05000354/FIN-2017010-01
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Finding | |
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| Title | Failed to follow site procedures resulting in a reactor scram |
| Description | Enclosure 1 Factual Summary of NRC Office of Investigations (OI) Case No. 1-2016-003 On September 28, 2015, an instrument and control (I&C) technician completed procedure HC.IC-FT.SA-0001, Redundant Reactivity Contro l System (RRCS) Division I Channel A and successfully tested the A channel of the RRCS. The I&C technician then proceeded into procedure HC.IC-FT.SA-0003, RRCS Division I Channel B to test the B channel of the RRCS. While the technician was performing this procedure, the reactor tripped. To determine the cause of the reactor trip, on September 30, 2015, PSEG performed complex troubleshooting, which included reviewing the data saved from plant parameters. Based on the troubleshooting, PSEG determined that the I&C technician had made an error during the surveillance testing, causing both RRCS channels to trip and the reactor to scram. OI interviewed a PSEG staff engineer involved in the troubleshooting. The engineer testified that he analyzed real-time printouts of reactor parameters at the time of the event to recreate the scenario on the reactor simulator. The engineer stated that, from the simulation, it was determined that the I&C technician had incorrect ly selected the A channel of RRCS and then selected the B channel with the test input still inserted in the A channel. This error then caused the reactor recirculation pumps to trip leading to the reactor scram. Additionally, the engineer testified that the full RRCS system wa s reviewed as part of the troubleshooting and no other failures were identified. The I&C technician testified that he had received training and was fully qualified to perform surveillances of the RRCS and had performed this particular surveillance numerous times. The technician acknowledged that he had received training on procedure use and adherence and understood that if an issue occurred, to stop and resolve the issue before moving forward in the procedure. The I&C technician stated that on September 28, 2015, he and another technician had been assigned to perform the RRCS surveillance on the Division 1 A and B channels. The technician testified that the cause of the reactor scram was something went wrong with RRCS, adding that he did not make any mistakes or deviate from the procedure. The I&C technician could not provide an explanation for the contradiction between PSEGs determination for the cause of the scram (i.e. human performance erro r) and the technicians own testimony. OI reviewed the copy of HC.IC-FT.SA-0003, used by the I&C technician on September 28, 2015. The technician had initialed the warning at the start of the applicable section of the procedure which stated Extreme caution should be exercised with key functions on Display Monitor. Careless keyboard manipulation can c ause a reactor scram. If any doubt or questions arise, THEN CONTACT Job Supervision immediately. Contrary to this warning, the I&C technician, as proven through plant data, did not stop and contact supervision after incorrectly selecting the A channel of RRCS. Instead, he selected the B channel with the test inputs still inserted in the A channel. OI concluded based on the preponderance of evidence, that the I&C technician deliberately failed to follow this procedure. ENCLOSURE 2 APPARENT VIOLATION Hope Creek Generating Station Technical Specification 6.8.1.d, Procedures and Programs, requires that written procedures shall be established, implemented, and maintained for surveillance and test activities of safety-related equipment. HC.IC-FT.SA- 0003, Redundant Reactivity Control System Division 1 Channel B, C-22-N-403E, N402E ATWS Recirculation Pump Trip, cautions that Careless keyboard manipulation can cause a reactor scram. IF any doubt or questions arise, THEN contact Job Supervisor immediately. Contrary to the above, on September 28, 2015, PSEG did not properly implement a procedure for a surveillance activity of safety-related equipment when the individual performing an RRCS surveillance test made an error and rather than immediately stopping and informing the job supervisor, attempted to correct the error. Specifically, when manipulating the keyboard, the individual selected the wrong channel to test. Rather than contacting the job supervisor, the individual attempted to correct for the error by selecting the proper channel with test inputs still inserted in the other channel, which ultimately led to a dual recirculation pump trip, alternate rod insertion (ARI) initiation, and a reactor scram. |
| Site: | Hope Creek  |
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| Report | IR 05000354/2017010 Section 4OA5 |
| Date counted | Dec 31, 2015 (2015Q4) |
| Type: | AV: |
| cornerstone | No Cornerstone |
| Identified by: | NRC identified |
| Inspection Procedure: | |
| Violation of: | Technical Specification |
| INPO aspect | |
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Finding - Hope Creek - IR 05000354/2017010 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Hope Creek) @ 2015Q4
Self-Identified List (Hope Creek)
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