05000412/FIN-2014004-01
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Finding | |
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| Title | Inadequate Plant Startup Procedure Led to Manual Reactor Trip |
| Description | A self-revealing NCV of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings was identified for FENOCs failure to have an adequate plant startup procedure. Specifically, 2OM-52.4A, Raising Power from 5% to Full Load Operation, did not adequately address plant startup with one condensate pump in operation. This led to an inability to adequately control steam generator (SG) level when the second condensate pump was started which required the operators to trip the reactor. FENOC is in the process of implementing corrective actions to revise procedure 2OM-52.4A and to address the human performance errors associated with this event. Additionally, FENOC entered the issue into their corrective action program as condition report (CR) 2014-09256. The finding is more than minor because it is associated with the procedure quality and human performance attributes of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the inadequate procedure led to SG level fluctuations that could not be adequately controlled when the second condensate pump was started, and required the operators to trip the reactor. The inspectors determined that this finding is of very low safety significance (Green), because while it did result in a reactor trip, it did not cause a loss of mitigation equipment relied upon to transition the plant from the onset of a trip to a stable shutdown condition. The finding has a cross-cutting aspect in Human Performance, Challenge the Unknown, because FENOC operators did not stop when faced with uncertain conditions. Specifically, the adequacy of the procedure was not sufficiently questioned when the plant was not in the normal start up configuration of two running condensate pumps nor later when the condensate pump discharge header pressure low alarm occurred. |
| Site: | Beaver Valley  |
|---|---|
| Report | IR 05000412/2014004 Section 4OA3 |
| Date counted | Sep 30, 2014 (2014Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | B Reyes D Werkheiser E Andrews H Gray J Krafty M Patel S Kennedy T Fish |
| Violation of: | 10 CFR 50 Appendix B Criterion V |
| CCA | H.11, Challenge the Unknown |
| INPO aspect | QA.2 |
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Finding - Beaver Valley - IR 05000412/2014004 | ||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Beaver Valley) @ 2014Q3
Self-Identified List (Beaver Valley)
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