05000461/FIN-2017001-03
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Finding | |
|---|---|
| Title | Failure to Develop and Review a Worker Tag Out |
| Description | Green. The inspectors documented a self-revealed finding of very low safety significance and associated non-cited violation of Technical Specification 5.4.1, Procedures, for the licensees failure to develop and review a worker tag out in accordance with station procedure OPAA10910, Clearance and Tagging, Revision 12. Specifically, the licensee failed to identify the effect of a worker tag out on the in-service steam jet air ejector suction valve, which caused condenser vacuum to degrade resulting in the operators entering the off normal procedure for loss of condenser vacuum. The licensee entered this issue into their corrective action program as action request (AR) 03980495. As corrective actions, the operations department issued a standing order to require worker tag outs to be challenged by a second senior reactor operator. The performance deficiency was determined to be more than minor because it impacted the Initiating Events cornerstone attribute of configuration control and adversely affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during power operations. Specifically, the failure to properly develop the worker tag out caused the condenser vacuum to degrade, challenging the operators to quickly diagnose the issue and take action to avoid a turbine trip. The finding was screened against the Initiating Events cornerstone and determined to be of very low safety significance because it did not cause a reactor trip or the loss of mitigation equipment relied upon to transition the plant from the onset of a trip to a stable shutdown condition. The inspectors determined that this finding affected the cross-cutting area of human performance in the aspect of avoid complacency, where individuals recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Individuals implement appropriate error reductions tools. Specifically, the operations department failed to implement appropriate error reduction tools such as questioning attitude and thorough work product reviews to ensure the worker tag out considered all potential effects to other plant equipment. [H.12] |
| Site: | Clinton  |
|---|---|
| Report | IR 05000461/2017001 Section 4OA3 |
| Date counted | Mar 31, 2017 (2017Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | E Sanchez-Santiago G Edwards J Wojewoda K Stoedter S Mischke W Schaup |
| Violation of: | Technical Specification - Procedures |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
| ' | |
Finding - Clinton - IR 05000461/2017001 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Clinton) @ 2017Q1
Self-Identified List (Clinton)
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