05000458/FIN-2016009-01

Finding

Title

Failure to Follow Procedure While Installing Jumpers for Shutdown Cooling

Description

The team reviewed a self-revealing, non-cited violation of Technical Specification 5.4, Procedures, for the licensees failure to correctly implement Procedure SOP-0031, Residual Heat Removal System, Revision 326. SOP-0031, Attachment 5, Step 5.4.1, required that a retractable sheathed banana jumper be used when bypassing the 135-psi SDC isolation. Instead, the licensee used a standard banana jumper, which resulted in a short circuit and inadvertent closure of Valves E12MOV-F008, Shutdown Cooling Suction Valve, and E12MOV-F053A, Shutdown Cooling Injection Valve. This caused a loss of decay heat removal. This issue was entered into the licensees corrective action program as Condition Report CR-RBS-2016-0210. Corrective actions included revising Procedure SOP-0031 to include actions to de-energize the applicable valves while bypassing the 135-psi shutdown cooling isolation. The failure to use the correct jumpers as specified in Procedure SOP-0031 was a performance deficiency. This performance deficiency is more than minor, and therefore a finding, because it is 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 shutdown as well as power operations. Specifically, the shorting of contacts resulting from the use of incorrect jumpers caused a loss of shutdown cooling and decay heat removal. The team evaluated the finding using NRC Inspection Manual Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Screening and Characterization of Findings. When applying Exhibit 2 - Initiating Events Screening Questions, the team determined the loss of residual heat removal event did not occur when the refuel cavity was flooded, and therefore it required a risk evaluation using the Appendix G, Attachment 3, Phase 2 Significance Determination Process Template for Boiling Water Reactors during Shutdown. The analyst determined that a modified but still conservative Phase 2 quantitative estimate in combination with qualitative and deterministic insights led to a final conclusion that the finding was of very low safety significance (Green). The finding has a field presence cross-cutting aspect within the human performance area because the licensee failed to promptly correct deviations from standards and expectations. Specifically, the licensee failed to correct deviations from standards and expectations during the performance of the pre-job brief and ensure proper communication and oversight is maintained in the control room during risk significant evolutions [H.2].

01
Site:	River Bend
Report	IR 05000458/2016009 Section 4OA5
Date counted	Mar 31, 2016 (2016Q1)
Type:	NCV: Green
cornerstone	Initiating Events
Identified by:	Self-revealing
Inspection Procedure:	IP 93812
Inspectors (proximate)	B Parks C Cowdrey G Warnick M Bloodgood R Deese S Makor
Violation of:	10 CFR 50 Appendix G Technical Specification
CCA	H.2, Field Presence
INPO aspect	LA.2
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Finding - River Bend - IR 05000458/2016009

1(0)2(3)3(0)4(0)5(0)6(0)7(3)9(4)10(0)11(0)12(0)201(1)301(0)401(0)402(0)403(0)404(6)405(0)406(0)407(0)501(0)

IR 05000458/2016009: 1 2 3 4

Finding List (River Bend) @ 2016Q1

CCA Matrix: 2016Q1

	Q	CCA	Title
05000458/FIN-2015008-02	2015Q3	H.9	Failure to Promptly Document Adverse Conditions in the Corrective Action Program
05000458/FIN-2015008-01	2015Q3	H.1	Failure to Recognize Violations of Contamination Control Requirements as Adverse Conditions
05000458/FIN-2015003-01	2015Q3	H.12	Failure to Operate the Unit 1 Feedwater System In Accordance With Procedures
05000458/FIN-2015405-01	2015Q3		Security
05000458/FIN-2015008-04	2015Q3	H.1	Failure to Identify an Adverse Trend in the Performance of Post Maintenance Testing on High Critical Components
05000458/FIN-2015008-03	2015Q3	H.2	Failure to Preclude Repetition of Consequential Gaps in Operator Performance
05000458/FIN-2015007-02	2015Q4		Failure to Obtain Prior NRC Approval for a Change in Reactor Core Isolation Cooling Injection Point
05000458/FIN-2015004-01	2015Q4	H.8	Failure to Ensure Work Hours are Within Work Hour Limits
05000458/FIN-2015403-01	2015Q4		Security
05000458/FIN-2015007-01	2015Q4	P.1	Failure to Establish Adequate Procedures for Severe Weather Operations
05000458/FIN-2015004-02	2015Q4	H.3	Failure to Properly Implement Surveillance Testing of Penetration Valve Leakage Control System Leads to Inoperability in Excess of Technical Specification Allowed Outage Time
05000458/FIN-2015004-03	2015Q4	H.5	Failure to Conduct Operations and Control Work Practices to Minimize Residual Radioactivity into the Site, including the Subsurface
05000458/FIN-2015004-05	2015Q4	H.12	Failure to Follow Procedure Results in Inadvertent Draindown of Reactor Pressure Vessel
05000458/FIN-2015004-06	2015Q4	H.8	Failure to Restore Main Steam Positive Leakage Control System to Operable Prior to Changing Modes
05000458/FIN-2015004-04	2015Q4		Failure to Make a Notification to NRC Operations Center Regarding a Radioactive Spill Reported to Another Government Agency
05000458/FIN-2015010-02	2016Q1	H.1	Failure to Adequately Assess Risk During Chiller Unavailability
05000458/FIN-2015010-01	2016Q1		Technical Specification Allowed Outage Time During Loss of Non-Technical Specification Supported Systems
05000458/FIN-2015010-04	2016Q1	H.14	Failure to Accomplish an Operability Determination In Accordance With Procedures
05000458/FIN-2016009-02	2016Q1		Failure to Establish Adequate Procedural Guidance
05000458/FIN-2016201-01	2016Q1		Security
05000458/FIN-2016009-03	2016Q1	P.2	Failure to Implement Corrective Actions to Prevent the Recurrence of a Reactor Scram Due to Grid Disturbances
05000458/FIN-2015010-03	2016Q1	P.5	Failure to Identify and Correct Circuit Breaker Failure Mechanism
05000458/FIN-2016009-04	2016Q1	H.14	Failure to Adequately Assess Risk During Motor Generator Set Unavailability
05000458/FIN-2016009-01	2016Q1	H.2	Failure to Follow Procedure While Installing Jumpers for Shutdown Cooling
05000458/FIN-2015010-05	2016Q1	H.12	Failure to Identify and Correct an Adverse Condition in a Timely Manner

Self-Identified List (River Bend)

	Q	Title
05000458/FIN-2015003-02	2015Q3	Licensee-Identified Violation
05000458/FIN-2015007-03	2015Q4	Licensee-Identified Violation
05000458/FIN-2015004-07	2015Q4	Licensee-Identified Violation
05000458/FIN-2015403-02	2015Q4	Licensee-Identified Violation

[River Bend Findings full list]

05000458/FIN-2016009-01

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