05000498/FIN-2010005-03
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Finding | |
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| Title | Failure to Follow Procedure Results in Protective Relay Trip of Residual Heat Removal Pump |
| Description | On October 17, 2010, the inspectors reviewed a self-revealing noncited violation of 10 CFR Part 50, Appendix B, Criteria V, Instructions, Procedures, and Drawings, for the failure to follow Procedure 0PSP03-RH-0003, Residual Heat Removal Pump 1C(2C) Inservice Test, Revision 16. The procedure directs the operator to establish the proper lineup for the test in step 5.2.2 and is followed by a table with various valves and breakers to be aligned by one individual and then verified by a second individual. This table lists mini flow isolation valve MOV-0067C as being required to be open. The first operator failed to perform an adequate self-check to ensure that he was following the procedure and the second operator also failed to perform an adequate selfcheck to ensure that the valve was in the correct position prior to starting the pump. Consequently, when the first operator started the pump, it tripped on low flow approximately 5 seconds later. The shift manager then refocused the control room operators, ensured that everyone was engaged, re-performed the procedure, and successfully completed the surveillance test. Corrective actions that the licensee implemented included remediating the individuals involved on the use of human performance tools and revising the surveillance test procedures to list the mini flow isolation valves as a separate stand alone step. The finding was more than minor because it affected the Mitigating Systems Cornerstone attributes of Procedure Quality and Human Performance and affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. This deficiency directly challenged the residual heat removal system by relying on the low flow trip to secure the pump before pump damage occurred. The inspectors performed the significance determination using NRC Inspection Manual Chapter 0609, Attachment 0609.04, Phase 1 Initial Screening and Characterization of Findings, dated January 10, 2008, because it affected the Mitigating Systems Cornerstone while the plant was at power. The finding was determined to be of very low safety significance because it was not a design or qualification deficiency; it did not result in the loss of a system safety function; it did not represent the loss of a single train for greater than technical specification allowed outage time; it did not represent a loss of one or more nontechnical specification risk-significant equipment for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />; and it did not screen as potentially risk significant due to seismic, flooding, or severe weather. In addition, this finding had human performance crosscutting aspects associated with work practices in that the licensee did not communicate human error prevention techniques, such as self checking, commensurate with the risk H.4(a)(Section 1R22). |
| Site: | South Texas  |
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| Report | IR 05000498/2010005 Section 1R22 |
| Date counted | Dec 31, 2010 (2010Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.22 |
| Inspectors (proximate) | B Tharakan W Walker A Fairbanks J Kramer S Hedger C Denissen L Micewski J Dixon G Guerra P Elkmann |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - South Texas - IR 05000498/2010005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (South Texas) @ 2010Q4
Self-Identified List (South Texas)
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