05000368/FIN-2015003-01
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Finding | |
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| Title | Failure to Follow Procedure Results in Increased Reactor Coolant Activity |
| Description | The inspectors reviewed a self-revealing non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for failure to follow the instructions in the chemical volume control system charging pump pulsation dampener bladder charging procedure. Specifically, maintenance personnel used a gas cylinder containing argon, carbon dioxide, and oxygen rather than a pure nitrogen cylinder to charge the dampener as required by procedure 2411.066, Charging Pump Dampener Bladder 115A, B, C and 2M-116A, B, C Checking and Depressurization, Revision 05. Because the dampener had an existing bladder leak, the gas leaked into the reactor coolant system and the argon subsequently activated when it passed through the reactor. Reactor coolant system activity significantly increased, which elevated dose rates in the auxiliary building. The licensee entered this issue into their corrective action program as Condition Report CR-ANO-2-2015-02576. The licensee revised the procedure to require an independent verification of the gas before charging the pulsation dampeners. The failure to follow the dampener charging procedure, which resulted in increased reactor coolant system activity and elevated dose rates in the auxiliary building, was a performance deficiency. The performance deficiency is more than minor because it is associated with the human performance attribute of the Occupational Radiation Safety Cornerstone and adversely 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. Specifically, charging argon into a pulsation dampener with a known bladder leak caused elevated dose rates in several plant areas. Using NRC Inspection Manual Chapter 0609 Appendix, C, Occupational Radiation Safety Significance Determination Process, issued August 19, 2008, the inspectors determined that the finding was of very low safety significance (Green) because it did not involve ALARA planning or work controls, did not involve an overexposure, did not have a substantial potential to be an overexposure, and the ability to assess dose was not compromised. The inspectors determined this finding had a cross-cutting aspect in the area of Avoid Complacency, because the plant maintenance mechanics failed to implement appropriate error reduction tools such as self-checking and peer-checking [H.12]. |
| Site: | Arkansas Nuclear  |
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| Report | IR 05000368/2015003 Section 1R15 |
| Date counted | Sep 30, 2015 (2015Q3) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.15 |
| Inspectors (proximate) | A Barrett B Correll B Tindell J Dixon M Williams N O 'Keefer Egli T Farina Z Hollcraft M Tobin |
| Violation of: | 10 CFR 50 Appendix B Criterion V |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Arkansas Nuclear - IR 05000368/2015003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Arkansas Nuclear) @ 2015Q3
Self-Identified List (Arkansas Nuclear)
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