05000440/FIN-2016001-03
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Finding | |
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| Title | Failure to Take Actions to Prevent a Loss of Safety Function during Reactor Recirculation Pump Downshift |
| Description | A finding of very low safety significance and an associated NCV of TS 5.4.1, Procedures, was self-revealed on January 24, 2016, when a loss of safety system function occurred as a result of the operators failing to take steps to prevent all operable average power range monitors (APRMs) from becoming out of specification in the non-conservative direction after a recirculation pump shift to slow speed. Specifically, while in the process of reducing power to allow for a drywell entry at low power, the recirculation pumps were shifted and all operable APRMs went out of specification low, which is the non-conservative direction. The operators immediately declared the APRMs inoperable and took actions to restore the operability of at least one APRM in each channel. The issue was entered into the licensees CAP as CR 201601058. The licensees failure to take action to prevent all operable APRMs from going out of calibration low, despite understanding the cause, was determined to be more than minor and thus a finding, because it was associated with the Mitigating Systems cornerstone attribute of human performance and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The finding was determined to be of very low safety significance because it did not result in the loss of reactivity control systems beyond a single trip signal function and did not result in a mismanagement of reactivity by the operators. This finding has a cross-cutting aspect in the area of human performance, avoid complacency, for knowing that the APRMs would go out of calibration because of the pump shift but without regard for the inherent risk while expecting the successful outcome that at least one would stay in calibration without any consideration of potential actions that could have been taken to prevent the loss of safety function and reportable condition [IMC 0310, H.12]. |
| Site: | Perry  |
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| Report | IR 05000440/2016001 Section 1R20 |
| Date counted | Mar 31, 2016 (2016Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | B Dickson J Nance M Marshfield |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Perry - IR 05000440/2016001 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2016Q1
Self-Identified List (Perry)
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