05000440/FIN-2009004-03
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Finding | |
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| Title | Unexpected Half Scram Due To Faulty Troubleshooting Plan |
| Description | A finding of very low safety significance and associated non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed for the licensees failure to have an appropriate troubleshooting plan for repairing Average Power Range Monitor (APRM) 'A.' Specifically, the troubleshooting plan for inoperable APRM 'A' did not provide proper guidance to the technicians resulting in an unexpected half scram on the reactor protection system and subsequent required operator actions. The licensee entered the error into their corrective action program as CR 09-63991. As part of its corrective actions, the licensee planned to place placards in the APRM cabinets warning of the special instructions to remove and replace the cards. The finding was determined to be more than minor because the finding was similar to IMC 0612, Appendix E, Example 4.b, and resulted in operator intervention to change reactor power to maintain reactor power at a stable value. Therefore, the performance deficiency impacted the Initiating Events cornerstone objective to limit the likelihood of those events that upset plant stability. The inspectors determined the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, Table 4a, for the Initiating Events cornerstone. While the finding increased the likelihood of a reactor trip, it did not increase the likelihood that mitigation equipment would not be available, and therefore, the inspectors determined the finding to be of very low safety significance. The finding has a cross-cutting aspect in the area of human performance, work control, per IMC 0305 H.3(a), because the licensee did not appropriately plan the work activity consistent with nuclear safety, incorporating risk insights, job site condition, or the need for planned contingencies, compensatory actions and abort criteria. Specifically, licensee personnel did not adequately research the impact of a circuit cards removal and reinsertion into the control circuitry for APRM 'A,' on other related systems contributing directly to an unplanned power transient on the reactor |
| Site: | Perry  |
|---|---|
| Report | IR 05000440/2009004 Section 4OA3 |
| Date counted | Sep 30, 2009 (2009Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | M Munir M Marshfield M Phalen G Wright J Bashore J Cameron P Voss R Murray |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Perry - IR 05000440/2009004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2009Q3
Self-Identified List (Perry)
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