Issue Date: 07/28/14 1 88161

NRC INSPECTION MANUAL NMSS/FCSS

INSPECTION PROCEDURE 88161

CORRECTIVE ACTION PROGRAM (CAP)

IMPLEMENTATION AT FUEL CYCLE FACILITIES

PROGRAM APPLICABILITY: 2600

88161-01 INSPECTION OBJECTIVES

The purpose of this Inspection Procedure (IP) is to (1) verify that the licensee’s Corrective 

Action Program (CAP) is consistent with licensee commitments and regulatory documents and 

(2) verify that the implementation of the program is effective. The initial program and 

implementation inspection will be performed after the licensee has committed to implement a 

CAP per Regulatory Guide (RG) 3.75 or an equivalent license amendment request and has 

requested an NRC inspection in writing. Each section of this procedure identifies inspection 

attributes for the verification of CAP effectiveness, including attributes for assessment of (1) 

CAP implementing documents and processes and (2) effectiveness of implementation of the 

CAP. 

In the event that the inspection determines that the licensee is identifying and correcting 

problems in accordance with the RG 3.75, as verified through implementation of this IP, the 

inspector will conclude that the licensee’s CAP was ‘effective.’ As a result of this determination, 

NRC will provide publically-available notification to the licensee that future Severity Level IV 

violations will typically be dispositioned as non-cited violations per Section 2.3.2a of the NRC 

Enforcement Policy.

Once the licensee’s CAP has been determined to be effective, this inspection procedure will be 

performed on a biennial basis.

For licensees that have not committed to the RG 3.75 guidance or an equivalent license 

amendment, the inspection procedure may be used as a reference for reactive or regional 

initiative inspections on an as-needed basis.

Since various aspects of the licensee’s CAP may have been reviewed during core inspection 

activities, inspectors should review facility inspection reports for the last two years to determine 

if credit is appropriate for any of the inspection requirements in this procedure. 

88161-02 INSPECTION REQUIREMENTS AND GUIDANCE

General Guidance

When selecting a sample of CAP items (i.e., condition reports) for review, choose reports that 

address issues involving conditions adverse to nuclear safety and security, such as:
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• issues associated with Items Relied on for Safety (IROFS) or management measures 

documented in the licensee’s Integrated Safety Analysis (ISA),

• inadequacies in emergency preparedness and fire protection programs,

• cited or non-cited violations of regulatory requirements,

• repeat system, component, or program failures,

• issues identified through operating experience, and/ or

• weaknesses or problems identified in licensee audits and assessments.

Selection of CAP items for evaluation during this inspection should be based on the safety or 

security significance of the issue, actual or potential impact on related activities, and past 

performance. Review of audit, surveillance, and trend reports should encompass a sample of 

items over the inspection period. If, during the inspection period, the licensee conducted any 

self-initiated assessments of the Safety Conscious Work Environment (SCWE), or of the safety 

culture that included an assessment of the environment for raising concerns and CAP, this 

assessment should be selected for review. Special focus should be given to condition reports, 

trends, and audit/surveillance findings in which the issue impacts an IROFS. 

When reviewing licensee policies and procedures, inspection activities should verify that 

program documents are adequately detailed to enable effective implementation and are 

internally consistent.

02.01 Organization.

a. Inspection Requirements

1. Verify that the licensee has a CAP organization that includes an Independent 

Reviewing Organization (IRO) that is auditable and independent of the licensee’s 

production organization. 

2. Verify that the IRO is provided appropriate authority, access to work areas and 

organizational independence to effectively perform its responsibilities.

b. Inspection Guidance 

1. Verify that the licensee has developed and implemented a CAP organization, 

including the identification of positions, responsibilities, and organizational 

interfaces. Determine whether an IRO is established with the authority, access 

to work areas and organizational independence required to effectively perform its 

responsibilities. The independent reviewing organization may be a separate, 

independent division of the licensee’s organization, such as a quality assurance 

or quality control organization. However, it is also acceptable for the licensee to 

assign independent review duties to an existing part of the licensee’s 

organization, such as Environmental Health and Safety, provided that the 

licensee describes this designation in the CAP documents and ensures that the 

organization and/or individuals are appropriately trained and sufficiently 

independent. If the designated IRO has concurrent duties, verify that the 
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licensee has described how possible conflicts of interest will be addressed. If the 

licensee has chosen to have a consultant perform the independent review duties, 

verify that the licensee retains overall responsibility for the CAP.

2. Determine if the IRO has sufficient authority, access to work areas and 

organizational independence to conduct its duties. Conduct interviews with 

members of the IRO to assess their independence and ensure they are able to 

act independent of production concerns and without pressure or fear of 

retaliation.

02.02 Policies, Programs, and Procedures. 

a. Inspection Requirements. 

1. Verify that the licensee-established CAP policies and procedures include 

definitions of key terms, CAP expectations, CAP requirements, personnel 

responsibilities and implementation processes. Ensure the policies and 

procedures provide sufficient guidance to ensure the licensee’s implementation 

of the requirements of Sections 02.01-02.06 of this procedure and that they are 

maintained up to date.

2. Verify that policies and procedures describe the management of sensitive 

information if that information will be managed outside the CAP database.

3. Verify that the IRO reviews and documents concurrence with new and revised 

CAP policies and procedures.

4. Verify that the delegation of CAP responsibilities is documented.

5. Verify that periodic audits and assessments are performed to evaluate the 

effectiveness of the licensee’s CAP. Ensure that the licensee retains 

responsibility for CAP effectiveness.

b. Inspection Guidance. 

1. Determine whether the CAP policies, programs and procedures are in 

accordance with commitments made in the facility’s license and delineated in 

Sections 02.01-02.06 of this procedure. Verify that licensee procedures are 

updated as necessary to be consistent with licensee processes, structure, and 

functions. Determine if policies and program documents pertaining to the CAP 

provide implementation of program responsibilities, requirements and 

expectations. Verify that the licensee’s CAP policies and procedures require all 

personnel to promptly identify, document and report conditions adverse to safety 

or security. 

 

Verify that key terms are defined and at a minimum include conditions adverse to 

safety or security and significant conditions adverse to safety or security (The 
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licensee may use equivalent terminology.) Verify that criteria are established for 

classifying the significance of conditions adverse to safety or security.

(a) “Conditions adverse to safety and security” is an inclusive term that 

applies to conditions that affect safety, security, or both safety and 

security. Security issues include those related to information security, 

physical security, and safeguards associated with licensed material.

(b) Conditions adverse to safety and security include failures, malfunctions, 

deficiencies, deviations, defective items, regulatory noncompliances, and 

nonconformances (a nonconformance is a deficiency in characteristic, 

documentation, or procedure that renders the safety and security attributes 

of an item or activity unacceptable or indeterminate).

(c) Significant conditions adverse to safety and security are conditions that, if 

left uncorrected, could have a serious effect on safety or security.

2. If the licensee chooses to manage sensitive or classified information (e.g., 

information associated with employee concerns; proprietary information or trade 

secrets; confidential, secret, or top secret information, etc.) in a database or 

system that is separate from the primary CAP database or information 

management system, determine if the licensee has established sufficient controls 

to ensure that the issue is tracked, trended, and corrected. This may entail the 

generation of a non-sensitive (usually numbered) placeholder in the CAP while 

the sensitive and/or classified information is housed separately.

3. Review the activities associated with all new and revised CAP policies and 

procedures implemented since the last performance of this inspection procedure. 

Verify that the IRO reviewed and documented approval for all new or revised 

CAP policies and procedures. 

4. Determine if any specific CAP responsibilities have been delegated to nonlicensee personnel, organizations, or contractors. If any delegations have been 

made, then verify that the delegation authority is documented in writing or 

electronically and that the delegated entity is sufficiently qualified to perform the 

delegated functions.

5. Verify that periodic audits and assessments are performed routinely and that 

such evaluations address all elements of the CAP, including the level of detail of 

CAP documentation and the adequacy of corrective action effectiveness and 

follow-up. Verify that the licensee is retaining full responsibility for CAP 

effectiveness. This entails ensuring that the licensee has not delegated 

programmatic responsibility and ownership of the CAP to an outside organization 

or contractor. 
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02.03 Identification, Reporting, and Documentation of Safety and Security Issues. 

a. Inspection Requirements. 

1. Verify that employees are trained on how to identify and enter items in the CAP. 

2. Verify that licensee employees are comfortable with the avenues available to 

raise safety concerns. Determine if individuals and organizations establish and 

maintain a positive safety culture commensurate with the safety and security 

significance of their activities and the nature and complexity of their 

organizations. 

3. Verify conditions adverse to safety or security are entered into the CAP.

b. Inspection Guidance. 

1. Verify that CAP training for all employees has provided the knowledge and ability 

to enter items into the CAP. Appendix A provides further detail on assessment of 

employee knowledge and use of the CAP. 

2. Determine if a SCWE is maintained where personnel feel free to raise safety 

concerns without fear of retaliation, intimidation, harassment, or discrimination. 

Inspectors should review the allegations for the past performance review period 

to date and determine if there is evidence of a chilled work environment/safety 

culture concern. Appendix A provides further detail on assessment of SCWE 

attributes and follow-up actions to take in the event that inspectors become 

aware of a negative SCWE.

1

 

3. Verify that conditions adverse to safety and security, as they occur throughout 

the facility, are promptly identified and documented.

(a) Select a sample of condition reports and confirm effective implementation 

of the program. Verify that the licensee has implemented its process for 

identifying conditions adverse to safety and that conditions identified 

include those delineated in 02.02.b.2.(b) above. Verify that the licensee 

documents, and reports conditions adverse to safety and security to 

appropriate levels of management responsible for the conditions and to 

the organization responsible for tracking and that such actions were taken 

in a timely manner. 

(b) Select a sample of documented CAP items (i.e. condition reports or 

equivalent) for conditions adverse to safety and security and verify that the 

 

1 Safety Conscious Work Environment (SCWE) is linked to 10 CFR 70.7, “Employee Protection,” and overall CAP 

effectiveness. As such, it is included as an inspection element in this procedure. Because SCWE is not a direct 

regulatory requirement or part of the license commitment to follow RG 3.75, observations and conclusions associated 

with SCWE will be documented as appropriate in inspection reports but will not be cited as violations.
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conditions are adequately described in the condition reports and issues 

are categorized based on significance. Verify that the condition reports 

provide enough detail regarding the condition, its assessment, and 

corrective actions/closure to facilitate trending and appropriate follow up.

Review licensee documentation of adverse conditions (including condition 

reports, failed IROFS reports, criticality incident logs, radiation protection 

logs, safeguards/security logs, and other tracking databases) and 

determine if measures were implemented to ensure that conditions 

adverse to safety and security were promptly identified and reported. 

Determine if the issues are categorized, as a minimum, by significance. 

Determine if a review to determine compliance with reportability 

requirements was conducted. Verify that the documentation for closure of 

the adverse condition was generated and was completed, signed off, and 

properly filed and logged into a system to allow for retrieval.

(c) Inspectors should also utilize alternate means to determine if issues or 

events occurred that were not entered into the CAP, as required by the 

licensee’s procedures. This can be done by performing interviews, 

reviewing plant logs, attending work planning or plan of the day meetings. 

If an inspector identifies examples, the inspector should determine if there 

is any significance for not documenting the issue in CAP, if corrective 

actions were taken, and if there are any additional consequences to the 

issue, such as reportability, not meeting performance requirements, etc. 

02.04 Significance Assessment and Causal Evaluation of Safety and Security Issues. 

a. Inspection Requirements. 

1. Verify that the licensee has applied its classification criteria and appropriately 

classified the significance of conditions that have been entered in the CAP.

2. Verify that for significant conditions adverse to nuclear safety or security, the 

licensee determines the root cause, evaluates the extent of condition, and takes 

actions to prevent recurrence.

b. Inspection Guidance.

1. Verify that criteria for determining the significance of conditions adverse to safety 

or security were implemented. 

(a) Select a sample of condition reports and verify that the issue significance 

is categorized using a graded risk approach. This sample should include 

conditions of higher risk. For example, select conditions that, if left 

uncorrected, would have the potential for serious negative impact on NRCregulated activities or protection of public health and safety.
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(b) Select a small sample of condition reports identified by the licensee to be 

in the low risk or safety significance category to determine if any of the 

condition reports may have been incorrectly categorized. If examples are 

identified, determine the significance for not categorizing the issue 

correctly. Determine if corrective actions taken were commensurate to the

actual safety significance and if there were any additional consequences 

to the issue, such as reportability or not meeting performance 

requirements. 

2. Verify that the licensee determined the root cause for significant conditions

adverse to nuclear safety and security. Determine if the licensee implemented 

procedural requirements for determining root causes for these issues, which may 

include approved methodology, analysis structure, qualifications, team structure, 

approval process, and/or completion timeliness requirements. 

(a) Verify that the causes identified for significant conditions adverse to safety 

and security are reasonable and appropriate for the event. Gain a level of 

understanding of the issue, including the sequence of events that led up to 

the issue, immediate and possible long-term effects, and overall 

consequences of the event through interviews, documentation review, 

and/or plant walk-down of the area where the event occurred. Discuss the 

issue with the NRC resident, Project Inspector or Branch Chief, if 

necessary. 

(b) Determine if the licensee performed a generic implications review for the 

root causes. This review should include extent of condition and extent of 

cause. Consider if the licensee’s reviews adequately evaluated the 

possibilities that this same condition or same cause currently exists in 

other IROFS, components, systems, program, people, etc. and if so, has 

the licensee taken or created corrective actions to address this. 

(c) Verify that the corrective actions to prevent recurrence address the 

licensee’s identified root cause. 

(d) Determine if the corrective actions to prevent recurrence were timely and 

achievable by the licensee in the timeframe needed. 

(e) Verify for significant conditions adverse to safety and security, that the 

licensee has also performed an effectiveness review to validate that the 

actions they created and implemented address the root cause and have 

been successful in preventing recurrence.

02.05 Development and Implementation of Corrective Actions. 

a. Inspection Requirements. 
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1. Verify that the licensee is promptly initiating corrective actions following the 

identification of conditions adverse to safety or security.

2. Verify that the IRO performs appropriate verifications of corrective actions to 

ensure CAP effectiveness. 

3. Verify that the licensee uses a graded approach to verify implementation and 

close out of corrective actions in a time frame consistent with the safety or 

security significance of the identified issue.

4. Verify that the licensee reports trends and adverse conditions to the appropriate 

level of management.

b. Inspection Guidance. 

1. Determine if corrective actions were developed, reviewed, and approved for 

conditions adverse to safety and security. 

(a) Verify that corrective actions are implemented commensurate with the 

significance of conditions. Select several conditions that were resolved 

and verify that proper implementation of corrective actions and closures 

were completed in a timely manner.

(b) Verify that the licensee had determined the extent of the adverse condition

and completed remedial action as soon as practical.

(c) Verify that significant conditions adverse to safety and security were 

evaluated for the impact of the condition on other work in progress and 

that appropriate actions were taken, including stopping work if needed.

2. Verify by review of condition reports that the IRO is appropriately involved in 

review of corrective action determination and implementation.

(a) IRO reviews the corrective actions for significant conditions adverse to 

safety or security.

(b) IRO takes follow-up actions as appropriate to verify the proper 

implementation of corrective actions.

3. Verify that corrective action implementation and follow-up is effective.

(a) Verify that the corrective actions taken for conditions adverse to safety and 

security adequately address the causes and were performed by qualified 

personnel using approved methods. For significant conditions adverse to 

safety and security, verify that corrective actions for root causes have 

been taken and are effective at addressing the root cause(s) and 

precluding recurrence of the condition. 
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(b) Verify that corrective actions are implemented and closed out in a timely 

manner consistent with the significance of the conditions.

(c) Determine if corrective actions have been effective at preventing 

recurrence of significant conditions adverse to safety and security.

4. Verify that conditions adverse to safety and security are reported to the 

appropriate levels of management responsible for the reported conditions and to 

the responsible organization for tracking.

02.06 Assessment of Corrective Action and Program Effectiveness. 

a. Inspection Requirements. 

1. Verify that the licensee is evaluating the effectiveness of the CAP at specified 

intervals.

2. Verify that the licensee is analyzing condition reports for conditions adverse to 

safety or security to identify adverse trends in performance.

b. Inspection Guidance. 

1. Review audits or self-assessments conducted on the corrective action program. 

(a) Verify that the licensee evaluated if the corrective action program was 

effective in identification, reporting, assessment of condition significance, 

and correction of conditions. Verify that the licensee evaluated the 

effectiveness of corrective actions in preventing the recurrence of the 

same or similar issues. 

(b) Determine if the organization’s ability to identify and correct program 

performance issues which reduce program effectiveness was evaluated. 

(c) Verify that the licensee reports to management the results of reviews 

conducted on audit reports, internal surveillance reports, or management 

assessments and initiates corrective actions as necessary.

(d) Determine if the licensee verifies completion of the corrective action and 

ensures timeliness of corrective action verification is commensurate with 

the safety or security significance of the identified issue. 

(e) Compare and contrast the problems identified and corrective actions being 

taken as a result of these audits and self-assessments with the results of 

this inspection.

2. Verify that criteria for identifying and tracking adverse trends are implemented. 

Verify that CAP data is periodically analyzed by the independent reviewing 
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organization to identify trends. Verify that trend evaluations are performed in a 

manner and at a frequency that provides for prompt identification of adverse 

trends. Verify that trend evaluations are distributed to affected organization 

management. Verify that identified adverse trends are reported to the 

management of the organization responsible for corrective action.

88161-03 RESOURCE ESTIMATE

The resource estimate to perform this inspection procedure is estimated to be 90 hours for the 

initial and subsequent biennial inspections.

88161-04 REFERENCES 

04.01 10 CFR Part 70, “Domestic Licensing of Special Nuclear Material."

04.02 DRAFT REGULATORY GUIDE DG-3.044, Corrective Action Programs for Fuel Cycle 

Facilities.

04.03 NUREG-1520, “Standard Review Plan for the Review of a License Application for a 

Fuel Cycle Facility.”

04.04 NUREG-1962, “Guidance on the Implementation of Integrated Safety Analysis 

Requirements for 10 CFR Part 40 Facilities Authorized to Possess 2,000 Kilograms or 

More of Uranium Hexafluoride — Draft Report for Comment.”

04.05 61 Federal Register 24336. Freedom of Employees in the Nuclear Industry To Raise 

Safety Concerns Without Fear of Retaliation; Policy Statement. May 14, 1996.

04.06 NRC Regulatory Issue Summary 2005-18. Guidance for Establishing and Maintaining a 

Safety Conscious Work Environment. August 25, 2006.

04.07 76 Federal Register 34773. Final Safety Culture Policy Statement. June 14, 2011.

04.08 NUREG/BR-0500. Safety Culture Policy Statement. Revision 1. December 2012.

88161-05 PROCEDURE COMPLETION

Implementation of each applicable inspection requirement will constitute completion of this 

procedure. Individual inspection samples and breadth of review will be determined by the 

inspector based on requirement compliance, risk- significance of activity, and extent of the 

activity or records available.

END
Issue Date: 07/28/14 1 88161 Appendix A

APPENDIX A

GUIDANCE FOR GATHERING INFORMATION ON EMPLOYEE USE OF THE CAP AND 

OTHER AVENUES TO RAISE SAFETY AND SECURITY CONCERNS

The following are questions that may be used when discussing issues with licensee individuals 

or during plant tours. It is not intended that these questions be asked verbatim, but rather, that 

they form the basis for gathering insights regarding whether the work environment is such that 

employees are comfortable with raising safety and security concerns. When performing 

interviews, inspectors should select a sample of employees that represents a cross-section of 

the licensee staff (i.e., skilled tradespersons, engineers, managers, etc.).

Interview Questions

Employee Knowledge and Use of the CAP:

1. Tell me about the CAP at [facility].

2. Can you describe the training you have had on the CAP?

3. How would you enter an item in the CAP? Are there other ways to enter an issue into the 

CAP (i.e., electronic, paper, anonymous, etc.)?

4. Have you ever entered an item into the CAP? 

a. If so, how was the issue resolved? Were you made aware of the status, reason for 

issue disposition, etc.?

5. Are there alternative means you could use to address issues found, other than the 

official CAP?

6. Can anyone at the site (contractor, security officer, etc.) enter an issue into the CAP? 

When someone enters an issue into the CAP, does the entry have to be approved by a 

supervisor? (If yes, does this affect what gets put in the CAP?)

Safety Conscious Work Environment:

Verify that the licensee meets the Statement of Policy regarding Safety Conscious Work 

Environment as described in 61 Federal Register 24336. If inspectors become aware of a 

negative SCWE, the inspectors should consult with management and Enforcement and Incident 

Coordination Staff (EICS) to determine whether an adjustment to the approved inspection plan 

or other actions are warranted. Follow-up actions may consider additional guidance in IP 

93100, “Safety Conscious Work Environment Issue Follow-up.”

1. Are you willing to raise a safety concern? Are there any conditions under which you 

would be hesitant to raise a safety concern? 
Issue Date: 07/28/14 2 88161 Appendix A

a. Have there been any issues recently (2 years) that would affect your willingness 

to raise safety issues? Your confidence in the corrective action program? 

b. Are you aware of any situations where any employee or contractor may have 

been hesitant to raise concerns? If so, could you tell me about them?

2. Where would you go to raise a safety issue? [The NRC inspector should be aware of the 

following avenues for raising concerns, but should not prompt the interviewee by listing 

them as potential answers to the question: supervisor, corrective action program, 

alternative program (Employee Concerns Program (ECP)/Ombudsman), NRC, or other 

avenue.]

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

know of any situations, that have influenced your decision to pick this avenue? If 

so, please describe.

b. Are there other avenues available to you for raising safety issues (i.e., 

supervisor, corrective action program, ECP/ombudsman, NRC, or other 

avenues)? Ask each of the questions listed below for each avenue available.

i. Do you think it’s worth taking time to place problems found into the CAP 

process?

ii. Have you ever submitted a safety issue to {insert method}? If not, why 

not? 

iii. If yes, was the issue adequately addressed? Why or why not? 

iv. If not adequately addressed, did you further pursue the issue? If not, why 

not? 

v. Given the nuclear safety importance of the issue, did you receive timely 

feedback?

3. In your opinion, if employees don’t receive a response that they are happy with, are they 

able to escalate their concern to a higher level of management? Is this encouraged by 

management?

4. What happens when a safety concern is raised that affects the schedule and thus the 

production goal is not met? 

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

retaliation and/or a chilling effect?

6. Are you aware of any instance in which someone on site has experienced a negative 

reaction from a supervisor or manager for raising a safety issue?
Issue Date: 07/28/14 Att1- 1 88161

Revision History for IP 88161

CORRECTIVE ACTION PROGRAM (CAP)

IMPLEMENTATION AT FUEL CYCLE FACILITIES

Commitment 

Tracking Number

Accession Number

Issue Date

Change Notice

Description of Change

Description of 

Training Required 

and Completion 

Date

Comment and

Feedback Resolution 

Accession Number

N/A ML14178A494

07/28/14

CN14-017

Initial issue of new Inspection 

Procedure

N/A ML14178A491