Text

2018 IP 71152 Assessment Per IMC 0307B - ML18324A434
	ML18324A434
Person / Time
Issue date:	04/24/2019
From:	Aron Lewin; NRC/NRR/DIRS/IRIB
To:	;
	Telson R, 415-2256, NRR/DIRS
References
	Download: ML18324A434 (36)
	v • d • e

Pg 1 of 36 ML18324A434.docx As of 4/26/2019 2018 Inspection Procedure Assessment Summary and Outline of Proposed Changes Inspection Procedure (IP):

71152 Problem Identification and Resolution (Captured in RRPS/ISTAR as 71152 and 71152B)

Data Years Analyzed:

2013 - 2017 Inspection Procedure Lead:

Ross Telson Estimated Hours to Complete Review:

80 Date Review Completed:

12/7/18 Date Review Updated:

1/8/19 Summary of Principle Observations & Recommendations by Section

1. Results and assessment of review of IMC 308, ROP basis document review

a. Root Cause Analysis - Few attributes of PI&R are more important to safety and security than the effectiveness with which licensees analyze the cause(s) of significant adverse conditions (i.e. significant conditions adverse to quality, greater-than-green findings, performance indicators, & escalated violations) to determine and implement prompt corrective actions to preclude repetition.

10 CFR 50 App. B Crit. XVI establishes quality assurance (QA) regulatory obligations for corrective action. In the case of significant conditions adverse to quality (SCAQs), Crit. XVI requires licensees to assure the cause of the SCAQ is determined and corrective action taken to preclude repetition (CAPR).

NEI initiatives, such as NEI 16-07 [CAP-002] reduce industry reliance on root cause analysis (RCA) to analyze SCAQs and identify CAPRs. Likewise, NEI 16-07 reduces reliance on RCA for significant adverse conditions (SACs) -issues yielding greater-than-green (GTG) findings and performance indicators (PIs) but which are not subject to Part 50 App. B.

The ROP is a voluntary oversight and assessment process designed to improve transparency, predictability, objectivity, and scrutability while preserving reasonable assurance of public safety and security. Compared to its predecessor, SALP, the ROP reduces regulatory burden in exchange for the shared expectation that participants will voluntarily establish and operate facilities in accordance with certain self-imposed standards that enable the regulatory burden reduction.

Self-imposed standards are not regulatory obligations and cannot be enforced. However, a licensees more-than-minor failure to meet a self-imposed standard that reasonably could and should have been satisfied constitutes a finding regardless of whether a violation occurred. If the significance of a finding is greater-than-green per the SDP, the licensee will be moved across the action matrix and subjected to supplemental inspection.

If the finding reflects the licensees failure to satisfy a fundamental ROP expectation / self-imposed standard necessary for continued full participation in the ROP and the licensee fails to correct the performance deficiency, the licensees participation in the ROP may be modified or terminated along with the benefits of participation.

Examples of ROP expectations / self-imposed standards might include (a) the periodic submittal of performance indicator (PI) data in support of reduced baseline inspection, (b) the

Pg 2 of 36 ML18324A434.docx As of 4/26/2019 establishment and maintenance of an effective quality-related problem identification and resolution (PI&R) program enabling the NRC to issue NCVs instead of NOVs for most non-escalated low significance violations, and (c) the routine application of RCA to reliably identify causal information enabling the implementation of CAPRs following SACs and SCAQs in support of timely and efficient NRC inspection, issue closure, and licensee return to Column I of the Action Matrix following SAC-and SCAQ-triggered supplemental inspections.

RCA has been integral to ROP inspection of SCAQs and SACs since its origin almost 20 years ago. The ROPs broad reliance on RCA is evidenced in the 26 references to root cause in SRM 99-007, 14 references in IMC 0308 Att. 2, 6 references in IMC 0308-proper, 52 references in IP 95001, 58 references in IP 95002, 10 references in IP 95003, and 2 references in IP 71152. For NRC to explicitly accept reduced reliance on RCA for SACs and SCAQs (i.e. to eliminate the above references from NRC governance or to endorse NEI 16-07) is for the NRC to accept reduced assurance that the cause of SCAQs (and SACs) will be determined and corrective action taken to preclude repetition.

Licensees benefit from RCA in that, when multiple root causes exist, RCA tends to identify most if not all of them. This enables licensees to select the CAPR that can be most promptly and cost-effectively implemented. Licensee and NRC both benefit from RCA in that, in addition to being more reliable, it tends to be more transparent, objective, and scrutable than other cause determination methods. As such, RCA can be more efficiently and effectively validated by licensee management and NRC inspectors.

b. Other IMC 0308, ROP basis document, & IP Alignment Issues - Misalignments between IP 71152, IMC 0308, and other ROP bases were identified in a 2013 IP 71152 self-assessment.

Since then, some of the conflicts have been addressed. Those that remain will require coordination and integration with more recent initiatives to enhance ROP efficiency and reduce regulatory burden.

RECOMMENDATION 1a: Carefully consider cost-benefit and regulatory requirements before altering NRC expectations or endorsing altered industry expectations that bypass RCA for significant issue resolution (including any NRC-endorsed definition or re-definition of significant).

Exercise the mandated Top-Down approach, engaging Commission, public, and industry before significant basis amendment or departure from the bases. Study carefully lessons-learned prior to implementing substantive changes to RCA expectations that could negatively influence (a) licensee PI&R program performance in resolving SCAQs and SACs, (b) compliance with 10 CFR 50 Appendix B, and (c) conformance with core tenants of the ROP, the Enforcement Policy, the Action Matrix, PI&R-related baseline inspection, and/or supplemental inspection programs.

RECOMMENDATION 1b: IP lead and ROP enhancement lead should coordinate with management and other internal and external stakeholders to develop input on PI&R for a SECY that addresses (a) remaining identified alignment issues between current SRMs, ROP Bases, and IP 71152, (b) current challenges, and (c) recommendations of proposed changes to ROP Bases, IP 71152, and impacted procedures for Commission approval. Upon receipt of the Commissions determination regarding recommendations, IMC 0308, IP 71152, and other impacted ROP governance should be revised to realign with each other and with updated Commission SRM(s).

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2. Results and assessment of review of any applicable changes to PIs Licensees maintain a variety of PI&R program performance metrics. These metrics and the licensees response to them are periodically reviewed by inspectors for PI&R program assessment insights during biennial PI&R inspections. The industry seeks to eliminate baseline PI&R baseline inspection. While this is not permissible in the context of Commission SECYs &

SRMs pertaining to PI&R in the ROP, it might be possible to reduce baseline inspection through the incorporation of PI&R performance indicators (PIs) that provide objective measures of PI&R effectiveness attributes.

RECOMMENDATION 2: Consistent with ROP principles, explore the potential to incorporate PI&R PIs to enhance PI&R assessment and support IP 71152 baseline inspection reduction,.

3. Results and assessment of review of any applicable changes to Rules or STSs A review of approved changes to STS over the past three years and rule changes did not reveal any significant changes that would impact IP 71152. However, industry initiatives have sought NRC endorsement. Others have not. The industry has largely adopted NEI 16-07 / CAP-002 to streamline corrective action programs. NEI did not seek NRC endorsement of NEI 16-07 and NRC did not endorse nor reject it but did conduct an informal review which identified potential concerns and made clear that NRC would continue to inspect licensee PI&R programs in accordance with regulatory requirements and ROP governance. A recent industry initiative addressing non-conservative TS sought NRC endorsement. The initiative guidance document referenced and established reliance on NEI 16-07 to address non-conservative TS.

RECOMMENDATION 3: NRC has not endorsed NEI 16-07 and must not endorse any industry position that references-or otherwise relies upon NEI 16-07 or any other non-endorsed industry guidance documents in a manner that may be reasonably be interpreted as endorsement without exercising appropriate agency review and endorsement processes and stakeholders.

Likewise, changes must not be allowed to ROP governance documents that create, in effect or appearance, the endorsement of an unendorsed industry guidance documents.

4. Results and assessment of review of recent Operating Experience IMC 040 describes the Operating Experience Smart Sample (OpESS) as a document that may be employed to integrate operating experience (OpE) into the ROP inspection process. The OpESS makes relevant OpE more accessible to inspectors in the form of a detailed synopsis of selected issues determined to have potential generic safety implications. OpESS are only employed when an inspection can be accomplished within existing ROP inspection requirements and level of effort. Issues that cannot be addressed within existing ROP inspection requirements and level of effort should be considered for a one-time inspection under a Temporary Instruction.

IMC 040 describes a Temporary Instruction (TI) as a temporary inspection procedure used for a one-time inspection or collection of information associated with a current safety issue or concern not currently addressed by established IPs or IMCs. TI requests must be approved by the DIRS Division-or Deputy Division Director. TI requests must provide the necessary background to understand why a TI is warranted including why the information should not be obtained by other means (e.g., OpESS or generic communication), an estimate of required resources and

Pg 4 of 36 ML18324A434.docx As of 4/26/2019 site applicability, an assessment of the safety or security significance providing justification for such resource expenditures, and the estimated dates for start and completion. When the stated purpose of the TI has been accomplished, the originating organization will prepare a final report documenting the TI results.

In November 2018, an OpESS titled Evaluation of Licensee Actions Taken in Response to 10 CFR Part 21 Notification of the Potential Existence of Defects Related to Control Rod Drive Mechanism (CRDM) Thermal Sleeves (ADAMS ML18263A261) was issued to supplement IP 71152. The OpESS addressed several sites subject to the referenced 10 CFR Part 21 notification.

While the OpESS did not explicitly mandate exceeding IP 71152-related inspection objectives, requirements, or level of effort, its intent - established through back channels - was to assure inspection satisfying the objectives of the OpESS at all referenced sites the and to capture information exceeding IP 71152 and IMC 0611 requirements. This raised at least two questions: (a) Did the OpESS circumvent the TI process and exceed OpESS constraints and (b) Was IP 71152 inappropriately employed to conduct what was, in effect, temporary inspection (TI).

Inappropriate employment of ROP IPs can contribute to mismatched objectives and requirements that may compromise the effectiveness of the inspection program, reduce transparency, objectivity, scrutability, and result in unnecessary regulatory burden.

RECOMMENDATION 4: Determine the answers to the two questions (a and b) above. If it is determined that this and/or similar future scenarios like this should not occur, make appropriate changes to IMC 040 and other governance documents and consider training to reduce the likelihood of recurrence. Examples of changes might include streamlining the TI approval process, enhancing controls over inappropriate use of the OpESS process, employing TI vs.

OpESS selection decision diagram, enhanced training of staff and managers who initiate OpESS and Tis, and periodic audits of OpESS and TIs to verify appropriate use.

5. Results and assessment of review based on RRPS data (see separate IP 71152 Assessment Data file for details of RRPS data).

Adverse Trends and Outliers: No noteworthy adverse trends in 71152 and 71152B findings or hours were identified during the 5-year period of review. However, an outlier in 71152B regional samples and hours was observed and is discussed below.

In examining the regional hours and samples documented against 71152B, the IP lead observed that Region III hours and samples, while well aligned to 71152B governance, were outliers when compared to the other three regions. Restated, Regions I, II, and IV hours and samples were not aligned with 71152B or Region III.

71152B budgets 0.5 samples per year (one biennial team inspection every other year). IP 28 lists normalized sample data but does not articulate the meaning of normalized or how the number is calculated. The IP lead interpreted the normalized samples by region to reflect the calculated average number of biennial team inspections per site per 2-year period. Based on this interpretation, the 71152B normalized requirement would be 1.0 and, according to IP 28, Region 3 showed a value of 1.0 normalized samples (1 biennial team inspection every other year). Regions 1, 2, and 4 showed 1.7, 1.6, and 1.7, respectively. 71152B budgets 212 to 288 hours0.00333 days 0.08 hours 4.761905e-4 weeks 1.09584e-4 months of direct inspection per biennial team inspection. Region 3 showed 246 hours0.00285 days 0.0683 hours 4.06746e-4 weeks 9.3603e-5 months whereas Regions 1, 2, and 4 reported 147, 160, and 151 hours0.00175 days 0.0419 hours 2.496693e-4 weeks 5.74555e-5 months respectively.

Pg 5 of 36 ML18324A434.docx As of 4/26/2019 RECOMMENDATION 5: Validate and clarify IP 28 reporting to confirm the validity of the assumptions and analysis above. If validity is confirmed, consult regions to determine (a) why 3 of 4 regions do not appear to be conforming to the IP-specified 71152B sample rate and (b) why the same three regions are reporting completion of 71152B team inspections in approximately 100 fewer hours than budgeted (while Region 3 is reporting effort in the budgeted range).

Consider substantial changes to 71152B to streamline and enhance the efficiency and effectiveness of ROP baseline inspection in this area. Specific changes recommended for consideration include:

A. Streamline 71152B biennial team baseline inspections (i.e Reduce scope, resource estimate, requirements, possibly team size, frequency, and/or duration) by eliminating those items that overlap and can be completed within existing (or slightly modified) 71152 semi-annual trend or annual follow-up inspection samples and do not require a specialized biennial team inspection to achieve IP 71152 objectives. Some elements of 71152B should be re-evaluated for deletion and/or enhancement in 9500X supplemental inspections B. Eliminate IMC 0305 direction to consider IP 71152 supplemental implementation (i.e. exceeding IP-specified sample frequency) each time a plant enters Column 3 or 4 of the Action Matrix and for the two-year period following the quarter in which the plant entered Column 3 or 4.

C. Enhance compliant implementation of IP 71152 (i.e. Inspection consistent with IP-specified sample frequency range, objectives, and requirements - or as approved in ROP deviation) and accurate resource reporting (i.e. actual resources expended) through improved accountability measures (e.g. periodic audits, field validations, metrics, and other oversight mechanisms).

D. Restore clarity to the line dividing screening and inspection by returning daily CAP screening (resources, objectives, requirements, and commitments) from IP 71152 to IMC 2515D Plant Status. Inspectors will continue to screen all daily CAP documents as before but follow-up of CAP screening issues of concern, like issues identified in other plant status activities will be prioritized for potential inspection in accordance with the risk-informed, performance-based baseline inspection process. Those issues warranting inspection must be directed to the appropriate baseline IP with available samples.

E. Continue to streamline and improve IP 71152 focus on core objectives (i.e. relocate previously-added requirements and reject new requirements that do not directly support IP 71152 objectives to hold the line in inspection objectives, requirements, and frequency.)

F. Enhance IP 71152-related inspection documentation in inspection reports and RRPS/ISTAR to support efficient and effective periodic licensee PI&R program assessment and/or validation of potential future PI&R PI(s) to justify future IP 71152 inspection scope or sample frequency reductions.

G. Clarify ROP deviation requirements and assure deviations are reconciled with subsequent permanent IP/IMC changes (i.e Detail those instances in which program deficiencies may warrant deviations from the IP-specified baseline sample range, objectives, or requirements).

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6. Feedback Forms As of November 19, 2018, the FBF Tracking System (Pilot) SharePoint site shows 27 open ROP IP 71152 feedback forms. The submittal dates range from 2011 to 2018 with 23 FBFs submitted prior to the current IP 71152 revision date (February 26, 2015). 24 of 27 FFs were submitted prior to the 2016 IP 71152 PI&R Assessment Report (ADAMS ML16091A367).

The current draft revision of IP 71152 (ADAMS ML15322A104), if issued as drafted, should fully address and close 8 of the 27 FFs and partially address some of the remaining 19 FFs. Others might be closed with no further action depending on management decisions limiting the IP 71152 change scope. Further stakeholder collaboration will be necessary to resolve differing stakeholder positions regarding the open FFs.

Additional discussion and detail regarding open FFs may be found in multiple documents including the December 2015 Reactor Oversight Process Problem Identification and Resolution Working Group Charter - Phase I (Public ADAMS ML15290A004) and a September 2016 PI&R Enhancement Matrix (ADAMS ML18323A111). Additional perspectives may be viewed in other tracking systems including ROP Self-Assessment and ROP Lessons Learned Tracker SharePoint sites.

The IP lead prepared a Draft White Paper (ADAMS ML18360A492) addressing a September 19, 2018, NEI letter (ADAMS ML18262A322) Recommendation 1E to Remove PI&R From Baseline Inspection Program.

7. Other Considerations RRPS SELF-ASSESSMENT NUMERICAL / GRAPHICAL ANALYSIS CHALLENGES The RRPS query-, reporting-, and export structures created challenges in the analysis effort.

Specifically, the IP lead found it difficult to extract and output usefully-structured data to all products including MS word, Excel, and Adobe to support of generation of data plots or efficient visual tabular analysis.

Report 28 limits analysis period to 5-years which precludes analysis of ROP lifetime trends if/when required such as when questioned by a congressional oversight committee or to validate/refute assertions that baseline inspection hours increased substantially over the life of the ROP.

Report 28 Word exports used non-standard (non-existant) paper sizes, truncated unnecessarily wide tables and awkwardly split tables across pages Report 28 Excel exports exhibited awkwardly merged columns that required substantial editing to convert into tables from which useful plots could be generated.

Report 28 PDF exports wrapped unnecessarily wide tables making visual trending difficult.

Report 28 provided calculated values under the heading normalized without providing sufficient information to assure clear understanding of the meaning of normalized in the report context or how the normalized value was calculated.

Report 28 provided numeric values without including appropriate context (i.e. When reporting hours expended, it would be appropriate to provide the IP-budgeted range;

Pg 7 of 36 ML18324A434.docx As of 4/26/2019 likewise, when reporting samples or normalized samples, it would be appropriate to provide the IP-specified range of samples.)

RECOMMENDATION 7a: Substantially improve RRPS data capture, validation, query, reporting, and export tools to support flexible, necessary, efficient, and effective analysis quantitative analysis.

RECURRING IP 71152 REVISION PROCESS DEFERMENTS Perhaps no baseline IP is more important to the ROP and to assuring safety than IP 71152.

Nevertheless, achieving internal stakeholder alignment regarding changes to IP 71152 and an agency commitment and ability to reserve staff resources necessary to complete an effective revision have been particularly challenging, contributing to recurring delays in the revision process. Improved mechanisms are needed to address and resolve contentious issues related to IP 71152 and a few other IPs at the appropriate staff, management, or Commission level in order to prevent continuing IP 71152 revision deferrals and delayed ROPFF closures as illustrated below:

In a 2013 IP 71152 analysis report (ADAMS ML18323A072), the IP lead documented several recommendations to address a variety of inputs to correct and enhance IP 71152. A February 26, 2015, IP 71152 revision (ADAMS ML14316A042) partially resolved some but not all of the identified issues. These issues were further discussed in the April 4, 2014 ROP Enhancement Project - Baseline Inspection Program, Enclosure 6 (ADAMS Package ML14017A338), the December 2015 ROP Problem Identification and Resolution Working Group Charter - Phase I (ADAMS ML15290A004), the May 2016 IP 71152 PI&R Assessment Report (ADAMS ML16091A367), and were consolidated and summarized in a September 2016 Matrix (ADAMS ML18323A111).

A draft revision of IP 71152 was developed with an intended effective date of January 2017.

The effort was suspended in September 2016 at management direction prioritizing other (perhaps less contentious) activities. The effort was resumed in early 2017 but suspended again for the IP lead to chair a team tasked to evaluate draft NEI 16-07, develop an NRC response (See ADAMS ML17319A140), and to develop and deliver regional PI&R / CAP-002 training (see ADAMS ML17337A057 and ML17291A191). IP 71152 revision efforts were resumed in early 2018 but again suspended when the IP lead was appointed to chair a team tasked with developing a SECY and related documents to enhance Resident Inspector Program Recruiting and Retention. Most recently, late in 2018, having moved the SECY sufficiently forward, the IP lead prepared an updated draft revision to IP 71152 (ADAMS ML15322A104) with an intended January 2019 effective date. As discussed under Current Draft Revision of IP 71152 (ADAMS ML15322A104), below, this draft would further address some but not all of the pending issues. The effort was suspended again in November 2018 at management direction.

The next revision will likely be deferred again pending resolution of global issues pertaining to ROP enhancement as proposed in a September 19, 2018 letter from NEI (ADAMS ML18360A492).

RECOMMENDATION 7b: Establish improved mechanisms to resolve contentious issues and to prevent continuing deferral of IP revisions and ROPFF closures - Especially in connection with IP 71152.

ROP (PI&R) Enhancement / Transformation Initiative NEI and NRC Senior Management have expressed a mutual desire to enhance ROP effectiveness, efficiency, and to reduce regulatory burden. One such initiative is discussed in a December 26, 2018, White Paper (ADAMS ML18360A492) containing the IP Leads Input for

Pg 8 of 36 ML18324A434.docx As of 4/26/2019 Consideration in Responding to NEIs September 19, 2018 ROP Enhancement Letter, Subj:

ROP Enhancement, Proj: 689 (ADAMS ML18262A322), Proposal 1E to Remove PI&R from Baseline Program. Proposed response to NEI's 19 September 2018 ROP Enhancement proposal 1E to remove PI&R Inspection from the baseline inspection program.

It is too early to determine how this initiative will impact IP 71152 and NRC oversight of licensee PI&R but changes are anticipated. It creates uncertainty regarding the path forward for IP 71152. As such, the potential to further delay IP 71152 revision and ROPFF closure continues.

NRC oversight of licensee PI&R remains fundamental to the ROP. However, several challenges associated with current biennial team inspection governance, its implementation, and the teams ability to meaningfully assess licensee PI&R program effectiveness, and the ROPs ability to integrate that assessment into the action matrix or elsewhere in the ROP assessment process and Action Matrix. IP 71152 biennial team inspection remains an area of opportunity for improving ROP effectiveness and efficiency and reduction of unnecessary regulatory burden. Consideration of changes to the biennial team inspection should be integrated into Recommendation 1, above, to assure a more holistic review and revision process outcome.

NEI 16-07 (CAP-002)

Much of the nuclear industry has standardized site corrective action programs on the governance contained in NEI Technical Report 16-07 Improving the Effectiveness of Issue Resolution to Enhance Safety and Efficiency.

Changes in site corrective action programs are expected to impact licensee PI&R performance as well as the NRCs inspection of those programs. No associated changes to IP 71152 have yet been identified.

NEI provided a draft for NRC review but did not seek nor receive NRC endorsement (See ML17319A140). The IP 71152 lead and DIRS Director presented PI&R training and reference materials during each of the four regions December 2017 inspector counterpart meetings (ML17337A057). NEI was invited to the meetings at which they gave presentations and answered questions.

As part of Recommendation 1, consider both positive and potentially adverse impact(s) of changes to licensee CAPs in connection with any changes to IP 71152-related baseline inspection and assessment processes.

Proposed Aging Management Changes The pending draft revision to IP 71152 (ADAMS ML15322A104) incorporates several changes to address aging management. These changes were requested by the Division of Material and License Renewal outside of the IMC 040 feedback process. The proposed changes include the mandatory use of one of the budgeted PI&R annual follow-up samples. A recent OpESS effectively mandates use of another of the budgeted PI&R samples. One of the principle recommendations in the April 4, 2014 Enclosure 6: Reactor Oversight Process Enhancement Project - Baseline Inspection Program; Inspection Area - Problem Identification and Resolution report (ADAMS ML14017A391) was to better focus the procedure on inspection of corrective action as opposed to the variety of issues that had found their way into IP 71152 over the years.

Proposed changes associated with aging management and future additions to IP 71152 should be routinely assessed as part of IMC 0307B to assure that proposed additions align with the basis and objectives of IP 71152.

IMC 040-Directed Restructuring of All IPs

Pg 9 of 36 ML18324A434.docx As of 4/26/2019 IMC 040, Preparing, Revising, and Issuing Documents for the NRC Inspection Manual, was revised in January 2018. The revision substantially altered requirements for the formatting of all baseline inspection procedure governance. The change required all IPs to be reissued to alter their structure from one that grouped all REQUIREMENTS (mandatory governance) into one section and all GUIDANCE (optional governance) into a separate section with a parallel structure to the REQUIREMENTS section. The IMC 040 revision substantially impacted all IP stakeholders. However, it was issued without: (a) training, (b) 30-day comment period, or (c) Issuing ROP Feedback Forms against all IPs to assure their respective leads were fully aware and addressed the change in pending revisions. In the case of IP 71152, a draft had already been developed with numerous proposed technical content changes. IMC 040 requires the use of change bars and red-line techniques to promote increased awareness among stakeholders (including reviewers of changes during the 30-day comment process and inspectors who must adjust their implementation accordingly). Implementing a major structural change in conjunction with technical content changes results in a reissue of the IP without red-line or change bars. Structural changes that require reissue of ROP governance should be separated from significant technical content changes to promote effective review, understanding, and inspector recognition and implementation of technical content changes.

RECOMMENDATION 7c: Conduct two revisions of IP 71152: (a) one revision to implement the IMC 040-required structural changes without incorporating technical content changes and (b) a second revision to the previously restructured IP to incorporate technical content changes with associated redline markups. Revise IMC 040 to prohibit revisions that concurrently incorporate substantial technical content changes and substantial structural changes that would constitute a document reissue and thus negate the benefit of change markings. Also consider incorporating, into the IMC 0307B periodic IP review, the examination of impacts on the IP that may have been created by changes to related ROP governance documents such as in the scenario above.

Current Draft Revision of IP 71152 (ADAMS ML15322A104)

If issued as presently edited, draft IP 71152 would:

a. Partially implement the 1/5/18 revision of IMC 0040: (a) Replacing text in INSPECTION BASIS with a hyperlinked reference to IMC 0308 Attachment 2, (b) replacing former sections 71152-04 RESOURCE ESTIMATE and 71152-05 PROCEDURE COMPLETION with SAMPLE REQUIREMENTS table, but (c) deferring elements of subparagraph 07.03 Baseline Inspection Procedures governance that restructure sections 71152-02 INSPECTION REQUIREMENTS and 71152-03 INSPECTION GUIDANCE.

b. Address elements of Reactor Oversight Process Problem Identification and Resolution Working Group Charter - PHASE I (ML15290A004). Specifically: (a) Requires annual follow-up of completed significant planned corrective actions, (b) addresses and closes ROPFF 71152-1833 (reference plant risk information e-book), (c) -1841 (replace App. A guidance for gathering SCWE and PI&R insights), (d) -1842 (enhanced SCWE assessment guidance), (e) -1870 (enhanced OWA guidance), (f) -1987 (periodic review of generic concerns), (g) -2155 (better address SL-III, -II, and -I NOVs);(h) required annual follow-up of long-term generic issues, when not pursuing (2)(a), above.

c. Address and close ROPFF 71152-1987 (periodic review of generic concerns) and -2021 (2014 ROP Enhancement Project - review past reactive inspection issues, long-standing CAP issues, dated generic communications).

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d. Relocate daily corrective action document screening commitment, requirements, guidance, and resources from the Routine Review subsection of this IP to IMC 2515 Appendix D Plant Status

e. Address concerns raised in 2013 in Enclosure 6: Reactor Oversight Process Enhancement Project - Baseline Inspection Program (ML14017A391) and 2016 IMC 0307 B Reactor Oversight Process Baseline IP Reviews [NP]. Governance pertaining to routine review was updated accordingly.

f.

Address additional enhancements: (1) Incorporates aging management considerations into PI&R inspections, mandating application of at least one of the Annual Follow-up samples to PEO-related issues, (2) integrates IMC 2201 Security Inspection Program for Commercial Nuclear Power Reactors [NP], adding IMC 2201A to PROGRAM APPLICABILITY to address inclusion of IP 71152 routine reviews in IMC 2201A IPs and closes ROPFF 71152-1988, (3) improves use of plain language (e.g. shall, must, should, may, etc.) and applicable regulatory language (e.g. prompt vs. timely), and (4) corrects issues with-and improves document formatting.

8. Results of discussions with regions The IP lead scheduled a conference call and invited the following regional IP 71152 points of contact (POCs).

Len Cline (R1)

S. Sandal (R2)

R. Ruiz (R3)

Eric Ruesch (R4)

The call was conducted from 1:00 to 1:45 PM EST on November 29, 2018. One regional POC participated. The IP leads understanding of the calls purpose, in accordance with IMC 0307B, was to obtain regional inspectors perspectives on flexibility and on IP implementation.

However, the IP lead accepted other inputs and conducted a general review of the IP 71152 assessment. Specifically:

One regional perspective was that agency efforts to reduce inspection documentation and raise the minor vs. MTM threshold (reduce the number of findings) may have a significant adverse impact on biennial PI&R inspection and assessment efforts.

Another observation that was shared was the perception that current efforts to document IP 71152 observations for issues that did not rise to the level of findings reflected an inefficient use of inspection resources for those sites in column 1 of the action matrix. It was not clear to the regional POC if or how anyone inside or outside the NRC was using these observations.

The IP lead reviewed much of the IP 71152 assessment with the POC who expressed general agreement with the assessment and did not object to any of the discussed elements or recommendations.

POST-CALL UPDATE:

At the time of the call, the IP lead had only completed a cursory assessment of the RRPS data due, in part, to challenges addressed in Section 5 and, in part, to other priority tasking. A more detailed review identified an RRPS data outlier that may warrant further regional engagement.

Pg 11 of 36 ML18324A434.docx As of 4/26/2019 In addition, the IP lead had not yet been tasked to prepare a Draft White Paper (ADAMS ML18360A492) addressing a September 19, 2018, NEI letter (ADAMS ML18262A322). The white paper addressed NEIs recommendation 1E to remove IP 71152 from the baseline inspection program.

Following the call, additional scope and detail were incorporated into the IP 71152 self-assessment including but not limited to a more detailed RRPS analysis and references to NEIs letter and associated white paper. In addition, the IP lead became aware of his oversight in interpreting IMC 0307B governance regarding the scope of the regional call. In reviewing IMC 0307 Appendix B Attachment 1 following the call, the IP lead recognized that the intended scope of the call was broader than he had previously interpreted. This was his first implementation of the revised IMC 0307B.

RECOMMENDATION 8: Share the updated analysis with the regional stakeholders listed above and provide an opportunity for further dialogue if regional interest is expressed.

9. Recommendations Roll-up RECOMMENDATION 1a: Carefully consider cost-benefit and regulatory requirements before altering NRC expectations or endorsing altered industry expectations that bypass RCA for significant issue resolution (including any NRC-endorsed definition or re-definition of significant).

Exercise the mandated Top-Down approach, engaging Commission, public, and industry before significant basis amendment or departure from the bases. Study carefully lessons-learned prior to implementing substantive changes to RCA expectations that could negatively influence (a) licensee PI&R program performance in resolving SCAQs and SACs, (b) compliance with 10 CFR 50 Appendix B, and (c) conformance with core tenants of the ROP, the Enforcement Policy, the Action Matrix, PI&R-related baseline inspection, and/or supplemental inspection programs.

RECOMMENDATION 1b: IP lead and ROP enhancement lead should coordinate with management and other internal and external stakeholders to develop input on PI&R for a SECY that addresses (a) remaining identified alignment issues between current SRMs, ROP Bases, and IP 71152, (b) current challenges, and (c) recommendations of proposed changes to ROP Bases, IP 71152, and impacted procedures for Commission approval. Upon receipt of the Commissions determination regarding recommendations, IMC 0308, IP 71152, and other impacted ROP governance should be revised to realign with each other and with updated Commission SRM(s).

RECOMMENDATION 2: Consistent with ROP principles, explore the potential to incorporate PI&R PIs to enhance PI&R assessment and support IP 71152 baseline inspection reduction,.

RECOMMENDATION 3: NRC has not endorsed NEI 16-07 and must not endorse any industry position that references-or otherwise relies upon NEI 16-07 or any other non-endorsed industry guidance documents in a manner that may be reasonably be interpreted as endorsement without exercising appropriate agency review and endorsement processes and stakeholders.

Likewise, changes must not be allowed to ROP governance documents that create, in effect or appearance, the endorsement of an unendorsed industry guidance documents.

RECOMMENDATION 4: Determine the answers to the two questions (a and b) above. If it is determined that this and/or similar future scenarios like this should not occur, make appropriate changes to IMC 040 and other governance documents and consider training to reduce the

Pg 12 of 36 ML18324A434.docx As of 4/26/2019 likelihood of recurrence. Examples of changes might include streamlining the TI approval process, enhancing controls over inappropriate use of the OpESS process, employing TI vs.

OpESS selection decision diagram, enhanced training of staff and managers who initiate OpESS and Tis, and periodic audits of OpESS and TIs to verify appropriate use.

RECOMMENDATION 5: Validate and clarify IP 28 reporting to confirm the validity of the assumptions and analysis above. If validity is confirmed, consult regions to determine (a) why 3 of 4 regions do not appear to be conforming to the IP-specified 71152B sample rate and (b) why the same three regions are reporting completion of 71152B team inspections in approximately 100 fewer hours than budgeted (while Region 3 is reporting effort in the budgeted range).

Consider substantial changes to 71152B to streamline and enhance the efficiency and effectiveness of ROP baseline inspection in this area. Specific changes recommended for consideration include:

A. Streamline 71152B biennial team baseline inspections (i.e Reduce scope, resource estimate, requirements, possibly team size, frequency, and/or duration) by eliminating those items that overlap and can be completed within existing (or slightly modified) 71152 semi-annual trend or annual follow-up inspection samples and do not require a specialized biennial team inspection to achieve IP 71152 objectives. Some elements of 71152B should be re-evaluated for deletion and/or enhancement in 9500X supplemental inspections B. Eliminate IMC 0305 direction to consider IP 71152 supplemental implementation (i.e. exceeding IP-specified sample frequency) each time a plant enters Column 3 or 4 of the Action Matrix and for the two-year period following the quarter in which the plant entered Column 3 or 4.

C. Enhance compliant implementation of IP 71152 (i.e. Inspection consistent with IP-specified sample frequency range, objectives, and requirements - or as approved in ROP deviation) and accurate resource reporting (i.e. actual resources expended) through improved accountability measures (e.g. periodic audits, field validations, metrics, and other oversight mechanisms).

D. Restore clarity to the line dividing screening and inspection by returning daily CAP screening (resources, objectives, requirements, and commitments) from IP 71152 to IMC 2515D Plant Status. Inspectors will continue to screen all daily CAP documents as before but follow-up of CAP screening issues of concern, like issues identified in other plant status activities will be prioritized for potential inspection in accordance with the risk-informed, performance-based baseline inspection process. Those issues warranting inspection must be directed to the appropriate baseline IP with available samples.

E. Continue to streamline and improve IP 71152 focus on core objectives (i.e. relocate previously-added requirements and reject new requirements that do not directly support IP 71152 objectives to hold the line in inspection objectives, requirements, and frequency.)

F. Enhance IP 71152-related inspection documentation in inspection reports and RRPS/ISTAR to support efficient and effective periodic licensee PI&R program assessment and/or validation of potential future PI&R PI(s) to justify future IP 71152 inspection scope or sample frequency reductions.

G. Clarify ROP deviation requirements and assure deviations are reconciled with subsequent permanent IP/IMC changes (i.e Detail those instances in which program deficiencies may warrant deviations from the IP-specified baseline sample range, objectives, or requirements).

Pg 13 of 36 ML18324A434.docx As of 4/26/2019 RECOMMENDATION 7a: Substantially improve RRPS data capture, validation, query, reporting, and export tools to support flexible, necessary, efficient, and effective analysis quantitative analysis.