05000387/FIN-2017003-01
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Finding | |
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| Title | Failure to Prepare Work Packages with Necessary Detail Results in Automatic Reactor Scram |
| Description | The inspectors identified a self -revealing finding of very low safety significance (Green) because Susquehanna did not ensure that a work package was prepared to the detail necessary based on task difficulty in accordance with administrative procedure, NDAP- QA -0502, Revision 51. Specifically, on June 8, 2017, maintenance workers inadvertently shorted the Unit 1 main electro -hydraulic control (EHC) logic power supply to ground while working in a cabinet with little space to manipulate tools, resulting in a reactor scram. This finding is more than minor because it is associated with the human performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, Susquehanna did not ensure measures were in place to prevent an adverse impact on the EHC control system during power supply voltage adjustment. This resulted in a rapid rise in reactor pressure and neutron flux, and subsequent automatic reactor scram. In accordance with IMC 0609.04, Initial Characterization of Findings, dated October 7, 2016, and Exhibit 1 of IMC 0609, Appendix A, The SDP for Findings At -Power, issued June 19, 2012, the inspectors determined that this finding is of very low safety significance (Green) because while the performance deficiency caused a reactor scram, it did not result in the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. The finding has a cross -cutting aspect in the area of Human Performance, Avoid Complacency, because the station failed to recognize and plan for the possibility of mistakes and inherent risk even while expecting successful outcomes. Specifically, individuals at various organizational levels did not ensure measures were in place to prepare maintenance technicians to perform a task on the EHC system that involved manipulating tools in a small space with tight clearances. |
| Site: | Susquehanna  |
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| Report | IR 05000387/2017003 Section 4OA3 |
| Date counted | Sep 30, 2017 (2017Q3) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | L Micewski T Daun P Ott D Schroeder |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Susquehanna - IR 05000387/2017003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Susquehanna) @ 2017Q3
Self-Identified List (Susquehanna)
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