1. 1 American Society of Quality September 20, 2005 Presented by Linda Smith USNRC Region IV

2. 2 Nuclear Regulatory Commission 104 Nuclear Power Reactors 104 Nuclear Power Reactors 36 Non-Power Reactors 36 Non-Power Reactors 47 Uranium Recovery Sites 47 Uranium Recovery Sites 9 Major Fuel Cycle Facilities 9 Major Fuel Cycle Facilities Approximately 4,500 Materials Licensees Approximately 4,500 Materials Licensees

3. 3 Nuclear Regulatory Commission Goals Safety Safety Security Security Openness Openness Effectiveness Effectiveness Management Management http://www.nrc.gov/reading-rm/doc- collections/nuregs/staff/sr1614/v3/sr161 4v3.pdf http://www.nrc.gov/reading-rm/doc- collections/nuregs/staff/sr1614/v3/sr161 4v3.pdf

4. 4 NRC/Stakeholders Value of Communication Value of Communication Safety is a Shared Objective Safety is a Shared Objective Predictable Effective Regulation Predictable Effective Regulation Learning Oversight Learning Oversight

5. 5 Reactor Oversight Integration of Inspection, Assessment, and Enforcement

6. 6 DAVIS-BESSE LESSONS LEARNED

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8. 8 Why was Davis-Besse Head Degradation allowed to occur? Why was Davis-Besse Head Degradation allowed to occur? http://www.nrc.gov/reactors/oper ating/ops-experience/vessel-head- degradation.html http://www.nrc.gov/reactors/oper ating/ops-experience/vessel-head- degradation.html

9. 9 DAVIS-BESSE LESSONS LEARNED FOR PI&R EDO Commissioned a Task Force to identify and recommend areas of improvement EDO Commissioned a Task Force to identify and recommend areas of improvement The report contained 51 recommendations The report contained 51 recommendations Four recommendations applied to PI&R Four recommendations applied to PI&R

10. 10 DAVIS-BESSE LESSONS LEARNED Forty percent of risk significant events involve problem identification and resolution (PI&R) weaknesses (Accident Sequence Precursor data). Forty percent of risk significant events involve problem identification and resolution (PI&R) weaknesses (Accident Sequence Precursor data). Facilities that have gone through extended shutdowns almost always have had PI&R problems Facilities that have gone through extended shutdowns almost always have had PI&R problems

11. 11 Recommendation LESSONS LEARNED FOR PI&R – Recommendation 1 Broaden inspection with the goal of assessing safety implications of : Broaden inspection with the goal of assessing safety implications of :  Long-standing, unresolved problems  Corrective actions phased in over several years or refueling outages  Deferred modifications

12. 12 Recommendation LESSONS LEARNED FOR PI&R – Recommendation 2 Assess issues similar to those experienced at Davis Besse Assess issues similar to those experienced at Davis Besse Improve guidance for screening to determine which problems will be reviewed Improve guidance for screening to determine which problems will be reviewed

13. 13 Recommendation LESSONS LEARNED FOR PI&R – Recommendation 3 Provide guidance for pursuing issues and problems identified during resident inspector plant status reviews Provide guidance for pursuing issues and problems identified during resident inspector plant status reviews

14. 14 Recommendation LESSONS LEARNED FOR PI&R – Recommendation 4 Provide guidance to provide for the longer-term follow-up of issues that have not progressed to a finding Provide guidance to provide for the longer-term follow-up of issues that have not progressed to a finding

15. 15 LESSONS LEARNED FOR PI&R – Big Picture Objective was to upgrade NRC oversight so that we recognize and draw attention to longstanding equipment degradation Objective was to upgrade NRC oversight so that we recognize and draw attention to longstanding equipment degradation

16. 16 LESSONS LEARNED FOR PI&R – Big Picture A Narrowly Focused Corrective Action Program did not serve us well at Davis Besse A Narrowly Focused Corrective Action Program did not serve us well at Davis Besse Broke-fix is not enough Broke-fix is not enough

17. 17 REACTOR OVERSIGHT ASSESSMENT PROGRAM NRC's Operating Reactor Assessment Program NRC's Operating Reactor Assessment Program http://www.nrc.gov/reading-rm/doc- collections/insp-manual/manual- chapter/mc0305.pdf http://www.nrc.gov/reading-rm/doc- collections/insp-manual/manual- chapter/mc0305.pdf

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19. 19 REACTOR OVERSIGHT PROCESS Indicators Plus Inspection Results Comprehensively Cover Cornerstones Indicators Plus Inspection Results Comprehensively Cover Cornerstones http://www.nrc.gov/reactors/operating/o versight/program-documents.html http://www.nrc.gov/reactors/operating/o versight/program-documents.html

20. 20 REACTOR OVERSIGHT PROCESS YELLOW GREEN WHITE RED - very low - low to moderate - substantial Risk Ranking Colors - high

21. Baseline Inspection Results Significance Threshold Significance Threshold Performance Indicator Results Regulatory Response Strategic Performance Areas Safety Cornerstones Action Matrix REACTOR OVERSIGHT PROCESS

22. 22 When Is the Assessment Process Over? Answer: Never Quiz

23. 23 NRC ASSESSMENT PROGRAM - KEY OVERSIGHT TOOL Objective Review of Industry Performance Action Matrix Determines NRC Response:   Supplemental Inspection   Management meetings   Orders for plant shutdown

24. 24 REACTOR OVERSIGHT PROCESS - ASSESSMENT Continuous Quarterly Middle of Cycle End of Cycle End of Cycle Summary Meeting Agency Action Review Meeting

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26. 26 Cross-Cutting Aspects (Bedrock - Safety Culture) Manual Chapter 0305 " Operating Reactor Assessment Program" Manual Chapter 0305 " Operating Reactor Assessment Program"  Problem Identification and Resolution  Human Performance  Safety Conscious Work Environment

27. 27 Human Performance Human Performance Evaluation Process: A Resource for Reviewing the Identification and Resolution of Human Performance Problems (NUREG CR6751) http://www.nrc.gov/reading-rm/doc- collections/nuregs/contract/cr6751/

28. 28 Safety Culture Safety Culture Group Developing Metrics Safety Culture Group Developing Metrics http://www.nrc.gov/what-we- do/regulatory/enforcement/safety- culture.html http://www.nrc.gov/what-we- do/regulatory/enforcement/safety- culture.html

29. 29 Crosscutting Issue Assessment Issue Binning Pattern Assessment Cornerstone Evaluation Number Of Findings Licensee Actions

30. 30 Is It Substantive? Are there more than 3 similar issues? Is the underlying concern (common performance characteristic) present in multiple cornerstones? Were the licensee’s actions insufficient and or incomplete? If you answer yes to all of the above then you have a substantive crosscutting issue.

31. 31 Substantive Crosscutting Issue Review If a substantive cross-cutting issue has been raised in at least two consecutive assessment letters NRC may request -   Licensee to provide a response at the next annual public meeting   Licensee to provide a written response to the substantive cross-cutting issues raised in the assessment letters,   Separate meeting to be held with the licensee.

32. 32 Substantive Cross-Cutting Issues The assessment letter should: The assessment letter should:  Identify the number of examples in various cornerstones and describe their cross- cutting aspects  Describe the NRC’s plan to monitor the issue   Defining criteria for clearing the cross- cutting issue

33. 33 REACTOR OVERSIGHT PROCESS - ASSESSMENT Action Matrix Column Substantive Cross-Cutting Issues

34. 34 SUMMARY We are looking for - We are looking for -  Longstanding equipment issues  Latent failures  Recurring equipment failures  Risk-significant equipment failures  Cracks in the Safety Culture bedrock

35. 35 NRC/Stakeholders Value of Communication Value of Communication Safety is a Shared Objective Safety is a Shared Objective Predictable Effective Regulation Predictable Effective Regulation Learning Oversight Learning Oversight