**NRC INSPECTION MANUAL**	IRAB

INSPECTION PROCEDURE 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

Effective Date:  10/01/2021

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

This procedure provides the follow-up for one Severity Level (SL) III and two SL IV or three or more SL IV violations when all occur within a single traditional enforcement area of willfulness, impeding the regulatory process, or actual consequence during any 12-month period, as specified by Inspection Manual Chapter (IMC) 0305, “Operating Reactor Assessment Program.”

92723-01	INSPECTION OBJECTIVES

01.01	To provide assurance that the cause(s) of multiple traditional enforcement violations are understood by the licensee.

01.02	To provide assurance that the extent of condition and extent of cause of multiple traditional enforcement violations are identified.

01.03	To provide assurance that licensee corrective actions to traditional enforcement violations are adequate to address the cause(s).

92723-02	INSPECTION REQUIREMENTS AND GUIDANCE

This follow-up inspection is designed to look at the licensee’s collective evaluation of multiple violations to identify and address any commonalities.  Violations that were satisfactorily inspected using IP 92702, “Follow-up on Traditional Enforcement Actions including Violations, Deviations, Confirmatory Action Letters, and Orders” or IP 71152, “Problem Identification and Resolution” should not be reinspected.

02.01	Problem Identification

Determine that the licensee’s evaluation identifies how each of the issues were identified, how long each issue existed, and prior opportunities for identification.

Guidance:  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.

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

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

Guidance:  The determination of 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 and until the problem(s) are fully understood.

2. A collective evaluation of the cause(s) for indications of more significant problems with a process or system should be done when there are multiple issues.  For example, issues associated with personnel failing to follow procedures may 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 how prior occurrences in the same traditional enforcement area (willfulness, regulatory process, or consequences) were addressed by the licensee.

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 violations are 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 repeated traditional enforcement violations and the extent that they could have resulted in additional violations.  The extent of cause review should assess the applicability of the root 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 identified for the group of violations or that there is an evaluation indicating that no actions are necessary.

Guidance:  The cause(s) of the group of violations and the extent of condition of the cause(s) should be addressed and 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.  Typically, this would be the result of finding that the violations were unrelated.

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

Guidance:  The corrective action plan should achieve 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-used.  In such cases, consideration should be given to more comprehensive corrective actions.

c. Determine that a schedule has been established for implementing and completing the corrective actions.

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

92723-04	RESOURCE ESTIMATE

It is estimated that this procedure will take between 24 to 32 man-hours to complete.

92723-05	PROCEDURE COMPLETION

This procedure is considered complete when the inspection objectives in Section 92723-01 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.

92723-06	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

Issue Date: 09/16/21	1	92723

Attachment 1:  Revision History for IP 92723

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Issue Date: 

Issue Date: 09/16/21	Att1-1	92723