**NRC INSPECTION MANUAL**	IRAB

INSPECTION PROCEDURE 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

Effective Date: 10/01/21

PROGRAM APPLICABILITY:  2515C, 2504A, 2504B, 2201C, 2200A, 2600

This procedure provides the follow up response for the following:

· Any Severity Level (SL) I and II violation in the traditional enforcement areas of willfulness, impeding the regulatory process or actual consequence.

· Two or more SL III violations in the traditional enforcement areas of willfulness, impeding the regulatory process or actual consequence in any 12-month period.

92722-01	INSPECTION OBJECTIVES

01.01 To provide assurance that the cause(s) of individual SL I and II violations or multiple SL III traditional enforcement violations are understood.

01.02 To independently assess the extent of condition and the extent of cause for individual SL I and II violations or for multiple SL III traditional enforcement violations.

01.03 To provide assurance that licensee corrective actions for escalated traditional enforcement violations are adequate to address the causes and preclude repetition.

01.04 To review the licensee’s evaluation of the contribution of safety culture to the escalated traditional enforcement violations.

92722-02	INSPECTION REQUIREMENTS

The following inspection requirements are generally applicable for a single SL I or SL II traditional enforcement violation.  However, the scope of this inspection should include all escalated traditional enforcement violations.  For example, if this procedure is being performed due to a single SL I or SL II violation, the inspection scope should also include any SL III traditional violations in the past 12 months.

If this procedure is being performed in response to two or more SLIII traditional enforcement violations in a 12-month period and if the violations were previously inspected using either IP 92702, “Follow-up on Traditional Enforcement Actions including Violations, Deviations, Confirmatory Action Letters, and Orders, IP 71152, “Problem Identification and Resolution,” or a supplemental inspection a re-inspection is not required.  This follow-up inspection is designed to look at the licensee’s collective evaluation of multiple violations.

The comprehensiveness of the licensee’s evaluation(s) should also be considered.  If significant weaknesses in the licensee’s evaluation of the violations are identified, including weaknesses in their evaluation of the contribution of safety culture, consideration should be given to performing a more in-depth programmatic review of the licensee’s corrective action program.

02.01	Problem Identification

a. Determine that the evaluation identifies who and under what conditions the issue(s) was identified.

Guidance:  The evaluation should state how and by whom the issue was identified. When appropriate, evaluate the failure of the licensee to identify the problem at a precursor level.  Examples would include a failure of the licensee’s staff to enter a recognized non-compliance into the corrective action program, or raise safety concerns to management, or the failure to complete corrective actions for a previous problem resulting in further degradation. If the NRC identified the violations, the licensee’s evaluation should address why processes such as peer review, supervisory oversight, inspection, testing, self-assessments, or quality activities did not identify the problem.

b. Determine that the evaluation documents how long the issue existed, and prior opportunities for identification.

No specific guidance

02.02	Evaluate Cause, Extent of Condition, and Extent of Cause Evaluations

a. Determine that the SL I or SL II violation or the group of SL III violations received an evaluation at an appropriate level of detail using a systematic method(s) to identify cause(s).

Guidance:  The determination of the cause(s) can be achieved using a variety of different methods. Regardless of the method or combination of methods selected by the licensee, the results should normally include:

1. A clear identification of the problem and the assumptions made as a part of the evaluation.  The evaluation should have been conducted until the causes were beyond the licensee’s control.

2. A collective evaluation of the causes for indications of more significant problems with a process or system should be done when there are multiple issues.  For example, a problem that involved several procedural inadequacies or errors may indicate a more fundamental or programmatic problem in the processes for procedural development, control, review, and approval.  Issues associated with personnel failing to follow procedures may also be indicative of a problem with supervisory oversight and communication of standards.

3. A determination of potential process issues (such as procedures, work practices, operational policies and supervision) and human performance issues (such as training, communications, human system interface, and fitness for duty).

b. Determine that the evaluation included a consideration of prior occurrences of similar problems.

Guidance:  The evaluation should include a proper consideration of repeat occurrences of the same or similar problems at the facility.  This review is necessary to help in determining if the violation(s) is due to a more fundamental concern involving weaknesses in the licensee’s corrective action program.

c. Determine that the evaluation addresses the extent of condition and the extent of cause of the problem.  See IMC 2515 Appendix B, “Supplemental Inspection Program” for extent of condition and the extent of cause definitions.

Guidance:

1. The extent of condition review should assess the degree that the actual condition (improper human action, etc.) may exist in other areas.

2. The extent of cause review should focus more on the actual causes of the condition and on the degree that they have resulted in additional weaknesses. The extent of cause review should assess the applicability of the causes across disciplines or departments, for different programmatic activities for human performance.

02.03	Corrective Actions

a. Determine that appropriate corrective action(s) are specified for each cause or that there is an evaluation that no actions are necessary.

Guidance:  Address each cause of the violation(s) and the extent of condition of the issue.  The corrective actions should be clearly defined.  The proposed corrective actions should not create new or different problems as a result of the corrective action.  If the licensee determines that no corrective actions are necessary, the basis for this decision should be documented in the evaluation

b. Determine that the corrective actions have been prioritized with consideration of the regulatory compliance.

Guidance:  The corrective action plan should include a review of the regulations to ensure that if compliance issues exist, the plan achieves compliance.   The licensees should prioritize the type of corrective action chosen.  Attention should be given to solutions that involve only changing procedures or providing training as they are sometimes over-utilized.  In such cases, consideration should be given to more comprehensive corrective actions.

c. 

d. Determine if a schedule has been established for implementing and completing the corrective actions.

Guidance:  The corrective actions are assigned to individuals or organizations that are appropriate to ensure that the actions are taken in a timely manner.  Also, the licensee should ensure that there is a formal tracking mechanism established for each of the specific corrective actions.

e. Determine if measures of success have been developed for determining the effectiveness of the corrective actions to preclude repetition.

Guidance:  The licensee should have identified a method to be used to measure the effectiveness of the corrective actions.  Effective methods would include, but are not limited to, assessments, audits, inspections, tests, and trending of plant data, or follow up discussions with plant staff.  Corrective actions are taken for any weaknesses identified during the licensee’s review of extent of condition and extent of cause.

02.04 Independent Assessment of the Extent of Condition and Extent of Cause.  Perform a focused inspection to independently assess the validity of the licensee’s conclusions regarding the extent of condition and extent of cause of the issues.  The intent is not to re-perform the licensee’s evaluation, but rather to independently review other areas of licensee performance for the key attributes of the violation.

For example, if the issue was a falsification of fire watch logs, the inspector should review logs for other areas.  If the issue involved an individual willfully providing incomplete or inaccurate information, other information provided by the individual should be reviewed as well as a sampling of information provided by others but in same area.

Guidance:  The objective of the independent extent of cause review is to ensure that the licensee’s evaluation was of sufficient breadth and depth to identify other plant processes or human performance issues that may have been affected by the causes of the violations. For those instances where multiple violations have been documented, a broad-based inspection(s) assessing the different performance areas should be considered. If this procedure is being performed due to a single escalated enforcement action, a more focused inspection would be appropriate.

02.05	Safety Culture Consideration

Review the licensee’s evaluation to determine if safety culture components were considered as a cause of or a contributor to the traditional enforcement violations.

Guidance:  Determine if the cause evaluation considered whether a weakness in any safety culture components was a direct cause or a significant contributing cause to escalated traditional enforcement actions.  Review the licensee’s evaluation and/or discuss with appropriate licensee personnel, whether safety culture was considered as a possible cause of the violations.  If so, verify that the evaluation included at least those components that the inspectors determined could reasonably have been a contributor to the violation(s).

92722-04	RESOURCE ESTIMATE

The resources required to complete this procedure will vary greatly depending upon the scope of the reviews needed to independently assess the validity of the licensee’s evaluation of extent of condition and extent of cause.  Generally, it would be expected that the procedure could be completed within 24-40 hours.  The amount of time to perform the inspection is a function of the number of findings followed up, as well as the scope and depth of the follow-up activity.

92722-05	PROCEDURE COMPLETION

Procedure is considered complete when the inspection objectives in Section 92722-01 are satisfied.  A failure to satisfy the inspection objectives may result in continuation or follow-up inspection under this IP, after the licensee indicates their readiness.  When applicable, document the reasons why the inspection objectives could not be satisfied.

92722-06	REFERENCES

IP 71152, “Problem Identification and Resolution”

IP 92702, “Follow-up on Traditional Enforcement Actions including Violations, Deviations, Confirmatory Action Letters, and Orders”

IMC 0305, “Operating Reactor Assessment Program”

IMC 2515 Appendix B, “Supplemental Inspection Program”

END

2

95002		Issue Date: 10/16/06

Issue Date:  09/16/21	1	92722

Attachment 1:  Revision History for IP 92722

2

Issue Date: 

Issue Date: 09/16/21	Att1-1	92722