05000219/FIN-2015002-04
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Finding | |
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| Title | Reset of the Automatic Voltage Regulator Controller Led to an Automatic Reactor Scram |
| Description | A self-revealing finding was identified because Exelon did not properly screen work in accordance with MA-AA-716-010, Maintenance Planning. Specifically, on September 12, 2014, Exelon did not screen the automatic voltage regulators (AVR) human machine interface (HMI) post-maintenance test per the maintenance planning procedure. As a result, on October 12, 2014, Exelon personnel performing the post-maintenance test did not have a work order, which would have included plant configurations and limitations associated with the test. This led to an automatic reactor scram. Exelon entered this issue into the corrective action program. Planned corrective actions include reinforcing with work planners that a work order is required for similar work activities. This finding was 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 plant operation. Specifically, resetting the three AVR controllers caused an automatic plant scram. 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, on October 12, 2014, Exelon personnel did not stop when faced with the uncertain situation of the HMI screen that did not respond as expected. |
| Site: | Oyster Creek |
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| Report | IR 05000219/2015002 Section 4OA3 |
| Date counted | Jun 30, 2015 (2015Q2) |
| Type: | Finding: 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 |
| 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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