**NRC INSPECTION MANUAL**	NMSS/DUWP

INSPECTION PROCEDURE 87305

# DECOMMISSIONING MANAGEMENT ORGANIZATION AND CONTROLS

Effective Date: 12/30/2022

PROGRAM APPLICABILITY: IMC 2602

# 8730501	INSPECTION OBJECTIVES

01.01	To ensure if licensee’s management organization and controls comply with licensee and U.S. Nuclear Regulatory Commission (NRC) requirements.

01.02	To ensure that that the licensee effectively manages facility organization, changes, independent review committees, internal reviews and audits, routine site inspections, and facility procedures. 

# 8730502	INSPECTION REQUIREMENTS 

Conduct  performance-based inspections with an emphasis on risk-significant activities that have impact of safety and the environment. As described in IMC 2602 risk modules are used to focus inspection efforts on onsite activities that have been determined to be important to reducing risks at decommissioning sites. This procedure specifically addresses risk module (RM-06) management organization and control which includes: facility organization during decommissioning, procedure controls, internal reviews and audits, safety committees, and decommissioning program management for radiation protection, fire protection, chemical safety, nuclear criticality safety (NCS), and quality assurance (QA) programs for uranium recovery, fuel cycle and materials decommissioning facilities as applicable. 

## 02.01	Organizational Structure

Verify that the licensee has implemented a decommissioning organization in accordance with license requirements.  The organization plan should include defined qualifications, responsibilities, and functions to administer the decommissioning program.

## 02.02	Management and Administrative Practices for Radiation Protection, Fire Protection, Chemical Safety, and NCS

Review the licensee’s safety program and policies, license and other commitments to NRC related to radiation safety, fire protection, chemical safety and nuclear criticality (if applicable) and verify that the program is being implemented as required based on the commitments made.  As needed review other useful documents such as: Material Safety Data Sheets, National Fire Protection Association recommendations, etc. to ensure the inspector understands the hazards onsite.

## 02.03	Procedure Controls

Verify that the licensee has implemented a system of written procedures that ensures the existence and use of only approved and current written procedures (including radiation work permits) for all decommissioning activities.

## 02.04	Problem Identification and Resolution and Incident Investigations

Ensure the licensee has implemented a system of internal reviews, self-assessments, and audits to identify, prioritize, and correct deficiencies related to regulated decommissioning activities. Verify the licensee has implemented a program for review of safety-significant events that meets NRC requirements.

## 02.05	Safety Committees

Determine whether the safety committee (or equivalent) required by the license is operating per the associated charter and implementing procedures.

## 02.06	QA Programs

Determine whether the QA programs (or equivalent) required by the license are being implemented per the relevant procedures.

## 02.07	Additional Protocol (AP) Reporting Requirements

For uranium recovery and fuel cycle facilities, determine if the licensee is reporting to the NRC in accordance with the AP to the Agreement Between the United States of America (U.S.) and the International Atomic Energy Agency (IAEA) for the Application of Safeguards in the United States. Reporting requirements for locations and sites are provided in Title 10 of the *Code of Federal Regulations* (10 CFR) 40.31(g), “Application for specific licenses,”10 CFR 70.21(g), “Filing,” 10 CFR 75.10, “Facilities,” and 10 CFR 75.11, “Locations.”

# 8730503	INSPECTION GUIDANCE

Although applicable requirements will be found in each specific facility license, the inspectors should review the specified program areas for general safety information. The items selected for inspection should be based on the risk significance or as deemed appropriate.

This decommissioning Inspection Procedure (IP) is based on IP 88005, “Management Organization and Controls,” which applies to operational fuel cycle facilities that are required to comply with 10 CFR Part 70, Subpart H, “Additional Requirements for Certain Licensees Authorized To Possess a Critical Mass of Special Nuclear Material,” including requirements for a safety program, integrated safety analysis (ISA), and management measures. However, the regulations in Subpart H do not apply to decommissioning activities. For this reason, decommissioning fuel cycle licensees may no longer have active safety programs, ISAs, and management measures, and, as a result, those Subpart H requirements are not cited in this procedure. Programs required by regulations other than Subpart H, such as proposed procedures to protect health and minimize danger to life or property that are described in the licensee’s decommissioning plan, such as radiation protection, fire protection, and criticality safety, should continue until regulated hazards are removed and the license is amended to remove these programs.

## 03.01	Organizational Structure

Discuss with licensee representatives any organizational changes, structural changes, and/or changes in personnel responsibilities and functions that have occurred since the last inspection. Determine whether the individuals who made the changes were qualified to make them, and whether the changes were approved by NRC's appropriate licensing branch, or as otherwise required by the license or the licensee’s procedures.

Review licensee procedures that govern the types of changes specified above. Determine whether these procedures were properly implemented to effect the changes made. By discussions with selected licensee managers who are new to their positions since the last inspection, and where appropriate, review of documentation, determine whether these managers meet the training and experience requirements for their positions as specified in the license.

Changes in organization and organizational structure need only be examined with particular attention to changes in personnel, qualifications of personnel, functions, responsibilities, and authorities. If no significant changes have occurred in the organization since the previous inspection, then the inspection report should state that there have been no significant changes in the organization since the previous inspection.

## 03.02	Management and Administrative Practices for Radiation Protection, Fire Protection, Chemical Safety, and NCS

Safety Policy. By discussions with management and review of documentation, determine whether the written policy describing each employee’s authority and responsibility for radiation protection, fire protection, chemical safety, and NCS remains unchanged. If changed, confirm that the changes do not adversely affect safety by reducing organizational and/or personal responsibility and are consistent with license requirements.

The safety policy should express the overall importance of safety in relation to decommissioning activities. The safety policy should empower each employee to question the adequacy of safety requirements and should prohibit decommissioning operations when safety questions cannot be immediately resolved. Furthermore, the safety policy should ensure that each individual, regardless of position, is ultimately responsible for safety in  their own work area. If any changes are made to the safety policy, the inspector should confirm that the changes do not diminish personal or organizational responsibility for safety.

a. Management Responsibilities for Safety

1. Decommissioning Managers. By observation and discussion with various employees, determine whether the decommissioning managers have empowered every employee with the authority, responsibility, and training to ensure safe decommissioning activities. Determine whether the decommissioning managers show adequate knowledge and interest in safety issues and that the decommissioning managers holds their staff accountable for safe decommissioning activities.

The decommissioning managers should demonstrate overall responsibility for safety by showing continued interest in the various safety disciplines. The responsibility for establishing practices carrying out the radiation protection, fire protection, chemical safety, and NCS requirements should be delegated through instructions and procedures. The decommissioning managers are also expected to monitor the safety program by instituting operational reviews and for periodic independent reviews of the safety organization. Determine the level of the decommissioning managers’ direct observations of safety conditions.

2. Decommissioning Supervisors. Interview selected decommissioning supervisors to determine the adequacy of their understanding of their roles in implementing the facility safety policies. Supervisors should demonstrate an appropriate level of knowledge of decommissioning safety, radiation protection, fire protection, chemical safety, and NCS for operations under their management. Determine the degree to which supervisors participate in the development and maintenance of procedures affecting their areas. Determine whether the supervisors expect and enforce procedural compliance. Supervisors should ensure that employees in their areas receive the required initial and periodic safety training.

3. Support Function Management. Support functions are those areas which are not directly involved in decommissioning activities, such as engineering, maintenance, QA, and quality control. Determine whether the managers in support functions are effectively involved in ensuring the effectiveness of the facility safety policy. Support function managers should carry out their responsibilities for radiation protection, fire protection, chemical safety, and NCS in a manner similar to decommissioning managers. Safety responsibilities should be conveyed to individuals in each manager's organization in written documents and covered in training programs.

4. Safety Culture Awareness. In general, there are no specific regulatory requirements for safety culture; however, the inspector should  determine a general sense of the licensee’s safety culture for licensed activities (e.g., workers have a “questioning attitude” and generally adhere to procedures, workers are duly cautious when engaged in licensed activities, or workers are willing to raise safety concerns). The inspector’s conclusions about safety culture may be useful when violations are identified and linked to significant risk (i.e., there are an unacceptable number of occurrences with unacceptable health and safety consequences). More information on NRC’s Safety Culture Policy Statement can be found at https://www.nrc.gov/about-nrc/safety-culture.html.

b. Management Involvement in Decommissioning Procedures and Safety Committees

1. Decommissioning Procedures. Determine whether administrative procedures exist to ensure that the radiation protection, fire protection, chemical safety, and NCS functions are consulted whenever a change or new activity affects these programs. Determine whether revised decommissioning procedures are approved by cognizant safety program managers whenever process changes are made.

Requirements should be established for developing, approving, and updating administrative and decommissioning procedures for activities involving radiation protection, fire protection, chemical safety, and NCS.

2. Safety Committee. Determine whether the safety committee (or equivalent) meets in accordance with its governing charter and procedures. Determine whether designated managers attend these committee meetings regularly.

## 03.03	Procedure Controls

Review any risk-significant changes made to the licensee’s procedures to determine whether the review and approval process was in accordance with program requirements.

a. Procedure Content and Approvals. Review a sample of recently changed procedures to determine whether the licensee’s system for approving procedures complies with license requirements. Such procedures should include, but not be limited to, decommissioning operations, maintenance, training, health physics, and NCS. Determine whether:

1. Procedure changes are reviewed and approved as required by the license;

2. All personnel affected by a procedure are adequately and timely informed of changes in the procedures;

3. Only approved and current procedures are used; and

4. Any previously approved field changes have been incorporated into the changed procedure within an established time period.

b. Procedure Revising and Updating. By reviewing a sample set of procedures, and  discussions with relevant staff, determine whether the licensee reviews and updates all safety-significant procedures on a periodic basis. This review should be conducted  as required by the license or a method defined by a licensee procedure. By discussions, or by reviewing corrective action documentation, determine whether revision and update of procedures is performed on a timely basis as a result of any procedural deficiencies found, regardless of the periodic review schedule.

## 03.04	Problem Identification and Resolution and Incident Investigations

A goal of the NRC’s oversight process is to establish confidence that each licensee is detecting and correcting problems in a manner that limits the risk to members of the public. One key component of this process is event review and/or incident investigation. Corrective action program reviews are completed during inspections.

a. Program Implementation. Perform a screening review of items entered into the corrective action program. The intent of this review is to be alert to conditions, such as repetitive equipment failures or human performance issues that might warrant additional follow-up through using this IP or core IPs. Use direct observation of operations, discussions with relevant staff, and review a sample of licensee corrective actions to:

1. Determine whether equipment, human performance, and program issues are being identified by the licensee at an appropriate threshold and actions are being taken to correct the issues.

2. By discussions with licensee staff, and reviewing records, determine whether the licensee is promptly reporting deficiencies to management, and adequately tracking corrective actions to completion.

3. Determine whether corrective actions commensurate with the significance of the issue have been identified and implemented by the licensee.

4. Determine whether the licensee is implementing a program for facility systems inspection (normally done on a shift or daily basis), or as otherwise required by license conditions and implementing procedures.

5. Determine whether the licensee has appropriately classified the issue and has taken appropriate short- and long-term corrective actions.

b. Audits and Assessments. Determine whether the licensee has conducted periodic reviews, audits, and assessments to assure that safety commitments in the license are assessed at an appropriate frequency. Select internal or contracted audits performed since the previous inspection and examine the records to determine whether there was a written plan for the audit, the audit adequately reviewed the audited area, appropriate corrective actions were taken whenever deficiencies were found, and whether there was a check of the effectiveness of the corrective action.

c. Incident Investigations. Review any safety-significant events occurring since the last inspection to determine compliance with the license including, as appropriate:

1. Determine whether all incidents have been reported to management (and NRC, if appropriate).

2. Determine whether an incident report, including date of incident, description of incident, contributing factors, root cause analysis, findings, and recommendations, has been provided to decommissioning management and NRC, if appropriate.

3. Ensure establishment of a system to promptly address and resolve findings and recommendations of the investigation team. Verify documentation of resolutions and corrective actions as required.

4. Verify that standard operating procedures, safety practices, training, configuration management, maintenance and inspection, emergency procedures, and planning are updated as required to prevent recurrence of the incident.

5. Ensure incident investigation reports are retained for a period specified in the license, or as stated in the licensee’s policy.

## 03.05	Safety Committees

Review changes since the last inspection to the membership, charter, and procedures for the onsite and/or offsite safety committees (or equivalent) to determine whether changes meet the license requirements. Determine whether meetings have been held at the required frequencies specified in the license. Examine the minutes of select meetings held by the safety committees since the previous inspection to determine whether the committees’ agenda items are in accordance with its charter. For recommendations made since the last inspection, determine whether management has accepted or rejected the advisory recommendations and that, for the accepted recommendations, implementing actions and schedules have been assigned to specific organizations. For rejected recommendations, the basis for rejection should be documented.

Determine whether the licensee has in place a process to designate alternate committee members when regular members are unavailable, as well as a stipulation as to what constitutes a quorum.

## 03.06	QA Programs

Determine whether the QA program is being conducted in accordance with the license requirements (if the license contains requirements for QA program). Examine QA records and interview licensee staff to determine if the licensee is implementing the QA program in accordance with license or regulatory requirements.

NOTE: Some licensees have a QA program for transportation only. Some licensees use 10 CFR Part 71, Subpart H, “Quality Assurance,” for transportation, or have an NRCapproved program combining the QA of 10 CFR Part 71, “Packaging and Transportation of Radioactive Material,” and 10 CFR Part 50, Appendix B, “Quality Assurance Criteria for Nuclear Power Plants and Fuel Reprocessing Plants.”

## 03.07	AP Reporting Requirements

Under the AP, commercial nuclear fuel cycle locations and sites are required to routinely report on peaceful nuclear activities within the U.S. to the Department of Commerce as required by one of the applicable regulations so that the U.S. fulfills its commitments under the AP. If a U.S. location or site is selected by the IAEA for implementation of international safeguards, these reporting requirements continue to apply during decommissioning activities until the location or site has been decommissioned for safeguards purposes as defined by the IAEA. When requested by NMSS, the inspector should determine if the licensee has been decommissioned for safeguards purposes. The purpose of this verification is to ensure these reports are accurate, complete, and consistent with regulatory requirements. The inspector should consult with International Safeguards Analysts in the NMSS Material Control and Accounting Branch for information on which annual submissions are required for facilities in decommissioning. 

# 8730504	RESOURCE ESTIMATE

An inspection performed using this IP is estimated to require 2-16 hours of inspector resources. This estimate is only for the direct inspection effort and does not include preparation for and documentation of the inspection.

# 87305-05	PROCEDURE COMPLETION

This IP is complete when the inspection staff observe the activities, interview site staff, and review records as needed to satisfy the objectives of this IP. This IP should be completed as needed during a decommissioning project, based on site activities, and as described in the inspection schedule.

# 8730506	REFERENCES

IMC 2602, “Fuel Cycle and Materials Decommissioning Inspection Program.” December 2022.

IP 88005, “Management Organization and Controls.”

NRC Regulatory Guide 3.52, Revision 1, "Standard Format and Content for the Health and Safety Sections of License Renewal Applications for Uranium Processing and Fuel Fabrication." November 1986

NUREG1520, "Standard Review Plan for the Review of a License Application for a Fuel Facility." March 2002.

END

# ATTACHMENTS

Attachment 1: Revision History for IP 87305

Issue Date: XX/XX/XXXX					    A1-1	88035, Att 1

Issue Date: 09/05/06		 				A-1				88005, Att 1

Issue Date: 12/15/22	1	87305

Attachment 1: Revision History for IP 87305

Issue Date: 12/15/22	Att1-1	87305