Exelon Comments on 

Cross-Cutting Issue Review Recommendations and Lessons Learned 

Page 1 of 20 

Cross-Cutting Issue Review Recommendations and Lessons Learned 

CI-1. The regions should be encouraged to 

consider conducting inspection debriefs which 

involve both reactor divisions with attendance 

including staff as well as management. Several 

regions have or are considering expanding their 

inspection debriefs. 

Cl-1. Agree 

CI-2. Revise IMC 0612 to provide additional 

guidance and examples for assigning and 

documenting crosscutting aspects. 

CI-2. We agree in general with this 

recommendation, with the following 

comments: 

While providing guidance and examples for 

assigning and documenting cross-cutting 

aspects appears prudent, we believe that 

more substantial guidance and training is 

required to ensure consistency in application 

of the guidance. 

Cross-cutting aspects are frequently issued 

without a final cause analysis due to timing of 

the inspection report issuance, resulting in 

conclusions that may be different from the 

licensee conclusion. This should be 

addressed in the guidance. . 

Guidance should clarified to stress that crosscutting aspects should be assigned to items 

that are a “significant contributor” (see MC 

0305 and MC0612 Appendix F). Frequently, 

aspects are assigned that are only 

tangentially associated with the condition and 

no clear definition of “significant” exists. 

Inconsistent Regional expectations contribute 

to some inspectors assigning cross-cutting 

aspects to all findings and violations, which 

we believe is not warranted. 

We agree with the proposal to clarify the 

guidance for “indicative of current 

performance.” 

We do not support the recommendation to 

require inspectors to document why a crosscutting aspect was not assigned. A simple 

statement that no cross-cutting aspect was 

assigned is sufficient. 

CI-3. NRR should continue their process of 

providing periodic refresher training to staff on 

IMC 0612 and 0305 as changes are made. 

IMC040 No changes needed. 

CI-3. Agree. Industry experience during 

supplemental inspections (95002) supports 

the recommendation that additional staff 

training on 0612 and MC 0305 is warranted. 
Exelon Comments on 

Cross-Cutting Issue Review Recommendations and Lessons Learned 

Page 2 of 20 

CI-4. Clarify that a crosscutting theme needs to 

involve 2 four or more inspection findings with 

the same crosscutting aspect (should not look 

for sub-cross-cutting aspects). (IMC0305 Inprogress) 

CI-4. Greater clarity is needed on this 

recommendation. The term “sub-cross-cutting 

aspect” is not defined in ROP guidance. The 

NRC inspectors should be following the 

guidance in MC 0305. Clarification regarding 

what an aspect is may be required to MC 

0305 through revision and/or training. 

CI-5. Identified redundancy in the first two 

criteria for a substantive cross-cutting issue in 

the problem identification and resolution and 

human performance cross-cutting areas. 

(IMC0305 In-progress) 

Cl-5. Agree. 
Exelon Comments on 

Palo Verde Lessons Learned Recommendations 

Page 3 of 20 

Palo Verde NRC Lessons Learned Recommendations 

PV-1. Consideration should be given to 

considering all 13 safety culture components 

during implementation of the baseline 

program. Additional criteria should be 

established for when to consider a crosscutting theme for the safety culture 

components of accountability, continuous 

learning environment, organizational change 

management, and safety policies. (IMC 0305 

In progress, working to incorporate the other 

safety culture components as crosscutting 

components.) 

PV-1. Disagree. The safety culture 

components in MC 0305 that are not currently 

in the cross-cutting components are subjective 

and much more difficult to evaluate in the 

context of individual findings and will result in 

significant subjectivity if utilized. The current 

guidance requires inspectors to use the 

licensee’s causal evaluations to assign crosscutting aspects; however these components are 

not typically evaluated in causal evaluations. 

The addition of safety culture components to 

the baseline program also has the potential to 

mask trends/insights associated with the 

effectiveness of the new safety culture 

provisions of the ROP (< 2 years in service). 

Significant stakeholder dialogue would be 

warranted on the related aspects to be 

developed. 

Originally, the staff concluded that the baseline 

could not assess these additional safety culture 

components. Therefore, it is not clear what the 

basis is for the staff's change in position relative 

to the ability of staff to assess the additional SC 

components as part of the baseline. 

PV-2. Consider revising IMCs 0305 and 0612 

to allow inspectors to assign multiple crosscutting aspects for each safety culture related 

cause associated with a performance 

deficiency. If the result is an increase in the 

number of cross-cutting aspects, then MC 

0305 should be revised to raise the criteria to 

satisfy the requirements for a substantive 

cross-cutting issue. In addition, for sites with 

multiple units, consideration should be given to 

raising the criteria to satisfy the requirements 

for a substantive cross-cutting issue. (IMC 

0612, IMC 0305 Not adopting this 

recommendation. Reinforcing existing 

flexibility to only assign multiple crosscutting 

aspects for unusual or complex issues.) 

PV-2. The assignment of multiple cross-cutting 

aspects should not be permitted. However, we 

agree that MC 0305 should be revised to raise 

the criteria for substantive cross-cutting issues 

based on the changing implementation of the 

program that has resulted in an increased ratio 

of findings and violations that are receiving 

cross-cutting issues. 
Exelon Comments on 

Palo Verde Lessons Learned Recommendations 

Page 4 of 20 

Palo Verde NRC Lessons Learned Recommendations 

PV-3. Cross-cutting safety culture issues 

challenge the ability of the NRC to reach 

accurate risk informed decisions and provide 

an appropriate level of regulatory oversight. 

Consideration should be given to evaluating 

and developing more assertive NRC actions 

(such as a direct input to the ROP action 

matrix) for repetitive or certain types of multiple 

substantive cross-cutting issues. 

IMC 0305 (In-progress, working to slightly 

modify NRC regulatory responses to a 

repetitive substantive crosscutting issue. No 

changes are proposed to the ROP Action 

Matrix inputs.) 

PV-3. Agree with the staff's position not to 

incorporate SCCIs into the action matrix. 

However, it is not clear what the staff's intent is 

relative to the Status comment "Working to 

slightly modify NRC regulatory responses to a 

repetitive SCCI.” Additional dialogue on this 

change is needed. 

PV-4. Consideration should be given to 

providing additional guidance in IMC 0609 on 

the acceptable methods to be used to assess 

the additional risk impact of findings with 

underlying causes that are associated with the 

safety culture components. IMC 0609, IMC 

0305, IP95003 (In-progress, working on 

amplifying the guidance.) 

PV-4. The staff should more clearly convey its 

intent relative to IMC 0609. However, an event 

has a finite risk value associated with it and the 

cause does not change that risk. The risk 

impact of a finding should be restricted to the 

quantifiable impact as measured by standard 

PRA methods. 

PV-5. Consideration should be given to adding 

specific guidance in IP 95003 that describes 

the acceptable method to be used to perform 

the cumulative risk assessment. IP 95003 (Inprogress working on amplifying the guidance.) 

PV-5. Does not appear to have explicit criteria. 

To provide a meaningful comment we need to 

better understand the intended modifications. 

Additional dialogue on this change is needed. 

PV-6. Consideration should be given to 

revising IP 95003 to include an allowance to 

validate the results of the licensee’s root cause 

investigation in lieu of the NRC performing a 

separate root cause investigation. The NRC’s 

completion of this activity should only occur if 

the licensee’s investigation is determined to be 

incomplete. IP 95003 (In-progress.) 

PV-6. Although we agree in theory, the 

practicality of this may be much more difficult in 

that NRC would be required to perform some 

level of an independent causal determination to 

achieve this. The methodology and required 

detail of this evaluation should be documented 

and transparent to external stakeholders and 

the conclusions should be repeatable 

regardless of who performs the causal 

determination. 

PV-7. Consideration should be given to 

describing root cause analysis tools other than 

MORT that could be used to complete the 

collective review of the root causes. 

Additionally, it may be necessary to add a root 

cause specialist to the team to complete the 

review. IP 95003 (In-progress.) 

PV-7. Agree. MORT is not the only valid root 

cause methodology. However, the reason for 

choosing a methodology should be documented 

sufficiently to ensure that the conclusions are 

repeatable regardless of who performs the root 

cause. 

PV-8. The NRC should consider partnering 

with industry in an effort to develop a 

standardized safety culture assessment 

process and tools, including a survey. 

IMC 0305 (IP95003 Considering this item.) 

PV-8. This recommendation is contrary to 

Commission direction in an SRM (SRM-SECY04-0111). The SRM directed the staff to not 

conduct surveys of licensee personnel. 

However, the NRC and the industry should 

develop a standardized safety culture 

assessment process and tools, which may 

include a standard survey that could be used by 

the licensee. 
Exelon Comments on 

Palo Verde Lessons Learned Recommendations 

Page 5 of 20 

Palo Verde NRC Lessons Learned Recommendations 

PV-9. Until an industry/NRC accepted 

standard is developed, the NRC should 

perform an independent detailed analysis of 

the survey tool and analytical techniques when 

evaluating a licensee’s safety culture 

assessment. IP 95003 (In-progress, intend to 

retain elements to validate licensee safety 

culture assessment methods.) 

PV-9. Disagree. The NRC should be 

concerned with the analysis results and whether 

a qualified person/organization performed the 

assessment. Review and approval of the 

survey tool and analytical techniques, while 

important for the NRC to understand, puts the 

NRC in a consultant/management role that is 

inappropriate. 

PV-10. Consider revising IP 95003 to provide 

the flexibility to initiate a variety of inspection 

responses consistent with the performance 

deficiencies at a particular facility. This should 

include an evaluation of the existing IP 95003 

boundary conditions. IP 95003 (In-progress, 

working to provide flexibility for site situations.) 

PV-10. We believe NRC already has this 

flexibility. Therefore, it’s not clear why this 

change is being made. Additional dialogue on 

this change is needed. 

PV-11. Consider revising IP 95003 to include 

an assessment of outage activities. IP 95003 

(In progress, plan to amplify outage coverage 

and sensitivity of the outage inspection burden 

on licensee.) 

PV-11. This assessment should only be called 

for if the findings(s) that resulted in the 

degraded cornerstone or their underlying 

cause(s) have a clear link to outage activities 

that cannot be assessed during non-outage 

periods. Inspections, especially those that 

require interviews or significant data requests, 

can be disruptive during outages and should be 

minimized. 

PV-12. Consider revising IP 95003 to treat the 

activity as a fact finding to understand the 

depth and breadth of performance concerns. 

This includes the potential for greater use of 

unresolved items. IP 95003 (In-progress, 

working to amend inspection approach.) 

PV-12. The NRC should more clearly convey 

its intent relative to the term "fact finding." It is 

not clear on what would constitute a “fact 

finding” nor is it clear how the greater use of 

unresolved items would help in the 

assessments. 

We agree in principle that it is desirable to 

expeditiously complete the 95003 inspection 

and not let lower level issues delay closure of 

the findings and causes that resulted in the 

need for a 95003 inspection. However, the 

potential for large numbers of unresolved items 

could be significant, thereby leading to open 

items for a significant period of time. Every 

attempt should be made to resolve the items 

during a 95003 inspection. Otherwise, specific 

controls should be in place so that the items do 

not linger. 

Additional dialogue on this change is needed. 

PV-13. Consideration should be given to 

establishing and assessing precursors as part 

of the baseline inspection program. These 

precursors should be assessed as part of the 

IMC 0305 assessment process. (IMC 0305 Inprogress, looking at correlation of safety 

culture components with qualitative 

precursors.) 

PV-13. The NRC should more clearly convey 

its intent relative to "assessing precursors." 

The ROP is founded on objective criteria for 

determining the level of oversight. Including 

precursor information will re-inject another 

element of subjectivity into the assessment 

process. 

Additional dialogue on this change is needed. 
Exelon Comments on 

Palo Verde Lessons Learned Recommendations 

Page 6 of 20 

Palo Verde NRC Lessons Learned Recommendations 

PV-14. Consideration should be given to 

developing innovative methods to assess the 

effectiveness of inspection program 

implementation. IMC 0307 (Under 

consideration.) 

PV-14. The NRC recently completed an effort 

for ROP alignment to assess and make 

changes to the current baseline inspection 

program. Additional dialogue will be needed to 

convey what the purpose and direction of this 

suggest change is. 

PV-15. Consideration should be given to 

permanently changing the resident inspector 

staffing requirements at three unit sites to 

ensure an appropriate level of oversight is 

maintained. (For a 3 Unit Site: 1 - Senior 

Resident Inspector, 3 - Resident Inspectors) 

IMC 0102 (Under consideration.) 

PV-15. Although we agree that an appropriate 

level of oversight is maintained is only prudent, 

we do not agree that four inspectors at a threeunit site is always the “appropriate level,” 

absent any justification on why this change is 

needed. 

PV-16. Consideration should be given to 

providing additional guidance to supervisory 

and management personnel for the conduct of 

management site visits at facilities where only 

a few findings have been identified. IMC 0102 

(Under consideration.) 

PV-16. The NRC should more clearly convey 

why this level of oversight would be warranted 

for sites with only a few findings identified. This 

recommendation is not clear regarding the 

purpose or the direction management site visits 

would take. 

Additional dialogue on this change is needed. 

PV-17. Consideration should be given to 

adding one FTE per region to focus on initial 

and continuing training needs of the inspection 

staff. IMC 0102 (Under consideration.) 

PV-17. Agree, assuming there is clear 

evidence that shows inadequate training 

resulted in inspectors failing to identify issues. 

However, without this evidence the NRC has a 

responsibility to limit unnecessary spending. 

PV-18. Consider revising IP 95003 to require 

implementation of the EP attachment and 

having an EP inspector from another regional 

office perform the attachment. IP 95003 

(Under consideration.) 

PV-18. Disagree. Additional inspection in an 

area that may or may not be a legitimate part of 

the scope creates unnecessary cost, 

paperwork, and time with no relationship to the 

inspection being performed. If the NRC has a 

particular concern about the EP area, we 

believe it should be pursued in another manner 

and not automatically included in IP 95003 

inspections. 

PV-19. Consideration should be given to 

evaluating the implementation of the EP 

baseline inspection program. IP 95003 (Under 

consideration.) 

PV-19. Although there may be some 

redundancy between inspections and 

performance indicators that could be eliminated, 

the intent and purpose for this change is not 

clear. Additional dialogue on this change is 

needed. 

PV-20. IP 95003 boundary conditions (1, 3, 

and 5) should be reevaluated. For condition 1, 

consider adding flexibility to allow the NRC to 

oversee independent inspections performed by 

a third party. Review consistency with having 

an independent third-party assess the 

licensee’s safety culture. For condition 3 

consider a revision to increase the flexibility of 

the procedure by allowing the use of 

unresolved items and a separate follow-up 

inspection to resolve the technical concerns 

(defer significance determination process 

evaluation). For condition 5 consider a 

PV-20. 

Boundary Condition 1

We agree with the proposed change to 

boundary condition 1 assuming that oversight 

does not include an independent validation of 

the methodology used. 

Boundary Condition 3

We disagree with the proposed change to 

boundary condition 3. Neither the increased 

use of URIs nor the delay of an SDP should be 

encouraged. 
Exelon Comments on 

Palo Verde Lessons Learned Recommendations 

Page 7 of 20 

Palo Verde NRC Lessons Learned Recommendations 

revision to increase the flexibility of the 

procedure by considering the implementation 

of portions of the inspection procedure before 

the licensee has completed their third party 

safety culture assessment and root cause 

evaluation in order to promptly assess the 

depth and breadth of potential problem areas. 

Additionally, consider a revision to allow for 

periodic NRC assessments during the 

performance of the licensee’s root cause 

analysis and third-party safety culture 

assessment. IP 95003 (In-progress.) 

Boundary Condition 5

We agree in part with the proposed change to 

boundary condition 5. The IP 95003 should not 

take place prior to the completion of the root 

cause analysis, although portions of the 

inspection could be completed before the thirdparty safety culture assessment. 

PV-21. IP 95003-02, Inspection Requirements, 

indicates that if the IP 95001 and IP 95002 

supplemental inspections have not been 

performed, then the IP 95003 should include 

an assessment of the licensee’s evaluation of 

those issues. A revision should be made to 

note that the licensee’s evaluation of the IP 

95001 and 95002 issues may not be complete 

at the time of the IP 95003 inspection. If so, 

the review of these issues should be included 

in the Confirmatory Action Letter. IP 95003 Inprogress. 

PV-21. We strongly believe that an adequate 

IP 95003 inspection cannot be completed 

without an evaluation of the licensee’s ability to 

complete the 95001 and 95002 issues. 

PV-22. Almost all of the inspection 

requirements in IP 95003 are performed as 

part of the baseline inspection program. 

However, IP 95003 indicates that a duplication 

of inspection efforts should not occur. A 

revision should be made to delete a statement 

in IP 95003 to prevent duplication of other 

inspection efforts. IP 95003 In-progress. 

PV-22. Agree. Duplication of inspection efforts 

is unwarranted and is an irresponsible use of 

resources that could be better served to focus 

on efforts that have not been previously 

inspected. However, reference to the 

applicable inspection report would suffice to 

adequately document that the area was in fact 

inspected. 

PV-23. To more efficiently integrate safety 

culture and inspection results, it may be more 

appropriate to embed some safety culture 

components in the key attributes. The 

additional safety culture component 

assessments should focus on those areas 

where implementation of the inspection 

program yields limited results. For example, 

most problem identification and resolution 

aspects can be evaluated using traditional 

inspection program techniques. Therefore, 

limited safety culture assessment interviews 

and focus groups are needed to assess this 

area. IP 95003 In-progress. 

PV-23. The key attributes in most cornerstones 

already contain aspects that are either very 

similar to the safety culture components or are 

identical. 

This purpose or the intent of this 

recommendation is not clear. Additional 

dialogue on this change is needed. 
Exelon Comments on 

Palo Verde Lessons Learned Recommendations 

Page 8 of 20 

Palo Verde NRC Lessons Learned Recommendations 

PV-24. The requirements and guidance in 

section 02.07 for conducting the safety culture 

portion of IP 95003 should be re-evaluated. If 

the NRC determines that the licensee’s thirdparty assessment was appropriate, then there 

should be no need to conduct an independent 

assessment of all 13 safety culture 

components. The NRC’s assessment should 

determine which, if any, of the 13 components 

have not been adequately addressed by the 

third-party assessment and which, if any, of 

the components are not likely to be addressed 

by the IP 95003 key attributes. The 

NRC should then implement safety culture 

assessment activities to address the remaining 

components that are expected to have 

insufficient data to meet the objectives. IP 

95003 In-progress. 

PV-24. Industry agreed to take the lead in 

development of NEI/Industry guidance to 

address safety culture assessment content and 

quality. 

PV-25. Re-evaluate sections 02.07 and 02.08 

to only include the specific inspection 

requirements. All other items should be 

moved to the guidance section. IP 95003 Inprogress. 

PV-25. Agree. 

PV-26. Section 95003-03 for just-in-time 

training should be better designed to meet the 

needs of the inspection teams. The training 

should include, in part, performance issues at 

the facility, root cause refresher training, 

administrative issues, and the conduct of the 

inspection. IP 95003 In-progress. 

PV-26. Agree 

PV-27. Regarding team staffing, a qualification 

program for safety culture assessors should be 

institutionalized in a manual chapter. Each 

region should be expected to maintain a cadre 

of Level 2 safety culture assessors that are 

capable of implementing most of the IP 95003 

inspection requirements. Validation of thirdparty safety culture assessment tools and 

methods requires an additional skill set, and 

can be performed by headquarters personnel 

or contractors. These skills may not be needed 

in every case if the NRC and industry develop 

and implement a standardized safety culture 

assessment tool and process. 

IMC TBD Under consideration. 

PV-27. The extensive resource commitment, 

given that Column 4 plants are rare, seems 

unwarranted and not a responsible use of 

resources. We recommend the focus be on the 

skills, knowledge and training required for 

inspectors to be able to make sound, 

responsible decisions in this area. 
Exelon Comments on 

Palo Verde Lessons Learned Recommendations 

Page 9 of 20 

Palo Verde NRC Lessons Learned Recommendations 

PV-28. At a minimum, a senior reactor analyst 

should be required to participate in the final 

onsite inspection week in order to collect all of 

the data needed to perform a collective risk 

assessment of the performance deficiencies 

and assist in collecting the data necessary to 

evaluate potentially significant inspection 

findings. The most desirable option would be 

to have a senior reactor 

analyst lead one of the sub-groups and 

perform the analyst functions as a collateral 

responsibility. IP 95003 Under consideration 

PV-28. We agree in that the NRC should 

ensure the team is comprised of the personnel 

needed to perform a collective risk assessment. 

However, depending on the circumstances 

surrounding the IP 95003, this may or may not 

require a senior reactor analyst and may take 

more or less than a week. This decision needs 

to be made on a case-by-case basis to 

responsibly address the issues and focus the 

appropriate resources. 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 10 of 20 

Page 2 General comment: It is not clear that the enclosures could be used as 

part of other inspections, such as IP 711152 review of a safety culture 

assessment or review of a safety culture survey outside of the 95003 

process. 

Page 2 Item 1: Rephrase as "The NRC is performing the inspection, which 

involves a graded approach to assess the licensee's safety culture. The 

scope of the inspection requirements related to safety culture will be 

based on an evaluation of the licensee’s third party safety culture 

assessment and root cause evaluation." 

Page 2 Item 3: We agree in principle that it is desirable to expeditiously complete 

the 95003 inspection and not let lower level issues delay closure of the 

findings and causes that resulted in the need for a 95003 inspection. 

However, the potential for large numbers of unresolved items could be 

significant, thereby leading to open items for a significant period of time. 

Every attempt should be made to resolve the items during a 95003 

inspection. Otherwise, specific controls should be in place so that the 

items do not linger. 

Page 2 Item 5: The first sentence stipulates that the licensee is expected to have 

completed the associated root cause evaluation and third party safety 

culture assessments. This conflicts with the second sentence that 

indicates the 95003 assessment can be conducted in parallel with such 

licensee evaluations. Recommend deleting the second sentence. 

Page 3 Section 95003-02 should be re-written to include cases where a single 

red finding moved the licensee to column 4. In addition, the 95001 and 

95002 inspections should not be deferred but should be included as part 

of the 95003, or performed prior to the 95003 inspection. Inputs as 

significant as 95001 or 95002 inspections can be performed prior to or 

concurrent with the 95003 but must not be excluded from the 95003 

scope or performed after the 95003 has been completed. 

Page 5 Item 02.03.a.1(a): Guidance should be provided for determining the time 

period for performance information to be collected. A maximum period of 

five years is recommended. This provides sufficient context for current 

performance issues and ensures that data requests are reasonable. This 

would also minimize recurrence of enormous data requests like Palo 

Verde's 95003 inspection, where more than 5000 documents were used 

by the inspection team. 

Page 15 Item 02.07.a.4: This step (and any other seeking information on previous 

safety culture assessments) should reflect that INPO assesses safety 

culture and a memorandum of agreement between NRC and INPO 

should be referenced for guidance on use of INPO material during NRC 

inspection activities (reference ML060060035 and letter from S. Richards 

(NRC) to L. Gard (INPO) dated March 27, 2007). 

Page 15 Item 02.07.b.2(b): Reword to reflect the typical role of corporate senior 

management – governance and oversight, rather than being responsible 

for plant operation. 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 11 of 20 

Page 17 Item 02.11: Is the intent to restrict distribution of this separate report so 

that it is not disclosed to the public? If so, what is the rationale for this 

position? 

Page 17 Second paragraph under General Guidance: Same comment as page 2, 

item 3 

Page 17 Third paragraph under General Guidance: This assessment should only 

be called for if the findings(s) that resulted in the degraded cornerstone or 

their underlying cause(s) have a clear link to outage activities that cannot 

be assessed during non-outage periods. Inspections, especially those 

that require interviews or significant data requests, can be disruptive 

during outages and should be minimized and not automatically included. 

Page 18 General comment for Team Staffing: Remove the collateral duty of the 

team leader to brief public officials, since this duty is more appropriate for 

the "team manager." The team leader should be determining the 

regulatory basis for inspection issues, which would preclude the need to 

issue URIs as contemplated in this draft. 

(Page 18) Team Staffing, 1st paragraph. Suggest changing the word “opinion” to 

“perspective.” 

Page 18 First paragraph under Team Staffing: The inspection team is required to 

be staffed with "qualified" Safety Culture Assessors, yet no such 

qualification exists under NRC IMC 1245. 

Page 18 Fifth paragraph under Team Staffing: This paragraph refers to 

"specialized training" for safety culture assessors, but does not describe 

such training. Significant leadership and management experience is 

equally as important for an effective safety culture assessment as 

experience and training, yet IP 95003 is silent in this regard. Further, 

documentation of staff qualifications to such specific requirements is not 

contained in IP 95003 reports. 

Page 19 First paragraph: The need for the lead safety culture assessor to have 

formal education in the social/behavioral sciences and experience in 

conducting organizational assessment activities is characterized as 

important, yet the NRC has found several third-party assessments of 

safety culture to be satisfactory without team members with such 

qualifications. Equally as important as experience and training to perform 

an effective safety culture assessment is significant leadership and 

management experience, yet IP 95003 is silent in this regard. 

Page 19 Second paragraph: Clarify requirements for safety culture assessors. 

Page 18, fifth paragraph referred to "specialized training," the first 

paragraph on page 19 calls for formal education and experience, and this 

paragraph refers to "appropriate credentials." Recommend that the 

expectations for safety culture assessors be located in a single section 

and referred to in a consistent manner. 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 12 of 20 

Page 19 Third bullet: The ability to conduct content analyses or written and verbal 

communication is called for; however, it is not clear that IP 95003 

provides a structured approach for conducting such analyses. 

Page 20 First bullet calls for knowledge of theories of safety culture; without 

specific expectations, this is ambiguous. 

Page 20 First paragraph under Inspection Planning and Logistics: This last 

sentence is inconsistent with other changes proposed by this draft. The 

last sentence discusses the licensee's formal acknowledgment of 95003 

readiness, including completion of root cause analysis and third party 

safety culture assessments; however, this draft contemplates that the 

95003 inspection could be conducted in parallel with these assessments. 

Except in rare cases, the licensee’s root cause should be completed prior 

to the 95003 inspection. 

Page 20 Third paragraph under Inspection Planning and Logistics: Same 

comments as page 20, first paragraph. How does a licensee 

acknowledge readiness when the NRC may elect to perform the 95003 

inspection in parallel with the root cause analysis and third party safety 

culture assessment? 

Page 39 Second paragraph under Item 1: Recommend deleting the reference to 

staff reduction in the 1990s since it adds no value to the inspection 

guidance for current conditions. 

Page 52 Section 03.07: Please clarify what is meant by “no specific guidance” in 

Item a.2 of this section. 

Page 54 Items 03.07.b.2(c)(1) and 03.07.b.2(c)(2): The basis for acceptable 

participation levels is not clear. If licensees are expected to achieve such 

numbers, the basis should be defined. 

Page 54 Item 03.07.b.3(a): The connection between the adequacy of data 

collection and analysis methods and potential to identify the source is not 

apparent. If the data is sound and properly connected, it should be 

adequate. Disclosure would not be appropriate, but it should not render 

the data collected suspect. 

Page 55 Item 03.07.b.3(f): There are no industry-wide "acceptable survey 

practices." The NRC's inspection guidance imposes standards that add 

to the costs of such surveys without a clear basis for the practice. The 

NRC is precluded from conducting independent surveys. It seems that 

licensees will also conclude surveys are not advantageous due to the 

cost and level of difficulty in complying with "acceptable survey practices." 

Page 55: Item 03.07.b.4(b): Guidance for assessing third party safety culture 

assessors ambiguously refers to qualification through "education and/or 

experience." This requires further clarity for industry to understand the 

expectations. For example, education is discussed, but no clear 

expectation is provided. "Knowledge and experience" are better terms 

when referencing team members since qualifications implies a more 

rigorous process than currently established in the industry. This is an 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 13 of 20 

important point since the level of NRC graded approach will, in part, 

depend on "qualifications" of the third party safety culture assessment 

team (reference page 56, item 03.08.a). 

Page 56 Second paragraph under Item 03.08.a: The last sentence reflects that 

satisfying NRC concerns with the third party safety culture assessment 

will adjust the scope and depth of the NRC's graded approach. 

Recommend deleting this sentence since it may impose undue pressure 

on the third party to accept NRC comments in order to minimize the NRC 

inspection impact on the licensee. 

Page 57 Item 03.08.a.3(a): The paragraph talks about low response rates – is this 

in reference to survey participation? Also, it directs the NRC to look at 

licensee response, such as conducting additional assessment activities. 

Is this referring to additional third party assessment activities or licensee 

efforts outside of the third party assessment? 

Page 59 Item 1: The connection between accuracy of communication of third 

party safety culture assessment results and health of a licensee's safety 

culture is unclear. The more pertinent subject would seem to be licensee 

response (i.e., corrective actions to close gaps) to the assessment. 

Page 59 Item 2(b): The term "behavior" is not in the NRC's definition of safety 

culture, but it does provide a key aspect to the meaning of safety culture, 

as recognized by the INPO definition. Consider adopting the INPO 

definition or adding "behavior" to the NRC definition (Attachment 

95003.02). 

Page 60 First bullet under Item 3: Change "licensee's" to "third party assessment 

team's" 

Page 60 First paragraph after the four bullets: Change "licensee's results" to "third 

party assessment team's results" in the first sentence. If additional 

assessment activities are conducted by the licensee, must they be by a 

third party? 

Page 61 Third paragraph under Item 03.10: Delete this paragraph. See previous 

comments under page 2, item 3 and page 17, second paragraph. 

Page 62 First paragraph: Use of URIs should not be endorsed in this manner. 

See previous comments. 

Page 62 Second paragraph: The first sentence needs correction. It implies that a 

cross-cutting aspect is required for each finding and cross-cutting aspects 

are assigned to URIs, which is not currently in IMC 0612. 

Page 64 The resource estimate is not aligned with the expectations in the body of 

IP 95003. For example, p. 18 of IP 95003 says at least one SRA should 

be assigned full time to the team, which would significantly exceed the 

estimated 0 – 40 man hours. 

Page 65 Add attachment header and title. 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 14 of 20 

Page 65 First and second paragraphs under Introduction: These paragraphs refer 

to behaviors as they pertain to safety culture, yet this term is not in the 

NRC's definition of safety culture. Recommend adopting the INPO 

definition or revising the NRC definition accordingly. 

Page 65 Last two bullets on the page (and first bullet on page 66): NRC attempts 

to quantify number of occurrences of behaviors to evaluate safety culture. 

What research is this nexus to safety culture based on and how many is 

an acceptable number before a concern exists regarding safety culture? 

Recommend deleting reference to frequency and focus on the behavior 

itself. 

Page 67 Item c.(2): Reword the main item and its sub-bullets to reference safety 

culture assessments rather than safety culture components, since the 

components of safety culture encompass virtually every aspect of nuclear 

operations. This would essentially be requesting every self or third party 

assessment. Also, the reference to assessments of "organizational 

factors" is unclear. What is the information being requested? 

Page 67 Item c.(4): The last sentence references "the guidance," but it is unclear 

what this means. 

Page 67 Item c.(5): Site financials and budgets are compared to what measurable 

standard? At what pre-defined point does this become a regulatory 

concern? 

Page 67 Bullet (2), leadership assessments. An NRC review of individual 

performance appraisals, even with names removed is inappropriate. 

There are privacy and confidentiality considerations that could put a 

licensee in a difficult legal situation. The NRC should review a process 

description of the job performance policy and process. 

Page 68 This section discusses reviewing corporate strategies and meeting 

minutes from site senior management meetings. These are inappropriate 

for NRC review and it is not clear how NRC would assess any information 

from these items in a meaningful, consistent way. 

Page 68 Item (8): Requesting all CAP documents that relate to safety culture 

components is too broad since essentially all conditions adverse to quality 

can be bucketed into one or more of the safety culture components. If the 

intent is to request a list of all CAP items for the last year, it could simplify 

the data request and eliminate confusion. 

Page 69 Item 2.a: Sampling plans should be included as attachments to the 

95003 inspection report. 

Page 69 Item 2.d: The reference to "performance deficiencies" is not clear. Is this 

referring to performance deficiencies per NRC IMC 0612? If so, this is 

already a requirement so IMC 0612 should be referenced. If it means 

something else, additional clarity is requested. 

Page 70 First bullet: Why call out security? Previous similar statements did not 

reference security (see 02.07.b.2(a) as an example). 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 15 of 20 

Enclosures A through F No changes to Enclosures A through F were identified by 

the NRC's efforts to capture lessons learned from Palo 

Verde's 95003 inspection. The NRC should re-engage 

those who developed the Palo Verde lessons learned to 

seek improvements from implementing these enclosures. 

Enclosure A, page E-A-8 The last two requirements on the page specify INPO 

documents as the source material. Please refer to the 

memorandum of agreement between NRC and INPO for 

guidance on use of INPO material during NRC inspection 

activities (reference ML060060035 and letter from S. 

Richards (NRC) to L. Gard (INPO) dated March 27, 2007) 

and revise these requirements accordingly. 

Enclosure B, page E-B-2 Item 1 under Continuous Learning Environment: The 

question calls for the interview to draw comparisons to 

other plants. Page 55 cautions the inspectors against 

using industry data. A significant amount of additional data 

would be required to fully understand the comparison and 

put it into context (e.g., age of workforce could have a 

substantial influence on amount of training. 

Enclosure B, page E-B-2 Item 3 under Continuous Learning Environment: The last 

two sentences should be reworded since they can bias the 

interviewee. The error is stated to have a negative impact 

on business and then the interviewee is asked about their 

willingness to report, which can lead to a natural reluctance 

to accurately answer the intent of the question. 

Enclosure B, page E-B-2 Item 5 under Continuous Learning Environment: This 

question calls for the interviewee to speculate what other 

departments have done. Should be deleted or redirected 

to the interviewee’s direct experiences. 

Enclosure B, page E-B-3 Item 3 under Corrective Action Program: The question 

about anonymous CRs is biased and leads the interviewee 

to believe that this is a feature desired or expected by the 

NRC. Should be rephrased to "How do you identify 

concerns when you want to remain anonymous?" The last 

sentence concerning the Employee Concerns Program 

(ECP) is ambiguous and should be deleted since the ECP 

is discussed in the Environment for Raising Concerns

section. 

Enclosure B, page E-B-3 Item 7 under Corrective Action Program: The question 

should be directed towards issues raised by the 

interviewee, since it calls for speculation otherwise. 

Enclosure B, page E-B-4 Item 16 through 18: These questions are better suited for 

the CAP process owner than the general plant population. 

Rephrase to make the questions more pertinent to an 

interviewee. 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 16 of 20 

Enclosure B, page E-B-5 Item 1: This item in its entirety needs to be reworded. It is 

biased and infers that schedule pressure is not in the best 

interest of nuclear safety. Schedules are developed to 

maximize safety system availability and minimize plant 

risk. Delaying return to service of an important safety 

system should cause significant reaction by the 

organization, yet this inappropriately implies that this is a 

negative reaction. 

Enclosure B, page E-B-5 Item 3: Delete "to continue operation" in the first sentence. 

This can cause confusion between the role of the 

interviewee and the role of the licensed operator and it 

adds no value to the context of the question. 

Enclosure B, page E-B-6 General comment on Environment for Raising Concerns: 

In part, this section seeks to understand if events have 

chilled the work environment. This is a very difficult area to 

accurately assess in a manner that does not bias the 

interviewee. For example, the specific event could be a 

procedure violation that was self-identified and the 

individual involved was disciplined. One perspective would 

be that the discipline makes the interviewee hesitant to 

self-report, yet accountability for our actions is a 

fundamental behavior inherent to a strong safety culture. 

Recommend some additional cautions and perhaps "do's 

and don'ts" to assist the inspector in obtaining meaningful 

insights in this area. 

Enclosure B, page E-B-7 Item 7: Delete "policy" since this is a leading question and 

infers that a policy is needed or required. Some stations 

may not have such a policy. 

Enclosure B, page E-B-7 Item 8: This question should end with "If yes to any of 

these questions, please explain." 

Enclosure B, page E-B-7 Item10: Why is it important for the interviewee to know the 

training taken by the supervisor? The more appropriate 

focus would be the actual behaviors of the supervisor. 

Enclosure B, page E-B-7 Item 12: Rephrase as "What actions do managers and 

supervisors take to maintain or improve SCWE? Are these 

actions effective? Why or why not?" As written, it leads 

the interviewee to conclude the actions were historical, 

tending to infer that these actions must have been in 

response to a SCWE problem. 

Enclosure B, page E-B-7 Item 2: Same comment as item 2 on page E-B-6. 

Enclosure B, page E-B-8 Items 4 and 6: When the term "safety" is used, most 

interviewees respond to the question as if it asks about 

"industrial safety." Is that the intent of the question? 

Recommend using the term "nuclear safety" to clarify. 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 17 of 20 

Enclosure B, page E-B-8 Item 8: Rephrase the question concerning advertising an 

appeal process to "How were you made aware that this 

process existed?" since most interviewees will not have 

responsibilities for advertising such a process. 

Enclosure B, page E-B-8 Item 9: Is the parenthetical question intended to be 

asked? Asking management to recall survey results does 

not appear to be pertinent to this area. Could be 

rephrased as "Are you aware of any concerns with the 

ECP/Ombudsman programs? If so, please describe." 

Enclosure B, page E-B-8 Item 10: This question is more applicable to those who 

oversee contractors. Delete "policy" since this is a leading 

question and infers that a policy is needed or required. 

Some stations may not have such a policy. Recommend 

replacing the first sentence with "Do you oversee 

contractors? If so, ..." 

Enclosure B, page E-B-8 Item 12: Replace "made available" with "communicated" 

since this infers documented results must be provided. 

Communication can take written or verbal form. 

Enclosure B, page E-B-9 Item 4: Delete the parenthetical "without having to wade 

through everything" since it is biased. 

Enclosure B, page E-B-9 Item 7: Replace "would you have liked to see" with 

"should have." The intent is to determine if something 

important received less than the appropriate amount of 

attention rather than invite the interviewee to speculate on 

their personal preferences. 

Enclosure B, page E-B-10 Item 7 under Organizational Change Management: This 

question implies that the common practice of "acting" 

managers is undesirable. The use of "acting" managers 

can be an effective tool for employee development and 

succession planning. The intent of the question should be 

refocused on prolonged vacancies and high turnover rates. 

Enclosure B, page E-B-10 Item 6 under Preventing, Detecting, and Mitigating 

Perceptions of Retaliation: Delete the parenthetical 

statement. Due to legal implications, details of disciplinary 

action cannot be communicated. 

Enclosure B, page E-B-10 Item 8: Add "to you" at the end of the sentence. 

Enclosure B, page E-B-11 Item 3: How does this relate to nuclear safety or safety 

culture? Rephrase the last question to "What impact did 

the lack of the ____ have on nuclear safety?" 

Enclosure B, page E-B-11 Item 6: This is a very leading question. Rephrase to 

"Have you ever turned down overtime? If yes, why?" 

Delete the parenthetical "or whoever you reported to being 

too tired to" since this is also biased. Consider asking 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 18 of 20 

"Have you been too fatigued to work safely? If yes, what 

did you do?" 

Enclosure B, page E-B-13 Item 7: This item rambles and is not well organized. 

Rephrase. 

Enclosure B, page E-B-13 Item 13: This item is very ambiguous. Whose reaction is 

being questioned? Management's? The interviewee's? It 

does not appear to be appropriate to solicit an 

organization's reaction to INPO. Why not the offsite safety 

review group? 

Enclosure B, page E-B-14 Item 4: Delete "What are they?" and replace with "Give an 

example of such an "abort criteria" since these are typically 

for risk-significant jobs and the same criteria is not used 

each time. 

Enclosure B, page E-B-14 Item 5: To provide context to this question, the question 

"How frequently does this occur?" should also be asked. 

Enclosure B, page E-B-14 Item 7: This question is too complex. Rephrase to 

simplify. 

Enclosure B, page E-B-15 Item 12: What is more reactive – 1 or 5? As worded, 

information may not be consistently obtained. "Then" 

should be "than" in the first sentence. 

Enclosure B, page E-B-15 Item 13: This is a very leading item that infers more 

outage time is necessary to increase the outage scope. 

Critical path dictates the outage duration and scope can be 

increased in many different ways, including adding 

additional resources or working additional jobs off of critical 

path. Rephrase the last sentence as follows to be less 

leading – "If work is moved from the outage to on-line 

maintenance, what is the typical basis for this action? Give 

examples." 

Enclosure B, page E-B-16 Item 13: Add "nuclear" before "safety." 

Enclosure C, page E-C-3 Item 2.3: Add limitations to describe the following: 

• Difficult to coordinate multiple focus groups 

concurrently. 

• High impact on licensee resources, especially during 

outages and risk-significant maintenance activities. 

Enclosure C, page E-C-3 General comment on Item 2.4: Include the typical amount 

of time expected to conduct the focus group (e.g., 60 to 90 

minutes). 

Enclosure C, page E-C-3 First paragraph under Item 2.4.1: Data is collected 

regarding length of time in the organization. No details are 

provided to the inspectors for how this data is to be used. 

Also, the last bullet on the page does not appear anywhere 
Exelon Comments on 

DRAFT NRC Inspection Procedure 95003, "Supplemental Inspection for 

Repetitive Degraded Cornerstones, Multiple Repetitive Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input" 

Page 19 of 20 

else in the guidance. This seems to provide a significant 

assurance for confidentiality of the focus group and should 

appear somewhere in the body of IP 95003. 

Enclosure F, page E-F-1 Last bullet under Strengths: The bullet references the 

existence of reliable and valid surveys. Recommend 

providing ML numbers so that acceptable survey 

methodologies are recognized and communicated, 

especially for consideration by licensee's in third party 

safety culture assessments.
Exelon Comments on 

DRAFT NRC Inspection Manual Chapter 0305, "Operating Reactor 

Assessment Program" 

Page 20 of 20 

Page 3 Section 04.17: The proposed changes imply that all assessments of 

safety culture require formal qualifications and a scope defined by NRC 

documents. This is too restrictive for self- and independent assessments. 

Many licensee personnel are capable of directing a self- or independent 

assessment of safety culture without formal education and training. The 

scope guidelines effectively ensure that the industry will have to adopt the 

NRC’s framework for defining safety culture. 

Page 34 Section 6.07.a.1: Assigning cross-cutting aspects to traditional 

enforcement actions will increase the population of aspects and should 

require re-evaluation of the thresholds for considering a substantive 

cross-cutting issue. 

Page 35 Section 6.07.a.2: The last sentence of this section is unclear. The term 

“sub-cross-cutting aspects” is not defined. 

Page 37 Section 6.07.b.1: The last paragraph of this section states that the SCWE 

input is considered for an extended period of three assessment periods. 

This is not appropriate. Three potential inputs to SCWE are discussed on 

page 36 as: 

-Finding with SCWE aspect 

-Chilling effect letter (CEL) 

-Enforcement action 

Often, enforcement actions and CELs are issued a significant time 

following an actual event and the licensee has already investigated, and 

corrected the condition. For these types of issues, holding the input open 

for four quarters should be sufficient. 

In the case of findings, the NRC has ample opportunity to sample for 

effectiveness of corrective actions within the four quarters and can also 

follow up outside the four quarters. 

During the four quarters the input is open, the NRC has ample opportunity 

and is obligated to monitor for SCWE concerns. The Resident Inspectors 

interact continuously with the licensee staff on SCWE and safety culture 

health. 

In summary, we see no reason to treat SCWE inputs differently form 

other inputs to the assessment process for substantive cross-cutting 

issues. The inspection process provides adequate opportunity and is the 

appropriate vehicle to monitor SCWE health. 

Page 45 Third paragraph. Guidance should be provided for circumstances in 

which it is not appropriate to request a licensee assessment of safety 

culture. For example, an assessment may not be warranted if a licensee 

has made reasonable progress in addressing issues, but has not met the 

specific closure criteria. 

Page 45 Third paragraph. It is not clear why a recurring substantive cross-cutting 

issue in problem identification and resolution requires an independent 

safety culture assessment, in contrast to human performance or SCWE 

issues, which only require a licensee self-assessment.