ML20236F720
| ML20236F720 | |
| Person / Time | |
|---|---|
| Site: | River Bend  |
| Issue date: | 06/30/1998 |
| From: | NRC (Affiliation Not Assigned) |
| To: | |
| Shared Package | |
| ML20236F715 | List: |
| References | |
| NUDOCS 9807020304 | |
| Download: ML20236F720 (14) | |
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1 1
Audit Reoort l
Commitment Manaoement i
Enterov Ocerstions incoroorstad River Band Station - Unit 1 Docket No. 50-458
- l. INTRODUCTION As part of the staffs activities related to improving the management of licensing basis I
information, audits of commitment management programs have been performed at eight reactor facilities. The audits assessed licensees' implementation of commitments made to the (NRC) staff and also assessed the long-term control of commitments as a follow-up to the issuance of industry guidance for evaluating and reporting changes to commitments made to the NRC. River Bend Station (RBS) was selected as one of eight facilities whose commitment management programs were audited by the staff.
The audits and other staff efforts related to managing licensee commitments made to the NRC are intended to improve the (1) identification of important licensee commitments or other supporting design features or operating practices used by the licensee to justify a proposed l
change or address design or operational problems, (2) determination of the most appropriate means important commitments or other supporting information should be verified, and (3)
. determination of 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 i
controls). The findings from the audits will be used in the staffs development of recommendations to the Commission regarding the need for further staff actions in the area of commitment management.
The audit at RBS was performed by David Wigginton and Robert Fretz of the Division of Reactor Projects, Office of Nuclear Reactor Regulation, during the period of May 4,1998, through May 6,1998. The audit consisted of interviewing personnel, and review!ng procedures, guiclance documents and other documentation related to the commitment management process used by the licensee at RBS. Additional reviews of work records, procedure changes, and other documentation were performed to verify the implementation of specific procedures or to i
evaluate changes made to commitments previously made to the NRC.
II. ' VERIFICATION OF LICENSEE IMPLEMENTATION OF PAST COMMITMENTS In order to verify that the licensee effectively implements those commitments made to the NRC during staff reviews related to licensing actions and licensing activities, the auditors selected a sample of commitments made during interactions between the licensee and NRR personnel.
ENCLOSURE l
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.9907020304 990630 l
PDR ADOCK 05000458 P
Pm j
y 2-The auditor's findings regarding the licensee's implementation of the selected commitments are described below:
1)
Three commitments identified in the Safety Evaluation Report (SER) for River Bend License Amendment 86 were chosen for review. This license amendment approved deletion of Technical Specifications response time testing requirements for Reactor Protection System instrumentation. The commitments selected for review were:
a.
RBS was to perform a hydraulic response time bench test prior to installation of a replacement transmitter. Implementation was to occur before RF-6.
- b. -
RBS was to revise calibration procedures to include fast ramp and step change tests during instrument calibrations.
c.
RBS was to revise Surveillance Test Procedures (STPs) to ensure calibration and functional tests allow simultaneous monitoring of input and output response.
Calibration procedures were to be revised to have technicians in direct communications to verify that response times were less than 5 seconds.
The three commitments were captured in the License Research System (LRS) under numbers A13950, A13951 and A13953, and were statuses as " closed". The LRS commitment tracking record showed that procedures STP-051-4205 through STP-051-4212 were changed to incorporate the new requirements. The' auditors verifed that the essential elements of the three commitments were incorporated within the body of the test procedure; however, a specific note or statement to require that technicians be in
' direct communications to verify response times was not identified. Further discussions with River Bend personnel familiar with the implementation of the test confirmed that direct communications between instrument technicians was implied, since this was necessary to perform the test. This practice appears satisfactory and, presently, the three commitments selected from License Amendment 86 are adequately implemented.
The implementation of commitments associated with Amendment 86 was not,' however, completed without problems. In 1996, the licensee initiated Condition Report 96-0303 following a QA audit which identified that procedures STP-051-4109 through -4212 had not been revised to incorporate steps to test transmitters for prompt response prior to RF-6. The procedures were immediately revised, and some surveillance tests were re-performed prior to the restart from RF-6. In this case, the licensee demonstrated the ability to self-identify this commitment implementation problem; however, the QA Audit revealed that ineffective verification steps were taken prior to closing out the associated i
commitment. The audit revealed the need for the licensee to have a more effective implementation effort to assure timely and adequate closure of commitments.
2)
One commitment associated with License Amendment 87 was identifed and chosen for review. This amendment deleted Technical Specification Surveillance requirements to
' periodically measure Drywell bypass leakage, and instead allowed RBS to perform qualitative testing outside the Technical Specifications. In SER section 2.2.7,
" Monitoring Leakage", RBS committed to trending Drywell pressure changes versus 4
l i
3-containment pressure changes as a gross indicator of Drywell bypass leakage. This change effectively created a recurring test program requirement similar to, but outside i
of, the structured Technical Specifications surveillance test requirements.
Three LRS commitment tracking records were created to document implementation of the new test procedure. The first record (A13948) tracked development of procedure TSP-0059, the second record (A13949) was associated with performance of the first test, and the third record (P15363) monitored continued compliance with the SER commitment. River Bend's tracking for continued compliance on " passive" commitments appeared to rely upon other processes or supervisory initiatives to trigger a review to determine whether a commitment was satisfactorily implemented. For example, the auditors were concemed about how the scheduling and integration of subsequent Drywell bypass leakage tests under TSP-0059 would be performed in order to maintain compliance with the commitment. It was unclear how this test would be integrated into RBS's work management process. The licensee's representative stated that rsrior to a scheduled maintenance or refueling outage, personnel would review continu9d '
compliance commitments to ensure that testing, such as in the case of TSP-0059, would be included within the scope of the outage. The auditors expressed concem to the licensee's representatives that this approach relied upon a manual step or intervention as opposed to an automatic process that, for example, routinely initiated a repetitive task, work order, surveillance, etc.
River Bend's current practice could inadvertently result in missing a periodic test that the staff relied upon in a SER, and in this case, one which allowed deletion of e similar Technical Specifications surveillance test. RBS licensing personnel agreed that there was a potential weakness with this process and later informed the auditors that routine scheduling of TSP-0059 would be made by including this test within the "T.S.
Surveillance Testing Matrix" Although this solution would provide the confidence that TSP-0059 would be appropriately performed, there appears to be a process weakness that would ensure a consistent approach would be taken to adequately schedule and implement similar continued compliance commitments in the field. Granted, the establishment of recurring testing requirements outside the STP is rare; however, the licensee did acknowledge that a standard approach would improve the overall implementation of similar recurring commitments.
3 l
t.
3).
License Amendment 94 authorized the performance of the 24-hour Emergency Diesel Generator (EDG) surveillance test run while in Modes 1 and 2. In the SER granting approval for this request, the licensee made three commitments:
I a.
During the 24-hour EDG test, no other EDG would be operated.
b.
The EDG would not be paralleled to off-site system during severe weather or unstable grid conditions.
c.
No maintenance would be performed on the other EDGs during the test.
l Using " Amendment 94" as a search criteria, the auditors were unable to find any records associated with these commitments during a pre-audit review or after numerous query 1
4 search attempts using the LRS while at the site. RBS representatives provided hard copy files demonstrating that their review of the docketed correspondence successfully
[
identified the three commitments. A copy of STP-309-0611 was reviewed which verified l-that the necessary precautions were present within the procedure body to fully implement the above commitments. The difficulty associated with obtaining a successful query was due to inconsistency in entering a " parent record" association, i.e.
" Amendment 94", in the commitment record. The information was available in the LRS
. commitment tracking system, but was listed under the licensee's record notation for the amendment request. This data input inconsistency was representative of a number of record data entry inconsistencies noted during the AUDIT. Similar human performance issues associated with the lack of consistency and/or rigor when entering data is discussed in Section ill of this audit report.-
4)
One commitment related to RBS License Amendment 95 was chosen for review and verification. - In the SER, RBS stated that the Service Water System (SWS) and the Standby Cooling Tower will continue to be treated for biofouling without the need for Cobicula detection. This commitment was identified by the licensee and found in the LRS under commitment numbers A15364 and P15365. A review of Chemistry
' Operating Procedure " COP-0123" also validated that this commitment is being -
successfully fulfilled by RBS. The auditors consider this commitment to be satisfactorily implemented.
i 5)
The audit team also selected two recent ASME Code exemptions / Code case requests for review to determine how the licensee handled commitments that appeared in SERs granting approval of the requests. The two Code requests submitted and approved under 10 CFR 50.55a were: (1) RBS requested to apply ASME Code Case N-508-1 to
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the Section XI snubber and safety relief valve programs, and (2) a Code Relief Request was granted on April 28,1998, which allowed vibration measurements on the EDG fuel transfer pumps to be taken on the pump case versus the pump shaft per Code j
requirements.
The above examples were chosen because SERs associated with the 10 CFR 50.55a submittal documented specific actions the licensee would take that appeared to be
" commitments". These actions would essentially be incorporated into the appropriate programs; however, the auditors wanted to know whether the licensee documented the i
" commitments" into their Commitment Management Program.
A review of the LRS commitment records prior-to the site audit did not reveal any active or continuing compliance commitments. RBS program representatives were interviewed and questioned about how they handled apparent commitments within SERs that granted Code case / exemption requests. In both cases, RBS did not consider 50.55a requirements as items to be tracked within the Commitment Management Program
. (LRS). The licensee representatives stated that commitments made in accordance with the 10 CFR 50.55a process should be incorporated into the inservice inspection (ISI) or
(
inservice testing (IST) Program Plan and not subject to LRS tracking.
l i
5-l In order to see if this approach was being applied to other program plans, such as the l
Quality Assurance Plan, Emergency Response Plan or Security Plan, the auditors interviewed a representative of the Security organization. The individualindicated that l
changes to the Security Plan, made in accordance with 10 CFR 50.54(p), are incorporated into the plan and are not tracked under the LRS. There was also a consistent viewpoint from site licensing personnel that commitments on various
" programs" should stay with the program plans and be subject to their associated change processes (i.e. 50.54(a),50.54(p),50.54(q),50.55a, etc.) The auditors confirmed that a consistent approach was being taken with regard to program-related commitments, and considered this practice satisfactory.
l 6)
A limited sample of NRC Bulletin and Generic Letter (GL) commitments was taken in order to ascertain whather RBS effectively extracted and implemented GUBulletin j
requirements. A pre-audit sample of Bulletin 93-02 (including Supplement 1) and l
Bulletin 95-02 commitments showed that the licensee identified at least 23 commitment action items within the LRS. The commitment records appeared to capture affected j
documents and procedures within the "related records" section. However, in some i
cases it was difficult to completely follow the source of the commitment and actions taken in order to justify a status of " complete"/" closed".
The licensee recently performed a self assessment of its Commitment Management i
Program and identified a concem with RBS's completeness in identifying, implementing and closing-out commitments associated with GL and Bulletin responses. The licensee also identified deficiencies in generating active and passive commitments associated with Bulletins 93-02 and 95-02, and initiated Condition Report 98-0407 to document the findings of the self assessment. Corrective actions identified in CR 98-0407 are now in progress. Included is a review of Bulletin and GL responses issued during the last five years to ensure appropriate identification of commitment actions from docketed l
correspondence. The licensee appears to have an understanding of potential deficiencies associated with GUBulletin responses and is taking appropriate action at this time.
111.
Licensee Programs for Managing (Changing) Commitments l'
The primary focus of thic part of the audit is to assess the licensee's programs and performance related to implementing controls for modifying or deleting commitments made to the NRC. The staff's interest in this matter is related to how changes to commitments (modifications or deletions) are evaluated and how the NRC is informed of commitment changes that have safety or regulatory significance.
l l
Current Commitment Management Procedural Controls L
l At RBS, there are three procedures and guidelines that are related to the licensee's Commitment Management Program:
RBNP-029 (Revision 8), " Commitment Management System",
4 f
L_______
..__.._.___.______._________.___________m
n NLP-10-016 (Revision 2)" Commitment Management Guidelines"
" Desktop Guide for Commitment Database" (Revision 5) l RBNP-029 provides overallinstruction to RBS personnel of the process for documenting and
' changing NRC commitments and obligations. NEl guidance for managing and changing commitments accepted by the NRC in SECY-95-300 has been incorporated into this revision of l
RBNP-029. Licensing personnel are responsible for screening incoming and outgoing L
correspondence for commitments, if a commitment is found, it is entered into the commitment l
- database (LRS). The Licensing organization identifies an " owner" for the commitment, and i
management reports are routinely issued to the appropriate supervisor for tracking their status.
If a commitment requires a one-time action, the owner is to provide documentation -
demonstrating adequate completion to the licensing organization. The database is updated, the l-active commitment is statuses " closed", and a continuing compliance commitment record may be created at this time if the licensing engineer determines that continued compliance tracking is necessary.
The two guidance documents provide more amplifying instructions aimed primarily to site
_ licensing personnel in utilizing the LRS. These documents outline River Bend's endorsement of NEl's distinction between obligations and regulatory commitments. RBS utilizes the following nomenclature to classify commitments within their LRS database:'
Obligations Regulatory Commitments implementation Live (L)
Active (A)
Continuing Compliance Sustaining (S)-
Passive (P)
' " Live" obligations and " Active" regulatory commitments can be in a status of "Open", " Awaiting NRC Closure", or " Closed". " Sustaining" and " Passive" continuing compliance obligations and i
commitments are either in a status of " Satisfactory" or "Not Satisfactory".
L i
' River Bend procedures identify three categories for NRC 0,,,w,;L.,ents and obligations and are defined as
' follows:
l-A Regulatory Obligation rneans any condition or action that is a legally binding requirement imposed on licensees l
through applicable rules, regulations, orders, and licenses (including technical specific.&,ns, license conditions and l'
other regulatory interaction).
A Regulatory Commitment means an explicit statement to take a specific action agreed to or volunteered by a licensee that has been submitted on the docket to the Commission, by designated licensee management, in writing.
A Non-regulatory Obligation encompasses the tracking of other actions in the Commitment Database which do not meet the definition of either a Regulatory Commitment or Regulatory Obligation. Examples include (1) licensee intended actions identified in an incoming NRC inspection report, (2) RBS consideration of concems expressed by the NRC in an inspechon report, or (3) intenbon to take an action which is verbally communicated to a regulator (NRC).
l
' RBNP-029 and LNP-10-016 only provide an overall summary of the commitment management process. The Desktop Guide becomes the document that provides detailed instructions regarding the NEl process for changing regulatory commitments and reporting changes to the NRC. The Desktop Guide essentially repeats NEl guidance incorporating the five step process to change regulatory commitments 1
Step 1: Is there a codified change process for the commitment?
Step 2: Is the change significant to safety?
Step 3: Was the original commitment necessary to achieve compliance with a regulatory obligation?
j Step 4: Did the NRC rely upon the original commitment being considered for change?
Step 5: Was the original commitment made to minimize recurrence of an adverse condition?
The NEl process flowcharts and screening form are essentially copied verbatim and are also included within the desktop guide.
Licensing Research System The Commitment Management Program is supported directly by the LRS database program.
The LRS is a Windows-based program which replaced the " TRAC" DOS-based system in September of 1994. This conversion was the first step taken in an overall effort to bring RBS more in line with other Entergy Operations (EOl) nuclear sites. The first version of LRS resided on River Bend's Local Area Network (LAN) and provided a more user-friendly interface to the database. Another improvement the LRS provided over the TRAC system was to convert it from a DOS-Foxpro database platform to an Oracle database. This should allow the system to
- be adequately maintained for the foreseeable future.
As with any computer database system, it is wholly dependent upon the user of the system to have the necessary knowledge and training in order to perform an effective database query.
For example, if a procedure writer was working on a revision to a STP, the individual would need to know the distinction between a." Parent Document", "Related Document", " Source Document" and the various document types, and how these relate to the LRS database structure. A' site " test" of the LRS showed that the query building screen was as simple to use as could be designed; however, the user had to have a good working knowledge of the i
database structure in order to perform a complete commitment database query. Based upon interviews with RBS personnel, licensing engineers (LE) and procedure writers appeared to have a good working knowledge of the LRS necessary to perform a complete search. Other individuals indicated that they routinely depended upon the LEs to assist them in performing a commitment search whenever a procedure change was contemplated.
Commitment Database ReviewProject in 1995 EOl formed a "LRS Peer Group" in order to improve standardization efforts as well as
. plan on a newer version of LRS. A part of the standardization effort was to separate Operating Experience and other INPO commitments from NRC-related commitments. Later that year,
' RBS also formed a " Commitment Database Review Project" A significant element of this initiative was to change the process to a two4ecord format in order to separate implementation
8 of the original commitment and to track continuing compliance commitments where warranted.
Previously, there was no differentiation between commitments that required one-time actions and those that required periodic follow-up. All commitment records were treated as continued compliance items. The two-record system provided the basis to eliminate numerous commitmenu records not necessary to maintain compliance, and would thus, in the opinion of the licensee, elimir. ate an administrative burden. The database review project evaluated over 8,000 records in its computer system. Approximately half were related to INPO/OE commitments and were separated from tk database. At the end of the project, approximately 300 continuing compliance commitment records remained active in LRS of the 4,000 reviewed.
In March 1996, the NRC performed an inspection of the RBS commitment management
- system. The inspector raised a number of concems regarding the current process and compliance tracking efforts, and documented these cencems in Inspection Report 96-03.
The inspectors concluded that management processes did not provide adequate barriers to consistently provide for NRC notification when commitments originating from SERs, GLs, Bulletins and responses to Notices of Violations were revised. It was also noted that the licensee's approach differed from NEl guidance endorsed in SECY-95-300.
In January 1997, the licensee's Quality Assurance organization performed an audit of the RBS licensing function. QA personnel also expressed concems that (1) continued compliance tracking for certain (ommitmee.t may have been inappropriately discontinued during the 1995 commitment database review, and (2) commitments to the NRC could be changed without appropriate NRC notification per NEl guidance. In response to this report, the licensee conducted a review of over 4,000 closed commitments for appropriate continuing compliance tracking. Approximately 260 items were targeted for a more detailed review and about 45 items that were originally listed for continued compliance would be discontinued. About half of the 260 records were eventually reinstated for continued compliance tracking.
TechnicalProcedures RBNP-001, " Control and Use of RBS Procedures", and its accompanying guideline are also impacted by the Commitment Management process. In step 3.2.4.4 of the RBNP-001 Guideline, the licensee directs preparers of a Procedure Action Request (PAR) form that "...a
- review of all commitments obtained through search of the LRS database should [ emphasis
'added) be reviewed." Additional details are offered in the Coi;imitment Management guidelines. The PAR initiator is also instructed to include copies of applicable commitments to the procedure sponsor in the review package.
Although the use of the word "should", at opposed to "shall", may not imply strong
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management expectations, interviews with various members of the licensee's staff concluded that there is a consistent understanding that all initiators of a PAR / procedure changes are to conduct a review of the LRS.
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The auditors were given a'dded confidence that a procedure change would not result in an unintentional change to a regulatory commitments. This is accomplished by the use at RBS of l-the procedure " templates". The " Procedure Template Guidance" document accompanies the RBS Procedure Writers Guide, and describes the process for marking specific procedure steps I
c_-- - - -___-_-. _ _ _ _ _ _ _ - _ _ - _ _ _ - _ _ _ _ - _ _ _ _ - _
i l
.g.
that are required as a result of a regulatory commitment / obligation with a "C" in the left margin.
l Technical Specification required steps, in procedures such as STPs, are marked with a "TG" in the left margin. This practice provides an important barrier to field personnel to prevent inadvertent changes to Technical Specification and commitment-related steps, prior-to a review of the LRS The auditors considered this practice, where applied, to be a strength.
I Entergy Operations Bench marking -
In order to compare River Bend's use of the LRS database in conjunction with procedure templates, the auditors and River Bend Licensing organization conducted a teleconference with representatives from EOl's three other nuclear sites. Representatives from Waterford 3, ANO and Grand Gulf discussed the approaches taken by each of the sites with respect to controls i
that are in place to ensure procedure changes do not unintentionally change a commitment. A l
summary of the various management EOl site practices is outlined below.
Comparison of EOI Nuclear SNe Procedure Change and Commitment Atanagement Prac6ces Management Practice River Bond ANO GGN8 Waterford 3 Are commitments identified in procedures by Yes Yes N:
No marking affected steps?
Are commitments identified as an attachment to
.No No Yes No a procedure?
Is there a requirement to review the commitment Yes Yes Yes " '
Yes database prior-to final approval?
Number of process barriers 2
2 2
1*2-Who is responsible for performing a commitment initiator initiator Licensing initiator i
=
search in LRS? Licensing? Change initiator?
sign-off is a Licensing staff member available to assist in Yes Yes N/A Yes I
the LRS search?
4 Is a LRS search required before a " temporary" or No " 8 Yes "
- Yes *
- Yes l
- immediate" procedure change is implemented?
I Estimated number of commitments in LRS
~4,600
-14,200
-34,000
-10,000 Note 1: Commitments are identified on a ' Requirements Cross-Reference List' which is included in procedures.
The requirement, the requirement section and the procedure paragraph number that implements the requirement are listed. Example: 10CFR 50.71(E)(1) 6.6.2.D Nolo 2: An independent technical review is performed for each psocedure that is being changed, revised, or doloted. One responsibility of the Technical Reviewer is to vert'y that the commitment evaluation has been performed for that procedure.
Note 3: RBS allows temporary approval of an "immediate* procedure change. A complete LRS commitment search is performed within 14 days, prior to final approval. Also commitment steps are marked with a 'C'
' designator in the margin.
Note 4: ' ANO annotates a procedure step with the commitment number in the margin, so in effect, a review is performed on the spoL u______________________________.
l l
10 Note 5: GGNS identifies all commitments, including INPO inspect.on, SOER/OE and Condition Report commitments, as an attachment to the procedure. As a result, the review is performed on the spot. For temporary procedure changes the author has the option to bypass Licensing's review, if no procedural commitments are e'locted I
Waterford 3 (W 3) was the only EOl site that did not either annotate a procedure step or provide an attachment listing commitments within a procedure. As a result, W-3 must place a greater reliance upon the accuracy and completeness of data entered in the LRS. Based upon the teleconference discussion, W-3 representatives appeared to understand this inherent aspect of their use of the LRS. They indicated that a significant emphasis is placed on the thoroughness of data entered in the commitment record. For example, a related document or parent document reference most always includes additional information, such as a procedure step, paragraph number, etc. In addition to the documer.t type and number. W-3 also stated that they hold the Technical Reviewer responsible for performing a thorough LRS search.
Although relying entirely upon the LRS can be an acceptable practice if the necessary rigor is
. present, the additional barrier created by annotating a procedure step associated with a commitment provides a grecter assurance that a commitment will not be inappropriately changed.
The audit team, however, did find a number of data entry irregularities in many of the
- commitment LRS database records. For example, there seemed to be an inconsistent -
approach in identifying and entering the " Source Document" and " Parent Document" felds in the commitment record. Some License Amendment commitments included the An,endment number in the " Parent 1" or " Parent 2" field and many others did not include the number.
Therefore if one was to search for all commitments related to a particular License Amendment, the individual may or may not obtain the correct listing of commitments associated with the amendment. Additionally, there were some inconsistencies associated with the "Related Documents" section of the data record. (There is a one-to-many relationship between a commitment record and its associated related records.) There were a number of examples where there were no implementing procedures referenced in the document " relationship" feld.
This situation makes it difficult to query the link between a procedure and a possible commitment when searching the LRS; however, RBS does have the added benefit that certain procedures have steps that are annotated with a "C" or "TS"if a commitment is involved.
Nevertheless, a more standardized approach as to what information is entered into critical fields is needed. The licensee is aware of this situation and is presently evaluating whether the more l
- distributed approach, which currently allows each responsible LE to enter data, remains valid.
IV. EVALUATION OF COMMITMENT CHANGES L
in order to verify that the licensee effectively controls changes to commitments made to the NRC, the auditor selected a sample of commitments that the licensee revised following the initial implementation.. Given the small number of items classired as commitments at RBS, the auditors identifed and reviewed only 6 commitment changes. The auditors' findings regarding the licensee's evaluation and reporting of the selected commitment changes are described
- below:
1 I
1
. {
l Commitment No. 8653 - This commitment was established in response to NRC Inspection
{
Report 90-27. The licensee (Gulf States Utilities at the time) committed to requiring its design l
engineering organization to identify specific pre-qualified weld joint details in design drawings.
i RBS has changed this commitment by allowing the maintenance craft to select the specific pre-qualified welding details in accordance with SSP-7002 "AWS Welding Procedure" as directed by the design drawings. If the design does not allow a pre-qualified welding procedure, the design organization would provide the necessary design details. Audit team members reviewed I
the commitment change evaluation form, which duplicates NEl guidance, and found it to be complete. An interview with the welding engineer responsible for the SSP-7002 procedure was conducted to validate RBS's rationale for the commitment change. The commitment change was found to be satisfactory.
Commitment No. 8894 - Violation 9029-02 addressed a situation where a boundary rope at a high radiation area entrance was not restored by an unidentified worker upon his/her entry or exit. RBS committed to "... change its philosophy with regard to radiation barriers -in that personnel will not be allowed to cross under or over radiation barriers. Only approved entrances / exits set up by Radiation Protection may be used." In the Commitment Evaluation Summary Report submitted to the NRC in April 1998, the licensee stried that "...the evolution of the River Bend Radiological Program has rendered this commitment obsolete and it is deleted."
The commitment change file and evaluation form was reviewed. It was somewhat difficult to follow the licensee's thought process with regard to the actual violation cited, original solution offered and the change explanation. Violation 9029-02 was based upon improper actions by an unidentified radiation worker. The commitment change justification comments discussed j
standardized posting requirements to high radiation areas, and did not seem to appropriately address the human performance aspects related to restoring the high radiation area boundary rope. In discussions with the licensee, the audit team and licensee concluded there was an appropriate basis for changing the commitment but the correct basis was not documented. The licensee will correct the documentation, however, it was of greater concem to the audit team that the original change documentation had been reviewed and approved as-is by a first line supervisor. The audit team recommends that management communicate the need for supervisors to maintain higher standards when reviewing and approving commitment changes and other formal documents.
Commitment Nos.13019/15232 - These commitments are two of many associated with NRC Bulletin 93-02," Debris Plugging of Emergency Core Cooling Suction Strainers". In the reply to j
the Bulletin, RBS stated that there is "...a policy to visually inspect the ECCS suction strainers located in the suppression pool for debris during each cold shutdown greater than 10 days."
Approximately two years later,Bulletin 95-02, " Unexpected Clogging of Residual Heat Removal (RHR) Pump Strainer While Operating in Suppression Pool Cooling Mode" was issued. One of the five recommended actions for 95-02 was to establish a suppression pool cleaning program.
i The licensee responded that "...RBS currently inspects all ECCS suction strainers during each cold shutdown of sufficient duration."
Since the issuance of the two Bulletins, the licensee has installed two modifications which have significantly reduced the risk of clogging ECCS/RHR pumps suction strainers. The first modification installed a " Suppression Pool Cleanup (SPC), Cooling, and Attemate Decay Heat i
Removal System". The suppression pool water clarity has noticeably improved since that time.
,* In addition, new larger-capacity passive suction strainers have been installed which further reduced the rich of debris clogging. As a result, the licensee has changed frequency of suppression pool surveillance from every cold shutdown greater than 10 days or of sufficient duration to every refueling outage. The commitment change evaluation _ form provided an appropriate basis for the change and appeared satisfactory. Additionally, a fold survey of the suppression pool, even with the cleanup system OOS for about 2 weeks, showed that the SPC is providing an adequate supp ession pool clarity level. This commitment change was appropriately documented.
Commdment No. 5067 - This commitment stated that "... control of security keys between Operatens personnel has been added to the Shift Tumover Log *, and was in response to inspechon Report 85-75. Since the time of the original violation on inedequate security key control, the RBS programs have substantially evolved. Key ring accountability is now being maintained by the use of Security computer / card key systems, which provides better control
. versus the shift tumover log. The change to discontinue this commitment was satisfactorily documented on the commitment change evaluation form.
Commdment No.10003 - In response to inspection Report 92-99, RBS stated that the
" Operations Department will monitcr plant housekeeping status and provide direct feedback
[
at plant meetings to improve effectiveness." The licensee's commitment change evaluation form cites improvement in plant materiel condition and housekeeping since 1992. Additionally, Operations is still responsible for monitoring plant cleanliness. The audit team agreed with the licensee's assessment that maintaining this item as a regulatory commitment in the LRS was not appropriate. Sufficient controls are available to ensure that plant cleanliness is maintained.
Commitment Nof 7775 - This commitment stated that "... current and future alarm station
. operators will be instructed on computer transfer /startup/ restart operations at both CAS (Central
- Alarm Station) and SAS (Secondary Alarm Station) on a periodic basis..." in 1996, RBS installed a new Security Computer system which did not have similar transfer /startup/ restart
- functions. Deletion of this commitment was appropriate.
Observations Although it was appropriate to change or otherwise eliminate commitment numbers 5067,7775 and 10003, a lack of timeliness for documenting the changes was noted. Commitment number 7775 was effechvely changed in 1996 when the licensee installed the new Security Computer system.~ Although there are controls to review for commitments whenever procedures are changed, there is no regulatory requirement to screen for commitment changes as a part of the 10 CFR 50.59 modifications process. However, there needs to be better ways to ensure that defacto changes in commitments as a result of modifications are identifed in a more timely manner. Additionally, there needs to be an improved awareness by site management regarding commitments on record affecting their area of responsibility. This will ensure that outdated commitments are not being maintained on the LRS as well as ensure that a commitment review is conducted coincident with the change in site practice and thus more timely reported, w
f.
- Interviews with plant personnel also found that there was a satisfactory understanding of the NEl commitment change process; however, two of the licensees' representatives showed some confusion over the use of the "No Significant Hazards Consideration" language. The individuals believed that "no significant increase in the probability" in fact meant "no increase in the probability" since personnel were more familiar with the 10 CFR 50.59 screening process. The representatives felt their management would be reluctant to use the "no significant increase",
vice "no increase", in commitment changes since it implies a negative impact to safety. In discussions with site personnel, they have the same feelings toward " minimal" in the 10 CFR 50.59 proposed process, i.e. the licensee is not likely to use either due to the strong perception that they would be exposed to a greater risk of tight inspection scrutiny.
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.V. LICENSEE SELF-ASSESSMENTS L
The licensee has recently conducted a number of intemal and corporate self-assessments, and appears to have an accurate understanding of their shortcomings and strengths associated with regulatory commitments. These assessments have been conducted in conjunction with EOl Peer Group and commitment management standardization efforts over the past three years.
l The LRS Peer Group was established in 1995 in order to collectively review EOl's commitment management system and to oversee the replacement of the TRAC system with the LRS.
Planning for a second generation LRS also began at that time. Since each of the four EOl sites l.
managed commitments differently, the peer group was able to share strengths and weakness, i
and initiate improvements to more standardize the program.
Following the publishing of NRC Inspection Report 96-03 and a January 1997, QA Audit, the licensee began a more determined effort to assess deficiencies in their commitment management program. IR 96-03 had concluded that RBS management processes did not provide adequate barriers to consistently provide for NRC notification when commitments originating from Safety Evaluation Reports, Generic Letters, Bulletins and responses to Notices i
. of Violations were revised. It was also noted that the licensee's approach differed from NEl guidance endorsed in SECY-95-300. The QA Audit also found deficiencies in the " Commitment l
Database Review" effort performed in 1995. As a result, the licensee began a top-down review under their corrective action program.
j As recently as April 1998, the licensee has conducted an additional self-assessment which has initiated a more detailed re-review of commitments made in response to Generic Letters and Bulletins. In order to support this effort, a former licensing engineer from Quality Assurance -
has been temporarily reassigned to the licensing organization.
To summarize, RBS licensing personnel have discovered many of the same weaknesses the audit team found during the May 4 - 6,1998 site audit.
VI. CONCLUSIONS The licensee has provided the necessary resources to create an excellent computerized commitment management system. The system uses up-to-date technology with a relatively easy to use human-computer interface. With minimal training, plant personnel are able to l
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!. effectively search the database for commitments. The auditors considered the LRS to be a strength.
The licensee's representatives interviewed during the audit expressed a consistent opinion that it is important to keep their commitments to the NRC. As a result, the auditors felt that the licensee is making an honest effort to comply with NRC and industry guidance. On the whole, the licensee is paying the necessary attention to commitments that could have a safety concem, since the audit only uncovered relatively lesser important issues.
However, the licensee's management should communicate that higher standards and expectations are needed, in some cases, from supervisors reviewing and approving commitment changes. Additionally, management needs to ensure improved consistency in
. database entry in order to increase confidence that the LRS can be depended upon as the principal tool in managing commitments.
In summary, the RBS appears to be effectively managing its commitments to the NRC, with only some exceptions noted. The licensee's management has a good understanding where corrective actions and improvements are needed, and is currently providing sufficient attention and resources to the documented deficiencies. As a result, there are no actions which would lead to additional rulemaking recommended at this time.
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