ML080420004

Audit of the Licensees Management of Regulatory Commitments

ML080420004
Person / Time
Site:	Palisades
Issue date:	02/26/2008
From:	Mahesh Chawla NRC/NRR/ADRO/DORL/LPLIII-1
To:	Balduzzi M Entergy Nuclear Operations
Chawla, ML, NRR/DLPM/LPD III-2, 415-8371
References
TAC MD6188
Download: ML080420004 (16)

Text

Mr. Michael Balduzzi February 26, 2008 Sr. Vice President, Regional Operations NE Entergy Nuclear Operations, Inc.

440 Hamilton Avenue White Plains, NY 10601

SUBJECT:

PALISADES NUCLEAR PLANT - AUDIT OF THE LICENSEES MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. MD6188)

Dear Mr. Balduzzi:

An audit of the Nuclear Management Company commitment management program was performed at the Palisades Nuclear Plant (PNP) site on August 27 through 31, 2007. The U.S.

Nuclear Regulatory Commission (NRC) staff concludes that, based on the audit, (1) PNP has established an effective commitment management program, (2) PNP 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 August 31, 2007, PNP has implemented an effective program for managing NRC commitment changes.

Details of the audit are set forth in the enclosed audit report. This audit report covers the commitment management program current at the time of the audit. You may have changed the commitment management program after the audit which is beyond the scope of this 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) 415-8371.

Sincerely,

/RA/

Mahesh Chawla, Project Manager Plant Licensing Branch III-1 Division of Licensing Project Management Office of Nuclear Reactor Regulation Docket No. 50-255

Enclosure:

Audit Report cc w/encl: See next page

Palisades Plant cc:

Supervisor Covert Township P. O. Box 35 Covert, MI 49043 Office of the Governor P. O. Box 30013 Lansing, MI 48909 U.S. Nuclear Regulatory Commission Resident Inspector's Office Palisades Plant 27782 Blue Star Memorial Highway Covert, MI 49043 Michigan Department Of Environmental Quality Waste and Hazardous Materials Division Hazardous Waste and Radiological Protection Section Nuclear Facilities Unit Constitution Hall, Lower-Level North 525 West Allegan Street P.O. Box 30241 Lansing, MI 48909-7741 Michigan Department of Attorney General Special Litigation Division 525 West Ottawa St.

Sixth Floor, G. Mennen Williams Building Lansing, MI 48913 Mr. Michael R. Kansler President & CEO/CNO Entergy Nuclear Operations 1340 Echelon Parkway Jackson, MS 39213 Mr. John T. Herron Sr. Vice President Entergy Nuclear Operations 1340 Echelon Parkway Jackson, MS 39213 Sr. Vice President, Engineering and Technical Services Entergy Nuclear Operations, Inc.

1340 Echelon Parkway Jackson, MS 39213 Mr. Christopher J. Schwarz Site Vice President Entergy Nuclear Operations Palisades Nuclear Plant 27780 Blue Star Memorial Highway Covert, MI 49043 General Manager, Plant Operations Entergy Nuclear Operations Palisades Nuclear Plant 27780 Blue Star Memorial Highway Covert, MI 49043 Mr. Oscar Limpias Vice President, Engineering Entergy Nuclear Operations 1340 Echelon Parkway Jackson, MS 39213 Mr. John F. McCann Director, Nuclear Safety & Licensing Entergy Nuclear Operations 440 Hamilton Avenue White Plains, NY 10601 Ms. Charlene D. Faison Manager, Licensing Entergy Nuclear Operations 440 Hamilton Avenue White Plains, NY 10601 Mr. Ernest J. Harkness Director, Oversight Entergy Nuclear Operations 1340 Echelon Parkway Jackson, MS 39213 Mr. William C. Dennis Assistant General Counsel Entergy Nuclear Operations 440 Hamilton Avenue White Plains, NY 10601 Mr. Joseph P. DeRoy VP, Operations Support Entergy Nuclear Operations, Inc.

1340 Echelon Parkway Jackson, MS 39213 Ms. Laurie A. Lahti Manager, Licensing Palisades Nuclear Plant 27780 Blue Star Memorial Highway Covert, MI 49043 Mr. John A. Ventosa GM, Engineering Entergy Nuclear Operations 440 Hamilton Aveune White Plains, NY 10601 Director, NSA Palisades Nuclear Plant 27780 Blue Star Memorial Highway Covert, MI 49043 Mr. William DiProfio 48 Bear Hill Road Newton, NH 03858 Mr. William T. Russell 400 Plantation Lane Stevensville, MD 21666 Mr. Gary Randolph 1750 Ben Franklin Drive, 7E Sarasota, FL 34246

ML080420004 OFFICE LPL3-1/PM LPL3-1/LA LPL3-1/BC(A)

NAME MChawla THarris PMilano DATE 2/25/08 2/25/08 2/26/08

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

AUDIT OF NUCLEAR MANAGEMENT COMPANY (NMC) MANAGEMENT OF REGULATORY COMMITMENTS MADE BY NMC TO THE NUCLEAR REGULATORY COMMISSION (NRC)

PALISADES NUCLEAR PLANT DOCKET NO. 50-255

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 No. 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 3 years.

2.0 AUDIT SCOPE AND RESULTS 2.1 Audit Scope The audit was performed at the Palisades Nuclear Plant (PNP) site from August 27 through 31, 2007. 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 8 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 performed Public, Web-Based ADAMS search for commitments listed in licensing action and licensing activity submittals dated in the last 8 years. From this list, the NRC staff selected a representative sample of regulatory commitments to audit. The selection of the sample list covered a variety of systems, disciplines and licensing actions important to NRC staffs decision-

making process. This list also included commitment changes. The licensee was also asked to provide a list of regulatory commitments related to licensing actions from its commitment management system. 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 is described in the Nuclear Management Company, LLC (NMC or the licensee) Policy NRC Commitment Management, Policy Number OP 0001, Rev. 0, dated October 2, 2002, and NMC generated Fleet Guidance Document FG-R-CM-01, Rev. 0, dated May 8, 2006, which superseded commitment management procedure No. 3.14, Rev. 9. The policy document does not provide any detailed instructions on how to manage commitments such as how to enter them in the existing database or change them. Also it does not provide any details on the existing tracking mechanism for the commitments. The fleet guidance document, FG-R-CM- 01 provides guidance on commitment management. However, it also does not describe the existing databases used to track commitments.

Interviews with the Palisades personnel provided the information on the existing tracking mechanism for commitments. At present, the licensee enters commitments made to the NRC into a commitment database called PassPort. The PassPort system handles the commitments which are open or active. The other terms used at the site for this category are approved or in progress. This database is used to track all commitments, including the regulatory commitments.

It also tracks other plant activities besides the commitments. The commitments are entered under the category of general action request (GAR). The commitments get an action request (A/R) number assigned by the system. The A/R Type is entered as a GAR. The assignment type is entered as COMM. This indicates that this action is a commitment. Also entered are the due date and the responsible individual for meeting the commitment.

The system, however, does not provide any automatic reminders to the individual when the due date approaches. The Licensing Department Technical Specialist III performs this function during periodic review of the existing open commitments. Individuals assigned for completing a NRC Commitment are responsible for updating PassPort upon completion of the commitment, and also providing the necessary documents to Licensing Department. The Licensing Department Technical Specialist III reviews and closes the commitment in PassPort. The commitments that are carried into plant procedures upon completion are called Resident Commitments or Ongoing Commitments. These commitments are manually entered into another database, Corrective Action Commitment Tracking Industry System (CACTIS).

The NRC staff found that the licensee's procedures OP 001, Rev. 0 and FG-R-CM-01, Rev. 0 meet the intent and are consistent with the guidance provided in NEI 99-04. There is however, one issue with the compliance of section 4.2.2 in OP 001, Rev. 0. This step states the responsibility to ensure the NRC Senior Resident Inspector is kept current on commitment changes. The discussions with the commitment co-ordinator revealed that this is not being done at Palisades. The Senior Resident Inspector (SRI), however, receives the annual report of Changes, Tests and Experiments, also known as 50.59 reported.

There is also a concern with the several older commitments which were made in response to License Event Reports (LERs), Notices of Violation (NOVs) and Inspection Reports (IRs). The definition of NRC commitment changed to the effect that these would no longer be considered commitments. However, at Palisades these commitments were incorporated into plant procedures. Over the course of time these procedures have been revised, and the commitment descriptions were also changed. These however did not get proper oversight from the SRIs because the SRIs are not kept current on the commitment changes. An example of such occurrence is documented in Condition Report, CR-PLP-2007-03172. It states, Corrective actions from a 1995 NRC inspection (IR95007/CMT952010267) have not been effectively implemented and maintained. There is also minor discrepancy in the title of Commitment Change Evaluation Form, FG-R-CM-01. It is referred to as Regulatory Commitment Change Request Form in step 5.3.1 of procedure FG-R-CM-01.

The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitments in response to different category of documents such as PNP Amendments, QA Topical Report, Bulletins and Generic Letters to assess the implementation of the licensees procedures, including the status of their completion.

The licensee has made changes to the Commitments using the Commitment Change Evaluation (CCE) Form. However, filling of CCE form to make a commitment change is not strictly adhered to. The Commitment Change process is being used to close the Commitments in response to the old LERs, NOVs and IRs, since these are no longer considered to be Commitments. 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. The review of PassPort system reflected their status consistent with the program. However, the NRC staff noted that implementation of the program had some minor deficiencies. 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 procedures OP 0001, Rev. 0, FG-R-CM-01, Rev. 0, and FP-PA-ARP-03, Rev. 2, against NEI 99-04, Revision 0. Regulatory Commitment Changes are processed and tracked by Site Licensing and are approved by the Site Management. The evaluation of any Commitment changes is to be done by filling a CCE form. The NRC staff reviewed this form and found it to be consistent with the Commitment Change Process described in NEI 99-04 with a minor difference. Palisades form CCE has broken out the three questions from the NEI 99-04 form into four questions for determination of significant hazards, thus achieving the same results.

The NRC staff found that the licensee's procedures for handling the commitment change are in general, consistent with the guidance in NEI 99-04.

4 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 there were several commitment changes which were not reported to the NRC. These were related to the old commitments made in response to inspection activities, LERs, etc., which did not meet the definition of commitments in accordance with NEI 99-04.

Therefore, these changes were not reported to the NRC.

2.3.2.3 Notifications to the NRC of Commitment Changes These changes were reviewed and found to be appropriate and acceptable by the NRC Staff.

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 Control of NRC Commitments. The licensees procedure, FG-R-CM-01, step 5.2.2 states, For ongoing commitments that cannot be annotated at individual steps, verify that the commitment is clearly identified in Pupose and/or the Reference section. The NRC staff reviewed the samples and found that to be the case. The commitment numbers were identified in the procedures and thus provided the cross reference. Under the category of Commitment Changes, Section 5.3.1 of FG-R-CM-01 recommends to include the following:

1. Verbatim description of the original commitment to be changed.

2. Identification of the implementing document(s) for the existing commitment.

3. Identification of the source document of the commitment.

4. A detailed description of the proposed change to the commitment to be evaluated. The change may be a revision to the commitment or cancellation of the commitment. If revised, include the exact wording of the proposed revised commitment.

5. Identification of the implementing documents for the proposed revised commitment, if different than the implementing documents for the original commitment.

It was, however, observed on some of the sample CCE forms that the above guidance was not strictly adhered to. For example, Commitment number COMM 922001909, the original description included the change that was being accomplished, causing confusion. Although, the licensee has maintained the traceability of these commitments, it is extremely confusing

5 since the tracking systems have changed from Old Team Track to PassPort and the resident commitments are tracked by CACTIS. The cross reference from one numbering system to another is not provided in any procedure. There are several procedures that govern the commitment tracking process, which is also a major factor of confusion. However, the station does have the capability to search the commitment database in order to retrieve the historical data.

The systems do not generate any reminders to the responsible departments for upcoming due dates. It is left to one individual acting as the coordinator for managing the commitments to ensure that these commitments are properly identified and incorporated into plant design features, procedures, and training programs may result in change in procedures. Procedural steps do provide traceability of the commitments to the procedures and vice versa. Procedure revisions are handled in accordance with Fleet Procedure FP-G-DOC-04, Rev. 4, titled Procedure Processing. Section 5.1.2.2.a of this procedure prompts the user to answer the question if the change is due to a commitment. Also, in Section V.5, the approver has to ensure that the procedure change doe not conflict with NRC commitments. Thus, traceability between commitments and procedural changes is maintained.

2.4 Audit Observations and Suggestions

1. The commitment process uses too many terms such as ongoing, resident, approved and in-progress, to describe commitments, and there is no single procedure which describes the commitment management at the site.

2. The commitment database does not differentiate between NRC commitments and other commitments since they all are entered under a GAR.

3. The completion dates do not reflect the completion of activities and the information is buried into the text.

4. NRC Resident Inspectors are not informed of all the commitment changes. Only the few selected commitment changes go to them for review.

5. The licensee does not strictly adhere to filling of CCE form. Although in some cases it may be trivial to fill the CCE form, adherence to NEI guidance is recommended.

6. The commitment tracking process is not transparent due to absence of having a single procedure, and also due to changeover from old databases to the new ones. This causes confusion in maintaining the traceability of the commitments.

3.0 CONCLUSION

The NRC staff concludes that, based on the above audit, (1) Entergy has established an effective commitment management program, (2) Entergy 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 August 31, 2007, Entergy has implemented an effective program for managing NRC commitment changes.

6 4.0 LICENSEE PERSONNEL CONTACTED FOR THIS AUDIT Barbara Dotson, Laurie Lahti Principal Contributor: Mahesh Chawla

AUDIT OF ENTERGY OPERATIONS, INC. (ENTERGY) MANAGEMENT OF REGULATORY COMMITMENTS AT PALISADES NUCLEAR PLANT PERFORMED DURING AUGUST 27 THROUGH AUGUST 31, 2007 LIST OF COMMITMENTS INCLUDED IN THE AUDIT Item No.

Category Commitment Number Commitment Letter/Date Description of Commitment Status ADAMS ACCESSION NO.

1 Amendment 6/3/2003 NMC will conduct operator training on the proposed power uprate prior to implementation of the proposed power uprate.

Closed ML031611053 2

Amendment 6/3/2003 NMC will revise plant procedures to address operation with the Crossflow ultrasonic flow measurement system out of service prior to implementation of the proposed power uprate.

Closed ML031611053 3

QA Topical Report L-HU 039, Dated 9/22/2004 Implementation of the NMC Quality Assurance Topical Report will be completed throughout NMC within 9 months following NRC approval. (revised commitment).

Closed ML042710439

Item No.

Category Commitment Number Commitment Letter/Date Description of Commitment Status ADAMS ACCESSION NO.

4 Amendment 1/30/2004 NMC has verified that a hydrogen monitoring system capable of diagnosing beyond design-basis accidents is installed at each facility and is making a regulatory commitment to maintain that capability. The hydrogen monitors will be included in the specific document or program identified in, Table 1. This regulatory commitment will be implemented by the implementation date.

Closed ML040330467 5

Bulletin 2003-01 5/17/2004 NMC will implement the following candidate operator actions by March 31, 2005, at the Palisades Nuclear Plant (COA #5 - #9).

Closed ML041410026 6

GL 96-06 1/16/2001 Compliance with Final Safety Analysis Report (FSAR) piping design criteria for the Containment Air Cooler (CAC) discharge piping will be verified prior to the completion of the 2001 refueling outage. (original commitment). Compliance with FSAR piping design criteria for the Containment Air Cooler (CAC) discharge piping, when subjected to realistically predicted waterhammers, will be verified prior to the completion of the refueling outage after the first full operating cycle following the NRC disposition of the industry initiative final report. (revised commitment).

Closed ML010230062

Item No.

Category Commitment Number Commitment Letter/Date Description of Commitment Status ADAMS ACCESSION NO.

7 Bulletin 2003-01 4/4/2006 Superseded COA #5 in Item No. 5 with the following: NMC will initiate transfer to start adding water to the SIRWT following a recirculation actuation signal at PNP. The procedures will be revised and the appropriate personnel will be trained within 90 days following the end of the spring 2006 refueling outage.

Closed ML060940502 8

GL 2003-01 11/23/2004 Perform the ASTM E741 testing [T] and,

[provide] the requested response to GL 2003-01 item 1(a).

Closed ML043420198 9

GL 2003-01 11/23/2004 Verify by ASTM E741 testing that the most limiting in leakage has been incorporated into the hazardous chemical assessments (GL 2003-01 item 1(b) part 1).

Closed ML043420198 10 GL 2003-01 11/23/2004

[Perform a] smoke assessment (GL 2003-01 item 1(b) part 2).

Closed ML043420198 11 GL 2003-01 11/23/2004 Development of technical specification changes (and any associated plant modifications) to support requested information GL 2003-01 item 1(c).

Closed ML043420198 12 Notification of Inoperability 1/14/2004 Full compliance with TS Table 3.3.7-1, Item 19, for core exit temperature in quadrant four, will be restored prior to startup from the next refueling outage.

Closed ML040280397

Item No.

Category Commitment Number Commitment Letter/Date Description of Commitment Status ADAMS ACCESSION NO.

13 Order EA-03-009 9/18/2003 NMC will perform ultrasonic testing of the reactor pressure vessel head penetration nozzles (eight instrumentation nozzles and 45 control rod drive nozzles) to extend 2 inches below the J-groove weld.

Open (1)

ML032731380 14 GL 2004-02 8/25/2005 NMC will implement all corrective actions to resolve GSI-191 prior to plant restart following the fall 2007 refueling outage at Palisades Nuclear Plant.

Open (2)

ML052500280 15 GL 2004-02 8/25/2005 NMC will submit license amendment requests on the safety injection refueling water tank volume and on the replacement strainer surveillance requirements, no later than September 1, 2006, for the Palisades Nuclear Plant.

Withdrawn ML052500280 16 GL 2004-02 8/25/2005 NMC will complete operator training determined to be necessary prior to the start of the 2007 refueling outage at Palisades Nuclear Plant.

Closed ML052500280 17 GL 2004-02 8/25/2005 NMC will review and revise the programmatic controls on debris loading in containment as part of the replacement strainer detailed design. Programmatic controls will be revised prior to the plant restart following the fall 2007 refueling outage at Palisades Nuclear Plant.

Closed ML052500280

1. Ongoing - Inspections continue until reactor head replacement.

2. Extension Received.

Item No.

Category Commitment Number Commitment Letter/Date Description of Commitment Status ADAMS ACCESSION NO.

18 GL 2004-02 8/25/2005 NMC will provide an update to the generic letter response for Palisades Nuclear Plant, within 60 days of acceptance of the final screen design.

Open ML052500280 19 Bulletin 2001-01 3/29/2002 NMC will perform a 100% effective visual examination of the reactor vessel head upper metal surface for the Palisades Plant in accordance with BL 2001-01 during the next refueling outage.

Closed ML021050154 20 Amendment 3/1/2002 Work order process controls for maintenance on containment spray system piping shall require that an engineering evaluation be performed, to determine whether verification is necessary to ensure the containment spray nozzles remain unobstructed.

Closed ML020720101 21 8/11/2000 Following issuance by NEI and endorsement by NRC of revised guidelines for Control Room Habitability analyses, existing Palisades Control Room Habitability analyses of record for radiological releases will be reviewed in light of the new guidelines and revised as required. Revised analyses will be provided for NRC review as appropriate.

Closed ML003742232

Item No.

Category Commitment Number Commitment Letter/Date Description of Commitment Status ADAMS ACCESSION NO.

22 GL 96-04 9/29/2000 RESCINDED: Consumers Energy will perform blackness testing on the Region II spent fuel storage racks during the spring of 2000. The need and timing of additional blackness testing will be based on the results of the 2000 testing and pool information considered to be good indicators of the Boraflex condition (e.g., pool silica concentration).

Closed ML003758966 23 GL 96-04 9/29/2000 If silica concentration in the spent fuel pool indicates significant Boraflex degradation, blackness testing will be performed. [The terms "blackness testing" is used here to correct our December 8, 1997, letter, which used the terms "Boraflex testing".]

Closed ML003758966 24 GL 96-04 9/29/2000 Consumers Energy will pursue changes to Technical Specifications which will eliminate the need to credit Boraflex Poison in Palisades Region II spent fuel pool racks.

Closed ML003758966