05000458/FIN-2012010-04

Finding

Title

Failue to Implement Effective Corrective Actions for Lockout Relay Failures

Description

The inspectors identified a non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, for the licensees failure to identify and correct a condition adverse to quality. Specifically, after a lockout relay mechanically bound in 2011, causing a fire, the licensee failed to identify and correct other susceptible relays. In response, the licensee tested other susceptible relays and replaced those that failed the test. The licensee entered the finding into the corrective action program as Condition Report CR-RBS-2012-05894. This performance deficiency was more than minor because it was associated with the equipment performance attribute of the initiating events cornerstone and adversely 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. In accordance with NRC Inspection Manual Chapter 0609, Attachment 4, Initial Characterization of Findings, and NRC Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process for Findings At-Power, Exhibit 1, Section B, this finding screened to a detailed risk evaluation because it had caused a reactor trip and the loss of mitigation equipment such as loss of main feedwater and normal service water. The detailed risk evaluation included a quantitative bounding analysis and a qualitative evaluation in accordance with NRC Inspection Manual Chapter 0609, Appendix M, Significance Determination Process Using Qualitative Criteria, to determine that this finding was of very low safety significance (Green). Because the most significant causal factor of the performance deficiency was that the licensee had failed to recognize the potential risk to the plant when performing the evaluations for the failed lockout relays, this finding has a human performance cross-cutting aspect associated with the work control component in that licensee did not plan and coordinate work activities by incorporating risk insights, consistent with nuclear safety.

04
Site:	River Bend
Report	IR 05000458/2012010 Section 4OA5
Date counted	Sep 30, 2012 (2012Q3)
Type:	NCV: Green
cornerstone	Initiating Events
Identified by:	NRC identified
Inspection Procedure:	IP 93800
Inspectors (proximate)	A Barrett B Tindell E Uribe B Hagar
Violation of:	10 CFR 50 Appendix B 10 CFR 50 Appendix B Criterion XVI
CCA	H.5, Work Management
INPO aspect	WP.1
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v • d • e

Finding - River Bend - IR 05000458/2012010

1(0)2(10)3(7)4(4)5(6)6(0)9(8)10(8)11(0)12(5)13(0)301(0)403(2)404(1)503(0)801(0)31(0)

IR 05000458/2012010: 1 2 3 4 5 6 7 8

Finding List (River Bend) @ 2012Q3

CCA Matrix: 2012Q3

	Q	CCA	Title
05000458/FIN-2011008-04	2011Q4		Station Blackout-Containment Venting
05000458/FIN-2011402-01	2011Q4	H.14	Security
05000458/FIN-2011008-09	2011Q4	H.9	Inadequate Simulator Fidelity for Emergency Diesel Generator Loading
05000458/FIN-2011008-08	2011Q4	P.5	Inadequate Emergency and Abnormal Procedures for Standby Diesel Generator Fail to Load Sequences
05000458/FIN-2011008-07	2011Q4	H.9	Inadequate Abnormal Procedure for Reducing Loads on Standby Diesel Generators
05000458/FIN-2011008-05	2011Q4		Inadequate Procedures for Monitoring Standby Service Water System Leakage
05000458/FIN-2011008-03	2011Q4		Failure to Establish Residual Heat Removal Heat Exchanger Testing Frequency
05000458/FIN-2011008-02	2011Q4	P.2	Failure to Use Conservative Design Assumptions in the Ultimate Heat Sink Inventory Calculation
05000458/FIN-2011008-01	2011Q4	P.2	Inadequate Testing of Division I and Division III Standby Diesel Generators
05000458/FIN-2011005-02	2011Q4	H.2	Failure to Adequately Monitor the Performance of the Control Building Chiller System
05000458/FIN-2011005-01	2011Q4	H.12	Standby Service Water Pump Motor Lubrication Deficiencies
05000458/FIN-2011008-06	2011Q4		Failure to Obtain NRC Approval for Change to Ultimate Heat Sink Inventory Requirements
05000458/FIN-2012002-03	2012Q1	H.14	Failure to Verify Assumptions used in Standby Equipment Room Temperature Analysis
05000458/FIN-2012002-04	2012Q1	H.7	Failure to Appropriately Set Reactor Core Isolation Cooling Flow Controller High Output Limit
05000458/FIN-2012002-06	2012Q1	H.7	Inadequate Maintenance Instructions for the Suppression Pool Cooling Isolation Valves
05000458/FIN-2012002-07	2012Q1	H.8	Failure to Perform a Radiation Survey
05000458/FIN-2012002-08	2012Q1	H.2	Failure to Control Access to a High Radiation Area
05000458/FIN-2012002-09	2012Q1		Failure to Properly Fabricate and Install the mid-Standard Turbine Shaft Brush
05000458/FIN-2012002-05	2012Q1	H.8	Inadequate Relief Valve Configuration Control Results in a Reactor Downpower
05000458/FIN-2012002-02	2012Q1	H.8	Failure to Appropriately Assess and Manage Risk for Internal Flooding Events
05000458/FIN-2012002-01	2012Q1	H.9	Failure to Adequately Monitor the Performance of the Digital Radiation Monitoring System
05000458/FIN-2012003-01	2012Q2	H.2	Failure to Follow Procedure to Protect Sensitive Plant Areas
05000458/FIN-2012003-02	2012Q2	H.13	Failure to Follow Severe Weather Operations Procedure
05000458/FIN-2012003-03	2012Q2	P.1	High Pressure Core Spray Diesel Generator Bearing Lubrication Deficiencies
05000458/FIN-2012003-04	2012Q2		Failure to Properly Assemble Turbine Control Valve Push ROD-SPRING Housing Coupling
05000458/FIN-2012003-05	2012Q2		Failure to Specify Manual Actions for Safety Relief Valve Operations During a Station Blackout Event
05000458/FIN-2012004-01	2012Q3		Improper Hydrogen Igniter Breaker Trip Coil Setting
05000458/FIN-2012010-02	2012Q3	H.14	Failure to Declare Reactor Core Isolation Cooling System Inoperable
05000458/FIN-2012009-08	2012Q3		Ability to Promptly Staff the Fire Brigade at All Times During Plant Operation
05000458/FIN-2012009-07	2012Q3		Onsite Safety Review Committee Implementation
05000458/FIN-2012009-06	2012Q3		Implementation of the Station Cable Reliability Program
05000458/FIN-2012009-05	2012Q3		Implementation of Vendor and Industry Recommended Relay Testing and Maintenance
05000458/FIN-2012009-04	2012Q3		Corrective Action Program Implementation for Prior Lockout Relay Failure in February 2011
05000458/FIN-2012009-03	2012Q3		Implementation of the Procedure for Infrequently Performed Tests or Evolutions
05000458/FIN-2012009-02	2012Q3		Past Operability of the Reactor Core Isolation Cooling System
05000458/FIN-2012009-01	2012Q3		Main Control Room Annunciator Control and Conduct of Operations
05000458/FIN-2012004-04	2012Q3	H.5	Inadequate Verification of Leading Edge Flow Meter Functionality
05000458/FIN-2012004-03	2012Q3	P.5	Failure to Appropriately Tune the Reactor Core Isolation Cooling Turbine Speed Controller
05000458/FIN-2012004-02	2012Q3	H.6	Untimely Corrective Actions to Ensure Reliability of the 480 Vac Molded Case Circuit Breakers and Unitized Motor Starters
05000458/FIN-2012010-03	2012Q3	H.14	Failure to Establish an Adequate Controlling Procedure for Stroking Safety Relief Valves at LOW Power
05000458/FIN-2012010-04	2012Q3	H.5	Failue to Implement Effective Corrective Actions for Lockout Relay Failures
05000458/FIN-2012010-05	2012Q3		Failure to Est Lockout Relays in Accordance with Vendor Testing Practices
05000458/FIN-2012010-06	2012Q3	P.5	Failure to Establish an Adequate Cable Reliability Program
05000458/FIN-2012010-01	2012Q3		Failure to Correct Spurious Isolation of Reactor Core Isolation Cooling System
05000458/FIN-2012010-07	2012Q3	H.13	Loss of Onsite Safety Review Committee Independence
05000458/FIN-2012010-08	2012Q3	H.7	Failure to Prevent Conflicts of Duty for Fire Brigade Members

Self-Identified List (River Bend)

	Q	Title
05000458/FIN-2012002-10	2012Q1	Licensee-Identified Violation
05000458/FIN-2012003-06	2012Q2	Licensee-Identified Violation
05000458/FIN-2012003-07	2012Q2	Licensee-Identified Violation
05000458/FIN-2012404-01	2012Q2	Security

[River Bend Findings full list]

05000458/FIN-2012010-04

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