05000298/FIN-2011008-01
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Finding | |
|---|---|
| Title | Unclear Work Instructions |
| Description | The inspectors identified a noncited violation of Technical Specification 5.4.1, for a failure to implement procedures described in Regulatory Guide 1.33, Appendix A. Specifically, the licensee failed to implement procedures that provide guidance on creating clear, accurate work instructions. As a result, the work instructions were not able to be completed as written and needed parts were not available. This directly contributed to three instrumentation and control technicians receiving an unexpected radiation dose. A site stand-down was held to discuss the lessons learned and the event was entered into the licensee\'s corrective action program as Condition Report CR-CNS-2011-4431. This deficiency was reasonable for the licensee to foresee and prevent occurrence. The finding was more than minor because it is associated with the human performance attribute of the Occupational Radiation Safety Cornerstone and affected the cornerstone objective to ensure the adequate protection of the worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. The inspectors evaluated this finding using Inspection Manual Chapter 0609, Appendix C, Occupational Radiation Safety Significance Determination Process. The inspectors determined that the finding is of very low safety significance (Green) because it was not associated with ALARA planning or work controls, there was no overexposure, there was no substantial potential for an overexposure, and the licensee\'s ability to assess dose was not compromised. The finding has a crosscutting aspect in the work practices component of the human performance area because the licensee did not effectively communicate expectations regarding procedural compliance and that personnel follow procedures. Specifically, the licensee displayed a cultural behavior that unacceptable behaviors, such as failing to follow procedures, are acceptable as long as the outcome is desirable. |
| Site: | Cooper  |
|---|---|
| Report | IR 05000298/2011008 Section 4OA5 |
| Date counted | Jun 30, 2011 (2011Q2) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 93812 |
| Inspectors (proximate) | B Tharakan D Overland V Gaddy |
| Violation of: | Technical Specification |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Cooper - IR 05000298/2011008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Cooper) @ 2011Q2
Self-Identified List (Cooper)
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