Form 366 Form 366 License Event Report

U.S. NUCLEAR REGULATORY COMMISSION

NRC FORM 366
(MM-YYYY)

LICENSEE EVENT REPORT (LER)

(See Page 3 for required number of digits/characters for each block)

(See NUREG-1022, R.3 for instruction and guidance for completing this form
http://www.nrc.gov/reading-rm/doc-collections/nuregs/staff/sr1022/r3/)

APPROVED BY OMB: NO. 3150-0104

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this mandatory collection request: 80 hours. Reported
lessons learned are incorporated into the licensing process and fed back to industry. Send comments
regarding burden estimate to the Information Services Branch (T-6 A10M), U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001, or by e-mail to [email protected], and to the
Desk Officer, Office of Information and Regulatory Affairs, NEOB-10202, (3150-0104), Office of
Management and Budget, Washington, DC 20503. If a means used to impose an information collection
does not display a currently valid OMB control number, the NRC may not conduct or sponsor, and a
person is not required to respond to, the information collection.

1. Facility Name

3. Page

2. Docket Number

1 OF

05000
4. Title

5. Event Date
Month

Day

6. LER Number

Year

Sequential
Number

Year

-

7. Report Date
Revision
No.

Month

Day

8. Other Facilities Involved
Facility Name

Year

Docket Number

05000

-

Facility Name

Docket Number

05000

9. Operating Mode

10. Power Level

11. This Report is Submitted Pursuant to the Requirements of 10 CFR §: (Check all that apply)

10 CFR Part 20

20.2203(a)(2)(vi)

50.36(c)(2)

50.73(a)(2)(iv)(A)

50.73(a)(2)(x)

20.2201(b)

20.2203(a)(3)(i)

50.46(a)(3)(ii)

50.73(a)(2)(v)(A)

10 CFR Part 73

20.2201(d)

20.2203(a)(3)(ii)

50.69(g)

50.73(a)(2)(v)(B)

73.71(a)(4)

20.2203(a)(1)

20.2203(a)(4)

50.73(a)(2)(i)(A)

50.73(a)(2)(v)(C)

73.71(a)(5)

50.73(a)(2)(i)(B)

50.73(a)(2)(v)(D)

73.77(a)(1)(i)

50.73(a)(2)(i)(C)

50.73(a)(2)(vii)

73.77(a)(2)(i)
73.77(a)(2)(ii)

20.2203(a)(2)(i)
20.2203(a)(2)(ii)

10 CFR Part 21
21.2(c)

20.2203(a)(2)(iii)

10 CFR Part 50

50.73(a)(2)(ii)(A)

50.73(a)(2)(viii)(A)

20.2203(a)(2)(iv)

50.36(c)(1)(i)(A)

50.73(a)(2)(ii)(B)

50.73(a)(2)(viii)(B)

20.2203(a)(2)(v)

50.36(c)(1)(ii)(A)

50.73(a)(2)(iii)

50.73(a)(2)(ix)(A)

OTHER (Specify here, in abstract, or NRC 366A).
12. Licensee Contact for this LER
Licensee Contact

Phone Number (Include area code)

13. Complete One Line for each Component Failure Described in this Report
Cause

System

Component

Manufacturer

Reportable to IRIS

14. Supplemental Report Expected

No

Yes (If yes, complete 15. Expected Submission Date)

16. Abstract (Limit to 1400 spaces, i.e., approximately 15 single-spaced typewritten lines)

Cause

System

Component

15. Expected Submission Date

Manufacturer Reportable to IRIS

Month

Day

Year

REQUIRED NUMBER OF DIGITS/CHARACTERS
FOR EACH BLOCK
BLOCK
NUMBER

NUMBER OF
DIGITS/CHARACTERS

TITLE

1

UP TO 110 / 2 LINES

FACILITY NAME

2

10 TOTAL
5 IN ADDITION TO 05000

DOCKET NUMBER

3

VARIES

PAGE NUMBER

4

UP TO 195 / 2 LINES

TITLE

5

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

EVENT DATE

6

9 TOTAL
4 FOR YEAR
3 FOR SEQUENTIAL NUMBER
2 FOR REVISIONS NUMBER

LER NUMBER

7

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

REPORT DATE

8

UP TO 25 -- FACILITY NAME
10 TOTAL -- DOCKET NUMBER
5 IN ADDITION TO 05000

OTHER FACILITIES INVOLVED

9

1

OPERATING MODE

10

3

POWER LEVEL

11

VARIES
CHECK ALL BOXES THAT APPLY

REQUIREMENTS OF 10 CFR

12

UP TO 75 FOR NAME
10 FOR TELEPHONE

LICENSEE CONTACT

13

CAUSE VARIES (UP TO 8)
2 FOR SYSTEM (UP TO 8)
4 FOR COMPONENT (UP TO 8)
4 FOR MANUFACTURER (UP TO 8)
IRIS VARIES (UP TO 10)

EACH COMPONENT FAILURE

14

1
CHECK BOX THAT APPLIES

SUPPLEMENTAL REPORT EXPECTED

15

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

EXPECTED SUBMISSION DATE

16

1400 SPACES OR 15 LINES OF TYPING

ABSTRACT

NRC FORM 366 (MM-YYYY)