ML20211G287
| ML20211G287 | |
| Person / Time | |
|---|---|
| Site: | Crane  |
| Issue date: | 02/18/1987 |
| From: | Kane W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Hukill H GENERAL PUBLIC UTILITIES CORP. |
| References | |
| NUDOCS 8702250333 | |
| Download: ML20211G287 (47) | |
Text
.
t FEB 181987 Docket No. 50-289 GPU Nuclear Corporation ATTN: Mr. H. D. Hukill Vice President and Director, TMI-1 P. O. Box 480 Middletown, Pennsylvania 17057 Gentlemen:
Subject:
LER Evaluation for TMI-1 The enclosed report is a review of your Licensee Event Reports (LERs) submitted to the NRC for the period January 1, 1986, through October 31, 1986. This re-view was completed by an NRC contractor for our Office of Analysis and Evaluation of Operational Data (AE00) and was an input to the recent NRC Systematic Assess-ment of Licensee Performance for TMI-1.
This report is provided for your use in assessing and improving the quality of your LERs.
Your cooperation in this matter is appreciated.
Sincerely, origina131sae d tys William F. Kane, Director Division of Reactor Projects
Enclosure:
As stated cc w/encls:
R. J. Toole, Operations and Maintenance Director, TMI-1 C. W. Smyth, TMI-1 Licensing Manager R. J. McGoey, Manager, PWR Licensing E. L. Blake, Jr.
TMI-1 OTSG Hearing Service List Public Document Room (PDR)
Local Public Document Room (LPDR)
Nuclear Safety Information Center (NSIC)
NRC Resident Inspector l
Commonwealth of Pennsylvania 8702250333 870218 PDR ADOCK 05000289 O
PDR s\\
3' o f
g o.
A GPU Nuclear Corporation 2
bec w/encls:
Region I Docket Room (concurrence copy)
J. Goodberg, OELD:HQ Management Assistant, DRMA (w/o encl)
RP & EP Branch Files R. Conte, DRP Section Chief W. Travers, NRR J. Thoma, PM, NRR T. Ross, PM, NRR K. Abraham, RI W. Baunack, RI F. Young, RI D. Johnson, RI J. Rogers, RI il I
I 1-P RI:DRP I:DRP RConte ABlough S 1 ins e
1/2[/87 9///87 1/
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. Operations 18 50-289
(
i 3 TMI-I Hearing Service List Sheldon J. Wolfe, Chairman Bruce W. Churchill, Esquire Administrative Judge Shaw, Pittman, Potts & Trowbridge Atomic Safety & Licensing Board Panel 2300 N Street, N.W.
U.S. Nuclear Regulatory Commission Washington, D.C.
20037 Washington, D.C.
20555 Dr. Oscar H. Paris Atomic Safety & Licensing Board Administrative Judge Panel Atomic Safety & Licensing Board Panel U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission Washington, D.C.
20555 Washington, D.C.
20555 Frederick J. Shon Atomic Safety & Licensing Appeal Administrative Judge Board Panel Atomic Safety & Licensing Board Panel U.S. Nuclear Regulatory Commission U.S. Nuclear Regulatory Commission Washington, D.C.
20555 Washington, D.C.
20555 Joanne Doroshow, Esquire Docketing & Service Section Three Mile Island Alert, Inc.
Office of the Secretary 315 Peffer Street U.S. Nuclear Regulatory Commission Harrrisburg, PA 17102 Washington, D.C.
20555 Louise Bradford Mary E. Wagner, Esquire 1011 Green Street Office of Executive Legal Director Harrisburg, PA 17102 U.S. Nuclear Regulatory Commission Washington, DC 20555 Thomas Y. Au USNRC Assistant Counsel Commonwealth Resident Inspector of Pennsylvania Box 311 Dept. of Environmental Resources Middletown, PA 170_57 Bureau of Environmental Resources Room 505, Executive House P. O. Box 2357 Harrisburg, PA 17120 i
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AE0D SALP INPUT FOR
\\
THREE MILE ISLAND 1 -
OPERATIONS (LER QUALITY) FOR THE ASSESSMENT PERIOD OF l
May 1, 1986 to October 31, 1986 i
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SUMMARY
An evaluation of the content and quality of the Licensee Event Reports (LERs) submitted by Three Mile Island during the May 1, 1986 to October 31, 1986 Systematic Assessmen-ticensee Performance (SALP) period could not be performed due to the,ack of LERs on file for the assessnent period (i.e., there as only one LER on file with an event date of May 1, 1986 or later). However, in order to provide a perspective of the content and quality of the Three Mile Island 1 LERs, an evaluation of all the 1986 LERs for Three Mile Island I was performed using a refinement of the basic methodology presented in NUREG-1022, Supplement 2.
The results of this evaluation indicate that Three Mile Island LERs have an overall average LER score of 8.7 out of a possible 10 points, compared to a current industry average score of 8.1 for those unit / stations that have been evaluated to date using this methodology.
Two weaknesses were identified in the Three Mile Island i LERs, in terms of safety significance. These involve Requirements 50.73(b)(3),
which requires a safety assessment of the event, and 50.73(b)(2)(11)(J)(2),
which requires a discussion of personnel and procedural errors.
Deficiencies in the safety assessment discussions prompts concern as to whether or not each event is being evaluated such that the potential consequences of the event are being identified.
Likewise, deficiencies in the personnel / procedural error discussions prompts concern as to whether or not the causes of these type errors are being determined such that adequate i
corrective actions to prevent recurrence are taken.
The Three Mile Island 1 LERs have several strong points, in terms of safety significance.
The discussions for root cause [ Requirement 50.73(b)(2)(11)(D)), corrective actions (Requirement 50.73(b)(4)], mode, mechanism, and effect [ Requirement 50.73(b)(2)(ii)(E)), and identification of failed components [ Requirement 50.73(b)(2)(11)(L)] were all considered to be well above average.
AEOD INPUT TO SALP REVIEW FOR THREE MILE ISLAND 1 Introduction In order to provide a perspective of the overall quality of the contents of the Licensee Event Reports (LERs) submitted by Three Mile Island 1 during the May 1, 1986 to October 31, 1986 Systematic Assessment of Licensee Performance (SALP) assessment period, all of the unit's 1986 LERs were evaluated using a refinement of the basic methodology presented in NUREG-1022, Supplement No. 2.
The sample consists of 11 LERs which was all the LERs on file at the time the evaluatiori was started (see Appendix A for a list of the LER numbers in the sample).
(Note: There was only one LER on file that was within the six month assessment period.)
It was necessary to start the evaluation before the end of the SALP assessment period because the input was due such a short time after the end of the SALP period. Therefore, not all of the LERs prepared during the SALP assessment period were available for review.
Methodology The evaluation consists of a detailed review of each selected LER to determine how well the content of its text, abstracts, and coded fields meet the criteria of 10 CFR 50.73(b).
In addition, each selected LER is 2
compared to the guidance for preparation of t.ERs presented in NUREG-1022 and Supplements No. I 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. This evaluation is not intended to increase the requirements concerning 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 that light.
However, the obvious minimum requirements of the regulation must be met.
1
The evaluation process for each LER is divided into two parts.
The first part of the evaluation censists 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 l
of each LER.
~
The LER specific comments serve two purposes:
(1) they point out what the analysts considered to be the specific deficiencies or observations concerning the information pertaining to the event, and (2) they provide a basis for a count of general deficiencies for the overall sample of LERs that was reviewed. Likewise, the scores serve two purposes:
(1) they 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 0, consists of LER sample information (Appendix A), a table of the scores for each sample LER 1
(Appendix B), tables of the number of deficiencies and observations for the text, abstract and coded fields (Appendix C), and comment sheets containing i
narrative statements concerning the contents of each LER (Appendix D).
When 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 l
deficiency when assigning scores.
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 i
k 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 requirements of 10 CFR 50.73(b).
1 Table 1 presents the average scores for the sample of LERs evaluated for Three Mile Island.
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 in figure 1.
Additional scores are added to Figure 1 each month as other units / stations are evaluated.
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, Three Mile Island l'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 before the event
[10 CFR 50.73(b)(2)(11)(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 licensee for the 11 LERs that were evaluated.
j Discussion of Specific Deficiencies A review of the percentage scores presented in Table 2 will quickly i
point out where the unit is experiencing the most difficulty in preparing LERs. 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:
j (1) excluded certain less significant information from most of the j
discussion 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 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 l
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a TA8LE 1.
SUMARY OF SCORES FOR THREE MILE ISLAND 1 Average Hiah Low Text 8.8 9.8 7.6 Abstract 8.6 10.0 6.6 Coded Fields 8.7 9.5 7.7 Overall 8.7 9.8 7.6 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 i
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9-8-
Three Mile Island 1
.9%
7-E) 6-E
=a 5-4-
3-h!h<h.hh,f,,!,hhfffhf,,h,!,,,,,
9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0
^
Overall average scores
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TA8LE 2.
LER REQUIREMENT PERCENTAGE SCORES FOR THREE MILE ISLAND 1 TEXT Percentage Requirements [50.73(b)1 - Descriptions
_ Scores ( )'
(2)(ii)(A) - - Plant condition prior to event 100 (11)
(2)(11)(8) - - Inoperable equipment that contributed b
(2)(11)(C) - - Date(s) and approximate times 84 (11)
(2)(11)(0) - - Root cause and intermediate cause(s) 92 (11)
(2)(11)(E) - - Mode, mechanism, and effect 100 ( 4)
(2)(ii)(F) - - EIIS Codes 77 (11)
(2)(11)(G) - - Secondary function affected b
t (2)(11)(H) - - Estimate of unavailability 100 ( 5) 4 (2)(ii)(I) - - Method of discovery 100 (11) l (2)(11)(J)(1) - Operator actions affecting course 100 ( 4)
(2)(ii)(J)(2) - Personnel error (procedural deficiency) 67 ( 6)
(2)(11)(K) - - Safety system responses 83 ( 6)
(2)(11)(L) - - Manufacturer and model no. information 100 ( 5)
(3)
Assessment of safety consequences 72 (11)
(4)
Corrective actions 92 (11)
(5)
Previous similar event information 100 (11)
(2)(i) - - - - Text presentation 90 (11)
A8STRACT Percentage Reautrements f50.73(b)(111 - Descriptions Scores ( )*
- Major occurrences (Immediate cause and effect 100 (11) information)
- Description of plant, system, component, and/or 100 ( 6) l personnel responses
- Root cause information 86 (11)
- Corrective Action information 70 (11)
- Abstract presentation 82 (11)
E.
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TABLE 2.
(continued)
CODED FIELDS Percentage Item Number (s) - Description Scores ( )#
1, 2, and 3 - Facility name (unit no.), docket no. and 98 (11) page number (s) i 4 - - - - - - Title 62 (11) 5, 6, and 7 - Event date, LER No., and report date 100 (11) 8 - - - - - - Other facilities involved 100 (11) 9 and 10 - - Operating mode and power level 88 (11) 11 - - - - - Reporting requirements 95 (11) 12 - - - - - Licensee contact information 100 (11) 13 - - - - - Coded component failure information 96 (11) 14 and 15 - - Supplemental report information 86 (11) 1 a.
Percentage scores are the result of dividing the total points for a requirement by the number of points possible for that requirement.
(Note:
Some requirements are not applicable to all LERs; therefore, the number of points possible was adjusted accordingly.) The number in parenthesis is the number of LERs for which the requirement was considered applicable.
b.
A percentage score for this requirement is meaningless as it is not possible to determine from the information available to the analyst whether this requirement is applicable to a specific LER.
It is always given 100%
if it is provided and is always considered "not applicable" when it is not.
o addition, the primary deficiencies in the abstract and coded fields are discussed.
The safety assessments for six of the LERs were considered to be marginal, Requirement 50.73(b)(3). A detailed safety assessment is j
required in all LERs and should include information such as:
1 1.
An assessment of the consequences and implications of the event including specifics as to why it was concluded that there were "no safety consequences", if applicable.
It is inadequate to state "this event had no safety consequences or implications" without explaining how that conclusion was reached.
2.
A safety assessment should discuss whether the event could have occurred under a different set of conditions where the safety implications would have been more severe.
If the conditions during the event are considered the worst probable, the LER should so state.
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3.
Finally, a safety assessment should name other systems (if any) that were available to perform the function of the safety systems l
that were unavailable during the event.
Four of the six LERs involving personnel error and/or procedural error appear to be deficient. When the root cause involves either personnel or procedural error, the text should then provide the specific information i
requested in Requirement 50.73(b)(2)(ii)(J)(2).
While there are no specific requirements for an abstract, other than those given in 10 CFR 50.73(b)(1), an abstract should, as a minimum, summarize the following information from the text:
i 1.
Cause/Effect What happened that made the event reportable.
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2.
Responses Major plant, system, and personnel responses as a result J
of the event.
3.
Root / Intermediate The underlying cause of the Causes event. What caused the I
component and/or system failure or the personnel error.
i 4.
Corrective Actions What was done immediately to restore the plant to a safe and stable condition and what was done or planned to prevent recurrence.
Three Mile Island had good discussions of item numbers 1, 2, and 3.
Item number 4 could, however, use some improvement. Abstract scores for these items should improve if the corrective action information contained in the text is summarized in the abstract.
i The main deficiency in the area of coded fields involves the title, i
Item (4).
Ten of the titles failed to indicate the root cause, one failed to indicate the result (i.e., why the event was required to be reported),
and two failed to include the link between the cause and the result. While result is considered the most important part of the title, cause i
i information (and link, if necessary) must be included to make a title j
complete. An example of a title that only addresses the result might be l
" 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 0 (Coded Fields section) for some of the titles that are considered to be deficient.
9
Table 3 provides a sununary of the major areas that need improvement for the Three Mile Island LERs.
For more specific information concerning additional deficiencies, the reader should refer to the information presented in Appendices C and D.
General guidance concerning requirements can be found in NUREG-1022, Supplement No. I and 2.
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TABLE 3.
AREAS MOST NEEDING IMPROVEMENT FOR THREE MILE ISLAND 1 LERs Areas Comments Safety assessment information All LERs should include a detailed safety assessnwnt. The text should discuss whether or not the event could have been worse had it occurred under different, yet probable circumstances and provide information concerning backup systems that were available to mitigate the consequences of the event.
Personnel / procedural When the root cause involves error discussion personnel or procedural error, the text discussion should address the specific requirements of Requirement 50.73(b)92)(ii)(J)(2).
Abstract Corrective action information is not being adequately summarized in the abstracts. Each abstract should contain a good summary of the major points that are discussed in the text.
Coded fields a.
Titles Titles need to be written such that they better describe the event.
This can be accomplished by including the root cause, result, and the link between them in each title.
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1 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, 12
t 8
APPENDIX A LER SAMPLE SELECTION INFORMATION FOR THREE MILE ISLAND 1
TA8LE A-1.
LER SAMPLE SELECTION FOR THREE MILE ISLAND 1 (289)
Sample Number LER Number Comments 1
86-001-00 2
86-002-00 SCRAM 3
86-003-00 4
86-004-00 5
86-005-00 6
86-006-00 SCRAM 7
86-007-00 8
86-008-01 ESF 9
86-009-00 10 86-010-00 SCRAM 11 86-011-00 SCRAM i
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4 A-1
O APPENDIX B EVALUATION SCORES Of INDIVIOUAL LERS FOR THREE MILE ISLAND 1
TA8LE 8-1.
EVALUATION SCORES OF INDIVIDUAL LERs FOR THREE MILE ISLAND 1 (289)
LER Sample Number #
1 2
3 4
5 6
7 8
Text 9.1 8.7 9.7 8.8 9.3 7.8 8.4 9.8 Abstract 9.2 8.8 10.0 9.4 9.9 7.2 6.6 9.3 Coded 9.3 9.0 9.5 9.1 8.4 8.5 7.7 8.7 Fields Overall 9.2 8.7 9.8 9.0 9.4 7.7 7.8 9.5 LER Sample Number
- 9 10 11 12 13 14 15 Averaae Text 7.6 7.9 9.5 8.8 Abstract 7.5 9.3 7.7 8.6 Coded 7.9 9.3 7.9 8.7 Fields Overall 7.6 8.4 8.8 8.7 4
a.
See Appendix A for a list of the corresponding LER numbers.
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t APPENDIX C DEFICIENCY AND OBSERVATION COUNTS FOR THREE MILE ISLAND 1 i
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TABLE C-1.
TEXT DEFICIENCIES AND OBSERVATIONS FOR THREE MILE ISLAND 1 (289)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)U a
50.73(b)(2)(ii)(Al--Plant operating 0 (11) conditions before the event were not included or were inadequate.
50.73(b)(2)(ii)(B)--Discussion of the status 0 ( 7) of the structures, components, or systems that were inoperable at the start of the event and that contributed to the event was not included or was inadequate.
50.73(b)(2)(ii)(C)--Failure to include 4 (11) 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 2 (11) intermediate failure, system failure, or personnel error was not included or was inadequate.
a.
Cause of component failure was not 0
included or was inadequate b.
Cause of system failure was not 0
included or was inadequate c.
Cause of personnel error was not 2
included or was inadequate.
l 50.73(b)(2)(11)(El--The failure mode, 0 ( 4) mechanism (immediate cause), and/or effect I
(consequence) for each failed component was not included or was inadequate.
l a.
Failure mode was not included or was l
inadequate j
b.
Mechanism (immediate cause) was not included or was inadequate l
c.
Effect (consequence) was not included or was inadequate.
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C-1
TABLE C-1.
(cointinued)
^
G Number of LERs with Deficiencies and
.I Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals #
Totals (
)
50.73(b)(2)(illff)--The Energy Industry 4 (11)
Identification System component function identifier for/each component or system was not included.
50.73(b)(2)Lii)_1G1--For a failure of a
-- ( 0) component with multiple functions, a list of systems.o secondary functions which were also affected was not included or was Inadequate.
50.73(b)(2)(ii)(H)--For a failure that 0 ( 5) rendered a train of a safety system inoperable, the estimate of elapsed time from the discovery of the failure until the train was' returned to service was not included.
50.73(b)(2)(11)(1)--The method of discovery 0 (11) of each component failure, system failure, personnel error, or procedural error was not included or was inadequate.
a.
Method of discovery for each component failure was not included or was inadequate b.
Method of discovery for each system
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failure was not included or was 4 -
inadequate c.
Method of discovery for each personnel error was not included or was inadequate d.
Method of discovery for each procedural error was not included or was inadequate.
C-2
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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 ( 4) affected the course of the event including operator errors and/or procedural deficiencies were not included or were inadequate.
50.73(b)(2)(ii)(J)(2)--The discussion of 4 ( 6) each personnel error was not included or was inadequate.
a.
OBSERVATION: A personnel error was 0
implied by the text, but was not expiteitly stated, b.
50.73(b)(2)(ii)(J)(2)(1)--Discussion 1
as to whether the personnel error was cognitive or procedural was not included or was inadequate.
c.
50.73(b)(2)(ii)(J)(2)(11)--Discussion 1
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 ) ( J ) ( 2 ) ( i i i )--Di s c u s s i on 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 0
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.
C-3
TABLE C-1.
(continued)
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 2 ( 6) safety system responses were not included or were inadequate.
50.73(b)(2)(11?(L)--The manufacturer and/or 0 ( 5) model number of each failed component was not included or was inadequate.
50.73(b)(3)--An assessment of the safety 6 (11) consequences and implications of the event was not included or was inadequate.
a.
OBSERVATION: The availability of 1
other systems or components capable of mitigating the consequences of the event was not discussed.
If no other systems or components were available, the text should state that none existed.
b.
OBSERVATION:
The consequences 1
of the event had it occurred under more severe conditions were not discussed.
If the event occurred under what were considered the most severe conditions, the text should so state.
50.73(b)(4)--A discussion of any corrective 4 (11) 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.
C-4
' TABLE C-1.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph a
b Description of Deficiencies and Observations Totals Totals (
l 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 1
reduce the probability of recurrence of the problem or similar event (correct the root cause) was not included or was inadequate.
c.
OBSERVATION: A discussion of actions 0
required to prevent similar failures in similar and/or other systems (e.g.,
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 0 (11) 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 a
b Description of Deficiencies and Observations Totals Totals (
l 50.73(b)(2)(il--Text presentation 6 (11) inadequacies.
a.
OBSERVATION: A diagram would have 0
aided in understanding the text discussion.
b.
Text contained undefined acronyms 6
and/or plant specific designators.
c.
The text contains other specific 0
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.
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C-6
TABLE C-2.
ABSTRACT DEFICIENCIES AND OBSERVATIONS FOR THREE MILE ISLAND 1 (289) l Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals Totals (
)b a
A summary of occurrences (immediate cause 0 (11) and effect) was not included or was inadequate A summary of plant, system, and/or personnel 0 ( 6) responses was not included or was inadequate.
a.
Summary of plant responses was not included or was inadequate.
b.
Summary of system responses was not included or was inadequate.
c.
Summary of personnel responses was not included or was inadequate.
A summary of the root cause of the event 4 (11) was not included or was inadequate.
A summary of the corrective actions taken or 6 (11) planned as a result of the event was not included or was inadequate.
C-7 y
w+
TABLE C-2.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals (
)
Abstract presentation inadequacies 3 (11) a.
OBSERVATION: The abstract contains 1
information not included in the text.
The abstract is intended to be a summary of the text, therefore, the text should discuss all information summarized in the abstract.
b.
The abstract was greater than 0
1400 characters c.
The abstract contains undefined 2
acronyms and/or plant specific designators.
d.
The abstract contains other specific 1
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.
C-8
TA8LE C-3.
CODED FIELDS DEFICIENCIES AND OBSERVATIONS FOR THREE MILE ISLAND 1 (289)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals' Totals (
)
Facility Name 0 (11) 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 1 (11) incorrect.
Page Number was not included or was 0 (11) incorrect.
Title was left blank or was inadequate 11 (11) a.
Root cause was not given in title 10 b.
Result (effect) was not given in title 1
c.
Link was not given in title 2
Event Date 0 (11) a.
Date not included or was incorrect, b.
Discovery date given instead of event date.
LER Number was not included or was incorrect 0 (11)
Report Date 0 (11) 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 (11) inconsistent with text and/or abstract.
Operating Mode was not included or was 4 (11) inconsistent with text or abstract.
C-9
TABLE C-3.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Total','
Totals (
)
Power level was not included or was 0 (11) inconsistent with text or abstract Reporting Requirements 1 (11) a.
The reason for checking the "0THER" 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 1
appropriate to report this event under an additional unchecked paragraph.
Licensee Contact 0 (11) 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 (11) 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 2
when no component failure occurred.
d.
Component failure occurred but entire 0
field left blank.
C-10
TABLE C-3.
(continued)
Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph b
Description of Deficiencies and Observations Totals' Totals (
l Supplemental Report 1 (11) 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 (11) inconsistent with the block checked in Item (14).
a.
The "sub-paragraph total" is a tabulation of specific deficiencies or observations within certain requirements.
Since an LER can have more than one deficiency for certain requirements, 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 nunser of LERs for which a certain requirement was considered applicable.
C-11
O e
4 9
e 8
APPENDIX D LER COMMENTS SHEETS FOR THREE MILE ISLAND 1 l
l l
l l
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 1.
LER Number: 86-001-00 Scores: Text - 9.1 Abstract - 9.2 Coded Fields - 9.3 Overall - 9.2 Text 1.
50.73(b)(2)(ii)(J)(2)--Discussion of the personnel error is inadequate. The discussion should ind'.cate whether or not the maintenance procedure is considered to be adequate.
2.
50.73(b)(31--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
The safety assessment should discuss the implications to the plant had the pressurizer spray line broken.
Abstract 1.
50.73(b)(1)--Summary of root cause is inadequate.
The abstract should be more specific about the personnel error (i.e., improper maintenance).
Coded Fields 1.
Item (4)--Title: Root cause is not included.
A more appropriate title might be " Inoperable Snubber Due to Maintenance (Personnel) Error Found During Surveillance Inspection".
D-1
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Consnents 2.
LER Number: 86-002-00 Scores: Text - 8.7 Abstract - 8.8 Coded Fields = 9.0 Overall = 8.7 Text 1.
50.73(b)(2)(ii)(C)--Date and time information for major occurrences is inadequate. The date that this event occurred is not provided in the text. Times should be provided for the completion of the corrective actions.
2.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
Information under heading VI, Assessment of the Safety Consequences and Implications of the Event, should discuss why there were no safety consequences.
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. The cause of the valve controller air ports being clogged l
with dirt / rust is not provided. What was done to reduce the probability of this occurring in the new l
controller?
4.
The outline format used is very good.
i Abstract 1.
50.73(b)(1)--Summary of the root cause is inadequate. Why did the valve controller fail?
2.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is ' inadequate. See text comment number 3.
l l
3.
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 event date is stated in the abstract, but not in f
the text. See text comment 1.
[
Coded Fields 1.
Item (4)--Title:
Root cause is not included.
I l
D-2 1
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 3.
LER Number: 86-003-00 Scores: Text - 9.7 Abstract - 10.0 Coded Fields - 9.5 Overall - 9.6 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.
Abstract 1.
No comments.
Coded Fields 1.
Item (4)--Title: Link (during surveillance testing) is not included.
0-3
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 4.
LER Number: 86-004-00 Scores: Text - 8.8 Abstract - 9.4 Coded Fields - 9.1 Overall - 9.0 Text 1.
50.73(b)(2)(ii)(F)--Be sure to include the EIIS codes for each component referred to in the text (i.e., the valve and drain codes should be provided).
2.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
The effect of an unidentified leak should be discussed.
In particular, other systems, if any, available to perform the function of the RM-A-5 monitor should be mentioned.
3.
Acronym (s) and/or plant specific designator (s) are undefined.
OTSG and plant identifiers such as RM-A-13 should be defined on their first usage.
Abstract 1.
No comment.
Coded Fields 1.
Item (2)--The docket number on page 3 is incorrect.
2.
Item (4)--Title:
Root cause is not included. A more appropriate title might be " Isolation of Condenser Offgas Radiation Monitor During Power Operation Due To Personnel Error".
l l
l D-4
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 5.
LER Number:
86-005-00 Scores: Text - 9.3 Abstract = 9.9 Coded Fields = 8.4 Overall - 9.4 Text 1.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate. The text states that Fire Door C310 was not functional, and the requirements of the Technical Specification 3.18.7 were not met.
It is not clear to the reader what "no detrimental safety consequences" means.
Even though Fire Door C310 is not used to separate mutually redundant equipment, the consequences of the fire door not performing its function, if a fire had occurred, should be discussed.
Abstract 1.
No comments.
Coded Fields 1.
Item (4)--Title: Root cause is not included.
2.
Item (9)--Operating mode is not included.
3.
Item (13)--Component failure field contains data when no component failure occurred.
l l
l t
D-5 l
g TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 1
6.
LER Number: 86-006-00 Scores: Text = 7.8 Abstract = 7.2 Coded Fields - 8.5 Overall - 7.7 Text 1.
50.73(b)(2)(ti)(C)--Time information for major occurrences is inadequate. When was the plant stabilized at Hot Shutdown conditions?
2.
50.73(b)(2)(ii)(F)--The EIIS codes for the lube oil coolers (i.e.. TD/CLR) is only necessary the first time the system / component is referred to in the text.
3.
50.73(b)(2)(11)(J)(2)--Discussion of the personnel error is inadequate.
Both a personnel error and a procedural inadequacy are mentioned but neither is explained.
4.
50.73(b)(2)(ii)(K)--Discussion of automatic and/or manual safety system responses is inadequate. Under Section VI is the statement "All systems functioned as designed". As a minimum, the safety systems / components that functioned as designed should be named.
5.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
Could there be other procedures that are deficient in the same manner? Given that, even with the Shift Foreman's help, the auxiliary operator couldn't transfer the coolers correctly, is this an area that requires additional personnel training emphasis?
6.
50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. More details concerning the procedure changes are required. See text comment number 3.
l Abstract 1.
50.73(b)(1)--Summary of root cause is not included.
2.
50.73(b)(1)--Summary of corrective actions taken or l
planned as a result of the event is inadequate.
The information provided in Section VIII of the text should have been mentioned in the abstract.
l 0-6 1
~ -
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 6.
LER Number: 86-006-00 (continued) 3.
Abstract does not adequately summarize the text.
Additional space is available within the abstract field to provide the necessary information but it was not utilized.
Coded Fields 1.
Item (4)--Title:
Root cause is not included. A better title might be " Personnel Error During Lube Oil Cooler Transfer Causes Low 011 Pressure Resulting In Turbine / Reactor Trip".
2.
Item (9)--Operating mode is not included.
l i
D-7
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 7.
LER Number: 86-007-00 Scores: Text - 8.4 Abstract - 6.6 Coded Fields - 7.7 Overall - 7.8 Text 1.
50.73(b)(2)(ii)(D)--Some discussion as to how the design verification might have failed to detect the error should be provided.
2.
50.73(b)(2)(ii)(F)--The EIIS codes for the check valves was not included. The EIIS codes for the system only need to be given on the first reference to the system.
3.
50.73(b)(4)--A supplemental report appears to be needed to describe the results of the single failure analysis. Without a commitment to submit a supplemental report, this LER must be considered incomplete.
4.
Acronym (s) and/or plant specific designator (s) are undefined. GPUN should be defined.
Abstract 1.
50.73(b)(11--Summary of corrective actions taken or planned as a result of the event is not included.
2.
Abstract contains acronym (s) and/or plant specific designator (s) which are undefined.
Coded Fields 1.
Item (4)--Title: Root cause is not included.
2.
Item (9)--Operating mode is not included.
3.
Item (14)--The block checked is inconsistent with information in the text (see text comment 3).
l l
l l
l 0-8 l
+c TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 8.
LER Number: 86-008-01 Scores: Text - 9.8 Abstract = 9.3 Coded fields - 8.7 Overall - 9.5 Text 1.
The components that tripped as a result of the loss of the "0" 4160V Bus, are listed using plant specific designators that are not defined.
Abstract 1.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate.
The abstract should mention the replacement of the failed breaker.
Coded Fields 1.
Item (4)--Title:
Result and root cause is not included.
D-9
~
TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 9.
LER Number: 86-009-00 Scores:
Text = 7.6 Abstract = 7.5 Coded Fields - 7.9 Overall = 7.6 Text 1.
50.73(b)(2)(11)(C)--Date/ time information for major occurrences is not included. For example, when was this discovery made?
2.
50.73(b)(2)(ii)(D)--The root and/or intermediate cause discussion concerning the unqualified cable i
installation is not included.
3.
50.73(b)(2)(ii)(H)--How long have these unqualified cables been installed? See text comment number 1.
4.
50.73(b)(2)(ii)(J)(2)--Discussion of the personnel 4
error is not included. See text comment number 2.
5.
50.73(b)(4)--The last paragraph under Section VI could have been included under Section VIII.
6.
The plant specific designator "AHE" should have been explained on its first usage.
Abstract 1.
50.73(b)(1)--Summary of root cause information is not included. The abstract fails to indicate that the cable was " user supplied".
2.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate.
The fact that other major motors were visually inspected is not mentioned in the abstract.
Coded Fields 1.
Item (4:--Title:
Root cause and link information is not inc'uded. A better title might be " User Supplied Cables for Three Emergency Cooling Fans Discovered To Be Different from Those Listed On Environmental Qualification Master List".
2.
Item (ll)--0BSERVATION:
It appears it would have been appropriate to also report this event under paragraph (s) 50.73(a)(2)(v).
3.
Item (13)--Component failure field contains data when no component failure occurred.
D-10
- e. 8 TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments 10.
LER Number: 86-010-00 Scores: Text = 7.9 Abstract = 9.3 Coded Fields = 9.3 Overall = 8.4 Text 1.
50.73(b)(2)(11)(J)(2)--Some details should be provided as to why the operator response was slow.
2.
50.73(b)(2)(11)(K)--It is not adequate to say the post trip response was normal.
If any safety systems actuated, they should be listed.
3.
50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate.
The safety assessment should provide the reader with details that justify the conclusion that there were no safety implications from this event.
4.
50.73(b)(4)--Some detail as to how the procedure was changed to prevent recurrence should be provided.
The last corrective action indicates a need for headset communication, but the need for this is not apparent from the remainder of the text discussion.
5.
Acronym (s) and/or plant specific designator (s) are undefined.
OTSG should be defined.
Abstract 1.
Abstract contains acronym (s) and/or plant specific designator (s) which are undefined.
Coded Fields 1.
Item (4)--Title:
Root cause (personnel error) is not included.
i l
D-Il
e,.
5 TABLE D-1.
SPECIFIC LER COMMENTS FOR THREE MILE ISLAND 1 (289)
Section Comments
- 11. LER Number:
86-011-00 Scores: Text - 9.5 Abstract - 7.7 Coded Fields - 7.9 Overall - 8.8 Text 1.
50.73(b)(2)(ii)(C)--Time information for major occurrences is inadequate. The times for completion of corrective actions 1 and 2, and the approximate time the plant reached a stable condition following the reactor trip, should be given.
Abstract 1.
50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is not included.
Coded Fields 1.
Item (4)--Title: Root cause is not included.
The use of undefined acronyms should be avoided in the title unless title length is a consideration.
2.
Item (9)--Operating mode is not included.
3.
Item (14)--The block checked is inconsistent with information in the text. A supplemental report appears to be necessary to list the additional administrative controls for the use of tie breakers.
0-12