05000298/FIN-2011005-03

Finding

Title

Failure to Follow Procedures for Dose Rate Alarms Received by Two Individuals

Description

The inspector reviewed a self-revealing, non-cited violation of Technical Specification 5.4.1, resulting from workers who failed to follow procedures to exit the area when two dose rate alarms were received while performing decontamination work in the reactor cavity during Refueling Outage 26. As corrective action, the licensee performed an apparent cause evaluation and documented the issues identified in Condition Report CR-CNS-2011-04891. The failure to follow procedures is a performance deficiency. The finding was more than minor because it was associated with the program and process attribute (exposure control) of the Occupational Radiation Safety Cornerstone and affected the cornerstone objective, in that, the failure to follow radiation procedures and not leave the work area after receipt of a dose rate alarm had the potential to increase personnel dose. Using NRC Manual Chapter 0609, Appendix C, Occupational Radiation Safety Significance Determination Process, the inspector determined the finding to be of very low safety significance because: (1) it was not associated with as low as is reasonably achievable (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 work practices component because the individuals failed to use self- and peer-checking human error prevention techniques.

03
Site:	Cooper
Report	IR 05000298/2011005 Section 2RS1
Date counted	Dec 31, 2011 (2011Q4)
Type:	NCV: Green
cornerstone	Or Safety
Identified by:	NRC identified
Inspection Procedure:	IP 71124.01
Inspectors (proximate)	C Graves J Josey L Carson L Ricketson M Chambers N Greene P Elkmann R Hagar V Gaddy
CCA	H.12, Avoid Complacency
INPO aspect	QA.4
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v • d • e

Finding - Cooper - IR 05000298/2011005

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 05000298/2011005: 1 2 3 4 5 6 7 8 9

Finding List (Cooper) @ 2011Q4

CCA Matrix: 2011Q4

	Q	CCA	Title
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-2011003-02	2011Q2	P.2	Failure to Follow Procedure Results in Inadequate Operability Determinations
05000298/FIN-2011008-01	2011Q2	H.8	Unclear Work Instructions
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-2011003-08	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-2011006-01	2011Q2	P.1	Failure to Promptly Identify and Correct Conditions Adverse to Quality
05000298/FIN-2011006-04	2011Q2	P.2	Failure to Take Action for an Ineffective Corrective Action
05000298/FIN-2011006-05	2011Q2	H.14	Failure to Correctly Translate Design Requirements into Installed Plant Configuration
05000298/FIN-2011006-03	2011Q2	P.2	Failure to Perform 10 CFR 50.59 Evaluation for Design Change
05000298/FIN-2011006-02	2011Q2	P.2	Failure to Report Conditions Prohibited by Technical Specifications and Safety System Functional Failures
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-2011003-04	2011Q2		Communication of an NRC Inspectors Presence by Station Personnel
05000298/FIN-2011008-06	2011Q2	H.12	Failure to Follow Radiation Protection Job Coverage Procedures
05000298/FIN-2011008-05	2011Q2	H.5	Failure to Perform an Adequate High Radiation Area Briefing
05000298/FIN-2011008-04	2011Q2	H.14	Failure to Revise Unclear Work Instructions
05000298/FIN-2011003-01	2011Q2	H.14	Failure to Assess Potential Adverse Effects on Internal Flooding Analysis
05000298/FIN-2011004-05	2011Q3	H.12	Failure to Follow Procedure Results in Personnel Contamination
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-2011004-04	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
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-2011005-01	2011Q4	H.2	Failure to Conspicuously Post a High Radiation Area
05000298/FIN-2011005-02	2011Q4	H.2	Failure to Maintain Control and Continuous Coverage of a Posted Locked High Radiation Area
05000298/FIN-2011005-03	2011Q4	H.12	Failure to Follow Procedures for Dose Rate Alarms Received by Two Individuals
05000298/FIN-2011005-05	2011Q4	P.1	Failure to Identify Deficient Performance During a Single-Facility Drill
05000298/FIN-2011005-06	2011Q4	P.2	Failure to Correctly Translate Design Requirements into Installed Plant Configuration
05000298/FIN-2011005-04	2011Q4		Failure to Provide Complete and Accurate Solid Radwaste Shipment Information in Annual Reports
05000298/FIN-2011005-07	2011Q4	H.14	Failure to Perform Required 10 CFR 50.59 Evaluations for Changes
05000298/FIN-2011202-02	2011Q4		Security

Self-Identified List (Cooper)

	Q	Title
05000298/FIN-2011002-06	2011Q1	Licensee-Identified Violation
05000298/FIN-2011003-11	2011Q2	Licensee-Identified Violation
05000298/FIN-2011003-12	2011Q2	Licensee-Identified Violation
05000298/FIN-2011005-08	2011Q4	Licensee-Identified Violation
05000298/FIN-2011005-09	2011Q4	Licensee-Identified Violation

[Cooper Findings full list]

05000298/FIN-2011005-03

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