05000361/FIN-2010003-11

Finding

Title

Failure to Follow Station Procedures on Written Instruction Use and Adherence

Description

The inspectors identified a finding for the failure of the licensee to follow its procedures for written instruction use and adherence during a test to determine the impact on main condenser vacuum of a damaged feedwater heater. Specifically, on May 5, 2010, while performing a vacuum test on a sixth point feedwater heater, an operator failed to stop the activity, as required by Procedure SO123-XV-HU-3, Written Instruction Use and Adherence, Revision 3, when he encountered unclear and conflicting work instructions. This issue was entered into the licensees corrective action program as Nuclear Notification NN 200909706. The performance deficiency is more than minor because it affected the human performance attribute of the Initiating Events Cornerstone objective to limit the likelihood of those events that upset plant stability during power operations, and is therefore a finding. Using 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 mitigation equipment or functions would not be available. This finding has a crosscutting aspect in the area of human performance associated with the component of work practices because the licensee failed to communicate human error prevention techniques such that work activities were performed safely H.4(a)

11
Site:	San Onofre
Report	IR 05000361/2010003 Section 4OA3
Date counted	Jun 30, 2010 (2010Q2)
Type:	Finding: Green
cornerstone	Initiating Events
Identified by:	NRC identified
Inspection Procedure:	IP 71153
Inspectors (proximate)	R Lantz P Elkmann J Reynoso G Warnick E Ruesch I Anchondo T Buchanan
CCA	H.12, Avoid Complacency
INPO aspect	QA.4
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v • d • e

Finding - San Onofre - IR 05000361/2010003

7(0)1(0)2(17)3(12)4(3)5(7)6(13)8(0)10(1)11(0)301(0)402(0)403(1)404(0)501(0)9(1)

IR 05000361/2010003: 1 2 3 4 5 6 7 8 9 10 11 12

Finding List (San Onofre) @ 2010Q2

CCA Matrix: 2010Q2

	Q	CCA	Title
05000361/FIN-2009004-04	2009Q3	P.1 P.1(a)	Failure to Notify the NRC within Required Timeframe
05000361/FIN-2009004-01	2009Q3	P.3	Failure to Submit Complete Revisions to Updated Final Safety Analysis Report for Penetration Seal Changes
05000361/FIN-2009004-02	2009Q3	P.3	Failure to Assess and Manage Risk for Maintenance that Could Impact Offsite Power Components
05000361/FIN-2009004-03	2009Q3	P.1 P.1(a)	Failure to Follow Corrective Action process for an Inadequate Postmaintenance Test
05000361/FIN-2009004-05	2009Q3		Failure to Specify Appropriate Requirements in Procurement Documents
05000361/FIN-2009404-01	2009Q3	H.7	Security
05000361/FIN-2009007-01	2009Q4	H.2	Failure to Adequately Store and Preserve Materials for Used in Safety-Related Concrete
05000361/FIN-2009005-09	2009Q4	H.2	Failure to Implement Fire Protection Plan Requirements Related to Hot Work Activities
05000361/FIN-2009007-02	2009Q4	H.2	Incorrect Mixing and Batching Associated with Concrete
05000361/FIN-2009402-01	2009Q4	P.1	Security
05000361/FIN-2009402-02	2009Q4	H.12	Security
05000361/FIN-2009005-01	2009Q4	P.1 P.1(a)	Failure to Initiate a Notification in a Timely Manner
05000361/FIN-2009005-02	2009Q4	H.14	Failure to Adequately Identify Problems in Correction Action Program
05000361/FIN-2009005-03	2009Q4	P.2	Failure to Correct Problems with Emergency Diesel Generator Train B
05000361/FIN-2009005-04	2009Q4	H.7	Failure to Correct Problems with Emergency Diesel Generator Train A
05000361/FIN-2009005-05	2009Q4	P.2	Failure to Follow the Operability Determination Process
05000361/FIN-2009005-06	2009Q4	H.13	Failure to Adequately Implement Compensatory Measures to Maintain Equipment Operable
05000361/FIN-2009005-10	2009Q4	H.7	Inadequate Design Control for Safety-Related Electrical Connections
05000361/FIN-2009005-07	2009Q4	H.4 H.5	Inadequate Circulating Water System Maintenance Procedures Contribute to Unit 2 Inadvertent Reactor Trip
05000361/FIN-2009005-08	2009Q4	H.7	Unit 2 Heat Treat Pre-Job Brief Not Performed in Accordance with Procedural Requirements
05000361/FIN-2010002-07	2010Q1	H.8	Failure to Adequately Implement Foreign Material Exclusion Controls
05000361/FIN-2010002-12	2010Q1	P.1	Failure to Enter Conditions Adverse to Quality into the Corrective Action Program
05000361/FIN-2010002-13	2010Q1	H.2	Failure to Adequately Implement Station Work Order
05000361/FIN-2010002-14	2010Q1	H.12	Failure to Follow Operations Procedure to Monitor Component Cooling Water Surge Tank Pressure
05000361/FIN-2010002-06	2010Q1	H.8	Failure to Perform an Adequate Postmaintenance Test
05000361/FIN-2010002-05	2010Q1	P.2	Failure to Follow Procedure Results in an Inadequate operability Determination
05000361/FIN-2010002-03	2010Q1	H.13	Failure to Enter Operating Experience into Corrective Action Program for Timely Evaluation
05000361/FIN-2009009-02	2010Q1	P.2	Failure to Maintaing Written Procedures Covered in Regulatory Guide 1.33
05000361/FIN-2010002-08	2010Q1		Failure to Appropriately Control Access to a Locked High Radiation Area
05000361/FIN-2010002-04	2010Q1	H.8	Failure to Assess and Manage risk for Electrical Switchyard Impacting Maintenance
05000361/FIN-2010002-02	2010Q1		Failure to Appropriately Scope Auxiliary Feedwater Pump Trench Eductors in the Maintenance Rule Monitoring Program
05000361/FIN-2010002-01	2010Q1	H.8	Failure to Implement Fire Protection Plan Requirements Related to Hot Work Activities
05000361/FIN-2009009-01	2010Q1	P.3	Failure to Follow a Level 1 Quality Assurance Program Affecting Human Performance Procedure
05000361/FIN-2010002-11	2010Q1		Failure to Obtain a License Amendment for a Technical Specification Basis Change
05000361/FIN-2010002-10	2010Q1		Failure to Report a Safety System Functional Failure
05000361/FIN-2010002-09	2010Q1	P.2	Failure to Notify the NRC Within Eight Hours of a Nonemergency Event
05000361/FIN-2010003-04	2010Q2	H.8	Failure to Define the Control Room as Required by Technical Specifications
05000361/FIN-2010006-08	2010Q2	P.2	Failure to Maintain Written Procedures Covered In Regulatory Guide 1.33
05000361/FIN-2010006-09	2010Q2	H.13	Failure to Establish Goals And Monitor for A(A) Auxiliary Feedwater Trains
05000361/FIN-2010006-10	2010Q2	H.14	Failure to Identify and Correct Use of Deficient Relays
05000361/FIN-2010006-12	2010Q2	P.1	Failure to Maintain Design Basis Information
05000361/FIN-2010006-03	2010Q2	H.6	Lack of Preventive Maintenance Results in Valve Failure and Inoperable Condensate Storage Tank
05000361/FIN-2010006-02	2010Q2	P.5	Failure to Translate Design Basis Information for Turbine-Driven Auxiliary Feedwater Pump Steam Admission Valves
05000361/FIN-2010006-01	2010Q2	H.14	Inadequate Operability Determination for Turbine-Driven Auxiliary Feedwater Pump Steam Admission Valves
05000361/FIN-2010006-04	2010Q2	P.2	Failure to Report Conditions That Could of Prevented Fulfillment of Safety Function
05000361/FIN-2010003-11	2010Q2	H.11 H.12	Failure to Follow Station Procedures on Written Instruction Use and Adherence
05000361/FIN-2010003-01	2010Q2	H.14	Unavailability Time for Component Cooling Water Incorrectly Counted
05000361/FIN-2010003-03	2010Q2	H.7	Improper Risk Assessment and Management for Work Activities
05000361/FIN-2010006-13	2010Q2	H.12	Failure to Meet Action Plan for Substantive Crosscutting Issues
05000361/FIN-2010006-11	2010Q2	H.5	Failure to Secure Loose Items in the Electrical Switchyard
... further results

Self-Identified List (San Onofre)

	Q	Title
05000361/FIN-2009005-11	2009Q4	Licensee-Identified Violation
05000361/FIN-2009005-12	2009Q4	Licensee-Identified Violation
05000361/FIN-2009005-13	2009Q4	Licensee-Identified Violation
05000361/FIN-2010002-15	2010Q1	Licensee-Identified Violation
05000361/FIN-2010002-16	2010Q1	Licensee-Identified Violation
05000361/FIN-2010002-17	2010Q1	Licensee-Identified Violation
05000361/FIN-2010003-12	2010Q2	Licensee-Identified Violation

[San Onofre Findings full list]

05000361/FIN-2010003-11

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