05000335/FIN-2008005-01
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Finding | |
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| Title | Unit 1 Loss of Shutdown Cooling |
| Description | A self-revealing Non-Cited Violation (NCV) of 10 CFR Part 50, Appendix B, Criterion V, \"Instructions, Procedures, and Drawings,\" was identified when a reactor operator (RO) failed to comply with a system surveillance procedure while restoring the 1A Low Pressure Safety Injection Pump from its minimum flow test resulting in a loss of shutdown cooling during a refueling operation on October 22, 2008. The licensee provided remedial training to those operators involved and entered the event in their corrective action program (CAP) as condition report (CR) 2008-32977. This finding is more than minor because it is associated with the configuration control and human performance attributes of the initiating events cornerstone and adversely impacted the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown operations. In addition, if left uncorrected, this finding would result in a more significant safety concern. At the time of the event, the unit was in Mode 6 and had been shutdown for approximately 7 days. The temperature change in the RCS was minimal (less than 10o F) and the time to boiling was greater than 300 minutes with the upper cavity flooded (RCS level > 23 feet) and the reactor vessel head removed. The inspectors evaluated the finding using Inspection Manual Chapter (IMC) 0609, Appendix G, Figure 1, Road Map for Shutdown Findings, Table 1, Losses of Control and Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Operational Checklist 4 PWR Refueling Operation, RCS level > 23 or PWR Shutdown Operation With Time to Boiling > 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> And Inventory in the Pressurizer. The inspectors determined that this finding was screened as having very low safety risk significance (Green) per Figure 1 because this finding did not increase the likelihood of a loss of RCS inventory or could result in a loss of RCS level instrumentation; the finding did not degrade the licensees ability to terminate a leak or add RCS inventory when needed; and the finding did not degrade the licensees ability to recover SDC once it is lost. Also, the inspectors determined that this finding did not meet conditions for Losses of Control Criteria per Table 1 and quantitative assessment was not required. This finding was related to the use of human error prevention techniques aspect in the work practices component in the human performance cross-cutting area (IMC 0305 aspect H.4.a). (Section 4OA2.1 |
| Site: | Saint Lucie  |
|---|---|
| Report | IR 05000335/2008005 Section 4OA2 |
| Date counted | Dec 31, 2008 (2008Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | A Nielsen E Michel G Kuzo M Sykes N Griffis R Carrion S Sanchez T Hoeg |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Saint Lucie - IR 05000335/2008005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Saint Lucie) @ 2008Q4
Self-Identified List (Saint Lucie)
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