A Green self-revealing non-cited violation of Unit 2
Technical Specification 6.8.1 was identified for the licensees failure to have an adequate procedure to ensure replacement of the pressurizer pressure master controller would not adversely impact plant stability. Specifically, on January 7, 2009, operators placed a pressurizer spray valve controller in automatic while the master controller was in manual with a large demand output signal present. This resulted in the spray valve fully opening and an associated
reactor coolant system pressure
transient. Operators immediately restored pressure to its normal value, and the finding was entered into the licensees corrective action program as Problem Evaluation Report (PER) 160504. The finding was greater than minor because it was associated with the procedure quality attribute of the
initiating events cornerstone and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions. Using Manual Chapter 0609,
Significance Determination Process, Attachment 4, the finding was determined to have very low safety significance (Green) because it did not contribute to both the likelihood of a
reactor trip and the likelihood that
mitigating systems will not be available. The cause of this finding was determined to be in the cross-cutting area of human performance associated with work practices and the aspect of human error prevention, in that, during the pre-job brief, the operators discussed minimizing the master controller demand signal but failed to self and peer check to ensure that the procedural steps were consistent with the appropriate actions
H.4(a) (Section 1R19)
