05000410/FIN-2014002-02
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Finding | |
|---|---|
| Title | Invalid Low Reactor Water Level Results in Unit 2 Automatic Reactor Scram |
| Description | Inspectors documented a self-revealing Green NCV of Technical Specification (TS) 5.4, Procedures, for CENGs failure to ensure proper communication of a change in work scope prior to implementation. Specifically, on March 10, 2014, valve label replacements at Unit 2 commenced in a trip sensitive area while the plant was on-line, although the work was previously scheduled to be conducted when the reactor was shut down. This change in work scope was not properly reviewed and communicated to the supporting work group prior to implementation. As a result, a reactor scram occurred when an instrumentation and control (I&C) technician inadvertently contacted an instrument rack located in a trip sensitive area while performing a valve label replacement. CENG generated condition report (CR)-2014- 001963 to document the Unit 2 reactor scram due to the technician contacting the instrument line while cutting the valve label. Immediate corrective actions included developing site communications to enhance awareness of trip sensitive equipment and to provide additional flagging barriers to ensure trip sensitive components are not inadvertently contacted. This finding is more than minor because it is associated with the human performance 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 power operations. Specifically, CENG staff did not properly ensure that the scope change was properly reviewed and communicated to the supporting work group prior to implementation. This resulted in work being performed while Unit 2 was online and a subsequent automatic reactor scram when an instrument rack was inadvertently contacted. In accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 1 of IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, issued June 19, 2012, the inspectors determined that this finding is of very low safety significance (Green) because while the performance deficiency caused a reactor scram, it did not result in the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. The finding has a cross-cutting aspect in the area of Human Performance, Conservative Bias, because CENG failed to use proper decision makingpractices that emphasize prudent choices over those that are simply all. |
| Site: | Nine Mile Point  |
|---|---|
| Report | IR 05000410/2014002 Section 4OA3 |
| Date counted | Mar 31, 2014 (2014Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | D Kern D Schroeder E Burket E Miller K Kolaczyk S Barr S Mccarver |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.14, Conservative Bias |
| INPO aspect | DM.2 |
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Finding - Nine Mile Point - IR 05000410/2014002 | |||||||||||||||||||||||||||||||||||||||||||
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Finding List (Nine Mile Point) @ 2014Q1
Self-Identified List (Nine Mile Point)
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