05000259/FIN-2009005-03

Finding

Title

Inadequate Operating Procedures Cause Partial Loss of Reactor Feedwater Which Results In Unit 2 Manual Reactor Scram

Description

A Green self-revealing noncited violation of Technical Specifications 5.4.1.a was identified for failure to adequately maintain the accuracy of critical operating procedures for Power Maneuvering, and Reactor Feedwater (RFW) and Condensate System operation, which subsequently resulted in a partial loss of RFW and a Unit 2 manual reactor scram. These procedures were subsequently revised to more accurately reflect integrated plant response and establish appropriate operating limitations for the RFW and Condensate systems. This event was entered into the licensees corrective action program as PER 203538. This finding was determined to be of greater than minor significance because it was associated with the Initiating Events cornerstone attribute of Procedure Quality, and adversely affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during at-power operations. Specifically, the licensees inappropriate revision of critical operating procedures directly contributed to an unintended partial loss of RFW flow resulting in a manual reactor scram. RFW was available throughout the event. The finding was evaluated using Phase 1 of the At-Power Significance Determination Process, and was determined to be of very low safety significance (Green) because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigating equipment or functions were not available. The cause of this finding was directly related to the cross-cutting aspect of complete, accurate and up-to-date procedures in the area of Human Performance because the licensee improperly revised several critical operating procedures H.2(c).

03
Site:	Browns Ferry
Report	IR 05000259/2009005 Section 4OA3
Date counted	Dec 31, 2009 (2009Q4)
Type:	NCV: Green
cornerstone	Initiating Events
Identified by:	Self-revealing
Inspection Procedure:	IP 71153
Inspectors (proximate)	C Stancil T Ross H Gepford E Guthrie L Miller K Korth
CCA	H.7, Documentation
INPO aspect	WP.3
'
v • d • e

Finding - Browns Ferry - IR 05000259/2009005

2(6)3(6)4(4)5(4)6(2)7(4)8(4)9(4)301(0)402(0)403(0)501(0)23(0)

IR 05000259/2009005: 1 2 3 4

Finding List (Browns Ferry) @ 2009Q4

CCA Matrix: 2009Q4

	Q	CCA	Title
05000259/FIN-2009002-02	2009Q1	P.2	Inadequate Surveillance Procedure Causes Loss of Unit 1 RHR System Safety Function (Section 1R22)
05000259/FIN-2009002-03	2009Q1		Unit 1 RPV Flange Leak Due to Lack of Prompt Identification and Resolution (Section 4OA2.3)
05000259/FIN-2009002-04	2009Q1	H.14	Main Generator Voltage Regulator Relay Failure Results in Unit 2 Reactor Scram (Section 4OA3)
05000259/FIN-2009002-01	2009Q2		Inappropriate Change to SSI Entry Conditions For Appendix R Fire Events (Section 1R15)
05000259/FIN-2009003-03	2009Q2	H.11 H.12	Failure to Comply with the Requirements of an RWP by Entering a Posted High Radiation Area
05000259/FIN-2009003-01	2009Q2	H.4 H.5	Failure to Assess and Manage Shutdown Risk Associated with Outage maintenance Activities
05000259/FIN-2009007-04	2009Q2		Categorization of Operator Manual Actions as Meeting Appendix R Section III.G.1 versus III.G.2
05000259/FIN-2009007-03	2009Q2		Operator Manual Actions to Isolate Main Steam Safety Relief Valves for a Unit 2 Appendix R Fire Event
05000259/FIN-2009007-02	2009Q2		Containment Isolation Valves not Included in the Appendix R Separation Analysis
05000259/FIN-2009007-01	2009Q2		Suppression Pool Initial Temperature Assumed in the Appendix R Thermo-Hydraulic Analysis May not be the Most Limiting Value
05000259/FIN-2009003-05	2009Q2	P.3	Untimely Actions to Resolve Excessive IBC System Condensation Results in Unit 1 Reactor Scram
05000259/FIN-2009003-02	2009Q2	H.7	Failure to Perform an Adequate Risk Assessment During Severe Weather Conditions
05000259/FIN-2009003-04	2009Q2		Inadequate Scoping of Risk Significant Systems For Online Risk Assessment
05000259/FIN-2009004-01	2009Q3		Unit 3 Reactor Core Isolation Cooling Pump Flow Oscillations
05000259/FIN-2009006-01	2009Q3	P.2	Standby Gas Treatment Subsystem A Inoperable Beyond the Technical Specification Allowed Outage Time
05000259/FIN-2009009-02	2009Q4	H.5	Failure to Establish Adequate Compensatory Measures for an Out-of-Service Hose Station
05000259/FIN-2009005-03	2009Q4	H.7	Inadequate Operating Procedures Cause Partial Loss of Reactor Feedwater Which Results In Unit 2 Manual Reactor Scram
05000259/FIN-2009005-04	2009Q4	P.1 P.1(a)	Unit 2 RCIC System Inoperable Beyond the Technical Specification Allowed Outage Time
05000259/FIN-2009008-01	2009Q4	P.5	Violation of Technical Specification 5.4.1 for Failure to Develop Adequate Procedures to Ensure Tornado Depressurization Protection of the Emergency Diesel Generators
05000259/FIN-2009008-02	2009Q4		Violation of 10CFR50, Appendix B, Criterion V for Inadequate Procedure for Emergency Equipment Cooling Water System Flow Balancing
05000259/FIN-2009009-03	2009Q4	P.3	Failure to Protect Cables of Systems Necessary to Achieve and/or Maintain Post-Fire Safe Shutdown Conditions for Fire Areas Subject to the Requirements of 10 CFR Part 50, Appendix R, Section III.G.2
05000259/FIN-2009009-01	2009Q4	H.5	Deficiencies with Emergency Lighting Units
05000259/FIN-2009008-03	2009Q4		Safety-Related Molded Case Circuit Breakers
05000259/FIN-2009009-04	2009Q4	P.2	Failure to Meet the Requirements of 10 CFR Part 50, Appendix R, Section III.G.1 for 20 Fire Areas
05000259/FIN-2009005-02	2009Q4	P.3	Failure to Report a Safety System Functional Failure Per 10 CFR 50.73
05000259/FIN-2009005-01	2009Q4	P.2	Failure to Report an Automatic RPS Actuation While Shutdown Per 10 CFR 50.73

Self-Identified List (Browns Ferry)

	Q	Title
05000259/FIN-2009002-05	2009Q1	Licensee-Identified Violation
05000259/FIN-2009002-06	2009Q1	Licensee-Identified Violation
05000259/FIN-2009003-06	2009Q2	Licensee-Identified Violation
05000259/FIN-2009004-02	2009Q3	Licensee-Identified Violation
05000259/FIN-2009004-03	2009Q3	Licensee-Identified Violation
05000259/FIN-2009004-04	2009Q3	Licensee-Identified Violation
05000259/FIN-2009006-02	2009Q3	Licensee-Identified Violation
05000259/FIN-2009008-04	2009Q4	Licensee-Identified Violation

[Browns Ferry Findings full list]

05000259/FIN-2009005-03

Navigation menu

Search