05000281/FIN-2015004-04
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Finding | |
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Title | Inadequate Procedure Causes Main Turbine and Reactor Trip |
Description | A self-revealing Green NCV of Surry TS 6.4.A.7 was identified because Unit 2 tripped during performance of 2-OP-TM-001, Turbine Generator Startup to 20% - 25% Turbine Power, on July 21, 2015. An inadequate procedure allowed the main turbine (MT) governor valves to open rapidly during MT overspeed protection controller (OPC) testing, increasing MT first stage pressure above the P-2 and P-7 reactor protection system (RPS) permissive step points, and subsequently causing a reactor trip. Specifically, 2-OP-TM-001 did not have the minimum level of information needed to ensure that there was no speed error between MT speed and the setter position before initiating the OPC test. This allowed the test to be conducted with a speed error that caused the governor valves to open rapidly at the end of the test and subsequently cause a reactor trip. This issue was documented in the licensees CAP as CR 1003328. The inspectors concluded that the failure of the licensee to have the minimum level of information needed to ensure task critical actions in 2-OP-TM-001 and for operators to avoid error traps in conducting the MT OPC test, as required by Dominion procedure SPAP-0504, was a PD. Using IMC 0612, Appendix B, Issue Screening, dated September 7, 2012, the inspectors determined that the performance deficiency was more than minor because it was associated with the procedural quality attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset stability and challenge critical safety functions during shutdown as well as power operations. Using IMC 0609.04, Initial Characterization of Findings, Table 2, dated June 19, 2012; the finding was determined to affect the Initiating Events Cornerstone. The inspectors screened the finding using IMC 0609, Appendix A, SDP for Findings at-Power, dated June 19, 2012, and determined that it screened as Green because the deficiency did not involve the complete or partial loss of a support system that contributes to the likelihood, or cause, an initiating event and affected mitigation equipment. This finding has a cross-cutting aspect in the documentation aspect of the human performance area, H.7, because the licensee did not create a complete procedure for testing the MT overspeed protection. |
Site: | Surry |
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Report | IR 05000281/2015004 Section 4OA3 |
Date counted | Dec 31, 2015 (2015Q4) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71153 |
Inspectors (proximate) | A Sengupta C Jones D Bacon P Mckenna R Kellner S Rose W Loo |
Violation of: | Technical Specification - Procedures Technical Specification |
CCA | H.7, Documentation |
INPO aspect | WP.3 |
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Finding - Surry - IR 05000281/2015004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Surry) @ 2015Q4
Self-Identified List (Surry)
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