05000346/FIN-2014005-03
Finding | |
|---|---|
| Title | Licensee-Identified Violation |
| Description | The following violation of very low significance (Green) was identified by the licensee and is a violation of NRC requirements which meets the criteria of Section 2.3.2 of the NRC Enforcement Policy for being dispositioned as an NCV. Wrong Channel Error Renders Safety Features Actuation System Channel 2 Inoperable During Testing on Channel 4 Appendix B of 10 CFR Part 50, Criterion V, Instructions, Procedures, Drawings requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Contrary to this requirement, on November 3, 2014, two reactor operators failed t
adequately perform procedure DBSC03113, "SFAS [Safety Features Actuation System] Channel 4 Functional Test." Specifically, the operators errantly began performing the test procedure on SFAS Channel 2 instead of SFAS Channel 4, as the procedure required. During the performance of the initial procedures steps, the operators placed the SFAS Channel 2 test trip bypass switch in the "reactor coolant pressure" position. This resulted in the "reactor coolant system pressurelow" and the "reactor coolant system pressurelow low" functions for SFAS Channel 2 being rendere inoperable and an unplanned entry into TS 3.3.5, Condition A. Shortly thereafter, the operators recognized that they were performing their actions on the wrong SFAS channel, stopped all associated activities, and reported the error to the on-shift unit supervisor in the control room. The operators were relieved from all licensed duties, and all SFAS test activities were halted. Within the hour, control room personnel had returned the SFAS Channel 2 test trip bypass switch to its normal position and restored all functions for SFAS Channel 2 to an operable status. The DBSC03113 procedure was successfully performed on SFAS Channel 4 on November 8, 2014. The objective of the Mitigating Systems Cornerstone of Reactor Safety is to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). A key attribute of this objective is human performance, and specifically, configuration control. In accordance with NRC IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, the inspectors determined that the violation was of more than minor significance in that it had a direct impact on this cornerstone objective. The licensees failure to complete DBSC03113 as written resulted in the unplanned inoperability of SFAS Channel 2 for the "reactor coolant system pressurelow" and the "reactor coolant syste pressurelow low" functions. The licensee had entered this issue into their CAP as CRs 201416542, 201416919, 201417011, and 201417037. A full apparent cause evaluation was performed and corrective actions included, but were not limited to: A lessons learned communication was provided to each operating crew prior to their next shift, and a site-wide human performance communication on the issue was developed and promulgated; The cabinet door key for SFAS Channel 4, which unintentionally was able to open the SFAS Channel 2 door, was replaced and this physical vulnerability removed; and As part of the extent of condition, it was validated that the keys for other similar safety, control, and instrumentation cabinets in the control room functioned onl in their proper and respective door locks. |
| Site: | Davis Besse  |
|---|---|
| Report | IR 05000346/2014005 Section 4OA7 |
| Date counted | Dec 31, 2014 (2014Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Licensee-identified |
| Inspection Procedure: | |
| Inspectors (proximate) | A Schwab D Kimble J Beavers J Cameron M Mitchell R Baker R Morris T Briley |
| Violation of: | Technical Specification - Procedures Technical Specification 10 CFR 50 Appendix B Criterion V |
| INPO aspect | |
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Finding - Davis Besse - IR 05000346/2014005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Davis Besse) @ 2014Q4
Self-Identified List (Davis Besse)
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