05000354/FIN-2016004-02
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Finding | |
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| Title | Inadequate Implementation of a Design Change Causes Multiple B Channel Instruments to be Inoperable |
| Description | Green. A self-revealing Green non-cited violation (NCV) of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion III, Design Control, and Technical Specification (TS) 3.0.4 was identified for PSEG not effectively implementing the design change package (DCP) process. Specifically, PSEG inadequately implemented their configuration change control procedure, CC-AA-103, and a design change package (DCP 80108179) for rerouting a B channel instrument line (LT-N085B) by not fully restoring the system upon completion of the DCP on November 3, 2016. As a consequence, multiple main control room (MCR) indicators became inoperable without PSEG identifying the problem until operators transitioned the reactor plant to startup, Operational Condition (OPCON) 2 or Mode 2, on November 9, 2016. This constituted a violation of TS 3.0.4 because PSEG transitioned to OPCON 2 while multiple limiting conditions for operability (LCO) were not met. PSEGs corrective actions included securing the reactor startup, conducting system troubleshooting/restoration prior to recommencing the reactor startup, completing an apparent cause evaluation of the issue and an extent of condition on all DCPs completed during the refueling outage, and revising their preventive maintenance procedures to ensure that the instrument racks are properly backfilled on a frequent reoccurring basis and following any instrument rack maintenance. The issue was more than minor because it was associated with the human performance attribute of the mitigating systems cornerstone and adversely affected its objective to ensure the availability and reliability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage), in that, multiple B channel reactor water level instruments that fed the RPS logic were inoperable. Additionally, the finding was similar to IMC 0612, Appendix E, example 3.g, which describes an operator not following a procedure and making a mode change without all the required equipment operable. The IMC 0609, Appendix G, Shutdown Operations Significance Determination Process (SDP), Section 4.1 Scope, states that if the plant is shut down and the entry conditions for Residual Heat Removal/Decay Heat Removal (RHR/DHR) and RHR/DHR cooling have not been met then Appendix G does not apply. Because of this, the finding was evaluated using IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power. Per Exhibit 2, Mitigating Systems Screening Questions, the finding was determined to be of very low safety significance (Green) because although the finding represented a deficiency affecting the qualification of a mitigating system and caused multiple B channel instruments to be inoperable, it did not represent a loss of system and/or function, or an actual loss of function for greater than its TS allowed outage time. This finding had a cross-cutting aspect in the area of Human Performance, Work Management, in that PSEG did not implement a process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority. Specifically, PSEG did not ensure restoration activities for the completed DCP ensured the affected instrumentation was returned to an operable status. [H.5] |
| Site: | Hope Creek  |
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| Report | IR 05000354/2016004 Section 4OA3 |
| Date counted | Dec 31, 2016 (2016Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | B Fuller F Bower J Deboer J Hawkins J Patel M Draxton R Rolph S Haney T Hedigan T O'Hara |
| Violation of: | 10 CFR 50 Appendix B Criterion III, Design Control Technical Specification |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
| Finding closed by | |
| IR 05000354/2016004 () | |
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Finding - Hope Creek - IR 05000354/2016004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Hope Creek) @ 2016Q4
Self-Identified List (Hope Creek)
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