ML13304A741

Virgil C. Summer Nuclear Station - Audit of the Licensee'S Management of Regulatory Commitments (TAC MF2978)

ML13304A741
Person / Time
Site:	Summer
Issue date:	04/18/2014
From:	Williams S A Plant Licensing Branch II
To:	Gatlin T D South Carolina Electric & Gas Co
Williams, Shawn NRR/DORL 415-1009
References
TAC MF2978
Download: ML13304A741 (30)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20555-0001 April 18, 2014 Mr. Thomas D. Gatlin Vice President, Nuclear Operations South Carolina Electric

& Gas Company Virgil C. Summer Nuclear Station Post Office Box 88, Mail Code 800 Jenkinsville, SC 29065 SUBJECT VIRGIL C. SUMMER NUCLEAR STATION-AUDIT OF THE LICENSEE'S MANAGEMENT OF REGULATORY COMMITMENTS (TAC NO. MF2978)

Dear Mr. Gatlin:

The U.S. Nuclear Regulatory Commission (NRC or the staff) informed licensees in Regulatory Issue Summary (RIS) 2000-17, "Managing Regulatory Commitments Made by Power Reactor Licensees to the NRC Staff," dated September 21, 2000, that the Nuclear Energy Institute (NEI) document NEI 99-04, "Guidelines for Managing NRC Commitment Changes,"

contains acceptable guidance for controlling regulatory commitments.

RIS 2000-17 encouraged licensees to use the NEI guidance or similar administrative controls to ensure that regulatory commitments are implemented and that changes to the regulatory commitments.are evaluated and, when appropriate, reported to the NRC. The NRC Office of Nuclear Reactor Regulation has instructed its staff to perform an audit of licensees' commitment management programs periodically to determine whether the licensees' programs are consistent with the industry guidance in NEI 99-04, and that regulatory commitments are being effectively implemented.

An audit of Virgil C. Summer Nuclear Station's (VCSNS, licensee) commitment management program was completed in March 2014. The NRC staff concludes that VCSNS has the procedures and processes used to manage commitments consistent with NEI 99-04. However, as detailed in the attached report, the documentation and tracking of these commitments have been inconsistently implemented.

In a follow-up audit discussion with the site, the l_icensee intends to make robust changes to their commitment management program to address the programmatic issues identified in the audit. There were no safety issues identified.

Details of the audit are set forth in the enclosed audit report. .

T. Gatlin The NRC staff appreciates the resources that were made available by your staff, both before and during the audit. If there are any questions, please contact Shawn Williams at (301) 415-1009.

Docket No .. 50-395

Enclosures:

1 -Audit Report Sincerely, Shawn Williams, Senior Project Manager Plant Licensing Branch 11-1 Division of Operating Reactor Licensing Office of Nuclear Reactor Regulation 2 -Regulatory Commitment Management Audit Table cc w/encls:

Distribution via Listserv UNITED STATES NUCLEAR REGULATORY COMMISSION WASHINGTON, D.C. 20555-0001 AUDIT REPORT BY THE OFFICE OF NUCLEAR REACTOR REGULATION LICENSEE MANAGEMENT OF REGULATORY COMMITMENTS VIRGIL C. SUMMER NUCLEAR STATION, UNIT 1 DOCKET NO. 50-395

1.0 INTRODUCTION

AND BACKGROUND The U.S. Nuclear Regulatory Commission (NRC or the staff) informed licensees in Regulatory Issue Summary (RIS) 2000-17, "Managing Regulatory Commitments Made by Power Reactor Licensees to the NRC Staff," dated September 21, 2000 (Agencywide Documents Access and Management System (ADAMS) Accession No. ML003741774),

that the Nuclear Energy Institute

. (NEI) document NEI 99-04, "Guidelines for Managing NRC Commitment Changes" (ADAMS Accession No. ML003680088) contains acceptable guidance for controlling regulatory commitments.

RIS 2000-17 encouraged licensees to use the NEI guidance or similar administrative controls to ensure that regulatory commitments are implemented and that changes to the regulatory commitments are evaluated and, when appropriate, reported to the NRC. NEI-99-04 defines a "regulatory commitment" as 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. The NRC Office of Nuclear Reactor Regulation (NRR) has instructed its staff to perform an audit of licensees' commitment management programs periodically to determine whether the licensees' programs are consistent with the industry guidance in NEI 99-04, and that regulatory commitments are being effectively implemented.

An audit of the Virgil C. Summer Nuclear Station's (VCSNS) commitment management program was completed in March 2014. The audit included a staff review of commitments made since the previous audit documented on February 27, 2009 (ADAMS Accession No. ML090570041

). NRR guidelines direct 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.). 2.0 AUDIT PROCEDURE AND SCOPE The audit consisted of three major parts: (1) _verification of the licensee's implementation of NRC commitments that have been completed (Section 4.0) Enclosure 1 (2) verification of the licensee's program for managing changes to NRC commitments (Section 5.0) (3) verification that all regulatory commitments reviewed were correctly applied in NRC staff licensing action reviews (Section 6.0)

• The audit addressed a sample of regulatory commitments made during the review period. The audit focused on regulatory commitments (as defined above) made in writing to the NRC as a result of past licensing actions (amendments, exemptions, etc.) or licensing activities (bulletins, generic letters, etc.). Regulatory commitments made in licensee event reports or in response to Notices of Violation may be included in the sample, but the review will be limited to verification of restoration of compliance, not the specific methods used. Before the audit, the NRC staff searched ADAMS for the licensee's submittals since the last audit and selected a representative sample for verification.

The audit excluded the following types of commitments that are internal to licensee processes:

(1) Non regulatory commitments made on the licensee's own initiative among internal organizational components.

(2) Non regulatory commitments that pertain to milestones of licensing actions/activities (e.g., respond to an NRC request for additional information by a certain date).

• Fulfillment of these commitments was indicated by the fact that the subject licensing action/activity was completed.

(3) Non regulatory commitments made as an internal reminder to take actions to comply with existing regulato_ry requirements such as regulations and Technical Specifications (TSs). Fulfillment of these commitments was indicated by the licensee having taken timely action in accordance with the subject requirements.

3.0 LICENSEE'S REGULATORY COMMITMENT MANAGEMENT PROGRAM The licensee uses the following procedures for managing regulatory commitments:

(1) Nuclear Licensing Procedure, NL-1 02, "Processing Regulatory and Industry Documents" (2) Station Administrative Procedure, SAP-999, "Corrective Action Program" (3) Station Administrative Procedure SAP-0630 "Procedure/Commitment Accountability Program" (4) Nuclear Licensing Procedure, NL-121, "Regulatory Commitment Management" The Station Administrative Procedure SAP-0630 "Procedure/Commitment Accountability Program" is the high level overarching procedure for Commitment Accountability Program.

NL-121 is the implementation procedure for the site's Commitment Managemknt Program.

The licensee's Computerized Maintenance Management System (CMMS) database is used as the primary method to document the implementation of regulatory commitments.

The licensee enters each regulatory commitment as a Condition Report (CR) in the CMMS database.

The status of the commitments, implementation dates, and associated information including site personnel comments are able to be captured in the CMMS database. In addition to tracking regulatory commitments in the CMMS database, the site's Nuclear Licensing Procedure, NL-121, Section 5.4, requires the Licensing department to maintain a "Commitment Log" that includes some basic tracking information for regulatory commitments, including the CR associated with each regulatory commitment.

NL-121, Section 5.4, states that the purpose of the Commitment Log is to "ensure recovery of commitment information during future NRC inspections."

4.0 VERIFICATION OF LICENSEE'S IMPLEMENTATION OF REGULATORY COMMITMENTS The purpose of this part of the audit is to: (1) Confirm that the licensee has implemented commitments made to the NRC as part of past licensing actions/activities.

(Section

4. 1) (2) For commitments not yet implemented, determine whether the commitments have been captured in an effective program for future implementation.

(Section 4.2) (3) Verify that the licensee's commitment management system includes a mechanism to ensure traceability of commitments following initial implementation.

This is to ensure that licensee personnel are able to recognize that future proposed changes to the affected design features or operating practices require evaluation in accordance with the commitment change control process.

(Section 4.3) 4.1 Confirm that the licensee has implemented commitments made to the NRC as part of past licensing actions/activities Per NRR Office Instruction, LIC-1 05 (ADAMS Accession No. ML 13193A358) the staff requested the licensee to provide a list of all open regulatory commitments and a list of closed regulatory commitments that were completed since the last audit on February 27, 2009. The licensee responded by providing their Commitment Log on December 6, 2013. The staff compared the information provided in the Commitment Log to the regulatory commitments that were submitted to the NRC on the docket since the last audit. 4.1.1 Staff Assessment See Enclosure 2, "Regulatory Commitment Management Audit Table" for the staff's detailed assessment and specific deficiencies for each audit sample. In summary, a review of the licensee's Commitment Log identified the following deficiencies:

• Missing open and closed (since the last audit) regulatory commitments (Audit Nos. 3, 10, 16, 17)

• Incorrect status (open vs. closed) of commitments (Audit Nos. 2,11)

• Incorrect due dates for open commitments (Audit No. 1 0)

• The Commitment Log included non-regulatory commitments (Audit Nos. 11, 13) ) In addition to the above summary, the staff notes that the Commitment Log often does not include fundamental information about the commitment such as. the date the commitment was originally due, any revised due date, the closure date (if applicable),

an explanation if the commitment was changed, an explanation if the commitment was identified as "continuous" and now indicates "closed."

Including this fundamental information in the Commitment Log would result in a more efficient audit of regulatory commitments and likely reduce the number of deficiencies found. The staff reviewed each CR associated with each audit sample. See the Enclosure 2 for the staff's detailed assessment and specific deficiencies for each audit sample.,

In summary, a review of the CRs identified the following deficiencies:

• The template CR database contains a "commitment" cell. For regulatory commitments*

submitted to the NRC, the licensee often identified it by including "NRC" in the commitment cell on the specific page that the regulatory commitment is discussed in the CR. The staff notes the licensee also uses "Licensing" in the commitment cell to identify internal commitments.

The use of the "NRC" identifier in the commitment cell was not a procedure requirement in NL-121, which may have led to the great lack of consistency in using "NRC" to clearly identify NRC regulatory commitment.

(Audit Nos. 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 17) .In a follow-up discussion with the licensee, it was determined that the option to choose "NRC" irJ *a dropdown menu of the commitment cell was inadvertently removed from the CMSS software in 2011. The licensee has requested the "NRC" option to be re-added to the commitment cell dropdown.

• Some CRs do not explicitly state anywhere in the CR that it includes a "regulatory commitment."

In addition, some CRs do not include the exact or similar wording of the regulatory commitment nor the associated due date as submitted to the NRC. Without the "NRC" identification in the commitment cell, no reference statement to a regulatory commitment, and without including the exact or very similar wording of the regulatory commitment, the staff had difficultly locating the implementation information regarding the regulatory commitment in the CRs. (Audit Nos. '3, 4, 7,' 8, 9, 11, 12, 15)

• For the CRs that included a reference to the regulatory commitment, sor>ne lacked fundamental details such that the staff could not determine the status of the regulatory commitments.

(Audit Nos. 5, 6, 14)

• Information in the CR was incorrect.

(Audit Nos. 2,11)

• Incorrectly reworded the regulatory commitment in the CR such that the meaning was changed resulting in an incorrect reason for closure.

(Audit No. 2)

• 4.1.1.1 Audit No. 2 -Focus Discussion Regarding Two Regulatory Commitments included in the June 9, 2009, "License Amendment Request For Use of Optimized ZIRLOŽ Fuel Rod Cladding."

(ADAMS Accession No. ML091620072) Commitment No. 1: The core reload process for VCSNS will ensure the conditions and lill)itations of the NRC SE for Optimized ZIRLOŽ as addressed in Enclosure are met when a batch of Optimized ZIRLOŽ is implemented.

• Due Date: Continuous, until the contingency requirements of the conditions and limitations have been satisfied.

Commitment No.2: SCE&G will confirm that Westinghouse will provide additional

( confirmatory data associated with LTA programs at other facilities prior to subsequent cycles of operation with Optimized ZIRLOŽ fuel rod cladding.

Background:

Due Date: Continuous, until the LTA data up through the fuel burnup limit applicable for VCSNS has been provided to the NRC. Regulatory commitments No. 1 and No. 2 originated from the staff's Final Safety Evaluation for Addendum 1 to Topical Report WCAP-12610-P-A and CENPD-404-P-A, "Optimized ZIRLOŽII" June 10, 2005 (Optimized ZIRLOŽ Report1). Both regulatory commitments were created to *document the licensee action to ensure Westinghouse provided the required data as outlined in the Conditions and Limitations (Conditions)

No.6 and No.7 in the Optimized ZIRLOŽ Report. On February 25, 2013, Westinghouse submitted the final letter to satisfy Conditions No. 6 and No. 7 (ADAMS Accession No. ML 13070A 188). NRC staff has not completed the review of the February 25, 2013 letter, and thus does not consider Conditions No. 6 and No. 7 to be closed. The staff will issue a closeout letter when the review is complete and accepted.

The staff further notes that the Conditions in the SE are included in VCSNS licensing basis in TS 6.9.1.11.

Therefore, the regulatory commitments are not necessary to ensure compliance with the Conditions.

Staff Assessment of Commitment No. 1: Commitment No. 1 was found on Page 5 of the CR. It was appropriately identified as an "NRC" commitment.

The licensee closed the regulatory commitment on 8/5/2010.

The commitment was inappropriately re-worded in the CR to "VCSNS will use approved methods for the reload design process for VCSNS reloads with Optimized ZIRLOŽ."

The staff determined that the rewording of Commitment No. 1 in the CR did not have the same meaning as the original commitment.

The licensee closed Commitment No. 1 based on the following reason per the CR: "Design Engineering satisfies commitment 1 by using the Westinghouse core design computer codes and the Westinghouse METCOM methodology for the reload design process.

The 1 Letter from H. N. Berkow, NRC, to J. A. Gresham, Westinghouse Electric

Company, Final Safety Evaluation for Addendum 1 to Topical Report WCAP-12610-P-A and CENPD-404-P-A, "Optimized ZIRLOŽ" June 10, 2005. ADAMS Accession No. ML051670403.

Non-Proprietary SE: ML051670408

/ ' Westinghouse design tools are NRC-approved methods and computer codes." o The reason provided does not address the original commitment.

The licensee's rewording of the original commitment apparently caused a misunderstanding of the requirements needed to close the commitment.

The reason provided in the CR does not address the original commitment.

o The licensee incorrectly closed Commitment No. 1, on August 5, 2010. The data to satisfy Commitment No. 1, and thus close out Conditions No. 6 and 7 of the Optimized ZIRLOŽ Report SE, was not provided to the NRC until February 24, 2013. o In a follow-up discussion with the licensee, the licensee provided that the commitment continues to be implemented as part of the reload analysis (an existing program).

Staff Assessment of Commitment No. 2 Commitment No. 2 was found on Page 5 of the CR. It was appropriately identified as an "NRC" commitment.

The licensee closed the regulatory commitment on August 5, 2010. The CR provided the following reason for closure:

"Westinghouse completed commitment 2 by submitting a report to the NRC for three cycles of operation data for Opt Zirlo clad fuel. The submittal was documented in the Westinghouse letter NF-CG-10-58, dated July 29, 2010, Mr. R. W. Kerr to Mr. W. M. Herwig."

( o The reference letter in the CR appears to be incorrect as the staff could not locate it after performing an extensive ADAMS search. However, an ADAMS search identified a Westinghouse submittal dated July 26, 2010, SER Compliance of WCAP-12610-P-A

& CENPD-404-P-A Addendum 1-A "Optimized ZIRLOŽ" (ADAMS PKG No._ML 1 02140223) that may have been the intended reference.

o The licensee incorrectly closed Commitment No. 2 on August 5, 2010. The data to satisfy Commitment No. 2, and thus close out Conditions No. 6 and 7 of the Optimized ZIRLOŽ Report SE, were not provided to the NRC until February 24, 2013. Commitments No. 1 and No. 2 should either be: Reopened and not closed until the staff issues a final closeout letter to Westinghouse acknowledging that Conditions 6 and 7 of the Optimized ZIRLOŽ SE have been met.; or Closed based on the regulatory commitments are included in VCSNS licensing basis in TS 6.9.1.11.

Page 6-16a, f. requires compliance with WCAP-1261 0-P-A and CENPD-404-P-A, Addendum 1-A, "Optimized ZIRLOŽ ," July 2006, which includes the staff's SE requiring Conditions 6 and 7, and thus Commitment No. 1 and No.2 to be met. In a follow-up discussion with the licensee, the licensee committed to reopen both commitments until the staff issues a final closeout letter to Westinghouse acknowledging that Conditions 6 and 7 of the Optimized ZIRLOŽ SE have been met. 4.1.2 Conclusion The primary purpose of Section 4.1 of this audit is to review the documentation associated with a sampling of regulatory commitments.

In general, the commitment management documentation was insufficient.

A summary is provided in Attachment

1. Specific details are provided in Enclosure

2. 4.2 For commitments not yet implemented, determine whether the commitments have been* captured in an effective program for future implementation The staff reviewed the CRs associated with the open regulatory commitments to determine if they have been captured in an effective program for future implementation.

4.2.1 Staff Assessment and Conclusion See Enclosure 2 for specific details.

A summary is provided below. Audit: No.2: No.3: No.5: No. 10: The commitment documentation was insufficient as explained in Section 4.1.1.1 of this audit. The commitment documentation was insufficient.

The staff was not able to locate the three security-related commitments i_n the CR that was referenced in the Commitment Log. In a follow-up discussion with the licensee, the licensee determined that although the commitments as provided to the NRC were not written clearly in the CR, the actions to implement the commitments were captured in the CR and are now closed. The commitment was not implemented by the original due date. Approximately nine months after the commitment due date, the licensee self-identified the missed commitment and opened a new CR. Upon reviewing the new CR, the staff could not determine the new due date to complete the regulatory commitment; thus, staff concludes the commitment documentation was insufficient.

In a follow-up discussion with the licensee, the licensee provided that the commitment is expected to be implemented in the second quarter of 2014. Although there are documentation issues explained in the enclosure, the staff concludes the two remaining open commitments are captured in an effective program for future implementation.

• No. 12: Although there are documentation issues explained in the enclosure, the staff concludes the open commitments are captured in an effective program for future implementation.

No. 15: The commitment documentation was insufficient.

The staff could not locate the open Commitment No. 1 in the CR referenced in the Commitment Log. In a follow-up discussion with the licensee, the licensee stated that they will enter the commitment in a CR. No. 17: The commitment documentation was insufficient.

The staff could not locate Commitment Nos. 1, 3, 4, 5, 6, 7, 8, 9, and 12 in the referenced CAs. In a follow-up discussion with the licensee, the licensee stated that they will enter the commitments in a CR. 4.3 Verify that the licensee's commitment management system includes a mechanism to ensure traceability of commitments following initial implementation 4.3.1 Staff Assessment The staff verified that the licensee's commitrnemt management system includes a mechanism to ensure traceability of commitments following initial implementation.

Procedure NL-121, Revision 6, Section 6.1.1 requires marking plant procedures with a "C" code that were revised in response to a regulatory commitment.

Section 6.1.2 requires an independent verification from the "Unit Evaluator" to ensure that the revision met the intent of the commitment made to the regulator and that the associated markings were properly applied.

4.3.2 Conclusion Based on the guidance in NL-121, the staff concludes that the licensee personnel are able to recognize that future proposed changes to the affected design features or operating practices require evaluation in accordance with the commitment change control process.

5.0 VERIFICATION OF THE LICENSEE'S PROGRAM FOR MANAGING NRC

• COMMITMENT CHANGES The purpose of this part of the audit is to: (1) Verify that the licensee has established administrative controls for modifying or deleting commitments made to the NRC. (Section 5.1) * (2) Review a sample of regulatory commitment changes that included changes that were or will be reported to the NRC. (Section 5.2) (3) Review of changes that were not or will not be reported to the NRC. (Section 5.3) The audit included a review of the documentation of regulatory commitments that were changed from the originally submitted commitments.

The staff evaluated the change to ensure it was completed in accordance with the licensee's procedures, that the licensee's technical evaluations adequately justify the change, and that the NRC was informed of the change, as *appropriate.

The staff primarily used the guidance in NL-121, Section 6.2, to audit this section.

5.1 Verify that the licensee has established administrative controls for modifying or deleting commitments made to the NRC 5.1.2 Staff Assessment NL-121 is the licensee's implementation procedure that establishes administrative controls for modifying or deleting commitments made to the NRC. The staff performed a comparison to the NRC endorsed NEI 99-04, "Guidelines for Managing NRC Commitment Changes" to the guidance in NL-121. Key comparisons include:

• NEI 99-04, Figure A-1, "Commitment Management Change Process" is identical to Nt-121, Enclosure A, "Commitment Change Process."

• NEI. 99-04, Figure A-2, "Safety Significance Assessment" is identical to NL-121, Enclosure B, "Safety Significance Assessment."

• NEI 99-04, Figure A-3, "Commitment Evaluation Summary" is near identical to NL-121, Attachment Ill, "Commitment Change Evaluation Worksheet."

5.1.3 Conclusion The staff concludes the licensee has established administrative controls consistent with NEI 99-04 for modifying or deleting commitments made to the NRC. 5.2 Review a sample of regul9-tory commitment changes that included changes that were or will be reported to the NRC.

• According to the licensee's NL-121 procedure, there are two types of licensee documents that report a change to a regulatory commitment to the NRC: (1) Annual Commitment Change Summary Report (Annual Report) referenced in NL-121, Section 5.2.3 and Enclosure A, Decision Step 5. (2) Timely Notification of an Intended Change to a Regulatory Commitment letter. NL-121, Enclosure A, Decisions Step 3 and 4, require a timely notification of the change to a regulatory commitment.

5.2.1 Staff Assessment Annual Report Accordi.ng to NL-121, Enclosure A, the licensee is required to submit the following in an Annual Report to the NRC: any change to a regulatory commitment that has already been implemented that the NRC relied upon the regulatory commitment in a safety evaluation to conclude a reasonable assurance finding 1 any change to a regulatory commitment that minimizes a reoccurring adverse condition for which the change was specifically to minimize recurrence of the adverse condition During the time frame of the audit, the licensee submitted the following Annual Reports:

a) 2009 -February 18, 2010 (ML 1 00541576) b) 2010-April 5, 2011 (ML 11 0960592) c) 2011 and 2012-Annual Reports were not submitted because there were no changes to regulatory commitments that met the requirements for the Annual Report. The staff questioned the licensee regarding the missing 2011 and 2012 Annual Reports.

The licensee responded that the requirement has been interpreted to only require an Annual Report if there were any changes that met the reportable criteria.

In response to the staff's question, the licensee submitted a revision to the NL-121, step 5.2.3, to add "If no commitment reductions are performed, no report is required to be sent." The licensee confirmed that Annual Reports 2011 and 2012 were not submitted because there

• were no changes that met the reportable criteria.

Timely Notification of an Intended Change to a Regulatory Commitment (Timely Notification Letter) According to NL-121, Enclosure A, the licensee is required to submit a Timely Notification Letter for an anticipated change to a regulatory commitment that the NRC relied upon in a safety evaluation to conclude a reasOnable assurance finding.

1 During the time frame of the audit, the licensee submitted one Timely Notification Letter on May 13,2013, (ML13142A142).

Audit Samples:*

Audit Nos. 14 and No. 16 were the only two regulatory commitments that were changed and subsequently reported to the NRC during the time frame of the audit. The staff requested and reviewed the documentation associated with the evaluation required in NL-121, Section 6.2.1 0 "Commitment Change Development" and Attachment Ill, "Commitment Change Evaluation Worksheet."

No deficiencies were noted. 1 OIG Audit report OIG-11-A-17, "memorandum from S. Dingbaum (OIG) toW. Borchardt (NRC) dated September 19, 2011, (ADAMS Accession No. ML 112620529) found that the staff has misapplied regulatory commitments in safety evaluations in the past. Going forward, the staff will no longer rely on a regulatory commitment to make a reasonable assurance finding. 5.2.2 Conclusion For the regulatory commitment changes that were reported to the NRC, the staff concludes that they were evaluated in accordance with licensee's programs and procedures and that the l technical evaluations adequately justified the change.

• 5.3 Changes to Regulatory Commitment that were Not Reported to the NRC 5.3.1 Staff Assessment and Conclusion During the time frame of the audit, there were no changes to regulatory commitments that were not reported to the NRC; therefore, the staff could not audit this section.

6.0 REVIEW OF SAFETY EVALUATION REPORTS FOR LICENSING ACTIONS SINCE THE LAST AUIDT TO DETERMINE IF THEY ARE PROPERLY CAPTURED AS COMMITMENTS OR OBLIGATIONS Review to Identify Misapplied Regulatory Commitments The commitments reviewed for this audit were also evaluated to determine if they had been misapplied.

A regulatory commitment is considered to be misapplied if the action comprising the commitment was relied on by the NRC staff in making a regulatory decision such as a finding of public health and safety in an NRC safety evaluation associated with a licensing action. Reliance on an action to support a regulatory decision must be elevated from a regulatory commitment to a legal obligation (e.g., license condition, condition of a relief request, regulatory exemption limitation or condition).

A regulatory commitment is also considered to have been misapplied if the commitment involves actions that were safety significant (i.e., commitments used to ensure safety).

Each of the commitments selected for the audit sample were reviewed to determine if any had been misapplied.

In addition to the commitments selected for the audit sample, all license amendment safety evaluations, exemptions and relief request safety evaluations (SE) that have been issued for V :c. Summer from February 1, 2009, to November 30, 2013, were evaluated to determine if they contained any misapplied commitments as described above. 6.1 Staff Assessment License Amendments:

1) Amendment No. 181 dated June 9, 2009 (ADAMS Accession No. ML091210666)

• Audit No. 1. The staff identified a misapplied commitment in the SE. The SE stated: "The staff considered the licensee's commitment to implement 10 CFR Part 26, Subpart I concurrently with the deletion of TS work hour requirements in its evaluation of the proposed change. Given the licensee's commitment, there is reasonable assurance that the licensee will comply with the regulations for work hour controls, either through TS I ' requirements or through the requirements of 10 CFR Part 26, Subpart /, at all times at VCSNS." The regulatory commitment was met and closed on October 1, 2009. Upon re-reviewing the regulatory commitment submitted and consulting with the technical reviewers who misapplied the commitment in the SE, it has been determined, in retrospect, that the regulatory commitment was not needed for a reasonable assurance finding.

The regulatory commitment is a commitment to comply with the existing regulatory requirement or the TSs requirements regarding work hour controls.

No further follow-up is necessary.

• 2) Amendment No. 182 dated March 22, 2010 (ADAMS Accession No. ML 10011 0377)

• The licensee's submittal dated June 9, 2009, included two regulatory commitments.

(ADAMS Accession No. ML091620072)

• The staff verified the SE did not contain a misapplied commitment.

3) Amendment No. 183 dated October 4, 2010 (ADAMS Accession No. ML 1 02160020)

• No regulatory commitments were included in the licensee's submittal.

4) Amendment No. 184 dated August 24, 2011 (ADAMS Accession No. ML 11201 A312)

• The licensee's submittal dated August 5, 2010, included three security-related regulatory commitments (ADAMS Accession No. ML 102210192)

• The staff verified the SE did not contain a misapplied commitment.

5) Amendment No. 185 dated February 22, 2012 (ADAMS Accession No ML 12030A035)

• The licensee's submittal dated August 23, 2011, included one regulatory commitment.

(ADAMS Accession No. ML 11237 A 1 03)

• The staff verified the SE did not contain a misapplied commitment.

6) Amendment No. 186 dated February 22, 2012 (ADAMS Accession No ML 11326A250)

• The licensee's submittal dated May 2, 2011, included one regulatory commitment.

(ADAMS Accession No. ML 11124A 123)

• The staff verified the SE did not contain a misapplied commitment.

7) Amendment No. 187 dated March 6, 2012 (ADAMS Accession No. ML 12047A192)

• The licensee's submittal dated April 18, 2011, contained three regulatory commitments.

(ADAMS Accession No. ML 111 09A 113)

• The staff verified theSE did not contain a misapplied commitment.

8) Amendment No. 188 dated March 20, 2012 (ADAMS Accession No. ML 11346A006)

• The licensee's submittal dated March 18, 2011, included multiple regulatory commitments.

(ADAMS Accession No. ML 11081 0688)

• The staff verified the SE did not contain a misapplied commitment.

9) Amendment No. 189 dated May 1, 2012 (ADAMS Accession No. ML 12121A034)

• No regulatory commitments were included in the licensee's submittal. 1 0} Amendment No. 190 dated May 30, 2012 (ADAMS Accession No. ML 12146A017)

• No regulatory commitments were included in the licensee's submittal.

11) Amendment No. 191 dated July 9, 2012 (ADAMS Accession No. ML 12184A 135)

• The licensee's submittal dated October 12, 2011 contained one regulatory commitment.

(ADAMS Accession No. ML 11286A318)

• The staff verified the SE did not contain a misapplied commitment.

12) Amendment No. 192 dated October 12, 2012 (ADAMS Accession No. ML 12270A301)

• The licensee's submittal dated June 29, 2012 contained one regulatory commitment.

(ADAMS Accession No. ML 121850005)

.

• The staff verified the SE did not contain a misapplied commitment.

13)Amendment No. 193 dated December 21, 2012 (ADAMS Accession No. ML 12292A056)

• The licensee's submittal dated August 30, 2012, contained one regulatory commitment.

(ADAMS Accession No. ML 12248A270)

• The staff verified the SE did not contain a misapplied commitment.

Relief Requests:

1) Relief Request (RR-111-07) dated July 19,2012 (ADAMS Accession No. ML12191A163)

• No regulatory commitments were included in the licensee's submittal.

2) Alternative Relief Request (RR-111-09) dated April 19, 2013 (ADAMS Accession No. ML13101A333)

• No regulatory commitments were included in the licensee's submittal.

3) . Relief Request (RR-4-01, RR-4-02, RR-4-03}

dated November 5, 2013 (ADAMS Accession No. ML 13301 A767)

• No regulatory commitments were included in the licensee's submittal.

Exemptions:

1) Emergency Plan Schedule Exemption dated December 17, 2009 (ADAMS Accession No. ML093240159}

• No regulato'ry commitments were included in the licensee's submittal.

2) Part 73 Physical Security Scheduler Exemption dated 3/1/2010 (ADAMS Accession No. ML 100070644)

• No regulatory commitments were included in the licensee's submittal.

Other Licensing Actions:

1) Virgil C. Summer, Unit 1 -Closeout of Generic Letter 2008-01 "Managing Gas Accumulation in Emergency Core Cooling, decay Heat Removal, and Containment Spray Systems" dated April 7, 2011. (ADAMS Accession No. ML 11 0872033)

• This document references 9 regulatory commitments.

• The staff verified the closeout letter did not contain a misapplied commitment.

• Region II inspected these commitments and documented the inspection in the Integrated Inspection Report dated May 11, 2012 (ADAMS Accession No. ML 12135A453).

6.2 . Conclusion Regarding Section 6.0 of the Audit, the staff identified one misapplied commitment.

The commitment has been adequately implemented and is now closed. The staff determined that, in retrospect, the regulatory commitment was not needed for a reasonable assurance finding.

No further follow-up is necessary.

7.0 OBSERVATIONS AND RECOMMENDATIONS 7.1 Previous Audit Observations and Recommendations The staff included the following recommendations in the last audit completed on February 27, 2009. Below is staff's assessment of implementation, if any, of the recommendations from the last audit: (1) " ... consider conducting an internal audit of the NRC regulatory commitments and establish a frequency of future internal audits ... " Staff Assessment:

The staff did not identify any reference that requires a self-assessment of the commitment management program in NL-121; however, the licensee provided that an internal audit was conducted in May 2012. The staff suggests revising NL-121 to include.

an internal audit requirement and frequency.

(2) "given that there is not a dedicated database to NRC regulatory commitments, compiling a repository of NRC regulatory commitments would address the seemingly burdensome task of searching the entire CR database for NRC regulatory commitments once every 3 years to support the NRC audit." Staff Assessment:

NL-121, Section 5.4, seems to address this recommendation as it requires a Commitment Log to be maintained by the Licensing Technician to ensure easy recovery of commitment information during future NRC inspections.

(3) "ensure CR actions are appropriately flagged as "NRC regulatory commitments" if applicable" Staff Assessment:

Based on the numerous deficiencies identified in Enclosure 1, "Regulatory Commitment Management Audit Table," the staff concludes this recommendation has not been implemented. 7.2 Audit Observations and Recommendations (1) Observation:

The Commitment Log was generally insufficient.

It lacked the fundamental information about each commitment such as: the date the commitment was originally due a revised due date, if applicable a closure date, if applicable if the commitment was changed from the original commitment if an NL-121, Attachment Ill, "Commitment Change Evaluation Worksheet" was completed There were also open commitments in the Commitment Log for which the due date was past due for completion.

There was no additional information provided regarding the reason that the commitment is past due and what is the new expected commitment completion date. Including this fundamental information in the Commitment Log would allow site personal and NRC staff to more efficiently audit and confirm that the regulatory commitments were completed per the original due dates without going through the timely and burdensome effort of reviewing each CR associated with each regulatory commitment.

Recommendation:

Include fundamental information regarding the regulatory commitments in the Commitment Log as indicated in the observation above. (2) Observation:

Generally, the CRs lacked clear identification that it contained regulatory

. commitments as described in the audit report Section 4.1.1. Recommendation:

Consistently use the identifier "NRC" in the commitment cell of the associated CR. In the description, explicitly state that the corrective action is a regulatory commitment and include the exact wording of the regulatory commitment that was submitted to the NRC. (3) Observation:

. Some CRs lacked fundamental information regarding the status and implementation of the commitments.

Recommendation:

Establish clear guidelines on the type of information and implementation records that should be included in the CR for regulatory commitments.

CR should include references to the following implementation records:

Procedure revisions Completed Work orders and/or plant walkcfowns Plant design calculations Plant drawings Issued memorandums Initiated licensing actions NL-121, Attachment Ill, "Commitment Change Evaluation Worksheet" / (4) The Licensee's submittal dated August 30, 2012 (ADAMS Accession No. ML 12248A270) contained a new regulatory table not submitted previously that included a separate column to identify if the regulatory commitment was a one-time action or a continuous commitment.

Recommendation:

Adopt this good practice for future submittals of regulatory commitments.

(5) Observation:

NL-121, Section 7.2.1 states, "Commitment change documentation maybe retained by NL as historical information."

The staff notes that the commitment change documentation is a primary focus for this audit and will be requested during all commitment management program audits. Recommendation:

Revise this statement to indicate that the commitment change documentation shall be retained for auditing purposes and, if applicable, clearly state in the Commitment Log and CR that an NL-121 Attachment Ill was completed for any change to the commitment.

(6) Observation:-

The staff notes there were many regulatory commitments submitted that set an implementation period for an amendment (Audit Nos. 1, 4, 7). The staff notes that these types of regulatory commitments are more appropriately licensee internal commitments.

Upon the issuance of an amendment, the NRC establishes the timeliness requirement for the licensee to implement the amendment.

The staff notes that in the more recent LARs, VCSNS has put the request for an implementation'period more appropriately in the cover letter. Recommendation:

The staff suggests reevaluating the licensee's criteria used to determine the threshold of whether an item should be a regulatory commitment or a licensee internal commitment.

8.0 CONCLUSION

The NRC staff concludes that VCSNS has the procedures and processes used to manage commitments consistent with NEI 99-04. However, the documentation and tracking of the commitments have been inconsistently implemented.

Key improvements that are needed are to improve the documentation and implementation details associated with regulatory commitments.

9.0 LICENSEE PERSONNEL CONTACTED FOR THIS AUDIT Renard Perry John Garza Principal Contributor:

Shawn Williams Date: April 18, 2014

Attachment:

Summary of Audit Results Summary of Audit Results Audit Sample: No. 1: The commitment was adequately implemented.

No. 2: The commitment documentation was insufficient as explained in Section 4.1.1.1.

No. 3: The commitment documentation was insufficient.

The staff was not able to locate the three security related commitments in the CR that was referenced in the Commitment Log. No. 4: The commitment was adequately implemented:

No. 5: The commitment was not implemented by the original due date. Approximately nine months after the commitment due date, the licensee self-identified the missed commitment and opened a new CR. Upon reviewing the new CR, the staff could not determine the new due date to complete the regulatory commitment thus, staff concludes the commitment documentation was insufficient.

No. 6: The commitment documentation was insufficient.

The staff could not locate the closure dates of the three commitments or information related to how the original "continuous" commitments were changed to "closed."

No. 7: The commitment was adequately implemented.

No. 8: The CR did not contain the commitment as written.

however, the staff can conclude based on the last page of the CR, that the commitment was implemented within the time frame. No. 9: The commitment documentation was insufficient.

The staff could not locate the commitments in the CR referenced in the Commitment Log. No. 1 0: Although there are documentation issues explained in the enclosure, the staff concludes the two remaining open commitments are captured in an effective program for future implementation.

No. 11: This audit sample was incorrectly included in the licensee's Commitment Log as a regulatory commitment.

It was never submitted as a regulatory commitment.

The staff further notes the Commitment Log and the CR incorrectly identifies the licensee's internal commitment as "open" contrary to a letter dated May 16, 2013, that indicates the internal commitment is closed. No. 12: Although there are documentation issues explained in the enclosure, the staff concludes the open commitments are captured in an effective program for future implementation.

Attachment No. 13: This audit sample was incorrectly included in the licensee's Commitment Log as a regulatory commitment.

It was never submitted as a regulatory commitment.

No. 14: The commitment documentation was insufficient.

The documentation did not include an explanation of why the commitment was closed when only the frequency of the commitment was changed.

No. 15: The commitment documentation was insufficient.

The staff could not locate the open Commitment No. 1 in the CR referenced in the Commitment Log. No. 16: The commitment was adequately implemented and closed. No. 17: The commitment documentation was insufficient.

The staff could not locate Commitment Nos. 1, 3, 4, 5, 6, 7, 8, 9, and 12 in the referenced CRs.

No. Licensee Ltr Date Condition RCNo. Description Report No. 1 3/2/2009 08-01332 09-0012 (ML0906504

76) LAR for Adoption of TSTF-511, Rev. 0, "Eliminate Working Hour Restrictions from TS 5.2.2 to Support Compliance with 10 CFR 26." 2 6/9/2009 09-00562 09-0068 (ML091620072)

LAR for Use Of Optimized ZirloŽ Fuel Rod Cladding Regulatory Commitment Management Audit Table February 2009 to December 2013 Regulatory Commitments Status provided Audit Results by Licensee Removal of the plant-specific Closed The commitment was included in the licensee's Commitment Log. TS requirements will be performed concurrently with A review of the CR identified the following:

the implementation of the 10 -The commitment was found on page 38 of the CR. It was CFR Part 26, Subpart I appropriately identified, implemented, and closed on requirements.

This 10/1/2009.

No deficiencies identified.

commitment will be completed no later than October 1, 2009. A review of the staff's Safety Evaluation identified that the staff had made reference that implied the regulatory commitment was necessary for a reasonable assurance.

The staff reviewed the SE and determined, in retrospect, the regulatory commitment was not necessary for the NRC staff to make a reasonable assurance finding because the commitment was to meet an existing requirement or regulation.

1. The core reload' process Closed The commitments were included in the licensee's Commitment for VCSNS will ensure the Log. However, the Commitment Log lacked any additional conditions and limitations of Due Date: information on why the "continuous" commitments, were closed. the NRC SE for Optimized Continuous, until ZIRLOŽ as addressed in the contingency See Section 4.1.1.1 for a detailed discussion

.. Enclosure are met when a requirements of the batch of Optimized ZIRLOŽ conditions and is implemented limitations have been satisfied

2. SCE&G will confirm that Due Date: Westinghouse will provide Continuous, until additional confirmatory data the L TA data up associated with L TA programs through the fuel at other facilities prior to burnup limit subsequent cycles of operation applicable for with Optimized ZIRLOŽ fuel VCSNS has been rod cladding.

provided to the NRC. Enclosure 2

3 8/5/2010 09-03585 10-0091 (ML 10221 0192) LAR "Withdrawal and resubmittal of License Amendment Request to Facility Operating License to Incorporate the Requirements of 1 0 CFR 73.54" 4 8/23/2011 11-01774 11-0063 (ML 11237A103)

LAR "Application to Eliminate License Condition 2.G.1 Requiring Reporting of Violations of Section 2.C Of the Operating License Using the CUIP" 5 5/2/2011' 09-00469 11-0052 (ML 11124A123) 13-01378 LAR for Adoption of TSTF-513, Revision 3, "Revise PWR Operability Requirements and Actions for RCS Leakage Instrumentation"

-Regulatory Commitment Management Audit Table February 2009 to December 2013 The submittal contained three The three security related commitments referenced in LAR regulatory commitments submittal were not included in the Commitment Log. identified as security related information; therefore, they are Reviewing the CR identified the following:

not included below. -The staff could not find the status of the three commitments made in RC 1 0-0091 in CR 09-03585.

-Page 5 was identified with an "NRC" in the commitment cell; however, that page does not appear to apply to any of the three regulatory commitments.

-The staff notes the CR does not include the exact or similar wording of commitments in RC 10-0091 In a follow-up discussion with the licensee, the licensee determined that although the commitments as provided to the NRC were not .written clearly in the CR, the actions to implement the commitments were captured in the CR and are now closed. The approved amendment will Closed The commitment was included in the licensee's Commitment Log. be implemented within 120 days. Reviewing the CR identified the following:

-Page 4 of the CR includes the regulatory commitment but was not identified as so (It did not have "NRC" in the commitment cell) nor was it described as a commitment.

-The commitment was closed on 5/17/2012, within the 120 day implementation requirement.

-Page 5 was incorrectly identified with an "NRC" in the commitment cell. Page 5 does not include a regulatory commitment.

Revise UFSAR to comply with Open The commitment was included in the licensee's Commitment Log. TSTF-513 within 120 days after Issuance of Amendment.

The Commitment Log included the licensee self-identified that this commitment was not implemented per the due date. The amendment was issued on 2/22/12, therefore, the commitment was due in approximately 8/22/12.

The licensee opened CR-13-' 01378 to document the failure to meet the commitment.

Action 18 was added to CR-09-00469 to update the FSAR per RC-11-0052.

Reviewing the CR 09-00469 identified the following:

-Page 7 was identified with an "NRC" in the commitment cell and included the commitment.

However, it was indicated a premature and closed since the NRC had not issued the LAR at that time. The commitment does not appear to have been added back in the CR after the LAR was complete, possibly the cause of the extended period Page 2 I I

-6 4/18/2011 04-02961 11-0062 (ML11109A113) LAR for slave relay surveillance testing.

Regulatory Commitment Management Audit Table February 2009 to December 2013 of time it was not identified as not being implemented in a timely manner. -Page 15 of 16, was identified as an NRC commitment, (It had "NRC" in the commitment cell} however, it is not the commitment as written in RC-11-0052.

Reviewing the CR 13-01378 identified the following:

-In March 2013, the licensee self-identified the regulatory commitment was not met by its due date of 8/22/12.

-The staff could not determine the new due date to complete the regulatory commitment in either CR. In a follow-up discussion with the licensee, the licensee provided that the commitment is expected to be implemented in the second quarter of 2014. 1. The Safety Related SSPS All three The commitments were included in the licensee's Commitment slave relays will be managed Commitments Log. to limit the qualified life to no Closed less than or equal to 40 years Reviewing the CR identified the following:

without refurbishment or -No commitment cell contained "NRC" identifying any replacement.

(Due Date -entry as an NRC commitment.

continuous for the life of the -The staff identified the three commitments on page 29 component and managed per thru page 34. The staff could not determine from the CR the Preventative Maintenance the exact date each commitment was closed. Program)

-References to implementation records were included in 2. The environmental the CR. conditions of the SSPS cabinet -The staff could not determine why the commitments will be monitored to ensure the were changed from a "continuous" commitment to a assumptions of the qualified "closed" commitment.

life analysis provided within the -The staff requested information regarding why the WCAP are maintained.

(Due continuous commitments are now considered closed. Date -Continuous, the room The licensee provided the following:

is currently monitored per -"Individually listed actions have been closed but the Technical Specification CR remains open. The commitment itself is requirements and continuous but the associated actions have been administrative procedures) closed. The Continuous aspects are managed by 3. SCE&G commits to tracking the Preventative Maintenance

Program, Technical of failures for Safety Related Specification Requirements, Administrative slave relays utilized within the Procedures and the Maintenance Rule Program."

SSPS cabinets.

(Due Date --The staff interprets the response as to mean the Continuous, to be incorporated commitments were closed because the "continuous" into the Maintenance Rule aspect of the commitments has been incorporated Program per 10CFR50.65) into plant procedures and proqrams.

The CR should Page 3 7 10/12/11 11-0157 (ML 11286A318)

LAR Request for Prior NRC Approval to Exempt Five High-Head Safety Injection Containment Isolation Valves from Local Leak Rate Testing Requirements 8 6/29/12 10-03912 12-0075 (ML 121850005)

LAR Technical Specification Change Request for TS 3.5.4, Refueling Water Storage Tank, 9 8/30/2012 11-04076 12-0125 (ML 12248A270)

LAR Cyber Security Plan Implementation Schedule Milestones

/ Regulatory Commitment Management Audit Table February 2009 to December 2013 have included a clear explanation on the disposition and closure dates of each regulatory commitment.

In a follow-up discussion with the licensee, the licensee provided that the commitments were closed based on the actions to implement the commitments were incorporated into licensee procedures and programs.

The approved amendment will Closed The commitment was included in the licensee's Commitment Log. be implemented within 120 days Reviewing the CR identified the following:

-No commitment cell contained "NRC" identifying it as an NRC commitment.

-Although not referenced as such, Page 3 includes the commitment.

The commitment was met and closed on 9/26/2012, within the 120 day requirement.

The approved amendment will Closed The commitment was included in the licensee's Commitment Log. be implemented within 14 days Reviewing the CR identified the following:

-No commitment cell contained "NRC" identifying it as an NRC commitment.

-The staff notes the CR does not appear to contain the commitment as provided to the NRC; however, the staff can conclude based on the last entry on Page 19 that the commitment was met. The commitment was closed on 1 0/13/12, within the 14 days per the commitment.

The commitment was identified Closed The commitment was included in the licensee's Commitment Log. as security related information; therefore, it is not included Reviewing the CR identified the following:

below. -No commitment cell contained "NRC" identifying it as an NRC commitment.

-The staff could not loJ:ate the commitment in the CR and verify its status. In a follow-up discussion with the licensee, the licensee determined that although the commitment as provided to the NRC was not written clearly in the CR, the actions to implement the commitments were captured iri the CR and are now closed. Page 4 10 10/13/2008 08-00162 08-0129 (ML082890534)

, GL 2008-01, Managing Gas Accumulation in Emergency Core Cooling, Decay Heat Removal, and Containment Spray Systems --Regulatory Commitment Management Audit Table February 2009 to December 2013 There were 9 commitments The Commitment Log did not include the closed regulatory

_ included in the 10/13/2008 commitments from the 1 0/13/2008 letter. (The staff requested the submittal.

Below are two open licensee to provide a list of closed commitments since the last commitments as provided by audit dated February 2009. Reviewing the 9 regulatory the licensee's in the commitments contained in the 10/13/2008, revealed that many of commitment log those commitments were closed after February 2009 and should (1) Open-Due have been included in the requested list of closed commitments.)

(1) Action 31: Monitor TSTF Date 6/30/13 and evaluate for submittal of a The Commitment Log included two open commitments from the LAR. original nine, with expected completion dates significantly past the (2) Open -Due due dates (6/30/13

& 3/30/13) with no further explanation in the (2) Action 32: Submit LAR to Date 3/30/13 Commitment Log. revise the TS within one year of TSTF approval.

Reviewing the CR identified the following:

-Page 33 correctly identified NRC commitment No. 4 (closed on 10/31/08)

-Page 37 correctly identified NRC commitment No. 3 (closed on 1 0/23/08)

-Page 38 included Commitment 1; however, it was not labeled as an "NRC" Commitment.

Commitment No. 1 is the same as Action 31 identified in the Commitment Log. It is indicated as an ongoing action to monitor the status of NRC approval of TSTF-523.

The due date per the CR is 2/28/14, not 6/30/13 as provided in the Commitment Log. -Page 41 included Commitment No. 2 (Action 32); however, it was not labeled as an "NRC" Commitment.

Action No. 32 is dependent on the approval of TSTF-523. The due date per the CR is 2/31/14, not 3/30/13 as provided in the Commitment Log. -Page 42 correctly identified commitment No.5 (closed on 11/18/09) and commitment No.6 (closed on 11 /18/09).

-Page 43 correctly identified-commitment No.7 (closed on 9/15/09.)

-Page 44 correctly identified commitments No. 8 and No. 9 (both closed on 7/30/09)

==

Conclusion:==

Although there are documentation issues, the staff concludes the two remaining open commitments are captured in an effective proqram for future implementation.

Page 5 11 5/1/2009, 04-02911 09-0060 (ML091270196)

Request for Additional Information for Generic Letter 2004-02 Response Due Date Extension 12 5/16/2013 04-02911 13-0006 (ML13140A007)

• Path Forward for Resolution of General Safety Issue (GSI)-191, "Assessment of Debris Accumulation on Pressurized Water Reactor Sump Performance."

Regulatory Commitment Management Audit Table February 2009 to December 2013 Within 90 days of issuance of Open This commitment was included in the Commitment Log; however, the final NRC staff SE on it was not submitted as a regulatory commitment in the letter WCAP-16793-NP, SCE&G will dated 5/1/2009.

respond to RAt No. 23 to demonstrate that the in-vessel The commitment as identified in the Commitment Log stated that downstream effects are the SCE&G would respond to RAI No. 23 within 90 days of the bounded by this WCAP and final NRC staff safety evaluation.

An ADAMS search resulted in the corresponding final NRC identifying that the staff had issued the referenced Final Safety staff SE, and by addressing Evaluation for Pressurized Water Reactor Owners Group Topical the conditions and limitations Report WCAP-16793-NP, Revision 2, on April 8, 2013 (ADAMS in the final SE. ML Package No. ML 13084A 161 ). Further research resulted in identifying-the Licensee's submitted a letter dated May 16, 2013 (ADAMS ML No. 13140A007) that stated in Attachment 1 the referenced commitment is now closed based on the new commitments described in Attachment II of the same letter. In summary, the Commitment Log incorrectly provided the commitment as a regulatory commitment, and incorrectly provided the status as "Open" as SCE&G letter dated 5/16/2013 status is closed. Reviewing the CR identified the following:

-Page 39 is the last entry related to the RAI No. 23 ' commitment, which also incorrectly identifies it as open. All Open: The commitments were included in the licensee's Commitment

1. Procedural updates to 1. July 1, 2014 Log. The staff notes the Commitment Log identified the same CR address core blockage to applies to both Audit No. 11 and 12. support Defense-In-Depth measures Reviewing the CR identified the following:

2. Refuel Outage -Pages 35-38 were correctly identified as NRC 2. Engineering walk downs, as 21 (Spring 2014) commitments that were submitted on 11/29/09, needed, for potential insulation (ML093360336).

Those commitments are unrelated to replacement remediation this Audit No. and are not included in the Audit sample. 3. Within 60 days -Page 40 and 41 included information regarding

3. Develop a plan for of the PWROG Commitment No. 1; however, it was not identified as a demonstrating compliance with establishing new in-"NRC" commitment nor was it referenced as one in the new PWROG program limits vessel acceptance description.

and communication plan to the criteria

-Page 41 of the CR included information regarding NRC 4. Within 6 months Commitment No.2. It was not identified as a "NRC" of establishing a commitment nor was it referenced as one in the final determination description.

of the scope of -Page 42 of the CR included informati<?n regarding

4. Submit a final updated insulation Commitment No. 3. It was not identified as a "NRC" supplemental response to replacement or commitment nor was it referenced as one in the Page 6 '

' 13 10/3/2013 13-01414 13-0134 (ML 13281 A 1 93) LAR Change of the Completion Date of Implementation Milestone

8. 04/05/2011 10-00881 11-0Q44 (ML 11 0960592)

(LTD662)

Submittal of Annual Commitment Change Summary Report for 201 0. ------Regulatory Commitment Management Audit Table February 2009 to December 2013 support closure of GL 2004-02 remediation description.

5. Update the Current 5. Following NRC -Page 43 of the CR included information regarding Licensing Basis (FSAR) acceptance of the Commitment No.4. It was not identified as a "NRC" updated commitment nor was it referenced as one in the supplemental description.

response for -Page 44 of the CR included information regarding

6. Discuss alternate resolution VCSNSand Commitment No. 5. It was not identified as a "NRC" plan with the NRC to gain completion of the commitment nor was it referenced as one in the acceptance of the proposed identified removal description.

path and to establish an or modification of -Page 45 of the CR included information regarding acceptable completion insulation debris Commitment No.6. It was not identified as a "NRC" schedule sources in commitment nor was it referenced as one in the containment per description.

plant modification procedures and ' processes

6. If SCE&G determines that Option 2 will not be viable By the completion date, Open This was not identified as a regulatory commitment in the LAR VCSNS Unit 1 Cyber Security dated 1 0/3/2013; yet it was incorrectly included in the Plan will be fully implemented Commitment Log as an open regulatory commitment.

for all SSEP functions in accordance with 10 CFR 73.54. Disassemble and inspect the Closed The commitments were included in the licensee's Commitment TDEFP every 5 years. Log. Commitment is being retained but the frequency has been Per the Commitment Log, the licensee provided that this changed from 5 yr to 10 yrs. commitment is closed. However, only the frequency of the commitment has been changed from 5 to 10 years, thus maintaining it as an open commitment.

Reviewing the CR identified the following:

-The 4/5/2011 letter stated "The commitment to perform an internal inspection is being retained; the frequency is being extended from 5 to 10 years ... " The CR does not explain why the commitment is now closed when the letter stated otherwise.

As requested, the licensee provided the NL-121, Attachment Ill, "Commitment Change Evaluation Worksheet."

The staff reviewed.

No deficiencies were identified.

Page 7 15 04/01/2013 06-0005 13-0054 (ML 13092A333)

LAR-06-00055

-License Amendment Request to Adopt NFPA 805 Additional Information Regarding Response to Request for Additional Information.

16 2/18/2010 CR-09-10-0017 (ML 1 00541576) 01206 2009 Annual Commitment Change Summary Report 17 5/13/2013, CR-06-13-0061 (ML13142A 142) 00055, Notification of an CR-13-Intended change to 01496 a Commitment Date CR-11-for NFPA 805 03925 Emergency Communications System made in LAR 06-00055 Regulatory Commitment Management Audit Table February 2009 to December 2013 In a follow-up discussion with the licensee, the licensee stated that the commitment is closed because it has been incorporated into the Preventative Maintenance Program.

1. Increase the scope of circuit 1 . Open -due date These commitments were included in the Licensee's commitment protection modifications_

2015 log. 2. Update Generic Reviewing the CR identified the following:

Methodology Calculation,

2. Closed -due -Commitment No. 1 -the staff could not locate this DC07808-001 July 31, 2013 commitment in the CR. -Commitment No. 2: Page 16 of the CR included sufficient information regarding the commitment;

however, it was not identified as a "NRC" commitment.

The commitment was closed on 6/24/13.

In a follow-up discussion with the licensee, the licensee stated -they intended to include Commitment No. 1 in the CR. The cable from PARR to No longer a This regulatory commitment was include in the 2009 Annual VCSNS will be used at regulatory Commitment Change Summary Report but not included in the conductor temperatures not to Commitment as of Commitment Log. The staff notes the original request was for all exceed 105 OC. The 6/12/2009 commitments that were closed after the last audit. emergency temperature rating will be 1400C for periods A review of the CR identified no deficiencies.

which shall not exceed 100 hours0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br /> per year. Such 100 hour0.00116 days <br />0.0278 hours <br />1.653439e-4 weeks <br />3.805e-5 months <br /> As requested, the licensee provided the NL-121, Attachment Ill, overloads shall not exceed 5 "Commitment Change Evaluation Worksheet."

The staff over the lifetime of the plant. reviewed.

No deficiencies were identified.

There were 12 commitments Note: The status The Commitment Log only Commitment No. 12 and identified as security related of each referenced CR-06-00055.

The staff could not locate Commitment information; therefore, they are commitment was No. 12 in CR-06-00055.

not included below. provided in the 11/26/13 Ltr. Reviewing the CRs identified the following:

-The staff could not locate Commitment No. 1. -Commitment No. 2 was referenced on Page 20 of CR-11-03925.

However, it was not identified as a "NRC" commitment nor was it referenced as one in the description.

The CR indicates it was closed on 8/7/2013.

-The staff could not locate Commitment Nos. 3, 4, 5, 6, 7, 8, 9, I -CR 13-01496 sufficiently included the status of Commitment No. 10. Although it was not identified with Page 8 Updated list of 13-0166 Regulatory Commitments in 11/26/2013, letter (ML 13333A283)

Attachment 3, List of Regulatory Commitments Regulatory Commitment Management Audit Table February 2009 to December 2013 "NRC" in the commitment cell. Reference to Commitment No. 11 was found on page 23 of CR-11-03925.

Page 16 of CR-06-00055 includes a regulatory commitment to update Generic Methodology Calculation, DC0780B-001.

However, this commitment does not seem to match any of the commitments in the 11/26/13 letter. The staff notes it was not identified with "NRC" in the commitment cell. In a follow-up discussion with the licensee, the licensee stated they intended to review the documentation and ensure each commitment is included in the appropriate CR. Page 9 T. Gatlin The NRC staff appreciates the resources that were made available by your staff, both before and during the audit. If there are any questions, please contact Shawn Williams at . (301) 415-1009.

Docket No. 50-395

Enclosures:

1 -Audit Report Sincerely,

/RAJ Shawn Williams, Senior Project Manager Plant Licensing Branch 11-1 Division of Operating Reactor Licensing Office of Nuclear Reactor Regulation 2 -Regulatory Commitment Management Audit Table cc w/encls:

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