05000293/FIN-2013003-01
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Finding | |
|---|---|
| Title | Failure to Follow Procedures Results in Loss of Shutdown Cooling |
| Description | A self-revealing NCV of Technical Specification (TS) 5.4.1, Procedures, was identified for operators not implementing procedures to supply safety-related alternate electrical power to shutdown cooling valves during shutdown cooling operation. Specifically, because operators did not perform all applicable steps in a procedure, a loss of shutdown cooling resulted when operators were shifting power supplies for the B train shutdown cooling suction and discharge valves on May 2, 2013. Corrective actions included restoring shutdown cooling following a prompt investigation of the event. Entergy has captured this event in their corrective action program (CAP) as CR-PNP-2013-3457. The performance deficiency is more than minor because it affects the objective of the Initiating Events cornerstone to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The unavailability of shutdown cooling for five hours challenged the safety function of decay heat removal (DHR) supplied by the residual heat removal (RHR) system. A review of IMC 0612, Appendix E, Examples of Minor Issues, found no more than minor examples that applied. The inspectors evaluated the finding using IMC 0609, Attachment 4, Phase 1 Initial Screening and Characterization of Findings. The inspectors determined that the finding required further review using IMC 0609, Appendix G, Shutdown Operations Significance Determination Process, because the issue affected the safety of the reactor during a refueling outage. The inspectors determined that this finding was of very low safety significance (Green), using IMC 0609, Appendix G, Checklist 7, BWR Refueling Operation with Reactor Coolant System (RCS) Level >23. This determination did not require a further phase 2 or phase 3 analysis in that it did not increase the likelihood of a loss of RCS inventory; did not result in the loss of RCS level instrumentation; did not degrade Entergys ability to terminate a leak path or add RCS inventory; and did not degrade Entergys ability to recover DHR once it was lost. In addition, a loss of thermal margin did not occur since the change in RCS temperature resulted in less than 20 percent of the temperature margin to boil. The inspectors determined that this finding had a cross-cutting aspect in the Human Performance area, Work Practices component, because personnel did not follow procedures. |
| Site: | Pilgrim |
|---|---|
| Report | IR 05000293/2013003 Section 1R20 |
| Date counted | Jun 30, 2012 (2012Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | T Moslak T Burns J Krafty J Laughlin F Bower B Smith M Schneider |
| INPO aspect | |
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Finding - Pilgrim - IR 05000293/2013003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Pilgrim) @ 2012Q2
Self-Identified List (Pilgrim)
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