ML20059J743

Provides Results of Commitment Mgt Audit Conducted by NRR at Plant on 930510-14

ML20059J743
Person / Time
Site:	Braidwood
Issue date:	01/21/1994
From:	Assa R Office of Nuclear Reactor Regulation
To:	Farrar D COMMONWEALTH EDISON CO.
References
TAC-M86152, NUDOCS 9402010150
Download: ML20059J743 (17)

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January 21, 1994 Docket Nos. STN 50-456 and STN 50-457 Mr. D. L. Farrar Manager, Nuclear Regulatory Services Comonwealth Edison Company Executive Towers West III, Suite 500 1400 OPUS Place Downers Grove, Illinois 60515

SUBJECT:

SPECIAL AUDIT OF CONTROL PROCESSES FOR COMMITMENTS THAT AFFECT THE CURRENT LICENSING BASIS, BRAIDWOOD STATION (TAC M86152)

This letter provides the results of the commitment management audit conducted by the Office of Nuclear Reactor Regulation at the Braidwood Station from-May 10 through 14, 1993.

As you are aware, the staff has conducted audits at a cross-section of reactor plants to assess the processes used by licensees for controlling commitments that affect t% plant's current licensing basis.

Braidwood was the fourth site visited by.he staff, and our audit report is enclosed.

The team focused on three principal areas:

(1) managing commitments made to the Nuclear Regulatory Commission (NRC), (2) reporting changes to commitments made to the NRC, and (3) maintaining and updating the Final Safety Analysis Report (FSAR).

In addition to reviewing the governing programs for these subjects, the team also reviewed the status of commitments made to the NRC in response to specific issues (selected Generic Letters, Bulletins, Licensee Event Reports, and Notices of Violation) in order to examine the programs in actual practice.

The team found that, in general, commitments affecting the plant's current licensing basis were being implemented and maintained. The team did find three separate instances in which the plant staff had changed commitments made in response to Notices of Violation without realizing they were changing commitments.

However, in making the changes that altered the original commitments, the actions taken by the plant staff had preserved the intent of the commitments, thus mitigating the significance of the changes.

The examples are described in detail in the report. The team also found that changes to commitments were evaluated by the Braidwood regulatory assurance group to determine if the NRC should be notified of the change.

Finally, the team found that the commitments it reviewed which affected the FSAR were generally captured by the FSAR updated process. The team did not identify any items of significance in its review of commitments made to the specific

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Mr. D. L. Farrar The team thanks the plant staff for its candor in our discussions and its cooperation in providing the team with the information necessary to conduct an efficient audit.

If you have any questions or comments concerning this report, please contact me at (301) 504-1362 or Eric Leeds at (301) 504-1133.

Sincerely, Orighc!St*M 9v:

Ramin R. Assa, Project Manager Project Directorate III-?.

Division of Reactor Projects - III/IV/V Office of Nuclear Reactor Regulation

Enclosure:

Audit Report cc w/ enclosure:

See next page DISTRIBUTION:

Docket File STN 50-456, 457 NRC & Local PDRs PDIII-2 r/f J. Roe J. Zwolinski J. Dyer T. Clark R. Assa E. Leeds OGC ACRS (10)

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Mr. D. L. Farrar The team thanks the plant staff for its candor.in our discussions and its cooperation in providing the team with the information necessary to conduct'an efficient audit.

If you have any questions or comments concerning this report, please contact me at (301) 504-1362 or Eric Leeds at (301) 504-1133.

Sincerely, Origho!Sf*M Br Ramin R. Assa, Project Manager Project Directorate III-2 Division of Reactor Projects - III/IV/V Office of Nuclear Reactor Regulation

Enclosure:

Audit Report cc w/ enclosure:

See next page j

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DISTRIBUTION:

Docket File STN 50-456, 457 NRC & Local'PDRs

'PDIII-2 r/f J. Roe J. Zwolinski J._ Dyer i

T. Clark R. Assa E. Leeds OGC ACRS (10)

B. Clayton RIII OFC-LA:PDIII-2 PM:PDIII-3 D:EDlJ,]dfh NAME TCLAR d b RASSA (

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DATE l/lh)94 l /2k/94 or /L4/94

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Mr. D. L. Farrar Braidwood Station Commonwealth Edison Company Units 1 and 2 cc:

Mr. William P. Poirier Chairman Westinghouse Electric Corporation Will County Board of Supervisors Energy Systems Business Unit Will County Board Courthouse i

Post Office Box 355, Bay 236 West Joliet, Illinois 60434 Pittsburgh, Pennsylvannia 15230 Ms. Lorraine Creek Joseph Gallo, Esquire Rt. 1, Box 182 Hopkins and Sutter Manteno, Illinois 60950 888 16th Street, N.W., Suite 700 Washington, D.C.

20006 Attorney General 500 South 2nd Street

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Regional Administrator Springfield, Illinois 62701 i

U. S. NRC, Region III 801 Warrenville Road Michael Miller, Esquire Lisle, Illinois 60532-4351 Sidley and Austin One First National Plaza Ms. Bridget Little Rorem Chicago, Illinois 60690 Appleseed Coordinator 117 North Linden Street George L. Edgar Essex, Illinois 60935 Newman & Holtzinger, P.C.

1615 L Street, N.W.

Mr. Edward R. Crass Washington, D.C.

20036 Nuclear Safeguards and Licensing Division Illinois Dept. of Nuclear Safety Sargent & Lundy Engineers Office of Nuclear Facility Safety 55 East Monroe Street 1035 Outer Park Drive Chicago, Illinois 60603 Springfield, Illinois 62704 V. S. Nuclear Regulatory Commission Commonwealth Edison Company Resident Inspectors Office Braidwood Station Manager Rural Route #1, Box 79 Rt. 1, Box 84 Braceville, Illinois 60407 Braceville, Illinois 60407 Mr. Ron Stephens EIS Review Coordinator Illinois Emergency Services U.S. Environmental Protection Agency and Disaster Agency 77 W. Jackson Blvd.

110 East Adams Street Chicago, Illinois 60604-3590 Springfield, Illinois 62706 Howard A. Learner Robert Neur. ann Environmental Law and Policy Office of Public Counsel Center of the Midwest State of Illinois Center 203 North LaSalle Street 100 W. Randolph, Suite 11-300 Suite 1390 Chicago, Illinois 60601 Chicago, Illinois 60601

E1 CLOSURE COMMITMENT MANAGEMENT AUDIT OF THE BRAIDWOOD STATION MAY 10-MAY 14, 1993 1.

Scope and Participants The purpose of the audit conducted at Braidwood was to assess the effectiveness of the licensee's programs for identifying and controlling commitments that af ett the facility's current licensing basis.

The audit focused on three principal areas:

(1) managing commitments made to the U.S.

Nuclear Regulatory Commission (NRC), (2) reporting changes to commitments made to the NRC, and (3) maintaining and updating the final safety analysis report (FSAR). The team reviewed the licensee's administrative procedures involving commitment management, reporting, control of design, configuration, test and experiments, and others. To examine the programs in actual practice, the team-reviewed the status of commitments made by the licensee to the NRC in response to specific issues.

Five of these issues, generic in nature, were the following:

10 CFR 50.62 Anticipated Transients Without Scram (ATWS)

Generic-Letter 89-13 Service Water System Problems Affecting Safety-

.Related Equipment Generic letter 88-14 Instrument Air System Problems Affecting Safety-Related Equipment Bulletin 85-01 Steam Binding of Auxiliary feedwater Pumps NUREG-0737, l.C.5 Procedures for feedback of Operating Experience to Plant Staff The remaining issues were specific to Braidwood, involving licensee commit-ments made in licensee event reports (LERs) and responses to notices of violation (NOVs).

The team relied on standard NRC inspection practices in conducting the review of specific commitments.

In conducting the audit, the team performed system walkdowns, reviewed applicable documentation (including design change packages, training records, and procedures), and interviewed plant staff. A detailed review for each issue specified above is contained in the appendix to this report.

The following NRC personnel participated in this audit:

Eric J. Leeds, Team Leader Steven A. Reynolds Steven R. Stein Ramin R. Assa

l

. II.

Findinos and Ccnclusions The following are the team's findings and conclusions for the three major areas of focus:

(1) commitment management, (2) reporting changes to commitments made to the NRC; and (3) maintaining and updating the FSAR.

Commitment Manaaement: Overall, the team found that, in general, commitments affecting the plant's current licensing basis were being implemented and maintained.

In its review of licensee commitments made in response to specific issues, the team found no significant deficiencies in identifying, tracking, completing and maintaining licensee commitments for design modifications, procedures and programs. The licensee's. processes.for the origination and the permanent revision of plant procedures provided assurance that existing commitments would be incorporated in new and revised procedures.

For plant modifications, the licensee's. design change process did not provide specific guidance to its staff to review previous modifications for commitments. The team did not identify any examples _ in which a committed i

modification was inadvertently altered by a subsequent modification and

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attributed this to the experience level of the engineering organization and the multiple levels of review and approval required by the design change process.

The team found three separate instances in which the licensee was unaware that the plant staff had changed commitments made in response to NOVs. However, in making the changes that altered the original commitments, the actions taken by the plant staff had preserved the intent of the commitments, thus mitigating the significance of the changes. The examples are described in detail in the l

appendix to this report.

i Reportina Chanaes to Commitments Made to the NRC: The team found that the licensee controlled the reporting of changes to commitments made to the NRC.

However, the process for changing commitments made to the NRC, other than those in the Updated FSAR (UFSAR) or technical specifications (TS), was not a

documented in procedures. The Braidwood regulatory assurance' group reviewed l

all changes to commitments (other than FSAR and TS commitments) for significance, age, and effect to determine if.the NRC should be informed of the change.

If the decision was to notify the NRC, the notification was made by docketed letter or revised LER.

As discussed above, the team found three instances.in which commitments had been changed and the regulatory assurance group was not aware of the changes.

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Thus, the changes had not been considered for NRC notification.- However, the 1

-team also foundJseveral examples of the licensee notifying the NRC of changes to commitments-before the commitments were fully implemented. The licensee also provided to the team several examples of the NRC being notified of changes to. commitments, including an FSAR response on diesel generator opera-tions and a program to address NRC concerns about leakage rates for the j

reactor coolant system.

l i

_.. _ ~ _

..Maintainina and Vodatina the Final Safety Analysis Report:

The licensee's programs used in the modification process, the 10 CFR 50.59 safety evaluation process, and the procedure preparation and change process ensured that changes made to the plant were incorporated into the UFSAR as appropriate. The team i

reviewed design changes made to support the installation of the ATWS system; the addition of a sodium bromide injection system, corrosion monitoring.

system, and flush taps for the service water system; changes to the instrument air system; and others. With the exception of a minor change involving the instrument air system, the team found that the changes that affected the UFSAR were captured in the UFSAR update process. With regard to the instrument air system, the licensee had determined that a particulate size more restrictive than originally committed to in the UFSAR was necessary but did not update the UFSAR to reflect this new plant requirement.

f III. Discussion A.

Commitment Manaaement The licensee's programs for managing commitments effectively identified commitments and tracked the commitments to completion.

In its review of licensee commitments made in response to specific issues, the team found no significant deficiencies in identifying, tracking, completing, and maintaining commitments for design modifications, procedures, and programs. The team i

found three separate instances in which the licensee was unaware that the plant staff had changed commitments made in response to NOVs.

However, the actions taken by the plant staff had preserved the intent of the commitments, thus mitigating the safety significance of the changes. The examples are described in detail in the appendix to this report.

i The licensee maintained a single computerized system for tracking commitment-a related items.

The Nuclear Tracking System'(NTS) was used both as an action 1

item tracking system, tracking commitments that, once completed, would be 1

considered closed, and for tracking commitments involving actions on a continuing or periodic basis.

The NTS databas~e was accessible to all Nuclear Operations Division (N00) employees for viewing and reporting.

It contained action items, commitments, and the full text of the' source documents, and had full text search capability by downloading the NTS to another database. The-NTS was a Commonwealth Edison (Ceco) corporate initiative and was part of an integrated database system that included the corporate offices and all six Ceco nuclear facilities. Commitments could be added to the system by each site's regulatory assurance group or by designated corporate licensing personnel.

The licensee's processes for the origination and the permanent revision of plant. procedures provided assurance that existing commitments' would be l

incorporated in new and revised procedures.

The licensee's administrative controls for permanent procedure preparation, revision, deletion and approval, BwAP 1300-2, instructed the preparer to list the commitment tracking numbers in the reference section of the procedure and to designate by asterisk the steps in the procedure written to fulfill commitments.

Instruction was also provided to ensure that a procedure or steps in a procedure written to fulfill commitments would not be changed or deleted without the concurrence of the source of the commitment. The team noted a number of examples of revised

i l procedures in which the applicable steps written to fulfill commitments had been maintained.

However, the team also found a number of examples where the licensee did not identify commitments in the procedures as required by its administrative controls. This inconsistent annotation of procedures was particularly evident in procedures that had been revised before 1990.

The team's concern was the increased potential that when a procedure was revised, commitments that were not well identified might be inadvertently deleted. The licensee was aware of this issue and indicated that one of the regulatory assurance group's goals was the referencing of commitments in procedures.

However, all procedures reviewed by the team, regardless of adequacy of annotation, contained the necessary steps reflective of the licensee's commitments.

i For plant modifications, the licensee's design change process did not provide specific guidance to its staff to review previous modifications for commitments. Although there was no defined process requiring the review of previous commitments for design modifications, the team did not identify any examples in which a committed modification was inadvertently altered by a subsequent modification.

The team attributed this to the experience level of the engineering organization and the multiple levels of review and approval required by the design change process. The team found several examples of modifications being clearly identified as commitments to specific issues.

The team also found several examples of modification packages which did not i

reference the associated commitments.

B.

Reportina Chanaes to Commitments Made to the NRC The licensee controlled the reporting of changes to commitments made to the NRC.

However, the process for changing commitments, other than those in the UFSAR and TS, was not documented in procedures.

Each change in commitment was evaluated individually by the Braidwood regulatory assurance group for commit-ments made in response to notices of violation, generic letters, bulletins, event reports, or by other means. When the regulatory assurance group was notified of a change to such a commitment, it reviewed the change for significance, age, and effect and decided whether or not to inform the NRC of the change.

If the decision was to notify the NRC, the notifica-tion was made by docketed letter or revised licensee event report.

The licensee was considering establishing a policy that would delineate when to inform the NRC of thanges to commitments.

Braidwood's program included, since 1984, procedural requirements to obtain concurrence from the source of a commitment before changing or deleting procedural commitments.

The program also required identifying commitments in procedures as described previously. The team, however, found that not all commitments in procedures were identified and changes to several commitments had been made without informing the regulatory assurance group or without recognizing that the changes affected established commitments. Of these, the most significant commitment that had been changed was the deletion of the special activities shift supervisor position in the new operations organiza-tion.

The-new organization included unit supervisor positions with similar responsibilities. Although the NRC was fully informed of the organizational change, the change was not specifically identified in the communications to

. the NRC, or in the licensee's NTS, as affecting a prior commitment.

None of the other changed commitments were significant or materially affected the intent of the commitment.

The team found several examples of the licensee informing the NRC of changes to commitments before the commitments were fully implemented. The examples included (1) design changes to the ATWS system for which the licensee requested NRC approval before implementing the changes, (2) a change in scope of an engineering evaluation of motor-operated valves in response to a notice of violation, and (3) revised submittal dates for a technical specification amendment in response to another notice of violation. The licensee also provided to the team two other examples of the NRC being notified of changes to commitments.

These examples included (1) an advance notification of changes to a response to an FSAR question on extended diesel generator opera-tion, and (2) cancellation of a valve replacement program begun in response to NRC concerns about leakage rates for the reactor coolant system.

C.

Maintaining and Updatina the Updated Final Safety Analysis Report The licensee controlled updates of the UFSAR through procedures used in the modification process, the 10 CFR 50.59 safety evaluation process, and the procedure preparation and change process.

During the audit, the team reviewed design changes made to support the installation of the ATWS system; the addition of a sodium bromide injection system, corrosion monitoring system and flush taps for the service water system; changes to the instrument air system; and others.

With the exception of a minor change involving the instrument air system, the team found that the changes that affected the UFSAR were captured in the UFSAR update process.

The modification process, the 10 CFR 50.59 safety evaluation process, and the procedure preparation and change process each contained a step or steps that required consideration of whether a UFSAR change was needed. Additionally, each licensee staff member interviewed by the team was aware that considera-tion of UFSAR updates was necessary when a modification was in progress, a 10 CFR 50.59 safety evaluation was being performed, or a procedure was added or changed.

However, no specific guidance was provided in any of the aforementioned processes indicating specific criteria to be used to determine if a UFSAR change was appropriate.

Almost every licensee staff member indicated that judgment and experience were solely relied on when determining what constituted a change to the UFSAR.

The licensee does have a document, N0D-0A.1, " Annual UFSAR Update Directive,"

promulgated by its corporate office, that contained guidance for determining what constituted a change to the UFSAR.

However, according to the licensee staff, it did not appear that the document was being used at all, with the possible exception of some regulatory assurance staff members.

The team found one instance, involving the instrument air system, in which j

the UFSAR should have been updated. The licensee's original commitment in its UFSAR regarding particles in the -instrument air system was to American National Standards Institute (ANSI)-Standard 45.2.1.

After surveying the vendors of its instrument air system components, the licensee determined

i

, that a more appropriate standard would be Instrument Air Society (ISA)

Standard S-7 3 and developed a new criterion for air quality based on that standard. The ISA standard and associated criteria were more restrictive than the ANSI standard discussed in the UFSAR, and the team believed a change to the wording in the UFSAR was necessary to reflect the new information from the equipment manufacturers.

f 1

APPENDIX A - SPECIFIC ISSUES REVIEWED AT BRAIDWOOD STATION

-To examine the implementation of the licensee's programs, the team reviewed the status of commitments made by the licensee to the NRC in regard to the following specific issues:

P 10 CFR 50.62 Anticipated Transients Without Scram Generic Letter 89-13 Service Water System Problems Affecting Safety-Related Equipment Generic Letter 88-14 Instrument Air System Problems Affecting Safety-Related Equipment Bulletin 85-01 Steam Binding of Auxiliary Feedwater Pumps NUREG-0737, I.C.5 Procedures for Feedback of Operating Experience to Plant Staff Notices of Violatinn 50-456/85-48, 50-456/87-35, 50-456/888-13 50-457/89-17, and 50-456/90-23 Licensee Event Reports 456-87-14, 456-87-25, 456-87-35, 456-88-17, 456-88-21, 457-88-09, 457-88-13, 457-89-01, 457-89-07 10 CFR 50,62 Anticipated Transients Without Scram (ATWS)

To identify the licensee's commitments relating to the ATWS rule,10 CFR 50.62, the team reviewed the following documents:

the Westinghouse Owners Group generic submittal and the staff's safety evaluation report (SER) on the generic submittal; the plant-specific submittal and the staff's plant-specific SER; the licensee's responses to Generic Letter (GL) 65-06, " Quality Assurance Guidance for ATWS Equipment that is not Safety Related"; inspection reports; and other letters between the licensee and the staff.

The team verified that all commitments for the ATWS mitigation system had been implemented and maintained.

The team noted that the licensee had changed several commitments after initial NRC approval.

However, the licensee had submitted the changes to the NRC for approval before implementation, and the NRC had approved the changes in commitments.

In addition to the commitments to install the ATWS mitigation system (AMS),

the licensee committed to test the system and. specific equipment every 6 months and during refueling outages. The commitments for testing were to ensure that the AMS was maintained highly reliable. Although these commitments had been implemented, they were not explicitly identified in the licensee's commitment tracking system.

The only commitments identified in the nuclear tracking system (NTS) that related to ATWS were the commitment for installing the AMS and a commitment related to GL 85-06.

The licensee's administrative procedure BwAP 1300-2, Revision 20, " Permanent Procedure Preparation, Revision, Deletion and Approval," required referencing commitments in the implementing documents and annotating the implementing documents to indicate the document satisfied a commitment.

However, the

. surveillance procedures for calibrating the ATWS steam generator level loops did not reference any commitments, and the procedures were not annotated as required by BwAP 1300-2.

The procedures for refueling outage end to end surveillance testing referenced the commitment, but the procedural steps were not annotated as required.

The surveillance procedures for semiannual surveillances did not reference the testing commitment, instead they referenced the commitment for installing the AMS; again these procedures were not annotated as required by BwAP 1300-2.

GL 89-13. " Service Water System Problems Affectina Safety-Related Eauioment" The licensee's commitments in response to GL 89-13 were identified and tracked in the NTS. The licensee's commitments included hardware modifications, procedure changes, and periodic testing. The hardware modifications included the addition of a sodium bromide injection system, a corrosion monitoring system and various flush taps.

All modifications had been installed although the licensee had just recently received permission from the Illinois State Environmental Protection Agency to use the sodium bromide injection system on a limited basis.

The licensee had initiated a heat exchanger testing program and a program to periodically inspect and flush stagnant service water system lines. Maintenance, training, and operating procedures affecting the service water system had been reviewed and, where necessary, modified to meet the licensee's commitments in response to GL 89-13.

The only anomalies identified by the team involved the lack of annotation of the modification packages for the sodium bromide injection system and the flush taps.

At the time GL 89-13 was issued, the licensee was already in the process of installing the flush taps and the sodium bromide injection system.

The licensee had taken credit for these modifications in its response to GL 89-13 but had failed to annotate the modification packages to indicate that the modifications were commitments to GL 89-13. At the entrance meeting, the licensee had acknowledged the need to improve its process for annotating activities in progress for which it had taken credit for in commitments to the NRC.

GL 88-14. " Instrument Air System Problems Affectina Safety-Related Eauipment" The licensee described its actions to address the generic letter requirements in a letter to the NRC dated February 6, 1989, and informed the NRC that it had completed all outstanding actions in a letter dated December 14, 1990.

All of the licensee's actions were programmatic or evaluative, and no hardware i

changes to the plant, system, or system components were necessary.

The audit team reviewed many of the commitments and actions discussed in the response letters and found that they had been implemented. Most of the actions discussed in the letters were tracked in the site's NTS under a common number for GL 88-14 with several items having specific tracking numbers.

Several items discussed in the licensee's response were not in the NTS.

These items were existing procedures or program requirements for which the-licensee was taking credit to meet the generic letter; however, the requirements and programs still existed and were being followed. One reason for the omission of these items from the NTS was that the NTS included the full text of the

. Braidwood response to GL 88-14 sent to the corporate office, but not the text of the corporate response that was sent to the NRC. The corporate response to the NRC expanded the Braidwood response in several areas.

The only changes in commitments identified by the team involved the existing procedures discussed in the licensee's response that were not in the NTS.

Procedural requirements were moved from one procedure to another or combined into one procedure, although the requirements themselves were not materially changed.

The licensee had determined that its actions in response to the GL did not require any change to its UFSAR, although the team believed that a minor change was necessary. The licensee's original commitment, in its UFSAR, regarding particles in the instrument air system was to American National Standards Institute (ANSI) Standard 45.2.1.

After surveying the vendors of its instrument air system components, the licensee determined that a more appropriate standard would be Instrument Air Society (ISA) Standard S-7.3 and developed a new criteria for air quality based on that standard. The ISA standard and associated criterion were more restrictive than the ANSI standard discussed in the UFSAR, and the team believed a change to the wording in the UFSAR was necessary to reflect the new information from the equipment manufac-turers.

NRC Bulletin 85-01. " Steam Bindina of Auxiliary Feedwater Pumos" The licensee's control and implementation of commitments in response to Bulletin 85-01 were complete and appropriate.

The licensee had committed to procedural changes including (1) monitoring of auxiliary feedwater (AFW) pump discharge piping temperature once per shift and (2) recognizing steam binding in the AFW pumps and recovering the steam-bound AFW pumps in accordance with the abnormal operation procedure, BWOA-SEC-7.

The licensee had implemented the commitments involving procedure changes, and these commitments existed in the current operating procedures. Additionally, the commitments and related material, including Bulletin 85-01, were contained in the NTS. The audit team reviewed the procedures, performed a system walkdown to verify the procedural steps for recovery of a steam-bound AFW pump, and located the instrumentation for obtaining the AFW pump discharge piping temperature.

It also reviewed the logged AFW pump discharge piping temperatures. No deficiencies or anomalies were noted. Additionally, the team reviewed the training records and found that Bulletin 85-01 and other material related to AFW pump steam binding were included in the licensed operator's training program and required reading material.

NUREG-0737 1.C.5. " Procedures for feedback of Operatina Experience to Plant Staff

• The licensee's control and implementation of commitments in response to 1.C.5 requirements were complete, and the resulting program for the review and feedback of operating experience met these requirements. The licensee's commitments were in the plant UFSAR, were in accordance with the guidance in NUREG-0737, 1.C.5, and were tracked in the NTS.

To examine the implementation and judge the effectiveness of the licensee's operating experience feedback

~

, program, the team reviewed the licensee's actions in. w ponse to NRC infor-mation Notice (IN) S8-13, " Water Hammer and Possible Piping Damage Caused by Misapplication of KER0 TEST Packless Metal Diaphragm Globe Valves," and IN 91-77, " Shift Staffing at Nuclear Power Plants."

Actions taken in response to IN 88-13 were in accordance with the licensee's program for the feedback of operating experience.

The licensee had provided additional pipe supports for the KER0 TEST valves and had placed operational restrictions in the Bw0P SI-7 procedures to eliminate possible pip vibra-tions.

These commitments were tracked in the NTS, and the commitment tracking number was referenced in the procedures. Subsequently, the licensee replaced the safety injection accumulator tank KER0 TEST valves, thereby eliminating the need for the operational restrictions. The team noted that, in this case, the feedback loop to remove a no longer needed commitment did not exist, and even though the modification approval letter indicated that the operational restrictions could be removed from the procedures, these restrictions still existed in the procedures.

Finally, the team reviewed the licensee's training records and found that the IN 88-13 subject matter was included in the training material for licensed operators.

The team a19 :sviewed feedback of the information in IN 91-77 and NRC Bulletin 85-to the plant staff and found that the program was being effectively implemented.

NOV 85-48-01. Incorrect Toroue Switch Settinos on Valve Motor Operators In response to the NOV, the licensee committed to perform an engineering review for approved torque switch settings and ensuring verification of actual equipment setting >.

The commitment was entered into the NTS, and the engineering review, the associated list of approved torque switch settings, and verification of the actual equipment settings were completed. Actual torque switch settings have since been overtaken by additional industry problems and regulatory recommendations for testing motor-operated valves.

The licensee had made two changes to its original commitment before its full implementation and had informed the NRC by letter of the changes. The first change, correcting a significant error in its response, was entered into the NTS, however, the later change, a reduction in the scope of the engineering review was not.

!LOV 87-35-01. Ineffective Short-Term Corrective Action i

The NRC had identified several examples of immediate corrective actions that were not completely effective in preventing additional problems. The licensee committed to add requirements to its process checklist for determining effective short-term and long-term corrective action. The change to the checklist was made and annotated as a commitment; however, the process was later replaced by a new process and the commitment was not recognized or transferred to the new process. The new process did include elements that effectively accomplished the same objective as the original commitment.

- NOV 88-13-01. Failure to Perform a Ouarterly Technical Specification Calibra-tion and NOV 88-13-02. Failure to Meet Technical SDecification Reouirements for Control Room Ventilation System in response to the first NOV, the licensee committed to change several technical specifications sections as discussed in Generic Letter 87-09.

It also committed to submit the technical specification change by a certain date.

The team found that the NOV response was entered into the NTS and referenced another NTS item to track the technical specification amendment.

The techni-cal specification amendment was submitted and incorporated into the technical specifications after NRC approval.

The team also found that the licensee kept the NRC informed by letter of delays in submitting the amendment.

In response to the second NOV, the licensee committed to change a corporate quality procedure to allow Braidwood personnel to better control site work performed by offsite licensee organizations. The commitment was entered in the NTS and linked to the violation. The team verified that the current revision of the quality procedure (QP 3-1) included the new requirement, but the requirement was not identified in the procedure as a commitment.

NOV 89-17-01. Charaina Pumo Isolation Valve in Wrona Position The NOV was issued after the licensee had determined that a charging pump l

miniflow isolation valve had been mistakenly closed for more than a week, rendering the system inoperable.

In response to the NOV, the licensee committed to make changes to its locked equipment program.

The licasee tracked its commitments with several entries in its NTS.

Several of the changes to its locked equipment program were tracked by an NTS item that referenced the licensee's discrepancy report written after the condition was found.

The team reviewed the program procedures and found they included the changes, even after several revisions, although not all the changes in the i

procedures were identified as commitments.

1 The team found tna the program's process for controlling keys had been changed without an associated procedure revision or recognizing the process as a commitment.

In its response to the NOV, the licensee stated that the master equipment keys would be in the possession of the fire marshall. The team determined that several months before the audit, the fire marshall's master equipment keys had been removed from his key ring and placed in a locked box in the shift engineer's office. The licensee indicated to the team that a procedure change would be processed.

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NOV 90-23-01. Various Examples of failure to Follow Administrative and l

Surveillance Procedures. and NOV 90-23-02. Inadeouate Procedures to Control Overtime In its response to the first NOV and, civil penalty, the licensee had made commitments in its cover letter as well as in its reply to the NOV. The commitments included enhancing existing programs and clarifying procedures,

. augmenting the operations organization with a special supervisor, and incorpo-rating the events into operator and technical staff training and management meetings. The cover letter and NOV response were entered into the NTS and linked to the violation in the inspection report. An additional NTS item, linked to an internal deficiency report, tracked a procedure change that resulted from a commitment made at the enforcement conference and discussed in general terms in the response letter. The team verified that a number of the commitments had been implemented and that changes to an administrative procedure were still in place. The changes to the administrative procedure were identified in the procedure as a commitment and referenced the NTS item number.

The licensee subsequently changed a significant commitment made to the NRC in response to the NOV. The licensee had committed to add a special activities shift supervisor (SASS) to its operations organization with responsibilities in overseeing complex or unusual surveillance activities.

The licensee later established a new operations organization that eliminated the SASS position and added a new unit supervisor, who had responsibilities similar to that of the SASS, for each unit. The licensee adequately informed the NRC of its new organization, but did not specifically identify the change in its communica-tions with the NRC or its NTS as a change to a previous cammitment.

In response to the second NOV, the licensee committed to extend the overtime policy to all workers at the Braidwood site and the response was entered into the NTS and linked to the violation. The team verified the issuance of a technical staff memorandum, issuance of a corporate interim policy on over-time, and changes to a Braidwood administrative procedure. The current revision of the administrative procedure included the changes but did not identify them as a commitment.

j Licensee Event Reports (LERs)

The audit team reviewed the commitments associated with the corrective actions contained in the following nine LERs:

456-87-14 f ailure to Maintain an Operable Airlock Door Closed k'hile Testing an Inoperable Door Due to Judgment Error by Licensed Supervisory Personnel 456-87-25 Inadvertent Opening of Main Steam Isolation Valve During Maintenance Activities Due to Procedural Error 456-87-35 Reactor Trip from Rod Control System Motor Generator Set Trip Due to Miscommunication 456-88-17 Missed Technical Specification Composite Samples Due to f ailure to Implement Required Changes 456-88-21 Axial flux Difference Monthly Surveillance Missed Due to Error in Tracking Due Date 457-88-09 Manual Reactor Trip Due to Inoperable Rod Control Stem

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. 457-88-13 Low Steam Generator Level Results in Reactor Trip Due to inadequate Procedure Guidance 457-89-01 Loss of 2B Residual Heat Removal loop as a Result of Procedural Deficiency 457-89-07 Dual Train Inoperability of Auxiliary Feedwater System for Six Minutes Due to Procedural Deficiency The sampled LEPs contained commitments to a wide variety of corrective actions including hardware modifications, UFSAR changes, procedure revisions, technical studies, and training. The team did not identify any safety significant deficiencies with respect to the licensee implementing and maintaining the commitments in the sampled LERs.

The team noted a number of examples of revised procedures in which the applicable steps written to fulfill commitments had been retained. However, the team found a number of examples where the licensee did not identify commitments in the procedures as required by its administrative controls.

This inconsistent annotation of procedures was particularly evident. in procedures that had been updated before 1990. The team's concern was the increased potential that when a procedure was revised, procedural steps that were not well identified as commitments might be inadvertently deleted.

However, the team did not find any examples in which an implemented procedural commitment was later altered or deleted in the review of the sampled LERs.

The licensee was aware of this issue and indicated that one of the regulatory assurance group's goals was to improve the referencing of commitments in procedures.

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