Issue Date: 09/28/98 - 1 - 92720 

NRC INSPECTION MANUAL HQMB 

INSPECTION PROCEDURE 92720 

 CORRECTIVE ACTION 

PROGRAM APPLICABILITY: 2515 

SALP FUNCTIONAL AREA: ENGINEERING 

92720-01 INSPECTION OBJECTIVE 

To determine whether the licensee is effectively implementing a corrective action process 

that identifies, follows, and corrects conditions adverse to quality, especially with regard to 

determination of the cause of the problem and elimination of both problem recurrence and 

occurrence of similar problems. 

92720-02 INSPECTION REQUIREMENTS 

02.01 Confirm Sources of Problem Identification

Confirm the sources from which problem identifications arise. The sources should include: 

a. Construction, testing, or operational events. 

b. Licensee-identified problems. 

c. Quality Assurance (QA) findings. 

d. NRC inspection findings. 

e. NRC generic correspondence. 

f. Employee and other concerns. 

g. Industry operating experience. 

h. Licensee maintenance rule monitoring and periodic evaluations. 

02.02 Investigation of Problems
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Select at least four identified, risk significant problems from each source described in 

Section 02.01a-h of this procedure, as available, and investigate the licensee's response to 

each. Include a determination of whether the identified problem was assessed; whether 

the licensee's corrective action was effective, timely; and whether the licensee: 

a. Reported the initially identified problem to the appropriate plant managers and to the 

NRC, if required. 

b. Effectively carried out established action and responsibilities for resolving each 

problem in accordance with the licensee's corrective action procedure with 

appropriate consideration given to risk significance. 

c. Classified and assigned priorities to any problems according to the safety 

significance of each. 

d. Considered potential generic concerns and underlying root causes of each problem. 

e. Closed out, documented, and promulgated to others completed action, as required. 

02.03 Inspection of Programs (as necessary)

For each source of problem identification that was found during the investigations 

described in Section 02.02 of this procedure, ensure that the licensee's program: 

a. Has adequate controls established for that source. 

b. Verifies through periodic QA audits and surveillances that the regulatory 

requirements and administrative policy and procedures are being implemented 

properly. 

c. Provides appropriate guidance for determining which events require detailed rootcause assessment or an assessment that uses human performance investigative 

tools. 

d. Uses a human performance evaluation system. 

e. Appropriately evaluates failures of SSCs within the scope of the maintenance rule. 

92720-03 INSPECTION GUIDANCE 

General Guidance

To assist the inspector with fulfilling the objective of an inspection of corrective action, this 

procedure outlines how to examine the licensee's corrective action activities broadly, 

whereas other procedures outline how to examine the licensee's performance in correcting 

problems in a narrow area. Part of this broad examination is to determine whether the 
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licensee's corrective action process is being implemented by all personnel and groups that 

perform activities that could impact plant safety. Under this procedure, problems include, 

but are not limited to, faults, failures, malfunctions, nonconformances, deficiencies, 

deviations, defective material and equipment, personnel errors, and incorrect or inadequate 

procedures. The term "problems" in this procedure is meant to be synonymous with 

conditions adverse to quality, and any other condition or defect that may be detrimental to 

plant safety. 

The inspector should concentrate on corrective action activities rather than on the program 

and procedures. If the corrective action activities are performed effectively and the plant 

equipment runs reliably, the licensee's program and procedures are most likely adequate. 

However, if the inspector notes problems or the plant equipment is not reliable, the 

inspector should investigate possible causes in the areas of personnel performance or 

training. 

To the extent practicable, the inspector should also evaluate whether the licensee has 

incorporated into its corrective action program the applicable requirements of the 

maintenance rule (10 CFR 50.65) and determine if poor equipment reliability and/or 

availability resulted from ineffective maintenance. 

 

Additional guidance relative to the maintenance rule can be found in NUMARC 93-01 

"Industry Guideline for Monitoring the Effectiveness of Maintenance at Nuclear Power 

Plants," Regulatory Guide 1.160 which endorses the industry guidance, and Inspection 

Procedure (IP) 62706, AMaintenance Rule@. When reviewing maintenance activities, the 

inspector should concentrate on risk significant performance examples that are a product of 

poor maintenance programs or implementation. 

Non-safety related SSCs within the scope of the maintenance rule are not governed by the 

licensee's Appendix B QA program; therefore, inspectors should exercise caution when 

inspecting to and enforcing the maintenance rule. If significant corrective action problems 

are identified within the auspices of the maintenance rule, the inspector should consult with 

and identify any concerns to regional management who may consider a more detailed 

inspection in accordance with IP 62706. 

Additionally, the inspector should consider the licensee's history of enforcement action in 

the area of corrective action. If the licensee's history of enforcement action includes a 

number of citations for poor corrective action, the inspector should ensure that the 

documented root causes have been corrected. 

If inspection of the corrective action activities and personal performance or training does 

not yield the source of the problems, then the inspector should examine the licensee's 

program and procedures. 

The requirement that problems (as defined in Section 03.01a of this procedure) be properly 

identified and corrected derives from 10 CFR Part 50, Appendix B, Criterion XVI; ANSI 

N18.7 - 1976; and the ANSI N45 series. These documents further require that, for 

significant conditions adverse to quality, the cause of the condition be determined and 

corrective action be taken to preclude repetition. The corrective action is required to be 

documented and reported to appropriate levels of management. 
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This procedure for a broad-based inspection of licensee corrective action should be 

performed as an initiative when a need for review is indicated by the identified problems (as 

defined in 03.01a). 

When following up on items where there are implications of wrongdoing, consult the Office 

of Investigations for guidance after discussing the wrongdoing issues with regional 

managers. 

Regarding the use of INPO reports and the information they contain, written guidance can 

be found in Inspection Procedure 71707. 

Specific Guidance

03.01 Confirm sources of problem identification. Licensees may have a single or 

numerous corrective action processes for identifying, tracking, and resolving issues 

associated with a facility. For each of the following eight general areas, the licensee should 

have some process for dealing with corrective action. Examples of typical processes or 

items that may be found in each area are as follows: 

a. Construction, testing, or operational events. Events at the facility are identified in 

reports made to the NRC in accordance with 10 CFR 50.55(e), 10 CFR 21, 10 CFR 

50.72, in licensee event reports (LERs), in the plant internal reporting process, and 

in station operating logs. Events that may influence operations at the facility and 

that have occurred at other sites are identified in NRC generic correspondence and 

other sources of industry operating experience. Follow-up of licensee action on 

confirmatory action letters is covered in Inspection Procedure 92703. 

b. Licensee-identified problems. Often a licensee has many internal systems for 

managing deficiencies that its facility staff identifies. These systems typically require 

documentation of the facility's problems in nonconformance reports, quality 

deficiency reports, procedure change requests, maintenance work orders, field 

change requests, and radiological deficiency reports. 

c. Quality Assurance (QA) findings. The QA organization performs audits and surveillances, and develops findings. Typically, the QA organization (or perhaps the offsite 

review committee or ISEG) performs periodic audits of the results of action taken to 

correct identified deficiencies affecting nuclear safety. The scope and findings of 

these audits may indicate the comprehensiveness and effectiveness of the 

licensee's corrective action process. 

The review of licensee corrective action related to QA activities may overlap with 

reviews required by Inspection Procedures 40702 and 40704. 

d. NRC inspection findings. The administrative section of most licensee technical 

specifications requires that the onsite committee address and deal with each 

violation identified as a result of an NRC inspection. 

e. NRC generic correspondence. Review of generic correspondence activities 
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involves review of the licensee's responses to NRC information notices, bulletins, 

and generic letters. 

f. Employee and other concerns. These concerns involve licensee responses to 

employee concerns that are raised outside the licensee's normal line organization. 

Some operating plants do not have a formal system for handling allegations and 

employee concerns, whereas other licensed facilities handle these concerns through 

an ombudsman or allegation process. In addition, regional Office Allegation 

Coordinators track and handle allegations made to the NRC. 

g. Industry operating experience. This experience involves the licensee's follow-up to 

operational problems in the industry. Licensees should have a process whereby 

events and discoveries, as well as good practices, experienced by other 

organizations are investigated for applicability to its plants and adapted as 

applicable for plant safety. Licensees should consider industry-wide operating 

experience when establishing goals for SSCs monitored under 50.65(a)(1) of the 

maintenance rule. The licensee should also review industry-wide operating 

experience when making adjustments to SSC preventive maintenance programs 

under 50.65(a)(3). 

h. Licensee maintenance rule monitoring and periodic evaluations. If licensees cannot 

demonstrate that the performance (or condition) of SSCs within the scope of the 

maintenance rule is being effectively controlled through preventive maintenance 

activities, they are required to monitor SSC performance (or condition) through goal 

setting and corrective action activities. Licensee periodic evaluations of the 

maintenance rule program may also contain assessments of corrective actions 

associated with maintenance activities. 

03.02 Investigation of Problems. Items selected for review should have been 

characterized as significant by the licensee. Criterion XVI of Appendix B to 10 CFR Part 50 

requires cause determination and corrective action to preclude repetition only for significant 

conditions adverse to quality. 

a. Requirements for reporting to the NRC are established in 10 CFR Parts 20, 21, and 

55; 10 CFR 50.72 and 50.73; and the licensee's technical specifications. 

b. Various licensee organizations performing activities that may impact plant safety 

may use individualized corrective action processes, or they may use a common, 

plant-wide process. Therefore, the inspection sample should include items from the 

various processes. When multiple corrective action processes exist onsite, the 

organizations' staffs should interact to ensure that all items for which corrective 

action needs to be performed, tracked, and trended are captured. The important 

questions are whether some process is implemented in all areas and whether the 

integrated process works effectively. 

c. The process for assigning priorities should focus on risk significance. 

d. The inspector should check that corrective action is taken in a timely fashion and 

that action is taken to prevent recurrence or occurrence of a similar or related 
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problem. Delinquent milestones should be receiving managerial attention. In 

addition, feedback on the corrective action should be provided to the initiator. 

e. The inspector should review the licensee's root-cause analysis of significant LER 

and plant operational events, including unplanned reactor trips and equipment 

failures, to determine the effectiveness and validity of the analysis. The root-cause 

analysis should identify primary causes and corrective action. In addition, the rootcause analysis should weigh the effect of generic problems on other equipment or 

systems. (The inspector should not avoid the pursuit of problems in the balance of 

plant when the analysis indicates the primary cause was in that area.) If permanent 

action to correct the problem takes an excessive amount of time, as in the case of 

significant plant modifications, for example, then interim action should be taken to 

control or minimize the problem until the permanent action can be implemented. 

03.03 Inspection of Programs (as necessary)

a. Ensure that each program has a level of review commensurate with the safety 

significance of the problems reported within it. 

b. Tracking data about quality and analyzing it for trends includes licensee 

identification of repetitive problems that are not readily apparent. This identification 

ensures that trends for repeated problems are developed, the data for them 

analyzed, and when necessary, improvements, replacements, and modifications to 

systems or equipment are made. In developing trends for quality, the licensee 

should consider the occurrence of problems that are related as well as those that 

are identical. Additionally, trends should not be exclusively for systems and 

equipment; trends can be invaluable to managers in identifying and correcting 

personnel performance issues. Communication of the results of trends to managers 

and these managers' involvement in resolving involved issues should also be 

considered. Developing trends for quality may involve any or all of the areas listed 

in Section 02.01 of this procedure. 

c-e No inspection guidance. 

92720-04 REFERENCES 

ANSI N18.7 - 1976 (As committed to by the licensee) 

ANSI N45.2 series standards (As committed to by the licensee) 

Facility Nuclear Quality Assurance Manual 

10 CFR Parts 20, 21, and 55 

10 CFR 50.55(e), 50.65, 50.72, and 50.73 

Criterion XVI of Appendix B to 10 CFR 50 
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Memorandum of February 14, 1986, from J. M. Taylor to Regional Administrators entitled, 

"NRC Use of Evaluation Reports." (NUDOCS accession No. 8602250196, microfiche No. 

68289/200) 

Inspection Procedure 71707, Operational Safety Verification 

Inspection Procedure 62706, Maintenance Rule 

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