05000528/FIN-2013002-01
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Finding | |
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| Title | Multiple Failures to Identify Conditions Adverse to Quality |
| Description | The inspectors identified two examples of a Green NCV of 10 CFR Part 50, Appendix B, Criterion XVI Corrective Action, for the failure of the licensee to promptly identify and correct conditions adverse to quality. Specifically, on July 19, 2012, personnel failed to follow Procedure 01DP-0AP12, Palo Verde Action Request Processing, and enter into the corrective action process a failure to comply with technical specifications to enter limiting condition for operation 3.0.3 when maintenance activities rendered safety related inverters inoperable. In addition, on May 2, 2011, the licensee also failed to enter an unanalyzed diversion of emergency core cooling system flow into the corrective action process, despite procedural guidance to the contrary. The licensee entered the issues into the corrective action program as Palo Verde Action Request (PVAR) 4347283 and PVAR 4389514 and is assessing corrective actions. The inspectors concluded that the failure to promptly identify and correct conditions adverse to quality was a performance deficiency. The inspectors determined the performance deficiency is more than minor, and therefore a finding, because it adversely affected the equipment performance attribute of the Mitigating Systems Cornerstone and its objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors determined the two issues had similar causal factors and should be documented as one NCV in accordance with NRC enforcement guidance. The inspectors evaluated the significance of each issue under the SDP, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix A, Significance Determination of Reactor Inspection Findings for At-Power Situations. For the issue associated with inoperable safety related inverters, the inspectors determined the finding to be of very low safety significance (Green) because all questions in Exhibit 2.A could be answered no. For the issue associated with an unanalyzed condition of the high pressure safety injection system, the inspectors determined that the finding represented a loss of system function and needed a detailed evaluation. The inspectors used the Palo Verde Standardized Plant Analysis Risk model, Revision 8.20, with a truncation limit of E-11 and performed a bounding significance determination and found the finding to be of very low safety significance (Green). The bounding change to the core damage frequency was 2.4E-9/year. The dominant core damage sequences included: medium break loss of coolant accident, system transient, and steam generator tube rupture. The very short exposure period minimized the significance. A Region IV senior reactor analyst reviewed the results and agreed with the conclustions. This finding has a cross-cutting aspect in the area of human performance associated with the decision making component because the licensee failed to use a systematic process for dealing uncertain conditions adverse to quality. |
| Site: | Palo Verde  |
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| Report | IR 05000528/2013002 Section 1R15 |
| Date counted | Mar 31, 2013 (2013Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.15 |
| Inspectors (proximate) | L Ricketson G Guerra M Brown P Elkmann L Carson D Allen J Melfi J Laughlin B Larson M Baquera D Reinert N Greenem Hair |
| Violation of: | 10 CFR 50 Appendix B Criterion XVI Technical Specification - Procedures Technical Specification |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Palo Verde - IR 05000528/2013002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2013Q1
Self-Identified List (Palo Verde)
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