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AND BACKGROUND On September 7, 2004, NRR Office Instruction L1C-105, Revision 1, "Managing Regulatory Commitments Made by Licensees to the NRC," was published.
AND BACKGROUND On September 7, 2004, NRR Office Instruction L1C-105, Revision 1, "Managing Regulatory Commitments Made by Licensees to the NRC," was published.
L1C-105, which is publicly available electronically from the Agencywide Documents Access and Management System (ADAMS) Public Electronic Reading Room on the Internet at the NRC website (Accession No. ML042320463), provides the NRC staff and its stakeholders with a common reference for handling regulatory commitments made by licensees of commercial nuclear reactors to the NRC staff. The guidance is consistent with the industry guidance prepared by the Nuclear Energy Institute (NEI), NEI 99-04, "Guidance for Managing NRC Commitment Changes." According to L1C-1 05, which cites the definition from NEI 99-04, a "regulatory commitment" is an explicit statement to take a specific action agreed to, or volunteered by a licensee, and submitted in writing on the docket to the NRC.
L1C-105, which is publicly available electronically from the Agencywide Documents Access and Management System (ADAMS) Public Electronic Reading Room on the Internet at the NRC website (Accession No. ML042320463), provides the NRC staff and its stakeholders with a common reference for handling regulatory commitments made by licensees of commercial nuclear reactors to the NRC staff. The guidance is consistent with the industry guidance prepared by the Nuclear Energy Institute (NEI), NEI 99-04, "Guidance for Managing NRC Commitment Changes." According to L1C-1 05, which cites the definition from NEI 99-04, a "regulatory commitment" is an explicit statement to take a specific action agreed to, or volunteered by a licensee, and submitted in writing on the docket to the NRC.
L1C-105 further directs the NRR Project Manager to "audit the licensee's commitment management program by assessing the adequacy of the licensee's implementation of a sample of commitments made to the NRC in past licensing actions (amendments, reliefs, exemptions, etc.) and activities (bulletins, generic letters, etc.)." The audit is to be performed every 3 years.  
L1C-105 further directs the NRR Project Manager to "audit the licensee's commitment management program by assessing the adequacy of the licensee's implementation of a sample of commitments made to the NRC in past licensing actions (amendments, reliefs, exemptions, etc.) and activities (bulletins, generic letters, etc.)." The audit is to be performed every 3 years.
 
2.0 AUDIT SCOPE AND RESULTS 2.1 Audit Scope The audit was performed at the Palisades Nuclear Plant (PNP) site from August 2 through 4, 2010. Since the previous audit was performed during the period of August 27 through 31, 2007, the scope of this audit encompasses approximately 3 years prior to the date of the audit.
===2.0 AUDIT===
SCOPE AND RESULTS  
 
===2.1 Audit===
Scope The audit was performed at the Palisades Nuclear Plant (PNP) site from August 2 through 4, 2010. Since the previous audit was performed during the period of August 27 through 31, 2007, the scope of this audit encompasses approximately 3 years prior to the date of the audit.
L1C-105 limits the audit of commitments to those made in writing to the NRC as a result of past licensing actions (amendments, exemptions, etc.) or licensing activities (bulletins, generic letters, etc.). Prior to the audit, in order to generate a list of items for the audit, the NRC staff performed Public, Web-Based ADAMS search for commitments listed in licensing actions and licensing activity submittals dated in the last 3 years. From this list, the NRC staff selected a Enclosure   
L1C-105 limits the audit of commitments to those made in writing to the NRC as a result of past licensing actions (amendments, exemptions, etc.) or licensing activities (bulletins, generic letters, etc.). Prior to the audit, in order to generate a list of items for the audit, the NRC staff performed Public, Web-Based ADAMS search for commitments listed in licensing actions and licensing activity submittals dated in the last 3 years. From this list, the NRC staff selected a Enclosure   
-2 representative sample of regulatory commitments to audit. The selection of the sample list covered a variety of systems, disciplines and licensing actions important to NRC staff's decision-making process. This list also included commitment changes. The licensee was also asked to provide a list of regulatory commitments related to licensing actions from its Commitment Management System (CMS). The NRC staff again ensured that the sample selected related to the licensee's licensing action and licensing activity submittals and asked the licensee to provide documentation to support the audit. The licensee provided the list and the documentation to support the NRC staff's audit in each of the sample areas discussed above. The licensee's documentation included summary sheets providing the status of the commitment and appropriate backup documentation, as needed (i.e., plant procedures, examination records, and/or other plant documentation). The attached table lists the commitments selected for this audit.  
-2 representative sample of regulatory commitments to audit. The selection of the sample list covered a variety of systems, disciplines and licensing actions important to NRC staff's decision-making process. This list also included commitment changes. The licensee was also asked to provide a list of regulatory commitments related to licensing actions from its Commitment Management System (CMS). The NRC staff again ensured that the sample selected related to the licensee's licensing action and licensing activity submittals and asked the licensee to provide documentation to support the audit. The licensee provided the list and the documentation to support the NRC staff's audit in each of the sample areas discussed above. The licensee's documentation included summary sheets providing the status of the commitment and appropriate backup documentation, as needed (i.e., plant procedures, examination records, and/or other plant documentation). The attached table lists the commitments selected for this audit.
 
2.2 Verification of Licensee's Implementation of NRC Commitments The primary focus of this part of the audit was to confirm that the licensee has implemented those commitments made to the NRC as part of past licensing actions/activities.
===2.2 Verification===
 
of Licensee's Implementation of NRC Commitments The primary focus of this part of the audit was to confirm that the licensee has implemented those commitments made to the NRC as part of past licensing actions/activities.
For commitments that had not yet been implemented, the NRC staff aimed to ascertain that they have been captured in an effective program for future implementation.
For commitments that had not yet been implemented, the NRC staff aimed to ascertain that they have been captured in an effective program for future implementation.
The licensee's Commitment Management Program is described in ENO's Nuclear Management Manual, "EN-L1-110", Rev. 2. The purpose of this procedure is to ensure that the commitments made to the NRC in written correspondence are actively managed through the use of a CMS.
The licensee's Commitment Management Program is described in ENO's Nuclear Management Manual, "EN-L1-110", Rev. 2. The purpose of this procedure is to ensure that the commitments made to the NRC in written correspondence are actively managed through the use of a CMS.
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-3 commitment in PCRS. All the pertinent documents related to the commitment are scanned into the system during the closeout process of the commitment. The system maintains all the necessary documentation relating to NRC commitments. The NRC staff found that the licensee's procedure EN-L1-11 0, Rev. 2, meets the intent and is consistent with the guidance provided in NEI 99-04, Rev.
-3 commitment in PCRS. All the pertinent documents related to the commitment are scanned into the system during the closeout process of the commitment. The system maintains all the necessary documentation relating to NRC commitments. The NRC staff found that the licensee's procedure EN-L1-11 0, Rev. 2, meets the intent and is consistent with the guidance provided in NEI 99-04, Rev.
O. If a NRC commitment affects a plant procedure, a cross-reference is provided in the procedure to identify the commitment. However, there is no distinction made between an "obligation" and a "commitment". The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitments in response to different categories of documents such as PNP Amendments, QA Topical Report, Bulletins and Generic Letters to assess the implementation of the licensee's procedures, including the status of their completion. The licensee has made changes to the commitments using the Commitment Change Evaluation (CCE) Form. However, filling of CCE form to make a commitment change is not strictly adhered to. The Commitment Change process is being used to close the commitments in response to the old licensee event reports, notice of violations and inspection reports, since these are no longer considered to be commitments. For the sample of commitments selected for the audit, the NRC staff found that the licensee's commitment tracking program had captured all of the regulatory commitments. The review of the PCRS reflected their status consistent with the program. However, the NRC staff noted that implementation of the program had some minor deficiencies.
O. If a NRC commitment affects a plant procedure, a cross-reference is provided in the procedure to identify the commitment. However, there is no distinction made between an "obligation" and a "commitment". The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitments in response to different categories of documents such as PNP Amendments, QA Topical Report, Bulletins and Generic Letters to assess the implementation of the licensee's procedures, including the status of their completion. The licensee has made changes to the commitments using the Commitment Change Evaluation (CCE) Form. However, filling of CCE form to make a commitment change is not strictly adhered to. The Commitment Change process is being used to close the commitments in response to the old licensee event reports, notice of violations and inspection reports, since these are no longer considered to be commitments. For the sample of commitments selected for the audit, the NRC staff found that the licensee's commitment tracking program had captured all of the regulatory commitments. The review of the PCRS reflected their status consistent with the program. However, the NRC staff noted that implementation of the program had some minor deficiencies.
These observations are described Section 2.4.  
These observations are described Section 2.4.
 
2.3 Verification of the Licensee's Program for Managing NRC Commitment Changes 2.3.1 Change Control Procedure Verification The NRC staff reviewed the licensee's procedure EN-L1-11 0, Rev. 2, against NEI 99-04, Revision O. Regulatory Commitment Changes are processed and tracked by Site Licensing and are approved by the Site Management. The evaluation of any commitment changes is to be done by filling a CCE form. The NRC staff reviewed this form and found it to be consistent with the Commitment Change Process described in NEI 99-04. The NRC staff found that the licensee's procedures for handling the commitment change are in general, consistent with the guidance in NEI 99-04.
===2.3 Verification===
2.3.2 Procedure Implementation Assessment 2.3.2.1 Commitment Changes Reported to the NRC The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitment Change. The NRC staff found that, with a few minor inconsistencies, the licensee had properly addressed each regulatory commitment change selected for this audit and that the licensee had implemented an effective program to manage commitment changes. The NRC staff observations and suggestions are described in Section 2.4.   
of the Licensee's Program for Managing NRC Commitment Changes 2.3.1 Change Control Procedure Verification The NRC staff reviewed the licensee's procedure EN-L1-11 0, Rev. 2, against NEI 99-04, Revision O. Regulatory Commitment Changes are processed and tracked by Site Licensing and are approved by the Site Management. The evaluation of any commitment changes is to be done by filling a CCE form. The NRC staff reviewed this form and found it to be consistent with the Commitment Change Process described in NEI 99-04. The NRC staff found that the licensee's procedures for handling the commitment change are in general, consistent with the guidance in NEI 99-04.  
 
====2.3.2 Procedure====
 
Implementation Assessment 2.3.2.1 Commitment Changes Reported to the NRC The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitment Change. The NRC staff found that, with a few minor inconsistencies, the licensee had properly addressed each regulatory commitment change selected for this audit and that the licensee had implemented an effective program to manage commitment changes. The NRC staff observations and suggestions are described in Section 2.4.   
-4 2.3.2.2 Commitment Changes Not Reported to the NRC The licensee indicated that there were several commitment changes which were not reported to the NRC. These were related to the old commitments made in response to inspection activities, License Event Reports, etc., which did not meet the definition of commitments in accordance with NEI 99-04. Therefore, these changes were not reported to the NRC.
-4 2.3.2.2 Commitment Changes Not Reported to the NRC The licensee indicated that there were several commitment changes which were not reported to the NRC. These were related to the old commitments made in response to inspection activities, License Event Reports, etc., which did not meet the definition of commitments in accordance with NEI 99-04. Therefore, these changes were not reported to the NRC.
2.3.2.3 Notifications to the NRC of Commitment Changes These changes were reviewed and found to be appropriate and acceptable by the NRC Staff.
2.3.2.3 Notifications to the NRC of Commitment Changes These changes were reviewed and found to be appropriate and acceptable by the NRC Staff.
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CR-PLP-2008-1111-01 or -CA1 or LO-WTPLP-2009-1111-01 or CA1. This creates a tremendous amount of confusion and makes it cumbersome for plant personnel to recognize and follow the commitments. After learning more about PCRS and discussion with other counterparts of ENO, it was recognized that LARs should be generated to track commitments. All current commitments are tracked with LARs. The number format for a LAR is LO-LAR-2009-0244-01, where -01 denotes the action number for the task. The cross reference from one numbering system to another is not provided in any procedure. There are several procedures that govern the commitment tracking process, which is also a major factor of confusion. However, the station does have the capability to search the commitment database in order to retrieve the historical data.   
CR-PLP-2008-1111-01 or -CA1 or LO-WTPLP-2009-1111-01 or CA1. This creates a tremendous amount of confusion and makes it cumbersome for plant personnel to recognize and follow the commitments. After learning more about PCRS and discussion with other counterparts of ENO, it was recognized that LARs should be generated to track commitments. All current commitments are tracked with LARs. The number format for a LAR is LO-LAR-2009-0244-01, where -01 denotes the action number for the task. The cross reference from one numbering system to another is not provided in any procedure. There are several procedures that govern the commitment tracking process, which is also a major factor of confusion. However, the station does have the capability to search the commitment database in order to retrieve the historical data.   
-5Procedural steps do provide traceability of the commitments to the procedures and vice versa.
-5Procedural steps do provide traceability of the commitments to the procedures and vice versa.
Procedure revisions are handled in accordance with procedure EN-AD-1 01, Rev. 11, titled "Procedure Process." This procedure provides cross-reference to EN-L1-11 0, Rev. 2, and has several caution steps regarding commitments during the procedure revision process. The procedural review and approval form (Attachment 9.1) require verification that the Nuclear Management Manual procedure commitment review process plateau is complete. Thus, traceability between commitments and procedural changes is maintained.  
Procedure revisions are handled in accordance with procedure EN-AD-1 01, Rev. 11, titled "Procedure Process." This procedure provides cross-reference to EN-L1-11 0, Rev. 2, and has several caution steps regarding commitments during the procedure revision process. The procedural review and approval form (Attachment 9.1) require verification that the Nuclear Management Manual procedure commitment review process plateau is complete. Thus, traceability between commitments and procedural changes is maintained.
 
2.4 Audit Observations and Suggestions In one case it was found that the commitment description was different in the response letter when compared to the original letter which made the commitment. It is recommended that the commitment description be maintained consistently. The commitments are entered in the database which also contains other tasks which are not commitments. However, the commitments made to NRC are identified. Having a separate database for NRC commitments may be an improvement to the system. The licensee could explore this option for feasibility. The identification of the various action items and tasks is buried into the text and may be carried over to other documents, thus making it difficult to identify completion of the commitments. The older commitments were entered as WTs thus lowering the threshold for extending due dates. In one case, the due date was extended eleven times. Although, this was a Updated Final Safety Analysis Report in accordance with 50.71(e) which is done every 18 months. But it was unusual to see due date extension every month. NRC Resident Inspectors are not usually kept informed of all the commitment changes. They do get the notification via letters on the dockets. The licensee's procedure EN-L1-11 0, Rev. 2, section 5.5 states "When changes to commitments are necessary, commitments are changed in accordance with the Commitment Change Process shown in Attachment 9.3." Attachment 9.3 provides a flow chart to follow in order to revise a commitment.  .4 in this procedure is the CCE form. However, the licensee does not strictly adhere to filling of the CCE form.
===2.4 Audit===
Observations and Suggestions In one case it was found that the commitment description was different in the response letter when compared to the original letter which made the commitment. It is recommended that the commitment description be maintained consistently. The commitments are entered in the database which also contains other tasks which are not commitments. However, the commitments made to NRC are identified. Having a separate database for NRC commitments may be an improvement to the system. The licensee could explore this option for feasibility. The identification of the various action items and tasks is buried into the text and may be carried over to other documents, thus making it difficult to identify completion of the commitments. The older commitments were entered as WTs thus lowering the threshold for extending due dates. In one case, the due date was extended eleven times. Although, this was a Updated Final Safety Analysis Report in accordance with 50.71(e) which is done every 18 months. But it was unusual to see due date extension every month. NRC Resident Inspectors are not usually kept informed of all the commitment changes. They do get the notification via letters on the dockets. The licensee's procedure EN-L1-11 0, Rev. 2, section 5.5 states "When changes to commitments are necessary, commitments are changed in accordance with the Commitment Change Process shown in Attachment 9.3." Attachment 9.3 provides a flow chart to follow in order to revise a commitment.  .4 in this procedure is the CCE form. However, the licensee does not strictly adhere to filling of the CCE form.
Although in some cases it may be trivial to fill the CCE form, adherence to NEI gUidance is recommended. The commitment tracking process is not transparent due to absence of having a single numbering system and also due to changeover from the old databases to the new one.
Although in some cases it may be trivial to fill the CCE form, adherence to NEI gUidance is recommended. The commitment tracking process is not transparent due to absence of having a single numbering system and also due to changeover from the old databases to the new one.
The commitments are under various numbering formats and also some of the older databases are maintained, which causes confusion in maintaining the traceability of the commitments.   
The commitments are under various numbering formats and also some of the older databases are maintained, which causes confusion in maintaining the traceability of the commitments.   
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ML091680321 3 Surveillance Program CMT0320 11139 04/07/03 01/26/09 NMC will inspect containment dome tendon 01-38 and adjacent tendons 36 and 01-40 for free water and Closed M L031 050404 ML090270928 chemically combined water during the 35-vear tendon surveillance.   
ML091680321 3 Surveillance Program CMT0320 11139 04/07/03 01/26/09 NMC will inspect containment dome tendon 01-38 and adjacent tendons 36 and 01-40 for free water and Closed M L031 050404 ML090270928 chemically combined water during the 35-vear tendon surveillance.   
-2 Item No. Category Commitment Number Commitment LetterlDate Description of Commitment Status ADAMS Accession No. 4 Amendment 03/31/2010  
-2 Item No. Category Commitment Number Commitment LetterlDate Description of Commitment Status ADAMS Accession No. 4 Amendment 03/31/2010
: 1. ENO will make repairs to correct Closed ML 100920476 00162 05/13/2010 the existing seal leakage on ML 101330455 06/02/2010 CRD-22 prior to entering Mode 2, following the next Mode 3 entry. 2. ENO will perform a reactor shutdown in accordance with current procedural requirements if CRD seal leakage exceeds two gallons per minute.
: 1. ENO will make repairs to correct Closed ML 100920476 00162 05/13/2010 the existing seal leakage on ML 101330455 06/02/2010 CRD-22 prior to entering Mode 2, following the next Mode 3 entry. 2. ENO will perform a reactor shutdown in accordance with current procedural requirements if CRD seal leakage exceeds two gallons per minute.
ML 101380534 5 Inspection 01/30/07 NMC will inspect the Alloy 600/82/182 Open ML07031 0270 04017 02/27/07 pressurizer butt welds per MRP-139, on (commitment ML070590333 09/22/08 a frequency of at least four years, until change was ML082680182 10/02/08 the Alloy 600/82/182 pressurizer butt-welds are mitigated or removed at PNP. NMC will notify the NRC in writing, prior to making any changes to this commitment.
ML 101380534 5 Inspection 01/30/07 NMC will inspect the Alloy 600/82/182 Open ML07031 0270 04017 02/27/07 pressurizer butt welds per MRP-139, on (commitment ML070590333 09/22/08 a frequency of at least four years, until change was ML082680182 10/02/08 the Alloy 600/82/182 pressurizer butt-welds are mitigated or removed at PNP. NMC will notify the NRC in writing, prior to making any changes to this commitment.
Line 92: Line 77:
9 License 4/26/06 NMC will revise the Alloy 600 Program to Closed ML061170214 Renewal 00244 9/28/06 update the PWSCC (primary water ML062710074 3/13/08 stress corrosion cracking) ...
9 License 4/26/06 NMC will revise the Alloy 600 Program to Closed ML061170214 Renewal 00244 9/28/06 update the PWSCC (primary water ML062710074 3/13/08 stress corrosion cracking) ...
ML080770454 10 Inspection 2009-00173 02/27/07 03/29/07 12/12/07 05/14/09 1. NMC will determine unidentified leakage daily ... 2. If the unidentified Primary Coolant System (PCS) leakage increases 0.1 gallons per minute...
ML080770454 10 Inspection 2009-00173 02/27/07 03/29/07 12/12/07 05/14/09 1. NMC will determine unidentified leakage daily ... 2. If the unidentified Primary Coolant System (PCS) leakage increases 0.1 gallons per minute...
Closed ML070590333 ML070800449 ML073461017 ML091350203  
Closed ML070590333 ML070800449 ML073461017 ML091350203
: 3. If unidentified PCS leakage increases 0.25 gpm above...  
: 3. If unidentified PCS leakage increases 0.25 gpm above...
: 4. NMC will determine the baseline PCS leakage rate from data... 5. NMC will provide inspection results of any bare metal visual examinations
: 4. NMC will determine the baseline PCS leakage rate from data... 5. NMC will provide inspection results of any bare metal visual examinations
... 6. NMC will complete inspections of the pressurizer Alloy 600/82/182 butt-welds ...
... 6. NMC will complete inspections of the pressurizer Alloy 600/82/182 butt-welds ...

Revision as of 21:23, 30 April 2019

Audit of the Licensee'S Management of Regulatory Commitments
ML102710381
Person / Time
Site: Palisades Entergy icon.png
Issue date: 11/03/2010
From: Chawla M L
Plant Licensing Branch III
To:
Entergy Nuclear Operations
Chawla M L, NRR/DORL, 415-8371
References
TAC ME4231
Download: ML102710381 (13)
v • d • e


Text

UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20555-0001 November 3, 2010 Vice President, Operations Entergy Nuclear Operations, Inc. Palisades Nuclear Plant 27780 Blue Star Memorial Highway Covert, MI 49043-9530 PALISADES NUCLEAR PLANT -AUDIT OF THE LICENSEE'S MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. ME4231)

Dear Sir:

An audit of the Nuclear Management Company commitment management program was performed at the Palisades Nuclear Plant (PNP) site on August 2 through 4,2010. The U.S. Nuclear Regulatory Commission (NRC) staff concludes that, based on the audit, (1) PNP has established an effective commitment management program, (2) PNP has implemented NRC commitments on a timely basis, and (3) with some minor inconsistencies, which were discussed with the licensee during the exit meeting on August 4, 2010, PNP has implemented an effective program for managing NRC commitment changes. Details of the audit are set forth in the enclosed audit report. This audit report covers the commitment management program current at the time of the audit. You may have changed the commitment management program after the audit which is beyond the scope of this report.

The NRC staff appreciates the resources that were made available by your staff for performing the audit. If you have any questions, I may be reached at (301) 415-8371.

Sincerely, Mahesh Chawla, Project Manager Plant Licensing Branch 111-1 Division of Licensing Project Management Office of Nuclear Reactor Regulation Docket No. 50-255

Enclosure:

Audit Report cc w/encl:

Distribution via ListServ UNITED NUCLEAR REGULATORY WASHINGTON, D.C. 20555-0001 AUDIT REPORT BY THE OFFICE OF NUCLEAR REACTOR REGULATION (NRR) AUDIT OF ENTERGY NUCLEAR OPERATIONS, INC. (ENO)

MANAGEMENT OF REGULATORY COMMITMENTS MADE TO THE NUCLEAR REGULATORY COMMISSION (NRC) PALISADES NUCLEAR PLANT DOCKET NO. 50-255

1.0 INTRODUCTION

AND BACKGROUND On September 7, 2004, NRR Office Instruction L1C-105, Revision 1, "Managing Regulatory Commitments Made by Licensees to the NRC," was published.

L1C-105, which is publicly available electronically from the Agencywide Documents Access and Management System (ADAMS) Public Electronic Reading Room on the Internet at the NRC website (Accession No. ML042320463), provides the NRC staff and its stakeholders with a common reference for handling regulatory commitments made by licensees of commercial nuclear reactors to the NRC staff. The guidance is consistent with the industry guidance prepared by the Nuclear Energy Institute (NEI), NEI 99-04, "Guidance for Managing NRC Commitment Changes." According to L1C-1 05, which cites the definition from NEI 99-04, a "regulatory commitment" is an explicit statement to take a specific action agreed to, or volunteered by a licensee, and submitted in writing on the docket to the NRC.

L1C-105 further directs the NRR Project Manager to "audit the licensee's commitment management program by assessing the adequacy of the licensee's implementation of a sample of commitments made to the NRC in past licensing actions (amendments, reliefs, exemptions, etc.) and activities (bulletins, generic letters, etc.)." The audit is to be performed every 3 years.

2.0 AUDIT SCOPE AND RESULTS 2.1 Audit Scope The audit was performed at the Palisades Nuclear Plant (PNP) site from August 2 through 4, 2010. Since the previous audit was performed during the period of August 27 through 31, 2007, the scope of this audit encompasses approximately 3 years prior to the date of the audit.

L1C-105 limits the audit of commitments to those made in writing to the NRC as a result of past licensing actions (amendments, exemptions, etc.) or licensing activities (bulletins, generic letters, etc.). Prior to the audit, in order to generate a list of items for the audit, the NRC staff performed Public, Web-Based ADAMS search for commitments listed in licensing actions and licensing activity submittals dated in the last 3 years. From this list, the NRC staff selected a Enclosure

-2 representative sample of regulatory commitments to audit. The selection of the sample list covered a variety of systems, disciplines and licensing actions important to NRC staff's decision-making process. This list also included commitment changes. The licensee was also asked to provide a list of regulatory commitments related to licensing actions from its Commitment Management System (CMS). The NRC staff again ensured that the sample selected related to the licensee's licensing action and licensing activity submittals and asked the licensee to provide documentation to support the audit. The licensee provided the list and the documentation to support the NRC staff's audit in each of the sample areas discussed above. The licensee's documentation included summary sheets providing the status of the commitment and appropriate backup documentation, as needed (i.e., plant procedures, examination records, and/or other plant documentation). The attached table lists the commitments selected for this audit.

2.2 Verification of Licensee's Implementation of NRC Commitments The primary focus of this part of the audit was to confirm that the licensee has implemented those commitments made to the NRC as part of past licensing actions/activities.

For commitments that had not yet been implemented, the NRC staff aimed to ascertain that they have been captured in an effective program for future implementation.

The licensee's Commitment Management Program is described in ENO's Nuclear Management Manual, "EN-L1-110", Rev. 2. The purpose of this procedure is to ensure that the commitments made to the NRC in written correspondence are actively managed through the use of a CMS.

Management includes capturing new commitments, changing existing commitments, and closing/deleting commitments. The procedure does not provide any detailed instructions on how to manage commitment related activities such as entering, changing or closing out the commitments in the database. Interviews with the Palisades personnel provided the information on the existing tracking mechanism for commitments. At present, the licensee enters commitments made to the NRC into a comprehensive database called "Paperless Condition Reporting System (PCRS)." The NRC commitments are entered as License Action Requests (LARs). The database also includes other types of documents such as Condition Reports (CRs), Work Tasks (WTs) etc.

The commitments are searchable by the date of the letter which made the original commitment. If a letter contains more than one commitment, each of the commitments is assigned the same LAR number with a sub-task designator such as LO-LAR-2009-0244-01, where -01 denotes the action number.

After the commitments are entered in the system, they get assigned to the appropriate plant personnel in co-ordination with the responsible department. The PCRS provides the current status of the commitments in addition to other information such as reportability requirements, due date, closure date etc. In the case of NRC commitments, there are also check boxes to ensure concurrence required for closure, and also approval requirement for an extension of a NRC commitment. The PCRS also sends to the designated personnel, an initial e-mail notifications of corrective action assignments and reminders 7 days prior to pending corrective action due dates. Individuals assigned for completing a NRC Commitment are responsible for updating PCRS upon completion of the commitment, and also providing the necessary closure documents to the Licensing Department. The Licensing Department Technical Specialist reviews and closes the

-3 commitment in PCRS. All the pertinent documents related to the commitment are scanned into the system during the closeout process of the commitment. The system maintains all the necessary documentation relating to NRC commitments. The NRC staff found that the licensee's procedure EN-L1-11 0, Rev. 2, meets the intent and is consistent with the guidance provided in NEI 99-04, Rev.

O. If a NRC commitment affects a plant procedure, a cross-reference is provided in the procedure to identify the commitment. However, there is no distinction made between an "obligation" and a "commitment". The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitments in response to different categories of documents such as PNP Amendments, QA Topical Report, Bulletins and Generic Letters to assess the implementation of the licensee's procedures, including the status of their completion. The licensee has made changes to the commitments using the Commitment Change Evaluation (CCE) Form. However, filling of CCE form to make a commitment change is not strictly adhered to. The Commitment Change process is being used to close the commitments in response to the old licensee event reports, notice of violations and inspection reports, since these are no longer considered to be commitments. For the sample of commitments selected for the audit, the NRC staff found that the licensee's commitment tracking program had captured all of the regulatory commitments. The review of the PCRS reflected their status consistent with the program. However, the NRC staff noted that implementation of the program had some minor deficiencies.

These observations are described Section 2.4.

2.3 Verification of the Licensee's Program for Managing NRC Commitment Changes 2.3.1 Change Control Procedure Verification The NRC staff reviewed the licensee's procedure EN-L1-11 0, Rev. 2, against NEI 99-04, Revision O. Regulatory Commitment Changes are processed and tracked by Site Licensing and are approved by the Site Management. The evaluation of any commitment changes is to be done by filling a CCE form. The NRC staff reviewed this form and found it to be consistent with the Commitment Change Process described in NEI 99-04. The NRC staff found that the licensee's procedures for handling the commitment change are in general, consistent with the guidance in NEI 99-04.

2.3.2 Procedure Implementation Assessment 2.3.2.1 Commitment Changes Reported to the NRC The NRC staff reviewed documentation generated by the licensee related to the sample items listed in the attached table that are categorized as Commitment Change. The NRC staff found that, with a few minor inconsistencies, the licensee had properly addressed each regulatory commitment change selected for this audit and that the licensee had implemented an effective program to manage commitment changes. The NRC staff observations and suggestions are described in Section 2.4.

-4 2.3.2.2 Commitment Changes Not Reported to the NRC The licensee indicated that there were several commitment changes which were not reported to the NRC. These were related to the old commitments made in response to inspection activities, License Event Reports, etc., which did not meet the definition of commitments in accordance with NEI 99-04. Therefore, these changes were not reported to the NRC.

2.3.2.3 Notifications to the NRC of Commitment Changes These changes were reviewed and found to be appropriate and acceptable by the NRC Staff.

2.3.2.4 Traceability of Commitments Although not specifically stated in the guidance from NEI 99-04, according to L1C-105, traceability of the commitments is advantageous for the licensee's control of NRC commitments. At Palisades, the numbering system for commitments is not consistent and part of the reason is the older commitments which are assigned the CR numbers. The commitments are tracked through CRs which provide the relevant information.

The fulfillment of the commitments is accomplished by corrective actions (CAs) generated from the CRs. They typically get assigned the same numbers as the CRs with a sub task number. As an example, for Alternative Source Term (AST) commitment made in ENO letter dated September 21, 2007 (ADAMS Accession No. ML072640608), there were two CRs generated (CR-PLP-2007-02645, and CR-PLP-2007-04434). The CAs have typical numbers such PLP-2007 -02645 CA-00005, which is the fifth task associated with this CR. However, these numbers do not show up in documents with consistency. There were minor typographical errors found, although the plant personnel do understand and recognize the associated tasks with the commitments, the system could be improved to make it more transparent and easy to use. The old numbering system is also carried through from programs such as "Passport" (number format such as 2010897), "CACTIS" (number format such as 01089722-01, -01 being the action number). PCRS initially used CRs or WTs to ensure commitment completion. Some of the number format examples are:

CR-PLP-2008-1111-01 or -CA1 or LO-WTPLP-2009-1111-01 or CA1. This creates a tremendous amount of confusion and makes it cumbersome for plant personnel to recognize and follow the commitments. After learning more about PCRS and discussion with other counterparts of ENO, it was recognized that LARs should be generated to track commitments. All current commitments are tracked with LARs. The number format for a LAR is LO-LAR-2009-0244-01, where -01 denotes the action number for the task. The cross reference from one numbering system to another is not provided in any procedure. There are several procedures that govern the commitment tracking process, which is also a major factor of confusion. However, the station does have the capability to search the commitment database in order to retrieve the historical data.

-5Procedural steps do provide traceability of the commitments to the procedures and vice versa.

Procedure revisions are handled in accordance with procedure EN-AD-1 01, Rev. 11, titled "Procedure Process." This procedure provides cross-reference to EN-L1-11 0, Rev. 2, and has several caution steps regarding commitments during the procedure revision process. The procedural review and approval form (Attachment 9.1) require verification that the Nuclear Management Manual procedure commitment review process plateau is complete. Thus, traceability between commitments and procedural changes is maintained.

2.4 Audit Observations and Suggestions In one case it was found that the commitment description was different in the response letter when compared to the original letter which made the commitment. It is recommended that the commitment description be maintained consistently. The commitments are entered in the database which also contains other tasks which are not commitments. However, the commitments made to NRC are identified. Having a separate database for NRC commitments may be an improvement to the system. The licensee could explore this option for feasibility. The identification of the various action items and tasks is buried into the text and may be carried over to other documents, thus making it difficult to identify completion of the commitments. The older commitments were entered as WTs thus lowering the threshold for extending due dates. In one case, the due date was extended eleven times. Although, this was a Updated Final Safety Analysis Report in accordance with 50.71(e) which is done every 18 months. But it was unusual to see due date extension every month. NRC Resident Inspectors are not usually kept informed of all the commitment changes. They do get the notification via letters on the dockets. The licensee's procedure EN-L1-11 0, Rev. 2, section 5.5 states "When changes to commitments are necessary, commitments are changed in accordance with the Commitment Change Process shown in Attachment 9.3." Attachment 9.3 provides a flow chart to follow in order to revise a commitment. .4 in this procedure is the CCE form. However, the licensee does not strictly adhere to filling of the CCE form.

Although in some cases it may be trivial to fill the CCE form, adherence to NEI gUidance is recommended. The commitment tracking process is not transparent due to absence of having a single numbering system and also due to changeover from the old databases to the new one.

The commitments are under various numbering formats and also some of the older databases are maintained, which causes confusion in maintaining the traceability of the commitments.

-6CONCLUSION The NRC staff concludes that, based on the above audit, (1) ENO has established an effective commitment management program, (2) ENO has implemented NRC commitments on a timely basis, and (3) with some minor inconsistencies, which were discussed with the licensee during the exit meeting on August 4, 2010, ENO has implemented an effective program for managing NRC commitment changes. LICENSEE PERSONNEL CONTACTED FOR THIS AUDIT Barbara Dotson Principal Contributor: Mahesh Chawla AUDIT OF ENO MANAGEMENT REGULATORY AT PALISADES NUCLEAR PERFORMED DURING AUGUST 2 THROUGH AUGUST 4. LIST OF COMMITMENTS INCLUDED IN THE Item Category Commitment Commitment Description of Commitment Status ADAMS No. Number Letter/Date Accession No.

1 Relief Request CMT082011303 07/31/07 08/10/07 09/25/07 Perform repair or replacement in accordance with the applicable code requirements no later than the end of fuel cycle 20, which is expected to be in 2009. Withdrawn ML072130503 ML072250407 ML072690239 2 Amendment A-36249 04/27/09 08/04/09 LAR -Removal of the plant-specific Technical Specification requirements will be performed concurrently with the implementation of the 10 CFR 26, Subpart I requirements. This commitment will be completed no later than October 1, 2009. Closed ML091390436

ML091680321 3 Surveillance Program CMT0320 11139 04/07/03 01/26/09 NMC will inspect containment dome tendon 01-38 and adjacent tendons 36 and 01-40 for free water and Closed M L031 050404 ML090270928 chemically combined water during the 35-vear tendon surveillance.

-2 Item No. Category Commitment Number Commitment LetterlDate Description of Commitment Status ADAMS Accession No. 4 Amendment 03/31/2010

1. ENO will make repairs to correct Closed ML 100920476 00162 05/13/2010 the existing seal leakage on ML 101330455 06/02/2010 CRD-22 prior to entering Mode 2, following the next Mode 3 entry. 2. ENO will perform a reactor shutdown in accordance with current procedural requirements if CRD seal leakage exceeds two gallons per minute.

ML 101380534 5 Inspection 01/30/07 NMC will inspect the Alloy 600/82/182 Open ML07031 0270 04017 02/27/07 pressurizer butt welds per MRP-139, on (commitment ML070590333 09/22/08 a frequency of at least four years, until change was ML082680182 10/02/08 the Alloy 600/82/182 pressurizer butt-welds are mitigated or removed at PNP. NMC will notify the NRC in writing, prior to making any changes to this commitment.

withdrawn)

ML082800455

-Item Category Commitment Commitment Description of Commitment Status ADAMS No. Number LetterlDate Accession No. 6 Relief Request 2009-00147 2/6/09 In lieu of implementing the "demonstrated volumetric or surface leak path assessment through all J-groove welds" as required by ASME Code Case N-729-1 as conditioned by 10 CFR 50.55a(g)(6)(ii)(D)(3), ENO will perform a volumetric leak path assessment in the 2009 PNP refueling outage that meets the requirements of the First Revised NRC Order EA-03-009, IV.C.(5)(b)(i).

The proposed volumetric leak path examination area will include the length and circumference of the nozzle annulus Closed ML090370840 sufficient to assess a potential leakage path. 7 Amendment CR-PLP-2007-09/07/07 Revised commitment:

Closed ML072540784 ML072640608 (Commitment Revision) 04434 09/21/07 Prior to restart (Mode 2) from 2007 refueling outage, ENO will revise Section 2.4, "Total Radial Peaking Factor," of the Core Operating Limits Report to include an evaluation on the pin powerlburnup of the design core against the following criteria: ...

8 Amendment CR-PLP-2007-04511 07/07/06 NMC will implement an alternate buffer program to achieve a pH of 7.0 -8.0 post-LOCA with recirculation, during the 2007 fall refueling outage at PNP.

Closed ML061920235

-Item Category Commitment Commitment Description of Commitment Status ADAMS No. Number Letter/Date Accession No.

9 License 4/26/06 NMC will revise the Alloy 600 Program to Closed ML061170214 Renewal 00244 9/28/06 update the PWSCC (primary water ML062710074 3/13/08 stress corrosion cracking) ...

ML080770454 10 Inspection 2009-00173 02/27/07 03/29/07 12/12/07 05/14/09 1. NMC will determine unidentified leakage daily ... 2. If the unidentified Primary Coolant System (PCS) leakage increases 0.1 gallons per minute...

Closed ML070590333 ML070800449 ML073461017 ML091350203

3. If unidentified PCS leakage increases 0.25 gpm above...
4. NMC will determine the baseline PCS leakage rate from data... 5. NMC will provide inspection results of any bare metal visual examinations

... 6. NMC will complete inspections of the pressurizer Alloy 600/82/182 butt-welds ...

11 License Renewal (commitment revision) 00244 03/23/09 03/10/10 ENO will submit the revised Reactor Vessel Internals Program for NRC review and approval by March 24, 2010.

Closed ML090830419 ML100710083 12 GL 2004-02 (commitment revision) 2008-0511 (Ref: 2011308) 06/17/08 06/30109 ENO will complete actions to resolve GSI-191 at PNP by December 31, 2008, provided no hardware modification is required. If plant hardware modification Open ML081690612 ML091820275

-Item Category Commitment Commitment Description of Commitment Status ADAMS No. Number Letter/Date Accession No. is required, then ENO will complete actions to resolve GSI-191 prior to restart from the 2009 refueling outage. 13 GL 2008-01 2008-512 05/13/08 1. Complete the detailed walkdowns of inaccessible sections of systems described in GL 2008-01 prior to startup from 2009 refueling outage. 2. Complete evaluations of GL 2008-01 subject systems within 60 days following the completion of the 2009 refueling outage. Closed Closed ML081340542 3. Any other corrective actions that are identified during 2009 refueling outage that cannot be completed during the outage will be implemented prior to restart following the 2010 refueling outaqe. Open November 3, 2010 Vice President, Operations Entergy Nuclear Operations, Inc. Palisades Nuclear Plant 27780 Blue Star Memorial Highway Covert, MI 49043-9530 PALISADES NUCLEAR PLANT -AUDIT OF THE LICENSEE'S MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. ME4231)

Dear Sir:

An audit of the Nuclear Management Company commitment management program was performed at the Palisades Nuclear Plant (PNP) site on August 2 through 4, 2010. The U.S.

Nuclear Regulatory Commission (NRC) staff concludes that, based on the audit, (1) PNP has established an effective commitment management program, (2) PNP has implemented NRC commitments on a timely basis, and (3) with some minor inconsistencies, which were discussed with the licensee during the exit meeting on August 4,2010, PNP has implemented an effective program for managing NRC commitment changes. Details of the audit are set forth in the enclosed audit report. This audit report covers the commitment management program current at the time of the audit. You may have changed the commitment management program after the audit which is beyond the scope of this report. The NRC staff appreciates the resources that were made available by your staff for performing the audit. If you have any questions, I may be reached at (301) 415-8371.

Sincerely, IRAJ Mahesh Chawla, Project Manager Plant Licensing Branch 111-1 Division of Licensing Project Management Office of Nuclear Reactor Regulation Docket No. 50-255

Enclosure:

Audit Report cc w/encl: Distribution via ListServ DISTRIBUTION:

PUBLIC LPL 3-1 rtf RidsNrrDorlLpl3-1 RidsNrrPMPalisades RidsNrrLABTully RidsOgcRp RidsAcrsAcnw&MailCenter JGiessner, Rill JEllegood, Rill RidsRgn3MailCenter ADAMS ACCESSION NUMBER: ML OFFICE LPL3-1/PM LPL3-1/LA LPL3-1/BC NAME MChawla BTully RPascarelli DATE 10/26/10 10/27/10 11/03/10 OFFICIAL RECORD

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