. In cases where an SSC has experienced an apparently
large amount of unavailability, the licensee=s PRA may provide some
insight as to the risk significance of this condition. Also, use of the
SDP or consultation with a regional SRA may be necessary to determine
whether the SSC availability performance problems are likely to result
in a significant risk increase. If licensee actions are not acceptable,
go to Regulatory Review for this issue, but continue to review MR
disposition of the issue(s) in question.

Block 20 - MR Monitoring Category. If the SSC is already classified as
(a)(1), continue to evaluate; if not, the inspector must decide if it
should have been in (a)(1). The inspector should determine independently
whether the licensee has demonstrated effective control of SSC or
function performance through appropriate preventive maintenance for
SSCs/functions in (a)(2), independent of whether performance criteria
were exceeded. For example, in general, repetitive MPFFs (i.e., multiple
failures of the same SSC for the same maintenance-related reason) can
demonstrate that preventive maintenance is not effective and may be
sufficient cause for placing the affected SSC in (a)(1) even if the
performance criterion was not exceeded. By the same token, as discussed
above, failures that are technically MPFFs and that exceed the
reliability performance criterion, but are not related to the health of
the SSC itself, may be reasonably judged by an expert panel not to
warrant the increased attention of (a)(1) status.

Note that (a)(2) performance criteria are not required or even
recognized per se by the MR. However, they are the means, established by
the industry MR guidance, NUMARC 93-01, by which licensees typically
determine whether they are demonstrating effective control of the
performance of SSCs within the MR scope through appropriate preventive
maintenance, and they have been endorsed by the NRC for this purpose in
RG 1.160. Meeting or not meeting (a)(2) performance criteria is not, by
itself, the sole test for a valid (a)(2) demonstration for MR compliance
with regard to those SSCs being carried in (a)(2) status, i.e., not
being monitored against goals in (a)(1) status. Therefore, not placing
an SSC into (a)(1) status for failing to meet (a)(2) performance
criteria alone may not be sufficient grounds for an (a)(1)/(a)(2)
violation; just as meeting (a)(2) performance criteria alone may not be
sufficient demonstration of effective control of SSC performance in
(a)(2).

If the inspector believes, on the basis of some objective standard
(e.g., the plant=s PRA, the EPRI PRA applications guide, or industry
operating experience) that unavailability and/or unreliability is
excessive, even if the existing performance criteria (which may no
longer be valid) are not exceeded, there may be justification to
conclude that the licensee is not effectively controlling the
performance of the affected SSC(s)/function(s) through appropriate
preventive maintenance. In such a case, the licensee should at least be
considering the affected SSC(s)/function(s) for monitoring under (a)(1).
However, not having recognized the unacceptable performance or
condition, the licensee will not have considered monitoring under
(a)(1). This may be grounds for identifying an (a)(2) violation, but
this kind of issue may be highly subjective and would require
considerable objective evidence to support a violation or a
risk-significant finding. In such cases, regulatory review must include
consultation with NRR and OE.

Block 21 - A Regulatory Review will take place if it is determined that
the affected SSC should have been in (a)(1), but was instead was being
carried in (a)(2) status even when effective control of SSC performance
or condition was not being demonstrated.

Block 22 - The (a)(1) monitoring goals must be appropriate and
commensurate with safety. Corrective actions must be timely and must
address the cause of the degraded performance or condition. For example,
in setting goals, the licensee (expert panel) should have considered:

> 1\. Both reliability and availability
>
> 2\. Balancing of reliability and availability
>
> 3\. Industry operating experience information
>
> 4\. Actual performance history
>
> 5\. Frequency of valid demands or expected operation within the
> monitoring period
>
> 6\. PRA or some other reasonable risk/safety consideration(s)

If (a)(1) goals are not appropriate or are not commensurate with safety,
go to Regulatory Review (RR). If (a)(1) goals are satisfactory, but have
not been met, evaluate the licensee=s corrective actions. Repeated
failure to meet goals may be indicative of inadequate corrective action.
However, note that failure to meet (a)(1) goals is not, by itself, an MR
violation. However, failure to take timely and adequate corrective
action when (a)(1) goals are not met (corrective action that addresses
the cause(s) of the problem(s)) may constitute a 50.65(a)(1) violation
(depending on the circumstances) in addition to any other
safety-significant findings.

Block 23 - For SSCs that remain in (a)(2) following the current problem,
the licensee=s performance criteria should be appropriate, i.e.,
technically justifiable. They should be sensitive enough to identify
unacceptably degraded performance while allowing a reasonable,
technically defensible (in terms of both deterministic and risk factors)
and balanced amount of unreliability and/or unavailability without
invalidating the (a)(2) demonstration. In general, the licensee (expert
panel) should consider factors similar to those used to establish (a)(1)
goals.

Block 24 - Determine whether the licensee=s goals and/or performance
criteria are reasonable and achievable, consistent with the PRA or
commensurate with safety, and appropriate. Consult the regional MR
contact if you conclude that the licensee=s performance criteria or
goals are not reasonable and also if you conclude that the actual number
of failures or amount of unavailability would have exceeded a more a
reasonable goal or performance criterion.

For example, it would be unreasonable if the number of MPFFs required to
exceed the reliability performance criterion or goal for a given SSC
exceeds the number of expected (or possible) valid demands during the
monitoring period. In this case, the goal or performance criterion could
never be reached, let alone exceeded, despite clearly degraded
performance or condition of the affected SSC. After consultation with
appropriate regional and possibly headquarters staff, such issues can be
addressed with the licensee, who should have a sound technical basis for
its goals and performance criteria. This area, if suspect, may also be a
candidate for further and more in-depth examination during the biennial
inspection of the licensee\'s (a)(3) periodic evaluation activities.

Block 25 - END - Develop Regulatory Position and Documentation

REGULATORY REVIEW (RR): In general, RR is entered whenever the resident
has occasion to question licensee actions or inaction and has not a
received satisfactory response or justification from the licensee, or
whenever the resident desires further evaluation of the validity of a
licensee response. On the basis of the results of the reviews prescribed
above, and concurrent with a continuing dialog with the licensee
(licensee engagement), in addition to normal discussion of issues with
the other resident inspectors on site and the senior resident inspector,
also consult (1) regional supervision, (2) regional DRS maintenance rule
contact(s), and (3) regional enforcement specialist(s). After
consultation with appropriate regional staff, and at least preliminary
significance determination and documentation as described below, consult
with Office of Nuclear Reactor Regulation (NRR) maintenance rule staff
and Office of Enforcement (OE) staff as necessary.

The following guidance is intended to supplement the general guidance of
IMCs 0612, 0609, and 0305 by providing specific guidance on the
disposition of ME issues. That is, where there are choices or
interpretations indicated in the applicable manual chapters, this
procedure is intended to provide the resident with the
staff-pre-selected choices and preferred interpretations unique to ME
issues and applicable under the vast majority of foreseeable
circumstances.

First, the licensee performance deficiency(ies) involved in or
associated with the ME issue(s) should be clearly identified. They
should be able to be characterized by a simple written statement as a
preliminary determination. A maintenance effectiveness (ME) performance
issue can involve various types of licensee performance problems,
including, but not limited to: deficient procedures,
instruments/measuring and test equipment, tools or other equipment,
deficient work practices, deficient maintenance support activities
(e.g., replacement parts procurement and dedication, storage and
material issue), inadequate recognition and handling of common cause
problems, or inadequate root-cause analysis and/or corrective actions
for degraded performance or condition of SSC(s)/function(s).

In addition, one or more of the identified performance deficiencies may
constitute a violation of one or more NRC regulations. Though not
limited to violations of 10 CFR 50.65, the Maintenance Rule (MR), this
section will focus on the disposition of ME issues involving MR
violations because treatment of violations of other regulations that may
be involved as well are covered adequately elsewhere. For ME issues
involving potential MR violations, refer to Enforcement Manual Section
8.1.11. Note that the provisions of NUMARC 93-01 and RG 1.160 are not
regulatory requirements, but may provide insights for characterization
of failures to meet one or more explicit requirements of the MR or
expectations of the Commission with regard to MR implementation as
described in the statements of considerations.

Next, the identified performance deficiency(ies) is/are screened against
the criteria in Appendix B to IMC 0612 to determine whether they are
minor or more than minor. Those issues that are determined to be minor,
although not normally to be documented in the inspection report, should
be brought to the licensee=s attention at a level and in a forum deemed
appropriate by the inspector and must be corrected. Effective corrective
action normally requires entry into the licensee=s corrective action
program. Appendix B to IMC 0612 will refer to the examples of minor
issues in Appendix E to IMC 0612. Note that specific examples of MR
violations are included in Appendix E to IMC 0612. These examples also
explain the conditions that make the violations more than minor. In
general, ME performance deficiencies will be more than minor when there
is or has been identifiable degraded performance or condition of
associated SSCs/functions, sometimes regardless of the extent to which
such degraded performance or condition has been recognized and/or
appropriately categorized or characterized by the licensee.

In processing more-than-minor ME performance deficiencies (i.e.,
findings), consider that MR violations do not always cause degraded
SSC/function performance or condition, but rather are often a separate
consequence of them. In some instances, equipment failures are found not
to be attributable to any licensee performance deficiencies and are
therefore not findings. Yet, in many instances, licensee ME performance
deficiencies contribute to the equipment problems, or allow them to
occur, persist, or get worse. In order to disposition ME issues
involving performance deficiency(ies) systematically and consistently,
all such issues will be categorized as follows:

Category I - ME issues involving performance deficiencies (including any
MR or other violations) that are minor, determined as described above.

Category II - ME issues involving more-than-minor performance
deficiencies (which are thus considered findings) where any identified
MR violation has occurred as a separate consequence of degraded
performance or condition of associated SSCs/functions within the scope
of the MR, but where the degraded SSC/function performance or condition
is not attributable to the MR violation.

In this category, the degraded SSC/function performance or condition
will have its own proximate, ultimate and/or contributing causes that
involve licensee ME performance deficiencies (findings) other than MR
violations. Those causal findings will be processed in accordance with
Appendix B to IMC 0612 and their significance will be determined,
independent of any associated MR violations, using the reactor safety
significance determination process (SDP) commensurate with the severity
and risk/safety significance of the degraded performance or condition of
the affected SSCs/function(s). Alternatively, the impact of the
equipment problems may be otherwise captured under the ROP such as by
the Mitigating Systems Performance Index (MSPI).

However, also in this category, the MR violation(s) itself/themselves
is/are also considered to be more than minor because actual problems
with the associated equipment have occurred. However, since the
equipment problems are not attributable to the MR violation, rather, the
MR violation has occurred as a consequence of those problems, they
cannot be processed through the SDP. Therefore, in accordance with
Appendix B to IMC 0612, such MR violations are considered to be GREEN by
definition.

Category III - ME issues involving more-than-minor performance
deficiencies where the identified MR violation(s) is/are among the
contributing causes of degraded SSC/function performance or condition.
Such instances will typically involve circumstances in which, in
addition to non-MR proximate causes, the lack of adequate preventive
maintenance or proper attention to degraded performance or condition of
affected SSCs/functions, which has allowed such degraded performance to
continue or the condition to deteriorate, can be shown to be the result
of one or more MR performance deficiencies, including MR violations. MR
findings in this category are bundled together with the other,
contributory, non-MR findings, and treated collectively as one finding,
involving multiple violations and/or other performance deficiencies,
which is then processed through the SDP. Note that only Category III MR
findings can be greater than green.

Note that in all three categories, cross-cutting issues may be involved.
However, where identified in conjunction with Category II or III ME
findings as described above, cross-cutting issue aspects should be
documented within the finding and dispositioned in accordance with IMCs
0612 and 0305.

Example of a MR Finding: Consider the very common case in which a
high-safety-significant (HSS) SSC in (a)(2) status has suffered one or
more MR functional failures (MRFFs), i.e., failures of one or more of
the functions for which it was included in the scope of the licensee=s
MR program. Typically one or more of the following circumstances exist:
(1) The resident inspector has determined that the MRFFs were
maintenance preventable (i.e., were MPFFs), but the licensee has not
recognized this. If counted appropriately as an MPFF, the latest MRFF
would exceed the licensee-established (a)(2) unreliability performance
criterion (PC); and/or (2) the latest MPFF constituted a repetitive MPFF
(i.e., same type of failure and same cause or type of cause); and/or (3)
regardless of the PC, the number of failures (and/or associated
unavailability) is excessive by one or more objective standards, e.g.,
the EPRI PRA Applications Guide, NRC, vendor or industry guidance
(including NEI, INPO, EPRI, and users or owners groups) or prevailing
industry practice or operating experience. In any of these three cases,
the circumstances may support an inspector determination that the
licensee has failed to demonstrate for the affected (a)(2) SSC that its
performance or condition has or is being effectively controlled through
appropriate preventive maintenance; although in the third case,
consultation with NRR and OE staff is required. This demonstration must
be made in order for the affected SSC/function to remain in (a)(2)
status under the MR. But having failed to make this demonstration, the
licensee must set goals and monitor the performance or condition of the
affected SSC under (a)(1) to be in compliance with the MR.

In practice, when licensees consider putting the affected SSC/function
in (a)(1), but can justify not doing so by reason, for example, of the
root cause being either corrected or unrelated to the equipment itself
(e.g., personnel issues only), then they may be deemed to be in
compliance with the MR while allowing the affected SSC/function to
remain in (a)(2) status. However, if the circumstances warrant
monitoring the affected SSC/function under (a)(1), and the licensee
commences monitoring under (a)(1) within a reasonable amount of time,
and takes prompt and adequate corrective action in case goals are not
met, there has, thus far, been no violation of the MR in this scenario.
Therefore, when the inspector reviews the circumstances described above,
and determines that the licensee has not yet complied with the MR, the
inspector must then determine whether the time that has passed since the
licensee=s first opportunity to comply is excessive, in which case, a
violation may be identified. In making this determination consider the
following:

When the inspector=s concerns are brought to the attention of the
licensee, the licensee may immediately recognize the situation, convene
its expert panel and at least consider putting the affected SSC into
(a)(1). In this case, the licensee may have avoided an MR violation
unless an excessive amount of time has already passed and/or the
licensee has missed one or more reasonable opportunities to comply.
However, the resident should also expect the licensee to take prompt
corrective action for the degraded performance or condition of the SSC
regardless of the MR disposition. There may still be grounds for a
violation of Criterion XVI of 10 CFR Part 50, Appendix B, for inadequate
corrective action for previous failures, assuming the affected SSC is
safety-related.

The second common situation is that the series of MPFFs that invalidated
the (a)(2) demonstration occurred some time ago, for example, before the
licensee=s last (a)(3) periodic evaluation, one or more expert panels
have been convened without addressing the issue, or more than one
rolling MR monitoring period has gone by, and the licensee has never
recognized that the SSC in question should have been in (a)(1). In this
case, there has clearly been a violation of (a)(2) and/or (a)(1) in that
effective preventive maintenance was not demonstrated under (a)(2), yet
the SSC was never put in (a)(1) despite several opportunities for the
licensee to comply with the MR. In either of the foregoing situations,
to determine the appropriate MR finding category, the history of the
performance or condition of the affected SSC(s)/function(s) must be
considered.

Category II Scenario: If during the period following the MPFF that first
invalidated the (a)(2) demonstration, there were no further MPFFs, no
additional related unavailability, or no further degradation of the
condition of the affected SSC(s)/function(s), then the equipment
problems are not considered attributable to the associated (a)(2)
violation. Therefore this situation would be consistent with Category
II. Accordingly, the non-MR performance deficiencies/findings
contributing to the equipment problems would be dispositioned as
otherwise provided for under the ROP. However, the associated,
more-than-minor, but non-contributory MR violation, identified as a
separate consequence of the equipment problems, would be colored green
by default and documented separately, but as an additional finding
related to the other non-MR ME findings.

Category III Scenario: However, if when the MR finding is identified by
the inspector, the historical review reveals a continued declining trend
in performance, i.e., more MPFFs and/or more unavailable hours after the
MPFF or amount of unavailability that first invalidated the (a)(2)
demonstration, such that failure to place the affected SSC/function in
(a)(1) has resulted in continued inadequate attention or corrective
action, then this is a Category III MR finding in that the MR (a)(2)
violation has contributed to the continued degraded performance of the
affected equipment. In this case, the MR violation and all other
contributing causes would be considered together. To determine the
significance of the composite finding, the resultant equipment problems
would not be aggregated, but the safety/risk significance of the most
severe of them would be processed through the SDP to color the finding.
Note that this single colored finding could comprise multiple
contributory performance deficiencies and violations, including MR
violations.

Other types of Category III MR findings would include, for example, an
(a)(3) violation in which there are MPFFs as a direct consequence of
failing to take industry operating experience into account, or a scoping
violation of (b)(1) or (b)(2) in which failure to include an SSC or
function in the scope of the MR program when required resulted in the
failure to recognize that no preventive maintenance or inadequate
preventive maintenance was being performed; which then resulted in
excessive MPFFs, excessive unavailability, or degraded condition of the
affected SSC, or failure even to recognize that the performance or
condition of the affected SSC/function was excessively degraded.

Finally, for regulatory assessment under the ROP, it is appropriate to
view the licensee=s MR program as one part of their overall problem
identification and resolution program. When an ME finding has problem
identification and resolution or human performance aspects, these
cross-cutting issues should be identified within the finding. The
cross-cutting aspects should be documented as a contributing cause of
the finding. Guidance related to evaluating and documenting issues in
cross-cutting area is provided in IMC 0305 and IMC 0612.

Documenting Maintenance Effectiveness (ME) Findings. In view of varying
inspector experience, the following discussion is intended as an aid to
effective ME finding documentation. It is meant to be general guidance
only, recognizing that many instances are complex and do not fit
preconceived patterns. Accordingly, in order to supplement the guidance
in IMC 0612, the following specific guidelines for documenting ME
findings (particularly those involving MR violations) in inspection
reports are provided. ME findings should be documented according to the
format prescribed by IMC 0612 for the findings section of an item under
report details, i.e., An introduction section, description of the
findings, an analysis section, and an enforcement section.

In the introduction, briefly state the finding, the safety/risk
significance and any enforcement action. Examples:

\[(a)(1) violation\]: A(Green) The licensee failed to take timely and
adequate corrective action for the AA@ service water pump when it did
not meet its (a)(1) monitoring goals. A non-cited violation of 10 CFR
50.65(a)(1) was identified.@ Note that this scenario is consistent with
a Category III finding when unsatisfactory equipment performance
continues as a result of the (a)(1) violation, i.e., inadequate
corrective action.

\[(a)(2) violation\]: A(Green) The licensee failed to shift the 22 CVC
pump from (a)(2) status to (a)(1) status, and had no justification for
not doing so, after a reasonable period of time and several
opportunities to comply, after it had failed to demonstrate effective
control of the performance or condition of the pump through appropriate
preventive maintenance. A non-cited violation of 10 CFR 50.65(a)(2) was
identified.@ This scenario would be a Category II finding if no further
degradation has occurred after that which first invalidated the (a)(2)
demonstration. It would be Category III if lack of adequate attention
due to remaining in (a)(2) contributed to further or prolonged degraded
performance.

\[(a)(3) violation\]: A(Greater than Green) During its most recent
periodic evaluation of its maintenance rule program, the licensee failed
to take industry operating experience regarding a technical service
bulletin on the emergency diesel generator (EDG) into account, which
would have been practicable. Failure to comply with the service bulletin
resulted in a subsequent failure of the diesel engine while the other
EDG was unavailable. A violation of 10 CFR 50.65(a)(3) was cited.@ This
one is non-green and therefore must be Category III.

\[(b)(1) violation\]: A(Green) The licensee failed to include the vital
station battery circuit breakers within the scope of its maintenance
rule program and therefore did not recognize that appropriate preventive
maintenance was not being performed. Failure to perform preventive
maintenance on the breakers resulted in a failure of the AB@ breaker
during a special test requested by the inspector which indicated that
the breaker would likely have failed upon demand in service. A non-cited
violation of 10 CFR 50.65(b)(1) was identified.@ This is another
Category III MR finding because the functional failure (in this case,
failure of the breaker=s overload/fault trip function) was a consequence
of the MR violation.

For the description, determine which of the two categories of
more-than-minor MR violations, described in Regulatory Review (RR)
above, best fit the circumstances. To the extent practicable, follow the
logic in the most pertinent examples of violations in Section 8.1.11 of
the NRC Enforcement Manual, or conditions that render violations more
than minor in Section 1, ARecord Keeping,@ of Appendix E to IMC 0612.
Summarize the facts and circumstances surrounding the issue. Provide a
brief chronology of events, including, for example, continued degraded
performance after an SSC/function should have been placed in (a)(1)
status, and citing, if relevant, any missed opportunities for licensee
action under the MR such as expert panel meetings, (a)(3) periodic
evaluations, or even the passing of multiple monitoring periods or
cycles after action should have been taken.

For issues involving MR scoping violations, establish that the affected
SSCs/functions are not within the scope of the MR, but should be, and
why they should be, citing the scoping criterion under which the
SSCs/functions in question should have been included. Then discuss any
consequences of the scoping deficiencies with some risk significance
(e.g., attributable degraded performance or condition of the associated
SSCs/functions).

For issues/findings involving in-scope SSCs/functions, discuss the
following: performance or condition problems that should have prompted
licensee actions and any continued degradation or further unsatisfactory
performance after action should have been taken as applicable; licensee
recognition and characterization of those problems and your assessment
of the appropriateness of that characterization; MR status of the
affected SSC(s)/function(s) and its appropriateness, any changes in MR
status, licensee rational for making MR status changes (or not) and its
validity; whether the problems caused (a)(2) performance criteria or
(a)(1) goals not to be met; and licensee handling of the issue and its
appropriateness with regard to the MR.

For issues involving SSCs/functions in (a)(2), make it clear that
deficiencies related to (a)(2) performance criteria and tracking
availability and reliability against those criteria are being described
only as supporting information for the determination of whether the
licensee has demonstrated effective control of the performance or
condition of the affected SSCs/functions through appropriate preventive
maintenance; this being the relevant regulatory consideration. Cite
basis(es) (e.g., repetitive MPFFs, industry standards, etc.) for any
determinations that unreliability and/or unavailability are excessive
such that it invalidates the demonstration of effective preventive
maintenance under (a)(2) regardless of the performance criteria, if
applicable (Note that this determination requires NRR/OE consultation).
Also, discuss corrective actions for the equipment problems themselves,
stating if and how the corrective action addressed the problem. In
addition, discuss any ME issues of broader significance than MR
compliance, such as work practices, maintenance support problems,
common-cause problems and cross-cutting issue aspects.

In the analysis section, per IMC 0612, describe the logic for entering
the SDP, how it was used, and the assumptions, using the guidance and
example for determining MR violation significance with the SDP that is
prescribed above in the Regulatory Review section of this procedure. If
appropriate (RR Category II), characterize the ME finding/MR violation
as being an additional, but separate consequence of the degraded
performance or condition of the associated SSCs/functions; or, if
appropriate (RR Category III), characterize the ME finding/MR violation
as a contributing cause of the degraded performance or condition of the
associated SSCs/functions. Describe any cross-cutting issue aspects of
the finding. In answering Question (1) in Appendix B to IMC 0612,
analysis section, use the considerations in the MR section (8.1.11) of
the Enforcement Manual and the MR examples in Appendix E to IMC 0612 to
establish how/why the issues are more than minor.

Follow the guidance in IMC 0612 for the enforcement section. There are
no special ME/MR considerations for this section.

10 CFR APPENDIX B CORRECTIVE ACTION. For safety-related MR SSCs (MR
paragraph (b)(1)), the determination of adequacy of corrective actions
may also be evaluated against the requirements of 10 CFR Part 50,
Appendix B, Criterion XVI.

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**APPENDIX B**

**MAINTENANCE EFFECTIVENESS**

**PERIODIC EVALUATION INSPECTION GUIDANCE**

This appendix provides the specific inspection guidance for Section
03.02, APeriodic Evaluation@ (PE), of IP71111.12. Biennially, assess the
effectiveness of the licensee=s PE(s) and resulting adjustments
performed pursuant to paragraph (a)(3) of 10 CFR 50.65, the Maintenance
Rule (MR), since the last PE inspection.

In addition to a general review of the PE for balancing, adjustment, and
use of industry operating experience, review the handling under the MR
of three to five specific examples of SSCs/functions with degraded
performance or condition (preferably of high risk significance)
indicative of the effectiveness of the licensee=s PE process. Using
Flowchart 2 as a guide, assess the effectiveness of licensee PE
activities including, as appropriate, the following:

1\. Use of SSC/function performance history (i.e., reliability and
availability data) in

adjusting preventive maintenance

2\. Use of SSC/function performance history in adjusting (a)(1) goals

3\. Use of SSC/function performance history in adjusting (a)(2)
performance criteria

4\. Balancing the objective of maintaining or improving reliability
against the objective

of maintaining or improving availability

5\. Use of industry operating experience in adjusting preventive
maintenance

6\. Use of industry operating experience in adjusting (a)(1) goals

7\. Use of industry operating experience in adjusting (a)(2) performance
criteria

8\. Review and adjustment of MR scoping (50.65(b), RG 1.160, NUMARC
93-01)

9\. Review and adjustment of definitions of functional failures (FFs),
Maintenance Rule

FFs (MRFFs) (i.e., failures of one or more MR-scoped functions), and
maintenance-

preventable FFs (MPFFs)

10\. Review/adjustment of definitions of available/unavailable hours and
required hours

11\. Review and adjustment of condition-monitoring parameters and action
levels

As learned through field experience, maintenance effectiveness,
particularly in terms of minimizing risk to public health and safety, is
dependent on the appropriate use of insights from the probabilistic
safety assessment (PSA) or probabilistic risk analysis (PRA) in the
maintenance rule program. Therefore, when deemed necessary or
appropriate, risk experts (e.g., regional staff and/or inspectors with
sufficient risk knowledge), with support as necessary and as available
from other agency risk analysis resources, may review maintenance
effectiveness activities related to the plant\'s PSA or PRA, if any, in
conjunction with the PE inspection, including:

1\. Use of risk insights in high/low safety significance (HSS/LSS)
categorization

2\. Use of risk insights in establishing/adjusting (a)(1) goals

3\. Use of risk insights in establishing/adjusting (a)(2) performance
criteria

4\. Use of risk insights in establishing/adjusting preventive
maintenance

5\. Updating the PRA/PSA with actual reliability and availability data

6\. Updating the PRA/PSA with industry operating experience

7\. Updating the PRA/PSA with major plant or procedure modifications

8\. Updating the PRA/PSA consistent with major routine maintenance
changes

9\. Maintaining risk assessment tools consistent with updated PRAs

The documentation related to any PRA/PSA peer reviews that may have been
conducted should provide considerable insight into the quality and
fidelity of the PRA/PSA.

Note that because there is no regulatory requirement for a PRA/PSA, this
review is not expected to identify any violations (except possibly
(a)(1) goals not commensurate with safety or potentially flawed (a)(4)
risk assessments or assessment tools). If it is determined that the
PRA/PSA is not being properly updated or applied, the impact on the
licensee=s risk-related activities must be evaluated as more than minor
for the issue to be classified as a finding. Should an impact on (a)(4)
risk assessment tools or risk assessments themselves be suspected, refer
to IP 62709 or IP 71111.13 respectively. Note that IP 62709 is normally
performed only for cause (e.g., as part of an IP 95002 type supplemental
inspection).

Block 1 - PE Performance

Verify that PEs have been completed within the time constraints of the
MR (i.e., once each refueling cycle, but not to exceed 24 months between
PEs). Verify that the licensee has reviewed its (a)(1) goals, (a)(2)
performance criteria, monitoring, and preventive maintenance activities.
Verify that industry operating experience (IOE) has been taken into
account where practicable. Verify that the licensee makes appropriate
adjustments as result of the PEs.

The inspector should perform all three parts on the flow chart \[i.e.,
balancing, (a)(1), and (a)(2)\]. Refer to NUMARC 93-01, Section 12.0.

Path 2 - Balancing

Verify that the licensee balanced reliability and
availability/unavailability (R&U) based on the results of each PE
performed since the last PE inspection. Examine licensee review and
adjustment of (a)(1) goals (refer to NUMARC 93-01, Section 12.2.4). Most
licensees reevaluate the balance between an SSCs unavailability and
reliability if the SSC performance criteria are exceeded. The licensee=s
assessment of balance should determine:

> a\. whether preventive maintenance should be reduced if unavailability
> performance criteria are exceeded with few MPFFs
>
> b\. whether preventive maintenance should be increased if reliability
> performance criteria are exceeded with low unavailability.

The PE and resulting adjustments should meet the MR requirement that the
objective of preventing failures of SSCs through maintenance is
appropriately balanced against the objective of minimizing
unavailability of SSCs due to monitoring or preventive maintenance.

Path 3 - (a)(1) Activities

Review SSCs/functions that are in (a)(1) status (goals and action plan)
and those that have been in (a)(1) and were moved to (a)(2) (evaluation)
since the last PE inspection. Verify that (a)(1) goals were met, or if
not, that timely and adequate corrective action (CA) was taken, that the
corrective action considered IOE, and that (a)(1) activities and related
goals were adjusted as needed. Samples selected should be mostly
high-safety-significant SSCs or scoped functions to the extent
practicable. Note that for certain SSCs, the licensee may monitor and
trend SSC condition in addition to or instead of SSC performance
(reliability and availability). Condition monitoring parameters can
include vibration, temperature, pressure, flow, lubricant analysis,
corrosion and erosion, response time, clearances, and electrical
operating characteristics (refer to NUMARC 93-01, Section 12.2.1).

Path 4 - (a)(2) Activities

Review SSCs/functions in (a)(2) status. Verify that the licensee has
established (a)(2) performance criteria (PC), examined any SSCs that
failed to meet their PC or reviewed any SSCs that have suffered repeated
maintenance-preventable functional failures (RMPFFs). Verify the failed
SSC was considered for (a)(1). Note: Some licensees use condition
monitoring such as vibration, lubricant or working fluid analyses,
temperature monitoring and the corrosion/erosion program) (refer to
NUMARC 93-01, Section 12.2.2).

Block 5 - Regulatory Review

The regulatory review block recurs at critical points throughout the
process to provide the inspector with assistance for clarification and
classification of a finding. Throughout this regulatory review process,
the inspector must perform regulatory evaluations and make related
decisions. The regulatory review process consists of licensee
engagement, the inspector=s own judgment and peer review, contact with
supervision as dictated by regional protocols, and consultation with
other agency resources, including regional and/or headquarters SRAs, DRS
and/or headquarters MR-cognizant staff, and regional enforcement staff.
For further specific guidance, see Regulatory Review in Appendix A to
this procedure.

Block 6 - END

End the process through a final evaluation, develop a regulatory
position, and document the results of the inspection. See Appendix A to
this procedure for further guidance.

FLOWCHART 2![](media/image2.wmf){width="6.8381944444444445in"
height="8.303472222222222in"}