05000277/FIN-2016002-03
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Finding | |
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| Title | Human Performance Event Results in Emergent Downpower |
| Description | A self-revealing finding of very low safety significance (Green) was identified for the failure of Exelon operators to use human performance error reduction tools during equipment manipulation in accordance with HU-AA-101, Human Performance Tools and Verification Practices. Specifically, on March 28, 2016, an equipment operator failed to use self-check (STAR) while removing a circuit breaker from service and incorrectly tripped the E-124 480 volt supply breaker which required a rapid manual power reduction to 80 percent rated thermal power (RTP) due to lowering main condenser vacuum and a partial loss of feedwater heating. Exelon entered the issue into their corrective action program (CAP) under issue report (IR) 2646772 and performed a root cause which identified corrective actions to address the adverse human performance behaviors at the station. The finding was more than minor because it was associated with the human performance attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown, as well as power operations. Specifically, an equipment operator failed to adequately use human performance error reduction tools and opened an incorrect breaker which required a rapid downpower. The inspectors evaluated the finding in accordance with Exhibit 1 of IMC 0609, Appendix A, The SDP for Findings At-Power, dated June 19, 2012, and determined the finding was of very low safety significance (Green) because it did not result in a reactor trip and the loss of mitigation equipment relied upon for transition to a stable shutdown condition. This finding was determined to have a cross-cutting aspect in the area of Human Performance, Field Presence, because Exelon did not ensure that deviations from standards and expectations, which were identified by leaders, were corrected promptly. Specifically, Exelon identified that adverse human performance behaviors existed with certain equipment operators, however, those observations were not appropriately input into their performance management system, such that the behaviors could be addressed. Thus, these adverse behaviors were a primary contributor to this human performance error. |
| Site: | Peach Bottom  |
|---|---|
| Report | IR 05000277/2016002 Section 4OA3 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | B Smith C Graves D Schroeder J Heinly J Kulp J Patel M Modes P Boguszewski |
| CCA | H.2, Field Presence |
| INPO aspect | LA.2 |
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Finding - Peach Bottom - IR 05000277/2016002 | ||||||||||||||||||||||||||||||||||||||
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Finding List (Peach Bottom) @ 2016Q2
Self-Identified List (Peach Bottom)
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