05000361/FIN-2010005-02

Finding

Title

Failure to Follow Procedure for Modifying Work Clearance Applications

Description

A self-revealing noncited violation of Technical Specification 5.5.1.1 was identified for the failure of operations personnel to follow Procedure SO123-XX- 5.1, Work Clearance Management Issue, Release, and Tagging Modification, Revision 22, to prepare and verify an adequate tagging boundary. Specifically, operations personnel implemented a change to the work clearance that subjected workers to hazards from contaminated water stored in the refueling water storage tank, without validating assumptions and drawings to determine the correct tank level was adequate as a tagging boundary. Consequently, on November 17, 2010, during implementation of Work Clearance Document WCD 30016930, an estimated 14,200 gallons of contaminated water drained into an area where people were working and resulted in a personnel contamination event. The performance deficiency was determined to be more than minor, and therefore a finding, because it is associated with the plant facilities/equipment attribute of the Occupational Radiation Safety Cornerstone and affects the associated cornerstone objective to ensure the adequate protection of the worker health and safety from exposure to radiation from radioactive material during routine nuclear reactor operation. Using Manual Chapter 0609, Significance Determination Process, Appendix C, the finding is determined to have very low safety significance because the finding: (1) is not related to ALARA; (2) does not involve an overexposure; (3) did not constitute a substantial potential for overexposure; and (4) did not involve a situation where the licensees ability to assess dose was compromised. The finding was determined to have a crosscutting aspect in the area of human performance, associated with the decision making component, because operations personnel failed to use conservative assumptions and formally validate and verify plant conditions and associated tagging boundaries H.1(b)

02
Site:	San Onofre
Report	IR 05000361/2010005 Section 4OA3
Date counted	Dec 31, 2010 (2010Q4)
Type:	NCV: Green
cornerstone	Or Safety
Identified by:	Self-revealing
Inspection Procedure:	IP 71153
Inspectors (proximate)	L Ricketson G Guerra P Elkmann L Carson S Garchow D Allen G Replogle J Reynoso S Alferink C Osterholtz R Telson B Larson S Makor P Capehart M Bloodgood I Anchondo G Tutak C Alldredge T Hedigan N Greene L Micewski Z Hollcraft F Sanchez M Jimenez S Achen
CCA	H.14, Conservative Bias
INPO aspect	DM.2
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v • d • e

Finding - San Onofre - IR 05000361/2010005

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 05000361/2010005: 1 2 3 4 5 6 7

Finding List (San Onofre) @ 2010Q4

CCA Matrix: 2010Q4

	Q	CCA	Title
05000361/FIN-2010002-10	2010Q1		Failure to Report a Safety System Functional Failure
05000361/FIN-2009009-01	2010Q1	P.3	Failure to Follow a Level 1 Quality Assurance Program Affecting Human Performance Procedure
05000361/FIN-2010002-14	2010Q1	H.12	Failure to Follow Operations Procedure to Monitor Component Cooling Water Surge Tank Pressure
05000361/FIN-2010002-13	2010Q1	H.2	Failure to Adequately Implement Station Work Order
05000361/FIN-2010002-12	2010Q1	P.1	Failure to Enter Conditions Adverse to Quality into the Corrective Action Program
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-2010002-01	2010Q1	H.8	Failure to Implement Fire Protection Plan Requirements Related to Hot Work Activities
05000361/FIN-2010002-02	2010Q1		Failure to Appropriately Scope Auxiliary Feedwater Pump Trench Eductors in the Maintenance Rule Monitoring Program
05000361/FIN-2010002-04	2010Q1	H.8	Failure to Assess and Manage risk for Electrical Switchyard Impacting Maintenance
05000361/FIN-2010002-08	2010Q1		Failure to Appropriately Control Access to a Locked High Radiation Area
05000361/FIN-2010002-07	2010Q1	H.8	Failure to Adequately Implement Foreign Material Exclusion Controls
05000361/FIN-2010002-11	2010Q1		Failure to Obtain a License Amendment for a Technical Specification Basis Change
05000361/FIN-2010002-09	2010Q1	P.2	Failure to Notify the NRC Within Eight Hours of a Nonemergency Event
05000361/FIN-2010003-06	2010Q2	H.14	Inadequate Operability Determination for Safety-Related Concrete Cracks
05000361/FIN-2010003-07	2010Q2	P.1 P.1(a)	Inappropriate Control of Operator Aids
05000361/FIN-2010003-08	2010Q2		Failure of Schedule 10S Piping
05000361/FIN-2010003-09	2010Q2	H.8	Failure to Appropriately Identify and Classify Degraded Voltage on a Class 1E Battery
05000361/FIN-2010003-10	2010Q2		Failure to Assure Circuit Breakers Were Qualified for Installation
05000361/FIN-2010003-11	2010Q2	H.11 H.12	Failure to Follow Station Procedures on Written Instruction Use and Adherence
05000361/FIN-2010003-04	2010Q2	H.8	Failure to Define the Control Room as Required by Technical Specifications
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
05000361/FIN-2010006-07	2010Q2	P.2	Failure to Establish Component Cooling Water Radiation Monitoring Procedures
05000361/FIN-2010006-06	2010Q2	H.2	Failure to Provide Adequate Procedure for Boron Dilution Activities
05000361/FIN-2010006-05	2010Q2	H.2	Control Room Operators\' Failure to Adhere to Conduct of Operations Procedural Requirements
05000361/FIN-2010006-08	2010Q2	P.2	Failure to Maintain Written Procedures Covered In Regulatory Guide 1.33
05000361/FIN-2010006-04	2010Q2	P.2	Failure to Report Conditions That Could of Prevented Fulfillment of Safety Function
05000361/FIN-2010006-01	2010Q2	H.14	Inadequate Operability Determination for Turbine-Driven Auxiliary Feedwater Pump Steam Admission Valves
05000361/FIN-2010006-02	2010Q2	P.5	Failure to Translate Design Basis Information for Turbine-Driven Auxiliary Feedwater Pump Steam Admission Valves
05000361/FIN-2010006-03	2010Q2	H.6	Lack of Preventive Maintenance Results in Valve Failure and Inoperable Condensate Storage Tank
05000361/FIN-2010003-05	2010Q2	H.8	Failure to Follow Work Control Procedures
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-2010003-01	2010Q2	H.14	Unavailability Time for Component Cooling Water Incorrectly Counted
05000361/FIN-2010003-02	2010Q2	H.8	Failure to Assess and Manage Risk for Maintenance on Emergency Diesel Generators
05000361/FIN-2010004-03	2010Q3		Failure to Provide Training Mandated by a Root Cause Evaluation
05000361/FIN-2010004-02	2010Q3		Failure to Promptly Identify and Correct a Condition Adverse to Wuality Associated with Safety-related Emergency Ventilation Fans
05000361/FIN-2010004-01	2010Q3	H.8	Failure to Follow Procedures While Implementing a Design Change
05000361/FIN-2010010-01	2010Q3	H.13	Failure to Define Authorities and Responsibilities of Work Process Area Operator
05000361/FIN-2010007-01	2010Q3	H.13	Failure to Ensure At Least One Train of Equipment Necessary to Achieve Hot Shutdown Conditions Is Free of Fire Damage
05000361/FIN-2010403-01	2010Q4		Security
05000361/FIN-2010005-02	2010Q4	H.14	Failure to Follow Procedure for Modifying Work Clearance Applications
05000361/FIN-2010005-03	2010Q4	H.14	Inadequate Control of Foreign Material over the Spent Fuel Pool during Surveillance Testing
05000361/FIN-2010005-01	2010Q4	P.2	Failure to Appropriately Classify Conditions Adverse to Quality for Significance
05000361/FIN-2010005-04	2010Q4	H.11 H.12	Failure to Properly Store C-Panels in the Radwaste Building

Self-Identified List (San Onofre)

	Q	Title
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
05000361/FIN-2010007-02	2010Q3	Licensee-Identified Violation
05000361/FIN-2010005-05	2010Q4	Licensee-Identified Violation
05000361/FIN-2010005-06	2010Q4	Licensee-Identified Violation
05000361/FIN-2010005-07	2010Q4	Licensee-Identified Violation

[San Onofre Findings full list]

05000361/FIN-2010005-02

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