Issue Date: 07/21/16 1 71114.05

NRC INSPECTION MANUAL NSIR/DPR

INSPECTION PROCEDURE 71114 ATTACHMENT 05

MAINTENANCE OF EMERGENCY PREPAREDNESS

Effective Date: 10/01/2016

PROGRAM APPLICABILITY: 2515 A

71114.05-01 INSPECTION OBJECTIVE

Evaluate the efficacy of licensee efforts to maintain their Emergency Preparedness (EP) 

programs by verifying accurate and appropriate identification of and correction of EP 

weaknesses during actual event critiques, drill and exercise critiques, program assessment 

activities (e.g., EP reviews performed in accordance with 10 CFR 50.54(t)) as well as review of 

Letters of Agreement and/or Memorandums of Understanding, 10 CFR 50.54(q) plan change 

process and practice, licensee maintenance of equipment important to emergency 

preparedness, record(s) of evacuation time estimate (ETE) population evaluation and 

emergency plan (E-plan) provisions for, and implementation of, primary, backup and alternate 

emergency response facility (ERF) maintenance (See 10 CFR Part 50 Appendix E §IV.E.8.b). 

71114.05-02 INSPECTION REQUIREMENTS

02.01 Review the licensee’s corrective action program (CAP) for EP issues.

02.02 Review documentation for all actual events that resulted in the implementation of the 

E-plan since the last inspection. 

02.03 Review all EP-related corrective actions identified in any actual event self-assessment 

for effectiveness and timeliness of completion.

02.04 Review a sample of drill critique documentation to determine if EP weaknesses are 

being properly identified and corrected.

02.05 Review a sample of EP corrective actions from drill critiques for effectiveness and 

timeliness of completion.

02.06 Review EP audit(s) performed in accordance with 10 CFR 50.54(t).

02.07 Review a sample of EP corrective actions from other EP self-assessment documents, 

such as quality assurance (QA) assessments of EP program elements, for effectiveness and 

timeliness of completion.
Issue Date: 07/21/16 2 71114.05

02.08 Review Letters of Agreement and/or Memorandums of Understanding (LOA/MOU) that 

support the E-plan for appropriate content and to verify they have not expired.

02.09 Review licensee maintenance of equipment important to emergency preparedness.

02.10 Review licensee record(s) of ETE population evaluation and implementation of any 

updated values into protective action recommendation (PAR) procedure(s).

02.11 Review licensee E-plan provisions for, and implementation of, primary, backup and 

alternate ERF maintenance (See 10 CFR Part 50 Appendix E §IV.E.8.b).

71114.05-03 INSPECTION GUIDANCE

The primary focus of this inspection is to evaluate the efficacy of a licensee’s ability to identify 

and correct EP weaknesses. Corrective action areas covered under other baseline inspection 

procedure attachments need not be included in this attachment.

03.01 Review a Sample of the Licensee’s CAP Documentation.

a. Review a sample of documentation from the following areas to ensure weaknesses are 

being captured and CAP inputs are being appropriately classified/prioritized.

1. EP CAP.

2. Identification of EP weaknesses and/or deficiencies during an actual event or

during drills and exercises.

3. Audits.

4. EP program reviews.

5. Critique conduct - responsibility for conduct of critiques may be assigned to 

multiple departments, (e.g., QA for audits, Emergency Preparedness for EP 

exercises and drills, and Operations Training for simulator evolutions). 

03.02 Determine the Adequacy of Licensee Actual Event Response.

a. Review related documentation for any actual event E-plan implementation since the last 

inspection for:

1. Documentation of notification forms.

2. Thoroughness and accuracy of logs.

3. Completeness of checklists. 

b. Review actual event documentation to determine if:
Issue Date: 07/21/16 3 71114.05

1. The licensee effectively implemented the requirements of the E-plan. 

2. Classifications, notifications and PAR development, if performed, were timely and 

accurate. 

Note: Actual event E-plan implementation may be inspected under the event follow-up 

inspection.

c. Compare the licensee self-assessment against the inspector’s evaluation of records of 

the actual event(s) to determine if the licensee correctly identified all EP weaknesses 

and entered them into the CAP. 

d. Review any evaluation(s) documented by the resident inspector of the actual event 

response.

03.03 Review all EP-related Corrective Actions Identified as a Result of an Actual Event SelfAssessment. Determine if the Licensee’s Corrective Actions were:

a. Timely (i.e., was the amount of time reasonable based on safety significance (refer to 

Inspection Manual Chapter (IMC) 0609, Appendix B for further guidance)), 

b. Effective. 

03.04 Review a Sample of Licensee Self-Assessments of Drill Performance (if available) to

Verify: 

a. Degraded DEP PI individual inputs for classification, notification, and PARs are being 

appropriately documented in the CAP.

b. Consistent and accurate use of EPIP forms and checklists used to support and 

document classification, notification, and PAR development.

c. Consistent and accurate documentation summaries of the drill critique and scenario. 

d. The critique process properly identifies performance weakness (es) in risk significant 

planning standard(s). 

03.05 Review a Sample of Corrective Actions from Drill Critiques, Performance Indicator 

Issues, and Other Self-Assessments for Effectiveness and Timeliness of Completion.

Note: If corrective actions appear to be complete, but not yet fully effective, consideration may 

be given to allow more time for performance improvement. Future drills would be expected to 

show such improvement. Actions taken by the licensee to enhance or improve performance 

need not be evaluated for effectiveness.

a. Review all corrective actions associated with classification, notification, PAR 

development and dose assessment and note any degraded performance in the three 

DEP input areas. 
Issue Date: 07/21/16 4 71114.05

b. Select a sample of corrective actions from other EP areas for review. The guidance 

provided in section 71114.01 Attachment 2, “Prioritization of Additional Areas for 

Inspection” may be used to select other areas for review.

c. If repeat items or trends are noted:

1. Determine whether corrective actions should have precluded recurrence.

Determination of a failure to correct a drill or exercise weakness requires a 

detailed review of the weakness and the associated corrective actions.

2. Determine if the licensee identified the trend or repeat weakness and entered it 

into the corrective action system. A single repetition of a weakness should not 

automatically be deemed an ineffective corrective action. Conversely, a single 

successful demonstration of a weakness should not necessarily be considered 

an effective corrective action.

d. If an apparent failure to resolve a weakness is observed:

1. Review the specific corrective actions for that weakness and similar occurrences 

of that weakness in actual events, drills, exercises, and training evolutions. 

2. Review relevant PI, corrective actions, self-assessments, and inspection records 

for the inspection cycle with an emphasis on similar weaknesses.

3. Review completed corrective actions for the weakness.

4. Assess corrective action effectiveness based on the complete history of the 

issue. Obtain a complete picture of the current problem by reviewing previous 

corrective actions to identify any pattern(s) of recurring performance problems in 

similar activities that would identify other ineffective corrective actions.

e. Select a sample of corrective actions for equipment and facilities or other areas of EP 

as deemed appropriate. Perform a detailed review of:

1. Closure documentation,

2. Corrective actions taken, and

3. Consistency of in-field completed corrective actions and the closure 

documentation. 

f. Should a particular area of the ERO program be noted as having no corrective action(s)

(e.g., field monitoring team equipment or team member performance), the inspector 

may request to inspect that area for compliance with the E-plan commitments. Lack of 

corrective actions identified in a given area may indicate a weakness in the critique 

process.
Issue Date: 07/21/16 5 71114.05

03.06 Review Emergency Preparedness Audit(s) Performed in Accordance With 

10 CFR 50.54(t).

a. Evaluate adequacy of audits to comply with regulatory requirements. 

b. Determine if the scheduling of audits is consistent with regulatory requirements and 

licensee program changes. 

1. If the licensee is using the 10 CFR 50.54(t)(1)(ii) option, review the licensee’s 

performance indicators, these PIs are not those described in NEI 99-02. (See 

statements of consideration at 64 FR 14814 dated March 29, 1999).

c. Select a sample of corrective actions associated with classification, notification, PAR 

development and dose assessment activities to review for effectiveness. 

03.07 Emergency Preparedness Self-Assessment Corrective Actions.

a. Review a sample of corrective actions from other EP self-assessment documents, for 

example:

1. QA assessments of drill performance

2. ERO readiness

3. EP facility readiness

b. Review the disposition of a sample of the corrective actions identified.

c. Determine if the licensee’s corrective actions were timely and effective (refer to MC 

0609, Appendix B, Sections 5.2 and 5.3 for further guidance).

03.08 Review licensee annual review / update of Letters of Agreement/Memorandum of 

Understanding

a. Verify Letters of Agreement (LOAs)/Memorandum of Understanding (MOUs) described 

in the E-plan are in accordance with evaluation criterion P.4 of NUREG-0654, Section 

II.P, including hostile action. 

Note: In general, LOAs/MOUs with Federal agencies with emergency planning responsibilities 

are not needed, since the Federal agencies are required by law to provide assistance. 

However, the inspector should be alert to instances in the E-plan where it may be appropriate 

for a letter of agreement with a local Federal office or representative of a Federal agency, such 

as a local Coast Guard station

b. Verify arrangements for offsite response organization (ORO) resources remain in effect 

and have not expired. 
Issue Date: 07/21/16 6 71114.05

c. Verify the type and extent of ORO resources needed to support onsite response 

activities during an emergency, including hostile action have been identified and 

documented.

d. Verify arrangements with State, local, and Federal agencies clearly identify and 

describe needed onsite support and response activities. Local agencies should include 

LLEA, firefighting, and medical assistance

e. Existing arrangements are updated as needed to clarify the types of assistance to be

provided by an agency or to address any shortfalls for support of onsite response 

activities identified.

Note: LOAs/MOUs may be provided in an appendix to the plan or, the plan itself may contain 

descriptions of these matters, and a signature page in the plan may serve to verify the 

agreements. The signature page format is appropriate for organizations where response 

functions are covered by laws, regulations, or executive orders where separate written 

agreements are not necessary.

03.09 Licensee maintenance of equipment important to emergency preparedness.

a. Sample instrumentation identified in the licensee’s EAL scheme to ensure the 

instrumentation identified is correct for the intended application and adequate to support 

declaration of the effected EALs.

b. Review EP equipment work control history to determine if:

1. Compensatory measures taken for equipment out of service were adequate, and 

2. Any 10 CFR 50.72 reporting requirements were met.

c. Required equipment (e.g., self-contained breathing apparatus, field monitoring team 

equipment, communication equipment, computers, etc.) is functioning and meets 

certification/calibration requirements.

03.10 Review licensee ETE population record(s) of evaluation to ensure.

a. The ETE is revised when new U.S. Census Bureau decennial census data is available.

Note: Population changes should be based on data from the U.S. Census Bureau, which

annually produces resident population estimates and State/local government population data, if 

available.

b. The licensee has annually reviewed for and/or evaluated changes in the emergency 

planning zone (EPZ) populations. The licensee’s documentation of the annual review 

must be sufficient for the inspector to arrive at the same conclusion.
Issue Date: 07/21/16 7 71114.05

Note: Supplement 3, “Guidance for Protective Action Strategies,” to NUREG-0654/ 

FEMA-REP-1, “Criteria for Preparation and Evaluation of Radiological Emergency Response 

Plans and Preparedness in Support of Nuclear Power Plants,” has replaced the previous 

version of Supplement 3, “Criteria for Protective Action Recommendations for Severe 

Accidents,” issued July 1996. The July 1996 version of Supplement 3 does not support the 

regulatory requirement to incorporate ETEs into the licensee’s PAR development and should no 

longer be used.

c. Review PAR strategy procedure(s) for appropriate update(s) to reflect new ETE times.

d. Review any PAR strategy procedure(s) change made to continue to comply with 

Supplement 3 or provide an acceptable method of compliance with 10 CFR Part 

50.47(b)(10) and Appendix E IV.3 regarding the use of ETEs in the formulation of 

PARs.

03.11 Review licensee E-plan provisions for, and implementation of primary, backup, and 

alternate ERF maintenance in accordance with 10 CFR Part 50 Appendix E §IV.E.8.b and as 

follows:

a. Records of ERF current and historical condition, support compliance with regulatory 

requirements and E-plan commitments for habitability.

b. Equipment required to perform the facility’s function is available and in sufficient 

quantity.

c. ERF power supplies are in compliance with regulatory requirements and E-plan 

commitments.

71114.05-04 RESOURCE ESTIMATE

The direct inspection effort is estimated to be, on average, between 9 hours and 15 hours 

biennially regardless of the number of reactor units at a site.

71114.05-05 PROCEDURE COMPLETION

This procedure is considered complete when all the inspection requirements listed in the 

procedure have been satisfied. For the purpose of reporting completion in the Reactor Program 

System (RPS), the sample size is defined as 1. A sample size of 1 will be reported in RPS 

when the procedure is completed in its entirety.

71114.05-06 REFERENCES

IN 05-19, “Effect of Plant Configuration Changes on the Emergency Plan” (ML051530520)

RG 1.219, “Guidance on Making Changes to Emergency Plans for Nuclear Power Reactors”
Issue Date: 07/21/16 8 71114.05

NUREG/CR-4831, “State of the Art in Evacuation Time Estimate Studies for Nuclear Power 

Plants,” March 1992.

NUREG/CR-6863, “Development of Evacuation Time Estimates for Nuclear Power Plants,” 

January 2005.

NUREG/CR-7002, “Criteria for Development of Evacuation Time Estimate Studies

EPFAQ Number: 2012-003, “Clarify the acceptable means for documenting discussions 

between licensees and OROs on the development of mutually acceptable PAR logic using 

Supplement 3 to NUREG-0654/FEMA-REP-1.” (ML12171A567)

EPFAQ No. 2012-005, “What is the timeline for the implementation of protective action 

recommendations per the revised NUREG-0654, Supplement 3 following the ETE 180 day 

review period?” (ML12348A786)

EPFAQ No. 2013-004, “Eight questions concerning the implementation of NUREG-0654/FEMAREP-1, Supplement 3, Guidance for Protective Action Strategies." (ML14007A652)

END
Issue Date: 07/21/16 Att 1-1 71114.05

Attachment 1 - Revision History For IP 71114.05

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

(Pre-Decisional, NonPublic Information)

N/A 10/25/06 Completed four-year historical CN search. N/A N/A

CN 06-029 10/25/06 Revised to clarify that this inspection is 

associated with Planning Standard 10 CFR 

50.47(b)(14), to focus on the timeliness and 

effectiveness of corrective actions based on 

safety significance, and conform to the ROP 

emphasis on correction of EP weaknesses. 

No ML061790135

N/A ML12122A958

05/29/12

CN 12-008

Changed Problem Identification & Resolution 

(PI&R) references to Corrective Action 

Program (CAP) 

Removed “Inspection Bases” in accordance 

with IMC 0040 “Preparing, Revising and 

Issuing Documents for the NRC Inspection 

Manual” formatting expectations.

Added a “Reference” section. 

Reformatted “Inspection Requirements” section 

to align with “Inspection Guidance” section of 

MC 0040 “Preparing, Revising, and Issuing 

Documents for the NRC Inspection Manual.” 

Deleted “Level of Effort” section; no longer in 

MC 0040.

Yes - Provided at EP 

Face to Face counterpart meeting 

09/09/2011

ML12122A943
Issue Date: 07/21/16 Att 1-2 71114.05

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

(Pre-Decisional, NonPublic Information)

Added inspection requirements and 

corresponding guidance sections:

02.08 Review Letters of Agreement and/or 

Memorandums of Understanding (LOA/MOU) 

that support the E-plan

02.09 Review 10 CFR 50.54(q) plan change 

process and practice.

02.10 Review licensee maintenance of 

equipment important to emergency 

preparedness.

02.11 Review licensee record(s) of ETE 

population evaluation.

02.12 Review licensee E-plan provisions for, 

and implementation of, primary, backup and 

alternate emergency response facility 
Issue Date: 07/21/16 Att 1-3 71114.05

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

(Pre-Decisional, NonPublic Information)

N/A ML15254A401

07/21/16

CN 16-017

Added note to step 03.10.b describing NUREG0654 Sup 3 dated July 1996 is no longer 

acceptable guidance.

Added inspection guidance for reviewing PAR 

strategy procedures and appropriate updates 

based on changes in ETE times.

Editorial change – Align procedure with standard 

section numbering format of completion section 

under 711xx.xx-05 and the references under 

711xx.xx-06 (see ROP Feedback Form 71114-

1925). Added inspection requirement and 

corresponding guidance section to review 

implementation of ETE update values.

Moved Review 10 CFR 50.54(q) plan change 

process and practice from IP 71114.05 to 

71114.04. EPFAQs 2012-003, 2012-005 and 

2013-004 to the “Reference” section.

Added to section 71114.05-05 “Procedure 

Completion” the IP 71152 “Problem 

Identification and Resolution” expectation for 

routine PI&R activity reviews to be 

approximately 10 to 15 percent of the baseline 

cornerstone inspection procedure resources 

estimates. The 10 to 15 percent approximation 

is based on the overall expected inspection 

effort and is a general estimate only. 

No Comment Form -

ML15084A214

Feedback Form –

71114.05-1925 

ML15236A354