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MENORANDUM FOR:
R. J. Msttson, Director TMI-2 Lessons Learned Task Forte FROM:
C. G. Long, Lessons Learned Task-Force Mefeber
SUBJECT:
REVIEW OF LER'S FOR LOSS OF SAFETY FUNCTION CUE TO PERSONNEL ERROR AND DEFECTIVE PROCEDURES (50-320)
In support of the Lessons Leanned Task Force recorrendation 2.2.3, " Revised Limiting Conditions for Operation of Nuclear Power Plants Based Upon Safety System Availability" contained in NUREG-OS78 dated July,1979, a review of the available LER's was perfonned. This review was intended to identify those instances in which personnel error or defective procedures cause,d a loss of safety system function.
The LER data printout was obtained covering 70 operating reactor units for the period of Noveter,1969 to May,1979. The total number of LER's reported fer the two subject categories was 2640. The review of these data on personnel and procedural error indicated a total of 139 LER's had resulted in a loss of r.
safety function.
A general breakdown of the type of loss and the number of occurrences is pre-sented below. Enclosed is a listing of the plants reporting losses of safety function by personnel or procedural error and the number per year. Note that these were twenty one plants with no apparent losses of this typa in the 10 year period.
Type:
Total.'(umber rWR BWR (cM_, -
Loss of Safety Cooling Systems 29 20 9
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Loss of Auxiliary Feedwater Systems 7
7 0
~ io) Loss of Emergency Power Systems 16 10 6
Loss of Primary Containment Integrity 40 24 16 r N) 8 Loss of Secondary Containment Integrity 6
26 4
22 GEg ' loss of Part of Reactor Protec. System 6
3 3
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Zq.41scellaneous 15 12 3
T ' 5'S TOTAL 139 80 59 F,
The data used to develop this information are only approximate and have several 6
qualifications that shculd be kept in mind.
First, not all losses of safety func-
' ion were hecessariTy reported in LERs. Secono the deview cone here was general are,an e.
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and based solely on the LER printout information.
It should also be noted i
that some of the safety function losses included in the above tabulation only
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lasted for a few minutes before correstive action was taken. These short time losses of safety function are, however, indicative of recurring losses
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- that did not appear to be corrected by simply instructing operations personnel' on the seriousness of the mistake.
f Based on this general review of the LER data, approximately 5% of the per- '
sonnel errors and d3fective procedures reported over a ten year period resulted in a complete loss of a safety function.
i C. G. Long, Mecter TMI-2 Lessons Leanned T23k Force
Enclosure:
As stated cc:
H. Denton E. Case R. Minogue V. Stello i
S. Levine i
D. Vassallo i
F. Schroeder D. Eisenhut D. Ross K. Cornell R. Ireland PLgRTask Force l
i DISTRIBUTION:
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MEMORANDUM FORT R. J. Mattson, Ofrector i
TMI-2 Lassons Learned Task Force' f
l FROM:
C. G. Long, Lessons. Learned Task Forc/e Member r
SUBJECT:
REVIEW OF LER'S FOR LOSS OF. SAFETY F%NCTION DUE TO PERSONNEL. ERROR AND DEFECTIVE PROCEDURES (50-320) r
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In support of the Lessons Leanned Task Force rec /oncendation 2.2.3, " Revised Limiting Conditions for Operation of Nuclear Power Plants Based Upon Safety System Availability" contained in NUREG-0578, dated July,,1979, a review of the ava41able LER's was perfanned. This review was limited to personnel error or defective procedures that caused a loss'of safety system function.
The LER da'ta printout was obtained cove ng 70 operating reactor units for the period of November,1969 to May,1979/ The total number of LER's reported for the two subject categories was 2640./.The review of these data indicated a total of 137 LER's had resulted inA loss of a safety function.
A generai kreakdown of the type.
loss and the number of occurrences is pre-I sented below. Enclosed is a 1 ' ting of the plants reporting losses and the number per year.
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l Loss of Sefety Cooling S stems 29 20 9
i Loss of Auxiliary Fe ter Systems 7
7 0
Loss of Emergency Pcwef Systems 16 10 6
Loss of Pri.wery Con nment Integrity
/.0 24 16
_,(c=0; Loss of Secondary C tainment Integrity 26 4
22 TN Loss of Part of R tor Protec. System 6
3 3
c c75 rM Miscellaneous 16 12, 3
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TOTAL lit 80 57 N ?) d-c~7. a: ~ ) The data review was general and based salely on the printout information.
t Sme of the safety function losses included in the above tabulation only lasted CM L] are,a few minutes due to corrective action being taken.
for These short time losses tw however, indicative of recccurring losses that did not appear to be cor-rected by simply instructing the plant personnel on the seriousness of the loss.
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l Therefore, based on this general review of the LER da,, approximtaly 5%
l of the personnel errors and defective procedures r rted over a ten year period resulted in a Toss of a safety function.
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C. G. L g, Member THI-2 hssons Learned Task Forca l
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