05000354/FIN-2016003-03
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Finding | |
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| Title | Inadequate Procedure Adherence Resulted in a Loss of Shutdown Cooling |
| Description | A self-revealing non-cited violation (NCV) of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, occurred when PSEG did not follow procedure during the transition from Cold Shutdown to refueling operations while filling up the reactor pressure vessel (RPV) to support RPV head cooling in preparation for reactor disassembly. This resulted in an automatic isolation of the operating residual heat removal (RHR) pump while it was providing decay heat removal in shutdown cooling. PSEG has entered this issue into their corrective action program (CAP) in notification (NOTF) 20684861, and corrective actions included performing a root cause evaluation for the event, revising the operating procedures to provide clarity, and conducting training with all operators on the lessons learned from the event. This issue was evaluated in accordance with IMC 0612, Appendix B, and determined to be more than minor since it was associated with the human performance attribute of the Initiating Events cornerstone and adversely affected its objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown, as well as power operations. The finding was evaluated using IMC 0609, Appendix G, Shutdown Operations Significance Determination Process (SDP), and per Attachment 1, Exhibit 2, required a Phase 2 risk evaluation which determined the safety significance of this performance deficiency to be in the mid E-8 range, or of very low safety significance (Green). The inspectors determined this finding has a cross-cutting aspect in the area of Human Performance, Conservative Bias, in that the operator did not use decision-making practices that emphasized prudent choices over those that are simply allowable, and the operators proposed action was not determined to be safe prior to proceeding with the action. Specifically, the operator did not ensure his actions were safe prior to aligning and operating the feedwater system to fill the RPV during plant cooldown using an uncommon method. |
| Site: | Hope Creek  |
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| Report | IR 05000354/2016003 Section 4OA3 |
| Date counted | Sep 30, 2016 (2016Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | F Arner F Bower J Hawkins M Draxton R Nimitz R Vadella S Freeman S Haney W Cook |
| Violation of: | 10 CFR 50 Appendix B 10 CFR 50 Appendix B Criterion V |
| CCA | H.14, Conservative Bias |
| INPO aspect | DM.2 |
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Finding - Hope Creek - IR 05000354/2016003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Hope Creek) @ 2016Q3
Self-Identified List (Hope Creek)
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