Issue Date: XX/XX/XX -1- 0305 

 

NRC INSPECTION MANUAL IPAB 

MANUAL CHAPTER 0305 

OPERATING REACTOR ASSESSMENT PROGRAM 

0305-01 PURPOSE 

01.01 The Reactor Oversight Process (ROP) integrates the NRC’s inspection, 

assessment, and enforcement programs. The Operating Reactor Assessment Program 

evaluates the overall safety performance of operating commercial nuclear reactors and 

communicates those results to licensee management, members of the public, and other 

government agencies. 

01.02 The assessment program collects information from inspections and performance 

indicators (PIs) in order to enable the agency to arrive at objective conclusions about 

the licensee’s safety performance. Based on this assessment information, the NRC 

determines the appropriate level of agency response, including supplemental inspection 

and pertinent regulatory actions ranging from management meetings up to and 

including orders for plant shutdown. The assessment information and agency response 

are then communicated to the public. Follow-up agency actions, as applicable, are 

conducted to ensure that the corrective actions designed to address performance 

weaknesses were effective. 

0305-02 OBJECTIVES 

02.01 To collect information from inspection findings and PIs. 

02.02 To arrive at an objective assessment of licensee safety performance using PIs 

and inspection findings. 

02.03 To assist NRC management in making timely and predictable decisions 

regarding appropriate agency actions used to oversee, inspect, and assess licensee 

performance. 

02.04 To provide a method for informing the public and soliciting stakeholder feedback 

on the NRC’s assessment of licensee performance. 

02.05 To provide a process to follow up on areas of concern. 
Issue Date: XX/XX/XX -2- 0305 

0305-03 APPLICABILITY 

This manual chapter applies to all operating commercial nuclear reactors except those 

sites that are under IMC 0350, “Oversight of Reactor Facilities in Shutdown Condition 

Due To Significant Performance And/Or Operational Concerns.” The contents of this 

manual chapter do not restrict the NRC from taking any necessary actions to fulfill its 

responsibilities under the Atomic Energy Act of 1954 (as amended). Refer to IMC 0320, 

“Operating Reactor Security Assessment Program” for guidance related to the 

assessment of security-related performance indicators and inspection findings. 

0305-04 DEFINITIONS 

04.01 Annual Assessment Cycle. A 12-month assessment period from January 1 

through December 31 of each year. 

04.02 Assessment Inputs. As used in this manual chapter, assessment inputs are the 

PIs and inspection findings for a particular plant that are combined in the assessment 

process in order to determine appropriate agency actions. As discussed in section 

06.01, traditional enforcement items should be considered when determining the range 

of agency actions within the appropriate column of the Action Matrix. 

04.03 Assessment Period. A rolling 12 month period that contains four quarters of 

performance indicators and inspection findings. An inspection finding is normally 

carried forward in the assessment process for a total of four calendar quarters and a 

performance indicator is recalculated on a quarterly basis. 

04.04 Cross-Cutting Area. Fundamental performance attributes that extend across all 

of the Reactor Oversight Process cornerstones of safety. These areas are human 

performance, problem identification and resolution, and safety conscious work 

environment. 

04.05 Cross-Cutting Aspect. Performance characteristics that comprise a crosscutting area component which are described in Section 06.07.c. 

04.06 Cross-Cutting Area Component. A component of safety culture that is directly 

related to one of the cross-cutting areas. The cross-cutting area components in 

alphabetical order are: Corrective Action Program; Decision-Making; Environment for 

Raising Concerns; Operating Experience; Preventing, Detecting, and Mitigating 

Perceptions of Retaliation; Resources; Self and Independent Assessments; Work 

Control; and Work Practices. [C4] 

04.07 Cross-Cutting Theme. Multiple inspection findings (i.e., four or more) that are 

assigned the same cross-cutting aspect. 

04.08 Degraded Cornerstone. A cornerstone that has two or more white inputs or one 

yellow input. 

Deleted: with causes 

Comment [rag1]: Recommendation 

CI-4 to clarify determination of a theme. 

Deleted: share 
Issue Date: XX/XX/XX -3- 0305 

04.09 Inspection Manual Chapter (IMC) 0350 Process. An oversight process that 

oversees licensee performance, inspections, and restart efforts for plants in shutdown 

conditions with significant performance and/or operational concerns. 

04.10 Multiple Degraded Cornerstones. Two or more cornerstones are degraded in 

any one quarter. 

04.11 Old Design Issue. An inspection finding involving a past design-related problem 

in the engineering calculations or analysis, associated operating procedure, or 

installation of plant equipment that does not reflect a performance deficiency associated 

with existing licensee programs, policy, or procedures. As discussed in section 06.06.a, 

some old design issues may not be considered in the assessment program. 

04.12 Parallel Performance Indicator Inspection Finding. An inspection finding issued 

at the same significance level of a safety-significant performance indicator when the 

supplemental inspection reveals a substantial inadequacy in the licensee’s evaluation of 

the root causes of the original performance deficiency, determination of the extent of the 

performance problems, or the actions taken or planned to correct the issue. See 

section 06.06.d for more details. 

04.13 Plant Performance Summary. A document prepared by the regional offices and 

used during the mid-cycle review, end-of-cycle review, and Agency Action Review (if 

applicable) meetings. This document is prepared for those plants that: (1) for any 

quarter during the assessment period have been in the degraded cornerstone, 

Multiple/Repetitive degraded cornerstone, or Unacceptable Performance column of the 

Action Matrix, or (2) have a current substantive cross-cutting issue. 

04.14 Repetitive Degraded Cornerstone. A single cornerstone that is degraded (2 

white inputs or 1 yellow input) for five or more consecutive quarters. This designation 

only applies to a single cornerstone when there are at least two separate safety 

significant PIs or inspection findings during this period. Additionally, this designation 

does not apply when the only safety-significant findings are those that have been held 

open greater than four quarters in accordance with section 06.06.d. 

04.15 Safety-Conscious Work Environment (SCWE). An environment in which 

employees feel free to raise safety concerns, both to their management and to the NRC, 

without fear of retaliation and where such concerns are promptly reviewed, given the 

proper priority based on their potential safety significance, and appropriately resolved 

with timely feedback to employees.

04.16 Safety Culture. That assembly of characteristics and attitudes in organizations 

and individuals which establishes that, as an overriding priority, nuclear plant safety 

issues receive the attention warranted by their significance.

04.17 Safety Culture Assessment. A comprehensive evaluation by qualified (through 

experience and formal education) individuals of the assembly of characteristics and 

Comment [rag2]: New definition to 

co-locate high level expectations on 

licensee safety culture assessments. 
Issue Date: XX/XX/XX -4- 0305 

attitudes, related to all of the safety culture components described in section 06.07, in 

licensee organizations and individuals. The assessment involves a comprehensive 

sample of the licensee staff population. A licensee safety culture self-assessment is 

performed by qualified in-house licensee personnel. A licensee independent safety 

culture assessment is performed by qualified individuals that have no direct authority 

and have not been responsible for any of the areas being evaluated (for example, staff 

from another of the licensee’s facilities, or corporate staff who have no direct authority 

or responsibility for the areas being evaluated). A licensee third-party safety culture 

assessment is performed by qualified staff who are not members of the licensee’s 

organization or utility operators of the plant (licensee team liaison and support activities 

are not team membership).

04.18 Safety-Significant Finding/ Performance Indicator. An inspection finding with a 

safety significance greater than green or a performance indicator that is greater than 

green. 

04.19 Significance Determination Process (SDP). A characterization process that is 

applied to inspection findings to determine their safety significance. Using the results of 

the SDP, the overall licensee performance assessment process can compare and 

evaluate the findings on a significance scale similar (i.e., white, yellow, red) to the 

performance indicators. 

04.20 Substantive Cross-Cutting Issue. As used in this chapter, a cross-cutting theme 

as evidenced by more than three current inspection findings in the cross-cutting areas 

of human performance, and problem identification and resolution. For safety-conscious 

work environment, at least one finding exists or the NRC has issued correspondence 

addressing SCWE cross-cutting issues. The SCWE issues must be more than an 

isolated instance, or have impacted, directly or indirectly, more than a single individual. 

In all cases, the NRC must identify a concern with the licensee’s scope of efforts or 

progress in addressing the cross-cutting theme. See section 06.07 for more details. 

0305-05 RESPONSIBILITIES AND AUTHORITIES 

05.01 Executive Director for Operations (EDO). 

 a. Oversees the activities described in this manual chapter. 

 b. Approves all deviations from the Action Matrix. [C1] 

 c. Informs the Commission of all approved deviations from the Action Matrix. [C1] 

05.02 Director, Office of Nuclear Reactor Regulation (NRR). 

 a. Implements the requirements of this manual chapter within NRR. 

 b. Develops assessment program policies and procedures. 
Issue Date: XX/XX/XX -5- 0305 

 c. Ensures uniform program implementation and effectiveness. 

 d. Concurs on regional requests for deviation from the Action Matrix. 

05.03 Regional Administrators. 

 a. Implements the requirements of this manual chapter within their respective 

regions. 

 b. Develops and issues assessment letters to each licensee. 

 c. Conducts assessment reviews and directs allocation of inspection resources 

within the regional office based on the Action Matrix. 

 d. Establishes a schedule and determines a suitable location for the annual public 

meeting with each licensee to ensure a mutual understanding of the issues 

discussed in the annual assessment letter. 

 e. Suspends the mid-cycle and/or end-of-year performance review for those plants 

that have been transferred to the Inspection Manual Chapter 0350 process (see 

IMC 0350). 

 f. Chairs the end-of-cycle review meetings. 

 g. Initiates requests for deviations from the Action Matrix. 

05.04 Director, Office of Public Affairs. Issues press releases following the completion 

of the mid-cycle and end-of-cycle reviews. 

05.05 Deputy Director, Division of Inspection and Regional Support (NRR/DIRS). 

 a. Develops assessment program guidance. 

 

 b. Collects feedback from the regional offices and assesses execution of the 

Operating Reactor Assessment Program to ensure consistent application. 

 c. Recommends, develops, and implements improvements to the Operating 

Reactor Assessment Program. 

 d. Provides oversight of the mid-cycle and end-of-cycle review meetings. 

 e. Concurs on proposals by the regional offices to not count an old design issue in 

the assessment program in accordance with section 06.06.a. 
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 f. Concurs on proposals by the regional office to extend an inspection finding in 

the assessment process beyond the normal four quarters in accordance with 

section 06.06.d. 

 g. Concurs on proposals by the regional office to initiate a parallel inspection 

finding in accordance with section 06.06.d. 

 h. Concurs on the supplemental inspection plan for plants in the Multiple/Repetitive 

Degraded Cornerstone column of the Action Matrix. 

05.06 Regional Division Directors. 

 a. Chairs the mid-cycle review meeting. 

 b. Approves proposals by the regional offices to not count an old design issue in 

the assessment program in accordance with section 06.06.a. 

 c. Approves proposals by the regional office to extend an inspection finding in the 

assessment process beyond the normal four quarters in accordance with 

section 06.06.d. 

 d. Approves proposals by the regional office to initiate a parallel inspection finding 

in accordance with section 06.06.d. 

 e. Approves the supplemental inspection plan for plants in the Multiple/Repetitive 

Degraded Cornerstone column of the Action Matrix. 

05.07 Agency Allegations Advisor. Provides any significant insights from the 

allegations program to the regional offices in preparation for the mid-cycle and end-ofcycle review meetings for discussions related to the SCWE cross-cutting area. 

05.08 Director, Office of Enforcement. Provides any significant insights from the 

enforcement program to the regional offices during the end-of-cycle review meetings. 

05.09 Director, Office of Investigations. Provides any significant insights from the 

office of Investigations to the regional offices during the end-of-cycle review meetings. 

05.10 Director, Office of Research. Provides any significant insights from the office of 

Research to the regional offices during the end-of-cycle review meetings. 

05.11 Director, Office of Nuclear Security and Incident Response. 

 a. Provides any significant insights from the Office of Nuclear Security and Incident 

Response to the regional offices during the end-of-cycle review meetings. 

 b. Provides guidance to the regional offices on performing the assessment 

program for the safeguards/security cornerstone. 
Issue Date: XX/XX/XX -7- 0305 

0305-06 BASIC REQUIREMENTS 

06.01 Overall Assessment Process. Licensee performance is reviewed over a 12-

month period through the operating reactor assessment process (Exhibit 3). 

A preliminary significant (i.e., preliminary white, yellow, or red) issue is not considered a 

safety-significant inspection finding and therefore not considered in the assessment 

process until after the final determination of significance is made through the SDP and 

the licensee has been informed of the decision. The safety-significant inspection finding 

will then be considered in the assessment process dated back to the end of inspection 

period, regardless of when the exit meeting was conducted, that initially resulted in 

designating the issue as an AV, violation (VIO), finding (FIN), or non-cited violation 

(NCV) in the reactor program system (RPS). Unresolved Items should be dispositioned 

according to IMC 0612 “Power Reactor Inspection Reports” and appropriately updated 

in RPS when additional information becomes available. 

A safety-significant inspection finding is carried forward for four calendar quarters or 

until appropriate licensee corrective actions have been completed, whichever is greater. 

Therefore, an inspection finding will no longer be considered in the assessment process 

after four calendar quarters unless the region has justification to keep the finding open 

in accordance with section 06.06.d of this manual chapter. Additionally, findings whose 

technical aspects have been adequately addressed by the licensee may be closed even 

if there are outstanding investigations by external agencies. 

Example: A preliminary white inspection finding in the second calendar year 

(CY) quarter whose final safety significance was determined to be white (low to 

moderate safety significance) during third CY quarter, would be considered a 

white finding in CY quarters 2, 3 and 4 plus the first quarter of the next CY. 

The inspectors normally use the SDP to evaluate inspection findings for safety 

significance. In addition, the NRC’s enforcement policy may apply to issues which the 

SDP process can not evaluate for safety significance (e.g., violations that involve 

willfulness, including discrimination). These non-SDP issues should be considered 

when determining (1) the range of agency actions within the appropriate column of the 

Action Matrix and (2) whether a substantive cross-cutting issue exists in the SCWE area 

(see section 06.07.b). Additionally, if applicable, the underlying technical issue should 

be separately evaluated using the Significance Determination Process and the results 

considered in the assessment program. 

06.02 Performance Reviews. The assessment process consists of a series of reviews 

which are described below. 

 a. Continuous Review. The resident inspectors and branch chiefs in each regional 

office continuously monitor the performance of their assigned plants using the 

results of the performance indicators and inspection findings. Inspections are 
Issue Date: XX/XX/XX -8- 0305 

conducted on a continuous basis in accordance with IMC 2515 and 

performance indicators are reported quarterly by the licensee. 

The region may issue an assessment follow-up letter and address an issue, in 

accordance with the Action Matrix, between the normal quarterly assessments 

if, (1) a safety significant inspection finding is finalized, or (2) if a performance 

indicator will cross a performance threshold at the end of the quarter based on 

current inputs. 

 b. Quarterly Review. Each region conducts a quarterly review utilizing PI data 

submitted by licensees and inspection findings compiled over the previous 

twelve months. This review is conducted within five weeks after the conclusion 

of each quarter of the annual assessment cycle. The most recent quarter of 

performance indicators and applicable inspection findings shall be considered in 

determining agency actions per the Action Matrix. 

The responsible DRP branch chief reviews the most recently submitted PIs 

(which should be submitted 21 days after the end of the quarter) and the 

inspection findings contained in the plant issues matrix (PIM) to identify any 

performance trends. The branch chief shall utilize the Action Matrix to help 

identify where there are NRC actions that should be considered which are not 

already embedded in the existing inspection plan. Assessment follow-up letters 

are normally issued within two weeks after the quarterly review for any new 

safety significant PIs or inspection findings. 

If based on the continuous review, as discussed above, the region issued an 

assessment follow-up letter for inspection findings or performance indicators 

during the past quarter, a subsequent quarterly assessment follow-up letter 

would not be necessary if its only purpose is to reiterate any issues that had 

been previously addressed to the licensee. 

Note: The regional office should still perform a supplemental inspection 

procedure even if a PI returns to the green band prior to conducting the 

supplemental inspection. 

Due to the fact that inspection findings count in the assessment process for four 

quarters, the staff may become aware that a plant will reach a repetitive 

degraded cornerstone categorization prior to five consecutive quarters actually 

being completed. Upon determination that a plant will reach a repetitive 

degraded cornerstone, the regional office should issue an assessment letter 

stating that the changes to the planned actions are consistent with the 

Multiple/Repetitive Degraded Cornerstone in the Action Matrix and make the 

appropriate change to the Action Matrix Summary. 

Additionally, for plants whose performance is in the Multiple/Repetitive 

Degraded Cornerstone column of the Action Matrix, consideration shall be given 
Issue Date: XX/XX/XX -9- 0305 

at each quarterly review of engaging senior licensee and agency management 

in discussions associated with (1) transferring the plant to the IMC 0350 

process, (2) declaring licensee performance to be unacceptable in accordance 

with the guidance contained within this manual chapter, and (3) taking additional 

regulatory actions (as appropriate). If there are significant changes in the 

inspection plan for a plant in the Multiple/Repetitive Degraded Cornerstone 

column of the Action Matrix, the regions should issue a separate assessment 

follow-up letter in order to ensure the licensee is aware of these changes. 

 c. Mid-Cycle Review. Each regional office conducts a mid-cycle review utilizing 

the most recent quarterly performance indicators and inspection findings 

compiled over the previous twelve months. This review incorporates activities 

from the quarterly review that followed the end of the first quarter of the CY. 

The review should consider the conclusions of any independent assessments of 

a licensee, such as Institute of Nuclear Power Operations (INPO) and 

International Atomic Energy Agency (IAEA) Operational Safety Review Team 

(OSART) inspections. The purpose of considering independent assessments is 

to provide a means of self-assessing the NRC inspection and assessment 

process. References to INPO conclusions will not be included in the 

assessment letters. [C3] The output of this mid-cycle review is a mid-cycle letter. 

The mid-cycle review and subsequent mid-cycle letter should only discuss 

issues where the inspection was completed prior to the end of the mid-cycle 

assessment period. Additional activities include planning inspection activities 

for approximately 15 months, as well as discussing any insights into potential 

substantive cross-cutting issues (problem identification and resolution, human 

performance, and safety-conscious work environment). The Action Matrix is 

used to determine the scope of agency actions in response to the assessment 

inputs. The mid-cycle review will be completed within seven weeks of the end 

of the second quarter of the annual assessment cycle. 

In preparation for the mid-cycle reviews, the regional offices shall develop a 

meeting agenda as well as provide the plant issues matrix, the results of the 

PIs, and the proposed inspection plan for all plants. The meeting agenda 

provides the areas that should be addressed by the regional offices for all plants 

except those that are required to prepare a Plant Performance Summary. A 

single written agenda is sufficient to conduct the meeting. The regional offices 

shall develop a Plant Performance Summary for those plants whose 

performance has been in the Degraded Cornerstone column, Multiple/Repetitive 

Degraded Cornerstone column, or Unacceptable Performance column of the 

Action Matrix during any quarter of the past twelve months. A Plant 

Performance Summary shall also be developed for those plants that the 

regional offices consider to have current substantive cross-cutting issues that 

should be included in the mid-cycle letter. In order to determine the need for a 

Plant Performance Summary, the existence of a potential substantive crosscutting issue should be discussed by the regional office prior to the mid-cycle 

review meeting. The Plant Performance Summary packages will assist the 

regional offices in conducting the meeting and will form the basis for the mid-
Issue Date: XX/XX/XX -10- 0305 

cycle letter, as well as providing input to the next end-of-cycle review meeting. 

The Plant Performance Summary should include an operating summary, a 

performance overview (current overall assessment and previous assessment 

results), inspection and PI results by cornerstones, other issues (i.e., crosscutting issues, PI verification, and non-SDP enforcement actions of at least 

severity level III), as well as a proposed inspection plan. Each page of the 

meeting agenda and Plant Performance Summary should be clearly marked as 

“pre-decisional” to ensure that the document is handled properly and not 

inadvertently released to the public. 

In order to aid in the discussion and integration of plant issues, the regional 

offices should prepare a plant-specific action matrix that details the timeline and 

consideration of PIs and inspection findings in the assessment program as an 

attachment to the Plant Performance Summary. The plant specific action matrix 

should display the quarterly status of safety significant inspection findings and 

PIs and the associated action matrix column over a sufficient timeline. The 

regional offices do not need to prepare this matrix for plants that are being 

discussed only for the purpose of having a potential substantive cross-cutting 

issue. 

 

The mid-cycle review meeting is chaired by a Division of Reactor Projects 

(DRP) or Division of Reactor Safety (DRS) Division Director (DD). The DRP 

branch chiefs responsible for their plants should take the lead in presenting the 

overall results of the review to the division director. The DRS branch chiefs 

shall coordinate with the appropriate DRP branch chiefs to provide adequate 

support for the presentation and the development of the inspection plan. Other 

participants shall include applicable resident inspectors and a representative 

from the Division of Inspection and Regional Support (DIRS). Additional 

participants may include the regional allegations coordinator or the agency 

allegations advisor, and any other additional resources deemed necessary by 

the regional offices. The following representatives should also participate if 

there are pertinent performance issues that should be factored into the 

performance for a particular plant: senior representatives from the Division of 

Operating Reactor Licensing, Office of Investigations, Office of Enforcement, 

Office of Nuclear Security and Incident Response, and Office of Research. The 

role of the various headquarters participants during the mid-cycle meeting is to 

provide: (1) an opportunity for these offices to share any significant insights into 

licensee performance over the course of the annual assessment period, (2) an 

independent validation of the regional office’s assessment of licensee 

performance from their office’s perspective, and (3) clarifying or ancillary 

remarks regarding ongoing or current issues under their cognizance. A senior 

reactor analyst (SRA) is not required to attend the meeting if their insights on 

safety significant performance issues have been provided before the meeting. 

The agency allegations advisor will provide any significant insights to the 

regional offices at least one week in advance of the mid-cycle meeting. The 

average time allocated for each plant review is intended to be between 20 
Issue Date: XX/XX/XX -11- 0305 

minutes and one hour. The time allotted per review should be consistent with 

the number and significance of plant issues. 

The mid-cycle letter shall be issued within nine weeks of the end of the 

completion of the second quarter assessment period. Signature authority for 

the mid-cycle letter is determined by the most significant column of the Action 

Matrix that the plant has been in over the first two quarters of the current 

assessment cycle. For example, findings from the previous assessment cycle 

that were no longer active in the assessment process during the first two 

quarters of the current assessment cycle would not factor in to the signature 

authority determination. This letter shall contain: 

 1. A summary of safety significant PIs and inspection findings for the most 

recent two quarters as well as discussion of previous action taken by the 

licensee and the agency relative to these issues. Note any changes in 

Action Matrix column status since the end of the previous cycle 

assessment period. Performance issues from previous quarters may be 

discussed if: 

 (a) The agency’s response to an issue had not been adequately 

captured in previous correspondence to the licensee. 

 (b) These issues, when combined with assessment inputs from the 

most recent quarter, result in increased regulatory action per the 

Action Matrix that would not be apparent from reviewing only the 

most recent quarter’s results. 

 2. A discussion of any deviations from the Action Matrix during the 

assessment period. 

 3. A discussion of any Degraded Cornerstone Column plant that has 

remained in that column for 3 years or more. The discussion should 

center on why the licensee has remained in this column for such a period 

of time and how they plan to address the performance issues. 

4. A discussion of any Multiple/Repetitive Degraded Cornerstone Column 

plant. The discussion should center on those performance issues 

contributing to why the licensee has been placed in this column and those 

actions the licensee is taking to address the performance problems. 

 5. A qualitative discussion of substantive cross-cutting issues, if applicable. 

 6. A discussion of the licensee’s progress in addressing a substantive crosscutting issue, if documented in the previous mid-cycle or annual 

assessment letter. 
Issue Date: XX/XX/XX -12- 0305 

7. A brief discussion of cross-cutting issues that meet the first criterion of 

Section 06.07 of this manual chapter regarding criteria for a substantive 

cross-cutting issue. 

 8. A discussion of non-SDP (severity level III or greater) enforcement 

actions. 

9. A discussion of findings that are currently being evaluated by the 

significance determination process that may affect the inspection plan. 

 10. A statement of any actions to be taken by the agency in response to 

safety significant issues, as well as any actions taken by the licensee. 

 11. An inspection plan consisting of approximately 15 months (from the 

issuance of the mid-cycle letter) of activities. The inspection plan will 

consist of report 22 from the Reactor Program System (RPS). 

 d. End-of-Cycle Review. Each regional office conducts an end-of-cycle review 

utilizing the most recent quarterly PIs and inspection findings compiled over the 

previous 12 months. This review incorporates activities from the mid-cycle and 

quarterly reviews, including consideration of the conclusions of any independent 

assessments, such as Institute of Nuclear Power Operations (INPO) and 

International Atomic Energy Agency (IAEA) Operational Safety Review Team 

(OSART) inspections. The purpose of considering independent assessments is 

to provide a means of self-assessing the NRC inspection and assessment 

process. References to INPO conclusions will not be included in assessment 

letters. The output of this review is an annual assessment letter. [C3] The endof-cycle review and subsequent annual assessment letters should only discuss 

issues where the inspection was completed prior to the end of the assessment 

period. Additional activities include planning inspection activities for 

approximately 15 months, discussing any potential substantive cross-cutting 

issues, and developing an input (if applicable) to support the Agency Action 

Review Meeting (AARM). The end-of-cycle review meeting will be held within 

seven weeks of the end of the assessment cycle. The Action Matrix will be 

used to determine the scope of agency actions in response to assessment 

inputs. 

 

In preparation for the end-of-cycle review meetings, the regional offices shall 

develop a meeting agenda as well as provide the plant issues matrix, the results 

of the PIs, and the proposed inspection plan for all plants. The meeting agenda 

provides the areas that should be addressed by the regional offices for all plants 

except those that are required to prepare a Plant Performance Summary. A 

single agenda is sufficient to conduct the meeting. The regional offices shall 

develop a Plant Performance Summary for those plants whose performance has 

been in the Degraded Cornerstone column, Multiple/Repetitive Degraded 

Cornerstone column, or Unacceptable Performance column of the Action Matrix 

during any quarter of the past twelve months. A Plant Performance Summary 

Comment [rag3]: Recommendation 

CI-5, change made as old SCCI criteria 1 

and 2 were combined. 

Deleted: two of three criteria
Issue Date: XX/XX/XX -13- 0305 

shall also be developed for those plants that the regional offices consider to 

have current substantive cross-cutting issues that should be discussed in the 

annual assessment letter. In order to determine the need for a Plant 

Performance Summary, the existence of a preliminary substantive cross-cutting 

issue should be discussed by the regional office prior to the end-of-cycle review 

meeting. The Plant Performance Summary packages will assist the regional 

offices in conducting the meeting and will form the basis for the annual 

assessment letters. These packages will also be used at the end-of-cycle 

summary meeting, as well as providing input to the Agency Action Review 

Meeting (if applicable). The Plant Performance Summary should include an 

operating summary, a performance overview (current overall assessment and 

previous assessment results), inspection and performance indicator results by 

cornerstones, other issues (i.e., cross-cutting issues, PI verification, and nonSDP enforcement actions of at least severity level III), as well as a proposed 

inspection plan. Each page of the meeting agenda and Plant Performance 

Summary should be clearly marked as “pre-decisional” to ensure that the 

document is handled properly and not inadvertently released to the public. 

In order to aid in the discussion and integration of plant issues, the regional 

offices should prepare a plant specific action matrix that details the timeline and 

consideration of PIs and inspection findings in the assessment program as an 

attachment to the Plant Performance Summary. The plant specific action matrix 

should display the quarterly status of safety significant inspection findings and 

PIs and the associated action matrix column over a sufficient timeline. The 

regional offices do not need to prepare this matrix for plants that are being 

discussed only for the purpose of having a potential substantive cross-cutting 

issue. 

The end-of-cycle review meeting is chaired by the regional administrator or 

his/her designee. The regional division directors and/or branch chiefs present 

the results of the annual review to the regional administrator (or designee). 

Other routine participants should include DRP and DRS branch chiefs, 

applicable regional and resident inspectors, a representative from the Division of 

Inspection and Regional Support (DIRS), the regional Allegations Coordinator or 

the Agency Allegations Advisor, and any other additional participants deemed 

necessary by the regional offices. The following representatives should also 

participate if there are pertinent performance issues that should be factored into 

the performance for a particular plant: senior representatives from the Division 

of Operating Reactor Licensing, Office of Investigations, Office of Enforcement, 

Office of Nuclear Security and Incident Response, and Office of Research. The 

role of the various headquarters participants during the end-of-cycle meeting is 

to provide: (1) an opportunity for these offices to share any significant insights 

into licensee performance over the course of the annual assessment period, (2) 

an independent validation of the regional office’s assessment of licensee 

performance from their office’s perspective, and (3) clarifying or ancillary 

remarks regarding ongoing or current issues under their cognizance. A senior 

reactor analyst (SRA) is not required to attend the meeting if their insights on 
Issue Date: XX/XX/XX -14- 0305 

safety significant performance issues have been provided before the meeting. 

The average time allocated for each plant review is intended to be between 20 

minutes and one hour. The time allotted per review should be consistent with 

the number and significance of plant issues. 

An end-of-cycle (EOC) summary meeting may be necessary at the conclusion 

of the end-of-cycle meeting to summarize the results of the end-of-cycle review 

with the Director of NRR (or another member of the NRR Executive Team). The 

regional staff will summarize the results of the end-of-cycle review for those 

plants whose performance in one or more quarters in the past twelve months 

has been in the Degraded Cornerstone column, Multiple/Repetitive Degraded 

Cornerstone column, or Unacceptable Performance column of the Action Matrix. 

Plants that are under the IMC 0350 process will also be discussed at this 

meeting. The regional staff will also present the results for those plants that the 

regional office consider to have current substantive cross-cutting issues that 

would be included in the annual assessment letter. The end-of-cycle summary 

meeting will be scheduled within one week after the completion of the last 

regional end-of-cycle review. This meeting will occur after the completion of all 

the EOC meetings but before the issuance of the annual assessment letters. 

During the EOC summary meeting, the Director of NRR (or another member of 

the NRR Executive Team) will preside over the meeting while each regional 

administrator will lead the discussion for his/her region. The EOC summary 

meeting is an informational meeting vice a decision-making meeting. In 

preparation for the meeting, IPAB will develop an agenda for the meeting with 

input from the regional offices. The regional offices should provide their input to 

IPAB three working days prior to the meeting. The purpose of this meeting is for 

regional management to engage headquarters management on those 

discussion plants in order to ensure awareness of the plants to be discussed at 

the AARM and those agency actions already taken in response to plant 

performance. 

The output of the end-of-cycle review is an annual assessment letter. The 

annual assessment letter shall be issued nine weeks from the end of the 

assessment cycle. Signature authority for each annual assessment letter is 

determined by the most significant column of the Action Matrix that the plant has 

been in over the four quarters of the assessment cycle. The letters shall 

contain: 

 1. A summary of safety significant PIs and inspection findings for the most 

recent two quarters as well as previous action taken by the licensee and 

the agency relative to these issues. Note any changes in Action Matrix 

column status since the end of the previous cycle assessment period. 

Performance issues from previous quarters may be discussed if: 

 (a) The agency’s response to an issue had not been adequately 

captured in previous correspondence to the licensee. 
Issue Date: XX/XX/XX -15- 0305 

 (b) These issues, when combined with assessment inputs from the 

most recent quarter, result in increased regulatory action per the 

Action Matrix that would not be apparent from reviewing only the 

most recent quarter’s results. 

 2. A discussion of any deviations from the Action Matrix during the 

assessment period. 

 3. A qualitative discussion of substantive cross-cutting issues, if applicable. 

 4. A discussion of the licensee’s progress in addressing a substantive crosscutting issue, if documented in the previous mid-cycle or annual 

assessment letter. 

 5. A brief discussion of cross-cutting issues that meet the first criterion of 

Section 06.07 of this manual chapter regarding criteria for a substantive 

cross-cutting issue. 

 6. A discussion of non-SDP (severity level III or greater) enforcement 

actions. 

7. A discussion of findings that are currently being evaluated by the 

significance determination process that may affect the inspection plan. 

8. A discussion of any Degraded Cornerstone Column plant that has 

remained in that column for 3 years or more. The discussion should 

center on why the licensee has remained in this column for such a period 

of time and how they plan to address the performance issues. 

9. A discussion of any Multiple/Repetitive Degraded Cornerstone Column 

plant. The discussion should center on those performance issues 

contributing to why the licensee has been placed in this and those actions 

the licensee is taking to address the performance problems. 

 10. A statement of any actions to be taken by the agency in response to 

safety significant issues, as well as any actions taken by the licensee. 

 11. An inspection plan consisting of approximately 15 months of activities 

(from the issuance of the annual assessment letter). The inspection plan 

will consist of report 22 from the Reactor Program System (RPS). 

06.03 Program Reviews

a. Agency Action Review Meeting. An Agency Action Review Meeting (AARM) is 

conducted several weeks after issuance of the annual assessment letters. This 

meeting is attended by appropriate senior NRC managers and is chaired by the 

Comment [rag4]: Recommendation 

CI-5, change made as old SCCI criteria 1 

and 2 were combined . 

Deleted: two of three criteria
Issue Date: XX/XX/XX -16- 0305 

Executive Director for Operations (EDO) or designee. This meeting is a 

collegial review by senior NRC managers of (1) the appropriateness of agency 

actions for plants with significant performance issues using data compiled 

during the end-of-cycle review, (2) trends in overall industry performance, (3) 

the appropriateness of agency actions concerning fuel cycle facilities and other 

materials licensees with significant performance problems, and (4) the results of 

the reactor oversight process self-assessment, including a review of approved 

deviations from the Action Matrix. [C2] Plants with significant performance 

weaknesses are those plants that are in the Multiple/Repetitive Degraded 

Cornerstone or Unacceptable Performance columns of the Action Matrix, [C5] 

and those plants that have remained in the Degraded Cornerstone Column of 

the Action matrix for 3 or more years. Plants that are under the IMC 0350 

process will also be discussed at this meeting. This meeting is more completely 

described in Management Directive 8.14, “Agency Action Review Meeting.” 

b. Commission Meeting. The EDO will brief the Commission annually to convey 

the results of the Agency Action Review Meeting, including a discussion of any 

deviations from the ROP Action Matrix. [C2] The Commission should be briefed 

within approximately four weeks of the Agency Action Review Meeting, 

consistent with Commission availability, to ensure that the information presented 

is as current as possible. 

06.04 Annual Meeting with Licensee

 a. Scheduling. A public meeting with the licensee is conducted after issuance of 

the annual assessment letters to discuss the results of the NRC’s annual 

assessment of the licensee’s performance. For plants that have been in the 

Degraded Cornerstone, Multiple/Repetitive Degraded Cornerstone, or 

Unacceptable Performance column of the Action Matrix, these meetings should 

be scheduled within 16 weeks of the end of the assessment period. These 

meetings should be conducted no earlier than one week after the annual 

assessment letters are issued in order to allow time for the licensee to review 

the contents of the letter. The 16-week requirement may occasionally be 

exceeded to accommodate the licensee’s schedule or regional scheduling 

conflicts. These meetings may be scheduled within six months of the issuance 

of the annual assessment letters for plants that have been in the Licensee 

Response or Regulatory Response column of the Action Matrix during the entire 

assessment period. The meeting is conducted onsite or in the vicinity of the site 

and should be scheduled to ensure that it is accessible to members of the 

public. The regional offices should use this meeting as an opportunity to 

engage interested stakeholders on the performance of the plant and the role of 

the agency in ensuring safe plant operations. NRC management, as specified 

in the Action Matrix, conducts the public meeting. The appropriate level of NRC 

management to chair this meeting is determined by the most significant column 

of the Action Matrix that the plant has been in over the assessment cycle. The 

highest level of NRC management, as allowed in the plant’s performance 

column of the Action Matrix, should chair the annual public meeting for those 
Issue Date: XX/XX/XX -17- 0305 

plants that currently have substantive cross-cutting issues as described in the 

annual assessment letter. 

b. Meeting Preparation. The region shall notify those on distribution for the annual 

assessment letters of the meeting with the licensee. The region shall notify the 

media and State and local government officials of the meeting with the licensee 

and the issuance of the annual assessment letter. Commensurate with the level 

of historical interest and/or performance issues, the regional offices should use 

the following additional tools to inform members of the public of the meeting, as 

appropriate: press releases, advertisements in local newspapers, or letters 

soliciting attendance to known interested parties. 

 c. Conduct of Licensee Meeting. The annual public meeting is intended to provide 

an opportunity for the NRC to engage interested stakeholders on the 

performance of the plant and the role of the agency in ensuring safe plant 

operations. NRC management, as specified in the Action Matrix, will discuss 

the agency’s evaluation of licensee performance as documented in the annual 

assessment letter. This meeting is considered to be a category 1 meeting in 

accordance with the Commission’s policy on public meetings. 

The annual assessment letters provide the minimum performance information 

that should be conveyed to the licensee in the annual public meeting. However, 

this does not preclude the presentation of additional plant performance 

information when placed in the proper context. The licensee should be given 

the opportunity to respond at the meeting to any information contained in the 

annual assessment letter. The licensee should also be given the opportunity to 

present to the NRC any new or existing programs that are designed to maintain 

or improve their current performance. 

The annual meeting will be a public meeting with the exception that the meeting 

must be closed for such portions which may involve matters that should not be 

publicly disclosed under Section 2.390 of Title 10 of the Code of Federal 

Regulations (10 CFR 2.390). Members of the public, the press, and 

government officials from other agencies are considered as observers during 

the conduct of the meeting. However, attendees should be given the 

opportunity to ask questions of the NRC representatives after the conclusion of 

the meeting. 

06.05 NRC Responses to Licensee Performance

 a. Description of the Action Matrix. The Action Matrix (Exhibit 4) was developed 

with the philosophy that, within a certain level of safety performance (e.g., the 

licensee response band), licensees would address their performance issues 

without additional NRC engagement beyond the baseline inspection program. 

Agency action beyond the baseline inspection program will normally occur only 

if assessment input thresholds are exceeded. The Action Matrix identifies the 

range of NRC and licensee actions and the appropriate level of communication 
Issue Date: XX/XX/XX -18- 0305 

for varying levels of licensee performance. The Action Matrix describes a 

graded approach in addressing performance issues. A few terms are used 

throughout the discussion of the Action Matrix. These are: 

1. Regulatory Performance Meetings. Regulatory performance meetings are 

held between licensees and the agency to discuss corrective actions 

associated with safety significant inspection findings. Each safety 

significant assessment input shall be discussed in one of the forums listed 

below in order to arrive at a shared understanding of the performance 

issues, underlying causes, and planned licensee actions. These meetings 

may take place at periodic inspection exit meetings between the agency 

and the licensee, a periodic NRC management visit, conference calls, or 

public meetings after completion of the supplemental inspection. This 

meeting should be documented in an inspection report or a public meeting 

summary, as appropriate. 

2. Licensee Action. Anticipated actions by the licensee in response to 

overall performance indicated by the appropriate column of the Action 

Matrix. If these actions are not being taken by the licensee then the 

agency may consider expanding the scope of the applicable supplemental 

inspection to appropriately address the area(s) of concern. This would not 

be considered a deviation from the Action Matrix in accordance with 

section 06.06.f of this manual chapter. 

 3. NRC Inspection. The range of NRC inspection activities in response to 

performance indicated by the appropriate column of the Action Matrix. 

 4. Regulatory Actions. Range of actions that may be taken by the agency in 

response to performance indicated by the appropriate column of the 

Action Matrix. 

5. Communication. Communication between the licensee and the NRC is 

based on a graded approach. For declining licensee performance, higher 

levels of agency management will review and sign the assessment letters 

and conduct the annual public meeting. 

 b. Expected Responses for Performance in Each Action Matrix Column. The 

Action Matrix lists expected NRC and licensee actions based on the inputs to 

the assessment process. Actions are graded such that the agency becomes 

more engaged as licensee performance declines. Listed below are the ranges 

of expected NRC and licensee actions for each column of the Action Matrix: 

1. Licensee Response Column. All assessment inputs are green. The 

licensee will receive only the baseline inspection program and identified 

deficiencies will be addressed through the licensee’s corrective action 

program. 
Issue Date: XX/XX/XX -19- 0305 

2. Regulatory Response column. Assessment inputs result in no more than 

one white input in any cornerstone and no more than two white inputs in 

any strategic performance area. The licensee is expected to place the 

identified deficiencies in its corrective action program and perform an 

evaluation of the root and contributing causes. The licensee’s evaluation 

will be reviewed during inspection procedure 95001, “Supplemental 

Inspection for One or Two White Inputs in a Strategic Performance Area.” 

Following completion of the inspection, the branch chief or division director 

should discuss the performance deficiencies and the licensee’s proposed 

corrective actions with the licensee. The regulatory performance meeting 

will normally occur at an inspection exit meeting, at a periodic NRC 

management visit, or a conference call between the licensee and the 

appropriate branch chief (or division director). 

3. Degraded Cornerstone Column. Assessment inputs result in a degraded 

cornerstone (2 or more white inputs or one yellow input) or 3 white inputs 

to any Strategic Performance Area. The licensee is expected to place the 

identified deficiencies in its corrective action program and perform an 

evaluation of the root and contributing causes for both the individual and 

the collective issues. This evaluation should also determine whether 

deficient safety culture components caused or significantly contributed to 

the risk-significant performance issues. If so, those safety culture 

deficiencies should be entered into the plant’s corrective action program. 

The licensee’s evaluation will be reviewed during inspection procedure 

95002, “Supplemental Inspection for One Degraded Cornerstone Or Any 

Three White Inputs in a Strategic Performance Area.” Also, an 

independent assessment of the extent of condition will be performed by 

the region using appropriate inspection procedures chosen from the tables 

contained in Appendix B to Inspection Manual Chapter 2515. Additionally, 

the NRC may request that the licensee complete an independent 

assessment of safety culture, if the NRC identified through the IP 95002 

inspection and the licensee did not recognize, that one or more safety 

culture component deficiencies caused or significantly contributed to the 

risk-significant performance issues. [C4] In this context, an independent 

assessment is an assessment that is performed by qualified individuals 

that have no direct authority and have not been responsible for any of the 

areas being evaluated. The staff should use appropriate elements from 

IP95003, “Supplemental Inspection for Repetitive Degraded Cornerstones, 

Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red 

Input” to evaluate the results of the licensee’s independent safety culture 

assessment. Following completion of the inspection, the regional 

administrator (or designee) should discuss the performance deficiencies 

and the licensee’s proposed corrective actions with the licensee. The 

regulatory performance meeting will normally consist of a public meeting 

between the licensee and the appropriate regional administrator (or 

designee). 

Comment [rag5]: Related to 

Recommendation PV-3 on need for 

inspection guidance on how NRC would 

evaluate the adequacy of a licensee safety 

culture assessment performed in response 

to an NRC request. 
Issue Date: XX/XX/XX -20- 0305 

Any licensee remaining in the Degraded Cornerstone Column for three 

years or more may be invited to meet with the Commission to discuss 

performance issues and their plan for addressing those issues. [C5] 

 4. Multiple/Repetitive Degraded Cornerstone column. Assessment inputs 

result in a repetitive degraded cornerstone (2 white or 1 yellow input for 

five or more consecutive quarters), multiple degraded cornerstones, 

multiple yellow inputs or a red input. Regarding repetitive degraded 

cornerstone, if the only greater than green findings in the fifth quarter have 

been held open greater than four quarters, the repetitive degraded 

cornerstone does not apply. If, however, one of the greater than green 

findings is still within the original four quarters and one or more findings 

has been held open greater than four quarters, the repetitive degraded 

cornerstone does apply. In this instance, the plant would stay in the 

Multiple/Repetitive Degraded Cornerstone column until there was only one 

greater than green finding, regardless of the length of time the findings 

have been opened. 

The licensee is expected to place the identified deficiencies in its 

corrective action program and perform an evaluation of the root and 

contributing causes for both the individual and the collective issues. This 

evaluation may consist of a third party assessment. The licensee is also 

expected to perform a third-party assessment of their safety culture. [C4] 

In this context, third-party assessment is an assessment that is performed 

by qualified individuals who are not employees of the plant or the utility 

operator(s) of the plant. 

Inspection procedure 95003, “Inspection for Repetitive Degraded 

Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or 

One Red Input,” will be performed to review the breadth and depth of the 

performance deficiencies, assess the licensee’s evaluation of their safety 

culture, and independently perform an assessment of the licensee’s safety 

culture. A decision not to independently perform an assessment of the 

licensee’s safety culture would be a deviation from the Action Matrix and 

would have to be approved in accordance with section 06.06.f. However, 

the results from a licensee’s third party safety culture assessment and the 

licensee’s root cause evaluation can be used to satisfy completion of the 

inspection requirements following the staff’s validation of the third party 

assessment methodology and assessment effort and root cause 

evaluation. The supplemental inspection plan must be approved by the 

appropriate regional division director with concurrence of the Deputy 

Director of the Division of Inspection and Regional Support (DIRS). 

 Following the completion of the inspection, the EDO or his designee, in 

conjunction with the regional administrator and the Director of NRR, will 

decide whether additional agency actions are warranted. These actions 

Deleted: an independent

Deleted: an independent

Deleted: that have no direct 

authority and have not been 

responsible for any of the areas being 

evaluated

Comment [rag6]: Changes made to 

align with IP95003 expectations for a 

third-party safety culture assessment. 

Comment [rag7]: Related to 

Recommendation PV-20 to allow 

additional flexibility for IP95003. 
Issue Date: XX/XX/XX -21- 0305 

could include additional supplemental inspection, a demand for 

information, a confirmatory action letter, or issuance of an order, up to and 

including a plant shutdown. At a minimum, the regional office will issue a 

confirmatory action letter to document the licensee’s commitments as 

discussed in their performance improvement plan, as well as any other 

written or verbal commitments. The regional administrator should 

document the results of their decision in a letter to the licensee. These 

regulatory actions may also be considered prior to the completion of 

inspection procedure 95003, if warranted. The regulatory performance 

meeting will normally consist of a public meeting between the licensee and 

the regional administrator (or the EDO and Deputy EDO). 

Note: Other than the CAL, the regulatory actions listed in this column of the 

Action Matrix are not mandatory. However, the regional office should 

consider each of these regulatory actions when significant new information 

regarding licensee performance becomes available. 

Due to the depth and/or breadth of performance issues reflected by a 

plant being in the Multiple/Repetitive Degraded Cornerstone column of the 

Action Matrix, it is prudent to ensure that actual performance 

improvements (which typically take longer than several quarters to 

achieve) have been made prior to closing out the inspection findings and 

exiting the Multiple/Repetitive Degraded Cornerstone column of the Action 

Matrix. [C2] In making this determination, the regional offices should 

consider whether: 

 (a) New plant events or findings do not reveal similar significant 

performance weaknesses. 

 (b) NRC and licensee performance indicators do not indicate similar 

significant performance weaknesses that have not been adequately 

addressed. 

 (c) The licensee’s performance improvement program has 

demonstrated sustained improvement. 

 (d) NRC supplemental inspections show licensee progress in the 

principal areas of weakness. 

 (e) There were no issues that led the NRC to take additional regulatory 

actions beyond those listed in the Multiple/ Repetitive Degraded 

Cornerstone Column of the Action Matrix. Additionally, the licensee 

has made significant progress on any regulatory actions which were 

imposed (i.e. CALs, orders, 50.54 (f) letters) because of the 

performance deficiencies which led to the Multiple/Repetitive 

degraded cornerstone designation. 
Issue Date: XX/XX/XX -22- 0305 

After the original findings have been closed out, the licensee will return to 

the Action Matrix column that is represented by the other outstanding 

safety-significant inspection findings and performance indicators. 

Additionally, for a period of up to one year after the initial findings have 

been closed out, the regional offices may utilize some actions that are 

consistent with the Degraded Cornerstone or Multiple/Repetitive Degraded 

Cornerstone column of the Action Matrix in order to ensure the appropriate 

level of agency oversight of licensee improvement initiatives. [C2] These 

actions, which do not constitute a deviation from the Action Matrix, include 

senior management participation at periodic meetings/site visits focused 

on reviewing the results of improvement initiatives (such as efforts to 

reduce corrective action backlogs and progress in completing the 

Performance Improvement Plan), non-baseline IP 95003 and CAL followup inspections (not to exceed 200 hours of direct inspection without 

concurrence from the Deputy Director of the Division of Inspection and 

Regional Support (DIRS), the annual public meetings, and authorization of 

the contents of the subsequent assessment letters. The actions taken 

above those required by the Action Matrix shall be discussed at the 

following mid-cycle and end-of-cycle review meetings to ensure an 

appropriate basis for needing the additional actions to oversee the 

licensee improvement initiatives. These actions will also be described in 

the following mid-cycle and annual assessment letters until the end of the 

extended period of time. All assessment letters that address these 

additional actions shall include the NRR Performance Assessment Branch 

(IPAB) on concurrence. 

 The regional offices must convey the specific actions that the licensee 

needs to address to remove the findings that caused the licensee to enter 

the Multiple/Repetitive Degraded Cornerstone column from consideration 

in the assessment program. The correspondence to the licensee 

describing the extension of the inspection finding(s) in the assessment 

program beyond the normal four quarters must be authorized by the 

appropriate regional division director with the concurrence of the Deputy 

Director of the Division of Inspection and Regional Support (DIRS). 

In addition, a licensee is expected to meet with the Commission within 6 

months of entering Column 4 to discuss their plans for addressing the 

performance deficiencies and their plans for improvement. [C5] 

5. Unacceptable Performance column. Licensee performance is 

unacceptable and continued plant operation is not permitted within this 

column. In general, it is expected, but not required, that entry into the 

Multiple/Repetitive Degraded Cornerstone column of the Action Matrix and 

completion of supplemental inspection procedure 95003 will precede 

consideration of whether a plant is in the Unacceptable Performance 

column. The EDO or Deputy EDO will meet with senior licensee 
Issue Date: XX/XX/XX -23- 0305 

management in a regulatory performance meeting to discuss the 

licensee’s degraded performance and the corrective actions. The 

Commission will meet with senior licensee management to discuss the 

issues which will need to be taken before operation of the facility can be 

resumed. The licensee is also expected to perform a third-party

assessment of their safety culture. [C4] A third-party assessment is 

performed by qualified individuals who are not employees of the plant or 

the utility operator(s) of the plant. The NRC will assess the licensee’s 

evaluation of their safety culture, and independently perform an 

assessment of the licensee’s safety culture using the guidance contained 

in Inspection Procedure 95003. A decision not to independently perform 

an assessment of the licensee’s safety culture would be a deviation from 

the Action Matrix and would have to be approved in accordance with 

section 06.06.f. However, the results from a licensee’s third party safety 

culture assessment and the licensee’s root cause evaluation can be used 

to satisfy completion of the inspection requirements following the staff’s 

validation of the third party assessment methodology and assessment 

effort and root cause evaluation. The NRC oversight of plant performance 

will also be placed under the guidance of IMC 0350. Unacceptable 

performance represents situations in which the NRC lacks reasonable 

assurance that the licensee can or will conduct its activities to ensure 

protection of public health and safety. Examples of unacceptable 

performance may include: 

(a) Multiple significant violations of the facility’s license, technical 

specifications, regulations, or orders. 

(b) Loss of confidence in the licensee’s ability to maintain and operate 

the facility in accordance with the design basis (e.g., multiple safety 

significant examples where the facility was determined to be outside 

of its design basis, either due to inappropriate modifications, the 

unavailability of design basis information, inadequate configuration 

management, or the demonstrated lack of an effective problem 

identification and resolution program). 

(c) A pattern of failure of licensee management controls to effectively 

address previous significant concerns to prevent recurrence. 

Note: If the agency determines that a 

licensee’s performance is unacceptable 

then a shutdown order will be issued. 

 6. IMC 0350 Process Column. The criteria for entrance into the IMC 0350 

process, as discussed in section 06.06.g of this manual chapter, has been 

met. Subsequent management review of licensee performance has 

determined that entrance into the Unacceptable Performance column is not 

Deleted: n independent

Comment [rag8]: Align with 

IP95003 expectations. 
Issue Date: XX/XX/XX -24- 0305 

warranted at this time. Additionally, NRC management will review licensee 

performance on a quarterly basis to determine if entrance into the 

Unacceptable Performance column is warranted. The licensee is expected 

to place the identified deficiencies into their performance improvement plan 

and perform an evaluation of the root and contributing causes for both the 

individual and collective causes. 

As discussed in IMC 0350, the regional offices will conduct baseline and 

supplemental inspections as appropriate, as well as special inspections per 

the restart checklist. Performance indicator data should continue to be 

gathered in accordance with IMC 0608, “Performance Indicator Program,” 

to the extent that it is applicable to shutdown conditions. 

Plants under the IMC 0350 process are considered to be outside of the 

normal assessment process and under the auspices of IMC 0350. 

However, this column has been added to the Action Matrix for illustrative 

purposes to demonstrate comparable agency response and 

communications and is not necessarily representative of the worst level of 

licensee performance. Plants under the IMC 0350 process should be 

discussed at the mid-cycle and end-of-cycle reviews to integrate inspection 

planning efforts across the regional office and to keep internal stakeholders 

abreast on ongoing inspection and oversight activities. Mid-cycle or annual 

assessment letters are generally not issued for these plants. Annual public 

meetings will not be conducted for these plants as the regional office 

conducts periodic public meetings to discuss licensee performance. As 

discussed in section 06.06.h, the regional offices may utilize some actions 

that are consistent with the Degraded Cornerstone or Multiple/Repetitive 

Degraded Cornerstone column of the Action Matrix in order to ensure the 

appropriate level of agency oversight of licensee improvement initiatives as 

the licensee exits the IMC 0350 Process. [C2] 

06.06 Additional Action Matrix Guidance

a. Treatment of Items Associated with Enforcement Discretion

A finding that includes a violation that meets all applicable requirements for 

enforcement discretion and meets the criteria discussed below, will be 

processed as specified in this section. The intent of this section is to establish 

ROP guidance that supports the objective of enforcement discretion, which is to 

encourage licensee initiatives to identify and resolve problems, especially those 

subtle issues that are not likely to be identified by routine efforts. 

Findings that include a violation subject to enforcement discretion must be 

dispositioned under one of the following categories: 

1. Treatment of Old Design Issues in the Assessment Process. The NRC 

may refrain from considering safety significant inspection findings in the 

assessment program for a design-related finding in the engineering 
Issue Date: XX/XX/XX -25- 0305 

calculations or analysis, associated operating procedure, or installation of 

plant equipment that meets all of the following criteria: 

(a) It was licensee-identified as a result of a voluntary initiative such as 

a design basis reconstitution. For the purposes of this manual 

chapter, self-revealing issues are not considered to be licenseeidentified. Self-revealing issues are those deficiencies which reveal 

themselves to either the NRC or licensee through a change in 

process, capability or functionality of equipment, or operations or 

programs. 

(b) It was or will be corrected, including immediate corrective action and 

long term comprehensive corrective action to prevent recurrence, 

within a reasonable time following identification (this action should 

involve expanding the initiative, as necessary, to identify other 

failures caused by similar root causes). For the purpose of this 

criterion, identification is defined as the time from when the 

significance of the finding is first discussed between the NRC and 

the licensee. Accordingly, issues being cited by the NRC for 

inadequate or untimely corrective action are not eligible for 

treatment as an old design issue. 

(c) It was not likely to be previously identified by recent ongoing 

licensee efforts such as normal surveillance, quality assurance 

activities, or evaluation of industry information. 

 (d) The finding does not reflect a current performance deficiency 

associated with existing licensee programs, policy, or procedure. 

The finding would be brought to a Significance and Enforcement Review 

Panel (SERP) and a Regulatory Conference, if applicable. The finding 

would be discussed in the appropriate inspection report cover letter and 

displayed on the NRC’s web site with its actual safety significance after 

the final safety significance is determined. 

If enough information is already known to determine whether the finding 

meets the old design issue criteria, the licensee should be notified in the 

inspection report cover letter that the finding has been determined to be 

an old design issue. The regional offices should then perform an IP 95001 

supplemental inspection for a white finding or an IP 95002 for a yellow or 

red finding to review the licensee’s root cause evaluation and corrective 

action plan for that particular issue. 

If additional information is needed to determine whether the finding meets 

the old design issue criteria, the inspection report cover letter should state 

that the finding is being considered for treatment as an old design issue. 

The regional offices should then perform an IP 95001 supplemental 
Issue Date: XX/XX/XX -26- 0305 

inspection for a white finding or an IP 95002 for a yellow or red finding to 

review the licensee’s root cause evaluation of that particular issue and to 

gather the additional information required to determine whether the finding 

meets the old design issue criteria. If the finding is determined not to have 

met the criteria for an old design issue, the regional office should conduct 

the additional supplemental inspection effort needed for the appropriate 

Action Matrix column. 

For example, the regional office does not have enough information to 

determine if a red finding meets the criteria for an old design issue. The 

regional office would perform an IP 95002 inspection to review the root cause 

evaluation and gather additional information on whether the finding meets the 

criteria for an old design issue. As a result of the inspection, the regional office 

determines that the criteria has not been met. The regional office would then 

perform the additional inspection activities to complete supplemental inspection 

requirements for an IP 95003 inspection. 

 

If the finding meets all the old design issue criteria, it would not aggregate 

in the Action Matrix with other performance indicators and inspection 

findings nor would additional agency actions be taken. If the finding is 

determined not to meet the old design issue criteria, it would be treated 

similar to any other inspection finding and additional agency actions would 

be taken in accordance with the Action Matrix. 

Example: The NRC has concluded that a white finding in the mitigating 

systems cornerstone meets the criteria for an old design issue for Plant A. 

Plant A also had a previous white PI in the mitigating systems cornerstone. 

This plant would be considered in the Regulatory Response column of the 

Action Matrix due to the white PI, and agency actions would be in accordance 

with that column including a 95001 supplemental inspection for the white PI. 

The old design issue does not aggregate for Plant A in determining the Action 

Matrix column or required agency response. Therefore, the white old design 

issue would be considered independently and a 95001 supplemental inspection 

for that issue would be conducted. 

 The purpose of this approach is to place a premium on licensees initiating 

efforts to identify and correct safety-significant issues that are not likely to 

be identified by routine efforts before degraded safety systems are called 

upon to work. The assessment program evaluates current performance 

issues and this approach excludes old design issues from consideration of 

overall licensee performance in the Action Matrix. The DRP or DRS 

division director will authorize the treatment of findings as old design 

issues with the concurrence of the Deputy Director of the Division of 

Inspection and Regional Support (DIRS). This is not considered a 

deviation from the Action Matrix in accordance with section 06.06.f. 
Issue Date: XX/XX/XX -27- 0305 

2. Violations in Specified Areas of Interest Qualifying for Enforcement 

Discretion. Findings that include violations subject to the following 

enforcement discretion may be dispositioned as described below: 

1. enforcement discretion in accordance with the Interim Enforcement 

Policy Regarding Enforcement Discretion for Certain Fire Protection 

Issues (10CFR50.48(c)) included in the Commission’s Enforcement 

Policy, and 

2. enforcement discretion for violations involving fire protection circuits 

as authorized by Office of Enforcement in Section 8.1.7.1 of the 

NRC Enforcement Manual. 

The NRC will normally refrain from processing the related inspection 

finding through SDP and into the Action Matrix if applicable. The finding 

must be documented in an inspection report noting that the related 

violation meets all applicable requirements for enforcement discretion as 

explicitly provided for in the associated authorizing document, and further 

meets the criteria listed below. 

(a) The licensee places the finding into their corrective action program. 

Licensees may track pre-existing performance 

deficiencies/violations and findings identified during the NFPA 805 

transition period, through the Licensee Event Response (LER) 

process. It is recommended that an LER be developed for each fire 

area or each area of assessment (NFPA 805). 

(b) In cases where the authorizing document requires that a finding 

being given discretion must not be evaluated as Red, the staff may 

meet this provision if they determine that an NRC response at a 

level for a Red finding is not necessary to assure public health and 

safety. The staff does not need to complete an SDP to make this 

determination. 

(c) The licensee performs an operability evaluation (when applicable) 

using the guidelines in Regulatory Information Summary (RIS) 2005-

20 to demonstrate that safety will be maintained during operation 

(both power operation and shutdown, as applicable) with 

compensatory measures as appropriate. 

Licensees will implement appropriate compensatory measures for each 

finding immediately upon identification. Such compensatory measures will 

be maintained while the licensee completes their NFPA 805 evaluation 

and (1) determines whether the existing configuration is acceptable based 

on risk analysis, or (2) there is a need for permanent corrective action if 

the existing configuration is not acceptable, and the corrective action is 

completed. 
Issue Date: XX/XX/XX -28- 0305 

If the above criteria are not met, the staff may take whatever action is 

deemed necessary and appropriate, including the issuance of 

enforcement action, entry into the SDP and (if applicable) the Action 

Matrix, and implementation of supplemental inspections. 

The cover letter that informs the licensee of the staff’s exercise of 

enforcement discretion should include a clear explanation of the staff’s 

basis for exercising enforcement discretion, including a reference to the 

applicable authorizing document(s) and this section of IMC 0305. Also, 

cover letters should be consistent with the guidance provided in Chapter 6 

of the Enforcement Manual. 

Note: If a single finding has multiple related violations of which only a 

subset are eligible to be granted enforcement discretion, then the finding 

will be dispositioned in accordance with the normal SDP and Action Matrix 

process using the assumption that only the violations not subject to 

enforcement discretion existed. The violations subject to enforcement 

discretion will be processed and documented as findings in accordance 

with the provisions of this section. 

 b. “Double-Counting” of Performance Indicators and Inspection Findings. Some 

issues may result in simultaneously crossing a performance indicator threshold 

and generating a safety significant inspection finding. This would result in two 

assessment inputs combining to cause increased regulatory action per the 

Action Matrix. For example, two white assessment inputs in the mitigating 

systems cornerstone would result in increased regulatory action per the 

Degraded Cornerstone column of the Action Matrix. 

Issues with the same underlying causes should not be “double-counted” in the 

assessment program. However, the most conservative significance 

characterization related to the performance indicator and the inspection finding 

(i.e., yellow vs. white) shall be used to determine the appropriate agency action 

according to the Action Matrix. 

Another example may include an inoperability of a support system that causes a 

white inspection finding as well as several performance indicators to cross the 

green/white threshold. Because the SDP characterization of the finding pertains 

to the same underlying issue, this should be considered a single white issue 

within a cornerstone and not “double-counted” in the assessment program. 

These examples are not considered a deviation from the Action Matrix as 

defined in section 06.06.f of this manual chapter. 

 c. Timeframe to Begin “Counting” Inspection Findings in the Assessment Program. 

The start date used for consideration of inspection findings in the assessment 

program is the end of the inspection period that designates the issue as an AV, 

violation (VIO), finding (FIN), or non-cited violation (NCV) in the reactor program 
Issue Date: XX/XX/XX -29- 0305 

system (RPS). Unresolved Items should be dispositioned according to IMC 

0612 “Power Reactor Inspection Reports”, and appropriately updated in RPS 

when additional information becomes available. For integrated inspection 

reports, this date should be the end of the quarterly inspection period regardless 

of when the exit meeting was conducted. After final determination of the 

significance of an inspection finding, the regional office shall refer back to the 

appropriate date discussed above to determine if any additional action would 

have been taken had the significance of the inspection finding been known at 

that time. 

For example, the performance indicator for Unplanned Scrams was white (low 

to moderate safety significance) for the second quarter of the assessment cycle. 

Additionally, there was an inspection finding in the same cornerstone from the 

second quarter of the assessment cycle whose final safety significance was 

determined to be white (low to moderate safety significance) in the third quarter 

of the assessment cycle. In this case, the appropriate action would be to 

perform supplemental inspection procedure 95002 vice 95001 since there were 

two white assessment inputs in the same cornerstone for the second quarter of 

the assessment cycle. This would be communicated to the licensee in the 

appropriate assessment letter. 

 d. Timeframe for Including Performance Indicators and Inspection Findings in the 

Assessment Program. Inspection findings are normally considered in the 

assessment program for four quarters. However, there may be instances in 

which the corresponding supplemental inspection reveals substantive

inadequacies in the licensee’s evaluation of the root causes of the original 

performance deficiency, determination of the extent of the performance 

problems, or the actions taken or planned to correct the issue. Significant 

weaknesses in the licensee’s evaluation of the performance issue (performance 

indicator or inspection finding) may be subject to additional agency action, 

including additional enforcement actions or an expansion of the supplemental 

inspection procedure as necessary to independently acquire the necessary 

information to satisfy the inspection requirements. Also, for inspection findings, 

the original performance issue will remain open and will not be removed from 

consideration in the assessment program until the weaknesses in the evaluation 

are addressed and corrected. The regional offices must convey the specific 

weaknesses that the licensee needs to address in order to remove this finding 

from consideration in the assessment program. The finding will be removed 

from consideration of future agency actions (per the Action Matrix) when the 

inadequacies in the licensee’s efforts to address the issue have been corrected 

and four quarters of consideration of the original finding in the assessment 

program have been completed. This notification should be included in the cover 

letter of the supplemental inspection report and the finding will be removed from 

consideration in the assessment program after the end of that quarter. In other 

words, the inspection finding will no longer be considered in the assessment 

program starting with the next calendar quarter. The correspondence to the 

licensee describing the extension of an inspection finding in the assessment 
Issue Date: XX/XX/XX -30- 0305 

process beyond the normal four quarters must be authorized by the appropriate 

regional division director with concurrence of the Deputy Director of the Division 

of Inspection and Regional Support (DIRS). 

For significant weaknesses in the licensee’s evaluation of a performance issue 

that are associated with a performance indicator, a parallel performance 

indicator inspection finding will be opened and given the same color as the 

performance indicator. However, this finding will not be double-counted in the 

assessment process. The finding should be discussed at a SERP prior to 

notifying the licensee of the issuance of a parallel performance indicator 

inspection finding. In electing this option, there must be a strong causal link 

between the original performance deficiency and the ineffective corrective 

actions. The regional offices must convey the specific weaknesses that the 

licensee needs to address in order to remove this finding from consideration in 

the assessment process. The finding will be removed from consideration of 

future agency actions (per the Action Matrix) when the inadequacies in the 

licensee’s efforts to address the issue have been corrected. This notification 

should be included in the cover letter of the supplemental inspection report and 

the finding will be removed from consideration in the assessment process after 

the end of that quarter. In other words, the inspection finding will no longer be 

considered in the assessment program starting with the next calendar quarter. 

The correspondence to the licensee describing the parallel inspection finding 

must be authorized by the appropriate regional division director with 

concurrence of the Deputy Director of the Division of Inspection and Regional 

Support (DIRS). 

If this approach is taken by the agency, the regions should issue a violation 

under 10 CFR Part 50, Appendix B, Criterion XVI, “Corrective Action,” if 

applicable. 

 e. Additional Supplemental Inspection Guidance. Generally, the supplemental 

inspection procedure associated with the most significant applicable column of 

the Action Matrix should only be performed on one occasion. One exception 

(see section 06.06.d for more details) is when the regional office has determined 

that the licensee has taken ineffective corrective actions associated with a 

safety significant PI or inspection finding. 

Supplemental inspection procedure scopes should include all white, yellow, or 

red performance issues in the associated degraded cornerstone or strategic 

performance area. For example, if a 95002 inspection is being performed due 

to a yellow PI in the mitigating systems cornerstone, the inspection scope 

should also include any white PIs and inspection findings in that cornerstone. If 

a 95002 procedure is being performed due to three white findings in the reactor 

safety strategic performance area, the inspection scope should include any 

white PIs and inspection findings in the reactor safety strategic performance 

area. 
Issue Date: XX/XX/XX -31- 0305 

If a white inspection finding or PI subsequently occurs in an unrelated 

cornerstone or strategic performance area, the associated supplemental 

inspection should be conducted at the appropriate level. For example, two 

white findings are discovered in the Initiating Events cornerstone which the 

region inspects using IP 95002. Additionally, a white inspection finding is 

discovered in the occupational radiation safety cornerstone. The regional office 

should inspect this finding using IP 95001. 

 f. Deviations from the Action Matrix. There may be rare instances in which the 

regulatory actions dictated by the Action Matrix may not be appropriate. In 

these instances, the agency may deviate from the Action Matrix (which is 

described in section 06.05.a of this manual chapter) to either increase or 

decrease agency action. A deviation is defined as any regulatory action taken 

that is inconsistent with the range of actions discussed in section 06.05 of this 

manual chapter. Deviations from the Action Matrix shall be documented in the 

appropriate letter to the licensee (i.e., assessment follow-up letter, mid-cycle or 

annual assessment letter) or separate docketed correspondence. The 

Executive Director for Operations (EDO) shall approve all deviations from the 

Action Matrix and inform the Commission when deviations are approved and 

annually at the Commission meeting on the results of the AARM. [C1] 

Memorandums requesting deviations from the Action Matrix should be initiated 

by the applicable regional administrator to the EDO and should go through the 

Office Director of NRR for program office approval. Any deviations from the 

Action Matrix shall be documented in the subsequent mid-cycle or annual 

assessment letter. 

Letters requesting deviations from the Action Matrix should include a synopsis 

of the licensee performance deficiencies, the required NRC actions per the 

Action Matrix for these inputs, the proposed alternative actions, and the region’s 

rationale for requesting the deviation. Examples of when deviations from the 

Action Matrix may be considered are: (1) multiple examples of non-SDP 

Severity Level III or greater enforcement actions, or (2) a type of finding 

unanticipated by the SDP that results in an inappropriate level of regulatory 

attention when entered into the Action Matrix. 

 g. Transitioning to the IMC 0350 Process. The normal criteria for considering a 

plant for the IMC 0350 process is (1) plant performance is in the 

Multiple/Repetitive Degraded Cornerstone column or the Unacceptable 

Performance column of the Action Matrix, or a significant operational event has 

occurred as defined by Management Directive 8.3; (2) the plant is shutdown or 

has committed to shutdown the plant to address these performance issues 

(whether voluntary or via an agency order to shutdown); (3) a regulatory hold is 

in effect, such as a Confirmatory Action Letter (CAL) or an agency order; and (4) 

an agency management decision is made to place the plant in the IMC 0350 

process. Management considerations in placing a plant under the IMC 0350 

process are discussed in IMC 0350. At this point, periodic assessment 

(quarterly, mid-cycle, and end-of-cycle) of licensee performance is no longer 
Issue Date: XX/XX/XX -32- 0305 

under the auspices of this manual chapter but is now under the IMC 0350 

process. This process is more completely described in IMC 0350. 

 The following are examples of the appropriate level of regulatory engagement 

between the agency and a licensee once a plant has entered the 

Multiple/Repetitive Degraded Cornerstone column of the Action Matrix and how 

IMC 0350 may be applied: 

 1. Plant A continues to operate and regulatory engagement is dictated by the 

Multiple/Repetitive Degraded Cornerstone column of the Action Matrix. 

The agency performs supplemental inspection procedure 95003 (if not 

already performed) and the plant remains under the level of oversight 

dictated by this manual chapter and is not transferred to the IMC 0350 

process. 

 2. Plant B performs a voluntary shutdown to address performance issues. 

The agency performs supplemental inspection procedure 95003 (if not 

already performed) and issues a confirmatory action letter (CAL) to 

document licensee commitments to the agency. The plant remains under 

the level of oversight dictated by this manual chapter and is not 

transferred to IMC 0350 process. 

 3. Plant C performs a voluntary shutdown to address performance issues. 

The agency issues a CAL to ensure a common understanding of licensee 

commitments to address the underlying performance deficiencies. The 

entry conditions for IMC 0350 have been met and agency management 

determines that this process should be implemented using the criteria in 

IMC 0350. At this point, periodic assessment of licensee performance is 

no longer dictated by this manual chapter and is transferred to the IMC 

0350 process. Plant performance is not determined to be unacceptable. 

 4. Plant D voluntarily shuts down to address performance issues. The 

agency determines that one of the criteria in paragraph 06.05.b for 

unacceptable performance is met. The plant is considered to be in the 

Unacceptable Performance column of the Action Matrix and a shutdown 

order is issued by the agency. The plant is transferred to the IMC 0350 

process. 

 5. Plant E, which is operating, is issued an order by the agency to shutdown 

because it is considered to have met one of the criteria in paragraph 

06.05.b. The licensee’s performance is declared to be unacceptable and 

the plant will be transferred to IMC 0350. 

h. Transitioning out of the IMC 0350 Process. Once the conditions for restart have 

been completed, as discussed in section 06.04 of IMC 0350, the regional 

administrator will issue a restart authorization letter. The restart authorization 

letter will include the basis for restart and the extent of continued Restart 
Issue Date: XX/XX/XX -33- 0305 

Oversight Panel engagement. The panel will determine the duration of their 

oversight activities and the date of the licensee’s return to the routine oversight 

process. 

Additionally, for a period of up to one year after the plant has exited the IMC 

0350 process, the regional offices may utilize some actions that are consistent 

with the Degraded Cornerstone or Multiple/Repetitive Degraded Cornerstone 

column of the Action Matrix in order to ensure the appropriate level of agency 

oversight of licensee improvement initiatives. [C2] These actions, which do not 

constitute a deviation from the Action Matrix, include senior management 

participation at periodic meetings/site visits focused on reviewing the results of 

improvement initiatives (such as efforts to reduce corrective action backlogs and 

progress in completing the Performance Improvement Plan), the annual public 

meetings, authorization of the contents of the subsequent assessment letters, 

and non-baseline Order and CAL follow-up inspections (not to exceed 200 

hours of direct inspection without concurrence from the Deputy Director of the 

Division of Inspection and Regional Support (DIRS). The actions taken, above 

those required by the Action Matrix, shall be discussed at the following midcycle and end-of-cycle review meetings. These actions will also be described in 

the following mid-cycle and annual assessment letters until the end of the 

extended period of time. All assessment letters that address these additional 

actions shall include the NRR Performance Assessment Branch (IPAB) on 

concurrence. 

i. Problem Identification and Resolution (PI&R) Inspections. Each time a facility 

enters the Degraded Cornerstone column of the Action Matrix, the region should 

assess the benefit of performing an additional PI&R team inspection in 

accordance with IP 71152. A maximum of one additional inspection should be 

considered for the two-year period following the quarter in which the facility 

reached the Degraded Cornerstone column of the Action Matrix. In those 

instances where an additional inspection is deemed appropriate, the region 

should provide the basis for its decision to conduct the inspection in the 

appropriate assessment letter (annual assessment letter, mid-cycle letter, or 

assessment follow-up letter) to the licensee. 

06.07 Substantive Cross-Cutting Issues. 

 a. Identification of Cross-Cutting Aspects and Cross-Cutting Themes

The ROP was developed with the presumption that plants which had significant 

performance issues with cross-cutting areas would be revealed through the 

existence of safety-significant PIs or inspection findings. Accordingly, in 

identifying a substantive cross-cutting issue, there must be an NRC concern that 

the licensee has had multiple performance deficiencies that had commonality in 

the central cross-cutting aspects. In order to determine whether substantive 

cross-cutting issues exist at a site, an assessment must be performed during 
Issue Date: XX/XX/XX -34- 0305 

the preparation for the mid-cycle and end-of-cycle assessment meetings. This 

is a three step process: 

1. During the inspection activity, the finding (and any subsequent 

developments associated with the issue) must be reviewed by the 

inspector to identify the cause(s) associated with the cross-cutting 

aspects, if any exists. The level of information available on the cause(s) 

for an issue is normally commensurate with the significance of the issue. 

For risk significant issues, licensees will typically perform a root cause 

evaluation. While for low risk issues, licensees will typically perform an 

apparent cause evaluation. Inspectors should identify the cross-cutting 

aspects of the finding, if any exists, using available causal information. 

The inspectors should identify the cause(s) that provides the most 

meaningful insight into the performance deficiency. Inspectors should 

also identify the cross-cutting aspect of the finding for traditional 

enforcement actions with an associated finding.

For example, consider the case of an inspection finding associated with an 

operator not restoring a component to its proper position as required by 

procedure because the operator failed to use the expected human error 

prevention tool, Place Keeping, which resulted in a procedural step being 

missed. The inspector should identify that the finding has a cross-cutting 

aspect in human performance because the operator failed to implement 

an expected human error prevention technique, NOT because the 

operator failed to follow procedure. 

Inspectors should make this decision based on available causal 

information. Inspectors are not expected to perform independent causal 

evaluations beyond what would be appropriate for the risk significance of 

the issue to obtain more precise causal information. In order to support 

the evaluation of findings with their assigned cross-cutting aspect(s), the 

inspectors should provide sufficient detail in the PIM and provide periodic 

updates as new information becomes available in accordance with IMC 

0306 and IMC 0612. In the event the cross-cutting aspect assignment to 

a finding changes following issuance of an inspection report, the change 

should also be discussed with the licensee in a re-exit and documented in 

a follow-up inspection report.

To assess whether a finding that has a cross-cutting aspect under SCWE 

represents an issue with the environment for raising concerns rather than 

an individual performance issue, the inspector should: confirm that the 

behavior or interaction which impacted the free flow of information relative 

to nuclear safety occurred; that other individuals witnessed the behavior or 

interaction; that the behavior or interaction would reasonably discourage 

individuals from raising safety issues; and that other individuals perceived 

the behavior or interaction as discouraging the raising of safety concerns. 

During the inspection, the inspector and their branch chief should contact 

Deleted: areas

Comment [rag9]: NRR clarification 

of expectations. 

Comment [rag10]: 

Recommendation CI-2, change to align 

with planned revisions to IMC0612 and 

need to keep the process transparent. 
Issue Date: XX/XX/XX -35- 0305 

the SCWE Finding Review Group to discuss the potential assignment of a 

SCWE cross-cutting aspect.

2. During preparation for the mid-cycle and end-of-cycle review meetings, 

each finding is evaluated along with the assigned cross-cutting aspect(s)

of the cross-cutting area components which are described in Section 

06.07.c. This should occur for only those findings that have been 

previously documented with a cross-cutting aspect in the applicable 

inspection report in accordance with IMC 0612. There should typically be 

only one principal cause and one cross-cutting aspect associated with 

each finding. However, on rare occasion it may be appropriate for some 

unique or complex inspection findings with multiple root causes to be 

associated with more than one cross-cutting aspect. In these cases, the 

regional office must obtain concurrence from the NRR Performance 

Assessment Branch Chief. 

3. The findings should be examined to identify whether there are 4 or more 

findings that have the same assigned cross-cutting aspect. The cause of 

the findings should not be evaluated with any greater degree of precision, 

such as attempting to identify sub-cross-cutting aspects.

 b. Criteria For a Substantive Cross-Cutting Issue

A substantive cross-cutting issue in the problem identification and resolution or 

human performance cross-cutting areas would exist if the following two criteria 

are met: 

1. There are 4 or more green or safety significant inspection findings in the 

PIM for the current 12-month assessment period with the same 

documented cross-cutting aspect (i.e., a cross-cutting theme(s)) in the 

cross-cutting areas of human performance or problem identification and 

resolution. The findings should be from more than one cornerstone. 

However, it is recognized that given the significant inspection effort 

applied to the mitigating systems cornerstone, a substantive cross-cutting 

issue may be observed through inspection findings associated with only 

this one cornerstone. Observations or violations that are not findings 

should not be considered in this determination. 

 2. The Agency has a concern with the licensee’s scope of efforts or progress 

in addressing the cross-cutting theme(s). In evaluating whether this 

criteria is met, the regional offices should consider if any of the following 

situations exist: 

- The licensee had not identified or recognized the cross-cutting theme(s)

affected other areas and had not taken any actions to address it. 

Comment [rag11]: Change to 

reinforce IMC0612 Appendix F provision 

on need to communicate with the SCWE 

finding review group.

Deleted: against

Deleted: 

Deleted: associated

Deleted: one of the

Deleted: areas

Deleted: The aspect(s) are expected 

to have been documented in 

accordance with IMC 0612.

Deleted: Once all findings are 

evaluated against the cross-cutting 

aspects, t

Deleted: identify cross-cutting 

themes, if any exists

Comment [rag12]: Recommendation 

CI-4. 

Comment [rag13]: Recommendation 

CI-5. to combine old SCCI criteria 1 and 

2. 

Deleted: all of 

Deleted: three

Deleted: than 3 

Deleted: s

Deleted: ¶

2. There is a cross-cutting theme. 

The findings should be from more 

than one cornerstone. However, it is 

recognized that given the significant 

inspection effort applied to the 

mitigating systems cornerstone, a 

substantive cross-cutting issue may 

be observed through inspection 

findings associated with only this one 

cornerstone.¶

Deleted: 3
Issue Date: XX/XX/XX -36- 0305 

- The licensee recognized the cross-cutting theme(s) affected other areas 

but failed to schedule or take appropriate corrective action.

- The licensee recognized the cross-cutting theme(s) affected other areas 

but waited too long in taking corrective actions. 

- The licensee has implemented a range of actions to address the crosscutting theme(s); however, these actions have not yet proven effective in 

substantially mitigating the cross-cutting theme(s) even though a 

reasonable duration of time has passed. 

If the assessment process identifies multiple cross-cutting themes within a 

cross-cutting area, the staff will identify a single substantive cross-cutting issue 

in the assessment letter based on the criteria above. However, each individual 

cross-cutting theme will be identified in the assessment letter. 

A substantive cross-cutting issue in the safety conscious work environment 

cross-cutting area would exist if the following two criteria are met: 

1. There is a green or safety significant inspection finding in the PIM with a 

documented cross-cutting aspect in the area of safety conscious work 

environment. Observations or violations that are not findings should not 

be considered in this determination, OR 

 

 . The licensee has received a chilling effect letter, OR 

 . The licensee has received correspondence from the NRC which 

transmitted an enforcement action with a severity level of I, II, or III, and 

which involved discrimination, or a confirmatory order which involved 

discrimination. 

 Additionally, for any of the 3 above situations which exists, there is an 

impact on safety conscious work environment that was not isolated, 

 

Note: For the purpose of meeting this criteria, not isolated is defined as 

“an impact where the sphere of influence spans beyond one individual, 

such that multiple individuals, involving different groups (i.e., each shift 

crew, and each functional group such as electrical maintenance, is 

considered a different group within the organization) within the 

organization or levels of the organization are affected. Consideration 

should be given to the roles, responsibilities, and job functions of the 

impacted individuals, as well as insights from the most recent PI&R 

inspection and the number and nature of allegations received during the 

review period.” 

Comment [rag14]: Change made to 

align SCWE with HP/PI&R new criteria 

1 and 2. Simplifies discussions on 

assessment letter content.

Deleted: for the current 12-month 

assessment period

Comment [rag15]: Change made in 

response to an ROP feedback form to 

consider a longer assessment window for 

SCWE inputs. 

Deleted: s

Deleted: 2

Deleted: 3

Deleted: both of the following criteria 

must also be met in order to have a 

substantive cross-cutting issue in 

SCWE: ¶

¶

1.

Deleted: T

Deleted: AND¶

Comment [rag16]: Clarification 

deemed appropriate by Safety Culture 

Focus Team based on insights from 18-

month implementation period.
Issue Date: XX/XX/XX -37- 0305 

This SCWE input is considered for an extended period of time of three 

assessment periods to allow the staff sufficient time to have confidence 

that the licensee has made progress in addressing the SCWE issue. 

 2. The Agency has a concern with the licensee’s scope of efforts or progress 

in addressing the individual and collective performance deficiencies that 

satisfied the previous criteria for SCWE. In evaluating whether this criteria 

is met, the regional offices should consider if any of the following 

situations exist: 

- The licensee had not identified or recognized the SCWE concern affected 

other areas and had not taken any actions to address it. 

- The licensee recognized the SCWE concern affected other areas but 

failed to schedule or take appropriate corrective action. 

- The licensee recognized the SCWE concern affected other areas but 

waited too long in taking corrective actions. 

- The licensee has implemented a range of actions to address the SCWE 

concern; however, these actions have not yet proven effective in 

substantially mitigating the area of concern even though a reasonable 

duration of time has passed.

c. Components Within the Cross-Cutting Areas

 

 The cross-cutting area components (i.e., the components of safety culture 

directly related to one of the cross-cutting areas) are described in this 

section. Descriptions of these components provide cross-cutting aspects 

that are associated with findings by the inspector. [C4] 

Human Performance (H)

1. Decision-Making. - Licensee decisions demonstrate that nuclear safety is 

an overriding priority. Specifically (as applicable): 

(a) The licensee makes safety-significant or risk-significant decisions 

using a systematic process, especially when faced with uncertain or 

unexpected plant conditions, to ensure safety is maintained. This 

includes formally defining the authority and roles for decisions 

affecting nuclear safety, communicating these roles to applicable 

personnel, and implementing these roles and authorities as 

designed and obtaining interdisciplinary input and reviews on safetysignificant or risk-significant decisions. H.1(a) 

Comment [rag17]: Change made for 

an ROP feedback form to consider a 

longer assessment time frame for SCWE 

inputs. 

Deleted: criterions

Comment [rag18]: To align with 

HP/PI&R evaluation aspects. 

Comment [rag19]: Will replace this 

section later with a re-write that 

integrates the 4 “Other” safety culture 

components. The group is also re-writing 

the existing components and aspects to 

make them more distinct, remove 

duplication, and address implementation 

issues. Consideration to look for crosscutting themes at the component level for 

SCCIs. 

Deleted: should be used in the 

evaluation conducted to identify 

cross-cutting themes
Issue Date: XX/XX/XX -38- 0305 

(b) The licensee uses conservative assumptions in decision making and 

adopts a requirement to demonstrate that the proposed action is 

safe in order to proceed rather than a requirement to demonstrate 

that it is unsafe in order to disapprove the action. The licensee 

conducts effectiveness reviews of safety-significant decisions to 

verify the validity of the underlying assumptions, identify possible 

unintended consequences, and determine how to improve future 

decisions. H.1(b) 

(c) The licensee communicates decisions and the basis for decisions to 

personnel who have a need to know the information in order to 

perform work safely, in a timely manner. H.1(c) 

2. Resources - The licensee ensures that personnel, equipment, procedures, 

and other resources are available and adequate to assure nuclear safety. 

Specifically, those necessary for: 

(a) Maintaining long term plant safety by maintenance of design 

margins, minimization of long-standing equipment issues, 

minimizing preventative maintenance deferrals, and ensuring 

maintenance and engineering backlogs which are low enough to 

support safety. H.2(a) 

(b) Training of personnel and sufficient qualified personnel to maintain 

work hours within working hours guidelines. H.2(b) 

(c) Complete, accurate and up-to-date design documentation, 

procedures, and work packages, and correct labeling of 

components. H.2(c) 

(d) Adequate and available facilities and equipment, including physical 

improvements, simulator fidelity and emergency facilities and 

equipment. H.2(d) 

3. Work Control - The licensee plans and coordinates work activities, 

consistent with nuclear safety. Specifically (as applicable): 

(a) The licensee appropriately plans work activities by incorporating 

H.3(a): 

• risk insights; 

• job site conditions, including environmental conditions which may 

impact human performance; plant structures, systems, and 

components; human-system interface; or radiological safety; and 

• the need for planned contingencies, compensatory actions, and 

abort criteria. 
Issue Date: XX/XX/XX -39- 0305 

(b) The licensee appropriately coordinates work activities by 

incorporating actions to address H.3(b) : 

• the impact of changes to the work scope or activity on the plant and 

human performance. 

• the impact of the work on different job activities, and the need for 

work groups to maintain interfaces with offsite organizations, and 

communicate, coordinate, and cooperate with each other during 

activities in which interdepartmental coordination is necessary to 

assure plant and human performance. 

• the need to keep personnel apprised of work status, the operational 

impact of work activities, and plant conditions that may affect work 

activities. 

• the licensee plans work activities to support long-term equipment 

reliability by limiting temporary modifications, operator workarounds, safety systems unavailability, and reliance on manual 

actions. Maintenance scheduling is more preventive than reactive. 

4. Work Practices - Personnel work practices support human performance. 

Specifically (as applicable): 

(a) The licensee communicates human error prevention techniques, 

such as holding pre-job briefings, self and peer checking, and proper 

documentation of activities. These techniques are used 

commensurate with the risk of the assigned task, such that work 

activities are performed safely. Personnel are fit for duty. In 

addition, personnel do not proceed in the face of uncertainty or 

unexpected circumstances. H.4(a) 

(b) The licensee defines and effectively communicates expectations 

regarding procedural compliance and personnel follow procedures. 

H.4(b) 

(c) The licensee ensures supervisory and management oversight of 

work activities, including contractors, such that nuclear safety is 

supported. H.4(c) 

 Problem Identification and Resolution (P)

 

1. Corrective Action Program - The licensee ensures that issues potentially 

impacting nuclear safety are promptly identified, fully evaluated, and that 

actions are taken to address safety issues in a timely manner, 

commensurate with their significance. Specifically (as applicable): 

(a) The licensee implements a corrective action program with a low 

threshold for identifying issues. The licensee identifies such issues 
Issue Date: XX/XX/XX -40- 0305 

completely, accurately, and in a timely manner commensurate with 

their safety significance. P.1(a) 

(b) The licensee periodically trends and assesses information from the 

CAP and other assessments in the aggregate to identify 

programmatic and common cause problems. The licensee 

communicates the results of the trending to applicable personnel. 

P.1(b) 

(c) The licensee thoroughly evaluates problems such that the 

resolutions address causes and extent of conditions, as necessary. 

This includes properly classifying, prioritizing, and evaluating for 

operability and reportability conditions adverse to quality. This also 

includes, for significant problems, conducting effectiveness reviews 

of corrective actions to ensure that the problems are resolved. 

P.1(c) 

(d) The licensee takes appropriate corrective actions to address safety 

issues and adverse trends in a timely manner, commensurate with 

their safety significance and complexity. P.1(d) 

(e) If an alternative process (i.e., a process for raising concerns that is 

an alternate to the licensee’s corrective action program or line 

management) for raising safety concerns exists, then it results in 

appropriate and timely resolutions of identified problems. P.1(e) 

 

2. Operating experience - The licensee uses operating experience (OE) 

information, including vendor recommendations and internally generated 

lessons learned, to support plant safety. Specifically (as applicable): 

(a) The licensee systematically collects, evaluates, and communicates 

to affected internal stakeholders in a timely manner relevant internal 

and external OE. P.2(a) 

(b) The licensee implements and institutionalizes OE through changes 

to station processes, procedures, equipment, and training programs. 

P.2(b) 

3. Self- and Independent Assessments - The licensee conducts self- and 

independent assessments of their activities and practices, as appropriate, 

to assess performance and identify areas for improvement. Specifically 

(as applicable): 

(a) The licensee conducts self-assessments at an appropriate 

frequency; such assessments are of sufficient depth, are 

comprehensive, are appropriately objective, and are self-critical. The 
Issue Date: XX/XX/XX -41- 0305 

licensee periodically assesses the effectiveness of oversight groups 

and programs such as CAP, and policies. P.3(a) 

 (b) The licensee tracks and trends safety indicators which provide an 

accurate representation of performance. P.3(b) 

(c) The licensee coordinates and communicates results from 

assessments to affected personnel, and takes corrective actions to 

address issues commensurate with their significance. P.3(c) 

 Safety Conscious Work Environment (S)

1. Environment For Raising Concerns - An environment exists in which 

employees feel free to raise concerns both to their management and/or 

the NRC without fear of retaliation and employees are encouraged to raise 

such concerns. Specifically (as applicable): 

(a) Behaviors and interactions encourage free flow of information 

related to raising nuclear safety issues, differing professional 

opinions, and identifying issues in the CAP and through self 

assessments. Such behaviors include supervisors responding to 

employee safety concerns in an open, honest, and non-defensive 

manner and providing complete, accurate, and forthright information 

to oversight, audit, and regulatory organizations. Past behaviors, 

actions, or interactions that may reasonably discourage the raising 

of such issues are actively mitigated. As a result, personnel freely 

and openly communicate in a clear manner conditions or behaviors, 

such as fitness for duty issues, that may impact safety, and 

personnel raise nuclear safety issues without fear of retaliation. 

S.1(a) 

(b) If alternative processes (i.e., a process for raising concerns or 

resolving differing professional opinions that are alternates to the 

licensee’s corrective action program or line management) for raising 

safety concerns or resolving differing professional opinions exists, 

then they are communicated, accessible, have an option to raise 

issues in confidence, and are independent, in the sense that the 

program does not report to line management (i.e., those who would 

in the normal course of activities be responsible for addressing the 

issue raised). S.1(b) 

2. Preventing, Detecting, and Mitigating Perceptions of Retaliation - A policy 

for prohibiting harassment and retaliation for raising nuclear safety 

concerns exists and is consistently enforced in that: 
Issue Date: XX/XX/XX -42- 0305 

(a) All personnel are effectively trained that harassment and retaliation 

for raising safety concerns is a violation of law and policy and will 

not be tolerated. S.2(a) 

(b) Claims of discrimination are investigated consistent with the content 

of the regulations regarding employee protection and any necessary 

corrective actions are taken in a timely manner, including actions to 

mitigate any potential chilling effect on others due to the personnel 

action under investigation. S.2(b) 

(c) The potential chilling effects of disciplinary actions and other 

potentially adverse personnel actions (e.g., reductions, outsourcing, 

and reorganizations) are considered and compensatory actions are 

taken when appropriate. S.2(c) 

d. Other Safety Culture Components

This section describes components of safety culture which are not associated 

with cross-cutting areas. These components, when combined with the crosscutting area components described in section 06.07.c., comprise the safety 

culture components. Components in this section are considered during the 

conduct of the supplemental inspection program, while the cross-cutting area 

components are considered during the conduct of both the baseline and 

supplemental inspection programs. [C4] 

1. Accountability - Management defines the line of authority and 

responsibility for nuclear safety. Specifically (as applicable): 

(a) Accountability is maintained for important safety decisions in that the 

system of rewards and sanctions is aligned with nuclear safety 

policies and reinforces behaviors and outcomes which reflect safety 

as an overriding priority. 

(b) Management reinforces safety standards and displays behaviors 

that reflect safety as an overriding priority. 

(c) The workforce demonstrates a proper safety focus and reinforce 

safety principles among their peers. 

2. Continuous learning environment - The licensee ensures that a learning 

environment exists. Specifically (as applicable): 

(a) The licensee provides adequate training and knowledge transfer to 

all personnel on site to ensure technical competency. 

(b) Personnel continuously strive to improve their knowledge, skills, and 

safety performance through activities such as benchmarking, being 

Comment [rag20]: The group is 

working on a re-write of 06.07.c that will 

integrate these 4 “Other” components into 

cross-cutting component space. 
Issue Date: XX/XX/XX -43- 0305 

receptive to feedback, and setting performance goals. The licensee 

effectively communicates information learned from internal and 

external sources about industry and plant issues. 

3. Organizational change management -Management uses a systematic 

process for planning, coordinating, and evaluating the safety impacts of 

decisions related to major changes in organizational structures and 

functions, leadership, policies, programs, procedures, and resources. 

Management effectively communicates such changes to affected 

personnel. 

4. Safety policies - Safety policies and related training establish and reinforce 

that nuclear safety is an overriding priority in that: 

(a) These policies require and reinforce that individuals have the right 

and responsibility to raise nuclear safety issues through available 

means, including avenues outside their organizational chain of 

command and to external agencies, and obtain feedback on the 

resolution of such issues. 

 (b) Personnel are effectively trained on these policies. 

 (c) Organizational decisions and actions at all levels of the organization 

are consistent with the policies. Production, cost and schedule goals 

are developed, communicated, and implemented in a manner that 

reinforces the importance of nuclear safety. 

(d) Senior managers and corporate personnel periodically communicate 

and reinforce nuclear safety such that personnel understand that 

safety is of the highest priority. 

 e Documentation and Follow-Up Actions

The assessment letter should summarize the specific substantive cross-cutting 

issue in one to two paragraphs of text including: 

• identifying the findings and their common cross-cutting aspect used to 

identify the substantive cross-cutting issue,

• for a substantive cross-cutting issue (within a cross-cutting area) that has 

multiple cross-cutting themes, both the single substantive cross-cutting 

issue and each individual cross-cutting theme will be identified in the 

assessment letter,

• placing the cross-cutting issue into the proper safety perspective, 

• describing the agency’s action in the baseline program to monitor the 

issue, specifically indicating how the substantive cross cutting issue will be 

followed up. The following are examples of how to follow up: 

Comment [rag21]: Administrative 

change. 

Deleted: s

Comment [rag22]: Insert to clarify 

historical practice. 
Issue Date: XX/XX/XX -44- 0305 

- through semi-annual trend reviews conducted during the End of 

Cycle and Mid-Cycle reviews; 

- as a PI&R follow-up inspection item in accordance with Inspection 

Procedure 71152, “Identification And Resolution of Problems,” 

Section 03.02, “Selected Issue Follow-up Inspection;” or 

- during a PI&R Team Inspection in accordance with Inspection 

Procedure 71152, “Identification And Resolution of Problems.” 

• stating the agency’s assessment of the licensee’s ability to address the 

substantive cross-cutting issue or the licensee’s progress to correct the 

issue, and 

• defining criteria for clearing the cross-cutting issue (for example, fewer 

number of findings with same causal factor or more confidence in the 

licensee’s corrective action program and their ability to correct issues. In 

the first case if the number of findings in the current assessment was less 

than the number when the cross-cutting issue was opened the substantive 

cross-cutting issue would be cleared. In the second case the substantive 

cross-cutting issue would be cleared if the staff had confidence in the 

licensee’s program even in situations where the substantive cross-cutting 

issue threshold was still exceeded. The trends in the number of findings, 

with the same cross-cutting aspect as the substantive cross-cutting issue, 

in the 2 most recent 6 month periods can also be evaluated when 

considering whether to clear the substantive cross-cutting issue). In the 

absence of clarification in the assessment letter, the criteria for continuing 

to highlight a substantive cross-cutting issue in the next assessment will 

be the criteria used to initiate a substantive cross-cutting issue, i.e. the 

findings for a 12 month assessment window (for PI&R and human 

performance) or the three assessment period window (for SCWE) will be 

analyzed against the above listed conditions in section 06.07.b. In this 

case if the number of findings in the current assessment is less than the 

substantive cross-cutting issue threshold the existing substantive crosscutting issue will be cleared, unless there is an overlapping Confirmatory 

Action Letter that remains open. For a substantive cross-cutting issue 

with multiple cross-cutting themes, all of the cross-cutting themes need to 

be cleared before the substantive cross-cutting issue can be cleared.

A plant that has an outstanding CAL with improvement issues similar to crosscutting areas does not have to meet the three listed conditions to continue to 

follow-up and assess those issues, as completion of the licensee’s 

commitments as specified in the CAL takes precedence. 

When the NRC identifies a substantive cross-cutting issue in the mid-cycle or 

annual assessment letter, the licensee should place this issue into its corrective 

action program, perform an analysis of causes of the issue, and develop 

appropriate corrective actions. The licensee’s completed evaluation may be 

reviewed by the regional office and documented in the next mid-cycle or annual 

assessment letter. 

Comment [rag23]: NRR input to 

provide more objective guidance on 

clearing SCCIs. 

Deleted: three 
Issue Date: XX/XX/XX -45- 0305 

If a substantive cross-cutting issue is discussed in a mid-cycle or annual 

assessment letter, then the next annual or mid-cycle assessment letter should 

address the licensee’s performance in this area. The regional office will 

evaluate the findings for the current assessment period with cross-cutting 

aspects against the above listed criteria and the criteria for clearing the 

substantive cross-cutting issue as outlined in the assessment letter. The next 

mid-cycle or annual assessment letter will either state that: 1) the issue has 

been satisfactorily resolved and reference the inspection report that 

documented the follow-up or summarize the agency’s assessment against the 

above listed criteria, 2) the substantive cross-cutting issue was resolved, while

substantive cross-cutting issue criterion 06.07b(1) was met, the agency does 

not have a concern with the licensee’s scope of efforts or progress in 

addressing the issue, or 3), the letter will summarize the licensee’s progress in 

addressing the issue. 

In the second consecutive assessment letter identifying the same substantive 

cross-cutting issue with the same cross-cutting aspect, the regional office may 

consider the following options. These options include requesting that: (1) the 

licensee provide a response at the next annual public meeting, (2) the licensee 

provide a written response to the substantive cross-cutting issues raised in the 

assessment letters, or (3) a separate meeting be held with the licensee. For the 

third option, the same guidance discussed in section 06.05.b for a regulatory 

performance meeting will be used to determine the appropriate level of 

management to chair the meeting and whether a public meeting is required. 

The regional branch chief or division director should chair the meeting for plants 

within the Licensee Response column of the Action Matrix. The regional office 

should use an IP71152, “Identification and Resolution of Problem” inspection(s) 

to evaluate the licensee’s progress in addressing the substantive cross-cutting 

issue as part of the more in-depth annual review sample.

Additionally, in the third consecutive assessment letter identifying the same 

substantive cross-cutting issue with the same cross-cutting aspect, the regional 

office would typically also request that the licensee perform an assessment of 

safety culture. [C4] Typically, this safety culture evaluation would consist of a 

licensee self-assessment using in-house staff, unless the recurring substantive 

cross-cutting issue was associated with deficiencies in the identification or 

evaluation aspects of the problem identification and resolution program. In this 

case, the licensee is expected to perform an independent assessment of safety 

culture. The regional office should review the safety culture assessment, using 

appropriate elements from IP95003, and document the NRC’s assessment in 

the next mid-cycle or annual assessment letter. If the region believes the 

licensee has failed to resolve the substantive cross-cutting issue in a timely 

manner, the regional office should consider conducting a focused IP71152 

biennial inspection on an annual basis to ensure an appropriate level of 

oversight of the corrective actions involving the safety culture of the facility. 

Comment [rag24]: Need to account 

for extended SCWE assessment period. 

Deleted: current 12-months of 

Deleted: but

Deleted: criteria

Deleted: and (2) were

Deleted: but 

Deleted: cross-cutting theme

Deleted: theme

Comment [rag25]: Administrative 

change. 

Deleted: The regional branch chief 

or division director should chair the 

meeting for plants within the Licensee 

Response column of the Action 

Matrix.

Comment [rag26]: Related to 

Recommendation PV-3. Declined to 

adopt recommendation to modify the 

Action Matrix to address consecutive 

SCCIs. 

Deleted: theme

Deleted: may 

Comment [rag27]: Related to 

Recommendation PV-3. Providing more 

guidance on regulatory responses that are 

appropriate for consecutive SCCIs. 

Declined to adopt recommendation to 

modify the Action Matrix to address 

consecutive SCCIs. 

Comment [rag28]: Clarification of 

expectation. 

Comment [rag29]: Recommendation 

PV-3. 
Issue Date: XX/XX/XX -46- 0305 

In recognition that SCWE related substantive cross-cutting issues are much 

more difficult for licensees to address, and for licensee remedial actions to take 

affect, the regional office can defer requesting the licensee to conduct a safety 

culture assessment, and the consideration of conducting the more frequent 

IP71152 inspections until the fourth consecutive assessment letter identifying 

the same substantive cross-cutting issue with the same SCWE cross-cutting 

aspect.

Note: Sample assessment letters, plant performance summary, and assessment 

meeting agenda, as well as the schedule of assessment activities are located at 

http://nrr10.nrc.gov/rop-digital-city/index.html. 

 

 

END 

EXHIBITS: 

1. Regulatory Framework 

2. Reactor Oversight Process 

3. Process Activities 

4. Action Matrix 

ATTACHMENT: 1. Revision History 

Comment [rag30]: Recommendation 

PV-3. 
Issue Date: XX/XX/XX E1-1 0305 

INITIATING

EVENTS

MITIGATING

SYSTEMS BARRIER

INTEGRITY

EMERGENCY

PREPAREDNESS Cornerstones PUBLIC

RADIATION

SAFETY

OCCUPATIONAL

RADIATION

SAFETY

PHYSICAL

PROTECTION

Strategic

Performance

Areas

REACTOR

SAFETY

RADIATION

SAFETY SAFEGUARDS

HUMAN

PERFORMANCE

SAFETY CONSCIOUS WORK

ENVIRONMENT

PROBLEM

IDENTIFICATION AND

RESOLUTION

PUBLIC HEALTH AND SAFETY

AS A RESULT OF CIVILIAN

NUCLEAR REACTOR

OPERATION

NRC’s Overall

Safety Mission

Exhibit 1: REGULATORY FRAMEWORK

Cross-Cutting Areas
Issue Date: XX/XX/XX E1-2 0305 

THIS PAGE INTENTIONALLY LEFT BLANK 
Issue Date: XX/XX/XX E2-1 0305 

Performance Indicators

Performance Indicators

Significance Evaluations

Management Conference

Monitor Licensee Actions

NRC Inspections

Additional Regulatory Actions

Assessment Process

(Action Matrix)

Enforcement

Significance Determination Process

Supplemental

Inspections

Exhibit 2: REACTOR OVERSIGHT PROCESS

Agency Response Public Meetings

Communications

 Press Releases

 NRC Web Site

 PDR/ADAMS

Assessment Reports

Inspection Plans

Inspection Findings

Performance Indicators

Inspections

Significance Evaluations

Performance Results in all 7 Cornerstones of Safety

Cornerstones of Safety

Performance Indicator Thresholds

Event Response

(SI/AIT/IIT)

Risk Informed

Baseline Inspections

Generic Safety

Inspections
Issue Date: XX/XX/XX E2-2 0305 

THIS PAGE INTENTIONALLY LEFT BLANK 
Issue Date: XX/XX/XX E3-1 0305 

Exhibit 3- Process Activities 

Level of Review

Frequency/ Timing Participants 

(* indicates chairperson)

Desired Outcome Communication

Continuous Continuous SRI, RI, regional 

inspectors, SRAs 

Performance awareness 

None required, notify licensee by an Assessment Follow-Up letter only if thresholds crossed

Quarterly Once per quarter/ 

Five weeks after end of quarter 

DRP: BC*, PE, SRI, RI Input/verify PI/PIM 

data, detect early trends 

Update data set, notify licensee by an Assessment Follow-Up letter only if thresholds crossed

Mid-Cycle At mid-cycle/ 

Seven weeks after end of second quarter 

Divisions of Reactor Safety (DRS) or DRP DD*, DRP and DRS BCs 

Detect trends, plan inspection 

Mid-cycle letter with an inspection plan of approximately 15 months 

End-of-Cycle At end-of-cycle/ 

Seven weeks after end of assessment cycle 

DRS or DRP DD, RAs*, BCs, principal inspectors, SRAs, HQ offices as appr. 

Assessment of plant performance, oversight and coordination of regional actions 

Annual assessment letter with an inspection plan of approximately 15 months 

End-of-Cycle Summary Meeting 

The end-of-cycle summary meeting will be scheduled within one week after the completion of the last regional end-of-cycle review 

DIR NRR, RAs, BCs, DIRS, OE, OI, other HQ offices as appr. 

Summarize results of the end-of-cycle review 

Information to be discussed at Agency Action Review Meeting 

Agency Action Review 

Annually/ Several weeks after issuance of the annual assessment letters 

EDO*,DIR NRR, RAs, DRS/DRP DDs, DIRS, OE, OI, other HQ offices as appr. 

Review of the appropriateness of agency actions 

Commission briefing, followed by public meetings with individual licensees to discuss assessment results 
Issue Date: XX/XX/XX E3-2 0305 

THIS PAGE INTENTIONALLY LEFT BLANK 
Issue Date: XX/XX/XX E4-1 03

Exhibit 4 – ACTION MATRIX 

1 The IMC 0350 Process column is included for illustrative purposes only and is not necessarily representative of the worst level of licensee performance. Plants under the IMC 035

oversight process are considered outside the auspices of the ROP Action Matrix. See IMC 0350, “Oversight of Reactor Facilities in a Shutdown Condition due to Significant Performance and/or Operational Concerns,” for more detail. 2 Other than the CAL, the regulatory actions for plants in the Multiple/Repetitive Degraded Cornerstone column and IMC 0350 column are not mandatory agency actions. Howeverthe regional office should consider each of these regulatory actions when significant new information regarding licensee performance becomes available. 

Licensee Response 

Column

Regulatory Response 

Column

Degraded Cornerstone 

Column

Multiple/ Repetitive 

Degraded Cornerstone 

Column

Unacceptable 

Performance 

Column

IMC 0350 

All Assessment Inputs (Performance Indicators (PIs) and Inspection Findings) Green; Cornerstone Objectives Fully Met

One or Two White Inputs (in different cornerstones) in a Strategic Performance Area; Cornerstone Objectives Fully Met

One Degraded Cornerstone (2 White Inputs or 1 Yellow Input) or any 3 White Inputs in a Strategic Performance Area; Cornerstone Objectives Met with Moderate Degradation in Safety Performance

Repetitive Degraded Cornerstone, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or 1 Red Input; Cornerstone Objectives Met with Longstanding Issues or Significant Degradation in Safety Performance

Overall Unacceptable Performance; Plants Not Permitted to Operate Within this Band, Unacceptable Margin to Safety

Plants in a shutcondition with pproblems placeIMC 0350 proce

Regulatory Performance Meeting

None Branch Chief (BC) or 

Division Director (DD) Meet with Licensee

Regional Administrator (RA) (or designee) Meet with Senior Licensee Management. 

EDO or DEDO Meet with Senior Licensee Management 

EDO or DEDO Meet with Senior Licensee Management 

RA (or EDO) MSenior Licensee Management

Licensee Action Licensee Corrective Action Licensee Root cause 

Evaluation and corrective action with NRC Oversight

Licensee cumulative root cause evaluation with NRC Oversight

Licensee Performance Improvement Plan with NRC Oversight

Licensee PerfoImprovement PPlan with NRC 

NRC Inspection Risk-Informed Baseline 

Inspection Program 

Baseline and supplemental inspection procedure 95001

Baseline and supplemental inspection procedure 95002

Baseline and supplemental inspection procedure 95003

Baseline and Sas Practicable, Inspections per Checklist.

Regulatory Actions2

None Supplemental inspection 

only 

Supplemental inspection only Plant Discussed at AARM if Conditions Met

-10 CFR 2.204 DFI -10 CFR 50.54(f) Letter - CAL/Order Plant Discussed at AARM

Order to Modify, Suspend, or Revoke Licensed 

Activities 

Plant Discussed at AARM

CAL/Order Req

Approval for Re

Plant Discussed 

Assessment Letters

BC or DD review/sign assessment report (w/ inspection plan)

DD review/sign assessment report (w/ inspection plan)

RA review/sign assessment report (w/ inspection plan)

RA review/sign assessment report (w/ inspection plan)

N/A. RA (or 035Chairman) Rev0350-Related Correspondenc

Annual Public Meeting

SRI or BC Meet with Licensee

BC or DD Meet with Licensee 

RA (or designee) Discuss Performance with Senior Licensee Management

EDO or DEDO Discuss Performance with Senior Licensee Management 

N/A. 0350 PanConduct Public Meetings Period

Commission Involvement

None None Possible Commission 

Meeting if Licensee Remains for 3 yrs 

Commission Meeting with Senior Licensee Management Within 6 mo.

Commission Meeting with Senior Licensee Management 

Commission MeRequested, Resin Some Cases

INCREASING SAFETY SIGNIFICANCE ---------->
Issue Date: XX/XX/XX E4-2 03

ATTACHMENT 1 

Revision History For IMC 0305 

4Commitment Tracking Number 

Issue Date 

Description of Change Training Needed Training 

Completion Date 

Comment Resolution Accession Number 

N/A 04/24/2000 

CN 00-009 

Provide guidance on thex 

None N/A 

C1 03/23/2001 

CN 01-009 

Incorporated feedback from stakeholders and added guidance on approval and notification of deviation requests (Staff Requirements memo dated 5/17/00) 

None N/A 

N/A 02/11/2002 

CN 02-005 

Incorporate lessons learned since ROP issuance 

None N/A 

N/A 02/19/2003 

CN 03-005 

Incorporated feedback from stakeholders 

None N/A 

N/A 01/29/04 

CN 04-002 

Incorporated feedback from stakeholders 

None N/A 
Issue Date: XX/XX/XX E4-3 03

C2 12/21/2004 

CN 04-028 

Incorporated feedback from stakeholders. Review deviations for possible changes to ROP guidance and discussion of the deviations (Staff Requirements memo dated 5/27/04) 

None N/A 

C3 12/21/2004 

CN 04-028 

Utilizing independent assessments of licensee performance (DBLLTF 3.3.3(1)) 

None N/A 

N/A 11/15/2005 

CN 05-029 

Incorporated feedback from stakeholders 

Yes, computerbased training 08/30/2005 

C4 06/22/06 

CN 06-015 

Enhancing the ROP to more fully address safety culture (SRM 04-0111) 

Yes, computerbased training and counterpart meeting training 

07/01/2006 ML 061520403 

N/A 01/25/07 

CN 07-003 

Incorporate feedback from stakeholders 

None N/A ML 070080358 

N/A 04/04/07 

CN 07-012 

Incorporated feedback from stakeholders to number cross-cutting aspects. 

None. N/A N/A (administrative 

change) 

C5 

CN 07-036 11/27/07 

Revised the Action Matrix for plants in Column 3 and 4 (SRM COMSECY-07-0005) 06/29/07 

None. N/A ML073230132