05000298/FIN-2016004-01
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Finding | |
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| Title | Failure to Maintain Reactor Vessel Assembly Procedure to Ensure Adequate Moisture Separator Shielding |
| Description | The inspectors reviewed a self-revealed, non-cited violation of Technical Specification 5.4.1.a for the licensee's failure to ensure sufficient radiological work controls were in place when the reactor pressure vessel moisture separator was installed during vessel reassembly. Specifically, the licensee failed to maintain sufficient detail in Station Procedure 7.4Reassembly, Reactor Vessel Reassembly, Revision 13, to ensure that the moisture separator had adequate water shielding during lifts, such that radiation fields were appropriately controlled. The licensee took immediate corrective action to ensure resubmergence of the radiologically significant sections of the moisture separator and restore the requisite water shielding, thereby restoring ambient refuel floor radiological conditions. The licensee entered this deficiency into the corrective action program as Condition Report CR-CNS-2016-07552. The licensee's failure to ensure sufficient radiological work controls were in place when the reactor pressure vessel moisture separator was lifted during vessel reassembly, in violation of Technical Specification 5.4.1.a, was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because it was associated with the program and process attribute of the Occupational Radiation Safety Cornerstone and adversely affected the cornerstone objective to ensure adequate protection of worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. Specifically, the failure to have sufficient procedural guidance to maintain adequate water shielding on the moisture separator resulted in unanticipated elevated dose rates on the refuel floor and unplanned radiological exposures to workers in the immediate work area. Using Inspection Manual Chapter 0609, Appendix C, Occupational Radiation Safety Significance Determination Process, dated August 19, 2008, the inspectors determined that the violation had very low safety significance (Green) because: (1) it was not an as low as reasonably achievable (ALARA) finding; (2) there was no overexposure; (3) there was no substantial potential for an overexposure; and (4) the ability to assess dose was not compromised. The inspectors determined that the finding had a cross-cutting aspect in the area of human performance associated with avoiding complacency. Specifically, the licensee failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes and failed to implement appropriate error reduction tools [H.12]. |
| Site: | Cooper  |
|---|---|
| Report | IR 05000298/2016004 Section 1R13 |
| Date counted | Dec 31, 2016 (2016Q4) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | C Henderson G Warnick J O 'Donnell M Phalen P Elkman P Vos |
| Violation of: | Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Cooper - IR 05000298/2016004 | |||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Cooper) @ 2016Q4
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