05000219/FIN-2009004-01
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Finding | |
|---|---|
| Title | Unexpected Power Drop When Transferring Mode of Control of Recirculation Pump |
| Description | A self-revealing NCV of Oyster Creek Technical Specification 6.8.1, Procedures and Programs, occurred when Exelon did not properly implement procedures to transfer the D reactor recirculation pump from local manual to remote manual control which resulted in an unplanned reduction in reactor power on August 6. Operations personnel misread the scoop tube position indicator on D reactor recirculation pump motor generator set and did not properly match it with the speed indicated on the remote controller in the control room as required by the procedure, resulting in a reduction in recirculation flow and a reduction in reactor power. Exelons corrective actions included restoring D reactor recirculation pump speed, replacement of the existing unmarked scoop tube position indicators with numbered position indicators and a revision of the procedure 301.2 Reactor Recirculation System to include cautions and additional information on how to read the scoop tube position indicators. This issue has been entered into Exelons corrective action program. This finding was more than minor because it was similar to example 4.b in Inspection Manual Chapter 0612, Appendix E and resulted in a power reduction of 3%.Additionally, the finding was more than minor in accordance with IMC 0612, Appendix B(Section 1-3), Issue Screening, because it was associated with the human performance attribute of the initiating events cornerstone and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. In accordance with IMC0609.04 (Table 4a), Phase 1 Initial Screening and Characterization of Findings, the finding was determined to be of very low safety significance (Green) because the finding affected the initiating events cornerstone and was a transient initiator contributor that did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available. The performance deficiency had a crosscutting aspect in the area of human performance, work practices [IMC 0305, Aspect H.4.(a), because Exelon did not effectively implement human error prevention techniques, such as self and peer checking. Specifically, Exelon did not effectively use peer checking when determining the position of the reactor recirculation pump motor generator set scoop tube and the operators proceeded in the face of uncertainty when faced with poorly marked scoop tube position indicators |
| Site: | Oyster Creek |
|---|---|
| Report | IR 05000219/2009004 Section 4OA3 |
| Date counted | Sep 30, 2009 (2009Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | J Kulp M Ferdas T Wingfield R Nimitz R Bellamy H Gray |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Oyster Creek - IR 05000219/2009004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Oyster Creek) @ 2009Q3
Self-Identified List (Oyster Creek)
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