05000361/FIN-2008003-03
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Finding | |
|---|---|
| Title | Failure to Properly Monitor and Execute a Unit 2 Reactivity Manipulation |
| Description | A self-revealing noncited violation of 10 CFR Part 50, Appendix B, Criterion V, (Procedures) was identified for the failure of operations personnel to understand, monitor and perform a Unit 2 reactivity manipulation in accordance with procedural requirements. This failure contributed to the overfeeding of both steam generators as well as the inadvertent addition of positive reactivity during a planned startup. Specifically, on June 3, 2008, operations personnel failed to follow Procedure SO123-0-A1, Conduct of Operations, Revision 14, step 6.5.2.7, which requires, in part, that all reactivity manipulations are to be identified and fully understood and shall be closely monitored to verify the expected magnitude, direction, and effects are realized. This finding was entered into the licensees corrective action program as Action Request 0080600073. The finding is greater than minor because it is associated with the human performance attribute of the Initiating Events Cornerstone and affects the cornerstone objective to limit the likelihood of events that upset plant stability. Using the Manual Chapter 0609, \"Significance Determination Process,\" Phase 1 Worksheets, the finding is determined to have very low safety significance because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigating equipment or functions would not be available. The finding has a crosscutting aspect in the area of human performance associated with work practices because operations personnel proceeded in the face of uncertainty or unexpected circumstances H.4(a) (Section 1R13.2) |
| Site: | San Onofre  |
|---|---|
| Report | IR 05000361/2008003 Section 1R13 |
| Date counted | Jun 30, 2008 (2008Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | R Kopriva G George J Reynoso G Warnick C Osterholtz M Hay S Makor M Baquera |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - San Onofre - IR 05000361/2008003 | |||||||||||||||||||||||||||||||||||||||||||
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Finding List (San Onofre) @ 2008Q2
Self-Identified List (San Onofre)
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