05000354/FIN-2014002-06
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Finding | |
|---|---|
| Title | Failure to Use Approved Method of Post-Scram Reactor Pressure Control |
| Description | A self-revealing Green NCV of TS 6.8.1, Procedures and Programs, was identified for PSEGs failure to use procedures during scram recovery on December 5, 2013. Specifically, PSEG failed to use an approved method of post-scram reactor pressure control, causing the main turbine bypass valves (BPVs) to cycle rapidly resulting in a reactor pressure transient, reactor water level transient, and reactor protection system (RPS) actuation. PSEG entered this issue into their CAP under notification (NOTF) 20632369 and chartered a quick human performance investigation. As part of PSEGs corrective actions, the operators involved in the event were removed from shift and retrained, and each shift manager (SM) reviewed post-scram reactor pressure control methods with their crew and received training on this event, decision making, and procedural adherence. The inspectors determined that the performance deficiency 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, PSEGs failure to implement procedures resulted in an unplanned reactor pressure transient, reactor water level transient, and ultimately resulted in RPS actuation and a trip signal to standby safety injection systems during scram recovery. Using IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, the finding was determined to be of very low safety significance (Green) because it was not a deficiency affecting the design or qualification of a mitigating structure, system or component; it did not represent a loss of system or function; it did not represent the loss of function for any TS system, train, or component beyond the allowed TS outage time; and it did not represent an actual loss of function of any non TS trains of equipment designated as high safety significant in accordance with the PSEGs maintenance rule program. This finding was determined to have a cross-cutting aspect in Human Performance, Consistent Process, because PSEG failed to ensure that individuals use a consistent, systematic approach to make decisions and incorporate risk insights as appropriate. Specifically, operators did not use a systematic approach when making the decision to lower reactor pressure using the digital electro-hydraulic control (DEHC) system cooldown controller on December 5, 2013. |
| Site: | Hope Creek  |
|---|---|
| Report | IR 05000354/2014002 Section 4OA3 |
| Date counted | Mar 31, 2014 (2014Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | B Reyes E Burket H Nieh J Hawkins M Orr S Ibarrola |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Hope Creek - IR 05000354/2014002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Hope Creek) @ 2014Q1
Self-Identified List (Hope Creek)
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