05000361/FIN-2010006-06

Finding

Title

Failure to Provide Adequate Procedure for Boron Dilution Activities

Description

The inspectors reviewed a self-revealing noncited violation of Technical Specification 5.5.1.1.a involving the failure to maintain adequate instructions in San Onofre Procedure S023-3-2.4, \"RCS Purification and De-borating Ion Exchanger Operation,\" Revision 21 to control borating of ion exchangers. The failure to maintain an adequate procedure resulted in an unplanned power reduction by control room operators. This issue was entered into the licensee\'s corrective action program as Nuclear Notification 200721702. Immediate corrective actions included revising the procedure and operator crew training. The finding was more than minor because it was associated with the Initiating Events Cornerstone attribute of human performance, and it affected the associated cornerstone objective to limit the likelihood of those events that upset plant stability and that challenge critical safety functions during shutdown, as well as during power operations. Using the Inspection Manual Chapter 0609, \"Significance Determination Process,\" Phase 1 Worksheet, the inspectors concluded that the transient initiator did not contribute to both the likelihood of a reactor trip and to the likelihood that mitigation equipment or functions would not be available. As a result, the issue was of very low safety significance (Green). The finding has a crosscutting aspect in the area of human performance associated with the work practices because licensee supervisory personnel did not ensure activities associated with re-activity control were performed in a controlled manner such that nuclear safety was assured.

06
Site:	San Onofre
Report	IR 05000361/2010006 Section 4OA2
Date counted	Jun 30, 2010 (2010Q2)
Type:	NCV: Green
cornerstone	Initiating Events
Identified by:	NRC identified
Inspection Procedure:	IP 71152
Inspectors (proximate)	C Long E Ruesch G Tutak G Wilson M Hay R Smith S Marquez S Matharu S Walker
CCA	H.2, Field Presence
INPO aspect	LA.2
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v • d • e

Finding - San Onofre - IR 05000361/2010006

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 05000361/2010006: 1 2 3 4 5 6 7 8 9 10 11 12 13

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-2010006-06

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