ML062700476

Audit of the Licensee'S Management of Regulatory Commitments

ML062700476
Person / Time
Site:	Davis Besse
Issue date:	03/02/2007
From:	Thomas Wengert NRC/NRR/ADRO/DORL/LPLIII-2
To:	Bezilla M FirstEnergy Nuclear Operating Co
Campbell S, NRC/NRR/DORL, 415-1486
References
TAC MD2452
Download: ML062700476 (17)

Text

March 2, 2007 Mr. Mark B. Bezilla Vice President FirstEnergy Nuclear Operating Company Davis-Besse Nuclear Power Station Mail Stop A-DB-3080 5501 North State Route 2 Oak Harbor, OH 43449-9760

SUBJECT:

DAVIS-BESSE NUCLEAR POWER STATION, UNIT NO. 1 - AUDIT OF THE LICENSEES MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. MD2452)

Dear Mr. Bezilla:

The Nuclear Regulatory Commission (NRC) staff is required to audit a licensees commitment management program once every 3 years, in accordance with the NRC Office of Nuclear Reactor Regulation Office Instruction LIC-105, Managing Regulatory Commitments Made by Licensees to the NRC. LIC-105 provides the NRC staff and its stakeholders with a common reference for handling regulatory commitments made to the NRC staff by licensees for commercial nuclear reactors. The guidance is consistent with the industry guidance prepared by the Nuclear Energy Institute (NEI) in NEI 99-04, Guidance for Managing NRC Commitment Changes.

An audit of the commitment management program of FirstEnergy Nuclear Operating Company (FENOC, the licensee) for Davis-Besse Nuclear Power Station, Unit No. 1, Facility Operating License No. NPF-3, was performed at the facility from July 5 through July 7, 2006. Based on this audit, the NRC staff concludes that: (1) the licensee had implemented NRC commitments in a timely manner; and (2) the licensee had generally implemented an effective program for managing NRC commitment changes. However, the NRC staff identified that you had not submitted to the NRC a periodic commitment change summary report, as required by your commitment management procedure, since November of 2003. The NRC staff concluded that effective processes and procedures were not in place to ensure these reports were submitted at the proper frequency.

The NRC staff identified three observations during the audit. In Section 2.2 of the enclosed audit report, the NRC staff noted that you did not incorporate the most recent NEI guidance into your commitment management program procedure. Although a minor issue, the NRC staff was concerned that the mechanism used (establishing a commitment) was ineffective for implementing the most current industry guidance during that period. You stated that the new guidance would be captured through the implementation of the operating experience program.

In addition, in Section 2.3, the NRC staff noted that your 2005 audit of the commitment tracking system did not provide documentation of the progress on addressing the issues and weaknesses identified in your 2003 audit report. The NRC staff observed that your quality assurance audit in 2005 was not thorough in addressing and assessing the significant weaknesses mentioned in the 2003 audit regarding the Regulatory Commitment Tracking System. Finally, the 2005 quality assurance audit of the Regulatory Commitment Tracking

M. Bezilla System missed identifying that a periodic commitment change summary report was not submitted to the NRC during the Updated Safety Analysis Report update in June of 2004.

There is no need for the licensee to respond to this letter. The NRC staff appreciates the resources that were made available by your staff during the audit. If you have any questions, please have your staff contact me at (301) 415-4037.

Sincerely,

/RA/

Thomas J. Wengert, Project Manager Plant Licensing Branch III-2 Division of Operating Reactor Licensing Office of Nuclear Reactor Regulation Docket No. 50-346

Enclosure:

Regulatory Commitments Audit Report cc w/encl: See next page

M. Bezilla System missed identifying that a periodic commitment change summary report was not submitted to the NRC during the Updated Safety Analysis Report update in June of 2004.

There is no need for the licensee to respond to this letter. The NRC staff appreciates the resources that were made available by your staff during the audit. If you have any questions, please have your staff contact me at (301) 415-4037.

Sincerely,

/RA/

Thomas J. Wengert, Project Manager Plant Licensing Branch III-2 Division of Operating Reactor Licensing Office of Nuclear Reactor Regulation Docket No. 50-346

Enclosure:

Regulatory Commitments Audit Report cc w/encl: See next page DISTRIBUTION:

PUBLIC LPLIII-2 R/F RidsNrrLAEWhitt RidsOgcRp RidsNrrDorlLpl3-2 RidsRgn3MailCenter RidsAcrsAcwnMailCenter RidsNrrDorlDpr RidsNrrPMTWengert ADAMS Accession Number: ML062700476 OFFICE LPL3-2/PM LPL3-2/LA LPL3-2/BC (A)

NAME TWengert:mw EWhitt MMarshall DATE 3/1/07 3/1/07 3/2/07 OFFICIAL RECORD COPY

Davis-Besse Nuclear Power Station, Unit 1 cc:

Manager, Site Regulatory Compliance Attorney General FirstEnergy Nuclear Operating Company Office of Attorney General Davis-Besse Nuclear Power Station 30 East Broad Street Mail Stop A-DB-3065 Columbus, OH 43216 5501 North State Route 2 Oak Harbor, OH 43449-9760 President, Board of County Commissioners of Ottawa County Director, Ohio Department of Commerce Port Clinton, OH 43252 Division of Industrial Compliance Bureau of Operations & Maintenance President, Board of County 6606 Tussing Road Commissioners of Lucas County P.O. Box 4009 One Government Center, Suite 800 Reynoldsburg, OH 43068-9009 Toledo, OH 43604-6506 Regional Administrator, Region III The Honorable Dennis J. Kucinich U.S. Nuclear Regulatory Commission United States House of Representatives Suite 210 Washington, D.C. 20515 2443 Warrenville Road Lisle, IL 60532-4352 The Honorable Dennis J. Kucinich United States House of Representatives Resident Inspector 14400 Detroit Avenue U.S. Nuclear Regulatory Commission Lakewood, OH 44107 5503 North State Route 2 Oak Harbor, OH 43449-9760 Gary R. Leidich President and Chief Nuclear Officer Dennis Clum FirstEnergy Nuclear Operating Company Radiological Assistance Section Supervisor Mail Stop A-GO-19 Bureau of Radiation Protection 76 South Main Street Ohio Department of Health Akron, OH 44308 P.O. Box 118 Columbus, OH 43266-0118 Joseph J. Hagan Senior Vice President of Operations and Carol OClaire, Chief, Radiological Branch Chief Operating Officer Ohio Emergency Management Agency FirstEnergy Nuclear Operating Company 2855 West Dublin Granville Road Mail Stop A-GO-14 Columbus, OH 43235-2206 76 South Main Street Akron, OH 44308 Zack A. Clayton DERR David W. Jenkins, Attorney Ohio Environmental Protection Agency FirstEnergy Corporation P.O. Box 1049 Mail Stop A-GO-18 Columbus, OH 43266-0149 76 South Main Street Akron, OH 44308 State of Ohio Public Utilities Commission 180 East Broad Street Columbus, OH 43266-0573

Davis-Besse Nuclear Power Station, Unit 1 cc:

Danny L. Pace Senior Vice President, Fleet Engineering FirstEnergy Nuclear Operating Company Mail Stop A-GO-14 76 South Main Street Akron, OH 44308 Manager, Fleet Licensing FirstEnergy Nuclear Operating Company Mail Stop A-GHE-115 395 Ghent Road Akron, OH 44333 Director, Fleet Regulatory Affairs FirstEnergy Nuclear Operating Company Mail Stop A-GHE-315 395 Ghent Road Akron, OH 44333 Jeannie M. Rinckel Vice President, Fleet Oversight FirstEnergy Nuclear Operating Company Mail Stop A-GO-14 76 South Main Street Akron, OH 44308 Richard Anderson Vice President, Nuclear Support FirstEnergy Nuclear Operating Company Mail Stop A-GO-14 76 South Main Street Akron, OH 44308

AUDIT REPORT OF REGULATORY COMMITMENTS MADE BY FIRSTENERGY NUCLEAR OPERATING COMPANY TO THE NUCLEAR REGULATORY COMMISSION DAVIS-BESSE NUCLEAR POWER STATION UNIT 1 DOCKET NO. 50-346

1.0 INTRODUCTION AND BACKGROUND

On September 7, 2004, the U.S. Nuclear Regulatory Commission (NRC) published the Office of Nuclear Reactor Regulation (NRR) Office Instruction LIC-105, Managing Regulatory Commitments Made by Licensees to the NRC, Revision 1 (Agencywide Documents Access and Management System (ADAMS) Accession No. ML042320463). LIC-105 provides the NRC staff and its stakeholders with a common reference for handling regulatory commitments made to the NRC staff by licensees for commercial nuclear reactors. The guidance is consistent with the industry guidance issued by the Nuclear Energy Institute (NEI) in 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, relief requests, exemptions, etc.) and activities (bulletins, generic letters, etc.). The audit is to be performed every 3 years.

2.0 AUDIT PROCEDURE AND RESULTS The audit of the FirstEnergy Nuclear Operating Company (FENOC, the licensee) Commitment Management Program for Davis-Besse Nuclear Power Station, Unit No. 1 (Davis-Besse) was performed at the Davis-Besse facility from July 5 through July 7, 2006. The NRC staff defined the scope of audit to obtain a sample of commitments created as a consequence of licensing actions and generic communications, affecting a variety of systems, structures and components, and involving a variety of technical disciplines. The selection of a valid sample for this initial audit covered a period of approximately 15 years prior to the date of the audit.

In accordance with LIC-105, audits consist of two major parts: (1) verification of the licensees implementation of NRC commitments that have been completed, and (2) verification of the licensees program for managing changes to NRC commitments.

ENCLOSURE

2.1 Verification of Licensees Implementation of NRC Commitments The primary focus of this part of the audit is 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 assessed whether the licensee managed regulatory commitments in an effective program for future implementation.

2.1.1 Audit Scope LIC-105 limits the audit of commitments to those made (or those that should have been made) in writing to the NRC as a result of past licensing actions (license amendments, relief requests, exemptions, etc.) or licensing activities (bulletins, generic letters, etc.). Accordingly, the audit excluded the following types of commitments:

• commitments made on the licensees own initiative among internal organizations.

• commitments that pertain to milestones of licensing actions/activities (e.g., response to an NRC request for additional information by a certain date). Fulfillment of these commitments was indicated by the fact that the subject licensing action/activity was completed.

• commitments made as an internal reminder to take actions to comply with existing regulatory requirements such as regulations, technical specifications, and updated final safety analysis reports. Fulfillment of these commitments was indicated by the licensee having taken timely action in accordance with the subject requirements.

Prior to the audit, in order to generate a list of items for the audit, the NRC staff performed public, web-based ADAMS searches for commitments. From the result of the searches, the NRC staff selected a representative sample of regulatory commitments to audit. The selection of the sample list covered a variety of systems, disciplines, commitment changes, and licensing actions important to the NRC staffs decision-making process. A summary of commitments and changes to commitments that were audited is contained in the attached table.

The licensee provided the documentation to support the NRC staffs audit in each of the sample areas discussed above. The licensees documentation included summary sheets providing the status of the commitment and appropriate backup documentation, as needed (e.g., plant procedures, examination records, and/or other plant documentation). The attached table summarizes the licensees commitments that were audited by the NRC staff and the current status of the licensees commitments.

2.1.2 Audit Results The licensees commitments are tracked in a computer database called CURATOR, as documented in Davis-Besse Business Practice DBBP-RA-0006, Revision 4, Commitment Management, and Administrative Procedure NG-RA-00802, Commitment Management.

CURATOR tracking is a web-based program and is relatively easy to use for accessing commitment documents. CURATOR appears to be able (1) to adequately record activities and, (2) to provide an adequate method of linking together the summary of the issue, the commitment type (e.g., internal or on-going commitments), the lead department, the responsible individual, due date, extensions, closure date and the summary of the issue. The CURATOR database provides an institutional memory over time and across successor systems

performing similar functions. For example, the document used for describing and planning the solution to a problem was formerly identified as a Potential Condition Adverse to Quality Report (PCAQR); the current document used for this purpose is the Condition Report (CR). Some regulatory commitments reviewed during the audit, even those that progressed to a closed condition, spanned the use of both types of documents and associated processes.

The NRC staff also audited commitments that involved orders, exemptions, responses to generic letters and bulletins, and licensee event reports. During the audit, the NRC staff reviewed documents generated by processes in effect during the scope of the audit, and other documents related to the commitments. In general, the NRC staff found that the licensees commitment tracking programs had captured the regulatory commitments that had been identified by the NRC staff prior to the audit.

Additionally, the NRC staff reviewed plant procedures that had been revised as a result of commitments made by the licensee to the NRC. The NRC staff noted that some of the new/revised procedures did not have annotations referring to the commitments associated with the change. An example of this was noted in Commitment Number 19823, which was summarized as operator will confirm the need for Boron Precipitation Control based on reactor coolant system conditions. The commitment was related to a Request for Exemption from 10 CFR 50, Appendix K, for Boric Acid Precipitation Control Methodology, by letter to the NRC dated March 15, 2000. Attachment 12, Establishing Long Term Boron Dilution, to Emergency Procedure DB-OP-02000, RPS, SFAS, SFRCS Trip, or SG Tube Rupture, was added to provide the necessary procedure steps for this confirmation. Although a procedure development form (Procedure Activity Tracking Number TA00-0587) had been initiated to incorporate Mod 97-0074 for long-term boron dilution and new atmospheric vent valves, no note in the body of Attachment 12 existed referencing this as being linked to Commitment Number 19823. The NRC staff believed that annotations would serve to prevent future procedure writers from inadvertently deleting or altering an item without first reviewing the commitment change history.

2.2 Verification of the Licensees Program for Managing NRC Commitment Changes The NRC staff reviewed the licensees process for managing commitment changes. The process is documented in procedure NG-RA-00802. The analysis and implementation of the proposed commitment changes, when required, are documented in Attachment 2, Commitment Change Questionnaire. The attachment was compared to Figure A-1, Commitment Management Change Process, in NEI-99-04. The NRC staff noted an inconsistency between the Attachment 2 and the NEI flow charts regarding a corrective action response to a notice of violation. In the NEI guidance, the licensee is required to determine if a commitment change is necessary and justified and, if so, is required to notify the NRC prior to the original date. Attachment 2, Step III.3(4) is missing the wording prior to the original date.

Additionally, Step 4.19 of the procedure listing the definition of a Regulatory Commitment was inconsistent with the same definition in NEI-99-04.

The NRC staff discussed these inconsistencies with the licensee and determined that the licensee has not implemented the most recent NEI guidance pertaining to commitment management. The licensee implemented the NEI document entitled, Guideline for Management of NRC Commitments, dated December 19, 1995. The licensee had an opportunity to incorporate NEI-99-04 into their procedure for managing regulatory commitments much earlier when Commitment A19937 was generated on September 21, 2000. The commitment identified that the NRC was issuing Regulatory Issue Summary (RIS)00-017 to

inform licensees that NEI-99-04 provides an acceptable way for licensees to control regulatory commitments. Commitment A19937 describes incorporating the NEI-99-04 guidance into procedure NG-NS-00802 (now NG-RA-00802) during subsequent procedure revisions. The due date associated with this commitment was extended five times because the anticipated procedure revision date was changed. The NRC staff observed, in this example, that the licensee did not use the regulatory commitment management tracking program appropriately, in that they used the tracking system to implement newly issued industry guidance, and not for its intended purpose to track regulatory commitments. In addition, the NRC staff concluded that during this period, the licensee did not have an appropriate mechanism for implementing the newly issued industry guidance. On January 12, 2006, the licensee documented in General Action Item Notification 600274296, efforts to develop a FENOC fleet-wide commitment management program, which would include the most recent NEI guidance on commitment management. Consequently, the licensee closed Commitment A19937 to this initiative without incorporating NEI-99-04 into the commitment management procedure. The licensee stated that newly issued industry guidance is currently captured by the Davis-Besse operating experience program.

Additionally, while reviewing NG-RA-00802, the NRC staff noted that Step 6.7.1.b required a periodic commitment change report be submitted to the NRC. A specific time frame for issuing the report was not established in the procedure; however, the licensee had not issued a periodic report to the NRC since November of 2002. The licensee determined that this should have been submitted with the Updated Safety Analysis Report (USAR) updates, which was last completed in June of 2004. The licensee initiated CR 06-02730 to document the NRC staffs concern. The licensee determined that the root cause of this issue was that a process did not exist to ensure the reports were submitted to the NRC at the proper frequency. By letter to the NRC dated August 15, 2006 (ADAMS Accession No. ML062300025), the licensee submitted a regulatory commitment change summary report for May 18, 2002 through May 31, 2006. The licensee reported 73 changes in this commitment change summary report.

The use of the change process was observed during the examination of specific commitments.

Although the licensee did not have the most recent guidance, the current change process generally conformed to the guidance in NEI-99-04 and was effective in determining whether another codified change process (such as 10 CFR 50.59, 10 CFR 50.54, or 10 CFR 50.71(e)),

or a license amendment process was appropriate. Therefore, the NRC staff concluded that the procedures and forms used by the licensee to manage commitments and their changes are generally appropriate and effective.

2.3 Internal Audits of Regulatory Commitment Management The NRC staff reviewed the past two Davis-Besse Nuclear Quality Assessment Quarterly Assessment Reports, DB-C-03-04 and DB-C-05-04, for the quarters covering October 6, 2003 through January 5, 2004, and October 1, 2005 through December 31, 2005, respectively, to determine the licensees assessment of the Davis-Besse Regulatory Commitment Tracking System.

Audit Report DB-C-03-04 noted, among other things, that the regulatory commitment tracking was rated satisfactory and contained the following assessment:

The use of the regulatory commitment tracking system (RCTS) in accordance with station procedures was evaluated. A sampling of correspondence since January 2003 was reviewed. In general, commitments were being properly

identified, documented, updated and implemented. A review of past condition reports was conducted and several exceptions to the implementation of NG-NS-00802, Commitment Tracking, were identified. These were appropriately documented in the corrective action program by Regulatory Affairs.

The licensee stated that the audit, documented in Audit Report DB-C-03-04, consisted of a review of the methodology for establishing, tracking and closure of commitments. From previous assessments, the licensee identified numerous issues and weaknesses with commitments (primarily inputting non-regulatory commitments into the RCTS and documenting these weaknesses in CRs). In the audit report, the licensee noted several positive attributes with the implementation of corrective actions such as the development of a commitment status plan to prioritize and address more important items. The licensee had noted that overall, although the progress to implement corrective actions for the regulatory commitment tracking program was satisfactory, the corrective action program was slow to address significant weaknesses. The licensee provided CR 02-07807 as an example.

Audit Report DB-C-05-04 noted that the RCTS was satisfactory. The audit team identified no deficiencies during quarterly assessment activities and made the following assessment:

The Davis-Besse regulatory commitment system is governed by procedure NG-RA-00802, Commitment Management. This procedure was reviewed for compliance with Nuclear Energy Institute (NEI) Guideline for Managing NRC Commitments (Revision 2, 12/19/95). Based on this review the assessment team concluded that the procedure is in compliance with the NEI guideline.

Procedure NG-RA-00802 is well structured; however, it does require updating to reflect the elimination of quality matrix (Q) commitments. An open notification in SAP is already tracking this change. This procedure and a selection of other procedures were reviewed for compliance with Davis-Besse commitments. The assessor verified that procedures adequately implemented ongoing commitments listed in the tracking database.

The NRC staff noted Audit Report DB-C-05-04 of the RCTS did not provide documentation concerning the progress on addressing numerous issues and weaknesses identified in Audit Report DB-C-03-04. The NRC staff was concerned that without considering Audit Report DB-C-03-05, justifying that the RCTS as satisfactory was questionable. The licensee was unable to explain the reasons the audit team omitted this assessment. The NRC staff determined that the quality assurance audit in 2005 was not thorough in assessing and addressing the significant weaknesses mentioned in the 2003 audit regarding the RCTS. This determination was supported by the fact that the 2005 quality assurance audit did not identify that a periodic commitment change summary report was not submitted to the NRC during the June of 2004 USAR update as mentioned above. The NRC staff determined that the 2005 quality assurance audit report should have reviewed this area since the 2003 quality assurance audit report consisted of a review of the methodology for establishing, tracking and closing out commitments.

3.0 CONCLUSION

The NRC staff concludes that, based on the above audit the licensee has: (1) implemented and is tracking regulatory commitments for future implementation; and (2) implemented a generally effective program to manage regulatory commitment changes. However, the NRC staff concluded that the failure to submit a periodic commitment change report to the NRC as required by the commitment management procedure was caused by ineffective processes and procedures in ensuring these reports were submitted at the proper frequency.

The NRC staff made the following observations during their review of the regulatory commitment management program:

C Implementation of the most recent NEI guidance into the commitment management program procedure was not completed in a timely manner because the due date associated with the commitment initiated to complete this action had been extended on several occasions. As a result, an effective mechanism for timely implementation of the newly issued industry guidance did not exist during that period.

C The 2005 quality assurance audit of the RCTS was not thorough in assessing and addressing the significant weaknesses mentioned in the 2003 quality assurance audit regarding the commitment tracking system.

C The 2005 quality assurance audit of the RCTS failed to identify that a periodic commitment change summary report had not been submitted to the NRC during the USAR update in June of 2004.

4.0 LICENSEE PERSONNEL CONTACTED FOR THIS AUDIT H. Hegrat T. Henderson M. Hess M. Leisure N. Nevins R. Slyker Principal Contributor: S. Campbell Date: March 2, 2007

Audited Davis-Besse Regulatory Commitments Subject to Audit Commitment Auditor's Assessment of the Regulatory Commitment Description Disposition Number disposition (adequate, inadequate)

Licensee Event Report (LER) 86003, Essential 4160 V Bus High Voltage. During periods of plant shutdown, the licensee had received numerous 4160V high voltage alarms. The licensee determined that the high voltage alarms were due to light electrical load on the station transformers during unit outage periods. Since this condition presented the potential for exceeding the voltage Commitment closed rating of safety-related equipment, the licensee committed to 3/26/86 to resident reduce the 4160 V bus voltage upon receipt of an essential bus C1 inspectors closure of LER or D1 high voltage alarm. During performance of the System No formal closure or commitment, however it was captured 01355 in Inspection Report dated Review and Test Program, however, the licensee discovered that it by regulatory commitment tracking system - adequate 6/30/87. The report listed had failed to meet this commitment. The failure was caused by the corrective actions inadequate incorporation of the commitment into design documents taken by the licensee.

and operating procedures. This commitment directed issuing a supplement Fields Change Request (FCR) 85-0244 to initiate changing the taps of start-up transformers 01 and 02 from 1 tap below nominal setting resulting in a reduction of voltage of approximately 2.5 percent to comply with Toledo Edisons present day commitment.

Commitment completed 10/18/85. No LER 86003: FCR 85-0237 was initiated to prepare a drawing for Commitment Closeout Reviewed Drawing E1 Sheet 3, Rev. 6 - found change documentation of station transformer tap settings to provide 01358 Form was filled. Issued implemented. No formal closure or commitment, however additional assurance that station electrical bus voltage is FCR to provide 2 tap it was captured by RCTS. - adequate maintained within previously analyzed limits.

settings for Startup Transformers 01 and 02 LER 86003: Change Procedures AP 3001.14, Essen Bus C1 Commitment closed Reviewed previous procedures and verified changes. No 01360 Voltage Hi Hi/ Lo Lo, and AP 3001.15, Essen Bus D1 Voltage Hi 3/26/86. No Commitment formal closure or commitment, however it was captured by Hi/ Lo Lo, to provide guidance on 4160V high voltage alarm. Closeout Form was filled. RCTS - adequate Verified procedures were changed. DB-OP-06903, Plant Startup, replaced PP 1102.10 and verified that Step 3.3 LER 86003: PP 1102.10, Plant Shutdown and Cooldown Commitment closed requires performance of DB-OP-06900 if load tap changes Procedure, and PP 1102.02, Plant Startup Procedure, will be 01365 5/5/86. No Commitment are not done. Determined that procedure DB-OP-06900, modified to include the appropriate time frame for the station Closeout Form was filled. Plant Heatup, Step 3.2.2 directed taps be changed from transformer tap changes.

position 2 to 3 (shutdown to startup). No formal closure or commitment, however it was captured by RCTS - adequate LER 86003: Establish Long Term Program to Review NRC Correspondence and Incorporate commitments into the Toledo Commitment closed Reviewed TERMS Project Final Report dated 1/6/90.

01366 Edison Licensing Commitment Tracking System. This commitment 1/5/90. Commitment TERMS was eventually replaced by the current CURATOR was satisfied by establishing the Toledo Edison Regulatory Closeout Form filled. system - adequate Management System (TERMS) project.

Commitment Auditor's Assessment of the Regulatory Commitment Description Disposition Number disposition (adequate, inadequate)

Commitment closed Reviewed the licensees safety evaluation dated 7/25/86 7/25/88. No Commitment for FCR 85-0349 to revise the high alarm setpoint for Closeout Form was filled, 01368 4160V safety-related buses C1 and D1 high voltage alarm LER 86003: FCR 85-0349 was initiated to revise the 4160V bus however, intra-company setpoints. The safety evaluation concluded that changing voltage high alarm setpoint to correspond with actual station memorandum dated the high voltage alarm setpoint from 102 percent to transformer tap settings. 10/5/87 requested 105 percent of 4160V provides a margin of 25 V for the closeout of this alarm relay setting without creating nuisance alarms. This commitment because FCR action was completed - adequate.

85-0349 was completed.

GL 81-21, Natural Circulation Cooldown. dated May 5, 1981 - Commitment was changed Toledo Edison justified the selected natural circulation cooldown to reflect 50 degrees/hour rate of 1.5-degrees/hour (Serial Numbers 770, 969 and 1124). By cooldown rate on 1/20/99.

letter to the NRC dated June 4, 1987, Toledo Edison reviewed Change questionnaire GPUN TMI-1 Topical Report 017, Natural Circulation Cooldown filled. Determined that Analysis Without Reactor Vessel Head Void Formation, dated July NRC needed to be By letter to the NRC dated November 15, 2000, Serial 2, 1985, and has concluded that it is applicable to the Davis-Besse informed in next 13824 Number 2678, the licensee notified the NRC in the configuration. Toledo Edison adopted the reports conclusion of 50 Regulatory Commitment Commitment Change Summary Report - adequate degrees/hour cooldown rate but conservatively limited the plant Change. No change cooldown rate of 10-degrees/hour. As demonstrated by the forms were available for Tornado Event of June 24, 1998, there is a need to allow a higher the first revision from natural circulation cooldown rate than 10 degrees/hour. 1.5-degrees/hour to Commitment was changed to use the 50 degrees/hour cooldown 10-degrees/hour cooldown rate. rate.

Commitment closed 8/3/90. Commitment Closeout Form not included. Closed out per No documentation existed demonstrating that a formal LER 90-005 - Class 1E Circuits Passing through containment NRC Inspection Report closeout process was used (i.e., no Commitment Closeout 15713 without adequate fault protection dated April 16, 1990. documenting closeout of Form could be located), however it was captured by the the LER. The report RCTS - adequate stated the backup fault protection will be installed by Mod 90-0036 Commitment closed 15714 LER 90-005: Qualify non-Equipment Qualification (EQ) circuits. 6/11/90. Commitment No issues - adequate Closeout Form filled.

No documentation existed demonstrating that a formal LER 90-005-01: Revision 1 to LER 90-005 (dated 8/3/90) provided Commitment was closed closeout process was used (i.e., no Commitment Closeout 15715 documentation of evaluation of the need to provide backup fault 7/31/90. No Commitment Form could be located), however it was captured by RCTS protection. Closeout Form was filled.

- adequate

Commitment Auditor's Assessment of the Regulatory Commitment Description Disposition Number disposition (adequate, inadequate)

Closed out per NRC Inspection Report No documentation existed demonstrating that formal LER 90-005-01: Revise LER 90-005/Submit letter to NRC documenting closeout of closeout process was used (i.e., no Commitment Closeout 15772 regarding Installing Non 1E backup protection during the 7th the LER. The report Form could be located), however it was captured by RCTS refueling outage. stated the backup fault

- adequate protection will be installed by Mod 90-0036.

LER 90-005-01: There was a total of 34 electrical circuits involving Commitment closed five containment penetrations that did not have backup fault 10/25/91. Commitment protection. This includes both class 1E and non-class 1E circuits. Closeout Form filled.

15853 Backup protection to one of these circuits was provided in the 6th Form indicated that field No issues - adequate refueling outage. Toledo Edison will provide backup fault protection implementation and to both class 1E electrical circuits that are normally energized testing of Mod 90-0036 during power operation by the end of the 7th refueling outage. has been completed.

GL 96-05, Periodic Verification of Design-Basis Capability of Safety-Related Power-Operated Valves: 60-day Written Response 18477 Action completed No issues - adequate to Address GL 96-05: Periodic Verification of Design Basis Capability of SR motor-operated valves ( MOVs) 18478 GL 96-05: 180-day response to Describe MOV Periodic Program Action completed No issues- adequate Commitment was established due to exemption from 10 CFR 50, Appendix K, ECCS Evaluation Models, for Davis-Besse boric acid Change DB-OP-02000 was altered via TA00-587 to add precipitation control (BPC) methodology. A plant modification was Attachment 12. This attachment incorporated the direction 12th refueling outage to add significant improvements in the post necessary by Modification 97-004 for Long Term Boron loss-of-coolant accident (LOCA) methodology by providing two new Dilution. This direction includes direction related to vapor active means of preventing boric acid precipitation within the Commitment closed entrainment.

19819 reactor vessel core region. However, since there are known single 5/12/00. Commitment failure vulnerabilities with the methodology, an exemption from Closeout Form filled. It appears that a commitment was created in the 10 CFR Part 50, Appendix K, Section I.D.1 is required in order to March 15, 2000 letter to provide pressure equalization path credit the methodology per 10 CFR 50.46(a)(1)(ii). This was for DH-1517 and DH-1518 to prevent pressure locking so transmitted to the NRC by letter dated March 15, 2000. valves can open post LOCA. This was not in commitment Commitment required providing specific guidance to operators to list.

ensure no vapor entrainment Exemption from 10 CFR Part 50, Appendix K: Ensure Procedure Commitment closed Verified that EP DB-OP-02000 was changed and made Controls are in Place - Establishing BPC (This was transmitted to 19820 5/8/00. Commitment effective on 5/21/97 to establish BPC. Auditor determined the NRC by letter dated March 15, 2000 for the 10 CFR Part 50, Closeout Form filled this is a repeat of commitment - adequate Appendix K exemption)

Exemption from 10 CFR Part 50, Appendix K: Ensure Procedural Verified that Attachment 12 to DB-OP-02000 was added to Commitment closed Controls are in place - Component cooling water (CCW) Inlet Flow ensure that the temperature of the CCW inlet flow to the 19821 5/8/00. Commitment (This was transmitted to the NRC by letter dated March 15, 2000 decay heat removal (DHR) cooler is at least 95 degrees Closeout Form filled.

for the 10 CFR Part 50, Appendix K exemption) prior to establishing the backup BPC method - adequate

Commitment Auditor's Assessment of the Regulatory Commitment Description Disposition Number disposition (adequate, inadequate)

Verified in Attachment 13 of DB-OP-02000 that instructions Exemption from 10 CFR Part 50, Appendix K: Valves will be Commitment closed to open valves DH-11 and DH-12 after sump switchover opened after sump switchover (This was transmitted to the NRC by 19822 5/8/00. Commitment when reactor coolant system pressure is within design and letter dated March 15, 2000 for the 10 CFR Part 50, Appendix K Closeout Form filled. temperature range for DHR drop line piping and exemption) components. No issues - adequate DB-OP-02000, RPS, SFAS, SFRCS Trip or SG Tube Rupture was altered via TA00-0587 to add Attachment 12.

Commitment closed Exemption from 10 CFR Part 50, Appendix K: Operator Will This attachment incorporated the direction necessary by 19823 5/12/00, Closeout form Confirm Need for BPC Based on RCS Conditions Modification 97-004 for long term boron dilution. This filled direction includes direction related to confirming need for boron precipitation based on RCS conditions - adequate The commitment requires training in conjunction with CR 03-00896 which addresses BCP at Davis-Besse.

CR 03-00896 drove the development and implementation Exemption from 10 CFR Part 50, Appendix K: Complete Operator Commitment closed of ECR 03-0146, Boron Precipitation Control (BPC) 21176 Training - Amending Exemption Appendix K, Boric Acid 9/29/04. Commitment Modification. Training on ECR 03-0146 was completed in Precipitation Control Methodology Closeout Form filled training cycle 03-05. Training on ECR 03-0146 was presented using lesson plan OPS-IER-1035 and tracked under training activity code QRQ-CTC 03 05 adequate Verified Revised procedures: Amending Exemption:

Appendix K, Boric Acid Precipitation Control Methodology.

This change was implemented by ECR 03-0146-01. The following procedures were identified requiring a change to support this commitment.

C DB-OP-0008, Operation and Control of Locked Valves Exemption from 10 CFR Part 50, Appendix K: Revise Procedures - Commitment closed (Rev 5) 21175 Amending Exemption Appendix K, Boric Acid Precipitation Control 3/29/05. Commitment C DB-OP-02000, RPS, SFAS, SFRCS Trip, or SG Tube Methodology Closeout Form filled.

Rupture (Rev 15)

C DB-OP-03004, Locked Valve Verification (rev. 06)

C DB-OP-06012, Decay Heat and Low Pressure Injection System Operating Procedure (Rev. 23)

C DB-OP-06021, Spent Fuel Pool Operating Procedure (Rev. 11)- adequate Exemption from 10 CFR Part 50, Appendix K: Complete USAR Commitment closed USAR Change Notice (UCN) No. 04-091U was initiated on 21177 Changes - Amending Exemption Appendix K, Boric Acid 3/29/05. Commitment 3/29/05 to provide a brief description of the piping and Precipitation Control Methodology Closeout Form filled components for a new method of BPC - adequate

Commitment Auditor's Assessment of the Regulatory Commitment Description Disposition Number disposition (adequate, inadequate)

Commitment closed.

Commitment closeout Form filled. Two options per IEB considered. Per M. Reimer, the 60-day response may not be necessary; the 30-day IEB 05-002: Emergency Preparedness & Response Actions for response will address the 21625 Verified procedures updated. Action completed - adequate Security Based Events issue. Per M. Reimer, Option 1 is being used to submit the written response providing the requested information within the requested time period. Therefore, no 30-day response is required Verified Emergency plan and the EALs were updated by January 20, 2006. RA-EP-01500, Emergency Classification, Revision 5 became effective August 31, Commitment closed IEB 05-002: E-Plan & emergency action levels (EALs) to be 2005. Definitions for the four emergency classifications 21663 1/11/06; closeout form Updated to Reflect Info Provided by NRC IEB 05-002 were updated to reflect the bulletin wording. Security filled EALs in Tab 7.1 were modified to incorporate the new security EAL concepts provided in bulletin for NUREG-0654 EALs - adequate Verified procedural guidance (DB-OP-02544) was Commitment closed IEB 05-002: Implement Proc Guidance. Establish Accelerated Call implemented on September 19, 2005, to establish an 21664 9/19/05, closeout form Following Discovery of Imminent Threat/Attack accelerated call to the NRC following the discovery of an filled imminent threat or attack against the station - adequate Commitment closed DB-OP-02544, RA-EP-02530 and - 02010 updated for IEB 05-002: Conduct Additional Review Onsite Protective actions 21665 1/20/06, closeout form evacuation, sheltering and dispersal of personnel -

for Considerations Discussed in IEB 05-002 filled adequate DB-OP-02544 and RA-EP-02530 updated for rapid IEB 05-002: Consider Development Onsite Protective Measure Commitment closed 21666 response and evacuation to security event, and rapid site Tool Enable Rapid Decision RE: Site Evac Routes 1/20/06 evacuation process, respectively - adequate IEB 05-002: Use Mustering Point established for Subset of Davis-Commitment closed RA-EP-02530 describes the personnel that are required to 21667 Besse Emergency Response Organization, All Others to Response 1/12/06 assemble at the site for credible aircraft threat - adequate described Due date extended from IEB 05-002: Revise E-Plan within 6 months following NRC/FEMA 21668 1/20/06 to 1/20/07, Projected drill schedule changed - adequate Endorsement of New Evaluated Exercise Process extension form completed

Commitment Auditor's Assessment of the Regulatory Commitment Description Disposition Number disposition (adequate, inadequate)

Answered GL by letter dated 2/16/06, Serial Number 3228. Processed amendment to revise TSs GL 06-001, Steam Generator Tube Integrity and Associated related to SG tube 21774 Technical Specifications: SG Tube Integrity & Associated TS No issues - adequate integrity to be consistent; Respond in 30/60 days closeout form completed on May 31, 2006 with TSTF-449, Serial Number 3231, letter dated 5/30/06 GL 06-001: Change Affected TS Bases Pages for Licensing Action 21843 Action completed No issues - adequate Request 05-0009, TS Improvement RE: SG Tube Integrity