05000334/FIN-2013005-01
Finding | |
|---|---|
| Title | Moisture Separator Reheater Valve Misposition Results in Plant Transient |
| Description | A self-revealing, Green NCV of TS 5.4.1 Procedures was identified when an operato
did not correctly implement procedure 1OM-52.4.A, Raising Power from 5% to Full Loa Operation, Revision 68, during the warm up the moisture separator reheaters. Specifically, a human performance error resulted in a main steam valve being mispositioned that subsequently caused a plant power transient. FENOC entered this issue into the corrective action program under CR 2013-17848 and reviewed the transient under the Reactivity Management Program. The site performed a limited apparent cause evaluation and plans to update the procedure. The finding is more than minor because it is associated with the Human Performance attribute of the Initiating Events cornerstone and affects the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, a human performance error resulted in a main stea valve being mispositioned that subsequently caused a plant power transient. The finding is also similar to the more than minor example 4.b in IMC 0612, Appendix E, Examples of Minor Issues. In accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 1 of IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, issued June 19, 2012, the inspectors determined that this finding is of very low safety significance (Green) because the performance deficiency did not cause both a reactor trip and the loss of mitigation equipment relied upon to transition the plant to a stable shutdown condition. This finding has a cross-cutting aspect in the area of Work Practices, Human Performance because FENOC did not ensure personnel work practices support human performance. Specifically, FENOC operators did not use an appropriate self-check and peer check during an activity with the potential to affect reactivity H.4(a). |
| Site: | Beaver Valley |
|---|---|
| Report | IR 05000334/2013005 Section 1R20 |
| Date counted | Dec 31, 2013 (2013Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | D Spindler E Carfang J Laughlin M Patel P Kaufman T Moslak W Cook A Dugandzic B Bickett D Silk |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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