ML050840071

NMC Root Cause Evaluation Charter: Attachment Q, RCE Report Template

ML050840071
Person / Time
Site:	Point Beach
Issue date:	03/21/2005
From:	- No Known Affiliation
To:	Office of Nuclear Reactor Regulation
References
FOIA/PA-2004-0282
Download: ML050840071 (2)

Text

,

NMC Root Cause Evaluation Manual ATTACHMENT Q RCE REPORT TEMPLATE Root Cause Evaluation Charter CAP# 55538, Potential Loss of Vent Path During Nozzle Dam Installation, RCE# 254 Issue Manager/Sponsor:

Pat Russell - Manager Performance Assessment Problem Statement:

A significant near miss occurred during the steam generator nozzle dam installation sequence.

Specifically, workers were allowed to proceed with the installation of hot leg nozzle -darnsprior to completion of removal of the pressurizer manway. This was contrary to the established outage schedule. (Removal of the pressurizer manway is required to provide a Hot Leg vent path during reduced inventory operations.) The issue was identified in Point Beach CAP055538.

Investieation Scone:

An Incident Response Team (IRT), composed of NMC staff, will perform a prompt investigation of issues associated with the event. They will provide a summary report to site management and the RCE team. Additionally, they will provide recommended corrective actions to site management for safe continuation of the outage.

The RCE investigation scope will include Organizational and/or Programmatic issues as well as human performance issues leading up to this event.

The RCE team will make recommendations for:

• Correcting the problem

• Preventing recurrence of the problem

• Applicability of the root cause to other areas (extent of condition)

Investieation Methodology:

The RCE team will perform document reviews and consolidate identified examples into failure modes/problem statements. Interviews may be used to gain additional understanding or validate identified problems. Investigations methodologies will include Event and Causal Factor Charting and Failure Mode Analysis.

The following sources of information have been identified for the document review phase:

• Interview notes

• Procedures and work instructions

• NUREG 1449/GL 88-17

• INPO SOER 88-03

t'In

- -- r NMC Root Cause Evaluation Manual ATTACHMENT Q RCE REPORT TEMPLATE

• Outage schedule

• Training lesson plans Incident Response Team Members:

Team Lead Paul Harden Palisades Site Director Team Member Dave Geisen KNPP NOS Manager Team Member Tom Taylor PINGP Assessment Manager Team Member Aldo Capristo NMC ECP Fleet Manager Team Member Joe Maurer PINGP Outage Manager Team Member Kari Den Herder PINGP Engineer (Nozzle Dam SME)

Team Member Craig Chovan NMC Fleet Outage Director RCE Team Members:

This will be a team RCE utilizing Point Beach Personnel and NMC personnel.

Team Leader Dennis Hettick Point Beach Assessment Team Member Jim Holmes (Part Time) Point Beach Training Team Member Chuck Smoker (Part Time) Hudson Assessment Milestones:

Date Assigned Date 4/12/2004 IRT Update Sr. Management Date 4/13/2004 (complete)

Status Update CARB or Screen Team Date 4/22/2004 Draft Report Date 5/06/2004 Final Report Date 5/13/2004 Communications Plan:

Initial communication to the station - Broadcastvoicemail and stand-downs (complete)

IRT debrief to NRC - 4/13/2004 (complete)

Communication to INPO - OE submittal Follow up to the station - Leadership Meeting (Date TBD)

Appro ved: Daate: C Z % '7' Maaet~ Sponsor Reviewed by e CAR on (circle one) Date

. . .