05000498/FIN-2011002-04
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Finding | |
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| Title | Failure to Follow Reactor Protection System Procedure Results in Automatic Reactor Trip |
| Description | The inspectors reviewed a self-revealing noncited violation of Technical Specification 6.8.1.a, for the failure to follow surveillance test Procedure 0PSP03-SP-0006R, Train R Reactor Trip Breaker TADOT, Revision 21, because operators did not block a reactor trip signal during the performance of the test. On August 20, 2010, operators inadvertently skipped a page in the test procedure, and at 3:25 p.m., the Unit 1 reactor tripped automatically from 100 percent power. The reactor trip was uncomplicated and the inspectors responded to the site to ensure the plant was in a safe condition. The licensees corrective actions included providing additional supervisory oversight for the test and implementing new place-keeping methods. This finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events Cornerstone and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown, as well as power operations, because it resulted in a reactor trip from 100 percent power. The inspectors performed the significance determination using NRC Inspection Manual Chapter 0609, Attachment 0609.04, Phase 1 Initial Screening and Characterization of Findings, dated January 10, 2008, because the finding affected the Initiating Events Cornerstone while the plant was at full power. The finding was determined to be of very low safety significance because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available. In addition, this finding had human performance cross-cutting aspects associated with work practices, in that, the licensee did not communicate human error prevention techniques, such as self-checking and proper documentation of activities, commensurate with the risk of the assigned task such that work activities are performed safely. |
| Site: | South Texas  |
|---|---|
| Report | IR 05000498/2011002 Section 1R22 |
| Date counted | Mar 31, 2011 (2011Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.22 |
| Inspectors (proximate) | P Goldberg J Dixon K Clayton G Guerra B Tharakan L Carson M Phalen W Walker R Latta B Rice N Greene |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - South Texas - IR 05000498/2011002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (South Texas) @ 2011Q1
Self-Identified List (South Texas)
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