05000461/FIN-2017003-04
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Finding | |
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| Title | Flow Control Valves Not Locked Out Results in Reactor Recirculation Pump Runback |
| Description | The inspectors documented a self-revealed finding of very low safety significance and an associated NCV of Technical Specification (TS) 5.4.1, Procedures, for the licensees failure to establish sufficient instructions in station procedure Clinton Power Station (CPS) 3103.01, Feedwater (FW), Revision 31e, for changing modes of operation for the nuclear steam supply system. Specifically, the station procedure did not provide instructions requiring the locking out the flow control valves (FCVs) to prevent a reactor recirculation FCV runback while changing the feedwater pump lineup resulting in an unexpected plant transient and 9.2 percent change in reactor power. The licensee entered this issue into their corrective action program (CAP) as Action Request (AR) 04007861. As corrective actions, the licensee revised their CPS 3103.01 procedure to require that the FCVs be locked out prior to shifting reactor feed water pumps. The performance deficiency was more than minor in accordance with IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, dated September 7, 2012,because the finding was associated with the procedure quality attribute of the Initiating Events cornerstone and adversely affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to have adequate procedures for shifting feedwater pumps during a plant shutdown on May 7, 2017, resulted in an unexpected recirculation pump run back and a 9.2 percent change in reactor power. Using IMC 0609, Attachment 4, Initial Characterization of Findings, andAppendix A, The Significance Determination Process for Findings At-Power, issuedJune 19, 2012, the finding was screened against the Initiating Events cornerstone and determined to be of very low safety significance because the event did not cause a reactor scram. The inspectors determined this finding affected the cross-cutting area of human performance in the aspect of conservative bias, where individuals use decision making practices that emphasize prudent choices over those that are simply allowable and a proposed action is determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically, the procedure provided for the option to lockout the reactor
3 recirculation flow control valves if deemed necessary during a shift of the reactor feedwater pumps and the operations crew did not make the prudent choice of locking out the valves before determining that it was safe to proceed. [H.14] |
| Site: | Clinton  |
|---|---|
| Report | IR 05000461/2017003 Section 4OA3 |
| Date counted | Sep 30, 2017 (2017Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | W Schaup E Sanchez -Santiago M Doyle J Wojewoda J Havertape L Rodriguez M Domke G Edwards S Mischke L Koza |
| Violation of: | Technical Specification |
| CCA | H.14, Conservative Bias |
| INPO aspect | DM.2 |
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Finding - Clinton - IR 05000461/2017003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Clinton) @ 2017Q3
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