05000255/FIN-2011014-05
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Finding | |
|---|---|
| Title | Failure to implement Emergency Operating Procedure Immediate Actions |
| Description | A finding of very low safety significance and associated non-cited violation of Technical Specification 5.4.1 was identified by the inspectors for the failure to implement procedures for combating emergencies and other significant events as required by Regulatory Guide (RG) 1.33, Section 6. Specifically, during the performance of EOP-1.0, Standard Post-Trip Actions, in response to a loss of the left train 125-Volt DC bus and subsequent plant trip, the control room reactor operators failed to immediately take the contingency action in the response not obtained column for an immediate action step that could not be met due to the partial loss of control room indications. Procedure EOP-1.0, Step 2.b. of Section 4.0, Immediate Actions, required the reactor operator in the control room to verify that the Main Generator was disconnected from the grid, and if that step cannot be completed, then the operator was required to connect a jumper across the corresponding relay terminals in the control room panel to open the output breakers. These actions were not immediately taken by the control room staff at the time of this event. Once the control room staff was aware of the closed status of the Main Generator output breakers from an update provided by an extra reactor operator who was in contact with transmission system operator, the action step was then taken by the turbine-side reactor operator to jumper the relay terminals in the control room panel to open the breakers. This issue was documented in the licensees corrective action program as CR-PLP-2011-06081 and at the end of the special inspection the licensee was still performing an evaluation to determine the causes and to develop corrective actions. As a remedial corrective action on October 28, 2011, each operations crew received a briefing about operator expectations, the usage of human performance tools and procedures, and an overview of the recent events. The inspectors determined that the finding was more than minor in accordance with IMC 0612 Power Reactor Inspection Reports, Appendix B, Issue Screening, because, if left uncorrected, the performance deficiency could have the potential to lead to a more significant safety concern. In particular, this loss of 125-Volt DC event could have become a more significant event with further complications and plant issues. The inspectors determined that the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, Table 4a, for the Initiating Events Cornerstone, dated January 10, 2008. The inspectors answered No to the Transient Initiator question of contributing to both the likelihood of a reactor trip and the likelihood that mitigating equipment or functions would not be available and screened the finding as having very low safety significance (Green). The finding had a cross-cutting aspect in the area of human performance related to the cross-cutting component of Work Practices, in that the licensee communicates human error prevention techniques, such as peer-checking, and that these techniques are used commensurate with the risk of the assigned task, such that work activities are performed safely |
| Site: | Palisades  |
|---|---|
| Report | IR 05000255/2011014 Section 4OA5 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 93812 |
| Inspectors (proximate) | A Dahbur A Scarbeary J Giessner R Krsek |
| Violation of: | Pending |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Palisades - IR 05000255/2011014 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palisades) @ 2011Q4
Self-Identified List (Palisades)
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