05000315/FIN-2013002-01
From kanterella
Jump to navigation
Jump to search
Finding | |
|---|---|
| Title | Failure to Establish Feed Pump Control Bands |
| Description | One self-revealing finding of very low safety significance (Green) with an associated NCV of Technical Specification (TS) 5.4.1 occurred because of a failure to implement plant procedure OHI-4000, Conduct of Operations (COOP). While responding to oscillating levels in steam generator (SG) #4 following a signal position controller failure and resultant power transient, control room operators failed to follow conduct of operations procedure requirements for establishing a control band for controllers placed in manual. This failure contributed to SG levels becoming unstable and rising to within 1 percent of the level for an automatic turbine trip and resultant reactor trip. The licensee stabilized the plant and restored controllers to automatic. Corrective actions included a debrief of personnel in the control room and a lessons learned to all operations personnel. The licensee entered the issue into the corrective action program. The inspectors determined that the failure to implement the COOP procedure during at power operation was a licensee performance deficiency that warranted an evaluation in accordance with the Significance Determination Process (SDP). The inspectors concluded that performance deficiency was more than minor because it was associated with the Initiating Event cornerstone attribute of human performance and adversely impacted the cornerstone objective of limiting the likelihood of events that upset plant stability. Since the performance deficiency did not result in a reactor trip, the inspectors concluded that the finding was of very low safety significance. The finding includes the H.4(c) cross-cutting aspect in the work practices component of the human performance area because supervisory personnel in the control room did not provide effective oversight to support nuclear safety. Specifically, supervisory command and control was not effective while responding to a SG level transient that approached the turbine trip setpoint. |
| Site: | Cook  |
|---|---|
| Report | IR 05000315/2013002 Section 4OA2 |
| Date counted | Mar 31, 2013 (2013Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | R Walton N Feliz P Laflamme M Phalen J Lennartz J Ellegood |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.2, Field Presence |
| INPO aspect | LA.2 |
| ' | |
Finding - Cook - IR 05000315/2013002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Finding List (Cook) @ 2013Q1
Self-Identified List (Cook)
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||