05000298/FIN-2011008-02

Finding

Title

Failure to Recognize Work Order Risk

Description

The inspectors identified a noncited violation of Technical Specification 5.4.1, for failure to implement procedures described in Regulatory Guide 1.33, Appendix A. Specifically, the licensee failed to implement procedures that provide guidance on recognizing risk associated with a maintenance activity and properly accounting for that risk. This directly contributed to three instrumentation and control technicians receiving an unexpected radiation dose. A site stand-down was held to discuss the lessons learned and the event was entered into the licensees corrective action program as Condition Report CR-CNS-2011-4435. This deficiency was reasonable for the licensee to foresee and prevent occurrence. The finding was more than minor because it is associated with the human performance attribute of the Occupational Radiation Safety Cornerstone and affected the cornerstone objective to ensure adequate protection of the worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. The inspectors determined that the finding is of very low safety significance (Green) because it was not associated with ALARA planning or work controls, there was no overexposure, there was no substantial potential for an overexposure, and the licensees ability to assess dose was not compromised. The finding has a cross-cutting aspect in the work control component of the human performance area because the licensee did not plan work activities by incorporating risk insights. Specifically, the licensee developed a work package that failed to recognize the risk associated with the activity.

02
Site:	Cooper
Report	IR 05000298/2011008 Section 4OA5
Date counted	Jun 30, 2011 (2011Q2)
Type:	NCV: Green
cornerstone	Or Safety
Identified by:	NRC identified
Inspection Procedure:	IP 93812
Inspectors (proximate)	B Tharakan D Overland V Gaddy
Violation of:	Technical Specification
CCA	H.5, Work Management
INPO aspect	WP.1
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v • d • e

Finding - Cooper - IR 05000298/2011008

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 05000298/2011008: 1 2 3 4 5 6

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-2011008-02

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