ML043520027

Audit of the Licensee'S Management of Regulatory Commitments

ML043520027
Person / Time
Site:	Grand Gulf
Issue date:	01/14/2005
From:	Bhalchandra Vaidya NRC/NRR/DLPM/LPD4
To:	Gerald Williams Entergy Operations
vaidya B, NRR/DLPM, 415-3308
References
TAC MC4983
Download: ML043520027 (12)

Text

January 14, 2005 Mr. George A. Williams Site Vice President Grand Gulf Nuclear Station Entergy Operations, Inc.

P.O. Box 756 Port Gibson, MS 39150

SUBJECT:

GRAND GULF NUCLEAR STATION, UNIT 1 - AUDIT OF THE LICENSEES MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. MC4983)

Dear Mr. Williams:

An audit of the Entergy Operations, Inc. (EOI) commitment management program was performed at the Grand Gulf Nuclear Station, Unit 1 plant on December 7 through 9, 2004. The U. S. Nuclear Regulatory Commission (NRC) staff concludes that, based on the audit, (1) EOI has established an effective commitment management program, (2) EOI has implemented NRC commitments on a timely basis, and (3) with some minor inconsistencies, which were discussed with the licensee during the exit meeting on December 10, 2004, EOI has implemented an effective program for managing NRC commitment changes. Details of the audit are set forth in the enclosed audit report.

The NRC staff appreciates the resources that were made available by your staff for performing the audit. If you have any questions, I may be reached at (301) 415-3308.

Sincerely,

/RA/

Bhalchandra K. Vaidya, Project Manager, Section 1 Project Directorate IV Division of Licensing Project Management Office of Nuclear Reactor Regulation Docket No. 50-416

Enclosure:

Audit Report cc w/encl: See next page

Mr. George A. Williams Site Vice President Grand Gulf Nuclear Station Entergy Operations, Inc.

P.O. Box 756 Port Gibson, MS 39150

SUBJECT:

GRAND GULF NUCLEAR STATION, UNIT 1 - AUDIT OF THE LICENSEES MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. MC4983)

Dear Mr. Williams:

An audit of the Entergy Operations, Inc. (EOI) commitment management program was performed at the Grand Gulf Nuclear Station, Unit 1 plant on December 7 through 9, 2004. The U. S. Nuclear Regulatory Commission (NRC) staff concludes that, based on the audit, (1) EOI has established an effective commitment management program, (2) EOI has implemented NRC commitments on a timely basis, and (3) with some minor inconsistencies, which were discussed with the licensee during the exit meeting on December 10, 2004, EOI has implemented an effective program for managing NRC commitment changes. Details of the audit are set forth in the enclosed audit report.

The NRC staff appreciates the resources that were made available by your staff for performing the audit. If you have any questions, I may be reached at (301) 415-3308.

Sincerely,

/RA/

Bhalchandra K. Vaidya, Project Manager, Section 1 Project Directorate IV Division of Licensing Project Management Office of Nuclear Reactor Regulation Docket No. 50-416

Enclosure:

Audit Report cc w/encl: See next page DISTRIBUTION: RidsNrrDlpmLpdiv1 (MWebb) RidsNrrPMBVaidya PUBLIC RidsNrrLADJohnson Mkotzalas PDIV-1 r/f RidsAcrsAcnwMailCenter RidsRgn4MailCenter (AHowell)

RidsOgcMailCenter MThorpe-Kavanaugh Accession No.: ML043520027 NRR-106 OFFICE PDIV-1/PM PDIV-1/PM PDIV-1/LA PDIV-1/SC(A)

NAME BVaidya MThorpe-Kavanaugh DJohnson MWebb DATE 1/11/05 1/11/05 1/11/05 1/14/05 OFFICIAL RECORD COPY

AUDIT REPORT BY THE OFFICE OF NUCLEAR REACTOR REGULATION (NRR)

AUDIT OF ENTERGY OPERATIONS, INC. (EOI) MANAGEMENT OF REGULATORY COMMITMENTS MADE BY EOI TO THE NUCLEAR REGULATORY COMMISSION (NRC)

GRAND GULF NUCLEAR STATION, UNIT 1 (GGNS)

DOCKET NO. 50-416

1.0 INTRODUCTION AND BACKGROUND

On September 7, 2004, NRR Office Instruction LIC-105, Revision 1, Managing Regulatory Commitments Made by Licensees to the NRC, was published. LIC-105, which is publicly available electronically from the Agencywide Documents Access and Management Systems (ADAMS) Public Electronic Reading Room on the Internet at the NRC website (Accession Number ML042320463), provides the NRC staff and its stakeholders with a common reference for handling regulatory commitments made by licensees of commercial nuclear reactors to the NRC staff. The guidance is consistent with the industry guidance prepared by the Nuclear Energy Institute (NEI), NEI 99-04, Guidance for Managing NRC Commitment Changes.

According to LIC-105, which cites the definition from NEI 99-04, a regulatory commitment is an explicit statement to take a specific action agreed to, or volunteered by, a licensee and submitted in writing on the docket to the NRC. LIC-105 further directs the NRR Project Manager to audit the licensees commitment management program by assessing the adequacy of the licensees implementation of a sample of commitments made to the NRC in past licensing actions (amendments, reliefs, exemptions, etc.) and activities (bulletins, generic letters, etc.). The audit is to be performed every three years.

2.0 AUDIT SCOPE AND RESULTS 2.1 Audit Scope The audit was performed at the GGNS site December 7 through 9, 2004. Since no such audit was performed prior to the issuance of LIC-105, the NRC staff defined the period covered by this audit to encompass approximately three to four years prior to the date of the audit.

LIC-105 limits the audit of commitments to those made in writing to the NRC as a result of past licensing actions (amendments, exemptions, etc.) or licensing activities (bulletins, generic letters, etc.). Prior to the audit, in order to generate a list of items for the audit, the NRC staff searched ADAMS for EOIs (or the licensees) licensing action and licensing activity submittals dated in the last three to four years, and also asked the licensee to provide a list of regulatory

commitments related to licensing actions from its commitment management system. Then from this list, the NRC staff selected a representative sample of regulatory commitments to audit and asked the licensee to provide documentation to support the audit.

In addition, the NRC staff selected a sample of items from GGNS Commitment Change Summary Reports, dated April 15, 2004, covering the period from November 1, 2002, to March 31, 2004, (which was provided by the licensee). The NRC staff again ensured that the sample selected related to the licensees licensing action and licensing activity submittals and asked the licensee to provide documentation to support the audit.

The licensee provided the list and the documentation to support the NRC staff's audit in each of the sample areas discussed above. The licensee's documentation included summary sheets providing the status of the commitment and appropriate backup documentation, as needed (i.e.,

plant procedures, examination records, and/or other plant documentation). The attached table lists the commitments selected for this audit.

2.2 Verification of Licensees Implementation of NRC Commitments The primary focus of this part of the audit was to confirm that the licensee has implemented those commitments made to the NRC as part of past licensing actions/activities. For commitments that had not yet been implemented, the NRC staff aimed to ascertain that they have been captured in an effective program for future implementation.

The licensees Commitment Management Program (CMS) is described in the licensee procedure LI-110, Revision 0, dated February 15, 2001. The licensee enters commitments made to the NRC into a commitment database. This database is used to track all commitments, including the regulatory commitments, obligations, promises, etc. However, the LI-110 does not require the program to remind the responsible department when the expected completion date approaches. The completion of the commitment is tracked via Commitment Closure Verification Form (CCVF).

The NRC staff found that the licensee's procedure LI-110 is consistent with the guidance in NEI 99-04.

The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitment Changes, Relief Requests, and GGNS Amendments, to assess the implementation of the licensees procedure LI-110, including the status of their completion. For the sample of commitments selected for the audit, the NRC staff found that the licensees commitment tracking program had captured all of the regulatory commitments and the program reflected their status consistent with the program.

However, the NRC staff noted that implementation of the program had some minor inconsistencies. These observations are described Section 2.4.

2.3 Verification of the Licensees Program for Managing NRC Commitment Changes 2.3.1 Change Control Procedure Verification The NRC staff reviewed the licensees procedure LI-110, against NEI 99-04. Changes to a commitment are reviewed by Plant Licensing Management and by the organization that made

the change to the commitment. The Commitment Change Evaluation (CCE) Form is used to document the evaluation of the commitment change.

The NRC staff found that the licensee's procedure for handling the commitment change is consistent with the guidance in NEI 99-04.

2.3.2 Procedure Implementation Assessment 2.3.2.1 Commitment Changes Reported to the NRC The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitment Change. The NRC staff found that, with a few minor inconsistencies, the licensee had properly addressed each regulatory commitment change selected for this audit and that the licensee had implemented an effective program to manage commitment changes. The NRC staff observations and suggestions are described in Section 2.4.

2.3.2.2 Commitment Changes Not Reported to the NRC The licensee indicated that they report all commitment changes to the NRC. The NRC staff selected a sample of items from GGNS Commitment Change Summary Reports, dated April 15, 2004, covering the period from November 1, 2002, to March 31, 2004. All items were reported to NRC. Therefore, this section is not applicable.

2.3.2.3 Notifications to the NRC of Commitment Changes The licensee indicated that they have not had any prompt notifications of commitment changes other than the licensee letter dated July 22, 2004, regarding the commitment change with respect to the Regulatory Commitment related to Kaowool Replacement. Regarding periodic notification of commitment changes, the licensee routinely provides these reports. As indicated above, the last such report was submitted on April 15, 2004.

2.3.2.4 Traceability of Commitments Although not specifically stated in the guidance from NEI 99-04, according to LIC-105, traceability of the commitments is advantageous for the licensees CMS. The licensees procedure, LI-110, refers to a licensee procedure titled, "Directive Submittal Requirements for RPTS [Requirements Procedure Tracking System]." In Section 5.1 of LI-110, it states "RPTS is a computerized program into which GGNS Requirements are entered and cross referenced to GGNS procedures, instructions, organizations, etc., that provides implementation of requirements." In Section 6.1.3, it states "All GGNS Operations Manual Administrative and Section Procedures that are new or revised, must have a Requirements Cross-Reference List developed." Also, the note in Section 6.2.4 states "A Requirements Cross-Reference List must reflect any commitment (especially those enforceable) that requires implementation by GGNS Directive. This also includes commitments made in GNRIs, GNRO, [Licensee documents] etc."

LI-110, Section 5.6 addresses the procedure to process the changes to the Implementing Procedure, transfer of ownership for commitment implementation from one department to another, etc. It describes that a commitment report, listing the affected commitments, is generated to assess the impact of the changes to the implementing procedure on the satisfactory completion of the affected commitments. The significant revisions to the implementing procedure are reviewed by the Plant Licensing Department. Responsible departments are encouraged to review all commitments implemented by their procedures for database accuracy, to ensure that commitments are maintained in their entirety, and to utilize the CLE Process to eliminate proceduralized steps incorporated by commitments that have negligible safety significance and/or regulatory interest.

The NRC staff found that the licensees commitments, with a few minor inconsistencies, were traceable. These inconsistencies are described in Section 2.4.

2.4 Audit Observations and Suggestions As stated above, the licensees CMS and the procedure LI-110 are consistent with the NEI Guidance, NEI 99-04. However, the NRC staff has made the following observations during the audit and believes that implementation of suggestions would enhance the process toward clearer understanding of the term Regulatory Commitments, proper use of the CCE Form, and add consistency to the implementation process:

1. The NRC staff noted that since the commitment tracking program is also used to track commitments other than regulatory commitments, the use of this procedure might identify regulatory commitments as a separate category. This would facilitate better tracking and reporting of the status of regulatory commitments, including the changes.

2. The NRC staff noted that when completing the CCE Form, the description of the Source Document needs to have sufficient details, such as the date of the document, in order to be able to trace the commitment change to the specific source document.

3. The NRC staff noted minor inconsistencies in the implementation of similar commitments involving the process used for changing the type of a commitment from

?Passive to Active (Commitment Numbers A35269, P35213, and A35275) and the process used for closing the documents (Commitment Numbers A35217, A35290, and A35207). Also, several terminologies were not used in a consistent manner, e.g.,

Active, Passive, Open, Closed, SAT, Continuous compliance, Closure Document versus Implementing Document, Origination Date, Implementation Date, Completed Date, and Closure Date. When closing/completing a commitment, it would be helpful to add clarification and confirmation in the database, such as a completed task note in the Status Section. The NRC staff believes that clearer instructions for the use of commitment processes and terminologies would help to add consistency in implementation.

4. The NRC staff noted a questionable use of the CCE Form. The CCE Form was used to indicate a change in the approved alternative to the American Society of Mechanical Engineers Boiler and Pressure Vessel Code (performance-based testing program) for CCE 2002-0009 and for CCE 2003-0009, to delete the relief originally approved by NRC by committing to comply with another paragraph of the applicable code. Both cases are

not Regulatory Commitments. Therefore, codified processes should have been used to evaluate these changes. Apparently, while completing Section 1.1 of the checklist in the CCE Form, it did not lead the preparer to the 10 CFR 50.55(a) change evaluation process. While this example did not require a change requiring prior NRC approval, the instructions for filling out the CCE Form, Section 1.1 of the licensees procedure, need to make it clear that the CCE Form should not be used instead of codified processes, such as 10 CFR 50.55, 10 CFR 50.59, in addition to 10 CFR 50.71(e) and 10 CFR 50.54, as currently specified on the CCE Form.

5. In two additional cases, CCE 2003-0004 and CCE 2003-0010, the CCE Form was used to indicate completion of the required actions. This was an incorrect use of the CCE Form. The CCVF described in licensee procedure LI-110 should have been used.

Again, clearer instructions are needed for implementing the process.

3.0 CONCLUSION

The NRC staff concludes that, based on the above audit, (1) EOI has established an effective commitment mangement program, (2) EOI has implemented NRC commitments on a timely basis, and (3) with some minor inconsistencies, which were discussed with the licensee during the exit meeting on December 10, 2004, EOI has implemented an effective program for managing NRC commitment changes.

4.0 LICENSEE PERSONNEL CONTACTED FOR THIS AUDIT Bill Abrahams and Matt Crawford Principal Contributors: B. K. Vaidya M. Thorpe-Kavanaugh Date: January 14, 2005

AUDIT OF ENTERGY OPERATIONS, INC. (ENTERGY) MANAGEMENT OF REGULATORY COMMITMENTS AT GRAND GULF NUCLEAR STATION, UNIT 1 (GGNS)

PERFORMED DURING DECEMBER 7 THROUGH DECEMBER 9, 2004 LIST OF COMMITMENTS INCLUDED IN THE AUDIT Item Category Commitment Description of Commitment Number Number 1 Commitment A-35091 (Instead of original commitment date of Change Status: Open 12/31/2004,) by 12/31/2005, GGNS plans to replace our Appendix R required fire barriers currently protected with Kaowool Fire Wrap with a fire wrap that satisfies all applicable NRC regulatory and technical requirements. (TAC No. MB0262) 2 Commitment A-35092 Compensatory measures (fire watches),

Change Status: Open consistent with the requirements of our Fire Protection Program have been implemented and will remain in effect until all corrective actions are complete by 12/31/2005 (fire watches to be removed as compliance is restored). (TAC No.

MB0262) 3 Commitment A-35093 In the interim, we will periodically keep NRC Change Status: Open apprised of the progress of our proposed resolution strategy. Quarterly Recurring Commitment until 12/31/2005. (TAC No.

MB0262) 4 Commitment CCE-2002- Valve P53F006 seat leakage will be tested at a Change 0009 frequency not to exceed 60 months versus every Originally 18 months. (TAC No. 87209)

P23936 Status: Not Applicable 5 Commitment CCE-2003- Delete the commitment to track and trend Change 0004 Rosemount transmitters that are susceptible to Originally fill-oil loss. (TAC No. M85392) 25027 Status: Not Applicable

Item Category Commitment Description of Commitment Number Number 6 Commitment CCE-2003- Check valves E38F002A/B and E38F003A/B will Change 0009 no longer be disassembled and inspected on a Originally sample basis. Instead, they will be full stroke 34432 opened and closed on a cold shutdown frequency per Ma-1988, Part 10. (TAC No.

MA0196) 7 Commitment CCE-2003- Delete commitment to perform a parametric Change 0010, study at the uprated conditions to quantify the Original impact of Thermal Power Optimization on GGNS A35207 wear rates and update the CHECWORKS model Status: as necessary. (TAC No. MB3972, Amendment Nuclear #156 for 1.7% Measurement Uncertainity (MU)

Energy Power Uprate)

Institute 8 Relief A-35288 Entergy will implement a code repair to remove Request Status: the degradation at the next scheduled outage Closed with a duration of 30 days or more, but no later than the next refueling outage (spring 2004).

(TAC No. MB6970. Also, Amendment #165) 9 Relief A-35321, Entergy will comply with the generic letter by Request Originally, performing a volumetric examination of the A-35289, repair at least every 3 months. (TAC No.

Status: MB6970. Also, Amendment #165)

Closed 10 Relief A-35290 Entergy will qualitatively assess Standby Service Request Status: Water leakage using normal operator rounds Closed and system engineering trending on at least a weekly basis. (TAC No. MB6970. Also, Amendment #165) 11 Relief A-35105 As part of root cause determination for the Request Status: degraded elbow, Entergy will perform destructive Closed metallurgical testing of the degraded elbow to aid in determining the actual cause of the pinhole leak. This determination will be completed six months following replacement of the elbow. (TAC No. MB1919) 12 Relief A-35106 The elbow will be replaced during the next Request Status: scheduled refueling outage. (TAC No. MB1919)

Closed

Item Category Commitment Description of Commitment Number Number 13 Relief A-35107 Initially, Ultrasonic Test (UT) measurements of Request Status: the weld overlay will be obtained after each of Closed the first two pump starts. These measurements will be evaluated to predict the maximum degradation of the weld overlay for its design life, which is the balance of the present operating cycle. Future inspections will be scheduled based upon the results of the evaluation as follows:

• UT measurements will be taken after every three pump starts, provided the maximum predicted degradation results in an overlay thickness that meets minimum design thickness requirements through the present operating cycle.

• UT measurements will continue to be performed after each pump start if the maximum predicted degradation results in an overlay thickness that does not meet minimum design thickness requirements through the present cycle.

(TAC No. MB1919) 14 Amendment A-35427 Each licensee should verify that it has, and make Status: a regulatory commitment to maintain, a Closed hydrogen monitoring system capable of diagnosing beyond design-basis accidents.

(TAC No. MC2177, Amendment #166) 15 Amendment P-35347 Operating procedures will require the Turbine Status: Trip/Throttle Valve to be maintained closed Satisfactorily during plant startup whenever the reactor core being isolation cooling (RCIC) steam supply line implemented penetration is not isolated and the low pressure (SAT) automatic isolation function is not available. This will preclude any inadvertent turbine operation while warming the steam lines at low pressure.

(TAC No. MB8958, Amendment #162)

Item Category Commitment Description of Commitment Number Number 16 Amendment P-35349 Because the RCIC turbine exhaust line vacuum Status: SAT breaker isolation valves will not have automatic isolation capability while the steam supply low pressure permissive signal is unavailable, operating procedures will require the valves to remain closed until the RCIC steam supply low pressure instrumentation is restored. (TAC No.

MB8958, Amendment #162) 17 Amendment A-35327 Entergy will perform new fluence calculation by Status: December 2006. A neutron fluence calculation Closed methodology, which has been approved by the Nuclear Regulatory Commission staff and is consistent with the attributes identified in United States NRC Regulatory Guide 1.190, Calculational and Dosimetry Methods for Determining Pressure Vessel Neutron Fluence, will be used for determination of Reactor Pressure Vessel and surveillance capsule neutron fluence values. (TAC No. MB8393, Amendment #160) 18 Amendment A-35328 Based on the results of this updated fluence Status: Open analysis [as stated above] and the results/data available through the Boiling Water Reactor Internals Program for the reactor vessel surveillance capsule testing, the current pressure/temperature limit curves will be reevaluated for validity and new ones will be developed, if needed. (TAC No. MB8393, Amendment #160) 19 Amendment A-35268 The reactor thermal power will be Status: administratively controlled at a level consistent Closed with the accuracy of the available instrumentation until the Leading Edge Flow Meter (LEFM) CheckPlusTM system is returned to an operable status. The administrative controls will be added to the GGNS technical requirements manual. (TAC No. MB3972, Amendment #156 for 1.7% MU Power Uprate)

Item Category Commitment Description of Commitment Number Number 20 Amendment P-35269 The Plant erosion/corrosion program currently Status: SAT monitors the affected systems. Continued monitoring of the systems provides confidence in the integrity of susceptible high-energy piping systems. Appropriate changes to piping inspection frequency will be implemented to ensure adequate margin exists for those systems with changing process conditions.

(Thermal Power Optimization Safety Analysis Report (TSAR) Section 3.5.2) (TAC No.

MB3972, Amendment #156 for 1.7% MU Power Uprate) 21 Amendment P-35275 Minor changes to power/flow map, flow-Status: SAT referenced set point, and the like will be communicated through normal operator training.

Simulator changes and validation for the Thermal Power Optimization uprate will be performed in accordance with American National Standards Institute/American Nuclear Society 3.5-1985. (TSAR Section 10.6) (TAC No.

MB3972, Amendment #156 for 1.7% MU Power Uprate) 22 Amendment P-35213 Calibration and maintenance work will be Status: SAT performed in accordance with Caldon recommendations. (TAC No. MB3972, Amendment #156 for 1.7% MU Power Uprate) 23 Amendment A-35216 If the plant experiences a down power of greater Status: than 10% during a 72-hour period, the permitted Closed maximum power level would be reduced to 3833 MWt upon return to full power, since a plant transient may result in calibration changes of the venturis (e.g., defouling). (TAC No. MB3972, Amendment #156 for 1.7% MU Power Uprate)

Amendment A-35217 With LEFM out of service for more than the 24 Status: above allowed outage time, GGNS will limit Closed power to the original licensed power level of 3833 MWt. (TAC No. MB3972, Amendment

1. 156 for 1.7% MU Power Uprate)

Item Category Commitment Description of Commitment Number Number 25 Amendment A-35218 Entergy will evaluate the risk metrics for the Status: Diesel Generator (DG) extended Allowable Closed Outage Time using the updated risk model, when available and provide a summary of the results to the NRC staff. (TAC No. MB3973, Amendment #151) 26 Amendment P-35223 High Pressure Injection Systems (High Pressure Status: SAT Core Spray (HPCS) and RCIC) will not be taken out of service for planned maintenance while DG A (Division 1) or DG B (Division 2) is out of service for extended maintenance. (TAC No.

MB3973, Amendment #151) 27 Amendment P-35221 The condition of offsite power supply and Status: SAT switchyard will be evaluated prior to entering the extended maintenance period. (TAC No.

MB3973, Amendment #151)

Notes: A - active commitment P - passive commitment

Grand Gulf Nuclear Station cc:

Executive Vice President Attorney General

& Chief Operating Officer Department of Justice Entergy Operations, Inc. State of Louisiana P. O. Box 31995 P. O. Box 94005 Jackson, MS 39286-1995 Baton Rouge, LA 70804-9005 Wise, Carter, Child & Caraway State Health Officer P. O. Box 651 State Board of Health Jackson, MS 39205 P. O. Box 1700 Jackson, MS 39205 Winston & Strawn 1400 L Street, N.W. - 12th Floor Office of the Governor Washington, DC 20005-3502 State of Mississippi Jackson, MS 39201 Chief Energy and Transportation Branch Attorney General Environmental Compliance and Asst. Attorney General Enforcement Division State of Mississippi Mississippi Department of Environmental P. O. Box 22947 Quality Jackson, MS 39225 P. O. Box 10385 Jackson, MS 39289-0385 Vice President, Operations Support Entergy Operations, Inc.

President P.O. Box 31995 Claiborne County Jackson, MS 39286-1995 Board of Supervisors P. O. Box 339 Director Port Gibson, MS 39150 Nuclear Safety Assurance Entergy Operations, Inc.

Regional Administrator, Region IV P. O. Box 756 U.S. Nuclear Regulatory Commission Port Gibson, MS 39150 611 Ryan Plaza Drive, Suite 400 Arlington, TX 76011-8064 Director Nuclear Safety & Licensing Senior Resident Inspector Entergy Operations, Inc.

U. S. Nuclear Regulatory Commission 1340 Echelon Parkway P. O. Box 399 Jackson, MS 39213-8298 Port Gibson, MS 39150 General Manager, GGNS Entergy Operations, Inc.

P. O. Box 756 Port Gibson, MS 39150 June 2004