05000305/FIN-2008004-03
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Finding | |
|---|---|
| Title | Inadequate Procedure Results In Unplanned Control Rod Motion |
| Description | A finding of very low safety significance and an associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed when control rods automatically stepped inward unexpectedly. Ultimately, it was determined that procedures for operation of the power range nuclear instrument were found to be inadequate for the circumstances. Specifically, procedures for bypassing nuclear instrument N-43 did not contain steps to place control rods in manual when placing a failed instrument in bypass. Corrective actions were taken to replace the inappropriately deleted steps from the associated procedures. The finding is greater than minor in accordance with IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, dated September 20, 2007, because the finding affected the procedure quality attribute of the Barrier Integrity Cornerstone of Reactor Safety. Specifically, the failure to either leave the step for placing rods in manual in multiple alarm response procedures, or transferring the step to the common procedure OP-KW-AOP-MISC-001, resulted in a preventable condition which resulted in an unexpected reactivity transient. The inspectors evaluated the finding using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, Table 2 for the Barriers Cornerstone. The inspectors answered no to all of the questions in this cornerstone column; therefore, the finding was determined to be of very low safety significance. The inspectors concluded that the finding had a crosscutting aspect in the area of human performance, decision-making, because interdisciplinary reviews performed by station personnel, including the on-site safety review committee, failed to make changes to the various procedures using a systematic process. Additionally, the inspectors reviewed the licensee evaluation of the cause of the issue and found that it agreed with their understanding of the issue. H.1(a) (Section 4OA3) |
| Site: | Kewaunee  |
|---|---|
| Report | IR 05000305/2008004 Section 4OA3 |
| Date counted | Sep 30, 2008 (2008Q3) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | J Cassidy P Higgins S Burton K Barclay D Dodson R Langstaff J Jandovitz |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Kewaunee - IR 05000305/2008004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Kewaunee) @ 2008Q3
Self-Identified List (Kewaunee)
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