05000443/FIN-2017004-03
From kanterella
Jump to navigation
Jump to search
Finding | |
|---|---|
| Title | Inadequate Procedure Implementation Results in a Manual Reactor Trip |
| Description | A self-revealing Green finding was identified for inadequate implementation of procedure MA 4.5, Configuration Control, Revision 18. Specifically, maintenance technicians failed to properly implement MA 4.5 while backfilling steam generator instrumentation, and inadvertently left an instrumentation valve partially open instead of fully open. This resulted in slow response of the instrument, and ultimately a high steam generator level, a feedwater isolation signal and a manual reactor trip. NextEra promptly rechecked other similar valves, then performed a root cause evaluation that eventually led to additional technician training and improved configuration controls during such evolutions. This finding is more than minor because it is associated with the configuration control attribute of the Initiating Events cornerstone and 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, the failure to effectively implement MA 4.5 resulted in a valve being left out of its required position, a subsequent lack of steam generator water level control during low power operations, and ultimately required a manual reactor trip. In accordance with IMC 0609.04, Initial Characterization of Findings, issued June 19, 2012, and Exhibit 2 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 the fin ding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of a trip to a stable shutdown condition. Additionally, the finding has a cross-cutting aspect in the area of Human Performance, Work Management, because the organization did not implement a process of planning, controlling, and executing the work activity such that nuclear safety was the overriding priority. Specifically, NextEra did not ensure that a steam generator backfilling activity was properly executed, which resulted in the slow response of a steam generator level indication, the overfeeding of the steam generator, a feedwater isolation signal, and the ultimate requirement to trip the reactor. [H.5] |
| Site: | Seabrook  |
|---|---|
| Report | IR 05000443/2017004 Section 4OA3 |
| Date counted | Dec 31, 2017 (2017Q4) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | P Cataldo T Daun P Meier N Perry B Dionne B Cook N Floyd A Buford D Silk F Bower |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
| ' | |
Finding - Seabrook - IR 05000443/2017004 | |||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Finding List (Seabrook) @ 2017Q4
| |||||||||||||||||||||||||||||||||