05000440/FIN-2009003-09: Difference between revisions

Finding

Title

Loss of Shutdown Cooling Water Flow to Reactor Vessel

Description

A finding of very low safety significance and associated NCV of 10 CFR Part 50,Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed when technicians performed maintenance on protected equipment without implementing risk management techniques specified in station procedures. This resulted in a loss of shutdown cooling flow to the reactor coolant system. Specifically, the licensee established Normal Operating Procedure NOP-OP-1005, Shutdown Defense in Depth, Revision 10, as the implementing procedure to manage risk during shutdown conditions. The licensee failed to implement the significant risk management actions prescribed in procedure NOP-OP-1005 for maintenance on protected equipment. This resulted in a blown fuse in the reactor protection system causing a loss of shutdown cooling flow to the reactor coolant system. The licensee replaced the fuse and restored shutdown cooling. This issue was entered into the corrective action program as CR 09-58110.The finding was more than minor because it was associated with the equipment 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 shutdown as well as power operations. Specifically, the finding resulted in a loss of reactor decay heat removal event while the reactor was shutdown. Using IMC 0609, Appendix G, Shutdown Operation Significance Determination Process, Checklist 8, the inspectors determined that the finding did not require a Phase 2 or Phase 3 analysis because the plant had appropriately met the safety function guidelines for core heat removal, inventory control, power availability, containment integrity, and reactivity control. The issue did not need a quantitative assessment and screened as having very low safety significance using Figure 1. This finding has a cross-cutting aspect in the area of human performance, work control, per IMC 0305 H.3(a), because the licensee did not appropriately plan the work activity consistent with nuclear safety, incorporating risk insights, job site conditions, or the need for planned contingencies, compensatory actions, and abort criteria

09
Site:	Perry
Report	IR 05000440/2009003 Section 4OA3
Date counted	Jun 30, 2009 (2009Q2)
Type:	NCV: Green
cornerstone	Initiating Events
Identified by:	Self-revealing
Inspection Procedure:	IP 71153
Inspectors (proximate)	M Wilk M Marshfield M Phalen D Jones M Franke J Bashore R Leidy J Cameron R Murray C Tilton J Coroju-Sandin
CCA	H.5, Work Management
INPO aspect	WP.1
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v • d • e

Finding - Perry - IR 05000440/2009003

14(0)16(0)1(0)2(7)3(14)4(6)5(5)6(1)7(3)8(0)301(0)402(0)403(0)404(0)501(0)13(0)

IR 05000440/2009003: 1 2 3 4 5 6 7 8 9 10 11 12 13 14

Finding List (Perry) @ 2009Q2

CCA Matrix: 2009Q2

	Q	CCA	Title
05000440/FIN-2008004-07	2008Q3	H.8	Loss of Configuration Control of the Hydrogen Water Chemistry Injection System Resulting in High Radiation Levels (Section 4OA3.3)
05000440/FIN-2008004-06	2008Q3	H.11 H.12	Failure to Adequately Manage Risk Associated With Working Around a Risk-Significant Underground Vault
05000440/FIN-2008004-05	2008Q3	H.7	Adequacy of Airlock Ball Valve Maintenance (4OA2.3)
05000440/FIN-2008004-04	2008Q3	H.12	Failure to Use Procedures for Work Affecting Safety
05000440/FIN-2008004-03	2008Q3	H.5	Failure to Implement a Procedurally-Required Risk Management Activity for a Protected Train (Section 1R13.2)
05000440/FIN-2008004-02	2008Q3	H.5	Failure to Implement Compensatory Measures for a Risk-Management Activity
05000440/FIN-2008004-01	2008Q3	H.11 H.12	Impaired Fire Barrier for Safety-Related Building
05000440/FIN-2008005-01	2008Q4	H.7	Inspection Procedure for RPV Head Strongback Omitted Non-Destructive Testing of Structural Welds
05000440/FIN-2008005-04	2008Q4	P.2	Failure To Report All 10 CFR 50.73 Reportable Events Associated With the Discovery of Loose Containment Grating
05000440/FIN-2008005-05	2008Q4		Unplanned Unavailability of the Motor Feedwater Pump After it was Placed in 10 CFR 50.65(a)(1) status
05000440/FIN-2008005-02	2008Q4		Containment Polar Crane Trolley Seismic Restraints Did Not Meet Seismic Category I Requirements
05000440/FIN-2008005-03	2008Q4	P.1 P.1(a)	Loss of the V-1F and V-2F Non-Vital Buses Resulting in the Loss of Technical Support Center Computers
05000440/FIN-2009002-06	2009Q1	H.5	Maintenance on HPCS System resulted in Emergency Operating Procedure Entry
05000440/FIN-2009002-05	2009Q1		Failure to Document All Applicable Hazards on Shipping Manifest
05000440/FIN-2009002-04	2009Q1	H.2	Failure to Perform an Adequate Evaluation to Determine the Use of Respiratory Protection Equipment and/or Engineering Controls
05000440/FIN-2009002-03	2009Q1	H.4 H.5	Loss of Service Air to Main Steam Line Plugs
05000440/FIN-2009002-02	2009Q1	P.2	Inadequate Inspections on the RPV Head Strongback Lifting Device Major Load-Carrying Welds and Critical Areas
05000440/FIN-2009002-01	2009Q1	P.2	Ineffective Corrective Actions Associated with the Motor Feedwater Pump in 10 CFR 50.65(a)(1) Status
05000440/FIN-2009006-01	2009Q1	H.2	Failure to Adhere to Procedures for Scaffold Affecting Containment Systems (Section 4OA2.1)
05000440/FIN-2009003-11	2009Q2	P.2	RHR System Over-pressurization Due to Failure to Implement Corrective Actions for a Condition Adverse to Quality
05000440/FIN-2009003-10	2009Q2	H.11 H.12	Work on Wrong Relay Affecting Shutdown Cooling
05000440/FIN-2009003-08	2009Q2		Dose Overrun on RWP 09-6035 for the Alternate Decay Heat Removal Project
05000440/FIN-2009003-06	2009Q2	H.4 H.5	Failure to Barricade and Conspicuously Post a High Radiation Area
05000440/FIN-2009003-05	2009Q2	H.14	Failure to Implement Adequate Compensatory Measures Associated with Moving Burned Fuel Coincident with Workers on the 360 Platform
05000440/FIN-2009003-03	2009Q2	H.2	Inability to Operate the RHR Common Suction Line Valve
05000440/FIN-2009003-02	2009Q2	H.2 H.5	Failure to Follow Industrial Safety Manual Results in Damage to Fuel Handling Building Roll-up Door
05000440/FIN-2009003-01	2009Q2	H.5	RCS Temperature Below Minimum Allowed by TS Due to Inadequate Station Procedures
05000440/FIN-2009003-04	2009Q2	H.11 H.12	Failure to Prevent Contact of Energized Components Renders RCIC System Inoperable
05000440/FIN-2009007-03	2009Q2	P.2	Failure to Provide Required Electrical Isolation for Post-Fire Safe Shutdown Electrical Circuits
05000440/FIN-2009007-02	2009Q2		Failure to Assure That Systems Structures and Components Necessary to Achieve and Maintain Hot Shutdown Conditions Were Free of Fire Damage Without Repair Actions
05000440/FIN-2009003-09	2009Q2	H.5	Loss of Shutdown Cooling Water Flow to Reactor Vessel
05000440/FIN-2009007-01	2009Q2		Failure to Maintain Procedures for Post-Fire Operation of Control Room HVAC Fans and Control of Remote Shutdown Room Toolbox Inventory
05000440/FIN-2009003-07	2009Q2		Employee Disregarded portal Monitor Alarm

Self-Identified List (Perry)

	Q	Title
05000440/FIN-2008004-08	2008Q3	Licensee-Identified Violation
05000440/FIN-2008004-09	2008Q3	Licensee-Identified Violation
05000440/FIN-2008004-10	2008Q3	Licensee-Identified Violation
05000440/FIN-2008005-06	2008Q4	Licensee-Identified Violation
05000440/FIN-2008005-07	2008Q4	Licensee-Identified Violation
05000440/FIN-2009002-07	2009Q1	Licensee-Identified Violation
05000440/FIN-2009003-14	2009Q2	Licensee-Identified Violation
05000440/FIN-2009003-12	2009Q2	Licensee-Identified Violation
05000440/FIN-2009003-13	2009Q2	Licensee-Identified Violation

[Perry Findings full list]

@@ Line 13: / Line 13: @@
 | identified by = Self-Revealing
 | Inspection procedure = IP 71153
-| Inspector = M Wilk, M Marshfield, M Phalen, D Jones, M Franke, J Bashore, R Leidy, J Cameron, R Murray, C Tilton, J Coroju,-Sandi
+| Inspector = M Wilk, M Marshfield, M Phalen, D Jones, M Franke, J Bashore, R Leidy, J Cameron, R Murray, C Tilton, J Coroju-Sandin
 | CCA = H.5
 | INPO aspect = WP.1

05000440/FIN-2009003-09: Difference between revisions

Latest revision as of 19:37, 20 February 2018

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05000440/FIN-2009003-09: Difference between revisions

Latest revision as of 19:37, 20 February 2018

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