IR 05000206/1986010

SALP Repts 50-206/86-10,50-361/86-09 & 50-362/86-09 for Oct 1984 - May 1986.AEOD Input Encl

ML20203L084
Person / Time
Site:	San Onofre
Issue date:	08/07/1986
From:	NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
To:
Shared Package
ML20203L077	List: IR 05000206/1986010 ML20203L074
References
50-206-86-10, 50-361-86-09, 50-361-86-9, 50-362-86-09, 50-362-86-9, NUDOCS 8608220380
Download: ML20203L084 (108)

Text

,_

-

%

,.,

Y i-

_

s

SALP. BOARD REPORT r,

, - U.S.: NUCLEAR REGULATORY COMMISSION

REGION V

SYSTEMATIC ASSESSMENT OF LICENSEE PERFORMANC '

50-206/86-10 50-361/86-09, -

50-362/86-09 SOUTHERN CALIFORNIA EDIS0N COMPANY SAN ONOFRE NUCLEAR GENRATING STATION UNITS 1, 2 AND 3 OCTOBER 1, 1984 THROUGH MAY 31, 1986-86082203eo e60ao7 PDR ADOCK 05000206 G PDR ,

s

. ' SUMMARY -' UNIT 1 Inspections Conducted * Enforcement Items **

Functional Inspection Percent Severity Level Area Hours of Effort I II III IV V Plant Operations 2575 48%

' Radiological 337 6%

Controls , Maintenance 356 >

101 2 2

. , Surveillance 364 7% 1 2 Fire Protection 33 1% Emergency Pre % 1 1- Security 64 1%; 1 Outage 906 17% Quality Programs / 301 6% 6 Administrative Licensing Activities - - Training /Qualifi- 75 1%

cation Effectiveness

_ _ _ _ _

Totals 5200 100% 2 11 3***

• Includes Inspection Report Nos. 84-24 through 86-22, 86-24, 86-25, and 86-2 ** Severity levels are discussed in 10 CFR 2, Appendix No deviations were identified during this SALP perio *** Violations and the units to which they apply are_ listed in Table Since some violations apply to more than one unit, the total of Tables 1A, IB, and 1C will exceed the number of violations listed in Table ,

L

, . .r:. . _ , - - . - - - - . , , _ , ,, -m- .

,,m , ..y.-,---wr,--w ,t- ,- ,_ , , - - ,

_ - - - - . - . -

.

, 40

-

.

s TABLE IB INSPECTION ACTIVITIES AND ENFORCEMENT SUMMARY - UNIT 2 Inspections Conducted * Enforcement Items **

Functional- Inspection Percent Severity Level Area Hours of Effort I II III IV V Plant Operations 1486 44% Radiological 247 8 Controls Maintenance 419 12% 1 Surveillance 333 10% 2 1 Fire Protection 43 1% 1 Emergency Pre % 1 1 Security 90 3% 1- Outages 289 8% Quality Programs / 239 7% 5 Administrative Licensing Activities - -

1K . Training /Qualifica- 90 3%

tion Effectiveness

_ _ _ _ _

Totals 3359 100% 11 2***

4 *

Includes Inspection Report Nos. 84-27 through 86-14 and 86-16 through 86-1 ** Severity levels are discussed in 10 CFR 2, ' Appendix No deviations were identified during this SALP perio ***' Violations and the units to which'they' apply are: listed in Table Since some violations apply to more than pne unit, the total of. Tables 1A, 1B, and 1C will exceed the. number of violations listed in Table _

e m--

9 - % - -- ,-%w-

- r - -

.gf y a p -W c -.w r q m -

. - . - _

.. .

4 I

.

, 41 TABLE IC INSPECTION ACTIVITIES AND ENFORCEMENT SUMMARY - UNIT 3 Inspections Conducted * Enforcement Items **

Functional Inspection Percent Severity Level Area Hours of Effort .I II III IV V Plant operations 1220 43% 1 Radiological 286 10%

Controls Maintenance 224 8% Surveillance 365 13% Fire Protection 27 1% 1 Emergency Pre % 1 1

. Security 49 2% Outages- 246 9% Quality Programs / 187 7% 6 Administrative Licensing Activities - - Training /Qualifica- 80 3%

tion Effectiveness

_. _ _ _

Totals 2796 100% 9 1***

,

-* Includes Inspection Report Nos. 84-28 through 86-14 and 86-16 through 86-1 ** Severity levels are discussed in 10 CFR 2, Appendix No deviations were identified during this SALP perio *** Violations and the units to which they apply are listed in Table Since some violations apply to more than one unit, the total of Tables IA, IB, and 1C will exceed the number of violations listed in Table 2.

,

-._ _ _ , . , , - . . . . - . , ,- . . - . _,.,y , , _ .

~_,.,31--r rr -r-

'

r . ,

'

. . l

,~

,' 42 Table 2' '

ENFORCEMENT ITEMS Inspection Applicable Severity Functional Report No.* Subject Unit (s) Level Area

'

206/84-28 Moisture seals were not IV I installed in the conduit / cable runs'at the solenoids for the reactor head and pressurizer valve /84-34 Three primary and six alternate 1,263 IV F individuals who occupy supervisory positions in the emergency response organization had not received all of the required annual retrainin /84-34 Nonessential personnel were not 1,2&3 V F reinstructed on the location of their new assembly area when the

_previously designated assembly area became unavailabl /85-06 Two intrusion alarms at Unit 1 1 IV G were not being tested at least once every seven day /85-09 Both doors of the personal escape 1 III C airlock were open simulataneousl /85-09 The functional acceptability of 1 IV C the interlock of the Unit 1 containment personnel escape airlock was not verified following maintenanc /85-12 The accessible AFW discharge 2 IV D piping high point vents were not vented during the months of November and December of 1984 and January 198 /85-12 A trip test of the steam driven '2 V D auxiliary feedwater pump was not conducted during the months of November and December of 1984 and January 198 /85-12 Eighteen month surveillance to 2 IV- D verify battery capacity was not; accomplished on two batterie .

5

~

'

y i

^

N

_ . _ _ . _ _ _ . _ _ , _ .--

_ _ . _ , _ . - _

_ _ _ _ _ _ _ _ . . _ _ _ . _ _ _ - - . . .

_

.

, ..

g.

. , , 43

. .

,

/

. ,

,

Inspection _ ' Applicable Severity Functional Report No.* Subject . Unit (s) Level Area 206/85-13 Lower strength stainless steel- -I

-

IV C studs replaced carbon steel body to bonnet stude without design reconciliation to determine if the new material would be satisfactory for servic /85-20 During a surveillance test, 1 IV D operations personnel did not perform independent verification that a valve was locked open prior to shutting the valv /85-26 The licensee IST program records 1 V D and station engineering files did not have available a complete summary of corrective actions take /85-26 Two Construction Safety 3 IV I Evaluations (CSE) did not document the bases for concluding that thechanges did not involve an unreviewed safety questio /85-30 Five separate violations dealing 1,2&3 IV I with inadequate records to -(5 Items)

demonstrate proper environmental qualification of equipmen /85-33 Foreign material was 1 III C introduced in the Unit 1 turbine-driven auxiliary feedwater pump oil sightglass; was not identified as a significant condition adverse to qualit /85-37 During setpoint testing of the 1 V D ten Unit 1 main steam safety valves, the as-found setpoint-pressure was not documented for six out of the ten valve /86-03 Inadequate security lighting in 2 IV G protected are /86-08 Failure to meet housekeeping 2,3 IV E and fire protection requirement /86-11 Improper installation of 2 IV C temporary reactor vessel level indicato ... - . .- - - , , . - . - . - . , , - . . - . . . , ,, .. - ,.-, - . ..

,

.

'

.

Inspection Applicable Severity Functional Report No.* Subject Unit (s) Level Area 362/86-11 Inadequate operator attention 3 IV -A to procedures and indications during reactor startup (involving early criticality and resulting

. reactor trip).

NOTE: Three apparent violations were identifed in 206/86-07. Enforcement Action is pendin Three apparent violations were identified in 206/86-17. Enforcement action is pendin * When the violation is applicable to more than one unit, the report number for the lowest docket number is indicate .'

-

a

..y -- . ,e. ,. - -

~ -

r -

-m .

, .. . - . . _ . _ _ .

4 'f.'

-

.. '

l; *' 45 TABLE 3A - UNIT 1 SYNOPSIS OF LICENSEE EVENT REPORTS-(LER's)-

Functional SALP Cause Code +

l ' Area A C D- E X * Totals A.. -Plant Op = Rad. Controls 5 1 1: 7 Maintenanc '1 Surveillance 2 , Fire Protection 1 1 i Emergency Preparedness O Security- 0

, Outages 0

' Quality / Admin 1 1 Licensing 0 Training / Qua Effectiveness-

'~

Totals 10 5 0' 5 8 0 '1' 29

+ '

. A - Personnel Error l-B - Design, Manufacturing or Installation Error C - External Cause ,

D - Defective Procedures E - Component Failure ,

,

X - Other

'

• - Cause not yet determined i The above data are based upon the LER's-84-08 and 84-10 through-86-0 '

s

'

>

b a

f

. _ ,. - , - - - ._. . - _ - , _ . . - , _ . - . _ . - - - - -- . - - - - - - - -- - - - , .--.- .- - - - ------ -

- . . -

t j

. 46 .

TABLE 3B - UNIT 2 SYNOPSIS OF LICENSEE EVENT REPORTS-(LER's)

J

~

,

Functional SALP Cause Code +

Area A B C D E X,- * Totals

, Plant Op '2 ' 60'

B.- Rad. Controls 3 3 1 .2 9

- Maintenance- 5 1 1 1 8 Surveillance 8 1 3 3 -15

'

, Fire Protection 3 l' 4

.

. Emergency Preparedness 0 Security 1 1 H.- Outages "2 2 I

, Quality / Admi O Licensing 1 1 Training / Qua .

.-- 0

'

Effectiveness -

<

Totals 24 . 36- 0 12 ,25 , 0 '3 100

' '

A - Personnel Error i B - Design, Manufacturing or Installation: Error C - External Cause i D - Defective Procedures '

E - Component Failure X - Other .

• - Cause not yet determined The above data are based upon LER's 84-49 through 86-0 ;

i

d

-#-.7 yg -

%,, .-.4w-~. w. * , ._ -

.+-g~m_ y -.g--g ,y,m- y .

-.% p gwp -g,pg,. ,,w,-w.9-.-----,-.g - e,.,--- t-* 9u

-

- _ ,.

.-

. -

7,, '

. . , 's *

',.. '

_

'

. . .; , ,~

'**

..

. ,,

'

473' .

',

.

i TABLE 3C - UNIT 3

, 1 t t SYNOPSIS OF LICENSEE EVENT REPORTS (LER's)

Functiona SALP Cause Code +

Area A_ B_ - C, D, E_ X_ ._

.

• Totals A .' Plant Op Rad. Controls - 1- 1 2' Maintenance 1 1 1 3 Surveillance 8 l' 1 10 E .' Fire Protection 1- 1 ~ Emergency Preparedness

.

0 Security 0 Outages 1 1- 2 Quality / Admin 0-

^ . Licensing 0

..

K .' Training / Qua Effectiveness Totals 17 10 0 2 22 1 1 53

.

+

A - Personnel Error B - Design, Manufacturing or Installation Error C - External Cause D - Defective Procedures E - Component Failure X -- Other

• - Cause not yet determined

.The above data are based upon LER's 84-35 through 86-0 .

~

'k , * * x . 4

.s ,s . , . . -

.

5

.

' ,

t AE00 INPUT TO SALP REVIEW FOR SAN ON0FRE 1, 2 AND 3 Introduction In order to evaluate the overall quality of tne contents of the Licensee Event Reports (LERs) submitted by San Onofre 1, 2 and 3 during the October 1, 1984 to March 31, 1986 Systematic Assessment of Licensee Performance (SALP) assessment period, a representative sample of each unit's LERs was evaluated using a refinement of the basic methodology presented in NUREG/CR-4178.1 The sample consists of a total of 30 LERs for the station (i.e., 5 LERs for San Onofre 1,17 for San Onofre 2, and 8 for San Onofre 3). Thirty is considered to be the maximum number of LERs required to be evaluated for each station during an assessment period. San Onofre LERs were evaluated as one sample because it was determined that their LERs are both written and formally reviewed at the station, rather than unit, level. See Appendix A for a list of the LER numbers in the sampl 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 j of the SALP period. Therefore, not all of the LERs prepared during the SALP assessment period were available for revie Methodology The evaluation consists of a detailed review of each selected LER to determine how well the contenc of its text, abstract, and coded fields meet the reauirements of NUREG-1022 2

, and Supplements3 1 and 42 to NUREG-102 The evaluation prcress for each LER is divided into two parts. The first part of the evaluation consists of documenting comments specific to the content and presentation of each LER. The second part consists of determining a score (0-10 points) for the text, abstract, and coded fields

' of each LER.

l l

l

.__ ._ . _ _ _ ___ . _ . _ _ , __ _

.

p c .

, ',

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, ano (2) they provice 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 tne information that was presented, and (2) they provide a basis for the overall score determined 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 ouality evaluation are divided into two categories: (1) detailed information and (2) summary information. The detailed, information, presented in Appendices A through D, consists of LER sample information (Appendix A), a table of the scores for each sample LER ( Appendix B), tables of the number of deficiencies and nbservations for the text, abstract and coded fields (Appendix C), and comment sheets containing narrative statements concerning the Contents of each LER ( Appendix D).

When referring to these appendices, the reader is cautioned not to try to directly correl. ate 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 score Although the purpose of this evaluation was to assess the content of the individual LERs selected for review, the analysts of ten make other observations which they believe should be brought to the attention of the licensee. The following discussion addresses a general observation that was noted during the evaluatio General Observation During the sample selection process, it was notea that 66 of 148 LERs on file for SALP period October 1, 1984 through March 31, 1986, were submitted without a text. Submittal of an LER without a text is

-

o

• . acceptable, however the abstract must then meet all of the requirements of a text and still be less than 1400 character Generally, only a simple event can be presented in the limited abstract field and still meet all the reauirements for a text. The twelve LERs in the audit sample submitted without a text had an average text score of only 7.6, while the 18 LERs in the audit sample submitted with a text had an average text score of The overall average was good compared to other units, but it might have been even higher had more LERs been submitted with a tex Discussion of Results

.

A discussion of the analysts' conclusions concerning LER auality is presented below. These conclusions are based solely on the results of the evaluation of the contents of the LERs selected for review and as such represent the analysts' assessment of the stations performance (on a scale of 0 to 10) in submitting LERs that meet the reouirements of 10 CFR 50.73(b). San Onofre 1, 2 and 3 LERs were evaluated as one sample, rather than three separate samples, because it was determined that the San Onofre LERs are,both written and formally reviewed at the station, rather y than the unit, leve Table 1 presents the average scores for the sample of LERs evaluated for San Onofre 1, 2 and 3. 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. In order to place the scores provided in Table 1 in perspective, the scores from other licensees that have been evaluated using the current methodology are provioed in Table 2. Additional licensees are added to Table 2 as they are evaluated. Table 3 and Appendix Table B-1 provide a summary of the information that is the basis for the average scores in Table 1. For example, San Onofre's average score for the text of the LERs that were evaluated was 8.1 out of a possible 10 points. From Table 3 it can be seen that the text score actually results from the review

~ and evaluation of 17 different requirements ranging from the discussion of

- _ ._, . _ _. _ . _ _ _ . _ - .

,

• .

. .

a TABLE SUMMARY OF SCORES FOR SAN ON0FRE 1, 2, 3 Average High Low Text .5 Abstract .9 Coded Fields .0 Overall 8.5 b 9,4 7,) See Appendix B for a summary of scores for each LER that was evaluate Overall Average = 60% Text Average + 30% Abstract Average + 10% Coded Fields Averag .

O

'

s e

.

- .,-.,-,--m - - - -----.--w - -

.-- - - - - - . - - -

-,-.,m

- - - - - --

/. ,

.

"A3:.;E 2: AVE 3AG3 SCO33 C O k P A R :: S O X

'

-

~ .

'

g_  :

.  :

B- -

I v2

H '7- 7 7

'

/ /

6- / / -

%

/

'

/ /

% . / / /

,

O' 5- 7 / / r /

g / / / / /

rol 4_ So~ O~oco.t 2 + 3 / / / / /

tQ / / / / /

N / / / / /

U 3- r / / / / /

/ / / / / / /

g_ / / / / / / /

, / / / / / / / / /

. . / / / / / / / / /

1- re / r / / / e / / r / r / r / e r

/ / / // / / / / / / / / / / / / /

/ / / // / / / / / / / / / // / / -

i i. i i i i i i i i i i i i i i i i i iiiiiiiiiiiiiiiii .0 B.5,, .5 .5 GRADE .

.

O o

.

TABLE LER REQUIREMENT PERCENTAGE SCORES FOR SAN ON0FRE 1, 2, 3

-

TEXT Percentage Reauirements [50.73(b)] - Descriptions Scores ( )'

(2)(ii)(A) - - Plant condition prior to event 77 (30)

(2)(ii)(B) - - Inoperable eauipment that contributed b (2)(ii)(C) - - Date(s) and approximate times 92 (30)

(2)(ii)(D) - - Root cause and intermediate cause(s) 92(30)

(2)(ii)(E) - - Mode, mechanism, and effect 100 (11)

(2)(ii)(F) - - EIIS Codes 98 (30)

(2)(ii)(G) - - Secondary function affected b (2)(ii)(H) - - Estimate of unavailability 93 (7)

(2)(ii)(I) - - Method of discovery 95 (30)

(2)(ii)(J)(1) - Operator actions affecting course (2)(ii)(J)(2) - Personnel error (procedural deficiency) 100(4))

90 (12 (2)(ii)(K) - - Safety system responses 81 (18)

'

(2)(ii)(L) - - Manufacturer and model no information 11 (11)

(3) ,---- Assessment of safety conseauences 84(30)

(4) -----

Corrective actions 87 (30)

(5) -----

Previous similar event information 22(30)

(2)(i) - - - - Text presentation 74 (30)

.

j ABSTRACT Percentage Reauirements [50.73(b)(1)] - Descriptions Scores ( )a

- Major occurrences (Immediate cause and effect 100 (30)

information)

- Description of plant, system, component, and/or 97 (15)

personnel responses

- Root cause information 92 (30)

- Corrective Action information 90 (30)

- Abstract presentation 80(30)

-

--r F ee W9-4Ti -

- -' m- - -

.

,

' .

TABLE (continued)

CODED FIELDS Percentage Item Number (s) - Description Scores ( )a 1, 2, and 3 - Facility name (unit no.), docket no. and 100(30)

page number (s)

4 - - - - - - Title 64(30)

5, 6, and 7 - Event date, LER No., and report date 99 (30)

8 - - - - - - Other f acilities involved 97 (30)

9 and 10 - - Operating mode and power level 100 (30)

11----- Reporting reauirements 98(30)

12 - - - - - Licensee contact information 100(30)

13 - - "- - Coded component failure information 96 (30)

14 and -15 - - Supplemental report information 97 (30) Percentage scores are the result of dividing the total points for a reouirement by the number of points possible for that reauiremen (Note: Some reouirements are not applicable to all LERs, therefore, the number of points possible was adjusted accordingly.) The number in z parenthesis is the number of LERs for which the reauirement was considered applicable, b. A percentage score for this reauirement is meaningless as it is not possible to determine from the information available to the analyst whether this reouirement is applicable to a specific LER. It is always given 100%

if it is provided and is always considered "not applicable" when it is no .

. - . . - - . - , - . - . . _ . _ _ ~ _ . - - _ _,,,_,__m .._._ ,

.

. plant operating conditions before the event [10 CFR 50.73(b)(2)(ii)(A)] to text presentation. Tne percentage scores in the text summary section of Table 3 provide an indication of how well each text reauirement was addressed by the licensee for the 30 LERs that were evaluate Discussion of Specific Deficiencies A review of the percentage scores presented in Table 3 will auickly point out where the San Onofre station is experiencing the most difficulty in preparing LERs. For example, requirement percentage scores of less tnan 75 indicate that the licensees probably need additional guidance concerning these reauirements. Scores of 75 or above, but less than 100, indicate that the licensees probably understand the basic reouirement but has either: (1) excluded certain less significant information from most of the discussi_o,ns concerning that reouirement or (2) totally f ailed to address the reauirement in one or two of the selected LERs. The licensees should review the LER specific comments presented in Appendix D in order to determine why a less than perfect score was received for certain reauirements. The text reouirements with a score of les5. than 75 are discussed below in their order of importanc In addition, the primary deficiencies in,the abstract and coded fields are discussed.

T The manufacturer and model number (or other uniaue identification) was not provided in the text of ten of the eleven LERs that involved a component f ailure, Reauirement 50.73(b)(2)(ii)(L). Such information is important in that it can lead to the identification of possible generic problems in the industr Although the score (77%) was marginally acceptable, twelve of 30 LERs did not provide adeauate information concerning the operating conditions just prior to the event, Reauirement 50.73(b)(2)(ii)(A). One LER failed to provide any information concerning operating conditions. The most common deficiency was however, the failure to define the operating mode that was provided. Mode definitions are not standardized to the point that a

..

-- __

.o .

.

o

'.

definition would be redundant to the reader. Sufficient information should be provided early in the discussion so that the reader has a reference point in terms of the possible effects on the plan Twenty of 30 LERs did not include previous similar event information, Reauirement 50.73(b)(5). While it may be difficulty to identify previous similar events, references to known previous similar events at the respective plant are reouired. If no previous similar events are known, the text should so stat The text presentation score of 74% is generally low. As discussed in the General Observations this was due to the large number of LERs submitted without a text. The space limitation of the abstract section does not allow for the necessary detail except for very simple event The main deficiency in the area of coded fields involves the title, Item (4). Twenty-three of the titles did not indicate root cause, nine f ailed to include the link (i.e., circumstances or conditions which tie the root cause to the result), and two failed to provide information concerning the result of the event (i.e., why the event was reouired to be reported).

While result is. considered the most important part of the title, cause and N link must be included to make the title complete. An example of a title that only addresses the result might be " Reactor Scram". This is inadeouate 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 Scran". From this title the reader knows the cause involved either personnel or procedures and testing Contributed to the even Table 4 provides a summary of the areas that need improvement for San Gnofre LERs. For more specific information concerning deficiencies the reader should refer to the information presented in Appendices C and General guidance concerning these reouirements can be found in NUREG-1022, Supplement No. .

--

. _ _

.

'

.

Ba TABLE AREAS MOST NEEDING IMPROVEMENT FOR SAN ON0FRE LERs Areas Comments Manufacturer and model number Component identification information'

information (manufacturer and model number)

should be included in the text for each failed component or whenever a component is suspected of contributing to the event because of its desig Operating conditions prior to Details such as power level, mode the event names and in some Cases, temperatures and pressures are reouired in the tex I Previous similar events Previous similar events should be '

referenced (e.g., by LER number) or if none are identified, the text

"

should so stat Text presentation Improvement in text presentation would result from submitting separate text and abstract section Coded fields Titles

'

Titles should be written such that they better describe the event. In N particular, include the root cause and result of the event and the link between them in all titles.

!

-

,.-,-. - - - - - . - . , _ _ , - - - , , ,

_

.

.

O e REFERENCES 1. S.' Anderson, C. F. Miller, B. M. Valentine, An Evaluation of Selected Licensee Event Reports Prepared Pursuant to 10 CFR 50.73 (DRAFT), NUREG/CR-4178, March 198 . Office for Analysis and Evaluation of Operational Data, Licensee Even Report System, NUREG-1022, U.S. Nuclear Regulatory Commission, September 198 . Office for Analysis and Evaluation of Operational. Data, Licensee Event Report System, NUREG-1022 Supplement No.1, U.S. Nuclear Regulatory Commission, February 198 . Office for Analysis and Evaluation of Operational Data, Licensee Event Report System, NUREG-1022 Supplement No. 2 U.S. Nuclear Regulatory Commission, September 198 .,

e O

-

_ _ _ _ _ - _ - . - - - _ _ - - . _ , _ _ , __.-__-______,,,,,.c - -, ,

.

• ,

's APPENDIX A LER SAMPLE SELECTION INFORMATION FOR SAN ONOFRE 1, 2 AND 3

.,

e

,

-

-- _

.

.

..

TABLE A- LER SAMPLE SELECTION FOR SAN ON0FRE 1, 2, 3 i

LER Sample Number Unit Number LER Number Comments 1 1 84-012-00 2 1 84-014-01 3 1 84-015-00 ESF

4 1 85-004-00 5 1 85-014-00 SCRAM 6 2 84-072-00 g

7 2 84-079-01

.

8 2 85-008-00 j! 2 85-011-00 ESF 10 2 85-018-00 SCRAM

.

11 2 85-021-00 ESF i 12 2 85-022-00 ESF 13 2 85-024-00 SCRAM 14 2 85-028-00 SCRAM 15 2 85-031-00 SCRAM 16 2 85-035-00 17 2 85-040-00 ESF 18 2 85-044-00 ESF 19 2 85-046-01 SCRAM 20 2 85-052-00 ESF 21 2 85-053-00 22 2 85-054-00 23 3 84-040-00 SCRAM 24 3 85-004-00

..

- , - - -+ c - .. .-,

-- - _ . . . _ . , _ _ , , , . _ _ . . _ , , _ _ - _ _ _ _ _ . . . ._ _ _ _ . . . , - ,

. - - .. - . .... -

.*

• .

-..

TABLE A- (continued)

LER Sample Number Unit Number LER Number Comments

! 25 3 85-006-00 ESF 26 3 85-008-00 SCRAM 27 3 85-017-01 28 3 85-019-01 ESF 29 3 85-027-00 ESF 30 3 ,_

85-028-00 ESF

..

O

\

.

!

..

p,e-- .- - - - - ,

--- , ,7.-m .g7,,n, nm,-7--mgm- . , - - - - - - + - - ,, - .,w , . - . . ,_,,,n.,,,,,, , - -.---- -. ,.,-,-,,--m-- -+ - - -

.

.

..

-

l

<

APPENDIX B_ _

EVALUATION SCORES OF INDIVIDUAL LERs FOR SAN ON0FRE 1, 2 AND 3

-.

e e

..

_ . _ _ - - . . - - . .- - - - - _- . - .. --. . - . .. .

/. ,

. -

.

i TABLE 8- EVALUATION SCORES OF IMOIVIDUAL LERs FOR SAN ONOFRE 1, 2. 3 *

.

LER Sample Number'

,

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

I Text .2 .2 .4 . 9 .6 .3 .4

! .3

!

Abstract .6 . 8 .1 8. 8 , 7. 7 .4 .5 .0 . 8 Coded Fields .5 .4 .5 .5 .7 .0

.4 .0 j Overall .3 .6 .6 . 9 9. 2 8. 9 7. 6 8. 7 .8 .8

!

l

'

LER Sample Number *

17 18 19 20 21 22 23 24 25 26 27 28 29 l 30 AVERAGE Text 8. 8 . 0 .0 7. 9 7. 7 7. 0 .1 .8 .3 Abstract .8 .9 .4 .8 .1 .1 .9 Coded j Fields 1 .3 .0 .2 .5 .3 .5 .5 9.0

.

Overall .1 .3 .5 . 8 . 7 . 3 .8 8.5

.,

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

1

4

e

_ _ _ - _ _ _ ,

.

• .

.

APPENDIX C DEFICIENCY AND OBSERVATION COUNTS FOR SAN ON0FRE 1, 2 AND 3

.,

,

-

,

e

.

.. . . - - . . . . .- .

-

4 .

'

' '

'

TABLE C- TEXT DEFICIENCIES AND OBSERVATIONS FOR SAN ON0FRE 1, 2, 3 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)--Plant operating 13 (30)

{

conaitions perore the event were not i included or were inadequat .73(b)(2)(ii)(B)--Discussion of the status 0 (8)

of the structures, components, or systems a that were inoperable at the start of the event and that contributed to the event was

not included or was inadeauat .73(b)(2)(ii)(C)--Failure to include 5 (30)

sufficient date and/or time informatio ,

a. Date information was insufficien b. T-ime information was insufficien I 50.73(b)(2)(ii)(D)--The root cause and/or 8 (30)

Intermeaiate tallure, system failure, or

'

personnel error was not included or was inadeauate.

i Cause of component failure was not

~ j\ included or was inadeauate .

.

'

b. Cause of system failure was not 1 included or was inadeauate c. Cause of personnel error was not 1 included or was inadequat .73(b)(2)(ii)(E)--The failure mode, 0 (11)

mechanism (immediate cause), and/or effect

'

(consecuence) for each failed component was not included or was inadeauate.

l a. Failure mode was not included or was

inadeauate l b. Mechanism (immediate cause) was not i

included or was inadeauate c. Effect (consecuence) was not included i or was inadeauate.

,

l l

l

[

t

-

.

. ,'

.

. .

TABLE C- (continued)

'

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )D 50.73(b)(2)(ii)(F)--The Energy Industry 1(30)

Identification System component function identifier for each component or system was not include .73(b)(2)(ii)(G)--For a f ailure of a 0 (1)

component witn multiple functions, a list of systems or secondary functions which were also affected was not included or was inaceauat .73(b)(2)(ii)(H)--For a f ailure that 1 (7)

rendereo 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 include .73(b)(2)(ii)(I)--The method of discovery 1 (30)

-

of each component failure, system failure, j personnel error, or procedural error was not

, included or was'inadeauat Method of discovery for each 0 component failure was not included or was inadeouate Method of discovery for each system 0 l failure was not included or was i inadeauate l

c.~ Method of discovery for each I personnel error was not included or was inadeauate Method of discovery for each 0 procedural error was not included or was inadeauat _ . _ _ -

_ - _ _ _ _ . ___

. . _ _ - .

.

. ,"

. ..

TABLE C- (continued)

-

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )b 50.73(b)(2)(ii)(J)(1)--Operator actions that 0 (4)

attected the course of the event including operator errors and/or procedural deficiencies were not included or were inadeauat .73(b)(2)(ii)(J)(2)--The discussion of 4 (12)

each personnel error was not included or was inadeauate, OBSERVATION: A personnel error was 1 implied by the text, but was not

-

explicitly state .73(b)(2)(ii)(J)(2)(1)--Discussion 1 as to whether the personnel error was cognitive or procedural was not included or was inadeouat .73(b)(2)(ii)(J)(2)(ii)--Discussion 0 as to whether the personnel error was contrary to an approved procedure, was a direct result of an error in an approved ' procedure, or was associated

\ with an activity or task that was not covered by an approved procedure was not included or was inadeauat .73(b)(2)(ii)(J)(2)(iii)--Discussion 0 of any unusual characteristics of the work location (e.g., heat, noise) that directly contributed to the personnel error was not included or was inadequate, . 73 ( b) ( 2 ) ( i i ) ( J ) ( 2 ) ( i v )--D i s c u s e'. nt 3 of the type of personnel involv:L (i.e., contractor personnel tPrlit-licensed operator, utility act . ige. e d operator, other utility personnel) was not included or was inadeouate.

l l

l

_ _ _ __ . _ , _ . . _ _ _ . _ . _ . _ _ _ _ _ _ . _ _ .

'

.

.

. .

TABLE C- (continued)

~

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )b 50.73(b)(2)(11)(K)--Automatic and/or manual 6 (18)

safety system responses were not included or were inadeauat .73(b)(2'(ii)(L)--The

) manufacturer and/or 10 (11)

moael number of each failed component was not included or was inadeauat .73(b)(3)--An assessment of the safety 10 (30)

ccnseauences and implications of the event was not included or was inadeauat OBSERVATION: The availability of 2 other systems or components capable of mitigating the conseauences of the event was not discussed. If no other systems or components were available, the text should state that none existe OBSERVATION: The consecuences 3

'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 stat .73(b)(4)--A discussion of any corrective 9 (30)

actions planned as L result of the event including those to reduce the probability of similar events occurring in the future was not included or was inadeouat _ . _ - _ . . ,.

. . - _ _ _ _ _

.

. ,'

. ..

TABLE C- (continued)

'

Number of LERs with Deficiencies and *

Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )b a. A discussion of actions reauired to 0 correct the problem (e.g., return the component or system to an operational condition or correct the personnel error) was not included or was inadeauat b. A discussion of actions reauired to 3 reduce the probability of recurrence of the problem or similar event (correct the root cause) was not included or was inadeauat c. OBSERVATION: A discussion of actions 0 reauired 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 inadeauat .73(b)(5)--Information concerning previous 21(30)

similar events was not included or was

inadeauat \

.. - -- . _ ..

_ _ _ . . _ _ _

.

.

.

,

..

TABLE C- (continued)

-

-

Number of LERS with Deficiencies and Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )D 50.73(b)(2)(i)--Text presentation 3 (30)

inaaeauacies, OBSERVATION: A diagram would have 0 aided in understanding the text discussio Text contained undefined acronyms 1 and/or plant specific designator The text contains other specific 2 deficiencies relating to the readabilit .. The "sub-paragraph total" is a tabulation of specific deficiencies or observations within certain reauirements. Since an LER can have more than one deficiency for certain reouirements, (e.g., an LER can be deficient in the area of both date and time information), the sub-paragraph totals do

't necessarily add up to the paragraph tota The " paragraph total" is the number of LERs that have one or more reauirement deficiencies or observations. The number in parenthesis is the N number of LERs for which the reauire7,ent was considered applicabl _ _ . .-. _ _ _ _ .

.__ - _ _ _ __________

'

-

.

,

.

.

TABLE C- ABSTRACT DEFICIENCIES AND OBSERVATIONS FOR SAN ON0FRE 1, 2, 3

_

-

Number of LERs with Deficiencies and Observatiors Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )b A summary of occurrences (immediate cause 0 (30)

and effect) was not included or was inadeauate A summary of plant, system, and/or personnel 1 (15)

responses was not included or was inadeauat a. Summary of plant responses was not 0 included or was inadeauat b. Summary of system responses was not 1 included or was inadeauat c. Summary of personnel responses was not 0 included or was inadeouat A summary of the root cause of the event 6 (30)

was not included or was inadeauat A summary of the corrective actions taken or 6 (30)

planned as a result of the event was not included or was inadeauat ,

- - ~ - - m -- sm-~ e u

.

>

,

.

TABLE C- (continued)

-.

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )D Abstract presentation inadeauacies 6 (30) OBSERVATION: The abstract contains 3 information not included in the tex The abstract is intended to be a summary of the text, therefore, the text should discuss all information summarized in the abstrac The abstract was greater than 1 1400 characters The abstract contains undefined 0 acronyms and/or plant specific ddsignator The abstract contains other specific 2 deficiencies (i.e., poor summarization, contradictions,etc.)

a. The "sub-paragraph tota!" is a tabulation of specific deficiencies or observations within certain requirements. Since an LER can have more tnan one deficiency 'for certain requirements, (e.g., an LER can be deficient in i the area of both date and time information), the sub-paragraph totals do not necessarily add up to the paragraph tota 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 reauirement was considered applicabl ,

- - - , - - - - - --- - - - - . - - , . . , - , - - - -

._ _ _ _ _ . _ . - .

.

• ,

i

. .

TABLE C- CODED FIELDS DEFICIENCIES AND OBSERVATIONS FOR SAN ON0FRE 1, 2, 3

-

.

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )D j Facility Name 0 (30) Unit number was not included or incorrect'. Name was not included or was incorrec c. Additional unit numbers were included s but not require Docket Number was not included or was 0(30)

incorrec ,

Page Number was not included or was 0 (30)

incorrect.

!

Title was left blank or was inadeauate 25(30) Boot cause was not given in title 23 Resu!t (effect) was not given in title 2 c. i. ink was ,not given in title 9

\ Event Date 0 (30) Date not included or was incorrect.

I Discovery date given instead of event

! dat LER Number was not included or was incorrect 0(30)

Report Date 1(30) Date not included I OBSERVATION: Report date was not 0 within thirty days of event date (or discovery date if appropriate).

Other Facilities information in field is 1 (30)

inconsistent with text and/or abstrac Operating Mode was not included or was 0(30)

inconsistent with text or abstrac _ _ _ -

_ _ _ _ _ _ _ , _ . _ . _ _ _ _ . _ . _ . _ _ . _ . _ _ , _ _ . _ _ . _ - _ _ _ _ - .-

.

,

'

.

TABLE C- (continued)

'

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph a

Description of Deficiencies and Observations Totals Totals ( )b Power level was not included or was 0 (30)

inconsistent with text or abstract Reporting'Reauf rements 1 (30) The reason for checking the "0THER" 0 reauirement was not specified in the abstract and/or tex OBSERVATION: It would have been more 0 appropriate to report the event under a different paragrap OBSERVATION: It would have been 1 appropriate to report this event under additional unchecked paragraph Licensee Contact 0 (30) Field left blank Position title was not included Name was not included d. ' Phone number was not include ,

\ Coded Component Failure Information 2 (30) One or more component failure 0 sub-fields were left blan Cause, system, and/or component code 1 is inconsistent with tex Component failure field contains data 0 when no Component failure occurre Component failure occurred but entire 1 field left blan .

-. -, - ,.n. ,,., .. - ---- . .n.- -,, a., - --. - . . . - - . . . , . - - - . -

.

,

. .

TABLE C- (continued)

-

Number of LERs with Deficiencies and Observations Sub-paragraph Paragraph Description of Deficiencies and Observations Totals a Totals ( )D Supplemental Report 1(30) Neither "Yes"/"No" block of the 0 supplemental report field was checked, The block checked was inconsistent I with the tex Expected submission date information is 0 (30)

inconsistent with the block checked in Item (14).

..

a. The "sub-paragraph total" is a tabulation of specific deficiencies or observations within certain reouirements. Since an LER can have more than one deficiency for certain reouirements, (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 tota The " paragraph total" is the number of LERs that have one or more reouirement def~iciencies or observations. The number in parenthesis is the

\ number of LERs for which a certain reouirement was considered applicabl :

i l

!

I i

- . _ , . _ . - - - - - _ , - .

.

.

.

.

,

. .

-

APPENDIX D LER COMMENT SHEETS FOR SAN ONOFRE 1, 2 AND 3

-,

o G

_

.

. .

,.

.

, TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 1 (206)

-

Section Comments 1. LER Number: 84-012-00 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(I)--How was it finally determined Inat LLw ano saitwater cooling flow were mismatched in the heat exchangers? .73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat . Acronym (s) and/or plant specific designator (s) are undefine ., Inclusion of a diagram was goo Abstract .73(b)(1)--Summary of root cause is inadeouat Mention the deficient procedure also, this is only

'

implied from corrective actions summar Coded Fields Item (4)--Title: Root cause is not include ; \

l

,

f I

_ , - , _ _ _ . _ _ _ _ _ _ _ . . _ _ _ _ _ _ _ _ . . _ _ _ _ . _ _ . _ _ _ . . _ _ . . - , - . _ , - . . . . . . . . _ . , _ . _ _ _ _ _ . _ . . . -_ _

. . _ . ,

.

.

,'

.

.

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 1 (206)

Section Comments

- LER Number: 84-014-01 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is inadeouate. Mode 3 should be defined (e.g., hot standby). .73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstract No commen Coded Fields Item (4)--Title: Root cause and link are not incluae ..

m

1

. - . . - . . _ . _ _ . . _.- _ _ _ - . _ _ _ _ _ _ . . _ _ _ _ _ _ _ . . _ _ . . . . _ _ _ _ . _ _ _ . _ . , . _ . . . . _ - . _ _ _ _ . , _ _ _ _ _ _ _ _ _ _ , _ . . . _ _ _ . . _ . . . . _ - . , _ . _ . . . _ _ _ . _ _ _

.

-

.

,.

.

. .

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 1 (206)

'

Section Comments LER Number: 84-015-00 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is inadeauate. Mode 3 should be defined (e.g., hot standby). .73(b)(2)(ii)(L)--Identification (e.g. manuf acturer and model no.) of the failed component (s) discussed in the text is not include . In the last paragraph, is the title of E0I S01-1.0-10

" Reactor Trip on Safety Injection" or " Reactor Trip or Safety InjeHion"?

" .73(b)(4)--Discussion of corrective actions taken or planned is inadeouate. Will the operation of the DC knife switches be checked more routinely in tne

-

future?

Abstract No commen Coded Fields Item (4)--Title: Link is not include .

., -.- - - --- ~,- -

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

_ - - - ._

.

'

. ,'

, . .

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 1 (206)

i j Section Comments -

, LER Number: 85-004-00

i Scores: Text = Abstract = Coded Fields = Overall = 8.6 i Text .73(b)(2)(ii)(A)--Include a brief description of

) each operating mode number referred to in the tex . 50.73(b)(2)(ii)(C)--Date and time (fifth paragraph)

l Information for occurrences is inadeauate. When was the pump returned to serivce?

.73(b)(2)(ii)(F)--Include the EIIS codes for each

!

component referred to in the text.

. .73(b)(2)(ii)(H)--A time estimate of the unavailability of the failed system is inadeauat (See text Comment 2).

l .73(b)(2)(ii)(L)--Identification (e.g. manufacturer

. and mooel no.) of the failed component (s) discussed

, in the text is not included.

i .73(b)(5)--Information concerning previous similar events is not included. If no previous similar events r,e known, the text snct:ld so state.

j - A supp ! mental report appears to be reeded to

y descrit,e the results of the continuing i investigation. Without a commitment to submit a supplemental report, this LER must be considered incomplete.

Abstract No comment.

i l Coded Fields Item (4)--Title: Root cause and link are not

, include . Item (ll)--0BSERVATION: It appears it would have i been appropriate to also report this event under

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

i Item (14)--The block checked is inconsistent with i information in the text (see text Comment 7).

I

!

!

!

I

=---.~.----.-n,,__,,._.n,,---,, --,--,,-,.-,nen ,,- ,-, -- n - n -----------~-,,---w- - + - - , . , , , - , - - , - - -~~---,---~~,-w

- . __. - _----

'

.

• ,

'

.

TABLE D SPECIFIC LER COMMENTS FOR SAN ON0FRE 1 (206)

~

!

Section Comments l

LER Number

85-014-00

Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(D)--What was the cause of the pressure switch and relay failure on the steam dump control circuit?

t J .73(b)(2)(ii)(L)--Identification (e.g. manufacturer

and model no.) of the failed component (s) discussed in the text is not include . 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 .73(b)(1)--Summary of root cause is inadeauat see comment 1 in tex ;

Coded Eields Item (4)--Title: Root cause is not include .

0

.

l

!

,

1 i

i y_---- .ym., .,.,_--,~-_.,--... _, --_,,..-c --- , . . . _ . __-_--,__.____,-__--__m,-,rm . _ - , . _ _ , - , . , . , , . . - , _ . . . . . . . . . .

.

-

.

,

, ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Sect' ion Conments

' LER Number: 84-072-00 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is inadeouate. Mode 4 should be defined (e.g., hot shutdown). .73(b)(3)--Discussion of the assessment of the safety conseouences and implications of the event is inadeouate. If radiation conditions had occurred during the time the radiation monitor was in alarm defeat, could the CREACUS have been actuated manually in time to perform its safety function?

OBSERVATION: The availability of other systems or

"

components capable of mitigating the conseouences of the event should be discussed. If no other systems or components are available, the text should so stat . .73(b)(4)--Discussion of corrective actions taken or planned is inadeouate. How will the various monitors be kept under continuous observation?

Abstract .73(o)(1)--Summary of corrective actions taken or planned as a result of the event is inadeouate. The interim action of continuously observing the monitors

\, is not mentione Coded Fields Item (4)--Title: Root cause and result are not included.

i l

l l

!

l

- . _ _ _ . -- , - . .- -- - , - . - . . - _ _ - - _ - _ _ _ _ - _ _ - _ _ _ _ _ - - , _ - _ - - _ _ _ _

.

'

. ,

, ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section

-

Comments LER Number: 84-079-01 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(C)--Date information for occurrences is inadeouate. Wnen will repairs be completed? .73(b)(2)(ii)(L)--Identification (e.g. manufacturer and model no.) of the failed component (s) discussed in the text is inadeouate. Are model numbers or sizes available for the failed snubbers? .73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstract .73(b)(1)--Summary of corrective actions taken or

"

planned as a result of the event is inadeouat Indicate that procedures will be changed, redesign

. will be made if necessary, and protective coverings will be used.

, Abstract contradicts the text. The total of 90 deficient snubbers contradicts the list of causes in the text and abstract. The list adds up to 8 Coded Fields Item (4)--The title should at least indicate some of

• \ the major root. causes.

i

. , , - , , , - . - . . . - . - . _ . - - _ . . - - - - - - - . .

_ -

--

.

.

,-

. ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ONOFRE 2 (361)

Section Comments

- LER Number: 85-008-00 Scores: Text = Abstract = Coded Fields = 8.5 Overall = Text .73(b)(2)(ii)(D)--What was the cause of the drain valves failing? .73(b)(2)(ii)(L)--Identification (e.g. manufacturer and model no.) of the failed component (s) discussed in the text is not include . 50.73(b)(4)--Discussion of corrective actions taken or planned is inadeouat A discussion of actions reouired to reduce the probability of recurrence (i.e, correction of the

.,

root cause) is not included or is inadeauat Abstract .73(b)(1)--Summary of root cause is inadeouat .

See text comment No. . 50.73(b)(1)--Summary of corrective actions taken or planned as a result of the event is inadeouate. What actions are planned to prevent recurrence of this event?

' 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 abstrac Coded Fields Item (4)--Title: Root cause and link are not included.

.

.- .

- -. . - _ _ - . . - - , _ _ _ _ - - - _ - - . _ _ _ _ _ _ _

_ _ - _ - .

_ _ .

.

-

.

,

'

..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section Comments - LER Number: 85-011-00 Scores: Text = Abstract = Coded Fields = Overall = Text 1 50.73(b)(2)(ii)(A)--Mode 6 should be defined (e.g.,

refueling). .73(b)(2)(ii)(J)(2)--Discussion of personnel error is inadeouat .73(b)(2)(ii)(J)(2)(iv)--Discussion of the type of personnel involved (i.e., contractor personnel, utility licensed operator, utility nonlicensed operator, other utility personnel) is not include . 50.73(b)(5)--Information concerning previous similar events is not included. If no previous similar

.. events are known, the text should so stat Abstrac,t No commen Coded Fields Item (4)--Title: Root cause and link (maintenance activities) are not include .

i i

I i

+

- __ _ _ - _ _ . _ - . -

_ - - _ _ .. . _ - - . . - - - . _ _ - ..-

.

• .

.

,

..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section Comments

"

10. LER Number: 85-018-00 Scores: Text = Abstract = Coded Fields = Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the requirements of a text and still be less tnan 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(J)(2)(iv)--Discussion of the type of personnel involved (i.e., contractor personnel, utility licensed operator, utility nonlicensed operator, other utility personnel) is not include . 50.73(b)(3)--Discussion of the assessment of the

safety consecuences and implications of the event is inadeauat .

OBSERVATION: The conseauences 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 stat * .73(b)(5)--Information concerning previous similar events is not included. If no previous similar i events are known, the text should so stat Abstract No commen Coded Fields No comment.

,

- . - . . - , , , , . .

- - - - - - - - - - _ _ - , , . - . , . -

- , - - - - - - - - - - - _ - -.-,.-__.v- ,-------.--.__,y_ -.--__-__-_y -, ,

.

. .

,.

. ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

'

Section Comments 11. LER Number: 85-021-00 Scores: Text = Abstract = Coded Fields = Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reauirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is inadeouate. Mode 5 should be define . 50.73(b)(2)(11)(0)--The root and/or intermediate cause oiscussion f or the vent valve being open is

,,

inadeauat . 50.73(b)(2)(ii)(J)(2)--It appears tnat personnel

-

error is involveo nn this event, but it is not

'

discussed. Wnen the normal valve lineup on valves upstream of the vent valve was performed, were personnel aware that the vent valve had been positioned to support ILRT preparations? Was there a conflict in the valve lineup procedures that were used?

\ .73(b)(51--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstract _50.73(b)(1)--Summary of root cause is inadeauat See text statements 3 and Coded Fields 1 Item (4)--Title: Root cause and link (e.g.,

personnel error during valve lineup causes--) are not

} included.

i

I f-n---,-

. - - - - - , - ,n --.,n--,... - , , -- , , , - - , . - - - . . -.-~n, ,-- - - .- .----.--- -

.

.

. .

,.

. ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

-

Section Comments 12. LER Number: 85-022-00 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(Althe conattions Defore event is inadeouate.-Discussion Mode 4 of plant operating should be define . 50.73(b)(2)(11)(C)--Time information for occurrences is not incluaea. At what time was the SIS actuated?

When was it secured? .73(b)(2)(ii)(K)--Discussion of automatic and/or manual safety system responses is inadeouate. The safety systems that " performed their function" (last paragraph) should be name " .73(b)(4)--The corrective actions taken to prevent recurrence were well thought out, especially the last

-

one (i.e., extending the actions to other procedures if necessary). .73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstract ' Boiler plate safety assessment conclusions are not

\. necessary in the abstrac Coded Fields Item (4)--Title: Root cause and link are not includeo.

,

l

- _ . _ _ _ _ _ _ _ , . _ _ . . . _ _ , _ . _ _ . . _ _ _ _ _ _ _ . . . , , , , . _ . _ . . . _ , , _ _ _ , . _ . . _ . . _ . _ . . _ _ _ . _ . . _ _ . _ . _ _ _ . _ . . _ _ _ _ , _ _ . . _ . _

,

.

.

.

'

..

TABLE D SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361) .

'

Section comments 13. LER Number: 85-024-00 Scores: Text = Abstract = Coded Fields = Overall = Text 1. 50.73(b)(2)(ii)(A)--Include a brief description of the operating mode numbe . 50.73(b)(2)(ii)(K)--The text should at least list all safety systems which actuated. A general statement that all systems operated satisfactorily is insufficien . OBSERVATION: The consecuences 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 stat .. .73(b)(4)--Be more specific about what changes are

. to be mad . 50.73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstract 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 abstrac Coded Fields Item (4)--Title: Root cause is not included.

l i

.

- - - - - - - . - - - - ,- .-- +m.. .-e - - - - - - - - - - , - -. - , - - - - - -------7

. _ -

.

.

. .

. ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section Comments

'

_

14. LER Number: 85-028-00 Scores: Text = Abstract = Coded Fields = Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the requirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(D)--The root and/or intermediate cause discussion for the regulator failure is not include '

' .73(b)(2)(ii)(K)--Discussion of automatic and/or manual safety system responses is inadeouate. What

essential control and safety systems functioned during and after the trip?

- .73(b)(2)(ii)(L)--Identification (e.g. manufacturer and model no.) of the failed component (s) discussed in the text is not include . 50.73(b)(5)--Information concerning orevious similar events is not included. If no previous similar events are known, the text should so stat \ Abstract .73(b)(1)--Summary of the root cause of the regulator failure is not included.

l Coded Fields Item (4)--Title: Root cause is not include _ . , _ . _ _ _ _ _ _ _ ._-_- __ , _ . _

_ __

. _ _ . _ . . _ _ _ _ _ _ _ _ - - _ _ _ _ _ _ _ _ _ _ _ _ _ . . _ _ . _

.

.

. .

'

. ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

'

Section Comments 15. LER Number: 85-031-00 Scores: Text = Abstract = Coded Fields = Overall = Text 1. Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reauirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were e tex . 50.73(b)(2)(ii)(C)--Date and time information for occurrences is inadeouate. At what time was the plant considered to be in a safe and stable condition after the transient? When was the unit returned to service? .73(b)(2)(ii)(K)--Discussion of automatic and/or

manual safety system responses is inadeauate. Major plant parameters resulting from the scram should be

.

provided. The safety systems that actuated should also be liste . 50.73(b)(3)--Discussion of the assessment of the safety conseauences and implications of the event is not included. Safety assessment statements

~

(conclusions) must be accompanied by a discussion of how such conclusions were reache . 50.73(b)(5)--Information concerning previous similar

,

events is not included. If no previous similar events are known, the text should so stat . How many rods are in Subgroup 67 l Abstract Boiler plate safety assessment conclusions are not necessary in the abstract.-

Coded Fields Item (4)--Title: Root cause is not include _

- , _ - - - -

- . . _ - , . _ - , _ - . - - - . - - - _ - - - - __

. - -

.

-

. .

. ..

TABLE 0- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section Comments

~

16. LER Number: 85-035-00 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(3)--Discussion of the assessment of the safety conseauences and implications of the event is inadeauat OBSERVATION: The availability of other systems or components capable of mitigating the conseauences of the event should be discussed. If no other systems or components are available, the text should so stat OBSERVATION: The conseauences of the event had it occurred under more severe conditions should be discussed. If the event occurred unoer what are considered the most severe conditions, the text

"

should so stat . 50.73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstract No commen Coded Fields , Item (4)--Title: Root cause is not include \

.

. .

,.

. . .

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

'

Section Comments 17. LER Number: 85-040-00 Scores: Text = Abstract = Coded Fields = 10.0 Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reauirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is inadeauate. Mode 5 should be define Abstract 1. No commen Coded Fields 1. No commen .

i

- _ _ _ . .__ .- _ _ - _- - - _ _ _ _ , _ _ _ - - _ , - _ - - - - _ - - _

- - - -

__

.

• .

,

..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section Comments

'

18. LER Number: 85-044-00 Scores: Text = Abstract = Coded Fields = Overall = Text 1. Submittal of an LER without a text is acceptable; however, the abstract must then meet all the requirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(K)--Discussion of automatic and/or manual safety system responses is inadeauate. Why did HPSI pump 2P-018 start or was it started for testing? A list of "all systems", referred to in the last sentence, should be provide . 50.73(b)(3)--Discussion of the assessment of the

"

sarety consecuences and implications of the event is not include .

4. 50.73(b)(4)--Discussion of corrective actions taken or planned is inadequate. Is anything planned to prevent recurrence during the time long term corrective actions are being investigated?

<

'

5. 50.73(b)(5)--Information concerning previous similar events is inadeouate. What type of event was S reported in LER 84-002?

6. A logical transition does not exist between all ideas. Some ideas are not presented clearly (hard to follow). The use of abstracts with no text should be limited to extremely simple event Abstract 1. 50.73(b)(1)--Summary of system responses is

inadeouate. See text comment No. 2.

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

text comment No. Cooed Fields 1. Item (4)--Title: Root cause is not included.

l

!

i I

!

-

.-. _ - . - . _ . - . . , - . - - , . . . - - - . - - _ - _ . _ . - . . . - _ _ . - - - - - - . . _ . . . , _ _ . . _ . - - - - , _ _ _ - . . - - - , - - - _ _ _ _

_ . _

- .

. .

,

'

. ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section Comments -

19. LER Number: 85-046-01 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(L)--Identification (e.g. manufacturer and model no.) of the f ailed component (s) discussed in the text is not include . 50.73(b)(4)--It would be helpful to know the trecuency of brush replacement after refinishing the slip rings to indicate to a reader whether or not the problem was fixed. From the text, it is not apparent that the brush wear problem was corrected.

' .73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstrect No commen Coded Fields Item (4)--Title: Root cause is not include .

r

,

. _ _ _ __ , , _ , _ , , . . _ . _ _ , . , . _ . . _ . _ . . -. . - , _ . . ,

.

b *

. . .

TABLE 0- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

Section Comments

"

20. LER Number: 85-Of2-00 Scores: Text = Abstract = Coded Fields = 1 Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reouirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(11)(A)--Discussion of plant operating conditions before the event is inadeouate. Mode 6 for Unit 3 is undefine . 50.73(b)(2)(ii)(D)--The root and/or intermediate cause discussion f or the spurious actuation is inadeouate. Were any investigations performed as to

"

wny the actuation occurred below the setpoints? .73(b)(4)--Discussion of corrective actions taken or planned is not included. Prior corrective actions that have been implemented reference LER 85-10. Each LER should stand alone. What corrective actions are being planned to prevent recurrence of this event?

Abstract , .73(b)(1)--Summary of the cause of the- spurious actuations is inadecuate. See text Statement \ .73(b)(1)--Summary of corrective actions taken or a planned as a result of the event.is not include . Abstract should nct contain a referenc Coded Fields No commen .. . _- .

___ - - - - _ _ . - --

.

4 i . ,

'

,. . ..

.

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 2 (361)

'

Section Comments 21. LER Number: 85-053-00 ,

j Scores: Text = Abstract = Coded Fields = Overall = 9.3

Text 1. 50.73(b)(3)--Discussion of the assessment of the

,

safety consecuences and implications of tne event is

inadequate. How was it determined that "the release remained well below Technical Specification limits"?

2. 50.73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat . Some ideas are not presented clearly (hard to follow). I 1. No commen Coded Fidids 1. Item (4)--Title: Root cause and result (technical specification violation) are not include ~

I  ;

.

t l

~.

$

,, = . - - - - - , - . , , , , . , . - - - - - . , , , , , , . - - - , , . - _ . . . - . - - - . - -. - - - - , . . - - - . - . - - , - - - - - . .-. --

.

h

• l ae TABLE D- SPECIFIC LER COMMENTS FOR SAN ONOFRE 2 (361)

Section Comments

'-

22. LER Number: 85-054-00 Scores: Text = Abstract = Coded Fields = Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reauirements of a text and still be less than 1400 characters. Tne following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(C)--When was Revision 4 completed? .73(b)(2)(ii)(J)(2)(iv)--Discussion of the type of personnel involved (i.e., contractor personnel, utility licensed operator, utility nonlicensed operator, other utility personnel) is not include Who was responsible for the omission?

., .73(b)(3)--Discussion of tne assessment of the

-

safety consecuences and implications of the event is inadeauate. The safety assessment should consider the consecuences had the breakers actually been found fault . 50.73(b)(5)--Information concerning previous similar

-

events is not included. If no previous similar events are known, the text should so stat Abstract The abstract contains greater than 1400 character Coaed Fields Item (4)--Title: Root cause is not include _ _ .

.

.

' *

.. ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ONOFRE 3 (362)

Section

'

Comments 23. LER Number: 84-040-00 Scores: Text = Abstract = Coded Fields = Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reauirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(K)--Discussion of automatic and/or manual safety system responses is inadeauate. What safety systems were verified for proper operation and what were the major plant responses? .73(b)(2)(ii)(L)--Identification (e.g. manuf acturer and model no.) of the failed component (s) discussed

--

in the text is not include . .73(b)(5)--Information concerning previous similar events is not included. If no previous similar

,

events are known, the text should so stat Abstract No comment.

'

Coded Fields , Item (4)--Title: Root cause is not include T Item (13)--Component failure occurred but entire field is blan .

!

._

O s .

'

,,'

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 3 (362)

~

Section__ Comments 24. LER Number: 85-004-00 Scores: Text = Abstract = Coded Fields = Overall = Text ~50.73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is inadeauate. Mode 5 should be define . 50.73(b)(2)(ii)(I)--Discussion of the method of aiscovery or tne celinauent sample is not include . 50.73(b)(3)--Discussion of the assessment of the safety conseauences and implications of the event is not include . 50.73(b)(5)--Information concerning previous similar

"

events is not included. If no previous similar events are known, the text should so stat . A logical transition does not exist between all ideas. Some ideas are not presented clearly (hard to follow). What is the reason for pointing out that the RCS sample (in first paragraph) was not reouired by the Technical Specifications? Was the 4 hour4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> sample reauired because of the high I-131 activity?

Abstract Abstract describes the text as opposed to summarizing

$ i Coded Fields Item (4)--Title: Root cause of the delinauent sample is not include .

!

!

- - -

. _ -

.

R

.

.

s ,.

TABLE D- SPECIFIC LER COMMENTS FOR SAN ONOFRE 3 (362)

'

Section Comments 25. LER Number: 85-006-00 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(A)--Include a brief description of the operating mode numbe . 50.73(b)(2)(ii)(D)--What caused the valve to stick? .73(b)(2)(ii)(L)--Identification (e.g. manufacturer and model no.) of the failed component (s) discussed in the text is not include . 50.73(b)(4)--Was any effort made to free the sticky operator and to prevent it from sticking in the future?

Abstract' 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 abstrac Unit 2 was not mentioned in the tex Coded Fields Item (4)--Title: Root cause and link are not include * Item (8)--Information in field is inconsistent with

\ text and/or abstrac __

.

. .

. ,.- '

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 3 (362)

Section Comment-

--

26. LER Number: 85-008-00 Scores: Text = Abstract = Coded Fields = 9.3 Overall = Text .73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat . 50.73(b)(2)(ii)(L)--Identification (e.g. manufacturer ano moael no.) of the failed component (s) discussed in the text is inadeouate. The failed component should be identified such that others can check for similar problems at their facility. From tne

>

information provided in the text, what probably should be identified is the manufacturer and model number of the valve which has the feedback mechanism attached with a carbon steel cap scre .,

Abstract .73(b)(l)--Summary of corrective actions taken or

-

planned as a result of the event is inadeouate. A summary of corrective actions to prevent recurrence should be include Coded Fields Item (4)--Title: Root cause is not include .

.

l l

l . , - _ _ _ _ _ _ . - .- ,-- , ,

"

.

s -

.

• '

. . ..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 3 (362)

'

-

Section Comments 27. LER Number: 85-017-01 Scores: Text = Abstract = Coded Fields = Overall = Text .73(b)(2)(ii)(L)--Identification (e.g. manufacturer ana model no.) of the failed component (s) discussed in the text is inadeauate. Model number of inoperable snubbers should be provide . The use of a " revision bar" is goo Abstract No commen Coded Fields Item (4)--Title: Link (post-maintenance check) is not include ..

.

e

l l

,

l .

l t

- -- w- - - - e ve,- >- , c ,r--m- - - - - - - - , - , . - - - - - - - - - - - - - - - - - - - - - - . - - - - . - - . - - - . - , , , - - - - . ,4----

.

,

. ,'... a'

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 3 (362)

'

Section Comments 28. LER Number: 85-019-01 Scores: Text = Abstract = Coded Fields = Overall = Submittal of an LER without a text is acceptable;

~

Text however, the abstract must then meet all the requirements of a text and still be less than 1400 cnaracters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(A)--Include operating conditions before each actuatio . 50.73(b)(2)(ii)(D)--The LER text is supposed to stand alone (i.e., contain all pertinent data about the event). While the cover letter indicates that the

"

most probable cause was ground current, the text only implies, from the corrective actions, that the grounds might be the proble . .73(b)(4)--As for the root cause (text Comment 3),

the cover letter discussion of corrective actions is more complete than the text. Be sure that the text includes all pertinent dat , .73(b)(5)--Information concerning previous similar events is not included. If no previous similar S events are known, the text should so stat . The fact that LER 85-019-00 indicated the need for a supplemental report to discuss the results of the engineering evaluation was goo Abstract No commen Coded Fields Item (4)--Title: Root cause is not include . Item (7)--The report date for LER 85-019-01 is okay, but it could not be determined if the report date for LER 85-019-00 was okay since the day field was left blan .

-p

-

..

o

. . . , TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 3 (362)

~

Section Comments 29. LER Number: 85-027-00 Scores: Text = Abstract = Coded Fields = Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reauirements of a text and still be less than 1400 characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(A)--Discussion of plant operating conditions before the event is not include . 50.73(b)(5)--Information concerning previous similar events is inadeauate. Since a previously planned modification is being implemented as a corrective action, it appears that this event has occurred

"

previousl Abstract No commen Coaed Fields Item (4)--Title: Root cause is not include .

j

-

.

+f.../.,.

..

TABLE D- SPECIFIC LER COMMENTS FOR SAN ON0FRE 3 (362)

.

Section Comments 30. LER Number: 85-028-00 Scores: Text = Abstract = Coded Fields = Overall = Text Submittal of an LER without a text is acceptable; however, the abstract must then meet all the reauirements of a text and still be less than 1400 Characters. The following comments apply to the abstract that was evaluated as if it were a tex . 50.73(b)(2)(ii)(C)--A date should have been provided in the second paragraph, the next to last sentenc . 50.73(b)(3)--Discussion of the assessment of the safety conseauences and implications of the event is inadeouate. It is not clear why it is alright to

"

place Monitor 3RT-7822 in alarm defeat when the readings are valid. If personnel are in the area,

_

the source of activity should not matte . 50.73(b)(5)--Information concerning previous similar events is not included. If no previous similar events are known, the text should so stat Abstract No commen _

T Coded Fields Item (4)--Title: Root cause and link (fuel transfer tube) are not included.

f

_ _ _

. _ _ _ _ _ . _ _ _ _