ML20059M582
| ML20059M582 | |
| Person / Time | |
|---|---|
| Site: | Diablo Canyon  |
| Issue date: | 08/17/1993 |
| From: | AFFILIATION NOT ASSIGNED |
| To: | |
| References | |
| OLA-2-I-MFP-009, OLA-2-I-MFP-9, NUDOCS 9311190172 | |
| Download: ML20059M582 (16) | |
Text
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May 6, 1993 g
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NCR DC0-93-TN-Null POTENTIAL MISSED NRC. COMMITMENT 4
MANAGEMENT
SUMMARY
l On December 11,
91, and May 1st, 1992 to support proposed In Service relief requests, PG&E in letters to the NRC committed to perform a full-flow stroke of check valve SI-8981 after disassembly, inspection, and manual exercising.
This commitment was used by the NRC as a justification for l approving the relief request as outlined in a June 15, 1992 SER.
However, during 1RS, STP V-4A was revised, no longer providing assurance that a full flow verification of SI-8981 was performed.
The root cause has been determined as personnel err r and programmatic deficiency. Not enough guidance was provided for processing commitments of the IST program.
As corrective action to prevejt recurrence, an, Administrative Procedure to control the IST program will be developed to include a requirement to place NRC approved relief requests in the CMD.
This draft dated May 6, 1993 contains the TRG meeting minutes from the TRG meeting held on April 27, 1993.
THE TRG IS SCHEDULED TO RECONVENE ON May 7, 1993 TO SIGN OFF THE NCR.
l 92NCRWP\\93TNN011.PGD Page 1
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NCR DCO-93-TN-N011'Rev. 00.
Draft:
May 6, 1993 NCR DCO-93-TN-N011' POTENTIAL' MISSED'NRC COMMITMENT.
I.
Plant Conditions Unit 1 and Unit 2 have been in various, modes at various power levels.
II.
Description of Event
~
A.
Summary:
Although PG&E committed to.the NRC, to perform a full'-
stroke of saf ety injection (SI). check' valve' SI-8981 after disassembly and_ manual exercising,:itLis not clear that during 1R5 this commitment.was met when STP V-1A was performed.
B.
Background:
Technical. Specification 4.0'5 provides.the surveillance requirements for. inservice inspection and' testing of ASME Code Class 1,2, and 3-components.
AEAE Section XI provides the inservice inspectiontand
~
inservice testing requirements for ASME Code Class 1,2 and 3 components.
ISI/IST prograns have been' or are.being. developed ' atl the utilities to meet the ASME Section'XI requirements.
PG&E IST program plan governs the IST program at DCPP.
Generic' Letter 89-04 dated April 3, 1987-described a series of industry issues'that had ariseniaround the ISI/IST Programs.
It provided guidance and generic relief.
Later that; year, in' June of 1989,.a conference was held further. clarifying these issues with minutes issued on October 25,~1989.
C.
Event
Description:
On May 10, 1983, PG&E submitted. Revision 1?of.the Unit-1 IST Program Plan.
On February 22, 1985, PG&E submitted Revision 0 of the Unit 2 IST-Program Plan.
Both of these Plans requested relief (ReliefERequest (RR) # 14) from performing theLCode-requiredL quarterly stroke testing of SI-8981 on each unit, respectively.
u As an alternative,- RR # 14 proposed that the valves be 92NCRWP\\93TNN011.PGD Page 2 'of 15
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a.
i NCR DCO-93-TN-N011 Rev. 00 Draft:
May 6, 1993 full-stroke tested during each refueling outage.
The IST Program Plans listed STP V-4A as the implementing procedure for this flow test.
NRC SSER 31, dated May 1985, formally approved the relief request.
In May 1988, a CMD record (T05961) was created for V-4A to ensure that the RR # 14 requirements were satisfied, i.e.,
that the valve should be full-stroke. tested every refueling outage.
This record was deleted in September 1990 and replaced by T05941, which also required that SI-8981 be full-stroke exercised every refueling outage.
This record remains open today.
Generic Letter 89-04 dated April 3, 1989 described a series of industry issues that had arisen around the ISI/IST Programs.
It provided guidance and generic relief.
Later that year, in June of 1989, a conference was held further clarifying these issues with minutes issued on October 25, 1989.
On February 27, 1991 (DCL-91-042), PG&E submitted Revision 8 (Unit 1) and Revision 5 (Unit 2) of the IST Program Plan (the Plans were combined in 1989 into a single Unit 1 and Unit 2 IST Program Plan).
This revision requested a change to RR # 14 and SI-8981 testing because PG&E identified that SI-8981 has a safety function in the closed (reverse-flow) position (reference LER 1-84-044 dated July 16, 1990, letter DCL-90-181).
Therefore, RR#14 was revised to request that SI-8981 be disassembled and tested each refueling outage to verify the valves' safety function in both' the open and closed position.
Following incpection, RR
- 14 proposed tn6. the valve be part-stroke tested.
The revised IST Program Plan also deleted STP'V-4A as the implementing procedure for SI-8981, replacing it with STP V-18.
On April 9, 1991, a CMD record (T34495) was created against STP V-18 to track the commitment for SI-8981 disassembly inspection and part-stroke testing.
During discussions with the NRC Staff in 1991 to obtain approval of RR # 14, the NRC indicated that a part-stroke of SI-8981 was sufficient to meet the intent of GL 89-04.
However a full stroke should be performed if possible.
PG&E agreed to perform the full stroke testing.
Therefore, in a letter dated December 11, 1991 (DCL-91-297), PG&E committed to 92NCRWP\\93TNN011.PGD Page 3
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NCR DCO-93-TN-N011 Rev. 00 Draft:
May 6, 1993 full-stroke SI-8981 following disassembly inspections.
PG&E followed up this commitment with a formally revised RR # 14 in a letter dated May 1,.1992 (DCL-92-110).
The NRC approved RR#14 in a letter dated June 15, 1992.
No CMD records were. changed to reflect the approved RR # 14.
To summarize, during 1RS, CMD record T34495 specified V-18 part-stroke testing of SI-8981 following refueling outage disassembly inspections, and CMD record-T05941 specified STP V-4A full-stroking of SI-8981 each refueling outage (with no reference to disassembly inspections).
These records were thus tracking contradictory testing requirements for SI-8981.
On October 23, 1992 an OTSC was issued to revise STP V-4A to leave valves SI-8701 and SI-8702 open during the test.
This STP now only documents that some flow would come through SI-8981, but did not establish full flow.
D.
Inoperable Structures, Components, or Systems that Contributed to the Event:
None.
E.
Dates and Approximate Times for Major Occurrences:
1.
May 10, 1983:
PG&E submits rr.-ision 1 of the Unit 1 IST. Program Plan.
2.
Februar{,22, 1985:
PG&E submitted Revision 0 o Pthe Unit 2 IST irbgram
.m Plan.
PG&E committed 3.
May 1985:
NRC SSER 31 formally approves relief request #
14.
4.
May 1988:
A.CMD record.(T05961) was created for V-4A to ensure that the RR # 14 requirements were satisfied.
5.
April 3, 1989:
Generic Letter 89-04 is issued describing a series of industry issues that had 92NCRWP\\93TNN011.PGD Page 4
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3-l 3.
NCR DCO-93-TN-N011 Rev. 00-J Draft:
May 6, 1993 arisen around the.ISI/IST Programs.
6.
-February 2 7, -1 9 9 1 ':
PG&E submitted' Revision'8
)
)
(Unit 1) and Revision.5 (Unit - 2) f of - the. IST.' Program l
Plan.
7.
April 9, 1991:
CMD record (T34495)1was created against STP V-18 to track.the commitmentJfor SI-8981. disassembly; inspection and part-stroke-testing.
l 8.
December 11, 1991 (DC'91-297) l anc May 1, 1992 (DCL-92-110):
PG&E committed-to the NRC to perform.a' full-stroke of SI-8981 after disassembly,,
inspection, and. manual-exercising.
'I 9.
June 15,. 1992:
This' commitment was used byc
.the NRC;as a. justification l
for the: relief-request as-outlined'in the1SER.
- 10. September 12, 1992-to November 11,,1992:
Event'date. During 1R5, STP V-4A wasg evised, and.it iE
.not clear that SI-8981 full l
l stroked during~the test.-
11.
October 23, 1992:
An OTSC was. issued to revise STP V-4A to leave valves SI-87011and'SI-8702 l
open'during.the test.
This STP nowJonly documents that t
some flow would.come through SI-8981, but did not-establishofull flow.
F.
Other Systems or Secondary Functions Affected:
None.
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s NCR DCO-93-TN-N011'Rev. 00 Draft:
May 6, 1993 G.
Method of Discovery:
During 1RS, STP V-4A was revised, and it was not clear during review of results that SI-8981 was fully stroked.
H.
Operator Actions:
None required.
I.
Safety System Responses:
None required.
4 III.
C3use of the Event A.
Imm^diate Cause:
Evidence was not immediately'available to verify that STP V-4A provided a full stroke of safety injection (SI) check valve SI-8981 after disassembly and manual exercising.
B.
Determination of Cause:
See Root Cause Analysis.
C.
Root Cause:
Personnel error / Programmatic deficiency. Not enough guidance was provided for processing commitments of the IST_ program.
5fA _
D.
Contributory Cause:
1.
During 1RS, STP V-4A was revised and did not meet was not clear that a full stroke of SI-8981 was performed.
2.
Personnel were aware of the commitment to the NRC.
3.
This commitment was tied to STP V-18 which is the only commitment tied with the IST plan, which was entered into CMD.
Therefore STP V-4A commitment was not entered into CMD.
92NCRWP\\93TNN011.PGD Page 6
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a, 00 NCR DCO-93-TN-N011'Rev.
Draft:
May 6, 1993 o
4.
STP V-4A commitment was not submitted'to the'C36) coordinator because personnel were not aware of methods for maintaining the IST program.
IV.
Analysis of the Event A.
Safety Analysis:-
The function of safety injection check valve'SI-8981 is to supply borated water from the RWST to the suction of RHR pumps.
This valve has also a safety functionlin the close-(reverse-flow) position toL1imit: potential-post-LOCA recirculation leakage to~the RWST.
Section XI of the Boiler and Pressure Vessel Code requires quarterly partial stroke testing of;SI-18981 on each unit, respectively after disassembly, and exercising.
Because it is impractical to perform a-stroke.testi during plant' operation, PG&Efsubmitted a, relief request and committed to perform a full s';roke test of SI-8981 following disassembly, inspections and exercising.
It:
was not clear that this commitment was met when STP V-4A was performed during 1RS.
Further investigations'and calculations determined that the commitment to the NRC was met and a' full ~ stroke ~was performed ~during 1R5.
Therefore, this event did not result on an unreviewed safety question and did not adversely affect'the health and safety of the public.
B.
Reportability:
1.
Reviewed under QAP-15.B and determined.to be non-conforming in accordance with Section-2.1.8.
2.
Reviewed under 10 CFR 50.72 and'10'CFR 50.73'per NUREG 1022 detennined not to be reportable, however-
)
a voiluntary LER will be 1
3.
Reviewed under 10 CFR Part 21 and' determined that 1
this problem will'not require a 10 CFR 21 report, since it does not involve defects in vendor-supplied services / spare parts in stock.
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NCR DCO-93-TN-N011 Rev. 00 Draft:
May 6,'1993 4.
This problem will not be reported via an INPO Nuclear Network entry.
5.
Reviewed under 10 CFR 50.9 and determined to be not reportable since this event does not have a significant implication for'public health and safety or common defense and security.
6.
Reviewed under the criteria of AP-C-29' requiring the issue and approval of an OE and determined that an OE is not required.
V.
Corrective Actions A.
Immediate Corrective Actions:
1.
Initiate a revision to STP V-4A to ensure that we have adequate indication of flow through check valve SI-8981 during performance of STP V-4A.
RESPONSIBILITY:
M.
Edwards DEPARTMENT:
Plant Engineering.
Tracking AR:
A0296981, AE # 01 STATUS:
COMPLETE REV. 13 (U1) AND REV 4 (U2) WERE APPROVED AND EFFECTIVE ON NARCH 17, 1993.
SUCTION PRESSURE CHANGE DURING SWITCHOVER FROM CAVITY TO ""ST SUCTION WILL BE MONITORED TO ENSURE FLOW IS FROM THE RWST WHILE VALVE 8980 IS OPEN (8981 CHECK VALVE TEST).
2.
Perform an" Engineering calculation to demonscrate that flow through check valve 8981 meet.or exceed the design flow of 3976 GPM during the performance of STP 4A in 1R5 or that the flow did not enter the RHR pumps from 8701.
RESPONSIBILITY:
T.R. Baldwin DEPARTMENT:
NECS Engineering.
Tracking AR:
A0296981, AE # 02' I
STATUS:
COMPLETE NES CALCULATION N-072 HAS BEEN PERFORMED TO DETERMINE THAT THE FLOW THROUGH SI-8981 DURING STP V-4A WAS APPROXIMATELY 7300 GPM.
THIS DEMONSTRATES THAT THE FLOW WAS UNQUESTIONABLY HIGHER THAN-THE.
DESIGN FLOW OF 3976 GPM.
92NCRWP\\93TNN011.PGD Page 8
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NCR DCO-93-TN-N011 Rev. 00 Draft:
May 6, 1993 B.
Investigative Actions:
1.
Determine the reason why the commitment was missed and the corrective actions to prevent recurrence.
RESPONSIBILITY: M. Cherubini DEPARTMENT:
NSARA.
Tracking AR:
A0296981, AE # 05 STATUS:
COMPLETE CMD HAS A RECORD WHICH TRACKS RELIEF REQUESTS 9, 13, AND 14 OF THE IST PROGRAM.
REFERENCE COMMITMENT # T34495).
HOWEVER, THIS COMMITMENT WAS TIED TO STP V-18, ONLY.
THE FACT THAT STP V-18 IS-THE ONLY IMPLEMENTING DOCUMENT IS CONSISTENT WITH THE CURRENT REVISION OF THE IST PLAN. TABLE 4.2.1 OF T"E IST PLAN LISTS VALVES 8924, 8977, AND SI-8981, THEIR RESPECTIVE RELIEF REQUEST # AND STP V-18 AS THE PROCEDURE NUMBER.
AS A CORRECTIVE ACTION, STP V-4A WAS ADDED TO THE ABOVE MENTIONED COMMITMENT TO ASSURE THAT THE REQUIREMENTS FOR FULL STROKE EXERCISING OF SI-8981 WOULD NOT BE OVERLOOKED.
ADDITIONALLY, STP V-15 WAS ADDED TO THE RECORD TO ASSURE THE REQUIREMENTS FOR FULL STROKE EXERCISING OF 8924 AND 8977 WOULD NOT BE OVERLOOKED.
C.
Corrective Actions to Prevent Recurrence:
1.
Develop an Administrative Procedure to control the IST program including a requirement to place NRC approved relief,Epquests in the CMD.
RESPONSIBILITY:
L. Cossette ECD: 09/01/93 DEPARTMENT:
Plant Engineering.
Tracking AR:
A0296981, AE # 03 STATUS:
ASSIGNED.
Outage Related? No OE Related?
No NRC Commitment? No CMD Commitment? Yes D.
Prudent Actions.
1.
Review the ISI/IST program for other possible missed commitments.
RESPONSIBILITY:
D.
Spencer ECD: 09/01/93 92NCRWP\\93TNN011.PGD Page 9
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b NCR DCO-93-TN-N011 Rev. 00 Draft:
May 6, 1993 C.
Pendleton DEPARTMENT:
Plant Engineering.
Tracking AR:
A0296981, AE # 04 STATUS:
ASSIGNED.
Outage Related? No OE Related?
No NRC Commitment? No CMD Commitment? Yes VI.
Additional Information A.
Failed Components:
None.
B.
Previous Similar Events:
1.
NCR DCO-91-TN-N026 - IST Program.
Check valves SI-9002A, SI-9002B, SI-8924, SI-8977, SI-8981, MS-5166, and MS-5167 were not being tested in accordance with ASME Section XI inservice test (IST) requirements The IST deficiencies were caused by a personnel error because plant engineering did not correctly identify testing requirements for these check valves in the closed position.
To prevent recurrence, the testing requirements of components in the IST program were reviewed to ensure consistency with the guidance of NRC Generic Letter 89-04.
The IST program has been revised to
, accurately reflect the p uper testing requirements for these check valves.
Check valves"in the IST program will be reviewed to confirm that the Generic Letter 89-04 review considered all appropriate design basis requirements.
The corrective actions in the above NCR will not have prevented this NCR since this NCR involves missed commitment to the NRC.
2.
NCR DCO-92-TN-N008 -
CVCS-8440 reverse flow.
Because VCT outlet check valve CVCS-8440 is not in DCPP's ASME Section XI Inservice Testing (IST) program, the potential has existed for a significant unanalyzed pathway for release of post-LOCA recirculation fluid.
92NCRWP\\93TNN011.PGD Page 10 of 15
NCR DC0-93-TN-N011 Rev. 00 Draft:
May 6, 1993 Corrective actions to prevent recurrence include:(1) Development of a valve test procedure for CVCS-8440 to periodically test for potential post-LOCA recirculation gross leakage (i.e., a Category C reverse flow test, not a Category A leak rate test), with initial performance of the test during 1R5/2R5; (2) Revision of DCPP Design Criteria Memorandum (DCM) S-8 to incorporate information determined as a result-of the current investigations; (3) Review of all valves in the post-LOCA recirculation flow path to determine if any other valves perform a previously unidentified safety function, due to a similar configuration (i.e.,
leak-by into a " closed" system, with potentially unanalyzed consequences) ; (4)
Revision of the IST Program Plan to include CVCS-8440.
The corrective actions in the above NCR will not have prevented this NCR since this NCR involves missed commitment to the NRC.
C.
Operating Experience Review:
1.
NPRDS:
Not applicable.
2.
NRC Information Notices,-Bulletins, Generic Letters:
GL 89-04. The NRC staff positions regarding check valve disassembly and inspection are explained in detail in GL 65 J4 regarding Position 2, Alternatives to Full-Flow Testing of Check Valves, further stipulate that a partial-stroke exercise test using flow is expected to be performed before the valve is returned to service after disassembly and inspection.
A full-stroke exercise using flow should be performed if possible.
The NRC staff considers valve disassembly and inspection to be a maintenance procedure with inherent risks which makes it routine use as a substitute for testing undesirable when other_ testing methods are possible.
Non-intrusive diagnostic techniques such as acoustics or radiography can be used to demonstrate that these valves-close promptly when subjected to reverse flow conditions.
92NCRWP\\93TNN011.PGD Page 11 of 15 i
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NCR DCO-93-TN-N011'Rev.- 00 Draft:
May 6,-1993!
3.
None.
4.
NRC Technical _ Evaluation Report (TER):
NRC Technical Evaluation-Report ' (TER) dated l
l December 8, 1988,.on:DCPP Unit l'and 2 IST program for pump and valves, section'4~.5.3.4 specify that SI-8981 cannot be exercised during power operation because the onlycavailable flow path'islinto the RCS and the RHR 1xunps do not _ develop 'suf ficient discharge pressure to. overcome RCS pressure.
During cold shutdown the RHR pumps are:alignedito; remove decay heat,from the'RCS_hence no flow path ~
is available for exercising this valve.
ComplianceL with.the Code required testing _is impractical since.
this would require. quarterly plant shutdown, cooldown and' reactor heatLremoval.. Based on.the impracticality of_ complying with the Code required >
testing frequency, the'NRC granted PG&E [ revised l
June 15, 1992) _ relief from quarterly testing to full-stroke exercise during; refueling; outages _of SI-8981.-
l D.
Trend Code:
Responsible department TP, and cause. code A4.
E.
Corrective Action Tracking:
1.
The tracking action request is A0296414.
xw.
w 2.
Are the_ corrective actions outage related?
No.
I F.
Footnotes and Special Comments:
None.
G.
References:
1.
Initiating Action Request A0296414, 2.
Tracking Action Request A0296981.
i 3.
STP V-4A.
92NCRWP\\93TNN011.PGD Page 12 of 15
a NCR DCO-93-TN-N011 Rev. 00 Draft:
May 6, 1993 4.
6.
DCL 91-297 7.
DCL 92-110 H.
TRG Meeting Minutes:
1.
On March 12, 1993, the TRG convened and considered the following:
Review of the ISI/IST submittal to the NRC.
In the past valve SI-8981 has been full-stroked testr every 18 months as per STP V-4A.
The revised IST program has not been entered into the CMD.
Considered to part stroke valve SI-8981 and ask for a relief.
The relief request on the IST program was rejected by the NRC.
The question is whether there was a full stroke of the valve during STP V-4A or the performance of STP V-4A was good enough to prove that valve SI-8981 was fully stroked.
v x
Considered to verify the flow and amp and measure
]
the stroke of valve SI-8981 with valve 8701 open of the RCS.
The RWST was at 66% level, and the refueling cavity at 21 ft at the end of the test.
It was determined that operability is not an issue.
The valve will be full-flow tested to demonstrate that a full stroke was performed.
The possibility to submit a letter to the NRC to the fact that a full-stroke on valve SI-8981 was considered and quickly discounted since it is possible to conduct a full-stroke on this valve.
Discussion whether this event is an NCR or just a QE.
It was decided that this event will remain as an NCR.
92NCRWP\\93TNN011.PGD Page 13 of 15
k F'
NCR DCO-93-TN-N011 Rev. 00 Draft:
May 6, 1993 Investigations will be made'to' determine whether-valve SI 8981 was full-stroke tested.
This potential' missed' commitment had no' operability issue.
This event is not reportable.
A requirement will be added to the' procedure-that all relief. requests will be reviewed prior' approval.
One immediate corrective _ action and three investigative actions were initiated.
For more i
information see paragraph V.A.1 and V.B.1 through V.B.3.
of this NCR.
l TRG TO RECONVENE ON APRIL'7. 1993 TO REVIEW THE..RESULTS j
OF THE IMMEDIATE CORRECTIVE AND INVESTIGATIVE ACTIONS AND DETERMINE THE ROOT CAUSE.
j i
2.
-On April 7, 1993, the TRG reconvened-:and considered-the following:
Discussion on.the cause of the event'.
Clarification on why the commitment'was not entered
~
in the CMD.
Review of the root cause.
i
.Beview of the corrective actions to prevent recurrence.
Comments were given on the NCR_ write-up.
This NCR will be submitted to the TRG members for review and comments.
Comments from TRG members due the TRG-secretary by April 21, 1993.
TRG TO RECONVENE ON APRIL 27. 1993 AT 10:00 AM FOR SIGN OFF.
NCR CLOSURE ECD:
OCTOBER 1, 1993.
92NCRWP\\93TNN011.PGD Page 14 of 15
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NCR DCO-93-TN-N011 Rev. CXF Draft:
May 6, 1993-3.
On April 27, 1993,.the TRG reconvened to sign off the NCR:and considered the following:
Review of the write-up.
Review of J. Arhar comments of the NCR.
Review of the root cause analysis.
Agreed that the NCR could be downgradedL to.a QE.
Ilowever, the TRG would like.to keep it'as.an NCR since there is no IST program.
Need to focus that' it is not the-TRG perspective that there is something wrong with the CMD.
Discussion on the OTSC of V-4A.'
It was. engineering-intention to issue an OTSC, but it was pushed;upon them and they could not find the documentation to convince management that an OTSC'was required.
IDAP XI3-ID1 describes the process for tracking.IST.
relief requests.
It was pointed that during_the' review it was realized that it was not a. full stroke.
This was before submittal of the OTSC.
The IST administrative procedure'should' track.the.
approval of the relief request.
TRG TO RECONVENE ON FRIDAY MAY, 7,
1993 AT 10:00-E
~
3.
On May 21, 1993, the TRG' reconvened and considered the following:
Discussion with Westinghouse I.
Remarks:
None.
J.
Attachments:
Root Cause Analysis.
92NCRWP\\93TNN011.PGD Page 15 of 15'
1 NCR 1.
J-93-TN-N011 Rev. 00 Draft:
May 6, 1993 jPOTENTIAL MISSED NRC COMMITMEffr ROOT CAUSE ANALYSIS Page 1 of 1 EFFECT h
CAUSE EVIDENCE BARRIER-1 During 1RS, valve SI-8981 STP V-4A did not_ require STP V-4A was not full stroked during sufficient data to be taken 1
performance of STP V-4A.
to ensure a full stroke test i
had been performed I
STP V-4A did not require Procedure STP V-4A was Procedure sufficient data to be taken OTSC'd on 10/23/92 to history sheet to ensure a full stroke maintain SI-1-8701 and for the OTSC test _had been performed SI-138702 in the open revision posidion Procedure STP V-4A was A-review of the Outage CMD for STP i '
OTSC'd on 10/23/92 to Safety Plan questioned V-18 and STP
-maintain SI-1-8701 and SI-closure of SI-1-8701 and V-4A Rev'8, 8702 in the open position SI-1-8702 and personnel were Feb. 15, 1991 unable to retrieve
- of the IST i
commitments relative to program.
SI-8981 A review of the.Outnge_
Personnel were not~ aware of AR A0296981 Proposed: Develop an i
Safety Plan questioned niethdds for maintaining AE-# 05 admin procedure to closure of 8701 and 8702 IST commitments govern-the IST and. personnel.were program unable to retrieve commitments relative to SI-8981-Personnel were not aware of ROOT CAUSE: Personnel error
't methods.for maintaining
--no procedure' existed.
IST commitments 1
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