05000458/FIN-2012009-01
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Finding | |
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| Title | Main Control Room Annunciator Control and Conduct of Operations |
| Description | The team identified an unresolved item associated with the operating crews use of human performance tools to reduce the probability of making errors during an event. This unresolved item was the result of observations made in the main control room and while observing operating crew performance on the simulator. The observations included an operator response to a plant transient requiring the use of the licensees abnormal and emergency operating procedures. The team identified the following: In the main control room and during the simulator scenario, the use of three-way communications was inconsistent. Three-way communication is an error-prevention tool in which the receiver of a communication repeats the message back to the sender, and the sender then confirms or corrects the repeat back. The team observed instances in which messages were not repeated back to the sender, the sender did not acknowledge the repeat-back, or the repeat-back was incorrect and not corrected by the sender. During the simulator exercise, the team observed operators silencing annunciators without visually scanning the panels to identify what parameter had just alarmed. The inspectors also observed that during startup preparations in the main control room, operators were unable to determine the precise time an annunciator had been received for the residual heat removal system. The simulator observations were similar to observations made by the resident inspectors in the control room during the actual event. This practice can lead to important alarms or plant conditions not being recognized and subsequent remedial actions not being taken. During the simulator observations, the team noted that operators silenced many alarms and left them in a fast-flash state (not acknowledged) for extended periods of time. The number of fast-flashing alarms increased over the course of the scenario, making it more difficult for operators to identify new alarms as they annunciated. This is similar to observations made in the main control room during the actual plant transient. During the simulator exercise, members of the crew provided no Updates. Updates are usually conducted when there is a change in a key parameter, to ensure the entire crew is aware of the change. Knowledge of a change in a key parameter can change the flow-path through an abnormal or emergency operating procedure or change crew priorities in mitigating the event. The operator behaviors observed by the team did not result in any actual consequences during the event response, but they are an area the team identified for further inspection |
| Site: | River Bend  |
|---|---|
| Report | IR 05000458/2012009 Section 4OA5 |
| Date counted | Sep 30, 2012 (2012Q3) |
| Type: | URI: |
| cornerstone | Mitigating Systems |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 93800 |
| Inspectors (proximate) | S Graves S Garchow G Miller S Alferink V Gaddya Barrettb Tindell E Uribe B Hagar |
| INPO aspect | |
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Finding - River Bend - IR 05000458/2012009 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (River Bend) @ 2012Q3
Self-Identified List (River Bend)
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