05000331/FIN-2009003-02
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Finding | |
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Title | Inadequate Surveillance Test Procedure Revision Results in a Plant Scram |
Description | A finding of very low safety significance and associated NCV of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed when Instrument and Controls (I&C) Technicians lifted a lead on a reactor water level recorder resulting in the indicated reactor water level failing low and an actual increase in reactor water level. This plant transient resulted in operators inserting a manual reactor scram to mitigate the transient condition. The inspectors determined that the failure of I&C Technicians and Procedure Writers to include adequate procedural guidance in the Surveillance Test Procedure (STP) was contrary to the requirements of 10 CFR 50, Appendix B, Criterion V, and was therefore a performance deficiency. The licensee entered this into their corrective action program as CAP 066292. The reactor operators completed the required actions for a reactor scram and placed the plant in a stable condition. The STP was revised to include appropriate guidance to remove the reactor level recorder from service, and an extent of condition review was performed for other Refueling Outage 21 modifications that could result in plant trips or downpowers if similar conditions existed. The performance deficiency was determined to be more than minor because the issue was associated with the Initiating Events Cornerstone attribute of procedure quality and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, I&C Technicians and Procedure Writers made an inadequate change to the STP that resulted in a plant transient that led to a reactor scram. The inspectors determined the finding was of very low safety significance (Green) because the finding only resulted in a reactor scram and did not contribute to the likelihood that mitigation equipment or functions would not be available. This finding has a cross-cutting aspect in the area of Human Performance, Resources, because the licensee did not ensure procedures were adequate to assure nuclear safety. Specifically, the inadequate change to the Reactor Water Level and Pressure Instrument Calibration STP resulted in an inaccurate procedure that caused a plant transient resulting in a reactor scram. H.2(c) |
Site: | Duane Arnold |
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Report | IR 05000331/2009003 Section 4OA3 |
Date counted | Jun 30, 2009 (2009Q2) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71153 |
Inspectors (proximate) | K Riemer R Orlikowski R Baker |
CCA | H.7, Documentation |
INPO aspect | WP.3 |
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Finding - Duane Arnold - IR 05000331/2009003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Duane Arnold) @ 2009Q2
Self-Identified List (Duane Arnold)
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