05000244/FIN-2014003-01
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Finding | |
|---|---|
| Title | Inadequate Procedure Implementation Results in |
| Description | A self-revealing Green NCV of Technical Specification (TS) 5.4.1, Procedures, was identified for failure to perform maintenance as required by Exelon Generation (Exelon) procedure STP-I-9.1.16, Undervoltage Protection 480 Volt Safeguard Bus 16, Revision 01001. Specifically, while performing step 6.4.2.1 to place the BX1/16 relay toggle switch in the trip position, an incorrect switch manipulation by an instrumentation and control (I&C) technician resulted in an engineered safety feature (ESF) actuation, which included the automatic start of the B emergency diesel generator (EDG) and the de-energization of a safety-related bus. Immediate corrective actions included restoring Bus 16 to its normal power supply and entering this issue into the corrective action program (CAP) as condition report (CR)-2014-002741. The finding was more than minor, because it is associated with the human performance attribute of the Initiating Events cornerstone and 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, due to a personnel error, an incorrect switch was manipulated during Bus 16 undervoltage testing. This resulted in the automatic start of the B EDG, the de-energization of Bus 16, and the transition of the outage defensein- depth from a Green to a Yellow risk condition. The inspectors evaluated the finding using IMC 0609, Attachment 0609.04, Initial Characterization of Findings. This attachment directed the inspectors to evaluate the finding using IMC 0609, Appendix G, Shutdown Operations Significance Determination Process. However, IMC 0609, Appendix G, directed the inspectors to contact the senior risk analyst for assistance as it does not apply when there are no fuel assemblies in the reactor vessel. The senior risk analyst directed the inspectors to evaluate the finding using Appendix M, Significance Determination Process Using Qualitative Criteria, which directed the inspectors to consider a bounding case. For this instance, if the bus had not been recovered with the fuel in the spent fuel pool (SFP), the only significant system lost would have been the redundant SFP cooling system. Therefore, the inspectors determined the finding to be of very low safety significance (Green). This finding has a cross-cutting aspect in the area of Human Performance, Avoid Complacency, because Exelon personnel did not recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, Exelon personnel did not implement appropriate error reduction tools or consider the potential undesired consequence of an ESF actuation before performing work. |
| Site: | Ginna  |
|---|---|
| Report | IR 05000244/2014003 Section 1R20 |
| Date counted | Jun 30, 2014 (2014Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | A Bolger A Rosebrook D Dodson D Schroeder E Burket H. Anagnostopoulus J Furia J Nicholson N Perry S Horvitz T Burns |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Ginna - IR 05000244/2014003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Ginna) @ 2014Q2
Self-Identified List (Ginna)
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