05000388/FIN-2014008-01
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Finding | |
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| Title | Inadequately Maintained Procedures for Plant Shutdown to Hot Standby led to Reactor Water Level and Power Transients |
| Description | A self-revealing Green NCV of Technical Specification (TS) 5.4.1, Procedures, was identified because PPL did not adequately maintain operating procedures for plant shutdown to hot standby. Specifically, the general operating procedure for plant shutdown to minimum power and the reactor feed pump (RFP) operating procedure were revised, and the technical reviews did not adequately verify the functional and technical adequacy of the procedures. The technical reviews did not identify a valve lineup conflict existed between the two procedures. The conflict resulted in an improper feed lineup to the reactor pressure vessel (RPV) causing two level transients and corresponding power transients of approximately five percent on March 20, 2014. PPLs corrective actions included mitigating the pressure vessel level transients, collecting personnel statements, revising the general operating procedure to remove the valve conflict, initiating an apparent cause evaluation to determine the cause of the level transients, resetting the Operations Department human performance clock due to operator performance issues during the event, reviewing the event with every Operations Department shift crew, performing a standdown for the Operations Department to compare operator performance issues between this event and the December 19, 2012 scram event, as well as entering the events of March 1, 2014, and March 20, 2014, into the corrective action program as condition report (CR)-2014-08941 and CR-2014-10388. The inspectors determined that PPLs inadequate maintenance of procedures for plant shutdown to hot standby was more than minor, because it is associated with the procedure quality attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the inadequate technical reviews associated with the revision of procedures for placing standby RFPs into service in startup level control and valve control (manual), and procedures for placing standby RFPs into service in the flow control mode (FCM) and valve control (manual) mode, resulted in two reactor power transients up to five percent and two significant reactor vessel water level transients which challenged the stability of the plant. Additionally, this issue is similar to Example 4b described in IMC 0612, Appendix E, Examples of Minor Issues, which states that issues are not minor if procedure issues cause a reactor trip or other transient. The inspectors evaluated the finding using Attachment 0609.04, "Initial Characterization of Findings," worksheet to IMC 0609, Significance Determination Process, issued June 2, 2011. The attachment instructs the inspectors to utilize IMC 0609, Appendix A, Significance Determination Process for Findings At-Power, issued June 19, 2012. The inspectors determined this finding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition (e.g. loss of condenser, loss of feedwater) and is therefore of very low safety significance (Green). A cross-cutting aspect was assigned in the area of Human Performance, Change Management, because leaders did not use a systematic process for evaluating and implementing change so that nuclear safety remained the overriding priority. Specifically, PPL did not maintain a clear focus on nuclear safety when implementing changes to the general operating procedure for shutdown to minimum power and this resulted in an unintended procedure discrepancy [H.3]. |
| Site: | Susquehanna  |
|---|---|
| Report | IR 05000388/2014008 Section 4OA5 |
| Date counted | Sep 30, 2014 (2014Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 93812 |
| Inspectors (proximate) | A Defrancisco C Bickett C Newport D Dodson F Bower J Ayala J Kulp J Richmond |
| Violation of: | Technical Specification |
| CCA | H.3, Change Management |
| INPO aspect | LA.5 |
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Finding - Susquehanna - IR 05000388/2014008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Susquehanna) @ 2014Q3
Self-Identified List (Susquehanna)
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