05000255/FIN-2012004-01
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Finding | |
|---|---|
| Title | Failure to Follow Work Management Processes |
| Description | A self-revealed finding of very low safety significance and two associated NCVs were identified for the failure to conduct maintenance activities in accordance with work management procedures. Two NCVs are being documented in accordance with NRC Enforcement Manual Section 2.13.8 because of a cause-and-effect relationship under one performance deficiency. The first NCV was of Technical Specification (TS) 5.4.1 for failure to implement work management procedures. Specifically, Fix-It-Now (FIN) maintenance personnel working on a control room light indication issue for the safetyrelated Component Cooling Water Surge Tank Fill Valve, CV-0918, conducted troubleshooting outside of what was originally planned and briefed. Contrary to work management procedures, the required documentation, independent and/or supervisory reviews, nor risk assessment were completed. This deviation resulted in the installation of jumpers from an 115V alternating current (AC) circuit to the safety-related 125V direct current (DC) power system, which actuated various control room alarms, including a ground alarm on the DC system. The second associated NCV, revealed as a result of the first, was for a failure to implement risk management actions as required by 10 CFR 50.65(a)(4), Maintenance Rule. Contrary to this, the licensee failed to perform a quantitative or qualitative risk assessment for work (installation of jumpers) on circuitry associated with CV-0918. Corrective actions consisted of entering the issue into the corrective action program (CAP) and reassigning the FIN team personnel back to their respective maintenance shops and a suspension of all tool pouch maintenance activities pending further investigation. The licensee also held information sharing sessions with the maintenance and operations departments about this incident, the work management process, the standards for implementing this process, and new checklists for use during work planning and authorization. The finding was more than minor utilizing IMC 0612, Appendix B, because it could reasonably be viewed as a precursor to a significant event and it affected the Initiating Events Cornerstone attribute of Human Performance, adversely impacting the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, planning and conducting work outside work management requirements resulted in a short circuit and various control room alarms. The finding screened as Green by answering 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 in Exhibit 1 of IMC 0609, Appendix A. Additionally, the inspectors screened the finding as Green utilizing an Incremental Core Damage Probability Deficit (ICDPD) calculation performed by a regional Senior Risk Analyst in accordance with IMC 0609, Appendix K, due to the one NCV associated with the Maintenance Rule. The finding had a cross-cutting aspect in the area of Human Performance, related to the cross-cutting component of Decision Making, in that the licensee uses conservative assumptions in decision making, adopts a requirement to demonstrate that the proposed action is safe in order to proceed, and identifies possible unintended consequences of a decision. In this finding, there were personnel in various departments that could have questioned the continuation of the maintenance with respect to following the work management process. |
| Site: | Palisades  |
|---|---|
| Report | IR 05000255/2012004 Section 1R13 |
| Date counted | Sep 30, 2012 (2012Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | T Bilik J Lennartz J Ellegood B Cushman M Jones P Laflamme T Taylor A Scarbeary |
| CCA | H.14, Conservative Bias |
| INPO aspect | DM.2 |
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Finding - Palisades - IR 05000255/2012004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palisades) @ 2012Q3
Self-Identified List (Palisades)
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