05000305/FIN-2011002-02
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Finding | |
|---|---|
| Title | Inadequate Work Instructions Results in Potential Orange Path |
| Description | A finding of very low safety-significance and associated non-cited violation (NCV) of Technical Specification 5.4.1, Procedures, was identified by the inspectors for the failure to implement procedures for shutdown operations involving shutdown operations safety assessments. Specifically, OU-KW-201, Shutdown Safety Assessment Checklist, step 3.3.1, stated, in part, that a shutdown safety assessment was required to be completed in accordance with the procedure for core cooling; however, the inspectors noted that the February 28, 2011, 6:00 p.m. analysis credited the safety injection system feed and bleed as an available alternate decay heat removal system when the system was not available as described in Section 5.3.2, Available/Availability, for work scheduled at that time on the emergency core cooling system (ECCS) sump. The licensee initiated condition report CR415539, and at the end of the inspection period, the licensee was performing a causal evaluation to determine the causes of the event and develop corrective actions. On February 28, as a remedial corrective action prior to the start of work, additional steps to the work instructions were added to ensure the equipment would meet the intended function, operators were designated to perform the local manual operations and a pre-job brief was conducted that provided training for using the equipment in the given situation. The finding was determined to be more than minor because the finding was associated with the Mitigating Systems Cornerstone attribute of human error (pre-event) and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, the availability of the ECCS sump was integral to ensuring that the plant was not in an orange risk path for the evolutions completed on February 28. The inspectors screened the finding as of very low safety significance (Green) because the finding did not degrade the licensees ability to establish an alternate core cooling path if decay heat removal could not be re-established and, therefore, did not require a Significance Determination Process phase 2 or phase 3 analysis. The finding has a cross-cutting aspect in the areas of human performance, work control, because the licensee failed to plan the work activities by incorporating the need for planned contingencies and compensatory actions to ensure the ECCS sump was available to ensure an orange risk path for core cooling was not entered (H.3(a)). |
| Site: | Kewaunee  |
|---|---|
| Report | IR 05000305/2011002 Section 1R13 |
| Date counted | Mar 31, 2011 (2011Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | A Shaikh E Sanchez-Santiago M Holmberg R Langstaff R Winter J Jandovitz J Cassidy M Kunowski R Krsek K Barclay R Jones |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Kewaunee - IR 05000305/2011002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Kewaunee) @ 2011Q1
Self-Identified List (Kewaunee)
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