**NRC INSPECTION MANUAL**IRAB

INSPECTION PROCEDURE 40100

INDEPENDENT SAFETY CULTURE ASSESSMENT FOLLOWUP

PROGRAM APPLICABILITY:IMC 2506, IMC 2515 C

CORNERSTONES:ALL

INSPECTION BASIS:This inspection procedure provides guidance for following up on a U.S. Nuclear Regulatory Commission (NRC) request for a licensee to perform an independent safety culture assessment.  The NRC can ask a licensee to perform an independent safety culture assessment for the following situations:  (1) a conclusion is reached during an inspection under Inspection Procedure (IP) 95002, “Inspection for One Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area,” that the licensee did not adequately evaluate the contribution of a safety culture trait to the performance issue, or (2) a licensee has not adequately addressed a repetitive cross-cutting issue (CCI), which may be indicative of underlying organizational issues with safety culture implications.  Inspection Manual Chapter (IMC) 0305, “Operating Reactor Assessment Program,” provides additional guidance related to these situations.  Some of the guidance in this inspection procedure could be applied to other unique situations (e.g., when reviewing a safety culture assessment performed as part of an alternative dispute resolution agreement).  Chapter 6.4 of the Nuclear Regulatory Commission Enforcement Manual contains additional guidance related to alternative dispute resolution.  As mentioned in the guidance, it is important that the inspector engage on a limited basis with the licensee early in the planning phase for the independent safety culture assessment.

ADVANCE \y12640100-01INSPECTION OBJECTIVES

01.01To provide assurance that the licensee recognizes the safety culture cross-cutting trait deficiencies that caused or significantly contributed to risk-significant performance issues or repetitive CCIs.

01.02To assess whether completed and proposed corrective actions should be considered sufficient and appropriate to address recognized cross-cutting traits deficiencies identified during the licensee’s independent safety culture assessment.  More guidance on conducting safety culture assessments can be found in IP 95003.02, “Guidance for Conducting an Independent NRC Safety Culture Assessment.”

40100-02 INSPECTION REQUIREMENTS

02.01Inspectors must have completed focus group moderation training before conducting focus group interviews.  For guidance on conducting individual interviews, refer to IP 95003.02‐B and C.

02.02Inspectors should review potential safety-conscious work environment (SCWE) issues at the site (e.g., allegations, chilled work environments).

02.03Inspectors should assess the licensee’s response to the results of its independent safety culture assessment to provide the following assurances:

a. The licensee’s evaluations identify safety culture trait deficiencies that caused or significantly contributed to risk-significant performance issues or a repetitive CCI.

b. The licensee’s completed and proposed corrective actions are adequate to address recognized cross-cutting trait deficiencies that caused or significantly contributed to risk-significant performance issues or a repetitive CCI.  The proposed corrective actions should provide reasonable assurance that risk-significant performance issues stemming from contributing and identified cross-cutting trait deficiencies will not recur.

02.04Inspectors should gather and evaluate the licensee’s methodology, independence of assessment, data, communications, evaluation, implementation, and effectiveness measurements for corrective actions.  The inspector’s evaluation should be captured in the inspection report.  If the inspector considers the licensee’s independent safety culture assessment to be germane to IP 95002 objectives and feels that the results of IP 40100 would result in holding open a finding, then the assessment belongs in the supplemental inspection report.  Otherwise, the assessment could usually be relegated to the quarterly integrated inspection report.

40100-03INSPECTION GUIDANCE

Some of the recommended followup activities, such as possible interviews or focus groups, can be more effectively performed by more than one inspector.  This allows inspectors to collaborate as they interview, take notes, and confer on gathered insights.

The inspection can be accomplished by conducting discussions with site personnel in individual interviews or during focus groups.  Discussions with focus groups would allow input from a broader number of individuals.  In preparing for interviews and focus group discussions, inspectors should also review documentation associated with the assessment and the licensee’s response to the assessment.  The purpose of the interviews and focus group discussions is for the inspectors to gain a direct understanding of the views of site personnel.  IP 95003.02‐C (Agencywide Documents Access and Management System (ADAMS) Accession No. ML082630691;http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html) provides guidance for conducting focus groups.

03.01Methodology Review.  Inspectors should evaluate whether the safety culture assessment scope and methodology are consistent with the NRC’s request that the licensee have an independent safety culture assessment performed.  The inspection focus in this area should be applied with less depth than an inspection effort under IP 95003, “Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input.”  For example, the inspector may include a brief sample review of the assessment tools and methodology.  IP 95003.02 contains guidance on what methodologies the NRC considers to be acceptable.  The inspector would use this information to conduct an independent safety culture assessment, if necessary.  Therefore, when evaluating an assessment done by another entity, the inspector should apply the same standards as those in IP 95003.02.

It is recommended that the inspector engage on a limited basis with the licensee early in the planning phase for the independent safety culture assessment.  This provides the opportunity for the inspector to gain an understanding of the licensee’s plans and methodology.  Similarly, it is useful for the inspector to observe the implementation facets of the licensee’s independent safety culture assessment on a limited or sampling basis.  However, when doing so, the inspector should be careful not to take any actions that could potentially affect the conduct or outcome of the licensee’s assessment.  For example, the inspector may review the intended protocol to guide the conduct of licensee focus groups, but the inspector should not observe the focus groups because his or her presence may affect the conduct of the focus group (e.g., licensee staff may be hesitant to fully participate because of the inspector’s presence).  Inspectors should take care to ensure that their presence and activities do not bias the outcome of the licensee’s assessment in either a positive or negative manner.

03.02Independence of Assessment Team Members.  Evaluate the degree of independence of the persons performing the assessment on behalf of the licensee.  For an independent assessment, assessor personnel should not have direct authority or responsibility for any of the areas being evaluated.  In this case, corporate licensee staff or utility staff from another site potentially could fulfill the assessor role.

03.03Data Review.  Inspectors should evaluate the licensee’s safety culture assessment data to determine if they support the assessment findings.  The inspectors should briefly review the safety culture assessment data to look for trends or outlier groups (e.g., low response rates or deviations from the averages) and evaluate if the licensee took any followup actions to compensate or further investigate the reasons for the differences.  Conducting a review of a sample of the data is important because sitewide averaging of the data could mask response rates from certain groups or specific negative inputs.

03.04Effectiveness of Licensee Communications.  Inspectors should evaluate a sample of the licensee’s communications about the safety culture assessment, the assessment results, and the site response.  Inspectors should determine if the licensee communicated the results of the safety culture assessment to plant staff using methods such as meetings in the field with plant staff and their supervisors, management presentations, or Internet postings.  Inspectors should review the communication materials and message.  During discussions (individual and/or focus group interviews) with site personnel, inspectors should gain an understanding of their interpretation of the messages.  Inspectors should compare the content of the licensee’s communication materials and intended messages with the message the site personnel received.  Evaluation of the licensee’s communication efforts about the safety culture assessment is needed because it is important for the inspectors to understand the level of effort, emphasis, and consideration the licensee gives to its safety culture assessment and how it communicates the results and corrective actions to its line organization.

03.05Licensee Evaluation of the Safety Culture Assessment Results and Implementation of Actions in Response to the Assessment  (Primary Followup Emphasis).

a.Inspectors should determine if the weaknesses identified by the safety culture assessment were tracked by the licensee using a formal program, such as a corrective action program, or an appropriate alternative, such as the employee concerns program (ECP).  In some cases, corrective actions may involve sensitive areas, such as personnel actions or other matters that warrant confidentiality.  This type of information may not be documented in any corrective action or ECP files  and must be solicited or inferred from discussions with licensee officials (such as human resource personnel or senior management).  The inspector should evaluate these circumstances and conduct activities to gather this information as needed.  The inspector should determine the extent of other team members’ involvement in and knowledge of these activities on a need-to-know basis.

b.Inspectors should determine if the weaknesses identified by the licensee’s evaluation of the safety culture assessment were appropriate based on the assessment results.

c.Inspectors should evaluate the adequacy of the licensee’s planned and completed actions for addressing the weaknesses identified by the safety culture assessment.  Inspectors should ensure that the licensee addresses both sitewide issues and any specific issues (for example, targeted at a specific part of the organization).  Inspectors should look for differences between sitewide versus unique organizational or departmental issues and evaluate how those differences are being treated by the licensee’s associated action plans.

Inspectors should evaluate whether licensee actions appear to be appropriate for the circumstances of the issue being targeted.  For example, if the safety culture assessment detected deeper organizational problems, such as potential departmental SCWE issues, the licensee should typically take more substantial actions in response to the concern than simply providing a short training session on SCWE.  Although short-term or limited-scope actions such as training or personnel changes can have positive impacts, effective corrective actions for producing lasting changes in organizational 

culture require a long-term focus.  Discrete activities, such as communications (e.g., stand-downs and publication of policies) and training sessions, should be reinforced and evaluated for effectiveness.  The licensee should have plans to monitor long-term progress and the capability and flexibility to make adjustments to corrective action plans as needed.

d.If the licensee is crediting existing or previously-planned action plans to resolve any weaknesses identified by the safety culture assessment, inspectors should ensure the appropriateness of this credit given the scope and depth of the safety culture assessment issues.  Although the issues may appear to be similar on the surface, insights from the safety culture assessment could indicate the need to expand or modify the preexisting action plans to thoroughly envelop the full scope and depth of the issues identified by the safety culture assessment, particularly because preexisting action plans could have contributed to the existing conditions.

e. Depending on the timing of the inspection, inspectors should evaluate the licensee’s progress based on the types of corrective actions and their intended effects.  The licensee may implement actions aimed at creating immediate changes or near-term improvements and other actions focused on long-term changes.  It is important to note that some cultural changes may require several years or longer to develop, depending on the circumstances.  However, short-term progress can be made and should be monitored.

f. Inspectors should conduct discussions with licensee personnel, either through individual or focus group interviews (IP 95003.2‐C contains guidance on conducting interviews and focus groups, as well as the strengths and weakness of each), to gain an understanding of their views on the conduct of the safety culture assessment, the assessment results, and the site’s response.  These discussions should include personnel perceptions about the independence of the assessment.  Inspectors should consider asking the questions listed below and evaluate if there appear to be any differences in the views of different levels of personnel or between groups.  If there are differences, inspectors should investigate if site management has an understanding of the differences and is taking appropriate actions to address them.  Inspectors should be prepared for discussion of other safety culture issues, SCWE issues, or allegations. (IP 95003.02 provides guidance for discussing safety culture issues, and IP 71152, “Problem Identification and Resolution,” provides guidance for discussing SCWE issues.)

1. What do you remember about the safety culture assessment?

2. What are your thoughts on the quality of the assessment tool(s) (e.g., the survey, if one was used)?

3. What are your thoughts on the independence of the assessment tool(s) (e.g., the survey, if one was used)?

4. What communication or changes have you received from your management about to the safety culture assessment (e.g., before the assessment was conducted, during the assessment, and concerning the results of the assessment)?

5.Have you been provided feedback on planned corrective actions for the issues identified by the assessment?  What are your views on the probable effectiveness of the corrective actions (both in progress and planned)?

6.What are your views on the overall trend of the site’s safety culture (e.g., trending in a positive or negative direction)? 

g.Inspectors should evaluate whether the licensee has established appropriate means to monitor or measure the effectiveness of the planned actions to address the weaknesses identified by the safety culture assessment.

03.06Documentation and Expected Licensee Followup.  The inspection report should document the inspector’s evaluation of the licensee’s independent safety culture assessment and observed weaknesses.  If the inspector considers the licensee’s independent safety culture assessment to be germane to IP 95002 objectives and feels that the results of IP 40100 would result in holding open a finding, then the assessment belongs in the supplemental inspection report.  Otherwise, the assessment could usually be relegated to the quarterly integrated inspection report.  The licensee is expected to address NRC-identified issues and weaknesses.  These actions can include a request to perform additional independent safety culture assessments, evaluations, or corrective actions.

40100-04RESOURCE ESTIMATE

An independent safety culture assessment followup inspection is estimated to take 50 to 60 hours.

40100-05PROCEDURE COMPLETION

Meeting the inspection objectives defined in Section 40100-01 of this IP will constitute completion.

40100-06REFERENCES

IMC 0305, “Operating Reactor Assessment Program”

IMC 0611, “Power Reactor Inspection Reports”

IMC 0612, “Issue Screening”

IMC 2515, “Light-Water Reactor Inspection Program—Operations Phase”

IP 71152, “Problem Identification and Resolution”

IP 95002, “Inspection for One Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area”

IP 95003, “Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input”

Nuclear Regulatory Commission Enforcement Manual

END

Attachment 1:  Revision History

ATTACHMENT 1 – Revision History for IP 40100

Issue Date:  03/14/14240100

Issue Date:  07/26/18140100