NRC Form 366 Licensee Event Report

NRC FORM 366

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0104

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may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the
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LICENSEE EVENT REPORT (LER)

(See Page 2 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/)
1. Facility Name

050

3. Page

2. Docket Number

1 OF

052
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
Year

-

Facility Name

050

Facility Name

9. Operating Mode

052

Docket Number

Docket Number

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)

10 CFR Part 50

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

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

73.1200(a)

20.2201(b)

20.2203(a)(3)(i)

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

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

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

73.1200(b)

20.2201(d)

20.2203(a)(3)(ii)

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

50.73(a)(2)(iii)

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

73.1200(c)

20.2203(a)(1)

20.2203(a)(4)

50.36(c)(2)

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

50.73(a)(2)(x)

73.1200(d)

50.46(a)(3)(ii)

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

10 CFR Part 73

73.1200(e)

50.69(g)

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

73.77(a)(1)

73.1200(f)

20.2203(a)(2)(iii)

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

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

73.77(a)(2)(i)

73.1200(g)

20.2203(a)(2)(iv)

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

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

73.77(a)(2)(ii)

73.1200(h)

20.2203(a)(2)(v)

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

50.73(a)(2)(vii)

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

10 CFR Part 21
21.2(c)

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 1326 spaces, i.e., approximately 13 single-spaced typewritten lines)

Cause

System

Component

15. Expected Submission Date

Manufacturer

Month

Reportable to IRIS

Day

Year

NRC FORM 366
(MM-YYYY)

LICENSEE EVENT REPORT (LER) (Continued)
REQUIRED NUMBER OF DIGITS/CHARACTERS FOR EACH BLOCK

BLOCK
NUMBER

NUMBER OF
DIGITS/CHARACTERS

TITLE

1

UP TO 127 / 2 LINES

FACILITY NAME

2

CHECK BOX FOR 050 OR 052
10 TOTAL
5 IN ADDITION TO 050 OR 052

DOCKET NUMBER

3

VARIES

PAGE NUMBER

4

UP TO 230 / 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 29 -- FACILITY NAME
CHECK BOX FOR 050 OR 052
10 TOTAL -- DOCKET NUMBER
5 IN ADDITION TO 050 OR 052

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 90 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

13 LINES OF TYPING

ABSTRACT