05000298/FIN-2011003-07

Finding

Title

Failure to Adequately Assess and Manage Risk When Disabling A Hazard Barrier

Description

The inspectors identified a noncited violation of 10 CFR 50.65(a)(4), Requirements for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants, associated with the licensees failure to perform an adequate risk assessment for a planned maintenance activity. Specifically, on August 19, 2010, during maintenance activities on emergency diesel generator 2, maintenance personnel inappropriately blocked open the steam exclusion boundary door N-103 that protected both emergency diesel generators, without properly assessing the potential effects on the emergency diesel generators and without appropriate compensatory measures in place. As such, this resulted in both emergency diesel generators being inoperable. These issues were entered into the licensees corrective action program as Condition Report CR-CNS-2011-7660. The licensees failure to adequately assess and manage the risk of planned maintenance activities was a performance deficiency. The performance deficiency was determined to be more than minor because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone, and affected the associated cornerstone objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences, and is therefore a finding. Using Manual Chapter 0609, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process, the finding was determined to have very low safety significance. Specifically, Flowchart 1, Assessment of Risk Deficit, requires the inspectors to determine the risk deficit associated with this issue. The senior reactor analyst performed a bounding analysis and determined that the probability that a high energy line breaks, causing the failure of both emergency diesel generators and initiating a consequential loss of offsite power, can be calculated as 3.0 x 10-7. Given that the change in core damage frequency would be lower than this probability, the analyst determined that the finding was of very low safety significance (Green). The inspectors determined that this finding did not represent current performance because the guidance that formed the basis for the licensees decision making was developed and approved over two years ago (Section 4OA3).

07
Site:	Cooper
Report	IR 05000298/2011003 Section 4OA3
Date counted	Jun 30, 2011 (2011Q2)
Type:	NCV: Green
cornerstone	Mitigating Systems
Identified by:	NRC identified
Inspection Procedure:	IP 71153
Inspectors (proximate)	G Pick J Josey L Ricketson M Chambers M Young N Greene V Gaddy
INPO aspect
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v • d • e

Finding - Cooper - IR 05000298/2011003

1(0)2(6)3(12)4(7)5(9)6(5)7(0)8(6)9(1)10(0)201(0)202(1)301(0)403(0)501(0)

IR 05000298/2011003: 1 2 3 4 5 6 7 8 9 10 11 12

Finding List (Cooper) @ 2011Q2

CCA Matrix: 2011Q2

	Q	CCA	Title
05000298/FIN-2010004-02	2010Q3	P.2	Failure to Follow Procedure Results in Repeat Equipment Failure
05000298/FIN-2010004-01	2010Q3	H.14	Failure to Adequately Monitor the Performance of the Screen Wash System
05000298/FIN-2010005-03	2010Q4	P.5	Failure to Adequately Assess and Manage Risk During Maintenance Activities
05000298/FIN-2010006-01	2010Q4	P.1	Inadequate Post-Fire Safe Shutdown Procedures
05000298/FIN-2010006-02	2010Q4	H.14	Failure to Monitor the Performance of the Emergency Lights Against the Maintenance Rule Criteria
05000298/FIN-2010005-01	2010Q4	H.14	Failure to Implement Fire Protection Plan Requirements Related to Hot Work Activities
05000298/FIN-2010005-02	2010Q4	H.14	Failure to Assess and Manage Risk for Electrical Switchyard Impacting Maintenance
05000298/FIN-2010005-05	2010Q4		Diesel Generator Overspeed Governor Loose Bolting Issue
05000298/FIN-2010005-06	2010Q4		Failure to Update Flood Protection for Safety Related Buildings
05000298/FIN-2010005-04	2010Q4	P.3	Failure to Have Guidelines for the Choice of Protective Actions During an Emergency Consistent with Federal Guidance
05000298/FIN-2010007-04	2010Q4	P.5	Inadequate Design Control
05000298/FIN-2010007-06	2010Q4	S.2	Faulty General Electric Switches
05000298/FIN-2010007-01	2010Q4	H.7	Failure to Translate Design and Operating Requirements into Procedures
05000298/FIN-2010007-02	2010Q4	H.14	Failure to promptly Correct Conditions Adverse to Quality
05000298/FIN-2010007-03	2010Q4	H.7	Inadequate Test Control
05000298/FIN-2010007-05	2010Q4	H.14	Ice Deflector Pontoon Barge Storage in Service Water Discharge Canal
05000298/FIN-2010007-07	2010Q4		URI 05000298/2007011-07, Fuel Oil Storage Tank Required Submergence To Prevent Vortexing And Available Volume Are Marginal Without Accounting For Instrument Uncertainties
05000298/FIN-2010007-08	2010Q4		URI 05000298/2007011-08, High Pressure Coolant Pump Swap-Over from Emergency Condensate Storage Tank to Torus Vortex Calculation
05000298/FIN-2011009-01	2011Q1	P.2	Inadequate Post-Fire Safe Shutdown Procedures
05000298/FIN-2011002-02	2011Q1	P.3	Failure to Assess and Manage Risk for Maintenance That Could Impact Initiating Events
05000298/FIN-2011002-04	2011Q1	P.3	Repeat Failure to Follow Procedure for Initiating Condition Reports
05000298/FIN-2011002-03	2011Q1	H.8	Failure to Adequately Implement Foreign Material Exclusion Controls
05000298/FIN-2011002-01	2011Q1	H.14	Failure to Properly Evaluate All Senior Operator License Holders during Annual Operating Test
05000298/FIN-2011002-05	2011Q1	H.14	Failure to Notify the NRC within Eight Hours of a Nonemergency Event
05000298/FIN-2011003-08	2011Q2	H.12	Failure to Follow Procedure Results in Degraded Emergency Diesel Generator
05000298/FIN-2011006-05	2011Q2	H.14	Failure to Correctly Translate Design Requirements into Installed Plant Configuration
05000298/FIN-2011003-01	2011Q2	H.14	Failure to Assess Potential Adverse Effects on Internal Flooding Analysis
05000298/FIN-2011008-01	2011Q2	H.8	Unclear Work Instructions
05000298/FIN-2011008-02	2011Q2	H.5	Failure to Recognize Work Order Risk
05000298/FIN-2011008-03	2011Q2	H.12	Failure to Implement Human Performance Procedure
05000298/FIN-2011008-04	2011Q2	H.14	Failure to Revise Unclear Work Instructions
05000298/FIN-2011008-05	2011Q2	H.5	Failure to Perform an Adequate High Radiation Area Briefing
05000298/FIN-2011008-06	2011Q2	H.12	Failure to Follow Radiation Protection Job Coverage Procedures
05000298/FIN-2011003-04	2011Q2		Communication of an NRC Inspectors Presence by Station Personnel
05000298/FIN-2011006-02	2011Q2	P.2	Failure to Report Conditions Prohibited by Technical Specifications and Safety System Functional Failures
05000298/FIN-2011006-03	2011Q2	P.2	Failure to Perform 10 CFR 50.59 Evaluation for Design Change
05000298/FIN-2011006-04	2011Q2	P.2	Failure to Take Action for an Ineffective Corrective Action
05000298/FIN-2011003-02	2011Q2	P.2	Failure to Follow Procedure Results in Inadequate Operability Determinations
05000298/FIN-2011003-03	2011Q2	H.4 H.5	Failure to Follow Procedure Results in Personnel Contaminations
05000298/FIN-2011003-05	2011Q2	H.11 H.12	Failure to Follow Radiation Work Permit Requirements
05000298/FIN-2011003-06	2011Q2		Failure to Correctly Translate Design Requirements into Installed Plant Configuration
05000298/FIN-2011003-07	2011Q2		Failure to Adequately Assess and Manage Risk When Disabling A Hazard Barrier
05000298/FIN-2011003-09	2011Q2	H.6	Failure to Initiate Condition Reports for Nonconformances Identified During System Walk Downs
05000298/FIN-2011003-10	2011Q2	P.1	Failure to Promptly Correct an Adverse Condition Related to Emergency Core Cooling System Venting
05000298/FIN-2011006-01	2011Q2	P.1	Failure to Promptly Identify and Correct Conditions Adverse to Quality

Self-Identified List (Cooper)

	Q	Title
05000298/FIN-2010004-03	2010Q3	Licensee-Identified Violation
05000298/FIN-2010403-01	2010Q4	Security
05000298/FIN-2011002-06	2011Q1	Licensee-Identified Violation
05000298/FIN-2011003-11	2011Q2	Licensee-Identified Violation
05000298/FIN-2011003-12	2011Q2	Licensee-Identified Violation

[Cooper Findings full list]

05000298/FIN-2011003-07

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