2. Unbo) Wftcted ImV tW AM 13wl13mtffw3E3#w=*3. Cotgno FWWM Ksywords: p

4. ACR SiGnMeance Uvet r_] A [313 P C E] 0 [3 W* S. Causal Factor

CW*s: ftiluteMo"Codo(s) FallwoGnum Coda(*) HUranPaton=rA*/Programmxticcwj"cocws)

1[3 WA WA 1[3 WA. Evam:

rmaki9e; Facie Ge&wmm- S*ppment -*CA d=.d lad*-krg kiftW owww 13 DxNW - dw -*wft Of Wl I TwW21128"t B !jet w0able ImmompUem

Distributlon List pftimmev"Ibn rmtmftl Pow-clasov rmwnnw

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Distribution Acton Codes: A- "alanad Lead In.emilgatw - gWor ta AZT30M PEOUMT and L*od kymw6gater Asatunmont Shamt (Form PtP 4-4) 8, Oth*r Action A*xlWwwnt - Rater I* ACTION REQUEST C. Wormatm Only No action Yequired. FuU ACP docwneM pe ge

0n, ýMbxcn requIrsct Traftaftow Sh**t aftly-

I

ALdvemConffitionlRe rt Nonbeag NV4" er.'jý Transmind,5bft

~pp-iq-n WF.D PM NUCLEAR LICE ~i GP0

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N )(rtbSZ Nder Adverse Condition Report ______

Lead Investigtor Assignent Sheet ACR#?fo

7hLea6 r b ulUUIWWStMWW*UW'.USSWdUCAIPS

0 Apwflcasa flr dan*~. SV i =M'~t. n* G 1 atsee awdrs~ n eiw

~ProidAe ag Reviewm T"*e byft or f AC P 4-7.bdwfrSi rrbide

condnasioa hat1

[0 ES e.iL-,dfdblwfrsftt rrW vnscaor&,stSewetE I

C PUAlS MAaintmnwnca History -Sevch, the PMMS database for the affeted sWath. tuctare arid coh4Wrpowf (SSCs) and related SQSC. The seawch should go back rive years.

C NPRDS - Cortac a MaWenlanCe or I&C NPRDS cocrdtruator and request a NPRDS sew~cl lox similar or relaed

components.

C NPO Inform.tion - R.v,#m the INIPO an4 nduhstry operating weariioc. informatcct liste below.

Cm~tbwabon hetf 0I

9 onnaider mo boflowing potmnliarty toelaed issues or Owicationz. or other, considerrzons dwurin the investigation

Confitnuatin SheetS

C. Required evalNations to support kwe~stgastlon As lead hwestgator. you ar* requited to bflltet at cowrdinate (suhas In11 the case of operabl~tty an~d roportabltty deternlnattions) these mvauaftmos

ED Op.rabiwr Evaftution - Lead kgudiduat _____________

9l Repoflýll Determination - Load sndv~at _ ____________

o PSSH (NGP2.01). 9 HPES Emluation 0 £0 (NO 2.29) 0 Omec____ _ Nwae

D. Is an LSR or other written report to the NRC required or potenitlany required?

q No 9 Yes - Type of reo-t 9 LEA 9 Othes -___ Raqurre stotic date _____

Lead bndividuad icr report prsparatcr

L. Thet following budividiak I groups muml review thob causal factoirs and eonetls actin plan:

1. Managementr UP to and hncWdiNg the tct[OwinT.

o Manage riDepartrnont ?41a± _______3wet Sr.vP - ,UTsOn

2. Other inditviuais or groups;

3. Oversight reviw groups.

Ol PORC: E] MPI C5 MP2 5 MPS 03 N______ one

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N&&saM toAdverse Conditon Report

Cast Fact"s ad Covemdn ACtio Pbs

ACR#710 I

~rImovstwn iped P-roc mmgemt wawt mad am ACt wa secn IN-t fpc w~dt Kcaemdyi pAew*miftnim ftftisac o t Mo~c atf

8Canal Gkt=r and correctiwe actions prepared by.

9. Acceptance oftcmzctve action responsibilities =6d planed camp kaon darm

Namn6Dcpfartmc D=

NamelDepatnext Dhrc

NameDepartmetc= Dow

10- Review of cauml fu vs, corrective actionts and planed comipletion dates.

Name/tridle: 4D4-0

Name/ T itir D=

S. Other required indlivxduals (refer to Form RP 4-6 Block E2)

Nazne/ TitLe- Due:

Name/ Tidle: Date:

C. Assigned Events Analysis Coordinator (refer wo Form P.P 4-5):

Name:-ýo%-*\D- N

1), Oversight Review Groups (refer to Farm RP 4-6 Block E.3):

PORC-Unit I Meeting Number Dar

PORC-Unit / Meeting Numb=r Deu:

flrhtr- Mtrting, Nnmhrr fare:

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QttbastNacur dverse Condition Repot A R N 01 Fo~~~m ~Initiation Form A RN 01

Rtr.O0fa at Ict

Appro~ved& 4 t('". SORC: qs',EW . 2 -q

Provide U* folUowing IrdnTad~on to the bee tit yoix abfy. Provide eonogh Infam~nn so Use hmna cm~ be

understood by thers whowia rwwLuu3 .e oI~cln p~ ~~~# a

Usept uporvlsacrb ine ow l0aiu Rmv dhft4F.

Adverse Candition InforMaI~on hiI awwidteDok1-.P'ndltmtwz

1. Descrbe the adverue condliost (The bak Cd Ofts $WMl 5MS ty" at k*x~waOf Youh ihwd kxk"*)

~ýikL Aq- 0. F/A t STI P WKQ. WLý 0

3.What inktal clsWR taken as a resgit C4 *ae kkdn? se

4. W4Atdo ou nowor suspect was the cause of the adverso a fitlow? j

S.WaCRo o Revi mrew da Eonsrrce acll etnen nomto isryWdad ntay*insae£di~t

11.~~-ý Suevio Reie IatIih

6. Sytam Engby.- t Lit/?CPW~tbz jcmedd)QN ~•'s-N

1C. Supavisor AR .avlew d wit "atSnRSzettl

TV=medlstaly bLka a pivWinde othffactud ShftSupwvSkar(ui ) No * Fwuwd tothu EwuwtuAnaiskoiar qbuin

sJ/Ak~o~f~r/dI FAXud LM Q)?A

*12. iniu tlathit supervisor Review (it ACA Want to SS):

Does ACR h&yS bl,V-W 5 EW. O Pcotho!flIaVif ~Of~t f ZW*,tV OP9Ub~tY~ r P~ OPereon2 g Ves- P1o. 'min FýOrm RP 44.

,Ma. Of ShM S4JP~rVWIeo/ /[, WA L-k•K ý Q- O NO- R.tan ACR bn Contrl R-J

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FAX NO, 860 440 2091

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Which 0Mw am riot OPERABLE "n wIt.

Doscrbe actýns bouh9 taken to resolve w.Etaimy:

Load ir6NkiU2 fesponsbte to raw"~v: Ext. _____ Coftwawsn lest

4. Yes*AZ REOTBE RN Uncertain

RepwcateoT. A (po~nmda* - attach a coNr of Nuclear Incident Ropoit Form Repofl~~ Cavg)y o8 LER) c mur utwes) [I Fr-D (Poti; linwws) 0 Other ___

Why is the AC4I REPOFMABLE

Cc-rua~a sr~ l

Dascrbe acUofk bomg taken~ to resolve ucertain~y-.

Duty Officur' (afl ACRS%) Date/Time:

Other (sp"cl) ____________________ ate no:

7._____SS____Signature:__________ Datefrime:___ rave)______

.9

'-00 WED 02:52 PN NUCLEAR LICENSING SVCS, FAX NO. 850 440 2091 P.10

Adverse Condition Report AR Nortean Nwadar Shift Supervisor Review L ~

Ann. ,dkak7 4 .. SORCr 9 O -Wci 2& aI'?5s

Pr~vd W. tilowng I~t~tim t~h. est I~jar b'Bi. ftoh btwdom na In U back~ cot. 1h% .*P dwiso yawx twvlew you consie oddUsa kdoumtbt Is ripqubud receWe O WdNB or aee bividwaW raide 1.zo

i. Piact Ccwvdonw Mods; 6 ftg p0*04c % =STw0ffp. / OF R P= swft "-g

2. Atm hiftWm cmeOrvl sefloam su~fthint? eYw No - Di~scbo aVW edd4Un aon Iaken o-r requlr

Am mas ofa the affected suucurma, systma or ow*neponts (SBCS) sa .ry-e.4 or -avetd by TacnihcaZ SpOGlka"Mo

(TS) or to. Todwcwla Ruqukaefti MoNUW (M"? g]yes No - 0o0 Smctý 4

im AjU ca S~~ssc3Mad wo~a~ TS I TRM Swtirqs):

Am. Owes. sbdz1*dtrn. tMs or componefts OPERABLE? MYes 0 o u c-iup au

P-1Q-nnf uJFP nq!v,2 PM NIJIrIP AP I 1(P~qNrI , p

Norheat uckar Adverse Condition Report AR i ~ EzNortes ula Management Review F PW Rey. Pag papI t1

Rater to b hCtlrnS oma the bm*J of this farm it daring your review you 8xksid r el ki a h~eon Is. rmqufrd ruqoemtatli neo opsvd ,poI y"My.I or meqest anussmnfom &M~w kiWbu&WvI:

1. Was UV.ACIA proceseed tmootw SMi $upWV*ottSS WiW&aFuaa~P3, E 4y-3V

N/A 00a 0 dawamur

LSW___AMO Co~oShea [3

The Events Analysi CoordkMor "cmpltes the folftwlnW A, Shoudti hs AC~tbe tevq*d byth*.SS? [3 No E] Yes - Takeoor provide ACA to Vie appropfiaf* SS(s) EL At r emmtaJonctive actios uftV 5~0~ Ye [] 5 N - DescRb. any a*MkXona adiln taken or required:

Coauiabon Sh"o

C, Should Me ACV4 be teviwed at a unit Morning mneeting? Q No EC Yes - Proces e=s kogi at hel morng e¶- nw.am

2. WtiR the ACR be closed f ollowing lbdtal reVIew? Ye m- ProvdO basis lto closure, then go to Block 6.No

L B"5 0 uelongs in another problem reponing syat-a IIFor 03 Low siga(canco. .au. . understood. corructive action camplaot, IM Mo gsnric irt~catons. ]Closure 0 Ote ruason (axplazy

3. What additional evaluations am requred durlrig the Investigation? E0 PSSi (NGP 2-01) E0 SPES Evaluation E] JC (XQP 2.29) 0-- O*.ri M__________

4. WMat adltkxnal reviews of the I wastigatin resuUi and corrective action ptan are requfred?

Omefc Op UP DS&9VP35 4 C3 te Nraon'iee

6. Comnpleted by: 7,R~-.~Otljn: 'i~''

Cannuabon Shm

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