Form NRC Form 366 NRC Form 366 Licensee Event Report

NRC FORM 366

U.S. NUCLEAR REGULATORY COMMISSION

(MM-DD-YYYY)

EXPIRES: (MM/DD/YYYY)

APPROVED BY OMB: NO. 3150-0104

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 FOIA, Library, and Information Collections Branch (T-6 A10M), U. S. Nuclear Regulatory
Commission, Washington, DC 20555-0001, or by email to [email protected], and the OMB reviewer
at: OMB Office of Information and Regulatory Affairs, (3150-0104), Attn: Desk Officer for the Nuclear Regulatory
Commission, 725 17th Street NW, Washington, DC 20503. The NRC may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless the document requesting or requiring the collection
displays a currently valid OMB control number.

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/)
1. Facility Name

050

3. Page

2. Docket Number

052

1 OF

053
4. Title

5. Event Date
Month

6. LER Number

Day

Year

7. Report Date

Sequential
Number

Year

-

Revision
No.

Month

Day

Year

-

8. Other Facilities Involved
Facility Name

Docket Number

050
Facility Name

Docket Number

052
Facility Name

Docket Number

053
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)(3)(i)

50.69(g)

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

53.1640(a)(2)(ii)(A)

73.77(a)(1)(ii)

20.2201(b)

20.2203(a)(3)(ii)

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

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

53.1640(a)(2)(ii)(B)

73.77(a)(2)(i)(A)

20.2201(d)

20.2203(a)(4)

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

50.73(a)(2)(vii)

53.1640(a)(2)(iii)

73.77(a)(2)(i)(B)

10 CFR Part 21

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

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

53.1640(a)(2)(iv)

73.1200(a)

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

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

53.1640(a)(2)(v)

73.1200(b)

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

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

53.1640(a)(2)(vii)(A)

73.1200(c)

20.2203(a)(1)
20.2203(a)(2)(i)

21.2(c)

20.2203(a)(2)(ii)

10 CFR Part 50

20.2203(a)(2)(iii)

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

50.73(a)(2)(iii)

50.73(a)(2)(x)

53.1640(a)(2)(viii)(A)

73.1200(d)

20.2203(a)(2)(iv)

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

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

10 CFR Part 53

53.1640(a)(2)(viii)(B)

73.1200(e)

20.2203(a)(2)(v)

50.36(c)(2)

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

53.1640(a)(2)(i)(A)

53.1640(a)(2)(ix)

73.1200(f)

20.2203(a)(2)(vi)

50.46(a)(3)(ii)

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

53.1640(a)(2)(i)(B)

10 CFR Part 73

73.1200(g)

53.1640(a)(2)(i)(C)

73.77(a)(1)(i)

73.1200(h)

OTHER (Specify here, in abstract, or NRC 366A).

12. Licensee Contact for this LER
Licensee Contact

Phone Number (Include area code)

NRC FORM 366

U.S. NUCLEAR REGULATORY COMMISSION

(MM-DD-YYYY)

LICENSEE EVENT REPORT (LER) (Continued)
13. Complete One Line for each Component Failure Described in this Report

Cause

System

Component

Manufacturer Reportable to IRIS

14. Supplemental Report Expected

No
16. Abstract

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

Cause

System

Component

15. Expected Submission Date

Manufacturer

Month

Reportable to IRIS

Day

Year

NRC FORM 366

U.S. NUCLEAR REGULATORY COMMISSION

(MM-DD-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 OR 053
10 TOTAL
5 IN ADDITION TO 050 OR 052 OR 053

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 OR 053
10 TOTAL -- DOCKET NUMBER
5 IN ADDITION TO 050 OR 052 OR 053

OTHER FACILITIES INVOLVED

9

1

OPERATING MODE

10

3

POWER LEVEL

11

VARIES
CHECK ALL BOXES THAT APPLY

REQUIREMENTS OF 10 CFR

12

316 CHARACTERS, 4 LINES FOR NAME
84 CHARACTERS, 4 LINES 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

CHECK 1 BOX THAT APPLIES

SUPPLEMENTAL REPORT EXPECTED

15

8 TOTAL
2 FOR MONTH
2 FOR DAY
4 FOR YEAR

EXPECTED SUBMISSION DATE

16

48 LINES OF TYPING

ABSTRACT