05000261/FIN-2016003-02
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Finding | |
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| Title | Failure to Assess and Manage Risk for Main Turbine Trip Maintenance Resulting in Turbine/Reactor Trip |
| Description | A self-revealing Green non-cited violation (NCV) of 10 CFR 50.65(a)(4) was identified for the failure to adequately assess and manage the increase in risk associated with online maintenance activities involving the removal of the cover to the main turbine trip mechanism in order to perform visual inspections. During removal of the cover, the turbine trip mechanism lever was contacted causing an automatic turbine/reactor trip. The licensee took immediate corrective actions to reemphasize the need to enter all applicable types of work activities into the work management process and to conduct formal risk assessments in accordance with the risk management program. The licensee entered this issue into the corrective action program (CAP) as condition report (CR) 2056554. The licensees failure to adequately assess and manage the risk of maintenance associated with visual inspection of the turbine trip mechanism was a performance deficiency (PD). The inspectors evaluated the PD in accordance with IMC 0612, Appendix B, Issue Screening, and determined it to be more than minor because it impacted the human performance attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during power operations. Specifically, the failure to assess and manage the risk associated with removing the turbine trip mechanism cover to conduct visual inspections resulted in a turbine/reactor trip. The inspectors evaluated the finding in accordance with IMC 0609, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process. In accordance with Appendix K, the inspectors requested that a regional Senior Reactor Analyst (SRA) independently evaluate the risk. A Region II SRA performed an analysis of the risk deficit for the unevaluated condition associated with the work activity on the turbine trip mechanism. The latest Robinson Standardized Plant Analysis Risk (SPAR) model was used to calculate an incremental core damage probability deficit (ICDPD). The result was an ICDPD of 3.74E-7 and represented the increase in core damage probability associated with a turbine/reactor trip coincident with the dedicated shutdown diesel generator being out of service at the time of the event. In accordance with IMC 0609, Appendix K, because the calculated ICDPD was not greater than 1E-6, the finding was screened as having very low safety significance (Green). The cause of the PD was directly related to the cross-cutting aspect of work management in the cross-cutting area of human performance because the licensee failed to adequately implement a process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority. Specifically, the licensee failed to adequately assess, manage, and implement risk management actions for activities associated with trip sensitive equipment. |
| Site: | Robinson  |
|---|---|
| Report | IR 05000261/2016003 Section 1R13 |
| Date counted | Sep 30, 2016 (2016Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | C Dykes J Reece J Zeiler R Kellner S Rose W Loo W Pursley |
| Violation of: | 10 CFR 50.65 10 CFR 50.65(a)(4) |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Robinson - IR 05000261/2016003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Robinson) @ 2016Q3
Self-Identified List (Robinson)
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