05000352/FIN-2013003-03
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Finding | |
|---|---|
| Title | Failure to Follow Partial Procedure Change Process |
| Description | A self-revealing Green finding of TS 6.8, Procedures and Programs , was identified because Exelon personnel did not implement procedure use and adherence requirements when operators changed the scope of work for surveillance testing of main turbine stop and control valves. This resulted in a reactor protection system automatic scram on April 16, 2013. This issue was identified in the Exelon CAP as IRs 1503749 and 1525552. The failure of station operators to follow the partial procedure performance process during the performance of two TS required surveillances was a performance deficiency that was reasonably within Exelons ability to foresee and correct and could have been prevented. The performance deficiency was also contrary to Exelons procedure use and adherence requirements. This finding was more than minor because, if improper implementation of the partial procedure performance process is left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern such as a more severe plant transient or engineered safeguard system actuation or malfunction. Additionally, this issue is similar to example 4.b in IMC 0612, Appendix E, Examples of Minor Issues, in that the procedural error resulted in a reactor scram or other transient. The finding was determined to be self-revealing because it was revealed through the receipt of a scram signal during performance of a surveillance test which required no active and deliberate observation by Exelon personnel. The finding was determined to be of very low safety significance (Green) in accordance with Appendix G of IMC 0609, Shutdown Operations Significance Determination Process, because the finding did not require a quantitative assessment. A quantitative assessment was not required because the finding did not increase the likelihood of a loss of reactor coolant system inventory or degrade the ability to recover decay heat removal if it was lost. This finding had a cross-cutting aspect in the area of Human Performance, Decision Making, because Exelon did not ensure that personnel made safety-significant or risk-significant decisions using a systematic process to ensure that safety is maintained H.1(a). Specifically, the partial procedure performance process was not properly implemented which resulted in plant conditions that were improper for the next evolution. This resulted in a reactor protection system automatic scram on April 16, 2013. |
| Site: | Limerick  |
|---|---|
| Report | IR 05000352/2013003 Section 4OA3 |
| Date counted | Jun 30, 2013 (2013Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | E Dipaolo J Ayala J Hawkins J Tomlinson M Gray O Masnyk Bailey R Nimitz S Hammann T Burnsa Turiline Dipaolo F Bower J Ayala J Bream R Montgomery R Nimitz |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Limerick - IR 05000352/2013003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Limerick) @ 2013Q2
Self-Identified List (Limerick)
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