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| Site | Quarter | Title | Description | |
|---|---|---|---|---|
| 05000461/FIN-2017001-03 | Clinton | 2017Q1 | Failure to Develop and Review a Worker Tag Out | 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) |
| 05000293/FIN-2012004-01 | Pilgrim | 2012Q3 | Inadequate Processing of Work Package Results in Reactor Scram | A finding of very low safety significance (Green) was identified for personnel not adequately classifying work in regards to processing an emergent work order. Specifically, personnel classified work on a reach rod position indication for valve 1-HO-163, Steam Jet Air Ejector (SJAE) steam supply valve, as minor maintenance, which resulted in the failure to identify and correct the reach rod indicator and position. This resulted in a degraded vacuum during a power maneuver and a subsequent reactor scram. Entergy entered this issue in the corrective action program (CR-PNP-2012-2304). The finding was determined to be more than minor because it was associated with the Configuration Control (i.e., Operating Equipment Lineup) attribute of the Initiating Events cornerstone, and adversely affected the cornerstones objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. The inspectors screened the issue for significance using IMC 0609.04, Phase 1 Initiating Screening and Characterization of Findings and IMC 0609 Appendix A, Exhibit 1, Initiating Events Screening. The finding was determined to be of very low safety significance (Green) because although the performance deficiency did result in a reactor scram, it did not cause a reactor scram combined with the loss of mitigating 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 Human Performance cross-cutting area, Work Control component, because Entergy did not appropriately plan and coordinate the repair of the SJAE steam supply valve by incorporating the operational impact of the work activity consistent with nuclear safety. |
| 05000341/FIN-2011002-03 | Fermi | 2011Q1 | Reactor Scram due to Loss of Vacuum | A finding of very low safety significance (Green) for failure to evaluate and incorporate the operating experience received from the Boiling Water Reactors Owners Group (BWROG) Off-Gas committee was self-revealed when Fermi 2 experienced a reactor scram due to degraded condenser vacuum on October 24, 2010. The cause of the loss of vacuum was the failure of No. 3 steam jet air ejector (SJAE) steam supply to nozzle gasket, which caused steam erosion of the seating surface and loss of capacity. The licensee repaired the air ejector. The inspectors determined this finding was more than minor because it was associated with the equipment performance attribute of the Initiating Events Cornerstone and impacted the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The issue resulted in a scram. This finding was determined to be of very low safety significance, Green, because, while it did contribute to the likelihood of a reactor trip, it did not contribute to the likelihood that mitigating equipment would not be available. This finding was not cross-cutting because the licensee received the operating experience input over 3 years ago and was not necessarily indicative of current licensee performance. Finally, no violation of NRC requirements was identified since the SJAEs and the off-gas system are nonsafety-related. |
| 05000458/FIN-2009005-03 | River Bend | 2009Q4 | Licensee-Identified Violation | Technical Specification 5.4.1.a requires implementation of applicable procedures recommended in Regulatory Guide 1.33, Revision 2, Appendix A, February 1978. Section 7(e) of the Appendix requires procedures for training in radiation protection and personnel monitoring. Section 4.0(1) of Procedure EN-RP-100, Radworker Expectations, Revision 0, requires, in part, that workers notify health physics upon receipt of any electronic alarming dosimeter alarm that was not prebriefed. Contrary to this, on January 17, 2008, a licensee worker failed to notify radiation protection personnel upon receipt of an electronic alarming dosimeter dose rate alarm that was not prebriefed in steam jet air ejector room B. This finding had very low safety significance (Green) because: (1) it was not an ALARA finding, (2) there was no overexposure, (3) there was no substantial potential for an overexposure, and (4) the ability to assess dose was not compromised. This item was entered into the licensees corrective action program as Condition Report CR-RBS-2008-00506 |
| 05000321/FIN-2009005-03 | Hatch | 2009Q4 | Failure to establish and perform preventive maintenance activities to replace aged electrolytic capacitors for Yokagawa controller power supply | A self-revealing finding was identified for the licensees failure to establish and perform preventive maintenance activities to replace electrolytic capacitors as required per licensee procedure, NMP-ES-006, Predictive Maintenance Implementation and Continuing Equipment Reliability Improvement. As a result, this failure directly resulted in a Unit 1 manual reactor scram on November 22, 2008 (LER 05000321/2008-004). The licensee replaced the steam jet air ejector intercondenser cooling water control valve differential pressure controller (1N21-K088) failed power supply. This issue was documented in the licensees corrective action program as CR 2008111605. This performance deficiency was more than minor because it is associated with the Equipment Performance attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations, in that, on November 22, 2008 the 1N21-K088 power supply failed which led to a manual reactor scram for Unit 1. The significance of this finding was screened with NRC Inspection Manual Chapter 0609 Attachment 4, and since it contributed to an increase in the likelihood of a reactor trip and affected the reliability and availability of mitigating system equipment, a phase 2 SDP analysis was required. The phase 2 review of the Hatch pre-solved worksheet did not have an appropriate column to evaluate the finding, therefore a phase 3 significance determination process (SDP) analysis was required. The phase 3 SDP analysis was performed by a regional senior risk analyst (SRA), as a loss of main feedwater initiating event assessment using the NRCs Standardized Plant Analysis Risk (SPAR) model. The result was <1E-6 for conditional core damage probability and <1E-7 for conditional large early release probability, a GREEN finding. The dominant sequences were Anticipated Transient Without Scram (ATWS) sequences. The analysis assumed condensate remained available throughout the transient, and that main feedwater was recovered with a human error probability determined using the NRCs SPAR H methodology. The large early release frequency (LERF) risk was determined using the ATWS LERF multiplier from the Hatch phase 2 notebook. The inspectors determined this finding has a cross-cutting aspect in the Operating Experience component of the Problem Identification and Resolution area, because the licensee did not implement and institutionalize operating experience through changes to station processes, procedures, equipment, and training programs, in that, the licensee did not make changes to station processes when internal and external operating experience indicated similar electrolytic capacitors failures were occurring. (P.2(b)) |