SEQ CHAPTER \h \r 1ATTACHMENT 95003.01

INSPECTABLE AREA:EMERGENCY PREPAREDNESS

CORNERSTONE:EMERGENCY PREPAREDNESS

INSPECTION BASIS:This attachment contains inspection requirements for the EP Cornerstone.  These requirements are to be implemented when the EP Cornerstone is degraded, or when a decision has been made that these provisions need to be inspected, and Inspection Procedure 95003 is being implemented.  If the EP Cornerstone is not degraded or it was decided that it is not necessary to inspect these provisions, the EP related inspection requirements in the body of Inspection Procedure 95003 are sufficient. 

95003.01-01INSPECTION OBJECTIVE

01.01To gather information in support of the determination whether the licensee is capable of implementing adequate measures to protect the public health and safety in the event of a radiological emergency. 

01.02To Verify that the Emergency Preparedness program complies with applicable NRC regulations.

01.03To verify that the licensee is complying with commitments made in the Emergency Plan.

01.04To the extent practical, verify the absence of findings greater than white by determining the extent of condition of problems in the EP Cornerstone.  The risk significant planning standards (RSPS) have the highest priority for inspection activities.

95003.01-02INSPECTION REQUIREMENTS

This attachment supplants EP related requirements contained in the body of Inspection Procedure 95003.  Inspection Procedure 82001, “Evaluation of Emergency Preparedness,” provides guidance for inspection of EP programs with a degraded cornerstone.  Baseline Inspection Procedure 71114, “Reactor Safety - Emergency Preparedness,” also provides guidance for the Baseline Inspection of EP programs.  This attachment identifies elements of Inspection Procedures 82001 and 71114 to be implemented in support of the inspection objective.  If those elements have been implemented recently (generally within the last 9 months) and the inspection results are still relevant, they need not be repeated and the information from those inspections may be used to support this supplemental inspection.  However, if the results of previous inspections are no longer relevant, the inspection elements should be repeated as described. This determination is left to the judgment of the assigned inspector and appropriate management.

This attachment is designed to be implemented at a licensee site with a degraded EP cornerstone or when determined to be necessary as part of the IP 95003 implementation.  This being the case, certain documentation and inspection techniques appropriate for the Baseline Inspection (i.e., implemented for EP  programs operating in the licensee response band,) are not appropriate.  Deficiencies and weaknesses identified should be documented in the EP section of the inspection report.  Where exercises or drills are inspected, the intent is to inspect performance and not just the critique process, as is done during baseline inspection.  While the licensee critique capability may be reviewed, weaknesses and deficiencies or other performance issues should be identified in the inspection report as stated above.  Licensee corrective action program identifying numbers may be included in the report to assist in future verification that problems have been corrected.

Inspection requirements 02.01 and 02.02 below are to be implemented for each inspection. Other inspection requirements may be judged as unnecessary to meet the inspection objectives by the assigned inspector and appropriate management. 

02.01 Inspection Preparation.

a. Review the EP inspection record, including relevant resident inspector  reports.  Identify any findings (or comments) that may be relevant to the current program problems.   Determine elements of Inspection Procedures 82001 and 71114 that have been recently implemented and whether the inspection findings are still relevant to the current program problems.

b. Review the EP related requirements of Inspection Procedure 95003 and 95003.01.  Determine, with management assistance, which of the requirements of 95003.01 may not be necessary to meet the inspection objectives.  Develop an inspection plan to cover the appropriate requirements. 

c. Review the Emergency Plan (Plan).  Develop an understanding of licensee commitments which implement planning standards and the guidance of NUREG-0654. 

d. Review the recent (e.g., 2-3 years) history of Plan changes against 10 CFR 50.54(q) for any potential decrease in effectiveness of the Plan.   Request that the licensee make available all applicable 50.54(q) determinations.  Include review of any concerns in the inspection plan.   

e. Inspection requirements 02.02 a, b, & c below are to be performed prior to arrival at the site, where practical. 

f. It may be appropriate to select a RSPS for in-depth review, IAW 02.07 below.  This determination is left to the inspector and appropriate management. 

g. To the extent practical, the inspection should be focused on those areas that have the potential to result in findings that are white or greater. 

02.02Correction of Weaknesses and Deficiencies. 

a. Review recent (e.g., 2-3 years) licensee corrective action documentation.   Identify problems of a similar nature and any that relate to the reasons for the degraded cornerstone.  Also review assessments performed by organizations not directly responsible for EP, such as QA or nuclear oversight departments.  Where trends or significant problems are identified, evaluate the adequacy of the licensee’s extent of condition and/or common cause analyses.  Review licensee disposition of corrective actions.  

b. Review licensee drill, exercise and EP related training critiques.  Review critiques for all recent (e.g., 2-3 years) actual events.   Determine if critiques have been adequate and review the disposition of corrective actions. 

c. Review corrective actions as related to current problems.   Include a review of the closure of any green findings in the past two years. 

d. Implement Inspection Procedure 71114.05, “Correction of Emergency Preparedness Weaknesses and Deficiencies”.  Extend the inspection effort to review licensee support of and interface with offsite agencies and determine that the 50.54(t) reviews have been made available to appropriate agencies.  

e. Review a robust sample of findings which include all facets of EP.  Review several closed corrective actions through completion, including verification of equipment/facility corrections, EPIP revisions, training program changes and interviews with personnel whose performance was corrected.

f. Determine if the corrective action program has been effective in identifying and resolving EP problems.  Identify any failures and place them in context through the significance determination process (SDP).  Identify corrective actions that could have positively affected the areas of current concern if implemented in a more effective manner, even if the poor corrective action is not a finding per SDP.

02. 03ERO Readiness. The inspection requirements under 95003-02.03 may be sufficient if ERO readiness was not identified as a contributing factor to the cornerstone degradation.  However, if ERO readiness was a contributing factor, the following requirements may apply.

a. Implement Inspection Procedure 71114.03, “Emergency Response Organization Augmentation Testing,” and perform the initial review of the ERO augmentation system design.  Determine if the licensee system for augmentation is adequate. 

b. If the augmentation program review performed above does not provide assurance that augmentation can support activation goals, or if past problems lead inspectors and management to doubt the ability to augment, request that the licensee perform an augmentation test that includes actual “report-in” by responders.  Performance of this test should be coordinated well in advance with the licensee.  Review results of the report-in test and determine if the licensee system for augmentation is adequate. 

c. Review licensee plan commitments for on shift response personnel and the administrative mechanisms to ensure shifts are adequately staffed.  Review immediate and long term corrective actions where problems occurred (e.g., licensee immediate corrective actions when on-shift required personnel call out sick.) 

02.04Facilities and Equipment. The inspection requirements under 95003.01-02.02, “Correction of Weaknesses and Deficiencies” includes review of facilities and equipment through the review of corrective actions.  This may be sufficient if facilities and equipment were not a significant contributing factor to the cornerstone degradation.  Otherwise, implement the requirements of Inspection Procedure 82001.04 “Facilities and Equipment.”

02.05Procedure Quality. The inspection requirements under 95003.01-02.02, “Correction of Weaknesses and Deficiencies” includes review of EPIP changes through the review of corrective actions.  This may be sufficient if EPIPs were not a significant contributing factor to the cornerstone degradation.  Otherwise, implement the requirements of Inspection Procedure 82001.05 “Procedure Quality.”

02.06ERO Performance.

a. Implement ERO Performance-Drills, as described in Inspection Procedure 82001.  Where this attachment is being implemented, the sample size for those drills should be increased to include a majority of staff ERO decision makers and half of shift crews. 

b. Review training program guidance documents.  Determine compliance with 10 CFR 50.47(b)(15) and appendix E to 10 CFR 50, section IV, F.

c. Review training program content, e.g., lesson plans,  to determine that the information necessary to provide the ERO with a knowledge base to implement the Plan is present.  Determine compliance with 10 CFR 50.47(b)(15) and appendix E to 10 CFR 50, section IV, F.

d. Review training program conduct, including the experience and qualifications of training personnel.  Review EP instructor certification status.  Determine compliance with the Plan or other training commitments.  

e. Review the corrective action program as it relates to training problems.  Determine if the training program has been effectively used to resolve performance problems.

f. Observe the conduct of training, if possible.  Determine compliance with the Plan.

g. Review training records to ensure ERO members have received required training, including respirator use training and qualifications.  Determine compliance with regulations and the Plan.

h. ERO Performance-Drills will be conducted to address performance in the RSPS.  However, where performance problems encompass other planning standards, performance-drills may be appropriate to review the level of licensee proficiency in those areas.

i. Where licensee EP response performance is a contributing factor to the degraded cornerstone status a licensee may elect to conduct an exercise of sufficient scope to demonstrate the proficiency of the emergency response organization. This may also be preferable where significant management or staff changes have resulted in an ERO that has not demonstrated the capability to implement the Plan and where program performance problems bring into question licensee capability to implement the Plan.  Where such a demonstration exercise is appropriate, Inspection Procedure 82001. 06 should be implemented.

j. Appendix E to 10 CFR 50, section IV, F, 2, f; discusses requirements regarding remedial exercises.  Where the performance of a licensee is such that the NRC determines that an evaluated exercise is not an adequate test of the Emergency Plan such that reasonable assurance can not be verified, it is appropriate to have the licensee perform a remedial exercise.  The inspection of this exercise should be performed using Inspection Procedure82001.06.

02.07In-Depth Review of RSPS.

a. An in-depth review of a RSPS is appropriate if failure to comply with a PS contributed to the degraded cornerstone status. The selection of the RSPS should be based on past problems and/or current concerns as well as support the NRC extent of condition determination. 

b. Review the implementation of the applicable regulations and regulatory guidance in the Plan, procedures and training program.

c. Where appropriate, determine that the knowledge base of responders is sufficient to implement the RSPS.  This may be accomplished as a portion of the performance-drills.

d. Review corrective actions in the RSPS.  This may be accomplished as a portion of the corrective action program review.

02.08 Offsite EP.  There are no inspection requirements associated with this Key Attribute for NRC inspectors.  Evaluation of offsite EP is performed by the Federal Emergency Management Agency.  However, inspection of licensee support of and interface with offsite agencies is performed (95003.01-02.02.)

95003.01-03INSPECTION GUIDANCE

03.01Inspection Preparation

a. No specific guidance.

b. It may be helpful to re-review the inspection objectives in 95003.01 and 95003.01 when determining which of the inspection requirements are appropriate (where this determination is left to judgment).  The inspection should be designed to support the determination whether the licensee has the expected level of EP capability and to assure the absence of findings greater than white. 

c. No specific guidance.

d. The licensee is required to maintain DIE determinations for Plan changes for 3 years.  These may be requested to facilitate the review.  For determinations older than 3 years, the licensee may be asked for justification.  

e. No specific guidance.

f. The RSPS may be selected based on past problems or current concerns.  This requirement may be based on the type and extent of problems.  This element should be performed where there is concern as to the efficacy of the licensee extent of condition or where needed to support NRC’s extent of condition efforts.

g. This inspection is to determine the extent of condition of problems in the EP Cornerstone.  This being the case, the inspection should focus on assuring that the RSPS are being met, e.g., the absence of yellow findings due to the functional failure (failure to meet) a RSPS.  Requirement 02.07 can contribute to this effort as can the performance-drills.  While the inspection should include review of other areas, the extent of condition WRT the RSPS is the highest priority.  Other areas should be prioritized IAW the priority guidance of Inspection Procedure 71114 and knowledge of program problems. 

The inspection should result in information that will allow an assessment of licensee progress toward program improvements and verify the capability to implement the Plan to protect public health and safety.  The extent of condition determination WRT the absence of yellow findings will support this effort. 

03.02Correction of Weaknesses and Deficiencies.

a. The status and history of the performance indicators should also be reviewed.  If the PI values have crossed the green band threshold, the reasons may provide relevant information and may be reviewed. 

b. No specific guidance.

c. A failure of corrective actions to absolutely eliminate reoccurrence of a performance problem may not necessarily be a failure of the program.  The green band threshold for the performance indicators would suggest that a failure rate of 10% for the activities measured (classification, notification and PAR development) is within the licensee response band.  However, during implementation of this procedure, (degraded cornerstone plant,) failure rates should be reviewed to determine if failures are concentrated in one area or with one set of responders.  It may be appropriate for the inspector to perform an in depth review of problem resolution to determine if corrective actions have been appropriate. Criteria for determination of a failure of the corrective action program is provided in IMC 0609 Appendix B, “Emergency Preparedness SDP.” 

d. NRC inspection may include licensee interface with and support of offsite agencies and but not the performance of the agencies themselves.  The distribution of the 50.54(t) review, adequacy of EOF accommodations and distribution of public information may be inspected.  The inspection may be conducted via a phone interview with appropriate officials.  

e. The selection of the robust sample could include subjects relevant to each planning standard or could be organized by areas such as: procedures, training, facilities, equipment, communications equipment, performance, staff augmentation, Plan changes, dose assessment, classification, notification, PAR development, sirens, worker protection, etc.  Another list of EP areas for consideration is suggested in Inspection Procedure 71114.  Inspection Procedure 71114.05 provides guidance for verifying completion of corrective actions through physical verification. 

f.No specific guidance.

03.03 ERO Readiness.  This key attribute is predicated on planning standard 10 CFR 50.47(b)(2), Appendix E to 10 CFR 50, section E, IV, C and commitments in the Emergency Plan which reflect the guidance of NUREG-0654. 

a. No specific guidance.

b. There is no regulation that requires a “report-in” augmentation test.  However, this test may be the most effective way to end concerns regarding augmentation.  If successful, the test verifies the capability and if there are problems, it bounds the area of concern.  It may be that this test is in the best interests of the licensee and NRC in addressing augmentation issues.  It may be appropriate for a regional manager to make the request, rather than the inspector.  The request should allow ample time for the licensee to coordinate the “report-in” drill.  Inspection Procedure 82001.03 contains guidance on the design and inspection of a “report-in” test.  This test should be performed at a convenient time, but after normal work hours.  The timing of the test must be unannounced to the responders, although the need for such a test and the scope of the drill itself may be communicated.  NRC inspectors should be cognizant of such communications to ensure the test will remain valid.  Management, local authorities or other appropriate personnel/agencies may be informed of the test if deemed necessary, as long as the test remains a valid indicator of the ability of the licensee to augment on-shift staff. 

c. Licensee provisions for shift staffing and augmentation may be found in the Emergency Plan and should be commensurate with the goals in Supplement 1 to NUREG-0737 and NUREG 0654.  It may be appropriate to also review fire brigade staffing requirements.  In addition, administrative mechanisms to ensure the required personnel are on shift or called in when necessary should be reviewed.

03.04Facilities and Equipment.  This key attribute is predicated on the following planning standards and requirements:

· 10 CFR 50.47(b)(5) [for the Alert and Notification System],

· 50.47(b)(6), Appendix E to 10 CFR 50, section IV, D [for communications equipment],

· 50.47(b)(8), Appendix E to 10 CFR 50, section IV, E [for facilities and equipment] and

· Commitments in the Emergency Plan which reflect the guidance of NUREG-0654.  

03.05Procedure Quality.  The sample size for reviewing EPIP changes is based on judgment and the nature of problem area.  A large sample or even all changes for a period of time may be appropriate.

03.06ERO Performance.

a. No specific guidance.

b. No specific guidance.

c. Compliance with training program requirements may also be determined.   Although such review may not result in findings, identified weaknesses may support the extent of condition determination.  A sample of lesson plans may be reviewed against EPIPs and the Plan to ensure adequate content.  

d. The body of Inspection Procedure 95003 contains additional guidance.

e. No specific guidance.

f. No specific guidance.

g. No specific guidance.

h. The guidance of Inspection Procedure 82001 may be generally applied for the development and conduct of performance-drills in areas other than the RSPS.  An example of this kind of drill would be an OSC drill to evaluate the licensee ability to issue and protect damage control teams.  

i. The inspection requirement is phrased in terms of “requesting” that the licensee conduct an evaluated exercise.  There are situations where an evaluated exercise is in the interests of both NRC and the licensee because it could demonstrate clearly that the licensee is capable of implementing the Emergency Plan.  An evaluated exercise may be the most expeditious method to resolve issues because if the implementation is fully successful, it demonstrates a continuation of reasonable assurance.  Alternatively, if areas of weakness are identified the inspection bounds the problems and clarifies the corrective actions necessary to restore the EP Cornerstone.

This exercise could be designed to focus on problem areas, if appropriate.  Offsite participation is not expected in such an exercise.  The need for offsite participation would be determined by FEMA.  It may be acceptable to use the next regularly scheduled drill for the purposes of the requested evaluated exercise, if it is of sufficient scope and the timing is compatible with resolution of EP cornerstone issues.  Regional management may make these determinations.  

As noted elsewhere, this exercise would not be evaluated under the baseline inspection program procedures, but would evaluate performance directly.  Inspection Procedure 82001.06 provides guidance on inspection of such exercises. 

j. This inspection requirement represents a situation where the licensee is directed to conduct a remedial exercise.  As noted in the inspection requirements, this exercise would not be evaluated under the baseline inspection program procedures, but would use Inspection Procedure82001.06. 

03.07In-Depth Review of RSPS.

a. The in-depth review is optional based on inspector and management inspection planning and supporting NRC efforts to determine extent of condition.  However, if the degraded cornerstone problem is related to a RSPS, the review is recommended.  The review can contribute to the inspection objective 01.04 (“To the extent practical, verify the absence of findings greater than white by determining the extent of condition of problems in the EP Cornerstone,”) if the review is in-depth and does not identify a RSPS functional failure.

b. No specific guidance.

c. It may be useful to interview responders to determine their knowledge base for implementing the RSPS. Memorization of requirements should not be expected, but the responder should demonstrate the ability to find and use the applicable EPIPs and know responsibilities.  The inspection should be designed to discern individual responder problems from wide spread lack of preparedness.  

d. No specific guidance.

03.08Offsite EP.  This key attribute is included for completeness, but NRC inspection responsibilities are limited in this area.  The Federal Emergency Management Agency is responsible for assessment of State and local EP programs that support nuclear plants.  That being the case, NRC will only support FEMA efforts as requested and there are no inspection requirements applicable to this key attribute that will be directly implemented by NRC inspectors. 

END

Revision History for IP 95001.01

Issue Date: 01/15/09- 10 -95003.01