ML20091H868

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Applicant Exhibit A-136,consisting of Rev 5 to Procedure 00057
ML20091H868
Person / Time
Site: Vogtle  Southern Nuclear icon.png
Issue date: 07/19/1995
From:
GEORGIA POWER CO.
To:
References
OLA-3-A-136, NUDOCS 9508140304
Download: ML20091H868 (26)
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Text

{{#Wiki_filter:__ V 0 - l h lo GPc F-136 -- lTidcsouas sc. AswslON MGE NO. VEGP 00057-C 5 [10CKETE028 Of 37 l uann6 Sheet 1 of 10 ~ ~ % JUL 27 P4 44 DATA SHEET 1 0FFICE OF SECRETARY a Re%BfT pgE]Cggsw i i 4 4 1 i EVENT RZPORT EVENT TITLE: DG 2A Start Failure i REPORT NUMBER: 2-90-005 i DATE(S) 0F EVENT: 7-11-90 EVENT CLASSIFICATION: 8 f Names of EVENT REVIEW TEAM MEMBERS Ed Kozinsky scorge trecer1CK Paul Kocnery []Oj[a j Ken stor.es g$ cneries coursey y{3g ii - j Joe o' Artico p -B % a 1 o 2 E RNI TEAM LEADER wdN k N g0 g

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DATE COMPLETED 7-19-90 p yi i 5 MANAGEMENT REVIEW AND APPROVAL H g 9aa

  • 66' PRB Review Required YES NO (]

I z K I E w ___ %, I i L T-7/ -7 6 g s i FRB Chairman Meeting No./ Date-9508140304 950719 {DR ADOCK 05000424 PDR m

,t-Paocaouna No. navissa ,,a, uo, 1 VEGP 00057-C 5 29 of-37 + r Sheet 2 of 10 1 j DATA SNEET l' i .= Report: Page 1 of tt:N i i TABLE OF CONTENTS FOR l l EVENT REPORT NO. 2 05 j

  • 'PAGE 1.

REPORT NARRATIVE (PER SECTION 4.6) I 2. EVENT DATA COLLECTION. 4 3. CHRON0LOGT. 4.** PERSONAL STATEMENTS...(Figure 2) 2 5. ROOT CAUSE DETERMINATION (PER 00058-C). 6. ADDITIONAL SUPPORTING ITEMS... ERTL TO NUMBER EACM PAGE OF THE REPORT AND ENTER APPROPRIATE PAGE NUMBERS. ADDITIONALLT, TR ERTL WILL ENSURE THE EVENT l REPORT NUMBER APPEARS ON EACH PAGE OF TB REPORT. i 1 I INFORMATION WILL BE PRESENTED ON THE INDICATED FIGURE. i l l 1 ~~ r i j

I t i f Q.Q.O$ Page 3 of gg a l l i UNIT STATUS l Unit 2 was at 80% power at the time of the 2A diesel start failure. Unit 1 was at 100% power. No equipment related to the diesel. test out of service. e EVENT DESCRIPTION 1 On July 11, 1990, diesel generator 2A was being tested during a !~ routine surveillance per procedure 14980-2. The right air bank was isolated for the July test of the left air bank. When the i engine start button was pushed by the control room operator, the engine began to roll with starting air. The engine rolled twice and stopped, according to the local operator in the diesel room. The engine failed to start. The diesel was declared inoperable and the Technical Specification action statement was initiated. On July 5, 1990 a similar event occurred when diesel generator 1B failed to start. The causes and corrective actions of this i event are consistent with the DG 2A incident of July 11, 1990. 4 i 1 l i i i N l 1 4 1 6 4 \\ r

l i i 4 g.qQ.05 TROUBLE SHOOTING The seizing of these air start valves was discovered by a " pop test" performed und<sr the manuf acturer's direction. This test applies approximata?.y 100 psi of air to the starting air valve at the engine subcover. An audible sound can be heard on valve opening and closing, if the valve is not sticking. All valves initially noted to be sticking were machined to a tolerance of 0.002 to 0.003 and retested with no problems found. The engine was started and loaded to 100X and maintained until temperatures stabilized. The " pop test" was re performed with seven air start valves still indicating problems. One cap stud was untorqued during cap removal for inspection when we heard the piston pop open. A few other caps were loosened with the same results. All caps were removed on the problem cylinders and placed on a true flat surface. Some were found to be warped and all had irregular bore surfaces. All caps were replaced and pistons machined to approximately 0.003. i I s i I i f

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4 Page 5 of 29 s 2 -80 CD i

ROOT CAUSE: l Diesel generator 2A failures to start due to starting air valve piston seizure within its associated cap assembly appears to be l the result of marginal clearance between the piston and cap. This condition exists apparently due to manufacturer machining process which allow uneven bore conditions on the cap and in some cases caps with flanged surfaces which are not flat. l Secondly, the tolerances specified by the manufacturer were 1 0.001 to 0.003 between piston and cap. This clearance may have been sufficient for ambient temperature but did not allow for expansion of the piston inside the cap during engine standby or t operating conditions or to overcome any machining irregularities. i The event critique team determined that ineffective corrective l actions exists with respect to the ability to resolve Diesel Generator start problems. The July 11, 1990 start fallure of DG 2A was the fourth occurrence of this problem. A troubleshooting MWO had been written but not yet implemented. The third fallure e l of DG 2A occurred on April 20, 1990. An event critique team was not convened after this fallure contrary to the policy i j established as a result of the SAE event critique. 1 5 i 3 i J i i 4 ~.

Page 6 cf ?90t 4 W g,C g. y i. CORBECTIVE ACTIONS. l All Diesel Generator 2A air start pilot valve pistons have been verified to move freely inside the cylinder walls. Pop tests are to be performed immediately on Diesel Generators 2B, 1A and IB to demonstrate freedom of movement. Any sticking conditions noted will be appropriately corrected.. Additionally. Maintenance Procedures 28714, 28713, 28575, and 28576 are being revised to include provisions for pop tests during each refueling outage. 1 i l To minimise the possibility of sticking, Engineering is i 4 i l assessing the gay minimum clearance distance between the piston j and cylinder walls. Any changes in the desired minimum gap clearance will be reviewed against recorded gap distances for Diesel Generator 1A, 1B, and 2B for possible replacement.

Also, changes to the minimum gay clearance will be incorporated into Maintenance Procedures 28714, 28713, 28575 and 28576.

4 During the next scheduled tear down of Diesel Generators 1A, 1B, l and 2B, the surfaces of the air start pilot valves will be j checked for machining irregularities that could lead to sticking conditions. Replacement or reconditioning will be performed as necessary. l' To correct the problem of ineffective corrective actions noted i as a result of four Diesel Generator faf, lures to start, the l event critique team recommends that the policy of having event critiques for Diesel Generator failures should be continued i until plant management determines that Diesel Generators are l sufficiently reliable. This policy was established as a corrective action from the 3/20/90 SAE event. l 4 1 i i i I a 4 i l i -~

4 Page 7 of 26 -3Ao 03 IV. ANALYSIS OF EVENT l Diesel Generator 2A is one of two independent power sources j that provide power to class 1E busses. During the time the 2A diesel engine was under investigation, the redundant 2B diesel 4 i generator was capable of performing its intended function The plant entered an action statement.for technical specification 3.8.1.1 which requires initiating a plant shutdown if the diesel ] l cannot be made operable within 72 hours. ~ Prior failures of this engine may not have been fully investigated to ensure the causes of the failures were found and corrected. The results of this investigation indicate that there existed a manufacturing or installation error that j resulted in deformed air start pilot valve cylinder. The j deformity revealed itself in a random pattern. The effects of l the deformity could only be observed on an engine start after the engine had been shut down from a previous run and the engine stopped with a particular combination of faulty pilot valve and crankshaft position alignment. There were a total of 7 i cylinders with questionable air start pilot valves. i i On a normal attempted restart with the air start pilot valve malfunctioning, the 5 second burst of air was not adequate to l start the engine rolling over. The burst of air was adequate to change the alignment of crankshaft position and fmulty pilot valves so that any subsequent attempt to start the engine would l be successful. l l Based on the availability of the redundant 2B diesel at the time the 2A diesel was declared inoperable and the fact that the 2A diesel should have started under emergency conditions, there was no adverse effect on plant safety or the health and safety l of plant staff or the general public. i I l l l - ~ - -

f l PROCEDURE NO-REVtSION PAGE NO. VEGP 00057-C 5 30 of 37 ~ Sheet 3 of 10 DATA SHEET 1 Eve t Report No ~ EVENT DATA COLLECTION Report: Page 8 of w% 1. EVENT DESCRIPTION EVENT DATE 7 l i i i ci o UNIT 2. FvalT TIME o t. 2. e t-~ DEFICIENCY CARD NUMBER

2. M 7 (IF REQUIRED) 2.

TTPE OF EVENT A. REACTOR TRIP ( ) F. RADI0 ACTIVE SPILL / B. FORCED REDUCTION ( ) UNCONTROLLED RELEASE ( ) C. FLANT TRANSIENT ( ) G. LIQUID INVENTORY LOSS ( ) D. ESFAS ( ) H. OTHZR SIGNIFICANT EVENT (W E. PERSONNEL CONTAMIN ( ) 3. EVENT REVIEW TEAM CALLED OUT: TINE 03co SAER INFORMED: TIME i CORPORATE DUTT MANAGER INFORMED: TIMR i 4. DATA COLLECTION ASSIGNMENT 'S b t.a i uu i,m_ % \\ 5. DATA: FOR REACTOR TRIPS COMPLETE 10006-C, AND GIVE A COPY M TEE EVENT REVIEW TEAM. FOR ALL OTHER EVENTS, COMPLETE m SECTION 5 THROUGH 16 AND PERSONAL STATEMENTS. STATEMENT ACTIVITY PERFORMED ATTACHED SHIFT PERSONNEL AT THE TIME OF THE EYZNT YES.OR NA SS 5"b u % w s b viu. b a-hvia Mlk USS E.is T % tuira r n SSS w Pc;.yEr rau 5 \\ y1A RO t., n a ca w \\ J/A PO s, c vtz._8 w/A STAI n t1,%,m s, it.cu n ut %.n h-i d Ja OTHERS INYOLVED _ d /A A. %.se_ & &-a Pn 9E$

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nAo u i:S 'S. C.e b b tJ t &A8 DES 6. DATA TO BE COLLECTED (SRIPT SUr'ERINTENDENT TO CRECK ITEMS) NOTE: REMNE TIE DISE PACK AFTER A TRIP /SI. PLANT COMPUTER ALARM PRINTOUT ( ) PLANT COMPUTER EVENT LOGS ( ) ATSI PRINTOUT ( ) ERF COMPUTER EVENT LOGS ( ) FAULT RECORDFR PRINTOUT ( ) ERF COMPUTEP. TREND PRI1rrS ( ) M ART RICORDERS (LIST) COPIES OF: NBC M NOTtPICATION WORASIIEt.I ( I Us3 LOGS ( ) AUI BLDC OPERATOR LOG ( ) T*dE&INE BLDG LOG ( ) RWO LOG-( ) CONTROL BLDG OPERATOR LOG ( ) ELECTRICAL LOG ( ) OUTSIDE OPERATOR LOG ( ) UNIT CONTROL ( ) CIEMISTRY RF N 3

l l i PROCEDURE NO. REVtSION PAGE NO. 1 VEGP 00057-C 5 31 of 37 1 Sheet 4 of 10 DATA SHEET 1 EventReportNo.h Report: Page 9 of Te.w 7. PLANT CONDITION WHEN APPROPRIATE MAXIMUM / MINIMUM PRE-EVENT VALUE POST EVENT MODE / 4 REACTOR POWER / I BORON CONCENTRATION / STEAM GENERATOR LEVEL 1* /

  • Use NR or WR, 2*

/ whichever is 3* / i indicating 4* / GENERAIt)R OUTPUT / MWE PRESSURIZER LEVEL / 4 8. PLANT CONFIGURATION 8.1 0FF NORMAL STATUS OF PLANT SYSTEMS A ena ptsp e n.s

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8.2 TESTS AND SURVEILLANCES IN PROCESS t 4C M - 2 %G l n mu w i e it v f ci-l 8.3 OTHER OPERATIONS IN PROGRESS AT THE TIME OF THE EVENT Nntt t% $a1 :- T lu-i u A 9. FOR ESFAS ACTUATION OR FAILURE AUTOMATIC ( ) MANUAL ( ) N/A ( ) 9.1 LIST CIANNEL ACTUATED / FAILED EXPLAIN SYSTEM RESPONSE 9.2 DID THE ES?!.5 COMPONE)f!S OPERATE CCRAr.CTLY? YES ( ) NO ( ) WITHOUT UNDUE DELAT? YES ( ) NO ( ) 9.3 EIPLAIN ANT ABNORMAL SYSTEM ESFAS RESPONSES. WRT?

i mx:souma No. navissoN Mgg No, VEGP - 00057-C 5 32 of 37 t J r 1 i Sheet 5 of 10 ~ i DATA SHEET 1 Event Report No.D -9,0 05 ' i Report: Page L of g j 9.4 DESCRIBE ANT OTHER MALFUNCTIONS NOTICED: l' l 9.5 AFFARENT EVENT CAUSE WAS I ]. j '10. CORRECTIVE ACTIONS i 10.1 WEAT DOEDIATE CORRECTIVE ACTIONS WERE TAEEN AS A RESULT OF THE EVENT? b u c 2. x m s&2.So-2 m v7-S,rc Sw ac e. J a_ n. i ;:,< & r ie u e' E u rit /2 E n e m 2 90-2+s i, I 10.2 WRAT SUBSEQUENT CORRECTIVE ACTIONS ARE IN FROGRESS AS A RESULT OF TIE i EVENT? cco '/._ - 9e - 2 A3 4 10.3 WEAT FURTEER CORRECTIVE ACTIONS ARE REC 000tMDD T 1

11..

LIST CORRECTIVE ACTION TAEEN FOR EACE ABNORMAL OCCURRENCE OR EQUIPMENT MALFUNCTION TEAT ACCOMPANIE TEE EVENT (STATE WRETIER COMPLETE. IN FROGRESS OR PROPOS D). / 1 l 4 1 12. WERI PROCEDURES USD ADEOUATEt TES ( ) NO ( ) } WNT NOTt l 1 i 13. DID TEE OPERATORS AND OTRER PERSONNEL BANDLE TIE EVENT CORRECTLY 7 EEFLAIN. DISCUSS CORRECTIVE ACTION TO DATE. k 4

-.. = _ -. -. { _ - i- ) 1 amocsoupe NO. REVl810N pagg NO. i VEGP 00057-C 5 33 of 37 J l SheeC 6 of"10 f DATA SHEET I Event Report No.N I l Report: Page 3 og Tr.w i l l l ] j 14. WAS AN DIERGENCY PLAN EAL REACREDt DESCRIBE LEVEL INVOLVED (NOUE, j ALERT, SITE AREA GENERAL). j i J i 15. LIST LCO's ENTERED

I LCO NO.

DESCRIPTION INITIALS 2 90-NJ D6 2A fA,t ca % bd i KJ < 3.1 8 A (_TALr 4 4 i b l 16. LIST ANY SAFETT LIMITS EXCEEDED. TECN SPEC AND DESCRIPTION i i I i ? i B d e l COMPLETED BY:NR 1

PmOCEDURE No. REVISION PAGE NO. VEGP 00057-C 5 34 of 37 ~ Sheet 7 of 10 DATA SHEET 1 Event Report No.

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Report: Page 12 o r -ee w SEQUENCE OF EVENTS CHRONOLOGY DATE/ TIME EVENT $9.- rover, f su 'n b bst i i -l l 1

P*oCEDURE No. AEVI5lCN pAGE No. VEGP 00057-C 5 35 of 37 es-Sheet 8 of 10 DATA SHEET 1 Event Report No. Report: Page 1 of s. 1 INVESTIGATION QUESTIONS A. GENERAL 1. DOES THE EVENT REPRESENT PREVIOUSLY UNFORESEEN ACCIDENT SEQUENCE? YES/ Q/ 2. DOES THE FAILURE DIRECTLY OR THROUGH INTERACTION WITH OTHER SYSTEMS DEGRADE THE PERE.RMANCE OF ANY O SAFETY-RELATED EQUIPMENT? @ NO 3. DOES THE FAILURE DIRECTLY OR THROUGH INTERACTION WITH OTHER J YSTEMS INCREASE THE PROBABILITY OF AN ACCIDENT? YES(H0,' 0 4 DOES THIS FAILURE CHALLENGE OR ACTIVATE SAFETY SYSTEMS? f YES{NO' 5. DOES THE EVENT INCREASE THE PROBABILITY OF TRANSIENT i OCCURRENCES AND/OR REACTOR TRIPS? YES/ { 6. DURING THE EVENT, DID THE OPERATIONS STAFF RESPOND CORRECTLY? gS/NO 7. ARE TRAINING KNOWLEDGE OBJECTIVES, PERFORMANCE TASKS AND CONTROLS ADEQUATE TO PROMOTE THE PROPER PERFORMANCE OFM RE OPERATIONS STAFF UNDER SIMILAR CIRCUMSTANCES? g/NO 8. BASED ON A COMPARISON OF THIS EVENT WITH PREVIOUS EVENT REPORTS AND/OR FSAR ANALYSES WERE THERE ANY ABNORMAL OR DEGRADED INDICATIONS? YES @ 9. BASED ON COMPARISON OF RELATED SIMILAR INDUSTRY AND IN-HOUSE EVENTS, J& THIS EVENT A REOCCURRENCE OF A PREVIOUS EVENT: {YES/NO nj r4 ycc yc p,c e, 10. DURING THIS,F, VENT, DID ALL AFTECTED SYSTEMS RESPOND AS EXPECTED? gS/NO 11. DID THE INITIAL EVENT PRODUCE UNANTICIPATED SECONDARY EFFECTS WHICH COMPLICATED OR INCREASED THE CONSEQ*vENLE: OF THE EVENT? YES/NO

. ~ l PeoCEDumE NO. REVI5loN pAGE NO. VEGP 00057-C 5 36 of 37 ~ ~ j Sheet 9 of 10 DATA SHEET 1 Event Report No.O M Report: Page 14 or re w 1 INVESTIGATION QUESTIONS (CONT'D) 12. I BASED ON COMPARISON OF SIMILAR INDUSTRY AND IN-HOUSE l EVENTS WERE PREVIOUS CORRECTIVE ACTIONS / IMPLEMENTATIO EFFECTIVE 1 YES(fN.V ^0 E%cIlA'Q[*g- [o l'a't-N oce.u w e d L w ige # reu.n# 13. IF QUESTIONS 1, 2, 3, 4', 5, 8,e$a,N 11 ARE ANSWERED 5 YES, DESCRIBE THE REASON IN DETAIL IN THE EVENT REPORT. 14. IF QUESTION 6, 7, 10, or 12 ARE ANSWERED NO, DESCRIBE j THE REASON IN DETAIL IN THE EVENT REPORT. B. PERSONNEL ERRORS 1 1. WERE JOB ENVIRONMENT CONDITIONS SUCH AS LIGHTING, VENTIM TION, EXTREME TEMPERATURE OF P ICAL ACCESS TO i THE TASK CONTRIBUTING FACTORS 7 YES 2. WERE PROPER TOOLS AVAILABLE AND USED? /NO h', 3. WERE WRITTEN-APPROVED PROCEDURE AVAIMBLE AND PROPERLY FOLLOWED7(YES/NO 4. IF THE PROCEDURE WERE FOLLOWED, WAS PRgDURE COMPLIANCE A CONTRIBUTORY CAUSE7 YES g 5. WERE ADEQ INSTRUCTIONS GIVEN AND COMPREHENSION l VERIFIED? No i 6. WERE THE PERSONNEL INVOLVED IN THE PROPER PHYSICAL i CONDITION 7 S/NO 1 7. DID THE PERSONNEL INVOLVED HAVE ERRONEOUSA"DEAS AND/OR CONCEPTS ABOUT THE SYSTEM INVOLVED 7 YES'/N0j i v. 8. DID THE PERSONNEL INVOLVED HAVE PREVIOUS EXPERIENCE AND/OR TRAINING ON THE SYSTEM INVOLVED 7 f YES/NO 9. DID THE PERSONNEL RECEIVE A BRIEFING QF THE EVOLUTION PRIOR TO STARTING 7 YES/NO gA m f.),, g /,e TA s -m/ i a 4. s su e-10. WERE COMMUNICATIONS ADEQUATE FOR THE EVOLUTION 7 g S ~~ ) 11. WERE COMMUNICATIONS TESTED PRIOR TO STARTING 7 YES/NO l sf 4 -apm

Tiiocsovat No. mevision ,,og so. VEGP 00057-C 5 37 of 37 Sheet 10 of 10 DATA SHEET 1 Event Report No. h Report: Page g ox! h. INVESTIGATION QUESTIONS (CONT'D) 4 12. WAS SUPERVISION IN NT ADEQUATE FOR THE EVOLUTION 4 BEING CONDUCTED? 5,No 13. WERE THE PERSONNEL THAT INITIATED OR ADVERSELY CONTRIBUTED TO THE EVENT QUALIFIED TO PERFOR&THEIR i ACTIVITIES PRIOP. TO AND DURING THE EVENT? y S)NO i j 14. IF QUESTIONS 1, 4 OR 7 ARE ANSWERED YES, DESCRIBE IN i 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. i I I i i i e a l f l

i j 1 PAOCEDURE NO. REVi$lON. PAGE NO. VEGP 00057-C 5 26 of 37 i j 1 i l Event Report No.1 CC s 3") p' Report: Page 1 or N 3 ] EVENT PERSONAL STATEMENT i

1. a.FOR THE PERIOD PRIOR TO, DURING, AND AFTER THE EVENT,-

i. SUMMARIZE THE. SEQUENCE OF EVENTS THAT YOU OBSERVED, AND YOUR 1 SPECITIC ACTIONS TAKEN BASED ON INDICATIONS. i Es(b. bCU kh.h 'EubGM [ r hb .1r-c 216 id i I. G~ l 1%;N.h 2f'( b Enl t'k. 1 h E 2hl rEI, i 'hc- "- I w m c '.T t N \\tkk. LOh. I & Ylib JM:k[ 3 ! c (7trb,1,% 14r5f (t<M.50). i 4 I r. Tl?J ! h.c.X S.; a h r-Dir(Frit< LE I. EM& f $ 5 CCYWc( !I FN. s a 1 jtc(t1. hic l0'tXtL. 4inrri tr 'k;e f lbc k ESCl. $.g.u-ln-lCnG i l

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b. List alarms that illuminated and/or were reset.

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DID ANY AUTOMATIC SYSTEMS OR EQUIPMENT (MALTUNCTIdN R s 2. i ANY OPERATOR INTERVENTION? (Describe) { i kt i i l 3. DID THIS EVENT REVEAL ANY PROCEDURAL INADEQUACIES? l (Describe) l VD (. ( 'I :k ct c' t <, 1 Cl it 6 4. M b n i l , FIGURE 2 EXAMPLE l 4 _q ,+--N .e M

1 j.. v-ocaouxa No. neve.ou ,,a, go, { _VECP 00057-C 5 27 of 37 ) ~. Event Report No.x~ 90. ~; Report: Page J or Te: - i i 4 IF THIS EVENT OCCURRED AGAIN, VMAT WOULD'YOU DIFFERENTLY? l- \\ t ..i.' s i ) 2 i j 5. ARE THERE ANY LESSONS LEARNED FROM THIS EVENT THAT YOU BELIEVE SHOULD BE INCLUDED IN TRAINING 7 (Describe) s ht r i ). 5 l 6. COMMENTS: i OsE M l r~UktyC..!< L M /c r ~ A CA 2. 2t a lu i, te, 2 rh., 6 t (, aly 'N ; & / if t. it g. t '. 2..u' S,1 i.. /. a ~ C ~2ct#d .:dl(,',Z i hEL c b5QLu Ed r f f t r?_.Nc , r,; d i e W 2_.+ i i 1 r i i i l i a i SIGNATURE (.c, lcm TITLE,. DATE. . ;- (.. - -tL t x. i e s i i %i;- Q f s i>. 7.* * - ~ c /For reaccor trips die personnel stat.::uent form in Procedure 100064 may be used in lieu of this form. FIGURE 2 (CONT'D.) EXAMPLE

t 1. i E emoctoumssc. aavision paos so. VIGP 00057-C 5 26 of'37 i Event Report.No.Q.-%Q O $ Report: Page - t r't r +3~ I tt %, e EVENT-PERSONAL STATEMENT i

l. a.FOR THE PERIOD PRIOR TO, DURING, AND AFTER THE EVENT, SUMMARIZE THE SEQUENCE OF EVENTS THAT YOU OBSERVED, AND YOUR SPECIFIC ACTIONS TAKEN BASED ON. INDICATIONS.

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b. List alarms that illuminated and/or were resec.

l. g NA. l s,l a~ Na s i' 2. DID ANY AUTOMATIC SYSTEMS OR EQUIPMENT MALFUNCTION REQUIRE l ANY OPERATOR INTERVENTION 7 (Describe) l 4<> i il' i. L 3. DID THIS EVENT REVEAL ANY PROCEDURAL INADEQUACIES? (Describe) i l L

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r \\ P*octoums No. mEVISloN PAGE No. VEGP 00057-C-5 27 of-37 t j i Evene Repore No.O. -40 C'.) l Report: Page g Tor - -om i 19 M *' 4 IF THIS EVENT OCCURRED AGAIN, WHAT WOULD YOU DIFFERENTLY?

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/ 4 i ? l 5. ARE THERE-ANY LESSONS LEARNED FROM THIS EVENT THAT YOU S -BELIEVE SHOULD BE INCLUDED IN TRAINING 7 (Describe) l u - 4.. w-J / L*s J.'p e i h 1 e i 6. COMMENTS: ') m1 l } 4 3' 4 j ~ l SIGNATURE TITLE DATE 3 i [g/ h ? f0

7. /^ 7)

For reactor'crips the personnel scacement form in Procedure 10004,=C may be used in lieu of this form. FIGURE 2 (CONT'D.) EXAMPLE ~

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"m memon j VEGF 00058-C 3 7 og is i " D Page 22 of 26 BOOT CAUSE DETERNINATION 180RESEEET UNIT 2 SEEET 1 0F __ 1. EYENT INVESTIGATED: ~Md M E4l/vr c b s-h c>n 1 -// 9D d l L. m m von (s)4xmuassscaton(sM.. gir/ 3. RESULTS OF INTESTIGAT105/EEVIEW (Inslude references and attach eestinuation sheets if aseded) j

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