Information Notice 1997-81, Deficiencies in Failure Modes and Effects Analyses for Instrumentation and Control Systems

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Deficiencies in Failure Modes and Effects Analyses for Instrumentation and Control Systems
ML031050048
Person / Time
Site: Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Crane  
Issue date: 11/24/1997
From: Roe J
Office of Nuclear Reactor Regulation
To:
References
IN-97-081, NUDOCS 9711190167
Download: ML031050048 (14)


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I

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR REACTOR REGULATION

WASHINGTON, D.C. 20555-001

November 24, 1997

NRC INFORMATION NOTICE 97-81: DEFICIENCIES IN FAILURE MODES AND EFFECTS

ANALYSES FOR INSTRUMENTATION AND CONTROL

SYSTEMS

Addressees

All holders of operating licenses for nuclear power reactors except those who have ceased

operations and have certified that fuel has been permanently removed from the vessel.

Purpose

The U.S. Nuclear Regulatory Commission (NRC) is issuing this information notice to alert

addressees to design inadequacies in safety-related instrumentation and control systems in

which the original failure modes and effects analysis (FMEA) failed to identify the inability to

perform intended function(s) in the presence of a single failure, which defeats the system

independence and redundancy. It is expected that recipients will review the information for

applicability to their facilities. However, suggestions contained in this information notice are not

NRC requirements; therefore, no specific action or written response is required.

Description of Circumstances

Five events have been identified related to the design deficiency noted above:

1.

On July 1, 1997, while Crystal River Unit 3 was in mode 5, the licensee discovered that in

a postulated design-basis loss-of-coolant accident (LOCA), concurrent with a loss of

offsite power (LOOP) and a single failure (such as a loss of the train A dc bus), the

train B engineered safeguards system actuation (ESSA) signal could not be bypassed.

The inability to bypass the train B ESSA signal removes the operators ability to restore

control complex chillers and causes certain train B high pressure injection (HPI) valves to

remain open. These valves cannot be closed remotely when the LOCA is caused by a

break on one of the HPI lines. This condition could lead to a potential for inadequate core

cooling. In addition, the operators may not be able to cope with the event, because the

station emergency operating procedures (EOPs) did not contain adequate guidance

(LER 97-21, Accession No: 9708290125).

2.

On July 25, 1997, while Three Mile Island, Unit 1 (TMI-1) was at 100-percent power, the

TMI licensee discovered that in a postulated condition of a large-break LOCA, concurrent

with LOOP and a single failure (such as a loss of the train A dc bus), the engineered

safeguards (ES) system components of train B would be actuated. However, because of

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7111901

-IN 97-81 November 24, 1997 the loss of power to ESSA system channels A and C (due to loss of the train A dc bus),

the operators would not be able to bypass the train B ESSA signal. The plant's design for

accident conditions with loss of dc bus "A", did not consider the need for throttling low- pressure injection and building spray pump flow to ensure adequate net positive suction

head when the suction is transferred to the reactor building sump from the borated

water storage tank. Maintaining the minimum required flow ensures that these pumps

remain operable, so that the cooling requirements of the reactor core and reactor building

are met. However, the plant design upon loss of train A dc power, prevents the operators

from taking manual control of the valves required to transfer low-pressure injection and

reactor building spray pump suction from the refueling water storage tank (RWST) to the

reactor building sump upon indication of a low-water-level condition in the RWST

(LER 97-009, Accession No: 9709020257).

3.

On May 15, 1997, while Waterford Unit 3 was at 100-percent power, the licensee

discovered that in the postulated conditions of a LOCA with one RWST-level monitoring

channel placed in a tripped state [as allowed by the Technical Specifications(TS)], if a

single failure, such as a failure of another RWST-level channel occurs, a potential for

premature initiation of the recirculation mode exists. In another situation, with one

channel of steam generator (SG) differential pressure (DP) instrumentation associated

with the emergency feedwater actuation signal (EFAS) placed in a tripped state, an event

such as a main steam line break or a feedwater line break concurrent with a single failure

such as loss of another SG DP instrument channel, results in a potential for not isolating

the faulted SG from the emergency feedwater supply line (LER 97-16, Accession

No: 9706180379).

4.

On September 16, 1997, while Arkansas Nuclear One, Unit 2 (ANO-2) was at 100-

percent power, the licensee discovered that a potential for premature actuation of the

recirculation mode exists in case of a LOCA concurrent with one of the RWST-level

instrumentation channels in a tripped state and a failure in another RWST-level

monitoring channel. In another situation, the automatic Isolation of a faulted SG during

certain main steam line or feedwater line breaks will not occur If one instrumentation

channel monitoring SG DP is in a tripped state and another SG DP channel has failed

(LER 97-03, Accession No: 9706190213).

5.

On October 30, 1996, while ANO-2 was at 100-percent power, the licensee discovered

that while one plant protective system (PPS) channel is in bypass, a scenario consisting

of a LOOP concurrent with a single failure, such as a loss of the train A dc bus, would

result in a failure of certain engineered safeguard function (ESF) systems to actuate

automatically. ESF systems affected are the containment Isolation system (CIS),

containment spray system (CSS), and emergency feedwater system (EFWS). The

consequence of a dc bus failure alone could lead to the same failures with loss of off-site

power and loss of on-site power in the affected train (LER 96-04-01, Accession

No: 9702120360).

Discussion

The first two events described above are examples in which a single failure in a train (loss of dc

bus A) not only prevented the train A safety system from performing the intended design

function(s), but also prevented equipment in train B safety systems from performing their

IN 97-81 November24, 1997 intended design function(s). The basic logic design of the ES system at both Crystal River

Unit 3 and Three Mile Island Unit 1 consists of three primary analog monitoring instrumentation

channels, powered from two redundant battery-backed dc buses and provides an ESSA signal

to train A and train B equipment in a two-out-of-three logic scheme. Two of the three

monitoring channels are powered from the train A dc bus and the third channel is powered from

the train B dc bus. Since the logic arrangement is based on a two-out-of-three configuration

and the train A dc bus feeds two channels, if dc bus A is lost, the ESSA signal cannot be

bypassed because the bypass circuitry is powered from the same source as the signal initiation

channels. This problem could exist at any other plant at which the ESSA signal is generated

with a two-out-of-three logic configuration with the three monitoring channels fed from only two

power sources.

As described in events 3 and 4 above, a failure in a single instrument channel with one other

instrument channel of the same function placed in the "tripped" state as permitted by the TS,

created a unique control-logic configuration that could prevent certain safety system(s) from

performing intended design function(s) for mitigating a LOCA or steam/feedwater line break

event(s). The ANO-2 vital power design for the plant protective system (PPS) consists of one

emergency diesel generator (EDG), one battery/dc distribution system and two inverters for

each power division. The ESF system actuation logic is based on a two-out-of four

configuration. The design configuration for some measurement channels (steam generator

pressure, pressurizer pressure, containment pressure) is such that upon loss of power, these

channels do not fail to their safe state and, therefore, during a loss-of-power condition, are

unable to automatically actuate the associated ESF systems if needed.

As described in event 5 above, during a postulated LOOP event concurrent with a loss of one

dc bus, the CIS, CSS, and EFWS will fail to actuate if one PPS channel fed from the operable

dc bus is in a bypassed state as permitted by the TS. The result of this existing condition is that

during the period when one PPS channel is bypassed, the plant could have been operated

outside its original design basis since many required automatic safety functions would have

been unavailable. If a channel is not in bypass, all PPS functions except the function that

controls feedwater flow/SG level to prevent SG overfill, will be available even if one power

division is lost concurrent with a LOOP. The SG overfill prevention feature Is not a required

safety function for the postulated loss-of-power scenario.

The previous ANO-2 TS allowed one PPS channel to be in bypass for up to 48-hours to perform

maintenance or testing based upon the low probability of a fault such as loss of a power division

affecting more than one channel during the 48 hour5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br /> interval. Thus, the failure of the automatic

actuation capability of some ESFAS functions was considered sufficiently unlikely for the limited

time one channel was permitted to be in bypass. Amendment 159 to the ANO-2 TS issued on

April 3, 1995, increased the allowed time In bypass for one PPS channel during plant operation

at full power from "48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />" to "until the next cold shutdown." Reviews to support this

amendment conciuded that bypassing of a specific protective channel combined with a single

' Ji

IN 97-81 November 24, 1997 failure would not prevent required protective actions. The discovery of the potential

unavailability of required protective actions under the conditions described above indicated

that the FMEA providing an acceptable basis for Amendment 159, was in error.

The FMEA did indicate that any of those PPS channels that generate a trip on a decreasing

value of the process signal will actuate on loss of power (because the logic will perceive the

loss of power as a decrease in the value of the process signal). However, the FMEA failed to

recognize that those PPS channels that generate a trip on an increasing value of the process

signal will never actuate if power Is lost to the measurement channel. Thus, the FMEA was in

error In its conclusion that "the vital ac power system did not have a single failure mechanism

that could cause failure of two vital AC power channel inputs" (a minimum of two channels is

required for a two-out-of four logic).

To alleviate the problem described in events I and 2 above, the Crystal River licensee decided

to revise the EOPs to provide procedural guidance on a loss of ES train bypass capability upon

loss of dc bus A. The revised EOPs will provide guidance to recognize the failure and an

alternative method to bypass the B train ESSA signal. This will allow the operators to regain

control of the necessary ES equipment to assure adequate high-pressure injection flow to the

reactor. It will also allow operators to throttle HPI flow when the subcooling margin is restored

to maintain RCS pressure below pressurized thermal shock limits. The TMI licensee is also

revising the EOPs to (1) proceduralize methods to diagnose an inability to bypass the ESSA

signal, (2) provide alternate methods to energize the train A dc bus so that the ESSA signals

can be bypassed, and (3) identify required operator actions necessary to achieve minimum flow

requirements for reactor core and reactor building cooling.

For the concerns described in events 3 and 4 above, relating to events (LOCA, main steam line

break or feedwater line break) with one instrument channel in a tripped state while another

channel has failed, the ANO-2 licensee provided the needed temporary administrative controls

until a permanent fix involving a TS change is implemented. The Waterford licensee has also

evaluated the conditions related to channel trip and provided temporary administrative controls

until a permanent fix involving a TS change is implemented.

To address the problem described in event 5 above, the ANO-2 licensee evaluated the

condition and concluded that the PPS will continue to perform its design function if a channel is

bypassed for no longer than 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />. As a short term corrective action, the licensee

established administrative controls which prevent a PPS channel from remaining in bypass for

more than 48 hours5.555556e-4 days <br />0.0133 hours <br />7.936508e-5 weeks <br />1.8264e-5 months <br />. A "Night Order" was issued to the ANO-2 operations personnel to remind

them of the guidance contained in the EOPs regarding actions to mitigate potential SG overfill

events. The licensee has indicated that its long term corrective action will be to install hardware

modifications which will allow a single channel to remain in bypass indefinitely with no loss of

safety function. The licensee will install these modifications by the end of refueling outage

2R13 in 1999, and incorporate changes to the Safety Analysis Report (including the FMEA for

dc bus failures) to reflect those modifications and resolve issues discovered during the root

cause evaluation of the condition following that outage.

The preceding examples describe inadequacies in the "design-process," in which the original

FMEA failed to identify and correct potential failure modes In the plant design, and the

'J GIN 97-81 November 24, 1997 independent design verification process failed to detect the FMEA inadequacies. This concern

is addressed in Title 10, Code of Federal Regulations, Part 50, Appendix B, Criterion IlIl,

"Design Control," which stipulates, "Measures shall be established to assure that applicable

regulatory requirements and the design basis, as defined in 50.2 and as specified In the license

application, for those structures, systems, and components to which this appendix applies are

correctly translated into specifications, drawings, procedures, ... components. The design

control measures shall provide for verifying or checking the adequacy of design ....

This information notice requires no specific action or written response. If you have any

questions about the information in this notice, please contact one of the technical contacts listed

below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

a k W. Roe, Acting Director

(Diviion of Reactor Program Management

ice of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

301-415-2974 E-mail: svalnrc.gov

Thomas Koshy, NRR

301-415-1176 E-mail: txk~nrc.gov

Attachment: List of Recently Issued NRC Information Notices

v-/ Attachment

IN 97-81

November 24, 1997 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information

Date of

Notice No.

Subject

Issuance

Issued to

97-80

97-79

Licensee Technical

Specifications

Interpretations

Potential Inconsistency

in the Assessment of

the Radiological Conse- quences of a Main Steam

Line Break Associated

with the Implementation

of Steam Generator Tube

Voltage-Based Repair

Criteria

11/21/97

11/20/97

All holders of OLs for

nuclear power reactors

All holders of OLs for

pressurized-water reactors

implementing a steam

generator tube voltage- based repair criteria in

accordance with the

guidance presented in

Generic Letter 95-05,

'Voltage-Based Repair

Criteria for Westinghouse

Steam Generator Tubes

Affected by Outside

Diameter Stress Corrosion

Cracking,' issued August 3,

1995

97-78

Crediting of Operator

Actions in Place of

Automatic Actions and

Modifications of Operator

Actions, Including Response

Times

10/23/97

All holders of OLs for

nuclear power reactors

except those who have

permanently ceased

operations and have

certified that fuel has

been permanently removed

from the reactor vessel

OL = Operating License

CP = Construction Permit

\\lIN

97-81 November24, 1997 independent design verification process failed to detect the FMEA inadequacies. This concern

is addressed in Title 10, Code of Federal Regulations, Part 50, Appendix B, Criterion IlIl,

"Design Control," which stipulates, "Measures shall be established to assure that applicable

regulatory requirements and the design basis, as defined in 50.2 and as specified in the license

application, for those structures, systems, and components to which this appendix applies are

correctly translated into specifications, drawings, procedures, ... components. The design

control measures shall provide for verifying or checking the adequacy of design ...."

This information notice requires no specific action or written response. If you have any

questions about the Information in this notice, please contact one of the technical contacts listed

below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

original signed by

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

301-415-2974 E-mail: sval

nrc.gov

Thomas Koshy, NRR

301 415-1176 E-mail: txk@nrc.gov

Attachment: List of Recently Issued NRC Information Notices

Tech Editor has reviewed and concurred on 10/1/97

  • SEE PREVIOUS CONCURRENCES

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This information notice requires no specific action or written response. If you have any

questions about the information in this notice, please contact one of the technical contacts listed

below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

301-415-2974 E-mail: sval@nrc.gov

Thomas Koshy, NRR

301-415-1176 E-mail: txk@nrc.gov.

Attachment: List of Recently Issued NRC Information Notices

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Control," which stipulates, "Measures shall be established to assure that applicable regulatory

requirements and the design basis, as defined in 50.2 and as specified in the license

application, for those structures, systems, and components to which this appendix applies are

correctly translated into specifications, drawings, procedures, ... components. The design

control measures shall provide for verifying or checking the adequacy of design .....

This information notice requires no specific action or written response. If you have any

questions about the information in this notice, please contact one of the technical contacts listed

below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

301-415-2974 E-mail: sval@nrc.gov

Thomas Koshy, NRR

301-415-1176 E-mail: txkenrc.gov

Attachment Ust of Recently Issued NRC Information Notices

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  • SEE PREVIOUS CONCURRENCES

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Page 5of 5 independent design verification process failed to detect the FMEA inadequacies. This concern is

addressed in Title 10, Code of Federal Regulations, Part 50, Appendix B, Criterion lii, "Design

Control," which stipulates, "Measures shall be established to assure that applicable regulatory

requirements and the design basis, as defined in 50.2 and as specified in the license

application, for those structures, systems, and components to which this appendix applies are

correctly translated into specifications, drawings, procedures, ... components. The design control

measures shall provide for verifying or checking the adequacy of design ...."

This information notice requires no specific action or written response. If you have any questions

about the information in this notice, please contact one of the technical contacts listed below or

the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

301-415-2974 E-mail: sval

nrc.gov

Thomas Koshy, NRR

301-415-1176 E-mail: txk@nrc.gov

Attachment: List of Recently Issued NRC Information Notices

  • SEE PREVIOUS CONCURRENCES

DOCUMENT NAME: INFORMATION NOTICE (97-103)

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requirements and the design basis, as defined in 50.2 and as specified in the license

application, for those structures, systems, and components to which this appendix applies are

correctly translated into specifications, drawings, procedures, ... components. The design

control measures shall provide for verifying or checking the adequacy of design ...."

This information notice requires no specific action or written response. If you have any

questions about the information in this notice, please contact one of the technical contacts listed

below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

301-415-2974 E-mail: sval nrc.gov

Thomas Koshy, NRR

301-415-1176 E-mail: txk@nrc.gov

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regulatory requirements and the design basis, as defined in 50.2 and as specified in the license

application, for those structures, systems, and components to which this appendix applies are

correctly translated into specifications, drawings, procedures, ... components. The design

control measures shall provide for verifying or checking the adequacy of design ...

This information notice requires no specific action or written response. If you have any

questions about the information in this notice, please contact one of the technical contacts listed

below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

(301)415-2974 E-mail: sval@nrc.com

Thomas Koshy, NRR

(301)415-1176 txk@nrc.com

Attachments: 1. List of Recently Issued NRC Information Notices

DOCUMENT NAME: INFORMATION NOTICE (97-103)

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10/

/97

OFFICIAL RECORD COPY

IN97-xx

October xx, 1997 This information notice requires no specific action or written response. If you have any

questions about the information in this notice, please contact one of the technical contacts listed

below or the appropriate Office of Nuclear Reactor Regulation (NRR) project manager.

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts: S.V. Athavale, NRR

(301)415-2974 E-mail: sval@nrc.com

Thomas Koshy, NRR

(301)415-1176 txk@nrc.com

Attachments: 1. List of Recently Issued NRC Information Notices

DOCUMENT NAME: INFORMATION NOTICE (97-103)

To receive a copy of this document. Indicate In the box:

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DATE

09/ /97

10/

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OFFICIAL RECORD COPY

This information notice requires no specific action or written response.

If

you have any questions about the information in this notice, please contact

one of the technical contacts listed below or the appropriate Office of

Nuclear Reactor Regulation (NRR) project manager.

Jack W. Roe, Acting Director

Division of Reactor Program Management

Office of Nuclear Reactor Regulation

Technical contacts:

S.V. Athavale, NRR

(301)415-2974

Thomas Koshi, NRR

(301) 415-1176 Attachments:

1. List of Recently Issued NRC Information Notices

DOCUMENT NAME:

INFORMATION.NOTICE

(97-103)

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