05000397/FIN-2016002-01
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Finding | |
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| Title | |
| Description | The inspectors reviewed a self-revealed, non-cited violation of Technical Specification 5.4.1.a, Procedures, for the licensees failure to follow procedure OI-41, Operations Work Control Expectations, Revision 59. Specifically, the licensee incorrectly marked steps of procedure OSP-FPC/IST-Q701, Fuel Pool Cooling System Operability Surveillance, Revision 34, as not applicable and therefore did not provide mechanical isolation between the non-safety reactor closed loop cooling system and the safety-related standby service water system. As a result, on March 28, 2016, the reactor closed loop cooling system was momentarily depressurized into the service water system and required a manual reactor scram due to a loss of reactor closed loop cooling for non-safety systems. The licensee entered this issue into their corrective action program as Action Request 346945. The failure to follow procedure OI-41, Operations Work Control Expectations, Revision 59, was a performance deficiency. This performance deficiency was more than minor, and therefore a finding, because it adversely affected the configuration control attribute of the Initiating Events Cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Using Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings, and Appendix A, The Significance Determination Process (SDP) for Findings At-Power, Exhibit 1, Initiating Events Screening Questions, dated June 19, 2012, the inspectors determined the finding was of very low safety significance (Green) because the 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. The finding had a cross-cutting aspect in the area of human performance associated with avoiding complacency because the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes including implementing appropriate error reduction tools. Specifically, licensed operators failed to recognize the possible latent issues and inherent risk of marking large portions of a procedure as not applicable. [H.12] |
| Site: | Columbia  |
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| Report | IR 05000397/2016002 Section 1R19 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.19 |
| Inspectors (proximate) | D Bradley G Guerra G Kolcum G Pick J Groom J Kirkland P Elkmann |
| Violation of: | Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Columbia - IR 05000397/2016002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Columbia) @ 2016Q2
Self-Identified List (Columbia)
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