    Nuclear Regulatory Commission: Oversight of Nuclear Power Plant
    Safety Has Improved, but Refinements Are Needed (27-SEP-06,
    GAO-06-1029).

    The Nuclear Regulatory Commission (NRC) is responsible for
    overseeing the nation's 103 commercial nuclear power plants to
    ensure they are operated safely. The safety of these plants has
    always been important, since an accident could release harmful
    radioactive material. NRC's oversight has become even more
    critical as the potential resurgence of nuclear power is
    considered. NRC implemented a new Reactor Oversight Process (ROP)
    in 2000 to address weaknesses in its oversight of nuclear plant
    safety. In this report, GAO reviewed (1) how NRC oversees nuclear
    power plants, (2) the results of the ROP over the past several
    years, and (3) the status of NRC's efforts to improve the ROP. To
    complete this work, GAO analyzed programwide information,
    inspection results covering 5 years of ROP operations, and
    detailed findings from a nonprobability sample of 11 plants.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-06-1029
        ACCNO:   A61465
      TITLE:     Nuclear Regulatory Commission: Oversight of Nuclear Power
    Plant Safety Has Improved, but Refinements Are Needed
         DATE:   09/27/2006
      SUBJECT:   Evaluation criteria
    	     Federal regulations
    	     Inspection
    	     Noncompliance
    	     Nuclear powerplant safety
    	     Nuclear powerplants
    	     Performance measures
    	     Radiation safety
    	     Risk assessment
    	     Safety regulation
    	     Safety standards
    	     Policies and procedures
    	     NRC Reactor Oversight Process

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    GAO-06-1029

         * Report to Congressional Requesters
              * September 2006
         * NUCLEAR REGULATORY COMMISSION
              * Oversight of Nuclear Power Plant Safety Has Improved, but
                Refinements Are Needed
         * Contents
              * Results in Brief
              * Background
              * NRC Uses Various Tools and Takes a Risk- Informed and Graded
                Approach to Ensuring the Safety of Nuclear Power Plants
                   * NRC Collects Information about Plant Performance from
                     Physical Inspections and Quantitative Measures Reported by
                     the Licensees
                   * NRC Uses Its Action Matrix to Categorize Plant Performance
                     and Apply Increased Oversight in a Graded Fashion
              * NRC Has Identified Low Risk Problems at Nuclear Power Plants,
                Resulting in Increased Oversight for Varying Periods
              * NRC Is Addressing Weaknesses in Various Areas of Its Oversight
                Process, but More Effort Is Needed
                   * NRC Is Taking Action to Improve Various Areas of Its
                     Oversight Process
                   * NRC Is Taking Its First Major Step to Address a Significant
                     ROP Weakness in the Area of Safety Culture
              * Conclusions
              * Recommendations for Executive Action
              * Agency Comments
         * Key Safety-Related Events at the Salem and Hope Creek Nuclear Power
           Plants from 2000 to 2006
              * Summary of Key Safety-Related Events at Salem and Hope Creek,
                April 2000 to June 2006
                   * White Performance Indicator for Unplanned Scrams
                   * White Performance Indicator for Unplanned Changes in Reactor
                     Power
                   * Substantive Cross-Cutting Issue in Problem Identification
                     and Resolution
                   * White Inspection Finding for Failure of a Part on an
                     Emergency Diesel Generator
                   * White Inspection Finding for the Failure of a Rotating
                     Screen That Is Part of the Station Service Water System at
                     Hope Creek
                   * White Inspection Finding for the Failure of a Drain Line in
                     the Moisture Separator System at Hope Creek
                   * Increased Oversight to Address Safety-Conscious Work
                     Environment Problems
         * Scope and Methodology
         * Nuclear Power Plant Performance Data on the Basis of the Results of
           NRC's Reactor Oversight Process, 2001 Through 2005
         * Comments from the Nuclear Regulatory Commission
         * GAO Contact and Staff Acknowledgments
         * PDF6-Ordering Information.pdf
              * Order by Mail or Phone

    Report to Congressional Requesters

    September 2006

    NUCLEAR REGULATORY COMMISSION

    Oversight of Nuclear Power Plant Safety Has Improved, but Refinements Are
    Needed

    Contents

    Tables

    Figures

    September 27, 2006Letter

    Congressional Requesters

    The Nuclear Regulatory Commission (NRC) is responsible for overseeing 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, since an accident could result in the release of radioactive
    material and potentially harm public health 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. No new orders for plants have been placed
    since the 1979 accident at the Three Mile Island plant in Pennsylvania.
    However, in the face of concerns about energy security, global warming,
    aging plants, and the ever increasing need for energy to fuel the nation's
    economy, nuclear power is resurfacing as a principal option. An accident,
    even on a relatively small scale, 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.

    NRC is responsible for issuing regulations, licensing and overseeing
    plants, and requiring necessary actions to protect public health and
    safety, up to and including shutting down a plant, if it is not meeting
    licensing conditions and it poses an undue risk to public health and
    safety. Plant operators are responsible for safely operating their plants
    in accordance with their licenses. Prior to 2000, NRC's oversight of
    plants' compliance, which is a critical part of the agency's regulatory
    program, was criticized because it did not always focus on the most
    important safety issues, and because some 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.
    NRC's goal is to ensure that its oversight of plants' safety performance
    is objective, predictable, understandable, and conducted openly to inform
    the public and maintain confidence about plant safety. The unexpected
    discovery in March 2002 of extensive corrosion and a pineapple-size cavity
    in the reactor vessel head-one of the vital barriers preventing a
    radioactive release-at the Davis-Besse nuclear power plant in Ohio led NRC
    to reexamine its safety oversight and other regulatory processes to
    determine how such corrosion could have been missed. On the basis of the
    lessons learned from that event, NRC made several changes to the ROP. NRC
    also has assessed the ROP annually since it was implemented in 2000 by
    obtaining feedback from the industry and other stakeholders, such as
    public interest groups.

    In this report, we examined (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, and (3) the status of NRC's efforts to improve the
    ROP.1 In addition, this report provides details on recent safety-related
    events at the Salem and Hope Creek nuclear power plants in New Jersey and
    on NRC's and the licensee's actions in response to these events (see app.
    I).

    To examine how NRC oversees plants, we reviewed the various tools and
    processes that comprise the ROP. In this regard, we reviewed NRC's
    policies, inspection manuals, and other guidance documents; interviewed
    NRC headquarters and regional program 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 reviewed the number and types of inspection findings NRC issued,
    along with other performance measures or indicators it collected from the
    plants, and the level of oversight it provided as a result of its
    findings. 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 program
    officials. We assessed the reliability of these data and determined that
    they were sufficiently reliable for the purposes of our report. To examine
    the status of NRC's efforts to improve the ROP, we analyzed NRC documents,
    including annual self-assessment reports; interviewed officials from NRC,
    including a former Commission Chairman who is largely credited with
    leading the development of the ROP, and outside stakeholder groups,
    including the Nuclear Energy Institute (NEI), the Union of Concerned
    Scientists (UCS), and Greenpeace; 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 Advisory Committee on Reactor Safeguards (ACRS)2 and the NRC
    Office of the Inspector General. In addition, we selected a nonprobability
    sample of 6 nuclear power sites (totaling 11 plants, including Salem and
    Hope Creek) that spanned each of NRC's four regions and represented
    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. Appendix II
    presents a detailed discussion of our scope and methodology. We conducted
    our work from July 2005 through July 2006 in accordance with generally
    accepted government auditing standards.

    Results in Brief

    NRC uses various tools and takes a risk-informed and graded approach to
    ensuring the safety of nuclear power plants. These tools include physical
    inspections of plants' equipment and records and quantitative measures or
    indicators of plant performance, such as the number of unplanned reactor
    shutdowns and the reliability of alert and notification system sirens that
    notify residents living near the plant in the event of an accident. NRC
    uses a risk-informed approach-that is, an approach that considers safety
    significance in selecting the equipment or operating procedures to be
    inspected-to apply these tools. NRC inspectors conduct baseline
    inspections of plant operations almost continuously at each nuclear power
    plant site. When NRC becomes aware of a performance problem at a plant, it
    uses a process to assign the inspection finding one of four colors to
    reflect the finding's risk significance, which is set on the basis of
    measures that reflect the potential health effects that could occur from
    radiological exposure. Green inspection findings equate to very low risk
    significance, while white, yellow, and red colors represent increasing
    levels of risk, respectively. In response to greater-than-green (white,
    yellow, or red) inspection findings, NRC conducts supplemental
    inspections, which expand the scope of baseline inspections and review (1)
    the extent of the problem, (2) the sufficiency of the licensee's
    evaluation of the root cause of the problem, and (3) the licensee's
    proposed corrective actions in response to the identified performance
    problem. NRC conducts special inspections to investigate specific safety
    incidents or events-such as reactor shutdowns due to equipment
    failures-that are of particular interest to NRC because of their potential
    significance to safety. Nuclear power plants also self-report on their
    safety performance, using performance measures or indicators in quarterly
    reports that they submit to NRC. The plants' reports are verified by NRC's
    on-site inspectors. On the basis of the number and risk significance of
    inspection findings and performance indicators, NRC places each plant into
    one of five oversight categories on its action matrix, which correspond to
    graded or increasing levels of oversight, largely consisting of
    supplemental inspections that increase in the breadth and depth of issues
    covered as plants move into higher oversight categories. NRC provides an
    overall assessment of each plant's performance through assessment letters
    issued to plants at the end of each 6-month period describing their
    specific performance and the level of oversight that will result. In
    addition, NRC has other mechanisms to make available its oversight
    results, such as an Internet Web site devoted to the ROP that provides
    detailed summaries of each plant's performance.

    Since 2001, the ROP has resulted in more than 4,000 inspection findings
    concerning nuclear power plant licensees' failure to fully comply with NRC
    regulations and industry standards for safe plant operation, and NRC has
    subjected more than 75 percent (79) of the 103 operating plants to
    increased oversight for varying periods. (See app. III for additional
    site-specific plant data.) About 97 percent of the inspection findings
    were green, meaning they were for actions or failures NRC considered
    important to correct but of very low significance to overall safe plant
    operations. 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. The other 3 percent (98) of the inspection
    findings were greater-than-green. Most of these findings (86 of the 98)
    were white, meaning they were considered to be of low-to-moderate risk
    significance. The other 12 inspection findings, or less than 1 percent,
    were of the highest levels of significance to safety (yellow and red). For
    example, NRC issued a finding of the highest risk significance (red) at
    one plant after a steam generator tube failed, causing an increased risk
    of the release of radioactive material. In the area of performance
    indicators, there were 156 instances out of more than 30,000 reports, or
    less than 1 percent, in which data reported for individual indicators were
    outside of NRC's acceptable performance category. On the basis of
    greater-than-green inspection findings and performance indicators, NRC has
    subjected more than 75 percent (79) of the 103 operating plants to
    oversight beyond the baseline inspections for varying periods. Most of
    these plants received the lowest level of increased oversight, consisting
    of a supplemental inspection to follow up on the corrective actions taken
    for performance problems identified through the issuance of 1 or 2 white
    inspection findings or performance indicators. Over the past 5 years, 5
    plants have been subjected to the highest level of NRC oversight that
    still allows continued operations. Plants in this category were generally
    subjected to this higher oversight for long periods due to the more
    intensive supplemental inspections conducted by NRC and the more systemic
    nature of the plants' performance problems and subsequent corrective
    actions NRC expected the licensees to take. 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. In assessing the results of
    the ROP between 2001 and 2005, we found an association between poorer
    performing plants and deficiencies in the plants' human performance and
    problem identification and resolution programs.

    NRC has improved its oversight process in various areas, but continued
    efforts will be needed to address other shortcomings or opportunities for
    improvement, particularly in improving the agency's ability to identify
    and address early indications of declining plant safety performance. NRC
    has made several improvements, 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 its
    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 to improve
    their quality. NRC also is assessing whether it needs to modify its
    oversight, including developing additional inspection procedures, as a
    result of some problems that have surfaced in areas not fully inspected by
    NRC, such as the recent discovery of groundwater contamination from
    radioactive materials at a number of sites. For the most part, NRC
    considers these efforts to be refinements to its oversight process, rather
    than significant changes. One important 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 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 actions, have a
    significant impact on a plant's safety performance, and that the lessening
    of these attributes can indicate a decline in safety performance before
    safety problems occur. However, NRC has been somewhat slow to react and
    only recently modified its oversight process by redefining and increasing
    its focus on cross-cutting safety issues-issues that comprise many of the
    elements of safety culture-and developing new requirements under the ROP
    to more directly assess safety culture at poorer performing plants.
    However, some of NRC's changes have been controversial. While some
    industry officials have expressed concern that the changes could introduce
    undue subjectivity to NRC's oversight, given the difficulty in measuring
    these often intangible and complex concepts, other stakeholders believe
    the changes will provide NRC with better tools to identify safety culture
    issues at plants and thus provide earlier indications of declining safety
    performance. NRC has been reluctant to incorporate safety culture into the
    ROP because it considered this type of activity a management function, and
    NRC did not believe that it should be directly involved in managing
    licensees' plants. NRC program officials view these changes as the
    beginning step in an incremental approach and acknowledge that they will
    need to assess the changes they made to the ROP to determine their
    effectiveness in better allowing inspectors to detect deteriorating safety
    conditions at plants before significant safety events occur.

    Given the importance of this initiative to the ROP's effectiveness, we are
    recommending that NRC aggressively monitor; evaluate; and, if needed,
    implement additional measures to increase the effectiveness of its safety
    culture changes. In line with NRC's desire to make the ROP an open
    process, we are also recommending that the agency make available
    additional information on plants' safety culture to the public and its
    other stakeholders to provide a more comprehensive picture of plant
    performance. In commenting on a draft of this report, NRC generally agreed
    with our findings, conclusions, and recommendations. Appendix IV contains
    a reproduction of NRC's letter.

    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 the Chair 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's staff work out of its headquarters office
    in Rockville, Maryland; out of its four regional offices; and at each of
    the operating commercial nuclear power plant sites (see fig. 1). NRC's
    Office of Nuclear Reactor Regulation provides overall direction for the
    oversight process and the Office of Enforcement is responsible for
    ensuring that appropriate enforcement actions are taken when performance
    issues are identified. NRC's regional offices are responsible for
    implementing the ROP, along with the inspectors who work directly at each
    of the nuclear power plant sites.

    Figure 1: NRC Regions and Operating Nuclear Power Plant Sites in the
    United States

    Nuclear power plant licensees have the primary responsibility for safely
    operating their plants in accordance with their licenses and NRC
    regulations. The 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 inspectors to assess plant conditions and the
    licensees' quality assurance programs, such as those required for
    maintenance and problem identification and resolution. Given the numerous
    activities going on during complex plant operations, NRC can inspect only
    a relatively small sample of the plants' activities. According to NRC, its
    focus on the more safety-significant activities is made possible because
    safety performance at plants has improved as a result of more than 25
    years of operating experience, and because improvements have been made in
    the risk assessment tools available to NRC inspectors.

    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 safety 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 radiation and provide emergency protection. For example,
    nuclear fuel is contained in a ceramic pellet to lock in the radioactive
    byproducts, 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.

    In addition, the nuclear power industry formed an organization, the
    Institute of Nuclear Power Operations (INPO), whose mission is 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 plants,
    focusing on plant safety and reliability, in the areas of operations,
    maintenance, engineering, radiological protection, chemistry, and
    training. Licensees make the results of these evaluations available to NRC
    for review, and NRC staff use the evaluations as a means to determine
    whether its oversight process has missed any performance issues.

    Prior to the ROP, NRC conducted Systematic Assessment of Licensee
    Performance (SALP) evaluations. SALP evaluations were largely based on
    physical plant inspections conducted at each operating plant. Every 12 to
    24 months, NRC provided an overall assessment of plant safety performance.
    As part of the assessment process, NRC's senior management met to evaluate
    plants' performance and develop a "watch list" of those plants requiring
    increased regulatory attention. The SALP process was heavily criticized by
    the industry and other internal and external stakeholders, however, for
    being inconsistently applied among NRC regions and for lacking clear and
    consistent responses once issues were identified. In 1997 and 1998, we
    reported that NRC's oversight needed substantial revisions to achieve its
    purpose as an early-warning tool, and that NRC did not consistently apply
    the SALP across the industry.3 We found the inconsistency could be
    attributed, in part, to a lack of specific criteria, the subjective nature
    of the process, and an ineffective process for ensuring that the licensees
    maintain competent management at their plants.

    To address these concerns, NRC undertook a major effort to revise its
    oversight process. NRC held a series of public meetings and workshops and
    formed several task groups to involve its internal and external
    stakeholders, including NEI, UCS, state agencies, and others. In 1999, NRC
    conducted a 6-month pilot program to implement the ROP at various sites
    across the country. On the basis of the input it received from its
    stakeholders and the results from the pilot program, NRC finalized its new
    process and implemented the ROP at all plants in April 2000, which was a
    significant departure from its prior SALP process.

    Soon after the ROP was implemented, NRC faced a number of unanticipated
    events- including the attacks of September 11, 2001, and the discovery of
    the Davis-Besse reactor vessel head degradation in 2002-that challenged
    its ability to complete its baseline inspection activities at all plants
    in 2002 and 2003. Therefore, NRC staff implemented "coping strategies,"
    which consisted of increasing the use of overtime and scheduling
    flexibility for its inspectors, reducing the level of effort for some of
    its inspection procedures, reducing some of the inspection preparation
    time, and deferring some inspections, among other things. A 2004 audit by
    the NRC Office of the Inspector General found that the resource challenges
    were largely due to changes in NRC's staffing policy, a hiring policy
    change, an increase in inspection activities due to unanticipated events
    such as Davis-Besse, and a loss of qualified inspectors.4 NRC increased
    its inspection resources by 9 percent in 2004, and then by another 5
    percent in 2005, and reported that it was able to fully implement its
    baseline inspection program at all plants for both years. NRC reports show
    that resources expended in 2005 were almost 20 percent higher than those
    expended in 2002, the lowest level of inspection resources devoted to the
    ROP since its inception in 2000. According to NRC, the additional
    resources expended in 2005 were due, in part, to increased oversight that
    was based on lessons learned from the Davis-Besse incident and on the
    increased focus on security and emergency preparedness. With its current
    resource levels, NRC program officials believe they will be able to
    continue to implement all program requirements without the need to employ
    coping strategies.

    NRC Uses Various Tools and Takes a Risk-Informed and Graded Approach to
    Ensuring the Safety of Nuclear Power Plants

    NRC's tools to oversee the safe operation of nuclear power plants
    generally consist of physical inspections of the various complex plant
    equipment and operations, reviews of plant records, and quantitative
    measures or indicators of plant performance. These tools are risk-informed
    in that they focus on the aspects of operations considered most important
    to plant safety. NRC bases its oversight process on the principle and
    requirement that licensees have programs in place to routinely identify
    and address performance issues without NRC's direct involvement. Thus, an
    important aspect of NRC's inspection process is ensuring the effectiveness
    of licensee programs designed to identify and correct problems. On the
    basis of the number and risk significance of inspection findings and
    performance indicators, NRC places each plant into one of five performance
    categories on its action matrix, which corresponds to graded, or
    increasing, levels of oversight. NRC assesses overall plant performance
    and communicates the results to licensees and the public on a semiannual
    basis.

    NRC Collects Information about Plant Performance from Physical Inspections
    and Quantitative Measures Reported by the Licensees

    Physical plant inspections are the main tool NRC uses to oversee plant
    safety performance. NRC defined specific inspection areas by developing a
    list of those elements most critical to meeting the overall agency mission
    of ensuring nuclear power plant safety. These safety elements-or key plant
    inspection areas-are known as cornerstones. Table 1 summarizes the
    objectives of each cornerstone.

    Table 1: Key ROP Plant Inspection Areas, or Cornerstones

             Cornerstone                           Objective
    Initiating events       Limit the frequency of those events that upset
                               plant operating stability and challenge critical
                               safety functions.
    Mitigating systems      Ensure the availability, reliability, and
                               capability of systems that mitigate initiating
                               events to prevent reactor accidents.
    Barrier integrity       Ensure that physical barriers, such as fuel
                               cladding and containment structures, protect the
                               public from radioactive releases caused by
                               accidents.
    Emergency preparedness  Ensure that actions taken by the emergency plan
                               would provide protection of the public health and
                               safety during a radiological emergency.
    Occupational radiation  Ensure adequate protection of worker health and
    safety                  safety from exposure to radioactive material
                               during routine civilian nuclear reactor operation.
    Public radiation safety Ensure adequate protection of public health and
                               safety from exposure to radioactive material
                               released into the public domain as a result of
                               routine civilian nuclear reactor operations.
    Physical protectiona    Provide assurance that the physical protection
                               system can protect against radiological sabotage.

    Source: NRC.

    aThe physical protection cornerstone consists of physical security issues
    and, therefore, is outside the scope of this review.

    During fiscal year 2005, NRC reported that inspectors spent 411,490 hours
    (an average of 77 hours per week at each plant) on plant inspections,
    which consist of baseline, supplemental, and special inspections. About 73
    percent of this time was devoted to baseline inspections, which are the
    minimum level of inspections that all plants receive regardless of
    performance, and are conducted on an almost continuous basis. Baseline
    inspections are conducted by the two or three NRC inspectors located at
    each site and specialists who travel to each site from NRC's regional
    offices. These inspections are designed to detect declining safety
    performance in each of the cornerstones, and to review licensee
    effectiveness at identifying and resolving its safety problems. There are
    more than 30 baseline inspection procedures conducted at intervals that
    range from quarterly to triennially. These procedures involve both
    physical observations of plant activities and reviews of plant reports and
    data. Each of the baseline procedures specify a range of sample activities
    to inspect. Inspectors then select the type and number of activities to
    review on the basis of factors such as the sample activities available;
    their risk significance; the amount of time since a particular system or
    component was last inspected; and the inspector's judgment, which is based
    on information such as reviews of the licensee's corrective action
    program, allegations, or plant employee interviews. Risk is factored into
    the baseline inspection procedures in the following four ways: (1) areas
    of inspection are included in the set of baseline procedures, in part, on
    the basis of 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. In addition to the
    more than 30 baseline inspection procedures, inspectors spend an average
    of 750 to 1,100 hours per year (14 to 21 hours per week), depending on the
    size of the site, conducting plant status reviews. These reviews are to
    ensure that inspectors are aware of plant conditions on a routine basis
    and include such activities as reviewing control room activities and
    status, attending licensee meetings, and conducting walk-downs of various
    plant areas.

    When NRC inspectors identify a finding they consider to be more than
    minor,5  they use a significance determination process (SDP) to assign the
    finding one of four colors to reflect the finding's risk significance. The
    SDP assesses how an identified inspection finding increases the risk that
    a nuclear accident could occur, or how the finding affects the ability of
    the plant safety systems or personnel to prevent such an accident. Risk
    thresholds for each color were set on the basis of measures that reflect
    the potential health effects that could occur from radiological exposure.6
    Green inspection findings equate to very low risk significance, while
    white, yellow, and red colors represent increasing levels of risk,
    respectively. For greater-than-green (white, yellow, or red) inspection
    findings, NRC issues a preliminary color determination after an initial
    analysis. It then analyzes any readily available information from the
    licensee pertinent to the finding to ensure that the final determination
    of risk significance is made with the best available information.

    When NRC issues one or more greater-than-green inspection findings at a
    plant, it conducts supplemental inspections. Supplemental inspections,
    performed by regional staff, expand the scope beyond baseline inspection
    procedures and focus on diagnosing the cause of the performance
    deficiency. There are three levels of supplemental inspections that are
    increasingly expansive in the breadth and depth of their analysis. The
    level of supplemental inspection to be carried out depends on the number
    and type of performance problem identified. The lowest level of
    supplemental inspection assesses the licensee's corrective actions to
    ensure they were sufficient in both correcting the problem and identifying
    and addressing the root and contributing causes to prevent recurrence. The
    second level of supplemental inspection has an increased scope that
    includes independently assessing the extent of the condition for both the
    specific and any broader performance problems. The highest level of
    supplemental inspection is even more comprehensive and includes
    determining whether the plant can continue to operate and whether
    additional regulatory actions are necessary. The highest level of
    supplemental inspection is usually conducted by a multidisciplinary team
    of NRC inspectors and may take place over several months. Also, as a part
    of this supplemental inspection, NRC inspectors assess the adequacy of the
    licensee's overall programs for identifying, evaluating, and correcting
    its performance issues, among other things.

    NRC conducts special inspections at plants when specific events occur that
    are of particular interest to NRC because of their potential safety
    significance at the plant or because of potential generic safety concerns
    important to all plants. Special inspections determine the cause of the
    event and assess the licensee's response to the event. For special
    inspections, a team of experts is often 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.7 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 additional leakage.

    As part of its inspection process, NRC evaluates all of its findings to
    determine if certain elements of plant performance, referred to as
    cross-cutting aspects, were a contributing cause to the performance
    problem. Cross-cutting aspects represent licensee performance elements
    that extend across all of the cornerstones of safety. There are three
    cross-cutting aspect areas: (1) problem identification and resolution, (2)
    human performance, and (3) a safety-conscious work environment. For
    example, in analyzing the failure of a valve to operate properly at one
    plant, NRC inspectors determined that plant employees had not followed the
    correct maintenance procedures. Thus, NRC concluded that the finding was
    associated with the human performance cross-cutting area. Every 6 months,
    NRC analyzes all findings issued at each plant during a 12-month
    assessment period. If more than three findings have similar causes within
    the same cross-cutting area and if NRC is concerned about the licensee's
    progress in addressing these issues, it determines that the licensee has a
    "substantive" cross-cutting issue. NRC notifies the licensee that it has
    opened a substantive cross-cutting issue, and it may ask the licensee to
    respond with the corrective actions it plans to take. Also, NRC inspectors
    said they provide additional focus on any substantive cross-cutting issues
    open through their baseline inspection efforts. For example, one regional
    official said that if a substantive cross-cutting issue in the problem
    identification and resolution area is identified, it is the region's
    practice to increase the frequency of certain baseline inspections that
    focus on the licensee's problem identification and resolution processes.

    In addition to its various inspections, NRC also collects plant
    performance information through its 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
    indicators8-quantitative measures of plant performance related to safety
    in the different 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 systems that notify residents living near the plant in the
    event of an accident. Working with the nuclear power industry, NRC set
    thresholds for acceptable performance and assigned colors to each of the
    indicators to reflect increasing risk. In contrast to inspection findings,
    a green indicator does not indicate a performance deficiency but instead
    reflects performance within the acceptable range, while white, yellow, and
    red represent decreasing levels of plant performance. NRC inspectors
    review and verify the data submitted for each performance indicator
    annually through their baseline inspections. If questions arise during the
    review and verification process about how to calculate a particular
    indicator or what the correct value should be, there is a formal feedback
    process to resolve the issue. Similar to its process for conducting
    supplemental inspections when greater-than-green inspection findings are
    identified, NRC conducts supplemental inspections in response to any
    greater-than-green performance indicators.

    NRC Uses Its Action Matrix to Categorize Plant Performance and Apply
    Increased Oversight in a Graded Fashion

    Under the ROP, NRC places each nuclear power plant into one of five
    performance categories on its action matrix, which corresponds to graded,
    or increasing, levels of oversight.9 The action matrix is NRC's formal
    method of determining how much additional oversight-mostly in the form of
    supplemental inspections-is required on the basis of the number and risk
    significance of inspection findings and performance indicators. (See fig.
    2 for an overview of the process that leads to plant placement on the
    action matrix.)

    Figure 2: NRC's Oversight Process in Determining Plant Placement on the
    Action Matrix

    The definitions for the categories of the action matrix indicate more
    pervasive and systematic declines in licensee performance as a licensee
    moves from left to right on the action matrix (see table 2). Also, as the
    licensee moves to the right on the action matrix, NRC's response and the
    corrective actions it expects of the licensee become more extensive. In
    determining a plant's placement on the action matrix, greater-than-green
    inspection findings are considered for additional oversight for a minimum
    of four quarters, regardless of whether the licensee corrected the
    problem, to allow sufficient time to identify additional findings that may
    indicate more pervasive performance problems. If a licensee fails to
    correct the performance problem within the initial four quarters, the
    finding may be held open and considered for additional oversight. NRC
    regional officials, with the approval of the Executive Director for
    Operations, can also increase or decrease oversight beyond the actions
    specified by the action matrix through deviations to the ROP. Deviations
    are for rare instances when the regulatory actions dictated by the action
    matrix are not appropriate and a more tailored approach is warranted.

    Table 2: NRC Reactor Oversight Process Action Matrix

        Oversight    Lowest    Second level Third level    Highest    Unacceptable
        category      level                              level (while performance
                                                           allowing      (plant
                                                          continued    shutdown)
                                                         operations)
    Plant       All green   One white    Two or more  Two white    Overall
    performance findings    finding or   white        findings or  unacceptable
                   and         performance  findings or  performance  performance
                   performance indicator,   performance  indicators   due to
                   indicators  or two white indicators   or one       unacceptable
                               findings or  in one       yellow       margin of
                               performance  cornerstone, finding or   safety
                               indicators   or one       performance
                               in different yellow       indicator in
                               cornerstones finding or   one
                                            performance  cornerstone
                                            indicator,   for five or
                                            or any three more
                                            white        quarters, or
                                            findings or  multiple
                                            performance  yellow or
                                            indicators   one red
                                                         finding or
                                                         performance
                                                         indicator
    NRC         Baseline    Baseline     Baseline     Baseline     Order to
    oversight   inspections inspections  inspections  inspections  modify,
    actions     only        and first    and second   and third    suspend, or
                               level, or    level, or    level, or    revoke
                               least        more         most         licensed
                               intensive,   intensive,   intensive,   activities
                               supplemental supplemental supplemental
                               inspection   inspection   inspection.a

    Source: NRC.

    Note: In addition to the actions listed in this table, increasingly higher
    levels of NRC management will meet with the licensee as it moves to the
    right on the action matrix.

    aFor plants at this oversight level, at a minimum, the licensee and NRC
    are to document agreement on the corrective actions the licensee will take
    through a performance improvement plan. NRC may also take actions
    including making a demand to the licensee for information or issuing an
    order up to and including a plant shutdown.

    Whether NRC takes enforcement actions in response to plant performance
    problems depends on whether there is a violation of a specific regulatory
    requirement.10 Some findings can have risk significance without violating
    a regulatory requirement because the ROP is a risk-informed process, while
    the underlying regulations are not all risk-informed. For example,
    regulatory requirements govern plants' safety-related equipment, which
    licensees define when their licenses are granted as equipment that would
    be employed to mitigate the effects of an accident. NRC's risk-informed
    oversight process considers the condition of all of the equipment at a
    plant, not necessarily just that included in its definition of
    safety-related equipment. As such, performance deficiencies could be
    identified through inspection findings that were not associated with
    safety-related equipment and, thus, were not violations of a regulatory
    requirement. More specifically, fire pumps are not typically defined as
    safety-related equipment under the regulations defining safety-related
    equipment, but they could be employed to provide water to cool the reactor
    in the event of an accident. If a licensee specified the use of fire pumps
    as part of its strategy to mitigate the effects of an accident, a
    performance problem associated with the pumps would not necessarily
    violate regulatory requirements, but the problem could be determined to be
    an inspection finding. Even though there is not a regulation requiring the
    licensee to correct such a problem, the finding would be considered for
    additional oversight under the ROP, thus providing an incentive for the
    licensee to correct it. NRC program officials acknowledge that applying
    the risk-informed ROP to regulations that are not risk-informed allows for
    these types of situations. The officials said NRC has efforts under way to
    risk-inform some of its regulations, which should reduce the likelihood of
    these types of situations occurring.

    On the basis of the results of its oversight process, NRC provides plant
    licensees and the public with an overall assessment of each plant's
    performance. At the end of each 6-month period, NRC issues an assessment
    letter to each plant to describe what level of oversight the plant will
    receive according to its placement on the action matrix, what actions NRC
    is expecting the plant licensee to take as a result of the performance
    issues identified, any specific enforcement actions NRC has taken, and any
    documented substantive cross-cutting issues. If a substantive
    cross-cutting issue is identified, the letter will describe what actions
    NRC intends to take to monitor the issue and how the licensee is expected
    to respond to NRC with the corrective actions it intends to take. NRC also
    holds an annual public meeting at or near each site to review its
    performance and address questions from members of the public and other
    interested stakeholders. In addition, NRC reviews the conclusions of
    independent plant assessments, such as those conducted by INPO. The
    purpose of this review is to self-assess the NRC inspection and assessment
    process to ensure that NRC is identifying similar performance issues.

    NRC communicates the results of much of its oversight process to members
    of the public through an Internet Web site devoted to the ROP. This Web
    site makes available plants' inspection reports and assessment letters,
    and other general materials related to NRC's oversight process. NRC also
    provides a quarterly summary of every plant's performance, consisting of
    its inspection findings, the color of each performance indicator, and its
    placement on the action matrix. NRC also provides a short description of
    each inspection finding issued during the quarter. While each description
    contains information about whether the finding was associated with a
    cross-cutting issue, the Web site itself does not provide information on
    those plants that have open substantive cross-cutting issues. This
    information can only be found on the Web site by linking to each plant's
    individual assessment letters. NRC program officials acknowledge that,
    without having the information available in summary form, it is difficult
    to determine which plants have substantive cross-cutting issues open. They
    said that they may look at the possibility of including such information
    on the Web site, although doing so is not part of their current plans.

    In addition to its plant-level assessments, NRC assesses the results of
    its oversight process on an industry-level basis. NRC management holds an
    annual meeting to (1) discuss any significant performance issues
    identified at specific plants and (2) analyze the overall results of its
    inspection and

    performance indicator programs and compare them with other
    industry-collected and reported performance data. NRC program officials
    said that if they identified any negative trends or inconsistencies, they
    would take action to better understand and address the cause.

    NRC Has Identified Low Risk Problems at Nuclear Power Plants, Resulting in
    Increased Oversight for Varying Periods

    The ROP has identified thousands of performance deficiencies through
    inspection findings at nuclear power plants between 2001 and 2005, but
    most of these findings were considered to be of very low risk to safe
    plant operations. In the performance indicator program, there have been
    very few instances in which performance indicator data were below
    acceptable standards during this period. While the majority of plants
    received some level of increased oversight due to greater-than-green
    inspection findings and performance indicators, only 5 plants were
    subjected to NRC's highest levels of oversight. Plants in this category
    were generally subjected to this higher oversight for long periods due to
    the more intensive supplemental inspections conducted by NRC and to the
    more systemic nature of the plants' performance problems and subsequent
    corrective actions NRC expected the licensees to take. In assessing the
    results of the ROP between 2001 and 2005, we found an association between
    poorer performing plants and deficiencies in the cross-cutting areas of
    human performance and problem identification and resolution.

    Of the more than 4,000 inspection findings identified between 2001 and
    2005, 97 percent were green. (See app. III for additional site-specific
    inspection findings data.) The number of green findings ranged from 15 at
    one site to 141 at another site, with an overall site average of 59 for
    the 5-year period. While green findings are considered to be of very low
    safety significance, they represent a performance deficiency on the part
    of the licensee and it is important that they be corrected. 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; rather, it relies on the licensee to
    address and track the finding's 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 program officials stated that
    even though they do not increase oversight as a result of green findings,
    green findings are assessed for the presence of cross-cutting aspects and
    provide useful information on plant performance. NRC inspectors told us
    they use green findings to identify performance trends in the various
    safety areas and these findings help inform their selection of future
    inspection samples.

    The other 3 percent of the inspection findings identified between 2001 and
    2005, or 98 of the more than 4,000, were greater-than-green (see app.
    III). Eighty-six findings were white, meaning they were considered to be
    of low to moderate risk significance. The white findings were
    well-distributed among the sites, with only 11 sites receiving more than 2
    white findings during the period. Twenty-three sites were not issued any
    white (or greater) findings during this period. White findings were issued
    for such things as (1) a licensee's failing to correct a condition in
    which the auxiliary service water pump could not be aligned in sufficient
    time to mitigate the loss of feedwater during a simulated tornado exercise
    and (2) a licensee's having an improper validation process for its
    licensed operator requalification examinations, which compromised the
    integrity of the exams. Less than 1 percent of the inspection findings
    issued since 2001 were of the highest risk significance-yellow or red.
    During this time, NRC issued 7 yellow findings and 5 red findings. The 7
    yellow findings were in the mitigating systems and emergency preparedness
    cornerstones and included issues such as the failure to develop and
    maintain emergency plans at one plant, the failure to ensure that
    safety-related equipment was adequately protected from flooding at another
    plant, and the failure to pass an annual licensed operator requalification
    examination by over half of the operator crews at one plant. Of the 5 red
    findings, 1 was issued for the degradation of the reactor vessel head at
    the Davis-Besse plant, 1 was issued for a steam generator tube failure at
    another plant, and the remaining 3 red findings were issued at 2 other
    plants for problems related to their auxiliary feedwater pumps.

    NRC's inspection results have remained relatively consistent from 2001 to
    2005. During this time frame, the number of green findings at all plants
    ranged from 657 to 889 per year, and the number of other findings ranged
    from 10 to 30 per year, with no strong trend (see fig. 3).

    Figure 3: Number of Inspection Findings at All Plants, 2001 Through 2005

    Only in the area of inspection findings for which one or more
    cross-cutting aspect was associated, is an increasing trend evident (see
    fig. 4). According to NRC, the increase in findings with cross-cutting
    aspects is due, in part, to the recent development of additional guidance
    for inspectors on the identification and documentation of cross-cutting
    aspects. The number of plants where the existence of cross-cutting aspects
    resulted in NRC's opening a substantive cross-cutting issue is shown in
    figure 5. (See app. III for additional data on plant-specific, substantive
    cross-cutting issues.)

    Figure 4: Number of Inspection Findings and Inspection Findings with
    Cross-Cutting Aspects at All Plants, 2001 Through 2005

    Note: Almost all inspection findings with cross-cutting aspects were in
    the areas of human performance and problem identification and resolution;
    only 5 out of 1,890 inspection findings were assigned to the
    safety-conscious work environment cross-cutting area.

    Figure 5: Number of Plants with Substantive Cross-Cutting Issues, 2001
    Through 2005

    Note: The totals include those plants that had one or more substantive
    cross-cutting issue open during at least some portion of the year. If a
    plant had more than one substantive cross-cutting issue open, only one was
    counted.

    In the performance indicator program, almost all of the indicator data
    were reported to be within the acceptable levels of performance (green).
    Only 156, or less than 1 percent of over 30,000 indicator reports from
    2001 to 2005, did not meet the acceptable performance threshold. (See app.
    III for additional plant-specific performance indicator data.) Four of the
    15 performance indicators have always been reported within acceptable
    performance levels. These 4 indicators include 1 that measures the amount
    of time that the residual heat removal safety system is unavailable, 1
    that monitors the integrity of a radiation barrier, 1 that measures the
    participation of emergency response organizations in emergency drills or
    exercises, and 1 that monitors radiological releases. In addition, 46
    plants have never had a performance indicator fall outside of the
    acceptable performance level, and no yellow or red indicators were
    reported during the period.

    On the basis of the greater-than-green inspection findings and performance
    indicators, NRC has subjected more than three quarters (79) of the 103
    operating plants to at least some level of increased oversight for varying
    periods. (See app. III for additional plant-specific oversight level
    data.)11 Most of these plants received the lowest level of increased
    oversight, consisting of the least intensive supplemental inspection, due
    to the identification of one or two white inspection findings or
    performance indicators. In most of these instances, the licensees did not
    accumulate additional greater-than-green findings, so oversight did not
    have to be increased to higher levels on the action matrix. For example,
    at one plant, NRC issued a white finding after a degraded valve resulted
    in the failure of a drain line from a moisture separator. After allowing
    time for the licensee to analyze the root cause, NRC completed a
    supplemental inspection to assess the licensee's evaluation and concluded
    that the licensee's actions were adequate. As a result, NRC did not
    require any further actions of the licensee, and NRC inspectors did not
    conduct further inspections beyond the baseline procedures. In some cases,
    however, either the licensee was not able to sufficiently correct the
    performance problem, thus triggering increased oversight, or additional
    greater-than-green inspection findings or performance indicators were
    identified, also triggering increased oversight. For example, a white
    finding was issued at one plant because the licensee's fire response
    procedures were not effective in ensuring a safe shutdown of the reactor
    during a postulated severe fire. Because this finding was issued during
    the same time that one of the plant's performance indicators was white,
    the plant was moved from the second to the third highest level of
    oversight and NRC conducted a second-level, more-intensive supplemental
    inspection. In this case, NRC determined that the licensee's corrective
    actions were sufficient to resolve the deficiencies related to both the
    inspection finding and performance indicator and thus reduced its
    oversight back to baseline inspections only.

    While more than three quarters of nuclear power plants received some level
    of increased oversight from 2001 through 2005, only 5 plants were placed
    into NRC's highest oversight category on the action matrix that still
    allows continued operations, and no plants were placed into NRC's

    unacceptable performance category.12 Plants subject to the highest level
    of NRC oversight generally remain in this category for longer periods of
    time than the other performance categories on the action matrix. It
    usually takes NRC longer to conduct the more intensive supplemental
    inspections and the licensees longer to implement the actions that NRC
    expects to correct the broader and more systemic performance issues that
    led to their placement in the highest oversight category. For example, one
    plant was subject to NRC's highest oversight level for approximately 2
    years because of several greater-than-green inspection findings and
    performance indicators, including a red inspection finding for the failure
    of a steam generator tube. In this case, NRC conducted its most intensive
    supplemental inspection 2 months after the final significance of the red
    inspection finding was determined. NRC inspectors found a number of
    underlying problems with the licensee's programs for design control, human
    and equipment performance, problem identification and resolution, and
    emergency preparedness. The licensee prepared a plan to address its
    performance deficiencies, as is required for all plants placed into this
    oversight category, and determined that a multiyear effort was necessary
    to adequately develop and implement all corrective actions. Once the
    corrective actions were in place, NRC inspectors conducted follow-up
    inspections to examine the adequacy of the licensee's efforts in
    implementing its corrective actions. NRC inspectors at the plants we
    reviewed explained that plants subjected to the highest oversight levels
    typically have underlying problems that can take longer periods to
    resolve. It is important for them to ensure that the corrective actions
    taken by the licensee are effective before oversight is reduced.
    Therefore, inspectors try to allow a sufficient amount of time to pass
    after the licensee has taken a corrective action, to be able to examine
    not only the corrective action itself but also whether it is working as
    intended, which requires it to have been in place for awhile.

    NRC inspectors at the plants we reviewed also said that a decline in plant
    performance is often the result of ineffective licensee 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 an association
    between plants that had been subjected to increased levels of oversight
    and the presence of substantive cross-cutting issues. For instance, all
    plants subjected to NRC's highest level of oversight also had a human
    performance and/or problem identification and resolution substantive
    cross-cutting issue open either prior to or during the time that they were
    subjected to increased oversight.

    NRC Is Addressing Weaknesses in Various Areas of Its Oversight Process,
    but More Effort Is Needed

    NRC has taken a proactive approach to constantly improving its oversight
    process over its first 6 years of implementation, but additional
    improvements are needed. NRC has several mechanisms in place to
    incorporate feedback from both external and internal stakeholders, and it
    is currently working on improving several areas of its oversight process
    by, for example, better focusing inspections on areas most important to
    safety, improving the timeliness and quality of determining the risk
    significance of its inspection findings, and modifying some of the
    performance indicators to improve their quality. NRC is also assessing
    whether it needs to modify its oversight, including developing additional
    inspection procedures, as a result of some problems that have surfaced in
    areas not fully inspected by NRC, such as the recent discovery of
    groundwater contamination from radioactive releases at a number of sites.
    In addition, NRC is working to address what we believe has been a
    significant shortcoming by making changes to its oversight process to
    improve its ability to better identify and address early indications of
    deteriorating safety at plants before performance problems develop. Some
    of its changes have been controversial, however, and NRC officials
    acknowledge the need to carefully assess the effectiveness of the changes.

    NRC Is Taking Action to Improve Various Areas of Its Oversight Process

    According to NRC, the ROP was implemented with the understanding that it
    would be an evolving process and improvements would be made as lessons
    were learned. Each year NRC conducts a self-assessment of its oversight
    process to compile feedback from various internal and external sources and
    to outline the changes it intends to make. As a part of its
    self-assessment, NRC developed numerous performance metrics for its
    various oversight components, including its inspections and performance
    indicator program, to provide quantitative insights into the timeliness,
    efficiency, and overall effectiveness of the ROP. The metrics are based on
    program data, such as the number and color of inspection findings, and
    feedback received from external and internal stakeholders. Each fall, NRC
    solicits feedback from external stakeholders through a survey published in
    the Federal Register. In 2005, NRC received 21 responses from the
    industry, industry organizations, public interest groups, state or local
    agencies, and members of the public. NRC also biannually surveys NRC
    management, program staff, and regional and site inspectors on the
    effectiveness of the ROP. In the most recent survey, which was conducted
    in 2004, NRC received responses from about 50 percent of the surveyed
    staff. In addition, NRC has 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
    holding various meetings, workshops, and conferences-to discuss the ROP.
    Through NRC's self-assessment process, its staff also incorporates
    direction provided by the NRC commissioners and recommendations from
    independent evaluations, such as from the ACRS, GAO, and the NRC Office of
    the Inspector General.

    According to NRC program officials, the changes made to the ROP since its
    inception in 2000-including those made in response to the Davis-Besse
    incident-have generally refined the existing oversight process, rather
    than significantly changing it. 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 its oversight process. Among the more significant
    ROP-related recommendations were those to (1) enhance the performance
    indicator that monitors unidentified leakage; (2) develop specific
    guidance to inspect licensee boric acid control programs and vessel head
    penetration nozzles; (3) modify the inspection program, including
    modifying an inspection procedure to better follow up on long-standing
    plant performance issues; and (4) enhance the guidance for managing plants
    that are shut down 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 NRC has recently made or is in the process of making
    include the following:

    o NRC recently revised 7 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. For example, NRC
    staff analyzed the number of findings resulting from each of its
    inspection procedures to better understand the areas where performance
    deficiencies were occurring, and compared the time that inspectors were
    spending directly observing plant activities as opposed to reviewing
    licensee paperwork to achieve a balance between the two. For this effort,
    NRC held constant the level of resources devoted to its baseline
    inspection effort and did not assess whether more or fewer inspection
    resources overall should be applied. NRC is now formalizing this analysis
    and making it a regular part of its yearly assessment so that it can
    continually refine its inspections to direct resources to the most
    critical performance areas.

    o NRC has efforts under way to improve its SDP. An audit by the NRC Office
    of the Inspector General, a review by a special task group formed by NRC,
    and feedback from other stakeholders such as NEI and UCS have pointed to
    several significant weaknesses with the SDP. Also, other internal and
    external stakeholders, including NRC inspectors and plant managers, have
    raised concerns about the amount of time, level of effort, and knowledge
    and resources required to determine the risk significance of some
    inspection 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 that the risk level issued for the
    finding is appropriate. This can add significant time to the process
    because licensees may use their own technical tools, including models,
    data, and assumptions, to analyze the issue. NRC then considers this
    information in its own analysis. At the plants we reviewed, the time it
    took NRC to determine the final significance of risk-significant
    inspection findings ranged from 24 days to over 200 days. The delay in
    assigning a color to a finding while the new information is being
    considered could 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 program officials said that even
    though there may be a delay in determining the final risk significance of
    the finding, the licensee takes immediate action to fix the identified
    problem. However, supplemental inspections are designed to uncover
    additional associated problems, if they exist, and delaying these
    inspections could delay NRC's ability to discover additional performance
    problems, potentially allowing performance to worsen.

    NRC developed a plan in 2002 to improve the timeliness of its
    decision-making process, enhance the quality of its various SDP tools, and
    track its progress in implementing key changes. For example, NRC
    introduced a new process aimed at improving timeliness by engaging
    decision makers earlier to more quickly identify the scope of the
    evaluation to be used to determine the inspection finding's risk
    significance, the resources needed, and the schedule to complete the
    evaluation.

    As a part of the SDP, NRC uses probabilistic risk assessment (PRA)
    methods, which overall has improved its ability to assess the performance
    and safety of nuclear power plants. PRA is an analytical tool for
    estimating the probability that a potential accident might occur by
    examining how physical structures, systems, and components, along with
    employees, work together to ensure plant safety. Using PRA tools, NRC and
    the plant licensees can estimate the likelihood that different accident
    scenarios at plants will result in reactor core damage and a release of
    radioactive materials. NRC often uses PRA tools to help it determine the
    risk significance of its inspection findings. However, we and others have
    found weaknesses with NRC's use of PRA.13 For instance, in our May 2004
    report on the Davis-Besse reactor vessel head incident, we found that NRC
    used some incomplete and faulty PRA analyses in deciding whether to allow
    the licensee to delay shutdown of the reactor for inspection.14 While NRC
    program officials acknowledge they can improve their current PRA tools,
    they said the tools are adequate for factoring risk into the oversight
    process and do achieve their intended purpose. NRC has several initiatives
    under way to improve its use of PRA in its decision making, many of which
    it plans to complete by June 2007. For example, NRC recently revised its
    models to assess events that occur at plants during at-power situations to
    better capture individual plant characteristics, and it is in the process
    of developing new models to assess events that occur at plants during
    low-power or shutdown conditions. NRC is also developing guidance to
    address broader PRA issues, including establishing overall quality
    requirements for risk information; providing specific instructions for
    documenting the decision process and conclusions; and developing improved
    methods for calculating risk, such as its practices for implementing human
    reliability analysis.

    o NRC is working with the nuclear power industry to improve several of its
    performance indicators, including making the definitions of some
    indicators more concise to improve their quality and to reduce the number
    of discrepancies between licensees and NRC inspectors. Because NRC
    inspectors verify indicator data only once a year, a potential
    disagreement with a licensee over these data might not surface for up to 1
    year after it is reported, and it may take even longer to resolve the
    disagreement. Similar to delays with the SDP, a delay in assigning a color
    while the disagreement is being 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. To date, NRC's
    efforts to improve the performance indicator program have largely centered
    on developing a key indicator to address known problems with the
    indicators that measure the unavailability of safety systems. NRC has been
    working jointly with the nuclear industry since 2001 to develop the
    indicator, which is now risk-informed and intended to provide a more
    accurate indication of the risks associated with changes in the
    availability and unreliability of important safety systems. This
    indicator, referred to as the mitigating systems performance index, was
    implemented in April 2006, and the first plant reports were submitted in
    July 2006. NRC is also in the process of changing the definition for
    several other indicators, in addition to considering the feasibility of
    new indicators.

    In addition, NRC program officials said they are taking a broad look at
    the performance indicator program to assess how they might increase its
    overall value to the ROP. The effort is intended, in part, to address
    concerns that performance indicators have not contributed to the early
    identification of poorly performing plants to the degree originally
    envisioned, since all of the indicators are almost always within
    acceptable performance levels (green). When the program was developed,
    thresholds were set using industry performance data such that about 5
    percent of the plants were expected to exceed the green-white
    threshold-that is, be designated either white, yellow, or red-for each of
    the performance indicators. However, from 2000 through 2005, less than 1
    percent exceeded it. Furthermore, there have been several cases where
    plants reported an acceptable performance indicator and performance
    problems in the area were subsequently identified. For example, NRC
    inspectors at one plant noted that while performance indicator data
    related to its alert and notification system for emergency preparedness
    had always been reported green, the system did not always function
    properly. On the other hand, industry officials believe that the high
    percentage of green indicators 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 that
    they will often take action to address performance issues well before the
    indicator crosses the acceptable threshold. To assess issues within the
    performance indicator program, NRC developed a standing working group,
    with representatives from both the industry and NRC, that meets on a
    monthly basis. This group, along with senior NRC and industry management,
    plans to explore overall program improvements to better identify declining
    plant performance.

    In addition to the previously mentioned efforts, NRC is assessing whether
    it needs to modify its oversight, including developing additional
    inspection procedures, as a result of some problems that have surfaced in
    areas not fully inspected by NRC. For example, NRC has reported that there
    have been inadvertent, unmonitored releases of radioactive liquids
    containing tritium at a number of nuclear power sites in the past few
    years.15 To date, NRC reports show that the measured levels of tritium
    discovered were low enough that they do not appear to pose a public health
    hazard. According to NRC, the releases were due to equipment failures or
    structural degradation at the plants. At one of the plants we reviewed,
    for example, elevated levels of tritium in the on-site groundwater were
    discovered during the licensee's testing of its monitoring wells. NRC
    reports suggest that this radioactive release was most likely due to
    leakage from the spent fuel pool's support structures. Shortly after the
    licensee reported the contamination, NRC initiated a special inspection to
    further investigate the source and cause of the leakage and the licensee's
    actions for mitigation. On the basis of this and other discoveries of
    contaminated groundwater, in March 2006, NRC formed a lessons-learned task
    force to evaluate NRC's regulatory processes related to the radioactive
    releases and to recommend areas for improvement. For example, NRC is
    reviewing related regulations and guidance, inspection program
    requirements, and its communications with external stakeholders and the
    public. In addition, the nuclear industry recently undertook an initiative
    to improve its groundwater protection, and intends to develop
    site-specific action plans at all plants and improve the industry's data
    collection, reporting, and protocols for sharing lessons learned.

    NRC is also taking action to improve its requirements for licensees to
    control and account for their spent nuclear fuel, that is, the used fuel
    periodically removed from reactors in nuclear power plants. NRC requires
    licensees to control and account for all of their spent fuel materials
    because of the hazardous nature of spent nuclear fuel.16 However, reviews
    by both GAO and the NRC Office of the Inspector General found weaknesses
    with NRC's oversight of licensees' spent fuel control and tracking
    programs.17 Between 2000 and 2004, several plants experienced instances of
    missing or unaccounted-for spent fuel, and NRC reported weaknesses in the
    material control and accounting programs at various other plants. In
    investigating these issues, we and the NRC Office of the Inspector General
    determined that NRC's inspections did not adequately ensure that all
    licensees properly controlled and accounted for their spent nuclear fuel.
    From the late-1980s through implementation of the ROP, NRC did not conduct
    routine material control and accounting inspections; instead it looked at
    these activities indirectly through other inspections, such as those of
    licensee operations during refueling of the reactor. We also found that
    while NRC requires plants to maintain an accurate record of all their
    spent fuel and its location, NRC regulations did not specify how licensees
    are to conduct physical inventories or how they are to control and account
    for loose spent fuel rods and fragments. NRC is currently in the process
    of revising several of its guidance documents and developing inspection
    procedures to better assess the effectiveness of licensee material control
    and accounting programs. NRC reports that most of these efforts will be
    completed by the end of 2007.

    NRC Is Taking Its First Major Step to Address a Significant ROP Weakness
    in the Area of Safety Culture

    One significant shortcoming in the ROP that we and others have found is
    that it has not been as effective as it could be in identifying and
    addressing early indications of deteriorating safety performance at
    nuclear power plants before problems develop. NRC and others have long
    recognized that a safety culture-the organizational characteristics that
    ensure that issues affecting nuclear plant safety receive the attention
    their significance warrants-can have a significant impact on a plant's
    safety performance. The identification of a weak safety culture-or
    weaknesses in the attributes that make up a safety culture, such as
    attention to detail, adherence to procedures, and effective corrective and
    preventative actions-can point to early signs of deteriorating safety
    performance before conditions become so serious that a safety accident
    occurs. As early as 1989, NRC recognized the importance of developing a
    safety culture at each nuclear power plant that ensures safe plant
    operations, but NRC's policy stated that it was the licensee's duty and
    obligation to monitor and maintain a strong safety culture.

    Despite the recognition of the importance of a safety culture and several
    external groups' recommendations to better incorporate safety culture
    aspects into NRC's oversight process, NRC did not include specific
    measures to comprehensively assess plant safety culture when it
    implemented the ROP in 2000. As its new oversight process was being
    developed, external stakeholders, including the ACRS, concluded that
    additional oversight measures were needed to characterize licensees' human
    performance and safety culture. The 2002 Davis-Besse reactor vessel head
    incident highlighted that this was a significant weakness in the ROP. Our
    May 2004 report concluded that the event occurred, in part, because NRC
    did not have an effective means to identify and address early indications
    of deteriorating safety at plants before performance problems develop.

    NRC did not take immediate action, however, contending that direct safety
    culture evaluations would cross the line from a regulatory function to a
    licensee management function. In August 2004, the NRC Commission directed
    the staff to improve the ROP by more fully addressing safety culture. In
    response, NRC staff formed a safety culture working group in early 2005 to
    lead the agency's efforts to make changes to the ROP to better incorporate
    safety culture into its oversight process. As a part of this initiative,
    the working group obtained the input of external stakeholders through a
    series of public meetings held in late 2005 and early 2006. The group also
    incorporated lessons learned from events that occurred at the Salem and
    Hope Creek site during this same period. In 2004, NRC confirmed there were
    problems with aspects of the site's safety culture. In addressing the
    problem, NRC concluded that the ROP did not provide adequate tools to
    monitor the situation or the sufficiency of the licensee's corrective
    actions. As a result, NRC deviated from the ROP to increase its oversight
    at the site, which included conducting special inspections and forming a
    team with expertise in the area to review the licensee's corrective
    actions. (See app. I for additional information on the events at Salem and
    Hope Creek.)

    In February 2006, NRC issued proposed changes to some of its inspection
    procedures and guidance documents to incorporate safety culture into the
    ROP, and implemented the changes in July 2006. NRC used the following two
    overall approaches: first, it developed additional guidance for
    identifying and addressing cross-cutting aspects, and, second, it
    developed a structured way to determine the need to evaluate plants'
    safety culture. Several inspection procedures were also modified to direct
    inspectors to be sensitive to and take into consideration safety culture
    components when planning and conducting their inspections. Although the
    three cross-cutting aspects (problem identification and resolution, human
    performance, and a safety conscious work environment) did not change, NRC
    developed new definitions for them to more fully encompass safety culture
    aspects. Also, NRC developed additional guidance on the treatment of
    cross-cutting aspects once they have been identified. For example, the
    problem identification and resolution cross-cutting area now has several
    components-a corrective action program, operating experience, and self and
    independent assessments. The human performance cross-cutting area is
    composed of decision making, resources, work control, and work practices.
    NRC inspectors are required 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. While the process for assessing
    inspection findings for the existence of cross-cutting aspects and
    substantive cross-cutting issues remains largely unchanged, now the
    definitions for the cross-cutting areas are more detailed and track more
    closely with those elements that comprise safety culture.18 In addition,
    under NRC's new guidance, if the same substantive cross-cutting issue is
    identified in three consecutive assessment periods, NRC may request that
    the licensee evaluate its safety culture. The intent is to provide an
    opportunity to diagnose a potentially declining safety culture before
    significant safety performance problems occur. NRC program officials said
    they consider the identification and treatment of substantive
    cross-cutting issues the most proactive element of the ROP, because all
    other oversight actions are taken only when more significant performance
    problems have been identified.

    NRC's changes to the ROP now also include a structured way for NRC to
    determine the need for a safety culture evaluation. NRC's new guidance
    calls for the licensees of plants with more than one white finding in the
    same cornerstone or one yellow finding to evaluate whether the performance
    issues were caused by any safety culture components, and NRC may request
    the licensee to independently evaluate its safety culture, if the licensee
    does not identify a safety culture component. Any safety culture
    deficiencies are expected to be entered into the licensee's corrective
    action program. Regional officials would discuss the licensee's proposed
    corrective actions with the licensee, and NRC may hold a public meeting to
    discuss the issues. For plants where more significant or multiple findings
    have been identified, NRC will not only independently assess the adequacy
    of the licensee's independent evaluation of safety culture, but may also
    conduct its own evaluation. Following the completion of any evaluations,
    regional and headquarters officials together determine whether additional
    agency actions are warranted, and, at a minimum, the licensee will be
    required to document its plan to make improvements and a public meeting
    will be held to discuss the licensee's performance. According to an NRC
    official familiar with the Salem and Hope Creek situation, had these
    requirements been in place at the time, they would have been adequate to
    address the concerns at Salem and Hope Creek without the need to deviate
    from the ROP.

    NRC's approach to incorporating safety culture into the ROP has been
    controversial, and some stakeholders disagree with certain changes. For
    example, some in the nuclear power industry have 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 aspect is associated with
    a finding, or what it will take to clear themselves once they have been
    identified as having a substantive cross-cutting issue. Some industry
    officials worry that the changes will further increase the number of
    findings that have cross-cutting aspects associated with them, and, if all
    of the findings have these aspects, whether the process will lose its
    value. Industry officials also warn that if the changes are not
    implemented carefully, resources could be diverted away from other
    important safety issues. Other external stakeholders, such as an official
    from UCS, on the other hand, suggest that this effort is an important step
    toward improving NRC's ability to identify performance issues at plants
    before they result in safety problems. Importantly, there are now
    additional tools in place for NRC to use when it identifies potential
    safety culture concerns. In reviewing NRC's proposed approach in April
    2006, the ACRS concluded that the approach was appropriate and will
    enhance the agency's ability to address safety culture issues; although
    after gaining some experience with the process, it stated that NRC should
    reassess the adequacy of some procedures.

    NRC program officials acknowledged that they will need to assess the
    changes they made to the ROP to determine if they better allow inspectors
    to detect deteriorating safety conditions at plants before significant
    safety events occur. Some at NRC view these changes as the beginning step
    toward an incremental approach. For its current efforts, NRC also
    acknowledged that additional training for its inspectors on safety culture
    is needed. NRC provided computer-based and regional training to its
    inspectors as the changes were being finalized, and it is currently
    working to incorporate aspects of its safety culture changes into its more
    permanent training programs. NRC plans to evaluate stakeholder
    feedback-both through its normal processes, such as its monthly meetings,
    and potentially through specific industry-sponsored workshops dedicated to
    the issue-and make additional changes on the basis of the lessons learned
    as part of its annual self-assessment process for 2007.

    Conclusions

    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. NRC's oversight process is finding
    safety problems and is getting the industry to constantly improve.
    However, weaknesses with its inspection and performance indicator programs
    have been identified-in particular, the timeliness of the process used to
    determine the risk significance of inspection findings, and the ability of
    performance indicators to contribute to the early identification of poorly
    performing plants. Importantly, NRC is demonstrating that it is aware of
    these weaknesses and is actively making changes to improve its oversight.
    NRC's proactive approach is demonstrated by the important progress it is
    making in several key areas, including making efforts to improve the
    timeliness and quality of its significance determination process,
    redefining some of its performance indicators, and assessing the need for
    additional inspection procedures based on careful analysis. Its efforts to
    continuously consider the need to improve and obtain feedback from both
    internal and external stakeholders are critical as nuclear power plants
    age and the nation considers building new plants. In this regard, it is
    also important that the ROP continue to be a very open process in which
    NRC provides the public and its other stakeholders with considerable
    information on its oversight activities and findings related to plant
    safety performance.

    Although NRC has been working to improve its oversight in several key
    areas, its efforts to incorporate safety culture into the ROP may be its
    most critical future change. More than 4 years have passed since
    Davis-Besse highlighted that a significant weakness in NRC's oversight was
    its inability to identify deteriorating safety conditions at plants before
    they resulted in performance problems. NRC has been reluctant to regulate
    in the area of safety culture because it did not want to be directly
    involved in managing the licensees' plants. However, NRC is now taking
    concrete actions to begin incorporating safety culture into the ROP,
    although it acknowledges that regulating the often complex and intangible
    aspects of safety culture is challenging, and that its recent changes are
    simply a first step. As a result, it will be important to closely monitor
    this effort to ensure that it is achieving the goal of objectively
    assessing safety culture, while providing an early indication of declining
    safety performance. An additional challenge for NRC will be how to provide
    information to the public and other stakeholders on this important but
    complex area of plant performance. Given that it may take some time for
    NRC to develop performance metrics for safety culture, data on substantive
    cross-cutting issues, which provide insight into aspects of plants' safety
    culture, could be useful to the public and other stakeholders as they look
    for assurances that plants are operated safely. Summary-level information
    on plants with substantive cross-cutting issues is not currently available
    to the public through NRC's Web site.

    Recommendations for Executive Action

    Given its importance to improving NRC's ability to identify declining
    safety performance at nuclear power plants before significant safety
    problems develop, we recommend that the NRC commissioners take the
    following two actions:

    o Aggressively monitor; evaluate; and, if needed, implement additional
    methods or processes to increase the effectiveness of its efforts under
    the ROP to assess safety culture at plants.

    o In addition to periodically evaluating the effectiveness of its safety
    culture efforts, NRC may also be able, through its performance indicator
    program, to develop specific indicators to measure important aspects of
    plants' safety culture. Trends in these performance indicators could be
    useful feedback to NRC on its safety culture activities. The indicators
    could also provide useful information to the public and other NRC
    stakeholders on the safety culture at plants.

    In addition, in the absence of performance indicators or other performance
    metrics for plants' safety culture, we recommend that the NRC
    commissioners make publicly available, through the ROP Web site,
    consolidated and comprehensive data on the plants that have substantive
    cross-cutting issues open. These data would provide a more comprehensive
    picture of plant performance and provide insights into aspects of the
    plants' safety culture that otherwise are not readily available on the Web
    site.

    Agency Comments

    We provided a draft of this report to NRC for its review and comment. In a
    letter from NRC's Executive Director for Operations, NRC generally agreed
    with the report's findings, conclusions, and recommendations (see app.
    IV). NRC also commented that the report is comprehensive, fair, and
    balanced. In addition, NRC provided minor, technical comments, which we
    have incorporated into the report, as appropriate.

    We are also sending copies of this report to interested congressional
    committees, the Chairman of NRC, and other interested parties. We also
    will make copies available to others upon request. In addition, the report
    will be available at no charge on the GAO Web site at http://www.gao.gov .

    If you or your staffs have any questions about this report, please contact
    me at (202) 512-3841 or wellsj@gao.gov . Contact points for our Offices of
    Congressional Relations and Public Affairs may be found on the last page
    of this report. GAO staff who made major contributions to this report are
    listed in appendix V.

    Jim Wells Director, Natural Resources and Environment

    List of Requesters

    The Honorable James M. Inhofe Chairman Committee on Environment and Public
    Works United States Senate

    The Honorable George V. Voinovich Chairman Subcommittee on Clean Air,
    Climate Change,   and Nuclear Safety Committee on Environment and Public
    Works United States Senate

    The Honorable Ed Whitfield Chairman Subcommittee on Oversight and
    Investigations Committee on Energy and Commerce House of Representatives

    The Honorable Joseph R. Biden, Jr. United States Senate

    The Honorable Tom Carper United States Senate

    The Honorable Michael N. Castle House of Representatives

    The Honorable Edward J. Markey House of Representatives

    Appendix I

    Key Safety-Related Events at the Salem and Hope Creek Nuclear Power Plants
    from 2000 to 2006

    This appendix summarizes key safety-related events at the Salem and Hope
    Creek nuclear power plants and the Nuclear Regulatory Commission's (NRC)
    and licensee's actions to follow up on and correct them. This information
    is presented to enhance the public's understanding of the events and
    timing of NRC's actions. We did not conduct an independent audit or
    assessment of the events, other than to help illustrate how NRC is using
    its oversight process to ensure plant safety.

    The Salem and Hope Creek plants are located at one site in Hancocks
    Bridge, New Jersey, 18 miles southeast of Wilmington, Delaware, on the
    Delaware River. The two Salem plants (Salem 1 and Salem 2) consist of two
    pressurized water reactors, and the Hope Creek plant is a boiling water
    reactor. The three plants produce a combined 3,237 megawatts of
    electricity. Salem 1 began operating in the late-1970s and Salem 2 and
    Hope Creek began operating in the 1980s. PSEG Nuclear LLC is licensed to
    operate all three plants, with their current licenses expiring roughly 40
    years after the start of their operations. In January 2005, PSEG entered
    into a nuclear operating services contract with Exelon, the first step of
    a planned merger between the two companies. Under the terms of this
    contract, Exelon manages operations at Salem and Hope Creek.

    From 2000 through 2006, there were several safety-related events at the
    site that affected the plants' performance. As a result, NRC increased its
    oversight to include supplemental and special inspections, and required
    the licensee to take specific actions to address its performance issues.
    NRC also deviated from its normal oversight process from August 2004
    through 2006 to increase its oversight and address problems with the
    licensee's ability to provide an adequate safety-conscious work
    environment (SCWE). A SCWE is defined by NRC as an environment in which
    employees feel free to raise safety concerns, both to their management and
    to NRC, without fear of retaliation. During this period, NRC and the
    licensee held several public meetings to discuss performance issues
    related to the site's safety work environment, or the SCWE, and the
    actions the licensee was taking to improve it.

    The following summary provides details on the key safety-related events at
    Salem and Hope Creek, along with NRC's and the licensee's responses to the
    events, from the initial implementation of NRC's reactor oversight process
    in April 2000 to June 2006.

    Summary of Key Safety-Related Events at Salem and Hope Creek, April 2000
    to June 2006

    White Performance Indicator for Unplanned Scrams

    During the fourth quarter of 2000, Salem 1 reported a white color for the
    unplanned scrams performance indicator, an indicator that monitors the
    number of unplanned scrams-reactor shutdowns-that occurred during the
    previous four quarters. During 2000, Salem 1 had four scrams, which is one
    more than the acceptable performance level. NRC conducted a supplemental
    inspection in March 2001 to follow up on why such a high number of scrams
    occurred and on the corrective actions the licensee was taking to address
    the problem. In conducting its inspection, NRC determined that the
    licensee had performed a comprehensive common cause analysis of the
    associated performance deficiencies, which identified human performance,
    equipment failure, and procedure and preventive maintenance program issues
    as root causes of the performance problems. The licensee documented these
    issues in its corrective action program and developed a plan to outline
    the actions it would take to address them. NRC concluded this effort was
    sufficient and did not require the licensee to take any additional
    corrective actions beyond what it had outlined in its plan.

    White Performance Indicator for Unplanned Changes in Reactor Power

    During the first quarter of 2002, Salem 1 reported a white color for the
    performance indicator that monitors unplanned changes in reactor power
    that could have challenged safety functions during the previous four
    quarters. Salem reported a total of seven power changes, which exceeded
    the acceptable performance threshold by one. NRC conducted a supplemental
    inspection in October 2002 and concluded that the licensee's
    implementation of several programs to address the underlying causes of the
    unplanned power changes, such as the replacement of certain pieces of
    equipment, sufficiently addressed the performance problem. NRC did not
    require the licensee to take any additional corrective actions.

    Substantive Cross-Cutting Issue in Problem Identification and Resolution

    In March 2003, NRC opened a substantive cross-cutting issue in the problem
    identification and resolution area at all three plants on the basis of the
    identification of a number of green inspection findings that documented
    ineffective problem evaluations and untimely, ineffective corrective
    actions by plant employees, including recurring equipment failures. Upon
    opening this substantive cross-cutting issue, NRC stated that it would
    closely monitor the licensee's performance in this area. This substantive
    cross-cutting issue remained open until March 2006, when NRC concluded
    that the licensee's efforts to improve its ability to identify and resolve
    performance problems were sufficient.

    White Inspection Finding for Failure of a Part on an Emergency Diesel
    Generator

    In May 2003, NRC determined that the failure of a part on an emergency
    diesel generator at the Salem 1 plant that occurred in September 2002
    would result in a white inspection finding. NRC conducted a supplemental
    inspection in October 2003 and concluded that although the licensee had
    adequately fixed the emergency diesel generator, it would need to take
    additional action to address broader performance problems. Specifically,
    NRC had concerns with the licensee's ability to ensure that the controls
    and procedural requirements determined to be necessary on the basis of
    evaluations of equipment failures, were reliably tracked and implemented.
    The licensee implemented procedural changes to more effectively track its
    corrective actions to prevent recurrence. NRC conducted a second,
    follow-up supplemental inspection in September 2004 and, on the basis of
    this inspection, concluded that the licensee's corrective actions were
    sufficient.

    White Inspection Finding for the Failure of a Rotating Screen That Is Part
    of the Station Service Water System at Hope Creek

    In May 2004, NRC determined that the failure in July 2003 of a rotating
    screen that is part of the station service water system at Hope Creek
    would result in a white inspection finding. NRC determined that the
    failure resulted from the licensee's inadequate maintenance procedures and
    its failure to adhere to procedural instructions. In September 2004, NRC
    conducted a supplemental inspection to follow up on the corrective actions
    that licensee had taken. It determined that the licensee's corrective
    actions, which included revising relevant maintenance procedures, were
    sufficient and did not require additional actions from the licensee.

    White Inspection Finding for the Failure of a Drain Line in the Moisture
    Separator System at Hope Creek

    In February 2005, NRC determined that the licensee's failure to properly
    evaluate and correct a degraded valve, which resulted in the failure of a
    drain system at Hope Creek in October 2004, would result in a white
    inspection finding. NRC conducted a supplemental inspection in June 2005
    to follow up on the licensee's corrective actions, which included the
    development of new guidance; revisions to relevant plant operating
    procedures; inspections of pipe hangers, one of which was determined to be
    the initiator of the degraded valve; and the development of a new
    procedure for additional monitoring of degraded equipment. NRC determined
    that these actions were sufficient and did not require additional actions
    from the licensee.

    Increased Oversight to Address Safety-Conscious Work Environment Problems

    In late 2003, NRC initiated a special review of the site's SCWE on the
    basis of allegations concerning its SCWE, plant events and inspection
    findings that indicated problems with its SCWE, insights from NRC
    interactions with the licensee, observations made by NRC inspectors, and
    the presence of a substantive cross-cutting issue in problem
    identification and resolution. NRC's special review consisted of (1)
    in-depth interviews by NRC experts of more than 60 current and former
    plant employees, (2) an analysis of the site's inspection and assessment
    record over the previous several years, and (3) information from plant
    employees' allegations related to the SCWE. NRC provided the interim
    results of its review to the licensee in January 2004. Although NRC did
    not identify any serious safety violations, the information led to
    concerns about the site's SCWE, particularly as it related to the handling
    of emergent equipment issues and associated operational decision making.
    The review accumulated information about a number of events that, to
    varying degrees, called into question the openness of management to
    concerns and alternative views, strength of communications, and
    effectiveness of the licensee's corrective action and feedback processes.
    There were several differences of opinion among operators and senior
    managers on plant operating decisions, particularly as they might impact
    continuing plant operation and outage schedules. On the basis of these
    interim results, NRC requested that the licensee conduct an in-depth
    assessment of its SCWE.

    NRC issued the final results of its special review in July 2004,
    confirming many of the concerns it identified through its interim review.
    In its final results, NRC concluded that there were weaknesses in the
    licensee's leadership and management approaches, leading to a perception
    among some staff and mangers that the company emphasized production over
    safety. NRC also determined that licensee management was not consistent in
    its support of staff identifying concerns and providing alternate views,
    and cited examples of unresolved conflicts and poor communication between
    management and staff.

    In May 2004, the licensee submitted an independent assessment of its SCWE.
    The assessment included interviews of employees, and reviews of the
    licensee's inspection record and employee concerns program, among other
    things. Among the findings of the assessment were that (1) some plant
    employees were hesitant to raise issues; (2) management was not receptive
    to or effective at addressing some employee concerns, such as those
    surrounding long-standing equipment problems; (3) a significant number of
    employees did not view the employee concerns program as a viable means to
    raise concerns; and (4) management was not effective at understanding or
    addressing the potential for a "chilling" effect--that is, an environment
    that discourages workers from raising safety concerns--in response to
    highly visible employee concerns and actions associated with operational
    events.

    As a result of the assessment, the licensee submitted to NRC in June 2004
    an action plan to improve its overall safety work environment. The plan
    addressed the licensee's corrective action program, work management
    program, and safety-conscious work environment. For example, to improve
    the licensee's corrective action program, the plan identified actions to
    improve monitoring, such as developing and implementing an integrated
    corrective action training program and developing performance indicators.
    The plan also included a number of actions to improve the licensee's
    management alignment, prioritization, support for and awareness of the
    workweek schedule, and communication and training strategies to support
    work management improvements. In addition, the plan included actions to
    improve the willingness of plant employees to raise concerns, improve the
    effectiveness of policies and procedures for resolution of issues, enhance
    key elements of the employee concerns program, and improve management
    effectiveness in detecting and preventing retaliation or a chilled
    environment. The licensee's action plan included 17 metrics designed to
    measure safety work environment improvements. The licensee provided the
    results of these metrics to NRC on a quarterly basis.

    In August 2004, NRC regional officials received approval from headquarters
    to deviate from the normal oversight process to increase oversight at the
    site to monitor the licensee's actions to improve its safety work
    environment. NRC's increased oversight consisted of (1) reviewing the
    results of the specific actions the licensee took as a part of its action
    plan, (2) creating an NRC team with expertise in the area to assist with
    coordinating and focusing these review efforts, and (3) conducting
    additional special inspections and enhancing existing inspections by
    adjusting their focus and scope. NRC determined that it could reduce its
    oversight to baseline levels once the licensee completed a self-assessment
    of its SCWE that concluded that it had made substantial, sustainable
    progress, and NRC confirmed the licensee's conclusion.

    NRC also opened a substantive cross-cutting issue in the SCWE area at all
    three plants in August 2004, on the basis of the results of its special
    review of the site's SCWE completed that July. Upon opening this
    substantive cross-cutting issue, NRC requested that the licensee discuss
    its progress in improving its SCWE and the effectiveness of its corrective
    action program in a public meeting planned for late 2004. This substantive
    cross-cutting issue remained open in the 2005 annual assessment letter,
    issued in March 2006. NRC will consider closing this substantive
    cross-cutting issue after the licensee provides the results of an
    assessment that concludes that it has made substantial, sustainable
    progress, and NRC has completed a review that confirms these results.

    In June 2005, NRC issued the results of an inspection of the licensee's
    employee concerns program (ECP) conducted as a part of its increased
    oversight to monitor the site's safety work environment. NRC inspectors
    did not identify any findings of safety significance and concluded that
    the ECP provided a framework for investigating concerns, maintaining the
    confidentiality of personnel who use the program, and protecting employees
    who use the program against retaliation. They also concluded, however,
    that it was too early to fully assess the effectiveness of recent program
    improvements and initiatives. The inspectors observed that a statistically
    significant portion of the personnel interviewed indicated that they would
    not use the ECP due to a perception that the process did not take adequate
    measures to protect users' confidentiality. NRC inspectors cited a section
    of the ECP that appeared to affirm this perception. The licensee
    emphasized that it was making efforts to protect confidentiality, and
    acknowledged that the ECP should reflect these efforts.

    NRC also provided the preliminary results of its review of the licensee's
    executive review board (ERB) process in June 2005. The ERB was established
    to improve the site's safety work environment and management's
    effectiveness in detecting and preventing retaliation and a chilled work
    environment. NRC inspectors determined that lapses in the licensee's use
    of the ERB process constituted a green inspection finding, although it did
    not represent a violation of regulatory requirements. NRC requested that
    the licensee reassess the review of the ERB in the broader context of the
    work environment, identify additional actions planned or taken to address
    negative worker perceptions, and provide a written response to NRC within
    30 days. The licensee responded with planned corrective actions, including
    developing and implementing continuing training on the SCWE, and
    developing and implementing a plan to improve its corrective action
    program.

    In July 2005, NRC headquarters extended regional officials' permission to
    deviate from the normal oversight process and provide increased oversight
    at Salem and Hope Creek. The extension was necessary because the licensee
    had not yet met the criteria to move back to normal, or baseline levels of
    oversight. Increased oversight included (1) continued management meetings
    and site visits to review the implementation of the licensee's corrective
    actions; (2) increased efforts, including using more inspectors and
    samples than what would typically be used, to conduct a baseline
    inspection of the site's effectiveness at identifying and resolving
    problems; and (3) an additional inspection to monitor the licensee's
    progress in resolving the substantive cross-cutting issue in the SCWE.

    In November 2005, NRC issued the results of the special inspection on the
    site's SCWE. The inspection included assessing the licensee's progress and
    plans for making improvements to its SCWE, its metrics to monitor the
    effectiveness of the improvements made, and effectiveness of the
    licensee's corrective actions and self assessment initiatives. NRC
    inspectors did not identify any findings of safety significance and
    determined that the licensee had made progress in improving its SCWE. For
    example, NRC inspectors concluded that workers' willingness to raise
    safety concerns had increased. In addition, the licensee had taken a
    significant number of actions to improve the corrective action and work
    management programs and had implemented several corrective actions for the
    employee concerns program. They also concluded that the licensee had made
    progress in preventing and detecting retaliation. However, NRC inspectors
    also observed that some issues required additional action and focused
    attention, such as the need for the licensee to fully evaluate and address
    negative perceptions about its work environment in certain work groups.
    The licensee initiated actions to address these observations.

    In May 2006, the licensee submitted to NRC an independent peer assessment
    that concluded that it had made substantial improvements to its SCWE, and
    a solid foundation existed to sustain them. The assessment included
    interviews with site personnel; observations of station activities and
    meetings; and reviews of the licensee's programs, procedures, policies,
    and other relevant information. Among the assessment's conclusions were
    that personnel throughout the organization exhibited a willingness to
    engage in open-and-candid discussions and raise safety and quality issues,
    the corrective action and work management programs had improved,
    management had been effective at detecting and preventing retaliation and
    addressing chilling effects in response to the raising of safety concerns,
    and management provided high-visibility and strong and continuous
    reinforcement of good work environment principles. In response, NRC began
    a review of the effectiveness of the licensee's actions to improve its
    safety work environment. The results of this review will be a key input
    into NRC's midcycle assessment of the site's overall safety performance to
    be completed in August 2006; through the midcycle assessment NRC will
    determine any changes in the level of oversight for Salem and Hope Creek.

    Appendix II

    Scope and Methodology

    To examine how NRC oversees plants, we reviewed the various tools and
    processes that comprise the Reactor Oversight Process (ROP). In this
    regard, we analyzed NRC's documentation of its oversight process,
    conducted interviews with NRC program staff and other officials, visited
    one NRC regional office, and visited one nuclear power plant site that was
    of specific interest to our requesters. In particular, we reviewed NRC's
    policies, inspection manuals, and other guidance documents outlining its
    various oversight process components-including reports discussing the ROP
    design basis; inspection and reporting requirements; performance indicator
    program guidance; and other requirements, such as those related to its
    enforcement and assessment processes. We interviewed NRC headquarters and
    regional officials and regional and on-site inspectors responsible for
    implementation of the ROP and visited the Salem and Hope Creek nuclear
    power plants to observe firsthand how the ROP is implemented by the
    resident inspectors located at each power plant. To learn more about how
    ROP results are communicated to the public, we attended the annual public
    meeting held at the Indian Point nuclear power plant. We also reviewed the
    information NRC makes available to the public on a Web site devoted to ROP
    topics, which includes both detailed plant-specific information and
    general program information and guidance. In addition, we interviewed
    external stakeholder individuals and groups about their experiences with
    the ROP, including the NRC Commission Chairman from 1995 to 1999, who is
    largely credited with leading the development of the ROP; officials from
    the NRC Office of the Inspector General, the Nuclear Energy Institute
    (NEI), the Union of Concerned Scientists (UCS), and Greenpeace; and
    nuclear power plant managers at six sites.

    To examine the results of the ROP over the past several years, we reviewed
    the number and types of inspection findings NRC issued, the performance
    indicators reported by the plants, and the level of oversight NRC provided
    to the plants. Specifically, we obtained and analyzed NRC data on its
    inspection findings for 2001 through 2005, the years since implementation
    of the ROP for which the data were available for the full year, and
    discussed our analysis with NRC program officials. We obtained inspection
    findings data from the NRC Reactor Program System (RPS) database and
    assessed the reliability of the RPS data by (1) performing electronic and
    manual testing of required data elements; (2) reviewing existing
    information about the data and the system that produced them; (3)
    reviewing an audit of the RPS database performed by the NRC Office of the
    Inspector General in 2005, and documents related to NRC's implementation
    of the audit's recommendations; and (4) interviewing agency officials
    knowledgeable about these data. We determined that these data were
    sufficiently reliable for the purposes of this report. Data elements
    included a breakout of inspection findings identified at each nuclear
    power plant, including information on their risk significance, or color;
    cornerstone; date; cross-cutting aspects; a brief description of the
    problem identified; and other related information. We also obtained and
    analyzed ROP data provided on NRC's Web site, including a list of
    performance indicator data broken out by plant and by quarter and a list
    of the plants in each column of the action matrix by quarter since
    inception of the ROP in 2000. We assessed the reliability of these data by
    interviewing the appropriate agency officials about how these data are
    reported on the Web site and compared the data with source information
    contained in inspection reports and assessment letters for sample plants.
    We determined that these data were sufficiently reliable for the purposes
    of this report. In addition, we reviewed every assessment letter issued to
    each of the 103 plants since the inception of the ROP to document the
    plants that had one or more substantive cross-cutting issue open and the
    length of time that the issue was held open. We discussed the results of
    our data analysis with NRC headquarters program officials and compared the
    results of the ROP with other industry-collected and reported performance
    data, including data collected through NRC's industry trends program, to
    identify any inconsistencies in trends or industry safety performance
    indicators.

    To examine the status of NRC's efforts to improve the ROP, we reviewed
    specific components of the ROP where weaknesses had been identified and
    recent and current staffs' efforts to improve them. We analyzed NRC
    documents, including all annual self-assessment reports issued by NRC
    since 2001; interviewed officials from NRC headquarters, regional, and
    site offices and outside stakeholder groups, including NEI and UCS; and
    attended two public meetings covering proposed changes to incorporate
    safety culture into its oversight process. In reviewing the annual
    self-assessment reports, we analyzed comments submitted by both internal
    and external stakeholders that were collected during recent surveys. We
    analyzed responses submitted by internal staff, including management,
    program staff, and regional and site inspectors, and responses from
    external stakeholders, including industry, industry organizations, public
    interest groups, state and local agencies, and members of the public. We
    examined all proposed and final documents related to NRC's safety culture
    changes, including inspection manuals, training documents, and other
    guidance documents. We also reviewed public comments submitted to NRC on
    its safety culture changes, such as those submitted by NEI, UCS, and
    meetings held on the topic by the Advisory Committee on Reactor Safeguards
    (ACRS). In addition, we assessed various external reports and evaluations
    related to the ROP or specific aspects relevant to NRC's oversight, such
    as issues surrounding safety culture, including our prior reports, those
    of the NRC Office of the Inspector General and of the ACRS. We met with
    NRC program officials responsible for assessing and implementing changes
    to the ROP to obtain a clear understanding of the actions they were taking
    and the status of their efforts.

    Additionally, we selected a nonprobability sample1 of 6 nuclear power
    sites (totaling 11 of the 103 operating plants)2 that provided coverage of
    each of NRC's four regional offices and varying levels of plant
    performance and NRC oversight since 2000. The following nuclear power
    sites were included in our review: Cooper (1 plant) located near Nebraska
    City, Nebraska; Indian Point 2 (1 plant) located near New York, New York;
    Oconee (3 plants) located near Greenville, South Carolina; Perry (1 plant)
    located near Painesville, Ohio; Salem and Hope Creek (3 plants) located
    near Lower Alloways Creek, New Jersey; and Surry (2 plants) located near
    Newport News, Virginia. Our selection criteria was designed to represent
    geographic diversity, a variety of safety problems in which inspection
    findings or performance indicators of higher risk significance (white,
    yellow, and red) were issued, trends reflecting both improving and
    declining safety performance, and plants that have been subjected to at
    least some level of increased oversight since the ROP was implemented. The
    purpose of our review was to understand how performance problems were
    identified by NRC's oversight process, what caused them, actions taken by
    NRC and the licensee in response to the problems, and how NRC documented
    their resolution. We analyzed all publicly available inspection reports
    and assessment documents covering years 2000 through 2005 for each site to
    examine how NRC applied the ROP to identify and correct safety problems.3
    We analyzed each green and greater-than-green inspection finding
    documented through the inspection reports and collected data associated
    with each finding, including how it was identified, which cornerstone it
    was assigned to, whether the finding was associated with a violation of
    regulatory requirements, and whether there were any cross-cutting elements
    associated with the finding. For the greater-than-green inspection
    findings, we collected additional information to determine the length of
    time it took the licensee to correct the performance problem, the length
    of time and level of effort NRC inspectors took to follow up on the issue,
    and the actions it required the licensee to take. Additionally, for each
    of the sites, we reviewed NRC reports and documentation showing that all
    baseline inspection procedures were completed (for 2004 and 2005), and
    that inspectors verified the licensees' reporting of the performance
    indicator data (for 2000 through 2005). We also interviewed NRC branch
    chiefs and resident inspectors and industry management officials at each
    site to learn more about NRC's implementation of the ROP at the site. We
    conducted our work from July 2005 through July 2006 in accordance with
    generally accepted government auditing standards.

    Appendix III

    Nuclear Power Plant Performance Data on the Basis of the Results of NRC's
    Reactor Oversight Process, 2001 Through 2005

    Table 3: Commercial Nuclear Power Plants Licensed to Operate in the United
    States

            Nuclear power plant                City           State   NRC region
    Arkansas Nuclear 1             Russellville           AR      IV
    Arkansas Nuclear 2             Russellville           AR      IV
    Beaver Valley 1                McCandless             PA      I
    Beaver Valley 2                McCandless             PA      I
    Braidwood 1                    Joilet                 IL      III
    Braidwood 2                    Joilet                 IL      III
    Browns Ferry 1                 Decatur                AL      II
    Browns Ferry 2                 Decatur                AL      II
    Browns Ferry 3                 Decatur                AL      II
    Brunswick 1                    Southport              NC      II
    Brunswick 2                    Southport              NC      II
    Byron 1                        Rockford               IL      III
    Byron 2                        Rockford               IL      III
    Callaway                       Fulton                 MO      IV
    Calvert Cliffs 1               Annapolis              MD      I
    Calvert Cliffs 2               Annapolis              MD      I
    Catawba 1                      Rock Hill              SC      II
    Catawba 2                      Rock Hill              SC      II
    Clinton                        Clinton                IL      III
    Columbia Generating Station    Richland               WA      IV
    Comanche Peak 1                Glen Rose              TX      IV
    Comanche Peak 2                Glen Rose              TX      IV
    Cooper                         Nebraska City          NE      IV
    Crystal River 3                Crystal River          FL      II
    D.C. Cook 1                    Benton Harbor          MI      III
    D.C. Cook 2                    Benton Harbor          MI      III
    Davis-Besse                    Toledo                 OH      III
    Diablo Canyon 1                San Luis Obispo        CA      IV
    Diablo Canyon 2                San Luis Obispo        CA      IV
    Dresden 2                      Morris                 IL      III
    Dresden 3                      Morris                 IL      III
    Duane Arnold                   Cedar Rapids           IA      III
    Edwin I. Hatch 1               Baxley                 GA      II
    Edwin I. Hatch 2               Baxley                 GA      II
    Fermi 2                        Toledo                 MI      III
    Fort Calhoun                   Omaha                  NE      IV
    Ginna                          Rochester              NY      I
    Grand Gulf 1                   Vicksburg              MS      IV
    H.B. Robinson 2                Florence               SC      II
    Hope Creek 1                   Lower Alloways Creek   NJ      I
    Indian Point 2                 New York               NY      I
    Indian Point 3                 New York               NY      I
    James A. FitzPatrick           Oswego                 NY      I
    Joseph M. Farley 1             Dothan                 AL      II
    Joseph M. Farley 2             Dothan                 AL      II
    Kewaunee                       Green Bay              WI      III
    La Salle 1                     Ottawa                 IL      II
    La Salle 2                     Ottawa                 IL      II
    Limerick 1                     Philadelphia           PA      I
    Limerick 2                     Philadelphia           PA      I
    McGuire 1                      Charlotte              NC      II
    McGuire 2                      Charlotte              NC      II
    Millstone 2                    New London             CT      I
    Millstone 3                    New London             CT      I
    Monticello                     Minneapolis            MN      III
    Nine Mile Point 1              Oswego                 NY      I
    Nine Mile Point 2              Oswego                 NY      I
    North Anna 1                   Richmond               VA      II
    North Anna 2                   Richmond               VA      II
    Oconee 1                       Greenville             SC      II
    Oconee 2                       Greenville             SC      II
    Oconee 3                       Greenville             SC      II
    Oyster Creek                   Toms River             NJ      I
    Palisades                      South Haven            MI      III
    Palo Verde 1                   Phoenix                AZ      IV
    Palo Verde 2                   Phoenix                AZ      IV
    Palo Verde 3                   Phoenix                AZ      IV
    Peach Bottom 2                 Lancaster              PA      I
    Peach Bottom 3                 Lancaster              PA      I
    Perry 1                        Painesville            OH      III
    Pilgrim 1                      Plymouth               MA      I
    Point Beach 1                  Manitowoc              WI      III
    Point Beach 2                  Manitowoc              WI      III
    Prairie Island 1               Minneapolis            MN      III
    Prairie Island 2               Minneapolis            MN      III
    Quad Cities 1                  Moline                 IL      III
    Quad Cities 2                  Moline                 IL      III
    River Bend 1                   Baton Rouge            LA      IV
    Salem 1                        Lower Alloways Creek   NJ      I
    Salem 2                        Lower Alloways Creek   NJ      I
    San Onofre 2                   San Clemente           CA      IV
    San Onofre 3                   San Clemente           CA      IV
    Seabrook 1                     Portsmouth             NH      I
    Seqouyah 1                     Chattanooga            TN      II
    Seqouyah 2                     Chattanooga            TN      II
    Shearon Harris 1               Raleigh                NC      II
    South Texas Project 1          Bay City               TX      IV
    South Texas Project 2          Bay City               TX      IV
    St. Lucie 1                    Ft. Pierce             FL      II
    St. Lucie 2                    Ft. Pierce             FL      II
    Summer                         Columbia               SC      II
    Surry 1                        Newport News           VA      II
    Surry 2                        Newport News           VA      II
    Susquehanna 1                  Berwick                PA      I
    Susquehanna 2                  Berwick                PA      I
    Three Mile Island 1            Harrisburg             PA      I
    Turkey Point 3                 Miami                  FL      II
    Turkey Point 4                 Miami                  FL      II
    Vermont Yankee                 Battleboro             VT      I
    Vogtle 1                       Augusta                GA      II
    Vogtle 2                       Augusta                GA      II
    Waterford 3                    New Orleans            LA      IV
    Watts Bar 1                    Spring City            TN      II
    Wolf Creek 1                   Burlington             KS      IV

    Source: NRC.

    Table 4: Total Number of Green Inspection Findings, 2001 Through 2005

                                 Number of green
                             inspection findings, by
                                      year
    Nuclear power sitea                       2001 2002 2003 2004 2005   Total
    Arkansas Nuclear                            12    9   15   23   23      82
    Beaver Valley                               14   10   10    8    9      51
    Braidwood                                   11   12    5    5    7      40
    Browns Ferry                                 5    5    4   10    8      32
    Brunswick                                    4    4    3    6    9      26
    Byron                                       13    9   16   14   19      71
    Callaway                                    17   11   15   17   17      77
    Calvert Cliffs                              18    4    6   19    6      53
    Catawba                                     10    6    7    5    8      36
    Clinton                                      8   10    5   16    8      47
    Columbia Generating                         11    5   21   17   10      64
    Station
    Comanche Peak                                6   12    3    9   11      41
    Cooper                                      32   23   29   23   34     141
    Crystal River                                5    4    5    5    5      24
    D.C. Cook                                   14   27   24    7   16      88
    Davis-Besse                                  4   16   24   46   12     102
    Diablo Canyon                               11   14   22   25   23      95
    Dresden                                     20   19   22   26   13     100
    Duane Arnold                                 1    7   22   12   19      61
    Farley                                       8    5    5    4   11      33
    Fermi                                        6    6   11   14   18      55
    FitzPatrick                                 12    7    8    5    8      40
    Fort Callhoun                                7   18   11   15   21      72
    Ginna                                        4   11   14    9   10      48
    Grand Gulf                                  13    9    6   10   11      49
    Harris                                       5    5    5    5    6      26
    Hatch                                       11    8    4    2    4      29
    Hope Creek                                  18   24   19   25   16     102
    Indian Point 2                              44   21   20   25   13     123
    Indian Point 3                              13    3   14    6    8      44
    Kewaunee                                    12    9   14   24   20      79
    La Salle                                     9   13    7   11   20      60
    Limerick                                    15   11   13    8    4      51
    McGuire                                      5    9    8   14    9      45
    Millstone                                   20   13    8   12   17      70
    Monticello                                  17    8   12   13    9      59
    Nine Mile Point                             16    9   15   19    8      67
    North Anna                                   4    4    5    9   12      34
    Oconee                                      16   11   13   11   19      70
    Oyster Creek                                11   12    7   15   12      57
    Palisades                                   23   13   13   10    8      67
    Palo Verde                                  16    3    4   46   29      98
    Peach Bottom                                14   13   18    7    9      61
    Perry                                        7   10   18   16   59     110
    Pilgrim                                      8    4    9    6    7      34
    Point Beach                                 15   10   28   24   23     100
    Prarie Island                                4    6    5   10   16      41
    Quad Cities                                  6   21   15   14   11      67
    River Bend                                  19    6   17   18    7      67
    Robinson                                     4    1    4    3    3      15
    Saint Lucie                                 13    7    6   10    9      45
    Salem                                       17   14   26   24   25     106
    San Onofre                                   4    9    9   16   13      51
    Seabrook                                    10    6   10    9    8      43
    Sequoyah                                    11   16    9    7    4      47
    South Texas                                 14    7   15   13   12      61
    Summer                                      13    9   10   10    9      51
    Surry                                        6    5    7    3    7      28
    Susquehanna                                 11   17   11   13    7      59
    Three Mile Island                           19    8    7   12   12      58
    Turkey Point                                 6    2    9   13    9      39
    Vermont Yankee                              11    9    9   14    3      46
    Vogtle                                       4    8    6    8    3      29
    Waterford                                    5   14   15   17   15      66
    Watts Bar                                    4   13   10    8    8      43
    Wolf Creek                                   5    3    7    9    6      30
    Total                                      751  657  774  889  835   3,906
    Site average                                11   10   12   13   13      59
    Range (for each                           1-44 1-27 3-29 2-46 3-59  15-141
    column)

    Source: GAO analysis of NRC data.

    aNRC reports these data by nuclear power site as opposed to by individual
    plant. Oftentimes, there are 2 or 3 plants located at each site.
    Therefore, data for all 103 plants are included here, but at the site
    level.

    Table 5: Total Number of Greater-Than-Green Inspection Findings Issued,
    2001 Through 2005

                                        Total number of inspection
                                            findings, by color
           Nuclear power sitea                                   White Yellow Red
    Arkansas Nuclear                                              1
    Beaver Valley                                                 2
    Braidwood                                                     1
    Browns Ferry
    Brunswick                                                     1
    Byron
    Callaway                                                      3
    Calvert Cliffs                                                3      1
    Catawba
    Clinton                                                       1
    Columbia Generating Station                                   1      1
    Comanche Peak                                                 2
    Cooper                                                        5
    Crystal River                                                 1
    D.C. Cook                                                     3
    Davis-Besse                                                   4      1   1
    Diablo Canyon
    Dresden                                                       2
    Duane Arnold
    Farley
    Fermi                                                         1
    FitzPatrick
    Fort Callhoun                                                 2
    Ginna                                                         1
    Grand Gulf
    Harris                                                        2
    Hatch                                                         1
    Hope Creek                                                    2
    Indian Point 2                                                2      1   1
    Indian Point 3
    Kewaunee                                                      4      1
    La Salle                                                      1
    Limerick                                                      2
    McGuire
    Millstone
    Monticello
    Nine Mile Point                                               1
    North Anna
    Oconee                                                        7
    Oyster Creek                                                  3
    Palisades                                                     2
    Palo Verde                                                           1
    Peach Bottom                                                  3
    Perry                                                         5
    Pilgrim
    Point Beach                                                   3      1   3
    Prarie Island                                                 1
    Quad Cities
    River Bend                                                    2
    Robinson
    Saint Lucie
    Salem                                                         1
    San Onofre
    Seabrook                                                      1
    Sequoyah                                                      1
    South Texas
    Summer
    Surry                                                         2
    Susquehanna                                                   1
    Three Mile Island                                             2
    Turkey Point
    Vermont Yankee                                                1
    Vogtle
    Waterford                                                     1
    Watts Bar                                                     1
    Wolf Creek
    Total                                                        86      7   5

    Source: GAO analysis of NRC data.

    aNRC reports these data by nuclear power site as opposed to by individual
    plant. Oftentimes, there are 2 or 3 plants located at each site.
    Therefore, data for all 103 plants are included here, but at the site
    level.

    Table 6: Type of Substantive Cross-cutting Issue Open At Least Some
    Portion of the Year, 2001 Through 2005

                           Type of substantive
                           cross-cutting issue
                              open, by year
         Nuclear power            2001           2002   2003     2004      2005
             plant
    Arkansas Nuclear                                PIR     PIR       PIR
    1
    Arkansas Nuclear                                PIR     PIR       PIR
    2
    Beaver Valley 1
    Beaver Valley 2
    Braidwood 1
    Braidwood 2
    Browns Ferry 2
    Browns Ferry 3
    Brunswick 1
    Brunswick 2
    Byron 1                                                           HP
    Byron 2                                                           HP
    Callaway                                 PIR    PIR     HP        HP
    Calvert Cliffs 1   PIR                   PIR
    Calvert Cliffs 2   PIR                   PIR
    Catawba 1
    Catawba 2
    Clinton
    Columbia           HP                    HP     PIR, HP PIR, HP   PIR, HP
    Generating
    Station
    Comanche Peak 1
    Comanche Peak 2
    Cooper             PIR,HP                PIR,HP PIR,HP  PIR,HP    PIR,HP
    Crystal River 3
    D.C. Cook 1                              PIR    PIR
    D.C. Cook 2                              PIR    PIR
    Davis-Besse
    Diablo Canyon 1                                 PIR,HP  PIR,HP
    Diablo Canyon 2                                 PIR,HP  PIR,HP
    Dresden 2                                               HP
    Dresden 3                                               HP
    Duane Arnold                                                      HP
    Farley 1
    Farley 2
    Fermi 2                                                 HP        HP
    FitzPatrick        PIR
    Fort Callhoun
    Ginna
    Grand Gulf 1
    Harris 1
    Hatch 1
    Hatch 2
    Hope Creek 1                             PIR    PIR     PIR, SCWE PIR,SCWE
    Indian Point 2     PIR,HP                PIR,HP PIR,HP  PIR       PIR
    Indian Point 3
    Kewaunee                                                PIR       PIR
    La Salle 1         HP                    HP             HP        HP
    La Salle 2         HP                    HP             HP        HP
    Limerick 1
    Limerick 2
    McGuire 1
    McGuire 2
    Millstone 2        PIR,HP                       PIR
    Millstone 3
    Monticello
    Nine Mile Point 1                               PIR
    Nine Mile Point 2                               PIR
    North Anna 1
    North Anna 2
    Oconee 1
    Oconee 2
    Oconee 3
    Oyster Creek       PIR                   HP     HP      PIR       PIR
    Palisades          PIR, HP               PIR    PIR
    Palo Verde 1                                            PIR, HP   PIR, HP
    Palo Verde 2                                            PIR, HP   PIR, HP
    Palo Verde 3                                            PIR, HP   PIR, HP
    Peach Bottom 2                                  PIR     PIR
    Peach Bottom 3                                  PIR     PIR
    Perry 1                                                 PIR,HP    PIR,HP
    Pilgrim 1
    Point Beach 1                            PIR    PIR, HP PIR, HP   PIR, HP
    Point Beach 2                            PIR    PIR, HP PIR, HP   PIR, HP
    Prairie Island 1
    Prairie Island 2
    Quad Cities 1                            HP     HP
    Quad Cities 2                            HP     HP
    River Bend 1
    Robinson 2
    Saint Lucie 1
    Saint Lucie 2
    Salem 1                                  PIR    PIR     PIR,SCWE  PIR,SCWE
    Salem 2                                  PIR    PIR     PIR,SCWE  PIR,SCWE
    San Onofre 2
    San Onofre 3
    Seabrook 1         PIR                   PIR
    Sequoyah 1
    Sequoyah 2
    South Texas 1
    South Texas 2
    Summer
    Surry 1
    Surry 2
    Susquehanna 1                            HP     PIR, HP PIR
    Susquehanna 2                            HP     PIR, HP PIR
    Three Mile Island  HP                    HP     PIR     PIR
    1
    Turkey Point 3                                  PIR
    Turkey Point 4                                  PIR
    Vermont Yankee
    Vogtle 1
    Vogtle 2
    Waterford 3                              PIR    PIR
    Watts Bar 1                                                       HP
    Wolf Creek 1

    Legend:

    HP       =  human performance PIR =  problem identification and resolution
    SCWE =  safety-conscious work environment

    Source: GAO analysis of NRC data.

    Table 7: Total Number of Greater-Than-Green Performance Indicators, 2001
    Through 2005

                          Number of greater-than-green
                           performance indicators, by
                                     yeara
         Nuclear power                            2001 2002 2003 2004 2005  Total
             plant
    Arkansas Nuclear
    1
    Arkansas Nuclear
    2
    Beaver Valley 1
    Beaver Valley 2
    Braidwood 1                                   1    2    3    1           7
    Braidwood 2
    Browns Ferry 2
    Browns Ferry 3
    Brunswick 1
    Brunswick 2                                                       1      1
    Byron 1
    Byron 2
    Callaway                                                     2           2
    Calvert Cliffs 1                              4    3                     7
    Calvert Cliffs 2
    Catawba 1
    Catawba 2
    Clinton
    Columbia                                                          5      5
    Generating
    Station
    Comanche Peak 1
    Comanche Peak 2
    Cooper                                                  1                1
    Crystal River 3                               1                          1
    D.C. Cook 1                                   1                          1
    D.C. Cook 2                                             4    5    2     11
    Davis-Besse                                                  1    1      2
    Diablo Canyon 1                                                   1      1
    Diablo Canyon 2                                                   1      1
    Dresden 2                                                    1           1
    Dresden 3                                          1    4    2           7
    Duane Arnold
    Farley 1
    Farley 2
    Fermi 2                                       4         1    4    1     10
    FitzPatrick                                   2                          2
    Fort Callhoun                                           1    2    2      5
    Ginna
    Grand Gulf 1
    Harris 1                                           1    3    1           5
    Hatch 1
    Hatch 2
    Hope Creek 1
    Indian Point 2
    Indian Point 3                                          3                3
    Kewaunee
    La Salle 1
    La Salle 2                                    2    1                     3
    Limerick 1
    Limerick 2
    McGuire 1
    McGuire 2
    Millstone 2                                   2              3           5
    Millstone 3
    Monticello
    Nine Mile Point 1                             4    2                     6
    Nine Mile Point 2                             1    1    1                3
    North Anna 1
    North Anna 2                                  1                          1
    Oconee 1                                           2                     2
    Oconee 2
    Oconee 3
    Oyster Creek
    Palisades
    Palo Verde 1
    Palo Verde 2
    Palo Verde 3
    Peach Bottom 2                                          1    1    3      5
    Peach Bottom 3
    Perry 1                                                 3    1           4
    Pilgrim 1
    Point Beach 1                                 4    1                     5
    Point Beach 2                                 2                          2
    Prarie Island 1
    Prarie Island 2
    Quad Cities 1
    Quad Cities 2
    River Bend 1                                                      2      2
    Robinson 2                                                   1           1
    Saint Lucie 1
    Saint Lucie 2                                           1    1           2
    Salem 1                                            2                     2
    Salem 2
    San Onofre 2                                            1    3    1      5
    San Onofre 3
    Seabrook 1                                              1                1
    Sequoyah 1
    Sequoyah 2                                         1    2                3
    South Texas 1
    South Texas 2                                      1    1                2
    Summer                                        3                          3
    Surry 1                                            3    6    3          12
    Surry 2                                       2    4    4    1          11
    Susquehanna 1
    Susquehanna 2
    Three Mile Island
    1
    Turkey Point 3                                                    1      1
    Turkey Point 4                                                    2      2
    Vermont Yankee
    Vogtle 1
    Vogtle 2
    Waterford 3
    Watts Bar 1
    Wolf Creek 1
    Total                                        34   25   41   33   23    156

    Source: GAO analysis of NRC data.

    Note: Plant licensees report their performance indicator data on a
    quarterly basis for 15 different indicators (excluding 3 physical security
    indicators). Yearly totals include a summary for all 15 indicators and the
    four quarters. Thus, if the same indicator was white for two quarters
    during the year, it would count twice in the yearly total.

    aAll of the greater-than-green indicators were white during this period,
    no yellow or red indicators were reported.

    Table 8: Highest NRC Oversight Level Applied during at Least Some Portion
    of the Year, 2001 Through 2005

                               Highest level of oversight
                              applied during at least some
                                  portion of the yeara
    Nuclear power plant                2001                2002 2003 2004 2005
    Arkansas Nuclear 1                                               L
    Arkansas Nuclear 2
    Beaver Valley 1                                        L    L    L
    Beaver Valley 2                                        L    L    L
    Braidwood 1          L                                 M    L    L
    Braidwood 2
    Browns Ferry 2
    Browns Ferry 3
    Brunswick 1
    Brunswick 2                                                      L    L
    Byron 1
    Byron 2
    Callaway             M                                 L    L    L
    Calvert Cliffs 1     M                                 M    L
    Calvert Cliffs 2                                       L    L    L
    Catawba 1
    Catawba 2
    Clinton              L                                 L
    Columbia Generating  M                                 M              L
    Station
    Comanche Peak 1                                        L         L
    Comanche Peak 2                                        L
    Cooper               M                                 H    H    H
    Crystal River 3      L                                                L
    D.C. Cook 1                                            L    L    L
    D.C. Cook 2                                            M    M    M    L
    Davis-Besse                                            b    b    b    b
    Diablo Canyon 1                                                       L
    Diablo Canyon 2                                                       L
    Dresden 2                                                        L
    Dresden 3                                              L    L    L
    Duane Arnold
    Farley 1             L
    Farley 2             L
    Fermi 2              L                                 L    L    L    L
    FitzPatrick          L
    Fort Callhoun                                          L    L    L    L
    Ginna                                                  L    L
    Grand Gulf 1
    Harris 1             L                                 M    L    L
    Hatch 1                                                               L
    Hatch 2                                                               L
    Hope Creek 1                                                     L    L
    Indian Point 2       H                                 H    M    L    L
    Indian Point 3                                              L
    Kewaunee             M                                 L    L         M
    La Salle 1
    La Salle 2           L                                 L
    Limerick 1           L                                 L
    Limerick 2           L                                 L
    McGuire 1
    McGuire 2
    Millstone 2          M                                           L
    Millstone 3
    Monticello
    Nine Mile Point 1    L                                 L    L
    Nine Mile Point 2    L                                 L    L
    North Anna 1
    North Anna 2         L
    Oconee 1             M                                 L    L    M    L
    Oconee 2             L                                      L    M    L
    Oconee 3             L                                 L    L    M    L
    Oyster Creek         L                                 L         L    L
    Palisades            L                                 L    L    L
    Palo Verde 1                                                          M
    Palo Verde 2                                                          M
    Palo Verde 3                                                          M
    Peach Bottom 2       L                                 L    L    L    L
    Peach Bottom 3       L                                 L    L
    Perry 1                                                L    M    H    H
    Pilgrim 1
    Point Beach 1        L                                 L    H    H    H
    Point Beach 2        L                                 L    H    H    H
    Prarie Island 1      L                                 L
    Prarie Island 2      L                                 L
    Quad Cities 1        L
    Quad Cities 2        L
    River Bend 1                                           L              L
    Robinson 2                                                       L
    Saint Lucie 1
    Saint Lucie 2                                               L    L
    Salem 1                                                L    L    L
    Salem 2
    San Onofre 2                                                L    L    L
    San Onofre 3
    Seabrook 1           L                                      L
    Sequoyah 1                                                       L    L
    Sequoyah 2                                             L    L
    South Texas 1
    South Texas 2                                          L    L
    Summer               L
    Surry 1              L                                 L    L    M
    Surry 2              L                                 L    L    L
    Susquehanna 1        L                                 L
    Susquehanna 2        L                                 L
    Three Mile Island 1  L                                                L
    Turkey Point 3                                                        L
    Turkey Point 4                                                        L
    Vermont Yankee                                         M         L    L
    Vogtle 1
    Vogtle 2
    Waterford 3                                                      L
    Watts Bar 1                                                           L
    Wolf Creek 1

    Legend:

    L  = 1st or lowest level of increased oversight beyond the baseline
    M = 2nd level of increased oversight beyond the baseline H  = 3rd and
    highest level of oversight that still allows continued plant operations

    Source: GAO analysis of NRC data.

    aAll plants receive a baseline level of oversight, regardless of their
    safety performance. Plants are also placed into performance categories on
    NRC's action matrix on a quarterly basis, which corresponds to the level
    of oversight NRC will provide based on the plant's safety performance. The
    level of oversight reported here corresponds to the highest oversight
    level the plant received during the year, even if it was only for a
    portion of the year. Thus, if a plant was placed into a different category
    each quarter, the highest category in which it was placed is reported
    here.

    bDavis-Besse was under a separate oversight category not considered part
    of the ROP due to the reactor vessel head incident that occurred in 2002.

    Appendix IV

    Comments from the Nuclear Regulatory Commission

    Appendix V

    GAO Contact and Staff Acknowledgments

    GAO Contact

    Jim Wells, (202) 512-3841 or wellsj@gao.gov

    Staff Acknowledgments

    In addition to the individual named above, Raymond H. Smith, Jr.
    (Assistant Director), Alyssa M. Hundrup, and Dave Stikkers made key
    contributions to this report. Also contributing to this report were Cindy
    Gilbert, Carol Kolarik, Alison O'Neill, Ilene Pollack, Keith A. Rhodes,
    and Barbara Timmerman.

    (360585)

    www.gao.gov/cgi-bin/getrpt? GAO-06-1029 .

    To view the full product, including the scope
    and methodology, click on the link above.

    For more information, contact Jim Wells at (202) 512-3841 or
    wellsj@gao.gov.

    Highlights of GAO-06-1029 , a report to congressional requesters

    September 2006

    NUCLEAR REGULATORY COMMISSION

    Oversight of Nuclear Power Plant Safety Has Improved, but Refinements Are
    Needed

    The Nuclear Regulatory Commission (NRC) is responsible for overseeing the
    nation's 103 commercial nuclear power plants to ensure they are operated
    safely. The safety of these plants has always been important, since an
    accident could release harmful radioactive material. NRC's oversight has
    become even more critical as the potential resurgence of nuclear power is
    considered. NRC implemented a new Reactor Oversight Process (ROP) in 2000
    to address weaknesses in its oversight of nuclear plant safety.

    In this report, GAO reviewed (1) how NRC oversees nuclear power plants,
    (2) the results of the ROP over the past several years, and (3) the status
    of NRC's efforts to improve the ROP. To complete this work, GAO analyzed
    programwide information, inspection results covering 5 years of ROP
    operations, and detailed findings from a nonprobability sample of 11
    plants.

    What GAO Recommends

    GAO recommends that NRC aggressively monitor; evaluate; and, if needed,
    implement additional measures to increase the effectiveness of its safety
    culture changes and make publicly available more information on nuclear
    power plants' safety culture. In commenting on a draft of this report, NRC
    generally agreed with GAO's findings, conclusions, and recommendations.

    NRC uses various tools and takes a risk-informed and graded approach to
    ensure the safety of nuclear power plants. These tools consist of physical
    inspections of plants and quantitative measures or indicators of plant
    performance. They are risk-informed in that they focus on the aspects of
    operations considered most important to plant safety. On the basis of the
    results of this information, NRC takes a graded approach to its oversight,
    increasing the level of regulatory attention to plants where safety is
    declining. NRC assesses overall plant performance and communicates the
    results to the public, including providing detailed results of its
    oversight process through a Web site devoted to the ROP.

    Since 2001, the ROP has resulted in more than 4,000 inspection findings
    concerning plants' failure to fully comply with safe operating procedures,
    and NRC has subjected more than 75 percent (79) of the 103 plants to
    increased oversight for varying periods. Almost all of the inspection
    findings were for actions NRC considered important to correct but of low
    significance to safe plant operations. While the majority of plants
    received some level of increased oversight, only 5 plants were subjected
    to NRC's highest level of oversight. Plants in this category were
    generally subjected to this higher oversight for long periods due to the
    more systemic nature of their performance problems.

    NRC has improved its oversight process in various areas, but it has been
    slow to act on needed improvements, particularly in improving the agency's
    ability to identify and address early indications of declining safety
    performance. NRC is improving its oversight process on the basis of
    feedback from stakeholders, including better focusing inspections on areas
    most important to safety. NRC also is addressing what GAO believes has
    been a significant shortcoming by modifying the ROP to improve its ability
    to address plants' safety culture-that is, the organizational
    characteristics that ensure issues affecting nuclear plant safety receive
    the attention their significance warrants. GAO and others, including some
    stakeholders, believe these changes could enable NRC to better identify
    safety culture issues and thus provide earlier indications of declining
    plant safety performance. However, some in the industry have opposed the
    changes because they believe the changes could introduce undue
    subjectivity to NRC's oversight, given the difficulty in measuring these
    often intangible and complex concepts. NRC has been reluctant to
    incorporate safety culture into the ROP because it considered this type of
    activity as a management function, and NRC did not believe that it should
    be directly involved in managing licensees' plants. NRC program officials
    view the current changes as the beginning of an incremental approach and
    acknowledge that they will need to assess their effectiveness at
    identifying declining safety performance at plants before significant
    safety events occur.

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