Review of the Directorate of Environmental and Radiation Protection and Assessment Inspection Processes

Table of contents

Executive Summary

The Canadian Nuclear Safety Commission (CNSC) has a mandate under the Nuclear Safety and Control Act (NSCA) to regulate all nuclear facilities and nuclear-related activities in Canada. Licensing and certification activities are in place for issuing licences or certifying persons and prescribed equipment involved in nuclear-related activities.

The Technical Support Branch (TSB) provides leadership and specialized expertise in the areas of nuclear science and engineering, safety analysis, safety management, human factors, personnel training and certification, environmental and radiation protection, security, nuclear emergency management, safeguards and nuclear non-proliferation. The TSB consists of four directorates; Directorate of Environmental and Radiation Protection and Assessment (DERPA), Directorate of Safety Management (DSM), Directorate of Assessment and Analysis (DAA) and Directorate of Security and Safeguard (DSS).

The review team reviewed and analyzed the available DERPA inspection data for the 2017‒18 fiscal year. The CNSC’s expert assessments of environmental risk were carried out under the NSCA and the Canadian Environmental Assessment Act, 2012 (CEAA 2012).

DERPA provides leadership and technical expertise in environmental assessments, geosciences, radiation protection (RP), environmental protection and laboratory services. DERPA is also responsible for licensing dosimetry services. DERPA is composed of the following five divisions:

  • Environmental Risk Assessment Division (ERAD)
  • Health Sciences and Environmental Compliance Division (HSECD)
  • Radiation Protection Division (RPD)
  • Laboratory Services Division (LSD)
  • Environmental Assessment Division (EAD)

The objective of this review was to determine whether DERPA has adequate inspection processes and procedures in place to cover each of the five recommendations outlined in the 2016 audit report on inspection processes by the Office of the Auditor General (OAG). For more detailed information, see Appendix A: Findings and Recommendations of the 2016 OAG Audit Report and Appendix B: Review Lines of Enquiry and Criteria.

The review report includes four recommendations aimed at addressing the areas of improvement noted in Appendix C. The following conclusions were made:

  • HSECD, ERAD and RP within RPD have adequate planning processes in place for the purpose of their inspections. There is opportunity to improve RPD’s dosimetry services (DS) planning process to ensure that it is systematic and risk-informed. It should also include the minimum required frequency and type of inspections, and detailed criteria to determine when to conduct Type I inspections.
  • All three selected divisions of DERPA (HSECD, ERAD and RPD) follow established procedures to conduct their inspections. Opportunities exist for DERPA to improve its inspection procedures and for DS to develop and implement inspection procedures.
  • Lessons learned were not systematically shared and documented by DERPA specialists. There is opportunity to improve DERPA procedures to document and share lessons learned.
  • DERPA processes for tracking the completion date of its contribution to the final inspection report need improvement. Tracking information should include whether the established service standard timeline was met. DS is to establish clear service standards for issuing final inspection reports.  

Management has agreed with the recommendations and provided a response indicating their commitment to take action (see Appendix C: 2019 Review Recommendations and Management Action Plans).

1. Introduction

1.1 Background

Office of the Auditor General 2016 Fall Report

In 2016, the Office of the Auditor General (OAG) issued the 2016 Fall Reports of the Commissioner of the Environment and Sustainable Development – Report 1—Inspection of Nuclear Power Plants—Canadian Nuclear Safety Commission (the OAG Audit Report).

The OAG Audit Report focused on whether the CNSC had adequately managed its site inspections of Canadian nuclear power plants (NPPs) to verify that the environment and the health, safety and security of Canadians were protected.

The OAG Audit Report included five recommendations for planning inspections, conducting inspections and reporting on inspection results (see Appendix A for detailed OAG report findings and recommendations). The CNSC agrees with each of the five recommendations and has provided a response detailing the actions it has taken or intends to take to address the findings.

In addition, the CNSC President has directed all non-nuclear power plant directorates that conduct inspections (i.e., directorates that were not within the scope of the OAG audit) to address the OAG Audit Report recommendations as they relate to their respective inspection processes.

Directorate of Environmental and Radiation Protection and Assessment (DERPA)

DERPA provides leadership and technical expertise in environmental assessments, geosciences, radiation protection, environmental protection and laboratory services. DERPA conducts inspections and compliance activities at the facilities that come under the Regulatory Operations Branch (ROB), including its Directorate of Nuclear Cycle and Facilities Regulation (DNCFR), Directorate of Nuclear Substance Regulation (DNSR) and Directorate of Power Reactor Regulation (DPRR). DERPA is also accountable for the licensing of dosimetry services. Each of the five DERPA divisions contributes unique expertise to achieve the Directorate’s goals overall, as described below.

Environmental Risk Assessment Division (ERAD)

ERAD provides regulatory leadership and expertise for the assessment of environmental risks from nuclear facilities and for the short- and long-term safety of human health and the environment. ERAD is involved in identifying gaps in the regulatory process for environmental risk assessments and safe waste management. It ensures that risks to the public and the environment are properly assessed and that appropriate mitigation measures are identified and taken. It also ensures that sound geoscientific principles are applied in the siting, design, construction, operation and decommissioning of nuclear facilities in order to minimize releases of radionuclides and hazardous substances to the environment.

ERAD specialists take part in compliance activities, including mid-term reviews and geotechnical inspections, and they assist the environmental protection staff from the Environmental Compliance and Laboratory Services divisions in specific matters, such as compliance activities that concern the geotechnical integrity of containment structures. In collaboration with project officers and other CNSC specialists, ERAD staff support the assessment of licence applications by ensuring that expert assessments of environmental risks are carried out in the context of the Nuclear Safety and Control Act (NSCA) and the Canadian Environmental Assessment Act, 2012 (CEAA 2012). ERAD participates as a subject matter expert (SME) and supports inspectors in the technical aspect of inspections with DNCFR and DPRR.

Health Sciences and Environmental Compliance Division (HSECD)

HSECD provides regulatory leadership and expertise as specialists in environmental and health sciences services. HSECD is involved in identifying gaps in the regulatory process related to environmental protection and radiation protection for workers and members of the public. HSECD experts are responsible for assessing the health effects of ionizing radiation and carrying out the CNSC’s compliance promotion, verification and enforcement activities for nuclear facilities and uranium mines and mills.

HSECD specialists participate in environmental protection compliance activities, which include desktop reviews of annual, quarterly and event reports submitted by the licensees. Compliance activities also include site inspections and audits of licensees’ environmental management system (EMS) and environmental protection programs (i.e., effluent and environmental monitoring programs). HSECD participates as SME and supports lead inspectors in technical aspects of inspections with DNCFR, DPRR and DNSR.

Radiation Protection Division (RPD)

RPD provides regulatory leadership and expertise with regard to operational radiation protection (RP) and licensing of dosimetry services (DS), including licensing assessment and compliance verification. RPD is responsible for directing the CNSC’s centre of excellence for operational RP for all proposed or licensed nuclear facilities and activities, and for CNSC compliance promotion, verification and enforcement activities for RP. The division is also responsible for licensing dosimetry services, implementing risk-based licensing and carrying out compliance activities.

RP specialists within RPD participate in compliance verification activities for operational radiation protection programs in collaboration with licensing and other technical support divisions, and determine whether licensees are appropriately implementing their radiation protection programs. RP specialists support lead inspectors in the technical aspects of inspections with DNCFR, DPRR and DNSR.

Specialists within RPD conduct DS licence compliance activities, which include conducting desktop reviews of annual reports submitted by the licensees, leading or participating in inspections of licensees for compliance with the requirements of CNSC regulatory standards and other compliance verification activities for DS licensees. DS leads its own inspection activities and establishes its own inspection processes and procedures, based on the CNSC’s inspection procedures.

Laboratory Services Division (LSD)

LSD provides radiation instrument calibration and various sample analysis services to the CNSC. The laboratory is also responsible for giving training courses and providing expert advice in selected areas, such as field sampling and radiation instrumentation. The laboratory is engaged in research and collaborative activities with various national and international partners on subjects that are of high significance to the CNSC's regulatory regime. The LSD does not lead or participate in any inspection processes.

Environmental Assessment Division (EAD)

EAD offers regulatory leadership and expertise on the environmental assessment (EA) program to support the CNSC’s mandate. EAD does not lead or participate in any inspection processes.

1.2 Authority

The review was conducted under the authority of CNSC’s approved Risk-Based Audit Plan for 2018–19 to 2020–21 that includes an audit of DERPA inspection processes. In subsequent discussions with senior management, it was decided that a reviewFootnote 1 of DERPA inspection processes would be more appropriate and more valuable to management than an audit.   

1.3 Objective and Scope

The objective of this review is to determine that DERPA inspection processes and procedures are in place to cover each of the five recommendations outlined in the 2016 OAG Audit Report on CNSC inspection processes. The lines of enquiry and review criteria are set out in detail in Appendix B. Specifically, the review is to determine whether:

  • DERPA has developed or integrated a systematic, risk-informed and well-documented planning process for inspections.
  • DERPA has developed or integrated detailed criteria to determine when to conduct Type I inspections.
  • The inspections carried out by DERPA follow the procedures.
  • DERPA has documented and/or participated in lessons learned carrying out inspections, and the lessons learned are accessible to its management and staff.
  • DERPA has participated in producing and/or issuing timely final inspection reports.

The scope of this review examined inspection processes used in three divisions of DERPA (ERAD, HSECD and RPD). The review team examined the practices and procedures that DERPA used to conduct inspections. The technical assessment of DERPA’s inspection methods and procedures was not examined. The review team reviewed and analyzed available DERPA inspection data for the 2017–18 fiscal year during the review period, from July to September 2019. The review required documentation from other branches, including the Regulatory Operations Branch (ROB) (DPRR, DNSR and DNCFR).

1.4 Methodology

The review was planned and performed in accordance with the requirements of the Treasury Board Policy on Internal Audit and Directive on Internal Audit, which together provide mandatory procedures for internal auditing in the Government of Canada.

The review was conducted in order to obtain a limited level of assurance that its objective was adequately assessed. The review team:

  • Conducted interviews with management and staff.
  • Reviewed and analyzed documentation on the five recommendations from the 2016 OAG Audit Report.
  • Assessed and analyzed the inspection data available for the 2017–18 fiscal year.

1.5 Statement of Conformance

The review was conducted in accordance with the Internal Auditing Standards for the Government of Canada, which includes the International Standards for the Professional Practice of Internal Auditing established by the Institute of Internal Auditors, as supported by the results of the quality assurance and improvement program administered by the CNSC’s Office of Audit and Ethics. The review procedures have been followed to support the accuracy of the findings and conclusions in this report while providing a limited level of assurance.

1.6 Acknowledgement

The review team would like to acknowledge and thank management and staff for their support throughout the conduct of this review.

2. Observations and Recommendations

2.1 Line of Enquiry 1 – Planning inspections

Criterion 1.1

The CNSC’s inspections, including DERPA’s, should follow well-documented planning processes that are systematic, risk-informed and risk-based, and should specify the minimum required frequency and type of inspections. (Ref: 2016 OAG Audit Report, paragraphs 1.33, 1.21 and 1.32)

Observations

In September 2016, DERPA helped to develop and implement the CNSC’s inspection process plan, Power Reactor Regulatory Program (PRRP) Annual Compliance Planning, which describes actions taken to establish a risk-informed list of approved compliance activities for the 2017–18 fiscal year.

In December 2016, DERPA participated in developing and implementing the CNSC’s inspection plan strategy, PRRP Compliance Verification Strategy, which describes the strategic process the CNSC uses to establish a risk-informed baseline compliance plan and reactive compliance plan for nuclear power plants (NPPs).

In May 2017, DERPA also contributed to developing and implementing the CNSC’s inspection annual plan, FY 2017–18 Power Reactor Regulatory Program Annual Compliance Verification Plan, which describes the minimum required frequency and type of inspections.

HSECD, ERAD, and RP within RPD

HSECD, ERAD and RP followed the CNSC planning process and their procedures in the 2017–18 fiscal year. HSECD and RP specialists work in collaboration with DPRR, DNCFR and DNSR, while ERAD works in collaboration with DPRR and DNCFR. In the  2017–18 fiscal year, ROB provided inspection plan activities for the year to HSECD, ERAD and RP. Upon receiving plans, HSECD, ERAD and RP reviewed ROB’s inspection plan activities to determine which inspections HSECD, ERAD and RP will be participating in. There is no risk-informed inspection process or procedures in HSECD, ERAD and RP, as these processes and procedures reside with other directorates, namely DPRR, DNCFR and DNSR.

Dosimetry services within RPD

Although DS is a very small portion of DERPA’s activities, it issues licences and owns its inspection process. The review indicated that the planning process for dosimetry inspections was not documented, and it was based on conducting one Type I inspection every licence term as a baseline. The review did not identify planning activities that constitute a systematic and risk-informed process specific to DS inspections, including  identifying the minimum required frequency and type of inspections.

Conclusion

DERPA divisions, with the exception of DS, adequately supported ROB’s systematic, risk-informed and well-documented inspection planning process. The review indicates that DS should formulate its planning process to ensure that it is systematic and risk-informed, and includes the required frequency and type of inspections.

Criterion 1.2

The CNSC’s inspection processes, including DERPA’s, should include detailed criteria to help determine when to conduct Type I inspections. (Ref: 2016 OAG Audit Report paragraphs 1.33, 1.21, 1.32, 1.35, and 1.34)

Observations

HSECD and ERAD

HSECD, ERAD and RP support DPRR, DNCFR and DNSR for Type I inspections. CNSC detailed criteria for determining when to conduct Type I inspections is described in the CNSC’s process document, Power Reactor Regulatory Program (PRRP) Compliance Verification Strategy. The review found that HSECD has not been asked to participate in Type I inspections since 2011. Similarly, ERAD has not been invited to participate in Type I inspections since 2014.

RP within RPD

RP is often invited to participate in Type I inspections for DNSR’s divisions, including for the Operations Inspection Division (OID), Accelerators, and Class II Facilities Division (ACFD). The review of documentation indicated that DNSR management identified a need for detailed criteria to initiate a Type I inspection. DNSR developed and recently approved two procedural documents for Type I inspections: the OID Type I Inspection Procedure, approved in February 2019, and ACFD Regulatory Program Oversight, approved in December 2018.

The review showed that RP specialists participated in Type I inspections during the 2017–18 fiscal year. The interviews noted that specialists are guided by the procedure documents, Type I Inspection Procedures, developed in 2005, and Type II Inspection Procedures, developed in 2011. However, neither of these documents described the criteria for when to use Type I inspections. Further, interviewees demonstrated limited knowledge of new DNSR procedures. While it is acknowledged that these new procedures are outside the timeframe of this review, it is observed that it would be a good practice that DERPA clearly communicate to its staff the new procedures that have been developed by DNSR.

DS within RPD

DS inspections generally have been Type I inspections. The dosimetry inspections are conducted approximately once every licence term as a baseline. While technical procedures for performing dosimetry inspections are required by DS, there was no well-documented procedures within DS to identify criteria that trigger Type I inspections.

Type I inspections are broad, program-based, audit-like inspections, and are a tool that RPD and DNSR use to determine whether the programs carried out by licensees are effective and compliant. Proper guidance is needed to perform the inspections and ensure regulatory compliance.

Conclusion

HSECD and ERAD followed the CNSC’s processes to determine when to conduct Type I inspections. HSECD and ERAD did not participate in Type I inspections in the 2017–18 fiscal year. Although DS inspections have generally been Type I inspections, there were no documented criteria to determine when to conduct Type I inspections.

Recommendation 1

It is recommended that:

  1. DERPA (DS) develop and implement a risk-informed inspection planning process that describes the minimum required frequency and type of inspections needed for DS to ensure compliance. This should include detailed criteria for determining when to conduct a Type I inspection.
  2. Once the planning process is finalized and approved, in this case by the Director of RPD and the Director General of DERPA, the plan should be clearly communicated.

Management response and action plan

Management agrees:

DERPA’s inspection plan will be amended to indicate the minimum frequency and type of inspection (Type I or Type II) planned. The approved and documented plan will be communicated to all CNSC stakeholders.

Target date for completion: August 2020

2.2 Line of Enquiry 2 – Conducting inspections

Criterion 2.1

DERPA should ensure that its inspections follow the procedures. (Ref: 2016 OAG Audit Report paragraphs 1.48, 1.43 and 1.47)

Sub-criterion 2.1.1

DERPA should develop and implement inspection guides that set out the key steps and criteria for each inspection, beforehand.

Observations

HSECD, ERAD and RP within RPD

As part of the DPRR inspection process, specialists from HSECD, ERAD and RP follow DPRR inspection checklists (approved inspection guide).

DPRR inspection procedures include approved inspection guides signed by the lead inspector and by the inspectors and directors of each division contributing to the inspections. The HSECD, ERAD and RP followed this procedure in the 2017–18 fiscal year.

The review also revealed that, as a good practice, the approved inspection guide could be more flexible to allow specialists to comment on items of concern that are outside of the scope of the inspection.

For inspections following DNCFR and DNSR inspection processes, HSECD, ERAD, and RP specialists follow the inspection compliance matrix provided by DNCFR and the inspection checklist provided by DNSR. The interviews with DERPA specialists indicated that prior to inspection, DERPA specialists work with DNCFR or DNSR to modify and revise the scope and criteria of the inspections related to health and the environment, and record observations and findings in revised inspection compliance matrices or inspection checklists. DERPA specialists are responsible for addressing technical issues. If safety or compliance issues are identified during the inspection, the lead inspector of DNCFR and DNSR relies on DERPA specialists to confirm these findings. For the 2017–18 fiscal year, the review showed that the process is not well documented, nor are there procedures in place to allow DERPA specialists and their respective directors to sign off on the inspection checklists. Failing to obtain pre-approval of the inspection matrix and checklist could result in inspection criteria that may be insufficient to demonstrate that the CNSC is conducting inspections using the most appropriate criteria to assess compliance with regulatory and licence requirements.

DS within RPD

The review indicated that DS primarily conducts Type I inspections. DS follows the CNSC procedures documented in Type I Inspection Procedures and the CNSC’s management system; however, DS requires technical procedures, including licensing assessments and compliance verification activities for performing dosimetry inspections. The review did not reveal any approved inspection checklist with appropriate criteria before conducting dosimetry inspections.

The review noted that RPD developed and approved its On-the-Job Training Guide for Radiation Protection Division Inspectors in March 2017 for new staff to the RP. The Review also noted an absence of training tools for DS. It would be a good practice that DS develop and implement a training guide to assist with conducting and reporting on dosimetry inspections.

Conclusion

DERPA specialists provide expertise and contribute to DNCFR inspection compliance matrices and DNSR inspection checklists; however, modifications by DERPA specialists are not well documented. There are no procedures in place to allow DERPA specialists and directors to sign off on inspection tools. Well-documented procedures ensure consistency and oversight of inspection criteria for DERPA inspections. DS does not have procedures for conducting its inspections.

Recommendation 2

It is recommended that:

  1. DERPA (HSECD, ERAD and RPD) establish and implement procedures that document DERPA specialists’ contribution to revising and signing off on the criteria and scope of the inspection compliance matrices and checklists. The procedures should include a requirement for DERPA directors to review and sign off on the matrices and checklists.
  2. DERPA (DS) develop and implement inspection procedures which include the responsibilities of specialists and provide a standardized approach for conducting inspections, completing checklists and reports, and documenting lessons learned.
  3. Once procedures have been finalized and approved, they should be clearly communicated to DERPA staff, management and the appropriate ROB staff.

Management response and action plan

Management agrees:

  1. DERPA will establish and implement a single procedural document that covers the roles of all DERPA subject matter experts in inspections.
  2. Inspection procedures for DS are intrinsically linked to the management response and action plan for Recommendation 1 and will be included in this response and action plan.
  3. Once this response and action plan is completed, it will be clearly communicated to the appropriate DERPA and ROB staff.

Target date for completion

April 2020: Response and action a

August 2020: Response and action b

August 2020: Response and action c

Sub-criterion 2.1.2

DERPA should clearly indicate to staff how long inspection records should be retained after the inspection reports are issued.

Observations

Although DERPA staff were not aware of the CNSC retention guide, they had a general understanding of which inspection records should be considered transitory (e.g., inspection notes) and which should be retained after inspection reports have been finalized (e.g., inspection checklists and inspection photos). The review showed that DERPA follows the Operations Management Committee (OMC) guide for the retention of inspection records. No recommendation is required.

The review report noted that inspection records were not kept in a centralized location for easy access and retrieval by DERPA specialists in 2017–18. Not all the inspection files were easily available to the specialists. DERPA staff send requests to ROB site inspectors for required documents, including previous inspection reports and lessons learned. Without ease of document access and tracking, specialists are unable to review the previous inspections files to assist with current inspections.

The review report noted that RPD has created a tracking tool for inspection records; however, it is not consistently maintained. As a good practice, DERPA could implement tracking and storage systems for its inspection records to offer more timely access to results, recommendations and lessons learned. Having a system in place to keep track of the inspection data will also allow DERPA specialists to assess and monitor planned and past inspection activities. This would also help to effectively track the completion and implementation of action items that stem from lessons learned when conducting subsequent inspections.

Conclusion

DERPA follows OMC’s guide for the retention of inspection records. No recommendation is required.

Criterion 2.2

DERPA should document and/or participate in lessons learned while carrying out inspections, and a record of the lessons learned should be accessible to its management and staff. (Ref: 2016 OAG Audit Report paragraphs 1.50 and 1.49)

Observations

HSECD, ERAD and RP within RPD

HSECD, ERAD and RP specialists discussed the lessons learned during post-inspection meetings with DPRR inspectors in 2017–18. DERPA specialists rely on site inspectors to provide them with the electronic document folder number, as DERPA inspectors do not have direct access to the lessons-learned documents to inform future inspections. Although DERPA specialists completed inspections with DNCFR and DNSR in 2017–18, DNCFR and DNSR rarely communicated the lessons learned to DERPA specialists. Lessons learned help improve the conduct of inspections and should be discussed and documented after each inspection.

DS within RPD

DS does not have any procedures in place to capture and document lessons learned; it did not document any lessons learned in 2017–18. Opportunities exist for better consistency when capturing, recording and sharing lessons learned from site and other inspections.

Lessons learned help improve the conduct of inspections and are to be discussed and documented after each inspection.

Conclusion

HSECD, ERAD and RPD did not have direct access to the lessons learned from inspections conducted during the 2017–18 fiscal year, as documented by DPRR site inspectors. HSECD, ERAD and RP did not discuss or document the lessons learned with DNCFR and DNSR in 2017–18. DS did not document lessons learned for inspections conducted in 2017–18. Opportunities for improvement exist for ensuring that DERPA staff participate in and document lessons learned and that the lessons learned are easily accessible to management and staff.

Recommendation 3

It is recommended that:

  1. DERPA (HSECD, ERAD and RPD) establish and implement within its inspection procedures lessons learned that are captured, documented and addressed in a consistent way to continuously improve its inspection practices
  2. DERPA (DS) develop and incorporate a lessons-learned procedure into its inspection process
  3. Once this procedure has been finalized and approved, it should be clearly communicated to DERPA staff and management, and to the appropriate ROB staff

Management response and action plan

Management agrees:

  1. The lessons-learned process is a vital element for continuous improvement and will be incorporated into the inspection procedure document for DERPA staff that will be prepared in response to Recommendation 2.
  2. The lessons-learned process is a vital element for continuous improvement and will be incorporated into the inspection procedure document for DS that will be prepared in response to Recommendation 1.
  3. The results of these actions will be communicated to DERPA and ROB staff and management.

Target date for completion

April 2020: Response and action plan item a

August 2020: Response and action plan item b

August 2020: Response to action plan item c

2.3 Line of Enquiry 3 – Reporting inspections

Criterion 3.1

DERPA should participate in and/or issue timely final inspection reports.
(Ref: 2016 OAG Audit Report paragraphs 1.61 and 1.60)

Observations

HSECD, ERAD and RP within RPD

HSECD, ERAD and RPD follow service standards established in the DPRR, DNCFR and DNSR planning processes and procedures. DERPA specialists, with the exception of DS, participate in the following aspects of the inspection: drafting compliance criteria, populating compliance checklist and drafting inspection analyses for the report. DERPA specialists also determine whether the licensees’ radiation protection programs and environmental protection programs meet the regulatory requirements. Specialists help draft the final inspection report. However, the date of completion of these activities was not consistently documented. It was challenging for the review team to assess the timeliness of final inspection reports because in some cases, inspection checklists and reports were not dated.

In 2017–18, final inspection reports were finalized or signed by the site lead inspectors and ROB directors only. There was no consistency in how reports were prepared. For example, it was unclear who was responsible for providing input, producing the reports and finalizing these reports. The review report indicated the absence of a final review and sign-off of DERPA contributions. Opportunities for improvement exist to clarify the roles and responsibilities of DERPA specialists in preparing and drafting the final inspection report.

DS within RPD

DS has not established service standards or standard practices for drafting, reviewing and approving its inspection reports. It was challenging for the review team, in some cases, to access the dosimetry files because the specialist responsible for them was no longer with the CNSC. Opportunities exist to improve the DS inspection process and establish service standards that include roles and responsibilities.

Conclusion

While DERPA specialists, with the exception of DS, performed most aspects of the inspections, they did not consistently record the date of their contribution to the final report and the date of submission to the lead inspector. As a result, it remains uncertain whether DERPA staff completed their work within the service standard timeline, particularly in cases where the final inspection report was issued by the lead inspector outside of this service standard. In 2017–18, the final inspection reports were finalized or signed by the site lead inspectors and ROB directors only. DS does not have an established service standard for issuing its final inspection reports.

Recommendation 4

It is recommended that:

  1. DERPA (HSECD, ERAD and RPD) update its tracking system for inspection data to include the completion date of their contribution to the final inspection report, and maintain this system in order to monitor its service standards, as set out in CNSC inspection processes.
  2. DERPA (DS) develop and implement a service standard in its procedures for issuing final inspection reports. Once the procedures have been developed and approved, they should be clearly communicated to appropriate staff.

Management response and action plan

Management agrees:

  1. Tracking of dates on which DERPA staff contribute to inspection reports will be incorporated into the DERPA staff inspection procedure document developed in response to Recommendation 2.
  2. The development of a service standard and the requirement to track completion dates will be incorporated into the inspection procedure document for DS that will be developed in response to Recommendation 1. The results will be communicated to the appropriate staff.

Target date for completion

April 2020: Response and action plan item a

August 2020: Response and action plan item b

3. Overall Conclusion

Overall, DERPA has adequate processes in place or relies on processes from lead inspectors from DPRR, DNCFR and DNSR to plan and conduct its inspections. For the most part, the inspection planning processes DERPA uses are systematic and risk-informed. Opportunities for improvement were identified and associated recommendations were made.

HSECD, ERAD and RP had adequate planning processes in place for the purpose of their inspections. The opportunity exists to include DS in the RPD planning process to ensure that the process is systematic and risk-informed, and that it includes the minimum required frequency and type of inspections, as well as detailed criteria to determine when to conduct Type I inspections.

All three selected divisions of DERPA (HSECD, ERAD and RPD) followed established procedures to conduct their inspections. Opportunities exist for DERPA to improve its inspection procedures and for DS to develop and implement inspection procedures.

Lessons-learned sessions were not systematically held and documented by DERPA specialists. The opportunity exists to improve DERPA procedures by documenting and sharing lessons learned.

DERPA processes need improvement to track the completion date of its contribution to the final inspection report and indicate whether the established service standard timeline was met. DS needs to establish clear service standards for issuing final inspection reports.

The review report includes four recommendations for addressing the areas of improvement noted above. Management agrees with the recommendations and its response indicates its commitment to take action.

Appendix A: Findings and Recommendations of the 2016 OAG Audit Report

The following table is an excerpt from the findings and recommendations in the 2016 OAG Audit Report. The numbers in the table indicate the paragraph in the report where each recommendation appears.

Findings Recommendations

Planning inspections

The Canadian Nuclear Safety Commission could not show that it had an adequate, systematic, risk-informed process for planning site inspections at nuclear power plants.

1.33 The Canadian Nuclear Safety Commission should develop and implement a well-documented planning process for site inspections of nuclear power plants that can demonstrate that the process is systematic and risk-informed. This should include determining the minimum required frequency and type of inspections needed to verify compliance, updating the five-year baseline inspection plan, and assessing whether it is assigning the appropriate number and levels of staff to carry out the number of inspections required to verify compliance.
1.35 The Canadian Nuclear Safety Commission should develop detailed criteria to help it identify when to conduct Type I inspections.

Conducting inspections

The Canadian Nuclear Safety Commission did not always follow its own inspection procedures.

1.48 The Canadian Nuclear Safety Commission should ensure that its inspections follow its own procedures. This requires that it develop approved inspection guides with appropriate criteria before conducting inspections to assess that nuclear power plants are complying with applicable regulatory and licence requirements. The Canadian Nuclear Safety Commission should also clearly explain to its staff how to decide which documents should be considered transitory and which documents should be retained after they issue inspection reports.
1.50 The Canadian Nuclear Safety Commission should ensure that it documents lessons learned in carrying out its inspections, to help it make continuous improvements to its inspection practices.

Enforcing compliance with regulatory and licence requirements

The Canadian Nuclear Safety Commission followed up to confirm that nuclear power plants corrected compliance violations it identified, but did not always issue final reports on time.

1.61 The Canadian Nuclear Safety Commission should determine why it does not issue timely final inspection reports and decide whether it needs to make any changes to its processes or standards.

Appendix B: 2019 Review Lines of Enquiry and Criteria

The Office of Audit and Ethics used OAG recommendations for the Lines of Enquiry and Criteria.

Line of Enquiry 1 – Planning inspections
Review Criteria Review Sub-criteria

1.1 The CNSC’s inspections, including DERPA’s, should follow well-documented planning processes that are systematic, risk-informed and risk-basedFootnote *, and should specify the minimum required frequency and type of inspections. (Ref: 2016 OAG Audit Report, paragraphs 1.33, 1.21 and 1.32)

1.1.1 DERPA should implement a CNSC well-documented planning process and the plan should demonstrate a systematic and risk-informed process.
1.1.2 DERPA planning process demonstrates minimum required frequency and type of inspections needed to verify compliance.
1.2 The CNSC’s inspection processes, including DERPA’s, should include detailed criteria to help determine when to conduct Type I inspections. (Ref: 2016 OAG Audit Report paragraphs 1.33, 1.21, 1.32, 1.35, and 1.34) 1.2.1 DERPA should implement CNSC detailed criteria to help it identify when to conduct Type I inspections.
Line of Enquiry 2 – Conducting inspections
Review Criteria Review Sub-criteria

2.1 DERPA should ensure that its inspections follow the procedures. (Ref: 2016 OAG Audit Report paragraphs 1.48, 1.43 and 1.47)

2.1.1 DERPA should develop and implement inspection guides for each inspection beforehand setting out key steps and criteria.

2.1.2 DERPA should clearly communicate with staff:

  • which inspection records should be considered transitory
  • which inspection records should be retained after the  inspection reports are issued
2.2 DERPA should document and/or participate in lessons learned in carrying out inspections and a record of the lessons learned should be accessible to its management and staff. (Ref: 2016 OAG Audit Report paragraphs 1.50 and 1.49)

2.2.1 DERPA should document lessons learned in carrying out its inspections to help it make continuous improvement to its inspection practices.

2.2.2 DERPA management and staff have access to the lessons learned carried out after completing inspections.

Line of Enquiry 3 – Reporting inspections
Review Criterion Review Sub-criterion
3.1 DERPA should participate in and/or issue timely final inspection reports. (Ref: 2016 OAG Audit Report paragraphs 1.61 and 1.60) 3.1.1 DERPA should document and/or participate in documenting inspections in final inspection reports in a timely manner to address the safety and control issues noted during an inspection.

Appendix C: 2019 Review Recommendations and Management Action Plan

Planning Inspections
OAE Recommendation DERPA Management Action Plan (MAP) Target Completion Date

Criteria 1.1 and 1.2 – Recommendation 1

It is recommended that:

  1. DERPA (DS) develop and implement a risk-informed inspection planning process that describes the minimum required frequency and type of inspections needed for DS to ensure compliance. This should include detailed criteria for identifying when to conduct a Type I inspection.
  2. Once the planning process is finalized and approved, in this case by Director of RPD and Director General of DERPA, it should be clearly communicated.

Management agreed:

  1. DERPA’s inspection plan will be updated to indicate the minimum frequency and type of inspection (Type I or Type II).
  2. The approved and documented plan will be communicated to all CNSC stakeholders.
August 2020
Conducting Inspections
OAE Recommendation DERPA Management Action Plan (MAP) Target Completion Date

Sub-criterion 2.1.1 – Recommendation 2

It is recommended that:

  1. DERPA (HSECD, ERAD, and RPD) establish and implement procedures that document DERPA specialists’ contribution to revising and signing off on the criteria and scope of the inspection compliance matrices and checklists. The procedures should include a requirement for DERPA directors to review and sign off on the matrices and checklists.
  2. DERPA (DS) develop and implement inspection procedures, which include the responsibilities of specialists and provides a standardized approach for conducting inspections and  completing checklists, reports and lessons learned.
  3. Once procedures are finalized and approved, they should be clearly communicated to DERPA staff and management and to the appropriate ROB staff.

Management agreed:

  1. DERPA will establish and implement a DERPA procedure document that covers all DERPA subject matter experts’ roles in inspections.
  2. Inspection procedures for dosimetry services are intrinsically linked to the management response and action plan for Recommendation 1 and will be included in this response and action plan.
  3. Once this response and action plan is completed, it will be clearly communicated to the appropriate staff in DERPA and ROB.
  1. April 2020
  2. August 2020
  3. August 2020

Criterion 2.2 – Recommendation 3

It is recommended that:

  1. DERPA (HSECD, ERAD, and RPD) establish and implement within its procedures that deficiencies and lessons learned are captured, documented and addressed in a consistent way to help make continuous improvements to its inspection practices.
  2. DERPA (DS) develop a lessons-learned procedure and incorporated it into its inspection process.
  3. Once this procedure has been finalized and approved, it should be clearly communicated to DERPA staff and management, and to the appropriate ROB staff

Management agreed:

  1. The process of lessons learned is a vital element for continuous improvement, and will be incorporated into the inspection procedure document that results from the response to Recommendation 2 for DERPA staff.
  2. The process of lessons learned is a vital element for continuous improvement, and will be incorporated into the inspection procedural document for dosimetry services that results from the response to Recommendation 1.
  3. The results of these actions will be communicated to DERPA and ROB staff and management.
  1. April 2020
  2. August 2020
  3. August 2020
Reporting Inspections
OAE Recommendation DERPA Management Action Plan (MAP) Target Completion Date

Criterion 3.1 – Recommendation 4

It is recommended that:

  1. DERPA (HSECD, ERAD, and RPD) update its tracking system for inspection data to include the completion date of their contribution to the final inspection report and maintain this system to monitor its service standard, as established in CNSC inspection processes.
  2. DERPA (DS) develop and implement a service standard for issuing final inspection reports in its procedures. Once these procedures have been developed and approved, they should be clearly communicated.

Management agreed:

  1. Tracking of dates on which DERPA staff contribute to inspection reports will be incorporated into DERPA staff inspection procedure document that will be developed in response to Recommendation 2.
  2. A service standard will be developed and the requirement to track completion dates will be incorporated into the inspection procedure document for dosimetry services that will be developed in response to Recommendation 1. The results of these actions will be communicated to the appropriate staff.
  1. April 2020
  2. August 2020

Appendix D: Acronyms

The following table presents acronyms used in this document.

ACFD
Accelerators and Class II Facilities Division
CNSC
Canadian Nuclear Safety Commission
DAA
Directorate of Assessment and Analysis
DERPA
Directorate of Environmental and Radiation Protection and Assessment
DNCFR
Directorate of Nuclear Cycle and Facilities Regulation
DNSR
Directorate of Nuclear Substance Regulation
DPRR
Directorate of Power Reactor Regulation
DS
dosimetry services
DSM
Directorate of Safety Management
DSS
Directorate of Security and Safeguards
EA
environmental assessment
EAD
Environmental Assessment Division
EMS
 Environmental management system
ERAD
Environmental Risk Assessment Division
HSECD
Health Sciences and Environmental Compliance Division
LSD
Laboratory Services Division
MAP
management action plan
NPP
nuclear power plant
NSCA
Nuclear Safety and Control Act
OAE
Office of Audit and Ethics
OAG
Office of the Auditor General
OID
Operations Inspection Division
OMC
Operations Management Committee
PRRP
Power Reactor Regulatory Program
ROB
Regulatory Operations Branch
RP
radiation protection
RPD
Radiation Protection Division
SME
subject matter expert
TSB
Technical Support Branch

>Endnotes

Footnote 1

A review provides broad or targeted information about the nature and scope agreed to with the engagement client with less depth and coverage than an audit. When performing a review, the internal auditor maintains independence and objectivity, but does not provide the same level of assurance to management on governance, risk management and process controls.

Return to 1 referrer

Footnote *

Risk-informed vs. risk-based:

Risk informed – A risk-informed approach relies more on judgment and on consideration of various deterministic factors for decision-making.

Risk based – A risk-based approach uses known risk metrics as the basis for decision making.

Return to * referrer

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