05000482/FIN-2014004-02
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Finding | |
|---|---|
| Title | Failure to Ensure That Outage Work Could Be Safely Performed During the Existing Plant Conditions |
| Description | A Green self-revealing non-cited violation of Technical Specification 5.4.1.a and Regulatory Guide 1.33, Section 9.e was identified for the failure to implement procedures for the control of maintenance involving motor operated valve testing to ensure that it did not affect safety-related equipment while the plant was aligned to support alternate decay heat removal. The activity resulted in unplanned reactor pressure transients during solid plant operations. The inspectors reviewed the clearance order paperwork and found that the precautions for dealing with potential fluid and energy sources, specifically out of service equipment were not clearly defined. The result was that the procedure assumed a normal refueling alignment of the residual heat removal system, when in fact the licensee had altered the system alignment to support an alternative reactor decay heat removal flow path using the spent fuel pool. This issue was entered into the corrective action program as Condition Report 81981. Failure to ensure that outage work could be safely performed during the existing plant conditions was a performance deficiency. Specifically, when the licensee revised the outage plan shortly before the start of the Mid-cycle Outage 20, they did not re-perform the risk evaluation for the potential fluid and energy sources to account for the unusual configuration established to allow for alternate decay heat removal. The performance deficiency is 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 region based senior reactor analyst performed a simplified risk evaluation and additionally considered guidance from Inspection Manual Chapter 0609, Appendix G, Shutdown Operations Significance Determination Process. 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 finding had very low safety significance (Green) because the risk deficit was less than 1E-6. 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 failed communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety is maintained. Specifically, the licensee developed the alternate decay heat removal alignment shortly before the outage, however the effects of the implementation were not communicated to the schedulers and operators who had already made risk assumptions based on different anticipated plant conditions [H.4]. |
| Site: | Wolf Creek  |
|---|---|
| Report | IR 05000482/2014004 Section 1R13 |
| Date counted | Sep 30, 2014 (2014Q3) |
| Type: | NCV: 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 |
| Violation of: | Technical Specification - Procedures Technical Specification |
| 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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