ML103620473

Audit of the Licensees Management of Regulatory Commitments

ML103620473
Person / Time
Site:	Davis Besse
Issue date:	12/29/2010
From:	Michael Mahoney Plant Licensing Branch III
To:	Allen B FirstEnergy Nuclear Operating Co
mahoney, m NRR/DORL/LPLIII-2 415-3867
References
tac me5005
Download: ML103620473 (12)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20555*0001 December 29, 2010 Mr. Barry S. Allen Site 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 LICENSEE'S MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. ME5005)

Dear Mr. Allen:

In Regulatory Issue Summary 2000-17, "Managing Regulatory Commitments Made by Power Reactor Licensees to the NRC Staff," dated September 21,2000 (Agencywide Documents Access and Management System Accession No. ML003741774), the U.S. Nuclear Regulatory Commission (NRC) informed licensees that the Nuclear Energy Institute (NEI) document NEI 99-04, "Guidelines for Managing NRC Commitment Changes," contains acceptable guidance for controlling regulatory commitments and encouraged licensees to use the NEI guidance or similar administrative controls to ensure that regulatory commitments are implemented, that changes to the regulatory commitments are evaluated, and when appropriate, reported to the NRC.

The NRC's Office of Nuclear Reactor Regulation has instructed its staff to perform an audit of the licensees' commitment management programs once every 3 years to determine whether the licensees' programs are consistent with the industry guidance in NEI 99-04. and that regulatory commitments are being effectively implemented.

The NRC's staff performed an audit of the Davis-Besse Nuclear Power Station, Unit 1 commitment management program at the site on December 20 and 21, 2010, and reviewed commitments made or changed over the past 3 years. Details of the audit are set forth in the enclosed audit report.

The NRC staff identified observation and has made recommendations which are detailed in the audit report. These observations/recommendations are minor issues, and did not change the conclusion that, based on this audit, that: (1) the licensee has an effective program for managing and implementing regulatory commitments, and (2) the licensee has an effective program for managing changes to regulatory commitment.

RAlien

- 2 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) 415-3857 or email at michael.mahoney@nrc.gov.

Sin.cerely, NIl vy / /

1//

//4i'£~

V~

Michael Mahoney, Project Manager Plant Licensing Branch 111-2 Division of Operating Reactor Licensing Office of Nuclear Reactor Regulation Docket No. 50-346

Enclosure:

As stated cc w/encl: Distribution via Listserv

AUDIT REPORT BY THE OFFICE OF NUCLEAR REACTOR REGULATION LICENSEE MANAGEMENT OF REGULATORY COMMITMENTS FIRST ENERGY NUCLEAR OPERATING COMPANY DAVIS-BESSE NUCLEAR POWER STATION, UNIT 1 DOCKET NO. 50-346

1.0 INTRODUCTION AND BACKGROUND

In U.S. Nuclear Regulator Commission (NRC) Regulatory Issue Summary 2000-17, "Managing Regulatory Commitments Made by Power Reactor Licensees to the NRC Staff," dated September 21, 2000 (Agencywide Documents Access and Management System (ADAMS)

Accession No. ML003741774), the NRC informed licensees that the Nuclear Energy Institute (NEI) document NEI 99-04, "Guidelines for Managing NRC Commitment Changes" (ADAMS Accession No. ML003680088), contains acceptable guidance for controlling regulatory commitments, and encouraged licensees to use the NEI guidance or similar administrative controls to ensure that regulatory commitments are implemented, that changes to the regulatory commitments are evaluated, and when appropriate, reported to the NRC.

The NRC's Office of Nuclear Reactor Regulation (NRR) has instructed its staff to perform an audit of licensees' commitment management programs once every 3 years to determine whether the licensees' programs are consistent with the industry guidance in NEI 99-04, and that regulatory commitments are being effectively implemented.

NEI 99-04 defines a "regulatory commitment" as 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. The NRR guidelines direct the NRR Project Manager to audit the licensee's commitment management program by assessing the adequacy of the licensee's 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 PROCEDURE AND RESULTS The NRC staff performed an audit of the Davis-Besse Nuclear Power Station, Unit 1 (DBNPS) commitment management program at the site on December 20 and 21,2010, and reviewed commitments made by FirstEnergy Nuclear Operating Company (FENOC, the licensee) for DBNPS over the past 3 years. The previous audit was performed on was documented in an audit report dated March 2, 2007 (ADAMS Accession No. ML062700476). For the audit, the NRC staff reviewed a sample of DBNPS regulatory commitments, associated tracking and close-out documentation, and the commitment management program procedures.

The audit consisted of two major parts: (1) verification of the licensee's management and implementation of regulatory commitments, and (2) verification of the licensee's program for managing changes to regulatory commitments.

Enclosure

- 2 2.1 Verification of Licensee's Management and Implementation of Commitments The primary focus of this part of the audit is to confirm that the licensee has managed and implemented commitments made to the NRC as part of past licensing actions/activities in accordance with NRC guidance and approved plant procedures. For commitments not yet implemented, the NRC staff determines whether they have been captured in an effective program for future implementation.

2.1.1 Audit Scope Prior to the audit, in order to generate a list of items for the audit, the NRC staff performed ADAMS searches for commitments and reviewed summary reports from the licensee's commitment tracking database. From the results of these searches, the NRC staff selected a representative sample of regulatory commitments to audit. The sample covered a variety of systems, disciplines, commitment changes, and licensing actions.

The sample excluded the following types of commitments that are internal to licensee processes:

1. Commitments made on the licensee's own initiative among internal organizational components.

2. Commitments that pertain to milestones of licensing actions/activities (e.g.,

respond 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.

3. Commitments made as an internal reminder to take actions to comply with existing regulatory requirements such as regulations, Technical Specifications, and the Updated Final Safety Analysis Report. Fulfillment of these commitments was indicated by the licensee having taken timely action in accordance with the subject requirements.

The specific closed, open, and changed commitments selected for the audit are listed in the tables at the end of this report.

The NRC staff reviewed two licensee procedures related to the Commitment Management Program:

1. Davis-Besse Nuclear Power Station Administrative Procedure NG-RA-00802, Revision 02, "Commitment Management."

2. Davis-Besse Nuclear Power Station Business Practice DBBP-RA-0006, Revision 07, "Commitment Management."

3. Davis-Besse Regulatory Commitment Change Questionnaire, Form DB-0665-0 NG-RA-00802 is the primary procedure for the handling of regulatory commitments. The procedure also allows for processing of internally-identified action items associated with other correspondence or management request.

- 3 This procedure establishes a defined methodology for the assignment, tracking, revision, and closing of commitment tasks.

As stated in NG-RA-00B02, Section 4.12, the licensee defines "Regulatory Commitment" as:

An explicit statement to take a specific action agreed to, or volunteered by FENOC, and submitted in writing on the docket to the NRC. Corrective actions identified by a Notice of Violation Response of Licensee Event Report are not normally considered to be regulatory commitments.

NG-RA-00B02 provides guidance for determining who defines regulatory commitments, who is authorized to make regulatory commitments, and who can sign correspondence to the NRC.

2.1.2 Audit Results The NRC staff reviewed procedure NG-RA-00B02 and business practice DBBP-RA-0006 to determine whether the licensee had an effective program in place to identify, manage, and close commitments made to the NRC as part of licensing actions/activities. In addition, the NRC staff reviewed the selected sample of open and closed commitments to confirm that the licensee had implemented closed commitments appropriately, and that commitments still open had been captured in an effective program for future implementation. In addition to the above-cited procedures, the NRC staff reviewed relevant reports and summary sheets providing the status of each commitment, tracking and change forms, and associated documentation, as appropriate (e.g., plant procedures, examination records, and/or other plant documentation).

The NRC staff compared the guidance in procedures procedure NG-RA-00B02 and business practice DBBP-RA-0006 to the guidance in NEI 99-04. The NRC staff also found that roles and responsibilities, processes, and metrics were clearly identified in the FENOC procedures. As a result of this comparison; the NRC staff found that the FENOC procedures were consistent with the NEI guidance for identifying, managing, and closing commitments.

The licensee's commitments are tracked in a computer database called FileNetB. Based on reports provided by the licensee and on queries of the FileNet8 database during the audit, the NRC staff found that FileNetB is able to provide the necessary information (e.g., summary of the commitment, commitment type, lead department, responsible individual, due date, extensions, closure method and date, and associated historical information) to effectively manage regulatory commitments.

Using FileNetB, the NRC staff was able to verify that the licensee could track when the commitment was made, its implementation status, and where the implementing documents could be found, including applicable procedures or submittals to the NRC. The licensee was also able to readily produce the documents referenced in FileNetB confirming when the licensee made the commitment, when the NRC acknowledged the commitment, and the status of the commitment including when the commitment was closed, modified, or deleted.

The NRC staff reviewed the documentation associated with the sampled closed regulatory commitments, particularly plant procedures that had been revised as a result of the commitments, and found that the commitments reviewed had been closed in a manner that fully

-4 satisfied the commitments made to the NRC. The NRC staff noted that the method of linking specific changes in procedures to specific regulatory commitments had improved over time, resulting in excellent traceability in the most recently-revised procedures. The results of the NRC staffs review of closed regulatory commitments are summarized in Table 1.

The NRC staff found that the licensee's commitment tracking program had captured the sampled open regulatory commitments in sufficient detail to clearly identify the due date, responsible party, and necessary steps/actions required to fully close out the commitment. The results of the NRC staff's review of open regulatory commitments are summarized in Table 1.

In addition, FileNet8 is compliant with NEI 99-04 in that it serves as an internal process to control commitments as recommended by NEI 99-04. FileNet8 appeared to be an effective tool to manage the commitment actions allowing the licensee to be able to provide detailed printouts of the status of audited items. The attached Audit Summary, Table 1, provides details of the audit and its results.

The NRC has made the following observations and where appropriate made recommedations while completing the audit, which are minor in nature:

Procedure NG-RA-00802 discusses creating a Commitment Record (form ED 7973) for each commitment. Most of commitments reviewed did not have a Commitment Record.

The information found in a Commitment Record appeared to be captured in FileNet8.

• As in the previous audit completed, the NRC staff noted that new/revised procedures did not have annotations referring to the commitments associated with the change.

Annotations may serve to prevent future procedure writers from inadvertently deleting or altering an item without first reviewing the commitment change history. The licensee stated that in revising procedures and other plant documents, there are administrative controls that would prevent this from occurring.

It was discussed with the licensee that currently when searching a commitment, there is no way to determine if there are other related commitments (Le. numerous commitments in one letter). Each commitment is tracking individually, however, could be beneficial to have capability to reference other related commitments.

• Procedure NG-RA-00802, note 6.3.1 states that "Regulartory commitments closed by NRC submittals do not require commitment closeout forms." It was discussed with the licensee staff that it could be beneficial for tracking and historical purposes to create closeout forms for all commitments.

All of the above were discussed with your staff during the audit.

The NRC staff found that the licensee's commitment tracking program had adequately captured all of the audited regulatory commitments.

2.2 Verification of the Licensee's Program for Managing Commitment Changes The primary focus of this part of the audit is to verify that the licensee has established administrative controls for modifying or deleting commitments made to the NRC. Accordingly, the NRC staff compared procedure NG-RA-00802 to NEI 99-04 to determine whether the

-5 procedure is consistent with the guidance in NEI 99-04 for evaluating and reporting changes to regulatory commitments. Also, the NRC staff reviewed the documentation associated with a sample of commitment changes.

2.2.1 Audit Results The NRC staff found that NG-RA-00802 follows closely the guidance of NEI 99-04. The NRC staff concludes that the procedure used by the licensee to manage commitment changes is appropriate.

The NRC has made the following observation while completing this portion of the audit, which is minor in nature:

• There was one inconsistency with the NEI guidance. Davis-Besse Regulatory Commitment Change Questionnaire, Form DB-0665-0, Step III is not consistent with Figure A-1, Commitment Management Change Process in NEI 99-04. This was discussed with the licensee.

The NRC staff observed that the licensee had generally complete and accurate records, and had documented the sampled commitment changes, appropriately.

The results of the NRC staff's review of changed regulatory commitments which required NRC notification are summarized in Table 2.

The NRC staff also reviewed a sample of changed regulatory commitments which did not require NRC notification. The results are summarized in Table 3.

3.0 CONCLUSION

The NRC staff concludes, based on this audit, that: (1) the licensee has an effective program for managing and implementing regulatory commitments, and (2) the licensee has an effective program for managing changes to regulatory commitment.

Based on the results of the audit, the NRC staff concludes that the licensee has implemented an effective program to manage current and future regulatory commitments and regulatory commitment changes in accordance with NEI 99-04.

4.0 LICENSEE PERSONNEL CONTACTED FOR THIS AUDIT Kathy Nevins Phil Lashley Gerry Wolf Principal Contributor: M. Mahoney Date: December 29, 2010

- 2 Commitment No.

Description Disposition Auditor's Assessment 021923 Administrative control of penetrations during refueling, Serial 3301 dated 2/12/07.

Commitment Closed 12/4/07.

Commitment Close-Out, CCN No. TSS-07-00037.

Verified that the commitment was closed properly.

Changes required to support this commitment were made to the following documents:

• Containment Leakage Rate Testing Program Manual

• DB-PF-03270 No issues - adequate.

A21976 Commitment related to Pressure-Temperature Limits Report Amendment, Letter No. L-09-072, dated 4/15/09.

Commitment Open.

Commitment is related to LAR which is currently under NRC review. Commitment opened properly.

No issues - adequate.

A21946 Regulatory sensitivity training, Serial 3354 dated 7116109.

Commitment Closed 11/30107. Commitment Close-Out attached with no CNN no. reference.

Verified training was complete on 11/29/07, however the attendance sheet was not attached to Commitment Close-Out form as stated and the form while attached to the commitment did not have a recordable reference number - adequate.

A21943 FENOC's policy on Regulatory Communications assessment, Serial 3350 dated 6/13/07.

Commitment Closed 11/20107. Commitment Close-Out attached with no CCN no. reference.

Verified that commitment was properly closed.

Memorandum FLiC 07-115 dated 10/23/07 includes an assessment of FENOC Policy NOPL PL-4002. No issues - adequate.

A21901 021901 Spent Fuel Pool internal strategy, Serial 3309 dated 1/26/07, Serial 3332 dated 4/19/07 and Serial 3365 dated 8/30/07.

Commitment Closed 11/15/07. Commitment Close-Out, CCN No. DSO 07-00064.

Verified that the commitment was closed properly.

Changes required to support this commitment were made to the following documents:

DB-OP-02600

• PFP-YD-STRA T No issues - adequate.

A21979 TIC phenomenon, Letter L-09-133 dated 7/17/09.

Commitment Closed 08/31/09. Commitment was withdrawn by FENOC.

Correspondence L-09-226 provides details on the withdrawal of this commitment.

No issues - adequate.

- 3 Commitment No.

Description

. Disposition Auditor's Assessment A21959 Licensed operator must have blood levels monitored by FENOC physician, Letter L-07 524 dated 12/28/07.

Commitment Closed 11/30/09. Commitment Close-out, CCN No.

RAS009-00094.

Verified that blood tests were performed through the DBNPS health center as required by the commitment. The commitment was properly closed via letter L-09-278. No issues - adequate.

A21963 Commitment related to Generic Letter 2008

01. Letter No. L-08-132 dated 04/11/08.

Commitment Closed 06/3/10.

Commitment Close-Out, CCN No. NPE-10-00025.

Verified that the commitment was closed properly.

In-field piping segment verifications where completed with the following SAP Orders:

200333035 200375944 200377898 200339951 200377976 200378027 No issues - adequate.

A21989 Commitment related to Confirmatory Action Commitments A21989, Commitment Close-Out, CCN RAS-10-00067 A21990 Letter, L-1 0-178 dated June 11, 2010.

A21990,A21991,A21992, indicates that it applies to A21993 (A21991 -

A21991 A21994 and A21995 are A21995). There could be confusion on whether A21992 Closed 06/29/10.

A21993 could have been closed out with the rest A21993 Commitment Close-Out, of the group and it is not clear in the Commitment A21994 CCN No. RAS-1 0-00067.

Close-Out form. However, the proper A21995 These commitments where commitments were closed and 2 remain open, A21996 superseded by NRC CAL letter R-1 0-138. Also commitment A21996 was created to track RPV head replacement, which is open.

Commitment A21993 is also open.

which is appropriate.

No issues-adequate.

TABLE 2 Audit Summary: Modified and/or Deleted Commitments FirstEnergy Nuclear Operating Company (FENOC)

Davis-Besse Nuclear Power Station, Unit 1 Docket No. 50-346 Commitment No.

Original Commitment Revised Commitment Auditor's Assessment 001479 Components within Q [nuclear safety related] systems are identified as Q on drawings and in equipment specifications.

The Q stamping of drawings was eliminated. Drawings will still clearly define the Q boundaries, but will not require a Q stamp.

FENOC Letter L-08-138 provides a commitment change summary report. Appropriate justification is provided for the change. No issues - adequate.

013478 A semi-annual preventative maintenance (PM) item specifically for cleaning and lubrication of the trip mechanism of each auxiliary feedwater pump turbine will be instituted.

The periodicity was changed to an annual PM.

FENOC Letter L-08-138 provides a commitment change summary report. Appropriate justification is provided for the change. No issues - adequate.

TABLE 3 Audit Summary: Modified and/or Deleted Commitments which did not require NRC notification FirstEnergy Nuclear Operating Company (FENOC)

Davis-Besse Nuclear Power Station, Unit 1 Docket No. 50-346 Commitment No.

Commitment Disposition Auditor's Assessment 016174 Procedures which open CRD trip breakers or initiate diverse scram system (DSS) trips above mode 3 are being revised to include a prerequisite step to verify that two phases are energized on the safety group power supplies prior to testing.

This action will ensure that K11A relay contacts are properly passing the associated motor return SCR gating signals.

Commitment closed 10/6/10, Commitment Close-Out, CCN No.

RAS-10-00111.

Since the creation of this commitment, procedure NG-RA-00802 was revised to appropriately change the definition of a regulatory commitment. This commitment no longer fit the definition of a commitment and was closed. A Regulatory Commitment Change Questionnaire (DB-0665-0) was filled out properly.

No issues - adequate.

015120 This commitment was made in response to NRC Information Notice IN 86-002. The commitment was made to capture motor current traces each outage to monitor MOV containing magnesium rotor for degraded conditions.

Commitment closed 1n/10, Commitment Close-Out, CCN No.

TSS-10-00001.

Since the creation of this commitment, procedure NG-RA-00802 was revised to appropriately change the definition of a regulatory commitment. This commitment no longer fit the definition of a commitment and was closed. A Regulatory Commitment Change Questionnaire (DB-0665-0) was filled out properly.

No issues - adequate.

B.Allen

- 2 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) 415-3857 or email at michael.mahoney@nrc.gov.

Docket No. 50-346

Enclosure:

As stated cc w/encl: Distribution via listserv DISTRI BUTION:

PUBLIC LPL3-2 R/F RidsAcrsAcnw_MailCTR Resource RidsNrrPMDavis-Besse Resource RidsOgcRp Resource JCameron, Rill JRutkowski, SRI Davis-Besse ADAMS ACCESSION No'.. ML103620473 Sincerely, IRA by N.DiFrancesco forI Michael Mahoney, Project Manager Plant Licensing Branch 111-2 Division of Operating Reactor licensing Office of Nuclear Reactor Regulation RidsRgn3MailCenter Resource RidsNrrLpl3-2 Resource RidsNrrLATHarris Resource SMeighan, NRR NRR-106 OFFICE NRRlLPL3-2/PM NRRlLPL3-2/LA NRR/LPL3-2/BC NRRlLPL3-2/PM NAME MMahoney THarris RCarlson(EBrown for}

MMahoney(NDiFrancesco for)

DATE 12/28/10 12/28/10 12/29/10 12/29/10 OFFICIAL RECORD COpy