05000323/FIN-2016002-01
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Finding | |
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| Title | Misplaced Spent Fuel Assembly in the Spent Fuel Pool |
| Description | The inspectors reviewed a self-revealed, non-cited violation of Technical Specification (TS) 5.4.1.a, Procedures, for the licensees failure to place a spent fuel assembly in its correct location in the spent fuel pool (SFP) in accordance with Procedure OP B-8H, Spent Fuel Pool Work Instructions. Specifically, the fuel handling crew moved spent fuel assembly TT69 to location E-37 rather than its intended location E-27. In response to this error, reactor engineering performed a technical specification verification in order to ensure that fuel assembly TT69 could remain in Cell E-37. The licensee suspended further fuel movements pending corrective action and remediation of the operators. The licensee entered this into the corrective action program as Notifications 50846834 and 50847067. The licensees failure to place a spent fuel assembly in its correct location in the SFP was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it is associated with the configuration control attribute of the Barrier Integrity Cornerstone and adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Using Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings, and Appendix A, Exhibit 3, Barrier Integrity Screening Questions, the inspectors determined that the finding was of very low safety significance (Green) because: (1) the finding did not adversely affect decay heat removal capabilities from the spent fuel pool causing the pool temperature to exceed the maximum analyzed temperature limit specified in the site-specific licensing basis, (2) the finding did not result from fuel handling errors, dropped fuel assembly, dropped storage cask, or crane operations over the SFP that caused mechanical damage to fuel clad and a detectible release of radionuclides, (3) the finding did not result in a loss of spent fuel pool water inventory decreasing below the minimum analyzed level limit specified in the site-specific licensing basis, and (4) the finding did not affect the SFP neutron absorber, fuel bundle misplacement (i.e., fuel loading pattern error) or soluble Boron concentration. This finding had a cross-cutting aspect in the area of human performance associated with avoiding complacency. Specifically, individuals failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes and individuals failed to implement appropriate error reduction tools (Section 4OA2). [H.12] |
| Site: | Diablo Canyon  |
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| Report | IR 05000323/2016002 Section 4OA2 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | I Anchando J Choate J Groom J O 'Donnellj Reynoso M Stafford N Greene |
| Violation of: | Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Diablo Canyon - IR 05000323/2016002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Diablo Canyon) @ 2016Q2
Self-Identified List (Diablo Canyon)
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