05000482/FIN-2014004-01
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Finding | |
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| Title | Failure to Maintain Control and Cognizance of Activities With the Potential to Impact Plant Conditions |
| Description | A self-revealing finding was identified for failure to recognize the potential effects on supported plant equipment while manipulating electrical power distribution components. The finding resulted in an unplanned reactor pressure transient during solid plant operations because the charging flow control valve failed open. Plant pressure increased from 84 to 345 psig before operators were able to control charging flow and lower pressure. The inspectors also concluded that the Licensed Operator Watchstation Expectations in station procedure AP 21-001, Conduct of Operations, was not met. Specifically step 6.3.2 states that Control Room personnel are responsible for in-plant activities and maintain control and cognizance of any activities which have the potential to impact plant conditions. This issue was entered into the corrective action program as Condition Report 80870. Failure to maintain control and cognizance of activities which have the potential to impact plant conditions was a performance deficiency. Specifically, operators failed to recognize the potential effects on primary plant pressure while manipulating electrical power distribution system. The performance deficiency was more than minor because it affected the configuration control attribute 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. A regional senior reactor analyst performed a simplified risk evaluation and additionally considered guidance from Inspection Manual Chapter 0609, Appendix G, Shutdown Operations Significance Determination Process, dated May 5, 2014, and determined that since this deficiency did not involve: 1) exceeding the pressure rating of low pressure piping; or 2) maintaining the low temperature over-pressure protection itself, this finding was of very low safety significance (Green). This was used to inform the assessment using Inspection Manual Chapter 0609, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process, dated May 15, 2005. The analyst determined that the risk deficit was much less than 1E-6/year. The inspectors determined that the finding had a cross-cutting aspect of teamwork in the area of human performance in that individuals and work groups did not communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety is maintained. Specifically, the licensee failed to coordinate the planned bus realignment with a replacement of a redundant power supply such that the momentary loss of power would not have occurred [H.4]. |
| Site: | Wolf Creek  |
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| Report | IR 05000482/2014004 Section 1R13 |
| Date counted | Sep 30, 2014 (2014Q3) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | C Hunt C Peabody N O'Keefe R Stroble T Hartman |
| CCA | H.4, Teamwork |
| INPO aspect | PA.3 |
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Finding - Wolf Creek - IR 05000482/2014004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Wolf Creek) @ 2014Q3
Self-Identified List (Wolf Creek)
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