ML20236F850
| ML20236F850 | |
| Person / Time | |
|---|---|
| Site: | Callaway, 05000365 |
| Issue date: | 06/30/1998 |
| From: | NRC (Affiliation Not Assigned) |
| To: | |
| Shared Package | |
| ML20236F842 | List: |
| References | |
| NUDOCS 9807020367 | |
| Download: ML20236F850 (10) | |
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AUDIT REPORT COMMITMENT MANAGEMENT UNION ELECTRIC COMPANY CALLAWAY PLANT. UNIT 1 DOCKET NO. 50-483
1.0 INTRODUCTION
As part of the stars activities related to improving the management of licensing basis information, audits of commitment management programs have been performed at eight reactor facilities. The audits assessed the licensees' implementation of commitments made to
. the NRC and the long-term control of commitments. The audit included a review of the licensees' program for commitment management and an assessment as to whether the
- program incorporates recent industry guidance for evaluating and reporting changes to -
commitments made to the NRC. Callaway Plant, Unit 1, was selected as one of eight facilities whose commitment management programs were audited by the staff.
The audits, in concert with other staff efforts related to managing licensee commitments made to the NRC, were intended to (1) improve performance in identifying licensee commitments or other supporting design features or operating practices used by the licensee to justify a proposed change or address design or operational problems, (2) determine the most appropriate method commitments or other supporting information should be verified, and (3) determine the appropriate placement of 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.) The findings from the audits will be used in the stafs development of recommendations to the Commission regarding the need for further staff actions in the area of commitment management.
The audit at the Callaway Plant was performed May 4 - 7,1998, by K. Thomas and M. Gray of the Division of Reactor Projects lil/IV, Office of Nuclear Reactor Regulation. Additional discussions between the licensee and staff and additionalin-office review of material provided by the licensee were performed from the NRC offices in Rockville, Maryland. The audit consisted of interviewing personnel and reviewing procedures, guidance documents, and other documentation related to the commitment management process used by Union Electric.
Additional reviews of work records, procedure changes, and other documentation were j
performed to verify the implementation of specific procedures and to evaluate changes made to commitments previously made to the NRC.-
2.0 VERIFICATION OF LICENSEE IMPLEMENTATION OF PAST COMMITMENTS The auditors selected the following sample of commitments made by the licensee to verify that the licensee effectively implemented commitments made to the NRC during staff reviews l
related to licensing activities:
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t 2-a.
By letter dated December 12,1996 (ULNRC-3507), Union Electric (UE) committed to provide the NRC with a supplement to their November 6,1996, response to GL 96-05 with more specific information regarding changes or the need for changes in UE's motor-operated valve periodic verification program brought about by industry and NRC activities over the last few years.
The auditors verified that by letter dated March 13,1997 (ULNRC-3548), UE provided a supplement to their November 6,1996 letter. However, although the auditors identified that the commitment was being tracked in the UE commitment tracking system, the system indicated the commitment was still open (i.e., not yet implemented) with a target date of March 17,1997.
b.
By letter dated May 1,1997 (ULNRC-3571), UE committed to provide the NRC with a 120-day response to GL 97-01.
The auditors verified that by letter dated July 17,1997, UE provided a 120-day response to GL 97-01. In addition, the auditors verified that the commitment was being tracked in the UE commitment tracking system and that the system indicated the commitment was closed.
c.
By letter dated February 13,1998, UE provided a summary of the results of the reviews performed on testing of safety-related logic circuits as discussed in GL 96-01. The letter committed to certain procedure revisions to incorporate corrective actions prior to the next required performance of the surveillance.
The auditors,'on a sampling basis, verified that the licensee had incorporated corrective actions in applicable surveillance procedures and had accomplished this action prior to performance of the the next required surveillance. Further, the auditors verified that commitments for the remaining items were being tracked in the commitment tracking system.
d.
By letter dated January 28,1997, (ULNRC-3526) UE committed to complete plant modifications of equipment, as necessary, in response to concems pertaining to pipe stresses as discussed in GL 96-06. UE indicated that evaluations and any required modifications would be complete by the end of Refuel 9 (Spring 1998) or Refuel 10 (Fall 1999).
I The auditors determined that UE had completed its preliminary analysis of pipe stresses, and based on the results, completed all expected plant modifications during Refuel 9. UE is in the process of finalizing the analysis, and will make additional modifications if determined to be necessary. Further, the auditors determined that the commitments were being properly tracked in the commitment tracking system.
e.
By letter dated October 10,1995, (ULNRC-03277), UE committed to complete the actions requested in GL 95-07 on pressure locking and thermal binding of safety-related power-operated gate valves.
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The auditors, determined that UE had recently completed all actions requested in GL 95-
- 07. Further, the auditors determined that the commitments were being properly tracked in the commitment tracking system, and the comments were closed, f.
By letter dated June 17,1996, the NRC issued Amendment 112 to the Callaway technical specifications (TS). The staffs safety evaluation indicated that through a plant procedure, the essential service water pump motor starting transient during the LOCA sequencing test would be demonstrated to be within a minimum voltage of 3120 Vac and to recover to 3680 Vac within 3 seconds and to be within a maximum voltage of 4784 Vac and recover to 4320 Vac within 20 seconds.
The auditors determined that the commitment had been properly incorporated into a surveillance procedure. However, the commitment was not being trackoo in the licensee's commitment tracking system.
g.
By letter dated June 28,1996, the NRC issued Amendment 113 to the Callaway TS.
The staff's safety evaluation indicated that UE committed to institute the provisions of GL 91-08 for manual operation of the component cooling water bypass motor-operated valves EGHV-127 and 131, such as establishing written procedures, performing operator training, and making available an operator, if needed, to manually close the valves. The safety evaluation further stated that it should be understood that prior to opening the valves, the valves should be either operable (i.e., capable of being closed from the control room under accident conditions) or administrative controls should be in place locally, at the valve, to ensure valve closure in the event of a containment isolation l
condition.
The auditors determined that although the commitment was being tracked in the I
commitment tracking system, the required actions, as discussed above, had not been taken. This issue has been forwarded to Region IV for followup in the NRC's inspection program.
h.
By letter dated November 22,1995, the NRC issued Amendment 104 to the Callaway TS. The staffs safety evaluation indicated that the licensee committed to writing an FSAR change notice after approval of the amendment to relocate the tables on response tin e limits to the updated FSAR.
The auditors determined that in Revision 9 to the Callaway FSAR, dated May 1997, UE relocated the tables on response time limits to the FSAR. Further, the auditors determined that the commitment was being properly tracked in the commitment tracking
- system,
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By letter dated October 9,1991, the NRC issued Amendment 64 to the Callaway TS.
The staffs safety evaluation indicated that the licensee committed to review "as found" and "as left" data for the channels with increased surveillance test intervals for a 1-year period to verify that setpoint drift remained within the existing allowance in the instrument setpoint calculation.
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The auditors determined that the licensee satisfed the commitment, the commitment was being properly tracked in the commitment tracking system, and the commitment was closed.
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By letter dated March 14,1995 (ULNRC-03165), UE committed to implement l
administrative controls during Refuel 7 to ensure the residence time of air flow through i
the control room filtration units was increased to greater than or equal to 0.25 seconds.
The increase in air flow residence time in the filters was required to support increased control room filter efficiency assumptions used in control room dose calculations. This i
commitment was documented in the staffs safety evaluation issued with Callaway TS Amendment 96.
The auditors determined that Work Requests W170501 and W170502 had been completed prior to Refuel 7 to ensure the required air flow residence time. The auditors also reviewed the associated safety evaluation and procedure changes. The commitment was appropriately tracked in the commitment tracking system. However, reference to the commitment was not made in the subject Work Requests.
i k.
By letter dated April 17,1996, UE proposed changes to the TS to support planned modifications to the digital portion of the main steam and feedwater isolation system.
l (MSFIS). To address NRC staff concems with crediting manual operator action as a back-up to MSFIS automatic isolation in the event of a common mode failure of the new digital components, UE described Emergency Operating Procedure (EOP) changes, operator aids and operator training that were completed to provide assurance that manual operator action would be successfully completed if required. By letter dated July 31,1996 (ULNRC-03408), UE provided a description of simulator runs that demonstrated operators would manually isolate the MSFIS in the time frame required.
UE committed to include manual isolation of MSFIS in requal training..These commitments were documented in the safety evaluation issued with Callaway TS Amendment 117.
.The auditors determined that these commitments were implemented. EOPs were revised with the appropriate step, operator aid procedures were developed (SA075A and SA0758) and the MSFIS requal lesson plan (file T61.R965.8) included operator training for verification /manualisolation of the MSFIS. While these commitments were implemented, they were not included in the commitment tracking system. Therefore, reference to the commitments was not made in the documents discussed above.
l.
By letter dated August 8,1997 (ULNRC-03681), UE requested changes to the TS for the main feedwater isolation function. This request required a plant modification to install a main feedwater isolation function bypass switch. in a follow-up letter dated November 10,1997 (ULNRC-03681), UE committed to provide administrative controls during startup to ensure this bypass switch is manually defeated and the feedwater isolation function restored prior to entry into Mode 2. This commitment was documented in the safety evaluation issued with Callaway TS Amendment 126.
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, The auditors reviewed the portion of Procedure ODP-ZZ-00014, Rev 15. " Operational Mode Change Requirements, Mode 3 to 2," that was completed during the most recent startup. The auditors verified that the procedure included steps to administratively verify the main feedwater isolation bypass was manually defeated and the feedwater isolation function restored prior to entry into Mode 2 and the commitment was appropriately tracked in the commitment tracking system.
m.
By letter dated May 28,1997, UE committed to revise their submittal for the Improved Standard Technical Specifications (ISTS) to include an additional surveillance requirement that would periodically test the diesel generator automatic transfer pump function. UE also committed to revise the associated Bases to correct an error.
The auditor determined that these commitments were not tracked in the commitment tracking system. Due to the magnitude of effort required to convert to the ISTS, UE indicated they maintain a stand alone list of commitments associated with ISTS conversion. The commitment to correct the error in the Bases was tracked in this list.
However, the more substantial commitment to revise the subject technical specification to include an additional surveillance requirement was not tracked in this stand alone list.
Upon identification by the auditor, UE revised their ISTS conversion tracking list to include this commitment.
3.0 LICENSEE PROGRAMS FOR MANAGING (CHANGING) COMMITMENTS i
in SECY-95-300, dated December 20,1995, the staff informed the Commission of its activities with regard to docketed commitments made by the licensee and acceptable methods for changing these commitments. In this regard, the staff informed the Commission that it intended to notify the Nuclear Energy Institute (NEI) by letter that its guidance document " Guideline for Menaging NRC Commitments" is an acceptable guide for licensees to follow for managing and changing their commitments to the NRC.
On January 23,1996, Union Electric Company revised procedure APA-ZZ-00540,
" Commitment Management Program" to incorporate the guidance contained in NEl guidance document " Guideline for Managing NRC Commitments", Revision 1, June 9,1995.
APA-ZZ-00540 defines " commitment" as:
"An action that Union Electric MUST perform to satisfy regulatory, inspection or audit agency requirements. Commitments are the result of the plant's primary licensing documents, correspondence, and intemal guidance of importance. A commitment made to an outside organization is identified by the use of words such as "SHALL" and "WILL". Intemal commitments are identified by a department head or above. The source documents for commitments are identified in Attachment 1." A " regulatory commitment" is defined as "An explicit statement to take a specific action agreed to or volunteered by a licensee that has been submitted in writing."
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Although not described in APA-ZZ-00540, the CGinn ;in,ent Coordinator in the Quality l
Assurance Department is responsible for maintenance of the Commitment Management Program. In this capacity, the Commitment Coordinator initiates placement of the majority of the commitments into the Commitment Management Program (i.e., commdment tracking system), as well as documents the majority of the commitment revisions and deletions.
L Individuals initiating a commitment perform the actions described in the " Commitment initiation q
Matnx"(Attachment 2 to APA-ZZ-00540). The " Commitment Revision / Deletion Matrix" provides I
the actens necessary to revise or delete a commitment. A " Commitment Revision, initiation, l
Deletion Request (CRIDR)" form (Attachment 4 to APA-ZZ-00540) is completed by the initiator of a now, revised, or deleted commitment.
Although not described in APA-ZZ-00540, the Commitment Coordinator receives copies of all correspondence between UE and the NRC to identify commitments made to the NRC. Once identified, the coordinator takes action as discussed above to place the commitment in the Commitment Management Program. The coordinator identifies the department (s) responsible
- for taking action to implement the commitment, and assigns a time frame for implementation.
Once implemented, the coordinator is notified, and the status of the commitment is updated in the commitment tracking system.
APA-ZZ-00540 indicates that changes to, or deletion of, commitments developed from primary license documents (i.e., final safety analysis report, operating license, etc.) cannot be changed / deleted until the source document has been revised. For commitments whose source document is not a primary licensing document, the commitment cannot be changed or deleted if l
It is determined that the change / deletion could negatively impact the ability of a structure, system, or component to perform its intended safety function. Commitments that are significant to safety are not to be changed.
Commitment actions are assigned a unique CTSN' Commitments implemented by Callaway Plant procedures are referenced within the procedure by the CTSN. The CTSN is normally placed closest to the statement (s) that satisfy the commitment action. Altematively the CTSN may be listed in the References section of the procedure. The procedure is listed in the l
commitment tracking system under the CTSN as an " action" document that implements the i
commitment. When revising a procedure, the preparer and qualified reviewer are required by j
procedure to review the commitment tracking system to identify the impact of the proposed change on previous commitments.
4.0 _
EVALUATION OF COMMITMENT CHANGES l
l The auditors revowed the commitments made to the NRC that have been revised to verify the licensee effectively controls changes to commitments made to the NRC.
a.
Commitment Changes To Be Reported to the NRC 1.
UE deleted several commitments pertaining to 10 CFR 50, Appendix J, Option A.
The commitments were deleted when UE requested, and received approval, to j
operate the Callaway Plant in accordance with Appendix J, Option B.
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7 The auditors determined that the commitments were being property tracked in the commitment tracking system and that deletion of the commitments appeared to be acceptable.
2.
UE deleted commitments made in response to GL 89-01 pertaining to the solidification of radioactive ws.ste. The commitments were deleted when UE discontinued the solidification of radioactive waste at the Callaway Plant.
The auditors determined that the commitw'its were being property tracked in the commitment tracking system and that deletion of the commitments appeared to be acceptable.
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UE deleted commitments pertaining to their responses to GL 95-07. The commitments were deleted when UE completed all required schons.
The auditors determined that the commitments were being property tracked in the commitment tracking system and that deletion of the commitments appeared to be acceptable.
b.
Commitment Changes Not Reported to the NRC 1.
UE deleted several commitments when it was determined that (1) the commitment was being tracked in duplicate, or (2) the commitment would be combined with another commitment.
The auditor determined the licensee's actions did not eliminate any commitments.
I 2.
UE deleted a one-time commitment pertaining to local leak rate testing that was l
satisfied in 1986.
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The auditor determined that deletion of the one-time commitment appeared to be acceptable.
l 3.
UE deleted a commitment pettaining to the required qualifications for the Callaway Maintenance Manager. The position of Maintenance Manager no 4
longer exists at Callaway.
The auditor determined that the deletion of the commitment appeared to be acceptable. The licensee established a commitment for the Maintenance Superintendent, requiring the same qualifestions as established for the l
Maintenance Manager.
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- c.
NRC Notifications The auditors determined that the licensee plans to submit its first report to the NRC on commitment changes in November 1998.
- 5.0 LICENSEE SELF ASSESSMENTS i
In April 1996, the licensee's Quality Assurance Department performed Audit AP96-006. The scope of this audit included "an assessment of the adequacy of procedure / program guidance for managing regulatory commitments, consistent with NEl guidance." The QA assessment i
concluded that procedures adequately addressed the NEl guidance. Additionally, the QA assessment concluded the commitment tracking program, as delineated by UE procedures, was not being implemented effectively. This conclusion was based on a sample of procedures that were reviewed for commitment tracking system numbers (CTSNs) and their irici.,,T,cietion into the commitment tracking database. The audit identified significant errors between the CTSNs within the procedures and the commitment tracking database. The QA assessment team identified instances where the CTSN was located within the procedure, but the procedure was not listed in the commitment database under the CTSN as an action document. The QA l
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. assessment team also identified instances where the database listed the procedure as an l
action document, but the procedure did not include the CTSN. The licensee took corrective action to correct these errors. The NRC auditor reviewed a sample of these corrective actons i
and verified them to be complete. To prevent recurrence, the licensee provided additional l
t training to commitment tracking program users on programmatic requirements and l
management expectations.
The licensee has not completed an audit subsequent to Audit AP96-006.
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- 6.0. -
CONCLUSIONS /
SUMMARY
i The licensee's Commitment Ma'nagement Program appeared to follow the NEl' guidance document. Overall the auditors observed that a minimal number of commitments were being revised by the licensee. The majority of resources in this area were being devoted to commitment identification and tracking activities. Approved commitment changes were being appropriately tracked for notification to the NRC staff as required by the licensee's procedure.
The auditors made the following observations pertaining to UE's implementation of the program and practices to ensure traceability of commitments.
1.
The licensee indicated there are roughly 6400 commitments being tracked in the commitment tracking system, roughly half of which are closed. The auditors identified that the majority of the commitments placed into the commitment tracking system were identified by the program coordinator, versus the plant personnel involved in the development of the correspondence with the NRC. The licensee's procedure indicates that the originators of correspondence identify the commitments and forward them to the commitment coordinator via a "CRIDR." However, in practice, the program coordinator I
reviews all outgoing correspondence and identifies commitments. Since the coordinator I
may not have had involvement in developing the submittal, judgment is used to
.g.
determine whether or not commitments were made in correspondence. As a result, the licensee's implementation of its commitment management program is vulnerable in that the program cor dinator may not identify all the commitments that were intended to be made by the originator of the submittal.
l 2.
Based on the sample of commitments that were reviewed, the auditors identified that commitments, as defined by the licensee's procedure, are not consistently captured in the commitment tracking system database in acmrdance with the licensee's procedure (see Section 2.0, items f and k.). While UE has implemented these commitments in the time frame required, traceability of these commitments is not being maintained via a l
CTSN in the appropriate implemerding documents. As a result, reviewers contemplating future changes to these documents may not be cognizant of the full impact of proposed changes on past commitments.
As an illustrative example, Section 2.0, item (k) identifies a completed commitment that added a step to the EOPs to direct operators to manually verify feedwater isolation. The safety evaluation documents the operators can complete this step within 6 minutes after the onset of the event. If in the future a change to the subject EOP is proposed that adds additional operator actions prior to the feedwater isolation verification step, the reviewer will not have the benefit of referencing them to the previous commitment. It is noted that the auditors did not identify any commitments " undone" in this manner during the audit.
3.
The above two implementation issues are similar in nature to the findings from the licensee's QA assessment completed in 1996. To assess program effectiveness, the licensees' QA department reviewed a sample of procedures and the CTSN's listed therein spinst the commitment tracking system. The QA reviewers identified weaknesses in program implementation with respect to consistency between CTSN numbers ar J the commitment tracking system database. This NRC audit focused on the front end of the program, i.e., identification of commitments, their inclusion in the l
commitment tracking system database, and subsequent identification by CTSN in implementing procedures, in that the two NRC observations above identify implementation practices at var;ance with program requirements, they are similar to the findings from the 1996 QA assessment of the program.
4.
During the audit, UE's commitment tracking system indicated 93 open commitments, with closure target dates up to April 1998. The auditors were informed that every Sunday, the commitment tracking system automatically sends an electronic message to i
plant personnel, notifying them that they have an open commitment that has exceeded the closure target date'. Based on the above, the auditors determined that either (1) the commitments have been implemented, but the tracking system has not yet been updated, or (2) the commitments have not yet been implemented. Increased management attention to these commitments with overdue " target" dates was not evident.
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10 5.
The auditors identified certain limitations inherent in UE's commitment management program and associated database. The program and database were developed to primarily trace commitments implemented in program manuals or plant procedures. The program does not provide for traceability of commitments implemented via work orders or plant modifications, since implementing documents for these activities are subsequently archived after implementation. The licensee indicated that the design process requires the engineer to retrieve the appropriate design basis, including the basis for any completed plant modifications. This process ensures identification of previously implemented commitments. The auditors also recognize that the vast majority of commitments are implemented in procedures or program manuals and this is an appropriate focus of the program. However, the program limitation should be recognized.
6.
All documents relevant to a commitment may not be referenced in UE's commitment 1
tracking system. The auditors identified examples of commitments entered into the commitment tracking system as they were presented in the initial license amendment request. During NRC staff review of a request, the licensee may submit subsequent
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letters that revise or expand the original commitments, or add new commitments. The NRC safety evaluation approving the licensing amendment will typically document these revised, expanded, or new commitments, in these instances the potential exists for the licensee to track incorrect commitment texts in tha commitment tracking system or fall to track new commitments. This is a vulnerability in the licensee's implementation of the I
commitment management program.
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