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NRC INSPECTION MANUAL IPAB 

INSPECTION PROCEDURE 71152 

IDENTIFICATION AND RESOLUTION OF PROBLEMS 

 

PROGRAM APPLICABILITY: 2515 

CORNERSTONES: ALL 

INSPECTION BASIS: A fundamental goal of the NRC=s reactor oversight process 

is to establish confidence that each licensee is detecting 

and correcting problems in a manner that ensures nuclear 

safety is a top priority and limits the risk to members of the 

public. A key premise of the Reactor Oversight Process is 

that weaknesses in licensee=s problem identification and 

resolution (PI&R) programs will manifest themselves as 

performance issues which will be identified during the 

baseline inspection program or by crossing predetermined 

performance indicator thresholds. However, several 

aspects of PI&R are not specifically addressed by either the 

individual cornerstone performance indicators or other 

baseline inspections. These are detailed in the following 

objectives. Completion of the inspection objectives is 

accomplished by screening all corrective action program 

issues, by performing a semiannual trend review, by 

sampling issues during each inspectible area inspection, by 

performing focused reviews of four to seven samples per 

year, and by performing a biennial PI&R team inspection. 

71152-01 INSPECTION OBJECTIVES 

01.01 To provide for early warning of potential performance issues that could result in 

crossing thresholds in the action matrix. 

01.02 To help the NRC gage supplemental response should future action matrix 
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thresholds be crossed. 

01.03 To provide insights into whether licensees have established a safety conscious 

work environment. 

01.04 To allow for follow-up of previously identified compliance issues (e.g., NCVs). 

01.05 To provide additional information related to the cross-cutting areas that can be used 

in the assessment process. 

01.06 To determine whether licensees are complying with NRC regulations regarding 

corrective action programs. 

01.07 To verify that the licensee is identifying operator workarounds at an appropriate 

threshold and entering them in the corrective action program. 

71152-02 INSPECTION REQUIREMENTS 

Within the baseline inspection program, problem identification and resolution (PI&R) 

activities are reviewed in three discrete but interdependent locations: as part of specific 

inspectible area inspection procedures (discussed in section 02.01 of this procedure); 

during follow-up to selected issues via paragraph 02.02 of this procedure; and during a 

biennial team inspection as specified in paragraph 02.03 of this procedure. 

02.01 Routine Review of Identification and Resolution of Problems. 

Inspections of problem identification and resolution activities include the following: 

 a. Resident inspectors (RIs) should screen of each item entered into the corrective 

action program to select the best samples for follow-up. This review can be 

accomplished by attending daily corrective action program review board meetings, 

by viewing computerized corrective action program entries, or by reading hard 

copies of corrective action program documents. The intent of this review is to be 

alert to conditions such as repetitive, long-term, or latent equipment failures or 

cross-cutting components that might warrant additional follow-up through other 

baseline inspection procedures or through section 02.02 or 02.03 of this inspection 

procedure. Further, be alert for adverse performance trends and risk significant or 

repetitive equipment failures. Among the items that might indicate a trend would be 

repeated entries into technical specifications. The time spent completing this 

review should be charged to this procedure and should generally be less than 30 

minutes per day. [C1] 

 b. Verify that corrective actions commensurate with the significance of the issue have 

been identified and implemented by the licensee. 

 c. Verify that equipment, human performance, and program issues are being identified 

by the licensee at an appropriate threshold, and being entered into the problem 

identification and resolution program.
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 d. Perform a semiannual review to identify trends (either NRC or licensee identified) 

that might indicate the existence of a more significant safety issue. Included within 

the scope of this review should be repetitive or closely related issues that may have 

been documented by the licensee outside the normal corrective action program, 

such as in trend reports or performance indicators, major equipment problem lists, 

repetitive and/or rework maintenance lists, departmental problem/challenge lists, 

issues that challenge operators in performing duties, including workarounds, 

system health reports, quality assurance audit/surveillance reports, self 

assessment reports, maintenance rule assessments, or corrective action backlog 

lists. Also consider emerging or existing cross-cutting themes during the semiannual trend review to develop insights into the licensee’s progress in addressing 

the themes. This review can be performed by summarizing the results of the 

licensee=s reviews and comparing those results to those identified by the NRC 

through the baseline or supplemental inspection program, including issues 

identified as a result of the daily review of corrective action program items 

discussed above. If a biennial PI&R inspection is scheduled within six months of 

the semiannual review, the senior resident inspector could forward any concerns to 

the PI&R team. This information should be incorporated into the scope of the team 

inspection. The results of this review should be documented as per paragraph 

03.01c of this procedure. [C1] 

One of the primary goals of these routine reviews is to verify that licensees are identifying 

issues at an appropriate threshold, entering issues into the corrective action program. This 

can be assessed by comparing those issues identified by the NRC during the conduct of 

the plant status and inspectible area portions of the program with those issues identified by 

the licensee. This requirement is normally to be accomplished by resident inspectors and 

region-based inspectors responsible for conducting plant status and baseline inspections. 

These routine reviews, along with those reviews conducted via section 02.02 of the 

procedure also allow for follow-up to selected issues and operational occurrences to ensure 

that corrective actions commensurate with the significance of the issues have been 

identified and implemented by the licensee. 

During inspector reviews of plant status and during inspections, inspectors should be alert 

for potential performance deficiencies such as equipment failures, inadequate maintenance 

work practices, personnel errors, inadequate risk assessment, management and emergent 

work control problems, procedure deficiencies, or noncompliances with procedures or 

regulatory requirements. When inspectors note such conditions, inspectors should examine 

the licensee=s corrective action program records and/or attend licensee corrective action 

program meetings, to verify that the licensee identified the conditions noted by the 

inspector, and entered those conditions into the licensee=s corrective action program. 

Inspectors should also be aware of the contribution that the cross-cutting components (as 

described in IMC 0305) make to these performance deficiencies, and consider insights that 

these issues may provide into the licensee’s progress in addressing any developing or 

existing cross-cutting themes. 
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In addition to the screening review that is required of all issues entered into the corrective 

action program, inspectors should also review a sample of issues to verify that the licensee 

has appropriately classified the issue and has taken appropriate short term corrective 

actions. [C1] 

Inspectors should remain alert to problems/conditions which are potentially not minor and 

for which the licensee=s investigation, conclusions, and/or corrective actions appear to be, 

in some way, inadequate. Inspectors should also review the circumstances associated with 

the licensee=s investigation and disposition of the problem/condition, to determine the 

reason(s) why the licensee=s results were not adequate. The selected samples should be 

reviewed against the performance attributes contained in paragraph 03.01.b, as applicable. 

When inspectors find that the licensee=s identification, classification, immediate disposition, 

and/or final disposition of a condition adverse to quality are not in compliance with the 

licensee=s procedures and/or regulatory requirements, the inspectors should assess the 

significance of that finding in accordance with IMC 0609. 

Document the results in accordance with the quarterly inspection report guidance contained 

in IMC 0612, Section 4OA2 of the sample inspection report, and section 03.01.c. of this 

procedure. [C1] 

02.02 Selected Issue Follow-up Inspection. 

In addition to the above reviews which are performed as part of Aplant status@ or other 

baseline inspection procedures, a sample of four to seven issues per year should be 

selected for a more in-depth periodic review. One of these samples must be an in-depth 

review of the operator workarounds. These samples need not be directly tied to the other 

baseline inspection procedure attachments and should generally be spread across the 

cornerstones of safety. 

The operator workaround review shall verify that the licensee is identifying operator 

workaround problems at an appropriate threshold and entering them in the corrective action 

program, and has proposed or implemented appropriate corrective actions. Use the 

general guidance contained in section 71152-03 as an aid in selecting samples for review. 

The selected samples should be reviewed against the performance attributes contained in 

paragraph 03.01.b. Document the inspection results in accordance with the quarterly 

inspection report guidance contained in IMC 0612, Section 4OA2 of the sample inspection 

report, and section 03.02.d. of this procedure. [C1] 

02.03 Biennial Problem Identification and Resolution Inspection. 

Perform a biennial inspection of the problem identification and resolution activities as 

follows: 
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a. Select a sample of risk significant issues that have been processed through the 

corrective action process. To the extent available, the sample selected should 

include (1) conditions adverse to quality which are in the licensee=s corrective 

action program, (2) cited or noncited violations of regulatory requirements and other 

documented findings, (3) issues identified through NRC operating experience, (4) 

issues identified through industry operating experience, which have been placed in 

the licensee=s corrective action program, and (5) licensee audits and assessments. 

Refer to section 3.3 of OEDO Procedure - 0220: Coordination with the Institute of 

Nuclear Power Operations , for guidance prior to reviewing any INPO documents. 

INPO findings, recommendations, corrective actions, and operating experience 

which are placed in the licensee=s corrective action program, can be considered 

appropriate for inspection. In addition, for a subset of the samples chosen for 

review, the scope of the review should be expanded to at least five years. Use 

general guidance contained in sections 71152-03 and 03.03.b as an aid in sample 

selection. [C1] 

b. Review each condition/problem selected for review using the performance 

attributes contained in paragraph 03.03.c of the procedure. 

c. Review the results of recent audits and/or assessments of the licensee=s corrective 

action program, and compare and contrast the results of those audits and/or 

assessments with the results developed through this inspection. 

d. Review issues that pose challenges to the free flow of information for adequate 

resolution. [C2] 

e. Complete the following items:

1. Perform an assessment of the effectiveness of the licensee=s corrective 

action program in identifying, evaluating, and correcting problems. 

2. Perform an assessment the licensee=s use of operating experience 

information. 

3. Perform an assessment of completed licensee audits and self assessments. 

4. Perform an assessment of the licensee=s safety conscious work environment 

for indication that licensee personnel are reluctant to report safety issues, 

using the guidance contained in paragraph 03.03.d. [C2] 

Base these assessments on the inspection results developed through steps a. 

through d. 

When conducting these inspections the inspector should be aware of the contribution that 

cross-cutting components make to performance deficiencies, and consider insights that 

these issues may provide into the licensee’s progress in addressing any developing or 

existing cross-cutting themes. 
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71152-03 INSPECTION GUIDANCE 

General Guidance

To the extent possible, this inspection should follow a performance-based approach. 

Evaluate products and results of the licensee=s corrective action program, including the use 

of operating experience and assessments/audits. Focus on the results associated with risk 

and safety significant issues. For the issues that are determined to be performance 

deficiencies, evaluate the causes that relate to cross-cutting components for insights on 

performance. Inspections performed under this procedure should concentrate on the 

identification of problems and the effectiveness of corrective actions for risk significant 

issues rather than on reviewing the administrative aspects of the corrective action program 

and associated procedures. 

In selecting issues for inspection, inspectors should seek the broadest range of examples 

within cornerstones, including the following considerations: 

1. Licensee identified issues, including issues identified during audits or self 

assessments, and LERs. Include a sample of the corrective actions with the highest 

priority. The licensee=s root cause analyses associated with these high significance 

level corrective action items should be assessed using the inspection guidance 

contained in Inspection Procedure 95001 as an aid.* 

2. NRC identified issues during routine, team, supplemental (programmatic 

weaknesses identified during IP95001 and IP95002 inspections are mandatory 

sample items*), and special inspections. Discuss such issues with respective NRC 

inspectors and management as part of inspection preparations. 

3. Issues related to NCVs (for the biennial inspection it is mandatory to review the 

licensee=s response to a sample of NCVs unless no NCVs were issued in the 

cornerstone).* 

4. Issues identified through NRC generic communications.* 

5. Issues identified through industry operating experience exchange mechanisms 

(including Part 21 reports, NSSS vendor reports, EPRI reports, experience reports 

from similar facilities).* 

6. Specific or cross-cutting issues identified by safety review committees or other 

management oversight mechanisms. 

7. Issues identified through alternative avenues, such as an employee concerns or 

similar programs. [C2] 

8. Issues that challenge operator performance. 

9. Issues identified through self assessments and audits.* 
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* mandatory samples during biennial inspection only 

Other than for the mandatory samples indicated above, it is not required to select one of 

each type of issue listed. The guidance is intended to help ensure that, over the course of 

an assessment cycle and through the performance of the baseline inspections, an 

appropriate sample will be obtained by which the NRC can obtain indication of the 

performance of the various elements of a licensee=s corrective action program. 

In selecting issues for review, inspectors should also use relevant risk insights such as: 

1. Maintenance Rule program basis documents; 

2. Current licensee risk analysis results or insights; and 

3. Significance Determination Program (SDP) Phase 2 worksheets for the plant. 

For example, in considering the inspection of licensee corrective actions associated with 

post maintenance testing (as required by IP 71111, Attachment 19), inspectors should 

review issues associated with high risk mitigating systems. Additional insights for 

determining appropriate samples can be obtained by region-based inspectors through 

discussion with resident or regional inspectors who are familiar with site issues and who are 

familiar with the licensee=s problem identification and resolution process. 

Review completed self assessment/audits to determine whether the results are consistent 

with the data collected. If substantial differences exist between results from the subject 

assessment/audit and the results of previous assessment/audits, verify that the reasons for 

those differences are reasonable. Review the licensee=s response to the assessment/audits 

to determine whether corrective actions were appropriate for resolving identified issues, 

and were tracked and timely. 

If the licensee performs a safety culture self assessment after the PI&R inspection, the 

NRC inspector may review the assessment as a quarterly sample of section 02.02. A 

safety culture assessment may also be considered as a composition of separate 

assessments of smaller scope. [C2] 

Detailed Review Guidance

The following additional guidance should be used in conducting a review of licensee 

problem identification and resolution activities. 

03.01 Routine Review of Identification and Resolution of Problems. 

a. Baseline Inspection Procedures. Most of the attachments to baseline inspection 

procedures contain a requirement to inspect problem identification and resolution 

performance within the attachment=s area. The routine inspection of PI&R 

performance as part of baseline inspections is intended to ensure that, over the 

course of an assessment cycle, a sample of PI&R performance in all cornerstones 
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is obtained. As stated in paragraph 02.01, the primary focus of this portion of the 

PI&R review should be on verifying that licensees are identifying issues at an 

appropriate threshold and entering them into their corrective action program. 

b. Performance Attributes. When evaluating the effectiveness of licensee corrective 

actions for a particular issue, the licensee=s actions must be viewed against the 

nature and significance (or potential significance) of the identified problem. While 

licensee corrective action programs may appropriately consider monetary, plant 

availability, and other concerns as factors in determining significance, risk should 

be a primary factor in the licensee=s significance determination. Attributes to 

consider during review of licensee actions associated with individual issues include: 

1. Complete and accurate identification of the problem in a timely manner 

commensurate with its significance and ease of discovery. 

2. Evaluation and disposition of operability/reportability issues. 

3. Consideration of extent of condition, generic implications, common cause, 

and previous occurrences. 

4. Classification and prioritization of the resolution of the problem 

commensurate with its safety significance. 

5. Identification of root and contributing causes of the problem (this attribute will 

typically only be assessed for significant conditions adverse to quality and 

may be deferred to the biennial inspection or in-depth reviews performed 

elsewhere in this procedure). 

6. Identification of corrective actions which are appropriately focused to correct 

the problem (may be deferred to biennial inspection). 

7. Completion of corrective actions in a timely manner commensurate with the 

safety significance of the issue (may be deferred to biennial inspection). If 

permanent corrective actions require significant time to implement, then 

verify that interim corrective actions and/or compensatory actions have been 

identified and implemented to minimize the problem and/or mitigate its 

effects, until the permanent action could be implemented. 

It is not expected that the inspectors assess each attribute for every issue selected 

for followup during these routine reviews. Rather, inspectors may choose to assess 

licensee performance against selected attributes, as necessary to be most 

effective. 

c. Documentation. In order to help focus the biennial PI&R inspection on areas where 

concerns have been identified and to provide a more complete assessment of the 

effectiveness of the licensee=s PI&R program, it is important that the NRC 

document findings resulting from the PI&R inspections conducted as part of the 

baseline procedure attachments. In general, findings associated with the PI&R 
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program itself should be documented in the PI&R section of the inspection report. 

Findings associated with the inspectible area and cornerstone should be 

documented in the associated areas of the inspection report. 

In addition, semiannually, a section should be added to the quarterly resident 

inspection report to document the inspectors= assessment of trends that might 

indicate the existence of a more significant safety issue. Unlike the level of 

documentation for the routine reviews above, the level of documentation for the 

trend review should include trends that might not rise to the level of an inspection 

finding. 

Additional guidance regarding documenting the inspection scope, the semiannual 

trend review, and the thresholds for PI&R issues is contained in IMC 0612 and its 

exhibits. 

d. Level of Effort. While it is expected that routine reviews of PI&R activities should 

equate to approximately 10-15 percent of the resources estimated for the 

associated baseline cornerstone procedures, this is a general estimate only based 

upon the overall effort expected to be expended in each strategic performance 

area. It is anticipated that the actual hours required to be expended may vary 

significantly from attachment to attachment, depending upon the nature and 

complexity of the issues that arise at the particular facility. Overall, an effort should 

be made to remain within the 10 to 15 percent estimate on a strategic performance 

area basis. Inspection time spent assessing PI&R as part of the baseline procedure 

attachments should be charged to the corresponding baseline procedure 

attachment. 

The daily review of corrective action items should take approximately 30 minutes. 

The semiannual trend review should take an average of 16-24 hours per year. The 

time spent performing these reviews should be charged to this procedure. 

03.02 Selected Issue Follow-up Inspection. 

a. An additional sample of the four to seven issues per year should be chosen for 

more in-depth review, as necessary to verify that the licensee has taken corrective 

actions commensurate with the significance of the issue. One of these issues shall 

be an operator workaround which may include cumulative effects of existing 

workarounds. These issues can be chosen using information obtained from 

condition report reviews and from reviews conducted as part of the baseline 

inspection procedure attachments, but need not be limited to those issues that are 

directly related to the inspection procedure attachments. Issues may also be 

chosen from the list contained in section 71152-03 of this procedure. The 

inspectors may also select an issue that is tracked by a performance indicator, for 

which a color change has yet to occur. Also consider emerging or existing crosscutting themes for a selected issue follow-up inspection to develop insights into the 

licensee’s progress in addressing the themes. The review should be scheduled at 

a time that will provide meaningful input to the assessment process. 
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b. An operator workaround is defined as operator action(s) taken to compensate for a 

degraded or non-conforming condition that complicates the operation of plant 

equipment. A risk significant operator workaround is defined as operator action(s) 

taken to compensate for a degraded or non-conforming condition which could result 

in an increase in the baseline core damage or large early release frequency and, if 

such actions could not be implemented effectively, would be a finding with 

potentially greater than green significance. 

The intention is to evaluate operator workarounds for mitigating systems to 

determine if the mitigating system function is affected or the operator=s ability to 

implement abnormal and emergency operating procedures is affected. Inspectors 

should be cognizant of: (1) operator workarounds that have not been evaluated by 

the licensee, (2) operator workarounds that have been formalized as the long-term 

corrective action for a degraded or non-conforming condition (and therefore may 

not be tracked by the licensee as an operator workaround), and (3) operator 

workarounds that increase the potential for personnel error, including operator 

workarounds that: 

1. Require operations contrary to past training or require more detailed 

knowledge of the system than routinely provided. 

2. Require a change from longstanding operational practices. 

3. Require operation of system or component in a manner dissimilar from 

similar systems or components. 

4. Create the potential for the compensatory action to be performed on 

equipment or under conditions for which it is not appropriate. 

5. Impair access to required indications, increase dependence on oral 

communications, or require actions under adverse environmental conditions. 

6. Require the use of equipment and interfaces that had not been designed with 

consideration of the task being performed. 

c. Performance Attributes. When evaluating the effectiveness of licensee corrective 

actions for a particular issue, the licensee=s actions must be viewed against the 

nature and significance of the identified problem. While licensee corrective action 

programs may appropriately consider monetary, plant availability, and other 

concerns as factors in determining significance, the potential impact on nuclear 

safety and risk should be primary factors in the licensee=s significance 

determination. Attributes to consider during review of licensee actions associated 

with individual issues include: 

1. Complete and accurate identification of the problem in a timely manner 

commensurate with its significance and ease of discovery. 
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2. Evaluation and disposition of operability/reportability issues. 

3. Consideration of extent of condition, generic implications, common cause, 

and previous occurrences. 

4. Classification and prioritization of the resolution of the problem 

commensurate with its safety significance. 

5. Identification of root and contributing causes of the problem (this attribute will 

typically only be assessed for significant conditions adverse to quality). Use 

inspection guidance contained in Inspection Procedure 95001 as an aid in 

assessing the adequacy of licensee root cause analyses. 

6. Identification of corrective actions which are appropriately focused to correct 

the problem. 

7. Completion of corrective actions in a timely manner commensurate with the 

safety significance of the issue. If permanent corrective actions require 

significant time to implement, then verify that interim corrective actions and/or 

compensatory actions have been identified and implemented to minimize the 

problem and/or mitigate its effects, until the permanent action could be 

implemented. 

In addition to the general performance attributes contained above, inspectors 

should refer to Inspection Procedure 95001 for additional guidance on assessing 

licensee evaluations of significant performance issues. It is not expected that 

inspectors assess each attribute for every issue selected for followup during these 

routine reviews. Rather, inspectors may choose to assess licensee performance 

against selected attributes, as necessary to be most effective. 

d. Documentation. The basis for selection and the scope of review of each sample 

should be documented in the AScope@ section of 4OA2 of the inspection report. In 

general, issues associated with PI&R programs should be documented in the 

AFindings@ section of 4OA2 of the report. This documentation should include factual 

information that relates to the performance attributes listed in 03.01.b, if that 

information indicates licensee performance weaknesses. This documentation 

standard is different from the standard used to document issues elsewhere in the 

quarterly inspection reports. Assessments of PI&R program effectiveness will not 

be done during these inspections; such assessments will be done only during the 

periodic team inspection. Only green or greater findings will be included in the 

summary of findings of the inspection report. Technical issues associated with 

other inspectible areas and cornerstones should also be documented in those 

sections of the report. 

e. Level of Effort. The review of four to seven samples should take an average of 125 

hours for a 1-unit site, 167 hours for a 2-unit site, and 208 hours for a 3-unit site 

annually in direct inspection effort and may be completed by resident and/or 

regional inspectors. Inspection time associated with this review should be charged 
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to this procedure. 

03.03 Biennial Problem Identification and Resolution Inspection. 

The biennial inspection of problem identification and resolution is intended to complement 

and expand upon the reviews described in Section 03.01 and 03.02 of this procedure by: 

1. Evaluating additional examples of licensee problem identification and 

resolution. 

2. Reviewing the resolution of issues that earlier had been assessed for the 

licensee=s identification efforts only. 

3. Comparing the NRC=s results against the licensee=s own assessment of 

performance in the PI&R area. 

4. Assessing whether PI&R deficiencies exist that might indicate potential 

programmatic issues. 

a. Planning. Obtain licensee administrative procedures that control the identification, 

evaluation, and resolution of problems. Selected licensee documents needed to 

support the inspection may be obtained prior to the inspection. These documents 

should only be reviewed to provide the inspectors with sufficient knowledge of the 

licensee=s programs and processes, as necessary to conduct an effective and 

efficient inspection. 

Obtain and review documents for the in-office review, such as a list of corrective 

action documents issued from the time of the last PI&R inspection (e.g., a list of 

work orders, work requests, temporary modifications, calibration failures, 

condition/problem identification reports, operability evaluations and determinations, 

etc.). Also, obtain relevant licensee corrective action program assessments, 

program performance information, and trend reports. 

Obtain and review procedures and documentation on licensee efforts to identify, 

resolve and prevent structure, system and component performance problems 

through performance monitoring, root cause analysis, cause determination and 

corrective action to meet the monitoring requirements of the Maintenance Rule 

(MR),10 CFR 50.65. 

Obtain and review all NRC inspection reports issued since the last PI&R inspection, 

including the inspection reports that contain the semiannual resident reviews to 

determine: 

1. the extent to which all cornerstones have been sampled by routine reviews of 

licensee PI&R activities and determine if additional PI&R samples are 

warranted in any cornerstone(s); 

2. the extent to which licensee actions to NCVs have been sampled by routine 
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reviews of licensee PI&R activities; and, 

3. whether there are any trends or patterns in corrective action program or 

performance issues which may warrant additional sampling to confirm. For 

example, a series of issues associated with Afailure to follow procedures@

within one cornerstone may indicate a corrective action performance 

deficiency within a portion of the licensee=s organization; a series of issues 

associated with failure to follow procedures in multiple cornerstones may 

indicate a broader concern. Also, a lack of licensee identified corrective 

action issues within a particular organization may be indicative of a problem 

with the identification threshold. Consider the need to follow-up on 

performance trends documented as a result of the semiannual trend review. 

b. Biennial Inspection Sample Selection. Based on the planning review, identify a 

sample of licensee corrective actions for review. 

1. The samples chosen for review should include a range of issues selected 

from the list in section 71152-03, including those sample types that are designated 

as requiring a mandatory review. In addition, for a subset of the samples chosen 

for review, the scope of the review should be expanded to at least five years. 

Among the samples chosen for this extended review should be those issues whose 

significance might be age dependent, such as issues associated with erosion of 

piping, degradation of safety-related raw water systems, boric acid accumulations, 

aging of electronic components, environmental qualification, etc. This review can 

be performed by requesting the licensee to perform a corrective action program 

search (computerized or other) for those items designated by the team for the fiveyear review. [C1] 

2. If the licensee conducted any periodic self-initiated assessments of safety 

culture during the review period, this assessment shall be included along with other 

non-safety culture self-assessments selected to review for this sample. If the 

licensee performed several assessments that collectively addressed safety culture 

issues, then those assessments combined should be considered as one 

assessment. [C2] The licensee’s periodic safety culture assessment should be 

reviewed from the PI&R perspective to ascertain the adequacy of the licensee’s 

corrective actions to address the issues identified by the safety culture assessment. 

See section 03.03.d for guidance on reviewing the licensee’s safety culture 

assessment from the safety conscious work environment perspective. 

3. In the event that the licensee has been requested by the NRC to perform a 

self or an independent safety culture assessment, perform an evaluation of the 

licensee’s assessment. The inspection guidance from sections 03.07 and 

03.09.a.2 of Inspection Procedure 95003, “Supplemental Inspection for Repetitive 

Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs 

or One Red Input” should be used, as applicable. Sections 03.07 and 03.09.a.2 

from 95003 provide guidance for conducting NRC’s evaluation of a licensee’s thirdparty safety culture assessment. The fundamental difference between a third party 

safety culture assessment and a self-assessment or an independent assessment is 

Comment [A1]: Clarification of 

guidance to address inspector 

implementation questions.

Comment [A2]: PV lessons learned 

report identified IMC0305 describes 

requests for licensees to perform SC 

assessments. However, no guidance 

exists in the inspection program on how 

the NRC will evaluate the licensee 

assessments. 
Issue Date: XX/XX/XX -14- 71152

the degree of separation between the safety culture assessors and the site. 

• For a third party assessment, assessor personnel are not members of the 

licensee’s organization or utility operators of the plant. 

• For a self-assessment, assessor personnel can be in-house licensee 

personnel. 

• For an independent assessment, assessor personnel have no direct 

authority and have not been responsible for any of the areas being 

evaluated. In this case, corporate licensee staff or utility staff from another 

site potentially could fulfill the assessor role.

In other respects, such as with the validity and reliability of the methodology and 

tools used, and the comprehensiveness of the assessment, there should not be 

any fundamental differences based on who conducted the assessment. 

The referenced sections from IP95003 should be used as general guidance, as 

applicable. There are two specific portions of the referenced sections that would 

not apply to these situations. The first are the sections regarding the review of the 

independence of the third-party safety culture assessors, which is only required 

during an IP95003 inspection. The second is section 03.07.a.1 regarding NRC 

interactions during the conduct of a licensee assessment. Typically, NRC follow-up 

of a self- or independent licensee safety culture assessment would not involve the 

activities described in this section. Otherwise, the guidance in section 03.07 should 

be utilized to perform sample checks of the licensee’s assessment scope, 

methodology, and tools. In general, the guidance should be applied at a lesser 

depth than for an IP95003 inspection. 

In particular the evaluation should focus on the licensee’s response to the 

assessment. Using the guidance in IP95003 section 03.09.a.2, determine whether 

the licensee’s evaluations of the weaknesses identified by the safety culture 

assessment were appropriate, whether planned corrective actions appear adequate 

for resolving those weaknesses, and whether the licensee has made reasonable 

progress in implementing those actions. 

Any issues or weaknesses identified with the licensee’s safety culture assessment 

efforts should be documented in the inspection report. The licensee is expected to 

perform additional safety culture assessment, evaluation, and corrective action 

efforts as necessary to address the issues or weaknesses identified by the NRC.

4. No specific number of previously reviewed or additional samples is specified. 

 Rather, the biennial inspection team leader should choose as many examples as 

warranted to complement the routine PI&R inspections and ensure a sufficient 

basis for evaluating the effectiveness of the licensee=s PI&R program. The team 

should also consider emerging or existing cross-cutting themes for review during 

the biennial inspection to develop insights into the licensee’s progress in 

addressing the themes. A more frequent biennial inspection may be implemented 

to perform a focused follow-up of a repetitive substantive cross-cutting issue. The 

inspectors, as an option, may consider selecting one or more risk significant 
Issue Date: XX/XX/XX -15- 71152

systems and using a Avertical slice@ approach to picking the inspection sample, so 

long as the system(s) selected will provide adequate coverage across all 

cornerstones in the reactor safety strategic performance area. In such cases, 

additional samples may be required to ensure adequate coverage across 

cornerstones in the radiations safety or safeguards strategic performance areas. 

An effort should however be made to maintain the total hours expended in 

completing this procedure to within the estimated level of resources contained in 

paragraph 71152-04. 

5. The inspection team should make every effort to walk down applicable 

portions of the selected systems or perform field verification of selected corrective 

action samples. 

c. Performance Attributes. When evaluating the effectiveness of licensee corrective 

actions for a particular issue or issues, the licensee=s actions must be viewed 

against the nature and significance of the identified problem. While licensee 

corrective action programs may appropriately consider monetary, plant availability, 

and other concerns as factors in determining significance, the potential impacts on 

nuclear safety and risk should be a primary factor in the licensee=s significance 

determination. Attributes to consider during review of licensee corrective actions 

include: 

 1. Complete and accurate identification of the problem in a timely manner 

commensurate with its significance and ease of discovery. 

2. Evaluation and disposition of operability/reportability issues. 

 3. Consideration of extent of condition, generic implications, common cause, and 

previous occurrences. 

4. Identification of significant negative trends associated with human or 

equipment performance. 

 5. Classification and prioritization of the resolution of the problem commensurate 

with its safety significance. 

6. Identification of root and contributing causes of the problem for significant 

conditions adverse to quality. Use inspection guidance contained in Inspection 

Procedure 95001 as an aid in assessing the adequacy of licensee root cause 

analyses. 

 7. Identification of corrective actions which are appropriately focused to correct 

the problem (and to address the root and contributing causes for significant 

conditions adverse to quality). 

 8. Completion of corrective actions in a timely manner commensurate with the 

safety significance of the issue (included within this attribute would be 

justifications for extending corrective action due dates). If permanent 
Issue Date: XX/XX/XX -16- 71152

corrective actions require significant time to implement, then verify that interim 

corrective actions and/or compensatory actions have been identified and 

implemented to minimize the problem and/or mitigate its effects, until the 

permanent action could be implemented. 

9. In addition, for the above samples that involve maintenance effectiveness, 

inspectors should verify the following: 

(a) Review repetitive maintenance preventable functional failures (MPFFs) 

for indications of weaknesses in the licensee=s corrective action 

program. In addition, identify any problems with root cause analysis or 

cause determination and corrective action for systems, structures, or 

components experiencing repetitive MPFFs or exceeding their goals or 

performance criteria. 

 (b) Ensure that risk assessment, risk management, and emergent work 

control problems associated with maintenance are identified and 

resolved promptly. 

 10. Operating experience is appropriately applied and applicable lessons learned 

are communicated to appropriate organizations and incorporated into plant 

operations. 

11. Self assessments and audits are effective at identifying issues. Those issues 

are evaluated and resolved commensurate with their significance. 

 Additional guidance relative to the MR can be found in Inspection Procedure 

71111.12. 

 d. Assessment of Safety Conscious Work Environment. 

 In conducting interviews with or observing other activities involving licensee 

personnel during the inspection, be sensitive to areas and issues that may 

represent challenges to the free flow of information, such as areas where 

employees may be reluctant to raise concerns or report issues in the corrective 

action program. [C2] The inspectors should also obtain insights about the safety 

conscious work environment during their review of the licensee’s most recent 

safety culture and other relevant assessments. The inspectors should be sensitive 

to areas of similarity, and dissimilarity, between the results of their safety conscious 

work environment interviews with plant staff and the results of the licensee’s safety 

culture and other relevant assessments.

 Although the licensee may be implementing an employee concerns or similar 

program regarding the identification of safety issues, the possibility of existing 

underlying factors that would produce a "chilling" effect or reluctance to report such 

issues could exist, and inspectors should be alert for such indications. Such factors 

could go beyond direct retaliation, and could include issues such as inadequate 

staffing that results in excessive overtime and an unwillingness to raise issues that 

Comment [A3]: Clarification of 

guidance to address inspector 

implementation questions. 
Issue Date: XX/XX/XX -17- 71152

might result in further increases to an already high workload, or cases where repeat 

issue identification have not resulted in adequate corrective action causing 

personnel to be reluctant to identifying additional related issues. 

 Appendix 1 to this procedure provides a list of questions that can be used when 

discussing PI&R issues with licensee individuals to help assess whether there are 

impediments to the establishment of a safety conscious work environment. It is not 

intended that inspectors conduct formal interviews solely for the purpose of 

assessing the work environment, but rather, that inspectors make use of the 

questions in Appendix 1 during discussions with licensee individuals concerning 

other attributes of the inspection. It is expected that during this inspection, 

discussions/interviews will be held with both licensee management and staff. 

 If, as a result of the interviews or observations, inspectors become aware of specific 

examples of employees being discouraged from raising safety or regulatory issues 

within the licensee=s or contractor=s organization or to the NRC, inspectors should 

inform regional management prior to further follow-up. If inspectors becomes aware 

of a Achilling@ effect or other general reluctance of employees to raise safety or 

regulatory issues unrelated to a specific event or incident, regional management 

should be informed prior to further follow-up. At regional management=s discretion, 

questions about raising concerns contained in IP 95003 may be used for further 

review and follow-up. 

 e. Development of PI&R Program Performance Insights. By reviewing a sufficient 

number and breadth of samples, the inspection team should be able to develop 

insights into the licensee=s corrective action program, use of operating experience, 

and self assessments/audits to identify, evaluate, and resolve problems. Compare 

the result of the team=s review of PI&R issues with licensee performance reviews, 

including specific licensee reviews of PI&R programs. Determine whether licensee 

reviews are consistent with the NRC review of PI&R issues. 

 The intent of this inspection procedure (both the routine and biennial inspection 

effort) is to provide insights into licensee performance in the PI&R area based upon 

a performance-based review of corrective action issues, operating experience and 

self assessments/audits. More detailed programmatic reviews of licensee 

performance in the PI&R area will be conducted during supplemental inspections, if 

established performance thresholds are crossed. 

 f. Documentation and Evaluation of Program Effectiveness. At the completion of 

inspection activities, the team should develop a clear and concise discussion of the 

results of their review. This discussion should be supported by the inspection 

activities conducted over the assessment cycle including routine inspections, 

selected sample follow-up inspections, and the biennial inspection of PI&R 

activities. The discussion should be documented in the inspection report for the 

biennial PI&R inspection and should be included in the PIM. 

 There should be a discussion to address (1) the effectiveness of the licensee=s 

corrective action program, (2) use of operating experience and (3) the results of 
Issue Date: XX/XX/XX -18- 71152

self assessments/audits. Included in the discussion should be conclusions and any 

issues associated with the conduct of a safety conscious work environment and 

any prohibition with the free flow of information that may have been detected during 

the inspection. [C2] This assessment of the safety conscious work environment 

should be based on the results of the biennial inspection interviews of plant staff 

along with any relevant insights obtained from the review of the licensee’s most 

recent safety culture and other relevant assessments.

 Additional evaluation of the licensee=s PI&R programs will be conducted as part of 

the mid-cycle and/or end of cycle plant performance review by assessing licensee 

performance using the results of this inspection, as well as other information, 

including performance indicator data and the results of any supplemental 

inspections. Additional guidance on documenting the biennial problem identification 

and resolution inspection is contained in Appendix D to IMC 0612. 

71152-04 RESOURCE ESTIMATE 

The effort for daily review of corrective action items is estimated at 30, 40, and 50 minutes 

for single-, dual-, and triple-unit sites, respectively. This equates to an annual effort of 125 

hours, 167 hours, and 208 hours for single-, dual-, and triple-unit sites, respectively. Time 

spent performing these daily reviews should be charged to IP 71152. 

The effort for the semiannual trend reviews is estimated to take, on average, 16-24 hours 

per year regardless of the number of units on site. The time spent performing these reviews 

should be charged to IP 71152. 

The annual effort for review of the four to seven samples per paragraph 02.02 is estimated 

to take 56 to 76 hours for a single-unit site, 58 to78 hours for a dual-unit site, and 60 to 80 

hours for a triple-unit site. The time spent reviewing the four to seven samples should be 

charged to IP 71152. 

The biennial team inspection is estimated to take, on average, 212 to 288 hours of direct 

inspection effort. Participation (either full or part time) on the inspection team by a member 

of the resident inspector staff should be strongly considered. If follow-up is performed of 

an NRC requested licensee safety culture assessment an additional [TBD] hours will be 

required. The time spent performing the biennial team inspection should be charged to IP 

71152B. 

Typical resources for annual samples or the biennial team inspection may be increased if 

needed to follow-up on safety conscious work environment issues. 

71152-05 PROCEDURE COMPLETION 

Inspection of the minimum sample size will constitute completion of this procedure in the 

Reactor Program System (RPS). The minimum sample size for the annual inspections is 6 

consisting of 2 semiannual trend reviews and 4 annual, in-depth reviews per paragraph 
Issue Date: XX/XX/XX -19- 71152

02.02 of this procedure. The minimum sample size for the biennial team inspection is 1 and 

is defined as the biennial team inspection. These minimum sample sizes apply regardless 

of the number of reactor units at the site. 

71152-06 REFERENCES 

NRC Inspection Manual Part 9900, ?Resolution of Degraded and Non-Conforming 

Conditions@

OEDO Procedure - 0220, ACoordination with the Institute of Nuclear Power Operations@

END

Appendix 1: Suggested Questions for Use in Discussions with Licensee Individuals 

Concerning PI&R Issues 

Attachment 1: Revision History 

Issue Date: XX/XX/XX A1-1 71152

APPENDIX 1 

 SUGGESTED QUESTIONS FOR USE IN DISCUSSIONS WITH LICENSEE 

 INDIVIDUALS CONCERNING PI&R ISSUES 

The following are suggested questions that may be used when discussing PI&R issues with 

licensee individuals. It is not intended that these questions are asked verbatim, but rather, 

that they form the basis for gathering insights regarding whether there are impediments to 

the formation of a safety conscious work environment. In cases where a potential problem 

with the employees willingness to raise concerns or other SCWE is identified in response to 

these questions, consult with regional management for directed course of action and, if 

appropriate, see Inspection Procedure 95003 for more detailed questions for the workforce 

and management. 

Suggested Questions

1. a. Are you willing to raise a safety concern? 

b. Are there any conditions under which you would be hesitant to raise a safety 

concern? 

c. If yes, does that condition exist here at (Insert Plant Name)? Please 

elaborate. 

2. a. Are you aware of situations where any employee or contractor may be 

hesitant to raise concerns, internally or externally? 

b. If yes, please explain. (If an NRC inspector is aware of a specific incident that 

may have caused such hesitation, then ask about it. Focus on whether or not 

the interviewee or others may be less likely to report concerns since that 

incident). 

3. a. Where would you go to raise a safety issue? [The NRC inspector should be 

aware of the following avenues for raising concerns, but not prompt the 

interviewee: supervisor, corrective action program (CAP), alternative program 

(Employee Concerns Program (ECP)/Ombudsman), NRC, or other avenue.] 

b. Why would you pick this avenue? Have you or others had any experiences, 

or know of any situations, that have influenced your decision to pick this 

avenue? If so, please describe. 
Issue Date: XX/XX/XX A1-2 71152

4. Are there other avenues available to you for raising safety issues? Ask each of the 

questions listed in the following table for each avenue available. 

Supervisor Corrective 

Action 

Program 

ECP/ 

Ombudsman 

NRC Other 

Have you ever submitted 

a safety issue to (insert 

method) If no, why not? 

If yes, was the issue 

adequately addressed? 

Why or why not? 

If not adequately 

addressed, did you further 

pursue the issue? If not, 

why not? 

Given the nuclear safety 

importance of the issue, 

did you receive timely 

feedback? 

Describe any instances in 

which you know of 

another employee who 

submitted an issue to 

(insert method) and you 

considered the response 

unacceptable? 

5. Would you say that your management is supportive of the ECP/Ombudsman 

program? 

a. If yes, how is such support demonstrated? 

b. If no, please describe what has led you to believe that they are not 

supportive. 

6. Are you aware of any actions taken by your management to prevent and detect 

retaliation and/or chilling effect? 

a. Are their actions effective? 

b. Has management=s handling of any chilling effect issues been consistent? 
Issue Date: XX/XX/XX A1-3 71152

 

7. Are you aware of any instances in which another individual experienced a negative 

reaction for raising a safety issue? If yes, please describe the incident, including any 

information conveyed by management concerning the incident. 

8. Would you say that your management is supportive of the SCWE policy? 

a. If yes, how is such support demonstrated? 

b. If no, please describe what has led you to believe they are not supportive. 

9. Have events or circumstances occurred in the past six months that have reduced: 

a. Your willingness to identify or raise safety issues? 

b. Your confidence in the corrective action program? 

c. Your willingness to challenge actions or decisions you believe are unsafe? 

END 

Issue Date: XX/XX/XX Att 1-1 711

ATTACHMENT 1 

Revision History to IP 71152 

Commitment Tracking Number 

Issue Date Description of Change Training 

Needed 

Training Completion Date 

Comment Resolution Accession Number 

N/A 03/06/2001 

CN 01-006 

Revised to delete certain inspection requirements (collective risk of maintenance backlog and equipment unavailability accounting), eliminate duplication within the procedure, and provide additional guidance concerning the review of a safety conscious work environment. 

NO N/A N/A 

N/A 01/17/2002 

CN 02-001 

Revised to include changing the inspection frequency to biennial and add guidance on the conduct of inspections of 3 to 6 samples per year outside of the team inspections. 

NO N/A N/A 
Issue Date: XX/XX/XX Att 1-2 711

C1 09/08/2003 

CN 03-032 

Revised to incorporate recommendations made by the PI&R focus group to address several items from the Davis Besse Lessons Learned Task Force. The changes include enhanced requirements regarding the routine PI&R reviews conducted by resident inspectors, biennial reviews of longstanding issues, and biennial reviews of operating experience issues. 

YES 09/24/2003 N/A 

N/A 01/05/2006

CN 06-001 

A requirement to inspect for cumulative effects of operator workarounds to IP 71152 as one of its annual samples was added. Also, the annual sample size and the estimate inspection resources required to complete this IP was increased to support review of operator work arounds. Completed historical CN search. 

NO N/A N/A 
Issue Date: XX/XX/XX Att 1-3 711

N/A C2 

06/22/06 CN 06-015 

Guidance added for procedure completion regarding annual sample size Procedure now requires that the time spent to review condition reports to be charged to IP71152 instead of the plant status procedure Hours have been increased for condition report reviews Incorporate safety culture initiatives described in, Staff Requirements - SECY-04-0111 - ARecommended Staff Actions Regarding Agency Guidance in the Areas of Safety Conscious Work Environment and Safety Culture" dated August 30, 2004 

NO 

YES

N/A 

July 1, 2006

ML061570086

N/A 09/20/07 

CN 07-029 

IP 71152 has been revised to add 

guidance on NRC use of INPO documents.

NO N/A ML071560246 

N/A 01/10/08 CN 08-001 IP revised to address ROP Feedback Form 95001-1125 and some 

enhancements identified by the Problem Identification and Resolution Best Practices draft report. 

NO N/A ML073540274