**NRC INSPECTION MANUAL**	IRAB

INSPECTION MANUAL CHAPTER 0305

# OPERATING REACTOR ASSESSMENT PROGRAM

Issue Date:  XX/XX/XXXX		0305

table of contents0305-01	PURPOSE	10305-02	OBJECTIVES	10305-03	APPLICABILITY	10305-04	 DEFINITIONS	20305-05	RESPONSIBILITIES AND AUTHORITIES	405.01	Executive Director for Operations (EDO).	405.02	Director, Office of Nuclear Reactor Regulation (NRR).	405.03	Regional Administrator (RA).	405.04	Director, Office of Public Affairs (OPA).	405.05	Deputy Director, Division of Reactor Oversight (DRO)	405.06	Regional Director, DRP, DRS, DORS, or DRSS.	505.07	Director, Office of Enforcement (OE)	505.08	Director, Office of Investigations (OI).	505.09	Director, Office of Research (RES).	505.10	Director, Office of Nuclear Security and Incident Response (NSIR).	505.11	Director, Office of Nuclear Material Safety and Safeguards (NMSS).	505.12	Director, Division of Operating Reactor Licensing (DORL).	605.13	Chief, Reactor Assessment Branch (IRAB), NRR/DRO.	605.14	Regional Branch Chief.	60305-06	ASSESSMENT PROCESS OVERVIEW	60305-07	PERFORMANCE REVIEWS	607.01	Continuous Review.	607.02	Quarterly Review.	707.03	End-of-Cycle Reviews.	907.04	End-of-Cycle Summary Meeting.	140305-08	PROGRAM REVIEWS	1508.01	Agency Action Review Meeting.	1508.02	AARM Commission Meeting.	150305-09	PUBLIC STAKEHOLDER INVOLVEMENT	1509.01	Scheduling.	1509.02	Preparation.	1609.03	Conduct.	170305-10	ROP ACTION MATRIX	1810.01	Description of the Action Matrix.	1810.02	Expected Responses for Performance in Each Action Matrix Column.	19a.	Licensee Response Column (Column 1)	19b.	Regulatory Response Column (Column 2)	19c.	Degraded Performance Column (Column 3)	20d.	Multiple/Repetitive Degraded Cornerstone Column (Column 4)	21e.	Unacceptable Performance Column (Column 5)	23f.	IMC 0350 Process Column	240305-11	ADDITIONAL ACTION MATRIX GUIDANCE	2511.01	Inspection Findings	2511.02	Performance Indicators	2711.03	Other Action Matrix Input Considerations	2811.04	Supplemental Inspections.	2911.05	Treatment of Items Associated with Enforcement Discretion	3111.06	Action Matrix Deviations	340305-12	TRANSITIONS BETWEEN OVERSIGHT PROCESSES	3512.01	Transitioning to the IMC 0350 Process.	3512.02	Transitioning out of the IMC 0350 Process	3612.03	Transitioning out of the ROP for Decommissioning Units	3712.04	Transitioning from New Construction to the ROP	370305-13	TRADITIONAL ENFORCEMENT FOLLOW-UP	3813.01	Traditional Enforcement in the Assessment Process	3813.02	Traditional Enforcement Follow-up Inspections	380305-14	CROSS-CUTTING ISSUES	3914.01	Cross-Cutting Themes	3914.02	Opening Cross-Cutting Issues	4114.03	Closing Cross-Cutting Issues	4114.04	Follow-up Actions for Cross-Cutting Issues	420305-15	REFERENCES	43Figure 1: Reactor Oversight Process Action Matrix	Fig1-1Figure 2: Assessment Activities	Fig2-1Figure 3: Reactor Oversight Process	Fig3-1Figure 4: Regulatory Framework	Fig4-1Attachment 1: Revision History for IMC 0305	Att1-1

List of Non-public exhibits available from the ROP Sharepoint website:

Exhibit 1: Schedule of Annual Assessment Cycle Events

Exhibit 2: End-of-Cycle Review Meeting Agenda Template

Exhibit 3: Plant Performance Summary Template

Exhibit 4: Assessment Follow-Up Letter Template

Exhibit 5: Eliminated

Exhibit 6: Annual Assessment Letter Template

Exhibit 7: Cross-Cutting Issues Excerpt Templates

Exhibit 8: Deviation Notification Letter and Request for Deviation Memorandum Templates

Exhibit 9: Non-Public Security Inspection Plan Letter Template

Exhibit 10: 	DRO End-of-Cycle Observation Form

Exhibit 11: 	Notification Letter Transitioning Decommissioning Units out of the ROP Template

Exhibit 12: 	Template for Inspection Plan Transmittal Letter

Issue Date: 05/04/23	iii	0305

# 0305-01	PURPOSE

01.01	The Operating Reactor Assessment Program evaluates the overall performance of operating commercial nuclear reactors and communicates this information to licensee management, members of the public, and other stakeholders. The Assessment Program is part of the Reactor Oversight Process (ROP), which integrates the U.S. Nuclear Regulatory Commission’s (NRC’s) inspection, performance indicator, assessment, and enforcement programs applicable to operating reactors.

01.02	The Operating Reactor Assessment Program collects information from inspections and performance indicators (PIs) to enable the NRC to develop objective conclusions about a licensee’s safety performance. Based on this assessment information, the NRC determines the appropriate level of its response, such as performing supplemental inspections, conducting meetings with NRC and licensee management, or issuing orders to shutdown plants. The assessment information and NRC response are then communicated to the public, except for certain security-related information associated with the Security Cornerstone that the Commission has determined to withhold from public disclosure. The NRC conducts follow-up actions, as applicable, to ensure that the corrective actions designed to address performance issues were effective.

# 0305-02	OBJECTIVES

02.01	To collect information from inspection findings and PIs.

02.02	To arrive at an objective assessment of licensee safety performance using inspection findings and PIs.

02.03	To assist NRC management in making timely and predictable decisions regarding appropriate NRC actions used to oversee, inspect, and assess licensee performance.

02.04	To provide a method for informing the public and soliciting stakeholder feedback on NRC’s assessment of licensee performance.

02.05	To provide a process to follow up on areas of concern.

# 0305-03	APPLICABILITY

This inspection manual chapter (IMC) applies to all operating commercial nuclear reactors except those sites that are under IMC 0350, “Oversight of Reactor Facilities in a Shutdown Condition Due to Significant Performance and/or Operational Concerns.” The contents of this IMC do not restrict the NRC from taking any necessary actions to fulfill its responsibilities under the Atomic Energy Act of 1954, as amended. A power reactor is no longer subject to this manual chapter after a licensee submits a written certification to cease operation in accordance with 10 CFR 50.82(a).

# 0305-04		DEFINITIONS

04.01	Action Matrix. A table (i.e., Figure 1) that categorizes various levels of plant performance and identifies the range of NRC and licensee actions and the appropriate level of communication for these various levels of performance.

04.02	Action Matrix Deviation. Any regulatory action taken that is inconsistent with the range of actions described in the pertinent column of the Action Matrix, as described in detail in section 11.06.

04.03	Action Matrix Inputs. Inspection findings and parallel PI findings that are used to determine a plant’s Action Matrix column.

04.04	Annual Assessment Cycle. The assessment period from January 1st through December 31st of each year.

04.05	Assessment Inputs. Information considered in the assessment process to determine appropriate NRC actions.

04.06	Assessment Letter. A letter from the NRC to a licensee that communicates assessment-related information. Assessment letters include assessment follow-up letters, and annual assessment letters.

04.07	Assessment Period. A period that contains four full consecutive calendar quarters. An end-of-cycle assessment period is the annual assessment cycle from January 1st to December 31st.

04.08	Cross-Cutting Area. Defined in IMC 0310, “Aspects within the Cross-Cutting Areas.”

04.09	Cross-Cutting Aspect (CCA). Defined in IMC 0310.

04.10	Cross-Cutting Issue (CCI). A CCI is a cross-cutting theme which has been identified in at least three consecutive assessment letters.

04.11	Cross-Cutting Theme. For the cross-cutting areas of problem identification and resolution (PI&R) and human performance (HU), a cross-cutting theme is reached when six findings with the same CCA exist in the four quarters assessed during the second quarter review and end-of cycle assessment period. For the Safety Conscious Work Environment (SCWE) area, a theme exists with one finding in an 18-month assessment period, or under circumstances described in section 14. A cross-cutting theme also exists when there are at least 20 findings in the Human Performance area or at least 12 findings in the PI&R area during the second quarterly assessment review or end-of-cycle assessment period.

04.12	Degraded Cornerstone. A cornerstone that has three or more White inputs concurrently or one Yellow input.

04.13	IMC 0350 Process. An oversight process that oversees licensee performance, inspections, and restart efforts for plants in shutdown conditions with significant performance and/or operational concerns.

04.14	IMC 0375 Process. Provides guidance for implementation of the ROP for plants in an extended shutdown condition for reasons not related to performance.

04.15	Multiple Degraded Cornerstones. Two or more cornerstones that are degraded concurrently for any period of time.

04.16	Nuclear Safety Culture. Defined in NUREG-2165, “Safety Culture Common Language.”

04.17	Old Design Issue. An inspection finding involving a past design-related problem in the engineering calculations or analyses, the associated operating procedure, or installation of plant equipment that does not reflect a performance deficiency associated with existing licensee programs, policy, or procedures.

04.18	Parallel PI Finding. A finding issued at the same significance level of a safety-significant PI that acts as the Action Matrix input. This would be captured as an FIN within RPS with no violation, SDP, or enforcement fields.

04.19	Plant Performance Summary (PPS). A document prepared by the regional offices and used during the end-of-cycle meeting and Agency Action Review Meeting (AARM) (if applicable) that describes assessment inputs and other pertinent information used to develop a conclusion about a plant’s safety performance.

04.20	Regulatory Performance Meeting. A meeting held between a licensee and the NRC to discuss corrective actions associated with safety-significant Action Matrix inputs.

04.21	Repetitive Degraded Cornerstone. A cornerstone that is degraded (three open White inputs or one open Yellow input in a single cornerstone) for more than five consecutive quarters with: (1) four or more concurrent White inputs (the additional White input(s) can be from any cornerstone), or (2) one Yellow and one concurrent White input (the additional White input can be from any cornerstone).

04.22	Safety-Conscious Work Environment. A work environment where employees feel free to raise safety concerns and where concerns are promptly reviewed, given the proper priority based on their potential safety significance, and appropriately resolved with timely feedback to the originator of the concerns and to other employees."

04.23	Safety Culture. Refer to “Nuclear Safety Culture.”

04.24	Safety Culture Assessment. A comprehensive evaluation of the assembly of characteristics and attitudes related to all of the safety culture attributes described in NUREG-2165. Individuals performing the evaluation can be qualified through experience and formal training.

a. An independent safety culture assessment is one performed by qualified individuals that have no direct authority and have not been responsible for any of the areas being evaluated (for example, staff from another of the licensee’s facilities, or corporate staff who have no direct authority or direct responsibility for the areas being evaluated).

b. A third-party safety culture assessment is one performed by qualified individuals who are not members of the licensee’s organization or utility operators of the plant (licensee team liaison and support activities are not team membership).

04.25	Safety-Significant. Having greater than very low (i.e., Green) safety significance.

04.26	Significance Determination Process (SDP). The process described in IMC 0609 and associated appendices that is applied to an inspection finding to determine its safety or security significance as either Green (very low), White (low-to-moderate), Yellow (substantial), or Red (high).

# 0305-05	RESPONSIBILITIES AND AUTHORITIES

## 05.01	Executive Director for Operations (EDO)

a. Oversees the activities described in this IMC.

b. *Approves all Action Matrix deviations*. [C1]

c. *Informs the Commission of all approved Action Matrix deviations*. [C1]

## 05.02	Director, Office of Nuclear Reactor Regulation (NRR)

a. Implements the requirements of this IMC within NRR.

b. Develops assessment program policies and procedures.

c. Ensures uniform program implementation and effectiveness.

d. Concurs on regional requests for Action Matrix deviations.

## 05.03	Regional Administrator (RA)

a. Implements the requirements of this IMC within its respective region.

b. Develops and issues assessment letters to each licensee.

c. Conducts assessment reviews and directs allocation of inspection resources within the regional office based on the Action Matrix.

d. Establishes a schedule and determines a suitable location for involvement of the public in the discussion of the results of the NRC’s annual assessment of the licensee’s performance to ensure a mutual understanding of the issues discussed in the annual assessment letter.

e. Suspends the end-of-cycle performance review for those plants that have been transferred to the IMC 0350 process.

f. Chairs the end-of-cycle review meetings.

g. Initiates requests for Action Matrix deviations.

## 05.04	Director, Office of Public Affairs (OPA)

Issues press releases following the completion of the end-of-cycle reviews.

## 05.05	Deputy Director, Division of Reactor Oversight (DRO)

a. Develops assessment program guidance.

b. Collects feedback from the regional offices and assesses execution of the Operating Reactor Assessment Program to ensure consistent application.

c. Recommends, develops, and implements improvements to the Operating Reactor Assessment Program.

d. Provides oversight of the end-of-cycle review meetings.

e. Confers with regional offices to align on proposals to not count old design issues in the assessment process.	

f. Confers with the regional offices to align on the supplemental inspection plans for plants in Column 4 of the Action Matrix.

## 05.06	Regional Director, Division of Reactor Projects (DRP), Division of Reactor Safety (DRS), Division of Operating Reactor Safety (DORS), or Division of Radiological Safety and Security (DRSS)

a. Approves proposals by the regional offices to not count an old design issue in the assessment process.	

b. Approves the supplemental inspection plans for plants in Column 4 of the Action Matrix.

## 05.07	Director, Office of Enforcement (OE)

a. Provides any significant insights from the enforcement program to the regional offices during the end-of-cycle review meetings.

b. Provides any significant insights from the NRC’s allegation program to the regional offices in preparation for the end-of-cycle review meetings for discussions related to the SCWE cross-cutting area.

## 05.08	Director, Office of Investigations (OI)

Provides any significant insights from OI to the regional offices during the end-of-cycle review meetings.

## 05.09	Director, Office of Research (RES)

Provides any significant insights from RES to the regional offices during the end-of-cycle review meetings.

## 05.10	Director, Office of Nuclear Security and Incident Response (NSIR)

Provides any significant licensee performance insights to the regional offices during the end-of-cycle review meetings, and as needed to ensure regulatory responses are appropriate.

## 05.11	Director, Office of Nuclear Material Safety and Safeguards (NMSS)

Provides any significant insights from NMSS to the regional offices during the end-of-cycle review meetings, and as needed to ensure regulatory responses are appropriate.

## 05.12	Director, Division of Operating Reactor Licensing (DORL)

Ensures operating reactor Project Managers provide significant insights from DORL to the regional offices during the end-of-cycle review meetings.

## 05.13	Chief, Reactor Assessment Branch (IRAB), NRR/DRO

For a period of up to two years after plants have exited Column 4 or the IMC 0350 process, concurs on all assessment letters describing NRC actions beyond those specified by the Action Matrix.

## 05.14	Regional Branch Chief

Responsible for continuously monitoring the performance of their assigned plants and discussing that performance at annual assessment meetings, reviewing performance indicator data, meeting with licensee management in regulatory performance meetings, and developing inspection plans consistent with plant performance in the Action Matrix.

# 0305-06	ASSESSMENT PROCESS OVERVIEW

Licensee performance is reviewed over a 12-month period as part of the Operating Reactor Assessment Program (Figure 2). The continuous assessment process includes the determination of a plant’s Action Matrix column, as described in sections 10, 11, and 12. The assessment process also includes performance reviews, as described in section 7, program reviews, as described in section 8, and public stakeholder involvement, as described in section 9. The performance reviews include traditional enforcement reviews, as described in section 13, and cross-cutting area reviews, as described in section 14. Figures 3 and 4 further illustrate how the assessment process is part of the ROP.

# 0305-07	PERFORMANCE REVIEWS

The assessment process consists of a series of reviews that are described below.

## 07.01	Continuous Review.

The resident inspectors and branch chiefs in each regional office continuously monitor the performance of their assigned plants using the results of inspection findings and PIs. Inspections are conducted on a continuous basis in accordance with IMC 2515, “Light-Water Reactor Inspection Program – Operations Phase,” and IMC 2201, “Security Inspection Program for Operating Commercial Nuclear Power Reactors,” and PIs are reported quarterly by licensees.

Between the normal quarterly assessments, the region may issue an assessment follow-up letter and address an issue in accordance with the Action Matrix if:

a. A safety-significant inspection finding is finalized (in this case, the assessment follow-up letter may be combined with the final SDP letter; Security Cornerstone findings are discussed below). The assessment follow-up letter should be issued within 2 weeks of issuance of the final SDP letter. The assessment follow-up letter need not be issued if a periodic (quarterly or annual) assessment letter including discussion of the issue will be issued within 4 weeks of final SDP letter issuance.

b. A finding will be closed after the appropriate supplemental inspection has been satisfactorily completed (in this case, the assessment follow-up letter may be combined with the inspection report cover letter).

For Security Cornerstone findings the assessment follow-up letter may be combined with the publicly available Security Cornerstone SDP letters or supplemental inspection reports. If the assessment follow-up letter is not combined with the Security Cornerstone SDP letters or supplemental inspection reports, then a separate publicly available assessment follow-up letter shall be issued. If the assessment follow-up letter is combined with another document as described above, ensure the document title includes “assessment follow-up letter,” to clearly communicate the assessment follow-up letter being combined with the other document.

An assessment follow-up letter shall also be issued to communicate that an Action Matrix deviation was issued or closed if not communicated in the annual assessment letter. The assessment follow-up letter should discuss planned actions and note applicable changes to the plant’s designation in the Action Matrix.

An assessment follow-up letter may also be issued after the second quarter to notify a licensee that a cross-cutting theme or cross-cutting issue (CCI) was identified. This letter can be combined with the inspection plan transmittal letter issued.

The assessment follow-up letter should be emailed to ROPassessment.Resource@nrc.gov. The ROP website will be updated as necessary to reflect the Action Matrix information discussed in the most recent assessment follow-up letter. Example assessment follow-up language can be found in Exhibit 4 (not publicly available). If security-related information, which is a type of Sensitive Unclassified Non-Safeguards Information (SUNSI), must be discussed in the assessment follow-up letter, it shall be provided to the licensee in a separate non-publicly available correspondence. Agency policy regarding SUNSI is provided in Management Directive 12.6, “NRC Controlled Unclassified Information (CUI) Program.” 

## 07.02	Quarterly Review

a. Requirements. Each region conducts a quarterly review for each plant using PI data submitted by licensees and inspection findings compiled over the previous assessment period. This review is conducted within five weeks following the conclusion of the first and third quarters of the annual assessment cycle and within seven weeks following the conclusion of the second quarter of the assessment period. The most recent quarter of PIs and applicable inspection findings shall be considered in determining NRC actions in accordance with the Action Matrix.

b. Preparation. The responsible regional DRP or DORS branch chief reviews the most recently submitted PIs, which should be submitted by the licensee 21 days after the end of the quarter, and the inspection findings contained in the plant issues matrix (PIM) to identify any performance trends. The branch chief shall use the Action Matrix to help identify if there are NRC actions that should be considered that are not already included in the existing inspection plan.

c. Conducting the quarterly review. The region determines the appropriate Action Matrix column for each plant and communicates the results to headquarters. The staff may become aware that a plant will reach a repetitive degraded cornerstone categorization prior to five consecutive quarters being exceeded. When the regional office determines that a plant will reach a repetitive degraded cornerstone, an assessment letter shall be issued after entering the sixth quarter stating that the changes to the planned actions are consistent with Column 4 in the Action Matrix unless a deviation is requested.

During the second quarter review, the staff shall review the PIM or Reactor Program System-Inspections (RPS-Inspections)/RRPS Reports/IR 12 Cross Cutting Aspect to determine if a cross-cutting theme or a CCI exists. The period of review should include the third and fourth quarters of the previous assessment year, and the first and second quarter of the current assessment year.

Additionally, for plants whose performance is in Column 4 of the Action Matrix, consideration shall be given at each quarterly review to engaging senior licensee and NRC management in discussions associated with (1) transferring the plant to the IMC 0350 process, (2) declaring licensee performance to be unacceptable in accordance with this IMC, and (3) taking additional regulatory actions (as appropriate). A discussion of this decision shall be documented in a quarterly assessment follow-up letter, annual assessment letter, or quarterly inspection report, as applicable.

d. Quarterly review output. The output of the quarterly review is a quarterly assessment follow-up letter, if applicable. Assessment follow-up letters are normally issued within two weeks after the quarterly review (a total of seven weeks after completion of the quarter, or nine weeks after completion of the second quarter) for any new safety-significant PIs or inspection findings. The licensee does not have to change Action Matrix columns for an assessment follow-up letter to be issued. New inputs, such as a White PI reported during the quarterly review, should be documented in an assessment follow-up letter even if the licensee does not change columns because they are already in a higher column due to an existing open Action Matrix input. Assessment follow-up letters should also be issued to communicate that a licensee has a cross-cutting theme or cross-cutting issue. If, based on the continuous review, as discussed above, the region issued an assessment follow-up letter for inspection findings, PIs, or Action Matrix deviations during the past quarter, then a subsequent quarterly assessment follow-up letter is not needed if its only purpose is to reiterate issues that had been previously communicated to the licensee. If there are significant changes in the inspection plan for a plant in Column 4 of the Action Matrix, the regions should issue a separate assessment follow-up letter to ensure the licensee is aware of these changes. A quarterly assessment follow-up letter is not required unless for the reasons described above or to communicate the opening or closing of an Action Matrix deviation. The quarterly assessment follow-up letter should be emailed to ROPassessment.Resource@nrc.gov. If security-related information, which is a type of SUNSI, must be discussed in the quarterly assessment follow-up letter, it shall be provided to the licensee in a separate non-publicly available correspondence. For example, regions can reference a final SDP letter previously issued that explains any greater-than-Green security issues. 

If during the second quarter review it is determined that the licensee has met the criteria for a cross-cutting theme, a continuing cross-cutting theme, or a CCI, the theme or CCI will be documented in an assessment follow-up letter. Refer to section 07.03.d.5 when documenting a cross-cutting theme or CCI.

After the second quarter review, an updated inspection plan consisting of approximately 24 months (from the end of the second quarter) of inspection activities should be issued to licensees within nine weeks of the end of the second quarter as a separate correspondence utilizing the inspection report numbering as described in IMC 0306 (See Exhibit 12, Inspection Plan Transmittal Letter). The inspection plan consists of RPS-Inspections/RRPS Reports/IP 22 Inspection Activity Plan Report. Updated security inspection plans should be included in the Report 22 and need not be transmitted via separate correspondence.

For a plant in Column 4 of the Action Matrix, documentation of the date of NRC’s quarterly review and discussion of NRC decision regarding transferring the plant to the 0350 process, for the unacceptable performance column, or taking any additional regulatory actions is required. The documentation can be in a quarterly assessment follow-up letter, annual assessment letter, or quarterly inspection report, as applicable.

## 07.03	End-of-Cycle Reviews

a. Requirements. Each regional office conducts an end-of-cycle review for each plant using PIs (including those applicable to the last quarter of the assessment period), inspection results, and enforcement actions compiled over the assessment period. The end-of-cycle review should also include a discussion of any open items (e.g., Licensee Event Reports (LERs), etc.). The regional office may also consider insights documented in the most recently issued biennial problem identification and resolution inspection report. The review meeting will be completed within seven weeks after the end of the last quarter of the assessment period. Additional activities include planning inspection activities for approximately 24 months following the end of the assessment period, discussing site performance in the cross-cutting areas, and determining if any traditional enforcement follow-up inspections are necessary. The end-of-cycle review also serves as input to support the End-of-Cycle Summary Meeting and the AARM. See sections 07.04 and 08.01 respectively for more information.

*The review shall consider the conclusions of any independent assessments of a licensee, such as Institute of Nuclear Power Operations (INPO) and International Atomic Energy Agency (IAEA) Operational Safety Review Team (OSART) inspections. The purpose of considering independent assessments is to provide a means of self-assessing the NRC inspection and assessment process. References to INPO conclusions will not be included in the assessment letters.* [C3]

The Action Matrix and assessment inputs will be used to determine the scope of NRC actions. The review and subsequent assessment letters should only discuss issues from inspections that were completed during the applicable assessment period.

b. Preparation. In preparation for the assessment review meetings, the regional offices shall:

1.	Develop a meeting agenda. The meeting agenda shall identify the areas that should be addressed by the regional offices for all plants except those for which a PPS is required. A single written agenda outlining planned discussion topics is sufficient to conduct the meeting. Exhibit 2 provides a sample agenda for Column 1 and 2 plants. Treat the meeting agendas as draft and pre-decisional, and apply the NRC’s SUNSI handling requirements, as necessary. At the conclusion of the assessment meetings, the regional office shall add the end-of-cycle agendas and plant performance summaries for all plants to the NRCs Agencywide Documents Access and Management System (ADAMS) to save them as agency records. They should be treated as internal documents and profiled as non-publicly available.

2.	Compile the PIM (RPS-Inspections/RRPS Reports/IR 3 PIM), the results of the PIs, and the proposed inspection plan (RPS-Inspections/RRPS Reports/IP 22 Inspection Activity Plan Report) for each plant. Regions are not required to email this information to ROPassessment.Resource@nrc.gov

In reviewing the PIM, staff shall review findings for the past two years to determine if there are any programmatic trends that should be considered during the assessment meeting. Suggested areas of consideration are engineering areas (i.e., Criterion III, 50.59, 50.65), the corrective action program (Criterion XVI), procedures (Criterion V or Technical Specifications), and security. If there are an abnormally high number of findings in a given area, staff should consider using the information to inform the inspection sample selection for the next inspection cycle. The staff should document in the plant assessment package that the review was completed and whether or not a programmatic trend was identified. If a trend is identified, document if the trend warrants a focused inspection, e.g., a semi-annual PI&R trend review sample.

3.	Develop a PPS for those plants whose performance has been in Column 3, 4, or 5 of the Action Matrix during any quarter of the applicable assessment period. Also develop a PPS for those plants that may or will have new or continuing CCIs.

The PPSs will assist the regional offices in conducting the meeting and form the basis for the assessment letters. The final revision of these summaries will also be used at the End-of-Cycle Summary Meeting and serve as input to the AARM.

Treat the summaries as draft and pre-decisional, and apply the NRC’s SUNSI handling requirements, as necessary. 

The PPS should include (an example template can be found in non-publicly available Exhibit 3):

(a)	an operating summary

(b)	a performance overview (current overall assessment and previous assessment results)

(c)	inspection and PI results by cornerstones

(d)	other issues (e.g., cross-cutting issues, PI verification, and enforcement actions of any SL over the assessment period)

(e)	a proposed inspection plan

Prepare a plant-specific action matrix as an attachment to the PPS. The plant-specific action matrix should show the timeline and consideration of PIs and inspection findings in the assessment program and display the quarterly status of safety-significant inspection findings and PIs and the associated Action Matrix column over a sufficient timeline. The plant-specific action matrix does not need to be included in a PPS that is developed only for the purpose of discussing a CCI.

4.	Consider operating experience insights. Additional guidance is provided in IMC 2523, “NRC Application of the Reactor Operating Experience Program in NRC Oversight Process.”

c. Conducting the assessment review.

The end-of-cycle review meeting is chaired by the RA or designee. The regional division directors and/or branch chiefs present the results of the annual review to the RA or designee.

The regional DRP or DORS branch chiefs shall coordinate with the appropriate branch chiefs to provide adequate support for the presentation and the development of the inspection plan. Because some infrequently performed inspections require advance planning and preparation, the presentation and development of the inspection plan shall include consideration of any upcoming activities planned for the next two years that need to be inspected using the inspection procedures identified in IMC 2515, Appendix C, “Special and Infrequently Performed Inspections.” Examples of activities that should be considered include extended power uprates, steam generator replacements, reactor vessel head replacements, and significant digital upgrades. The station’s intent to perform these activities should be ascertained through discussion with the NRR PM or the resident inspectors.

Other participants should include applicable regional and resident inspectors, a representative from NRR/DRO, the regional allegations coordinator or the agency allegations advisor, and any other additional participants deemed necessary by the regional offices. The agency allegations advisor will provide any significant insights to the regional offices in advance of the assessment meeting to support meeting preparation. The DRO observer should complete Exhibit 10, “DRO End-of-Cycle Observation Form,” during the meetings to gather lessons learned.

Representatives from the Division of Operating Reactor Licensing (NRR/DORL) are expected to participate in the semi-annual assessment reviews. Representatives from OI, OE, NSIR, and RES should also participate if there are pertinent performance issues that should be factored into the performance for a particular plant. The role of the various headquarters participants during the assessment meeting is to provide: (1) an opportunity for these offices to share any significant insights into licensee performance over the course of the annual assessment period, (2) an independent validation of the regional office’s assessment of licensee performance from their office’s perspective, and (3) clarifying or ancillary remarks regarding ongoing or current issues under their cognizance. The licensing Project Manager, with the support of the technical staff, should be prepared to discuss significant performance concerns that may come to light through 10 CFR 2.206 petitions, licensing issues, or financial issues that are within the scope of NRC regulations. Inspectors should consider using the insights provided to develop the scope of inspections in areas of potential concern, balanced with risk insights, e.g., weak engineering support could be considered in Comprehensive Engineering Team Inspections (CETIs).

A senior reactor analyst (SRA) is not required to attend the meeting if the SRA’s insights on safety-significant performance issues have been provided before the meeting.

The average time allocated for each plant review is intended to be between 20 minutes and one hour. The time allotted per review should be consistent with the number and significance of plant issues.

For plants with several violations dispositioned through traditional enforcement during the assessment period, consideration should be given for conducting follow-up inspections utilizing IP 92722, “Follow Up Inspection For Any Severity Level I or II Traditional Enforcement Violation or for Two or More Severity Level III Traditional Enforcement Violations in a 12 Month Period,” or IP 92723, “Follow-Up Inspection for One Severity Level III and Two Severity Level IV Traditional Enforcement Violations or for Three or More Severity Level IV Traditional Enforcement Violations in the Same Area in a 12-Month Period,” if the licensee meets the criteria discussed in section 0305-13 of this manual chapter. Regions should consider only TE violations that involve willfulness, impeding the regulatory process, or which involve actual safety consequences when determining whether to discuss the need to perform a TE follow-up inspection. The decision to conduct one of these follow-up inspections should be made at the time a licensee meets the criteria. The decision to conduct one of these follow-up inspections should be made at the time a licensee meets the criteria. This decision should be discussed at the assessment meeting as part of the inspection plan and under licensee performance. The decision to conduct or not conduct one of these follow-up inspections should be documented in accordance with section 13.02 of this manual chapter.

When reviewing allegations, staff should be alert for trends that might be indicative of declining confidence in a licensee’s Employee Concerns Program (ECP). That information should be communicated to the biennial PI&R team for review.

d. End-of cycle review output.

The output of the end-of-cycle review is an annual assessment letter. The annual assessment letter shall be issued within nine weeks after the end of the end-of-cycle assessment period. Signature authority for the annual assessment letter is determined by the most significant column of the Action Matrix that the plant has been in during the end-of-cycle assessment period. A four-quarter look-back to determine signature authority is warranted because these letters support the EOC Summary Meeting and the AARM. If a plant has an open deviation memo, the RA or designee should have signature authority for the end-of-cycle letter.

If security-related information, which is a type of SUNSI, must be discussed in the annual assessment letter, it shall be provided to the licensee in a separate non-publicly available correspondence. For example, regions can reference a final SDP letter previously issued that explains any greater-than-Green security issues. 

The assessment letters shall contain:

Note: Publicly available discussion of Security Cornerstone issues will consist of indicating the existence of one or more greater-than-Green security inputs. Do not list the specific number, safety significance (i.e. White, Yellow or Red) or other more detailed information regarding Security Cornerstone Action Matrix inputs in publicly available assessment letters.

1.	A summary of safety-significant PIs and inspection findings for the applicable assessment period as well as discussion of previous action taken by the licensee and the NRC relative to these issues. Also discuss any actions to be taken by the NRC in response to safety-significant issues. The assessment letter shall note any changes in Action Matrix column status since the end of the previous assessment period.

Performance issues from previous quarters may be discussed if:

(a)	The NRC’s response to an issue had not been adequately captured in previous correspondence to the licensee.

(b)	These issues, when considered with assessment inputs from the most recent quarter, result in increased regulatory action per the Action Matrix that would not be apparent from reviewing only the most recent quarter’s results.

2.	A discussion of any Action Matrix deviations during the assessment period.

3.	For plants that have remained in Column 3 for three years or more, a discussion on why the plant has remained in this column for such a period of time and how the licensee plans to address the performance issues.

4.	For plants that are in Column 4, a discussion of the performance issues contributing to the plant being placed in this column and the licensee’s actions being taken to address the performance problems. The end-of-cycle letter should also document NRC’s decision regarding the need to transfer the plant to the 0350 process, or the unacceptable performance column, or to take additional regulatory actions.

5.	A qualitative discussion of CCIs, if applicable. The assessment letter shall document any cross-cutting themes and CCIs that are new, remaining open, or being closed.

(a)	The assessment letter shall include the following information for new CCIs: (1) the alpha-numeric identifier of the new CCI or the cross-cutting area (HU, PI&R, SCWE), if applicable, (2) the basis for the cross-cutting theme and CCI criteria being met, (3) the purpose of identifying a CCI, (4) the CCI closure criteria, and (5) a brief description of the region’s plans to follow-up on the CCI.

(b)	If a CCI is remaining open, the assessment letter shall include the following information: (1) the alpha-numeric identifier of the CCI or the cross-cutting area (HU, PI&R, SCWE), if applicable, (2) the date of the assessment letter(s) that opened and/or discussed the CCI, (3) the region’s basis for continuing the CCI, including a summary of the licensee’s progress in addressing the CCI, (4) the CCI closure criteria, (5) a brief description of the region’s plans to follow-up on the CCI, and 	(6) any requests for additional meetings with the licensee or safety culture assessments to be performed.

(c)	If a CCI is being closed, the assessment letter shall include the following information: (1) the alpha-numeric identifier of the CCI or the cross-cutting area (HU, PI&R, SCWE), if applicable, (2) the date of the assessment letter(s) that opened and/or discussed the CCI, and (3) the region’s basis for closing the CCI, including a summary of the licensee’s actions to address the CCI.

(d)	A statement that a cross-cutting theme exists if the licensee meets the criteria for a theme and has not yet met the criteria to be documented as a CCI. The letter should include a detailed discussion of any insights, NRC concerns with licensee performance in the area, if applicable, and any NRC decisions, with a basis for any decisions being made, and a brief description of cross-cutting theme followup actions taken or planned. See additional guidance for documentation in Exhibit 7.

6.	A discussion of any traditional enforcement follow-up inspection (i.e., IP 92702, 92722, or 92723) to be performed as an Appendix C type inspection, if applicable.

7.	A discussion of potentially safety-significant findings that are currently being evaluated by the SDP that may affect the inspection plan.

8.	An inspection plan consisting of approximately 24 months (from the end of the applicable assessment period) of activities. The inspection plan consists of RPSInspections/RRPS Reports/IP 22 Inspection Activity Plan Report. The Report 22 shall also include the updated plan for security inspections.

9.	If applicable, the letter should describe any impact to the inspection plan for plants subject to IMC 0375, “Implementation of the Reactor Oversight Process at Reactor Facilities in an Extended Shutdown Condition for Reasons Not Related to Performance.”

## 07.04	End-of-Cycle Summary Meeting

The End-of-Cycle Summary Meeting is conducted following the conclusion of the end-of-cycle review meetings to summarize the results of the end-of-cycle review with the Director, NRR, or another member of the NRR Executive Team.

a. Requirements. The End-of-Cycle Summary Meeting is an informational meeting whose purpose is for regional management to engage headquarters management to ensure awareness of:

1.	plants to be discussed at the AARM

2.	plants with significant performance issues

3.	plants with open Action Matrix deviations

4.	plants with a CCI for more than two consecutive assessment letters

5.	NRC actions already taken in response to plant performance

The End-of-Cycle Summary Meeting will be scheduled after the completion of the last regional end-of-cycle review. This meeting should occur after the completion of all the end-of-cycle meetings but before the issuance of the annual assessment letters, if possible.

b. Preparation. NRR/DRO/IRAB will start coordinating with the regional offices upon completion of the end-of-cycle meetings to identify plants that will be discussed at the End-of-Cycle Summary Meeting and draft an agenda.

c. Conducting the End-of-Cycle Summary Meeting. Each RA will lead the discussion for their region. The regional presentation should:

1.	Summarize the results of the end-of-cycle review for those plants whose performance in one or more quarters in the past twelve months has been in Column 3, 4, or 5 of the Action Matrix. RAs may discuss plants with performance issues considered to be at the threshold for more significant regulatory action (i.e., at risk of moving to Columns 3 or 4 of the Action Matrix.)

2.	Discuss plants that are in the IMC 0350 process.

3.	Present the results for those plants that have new or continuing CCIs.

4.	Discuss any open Action Matrix deviations, including their bases and actions required to close.

# 0305-08	PROGRAM REVIEWS

## 08.01	Agency Action Review Meeting

An AARM is conducted several weeks after issuance of the annual assessment letters. This meeting is attended by appropriate senior NRC managers and is chaired by the EDO or designee.

This meeting is a collegial review by senior NRC managers of:

a. the appropriateness of NRC actions for plants with significant performance issues based on data compiled during the end-of-cycle review and those that have moved into Column 4 or 5 of the Action Matrix during the first quarter of the year in which the AARM is held

b. the appropriateness of NRC actions concerning fuel cycle facilities and other materials licensees with significant performance problems

c. the results of the ROP self-assessment, *including a review of approved Action Matrix deviations* [C2]

Management Directive (MD) 8.14, “Agency Action Review Meeting,” includes a complete description of the meeting.

## 08.02	AARM Commission Meeting

The EDO will brief the Commission annually to convey the results of the AARM, *including a discussion of any ROP Action Matrix deviations*. [C2] The Commission should be briefed within approximately four weeks of the AARM, consistent with Commission availability, to ensure that the information presented is as current as possible.

# 0305-09	PUBLIC STAKEHOLDER INVOLVEMENT

## 09.01	Scheduling

Involvement of the public in the discussion of the results of the NRC’s annual assessment of the licensee’s performance can occur in various ways. The regional offices should use this opportunity to engage interested stakeholders on the performance of the plant and the role of the NRC in ensuring safe plant operations. Although the Security Cornerstone is included in the assessment process, the Commission has decided that specific information related to findings pertaining to the Security Cornerstone will not be publicly available to ensure that security information is not provided to a possible adversary. Therefore, security-related information other than what is publicly available in assessment letters, final significance determination letters and security inspection report cover letters will not be discussed during public meetings. If security-related information, which is a type of SUNSI, must be discussed during the meeting, it shall be discussed during a closed meeting, or during a closed session following a public meeting. 

For plants that have been in Column 3, 4, or 5 of the Action Matrix, involvement of the public in a meeting or some other appropriate venue should be scheduled within 16 weeks of the end of the assessment period. The 16-week guideline may occasionally be exceeded to accommodate the regional office or licensee’s schedule. For these plants, public involvement should include a formal public meeting with the licensee if one has not already been held to close out the performance issues.

For plants that have been in Column 1 or 2 of the Action Matrix during the entire assessment period, public stakeholder involvement should be scheduled during the year at a time that presents the best opportunity to effectively engage public stakeholders. Public stakeholder involvement can be a meeting tailored to the public, an open house for the public, poster sessions, virtual meetings, or other similar activities that allow the NRC to effectively engage public stakeholders. Participating in an event sponsored by another organization can be considered if such an event would maximize public engagement.

The region may decide whether the outreach activity should be conducted onsite or in the vicinity of the site. The outreach effort should be scheduled to ensure that it is accessible to members of the public. Two separate venues/events can be considered, such as a public assessment meeting with the licensee and a public event to discuss topics of local interest. In determining what type of event or forum to conduct, the regions should consider, among other things, plant performance, public interest in plant performance, any discussion the regions need to have with the licensee, and any other areas of public interest.

## 09.02	Preparation

The region shall notify: (1) those on distribution for the annual assessment letters of the opportunity for public involvement in the discussion of the results of the NRC’s annual assessment and (2) the media and state and local government officials of the event with the licensee and the issuance of the annual assessment letter. A meeting notice shall be posted at least 10 calendar days prior to any public meeting to discuss the annual assessment of licensee performance.

The region should consider the level of historical interest and performance issues, and should use the following additional tools, as appropriate, to inform members of the public of the event: press releases, advertisements in local newspapers, or letters soliciting attendance and/or interest to known parties.

The regions should also consider:

a. practice sessions before meetings/events. (Prior to the annual meeting(s), the region should map out a strategy for the public meetings for all the plants in the region and conduct preparation sessions for higher-profile meetings, as needed.)

b. using the sample assessment event slides available from the Assessment Program Sharepoint site (internal website not available to external stakeholders).

c. using the same NRC spokesperson(s) at more than one site to give a consistent message and developing standard responses to repeated questions.

The regions should also consult with the regional public affairs staff in determining the end-of-cycle meetings and/or events at each site. NRC management, as specified in the Action Matrix and determined by the most significant column that the plant has been in over the assessment cycle, should normally be involved at the event. For plants with heightened stakeholder interest, media inquiry, or contentious issues, regions should consider sending an appropriate level of management needed to respond to stakeholder interest and effectively conduct the meeting. For plants that have been in the Column 3, 4, or 5 of the Action Matrix and a formal public meeting has not been conducted (e.g., regulatory performance meeting after completion of a 95001, 95002, or 95003), a formal public meeting with the licensee is required, at a minimum.

Because security-related information is not discussed in public meetings as outlined in the preceding section, a formal public meeting is not necessary for plants that have been in Column 3, 4 or 5 solely as a result of security issues. These plants may also be required to meet with the Commission depending on the circumstances as discussed in section 10.02.

## 09.03	Conduct

The annual involvement of the public in the results of the NRC’s assessment of licensee performance is intended to provide an opportunity for the NRC to engage interested stakeholders on the performance of the plant and the role of the NRC in ensuring safe plant operations. Public involvement in the results of the NRC’s assessment of licensee performance should focus on topics of interest to the public. The format for the public involvement should not be limited to a formal type public meeting; it could be in an open house, a webinar, a round table discussion, or a poster board session. For higher-profile events, consideration should include NRC or non-NRC facilitators.

The annual assessment letters provide the minimum performance information that should be conveyed to interested stakeholders in a public meeting, if conducted. However, this does not preclude the presentation of additional plant performance information when placed in the proper context. The licensee, if present, should be given the opportunity to respond at the meeting to any information contained in the annual assessment letter. The licensee, if present, should also be given the opportunity to present to the NRC any new or existing programs that are designed to maintain or improve their current performance.

If the staff uses a formal public meeting format for public involvement, the meeting should be conducted as an observation meeting with the licensee. An important exception is that the meeting must be closed for such portions which may involve matters that should not be publicly disclosed under section 2.390 of Title 10 of the *Code of Federal Regulations* (10 CFR 2.390). Members of the public, the press, and government officials from other agencies are considered observers during the conduct of these public meetings.

If the licensee will not be formally represented at the meeting, the meeting should be conducted as an information meeting with a question-and-answer session. A comment-gathering meeting may also be used, but this is expected to be rare for formal public meetings conducted in accordance with this manual chapter.

In any of these formal public meeting formats, a designated opportunity for the public to ask questions of the NRC representatives should be made available. The NRC staff should strive to ensure sufficient time is allotted to ensure that the public can pose questions and have them answered during the meeting. Whether all questions are addressed or not, the NRC staff should emphasize ways members of the public can ask questions outside the meeting.

Upon completion of the annual public engagement to discuss the assessment of licensee performance, a meeting summary shall be completed for all formal public observation meetings, information meetings with question-and-answer sessions, and commentgathering meetings. If a more informal format was used, a meeting summary is not required if the assessment letter was attached to the meeting notice.

# 0305-10	ROP ACTION MATRIX

## 10.01	Description of the Action Matrix

The Action Matrix (Figure 1) identifies the range of NRC and licensee actions and the appropriate level of communication for different levels of licensee performance. The Action Matrix describes a graded approach for addressing performance issues and was developed with the philosophy that within a certain level of safety performance (e.g., the licensee response band), licensees would address their performance issues without additional NRC engagement beyond the baseline inspection program. NRC actions beyond the baseline inspection program will normally occur only if assessment input thresholds are exceeded. The NRC’s public “ROP Action Matrix Summary and Current Regulatory Oversight” website is updated in accordance with IMC 0306.

The following terms are used throughout the discussion of the Action Matrix.

a. Regulatory Performance Meetings. Regulatory performance meetings are held between licensees and the NRC to discuss corrective actions associated with safety-significant Action Matrix inputs. The purpose of the meeting is to provide a forum in which to develop a shared understanding of the performance issues, underlying causes, and planned licensee actions for each safety-significant Action Matrix input.

These meetings may take place during periodic inspection exit meetings between the NRC and the licensee, a periodic NRC management visit, conference calls, a public supplemental inspection exit meeting, or public meetings after completion of the supplemental inspection. These meetings are documented in either an inspection report or a public meeting summary, as appropriate.

If security-related information, which is a type of SUNSI, must be discussed during the regulatory performance meeting, it shall be discussed during a closed meeting, or during a closed session following a public meeting to discuss inputs in other cornerstones. 

b. Licensee Actions. Anticipated licensee actions in response to overall performance are identified for each column of the Action Matrix. If these actions are not being taken by the licensee, then the NRC may consider expanding the scope of the applicable supplemental inspection to appropriately address the area(s) of concern. This would not be considered an Action Matrix deviation.

c. NRC Inspections. The range of NRC inspection activities to be conducted in response to licensee performance is identified for each column of the Action Matrix.

d. Regulatory Actions. The range of actions that may be taken by the NRC in response to licensee performance is identified for each column of the Action Matrix.

e. Communications. Communication between the licensee and the NRC is based on a graded approach. Normally, declining licensee performance will result in higher levels of NRC management reviewing and signing the assessment letters and conducting the annual public stakeholder involvement.

## 10.02	Expected Responses for Performance in Each Action Matrix Column

The Action Matrix lists expected NRC and licensee actions based on the Action Matrix inputs. Actions are graded such that the NRC becomes more engaged as licensee performance declines. Listed below are the ranges of expected NRC and licensee actions for each column of the Action Matrix:

a. Licensee Response Column (Column 1)

1.	All Action Matrix inputs are Green.

2.	The licensee will receive the complete risk-informed baseline inspection program, and any identified deficiencies are expected to be addressed through the licensee’s corrective action program.

b. Regulatory Response Column (Column 2)

1.	Action Matrix inputs result in one or two White inputs in a strategic performance area.

2.	The licensee is expected to place the identified deficiencies in its corrective action program and perform a causal evaluation. When two White inputs correspond to the same cornerstone, the licensee is expected to also perform a causal evaluation for the collective issues.

3.	The licensee’s evaluation will be reviewed using IP 95001, “Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response) Inputs.”

4.	Following completion of the inspection, the branch chief or division director should discuss the performance deficiencies and the licensee’s proposed corrective actions with the licensee. The regulatory performance meeting can occur at an inspection exit meeting, a periodic NRC management visit, or a conference call between the licensee and the appropriate branch chief (or division director). If security-related information, which is a type of SUNSI, must be discussed during the regulatory performance meeting, it shall be discussed during a closed meeting, or during a closed session following a public meeting to discuss inputs in other cornerstones. Agency policy regarding SUNSI is provided in Management Directive 12.6.

c. Degraded Performance Column (Column 3)

1.	Action Matrix inputs result in a degraded cornerstone (three or more concurrent, i.e., existing at the same time) White inputs or one Yellow input in any cornerstone) or three concurrent White inputs in any strategic performance area.

2.	The licensee is expected to place the identified deficiencies in its corrective action program and perform a causal evaluation for both the individual and the collective issues. This evaluation should also determine whether deficiencies in the licensee’s nuclear safety culture caused or significantly contributed to the risk-significant performance issues. If so, then the licensee should address these deficiencies.

3.	The licensee’s evaluation will be reviewed using IP 95002, “Supplemental Inspection Response to Action Matrix Column 3 (Degraded Performance) Inputs.” The region will also perform an independent assessment of the extent of condition using appropriate inspection procedures chosen from the tables contained in Appendix B to IMC 2515.

Additionally, the NRC may request that the licensee complete an independent safety culture assessment, if the NRC identified through the IP 95002 inspection and the licensee did not recognize, that one or more safety culture deficiencies caused or significantly contributed to the risk-significant performance issues. [C4]

The guidance in IP 40100, “Independent Safety Culture Assessment Follow-up,” shall be used to follow up when the NRC requests the licensee to perform an independent safety culture assessment. The regional office shall treat the use of this guidance as an expansion of the IP 95002 inspection and should still charge time to IP 95002. The focus of the follow-up effort will be to confirm that the licensee is appropriately dealing with the weaknesses identified by its safety culture assessment. Regional staff can contact the Chief, Reactor Assessment Branch, NRR/DRO, for additional assistance and guidance.

4.	Following completion of the IP 95002 inspection, the RA or designee should discuss the performance deficiencies and the licensee’s proposed corrective actions with the licensee. The regulatory performance meeting should be a public meeting between the licensee and the appropriate RA or designee. If security-related information, which is a type of SUNSI, must be discussed during the regulatory performance meeting, it shall be discussed during a closed meeting, or during a closed session following a public meeting to discuss inputs in other cornerstones. 

5.	Each time a plant enters Column 3 of the Action Matrix, the region should assess the benefit of performing an additional PI&R team inspection in accordance with IP 71152, “Problem Identification and Resolution.” A maximum of one additional inspection should be considered for the two-year period following the quarter in which the plant entered Column 3 of the Action Matrix. In those instances where an additional inspection is deemed appropriate, the region should provide the basis for its decision to conduct the inspection in the appropriate assessment letter to the licensee.

6.*Any licensee remaining in Column 3 for three years or more may be invited to meet with the Commission to discuss performance issues and its plan for addressing those issues. [C5]*

d. Multiple/Repetitive Degraded Cornerstone Column (Column 4)

1.	Action Matrix inputs result in a repetitive degraded cornerstone, multiple degraded cornerstones, multiple Yellow inputs, or one Red input.

2.	The licensee is expected to place the identified deficiencies in its corrective action program and perform a causal evaluation for both the individual and the collective issues. This evaluation may consist of a third-party assessment.

In addition, a licensee is expected to meet with the Commission within six months of entering Column 4 to discuss its plans for addressing the performance deficiencies and its plans for improvement. The timing of the meeting shall be based on a collegial determination by the Commission informed by a recommendation from the EDO, and may exceed six months. [C5] 

The licensee is also expected to have a third-party safety culture assessment performed. [C4]

3.	IP 95003, “Supplemental Inspection Response to Action Matrix Column 4 (Multiple/Repetitive Degraded Cornerstone) Inputs,” will be performed to review the breadth and depth of the performance deficiencies, assess the licensee’s evaluation of its safety culture, and independently perform a graded assessment of the licensee’s safety culture. A decision to not independently perform an assessment of the licensee’s safety culture would be an Action Matrix deviation. However, the staff can use the results from a licensee’s third-party safety culture assessment and the licensee’s causal evaluation to satisfy the inspection requirements if the staff has completed a validation of the third-party safety culture assessment methodology, assessment effort, and causal evaluation. This situation would not be an Action Matrix deviation. The supplemental inspection plan must be approved by the appropriate regional division director after conferring with the Director or Deputy Director, NRR/DRO.

When the objectives of the IP 95003 supplemental inspection have been satisfactorily met, the findings may be closed. However, the licensee will remain in the higher column until the requirements to transfer out of Column 4 described in the CAL have been inspected and met. When that is accomplished, the Region will issue an assessment follow-up letter moving the licensee out of Column 4.

4. 	Each time a plant enters Column 4 of the Action Matrix, the region should assess the benefit of performing an additional PI&R team inspection in accordance with IP 71152. In those instances where an additional inspection is deemed appropriate, the region should provide the basis for its decision to conduct the inspection in the associated communication to the licensee.

5.	Following the completion of the inspection, the EDO or designee, in conjunction with the RA and the Director, NRR, will decide whether additional NRC actions are warranted. At a minimum, the regional office will issue a Confirmatory Action Letter (CAL) to document the licensee’s commitments, as discussed in its performance improvement plan, and any other written or verbal commitments. The CAL should explicitly identify licensee actions, which, when effectively implemented and validated by the NRC, will provide the necessary bases to transition the plant out of Column 4 when an assessment follow-up letter is issued. These actions need to be as clear and objective as possible. The licensee will remain in Column 4 until meeting the criteria specified in the CAL, even though there may be no open Action Matrix inputs. This will be annotated on the public website. Normally CAL follow-up inspections are conducted to conclude licensee actions have been effectively implemented.

Other actions will also be considered, including performing additional supplemental inspections, issuing a demand for information, or issuing an order, up to and including a plant shutdown. The RA should document the results of the staff’s decision in a letter to the licensee. These regulatory actions may also be considered prior to the completion of IP 95003, if warranted.

Note: Other than the CAL, the regulatory actions listed in this column of the Action Matrix are not mandatory. However, the regional office should consider each of these regulatory actions when significant new information about licensee performance becomes available.

6.	The regulatory performance meeting should be a public meeting between the licensee and the EDO or designee. The regions should consider the following as indicative of actual performance improvements:

(a)	New plant events or findings do not reveal similar significant performance weaknesses.

(b)	NRC findings and licensee PIs do not indicate similar significant performance weaknesses that have not been adequately addressed.

(c)	The licensee’s performance improvement program has demonstrated sustained improvement.

(d)	NRC supplemental inspections show licensee progress in the principal areas of weakness.

(e)	There were no issues that led the NRC to take additional regulatory actions beyond those listed in Column 4 of the Action Matrix.

(f)	Additionally, the licensee has made significant progress on any regulatory actions imposed (e.g., orders, or 50.54 (f) letters) because of the performance deficiencies leading to the Column 4 designation.

If security-related information, which is a type of SUNSI, must be discussed during the regulatory performance meeting, it shall be discussed during a closed meeting, or during a closed session following a public meeting to discuss inputs in other cornerstones. 

Due to the depth and/or breadth of performance issues reflected by a plant being in Column 4 of the Action Matrix, it is prudent to ensure that actual performance improvements, which typically take longer than several quarters to achieve, have been made prior to closing out the inspection findings and allowing the plant to exit Column 4 of the Action Matrix. [C2]

7.	After the original findings and required CAL items have been closed, an assessment follow-up letter is issued, and the licensee will return to the Action Matrix column that is represented by applicable Action Matrix inputs.

Additionally, for a period of up to two years after the initial findings have been closed out, the regional offices may use some actions that are consistent with Column 3 or 4 of the Action Matrix in order to ensure the appropriate level of NRC oversight of licensee improvement initiatives.**[C2] 

These actions, which do not constitute Action Matrix deviations, include:

(a)	senior management participation at periodic meetings or site visits focused on reviewing the results of improvement initiatives (such as efforts to reduce corrective action backlogs and progress in completing a performance improvement plan)

(b)	conducting supplemental IP 95003 and follow-up inspections (not to exceed 200 hours of direct inspection over a maximum two-year period) after conferring with the Deputy Director, NRR/DRO

(c)	annual public meetings and authorization of the contents of the subsequent assessment letters

The actions taken beyond those required by the Action Matrix shall be discussed at the following end-of-cycle review meetings to ensure an appropriate basis for needing the additional actions to oversee the licensee improvement initiatives. These actions will also be described in the following annual assessment letters until the end of the extended period of time. All assessment letters that address these additional actions shall include the NRR/DRO/IRAB branch chief on concurrence.

e. Unacceptable Performance Column (Column 5)

1.	Licensee performance is unacceptable, and continued plant operation is not permitted within this column. Unacceptable performance represents situations in which the NRC lacks reasonable assurance that the licensee can or will conduct its activities to ensure protection of public health and safety. Examples of unacceptable performance may include:

(a)	Multiple escalated violations of the facility’s license, technical specifications, regulations, or orders.

(b)	Loss of confidence in the licensee’s ability to maintain and operate the facility in accordance with the design basis (e.g., multiple safety-significant examples where the facility was determined to be outside of its design basis, either because of inappropriate modifications, the unavailability of design basis information, inadequate configuration management, or the demonstrated lack of an effective Corrective Action Program).

(c)	A pattern of failure of licensee management controls to effectively address previous significant concerns to prevent recurrence. In general, it is expected, but not required, that entry into Column 4 of the Action Matrix and completion of IP 95003 will precede consideration of whether a plant is in Column 5.

2.	The licensee is expected to have a third-party safety culture assessment performed. [C4]

3.	If the NRC determines that a licensee’s performance is unacceptable, then a shutdown order will be issued.

4.	The NRC will assess the licensee’s evaluation of its safety culture and independently perform a graded assessment of the licensee’s safety culture using the guidance in IP 95003. A decision not to independently perform an assessment of the licensee’s safety culture would be an Action Matrix deviation. However, the staff can use the results from a licensee’s third-party safety culture assessment and the licensee’s causal evaluation to satisfy the inspection requirements if the staff has completed a validation of the third-party assessment methodology, assessment effort, and causal evaluation.

5.	The EDO or designee will meet with senior licensee management in a regulatory performance meeting to discuss the licensee’s degraded performance and corrective actions. The Commission will also meet with senior licensee management to discuss the issues which will need to be taken before operation of the facility can be resumed. If security-related information, which is a type of SUNSI, must be discussed during the regulatory performance meeting, it shall be discussed during a closed meeting, or during a closed session following a public meeting to discuss inputs in other cornerstones. 

6.	The NRC oversight of plant performance will be conducted in accordance with IMC 0350.

f. IMC 0350 Process Column

1.	The criteria for entrance into the IMC 0350 process, as discussed in section 12.01 of this IMC, have been met, and subsequent management review of licensee performance has determined that entrance into Column 5 is not warranted at this time. Plants that meet these criteria are considered to be outside of the normal assessment process and under the control of IMC 0350. However, this column has been added to the Action Matrix for illustrative purposes to demonstrate comparable NRC response and communications and is not necessarily representative of the worst level of licensee performance.

2.	NRC management will review licensee performance on a quarterly basis to determine if entrance into Column 5 is warranted.

3.	The licensee is expected to place the identified deficiencies into its performance improvement plan and perform a causal evaluation for both the individual and collective causes.

4.	As discussed in IMC 0350, the regional offices will conduct baseline and supplemental inspections as appropriate, as well as special inspections per the restart checklist. PI data should continue to be gathered in accordance with IMC 0608, “Performance Indicator Program,” to the extent that it is applicable to shutdown conditions. Plants under the IMC 0350 process should be discussed at the end-of-cycle review to integrate inspection planning efforts across the regional office and to keep internal stakeholders informed of ongoing inspection and oversight activities. Annual assessment letters are generally not issued for these plants. Annual public meetings will not be conducted for these plants as the regional office conducts periodic public meetings to discuss licensee performance.

As discussed in section 12.02, the regional offices may use some actions that are consistent with the Column 3 or 4 of the Action Matrix in order to ensure the appropriate level of NRC oversight of licensee improvement initiatives as the licensee exits the IMC 0350 Process. [C2]

# 0305-11	ADDITIONAL ACTION MATRIX GUIDANCE

The determination of a plant’s Action Matrix column considers inspection findings, PIs, the timing of inputs, and the status of supplemental inspections and reports. Action Matrix inputs are monitored continuously and plants can change Action Matrix column designation throughout the quarter in accordance with section 07.01. The first calendar quarter is from January 1st through March 31st. The second quarter is from April 1st through June 30th. The third quarter is from July 1st through September 30th. The fourth quarter is from October 1st through December 31st.

## 11.01	Inspection Findings

a. Use of Safety-Significant Inspection Findings. Safety-significant inspection findings are considered in the assessment process when (1) the NRC determines the final significance in accordance with IMC 0609, “Significance Determination Process,” and (2) the licensee has been informed of the decision. The start date of the finding and the timeframe for consideration of the finding as an Action Matrix input are described below.

b. Start Date of Findings. The start date used for consideration of inspection findings in the assessment process and Action Matrix, also known as the PIM date, is the end of the inspection activities that designate the issue as an apparent violation (AV), violation (NOV), finding (FIN), or non-cited violation (NCV) in the RPS-Inspections. For quarterly integrated inspection reports, the last day of the quarter being assessed is the start date or the date of a re-exit if the finding disposition has changed since the original exit meeting. For all other inspection reports, the start date is the exit meeting or the date of a re-exit if the disposition of the finding or violation changed since the original exit meeting. The finding’s start date is used to determine the first quarter in which the finding becomes an Action Matrix input. A safety-significant finding is considered an Action Matrix input beginning on the first day of the quarter that includes the finding’s start date until satisfaction of all supplemental inspection objectives.

Example 11.01-1: A preliminary White inspection finding is identified and communicated to the licensee in an exit meeting in the second quarter. The NRC makes its final determination that the finding had low to moderate (i.e., White) safety significance during the third quarter. Because the exit meeting date, or start date, was in the second quarter, the finding would be considered a White input to the Action Matrix beginning on the first day of the second quarter.

c. Closure Date of Findings

A finding is closed and no longer considered an Action Matrix input after the licensee satisfies all the objectives of the appropriate supplemental inspection. The closure date will be the date of the exit meeting for the appropriate supplemental inspection. While the finding is no longer considered an input into the Action Matrix as of the exit meeting date for a satisfactory supplemental inspection, it can’t officially be closed until the inspection report and assessment follow-up letter are issued. The assessment follow-up letter will state that the finding is closed and no longer considered an Action Matrix input as of the exit meeting date. The assessment follow-up letter will also notify the licensee of any changes to the Action Matrix assignment. A region may close a finding if external agencies have not completed their investigations.

A finding is only considered an Action Matrix input during the time it was open. Once the finding is closed, it is no longer an Action Matrix input.

d. Concurrent inputs. After a safety-significant finding’s final significance determination is made and the regional office determines the finding’s start date, as discussed above, the regional office shall determine (1) how the plant’s Action Matrix column designation is affected by other concurrent inputs (including those that are closed) that are applicable during the time in which the finding is applicable and (2) if any additional action needs to be taken as a result.

Example 11.01-2: A licensee is in Column 2 because a White parallel PI finding exists for the first quarter and a White inspection finding in the same cornerstone is open. The inspection finding closes in the middle of the first quarter due to satisfying all the objectives of the appropriate supplemental inspection. Inspectors complete a team inspection in March of that year, and in the exit meeting they identify an AV in the same strategic performance area that is potentially greater-than-Green. The finding is finalized White near the end of the second quarter. The start date of the new finding is the same date as the exit meeting in which it was identified as an AV, held during the first quarter. Therefore, the new finding counts as an Action Matrix input as of January 1st. Because on January 1st the licensee had two White findings open and a White PI in the same strategic performance area, three White Action Matrix inputs are open concurrently, tripping the criteria for Column 3, the Degraded Performance Column, as of the beginning of the first quarter, even though one of the inputs was closed before that determination was made. Therefore, a 95002 supplemental inspection would have to be scheduled.

e. Unresolved Items (URIs). URIs should be dispositioned in accordance with IMC 0612, “Issue Screening,” and updated in RPS-Inspections when additional information becomes available.

f. Significance Determinations under Appeal. The process by which a licensee may appeal the staff’s final significance determination of an inspection finding documented in an NRC inspection report or final significance determination letter is described in IMC 0609, Attachment 2, “Process for Appealing NRC Characterization of Inspection Findings (SDP Appeal Process).” If a licensee appeals the significance determination of a finding, that finding is counted in the Action Matrix until the staff notifies the licensee in writing of a change in the final significance determination.

## 11.02	Performance Indicators

a. Licensees submit PI data on a quarterly basis. The PI data for a quarter are submitted to the NRC approximately 21 days after the end of that quarter. If a greater-than-Green PI is reported, a parallel PI finding will be issued with the same color as the PI. This parallel PI finding becomes the Action Matrix input, with a start date being the first date of the quarter for which the data were collected.

Example 11.02-1: A licensee submits its PI results for the first quarter to the NRC on April 21st. For PIs that exceed a safety-significant threshold, a parallel PI finding will be issued with a start date of January 1st.

When new PI data are received and become Action Matrix inputs for the applicable quarter, the PI inputs should be considered with any other Action Matrix inputs that are applicable during that quarter to determine the appropriate Action Matrix column and associated actions.

Example 11.02-2: A White Mitigating Systems Cornerstone finding was closed after 1Q20YY. The licensee submits a White Mitigating Systems Cornerstone PI on April 21, 20YY. Because the parallel White PI finding would have a start date of January 1st and the White finding is still an Action Matrix input for that quarter, the plant would remain in Column 2 for two White inputs in the same cornerstone. If there were an additional White finding or parallel PI finding in 1Q20YY, then the plant would transition to Column 3 in 1Q20YY, and an IP 95002 supplemental inspection would have to be performed.

b. PIs are not intended to be monitored on a real time basis. However, the regional office may take the appropriate action if, based on current inputs, a PI will cross a performance threshold at the end of the quarter. Appropriate actions can include supplemental inspection planning, scheduling and informal communication with the licensee. However, the plant does not change columns in the Action Matrix until the final PI data are submitted, reviewed and posted following the end of the quarter, and any formal communication with the licensee should not indicate the future Action Matrix column designation except in an assessment follow-up letter.

c. If a safety-significant PI returns to the Green performance band in a subsequent quarter, the PI is reported as Green on the ROP public website, the parallel PI finding remains open and the licensee remains in the higher column of the Action Matrix until the licensee satisfies the objectives of the appropriate supplemental inspection.

d. When a licensee satisfies the objectives of the appropriate supplemental inspection, the parallel PI finding will be closed and no longer count as an Action Matrix input as of the date of the exit meeting, or re-exit meeting, if applicable, after the final inspection report and assessment follow-up letter are issued, similar to the closure of safety-significant inspection findings. If the PI continues to be safety significant, e.g., White, the PI will be reported as such on the ROP public website, but the plant will still transition to a lower column of the Action Matrix based on closure of the parallel PI finding if there are no other Action Matrix inputs.

e. If a parallel PI finding is closed because of satisfactory completion of the appropriate supplemental inspection, and the licensee continues to accumulate additional occurrences to the same PI, the region has several options. First, if the supplemental inspection was completed before the licensee implemented the corrective actions reviewed, then additional occurrences to the PI may not be unexpected until those corrective actions have been implemented or have had time to become effective. In this case, the region may take no action pending implementation of those corrective actions. If corrective actions have been implemented and there are additional hits to the PI, inspectors could perform a PI&R semi-annual trend review or focused PI&R sample to determine if the corrective actions to prevent recurrence have been effective or not, depending on the causes. The regional office should consider issuing a violation of 10 CFR Part 50, Appendix B, Criterion XVI, “Corrective Action,” if appropriate. If a licensee reports the PI in a subsequent quarter as having crossed the next higher significance threshold, e.g., Yellow, then a Yellow parallel PI finding will be opened, the original White parallel PI finding will be closed, and an assessment follow-up letter will be issued moving the plant to the appropriate Action Matrix column, in this case Column 3.

f. If the licensee does not satisfy all the objectives of the appropriate supplemental inspection, the region should follow the guidance described above in sections 11.01.d and 11.01.e.

## 11.03	Other Action Matrix Input Considerations

a. Double-Counting PIs and Inspection Findings. Some issues may result in a simultaneous safety-significant PI and safety-significant inspection finding. For example, a single performance issue in the Mitigating Systems Cornerstone could result in an inspection finding and count toward the PI as a failure with unavailability. In accordance with the Action Matrix, this would result in two or more assessment inputs causing increased regulatory action.

However, when safety-significant inspection findings and PIs have the same underlying cause, they should not be “double-counted” in the Action Matrix in any given quarter. The double counting principle should be applied each quarter in order to reassess Action Matrix inputs using the available current PIs and inspection findings. The Action Matrix column representing the highest degree of safety significance should be used when there is flexibility in deciding which inputs should be used or excluded from the Action Matrix.

The double-counting principle is not applied across PIs. For example, a system failure could be counted in two PIs with both crossing performance thresholds into the White performance band. In this situation, the plant would remain in Column 2 assuming no other safety-significant Action Matrix inputs. However, if the failure resulted in only one PI crossing a performance threshold, and the system failure was assessed by the SDP as a White finding, the double-counting rule would need to be considered.

When applying the double-counting criteria and the most conservative outcome, the inspection finding input should be calculated out (removed) from the PI calculation, and the remaining inputs should be evaluated and used in the Action Matrix. The PI does not actually change color. If there is a safety-significant PI and an inspection finding with the same underlying cause and if it was determined that the PI would remain White even with the failure removed from the PI calculation, then both the PI input and the inspection finding would count.

Example 11.03-1: A licensee accrues three PI occurrences in occupational radiological health in the first quarter resulting in a White PI. In the third quarter, two of the occurrences roll off and the PI returns to Green. In the fourth quarter, the licensee accrues two additional PI occurrences. The NRC conducts a supplemental inspection in the fourth quarter that reviews the first three occurrences and concludes that the parallel PI finding remains open. In the first quarter of the following year, one occurrence rolls off but the licensee accrues a third additional PI occurrence.

In the fourth quarter, the PI again goes White, but because one of the PI occurrences is already covered by the parallel finding, the White PI is not considered in determining the Action Matrix column. However, in the first quarter of the following year, the third additional PI occurrence results in a White PI based solely on new PI occurrences, so the plant would remain in Column 2 because of two White inputs in the Action Matrix. If there were an additional White finding or PI in the same cornerstone, the plant would move to Column 3 due to the three White inputs.

When processing an inspection finding that is being considered under the double counting rule, the Region may consider delaying the performance of the supplemental inspection for the greater-than-Green PI until the final significance determination has been completed to ensure the appropriate supplemental inspection is conducted.

b. Repetitive Degraded Cornerstone. A repetitive degraded cornerstone is defined in section 04.

If multiple safety-significant findings are concurrent Action Matrix inputs, a supplemental inspection can close one or more findings to prevent entry into Column 4. For example, suppose three White findings, which meet the Column 3 entry criteria, all start in the same quarter. If the IP 95002 supplemental inspection results in two of the findings being closed but the other White finding remaining open, the plant would not transition to Column 4. Although the plant would remain in Column 3 until the IP 95002 could be completed successfully, a degraded cornerstone would not exist for more than five quarters.

## 11.04	Supplemental Inspections

a. Until the supplemental inspection is satisfactorily completed for the highest column of the Action Matrix assigned, the licensee shall remain in the higher column of the Action Matrix, even though subsequent quarters might indicate that one or more greater-than-Green inspection findings or PIs are no longer present in the Action Matrix.

b. When the assessment program was being developed, the Commission directed the staff to improve the timeliness of the NRC assessment program in order to enhance the ability to identify declining performance early. To support this objective, the NRC’s supplemental inspections should be completed in a timely manner.

c. If a supplemental inspection is performed for a safety-significant inspection finding, and the region concludes that the licensee adequately addressed the finding and exits the inspection, then the finding will be closed, and the plant can change Action Matrix columns. While the closure date of the finding will be the date of the exit meeting for the satisfactorily completed supplemental inspection, no finding may be closed without the closure being documented in an inspection report, and no licensee may change Action Matrix columns without the movement being documented in an assessment follow-up letter. When the supplemental inspection report and assessment follow-up letter are issued, the cover letter will state that the finding is closed and no longer an Action Matrix input as of the date of the exit meeting. If no other safety-significant Action Matrix inputs exist, then the letter will state the licensee moved back to Column 1 as of the date of the exit meeting. An assessment follow-up letter would be issued in accordance with section 07.01, and the NRC’s public Action Matrix website would be updated in accordance with IMC 0306.

d. The regional office shall still perform a supplemental inspection if a safety-significant PI returns to the Green performance band before the supplemental inspection is completed because the parallel PI finding remains open. This includes the situation where a PI reverts to Green because of the time dependence of the PI calculation, plant modifications, and/or changes to the probabilistic risk assessment before the supplemental inspection has been conducted. The plant remains in the higher column until all objectives of the supplemental inspection have been met.

Example 11.04-1: A PI turns White in the second quarter and returns to Green in the third quarter. The region exits an IP 95001 inspection in the fourth quarter, and issues the inspection report and assessment follow-up letter late in the fourth quarter. All other Action Matrix inputs are currently Green in the fourth quarter. The plant would transition to Column 1 in the fourth quarter on the date of the exit meeting for the supplemental inspection upon issuance of the assessment follow-up letter.

e. The scope of supplemental inspections could include all currently open safety-significant performance issues in all cornerstones and strategic performance areas.

Example 11.04-2: If an IP 95002 inspection is being performed because of a Yellow PI in the Mitigating Systems Cornerstone, the scope could also include any White inspection findings and PIs in that cornerstone or any other cornerstone.

Example 11.04-3: If an IP 95002 inspection is being performed because of three White findings in the Reactor Safety Strategic Performance Area, the scope could include White PIs and inspection findings in all strategic performance areas and cornerstones.

f. If a White inspection finding or PI subsequently occurs in an unrelated cornerstone or strategic performance area, the associated supplemental inspection should be conducted at the appropriate level.

Example 11.04-4: A regional office is performing an IP 95002 for three White findings in the Initiating Events Cornerstone. If an additional White inspection finding is identified in the Occupational Radiation Safety Cornerstone, then the regional office should inspect this finding using IP 95001.

g. If a plant moves to the right in the Action Matrix (i.e., has a higher column number) because a safety-significant input starts while other safety-significant inputs are open, then the applicable supplemental inspection for the higher column shall be performed even if the lower column’s supplemental inspection was already performed or scheduled to be performed for the first input. The plant will remain in the higher column until the supplemental inspection for the higher column is completed and the conditions in section 11.04.b or 11.04.c are met.

The regional office can perform the first supplemental inspection before performing the supplemental inspection for the higher column. If the first supplemental inspection objectives are met, then the applicable input would no longer be considered with other Action Matrix inputs in accordance with the guidance in section 11.

Likewise, any inspection finding, which is satisfactorily inspected and resolved through an IP 95001 inspection and considered isolated from the other findings or PIs inspected, can be closed once the supplemental inspection has been satisfactorily completed. The basis for the NRC’s actions should be stated in the inspection report cover letter. The cover letter should also include the licensee actions necessary to close any open findings or parallel PI findings. However, the licensee shall not move across the Action Matrix column in accordance with section 11.04.a.

Example 11.04-5: A plant has a White finding starting in the first quarter, the NRC completes an IP 95001 inspection in the third quarter, and the plant has two additional White inputs in the same cornerstone starting in the third quarter. Because the plant would enter Column 3 in the third quarter, the licensee would stay in Column 3 until the IP 95002 inspection results in the determination that the licensee adequately evaluated and addressed the issues. Even though the initial White finding would no longer be active in the Action Matrix because it was closed upon satisfactory completion of the supplemental inspection, the plant remains in Column 3 until the IP 95002 is completed as just described.

h. The regional offices should coordinate with NSIR to close greater-than-Green security findings related to force-on-force exercise deficiencies because closure of these types of findings may require a force-on-force exercise re-inspection performed by NSIR.

i. For licensees transitioning to Column 4, the Region should consider a phased approach for conducting the IP 95003 supplemental inspection to inform whether continued operation of the facility is acceptable and to decide whether additional regulatory actions are necessary to arrest declining plant performance. This could entail conducting some sample reviews of key attributes of the affected Strategic Performance Area before the licensee completes its evaluations to provide NRC decision-makers with timely information.

## 11.05	Treatment of Items Associated with Enforcement Discretion

A finding that includes a violation that meets the criteria discussed below will be processed as specified in this section. The intent of this section is to establish ROP guidance that supports the objective of enforcement discretion, which is to encourage licensee initiatives to identify and resolve problems, especially those subtle issues that are not likely to be identified by routine efforts.

The purpose of this approach is to place a premium on licensees initiating efforts to identify and correct safety-significant issues, which are not likely to be identified by routine efforts, before degraded safety systems are called upon to work. The assessment program evaluates present performance issues, and this approach excludes old design issues from consideration of overall licensee performance in the Action Matrix. The DRP or DRS division director will authorize the treatment of findings as old design issues after conferring with the Deputy Director, NRR/DRO. This is not an Action Matrix deviation.

A finding that includes a violation subject to enforcement discretion must be dispositioned under one of the following categories:

a. Treatment of Old Design Issues in the Assessment Process. A finding associated with engineering calculations or analysis, associated operating procedure, or installation of plant equipment is considered an Old Design Issue if it meets all of the following criteria:

1.	It was licensee-identified as a result of a voluntary initiative, such as a design basis reconstitution. For the purposes of this IMC, self-revealing findings, which are defined in IMC 0612, are not considered to be licensee-identified.

2.	It was or will be corrected, including immediate corrective actions and long-term comprehensive corrective actions to prevent recurrence, within a reasonable time following identification (this action should involve expanding the initiative, as necessary, to identify other failures resulting from similar causes). For the purpose of this criterion, identification is defined as the time when the significance of the finding is first discussed between the NRC and the licensee. Accordingly, issues being cited by the NRC for inadequate or untimely corrective action are not eligible for treatment as old design issues.

3.	It was not likely to be previously identified by recent ongoing licensee efforts, such as normal surveillance, quality assurance activities, or evaluation of industry information.

4.	It does not reflect a current performance deficiency associated with existing licensee programs, policy, or procedure.

If all the old design issue criteria are met, then the finding would not aggregate in the Action Matrix with other PIs and inspection findings.

If the old design issue criteria are not met, then the finding would be treated similar to any other inspection finding and additional NRC actions would be taken in accordance with the Action Matrix.

Overall Inspection Approach

The finding considered for treatment as an old design issue shall be brought to a SERP and a Regulatory Conference, if applicable. The finding shall be discussed in the appropriate inspection report cover letter and displayed on the NRC’s website with its actual safety significance after the final safety significance is determined.

If enough information is known to determine that the finding meets the old design issue criteria, then the licensee shall be notified in the inspection report cover letter that the finding was determined to be an old design issue. The regional office shall perform an IP 95001 supplemental inspection for a White finding or an IP 95002 supplemental inspection for a Yellow or Red finding to review the licensee’s causal evaluation and corrective action plan for that particular issue. Because old design issues often predate current licensee policies and practices, performing a review of the licensee’s safety culture as part of an IP 95002 inspection may not be necessary. If the region determines that a safety culture review is not required as part of an IP 95002 inspection for an old design issue, the region should document that the review was not performed and include justification in the inspection report.

Example 11.05-1: The NRC concluded that a White finding in the Mitigating Systems Cornerstone meets the criteria for an old design issue for a plant. The plant also has a White PI in the Mitigating Systems Cornerstone. This plant would be placed in Column 2 of the Action Matrix because of the White PI, and NRC actions would be taken in accordance with that column, including an IP 95001 supplemental inspection for the White PI. The old design issue does not aggregate with other inputs in determining the Action Matrix column or required NRC response. Therefore, the White old design issue would be considered independently, and an IP 95001 supplemental inspection for that issue would be conducted.

If additional information is needed to determine whether the finding meets the old design issue criteria, the inspection report cover letter should state that the finding is being considered for treatment as an old design issue. The regional offices should then perform an IP 95001 supplemental inspection for a White finding or an IP 95002 supplemental inspection for a Yellow or Red finding to review the licensee’s causal evaluation of that particular issue and to gather the additional information required to determine whether the finding meets the old design issue criteria.

Example 11.05-2: The regional office does not have enough information to determine if a Red finding meets the criteria for an old design issue. The regional office would perform an IP 95002 inspection to review the causal evaluation and gather additional information on whether the finding meets the criteria for an old design issue. As a result of the inspection, if the regional office determines that the criteria have not been met, the regional office would perform the additional inspection activities to complete supplemental inspection requirements for an IP 95003 inspection.

b. Violations in Specified Areas of Interest Qualifying for Enforcement Discretion. Findings that include violations subject to the following enforcement discretion may be dispositioned as described below:

Enforcement discretion in accordance with the Interim Enforcement Policy Regarding Enforcement Discretion for Certain Fire Protection Issues (10 CFR 50.48(c)) included in the Commission’s Enforcement Policy.

The NRC will normally refrain from processing the related inspection finding through the SDP and into the Action Matrix, if applicable. The finding must be documented in an inspection report noting that the related violation meets all applicable requirements for enforcement discretion as explicitly provided for in the associated authorizing document, and further meets the criteria listed below.

1.	The licensee places the finding into its corrective action program. Licensees may track pre-existing performance deficiencies/violations and findings identified during the National Fire Protection Association (NFPA) 805, “Performance-Based Standard for Fire Protection for Light-Water Reactor Electric Generating Plants,” transition period, through the Licensee Event Report (LER) process. It is recommended that an LER be developed for each fire area or each area of assessment.

2.	In cases where the finding is being given discretion, the staff may perform the most expeditious of either an SDP evaluation using IMC 0609 Appendix F, “Fire Protection Significance Determination Process,” or a qualitative evaluation using IMC 0609 Appendix M, “Significance Determination Process Using Qualitative Criteria,” to ensure the finding is not of high safety significance (red).

3.	The licensee performs an operability evaluation (when applicable) using the guidelines in IMC 0326, “Operability Determinations”,” to demonstrate that safety will be maintained during operation (both power operation and shutdown, as applicable) with compensatory measures as appropriate.

4.	Licensees will implement appropriate compensatory measures for each finding immediately upon identification. Such compensatory measures will be maintained while the licensee completes their NFPA 805 evaluation and (1) determines whether the existing configuration is acceptable based on risk analysis, or (2) there is a need for permanent corrective action if the existing configuration is not acceptable, and the corrective action is completed.

If the above criteria are not met, the staff may take whatever action is deemed necessary and appropriate, including the issuance of enforcement action, entry into the SDP, and, if applicable, the Action Matrix, and implementation of supplemental inspections.

The cover letter that informs the licensee of the staff’s exercise of enforcement discretion should include a clear explanation of the staff’s basis for exercising enforcement discretion, including a reference to the applicable authorizing document(s) and this section. Cover letters should also be consistent with the guidance provided in the Enforcement Manual.

If a single finding has multiple related violations of which only a subset are eligible to be granted enforcement discretion, then the finding will be dispositioned in accordance with the normal SDP and Action Matrix process using the assumption that only the violations not subject to enforcement discretion existed. The violations subject to enforcement discretion will be processed and documented as findings in accordance with the provisions of this section.

PI inputs received as a result of issues receiving enforcement discretion during transition to NFPA 805 should be evaluated for exclusion from consideration of overall licensee performance in the Action Matrix on a case-by-case basis. The DRP, DRS, DORS, or DRSS division director will authorize the exclusion of inputs after conferring with the Deputy Director, NRR/DRO. This is not an Action Matrix deviation.

## 11.06	Action Matrix Deviations

The regulatory actions dictated by the Action Matrix may not be appropriate in rare instances. In these instances, the NRC may deviate from the Action Matrix to either increase or decrease NRC action. The application of additional resources to evaluate issues not related to licensee performance is not considered a deviation from the Action Matrix. Guidance for applying additional resources can be found in section 07.03 of IMC 2515.

a. An Action Matrix deviation is defined in section 04.02. An Action Matrix deviation may be considered for a situation such as a type of finding unanticipated by the SDP that results in an inappropriate level of regulatory attention when entered into the Action Matrix. Examples of approved deviations can be found on the NRC’s public “ROP Action Matrix Deviations” website.

b. A memorandum requesting an Action Matrix deviation shall be initiated by the applicable regional office. The memorandum shall include a synopsis of the licensee’s performance issues, the required NRC actions per the Action Matrix for these issues, the proposed alternative actions, and the region’s basis for requesting the deviation. The draft memorandum should be emailed to NRR/DRO/IRAB via ROPassessment.Resource@nrc.gov for awareness. Comments may be offered for regional consideration. The region should then place the document in the NRC’s ADAMS, create a concurrence package, and the RA should send the memorandum to the Office Director of NRR for concurrence. NRR will then forward the memorandum to the EDO for approval.

c. The EDO shall approve all deviations from the Action Matrix and inform the Commission when deviations are approved and at the annual AARM Commission Meeting. [C1] After the EDO approves the deviation, the document shall remain draft in ADAMS until the licensee is notified via publicly available docketed correspondence, which is described below.

d. Deviations from the Action Matrix shall be communicated to the licensee in an assessment follow-up letter or annual assessment letter. This letter shall contain the EDO-signed memorandum as an enclosure and shall also be emailed to ROPassessment.Resource@nrc.gov. Both the letter and memorandum shall be made publicly available after the licensee is notified of the deviation. The NRC’s public “ROP Action Matrix Deviations” website will be updated in accordance with IMC 0306.

e. MD 8.14 requires NRR to ensure that the causes for deviations are understood and to identify any necessary changes to the ROP guidance. To ensure that this requirement is met, NRR/DRO/IRAB shall coordinate with the regional office that requested the deviation to generate an ROP Feedback Form in accordance with IMC 0801, “Inspection Program Feedback Process,” that describes the causes for the deviation, recommendations for changes, if any, to ROP guidance, and the basis for the recommendations to change or not change ROP guidance. In the ROP Feedback Form, the regions should request that any recommended changes to ROP guidance be shared with the other regional offices to ensure that all perspectives are considered.

f. Ensure that deviation documents containing SUNSI information are marked and handled in accordance with Management Directive 12.6.

# 0305-12	TRANSITIONS BETWEEN OVERSIGHT PROCESSES

## 12.01	Transitioning to the IMC 0350 Process

The criteria for considering a plant for the IMC 0350 process include: (1) plant performance is in Column 4 or 5 of the Action Matrix, or a significant operational event has occurred as defined by MD 8.3, “NRC Incident Investigation Program;” (2) the plant is shutdown or the licensee has committed to shut down the plant to address these performance issues (whether voluntary or via an NRC order to shutdown); (3) a regulatory hold is in effect, such as an NRC order; and (4) an NRC management decision is made to place the plant in the IMC 0350 process.

Management considerations in placing a plant under the IMC 0350 process are discussed in IMC 0350. At this point, periodic assessments (quarterly and end-of-cycle) of licensee performance are no longer under the auspices of this IMC; rather, they are now under the IMC 0350 process. This process is more completely described in IMC 0350.

The following are examples of the appropriate level of regulatory engagement between the NRC and a licensee once a plant has entered Column 4 of the Action Matrix and how IMC 0350 may be applied:

a. Plant A continues to operate, and regulatory engagement is dictated by Column 4 of the Action Matrix. The NRC performs an IP 95003 supplemental inspection (if not already performed), issues a CAL to document licensee commitments, and the plant remains under the level of oversight dictated by this IMC and is not transferred to the IMC 0350 process.

b. Plant B performs a voluntary shutdown to address performance issues. The NRC performs an IP 95003 supplemental inspection (if not already performed) and issues a CAL to document licensee commitments to the NRC. The plant remains under the level of oversight dictated by this IMC and is not transferred to IMC 0350 process.

c. Plant C performs a voluntary shutdown to address performance issues. The NRC issues a CAL to ensure a common understanding of licensee commitments to address the underlying performance deficiencies. The entry conditions for IMC 0350 have been met and NRC management determines that this process should be implemented using the criteria in IMC 0350. At this point, periodic assessment of licensee performance is no longer dictated by this IMC and is transferred to the IMC 0350 process. Plant performance is not determined to be unacceptable.

d. Plant D voluntarily shuts down to address performance issues. The NRC determines that one of the criteria in section 10.02.e. for unacceptable performance is met. The plant is considered to be in the Unacceptable Performance Column of the Action Matrix, and a shutdown order is issued by the NRC. The plant is transferred to the IMC 0350 process.

e. Plant E, which is operating, is issued an order by the NRC to shut down because it is considered to have met one of the criteria in section 10.02.e. The licensee’s performance is declared to be unacceptable, and the plant will be transferred to IMC 0350.

## 12.02	Transitioning out of the IMC 0350 Process

Once the conditions for restart have been completed, as discussed in IMC 0350, the RA will issue a restart authorization letter. If preexisting orders are involved, Commission or EDO approval may be required. The restart authorization letter will include the basis for restart and the extent of continued Restart Oversight Panel engagement. The panel will determine the duration of its oversight activities and the date that the plant will be assessed in accordance with IMC 0305.

Additionally, for a period of up to two years after the plant has exited the IMC 0350 process, the regional offices may use some actions that are consistent with the Column 3 or 4 of the Action Matrix in order to ensure the appropriate level of NRC oversight of licensee improvement initiatives. [C2]

These actions do not constitute a deviation from the Action Matrix. Actions can include senior management participation at periodic meetings/site visits focused on reviewing the results of improvement initiatives (such as efforts to reduce corrective action backlogs and progress in completing the Performance Improvement Plan), the annual public meetings, authorization of the contents of the subsequent assessment letters, and non-baseline Order and follow-up inspections (not to exceed 200 hours of direct inspection over a maximum two-year period without concurrence from the Deputy Director, NRR/DRO). The actions taken above those required by the Action Matrix shall be discussed at the following end-of-cycle review meetings. These actions will also be described in the following annual assessment letters until the end of the extended period of time. All assessment letters that address these additional actions shall include the Chief, NRR/DRO/IRAB on concurrence.

## 12.03	Transitioning out of the ROP for Decommissioning Units

Once licensees have submitted the 10 CFR 50.82 certifications for cessation of power operations and permanent removal of fuel from the reactor vessel, the Region shall notify the licensee, via letter, of their removal from oversight in accordance with the operating power reactor inspection program. The licensee will then be subject to oversight under IMC 2561, “Decommissioning Power Reactor Inspection Program.” A template for the decommissioning oversight letter is provided in Exhibit 11.

The Region shall document the final assessment of licensee performance under the ROP based on active Action Matrix inputs in the final resident inspection report cover letter.

## 12.04	Transitioning from New Construction to the ROP

After the 10 CFR 52.103(g) determination (henceforth referred to as the 103(g)), the staff will use this IMC to assess licensee performance and will consider results of all inspection activities conducted onsite (i.e., ROP baseline, Operational Program, Startup Testing, etc.). The staff will issue a single assessment letter that will focus on the ROP assessment and status after the 103(g) finding. The letter will also note any open operational program findings or construction ROP (cROP)-related issues.

When licensees transition to oversight under the ROP from a construction status, there may be greater-than-Green operational program inspection findings identified under construction oversight that remain open after the 103(g) determination is made.

If there are greater-than-Green findings associated with an operational program for which the supplemental inspections were not successfully completed before the 103(g) determination was made, the findings will remain open and will be assigned to the ROP cornerstone that is most closely related to the finding. These findings will be considered as inputs to the ROP Action Matrix upon initial implementation of the ROP. These findings will remain open until the appropriate supplemental inspection is completed.

Greater-than-Green inspection findings mapped to a cornerstone that is more reliant on a probabilistic risk assessment (PRA) (i.e., initiating events, mitigating systems, barrier integrity), will not count in the ROP Action Matrix, but the licensee will be required to have the appropriate supplemental inspection completed in order to close the finding.

Additional details on this topic can be found in the memo, “Transition to Reactor Oversight Process for Vogtle Electric Generating Plant, Units 3&4” (ML20191A383).

# 0305-13	TRADITIONAL ENFORCEMENT FOLLOW-UP

## 13.01	Traditional Enforcement in the Assessment Process

Violations involving willfulness, impacting the regulatory process, or having actual safety consequences are not adequately characterized by the SDP alone. For this reason, such violations are referred to in this IMC as traditional enforcement violations. These violations are processed in accordance with the NRC’s Enforcement Policy and Enforcement Manual. Traditional enforcement violations may have underlying findings that are assessed for significance using the SDP, and these findings shall be considered in the assessment program and the Action Matrix.

Traditional enforcement violations shall be considered during the end-of-cycle review when determining: (1) the range of NRC actions within the appropriate column of the Action Matrix when various actions are possible within a column, (2) whether a cross-cutting theme exists in the SCWE cross-cutting area (see section 14), and (3) the need for more detailed follow-up in response to escalated enforcement actions or a series of violations in one of the traditional enforcement areas of willfulness, impacting the regulatory process, or actual consequences.

## 13.02	Traditional Enforcement Follow-up Inspections

Traditional enforcement violations without an underlying performance deficiency do not influence the findings that result in a plant being assigned to a specific column of the Action Matrix. However, traditional enforcement violations normally receive some level of follow-up. If follow-up of traditional enforcement violations is planned, then it should be coordinated with any other follow-up or supplemental inspections to avoid duplication of effort. Follow-up of traditional enforcement violations is not considered an Action Matrix deviation because traditional enforcement violations are outside of the ROP.

a. If a traditional enforcement violation was resolved using corrective actions negotiated through the NRC’s Alternative Dispute Resolution (ADR) program, then the regional office must follow up on items identified in the ADR confirmatory order. The unique nature of each ADR settlement agreement should be used as a guide when selecting the most appropriate inspection follow-up procedure. ADR follow-up may be performed using IP 92702, “Follow up on Traditional Enforcement Actions Including Violations, Deviations, Confirmatory Action Letters, Confirmatory Orders, And Alternative Dispute Resolution Confirmatory Orders,” IP 92722, “Follow Up Inspection For Any Severity Level I or II Traditional Enforcement Violation or for Two or More Severity Level III Traditional Enforcement Violations in a 12-Month Period,” or IP 92723, “Follow-Up Inspection for One Severity Level III and Two Severity Level IV Traditional Enforcement Violations or for Three or More Severity Level IV Traditional Enforcement Violations in the Same Area in a 12-Month Period.”

b. Traditional enforcement actions incurred by the licensee shall be continuously monitored to determine if follow up inspection is needed. At the time a traditional enforcement action is issued, the staff shall determine if the licensee meets the criteria for a follow-up inspection under IP 92723 or IP 92722 by determining if any additional traditional enforcement actions were issued during the previous 12 months within the same area of willfulness, impeding the regulatory process, or actual consequences. If the region determines that follow up inspection is appropriate, this will be documented in the cover letter accompanying the enforcement action. If the region determines that follow up inspection is not warranted, this should also be documented. The basis for either decision should be described. Regions should consider only TE violations that involve willfulness, impeding the regulatory process, or which involve actual safety consequences when determining whether to discuss the need to perform a TE follow-up inspection. The staff may also consider if additional followup inspection is warranted for the traditional enforcement action under IP 92702; however, because individual TE violations are outside of the ROP and follow-up may be conducted under a baseline inspection procedure, documentation of the decision to implement or not implement IP 92702 is not required.

Individual traditional enforcement violations not involving ADR normally receive limited follow-up using IP 92702 to ensure they have been captured in the licensee’s corrective action program. If more detailed follow-up is planned using other inspection procedures, performing the limited follow-up using IP 92702 is not required.

The regional office may perform IP 92722 to follow up on any SL I or II traditional enforcement violation or two or more SL III violations incurred by the licensee during any 12-month period. The purpose of this inspection is to ensure that the causes of the violations are understood and that the licensee has adequately evaluated the extent of cause and the impact of the violations on safety culture. The regional office may perform IP 92723 to follow up on three or more SL IV violations or one SL III and two SL IV violations in one of the traditional enforcement areas of willfulness, impacting the regulatory process, or actual consequences incurred by the licensee during any 12-month period. Non-cited violations (NCVs) should be counted. The purpose of this inspection is to ensure that the causes of the group of violations are understood, and that licensee has adequately evaluated the extent of condition.

# 0305-14	CROSS-CUTTING ISSUES

The NRC identifies a cross-cutting issue (CCI) to inform the licensee that the NRC has a concern with the licensee’s performance in the cross-cutting area and to encourage the licensee to take appropriate actions before more significant performance issues emerge. The CCAs are described in IMC 0310. CCAs are assigned, themes are monitored, and CCIs are identified on a “per site” basis, not on a “per unit” basis. In order to determine whether CCIs exist at a site, an assessment must be performed during the preparation for the second quarter assessment review (four quarters from July – June) and end-of-cycle assessment meetings (four quarters from January – December), as described below.

## 14.01	Cross-Cutting Themes

To determine if a cross-cutting theme exists at a site, the regional offices shall gather inspection results related to CCAs, as described below.

a. Human Performance and Problem Identification and Resolution Themes. A search of PIM entries should be conducted for findings having CCAs in the cross-cutting areas of HU and/or PI&R. This should be completed based on two, overlapping, 12-month assessment periods: January-December and July-June. A cross-cutting theme in the area of HU or PI&R exists if six or more of these findings were assigned the same CCA. The findings should be representative of more than one cornerstone; however, given the significant inspection effort applied to the Mitigating Systems Cornerstone, a cross-cutting theme can exist consisting of inspection findings associated with only this one cornerstone.

A cross-cutting theme also exists if during the assessment period, a licensee has at least 20 findings with CCAs in the Human Performance cross-cutting area, or 12 findings with CCAs in the Problem Identification and Resolution cross-cutting area.

b. Safety Conscious Work Environment Themes. SCWE-related issues from an 18-month period (i.e., the second quarter assessment review or the end-of-cycle assessment period and the two quarters preceding that period) shall be considered. Declining SCWE trends take time to manifest; similarly, they also require time to correct and improve. For this reason, an 18-month period after a SCWE theme is identified is warranted to assess the effectiveness of SCWE-related corrective actions. The start date is the beginning of the quarter in which the input counted, i.e., the same quarter as the start date of the finding, or the date of the chilling effect letter or correspondence documenting potential discrimination. A cross-cutting theme in the area of SCWE exists if at least one of the following three conditions exists:

1.	There is a finding in the PIM with a documented CCA in the area of SCWE, and the impact on SCWE was not isolated.

For the purpose of this IMC, “not isolated” means more than one individual is impacted (e.g., multiple individuals, functional groups, shift crews, or levels within the organization are affected). Consideration should be given to: the roles, responsibilities, and job functions of the impacted individuals; insights from the most recent PI&R inspection; and the number and nature of allegations received during the review period.

2.	The licensee has received a chilling effect letter during the assessment period, or one remains open.

3.	The licensee has received correspondence from the NRC that transmitted (1) a SL I, II, or III enforcement action that involved discrimination or (2) a confirmatory order that involved discrimination. The theme applies only to the sites(s) where the discrimination occurred.

If the Region documents that the licensee has adequately addressed the SCWE concern identified in the chilling effect letter or enforcement correspondence and concludes it is no longer indicative of current licensee performance during the 18-month review, then the cross-cutting theme no longer exists and does not require documentation as a cross-cutting theme in subsequent assessment letters.

## 14.02	Opening Cross-Cutting Issues

The first time that a licensee meets the criteria for a cross-cutting theme, the region will document the theme in the assessment letter. The region should review licensee actions with regards to a causal analysis and/or corrective actions for that theme.

For the second consecutive assessment period with the same cross-cutting theme, the region will document the theme in the assessment letter again. If not already done, the region should consider the effectiveness of licensee actions (e.g., additional findings with the same aspect during the last six months of the assessment cycle) in determining whether or not to perform additional follow-up of licensee corrective actions. Regional follow-up of licensee corrective actions could be accomplished through a PI&R inspection sample, a semi-annual trend review focused on the theme, or including it within the scope of a biennial PI&R inspection, if one is scheduled during the period.

For the third consecutive assessment period with the same cross-cutting theme, the region will open and document a cross-cutting issue (CCI) in the assessment letter, except if the theme is in SCWE. Because SCWE-related issues take time to correct, an 18-month period after a SCWE theme is identified is warranted to assess the effectiveness of SCWE-related corrective actions. Therefore, upon the fourth consecutive assessment cycle with the same theme in SCWE, the Region should open a CCI. However, if the Region concludes that the licensee has made sufficient progress in addressing the SCWE concern, they may choose not to open a CCI, but continue to document the cross-cutting theme until the licensee no longer meets the criteria.

If a licensee meets the criteria for a cross-cutting theme in more than one CCA and/or a cross-cutting area, each theme will be documented separately in the assessment letter. Multiple CCIs shall also be documented separately, if appropriate.

## 14.03	Closing Cross-Cutting Issues

a. CCIs can be closed only in assessment follow-up letters and annual assessment letters. If applicable, CAL closure could serve as a basis for closing a CCI in the following annual assessment letter. CAL closure for licensees exiting Column 4 of the Action Matrix will serve as the basis for closing out any existing CCIs.

b. The regional office shall establish the criteria for closing the CCI, and that criteria should be clearly described in the assessment letter. The CCI should be closed out through a follow-up inspection. IP 71152 can be used to close out CCIs in the Human Performance and PI&R cross-cutting areas. IP 93100 can be used to close out SCWE-related CCIs; however, it would not typically be used to follow-up on licensee actions when a SCWE theme is initially identified in order to give the licensee time to correct the concern. Additional examples of closure criteria include, but are not limited to, the following or any combination of the following:

1.	Fewer findings with the same CCA as the CCI. In this case, if the number of findings with the same CCA as the CCI in the current assessment period is less than the number of findings when the CCI was opened, then the CCI could be closed.

2.	Increased confidence in the licensee’s ability to address the CCI. In this case, if the staff has confidence in the licensee’s scope of efforts or progress in addressing the CCI, even though the cross-cutting theme criteria continue to be met, then the CCI would be closed.

3.	An improving trend in the number of findings with the same CCA as the CCI during the most recent half of the assessment period. In this case, if the licensee made significant improvements in the last half of the assessment period but still meets the cross-cutting theme criteria, then the CCI could be closed.

c. The decision to continue to identify a CCI in the next assessment letter will be based on whether the closure criteria were met.

## 14.04	Follow-up Actions for Cross-Cutting Issues

a. If the NRC issues a CAL to a licensee that confirms a licensee’s agreement to make improvements and if the improvements would provide a basis for the region to close a CCI, then the NRC’s follow-up and closure actions for the CAL can serve as CCI follow-up. The CCI closure criteria defined in the assessment letter can reference the CAL actions.

b. After identifying a CCI to a licensee in an assessment letter, the staff shall follow-up on the CCI. Examples of how the staff may follow-up on a CCI include: (1) semi-annual evaluations conducted during the second quarter assessment and end-of-cycle performance reviews, and (2) inspections performed in accordance with IP 71152. ADR follow-up actions, as described in section 13.02.a, may also provide an additional mechanism for CCI follow-up, if applicable.

c. In the second consecutive assessment letter identifying the same CCI, the regional office may consider requesting: (1) the licensee to provide a response at an annual or other public meeting; (2) the licensee to provide a written response to the CCI(s) identified in the assessment letters, or (3) a separate meeting be held with the licensee.

If the NRC requests a meeting with the licensee, the plant’s Action Matrix column will be used to determine the appropriate level of management to chair the meeting and whether a public meeting is required. The regional branch chief or division director should chair the meeting for plants in Column 1.

The regional office should use IP 71152 to evaluate the licensee’s progress in addressing the CCI.

The regional office may request the licensee to perform an assessment of safety culture. [C4] The regional office would typically request the licensee to perform an independent safety culture assessment. The regional office could decide that a safety culture assessment request is not necessary if the licensee has made reasonable progress in addressing the issue but has not yet met the specific CCI closure criteria.

The regional office should review the licensee’s safety culture assessment using the IMC 2515, Appendix C, infrequently performed inspection procedure, IP 40100. The purpose of this inspection will be to confirm that the licensee is appropriately addressing any weaknesses identified by the safety culture assessment. The inspection results should be documented in an inspection report and can serve as a basis for closing the CCI in the next assessment letter.

Because SCWE-related CCIs may be more difficult for licensees to address and that corrective actions require more time to take effect, the regional office can defer requesting the licensee to conduct a safety culture assessment and deciding to perform the IP 40100 inspection until the third consecutive assessment letter identifying the same SCWE-related CCI.

d. If the same CCI is identified beyond the second consecutive assessment letter, and all of the options proposed above have been exhausted, the regional office may consider additional actions (e.g., actions not prescribed by the Action Matrix) to address the issue. One option is either the Regional Administrator, the Director of NRR, or both may choose to meet with the licensee’s Board of Directors to discuss licensee performance. Additional actions should be developed in consultation with the Director of NRR and the EDO.

# 0305-15	REFERENCES

Atomic Energy Act of 1954 as amended

IMC 0306, “Planning, Scheduling, Tracking and Reporting of the Reactor Oversight Process (ROP)”

IMC 0310, “Aspects within the Cross-Cutting Areas”

IMC 0326, “Operability Determinations”

IMC 0350, “Oversight of Reactor Facilities in Shutdown Condition Due To Significant Performance and/or Operational Concerns”

IMC 0375, “Implementation of the Reactor Oversight Process at Reactor Facilities in an Extended Shutdown Condition for Reasons Not Related to Performance”

IMC 0608, “Performance Indicator Program”

IMC 0609, “Significance Determination Process”

IMC 0609, Attachment 2, “Process for Appealing NRC Characterization of Inspection Findings (SDP Appeal Process)”

IMC 0612, “Issue Screening”

IMC 0801, “Inspection Program Feedback Program”

IMC 2201, “Security Inspection Program for Operational Commercial Power Reactors”

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

IMC 2515, Appendix B, “Supplemental Inspection Program”

IMC 2515, Appendix C, “Special and Infrequently Performed Inspections”

IP 40100, “Independent Safety Culture Assessment Follow-up”

IP 71152, “Problem Identification and Resolution”

IP 92702, “Follow up on Traditional Enforcement Actions Including Violations, Deviations, Confirmatory Action Letters, Confirmatory Orders, And Alternative Dispute Resolution Confirmatory Orders”

IP 92722, “Follow Up Inspection for Any Severity Level I or II Traditional Enforcement Violation or for Two or More Severity Level III Traditional Enforcement Violations in a 12 Month Period”

IP 92723, “Follow-Up Inspection for One Severity Level III and Two Severity Level IV Traditional Enforcement Violations or for Three or More Severity Level IV Traditional Enforcement Violations in the Same Area in a 12-Month Period”

IP 93100, “Safety-Conscious Work Environment Issue of Concern Follow-up “

IP 95001, “Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response) Inputs”

IP 95002, “Supplemental Inspection Response to Action Matrix Column 3 (Degraded Performance) Inputs”

IP 95003, “Supplemental Inspection Response to Action Matrix Column 4 (Multiple/Repetitive Degraded Cornerstone) Inputs”

MD 8.3, “NRC Incident Investigation Program”

MD 8.14, “Agency Action Review Meeting”

NFPA 805, “Performance-Based Standard for Fire Protection for Light-Water Reactor Electric Generating Plants”

NRC Enforcement Manual

NRC Enforcement Policy

NUREG-2165, “Safety Culture Common Language”

END

Issue Date: 05/04/23	1	0305

Figure 1: Reactor Oversight Process Action Matrix

Issue Date: 05/04/23	F1-1	0305

1 The IMC 0350 Process column is included for illustrative purposes only and is not necessarily representative of the worst level of licensee performance. Plants in the IMC 0350 oversight process are considered outside the auspices of the ROP Action Matrix. See IMC 0350, “Oversight of Reactor Facilities in a Shutdown Condition due to Significant Performance and/or Operational Concerns,” for more information.

2 Other than the CAL, the regulatory actions for plants in the Multiple/Repetitive Degraded Cornerstone and IMC 0350 columns are not mandatory NRC actions. However, the regional office should consider each of these regulatory actions when significant new information regarding licensee performance becomes available.

3 These specific stakeholders shall be notified if a plant is moving to the specified column because of security-related issues. 

4 The timing of the meeting shall be based on a collegial determination by the Commission informed by a recommendation from the EDO, and may exceed the six-month requirement.

Issue Date: 05/04/23	F1-1	0305

Figure 2: Assessment Activities

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Figure 3: Reactor Oversight Process

* The Commission has decided that certain information related to findings and performance indicators pertaining to the Security Cornerstone will not be publicly available to ensure that security information is not provided to a possible adversary. Therefore, security-related information will not be discussed during public meetings.

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Figure 4: Regulatory Framework

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Attachment 1: Revision History for IMC 0305

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