05000387/FIN-2010004-01
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Finding | |
|---|---|
| Title | Procedural Inadequacies Result in Reactor Scram and Loss of Normal Heat Sink |
| Description | A self-revealing preliminary White finding regarding procedure NDAP-QA-0008, Procedure Writer\\\'s Guide, Revision 8, was identified following a July 16, 2010, flooding event in the Unit 1 condenser bay which resulted in a manual reactor scram and loss of the normal heat sink. There were three instances of inadequate procedures identified. The first instance involved maintenance procedure MT-043-001 which provided inadequate instructions regarding installation of the condenser waterbox gaskets and led to the event. In addition, two other off-normal procedures were inadequate in that they complicated operator response to the event. Specifically, operators used a diagram in off-normal procedure ON-100-003, Chemistry Anomaly, to identify and isolate the leak which was incorrect, delayed leak isolation, and resulted in a manual reactor scram in anticipation of a loss of the normal heat sink. Finally, ON-142-001, Circulating Water (CW) Leak, did not contain specific instructions to isolate a condenser waterbox leak which contributed to operators using ON-100-003 which was not intended to be used to isolate the condenser box during flooding conditions. PPL corrected the diagram error, dewatered and repaired affected equipment, and entered this issue into their CAP (1282128). This finding was determined to be more than minor as it affected the Initiating Events cornerstone attribute of Procedure Quality and its objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operation. The finding was evaluated using Phases 1, 2, and 3 of the Significance Determination Process. The conclusion of the Phase 3 analysis was an estimated change in core damage frequency (CDF) of 1.1 E-6/yr (White) and an estimated change in large early release frequency (LERF) of 2.6E-7/yr (White). The finding is related to the cross-cutting area of Problem Identification and Resolution, Corrective Acton Program, in that PPL did not thoroughly evaluate problems such that the resolutions address the causes and extent of condition, as necessary. Specifically, PPL did not appropriately evaluate and correct a known issue in an off-normal procedure or adequately evaluate previous CW system waterbox manway gasket leaks to ensure that future occurrences could be prevented. |
| Site: | Susquehanna  |
|---|---|
| Report | IR 05000387/2010004 Section 1R06 |
| Date counted | Sep 30, 2010 (2010Q3) |
| Type: | Finding: White |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.06 |
| Inspectors (proximate) | A Defrancisco D Holody D Lew D Roberts G Gulla K Farrar P Krohn W Dean W Schmidtb Bickettd Roberts P Mckennaa Rosebrookd Molteni J Furia J Greives P Finney P Krohn R Mckinley |
| CCA | P.2, Evaluation |
| INPO aspect | PI.2 |
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Finding - Susquehanna - IR 05000387/2010004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Susquehanna) @ 2010Q3
Self-Identified List (Susquehanna)
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