05000336/FIN-2011003-04
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Finding | |
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| Title | Failure to Follow Procedure for Starting a Second SGFP Results in Reactor Trip |
| Description | A self-revealing finding (FlN) of very low safety significance (Green) was identified for Dominion\'s failure to follow procedure OP 2204, Load Changes, when starting the \'A\' steam generator feedpump (SGFP). Specifically, the operating crew failed to maintain adequate SGFP suction pressure (greater than 325 psig) while starting the \'A\' SGFP, which led to a trip of the \'B\' SGFP and subsequent reactor trip on low steam generator level. Dominion entered this issue into their corrective action program (CR431574); conducted training exercises emphasizing safe operating envelopes, critical parameters to monitor, and actions to take to restore margin if plant conditions degrade; and has revised procedure OP 2204. The finding is more than minor because it is similar to NRC Inspection Manual Chapter 0612, Appendix E, Examples of Minor lssues, Example 4b; in that, a failure to follow procedure led to a reactor trip. This issue is associated with the Human Performance attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure of the operators to properly monitor SGFP suction pressure led to a loss of adequate feedwater flow and a reactor trip. The inspectors conducted a Phase 1 screening in accordance with NRC Inspection Manual Chapter (lMC) Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, and determined that the finding was of very low safety significance (Green) because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available. The inspectors determined that this finding had a cross-cutting aspect in the Human Performance cross-cutting area, Work Practices component, because Dominion personnel did not properly follow the load changes procedure. |
| Site: | Millstone  |
|---|---|
| Report | IR 05000336/2011003 Section 4OA3 |
| Date counted | Jun 30, 2011 (2011Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | T Moslak D Jackson M Modes B Haagensen J Krafty S Shaffer |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Millstone - IR 05000336/2011003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Millstone) @ 2011Q2
Self-Identified List (Millstone)
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