05000400/FIN-2011004-01
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Finding | |
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| Title | Inadvertent Actuation of Turbine Driven Auxiliary Feedwater Pump Caused by Inadequate Procedure |
| Description | A self-revealing Green NCV of Technical Specifications (TS) 6.8.1, Procedures, was identified for the licensees failure to develop an adequate post maintenance test (PMT) procedure for the replacement of a defective 6.9kV undervoltage relay (UVTXSB/1732). Specifically, the licensee failed to ensure that the PMT procedure CM-E0032 (UVTXSB/1732 relay replacement) established adequate steam isolation to the turbine driven auxiliary feedwater (TDAFW) pump to prevent an inadvertent actuation. This resulted in the TDAFW pump inadvertently starting and injecting water into the steam generators which caused an increase in reactor power to 100.2 percent for approximately one minute. As corrective actions, the licensee secured the TDAFW pump, restored reactor power to 100 percent, and replaced the failed relay. In order to return the TDAFW pump to operable, the licensee performed a surveillance test to meet the requirements of the PMT. The applicable procedures were placed on administrative hold for evaluation and revision. Additionally, an investigation was performed to determine further corrective actions. The issue was placed into the CAP as AR #472616. The licensees failure to develop an adequate PMT procedure CM-E0032 (UVTXSB/1732 relay replacement) to ensure adequate steam isolation to the TDAFW pump and prevent an inadvertent actuation was a performance deficiency. The performance deficiency was more than minor because it is associated with the human performance attribute of the Mitigating System cornerstone, and it affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, it resulted in the automatic start of the TDAFW pump, water flowing to the steam generators, and a resultant increase in reactor power to 100.2 percent. Using IMC 0609, Significance Determination Process, Phase 1 screening worksheet, this finding was determined to be very low safety significance because it was not a design or qualification deficiency confirmed to result in a loss of operability or functionality, did not represent a loss of system safety function, did not result in a loss of safety system function for a single train for greater than TS allowed outage time, did not result in a loss of safety function of one or more non-TS trains of equipment designated as risk significant for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, and did not screen as potentially risk significant due to seismic, flooding, or severe weather initiating event. The finding has a cross-cutting aspect of Human Error Prevention, as described in the Work Practices component of the Human Performance cross-cutting area, because the licensee did not apply sufficient human error prevention measures during the development and implementation of the PMT procedure (CM-E0032), to establish adequate steam isolation and prevent an inadvertent TDAFW pump actuation |
| Site: | Harris  |
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| Report | IR 05000400/2011004 Section 1R19 |
| Date counted | Sep 30, 2011 (2011Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.19 |
| Inspectors (proximate) | J Austin M Bates R Musser P Lessard A Nielson R Hamilton W Loo |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Harris - IR 05000400/2011004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Harris) @ 2011Q3
Self-Identified List (Harris)
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