05000298/FIN-2014002-04
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Finding | |
|---|---|
| Title | Failure to Follow Tagout Procedure |
| Description | Inspectors reviewed a self-revealing, non-cited violation of Technical Specification 5.4.1.a, associated with the licensees failure to follow station procedures which resulted in secondary containment inoperability. Specifically, on January 6, 2014, a station operator failed to follow Station Procedure 0.9, Tagouts, and closed the wrong valve while hanging a clearance order to support maintenance. This resulted in an unexpected rise in the reactor buildings differential pressure, which caused the secondary containment to be declared inoperable when pressure went above negative 0.25 inches of water. The corrective action for this issue was to open the mispositioned valve, which restored secondary containment differential pressure. The licensee entered this deficiency into their corrective action program as Condition Report CR-CNS-2014-00062. The failure to follow Station Procedure 0.9 while hanging a clearance order was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the human performance attribute of the Barrier Integrity Cornerstone and affected the cornerstone objective to provide reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, inspectors determined that the finding was of very low safety significance (Green) because the finding only represented a degradation of the radiological barrier function for the reactor building. The finding has a cross-cutting aspect in the area of human performance associated with avoiding complacency because individuals failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes, which resulted in individuals not implementing appropriate error reduction tools. |
| Site: | Cooper  |
|---|---|
| Report | IR 05000298/2014002 Section 4OA3 |
| Date counted | Mar 31, 2014 (2014Q1) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | C Henderson D Allen J Josey P Elkmann |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Cooper - IR 05000298/2014002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Cooper) @ 2014Q1
Self-Identified List (Cooper)
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