05000483/FIN-2008005-04
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Finding | |
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Title | Failure to Maintain an Adeuquate Plant Shutdown Procedure |
Description | The inspectors identified a self-revealing noncited violation of Technical Specification 5.4.1.a, Procedures, after improper isolation of the main steam isolation valves by the Callaway control room operators resulted in a reactor trip signal and auxiliary feedwater actuation on October 11, 2008. Procedure OTG-ZZ-00006, \"Plant Cooldown Hot Standby to Cold Shutdown,\" allowed premature main steam isolation valve closures just after entering Mode 4. The operator then decided to reopen main steam isolation Valve A and atmospheric Steam Dump A. This created a significant increase in steam flow from the steam generator which caused the steam generator level to swell up to the P-14 steam generator high level feedwater isolation setpoint. The steam generator levels all decreased to the steam generator narrow range low-low setpoint generating the need for auxiliary feedwater actuation. This finding was greater than minor because it was associated with the Initiating Events cornerstone attribute of procedural quality and it affected the objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings,\" this finding is determined to be of very low safety significance since this finding did not affect the Technical Specification limit for reactor coolant system leakage, did not contribute to both the likelihood of a reactor trip and mitigation equipment or functions not being available, and did not increase the likelihood of a fire or internal/external flooding. This finding had a crosscutting aspect in the area of human performance associated with the decision making component because the licensee failed to communicate, in a timely manner, decisions to personnel who have a need to know the information in order to perform work safely H.1(c) (Section 1R20) |
Site: | Callaway |
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Report | IR 05000483/2008005 Section 1R20 |
Date counted | Dec 31, 2008 (2008Q4) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | NRC identified |
Inspection Procedure: | IP 71111.2 |
Inspectors (proximate) | L Ricketson D Dumbacher R Kopriva D Stearns J Adams V Gaddy J Groom |
CCA | H.10, Bases for Decisions |
INPO aspect | CO.2 |
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Finding - Callaway - IR 05000483/2008005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Callaway) @ 2008Q4
Self-Identified List (Callaway)
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