05000313/FIN-2011002-02

Finding

Title

Failure to Follow Procedure Results in Depressurizing One Emergency Core Cooling System Suction Header

Description

The inspectors documented a self-revealing noncited violation of Unit 1 Technical Specification 5.4.1.a for the failure to follow procedure OP-1104.002 Makeup and Purification System Operation, Revision 69. Specifically, while draining to depressurize the emergency core cooling system suction header from 55.6 psig to approximately 20 psig to support testing BW-2, P-36 B/C suction stop check isolation valve, operations personnel monitored the incorrect suction pressure indication, drained and depressurized significantly longer than specified in the procedure resulting in the suction header pressure lowering to approximately 1.6 psig before securing the draining evolution. Immediate actions taken to restore compliance included operations personnel filling the emergency core cooling system suction header and subsequent ultra sonic testing on the effected piping to verify no voids existed. This issue was entered into the licensees corrective action program as Condition Report CR-ANO-1-2011-0290. The inspectors determined that operations personnel failed to follow the requirements of procedure OP-1104.002, by failing to monitor the correct pressure indication and by draining significantly longer than the procedure specified. This resulted in inadvertently depressurizing the emergency core cooling suction header to approximately 1.6 psig. This was determined to be a performance deficiency. Specifically, the failure to follow OP-1104.002, as required by Technical Specification 5.4.1.a, and inadvertently depressurizing the emergency core cooling system header was reasonably within the licensees ability to foresee and correct. The performance deficiency was more than minor because it was associated with the human performance attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability and capability of systems that respond to initiating events to prevent undesirable consequences and is therefore a finding. Specifically, lowering pressure below 20 psig potentially voided the emergency core cooling system suction header which would affect the availability of the emergency core cooling system train. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings, the finding was determined to have very low safety significance, Green, because: (1) the finding was not a qualification deficiency that resulted in a loss functionality of the emergency core cooling system header, (2) it did not lead to an actual loss of safety function of the system or train, (3) it did not result in an actual loss of safety function of a single train for greater than its technical specification allowed outage time, (4) it did not represent an actual loss of safety function of one or more nontechnical specification trains of equipment designated as risk-significant per 10 CFR 50.65, for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> and (5) it did not screen as potentially risk-significant due to a seismic, flooding, or severe weather initiating event. The finding was determined to have a crosscutting aspect in the area of human performance, associated with work practices in that the licensee failed to ensure supervisory and management oversight of work activities were such that nuclear safety was supported when the control room supervisor unknowingly became involved in the task and did not maintain supervision, H.4(c).

02
Site:	Arkansas Nuclear
Report	IR 05000313/2011002 Section 1R22
Date counted	Mar 31, 2011 (2011Q1)
Type:	NCV: Green
cornerstone	Mitigating Systems
Identified by:	Self-revealing
Inspection Procedure:	IP 71111.22
Inspectors (proximate)	L Ricketson W Schaup A Sanchez B Baca C Graves I Anchondo J Clark J Melfi J Rotten
CCA	H.2, Field Presence
INPO aspect	LA.2
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v • d • e

Finding - Arkansas Nuclear - IR 05000313/2011002

1(0)2(5)3(2)4(9)5(8)6(1)8(0)302(0)402(2)403(1)501(0)9(3)301(0)

IR 05000313/2011002: 1 2 3 4 5

Finding List (Arkansas Nuclear) @ 2011Q1

CCA Matrix: 2011Q1

	Q	CCA	Title
05000313/FIN-2010004-03	2010Q3	H.14	Failure to Promptly Identify and Correct a Condition Adverse to Quality Associated with Emergency Switchgear Chiller VCH-4A
05000313/FIN-2010004-08	2010Q3	H.8	Failure to Follow Procedures and Generate Adequate Work Orders for Maintenance on Safety Related Equipment
05000313/FIN-2010004-05	2010Q3	P.3	Failure to Adequately Implement Foreign Material Exclusion Controls
05000313/FIN-2010004-07	2010Q3	P.1	Failure to Provide an Accurate Shipping Manifest
05000313/FIN-2010004-01	2010Q3	H.12	Excessive Overlap of Unit 2 Written Examinations
05000313/FIN-2010006-01	2010Q3		Fire Protection Compensatory Measures Did Not Cover All Fire Protection Features
05000313/FIN-2010004-09	2010Q3	H.2	Failure to Follow Procedure Results in Draining Unit 1 Pressurizer to Reactor Building Floor
05000313/FIN-2010004-06	2010Q3		Failure to Correctly Translate VCH-4B Design Requirements into Installed Plant Equipment
05000313/FIN-2010004-04	2010Q3	H.12	Failure to Follow Station Work Control Procedure Results in Unavailable Equipment
05000313/FIN-2010004-02	2010Q3	H.14	Failure to Promptly Identify and Correct a Condition Adverse to Quality Associated with Emergency Diesel Generators Heating, Ventilation, and Air Conditioning Ducting Susceptibility to Tornado Loading
05000313/FIN-2010006-02	2010Q3		Failure to ensure that the pressurizer level would remain within levels predicted for a loss of normal a.c. power
05000313/FIN-2010005-06	2010Q4		Failure to Verify the Adequacy of the Unit 2 Refueling Water Tank and the Condensate Storage Tank Transfer Setpoints
05000313/FIN-2010402-01	2010Q4	H.9	Security
05000313/FIN-2010005-05	2010Q4	H.2	Failure to Use Human Performance Tools Results in Two Turbine Building Roof Fires
05000313/FIN-2010005-07	2010Q4	H.14	Failure to Perform Face-to-Face Supervisory Assessments Less than 4 Hours Before Individuals Began Performing Work Activities Under a Waiver
05000313/FIN-2010005-03	2010Q4	H.13	Failure to Perform Required Quality Control Inspections
05000313/FIN-2010005-04	2010Q4		Failure to Implement the Experience and Qualification Requirements of the Quality Assurance Program
05000313/FIN-2010005-02	2010Q4		Failure to Submit for Approval a Decrease in Effectiveness of Emergency Plan
05000313/FIN-2010005-01	2010Q4	H.14	Exceeded Technical Specification Allowed Outage Time for Electrical Power Systems Due to Loss of Non-Technical Specification Supported System
05000313/FIN-2011201-01	2011Q1	H.5	Security
05000313/FIN-2011006-01	2011Q1		Failure to Resolve Adverse Conditions in 120 Volt Vital Inverters in a Timely Manner
05000313/FIN-2011002-04	2011Q1	H.5	Failure to Take Timely Corrective Action to Correct a Condition Adverse to Quality Associated with 4160 Volt Vacuum Breakers
05000313/FIN-2011002-03	2011Q1		Inadequate Procedural Guidance Results in Damaged Emergency Control Room Ventilation System Air Damper
05000313/FIN-2011002-02	2011Q1	H.2	Failure to Follow Procedure Results in Depressurizing One Emergency Core Cooling System Suction Header
05000313/FIN-2011002-01	2011Q1	H.7	Failure to Incorporate Adequate Clearance Guidance Prevents Full Operation of the Unit 1 Emergency Control Room Ventilation Makeup Air Supply Damper

Self-Identified List (Arkansas Nuclear)

	Q	Title
05000313/FIN-2010005-08	2010Q4	Licensee-Identified Violation
05000313/FIN-2011002-05	2011Q1	Licensee-Identified Violation

[Arkansas Nuclear Findings full list]

05000313/FIN-2011002-02

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