05000331/FIN-2011004-02
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Finding | |
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| Title | Misplaced Spent Fuel Assembly in Spent Fuel Pool |
| Description | A finding of very low safety significance and associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed on August 16, 2011, for the failure of the licensee to place a spent fuel assembly in its correct location in the spent fuel pool (SFP) in accordance with Refueling Procedure (RFP) 301, Refueling Bridge Operations. Specifically, the fuel handling team failed to move spent fuel assembly JLE323 to its intended location in the SFP in accordance with Item Control Area (ICA) Transfer Report, Plan Number 11-002. This error was contrary to the requirement of step 4.3.13 of procedure RFP 301 which required movement of spent fuel assemblies in accordance with the ICA Transfer Report. The issue was documented in the licensees corrective action program as CR 01678733. A prompt evaluation of JLE323 being placed into the incorrect location was performed and determined that the assembly could remain in the incorrect location with no reduction in safety margin. Additional corrective actions included a work stand down, and enhanced fuel handler training and briefings with additional management oversight. The inspectors determined that the issue of concern represented a performance deficiency because it was the result of the licensees failure to meet a procedural requirement, and the cause was reasonably within the licensees ability to foresee and correct and should have been prevented. The performance deficiency was determined to be more than minor and a finding because it was associated with the Barrier Integrity Cornerstone attributes of configuration control and human performance, and it affected the cornerstone objective of providing reasonable assurance that physical design barriers (i.e., fuel cladding) protect the public from radionuclide releases caused by accidents or events. The inspectors applied IMC 0609, Attachment 4, Phase 1 - Initial Screening and Characterization of Findings, to this finding. Because the inspectors answered No to all questions under Spent Fuel Pool Issues, under the Barrier Integrity Cornerstone column of Table 4a, the finding as very low safety significance (Green). The inspectors determined that the contributing cause that provided the most insight into the performance deficiency was associated with the cross-cutting aspect of Human Performance, having Work Practices components, and involving the licensee using human performance error prevention techniques commensurate with the risk of the assigned task. Specifically, the fuel handling team made the error when they did not correctly apply human performance error prevention tools which were required, expected and appropriate for an activity involving the movement of irradiated fuel and classified as a high risk activity. |
| Site: | Duane Arnold  |
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| Report | IR 05000331/2011004 Section 4OA2 |
| Date counted | Sep 30, 2011 (2011Q3) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | R Winter K Riemer M Mitchell L Haeg J Draper R Murray J Beavers V Myers |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Duane Arnold - IR 05000331/2011004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Duane Arnold) @ 2011Q3
Self-Identified List (Duane Arnold)
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