ML20214G953

Forwards Assessment of LERs Serving as Example of New Methodology,Described in 850701 & 24 Memos,For LER Preparation & Summary of Results.Lers of Average Quality

ML20214G953
Person / Time
Site:	Fort Saint Vrain
Issue date:	05/16/1986
From:	Hebdon F NRC OFFICE FOR ANALYSIS & EVALUATION OF OPERATIONAL DATA (AEOD)
To:	Johnson E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV)
Shared Package
ML20214G956	List: ML20214G953 ML20215G555
References
NUDOCS 8605270097
Download: ML20214G953 (43)

Text

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May 16, 1986~ Distribution:

. DCS (w/o encl.

AE00 CF (w/o en)cl.~) 'l AJ0D SF -(w/o encl.)

/F. Hebdon (w/ encl.)

C. Heltemes (w/o encl.) -i MEMORANDUM FOR: :Eric H. Johnson, Director Division of Reactor Safety and Projects, Region IV

-FROM:

Fra derick J. Hebdon, Deputy Director ,

Office-for Analysis and Evaluation ]

of Operational Data

SUBJECT:

SALP ASSESSMENT INPUT FOR FORT ST. VRAIN l

l In his memos dated July 1, 1985.and July 24, 1985, Jack Heltemes. 1 I

described a new methodology that we are using to' assess the, quality of LERs submitted by' licensees. This assessment would then serve as an input to the SALP evaluation of the subject facility.

Enclosed (Attachment B). is the assessment of the LERs from Fort St. Vrain. We suggest that this attachment be given to the' .

licensee for use in preparing future LERs. Attachment A is a brief summary of the results of this assessment. You may find this summary l useful as a direct. input into'the SALP report.

I In general, we find these LERs to be of average quality based on the requirements contained in 10 CFR 50.73. The enclosed report provides i the basis for this finding.

.f Please call me on (FTS) 492-4484 if you have any questions concerning this matter.

Original Signed By

- Frederick J. Hebdon -

Frederick J. 'Hebdon, Deputy Director Office for Analysis and Evaluation of Operational Data ,

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Enclosures:

l As stated c cc: C. Miller,INEL(w/oencl.) )

. MA67 3yo IFC :DD/AE00 :D/AEOD-  :

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5/16/86 0FFICIAL RECORD COPY l M%Smd%@ 54 1

SUMMARY

An. evaluation of the content and Quality of a representative sample of the Licensee Event Reports (LERs) submitted by Fort St. Vrain during the March 1, 1985 to April 30, 1986 Systematic Assessment of Licensee Performance (SALP) period was performed using a refinement of the basic ,

methodology presented in NUREG/CR-4178.I The results of this evaluation ,

. indicate that Fort St. Vrain has an overal.1 average.LER score of 8.0 out of a possible 1 points,thusranEingit19thoutof'the62 units (i.e.,

licensees) that have been evaluated to date using this methodology.

The principle weaknesses identified, in terms of plant safety significance, involve the personnel error and identification of f ailed component discussions. Deficiencies in the personnel error discussion prompts concern .as to whether or not the cause for the error is being sufficiently investigated so as to ensure the implementation of aaeauate corrective actions. The f ailure to adequately identify the manufacturer and model number of the components that f ail prompts concern that others in ,

the industry won't have immediate access tc information involving possible generic problems.

A strong point for Fort St. Vrain LERs is that the root cause for each event is generally well discussed. The Fort St. Vrain.LERs also provide a good discut 00 of the, f ailure mode, mechanism, and effect of each failed 4

component. .

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l Attachment A

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AE00 INPUT TO SALP REVIEW FOR FORT ST. VRAIN i

introduction In order to evaluate the overall cuality of the contents of the Licensee Event Reports (LERs) submitted by Fort St. Vrain during the l March 1, 1985 to April 30, 1986 Systematic Assessment of Licensee.

Performance (SALP) assussment period, a representative sample'of the licensee's LERs was evaluated using a refinement of the basic methodology presented in NUREG/CR-4178.I The sample consists of 10 LERs, which is half of the LERs tnat were on file at the time the evaluation was started.

Sea Appenaix A for a list of the LER numbers in the sample.

It was necessary to start the evaluation before the end of the SALP I 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 c.onsists of.a detailed review of each seJected LER to deter'm ine how wel'1 the contenk of its text, abstract, and coded fields meet 2 3 4 the reanir.ements of NUREG-1022 , and Supplements 1 and 2 ,to NUREG-1022. ,

l 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 ano presentation of each LER. The second part consists of

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determining a score (0-10 points) for the text, abstract ~, and coaed fields i

of each LER. i 1

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The LER specific comments serve two purposes: (1) they point out what the analysts considereo to be the specific deficiencies or observ$tions concerning the information pertaining to the event, and (2) they provide a f Attachment B

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basis f,or a count of gen,eral deficiencies for the overall sample of LERs.

Likewise, the stores serve two purposes: (1) they serve to illustrate .in nunerical. terms how the analysts perceived the content of the informatio.n that was presenteo, ano-(2) they provide a basis for the overall score determined for each LER. The overall score for each LER is the result of comoining the scores for the text, abstract, and cooed fields (i e.,

0.6 x text score + 0.3 x abstract score + 0.1 x coded fields .

s. core y o.verall LER score). - -

. . . I The results of the LER ouality 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 f

( Appendix B), tables of the number of deficiencies and observations for the text, abstract and coded fields (Appendix C), and comment sheets containing narrative statements concerning the contents of each LER (Appendix 0).

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 analyst has flexibility to consider the magnitude of a deficiency when assigning scores.

Discussion of Results A' discussion of the analysts' conclusions concerning LER ouality is'  ;

presented below. These conclusions are based solely on the results of the evaluation of the contents of the LERs selected for review ano as such represent the analysts assessment of each units performance (on a scale of 0 to 10) in submitting LERs that meet the requirements of 10 CFR 50.73(b).

Table 1 presents the average scores for the sample of LERs evaluated f or Fort St. Vrain. The reader is cautioned that the scores resulting from the methodology used for this evaluation are not directly comparable to the

-scores contained in NUREG/CR-4178 due to refinements in the methodology. i in order to place the scores provided in Table 1 in perspective, 'the distribution of the overall score for all licensees that have been i

evaluated usirrg the current methodology is provided on Figure 1.

Additional'sco,res',are added to Figure 1 each. month as other licensees are evaluated. Table 2 'and Appendix Table B-1 provide a summary of the information that is the basis.'for the average scores irl .TabTe 1. For example, Fort St. Vrain's average score for the text of the LERS that were evaluated was 8.4 out of a possible 10 points. From Table 2 it can be seen that the text score actually resulted from the review and evaluation of 17 different reauirements ranging fr.om the discussion of plant operating conditions before the event [10 CFR 50.73(b)(2)(ii)(A)] to text .

presentation. The percentage scores in the text summary section of Table 2 proviae an indication of how well each text requirement was addressed by the licensee for the 10 LERs that were evaluated.

Discussion of Specific Deficiencies A review of the percentage scores presented in Table 2 will quickly point out where the licensee is experiencing the most difficulty in preparing LERs. For example, reauirement percentage scores of less than 75 indicate that the licensee probably needs additional guidance concerning these reauirements. Scores of 75 or above, but less than 100, indicate  !

that the licensee probably understands the basic requirement but has either: (1) excluded certain less s'ignificant information from a large f

number of the discussions ~concerning that requirement,or (2). totally failed to address the. requirement in one or two df the selected LERs. The licensee should review the LER specific comments presented in Appendix 0 in order to determine why he received less than a perfec't score for certain I

reouirements. The text reauirements with a score of less than 75 are discussed below in their order of importance. In addition, the primary deficiencies in the abstract ano coaed fields are discussed.

Discussions were considered inadeauate in two of the three LERs that involved personnel error. Two of these LERs failed to meet Reauirement 50.73(b)(2)(ii)(J)(2)(i) as to whether the personnel error was cognitive or procedural. One LER did not adequately identify the' type of personnel involved, Requirement 50.73(b)(2)(ii)(J)(2)(iv). l I

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TABLE 1.

SUMMARY

OF SCORES FOR FORT ST. VRAIN j

Av'erage High Low Text 8.4 9.6 7.6 6.8 8.3 5.0

. A6stract .

.. Coded Fields 8.8 9.4 7.9 -

Overall 8.0 b 8.9 7.4

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

b. Overall Average = 60% Text Average + 30% Abstract Average + 10% Coded Fields. Average.

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t TABLE 2. LER REQUIREMENT.P'ERCENTAGE SCO'RES FOR'F.0RT ST. VRAIN TEXT Percentage Reauirements (50.73(b)) - Descriptions Scores ( )*

(2)(ii)(A) - - Plant condition prior to event 90(10)

(2)(ii)(B) - - Inoperable equipment that . contributed b (2')(ii)(C) - ' Date(s).and. approximate times 97 (10)

(2)(11)(0) - - Root cause and inte.rmediate cause(s) 96(10)

'(2)(ii)(E) - - Mode, mechanism, and effect 100(4)

(2)(ii)(F) - - Ells Codes 0(10)

(2)(ii)(G) - - Secondary function affected b (2)(ii)(H) - - Estimate of unavailability 75 (4)

(2)(ii)(1) - - Method of discovery 100 (10)

(2)(ii)(J)(1) - Operator actions affecting course 100 (5) '

(2)(ii)(J (2) - Personnel error (procedural deficiency) 71 3)

(2)(ii)(K - - Safety system responses 100 5)

(2)(ii)(L) - - Manufacturer and model no. information Assessment of safety consequences 50 88 (10(4))

( 3) -----

(4) ----- Corrective actions 83 (10)

(5) ----- Previous similar event information 20 (10)'

(2)(i) - - - - Text presentation . 85(10) i ABSTRACT .

Percentage Requirements (50.73(b)(1)] - Descriptions Scores ( )*

- Major occ'urrences (Immediate cause and effect 97(10) information) ,

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- Description of plant, system, component, and/,or 94 (4)  ;

personnel responses l

- Root cause information 73(10)

- Corrective Action information 26 (10) l

- Abstract presentation 66 (10)

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TABLE 2. (c'ontinued)

CODED FIELOS ,

Percentage i Item Number (s) - Description Scores ( )a 1, 2, and 3 - Facility name (unit no.), docket no. and 100 (10) pagenumber(s) -

4 - - - - - - Title .

66 (10) 5, 6, and 7 - Event date, LER No., and report date 99 (l'0) 8 - - - - - - Other f acilities involved , 100 (10)

- 9 and 10 - -' Operating mode and power level 100 (10) 11----- Reporting requirements 85 (10) 12 - - - - - Licensee contact information 100(10) 13 - - - - - Coded component f ailure information 82(10)  ;

1 14 and 15 - - Supplemental report information 90 (10)

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 poi.nts possible was ,adjus,ted 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 no.t possible to determine from the' information available to the ana'lyst whether this requirement is applicable to a. specific LER, It is always given 100%-

if it is provided and is always con'sidered anot applicable" when it is not.

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Tne manufacturer and/or model number'(or other unique identification) was not provided in the text of two of_the four LERs that involved a  ;

component f ailure, Reauirement 50.73(b)(2)(ii)(L). Components that f a'il, {

l' or whose design contributes to the event, should be identified in the text so that others in the industry can be made aware of potential problems. An event at one station can ofte,n lead to the identification of a generic problem'tha't can be i:orrected at'other plants or stations b.efore they experience a similar. prob'lem. (Note:" The analysts realize that this licensee is uniaue in the industry, in terms of reacto.r type; therefore, many of Fort St. Vrain's problems will not be applicable to the light wa,ter reactors. Some of Fort St. Vrain's components and many of its problems'may i be'similar to those at other plants however, and that is why this licensee's LERs were evaluated using the same criteria as all other j licensees.)

i Eight of the 10 LERs reviewed f ailed to mention previous similar l 1

events or state that there were none, Requirement 50.73(b)(5). Previous similar events should be referenced appropriately (LER number if possible),

and if there ar'e none, the text should so state.

None of the LERs included the Energy Industry Jdentification System (Ells) codes. Requirement 50.73(b)(2)(ii)(F) reauires' inclusion of the ,

appropriate EIIS code {or each system and component referred to in the text.

All of ,,the LERs are presented using an outlin,e format which en'hanced the readability of the text. Thebackgroun'dsectionisparticular]y," .

. helpful as it provides detailed information concerning system descriptions and ad.ninistrative practices that are relevant to the event.

Diagrams and figures are used in many of the LERs. This is a good practice and is encouraged whenever appropriate.

The abstracts are deficient in two major areas; namely, the*

sunmarization of cause and corrective action information. Had the cause ano corrective action information, which was presented in the text, been adequately summarized in the abstracts, these areas of the abstract would f

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have received scores that better reflected the text scores. Six LERs' .

f ailed to adequately summarize the cause inf'ormation, and one f ailed .to mention it at All. Four.LERs' f ailed to adeopately summarize the corrective actions, while five LERs did not include any corrective actions in the abstract. These are two of the text discussions that must be summarized in j every abstract in order for the abstract to be considered complete.

The, presentation of the abstract.s is generally poor in.that the , ,  !

. .. abstracts, do not adeouately summaiize the information in the text. Three f abstracts contain information that is not presented in the text discussion. It is good to provide all necessary information, but if this i information is deemed necessary in the abstract, it should always be included in the text. One abstract contains information that contraoicts the text.

The main deficiency in the area of coded fields involves the title, Item (4). Nine of the titles did not indicate root cause, one f ailed to I include the link (i.e., circumstances or conditions which tie the root '

cause to the result), and two f ailed to provide information concerning the result of the event (i.e., why the event was required to be reported).

While result is considered the most important part of the title, cause and link must be . incl'uded to make a title complete'. An example of a title that only addresses the result might be "Reactpr Scram". This is inadecuate in that the cause and link are not provided. I more appropriate title might be " Inadvertent Relay detuation During Surveillance Test LOP 1 Causes Reactor Scram". From.this title, the reader knows' the cause was eithe.r personnel, or procedural and testing contributed to the event.

Table 3 provides a summary of the areas that need improvement for the Fort St. Vrafn LERs. For additional and more specific information. ~

l concerning aeficiencies, the reader 'should 'ref'er to the information 4 presented in Appendices C and D. General guidance concerning these requirements can be found in NUREG-1022, Supplement No. 2.

TABLE'3. AREAS MOST NEEDING IMPROVEMENT FOR FORT ST. VRAIN LERs'

' Areas Comments Personnel error All LERs that involve personnel error should include a discussion as to whether the personnel error was cognitive or procedural and the type of~ personnel involved. ,

' Manufacturer and model numbdr Component identification information information should be included in the text for each component failure or whenever a

, component is suspected of contributing to the event because of I its design.

EIIS codes Codes for each component and system referred to in the text should be provided.

Abstracts Cause and corrective action information was of ten inadequate.

Abstracts should summarize the -

information that is discussed in the text. If it is necessary to include additional information in the ,

abstract, the text should be revised f so as to discuss it.

Coded fields l

a. Titles Titles should be written such that

- they better describe the event. In

- particular, include the root cause of the ev'ent:

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. REFERENCES

1. .B. S. Ander' son, C. F. Miller, B. M. Valen' tine, An Evaluation of Selected Licensee Event Reports Prepared Pursuant to 10 CFR 50.73 10 RAFT), NUREG/CR-4178, March ,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 Analysi.s and Evaluation of. Operational Data, Licensee Event

- Report System, NUREG-1022 Supplement No.1. U.S. Nuclear Regulatory

.comnnssion, February 1984. .

4. Office for Analysis and Evaluation of Operational Data, Licensee Event

. Report System, NUREG-1022 Supplement No. 2, U.S. Nuclear Regulatory Commission, September 1985.

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APPENDIX A LER SAMPLE SELECTION l INFORMATION FOR FORT ST. VRAIN O

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' ' TABLE' A-1.

. ' LER SAMPLE SELECT 10N'FOR F_0RT ST. VRAIN LER Number Comments LER Sample Number 1 85-004-00 ,

2 85-007-00

' ' SCRAM .

3 .85-008.00 .

ESF 4 4- 85.-011-00 .

85-016-00 ESF 5.

85-017-00 ESF 6

7. 85-020-00 i

85-021-01 SCRAM 8

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I APPENDIX B EVALUATION SCORES OF IN0lV10 VAL LERs FOR FORT ST. VRAIN l

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APPENDIX C OEFICIENCY AND OBSERVATION COUNTS FOR FORT ST. VRAIN l

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TABLE C.'l. TEXT DEFICIENCIES AND OBSERVATIONS FOR FORT ST. VRAIN Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals a '

Totals ( )b

.50.73(b')(2)(ii)(A)--Plantope, rating. 1 (10) conditions before the event were not ,

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included or were inadeouate.

50.73(b)(2)(ii)(B) -Discussion of the status 0 (1)

_f o 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 inadeauate.

50.73(b)(2)(ii)(C)--Failure to include 1 (10) suf f icient date and/or time information.

a. Date information was insufficient. 0

b. Time information was insufficient. 1 50.73(b)(2)(ii)(0)--The' root cause and/or 1 (10)

Intermediate tailure, system failure, or personnel error was not included or was inadequate.

a. Cause of component f ailure was not 1 included or was iriadeouate

b. Cause of system f ailure was not 0 included or was inadeouate

c. Cause of personnel error was not 0 '

included or was inadeouate.

. 50.73(b)(2)(ii)(E)--The,failuremode, 0 (4) ,

mechanism (immediate Cause), and/or effect (consecuence) for each failed component was '

not included or was inadequate.

a. . Failure mode was not included or was inadequate

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

c. Effect (consequence) was not included .

or was inadequate.

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TABLE C-1. -(continued)

Number of.LERs with  !

. Deficiencies and 4 s

Observations Sub-paragraph -Paragraph l

D acription of, Deficiencies and Observations Totals . Totals ( )D

' 50.73(b)(2)(ii)(F)_--The Energy Industry 10 (10) 1

- Identification System component function -

identifier for each cmiponent or. system was

• not included. ,

50.73(b)(2)(ii)(G)--For' a f ailure of a 0 (1) <

component with multiple ~ fonctions, a lis+. l of systems or secondary functions which were also affected was not-included or was i nadequate. - i- Il. j 50.73(b)(2)(ii)(H)UFor a f ailure that 1(4) {

rendered a train of a safety system inoperable, the estimate of elapsed time

- from the discovery of the failure until the train was retur.ned to service was not ]

included.

50.73(b)(2)(ii)(I)--The method of discovery 0 (10) of enciccomponent failure, system failure, personnel error, or procedural error was not incluceo or was inadeouate, ,

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a. Method of discovery for each l component f ailure was not included or was inadeouate

b. Method of discovery for each system j

.f ailure was'not included or was

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

• was inadeouate

'd. Method of di'scovery for each ]

procedural error was not included or was inade'ouate.

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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'( )

50.73(b)(2)(ii)(J)(11--Operator actions that 0 (5) l 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)(21--The discussion of 2 (3) each personnel error was not included or was inadequate.  !

a. OBSERVATION: A personnel error was 0 implied by the text, but was not explicitly stated. '

b. 50.73( b )( 2 )( ii )( J )( 2 )( i )--Di scuss ion 2 as to whether the personnel error was cognitive or procedural was not .

included or was inadequate.

c. 50.73(b)(2)(ii)(J)(2)(iil--Discussion 0 as to whether the personnel error was contrary to an approved procedure, was a direct result of an error in an approved procedure, or was associated with an activity or task that was not 1 i

covered by an approved procedure was not included or was inadequate. i

d. 50.73(b)(2)(ii)(J)(2)(till--Discussion 0 {

j of any unusual characteristics of the -

work. location (e.g., heat, noise) that directly contributed to the personnel error was not included or was j inadequate.

e. 50.73(b)(2)(ii)(J)(2)(iv)--Discussion 1 of the type of personnel involved I (i.e., contract'or personnel, utility licensed operator, utility nonlicensed operator, other utility personnel) was not included or was inadequate. ,

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TABLE C-1. (continued).

Nunter of LERs with

- Deficiencies and Observations Sub-paragraph Paragraph:

a Description of Deficiencies and Observations Totals Totals ( )D 50.73(b)(2)(ii)(K)--Automatic and/or manual 0 (5) safety system responses were not . included or were inadequate.

50.73(b)(2)(ii)(L)--The manuf acturer and/or 2(4) moaet numoer of each failed component was not included or was inadequate.

50.73(b)(3)--An assessment of the safety 6(10) consecuences and implications of the event was not included or was-inadequate.

a. OBSERVATION: The availability of I other systems or components capable of mitigating the consecuences of the l event was not discussed. If no other systems or components were available, the text should state that none existed, 3

b. OBSERVATION: The conseauences j of the event had it occurred under i 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 3(10) 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 inaceauate.

4 4 TABLE C-1. (continued) -

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph 0:scription of Deficiencies and Observations Totals a Totals ( )b

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 inadeauate,

b. A discussion of actions required to 3 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 f aulty part in all components with the same manufacturer and model number) was not included or was inadequate.

50.73(b)(5)--Information concerning previous 8(10) similar events was not included or was inadecuate.

TABLE C-1. (continued)

Number of LERs with Deficiencies and Observations _

Sub-paragraph Paragraph Description of Defic.iencies and Observations Totals a Totals ( )D 50.73(b)(2)(1)--Text presentation 2(10) inadequacies.

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

b. Text contained undefined acronyms 2 and/or plant specific designators.

c. The text contains other specific 0 deficiencies relating to the readability. l j

\

a. The "sub-paragraph total" is a tabulation of specific deficiencies or Cbservations 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 1 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 {

numoer of LERs for which the requirement was considered applicable, j I

l l

l l

l I

l l

l

\

• * \

- i I

, -TABLE C'-2'. ABSTRACT DEFICIENCIES AND OBSERVATIONS FOR FORT ST. VRAIN Num6er' of LERs with Deficiencies and Observations Sub-paragraph Paragraph  !

a Description of Deficiencies and Observations Totals Totals ( )D i(10)

..A sumary of occurrences (tmediate cause

'and effect) was not included or was -

inadeouate A sumary of plant, system, and/or personnel 1(4) -

responses'was not included or was inadequate.

a. Sumary of plant responses was not 0 incleded or was inadeauate. (

b. Sumary of system responses was not 1 included or was inadequate.

c. Sumary of personnel responses was not 0 included or was inadequate.

A summary of the root cause of the event 7 (10) e:as not included or was inadequate. ,

A sumary of the correct.ive actions taken or 9.(10)

-l planned as a result of the event was not included or was inadequate. ,

e 4

0 9

0 i

. 4

. i TABLE C-2. (continued).- i Number'of LERs with Deficiencies and  !

Observations Sub-paragraph Paragraph

. D2scription of Deficiencies and Observations Totals a Totals ( )D ,

Abstract. presentation'inadequaci.es _5(10)

, i

a. OBSERVATION: The abstract contains 3 information not included in the text. j. ,f The abstract is intended to be a summary of the text,.therefore, the j '

text should discuss all information summarized in the abstract. I

b. The abstract was greater than 0

'1400 characters

c. The abstract contains undefined 0 a'cronyms and/or plant specific designators, i

d. The abstract contains other specific 4 l deficiencies (i.e., poor i summarization, contradictions, etc.) ,

l

a. The "sub-paragraph total" is a tabulation of specific deficiencies, or

'cbservations within certain reauirements.' Since an LER can have more.than

{

, one deficiency for certain reouirements, (e.g., kn i.ER can be deficient in  !

the area of both date and time information), the sub-paragraph totals do oot necess'arily add up to the paragraph total. .

, b. The " paragraph total" is the number of LERs that h. ave one or more l deficiency or observation. The number in parenthesis is the number of LERs j fcr which a certain requirement was considered applicab.le. ,

l 1

. \

i i

l 1

e b

• 1 l

(

'i

. TABLE C-3. CODED FIELOS DEFICIENCIES AND OBSERVATIONS FOR F.0RT ST. VRAIN ,

Number of LERs with  !

Deficiencies and l Observations Sub-paragraph Paragraph Totals a Description of. Deficiencies and Observations . Totals'-( )b

,0 (10)~

j facilityName

a. Unit number was not included or incorrect.

~

b. Name was not included or was incorrect. ,

f

c. Additional unit numbers were included but not reouired. ,.

Docket' Number was not included or was 0(10) ,

incorrect. ,

1 j

Page Number was not included or was 0 (10) l incorrect. )

Title was lef t blank or was inadequate 10(10) ,

a. Root cause"was not given in title 9 i

b. Result (effect) was' not giv.en in title- 2 '

c. -Link was not given in title I Event Date -

0 (10) -

Date not included or was inc'orrect.

a.

b. Di'scovery date given instead of event  ;

date. .

LER Number was not included pr was incorrect ,- ,

0.(10) ,

Report Date' - 0(10)

a. Date not included

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

Other f acilities information in field is 0 (10) inconsistent with text and/or abstract. .

Operating Mode was not included or was 0(10) inconsistent with text or abstract.

l l

l

TABLE C-3. (continued) i Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph l

' Totals (

Description of Deficiencies and Observations Tota ~1s ' -) l Power level was not included or was

• 0 (10) inconsistent with text or' abstract .

Reporting Requirements 3 (10)

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 1 appropriate to report the event under a different paragraph. l j

c. OBSERVATION: It may have been 2 appropriate to report this event under an additional unchecked paragraph.  ;

i I

Licensee Contact .

0 (10) 1

a. Field left blank .

. b. Position title was not included '

c. Name was not included ,

d. Phone number was not included.. -

Coded C. o mponent f ailure Information - 4 (10) l

)

a. One or more component failure 0

. sub-fields were left blank.

b. Cause, system, and/or component code 1 ,

is inconsistent with text.

c. Component failure field contains data 2 when no component failure occurred. *

,d . Component failure occurred but entire 1 i

- field left blank.

O l

l I

e

' l\

.TABLE C-3. (continued)

Ii l

I Number of LERS with Deficiencies and Sub-paragraph Observations Paragraph ll l

']j a

Description of Deficienc'ies and Observation.s Totals Totals ( )D-

' Supplemental Report 1(10.) .

'I

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

b. The block checked was inconsistent I with the text. . l I

Expected submission date information is 0(10) i inconsistent with the block checked in {'

Item (14).

a. The "sub-paragraph total" is a tabulation of specific deficiencies or i observations within certain requirements. Since an LER can have more than -

one deficiency for certain reauirem.ents the area of both date and time information(e.g., an LER cantotals

), the sub-paragraph be deficient do in not necessarily add up to the' paragraph total.

. b. . The " paragraph total" is the number of LERs that have one or more reoutrement deficiencies or observations. The number in parenthesis is the number of LERs for which a certain reQui.rement was considered applicable.

]

9 S

5 8 0

S a 8

• 6 e

s 9'

e I

s t

e 0

e APPENDIX 0 I e

LER COMMENT SHEETS FOR FORT ST. VRAIN O

g. -

e 6

4 9

4 e

b e

4 e

l l

1 l

1 1

l l

i I

l l<

I

. l TABLE D-1. SPECIFIC LER' COMMENTS FOR FORT ST. VRAIN (267)

Section Coments

1. LER Number: 85-004-00 Abstract = 5.0 Coded Fields = 9.1 Overall = 7.7 Scores: Text = 8.8 Text .

'l . 50.73(b)(2)(ii)( A)--Discussion of plant opera' ting 4

]

1 conditions Detor.e the event is not included. .

2. 50.73(b)(2)(ii)(F)--The Energy Industry Identification System component function identifier (s) ano/or system name of each component or system referred to in the LER is not included.

3. 50.73(b)(2)(ii)(L)_--It would be desirable to identify the valve (manuf acturer and model number) although it did not actually. fail. This could aid other plants

- in determining whether they use this type valve in a similar situation and, therefore, need to also install a strainer.

4. 50.73(b)(3)--0BSERVATION: The consecuences of the event had it occurred under more severe conditions snould be discussed. 'If the event occurred under what are considered the most severe conditions, the j text should so state.

s

5. 50.73(b)(5)--Information co'ncerning previous similar

' events is not , included.- If no. previous similar' events are known, the text should so state. ,

1 50.73(b)(1)--Sumary of root cause is inadequate. i Abstract 1. j Tne valve did not actually f ail, the leakage was I caused by sedi. ment pr.eventing it from closing.- This

. Should be Mentioned in the abstract.

2. 50.73(o)(1)--Sumary of corrective actions taken or plannea as a result of the event is not included.

3. Abstract does not adequately sumarize the text. Use the abstract space to discuss items mentioned in abstract coments I and 2, and to give a brief overview of the event.

l l

l

TABLE D-1. SPECIFIC LER COMMENTS FOR FORT'ST. VRAIN'(267), .

Comments Section _

1. LER Number: 85-004-00(continued)

'l Coded Fields 1. ,

ltem(4)--Title: Root cause is not included. .

2. Item'(7)--Themonthcppearsto,beatypogra'ph'icai error.

4 4

6 4

9 e

o D-9 9

9 4

e 6

• 6 9

e 9

l i

TABLE D-1. S'PECIFIC LER COMMENTS FOR FORT ST. VRAIN (267) {

I I

Section Comments l

2. LER Number: 85-007-00 Scores: Text = 9.6 Abstract - 7.5 Coded Fields 8.9 Overa11'= 8.9

~

Text- -

1. 50.73(b)(2)(ii)(F)--The Energy' Industry . ,

Identification System component function- .

identifier (s) and/or' system narne of each component or system referred to in the LER is not included.

2. Acronym (s) and/or plant specific designator (s) are undefined. PCRV should have been identified on its initial use in the text, as it is in the abstract.

3. It appears that the corrective acti:n5 discussed should prevent recurrence of this event. If additional corrective actions are found to be  !

necessary as a result of the continuing investigation, a supplemental report would be ,

approprlate.

4. The outline format and figures were very beneficial i' to the reader in understanding this event.

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 nbl' included.

2. Undefined acronyms should not be used in the title.

(PCRV).

3. Item (131--Cause Tystem, and/or component code is ,

inconsistent w'ith text. The text does not indicate ~

that a moisture indicator (EIIS MI) fiiled'. .

l O

> j TA8tl D-1. . SPECIFIC LER COMMENTS FOR FORT ST. VRAIN (267) ,

Section -

Comments

3. -LER Number: 85-008-00 l Overall - 7.7 Scores: Text, 8.4 Abstract - 6.1 Coded fields = 8.5

^~'

Text 1. .50.73('b)(2)(ti)(C)--Time information for occurrences

- is inadequate. At what time did the Channel I .

. indication return to norinal af ter the connector was '

cleaned? figure 3 doesn't have a' time reference but if the trace shown after the approximate time of scram is the result of-cleaning the connector (i.e.,

it is a normal trace), it appears that there was some  !

indication of a proble'm with this channel prior to the scram.

2. 50.73(b)(2)(ii)(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)(11)(H)--A time estimate of the unavailability of the failed system is not included.

4. 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. It appears that the

. design of the connector contributed to the event; '

therefore, it should be identified. .

5. 50.73(b)(31--What is the "res'ponse shutdown material" and how fast could it have been inserted if necessary? l

. . 6. 50.73(b)(Sl--Information concerning previous similar events is not included. If no previous's.imilar .

events are known, the text sho.uld so state. ,-

~

7. The use,of figures is good.

Abstract 1. 50.73(b)(1)--Summary of root cause is not included.

2. 50.73(b)(1)--Summary of corrective actions taken.or  !

planned as a result of the event is not included.

3. 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.

1

• e i

TABLE 0-1. SPECIFIC LER COMMENTS FOR FORT ST.'VRAIN (267)

Section .Consnent s

3. LER Number: 85-008-00 (continued) l l

4. The information provided in the second and third paragraphs of the abstract is not a requirement;

- 'however, .information concerning cause and correc,tive action should always be provided in the abstract:

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

2. Item (13)--Component failure occurred but ' entire field is blank.

l 9

i

. 1 l

3 l

l 1

. j i

f i

l TABLE 0-1. SPECIFIC L1:R COMMENTS FOR FORT ST. VRAIN (267)

. 1 Section Comments

4. LER Number: 85-011-00 Scores: Text = 9.0 Abstract = 7.2 Coded Fields = 8.6 Overall = 8.4 i Text 1. 50.73(b)(2)(ii)(F)--The Energy Industry Identification System Component function .

identifier (s) and/or system name (if each component or.

system referred to in the LER is not included.

2. 50.73(b)(3)--0BSERVATION: The consequences of the event had it occurred under more severe conditions ,

should be discussed,. If the event occurred under l what are considered the most severe conditions , the text should so state.

3. 50.73(b)(5)--Information concerning previous similar events is not included. If no previous similar  !

events are known, the text should so state. j l

4. Use of a diagram is good. l Abstract ' l. 50.73(b)(1)--Summary of root cause is inadeauate.

The proceaural deficiency should be mentioned.

2. 50.'73(b)(1)--Summary of corrective actions taken or

. planned as a result of the event is inadequate.

Menti'on change to pro ~cedure and retraining o.f personn'el.

Coded Fields 1. Item (4)--Title: Root cause is not included. j It appears it would have .

2. Item (ll)--0BSERVATION:

been appropriate to also report this event unde'r -

paragraph (s) 50.73(a)(2)(iv). .

3. Item (13)--Component f ailure field contains data when n.o component . failure occurred. The cause field contains two codes, only the more appropriate code (in this case probably "D") should be used. ,

I l

l

. 1

~

i TABLE 0-1. SPECIFIC'LER COMMENTS FOR FORT ST. VRAIN -(267). ,

i Section Comments  !

~5. LER Number: 85-016-00 Scores: ' Text = 8.1 Abstract = 6.3 Coded Fields = 9.2 Overall = 7.6 Text *

1. 50.73(b)(2)(ii)(F)--The Energy Industry ,

Identification System component function identifier (s) and/or system name of each component or '.

system referred to in the LER is not included. ,

2. 50.73(b)(4)--Discussion of corrective actions taken or pianneo 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 is inadeauate.

wny ata water enter the mid-buffer sensing line?

2. 50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is not included.  !

Item (4)--Title: Root cause is not included.

Coded Fields 1.

o 8

• e a 9 6

D

. TABLE D-1.. SPECIFIC LER COMMENTS FOR FORT ST. VRAINI(267)

! l Section Coments

! 6. LER Number: 85-017-00 )

l Scores: . Text = 8.8 Abstract = 8.3 Coded Fields = 9.4 Overall = 8.7 i

Text 1. 50.73(b)(2)(ii)(F)_--The Energy Industry .

Identification System component function identifier (s) and/or system n'ame of each component or

" system referred to in the LER is not included. j I

2. 50.73(b)(2)(ii)(J)(2)_--Discussionofpersonnelerror is.inaaeauate. wny aid the Shif t Supervisor misinterpret the reportability requirements of 10 CFR 50.727 50.73(b)(2)(ii)(J)(2)(iv)--Discussionofth'e-typeof  !

personnel involved (i.e., contractor personnel, j

utility licensed operator, utility nonlicensed operator, other utility personnel) is inadeauate.

What is a "Results Technician"? ,

3. 50.73(b)(4)--Discussion of corrective actions taken or planned is inadeauate. Are there other Result Technicians who might be assigned to perform this same surveillance and, if so, should they' be made- -

aware of this event? ,

4. 50.73(b)(5)--Information concerning prev,ious similar events is not included. If no previous similar events are known, the text should so state.

Abstract 1. - 50.73('b)(1)--Summary of component response is anaaeouate. Tell the readec that no control rod movement resulted but the brake power was deenergized.

2. 50.73(b)(1)--Summary of root,cause is,. inadequate.

Tell the reader that the event resulted because the technician f ailed to perform the final step of a,. '

procedure (i.e.,cognitiveerror)

Additional space is available in the abstract field 3.

to provide more information but it was not utilized.

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

2. Item (13)--Component f ailure field contains data when no component failure occurred.

l .- . , , ,

TABLE ' 0-1. SPECIFIC LER COMMENTS FOR f0RT ST. V' RAIN (267) .

Section Comments

7. LER Number: 85-020-00 Scores: Text = 7.6 Abstract = 6.7 Coded Fields = 7.9 Overall = 7.4  !

Text 1. 50.73(b)(2)(ii)(0)--Why was the reference leg of the '

outside auxiliary boiler empty?

1

2. 50.73(b)(2)(ii)(F)_--The Energy Industry  !

Identification System component function - l identifier (s) and/or system name of each component or system referred to in the LER is not included.

3, 50.73(b)(31--0BSERVATION: The consequences.of the event had it occurred under more severe conditions should be discussed. If the event occurred under what are considered the most severe conditions, the text should so state.

4. 50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. A discussion of actions i required to reduce the probability of recurrence (i.e, correction'of the root cause) is not included or is inadequate. Without knowing the root cause (see text comment 1), the proper preventative actions cannot be taken. 4

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

Abstract 1. 50.73(b)(1)--Summary of root cause is inadequate.

Mention the oil in the purge line and.the empty ,

reference leg. ,

2. 50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate.

Mention moisture trap and filling of reference leg.

Coded Fields 1. Item (4)--Title: Link and root cause are not included.

2. Item (ll)--0BSERVATION: It appears it would have been more appropriate to report this event'under paragraph (s) 50.36(c)(2) and 50.73(a)(2)(iv).

l l

)

l

}

TABLE 0-1. SPECIFIC LER COMMENTS FOR FORT ST. VRAIN (267)

Section Comments

8. LER Number: 85-021-00 Scores: Text 8.1 Abstract = 8.1 Coded fields = 9.4 Overall = 8.2

/

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)--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)(ii)(L)--Identification (e.g. manufacturer and model no.) of the failed component (s) discussed-in the text is not included.

4. 50.73(b)(3)--Discussion of the assessment of the safety consequences and implications of the event is inadequate. The analysis in Table 1 for Items- 7, 9, and 10 states that failure of these valves upon a' required loop shutdown could prevent automatic isolation functions. What would be the consequences if this were to occur?

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

Abstract 1. 50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadequate. A  ;

statement that these deficiencies are being evaluated should be included.

Coded fields 1. Item (4)--Title: Result is not included. The type I

of equipment that was deficient should be identified l j

(i.e., safe shutdown equipment).

f l

TABLE 0-1. SPECIFIC LER COMMENTS FOR FORT ST. VRAIN (267)

Section Comments i

9. LER Number: 85-024-00 Scores: Text 8.2 Abstract - 6.7 Coded fields 9.0 Overall - 7.8 Text 1. 50.73(b)(2)(ii)(F)--The Energy Industry Identification System component function identifier (s) and/or system name of each component or '

system referred to in the LER is not included.

2. 50.73(b)(2)(ii)(J)(2)--Discussion of personnel error is inadequate. Was HS-1221 left in the wrong position following the maintenance work performed earlier in the week because a procedure was not followed, or was there even a procedure involved with this maintenance work? See second paragraph of "CAUSE".

3. 50.73(b)(3)--Discussion of the assessment of the  !

safety consequences and implications of the event is inadequate. Is there an undesirable consequence from l inserting the rods out of sequence? The fact that the operators verified the sequence prior to l inserting the rods implies there is.

4. 50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. Should there be a  !

procedural change to ensure the switch (HS-1221) is J placed back in the Off position to11owing testing?

See comment num' o er 2.

5. 50.73(b)(5)--Inf ormation concerning previous similar events is not Weluded. If no previous similar events are know, the text should so state.

Abstract 1. 50.73(b)(11--Summary of occurrences [immediate I cause(s) and ef fects(s)] is inadequate. The abstract j should indicate why the operators felt justified to l insert the rods while receiving alarms. l l

2. 50.73(b)(1)--Summary of root cause is inadequate. l The reason that HS-1221 was believed to be in the wrong position should be provided. l i

3. 50.73(b)(11--Summary of corrective actions taken or i i

planned as a result of the event is inadequate.

Those actions taken to prevent possible recurrence l are not provided.

l l _

1 TABLE 0-1. SPECIFIC LER COMMENTS FOR FORT ST. VRAIN (267) l I

Section Comments

9. LER Number: 85-024-00(continued) i

4. OBSERVATION: The abstract contains information not included in the text. The abstract is intended to be a summary of the text; therefore, the text should ,

discuss all information summarized in the abstract. i

5. The last paragraph of the abstract should be in the text so that there is room for the information needed in the abstract.

Coded Fields 1. Item (4)--Title: Root cause and result are not included.

2. Item (ll)--0BSERVATION: It appears it would have been appropriate to also report this event under paragraph (s)"0THER".

1 i

~ ~ - ~ ~ " - - - - - - - ~ _ - _ _ - _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - - - - _ _ _ _ _ . _ _ _ _ _ , _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3 e

T ABLE 0-1. SPECIFIC LER COMMENTS FOR FORT ST. VRAIN (267)

Section Coments i

i

10. LER Number: 85-025 00 Scores: Text = 8.0 Abstract = 6.3 Coded Fielos = 7.9 Overall = 7.4 l

1. -The Energy Industry Text 50.73(o)(2)(11)(FJ_

Identit1 cation dys tem component function l

identifier (s) and/or system name of each component or ,

system referred to in the LER is not included.

I

2. A supplemental re ort ap ears to be needed to l describe N esults of the inspection and j1 evaluations. Without a comitment to submit a I supplemental report, this LER must be considered  !,

incomplete.

3. 50.73(b)(5)--Information concerning previous similar  ;

events is not included. If no previous similar j_l events are known, the text should so state,

4. Acronym (s) and/or plant specific designator (s) are ,

undefined.

Abstract 1. 50.73(b)(1)--Sumary of corrective actions taken or planned as a result of the event is not included.

2. OBSERVATION: The abstract contains information not  !

included in the text. The abstract is intended to be a sumary of the text; therefore, the text should discuss all information sumarized in the abstract.

3. Abstract contradicts the text. The text indicates that the RWP is part of the PPS.

Coded Fields 1. Item (4)--Title: Root cause (plant equipment electrical noise) is not included. It is best not to use acronyms in a title.

2. Item (14)--The block checked is inconsistent with MrmTETon in the text (see text comment 2).

l

.