UNITED STATES 

NUCLEAR REGULATORY COMMISSION 

WASHINGTON, D.C. 20555-0001 

OFFICE OF THE 

INSPECTOR GENERAL 

 November 17, 2009 

MEMORANDUM TO: R. William Borchardt 

 Executive Director for Operations 

FROM: Stephen D. Dingbaum /RA/ 

 Assistant Inspector General for Audits 

SUBJECT: MEMORANDUM REPORT: AUDIT OF NRC’S 

MANAGEMENT DIRECTIVE 6.8, LESSONS 

LEARNED PROGRAM (OIG-10-A-03) 

The Office of the Inspector General (OIG) conducted an audit of the Nuclear 

Regulatory Commission’s (NRC) Management Directive (MD) 6.8, Lessons 

Learned Program. The audit was initiated based on concerns identified during 

OIG’s Audit of NRC’s Oversight of Construction at Nuclear Facilities. OIG’s audit 

of MD 6.8 identified issues pertaining to the agencywide Lessons Learned 

Program (the program) that warrant your attention. Specifically, 

 The program could have been more effectively communicated to 

NRC staff. 

 Management’s attention to and support for certain aspects of the 

program has diminished over time. 

As a result, the program is missing opportunities to identify and inform NRC staff 

of significant agencywide lessons learned that would improve agency operations. 
Audit of NRC’s Management Directive 6.8, Lessons Learned Program

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BACKGROUND

In 2002, NRC created the Davis-Besse Lessons Learned Task Force to evaluate 

the agency’s regulatory processes used during the Davis-Besse event.1

 The 

Davis-Besse Lessons Learned Task Force recommended, among other things, 

that NRC conduct an effectiveness review of the actions taken in response to 

past lessons learned reviews. Consequently, the Office of Nuclear Reactor 

Regulation (NRR) established the Effectiveness Review Lessons Learned Task 

Force (ERLLTF). This task force found that some corrective actions 

implemented prior to the Davis-Besse event had not been effective. In response, 

the Executive Director for Operations assigned the ERLLTF to establish a 

program to institutionalize significant agencywide lessons learned. 

On August 1, 2006, the agency issued MD 6.8 to establish the formal and 

structured process needed to manage corrective actions for significant 

agencywide lessons learned. The Executive Director for Operations has primary 

oversight of the program, but has delegated this responsibility to a Lessons 

Learned Program Manager (the program manager) and a Lessons Learned 

Oversight Board (the Oversight Board). The Oversight Board is composed of 

deputy office directors from NRR, the Office of New Reactors, the Office of 

Nuclear Material Safety and Safeguards, the Office of Federal and State 

Materials and Environmental Management Programs, the Office of Nuclear 

Regulatory Research (RES), the Office of Nuclear Security and Incident 

Response, and a representative from one of the four NRC regions. The 

Executive Director for Operations transferred primary oversight of the program to 

RES on May 26, 2009. The current program manager and Chairman of the 

Oversight Board are both RES employees. 

MD 6.8 establishes the process for screening, evaluating, and implementing 

potential agencywide lessons learned. The program manager is responsible for 

compiling potential lessons learned issues. The program manager then 

schedules an Oversight Board meeting to discuss whether the selected issues 

should be considered as agencywide lessons learned. The Oversight Board 

compares the issues to threshold criteria established in MD 6.8, and only if the 

criteria are met can an issue be considered an agencywide lessons learned. 

Issues that do not meet the lessons learned criteria established in MD 6.8 may 

be addressed by NRC offices through other corrective action mechanisms. The 

program manager posts the Oversight Board meeting minutes and annual 

program updates in the Agencywide Document Access and Management 

System. 

 

1

 In March 2002, plant workers at the Davis-Besse Nuclear Power Station found significant 

damage to a reactor vessel while conducting a routine repair. This problem led to a leakage of 

reactor cooling water, which contains boric acid and can damage other areas of the nuclear 

reactor. 
Audit of NRC’s Management Directive 6.8, Lessons Learned Program

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The Executive Director for Operations assigns a lead NRC office to create and 

implement a corrective action plan when a lesson learned is identified. Once the 

lead office implements the corrective action plan, the Oversight Board 

determines if that plan was satisfied. Upon successful completion of the 

corrective action plan, the Oversight Board determines when the lead office 

conducts an effectiveness review. When completed, the Oversight Board 

reviews and makes recommendations if necessary. 

PURPOSE

The objective of this audit was to determine whether NRC's agencywide Lessons 

Learned Program meets its intended purpose to ensure that knowledge gained 

from significant lessons learned is retained and disseminated in a manner that 

will maximize its benefit and usefulness to the staff.

RESULTS

Although NRC has identified significant agencywide lessons learned, agency 

staff are generally unaware of the program’s lessons and activities. The purpose 

of the program is to ensure that knowledge gained from significant lessons 

learned is retained and disseminated in a manner which maximizes its benefit 

and usefulness to staff. However, the program could have been more effectively 

communicated to staff, and management’s attention to and support for certain 

aspects of the program has diminished over time. As a result, the program is 

missing opportunities to identify and inform NRC staff of significant agencywide 

lessons learned that would improve agency operations. 

Purpose of the Lessons Learned Program 

MD 6.8 establishes the formal and structured process needed to manage the 

Lessons Learned Program. The purpose of the program is to ensure that: 

 Knowledge gained from significant lessons learned is retained and 

disseminated. 

 Knowledge is beneficial and useful to agency staff. 

 Major organizational problems identified by lessons learned will not 

recur. 
Audit of NRC’s Management Directive 6.8, Lessons Learned Program

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NRC Staff Generally Unaware of the Program 

Although the Oversight Board has identified significant lessons learned, agency 

staff are generally unaware of the program’s lessons and activities. Specifically, 

staff are unaware of the issues considered for potential agencywide lessons 

learned, the lessons learned identified, and who has oversight of the program. 

Staff Unaware of Issues Considered and Identified as Agencywide 

Lessons Learned

As seen on the following chart, the Oversight Board evaluates a broad range of 

issues from multiple sources including the following: Government Accountability 

Office (GAO) reports, OIG reports, internal NRC documents, and external events. 

Oversight Board members also bring to the meetings issues for consideration as 

lessons learned. From these sources, the Oversight Board has identified a few 

significant agencywide lessons learned and assigned corrective actions to 

incorporate these lessons into agency guidance and procedures. 

Sources of Issues Reviewed by the Lessons Learned Oversight Board 

OIG Reports

46% NRC Internal Reports

36%

GAO Reports

10%

International Events

3%

Licensee Reports

1%

Special Interest Groups

Other Federal Agency 1%

Reports

3%

Source: OIG analysis and review of Oversight Board meeting minutes dated September 12, 2006, 

through May 5, 2009.

Although the Oversight Board has considered multiple issues and identified 

significant agencywide lessons learned, agency staff are generally unaware of 

these activities. The Oversight Board meeting minutes document that four 
Audit of NRC’s Management Directive 6.8, Lessons Learned Program

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agencywide lessons learned have resulted from the program (see table, below). 

However, OIG interviewed 24 NRC office points-of-contact (POCs) identified by 

the Office of the Executive Director for Operations and found that 92 percent of 

the POCs had limited knowledge of the program. Moreover, none of the POCs 

could identify all the agencywide lessons learned established through the 

program and many could not identify where to find information about the 

program. 

Lessons Learned Identified by the Oversight Board 

Source: OIG analysis and review of Oversight Board meeting minutes dated September 12, 2006, through 

May 5, 2009. 

Current and former Oversight Board members were unable to name all of the 

lessons identified through the program and acknowledged that the program could 

do a better job of gathering issues from the “non-technical” offices. Although 

agencywide lessons learned identified by the Oversight Board are documented in 

meeting minutes and annual reports, most of the current and former Oversight 

Board members could only identify some of the lessons learned, and none could 

identify all four. OIG also noted that three out of the four identified agencywide 

lessons learned were “non-technical” in nature (see table above); however, the 

Oversight 

Board 

Meeting Date 

Source Agencywide Lessons Learned 

Identified 

11-20-2007 

GAO-07-1038T, Actions Taken by NRC to 

Strengthen Its Licensing Process for Sealed 

Radioactive Sources are Not Effective.

There are weaknesses in the 

process NRC uses to approve 

license applications. 

11-20-2007 

Actions taken to address findings identified 

by the Information Technology (IT) 

Development Analysis Team, a task team 

established to evaluate the process used for 

awarding and managing large IT system 

development contracts. 

NRC needs to incorporate greater 

consistency in its processes 

related to planning, developing, 

and implementing large IT 

systems. 

11-25-2008 

Report of Lessons Learned from the June 

25, 2008, Medical Event at the Executive 

Boulevard Building. 

Further efforts are required to 

clarify and expand on procedures 

to be followed during medical 

emergencies. 

05-05-2009 

OIG-09-A-07, Audit of NRC’s Occupant 

Emergency Program.

NRC staff lacks awareness of 

emergency procedures, 

emergency equipment is 

inadequate and poorly 

maintained, and signage in NRC's 

White Flint complex is inadequate 

and inconsistent. 
Audit of NRC’s Management Directive 6.8, Lessons Learned Program

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Oversight Board does not have any representatives from the “non-technical” 

offices. 

Potential lessons learned are also gathered through the agency’s Knowledge 

Management (KM) program; however, there is not a direct linkage between the 

KM program and the Lessons Learned Program. MD. 6.8 states that a 

successful lessons learned program should be integrated with other agency 

knowledge management initiatives. An NRC staff member involved with the KM 

program stated that there is little interaction between the Lessons Learned 

Program and the KM program. Moreover, MD 6.8 does not describe how the 

Lessons Learned Program is linked to agency knowledge management efforts. 

 Staff Unaware of Program Oversight

Office POCs identified by OEDO are also unaware of who has oversight of the 

Lessons Learned Program. Despite statements by several Oversight Board 

members that the program manager position is a key element to the success of 

the program, most of the POCs and some Oversight Board members did not 

know who is designated as the program manager. OIG analysis showed that 

since the program’s inception in 2006, there have been five different program 

managers. All program managers held the position for less than a year, including 

one who held the position for only 2 months. 

Further, current and former Oversight Board members and project managers 

were unaware of the status of a Lessons Learned Program database, the 

SharePoint Enterprise Lessons Learned (SPELL). SPELL was developed for the 

Lessons Learned Program so that issues considered by the Oversight Board and 

the identified agencywide lessons learned could be documented and shared with 

agency staff. Specifically, Oversight Board members and program managers 

were unsure as to: 

 What information should be available in SPELL. 

 Who has ownership of the system. 

 Who should have access to the system. 

OIG identified that the Office of Information Services (OIS) currently has 

ownership of SPELL, which has been ready for use since November 2008. 

During the development of SPELL, a former project manager used the system to 

document two Oversight Board meetings in fiscal year 2009. However, the 

system has not yet been implemented for agencywide use and OIS is unsure as 

to who will take eventual ownership of the system. As of June 2009, SPELL has 

cost the agency about $342,000. 
Audit of NRC’s Management Directive 6.8, Lessons Learned Program

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OIS demonstrated to OIG that SPELL has the capability to track the issues 

considered by the Oversight Board and the identified lessons learned and 

corrective actions associated with them. It also allows staff to submit issues for 

consideration as potential lessons learned. 

After OIG completed this audit, NRC issued a communications plan for SPELL 

on October 7, 2009. The communications plan demonstrates how NRC intends 

to use SPELL as a mechanism to support the agency’s knowledge management 

efforts. 

The Program Has Not Been Effectively Communicated; Program Missing 

Opportunities 

The program could have been more effectively communicated to NRC staff, and 

management’s attention to and support for certain aspects of the program has 

diminished over time. As a result, the program may be missing opportunities to: 

 Obtain potential lessons learned information from staff. 

 Inform staff of significant agencywide lessons learned that would 

improve NRC operations. 

Without proper knowledge of the identified agencywide lessons learned by the 

NRC staff associated with the Lessons Learned Program, MD 6.8 cannot achieve 

its purpose of disseminating agencywide lessons learned. Consequently, NRC 

runs the risk of repeating problems that have already been identified. By 

enhancing communication to the staff, the program can achieve its intended 

purpose to ensure that knowledge gained from significant lessons learned is 

retained and disseminated in a manner that will maximize its benefit and 

usefulness to the staff. 

RECOMMENDATIONS

OIG recommends that the Executive Director for Operations: 

1. Develop and implement a strategy for communicating agencywide 

lessons learned and program activities to agency staff. 

2. Implement the plan to release SPELL for agency staff use. 

3. Re-affirm and communicate management’s support for the program. 
Audit of NRC’s Management Directive 6.8, Lessons Learned Program

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AGENCY COMMENTS

OIG held an exit meeting with NRC management on September 25, 2009. After 

the meeting, agency management provided informal comments to the draft 

report. On October 8, 2009, OIG held an additional meeting with NRC 

management to discuss the agency’s informal comments to the draft report. 

After that meeting, OIG provided NRC with a revised draft report and agency 

management generally agreed with the report’s finding and recommendations. 

The agency decided not to provide formal comments. This report incorporates 

revisions made, where applicable, as a result of meetings with NRC staff. 

Please provide information on actions taken or planned on each of the 

recommendations within 30 days of the date of this report. Actions taken or 

planned are subject to OIG followup as stated in MD 6.1.

SCOPE AND METHODOLOGY

To accomplish the audit objective, the OIG audit team reviewed NRC lessons 

learned task force reports, MD 6.8, Oversight Board meeting minutes, 

documentation regarding SPELL, and other program related documentation. The 

audit team interviewed agency staff, including past and current program 

managers and Oversight Board members and agency POCs. 

OIG conducted this audit between June 2009 and August 2009 in accordance 

with generally accepted Government auditing standards. Those standards 

require that we plan and perform the audit to obtain sufficient, appropriate 

evidence to provide a reasonable basis for our finding and conclusions based on 

our audit objective. We believe that the evidence obtained provides a 

reasonable basis for our finding and conclusions based on our audit objective. 

Major contributors to this report were Sherri Miotla, Team Leader; Eric Rivera, 

Audit Manager; Catherine Colleli, Audit Manager; Timothy Wilson, Senior 

Analyst; and Vidya Sathyamoorthy, Student Management Analyst. 

cc: N. Mamish, OEDO 

 J. Andersen, OEDO 

 J. Arildsen, OEDO 

 C. Jaegers, OEDO