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American Society of Quality

September 20, 2005

Presented by Linda SmithPresented by Linda Smith

USNRC Region IVUSNRC Region IV

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Nuclear Regulatory Commission 104 Nuclear Power Reactors104 Nuclear Power Reactors 36 Non-Power Reactors36 Non-Power Reactors 47 Uranium Recovery Sites47 Uranium Recovery Sites 9 Major Fuel Cycle Facilities9 Major Fuel Cycle Facilities Approximately 4,500 Materials Approximately 4,500 Materials

LicenseesLicensees

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Nuclear Regulatory Commission Goals SafetySafety SecuritySecurity OpennessOpenness EffectivenessEffectiveness ManagementManagement http://www.nrc.gov/reading-rm/doc-http://www.nrc.gov/reading-rm/doc-

collections/nuregs/staff/sr1614/v3/collections/nuregs/staff/sr1614/v3/sr1614v3.pdfsr1614v3.pdf

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NRC/Stakeholders

Value of CommunicationValue of Communication Safety is a Shared ObjectiveSafety is a Shared Objective Predictable Effective RegulationPredictable Effective Regulation Learning OversightLearning Oversight

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Reactor Oversight

Integration of Integration of Inspection, Inspection, Assessment, and Assessment, and EnforcementEnforcement

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DAVIS-BESSE LESSONS LEARNED

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DAVIS-BESSE LESSONS LEARNED

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DAVIS-BESSE LESSONS LEARNED

Why was Davis-Besse Head Why was Davis-Besse Head Degradation allowed to occur?Degradation allowed to occur?

http://www.nrc.gov/reactors/http://www.nrc.gov/reactors/operating/ops-experience/vessel-operating/ops-experience/vessel-head-degradation.htmlhead-degradation.html

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DAVIS-BESSE LESSONS LEARNED FOR PI&R

EDO Commissioned a Task Force to EDO Commissioned a Task Force to identify and recommend areas of identify and recommend areas of improvementimprovement

The report contained 51 The report contained 51 recommendationsrecommendations

Four recommendations applied to PI&RFour recommendations applied to PI&R

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DAVIS-BESSE LESSONS LEARNED

Forty percent of risk significant Forty percent of risk significant events involve problem events involve problem identification and resolution (PI&R) identification and resolution (PI&R) weaknesses (Accident Sequence weaknesses (Accident Sequence Precursor data).Precursor data).

Facilities that have gone through Facilities that have gone through extended shutdowns almost extended shutdowns almost always have had PI&R problemsalways have had PI&R problems

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LESSONS LEARNED FOR PI&R – RecommendationRecommendation 1

Broaden inspection with the goal of Broaden inspection with the goal of assessing safety implications of :assessing safety implications of : Long-standing, unresolved problemsLong-standing, unresolved problems Corrective actions phased in over Corrective actions phased in over

several years or refueling outagesseveral years or refueling outages Deferred modificationsDeferred modifications

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LESSONS LEARNED FOR PI&R – RecommendationRecommendation 2

Assess issues similar to those Assess issues similar to those experienced at Davis Besseexperienced at Davis Besse

Improve guidance for screening to Improve guidance for screening to determine which problems will be determine which problems will be reviewedreviewed

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LESSONS LEARNED FOR PI&R – RecommendationRecommendation 3

Provide guidance for pursuing issues Provide guidance for pursuing issues and problems identified during resident and problems identified during resident inspector plant status reviewsinspector plant status reviews

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LESSONS LEARNED FOR PI&R – RecommendationRecommendation 4

Provide guidance to provide for the Provide guidance to provide for the longer-term follow-up of issues that longer-term follow-up of issues that have not progressed to a findinghave not progressed to a finding

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LESSONS LEARNED FOR PI&R – Big Picture

Objective was to upgrade NRC Objective was to upgrade NRC oversight so that we recognize and oversight so that we recognize and draw attention to longstanding draw attention to longstanding equipment degradationequipment degradation

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LESSONS LEARNED FOR PI&R – Big Picture

A Narrowly Focused Corrective Action A Narrowly Focused Corrective Action Program did not serve us well at Davis Program did not serve us well at Davis BesseBesse

Broke-fix is not enoughBroke-fix is not enough

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REACTOR OVERSIGHT ASSESSMENT PROGRAM

NRC's Operating Reactor NRC's Operating Reactor Assessment ProgramAssessment Program

http://www.nrc.gov/reading-rm/http://www.nrc.gov/reading-rm/doc-collections/insp-manual/doc-collections/insp-manual/manual-chapter/mc0305.pdfmanual-chapter/mc0305.pdf

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REACTOR OVERSIGHT PROCESS

Indicators Plus Inspection Results Indicators Plus Inspection Results Comprehensively Cover Comprehensively Cover CornerstonesCornerstones

http://www.nrc.gov/reactors/http://www.nrc.gov/reactors/operating/oversight/program-operating/oversight/program-documents.htmldocuments.html

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REACTOR OVERSIGHT PROCESS

YELLOWYELLOW

GREENGREEN

WHITEWHITE

REDRED

- very low- very low

- low to moderate- low to moderate

- substantial- substantial

Risk Ranking ColorsRisk Ranking Colors

- high- high

Baseline Inspection Results

Significance Threshold

Significance Threshold

Performance IndicatorResults

Regulatory Response

StrategicPerformance Areas

SafetyCornerstones

Action Matrix

REACTOR OVERSIGHT PROCESS

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When Is the Assessment Process Over?

Answer: NeverAnswer: Never

Quiz

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NRC ASSESSMENT PROGRAM - KEY OVERSIGHT TOOL Objective Review of Industry

Performance Action Matrix Determines NRC

Response:Supplemental InspectionManagement meetingsOrders for plant shutdown

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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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Cross-Cutting Aspects (Bedrock - Safety Culture)

Manual Chapter 0305 "Manual Chapter 0305 "Operating Operating Reactor Assessment Program"Reactor Assessment Program" Problem Identification and ResolutionProblem Identification and Resolution Human PerformanceHuman Performance Safety Conscious Work EnvironmentSafety Conscious Work Environment

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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/

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Safety Culture Safety Culture Group Developing Safety Culture Group Developing

Metrics Metrics http://www.nrc.gov/what-we-do/http://www.nrc.gov/what-we-do/

regulatory/enforcement/safety-regulatory/enforcement/safety-culture.htmlculture.html

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Crosscutting Issue Assessment

Issue Binning Pattern Assessment Cornerstone Evaluation Number Of Findings Licensee Actions

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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.

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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.

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Substantive Cross-Cutting Issues The assessment letter should:The assessment letter should:

Identify the number of examples in various Identify the number of examples in various cornerstones and describe their cross-cornerstones and describe their cross-cutting aspectscutting aspects

Describe the NRC’s plan to monitor the Describe the NRC’s plan to monitor the issue issue

Defining criteria for clearing the cross-cutting issue

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REACTOR OVERSIGHT PROCESS - ASSESSMENT

Action Matrix Column Substantive Cross-Cutting Issues

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SUMMARY

We are looking for - We are looking for - Longstanding equipment issuesLongstanding equipment issues Latent failures Latent failures Recurring equipment failuresRecurring equipment failures Risk-significant equipment failures Risk-significant equipment failures Cracks in the Safety Culture bedrockCracks in the Safety Culture bedrock

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NRC/Stakeholders

Value of CommunicationValue of Communication Safety is a Shared ObjectiveSafety is a Shared Objective Predictable Effective RegulationPredictable Effective Regulation Learning OversightLearning Oversight