05000440/FIN-2016001-01
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Finding | |
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| Title | Failure to Properly Implement System Operating Instructions to Maintain Control of Reactor Pressure Vessel Level |
| Description | A finding of very low safety significance and an associated non-cited violation (NCV) of Technical Specification (TS) 5.4.1., Procedures, was self-revealed on January 24, 2016, when an unplanned automatic reactor protection system (RPS) actuation occurred as a result of the licensees failure to correctly implement the steps outlined in procedure SOIC34, Feedwater Control System, Section 4.2.12.c to balance inservice flow controller outputs. Specifically, while in the process of reducing power to allow for a drywell entry to determine the location of an unidentified leak into the drywell floor drain sump, the operators failed to control reactor pressure vessel water level during shifting of feedwater pumps from a turbine-driven reactor feed pump to the motor-driven reactor feed pump, resulting in a RPS actuation initiated on reactor vessel water Level 8, shutting down the reactor. Following the reactor scram, the licensee took immediate actions to restore and maintain RPV water level in accordance with procedure ONIC711, Reactor Scram, Revision 20. The issue was entered into the licensees corrective action program as CR 201601063. The licensees failure to properly implement the steps in the procedure was a performance deficiency that was determined to be more than minor and thus a finding, because it was associated with the Initiating Events cornerstone attribute of human performance 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. The finding was determined to be of very low safety significance because it did not result in the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. This finding has a cross-cutting aspect in the area of human performance, resources, because the licensee failed to ensure that personnel, equipment, procedures, and other resources are available and adequate to support nuclear safety. Specifically, the licensee failed to provide adequate, procedural guidance on when to conduct the feedwater pump shift [IMC 0310, H.1]. |
| Site: | Perry  |
|---|---|
| Report | IR 05000440/2016001 Section 1R20 |
| Date counted | Mar 31, 2016 (2016Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | B Dickson J Nance M Marshfield |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.1, Resources |
| INPO aspect | LA.1 |
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Finding - Perry - IR 05000440/2016001 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2016Q1
Self-Identified List (Perry)
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