ML20151Y985
| ML20151Y985 | |
| Person / Time | |
|---|---|
| Site: | Kewaunee  |
| Issue date: | 02/05/1986 |
| From: | Norelius C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Hintz D WISCONSIN PUBLIC SERVICE CORP. |
| References | |
| NUDOCS 8602130237 | |
| Download: ML20151Y985 (54) | |
Text
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$ /n 13 FEB 5 1986 Docket No. 50-305 Wisconsin Public Service Corporation ATTN:
Mr. D. C. Hintz Manager Nuclear Power Post Office Box 19002 Green Bay, WI 54307-9002 Gentlemen:
The NRC's Office for Analysis and Evaluation of Operational Data (AEOD) has recently completed an assessment of 13 Kewaunee Licensee Event Reports (LERs) as part of the NRC's Systematic Appraisal of Licensee Performance (SALP).
The LERs were found to be of acceptable quality based on the requirements of 10 CFR 50.73 and when compared to other facilities that have been evaluated using the same methodology.
We are providing a copy of AE0D's assessment before we issue the SALP 5 report so that you might be aware of these findings and take action to improve the overall quality of future LERs.
We request that you provide-Region III with the actions you intend to take to improve the overall quality of future LERs.
We appreciate your cooperation with us in this matter.
If you have any questions, please contact N. Chrissotimos (790-5716).
Sincerely,
Cc hi:::.1 Si;ci T y 7.G Cm2.a;l' Charles E. Norelius, Director Division of Reactor Projects
Enclosure:
Kewaunee AE0D Assessment cc w/ enclosure:
C. R. Steinhardt, Plant Manager DCS/RSB (RIDS)
Licensing Fee Management Branch Resident Inspector, RIII John J. Duffy, Chief 8602130237 060205 Boiler Section PDR ADOCK 05000305 PDR Ness Flores, Chairperson Wisconsin Public Service Commission
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FEB 5 1986 Docket No. 50-305 Wisconsin Public Service Corporation ATTN:
Mr. D. C. Hintz Manager Nuclear Power Post Office Box 19002 Green Bay, WI 54307-9002 Gentlemen:
The NRC's Office for Analysis and Eveluation of Operational Data (AE00) has recently completed an assessment of 13 Kewaunee Licensee Event Reports (LERs) as part of the NRC's Systematic Appraisal of Licensee Performance (SALP).
The LERs were found to be of acceptable quality based on the requirements of 10 CFR 50.73 and when compared to other facilities that have been evaluated using the same methodology.
We are providing a copy of AE00's assessment before we issue the SALP 5 report so that you might be aware of these findings and take action to improve the overall quality of future LERs.
We request that you provide Region III.with the actions you intend to take to improve the overall quality of future LERs.
We appreciate your cooperation with us in this matter.
If you have any questions, please contact N. Chrissotimos (790-5716).
Sincerely, "O.ti:2.1 Siy d !7 E.G. Gr00:.r.x,"
Charles E. Norelius, Director Division of Reactor Projects
Enclosure:
Kewaunee AE00 Assessment cc w/ enclosure:
C. R. Steinhardt, Plant Manager DCS/RSB (RIDS)
Licensing Fee Management Branch Resident Inspector, RIII John J. Duffy, Chief Boiler Section Ness Flores, Chairperson Wisconsin Public Service Commission k
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APPEN0!x A 1984 REACIOR TRIP RATES NAME MANUAL AUTO LESS IHAN GREATER CRITICAL TRIP RATE PER HEAN f!HE HAi!C OR EQUAL THAN HOURS 1000 HOURS BETWEEN TRIPS 15% PCNER 15% POWER POWER OT 15 POWER Of 15%
WPPSS 2 4
20 7
17 2983.0 5.70 175.5 CALLAWAY I i
13 6
6 1131.5 5.30 188.6 GRAND GULF 1 2
6 3
4 1010.0 3.96.
252.5
$USOUEHANNA 2 2
8 1
7 2145.9 3.26 306.6 SALEM i 0
10 3
7 2672.3 2.62 381.8 MCGUIRE 2 5
13 0
16 6138.3 2.61 383.8 SALEM 2 0
to 2
8 3386.0 2.36 423.3 HAICH 2 0
7 0
7 3108.7 2.25 444.1 DIADLO CANYON 1 0
7 3
2 967.1 2.07 483.6 4
LASALLE 2 3
8 2
9-4469.8 2.01 496.6 SURRY 2 2
13 2
12 7435.3 1.61 619.6 OROWNS FERRY 3 2
0 1
1 700.7 1.43 700.7 LASALLE 1 0
9 0
9 6240.0 1.43 697.8 SEQUOYAH 2 0
10 0
9 6334.0
-1.42 703.8 l
NORTH ANNA 1 2
7 2
6 4759.9 1.26 793.3 ST.LUCIE 2 1
9 0
9 7379.2 1.22 819.9 TURKEY POINT 4 0
11 3
6 5079.8 1.18 846.6
$URRY 1 1
7 2
6 5293.7 1.13 882.3 0.C.C00K 2 2
6 1
6 5294.8 1.13 882.5 SEQUOYAH I i
12 4
7 6206.1 1.13 886.6 SUMMER 0
12 5
6 5553.4 1.08 925.6 SuSOUEHANNA 1 1
6 0
7 6549.3 1.07 935.6 DRESDEN 3 0
9 4
4 3889.0 1.03 972.3 TROJAN O
7 2
5 4895.4 1.02 979.1 IN0!AN POINT 3 0
9 0
7 6941;6 1.01 991.7 TURKEY POINT 3 1
8 1
7 7366.6 0.95 1052.4 LA CROSSE 1
8 0
7 7437.0 0.94 1062.4
=
ST.LUCIE 1 2
4 1
5 5555.2 0.90 1111.0 HATCH 1 3
7 3
5 5638.7 0.89 1127.7 MCCU1RE 1 0
5 0
5 6090.8 0.82 1218.2 SAN ONOFRE 3 0
9 3
4 5070.7 0.79 1267.7 3)
ARKANSAS 2 0
15 6
6 7631.9 0.79 1272.0
--J YANKEE ROWE 2
3 0
5 6398.6 0.78 1279.7
-d RANCHO SECO 1 0
4 0
4
-$338.8 0.75 1334.7 Is BRUNSWICK 2 0
3 1
2 2650.1 0.75 1325.1 O
OUANE ARNOLD 0
6 1
5 6627.1 0.75 1325.4 DAVIS-BESSE 1 1
4 0
4 5529.0 0.72 1382.3
--b FARLEY 2 1
5 0
6 8375.7 0.72 1396.0 L
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APPEN0tx A 1984. REACTOR TRIP RATES NAME MANUAL AUTO LESS THAN OREATER CRITICAL TRIP RATE PER HEAN T!HE MATIC OR EQUAL THAN HOURS 1000 HOURS 6ETWEEN TRIPS' 15% POWER 15% POWER POWER OT 15 POWER QT 15%
q BRUNSw!CK I O
7 2
5 7023.8 0.71 1404.8 CALVERT CLIFFS 1 4
1 0
5 7531.0 0.66 1506.2 PALISADES 0
1 0
1 1550.5 0.64 1550.5 PEACH BOTTOM 3 1
4 0
5 1757.7 0.64 1551.5 QUA0 Cit!ES 1 1
3 0
3
^4766.9 0.63 1589.0 lloM 1 0
6 2
4 6319.8 0.63 1579.9 B R 0wr4S FERRY l 4
4 3
5 8067.4 0.62 1613.5 BEAVER VALLEY 1 1
6 0
4 6476.3 0.62 1619.1 OCONEE 3 0
4 0
4 6520.7 0.61 1630.2 MAINE YANKEE 1
7 3
4 6688.8 0.60 1672.2 SAN ONOFRE 2 1
4 2
3 5272.4 0.57 1757.5 flT2 PATRICK 0
4 0
4 1087.2 0.56 1771.8 J
ARKANSAS 1 0
3 3
3 6222.4 0.48 2074.1 i
DRESDEN 2 0
3 0
3 6511.4.
0.46 2170.5 INotAN POINT 2 1
5 2
2 4718.4 0.42 2359.2 OCONEE 1 0
3 0
3 7452.4 0.40 2484.1 0.C. COCK t 0
3 0
3 8085.9 0.37 2695.3 PRAIRIE ISLAND 1 0
4 1
3' 3321.3 0.36 2773.8 BROWNS FERRY 2 0
3 0
2 5895.7 0.34 2947.9 COOPER 0
3 1
2 5952.6 0.34 2976.3 NORTH ANNA 2 1
4 2
2 6136.0 0.33 3068.0 ZION 2 2
6 5
2 6285.2 0.32 3142.6 NA00AM NECK 1
3 1
2 6515 6 0.31 3257.8 CALVERT CLIFFS 2 0
2 0
2 6630.2 0.30 3315.1 6988.6 0.29 3494.3 QUA0 CITIES 2 1
4 0
2 VEkMONT YANKEE o
2 0
2 7115.2 0.28 3557.6 1
KEWAUNEE O
5 1
2 7570.5 0.26 3785.3 e
CRYSTAL RIVER 3 0
2 0
2 8346.5 0.24 4173.3 MILLSTONE 2 1
2 1
2 8596.8 0.23 4293.4 FORT CALHOUN 1 0
1 0
1 5386.3 0.19 5386.3 R.E.0!NNA 0
1 0
1 6848.7 0.15 6848.7 TARLEY 1 0
2 1
1 7005.8 0.14 7005.8 813 ROCK POINT 0
3 3
0 6981.9 0.00 SAN ONOFRE 1 0
0 0
0 888.6 0.00 OYSTER CREEK 0
2 2
0 1700.0 0.00 NINE MILE POINT 1 0
1 1
0 6414.0 0.00 NILLSTONE 1 0
0 0
0 6990.2 0.00 N.B. ROBINSON 0
1 0
0 616.1 0.00 i
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a APPEN0!x A 1984. REACTOR TRIP RATES NAME MANUAL AUTO LESS THAN OREATER CRITICAL.
TRIP RATE PER HEAN T!HE MATIC OR EQUAL THAN HOURS 1000 HOURS BETWEEN TRIPS
!$% POWER 15% POWER POWER QT 15 POWER OT 15%
MONTICELLO O
.0 0
0 810.6 0
POINT 8EACH 1 1
I O
O 6420.1 0
OCOMEL 2 0
0 0
0 8784.0 0
etACH BOTTOM 2 0
0 0
0 2583.9 0
4 PILGRIM 0
0 0
0 170.3.
0 POINI BEACH 2 0
1 0
0 7544.2 0
1 PRAIRIE ISLAND 2 0
0 0
0 7844.0 0
BYRON 1 2
0 0
0
' 0. 0 1
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StM4ARY An evaluation of the content and quality of a representative sample of the Licensee Event Reports (LERs) submitted by Kewaunee during the July 1, 1984 to December 31, 1985 Systematic Assessment of Licensee Performance (SALP) period was perfonned using a refinement of the basic methodology presented 1
in NUREG-CR-4178. The results of this evaluation indicate that Kewaunee has an overall average LER score 7.6 of a possible 10 points, thus ranking it 13th out of the 35 units that have been evaluated to date using this methodology.
The principal weaknesses identified involves the personnel error and safety consequence discussions. Deficiencies in the personnel error discussions prompts concern as to whether or not the corrective actions adequately address personnel and procedural problems.
Deficiencies in the safety consequence discussion prompts concern as to whether or not the event was evaluated so that the implications of the event, had it occurred under a different set of conditions, are known, rM Strong points.for the Kewaunee LERs are the failure mode, mechanism, and effect discussions and the plant safety system responses-[ requirements 50.73(b)(2)(ii)(E) and(K),respectively].
In addition, Kewaunee's LERs usually address the problem of recurrence.
Attachment B
9 4
AE00 INPUT TO SALP REVIEW FOR KEWAUNEE
~
Introduction In order to evaluate the overall quality of the contents of the Licensee Event Reports (LERs) submitted by Kewaunee during the July 1,1984 to December 31, 1985 Systematic Assessment of Licensee Performance (SALP) assessment period, a representative sample of the unit's LERs was evaluated I
using a refinement of the basic methodology presented in NUREG/CR-4178.
The sample consists of 13 LERs, which is half of the LERs that were on file at the time the evaluation was started. See Appendix A for a list of the LER numbers in the sample.
It was necessary to start the evaluation before the end of the SALP assessment period because the input was due such a short time after the end of the SALP period. Therefore, not all of the LERs prepared during the SALP assessment period were available for review.
Methodology The evaluation consists of a detailed review of each selected.LER to determine how well the content of its text, abstract, and coded fields meet 2
3 4
the requirements of NUREG-1022, and Supplements 1 and 2 to NUREG-1022.
The evaluation process for each LER is divided into tws parts. The first part of the evaluation consists of documenting comments specific to the content and presentation of each LER. The second part consists of determining a score (0-10 points) for the text, abstract, and coded fields of each LER..
The LER specific comments serve two purposes:
(1) they point out what the analysts considered to be the specific deficiencies or observations concerning the information pertaining to the event, and (2) they provide a basis for a count of general deficiencies for the overall sample of LERs that was reviewed. Likewise, the scores serve two purposes:
(1) they
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serve to illustrate in numerical terms how the analysts perceived the content'of the information that was presented, and (2) they provide a basis
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for the overall score determined for each LER. The overall score for each LER is the result of combining the scores for the text, abstract, and coded fields (i.e., 0.6 x text score + 0.3 x abstract score + 0.1 x coded fields score = overall LER score).
The results of the LER quality evaluation are divided into two categories: (1) detailed information and (2) sumary information. The detailed information, presented in Appendices A through D, consists of LER sample information (Appendix A), a table of the scores for each sample LER (Appendix B), tables of the number of deficiencies and observations for the text, abstract and coded fields (Appendix C), and comment sheets containing narrative statements concerning the contents of 'each LER ( Appendix D).
When refer-ring to these appendices, the reader is cautioned not to try to directly correlate the numbar of comments on a coment sheet with the LER scores, as the analyst has flexibility to consider the magnitude of a deficiency when assigning scores.
Although the purpose of this evaluation was to assess the content of the individual LERs selected for review, the analysts often make other observations which they believe should be brought to the attention of the licensee. The following discussion addresses a general observation that was noted during the evaluation.
General Observation LER 84-018-01 was submitted under the reporting requirement "0THER"
[ Item (11) of NRC form 366]. While this is acceptable, checking the "0THER" box usually implies an informational or voluntary report. As pointed out~in the specific comments (Appendix D), this LER is actually reporting a potentially serious problem apparently reportable under-requirement 50.73(a)(2)(v). Credit is given for reporting the event but the discussion appears to understate the potential seriousness of the event by the use of vague terms in the text. For example, "short-term failure of
ESF equipment" was shown to be unlikely, but no indication of what ESF equipment would be affected is given nor whether these ESF systems would be needed for more than a "short term" period. Further "short term" is not defined. Based on the fact that the original problem for potential ESF f ailure was found during the 1984 refueling outage (date not given) and will not be repaired until the 1985 refueling outage (again, date not given), it appears that potential failure of ESF systems could exist for approximately a year. This LER illustrates the need to evaluate the potential seriousness of all events, and to discuss in detail all aspects of the event.
Discussion of Results A discussion ~of the analysts' conclusions concerning LER quality are presented below. These conclusions are based solely on the results of the evaluation of the contents of the LERs selected for review and as such represent.the analysts' assessment of each units performance (on a scale of 0 to 10) in submitting LERs that meet the requirements of 10 CFR 50.73(b).
Table 1 presents the average scores for the sample of LERs evaluated for Kewaunee. The reader is cautioned that the scores resulting from the methodology used for this evaluation are not directly comparable to the scores contained in NUREG/CR-4178 due to refinements in the methodology.
In order-to place the scores provided in Table 1 in perspective, the scores from other units that have been evaluated using the current methodology are provided in Table 2.
Additional units are added to Table 2 as they are evaluated. Table 3 and Appendix Table 8-1 provide a summary of the information that is the basis for the average scores in Table 1.
For example, Kewaunee's average score for the text of the LERs that were evaluated was 7.3 out of a possible 10 points. From Table 3 it can be seen that the text score actually resulted from the review and evaluation of 17 different requirements ranging from the discussion of plant operating conditions before the event [10 CFR 50.73(b)(2)(ii)(A)] to text
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TABLE 1.
SUMMARY
OF SCORES FOR KEWAUNEE Average High Low Text 7.3 9.7 4.2 Abstract 7.8 10.0 3.8 Coded Fields 8.7 9.5 5.0 Overall 7.6b 9.3 4.5 a.
See Appendix B for a summary of scores for each_ LER that was evaluated.
b.
Overall Average = 60% Text Average + 30% Abstract Average + 10% Coded Fields Average.
TABLE 2.
COMPARISON OF AVERAGE SCORES FROM OTHER UNITS Coded End SALP Text Abstract fields.
Overall a
Unit Name Period Averaae Average Average Averaae 1.
Salem 2 9-30-85 8.9 8.9 8.6 8.9 2.
Salem 1 9-30-85 8.6 9.0 8.9 8.8 3.
Palisades 10-31-85 8.4 8.3 8.5 8.4 4.
Washington Nuclear 2 1-31-86 8.9 6.2 8.2 8.0 5.
LaSalle 2 9-30-85 8.0 7.7 8.6 8.0 6.
LaSalle 1 9-30-85 7.9 8.1 8.6 8.0 7.
Browns Ferry 3 11-30-85 7.8 8.1 8.5 8.0 8.
Catawba 1 9-30-85 8.0 7.4 8.6 7.9 9.
Trojan 10-31-85 7.8 7.6 8.9 7.8 10.
Browns Ferry 1 11-30-85 7.8 7.6 8.3 7.8 11.
Pilgrim 1 10-31-85 7.6 7.8 8.1 7.7 12.
8eaver Valley 1 9-30-85 7.2 8.3 8.8 7.7 13.
Kewaunee 12-31-85 7.3 7.8 8.7 7.6 14.
Quad Cities 1 9-30-85 7.9 6.5 8.4 7.5 15.
Quad Cities 2 9-30-85 7.9 6.4 8.6 7.5 16.
Maine Yankee 10-31-85 7.5 7.3 8.5 7.5 17.
Byron 1 10-31-85 7.5 7.3 8.3 7.5 18.
Browns Ferry 2 11-30-85 7.3 7.7 8.5 7.5 19.
Indian Point 3 11-30-85 7.1 7.7 8.5 7.5 20.
Brunswick 1 10-31-85 6.8 8.5 8.5 7.5 4
21.
Summer 12-31-85 7.1 7.7 8.3 7.4 22.
Sequoyah 1 11-30-85 7.8 5.9 8.3 7.3
TABLE 2.
(continued)
Coded End SALP Text Abstract Fields Overall a
Unit Name Period Averaae Averaae Average Averaae 23.
Waterford 3 12-31-85 7.8 5.9 8.2 7.3 24.
Dresden 3 9-30-85 7.2 7.3 8.0 7.3 25.
Palo Verde 1 9-30-85 6.8 7.7 8.4 7.3 26.
D. C. Cook 2 9-30-85 6.7 8.3 8.4 7.3 27.
D. C. Cook 1 9-30-85 6.4 8.3 8.4 7.2 28.
Sequoyah 2 11-30-85 8.0 4.6 8.9 7.1 29.
Zion 2 9-30-85 7.2 6.7 8.2 7.1 30.
Robinson 2 10-31-85 7.1 6.9 7.8 7.1 31.
Vermont Yankee 10-18-85 7.0 7.0 8.2 7.1 32.
Dresden 2 9-30-85 6.9 7.3 7.9 7.1 33.
Fitzpatrick 11-30-85 6.2 8.5 8.7 7.1 34.
Brunswick 2 10-31-85 6.0 7.9 8.8 6.8 35.
Zion 1 9-30-85 6.0 7.5 7.9 6.6 a.
Units are ordered by overall average score.
.i TABLE 3.
LER REQUIREMENT PERCENTAGE SCORES FOR KEWAUNEE TEXT Percentage Requirements [50.73(b)] - Descriptions Scores ( )a (2)(ii)(A) - - Plant condition prior to event 77(13)
(2)(ii)(B) - - Inoperable equipment that contributed b
(2)(ii)(C) - - Date(s) and approximate times 90 (13)
(2)(ii)(D) - - Root cause and intermediate cause(s) 75 (13)
(2)(ii)(E) - - Mode, mechanism, and effect 95 (5)
(2)(ii)(F) - - EIIS Codes 96 (13)
(2)(ii)(G) - - Secondary function affected b
(2)(ii)(H) - - Estimate of unavailability 63 (8)
(2)(ii)(I) - - Method of discovery 85(13)
(2)(ii)(J)(1) - Operator actions affecting course 79 (7)
(2)(ii)(J)(2) - Personnel error (precedural deficiency) 50 (7)
(2)(ii)(K) - - Safety system responses 93 (7)
(2)(ii)(L) - - Manufacturer and model no. information 60 (5)
(3). - - - - - Assessment of safety consequences 53(13)
(4)
Corrective actions 85 (13)
(5)
Previous similar event information 15 (13)
(2)(i) - - - - Text presentation 72 (13)
ABSTRACT Percentage Requirements [50.73(b)(1)] - Descriptions Scores ( )a
- Major occurrences (Immediate cause and effect 96 (13) information)
- Description of plant, system, component, and/or 91 (8) personnel responses
- Root cause information 64 (13)
- Corrective Action information 69(13)
- Abstract presentation 73 (13)
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TABLE 3.
(continued)
CODED FIELDS Percentage Item Number (s) - Description Scores ( )a 1, 2, and 3 - Facility name (unit no.), docket no. and 100 (13) page number (s) 4 - - - - - - Title 66 (13) 5, 6, and 7 - Event date, LER No., and report date 92(13) 8 - - - -
- Other f acilities involved 100 (13) 9 and 10 - - Operating mode and power level 91(13) 11-----
Reporting requirements 92 (13) 12 - - - - - Licensee contact information 100 (13) 13 - - - - - Coded component failure information 86(13) 14 and 15 - - Supplemental report information 100 (13) a.
Percentage scores are the result ~of dividing the total points for a requirement by the number of points possible for that requirement.
(Note: Some requirements are not applicable to all LERs, therefore, the number of points possible was adjusted accordingly.) The number in parenthesis is the number of LERs for which the requirement was considered applicable.
b.
A percentage score for this requirement is meaningless as it is not possible to determine from the information available to the analyst whether this requirement is applicable to a specific LER.
It is always given 100%
if it is provided and is always considered "not applicable" when it is not.
. presentation. The percentage scores in the text summary section of Table 3 provide ~an indication of how well each text requirement was addressed by the licensee for the 13 LERs that were evaluated.
4 Dis'cussion of Specific Deficiencies A review of the percentage scores presented in Table 3 will ouickly point out where the licensee is experiencing the most difficulty in preparing LERs.. For example, requirement' percentage scores of less than 75 indicate that the licensee probably needs additional guidance concerning these requirements. Scores of 75 or above, but less than 100, indicate
~that the licensee probably understands the basic requirement but has
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either:
(1) excluded certain less significant information from most of the discussions concerning that requirement or (2) totally failed to address the requirement in one or two of the selected LERs. The licensee should review the LER specific c6cments presented in Appendix D in order to 2
determine why he received less than a perfect score for certain requirements. The text requirements with a score of less than 75 are
- discussed below in their order of importance.
In addition, the primary-deficiencies in the abstract and coded fields are discussed.
Six of the thirteen LERs f ailed to provide adequate root cause
. discussion [ Requirement 50.73(b)(2)(ii)(D)]. Root cause information is very useful to the analyst who uses LER data for the purpose of looking for generic problems, but root cause information is even more important to the licensee that has experienced the event. It is only through adequate determination of root causes that implementation _of the necessary corrective actions can be accomplished, thereby preventing recurrence of the event or similar events.
It appeared that further investigation would solve this deficiency. For example, a valve stem may break preventing a valve from operating,'but the valve steam failure is not the root cause..
Questions should be asked as to why the stem broke, so that the source of the breakage (such as, vibration) can be corrected to prevent failure of the replacement stem. Similarly for personnel error, questions should be h
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asked as to why the error occurred (e.g., was training adequate, was there a procedural deficiency, or was a special problem such as fatigue involved?).
Four of the thirteen Xewaunee LERs which were evaluated had inadequate safety assessments [ Requirement 50.73(b)(3)], and four LERs did not include a safety assessment at all. A safety assessment is required for all LERs and should be specific as to whether or not a more severe problem could have occurred as a result of the event. For example, it is inadequate to state that "there were no safety consequences because the reactor was shutdown" if it is possible to have the same scenario happen during power operation. The assessment should indicate what could have happened if the problem had not been found or had occurred at a less opportune time. The assessment should also indicate whether or not other systems were available as backup and name those systems considered to be backup.
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Discussion of personnel errors [ Requirement 50.73(b)(2)(ii)(J)(2)] has a percentage of score (50%). Seven LERs appeared to have personnel error involved, and all seven of these were found to have a deficiency. Three failed to indicate whether the error was cognitive or procedural, one failed to indicate whether'or not the error was covered by a procedure, and two did not discuss the type of personnel involved in the event. Lack of this kind of information could be related to the inadequate root cause information discussed previously. Further investigation is probably needed if personnel crror is to be adequately discussed.
Two LERs of the five involving component failures, f ailed to identify the failed component in the text [ Requirement 50.73(b)(2)(ii)(L)].
Adequate identification is usually considered to be manufacturer name and model number. This information is important for the identification of possible generic problems in the nuclear industry.
Four of the eight LERs involving safety system trains did not provide adequate dates and/or times so that the unavailability time of the train could be determined [ Requirement 50.73(b)(2)(ii)(H)]. This kind of
- ~.. _ _ ___ _
information is required as it becomes part of the generic data necessary to.
perform probabilistic risk assessments (PRAs). Adequate attention' paid to
' l Requirement 50.73(b)(2)(ii)(C), which requires dates and times of occurrences, will usually ensure that this requirement is met.
Information concerning previous similar' events was generally lacking.
Eleven of the thirteen LERs reviewed had no reference to. previous similar events. Previous similar events should be referenced appropriately (LER number if possible), and if there are none, the text should state this.
Finally, the text presentations were marginally adequate-(score = 72%).. The only repeatative error found (in three LERs) was failure to define all acronyms on the first usage. A general comment on all Kewaunee presentations would be to use an outline format with appropriatehighlighted(underlined) headings. Many cf the errors discussed above could be eliminated by using an outline since this would remind the writer of the text requirements needed in the LER. An outline also guides a reader through the event with less confusion.
The' root cause summary (score = 64%) was missing in six of the abstracts. The abstract's corrective action summary was marginally acceptable (score = 69%). While the abstract is not supposed to be as detailed as the text, root cause and corrective actions are important and should be included in every abstract. The root cause summarys in the abstract probably reflect to a certain extent the short comings in the lack of the root cause discussion in the text.
The abstract presentations (score = 72%) is marginally acceptable.
The abstract sunenary should not introduce information not mentioned in the
- text (found in 3 LERs).
If it is necessary to include such information, the text should be revised so as to adequately discuss it.
The main deficiency in the area of coded fields involves the title, Item (4). Eleven of the titles did not indicate root cause, two failed to i
include the link (i.e., circumstances or conditions which tie the root y
-.e--.,.-
..m n
,- w r e - e m e
--,y,.r-r,,
,,py,,
,--.m,--
--m--
,-t, c--
-,- - --w. - - - -
cause to the result), and two failed to provide information concerning the result.of the event (i.e., why the event was required to be reported).
While result is considered the most important part of the title, cause and link must be included to mak'e 'he title complete. An example of a title t
that~ only addresses the result might be " Reactor Scram". This is inadequate in that the cause and' link are not provided. A more appropriate title might be " Inadvertent Relay Actuation During Surveillance Test LOP-1 Causes Reactor Scram". From this title the reader knows the cause was either personnel or procedural and testing contributed to the event.
Table 4 provides a suninary of the areas that need improvement for Kewaunee LERs. For more specific information concerning deficiencies the reader should refer to the information presented in Appendices C and D.
General guidance concerning these requirements can be found in NUREG-1022, 4
Supplement No. 2.
4 I
,_,n,--
TABLE 4.
AREAS MOST NEEDING IMPROVEMENT FOR KEWAUNEE LERS Areas Comments i
Root cause information Further investigation is ~needed.
Questions about why the failure occurred should be asked and answered, if possible.
Safety assessment information Be sure to include a complete safety assessment in all LERs. The text should discuss whether.or not the event could be worse under different circumstances and provide information about backup systems which could limit the consequences of the event.
Personnel error discussions Details should be explicitly stated; the cause of personnel error should be discussed, (e.g., cognitive or procedural). Contributing factors should be provided when appropriate.
Manufacturer and model number Component identification information information should be included in the text for each component failure or whenever a component is suspected of contributing to the event because of its design.
Safety train unavailability Sufficient dates and times should be included in the text to enable the reader to determine the length of i
time that safety system trains or components were out of service.
Previous similar events Previous similar events should be referenced (LER Number) or the text should state there are none.
Text presentation Improvement in text presentation would be made by using an outline format. Be sure to define all acronyms on their first usage.
-v
,,--w.
r--,.e
,,r-------
-m..,
-- n - m
,rw
,---re--~
w
-.m--..
--,-v-,-w.w---,-.n w v- -- - - - - -
--n-+w r~we
i TABLE 4.
(c'ontinued)
Areas Comments Abstracts Root cause and corrective action information was often inadequate or was not included. Abstracts should not contain information which was not discussed in the text, 'If it is necessary to include this information, the text should be revised so as to discuss it.
- Coded fields a.
Titles Titles should be written such that they better describe the event.
In particular, include the root cause and result of the event in all titles.
t
,.-n
,,,---,,,-,-,_,-,,e
-,, - ~...,
n,,---
,--n.
,---n,.- -,,, -.,, -
,.,,_,-,-,,--,,--g_,--,
REFERENCES 1.
B. S. Anderson, C. F. Miller, B. M. Valentine, An Evaluation of Selected Licensee Event Reports Prepared Pursuant to 10 CPR 50.73 (DRAFT), NUREG/CR-4178, March 1985.
2.
Office for Analysis and Evaluation of Operational Data, Licensee Event Report System, NUREG-1022, U.S. Nuclear Regulatory Commission, September 1983.
3.
Office for Analysis and Evaluation of Operaticaal Data, Licensee Event Report System, NUREG-1022 Supplement No. 1, U.S. Nuclear Regulatory Commission, February 1984.
4.
Office for Analysis and Evaluation of Operational Data, Licensee Event Report System, NUREG-1022 Supplement No. 2, U.S. Nuclear Hegulatory Commission, September 1985.
i l
APPENDIX A LER SAMPLE SELECTION INFORMATION FOR KEWAUNEC e
i
TABLE A-1.
LER SAMPLE SELECTION FOR KEWAUNEE LER Sample Number LER Number Comments 1
84-014-00 SCRAM 2
84-015-00 3
84-018-01 4
84-020-00 ESF 5
85-001-00 ESF 6
85-005-00 ESF 7
85-006-00 8
85-007-00 ESF 9
85-010-00 SCRAM 10 85-011-01 ESF
-11 85-014-00 12 85-015-00 13 85-018-00 1
l l
I-i in
9 9
e 4
APPENDIX B EVALUATION SCORES OF INDIVIDUAL LERS FOR KEWAUNEE
1ABLE B-l.
EVALUATION SCORES OF INDIVIDUAL LERs FOR KEWAUNEE l
l LER Sample Number
- 1 2
3 4
5 6'
7 8
9 10 11 12 13 14 15 16 Text 7.2 7.7 4.8 7.6 9.7 8.3 8.6 7.0 6.6 4.2 5.1 9.2 8.9 Abstract 9.5 9.0 3.8 6.3 7.5 5.5 9.7 9.2 6.8 7.1
- 7. 5 9.2 10.0 Coded F ields 9.4 8.9 5.0 9.0 9.5 8.5 9.5 8.3 9.0 8.3 9.0 9.5 9.5 Overall 8.1 8.2 4.5 7.3 9.0 7.5 9.1 7.8 6.9 5.5 6.2 9.2 9.3 a
LER Sample Number 17 18 19 20 21 22 23 24 25 26 27' 28 29 30 AVERAGE 7.3 Text 7.8 Abstract Coded 8.7
' Fields o
7.6 8
Overall
?
4 a.
See Appendix A for a list of the corresponding LER numbers.
I e
1 t
I 1
.TPPENDIX C DEFICIENCY AND OBSERVATION COUNTS FOR KEWAUNEE e-
TABLE C-1.
TEXT DEFICIENCIES AND OBSERVATIONS FOR KEWAUNEE Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph-Description of Deficiencies and Observations Totals Totals (
)b-a 50.73(b)(2)(ii)(A)--Plant operating 3 (13) conditions before the event were not
- included or were inadequate.
f0.73(b)(2)(ii)(B)--Discussionofthestatus 0 (2) of the structures, components, or systems that were inoperable at the start of the event and that contributed to the event was.
not included or was inadequate.
- 50.73(b)(2)(ii)(C)--Failure to include 2 (13) sufficient date and/or time information, a.
Date information was insufficient.
1 b.
Time information was insufficient.
1 50.73(b)(2)(ii)(D)--The root cause and/or 5 (13) intermediate failure, system failure, or personnel error was not included or was inadequate.
a.
Cause of component failure was not 3
included or was inadequate
- b. - Cause of system failure was not 0
included or was inadequate c.
Cause of personnel error was not 3
included or was inadequate.
50.73(b)(2)(ii)(E)--The failure mode, 0 (4) mechanism (immediate cause), and/or effect (consequence) for each failed component was not included or was inadequate.
a.
Failure mode was not included or was inadequate b.
Mechanism (immediate cause) was not included or was inadequate c.
Effect (consequence) was not included or was inadequate.
4 4
t S
, _. ~, _....
,._...,,.....,_.,,-,...._,,.y
_ _.,,3_ - _. _,...,
,___cr__.-__ -,,.,
.-r.~,,
1 TABLE C-1.
(continued) 1 Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
50.73(b)(2)(ii)(F)--The Energy Industry 1 (13)
Identification System component function identifier for each component or system was not included.
50.73(b)(2)(ii)(G)--For a failure of a component with multiple functions, a list.
0 (0) of systems or secondary functions which were also affected was not included or was inadequate.
50.73(b)(2)(ii)(H)--For a failure that 4 (8) rendered a train of a safety system inoperable, the estimate of elapsed time from the discovery of the failure until the train was returned to service was not included.
50.73(b)(2)(ii)(I)--The method of discovery 2 (13) of each component failure, system failure, personnel error, or procedural error was not included or was inadequate.
a.
Method of discovery for each 2
component failure was not included 4
or was inadequate b.
Method of discovery for each system 0
failure was not included or was inadequate c.
Method of discovery for each 0
personnel error was not included or was inadequate d.
Method of discovery for each 0
procedural error was not included or was inadequate.
m.
e TABLE C-1.
(continued)
Number ~of LERs with Deficiencies and Observations Sub-paragraph Paragraph
~
Totals (
)b Description of Deficiencies and Observations Totalsa 50.73(b)(2)(ii)(J)(1)--Operator actions that 2 (7) affected the course of the event including operator errors and/or procedural deficiencies were not included or were inadequate.
50.73(b)(2)(ii)(J)(2)--The discussion of 7(7) each personnel error was not included or was inadequate.
a.
OBSERVATION: A personnel error was 0
implied by the text, but was not explicitly stated.
b.
50.73(b)(2)(ii)(J)(2)(1)--Disctssion-3 as to whether the personnel r or was cognitive or procedural was act included or was inade 50.73(b)(2)(ii)(J)(2)quate.(ii)--Discussion 1
c.
as to whether the personnel error was contrary to an approved procedure, was a direct result of an error in an approved procedure, or was associated with an activity or task that was not covered by an approved procedure as not included or was inadequate.
d.
50.73(b)(2)(ii)(J)(2)(iii)--Discussion 0
of any unusual characteristics of the work location (e.g., heat, noise) that directly contributed to the personnel error was not included or was inadaquate.
e.
50.73(b)(2)(ii)(J)(2)(iv)--Discussion 2
of the type of personnel involved (i.e., contractor personnel, utility licensed operator, utility nonlicensed operator, other utility personnel) was not included or was inadequate.
e
-_,_,,_.,_,-,_,m
,,,y.-_---,-.,m.
C
.n TABLE C-l.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
50.73(b)(2)(ii)(K)--Automatic and/or manual 1 (7) safety system responses were not included or were inadequate.
50.73(b)(2)(ii)(L)--The manufacturer and/or 2 (5) model number of each failed component was not included or was inadequate.
50.73(b)(3)--An assessment of the safety 8 (13) consequences and. implications of the event was not included or was inadequate.
a.
OBSERVATION: The availability of 1
other systems or components capable of mitigating the consequences of the event was not discussed.
If no other systems or components were available, the text should state that none existed.
b.. OBSERVATION: The consequences 1
of the event had it occurred under more severe conditions were not discussed.
If the event occurred under what were considered the most severe conditions, the text should so state.
50.73(b)(4)--A discussion pf any corrective 4 (13) actions planned as a result of the. event including those to reduce the probability of similar events occurring in the future was not included or was inadequate.
.m.
^
TABLE C-1.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (-
)b a
a.
A' discussion of actions required to 1
correct the problem (e.g., return the component or system to operation
. condition or correct the personnel error) was not included or was ina6:quate.
b.
A discussion of. actions required to 1
reduce the probability of recurrence of the problem or similar event (correct the root cause) was not included or was inadequate.
c.
OBSERVATION: A discussion of actions 0
required to prevent similar failures
-in similar and/or other systems (e.g.,
2 correct the f aulty part in all components with the same manufacturer L
and model number) was not included or was inadequate.
50.73(b)(5)--Information concerning previous 11(13) similar events was not included or was inadequate.
6 4
9 1
s
. _... _. _... _ _. _,. _ ~ -. _.,, _, -. ~
TABLE C-1.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
50.73(b)(2)(i)--Text presentation 5 (13) inadequacies.
a.
OBSERVATION: A diagram would have 0
aided in understanding the text discussion.
b.
Text contained undefined acronyms 3
and/or plant specific designators.
c.
The text contains other specific 2
deficiencies relating to the readability.
a.
The "sub-paragraph total" is a tabulation of specific deficiencies or observations within certain requirements. Since an LER can have more than one deficiency for ce:tain requirements, (e.g., an LER can be deficient in the area of both ri:ce and time information), the sub-paragraph totals do not necessarib add up to the paragraph total.
b.
The " paragraph total" is the number of LERs that have one or more requirement deficiencies or observations. The number in parenthesis is the number of LERs for which the requirement was considered applicable.
TABLE C-2.
ABSTRACT DEFICIENCIES AND OBSERVATIONS FOR KEWAUNEE Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
A summary of occurrences (immediate cause 1 (13) and effect) was not included or was inadequate A summary of plant, system, and/or persone.i 2 (8) responses was not included or was inadequate.
a.
Summary of plant responses was not 0
included or was inadequate.
b.
Summary of system responses was not 1
included or was inadequate..
c.
Summary of personnel responses was not 1
included or was inadequate.
A summary of the root cause of the event 7(13) was not included or was inadequate.
A summary of the corrective actions taken or 6 (13) planned as a result of the event was not included or was inadequate.
4
TABLE C-2.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Totals (
)b Description of Deficiencies and Observations Totalsa Abstract presentation inadequacies 4 (13) a.
OBSERVATION: The abstract contains 3
information not included in the text.
The abstract is intended to be a summary of the text, therefore, the text should discuss all information summarized in the abstract.
b.
The abstract was greater than 0
1400 characters c.
The abstract contains undefinea 1
acronyms and/or plant specific designators.
d.
Tne abstract contains other specific 3
deficiencies (i.e.. poor summarization, contradictions,etc.)
a.
The "sub-paragraph total" is a tabulation of specific deficiencies or observations within certain requirements. Since an LER can have more than one deficiency for certain requirements, (e.g., an LER can be deficient in the area of both date and time information), the sub-paragraph totals do not necessarily add up to the paragraph total.
b.
The " paragraph total" is the number of LERs that have one o~r more deficiency or observation. The number in parenthesis is the number of LERs for which a certain requirement was considered applicable.
I
..,m.sv.,,,,,_,.,.~.._...r.
.__,-r-,, -,,..,..
.,.~-_r-..,
,,......,y,.,
,. ~.,.,.,,,
s f.
TABLE C-3.
CODED FIELDS DEFICIENCIES AND OBSERVATIONS FOR KEWAUNEE Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
Facility Name 0(13) a.
Unit number was not included or incorrect.
b.
Name was not included or was incorrect.
c.
Additional unit numbers were included but not required.
Docket Number was not included or was 0(13) incorrect.-
Page Number was not included or was 0 (13) incorrect.
Title was left blank or was inadequate 11(13) a.
Root cause was not given in title 11 b.
Result (effect) was not given in title 2
c.
Link was not given in title 2
Event Date 1(13) a.
Date not included or was incorrect.
I b.
Discovery date given instead of event 0
date.
LER Nu.nber was not included or was incorrect 0 (13)
Report Dete 2 (13) a.
Date not included 0
b.
OBSERVATION: Report date was not 2
within thirty days of event date (or discovery date if appropriate).
Other Facilities information in field is 0 (13) inconsistent with text and/or abstract.
Operating Mode was not included or was 1(13) inconsistent with text or abstract.
-a TABLE C-3.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
Power level was not included or was 1 (13) inconsistent with text or abstract Reporting Requirements 1 (13) a.
The reason for checking the "0THER" 0
requirement was not specified in the abstract and/or text.
b.
OBSERVATION:
It would have been more 1
appropriate to report the event under a different paragraph.
c.
OBSERVATION:
It would have been 0
appropriate to report this event under additional unchecked paragraphs.
' Licensee Contact 0 (13) a.
Field left blank b.
Position title was not included c.
Name was not included d.
Phone number was not included.
Coded Component Failure Information 3 (13) a.
One or more component failure 0
sub-fields were left blank.
b.
Cause, system, and/or component code 2
is inconsistent with text.
c.
Component failure field contains data 1
when no component f ailure occurred.
d.
Component failure occurred but entire 0
field left blank.
i
.-.,__.,_..,__ -_.-,-__,-..-- -._ _,.,.-,-._, -,__ -- -....~,....,,..-..-.._..-
f-TABLE C-3.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
Supplemental Report 0 (13) a.
Neither "Yes"/"No" block of the supplemental report field was checked.
b.
The block checked was inconsistent with the text.
Expected submission date information is 0(13) inconsistent with the block checked in Item (14).
a.
The "sub-paragraph total" is a tabulation of specific deficiencies or observations within certain requirements. Since an LER can have more than one deficiency for certain requirements, (e.g., an LER can be deficient in the area of both date and time information), the sub-paragraph totals do not necessarily add up to the paragraph total.
b.
The " paragraph total" is the number of LERs that have one or more requirement deficiencies or observations. The number in parenthesis is the number of LERs for which a certain requirement was considered applicable.
D 9
s G
l 4
APPENDIX D LER COMMENT SHEETS FOR KEWAUNEE
~
.h TABLE D-1.
SPECIFIC LER COM'4ENTS FOR KEWAUNEE (305)
Section Comments 1.
LER Number: 84-014-00 Scores: Text = 7.2 A**
4ct = 9.5
' Coded Fields = 9.4 Overall = 8.1 Text 1.
50.73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is not included.
2.
50.73(b)(2)(ii)(L)--Identification (e.g. manufacturer and model no.) of the f ailed component (s) discussed in the text is not included.
3.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is not included.
4.
50.73(b)(4)--The text should at least indicate whether the connector was refastened or replaced.
5.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
6.
Acronym (s) and/or plant specific designator (s) are undefined.
Abstract 1.
No comments.
Coded Fields 1.
Item (4)--Title: Root cause is not included. An intermediate cause was the loose conr.ection. The link between the loose connection a.id the reactor trip was the loss of power. Nott. Cause of loose connection is unknown.
2.
Item (13)--A more appropriate component code would probably be " CON" for connector.
[
-TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305) r-Section Comments 2.
LER Number: 84-015-00 Scores: Text = 7.7 Abstract = 9.0 Coded Fields = 8.9 Overall = 8.2 Text 1.
50.73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is not included.
2.
50.73(b)(2)(ii)(D)--The root and/or intermediate cause discussion for the personnel error is not included.
3.
50.73(b)(2)(ii)(J)(2)--Discussion of personnel error is inadequate. Why did the operator fail to close the filter drain valve (FPC-1100)?
4.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
Abstract 1.
50.73(b)(1)--Summary of root cause is not included.
Coded Fields.
1.
Item (4)--Title: Root cau'se is not included.
- 2..
Item (13)--Component f ailure field contains data when no component failure occurred.
l
. - - -. - - - - - - - - - - - - ~
8 TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305) n Section Comments 3.
LER Number: 84-018-01 Scores: Text = 4.8 -
Abstract = 3.8 Coded Fields = 5.0 Overall = 4.5 Text 1.
50.73(b)(2)(ii)(C)--Date and time information for occurrences is inadequate. A date should be provided-for the " discovery of less than design air flow".
Dates for completion of subsequent studies (evaluations) should be provided. When will the corrective actions be completed?
2.
50.73(b)(2)(ii)(D)--The root and/or intermediate cause discussion for the " increased fin fouling",
" silt", and " insufficient cooling capacity" is inadequate.
3.
50.73(b)(2)(ii)(F)--The Energy Industry Identification System component function identifier (s) and/or system name of each component or system referred to in the LER is not included.
4.
50.73(b)(2)(ii)(I)--Discussion of the method of discovery of the FCU's airflow problem is not included.
5.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate. What is meant by "short-term failure" and " reasonable assurance"?
It appears from the overall discussion that the present units would not protect ESF equipment given worst case conditions; therefore, what is the justification for not implementing immediate upgrades?
6.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
7.
Some conclusions reached are inconsistent with the facts presented.
50.73(b)(1)--Summary (ofoccurrences[immediate Abstract 1.
cause(s) and effects s)] is inadequate.
2.
50.73(b)(1)--Summary of root cause information is not included.
$\\
TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments 3.
LER Numoer: 84-018-01 (continued) 3.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate.
Information from text should be sunnarized in more detail.
4.
Abstract contradicts the text. Second sentence of abstract contradicts last sentence of second paragraph in text.
5.
Abstract contains acronym (s) and/or plant 9ecific designator (s) which are undefined.
Coded Fields 1.
Item (4)--Title: Root cause and result are not included.
2.
Item (5)--Event date is incorrect. Event date should be when it was determined that there was insufficient cooling capability to ensure proper post-accident operation of ESF equipment.
3.
Item (7)--0BSERVATION: Report date is not within thirty days of event date (or discovery date if appropriate).
4.
Item (10)--Power level is incorrect. Problem was apparently discovered during a refueling outage.
5.
Item (ll)--0BSERVATION:
It appears it would have been more appropriate to report this event under paragraph (s)50.73(a)(2)(v).
i r
r3 TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305) 4 Section Comments 4.
LER Number: 84-020-00 Scores: Text = 7.6 Abstract = 6.3 Coded Fields = 9.0 Overall = 7.3 Text 1.
50.73(b)(2)(ii)(JD--IfthereasonfortheJohnson solenoid valve tailures is known, the text should '
discuss it.
2.
50.73(b)(2?fii)(H)--A time estimate of the l
unavailabiltty of the failed system is not included.
I 3..
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is i
not included, i
Abstract 1.
50.73(b)(1)--Summary of personnel responses is inadequate. The abstract should indicate that attempts were made to secure the fan.
2.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is not included.
OBSERVATION: The abstract contains information not included in the text. The abstract is intended to be a summary of the text; therefore, the text should i
discuss all information summarized in the abstract.
3.
Additional space is available within the abstract l
field to provide the necessary information but it was not utilized.
l Coded Fields 1.
Item (4)--Title: Root causes and link are not included.
l
-.----~,-,.-~.._..-.._.__.--_m.-,,-._..,..y.,
m.__-,,,..,~--,..,.-cw.___,-.m--,.,-,_,.,.,m
-yy,., - - - - -..., -,.,
y-y---
i'-
TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments 5.
LER Numbee: 85-001-00 Scores: Text = 9.7 Abstract = 7.5 Coded Fields = 9.5 Overall = 9.0 Text 1.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
Abstract 1.
50.73(b)(1)--Summary of root cause is not included.
Coded Fields 1.
Item (13)--Cause, system, and/or component code is inconsistent with text.-
I
.t O'
TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments 6.
LER Number: 85-005-00 Scores: Text = 8.3 Abstract = 5.5 Coded Fields = 8.5 Overall = 7.5
~ Text 1.
50.73(b)(2)(ii)(H)--A time estimate of the unavailability of the failed system is not included.
What time on 2/13/85 was the system returned to service?
2.
50.73(b)(2)(ii)(I)--Discussion of the method of discovery of the ABSV fan running is not included.
What was the control operator doing in connection with the discovery (e.g., plant walkdown, 8-hour readings,etc.)?
3.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate. OBSERVATION: The availability of other systems or components capable of mitigating the consequences of the event should be discussed.
If no other systems or compenents are available, the text should so state.
4.
If the WPSC finds other V-24 solenoid valves that are critical to plant operation, will these be change'd out immediately?
5.
Acronym (s) and/or plant specific designator (s) are undefined.
Abstract 1.
50.73(b)(1)--Summary of root cause is not included.
2.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is not included.
3.
It is not necessary to include in the abstract a generic statement concerning the impact of the event on the health and safety of the public. However, a discussion of how such a conclusion was reached should be included in the text of every LER.
4.
Abstract does not adequately summarize the text.
Additional space is available within the abstract field to provide the necessary information but it was not utilized.
Coded Fields 1.
Item (4)--Title: Root cause and result (ESF actuation) are not included.
TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Scction Comments 7.
LER Number: 85-006-00 Scores: Text = 8.6 Abstract = 9.7 Coded Fields = 9.5 Overall = 9.1 Text 1.
50.73(b)(2)(ii)(H)--Specific dates for the previous tube pluggings should be given.
2.
50.73(b)(2)(ii)(J)(2)--Discussion of personnel error is inadequate.
3.
50.73(b)(2)(ii)(J)(2)(i)--Discussion as to whether the personnel error was cognitive or procedural is not included.
4.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
Abstract 1.
No comments.
Coded Fields 1.
No comments.
. _ - - - -... - _ -, - _ - - -. - - -. ~ - -.
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TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments 8.
LER Number: 85-007-00 Scores: Text = 7.0 Abstract = 9.2 Coded Fields = 8.3 Overall = 7.8 Text 1.
50.73(b)(2)(ii)(J)(1)--Discussion of operator actions that affected the course of the event is not included.
~
2.
50.73(b)(2)(ii)(J)(2)--Discussion'of personnel error is inadequate.
3.
50.73(b)(2)(ii)(J)(2)(1)--Discussion as to whether the personnel error was cognitive or procedural is not included.
4.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate. How did the "at shutdown plant equipment line-up" prevent this event from having any safety implications?
OBSERVATION: The consequences of the event had it occurred under more severe conditions should be discussed. If the event occurred under what are considered the most severe conditions, the text should so state.
5.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. Corrective actions did not indicate whether or not the I & C Technicians were counseled.
6.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
Abstract 1.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate.
Coded Fields 1.
Item (4)--Title: Root cause is not included.
2.
Item (9)--Operating mode is not included.
TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305) g Section Coments 9.
LER Number: 85-010-00 Scores: Text = 6.6 Abstract = 6.8 Coded Fields = 9.0 Overall = 6.9 Text 1.
50.73(b)(2)(ii)(D)--The root and/or intermediate cause discussion for the personnel error and instrument calibration problem is not included.
2.
50.73(b)(2)(ii)(J)(2)--Discussion of personnel error is inadequate. Why did the operator allow the level to drop?
3.
50.73(b)(2)(ii)(K)--Discussion of automatic and/or manual safety system responses is inadequate. More details are needed rather than simply stating that "The Reactor Protection System performed as required".
4.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate. The abstract says "the operators perf ormed the imediate actions prescribed in the Reactor Trip procedure".
This is not mentioned in the text.
5.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
OBSERVATION: The consequences of the event had it occurred under more severe conditions should be discussed. If the event occurred under what are considered the most severe conditions, the text should so state.
6.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. What was done or planned to prevent recurrence of the feed / steam flow transmitters being out of calibration such that a trip signal is present?
7.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
8.
Some ideas are not presented clearly (hard to follow).
. jo TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments 9.
LER Number: 85-010-00(continued)
Abstract 1.
50.73(b)(1)--Summary of system responses is inadequate.
2.
50.73(b)(1)--Summar of root cause is not included.
(see text comment 1.
3.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate.
(See text comment 6).
OBSERVATION: The abstract contains information not included in the text. The abstract is intended to be a summary of the text; therefore, the text should discuss all information summarized in the abstract.
i Coded Fields 1.
Item (4)--Title: Root cause is not included.
1 1
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TABLE 0-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments
- 10. LER Number: 85-011-01 Scores: Text = 4.2 Abstract = 7.1 Coded Fields = 8.3 Overall = 5.5 Text 1.
50.73(b)(2)(ii)(C)--Additional times are needed.
2.
50.73(b)(21(ii)(0) and 50.73(b)(2)(ii)(E)--The faulty 1
i control vatv7 was not discussed.
3.
50.73(b)(2)(ii)(H)--A time estimate of the unavailability of the failed system is not included.
4 50.73(b)(2)(ii)(J)(2)--The corrective actions imply a personnel error in not using manual isolation valves, l
but do not indicate if the error was cognitive or procedural nor the type of personnel involved.
5.
50.73(b){2)(ii)(L)--Identification (e.g. manufacturer and model no.) of the failed component (s) discussed in the text is not included.
6.
50.73(b)(3)--Discussion of'the assessment of the I
safety consequences and implications of the event is not included.
7.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. As a minimum, the corrective actions should indicate that steam flow out the rupture disc was stopped. Other corrective actions should address the leaky control valve and replacement of the rupture disc. Long term corrective actions should address the adequacy of the procedure, so that new employees will also be aware
(
of the problem.
8.
50.73(b)(5)--Information concerning previcus similar events is not included.
If no previous similar events are known, the text should so state.
9.
Acronym (s) and/or plant specific designator (s) are undefined.
Abstract 1.
50.73(b)(1)--The root cause and corrective actions summaries are deficient for the same reasons given for these items in the text.
TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments
- 10. LER Number: 85-011-01(continued)
Coded Fields 1.
Item (4)--Title: Root cause and link are not included.
2.
Item (7)--0BSERVATION: Report date is not within thirty days of event date (or discovery date if appropriate).
3.
Item (13)--It would be more appropriate to fill in a line for the control valve. The rupture disc actually performed its intended (designed) function.
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TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305) c Section Comments
- 11. LER Number: 85-014-00
- Scores: Text = 5.1 Abstract = 7.5 Coded Fields = 9.0 Overall = 6.2 Text 1.
Submittal of an LER without a text is acceptable; however, the abstract must then meet all the a
requirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a text.
2.
50.73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is inadequate.
3.
50.73(b)(2)(11)(D)--The root and/or intermediate cause discussion for the personnel error is not included.
4.
50.73(b)(??(ii)(J)(2)--Discussion of personnel error is not inc'uded.
5.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is not included.
6.
50.73(b?(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
Abstract 1.
50.73(b)(1)--Summary of root cause is not included.
Coded Fields 1.
Item (4)--Title: Root cause is not included.
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.,s TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments
- 12. LER Number: 85-015-00 Scores: Text = 9.2 Abstract = 9.2 Coded Fields = 9.5 Overall = 9.2 Text 1.
OBSERVATION:
Ccores for this LER are based on the assumption tnt, the supplemental report will contain all the necessary information.
2.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous simil;r events are known, the text should so state.
Abstract 1.
No comments.
Code'd Fields 1.
Item (4)--Title: Root cause is not included.
9
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TABLE D-1.
SPECIFIC LER COMMENTS FOR KEWAUNEE (305)
Section Comments
- 13. LER Number: 85-018-00 Scores: Text = 8.9 Abstract = 10.0 Coded Fields = 9.5 Overall = 9.3 Text 1.
Submittal of an LER without a text is acceptable; however, the abstract must then meet all the requirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were'a text.
2.
50.73(b)(2)(ii)(J)(2)--Discussion of personnel error is inadequate.
3.
50.73(b)(2)(ii)(J)(2)(iv)--Discussion of the type of personnel involved (i.e., contractor personnel, utility licensed operator, utility nonlicensed operator, other utility personnel) is not included.
4.
50.73(b)(5)--Information concerning previous similar events is not included.
If no previous similar events are known, the text should so state.
Abstract 1.
No comments.
Coded Fields 1.
' Item (4)--Title: Root cause is not included.
_ _ _