ML20198K509

Guidance for NRR Audit of Licensee Programs for Managing Commitments Made to NRC, Rev 971110

ML20198K509
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Issue date:	11/10/1997
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PROC-971110, NUDOCS 9801150021
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GUIDANCE FOR NRR AUDIT OF LICENSEE PROGRAMS FOR MANAGING COMMITMENTS MADE TO THE NRC 1.0 OBJECTIVES The audits will assess the adequacy of licensees' implementation of a sample of comitments made to the NRC in past licensing actions (amendments, exemptions, etc.) and licensing activities (aulletins. generic letters, etc.). The NRC staff informed the Comission that such assessments would be conducted as a follow-up to the licensing basis issues identified at facilities such as Maine Yankee and Millstone. The audits will also deternine if licensees have implemented a)propriate controls for managing current and future comitments made to the NRC tlat are not controlled by a codified regulatory process such as 10 CFR 50.59 or 50.54 including notification of the NRC when changes to commitments are determined to have safety or regulatory significance. The combined results of these audits and other NRC activities will help to determine if additional regulatory actions are needed in the area of comitaent management.

2.0 BACKGROUND

In the original Statements of Consideration for 10 CFR Part 54 " Requirements for Renewal of Operating Licenses for Nuclear Power Plants." dated December 13.1991 (56 FR 64943). the Commission explained in some detail the basis for its belief that the current regulatory process provides an acceptable level of safety.

Among other things, the Commission described a process whereby licensee-initiated changes to any particular plant's licensing basis are subject to the Comission's formal regulatory controls. This process ensures that a documented basis for .

licensee initiated changes in the licensing basis exists and that NRC staff review and approval is obtained before implementation if the changes to the licensing basis raise an unreviewed safety question or involve changes to the technical specifications.

'n SECY-92-314. " Current Licensing Basis for aperating Plants." dated September

10. 1992, the staff responded to the Comission's request to 3rovide information and recommendations concerning compilation of the current 'icensing basis for operating reactors and current industry practices for updating the Final Safety Analysis Report (FSAR). In conducting the activities necessary to respond to the Comission. the staff noted that some licensee commitments are not contained in the plant's FSAR and, therefore, are not controlled by a defined regulatory process such as 10 CFR 50.59. As a result of the findings described in SECY 314. the staff proposed a series of actions to further examine the issues. The staff summarized these actions in SECY-94-066. " Evaluation of Issues Discussed in SECY-92-314. ' Current Licensing Basis for Operating Plants'."

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On encary 4,1993, the ED0 established the Regulatory Review Group (RRG) to identify those areas in which increased flexibility in the regulatory process could be made available to licensees without adversely affecting the level of safety at operating plants. Ir SECY-94-003. " Plan for Implementing Regulatory Review Group Recommendations." the staff informed the Comission of its plan to implement recommendations made by the RRG. One of the areas identified in SECY-94 003 that would substantially reduce unnecessary regulatory burden was the development of guidance for use by licensees to control docketed comitments that are not contained in the FSAR. Two options were discussed in SECY-94-003 to complete this RRG item: (1) to develop and promulgate staff guidance on what constitutes a "comitment" and the types of controls to be placed on changing comitments: or (2) to endorse a guideline developed by the industry. As described below, the Nuclear Energy Institute (NEI) volunteered to develop a guideline for managing comitments.

In SECY-94-066. the staff submitted to the Comission the results of its further evaluation of the issues identified in SECY-92-314. To address the issues pertaining to comitments made to the NRC but not controlled by procuses defined in regulations, the staff performed audits of licensee programs at Hope Creek.

Crystal River. Fort Calhoun, Braidwood Davis-Besse. Beaver Valley, and McGuire.

On the basis of the audit findings, the staff concluded that. in general, licensees had developed their own programs and processes that effectively managed comitments made to the NRC and controlled changes to these comitments. In its evaluation, the staff found that many licensees and NRC staff members did not have a clear understanding of when comitments can be changed without NRC interaction. This circumstance led most licensees to act conservatively, interacting with NRC staff and reporting changes to comitments regardless of safety significance. This type of action resulted in an inefficient expenditure of both licensee and NRC resources. lherefore in SECY-94-066. the staff referred to the recomendation of the RRG in SECY-94-003 to develop guidance, either by the staff or by the nuclear industry, on what constitutes a comitment and the types of controls to be placed on comitments.

The guidance developed by NEI on managing commitments provides a structured process, found acceptable to the staff in late 1995, that licensees can use on a voluntary basis. The NRC accepted version of the NEI document. " Guideline for Managing NRC Comitments." Revision 2. dated December 19. 1995. is provided as an attachment to this audit guidance. The NEI guidance describes a process that can be used by licensees to modify or delete comitments and defines the circumstances in which interaction with the staff is appropriate.

The NEI guidance document provides the following definitions to help clarify the regulatory significance of, and distinction between, an obligation and a regulatory comitment:

Oblication means any condition or action that is a legally binding requirement imposed on licensees through applicable rules regulations, orders, and licenses (including technical specifications and license conditions).

Audit Guide Revision: 11/10/97

Beaulatory Commitment means an explicit stetement to take a specific action agreed to or volunteered by a licensee that has been submitted in writing on the docket to the Comission.

In SECY-95-300. " Nuclear Energy Institute's Guidance Document ' Guideline for Managing. NRC Comitments'." dated December 20, 1995, the staff informed the Comission that the licensees' comitment change processes, either implementation of the NEI guideline or licensee-specific programs, would be monitored to verify that commitments are being appropriately controlled. If the audit process shows that licensees have not implemented the NEl guidance, or have not adopted some equivalent level of control and documentation of changes to their comitments, the staff will reassess the need to promulgate staff guidance or initiate rulemaking. This reassessment will be initiated after the comitment control process at selected facilities has been audited using ths guidance.

The NRC staff evaluated problems encountered with licensing basis issues at Millstone and Maine Yankee and offered lessons learned from these experiences in SECY-97-036. " Millstone Lessons Learned Report, Part 2- Policy Issues," dated February 12. 1997, and SECY-97-042, "Res Regarding Maine Yankee " dated February 18. reports 1997. Both ponserecommended to Olb Eventthat, Inquiry 96-04 as part of an overall revision of its oversight of licensing basis information, the staff proceed with its plans to perform this audit to evaluate the industry's implementation of commitment management systems As a result of the lessons learned from these efforts, it was deemed prudent to have the staff define a sample of previous comitments made to the NRC in licensing actions and licensing activities and to verify the licensees' implementation of those commitments.

This and other staff efforts related to managing licensee commitments made to the NRC are integral to 1.nproving the staff's performance in (1) identifying important licensee comitments or other supporting design features or operating practices used by the licensee to justify a proposed change or address design or operational problems. (2) determining by what means im)ortant commitments or other supporting aformation should be verified, anc (3) determining the appropriate placement of the information within the various licensing basis documents associated with the affected facility (i.e., the license or technical specifications, the FSAR, program description documents, or docketed correspondence without formal regulatory controls). NRR process changes are being made to address these concerns for future activities. The part of this audit that looks at licensee implementation of past comitments will be included, along with reviews of past audit and inspection findings, in an assessment of the need for additional staff actions. This assessment will include. to the extend practical. a review of the findings from those inspections- performed in accordance with temporary iastructions associated with licensing activities such as bulletins and generic letters. Additional staff actions following the assessment may include additional NRC inspections, requests for information from licensees, or proposing changes to NRC regulations.

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3.0 AUDIT GUIDELINES 3.1 VERIFICATION OF LICENSEE IMPLEMENTATION OF PAST COMfilTMENTS The primary focus of this part of the audit is to confirm that licensees have implemented those comitments made to the NRC as part of past licensing actions and resolution of past licensing activities. The audit should ensure that the sample of past comitments were implemented in a manner that satisfied both the action comitted to and the overall intent of the comitment. The auditor should select a sample of approximately 15 individual and unrelated comitments that were included in licensee correspondence in order to justify a licensing action (amendment, exemption, etc.) oc resolve a licensing activity (bulletin, generic letter, etc.). The sample should be selected following informal discussions with appropriate regional staff, review of licensee tracking data, review of any reports submitted by the licensee, and consideration of other information or concerns of individual auditors.

.3.2 LICENSEE PROGRAMS FOR MANAGING COMMITMENTS MADE TO THE NRC The primary focus of this part of the audit is the licensee's performance related to implementing controls for modifying or deleting comitments made to the NP.

The audit should ensure that changes to comitments (modifications or deletions) are evaluated in accordance with the licensee's programs and procedures, the licensee's technical evaluations adequately justify the change, and that the NRC is informed of comitment changes that have safety or regulatory significance.

The auditor should, as a minimum, determine whether the iicensee using the NEI guidelines or alternative process, resolved safety issues pertinent to the associated comitment and has or will inform the NRC of the change if the applicable notification threshold is exceeded.

3.2.1 Procedures and Controls

a. Verify that tha licensee has established administrative controls for modifying or delet.Mg commitments made to the NRC. The controls for changing cemitments made to the NRC may be included in a stand-alone commitment manag= cat system or may be incorporated into other licensee administrative programs.

b. Verify that the programs provide guidance regarding the evaluation of proposed changes to comitments in terms of safety and regulatory significance. The licensee's guidance should likewise include criteria for determining when it would be ap3ropriate to notify the NRC of a comitment change. The NEl guidance cocument is an acceptable guide for licensees to follow for managing and changing their comitments to the NRC. For those licensees that have not adopted the NEI methodology, document a comparison of the licensee's process, including criteria for evaluation of changes and NRC notification, to that recomended in the NEI guideline.

Audit Guide Revision: 11/10/97

3.2.2 Imolementation

a. Commitment Chanaes Reoorted to NRC. Select en appropriate sample of comitment changes (modifications or deletions) that were reported or will be reported to the NRC. Ten or more examples should be used if the licensee has performed many evaluations since the last major revision of its comitment change process; otherwise. includc as many examples as practical to assess the licensee *s program for controlling commitment chanaes. Each comitment will be reviewed to determine the adequacy of the licensee's technical justification for the change in comitment. The sample should be selected following informal discussions with appropriate regional staff, review of licensee tracking data review of any reports submitted by the licensee, and consideration of other information or concerns of individual auditors. Try to select comitment changes from as many of the following categories as practical: .

1. Generic Letter Responses:

2. Bulletin Responses:

3. Licensing Actions (amendments, reliefs, or exemptions); or

4. Responses to Notices of Violation (NOVs):

5. Licensee Event Reports (LERs):

6. Inspection Reports:

7. Other docketed correspondence,

b. Commitment Chanaes Not. ReDorted to NRC. Select examples of commitment changes (modifications or deletions) that the licensee has not and does not )lan to report to the NRC, Approximately 10 commitment changes shou'd be selected using the various categories and considerations discussed above. Each selected commitment change will be reviewed to determine the adequacy of the licensee's technical justific'ation for the change as well as the determination that notification of the NRC was not warranted. The sample should be selected following informal discussions with appropriate regional staff, review of licensee tracking data, and consideration of other information or concerns of individual auditors,

c. Notifications to the NRC. For those comitment changes that are determined to warrant NRC notification, confirm that the notification has or is planned to be made and that the notification accurately describes

'the change,

d. Jraceabiljtv of Commitments. Confirm that the licensee has implemented a process to ensure the traceability of comitments tr support the change control process. Such processes should ensure that licensee personnel are able to identify when their activity may involve changing a regulatory commitment and direct them to ' the commitment management Revision: 11/10/97 Audit Guide

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process. SelectLa sampleL of recently implemented commitments and evaluate whether the licensee's: process would .reasonablyLsupport

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identification ofithe commitment-in case personnelLsubsequently propose ito alter the design features or operating practices that were the subject.

of the comitments. - The sample should be selected following informal o discussions with appropriate regional staff, review of licensee tracking data review of any reports submitted by the licensee, and consideration of- other information or. concerns of individual auditors. Note that the-

.NEl guide does not-provide recommendations for performing this function.

4.0 LGUIDANCE Regulatory commitments are specific actions- that have been agreed to or volunteered by a licensee and are documented in docketed correspondence. Unlike regulatory requirements (obligations) contained in regulations, licenses, and ,

orders, regulatory commitments are not legally-binding. However, the regulatory process appropriately relies on commitments in many instances and the NRC expects licensees to honor, in good faith, commitments that have a safety or regulatory purpose. In large measure, regulatory commitments are not contained in the FSAR, '

but-in other docketed correspondence such as licensee event reports, responses to Notices of Violation, responses to generic letters, applications for licensing ,

actions,'and responses to requests for additional information. Those commitments not contained in the FSAR may not be controlled by a defined regulatory process such as 10 CFR 50.59. Therefore, licensees mav have the ability to change .

docketed commitments not contained in the FSAR without informing the Commission.

The NRC staff has the ability to issue an enforcement action if the failure to implement a commitmmt has the potential to adversely affect reactor safety. The staff may also use the administrative enforcement tool of a Notice of Deviation if a' licensee -fails to satisfy a commitment. In addition, issues regarding completeness and accuracy of .information submitted to the NRC may warrant consideration of the requirements of 10 CFR 50.9. Additional measures are being implemented to ensure that licensee comitments and other important information regarding plant design and operating practices are placed into the most appropriate licensing- basis document whether that be the license, FSAR or docketed-correspondence, Although a specific action committed to by a licensee may not be legally-binding, the auditors should carefully consider whether the commitment, or an alternative action,1s necessary to ensure compliance with an NRC regulation or otherwise ensure safe plant operation. For example, a licensee's response to a generic letter may comit to perform routine surveillances or tests beyond those contained in a _ plant's technical specifications in order to . ensure the operability of an important system or component. The licensee's failure to implement.such a commitment or failure to adequately evaluate changes to that comitment may call into question the operability of the related system or

-component. . Safety concerns or possible regulatory nonconformances that are this audit should be : forwarded t- the appropriate regional '

discovered personnel for durinflow-up

_fo as part of the NRC's inspecton program.

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9-4.1 VERIFICATION OF LICENSEE IMPLEMENTATION OF PAST COMMITMENTS In defining the audit sample of approximately 15 comitments from past licensing actions and licensing activities, the auditors should consider the following in selecting comitment changes for review: .

1. Choose comitments related to a variety of systems:

2. Choose comitments involving a variety of engineering disciplines, such as nuclear, mechanical, -ivil, and electrical:

3. Choose comitments that involve a variety of licensee actions, such as ' design modifications, temporary modifications, procedure revisions, personnel training, and revised administrative controls:

4. Ensure that the sample of selected comitments includes some which were important to the NRC staff's decision making '3rocess for licensing actions and licensing activities during the ast several years.

To the extent practical, identify comitments for wrification that have not been previously addressed by NRC inspections or audits. It is desirable to choose commitments with a preference to risk significant issues or systems, In addition, the auditor should attempt to verify that not only the stated commitments have been satisfied but that the underlying intents of the commitments have been fulfilled. For example, in contrast to verifying the installation of major pieces of equi) ment or issuance of major procedure or i program documents, the auditor shoulc assess the lower profile but essential <

aspects of implementation such as the commitments regarding maintenance or surveillance of the subject equ1] ment and training or effectiveness measures for the cubject process changes, The commitment or aspect of a commitment being verified and the information needed to perform the verification should, as much as possible, be identified and communicated to the licensee prior to the si+ -

visit in order to minimize time spent waiting for information. The auditor should have informal discussions with the regional staff and other NRC staff with potential insights- pertaining to a licensee's performance in the area of implementing commitments in preparation for the audit.

To verify the implementation of specific commitments, review licensee comitment management records, work orders, revised procedures, NRC inspection reports, and -

other documentation that could demonstrate that the specific actions were completed in accordance with the stated comitment and related scheoule.

Discussions with licensee personnel in licensing, system engineering, and other organizations may be useful in placing the comitment and its implementation in

-the app riate historical and technical context. Where ap]ropriate, utilize actual sical verifications of affected equipment or procecures. The auditor snould. :termine the needed level of investigation to verify the implementation Mf each selected comitment. Whereas some comitments may-be verified by a simple review of a revised procedure, training record, or completed work order, verification of cther comitments may require more exhaustive reviews of design Revision: 11/10/97- - Audit Guide

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documents and- surveillance- histories, comparison of corrective actions to-appropriate effectiveness measures -or interviews with licensee personnel.

For each selected comitment, determine if the implementation of the comitment resulted--in an update to the ~ facility's updated final safety analysis report (UFSAR).- additional: docketed correspondence (e.g., a letter confirming

-implementation), or other communications with the NRC staff. The auditor shoula also determine if the comitment should have been captured in an update of the-UFSAR. Concerns regarding a. potential violation of 10 CFR 50.71(e) identified during this budit should be referred to the appropriate regional office for follow up or otherwise pursued using other inspection and enforcement guidance.

4.2 LICENSEE PROGRAMS FOR MANAGING COMMITMENTS MADE TO THE NRC This guidance 'is intended to help auditors in evaluating licensee programs related to the revision of comitments made to the NRC. The audit consists of two parts: (1) procedures and controls; and (2) implementation. Reviewing the licensee's comitment management program procedures in the office will allow more

• time for implementation review while onsite. Choose the initial selection of commitment changes in the office using licensee supplied lists of proposed and -

completed comitment changes and any available independent knowledge of recent changes -to previous comitments or activities that would likely affect past comitments, in addition, select recent comitments from dockesed correspondence for performing the part of the audit dealing with traceability. At least one week before the audit. inform the licensee which comitment changes have been selected for possible review. This should minimize the time waiting for the licensee to produce the requested documentation.

NEI's guidance document is an acceptable quide for licensees to follow for managing and changing their commitments to the NRC. The defined process and controls of the NEI guidance document are the preferred method, but auditors may encounter various degrees of formality and involvement of NRC staff in licensee processes for changing commitments. Various inspection and NRR activities include, or will include, verification that commitments agreed to or volunteered by the licensee have been implemented in accordance with the original licensee comitment- and related schedule. This part of the audit focuses on subsequent changes to licensee comitments that may or may not involve interactions with the NRC. The audit should (1) evaluate the licensee's method for evaluating proposed changes to regulatory commitments with consideration given to the intent of the original comitment and the safety and regulatory significance of the proposed change. :and (2) evaluate the licensee's method for communicating commitment changes to the NRC when such changes are deemed significant to safety or the NRC's regulatory function.

An important aspect of comitment management that is not addressed in the NEI guideline is the part of the process that ensures traceability of comitments.

The NEI guideline provides -a. basic framework for evaluating a change to a comitment once licensee personnel propose such a change. However, for those personnel to utilize the NEI guideline, they must realize when -a change to a plant design feature or operating practice affects a comitment made to the NRC staff. - For example, a licensee comits to perform independent verification at Audit Guide Revision: 11/10/97

- a specific point in the execution of a procedure as a result of problems identified in an NRC Notice of Violation. Several years later, the licensee  ;

determines that the independent verification step is no longer necessary due to improved performance of its personnel. In order for a comitment change process to work effectively, the personnel likely to propose a revision to the affected procedure must be able to identify that the independent verification was added to the procedure as ) art of a regulatory comitment. Possible ways to provide traceability incluc e markings or notations within the procedure and administrative requirements to investigate proposed procedure changes that might affect regulatory comitments. Similar processes would be necessary for design features or other licensee comitments not incorporated into controlled procedures.

4.2.1 Procedures and Controls

a. Verify that the licensee has defined a process for managing comitments made to the NRC. Such process descriptions may be contained in licensee procedures, general guidance documents, program descriptions, training material, administrative documents or combinations of these documents.

The controls for changing comitments made to the NRC may be included in a stand alone comitment management system or may be incorporated into other licensee corrective action, licensing, or administrative programs.

Comitment management syttems may involve periodic assessments of all outstanding comitments or may evaluate changes on a case by case basis.

Indentify the governing procedures and guidance documents and discuss the licensee's comitment change process with the responsible licensee personnel. Document how the licensee's process is controlled as well as the how the process is used to evaluate proposed changes to commitments.

For example, the process may be governed by an administrative procedure or other document that is controlled in accordance with facility technical specifications and quality assurance programs or the process may be controlled within a licensing group as a relatively informal procedure. In either case, the effectiveness of a licensee program will consider the assessments performed for Item 3.2.2. Implementation, of this audit,

b. Verify that licensec programs include guidance regarding the evaluation of proposed changes to comitments in terms of safety and regulatory signi" cance. The comitment chdnge process should distinguish between the changes licensees can implement without interaction with the NRC and those governed by regulations that may require NRC review and a> proval prior to implementation. The process should include a mechan'sm for determining when it would be appropriate to notify the NRC of a comitment change. The NEl auidance document is an acceptable guide for licensees to follow for managing and changing their comitments to the NRC. Ensure that the licer.see has integrated the comitment management system with other line organization functions to ensure traceability of a regulatory comitment following its initial implementation. Such syttems are necessary to ensure that licensee personnel are able to '

reccynize that future changes to the affected design features or Revision: 11/10/97 9- Audit Guide

. I operating practices require evaltation of the proposed change in-accordance with the commitment change process as well as the normal j;

design or procedure change process. j Although the process and review criteria in the NE! guidance document is the preferred method for controlling changes to commitments, there is no i

defined regulatory requirement that specifies how licensees must control i those changes. Therefore. licensees may define criteria for.  ;

, justification of commitment changes and NRC notification of such changes i that are different than those recomended in the NEl guidance. For those i licensees that have not adopted the NEI methodology, document a f comparison of the licensee's process, including criteria for evaluation i of changes and NRC notification, to that recommended in the NEl guide.  !

Although -observations regarding the licensee's process or related  ;

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criteria should be included in the documentation of the audit, any concerns related to the actual effectiveness of licensee programs should j

-be reinforced by actual examples reviewed in accordance with Item 4.2.2. i Implementation, of this audit guidance. }

4.2.2 'Imolementation -

The implementation area of the audit assesses the licensee's performance implementing its commitment change process. Commitments and changes thereto can- l involve all technical disciplines associated with a nuclear plant. Few auditors  ;

are expert in every nuclear related discipline. Therefore, the auditor should 4

recognize when technical assistance is needed to effectively review a safety evaluation or resolve a safety concern. The need for assistance can be i anticipated based on the commitment changes selected for review, Also acceptable is simply identifying and documenting (in the documentation of the audit) technical questions for follow up at a later date (either by the region or NRR).

- Recognizing failures of the licensee to comply with the administrative control '

requirements of its commitment change process is important. However, recognizing failures of the licensee to adequately assess how a change will affect plant ,

operational safety or compliance with applicable regulations is more important.  :

The focus of the implementation part of the audit should, therefore, be on safety  !

and ensuring that revised commitments have not led to noncompliance with  !

- applicable regulations. For exa.nple. if you agree that a commitment change was safe and believe it would not introduce issues of compliance with any regulations, cuestions or concerns regarding the change process can. simply be '

documented in the audit report. By contrast, a commitment change evaluation that failed to address an obvious safety or regulatory consideration would be more ,

significant. Failure to recognize that a commitment change required assessment i

. by regulations such as 10 CFR 50.59 or 50.54 may also be-significant. Safety.

concerns or possible regulatory nonconformances that are discovered during this audit should be forwarded to the appro

. part~ of the NRC's inspection program.priate regional personnel for follow up a, 7

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a. Commitment Cianoes Reoorted to the NRC. -In addition to the selection of commitment clanges from various sources such as submittals pertaining to ,

licensing actions. responses to bulletins and generic letters, res>onses ,

to NOVs. and t.ERs. Other considerations for selecting commitment c1anges i for review are: j

1. Choose changes related to a variety of systems:  !

. 2. Choose changes involving a variety of engineering disciplines, such f as nuclear, mechanical, civil, and electrical:  ;

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3. Choose changes that involve a variety of licensee actions such as  ;

design modifications, temporary modifications procedure revisions.  ;

personnel training, and revised administrative controls:

4. The selected sample of commitments and commitment changes to be reviewed may need to give preference to recent items since the '

commitment management systems being evaluated vary in regard to when they were developed and the extent to which past comitments have been captured:

5. Since chan es to the FSAR and other programs are, or will be, assessed in NRC ins 3ection procedures, this review should exclude

, commitments integra ed into the FSAR. Quality Assurance Program.  !

Site Security Plan. Emergency Plan, or other document governed by a change control mechanism contained-in regulations such as 10 CFR i 50.59 or 50.54: and .

6. Give preference to changes related to commitments which were 4

previously considered in an NRC decision making process. Examples include commitments related to enforcement discretion resolution of generic safety issues, and resolution of significant inspection c issues. ,

Review each selected commitment change against the requirements and guidance established in the licensee's procedures or guidance. For each change, consider

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e the relationship between the commitment being changed and regulatory requirements (obligations): ,

e the relationship between the commitment being changed and overall plant safety or risk profile: I e the licensee's criteria for determining the acceptability of a proposed commitment change (e.g. the NEl guidance includes the use of the. questions from 10 CFR 50.92):

e- . systems and components affected by the change (What is the effect of the.- change on their capability to perform their specified or ,

7 intended functions?);  ;

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e intent of the original comitment (Was commitment related to regulatory compliance, required safety function. or process enhancement?):

e potential effects of comitment change (Has licensee reasonably concluded that revised comitment will maintain plant safety and regulatory compliance, that original comitment was unnecessary or ineffective, or that revised comitment will improve performance?):

e documentation of the comitment change (Each evaluation of a comitment change should be documented in accordance with the licensee's procedural requirements. Auditors should note that the NRC accepted NEl guidance recommends less documentation for the justification of comitment changes than that typically provided in licensee 10 CFR 50.59 safety evaluations or design documents.): and e of fective implementation of the revised comitment (Select several comitment changes for verification of implementation. Review licensee comitment management records, work orders, revised procedures. NRC inspection reports, and other documentation that could demonstrate that the specific revised actionc. were completed in accordance with the stated comitment revision and related schedule. Where appropriate, utilize actual physical verifications of equipment and processes.).

b. Commitment Chances Not Reported to NRC. Review each selected evaluation of a commitment change against the requirements and guidance established in the licensee's procedures or guidance. For each change, consider the technical factors listed above as well as the licensee's criteria for determining if the commitment change requires notification of the NRC.

For those commitment changes not requiring NRC notification, ensure that the justification for the change is documented in a record that will be maintained for the life of the facility (maintenance of current licensing basis).

c. Notifications to the NRC. Verify that each comitment change determined to warrant NRC notification, has been or will be included in either a periodic or individual report to the NRC. Ensure that the description of the commitment change submitted to the NRC is consistent with the action taken by the licensee,

d. Traceability of Comitments. Verify that each sample of a recently implemented comitment would be reasonably identifiable as a comitment to those licensee personnel most likely to be involved in a subsequent change to the affected design feature or operating practice.

Audit Guide Revision: 11/10/97

4 5.0 REPORTING REOUIREMENTS Document the results of this audit in an audit report which summarizes the licensee's comitment management process, specific reviews performed, and other pertinent information (recent changes in programs, planned changes in programs, etc.). The report will be transmitte( to the licensee in a standard letter from .

the project manager, t 6.0 ENFORCEMENT The failure of any licensee to adopt the approach recommended by NEl and accepted by the NRC is not subject to enforcement action. However, an administrative action, such as a Notice of Deviation, may be warranted if poor licensee controls of commitment changes resulted in a significant failure to satisfy a comitment made to the NRC. In addition issues regarding completeness and accuracy of information submitted to the NRC may warrant consideration of the requirements of 10 CFR 50.9. Suggested items for a Notice of Deviation and apparent violations of NRC regulations, operating licenses, or other regulatory requirements discovered during execution of this audit must be referred to the appropriate regional office for follow up or otherwise pursued using other inspection and enforcement guidance.

7.0 COMPLETION SCHEDULE This audit shall be performed and documented for the facilities selected for the pilot effort by May 31, 1998. Subsequent audits or inspections if necessary, will be determined on the basis of the lessons learned from the first set of audits.

8.0 CONTACT If you have questions regarding this audit guidance, contact William Reckley, NRR/DRPW/PD3-3. at (301) 415 1314 e mail WDR.

9.0 STATISTICAL DATA REPORTING TAC numbers will be opened for the reporting of time spent in the preparation for and execution of this audit.

10.0 RESOURCE ESTIMATE It is estimated that approximately 125 hours0.00145 days <br />0.0347 hours <br />2.066799e-4 weeks <br />4.75625e-5 months <br /> per facility will be expended in performing this audit. The required time will consist of an in office review of process descriptions, procedures, and documentation related to commitments and commitment changes that has been provided by the licensee in support of the audit and an onsite portion involving interviews, review of supporting documentation for comitment changes, and verification of implementation of specific comitments. Subsequent evaluation of the audit reports and pre recommendations is estimated to require an additional- 100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br />. The paration total of resource estimate, assuming audits at eight facilities is 1100 hours0.0127 days <br />0.306 hours <br />0.00182 weeks <br />4.1855e-4 months <br />.

Revision: 11/10/97 Audit Guide

The development- of this guidance and the performance of the audits have been incorporated into NRR's Operating Plan for 1998 1999 as as part of the Reactor-Licensing Program as well as being part of the divistor, level operating plan for

' DRPE/DRPW. -

11.0 REFERENCES

Nuclear Energy institute's, " Guideline for Managing NRC Comitments."

Revision 2. dated December 19, 1995 (copy attached).

SECY 95 300. Nuclear Ener " Guideline for Managing NRC Comitments."gy Institute's dated December Guidance Document.

20, 1995.

SECY 94 066. " Evaluation of Issues Discussed in SECY 92 314. ' Current Licensing Basis for Operating Plants'." dated March 15. 1994.

SECY 92 314 _" Current Licensing Basis-for Operating Plants." dated September 10.'1992.

. SECY 94 003. " Plan for implementing Regulatory Review Group Recommendations."

-dated January 7, 1994.

SECY 97 036. " Millstone Lessons Learned Report. Part 2: Policy issues." dated--

. February 12. 1997.

SECY 97 042 " Response to OIG Event Inquiry 96 04S Regarding Maine Yankee " dated February 18. 1997.

END

Attachment:

NEI Guideline For Managing NRC Commitments. Rev, 2, 12/19/95 i

LAudit Guide: . Revision:- 11/10/97

s GUIDELINE FOR MANAGING NRC COMMITMENTS Nuclear Energy Institute Revision 2 December 19,1995

- *

• e se e -

t 9

Attachment Al$lNWW 9,ss,.

distinction between commitments Cf high and low (or even no) safety significance, and the lack of a readily acceptable and practical method for eliminating or changing multing commitments when warranted, impedes the achievement of this objective.

Licenseet have historically treated commitments seriously and only make changes after due consideration of any safety impacts. At times, licensees have hesitated to change commitments, even though justified kom a safety standpoint, due to concems that the NRC may negatively view the commitment changes, or because the process for changing commitments is perceived as burdensome. A uniform practice regarding commitments and commitment change mechanisms within the industry would assist individual utilities  ;

in focusing resources on significant issues and in changing past commitments that no longer serve their intended purpose.

RECOMMENDED ACTIONS Managing Commitments

. Any significant commitment of utility resources, whether to satisfy a concem of an NRC inspector, to respond to a NRC generic communication, or to determine the appropriate manner to implement a regulatory requirement, should be the result of a reasoned management decision-making process. To ensure proper management control of utility resources, an intemal process to control commitments should be established. For example:

- Commitments and their relative priority should be based upon an evaluation of the safety benefit that will be attained; the pertinent legal requirement, if any; the technical bases for the contemplated

action or activity; and the resources available, in the context of other requirements and commitments. The cost (both initial costs and those that would be incurred over the life of the unit) and value added (,f an action being considered in response to an NRC request should be carefully evaluated, including consideration of any peninent regulatoly requirement (s).

. Corranitments si ould be made only by previously deeignated persons. Consistent with the utility's management apprcach, the number ofindividuals designated could be very few, or the responsibility could be delegated fairly broadly within each indMdual's area of responsibility.

2 Revision 2: 12/19/95

+

- Notices cf Violation and Licensee Event Reports identify actions to minimiu recurrence of the adverse condition. Historically, not all .

such actions were necessary to minimin recurrence - some represented enhancements to ongoing practices not directly related to the cause of the event. Future correspondence should not identify i

these actions as commik unts, r

Chanetne cammitmente f

. Changes to commitments should also be the result of a reasoned management decision making process. To ensure continued managemet control of ruources applied to commitments, the following commitment change practices are recommended:

- Each licensee should periodically consider evaluating its outst mding .

commitments and the manner in which its commitments have been implemented, to the extent that the conduct of the evaluation itselfis e cost-effective (e.g., focuses on those commitments that have a major impact on the utility's costs). '!he licensee should determine whether ,

the current commitment represents the most cost effective way of satisfying the safety issue that prompted the commitment and should change those commitments as appropriate. ,

- Each licensee should establish a practical commitment change process that distinguishes the relative safety significance and

• regulatory interest of commitments communicated to the NRC staff.

Attachment A to this guideline provides an example commitment change process.

- Each licensee should consider including a " sunset clause" in commitments, where appropriate, to establish a period of time to evaluate the effectiveness of the commitment.

4 Revision 2: 12/19/95

i to comet or preclude the recurrence of adverse conditions or to make improvements to the plant or plant processes. A Regulatory Commitment is an  !

intentional undertaking by a licensee to complete a specific action. In the past, not  !

! all licenses correspondence has clearly distinguished the difference between ,

Regulatory Commitments and factual statements, descriptive information, and voluntary enhancements not intended to constitute commitments. Potential  !

4 confbsion resulting Acm this lack of clarity will require dialogue between a i

. licensee and the NRC on a case-by case basis. Implementation of the Guidelines Jbr Managing NAC Commitments should remedy this situation in the ibture.

l i

Because Regulatory Commitments are not legally binding requirements, licensee management has the latitude to decide the scope and details of the intended actions l without sipificant interaction or guidance from NRC management. -

l 1

j  :

CHANGE PROCESS The following outlines a recommended change process intended to provide

. llcensee management with the necessary flexibility to effectively manage the safe and  !

efficient operation of their nuclear plants, while ensuring that changes that are sipificant to safety and/or of high regulatory interest are communicated to the NRC. The recommended change process does not apply to confirmatory action letter commitments as described in the NRC's Enforcement Policy, NUREC 1600.

Obligations No changes from current requirements are needed. The available statutory based mechanisms include petitions for rulemaking under 10 CFR 2.302, exemption

requests under 10 CFR 50.12, license amendment requests under 10 CFR 50.90, o changes to certain plans under 10 CFR 50.54 and requests to modify or rescind orders issued under 10 CFR 2.202.

4 Regulatory Cammitments The attached flowcharts, Figures A 1 and A 2, outline a regulatory commitment management change proress that (1) delineates commitments that havt: safety

~,

sipificance and/or regulatory interest; (2) establishes guidance for notifying the NRC of changes to commitments that have safety sipificance and/or regulatory .

interest; and, (3) establishes a rationale for eliminating past regulatory commitments that have negligible safety significance and/or regulatory interest.

Figure A 3 is a summary sheet that provides an adequate level of documentation for the decisions made in revising a commitment using this change process.

6 Revision 2: 12/19/95 l

_ . . . . . - . . , _ _ . - . . . - . - , - . . . . _ . , - . . _ . . . , . ~ . _ . . _ _ . _ _ _ _ _ _ . , . . . _ _ _ , . _ . . . . . - - _ . - - _ . _ - _ _ - . _ .

i l

i

, STEP 2: 15 DIE CHANGE ElGNIFICANT TO EAFETY?

^

Commitment changes that are om captured by the codi6ed processes identified in

, Step 1 above still need to be evaluated in terms of their safety significance unless  !

application of the NSAC 125 sceeening criteria under Step 1 determined that the i change does am impact the ability of a SSC to perform its safety thnetion. Figure  !

A 2 outlines a de;stmiandently based approach for conducting safmy assessmems. l

! The process is briefly desceibed below: l e

The Arst step is to evaluate if the change could negatively impact the ability of a SSC to perform its intended safety function. NSAC 125, Section 4, contains ,

. usefut criteria for performing this evaluation. Other relevant infonnation in l performing this evaluation is an understanding of the safety bs21s for the original l commitment. A review of pertinent documentation (e.g., NRC Bulletin or Generic Letter, LER, NOV, etc.) that prompted the original commitment is a source for basis information. A further factor to be considered in performing the evaluation is whether the change could neptively impact the ability oflicensee personnel to ensure the SSC is capable of performing its intended safety function as a result of changes to procedures, programs and other human performance elements. If the evaluation determines that the change could not negatively impact the ability of a SSC to perform its intended safety function, the change is not safety sipificant. ,

if the evaluation determines that the change could impact the ability of a SSC to perform its intended safety function, then an assessment applying the criteria of 10 CFR 50.92 (c), (1) through (3), should be performed to determine if the change involves a sipificant hazards consideration. Probabilistic Safety Assessment (PSA) insights can be used to supplement deterministic based assessments. If the assessment determines that a sipificant hazards consideration exists, the change is ,

sipificant to safety. Otherwise, the change is not safety sipificant.

Changes to commitments that are evaluated as being sipificant to safety would either not be implemented or would require discussion with the NRC and review .

. and approval, as appropriate, or written nptification. Changes evaluated as not sipificant to safety would proceed to Step 3 to assess if a compliance issue exists.

4 8

Revision 2: 12/19/95' t

7

- __- - . . ~ _.. _ - . .-.. . - . - _ . . . . . . - - - . - - . - . - - , _ - . - . . , - - , - , , - . , - , .._ - .-.- ,-.. - ,.. -

. 3-l

~

• information under 10 CFR 50.54(f) or 10 CFR 2.204; and, (4) commitments  !

, identified as long term corrective actions in response to a NRC Notice of l Violation. Regulatory commitments may involve both new actions as well as l' existing actions credited by licensees in responding to NRC requests. For example, responses to an item in an NRC Bulletin crediting an existing program, i practice or plant feature as meeting the intent cf the requested action is a ~

regulatory commitment. Changes to regulatory commitments not captured in

~

categories (1) through (4) would proceed to Step 5.

l If the original commitment has yet to be implemented, the licensee can proceed i with the change, but the NRC should be notified of the change as soon as l l

practicable aAer the change is approved by licemee management, but before any committed completion date. Notification should be accomplished by suppk;nenting the docketed correspondence containing the original commitment.

t If the original commitment was made in respose to a Notice of Vielation, the licensee can proceed with the change, but the NRC should be notified of the change as soon as practicable after the change is approved by licemee management if the commitment has been in place less than two years. Notification should be accomplished by supplementing the NOV respose.

l For other commitments in this category, if the commitment has been implemented, or is of a recurring nature, the licemee can make the change and provide annual or refueling outage interval notification to the NRC.

STEP 5: WAS THE ORIGINAL COMMITMFNT MADE TO MINIM 17F RECURRFNCE OF AN ADVEREF CONDITION?

Commitments to take long term corrective actions in Licensee Event Reports (LERs) are made to minimize recurrence of adverse conditions. A good measure of the effectiveness of these commitments is the success in avoiding recurrent adverse conditions. The NRC, under its enforcement policy, uses a two year time period fkom the date of the last inspection'or the period within the last two inspections, whichever is longer, as. an indication that the adverse condition related to a parti:ular brea has been corrected.

Licensees may find h usefbl to periodically review the necessity of cemitments related to minimizing recurrence of adverse conditions. Licemees need the flexibility to change or eliminate commitments they determine are no longer necessary based on:

10 Revision 2: 12/19/95 .

- bases. For example, all LER commitment changes related to procedures for which a I

' revised commitment was identiSed that minimized recurrence of the original adverse i condition could be provided as a listing in the report under a general basis description. j m.. s. 1 4

Figure A 3, " Revised Commitment Evaluation Summary," provides l documentation of the decisions made in applying the above change process. 'Ihe form would serve as proof that an evaluation was performed ami should be retained by the ,

i licensee either (1) until submittal of the annual repost or report Aled coincident with the FSAR updates per 10 CFR 50.71(e) for commitment changes that require NRC l notification, or (2) for the life of the facility for commitment changes that do not require

NRC notl6 cation. Where the form calls for a description of the rationale for a decision, it ,

is expected that, in the majority ofinstances, ajustl6 cation of one or two sentences would ,

be sumcient. In some cases a more detailed explanation or reference to a backup j assessment may be appropriate, it is not the intent to generate lengthy descriptions supported by detailed analyses, but rather to capture the essence of the basis for changing the commitment.

1 l

1

'i 12 Revision 2: 12/19/95

FIGURE A 2 SAFETY SIGNIFICANCE AREEERMENT (DECISION STEP 2)

PROM DEC680N STEP 1 9 P COULD g CHANGEalPACT ABERYOF 84C TO PEAPORM SAFETV PUNCT10N YE8 1f PrRFORu AsstasutNT USMG CRITERlA 0F 10 CFR M.92 (C),(1) THRU (3) 1 P DOES CHANot RE$ ULT YES CHANGEil N ION #EE NI I $@NIFCANT TO SAFETY CONSIDERAfl0N NO 1I CONTNUE WITH DEC410N STEP 2 V

II wu, t

• DOCUMENT RAtl0NALE If CoentfTMENT CHANGE 18 &

180T SAFETY 840leFICANT r PROCEED TO DECit10N STEP 3 14 Revision 2: 12/19/95

' , 3. (Continued) ~

.'.' Has the original commitment been implemented?

No. EXIT PROCESS'. Provide timely notification of revised commitment to NRC, Yes. EXIT PROCESS *. Notify NRC of revised commitment in next annual /RFO interval summary report.

4. Was the original commitment (1) explicitly credited as the basis for a safety decision in an NRC SER, (2) made in response to an NRC Bulletin or Generic Letter, (3) made in respoase to a request for information under 10 CFR 50.54(f) or 10 CFR 2.204, or, (4) identified as a long term corrective action in response to a NRC Notice of Violation?

No. Continue with STEP $.

Yes. Has the commitment been implemented? (see page 11 of the guidance if the commitment was made in respor.se to a Notice of Violation.)

No. EXIT PROCESS *. Provide timely notification of revised commitment to NRC.

Yes. EXIT PROCESS' Notify NRC ofrevised commitment in next annual /RFO interval summary report.

5. Was original commitment made to .ninimize recurrence of an advase condition (i.e., a long term corrective action stated in a LER)?

,, No. Change commitment. No NRC notification required.

Yes. Is the revised commitment necessary to minimize recurrence of the adverse condition?

No. Brie 0y describe rationale **:

Change commitment. No NRC notification required.

Yes. Notify NRC of revised commitment in next annual /RFO 2ntenal summary report.

• EX1T PROCESS means the balance of this summary is not to be completed.

• • Attach additional sheets providing rationale, if necessary.

. 16 Revision 2: 12/19/95

a specific point in the execution of a procedure as a result of problems identified in an NRC Notice of Violation. Several years later, the licensee determines that the independent verification step is no longer necessary due to improved performance of its personnel, in order for a commitment change process the personnel likely to propose a revision to the affected to work effectively,le procedure must be ab to identify that the independent verification was added to the procedure as ) art of a regulatory commitment. Possible ways to provide traceability incluce markings or notations within the procedure and administrative requirements to investigate proposed procedure changes that might af fect regulatory comitments. Similar processes would be necessary for design 1 features or other licensee comitments not incorporated into controlled procedures.

4.2.1 Procedures and Controls

a. Verify that the licensee has defined a process for managing commitments made to the NRC. Such process descriptions may be contained in licensee procedures, general guldance docume.4ts, program descriptions, training material, administrative documents, or combinations of these documents.

The controls for changing commitments made to the NRC may be included in a stand alone commitment management system or may be incorporated into other licensee corrective action, licensing, or administrative programs.

Comitinent management systems may involve periodic assessments of all outstanding comitments or may evaluate changes on a case by case basis.

Indentify the governing procedures and guidance documents and discuss the licensee s comitment change process with the responsible licensee personnel. Document how the licensee's process is controlled as well as the how the process is used to evaluate p posed changes to comitments.

For example, the process may be governed an administrative procedure or other document that is controlled n accordance with facility technical specifications and quality assurance programs or the process may be controlled within a licensing group as a relatively informal procedure, in either case, the effectiveness of a licensee program will consider the assessments performed for item 3.2.2, Implementation, of this audit,

b. Verify that licensee arograms in ide guidance regarding the evaluation of pro)osed changes to comitmess in terms of safety and regulatory signif cance. The comitment change process should distinguish between the changes licensees can implement without interaction with the NRC and those governed by regulations that may require NRC review and a> proval prior to implementation. The process should include a mechantsm for determining when .it would be appropriate to notify the NRC of a comitment change. The NE! guidance document is an acceptable guide for licensees to follow for managing and changing their comitments to the NRC. Ensure that the licensee has integrated the comitment management system with other line organization functions to ensure traceability of a regulatory comitment following its initial implementatic - Such systems are necessary to ensure that licensee personnel are able to recognize that future changes to the affected design features or Revision: 10/28/97 9- Audit Guide

-w ~- ~ - - .,

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operating practices require evaluation of the proposed chMge in accordance with the comitment chan design or procedure change process. ge process as well as the normal Although the process and review criteria in the NEl guidance document is the preferred method for controlling changes to comitments there is no defined regulatory requirement that specifies how licensees must control those changes. Therefore, licensees may define criteria for justification of comitment changes and NRC notification of such changes that are different than those recommended in the NEl guidance. For those licensees that have not adopted the NEl methodology. document a comparison of the licensee's process including criteria for evaluation of changes and NRC notification, to that recomended in the NEI guide.

Although observations regarding the licensee's process or related criteria should be included in the documentation of the audit, any concerns related to the actual effectiveness of licensee programs should be reinforced by actual examples reviewed in accordance with item 4.2.2.

Implementation, of this audit guidance.

4.2.2 Imolementation The implementation area of the audit assesses the licensee's performance implementing its comitment change process. Comitments and changes thereto can involve all technical disciplines associated with a nuclear plant. Few auditors are expert in every nuclear related discipline. Therefore, the auditor should recognize when technical assistance is needed to effectively review a safety evaluation or resolve a safety concern. The need for assistance can be ahticipated based on the comitment changes selected for review Also acceptable is simply identifying and documenting (in the documentation of the audit) technical questions for follow up at a later date (either by the region or NRR).

Recognizing failures of the licensee to comply with the administrative control requirements of its commitment change process is important. However, recognizing failures of the licensee to adequately assess how a change will affect plant operational safety or compliance with applicable regulations is more important.

The focus of the implementation part of the audit should, therefore, be on safety and ensuring that revised comitments have not led to noncompliance with applicable regulations. For example, if you agree that a comitment change was safe and believe it would not introduce issues of compliance with any regulations, questions or concerns regarding the change process can simply be documented in the audit report. By contrast, a comitment change evaluation that failed to address an obvious safety or regulatory consideration would be more significant. Failure to recognize that a comitment change required assessment by regulations such as 10 CFR 50.59 or 50.54 may also be significant. Safety concerns or possible regulatory nonconformances that are discovered during this audit should be forwarded to the appropriate regional personnel for follow-up as part of the NRC's inspection program.

Audit Guide 10 - Revision: 10/28/97

, .- , j

• i

a. Cggiitment Chances Reoorted to the NRC. In addition to the selection of commitment cnanges from various sources such as submittals pertaining to j licensing actions, responses to bulletins and generic letters, reuonses -

to NOVs. and !.ERs. Other considerations for selecting comitment c1anges

. for review are: .

i

1. Choose changes related to a variety of systems: l

2. Choose changes involving a variety of engineering disciplines, such I as nuclear, mechanical, civil, and electrical: ,

i

3. Choose changes that involve a variety of licensee actions, such as design modifications, temporary modifications procedure revisions, personnel trainirg, and revised administrative controls:

4. The selected sample of commitments and commitment changes to be  ;

reviewed may need to give preference to recent items since the comitment management systems being evaluated vary in regard to when .

they were developed and the extent to which past commitments have  !

been captured; i

~

5. Since changes to the FSAR and other programs are, or will be.

assessed in NRC ins)ection procedures, this review should exclude  !

c0mmitments integra;ed into the FSAR. Quality Assurance Program.

, Site Security Plan. Emergency Plan, or other document governed by a j change control mechanism contained in regulations such as 10 CFR 50.59 or 50.54: and 6, Give preference to changes related to comitments which were previously considered in an NRC decision making process. Examples include comitments related to enforcement discretion, resolution of  ;

generic safety issues, and resolution of significant inspection issues.

Review each selected comitment change against the requirements and guidance established in the licensee's procedures or guidance. For each change, consider:

e the relationship between the commitment being changed and regulatory requirements (obligations);

e the relationship between the comitment being changed and overall plant safety or risk profile; e the licensee's criteria for determining the acceptability of a proposed comitment change (e.g. the NEl guidance includes the use-of the questions from 10 CFR 50.92):

e - systems and components affected by the change (What is the effect of the change on their capability to perform their- specified or intended functions?): 1 Revision: 10/28/97 Audit Guide

i

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e intent of the original comitment (Was comitment related to regulatory com required safety function, or process enhancement?); pliance, e potential effects of comitment change (Has licensee reasonably concluded that revised comitment will maintain plant safety and or regulatory compliance, ineffective, or that revised comitment will improve performance that original commitment was unnecessary?):

e documentation of the comitment change (Each evaluation of a comitment chaNe should be documented in accordance with the-licensee's procedurcl requirements. Auditors should note that the NRC accepted NEl guidance recomends less documentation for the justification of comitment changes than that typically provided in licensee 10 CFR 50.59 safety evaluations or design documents.): and o effective implementation of the revised comitment (Select several-commitment changes for verification of implementation. Review licensee comitment management records, work- orders, revised procedures. NRC inspection reports, and other documentation that wuld demonstrate that the specific revised actions were completed in. accordance with the stated comitment revision and related schedule. Where appropriate, utilize actual physical verifications of equipment and processes.).

b. Qm1+ ment Chances Not Reoorted to NRC. Review each selected evaluation of a commitment change against the requirements and guidance established in the licensee's procedures or guidance. For each change, consider the technical factors listed above as well as the licensee's criteria for determining if the comitment change requires notification of the NRC.

for those comitment changes not requiring NRC notification, ensure that the justification for the change is documented in a record that will be maintained for the life of the facility (maintenance of current licensing basis).

c. Notifications to the NRC. Verify that each comitment change determined to warrant NRC notification, has been or will be included in either a periodic or individual report to the NRC. Ensure that the description of the commitment change submitted to the NRC is consistent with the action taken by the licensee.

-d. IrEeAbility of Comitments. Verify that each sample of a recently implemented commitment would be reasonably identifiable as a commitment to those licensee personnel most likely to be involved in a subsequent change to the affected design feature or operating practice.

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