05000335/FIN-2016012-01
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Finding | |
|---|---|
| Title | Failure to Maintain Component Configuration Control Resulted in a Complicated Reactor Trip |
| Description | To Be Determined (TBD). A self-revealing finding was identified for the licensees failure to maintain configuration control of the inadvertent energization lockout relay manual synchronization circuitry as required by licensee procedures MA-AA-100 and ADM-08.12, during the October 2013 modification to the Unit 1 automatic main generator synchronization circuit. The performance deficiency was more than minor because it was associated with the human performance attribute of the Initiating Events Cornerstone and it adversely affected the associated cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions because it resulted in an actual plant trip. The inspectors screened the finding under the initiating events cornerstone using Attachment 4 (October 7, 2016) and Appendix A (June 19, 2012) of Inspection Manual Chapter 0609, Significance Determination Process (April 29, 2015). The inspectors determined the finding required a detailed risk evaluation because the finding caused a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition (e.g. loss of condenser and loss of feedwater). A preliminary significance characterization of White has been assigned. The preliminary finding involved the cross-cutting area of human performance associated with the cross-cutting aspect of avoiding complacency because the individuals involved failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk and failed to implement human error reduction tools associated with configuration control. (H.12) |
| Site: | Saint Lucie  |
|---|---|
| Report | IR 05000335/2016012 Section 4OA3 |
| Date counted | Dec 31, 2016 (2016Q4) |
| Type: | Finding: White |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Saint Lucie - IR 05000335/2016012 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Saint Lucie) @ 2016Q4
Self-Identified List (Saint Lucie)
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