05000482/FIN-2013003-05
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Finding | |
|---|---|
| Title | Failure to Properly Manage Reactivity Changes when Swapping Turbine Steam Admission Modes from Full to Partial Arc |
| Description | Inspectors identified a Green non-cited violation of Technical Specification 5.4.1.a for the failure to follow Conduct of Operations and Reactivity Management procedures. The inspectors reviewed an unplanned 11 percent power increase during a shift in turbine control modes, and identified that pre-job briefings did not adequately discuss expected plant response, operators did not take action to limit the power increase when an unexpected response was observed, and management was not adequately involved in decision making prior to continuing power ascension before the details of an apparent turbine control malfunction were fully understood. This issue was entered into the licensees corrective action program under Condition Report 68711. Failure to provide contingency actions for a greater than anticipated reactor transient in the pre-job reactivity brief, and continuing with power ascension without understanding the cause of the unexpected turbine control system behavior is a performance deficiency. The performance deficiency is more than minor because it affected the human performance attributes of the Initiating Events cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Using Inspection Manual Chapter 0609 Appendix A, Checklist 1, Initiating Events Screening Questions, and the inspectors determined that the finding was of very low safety significance (Green) because the finding did not result in a reactor trip coincident with the loss of mitigation equipment. The inspectors determined that this finding had a cross-cutting aspect in the area of human performance area of work practices because the licensee failed to communicate human error prevention techniques, such as holding pre-job briefings, self and peer checking, and proper documentation of activities such that work activities were performed safely. In addition, personnel proceeded in the face of uncertainty or unexpected circumstances. Specifically, in the first example control room operators pre-job reactivity brief was not appropriate commensurate with the risk of the assigned task; in the second example station personnel proceeded in the face of uncertainty. |
| Site: | Wolf Creek  |
|---|---|
| Report | IR 05000482/2013003 Section 4OA3 |
| Date counted | Jun 30, 2013 (2013Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | B Correll C Hunt C Peabody C Speer J O'Donnell L Ricketson M Bloodgood M Williams N O'Keefe R Kopriva |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Wolf Creek - IR 05000482/2013003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Wolf Creek) @ 2013Q2
Self-Identified List (Wolf Creek)
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