Nuclear Power: Analysis of Regional Differences and Improved Access to Information Could Strengthen NRC Oversight
Published: 2013-09-27T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The 2011 disaster at Japan's Fukushima Daiichi Nuclear Power Plant demonstrated that unexpected nuclear accidents with extreme consequences can occur and, thus, heightened concerns about NRC's ability to oversee the safety of U.S. commercial nuclear power reactors. NRC oversees safety through multiple processes, such as physically inspecting reactors and also responding to signs of declining performance (i.e., findings) or violations of its requirements.
GAO was asked to review NRC's oversight of the U.S. nuclear power industry. This report examines (1) how NRC implements its processes for overseeing the safety of commercial nuclear power reactors; (2) the extent to which NRC consistently identifies and resolves findings through these processes; and (3) NRC's methods for developing lessons learned to improve its oversight and challenges, if any, NRC faces in doing so. GAO reviewed NRC policies and guidance; visited five nuclear power plants located in multiple NRC regions; analyzed NRC data on findings, violations, licensee performance, and inspection hours; interviewed NRC officials and industry representatives; and observed demonstrations of NRC's database search tools.
section_title: What GAO Found
paragraphs: The Nuclear Regulatory Commission (NRC) relies on its staff's professional judgment in implementing its processes for overseeing the safety of U.S. commercial nuclear power reactors. In implementing this oversight, NRC allocates specific roles and responsibilities to resident inspectors assigned to each plant, regional officials at one of four regional offices responsible for most oversight activities, headquarters officials, and the nuclear power industry. NRC also builds into its processes incentives for plant managers to identify concerns about reactor safety, report those concerns to NRC, and take prompt actions to correct them. NRC's processes for identifying and assessing findings and violations are based on prescribed agency procedures and include several points where NRC staff must exercise their professional judgment, such as determining whether issues of concern identified during physical inspections constitute findings or violations and the risk significance of any findings or the severity of any violations, among other things.
NRC is aware of differences across regional offices in identifying and resolving findings that result from physical inspections. GAO's analysis of NRC's data indicated that the number of escalated findings had fewer differences across regions than nonescalated findings, which are lower-risk findings and less severe violations. According to NRC officials, several factors, such as the hours spent on inspections, may explain the differences in nonescalated findings. However, GAO found that the regional office with the fewest reactors and the fewest inspection hours had the most nonescalated findings. NRC officials and industry representatives have raised concerns that the differences may also be due to differences in how NRC staff identify and resolve findings. NRC has taken some steps to examine the consistency of its oversight. For example, in 2009, the four regional offices implemented an initiative to explore how the regional offices identify and assess inspection findings. However, NRC has not conducted a comprehensive analysis of the causes of the differences in the number of nonescalated findings across regions. Under federal standards for internal control, managers are to compare actual performance with planned or expected results throughout the organization and analyze significant differences. Without such an analysis, NRC does not know whether its regional offices are applying regulations and guidance consistently.
NRC has both formal and informal methods for developing lessons learned to improve its oversight. Formal methods include agencywide programs, annual and biennial assessments, and special initiatives. Informal methods include reaching out to peers and technical experts across the agency and accessing various agency databases. Although NRC guidance directs inspectors to use information in agency databases on past experiences to plan and conduct inspection activities, inspectors face challenges accessing this information, which may limit their ability to use it. For example, several NRC inspectors reported contacting other inspectors informally because NRC's database search tools contain limited instructions and do not ensure thorough results. Without better search tools, inspectors may overly rely on information available through informal channels.
section_title: What GAO Recommends
paragraphs: GAO recommends, among other things, that NRC analyze the causes of differences in identifying and resolving findings across regional offices and address these differences, and that it improve its database search tools. NRC agreed with GAO's recommendations.

section_title: Letter
paragraphs: In March 2011, an earthquake off the Pacific coast of Japan triggered a  tsunami that caused significant accidents at three reactors in the  Fukushima Daiichi Nuclear Power Plant complex, demonstrating that low- probability, high-consequence nuclear accidents can and do occur.  According to the Japanese parliament’s formal investigation, the damage  to the Fukushima reactors could have been avoided and resulted, in part,  from a failure of regulatory oversight in Japan. This event heightened  concerns about the safety of commercial nuclear power plants worldwide  and the ability of the Nuclear Regulatory Commission (NRC)—the  independent federal agency responsible for licensing and regulating U.S.  civilian nuclear activities—to oversee the safe operation of commercial  nuclear power reactors in the United States. In response to these  concerns, NRC convened a Fukushima Near-Term Task Force, which in  a July 2011 report concluded that a similar accident is unlikely to occur in  the United States and identified many opportunities for improving NRC’s  oversight.
NRC’s mission is, in part, to ensure adequate protection of public health  and safety from accidents involving commercial nuclear power reactors.  In fiscal year 2012, the licensing and regulating of commercial reactors  comprised over 75 percent—or approximately $800 million—of NRC’s  budget, of which the vast majority (87 percent) is collected in the form of  fees from industry. One of NRC’s stated goals is to ensure that its  oversight of reactor safety is objective, predictable, and understandable,  and according to NRC’s strategic plan, a key strategy in achieving its  mission is to conduct this oversight openly to inform the public and  maintain confidence in reactor safety. However, NRC’s Office of the  Inspector General (IG) reported in 2010, 2011, and 2012, that one of the  most serious management and performance challenges facing NRC is  the ability to effectively carry out its oversight responsibilities while  responding to emerging demands associated with licensing and  regulating new reactors.
NRC’s oversight will soon likely take on even greater importance as many  commercial reactors in the United States are reaching or have reached  the end of their initial 40-year operating period. Nuclear power’s  contribution to the nation’s supply of electricity—about 20 percent in  2012—will depend, in large part, on the continued operation of the  nation’s 100 operating commercial reactors. Most of these reactors have  had their licenses renewed to operate for another 20 years. However, as  we recently reported, NRC’s license renewal process primarily considers  issues related to the negative effects of aging on reactors and their  components. Other ongoing safety matters are not explicitly covered in  the license renewal process because NRC considers its ongoing  oversight processes as adequate to ensure that reactors are operated  safely and will continue to be in the future.
We and others have reported on NRC’s oversight of reactor safety. In  September 2006, we reported that NRC had taken several steps to  improve its oversight of nuclear reactors but had been slow to act on  needed improvements, in particular, in improving the agency’s ability to  identify and address early indications of declining safety performance. In  2008, NRC’s IG found that NRC’s regional offices were not consistently  implementing the agency’s enforcement program. Additionally, the  National Academy of Sciences is conducting a study and preparing a  report to NRC and Congress on lessons learned from the Fukushima  nuclear accident for improving the safety and security of U.S. nuclear  power plants. According to the National Academy of Sciences, this report  is expected to be issued publicly by the summer of 2014.
In this context, you asked us to review NRC’s oversight of the U.S.  commercial nuclear power industry. This report: (1) describes how NRC  implements its processes for overseeing the safety of commercial nuclear  power reactors; (2) evaluates the extent to which NRC consistently  identifies and resolves findings through these processes; and (3)  describes NRC’s methods for developing lessons learned to improve its  oversight and challenges, if any, NRC faces in doing so.
To address these objectives, we reviewed relevant federal laws,  regulations, and agency guidance covering NRC’s processes for  overseeing reactor safety. In addition, we reviewed previous GAO and  NRC IG reports that identified safety-related challenges or made  recommendations to improve NRC oversight. We also reviewed NRC’s  efforts to update its oversight processes. We interviewed NRC  headquarters officials, regional officials, and inspectors. We also visited a  nonprobability sample of five selected nuclear power plants and  conducted interviews with the NRC inspectors and plant managers and  operators at the plants. To select the five plants we visited—Calvert  Cliffs Nuclear Power Plant in Maryland, Byron Station in Illinois, Palisades  Nuclear Plant in Michigan, Cooper Nuclear Station in Nebraska, and Wolf  Creek Generating Station in Kansas—we used multiple criteria, including  whether a plant’s performance (as determined by NRC) has changed  (i.e., by improving or declining) in the past 2 years, and whether,  collectively, plants were located in multiple NRC regions, operated by  different companies that hold licenses to operate reactors (i.e., licensees),  and included different reactor types. We also analyzed NRC performance  data for all 65 plant sites from 2000 through 2012. To assess the  reliability of NRC’s data, we reviewed existing information about the data  and the system that produced them and interviewed agency officials  knowledgeable about the data. We found that these data were sufficiently  reliable for the purposes of our report. Our review focuses on NRC’s  oversight of the safe operation of reactors; physical security of plants is  outside the scope of this review. A detailed description of our objectives,  scope, and methodology is presented in appendix I.
We conducted this performance audit from May 2012 to September 2013  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: This background section describes NRC’s role and its processes for  overseeing reactor safety, specifically the Reactor Oversight Process and  the Traditional Enforcement Process.
subsections: section_title: Role of NRC
paragraphs: NRC is an independent agency of about 4,000 employees established by  the Energy Reorganization Act of 1974 to license and regulate U.S.  civilian—that is, commercial, industrial, academic, and medical—use of  nuclear materials. NRC is headed by a five-member Commission. The  President appoints these Commission members, who are confirmed by  the Senate, and designates one of them to serve as the Chair and official  spokesperson. NRC seeks to carry out its mission of ensuring safe  operation of the 100 commercial nuclear power reactors currently  operating in the United States from its headquarters office in Rockville,  Maryland, its four regional offices—in King of Prussia, Pennsylvania  (Region I); Atlanta, Georgia (Region II); Lisle, Illinois (Region III); and  Arlington, Texas (Region IV)—and resident (on-site) inspectors’ offices  located at 62 nuclear power plants in 31 states. (See fig. 1.) Appendix II  provides a complete list of the commercial nuclear power reactors  operating in the United States and additional information about each one.
Under the Atomic Energy Act, as amended, NRC is responsible for  issuing licenses to commercial nuclear reactors and conducting oversight  of activities under such licenses to protect the health and safety of the  public, among other things. NRC is authorized to conduct inspections and  investigations, to enforce its requirements, such as by issuing orders and  imposing civil (monetary) penalties, and to revoke licenses. To oversee  the activities of licensed commercial reactors, NRC has established  regulations, as well as guidance, including regulatory guides, standard  review plans, and NRC’s Inspection Manual. These regulations and  guidance, along with plant-specific licenses and technical specifications,  form the basis by which NRC provides continuous oversight of reactor  operations.
NRC’s oversight of commercial nuclear reactors includes monitoring their  performance in three strategic areas: (1) reactor safety, that is, avoiding  accidents and reducing the consequences of accidents if they occur; (2)  radiation safety, that is, ensuring safety from radiation for both plant  workers and the public during routine operations; and (3) safeguards, that  is, protecting of the plant against sabotage or other security threats.  These areas comprise seven cornerstones of NRC’s oversight (see table  1). According to NRC, reactors’ satisfactory performance in these  cornerstones provides reasonable assurance of safe operation. Our  review focuses on NRC’s oversight of the safe operation of reactors;  therefore, the physical security of plants (Physical Protection cornerstone)  is outside the scope of this review.
NRC also looks for systemic problems by monitoring reactors’  performance in three cross-cutting areas that extend across the  cornerstones:
Problem identification and resolution. The licensee (1) ensures that  issues potentially affecting nuclear safety are promptly identified, fully  evaluated, and addressed in a timely manner; (2) uses operating  experience information to support plant safety; and (3) conducts  performance assessments to identify areas for improvement.
Human performance. The licensee (1) makes decisions  demonstrating that nuclear safety is an overriding priority; (2) ensures  that staff, equipment, procedures, and other resources are available  and adequate to assure nuclear safety; (3) plans and coordinates  work activities consistent with nuclear safety; and (4) uses work  practices that support human performance.
Safety-conscious work environment. The licensee maintains an  environment in which employees feel free to raise safety concerns,  both to their management and to NRC, without fear of retaliation and  where such concerns are promptly reviewed, properly prioritized, and  appropriately resolved.
section_title: The Reactor Oversight Process
paragraphs: The Reactor Oversight Process (ROP) is the central component of NRC’s  oversight efforts. Under the ROP, NRC undertakes four key actions: (1)  reviewing key indicators of licensees’ performance; (2) physically  inspecting reactors; (3) assessing whether any findings resulting from  inspections are associated with any of the cross-cutting areas; and (4)  determining what actions, if any, to take in response to signs of declining  performance and any related violations of NRC requirements.
NRC technical specialists located at its regional offices review licensee  performance using quantitative measures or indicators of that  performance. According to NRC documents, performance indicators are  designed to illustrate a long-term view of a licensee’s performance—over  multiple quarters. Currently, NRC uses 17 performance indicators it  developed collaboratively with the industry to measure licensee  performance. Each performance indicator is designed to help gauge a  licensee’s performance within the different cornerstones outlined above.  For example, a performance indicator under the “Initiating Events”  cornerstone measures the number of unplanned reactor shutdowns  during the previous four quarters. Appendix III provides a list of the  safety-related (nonsecurity) performance indicators and related  cornerstones.
Each licensee voluntarily submits data quarterly for each performance  indicator, and NRC measures licensee performance from these data  against established numerical thresholds; assigning a color—green,  white, yellow, or red—to reflect increasing risk to reactor safety based on  these performance data. Specifically, a green indicator reflects  performance within an expected range, but white, yellow, and red  represent decreasing levels of a licensee’s performance (see table 2).
Physical inspections are one of the main tools NRC uses to oversee  licensee performance. During these inspections, NRC inspectors are to  verify the accuracy of the quarterly data for each performance indicator  supplied by the licensee and to assess aspects of licensee performance  that are not directly measured by the performance indicator data—for  example, confirming that fire protection equipment is in place and that  certain maintenance operations have occurred. These inspections cover  a wide variety of major systems and technical areas of nuclear power  reactors that NRC considers most critical to meeting the overall agency  mission of ensuring nuclear power plant safety. NRC currently has 52  different inspection procedures, and they are divided into three broad  types of inspections—baseline (46), supplemental (3), and reactive (3)— that vary by depth and objective. Appendix IV provides a list of inspection  procedures.
Baseline inspections. Baseline inspections are the minimum level of  inspections performed at all nuclear power reactors, regardless of  performance, and are designed to detect declining safety performance in  each of the cornerstones and to review licensee effectiveness at  identifying and resolving safety problems. NRC resident inspectors, who  are located at each plant, and regional technical specialists, who travel to  each plant from NRC regional offices, conduct 46 baseline inspection  procedures both as needed and at intervals ranging from quarterly to  triennially, involving physical observations of licensee activities and plant  performance, reviewing and verifying licensee reports, and interviewing  licensee personnel. Each of the baseline procedures specifies a range of  sample activities to inspect. Within the scope and requirements of each  procedure, inspectors select the type and number of activities to review  on the basis of factors, such as the sample activities available; their risk  significance; and the amount of time since a particular system or  component was last inspected. NRC assesses any issues of concern  and determines whether to elevate them to a finding based on certain  criteria. To determine whether an issue of concern constitutes a finding,  inspectors must first decide whether it is associated with a performance  deficiency, which NRC guidance defines as “an issue that is the result of  a licensee not meeting a requirement or standard where the cause was  reasonably within the licensee’s ability to foresee and correct, and  therefore should have been prevented.” NRC guidance defines a finding  as an issue of concern associated with a performance deficiency that  inspectors or regional officials then determine to be more than minor.  NRC then assesses—through its ROP Significance Determination  Process—the finding’s risk significance. Similar to performance  indicators, NRC assigns the finding one of four colors to reflect increasing  risk to reactor safety. Green findings—also called nonescalated  findings—equate to very low risk significance, while white, yellow, and red  findings—considered to be escalated findings—represent increasing  levels of risk (see table 3). Appendix V provides select examples of NRC  findings and related information that illustrate the varying levels of risk  significance.
Supplemental inspections. When NRC identifies one or more escalated  findings or a performance indicator exceeding the green threshold at a  reactor, regional officials conduct supplemental inspections, which  expand the scope beyond baseline inspection procedures and focus on  diagnosing the cause of the finding. There are three levels of  supplemental inspections that increase in breadth and depth of analysis,  depending on the number and type of performance problems identified.  The first and lowest level of supplemental inspection assesses the  licensee’s corrective actions to ensure they were sufficient in both  correcting the problem and addressing the root and contributing causes to  prevent recurrence. The second level of supplemental inspection has an  increased scope that includes independently assessing the extent of the  condition for both the specific and any broader performance problems.  The third and highest level of supplemental inspection is more  comprehensive and includes determining whether the reactor can  continue to operate and whether additional regulatory actions are  necessary. The highest level of supplemental inspection is usually  conducted by a multidisciplinary team of NRC inspectors and may take  place over several months. Also, as a part of this inspection, NRC  inspectors assess the adequacy of the licensee’s overall programs for  identifying, evaluating, and correcting performance issues.
Reactive inspections. NRC conducts reactive inspections of licensee  performance when specific events occur that are of particular interest to  NRC because of their potential safety significance or because of potential  generic safety concerns important to multiple licensees. Reactive  inspections determine the cause of the event and assess the licensee’s  response to the event. Reactive inspections have three levels that are  normally determined by an event’s safety, or risk significance. According  to NRC officials, recent reactive inspections have focused on issues such  as an automatic reactor shutdown following a loss of offsite power, and a  flaw discovered in a weld on a reactor component. To conduct reactive  inspections, a team of experts is formed and an inspection charter issued  that describes the scope of the inspection efforts.
NRC inspectors assess all of the findings that result from physical  inspections to determine if any of the three cross-cutting areas  contributed to a performance problem. If regional officials determine that  one of the cross-cutting areas contributed to a finding, NRC assigns what  it calls a cross-cutting aspect within that area to the finding. More than  one cross-cutting aspect may be assigned to a finding, but this does not  occur often, according to NRC officials. Every 6 months, NRC regional  officials analyze all findings issued at each plant during the prior 12- month assessment period. In general, if a nuclear plant has four findings  with the same cross-cutting aspect assigned during the previous year,  and NRC is concerned about the licensee’s progress in addressing them,  NRC determines that the nuclear plant has what NRC calls a substantive  cross-cutting issue. According to NRC documents, the agency identifies  substantive cross-cutting issues to inform the licensee that it has a  concern with its performance and to further encourage it to take  appropriate actions before more significant performance issues emerge.
NRC assesses its reviews of performance indicators and all findings that  result from its physical inspections to determine what actions, if any, to  take in response to signs of declining performance, including violations of  NRC requirements. The significance of any violations associated with a  finding is incorporated into the color coded risk assessment made during  the Significance Determination Process. For enforcement of violations  associated with nonescalated findings, NRC establishes a public record  of the violations and requires the licensee to take steps to correct the  violations, but it does not usually require the licensee to document its  responses. For enforcement of violations associated with escalated  findings, NRC issues written notices of violation (to which licensees are  typically required to respond), civil penalties, or orders.
Based on NRC’s assessment of licensee performance under the ROP,  NRC places each of the licensee’s reactors into one of five performance  categories on its action matrix, which corresponds to graded, or  increasing, levels of oversight. The action matrix is NRC’s formal method  of determining how much additional oversight—mostly in the form of  supplemental inspections—is required on the basis of the number and  risk significance of performance indicators and inspection findings. NRC  considers licensee performance to be acceptable until it reaches column  5 (see table 4).
On the basis of the results of the ROP, NRC provides licensees and the  public with an overall assessment of each reactor’s performance. At the  end of each 6-month period, NRC issues an assessment letter to each  plant to describe what level of oversight the plant’s reactors will receive  according to their placement on the action matrix, what actions NRC is  expecting the licensee to take as a result of the performance issues  identified, any specific enforcement actions NRC has taken, and any  documented substantive cross-cutting issues. If a substantive cross- cutting issue is identified, the letter will describe what actions NRC  intends to take to monitor the issue. If the issue persists, NRC can  request a number of actions from the licensee, including a written  response describing the corrective actions the licensee intends to take.  NRC also holds an annual public meeting at or near each plant to review  its performance and address questions from members of the public and  other interested stakeholders. Additionally, NRC has other mechanisms  to make available its oversight results, such as a website that provides  summaries of each reactor’s current overall performance. While it  addresses most violations through the ROP, NRC also responds to some  violations identified during the ROP under what it calls its Traditional  Enforcement Process.
section_title: NRC’s Traditional Enforcement Process
paragraphs: NRC uses this process to assess and determine the enforcement actions,  if any, to take in response to violations that, according to NRC guidance,  cannot be addressed fully through the ROP. The process typically applies  to violations that result in actual safety consequences, may impede  NRC’s oversight of licensed activities, or involve deliberate misconduct or  discrimination matters, as well as certain technical violations involving  specific areas, such as operator licensing and fuel storage. The  Traditional Enforcement Process, including possible civil penalties, is  managed outside the ROP action matrix.
The Traditional Enforcement Process focuses on a violation’s  consequences and results in the assignment of a significance level  ranging from Severity Level IV for the least significant to Severity Level I  for the most significant concerns, according to NRC policy. NRC’s  response to Severity Level IV violations is considered “nonescalated  enforcement,” while its response to Severity Levels I, II, and III is  considered “escalated enforcement.” In assigning a Severity Level to the  violation, NRC assesses the following: (1) the actual safety  consequences; (2) the potential safety consequences; (3) the potential for  impacting NRC’s ability to perform its regulatory function (e.g., failure to  provide complete and accurate information); and (4) any willful aspects of  the violation. Severity Levels I and II violations generally involve actual or  high potential consequences to public health and safety. Severity Level III  violations are cause for significant concern, and Severity Level IV  violations are less serious but are of more than minor concern. Appendix  V provides select examples of violations that illustrate varying levels of  severity. NRC includes results from the Traditional Enforcement Process  in the overall semiannual assessment of each plant’s performance that it  provides to plant licensees and the public.
section_title: NRC Relies on Staff’s Professional Judgment in Implementing Its Processes for Overseeing the Safety of Commercial Nuclear Reactors
paragraphs: NRC relies on its staff’s professional judgment in implementing its  processes, which are largely prescribed in guidance, for overseeing the  safety of commercial nuclear power reactors. In implementing its  oversight programs, NRC allocates specific roles and responsibilities to  resident inspectors, regional staff, headquarters officials, and the nuclear  power industry. NRC also provides incentives for licensees to identify and  report any concerns about reactor safety to NRC. NRC oversight relies on  its staff’s professional judgment in applying regulations and guidance,  such as determining: (1) whether issues of concern identified in  inspections constitute findings, (2) the risk significance of any findings,  and (3) whether these findings have cross-cutting aspects, among other  things.
subsections: section_title: NRC Allocates Specific Oversight Roles and Responsibilities among Regional Officials, Resident Inspectors, Headquarters Officials, and the Nuclear Power Industry
paragraphs: To implement its oversight, NRC allocates specific roles and  responsibilities to regional officials, resident inspectors, headquarters  officials, and the nuclear power industry. According to NRC officials,  doing so allows decisions to be made at the appropriate level within the  agency, but it also necessitates open communication between the various  offices to effectively share information and ensure policies and processes  are implemented consistently across the agency.
Officials from NRC’s four regional offices are responsible for  implementing the ROP and the Traditional Enforcement Process and  establish—consistent with agency guidelines—the region’s procedures for  assessing issues of concern and resolving most findings. According to  NRC documents, the inspection program is intended to provide regional  administrators flexibility with the planning and application of inspection  resources to deal with risk-significant issues and problems. According to  NRC officials, regional branch chiefs supervise small groups of resident  inspectors, facilitate information sharing among inspectors in their region,  and manage specialized teams of inspectors that conduct periodic plant  inspections focused on specific technical areas, such as fire safety.  Further, NRC officials said that regional branch chiefs are largely  responsible for deciding whether an issue of concern raised during  physical inspections constitutes a finding. Agency guidance provides  them with relative autonomy in determining when an issue constitutes a  more-than-minor performance deficiency.
Since NRC established the ROP in 2000, regional offices have been  responsible for addressing all nonescalated findings and violations, which  constituted about 90 percent of findings and violations, according to our  analysis of NRC data. In addition, though subject to oversight by NRC  headquarters, regional offices play a lead role when assessing and  responding to escalated findings or violations, including requiring  licensees to provide a written response describing the reasons for a  performance deficiency, actual and proposed corrective actions, and the  expected date of compliance. After assessing licensee performance  based, in part, on the findings or violations, regional offices then conduct  supplemental inspections as appropriate, according to NRC guidance.
NRC assigns resident inspectors to each nuclear power plant to conduct  baseline inspections. According to NRC guidance, resident inspectors  are responsible for routinely conducting plant status reviews that include  observing control room activities; attending licensee meetings; and  conducting walk-downs, or inspections, of various plant areas. In addition  to these duties, resident inspectors are responsible for ensuring that plant  representatives implement corrective actions within a “reasonable period  of time” in response to nonescalated findings.
NRC headquarters officials play a key role in addressing escalated  findings and violations, those assigned the highest categories of risk  significance or severity levels. For example, NRC officials told us that,  before findings are assessed as being escalated, NRC headquarters  officials participate in meetings with regional officials and resident  inspectors to ensure that the assessment is accurate and any proposed  enforcement actions are justifiable. Moreover, according to NRC  guidance, officials in NRC headquarters must approve all enforcement  actions against licensees. Specifically, this includes the Director of NRC’s  Office of Enforcement, and, in certain cases, such as when responding to  Severity Level I violations, the Deputy Executive Director, after  consultation with the Commission. These actions can include anything  from monetary penalties, to orders to take specific actions, to shutting  down a plant.
In addition to NRC, the commercial nuclear power industry also plays a  key role to ensure that nuclear plants operate safely and comply with  regulations. According to NRC policy, licensees have the primary  responsibility for safely operating their plants, as well as in accordance  with their licenses and NRC regulations. Each plant has many physical  structures, systems, and components, and licensees have numerous  activities under way 24 hours a day to ensure that plants operate safely.  These plants were designed according to a “defense-in-depth” philosophy  revolving around redundant, diverse, and reliable safety systems. For  example, two or more key safety components are in place so that if one  fails, another one is present to serve as a backup. These include safety  components such as safety injection pumps, sources of power, and  physical barriers to contain radiation.
Furthermore, the Institute of Nuclear Power Operations (INPO)—the  industry’s self-regulator—is a nonprofit organization formed in 1979 by  the nuclear power industry in response to the accident at Three Mile  Island. INPO has a key role in ensuring that plants operate safely by  seeking to promote high levels of safety and reliability in the operation of  nuclear power plants. According to its website, INPO sets performance  objectives, criteria, and guidelines for the nuclear power industry,  conducts evaluations of nuclear power plants, and communicates lessons  learned and best practices throughout the nuclear power industry.  According to INPO information, all organizations with direct responsibility  to operate or construct commercial nuclear power plants in the United  States have maintained continuous membership in INPO since its  inception, and are primarily responsible for its funding. INPO provides a  variety of services to the nuclear power industry, including personnel  training for key positions at nuclear power plants, periodic evaluations  and peer reviews of operating plants that are focused on plant safety and  reliability, and assessments of plant performance across the industry to  help licensees to understand issues that arise at other plants. According  to INPO information, the organization has conducted nearly 1,200 plant  evaluations, inspecting each plant approximately every 2 years, since  1980. Also, according to an INPO official, INPO uses peer pressure to  influence plants to improve, and in an industry presentation, its president  and chief executive officer stated that its policy of providing licensees with  confidential evaluation reports allows it to have more open and candid  discussions with plants about problems and areas for improvement. In  addition, the industry’s collective insurance company for operational  losses—Nuclear Electric Insurance Limited—uses INPO ratings as a  factor in setting insurance premiums for insuring for costs associated with  certain long-term interruptions of electricity supply and damages to plants,  among other things. According to INPO and NRC documents, INPO and  NRC communicate on topics of mutual interest related to improving the  performance of commercial nuclear power plants.
NRC also builds into its processes incentives for licensees to identify  concerns about reactor safety, discuss those concerns with NRC, and  identify actions to correct them. According to NRC guidance, these  concerns—known as licensee-identified findings—include any findings  the licensee is already addressing through the plants’ respective  corrective action programs. If NRC’s preliminary assessment of a  licensee-identified finding indicates that the finding is green, NRC does  not consider it when assessing licensee performance, does not consider it  to count toward substantive cross-cutting issues, and does not apply  additional oversight or require additional response from the licensee.  According to NRC officials, licensee-identified findings demonstrate that  the licensee is taking a proactive approach and can identify and correct  problems before NRC identifies them; therefore NRC gives licensees  credit for identifying potential problems during their own inspection  processes. Regarding licensee-identified violations, according to NRC’s  enforcement policy, NRC should normally give the licensee “credit” when  assessing for civil penalties—that is, the violation should be issued with  no civil penalty—for identifying the violation and taking prompt and  comprehensive corrective actions. On the other hand, the policy states  that NRC should issue a civil penalty, regardless of whether the violation  is licensee-identified, if NRC officials determine that the corrective actions  have not been prompt and comprehensive.
Conversely, according to its enforcement policy, NRC considers some  findings and violations—whether identified by a licensee or an inspector— to be “self-revealing.” For example, according to an agency official, a  licensee may discover a pool of oil on the floor next to a diesel generator,  indicating that something is wrong with the equipment. NRC may consider  such a finding to be self-revealing, even if the licensee identified it. Under  NRC’s enforcement policy, it may give the licensee credit for such  findings under certain circumstances, such as licensee effort in  discovering the root cause of the finding.
section_title: NRC Oversight Relies on Its Staff’s Professional Judgment in Applying Regulations and Guidance
paragraphs: NRC’s oversight processes are based in regulation, and its specific  processes for identifying and assessing findings and violations are largely  prescribed in guidance, but rely on several key points where NRC staff  must exercise their professional judgment, such as determining (1)  whether an issue of concern constitutes a finding or violation, (2) a  finding’s risk significance or a violation’s severity, and (3) whether findings  or violations have cross-cutting aspects, among other things.
According to NRC documents and officials, NRC inspectors use their  professional judgment and a combination of education, experience, and  prescribed agency procedures to make initial assessments as to whether  an issue of concern identified during an inspection constitutes a finding.  NRC officials told us that performance deficiency was defined broadly to  allow officials to use their professional judgment when assessing issues  of concern. If NRC inspectors determine that there is a performance  deficiency, they and regional staff then determine whether the  performance deficiency is more than minor. In doing so, these officials  have NRC-established questions and guidance and use their professional  judgment in applying them. If inspectors and regional staff determine that  a performance deficiency is not more than minor, then it is not considered  a finding and the matter is not pursued any further under the ROP. To  help in making these determinations, inspectors can request additional  information from licensees and consult NRC inspectors assigned to other  nuclear plants, according to NRC officials. If resident inspectors conclude  they cannot adequately assess an issue of concern, they can seek  assistance from their regional office or NRC headquarters—typically from  technical specialists or branch chiefs who supervise resident inspectors at  two to three plants—to help make a determination. As we previously  reported, inspectors also select the type and number of activities to  review during inspections, in part, on the basis of an inspector’s  professional judgment, which is based on information such as reviews of  the licensee’s corrective action program, allegations, or interviews with  plant employees.
Professional judgment also plays a key role in regional officials’  determining the risk significance of a finding and the severity of a  violation. If NRC determines that a performance deficiency is more than  minor, it is considered a finding, and NRC regional officials assess its  significance using the Significance Determination Process, which also  requires the staff to exercise their professional judgment, according to  NRC officials. This process provides an initial screening to identify those  nonescalated findings—that is, those findings that do not result in a  significant increase in plant risk and thus need not be analyzed further.  Remaining findings are subjected to additional reviews to determine their  risk significance, using the next phase of the Significance Determination  Process—the Significance and Enforcement Review Panel (SERP).  According to NRC guidance, this more detailed assessment may involve  NRC risk experts from the appropriate regional office or NRC  headquarters and further review by the licensee’s plant staff. The final  outcome of the ROP review—evaluating whether the finding is green,  white, yellow, or red—is used to determine NRC actions that may be  needed. For any escalated violations identified during the ROP that are to  go through the Traditional Enforcement Process, the severity level of  violations is determined using a combination of NRC’s enforcement  policy, professional judgment, and information obtained from the licensee  during a conference with them, if necessary. NRC officials initially  determine enforcement actions during an enforcement panel, and then  make a final determination during a meeting, or caucus, both of which  loosely correspond to the SERP.
Regarding violations, NRC’s enforcement policy states that, because the  regulation of nuclear activities does not lend itself to a mechanistic  treatment in many cases, judgment and discretion must be exercised in  determining the severity levels of violations and the appropriate  enforcement sanctions. According to this policy, the use of judgment and  discretion includes the decision to issue a notice of violation or to propose  or impose a civil penalty and the amount of the penalty, after considering  the general principles of NRC’s enforcement policy and the significance of  the violation, as well as the surrounding circumstances. According to its  enforcement policy, NRC may choose to exercise discretion and either  escalate or mitigate enforcement sanctions or otherwise refrain from  taking enforcement action within the Commission’s statutory authority.  According to this policy, NRC may exercise judgment and discretion to  determine the severity levels of violations and the appropriate  enforcement sanctions to be taken. For example, NRC may refrain from  issuing a notice of violation or a proposed civil penalty for a Severity Level  II, III, or IV violation that is identified after NRC has taken enforcement  action, if the violation is identified by the licensee as part of the corrective  action for the previous enforcement action and the violation has the same  or similar root cause as the violation for which enforcement action was  previously taken, among other things.
In addition, according to NRC guidance, inspectors should also use their  professional judgment when assessing whether a finding is associated  with any cross-cutting aspects. For example, as we reported, in  analyzing the failure of a valve to operate properly at one plant, NRC  inspectors determined that plant employees had not followed the correct  maintenance procedures; thus, the finding was associated with the  human performance cross-cutting area.
Both opening and closing a substantive cross-cutting issue requires the  use of professional judgment. According to NRC guidance, before  opening a substantive cross-cutting issue, regional officials must  determine, among other things, whether the licensee is already taking  actions to address the issue and, if so, whether these actions are timely,  are commensurate with its significance, and will be effective in  substantially mitigating it. Once a substantive cross-cutting issue has  been opened, the regional office that opened it is responsible for  establishing the criteria for closing it. These criteria may include having  fewer findings with the same cross-cutting area in a subsequent  assessment period or the regional staff’s increased confidence in the  licensee’s ability to address the substantive cross-cutting issue. The  decision to close a substantive cross-cutting issue is made by regional  staff, including the senior resident inspector, branch chief, and other  regional management, but NRC headquarters officials told us they also  participate.
NRC can require licensees to take several actions to close substantive  cross-cutting issues. According to NRC guidance, after first issuing a  letter identifying a substantive cross-cutting issue to a licensee, NRC staff  may follow up on these issues in multiple ways, including semiannual  evaluations or additional inspections. In the second consecutive  assessment letter identifying the same substantive cross-cutting issue,  the regional office may consider requesting the licensee provide a  response at a public meeting or provide a written response or hold a  separate meeting. In the third consecutive letter, according to NRC  guidance, the regional office would typically request that the licensee  perform an independent assessment of safety culture, although the  regional office could decide that a safety culture assessment is not  necessary if the licensee has made reasonable progress addressing the  issue. If the substantive cross-cutting issue continues beyond the third  letter, the regional office may consider additional actions not prescribed  by the action matrix developed in consultation with the Director of NRC’s  Office of Nuclear Reactor Regulation and its Executive Director of  Operations.
Figure 2 outlines NRC’s processes for identifying and assessing findings  and violations and key points where professional judgment plays a role.
section_title: Differences Exist across NRC Regions in Identifying and Resolving Findings, and NRC Has Taken Some Steps to Address Them
paragraphs: NRC is aware of differences across regions in identifying and resolving  the findings that result from its oversight processes and has taken some  steps to address them. In particular, the extent to which nonescalated  findings, which equate to very low risk significance, have been identified  differs across regions. Several factors may explain these differences,  but NRC officials and industry representatives have raised concerns that  they may be due, in part, to differences in how NRC staff identify and  resolve findings. The four NRC regions also differed in the number of  cross-cutting aspects they assigned to findings. NRC has taken some  steps to address these differences but has not undertaken a  comprehensive review of them. The number of escalated findings, which  equate to greater risk significance, were more similar across regions.  However, the information NRC makes publicly available about findings  and how they are resolved is difficult to search and assess.
subsections: section_title: Extent to Which Nonescalated Findings Have Been Identified Differs across NRC Regions
paragraphs: Some regions identify more nonescalated findings than others, even  though they oversee fewer reactors. For example, as table 5 indicates,  from 2000 through 2012, Region IV recorded more nonescalated findings  than each of the other three regions, even though it oversaw the fewest  number of reactors at the fewest number of plants. During the same  period, Region II—the region with the greatest number of reactors and  plants—recorded the fewest number of nonescalated findings. More  specifically, Region IV recorded over 70 percent more nonescalated  findings than Region II even though Region IV oversaw over one-third  fewer reactors; resulting in an average number of nonescalated findings  per reactor for Region IV to be over 2.6 times that of Region II.
As figure 3 shows, from 2000 through 2012, the number of nonescalated  findings identified differed across NRC’s four regions, but Region IV  recorded more nonescalated findings than any of the other three regions  for 6 consecutive years—2007 through 2012. Appendix VI lists the  number of nonescalated findings identified at each plant from 2000  through 2012.
NRC officials stated that various factors may contribute to differences in  the number of nonescalated findings identified across regions, including  differences in the (1) number of hours spent inspecting reactors; (2)  amount of time reactors are under increased oversight as a result of  performance deficiencies; (3) age of reactors; and (4) benefits from the  combined resources of multiple plants owned or managed by one  licensee.
Differences in inspection hours. NRC officials stated that differences in  the number of hours regions spent inspecting reactors may have  contributed to the differences in the number of nonescalated findings  across regions, because more inspection hours would lead to more  findings. However, according to 2000 through 2012 NRC data, while the  total number of inspection hours has varied across the regions, the  number of inspection hours has been fairly consistent across regions  when accounting for the number of reactors in each region. When  comparing the number of nonescalated findings in each region to the  number of inspection hours and accounting for the regional differences in  the number of reactors, we found that the number of nonescalated  findings per inspection hour varies widely. Specifically, Region II identified  the least number of nonescalated findings per inspection hour per reactor,  and Region IV identified the most, with more than 3.5 times as many  nonescalated findings per 1,000 inspection hours per reactor as Region II  (see table 6).
Differences in the amount of time reactors are under increased oversight.  NRC officials stated that differences in the amount of time reactors are  under increased oversight as a result of performance deficiencies— defined as being in column 2 or higher on NRC’s action matrix—may  contribute to differences in the number of nonescalated findings across  regions, because increased oversight results in more scrutiny and more  findings. However, according to 2001 through 2012 NRC data, the  number of quarters that reactors in each region were under increased  oversight were fairly consistent across regions when accounting for the  number of reactors in each region. When comparing the number of  nonescalated findings in each region to the number of quarters that  reactors in each region were under increased oversight, and accounting  for the regional differences in the number of reactors, we found that the  results varied widely. Specifically, Region II identified the least number of  nonescalated findings per quarter under increased oversight, and Region  IV recorded the most, with more than 4 times as many nonescalated  findings per quarter under increased oversight as Region II (see table 7).  Furthermore, Region II had more reactors under increased oversight than  Region IV for 36 of the 48 quarters we reviewed. Appendix VII  summarizes NRC’s performance assessments for each reactor from 2001  through 2012.
Differences in the age of reactors. NRC officials stated that differences in  the age of reactors may contribute to the differences in the number of  nonescalated findings across regions because nonescalated findings  become more prevalent as reactors age. We analyzed the age of reactors  across the regions and identified regional differences in their age.  However, we found that reactors in Region II, which had the fewest  nonescalated findings from 2000 through 2012, have been in commercial  operation, on average, more years than, and have collectively been in  commercial operation for almost twice as long as, reactors in Region IV,  which had the most nonescalated findings over that period (see table 8).
Differences in resources available to plants. NRC officials stated that,  when one licensee owns or manages multiple plants (collectively referred  to as a licensee’s “fleet”), benefits derived from plants’ combined  resources may contribute to the differences in the number of  nonescalated findings across regions, because some regions have more  plants in fleets than others. For example, according to NRC officials,  licensees often require all plants that they manage or own to make  improvements in response to findings made at only one of their plants,  which could lead all the plants in this fleet to experience fewer findings  over time. NRC officials told us that plants associated with fleets typically  perform better because the licensee holds all plants to the same  performance levels and provides resources and shares what would  otherwise be proprietary information to make that happen. Some  independent plants—those not part of a fleet—share resources by  forming alliances with other plants, entering into management contracts  with larger companies, or both. However, NRC officials stated that  independent plants are limited in how much information they can share  because some information is considered to be proprietary. We analyzed  whether individual plants were associated with licensee fleets and found  that being associated with a fleet may be a factor in the number of  nonescalated findings a region identifies. For example, Region II, which  had the fewest nonescalated findings from 2000 through 2012, had the  highest percentage of its reactors located at plants associated with fleets.  Conversely, Region IV, which had the most nonescalated findings during  the same period, had the lowest percentage of its reactors located at  plants associated with fleets (see table 9). However, because NRC has  not conducted a comprehensive analysis of several potential factors, it is  not clear to the extent this factor influences the differences in the number  of findings across regions.
In addition, NRC officials stated that the quality of reactor maintenance  may contribute to the regional differences in the number of nonescalated  findings. For example, the resident inspectors at a plant with a high  number of findings in recent years told us that this was due, in part, to  plant managers not fully addressing maintenance items for many years to  save on costs. However, we could not analyze this factor because,  according to NRC officials, the data are not readily available.
section_title: NRC Officials and Industry Representatives Have Raised Concerns about Differences in the Number of Findings Identified across NRC Regions
paragraphs: NRC officials and industry representatives have raised concerns that  differences in the number of findings NRC regions identify may be due, in  part, to differences in how NRC staff identify and resolve findings. NRC  officials, including some resident inspectors in Region IV, told us that they  believe Region IV identifies nonescalated findings more aggressively than  other regional offices and that some regional branch chiefs differently  interpret the criteria for assessing performance deficiencies and what  constitutes more-than-minor findings. Some NRC officials also noted that  the regions have flexibility to combine issues into a single finding or to  split them into multiple findings, which may also account for some of the  regional variation in the number of findings identified. These officials told  us that, in their view, this autonomy and discretion is a good and  desirable part of the ROP. Nonetheless, in 2008, NRC’s IG reported that  NRC was inconsistently resolving findings across its regional offices due,  in part, to not having clear and comprehensive guidance needed to  facilitate consistency.
NRC officials told us they survey industry annually as part of a ROP self- assessment process and have received feedback since the  implementation of the ROP in 2000 about concerns from the appearance  of differences in identifying and resolving findings across regions. They  also stated that the Nuclear Energy Institute—the commercial nuclear  trade organization—frequently raises these concerns with them. Plant  managers we interviewed—several of whom have worked at plants  across different regions—also raised concerns about these apparent  differences. These plant managers told us that such differences could  lead to several challenges, including focusing limited plant resources on a  greater number of issues of very low risk significance (i.e., nonescalated  findings).
NRC officials also told us that another concern that is sometimes raised  about its findings by industry is that findings at different plants that appear  to be similar sometimes result in different risk assessments. NRC officials  provided the example of two findings at two different plants that appeared  similar but that led to different assessments. Specifically, both findings  dealt with problems with certain components of auxiliary feedwater pumps  that rendered the pumps inoperable. Even though these findings  appeared similar, they resulted in different risk significance levels—one  green and one white—because they affected the safety of the two plants  differently. NRC officials told us the process of assessing the risk  significance of a finding is inherently complex and includes several  factors, such as design of the plant, including availability of backup equipment and  whether the site uses cooling towers or lakes or rivers for its ultimate  source of cooling water;  the effect that the finding had on the performance and availability of  safety equipment;  the amount of time the equipment was inoperable;  criticality of the safety equipment associated with the finding; and historical reliability of the equipment in question for that plant design,  among others.
Once NRC accounts for these factors, similar findings may result in  different assessments because the risk that a finding poses is plant- specific, according to NRC officials.
section_title: NRC Regions Also Differed in the Cross-cutting Aspects They Assigned to Findings
paragraphs: The four NRC regions also differed in the number of cross-cutting aspects  they assigned to findings and the percentage of findings assigned cross- cutting aspects. For example, Regions III and IV had about twice as many  findings assigned at least one cross-cutting aspect as Region II (see table  10).
Table 11 shows the types of cross-cutting aspects assigned to findings  across regions.
According to NRC guidance, identifying cross-cutting aspects is NRC’s  primary means of identifying trends. The guidance states that a cross- cutting aspect is a performance characteristic of a finding that is the most  significant causal factor of the performance deficiency. The guidance  further states that the ROP was developed with the presumption that  inspection findings with cross-cutting aspects would help them identify the  plants with significant performance issues. Therefore, according to NRC  officials, the greater the number of findings with cross-cutting aspects, the  greater the chance that NRC could assign a substantive cross-cutting  issue to the plant. Once NRC assigns a substantive cross-cutting issue to  a plant, closing the issue requires additional efforts by the licensee and  additional oversight from NRC. The number of plants assigned  substantive cross-cutting issues at some time during calendar years 2001  through 2012 varied across the regions (see table 12). In Region II, less  than half the plants were assigned a substantive cross-cutting issue,  whereas a substantial majority of plants in other regions were assigned  substantive cross-cutting issues. Appendix VIII summarizes the  substantive cross-cutting issues assigned to plants from 2001 through  2012.
According to NRC officials, because the criteria for closing a substantive  cross-cutting issue involve professional judgment, determining whether to  close one is somewhat subjective. The relevant regional office considers  whether to close a substantive cross-cutting issue in its semiannual or  annual assessment letters to licensees. Industry officials told us that,  because NRC only considers closing substantive cross-cutting issues in  these 6-month increments, it is difficult to close a substantive cross- cutting issue in a timely fashion.
section_title: Number of Escalated Findings Had Fewer Differences across NRC Regions
paragraphs: The number of escalated findings had fewer differences across regional  offices. As shown in table 13, each region had between 46 and 93  escalated findings from 2000 through 2012. Region III had more Severity  Level III violations than the other regions, but otherwise, the number of  escalated findings was largely consistent. Appendix IX lists the number of  escalated findings identified at each plant from 2000 through 2012.
NRC officials told us that escalated findings are identified and addressed  more consistently than nonescalated findings because they receive a  much higher level of review than do nonescalated findings. For example,  according to NRC’s enforcement policy, regional offices—subject to  oversight by NRC headquarters—typically require licensees to provide a  written response to an escalated finding that describes the reasons for  the identified deficiency, actual and proposed corrective actions, and the  expected date of compliance. Regional offices then conduct supplemental  inspections for most escalated findings. Supplemental inspections expand  the scope of baseline inspections to review, in part (1) the extent of the  problem, (2) the sufficiency of the licensee’s evaluation of the root cause  of the problem, and (3) the licensee’s proposed corrective actions. In  addition, NRC officials told us that headquarters officials participate in  meetings with regional officials and inspectors to ensure that an escalated  finding is accurately assessed and that any proposed enforcement  actions are justifiable. Moreover, according to NRC guidance, the Director  of NRC’s Office of Enforcement (or designee)—located in headquarters— has to approve any enforcement actions against licensees in response to  escalated findings.
section_title: NRC Has Taken Some Steps to Reduce Differences across Regions Concerning Nonescalated Findings but Has Not Conducted a Comprehensive Analysis
paragraphs: NRC has taken some steps to reduce differences across the regions in  the identification and resolution of nonescalated findings but has not  conducted a comprehensive analysis of the differences to determine its  consistency in handling findings or reasons for the differences.
A key effort NRC has undertaken to reduce differences in how the regions  implement the ROP is the ROP Reliability Initiative, which NRC’s regional  offices initiated in 2009. According to NRC officials, the initiative was  intended to explore how the different regional offices identify and assess  inspection findings. Some NRC officials said that the initiative examines  issues related to consistency, such as how to control the subjectivity in  making distinctions between minor and more-than-minor performance  deficiencies and violations. Each region took the lead on one of the  following specific efforts:
Enhanced inspection resource sharing among regions: This effort was  a pilot program for sharing inspection resources across regional  offices. Inspectors from different regions and resident inspectors from  other plants participated on several types of team inspections. This  initiative was led by Region IV and began in 2009.
Branch chief visits to other regions: This effort included each region  designating one branch chief to visit each of the other regions to  identify best practices and implementation differences across the  regions. This effort was led by Region II and began in 2009.
Periodic discussion of reliability topics: This effort included quarterly  videoconferences among regional officials to share insights on the  application of ROP inspection guidance and gain insight into different  regional decision making. This effort was led by Region I and began in  2009.
ROP self-assessments of inspection report quality: This effort  included a team of staff from all regions that selected a cross-section  of inspection reports from each region to assess their conformance  with applicable guidance, identify key differences between regions,  and identify any weaknesses. This effort was led by Region III and  concluded in 2012.
The ROP Reliability Initiative has not resulted in a formal report, and  according to NRC officials, the sample of activities reviewed was not large  enough to draw agencywide conclusions. In late 2011, NRC’s regional  offices decided to continue the ROP Reliability Initiative by applying the  approach of the individual efforts to an in-depth review of a specific  inspection area each fiscal year. For example, the first such review done  in fiscal year 2012 resulted in an internal memorandum making 25  recommendations to provide additional guidance and training on limited  aspects of NRC’s efforts to inspect for weaknesses in licensees’  corrective action programs. NRC officials told us that the overall initiative  is still under way and that ongoing activities are intended to improve  regions’ consistency of actions adhering to the ROP guidance; however,  agency officials said that, due to the ROP Enhancement Project (see  below) and increased inspection activities following the Fukushima  accident, the regional offices have not identified a specific inspection area  to focus on for the fiscal year 2013 review.
NRC has also conducted other efforts aimed at improving the consistency  of its oversight processes:
Assessment of regional enforcement. According to NRC officials, in  2011, NRC established an initiative aimed at improving consistency in  how regional offices resolve inspection findings through enforcement  activities. This initiative was conducted to address findings of  enforcement inconsistency in the 2008 report by the NRC IG.  Officials stated that NRC recently completed four regional  assessments that were intended to improve consistency of  interpreting minor and more-than-minor thresholds for violations.  According to NRC officials, this initiative resulted in a final report in  May 2013 recommending that regional enforcement staff conduct  periodic audits of nonescalated enforcement actions.  “Minor” ROP realignment. According to NRC officials, in 2006, NRC  undertook an internal review of substantive cross-cutting issues  across regions. The review resulted, in part, from complaints from  industry that some plants were assigned cross-cutting aspects more  frequently than others, especially in Region IV. NRC officials stated  that Region IV led the review, which found that, while each region was  following guidance, it also had its own culture and exercised some  subjective judgment. Therefore, the regions had some differences in  interpretations, especially in their approaches to determining what  constitutes a more-than-minor performance deficiency. In response,  according to NRC officials, NRC conducted additional training but  made no key changes to its ROP procedures.
In addition, NRC officials said that several of the agency’s formal ongoing  reviews examine, to a limited extent, the consistency of its oversight  processes:
ROP Enhancement Project. In January 2013, as part of its annual  self-assessment, NRC initiated the ROP Enhancement Project, which  is intended as a long-term, strategic review of how it implements the  ROP, among other things. NRC officials said that they expect this  review to consider regional differences in the number of nonescalated  findings, but according to an NRC status report, the assessment  portion of the review has been delayed pending the outcome of an  independent review of the ROP. NRC officials told us they expect  procedural changes in response to the project to begin in 2014.
ROP realignment process. In 2009, NRC implemented the ROP  realignment process, a biennial review of its ROP baseline inspection  procedures and inspection hours per procedure to ensure the most  effective overall applications of inspection resources. NRC officials  told us that this effort also touches on the consistency of how NRC  implements its oversight of safety.
Self-assessments. In 2001, NRC initiated annual self-assessments,  which are to assess whether the ROP met its program goals and  achieved its intended outcomes. NRC officials said that these self- assessments consider, to a limited extent, issues related to  consistency, and according to NRC guidance, these self-assessments  assess, in part, the extent to which NRC implements the ROP  predictably.
However, the biennial ROP realignment process evaluates specific  inspection procedures agencywide to ensure the most effective  application of inspection resources, and according to NRC guidance, the  self-assessments are not intended to audit the performance of the regions  in implementing the ROP. Thus even with taking these steps to examine  the consistency of its oversight processes, agency officials told us that  NRC has not conducted a comprehensive analysis of the causes of the  differences in the number of nonescalated findings identified across  regions. Under federal standards for internal control, managers at the  functional or activity level are to compare actual performance to planned  or expected results throughout the organization and analyze significant  differences. Without conducting such an analysis, NRC (1) does not  know whether its regional offices or individual inspectors are applying  regulations and guidance consistently in handling findings; or (2) cannot  identify other factors that may have led to the differences.
Moreover, NRC’s 2008 to 2013 strategic plan states that the agency will  establish and maintain stable and predictable regulatory programs and  policies, and other NRC guidance states that the agency should use an  objective, understandable, and predictable process to ensure that  licensees fulfill their responsibility for ensuring the safe operation of  commercial nuclear reactors. In particular, the agency’s enforcement  manual emphasizes that staff should ensure that oversight efforts are  objective and consistent. NRC is aware of differences across regions in  identifying and resolving the findings that result from its oversight  processes. However, without a comprehensive analysis of the causes of  the differences in the number of nonescalated findings across regions,  NRC cannot ensure that oversight efforts are objective and consistent, as  specified in its enforcement manual, or know whether its regional offices  or individual inspectors are applying regulations and guidance  consistently.
section_title: Records of Findings Are Difficult to Search and Assess
paragraphs: NRC maintains records of its identification of and response to both  escalated and nonescalated findings; however, these records are difficult  to search for several reasons, and limited our ability to assess the extent  to which NRC followed its procedures and, thus, consistently identified  and resolved findings. According to NRC’s strategic plan, the agency’s  organizational values include openness in communication and decision  making. Furthermore, NRC guidance states that the agency  communicates ROP results to, in part, keep external stakeholders  informed of licensee performance and to enhance confidence that NRC is  accomplishing its mission. NRC’s enforcement policy states that its  mission includes promoting the transparency and openness of its  enforcement program for all stakeholders.
In reviewing NRC’s findings data since the ROP’s inception in 2000  through 2012, we found that NRC has recorded approximately 12,000  findings––about 2 percent of which were escalated. For 95 percent of the  findings data we reviewed—including numerous escalated findings—NRC  did not include a case number for each finding, making it time-consuming  and difficult to locate all documents associated with a single finding.  According to NRC officials, although nonescalated findings each have a  unique identifier, only the case number is searchable in NRC’s  databases. NRC officials told us that, as a matter of policy, they do not  assign case numbers to nonescalated findings; only to escalated findings.  However, our review of NRC findings data also found 38 instances of  escalated findings that had not been assigned a case number, during this  period.
The information NRC makes publicly available on its identification of and  response to findings was also difficult to use. NRC communicates the  results of much of its oversight process to the public through its ROP  website. This website makes available inspection reports, assessment  letters, and other general materials related to NRC’s oversight process.  NRC also provides a quarterly summary of every reactor’s performance,  consisting of its inspection findings, the color of each performance  indicator, and the reactors’ placement on the action matrix. However, to  review this information, users must search a link for each plant on a  quarterly basis. Since the ROP has been in place for more than 12 years,  users may have to search dozens of links per plant and read many  different documents to get complete information on individual findings. In  addition, while descriptions in each document contain information about  whether a finding was associated with a cross-cutting issue, the website  itself does not provide information on those plants that had open  substantive cross-cutting issues prior to the most recent assessment  period. This information can be found on the website by linking to each  plant’s individual assessment letters. NRC program officials  acknowledged that it is difficult for users of the website to determine  which plants had substantive cross-cutting issues open in the past.  Therefore, it is difficult to identify, over time, those that NRC views as  having potentially more significant problems.
NRC also makes publicly available its official recordkeeping system, the  Agencywide Documents Access and Management System (ADAMS).  ADAMS contains more than 730,000 documents dating back to  November 1999, and several hundred new documents on NRC’s reactor  oversight processes—as well as other NRC activities—are added each  day. However, we found ADAMS difficult to navigate. For example, using  an inspection report as our starting point, we tried to retrace the steps in  NRC’s response to the findings in the report using ADAMS; however, our  searches resulted in numerous unrelated documents as well as  documents with ambiguous names that had to be opened to determine  whether they were related to the findings. Further, we had no way of  determining whether our searches returned a complete set of results and  had identified all the documents related to the findings. NRC officials  acknowledged that, while ADAMS can be used to conduct searches on  specific words or other criteria, such searches may produce a large  number of unrelated documents, in addition to relevant documents.
We asked NRC officials how we could track a finding through its  resolution, and they told us that doing so is difficult because findings and  enforcement actions are recorded in separate databases and that these  databases are not linked. The officials told us that users with expertise in  both databases’ search capabilities could craft a data search that linked  inspection and enforcement records. However, because external users  cannot craft such a search, they cannot independently track NRC’s  identification and resolution of findings. NRC’s Chairman reiterated the  agency’s support for transparency in prepared remarks before the annual  NRC Regulatory Information Conference in March 2013, stating that the  agency must have a continued commitment to openness and  transparency and communicate with interested parties in ways they  understand, and that clear, consistent communication is a principle of  good regulation. However, because external users cannot independently  track findings and their resolution, NRC cannot ensure that the public,  Congress, and others are kept informed of licensee performance, as  specified in guidance, to enhance confidence that NRC is accomplishing  its mission and following its oversight processes.
section_title: NRC Uses Numerous Methods to Develop Lessons Learned for Improving Oversight, but Challenges Remain in Accessing This Information
paragraphs: NRC has both formal and informal methods for developing lessons  learned to improve its oversight. Formal methods include agencywide  programs and annual assessments. Informal methods include reaching  out to peer groups and technical experts throughout the agency and  accessing various agency databases. Although NRC guidance directs  inspectors to use information in agency databases on past experiences to  plan and conduct future inspection activities, inspectors face challenges  accessing this information, which may limit their ability to use it.
subsections: section_title: NRC Has Formal Methods for Collecting and Analyzing Information to Develop Lessons Learned
paragraphs: NRC has ongoing, formal methods through which it collects and analyzes  information to develop lessons learned for improving reactor oversight,  including the following agencywide programs:
Operating Experience Program, which captures information on past  experience based on inspection findings, events, and documents from  industry, international nuclear agencies, and others to inform agency  activities, including reactor inspections.
Generic Issues Program, which tracks the status and resolutions of  certain issues involving public health and safety, among other things,  that could affect multiple entities under NRC jurisdiction, such as  multiple commercial nuclear plants.
ROP Feedback Program, which enables staff to submit comments  and suggestions for improving the ROP based on their experiences; a  central coordinator then directs these comments and suggestions to  appropriate internal stakeholders for their review.
Industry Trends Program, which monitors trends in indicators of  industry performance. NRC evaluates any adverse trends to  determine whether regulatory action is appropriate, and reports  statistically significant trends to Congress.
Monthly ROP working group meetings, which, according to NRC  officials, NRC hosts and include the Nuclear Energy Institute, other  industry representatives, and members of the public to discuss  operating experience, inspection and performance assessment topics,  potential changes and questions regarding performance indicator  guidance, and other topics.
Additionally, according to NRC documents, NRC identifies lessons  learned during its annual self-assessments to determine whether the  ROP met goals and during its biennial ROP realignment process. For  example, the ROP realignment process assesses feedback from  inspectors and other NRC officials submitted through the ROP Feedback  Program.
NRC has also undertaken special initiatives, such as the Fukushima  Near-Term Task Force, to develop lessons learned from the accident at  the Fukushima Daiichi Nuclear Power Plant in Japan that it could apply in  its oversight of U.S. commercial nuclear power reactors. NRC convened  the task force in 2011 to review its processes and regulations and  determine whether lessons learned from the accident could inform its  oversight processes. The task force concluded that a sequence of events  like the Fukushima accident is unlikely to occur in the United States and  that the continued operation of the nation’s commercial nuclear reactors  does not pose an imminent risk to public health and safety. In addition, in  2011 the task force made 12 recommendations, such as for NRC to  clarify its regulatory framework and to require licensees to reevaluate and  upgrade seismic and flooding protection of reactors and related  equipment, strengthen capabilities at all reactors to withstand loss of  electrical power, and take other actions to better protect their plants for a  low-probability high-impact event. NRC accepted these recommendations  and is in the process of implementing them (see app. X).
To follow up on the task force’s recommendations, in 2011, NRC  established the Japan Lessons Learned Project Directorate—a group of  over 20 NRC staff focused on implementing the lessons the task force  identified. As part of this effort, NRC issued the following three orders to  licensees in March 2012:  improve capability to reliably and remotely monitor a wider range of  conditions in the pools that contain spent fuel;  install vent systems for certain types of reactors to help prevent an  excess buildup of hydrogen gas in the reactor buildings; enhance plants’ capabilities to maintain or restore core cooling,  containment, and spent fuel pool cooling in the case of external  events, such as an earthquake, that exceeds plants’ design  capabilities.
NRC has also undertaken special initiatives in response to other unique  events. For example, following the terrorist attacks on September 11,  2001, NRC issued orders to licensees to enhance security measures to  protect their reactors against an increased terrorism threat. In addition, in  2002, after extensive degradation was discovered in the reactor vessel  head at the Davis-Besse Nuclear Power Station in Ohio, NRC  established a lessons learned task force and implemented many of its  recommendations, including inspection procedure changes, enhancing its  training program, and enhancing aspects of program management of the  ROP. In May 2004, we made several recommendations to ensure that  NRC addresses weaknesses that contributed to the Davis-Besse incident,  which NRC has since implemented.
section_title: NRC Also Has Informal Methods for Collecting and Analyzing Information to Develop Lessons Learned
paragraphs: NRC officials told us they also have more informal methods of collecting  and analyzing information to develop lessons learned for improving  reactor oversight. These informal means include reaching out to peers by  telephone or e-mail, reaching out to regional or headquarters technical  experts by telephone or e-mail, and informal gatherings during peer group  meetings. For example, several resident inspectors told us they typically  rely on a small group of fellow resident inspectors—often within the same  branch overseeing a small number of plants—that they call periodically  for updates on issues about which they are known to have prior  experience.
Inspectors told us that this type of outreach is especially important  because it allows them to tap into other inspectors’ different experiences  performing inspections and unique engineering expertise, given that  resident inspectors come from a variety of engineering backgrounds.  They also told us that this form of outreach can have a large influence on  an inspector’s perspective about potential findings. Resident inspectors  stated that they hold many informal discussions about lessons learned— including sharing findings and reviewing changes to guidance—during  their semiannual conferences with peers from across their region and  during periodic visits to plants in other regions. NRC uses e-mail to  distribute updates agencywide to its guidance and other policy statements  on how to respond to lessons learned from different plants; however,  according to inspectors, individual inspectors are responsible for  incorporating these lessons learned into their oversight activities. In  addition, according to NRC officials, each region determines its policy for  e-mailing lessons learned from across the region or lessons learned with  generic safety implications.
section_title: Challenges Accessing Information on Past Experiences May Limit Inspectors’ Ability to Benefit from It
paragraphs: Although NRC guidance directs inspectors to use information on past  experiences to plan and conduct future inspection activities, inspectors  reported facing challenges in accessing information on past experiences,  which may limit their ability to benefit from it. Under NRC guidance,  inspectors are to use information on past plant experiences to prepare  for, conduct, and document inspection activities. According to several  inspectors, this information can be important for helping them choose  inspection samples. Some inspectors we interviewed also stated that  complete access to lessons learned from past plant experience is  important to help them understand how NRC identified and resolved  similar findings at other plants. In addition, industry representatives have  stated that information on past experiences is beneficial because the  industry is mature and there is a robust body of information on past  experiences to learn from.
However, several NRC officials told us that the Reactor Operating  Experience (ROE) Gateway—the agency’s internal website for the  Operating Experience Program—and its search tools are not user- friendly. For example, they noted that the website provides links to more  than a dozen search tools that all contain different information but does  not explain how to use them. The officials said that providing instructions  on how to use these tools would be helpful. Moreover, they told us that  conducting a thorough search on a specific topic may require multiple  keyword searches because different reactor equipment manufacturers  use different terms to describe the same type of equipment. For example,  one manufacturer of commercial nuclear reactors calls certain pumps  Auxiliary Feedwater Pumps, while another manufacturer calls them  Emergency Feedwater Pumps, although both serve the same function— removing heat from the reactor core when the plant experiences a  complete loss of electrical power. As a result, inspectors and other  agency users—including officials in the Operating Experience Program  and technical specialists in the regional offices—have to conduct  searches on several possible keywords in each of the various search  tools. NRC officials told us the various terms used to describe the same  equipment are not officially documented so staff must learn about them  through their own experiences. For example, if an NRC official  encountered a problem at a plant with a particular type of pump, using  ROE Gateway to search for past experiences with this pump would  require the official to know that this piece of equipment had more than  one name and to search on both names in each of the search tools. At  least one of the search tools on ROE Gateway now uses drop-down lists  to eliminate the need to conduct multiple keyword searches, but the  remaining search tools do not have this capability.
Given the challenges in navigating ROE Gateway, several resident  inspectors told us they prefer contacting other inspectors informally or  requesting assistance from NRC headquarters staff when trying to obtain  information on past experience. They also told us they have developed  informal “workarounds” to facilitate searches, such as creating and  sharing slide presentations with one another on keyword searches for  various common inquiries. We have previously reported that informal  relationships could end once personnel move to their next assignments.  Thus an informal workaround cannot substitute for a user-friendly,  searchable system. Without better search tools, inspectors could overly  rely on information available through informal channels rather than the  more comprehensive information located in agency databases. NRC  guidance states that the efficient retrieval of information on past  experiences is a basic requirement for meeting agencywide objectives  and that such information is necessary to improve safety assessments  and NRC decisions. Further, NRC officials noted that inspectors have  varied backgrounds—that is, some may have expertise in mechanical  engineering, while others have expertise in electrical engineering— therefore they depend on NRC’s network of information to assess most  issues and determine their importance. Past inspection results and  related information are crucial parts of that network. NRC officials have  acknowledged the difficulty of using ROE Gateway and noted at their  most recent annual meeting in March 2013 that NRC has struggled to  make information about past experiences accessible and distribute this  information efficiently.
Several resident inspectors also told us that e-mail updates on past  experiences could be managed more effectively. For example, once  resident inspectors receive an e-mail, it is their responsibility to  incorporate the information on past experiences at their plant. However,  these resident inspectors noted that not all e-mail updates apply to all  plants; for example, an update may apply to a certain type of reactor that  is not in use at all plants. Some resident inspectors stated that one way to  improve this system would be to prioritize the e-mail notices and indicate  the extent to which they are relevant to the inspectors. In addition, some  resident inspectors noted that nonurgent e-mail updates should be  compiled, whereas now they are included alongside all e-mail updates.
Resident inspectors play an essential role in ensuring that reactors are  operating safely because they have the opportunity and authority to, at  any time, physically inspect plant equipment and operations, review plant  records, and verify the accuracy of licensee-reported quantitative  measures or indicators of plant performance. NRC officials told us that,  because of their essential role in NRC’s oversight, inspectors need  complete and efficient access to all the information necessary to do their  jobs effectively. In addition, information on past plant performance and  oversight actions helps inspectors know where to begin looking for  potential issues of concern, and NRC guidance states that inspectors  should consider this information in preparing for, conducting, and  documenting inspection activities. For example, prior to the reactor  damage found at the Davis-Besse plant in 2002, inspectors did not  regularly focus on identifying reactor vessel head corrosion; however, as  a result of this incident, NRC inspectors now focus on this issue regularly.
section_title: Conclusions
paragraphs: NRC oversees the safety of commercial nuclear power reactors using  established, ongoing processes. NRC’s oversight has taken on even  greater importance as many commercial reactors in the United States are  operating under renewed licenses that will allow them to operate beyond  their initial 40-year operating periods. NRC is aware of differences across  its regions in the identification and resolution of findings that result from  its oversight processes and has taken some steps to address them,  particularly in the differences of nonescalated findings. However, while  NRC has undertaken these steps, NRC has not conducted a  comprehensive analysis of these differences consistent with federal  standards of internal control. Without a comprehensive analysis of the  differences in the number of nonescalated findings across regions and  their causes, NRC cannot ensure that oversight efforts are objective and  consistent, as specified in its enforcement manual, or know whether its  regional offices or individual inspectors are not applying regulations and  guidance consistently.
Furthermore, NRC policy states that the agency’s mission includes  promoting transparency and openness for all stakeholders. As part of  such transparency, NRC makes publicly available its official  recordkeeping system, which contains hundreds of thousands of  documents on NRC’s reactor oversight processes—as well as other NRC  activities. However, we found this system difficult to navigate, and  external users cannot use it to independently track findings, all  documents related to the findings, and the findings’ resolution. As a  result, NRC cannot ensure that the public, Congress, and others are kept  informed of licensee performance, as specified in agency guidance, to  enhance public confidence that NRC is accomplishing its mission and  following its oversight processes.
Information about reactor operators’ past experiences and NRC’s  responses to them also plays a key role in NRC’s oversight processes.  Although NRC guidance directs inspectors to use information on past  experiences to plan and conduct future inspection activities, inspectors  reported facing challenges in accessing information on past experiences,  which may limit their ability to benefit from this information. Given the  challenges in navigating ROE Gateway, several resident inspectors  reported contacting other inspectors informally or requesting assistance  from NRC headquarters staff when trying to obtain information on past  experience. Without better search tools, inspectors could overly rely on  information available through informal channels. NRC guidance states  that the efficient retrieval of information on past experiences is a basic  requirement for meeting agencywide objectives and that such information  is necessary to improve safety assessments and NRC decisions.
section_title: Recommendations for Executive Action
paragraphs: To improve NRC’s oversight processes, we are making three  recommendations to the NRC Commissioners:
To better meet its goal of implementing objective and consistent  oversight, direct agency managers to conduct a comprehensive  analysis of the causes of the differences in the identification and  resolution of findings.
To improve transparency and better enable the public, Congress, and  others to independently track findings, all documents related to the  findings, and the findings’ resolution, direct the agency to either  modify NRC’s publicly available recordkeeping system to do so or  develop a publicly accessible tool that does so.
To help NRC staff more efficiently use past experiences in their  oversight activities, direct agency officials to evaluate the challenges  inspectors face in retrieving all relevant information on plant  performance and previous oversight activities and improve its systems  accordingly to address these challenges.
section_title: Agency Comments
paragraphs: We provided a draft copy of this report to the Executive Director for  Operations of NRC for review and comment. In its written comments,  reproduced in appendix XI, NRC generally agreed with our findings and  recommendations. NRC also provided technical comments, which we  incorporated, as appropriate.
To address our first recommendation, NRC stated that it will revisit its  initiatives with respect to implementation of the ROP and the  nonescalated enforcement process to identify potential enhancements.  For our second recommendation, NRC stated that it will identify ways to  improve transparency and track documents related to inspection findings  through improved tools to facilitate public access to inspection  information. To address our third recommendation, NRC stated that it will  make plant performance and oversight information more readily  searchable and available to inspection staff and other NRC personnel.
In addition, in its comment letter, concerning regional differences, NRC  stated that, although it believes adequate internal controls to ensure  alignment between regions exist through program office oversight and  audits, among other things, it agrees to seek enhancements in this area.  NRC raised concerns about repeated references in the draft report to the  use of professional judgment by NRC staff members in the ROP and  Traditional Enforcement Process, stating that these references imply a  high degree of subjectivity in the agency’s implementation of its oversight  processes and that its use of professional judgment is excessive or  inconsistent. NRC stated that it believes its use of professional judgment  is limited and controlled through its guidance. As stated in the report, we  agree that NRC’s oversight processes are largely prescribed in guidance.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committees, NRC, and other interested parties. In addition,  this report also will be available at no charge on the GAO website at  http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-3841 or ruscof@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. Key contributors to this report are listed in  appendix XII.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: Our objectives were to (1) describe how the Nuclear Regulatory  Commission (NRC) implements its processes for overseeing the safety of  commercial nuclear power reactors; (2) evaluate the extent to which NRC  consistently identifies and resolves findings through these processes; and  (3) describe NRC’s methods for developing lessons learned to improve its  oversight and challenges, if any, NRC faces in doing so.
To describe how NRC implements its processes for overseeing the safety  of commercial nuclear power reactors, we reviewed relevant federal laws,  regulations, and guidance, including NRC’s Enforcement Policy,  Enforcement Manual, and Inspection Manual, among many other  guidance documents. We also reviewed previous GAO and NRC  Inspector General reports that identified safety-related challenges or  made recommendations for improving NRC’s oversight of reactor safety,  and we reviewed documentation of NRC efforts to update its oversight  processes. We interviewed NRC headquarters officials from the Offices of  Nuclear Reactor Regulation, Enforcement, Nuclear Regulatory Research,  and the Inspector General. We also conducted semistructured interviews  with officials from all four NRC regions, as well as resident inspectors and  plant representatives during site visits to five nuclear power plants  (discussed further below). During these semistructured interviews, we  asked NRC officials and plant representatives about (1) the  implementation and consistency of NRC’s oversight activities, (2) the  extent to which NRC’s oversight includes lessons learned from operating  experience and safety-related findings, (3) the level of communication  between NRC and plant representatives, (4) NRC actions taken to identify  and resolve specific safety-related findings, and (5) site-specific  considerations related to safety. In addition, we interviewed  representatives from the Nuclear Energy Institute, the Union of  Concerned Scientists, academic specialists, and other groups and  individuals to discuss their views and gain additional insight into NRC’s  oversight of reactor safety.
We made site visits to a nonprobability sample of five nuclear power  plants. During these site visits, we held separate semistructured  interviews with NRC resident inspectors and plant representatives,  including licensee managers and plant operators, to obtain in-depth  information about their experiences with NRC’s oversight process. We  also toured several of the sites with the resident inspectors and observed  areas and equipment related to previous findings, in addition to current  issues of concern being assessed for potential findings. Because this was  a nonprobability sample, the information we gathered from these site  visits is not generalizable to all U.S. nuclear power plants but provides  important illustrative information for understanding the oversight of  reactors at the selected plants. To select these sites, we applied the  following criteria to capture a variety of characteristics: whether NRC’s  assessment of the plant’s safety significance has changed in the past 2  years, and whether, collectively, they were located in multiple NRC  regions, operated by different licensees, and included different reactor  types. In Region I, we visited the Calvert Cliffs Nuclear Power Plant in  Maryland. In Region III, we visited the Byron Station in Illinois and  Palisades Nuclear Plant in Michigan. In Region IV, we visited the Cooper  Nuclear Station in Nebraska and Wolf Creek Generating Station in  Kansas.
To evaluate the extent to which NRC consistently identifies and resolves  findings through its processes for overseeing reactor safety, in addition to  reviewing NRC guidance and interviewing NRC officials (as described  above), we analyzed the nonsecurity findings and violations for all plants  from the beginning of NRC’s Reactor Oversight Process in 2000 through  2012. We obtained these data from NRC’s Reactor Program System  database. We also analyzed separate NRC data on (1) the number of  inspection hours from 2000 through 2012, (2) descriptive information  about licensees, (3) substantive cross-cutting issues assigned to each  plant from 2001 through 2012, and (4) the quarterly action matrix  assessment for each reactor from 2001 through 2012. In order to assess  the reliability of the data we analyzed, we reviewed database  documentation, interviewed NRC officials familiar with the data, and  conducted electronic tests of the data, looking for missing values, outliers,  or other anomalies. We determined that the data were sufficiently reliable  for our purposes. We also searched documents in NRC’s publicly  available, web-based Agencywide Documents Access and Management  System (ADAMS) database, which is the official recordkeeping system for  all NRC documents.
To describe NRC’s methods for developing lessons learned to improve its  oversight and challenges, if any, NRC faces in doing so, in addition to  reviewing NRC guidance and interviewing NRC officials (as described  above), we observed NRC headquarters officials demonstrating the  various computer-based tools they use for communicating and providing  access to information on past experiences and lessons learned. We also  observed resident inspectors, during our site visits to nuclear power  plants, demonstrating how they access agency information on past  experiences and lessons learned. In addition, we observed meetings  where NRC staff updated the Commission and the public on the status of  the development and implementation of lessons learned from the  Fukushima disaster, among other safety-related concerns.
We conducted this performance audit from May 2012 to September 2013  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Summary Information about Operating Nuclear Power Reactors in the United States
paragraphs: This appendix provides summary information about the 104 commercial  nuclear power reactors at 65 power plants for which we analyzed NRC  data and that were operating in the United States through the end of  calendar year 2012. For each reactor, table 14 lists the NRC region,  state, date commercial operation began, and licensee.
section_title: Appendix III: NRC Safety Cornerstones and Related Performance Indicators
paragraphs: Appendix III: NRC Safety Cornerstones and  Related Performance Indicators Initiating Events cornerstone – This cornerstone focuses on operations and events at a nuclear plant that could lead to a possible  accident, if plant safety systems did not intervene. These events could include equipment failures leading to a plant shutdown,  shutdowns with unexpected complications, or large changes in the plant’s power output. (In this table, “scram” refers to automatic and  manual reactor shutdowns.)
Performance indicator  Unplanned scrams per 7,000 critical hours  This performance indicator monitors the number of unplanned scrams. It measures the  rate of scrams per year of operation at power and provides an indication of initiating  event frequency. The value of 7,000 hours is used because it represents 1 year of  reactor operation at 80 percent capacity.
This performance indicator monitors the subset of unplanned scrams while critical that  require additional operator actions beyond that of the “normal” scram. Such events or  conditions have the potential to present additional challenges to the plant operations  staff and therefore, may be more risk-significant than uncomplicated scrams.
This performance indicator monitors the number of unplanned power changes (excluding  scrams) that could have, under other plant conditions, challenged safety functions. It  may provide leading indication of risk-significant events but is not itself risk-significant.  The indicator measures the number of plant power changes for a typical year of  operation at power.
Mitigating Systems cornerstone – This cornerstone measures the function of safety systems designed to prevent an accident or  reduce the consequences of a possible accident. The equipment is checked by periodic testing and through actual performance.  Performance indicator  Mitigating system performance index –  emergency alternating current power  systems   Objective   This performance indicator monitors the readiness of the emergency alternating current  power systems to perform their safety functions in response to off-normal events or  accidents.
This performance indicator monitors the readiness of the high pressure injection systems  to perform their safety functions in response to off-normal events or accidents.
This performance indicator monitors the readiness of the heat removal systems to  perform their safety functions in response to off-normal events or accidents.
This performance indicator monitors the readiness of the residual heat removal systems  to perform their safety functions in response to off-normal events or accidents.
This performance indicator monitors the readiness of the cooling water support systems  to perform their safety functions in response to off-normal events or accidents.
This performance indicator monitors events or conditions that alone prevented, or could  have prevented, the fulfillment of the safety function of structures or systems that are  needed to: shut down the reactor and maintain it in a safe shutdown condition; remove  residual heat; control the release of radioactive material; or mitigate the consequences of  an accident.
Barrier Integrity cornerstone – This cornerstone focuses on the physical barriers between the highly radioactive materials in fuel  within the reactor and the public and the environment outside the plant. These barriers are the sealed rods containing the fuel pellets,  the heavy steel reactor vessel and associated piping, and the reinforced concrete containment building surrounding the reactor. The  integrity of the fuel rods, the vessel, and the piping is continuously checked for leakage, while the ability of the containment to prevent  leakage is measured on a regular basis.  Performance indicator  Reactor coolant system specific activity  Objective   This performance indicator monitors the integrity of the fuel cladding, the first of the three  barriers to prevent the release of fission products. It measures the radioactivity in the  reactor coolant system as an indication of functionality of the cladding.
This performance indicator monitors the integrity of the reactor coolant system pressure  boundary, the second of the three barriers to prevent the release of fission products. It  measures reactor coolant system identified leakage as a percentage of the technical  specification allowable identified leakage to provide an indication of reactor coolant  system integrity.
Emergency Preparedness cornerstone –This cornerstone measures the effectiveness of plant staff in carrying out emergency plans  for responding to a possible accident. Such emergency plans are tested every 2 years during emergency exercises involving the plant  staff and local, state, and, in some cases, federal agencies.  Performance indicator  Drill/exercise performance  Objective   This performance indicator monitors timely and accurate licensee performance in drills  and exercises when presented with opportunities for classification of emergencies,  notification of off-site authorities, and development of protective action  recommendations. It is the ratio, in percent, of timely and accurate performance of those  actions to total opportunities.
This performance indicator tracks the participation of emergency response organization  members assigned to fill key positions in performance enhancing experiences, and  through linkage to the drill/exercise performance indicator ensures that the risk- significant aspects of classification, notification, and protective action recommendations  development are evaluated and included in the performance indicator process. This  indicator measures the percentage of emergency response organization members  assigned to fill key positions who have participated recently in performance-enhancing  experiences such as drills, exercises, or in an actual event.
This performance indicator monitors the reliability of the off-site alert and notification  system, a critical link for alerting and notifying the public of the need to take protective  actions. It provides the percentage of the sirens that are capable of performing their  safety function based on regularly scheduled tests.
Occupational Radiation Safety cornerstone – NRC regulations set a limit on radiation doses received by plant workers, and this  cornerstone monitors the effectiveness of the plant’s program to control and minimize those doses.  Performance indicator  Occupational exposure control  effectiveness  Objective   This performance indicator monitors the control of access to and work activities within  radiologically-significant areas of the plant and occurrences involving degradation or  failure of radiation safety barriers that result in readily-identifiable unintended dose.
Public Radiation Safety cornerstone – This cornerstone measures the procedures and systems designed to minimize radioactive  releases from a nuclear plant during normal operations and to keep those releases within federal limits.
Objective   This performance indicator assesses the performance of the program to control  radiological effluent occurrences, which are radiological releases that exceed pre-set  limits for liquid and gaseous releases.
section_title: Appendix IV: NRC Safety Cornerstones and Related Inspection Procedures
paragraphs: This appendix provides summary information about NRC’s inspection  procedures. Table 15 lists the safety cornerstone, title, and objective for  each of the 36 safety-related (nonsecurity) baseline inspection  procedures. Table 16 lists the title and objective for each of the 3  supplemental inspection procedures, and table 17 lists the title and  objective for each of the 3 reactive inspection procedures.
section_title: Appendix V: Examples of NRC Findings and Violations
paragraphs: This appendix provides summary information about select examples of  NRC findings and violations. Table 18 provides a brief description,  nuclear power plant location, and date recorded for select examples of  NRC findings illustrating different risk significance levels. Table 19  provides a brief description, nuclear power plant location, and date  recorded for select examples of NRC violations illustrating different  severity levels.
section_title: Appendix VI: NRC Nonescalated Findings at Operating Nuclear Power Plants in the United States
paragraphs: This appendix provides performance information about the 104  commercial nuclear power reactors at 65 power plants for which we  analyzed NRC data and that were operating in the United States through  the end of calendar year 2012. Table 20 lists the number of nonescalated  findings identified at each plant from 2000 through 2012.
section_title: Appendix VII: Summary of NRC Performance Assessments for Nuclear Power Reactors Operating from 2001 through 2012
paragraphs: This appendix provides performance information about the 104  commercial nuclear power reactors at 65 power plants for which we  analyzed NRC data and that were operating in the United States through  the end of calendar year 2012. Based on NRC’s assessment of licensee  performance under the ROP, NRC places each of the licensee’s reactors  into one of five performance categories on its action matrix, which  corresponds to increased levels of oversight. The action matrix is NRC’s  formal method of determining how much additional oversight—mostly in  the form of supplemental inspections—is required on the basis of the  number and risk significance of performance indicators and inspection  findings. The level of oversight reported here corresponds to the highest  level the plant received during the year, even if it was only a portion of the  year. Thus, if a plant was placed into a different category each quarter,  the highest category in which it was placed is reported here. (See table  21.)
section_title: Appendix VIII: Substantive Cross-cutting Issues Identified by NRC at Operating Nuclear Power Reactors in the United States
paragraphs: This appendix provides performance information about the 104  commercial nuclear power reactors at 65 power plants for which we  analyzed NRC data and that were operating in the United States through  the end of calendar year 2012. Table 22 lists the substantive cross-cutting  issues assigned to each reactor from 2001 through 2012.
section_title: Appendix IX: NRC Escalated Findings at Operating Nuclear Power Plants in the United States
paragraphs: This appendix provides performance information about the 104  commercial nuclear power reactors at 65 power plants for which we  analyzed NRC data and that were operating in the United States through  the end of calendar year 2012. Table 23 lists the number of escalated  findings identified at each plant from 2000 through 2012.
section_title: Appendix X: NRC Fukushima Near-Term Task Force Recommendations
paragraphs: NRC convened the Fukushima Near-Term Task Force to review its  processes and regulations and determine whether its oversight could be  informed by lessons learned from the March 2011 disaster at the  Fukushima Daiichi Nuclear Power Plant in Japan. The task force  concluded that a sequence of events like the Fukushima accident is  unlikely to occur in the United States and that the continued operation of  the nation’s commercial nuclear reactors does not pose an imminent risk  to public health and safety. To improve NRC’s oversight, the task force  recommended:  1.  Establishing a logical, systematic, and coherent regulatory framework  for adequate protection that appropriately balances defense-in-depth  and risk considerations.  2.  NRC require licensees to reevaluate and upgrade as necessary the  design-basis seismic and flooding protection of structures, systems,  and components for each operating reactor.  3.  As part of the longer term review, that NRC evaluate potential  enhancements to the capability to prevent or mitigate seismically  induced fires and floods.  4.  NRC strengthen station blackout mitigation capability at all operating  and new reactors for design-basis and beyond-design-basis external  events.  5.  Requiring reliable hardened vent designs in boiling water reactor  facilities with Mark I and Mark II containments.  6.  As part of the longer term review, that NRC identify insights about  hydrogen control and mitigation inside containment or in other  buildings as additional information is revealed through further study of  the Fukushima Dai-ichi accident.  7.  Enhancing spent fuel pool makeup capability and instrumentation for  the spent fuel pool.  8.  Strengthening and integrating onsite emergency response capabilities  such as emergency operating procedures, severe accident  management guidelines, and extensive damage mitigation guidelines.  9.  NRC require that facility emergency plans address prolonged station  blackout and multiunit events.  10. As part of the longer term review, that NRC pursue additional  emergency preparedness topics related to multiunit events and  prolonged station blackout.
11. As part of the longer term review, that NRC should pursue emergency  preparedness topics related to decisionmaking, radiation monitoring,  and public education.  12. NRC strengthen regulatory oversight of licensee safety performance  (i.e., the Reactor Oversight Process) by focusing more attention on  defense-in-depth requirements consistent with the recommended  defense-in-depth framework.
section_title: Appendix XI: Comments from the Nuclear Regulatory Commission
section_title: Appendix XII: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Ned Woodward (Assistant  Director), John Barrett, Elizabeth Beardsley, John Delicath, R. Scott  Fletcher, Kimberly Gianopoulos, Cindy Gilbert, Chad M. Gorman,  Catherine Hurley, Jonathan Kucskar, Alison O’Neill, Dan Royer, Carol  Herrnstadt Shulman, and Michelle R. Wong made key contributions to  this report.