ML19340E751

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Preliminary Rept, Evaluation of Emergency Procedures for AR Nuclear 1
ML19340E751
Person / Time
Site: Arkansas Nuclear 
Issue date: 12/29/1980
From:
XYZYX INFORMATION CORP.
To:
Shared Package
ML19340E750 List:
References
CON-NRC-03-80-18, CON-NRC-3-80-18 S231C.80.21, NUDOCS 8101150592
Download: ML19340E751 (25)


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O EVALUATION OF EMERGENCY PROCEDURES FOR ARKANSAS NUCLEAR ONE PRELIMINARY REPORT 29 December 1980 Preoared for Nuclear Regulatory Commission 7920 Norfolk Avenue Bethesde, Maryland 20014 Prepared by k

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TABLE OF CONTENTS SECTION PAGE 1

BASIS FOR EVALUATION OF EMERGENCY PROCEDURES 1

Sets of Evaluation Criteria 1

Rationale for Presumption of Need for Procedural Detail 2

2 SPECIFIC CRITERIA 4

3 EVALUATION OF SPECIFIC EMERGENCY PROCEDURES

. 11 Overview.

. 12 Checklist 13 Discussion of Negative Comments 19 4

LIMITATIONS, CONCLUSIONS, AND RECOMMENDATIONS 21 Limitations 21 Conclusions 21 Recommendations 22 i

l 11 5231C.80.21

1 I

SECTION 1 BASIS FOR EVALUATION OF EMERGENCY PROCEDURES SETS OF EVALUATION CRITERIA There are four basic sets of properties that determine the ad-equacy of an emergency procedure.

They are:

completeness and accuracy, presentation style, level of detail, and administra-tive control.

Completeness and accuracy are technical properties.

They re-fer to the extent to which required actions are covered with-out errors of omission, sequence, or detail fact.

Evaluation of these properties is outside the scope of the present ef-fort.

Completeness and accuracy must be checked by personnel f amiliar with the specific characteristics of the object system.

Presentation style is a human factors property that can be evaluated without knowledge of the object system.

Presen-tation style involves factors that affect the operator's comprehension of the message being delivered.

Those factors are based on established principles of information transfer that apply to all procedures of any kind.

Presentation style is covered in this evaluation.

Level of detail refers to the~ degree of guidance provided beyond the identification of essential actions.

Such detail normally is expressed in terms of "how-to" steps and point locations.

The need for "how-to" and point location data is absolute.

There is no way the operator can functica without them.

However, that need is sometimes satisfied by the fact that the operator already holds the data in his memory.

Where he does, detailed procedures are of limited use (except in training).

Where he does not, detailed procedures are essen-tial.

In this evaluation, the latter condition is presumed to exist.

The rationale for that presumption is summarized later in the discussion.

Administrative control refers to other properties of impor-tance to the procedure user.

It includes provisions for:

ac~

cess, denotation of identity and revision status, and verifi-cation of completed work by the user.

Those aspects of admin-istrative control are covered by this evaluation.

In same plants, administrative control is also used to govern the pro-cedure development process.

That aspect is not covered here.

The procedure development process is extremely important but its evaluation lies beyond the scope of the present study.

1 S231C.80.21

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RATIONALE FOR PRESUMPTION OF NEED FOR PROCEDURAL DETAIL A presumption has been stated that nuclear power plant oper-ators confronted with an emergency involving loss of coolant need procedures that tell them not only what to do but how to do it.

Further, the procedure must indicate the location of each required control and indicator.

The rationale for that presumption is based on the personal experience of the author and ample evidence provided by Swain and Guttman in a recent report for the NRC.

That report is the Handbook of Human Reliability Analysis With Emphasis on Nuclear Power Plant Applications (NUREG/CR-1278).

The rationale is summarized below.

1. The LOCA task is relatively long in terms of the number of actions required.

Some actions lie in arbitrary se-quences.

Others are of a diagnostic nature, requiring operator judgement.

2.

Proper execution of the task is not self-evident in the physical structure of the hardware.

That is, the comple-tion of one action typically furnishes no clue regarding the action next required.

3. The task is accompanied by a level of stress high enough to disrupt human behavior.

Such disruption tends to in-crease the likelihood of operator crrors.

4. Some operator errors are recoverable; others are not.

Recoverable errors carry in-process time penalties.

Non-recoverable errors involve much graver consequences af-fecting plant integrity.

5. Each operator comes to the job with enough training to assure that he understands the object system.
Moreover, during that training, the operator receives enough prac-tice to assure that he can correctly perform this par-ticular task.

However, in the months and years following basic training, operator skills relative to this task can be expected to decay, if further practice is not received on a periodic basis.

That is, the operator will gradual-ly forget what to do and how to do it.

Sufficient prac-tice typically has not been provided in the past.

6. The ability of the operator to carry out this task effec-tively will be further impeded if the control panels are not marked to help him locate key instruments quickly and accurately.

Adequate panel markings have not been pro-vided for in the past.

2 S231C.80.21

7.

In view pf these circumstances, the most defensible posi-tion to take with regard to LOCA procedures is to require that they be designed for use under worst-case condi-tions.

That is, operators will feel the stress, will be out of practice, and will have to work at poorly marked control panels.

Therefore, they must have procedures able to supply all the information they need.

That means what to do, how to do it, and where to do it.

3 S231C.80.21

SECTION 2 SPECIFIC CRITERIA Specific criteria for evaluating a given set of LOCA proce-dures are presented here in four parts.

All are in the form of checklists.

The first three check).ists correspond to the three properties discussed ? ? ? _. le t i

,resentation style, level of detail, and administraties control.

The fourth checklist provides for a walk-thecc7b of the procedures.

All four checklists are designed to obtain "yes" answers for acceptable conditions and."no" answers for conditions that are not acceptable.

In actual use, each checklist is accom-panied by an explanation and/or illustration of every "no" answer.

Most questions can be answered by reference to the proce-dures themselves.

These questions nye marked DOCUMENT.

Some require direct contact with the plant.

These questions are marked SITE.

Most of the questions are straightforward in nature and re-quire no explanation, except for Questions 6 and 7 on Check-list II.

Questions 6 and 7 provide an opportunity to verify by inspection the condition of the control panels and the practice schedule.

The answers to these questions can be used to help determine the urgency of the need for step-l level instructions and control / indicator location data in the LOCA procedures.

Checklist IV provides one final opportunity to gauge the adequacy of the LOCA procedures within the context of the t

i existir.g operator skill levels and control panel design.

In l

applying Checklist IV, it is important to observe all the stated precautions.

Otherwise, an erroneous conclusion might be drawn regarding procedure quality.

?

I I

d S231C.80.21

EMERGENCY IAOCEDURE HUMAN FACTORS CHECKLIST I.

PRESENIATION STYLE INFO SOURCE ITEM COMMENT DOCUMENT 1.

Are approximately 90% or more of the instructions written in short, concise, identifiable stepe (as opposed to paragraphs)?

DOCUMENT 2.

Evaluate the complexity of the ac-tion instructions by determining the average number of actions (verbs) called out per step. Base estimate on a sample of 20% of the steps or, if the sample size is less than 10, use all steps.

Is the average number of actions per step 1.5 or less?

DOCUMENT 3.

Where a decision must be made based on more than two variables, is the information organized to support the decision?

DOCUMENT 4'.

If precautions apply to the performance of specific steps or series of steps, are they always placed immediately ahead of the step (s) to which they apply?

DOCUMENT 5.

Are command statements kept out of precautions and explanations?

DOCUMENT 6.

If equipment is operating outside the range specified by the proce-dure, is the operator told what action to take?

DOCUMENT 7.

Are graphs, charts, and tables ad-equate for readability and inter-polation or extraction of values?

5

i EMERGENCY PROCEDURE HIDfAN FACTORS CHECKLIST l

i I.

PRESENTATION STTLE (continued)

INFO SOURCI ITEM C000GUIT DOCIMENT 8.

If worksheets are needed to facilitate some actions, are spaces provided for recording all data and processing them (performing additions, multi-plications, etc.)?

DOctMENT 9.

If more than one person is re-quir ed to perform the procedure, is t.te procedure written to one

" primary" user; that is, is it clear from the way that instruc-tions are written that one person is responsible for coordinating the activity?

SITE

10. Are references to external pro-cedures limited to situations where it would be inconvenient for the operator to have the entire (referenced) instruction reitera-ted within this procedure?

DOCIMENT

11. Are externally referenced proce-dures listed at the beginning of the procedure?

6

EMERGENCY PROCEDURE HUMAN FACTORS CHECKLIST II.

LEVEL OF DETAIL INFO SOURG ITEM COMMENT DOCLHENT 1.

Are actions expressed at the step level? That is, are they driven by verbs (e.g., open, close, ad-just) against specific controls and indicators?

DOCLHENT 2.

Where actions require the use of controls, are specific positions given?

DOCLHENT 3.

Where actions require the use of indicators, are specific values given?

DOCLEENT 4.

Are control / indicator panel locations given?

SITE 5.

Is the nomenclature used in che procedure identical to that dis-played on the panels, controls, and indicators?

SITE 6.

Are indicator values called out in the procedure expressed in the l

same units as are shown on the indicators?

SITE 7.

Are all control panels properly marked to support this procedure?

SITE 8.

Is every operator required to practice this procedure under simulated emergency conditions at least once per month?

7

EMERGENCT PROCEDURE HGfAN FACTORS CHECILIST III. AIMINISTRATIVE CONTROLS INFO SOURCE ITEM C(30ENT SITE 1.

Is an emergency procedure manual located in the control room and accessible by all operators?

DoctMENT 2.

Is the title of the primary IDCA procedure referenced to an observable emergency condition?

SITE 3.

Are the LOCA procedures easily located within the manual?

DOCUMENT 4.

Does each page provide the follow-ing identification information?

4.1 Procedure number and/or title 4.2 Date of issue 4.3 Revision number 4.4 Page number DOCLHENT 5.

Is the last page of the procedure clearly identifiable by marking; e.g.,

Page of

Final Page?

SITE 6.

Does the procedure have a unique and permanently assigned number?

Ihat is, if the procedure becomes deleted, will the number be re-tired rather than reassigned?

SITE 7.

If this is a temporary procedure, is it clearly marked with the expiration date?

SITE 8.

Are personnel prevented from taking the LOCA procedures out of the control roomi SITE 9.

Are documents referenced by the I4CA procedures easily located in an emergency?

l 8

EMERGENCY PROCEDURE HUMAN FACTORS CHECKLIST III. ADMINISTRATIVE CONTROLS (continued)

INFO SOURCE ITEM COMMENT DOCLMENT

10. Does the procedure provide for verification and signoff of actions?

DOCLMENT

11. If yes, is every step signed off or initialed?

SITE

12. If yes, are the verifications pre-dominantly perfor:ned by persons other than those performing the action?

I t

l 9

1

EMERGENCY PROCEDURE HUMAN FACTORS CHECKLIST IV.

OPERATIONAL TEST OF LOCA PROCEDURES (SITE)

Plan a walk-through of the IDCA procedures under simulated conditions of use.

Observe the following precautions:

a.

Employ a Reactor Operator selected from a group having the least experience at the plant involved.

b.

Employ a Senior Reactor Operator selected from a group having the least experience in that capacity.

c.

Postulate a plant situation known to represent IACA conditions, but do not tell the RO or SRO in advance what it is.

d.

Plan for the operator to verbalize each step.

Conduct the walk-through under close observation, COMMENT while collecting answers to the questions listed below.

1.

L..n the procedure be performed in the sequence it is written?

2.

Can the operator locate and identify all controls and indicators referred to in the instructions?

3.

Where general rather than specific instruc-tions are provided, can the operator explain in detail how to perform each general instruction?

4.

Can the operator perform the procedure with-out obtaining additional information or assistance from persons or documents not specified by the procedure?

10

SECTION 3 EVALUATION OF SPECIFIC EMERGENCY PROCEDURES Emergency procedure guidelines from Arkansas have been par-tially evaluated, using the criteria presented in Section 2.

The guidelines evaluated were produced by Babcock and Wil-cox.

The guidelines were issued in July of 1980.

The complete evaluation calls for examination of the pro-cedures themselves and for observation of various factors at the plant site.

Thus far, only tne guidelines have been re-viewed.

A visit to the plant site and a review of the actu-al procedures is tentatively scheduled for January 1981.

Part 1, Procedural Guidelines, of Abnormal Transient Opera-ting. Guidelines (ATOG) was used for this evaluation.

The results of the review are expressed in terms of an annotated checklist and a brief discussion of negative comments.

A summary page appears at the beginning of the review.

G e

e 11 S231C.80.21

EMERGENCY PROCEDURES HUMAN FACTORS CHECKLIST Plant M IM Procedure No. [8E p.//) Title

[p. //)

p. //)

Review Deee /2/,2c/70 Reviever / [aqt/Sc44//

Revision OVERVIEW YES NO TOTAL QUANIITY QUANIITY ITEMS I.

PRESENTATION STYLE Document Items 10 b

/

Site Items 1

Total Items 11 II.

EVEL OF DETAIL Document Items 4

2/Ao

/,2,3,+f Site Items 4

Total Items 8

III. AIMINISTRATIVE CONTROLS s

Document Items 8

lUIO f

oi WI~f'3, j

b, //

Site Items 7

Total Items 15 IV.

OPERATIONAL TEST Document Items O

Site Items 4

Total Items 4

12

l EMERGENCY PROCEDURE HUMAN FACTORS CHECILIST I.

PRESENTA710N STYLE INFO SOURCE ITEM COMMENT DOCUMENT 1.

Are approximately 90% or more of the instructions written in short, concise, identifiable steps (as opposed to paragraphs)?

[U DOC 12ENT 2.

Evaluate the complexity of the ac-tion inntructions by determining the average number of actions (verbs) called out per step. Base estimate on a sample of 20% of the steps or, if the sample size is less than 10, use all steps.

Is the average number of actions per step 1.5 or less?

yM DOCUMENT 3.

Where a decision must be made based on more than two variables, is the information organized to support the decision?

DOCUMENT 4.

If precautions apply to the performance of specific steps or series of steps, are they always placed immediately ahead of the step (s) to which they apply?

W DOCEMENT 5.

Are command statements kept out of precautions and explanations?

y DOCUMENT 6.

If equipment is operating outside the range specified by the proce-dure, is the operator told what action to take?

[M DOCUMENT 7.

Are graphs, charts, and tables ad-equate for readability and ir.ter-polation or extraction of values?

-)w 13

EMERGENCY PROCEDURE HUMAN FACTORS CHECKLIST I.

PRESENIATION STYLE (continued)

INFO SOURCE ITEM COMMENT DOCUMENT 8.

If worksheets are needed to facilitate some actions, are spaces provided for recording all data and processing them (performing additions, multi-plications, etc.)?

DOCUMENT 9.

If more than one person is re-quired to perform the procedure, is the procedure written to one

" primary" user; that is, is it clear from the way that instruc-tions are written that one person is responsible for coordinating the activity?

~

~

SITE

10. Are references to external pro-cedures limited to situations where it would be inconveniene for the operator to have the entire (referenced) instruction reitera-ted within this procedure?

DOCUMENT

11. Are externally referenced proce-dures listed at the beginning of D

the procedure?

14 4.

EMERGENCY PROCEDURE HUMAN FACTORS CHECKLIST II.

LEVEL OF DETAIL INFO SOURCE ITEM C010ENT DOCUMENT 1.

Are actions expressed at the step level? That is, are they driven by verbs (e.g., open, close, ad-just) against specific controls and indicators?

Doct: MENT 2.

Where actions require the use of controls, are specific positions given?

DOCI: MENT 3.

Where actions require the use of indicators, are specific values given?

DOCL%NT 4.

Are control / indicator panel locations given?

g SITE 5.

Is the nomenclature used in the procedure identical to that dis-played on the panels, controls, and indicatorc?

SITE 6.

Are indicator values called out in the procedure expressed in the same units as are shown on the indicators?

SITE 7.

Are all control panels properly marked to support this procedure?

SITE 8.

Is every operator required to practice this procedure under simulated emergency conditions at least once per month?

15 4

DERGENCY PROCEDURE HUMAN FACTORS CHECKLIS1 III. ADMINISTRATIVE CONTROLS INFO SOURCE ITEM COMMENT SITE 1.

Is an emergency procedure manual located in the control room and accessible by all operators?

DOCDENT 2.

Is the title of the primary IDCA procedure referenced to an observable emergency condition?

w SITE 3.

Are the LOCA procedures easily located within the manual?

DOCUMENT 4.

Does each page provide the follow-ing identification information?

4.1 Procedure number and/or title 40 4.2 Date of issue fw 4.3 Revision number fp 4.4 Page number es DOCQiENT 5.

Is the last page of the procedure clearly identifiable by marking; e.g.,

Page of

Final Page?

fgo SITE 6.

Does the procedure have a unique and permanently assigned number?

Ihat is, if the procedure becomes deleted, will the number be re-tired rather than reassigned?

SITE 7.

If this is a temporary procedure, is it clearly marked with the expiration date?

SITE 8.

Are personnel prevented from taking the IDCA procedures out of the control room?

SITE 9.

Are documents referenced by the i

l IDCA procedures easily located in an emergency?

16

EMERGENCY PROCEDURE HUMAN FACTORS CHECKLIST III. ADMINISTRATIVE CONTROLS (continued)

INFO SOURCE ITEM COMMENT DOCLMENT

10. Does the procedure provide for verification and signoff of y

actions?

DOCLKENT

11. If yes, is every step signed off 9

or initialed?

SITE

12. If yes, are the verifications pre-dominantly performed by persons other than those performing the action?

l l

l l

t I

i 17

EMERGENCY PROCEDURE HUMAN FACTORS CHECELIST IV.

OPERATIONAL TEST OF LOCA PROCEDURES (SITE)

Plan a walk-through of the LOCA procedures under simulated conditions of use.

Observe the foll.owing precautions:

a.

Employ a Reactor Operator selected from a group having the least experience at the plant involved.

b.

Employ a Senior Reactor Operator selected from a group having the least experience in that capacity.

c.

Postulate a plant situation known to represent IDCA conditions, but do not tell the RO or SRO in advance what it is.

d.

Plan for the operator to verbalize each step.

Conduct the walk-through under close observation, C09 TENT while collecting answers to the questions listed below.

1.

Can the procedure be performed in the sequence it is written?

2.

Can the operator locate and identify all controls and indicators referred to in the instructions?

i l

3.

Where general rather than specific instruc-tions are provided, can the operator explain in detail how to perform each general instruction?

4.

Can the operator perform the procedure with-out obtaining additional information or assistance from persons or documents not specified by the procedure?

4 18

DISCUSSION OF NEGATIVE COMMENTS ON ARKANSAS PROCEDURAL GUIDELINES I.

PRESENTATION STYLE Item 3:

Where a decision must be made based on more than two variables, the information is not always organ-ized to support such a decision.

In some cases, decision criteria are scattered and difficult to locate.

An example is the separation of decision information in Section II, Step 7.0, Pages 3, 4,

and 5.

Item 4:

Cautions and notes should be placed immed iately ahead of the actions to which they apply.

Any other location incurs the risk of their being read too early or too late for most effective use.

An example of a misplaced note is shown below from Section II, Step 7.0, Page 4.

This note follows the applicable actions.

NOTE:

All bypass and feedwater valves are func-tional from the control room hand-auto stations.

Feed the "A" OTSG only enough --

feedwater to maintain its pressure equal to "B"

OTSG.

Maintain the plant stable until NNI power is restored.

Item 5:

Cautions and notes should NEVER be used to deliver command data.

Any intended action or decision must be presented as a separate numbered statement to attract the operator's attention.

An example of command data in a note is found in the example cited above in Item 4.

Item 7:

Procedures of ten include graphs, diagrams, and l

charts to aid the operator.

Unfortunately, print l

may be so small and quality of reproduction so poor that the illustration is practically illegible.

Shading used to highlight procedures often obliter-ates headings which presumably have been included for context.

An example of an inadequate diagram is found in Section III B, Steps 3.13 to 3.15, Page 15.

Item 9:

Some steps appear to require that several actions be performed concurrently.

Such steps are not ori-ented to a primary user and do not indicate respon-sib.ility for coordination of activities.

Item 11: Externally referenced procedures are not listed at the beginning of each section.

19 S231C.80.21

II.

LEVEL OF DETAIL Item 1:

Although some of the actions are expressed as di-rect commands against specific controls and indi-cators, this is rarely the case.

An example is given below from Section III C, Step 6.5, Page 24.

6.5 A problem in the feed water control system is indicated (over f eed ing).

Station manage-ment needs tc decide whether or not a cool-down is rec.. red.

If there are other ab-normal symptoms, treat them per the applic-able section of this procedure.

If there are not abnormal symptoms, this procedure is complete.

Item 2:

As indicated in Item 1, above, specific controls are rarely given.

Where controls are mentioned, exact positions for the controls are generally not indicated.

The verb " select" is often used where its meaning is unclear.

Item 3:

Specific values for indicators are rarely prov ided.

Item 4:

Control / indicator panel locations are not given.

III.

ADMINISTRATIVE CONTROLS Item 2:

The procedure titles do not refer to observable emergency conditions.

Item 4.1: Titles are provided only at the beginnings of sections.

Procedure numbers are provided only on tabulated dividers.

4.2: The date of issue is indicated only by the dated signatures on the first page of the guidelines.

4.3: Revision numbers are nowhere indicated in the guidelines.

Item 5:

Pages are marked for the purpose of assuring the reader that he has (or does not have) the complete set.

The final pages of the procedures evaluated are not clearly marked.

Item 11:

While some steps provide for verification and signoff of actions, such provisions are not made for all steps.

20 S231C.80.21

SECTION 4 LIMITATIONS, CONCLUSIONS, AND RECOMMENDATIONS LIMITATIONS This evaluation is subject to the following limitations:

1.

This evaluation does NOT address procedural completeness or accuracy.

Evaluation of those properties requires knowledge of the object system.

2.

This evaluation provides for but has not yet addressed SITE items.

There are 16 questions that cannot be an-swered without observation of conditions at the plant itself.

This will be accomplished at a site visit ten-tatively scheduled for January 1981.

3.

This evaluation addresses DOCUMENT items only.

It poses 22 questions regarding procedural presentation style, level of detail, and administrative controls.

4.

In identifying kinds of deficiencies, no ef fort was made to specify individual instances within kind.

5.

All deficiencies noted are considered to be correctable prior to active use of the procedures.

6.

This document evaluation is based on the procedural guidelines provided by Babcock and Wilson.

A complete evaluation requires a review of the actual procedures from the plant.

CONCLUSIONS The evaluation resulted in the following conclusions:

1.

The guidelines were found to be acceptable on six of the 22 document characteristics examined.

2.

The guidelines were found to be deficient on 16 of the 22 document characteristics examined.

3.

The deficiencies f all into three categories, as follows:

o Presentation Style 6 kinds e

Level of Detail 4 kinds e

Administrative Controls 6 kinds 21 S231C.80.21

4.

Presentation style deficiencies concern multiple-variable decisions; placement and content of cautions and notes; legibility of graphs and charts; indication of a primary user; and listing of referenced procedures.

5.

Level of detail deficiencies concern specificity of ac-tions, control positions, and indicator values; and con-trol / indicator panel location data.

6.

Administrative control deficiencies concern titles of procedures, page identification data, and provisions for verification.

RECOMMENDATIONS The following recommendations are presented in pursuit of effective emergency procedures at Arkansas Nuclear One.

(I-3) on actions where decisions must be made based on more than two variables, reorganize the copy so as to make it clearer.

Use a tabular format, linking desired actions or step references to specific indications or groups of indications.

Number sub-steps clearly.

(I-4)

Place all caution and note messages immedi-ately ahead of the steps to which they apply.

(I-5)

Remove all command statements from caution and note messages.

Where operator actions are required, provide command steps.

(I-7)

Provide clear, legible graphs and charts to aid the operator.

(I-9)

Where necessary, indicate the need for more than one operator and provide directions for partitioning the work among them.

(I-ll)

Whenever a procedure requires the use of other procedures, provide a list of these other procedures up front.

(II-1)

Express all actions at the step level, i.e.,

as direct command verbs against specific controls and indicators.

(II-2)

Always provide specific control positions.

(II-3)

Always provide specific indicator values.

22 S231C.80.21-

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(II-4)

Show the panel location of controls and in-dicators referred to in the procedure.

(III-2)

Provide procedure titles that clearly refer-ence an observable emergency condition.

(III-4)

Provide the following information on eve:y pag e :

e procedure number and/or title e

date of issue e

revision number (III-5)

Provide a method of clearly identifying the final page of each procedure.

Consider marking each page as Page of (III-ll)

Provide a method of verifying all operator actions.

2.

Extend the evaluation to cover procedural characteris-tics observable only at the plant site.

3.

Revise the procedures as indicated by the results of the plant site review.

1 23

~S231C.80.21

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