05000529/FIN-2017003-03
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Finding | |
|---|---|
| Title | Failure to Follow Conduct of Operations Procedure |
| Description | The inspectors reviewed a self-revealed, Green, non-cited violation of Technical Specification 5.4.1.a. Procedures, for the licensees failure to implement their Conduct of Operations procedure. Specifically, licensee personnel improperly performed a reactor coolant pump seal injection filter flushing evolution as a skill of the craft task without written instructions. Consequently, Unit 2 experienced a loss of letdown and exceeded the pressurizer level technical specification limit of 56 percent. Licensed operators took immediate corrective actions to restore letdown and lower pressurizer level to within acceptable limits. The licensee entered this issue into their corrective action program as Condition Report 17-09326.The inspectors determined that the failure to follow the Conduct of Operations procedure for performance of skill of the craft tasks is a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it was associated with the configuration control attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the decision to perform the reactor coolant pump seal filter flushing evolution without a controlled procedure allowed operators to place the system in a configuration causing an automatic isolation of the letdown system that challenged the availability of the pressurizer to respond to reactor coolant system pressure transients. The inspectors evaluated the significance of the issue under the Significance Determination Process, as defined in Inspection Manual Chapter 0609.04, Initial Characterization of Findings, and Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power. The inspectors determined that the finding was of very low safety significance (Green) because it only contributed to the likelihood of a reactor trip and not the likelihood that mitigation equipment or functions would not be available. The inspectors determined this finding had a cross-cutting aspect in the area of human performance, avoid complacency, because the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk. Specifically, licensee personnel did not recognize the inherent risks associated with the reactor coolant pump seal filter flushing evolution before proceeding to perform the task without formal written instructions [H.12]. |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000529/2017003 Section 4OA2 |
| Date counted | Sep 30, 2017 (2017Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | C Peabody D Reinert D You G Miller |
| Violation of: | Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Palo Verde - IR 05000529/2017003 | ||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2017Q3
Self-Identified List (Palo Verde)
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