05000298/FIN-2015003-05
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Finding | |
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Title | Failure to Follow Primary Containment Atmosphere Sampling Procedure |
Description | The inspectors reviewed a self-revealing, non-cited violation of Technical Specification 5.4.1.a for the licensees failure to appropriately implement a procedure required by Regulatory Guide 1.33, Revision 2, Appendix A, February 1978. Specifically, on June 2, 2015, a chemistry technician failed to implement Station Procedure 8.8.12, Primary Containment Oxygen or Noble Gas Activity Grab Sample Analysis, Revision 14. This resulted in the incorrect primary containment isolation sample valve being operated, which resulted in both divisions of primary containment H2O2 analyzers tripping on low pressure/flow. Operations personnel declared both divisions of primary containment H2O2 analyzers inoperable and entered Limiting Condition for Operation 3.3.3.1, Post Accident Monitoring Instrumentation, Conditions A and C, and restored them to an operable status in accordance with station procedures. The licensee entered this deficiency into the corrective action program as Condition Reports CR-CNS-2015-03292. The licensees failure to operate the correct primary containment isolation sample valve, in support of primary containment atmosphere sampling, in violation of Station Procedure 8.8.12, was a performance deficiency. The performance deficiency was determined to be more than minor, and therefore a finding, because it was associated with the human performance attribute of the Mitigating Systems Cornerstone, and affected the associated cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, Exhibit 2, Mitigating Systems Screening Question, dated June 19, 2012, inspectors determined that the finding was of very low safety significance (Green) because it: (1) was not a deficiency affecting the design or qualification of a mitigating structure, system, or component, and did not result in a loss of operability or functionality; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of at least a single train for longer than its technical specification allowed outage time, or two separate safety systems out-of-service for longer than their technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more non-technical specification trains of equipment designated as high safety-significant in accordance with the licensees maintenance rule program. The finding has a human performance cross-cutting aspect within the avoid complacency area because the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes, which resulted in individuals not implementing appropriate error reduction tools [H.12]. |
Site: | Cooper |
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Report | IR 05000298/2015003 Section 4OA2 |
Date counted | Sep 30, 2015 (2015Q3) |
Type: | NCV: Green |
cornerstone | Mitigating Systems |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71152 |
Inspectors (proximate) | C Henderson D Reinert G Warnick J Braisted J Nance J O'Donnell L Carson M Hayes M Phalen P Elkmann P Hernandez |
Violation of: | Technical Specification - Procedures Technical Specification |
CCA | H.12, Avoid Complacency |
INPO aspect | QA.4 |
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Finding - Cooper - IR 05000298/2015003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Cooper) @ 2015Q3
Self-Identified List (Cooper)
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