05000348/FIN-2012003-04
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Finding | |
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| Title | |
| Description | A self-revealing Green non-cited violation of Technical Specification 5.4.1, Procedures, was identified for the licensees failure to adhere to the information contained within clearance 1-DT-24-E21-03211. This failure resulted in the unplanned transfer of approximately 5000 gallons of borated water from the refueling water storage tank (RWST) to the reactor coolant system (RCS) refueling cavity and spent fuel pool. In the evening hours of April 10, 2012, operations permit tagout holders allowed the manipulation of Q1E11MOV8706B and Q1E21LCV115D which created an open pathway from the RWST to the RCS refueling cavity and spent fuel pool. Q1E21LCV115D was prohibited from being open by clearance 1-DT-24-E21-03211 while Q1E11MOV8706B was open. The control room staff isolated the unintended flow path and entered the condition into their corrective action program. The licensee conducted an apparent cause determination. The licensee failure to adhere to the information contained within clearance 1-DT-24- E21-03211 is a performance deficiency. This performance deficiency is more than minor because it is associated with the configuration control attribute of the Initiating Events cornerstone and adversely affected the objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the configuration of the residual heat removal (RHR), chemical volume and control system, and refueling water storage tank were not maintained as required and approximately 5000 gallons of borated water was transferred from the RWST to the reactor refueling cavity. The significance of this finding was screened using IMC 0609, Significance Determination Process (SDP), Phase 1 worksheets of Attachment 4. The inspectors also referenced IMC 0609, SDP worksheets of Appendix G, Shutdown Operations Significance Determination Process. The finding screened very low safety significance, Green, because it did not meet any of the loss of coolant accident, transient and external event initiators of the worksheets of Attachment 4. The inspectors reviewed this performance deficiency for cross-cutting aspects and determined the licensee failed to appropriately coordinate work activities by incorporating actions to address the impact of the work on different job activities, and the need for work groups to communicate, coordinate, and cooperate with each other during activities in which interdepartmental coordination is necessary to assure plant and human performance. The finding was assigned a cross-cutting aspect in the work control component of the human performance area. |
| Site: | Farley  |
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| Report | IR 05000348/2012003 Section 4OA2 |
| Date counted | Jun 30, 2012 (2012Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | E Crowe A Nielsen F Ehrhardt G Kuzo S Sandal B Collins J Sowa C Dykes |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Farley - IR 05000348/2012003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Farley) @ 2012Q2
Self-Identified List (Farley)
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