05000482/FIN-2011003-02
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Finding | |
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Title | Failure to Properly Establish Clearance Order Boundary Isolation Resulting in Loss of Component Cooling Water Inventory |
Description | The inspectors reviewed a self-revealing noncited violation of Technical Specification 5.4.1a, Administrative Procedures, for a loss of component cooling water train B inventory caused by inadequate clearance order verification. Valve HBV110 was stuck in position and was partially open. When the clearance order was implemented, the operators concluded the valve was already closed. Subsequently, the valve created a leakage path which exceeded the surge tank makeup flow capacity and required manual isolation by the control room operators to protect safety-related components. Wolf Creek has taken corrective actions to include communication of expected as-found equipment positions in pre-job briefings and the clearance order template. This issue is captured in the corrective action program as Condition Reports 34505 and 40219. Failure to properly establish clearance order boundary isolation was a performance deficiency. The performance deficiency is more than minor because it is associated with the equipment performance and human performance attributes of the Mitigating Systems Cornerstone and impacted the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Inspection Manual Chapter 0609.04, the finding was determined to be of very low safety significance because the finding did not result in the loss of operability or functionality of the component cooling water train or screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event or screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The inspectors found that the finding had a cross-cutting aspect of work practices in the area of human performance associated with the communication of human error prevention techniques, such as holding pre-job briefings, self- and peer-checking, and proper documentation of activities |
Site: | Wolf Creek ![]() |
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Report | IR 05000482/2011003 Section 1R04 |
Date counted | Jun 30, 2011 (2011Q2) |
Type: | NCV: Green |
cornerstone | Mitigating Systems |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71111.04 |
Inspectors (proximate) | A Fairbanks C Long C Peabody D Reinert D Strickland G Guerra G Miller G Pick J Drake |
CCA | H.12, Avoid Complacency |
INPO aspect | QA.4 |
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Finding - Wolf Creek - IR 05000482/2011003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Wolf Creek) @ 2011Q2
Self-Identified List (Wolf Creek)
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