05000336/FIN-2015012-01
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Finding | |
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Title | Failure to Implement Procedural Guidance During a Loss of RCS Inventory |
Description | The NRC identified a Green NCV of Millstone Power Station Unit No. 2 Technical Specifications (TS) 6.8.1, Procedures involving Dominions failure to implement procedural steps when prompted by plant conditions to mitigate the event. Specifically, when pressurizer (PZR) level began to decrease while placing the shutdown cooling (SDC) system in service, the crew did not implement procedural guidance in OP-2207, Plant Cooldown, nor enter AOP 2568A, RCS Leak, Mode 4, 5, 6, and Defueled, as these procedures would have directed operators to locate the source of the leak. Later in the event, once the procedural guidance was implemented, action was taken to identify the location of the leak and it was isolated. After the event, selected crew members were removed from watch standing duties pending remediation. Dominion entered this issue into their corrective action program as CR1012358. The finding was more than minor because it is associated with the human performance attribute of the Mitigating Systems cornerstone and adversely affected its objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, when entry conditions were met, operators did not implement procedural guidance that would have directed them to locate the source of the leak. The finding screened to very low safety significance (Green) using Manual Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Screening and Characterization of Findings, Exhibit 3 - Mitigating Systems Screening Questions. Specifically, the finding did not represent a loss of system safety function. This finding had a cross-cutting aspect in the area of Human Performance, Procedure Adherence, in that licensed operators are expected to implement processes, procedures, and work instructions. Specifically, Dominion operators did not implement procedural guidance when prompted by plant conditions immediately after starting the A Low Pressure Safety Injection Pump (LPSI). |
Site: | Millstone |
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Report | IR 05000336/2015012 Section 4OA5 |
Date counted | Dec 31, 2015 (2015Q4) |
Type: | NCV: Green |
cornerstone | Mitigating Systems |
Identified by: | NRC identified |
Inspection Procedure: | IP 93812 |
Inspectors (proximate) | B Haagensen C Cahill D Jackson D Silk E Gray F Arner K Mangan P Presby T Daun W Cook |
Violation of: | Technical Specification Technical Specification - Procedures |
CCA | H.8, Procedure Adherence |
INPO aspect | WP.4 |
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Finding - Millstone - IR 05000336/2015012 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Millstone) @ 2015Q4
Self-Identified List (Millstone)
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