Nuclear Regulatory Commission
Preliminary Observations on Its Oversight to Ensure the Safe Operation of Nuclear Power Plants Gao ID: GAO-06-886T June 15, 2006The Nuclear Regulatory Commission (NRC) has the responsibility to provide oversight to ensure that the nation's 103 commercial nuclear power plants are operated safely. While the safety of these plants has always been important, since radioactive release could harm the public and the environment, NRC's oversight has become even more critical as the Congress and the nation consider the potential resurgence of nuclear power in helping to meet the nation's growing energy needs. Prior to 2000, NRC was criticized for having a safety oversight process that was not always focused on the most important safety issues and in some cases, was overly subjective. To address these and other concerns, NRC implemented a new oversight process--the Reactor Oversight Process (ROP). NRC continues to modify the ROP to incorporate feedback from stakeholders and in response to other external events. This statement summarizes information on (1) how NRC oversees nuclear power plants, (2) the results of the ROP over the past several years, and (3) the aspects of the ROP that need improvement and the status of NRC's efforts to improve them. This statement discusses preliminary results of GAO's work. GAO will report in full at a later date. GAO analyzed program-wide information, inspection results covering 5 years of ROP operations, and detailed findings from a sample of 11 plants.
NRC uses various tools to oversee the safe operation of nuclear power plants, including physical plant inspections and quantitative measures or indicators of plant performance. To apply these tools, NRC uses a risk-informed and graded approach--that is, one considering safety significance in deciding on the equipment and operating procedures to be inspected and employing increasing levels of regulatory attention to plants based on the severity of identified performance problems. The tools include three types of inspections--baseline, supplemental, and special. All plants receive baseline inspections of plant operations almost continuously by NRC inspectors. When NRC becomes aware of a performance problem at a plant, it conducts supplemental inspections, which expand the scope of baseline inspections. NRC conducts special inspections to investigate specific safety incidents or events that are of particular interest to NRC because of their potential significance to safety. The plants also self-report on their safety performance using performance indicators for plant operations related to safety, such as the number of unplanned reactor shutdowns. Since 2001, NRC's ROP has resulted in more than 4,000 inspection findings concerning nuclear power plant licensees' failure to comply with regulations or other safe operating procedures. About 97 percent of these findings were for actions or failures NRC considered important to correct but of low significance to overall safe operation of the plants. In contrast, 12 of the inspection findings, or less than 1 percent, were of the highest levels of significance to safety. On the basis of its findings and the performance indicators, NRC has subjected more than three-quarters of the 103 operating plants to oversight beyond the baseline inspections for varying amounts of time. NRC has improved several key areas of the ROP, largely in response to independent reviews and feedback from stakeholders. These improvements include better focusing its inspections on those areas most important to safety, reducing the time needed to determine the risk significance of inspection findings, and modifying the way that some performance indicators are measured. NRC also recently undertook a major initiative to improve its ability to address plants' safety culture--that is, the organizational characteristics that ensure that issues affecting nuclear plant safety receive the attention their significance warrants. GAO and others have found this to be a significant shortcoming in the ROP. Although some industry officials have expressed concern that its changes could introduce undue subjectivity to NRC's oversight, given the difficulty in measuring these often intangible and complex concepts, other stakeholders believe its approach will provide NRC better tools to address safety culture issues at plants. NRC officials acknowledge that its effort is only a step in an incremental approach and that continual monitoring, improvements, and oversight will be needed to fully detect deteriorating safety conditions before an event occurs.
GAO-06-886T, Nuclear Regulatory Commission: Preliminary Observations on Its Oversight to Ensure the Safe Operation of Nuclear Power Plants
This is the accessible text file for GAO report number GAO-06-886T
entitled 'Nuclear Regulatory Commission: Preliminary Observations on
Its Oversight to Ensure the Safe Operation of Nuclear Power Plants'
which was released on June 22, 2006.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Testimony:
Before the Subcommittee on Clean Air, Climate Change, and Nuclear
Safety, Committee on Environment and Public Works, United States
Senate:
United States Government Accountability Office:
GAO:
Not to Be Released Before 9:30 a.m. EDT:
Thursday, June 22, 2006:
Nuclear Regulatory Commission:
Preliminary Observations on Its Oversight to Ensure the Safe Operation
of Nuclear Power Plants:
Statement for the Record by Jim Wells, Director:
Natural Resources and Environment:
GAO-06-886T:
GAO Highlights:
Highlights of GAO-06-886T, a statement for the record for the
Subcommittee on Clean Air, Climate Change, and Nuclear Safety,
Committee on Environment and Public Works, United States Senate.
Why GAO Did This Study:
The Nuclear Regulatory Commission (NRC) has the responsibility to
provide oversight to ensure that the nation‘s 103 commercial nuclear
power plants are operated safely. While the safety of these plants has
always been important, since radioactive release could harm the public
and the environment, NRC‘s oversight has become even more critical as
the Congress and the nation consider the potential resurgence of
nuclear power in helping to meet the nation‘s growing energy needs.
Prior to 2000, NRC was criticized for having a safety oversight process
that was not always focused on the most important safety issues and in
some cases, was overly subjective. To address these and other concerns,
NRC implemented a new oversight process”the Reactor Oversight Process
(ROP). NRC continues to modify the ROP to incorporate feedback from
stakeholders and in response to other external events.
This statement summarizes information on (1) how NRC oversees nuclear
power plants, (2) the results of the ROP over the past several years,
and (3) the aspects of the ROP that need improvement and the status of
NRC‘s efforts to improve them. This statement discusses preliminary
results of GAO‘s work. GAO will report in full at a later date. GAO
analyzed program-wide information, inspection results covering 5 years
of ROP operations, and detailed findings from a sample of 11 plants.
What GAO Found:
NRC uses various tools to oversee the safe operation of nuclear power
plants, including physical plant inspections and quantitative measures
or indicators of plant performance. To apply these tools, NRC uses a
risk-informed and graded approach”that is, one considering safety
significance in deciding on the equipment and operating procedures to
be inspected and employing increasing levels of regulatory attention to
plants based on the severity of identified performance problems. The
tools include three types of inspections”baseline, supplemental, and
special. All plants receive baseline inspections of plant operations
almost continuously by NRC inspectors. When NRC becomes aware of a
performance problem at a plant, it conducts supplemental inspections,
which expand the scope of baseline inspections. NRC conducts special
inspections to investigate specific safety incidents or events that are
of particular interest to NRC because of their potential significance
to safety. The plants also self-report on their safety performance
using performance indicators for plant operations related to safety,
such as the number of unplanned reactor shutdowns.
Since 2001, NRC‘s ROP has resulted in more than 4,000 inspection
findings concerning nuclear power plant licensees‘ failure to comply
with regulations or other safe operating procedures. About 97 percent
of these findings were for actions or failures NRC considered important
to correct but of low significance to overall safe operation of the
plants. In contrast, 12 of the inspection findings, or less than 1
percent, were of the highest levels of significance to safety. On the
basis of its findings and the performance indicators, NRC has subjected
more than three-quarters of the 103 operating plants to oversight
beyond the baseline inspections for varying amounts of time.
NRC has improved several key areas of the ROP, largely in response to
independent reviews and feedback from stakeholders. These improvements
include better focusing its inspections on those areas most important
to safety, reducing the time needed to determine the risk significance
of inspection findings, and modifying the way that some performance
indicators are measured. NRC also recently undertook a major initiative
to improve its ability to address plants‘ safety culture”that is, the
organizational characteristics that ensure that issues affecting
nuclear plant safety receive the attention their significance warrants.
GAO and others have found this to be a significant shortcoming in the
ROP. Although some industry officials have expressed concern that its
changes could introduce undue subjectivity to NRC‘s oversight, given
the difficulty in measuring these often intangible and complex
concepts, other stakeholders believe its approach will provide NRC
better tools to address safety culture issues at plants. NRC officials
acknowledge that its effort is only a step in an incremental approach
and that continual monitoring, improvements, and oversight will be
needed to fully detect deteriorating safety conditions before an event
occurs.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-886T].
To view the full product, including the scope and methodology, click on
the link above.
For more information, contact Jim Wells (202) 512-3841 or
wellsj@gao.gov.
[End of Section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to have the opportunity to comment on our ongoing review
of how the Nuclear Regulatory Commission (NRC) oversees the safe
operation of the nation's 103 operating commercial nuclear power
plants, which provide about 20 percent of U.S. electricity. The safety
of these plants, which are located at 65 sites in 31 states, has always
been important, as an accident could result in the release of
radioactive material and potentially harm public health and the
environment. NRC is responsible for issuing regulations, licensing and
overseeing plants, and requiring necessary actions to protect public
health and safety, while plant operators are responsible for safely
operating their plants in accordance with their licenses. NRC's
oversight has become even more critical as the Congress and the nation
consider the potential resurgence of nuclear power in helping to meet
the nation's growing energy needs. No new orders for a plant have been
placed since the 1979 accident at the Three Mile Island plant, but in
the face of concerns about aging plants, energy security, global
warming, and the ever increasing need for energy to fuel the nation's
economy, nuclear power is resurfacing as a principal option. An
accident could threaten public confidence in nuclear power just as it
begins to emerge from the shadows of the Three Mile Island accident. It
is critical that NRC be able to ensure that nuclear power plants are
operated safely and that public confidence about their safety is high.
Prior to 2000, NRC was criticized for having a safety oversight process
that was not always focused on the most important safety issues and in
some cases, regulatory activities were redundant, inefficient, and
overly subjective. While its new process--which NRC refers to as the
Reactor Oversight Process (ROP)--is similar to its prior process in
that the oversight activities largely consist of physical plant
inspections, the inspections now focus on more important safety issues
and the goal is to make assessments of plants' safety performance more
objective, predictable, and understandable. The unexpected discovery,
in March 2002, of extensive corrosion and a pineapple-size hole in the
reactor vessel head--a vital barrier preventing a radioactive release-
-at the Davis-Besse nuclear power plant in Ohio led NRC to re-examine
its safety oversight and other regulatory processes to determine how
such corrosion could be missed. Based on the lessons learned from the
event, NRC made several changes to the ROP. NRC continues to annually
assess the ROP by obtaining feedback from the industry and other
stakeholders such as public interest groups, and incorporates this
feedback and other information into specific performance metrics to
assess its effectiveness.
We are preparing a report to you and other Members of the Congress
later this year on (1) how NRC oversees nuclear power plants to ensure
that they are operated safely, (2) the results of the ROP over the past
several years in terms of the number and types of inspection findings,
and (3) the aspects of the ROP that need improvement and the status of
NRC's efforts to improve them.[Footnote 1] To examine how NRC oversees
plants, we reviewed NRC's regulations, inspection manuals, and other
guidance documents; interviewed NRC headquarters and regional officials
and regional and on-site inspectors; visited the Salem and Hope Creek
nuclear power plants; and attended several public meetings covering
various nuclear power plant oversight topics. To examine the results of
the ROP over the past several years, we analyzed NRC data on nuclear
plant safety for 2001 through 2005, the years since implementation of
the ROP for which data were available for the full year, and discussed
our analysis with NRC officials. We assessed the reliability of this
data and determined that the data were sufficiently reliable for the
purposes of our report. To examine areas of the ROP that need
improvement and the status of NRC's efforts to improve them, we
reviewed NRC documents, including annual self-assessment reports;
interviewed officials from NRC and outside stakeholder groups; and
attended several key public meetings covering proposed changes to
oversight procedures. We also reviewed various external evaluations of
the ROP, including our prior reports and those of the NRC Inspector
General. Additionally, we selected a nonprobability sample of 6 nuclear
power sites (totaling 11 plants) that provided coverage of each of
NRC's four regional offices and varying levels of plant performance and
NRC oversight since 2000. We reviewed relevant inspection reports and
assessment documents and interviewed NRC and industry officials at each
site to examine how NRC applies the ROP to identify and correct safety
problems. We are conducting this work in accordance with generally
accepted government auditing standards. We performed the work reflected
in this statement from July 2005 to June 2006.
To date, our work indicates the following:
* NRC uses various tools to oversee the safe operation of nuclear power
plants, including physical plant inspections of equipment and records
and quantitative measures or indicators of plant performance such as
the number of unplanned shutdowns. NRC uses a graded and risk-informed
approach--that is, one considering safety significance in deciding on
the equipment or operating procedures to be inspected and employing
increasing levels of regulatory attention to plants based on the
severity of identified performance problems--to apply these tools. All
plants receive baseline inspections, which are inspections of plant
operations that are conducted almost continuously by NRC inspectors
usually located at each nuclear power plant site. When NRC becomes
aware of a performance problem at a plant, it conducts supplemental
inspections, which expand the scope of baseline inspections. NRC
conducts special inspections to investigate specific safety incidents
or events that are of particular interest to NRC because of their
potential significance to safety. The plants also self-report on their
safety performance using performance measures or indicators in
quarterly reports submitted to NRC. Plants' quarterly reports of
performance indicators are verified by NRC's on-site inspectors. NRC
analyzes each of its inspection findings to determine the finding's
significance in terms of safety, and applies increasing levels of
oversight based on the number and level of risk of the findings
identified.
* Since 2001, NRC's ROP has resulted in more than 4,000 inspection
findings concerning nuclear power plant licensees' failure to comply
with regulations or other safe operating procedures. About 97 percent
of these findings were for actions or failures NRC considered important
to correct but of very low significance to overall safe operation of
the plants. For example, a finding of very low risk significance was
issued at one plant after a worker failed to wear the proper radiation
detector and at another plant because the operator failed to properly
evaluate and approve the storage of flammable materials in the vicinity
of safety-related equipment. In contrast, 12 of the inspection
findings, or less than 1 percent, were of the highest levels of
significance to safety. For example, NRC issued a finding of the
highest risk significance at one plant after a steam generator tube
failed, causing an increased risk of the release of radioactive
material. Similarly, there were 156 instances, or less than 1 percent,
in which data reported for individual performance indicators were
outside NRC's acceptable category of performance. On the basis of its
findings and the performance indicators, NRC has subjected more than
three-quarters of the 103 operating plants to oversight beyond the
baseline inspections for varying amounts of time. Over the past 5
years, 5 plants have been subject to the highest level of NRC oversight
that still allows continued operations. According to NRC officials, the
results of its oversight process at an industry or summary level serve
as an indicator of overall industry performance, which to date
indicates good safety performance.
* NRC has improved several key areas of the ROP, largely in response to
independent reviews and feedback from stakeholders, including its
regional and on-site inspectors, usually obtained during NRC's annual
self-assessment of the oversight process. These improvements include
better focusing its inspections on those areas most important to
safety, reducing the time needed to determine the risk significance of
inspection findings, and modifying the way that some performance
indicators are measured. For the most part, NRC considers these efforts
to be refinements rather than significant changes. One significant
shortcoming in the ROP that we and others have found is that it is not
as effective as it could be in identifying and addressing early
indications of deteriorating safety at nuclear power plants before
problems develop. In response to this concern, NRC recently undertook a
major initiative to improve its ability to address plants' safety
culture--that is, the organizational characteristics that ensure that
issues affecting nuclear plant safety receive the attention their
significance warrants. NRC and others have long recognized that safety
culture attributes, such as attention to detail, adherence to
procedures, and effective corrective and preventative action, have a
significant impact on a plant's safety performance. NRC is taking
action to improve how it incorporates safety culture into the ROP by
redefining and increasing its focus on more qualitative and cross-
cutting issues or aspects of plant performance--including a safety
conscious work environment, human performance, and problem
identification and resolution--and developing new requirements to more
directly assess safety culture at poorer performing plants. Some of its
actions have been controversial. Although some industry officials have
expressed concern that these changes could introduce undue subjectivity
to NRC's oversight, given the difficulty in measuring these often
intangible and complex concepts, other stakeholders believe this
approach will provide NRC better tools to address safety culture issues
at plants. NRC officials acknowledge that this effort is only a step in
an incremental approach and that continual monitoring, improvements,
and oversight will be needed to fully detect deteriorating safety
conditions before an event occurs.
NRC is devoting considerable effort to overseeing the safe operation of
the nation's commercial nuclear power plants, and its process for doing
so appears logical and well-structured. This does not mean that NRC's
oversight is perfect. However, NRC is also demonstrating that it is
aware of this fact and is willing to make changes to improve. Its
efforts to continuously obtain feedback and consider the need for
improvement to the ROP are important as nuclear power plants age and
the nation considers building new plants. In this regard, its safety
culture initiative may be its most important improvement to the ROP. As
we complete our work, we will be examining whether NRC needs a more
formal mechanism to assess the effectiveness of this initiative,
including incorporating stakeholder feedback and developing specific
measures to assess its performance. It has been more than 4 years since
Davis-Besse, and it appears that NRC is now taking concrete actions to
begin incorporating safety culture into the ROP.
I would also like to point out that the ROP is a very open process in
that NRC provides the public and its other stakeholders with
considerable specific and detailed information on its activities and
findings with regard to safety at individual plants. However, to ensure
or foster even greater public confidence in safety oversight, as we
complete our work, we will be examining whether NRC can make this
information more meaningful by providing industry-wide or summary data
for key components of its oversight process. This information may
provide a useful measure of overall industry performance and allow for
comparisons between the safety performance of a specific plant to that
of the industry as a whole.
Background:
NRC is an independent agency of over 3,200 employees established by the
Energy Reorganization Act of 1974 to regulate civilian--that is,
commercial, industrial, academic, and medical--use of nuclear
materials. NRC is headed by a five-member Commission. The President
appoints the Commission members, who are confirmed by the Senate, and
designates one of them to serve as Chairman and official spokesperson.
The Commission as a whole formulates policies and regulations governing
nuclear reactor and materials safety, issues orders to licensees, and
adjudicates legal matters brought before it.
NRC and the licensees of nuclear power plants share the responsibility
for ensuring that commercial nuclear power reactors are operated
safely. NRC is responsible for issuing regulations, licensing and
inspecting plants, and requiring action, as necessary, to protect
public health and safety. Plant licensees have the primary
responsibility for safely operating their plants in accordance with
their licenses and NRC regulations. NRC has the authority to take
actions, up to and including shutting down a plant, if licensing
conditions are not being met and the plant poses an undue risk to
public health and safety.
Nuclear power plants have many physical structures, systems, and
components, and licensees have numerous activities under way, 24-hours
a day, to ensure that plants operate safely. NRC relies on, among other
things, its on-site resident inspectors to assess plant conditions and
the licensees' quality assurance programs such as those required for
maintenance and problem identification and resolution. With its current
resources, NRC can inspect only a relatively small sample of the
numerous activities going on during complex plant operations. According
to NRC, its focus on the more safety significant activities is made
possible by the fact that safety performance at plants has improved as
a result of more than 25 years of operating experience.
Commercial nuclear power plants are designed according to a "defense in
depth" philosophy revolving around redundant, diverse, and reliable
safety systems. For example, two or more key components are put in
place so that if one fails, there is another to back it up. Plants have
numerous built-in sensors to monitor important indicators such as water
temperature and pressure. Plants also have physical barriers to contain
the radiation and provide emergency protection. For example, the
nuclear fuel is contained in a ceramic pellet to lock in the
radioactive byproducts and then the fuel pellets are sealed inside rods
made of special material designed to contain fission products, and the
fuel rods are placed in reactors housed in containment buildings made
of several feet of concrete and steel.
Furthermore, the nuclear power industry formed an organization, the
Institute of Nuclear Power Operations (INPO) with the mission to
"promote the highest levels of safety and reliability-to promote
excellence-in the operation of nuclear electric generating plants."
INPO provides a system of personnel training and qualification for all
key positions at nuclear power plants and workers undergo both periodic
training and assessment. INPO also conducts periodic evaluations of
operating nuclear plants, focusing on plant safety and reliability, in
the areas of operations, maintenance, engineering, radiological
protection, chemistry, and training. Licensees make these evaluations
available to the NRC for review, and the NRC staff uses the evaluations
as a means to determine whether its oversight process has missed any
performance issues.
NRC Uses Various Tools and Takes a Graded and Risk-Informed Approach to
Ensuring the Safety of Nuclear Power Plants:
NRC uses various tools to oversee the safe operation of nuclear power
plants, generally consisting of physical plant inspections of equipment
and records and objective indicators of plant performance. These tools
are risk-informed in that they are focused on the issues considered
most important to plant safety. Based on the results of the information
it collects through these efforts, NRC takes a graded approach to its
oversight, increasing the level of regulatory attention to plants based
on the severity of identified performance issues. NRC bases its
regulatory oversight process on the principle and requirement that
plant licensees routinely identify and address performance issues
without NRC's direct involvement. An important aspect of NRC's
inspections is ensuring the effectiveness of licensee quality assurance
programs. NRC assesses overall plant performance and communicates these
results to licensees on a semi-annual basis.
During fiscal year 2005, NRC inspectors spent a total of 411,490 hours
on plant inspection activities (an average of 77 hours per week at each
plant). The majority of these inspection efforts were spent on baseline
inspections, which all plants receive on an almost continuous basis.
Baseline inspections, which are mostly conducted by the two to three
NRC inspectors located at each nuclear power plant site, evaluate the
safety performance of plant operations and review plant effectiveness
at identifying and resolving its safety problems.[Footnote 2] There are
more than 30 baseline inspection procedures, conducted at varying
intervals, ranging from quarterly to triennially, and involving both
physical observation of plant activities and reviews of plant reports
and data. The inspection procedures are risk-informed to focus
inspectors' efforts on the most important areas of plant safety in four
ways: 1) areas of inspection are included in the set of baseline
procedures based on, in part, their risk importance, 2) risk
information is used to help determine the frequency and scope of
inspections, 3) the selection of activities to inspect within each
procedure is informed with plant-specific risk information, and 4) the
inspectors are trained in the use of risk information in planning their
inspections.
For inspection findings found to be more than minor,[Footnote 3] NRC
uses its significance determination process (SDP) to assign each
finding one of four colors to reflect its risk significance.[Footnote
4] Green findings equate to very low risk significance, while white,
yellow, and red colors represent increasing levels of risk,
respectively. Throughout its application of the SDP, NRC incorporates
information from the licensee, and the licensee has the opportunity to
formally appeal the final determination that is made.
In addition to assigning each finding a color based on its risk
significance, all findings are evaluated to determine if certain
aspects of plant performance, referred to as cross-cutting issues, were
a contributing cause to the performance problem. The cross-cutting
issues are comprised of (1) problem identification and resolution, (2)
human performance, and (3) safety consciousness in the work
environment. To illustrate, in analyzing the failure of a valve to
operate properly, NRC inspectors determined that the plant licensee had
not followed the correct procedures when performing maintenance on the
valve, and thus NRC concluded the finding was associated with the human
performance cross-cutting area. If NRC determines that there are
multiple findings during the 12-month assessment period with documented
cross-cutting aspects, more than three findings with the same causal
theme, and NRC has a concern about the licensee's progress in
addressing these areas, it may determine that the licensee has a
"substantive" cross-cutting issue. Opening a substantive cross-cutting
issue serves as a way for NRC to notify the plant licensee that
problems have been identified in one of the areas and that NRC will
focus its inspection efforts in the cross-cutting area of concern.
When NRC becomes aware of one or more performance problems at a plant
that are assigned a risk color greater-than-green (white, yellow, or
red), it conducts supplemental inspections. Supplemental inspections,
which are performed by regional staff, expand the scope beyond baseline
inspection procedures and are designed to focus on diagnosing the cause
of the specific performance deficiency. NRC increases the scope of its
supplemental inspection procedures based on the number of greater-than-
green findings identified, the area where the performance problem was
identified, and the risk color assigned. For example, if one white
finding is identified, NRC conducts a follow-up inspection directed at
assessing the licensee's corrective actions to ensure they were
sufficient in both correcting the specific problem identified and
identifying and addressing the root and contributing causes to prevent
recurrence of a similar problem. If multiple yellow findings or a
single red finding is identified, NRC conducts a much more
comprehensive inspection which includes obtaining information to
determine whether continued operation of the plant is acceptable and
whether additional regulatory actions are necessary to address
declining plant performance. This type of more extensive inspection is
usually conducted by a multi-disciplinary team of NRC inspectors and
may take place over a period of several months. NRC inspectors assess
the adequacy of the licensee's programs and processes such as those for
identifying, evaluating, and correcting performance issues and the
overall root and contributing causes of identified performance
deficiencies.
NRC conducts special inspections when specific events occur at plants
that are of particular interest to NRC because of their potential
safety significance. Special inspections are conducted to determine the
cause of the event and assess the licensee's response. For special
inspections, a team of experts is formed and an inspection charter
issued that describes the scope of the inspection efforts. At one plant
we reviewed, for example, a special inspection was conducted to
investigate the circumstances surrounding the discovery of leakage from
a spent fuel storage pool. Among the objectives of this inspection were
to assess the adequacy of the plant licensee's determination of the
source and cause of the leak, the risk significance of the leakage, and
the proposed strategies to mitigate leakage that had already occurred
and repair the problem to prevent further leakage.
In addition to its various inspections, NRC also collects plant
performance information through a performance indicator program, which
it maintains in cooperation with the nuclear power industry. On a
quarterly basis, each plant submits data for 15 separate performance
indicators. These objective numeric measures of plant operations are
designed to measure plant performance related to safety in various
aspects of plant operations. For example, one indicator measures the
number of unplanned reactor shutdowns during the previous four quarters
while another measures the capability of alert and notification system
sirens, which notify residents living near the plant in the event of an
accident. Working with the nuclear power industry, NRC established
specific criteria for acceptable performance with thresholds set and
assigned colors to reflect increasing risk according to established
safety margins for each of the indicators. Green indicators reflect
performance within the acceptable range while white, yellow, and red
colors represent decreasing plant performance, respectively. NRC
inspectors review and verify the data submitted for each performance
indicator annually through the baseline inspection process. If
questions arise about how to calculate a particular indicator or what
the correct value should be, there is a formal feedback process in
place to resolve the issue. When performance indicator thresholds are
exceeded, NRC responds in a graded fashion by performing supplemental
inspections that range in scope depending on the significance of the
performance issue.
Under the ROP, NRC places each plant into a performance category on the
agency's action matrix, which corresponds to increasing levels of
oversight based on the number and risk significance of inspection
findings and performance indicators. The action matrix is NRC's formal
method of determining what additional oversight procedures--mostly
supplemental inspections--are required.[Footnote 5] Greater-than-green
inspection findings are included in the action matrix for a minimum of
four quarters to allow sufficient time for additional findings to
accumulate that may indicate more pervasive performance problems
requiring additional NRC oversight. If a licensee fails to correct the
performance problems within the initial four quarters, the finding may
be held open and considered for additional oversight for more than the
minimum four quarters.
At the end of each 6-month period, NRC issues an assessment letter to
each plant licensee. This letter describes what level of oversight the
plant will receive according to its placement in the action matrix
performance categories, what actions NRC is expecting the plant
licensee to take as a result of the performance issues identified, and
any documented substantive cross-cutting issues. NRC also holds an
annual public meeting at or near each plant site to review performance
and address questions about the plant's performance from members of the
public and other interested stakeholders. Most inspection reports,
assessment letters and other materials related to NRC's oversight
processes are made publicly available through a NRC website devoted to
the ROP. The website also includes plant-specific quarterly summaries
of green or greater inspection findings and all the performance
indicators.
NRC Has Continually Identified Problems at Nuclear Power Plants but Few
Have Been Considered Significant to Safe Operation of the Plants:
The ROP has identified numerous performance deficiencies as inspection
findings at nuclear power plants since it was first implemented, but
most of these were considered to be of very low risk to safe plant
operations. Similarly, there have been very few instances in which
performance indicator data exceeded acceptable standards. As a result,
few plants have been subjected to high levels of oversight.
Of more than 4,000 inspection findings identified between 2001 and
2005, 97 percent were green. While green findings are considered to be
of "very low" safety significance, they represent a performance
deficiency on the part of the plant licensee and thus are important to
correct. Green findings consist of such things as finding that a worker
failed to wear the proper radiation detector or finding that a licensee
did not properly evaluate and approve the storage of flammable
materials in the vicinity of safety-related equipment. NRC does not
follow-up on the corrective action taken for every green finding
identified; rather, it relies on the licensee to address and track
their resolution through the plant's corrective action program. NRC
does, however, periodically follow-up on some of the actions taken by
the licensee to address green findings through an inspection
specifically designed to evaluate the effectiveness of the licensee's
corrective action program. NRC officials stated that green findings
provide useful information on plant performance and NRC inspectors use
the findings to identify performance trends in certain areas and help
inform their selection of areas to focus on during future inspections.
In contrast to the many green findings, NRC has identified 12 findings
of the highest risk significance (7 yellow and 5 red), accounting for
less than 1 percent of the findings since 2001. For example, one plant
was issued a red finding--the highest risk significance--after a steam
generator tube failed, causing an increased risk in the release of
radioactive material.
Similar to the inspection findings, most performance indicator reports
have shown the indicators to be within the acceptable levels of
performance. Only 156, or less than one percent of over 30,000
indicator reports from 2001 to 2005, exceeded the acceptable
performance threshold. Four of the 15 performance indicators have
always been reported to be within acceptable performance levels. In
addition, 46 plants have never had a performance indicator fall outside
of the acceptable level and only three plants reported having a yellow
indicator for one performance measure; no red indicators have ever been
reported.
On the basis of its inspection findings and performance indicators, NRC
has subjected more than three quarters of the 103 operating plants to
at least some level of increased oversight (beyond the baseline
inspections) for varying amounts of time. Most of these plants received
the lowest level of increased oversight, consisting of a supplemental
inspection, to follow-up on the identification of one or two white
inspection findings or performance indicators. Five plants have
received the highest level of plant oversight for which NRC allows
plants to continue operations, due to the identification of multiple
white or yellow findings and/or the identification of a red
finding.[Footnote 6] One plant received this level of oversight because
NRC determined that the licensee failed to address the common causes of
two white findings and held them open for more than four quarters. One
of these findings involved the recurrent failure of a service water
pump because the licensee failed to take adequate corrective action
after the first failure.
NRC inspectors at the plants we reviewed indicated that, when plant
performance declines, it is often the result of ineffective corrective
action programs, problems related to human performance, or complacent
management, which often results in deficiencies in one or more of the
cross-cutting areas. In assessing the results of the ROP data, we found
that all plants subjected to NRC's highest level of oversight also had
a substantive cross-cutting issue open either prior to or during the
time that it was subjected to increased oversight inspections.
Overall, NRC's oversight process shows mostly consistent results from
2001 to 2005. For example, the total number of green findings at all
plants ranged from 657 to 889 per year and the total number of other
findings ranged from 10 to 30 per year with no strong trend (see fig.
1).
Figure 1: ROP Inspection Findings by Year:
[See PDF for image]
[End of figure]
Only in the area of cross-cutting issues--or inspection findings for
which one or more cross-cutting issues was associated--is an increasing
trend evident (see fig. 2). According to NRC, the reason for this
increase is due in part to the development of guidance on the
identification and documentation of cross-cutting issues and its
increased emphasis in more recent years.
Figure 2: Trend of ROP Findings with Cross-Cutting Issues:
[See PDF for image]
[End of figure]
According to NRC officials, the results of its oversight process at an
industry or summary level serve as an indicator of industry
performance, which to date indicates good safety performance. On an
annual basis, NRC analyzes the overall results of its inspection and
performance indicator programs and compares them with industry level
performance metrics to ensure all metrics are consistent and takes
action if adverse trends are identified. While NRC communicates the
results of its oversight process on a plant-specific basis to plant
managers, members of the public, and other government agencies through
annual public meetings held at or near each site and an internet Web
site, it does not publicly summarize the overall results of its
oversight process, such as the total number and types of inspection
findings and performance indicators falling outside of acceptable
performance categories, on a regular basis.
NRC Continues to Make Improvements to its Reactor Oversight Process in
Key Areas:
NRC has taken a proactive approach to improving its reactor oversight
process. It has several mechanisms in place to incorporate feedback
from both external and internal stakeholders and is currently working
on improvements in key areas of the process, including better focusing
inspections on areas most important to safety, improving its timeliness
in determining the risk significance of its inspection findings, and
modifying the way that it measures some performance indicators. NRC is
also working to address what we believe is a significant shortcoming in
its oversight process by improving its ability to address plants'
safety culture, allowing it to better identify and address early
indications of deteriorating safety at plants before performance
problems develop.
According to NRC officials, the ROP was implemented with the
understanding that it would be an evolving process and improvements
would be made as lessons-learned were identified. Each fall NRC
solicits feedback from external stakeholders, including industry
organizations, public interest groups, and state and local officials,
through a survey published in the Federal Register. NRC also conducts
an internal survey of its site, regional, and headquarters program and
management staff every other year to obtain their opinions on the
effectiveness of the ROP. Additionally, NRC has in place a formal
feedback mechanism whereby NRC staff can submit recommendations for
improving various oversight components and NRC staff meet with industry
officials on a monthly basis--in addition to various meetings,
workshops, and conferences--to discuss oversight implementation issues
and concerns. NRC staff also incorporates direction provided by the NRC
Commissioners and recommendations from independent evaluations such as
from GAO and the NRC Inspector General. The results of these efforts
are pulled together in the form of an annual self-assessment report,
which outlines the overall results of its outreach and the changes it
intends to make in the year ahead.
According to NRC officials, the changes made to the ROP since its
implementation in 2000--including those made in response to the Davis-
Besse incident--have generally been refinements to the existing process
rather than significant changes to how it conducts its oversight. In
the case of Davis-Besse, NRC formed a task force to review the agency's
regulatory processes. The task force's report, issued in September
2002, contained more than 50 recommendations, many associated with the
ROP. Among the more significant ROP-related recommendations were those
to enhance the performance indicator that monitors unidentified leakage
to be more accurate, develop specific guidance to inspect boric acid
control programs and vessel head penetration nozzles, modify the
inspection program to provide for better follow-up of longstanding
issues, and enhance the guidance for managing plants that are in an
extended shutdown condition as a result of significant performance
problems. NRC program officials told us that the task force's most
significant recommendations were in areas outside of the ROP, such as
improving the agency's operating experience program. According to NRC,
it has implemented almost all of the task force's recommendations.
Other modifications that NRC has recently made or is in the process of
making include the following:
* NRC recently revised seven of its baseline inspection procedures to
better focus the level and scope of its inspection efforts on those
areas most important to safety. These revisions resulted from a
detailed analysis in 2005 of its more than 30 baseline inspection
procedures. The effort involved analyzing the number of findings
resulting from each of its inspection procedures and the time spent
directly observing plant activities or reviewing licensee paperwork,
among other things.
* NRC has efforts underway to improve what it refers to as its
significance determination process (SDP). An audit by the NRC Inspector
General, a review by a special task group formed by NRC, and feedback
from other stakeholders have pointed to several significant weaknesses
with the SDP. For example, internal and external stakeholders raised
concerns about the amount of time, level of effort, and knowledge and
resources required to determine the risk significance of some findings.
Industry officials commented that because most inspection findings are
green, one white finding at a plant can place it in the "bottom
quartile" of plants from a performance perspective. Therefore, industry
officials explained, licensees try to avoid this placement and will
expend a great deal of effort and resources to provide additional data
to NRC to ensure the risk level of a finding is appropriately
characterized. This can add significant time to the process because
different technical tools may be used that then must be incorporated
with NRC's tools and processes. The delay in assigning a color to a
finding while the new information is being considered could also affect
a plant's placement on NRC's action matrix, essentially delaying the
increased oversight called for if the finding is determined to be
greater-than-green. NRC developed a SDP Improvement Plan in order to
address these and other concerns and track its progress in implementing
key changes. For example, NRC introduced a new process aimed at
improving timeliness by engaging decision-makers earlier in the process
to more quickly identify the scope of the evaluation, the resources
needed, and the schedule to complete the evaluation.
* NRC is also taking actions to improve its performance indicators.
These actions are partly to address concerns that the indicators have
not contributed to the early identification of poorly performing plants
to the degree originally envisioned as they are almost always within
acceptable performance levels (green). There have been several cases
where plants reported an acceptable performance indicator and
performance problems were subsequently identified. For example, NRC
inspectors at one plant noted that while performance indicator data
related to its alert and notification system in place for emergency
preparedness had always been reported green, the system had not always
been verified to be functioning properly. On the other hand, industry
officials believe that the high percentage of indicators that are green
is indicative of plants' good performance. Several plant managers told
us that they closely monitor and manage to the acceptable performance
thresholds established for each indicator, and will often take action
to address performance issues well before the indicator crosses the
acceptable performance threshold. Because NRC inspectors verify
indicator data once a year, a potential disagreement over the data
might not surface for up to a year after it is reported, and it may
take even longer to resolve the disagreement with the licensee. Similar
to delays with the SDP, a delay in assigning a color while the
disagreement is resolved could affect a plant's placement on NRC's
action matrix, and delay the increased oversight called for if the
indicator is determined to be greater-than-green. NRC plans to work
with the industry to review selected indicator definitions to make
interpretation more concise and reduce the number of discrepancies. To
date, NRC has focused significant effort on developing a key indicator
to address known problems with the performance indicators measuring the
unavailability of safety systems. NRC is also in the process of
changing the definition for several other indicators, in addition to
considering the feasibility of new indicators.
I would now like to discuss what we believe is one of NRC's most
important efforts to improve its oversight process by increasing its
ability to identify and address deteriorating safety culture at plants.
NRC and others have long recognized that safety culture and the
attributes that make up safety culture, such as attention to detail,
adherence to procedures, and effective corrective and preventative
action, have a significant impact on a plant's performance. Despite
this recognition and several external groups' recommendations to better
incorporate safety culture aspects into its oversight process, it did
not include specific measures to explicitly address plant safety
culture when it developed the ROP in 2000. The 2002 Davis-Besse reactor
vessel head incident highlighted that this was a significant weakness
in the ROP. In investigating this event, we and others found that NRC
did not have an effective means to identify and address early
indications of deteriorating safety at plants before performance
problems develop.[Footnote 7] Largely as a result of this event, in
August 2004, the NRC Commission directed the NRC staff to enhance the
ROP by more fully addressing safety culture.
In response to the Commission's directive, the NRC staff formed a
safety culture working group in early 2005. The working group
incorporated the input of its stakeholders through a series of public
meetings held in late 2005 and early 2006. In February 2006, NRC issued
its proposed approach to better incorporate safety culture into the
ROP. NRC officials expect to fully implement all changes effective in
July 2006.
NRC's proposed safety culture changes largely consist of two main
approaches: first, clarifying the identification and treatment of cross-
cutting issues in its inspection processes and second, developing a
structured way for NRC to determine the need for a safety culture
evaluation of plants. NRC has developed new definitions for each of its
cross-cutting issues to more fully address safety culture aspects and
additional guidance on their treatment once they are identified. For
example, the problem identification and resolution cross-cutting area
is now comprised of several components--corrective action program, self
and independent assessments, and operating experience. NRC inspectors
are to assess every inspection finding to determine if it is associated
with one or more of the components that make up each of the cross-
cutting areas. Inspectors then determine, on a semi-annual basis, if a
substantive cross-cutting issue exists on the basis of the number and
areas of cross-cutting components identified. If the same substantive
cross-cutting issue is identified in three consecutive assessment
periods, NRC may request that the licensee perform an assessment of its
safety culture. The intent is to provide an opportunity to diagnose a
potentially declining safety culture before significant safety
performance problems occur.
Under its approach, NRC would expect the licensees of plants with more
than one white color finding or one yellow finding to evaluate whether
the performance issues were in any way caused by any safety culture
components, and NRC might request the licensee to complete an
independent assessment of its safety culture, if the licensee did not
identify an important safety culture component. For plants where more
significant or multiple findings have been identified, the NRC would
not only independently evaluate the adequacy of the independent
assessment of the licensee's safety culture, but it might also conduct
its own independent assessment of the licensee's safety culture.
Some of NRC's proposed actions regarding safety culture have been
controversial, and not all stakeholders completely agree with the
agency's approach. For example, the nuclear power industry has
expressed concern that the changes could introduce undue subjectivity
to NRC's oversight, given the difficulty in measuring these often
intangible and complex concepts. Several of the nuclear power plant
managers at the sites we reviewed said that it is not always clear why
a cross-cutting issue was associated with finding, or what it will take
to clear themselves once they've been identified as having a
substantive cross-cutting issue open. Some industry officials worry
that this initiative will further increase the number of findings that
have cross-cutting elements associated with them and if all of the
findings have them they will lose their value. Industry officials also
warn that if it is not implemented carefully, it could divert resources
away from other important safety issues. Other external stakeholders,
on the other hand, suggest that this effort is an important step in
improving NRC's ability to identify performance issues at plants before
they result in performance problems. Importantly, there will be
additional tools in place for NRC to use when it identifies potential
safety culture concerns. NRC officials view this effort as the
beginning step in an incremental approach and acknowledge that
continual monitoring, improvements, and oversight will be needed in
order to better allow inspectors to detect deteriorating safety
conditions at plants before events occur. NRC plans to evaluate
stakeholder feedback and make changes based on lessons learned from its
initial implementation of its changes as part of its annual self-
assessment process for calendar year 2007.
GAO Contact and Staff Acknowledgments:
For further information about this statement for the record, please
contact me at (202) 512-3841 (or at wellsj@gao.gov). Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this statement. Raymond H. Smith, Jr. (Assistant
Director), Alyssa M. Hundrup, Alison O'Neill, and Dave Stikkers made
key contributions to this statement.
FOOTNOTES
[1] Physical security, which is also covered by the ROP, is not
included in this review. For information on NRC's physical security,
see GAO, Nuclear Power Plants: Efforts Made to Upgrade Security, but
the Nuclear Regulatory Commission's Design Basis Threat Process Should
Be Improved, GAO-06-388 (Washington, D.C.: Mar. 14, 2006).
[2] Certain baseline inspections may also be done by regional staff
because of their expertise in particular aspects of plant operations.
[3] Minor issues are defined by NRC as those that have little actual
safety consequences, little or no potential to impact safety, little
impact on the regulatory process, and no willfulness.
[4] The SDP essentially evaluates how an inspection finding impacts the
margin of safety of a plant. The impact is largely evaluated through
the use of information on operating experience and risk estimates
calculated using probabilistic risk assessment (PRA).
[5] NRC officials can also increase or decrease oversight in ways not
in accordance with those specified by the action matrix by requesting a
deviation. This provision is intended for rare instances when the
oversight levels dictated by the action matrix are not appropriate to
address a particular performance problem and a more tailored approach
is required.
[6] NRC has one additional oversight category for plants with
unacceptable performance. Plants placed into this category are not
permitted to operate.
[7] GAO, Nuclear Regulation: NRC Needs to More Aggressively and
Comprehensively Resolve Issues Related to the Davis-Besse Nuclear Power
Plant's Shutdown, GAO-04-415 (Washington, D.C.: May 17, 2004).
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site (www.gao.gov). Each weekday, GAO posts
newly released reports, testimony, and correspondence on its Web site.
To have GAO e-mail you a list of newly posted products every afternoon,
go to www.gao.gov and select "Subscribe to Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office 441 G Street NW, Room LM
Washington, D.C. 20548:
To order by Phone: Voice: (202) 512-6000 TDD: (202) 512-2537 Fax: (202)
512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 U.S.
Government Accountability Office, 441 G Street NW, Room 7125
Washington, D.C. 20548:
Public Affairs:
Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149
Washington, D.C. 20548:
