05000255/FIN-2014002-05
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Finding | |
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| Title | Failure to Follow Procedures During Reactor Vessel Head Lift |
| Description | A finding of very low safety significance and an associated non-citied violation of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self revealed when licensee personnel failed to follow maintenance procedure RFL-R-16, Reactor Vessel Closure Head Installation. Specifically, during the reactor vessel head lift on March 5, 2014, to support reinstallation onto the vessel flange, workers failed to identify an interference with the reactor head lift structure, causing the head to impact a jack screw on the structure and increasing the total load weight to approximately 283,000 pounds, which was greater than the procedural maximum polar crane load rating of 270,000 pounds. The licensee entered this issue into their CAP as CR-PLP-2014-01903, Reactor Head Flange Contacted Jacking Screw While Raising it Off the Head Stand. As part of their corrective actions, the licensee conducted a Level 1 Human Performance Evaluation, generated a site-wide Human Performance error communication, and performed work crew stand downs to discuss crane and rigging expectations. The inspectors determined that this finding was more than minor in accordance with IMC 0612, Appendix B, Issue Screening, because the finding was associated with the Human Performance attribute of the Barrier Integrity cornerstone and adversely impacted the cornerstone objective of providing reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Additionally, the inspectors determined that the performance deficiency could reasonably be viewed as a precursor to a significant event and that if left uncorrected the performance deficiency would have the potential to lead to a more significant safety concern. Specifically, the operability of the containment polar crane was required to be evaluated and the reactor vessel head was required to be inspected after the event occurred to verify no significant damage was caused and the maximum design limit of the crane could have been exceeded if the evolution was not stopped when it was, which increased the risk of dropping the head during the lift. The finding was screened in accordance with IMC 0609, Appendix G, Shutdown Operations Significance Determination Process, Attachment 1, Phase 1 Operational Checklists for both PWRs and BWRs. The finding was determined to be of very low safety significance (Green) based on not requiring a quantitative assessment after reviewing the five shutdown safety functional areas in Checklist 3, PWR Cold Shutdown and Refueling Operation RCS Open and Refueling Cavity Level < 23' Or RCS Closed and No Inventory in Pressurizer Time to Boiling <2 hours. This finding had an associated cross-cutting aspect in the Challenge the Unknown (H.11) component of the Human Performance cross-cutting area. Specifically, human performance investigations identified that workers exhibited a lack of rigor when performing interference verifications prior to and during the reactor head lift, and an inadequate stop when unsure mentality when assessing the situation before continuing with the head lift. In addition, the workers and supervisors for this task did not understand that the load cell increase exceeded the procedural maximum value and did not inform decision-makers outside of the immediate work area to validate it was safe to proceed with the evolution. |
| Site: | Palisades  |
|---|---|
| Report | IR 05000255/2014002 Section 1R20 |
| Date counted | Mar 31, 2014 (2014Q1) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | A Garmoe A Scarbeary E Duncan E Sanchez Santiago G Hansen J Cassidy J Lennartz M Jones M Phalen T Bilik T Taylor |
| Violation of: | 10 CFR 50 Appendix B Criterion V |
| INPO aspect | |
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Finding - Palisades - IR 05000255/2014002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palisades) @ 2014Q1
Self-Identified List (Palisades)
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