05000298/FIN-2011004-05

Finding

Title

Failure to Follow Procedure Results in Personnel Contamination

Description

The inspectors reviewed a self revealing, noncited violation of Technical Specification 5.4.1, resulting from a plant individual who failed to follow radiation work permit requirements and was contaminated as a result. The condition was detected when the contamination monitor alarmed during the individuals attempt to process out of the radiologically controlled area. The individual was then decontaminated prior to exiting. The licensee entered the issue into the corrective action program as Condition Report CR-CNS-2011-8582. The failure to follow radiation work permit requirements is a performance deficiency. The finding was more than minor because it was associated with the Occupational Radiation Safety Cornerstone attribute (exposure control) of program and process and affected the cornerstone objective, in that, working outside the scope of the radiation work permit resulted in personnel contamination and contamination levels in the area had the potential to increase personnel dose. Using the Occupational Radiation Safety Significance Determination Process, the inspectors determined the finding to have very low safety significance because: (1) it was not associated with ALARA planning or work controls, (2) there was no overexposure, (3) there was no substantial potential for an overexposure, and (4) the ability to assess dose was not compromised. The finding has a human performance cross-cutting aspect associated with the work practices component, when the licensee failed to assure that human error prevention techniques, such as self checking, are used to assure that work activities are performed safely when an individual failed to self check requirements prior to entering the radiation controlled area and was contaminated.

05
Site:	Cooper
Report	IR 05000298/2011004 Section 4OA2
Date counted	Sep 30, 2011 (2011Q3)
Type:	NCV: Green
cornerstone	Or Safety
Identified by:	Self-revealing
Inspection Procedure:	IP 71152
Inspectors (proximate)	J Josey V Gaddy M Chambers N Okonkwo
CCA	H.12, Avoid Complacency
INPO aspect	QA.4
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Finding - Cooper - IR 05000298/2011004

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 05000298/2011004: 1 2 3 4 5 6 7

Finding List (Cooper) @ 2011Q3

CCA Matrix: 2011Q3

	Q	CCA	Title
05000298/FIN-2010005-06	2010Q4		Failure to Update Flood Protection for Safety Related Buildings
05000298/FIN-2010006-02	2010Q4	H.14	Failure to Monitor the Performance of the Emergency Lights Against the Maintenance Rule Criteria
05000298/FIN-2010006-01	2010Q4	P.1	Inadequate Post-Fire Safe Shutdown Procedures
05000298/FIN-2010005-03	2010Q4	P.5	Failure to Adequately Assess and Manage Risk During Maintenance 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-2010005-01	2010Q4	H.14	Failure to Implement Fire Protection Plan Requirements Related to Hot Work Activities
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-2010007-01	2010Q4	H.7	Failure to Translate Design and Operating Requirements into Procedures
05000298/FIN-2010007-06	2010Q4	S.2	Faulty General Electric Switches
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-2010007-04	2010Q4	P.5	Inadequate Design Control
05000298/FIN-2011009-01	2011Q1	P.2	Inadequate Post-Fire Safe Shutdown Procedures
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-2011002-02	2011Q1	P.3	Failure to Assess and Manage Risk for Maintenance That Could Impact Initiating Events
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-2011008-01	2011Q2	H.8	Unclear Work Instructions
05000298/FIN-2011006-05	2011Q2	H.14	Failure to Correctly Translate Design Requirements into Installed Plant Configuration
05000298/FIN-2011006-04	2011Q2	P.2	Failure to Take Action for an Ineffective Corrective Action
05000298/FIN-2011006-01	2011Q2	P.1	Failure to Promptly Identify and Correct Conditions Adverse to Quality
05000298/FIN-2011003-05	2011Q2	H.11 H.12	Failure to Follow Radiation Work Permit Requirements
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-2011003-01	2011Q2	H.14	Failure to Assess Potential Adverse Effects on Internal Flooding Analysis
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-2011003-06	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-2011003-08	2011Q2	H.12	Failure to Follow Procedure Results in Degraded Emergency Diesel Generator
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-2011004-02	2011Q3		Failure to Scope Reactor Building Drain Components and Steam Exclusion Doors that Affect Safety-related Systems in the Maintenance Rule Monitoring Program
05000298/FIN-2011004-01	2011Q3	H.7	Failure to Place the Essential Service Water System Strainers in (a)(1)
05000298/FIN-2011004-07	2011Q3		Inadequate Procedure Results in Inoperable Essential Pump
05000298/FIN-2011004-06	2011Q3	P.2	Failure to Identify, Correct, and Prevent Recurrence of a Significant Condition Adverse to Quality
05000298/FIN-2011004-05	2011Q3	H.12	Failure to Follow Procedure Results in Personnel Contamination
05000298/FIN-2011004-04	2011Q3	P.3	Failure to Assess and Manage Risk for Maintenance Near an Operating Reactor Feed Pump That Could Impact Initiating Events
05000298/FIN-2011004-03	2011Q3	H.8	Failure to Assess and Manage Risk for Maintenance Near Electrical Towers That Could Impact Initiating Events

Self-Identified List (Cooper)

	Q	Title
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-2011004-05

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