ML18100A707

Rev 1 to Procedure NC.NA-AP.ZZ-0061(Q), Significant Event Response Team Mgt. Procedure Reformatted to Comply W/ Artificial Island Administrative Writers Guide NC.NA-WG.ZZ-0001(Z)

ML18100A707
Person / Time
Site:	Salem, Hope Creek
Issue date:	02/07/1991
From:	Public Service Enterprise Group
To:
Shared Package
ML18100A706	List: IR 05000311/1992081 ML18100A705 ML18100A707
References
NC.NA-AP.ZZ-006, NC.NA-AP.ZZ-6, NUDOCS 9311180266
Download: ML18100A707 (36)

Text

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PSE&G NUCLEAR DEPARTMENT I

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NC.NA-AP.ZZ-0061(Q) REVISION 1 SIGNIFICANT EVENT RESPONSE TEAM MANAGEMENT

• SPONSOR ORGANIZATION: Vice President - Nuclear Operations REVISION

SUMMARY

1. This minor revision adds the Manager - Nuclear Training Department to the list of people who are to receive SERT reports (Section 5.7.2.a.).

2. The procedure has been reformatted to comply with the Artificial Island Administrative Procedure Writer's Guide, NC.NA-WG.ZZ-OOOl(Z).

IMPLEMENTATION REQUIREMENTS The station's SERT coordinators will ensure copies of all SERT reports issued prior to the implementation of this revision to the procedure are transmitted to the Manager - Nuclear Training Center.

This revision to the procedure is effective upon issuance.

CONCUR:

r - Quality Assurance/

Nuclear Safety Review APPROVED: :Jhlyl_

V10ce President - Nuclear Operations ~

APPROVED: ~Jv~

~~

AP~ROVED:

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/h5/_v 1 Manager - Salem Operations 9311180266 9311CW- Page 1 of 1 aPDR ADOCK 050f)0311

---FDR

NC.NA-AP.ZZ-006l(Q)

SIGNIFICANT EVENT RESPONSE TEAM MANAGEMENT TABLE OF CONTENTS Section Title Page 1.0 PURPOSE ***..*......**...**...*........*.*..*..* o * * * * * *

• 2

2. 0 SCOPE . . * * * . . . . * . * * . * * . . . * . . . * . . * * * * . * * . . . . . . . . . . * * . . . . . 2

3. 0 RESPONSIBILITIES * * . * . . * * . . . * . . * . . . . . * * . * * * * * . * * * * . . * . .

• 3

4. 0 PROCESS DESCRIPTION .*...*..**..**.*..*.**.* '* . * * . . . . * * . . 7

5. 0 PROCEDURE * . * * . * . * * * * * * * * * * . . * * * * * * * * * * * * * * * * * * * . * * . * * . . 8 5.1 Convening the SERT - Immediate Response Events 8 5.2 Convening the SERT - Events Not Requiring Immediate Response *****o************************ 13 5.3 Analyzing the Event ***"************************* 15 5.4 Identifying the Root Cause ..******....*.***.***. 17 5.5 Determining Corrective Actions **...*********.... 18 5.6 Preparing the SERT Report ***.**************..... 19

• 6.0

• 5.7 5.8 Issuing the SERT Report ***********************.. 20 Records . * * * * * * . * . * * * . * * . * * * * * .. * * * * * . . . * * * * * * . * . .

DEFINITIONS . * * * . . . * . . . . . . * . . . . . . . . . . * * . . . . . . . * . . . . . . . . l 1

~ 1

7.0 REFERENCES

• * * * * * * * * * * * * * * * . * . * * . * * * * * * * * . * * * * * * * . * . . . . :i ~

A'PI'ACHMENTS Attachment 1 - Flowchart - Immediate Response Events Attachment 2 - Flowchart - Events Not Requiring Immediate Responae Attachment 3 - Flowchart - Analysis & Rep6rt Preparation Attachment 4 - Data/Information to be Considered Attachment 5 - Corrective Action Guidelines Attachment 6 - Sample SF.RT Report Nuclear Common Page 1 of 22 Rev. 1

NC.NA-AP.ZZ-0061(Q)

SIGNIFICANT EVENT RESPONSE TEAM MANAGEMENT 1.0 PURPOSE

• 1.1 To proceduralize the Significant Event Response Team (SERT) process.

1.2 To provide a structured process for independent assessment of selected events, trends, or certain repetitive situations.

1.3 To fulfill the Nuclear Department commitment to perform an independent review of each reactor trip/safety injection.

1.4 To provide a timely, uniform, and comprehensive report for each reviewed event.

1.5 To ensure that all relevant aspects of an event or situation have been considered and appropriate corrective actions identified to prevent recurrence.

2. 0 SCOPE 2.1 Applies to events determined to warrant a SERT by either a Station Manager or a Nuclear Department Vice President, including the following:

o All reactor trips/scrams o All safety injections o Other concerns, problems, or events at the discretion of the above members of senior management.

Within this procedure the term Station Manager refers to the General Manager - Salem/Hope Creek Operations, his designated representative, or the Nuclear Department Vice President who collllllissioned the SERT 2.2 Includes the following activities related to SERT duties:

o Convening a SERT and responding in an appropriate time frame.

o Investigating and analyzing the event.

o Preparing the SERT report.

o Issuing the SERT report.

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NC.NA-AP.ZZ-006l(Q) 3.0 RESPONSIBILITIES 3.1 The Station Manager is responsible for:

o Determining the need for a SERT.

o Designating a SERT Manager and arranging for a Technical Staff member.

o Providing a base of operation for the SERT.

o Defining the initial objectives of the SERT.

o Making available to the SERT all data/information obtained relative to the event.

o Making decisions regarding implementation of SERT recommendations.

o Tracking implementation status of SERT recommen.dations utilizing the Action Tracking System IAW NC.NA-AP.ZZ-0057(Q).

3.2 The SERT Manager is responsible for:

o Determining SERT membership needs.

o Coordinating SERT activities.

o Providing an independent assessment of the event, including root cause(s) and corrective action recommendations.

o Ensuring prompt and complete data collection and interviews pertaining to personnel performance, beginning no later than 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> after the event, when possible.

o Ensuring that relevant management issues are identified and addressed as part of the investigation.

o Interfacing with station department managers.

o Interfacing with the Station Manager concerning regulatory, external, and management issues, as required.

o Obtaining initial SERT objectives from the Station Manager.

o Issuing a complete and accurate SERT report .

• Nuclear Common Page 3 of 22 Rev. 1

NC.NA-AP.ZZ-0061{Q) o Issuing the report in a time frame consistent with the needs of the Station Manager.

As a goal, the report should be issued within 7 days of the event.

3.3 SERT member responsibilities are both general and discipline specific.

Team membership for any particular investigation is at the discretion of the SERT Manager.

3.3.1 All SERT members are responsible for:

o Coordinating fact finding interviews with department conducted interviews and higher priority plant activities.

o Providing a central point of contact for procedure review and investigation activities affecting their department.

o Participating in root cause analysis/determination.

o Participating in the development of corrective action recommendations.

o Performing any other duties or tasks assigned by the SERT Manager.

Ultimately, the duties or tasks of all team members are at the d~scretion of the SERT Manager

• 3.3.2 .The Maintenance Department member is responsible for:

o Coordinating the investigation of event related site work activities, including the proper implementation of applicable work methods, safety rules, procedure compliance and procedure adequacy.

o Coordinating the scheduling of SERT related activities, including consideration of the impact.of desired work on other plant activities.

o Reviewing preplanning of work activities which led to the event.

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NC.NA-AP.ZZ-0061(Q) 3.3.3 The System Engineer member is responsible for:

0 Coordinating deficiency resolution liaison activities.

0 Preparing special investigative and test rocedures.

o Preparing industry experience reports {Nuclear Network) .

0 Preparing 10CFR50.59 Safety Evaluations.

0 Preparing design change requests (minor or major) .

0 Performing technical review of Change Packages (CPs) and procedures associated with the event.

3.3.4 The Technical Staff member is responsible for:

0 Providing administrative support to the SERT Manager, including calling out additional members as assigned.

o Maintaining a log of SERT activities and time keeping.

o Acting as the focal point for collecting material to be included in the SERT report.

o Preparing the SERT report.

o For events requiring immediate response, coordinating the investigation with plant activities.

3.3.5 The Operations Department member (currently or previously licensed or certified) is responsible for:

o Providing the SERT with available requested information related to plant and personnel response.

o Evaluating Op~rations Department procedures for adequacy and compliance.

o Coordinating the investigation with plant operations activities.

3.3.6 The Radiation Protection/Chemistry Department member is responsible for:

o Coordinating ALARA considerations, such as dose rate assessment and shielding requirements, with SERT investigation activities.

o Obtaining and performing analysis of radiological and chemical/rad~ochemical trends and parameters prior to, during, and after the event.

o Developing corrective action recommendations based upon analysis of radiological and chemistry data.

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NC.NA-AP.ZZ-0061(Q) o Determining cause(s) and failure mechanisms related to radiological and chemistry effects.

o Coordinating job coverage in support of S~RT investigations, including performing radiological surveys and air samples.

o Coordinating RWP preparation and issue necessary to support SERT activities.

3.3.7 The Quality Assurance member is responsible for:

o Identifying and reviewing administrative and engineering controls that might have failed during the event.

o For events requiring immediate response, performing fact finding interviews in the Maintenance, Radiation Protection, and Chemistry disciplines.

3.3.8 The Nuclear Safety Review member is responsible for:

o Reviewing plant data for correlation to the correctness of the plant response(s) to the event.

o Acting as the focal point for constructing the event chronology.

o Ensuring that the root cause analysis is thorough and comprehensive.

o For events requiring immediate response, participating in fact finding interviews in the Operations and Techni9al disciplines.

3.3.9 The Nuclear Training Center (NTC) member is responsible for:

o Reviewing the event for issues related to adequacy of training programs.

o Developing corrective action recommendations related to personnel indoctrination and training.

o Performing additional tasks as directed by the SERT Manager.

o For events requiring immediate response, making necessary short term changes to NTC training prograas.

3.3.10 Nuclear Engineering Department, Nuclear Services, and vendor personnel may be matrixed to the SERT, and are responsible fo~ specific support or oversight functions as assigned by the SERT manager .

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NC.NA-AP.ZZ-0061(Q) 4.0 PROCESS DESCRIPTION 4.1 The major elements of the SERT process include:

o The SERT itself.

o Independence of the team from routine event investigation and reporting processes.

o A focus on producing a comprehensive report.

o A special variation of the process for situations, such as reactor trips and Sis, that require immediate response.

o The SERT report as the major process output.

4.2 The SERT is a team of experienced personnel assembled to independently investigate events of concern. The following are characteristics of the SERT:

o The SERT Manager and members are selected from lists of designated individuals to facilitate convening the SERT and to ensure an appropriate level of experience on the team.

Emergency Preparedness will maintain a list of designated to act as SERT Managers and members.

o The SERT Manager is a non-station manager to ensure independence of the SERT from routine.station investigation and reporting activities.

o A SERT team membership is identified to provide immediate response capability (see Section 5.1) for situations such as reactor trips or safety injections (SI)s, or for events where the need for a SERT is identified within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> after event occurrence.

o Full SERT membership is adjusted based on the natµre of the event.

4.3 Although interfacing with the Station Manager, SERT operates independently from station management. The following features of the SERT - Station Manager relationship ensure SERT independence:

o The Station Manager sets only the initial objectives of SERT activity.

o The SERT Manager is free to pursue any aspects associated with the event, or any situations or concerns that evolve during the course of the investigation.

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NC.NA-AP.ZZ-0061(Q) o The SERT is independent of station management in developing its conclusions and recommendations.

4.4 The SERT process is aimed at producing a timely, accurate and comprehensive report of the event. The following aspects of the process relate to this goal:

o A special variation of the process is established for immediate response to reactor trips/Sis or any other event where an immediate response is justified.

o The SERT report incorporates the findings of all investigative activities pertaining to the event.

o The independent SERT process is integrated with other routine processes as appropriate, including the Incident Report/Reportable Event Program and Quality/ Safety Concerns Reporting System (NC.NA-AP.ZZ-0006(Q)) and* post trip review process (AD-16 at Salem, OP-AP.ZZ-lOl(Q) at Hope Creek)

• o The process is flexible (for instance, relative to assigned duties and team membership) to facilitate adaptation to different situations.

4.5 The SERT report is the major deliverable from the process.

Key features of the report include:

o A standard format and content.

o An independent point of view.

o A comprehensive scope.

o Identification of root causes and recommendations for short and long term corrective actions to prevent the event from recurring.

4.6 The report will be retained in a file by Nuclear Safety Review for use in assessing the effectiveness of corrective actions or for analyzing future events.

5.0 PROCEDURE 5.1 Convening the SERT - Immediate Response Events The process described in Section 5.1 would normally apply to events where restart is a primary consideration or for events where the decision to formulate a SERT is made within 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> after event occurrence. For other situations go directly to Section 5.2.

When the Section 5.1 process is utilized, the primary objective of the immediate response team is to identify and pinpoint human performance aspects associated with the event (who was doing what, where, when and why).

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NC.NA-AP.ZZ-006l(Q) 5 .1.1 Call Out - First Step Upon deciding to convene a SERT for a reactor trip, SI, or

• other event requiring immediate response, the _Station Manager shall assemble an initial response team as follows:

a. Designate a SERT Manager from the list of qualified individuals.

b. Call the designated SERT Manager and a Technical Staff member.

c. Brief them on the event and identify where the team will assemble.

NOTE The assigned Technical Staff member is normally an individual experienced in licensee event report preparation.

5.1.2 Call Out - Second Step Upon being called by the Station Manager, the Technical Staff member shall:

• a. Notify the designated team member (or point of contact) from each of the following departments:

1.

2.

Station Quality Assurance (SQA)

Nuclear Safety Review (NSR)

3. Nuclear Training Center (NTC)

b. Brief them on the event and identify where the team will assemble.

c. Travel to the site.

1. If a point of contact is reached, that person is responsible to notify an appropriate team member.

2. Additional members of the initial response team may be called out at the discretion of the Station Manager or SERT Manager.

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NC.NA-AP.ZZ-006l(Q) 5.1.3 Assembling the Initial Response Team Following call out, the designated SERT Manager and initial response team members shall:

a. Travel to the site as soon as possible.

b. Gather at the identified location.

c. Participate in an initial briefing.

d. Perform an initial assessment of the event.

e. Begin investigating the event in accordance with the general tasks outlined in Sections 5.1.4 through 5.1.8.

Due to the need for flexibility in investigating different types of events, the requirements in the following subsections are only guidelines and may be varied or performed in different sequence as the event dictates or at the discretion of the SERT Manager.

5.1.4 SERT Manager Tasks During the initial investigation phase, the SERT Manager should perform the following duties or tasks:

a. Contact the Station Manager and other department managers as necessary to develop a strategy for investigating the event. Considerations include:

o Defining .the initial SERT objectives o Obtaining an up-to-date assessment of the event status o Arranging for the turnover of any data or information collected to date o Establishing specific SERT member responsibilities o Establishing meeting frequency o Establishing plans for relief (if needed)

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o Identifying needed resources

• Participation on the SERT is assumed to be the "exclusive" duty of team members during the early stages of an investigation. SERT participation may become "non exclusive" as the investigation evolves.

b. Discuss the strategy for investigating the event with all team members.

c. Maintain an overview of the event to focus investigation activities.

d. Ensure that communication is maintained with the Station Manager, other managers and team members to ensure coordination of investigation activities.

e. Ensure the prompt collection of data pertaining to personnel performance.

Experience shows that the quality of such data degrades rapidly with time. The target is to complete collection of personnel performance data within 2-3 hours following the event.

f. Discuss SERT preliminary findings and any restart recommendations with the Station Manager prior to restart.

g. At an appropriate point in the initial investigation.

review the situation to determine the need for addit1on*l team members to complete the investigation in a tiael~*

fashion or to do an adequate assessment of root cau*e(sJ and corrective actions. Go to Section 5.1.9.

5.1. 5 Technical Staff Member Tasks During the initial investigation phase, the Technical St*f f member should perform the following duties or tasks:

a. Maintain an awareness of station activities related to the event and inform team members.as needed. Station activities of interest include equipment trouble-shooting, incident investigation and reporting, and SORC meeting~. *

b. Maintain a log of team activities, findings, and t1ae spent on the SERT.

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c. Provide administrative support for the SERT Manager, as needed.

d. Start collecting material for the SERT report. Prepare draft report material as requested. See Section 5.6.

e. Provide data to other team members as appropriate.

f. Participate in team meeting(s) to identify root causes and corrective actions. Go to Section 5.1.9.

5.1.6 Nuclear Safety Review Member Tasks During the initial investigation phase, the Nuclear Safety Review Department member should perform the following duties or tasks:

a. Contact appropriate Operations and Technical Department personnel, as required to ascertain the facts surrounding the event.

b. Interview pertinent personnel in these departments.

c. Start forming a sequence of events to be used in reconstructing the event during the event analysis phase. See Section 5.3.

d. Identify data needed for determining root ~auses or contributing factors of the event. See Section 5.4.

e. Provide data to other team members as appropriate.

f. Participate in team meetings to identify root causes and corrective actions. Go to Section 5.1.9.

5.1.7 Quality Assurance Member Tasks During the initial investigation phase, the Quality Assurance Department member should perform the following duties or tasks:

a. Contact appropriate Maintenance, Radiation Protection, and Chemistry Department personnel as required to ascertain the facts surrounding the event.

b. Interview pertinent personnel in these departments.

c. Collect data related to the use of procedures, documents, or other administrative controls.

d. Provide data to other team members as appropriate.

e. Participate in team meetings to identify root causes and corrective actions. Go to Section 5.1.9

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'\

5.1.8 Nuclear Training Center Member Tasks During the initial investigation phase, the NTC Member

• should perform the following duties or tasks: .

a.

b.

Assist in contacting and interviewing personnel involved in the event as directed.

Collect data related to the adequacy of training programs.

c. Provide data to other team members as appropriate.

d. Participate in team meetings to identify root causes and corrective actions. Go to Section 5.1.9.

5 .1. 9 Assembling the Full SERT At an appropriate point after assembling the initial response team, the SERT Manager shall:

a. Assess the adequacy of the team in terms of continuing the investigation to completion.

b. If additional members are needed, have additional members identified and called out to the site to participate in the ongoing investigation.

c. If the present team is adequate, continue the investigation. To provide continuity, initial response team members should be maintained to the completion of SERT activity, if possible. If replaced they are expected to maintain contact with the team.

d. After increasing membership as appropriate, continue the investigation. Go to Section 5.3.

5.2 Convening the SERT - Events Not Reau.iring Immediate Response 5.2.1 If the event does not require immediate response, or the opportunity for immediate response is lost, the Station Manager shall:

a. Designate a SERT Manager from the list of qualified individuals.

b. Contact the assigned SERT Manager and meet with him/her to discuss the event.

5.2.2 Upon reviewing the event with the Station Manager, the assigned SERT Manager shall:

a. Set up a base of operations at a convenient location.

b. Assess needs for membership of the SERT.

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c. Coordinate assignment of additional members. As a minimum, the SERT should consist of individuals from the following departments:

• 1.

2.

3.

Station Technical Station Quality Assurance Nuclear Safety Review

4. Nuclear Training Center

d. It is anticipated that most events significant enough to warrant a SERT would also require membership from Operations, Maintenance, and System Engineering. Also, specialty services may be desirable. For instance, events with strong human performance implications would require HPES trained personnel.

e. Make plans for the initial SERT meeting. Have the Technical Staff member contact assigned members and inform them of the time and location of the meeting. Go to 5.2.4.

5.2.3 The Technical Staff member shall:

a. Call assigned members as instructed by the SERT Manager.

b. Start the event log and time-keeping.

c. Prepare materiais for the initial meeting. Such materials may include at the direction of the SERT Manager:

o Initial event description o Copies of data collected to date o An outline of plans for the investigation 5.2.4 The SERT Manager and assigned members shall assemble as the full SERT and commence investigation of the event. The following apply to SERT investigation activities:

a. The initial duties and tasks in investigating the event somewhat parallel those in Sections 5.1.4 through 5.1.8 above and should be performed by the SERT Manager and team members as applicable.

b. If a SERT member is assigned from a particular specialty, that member is responsible for the identification and adequate resolution of issues related to the specialty.

c. Personnel will be assigned to conduct interviews at the discretion of the SERT manager.

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d. The investigation for an event not requiring immediate response may be conducted with less urgency than one for a reactor trip or SI (for example, round the clock coverage probably won't be required).

e. Depending on the nature of the event and other factors, such as the availability of resources, the investigation may vary considerably. Planning should include obtaining agreement of affected managers on resource allocations.

f. Upon completion of the initial investigation, SERT performs the event analysis as covered in the following section.

5.3 Analyzing the Event All team members participate in the following. The overall purpose is to reconstruct the event, identify human performance and equipment contributors to the event, and to identify root cause(s) and corrective actions to prevent recurrence.

5.3.1 Data/information collected by the team is used to reconstruct the event and assess equipment and'human performance.

a. Data/information reviewed pertaining to the event would include:

o Alarm activations.

o Equipment response information.

o Chart indications or printouts.

o Written statements from personnel involved in the event.

o Personnel actions obtained from interviews.

b. As the analysis progresses, the SERT should periodi~ally review the emerging picture of the event to assess its completeness and identify any additional data/information needs.

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\

5.3.2 The SERT should assess the need to obtain additional in house records that may be relevant to understanding the scenario, identifying the root cause(s) or corrective actions, or assessing the adequacy of past corrective actions. Such records may include:

a. Records of any similar events with which the event may be compared. Such events may be described in !Rs, LERs, or other reports.

b. Any other records that may be of value in the analysis or reconstruction of the event. For instance, start-up test records may indicate that a certain item had failed in a similar manner during original installation.

5.3.3 The SERT should review additional information as needed to analyze or understand the event.

a. Such information may include:

o Laboratory tests o Views or photographs of pertinent locations

o. Interviews of other individuals who have performed the same task Communication with vendors 0

0 General references needed to provide theory or background information.

b. Additional information reviewed shall include relevant industry operating experience.

c. The SERT should specify any special tests or experi*ents needed to complete their understanding of the event. The following requirements apply:

1. Prepare a test procedure or test CP for perfor*1n9 the test IAW NC.NA-AP.AD-0032(Q), Preparation, Review, and Approval of Procedures, or NC.NA-AP.ZZ-0008(Q), Control of Design and Configuration Change, Tests and Experiments, respectively.

2. Cl6sely coordinate test preparation with all SERT members and appropriate station management .

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3. Use existing systems in support of these efforts.

These systems include the planning function, design change process, and temporary modification control .

• Attachment 4 lists the kinds of data/information that should be considered for retrieval.

5.4 Identifying the Root Cause(s) 5.4.1 Upon assembling the various data and information into a chronology, the SERT should analyze the data and reconstruct the event (determine what, when, why, who).

a. Reconstructing the event is typically an iterative process involving:

1. Generating hypotheses as to possible relationships of different data.

2. Inferring possible facts from the observed data and possible relationships.

3. Deducing possible facts from the data, given theories or assumptions that may apply.

4. Testing the validity of the overall event description against known data.

b. The primary objective of the reconstruction process is to provide a model of the event that may be used in identifying the root cause(s) and contributing causes.

5.4.2 When the reconstruction is complete, the SERT shall analyze the event to identify the root cause(s) and any contributing causes. The following general considerations apply to root cause analysis:

o The purpose of root cause analysis is to provide the basis for corrective actions to prevent recurrence of similar events.

o Consider all possible causal factors. There are usually more than one.

o Consider all aspects of the event, including the technical, human, and environmental aspects.

o The general implications of a possible root cause should be kept in mind, as too narrow a view may result in overlooking the possibility of other events or consequences occu~ring.

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NC.NA-AP.ZZ-0061(Q) 5.4.3 The SERT should validate identified root cause(s) and contributing causes as follows:

• a. Determine if the root cause is valid using the following criteria:

o The problem would not have occurred if the cause had not been present.

o The problem will not recur due to the same causal factors if the causes are corrected or eliminated.

o Correction or elimination of the cause(s) will prevent occurrence of similar conditions.

b. Validate any major contributing causes using the same criteria as for root causes.

5.4.4 Any contributing factors may be validated by using tempered criteria. For instance, "the situation would have been less severe if .... " (the contributor had not been present)".

5.5 Determining Corrective Actions 5.5.1 Upon identifying the causes and contributing factors, the SERT shall develop recommendations for short and long term corrective actions as appropriate. The following guidelines apply to corrective actions in general:

a. The objective of a corrective action is to prevent recurrence of similar events.

b. At least one viable corrective action should be developed for each root cause or contributing cause.

c. A viable corrective action has the following characteristics:

o It will prevent recurrence of the situation.

o It is within our resources to implement.

o It supports our primary objective of safe and reliable power production.

d. The SERT should consider the adequacy of a recommended corrective action. Attachment 5 contains guidance for making this determination.

e. Final decisions regarding the implementation of recommended corrective actions are the responsibility of the Station Manager.

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NC.NA-AP.ZZ-0061{Q) 5.5.2 The SERT should expedite completing short term corrective action recommendations in a time frame consistent with ongoing Station corrective action activities.

5.5.3 For events where restart is involved (e.g., reactor trips or Sis), SERT recommendations could influence the restart decision. The SERT Manager should communicate short term recommendations to the Station Manager in a timely manner so they can be considered in restart decision making.

5.6 Preparing the SERT Report 5.6.1 The SERT shall prepare a report documenting their investigation. The following guidelines apply in general:

a. A report shall be issued for each convened SERT.

b. The report issue date should be negotiated between the Station Manager and the SERT Manager. As a goal, the report should be issued within 7 days of the event.

c. The report should be a comprehensive source of information about the event incorporating the results of relevant analyses.

d. The SERT report should:

Contain sufficient information to form.the basis 0

for any other required reports, such as the LER.

0 Incorporate the results of other investigative activities related to the event, such as the post trip review or System Engineering assessments.

o Specifically address relevant management or programmatic issues.

o Be a "stand alone" document. If supporting information from other documents is used but not included in the SERT report, the documents should be referenced in the bibliography. The names of individuals interviewed should also be included in the bibliography.

5.6.2 The Technical Staff member is responsible for preparing the draft report. The overall responsibility for the content of the report lies with the SERT Manager.

5.6.3 As specific conclusions or parts of the report are developed, the cognizant SERT member should review them with affected manager{s), both inside and outside of the station. The early awareness of management may facilitate acceptance and implementation of recommended corrective actions.

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NC.NA-AP.ZZ-0061(Q) 5.6.4 An example of a final report is included as Attachment 6.

The following guidelines apply to the final report content:

a. As a minimum, include the essential facts .surrounding the event and SERT conclusions, including:

o An event description o An assessment of equipment performance o The results of the root cause analysis o Short term corrective action recommendations o Long term corrective action recommendations o Man-hours spent investigating the event and preparing the report o Identification of SERT members

b. Identify any other observed issues not specifically addressed by SERT but needing corrective action.

5.6.5 The Technical Staff member should compile a bibliography of source documents and references including persons interviewed to be filed with the report for future use.

5.7 Issuing the SERT Report 5.7.1 The SERT report is issued under the signature of the SERT Manager.

a. The concurrence of all SERT members with the contents of the report is implied in the SERT Manager approval.

b. If there is disagreement between members as to particular conclusions or recommendations, the alternative views should be documented in the report.

5.7.2 The SERT Manager shall forward the SERT report to the Station Manager.

a. The SERT Manager shall distribute a copy of the SERT report to the Vice President - Nuclear Operations, General Manager - Quality Assurance/ Nuclear Safety Review, General Manager - External Affairs, Manager -

Nuclear Training Department and other affected Department Managers.

b. SERT responsibilities generally end with issuance of the report. However, the SERT may be reconvened to discuss the SERT report findings or any related details.

Nuclear Common Page 20 of 22 Rev. 1

NC.NA-AP.ZZ-006l(Q) 5.7.3 Upon receipt of the SERT report, the Station Manager will review the report and make a decision as to the implementation of SERT recommendations.

5.8 Records 5.8.1 A copy of the completed report, the bibliography and other supporting documents or data shall be forwarded by the Technical Staff member to the applicable Safety Review Group for their use. Generally, the hard copy file will be maintained by the appropriate On-Site Safety Review Group for station events and the Off-Site Safety Review Group for other events.

5.8.2 The report is a QA Record and shall be forwarded by the Technical Staff for retention !AW NC.NA-AP.ZZ-OOll(Q),

Records Management Program.

6.0 DEFINITIONS (For Purpose of This Procedure) 6.1 Significant Event - Any event or condition determined by senior management to warrant investigation by a SERT.

Includes all reactor trips and safety injections, as well as other concerns or problems that impact major systems important to safe operation of the plant. May also include conditions of concern such as adverse trends, performance problems, repetitive events, or unexpected conditions *

• 6.2 Significant Event Response Team (SERT) - A team of experienced personnel convened to independently investigate and report on events or situations of concern. The teaa 1s headed by a SERT Manager selected from a list of designated non-station managers. Team members are selected from a list of qualified individuals from the various technical disciplines.

6.3 Root Cause - The fundamental cause(s) that, if corrected.

will prevent recurrence of an event or condition.

6.4 Contributing Causes - Causes that, if corrected, would not by themselves have prevented the event, but are important enough to be recognized as needing corrective action to improve the quality of the process or product.

6.5 Contributing Factor - A condition that may have affected the event.

6.6 Root Cause Analysis - Any method used to identify root cause(s) of problems or trends.

6.7 Corrective Action - Action taken to prevent recurrence of an identified adverse condition or trend. Includes Short and Long Term Corrective Action.

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_J

NC.NA-AP.ZZ-0061(Q) 6.8 Short Corrective Term Action - Corrective action taken in the approximate. time frame of the event to allow continued operation and development/implementation of effective long term corrective action.

6.9 Lonq Term Corrective Action - Corrective action taken in an extended period following the event to permanently prevent recurrence of the event.

7.0 REFERENCES

7.1 INPO Good Practice OE-907 (Preliminary May 1989), "Root Cause Analysis" 7.2 INPO Good Practice OP-211 (December 1988), "Post Trip Reviews" 7.3 US NRC Order Modifying License Nos. DPR-70 and DPR-73 (Salem Units 1 and 2). Enclosure to letter from D. G.

Eisenhut to R. A. Uderitz,dated May 6, 1983 7.4 Cross - References 7.4.1 NC.NA'-AP.ZZ-0006(Q), Incident Report/Reportable Event Program and Quality/Safety Concerns Reporting System 7.4.2 NC.NA-AP.ZZ-0008(Q), Control of Design and Configuration Change, Tests and Experiments *

• 7.4.3 NC.NA-AP.ZZ-OOll(Q), Records Management Program 7.4.4 NC.NA-AP.ZZ-0057(Q)~ Action Tracking Program Nuclear Common Page 22 of 22 Rev. 1

s NC.NA-AP.ZZ-0061{Q)

ATTACHMENT 1 FLOWCHART - IMMEDIATE RESPONSE EVENTS

( START SERT l NSR HEHll£R l NTC HEHBER I

TS HEtHR tl;R TS HEllJER DA HEllJER STATUS

/ST*TIHM OETERHltES SERT tEEOED auHEtHRS DA ' NSR DISCUSS PlfWS llTH STRTlllt tl;R, YEAH STATION ACTIVITIES '

fl.ERT TEllt INTERVIEI OPS. TECH INTERVIEI HAINT. RP, CtEH ASSIST llTH INTERVIEIS AS DIRECTED STAT ION tl;R SERT SERT ta TS HEteER NSR HEtlJER DA tEHBER NTC HEHBER OBTAIN START LOG. START FIJIHING DESIGNATE SERT llH1GER

- TRAVEL TD PLfWT OVERVIEI OF EVENT, COORDINATE INVESTIGATION TIHE KEEPING, PREPARING REPlllT SEQ OF EVENTS.

COLLECTING ROOT COOSE ORTA DORK SPEClll.

ASSIGtKNTS WORK SPECIAL ASSIGNMENTS STATION tal SERT SERT 0 Cfl..L SERT ASSESS l:JWR* ASSEHBLE IUCUICY OF

...--- IEF Cit INITIAL SERT INJT IAL TEllt EVENT TEflt TO CIH'l.ETE REVIEI ta d*~, . ~I STATION SERT TS HEHBER ROD HEtlJERS PERF mt CALL TECH INITIAL ROOITIDNRL y CALL STfFF HEHBER RSSESSHENT OF HEHBERS ROOITIONRL i-. .lliN TERH RSSEHBLED EVENT tEEIED? tEHBERS N

~O 10 RlT 3 Nuclear Common Page 1 of 1 Rev. 1

NC.NA-AP. 06l(Q)

ATTACHMENT 2 FLOWCHART - EVENTS NOT REQUIRING IMMEDIATE RESPONSE START SERT HGR TS HEHBER . fDJ HElllERS Cfl.L TECH STATION HGR STIFF HEll!ER, CALL DETERHlt.ES BRIEF ON SERT fDJITIWU. JOIN TEAH SERT t.EEIED RRRfNj[tENTS SERT HEll!ERS STATION HGR SERT HGR TS HElllER RSSEHBLE ICENTIFY SERT CEVELOP HRTERlfl.S, HAAAGER INITlfl. START LOG, REVIEI PLANS TUEKEEPING STATION t<<;R SERT HEET llTH RSSEHBLE SERT SERT HRNAGER, TEflt DISCUSS EVENT SERT HGR ASSESS NEEDS Fl.LL TEflt FOR SERT RSSEHBLED HEll!ERSHIP GO TO RTT. 3 Nuclear Common Page 1 of 1 Rev. 1

r

• *ATTACHMENT 3 NC.NA-AP.ZZ-0061(Q)

FLOWCHART - ANALYSIS & REPORT PREPARATION c START I I RECONSTRUCT IDENTIFY FlLL SERT THE EVENT SHORT TERH ASSEHSLEO USING Tt£ ACTION TO '

ORTA RESTORE SAFE OPERATION C(lfllETE DATA IDENTIFY ROOT aLLECT UW, CAUSE (. COHMUNICATE PREPARE INITIAL CONTRIBUTING TO STATION REPORT INVESTIGATION FACTORS HRHRGER VfUDATE ROOT IDENTIFY LOOG ASSEMBLE CflJSE C TERM RELEVANT CONTRIBUTING CORRECTIVE ISSUE REPORT RECORDS FACTORS FICTIONS RSSEMSLE EXPLORE S(l..ICIT FORIARO ADDITIONAL AOOITJOtR.. AGREEMENT OF REPORT ANO JtEORHATION FACTORS, fFFECTEO INFORMATION NEEDED CONCERNS, OROONilZATJOOS FOR RETENTION INTERESTS FINISH Page 1 of 1 Rev. 1 Nuclear Common

-~-----

NC.NA-AP.ZZ-006l(Q)

ATTACHMENT 4 DATA/INFORMATION TO BE CONSIDERED Control room charts and printouts

• Operating logs

• Related correspondence

• Inspection/surveillance records

• Maintenance records

• Meeting minutes

• Procedures and instructions

• Vendor manuals

• Drawings and specifications

• Equipment history records Design basis information FSAR/technical specifications Nuclear Plant Reliability Data System reports

• Trend charts and graphs

• Training lesson plans

• SRG reports

+ LE Rs

+ IRs Nuclear Common Page 1 of 1 Rev. 1

NC.NA-AP.ZZ-0061(Q)

ATTACHMENT 5 CORRECTIVE ACTION GUIDELINES

• In developing and implementing corrective actions, consideration of the following questions can help ensure adequacy:

o Do the corrective actions address all the root causes?

o Will the corrective actions cause detrimental effects?

o What are the consequences of implementing the corrective actions?

o What are the consequences of not implementing the corrective actions?

o What is the cost of implementing the corrective actions?

Capital costs?

O&M costs?

o Will ~raining be required as part of the implementation?

o In what time frame can the corrective actions reasonably be implemented?

o What resources are required for successful development of the corrective actions?

o What resources are required for successful implementation and continued effectiveness of the corrective actions?

o What impact will the development and implementation of the corrective action have on other work groups?

Plant Engineering? Design Engineering?

Quality Assurance? Maintenance?

Security? Health Physics?

Operations? Training?

Drafting? Drawing Control?

Materials Management? Document Control?

Licensing? Chemistry?

Rad waste? Computer Support?

Work Control Center? Plant Modifications?

Safety Reviews? Configuration Management?

o Is the implementation of the corrective actions measurable?

(For example, "Revise step 6.2 of the procedure to reflect the correct equipment location," is measurable; "Ensure the actions of procedure step 6.2 are performed correctly in the future," is not measurable.)

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NC.NA-AP.ZZ-0061(Q)

ATTACHMENT 6 SAMPLE SERT REPORT

• August 31, 1989 RSR-89-079 To the General !1anager- Rope Creek Operations SCRAM ON LO~ LEVEL OF AUGUST 30, 1989 SIGNIFICANT EVENT RESPONSE TEAM REPORT At your request, a Signi.ficant Event Response Team was convened at 0600 on August 30, 1989 to inv**tigate and report on the unplanned automatic scram which took place at Hope Creek earlier that day. The SERT team con*isted ot:

.John P. Ronafalvy E&PB Manager Dana E. Cooley SRG Member Richard T. Griffith QA Member Robert F. Briggs QA Mellber Jamee T. Ormond *!1aintenance Member Gregory J. Ruane EHB Mellber Mitchell s. Dior Technical Member

• We concluded our work at 1630 on August 31, 1989.

Our report is presented below:

EyENT CHRONOLOGY The unit was operating steadily at approximately 81\ power.

limited by fuel content in a gradual coa*tdovn to September 16, 1989, the start of a scheduled refueling outage. No control rod evolutions or surveillance* were in progress.

RCIC wa* out of service under an NRC-approved extended action etate*ent. and Reactor Feed Pump *c* wa* cleared and tagged fer maintenance. Service air compre**or l0Kl07 was in service, with compressor OOK107 cleared and tagged fer maintenance. A standby diesel compres*or wa* available to augment service air.

Equipment operators were making normal rounds, including vi*its to the reactor building at 2040 and 2240 to add nitroqen to HCU accumulators (58-19 and 02-39). No unusual conditions were noted *

• Nuclear Common Page 1 of 7 Rev. 1

NC.NA-AP.ZZ-0061(Q)

... ATTACHMENT 6 (continued)

• GM-Hope Creek Operations Ol IZ t:;fi.C.

2 At ~the "Accumulator Trouble Alarm annunciated, followed by the rapid automatic insertion of control rods in the 8/31/89 lower right hand quadrant of th* full core display. As the insertion of control rods progreesed to the left side of the display, the reactor then scrammed automatically on low level (*12.5 inches). with all rods inserted. Th* elapsed time was about 13 seconds. [CRIDS later showed that the interval between "CRD Accumulator Trouble" to CRD Pilot Air Header Pressure at *o psig w~s a.bout 23 seconds.]

Aa part of.scram recovery, equipment operators were dispatched to the local !eedwater level controllers in the turbine building. After the shift stabilized !*edwater !low and reactor level. they attempted to reset the scraa without success. Scram air header pre*sure wa* 20-30 P*ig, well below the operating pres*ure of 70 p*ig. Th* shift became concerned whether the ~stv*s could re*ain open with th* los*

of header air pres*ure. Equipment operators were then sent to the reactor building to invcotigat~ th* pr***ure los*.

(time after event: 30 minute*>*

1'hey su*pected failure of an authorized te*porary repair to a 3" instrument air riser on Elevation 102.' Finding it intact, they proceeded to th* HCU area. In the south bank the operators* attention wa* drawn by a hi**ing sound which led th** to a failed 1/2" soldered connection above th*

scram valve pilot air valve on HCU 34-59 *

• 1'h*Y attempted to in*ert the tub* back into it* fitting, holding th* joint in place with wire and tape. Later th*

shift electrician att**Pted a more permanent repair with solder, but wa* un*ucc***ful due to r**idual air line pres*ure. The SNSS halted further attempt* at soldering.

The tape and wire w*r* replaced, and air header pre*sure increased sufficiently to allow scraa re*et.

Several significant de*igned plant !eatur** did not perform a* intended:

o Th* startup level control valve (1-AE-HV1785) did not re*pond in automatic.

o control rod 34-27 did not indicated fully inserted, although it wae verified to be in**rted.

o One channel of *Reactor scram* (W, CRIDS point 02131) did a.ct indicate on the printout, although it wae verified to have occurred.

Nuclear Common Page 2 of 7 Rev. 1

~ NC.NA-AP.ZZ-0061(Q)

ATTACHMENT 6 (continued)

GM - Hope Creek 3 8/31/89 Operations o Some or all of the main steam line seat drains did not open.

o Scram discharge volume outboard valves closed before inboard valves.

The Alarm Chronolog/Sequence of Events Record bears out this chronology. Within ten seconas attar the se~a* the operators backed it up with a manual scram. Fifteen seconds after the scram the high SDV level scram logic actuated.

ROOT CAUSE AND ANALYSIS The Significant Event Response Teaa concurs with the station's determination that the scraa*s initiating event was the near-instantaneous failure of a 112* soldered connection where the scram valve pilot air line from HCU 34-59 joined th* 1-112* head*r interconnwetinq a bank of HCU's on the south side of Reactor Building Elevation 102.

Th* te- concludes tbat tb* root caue of .thi* failure va* a coabination of i1U1Ufficient deptb of 1D8*rtioa and undesirable joint ali91111ent during original in.tallation. Tbere i* evidence of excessive force having been IUled ill th* pa11t OD a nearby isolation valve witb th* potential to bave tr....aitted veakend the already deficient joint. Activiti** of a . .rby painters cannot be directly linked to th* break.

Our detailed analysis and ranking of root cau*** is a*

follows:

Insufficient Tubing inaertion - Viaual examination of the failed joint revealed that only about l/4* out of a possible 1/2* insertion had been achieved during original construction. RANK: Highly probable a* Root Cause and Potential Future Probl***

Poor Soldering Tecbniqu* - Examination of tbe failed joint showed a uniformly wetted appearance, de*pite tb* limited engageaent. RANK: Improbable.

Inadequate Becbt*l Procedure- Procedure P107H-l01-S1 dated December 28; 1973 and amended in April 1984 was reviewed and found to require correct solder and insertion for the given service. RANK: Eliminated *

• Nuclear Common Page 3 of 7 Rev. 1

NC.NA-AP.ZZ-0061(Q)

ATTACHMENT 6 (continued)

GM - Hope Creek 4 8/Jl/89 Opera u.o!ls Incorrect Solder Used - The AWS Soldering ~anual. 2nd Ed ..

shows that metal-to-me.tal shear strengths for properly soldered joints should be about 5600 psi for 50\ lead/SO\

tin soldered joints, aa specified for this application. Use ot a 90\ lead/10\ tin "household* solder, would yield about 2100 psi shear strength, adequate strength for the intended service. RANK: Elimin~ted.

Di!!erent Styles of Tee Fittinq - It was determined that two style* of t9e fittinq had been used in the 185 soldered connections. Neither seemed to predominate. and both called for the saa* level of soldering skill. RANK: Eliminated Shock and Vibration in Normal service - A team member ob*erved tvo half-scram deaon*tration* of HCU 34-59 and observed no movement of th* subject tullinq. In addition, in*pection of the l-1/2* lin* in th* area of its supports for chafing and wear determined that vibration is not a conc*rn. RANK: Eliminated.

Accidental Bumping by Nearby Work - Extensive painting ha*

gone on in th* immediate area tor about a month. Th* entire HCU bank wa* enshrouded in scaffolding and plastic tarpaulin* at th* time of th* event. Vi*ual exaaination of the tulling revealed no mark* other than a band print on the l-l/ 2* header. [Note: the l/2* line is cantilevered from the tee fitting and un*upported in it* 4-foot vertical drop to the HCU. It i* behind tvo other steel hydraulic lines, relative to the neare*t scaffolding, set in about 2 feet.

Although it i* difficult to get to, it is unsupported and susceptible to bumping.) RANK: Po**ibl* Contributing Cause and Potential Future Problem.

Isolation Valve Manipulation - Imaediately upatream of each HCU's pilot air valve is a GE-supplied, pluq type iaolation valve. There 1* no installed handle, only a square stem.

Many st*. . bore scars from prior manipulation* and still had old string* and reananta from red taq*. The teaa requested Operation* to demonstrate the u** of th*** valve*. An EO, u*ing a 112* box wrench wa* unable to turn tvo repre*entative valve*. Th* tubing wa* observed to deflect 1/4* inch at the elbow. Uaing more force would have cau*ed undue deflection on th* u119upported 4-ft riser, placing stre** on the failed joint. RANK: Probable contributing cau*e and Potential Future Probl***

• Nuclear Common Page 4 of 7 Rev. 1

NC.NA-AP.ZZ-0061(Q)

ATTACHMENT 6 (continued)

• GM - Hope Creek Op*rations 5

PSE&G Rework of Fitting - At SERT's request. Station Planning reviewed !'!HIS and its predecessor. FOCUS, and 8/31/89 determined that PSE&G had never P*rform*d corrective maintenance on the subject HCU or any of its related fittings. RANK: Eliminated as Root cau** but Potential Future Problem.

Joint Cocked - This joint and several others appeared to have be*n made s*veral degrees out of linear alignment. All such joints were included in the 20 s*l*cted !or radiography.

None w*re found to be internally miaaliqn8d. RANK: High Root Cause Probability, but low potenti4l for future problems.

Operator Inattention/Error - Had th* joint b**n leaking slightly before the failure, it would hav* b**n concealed aaong th* racks of tubinq abov* the HCU's. Any slight hissing would hav* b**n inaudible abov* the normal soun~ of the KCU's. Th* scr!!!!! di~charq@ air he*d*r pre**ur* in th*

control room is track*d on a "quie*c*nt* CRIDS scr**n and referred to regularly by the NCO's. Th* depres*urization was too rapid to be corr*cted and the scraa av*rted. RANK:

Eliminated.

SAf£IY SIGNIFICAHCE The imtruaent air sy*t. . serve* UDY plim.t ~t=i=Q wbieh,

• although thoy fail safe upon lo** of air, C1111Ulatively affect nuclear safety. Tb* principal incentive for a**urinq in*tru11ent air integrity Uld reliable *upply i* to avoid challenqe* to th*** fail-safe arraav...nt* and to *in.U.ize unplaDDed abutd0Vll8. Inability to *fail-*afe* ** a re*ult of deqrad9Cl air quality 1* th* subject of Generic Letter 81-14. to which PBEM; ra*ponded earlier tbi* year.

The irreqular rod pattern which exi*ted briefly durinq the early *8CIDD:da of th* event i* bein9 evaluated by Reactor EnqineerinCJ and General Electric. It 18 PD9*il>l* that this pattern c:atlld bave exi*ted a011e11bat lonqer bad low level not been nac:bed Uld th* reactor not scr....ct until th* SDV level 1"08**

TECHNICAL ASPECIS Solder8d joints exist in various other low pressure systems of th* plant, and the potential tor improperly made joints still exists there.

Nuclear Common Page 5 of 7 Rev. 1

NC.NA-AP.ZZ-006l(Q)

ATTACHMENT 6 (continued)

GM - Hope Creek 6 8/31/89 Operations

~EAR TERM RECOM?1£NDATIONS These r9commendations were developed by the team and include some activities which were intiated by the station:

Testing Prior to Restart -

a. Perform and interpret radiographic examinations on 20 selected 112= to 1-112* tee connections.

Verify the above for complete inaertion and proper utilization of in*taller's scribe marks.

b. If any deficiencies are found in the saaplinq, resolve them or radiographicallY examine all reaa1ning tee fitting*.

c. Leak check (*snoop*) all 185 scraa pilot air header risers at all four soldered conn@ctions

<i.e. at the isolation valve, at th* 90 d99r*e elbow and at th* te*I *

d. *pu11* te*t all 185 tee joint* to demonstrate th* ability to with*tand normal operating stre*****

LONG TtRM R£COMM£NQATIONS Otber Te*tinCJ -

a. Continue the ongoing te*ting proqram tor *1arqe bore instrWllent air piping, which b99an prior to tbis event. Coapl*t* it prior to r**tart after th* refueling outage.

b. Expand th* above prograa to include smaller siz** of in*trument air tuoiDCJ (down to 1/2*.J. Complete thi* t**tiDCJ prior to re*tart after th* refueling outage.

Procedure ChanCJ** -

• • Reaove th* word *recomaended* froa MD-SP.ZZ-OOlCZJ, Step 5.2.J. Provide required minimum insertion depth**

b. Revise Step 5.2.S to improve and standardize all future scribing of soldered joints.

Nuclear Common Page 6 of 7 Rev. 1

i iJ, NC.NA-AP.ZZ-0061(Q)

... ATTACHMENT 6 (continued)

GM - Hope Creek 7 8/31/89 Operations Operational Changes-

a. Ensure. by administrative controls. that excessive force is never used to manipulate the scram valve pilot air header isolation valves on the HCU's.

b. Develop instructions for Operations ana/or Mmintenanee on how to free and lW:lricate a stuck HCU scram valve pilot air header isolation valve.

c. Inform GE and the industry of our operating experience With th*** valv*** Search for existing operating experience on these valves.

d. Develop a preventive maintenance proqram to en*ure ea** of operability of th**@ v~lve= OR consid*r replacing th*** valve* with a d**iqn resistant to drying and airborne impurities, depending on co*t-benet1t.

f. Aesure that Maintenance procedure* address supporting the cantilevered 1/2* line in the event the HCU and/or it* air valve require re*oval *

• q. Publicize to plant personnel the need for care when working around soldered or brazed connections.

The members of the Siqnif1cant Event R**pon.e Te ..

appreciate the opportunity to a**iat Rope Creek by performing this root cause analysis. Th* t*a* wa* in operation tor two day* a* mentioned aaove and involved approximately 95 work hours.

We remain available to an*w*r any que*tioa. you may have.

-yf F-. htvc.

J. P. Ronatalvy

.SERT Manag@r C{}ft.srg Nuclear Common Page 7 of 7 Rev. 1

NLR-N93172 ATTACHMENT 2 SERT MEMBERSHIP The SERT consisted of the following personnel:

SERT MANAGER Craig Lambert Manager - Nuclear Engineering and Project Services SERT MEMBERS Dan Eskesen Salem - Operations Lou Miceli Salem - Technical Ken Moore Salem - Onsite Safety Review Scott Ward Salem - Station Quality Assurance Mike Reese Nuclear Training Center Wayne Choromanski Reliability and Assessment Lyle Mayer Nuclear Electrical Engineering Dennis Connell Salem - General Manager's Staff