05000482/FIN-2016009-01
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Finding | |
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| Title | Failure to Evaluate and Address Failures of Prior Corrective Actions to Prevent Repeat Events |
| Description | The team identified several examples in which multiple station events had occurred due to similar programmatic or organizational-behavior causes (i.e., potential gaps in nuclear safety culture). The licensees evaluations for these repeat events and issues having similar causes to previous events do not effectively evaluate why corrective actions for the earlier events had failed to eliminate the safety culture or organizational performance gaps that allowed the events to occur, despite requirements in the licensees corrective action program procedures to perform such evaluations. The licensees failure to determine and correct the causes of previous events when evaluating subsequent events for cause and corrective actions, as required by corrective action program procedures, was a performance deficiency. This performance deficiency was more than minor because if left uncorrected, it had the potential to lead to a more significant safety concern. Specifically, the licensees continued failure to ensure causes of conditions are effectively corrected has the potential to lead to a preventable initiating event. Therefore, this finding is associated with the Initiating Events cornerstone. Using the transient initiators and support system initiators screening questions from Exhibit 1 of Inspection Manual Chapter 0609 Appendix A, the team determined that this finding was of very low safety significance (Green) because the finding did not cause a reactor trip or the complete or partial loss of a support system that contributed to the likelihood of an initiating event. This was a programmatic failure within the corrective action program that contributed to, but did not directly cause, the individual events; each individual event that evidenced this programmatic failure had been previously evaluated by the NRC to determine if a performance deficiency existed and, if so, separately screened. This finding has an evaluation cross-cutting aspect in the problem identification and resolution cross-cutting area because the organization failed to thoroughly evaluate issues to ensure that resolutions addressed causes and extents of condition commensurate with their safety significance (P.2). Specifically, underlying organizational and safety culture contributors to issues were not thoroughly evaluated and given the necessary time and resources to be clearly understood, and managers failed to effectively conduct effectiveness reviews of significant corrective actions to ensure that the resolution effectively addressed the causes. |
| Site: | Wolf Creek  |
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| Report | IR 05000482/2016009 Section 4OA2 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | C Stott E Ruesch F Thomas P Jayroe T Hipschman |
| CCA | P.2, Evaluation |
| INPO aspect | PI.2 |
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Finding - Wolf Creek - IR 05000482/2016009 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Wolf Creek) @ 2016Q2
Self-Identified List (Wolf Creek)
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