ML20205R844

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Forwards Summary of 881006 Enforcement Conference W/Util Re Insp Rept 50-458/88-22.Viewgraphs Encl
ML20205R844
Person / Time
Site: River Bend Entergy icon.png
Issue date: 11/02/1988
From: Callan L
NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To: Deddens J
GULF STATES UTILITIES CO.
References
EA-88-249, NUDOCS 8811100144
Download: ML20205R844 (31)
v • d • e


See also: IR 05000458/1988022

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Docket: 50-458

License No. NPF-47

EA No.88-249

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Gulf States Utilities

ATTN: .Mr. James C. Deddens

Senior Vice President (RBNG) .

P.O. Box 220

St..Francisville, Louisiana 70775,

Gentlemen:

.This refers to the Enforcement Conference conducted on October 6,1988, with you '

and other members of your staff Region IV, and Office of Nuclear Reactor

Regulation personnel. This conference, conducted by telephone because of the

number of ongoing site activities as a result of an unplanned outage, involved

the findings of the NRC inspection conducted during the period August 29 through.

September 15, 1988 (NRC Inspection Report 50-458/88-22 dated September 29,

1988).

The subjects discussed at this meeting are described in the enclosed Meeting

Summary.

In accordance with Section 2.790 of the NRC's "Rules of Practice," Part 2

Title 10, Code of Federal Regulations, a copy of this letter will be placed in

the NRC's Public Document Room.

Should you have any questions concerning this matter, we will be pleased to

discuss them with you.

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Sincerely,

I

Original Signed By

A. II. Beacli

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L. J. Callan, Director

, Division of Reactor Projects

Enclosure:

Meeting Sumary

cc w/ enclosure: (seenextpage)

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Gulf Statr,s Utilities .

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P.O. Bor 2951

Beaumont, Texas 77/04

Gulf States' Utilities

ATTN: Les England, Director

' Nuclear Licensing - RBNG-

P.O. Box 220

St. Francisville, Louisiana 70775

i ' Louisiana State University,

. Government Documents Department

Louisiana Radiation Control Program Director,

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bec distrib. by RIV:

DRP RRI-

R. D. Martin, RA SectionChief.(DRP/C)

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.Lisa Shea, RM/ALF MIS System

RPB-DRSS RSTS Operator

Project Engineer, DRP/C RIV File

W. Paulson, NRR Project Manager DRS

G. F. Sanborn, EO A. B. Beach, DD:DRP

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ATTACRMENT

[ GULF STATES UTILITIES

OCTOBER 6, 1988

MEETING SUMMARY

Licensee: Gult States Utilities (GSU).

Facility: River Bend Station (RBS)

License No.: NPF-47

Docket No.: 50-458

SUBJECT: ENFORCEMENT CONFERENCE CONCERNING NRC *.NSPECTION FINDINGS

(INSPECTION REPORT 50-458/88-22) 1

.

On October 6,.1988, representatives of Gulf States Utilities held an

enforcement conference by_ telephone with NRC Region IV and NRk personnel to

discuss the findings documented in the NRC Inspection Report dated -

September 29, 1988. The attendance list and licensee presentation material are

attached. The conference call was held at the request of NRC, Region IV.

The NRC discussed its concern regarding both divisions of the fuel building

ventilation charcoal filtration subsystems being placed in an inoperable ,

condition. The NRC staff also expressed concern that in 1986 a similar event '

had occurred and actions to prevent recurrence had not been completed at the

time of this, event. The licensee discussed the sequence of events, the safety

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significance of the matter and corrective actions taken. A handout prepared by

GSU for the meeting is attached.

Enclosures: .

1. Attendance List i

2. GSU Presentation ,

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EN[LOSURE1

. ENFORCEMENT CONFERENCE ATTENDANCE LIST

' GULF STATES UTILITIES

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.NRC Attendees: A. Beach, Deputy Director, Division of Reactor Projects  !

G. Sanborn, Enforcement Officer

G. Constable, Chief, Project Section C, DRP

W. Seidle, Chief. Test Programs Section, DRS ,

E. Ford, Senior Resident Inspector

W. Jones, Resident Inspector

W. Paulson, Project Manager, NRR-(via telephone)

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Attendees: J. Deddens, Senior Vice President, River Bend Nuclear Group '

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(via telephone) J. Booker, Manager, Oversight

T. Plunkett, Plant Manager

P. Graham, Assistant Plant Manager ,

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T. Crouse Manager, Quality Assurance

L. England, Director, Nuclear Licensing

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R. King, Supervisor, Nuclear LicenAing ,

A. Frediem, Operations Supervisor

M. Sankovich, Manager, Engineering

D. Williamson, EPS Supervisor

J. Miller, Supervisor, Engineering Analysis

T. Murphy, Supervisor, Planning and Scheduling

J. Schippert, Operations Engineer

M. Morris, Senior Engineer

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AGENDA

October 6, 1988

' ENFORCEMENT CONFERENCE CALL

INSPECTION REPORT 88-22

INTRODUCTIONS L. England

OPENING REMARKS J. Deddens

DISCUSSION OF EVENTS AND GSU INVESTIGATION T. Plunkett

SAFETY SIGNIFICANCE T. Plunkett

CORRECTIVE ACTIONS T. Plunkett/M. Sankovich

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FOLLOW-UP L. England

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OCTOBER 6, 1988  !

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RIVER BEND

PAGE

INTRODUCTION 1

DESCRIPTION 2,3,4

SEQUENCE OF EVENTS 5, 6

ROOT CAUSE DETERMINATION 7, 8, 9, 10

SAFETY SIGNIFICANCE 11, 12

CORRECTIVE ACTION 13, 14, 15, 16

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SUMMARY 17, 18, 19

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INTRODUCTION

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MISPOSITIONED CONTROL SWITCHES RESULTED IN OPEN SUPPLY

BREAKERS TO THE HEATERS FOR BOTH FUEL BUILDING CHARC0AL

FILTER TRAINS, 1HVF*FLT2AH (BH).

MISPOSITIONED CONTROL SWITCHES

' WORST CASE, WERE UNDETECTED FOR NINE OPERATIONS SHIFT

TURNOVERS, INCLUDING REQUIRED CONTROL BOARD WALKDOWNS.

  • MOST PROBABLE CASE, WERE UNDETECTED FOR SIX OPERATIONS

SHIFT TURNOVERS, INCLUDING REQUIRED CONTROL BOARD

WALKDOWNS.

MISPOSITIONED CONTROL SWITCHES RESULTED IN FUEL BUILDING

CHARC0AL FILTRATION SYSTEMS TO BE INOP, VIOLATING

TECHNICAL SPECIFICAi!ONS 3.0.3, 3.0.4, AND 3.6.5.6.

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SEQUENCE OF EVENTS'

JULY 30, 1988/0622: PREVIOUS PERFORMANCE OF * FUEL 'l

BUILDING HVAC CHARCOAL FILTER (HVF)  ;

MONTHLY OPERABILITY IEST,"

STP-406-0201, VERIFIED LOCAL

BREAKER CLOSURE AND ENERGIZED

HEATERS.

AUGUST 25, 1988/1232: SCRAM 88-04, INCLUDING AN HVF

ACTUATION

AUGUST 25, 1988/1235: ENTERED "LOSS OF ONE RPS bus,"

A0P-0010. SUBSEQUENT ACTIONS

INCLUDED HVF RESTORATION.

AUGUST 26, 1988/0502: LOGGED VERIFICATION BY A LICENSED

OPERATOR OF ALL PLANT SYSTEMS

RESTORED AFTER SCRAM 88-04. PLANT

IN HOT SHUTDOWN.

AUGUST 27, 1988/0251: INADVERTENT HVF ACTUATION DURING

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PERFORMANCE OF STP

AUGUST 27, 1988/0332: LOGGED VERIFICATION BY TWO LICENSED

OPERATORS OF HVF SYSTEM RESTORATION

AFTE". INADVERTENT HVF ACTUATION

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AUGUST 27, 1988/0600 - UNDOCUMENTED YERIFICATION OF HVF

1800: SYSTEM LINEUP BY TWO LICENSED

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OPERATORS, PRIOR TO MODE CHANGE

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AucoST 28, 1988/0000: MODE CHANGE, HOT SHUTDOWN TO STARTuP

AUGUST 28, 1988/1229: MODE CHANGE, STARTyf TO POWER

OPERATION

AUGUST 29, 1988/1950: MISPOSITIONED CONTROL SWITCHES

DETECTED DuRING PERFORMANCE OF "FUEL

BUILDING HVAC CHARC0AL FILTER MONTHLY

OPERABILITY TEST," STP-406-0201.

IMMEDIATE ACTION TAKEN TO ENTER SHORT-

TERM LC0 AND ACTION STATEMENT FOR TECH

SPEC 3.0.3, AND TO RESTORE FUEL

BUILDING FILTER HEATERS TO OPERABLE

STATUS BY CLOSING SUPPLY BREAKERS.

EXITED SHORT-TERM LCO AND NOTIFIED

NRC OPERATIONS CENTER.

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CONCLUSION

IIME OF HEATER SUPPLY BREAKER OPENING CANNOT BE DETERMINED.

. HEATER SUPPLY BREAKERS MOST PROBABLY OPENED BETWEEN

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AUGUST 27 AND AUGUST 29.

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ROOT CAUSE

DETERMINATI0N

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ROOT CAUSE DETERMINATION

- SHIFT IURNOVER DEFICIENCIES - SIX SHIFT TURNOVERS, INCLUDING

CONTROL BOARD WALKDOWNS, TOOK PLACE DURING THE PERIOD

BETWEEN THE LAST VERIFICATION OF SWITCH POSITION AND

DISCOVERY OF SWITCH MISPOSITION.

- SHIFT TURNOVER PROCEDURE DEFICIENCIES - OPERATIONS SECTION

PROCEDURE "SHIFT RELIEF AND TURNOVER," 0SP-0002,

REV. 4, DATED 4-30-87, DELETED A SYSTEM STATUS

CHECKLIST THAT HAD BEEN PART OF THE UNIT OPERATOR S

BOARD WALKDOWN. THIS WAS BASED ON THE EARLIER

INCLUSION OF A CONTROL ROOM ROUNDS CHECKLIST INTO

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THE "DAILY LOG REPORT," 0SP-0012. HOWEVER, THE

CONTPOL ROOM ROUNDS DID NOT INCLUDE THE HVF SYSTEM.

- ANNUNCIATOR DEFICIENCIES - TROUBLE /INOP INDICATION HAS

NOT BEEN PROVIDED TO ALARM THE LOSS OF CONTROL POWER

TO THE HEATER CIRCUIT DUE TO HEATER OVERTEMPERATURE

TRIP OR BREAKER MISPOSITION. THIS PROBLEM WAS

IDENTIFIED ON CR 86-0875 (CORRECTIVE ACTION INCLUDES

MR 86-1213 AND 86-1214) AND MR 86-1701.

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HUMAN FACTORS DEFICIENCIES - HEATER SUPPLY BREAKER CONTROL

MAY HAVE BEEN MISTAKEN FOR FAN CONTROL SWITCH, SINCE

DESIGN RESEMBLES SIMILAR (GTS*FNIA(B)) CONTROL SWITCH.

- STARTUP COMMUNICATIONS DEFICIENCIES -

- OPERATIONS MANAGEMENT REQUESTED CONTROL BOARD LINEUPS

REVERIFIED PRIOR TO MODE CHANGES ON AUGUST 28,

. OPERATIONS PERSONNEL MISUNDERSTOOD AND SIGNED OFF

SYSTEMS ON THE MASTER STARTUP CHECKLIST BASED ON

PREVIOUSLY DOCUMENTED CONTROL BOARD LINEUPS.

. OPERATIONS MANAGEMENT NOTED THE MISUNDERSTANDING

AND REPEATED THE INSTRUCTION FOR LINEUP

REVERIFICATION.

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REATERIN0PANNUNCIATORS

JULY 1, 1986: CR 86-0875 INITIATED DUE TO INABILITY

TO ENERGIZE CONTROL ROOM CHARCOAL FILTER

HEATER. HEATER OVERTEMPERATURE TRIP WAS

RESET, AND HEATER WAS RETURNED TO SERVICE.

JULY 28, 1986: MR'S 86-1213 (HVC) AND 86-1214 (HVF)

INITIATED TO ALARM HEATER CIRCUIT INOP

CONDITION, AS CORRECTIVE ACTION TO

CR 86-087S.

NOVEMBER 2, 1986: CR 86-1676 INITIATED DUE TO INABILITY TO

ENERGIZE CONTROL ROOM CHARCOAL FILTER

HEATER. HEATER OVERTEMPERATURE TRIP WAS

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RESET, AND HEATER WAS RETURNED TO SERVICE.

SUBSEQUENT INVESTIGATION TIED COMMON ROOT

CAUSE TO CR 86-0875.

NOVEMBER 6, 1986: MR 86-1701 INITIATED TO REVISE FUEL

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BUILDING CHARCOAL FILTER HEATER FLOW SWITCH

ARRANGEMENT AND TO ALARM HEATER CIRCUIT

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INOP CONDITION.

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APRIL 28, 1987: MR 86-1701 WAS RELEASED TO THE FIELD FOR

I WORKJ HOWEVER, THE INOP ALARM WAS NOT

ADDRESSED BY THE DESIGN. THE MR WAS

SUBSEQUENTLY INSTALLED AS DESIGNED.

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APRIL 9, 1988: MR 86-1213 WAS CANCELLED.

APRIL 23, 1988: MR 86-1214 WAS CANCELLED.

MAY 25, 1988: ISSUED REVISION TO "RBS DESIGN

AND MODIFICATION REQUEST CONTROL

PLAN," ENG-3-006, REY. 4,

REQUIRING QA REVIEW OF CR

CO."RECTIVE ACTION MR'S PRIOR TO

CANCELLATION.

JUNE 16, 1988: QA ENGINEERING RETURNED MR 86-1214 TO

DESIGN ENGINEERING DUE TO UNSAT

CANCELLATION OF CR CORRECTIVE ACTION MR.

JUNE 30, 1988: ISSUED RIVER BEND "CORRECTIVE

ACTION PROGRAM," RBNP-47, REV 0,

REQUIRING JUSTIFICATION PRIOR

TO CANCELLATION OF MR'S

RESULTING FROM CORRECTIVE ACTION

DOCUMENTS.

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AFETY SIGNIFICANCE

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SAFETY SIGNIFICANCE

- NO IMPACT TO THE PUBLIC HEALTH AND SAFETY

  • NO OCCURRENCE OF A LOCA, FUEL HANDLING ACCIDENT, OR

RELEASE OF RADI0 ACTIVITY FROM THE FUEL BUILDING

DURING THE PERIOD OF CHARCOAL FILTER HEATER INOPERABILITY

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HEATERS - MAXIMIZE CHARC0AL FILTER PERFORMANCE BY MAINTAINING

INFLUENT AIR < 70% RELATIVE HUMIDITY (RH) WHEN FILTERE ARE

IN SERVICE, THUS ASSURING FILTER EFFICIENCY REMAINS > 99%

FUEL BUILDING DESIGN MAXIMUM RH FOR NORMAL OPERATIONS AND

POST ACCIDENT IS < 70% RH

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VERIFIED FUEL BUILDING WAS < 70% RH BY FIELD MEASUREMENT

DURING ENGINEERING SAFETY REVIEW OF THIS EVENT. THEREFORE,

FUEL BUILDING IS ASSUMED TO HAVE BEEN < 70% RH DURING THE ,

PERIOD OF CHARCOAL FILTER HEATER INOPERABILITY, THUS THERE

WAS NO ACTUAL EFFECT ON CHARCOAL FILTER EFFICIENCY.

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  • BEYOND DESIGN BASIS (LOSS OF BOTH DIVISIONS OF SPENT FUEL i

I COOLING FOR 30 DAYS) WITHOUT HEATERS, CHARCOAL FILTER

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EFFICIENCY MAY DROP TO 97%, ADDING < 1 REM (0.3%) TO LOCA

2 HOUR EXCLUSION AREA B0UNDARY THYROID DOSE.

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  • BEYOND DESIGN BASIS, ASSUMING COMPLETE LOSS OF FILTERS,

< 6 REM (2%) IS ADDED TO LOCA 2 HOUR EXCLUSION

AREA BOUNDARY THYROID DOSE, AND TOTAL DOSE REMAI.1S LESS

THAN 10 CFR 100 LIMIT.

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CORRECTIVE ACTION

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CORRECTIVE ACTION

IMMEDIATELY RESTORED FUEL BUILDING CHARCOAL FILTER TRAIN

HEATERS TO OPERABLE STATUS BY CLOSING SUPPLY BREAKERS.

IMMEDIATELY REVERIFIED ALL SAFETY RELATED CONTROL BOARD

LINEUPS IN ACCORDANCE WITH THE MASTER STARTUP CHECKLIST,

,

AND DISCOVERED NO MISPOSITIONED SWITCHES.

THE ASSISTANT PLANT MANAGER OF OPERATIONS MET WITH EACH

CREW ON SHIFT TO EMPHASIZE THE FOLLOWING:

SAFETY SIGNIFICANCE OF THE DISCOVERED MISPOSITIONING

PANEL AWARENESS

IMPORTANCE OF TURNOVER

NECESSITY FOR COMPLETE AND ADEQUATE BOARD WALKDOWNS

' USE OF THE NEW U. O. CHECKLIST

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SHIFT SUPERVISOR'S REVIEW OF THE CHECKLIST

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OPERATIONS SUPERVISOR ISSUED A MEMORANDUM TO ALL OPERATIONS

PERSONNEL, NOTING THE DEFICIENCIES OBSERVED IN THE SHIFT

TURNOVER PROCESS AND THE NECESSARY CORRECTIVE ACTION TO

IMPROVE PERFORMANCE.

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THE APM-0 AND OS HAVE BEGUN CONDUCTING INTERVIEWS WITH

EACH OPERATOR, DISCUSSING MANAGEMENT'S P ILOSOPHY OF

OPERATOR PERFORMANCE.

REVISED OSP-0002 TO INCLUDE A SYSTEM STATUS CHECKLIST AS

PART OF THE UNIT OPERATOR'S BOARD WALKDOWN. THE CHECKLIST

INCLUDES THE CHARC0AL FILTER HEATER SWITCHES AND OTHER

SAFETY RELATED EQUIPMENT.

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THE SHIFT SUPERVISOR IS REQUIRED TO REVIEW THE UNIT

OPERATOR'S CHECKLIST EARLY IN THE SHIFT.

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REVISED OSP-0012 TO INCLUDE LOCAL VERIFICATION OF CHARCOAL

FILTER HEATER DISCONNECT SWITCH.

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REVIEWED EQUIPMENT RELATED OPERATIONS SECTION PROCEDURES

FOR DELETIONS OF SAFETY SYSTEMS EQUIPMENT MONITORING.

NO ADDITIONAL ITEMS WERE FOUND.

- REVISED "CONDUCT OF OPERATIONS," ADM-0022, TO REQUIRE

PLANT MANAGER'S APPROVAL FOR DELETION OF SAFETY SYSTEM

EQUIPMENT MONITORING FROM THE OPERATIONS SECTION PROCEDURES.

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- REVIEWED THE ACTIVITIES OF OTHER PLANT STAFF DEPARTMENTS

FOR THE PROCEDURAL DELETION OF SAFETY EQUIPMENT MONITORING.

NONE WERE FOUND.

. COMPLIANCE EVALUATED THE PROCEDURE REVIEW PROCESS FOR l

OSP'S AND DETERMINED ADEQUATE REVIEWS EXIST. "0PERATIOP.h  !

PROCEDURE REVIEW AND REVISION," OSP-0005, HAS BEEN REVf6ED

TO INCLUDE sN OSP CHECKLIST ITEM FOR OSP'S DELETING SAFETY

RELATED OBSERVATIONS, ACTIONS, OR LINEUPS.

. ADDED ADDITIONAL CONTROL SWITCH POSITION AWARENESS TRAINING

TO OPERATOR REQUAL SIMULATOR EXERCISES.

' DEVELOPING CONTROL PANEL NORMAL LINEUP SHEETS TO FACILITATE

VERIFICATION OF SYSTEM CONTROL SWITCH POSITIONS DURING

NORMAL PLANT OPERATION, TO BE COMPLETE PRIOR TO THE

NEXT STARTUP.

ADDED SWITCH COVERS TO HEATER CONTROL SWITCHES TO PREVENT

INADVERTENT REPOSITIONING, PENDING HUMAN FACTORS REVIEW.

COVERS WERE ADDED TO HVf*FLT2AH (BHb GTS*HIA (B),

INC* CHIA (B).

. E% ALUATING PROPOSED ENHANCEMENTS TO THE CONTROL BOARD FOR

A SELECTED SYSTEM ON THE PLANT SIMULATOR, TO DESIGNATE

NORMAL STANDBY LINEUP. FOLLOWING FINAL HUMAN FACTORS

l EVALUATION, ENHANCEMENTS WILL BE IMPLEMENTED IN THE MAIN

CONTROL ROOM FOR ALL SAFETY RELATED SYSTEMS.

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THE MR CANCELLATION PROCEDURE WILL BE IMPROVED TO PROVIDE

A MORE Dr. TAILED WRITTEN TECHNICAL JUSTIFICATION FOR

CANCELLATION OF QA PROGRAM APPLICABLE, CR RELATED MR'S,

. ENGINEERING WILL REYli.ti JA PROGRAM APPLICAC'.E CR

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CORRECTIVE ACTION HR'S stNCELLED PRIOR TO ENG-3-006, REV. 4

(MAY 25, 1988)

. MR 86-1213 HAS BEEN REPLACED BY MR 88-300, WHICH WILL l

PROVIDE A LOCAL HEATER OPERABILITY INDICATOR LIGHT.

. MR 86-1214 WILL BE PROCESSED AND WI_L PROVIDE A LOCAL

HEATER OPERABILITY LIGHT, AND AN IMPROVED BREAKER STATUS

ALARM IN THE CONTROL ROOM,

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SUMMARY

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SUMMARY

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IHE SAFETY SIGNIFICANCE OF THIS EVENT WAS MINIMUM.

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NO IMPACT TO THE PUBLIC HEALTH AND SAFETY

' THE HEATERS FUNCTION INSURES THE FUEL BUILDING

CHARCOAL FILTERS PERFORM AT 99% EFFICIENCY BY

MAISTAINING INFLUENT AIR < 70% RHJ THE DESIGN BASIS

NORMAL OPERATION AND ACCIDENT FUEL BUILDING ATMOSPHERE

IS < 70% RH WITHOUT HEATERS.

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A BOUNDING CALC'JLATION /.SSUMING 0% EFFICIENCY OF THE

FUEL BUILDING CHARCOAL FILTERS DEMONSTRATES AN

EXCLUSION AREA BOUNDARY 2 HOUR THYROID DOSE EXPOSURE

< 10CFR100 LIMITS,

.

ROOT CAUSE OF THE UNDETECTED MISPOSITIONING WAS

INADEQUATE SHIFT TURNOVER AND FAILURE TO PROPERLY

COMPLETE CORRECTIVE ACTION.

. COMPLETED CORRECTIVE ACTION INCLUDES:

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IMMEDIATE RETURN TO SERVICE UPON DISCOVERY

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REVERIFICATION OF ALL SAFETY RELATED CONTROL BOARD

LINEUPS

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  • DISCUSSIONS WITH ALL OPERATING CREWS

' UPGRADED OPERATIONS PROCEDURES REGARDING TURNOVER,

ROUNDS, CONTROL BOARD LINEUPS, AND PROCEDURE REVIEWS

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REVISED ENGINEERING PROCEDURE TO INCLUDE QA REVIEW I

PRIOR TO CONDITION REPORT CORRECTIVE ACTION MR

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CANCELLATION

  • ADDITIONAL BOARD AWARENESS TRAINING

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INTERIM HUMAN FACTORS IMPROVEMENTS

  • CONTINUING CORRECTIVE ACTION INCL,UDES:
  • USE OF SYSTEM STATUS CHECKLIST AT EACH SHIF T TURNOVER

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  • USE OF CONTROL PANEL NORMAL LINEUP SHEETS FOR EACH

STARTUP, AND FOR REFERENCE AT ANY TIME

  • PLANT MANAGER INVOLVEMENT IN FUTURE DELETIONS OF

SAFETY RELATED ACTIVITIES FROM OPERATIONS SECTION

PROCEDURES

  • EVALUATION OF HUMAN FACTORS ENHANCEMENTS ON THE

SIMULATOR, LEADING TO INCORPORATION ONTO THE MAIN

CONTROL ROOM PANELS

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UPGRADING OF ENGINEERING MR DELETION PROCEDURE

  • ENGINEERING REVIEW OF CR CORRECTIVE ACTION MR'S

PREVIOUSLY CANCELLED

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TWO PREVIOUS CONTROL SWITCH LINEUP TURNOVER DEFICIENCIES ,

. RCIC FLOW CONTROLLER IN MANUAL

- CMS SAMPLE VALVES NOT SELECTED

,

BOTH DEFICIENCIES DETECTED AND CORRECTED PRIOR TO

EXCEEDING LC0 REQUIREMENTS

  • CORRECTIVE ACTION SUCCESSFUL IN PREVENTING REOCCURRENCE

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