ML20086U231
| ML20086U231 | |
| Person / Time | |
|---|---|
| Site: | Vogtle  |
| Issue date: | 06/01/1995 |
| From: | GEORGIA POWER CO. |
| To: | |
| References | |
| OLA-3-A-081, OLA-3-A-81, NUDOCS 9508040007 | |
| Download: ML20086U231 (37) | |
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VEGP 00057-C 4
USNRC 37 er 37 sheet to of to Ya JUL 14 A10:21 h
DATA SHEET 1 Event Report No.
OFFICE $#SfbhETAh*
INVESTICATION QUZMT gg)VICE 12.
WAS SUPERVISION INVOLVEMENT ADEQUATE FOR THE EVOLUTION BEING CONDUCTED 7 YES/NO 13.
WERE THE PERSONNEL THAT INITIATED OR ADVERSELY CONTRIBUTED TO THE EVENT QUALIFIED TO PERFORN THEIR ACTIVITIES PRIOR TO AND DURING THE EVENT 7 YES/NO 14.
IF QUESTIONS 1, 4 OR 7 ARE ANSWERED TES, DESCRIBE IN DETAIL IN THE EVENT REPORT.
15.
IF QUESTIONS 2, 3, 5, 6, 8, 9, 10, 11, 12 OR 13 ARE ANSWERED NO, DESCRIBE IN DETAIL IN THE EVENT REPORT.
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EVENT INVESTICATION 1.0 PURPOSE This procedure provides instructions for event investigations.
It is to be performed for, but not i
limited to, the following events:
I a.
Unplanned Reactor Trips, f
b.
Unplanned Turbine Trips, c.
Unplanned Engineered Safety Features (ESF)
)
actuations, 4
d.
Significant Radiological events, e.
Events identified by site management (Office of the General Manager)
NOTE 3
Security related event investigations will be handled in accordance with procedure 90142-C, " Security Report Procedure".
2.0 pEFINITION EVENT A definite and separate occurrence that happens as a result of, or in connection with, a planned evolution.
Reactor trips, engineered safeguard feature actuations and challenges, and other events deemed significant are examples.
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2 of 37 3.0 RESPONSIBILITIES 3.1 0FFICE OF THE CENERAL MANAGER The General Manager - Nuclear Plant (CHNP)
Assistant Ger.eral Manager - Plant Operations (AGM-Ops), Assistant General Manager - Plant Support (ACM-SPT) as appropriate, is responsible for the following:
3.1.1 Ensuring the Event Investigations are properly i
i conducted.
l 3.1.2 Directing aparopriate departments to provide necessary l
support to the ERTL.
l 3.1.3 Reviewing the results of event investigations.
i 3.1.4 Recommending a review, as appropriate, by the Plant Review Board (PRB) of any reports.
3.1.5 Extending the seven day completion period for the investigation review, when appropriate.
3.2 MANAGER TECHNICAL SUPPORT I
The Manager Technical Support (MTS) will ensure l
3.2.1 Corrective actions resulting from Event Investigations are assigned and tracked to completion.
4 3.2.2 Appropriate processing of the completed event investigation report.
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3.2.3 Providing information concerning similar in-house and related industry events.
1 3.3 MANAGER OPERATIONS 3.3.1 The Manager Operations, or designee, determines if i
Operations shift personnel involved / associated with the Event should be relieved by additional personnel to l
participate in the the Event Investigation.
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3.3.2 The Manager Operations is responsible for ensuring the event data is collected and provided to the ERTL.
3.4 ON SHIFT OPERATIONS SUPERVISOR The On Shift Operations Supervisor (0505) has the l
following responsibilities:
3.4.1 Informing the Vogtle Duty Manager of events described l
in 1.0.
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3.4.2 Ensuring a Deficiency Card is initiated for the event in accordance with Procedure 00150-C, " Deficiency Control".
3.4.3 Initially determining hardcopy data to be collected.
3.4.4 Designating the individual responsible for the collection of appropriate hard copy information listed in Dats Sheet 1.
3.4.5 Ennuring each appropriate individual involved in the Event initiates an Event Personal Statement.
3.4.6 Providing the event data to the Manager Operations for the Event Review Team.
3.5 DEPARTMENT MANAGERS I
Department Managers are responsible for the following:
3.5.1 Supporting a thorough review of events and providing personnel to perform the Event Investigation.
3.5.2 Ennuring corrective actions are sufficient to preclude recurrence of events of the same nature.
3.5.3 Providing additional personnel to relieve shift personnel to allow the investigation to occur while the information is fresh.
3.5.4 Review and approve /disaparove recommended corrective actions.
Disapprovals s1ould be accompanied by an explanation.
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3.6 V0GTLE DUTY MANAGER l
The Vogtle Duty Manager (in accordance with procedure 00007-C, "Vogtle Duty Manager / Response Team") is responsible for the following:
3.6.1 Assignment of the ERTL (Critique Leader) for events g
listed in Section 1.0.
3.6.2 Determination if event review is required (and assignment of an ERTL) for those events not listed in Section 1.0.
3.6.3 Calling out the Event Review Team.
3.7 EVENT REVIEW TEAM LEADER The Event Review Team Leader (ERTL) has the following responsibilities:
3.7.1 Designating an individual for Event Data Collection, if-the data has not already been compiled.
3.7.2 Ensuring personnel involved / associated with the Event fill out an Event Personal Statemert, when not already completed.
3.7.3 Obtaining Event Review Team membern from other departments including, as necessary, representation from Operations, and an 2ngineer to ensure an overall plant perspective.
For some eventa HPES, NSAC, or QA representation may be appropriate.
3.7.4-Assigning specific duties and responsibilities to F, vent Review Team members in order to complete the review and report.
3.7.5 Providing recommendations to the CMNP, AGM-OPS, AGM-SPT l
for consideration in determining readiness to restarting the work or the reactor, unless a restart decision has already been made per step 4.1.4.
3.7.6 Informing the CMNP, AGM-OPS, AGM-SPT, Manager Operations and the Manager Engineering Support when an Event is classified as being of unknown cause or when safety-related equipment did not function properly during the event.
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Completing the Event Report per Data Sheet 1 (Data 3.7.7 Sheet 2 for security events). The ERTL will designate someone to coordinate completion of required forms.
3.7.8 Determining root cause(s) per Procedure 00058-C, " Root Cause Determination".
3.7.9 Recommending corrective actions.
i 3.7.10 Reviewing investigation results with responsible department managers and site management within seven days of the event.
1 3.7.11 Obtain approvals and expected completion dates for corrective actions to be performed.
3.7.12 Requesting, by memo, an extension of the seven day requirement, when appropriate, from the Office of the General Manager.
Documentation of extention is to be retained as part of the Event Report.
3.7.13 Ensuring a copy of the full report is sent to the Technical Support Department within 3 days of submission to the CMNP/AGM-OPS /AGM-SPT so that necessary NRC reports can be completed, when applicable.
4 3.8 EVENT REVIEW TEAM 3.8.1 The Event Review Team is responsible for conducting and documenting Event Investigation, Root Cause Determination, Recommended Corrective Actions, and preparing final report for the General Manager-Nuclear
?lant.
3.8.2 For reactor trips, the POST-TRIP REVIEW TEAM (Event Review Team) consists of the following:
Team Leader:
Management or Supervision, (D)
I Member: ISEG Supervisor or Alternate (D) l Member: An IEC Supervisor or Superintendent (D)
Member: An Engineering Supervisor (D) l Member: Operations Supervisor or Shift Supervisor (D)
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6 of 37 Member: Maintenance Supervisor or Superintendent (D) l Member: Other members as requested by the Team Leader (e.g., HPES, Outage & Planning, Technical Support or SAER)
(D) = designated 3.8.3 For other events the Event Review Team composition will be designated by the Event Review Team Leader as appropriate.
An Engineering representative will participate in all event investigations.
A Maintenance representative will normally participate in event l
investigations when abnormal component operation was a cause of the event.
I 3.8.4 For other events identified by site management, the department manager responsible in the event or for the procedure involved, will be designated the ERTL, unless otherwise specified by site management.
3.8.5 Event Review team members should be someone who will be available for the duration of the Event Review.
l 3.8.6 Team members are responsible for action plan items assigned to their department, as well as other duties l
assigned by ERTL.
3.8.7 Outage & Planning is responsible for checking the mode i
deferred binder to ensure required surveillances have not been missed.
3.9 MANAGER PLANT TRAINING AND TMERGENCY PREPAREDNESS l
l The Manager Plant Training and Emergency Preparedness reviews the event report to determine what aspects of the even may impact training programs.
3.10 PLANT PERSONNEL Plant Personnel are responsible for the following:
3.10.1 Completing an Event Personal Statement when involved / associated with an event, prior to leaving the i
i site.
3.10.2 Providing information to the Event Review Team during the Data Collection.
3.10.3 Participating in any critique or post event review as i
1 requested.
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7 of 37 3.11 ISEG 3.11.1 Maintain an Event Report Log to include the event number, event date, ERTL name and description of the event.
3.11.2 Support a thorough review of events by providing personnel to participate in Event Investigations.
4.0 INSTRUCTIONS 4.1 GENERAL 4.1.1 The event investigation process is a six-step process.
Step Responsibility Initial Data Collection OSOS Event Investigation & Report Event Review Team Leader Restart Decision CMNP/ACM-OPS Event Investigation Review ACM-OPS /PRB Identification of Corrective Event Review Team Leader Actions i
Follow-up Technical Support I
Duty Manager for reactor trips as stated in step 4.1.5 4.1.2 The initial objective of an investigation is to determine the neceptabit'.ty of performing a reactor restart or operational work resumption.. Jut investigation should determine root cause(s), and recommend corrective actions (s).
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4.1.3 The OSOS informs the Vogtle Duty Manager of events.
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4.1.4 For unplanned reactor trips where the direct cause is known, plant conditions have stabilized and emergency systems have appropriately operated, a restart decision may be made in accordance with Procedure 00300-C
" Authority To dtartup And Shutdown Reactors",by the prior to the event investigation and report performed ERTL.
The initial data collection step and procedure 10006-C, " Reactor Trip Review" will be followed prior to determining a reactor restart.
l 4.1.5 The Vogtle Duty Manager determines if an Event warrants callout of an Event Review Team.
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4.1.6 The Vogtle Duty Manager assigns an ERTL for events I
requiring further evaluation.
4.1.7 The Event Investigation and evaluation will be initiated by the Event Review Team after plant conditions have stabilized.
4.1.8 The Event Investigation must not distract the OSOS or operating personnel from their primary responsibility of monitoring plant parameters and maintainin4 the plant in a safe condition.
4.1.9 If deemed necessary by the Vogtle Duty Manager or l
respective department management, additional personnel will relieve shift personnel to allow the investigation to occur while the information is fresh.
4.1.10 The Vogtle Duty Manager /ERTL can modify the team size i
or scope of effort when revealed facts show that the Event Investigation can be modified.
4.2 DATA COLLECTION 4.2.1 The purpose of the data collection-phase of the event review is to gather sufficient data to reconstruct the event from a point prior to the initiating event until plant parameters have stabilized after the event NOTE Procedure 10006-C, " Reactor Trip 1
Review" will be used to supplement Data Sheet 1 for reactor trips.
4.2.2 The OSOS, or OSOS designate, is responsible for I
determining information and records to be collected.
The OSOS designates the individual to conduct data i
collection of appropriate hard copy information listed in Data Sheet 1.
Strip chart recordings must l
1 accurately reflect real time to have meaningful information.
If this is not the case, the OSOS designate will ensure that the chart paper is annotated with a time mark, chart speed (chart speed may change during transient), and time scale.
Appropriate commuter tapes should be retained until released by the ERTL.
Prior to resetting annunciators and flags not on the slarm printer, they should be recorded (i.e., generator LEDS or comon alam lockouts).
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'4.2.3 After the plant is in a safe, stable condition, the ERTL will ensure appropriate individuals involved in the event (e.g., plant operator, mechanic, technician, shift supervision etc.) have provided a statement concerning his/her involvement in the event prior to leaving the site.
These statements may be obtained in l
any one or combination of the following ways.
u a.
Written personal statements b.
Event Review Team interviews with personnel involved in the event c.
Critique with all involved personnel 4.2.4 If either of the last two techniques is used, the information should be recorded to ensure future availability of the information.
The event personal statements will be restricted to facts personally observed concerning the event, and the facts should be stated chronologically, if possible.
Conjecture and opinions stated should be annotated as such.
The statement will include the followings a.
Plant ennditions prior to the event (for maintenance personnel, this will include the status of maintenance or testing).
h.
First indication that a problem existed (e.g., f2 S/G decreasing level at 30% or radiation monitor RE-006 increasing),
c.
Individual's specific actions as a result of the indications (e.g., opened B/P FRV or started a leak rate determination).
l d.
Subsequent indications and plant response, including manual actions.
e.
Noted equipment malfunctions or inadequacies.
f.
Procedure deficiencies identified during the situation.
g.
Recommendations to prevent recurrence.
The written statements or tape recordings will be included in the Event Report to assist in event reconstruction.
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4.2.5 As part of the investigation the Investigation Questions, listed in Data Sheet 1, as appropriate, will I
be answered by the Event Review Team at the completion of interviews.
4.2.6 The OSOS designate assembles the initial hard copy information and personal statements for the Event Report.
This information will be submitted to the Manager Operations to be used during the event l
investigation.
4.2.7 The Manager Operations ensures the event report data is in provided to the ERTL 4.3 EVENT INVESTICATION e
4.3.1 The Event Review Team, under the direction of the ERTL, is responsible for the investigation and analysis.
The Event Review Team will complete the requirements of, and answer the questions on, Data Sheet 1, as I
appropriate.
4.3.2 The Event Review Team will chronologic. ally reconstruct the trannient in the event investigation, using the collected data.
A chronological description of the event will be developed using all available data.
Pertinent alarms, tripa, actuations, and isolations will be listed, or marked on, the sequence-of-events or alarm-type printout.
Pertinent plant parameters shot:1d be inenrporated into the chronological list of events during the reconstruction.
4.3.2.1 For plant transients, a comparison of the reconstruction with past experience should be made by the Event Review Team based on their training and experiences.
A review will be conducted of the in-house Operating Ex1erience Report (OER) to identify similar industry OERs and similar previous in-house Event Review Reports available on the Operating Experience Program data base.
This review may be conducted by Technical Support or ISEG and should be orovided to the Event Review Team for evaluation.
Tais will assist in identifying indications of abnormal or degraded conditica, identify trends and indicate whether past corrective actions have been effective.
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11 of 37 The event reconstruction will also be comsared with the required procedure actions to determine tie effect of those actions on the plant response.
In some cases it may be worthwhile to compare the transient with a similst transient descri' sed in the Final Safety Analysis Report (FSAR).
However, it should be noted that FSAR transients are " Worst case" or limiting conditions and it should not be assumed that, because a transient did not result in pesk parameters exceeding the FSAR values, the plant response was acceptable.
A review will also be co7 ducted, as necessary, to evaluate susceptibility of other systems or components to a similar occurrence.
4.3.2.2 The Event Review Team will analyze and evaluate the event reconstruction and event comparison.
They will determine the cause(s) of the event and will provide operational recommendations to the Assistant General e
Manager-Plant Operations.
The' Event Review Team will look beyond the obvious indications to diagnose the root and contributory causes of the event and evaluate the plant response.
They will review the available information thoroughly, looking for (1) abnormal indications or degraded trends performance, (2) events occurring out of the normal or anticipated sequence, (3) failed or degraded responsa of equipment to control signals, (4) unusual chemistry results or radiation readings, and (5) unanticipated alarms.
The actual or suspected cause of the event and any abnormal or degraded indication identified during the transient will be documented in the Event Report.
4.3.3 A preliminary safety assessment of the event and subsequent plant response will he performed by the Event Review Team.
The maximum and minimum values of selected parameters will be compared with their established specifications.
The Event Report will document this safety assessment.
4.3.4 A root cause determination is to M conducted ptr Procedure 00058-C,
" Root Cauts hvermination".
The root cause worksheet and the Ntommended corrective actions with actions to prevent recurrence are attached l
to the Evert Review and presented to management for approval.
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12 of 37 4.3.5 Corrective actions assigned by the Event Review Team must have the receiving departments concurrence.
This may be achieved by having the Event Team members contact their department manager directly or having the i
ERTL obtaining concurrence at the daily status meeting.
If concurrence is not obtained the affected department manager (s) will attend the presentation to asnagement.
Their concerns will be resolved by management at this meeting.
4.3.6 The Event classification guidelines in section 4.10 should be used for event classification. The statements following the identified classification (s) should be addressed in the Event Report.
Once the event is classified, the Event Review Team Leader (ERTL) will inform the CMNP/ACH-OPS /ACM-SPT.
If I
the event is classified as being of unknown cause or safety-related equiament did not function properly during the event, tTe ERTL will also inform the OSOS, Manager Operations and the Manager Engineering Support.
I 4.4 RESTARTING WORK /0PERATIONS 4.4.1 Tha OSOS and ERTL may recommend a restart of the reactor or work, whenever the cause of the event is known, corrected, and all associated safety-related i
equipment operated satisfactorily during the event.
4.4.2 The ERTL will inform the CNNP/ACM-OPS /ACM-SPT when an l
l event cause is unknown.
At the request of the ERTL, i
appropriate management or personnel will report to the plant site to assist in further investigation of the event and to determine necessary corrective action before restart.
In some cases restarting work or the reactor is aapropriate without the investigation being complete.
be restarted as allowed by The reactor may only' Reactor Trip Review" and Procedure Procedure 10006-C, 00300-C, " Authority To Startup And Shutdown Reactors".
Operations and Engineering management will analyte the event reconstruction, emphasizing the root cause(s) of the event and the resolution of abnormal or degraded indications.
They will use available expertise to resolve questions concerning the cause and plant response.
Sources of expertise that should be considered include nuclear steam supply vendors, vendor engineers, on-site engineering staff, corporate engineering staff, and other experienced operations and maintenance personnel.
The following information will i
be presented to management
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a.
-The actual or most probable cause of the event b.
The maintenance and testing necessary before restart including additional measures to verify j
the most probable cause i
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Additional monitoring or trending required during and/or after reactor restart d.
Necessary briefings to Operations and/or Maintenance personnel concerning specific equipment indications or possible malfunctions e.
The conditions necessary for resumption of work or for a reactor restart 4.5 REPORT. NUMBERING Each Event Report will be assigned a sequential number with the unit number and last two digits of the current year preceding the assigned number (e.g. 1-89-XXX).
The sequence will begin at X-XX-001 (e.g. 1-89-001) at the beginning of each year.
An Event Report log will be kept by ISEG and updated an each event occurs.
4.6 EVENT REPORT The following basic information should be included by the ERTL in an Event Report.
The ERTL may delete non-applicable sections.
4.6.1 Unit (s) Status at Time of Event List the plant operating conditions prior to the event for each unit involved.
These include:
- 1) megawatts thermal, 2) percent of rated thermal power, and 3) mode.
The information may be augmented by reactor reactor coolant temperature, or other pressure applicableinformation.
This section should also include any inoperable equipment, structures or components that contributed to the event.
The status of these systems must be stated.
This section will have two major subheadings:
1.
Power Level / Mode and 2.
Inoperable Equipment.
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14 of 37 The sections should he in the form:
1.
Power Level / Mode Unit I was in steady state operation at an approximate power of 3411 MWe (100 percent of rated thermal power).
The reactor was in mode 1.
2.
Inoperable Equipment The TD AFW system was tagged out of service for maintenance.
4.6.2 Description of Event This section has 6 subsections.
These are:
- 1) Event,
- 2) Dates / Times, 3) Other Systems Affected
- 4) Method of Discovery, 5) Operator Actions, and 6) Auto / Manual j
Fafety System Response.
This section of the report may be written in a narrative fashion where possible.
4.6.2.1 Event The description of the event shall be written in sufficient depth so that knowledgeable readers conversant with the design of commercial nuclear power plants, but not familiar with the details of a can understand the complete event.
particular plant,f a plant that are unique and that Characteristics o influenced the event, favorable or unfavorable should be described.
Also, describe how system, component, and operating personnel performance affected the course of the event.
The descriation of the event should also describe the event from t1e perspective of the operator, for example, what the operator saw, did, perceived, understood, or misunderstood during the event.
4.6.2.2 Dates / Times This section may be done in a serial (list) fashion.
However, every attempt should be made to maintain each item in the list in a narrative form.
Include the dates and approximate time for all major
., discoveries, immediate corrective occurrences (e.g/ components declared actions, sy/ operable, reactor trip, stable conditions stems inoperable achieved).
Include an estimate of the time and date of failure of components, trains, and systems if different than the time and date of discovery.
For failure that rendered a train of a safety system inoperable, provide an estimate of the elapsed time from the discovery of the failure until the train was returned to service.
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15 of 37 4.6.2.3 Other Systems Affected Provide a list of other systems or secondary functions that were also affected by each component failure or fault, if the component had multiple functions (if none, so state).
4.6.2.4 Method of Discovery Describe the method of discovery of each component failure, system failure, personnel error or procedural deficiency (e.g., while reviewing surveillance procedures or results.... during a pre-startup valve lineup check..., while performing quarterly maintenance on.
during a plant walkdown...).
4.6.2.5 Operator Actions Describe all major operator action that affected the course of the event (including immediate corrective actions, operator errors, etc.) and any procedural deficiencies that contributed to the event (if none, so state).
4.6.2.6 Auto / Manual Safety System Response List all automatic and manually initiated safety system responser that occurred including those necessary "to i
place the plant in a safe and stable condition.
( All systems responded as designed" is not sufficient.
If none, so state.)
4.6.3 Cause of Event This section has two subsections:
- 1) Direct Cause, and
- 2) Root Cause(s).
Both of these sections should be i
written in as close as possible to a narrative format.
i Each subsection is more fully described below.
j 4.6.3.1 Direct Cause Describe the cause of the event.per section 4.10 and
)
include the failure mode, mechanism (direct cause), and i
effect (consequence) of each failed component (e.g.
valve failed to open because the stem broke resulting in no flow to the reactor).
4.6.3.2 Root Cause (Perform per Procedure 00058-C. " Root Cause j
Determination" and attach a copy of the root cause dete rmination worksheets).
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16 of 37 If the event involved personnel error, the cause discussion must also include:
Information as to whether the personne1' error was the result of a cognitive error or the result of a procedural error.
Also..information as to whether the personnel error was a result of not adequately following an approved procedure, was a direct result of an error in an approved procedure, or was a result of the activity or task not being covered by an approved procedure, j
l The type of personnel involved in the event (e.g.,
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' contractor maintenance personnel, utility-licensed operator, utility-nonlicensed operator, utility maintenance personnel).
Any unusual characteristics of the work location (e.g., heat, noise, smoke, poor lighting) that directly contributed to the personnel error.
If the cause of a failure cannot be readily determined and the investigation is to continue, stater (a) the steps pisnned to continue the investigation, and (b) that a supplemental report will be rubmitted that discusses the results of the investigation and includes the cause and all planned corrective actions.
4.6.4 Analysis of Event An assessment of the safety consequences and implications of the event should be made.
This assessment must include the availability of other systems or components that could have performed the same function as the systems or components that failed (or otherwise became inoperable) during the event.
The assessment should also include the safety consequences and implications had it been possible for the event to have occurred under a more severe set of initial conditions (e.g., at power rather than shutdown, at 100I power rather than 201).
If it is concluded that no safety consequences resulted from the event, state how this conclusion was reached.
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17 of 37 As general guidance, when an event involves the loss of a system, t3e analysis should focus on the other systems available to mitigate the event.
If the event involves a hardware breakdown or design deficiency / inadequacy the analysis can focus on the
. administrative controls (procedural guidance that are in effect and which can mitigate the event).
Where the event involves an administrative problem, the snelysis can focus on the hardware and design that mitigate the consequences of the event.
4.6.5 Corrective Actions I
A description of any corrective action planned or taken as a result of the event should be provided.
This should include a discuasion of repair or replacement actions as well as those actions that will reduce the prohnbility of a similar event occurring in the future (e
r,., "the valve was replaced and the ersonnel i
involved in the event were counseled," p'the pump was repaired and a d acussion of the event was included in the training leccures " "no modification to the instrument was deemed necesrary but a Caution Notice was inserted into its calibration procedure jusc prior to the step that initiated the event").
This section should address the four elements of the corrective action program:
- 1) correction of the i
deficiency, 2) investigation of similar conditions, 3) decermination of root cause of the event, and 4) development of long term corrective action to prevent recurrence.
1 4.7 INVESTIGATION REVIEW 4.7.1 The Event Review Team Leader is to have completed the-Event Report within 7 days of the event and present it to appromriate management for approval.
The ERTL will I
cnsure tlat a minority opinion is attached to the report whenever a team member does not agree with finding of the team and request his opinion be included.
4.7.2 Department managers who have not provided approval to l
corrective actions assigned by the Event Review Team will be present at the presentation to management.
Department managers will approve of corrective actions l
or provide alternative corrective actions.
Differences will be resolved by plant management.
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18 of 37 4.7.3 Events with known causes and proper system response wili be revtewed by management.
If deemed appropriate by the AGM-OPS, as a result of safety significance or potential generic aspects, the AGM-OPS will forward the 4
report to the PRB for review.
4.7.4 Events with unknown causes or with significant systems not responding properly during the event, if directed by the GMNP/ACH-OPS /ACM-SPT, will be reviewed by the l
PRB before a reactor or work restart is consnenced.
In any case, the CMNT/AGM-OPS /AGM-SPT will forward the l
Event report to the PRB for review.
l 4
4.8 FOLLOW-IfP 4.8.1 Complete and incomplete corrective actions vill be forwarded to the Technical Support Department as part of the original Event Report for input to the Oaen Item /Comitment Tracking Program.
At this point I
t:1e Event Report Log should be marked with the Investigation report completion date.
4.8.2 When all corrective actions have been implemented and action items closed the Technical Support Deparen.ent I
will transmit the completed report to Document Control for retention as a lifetime record.
4.9 EVENT CLASSIFICATION CUIDE Each Event Report will be classified according to the direct cause of the event.
Root and contributcry causes are to be classified in the Root Cause Determination.
This is to aid in finding problem indicating trends, clarifying administrative areas,ls, and improving the operational reliability of contro the plant.
DIRECT CAUSE CODES Cause Code Mesning A
Personnel error B
Design Manufacturing, Construction / Installation C
External Cause D
Defective Procedure
E
!!anagement/ Quality Assurance Deficiency X
Other The general definitions of these classification are ao follows:
A.
Personnel Error _ -
This classification is assigned to inilutes actributed to human errors.
When errors were made as a result,f following beorrnet written procedures, the occurrence should he entered under defective procedure (see Paragraph D below).
W.en errors were made because written procedures were not followed or beenuse i
personnel did not perform in accordance trith accepted or approved practice, the occurrence j
should be classified under personnel error.
For example:
failure to use an approved procedure, failure to pro erly identify equipment, failure to observeradiat!onprotectionrules,failureof qualified personnel to perform in accordance with accepted or approved practices.
In addition, personnel errors may be due to lack of or insufficient training, experience, supervisicq, environmental conditions, proper tools, poor health, etc.
An event classified as A. Personnel Error should include the following A description of the personnel error as well a.
as a concise statement of the personnel error (i.e., Tech "A" did not follow procedure).
b.
A discussion of the rocedural involvement as well as employee qua ification to perform the indicated task.
c.
An evaluation of the corrective action taken pursuant to the personnel error.
B.
Design. Manufacturing. Construction / Installation -
This class 111 cation in assi6ned to taitures reasonably attributed to design, manufacture, construction or installation of a system.
component or structure.
For example, failures that were traced to such things as defective materials, significant breakdown in the quality assurance program or components otherwise unable to meet the specified functional requirements or performance specifiestion should be included in this classification.
DO a
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PROCEDURE No.
REVISION PAGE NO.
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20 of'37 1.
Design Deficiency An event classified as B. Design Defic'ency should include the followings a.
Describe in detail the deficiency and how it reisted to or contributed to thu event.
Provide sketches as appropriate.
I b.
Address the same or similar design deficiency aR it may exist elsewhere at the station.
c.
Discuss how long the existence of the deficiency has been known and describe any action taken previously to correct it.
2.
Manufreturina Deficiency - This classitication is assigned to events attributed to a manufacturer's fabrication activities.
Cenorally it will cover a component or system that fails to perfora its intended function as specified in design or procurement documents, manufacturer's technical manuals, etc.
For example failures traced to defective material, incorrect materials, abnormal wear or cther degradation under normally anticipated plant conditions.
An event classified as B. Manufacturing Deficiency should include the followings a.
Describe in detail the deficiency and how it related to or contributed to the event.
Provide sketches as appropriate.
b.
Provide manufacturer data such at make, model or part number, sufficient to uniquely identify the deficient item.
c.
Indicate whether or not the manufacturer has been notified.
d.
Review NPRDS for industry experience.
mwn j
enocsouns na nevision me no.
VEGP 00057-C 4
21 of'37 3.
Construction / Installation Deficiency - This
'classificacion is assigned to evencs attributed to field construction and/or installation errors.
For exam >1e:
location of components different from tsat shown on drawings: not following inspection or cleanliness specifications or installing valves backwards.
An event classified as a B. Construction /
Installation Deficiency should include the following n.
Describe in detail the deficiency and how it reisted to or contributed to the event.
Provide sketches as appropriate.
Does the same or similar deficiency ?
b.
exist elsewhere in the plant?
Where c.
How did the deficiency occur?
(if able to determine) d.
If the deficiency was previously known, describe any action taken to correct the deficiency.
4.
Component Failure / Malfunction - This classificacion is asmigned co events whenever the cause of equipment failure cannot reasonably be attributed to inadequate design, manufacturing, construction, or installation.
An event classified as B. Component Failure /
Malfunction should include the followings a.
Describe in detail the failure and how it occurred, b.
Describe previous failure of a similar nature and previous corrective actions taken.
c.
Discuss how the failure relates to or contributed to the event.
d.
Address potential generic concerns if applicable.
mM.i
PAoCEDURE NO.
REvi5 son PAGENO.
VEGP 00057-C 4
22 of 37 e.
Discuss any relevant preventive maintenance or surveillance testing concerning the item, f.
Review NPRDS for similar iter.a.
C.
External Cause - This classification is assigned to tailures actributed to natural phenomena.
A typical example includes failure resulting from a i
lightning strike, tornado, or flood.
This classification is also assigned to man-made external causes that originate off-site (e.g., an industrial accident at a near-by industrial facility).
An event classified as C. External cause should include the followings a.
Describe in detail the unusual service condition end what created it.
b.
Describe how the condition related to or contributed to the event, c.
Address the same or similar condition which has been identified during the investigation.
d.
Address how long the condition had existed and what arevious action (s) had been taken to correct tTe condition.
e.
Review industry experience for similar events and corrective action.
D.
Defective Procedure - This classification is assigned co tailures caused by(inadequate orsee Paragraph A incomplete written procedures above) or instruction.
The absence of good judgement or good engineering practice generally should be classified as A. Personnel Error.
All circumstance cannot be covered by procedures.
An event classified as D. Defective Procedure should include the following:
a.
Describe in detail the deficiency and how it related to or contributed to the event.
Attach procedures, directives, etc., clearly marked as to problem areas if appropriate.
- m...
~
+
~~
lll l
b.
Address the same or similar deficiencies which have been identified during the investigation process.
c.
Discuss procedural involvement, if any, as well as personnel qualifications to perform the procedure.
Management / Quality Annurance Deficiency - This E.
class 111 cation is assigned to a failure of management or management systems (e.g., major breakdowns in the administrative controls, preventive maintenance program, surveillance program, or quality assurance controls).
An event classified ad E. Management / Quality Anaurance Deficiency should include the followings a.
Describe in detail the deficiency and how it related to or contributed to the event.
Attach procedure or directives clearly marked
-ss to problem areas if appropriate.
b.
Address the same or similar deficiencies which have been identified during the investigation process.
c.
Discuss procedural involvement, if any, as well as personnel qualifications to perform the procedure.
X.
Other - This classification will be assigned to failures for which the approximate cause cannot be identified or which cannot be assigned to one of the classifications noted above.
An event classified as X. Other should include the followings a.
Describe in detail the event and how it was discovered.
i b.
Discuss previous occurrences of similar nature.
c.
Discuss what possible causes have been considered as well as any reasonable postulated cause.
I i
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'.....u.y r !':..... -
- _.
- ;..y....
' ' S' PROCEDURE NO.
REVWON PAGE R '
'._},
VEGP 00057 C 4
: y g,g 3 y
.s
- /h
5.0 REFERENCES
l, '
- e l...
5.1 PROCEDURES e,
5.1.1 00007-C, "Vogtle Duty Hansger/ Response Team" l
'y '
5.1.2 00058-C,
" Root Cause Determination" 5.1.3 00150-C,
" Deficiency Control" 5.1.4 00300-C,
" Authority To Startup And Shutdown Reactors" 5.1.5 10006-C,
" Reactor Trip Review" 5.1.6 90142-C.
" Security Report Procedure" l
END OF PROCEDURE TEXT b
r 1
PROCEDURE NO.
REYl510N PAGE NO.
VEGP 00057-C 4
25 of 37 EVENT INVESTICATION GUIDELINES 1.
COLLECT DATA PACKAGE FROM MANAGER OPERATIONS OR OSOS, 1
OR DESIGNEE, AND REVIEW.
2.
PREPARE AN INTERVIEW
SUMMARY
OF QUESTIONS AND ANSVERS FOR EACH IUTERVIEW CONDUCTED.
3.
REQUEST AND KEEP HARD COPIES OF ALL PERTINENT RECORDS (HWO'S, SECTIONS OF VENDOR MANUALS, PRINT, ETC.)
4.
ANSWER QUESTIONS ON SHEETS 8, 9 AND 10.
5.
DETEMINE THE SEQUENCE OF EVENTS AND LIST ON SHEET 7.
6.
KEEP TRACK OF ACTIONS AND SOLUTIONS FOR USE IN THE EVENT REPORT.
7.
WHEN ALL CONCERNS ARE ANSWERED, PERFORM A ROOT CAUSE DETEMINATION PER PROCEDURE 00058-C.
8.
DETERMINE THE EVENT CLASSIFICATION AS DESCRIBED IN THE CLASSIFICATION CUIDE, SECTION 4.9.
9.
DETER"tNE AND DOCUMENT ANY ADDITIONAL RECOMMENDED CORRECTIVE ACTION ON ROOT CAUSE DETERMINATION SHEETS.
10.
COMPLETE AN EVENT REVIEW KEPORT BASED trPON THE REQUIREMENTS OF SECTION 4.6.
11.
PERFORM A SAFETY ASSESSMENT PER 4.3.3 and 4.6.4.
12.
DEPARWENT MANAGER REVIEW AND APPROVAL OF RECOMMENDED 1
CORRECTIVE ACTION AND EXPECTED COMPLETION DATES GIVEN ON THE ROOT CAUSE DETERMINATION SHEETS.
13.
PRESENT INVESTIGATION RESULTS TO RESPONSIBLE DEPARTMENT MANAGERS AND SITE MANAGEMENT WITHIN 7 DAYS OF THE I
EVENT.
14.
PROVIDE TRAINING A COPY OF EVENT REPORT FOR REVIEW AND USE IN CONTINUING TRAINING.
15.
FORWARD THE EVENT REVIEW PACKAGE TO TECHNICAL SUPPORT DEPARWENT FOR INPUT TO OPEN ITEM / COMMITMENT TRACKING.
16.
TECHNICAL SUPPORT FORWARDS THE EVENT REVIEW PACKAGE TO I
DOCUMENT CONTROL OR RETAINS AS A HISTORICAL DOCUMENT PER OTHER INSTRUCTIONS.
FICURE 1 EXAMPLE
emoctount NO.'
REVISION PAGENO.
VEGP 00057-C 4
26 of 37 i
i Event Report No.
Report:
Page _ of EVENT PERSONAL STATEMENT
- 1.
FOR THE PERIOD PRIOR T0. DURING, AND AFTER THE EVENT, SUMMARIZE THE SEQUENCE OF EVENTS THAT YOU OBSERVED, AND YOUR SPECIFIC ACTIONS TAKEN BASED ON INDICATIONS.
2.
DID ANY AUTOMATIC SYSTEMS OR EQUIPMENT MALFUNCTION REQUIRE ANY OPERATOR INTERVENTION?
(Describe) 3.
DID THIS EVENT REVEAL ANY PROCEDURAL INADEQUACIES?
(Describe)
FIGURE 2 EXAMPLE mm
PROCEDURE NO.
REVi$lON PAGE NO.
VEGP 00057-C 4
27 of 37 Event Report NO.
Report:
Page _ or 4.
IF THIS EVENT OCCURRED ACAIN, WHAT WOULD YOU DIFFERENTLY 7 5.
ARE THERE ANY LESSONS LEARNED FROM THIS EVENT THAT YOU BELIEVE SHOULD BE INCLUDED IN TRAINING 7 (Describe) 6.
COMMENTS:
2 SIGNATURE TITLE DATE For reactor trips the personnel statement form in Procedure 10006-C may be used in lieu of this form.
FIGURE 2 (CONT'D) EXAMPLE l
r
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- n. g.,.
I_
Paoctount no, navseon ease no.
l VECF 00057-C 4
28 of 37 Sheet 1 of 10
[
DATA SHEET 1 Report:
Page _ of
(
i EVENT REPORT i
EVENT TITLE:
{
f I
REPORT NUMBER:
DATE(S) OF EVENT:
EVENT CIASSITICATION:
J l
Names of EVENT REVIEW TEAM MEMBERS j
i i
Signature of EVENT REVIEW TEAM LEADER l
1 DATE COMPLETED 4
MANAGEMENT REVIEW AND APPROVAL PRB Review Required YES []
N0 []
1 4
I FRB Chairman Meeting No./ Date j
i j
mue 5
.-,.l
PnocEouME NO.
REVISCN PAGENO.
VEGP 00057-C 4
29 of 37 SheeE 2 of 10 DATA SHEET 1 Report:
Page _ of TAALE OF CONTENTS FOR EVENT REPORT NO.
- PACE 1.
REPORT NARRATIVE (PER SECTION 4.6) 2.
EVENT DATA COLLECTION................
3.
CHRONOLOGY......................
4.** PERSONAL STATEMENTS...(Figure 2).
5.
ROOT CAUSE DETERMINATION (PER 00058-C).
4 6.
ADDITIONAL SUPPORTING ITEMS.............
ERTL TO NUMBER EACH PACE OF TIIE REPORT AND ENTER APPROPRIATE PACE NUMBERS.
ADDITIONALLY THE ERTL WILL ENSURE THE EVENT REPORT NUMBER APPEARS ON EACH PACE OF THE REPORT.
INFORMATION WILL BE PRESENTED ON THE INDICATED FICURE.
r I
4 f
~~
-e enocsouns no.
amsson pros no.
VECP 00057-C
=4 30 of 37 Sheet 3 of 10 DATA SNEET 1 Event Report No.
RVENT DATA COLLECTION Report Page _ wI _
EVENT DESCRIPTION EVENT DATE UNIT.
EVENT TIME DEFICIENCY CARD NUMBER l
(IF REQUIRED) 2.
TYPE OF EVENT A.
( )
P.
RADICACTIVE SPitt/
S.
FORCED RF. DUCTION
( )
UNCONTROLLED RELEASE
( )
C.
PLANT TRANS!ENT
( )
C.
LIQUID INVENTORY Loss
( )
D.
( )
N.
OTHER SICMIFICANT EVTNT ( )
E.
PERSONNEL CONTAMIN
( )
3.
EVENT REVIEW TEAM CALLED OUT TIME SAER INFORMEdt TIME CORPORATE DUTY MANAGER INFORMED TIME 4.
DATA COLLECTION AS$1CNMENT 3.
DATA: FOR REACTOR TRIPS COMPLETE 10006-C. AND CIVE A COPY TO THE EVENT REY!EW TEAM. POR ALL OTHER EVENTS COMPLETE THE SECTION 5 THROUCN 16 AND PERSONAL STATEMENTS.
STATDfENT ACTIVITY PERFORMED ATTACNED SHIFT PERSONNEL AT THE TIME OF THE EVENT TES OR NA 050$
l R0 PO STA OTHER5 1Mv0LVED _
6.
DATA 70 SE COLLECTED (0$0S TO CNECR ITDis)
NOTE: REMOVE THE DISR PACR AFTER A TRIP /St.
PLANT COMPUTER AtARM PRINTOUT ( )
PLANT COMPUTER EYDt? LOCS (
-)
ATSI PRINTOUT
( )
ERP COMPUTER EVENT 14CS
(
)
FAULT RECORDER PRtNTOUT
( )
ERP COMPUTER TREND PRINTS (
)
CNART RECORDERS (LIST)
I COPIES oft NRC-0C WOTIFICATION WORK $NEET (
)
$$ LOCS
(
)
AUX SLDC OPERATOR 1AC
(
)
TURRINE SLDC LOC
(
)
RWD LOC
(
)
CONTROL SLDC OPERATOR LOC (
)
ELECTRICAL IDC
(
)
OUTSIDE OPERATOR 14C
(
)
UNIT CONTROL
(
)
i 1
CNEMISTRY NP MWD's 4
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l l
c.
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PROCEDURE NO.
REvillON PAGENo.
VEGP 00057-C 4
31 of '7 Sheet 4 of 10 DATA $NEET 1 Event Report No.
Report: Page of 7.
PLANT CONDITION WHEN APPROPRIATE MAXIMUM /MININUM PRE-EVENT VALUE POST F*/PNT NODE
/
XTACTOR POWER
/
I BORON CONCENTRATION
/
STEAM CENERATOR LEVEL 18
/
- Use NR or WR, 28
/
whichever is 3*
/
indicating 4*
/
CENERATOR OUTPUT
/
MvE PRESSURIZER LEVEL
/
8.
Pt. ANT CONFICURATION 8.1 OPP NORMAL STATUS OF PLANT SYSTEMS 8.2 TESTS AND SURVEILLANCES IN PROCESS 8.3 OTHER OPERATIONS IN PROGRESS AT THE TIME OF THE EVENT 9.
FOR ESPAS ACTUATION OR PA! LURE AUTOMATIC ( ) MANUAL ( ) N/A ( )
9.1 LIST CHANNEL ACTUATED /PAILED EXPLAIM SYSTEM RESPONSE I
9.2 DID THE ESPAS COMPONENTS OPERATE CORRECTLY?
TES ( )
NO ( )
WITN0UT UNDUE DE1Aff TES ( )
NO ( )
9.3 EXP! AIM ANT ABNORMAL SYSTEM ESTAS RESPON$tS. WRTt
,o.n
PROCEDURENO.
REVl&lON PAGENQ.
VECT 00057-c 4
32 of 37 Sheet 5 of 10 DATA SHEET 1 Event Report No.
Reports Page _ of 9.4 DESCRIBE ANY OTHER MALFUNCTIONS NOTICED:
l l
9.5 APPARENT EVENT CAUSE WAS l
l l
10.
CORRECTIVE ACTIONS 10.1 WHA IMMEDIATE CORRECTIVE ACTIONS WERE TAKEN AS A RESULT OF THE EVDIT?
10.2 WAT SUBSEQUENT CORRECTIVE ACTIONS ARE IN PROCRESS AS A RESUI.T OF TNE EVENT 7 10.3 WAT FURTHER CORRECTIVE ACTIONS ARE REC 0HKENDED?
I 11.
LIST CORRECTIVE ACTION TAREN TOR EACN ABNORMAL OCCURRENCE OR EQUIPMENT.
MALFUNCTION THAT ACCOMPANIED THE EVENT (STATE WHETNER COMPLETED, IN PROCRESS. OR PROPOSED).
12.
WERE PROCEDURES USED ADEQUATE?
YES (
)
NO (
)
VHY NOT7 13.
DID TNE OPERATOR $ AND 01MER PERSONNEL MANDLE THE EVENT CORRECTLYf EXPLAIN. DISCUSS CORRECTIVE ACTION TO DATE.
Ny g--,
r
I I
Sheet 6 of 10 l-DATA SHEET 1 Event Report No.
Report: Page _ of l
l l
l 14.
WAS AN EMERCENCY PLAN EAL REACRED? DESCRIBE LEVEL INVOLVED (NOUE, ALERT, SITE AREA, CENERAL).
15.
LIST LCO'S ENTERED LC0 NO.
DESCRIPTION INITIALS i
16.
LIST ANT SATETY LIMITS EXCEEDED. TECH SPEC AND DESCRIPTION i
.I
\\
COMPLETED BTt DATA COLLECTOR
1 l
PROCEDURE NO.
REVIMON PAGENQ.
VECP 00057-C 4
34 of 37 Sheet 7 of 10 DATA SHEET 1 Event Report No. _,
Report:
Page _ v.
SEQUENCE OF EVENTS CHRONOLOGY i
DATE/ TIME EVENT l
-,. 3
ltt l
PROCEDURE Nf LEvtSION PAGENO.
VEGP 00057-C 4
35 of 37 Sheet 8 of 10 DATA SHEET 1 Event Report No.
Report:
Page of INVESTICATION QUESTIONS A.
CENERAL 1.
DOES THE EVENT REPRESENT A PREVIOUSLY UNFORESEEN ACCIDENT SEQUENCE 7 YES/NO 2.
DOES THE FAILURE DIRECTLY OR THROUGH INTERACTION WITH OTHER SYSTEMS DECRADE THE PERFORMANCE OF ANY SAFETY-RELATED EQUIPMENT 7 YES/NO 3.
DOES THE FAILURE DIRECTLY OR THROUGH INTERACTION WITH OTHER SYSTEMS INCREASE THE PROBABILITY OF AN ACCIDENT 7 YES/NO 4.
DOES THIS FAILURE CHALLENCE OR ACTIVATE SAFETY SYSTEMS 7 YES/NO 5.
DOES THr. EVENT INCREASE THE PROBABILITY OF TRANSIENT-OCCURRENCES AND/OR REACTOR TRIPS 7 YES/NO 6.
DURING THE EVENT DID THE OPERATIONS STAFF RESPOND CORRECTLY 7 YES/NO 7.
ARE TRAINING RNOWLEDGE OBJECTIVES PERFORMANCE TASRS AND CONTROLS ADEQUATE TO PROMOTE THE PROPER PERFORMANCE OF THE OPERATIONS STAFF UNLER SIMIIAR CIRCUMSTANCES 7 YES/NO 8.
BASED ON A COMPARISON OF THIS EVENT WITH PREVIOUS EVENT REPORTS AND/OR FSAR ANALYSES VERE THERE ANY ABNORMAL OR DEGRADED INDICATIONS 7 TES/NO 9.
BASED ON COMPARISON OF REIATED SIMIIAR INDUSTRY AND IN-HOUSE EVENTS, IS THIS EVENT A REOCCURRENCE OF A PREVIOUS EVENT:
YES/NO 10.
DURING THIS EVENT, DID ALL AFFECTED SYSTEMS RESPOND AS EXPECTED 7 YES/NO 11.
DID THE INITIAL EVENT PRODUCE UNANTICIPATED SECONDARY EFFECTS WHICH COMPLICATED OR INCREASED THE CONSEQUENCES OF THE EVENT 7 YES/NO l
1
M PROCEDUAE NO.
MEV1580N PAGE NO.
VEGP 00057-C 4
36 of 37 Sheet 9 of 10 l
DATA SHEET 1 Event Report No.
Report:
Page _ of i
INVESTICATION QUESTIONS (CONT'D) 12.
BASED ON COMPARISON OF SIMILAR INDUSTRY AND IN-HOUSE EVENTS WERE PREVIOUS CORRECTIVE ACTIONS / IMPLEMENTATION EFFECTIVE 7 YES/NO 13.
IF QUESTIONS 1, 2, 3, 4, 5, 8, 9, OR 11 ARE ANSWERED YES, DESCRIBE THE REASON IN DETAIL IN THE EVENT REPORT.
14 IF QUESTION 6, 7, 10 or 12 ARE ANSWERED NO, DESCRIBE THE REASON IN DETAIL IN THE CVENT REPORT.
B.
PERSONNEL ERRORS 1.
WERE JOB ENVIRONMENT CONDITIONS SUCH AS LICHTING, VENTILATION, EXTREME TEMPERATURE OF PHYSICAL ACCESS TO THE TASK CONTRIBUTING FACTORS?
YES/NO 2.
WERE PROPER TOOLS AVAILABLE AND USED?
YES/NO 3.
VERE WRITTEN APPROVED PROCEDURE AVAILABLE AND PROPERLY I
FOLLOWED?
YES/NO 4.
IF THE PROCEDURE WERE FOLLOWED, WAS PROCEDURE.
i COMPLIANCE A C0t;TRIBUTORY CAUSE?
YES/NO 5.
WERE ADEQUATE INSTRUCTIONS CIVEN AND COMPREHENSION l
VERIFIED?
YES/NO 6.
WERE THE PERSONNEL INVOLVED IN THE PROPER PHYSICAL CONDITION?
YES/NO 7.
DID THE PERSONNEL INVOLVED MAVE ERRONEOUS IDEAS AND/OR CONCEPTS ABOUT THE SYSTEM INVOLVED?
YES/NO 8.
DID THE PERSONNEL INVOLVED HAVE PREVIOUS EXPERIENCE AND/OR TRAINING ON THE SYSTEM INVOLVED?
YES/NO 9.
DID THE PERSONNEL RECEIVE A BRIEFING OF THE EVOLUTION PRIOR TO STARTING?
YES/NO 10.
WERE COMMUNICATIONS ADEQUATE FOR WE EVOLUTION?
YES/NO 11.
WERE COMMUNICATIONS TESTED PRIOR TO STARTING?
YES/NO
+
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_