05000416/FIN-2016002-02
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Finding | |
|---|---|
| Title | Failure to Provide Detailed Work Instructions Resulted in a Reactor Scram |
| Description | The inspectors reviewed a Green, self-revealed finding of Procedure EN-WM-105, Planning, Revision 16, for the failure to ensure Work Order 397549 provided detailed instructions for performing troubleshooting on the B phase of the main transformer. Specifically, Work Order 397549 did not contain detailed instructions for performing troubleshooting on the B phase of the main transformer, which resulted in an incorrect current transformer ratio and subsequent reactor scram. The licensees corrective actions were to incorporate more detailed instructions to the work order, repair the improper wiring, and restore the main transformer prior to transitioning from Mode 3 to Mode 1. Inspectors did not identify a violation of regulatory requirements associated with this finding. This finding was entered into the licensees corrective action program as Condition Report CR-GGN-1-2016-02950. The failure to ensure Work Order 397549 provided detailed instructions for performing troubleshooting on the B phase of the main transformer in accordance with Procedure EN-WM-105 was a performance deficiency. This performance deficiency is more than minor, and therefore a finding, because it is associated with the procedure quality attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, on March 29, 2016, the licensee failed to ensure Work Order 397549 provided detailed instructions for performing troubleshooting on the B phase of the main transformer, which resulted in an incorrect current transformer wiring ratio and subsequent reactor scram. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, and Inspection Manual Chapter 0609, Appendix A, Exhibit 1, Initiating Events Screening Questions, the inspectors determined that the finding was of very low safety significance (Green) because the finding did result in a reactor trip, but did not result in the loss of mitigating equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. This finding has a cross-cutting aspect in the area of human performance associated with field presence, in that, senior managers failed to ensure supervisory and management oversight of work activities, including contractors and supplemental personnel. Specifically, while performing Work Order 397549, the licensee did not have contractor oversight established, and the contract workers performed troubleshooting without detailed instructions to ensure work was performed properly. |
| Site: | Grand Gulf  |
|---|---|
| Report | IR 05000416/2016002 Section 4OA3 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | G George G Warnick M Young N Day P Hernandez |
| CCA | H.2, Field Presence |
| INPO aspect | LA.2 |
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Finding - Grand Gulf - IR 05000416/2016002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Grand Gulf) @ 2016Q2
Self-Identified List (Grand Gulf)
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