ML23082A044
| ML23082A044 | |
| Person / Time | |
|---|---|
| Issue date: | 03/23/2023 |
| From: | Molly Keefe-Forsyth NRC/NRR/DRO/IRAB |
| To: | |
| References | |
| Download: ML23082A044 (21) | |
Text
2022 ROP Self Assessment:
Safety Culture Effectiveness Review Molly Keefe-Forsyth Safety Culture Program Manager Office of Nuclear Reactor Regulation
Safety Culture Effectiveness Review Final Paper ML22340A452
Intent of ROP Safety Culture 3-Tiered Approach based on SRM & RIS 2006-013 Provide process to allow for evaluating safety culture after performance issues occur Provide better opportunities for NRC staff to consider safety culture weaknesses & encourage licensees to take appropriate actions Before significant performance degradation occurs Provide a process to evaluate safety culture for plants in Column 4
Effectiveness of Safety Culture Oversight Column 1 Column 2 Column 3 Column 4 Column 5 Partially Effective Highly Effective Column 4: structured process to evaluate the licensees safety culture assessment and to independently conduct a safety culture assessment Columns 2 & 3: process to determine the need to specifically evaluate a licensees safety culture Column 1: consider safety culture weaknesses and encourage licensees to take appropriate actions before significant performance degradation occurs.
Effective Mostly Effective Partially Effective
Recommendation One
- IMC 0305 and IP 95001 should be updated with language similar to that used for IP 95002 allowing for an NRC evaluation of safety culture for Column 2 plants if the circumstances warrant
- This would not require the licensees to perform an independent third-party safety culture assessment. It would provide for independent NRC consideration of the need for sampling and assessing safety culture.
Recommendation Two Improve training available to inspectors to better meet Commission objectives stated in SRM 04-0111
Recommendation Three Update IP 93100 to review all of safety culture using one of three potential options:
3-1. Enhance PI&R to Look at All Safety Culture
- Use updated IP 93100 to sample all safety culture traits
- Safety culture assessors as part of team as needed
3-2. Adjust Existing Inspection Framework
- Maintain IP 93100 as an Appendix C procedure available for use at RA discretion when NRC has concerns about licensee safety culture and its potential impact on performance
- Supplement PI&R inspections with qualified safety culture assessors as needed
- Update IP 93812 and IP 93800 (SIT & AIT) to provide for safety culture assessor as part of team if known safety culture issues are thought to be a factor
3-3. Baseline Safety Culture IP
- Add IP 93100 as a baseline inspection to look specifically at safety culture on a bi/tri-ennial basis.
- Though initial Commission direction specifically said no additional IP, this review has found that one intended goal of the program, to identify safety culture issues and encourage action before more significant issues develop, is challenged under the current program.
- Resources currently devoted to SCWE in PI&R would be transferred to this inspection
All Recommendations
- 1. Update 95001 to allow for safety culture review when indicated
- 2. Update inspector training based on User Need input from RES
- 3. Improve ability to encourage action in Column 1 using revised IP 93100 1.
Enhance PI&R or 1.
Flex existing inspection framework or 3.
Baseline IP
Internal Discussion Feedback During discussions with NRC Regional Administrators and Division Directors, an alternative recommendation was proposed which leverages the existing IMC 0305 quarterly ROP trend reviews of licensee performance.
The recommendation is to revise existing assessment guidance to prompt NRC Management discussions with licensees on any safety culture aspects discussed during quarterly reviews.
The recommendation would encourage licensee action to address safety culture aspects before significant performance degradation occurs.
This recommendation would not require additional inspection or significant additional resources, consistent with the graded approach in SRM-04-0111 for licensees in Column 1 or Column 2 of the ROP Action Matrix.
Background slides
=
Background===
In January of 2022, a multi-disciplinary team of staff from multiple agency offices was assigned to conduct an effectiveness review of the Safety Culture program as part of the ROP self-assessment program.
Team Members Molly Keefe-Forsyth, Safety Culture Program Manager NRR/DRO/IRAB (Team Lead)
Rebecca Sigmon, Reactor Systems Engineer, NRR/DRO/IOEB April Nguyen, Senior Resident Inspector, Region III Elise Eve, Senior Reactor Inspector, Region I Dori Willis, OE/Allegations Team Lead Chris Hunt, Senior Resident Inspector, Region III Alex Garmoe, Senior Risk Analyst NRR/DRO/IRAB (Team consultant)
Column 4 Plants Provide the NRC staff with a structured process to evaluate the licensees safety culture assessment and to independently conduct a safety culture assessment for a licensee in the multiple/repetitive degraded cornerstone column of the action matrix.
Effective IP 95003 provides a framework for NRC staff to perform an independent assessment of licensee safety culture The ROP provides for assessment and feedback following IP 95003 inspections that has helped shape and improve the NRCs independent safety culture evaluation for subsequent plants in Column 4
Plants with Degraded Performance Provide the NRC staff with a process to determine the need to specifically evaluate a licensees safety culture after performance problems have resulted in the placement of licensee in the degraded cornerstone column of the action matrix Mostly Effective IP 95002 provides a process for incorporating aspects of IP 95003 safety culture evaluation as needed
- When used for Column 3 plants it has effectively identified underlying safety culture issues 2015 changes to ROP assessment process raised the threshold for reaching Column 3
- IP 95001 does not provide an option for independent NRC safety culture assessment
- Plants with safety culture issues that would have reached Column 3 instead bounced back and forth from Column 2 to Column 1 multiple times
Column 1 Plants Provide better opportunities for the NRC staff to consider safety culture weaknesses and to encourage licensees to take appropriate actions before significant performance degradation occurs.
Partially Effective Consider safety culture weaknesses Cross-Cutting Aspects allow NRC staff to independently and objectively tag ROP findings with individual safety culture attributes.
- Trends in these attributes demonstrate statistically significant predictive associations with future performance issues Encourage appropriate actions The framework is less effective at encouraging action before this significant performance degradation occurs Effective Partially Effective
Identification of Issues
- Since 2007, cross-cutting aspects have been consistently assigned to about 80% of ROP inspection findings each year
- Inspectors with additional training in safety culture find they can identify developing concerns before they reach the level of a finding, and engage licensees even earlier in the process 0%
20%
40%
60%
80%
100%
Percent of Green Findings with a Cross-Cutting Aspect All CCAs Human Perf PI&R
Predictive Associations - Action Matrix 17.5%
42.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Plants in Col 1 with <14
% Plants in Col 1 with 14 Human Performance Cross-Cutting Aspects Increased Oversight the Following Year Remained in Col 1 the Following Year 17.0%
43.2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% Plants in Col 1 with <6
% Plants in Col 1 with 6 PI&R Cross-Cutting Aspects Increased Oversight the Following Year Remained in Col 1 the Following Year
Retrospective - 95003 Case Studies
- Underlying themes
- Safety culture issues were always apparent in hindsight
- In some cases multiple SCCIs were open, but the ROP did not encourage meaningful action
- Often the underlying issues are outside the safety culture attributes allowed to be tagged in baseline ROP (Other)
- Safety culture issues not resulting in enough findings to trigger CCI thresholds
- Noted in multiple 95003 lessons learned reports and CCI reviews in both 2015 and 2020.
IP 93100 Experience to Inform a Path Forward
- IP 93100 Safety Conscious Work Environment Issue of Concern Followup
- SCWE included in ROP cross-cutting framework, but aspects of SCWE are also dealt with outside the ROP with inspection using IP 93100 including:
- Allegations and Investigations
- Traditional Enforcement
- Chilling Effects Letter