05000293/FIN-2011012-01: Difference between revisions

Finding

Title

Failure to Implement Conduct of Operations and Reactivity Control Procedures during Reactor Startup

Description

A self-revealing finding was identified involving the failure of Pilgrim personnel to implement conduct of operations and reactivity control standards and procedures during a reactor startup, which contributed to an unrecognized subcriticality followed by an unrecognized return to criticality and subsequent reactor scram. The significance of the finding has preliminarily been determined to be White, or of low to moderate safety significance. The finding is also associated with one apparent violation of NRC requirements specified by Technical Specification 5.4, Procedures. There was no significant impact on the plant following the transient because the event itself did not result in power exceeding license limits or fuel damage. Additionally, interim corrective actions were taken, which included removing the Pilgrim control room personnel involved in the event from operational duties pending remediation, providing additional training for operators not involved with the event, and providing increased management oversight presence in the Pilgrim control room while long term corrective actions were developed. Entergy staff entered this issue, including the evaluation of extent of condition, into its corrective action program (CR-PNP-2011-2475) and performed a Root Cause Evaluation (RCE). The finding is more than minor because it was associated with the Human Performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, the failure of Pilgrim personnel to effectively implement conduct of operations and reactivity control standards and procedures during a reactor startup caused an unrecognized subcriticality followed by an unrecognized return to criticality and subsequent reactor scram. Because the finding primarily involved multiple human performance errors, probabilistic risk assessment tools were not well suited for evaluating its significance. The inspection team determined that the criteria for using IMC 0609, Appendix M, Significance Determination Process Using Qualitative Criteria, were met, and the finding was evaluated using this guidance, as described in Attachment 4 to this report. Based on the qualitative review of this finding, the NRC has preliminarily concluded that the finding was of low to moderate safety significance (preliminary White). The inspection team determined that multiple factors contributed to this performance deficiency, including: inadequate enforcement of operating standards, failure to follow procedures, and ineffective operator training. The Entergy RCE determined that the primary cause was a failure to adhere to established Entergy standards and expectations due to a lack of consistent supervisory and management enforcement. The inspection team concluded that the finding had a cross-cutting aspect in the Human Performance cross-cutting area, Work Practices component, because Entergy did not adequately enforce human error prevention techniques, such as procedural adherence, holding pre-job briefs, self and peer checking, and proper documentation of activities during a reactor startup, which is a risk significant evolution. Additionally, licensed personnel did not effectively implement the human performance prevention techniques mentioned above, and they proceeded when they encountered uncertainty and unexpected circumstances during the reactor startup

01
Site:	Pilgrim
Report	IR 05000293/2011012 Section 4OA5
Date counted	Sep 30, 2011 (2011Q3)
Type:	Violation: White
cornerstone	Initiating Events
Identified by:	Self-revealing
Inspection Procedure:	IP 93812
Inspectors (proximate)	A Defrancisco C Miller D Holody D Jackson D Roberts K Farrar L Casey R Bellamy W Deanb Haagensend Jackson D Molteni R Mckinley
Violation of:	Pending
CCA	H.12, Avoid Complacency
INPO aspect	QA.4
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v • d • e

Finding - Pilgrim - IR 05000293/2011012

1(0)2(3)3(5)4(3)5(6)7(3)8(2)9(0)10(0)11(1)12(1)13(0)202(0)301(0)302(0)403(0)404(0)405(1)406(0)407(0)501(0)4(0)

IR 05000293/2011012: 1

Finding List (Pilgrim) @ 2011Q3

CCA Matrix: 2011Q3

	Q	CCA	Title
05000293/FIN-2010005-03	2010Q4		Failure to Implement the Experience and Qualification Requirements of the Quality Assurance Program
05000293/FIN-2010005-02	2010Q4	H.13	Failure to Perform Required Quality Control Inspections
05000293/FIN-2010005-01	2010Q4	H.5	Failure to Manage a Yellow Risk Condition During HPCI Testing from the Alternate Shutdown Panel
05000293/FIN-2011002-02	2011Q1	P.2	Inadequate Corrective Actions for RCIC Torus Suction Valve
05000293/FIN-2011002-03	2011Q1		Need For Clarification on Condensate Storage Tank Suction Piping ASME Classification
05000293/FIN-2011002-01	2011Q1		Application of TS 3.3.8.1 When Control Rod Position Indication is Lost
05000293/FIN-2011008-02	2011Q1	P.2	Torus Air Temperature 10 CFR 50.65(a)(2) Performance Demonstration Not Met
05000293/FIN-2011008-01	2011Q1	P.1	Failure to Follow Corrective Action Process for HPCI Diaphragm Degraded Condition
05000293/FIN-2011011-01	2011Q2		Security
05000293/FIN-2011004-02	2011Q3	H.14	Failure to Identify a Primary Containment System Maintenance Rule Functional Failure and Thereby Establish Monitoring Requirements for the System
05000293/FIN-2011004-03	2011Q3	H.5	Failure to Accurately Assess Risk of Maintenance on Standby Gas and Secondary Containment
05000293/FIN-2011004-01	2011Q3		Failure to Verify the Adequacy of the Design for the \'C\' Salt Service Water Pump
05000293/FIN-2011003-05	2011Q3	H.14	Failure to Enter Technical Specifications after Loss of Control Rod Indication
05000293/FIN-2011003-04	2011Q3	H.4 H.5	Failure to Enter Technical Specifications for CHREAFS
05000293/FIN-2011003-03	2011Q3	H.13	lnadequate Risk Assessment for Planned Maintenance and Testing on RCIC, SLC and ATS Systems
05000293/FIN-2011003-02	2011Q3	P.3	Submerged Medium Voltage Cables
05000293/FIN-2011003-01	2011Q3	H.4 H.5	Transient Combustible Loading in SLC Room in Excess of the Fire Hazards Analysis Limit
05000293/FIN-2011012-01	2011Q3	H.12	Failure to Implement Conduct of Operations and Reactivity Control Procedures during Reactor Startup

Self-Identified List (Pilgrim)

	Q	Title
05000293/FIN-2010005-04	2010Q4	Licensee-Identified Violation

[Pilgrim Findings full list]

@@ Line 12: / Line 12: @@
 | identified by = Self-Revealing
 | Inspection procedure = IP 93812
-| Inspector = A Defrancisco, C Miller, D Holody, D Jackson, D Roberts, K Farrar, L Casey, R Bellamy, W Deanb, Haagensen D, Jackson D, Molteni R, Mckinle
+| Inspector = A Defrancisco, C Miller, D Holody, D Jackson, D Roberts, K Farrar, L Casey, R Bellamy, W Deanb,  Haagensend Jackson, D Molteni, R Mckinley
 | CCA = H.12
 | INPO aspect = QA.4

05000293/FIN-2011012-01: Difference between revisions

Latest revision as of 19:44, 20 February 2018

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05000293/FIN-2011012-01: Difference between revisions

Latest revision as of 19:44, 20 February 2018

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