05000336/FIN-2011008-01
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Finding | |
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| Title | Multiple Examples of Procedural Violations and Inadequate Procedures Relating to Control Room Crew Performance During a Plant Transient |
| Description | A self-revealing finding was identified involving the failure of Millstone personnel to carry out their assigned roles and responsibilities and inadequate reactivity management during main turbine control valve testing on February 12, 2011, which contributed to the unanticipated reactor power increase. Specifically, the Millstone Unit 2 operations crew failed to implement written procedures that delineated appropriate authorities and responsibilities for safe operation and shutdown and a procedure for controlling reactor reactivity. In addition, the licensee failed to establish written procedures for the Reactor Protection System (RPS) Variable High-Power Trip (VHT), and for power operation and transients involving multiple reactivity additions. The finding has preliminarily been determined to be White, or of low to moderate safety significance. The finding is also associated with two apparent violations of NRC requirements specified by Technical Specifications. There were no immediate safety concerns following the transient because the event itself did not result in power exceeding license limits or fuel damage. Additionally, interim corrective actions were taken, which included removing the Millstone Unit 2 control room crew involved in the transient from operational duties pending remediation, and establishment of continuous management presence in the Millstone Unit 2 control room while long term corrective actions were developed. Dominion entered this issue, including the evaluation of extentof- condition, into the corrective action program (CR413602) and performed a root cause evaluation (RCE). The finding is more than minor because the performance deficiency (PD) was associated with the human performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Additionally, the PD could be viewed as a precursor to a significant event. Because the finding primarily involved human performance errors, probabilistic risk assessment tools were not well suited for evaluating its significance. The team determined that the criteria for using IMC 0609, Appendix M, Significance Determination Process Using Qualitative Criteria, were met, and the finding was evaluated using this gUidance, as described in Attachment 4 to this report. Based on the qualitative review of this finding, regional management concluded the finding was preliminary of low to moderate safety significance (preliminary White). The team determined that the PD resulted from several causes; however, the team concluded that the primary cause was ineffective reinforcement of Dominion standards and expectations. The team also concluded that this finding had a cross-cutting aspect in the Human Performance area, Decision Making component, because Dominion licensed personnel did not make the appropriate safety-significant decisions, especially when faced with uncertain or unexpected plant conditions to ensure safety was maintained. This includes formally defining the authority and roles for decisions affecting nuclear safety, communicating these roles to applicable personnel, and implementing these roles and authorities as designed. |
| Site: | Millstone  |
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| Report | IR 05000336/2011008 Section 4OA5 |
| Date counted | Jun 30, 2011 (2011Q2) |
| Type: | Violation: White |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 93812 |
| Inspectors (proximate) | B Fuller B Haagensen D Galloway P Presby S Hansell |
| Violation of: | Pending |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Millstone - IR 05000336/2011008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Millstone) @ 2011Q2
Self-Identified List (Millstone)
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