05000293/FIN-2017002-04

Finding

Title

Improper System Restoration Results in Suppression Pool Inoperability

Description

A self-revealing Green NCV of TS 5.4.1.a, Procedures, was identified on March 31, 2017, when operators did not follow procedures and caused an inadvertent increase in the suppression pool water level. The inspectors determined that the operators did not restore the core spray system valve line-up as prescribed in Attachment 11 of Entergy Procedure 2.2.20, Core Spray, and the maintenance safety tag clearance sheet. Operator implementation of these documents is directed by Entergy Procedure EN-OP-102, Protective Caution Tagging, section 5.19[4](b). As corrective actions, Entergy performed additional management oversight of control room operations and performed a root cause evaluation (RCE). This issue was entered into the CAP as CR-2017-2785. The performance deficiency is more than minor because it is associated with the equipment reliability attribute of the Mitigating Systems cornerstone objective and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the out of specification conditions on March 31, 2017, impacted suppression pool reliability because the suppression pool was not maintained within parameters required to ensure operability. Additionally, significant analysis was necessary to show the suppression pool and associated supports remained functional when TS requirements were not met. Using IMC 0609, Appendix A, Exhibit 2, issued June 19, 2012, The Significance Determination Process for Findings At-Power, the inspectors determined the finding was of very low safety significance (Green) because the finding did not affect the design or qualification of a mitigating structure, system, or component (SSC), the finding did not represent a loss of system and/or function, the finding did not represent an actual loss of a function of a single train for greater than the TS allowed outage time (AOT), and the finding did not represent an actual loss of a function of one or more non-TS trains of equipment. Specifically, the suppression pool, including downcomers and supports, remained functional following the influx of water. The finding has a cross-cutting aspect in the area of Human Performance - Procedure Adherence, because Entergy personnel did not follow processes, procedures, and work instructions. Specifically, Entergy personnel did not follow procedures and work instructions during the restoration of the core spray system. [H.8]

04
Site:	Pilgrim
Report	IR 05000293/2017002 Section 4OA3
Date counted	Jun 30, 2017 (2017Q2)
Type:	NCV: Green
cornerstone	Mitigating Systems
Identified by:	Self-revealing
Inspection Procedure:	IP 71153
Inspectors (proximate)	E Carfang B Pinson J Vazquez J Pfingstein C Highley S Mccarver B Dionne J Schoppy J Kulp J Furia T Dunn P Boguszewski A Burritt
Violation of:	Technical Specification
CCA	H.8, Procedure Adherence
INPO aspect	WP.4
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v • d • e

Finding - Pilgrim - IR 05000293/2017002

1(4)2(8)3(0)4(0)5(0)6(0)7(2)8(0)9(0)10(0)201(0)301(0)403(4)404(0)405(2)14(3)

IR 05000293/2017002: 1 2 3 4 5 6 7 8

Finding List (Pilgrim) @ 2017Q2

CCA Matrix: 2017Q2

	Q	CCA	Title
05000293/FIN-2016003-04	2016Q3	H.8	Failure to Adequately Evaluate the Effect of Degraded Normally Energized Agastat relays on PCIVs Operability
05000293/FIN-2016003-03	2016Q3		Failure to Properly Implement Agastat Control Relays Preventive Maintenance Procedure in Accordance with TS 5.4.1
05000293/FIN-2016003-02	2016Q3	P.5	Inadequate Operability Assessment on EDG B
05000293/FIN-2016003-01	2016Q3	P.2	Process Radiation Monitor Subsystems 10 CFR 50.65(a)(2) Not Met
05000293/FIN-2016403-02	2016Q4	H.1	Security
05000293/FIN-2016403-10	2016Q4		Security
05000293/FIN-2016004-05	2016Q4	H.5	Feedwater Regulating Valve Failure Results in Reactor Scram
05000293/FIN-2016004-04	2016Q4	H.14	Failure to Correct a Condition Adverse to Quality Associated with Main Steam Isolation Valve
05000293/FIN-2016004-02	2016Q4	H.6	Ineffective Corrective Actions to Correct High Pressure Coolant Injection System Vibrations
05000293/FIN-2016403-01	2016Q4	H.12	Security
05000293/FIN-2016403-03	2016Q4	H.11	Security
05000293/FIN-2016403-04	2016Q4	H.14	Security
05000293/FIN-2016403-06	2016Q4		Security
05000293/FIN-2016004-03	2016Q4	H.12	Failure to Properly Assess and Manage Risk Associated with Shutdown Transformer Protective Relay Testing
05000293/FIN-2016403-05	2016Q4	H.7	Security
05000293/FIN-2016004-01	2016Q4	H.14	Failure to Promptly Perform an Operability Evaluation for a Recirculation Flow Converter
05000293/FIN-2017001-03	2017Q1	P.2	Untimely Corrective Actions associated with Boraflex degradation in the Spent Fuel Pool
05000293/FIN-2017001-01	2017Q1		Concern Regarding Ability to Declare EALs during Loss of Control Room Air Conditioning
05000293/FIN-2017406-01	2017Q1		Security
05000293/FIN-2017001-04	2017Q1		Failure to Submit a Required 50.72 Notification
05000293/FIN-2016011-07	2017Q1		Failure to Report Condition Prohibited by Technical Specifications and a Safety System Functional Failure
05000293/FIN-2017001-02	2017Q1	H.8	Failure to Follow Procedures for Controlled Shutdown
05000293/FIN-2016011-11	2017Q1	H.3	Failure to Adequately Develop and Implement Targeted Performance Improvement Plans
05000293/FIN-2016011-10	2017Q1	H.14	Failure to Promptly Correct a Condition Adverse to Quality for the Residual Heat Removal System
05000293/FIN-2016011-09	2017Q1	P.2	Ineffective Corrective Actions to Address Conditions Adverse to Quality Regarding Components in Contact with or Close Proximity to the Drywell Liner
05000293/FIN-2016011-08	2017Q1	P.2	Failure to Adequately Monitor the Performance of Maintenance Rule Scoped Components
05000293/FIN-2016011-05	2017Q1	H.1	Failure to Establish Corrective Actions to Address Scope of Procedure Quality Issues
05000293/FIN-2016011-04	2017Q1	H.4	Programmatic Issue with Implementation of the Operability Determination Process
05000293/FIN-2016011-03	2017Q1	H.8	Failure to Issue Appropriate Corrective Actions to Preclude Repetition for the Causes of the September 2016 Scram
05000293/FIN-2016011-02	2017Q1	H.8	Failure to Establish Corrective Actions to Preclude Repetition of a Significant Condition Adverse to Quality
05000293/FIN-2016011-01	2017Q1	H.12	Failure to Identify All Root Causes of a Significant Condition Adverse to Quality
05000293/FIN-2016011-06	2017Q1		Design Change Not Appropriately Reviewed by Entergy
05000293/FIN-2017002-07	2017Q2		Untimely 10 CFR 50.72 Notification of a Secondary Containment System Functional Failure
05000293/FIN-2017002-01	2017Q2	H.8	Failure to Follow Procedure Requirements for the Control of a Flood Protection Barrier
05000293/FIN-2017002-03	2017Q2	P.1	Inaccurate Suppression Pool Water Level Instrument not Identified during Post-event Prompt Investigation
05000293/FIN-2017002-04	2017Q2	H.8	Improper System Restoration Results in Suppression Pool Inoperability
05000293/FIN-2017002-05	2017Q2	P.3	Damper Failure Causes Loss of Secondary Containment
05000293/FIN-2017002-06	2017Q2	H.14	Secondary Containment Testing not performed per Technical Specifications
05000293/FIN-2017002-02	2017Q2		Reporting of Unplanned Scrams with Complications Performance Indicator for Feedwater Regulating Valve Scram

Self-Identified List (Pilgrim)

	Q	Title
05000293/FIN-2016403-07	2016Q4	Licensee-Identified Violation
05000293/FIN-2016403-08	2016Q4	Licensee-Identified Violation
05000293/FIN-2016403-09	2016Q4	Licensee-Identified Violation
05000293/FIN-2016004-06	2016Q4	Licensee-Identified Violation
05000293/FIN-2016011-12	2017Q1	Licensee-Identified Violation
05000293/FIN-2016011-13	2017Q1	Licensee-Identified Violation
05000293/FIN-2017002-08	2017Q2	Licensee-Identified Violation

[Pilgrim Findings full list]

05000293/FIN-2017002-04

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