ML20207P234
| ML20207P234 | |
| Person / Time | |
|---|---|
| Site: | LaSalle  |
| Issue date: | 01/02/1987 |
| From: | Norelius C NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | Reed C COMMONWEALTH EDISON CO. |
| References | |
| NUDOCS 8701150272 | |
| Download: ML20207P234 (53) | |
Text
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JAN 0 21987 Docket No. 50-373 Docket No. 50-374 Commonwealth Edison Company ATTN: Mr. Cordell Reed Vice President Post Office Box 767 Chicago, IL 60690 Gentlemen:
A copy of the second Office for Analysis and Evaluation of Operational Data (AE00) assessment of your Licensee Event Reports (LERs) for LaSalle 1 and 2 was sent to you.on August 15, 1986. This report was issued to support our SALP 6 assessment, originally scheduled to end on August 31, 1986. Subsequent to receiving this AE0D assessment, we decided to extend the SALP 6 assessment period to November 15, 1986. Therefore AEOD revised its LER assessment to include review of LERs issued by you through November 15, 1986. We are providing you a copy of this updated AE0D assessment prior to the issuance of the SALP 6 Board Report so that you might be aware of the additional findings.
The AE0D conclusions did not change from those identified in the previous report, and indicated a commitment on your part to write LERs that provide the NRC with information that consistently meets 10 CFR 50.73 requirements.
We appreciate your cooperation with us.
Please let us know if you have any questions Sincerely, Charles E. Norelius, Director Division of Reactor Projects
Enclosure:
AE0D Assessment See Attached Distribution Dhho00hh73 PDR 0
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- Commonwealth Edison Company Distribution cc w/ enclosure:
D. L. Farrar, Director of Nuclear Licensing G. J. Diederich, Plant Manager DCS/RSB (RIDS)
Licensing Fee Management Branch Resident Inspector, RIII Phyllis Dunton, Attorney General's Office, Environmental Control Division David Rosenblatt, Governor's Office of Consumer Services cc w/o enclosure:
M. R. Johnson, IE SALP Coordinator l
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AE00 SALP INPUT FOR LASALLE 1, 2 -
OPERATIONS (LER QUALITY) FOR THE ASSESSMENT PERIOD OF October 1, 1985 to November 15, 1986 i
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SUMMARY
An evaluation of the content and quality of a representative sample of the Licensee Event Reports (LERs) submitted by LaSalle 1 and 2 during the October 1,1985 to November 15, 1986 Systematic Assessment of Licensee Performance (SALP) period was performed using a refinement of the basic methodology presented in NUREG-1022, Supplement No. 2.
This is the second time that the LaSalle LERs have been evaluated using this methodology.
The results of this evaluation indicate that the LaSalle LERs now have an overall average score of 8.9 out of a possible 10 points, compared to their previous overall average score of 8.0 and a current industry average of 8.1 (i.e., the average of the latest overall average LER score for each unit / station that has been evaluated to date using this methodology).
One weakness that still remains in the LaSalle LERs, in terms of safety significance, involves the requirement to provide the manufacturer l
and model number (or other appropriate identification) for those component that f ail. The failure to provide information concerning the identification of failed components prompts concern that others in the industry may not obtain information in a timely manner that might enable them to identify and correct generic problems prior to having a similar failure at their station.
A strong point for the LaSalle LERs is that information concerning root cause, and the mode, mechanism, and effect of failed component was well written for the LERs that were evaluated.
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4 AE00 INPUT TO SALP REVIEW FOR LASALLE 1 AND 2 Introduction In order to evaluate the overall quality of the contents of the Licensee Event Reports (LERs) submitted by LaSalle 1 and 2 during the October 1, 1985 to November 15, 1986 Systematic Assessment of Licensee Performance (SALP) assessment period, a representative sample of the station's LERs was evaluated using a refinement of the basic methodology l
presented in NUREG-1022, Supplement No. 2.
The sample consists of a total of 15 LERs (i.e., 9 LERs for LaSalle 1 and 6 for LaSalle 2).
The LaSalle LERs were evaluated as one sample for this SALP period because it was determined that their LERs are both written and formally reviewed at the station, rather than unit, level.
See Appendix A for a list of the LER l
numbers in the sample.
i 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, all of the LERs prepared during the SALP assessment period were not available for review.
Methodology l
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 evluation is to provide feedbacA to improve the quality of LERs.
It is not intended to increase the requirements concerninng the
" content" of reports beyond the current requirements of 10 CFR 50.73(b).
Therefore, statements in this evaluation that specify measures that should be taken are not intended to increase requirements and should be viewed in l
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5 that light. However, the obvious minimum requirements of the regulation must be met.
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 cannents 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 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 l
detailed to*ormation, presented in Appendices A through 0, consists of LER sample inforattion (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 connent sheets containing narrative statements concerning the contents of each LER (Appendix D).
idhen referring to these appendices, 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 deficiency when assigning scores.
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Discussion of Results 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 represent the analysts' assessment of the station's performance (on a scale of 0 to 10) in submitting LERs that meet the requirements of 10 CFR 50.73(b). Again, LaSalle LERs were evaluated as one sample, rather than two separate samples (by unit), because it was determined that the LaSalle LERs are both written and formally reviewed at the station, rather than the unit, level.
Table 1 presents the average scores for the sample of LERs evaluated for the station.
In order to place the scores provided in Table 1 in perspective, the distribution of the overall average score for all units / stations that have been evaluated using the current methodology is provided on Figure 1.
Additional scores are added to Figure 1 each month as other units / stations are evaluated.
Table 2 and Appendix Table 8-1 provide a summary of the information that is the basis for the average scores in Table 1.
For example, LaSa11e's average score for the text of the LERs that were evaluated is 8.8 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 conditions b fore the event [10 CFR 50.73(b)(2)(11)(A)] to text presentation.
The percentage scores in the text sunnary section of Table 2 provide an indication of how well each text requirement was addressed by the station 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 station is experiencing the most difficulty in preparing LERs. For example, requirement percentage scores of less than 75 l
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SUMMARY
Of SCORES FOR LASALLE 1 AND 2 Averace Hiah Low Text 8.8 9.5 7.6 Abstract 8.9 10.0 7.3 Coded Fields 9.0 9.8 8.2 Overall 8.9 9.5 7.9 See Appendix 8 for a sunnary of scores for each LER that was evaluated.
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Blank page for Figure 1.
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Figure 1. Distribution of overall average LER scores 10 9-l 8
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3-7, F,
7, h 36, f, l,d,, f, l,,l l l l l l l l f, 3,s,,, l l
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o 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 Overall average scores
TABLE 2.
LER REQUIREMENT PERCENTAGE SCORES FOR LASALLE 1 AND 2 TEXT Percentage Reautrements t50.73(b)1 - Descriptions
_ Scores ( l' (2)(ii)(A) - - Plant condition prior to event (2)(ii)(B) - - Inoperable equipment that contributed 100 (15) b (2)(ii)(C) - - Date(s) and approximate times 90 (15)
(2)(11)(D) - - Root cause and intermediate cause(s) 93 (15)
(2)(ii)(E) - - Mode, mechanism, and effect (2)(11)(F) - - EIIS Codes 96 ( 7) 67 (15)
(2)(11)(G) - - Secondary function affected b
(2)(11)(H) - - Estimate of unavailability 100 ( 5)
(2)(11)(1) - - Method of discovery 87 (15)
(2)(ii)(J)(1) - Operator actions affecting course (2)(ii)(J)(2) - Personnel error (procedural deficiency) 100 ( 4)
(2)(ii)(K) - - Safety system responses 88 ( 6) 100 ( 5)
(2)(ii)(L) - - Manufacturer and model no. information 43 ( 7)
(3)
Assessment of safety consequences 89 (15)
(4)
Corrective actions 87 (15)
(5)
Previous similar event information (2)(i) - - - - Text presentation 100 (15) 86 (15)
A_8STRACT Percentage.
Requirements ISO.73(b)(111 - Descriptions Scores ( l' i
- Major occurrences (Immediate cause and effect information) 94 (15)
- Description of plant, system, component, and/or personnel responses 100 ( 4)
- Root cause information 92 (15)
- Corrective Action information 85 (15)
- Abstract presentation 82 (15) l l
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TABLE 2.
(continued)
CODED f!ELOS Percentage item Number (s) - Description Scores ( l' 1, 2, and 3 - f acility name (unit no.), docket no. and page number (s) 95 (15) 4 - - - - - - Title 73 (15) 5, 6, and 7 - Event date, LER No., and report date 100 (15) 8 - - --- - - Other facilities involved 89 (15) 9 and 10 - - Operating mode and power level 100 (15) 11 - - - - - Reporting requirements 91 (15) 12 - - - - - Licensee contact information 92 (15) 13 - - - - - Coded component failure information 87 (15) 14 and 15 - - Supplemental report information 95 (15) percentage scores are the result of dividing the total points for a 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.
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indicate that the station probably needs additional guidance concerning these requirements. Scores of 75 or above, but less than 100, indicate that the station probably understands the basic requirement but has either:
(1) excluded certain less significant information from most of the discussion concerning that requirement or (2) totally failed to address the requirement in one or two of the selected LERs.
The station should review the LER specific consnents presented in Appendix 0 in order to determine why it 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.
The manufacturer and/or model number (or other identification) was not provided in the text of four of the seven LERs that involve a component I
failure, Requirement 50.73(b)(2)(ii)(L).
Components that fail should be identified in the text so that others in the industry can be made aware of possible generic problems. An event at one station can often lead to the identification of a generic problem that can be corrected at other units or stations before they experience a similar event. It would also be helpful to identify components, which may not have failed, but whose design contributed to the event.
The Energy Industry Identification System component function identifier and system name codes were not consistently provided in the text.
Five LERs partially provided these codes, and three LERs failed to provide them at all. The EIIS codes are required to be provided for each system and component referred to in the LER, [ Requirement 50.73(b)(2)(11)(F)).
The main deficiency in the area of coded fields involves the title, t
Item (4). U ne of the titles failed to adequately indicate root cause, four failed to include the result, and one failed to include the link between the cause and result. While the result is considered to be the most important part of the title, cause and link information must be ir.cluded to make a title complete. 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 8
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more appropriate title might be " Inadvertent Relay Actuation During Surveillance Test LOP-1 Causes Reactor Scram". From this title the reader knows the cause involved either personnel or procedures and that testing linked the personnel / procedure error and the scram.
Another area of coded fields contained a minor deficiency; six of the i
fifteen LERs evaluated failed to include the Licensee Contact position title (Item 12, NRC form 366).
Table 3 provides a summary of the areas that require improvement for the LaSalle LERs. For additional and more specific information concerning deficiencies, the reader should refer to the specific information presented in Appendix D.
General guidance concerning these requirements can be found in NUREG-1022, Supplement No. 2.
It should be noted that this is the second time that the LaSalle LERs have been evaluated using this same methodology. The previous evaluation, which was reported in September of 1985, was performed on the unit, rather than the station, level; however, after averaging the individual units scores from the previous evaluation, a direct comparison of scores for both evaluations can be made, see Table 4.
As can be seen, LaSalle LERs have improved since the previous evaluation and are now well above the current industry overall average of 8.1.
(Note: The industry overall average is the result of averaging the current overall average scores for each unit / station that has been evaluated using this methodology.)
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TABLE 3.
AREAS MOST NEEDING IMPROVEMENT FOR LASALLE 1 AND 2 LERs Areas Comments Failed component identification Component identification information such as manufacturer and model number, must be included in the text for each component that fails.
Additionally, it would be helpful to identify components whose design contributed to the event even though the component didn't " fail".
EIIS codes EIIS codes should be provided in the text for all systems and/or components discussed in the text.
Coded fields a.
Titles All titles should include the result of the event (i.e., why the event was reportable) as well as root cause information. The link between the cause and result should be provided when it is not readily apparent how the root cause led to the result.
b.
Licensee contact The position title of the Licensee Contact should be provided. See NUREG-1022, page 24. Item 12, i
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TABLE 4.
COMPARISON Of LER SCORES FROM PREVIOUS EVALUATIONS Report Date September-85 Auaust-85 Text average 8.0a 8.8 Abstract average 7.9a 8.9 Coded fields average 8.6a 9.0 Overall average 8.0a 8.9 a.
These average scores are the result of weight averaging the September-85 scores for the two LaSalle units to produce a station average.
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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 Comission, 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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i APPENDIX A LER SAMPLE SELECTION INFORMATION FOR LASALLE 1 and 2 l
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TABLE A-1.
LER SAMPLE SELECTION FOR LASALLE 1 ANO 2 (373/374)
Sample Number Unit Number LER Number Coments 1
-1 85-063-01 ESF 2
1 85-066-00 3
1 85-069-00 4
1 86-002-00 5
1 86-003-00 6
1 86-004-00 ESF 7
1 86-016-00 a
1 86-019-00 9
1 86-029-00 10 2
85-044-00 SCRAM 11 2
85-046-00 12 2
85-047-00 13 2
85-048-00 14 2
86-003-00 ESF 15 2
86-004-00 SCRAM e
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APPENDIX 8 EVALUATION SCORES Of INDIVIDUAL LERs FOR LASALLE 1 and 2 l
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TABLE 8-1.
EVALUATION SCORES OF INDIVIDUAL LERs FOR LASALLE 1 AND 2 (373/374)
LER Sample Number 1
2 3
4 5
6 7
8 Text 9.0 8.9 8.6 8.4 9.3 8.7 9.3 8.5 Abstract 9.1 9.2 9.4 8.0 3.2 8.1 9.1 8.9 Coded 8.6 9.2 8.8 8.5 9.4 9.8 9.1 9.0 Fields Overall 9.0 9.0 8.8 8.3 9.3 8.6 9.3 8.7 LER Sample Number 9
10 11 12 13 14 15 Average Text 9.1 9.1 9.5 7.6 8.9 9.5 7.9 8.8 Abstract 8.9 9.7 8.8 8.5 10.0 9.7 7.3 8.9 Coded 8.2 9.0 9.0 8.6 9.0 9.1 9.5 9.0 Fields Overall 8.9 9.3 9.2 8.0 9.3 9.5 7.9 8.9 See Appendix A for a list of the corresponding LER numbers.
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t APPENDIX C DEFICIENCY AND OBSERVATION COUNTS FOR LASALLE 1 and 2
TABLE C-1.
TEXT DEFICIENCIES AND OBSERVATIONS FOR LASALLE 1 AND 2 Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals (
)
50.73(b)(2)(ii)( Al--Plant operating 0 (15) conditions before the event were not included or were inadequate.
50.73(b)(2)(11)(81--Discussion of the status 0 ( 3) 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.
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50.73(b)(2)(11)(C)--Failure to include 4 (15) sufficient date and/or time information.
a.
Date information was insufficient.
2 b.
Time information was insufficient.
4 50.73(b)(2)(11)(D)--The root cause and/or 4 (15) intermediate failure, system failure, or personnel error was not included or was inadequate.
l a.
Cause of component failure was not 3
included or was inadequate b.
Cause of system failure was not 1
included or was inadequate c.
Cause of personnel error was not 0
included or was inadequate.
50.73(b)(2)(11)(El--The failure mode, 1 ( 7) mechanism (immediate causa), and/or effect (consequence) for each failed component was not included or was inadequate.
a.
Failure mode was not included or was 0
inadequate b.
Mechanism (immediate cause) was not 0
included or was inadequate c.
Effect (consequence) was not included G
or was inadequate.
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(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals #
Totals (
)
50.73(b)(2)(11)(F)--The Energy Industry Identification System component function 8 (15) identifier for each component or system was not included.
50.73fbil2)(ii)(G)--For a failure of a component with multiple functions, a list 0 ( 1) of systems or secondary functions which were also affected was not included cr was inadequate.
50.73(b)(2)(ii)(H)--For a failure that rendered a train of a safety system 0 ( 5) 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 of each component failure, system failure, 2 (15) personnel error, or procedural error was not included or was inadequate.
a.
Method of discovery for each 0
component failure was not included t
or was inadequate b.
Method of discovery for each system 0
failure was not included or was i
inadequate c.
Method of discovery for each 2
personnel error was not included or t
I was inadequate d.
Method of discovery for each 0
procedural error was not included or was inadequate.
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TABLE C-1.
(continued) l Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals (
)
50.73(b)(2)(ii)(J)(1)--Operator actions that 0 ( 4) affected the course of the event including operator errors and/or procedural deficiencies were not included or were inadequate.
50.73(b)(2)(tilfJ)(2)--The discussion of 3 ( 6) each personnel error was not included or was inadequate.
a.
OBSERVATION: A personnel error was 1
implied by the text, but was not explicitly stated, b.
- 50. 73 ( b ) ( 2 ) ( 11 ) ( J ) ( 2 ) ( 11--D i s c u s s i on 2
as to whether the personnel error was cognitive or procedural was not included or was inadequate.
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50.73(b)(2)ftil(J)(2)(11)--Discussion 0
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 was not included or was inadequate.
d.
50.73(b)(2)(11)fJ)(2)(iill--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.
- 50. 73 ( b ) ( 2 ) ( i i ) (RL2M--D i s c u s s i on 0
e.
of the type of personnal involved (i.e., contractor personnel, utility licensed operator, utility nonlicensed operator, other utility personnel) was not included or was inadequate.
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j TABLE C-1.
(continued) l Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals
- Totals (
)
50.73(b)(2)(ii)(K)--Automatic and/or manual safety system responses were not included or 0 ( 5) were inadequate.
50.73(b)(2)(ii)(L)--The manufacturer and/or 4 ( 7) model number of each failed component was not included or was inadequate.
50.73(b)(31--An assessment of the safety 5 (15) consequences and implications of the event was not included or was inadequate.
a.
OBSERVATION: The availability of 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 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 8 (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.
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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 (
)
a.
A discussion of actions required to 1
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 6
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 1
rcquired 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)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals #
Totals (
)
50.73fb)(2)(il--Text presentation 4 (15) 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
l deficiencies relating to the readability.
The "sub-paragraph total" is a tabulation of specific deficiencies or a.
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 l
number of LERs for which the requirement was considered applicable.
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TABLE C-2.
ABSTRACT DEFICIENCIES AND OBSERVATIONS FOR LASALLE 1 AND Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Tot a ls' Totals (
)
A summary of occurrences (immediate cause and effect) was not included or was 4 (15) inadequate A summary of plant, system, and/or personnel responses was not included or was 0 ( 4) inadequate, Summary of plant responses was not a.
included or was inadequate.
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b.
Summary of system responses was not included or was inadequate.
Summary of personnel responses was not c.
included or was inadequate.
A summary of the root cause of the event was not included or was inadequate.
5 (15)
A summary of the corrective actions taken or planned as a result of the event was not 6 (15) included or was inadequate.
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- - - - - - - - - - - - - - - - - - - ~ - - - - ~ ' ~ ~ ~ ~ ~
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TABLE C-2.
(continued) l Number of LERs with Deficiencies and Observations i
Sub-paragraph Paragraph j
Description of Deficiencies and Observations Totals #
Totals (
)
Abstract presentation inadequacies 5 (15) l 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, i
b.
The abstract was greater than 0
1400 characters c.
The abstract contains undefined 1
acronyms and/or plant specific designators.
d.
The abstract contains other specific 2
deficiencies (i.e., poor summarization, contradictions, etc.)
The "sub-paragraph total" is a tabulation of specific deficiencies or a.
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 LASALLE 1 AND 2 Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals (
)
Facility Name 1 (15) a.
Unit number was not included or 1
incorrect.
b.
Name was not included or was 1
incorrect.
c.
Additional unit numbers were included 0
l but not required.
I Docket Number was not included or was incorrect.
1 (15)
Page Number was not included or was incorrect.
1 (15)
Title was left blank or was inadequate 13 (15) a.
Root cause was not given in title 9
b.
Result (effect) was not given in title 4
c.
Link was not given in title 1
Event Date 0 (15) a.
Date not included or was incorrect.
b.
Discovery date given instead of event date.
LER Nun 6er was not included or was incorrect 1 (15)
Report Date 1 (15) a.
Date not included 0
b.
OBSERVATION:
Report date was not 1
within thirty days of event date (or discovery date if appropriate).
Other Facilities information in field is inconsistent with text and/or abstract.
3 (15)
Operating Mode was not included or was 0 (15) inconsistent with text or abstract.
l C-9
TABLE C-3.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals (
)U Power level was not included or was inconsistent with text or abstract 0 (15)
Reporting Requirements 4 (15)
The reason for checking the "0THER" a.
0 requirement was not specified in the abstract and/or text.
b.
OBSERVATION:
It may have been more 0
appropriate to report the event under a different paragraph.
c.
OBSERVATION:
It may have been 4
appropriate to report this event under an additional unchecked paragraph.
Licensee Contact 6 (15)
Fiekdleftblank i
a.
0 b.
Position title was not included 6
c.
Name was not included 0
d.
Phone number was not included.
O Coded Component Failure Information 10 (15) a.
One or more component failure 1
sub-fields were left blank.
b.
Cause, system, and/or component code 2
is inconsistent with text.
Component failure field contains data c.
7 when no component failure occurred.
d.
Component failure occurred but entire 0
field left blank.
C-10 N
w -- -
=m-yw
..w.,
w.-
---..--,--,--,,,--.y.---y-
_w-,y-
- - - - ---v,-----
TABLE C-3.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals #
Totals (
)
Supplemental Report 2 (15) a.
Neither "Yes"/"No" block of the 0
supplemental report field was checked.
b.
The block checked was inconsistent 2
with the text.
Expected submission date information is inconsistent with the block checked in 0 (15)
Item (14).
The "sub-paragraph total" is a tabulation of specific deficiencies or a.
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.
l l
i l
C-11
APPENDIX D LER COMMENT SHEETS FOR LASALLE 1 and 2 1
l l
i
(
1ABLE 0-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 1.
LER Number:
85-063-01 Scores: Text = 9.0 Abstract = 9.1 Coded Fields - 8.6 Overall - 9.0 Text 1.
50.73(b)(2)(11)(D)--The root and/or intermediate cause discussion concerning the clogged orifice is not included.
2.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate.
The text should discuss whether or not anything needs to be done to prevent the orifice from clogging again.
Abstract 1.
No comments.
Coded Fields 1.
Item (4)--Title: Root cause is not included.
It is best not to use acronyms in the title. A better title might be " Spurious Trip of the Control Room Chlorine Detector due to a Clogged Detector Orifice".
2.
Item (8)--Information in field is inconsistent with text and/or abstract.
The text and abstract do not clarify how Unit 2 was affected.
Is the control room a common facility to both units?
3.
_ Item (12)--Position title is not included.
D-1
(
?
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 2.
LER Number: 85-066-00 Scores: Text - 8.9 Abstract -9.2 Coded Fields - 9.2 Overall - 9.0 Text 1.
OBSERVATION: Scores for this LER are based on the assumption that the supplemental report will contain all the necessary information.
2.
50.73(b)(2)(ii)(F)--EIIS codes are required for each component and system referred to in the text.
Codes should be provided for the valves mentioned in the text.
3, 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.
4.
The use of an outline format is very good.
Abstract 1.
50.73(b)(11--Summary of occurrences [immediate cause(s) and effects (s)] is inadequate. The abstract should state that the leak rate is in excess of that allowed by Technical Specifications.
Coded Fields 1.
Item (4)--Title:
Root cause is not included.
"Cause Unknown' can be included in the title.
2.
Item (ll)--0BSERVATION:
It appears it would have been appropriate to also report this event under paragraph (s) 50.73(a)(2)(1)(8).
3.
Item (12)--Position title is not included.
4.
Item (13)--Cause, system, and/or component code is inconsistent with text. Since the cause of the l
failure is not known at this time, 'X" may be a more appropriate cause code.
l l
l l
i l
D-2
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 3.
LER Number:
85-069-00 Scores:
Text - 8.6 Abstract - 9.4 Coded Fields - 8.8 Overall - 8.8 i
Text 1.
50.73(b)(2)(ii)(c)--Time information for major occurrences is inadequate.
The time that the uninspected fire hose stations were declared inoperable should have been provided, given that T.S. 3.7.5.4 has a 1-hour Action Statement.
2.
50.73(b)(2)(ii)(I)--Discussion of the method of discovery of the overdue surveillance is not included. Who notified the Station Fire Marshall and the Unit 1 Operating Engineer?
3.
50.73(b)(2)(11)(J)(2)--Discussion of the personnel error is inadequate.
50.73(b)(2)(11)(J)(2)(il--Discussion as to whether the perscnnel error was cognitive or procedural is not included.
4.
50.73(b)(31--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
If all required fire equipment had not l
been at the fire hose station as required, was there any other system or method of providing fire protection to those areas that would normally be t
protected by the hese stations?
5.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate.
Given the four previous occurrences of a similar nature, is there a need for some procedure changes involving the General Surveillance Program? Will all future personnel (required to schedule, perform, or ensure turnover) receive the necessary training to prevent recurrence of this event?
6.
Some conclusions reached are inconsistent with the facts presented.
It is not clear why the temporary surveillance foreman decided his manpower was insufficient, given he had a crew of 12 instead of the normal of 6.
D-3 l.
.c.
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE I (373)
Section Comments 3.
LER Number: 85-069-00 (continued)
Abstract 1.
The abstract should contain the "date" information that was presented in the text so that the reader will have an idea of the time-history of the event.
Coded Fields 1.
Item (4)--The title should indicate that the missed surveillance is a Technical Specification violation.
2.
Item (8)--It is not apparent from the information provided in the text why LaSalle Unit 2 was named as another facility that was directly affected by (involved in) the event.
3.
Item (12)--Position title is not included.
4.
Item (13)--Component failure field contains data when no component failure occurred.
1 i
D-4
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 4.
LER Number:
86-002-00 Scores:
Text - 8.4 Abstract - 8.0 Coded Fields - 8.5 Overall - 8.3 Text 1.
50.73(b)(2)(ii)(F)--The text did not include the EIIS component codes for each component referred to in the text.
2.
50.73(b)(31--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
The assessment should indicate whether or not the 14 SRV's, which would open before SRV 1821-F0130, are adequate to handle any possible pressure transient.
If the 14 valves are not sufficient protection, then the assessment should discuss the effect of the late opening of SRVs 1821-F0130 E, and H.
3.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate.
A discussion of actions required to reduce the probability of recurrence (i.e. correction of the root cause) is not included or is inadequate.
Could anything be done to minimize the foreign material, dirt, and rust in the system? Could surveillance be done with less pressure differential across the valves?
i Abstract 1.
50.73(b)(1)--Summary of r'oot cause is inadequate.
The foreign material, dirt, and rust, as well as, the high differential pressure curing surveillance cycling should be mentioned.
2.
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.
The third paragraph in the abstract addresses the text deficiency discussed in text comment 3.
i D-5 l
l
i TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373) i Section Coments 4.
LER Number: 86-002-00 (continued)
Coded Fields 1.
Item (4)--Title:
Root cause is not included.
2.
Item (ll)--0BSERVATION:
It appears it would have been appropriate to also report this event under paragraph (s) 50.73(a)(2)(1) and 50.73(a)(2)(vii).
3.
Item (13)--Where all three valves are identical and in identical systems only one line needs to be filled in for the three valves.
D-6 i
i
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 5.
LER Number: 86-003-00 Scores: Text - 9.3 Abstract - 9.2 Coded Fields - 9.4 Overall - 9.3 Text 1.
Since the initiating problem that led to the missed Technical Specification surveillance was the no flow condition through the sample line, the cause and corrective action for this should be discussed.
Abstract 1.
50.73(b)(1)--See text comment 1.
Coded Fields 1.
Item (41--Title:
Result is not included.
The title should indicate the missed surveillance was required by the Technical Specifications.
2.
Item (131--Cause, system, and/or component code is inconsistent with text. The text does not indicate the sample panel failed due to personnel error.
l D-7
TA8LE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 6.
LER Number:
86-004-00 Sccres: Text - 8.7 Abstract - 8.1 Coded Fields - 9.8 Overall - 8.6 Text 1.
50.73(b)(2)(11)(E)--The effect discussion of each f ailed component is inadequate.
The ESF actuation should have been described in the first sentence of Section I.
Section III implies that the ammonia alarm resulted in the "A" HVAC train going to the recirculation mode but Section I implies that the "A"
~
HVAC train was already in the recirculation mode at the time of the event (i.e., at 1917 on February 5, 1986).
It is also not clear whether the j
trip of the chlorine detector causes only an alarm or would also cause an ESF' actuation (had the signal not l
already been present from the ammonia detector).
2.
50.73(b)(2)(11)(F1--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.
3.
50.73(b)(2)f ti)(J)(21--It appears that personnel error is involved in this event, but it is not discussed.
It appears that the non-licensed operator reset the wrong detector by mistake.
4.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate.
A discussion of actions required to reduce the probability of recurrence (i.e correction of the root cause) is not included or is inadequate.
I What will the warning sign on the four chlorine detectors say? If the reader knew this, he would probably have the answer to the concern expressed in text comment number 1.
5.
Some ideas are not presented clearly (hard to follow).
For example, the second paragraph in Section II states that " Optical equipment ccmpares the exposed tape portion to an exposed section of the l
tape -
l D-8 l
l
-.,----,,,-n-_,-
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 6.
LER Number:
86-004-00 (continued) 6.
A logical transition does not exist between all ideas.
" Odor eaters' are introduced in Section I but not defined until Section III.
7.
Acronym (s) and/or plant specific designator (s) are undefined. What is AIR 373-200-86-012007
'It is not apparent which system the ammonia detector 8.
is associated with, (i.e., "VI", "VC", or "VE").
Abstract 1.
50.73(b)(1)--Summary of occurrences (immediate cause(s) and effects s)) is inadequate.
The chlorine detector occurrence s(hould have been mentioned.
2.
50.73(b)(11--Summary of the root cause of the tape breakage is not included.
3.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate. See text consent number 4.
4.
Abstract contradicts the text.
The " hour" of the ammonia detector trip is different in the abstract.
In addition see the second sentence of text comment number 1.
Coded Fields 1.
Item (8)--It is not apparent from the text how Unit 2 is directly affected by the event; (it is assumed that the control room is common to both units, but this is not stated in the text).
2.
Item (13)--One or more component failure sub-fields are blank; namely the manufacturer of the detector.
l l
l I
D-9
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 7.
LER Number:
86-016-00 Scores: Text -
v.
Abstract - 9.1 Coded fields - 9.1 Overall - 9,3 Text 1.
50.73(b)(2)(11)(C)--Date/ time information for major occurrences is inadequate.
The dates / times when the SRM was reinstalled and when the corrective action were completed should be given.
2.
50.73(b)(31--Discussion of the assessment of the safety consequ?nces and implications of the event. is inadequate. W<thout SRM the text should discuss tht consequences 11 the fuel rod was inserted in the wrong location or in the wrong sequence.
i Abstract 1.
50.73(b)(1)--Summary of corrective actions taken or i
planned as a result of the event is inadequate.
The revision to the procedures should be mentioned.
Coded Fields 1.
Item (31--The page number on page 1 is incorrect. It should be 1 of 4 not 1 of 3.
2.
Item (4)--The use of acronyms should be avoided in a title unless space is a consideration.
3.
Item (ll)--0BSERVATION:
It appears it would have been appropriate to also report this event under paragraph (s) 50.73(a)(2)(1).
4.
Item (13)--Component failure field contains data when no component failure occurred.
This item should be filled out only for component failure, and then all five fields should be filled in.
}
i 4
i l
D-10
+-,~,-,.n----,-
-,n
-.,m _ -,
_=,----,c-~m--en----,._,-_,-.----
--.,.n~,---
....._...n.-
TABLE 0-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Coments 8.
LER Number: 86-019-00 Scores: Text - 8.5 Abstract - 8.9 Coded Fields - 9.0 Overall = 8.7 Text 1.
50.73(b)(2)(11)(C)--Approximate time information for major occurrences is not included.
2.
50.73(b)(2)(11)(D)--The root and/or intermediate cause discussion concerning the preservice repair weld is inadequate.
Elaborate on why the repair weld was made and whether adequate testing was performed at that time.
3.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. A discussion of actions required to reduce the probability of recurrence (i.e, correction of the root cause) is not included or is inadequate.
Abstract 1.
50.73(b)(1)--Summary of root cause (repair weld defect) is inadequate. See text comment number 2.
2.
50.73(b)(11--Sumary of corrective actions taken or planned as a result of the event is inadequate. See text coment number 3.
Coded Fields 3.
Item (4)--Title:
Root cause (weld defect) is not included.
l l
i i
D-11
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 1 (373)
Section Comments 9.
LER Number:
86-029-00 Scores:
Text - 9.1 Abstract = 8.9 Coded Fields - 8.2 Overall = 8.9 Text 1.
50.73(b)(2)(ii)(C)--Date/ time information for major occurrences is inadequate.
The dates / times when the investigation into the problem and corrective actions were taken were not included.
2.
50.73(b)(2)(ii)'F)--The EIIS codes for components referred to in
'tHe text were not included.
3.
Acronym (s) and/or plant specific designator (s) are undefined.
IRM, APRM, SRM, and RMCS should be defined.
Abstra:t 1.
Abstract contains acronym (s) and/or plant specific i
designator (s) which are undefined.
I Coded Fields 1.
Item (4)--Title:
Result (Inoperable Intermediate Range Monitoring System) is not included. The use of acronyms in a title should be avoided unless space is a consideration.
l 2.
Item (11)--08SERVATION:
It appears it would have 4
been appropriate to also report this event under paragraph (s) 50.73(a)(2)(v11).
I 3.
Item (131--Component failure field contains data when no component failure occurred. This item should be filled out only for component failures and then all five fields should be filled in.
4.
Item (141--The block checked is inconsistent with information in the text. Neither the text or abstract explains the need for the supplemental report.
i l
l D-12
. - - - =
TABLE D-1.
SPECIFIC LER CDMMENTS FOR LASALLE 2 (374)
Section Comments
- 10. LER Number: 85-044-00 Scores:
Text - 9.1 Abstract - 9.7 Coded Fields - 9.0 Overall - 9.3 Text 1.
50.73(b)(2)(11)(F1--The EIIS component codes for each component referred to in the text were not included.
The presentation of plant acronyms and EIIS system codes together is confusing.
2.
50.73(b)f2)(ii)(t1--Identification (e.g. manufacturer and model no.) of the failed component (s) discussed in the text is not included. The manufacturer and model number of the timer are not included.
Abstract 1.
No comments.
Coded Fields 1.
Item (4)--Title:
Root cause is not included.
It is 4
not recommended to use acronyms in the title unless i
title length is a problem.
1 2.
Item (12)--Position title is not included.
3.
Item (13)--The first line is appropriate, but the partially filled in second line should be left out.
t 0-13
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 2 (374) i Section Comments
- 11. LER Number: 85-046-00 Scores: Text - 9.5 Abstract = 8.8 Coded Fields = 9.0 Overall - 9.2 Text 1.
No comment.
Abstract 1.
50.73(b)(1)--Summary of occurrences [immediate cause(s) and effects (s)] is inadequate. The abstract should state that this was a condition prohibited by the Technical Specifications.
2.
OBSERVATION: The abstract contains information not included in the text.
The abstract is intended to be 4
a sumary of the text; therefore, the text should discuss all information summarized in the abstract.
The information in last sentence is not included in the text.
Coded Fields 1.
Item (4)--Title:
Root cause is not included.
2.
Item (71--08SERVATION: Report date is not within thirty days of event date (or discovery date if appropriate).
3.
Item (12)--Position title is not included.
4.
Item (13)--Component failure field contains data when no component failure occurred.
i I
D-14
TABLE D-1.
SPECIFIC LER CDMMENTS FOR LASALLE 2 (374)
Section Comments
- 12. LER Number: 85-047-00 Scores:
Text - 7.6 Abstract - 8.5 Coded Fields - 8.6 Overall = 8.0 Text 1.
50.73(b)(2)(11)(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. No code is provided for the components referred to in the text.
2.
50.73(b)(2)(11)(I)--Discussion of the method of discovery of the missed samples is not included.
When and how was it determined that the samples had not been taken as required?
3.
50.73(b)(2)(11)(J)(21--Discussion of the personnel error is inadequate. Was it a cognitive or procedural error (or a part of the work request) that resulted in the decision by the Shift Foreman to leave the RHR SW system running.
4.
50.73(b)(31--Discussion of the assessment of the safety consequences and implications of the event is inadequate. What would have been the consequences, if any, of the system becoming contaminated (radioactively) during the period that the system was not monitored?
5.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate.
A supplemental report appears to be needed to describe the corrective actions that result from AIR 374-200-85-13100 and 13101. Without a commitment to submit a supplemental report, this LER must be considered incomplete. What interim corrective actions were taken? Is there a need to provide all operators with additional information concerning the use of the time clock easel?
l 6.
Acronym (s) and/or plant specific designator (s)'are undefined; (NS0).
D-15
f TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE ? (374)
Section Comments 12.
LER Number: 85-047-00 (continued)
Abstract 1.
50.73(b)(11--Summary of occurrences (immediate cause(s) and effects (s)) is inadequate. The tie between the test failure and the decision to leave the RHR SW system running should be provided. See text comment number 3.
2.
50.73(b)(11--Summary of corrective actions taken or planned as a result of the event is inadequate.
AIR 374-200-85-13101 should have been mentioned.
Coded Fields 1.
Item (41--Title: Root cause (inadequate shift turnover procedures) and end result (Technical Specification violation) are not included.
2.
Item (12)--Position title is not included.
3.
Item (13)--Component failure field contains data when no component failure occurred.
4.
Item (14)--The block checked is inconsistent with information in the text. See text comment number 5.
l D-16
TABLE D-1.
SPECIFIC LER COMMENTS FOR LASALLE 2 (374)
Section Comments 13.
LER Number: 85-048-00 Scores: Text - 8.9 Abstract - 10.0 Coded Fields - 9.0 Overall - 9.2 Text 1.
50.73(b)(2)(11)(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.
2.
50.73(b)f2)(11)(L)--Identification e.g. manufacturer and model no.) of the failed compone(nt(s) discussed in the text is not included.
Abstract 1.
No comments.
i Coded Fields 1.
Item (4)--Title:
Root cause (unknown is not It is best not to use acron)yms in the included.
title.
7 1
D-17
TABLE 0-1.
SPECIFIC LER COMMENTS FOR LASALLE 2 (374)
Section Comments
- 14. LER Number: 86-003-00 Scores: Text - 9.5 Abstract = 9.7 Coded Fields - 9.1 Overall = 9.5 1
Text 1.
50.73(b)(2)(ii)(F1--The EIIS codes for the components referred to in the text were not included.
2.
The text should be provided on NRC form 366A.
Abstract 1.
The abstract should indicate that the mode switch was required to be moved to the " shutdown" position.
Coded Fields 1.
The plant name (Item 1), docket number (Item 2), and LER number (Item 6) should be included at the top of each text page in case the LER pages become separated (see text comment 2).
2.
Item (41--Title: Link (surveillance testina) is not 4
included.
3.
Item (131--Component failure field contains data when l
no component failure occurred. This item should be t
filled out only for component failures, and then all five fields should be filled in.
0-18 l
- - ~ - - - - - - - - - - - -
~ _
TA8LE O-1.
SPECIFIC LER COMMENTS FOR LASALLE 2 (374)
Section Comments
- 15. LER Number: 86-004-00 1
Scores: Text - 7.9 Abstract = 7.3 Coded Fields - 9.5 Overall = 7.9 Text 1.
50.73(b)(2)(ii)(01--The root and/or intermediate cause discussion concerning the missing transformer shorting link is not included. Was personnel error involved?
2.
50.73(b)(2)(ii)(L)--Identification (e.g.,
manufacturer and model no.) of the failed i
component (s) discussed in the text is not included.
i 3.
50.73(b)(31--Discussion of the assessment of the safety consequences and implications of the event is inadequate. More details concerning the adequate i
backup protection for differential overcurrent on the 2 East Main Transformer would be appropriate.
4.
50.73(b)(41--Discussion of corrective actions taken j
or planned is inadequate. A discussion of actions required to reduce the probability of recurrence (i.e correction of the root cause) is not included i
or is inadequate.
Abstract 1.
50.73(b)(11--Summary of root cause is inadequate.
See text comment 1.
2.
50.73(b)(11--Summary of corrective actions taken or planned as a result of the event is not included.
I Coded Fields 1.
Item (4)--Title:
Root cause (missing shorting link) is not included.
i l
l D-19
. -. -