05000348/FIN-2016004-03
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Finding | |
|---|---|
| Title | Failure to Follow Procedure Resulted in Automatic Reactor Trip and Safety Injection |
| Description | A self-revealing non-cited violation (NCV) of Technical Specification 5.4, Procedures, was identified on October 1, 2016, when the Unit 1 operations shift crew failed to comply with annunciator response procedure FNP-1-ARP-1.9, Ver. 50 for the JC4 annunciator. Conditions were met to trip the reactor, but the operations shift crew failed to do so. As a result, approximately 35 minutes later, MSIV 3369A closed which resulted in an automatic reactor trip and safety injection actuation. The failure of the operations shift crew to follow procedure FNP-1-ARP-1.9 was a performance deficiency (PD). This event was captured in the licensees corrective action program with condition report (CR) 10280729. The licensee established a root cause evaluation team, identified the root causes, and implemented corrective actions (CAR 266911). The PD was more than minor because it was associated with the human performance attribute of the Initiating Events cornerstone objective and adversely affected that objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during power operations. Specifically a manual reactor trip of Unit 1 as required by the ARP, would have prevented the automatic reactor trip and the automatic safety injection actuation. The significance of this finding was evaluated using IMC 0609, Appendix A, "The Significance Determination Process (SDP) for findings at Power, dated June 19, 2012. This finding was determined to be of very low safety significance (Green) because, while this issue resulted in a reactor trip, it did not cause the loss of mitigation equipment relied upon to transition the plant from the onset of a trip to a stable shutdown condition. The inspectors determined the finding had a cross-cutting aspect of Procedure Adherence in the Human Performance area, because the ARP was not followed and the operations crew did not trip the reactor as required by the procedure. [H.8] |
| Site: | Farley  |
|---|---|
| Report | IR 05000348/2016004 Section 4OA3 |
| Date counted | Dec 31, 2016 (2016Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | A Nielsen B Caballero B Collins D Mas J Panfel K Miller P Niebaum S Sandal W Pursley |
| Violation of: | Technical Specification - Procedures |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Farley - IR 05000348/2016004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Farley) @ 2016Q4
Self-Identified List (Farley)
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