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Jim Wells, GAO

TO:

Klein

FOR SIGNATURE OF: ** PRI ** CRC NO: 06-0481

Chairman Klein

DESC: ROUTING:

GAO Report, "NRC: Oversight of Nuclear Power

Plant Safety Has Improved, but Refinements Are

Needed (GAO-06-1029) (Due to GAO: 11/24/06)

DATE: 09/28/06

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Virgilio

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GAO'File

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CONTACT:

.Dyer

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SUBJECT:

Jim Wells

GAO

Dale Klein

GAO-06-1029..NRC: Oversight of Nuclear Power Plant Safety Has Improved, but Refinements

are Needed

ACTION:

DISTRIBUTION:

LETTER DATE:

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DATE DUE: 11/08/2006 DATE SIGNED:

EDO ---G20060810O
Accountability - Integrity * Reliability

United States Goverunment Accountability Office

Washington, DC 20548

SEP 2 72006*

The Honorable Dale E. Klein

Chairman

Nuclear Regulatory Comm-ission

Dear Mr. Chairman:

Enclosed is a copy of our report entitled Nuclear Regulator~y Commission:

Oversight of Nudlear Pcwer Plant Safety Has Improved, but Refinements Are

Needed (GAO-06-1029). This report discusses NRC's Reactor Oversight Process,

including efforts it is making to improve its oversight process.

This report contains recommendations to you. As you know, 31 U.S.C. 720

requires the head of a federal agency to submit a written statement of the actions

taken on our recommendations to the Senate Committee on Homeland Security

and Governmental Affairs and the House Committee on Governmnent Reform not

later than 60 calendar days from the date of this letter and to the House and

Senate Committees on Appropriations with the agency's first request for

appropriations made more than 60 calendar days after that date. Because agency

personnel serve as the primary source of information on the status of

recommendations, we request that you also provide us with a copy of your

agency's statement of action to serve as preliminary information on the status of

open recommendations.

We appreciate the assistance and cooperation of your staff during our review.

Sincerely yours,

Director, Natural Resources and Environment

Enclosure
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AGAO

AccouMf~lty- nof-Reildkb

Highlights of GAO-06-1029, a report to

congressional requesters

Why GAO Did This Study

The Nuclear Regulatory

Cominnssion (NRC) is responsible

for overseeing the nation's 103

commercial nuclear power plants

to ensure they are operated safely.

The safety of these plants has

always been important, since an

accident could release harmnful

radioactive material- NRC's

oversight has become even more

critical as the potential resurgence

Of nuclear power is considered.

NRC implemented a new Reactor

Oversight Process (ROP) in 2000 to

address weaknesses in its oversight

of nuclear plant safety.

In this report, GAO reviewed

(1) how NRC oversees nuclear

power plants, (2) the results of the

ROP over the past several years,' and (3) the status of NRC's efforts

to improve the ROP. To complete this work, GAO analyzed

programwide information,

inspection results covering 5 years

of ROP operations, and detailed

findings from a nonprobability

sample of 11 plants.

Yh~t AO Recommens

GAO recommends that NRC

aggressively monitor, evaluate; and, if needed, implement additional

measures to increase the

effectiveness of its safety culture

changes and make publicly

.available more information on

nuclear power plants' safety

culture. In commenting on a draft

of this report, NRC generally agreed with GAO's findings, conclusions, and

recommendations.

www.gao.gov/ogi-bin/getrpt?GAO-06-1 029.

To view the full product, including the scope and methodology, click on the link above.

For more information, contact Jim Wells at (202) 512-3841 or wellej@gao.gov.

Setme 2006s

NUCLEAR REGULATORY COMMISSION

Oversight of Nuclear Power Plant Safety Has Improved, but Refinements Are

Needed

What GAO Found

NRC uses various tools and takes a risk-informed and graded approach to

ensure the safety of nuclear power plants. These tools consist of physical inspections of plants and quantitative measures or indicators of plant performance. They are risk-informed in that they focus on the aspects of

operations considered most important to plant safety. On the basis of the

results of this information, NRC takes a graded approach to its oversight, increasing the level of regulatory attention to plants where safety is

declining. NRC assesses overall plant performance and conmmuicates the

results to the public, including providing detailed results of its oversight

process through a Web site devoted to the ROP.

Since 2001, the ROP has resulted in more than 4,000 inspection findings concerning plants' failure to fully comply with safe operating procedures, and NRC has subjected more than 75 percent (79) of the 103 plants to

increased oversight for varying periods. Almost all of the inspection findings

were for actions NRC considered important to correct but of low

significance to safe plant operations. While the majority of plants received

some level of increased oversight, only 5 plants were subjected to NRC's

highest level of oversight. Plants in this category were generally subjected to

this higher oversight for long periods due to the more systemic nature of

their performance problems.

NRC has improved its oversight process in various areas, but it has been

slow to act on needed improvements, particularly in improving the agency's ability to identify and address early indications of declining safety performance. NRC is improving its oversight process on the basis of

feedback from stakeholders, including better focusing inspections on areas

most important to safety. NRC also is addressing what GAO believes has

been a significant shortcoming by modifying the ROP to improve its ability

to address plants' safety culture-that is, the organizational characteristics

that ensure issues affecting nuclear plant safety receive the attention their

significance warrants. GAO and others, including some stakeholders, believe these changes could enable NRC to better identify safety culture

issues and thus provide earlier indications of declining plant safety performance. However, some in the industry have opposed the changes because they believe the changes could introduce undue subjectivity to

NRC's oversight, given the difficulty in measuring these often intangible and

complex concepts. NRC has been reluctant to incorporate safety culture

into the ROP because it considered this type of activity as a management function, and NRC did not believe that it should be directly involved in

managing licensees' plants. NRC program officials view the current changes

as the beginning of an incremental approach and acknowledge that they Will

need to assess their effectiveness at identifying declining safety performance

at plants before significant safety events occur.

.United States Government Accountability Office
1 Contents

Letter

Results in Brief

Background

NRC Uses Various Tools and Takes a Risk-Informed and Graded

Approach to Ensuring the Safety of Nuclear Power Plants

NRC Has Identified Low Risk Problems at Nuclear Power Plants,

Resulting in Increased Oversight for Varying Periods

NRC Is Addressing Weaknesses in Various Areas of Its Oversight

Process, but More Effort Is Needed

Conclusions

Recommendations for Executive Action

Agency Comments

1

3

6

11

21

28

38

39

40

App endixes

Appendix 1:

Appendix II:

Appendix III:

Appendix MV

Appendix V:

Key Safety-Related Events at the Salem and Hope Creek

Nuclear Power Plants from 2000 to 2006

Summary of Key Safety-Related Events at Salem and Hope Creek,

April 2000 to June 2006

Scope and Methodology

Nuclear Power Plant Performance Data on the Basis of the

Results of NRC's Reactor Oversight Process, 2001 Through

2005

Comments from the Nuclear Regulatory Commission

GAO Contact and Staff Acknowledgments

43

44

51

55

73

74

12

Tables Table 1: Key ROP Plant Inspection Areas, or Cornerstones

Table 2: NRC Reactor Oversight Process Action Matrix

Table 3: Commercial Nuclear Power Plants Licensed to Operate in

the United States

Table 4: Total Number of Green Inspection Findings, 2001 Through

2005

Table 5: Total Number of Greater-Than-Green Inspection Findings

Issued, 2001 Through 2005

Table 6: Tlype of Substantive Cross-cutting Issue Open At Least

Some Portion of thelYear, 2001 Through 2005

Table 7: Total Number of Greater-Than-Green Performance

Indicators, 2001 Through 2005

12

55

58

60

62

65

Page i Page iGAO-06-1029 Oversight of Nuclear Power Plant Safety
Contents if

Table 8: Highest NRC Oversight Level Applied during at Least Some

Portion of the Year, 2001 Through 2005 69

Figures Figure 1: NRC Regions and Operating Nuclear Power Plant Sites in

the United States

Figure 2: NRC's Oversight Process in Determining Plant Placement

on the Action Matrix

Figure 3: Number of Inspection Findings at All Plants, 2001

Through 2005

Figure 4: Number of Inspection Findings and Inspection Findings

with Cross-Cutting Aspects at All Plants, 2001 Through

2005

Figure 5: Number of Plants with Substantive Cross-Cutting Issues,

2001 Through 2005

23

24

25

Abbreviations

ACRS

ECP

ERB

INPO

NEI

NRC

PRA

ROP

RPS

SALP

SCWE

SDP

UCS

Advisory Committee on Reactor Safeguards

Employee Concerns Program

Executive Review Board

Institute of Nuclear Power Operations

Nuclear Energy Institute

Nuclear Regulatory Commidssion

Probabilistic Risk Assessment

Reactor Oversight Process

Reactor Program System

Systematic Assessment of Licensee Performance

safety-conscious work environment

Significance Determination Process

Union of Concerned Scientists

This is a work of the U.S. government and is not subject to copyright protection in the

United States. It may be reproduced and distributed in its entirety without further

permission from GAO. However, because this work may contain copyrighted images or

other material, permission from the copyright holder may be necessary if you wish to

reproduce this material separately.

Page 11 Page iiGAO-06-1029 Oversight of Nuclear Power Plant Safety
G A

.Accoccuntablllty * Integrity * Reliability

United States Government Accountability Office

Washington, D.C. 20548

September 27, 2006

Congressional Requesters

The Nuclear Regulatory Commission (NRC) is responsible for overseeing

the safe operation of the nation's 103 operating commercial nuclear power

plants, which provide about 20 percent of U.S. electricity. The safety of

these plants, which are located at 65 sites in 31 states, has always been

important, since an accident could result in the release of radioactive

material and potentially harm public health and the environment. NRC'S

oversight has become even more critical as the Congress and the nation

consider the potential resurgence of nuclear power in helping to meet the

nation's growing energy needs. No new orders for plants have been placed

since the 1979 accident at the Three Mile Island plant in Pennsylvania.

However, in the face of concerns about energy security, global warming,

aging plants, and the ever increasing need for energy to fuel the nation's

economy, nuclear power is resurfacing as a principal option. An accident,

even on a relatively small scale, could threaten public confidence in

nuclear power just as it begins to emerge from the shadows of the Three

Mile Island accident. It is critical that NRC be able to ensure that nuclear

power plants are operated safely and that public confidence about their

safety is high.

NRC is responsible for issuing regulations, licensing and overseeing plants,

and requiring necessary actions to protect public health and safety, up to

and including shutting down a plant, if it is not meeting licensing conditions

and it poses an undue risk to public health and safety. Plant operators are

responsible for safely operating their plants in accordance with their

licenses. Prior to 2000, NRC'S oversight of plants' compliance, which is a

critical part of the agency's regulatory program, was criticized because it

did not always focus on the most important safety issues, and because

some activities were redundant, inefficient, and overly subjective. While its

new process-which NRC refers to as the Reactor Oversight Process

(ROP)-is simidlar to its prior process in that the oversight activities largely

consist of physical plant inspections, the inspections now focus on more

important safety issues. NRC's goal is to ensure that its oversight of plants'

safety performance is objective, predictable, understandable, and

conducted openly to inform the public and maintain confidence about plant

safety. The unexpected discovery in March 2002 of extensive corrosion and

a pineapple-size cavity in the reactor vessel head-one of the vital barriers

preventing a radioactive release-at the Davis-Besse nuclear power plant

in Ohio led NRC to reexamine its safety oversight and other regulatory

Page 1 Page 1GAO-06-1029 Oversight of Nuclear Power Plant Safety
I

processes to determine how such corrosion could have been missed. On

the basis of the lessons learned from that event, NRC made several changes

to the ROR NRC also has assessed the ROP annually since it was

implemented in 2000 by obtaining feedback from the industry and other

stakeholders, such as public interest groups.

In this report, we exam-ined (1) how NRC oversees nuclear power plants to

ensure that they are operated safely, (2) the results of the ROP over the

past several years, and (3) the status of NRC'S efforts to improve the ROE'

In addition, this report provides details on recent safety-related events at

the Salem and Hope Creek nuclear power plants in New Jersey and on

NRC's and the licensee's actions in response to these events (see app. D).

To examine how NRC oversees plants, we reviewed the various tools and

processes that comprise the ROP. In this regard, we reviewed NRC'S

policies, inspection manuals, and other guidance documents; interviewed

NRC headquarters and regional program officials and regional and on-site

inspectors; visited the Salem and Hope Creek nuclear power plants; and

attended several public meetings covering various nuclear power plant

oversight topics. To examine the results of the ROP over the past several

years, we reviewed the number and types of inspection findings NRC

issued, along with other performance measures or indicators it collected

from the plants, and the level of oversight it provided as a result of its

findings. We analyzed NRC data on nuclear plant safety for 2001 through

2005, the years since implementation of the ROP for which data were

available for the full year, and discussed our analysis with NRC program

officials. We assessed the reliability of these data and determined that they

were sufficiently reliable for the purposes of our report. To examine the

status of NRC'S efforts to improve the ROP, we analyzed NRC documents,

including annual self-assessment reports; interviewed officials from NRC,

including a former Commission Chairman who is largely credited with

leading the development of the ROP, and outside stakeholder groups,

including the Nuclear Energy Institute (NEI), the Union of Concerned

Scientists (UCS), and Greenpeace; and attended several key public

meetings covering proposed changes to oversight procedures. We also

reviewed various external evaluations of the ROP, including our prior

'Physical security, which is also covered by the ROP, is not included in this review. For

information on NRC's physical security, see GAO, Nuclear Power Plants: Efforts Made to

Upgrade Security, but the Nuclear Regulatory Commission's Design Basis Threat Process

Should Be Improved, GAO-06-388 (Washington, D.C.: Mar. 14, 2006).

Page 2 Page 2GAO-06.1029 Oversight of Nuclear Power Plant Safety
reports and those of the Advisory Committee on Reactor Safeguards

(ACRS)2 and the NRC Office of the Inspector General. In addition, we

selected a nonprobability sample of 6 nuclear power sites (totaling 11

plants, including Salem and Hope Creek) that spanned each of NRC's four

regions and represented varying levels of plant performance and NRC

oversight since 2000. We reviewed relevant inspection reports and

assessment documents and interviewed NRC and industry officials at each

site to examine how NRC applies the ROP to identify and correct safety

problems. Appendix II presents a detailed discussion of our scope and

methodology. We conducted our work from July 200.5 through July 2006 in

accordance with generally accepted government auditing standards.

Results in Brief NRC uses various tools and takes a risk-informed and graded approach to

ensuring the safety of nuclear power plants. These tools include physical

inspections of plants' equipment and records and quantitative measures or

indicators of plant performance, such as the number of unplanned reactor

shutdowns and the reliability of alert and notification system sirens that

notify residents living near the plant in the event of an accident. NRC uses a

risk-informed approach-that is, an approach that considers safety

significance in selecting the equipment or operating procedures to be

inspected-to apply these tools. NRC inspectors conduct baseline

inspections of plant operations almost continuously at each nuclear power

plant site. When NRC becomes aware of a performance problem at a plant,

it uses a process to assign the inspection finding one of four colors to

reflect the finding's risk significance, which is set on the basis of measures

that reflect the potential health effects that could occur from radiological

exposure. Green inspection findings equate to very low risk significance,

while white, yellow, and red colors represent increasing levels of risk,

respectively. In response to greater-than-green (white, yellow, or red)

inspection findings, NRC conducts supplemental inspections, which

expand the scope of baseline inspections and review (1) the extent of the

problem, (2) the sufficiency of the licensee's evaluation of the root cause of

2The Advisory Committee on Reactor Safeguards is an independent committee, mandated

by the Atomic Energy Act of 1954, as amended, which provides advice on nuclear facility

safety-related topics, among other topics. The ACRS is currently composed of 11 individuals

with a wide variety of engineering and technical expertise, including nuclear engineering;

risk assessment; chem-istry; and mechanical, civil, and electrical engineering, as well as

many others. The AGRS is structured to provide a forum where these experts can provide

independent advice that can then be factored into NRC's decision-making process. Each

year, the ACRS produces several reports, many of them related to the ROP.

Page 3 Page 3GAO-06-1029 Oversight of Nuclear Power Plant Safety
the problem, and (3) the licensee's proposed corrective actions in response

to the identified performance problem. NRC conducts special inspections

to investigate specific safety incidents or events-such as reactor

shutdowns due to equipment failures-that are of particular interest to

NRC because of their potential significance to safety. Nuclear power plants

also self-report on their safety performance, using performance measures

or indicators in quarterly reports that they submit to NRC. The plants'

reports are verified by NRC's on-site inspectors. On the basis of the number

and risk significance of inspection findings and performance indicators,

NRC places each plant into one of five oversight categories on its action

matrix, which correspond to graded or increasing levels of oversight,

largely consisting of supplemental inspections that increase in the breadth

and depth of issues covered as plants move into higher oversight

categories. NRC provides an overall assessment of each plant's

performance through assessment letters issued to plants at the end of each

6-month period describing their specific performance and the level of

oversight that will result. In addition, NRC has other mechanisms to make

available its oversight results, such as an Internet Web site devoted to the

ROP that provides detailed summaries of each plant's performance.

Since 2001, the ROP has resulted in more than 4,000 inspection findings

concerning nuclear power plant licensees' failure to fully comply with NRC

regulations and industry standards for safe plant operation, and NRC has

subjected more than 75 percent (79) of the 103 operating plants to

increased oversight for varying periods. (See app. III for additional sitespecific plant data.) About 97 percent of the inspection findings were

green, meaning they were for actions or failures NRC considered important

to correct but of very low significance to overall safe plant operations. For

example, a finding of very low risk significance was issued at one plant

after a worker failed to wear the proper radiation detector, and at another

plant because the operator failed to properly evaluate and approve the

storage of flammable materials in the vicinity of safety-related equipment.

The other 3 percent (98) of the inspection findings were greater-than-green.

Most of these findings (86 of the 98) were white, meaning they were

considered to be of low-to-moderate risk significance. The other 12

inspection findings, or less than 1 percent, were of the highest levels of

significance to safety (yellow and red). For example, NRC issued a finding

of the highest risk significance (red) at one plant after a steam generator

tube failed, causing an increased risk of the release of radioactive material.

In the area of performance indicators, there were 156 instances out of more

than 30,000 reports, or less than 1 percent, in which data reported for

individual indicators were outside of NRC'S acceptable performance

Page 4 Page 4GAO-06-1029 Oversight of Nuclear Power Plant Safety
category. On the basis of greater-than-green inspection findings and

performance indicators, NRC has subjected more than 75 percent (79) of

the 103 operating plants to oversight beyond the baseline inspections for

varying periods. Most of these plants received the lowest level of increased

oversight, consisting of a supplemental inspection to follow up on the

corrective actions taken for performance problems identified through the

issuance of 1 or 2 white inspection findings or performance indicators.

Over the past 5 years, 5 plants have been subjected to the highest level of

NRC oversight that still allows continued operations. Plants in this

category were generally subjected to this higher oversight for long periods

due to the more intensive supplemental inspections conducted by NRC and

the more systemic nature of the plants' performance problems and

subsequent corrective actions NRC expected the licensees to take. NRC

inspectors at the plants we reviewed indicated that when plant

performance declines, it is often the result of ineffective corrective action

programs, problems related to human performance, or complacent

management. In assessing the results of the ROP between 2001 and 2005,

we found an association between poorer performing plants and

deficiencies in the plants'lhuman performance and problem identification

and resolution programs.

NRC has improved its oversight process in various areas, but continued

efforts will be needed to address other shortcomings or opportunities for

improvement, particularly in improving the agency's ability to identify and

address early indications of declining plant safety performance. NRC has

made several improvements, largely in response to independent reviews

and feedback from stakeholders, including its regional and on-site

inspectors, usually obtained during NRC's annual self-assessment of its

oversight process. These improvements include better focusing its

inspections on those areas most important to safety, reducing the time

needed to determine the risk significance of inspection findings, and

modifying the way that some performance indicators are measured to

improve their quality. NRC also is assessing whether it needs to modify its

oversight, including developing additional inspection procedures, as a

result of some problems that have surfaced in areas not fully inspected by

NRC, such as the recent discovery of groundwater contamination from

radioactive materials at a number of sites. For the most part, NRC

considers these efforts to be refinements to its oversight process, rather

than significant changes. One important shortcoming in the ROP that we

and others have found is that it is not as effective as it could be in

identifying and addressing early indications of deteriorating safety at

nuclear power plants before problems develop. In response to this concern,

Page 5 Page 5GAO-06-1029 Oversight of Nuclear Power Plant Safety
NRC recently undertook a major initiative to improve its ability to address

plants' safety culture-that is, the organizational characteristics that

ensure issues affecting nuclear plant safety receive the attention their

significance warrants. NRC and others have long recognized that safety

culture attributes, such as attention to detail, adherence to procedures, and

effective corrective and preventative actions, have a significant impact on a

plant's safety performance, and that the lessening of these attributes can

indicate a decline in safety performance before safety problems occur.

However, NRC has been somewhat slow to react and only recently

modified its oversight process by redefining and increasing its focus on

cross-cutting safety issues-issues that comprise many of the elements of

safety culture-and developing new requirements under the ROP to more

directly assess safety culture at poorer performing plants. However, some

of NRC's changes have been controversial. While some industry officials

have expressed concern that the changes could introduce undue

subjectivity to NRC'S oversight, given the difficulty in measuring these

often intangible and complex concepts, other stakeholders believe the

changes will provide NRC with better tools to identify safety culture issues

at plants and thus provide earlier indications of declining safety

performance. NRC has been reluctant to incorporate safety culture into the

ROP because it considered this type of activity a management function, and

NRC did not believe that it should be directly involved in managing

licensees' plants. NRC program officials view these changes as the

beginning step in an incremental approach and acknowledge that they Wili

need to assess the changes they made to the ROP to determine their

effectiveness in better allowing inspectors to detect deteriorating safety

conditions at plants before significant safety events occur.

Given the importance of this initiative to the ROP's effectiveness, we are

recommending that NRC aggressively monitor; evaluate; and, if needed,

implement additional measures to increase the effectiveness of its safety

culture changes. In line with NRC'S desire to make the ROP an open

process, we are also recommending that the agency make available

additional information on plants' safety culture to the public and its other

stakeholders to provide a more comprehensive picture of plant

performance. In commenting on a draft of this report, NRC generally

agreed with our findings, conclusions, and recommendations. Appendix IV

contains a reproduction of NRC's letter.

Background NRC is an independent agency of over 3,200 employees established by the

Energy Reorganization Act of 1974 to regulate civilian-that is,

Page 6 Page 6GAO-06-1029 Oversight of Nuclear Power Plant Safety
commercial, industrial, academic, and medical-use of nuclear materials.

NRC is headed by a five-member Commission. The President appoints the

Commission members, who are confirmed by the Senate, and designates

one of them to serve as the Chair and official spokesperson. The

Commission as a whole formulates policies and regulations governing

nuclear reactor and materials safety, issues orders to licensees, and

adjudicates legal matters brought before it. NRC'S staff work out of its

headquarters office in Rockville, Maryland; out of its four regional offices;

and at each of the operating commercial nuclear power plant sites (see fig.

1). NRC'S Office of Nuclear Reactor Regulation provides overall direction

for the oversight process and the Office of Enforcement is responsible for

ensuring that appropriate enforcement actions are taken when

performance issues are identified. NRC's regional offices are responsible

for implementing the ROP, along with the inspectors who work directly at

each of the nuclear power plant sites.

Page 7 Page 7GAO-06-1029 Oversight of Nuclear Power Plant Safety
Figure 1: NRC Regions and Operating Nuclear Power Plant Sites in the United States

A Plants licensed to operate

WRegion I

SRegion 11 (includes PR and VI)

WRegion Ill

SRegion IV (includes AK and HI)

Sources: NRC and Map Resources (map).

Nuclear power plant licensees have the primary responsibility for safely

operating their plants in accordance with their licenses and NRC

regulations. The plants have many physical structures, systems, and

components, and licensees have numerous activities under way 24 hours a

day to ensure that plants operate safely. NRC relies on, among other things,

its on-site inspectors to assess plant conditions and the licensees' quality

assurance programs, such as those required for maintenance and problem

identification and resolution. Given the numerous activities going on

during complex plant operations, NRC can inspect only a relatively small

Page 8 Page 8GAO-06-1029 Oversight of Nuclear Power Plant Safety
sample of the plants' activities. According to NRC, its focus on the more

safety-significant activities is made possible because safety performance at

plants has improved as a result of more than 25 years of operating

experience, and because improvements have been made in the risk

assessment tools available to NRC inspectors.

Commercial nuclear power plants are designed according to a "defense-indepth" philosophy revolving around redundant, diverse, and reliable safety

systems. For example, two or more key safety components are put in place

so that if one fails, there is another to back it up. Plants have numerous

built-in sensors to monitor important indicators, such as water temperature

and pressure. Plants also have physical barriers to contain radiation and

provide emergency protection. For example, nuclear fuel is contained in a

ceramic pellet to lock in the radioactive byproducts, the fuel pellets are

sealed inside rods made of special material designed to contain fission

products, and the fuel rods are placed in reactors housed in contaimnment

buildings made of several feet of concrete and steel.

In addition, the nuclear power industry formed an organization, the

Institute of Nuclear Power Operations (INPO), whose midssion is to

"promote the highest levels of safety and reliability, to promote excellence,

in the operation of nuclear electric generating plants." INPO provides a

system of personnel training and qualification for al key positions at

nuclear power plants, and workers undergo both periodic training and

assessment. INPO also conducts periodic evaluations of operating plants,

focusing on plant safety and reliability, in the areas of operations,

maintenance, engineering, radiological protection, chemidstry, and training.

Licensees make the results of these evaluations available to NRC for

review, and NRC staff use the evaluations as a means to determine whether

its oversight process has missed any performance issues.

Prior to the ROP, NRC conducted Systematic Assessment of Licensee

Performance (SALP) evaluations. SALP evaluations were largely based on

physical plant inspections conducted at each operating plant. Every 12 to

24 months, NRC provided an overall assessment of plant safety

performance. As part of the assessment process, NRC'S senior management

met to evaluate plants' performance and develop a "watch list" of those

plants requiring increased regulatory attention. The SALP process was

heavily criticized by the industry and other internal and external

stakeholders, however, for being inconsistently applied among NRC

regions and for lacking clear and consistent responses once issues were

identified. In 1997 and 1998, we reported that NRC'S oversight needed

Page 9 Page 9GAO-06-1029 Oversight of Nuclear Power Plant Safety
substantial revisions to achieve its purpose as an early-warning tool, and

that NRC did not consistently apply the SALP across the industry.' We

found the inconsistency could be attributed, in part, to a lack of specific

criteria, the subjective nature of the process, and an ineffective process for

ensuring that the licensees maintain competent management at their

plants.

To address these concerns, NRC undertook a major effort to revise its

oversight process. NRC held a series of public meetings and workshops

and formed several task groups to involve its internal an d external

stakeholders, including NEI, UCS, state agencies, and others. In 1999, NRC

conducted a 6-month pilot program to implement the ROP at various sites

across the country. On the basis of the input it received from its

stakeholders and the results from the pilot program, NRC finalized its new

process and implemented the ROP at all plants in April 2000, which was a

significant departure from its prior SALP process.

Soon after the ROP was implemented, NRC faced a number of

unanticipated events- including the attacks of September 11, 2001, and

the discovery of the Davis-Besse reactor vessel head degradation in 2002-

that challenged its ability to complete its baseline inspection activities at all

plants in 2002 and 2003. Therefore, NRC staff implemented "coping

strategies," which consisted of increasing the use of overtime and

scheduling flexibility for its inspectors, reducing the level of effort for some

of its inspection procedures, reducing some of the inspection preparation

time, and deferring some inspections, among other things. A 2004 audit by

the NRC Office of the Inspector General found that the resource challenges

were largely due to changes in NRC'S staffing policy, a hiring policy change,

an increase in inspection activities due to unanticipated events such as

Davis-Besse, and a loss of qualified inspectors.' NRC increased its

inspection resources by 9 percent in 2004, and then by another 5 percent in

2005, and reported that it was able to fully implement its baseline

inspection program at all plants for both years. NRC reports show that

resources expended in 2005 were almost 20 percent higher than those

'GAO, Nuclear Regulatory Commission: Preventing Problem Plants Requires More

Effective Action by NRC, GAO-T-RCED-98-252 (Washington, D.C.: July 30, 1998); and

Nuclear Regulation: Preventing Problem Plants Requires More Effective NRC Action,

GAO/RCED-97-145 (Washington, D.C.: May 30, 1997).

4 NRC, Office of the Inspector General, US Nuclear Regulatory Commission: Audit of NRC's

Baseline Inspection Program, OIG-05-A-06 (Dec. 22, 2004).

Page 10 Page 10GAO-06-1029 Oversight of Nuclear Power Plant Safety
expended in 2002, the lowest level of inspection resources devoted to the

ROP since its inception in 2000. According to NRC, the additional resources

expended in 2005 were due, in part, to increased oversight that was based

on lessons learned from the Davis-Besse incident and on the increased

focus on security and emergency preparedness. With its current resource

levels, NRC program officials believe they will be able to continue to

implement all program requirements without the need to employ coping

strategies.

NRC Uses Various

Tools and Takes a RiskInformed and Graded

Ap1proach to' Ensuring

the Safety of Nuclear

Power Plants

NRC'S tools to oversee the safe operation of nuclear power plants generally

consist of physical inspections of the various complex plant equipment and

operations, reviews of plant records, and quantitative measures or

indicators of plant performance. These tools are risk-informed in that they

focus on the aspects of operations considered most important to plant

safety. NRC bases its oversight process on the principle and requirement

that licensees have programs in place to routinely identify and address

performance issues without NRC's direct involvement. Thus, an important

aspect of NRC's inspection process is ensuring the effectiveness of licensee

programs designed to identify and correct problems. On the basis of the

number and risk significance of inspection findings and performance

indicators, NRC places each plant into one of five performance categories

on its action matrix, which corresponds to graded, or increasing, levels of

oversight. NRC assesses overall plant performance and communicates the

results to licensees and the public on a semiannual basis.

NRC Collects Information

about Plant Performance

from Physical Inspections

and Quantitative Measures

Reported by the i~censees

Physical plant inspections are the main tool NRC uses to oversee plant

safety performance. NRC defined specific inspection areas by developing a

list of those 'elements most critical to meeting the overall agency mission of

ensuring nuclear power plant safety. These safety elements-or key plant

inspection areas-are k nown as cornerstones. Table 1 summarizes the

objectives of each cornerstone.

Page 11 Page 11GAO-06-1029 Oversight of Nuclear Power Plant Safety
Table 1: Key ROP Plant Inspection Areas, or Cornerstones

Cornerstone Objective

Initiating events Limit the frequency of those events that upset plant operating stability and challenge critical

safety functions.

Mitigating systems Ensure the availability, reliability, and capability of systems that mitigate initiating events to

prevent reactor accidents.

Barrier integrity Ensure that physical barriers, such as fuel cladding and containment structures, protect the

public from radioactive releases caused by accidents.

Emergency preparedness Ensure that actions taken by the emergency plan would provide protection of the public health

and safety during a radiological emergency.

Occupational radiation safety Ensure adequate protection of worker health and safety from exposure to radioactive material

during routine civilian nuclear reactor operation.

Public radiation safety Ensure adequate protection of public health and safety from exposure to radioactive material

released into the public domain as a result of routine civilian nuclear reactor operations.

Physical protectiona Provide assurance that the physical protection system can protect against radiological

sabotage.

Source: NRC.

aThe physical protection cornerstone consists of physical security issues and, therefore, is outside the

scope of this review.

During fiscal year 2005, NRC reported that inspectors spent 411,490 hours

(an average of 77 hours per week at each plant) on plant inspections, which

consist of baseline, supplemental, and special inspections. About 73

percent of this time was devoted to baseline inspections, which are the

minimum level of inspections that all plants receive regardless of

performance, and are conducted on an almost continuous basis. Baseline

inspections are conducted by the two or three NRC inspectors located at

each site and specialists who travel to each site from NRC's regional

offices. These inspections are designed to detect declining safety

performance in each of the cornerstones, and to review licensee

effectiveness at identifying and resolving its safety problems. There are

more than 30 baseline inspection procedures conducted at intervals that

range from quarterly to triennially. These procedures involve both physical

observations of plant activities and reviews of plant reports and data. Each

of the baseline procedures specify a range of sample activities to inspect.

Inspectors then select the type and number of activities to review on the

basis of factors such as the sample activities available; their risk

significance; the amount of time since a particular system or component

was last inspected; and the inspector's judgment, which is based on

information such as reviews of the licensee's corrective action program,

allegations, or plant employee interviews. Risk is factored into the baseline

inspection procedures in the following four ways: (1) areas of inspection

Page 12 Page 12GAO-06-1029 Oversight of Nuclear Power Plant Safety
are included in the set of baseline procedures, in part, on the basis of their

risk importance; (2) risk information is used to help determine the

frequency and scope of inspections; (3) the selection of activities to inspect

within each procedure is informed with plant-specific risk information; and

(4) the inspectors are trained in the use of risk information in planning their

inspections. In addition to the more than 30 baseline inspection

procedures, inspectors spend an average of 750 to 1, 100 hours per year (14

to 21 hours per week), depending on the size of the site, conducting plant

status reviews. These reviews are to ensure that inspectors are aware of

plant conditions on a routine basis and include such activities as reviewing

control room activities and status, attending licensee meetings, and

conducting walk-downs of various plant areas.

When NRC inspectors identify a finding they consider to be more than

minor,5 they use a significance determination process (SDP) to assign the

finding one of four colors to reflect the finlding's risk significance. The SDP

assesses how an identified inspection finding increases the risk that a

nuclear accident could occur, or how the finding affects the ability of the

plant safety systems or personnel to prevent such an accident. Risk

thresholds for each color were set on the basis of measures that reflect the

potential health effects that could occur from radiological exposure.'

Green inspection findings equate to very low risk significance, while white,

yellow, and red colors represent increasing levels of risk, respectively. For

greater-than-green (white, yellow, or red) inspection findings, NRC issues a

preliminary color determination after an initial analysis. It then analyzes

any readily available information from the licensee pertinent to the finding

to ensure that the final determination of risk significance is made with the

best available information.

'"Minor issues" are defined by NRC as those that have little actual safety consequences, little

or no potential to impact safety, little impact on the regulatory process, and no willfulness.

For example, if a licensee missed providing an hourly update to a state agency during a

declared unusual event that resulted in no actual safety consequences, it would be

considered minor if it did not detract significantly from the state agency's abililty to function

during the emergency. Also, if a licensee failed to record one section of a surveiliance test,

but the test was performed and the last completed survelillance test revealed that the

equipment adequately performed its safety function, the finding would be considered minor.

'Mhe measures used for the characterization of risk are core damage frequency and large

early release frequency. In some situations, risk calculations cannot be made using these

measures, such as in the case of measuring the risk for emergency preparedness inspection

findings. In these cases, thresholds were determined by panels of experts on the basis of

operating experience and a determination of what the appropriate response would be.

Page 13 Page 13GAO-06-1029 Oversight of Nuclear Power Plant Safety
When NRC issues one or more greater-than-green inspection findings at a

plant, it conducts supplemental inspections. Supplemental inspections,

performed by regional staff, expand the scope beyond baseline inspection

procedures and focus on diagnosing the cause of the performance

deficiency. There are three levels of supplemental inspections that are

increasingly expansive in the breadth and depth of their analysis. The level

of supplemental inspection to be carried out depends on the number and

type of performance problem identified. The lowest level of supplemental

inspection assesses the licensee's corrective actions to ensure they were

sufficient in both correcting the problem and identifying and addressing the

root and contributing causes to prevent recurrence. The second level of

supplemental inspection has an increased scope that includes

independently assessing the extent of the condition for both the specific

and any broader performance problems. The highest level of supplemental

inspection is even more comprehensive and includes determining whether

the plant can continue to operate and whether additional regulatory actions

are necessary. The highest level of supplemental inspection is usually

conducted by a multidisciplinary team of NRC inspectors and may take

place over several months. Also, as a part of this supplemental inspection,

NRC inspectors assess the adequacy of the licensee's overall programs for

identifying, evaluating, and correcting its performance issues, among other

things.

NRC conducts special inspections at plants when specific events occur that

are of particular interest to NRC because of their potential safety

significance at the plant or because of potential generic safety concerns

important to all plants. Special inspections determine the cause of the

event and assess the licensee's response to the event. For special

inspections, a team of experts is often formed and an inspection charter

issued that describes the scope of the inspection efforts. At one plant we

reviewed, for example, a special inspection was conducted to investigate

the circumstances surrounding the discovery of leakage from a spent fuel

storage pool.' Among the objectives of this inspection were to assess the

adequacy of the plant licensee's determination of the source and cause of

the leak, the risk significance of the leakage, and the proposed strategies to

mitigate leakage that had already occurred and repair the problem to

prevent additional leakage.

'Spent fuel storage pools are typically 40-foot deep, steel-lined, concrete vaults filled with

water to store spent fuel rods no longer capable of being used for nuclear power generation.

The water is to provide shielding from radiation that is left in the rods.

Page 14 Page 14GAO-06-1029 Oversight of Nuclear Power Plant Safety
As part of its inspection process, NRC evaluates all of its findings to

determine if certain elements of plant performance, referred to as crosscutting aspects, were a contributing cause to the performance problem.

Gross-cutting aspects represent licensee performance elements that extend

across all of the cornerstones of safety. There are three cross-cutting aspect

areas: (1) problem identification and resolution, (2) human performance,

and (3) a safety-conscious work environment. For example, in analyzing

the failure of a valve to operate properly at one plant, NRC inspectors

determined that plant employees had not followed the correct maintenance

procedures. Thus, NRC concluded that the finding was associated with the

human performance cross-cutting area. Every 6 months, NRC analyzes all

findings issued at each plant during a 12-month assessment period. If more

than three findings have similar causes within the same cross-cutting area

and if NRC is concerned about the licensee's progress in addressing these

issues, it determines that the licensee has a "substantive" cross-cutting

issue. NRC notifies the licensee that it has opened a substantive crosscutting issue, and it may ask the licensee to respond with the corrective

actions it plans to take. Also, NRC inspectors said they provide additional

focus on any substantive cross-cutting issues open through their baseline

inspection efforts. For example, one regional official said that if a

substantive cross-cutting issue in the problem identification and resolution

area is identified, it is the region's practice to increase the frequency of

certain baseline inspections that focus on the licensee's problem

identification and resolution processes.

In addition to its various inspections, NRC also collects plant performance

information through its performance indicator program, which it maintains

in cooperation with the nuclear power industry. On a quarterly basis, each

plant submits data for 15 separate performance indicators-quantitative

measures of plant performance related to safety in the different aspects of

plant operations. For example, one indicator measures the number of

unplanned reactor shutdowns during the previous four quarters, while

another measures the capability of alert and notification systems that

notify residents living near the plant in the event of an accident. Working

with the nuclear power industry, NRC set thresholds for acceptable

performance and assigned colors to each of the indicators to reflect

increasing risk. In contrast to inspection findings, a green indicator does

not indicate a performance deficiency but instead reflects performance

'Mere also are 3 performnance indicators in the area of physical security, and, therefore, they

are outside the scope of this review.

Page 15 Page 15GAO-06-1029 Oversight of Nuclear Power Plant Safety
within the acceptable range, while white, yellow, and red represent

decreasing levels of plant performance. NRC inspectors review and verify

the data submitted for each performance indicator annually through their

baseline inspections. If questions arise during the review and verification

process about how to calculate a particular indicator or what the correct

value should be, there is a formal feedback process to resolve the issue.

Similar to its process for conducting supplemental inspections when

greater-than-green inspection findings are identified, NRC conducts

supplemental inspections in response to any greater-than-green

performance indicators.

NRC Uses Its Action Matrix

to Categorize Plant

Performance and Apply

Increased Oversight in a

Graded Fashion

Under the ROP, NRC places each nuclear power plant into one of five

performance categories on its action matrix, which corresponds to graded,

or increasing, levels of oversight.' The action matrix is NRC'S formal

method of determining how much additional oversight-mostly in the form

of supplemental inspections-is required on the basis of the number and

risk significance of inspection findings and performance indicators. (See

fig. 2 for an overview of the process that leads to plant placement on the

action matrix.)

'While NRC formally places plants into performance categories on its action matrix on a

quarterly basis, NRC assesses plant performance on a continuous basis and takes actions in

accordance with the action matrix as performance issues are identified.

Page 16 Page 16GAO-06-1029 Oversight of Nuclear Power Plant Safety
Figure 2: NRC's Oversight Process in Determining Plant Placement on the Action

Matrix

Source: GAO analysis ot NRC guidance.

The definitions for the categories of the action matrix indicate more

pervasive and systematic declines in licensee performance as a licensee

moves from left to right on the action matrix (see table 2). Also, as the

licensee moves to the right on the action matrix, NRC's response and the

corrective actions it expects of the licensee become more extensive. In

determining a plant's placement on the action matrix, greater-than-green

inspection findings are considered for additional oversight for a minimum

of four quarters, regardless of whether the licensee corrected the problem,

to allow sufficient time to identify additional findings that may indicate

Page 17 Page 17GAO-06-1029 Oversight of Nuclear Power Plant Safety
more pervasive performance problems. If a licensee falls to correct the

performance problem within the initial four quarters, the finding may be

held open and considered for additional oversight. NRC regional officials,

with the approval of the Executive Director for Operations, can also

increase or decrease oversight beyond the actions specified by the action

matrix through deviations to the ROP. Deviations are for rare instances

when the regulatory actions dictated by the action matrix are not

appropriate and a more tailored approach is warranted.

Table 2: NRC Reactor Oversight Process Action Matrix

Highest level (while Unacceptable

allowing continued performance (plant

Oversight category Lowest level Second level Third level operations) shutdown)

Plant performance All green findings One white finding or Two or more white Two white findings or Overall

and performance performance findings or performance indicators unacceptable indicators indicator, or two performance indicators or one yellow finding or performance due to

white findings or in one cornerstone, or performance indicator unacceptable performance one yellow finding or in one cornerstone for margin of safety

indicators in different performance indicator, five or more quarters, cornerstones or any three white or multiple yellow or

findings or one red finding or

performance indicators performance indicator

NRC oversight Baseline Baseline inspections Baseline inspections Baseline inspections Order to modify, actions inspections only and first level, or and second level, or and third level, or most suspend, or revoke

least intensive, more intensive, intensive, licensed activities

supplemental supplemental supplemental inspection inspection inspection.'

Source: NRC.

Note: In addition to the actions listed in this table, increasingly higher levels of NRC management will

meet with the licensee as it moves to the right on the action matrix.

'For plants at this oversight level, at a minimum, the licensee and NRC are to document agreement on

the corrective actions the licensee will take through a performance improvement plan. NRC may also

take actions including making a demand to the licensee for information or issuing an order up to and

including a plant shutdown.

Page 18 Page 18GAO-06-1029 Oversight of Nuclear Power Plant Safety
Whether NRC takes enforcement actions in response to plant performance

problems depends on whether there is a violation of a specific regulatory

requirement.'" Some findings can have risk significance without violating a

regulatory requirement because the ROP is a risk-informed process, while

the underlying regulations are not all risk-informed. For example,

regulatory requirements govern plants' safety-related equipment, which

licensees define when their licenses are granted as equipment that would

be employed to mitigate the effects of an accident. NRC'S risk-informed

oversight process considers the condition of all of the equipment at a plant,

not necessarily just that included in its definition of safety-related

equipment. As such, performance deficiencies could be identified through

inspection findings that were not associated with safety-related equipment

and, thus, were not violations of a regulatory requirement. More

specifically, fire pumps are not typically defined as safety-related

equipment under the regulations defining safety-related equipment, but

they could be employed to provide water to cool the reactor in the event of

an accident. If a licensee specified the use of fire pumps as part of its

strategy to mitigate the effects of an accident, a performance problem

associated with the pumps would not necessarily violate regulatory

requirements, but the problem could be determined to be an inspection

finding. Even though there is not a regulation requiring the licensee to

correct such a problem, the finding would be considered for additional

oversight under the ROP, thus providing an incentive for the licensee to

correct it. NRC program officials acknowledge that applying the riskinformed ROP to regulations that are not risk-informed allows for these

types of situations. The officials said NRC has efforts under way to riskinform some of its regulations, which should reduce the likelihood of these

types of situations occurring.

"I1n some cases, a violation of regulatory requirements can occur that results in an

inspection finding, but the finding is not assigned a color because the issue associated with

the violation is not amenable to a risk calculation. For these types of findings, a severity

level is assigned to reflect the significance of the finding, ranging from I for the most

significant, to IV for the least significant. In assigning a severity level to the finding, NRC

assesses the following: (1) the actual safety consequences; (2) the potential safety

consequences; (3) the potential for impacting NRC'S ability to perform its regulatory

function (e.g., failure to provide complete and accurate information); and (4) any willful

aspects of the violation. Severity levels I and II violations generally involve actual or highpotential consequences to public health and safety. Severity level III violations are cause for

significant concern, and severity level IV violations are less serious but are of more than

minor concern.

Page 19 Page 19GAO-06-1029 Oversight of Nuclear Power Plant Safety
On the basis of the results of its oversight process, NRC provides plant

licensees and the public with an overall assessment of each plant's

performance. At the end of each 6-month period, NRC issues an assessment

letter to each plant to describe what level of oversight the plant will receive

according to its placement on the action matrix, what actions NRC is

expecting the plant licensee to take as a result of the performance issues

identified, any specific enforcement actions NRC has taken, and any

documented substantive cross-cutting issues. If a substantive cross-cutting

issue is identified, the letter will describe what actions NRC intends to take

to monitor the issue and how the licensee is expected to respond to NRC

with the corrective actions it intends to take. NRC also holds an annual

public meeting at or near each site to review its performance and address

questions from members of the public and other interested stakeholders. In

addition, NRC reviews the conclusions of independent plant assessments,

such as those conducted by INPO. The purpose of this review is to selfassess the NRC inspection and assessment process to ensure that NRC is

identifying similar performance issues.

NRC communicates the results of much of its oversight process to

members of the public through an Internet Web site devoted to the ROP

This Web site makes available plants' inspection reports and assessment

letters, and other general materials related to NRC'S oversight process.

NRC also provides a quarterly summary of every plant's performance,

consisting of its inspection findings, the color of each performance

indicator, and its placement on the action matrix. NRC also provides a

short description of each inspection finding issued during the quarter.

While each description contains information about whether the finding was

associated with a cross-cutting issue, the Web site itself does not provide

information on those plants that have open substantive cross-cutting

issues. Thi-s information can only be found on the Web site by linking to

each plant's individual assessment letters. NRC program officials

acknowledge that, without having the information available in summary

form, it is difficult to determine which plants have substantive crosscutting issues open. They said that they may look at the possibility of

including such information on the Web site, although doing so is not part of

their current plans.

In addition to its plant-level assessments, NRC assesses the results of its

oversight process on an industry-level basis. NRC management holds an

annual meeting to (1) discuss any significant performance issues identified

at specific plants and (2) analyze the overall results of its inspection and

Page 20 Page 20GAO-06-1029 Oversight of Nuclear Power Plant Safety
performance indicator programs and compare them with other industrycollected and reported performance data. NRC program officials said that

if they identified any negative trends or inconsistencies, they would take

action to better understand and address the cause.

NRC Has Identified

Low Risk Problems at

Nuclear Power Plants,

Resulting in Increased

Oversight for Varying

Periods

The POP has identified thousands of performance deficiencies through

inspection findings at nuclear power plants between 2001 and 2005, but

most of these findings were considered to be of very low risk to safe plant

operations. In the performance indicator program, there have been very

few instances in which performance indicator data were below acceptable

standards during this period. While the majority of plants received some

level of increased oversight due to greater-than-green inspection findings

and performance indicators, only 5 plants were subjected to NRC's highest

levels of oversight. Plants in this category were generally subjected to this

higher oversight for long periods due to the more intensive supplemental

inspections conducted by NRC and to the more systemic nature of the

plants' performance problems and subsequent corrective actions NRC

expected the licensees to take. In assessing the results of the POP between

2001 and 2005, we found an association between poorer performing plants

and deficiencies in the cross-cutting areas of human performance and

problem identification and resolution.

Of the more than 4,000 inspection findings identified between 2001 and

2005, 97 percent were green. (See app. III for additional site-specific

inspection findings data.) The number of green findings ranged from 15 at

one site to 141 at another site, with an overall site average of 59 for the 5-

year period. While green findings are considered to be of very low safety

significance, they represent a performance deficiency on the part of the

licensee and it is important that they be corrected. Green findings consist

of such things as finding that a worker failed to wear the proper radiation

detector, or finding that a licensee did not properly evaluate and approve

the storage of flammable materials in the vicinity of safety-related

equipment. NRC does not follow up on the corrective action taken for

every green finding; rather, it relies on the licensee to address and track the

finding's resolution through the plant's corrective action program. NRC

does, however, periodically follow up on some of the actions taken by the

licensee to address green findings through an inspection specifically

designed to evaluate the effectiveness of the licensee's corrective action

program. NRC program officials stated that even though they do not

increase oversight as a result of green findings, green findings are assessed

for the presence of cross-cutting aspects and provide useful information on

Page 21 Page 21GAO-06-1029 Oversight of Nuclear Power Plant Safety
plant performance. NRC. inspectors told us they use green findings to

identify performance trends in'the various safety areas and these findings

help inform their selection of future inspection samples.

The other 3 percent of the inspection findings identified between 2001 and

2005, or 98 of the more than 4,000, were greater-than-green (see app. LIDI.

Eighty-six findings were white, meaning they were considered to be of low

to moderate risk significance. The white findings were well-distributed

among the sites, with only 11 sites receiving more than 2 white findings

during the period. Twenty-three sites were not issued any whidte (or greater)

findings during this period. White findings were issued for such things as

(1) a licensee's failing to correct a condition in which the auxiliary service

water pump could not be aligned in sufficient time to mitigate the loss of

feedwater during a simulated tornado exercise and (2) a licensee's having

an improper validation process for its licensed operator requalification

examinations, which compromised the integrity of the exams. Less than 1

percent of the inspection findings issued since 2001 were of the highest risk

significance-yellow or red. During this time, NRC issued 7 yellow findings

and 5 red findings. The 7 yellow findings were in the mitigating systems and

emergency preparedness cornerstones and included issues such as the

failure to develop and maintain emergency plans at one plant, the failure to

ensure that safety-related equipment was adequately protected from

flooding at another plant, and the failure to pass an annual licensed

operator requalification examination by over half of the operator crews at

one plant. Of the 5 red findings, 1 was issued for the degradation of the

reactor vessel head at the Davis-Besse plant, 1 was issued for a steam

generator tube failure at another plant, and the remaining 3 red findings

were issued at 2 other plants for problems related to their auxiliary

feedwater pumps.

NRC's inspection resulIts have remained relatively consistent from 2001 to

2005. During this time frame, the number of green findings at all plants

ranged from 657 to 889 per year, and the number of other findings ranged

from 10 to 30 per year, with no strong trend (see fig. 3).

Page 22 Page 22GAO-06-1029 Oversight of' Nuclear Power Plant Safety
Figure 3: Number of Inspection Findings at All Plants, 2001 Through 2005

Number of Inspection findings

900

800

700

600

500

400

300

200

100

0

774 751

889

835

657

2 28 2 11 2 1 18 1 0 - b - h - h - i ~ h - h

2001 2002 2003 2004 2005

Year

WGreen

L White

Yellow

Source: GAO analysis of NRC data.

Only in the area of inspection findings for which one or more cross-cutting

aspect was associated, is an increasing trend evident (see fig. 4). According

to NRC, the increase in findings with cross-cutting aspects is due, in part, to

the recent development of additional guidance for inspectors on the

identification and documentation of cross-cutting aspects. The number of

plants where the existence of cross-cutting aspects resulted in NRC's

opening a substantive cross-cutting issue is shown in figure 5. (See app. III

for additional data on plant-specific, substantive cross-cutting issues.)

Page 23 Page 23GAO-06-1029 Oversight of Nuclear Power Plant Safety
Figure 4: Number of Inspection Findings and Inspection Findings with CrossCutting Aspects at All Plants, 2001 Through 2005

Number of Inspection findings

900

800

700

600 68%

500

52%

400 * S

300

20023%.............

100

0

2001 2002 2003 2004 2005

Year

- Total inspection findings

.... Inspection findings with cross-cutting issues

Source: GAO analysis of NRC data.

Note: Almost all inspection findings with cross-cutting aspects were in the areas of human

performance and problem identification and resolution; only 5 out of 1,890 inspection findings were

assigned to the safety-conscious work environment cross-cutting area.

Page 24 Page 24GAO-06-1029 Oversight of Nuclear Power Plant Safety
Figure 5: Number of Plants with Substantive Cross-Cuffing Issues, 2001 Through

2005

Number of plants

35

30

30 29

25 24 24

20

15 13

10

5

0 - - - - -

2001 2002 2003 2004 2005

Year

Source: GAO analysis of NRC data.

Note: The totals Include those plants that had one or more substantive cross-cutting issue open during

at least some portion of the year. If a plant had more than one substantive cross-cutting issue open,

only one was counted.

In the performance indicator program, almost all of the indicator data were

reported to be within the acceptable levels of performance (green). Only

156, or less than 1 percent of over'30,000 indicator reports from 2001 to

2005, did not meet the acceptable performance threshold. (See app. III for

additional plant-specific performance indicator data.) Four of the 15

performance indicators have always been reported within acceptable

performance levels. These 4 indicators include 1 that measures the amount

of time that the residual heat removal safety system is unavailable, 1 that

monitors the integrity of a radiation barrier, 1 that measures the

participation of emergency response organizations in emergency drills or

exercises, and 1 that monitors radiological releases. In addition, 46 plants

have never had a performance indicator fall outside of the acceptable

performance level, and no yellow or red indicators were reported during

the period.

On the basis of the greater-than-green inspection findings and performance

indicators, NRC has subjected more than three quarters (79) of the 103

Page 25 Page 25GAO-06-1029 Oversight of Nuclear Power Plant Safety
operating plants to at least some level of increased oversight for varying

periods. (See app. III for additional plant-specific oversight level data.)"

Most of these plants received the lowest level of increased oversight,

consisting of the least intensive supplemental inspection, due to the

identification of one or two white inspection findings or performance

indicators. In most of these instances, the licensees did not accumulate

additional greater-than-green findings, so oversight did not have to be

increased to higher levels on the action matrix. For example, at one plant,

NRC issued a white finding after a degraded valve resulted in the failure of

a drain line from a moisture separator. After allowing time for the licensee

to analyze the root cause, NRC completed a supplemental inspection to

assess the licensee's evaluation and concluded that the licensee's actions

were adequate. As a result, NRC did not require any further actions of the

licensee, and NRC inspectors did not conduct further inspections beyond

the baseline procedures. In some cases, however, either the licensee was

not able to sufficiently correct the performance problem, thus triggering

increased oversight, or additional greater-than-green inspection findings or

performance indicators were identified, also triggering increased oversight.

For example, a white finding was issued at one plant because the licensee's

fire response procedures were not effective in ensuring a safe shutdown of

the reactor during a postulated severe fire. Because this finding was issued

during the same time that one of the plant's performance indicators was

white, the plant was moved from the second to the third highest level of

oversight and NRC conducted a second-level, more-intensive supplemental

inspection. In this case, NRC determined that the licensee's corrective

actions were sufficient to resolve the deficiencies related to both the

inspection finding and performance indicator and thus reduced its

oversight back to baseline inspections only.

While more than three quarters of nuclear power plants received some

level of increased oversight from 2001 through 2005, only 5 plants were

placed into NRC'S highest oversight category on the action matrix that still

allows continued operations, and no plants were placed into NRC'S

"During this period, NRC also requested and received approval to deviate from its oversight

process at 6 plants, with 1 of the plants subjected to increased oversight from a deviation on

two separate occasions. At 4 of the plants, the deviation resulted in increased oversight, while at 2 plants it resulted in decreased oversight.

Page 26 Page 26GAO-06-1029 Oversight of Nuclear Power Plant Safety
unacceptable performance category.'12 Plants subject to the highest level of

NRC oversight generally remain in this category for longer periods of time

than the other performance categories on the action matrix. It usually takes

NRC longer to conduct the more intensive supplemental inspections and

the licensees longer to implement the actions that NRC expects to correct

the broader and more systemidc performance issues that led to their

placement in the highest oversight category. For example, one plant was

subject to NRC'S highest oversight level for approximately 2 years because

of several greater-than-green inspection findings and performance

indicators, including a red inspection finding for the failure of a steam

generator tube. In this case, NRC conducted its most intensive

supplemental inspection 2 months after the final significance of the red

inspection finding was determined. NRC inspectors found a number of

underlying problems with the licensee's programs for design control,

human and equipment performance, problem identification and resolution,

and emergency preparedness. The licensee prepared a plan to address its

performance deficiencies, as is required for all plants placed into this

oversight category, and determined that a multiyear effort was necessary to

adequately develop and implement all corrective actions. Once the

corrective actions were in place, NRC inspectors conducted follow-up

inspections to examine the adequacy of the licensee's efforts in

implementing its corrective actions. NRC inspectors at the plants we

reviewed explained that plants subjected to the highest oversight levels

typically have underlying problems that can take longer periods to resolve.

It is important for them to ensure that the corrective actions taken by the

licensee are effective before oversight is reduced. Therefore, inspectors try

to allow a sufficient amount of time to pass after the licensee has taken a

corrective action, to be able to examine not only the corrective action itself

but also whether it is working as intended, which requires it to have been in

place for awhile.

NRC inspectors at the plants we reviewed also said that a decline in plant

performance is often the result of ineffective licensee corrective action

programs, problems related to human performance, or complacent

management, which often results in deficiencies in one or more of the

"

2While it was not placed into NRC's unacceptable performance category on the action

matrix, the Davis-Besse plant was subjected to a special oversight process due to its

significant performance problems related to the reactor-vessel head degradation that

occurred in 2002. On the basis of this event, NRC placed the plant, which was already in a

shutdown condition, into an oversight process outside of the ROP and conducted by a

special oversight panel consisting of region and headquarters NRC officials.

Page 27 Page 27GAO-06-1029 Oversight of Nuclear Power Plant Safety
cross-cutting areas. In assessing the results of the ROP data, we found an

association between plants that had been subjected to increased levels of

oversight and the presence of substantive cross-cutting issues. For

instance, all plants subjected to NRC's highest level of oversight also had a

human performance and/or problem identification and resolution

substantive cross-cutting issue open either prior to or during the time that

they were subjected to increased oversight.

NRC Is Addressing

Weaknesses in Various

Areas of Its Oversight

Process, but More

Effort Is Needed

NRC has taken a proactive approach to constantly improving its oversight

process over its first 6 years of implementation, but additional

improvements are needed. NRC has several mechanisms in place to

incorporate feedback from both external and internal stakeholders, and it

is currently working on improving several areas of its oversight process by,

for example, better focusing inspections on areas most important to safety,

improving the timeliness and quality of determining the risk significance of

its inspection findings, and modifying some of the performance indicators

to improve their quality. NRC is also assessing whether it needs to modify

its oversight, including developing additional inspection procedures, as a

result of some problems that have surfaced in areas not fully inspected by

NRC, such as the recent discovery of groundwater contamination from

radioactive releases at a number of sites. In addition, NRC is working to

address what we believe has been a significant shortcoming by making

changes to its oversight process to improve its ability to better identify and

address early indications of deteriorating safety at plants before

performance problems develop. Some of its changes have been

controversial, however, and NRC officials acknowledge the need to

carefully assess the effectiveness of the changes.

NRC Is Taking Action to

Improve Various Areas of Its

Oversight Process

According to NRC, the ROP was implemented with the understanding that

it would be an evolving process and improvements would be made as

lessons were learned. Each year NRC conducts a self-assessment of its

oversight process to compile feedback from various internal and external

sources and to outline the changes it intends to make. As a part of its selfassessment, NRC developed numerous performance metrics for its various

oversight components, including its inspections and performance indicator

program, to provide quantitative insights into the timeliness, efficiency, and

overall effectiveness of the ROP. The metrics are based on program data,

such as the number and color of inspection findings, and feedback received

from external and internal stakeholders. Each fall, NRC solicits feedback

Page 28 Page 28GAO-06-1029 Oversight of Nuclear Power Plant Safety
from external stakeholders through a survey published in the Federal

Register. In 2005, NRC received 21 responses from the industry, industry

'organizations, public interest groups, state or local agencies, and members

of the public. NRC also biannually surveys NRC management, program

staff, and regional and site inspectors on the effectiveness of the ROP. In

the most recent survey, which was conducted in 2004, NRC received

responses from about 50 percent of the surveyed staff. In addition, NRC has

a formal feedback mechanism whereby NRC staff can submit

recommendations for improving various oversight components, and NRC

staff meet with industry officials on a monthly basis-in addition to holding

various meetings, workshops, and conferences-to discuss the ROP.

Through NRC'S self-assessment process, its staff also incorporates

direction provided by the NRC commissioners and recommendations from

independent evaluations, such as from the ACRS, GAO, and the NRC Office

of the Inspector General.

According to NRC program officials, the changes made to the ROP since its

inception in 2000-including those made in response to the Davis-Besse

incident-have generally refined the existing oversight process, rather than

significantly changing it. In the case of Davis-Besse, NRC formed a task

force to review the agency's regulatory processes. The task force's report,

issued in September 2002, contained more than 50 recommendations, many

associated with its oversight process. Among the more significant ROPrelated recommendations were those to (1) enhance the performance

indicator that monitors unidentified leakage; (2) develop specific guidance

to inspect licensee boric acid control programs and vessel head penetration

nozzles; (3) modify the inspection program, including modifying an

inspection procedure to better follow up on long-standing plant

performance issues; and (4) enhance the guidance for managing plants that

are shut down as a result of significant performance problems. NRC

program officials told us that the task force's most significant

recommendations were in areas outside of the ROP, such as improving the

agency's operating experience program. According to NRC, it has

implemented almost all of the task force's recommendations.

Other modifications NRC has recently made or is in the process of making

include the following:

*NRC recently revised 7 of its baseline inspection procedures to better

focus the level and scope of its inspection efforts on those areas most

important to safety. These revisions resulted from a detailed analysis in

2005 of its more than 30 baseline inspection procedures. For example,

Page 29 Page 29GAO-06-1029 Oversight of Nuclear Power Plant Safety
NRC staff analyzed the number of findings resulting from each of its

inspection procedures to better understand the areas where

performance deficiencies were occurring, and compared the time that

inspectors were spending directly observing plant activities as opposed

to reviewing licensee paperwork to achieve a balance between the two.

For this effort, NRC held constant the level of resources devoted to its

baseline inspection effort and did not assess whether more or fewer

inspection resources overall should be applied. NRC is now formalizing

this analysis and making it a regular part of its yearly assessment so that

it can continually refine its inspections to direct resources to the most

critical performance areas.

*NRC has efforts under way to improve its SDP. An audit by the NRC

Office of the Inspector General, a review by a special task group formed

by NRC, and feedback from other stakeholders such as NEI and UCS

have pointed to several significant weaknesses with the SDP Also, other

internal and external stakeholders, including NRC inspectors and plant

managers, have raised concerns about the amount of time, level of

effort, and knowledge and resources required to determine the risk

significance of some inspection findings. Industry officials commented

that because most inspection findings are green, one white finding at a

plant can place it in the "bottom quartile" of plants from a performance

perspective. Therefore, industry officials explained, licensees try to

avoid this placement and will expend a great deal of effort and

resources to provide additional data to NRC to ensure that the risk level

issued for the finding is appropriate. This can add significant time to the

process because licensees may use their own technical tools, including

models, data, and assumptions, to analyze the issue. NRC then considers

this information in its own analysis. At the plants we reviewed, the time

it took NRC to determine the final significance of risk-significant

inspection findings ranged from 24 days to over 200 days. The delay in

assigning a color to a finding while the new information is being

considered could affect a plant's placement on NRC's action matrix,

essentially delaying the increased oversight called for if the finding is

determined to be greater-than-green. NRC program officials said that

even though there may be a delay in determining the final risk

significance of the finding, the licensee takes immediate action to fix the

identified problem. However, supplemental inspections are designed to

uncover additional associated problems, if they exist, and delaying these

inspections could delay NRC'S ability to discover additional

performance problems, potentially allowing performance to worsen.

Page 30 Page 30GAO-06-1029 Oversight of Nuclear Power Plant Safety
NRC developed a plan in 2002 to improve the timeliness of its decisionmaking process, enhance the quality of its various SDP tools, and track

its progress in implementing key changes. For example, NRC introduced

a new process aimed at improving timeliness by engaging decision

makers earlier to more quickly identify the scope of the evaluation to be

used to determ-ine the inspection finding's risk significance, the

resources needed, and the schedule to complete the evaluation.

As a part of the SDP, NRC uses probabilistic risk assessment (PRA)

methods, which overall has improved its ability to assess the

performance and safety of nuclear power plants. PRA is an analytical

tool for estimating the probability that a potential accident might occur

by exam-ining how physical structures, systems, and components, along

with employees, work together to ensure plant safety. Using PRA tools,

NRC and the plant licensees can estimate the likelihood that different

accident scenarios at plants will result in reactor core damage and a

release of radioactive materials. NRC often uses PRA tools to help it

determine the risk significance of its inspection findings. However, we

and others have found weaknesses with NRC's use of PRA." For

instance, in our May 2004 report on the Davis-Besse reactor vessel head

incident, we found that NRC used some incomplete and faulty PRA

analyses in deciding whether to allow the licensee to delay shutdown of

the reactor for inspection.'" While NRC program officials acknowledge

they can improve their current PRA tools, they said the tools are

adequate for factoring risk into the oversight process and do achieve

their intended purpose. NRC has several initiatives under way to

improve its use of PRA in its decision making, many of whiceh it plans to

complete by June 2007. For example, NRC recently revised its models to

assess events that occur at plants during at-power situations to better

capture individual plant characteristics, and it is in the process of

developing new models to assess events that occur at plants during lowpower or shutdown conditions. NRC is also developing guidance to

address broader PRA issues, including establishing overall quality

requirements for risk information; providing specific instructions for

"

3Currently, the NRC Office of the inspector General is also completing a review, through a

contract with technical experts, to assess NRC's use of PRA in its regulation of licensees

given the current state of the art in the technology.

"

4GAO, Nuclear Regulation: NRC Needs to More Aggressively and Comprehensively

Resolve Issues Related to the Davis-Besse Nuclear Power Plant's Shutdown, GAO-04-415

(Washington, D.C.: May 17, 2004).

Page 31 Page 31GAO-06-1029 Oversight of Nuclear Power Plant Safety
documenting the decision process and conclusions; and developing

improved methods for calculating risk, such as its practices for

implementing human reliability analysis.

*NRC is working with the nuclear power industry to improve several of

its performance indicators, including making the definitions of some

indicators more concise to improve their quality and to reduce the

number of discrepancies between licensees and NRC inspectors.

Because NRC inspectors verify indicator data only once a year, a

potential disagreement with a licensee over these data might not surface

for up to 1 year after it is reported, and it may take even longer to

resolve the disagreement. Similar to delays with the SDP, a delay in

assigning a color while the disagreement is being resolved could affect a

plant's placement on NRC'S action matrix, and delay the increased

oversight called for if the indicator is determined to be greater-thangreen. To date, NRC's efforts to improve the performance indicator

program have largely centered on developing a key indicator to address

known problems with the indicators that measure the unavallability of

safety systems. NRC has been working jointly with the nuclear industry

since 2001 to develop the indicator, which is now risk-informed and

intended to provide a more accurate indication of the risks associated

with changes in the availability and unreliability of important safety

systems. This indicator, referred to as the mitigating systems

performance index, was implemented in April 2006, and the first plant

reports were submitted in July 2006. NRC is also in the process of

changing the definition for several other indicators, in addition to

considering the feasibility of new indicators.

In addition, NRC program officials sald they are taking a broad look at

the performance indicator program to assess how they might increase

its overall value to the ROP The effort is intended, in part, to address

concerns that performance indlicators have not contributed to the early

identification of poorly performing plants to the degree originally

envisioned, since all of the indicators are almost always within

acceptable performance levels (green). When the program was

developed, thresholds were set using industry performance data such

that about 5 percent of the plants were expected to exceed the greenwhite threshold-that is, be designated either white, yellow, or red-for

each of the performance indicators. However, from 2000 through 2005,

less than 1 percent exceeded it. Furthermore, there have been several

cases where plants reported an acceptable performance indicator and

performnance problems in the area were subsequently identified. For

Page 32 Page 32GAO-06-1029 Oversight of Nuclear Power Plant Safety
example, NRC inspectors at one plant noted that while performance

indicator data related to its alert and notification system for emergency

preparedness had always been reported green, the system did not

always function properly. On the other hand, industry officials believe

that the high percentage of green indicators is indicative of plants' good

performance. Several plant managers told us that they closely monitor

and manage to the acceptable performance thresholds established for

each indicator, and that they will often take action to address

performance issues well before the indicator crosses the acceptable

threshold. To assess issues within the performance indicator program,

NRC developed a standing working group, with representatives from

both the industry and NRC, that meets on a monthly basis. This group,

along with senior NRC and industry management, plans to explore

overall program improvements to better identify declining plant

performance.

In addition to the previously mentioned efforts, NRC is assessing whether it

needs to modify its oversight, including developing additional inspection

procedures, as a result of some problems that have surfaced in areas not

fully inspected by NRC. For example, NRC has reported that there have

been inadvertent, unmonitored releases of radioactive liquids containing

tritium at a number of nuclear power sites in the past few years.'" To date,

NRC reports show that the measured levels of tritium discovered were low

enough that they do not appear to pose a public health hazard. According

to NRC, the releases were due to equipment failures or structural

degradation at the plants. At one of the plants we reviewed, for example,

elevated levels of tritium in the on-site groundwater were discovered

during the licensee's testing of its monitoring wells. NRC reports suggest

that this radioactive release was most likely due to leakage from the spent

fuel pool's support structures. Shortly after the licensee reported the

contamination, NRC initiated a special inspection to further investigate the

source and cause of the leakage and the licensee's actions for miitigation.

On the basis of this and other discoveries of contaminated groundwater, in

March 2006, NRC formed a lessons-learned task force to evaluate NRC'S

regulatory processes related to the radioactive releases and to recommend

areas for improvement. For example, NRC is reviewing related regulations

'

5

Tritium is a mildly radioactive type of hydrogen that occurs both naturally and during the

operation of nuclear power plants. Water containing tritium and other radioactive

substances is normally released from nuclear plants under controlled, monitored conditions

that NRC mandates to protect public health and safety.

Page 33 Page 33GAO-06-1029 Oversight of Nuclear Power Plant Safety
and guidance, inspection program requirements, and its communications

with external stakeholders and the public. In addition, the nuclear industry

recently undertook an initiative to improve its groundwater protection, and

intends to develop site-specific action plans at all plants and improve the

industry's data collection, reporting, and protocols for sharing lessons

learned.

NRC is also taking action to improve its requirements for licensees to

control and account for their spent nuclear fuel, that is, the used fuel

periodically removed from reactors in nuclear power plants. NRC requires

licensees to control and account for all of their spent fuel materials

because of the hazardous nature of spent nuclear fuel.'" However, reviews

by both GAO and the NRC Office of the Inspector General found

weaknesses with NRC's oversight of licensees' spent fuel control and

tracking programs.'" Between 2000 and 2004, several plants experienced

instances of missing or unaccounted-for spent fuel, and NRC reported

weaknesses in the material control and accounting programs at various

other plants. In investigating these issues, we and the NRC Office of the

Inspector General determined that NRC's inspections did not adequately

ensure that all licensees properly controlled and accounted for their spent

nuclear fuel. From the late-1980s through implementation of the ROP, NRC

did not conduct routine material control and accounting inspections;

instead it looked at these activities indirectly through other inspections,

such as those of licensee operations during refueling of the reactor. We also

found that while NRC requires plants to maintain an accurate record of all

their spent fuel and its location, NRC regulations did not specify how

licensees are to conduct physical inventories or how they are to control

and account for loose spent fuel rods and fragments. NRC is currently in

the process of revising several of its guidance documents and developing

inspection procedures to better assess the effectiveness of licensee

material control and accounting programs. NRC reports that most of these

efforts will be completed by the end of 2007.

"

6

While spent nuclear fuel is too inefficient to power a nuclear reaction, it is still intensely

radioactive and continues to generate heat for thousands of years. Thus, the potential health

and safety implications make the control of spent nuclear fuel of great importance.

1 7 GAO, Nuclear Regulatory Commission: NRC Need~s to Do More to Ensure that Power

Plants Are Effectively Controlling Spent Nuclear Fuel , GAO-05-339 (Washington, D.C.: Apr.

8, 2005); and NRC, Office of the Inspector General, US Nuclear Regulatory Commission:

Audit of NRC's Regulatory Oversight of Special Nuclear Materials , OIG-03-A-15 (May 23,

2003).

Page 34 Page 34GAO-06-1029 Oversight of Nuclear Power Plant Safety
NRC Is Taking Its First

Major Step to Address a

Significant ROP Weakness

in the Area of Safety Culture

One significant shortcoming in the ROP that we and others have found is

that it has not been as effective as it could be in identifying and addressing

early indications of deteriorating safety performance at nuclear power

plants before problems develop. NRC and others have long recognized that

a safety culture-the organizational characteristics that ensure that issues

affecting nuclear plant safety receive the attention their significance

warrants-can have a significant impact on a plant's safety performance.

The identification of a weak safety culture-or weaknesses in the

attributes that make up a safety culture, such as attention to detail,

adherence to procedures, and effective corrective and preventative

actions-can point to early signs of deteriorating safety performance

before conditions become so serious that a safety accident occurs. As early

as 1989, NRC recogn ized the importance of developing a safety culture at

each nuclear power plant that ensures safe plant operations, but NRC's

policy stated that it was the licensee's duty and obligation to monitor and

maintain a strong safety culture.

Despite the recognition of the importance of a safety culture and several

external groups' recommendations to better incorporate safety culture

aspects into NRC's oversight process, NRC did not include specific

measures to comprehensively assess plant safety culture when it

implemented the ROP in 2000. As its new oversight process was being

developed, external stakeholders, including the ACRS, concluded that

additi onal oversight measur 'es were needed to characterize licensees'

human performance and safety culture. The 2002 Davis-Besse reactor

vessel head incident highlighted that this was a significant weakness in the

ROP. Our May 2004 report concluded that the event occurred, in part,

because NRC did not have an effective means to identify and address early

indications of deteriorating safety at plants before performance problems

develop.

NRC did not take immediate action, however, contending that direct safety

culture evaluations would cross the line from a regulatory function to a

licensee management function. In August 2004, the NRC Commission

directed the staff to improve the ROP by more fully addressing safety

culture. In response, NRC staff formed a safety culture working group in

early 2005 to lead the agency's efforts to make changes to the ROP to better

incorporate safety culture into its oversight process. As a part of this

initiative, the working group obtained the input of external stakeholders

through a series of public meetings held in late 2005 and early 2006. The

group also incorporated lessons learned from events that occurred at the

Salem and Hope Creek site during this same period. In 2004, NRC

Page 35 Page 35GAO-06-K1029 Oversight of Nuclear Power Plant Safety
confirmed there were problems with aspects of the site's safety culture. In

addressing the problem, NRC concluded that the ROP did not provide

adequate tools to monitor the situation or the sufficiency of the licensee's

corrective actions. As a result, NRC deviated from the ROP to increase its

oversight at the site, which included conducting special inspections and

forming a team with expertise in the area to review the licensee's corrective

actions. (See app. I for additional information on the events at Salem and

Hope Creek.)

In February 2006, NRC issued proposed changes to some of its inspection

procedures and guidance documents to incorporate safety culture into the

ROP, and implemented the changes in July 2006. NRC used the following

two overall approaches: first, it developed additional guidance for

identifying and addressing cross-cutting aspects, and, second, it developed

a structured way to determine the need to evaluate plants' safety culture.

Several inspection procedures were also modified to direct inspectors to be

sensitive to and take into consideration safety culture components when

planning and conducting their inspections. Although the three cross-cutting

aspects (problem identification and resolution, human performance, and a

safety conscious work environment) did not change, NRC developed new

definitions for them to more fully encompass safety culture aspects. Also,

NRC developed additional guidance on the treatment of cross-cutting

aspects once they have been identified. For example, the problem

identification and resolution cross-cutting area now has several

components-a corrective action program, operating experience, and self

and independent assessments. The human performance cross-cutting area

is composed of decision making, resources, work control, and work

practices. NRC inspectors are required to assess every inspection finding to

determine if it is associated with one or more of the components that make

up each of the cross-cutting areas. While the process for assessing

inspection findings for the existence of cross-cutting aspects and

substantive cross-cutting issues remains largely unchanged, now the

definitions for the cross-cutting areas are more detailed and track more

closely with those elements that comprise safety culture.'8 In addition,

under NRC's new guidance, if the same substantive cross-cutting issue is

'

8NRC also defined four additional components-accountability, continuous learning

environment, organizational change management, and safety policies-that are not

associated with the cross-cutting issues, but when combined with them, comprise all

components that make up safety culture. While these additional components are not

considered in relation to baseline inspection findings, they would be considered during the

conduct of supplemental inspections.

Page 36 Page 36GAO-06-1029 Oversight of Nuclear Power Plant Safety
identified in three consecutive assessment periods, NRC may request that

the licensee evaluate its safety culture. The intent is to provide an

opportunity to diagnose a potentially declining safety culture before

significant safety performance problems occur. NRC program officials said

they consider the identification and treatment of substantive cross-cutting

issues the most proactive element of the ROP, because all other oversight

actions are taken only when more significant performance problems have

been identified.

NRC's changes to the ROP now also include a structured way for NRC to

determine the need for a safety culture evaluation. NRC's new guidance

calls for the licensees of plants with more than one white finding in the

same cornerstone or one yellow finding to evaluate whether the

performance issues were caused by any safety culture components, and

NRC may request the licensee to independently evaluate its safety culture,

if the licensee does not identify a safety culture component. Any safety

culture deficiencies are expected to be entered into the licensee's

corrective action program. Regional officials would discuss the licensee's

proposed corrective actions with the licensee, and NRC may hold a public

meeting to discuss the issues. For plants where more significant or multiple

findings have been identified, NRC will not only independently assess the

adequacy of the licensee's independent evaluation of safety culture, but

may also conduct its own evaluation. Following the completion of any

evaluations, regional and headquarters officials together determine

whether additional agency actions are warranted, and, at a minimum, the

licensee will be required to document its plan to make improvements and a

public meeting will be held to discuss the licensee's performance.

According to an NRC official familiar with the Salem and Hope Creek

situation, had these requirements been in place at the time, they would

have been adequate to address the concerns at Salem and Hope Creek

without the need to deviate from the ROP.

NRC's approach to incorporating safety culture into the ROP has been

controversial, and some stakeholders disagree with certain changes. For

example, some in the nuclear power industry have expressed concern that

the changes could introduce undue subjectivity to NRC'S oversight, given

the difficulty in measuring these often intangible and complex concepts.

Several of the nuclear power plant managers at the sites we reviewed said

that it is not always clear why~a cross-cutting aspect is associated with a

finding, or what it will take to clear themselves once they have been

identified as having a substantive cross-cutting issue. Some industry

officials worry that the changes will further increase the number of findings

Page 37 Page 37GAO-06-1029 Oversight of Nuclear Power Plant Safety
that have cross-cutting aspects associated with them, and, if all of the

findings have these aspects, whether the process will lose its value.

Industry officials also warn that if the changes are not implemented

carefully, resources could be diverted away from other important safety

issues. Other external stakeholders, such as an official from UCS, on the

other hand, suggest that this effort is an important step toward improving

NRC's ability to identify performance issues at plants before they result in

safety problems. Importantly, there are now additional tools in place for

NRC to use when it identifies potential safety culture concerns. In

reviewing NRC's proposed approach in April 2006, the ACRS concluded

that the approach was appropriate and will enhance the agency's ability to

address safety culture issues; although after gaining some experience with

the process, it stated that NRC should reassess the adequacy of some

procedures.

NRC program officials acknowledged that they will need to assess the

changes they made to the ROP to determine if they better allow inspectors

to detect deteriorating safety conditions at plants before significant safety

events occur. Some at NRC view these changes as the beginning step

toward an incremental approach. For its current efforts, NRC also

acknowledged that additional training for its inspectors on safety culture is

needed. NRC provided computer-based and regional training to its

inspectors as the changes were being finalized, and it is currently working

to incorporate aspects of its safety culture changes into its more permanent

training programs. NRC plans to evaluate stakeholder feedback-both

through its normal processes, such as its monthly meetings, and potentially

through specific industry-sponsored workshops dedicated to the issueand make additional changes on the basis of the lessons learned as part of

its annual self-assessment process for 2007.

Conclusions NRC is devoting considerable effort to overseeing the safe operation of the

nation's commercial nuclear power plants, and its process for doing so

appears logical and well-structured. NRC'S oversight process is finding

safety problems and is getting the industry to constantly improve. However,

weaknesses with its inspection and performance indicator programs have

been identified-in particular, the timeliness of the process used to

determine the risk significance of inspection findings, and the ability of

performance indicators to contribute to the early identification of poorly

performing plants. Importantly, NRC is demonstrating that it is aware of

these weaknesses and is actively making changes to improve its oversight.

NRC's proactive approach is demonstrated by the important progress it is

Page 38 Page 38GAO-06-1029 Oversight of Nuclear Power Plant Safety
making in several key areas, including making efforts to improve the

timeliness and quality of its significance determination process, redefining

some of its performance indicators, and assessing the need for additional

inspection procedures based on careful analysis. Its efforts to continuously

consider the need to improve and obtain feedback from both internal and

external stakeholders are critical as nuclear power plants age and the

nation considers building new plants. In this regard, it is also important that

the ROP continue to be a very open process in which NRC provides the

public and its other stakeholders with considerable information on its

oversight activities and findings related to plant safety performance.

Although NRC has been working to improve its oversight in several key

areas, its efforts to incorporate safety culture into the POP may be its most

critical future change. More than 4 years have passed since Davis-Besse

highlighted that a significant weakness in NRC's oversight was its inability

to identify deteriorating safety conditions at plants before they resulted in

performance problems. NRC has been reluctant to regulate in the area of

safety culture because it did not want to be directly involved in managing

the licensees' plants. However, NRC is now taking concrete actions to

begin incorporating safety culture into the POP, although it acknowledges

that regulating the often complex and intangible aspects of safety culture is

challenging, and that its recent changes are simply a first step. As a result, it

will be important to closely monitor this effort to ensure that it is achieving

the goal of objectively assessing safety culture, while providing an early

indication of declining safety performance. An additional challenge for

NRC will be how to provide information to the public and other

stakeholders on this important but complex area of plant performance.

Given that it may take some time for NRC to develop performance metrics

for safety culture, data on substantive cross-cutting issues, which provide

insight into aspects of plants' safety culture, could be useful to the public

and other stakeholders as they look for assurances that plants are operated

safely. Summary-level information on plants with substantive cr oss-cutting

issues is not currently available to the public through NRC's Web site.

Recommendations for Given its importance to improving NRC'S ability to identify declining safety

Execuive A tionperformance at nuclear power plants before significant safety problems Execuive A tiondevelop, we recommend that the NRC commissioners take the following

two actions:

Page 39 GAO-06-1029 Oversight of Nuclear Power Plant Safety
*Aggressively monitor; evaluate; and, if needed, implement additional

methods or processes to increase the effectiveness of its efforts under

the ROP to assess safety culture at plants.

*In addition to periodically evaluating the effectiveness of its safety

culture efforts, NRC may also be able, through its performance indicator

program, to develop specific indicators to measure important aspects of

plants' safety culture. Trends in these performance indicators could be

useful feedback to NRC on its safety culture activities. The indicators

could also provide useful information to the public and other NRC

stakeholders on the safety culture at plants.

In addition, in the absence of performance indicators or other performance

metrics for plants' safety culture, we recommend that the NRC

commnissioners make publicly available, through the ROP Web site,

consolidated and comprehensive data on the plants that have substantive

cross-cutting issues open. These data would provide a more

comprehensive picture of plant performance and provide insights into

aspects of the plants' safety culture that otherwise are not readily available

on the Web site.

Agency Comments We provided a draft of this report to NRC for its review and comment. In a

letter from NRC's Executive Director for Operations, NRC generally agreed

with the report's findings, conclusions, and recommendations (see app. IV).

NRC also commented that the report is comprehensive, fair, and balanced.

In addition, NRC provided m-inor, technical comments, which we have

incorporated into the report, as appropriate.

We are also sending copies of this report to interested congressional

committees, the Chairman of NRC, and other interested parties. We also

will make copies available to others upon request. In addition, the report

will be available at no charge on the GAO Web site at http://www.gao.gov.

Page 40 Page 40GAO-06-1029 Oversight of Nuclear Power Plant Safety
If you or your staffs have any questions about this report, please contact

me at (202) 512-3841 or wellsj@gao.gov. Contact points for our Offices of

Congressional Relations and Public Affairs may be found on the last page

of this report. GAO staff who made major contributions to this report are

listed in appendix V.

Jim Wells

Director, Natural Resources and Environment

Page 41 Page 41GAO-06-1029 Oversight of Nuclear Power Plant Safety
List of Requesters

The Honorable James M. Inhofe

Chairman

Committee on Environment and Public Works

United States Senate

The Honorable George V. Voinovich

Chairman

Subcommittee on Clean Air, Climate Change,

and Nuclear Safety

Committee on Environment and Public Works

United States Senate

The Honorable Ed Whitfield

Chairman

Subcommittee on Oversight and Investigations

Commidttee on Energy and Commerce

House of Representatives

The Honorable Joseph R. Biden, Jr.

United States Senate

The Honorable Tom Carper

United States Senate

The Honorable Michael N. Castle

House of Representatives

The Honorable Edward J. Markey

House of Representatives

Page 42 Page 42GAO-06-1029 Oversight of Nuclear Power Plant Safety
App endix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

This appendix summarizes key safety-related events at the Salem and Hope

Creek nuclear power plants and the Nuclear Regulatory Commission's

(NRC) and licensee's actions to follow up on and correct them. This

information is presented to enhance the public's understanding of the

events and timling of NRC'S actions. We did not conduct an independent

audit or assessment of the events, other than to help illustrate how NRC is

using its oversight process to ensure plant safety.

The Salem and Hope Creek plants are located at one site in Hancocks

Bridge, New Jersey, 18 miles southeast of Wilmington, Delaware, on the

Delaware River. The two Salem plants (Salem 1 and Salem 2) consist of two

pressurized water reactors, and the Hope Creek plant is a boiling water

reactor. The three plants produce a combined 3,237 megawatts of

electricity. Salem 1 began operating in the late-1970s and Salem 2 and Hope

Creek began operating in the 1980s. PSEG Nuclear LLC is licensed to

operate all three plants, with their current licenses expiring roughly 40

years after the start of their operations. In January 2005, PSEG entered into

a nuclear operating services contract with Exelon, the first step of a

planned merger between the two companies. Under the terms of this

contract, Exelon manages operations at Salem and Hope Creek.

From 2000 through 2006, there were several safety-related events at the site

that affected the plants' performance. As a result, NRC increased its

oversight to include supplemental and special inspections, and required the

licensee to take specific actions to address its performance issues. NRC

also deviated from its normal oversight process from August 2004 through

2006 to increase its oversight and address problems with the licensee's

ability to provide an adequate safety-conscious work environment (SCWE).

A SCWE is defined by NRC as an environment in which employees feel free

to raise safety concerns, both to their management and to NRC, without

fear of retaliation. During this period, NRC and the licensee held several

public meetings to discuss performance issues related to the site's safety

work environmient, or the SCWE, and the actions the licensee was taking to

improve it.

The following summary provides details on the key safety-related events at

Salem and Hope Creek, along with NRC'S and the licensee's responses to

the events, from the initial implementation of NRC's reactor oversight

process in April 2000 to June 2006.

Page43 Page 43GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

Summary of Key

Scaffety-Related Events

at Salem and Hope

Creek, April 2000 to

June 2006

White Performance

Indicator for Unplanned

Scrams

During the fourth quarter of 2000, Salem 1 reported a white color for the

unplanned scrams performance indicator, an indicator that monitors the

number of unplanned scrams-reactor shutdowns-that occurred during

the previous four quarters. During 2000, Salem 1 had four scrams, which is

one more than the acceptable performance level. NRC conducted a

supplemental inspection in March 2001 to follow up on why such a high

number of scrams occurred and on the corrective actions the licensee was

taking to address the problem. In conducting its inspection, NRC

determined that the licensee had performed a comprehensive common

cause analysis of the associated performance deficiencies, which identified

human performance, equipment failure, and procedure and preventive

maintenance program issues as root causes of the performance problems.

The licensee documented these issues in its corrective action program and

developed a plan to outline the actions it would take to address them. NRC

concluded this effort was sufficient and did not require the licensee to take

any additional corrective actions beyond what it had outlined in its plan.

White Performance

Indicator for Unplanned

Changes in Reactor Power

During the first quarter of 2002, Salem 1 reported a white color for the

performance indicator that monitors unplanned changes in reactor power

that could have challenged safety functions during the previous four

quarters. Salem reported a total of seven power changes, which exceeded

the acceptable performance threshold by one. NRC conducted a

supplemental inspection in October 2002 and concluded that the licensee's

implementation of several programs to address the underlying causes of

the unplanned power changes, such as the replacement of certain pieces of

equipment, sufficiently addressed the performance problem. NRC did not

require the licensee to take any additional corrective actions.

Page 44 Page 44GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

Substantive Cross-Cutting

Issue in Problem

Identification and

Resolution

In March 2003, NRC opened a substantive cross-cutting issue in the

problem identification and resolution area at all three plants on the basis of

the identification of a number of green inspection findings that

documented ineffective problem evaluations and untimely, ineffective

corrective actions by plant employees, including recurring equipment

failures. Upon opening this substantive cross-cutting issue, NRC stated that

it would closely monitor the licensee's performance in this area. This

substantive cross-cutting issue remained open until March 2006, when NRC

concluded that the licensee's efforts to improve its ability to identify and

resolve performance problems were sufficient.

White Inspection Finding

for Failure of a Part on an

Emergency Diesel

Generator

In May 2003, NRC determined that the failure of a part on an emergency

diesel generator at the Salem 1 plant that occurred in September 2002

would result in a white inspection finding. NRC conducted a supplemental

inspection in October 2003 and concluded that although the licensee had

adequately fixed the emergency diesel generator, it would need to take

additional action to address broader performance problems. Specifically,

NRC had concerns with the licensee's ability to ensure that the controls and

procedural requirements determined to be necessary on the basis of

evaluations of equipment failures, were reliably tracked and implemented.

The licensee implemented procedural changes to more effectively track its

corrective actions to prevent recurrence. NRC conducted a second, followup supplemental inspection in September 2004 and, on the basis of this

inspection, concluded that the licensee's corrective actions were sufficient.

White Inspection Finding

for the Failure of a Rotating

Screen That Is Part of the

Station Service Water

System at Hope Creek

In May 2004, NRC determined that the failure in July 2003 of a rotating

screen that is part of the station service water system at Hope Creek would

result in a white inspection finding. NRC determined that the failure

resulted from the licensee's inadequate maintenance procedures and its

failure to adhere to procedural instructions. In September 2004, NRC

conducted a supplemental inspection to follow up on the corrective actions

that licensee had taken. It determined that the licensee's corrective actions,

which included revising relevant maintenance procedures, were sufficient

and did not require additional actions from the licensee.

Page 45 Page 45GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

White Inspection Finding

for the Failure of a Drain

Line in the Moisture

Separator System at Hope

Creek

In February 2005, NRC determined that the licensee's failure to properly

evaluate'and correct a degraded valve, which resulted in the failure of a

drain system at Hope Creek in October 2004, would result in a white

inspection finding. NRC conducted a supplemental inspection in June 2005

to follow up on the licensee's corrective actions, which included the

development of new guidance; revisions to relevant plant operating

procedures; inspections of pipe hangers, one of which was determined to

be the initiator of the degraded valve; and the development of a new

procedure for additional monuitoring of degraded equipment. NRC

determined that these actions were sufficient and did not require additional

actions from the licensee.

Increased Oversight to

Address Safety-Conscious

Work Environment

Problems

In late 2003, NRC initiated a special review of the site's SCWE on the basis

of allegations concerning its SCWE,, plant events and inspection findings

that indicated problems with its SCWE, insights from NRC interactions

with the licensee, observations made by NRC inspectors, and the presence

of a substantive cross-cutting issue in problem identification and

resolution. NRC's special review consisted of (1) in-depth interviews by

NRC experts of more than 60 current and former plant employees, (2) an

analysis of the site's inspection and assessment record over the previous

several years, and (3) information from plant employees' allegations

related to the SCWE. NRC provided the interim results of its review to the

licensee in January 2004. Although NRC did not identify any serious safety

violations, the information led to concerns about the site's SCWE,

particularly as it related to the handling of emergent equipment issues and

associated operational decision making. The review accumulated

information about a number of events that, to varying degrees, called into

question the openness of management to concerns and alternative views,

strength of communications, and effectiveness of the licensee's corrective

action and feedback processes. There were several differences of opinion

among operators and senior managers on plant operating decisions,

particularly as they might impact continuing plant operation and outage

schedules. On the basis of these interim results, NRC requested that the

licensee conduct an in-depth assessment of its SCWE.

NRC issued the final results of its special review in July 2004, confirming

many of the concerns it identified through its interim review. In its final

results, NRC concluded that there were weaknesses in the licensee's

leadership and management approaches, leading to a perception amnong

some staff and mangers that the company emphasized production over

Page 46 Page 46GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

safety. NRC also determined that licensee management was not consistent

in its support of staff identifying concerns and providing alternate views,

and cited examples of unresolved conflicts and poor communication

between management and staff.

In May 2004, the licensee submitted an independent assessment of its

SCWE. The assessment included interviews of employees, and reviews of

the licensee's inspection record and employee concerns program, among

other things. Among the findings of the assessment were that (1) some

plant employees were hesitant to raise issues; (2) management was not

receptive to or effective at addressing some employee concerns, such as

those surrounding long-standing equipment problems; (3) a significant

number of employees did not view the employee concerns program as a

viable means to raise concerns; and (4) management was not effective at

understanding or addressing the potential for a "chilling" effect-that is, an

environment that discourages workers from raising safety concerns-in

response to highly visible employee concerns and actions associated with

operational events.

As a result of the assessment, the licensee submitted to NRC in June 2004

an action plan to improve its overall safety work environment. The plan

addressed the licensee's corrective action program, work management

program, and safety-conscious work environment. For example, to

improve the licensee's corrective action program, the plan identified

actions to improve monitoring, such as developing and implementing an

integrated corrective action training program and developing performance

indicators. The plan also included a number of actions to improve the

licensee's management alignment, prioritization, support for and

awareness of the workweek schedule, and communication and training

strategies to support work management improvements. In addition, the

plan included actions to improve the willingness of plant employees to

raise concerns, improve the effectiveness of policies and procedures for

resolution of issues, enhance key elements of the employee concerns

program, and improve management effectiveness in detecting and

preventing retaliation or a chilled environment. The licensee's action plan

included 17 metrics designed to measure safety work environment

improvements. The licensee provided the results of these metrics to NRC

on a quarterly basis.

In August 2004, NRC regional officials received approval from headquarters

to deviate from the normal oversight process to increase oversight at the

site to monitor the licensee's actions to improve its safety work

Page 47 Page 47GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

environment. NRC's increased oversight consisted of (1) reviewing the

results of the specific actions the licensee took as a part of its action plan,

(2) creating an NRC team with expertise in the area to assist with

coordinating and focusing these review efforts, and (3) conducting

additional special inspections and enhancing existing inspections by

adjusting their focus and scope. NRC determined that it could reduce its

oversight to baseline levels once the licensee completed a self-assessment

of its SCWE that concluded that it had made substantial, sustainable

progress, and NRC confirmed the licensee's conclusion.

NRC also opened a substantive cross-cutting issue in the SCWE area at all

three plants in August 2004, on the basis of the results of its special review

of the site's SCWE completed that July. Upon opening this substantive

cross-cutting issue, NRC requested that the licensee discuss its progress mn

improving its SCWE and the effectiveness of its corrective action program

in a public meeting planned for late 2004. This substantive cross-cutting

issue remained open in the 2005 annual assessment letter, issued in March

2006. NRC will consider closing this substantive cross-cutting issue after

the licensee provides the results of an assessment that concludes that it has

made substantial, sustainable progress, and NRC has completed a review

that confirms these results.

In June 2005, NRC issued the results of an inspection of the licensee's

employee concerns program (ECP) conducted as a part of its increased

oversight to monitor the site's safety work environment. NRC inspectors

did not identify any findings of safety significance and concluded that the

ECP provided a framework for investigating concerns, maintaining the

confidentiality of personnel who use the program, and protecting

employees who use the program against retaliation. They also concluded,

however, that it was too early to fully assess the effectiveness of recent

program improvements and initiatives. The inspectors observed that a

statistically significant portion of the personnel interviewed indicated that

they would not use the ECP due to a perception that the process did not

take adequate measures to protect users' confidentiality. NRC inspectors

cited a section of the ECP that appeared to affirm this perception. The

licensee emphasized that it was making efforts to protect confidentiality,

and acknowledged that the ECP should reflect these efforts.

NRC also provided the preliminary results of its review of the licensee's

executive review board (ERB) process in June 2005. The ERB was

established to improve the site's safety work environment and

management's effectiveness in detecting and preventing retaliation and a

Page 48 Page 48GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

chilled work environment. NRC inspectors determidned that lapses in the

licensee's use of the ERB process constituted a green inspection finding,

although it did not represent a violation of regulatory requirements. NRC

requested that the licensee reassess the review of the ERB in the broader

context of the work environment, identify additional actions planned or

taken to address negative worker perceptions, and provide a written

response to NRC within 30 days. The licensee responded with planned

corrective actions, including developing and implementing continuing

training on the SCWE, and developing and implementing a plan to improve

its corrective action program.

In July 2005, NRC headquarters extended regional officials' permission to

deviate from the normal oversight process and provide increased oversight

at Salem and Hope Creek. The extension was necessary because the

licensee had not yet met the criteria to move back to normal, or baseline

levels of oversight. Increased oversight included (1) continued

management meetings and site visits to review the implementation of the

licensee's corrective actions; (2) increased efforts, including using more

inspectors and samples than what would typically be used, to conduct a

baseline inspection of the site's effectiveness at identifying and resolving

problems; and (3) an additional inspection to monitor the licensee's

progress in resolving the substantive cross-cutting issue in the SCWE.

In November 2005, NRC issued the results of the special inspection on the

site's SCWE. The inspection included assessing the licensee's progress and

plans for making improvements to its SCWE, its metrics to monitor the

effectiveness of the improvements made, and effectiveness of the licensee's

corrective actions and self assessment initiatives. NRC inspectors did not

identify any findings of safety significance and determined that the licensee

had made progress in improving its SCWE. For example, NRC inspectors

concluded that workers' willingness to raise safety concerns had increased.

In addition, the licensee had taken a significant number of actions to

improve the corrective action and work management programs and had

implemented several corrective actions for the employee concerns

program. They also concluded that the licensee had made progress in

preventing and detecting retaliation. However, NRC inspectors also

observed that some issues required additional action and focused

attention, such as the need for the licensee to fully evaluate and address

negative perceptions about its work environment in certain work groups.

The licensee initiated actions to address these observations.

Page 49 Page 49GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix I

Key Safety-Related Events at the Salem and

Hope Creek Nuclear Power Plants from 2000

to 2006

In May 2006, the licensee submitted to NRC an independent peer

assessment that concluded that it had made substantial improvements to

its SCWE, and a solid foundation existed to sustain them. The assessment

included interviews with site personnel; observations of station activities

and meetings; and reviews of the licensee's programs, procedures, policies,

and other relevant information. Among the assessment's conclusions were

that personnel throughout the organization exhibited a willingness to

engage in open-and-candid discussions and raise safety and quality issues,

the corrective action and work management programs had improved,

management had been effective at detecting and preventing retaliation and

addressing chilling effects in response to the raising of safety concerns, and

management provided high-visibility and strong and continuous

reinforcement of good work environment principles. In response, NRC

began a review of the effectiveness of the licensee's actions to improve its

safety work environment. The results of this review will be a key input into

NRC's midcycle assessment of the site's overall safety performance to be

completed in August 2006; through the middcycle assessment NRC will

determine any changes in the level of oversight for Salem and Hope Creek.

Page 50 Page 50GAO-06-1029 Oversight of Nuclear Power Plant Safety
A ppendix 11

Scope and Methodology

To examine how NRC oversees plants, we reviewed the various tools and

processes that comprise the Reactor Oversight Process (ROP). In this

regard, we analyzed NRC's documentation of its oversight process,

conducted interviews with NRC program staff and other officials, visited

one NRC regional office, and visited one nuclear power plant site that was

of specific interest to our requesters. In particular, we reviewed NRC'S

policies, inspection manuals, and other guidance documents outlining its

various oversight process components-including reports discussing the

ROP design basis; inspection and reporting requirements; performance

indicator program guidance; and other requirements, such as those related

to its enforcement and assessment processes. We interviewed NRC

headquarters and regional officials and regional and on-site inspectors

responsible for implementation of the ROP and visited the Salem and Hope

Creek nuclear power plants to observe firsthand how the ROP is

implemented by the resident inspectors located at each power plant. To

learn more about how ROP results are communicated to the public, we

attended the annual public meeting held at the Indian Point nuclear power

plant. We also reviewed the informnation NRC makes available to the public

on a Web site devoted to ROP topics, which includes both detailed plantspecific information and general program information and guidance. In

addition, we interviewed external stakeholder individuals and groups

about their experiences with the ROP, including the NRC Commission

Chairman from 1995 to 1999, who is largely credited with leading the

development of the ROP; officials from the NRC Office of the Inspector

General, the Nuclear Energy Institute (NED), the Union of Concerned

Scientists (UCS), and Greenpeace; and nuclear power plant managers at six

sites.

To examine the results of the ROP over the past several years, we reviewed

the number and types of inspection findings NRC issued, the performance

indicators reported by the plants, and the level of oversight NRC provided

to the plants. Specifically, we obtained and analyzed NRC data on its

inspection findings for 2001 through 2005, the years since implementation

of the ROP for which the data were available for the full year, and

discussed our analysis with NRC program officials. We obtained inspection

findings data from the NRC Reactor Program System (RPS) database and

assessed the reliability of the RPS data by (1) performing electronic and

manual testing of required data elements; (2) reviewing existing

information about the data and the system that produced them; (3)

reviewing an audit of the RPS database performed by the NRC Office of the

Inspector General in 2005, and documents related to NRC's implementation

of the audit's recommendations; and (4) interviewing agency officials

Page 51 Page 51GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix 11

Scope and Methodology

knowledgeable about these data. We determined that these data were

sufficiently reliable for the purposes of this report. Data elements included

a breakout of inspection findings identified at each nuclear power plant,

including information on their risk significance, or color; cornerstone; date;

cross-cutting aspects; a brief description of the problem identified; and

other related information. We also obtained and analyzed ROP data,

provided on NRC's Web site, including a list of performance indicator data

broken out by plant and by quarter and a list of the plants in each column of

the action matrix by quarter since inception of the ROP in 2000. We

assessed the reliability of these data by interviewing the appropriate

agency officials about how these data are reported on the Web site and

compared the data with source information contained in inspection reports

and assessment letters for sample plants. We determined that these data

were sufficiently reliable for the purposes of this report. In addition, we

reviewed every assessment letter issued to each of the 103 plants since the

inception of the ROP to document the plants that had one or more

substantive cross-cutting issue open and the length of time that the issue

was held open. We discussed the results of our data analysis with NRC

headquarters program officials and compared the results of the ROP with

other industry-collected and reported performance data, including data

collected through NRC'S industry trends program, to identify any

inconsistencies in trends or industry safety performance indicators.

To examine the status of NRC's efforts to improve the ROP, we reviewed

specific components of the ROP where weaknesses had been identified and

recent and current staffs' efforts to improve them. We analyzed NRC

documents, including all annual self-assessment reports issued by NRC

since 2001; interviewed officials from NRC headquarters, regional, and site

offices and outside stakeholder groups, including NEI and UCS; and

attended two public meetings covering proposed changes to incorporate

safety culture into its oversight process. In reviewing the annual selfassessment reports, we analyzed comments submitted by both internal and

external stakeholders that were collected during recent surveys. We

analyzed responses submitted by internal staff, including management,

program staff, and regional and site inspectors, and responses from

external stakeholders, including industry, industry organizations, public

interest groups, state and local agencies, and members of the public. We

examined all proposed and final documents related to NRC'S safety culture

changes, including inspection manuals, training documents, and other

guidance documents. We also reviewed public comments submitted to

NRC on its safety culture changes, such as those submitted by NEI, UCS,

and meetings held on the topic by the Advisory Committee on Reactor

Page 52 Page 52GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix 11

Scope and Methodology

Safeguards (ACRS). In addition, we assessed various external reports and

evaluations related to the ROP or specific aspects relevant to NRC's

oversight, such as issues surrounding safety culture, including our prior

reports, those of the NRC Office of the Inspector General and of the ACRS.

We met with NRC program officials responsible for assessing and

implementing changes to the ROP to obtain a clear understanding of the

actions they were taking and the status of their efforts.

Additionally, we selected a nonprobability sample' of 6 nuclear power sites

(totaling 11 of the 103 operating plants) 2 that provided coverage of each of

NRC's four regional offices and varying levels of plant performance and

NRC oversight since 2000. The following nuclear power sites were included

in our review: Cooper (1 plant) located near Nebraska City, Nebraska;

Indian Point 2 (1 plant) located near New York, New York; Oconee (3

plants) located near Greenville, South Carolina; Perry (1 plant) located

near Painesville, Ohio; Salem and Hope Creek (3 plants) located near

Lower Alloways Creek, New Jersey; and Surry (2 plants) located near

Newport News, Virginia. Our selection criteria was designed to represent

geographic diversity, a variety of safety problems in which inspection

findings or performance indicators of higher risk significance (white,

yellow, and red) were issued, trends reflecting both improving and

declining safety performance, and plants that have been subjected to at

least some level of increased oversight since the ROP was implemented.

The purpose of our review was to understand how performance problems

were identified by NRC's oversight process, what caused them, actions

taken by NRC and the licensee in response to the problems, and how NRC

documented their resolution. We analyzed all publicly available inspection

reports and assessment documents covering years 2000 through 2005 for

each site to examine how NRC applied the ROP to identify and correct

safety problems.3 We analyzed each green and greater-than-green

inspection finding documented through the inspection reports and

'Because these plants represent a nonprobability sample, results cannot be used to make

inferences about the population, or nuclear power industry as a whole. This is because in a

nonprobability sample, some elements of the population being studied have no chance or an

unknown chance of being selected as part of the sample.

'The 6 sites are out of a total possible of 65. Oftentimes, there are 2 or 3 operating plants

located at each nuclear power site, often operated and licensed by the same company, and

therefore combined for NRC oversight purposes.

'Physical security inspection reports were not included in our analysis because physical

security issues were not within the scope of this review.

Page 53 Page 53GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix Il

Scope and Methodology

collected data associated with each finding, including how it was identified,

which cornerstone it was assigned to, whether the finding was associated

with a violation of regulatory requirements, and whether there were any

cross-cutting elements associated with the finding. For the greater-thangreen inspection findings, we collected additional information to determine

the length of time it took the licensee to correct the performance problem,

the length of time and level of effort NRC inspectors took to follow up on

the issue, and the actions it required the licensee to take. Additionally, for

each of the sites, we reviewed NRC reports and documentation showing

that all baseline inspection procedures were completed (for 2004 and

2005), and that inspectors verified the licensees' reporting of the

performance indicator data (for 2000 through 2005). We also interviewed

NRC branch chiefs and resident inspectors and industry management

officials at each site to learn more about NRC's implementation of the ROP

at the site. We conducted our work from July 2005 through July 2006 in

accordance with generally accepted government auditing standards.

Page 54 Page 54GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendilx III

Nuclear Power Plant Performance Data on the

Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

Table 3: Commercial Nuclear Power Plants Licensed to Operate in the United States

Nuclear power plant

Arkansas Nuclear 1

Arkansas Nuclear 2

Beaver Valley 1

Beaver Valley 2

Braidwood 1

Braidwood 2

Browns Ferry 1

Browns Ferry 2

Browns Ferry 3

Brunswick 1

Brunswick 2

Byron 1

Byron 2

Callaway

Calvert Cliffs 1

Calvert Cliffs 2

Catawba 1

Catawba 2

Clinton

Columbia Generating Station

Comanche Peak 1

Comanche Peak 2

Cooper

Crystal River 3

D.C. Cook 1

D.C. Cook 2

Davis-Besse

Diablo Canyon 1

Diablo Canyon 2

Dresden 2

Dresden 3

Duane Arnold

Edwin 1. Hatch 1

Edwin 1. Hatch 2

Fermi 2

City

Russellville

Russellville

McCandless

McCandless

Joilet

Joilet

Decatur

Decatur

Decatur

Southport

Southport

Rockford

Rockford

Fulton

Annapolis

Annapolis

Rock Hill

Rock Hill

Clinton

Richland

Glen Rose

Glen Rose

Nebraska City

Crystal River

Benton Harbor

Benton Harbor

Toledo

San Luis Obispo

San Luis Obispo

Morris

Morris

Cedar Rapids

Baxley

Baxley

Toledo

State

AR

AR

PA

RA

IL

IL

AL

AL

AL

NC

NC

IL

IL

MO

MD

MD

SC

SC

IL

WA

TX

TX

NE

FL

Ml

MI

OH

CA

CA

IL

IL

IA

GA

GA

Ml

NRC region

IV

IV

Ill

II

II

11

IV

IV

IV

IVI

Ill

IV

III

III

III

Page 55 Page 55GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page

Nuclear power plant

Fort Calhoun

Ginna

Grand Gulf 1

H.B. Robinson 2

Hope Creek 1

)

Indian Point 2

Indian Point 3

James A. FitzPatrick

Joseph M. Farley 1

Joseph M. Farley 2

Kewaunee

La Salle 1

La Salle 2

Limerick 1

Limerick 2

McGuire 1

McGuire 2

Millstone 2

Millstone 3

Monticello

Nine Mile Point 1

Nine Mile Point 2

North Anna 1

North Anna 2

Oconee 1

Oconee 2

Oconee 3

Oyster Creek

Palisades

Palo Verde 1

Palo Verde 2

Palo Verde 3

Peach Bottom 2

Peach Bottom 3

Perry 1

Pilgrim 1

City

Omaha

Rochester

Vicksburg

Florence

Lower Alloways

Creek

New York

New York

Oswego

Dothan

Dothan

Green Bay

Ottawa

Ottawa

PhiladelphiaPhiladelphia

Charlotte

Charlotte

New London

New London

Minneapolis

Oswego

Oswego

Richmond

Richmond

Greenville

Greenville

Greenville

Toms River

South Haven

Phoenix

Phoenix

Phoenix

Lancaster

Lancaster

Painesville

Plymouth

State

NE

NY

MS

SC

NJ

NRC region

IV

IV

IV

NY

NY

NY

AL

AL

WI

IL

IL

PA

PA

NC

NC

CT

CT

MN

NY

NY

VA

VA

SC

SC

SC

NJ

Ml

AZ

AZ

AZ

PA

PA

OH

MA

Page 56 Page 56GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Nuclear power plant

Point Beach 1

Point Beach 2

Prairie Island 1

Prairie Island 2

Quad Cities 1

Quad Cities 2

River Bend 1

Salem 1

Salem 2

San Onofre 2

San Onofre 3

Seabrook 1

Seqouyah 1

Seqouyah 2

Shearon Harris 1

South Texas Project 1

South Texas Project 2

St. Lucie 1

St. Lucie 2

Summer

Surry 1

Surry 2

Susquehanna 1

Susquehanna 2

Three Mile Island 1

Turkey Point 3

Turkey Point 4

Vermont Yankee

Vogtle 1

Vogtle 2

Waterford 3

Watts Bar 1

Wolf Creek 1

Source: NRC.

City

Manitowoc

Manitowoc

Minneapolis

Minneapolis

Moline

Moline

Baton Rouge

Lower Alloways

Creek

Lower Alloways

Creek

San Clemente

San Clemente

Portsmouth

Chattanooga

Chattanooga

Raleigh

Bay City

Bay City

Ft. Pierce

Ft. Pierce

Columbia

Newport News

Newport News

Berwick

Berwick

Harrisburg

Miami

Miami

Battleboro

Augusta

Augusta

New Orleans

Spring City

Burlington

State

WI

WIMN

MN

IL

IL

LA

NJ

NRC region

IVl

IV

NJ I

CA

CA

NH

TN

TN

NC

TX

TX

FL

FL

SC

VA

VA

PA

PA

PA

FL

FL

VT

GA

GA

LA

TN

KS

IV

IV

II

11

11

IV

IV

IV

11

IV

Page 57 Page 57GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

Table 4: Total Number of Green Inspection Findings, 2001 Through 2005

Number of green inspection findings, by

year

Nuclear power sitea

Arkansas Nuclear

Beaver Valley

Braidwood

BrownsFerry

2001 2002 2003

12 9 15

14 10 10

11 12 5

5 5 4

2004 2005

23 23

8 9

5 7

10 8

Total

82

51

40

32

Brunswick

Byron

4

13

4

9

3

16

6

14

9

19

Callaway

Calvert Cliffs

Catawba

Clinton

Columbia Generating

Station

Comanche Peak

Cooper

Crystal River

D.C. Cook

Davis-B esse

Diablo Canyon

Dresden

Duane Arnold

Farley

Fermi

FitzPatrick

Fort Calihoun

Ginna

Grand Gulf

Harris

Hatch

Hope Creek

Indian Point 2

Indian Point 3

Kewaunee

La Salle

Limerick

17

18

10

8

11

4

6

10

15

6

7

5

17

19

5

16

17

6

8

8

26

71

77

53

36

47

11

6

32

5

14

4

11

20

1

8

6

12

7

4

13

5

11

18

44

13

12

9

15

5

12

23

4

27

16

14

19

7

5

6

7

18

11

9

5

8

24

21

3

9

13

11

21

3

29

5

24

24

22

22

22

5

11

8

11

14

6

5

4

19

20

14

14

7

13

17

9

23

5

7

46

25

26

12

4

14

5

15

9

10

5

2

25

25

6

24

11

8

10

11

34

5

16

12

23

13

19

11

18

8

21

10

11

6

4

16

13

8

20

20

4

64

41

141

24

88

102

95

100

61

33

55

40

72

48

49

26

29

102

123

44

79

60

51

Page 58 Page 58GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Number of green inspection findings, by

year

Nuclear power sitea 2001 2002 2003 2004 2005 Total

McGuire

Millstone

Monticello

Nine Mile Point

North Anna

Oconee

Oyster Creek

Palisades

Palo Verde

Peach Bottom

Perry

Pilgrim

Point Beach

Prarie Island

Quad Cities

River Bend

Robinson

Saint Lucie

Salem

San Onofre

Seabrook

Sequoyah

South Texas

Summer

Surry

Susquehanna

Three Mile Island

Turkey Point

Vermont Yankee

Vogtle

Waterford

5

20

17

16

4

16

11

23

16

14

7

8

15

4

6

19

4

13

17

4

10

14

13

6

11

19

6

11

4

5

9

13

9

4

11

12

13

3

13

10

4

10

6

21

6

1

7

14

9

6

16

7

9

5

17

8

2

9

8

14

8 14

8 12

12 13

15 19

5 9

13 11

7 15

13 10

4 46

18 7

18 16

9 6

28 24

5 10

15 14

17 18

4 3

6 10

26 24

9 16

10 9

9 7

15 13

10 10

7 3

11 13

7 12

9 13

9 14

6 8

15 17

9

17

9

8

12

19

12

8

29

9

59

7

23

16

11

7

3

9

25

13

8

4

12

9

7

7

12

9

3

3

15

45

70

59

67

34

70

57

67

98

61

110

34

100

41

67

67

15

45

106

51

43

47

61

51

28

59

58

39

46

29

66

Page 59 Page 59GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Number of green inspection findings, by

year

Nuclear power site3

a 2001 2002 2003 2004 2005 Total

Watts Bar 4 13 10 8 8 43

Wolf Creek 5 3 7 9 6 30

Total 751 657 774 889 835 3,906

Site average 11 10 12 13 13 59

Range (for each column) 1-44 1-27 3-29 2-46 3-59 15-1 41

Source: GAO analysis of NRPC data.

8

NRC reports these data by nuclear power site as opposed to by individual plant. Oftentimes, there

are 2 or 3 plants located at each site. Therefore, data for all 103 plants are included here, but at the

site level.

Table 5: Total Number of Greater-Than-Green Inspection Findings Issued, 2001

Through 2005

Nuclear power site8

Arkansas Nuclear

Beaver Valley

Braidwood

Browns Ferry

Total number of inspection findings, by color

White Yellow Red

1

2

1

Brur

Byrc

Call

Cal%

Caft

Clin

COIL

Con

Coo

Cryf

D.C.

Day

Diat

Dref

nswick 1

away 3

pert Cliffs 3

awba

ton 1

imbia Generating Station 1

ianche Peak 2

per 5

stal River 1

Cook 3

is-Besse 4

)lo Canyon

sden 2

Duane Arnold

Farley

Page 60 Page 60GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Total number of Inspection findings, by color

Nuclear power site8 White Yellow Red

Fermi 1

FitzPatrick

Fort Callhoun 2

Ginna 1

Grand Gulf

Harris 2

Hatch 1

Hope Creek 2

Indian Point 2 211

Indian Point 3

Kewaunee 41

La Salle 1

Limerick 2

McGuire

Millstone

Monticello

Nine Mile Point 1

North Anna

Oconee 7

Oyster Creek 3

Palisades 2

Palo Verde

Peach Bottom 3

Perry 5

Pilgrim

Point Beach 3 1 3

Prarie Island 1

Quad Cities

River Bend 2

Robinson

Saint Lucie

Salem 1

San Onofre

Seabrook 1

Sequoyah 1

South Texas

Page 61 Page 61GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Total number of inspection findings, by color

Nuclear power site3 White Yellow Red

Summer

Surry 2

Susquehanna 1

Three Mile Island 2

Turkey Point

Vermont Yankee 1

Vogtle

Waterford 1

Watts Bar 1

Wolf Creek

Total 86 7 5

Source: GAO analysis of NRC data.

ONRC reports these data by nuclear power site as opposed to by individual plant. Oftentimes, there are

2 or 3 plants located at each site. Therefore, data for all 103 plants are included here, but at the site

level.

Table 6: Type of Substantive Cross-cutting Issue Open At Least Some Portion of the

Year, 2001 Through 2005

Nuclear power plant

Arkansas Nuclear 1

Arkansas Nuclear 2

Beaver Valley 1

Beaver Valley 2

Braidwood 1

Braidwood 2

Browns Ferry 2

Browns Ferry 3

Brunswick 1

Brunswick 2

Byron 1

Byron 2

Callaway

Calvert Cliffs 1

Calvert Cliffs 2

Type of substantive cross-cutting issue open, by year

2001 2002 2003 2004 2005

PIR PIR PIR

PIR PIR PIR

HP

HP

PIR PIR HP HP

PIR PIR

PIR PIR

Page 62 Page 62GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Type of substantive cross-cutting issue open, by year

Nuclear power plant 2001 2002 2003 2004 2005

Catawba 1

Catawba 2

Clinton

Columbia Generating Station HP HP PiR, HP PiR, HP PIR, HP

Comanche Peak 1

Comanche Peak 2

Cooper PIR,HP PIR,HP PIR,HP PIR,HP PIR,HP

Crystal River 3

D.C. Cook 1 PIR PIR

D.C. Cook 2 PIR PIR

Davis-B esse

Diablo Canyon 1 PIR,HP PIR,HP

Diablo Canyon 2 PIR,HP PIR,HP

Dresden 2 HP

Dresden 3 HP

Duane Arnold HP

Farley 1

Farley 2

Fermi 2 HP HP

FitzPatrick PIR

Fort Calihoun

Ginna

Grand Gulf 1

Harris 1

Hatch 1

Hatch 2

Hope Creek 1 PIR PIR PIR, PIR,SCWE

SCWE

Indian Point 2 PIR,HP PIR,HP PIR,HP PIR PIR

Indian Point 3

Kewaunee PIR PIR

La Sallel1 HP HP HP HP

La Salle 2 HP HP HP HP

Limerick 1

Limerick 2

McGuire 1

Page 63 Page 63GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC'S Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page),

Type of substantive cross-cutting issue open, by year

Nuclear power plant 2001 2002 2003 2004 2005

McGuire 2

Millstone 2 PIR,HP PIR

Millstone 3

Monticello

Nine Mile Point 1 PIR

Nine Mile Point 2 PIR

North Anna 1

North Anna 2

Oconeel1

Oconee 2

Oconee 3

Oyster Creek PIR HP HP PIR PIR

Palisades PIR, HP PIR PIR

Palo Verde 1 PIR, HP PIR, HP

Palo Verde 2 PIR, HP PIR, HP

Palo Verde 3 PIR, HP PIR, HP

Peach Bottom 2 PIR PIR

Peach Bottom 3 PIR PIR

Perry 1 PIR,HP PIR,HP

Pilgrim 1

Point Beach 1 PIR PIR, HP PIR, HP PIR, HP

Point Beach 2 PIR PIR, HP PIR, HP PIR, HP

Prairie Island 1

Prairie Island 2

Quad Cities 1 HP HP

Quad Cities 2 HP HP

River Bend 1

Robinson 2

Saint Lucie 1

Saint Lucie 2

Salem 1 PIR PIR PIR,SCWE PIR,SCWE

Salem 2 PIR PIR PIR,SCWE PIR,SCWE

San Onofre 2

San Onofre 3

Seabrooki1 PIR PIR

Sequoyah 1

Page 64 Page 64GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NEC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Type of si

Nuclear power plant 2001

Sequoyah 2

South Texas 1

South Texas 2

Summer

Surry 1

Surry 2

Susquehanna 1

Susquehanna 2

Three Mile Island 1 HP

Turkey Point 3

Turkey Point 4

Vermont Yankee

Vogtle 1

Vogtle 2

Waterford 3

Watts Bar 1

Wolf Creek 1

Legend:

HP = human performance PIR = problem identification and resolution

SOWE = safety-conscious work environment

Source: GAO analysis of NRC data.

ubstantive cross-cutting issue open, by year

2002 2003 2004 2005

HP

HP

HP

PIR, HP PIR

PIR, HP PIR

PIR PIR

PIR

PIR

PIR PIR

HP

Table 7: Total Number of Greater-Than-Green Performance Indicators, 2001 Through

2005

Number of greater-than-green performance

indicators, by year8

Nuclear power

plant 2001 2002 2003 2004 2005 Total

Arkansas Nuclear 1

Arkansas Nuclear 2

Beaver Valley 1

Beaver Valley 2

Braidwood 1 1 2 3 1 7

Braidwood 2

Browns Ferry 2

Page 65 Page 65GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Number of greater-than-green performance

indicators, by yeara

Nuclear power

plant 2001 202 2003 2004 2005 Total

Browns Ferry 3

Brunswick 1

Brunswick 2 1 1

Byron 1

Byron 2

Callaway 2 2

Calvert Cliffs 1 4 3 7

Calvert Cliffs 2

Catawba 1

Catawba 2

Clinton

Columbia

Generating Station 5 5

Comanche Peak 1

Comanche Peak 2

Cooper 1 1

Crystal River 3 1 1

D.C. Cook 1 1 1

D.C. Cook 2 4 5 2 11

Davis-Besse 1 1 2

Diablo Canyon 1 1 1

Diablo Canyon 2 1 1

Dresden 2 1 1

Dresden 3 1 4 2 7

Duane Arnold

Farley 1

Farley 2

Fermi 2 4 1 4 1 10

FitzPatrick 2 2

Fort Callhoun 1 2 2 5

Ginna

Grand Gulf 1

Harrisi1 1 3 1 5

Hatch 1

Hatch 2

Page 66 Page 66GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Number of greater-than-green performance

indicators, by year'

Nuclear power

plant 2001 2002 2003 2004 2005 Total

Hope Creek 1

Indian Point 2

Indian Point 3 3 3

Kewaunee

La Salle 1

La Salle 2 2 1 3

Limerick 1

Limerick 2

McGuire 1

McGuire 2

Millstone 2 2 3 5

Millstone 3

Monticello

Nine Mile Point 1 4 2 6

Nine Mile Point 2 1 1 1 3

North Anna 1

North Anna 2 1 1

Oconee 1 2 2

Oconee 2

Oconee 3

Oyster Creek

Palisades

Palo Verde 1

Palo Verde 2

Palo Verde 3

Peach Bottom 2 1 1 3 5

Peach Bottom 3

Perryl1 3 1 4

Pilgrim 1

Point Beachi1 4 1 5

Point Beach 2 2 2

Prarie Island 1

Prarie Island 2

Quad Cities 1

Quad Cities 2

Page 67 Page 67GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Number of greater-than-green performance

indicators, by yeara

Nuclear power

plant 2001 2002 2003 2004 2005 Total

River Bendi1 2 2

Robinson 2 1 1

Saint Lucie 1

Saint Lucie 2 1 1 2

Salemi1 2 2

Salem 2

San Onofre 2 1 3 1 5

San Onofre 3

Seabrook 1 1 1

Sequoyah 1

Sequoyah 2 1 2 3

South Texas 1

South Texas 2 1 1 2

Summer 3 3

Surry 1 3 6 3 12

Surry 2 2 4 4 1 11

Susquehanna 1

Susquehanna 2

Three Mile Island 1

Turkey Point 3 1 1.

Turkey Point 4 2 2

Vermont Yankee

Vogtle 1

Vogtle 2

Waterford 3

Watts Bar 1

Wolf Creek 1

Total 34 25 41 33 23 156

Source: GAO analysis of NRC data.

Note: Plant licensees report their performance indicator data on a quarterly basis for 15 different

indicators (excluding 3 physical security indicators). Yearly totals include a summary for all 15

indicators and the four quarters. Thus, if the same indicator was white for two quarters during the year, it would count twice in the yearly total.

aAll of the greater-than-green indicators were white during this period, no yellow or red indicators were

reported.

Page 68 Page 68GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

Table 8: Highest NRC Oversight Level Applied during at Least Some Portion of the

Year, 2001 Through 2005

Highest level of oversight applied during at least

some portion of the year'

Nuclear power plant 2001 2002 2003 2004 2005

Arkansas Nucleari1 L

Arkansas Nuclear 2

Beaver Valley 1 L L L

Beaver Valley 2 L L L

Braidwood 1 L M L L

Braidwood 2

Browns Ferry 2

Browns Ferry 3

Brunswick 1

Brunswick 2 L L

Byron 1

Byron 2

Callaway M L L L

Calvert Cliffs 1 M M L

Calvert Cliffs 2 L L L

Catawba 1

Catawba 2

Clinton L L

Columbia Generating Station M M L

Comanche Peak 1 L L

Comanche Peak 2 L

Cooper M H H H

Crystal River 3 L L

D.C. Cookl1 L L L

D.C. Cook 2 M M M L

Davis-Besse b b b b

Diablo Canyon 1 L

Diablo Canyon 2 L

Dresden 2 L

Dresden 3 L L L

Duane Arnold

Farley 1 L

Farley 2 L

Page 69 Page 69GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Highest level of oversight applied during at least

some portion of the year'

Nuclear power plant 2001 2002 2003 2004 2005

Fermi 2 L L L L L

FitzPatrick L

Fort Calihoun L L L L

Ginna L L

Grand Gulf 1

Harrisi1 L M L L

Hatch 1 L

Hatch 2 L

Hope Creeki1 L L

Indian Point 2 H H M L L

Indian Point 3 L

Kewaunee M L L M

La Salle 1

La.Salle 2 L L

Limericki1 L L

Limerick 2 L L

McGuire 1

McGuire 2

Millstone 2 M L

Millstone 3

Monticello

Nine Mile Pointi1 L L L

Nine Mile Point 2 L L L

North Anna 1

North Anna 2 L

Oconeel M L L M L

Oconee 2 L L M L

Oconee 3 L L L M L

Oyster Creek L L L L

Palisades L L L L

Palo Verdel1 M

Palo Verde 2 M

Palo Verde 3 M

Peach Bottom 2 L L L L L

Peach Bottom 3 L L L

Page 70 Page 70GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix III

Nuclear Power Plant Performance Data on the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

(Continued From Previous Page)

Highest level of oversight applied during at least

some portion of the yeara

Nuclear power plant 2001 2002 2003 2004 2005

Perryl1 L M H H

Pilgrim 1

Point Beachi1 L L H H H

Point Beach 2 L L H H H

Prarie Island 1 L L

Prarie Island 2 L L

Quad Cities 1 L

Quad Cities 2 L

River Bend 1 L L

Robinson 2 L

Saint Lucie 1

Saint Lucie 2 L L

Salemi1 L L L

Salem 2

San Onofre 2 L L L

San Onofre 3

Seabrook 1 L L

Sequoyah 1 L L

Sequoyah 2 L L

South Texas 1

South Texas 2 L L

Summer L

Surryl1 L L L M

Surry 2 L L L L

Susquehanna 1 L L

Susquehanna 2 L L

Three Mile Islandi1 L L

Turkey Point 3 L

Turkey Point 4 L

Vermont Yankee M L L

Vogtle 1

Vogtle 2

Waterford 3 L

Watts Bar 1 L

Wolf Creek 1

Page 71 Page 71GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix HII

Nuclear Power Plant Performance Data on

the Basis of the Results of NRC's Reactor

Oversight Process, 2001 Through 2005

Legend:

L = l'or lowest level of increased oversight beyond the baseline

M = 21d level of increased oversight beyond the baseline

H = 3rd and highest level of oversight that still allows continued plant operations

Source: GAO analysis of NRC data.

aAl1 plants receive a baseline level of oversight, regardless of their safety performance. Plants are also

placed into performance categories on NRC's action matrix on a quarterly basis, which corresponds to

the level of oversight NRC will provide based on the plant's safety performance. The level of oversight

reported here corresponds to the highest oversight level the plant received during the year, even if it

was only for a portion of the year. Thus, if a plant was placed into a different category each quarter, the

highest category in which it was placed is reported here.

b Davis-Besse was under a separate oversight category not considered part of the ROP due to the

reactor vessel head incident that occurred in 2002.

Page 72 Page 72GAO-06-1029 Oversight of Nuclear Power Plant Safety
Appendix IV

Comments from the Nuclear Regulatory

Commission

UNITED STATES

NUCLEAR REGULATORY COMMISSION

WASHINGTON, D.C. 20555-0001

September 6, 2006

Mr. James E. Wells, Jr.

Director, Natural Resources

and Environment

U.S. Government Accountability Office

441 G Street, NW.

Washington, DC 20548

Dear Mr. Wells:

Thank you for the opportunity to review and submit comments on the U.S. Government

Accountability Office (GAO) draft report, "Nuclear Regulatory Commission Oversight of Nuclear

Power Plant Safety has Improved but Refinements are Needed" (GAO-06-1029). The U.S.

Nuclear Regulatory Commission (NRC) appreciates the time and effort you and your staff have

invested to review the NRC oversight program for commercial nuclear power plants. We also

appreciate the willingness of your staff to maintain a continuing dialogue with the NRC to

ensure that your report is accurate.

Overall, the NRC considers the draft report to be comprehensive, fair, and balanced. The

report is well written and provides an accurate reflection of the review. The NRC generally

agrees with the findings, conclusions, and recommendations. We have no substantive

comments on the draft report.

The enclosure provides some minor comments for your consideration. Should you have

questions about these comments, please contact Ms. Melinda Malloy at (301) 415-1785 or

Mr. James Andersen at (301) 415-3565.

Sincerely,

Luis A. Reyes Excuiv Dre ?

for Operations

Enclosure:

Minor Comments on Draft Report

Page 73 Page 73GAO-06-1029 Oversight of Nuclear Power Plant Safety
0

Appendix V

GIAO Contact and Staff Acknowledgments

GAO Contact Jim Wells, (202) 512-3841 or wellsj@gao.gov

Staff

Acknowledgments

In addition to the individual named above, Raymond H. Smith, Jr. (Assistant

Director), Alyssa M. Hundrup, and Dave Stikkers made key contributions

to this report. Also contributing to this report were Cindy Gilbert, Carol

Kolarik, Alison O'Neill, Ilene Pollack, Keith A. Rhodes, and Barbara

Timmerman.

(360585) Page 74 (36055) Oversight Pae 74GAO-06-1029 of Nuclear Power Plant safety
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