ML19325D499

LER 89-027-00:on 890915,preheaters Did Not Start Because Air Flow Permissive Was Not Made & Cross Connect Dampers Were Closed & Tagged & Ventilation Sys Train a Remained Logged Inoperable.Caused by Design deficiency.W/891016 Ltr

ML19325D499
Person / Time
Site:	McGuire
Issue date:	10/16/1989
From:	Mcconnell T, Sipe A DUKE POWER CO.
To:	NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-89-027, LER-89-27, NUDOCS 8910240267
Download: ML19325D499 (11)

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(704) 575 4ogy McGuart Nuclear Station

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DUKEPOWER 1

October 16, 1989 l

U.S. Nuclear Regulatory Commission I Document Control Desk j Washington, D.C. 20555 1 1

Subject:

McGuire Nuclear Station Unit 1 and 2 i Docket No. 50-369 Licensee Event Report 369/89-27 Gentlemen l Pursuant to 10 CFR 50.73 Sections (a)(1) and (d), attached is Licensee Event Report 369/89-27 concerning the inoperability of the Annulus Ventilation System. [

This report is being submitted in accordance with 10 CFR 50.73(a)(2)(v) and t (a)(2)(i). This event is considered to be of no significance with respect to the  !

health and ssfety of the public. .

t Very truly yours,  ;

A WYvO T.L. McConnell l t

I DVE/ADJ/cb1 i

Attac'iment  ;

xc Mr. S.D. Ebneter American Nuclear Insurers  !

Administrator, Region II c/o Dottie Sherman, ANI Library  !

U.S. Nuclear Regulatory Commission The Fxchange, Suit 245 ,

101 Marietta St., NW, Suite 2900 270 Farmington Avenue  ;

Atlanta, GA 30323 Farmington, CT 06032 i L  !

j INPO Records Center Mr. Darl licod l Suite 1500 U.S. Nuclear Regulatory Cotaission '

i 1100 circle 75 Parkway Office of Nuclear Reactor Regulation Atlanta, GA 30339 Washington, D.C. 20555 i

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t M&M Nuclear Consultants Mr. P.K. Van Doorn 1221 Avenue of the Americas NRC Resident Inspector New York, h"t 10020 McGuire Nuclear Station i

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't bxc: B.W. Bline l A.S. Daughtridge l R.C. Tutrell i R.L. '.111 1 R.M. Glover (CNS)

T.D. Curtis (ONS) ,

P.R. Herran i S.S. Kilborn (W)  !

S.E. LeRoy  !

R.E. Lopez-Ibanez J.J. Maher  :

R.O. Sharpe (MNS) l G.B. Swindlehurst'  ;

K.D. Thomas  !

L.E. Weaver 4

R.L. Weber J.D. Wylie (PSD)

J.W. Willis QA Tech. Services NRC Coordinator (EC 12/55) l MC-815-04 (20) I i

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"' The Aunulus Ventilation System Vas Inoperable Because Of A Design Deficiency, A J Manaaement Deficiency And Inappropriate Actions t vtWT Daf t ill LOR.ettiADIA @ htPOa t DATE <Fi OtMt m S ACILifitG IWVOLVID .06 68 Q*y*,'Q wogem Day glam e stative hawas DO;a t t h.w s t e si MONTu Day vtam vlam h'h McGuire, Unit 2 o16tol01 0 13 , 7 t o 0l 9 1l 5 89 8l9 0 l 2j7 0l0 1l 0 1l6 8l 9 ois,o,o,o, , ,

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able. COCE l Alan Sipe, Chairman, McGuire Safety Review Group 7,0,4 8,7; 5, ,4, l B,3 i COMPLif t Okt LINE FOR 4 ACM ComeP0hthf SalLuht DitCnieto i% TMit 8tPORT (138 .

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During performance testing of the Annulus Ventilation System (VE) on September 15, 1989, the preheaters did not start because the air flow permissive was not made.

The cross connect dampers were closed and tagged and the Unit 1 VE Train A remained l logged inoperable. Performance personnel tested the Unit 2 VE system and determined that the same problem existed. The Unit 2 VE Train A was logged inoperable and the cross conne.ct dampers were closed and tagged. Subsequently,

Design Engineering personnel evaluated the problem and determined that the VE system would be considered conditionally oparable if a lead was lifted on the differential pressure switches. This event ia, a

signed c,uses of Design Deficiency, Inappropriate Action and Management Deficiency. Unit I was in Mode 1, Power Operation, at 100 percent power and Unit 2 was in Mode 3, Hot Stendby, at the time of this incident. On September 18, 1989 during implementation.of McGuire Exempt Variation Notice (MEVN) 1078, Unit 1 entered Technical Specification 3.0.3 when both trains of the VE system became inoperable. The MEVN was implemented on the Unit 2 VE Train B, and Train B was restored to operability. This event is assigned a cause of Inappropriate Action resulting from deficient communication.

Unit I was in Mode 1, Power Operation, at 100 percent power and Unit 2 was in Mode 2, Startup, at the time of entry into Technical Specifit.ation 3.0.3.

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Background

The VE system [EIIStVD) serves to produce and maintain a negative pressure in the j Containment Annulus following a Loss of Coolant Accident (LOCA), minimize the  ;

release of radioisotopes, and provide long-term fission product removal capability l 1

by decay and filtration. The system consists of two 100 percent capacity trains of j equipment and is actuated by 2 of 4 high-high containment pressure signals.

The VE filter [E1IS:FLT) trains are each equipped with demisters and electric preheaters. The demisters and preheaters are installed to limit the relative  ;

humidity of the air entering the filters to below 70 percent to keep the charcoal l in a dried condition, conservatively assuming the entering air is at 100 percent relative humidity. ,

The preheaters are designed to run continuously while the fans [EIIS: FAN) are '

running. Both trains of VE are started automatically by the Solid State Protection System (SSPS) on a 3 psig signal.

• Procedure PT/1,2/A/4450/03A, Annulus Ventilation System Train A Operability Test, ,

and procedure PT/1,2/A/4450/03B, Annulus Ventilation System Train B Operability Test, are required to be performed once every 31 days. The purpose of these procedures is to demonstrate operability of each train of the VE system. These procedures are performed by Operations personnel.

Procedure PT/1/A/4450/03C, Annulus Ventilation System Performance Test, is required to be performed once every 18 months. The purpose of this procedure is to verify  :

proper operation of the VE system to maintain a negative pressure in the annulus '

region between the Containment Vessel and the Reactor Building, and to verify leakage integrity of the Annulus barriers. This procedure is performed by Performance personnel.

Procedure PT/1/A/4450/03D, Annulus Filter Train Heaters Dissipation Test, is required to be performed every 18 months. The purpose of the test is to verify the annulus filter train heaters [EIIS:HTR) dissipate the proper power. This test had  !

been included in the Annulus Ventilation System Performance Test. It was separated e into a separate procedure in December of 1987. Performance personnel also perform '

this test.

Procedure OP/1/A/6450/02, Annulus Ventilation System, defines the operation of the VE system.  ;

As a result of an event on December 2,1987 whf ch was caused by the surveillance '

testing program being inadequate te positively verify operability, the Failed

< Surveillance Analysis Program was developed by Performance personnel. The Failed ,

' Surveillance Analysis Program was adopted as a station requirement. Each technical section has their own customized version to fulfill the station requirements. The purpose of this program was to ensure that any surveillance test affecting equipment operability which fails will be followed by a reevaluation of the y*ou ues .v.s . m ,,,,m ,,, w e

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l surveillance interval. The Failed Surveillance Analysis Program was fully  !

implemented in October 1988 by the Operations (OPS), Performance, Mechanical  :

Maintenanu, Instrument and Electrical (IAE), Chemistry and Radiation Protection  :

sections. l Solon pressure switches [EIIS:PS), Catalogt.e number PSIDW, are used in the Auxiliary Building Ventilation System (VA) (EIIS:VF], the Control Area Ventil; tion "

, System (VC) [EIIS:VI), the Diesel Building Ventilation System (VD) [EIIS:VJ) and I the VE system. In the VE system, this type of pressure switch is used as the l differential pressure switch for the carbon bed. The VE differential pressure i switches are identified by Anstrument numbers IMVEPS5180, IMVEPS5190, 2MVEPS$180 ,

and 2MVEPS5190.

l Technical Specification 3.6.1.8 requires that two independent Annulus Ventilation l Systems shall be operable in Mode 1 (Power Operation), Mode 2 (Startup), Mode 3 ,

• I (Hot Standby) and Mode 4 (Hot Shutdown).

Technical Specification 3.0.3 states th t when a Limiting Condition of Operation is not met, except as provided in associated Action Statements, within one hour action must be initiated to place the affected units in a mode in which the specification does not apply.

Description of Event on September 15, 1989, Performance personnel began the Annulus Filter Train Heaters Dissipation Test. At 0850 that day, Unit 1 VE Train A was declart ' and Ic gged -

inoperable for the test. VE Fan IA was started in accordance with tr.c procedure, but the preheaters did not activate. Performance personnel thought the pressure

switches which measure the differential pressure (DP) across the carbon filters i (and give a preheater start permissive) may be out of calibration and checked the i DP. The DP was 0.4 inches water gauge (in.wg) on VE Train A and 0.4 in.wg on VE Train B. A DP of 0.5 in.wg gives the air flow permissive to activate the preheaters.

While monitoring the differential pressure, Performance personnel noted that the  !

cross connect dampers between VE Train A and VE Train B were open. (This is the normal operating alignment.) The Annulus Filter Train Heaters Dissipation Test did  ;

not require isolating the cross connect dampers [EIIS:DMP). Subsequently, Performance personnel wrote a procedure change to require closing the cross connect daropers to perform the procedure and decided to write a Problem Investigation Report (PIR) to have the setpoint for the pressure switch changed. During the approval' process for the procedure change, Performance personnel and the OPS Euperintendent discussed the problem. The OPS Superintendent requested that the Performance personnel contact Design Engineering (DE) personnel concerning the ,

problem. The' procedure change was never implemented for Unit 1. The procedure change was implemented for Unit 2 to allow troubleshooting and data collection for ,

DE persortnel.

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The PIR was forwarded to DE personnel for evaluation on September 15, 1989. DE personnel determined that the VE system would be considered conditionally operable i if the preheater differential pressure switches were jumpered out of service. l At 1405 on September 15, 1989, a notification was made to the NRC as required by i procedure RP/0/A/5700/10, NRC Immediate Notification Requirements. The Unit 2 VE system was tested and the determination was made at 1550 that the same problem -

existed. At 1605, Unit 2 VE train A was declared inoperable. The VE Train A cross connect damper was closed and red tagged.

Work requests 96983, 96984, 96985, and 96986 were written on September 15, 1989 to implement MEVNs 1663 and 1694 which addressed changing the setpoint of the pressure .

switches to a lower setting. IAE personnel began work under work request 96983 on the Unit 2 VE Train A. The pressure switches were calibrated to the new settings 1 according to MEVN 1663. The preheaters did not energize. IAE personnel lowered the pressure switches setpoint a second time. Performance personnel tested the preheaters. They energized approximately one minute after the fan started.  ;

Performance personnel notified DE personnel. DE personnel determined that this was an unacceptable delay for the preheaters to energize. The decision was made at this time to delete the function of the pressure switches. This modification would ,

result in the preheaters energizing on a fan start rather than energizing on a fan start and the actuation of the pressure switch. McGuire Nuclear Production r Variation Notices (MPVNs) 1077 and 1078 were written on September 16, 1989 to supersede MEVNs 1663 and 1694 for Unit 2 and Unit 1, respectively.

IAE personnel implemented MPVN 1077 for the Unit 2 VE Train A. OPS personnel verified that the preheaters energized by starting the fan. The preheater -

energized and functioned properly. At 1650 on September 15, 1989, the Unit 2 VE 6 Train A was declared operable. At the same time, the Unit 2 VE Train B was declared inoperable for implementation of MPVN 1077 under work request 96984. IAE personnel implemented the changes and worked with OPS personnel to complete the functional verification. At 1740, the Unit 2 VE Train B was declared operable.  ;

On September 18, 1989, IAE personnel went to the Control Room to obtain clearance i to begin work under work request 96986. This work request would implement MPVN 1078 for the Unit 1 VE Train B. IAE Technician A discussed the work to be done with' Assistant Shift Supervisor A. Assistant Shift Supervisor A gave clearance to >

begin work,.and declared the Unit 1 VE Train B inoperable at 1615. Subsequently,  ;

IAE personnel contacted the Control Room and informed Assistant Shift Supervisor A '

that by allowing IAE personnel to remove the differential pressure switches from the preheater circuit, both trains of VE vere functionally inoperable. With both trains of VE inoperable, Technical Specification 3.0.3 was entered for Unit 1 at 1

1615. 1 IAE personnel implemented the changes required by MPVN 1078, and worked with OPS l personnel to complete the functional verification. At 1655, the Unit 1 VE Train B was declared operable, and Unit I was logged out of Technical Cpecification 3.0.3.

IAE personnel proceeded to implement MPVN 1078 under work request 96985 on the Unit 1 VE Train A. The changes were made and IAE personnel worked with OPS personnel to '

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Conclusion The event resulting in the preheater not starting because of the M fferential pressure air flow permissive not being made is assigned a cause :i thsign  ;

Deficiency because the wrong setpoint for the differential prer m - W tch was selected. The setpoint was selected based on available informatP" n t' time, f

This event is clso asiigned a cause of Inappropriate Action resulting in no action being taken when required because of a lack of attention to detail. In March of 1983, work was performed under work requests 84608 and 84609. The wo M involved calibrating pressure switches 2MVEPS5180 and 2MVEPSS190. The pressure switches were set to 0.5 in.wg as specified, but operations specifications co.uld not be ,

achieved. The saitches were reset to 0.4 in.wg (2MVEPS5180) and 0.38 in.wg '

(2MVEPSS190). As documented on the work requests, Performance Engineer A was to notify DE personnel of thiP setpoint change. Performance Engineer A stated that he ,

vaguely remembered this sin.ation, but apparently failed to follow up on the problem. A second Inappropriate Action resulting in no action being taken when required becuse of a lack of attention to detail is also assigned to this event.

IAE General Supervisor A failed to follow up to ensure the setpoint change was adequately documented prior to mproving and closing out the work requests. This occurred in 1983 and personnel recollections are vague. Mitigating circumstances that may have centributed to these inappropriat actions could not be identified during this investigation.

l This event is also assigned a cause of Mana. , . Deficiency resulting from deficient procedure review and maintenance. In November 1983, changes were incorporated in the VE System Operability Test procedures for Unit 1 and Unit 2.

The changes added steps to the procedures to close the crose connect dampers. The reason given for the change was as follows:

" Prevent bypass flou through opposite train which prevents preheaters from operating due to low flow."

The problem sith the preheaters not energizing because of low flou was apparently identified, but the only action taken that could be found during this itivestigativa was the procedure changes.

During the investigstion of this event, the work request history for differential prr sure switches, IMVEPS5180, IMVEPS5:.90, 2MVEPS5180 and 2MVEPSS190, was researched. Eighteen preventative maintenance (PM) work regt.ests were reviewed f or the time period from July 1985 through May 1989. The as found setting for the

, pressure switch in eleven of the eighteen cases was out of calibration. ~

"enteen repair work requests for the time period from December 1982 to September a d9 were eviewed. Eleven of these worx requests were completed in 1987, 1988, or 1989.

Fourteen of the sc- ' teen work requests described problems with the preheaterc nom energizing. Ten L. ..ae fourteen problems resulted because the pressure switch wA out of calibrathn.

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1 In July 1988, Maintenance Engineering Services (MES) personnel performed a Failed Surveillaa.ce Analysir for pressure switch IMVEPS5180 when the switch was found out of calibration during work performed under work request 135093. Six previous work requests dating bacx to August 1985 for the pressure switch were reviewed. Tive of the six work requests documented that the pressure switch was found out of l calibration. Based on this information, MES personnel changed the preventative maintenance frequency from twelve months to eight months. In addition, work request 68230 was written to replace the pressure switch. The basis for this action was that this pressure switch had not been replaced since the failures began in 1985. A second Failed Surveillance Analysis was conducted in December 1988 on pressure switch INVEPS5180 when it was discovered that the switch was out of calibration. Work request 68230 to replace the switch had not been completed at the time of this failure. MES persontel added a step to the work request to have

'the pressure switch returned to MES so that at could be sent to a testing facility.

The work request was completed on March 7, 1989. The switch was not sent to the, testing facility; however, repeatability tests on the switch were conducted by MES personnel. The results were inconclusive.

MES personnel also performed a Failed Surveillance Analysis for pressure switch 1MVEPS5190 in July 1988 when the setpoint was found out of tolerance. Action was taken to decrease the preventative maintenance frequency from 12 months to eight months. In addition, work request 68304 was written to replace the prest,ure switch.

, In .uguat 1989, OPS personnel performed a failure analysis on procedure i

PT/1/A/4450/03A, Annulus Ventilation System Train A operability Test, after the preheaters failed to energize during performince of the test. Operations

Management Proaedure 1-4 outlines the requitad analysis for failed periodic tects.

l The guidance concerning Surveillance / Equipment History states:

1

" Review past surveillance history or equipirent histoty (whichever is appropriate) over a period of the last 10 curveillances or 2 years whichever is shorter."

OPS personnel based the review on completed periodic operah 'ity tests for VE Train A for the previous two years. No documented failures were identified; therefore, OPS personnel determined that a change in the test frequency was not required.

In 1989, MES personnel began performing a review of Solon pressure switches. There

, have been recurring drift problems with these switches which are used in several ventilation systems (VA, VC, VD, and VE) at McGuire. During this review, PIR 0-M89-0096 was written by MES personnel in April 1989. 'lhe PIR addressed a high rate of out of calibration occurrences for Solon pressure switches. The PIR was assignei to DE personnel for evalu tion. DE personnel evaluated the problem and eluded that there were no appropriately qualified replacement switches suited rb 'entilation system application. DE personnel made recommendations for two

/ jotaible alternative solutions. The PIR was reassigned to MES personnel to evaluate the DE response. If MES personnel determine that leaving the Solen pressure switches in plata is not acceptable, DE personnel recommended that a design study be initiated by the Nuclear Production Department. In addition, MES grosu seen n.e. m,sm ao

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personnel initiated Station Problem Report (SPR) 2770 in August, 1989, which described the problem with pressure switches 1MVEPS5180, IM?EPS5190, 2MVEPS5180 and 2MVEPS5190. The proposed resolution was to lower the setpoint of the switches.  !

MEVNs 1663 and 1694 were written to implement SPR 2770. As previously discussed in  !

the description of the event, MEVNs 1663 and 1694 were superseded by MPVNs 1077 and  ;

1078.

l During the investigation, a possible procedure weakness was identified in procedure  ;

PT/1/A/4450/03D, Annulus Filter Train Heaters Dissipation Test. The procedure does not include a prerequisite system condition which specifies VE system alignment for  ;

the test. The procedure could be enhanced by adding a prerequisite system condition for VE system alignment. The VE System Expert will evaluate the Annulus Filter Train Heaters Dissipation Test and incorporate enhancements as needed.

Performance personnel stated that they did not remember how the VE system was aligned for the heater dissipation tests performed prior to this event. g A cause of Inappropriate Action resulting from deficient communication is assigned to the event resulting in Unit 1 entering Technical Specification 3.0.3. Assistant Shif t Supervisor A stated that his impression of the work to be done was to place a jumper across the pressure switch which would not make VE Train B inoperable. The actual work involved lifting a lead which functionally made tne Unit 1 VE Train B inoperable. The Unit 1 VE Train A was already inoperable and had been since September 15, 1989, when the problea with the VE preheaters was discovered.

! Assistant Shift Supervisor A stated that he was aware that the Unit 1 VE Train A was inoperable when he gave IAE Technician A parmission to begin work on the Unit 1 VE Train B. I/.E Technician A stated that he was not aware that the Unit 1 VE Train A was inoperable during the time he was discussing the work to be done with l Assistant Shif t Supervisor A. This investigation did not. identify any mitigating l circumstances resulting from human factors problews that contcibuted to the l

inappropriate actions.

A review of the McGuire LER data base for the previous twelve months revealed one i

other event involving a TS violation for the VE system caused by a Design Deficiency. This event, detailed in LEP 369/89-21 involved deficiencies in the temperature-induced difference in the pressure gradients inside and outside the Annulus. The corrective actions were specific to the event and would not have prevented this event from occurring. This event is considered recurring.

The McGuire LER data base was also searched for the previous 12 months for events where TS 3.0.3 was entered. One event, detailed in LER 369/89-01, involved entry lato TS 3.0.3 for the Control Room Ventilation System with a contributing cause of inapproprir.ce action resulting from deficient communications. however, the deficient communications resulted from misunderstood written instructions rather than misunderstood verbal communicati. a. This event is not considered recurring.

As a rest or other events involving Ventilation System problems caused by Design

' Deficiencies, the problem of Technical Specification violations caused by Design Deficiencies 'n general is considered to be recurring.

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This event is reoortable to the Nuclear Plant Reliability Data System (NPRDS) because pressure switch 2MVEPS5180 was found out of calibration during l implementation of MEVN 1664. McGuire has previously reported one failure of a p.easure switch used d.n this application in the VE system to NPRDS.

There were no personnel injuries, radiation overexposures, or releases of radioactive material as a result of this incident.

CORRECTIVE ACTIONS: '

Immediate:

For Event of September 15, 1989:

1) A procedure change was written for procedures PT/1,2/A/4450/03D, Annul.us Filter Train Heaters Dissipation Test, to require that the cross conne'ct dampers betw'en VE Train A and B be closed.

2) The Unit 1 VE Train A was declared inoperable, and the VE Train A cross connect damper was closed and tagged.

For Event of September 18, 1989:

1) MPVN 1078 was implemented for the Unit 1 VE Train B, and VE Train B was .

declared operable.

Subsequent: >

l For Event of September 15, 1989:

1) Performance personnel tested the Unit 2 VE system to determine if the same problem existed for Unit 2.

2) The Unit 2 VE Train A was declared inoperable, and the VE Train A cross connect damper was closed and tagged.

3) Work requests 96983, 96984, 96985, and 96986 were written to implement MEVNs 1663 and 1694.

4) MEVNs 1663 and 1694 were superseded by MPVNs 1777 and 1778.

5) Work requests 96983, 96994, 96985, and 96986.were completed and MPVNs 1077 and 1078 were implemented.

For Event of September 18, I?89- '

Thic event was discussed with the Operations personnel involved.

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'." LICENSEE EVTNT REPORT (LER) TEXT CONTINUATION ueRovio ou No. mo-om

, , smRes. enven FACILif v NAME tu DOCR4T NUtdSSR 62) LBRNURASSR W #AOS (31 vtan 88 g g ab QV,8y McGuire Nuclear Station, Unit 1 0 l6 l0 lo lo l3 l 6l 9 8l9 -

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0l0 0l9 0F 0 l9 texw . = wc e am wnn 2 Planned: 1) DE personnel will further evaluate the correctise actions taken to 'I determine if the operation and long term reliability of the VE system can be better enhanced by other alternatives. l

2) The VE System Expert will evaluate procedure PT/1/A/4450/03D, l Annulus Filter Train Heaters Dissipation Test, and incorporate appropriate enhancements as needed relative to system alignment.

3) Operations personnel will review and incorporate appropriate changes ,

with respect to correct damper position into procedure  !

PT/1,2/A/4450/03A, Annulus Ventilation System Tr in A Operability )

Test, and procedure PT/1,2/A/4450/03B, Annulus Ventilation System Train B Operability Test. These changes will be incorporated into  ;

each procedure prior to the next scheduled operability test.

4) This event will be covered in an OPS Shift Supervisors meeting. The importance of clear communications will be stressed.

5) Applicable portions of this event will be covered with appropriate IAE personnel. ,

l SAFETY ANALYSIS:

The Operability Evaluation concluded that the VE system is conditionally operable provided that the function of differential pressure switches is deleted. In addition to the differential pressure switches, there are other preheater and fire safeties provided. The preheater also receives a permissive cignal from the associated VE fan. The differential pressure switch acts as a , safety to protect the heater itself. To address the concern of overheating resulting from low flow across the preheater, there are high temperature alarms and fire alarms downstream of the heater which are .st at 220 degrees-F and 325 degrees-F, respectively. In addition to the high temperature safety switches, low filter train flow (below 6400 CFM) is indicated on the main control board. These safeties provide protection to the heater and filter train, in addition to identifying abnormal operation.

If the preheaters had failed to energize under accident conditions, carbon filter performance may have become degraded which could have resulted in higher radioactive releases through the unit vent. Partial filter fculing is assumed to occur in the accident analytis. Such fouling would result in an inc ease in differential pressure across the filter, which may have been sufficient to energize the heaters. Even if the heaters remained deenergized throughout the event (no credit taken for operator action to energize the heaters), the resulting dose consequences would have remaired within 10CFR100 limits.

The health and safety of the public were not affected by this event.

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