ML20058N738
| ML20058N738 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek |
| Issue date: | 12/17/1993 |
| From: | Carns N WOLF CREEK NUCLEAR OPERATING CORP. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| WM-93-0176, WM-93-176, NUDOCS 9312220233 | |
| Download: ML20058N738 (13) | |
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WsLF CREEK
' NUCLEAR OPERATING CORPORATION i
k Ned S Buzr Carns December 17, 1993 i
President anc Cruef Executwe officer
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U. S. Nuclear Regulatory Commission ATTN: Document Control Desk l
Mail Station P1-137
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Washington, D.
C. 20555 l
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Reference:
Letter dated November 19, 1993, from A.
B. Beach, NRC, to N.
S.
Carns, WCNOC i
Subject:
Docket No.
50-482:
Reply to Notices of Violation 482/9327-01, 482/9327-02, 482/9327-03, 482/9327-04 and 482/9327-05 Gentlemen:
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Attached is Wolf Creek Nuclear Operating Corporation's (WCNOC) Reply to Notices of Violation 482/9327-01, 482/9327-02, 482/9327-03, 482/9327-04 and 482/9327-05 which were documented in the Reference (NRC Inspection Report 50-452/93-27).
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Violation 482/9327-01 concerned personnel failure to position and - verify that the actual valve positions for boric acid filter inlet and outlet 3
valves reflected that required by the reach rod position.
Violation f
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482/9327-02 concerned personnel failure to correctly immobilize temporary l
equipment having rollers and wheels.
Violation 482/9327-03 concerned two 7
l examples of WC;OC's failure to correctly control scaffolding erected j
l adjacent to safety-related equipment.
Violation 482/9327-04 concerned l
personnel that were observed performing work under Work Request 02815-93
'l without first obtaining the Shift Supervisors permission.
Violation 182/9327-05 concerned WCNOC's failure to complete corrective actions to i
prevent recurrence documented in WC40C Licensee Event Report 93-003-00.
WCNOC understands that the above violations indicate the necessity to improve behavior in utilizing a questioning attitude and placing emphasis on consistently paying attention to detail for our varicus work activities.
Personnel must effectively use good self-checking technngues, be attentive to detail and have procedures which provide effective and clear guidance.
l To assi in this effort, WCNOC has established a questioning attitude for I
the daily management meetinge that focuses on plant operations and has l
temporarily placed seasoned managers on shift to provide guidance to personnel and to improve personnel performance by re-enforcing management's expectations, ensuring the use of self-checking, attention-to-detail and procedural adherence. Additionally, as part of the action items identified from the Performance Enhancement Program, WC;OC is currently upgrading l
l procedures which affect quality / safety.
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l 9312220233 931217 C
'O Box 411/ Burlington, KS (4839 / Phone: (310) 364 8831 l
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j ADOCK0500g2 e oue omrtun,tgwr u we.vtT
WM 93-0176 Page 2 Of 2 If you have any questions regarding these matters please contact me at (313) 364-8831 extension 4000 or Mr. K. J. Moles at extension 4565.
Very truly yours
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.Neil S. Carns President and Chief Executive Officer NSC/jan Attachment cc:
J.
L. Milhoan (NRC), w/a G. A.
Pick (NRC), w/a W.
D. Reckley (NRC), w/a L. A.
Yandell (NRC), w/a l
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Attachment to WM 93-0176 l
Page 1 of 11 l
l Reply to Notices of Violation 482/9327-01, 482/9327-02, 482/9327-03, j
482/9327-04 and 482/9327-05 Violation 482/9327-01:
Personnel failed to position and verify that the actual valve positions for boric acid filter inlet and outlet valves reflected that required by the reach rod position.
"Inadeauate Clearance Order Imolementation j
Technical Specification 6.8.1.a states that written procedures shall be l
established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2,
dated l
February 1978.
Regulatory Guide 1.33, Appendix A,
Item 1.c, requires administrative procedures for equipment control (e.g.,
locking and tagging).
This is accomplished, in part, by Procedure ADM 02-100,
" Clearance Order Procedure," Revision 27.
Procedure ADM 02-100, Step 6.14, specified that the valve should be checked to ensure that the reach rod reflects the actual valve position.
j Contrary to the above, on September 21, 1993, the licensee determined that personnel failed to position and verify that the actual valve positions for boric acid filter inlet and outlet valves reflected the required reach rod position."
J Admission of Violation:
i Wolf Creek Nuclear Operating Corporation (WCNOC) agrees that a violation of Technical Specification (TS) 6.8.1.a occurred when Operations personnel failed to position and verify that the actual valve positions for boric l
acid filter inlet and outlet valves reflected the required reach rod position.
Upon self-identification of this problem the inlet and outlet i
valves were placed in the required position.
Reason for Violaticn:
j Clearance Order 93-1825-BG had been revised to include isolating and j
bypassing the boric acid filter, and a trouble alarm (boric acid flow deviation alarm) was expected whenever automatic make-up to the Volume Control Tank occurred.
Therefore, when Control Room Operators noted that l
automacic make-up to the Volume Control Tank had occurred without the receipt of the alarm, a review of the clearance order and the system line up was performed.
As a result of this review, it was determined that the Boric Acid Filter Inlet and Outlet Isolation Valves BG-V149 and BG-V152 were approximately one-quarter turn open.
Based on review of the applicable documentation and on interviews with Operations personnel the root cause for this violation was determined to be a failure to follow procedures. The Clearance Order procedure, ADM 02-100, Revision 27,
" Clearance Order," and Operations Standing Order No.
1, Revision 22, " Valve Setup and Operation", states that whenever a valve with i
a reach rod is part of a clearance, the valve will be verified locally (not by the reach rod only).
The Safety Tagger stated he did this, but the f
Attachment to WM 93-0176 Page 2 of 11 Verifier stated he looked at reach rod indication only.
Contributing to the problem was the lack of teamwork and the lack of appropriate use of the i
Stop, Think, Act and Review (STAR) Program (WCNOC's Self-Checking Program) by the Operating Personnel (both licensed and non-licensed) involved in the I
clearance.
Corrective Steos Taken and Results Achieved j
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bubsequent tc the Control Room Operator's review of the clearance order and syctem line up, the bypass valves were opened and the boric acid filter isolation valves locally closed.
i The Manager Operations and the Supervisor Levrations held a-meeting with
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the Shift Supervisor involved in this event to discuss the importance of teamwork and emphasized the use of WCNOC's Self-Checking Program.
l Performance Improvement Request # OP 93-1056 was issued as Operations Required Reading on October 26, 1993.
The Manager Operations held a meeting with all of the Shift Supervisors and
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Supervising Operators on October 30, 1993, to discuss the. importance of reducing personnel errors through the better application of methods such as
" STAR",
teamwork, personnel accountability and a questioning attitude towards work activities.
Corrective Steps That Will Be Taken to Avoid Further Violations:
The corrective actions described above are considered appropriate and
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sufficient to avoid further violations.
Therefore, all corrective actions are complete.
Date When Full Comoliance Will Be Achieved:
All corrective actions were completed by October 30, 1993.
Therefore, WCNOC is in full compliance with TS 6.8.1.a.
Actual or Potential Consecuences of This Violation:
i WCNOC recognizes that a violation of Technical Specification 6.8.1.a l
occurred when Operations Personnel failed to follow the requirements specified in Procedure ADM 02-100 and Standing Order 1.
Additionally, it i
is understood that the failure to follow these procedures could have led to the generation of unnecessary radioactive waste.
Further, errors of this l
nature made under slightly different circumstances could have resulted in i
the damaging of equipment important to safety or the injuring of site personnel.
However, in this instance no equipment damage or personnel j
injury occurred.
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Attachment to WM 93-0176
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Page 3 of 11 violation 482/9327-02:
Failure to correctly immobilize temporary equipment l
having rollers or wheels.
"Inadeauate Control of Temocrary Eauioment
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Technical Specification 6.8.1.a states that written procedures shall be established, implemented, and maintained covering the applicable procedures l
recommended in Appendix A of Regulatory Guide 1.33, Revision 2,
dated l
February 1978.
Regulatory Guide 1.33, Section 1, requires administrative i
procedures.
Criterion V,
" Instructions, Procedures, and Drawings," requires that activities affecting quality shall be prescribed by procedures of a type appropriate to the circumstances.
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Procedure ADM 01-201, " Control of Temporary Equipment," Revision 5,
Step I
4.3.3, specifies that equipment having rollers or wheels capable of moving i
during a seismic condition shall be immobilized to restrict / limit movement.
i Contrary to the above, on Septamber 26, 1993, during a plant - tour the f
inspector identified several carts with rollers located in the auxiliary l
building that were not immobilized."
Admission of Violation:
WCNOC acknowledges and agrees that a violation of Technical Specification 6.8.1.a and Administrative Procedure ADM 01-201 occurred when WCNOC personnel failed to immobilize temporary equipment on rollers or wheels j
located in the Auxiliary Building.
i Reason for Violation:
i Recently, several instances of non-compliance with procedure ADM 01-201, I
were identified.
The non-compliances were determined to have occurred in i
area of the Motor Operated Valve (MOV) Storage Rack and the open area i
directly North and South of the Hot Tool Room.
Interviews with. WCNOC personnel from varicus work groups, whien use temporary equipment in the
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- plant, identified the root cause for this violation as personnel i
misinterpretation of the procedure guidance and personnel lack of familiarity with the procedural requirements.
Corrective Steos Taken and Results Achieved:
i A series of Mechanical Maintenance Quality Time Meetings were held
't beginning October 7, 1993. During these meeting, management clarified it's
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expectations on following the requirements set forth in ADM 01-201.
l Additionally, the specific guidance provided in the procedure was
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discussed.
This discussion should effectively eliminate any procedural j
interpretation errors and adequately familiarized personnel with-the temporary equipment handling and storage requirements set forth in ADM 01-l 201.
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Attachment to WM 93-0176 Page 4 of 11 I
A memo was issued, on October 10, 1993, to all Mechanical Maintenance l
personnel whose job respcnsibility may require them to move temporary equipment into the safety-related areas in the power plant.
This memo provided management's expectations for following the requirements set forth in ADM 01-201, addressed known procedural interpretation problems and I
f amiliarized personnel with the temporary equipment handling and storage I*guirements set forth in ADM 01-201.
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A memo was issued to the applicable managers and supervisors requesting I
I they have their personnel, who use temporary equipment in safety-related i
areas, review the changes made in ADM 01-201 and Performance Improvement Request MA 93-1075.
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X Also, procedure ADM 01-201 was revised.
This revision clarified that the procedure applies only to Seismic Category 1 structures and eliminated the temporary equipment exemption list.
In place of the exemption list, the l
procedure defines specific conditions that will apply to any temporary equipment by providing a clear definition of what is considered tempornry equipment.
Consequently, this allows WCNOC to place more emphasis on the areas needing attention and reduces the potential for misapplication of l
procedural requirements.
j Engineering Evaluation Request 93-XX-08 was initiated on December 12, 1993, to establish approved designated storage areas within the power block.
System Engineering is currently evaluating the feasibility of implementing j
this request.
Implementation of this request is considered a program enhancement; not a specific corrective action necessary for assuring 1
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compliance for this violation.
q Corrective Steos That Will Be Taken to Avoid Further Violations:
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Systems Engineering will meet with the procedure user groups by January 31, 1994, to provide an overview of the changes which have been incorporated into ADM 01-201.
Date When Full Comoliance Will Be Achieved:
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All corrective actions will be completed by January 31, 1994.
t Actual or Potential Consecuences of This Violation:
WCNOC recognizes its responsibility to establish adequate controls for the use st temporary equipment in safety-related areas and for assuring the requirements are adhered to.
Further, WCNOC recognizes that failure to follow these work practices could lead to equipment damage, which could result in a degraded safety condition during a seismic event.
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during the time period of this noncompliance, no seismic events were 1
2 detected and no safety-related equipment was impacted by incorrectly secured mobile carts.
Therefore, the health and safety of plant personnel
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and the public was not adversely affected.
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Attachment to WM 93-1076 Page 5 of 11 Violation 482/9327-03:
Two examples of WCNOC's failure to correctly control scaffolding erected adjacent to safety-related equipment.
i "Imorecer Scaffold Construction Technical Specification 6.8.1.a states that written procedures chall be established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision 2,
dated February 1978.
Regulatory Guide 1.33, Appendix A,
Item 9.a, requires I
procedures for maintenance that can affect the performance of safety-related equipment.
Procedure ADM 01-113, "Scaf fold Construction, " Revision 5, Section 5.2.d, required that scaffolding shall not be in contact with or secured to any safety-related or special scope structure / equipment unless allowed by the evaluation.
Contrary to the above, two examples of scaffolding which did not meet the requirements of Procedure ADM 01-113 were identified:
i (1) on October 5,
- 1993, the inspector identified that scaffolding constructed over a safety-related heat exchanger contacted valve EG-V205, Component Cooling Water Heat Exchanger A temperature bypass upstream isolation, and was secured to safety-related room cooler and piping supports.
Scaffold Request 93-S0836 evaluation did not allow this scaffold to be in contact with the valve or secured to the supports.
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On October 21,
- 1993, the inspector identified that scaffold constructed near the Spent Fuel Pool Cooling Heat Exchanger B was secured to a support for special scope equipment.
Scaffold Request 93-50850 evaluation did not allow this scaffold to be secured to this 7
support."
f Admission of Violation:
WCNOC acknowledges and agrees that a violation of Technical Specification 6.8.1.a and Administrative Procedure ADM 01-113 occurred when on October 5, 1993, and October 21, 1993, WCNOC personnel failed to erect scaffolding in accordance with the requirements set forth in ADM 01-113, Reason for Violation:
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The root causes for the above noted failures to correctly erect scaffolding was determined to be:
Inadequate procedure guidance:
- 1. The procedure failed to give adequate guidance on minimum separation criteria for the erection of scaffolding adjacent to safety-related components.
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Attachment to WM 93-0176 i
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- 2. The procedure failed to give adequate guidance on the acceptability of securing scaffolding to supports for electrical conduits that contain non-safety related circuits.
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- The responsible Engineering personnel failed to adequately communicate to the scaffold erection personnel that the phrase
" permanent structures" in the scaffold request meant " permanent structural steel,"
i not just any " permanent structure",
i Corrective Stecs Taken and Results Achieved:
The subject scaffold was removed from the area.
Engineering inspected Valve EG-V0205 and the equipment supports to which the scaffold was secured, and no apparent damage was observed.
A report of open scaffold requests was obtained to identify locations of all existing scaffolds in safety-related areas.
A walkdown of these i
scaffolds was performed on October.7, 1993, to determine if any were in contact with safety-related equipment.
One scaffold, the shielding frame in Room 1322 erected per Scaffold Request 91-S0275, was found to be loosely
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tied to the pipe support upstream of Containment Integrated Leak Rate Test j
Valve GP-V0011 on line GP-003-HBB-1.
The site scaffold coordinator was i
notified, and the wire securing the scaffold to the support was removed on l
October 7,
1993.
An engineering evaluation was performed and it was determined that the wire used to secure the scaffold to the pipe support
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would have failed prior to the support being damaged.
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WCNOC personnel walked down the entire Auxiliary Building on October 17, 1993, to verify that no additional scaffolds, other than those listed in the open scaffold request report, were existing.
As a result of this activity, none were found.
It is important to note that this walkdown only l
evaluated the scaffolds erected in the Auxiliary Building.
Scaffolds i
l erected in other safety-related areas were not evaluated.
The October 21, 1993, event occurred in the Spent Fuel Building and therefore was not evaluated during this walkdown.
i A joint walkdown was performed by the carpenter supervisor and Results Engineering en October 22, 1993, to inspect existing scaffolds in all safety-related areas for similar concerns. As a result of this activity, none were identified.
l The wire incorrectly securing the scaffold to the conduit support, for conduit GJ4BIA, was removed on October 22, 1993.
Procedure ADM 01-113 was revised on October 28, 1993.
This revision added a requirement to have an Engineer expeditiously inspect all newly erected scaffolding in safety-related areas prior to releasing the scaffold for use.
Scaffold erectors were counseled to attach scaffolds only to the buildings, permanent structures or component supports specified on the scaffold j
1 evaluation.
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4 Attachment to WM 93-0176 Page 7 of 11 Corrective Stens That Will Be Taken to Avoid Further Violations:
WCNOC decided all newly erected scaffolds in areas containing safety-related equipment and components would be reviewed in the field by an engineer.
This review is documented in Section E,
" Post Installation," of the Scaffolding Request Form.
The field reviews will continue until the l
scaffold program is determined to be effectively upgraded.
j WCNOC acknowledges that the scaffold program had weaknesses.
Engineering is revising the scaffold program to provide better guidelines for the support and bracing of scaffolding and to make the procedure more user-r friendly for the scaffold erectors.
This activity, is considered by WCNOC to be a program enhancement outside of the actions necessary to bring WCNOC into compliance with TS 6.8.1.a.
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t Date When Full Comoliance Will Be Achieved:
I All corrective actions necessary for full compliance by WCNOC have been l
completed.
WCNOC will upgrade the scaf folding program by March 15, 1994.
The additional actions or training that are to be completed beyond this
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date are considered enhancements to this program.
Therefore, WCNOC is in full compliance with TS 6.8.1.a.
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Actual or Potential Consecuences of This Violation:
l WCNOC recognizes its responsibility to ensure scaffold erection procedures provide adequate guidance and that scaffold erection activities are carried
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out in accordance with approved procedures.
WCNOC acknowledges that it's l
scaffold erection program was weak and that this weakness.resulted in the i
above noted violations.
However, careful review of the above noted violations clearly showed there was no adverse safety consequence to j
equipment and thus no reduction in the health and safety of plant personnel resulting from these violations.
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Attachment to WM 94-0176 Page 8 of 11 l
li Violatic' 482/9327-04: WCNOC personnel were observed performing work under Work Request 02815-93 without first obtaining the shift supervisors permission.
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" Failure to Obtain Permission to Start Work
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l Technical Specification 6.8.1.a states that written procedures shall be d
established, implemented, and maintained covering the applicable procedures recommended in Appendix A of Regulatory Guide 1.33, Revision
'2, dated I
February 1978.
Regulatory Guide 1.33, Appendix A,
Item 9 a, requires procedures for maintenance that can affect the performance of safety-related equipment.
Procedure ADM 01-057, " Work Request," Revision 27, Section 7.24, required that the shift supervisor, " Sign and date to give permission to START
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work."
In addition, Procedure ADM 01-057, Figure 6,
" Work Request Flow Chart," requires a worker to obtain the shift supervisor's permission prior i
to starting work.
Contrary to the above, on October 12, 1993, the inspector observed a machinist perform work under Work Request 02815-93 without first obtaining.
the shift supervisor's permission."
Admission of Violation.
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WCNOC acknowledges and agrees that a violation of TS 6.8.1.a and f
Administrative Procedure ADM 01-057,
" Work Request,"
occurred when i
Maintenance personnel performed work under Work Request 02815-93 without
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first obtaining the Shift Supervisor's permission to start work.
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Reason for Violation:
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The root cause for the failure to obtain the Shift Supervisor's permission to start work has been determined to be a lack of attention to detail on l
the part of mainteriance personnel, the lack of appropriate self-checking on j
the part of all personnel involved and the failure to perform proper pre-job briefings, turnovers, and independent reviews of the work request
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package.
l Corrective Steos Taken and Results Achieved:
On Novenber 2,
1993, Mechanical Maintenance discussed the issue in a Quality Time Meeting.
This discussion emphasized the importance of the l
worker first obtaining the Shift Supervisor's permission to start work prior to going to the field to perform the work activity, paying close 1
attention to detail anc'
'2 sing WCNOC's " STAR" Program (the WCNOC Self-Checking Program).
Additionally, a memo was sent to Mechanical Maintenance Personnel who were not at the quality time meeting, emphasizing Management's position that the Shift Supervisor's permission to start work is required prior to going to the field to perform work activities that impact the plant, paying close attention to detail and using WCNOC's " STAR" Program, i
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I Attachment to WM 93-0176 page 9 of 11 i
Corrective Steos That Will Be Taken to Avoid Further Violations:
The corrective actions described above are considered appropriate and sufficient to avoid further violations.
Therefore, all corrective actions are complete and WCNOC is in full compliance with TS 6.8.1.a.
Date When Full Comoliance Will Be Achieved:
All corrective actions were completed by November 2, 1993.
Actual or Potential Consecuences of This Violation:
i WCNOC recognizes its responsibility to establish safe work practices and to ensure work activities are performed in accordance with these work
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practices.
Further, WCNOC recognizes that fa4. lure to follow these work practices could lead to personnel injury and / or equipment damage which j
could result in a degraded safety condition.
However, in this case, no personnel injuries or equipment damage occurred.
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Attachment to WM 93-0176 Page 10 of 11
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Violation 482/9327-05:
WCNOC's failure to complete corrective actions to l
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prevent recurrence documented in WCNOC Licensee l
Event Report 93-003-00.
j "Inadecuate corrective Actions 10 CFR Part 50, Ap mdix B,
Criterion XVI, specifies, in part, that measures shall be established to assure that conditions adverse to quality l
are promptly identified and corrected.
10 CFR 50.72. (b) (4) specifies that t
the contents of a licensee event report will include a description of any corrective actions planned as a result of the event, including those to reduce the probability of similar events occurring in the future.
Licensee Event Report 482/93-003 identified that personnel created a direct path out of containment while draining the essential service water system.
The licensee determined that procedure steps failed to ensure personnel j
understood that performance of thi; step violated containment integrity.
l As corrective action Licensee Event Report 482/93-003 specified that a review of SYS procedure utilized to drain systems which penetrate containment would be conducted to ensure that potential similar situations
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could not occur or do not exist.
j Procedure SYS EG-401,
" Component Cooling Water System Drain Procedure,"
Revision 0,
provided guidance for draining the component cooling water
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system.
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Contrary to the above, on October 7,
1993, the inspector found that the licensee failed to correct weaknesses contained in Procedure SYS EG-401 in 1
order to reduce the probability of a similar event occurring in the i
future."
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Admission of violation:
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q WCNOC acknowledges and agrees that a violation of Criterion
- XVI, l
" Corrective Action," of Appendix "B" to 10 CFR 50 occurred when WCNOC did l
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not sufficiently implement corrective actions to reduce the probability of I
a similar event occurring in the future.
a Reason for Violation:
4 The root cause of this violation is less than thorough evaluation of the 4
corrective action needed, which may not have provided sufficient barriers to prevent recurrence of the event.
Corrective Steos Taken and Results Achieved:
Procedure SYS EG-401 was revised on October 15, 1993.
This revision j
included adding a caution prior to step 3.4.1.
This note cautions - the procedure user that performance of step 3.4.1 will cause a violation of containment integrity / closure. And that if containment integrity / closure is to be maintained a dedicated operator shall be stationed at Valves EG-V090, EG-V371 and EG-V372 while they are open.
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Attachment to WM 93-0176 Page 11 of 11 Performance Improvement Request (PIR) OP 93-1490 which documents this eve..t, was placed in Operations' Required Reading to alert all Operations personnel to the importance of identifying and taking thorough and complete corrective actions.
Corrective Stecs That Will Be Taken to Avoid Further Violations:
The corrective actions described above are considered appropriate and sufficient to avoid further violations.
Therefore, all corrective actions are complete.
Date When Full Comoliance Will Be Achieved:
All corrective actions were completed by December 3,
1993.
Therefore, WCNOC is in full compliance with the provisions of 10 CFR 50, Appendix B, Criterion XVI.
Actual or Potential Consecuences of This Violation:
It was determined that past revisions of SYS EG-401 provided some guidance (in the Initial Conditions) by referring to Technical Specification 3.9.4,
" Containment Building Penetrations," prior to performing the procedure.
This guidance has been effective in preventing a failure to meet Containment Closure Requirements to date.
However, WCNOC agrees the placement of a caution prior to Step 3.4.1 provides additional assurance that a failure to maintain Containment Closure similar to that documented in LER 93-003-00 will not occur.
Therefore, the health and safety of the public and plant safety was assured during this condition.