05000244/FIN-2014002-04
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Finding | |
|---|---|
| Title | Failure to Adhere to Procedural Requirements for Authorizing the Application of a Tagout |
| Description | A self-revealing Green finding (FIN) was identified because Constellation Energy Nuclear Group, LLC (CENG) failed to authorize the application of a tagout in accordance with procedure CNG-OP-1.01-1007, Clearance and Safety Tagging, Revision 01101. Specifically, CENG did not adequately implement equipment tagging procedural requirements to verify plant effects and tagout boundary impact prior to removing the specified equipment from service. As a result, two air operated valves (AOVs) unexpectedly opened when a tagout was being hung and resulted in a trip of all running condensate booster pumps on low suction pressure and a plant transient. The inspectors determined that the failure to follow procedural requirements was more than minor because it was associated with the configuration control 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, CENG did not follow procedural guidance when reviewing the tagout to ensure that the consequences of removing the specified equipment from service had been evaluated from the perspective of plant effects and tagout boundary impacts. This resulted in a plant transient as operators rapidly reduced plant power in order to avoid a more significant plant transient. Additionally, the finding is similar to IMC 0612, Appendix E, Examples of Minor Issues, Example 4.b., in that a personnel error caused a plant transient. The inspectors evaluated the finding using IMC 0609, Attachment 4, Initial Characterization of Findings, worksheet to IMC 0609, Significance Determination Process. The attachment instructed the inspectors to utilize IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power. The inspectors determined the performance deficiency to be of very low safety significance (Green), because it did not involve the complete or partial loss of a support system that contributes to the likelihood of, or cause, an initiating event and affected mitigation equipment. This finding has a cross-cutting aspect in the area of Human Performance, Avoid Complacency, because CENG individuals did not recognize and plan for the possibility of mistakes, even while expecting successful outcomes. |
| Site: | Ginna  |
|---|---|
| Report | IR 05000244/2014002 Section 4OA3 |
| Date counted | Mar 31, 2014 (2014Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | D Dodson D Schroeder D Silk E Burket M Orr N Perry |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Ginna - IR 05000244/2014002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Ginna) @ 2014Q1
Self-Identified List (Ginna)
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