Issue Date: 07/21/16 1 71114.04

 NRC INSPECTION MANUAL NSIR/DPR

INSPECTION PROCEDURE 71114 ATTACHMENT 04

EMERGENCY ACTION LEVEL AND EMERGENCY PLAN CHANGES

Effective Date: 10/01/2016

PROGRAM APPLICABILITY: 2515 A

71114.04-01 INSPECTION OBJECTIVE

Evaluate the efficacy of changes made to the emergency action level (EAL) scheme and 

emergency plan to have not reduced the effectiveness of the emergency plan without the U.S. 

Nuclear Regulatory Commission’s (NRC’s) approval prior to being implemented. 

Verify the EAL scheme used by the license is:

 in compliance with 10 CFR 50.47(b)(4) and NRC endorsed guidance or is an approved 

alternative,

 any changes made to the EAL scheme and or emergency plan do not cause either to no 

longer meet the requirements of 10 CFR 50.54(q). 

In addition, this inspection activity provides monitoring of the effectiveness of the licensee’s 

program/procedures for implementing the 10 CFR 50.54(q) change process as well as the

licensee’s change documentation, i.e., their justification for their 10 CFR 50.54(q) decision. The

documentation should be comprehensive enough to allow the i nspector to reasonably reach

the same conclusion as the licensee.

This inspection verifies aspects of the EmergencyPreparedness Cornerstone for which there are

no indicators to measure performance.

This inspection procedure may be performed in the office or on site.

71114.04-02 INSPECTION REQUIREMENTS

02.01 Review all licensee EAL changes and EAL basis document changes to determine if any

reduced the effectiveness of the EAL scheme.

02.02 Screen all emergency plan changes and select a sample of the changes for review to 

ensure the changes did not reduce the effectiveness of the emergency plan.

Note: Lower tier documents may also be in the scope of this review if these lower tier documents

are controlled by the licensee via 10 CFR 50.54 (q).
Issue Date: 07/21/16 2 71114.04

02.03 Review 10 CFR 50.54(q) emergency plan change process and practice.

71114.04-03 INSPECTION GUIDANCE

General Guidance

If any emergency plan revision is extensive such that the inspector would expend an inordinate 

amount of time to complete the review (more than about 20 hours), then the inspector should 

consider submitting the revision to NRC Headquarters (HQ) Office of Nuclear Security and

Incident Response (NSIR) for review.

Note: Licensee submittals, such as license amendments, which have already been identified as 

requiring NRC approval, should be reviewed by NSIR rather than as an inspection activity under 

this inspectable area.

Based on the screening, the inspector shall perform an in-depth review of a sample of 

emergency plan changes which could potentially result in a reduction in effectiveness (RIE). 

Emergency plan changes implementing risk significant planning standards should be given 

priority for review. Over the course of a year, the in-depth review effort should include at least 

one emergency plan change, if any are submitted. In most cases, and all cases involving a risk 

significant planning standard, determining whether a change is an RIE will require a review of the 

licensee’s 10 CFR 50.54(q) documentation for the specific emergency plan change.

For any emergency plan change that resulted in a RIE of the emergency plan or the changed 

emergency plan no longer meets the requirements of 10 CFR 50.47(b) or Appendix E, the 

inspector shall conduct a further review. If the emergency plan change was implemented without 

prior NRC approval, the change shall be evaluated in accordance with the guidance in Section IV 

of the Enforcement Policy (traditional enforcement) and documented accordingly.

10 CFR 50.54(q) requires licensees to (1) follow and maintain the effectiveness of their approved 

emergency plans, (2) evaluate proposed changes to these plans for their impact on the 

effectiveness of the plans, and (3) obtain prior NRC approval for changes that would reduce the

effectiveness of the plans. 

The “emergency plan” is defined as including any document that describes the programmatic 

methods used by the licensee to maintain preparedness and to respond to an emergency, and to 

demonstrate compliance with the requirements of Appendix E, and for nuclear power reactors,

the planning standards of § 50.47(b).

Note: Lower tier documents may also be in the scope of this review if these lower tier 

documents are controlled by the licensee via 10 CFR 50.54 (q).

Section 50.54(q)(1)(iv) defines the term “reduction in effectiveness” as a change to the 

emergency plan that results in a reduction of the licensee’s capability to perform an emergency 

planning function in the event of a radiological emergency. The phrase “reduction in 

effectiveness” is an evaluation concept that is used in § 50.54(q) to differentiate between 

changes that the licensee is allowed to make without prior NRC approval and those that require 
Issue Date: 07/21/16 3 71114.04

prior NRC approval. A determination that a change may result in a RIE does not imply that the 

licensee could no longer implement its emergency plan and provide adequate measures for the 

protection of the public. The NRC may approve a proposed emergency plan change that the 

licensee determined to be a RIE if the NRC can find that the emergency plan, as modified, 

continues to meet the requirements of Appendix E, and for nuclear power reactor licensees, the 

planning standards of § 50.47(b), and continues to provide reasonable assurance that adequate 

protective measures can and will be taken in the event of a radiological emergency.

The licensee’s determination of a RIE is used only to determine whether the licensee has the 

authority to implement the change without prior NRC approval under § 50.54(q)(3) or must 

submit for prior NRC approval under § 50.54(q)(4). 

A licensee’s emergency plan is part of the licensee’s licensing basis and is approved only for the 

licensing basis with which it is submitted. If a licensee changes their licensing basis in a fashion 

that affects the emergency plan, the change must be submitted as a license amendment request 

and be approved prior to being implemented.

A licensee may revise their emergency plan, EAL scheme and or EAL basis after receiving their

NRC Safety Evaluation Review (SER) approval for their emergency plan. Subsequent changes 

made to the emergency plan, EAL scheme or EAL Basis are required to be compared to the 

licensee’s latest NRC SER approved emergency plan. A licensee desiring to change its entire 

emergency action level scheme shall submit an amendment request for its license and receive 

NRC approval before implementing the change per Appendix E.IV.B.2 of 10 CFR 50. 

The requirements of 10 CFR 73.58 “Safety/security interface requirements for nuclear power 

reactors” also need to be considered for changes made that could potentially have an adverse 

effect on the safety and security interface, such as implementing changes to plant configurations, 

facility conditions, or security.

03.01 EAL and EAL Bases Document Change Review.

Licensees normally use an NRC endorsed EAL scheme when submitting their required 

emergency classification and action level scheme but may propose an acceptable alternative 

method.

Guidance on acceptable EAL change methodology is contained in RIS 2003-18, “Use of 

NEI 99-01, Methodology for Development of Emergency Action Levels,” Revision 4, Dated 

January 2003,” and its supplements, should be used for changes implemented prior to

February 21, 2012, and may be used for subsequent changes to the extent that it does not 

conflict with the guidance in Regulatory Guide 1.219. NRC HQ NSIR Division of Preparedness 

and Response (DPR) assistance may be requested for review and approval of EAL changes 

which involve a significant portion of the EAL scheme or incorporate an alternative EAL 

methodology.

Licensees should have an EAL Bases Document. The bases document is considered an integral 

part of the EALs and should be controlled accordingly. The EAL Bases Document should be 

readily available for decision makers to clarify the intent of the EAL and provide the necessary 

context. The EAL basis document should not contain information that modifies the meaning or 
Issue Date: 07/21/16 4 71114.04

intent of the initiating condition (IC) or EAL or give direction for actions beyond those necessary 

to obtain the IC or EAL threshold values except for those such as dose assessments, chemistry 

sampling, reactor coolant system leak rate calculation, etc.

When reviewing EAL changes, the inspector should be sensitive to EALs that refer to other 

documents, such as the security contingency plan, industrial hygiene standards, Offsite Dose 

Calculation Manual, and manufacturer’s specifications. The referenced documents may be 

considered sensitive or may not be readily available to the decision makers; however, the 

information in the EAL Bases Document should contain the information necessary to provide the 

appropriate context. The inspector should review changes to the EAL and the EAL Bases

Document together.

A review of security related EALs or EAL Bases Document changes should be performed to 

ensure consistency with the Security Contingency Plan. Likewise, a review of the security 

contingency plan should be performed to ensure consistency with the emergency plan. The 

inspector should also consult with NRC security specialist inspectors when conducting reviews of

security-related EALs and EAL Bases Documents.

a. Perform the EAL change review in accordance with Figure 1, “EAL Change Review

Flowchart.” The following comments are intended to clarify expectations:

• Administrative changes are considered to be changes made to correct

typographical errors or other information other than EAL content.

• Review the licensee’s documentation used to support their 10 CFR 50.54(q) 

determination. Evaluate this documentation to determine if the licensee’s position is 

justifiable and appropriate.

• Contact NRC HQ (NSIR/DPR) if it appears that a RIE may have occurred, or when 

assistance in determining a potential RIE is needed. 

• If the licensee made the EAL change(s) due to receipt of a Safety Evaluation

Report (SER) or due to NRC direction via advisories, orders, bulletins, etc.,

review the change and evaluate if the change was made in accordance with

the stated NRC guidance or SER.

b. Verify that the licensee performed the annual EAL review with State/County authorities in 

accordance with the requirements of 10 CFR 50, Appendix E, Section IV.B. (may be 

performed in the office or onsite during the baseline EP inspection) [C1]

03.02 Emergency Plan Change Review.

On occasion, emergency plans undergo extensive changes, (e.g., the combination of multiple 

emergency plans from different sites) and may be implemented without prior approval if the 

changes are made in accordance with 10 CFR 50.54(q). If the review of a given change is 

estimated to take in excess of 20 hours, then the inspector should consider submitting the 

revision to NRC HQ (NSIR/DPR) for review. The inspector should consult with NRC security 

specialist inspectors when the emergency plan changes refer to the security contingency plan,

including EALs.
Issue Date: 07/21/16 5 71114.04

Licensees may develop alternative methods for meeting the planning standards and these 

should be considered for adequacy, however these alternative methods should have been 

approved by the NRC prior to implementation. If it appears that an emergency plan element 

is not in compliance with the requirements of 10 CFR 50.47(b), the situation may be a failure 

to meet a planning standard. Refer to RIS 2005-02 and contact NRC HQ to aid in determining 

potential RIEs.

Changes selected for review should not be administrative (e.g., typographical corrections).

Licensees may develop alternative methods for meeting the planning standards and these 

should be considered for adequacy, however these alternative methods should have been 

approved by the NRC prior to implementation.

a. Screen all 10 CFR 50.54(q)(5) emergency plan change summary submittals and select a

sample of changes to perform an in-depth review of the supporting documentation using 

Figure 2 as a reference. The sample should consist of:

1. Emergency plan changes implementing risk significant planning standards should 

be given priority for review. 

2. Lower tier documents which contain emergency plan commitments removed from 

the emergency plan, but must be maintained in accordance with 

10 CFR 50.54(q) change process. These lower tier documents shall be

administratively tracked by the licensee to ensure the emergency plan integrity and

must be available for NRC inspection.

03.03 Review 10 CFR 50.54(q) emergency plan change process and practice. 

a. Verify individuals responsible for performing the screenings and evaluation understand 

the intent and procedure steps (i.e., reviews are to be performed against the last 

emergency plan with an SER).

b. Verify screenings and evaluations contain a level of detail appropriate to support the 

change (i.e., does the screening block for a given planning standard describe more than 

just “yes” or “no”).

c. Review licensee 10 CFR 50.54(q)(3) violations since the last inspection to determine if 

the violation could or should have been prevented by an appropriate and accurate 

screening or evaluation and if so has the licensee taken action to correct the issue.

71114.04-04 RESOURCE ESTIMATE

The direct inspection effort for EAL reviews is estimated to be, on average, between 12 hours 

and 20 hours annually, regardless of the number of reactor units at a site. However, all sites do 

not submit EAL changes every year. This estimate is based on regional experience in reviewing 

EAL changes and suggests that each region will expend about 8 hours times the number of sites 

in the region reviewing EAL changes. This time will be spent on the few sites that submit EAL 

changes, but should average out to the estimate provided.
Issue Date: 07/21/16 6 71114.04

The direct inspection effort for emergency plan reviews is estimated to be, on average, between 

12 hours and 20 hours annually, regardless of the number of reactor units at a site.

71114.04-05 PROCEDURE COMPLETION

The emergency plan change reviews and screenings should be documented in an inspection 

report in accordance with Inspection Manual Chapter 0612. Performance of this inspection 

procedure’s change review or screening does not constitute approval of the affected emergency 

plan changes. Sample documentation wording for EAL and emergency plan changes with no 

apparent RIE is as follows:

“Since the last NRC inspection of this program area, Emergency Plan Revision(s) XX to XX were 

implemented based on your determination, in accordance with 10 CFR 50.54(q), that the 

changes resulted in no reduction in effectiveness of the emergency plan, and that the revised 

emergency plan as changed continues to meet the requirements of 10 CFR 50.47(b) and

requirements of Appendix E to 10 CFR 50. The inspectors conducted a {(1) sampling review of 

the emergency plan changes, and/or (2) review of EAL changes} to evaluate for potential 

reductions in effectiveness of the emergency plan. However, this review does not constitute 

formal NRC approval of the changes. Therefore, these changes remain subject to future NRC 

inspection in their entirety.”

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

procedure have been satisfied. Routine reviews of problem identification and resolution activities 

performed in this attachment should equate to approximately 10 to 15 percent of the resource 

estimate range described above. 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.

71114.04-06 REFERENCES 

Regulatory Guide 1.219, “Guidance on Making Changes to Emergency Plans For Nuclear Power 

Reactors”

Regulatory Issue Summary 2005-02, “Clarifying the Process for Making Emergency Plan 

Changes,” February 14, 2005

RIS 2003-18, “Use of NEI 99-01, ‘Methodology for Development of Emergency Action Levels,’ 

Revision 4, Dated January 2003,” and supplements

END
Issue Date: 07/21/16 7 71114.04

Figure 1 EAL Change Review Flowchart
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Figure 2: Emergency Plan Review Flowchart
Issue Date: 07/21/16 Att1-1 71114.04

Attachment 1- Revision History for IP 71114.04

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

C1 09/09/01 Revised to add previously deleted inspection

requirement considered necessary for the 

baseline inspection program.

Reference is Davis-Besse Lessons Learned 

Task Force Item No. 3.3.4.7. (this commitment

was confirmed to be still in effect, as of 9/24/08)

N/A N/A

10/25/06

CN 06-029

Complete rewrite of document structure to align

it with RIS 2005-02 concerning the correct

process for making Emergency Plan changes

with two clarifying flowcharts (Figures 1 & 2), 

addition to meet one commitment.

N/A ML061790125

10/31/08

CN 08-031

N/A Revision to incorporate a review of securityrelated Emergency Action Levels and Emergency

Plan changes

No ML081640372
Issue Date: 07/21/16 Att1-2 71114.04

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)

ML15245A748

07/21/16

CN 16-017

Editorial changes:

 Removed “Inspection Bases” and “Level or 

Effort” and added “Inspection Objective” in 

accordance with IMC 0040 “Preparing, Revising 

and Issuing Documents for the NRC Inspection 

Manual” formatting expectations.

 Change “decrease in effectiveness” to 

“reduction in effectiveness” and corresponding 

DIE to RIE

 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 statement “This inspection procedure may 

be performed in the office or on site” to the 

inspection objective section.

Added Inspection requirement 02.03 Review 10 

CFR 50.54(q) emergency plan change process 

and practice and guidance step 03.03 from IP 

71114.05 to this IP.

Updated 10 CFR 50.54(q) description in 

accordance with new EP rule effective December 

2011

None Comment Resolution 

– ML15245A773

Feedback Form –

71114.04-1925 

ML15245A742
Issue Date: 07/21/16 Att1-3 71114.04

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 10 CFR 50 Appendix E.IV.B guidance for a 

licensee desiring to change its entire EAL scheme 

would require prior NRC approval before 

implementing the change and that less substantial 

EAL changes may be made using the § 50.54(q) 

process. 

Added description of 10 CFR 73.58 

“Safety/security interface requirements for nuclear 

power reactors”

Inspection Guidance step 03.01, replaced EAL

scheme references with NRC endorsed schemes.

Deleted step 03.02.b – Skill of the craft

Added section 71114.04-06 “References” 

Inconsistent use of the term “emergency response 

plan” and “emergency plan” changed to 

“emergency plan.”

Move documents referenced within the procedure 

to the “references” section.

Added 02.03 “Review 10 CFR 50.54(q) plan 

change process and practice” moved in from IP 

71114.05.

“General Guidance” Page 3

 2 paragraph change to “which with it is 

submitted.”
Issue Date: 07/21/16 Att1-4 71114.04

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)

 4th paragraph last sentence “A licensee 

desiring to change its entire emergency 

action level scheme shall submit an 

amendment request for its license and 

receive NRC approval before implementing 

the change per Appendix E.IV.B.2 of 10 CFR 

50.” 

03.01 ”EAL and EAL Bases Document Change 

Review”

 Change 4th paragraph to read “, and 

manufacturer’s specifications.

 added “together” to the 2nd to last paragraph 

last sentence “The inspector should review

changes to the EAL and the EAL Bases

Document together”

03.02 “Emergency Plan Change Review,” 

removed specifics about how to handle 

enforcement and documentation of.

Added References section 71114.06

Added to section 71114.04-05 “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.