05000219/FIN-2017003-01
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Finding | |
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| Title | Inadequate Augmented Offgas System Procedure Resulted in a Manual Scram |
| Description | A self -revealing NCV of Technical Specification 6.8.1, Procedures and Programs, was identified because Exelon did not adequately establish and maintain the augmented offgas (AOG) system operation procedure as required by NRC Regulatory Guide 1.33, Quality Assurance Requirements (Operation), Appendix A, Section 7, Procedures for Control of Radioactivity. Specifically, Exelon procedure 350.1, Augmented Offgas System Operation, did not include adequate guidance for placing the AOG system into a recycle or shutdown configuration following a system trip. Without this guidance, Operations personnel failed to ensure the correct configuration of the AOG system following a partial trip of the system which resulted in degraded main condenser vacuum and a subsequent manual reactor scram on July 3, 2017. This issue was entered into the corrective action program as issue report 4028402. The corrective actions included placing the AOG system in the correct configuration and revising the AOG system operation procedure to provide guidance for verifying proper alignment of the AOG system when the system is in recycle or shutdown. The inspectors determined the performance deficiency was more than minor because it was associated with the Initiating Events cornerstone attribute of Procedure Quality 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. Specifically, the failure to establish an adequate procedure for verifying proper alignment of the AOG system following a full or partial trip of the system resulted in the AOG inlet valve being left in the open position, which allowed demineralized water to be siphoned from the flame arrestor tank and slowly fill the offgas hold- up pipe. This caused a degradation of main condenser vacuum and resulted in operators inserting a manual reactor scram on July 3, 2017. The inspectors evaluated the finding using IMC 0609, Attachment 4, Initial Screening and Characterization of Findings, and IMC 0609, Appendix A, Exhibit 1, Initiating Event Screening Questions. The inspectors determined the finding was a transient initiator that did not contribute to both the likelihood of a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of a trip to a stable shutdown condition, and therefore was of very low safety significance (Green). The finding had a cross- cutting aspect in the area of Human Performance, Avoid Complacency , because Exelon failed to recognize and plan for the possibility of mistakes or latent errors and implement appropriate error reduction tools by verifying the AOG system was properly aligned following a system trip ; instead , Operations personnel relied upon using a procedure that did not contain adequate guidance to place the AOG system in the correct configuration following a system trip [H. 12] |
| Site: | Oyster Creek |
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| Report | IR 05000219/2017003 Section 4OA3 |
| Date counted | Sep 30, 2017 (2017Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | K Carrington E Andrews S Elkhiamy T Fish B Fuller T Hedigan J Kulp J Lilliendahl J Schoppy S Shaffer S Kennedy |
| Violation of: | Technical Specification - Procedures |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Oyster Creek - IR 05000219/2017003 | |||||||||||||||||||||
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Finding List (Oyster Creek) @ 2017Q3
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