05000424/FIN-2014004-04
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Finding | |
|---|---|
| Title | Failure to Correctly Implement a Chemical and Volume Control System Procedure for Reactor Water Makeup |
| Description | A self-revealing NCV of TS 5.4.1.a, Procedures, was identified for the licensees failure to implement SOP 13009-1, CVCS Reactor Makeup Control System, Version 50.1. Specifically, on July 9, 2014, the licensee conducted a blended makeup to the volume control tank (VCT) at a boric acid concentration lower than what the procedure required, which resulted in an inadvertent boron dilution of the reactor coolant system (RCS), and caused a subsequent power excursion. Upon recognition, the unit operator took immediate actions to reduce power to an acceptable level. The licensee entered this issue into their corrective action program as 837899. The performance deficiency was more than minor because it was associated with the human performance 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 power operations. Specifically, the performance deficiency was associated with a human error during implementation of SOP 13009-1, resulting in a reactivity event (i.e. inadvertent boron dilution), that subsequently upset plant stability. The inspectors evaluated the finding using IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, issued June 19, 2012. The finding screened as Green because it did not cause a reactor trip. The inspectors determined the finding had a cross-cutting aspect of avoid complacency in the human performance area because the reactor operator did not implement error reduction tools, such as STAR (Stop, Think, Act, Review), as self-check to ensure that work activities were performed safely. |
| Site: | Vogtle  |
|---|---|
| Report | IR 05000424/2014004 Section 4OA2 |
| Date counted | Sep 30, 2014 (2014Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | A Alen A Sengupta M Cain M Franke W Pursley |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Vogtle - IR 05000424/2014004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Vogtle) @ 2014Q3
Self-Identified List (Vogtle)
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