05000440/FIN-2013009-05
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Finding | |
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| Title | Failure to Implement a Procedure Appropriate to the Circumstances Leads to Reactor Overfeed Event |
| Description | A finding of very low safety significance and associated non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed when the licensee failed to perform a procedure that was appropriate to the circumstances. Specifically, on May 12, 2013, work instruction PTI-N27-P0012, Revision 5, was performed when the condition of the plant, i.e., the specific configuration of the feedwater system and the relatively low reactor pressure, was incapable of supporting the test and resulted in a reactor overfill event. The issue was entered into the corrective action program as condition report 2013-07473. The licensee performed an apparent cause evaluation to identify the most likely causal factors, citing the inadequacy of the procedure and the lack of proper planning as contributing causes. The inspectors reviewed Inspection Manual Chapter (MC) 0612, Appendix B, Issue Screening, and determined that the issue was more than minor because it was associated with the Initiating Events Cornerstone attribute of procedure quality and adversely affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The inspectors determined that the finding was of very low safety significance (Green) in accordance with IMC 0609, Appendix A, Significance Determination Process. This finding has a cross-cutting aspect in the area of human performance, work control, for the licensees failure to plan work activities such that they could be performed while the plant was in an appropriate operational condition. Specifically, the licensee rescheduled the activity without performing an adequate impact review of the different plant conditions on the activity. |
| Site: | Perry  |
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| Report | IR 05000440/2013009 Section 4OA4 |
| Date counted | Jun 30, 2013 (2013Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 95002 |
| Inspectors (proximate) | A Garmoe G Hansen J Furia J Jandovitz M Kunowski M Phalen P Cardona _Morales R Lerch R Rui |
| Violation of: | 10 CFR 50 Appendix B 10 CFR 50 Appendix B Criterion V |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Perry - IR 05000440/2013009 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2013Q2
Self-Identified List (Perry)
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