05000348/FIN-2012003-04

Finding

Title

Inadvertent transfer of approximately 5000 gallons of borated water from the RWST to the RCS refueling cavity and spent fuel pool

Description

A self-revealing Green non-cited violation of Technical Specification 5.4.1, Procedures, was identified for the licensees failure to adhere to the information contained within clearance 1-DT-24-E21-03211. This failure resulted in the unplanned transfer of approximately 5000 gallons of borated water from the refueling water storage tank (RWST) to the reactor coolant system (RCS) refueling cavity and spent fuel pool. In the evening hours of April 10, 2012, operations permit tagout holders allowed the manipulation of Q1E11MOV8706B and Q1E21LCV115D which created an open pathway from the RWST to the RCS refueling cavity and spent fuel pool. Q1E21LCV115D was prohibited from being open by clearance 1-DT-24-E21-03211 while Q1E11MOV8706B was open. The control room staff isolated the unintended flow path and entered the condition into their corrective action program. The licensee conducted an apparent cause determination. The licensee failure to adhere to the information contained within clearance 1-DT-24- E21-03211 is a performance deficiency. This performance deficiency is more than minor because it is associated with the configuration control attribute of the Initiating Events cornerstone and adversely affected the 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 configuration of the residual heat removal (RHR), chemical volume and control system, and refueling water storage tank were not maintained as required and approximately 5000 gallons of borated water was transferred from the RWST to the reactor refueling cavity. The significance of this finding was screened using IMC 0609, Significance Determination Process (SDP), Phase 1 worksheets of Attachment 4. The inspectors also referenced IMC 0609, SDP worksheets of Appendix G, Shutdown Operations Significance Determination Process. The finding screened very low safety significance, Green, because it did not meet any of the loss of coolant accident, transient and external event initiators of the worksheets of Attachment 4. The inspectors reviewed this performance deficiency for cross-cutting aspects and determined the licensee failed to appropriately coordinate work activities by incorporating actions to address the impact of the work on different job activities, and the need for work groups to communicate, coordinate, and cooperate with each other during activities in which interdepartmental coordination is necessary to assure plant and human performance. The finding was assigned a cross-cutting aspect in the work control component of the human performance area.

04
Site:	Farley
Report	IR 05000348/2012003 Section 4OA2
Date counted	Jun 30, 2012 (2012Q2)
Type:	NCV: Green
cornerstone	Initiating Events
Identified by:	Self-revealing
Inspection Procedure:	IP 71152
Inspectors (proximate)	E Crowe A Nielsen F Ehrhardt G Kuzo S Sandal B Collins J Sowa C Dykes
CCA	H.5, Work Management
INPO aspect	WP.1
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v • d • e

Finding - Farley - IR 05000348/2012003

1(0)2(0)3(6)4(3)5(1)8(2)301(0)403(2)405(0)406(2)502(0)404(1)

IR 05000348/2012003: 1 2 3 4 5 6

Finding List (Farley) @ 2012Q2

CCA Matrix: 2012Q2

	Q	CCA	Title
05000348/FIN-2011202-02	2011Q3	H.7	Security
05000348/FIN-2011004-01	2011Q3	H.7	Failure to properly pre-plan maintenance activities while conducting tagout operations on the 2C charging pump
05000348/FIN-2011202-04	2011Q3		Security
05000348/FIN-2011202-03	2011Q3	H.5	Security
05000348/FIN-2011010-10	2011Q4		Administrative Controls in lieu of Automatic Actions for Degraded Voltage Protection
05000348/FIN-2011010-09	2011Q4		Evaluation of MDAFW Pump Suction Check Valves
05000348/FIN-2011010-05	2011Q4		Non-Conservative Assumptions Regarding AFW Net Positive Suction Head
05000348/FIN-2011010-04	2011Q4		Evaluation of CST Vortex Effect on AFW Pump Minimum Submergence
05000348/FIN-2011014-01	2011Q4	H.4 H.5	TDAFW Pump Inoperable due to Improper Control of Station Drawings
05000348/FIN-2011010-08	2011Q4	H.7	Failure to Develop an Adequate Procedure to Test the Turbine Driven Auxiliary Feedwater Pump Discharge Check Valves
05000348/FIN-2011010-07	2011Q4	P.3	Failure to Monitor or Perform Effective Preventive Maintenance on the 2C EDG Exhaust Fan Louvers
05000348/FIN-2011010-06	2011Q4		Failure to Correctly Translate the Design Basis into Procedures for Minimum CCW Flow to the RHR Seal Coolers and Minimum Flow Requirements for the AFW Pumps
05000348/FIN-2011010-03	2011Q4		Failure to Provide Adequate Procedural Guidance for Controlling Steam Generator and Pressurizer Level During Loss of Air Events
05000348/FIN-2011010-02	2011Q4		Failure to Implement Design Control Measures to Verify the Adequacy of AFW Design
05000348/FIN-2011010-01	2011Q4		Failure to Implement Design Control Measures to Verify the Adequacy of CST Design
05000348/FIN-2013009-01	2012Q1		Deliberate Failure to Conduct Fire Watches
05000348/FIN-2012003-01	2012Q2	P.2(b)	Failure to Perform ISI General Visual Examinations of Containment Moisture Barrier Associated with Containment Liner Leak Chase Test Connection Threaded Pipe Plugs
05000348/FIN-2012003-02	2012Q2		Failure to Implement Design Control Measures to Verify the Adequacy of CST Design
05000348/FIN-2012003-03	2012Q2	H.1 H.2(d)	Failure to Monitor for Auxiliary Building Airborne Radioactivity Levels as Described in the FSAR
05000348/FIN-2012003-04	2012Q2	H.5	Inadvertent transfer of approximately 5000 gallons of borated water from the RWST to the RCS refueling cavity and spent fuel pool
05000348/FIN-2012403-01	2012Q2	H.8	Security
05000348/FIN-2012403-02	2012Q2	H.1	Security

Self-Identified List (Farley)

	Q	Title
05000348/FIN-2012003-05	2012Q2	Licensee-Identified Violation
05000348/FIN-2012003-06	2012Q2	Licensee-Identified Violation

[Farley Findings full list]

05000348/FIN-2012003-04

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