|
---|
Category:LICENSEE EVENT REPORT (SEE ALSO AO
MONTHYEARML20024J2451994-10-0606 October 1994 LER 94-006-00:on 940907,observed Receipt of Annunciator 12 Charging Pump Overload Trip.Caused by Overheated C Phase Loadside Connection at Mccb.Breaker Was Replaced & Tested. W/941006 Ltr ML20029E4701994-05-12012 May 1994 LER 94-001-00:on 940412,discovered That Total Pressure Offset Constant in Error.Caused by Technician Error. Procedure Will Be Revised to Prevent recurrence.W/940512 Ltr ML20029D7761994-05-0404 May 1994 LER 94-002-00:on 940303,noble Gas Monitor in R-35 Did Not Respond When source-checked During Surveillance.Caused by Component Failure.Corrective Actions:Monitor Repaired & Returned to svc.W/940504 Ltr ML20046C7791993-08-0505 August 1993 LER 93-009-00:on 930715,receipt of Annunciator Charging Pump 12 Overload Trip Observed by CR Operators,Resulting in Unplanned Closure of Containment Isolation Valve.Standby Charging Pump Started Immediately ML20046A9151993-07-26026 July 1993 LER 93-007-01:on 930413,discovered That Valves Required to Mitigate Consequences of Accident Not Included in Section XI ISI & Testing Program.On 930624,identified Six Addl Valve Inappropriately Ommitted from Subj Program.Valves Included ML20046A8931993-07-23023 July 1993 LER 93-008-00:on 930624,observed That Valve CV-31740, Instrument Air to Unit 1 Containment Closed Due to Failure of Coil in Solenoid Operated Pilot Valve.Valve Reopened Locally to Restore Instrument air.W/930723 Ltr ML20044D2181993-05-13013 May 1993 LER 93-002-00:on 930403,containment Isolation Valve Which Controls Reactor Makeup Water to Containment Exceeded Max Time for Closure.On 930413,lockwire & Safety Tag Removed. Caused by Communication Errors.Safety Tag Process Reviewed ML20044D2241993-05-13013 May 1993 LER 93-007-00:on 930413,discovered That Certain Feedwater Valves,Required to Mitigate Consequences of Accident,Not Included in ASME Section XI ISI & Test Program.Caused by Failure to Interpret Requirements.Valves Tested ML20024H2061991-05-23023 May 1991 LER 91-003-00:on 910423,auto-start Occurred of One Train of Auxiliary Bldg Special Ventilation Sys.Cause Unknown.Plant Mod Initiated Removing Unnecessary Wiring That Could Short Monitor module.W/910523 Ltr ML20024G7001991-04-22022 April 1991 LER 91-002-00:on 910323,auto-start of Control Room Special Ventilation Sys Occurred.Caused by Spike on Newly Installed Radiation Monitor.Wiring Changed to Provide Time Delay Feature for Remaining Four modules.W/910422 Ltr ML20028H8491991-01-28028 January 1991 LER 90-012-00:on 901229,control Room Operators Received Annunciation of Reactor Trip.Caused by Rod Control Sys Failures.Failed Cards in Rod Control Sys replaced.W/910128 Ltr ML20028H0461990-09-26026 September 1990 LER 89-018-03:on 891024,automatic Start of Auxiliary Bldg Ventilation Sys Occurred.Caused by Electronic Spike on Radiation Monitor.Radiation Monitor Modules Will Be Replaced by Upgraded Monitor module.W/900927 Ltr ML20043G1971990-06-15015 June 1990 LER 90-006-00:on 900517,electrical Spike on Radiation Monitor R-25 Caused auto-start of Spent Fuel Pool Special Ventilation Sys.Caused by Procedural Inadequacy.Request for Training Issued Re Basics of Procedure writing.W/900615 Ltr ML20043E0601990-06-0404 June 1990 LER 90-005-00:on 900504,control Room Received High Radiation Alarm & Indication of Automatic Start of Spent Fuel Pool Special Exhaust Fan 121 on Two Occasions.Caused by Electrical Spike on Monitor.Modules replaced.W/900604 Ltr ML20043B6041990-05-24024 May 1990 LER 90-004-00:on 900424,discovered That Surveillance Test SP1042, Resistance Temp Detector Bypass Flow Meter Functional Test Not Performed within Required Time Period. Caused by Personnel Error.Test performed.W/900524 Ltr ML20043E3761990-05-18018 May 1990 LER 90-007-00:on 900517,discovered That Several Relays Deenergized & Automatic Start & Loading of Diesel Generator D1 Initiated.Caused by Inadequate Design.Mod Initiated to Install Test points.W/900608 Ltr ML20042F5681990-05-0404 May 1990 LER 89-021-01:on 891212,chlorine Monitors on One Train of Control Room Ventilation Inoperable for More than 11 H. Caused by Personnel Error.Operating Procedure for Chlorine Monitoring Sys Issued & Training provided.W/900504 Ltr ML20042E6811990-04-23023 April 1990 LER 90-003-00:on 900323,automatic Start of Safeguards Cooling Water Pump Occurred Due to Inadequate Procedures. Plant Procedures Revised to Improve Guidance for Detecting Loss of prime.W/900423 Ltr ML20012D4941990-03-19019 March 1990 LER 89-004-01:on 891221,reactor Trips & Loss of Power to Reactor Coolant Pumps Occurred.Caused by Malfunctions in MG Sets,Rod Control Sys & Substation Breaker Control Sys. Voltage Regulator for MG Set replaced.W/900319 Ltr ML20006E8211990-02-20020 February 1990 LER 90-002-00:on 900117,review of Cooldown Data Showed That Cooldown Rate of Pressurizer Exceeded Tech Spec Limit.Caused by Procedure Inadequacy.Procedures Revised to Require Use of Water Space Temp to Find Cooldown rate.W/900220 Ltr ML20006E4581990-02-16016 February 1990 LER 90-001-00:on 900117,technician Mirror Contacted Bare Power Supply Terminal & Shorted Terminal to Ground,Causing Power Supply to Trip & Isolation of Outside Air to Control Room.Exposed Wire Terminal Points covered.W/900216 Ltr ML20006A9721990-01-22022 January 1990 LER 89-004-00:on 891221,unit Tripped & Reactor Coolant Pumps Lost Power.Caused by Faulty Voltage Regulation of One CRD Mechanism motor-generator Set.Regulator for Set Replaced & Tested.On 891226,identical Trip occurred.W/900122 Ltr ML20005G3731990-01-11011 January 1990 LER 89-021-00:on 891211,computer Alarmed Indicating Malfunction of Chlorine Monitors 121 & 122 & Leaving Control Room Ventilation Sys Inoperable for More than 11 H.Caused by Personnel Error.Monitor 122 Returned to normal.W/900111 Ltr ML19351A4681989-12-11011 December 1989 LER 89-020-00:on 891108,17,20,23,1201 & 08,automatic Isolation of Control Room Supply & Exhaust Occurred.Caused by Malfunctions of Chlorine Gas Detectors.Addl Monitors Installed & Actuation Logic modified.W/891211 Ltr ML20005D7071989-11-30030 November 1989 LER 89-018-01:on 891024,25,31 & 1112,control Room Received High Radiation Alarm Which Initiated Automatic Start of Auxiliary Bldg Special Ventilation Sys.Caused by Radiation Monitor Spikes.Monitor Modules replaced.W/891130 Ltr ML19332C6171989-11-22022 November 1989 LER 89-018-00:on 891024,25 & 1112,control Room Received Train a High Radiation Alarm,Initiating Automatic Start of Auxiliary Bldg Special Ventilation Sys.Caused by Spike of Radiation Monitor.Monitor replaced.W/891122 Ltr ML19332C6241989-11-22022 November 1989 LER 89-003-00:on 891023,measured Leakage Rate Exceeded Tech Specs Limit While Performing Surveillance Test Sp 2136. Caused by Wear of Grafoil Packing Due to High Frequency of Door Usage.Test Procedures modified.W/891122 Ltr ML19332C7001989-11-20020 November 1989 LER 89-019-00:on 891025,Train a of Auxiliary Bldg Special Ventilation Sys Started Automatically When Power Mistakenly Turned Off.Caused by Personnel Error.Involved Personnel Counseled.Clarifying Revs Made to procedure.W/891121 Ltr ML19325D4901989-10-16016 October 1989 LER 89-017-00:on 890914,discovered That Present Position of Transfer Switch for Power Supplying Control & Protection Relays for Diesel Generator Does Not Meet Requirements of App R.Caused by Inadequate procedures.W/891016 Ltr ML19325C7491989-10-10010 October 1989 LER 89-016-00:on 890908,control Room Received Train B High Radiation Alarm,Which Initiated Automatic Start of Auxiliary Bldg Special Ventilation Sys.Caused by Spike on Radiation Monitor 2R-30.Monitor Upgrade Being pursued.W/891010 Ltr ML19325C1991989-10-0505 October 1989 LER 89-015-00:on 890905 & 23,special Ventilation Sys of Control Rooms 122 & 121 Actuated Automatically.Caused by False High Chlorine Signal & Broken Chlorine Sensitive Paper Tape,Respectively.Detectors repaired.W/891005 Ltr ML19325C1981989-10-0505 October 1989 LER 89-014-00:on 890905,operations Personnel Recalled That SP1093.1 Performed Two Wks Previously Instead of SP1093.2. Caused by Personnel Error in Selecting Incorrect Procedure. Proper Notifications Made & SP1093.2 performed.W/891005 Ltr ML20028E3301983-01-12012 January 1983 LER 82-029/01T-0:on 821228,tiny through-wall Crack Found in heat-affected Zone of Weld on Safety Injection Supply Line from Boric Acid Storage Tanks.Cause Unknown. Fracture Mechanics Analysis Underway ML20028C2441982-12-30030 December 1982 LER 82-025/03L-0:on 821130,one Steam Flow Channel Differed from Redundant Channels During Power Reduction Due to out- of-calibr Transmitter.Cause Not Known.Transmitter Recalibr & Returned to Svc.Transmitter to Be Replaced If Drift Recurs ML20028C3681982-12-30030 December 1982 Signed LER 82-025/03L-0:on 821130,during Power Reduction,One Steam Flow Channel Differed from Redundant Channels. Transmitter Showed Out of Calibr.Cause Unknown.Transmitter Recalibr.Bistables Placed in Trip During Recalibr ML20028C1651982-12-22022 December 1982 LER 82-024/03L-0:on 821123,diesel Generator D1 Inoperable for Approx 4 Minutes After Lockout of Engine Shutdown Circuit Occurred.Probably Caused by Sticky Action of Speed Switch.Further Exam of Circuitry Will Be Performed ML20028A9761982-11-17017 November 1982 LER 82-021/03L-0:on 821027,following Use in Routine Sampling Procedure SV-33655,hot Leg Loop B Sample Inside Containment Isolation Valve Failed to Remain Closed.Caused by Malfunction of Limit Switch.Switch Replaced ML20051A9561982-05-0707 May 1982 LER 82-006/01T-0:on 820423,during Surveillance Test Sp 1104, Measured Reactor Coolant Boron Concentration Higher than Originally Predicted Value.Caused by Miscalculation of Predicted Worth.Analysis Performed to Monitor Disagreement ML20052B2731982-04-21021 April 1982 LER 82-005/03L-0:on 820322,review of Chemistry Logs Showed That Boric Acid Tank 11 Had Not Been Sampled.Caused by Communication Breakdown.Tank Sampled & Involved Personnel Will Review Rept ML20050A8331982-03-24024 March 1982 LER 82-004/03L-0:on 820226,maint Workman Accidentally Bumped Overspeed Trip Mechanism on Auxiliary Feedwater Pump, Tripping Valve & Making Pump Inoperable.Caused by Personnel Error.Valve Operator Reset ML20042A5101982-03-12012 March 1982 LER 82-003/03L-0:on 820209,during Annual Visual Insp,One Steam Exclusion Control Damper Found Inoperable.Caused by Failure of Drive Gear in Pacific Air Products Damper Model R-35-FS.Gear Replaced ML20049H6061982-02-24024 February 1982 LER 82-001/03L-0:on 820125,one Overpower Delta T Summing Unit Found Out of Spec.Caused by Foxboro Model 66RC-OL Summing Unit Instrument Drift.Device Recalibr.Evaluation Underway ML20049H6841982-02-24024 February 1982 LER 82-002/03L-0:on 820125,one Overpower Delta T Summing Unit Found Out of Spec High.Caused by Instrument Drift. Device Recalibr ML20041B4041982-02-12012 February 1982 Updated LER 81-030/03L-0:on 811211,during Testing,Degraded Voltage Relay 27A1/B25 Found W/Voltage Setpoint Outside Allowable Band.Exact Cause Unknown.Relays Recalibr & Found to Operate Correctly ML20041B3991982-02-12012 February 1982 Updated LER 81-029/03L-0:on 811210,during Surveillance Test of Bus 16 Undervoltage Relays,Error in Disconnecting Test Equipment Resulted in Blown Fuse for A-phase Relays.Fuses Replaced & Normal Power Restored to Bus ML20040A5841982-01-15015 January 1982 LER 81-029/03L-0:on 811210,during Testing of Bus 16 Undervoltage Relays,Error in Disconnecting Test Equipment Resulted in Blown Fuse for a Phase Relays.Fuses Replaced. Undervoltage Relay Tests Will Be Revised ML20040A5671982-01-15015 January 1982 LER 81-030/03L-0:on 811210,degraded Voltage Relay 27A1/B25 Found W/Voltage Setpoint Outside Allowable Band.Causes Being Considered Are Last Calibr Error & Unfamiliarity W/Time Delay Relay Characteristics ML20039E5521981-12-30030 December 1981 LER 81-031/01T-0:on 811216,during Transfer of Spent Fuel in Preparation for Reracking of Pool 2,spent Fuel Assembly Top Nozzle Separated,Causing Assembly to Tip Toward Edge of Pool.Cause Unknown.Fuel Handling Operations Suspended ML20039C2751981-12-18018 December 1981 LER 81-028/03L-0:on 811118 & 1218,bistables 2-PC-431 G & I Found Out of Tolerance.Caused by Defective Potentiometer on 811118.On 811218,leads Were Tightened,Correcting Problem ML20039C2681981-12-16016 December 1981 LER 81-027/03L-0:on 811116,discovered That Pre,Absolute & Charcoal Filter Test Not Done on 11 Shield Bldg Ventilation Sys Replacement on 811112.Caused by Procedural Inadequacies & Poor Communications 1994-05-04
[Table view] Category:RO)
MONTHYEARML20024J2451994-10-0606 October 1994 LER 94-006-00:on 940907,observed Receipt of Annunciator 12 Charging Pump Overload Trip.Caused by Overheated C Phase Loadside Connection at Mccb.Breaker Was Replaced & Tested. W/941006 Ltr ML20029E4701994-05-12012 May 1994 LER 94-001-00:on 940412,discovered That Total Pressure Offset Constant in Error.Caused by Technician Error. Procedure Will Be Revised to Prevent recurrence.W/940512 Ltr ML20029D7761994-05-0404 May 1994 LER 94-002-00:on 940303,noble Gas Monitor in R-35 Did Not Respond When source-checked During Surveillance.Caused by Component Failure.Corrective Actions:Monitor Repaired & Returned to svc.W/940504 Ltr ML20046C7791993-08-0505 August 1993 LER 93-009-00:on 930715,receipt of Annunciator Charging Pump 12 Overload Trip Observed by CR Operators,Resulting in Unplanned Closure of Containment Isolation Valve.Standby Charging Pump Started Immediately ML20046A9151993-07-26026 July 1993 LER 93-007-01:on 930413,discovered That Valves Required to Mitigate Consequences of Accident Not Included in Section XI ISI & Testing Program.On 930624,identified Six Addl Valve Inappropriately Ommitted from Subj Program.Valves Included ML20046A8931993-07-23023 July 1993 LER 93-008-00:on 930624,observed That Valve CV-31740, Instrument Air to Unit 1 Containment Closed Due to Failure of Coil in Solenoid Operated Pilot Valve.Valve Reopened Locally to Restore Instrument air.W/930723 Ltr ML20044D2181993-05-13013 May 1993 LER 93-002-00:on 930403,containment Isolation Valve Which Controls Reactor Makeup Water to Containment Exceeded Max Time for Closure.On 930413,lockwire & Safety Tag Removed. Caused by Communication Errors.Safety Tag Process Reviewed ML20044D2241993-05-13013 May 1993 LER 93-007-00:on 930413,discovered That Certain Feedwater Valves,Required to Mitigate Consequences of Accident,Not Included in ASME Section XI ISI & Test Program.Caused by Failure to Interpret Requirements.Valves Tested ML20024H2061991-05-23023 May 1991 LER 91-003-00:on 910423,auto-start Occurred of One Train of Auxiliary Bldg Special Ventilation Sys.Cause Unknown.Plant Mod Initiated Removing Unnecessary Wiring That Could Short Monitor module.W/910523 Ltr ML20024G7001991-04-22022 April 1991 LER 91-002-00:on 910323,auto-start of Control Room Special Ventilation Sys Occurred.Caused by Spike on Newly Installed Radiation Monitor.Wiring Changed to Provide Time Delay Feature for Remaining Four modules.W/910422 Ltr ML20028H8491991-01-28028 January 1991 LER 90-012-00:on 901229,control Room Operators Received Annunciation of Reactor Trip.Caused by Rod Control Sys Failures.Failed Cards in Rod Control Sys replaced.W/910128 Ltr ML20028H0461990-09-26026 September 1990 LER 89-018-03:on 891024,automatic Start of Auxiliary Bldg Ventilation Sys Occurred.Caused by Electronic Spike on Radiation Monitor.Radiation Monitor Modules Will Be Replaced by Upgraded Monitor module.W/900927 Ltr ML20043G1971990-06-15015 June 1990 LER 90-006-00:on 900517,electrical Spike on Radiation Monitor R-25 Caused auto-start of Spent Fuel Pool Special Ventilation Sys.Caused by Procedural Inadequacy.Request for Training Issued Re Basics of Procedure writing.W/900615 Ltr ML20043E0601990-06-0404 June 1990 LER 90-005-00:on 900504,control Room Received High Radiation Alarm & Indication of Automatic Start of Spent Fuel Pool Special Exhaust Fan 121 on Two Occasions.Caused by Electrical Spike on Monitor.Modules replaced.W/900604 Ltr ML20043B6041990-05-24024 May 1990 LER 90-004-00:on 900424,discovered That Surveillance Test SP1042, Resistance Temp Detector Bypass Flow Meter Functional Test Not Performed within Required Time Period. Caused by Personnel Error.Test performed.W/900524 Ltr ML20043E3761990-05-18018 May 1990 LER 90-007-00:on 900517,discovered That Several Relays Deenergized & Automatic Start & Loading of Diesel Generator D1 Initiated.Caused by Inadequate Design.Mod Initiated to Install Test points.W/900608 Ltr ML20042F5681990-05-0404 May 1990 LER 89-021-01:on 891212,chlorine Monitors on One Train of Control Room Ventilation Inoperable for More than 11 H. Caused by Personnel Error.Operating Procedure for Chlorine Monitoring Sys Issued & Training provided.W/900504 Ltr ML20042E6811990-04-23023 April 1990 LER 90-003-00:on 900323,automatic Start of Safeguards Cooling Water Pump Occurred Due to Inadequate Procedures. Plant Procedures Revised to Improve Guidance for Detecting Loss of prime.W/900423 Ltr ML20012D4941990-03-19019 March 1990 LER 89-004-01:on 891221,reactor Trips & Loss of Power to Reactor Coolant Pumps Occurred.Caused by Malfunctions in MG Sets,Rod Control Sys & Substation Breaker Control Sys. Voltage Regulator for MG Set replaced.W/900319 Ltr ML20006E8211990-02-20020 February 1990 LER 90-002-00:on 900117,review of Cooldown Data Showed That Cooldown Rate of Pressurizer Exceeded Tech Spec Limit.Caused by Procedure Inadequacy.Procedures Revised to Require Use of Water Space Temp to Find Cooldown rate.W/900220 Ltr ML20006E4581990-02-16016 February 1990 LER 90-001-00:on 900117,technician Mirror Contacted Bare Power Supply Terminal & Shorted Terminal to Ground,Causing Power Supply to Trip & Isolation of Outside Air to Control Room.Exposed Wire Terminal Points covered.W/900216 Ltr ML20006A9721990-01-22022 January 1990 LER 89-004-00:on 891221,unit Tripped & Reactor Coolant Pumps Lost Power.Caused by Faulty Voltage Regulation of One CRD Mechanism motor-generator Set.Regulator for Set Replaced & Tested.On 891226,identical Trip occurred.W/900122 Ltr ML20005G3731990-01-11011 January 1990 LER 89-021-00:on 891211,computer Alarmed Indicating Malfunction of Chlorine Monitors 121 & 122 & Leaving Control Room Ventilation Sys Inoperable for More than 11 H.Caused by Personnel Error.Monitor 122 Returned to normal.W/900111 Ltr ML19351A4681989-12-11011 December 1989 LER 89-020-00:on 891108,17,20,23,1201 & 08,automatic Isolation of Control Room Supply & Exhaust Occurred.Caused by Malfunctions of Chlorine Gas Detectors.Addl Monitors Installed & Actuation Logic modified.W/891211 Ltr ML20005D7071989-11-30030 November 1989 LER 89-018-01:on 891024,25,31 & 1112,control Room Received High Radiation Alarm Which Initiated Automatic Start of Auxiliary Bldg Special Ventilation Sys.Caused by Radiation Monitor Spikes.Monitor Modules replaced.W/891130 Ltr ML19332C6171989-11-22022 November 1989 LER 89-018-00:on 891024,25 & 1112,control Room Received Train a High Radiation Alarm,Initiating Automatic Start of Auxiliary Bldg Special Ventilation Sys.Caused by Spike of Radiation Monitor.Monitor replaced.W/891122 Ltr ML19332C6241989-11-22022 November 1989 LER 89-003-00:on 891023,measured Leakage Rate Exceeded Tech Specs Limit While Performing Surveillance Test Sp 2136. Caused by Wear of Grafoil Packing Due to High Frequency of Door Usage.Test Procedures modified.W/891122 Ltr ML19332C7001989-11-20020 November 1989 LER 89-019-00:on 891025,Train a of Auxiliary Bldg Special Ventilation Sys Started Automatically When Power Mistakenly Turned Off.Caused by Personnel Error.Involved Personnel Counseled.Clarifying Revs Made to procedure.W/891121 Ltr ML19325D4901989-10-16016 October 1989 LER 89-017-00:on 890914,discovered That Present Position of Transfer Switch for Power Supplying Control & Protection Relays for Diesel Generator Does Not Meet Requirements of App R.Caused by Inadequate procedures.W/891016 Ltr ML19325C7491989-10-10010 October 1989 LER 89-016-00:on 890908,control Room Received Train B High Radiation Alarm,Which Initiated Automatic Start of Auxiliary Bldg Special Ventilation Sys.Caused by Spike on Radiation Monitor 2R-30.Monitor Upgrade Being pursued.W/891010 Ltr ML19325C1991989-10-0505 October 1989 LER 89-015-00:on 890905 & 23,special Ventilation Sys of Control Rooms 122 & 121 Actuated Automatically.Caused by False High Chlorine Signal & Broken Chlorine Sensitive Paper Tape,Respectively.Detectors repaired.W/891005 Ltr ML19325C1981989-10-0505 October 1989 LER 89-014-00:on 890905,operations Personnel Recalled That SP1093.1 Performed Two Wks Previously Instead of SP1093.2. Caused by Personnel Error in Selecting Incorrect Procedure. Proper Notifications Made & SP1093.2 performed.W/891005 Ltr ML20028E3301983-01-12012 January 1983 LER 82-029/01T-0:on 821228,tiny through-wall Crack Found in heat-affected Zone of Weld on Safety Injection Supply Line from Boric Acid Storage Tanks.Cause Unknown. Fracture Mechanics Analysis Underway ML20028C2441982-12-30030 December 1982 LER 82-025/03L-0:on 821130,one Steam Flow Channel Differed from Redundant Channels During Power Reduction Due to out- of-calibr Transmitter.Cause Not Known.Transmitter Recalibr & Returned to Svc.Transmitter to Be Replaced If Drift Recurs ML20028C3681982-12-30030 December 1982 Signed LER 82-025/03L-0:on 821130,during Power Reduction,One Steam Flow Channel Differed from Redundant Channels. Transmitter Showed Out of Calibr.Cause Unknown.Transmitter Recalibr.Bistables Placed in Trip During Recalibr ML20028C1651982-12-22022 December 1982 LER 82-024/03L-0:on 821123,diesel Generator D1 Inoperable for Approx 4 Minutes After Lockout of Engine Shutdown Circuit Occurred.Probably Caused by Sticky Action of Speed Switch.Further Exam of Circuitry Will Be Performed ML20028A9761982-11-17017 November 1982 LER 82-021/03L-0:on 821027,following Use in Routine Sampling Procedure SV-33655,hot Leg Loop B Sample Inside Containment Isolation Valve Failed to Remain Closed.Caused by Malfunction of Limit Switch.Switch Replaced ML20051A9561982-05-0707 May 1982 LER 82-006/01T-0:on 820423,during Surveillance Test Sp 1104, Measured Reactor Coolant Boron Concentration Higher than Originally Predicted Value.Caused by Miscalculation of Predicted Worth.Analysis Performed to Monitor Disagreement ML20052B2731982-04-21021 April 1982 LER 82-005/03L-0:on 820322,review of Chemistry Logs Showed That Boric Acid Tank 11 Had Not Been Sampled.Caused by Communication Breakdown.Tank Sampled & Involved Personnel Will Review Rept ML20050A8331982-03-24024 March 1982 LER 82-004/03L-0:on 820226,maint Workman Accidentally Bumped Overspeed Trip Mechanism on Auxiliary Feedwater Pump, Tripping Valve & Making Pump Inoperable.Caused by Personnel Error.Valve Operator Reset ML20042A5101982-03-12012 March 1982 LER 82-003/03L-0:on 820209,during Annual Visual Insp,One Steam Exclusion Control Damper Found Inoperable.Caused by Failure of Drive Gear in Pacific Air Products Damper Model R-35-FS.Gear Replaced ML20049H6061982-02-24024 February 1982 LER 82-001/03L-0:on 820125,one Overpower Delta T Summing Unit Found Out of Spec.Caused by Foxboro Model 66RC-OL Summing Unit Instrument Drift.Device Recalibr.Evaluation Underway ML20049H6841982-02-24024 February 1982 LER 82-002/03L-0:on 820125,one Overpower Delta T Summing Unit Found Out of Spec High.Caused by Instrument Drift. Device Recalibr ML20041B4041982-02-12012 February 1982 Updated LER 81-030/03L-0:on 811211,during Testing,Degraded Voltage Relay 27A1/B25 Found W/Voltage Setpoint Outside Allowable Band.Exact Cause Unknown.Relays Recalibr & Found to Operate Correctly ML20041B3991982-02-12012 February 1982 Updated LER 81-029/03L-0:on 811210,during Surveillance Test of Bus 16 Undervoltage Relays,Error in Disconnecting Test Equipment Resulted in Blown Fuse for A-phase Relays.Fuses Replaced & Normal Power Restored to Bus ML20040A5841982-01-15015 January 1982 LER 81-029/03L-0:on 811210,during Testing of Bus 16 Undervoltage Relays,Error in Disconnecting Test Equipment Resulted in Blown Fuse for a Phase Relays.Fuses Replaced. Undervoltage Relay Tests Will Be Revised ML20040A5671982-01-15015 January 1982 LER 81-030/03L-0:on 811210,degraded Voltage Relay 27A1/B25 Found W/Voltage Setpoint Outside Allowable Band.Causes Being Considered Are Last Calibr Error & Unfamiliarity W/Time Delay Relay Characteristics ML20039E5521981-12-30030 December 1981 LER 81-031/01T-0:on 811216,during Transfer of Spent Fuel in Preparation for Reracking of Pool 2,spent Fuel Assembly Top Nozzle Separated,Causing Assembly to Tip Toward Edge of Pool.Cause Unknown.Fuel Handling Operations Suspended ML20039C2751981-12-18018 December 1981 LER 81-028/03L-0:on 811118 & 1218,bistables 2-PC-431 G & I Found Out of Tolerance.Caused by Defective Potentiometer on 811118.On 811218,leads Were Tightened,Correcting Problem ML20039C2681981-12-16016 December 1981 LER 81-027/03L-0:on 811116,discovered That Pre,Absolute & Charcoal Filter Test Not Done on 11 Shield Bldg Ventilation Sys Replacement on 811112.Caused by Procedural Inadequacies & Poor Communications 1994-05-04
[Table view] Category:TEXT-SAFETY REPORT
MONTHYEARML20217G4461999-09-30030 September 1999 Monthly Operating Repts for Sept 1999 for Pingp.With ML20217A9931999-09-30030 September 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data ML20217A1691999-09-22022 September 1999 Part 21 Rept Re Engine Sys,Inc Controllers,Manufactured Between Dec 1997 & May 1999,that May Have Questionable Soldering Workmanship.Caused by Inadequate Personnel Training.Sent Rept to All Nuclear Customers ML20216E7151999-08-31031 August 1999 Monthly Operating Repts for Aug 1999 for Pingp,Units 1 & 2. with ML20211D3981999-08-24024 August 1999 Safety Evaluation Supporting Requested Actions to Licenses DPR-42 & DPR-60,respectively ML20211C2531999-08-0404 August 1999 Unit 1 ISI Summary Rept Interval 3,Period 2 Refueling Outage Dates 990425-990526 Cycle 19 971212-990526 ML20210Q4891999-07-31031 July 1999 Monthly Operating Repts for July 1999 for Pingp,Units 1 & 2. with ML20211B5971999-07-31031 July 1999 Cycle 20 Voltage-Based Repair Criteria 90-Day Rept ML20209J1131999-07-15015 July 1999 Safety Evaluation of Topical Rept NSPNAD-8102,rev 7 Reload Safety Evaluation Methods for Application to PI Units. Rept Acceptable for Referencing in Prairie Island Licensing Actions ML20196H8621999-06-30030 June 1999 NRC Regulatory Assessment & Oversight Pilot Program, Performance Indicator Data, June 1999 Rept ML20209F9811999-06-30030 June 1999 Monthly Operating Repts for June 1999 for Prairie Island Nuclear Generating Plant,Units 1 & 2.With ML20196F4081999-06-23023 June 1999 Revised Pages 71,72 & 298 to Rev 7 of NSPNAD-8102, Prairie Island Nuclear Power Plant Reload Safety Evaluation Methods for Application to PI Units ML20195G5181999-05-31031 May 1999 Monthly Operating Repts for May 1999 for Prairie Island Nuclear Generating Plant,Units 1 & 2.With . Page 3 in Final Rept of Incoming Submittal Was Not Included ML20207B5931999-05-26026 May 1999 SER Accepting Licensee Proposed Alternative to ASME Code for Surface Exam (PT) of Seal Welds on Threaded Caps for Unit 1 Reactor Vessel Head Penetrations for part-length CRDMs ML20196L2501999-05-13013 May 1999 Rev 0 to PINGP Unit 1 COLR Cycle 20 ML20206L6191999-04-30030 April 1999 Monthly Operating Repts for Apr 1999 for Pingp,Units 1 & 2. with ML20205N1081999-03-31031 March 1999 Monthly Operating Repts for Mar 1999 for Pingp,Units 1 & 2. with ML20205Q5101999-03-15015 March 1999 Inservice Insp Summary Rept Interval 3,Period 1 & 2 Refueling Outage Dates 981109-1229 Cycle 19,970327-981229 ML20207J6951999-02-28028 February 1999 Monthly Operating Repts for Feb 1999 for Prairie Island Nuclear Generating Plant ML20202J7711999-02-0404 February 1999 Simulator Certification Rept for Prairie Island Plant Simulation Facility,1998 Annual Rept ML20202G3761999-01-31031 January 1999 Non-proprietary Rev 7 to NSPNAD-8102-NP, Prairie Island Nuclear Power Plant Reload SE Methods for Application to PI Units ML20207L2811999-01-31031 January 1999 Revised Monthly Operating Repts for Jan 1999 for Pingp,Units 1 & 2 ML20202J1731999-01-22022 January 1999 Safety Evaluation Concluding That NSP Proposed Alternative to Surface Exam Requirements of ASME BPV Code for CRD Mechanism Canopy Seal Welds Will Provide Acceptable Level of Quality & Safety ML20206P7861998-12-31031 December 1998 Monthly Operating Repts for Dec 1998 for Prairie Island Nuclear Generating Plant.With ML20205H0561998-12-31031 December 1998 Northern States Power Co 1998 Annual Rept. with ML20198J6441998-12-17017 December 1998 Rev 0 to PINGP COLR Unit 2-Cycle 19 ML20206N2731998-11-30030 November 1998 Monthly Operating Repts for Nov 1998 for Prairie Island Nuclear Generating Plant,Units 1 & 2.With ML20196D7341998-11-20020 November 1998 Third Quarter 1998 & Oct 1998 Data Rept for Prairie Island Isfsi ML20155K6301998-10-31031 October 1998 Monthly Operating Repts for Oct 1998 for Prairie Island Nuclear Generating Plant,Units 1 & 2.With ML20154H4061998-09-30030 September 1998 Monthly Operating Repts for Sept 1998 for Prairie Island Nuclear Generating Plant.With ML20202J7991998-09-30030 September 1998 Non-proprietary Version of Rev 3 to CEN-629-NP, Repair of W Series 44 & 51 SG Tubes Using Leaktight Sleeves,Final Rept ML20198P0571998-09-0303 September 1998 Rev 1 to 95T047, Back-up Compressed Air Supply for Cooling Water Strainer Backwash Valve Actuator ML20153B0761998-08-31031 August 1998 Monthly Operating Repts for Aug 1998 for Prairie Island Nuclear Generating Plant.With ML20237A3961998-08-11011 August 1998 Safety Evaluation on Westinghouse Owners Group Proposed Insp Program for part-length CRDM Housing Issue.Insp Program for Type 309 Welds Inadequate from Statistical Point of View ML20237A8171998-08-0505 August 1998 SER Related to USI A-46 Program GL 87-02 Implementation for Prairie Island Nuclear Generating Plant,Units 1 & 2 ML20236X8531998-07-31031 July 1998 Monthly Operating Repts for July 1998 for Prairie Island Nuclear Generating Plant ML20236R6481998-07-15015 July 1998 Metallurgical Investigation & Root Cause Assessment of Part Length CRDM Housing Motor Tube Cracking at PINGP Unit 2 - Preliminary Summary Rept ML20236R0771998-06-30030 June 1998 Monthly Operating Repts for June 1998 for Prairie Island Nuclear Generating Plant ML20249A5751998-05-31031 May 1998 Monthly Operating Repts for May 1998 for Prairie Island Nuclear Generating Plant ML20247G7011998-05-31031 May 1998 Metallurgical Investigation & Root Cause Assessment of Part Length CRDM Housing Motor Tube Cracking at Prairie Island Nuclear Generating Plant,Unit 2 ML20248M0561998-05-31031 May 1998 Rev 5 to CEN-620-NP, Series 44 & 51 Design SG Tube Repair Using Tube Rerolling Technique ML20247E2671998-05-0505 May 1998 Rev 0 to Pingp,Units 1 & 2,Pressure & Temp Limits Rept (Effective Until 35 Efpy) ML20247G2921998-04-30030 April 1998 Monthly Operating Repts for Apr 1998 for Prairie Island Nuclear Generating Plant ML20217M6901998-04-29029 April 1998 Safety Evaluation Accepting Methodology for Relocation of Reactor Coolant Sys P/T Limit Curves & LTOP Sys Limits Proposed by NSP for Pingp,Units 1 & 2 ML20216C6361998-03-31031 March 1998 Monthly Operating Repts for Mar 1998 for Prairie Nuclear Generating Plant Units 1 & 2 ML20216H0341998-03-31031 March 1998 Cycle-19 Voltage Based TSP Alternate Repair Criteria 90-Day Rept ML20217D2041998-03-13013 March 1998 Rev 1 to 28723-A, Intake Canal Liquefaction Analysis Rept for Pingp,Welch,Mn ML20236P9801998-03-12012 March 1998 Rev 0 to 97FP02-DOC-01, Compliance Review of 10CFR50,App R, Section Iii.O RCP Lube Oil Collection Sys ML20248L3931998-03-10010 March 1998 ISI Summary Rept Interval 3,Period 1 & 2 Refueling Outage Dates 971018-971212 Cycle 18,960303-971212 ML20216D0911998-03-0606 March 1998 Rev 0 to Prairie Island Generating Plant,Units 1 & 2, Pressure & Temp Limits Rept 1999-09-30
[Table view] |
Text
. . !
Northem States Power Company 414 Nicollet Mall l Minneapolis, Minnesota 55401 1927 j Telephone (612) 330-5500 !
I i
May 12, 1994 10 CFR Part 50 l Section 50.73 U S Nuclear Regulatory Commission Attn: Document Control Desk Washington, DC 20555 PRAIRIE ISiAND NUCLEAR GENERATING PLANT Docket Nos. 50-282 License Nos. DPR-42 50-306 DPR-60 Inoperability of one Train of Post-Accident Containment Hydrogen Monitoring r
The Licensee Event Report for this occurrence is attached. In the report, we made one new NRC commitment:
The subject surveillance procedures will be revised to record as-left containment data explicitly, provide technicians better instructions on critical steps, and provide cautions in steps that could corrupt calibration constants.
Please contact us if you require additional information related to.this event. ,
j G), . ; ; ,
trp, Ande o Director Licensing and Management Issues c: Regional Administrator - Region III, NRC NRR Project Manager, NRC Senior Resident Inspector, NRC Kris Sanda, State of Minnesota Attachment
,n-9405180357 940512 PDR ADOCK 05000306
6 KRC FORM 366 U.S. BiUCLEAR REGULATORY CDutSSICN APPROYED BY (MB Wo. 3150-0104 (5 92) EXP!RES 5/31/95 ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECTION REQUEST: 50.0 HRS.
LICENSEE EVENT REPORT (LER) FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNSB 7714), U.S. NUCLEAR REGULATORY COMMISSION, (See reverse for required ruber of digits / characters for each block) WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150 0104), OFFICE OF
[ MANAGEMENT AND BUDGET, WASHINGTON, DC 20503.
FACILITT KAME (1) DOCKET MUMBER (2) PAGE (3)
Prairie Island Nuclear Generating Plant U2 05000 306 1 OF 4 TITLE (4)lnaperability of One Train of Post-Accident Contairacnt Hydrogen Monitoring EVtWT DATE (5) I ER NtMBER (6) REPORT DATE (7) OTHER FACILITIES INVDtVED (8)
SEQUENTIAL REVISION FACILITY NAME DOCKET NUMBER MONTH DAY YEAR YEAR """ ^ "
NUMBER WUMBER Prairie Island U1 05000 282 04 12 94 94 --
01 --
00 05 12 94 0 0 OPERATING THIS REPORT IS SLMiNITTID PURSUANT TO THE Rf0VIRIMENTS OF 10 CFR i: (Check one or more) (11)
MUDE (9)
N 20.402(b) 20.405(c) 50.73(a)(2)(iv) 73.71(b) payg g 20.405(a)(1)(1) 50.36(c)(1) 50.73(a)(2)(v) 73.71(c)
LEVEL (10) 20.405(a)(1)(ii) 50.36(c)(2) 50.73(a)(2)(vil) OTHER 20.405(a)(1)(tii) X 50.73(a)(2)(i) 50.73(a)(2)(vi i i)( A ) (Specif y in 20.405(a)(1)(iv) 30.73(a)(2)(ii) 50.73(a)(2)(viii)(B) ",D*
nd 20.405(a)(1)(v) 50. 73( a)(2)( i i i ) 50.73(a)(2)(x) NRC Form 366A)
LICENSEE CONTACT FOR THIS L ER (12)
NAME TELEPHONE NUMBER (include Area Code)
Arne A Hunstad 612-388-1121 COMPLETE ONE llNE FOR FACH COMPONENT FAllURE OFSCRIBFD IN THIS REPORT (13)
CAUSE SYSTEM COMPOWENT MANUFACTURER CAUSE SYSTEM COMPONENT MANUFACTURER TO S g SUPPlf MTNTAL RFPORT EXPf CTED (14) EXPECTED MONTH DAY YEAR YE S S'JBMISSION No (if yes, com lete EXPECTED SUBMISSION DATE). DATE (15)
ABSTRACT (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines) (16)
On April 12, 1994 an I&C Technician was performing a routine surveillance test of the Unit 2 containment hydrogen monitors. When taking as-found readings, the technician noticed that the containment pressure reading on Train B was significantly out of specification. The calibration constants were read, and it was then discovered that the Total Pressure Offset constant was in error. The technician entered the correct value, as directed by the procedure, and notified the system engineer. At the conclusion of the test, the technician and the system engineer reviewed the procedure and calibration card data. Based on review of previous surveillance data and discussions with several technicians, it was determined that the Train B hydrogen monitor had probably been inoperable ,
since March 15, when the monthly test had last been performed. The '
technician that performed the March 15 test apparently had made an erroneous keystroke while displaying containment data. After the Total Pressure Offset was read, the technician should have pushed the ENTER key to move on to the next calibration constant. Instead, it appears the technician pushed the NEW CONSTANT key inadvertently, and then when the ENTER key was pushed, the incorrect calibration constant was entered. i Procedures will be revised to prevent recurrence. ;
i NRC FORM 366 (5 92)
CRC FORM 366A U.S. C3) CLEAR REEJLATQ3Y CDPMISSICJ APPROVED BY OMB CD. 3150-0104 (5-92) EXPIRES 5/31/95
, ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH THIS INFORMATION COLLECil0N REDUEST: 50.0 HRS.
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH TEXT CONTINUATION (MNBB TM4), U.S. NUCLEAR REGULATORY COMMISSION, WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150-0104), OFFICE OF MANAGEMENT AWD BUDGET, WASHINGTON, DC 20503.
FACILITY kAMF (1) DOCKET NtMBf R (?) LER NAMR (6? PAGE (3)
YEAR SEQUENTIAL REVISION NUMBER HUMBER Prairie Island Unit 2 05000 306 94 __ 91 __ 00 TEXT (if more space is rewired, use additional copies of NRC Form 366A) (17)
EVENT DESCRIPTIOli On April 12, 1994 Unit 2 was at 100% power. An Instrument & Controls Technician was performing routine surveillance procedure SP1226A, Containment Hydrogen Monitor Monthly Test. The procedure verifies that correct calibration constants are being used in the post-accident containment hydrogen monitor computer. When taking as-found readings, the technician noticed that the containment pressure reading on Train B was 42.1 atmospheres, significantly out of specification. A normal reading is 1.0 atmospheres. The as-found data were recorded. The calibration constants were read, and it was then discovered that the Total Pressure Offset constant had a value of 41.0. Comparison of the data against the results of the latest calibration revealed that the offset should have been
-0.0426. The technician entered the correct value, as directed by the procedure, and notified the system engineer. At the conclusion of the test, the technician and the system engineer reviewed the procedure and calibration card data to determine the reason for the incorrect calibration constant.
The vendor was consulted to assist in determining operability of the monitor. The vendor confirmed that an additional 41.0 atm of pressure would be added, offsetting actual measured containment pressure, so that indicated hydrogen concentration would be significantly lower than actual.
Based on a review of previous surveillance data and discussions with several technicians, it was determined that the Train B hydrogen monitor had probably been inoperable since March 15, 1994 when the monthly test had last been performed.
The technician that performed the March 15 test was also interviewed. The last step in the channel test is to verify that containment data are displayed normally. The technician completed this step, but then read the calibration constants again, which is incorrect. After the Total Pressure Offset was read, the technician should have pushed the ENTER key to move on to the next calibration constant. Instead, it appears the technician i pushed the NEW CONSTANT key inadvertently, and then when the ENTER key was l pushed, the incorrect calibration constant was entered. I i
CAUSE OF THE EVENT l The surveillance procedure is deficient in some areas. It is not clear about which data is required to verify operability. It could easily be l misconstrued that verification of calibration data is required in addition l to the containment data. Also, the procedure requires observation but not I
l l
- l I;RC FORM 366A U.S. RTJCLEAR REGULATG2Y CIM(ISSIC;I APPROVED BY CNB C:0. 3150-0104 (5-92) EXPIRES 5/31/95
' ESTIMATED BURDEN PER RESPONSE TO COMPLY WITH
. THIS INFORMATION COLLECTION REQUEST: 50.0 HRS. !
FORWARD COMMENTS REGARDING BURDEN ESTIMATE TO I LICENBEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH l TEXT CONTINUATION (MNBB 7714), U.S. NUCLEAR RECULATORY COMMISSION, WASHINGTON, DC 20555-0001 AND TO THE PAPERWORK REDUuTION PROJECT (31!IO0104), OFFICE OF MANAGEMENT AND BUDCET, WASHINGTON, DC 20503.
FACitITY NAMF (1) DOCETT WlMRTR (?) (ER MlMBER (6? PAGE (3)
YEAR SEQUENTIAL REVISION Prairie island Unit 2 NUMBER NUMBER 05000 306 94 __
oi __ 00 i
TLxi (If mere space is reauired, use additional cocies of WC Form 366A) (17) recording of as-left containment readings. l 1
Calibration data was corrupted when accessed improperly and not checked l afterwards. Accessing the calibration constants followed from a l misunderstanding of the verification requirements. The procedure could !
have prevented the event that caused improper calibration constants to be l introduced had the procedure provided the technician more specific l direction on verification requirements, provided explicit cautions at certain key points in the procedure prior to accessing any calibration data, and recorded as-left containment data.
The installed equipment has some limitations that require careful censideration when maintaining the system. For example, calibration constants cannot be read directly without introducing the possibility of altering them.
ANALYSIS OF THE EVENT The event is reportable pursuant to 10CFR50.73 (a) (2) (1) (B) since one train of post-accident hydrogen monitoring was inoperable for more than 7 days, in violation of Technical Specification 3.15.A.1. Train B of Unit 2 post- l accident hydrogen monitoring was inoperable from March 15 to April 12, l 1994. Train A was operable throughout the period. Unit 1 was unaffected I by this event.
The error in Total Pressure Offset would have caused the hydrogen monitor to read lower percent volume of hydrogen than actual. The error varies with containment pressure, such that the hydrogen concentration read at low I containment pressure would be about 1/40th of actual and at high j containment pressure would be about 1/2 of actual. '
Recalibration of the monitors is required about 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> after the postulated accident. Recalibration would have corrected the error.
Venting of containment gases based on hydrogen concentration does not occur until at least 10 days after the accident. Likewise, operation of the hydrogen recombiners based on hydrogen concentration is not required until several days after the accident. For the above reasons, health and safety of the public was not affected.
CORRECTIVE ACTION The surveillance procedures will be revised to record as-left containment data explicitly, provide technicians better instructions on critical steps, and provide cautions in steps that could corrupt calibration constants.
This event will be reviewed by I&C engineers, supervisors, technicians and
e tRC FORM 346A U.S. 53UCLEAR REQJLATC2T C099t!SSICa APPROVED BY OMB to. 3150-0104 (5 92) EXPIRES 5/31/95
. ESilMATED BURDEN PER RESPONSE TO COMPLY WITH THis INFORMATION COLLECTION REQUEST: 50.0 HRS.
FORWARD COMMENTS REGARDING BURDEN ESilMATE TO LICENSEE EVENT REPORT (LER) THE INFORMATION AND RECORDS MANAGEMENT BRANCH (MNas 7714), u.S. NUCLEAR REGULATORY COMMIS$10N, TEXT CONTINUATION WASHINGTON, DC 20555-0001, AND TO THE PAPERWORK REDUCTION PROJECT (3150 0104), OFFICE OF MANAGEMENT AND BUDCET, WASHINGTON OC 20503.
FACillTY NAME (1) DOCKET NUMBER (2) LER WUMRTR (6? PAGE (3)
YEAR SEQUENTIAL REVISION NUMBER NUMBER Prairic Island Unit 2 4 4 05000 306 94 __ oi __ 00 TEXT (if more space is required, use additional copies of NPC Form 366A) (17) trainers.
l l
FAILED COMPONENT IDENTIFICATION None.
PREVIOUS SIMILAR EVENTS There have been no previous similar events reported at Prairie Island. As i followup to Unit 1 LER 93-003 describing instrument miscalibration, a generic review of I&C activities was done and several procedures were identified for potential enhancements to help prevent recurrence of such events. SP1226A was one of those procedures identified, but revisions had not been fully implemented.
l l
l i
l