05000400/FIN-2010005-02
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Finding | |
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| Title | Failure to Follow Procedure Results in Emergency Safeguards Sequencer Actuation and Safety Injection Signal (SIS) while the Plant was in Mode 6 |
| Description | A self-revealing Green NCV of Technical Specifications (TS) 6.8.1, Procedures, was identified for the licensees failure to follow procedure MST-I0073, Train B 18 Month Manual Reactor Trip, Solid State Protection System Actuation Logic & Master Relay Test. Specifically, step 7.4.14 of MST-I0073 required the licensee to place the Master Relay Selector Switch (MRSS) in the Off position. Contrary to this requirement on October 28, 2010, the licensee failed to place the MRSS in the Off position at step 7.4.14. Instead, at step 7.5.85, the technicians noticed that the MRSS remained in Position 3 and then placed the MRSS in the Off position. This action combined with the current plant condition caused an invalid B train safety injection signal (SIS) and B Emergency Safeguards Sequencer (ESS) actuation while the plant was in Mode 6. The licensee entered this issue into their corrective action program (CAP) as action request (AR) #430289. As corrective action, the licensee restored the plant to the pre-actuation condition and conducted training for the maintenance technicians. The failure to follow procedure MST-I0073 for the proper operation of the MRSS was a performance deficiency. The finding was more than minor because it is similar to the more than minor example 4.b from MC 0612 Appendix E in that an operator incorrectly operated a switch causing a plant transient. Additionally, it is associated with the human performance attribute of the Mitigating Systems cornerstone, and it affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, it resulted in an invalid SIS causing the ESS to start the B ESW and B CCW pumps. Using IMC 0609, Significance Determination Process, Phase 1 screening worksheet and Appendix G (Shutdown Operations), Attachment 1, Checklist 4, this finding was determined to be of very low safety significance because it did not meet any of the guidelines which require quantitative assessment. The finding has a cross-cutting aspect of Human Error Prevention, as described in the Work Practices component of the Human Performance cross-cutting area because the technicians proceeded in the face of uncertainty without consulting supervision when they encountered unexpected plant conditions (H.4(a)). |
| Site: | Harris  |
|---|---|
| Report | IR 05000400/2010005 Section 1R12 |
| Date counted | Dec 31, 2010 (2010Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | R Kellner A Nielsen J Rivera-Ortiz R Hamilton W Loo J Austin M Bates S Walker R Musser D Mas-Penaranda M Coursey P Lessard J Eargle N Childs |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Harris - IR 05000400/2010005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Harris) @ 2010Q4
Self-Identified List (Harris)
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