05000461/FIN-2012003-02
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Finding | |
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| Title | Failure to Establish Instructions Appropriate for Installation of Shutdown and Upset Level Instrument Reference Leg Piping |
| Description | A finding of very low safety significance with an associated Non-Cited Violation of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed on December 18, 2011, when an automatic reactor scram signal and loss of decay heat removal occurred due to low reactor pressure vessel (RPV) water level while lowering water level following an RPV hydrostatic pressure test. These actions occurred because the licensee failed to establish an adequate procedure to perform reinstallation of common shutdown and upset level instrument reference leg piping. Specifically, inadequacies with the procedure resulted in improper filling and venting of the reference leg piping causing inaccurate indication of RPV level -an error of approximately 108 inches. In addition, the licensee failed to use appropriate acceptance criteria when accepting that the instrument restoration activities had been successfully accomplished. The licensee entered this issue into its corrective action program for evaluation and initiated corrective actions to revise procedures to more rigorously control the evolution and to train personnel. The finding was of more than minor significance since it was associated with the Mitigating Systems Cornerstone attribute of Procedure Quality and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the licensee failed to establish procedures adequate to maintain correct indication of RPV water level upon the reinstallation of permanent shutdown and upset level instrument reference leg piping. The finding was determined to be a licensee performance deficiency of very low safety significance based upon a Phase 3 Significance Determination Process evaluation by the Regional Senior Reactor Analyst with a risk result of approximately 4E-7 for Core Damage Frequency and no Large Early Release Frequency contribution since the event occurred more than 8 days from the beginning of the refueling outage. The inspectors concluded that this finding affected the cross cutting area of human performance. Specifically, in the area of work control, the licensee did not ensure that personnel, equipment, procedures, and other resources were available and adequate. Complete, accurate, and up-to-date procedures and work packages were not available to ensure nuclear safety. |
| Site: | Clinton  |
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| Report | IR 05000461/2012003 Section 4OA2 |
| Date counted | Jun 30, 2012 (2012Q2) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | B Kemker D Lords D Reeser M Phalen M Ring R Walton S Mischke |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Clinton - IR 05000461/2012003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Clinton) @ 2012Q2
Self-Identified List (Clinton)
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