05000272/FIN-2014004-01
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Finding | |
|---|---|
| Title | Improper Risk Assessment and Risk Management Actions for a Reheater Drain Valve |
| Description | A self-revealing, Green NCV of 10 CFR 50.65(a)(4) was identified when PSEG did not properly assess and manage risk on Salem Unit 1 during an evolution with the potential to cause a reactivity change and overpower event. Specifically, while working on a moisture separator reheater (MSR) drain valve, it failed closed, reduced MSR reheat efficiency, led to turbine control valves opening further, and resulted in an overpower event. Consequently, this resulted in violating the thermal power limit in license condition 2.C.(1). PSEG took actions in accordance with procedures to place the valve in manual and lower power to restore it within the license limit. Additionally, they classified this as a reactivity event, entered it in their corrective action program, and performed an apparent cause evaluation. The issue was more than minor since it was associated with the configuration control attribute of the barrier integrity and adversely affected its objective to provide reasonable assurance that physical design barriers protect the public from radionuclide releases caused by accidents or events. Specifically, the system alignment was impacted during maintenance, resulting in an overpower event. It was also similar to IMC 0612, Appendix E, Example 8.a. The finding was then evaluated using IMC 0609, Attachment 4 and Appendix A, Exhibit 3, where it screened to Green since it was only associated with the fuel cladding barrier. The finding was determined to have a cross-cutting aspect in Human Performance, Avoid Complacency, in that individuals recognize and plan for the possibility of mistakes, latent issues, and inherent risk even while expecting successful outcomes. Individuals are expected to consider potential undesired consequences and implement appropriate error reduction tools. Specifically, PSEG staff relied on past successes and assumed conditions working on this and similar drain valves and did not perform adequate, successive activity reviews when the valve exhibited unexpected responses. |
| Site: | Salem  |
|---|---|
| Report | IR 05000272/2014004 Section 1R13 |
| Date counted | Sep 30, 2014 (2014Q3) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | A Patel A Ziedonis E Burket G Dentel J Schoppy P Finney R Barkley |
| Violation of: | 10 CFR 50.65(a)(4) 10 CFR 50.65 License Condition |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Salem - IR 05000272/2014004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Salem) @ 2014Q3
Self-Identified List (Salem)
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