05000219/FIN-2015002-03
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Finding | |
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Title | Reactor Water Cleanup Procedure Not Followed Resulting in a Level Transient |
Description | A self-revealing NCV of Technical Specification 6.8.1(a), Procedures and Programs, was identified because Exelon did not follow procedure 303, Reactor Cleanup Demineralizer System, during the system restoration on March 26, 2015. Specifically, during startup from a forced outage (1F36), Exelon did not follow procedure 303, which required correct valve lineups for system restoration of reactor water cleanup (RWCU) after system isolation. This resulted in decreasing reactor water level, which was automatically terminated by a second RWCU isolation. Exelon entered this issue into the corrective action program. Planned corrective actions include enhancing operator training in system knowledge and procedure compliance and revising startup procedures. This finding is determined to be more than minor because it is associated with the human performance attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, Exelon did not properly lineup the RWCU system after isolation, which resulted in a water level transient and challenging the critical safety function of inventory control. This finding is determined to be of very low safety significance (Green), because it did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. This finding has a cross-cutting aspect in the area of Human Performance, Challenge the Unknown, because Exelon did not recognize and plan for the possibility of mistakes, or implement appropriate error reduction tools. Specifically, the operators did not stop and fully communicate plant condition after the initial RWCU isolation. Consequently, operators opened the RWCU system inlet valve due to the increasing water level without following procedure guidance. |
Site: | Oyster Creek |
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Report | IR 05000219/2015002 Section 4OA3 |
Date counted | Jun 30, 2015 (2015Q2) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71153 |
Inspectors (proximate) | A Patel B Dionne E Andrews M Patel S Kennedy T Fish |
Violation of: | Technical Specification - Procedures Technical Specification |
CCA | H.11, Challenge the Unknown |
INPO aspect | QA.2 |
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Finding - Oyster Creek - IR 05000219/2015002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Oyster Creek) @ 2015Q2
Self-Identified List (Oyster Creek)
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