05000298/FIN-2017001-05
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Finding | |
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Title | Loss of Shutdown Cooling due to Relay Maintenance |
Description | The inspectors reviewed a self-revealed, non-cited violation of Technical Specification 5.4.1.a, for the licensees failure to implement Maintenance Procedure 7.3.16, Low Voltage Relay Removal and Installation, Revision 22, for relay replacement work. Specifically, on October 28, 2016, the licensee failed to evaluate the potential impact of primary containment isolation system relay PCIS-REL-K27 work on shutdown cooling relay PCIS-REL-K30, which was mounted next to K27 and shared a common mounting rail. As a result, the licensee did not identify the potential of losing residual heat removal shutdown cooling, and while installing the K27 relay and snapping it into the mounting rail, workers caused a momentary actuation of relay K30 and a loss of residual heat removal shutdown cooling. Corrective actions to restore compliance included restoration of shutdown cooling, completion of the K27 relay maintenance with shutdown cooling out of service, and an outage risk management procedure change that prohibited work on or near shutdown cooling relays while the system was required to be in service. The licensee entered this deficiency into the corrective action program as Condition Report CR-CNS-2016-07645. The licensees failure to implement Maintenance Procedure 7.3.16, in violation of Technical Specification 5.4.1.a, was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the Initiating Events Cornerstone and affected the associated cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown operations. Using Inspection Manual Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Process Phase 1 Initial Screening and Characterization of Findings, dated May 9, 2014, the inspectors determined that the finding did not require a quantitative assessment because the event occurred when the refuel canal/cavity was flooded. Therefore, the finding screened as very low safety significance (Green). The finding had a cross-cutting aspect in the area of human performance associated with work management, because the licensee failed to implement a process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority, including the need for coordination with different work groups or job activities. Specifically, the licensee failed to control, execute, and coordinate safety-related primary containment isolation system relay work activities to ensure residual heat removal shutdown cooling was not adversely impacted [H.5]. |
Site: | Cooper |
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Report | IR 05000298/2017001 Section 4OA3 |
Date counted | Mar 31, 2017 (2017Q1) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71153 |
Inspectors (proximate) | C Henderson E Uribe G Warnick I Anchondo J Watkins P Elkmann P Voss R Deese |
Violation of: | Technical Specification |
CCA | H.5, Work Management |
INPO aspect | WP.1 |
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Finding - Cooper - IR 05000298/2017001 | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Cooper) @ 2017Q1
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