05000293/FIN-2009003-01
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Finding | |
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| Title | Failure to Follow Procedure Resulting in Damage to Refueling Mast |
| Description | A self-revealing non-cited violation (NCV) of Technical Specification 5.4.1 Procedures, was identified, because Entergys refueling bridge operators did not continuously monitor a Double Blade Guide (DBG) that was moved into the core to ensure the DBG did not encounter any obstructions, interferences, or other abnormal indications required by Pilgrim Procedure 4.3, Revision 113, Fuel Handling. Specifically, the failure to follow the procedure resulted in damaging the refueling mast when the mast was moved and still latched to the DBG. Entergy entered this issue into their corrective action program as CR-PNP-2009-2083. Corrective actions included replacing a section of the refueling mast, replacing the grapple camera, conducting additional training with the refueling crews including a table top dry run, performing a Human Performance Error Review and requiring Operations Senior Management to provide oversight during one hour of each three hour shift when the refueling crew was on the bridge moving fuel. The inspectors determined that the finding was more than minor because the finding was associated with the human performance attribute of the Barrier Integrity Cornerstone and adversely affected the cornerstones objective to provide reasonable assurance that physical design barriers (i.e. fuel cladding) protect the public from radionuclide releases caused by accidents or events. The risk significance of the performance deficiency was determined to be of very low safety significance (Green) using IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 Initial Screening and Characterization of Findings. Specifically, since the finding did not affect spent fuel pool cooling or inventory and since no fuel or control rod was damaged when the mast was bent, the finding was determined to be of very low safety significance. The finding has a cross cutting aspect in Human Error Prevention Techniques in the Work Practices component of the Human Performance area. Specifically, Entergy did not employ effective self and peer checking techniques such that refueling activities were performed safely. |
| Site: | Pilgrim |
|---|---|
| Report | IR 05000293/2009003 Section 1R20 |
| Date counted | Jun 30, 2009 (2009Q2) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | D Jackson T Burns R Rolph B Smith M Schneider S Rich |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Pilgrim - IR 05000293/2009003 | |||||||||||||||||||||||||||||
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Finding List (Pilgrim) @ 2009Q2
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