ML20206R698

Forwards AEOD Evaluation of Performance in Preparing LERs During Feb 1986 - Feb 1987.Evaluation Incorporated Into SALP Which Should Be Issued in Near Future.Rept Provided to Assist in Correcting Specific Deficiencies

ML20206R698
Person / Time
Site:	Wolf Creek
Issue date:	04/17/1987
From:	Gagliardo J NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
To:	Witherd B WOLF CREEK NUCLEAR OPERATING CORP.
References
NUDOCS 8704220220
Download: ML20206R698 (47)

Text

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... 'W In Reply Refer To:

Docket: STN 50-482 Wolf Creek Nuclear Operating Corporation ATTN: Bart D. Withers President and Chief Executive Officer P. O. Box 411 Burlington, Kansas 66839 Gentlemen:

The attached report issued by our Office for Analysis and Evaluation of Operational Data (AE00) is an evaluation of your performance in preparing Licensee Event Reports (LERs) during the period of February 1,1986, to February 28, 1987. We have incorporated it into the SALP report which should be issued in the near future.

This report is provided for your information to assist you in correcting the specific deficiencies cited in future LERs.

Thould you have any questions concerning this report, we will be pleased to discuss them with you.

Sincerely, Cricina? SunM CY.

J. E. G$lardo J. E. Gagliardo, Chief Reactor Projects Branch

Enclosure:

AE00 Input to SALP Review for Wolf Creek cc w/ enclosure:

Wolf Creek Nuclear Operating Corporation ATTN: Otto Haynard, Manager of Licensing P. O. Box 411 Burlington, Kansas 66839 Gary Boyer, Plant Manager Wolf Creek Nuclear Operating Corporation

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Wolf Creek Nuclear Operating Corporation 1

Forrest Rhodes, Vice President, Nuclear Operations Wolf Creek Nuclear Operating Corporation P. O. Box 411 Burlington, Kansas 66839

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RRI R. D. fiartin, RA Section Chief (RPB/B) DRSP R&SPB R. P. Warnick, RIII RIV File Resident Inspector, RIII MIS System RSB RSTS Operator Project Inspector D. Weiss, RM/ALF R. Hall I

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. o LICENSEE EVENT REPORT (LER)

QUALITY EVALUATION FOR WOLF CREEK -

DURING THE PERIOD FROM 1 FEBRUARY 1986 TO 28 FEBRUARY 1987 l

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SUMMARY

An evaluation of the content and quality of a representative sample of the Licensee Event Reports (LERs) submitted by Wolf Creek'during the period from February 1, 1986 to February 28, 1987 was performed using a refinement of the basic methodology presented in NUREG-1022, Supplement No. 2. The results of this evaluation indicate that Wolf Creek LERs have an overall average LER score of 9.1 out of a possible 10 points, compared to a current industry average score of 8.2 for those unit / stations that have been

, evaluated to date using this methodology.

The principle weakness identified in the Wolf Creek LERs involves the requirement to identify failed components in the text [ Requirement 50.73(b)(2)(11)(L)]. The failure to adequately identify each component that fails prompts concern that possible generic problems may not be ioentified in a timely manner by others in the industry.

Strong points for the Wolf Creek LERs are the discussions of the root cause [ Requirement 50.73(b)(2)(ii)(D)], the failure mode, mechanism, and effect of failed component (Requirement 50.73(b)(2)(ii)(E)], and personnel and/or procedural errors [ Requirement 50.73(b)(2)(ii)(J)(2)].

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LER QUALITY EVALUATION FOR WOLF CREEK Introduction

.In order to evaluate the overall quality of the contents of the Licensee Event Reports (LERs) submitted by Wolf Creek during the period from February 1, 1986 to February 28, 1987, a representative sample of the unit's LERs was evaluated using a refinement of the basic methodology presented in NUREG-1022, Supplement No. 2.1 The sample consists of a total of 15 LERs, which is considered to be the maximum number of LERs necessary to have a representative sample. See Appendix A for a list of the LER nusr.bers in the sample.

It was necessary-to start the evaluation before the end of the assesstent period because the input was due such a short time af ter the end of the assessment period. Therefore, all of the LERs prepared by the unit during the assessment period were not 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 the criteria of 10 CFR 50.73(b). In addition, each selected LER is compared to the guidance for preparation of LERs presented in NUREG-1022 and Supplements No. 1 and 2 to NUREG-1022; based on this comparison, suggestions were developed for improving the quality of the reports. The purpose of this evaluation is to provide feedback to improve the quality of LERs. It is not intended to increase the requirements concerning the

" content" of reports beyc,nd the current requirements of 10 CFR 50.73(b).

Therefore, statements in this evaluation that suggest measures be taken are not intended to' increase requirements and should be viewed in that light.

However, the minimum requirements of the regulation must be met.

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-The evaluation process for each LER is divided into two 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 evaluated. Likewise, the scores serve two purposes: (1) they serve to illustrate in numerical terms how the analysts perceived the content of the information that was presented, and (2) they provide a basis

'for determining an overall score 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) summary 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 referring to Appendix 0, the reader is cautioned not to try to directly correlate the number of comments on a comment sheet with the LER scores, as the analysts has flexibility to consider the magnitude of a j deficiency when assigning scores (e.g., the analysts sometimes make comments relative to a requirement without deduction points for that requirement).

Discussion of Results 4

A discussion of the analysts' conclusions concerning LER quality is 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 2

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represent the analysts' assessment of the unit's performance (on a scale of '

0 to 10) in submitting LERs that meet the criteria of 10 CFR 50.73(b) and j

.the guidance present in NUREG-1022 and its supplements. 1 i

Table 1 presents the average scores for the sample of LERs evaluated for Wolf Creek. In order to place the scores provided in Table 1 in perspective, the distribution of the latest overall average score for all unit / stations that have been evaluated using the current methodology is provided on Figure 1. Figure 1 is updated each month to reflect any changes in this distribution resulting from the inclusion of data for those units / stations that have not been previously evaluated or those that have ,

been reevaluated. (Note: Previous scores for those units / stations that are reevaluated are replaced with the score from the latest evaluation).

Table 2 and Appendix Table B-1 provide a summary of the information that is the basis for the average scores in Table 1. For example, Wolf Creek's average score for the text of the LERs that were evaluated is 9.0 out of a possible 10 points. From Table 2 it can be seen that the text score actually results from the review and evaluation of 17 different requirements ranging from the discussion of plant operating cenditions before the event [10 CFR 50.73(b)(?)('.1)(A)] to text presentation. The percentage _ scores in-the text summary section of Table 2 provide an indication of how well each text requirement was addressed by the unit for the 15 LERs that were evaluated.

Discussion of Specific Deficiencies A review of the percentage scores presented in Table 2 will quickly point out where the unit is experiencing the most difficulty in preparing iIRs. For example, requirement percentage scores of less than 75 indicate that the unit probably needs additional guidance concerning these requirements. Scores of 75 or above, but less than 100, indicate that the unit probably understands the basic requirement but has either: (1) excluded certain less significant information from many of the discussions concerning that requirement or (2) totally failed to address the requirement in one or two of the selected LERs. The unit should review the LER specific comments presented in Appendix D in order to determine why 3

a TABLE 1. .

SUMMARY

OF SCORES' FOR WOLF CREEK Average' High Low Text 9.0 10.0 7.8 a

Abstract' 9.2 10.0 7.7 Coded Fields 9.0 10.0 7.9 Overall 9.1 9.7 8.2-

- a. See Appendix B for a summary of scores for each LER that was evaluated.

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Figure 1. Distribution of overall average LER scores.

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E N Wolf Creek 3 7- -

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9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 4

Overall average scores

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TABLE 2. LER REQUIREMENT PERCENTAGE SCORES FOR WOLF CREEK TEXT Percentage a

Requirements [50.73(b)] - Descriptions Scores ( )

(2)(ii)(A) - - Plant condition prior-to event 100 (15)

(2)(ii)(B) - - Inoperable equipment that contributed b (2)(ii)(C) - - Date(s) and approximate time (s) 97 (15)

(2)(ii)(D) - - Root cause and intermediate cause(s)

- - Mode, mechanism, and effect 94 (15)

(2)(ii)(E) 96 ( 6)

(2)(ii)(F) - - EIIS codes ,

87 (15)

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(2)(ii)(G) - - Secondary function affected b (2)(ii)(H) - - Estimate of unavailability 92 ( 6)

(2)(ii)(I) - - Method of discovery 90 (15)

(2)(ii)(J)(1) - Operator actions affecting course 100 ( 6)

(2)(ii)(J)(2) - Personnel error (procedural deficiency) 95 (14)

.(2)(ii)(K) - - Safety system responses 100 ( 8)'

(2)(ii)(L) - - Manufacturer and model no. information 71 ( 6)

(3) - - - - - - Assessment of safety consequences 87 (15)-

(4) - - - - - - Corrective actions 90 (15)

(5) - - - - - - Previous similar event information 93 (15)

(2)(1) - - - - Text presentation 84 (15)

ABSTRACT Percentage a

Requirements [50.73(b)(1)] - Descriptions Scores ( )

Major occurrences (immediate cause/effect) 100 (15) 1lant/ system / component / personnel responses 98 (10) hoot cause information 90 (15)

- Corrective action information 91 (15)

- Abstract presentation 82 (15) 6

TABLE 2. (continu;d)

. CODED FIELDS Percentage a

Item Number (s) - Descriptions Scores ( )

1, 2, and 3 - Plant name(unit #), docket #, page #s 100 (15) 4------ Title 63 (15) 5, 6, and 7 - Event cate, LER no., report date 100 (15) 8------ Other facilities involved 100 (15) 9 and 10 --

Operating mode and power level 100 (15) 11 -----

Reporting requirements 100 (15) 12 -----

Licensee contact information 100 (15) 13 -----

Coded component failure information 91 (15)'

14 and 15 - - Supplemental report information 93 (15)

e. 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.

t A percentage score for this requirement is meaningless as it is not

cible to determine from the information available to the analyst whether is requirement is applicable to a specific LER. It is always given 100%

!! is provided and is always considered "not applicable" when it is not.

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it received less than a perfect score for certain requirements. The text requirements with a score of less than 75 or-those with numerous deficiencies are discussed below in their order of importance. In addition, the primary deficiencies in the abstracts and coded fields are discussed.

The manufacturer and/or model number (or other unique identification) was not provided in the text of the two LERs that involved a component failure, Requirement 50.73(b)(2)(11)(L). Components that fail must be identified in the text so that others in the industry can be made aware of potential problems. An event at one station can often lead to the identification of a generic problem that can be corrected at other plants or stations before they experience a similar event. In addition, although not specifically required by the current regulation, it would be helpful to identify components whose design contributes to an event even though the component does not actually fail. Be sure to give enough information to uniquely identify the failed component (e.g. manufacturer and model number).

The text presentation, while acceptable, could be improved by presenting the information in an outline format as suggested in NUREG-1022, Supplement No. 2.

Wolf Creek provided very good abstracts, but the presentation score would have been better if six of the abstracts had not exceeded the 1400 space limit. Information concerning safety consequences and previous similar events can be deleted from the abstracts if space is a problem. In addition, new information (i.e., information which was not discussed in the text) should not be introduced in the abstracts. If such information is deemed necessary in the abstract, the text should be revised so as to include it.

The main deficiency in the area of coded fields involves the title, Item (4). Twelve of the titles failed to indicate the root cause, six failed to adequately indicate the result (i.e., why the event was required to be reported), and three failed to include the link between the cause and the result. While the result is considered the most important part of the 8

title, the lack of cause information (and link, if necessary) results in an incomplete title. An example of a title 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 surveillance testing was the link between the cause and the result.

Example titles are provided in Appendix D (Coded fields Section), for some of the titles that are considered to be deficient.

Table 3 provides a summary of the areas that need improvement for the Wolf Creek LERs. For additional and 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, Supplement No. 1 and 2. ,

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TABLE 3.

AREAS MOST NEEDING IMPROVEMENT FOR WOLF CREEK LERs Areas Comments Manufacturer and model number Component identification information should be included in the text whenever a component fails or (although not specifically required by current regulation) is suspected of contributing to the event because of its design.

Text presentation use of an outline, as suggested in NUREG-1022, Supplement No. 2, page 36, would aid the presentation of the material.

Abstract presentation The abstract should not introduce new information (information which is not discussed in the text). If such information is considered necessary, the text should be revised to include it.

Abstracts should not exceed 1400 spaces in length.

Coded fields

a. Titles Titles should include root cause, result, ,

and the link between them, when necessary.

See NUREG-1022, Supplement No. 2, pages 29 and 30.

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REFERENCES

1. Office for Analysis and Evaluation of Operational Data, Licensee Event Report System, NUREG-1022 Supplement No. 2. U.S. Nuclear Regulatory Commission, September 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 Operational Data, Licensee Event Report System, NUREG-1022 Supplement No.1, U.S. Nuclear Regulatory Commission, February 1984.

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,9 O O APPENDIX A LER SAMPLE SELECTION INFORMATION FOR WOLF CREEK

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TABLE A-1. LER SAMPLE SELECTION FOR WOLF CREEK Sample Number LER Number Comments 1 86-007-00 SCRAM /ESF 2 86-008-00 ESF 3 86-011-01 ESF 4 86-013-00 5 86-017-00 6 86-018-00 SCRAM 7 86-023-00 8 86-025-00 9 86-035-00 ESF ,

10 86-037-00 SCRAM /ESF 11 86-038-00 SCRAM /ESF 12 86-047-00 13 86-057-00 ESF 14 86-058-00 15 86-061-00 l

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s APPENDIX B EVALUATION SCORES OF INDIVIDUAL LERS FOR WOLF CREEK

l' TABLE B-1. EVALUATION SCORES OF INDIVIDUAL LERS FOR WOLF CREEK a

LER Sample Number 1 2 3 4 5 6 7 8 Text 7.8 9.7 9.7 9.1 9.7 8.6 8.0 9.7 Abstract 8.7 10.0 7.7 9.3 9.4 9.1 9.6 9.4 Coded Fields 8.8 9.0 9.3 9.3 9.0 9.3 8.0 8.5 Overall 8.2 9.7 9.0 9.2 9.5 8.8 8.5 9.5 a

LER Sample Number 9 10 11 12 13 14 15 Average Text 9.5 8.5 10.0 9.0 9.3 8.0 9.1 9.0 Abstract 9.5 8.8 9.5 9.0 9.0 9.0 9.4 ' 9. 2 Coded Fields 8.5 7.9 8.5 9.5 9.4 9.3 10.0 9.0 Overall 9.4 8.6 9.7 9.0 9.3 8.4 9.2 9.1

a. See Appendix A for a list of the corresponding LER numbers.

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APPENDIX C DEFICIENCY AND OBSERVATION COUNTS FOR WOLF CREEK i

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TABLE C-1. TEXT DEFICIENCIES AND OBSERVATIONS FOR WOLF CREEK Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals ( )

50.73(b)(2)(11)(A)--Plant operating 0 (15) conditions before the event were not included or were inadequate.

50.73(b)(2)(ii)(8)--Discussion of the status 0 ( 4) of the structures, components, or systeras 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)(11)(C)--failure to include 2 (15) sufficient date and/or time information.

a. Cate information was insufficient. O

b. Time information was insufficient. 2 50.73(b)L2)(ii)(D)--The root and/or 5 (15) intermedlate cause of the component or system failure was not included or was inadequate,

a. Cause of component failure was not 4 included or was inadequate.

b. Cause of system failure was not 1 included or was inadequate.

50.73(b)(2)(ii)(E)--The failure mode, 2 ( 6) 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 1 inadequate,

b. Mechanism (immediate cause) was not 0 included or was inadequate.

c. Effect (consequence) was not included 1 or was inadequate.

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TA8LE C-1. (continued)

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph i Description of Deficiencies and Observations Totals

• Totals ( )

50.73(b)(2)(ii)(F1--The Energy Industry 3 (15)

Identification System component function identifier for each component or system was not included.

50.73(b)(2)(11)(G --for a failure of a -- ( 0) component with multiple functions, a list of systems or secondary functions which were also affected was not included or was inadequate.

50.73(b)(2)t ?i)(H)--For a failure that 1 (6) rendered a train of a safety system inoperable, the estimate of elapsed time from the time of the failure until the train was returned to service was not included.

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50.73(b)(2)(11)(I)--The method of discovery 2 (15) of each component failure, system failure, personnel error, or procedural error was not included or was inadequate. ,

a. Method of discovery for each 0 component failure was not included or was inadequate,

b. Method of discovery for each system 1 failure was not included or was inadequate.

c. Method of discovery for each 1 i personnel error was not included or

( was inadequate.

i d. Method of discovery for each 0 l procedural error was not included or j was inadequate.

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TA8LE C-1. (continued)

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals ( )

50.73(b)(2)(11)(J)(11--Operator actions that 0 ( 6) affected the course of the event including operator errors and/or procedural deficiencies were not included or were inadequate.

50.73(b)(2)(11)(J)(2)--The discussion of 3 (14) each personnel error was not included or was inadequate,

a. OBSERVATION: A personnel and/or 0 procedural error was implied by the .

text, but was not explicitly stated,

b. 50.73(b)(2)(11)(J)(2)(11--01scussion 1 as to whether the personnel error was cognitive or procedural was not included or was inadequate.

c. 50.73(b)(2)(11)(J)(2)(11)--Discussion 0 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 was not included or was inadequate.

d. 50.73(b)(2)(ii)(J)(2)(111)--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 inadequate.

e. 50.73(b)(2)(11)(J)(2)(iv)--Discussion 1 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.

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F TABLE C-1. (continued)

Number of LERs with Deficier.cies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals ( )D 50.73(b)(2)(11)(K)--Automatic and/or manual 0 ( 8) safety system responses were not included or were inadequate.

50.73(b)(2)(ii)(L1--The manufacturer and/or 2 ( 6) model number of each failed component was not included or was inadequate.

50.73(b)(3)--An assessment of the safety 5 (15) consequences and implications of the event was not included or was inadequate.

a. OBSERVATION: The availability of 2 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 0 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 of any corrective 6 (15) 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, t

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TABLE C-1. (continued)

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Tctals ( )

a. -A discussion of actions required to O correct the problem (e.g., return the component or system to an operational condition or correct the personnel error) was not included or was inadequate.

b. A discussion of actions required to 4 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 I '

required to prevent similar failures in similar and/or other systems (e.g.,

correct the faulty part in all components with the same manufacturer and model number) was not included or was inadequate.

50.73(b)(5)--Information concerning previous 1 (15) similar events was not included or was inadequate.

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TABLE C-1. (continued) l l

Number of LERs with Deficiencies and l Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals ( )

50.73(b)(2)(1)--Text presentation 2 (15) inadequacies.

a. OBSERVATION: A diagram would have 0 aided in understanding the text discussion,

b. Text contained undefined acronyms 0 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 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 the requirement was considered applicable, j

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TABLE C-2. ABSTRACT DEFICIENCIES AND OBSERVATIONS FOR WOLF CREEK Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals ( )

A summary of occurrences (immediate cause 0 (15) and effect) was not included or was inadequate.

A summary of plant, system, and/or personnel 1 (10) 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 0 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 4 (15) was not included or was inadequate.

A summary of the corrective actions taken or 3 (15) planned as a result of the event was not included or was inadequate.

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TABLE C-2. (continued)

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals ( )

Abstract presentation inadequacies. 9 (15)

a. OBSERVATION: The abstract contains 2 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 7 1400 spaces.

c. The abstract contains undefined 0 acronyms and/or plant specific

• designators.

d. The abstract contains other specific 0 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, 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 deficiency or observation. The number in parenthesis is the number of LERs for which a certain requirement was considered applicable.

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TABLE C-3. CODED FIELDS DEFICIENCIES AND OBSERVATIONS FOR WOLF CREEK Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph b

Description of Deficiencies and Observations Totals' Totals ( l Facility Name 0 (15)

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 (15) incorrect.

Page Number was not included or was 0 (15) incorrect.

Title was left blank or was inadequate. 14 (15)

a. Root cause was not given or was 12 inadequate.

b. Result (effect) was not given or was 6

inadequate.

, c. Link was not given or was 3 inadequate.

Event Date 0 (15)

a. Date not included or was incorrect,

b. Discovery date given instead of event date.

LER Number was not included or was incorrect. 0 (15) keport Date 0 (15)

a. Date not included,

b. OBSERVATION: Report date was not within thirty days of event date (or discovery date if appropriate).

Other Facilities information in field is 0 (15) inconsistent with text and/or abstract.

Operating Mode was not included or was 0 (15) inconsistent with text or abstract.

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TABLE C-3. (continued)

Number of LERs with Deficiencies and '

Observations Sub-paragraph Paragraph

< Description of Deficiencies and Observations Totals # Totals ( )

Power level was not included or was 0 (15) inconsistent with text or abstract.

Reporting Requirements 0 (15) i a. The reason for checking the "0THER" i requirement was not specified in the abstract and/or text.

b. OBSERVATION: It may have been more appropriate to report the event under a different paragraph.

c. OBSERVATION: It may have been appropriate to report this event under an additional unchecked paragraph.

4 Licensee Contact 0 (15)

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 2 (15)

a. One or more component failure 0 sub-fields were left blank.

b. Cause, system, and/or component code 0 is inconsistent with text.

c. Component failure field contains data 0 when no component failure occurred.

d. Component failure occurred but entire 2 field left blank, s

I l

C-10

,e ,n,-,. ,,.----,,-.,r -,m- . ~ , , - ,---,_--,,~,-r,,,7 - - --- - -,e ,---,--e-,--> ,-m n--m r -w - e n-e-~ --,.,,---r--, - - - , , - - - ,

? .

TABLE C-3. (continued)

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals ( )

Supplemental Report 1 (15)

a. Neither "Yes"/"No" block of the 0 supplemental report field was checked.

b. The block checked was inconsistent 1 with the text.

Expected submission date information is 0 (15) inconsistent with the block checked in ltem (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, 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.

C-11

f 1 APPENDIX D LER COMMENT SHEETS FOR WOLF CREEK

r-s TABLE 0-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

1. LER Number: 86-007-00 Scores: Text = 7.8 Abstract = 8.7 Coded Fields - 8.8 Overall = 8.2 Text 1. 50.73(b)(2)(11)(D)--Possible reasons fcr the card failure (e.g., overcurrent, exposure to water or heat, etc.) and the gasket failure are not discussed.

2. 50.73(b)(2)(iil(E)--The effect of the failed gasket on system operability is not discussed.

3. 50.73(b)(2)(ii)(L)--A model number of the failed card is given, but not the name of the manufacturer. The failed gasket was not identified.

4. 50.73(b)(41--Without an adequate root cause discussion for the failed control card (see text comment 1), it is not possible to determine if simply replacing the card is adequate to prevent recurrence. Corrective action concerning the leaky gasket is not discussed.

5. 50.73(b)(51--Information concerning previous similar events is not included. If no previous similar events are known, the text should so state.

Abstract 1. OBSERVATION: The abstract is intended to be a summary of the text; therefore, the text must include all information summarized in the abstract. This

! abstract contains information that was not included i in the text. The last paragraph mentions that no l release occurred and that there were no similar .

events. This information is not provided in the text.

Coded Fields 1. Item (4)--Title: Root cause (failed control card) and link are not included. A more appropriate title

! might be " Reactor Trip on Low Steam Generator l

Pressure due to a Failed Turbine Control Card".

! 2. Item (13)--A line for the failed gasket would be appropriate. '

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0-1

. .o ,-

l TABLE 0-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

2. LER Number: 86-008-00 Scores: Text - 9.7 Abstract - 10.0 Coded Fields - 9.0 Overall - 9.7 Text 1. OBSERVATION: A well-written presentation that probably could be improved only by using an outline format.

Abstract 1. No comments.

Coded Fields 1. Item (4)--Title: Root cause (personnel error) is not

• included. A better title might be: " Cognitive Personnel Error While Placing Block Switch in

" Permit" Results in Auxiliary Feedwater Actuation and Steam Generator Blowdown Isolation". -

0-2

r ,

TABLE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

3. LER Number: 86-011-01 Scores: Text = 9.7 Abstract - 7.7 Coded Fields - 9.3 Overall = 9.0 Text 1. 50.73(b)(2)(ii)(C)--Time of the manual start of the ESW pump "B" is not included.

2. 50.73(b)(2)(ii)(J)(2)(ii)--Does the training program for this annual maintenance check specifically address which breakers have parallel links?

3. 50.73(b)(2)(it)(L)--Given that the design of breaker 69-14 contributed to this event, identification of this breaker would be useful information.

Abstract 1. 50.73(b)(ll--Summary of cause information is ,

inadequate. The personnel error could have been summarized (e.g., by mentioning the parallel link problem). The fact that the cause of the trip for breaker CGK02A could not be determined should have been mentioned in the abstract.

2. 50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate. The fact that the circuit involved (and three other breakers) have been tagged to alert the technicians to the presence of parallel links should be mentioned in the abstract.

Coded Fields 1. Item (4)--Title: Root cause is not included. The title should indicate that personnel error caused the partial loss of off-site power.

0-3

TABLE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

4. LER Number: 86-013-00

Scores: Text - 9.1 Abstract - 9.3 Coded Fields - 9.3 Overall - 9.2 4

Text 1. 50.73(b)(2)(ii)(0)--Why had the circuit board in the i

monitor become unseated?

2. 50.73(b)(2)(ii)IF)--Energy Industry Identification System component identifier code for the circuit board and valves are not given.

3. 50.73(b)(4)--W111 reseating of the circuit board be adequate to prevent the board from becoming unseated again (see text comment 1).

Abstract 1. The abstract contains greater than 1400 spaces.

I Coded Fields 1. Item (41--The result portion of the title is vague.

The technical specification violation should be explained (i.e., containment integrity violated).

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! D-4 l

1

,, .~ .

• TABLE 0-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

5. LER Number: 86-017-00 Scores: Text - 9.7 Abstract - 9.4 Coded Fields - 9.0 Overall - 9.5 Text 1. OBSERVATION: A well-written presentation that -

probably could be improved only by use of an outline format.

Abstract 1. The abstract contains greater than 1400 spaces.

Previous similar event and the safety assessment information is not necessary in the abstract if space is a problem.

Coded Fields 1. Item (41--Title: Root cause and effect are inadequate. A better title might be: " Design Oversight and Failure to Assess Technical Specification Applicability Resulted in Auxiliary Building Fire Barrier Inoperability--Cognitive Personnel Errors".

0-5

F TABLE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments _

6. LER Number: 86-018-00 Scores: Text 8.6 Abstract = 9.1 Coded Fleids - 9.3 Overall - 8.8 Text 1. 50.73(b)(2)(11)(F1--The Energy Industry Identification System codes for each component and/or system referred to in the text is not included.

2. 50.73(b)(2)(11)(J)(21--Discussion of the personnel error / procedural deficiency error is inadequate. It is not apparent why this personnel error is considered cognitive given that "this method of testing is standard practice".

3. 50.73(b)(3)--01scussion of the assessment of the '

safety consequences and impitcations of the event is inadequate. The safety assessment discussion should explain how (why) the conclusion (that the health and safety of the public was not threatened) was reached (e.g., "- - because all safety systems actuated as designed and no abnornal transients resulted.").

4. 50.73(b)(41--Discussion of corrective actions taken or planned is inadequate. If relocation of the oscillograph 1 and/or modification of the flexitest switch is not implemented, will the planned meetings reduce the probability of future occurrences of this nature?

5. The " cross trip" should be explained in more detail.

Abstract 1. 50.73(b)(11--Summary of cause is inadequate. The abstract should say cognitive personnel error (as was stated in the text).

(oded fields 1. Item (41--Title: Root cause is not included. A better title might be " Personnel Error During Switchyard Test Resulted in A Reactor Trip."

0-6 Emim --

TABLE 0-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482) i i

Section Coments j 7. LER Number: 86-023-00 Scores: Text . 8.0 Abstract . 9.6 Coded Fluids - 8.0 Overall . 8.5 i Text 1, 50.73(b)(2)(11)(D) and 50.73(b)(2)(11)(E)--Additional I discussion concerning the problem with the monitors would be appropriate.

2. 50.73(b)(2)(ii)(I)--Discussion of the method of

discovery of the technical specification violation is

not included. What brought the oversight to the i attention of the operators?

$ 3. 50.73(b)(2)(11)(L)--Identification (e.g.,

4 manufacturer and model no.) of the failed

component (s) discussed in the text is not included. -

4. 50.73(b)(3)--Discussion of the assessment of the j safety consequences and implications of the event is

inadequate. The assessment should discuss the i

' consequences of a chlorine leak occurring when the monitors were inoperable. This assessment should i indicate how other systems, if any, could mitigate j the consequences of a leak, j Abstract 1. No comment.

Coded F telds 1. Item (41--The root cause is not included and the i result is vague. A more appropriate title might be

" Action Statement Time for Inoperable Chlorine

Monitors Exceeded (Technical Specification Violation) due to Personnel Error".

1 2. Item (13)--Component failure occurred but entire field is blank. A line filled in for the chlorine 4

j monitor would be appropriate, i

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i 0-7

TABLE D-1. SPECIFIC LER COMNENTS FOR WOLF CREEK (482)

Section Comments

8. LER Number: 86-025-00 Scores: Text - 9.7 Abstract - 9.4 Coded Fields - 8.5 Overall - 9.5 Text 1. OBSERVATION: A well-written presentation that probably could be improved only by an outline format.

Abstract 1. The abstract contains greater than 1400 spaces.

Safety assessment information is nct necessary in the abstract if space is a problem.

Coded Fleids 1. Item (4)--Title: Root cause (personnel error) and effect (SI flow path disabled) are not included.

D-8 h u-

r-TA8LE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

9. LER Number: 86-035-00 Scores: Text - 9.5 Abstract - 9.5 Coded Fields - 8.5 Overall - 9.4 Text 1. 50.73'b)(2)(ii)(C)--Time of entry into the applicable T.S. action Statement is not included.

2. 50.73(b)(31--Discussion of the assessment of the safety consequences and implications of the event is inadequate. A discussion (rather than one statement) of the safety impitcations of the event would be appropriate.

Abstract 1. 50.73(b)(1)--Summary of personnel responses is inadequate. The fact that an Action Statement was entered should have been mentioned in the abstract. .

2. OBSERVATION: The abstract is intended to be a summary of the text; therefore, the text must include all information summarized in the abstract. This abstract contains information that was not included in the text. The identification number of the control room air conditioning unit is not provided in the text. ,

Coded Fields 1. Item (4)--Title: Root cause and link are not included. A better title would be " Personnel Error While Performing Preventive Maintenance Results In An ESF Actuation".

D-9

r TABLE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

10. LER Number: 86-037-00 Scores: Text - 8.5 Abstract - 8.8 Coded Fields - 7.9 Overall - 8.6 Text 1. 50.73(b)(2)(it)(J)(2)--It is not clear from the text whether the procedure was adequate or not, since the text only states that the procedure was reviewed. It is also unclear from the text whether or not the operators were following the procedure as written.

2. 50.73(b)(4)--A supplemental report appears to be needed to describe the results of the on-going engineering evaluation.

Abstract 1. 50.73(b)(1)--Summary of corrective actions taken or

• planned as a result of the event is inadequate. The on going engineering evaluation into the problem should be mentioned.

2. The abstract contains greater than 1400 spaces.

Coded fields 1. Item (4)--Title: Root cause and link are not included. A more appropriate title might be

" Engineering Safety Feature Actuations and Reactor Trip during Startup due to Improper Manual Steam Generator Level Control".

2. Item (141--The block checked appears to be inconsistent with information provided in the text (see text consent number 2).

0-10

7____

, .* .m TA8LE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK'(482)

Section Comments

11. LER Number: 86-038-00 Scores: Text - 10.0 Abstract - 9.5 Coded Fields - 8.5 Overall - 9.7 Text 1. OBSERVATION: A very well-written presentation.

Abstract 1. The abstract contains greater than 1400 spaces.

Safety assessment information is not necessary in the abstract if space is a problem.

Coded Fields 1. Item (4)--Title: Root cause (personnel error) and link (during calibration of high pressure condenser level switches) are not included.

0 0-11

TABLE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

12. LER Number: 86-047-00 Scores: Text - 9.0 Abstract = 9.0 Coded fields - 9.5 Overall - 9.0 Text 1. 50.73(b)(2)(ii)(0)--The root and/or intermediate cause discussion concerning why the travel stop on the drain valve for THAOID was out of adjustment is not included.

2. 50.73(b)(2)(it)(I)--Discussion of the method of discovery of the pressure decrease in Tank #8 is not included.

3. 50.73(b)(2)(ii)(H)--It appears that THA010 would have leaked through whenever another tank that was tied to -

the common header was lined up for discharge, for how long a time was the travel stop out of adjustment on the THA010 drain valve?

4. 50.73(b)(2)(ii)(J)(2)(tv)--Discussion of the type of personnel involved (e.g., contractor personnel, utility Itcensed operator, utility nonlicensed operator, other utility personnel) is inadequate.

Who (by title) was responsible for the " postulated excessive force" appiled to HA-V1527

5. Some conclusions reached are inconsistent with the facts presented. See text comment number 3 and the last sentence of the third paragraph on page 2 of 2.

Abstract 1. 10.73(b)(11--Summary of cause information is inadequate (see text conment number 1). In addition, the information concerning the " postulated excessive force" used to close HA-V152 should be mentioned in the abstract.

2. The drain valve mentioned in the seventh sentence of the abstract should be identified by name or number.

It appears that is it HA-V152, based on text information.

Coded Fleids 1. Item (41--Title: Result is inadequate. A better title might be " Waste Gas Decay Tank Not Sampled Prior To Release (T.S. Violation) Due To A Leaking Drain Valve".

0-12

i t

3 . .. . a TA8LE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comments

13. LER Number: 86-057-00 Scores: Text - 9.3 Abstract - 9.3 Coded Fields - 9.4 Overall - 9.3 Text 1. 50.73(b)(41--Is a warning needed in the procedure to remind operators to be careful when resetting monitors?

/.bstract 1. The abstract contains greater than 1400 spaces.

Coded Fields 1. Item (41--Title: Root cause (personnel error) is not included.

0-13

g . .. . . o TABLE 0-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482)

Section Comnent s

14. LER Number: 86-058-00 Scores: Text - 8.0 Abstract = 9.0 Coded fields 9.3 Overall - 8.4 Text 1. 50.73(b)(2)(11)(01--The root and/or intermediate cause discussion concerning the "one impairment" for which the hourly fire watch was missed is inadequate. What condition existed for the fire impairment that required an hourly ftre watch?

2. 50.73(b)(?)(it)(F)--The Energy Industry identification System codes for each component and/or system referred to in the text is not included.

3. 50.73(b)(31--Otscussion of the assessment of the -

saf ety consequences and imp'1 cations of the event is inadequate. OBSERVATION: The availability of other i systems, components, or means (e.g. personnel I

actions, procedural requirements, etc.) capable of mitigating the consequences of the event were not discussed, if no other systems, components, or means are available, it would be helpful to state so in the text. What was the availability and operability of any fire control systems in the area of the "one impairment" which could have mitigated the consequences had a fire occurred during the missed fire watch?

I 4. Some ideas are not presented clearly (hard to follow). The third sentence of the first paragraph of the text is not clear. Why is a fire watch required if fire detection systems are gpeJatyJf,7 A better definition of " fire impairment" would be helpful.

M. . t r ac t 1. $QJLb1Lll--Sunvnary of the cause for missing the fire watch for the unspecified "one area" is inadequate.

2. The abstract contains greater than 1400 spaces. The sumarles of the safety ansonsment and previous similar events are not needed in the abstract if space is a problem.

Coded fleids 1. Ihm_(4j --il t le: Root cause (personnel error by inexperienced personnel) is not included.

0-14

(-_________ - -_ _ _ _ _ _ _ _ _ _ ________ ____ ___ _ _ _ _ _ - _ - _

i e . 4. .n l l

l TA8LE D-1. SPECIFIC LER COMMENTS FOR WOLF CREEK (482) l I

Section Comments

15. LER Number: 86-061-00 Scores: Text . 9.1 Abstract 9.4 Coded Fields . 10.0 Overall 9.2 Text 1. 50.73(b} m --Olscussion of the assessment of the  !

safety consequences and implications of the event is inadequate. What is the length of time within which boron injection flow would have to be started to l ave.id possible damage and how does this compare with I the "short period of time" mentioned in the last  !

sentence of the first paragraph on page 3 of 3. .

2. 50.73(bif41--Is there a check-off sheet, which the  !

operator must complete prior to core alterations, ,

that addresses charging pump operability? Are the l

" involved personnel" operators? See the last two i sentences of the last paragraph on page 2 of 3. i Abstract 1. 10.73(b)(II.-Sume ry of corrective actions taken or planned as a result of the event is inadequate. The fact that the LIR will be incorporated into the required reading Ilst for operating personnel should  ;

be mentioned in the abstract. I Coded Fleids 1. No comments.

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