05000293/FIN-2015007-04
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Finding | |
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| Title | Failure to Follow RCIC System Manual Restart Procedure |
| Description | A self-revealing Green NCV of TS 5.4.1, Procedures, was identified because the operating crew failed to implement a procedure step to open the reactor core isolation cooling (RCIC) system cooling water supply valve during a manual startup of the system. As a result, the RCIC system was operated for over 2 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> with no cooling water being supplied to the lubricating oil cooler or to the barometric condenser. Entergy entered the issue into the CAP as CR-PNP-2015-0566, CR-PNP-2015-0570, and CR-PNP-2015-0952 and conducted a human performance review of the Control Room operators involved with the issue. The inspectors determined that the failure to implement Procedure 5.3.35.1, Attachment 29, RCIC Injection Manual Alignment Checklist, and the Vacuum Tank Pressure Hi Alarm, C904L-F3, alarm response procedure was a performance deficiency and was reasonably within the ability of Entergy personnel to foresee and prevent. This self-revealing finding was more than minor because it was associated with the human performance attribute of the Mitigating System cornerstone and adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesired consequences. Specifically, on January 27, 2015, reactor operators failed to open MO-1301-62, cooling water supply valve, during a manual restart of the RCIC system in accordance with procedure 5.3.35.1, RCIC Injection Manual Alignment Checklist. Additionally, the operating crew failed to identify the valve was out of position even after the Vacuum Tank Pressure Hi Alarm, C904L-F3, was received two minutes after the system was re-started and the alarm response procedure identified Improper Valve Lineup as a probable cause. The team evaluated the finding using IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The team determined this finding was not a design or qualification deficiency and was not a potential or actual loss of system or safety function, and is therefore of very low safety significance (Green). During the period when the RCIC system was operated in this condition, no temperature limits were exceeded. The inspectors noted that in the event of a RCIC system automatic start, the cooling water supply valve would have opened automatically. This finding had a cross-cutting aspect in the area of Human Performance, Procedure Adherence, because Entergy licensed personnel did not implement procedure 5.3.35.1, RCIC Injection Manual Alignment Checklist , to open MO-1301-62. Additionally, Entergy licensed personnel did not implement the Vacuum Tank Pressure Hi Alarm, C904L-F3, response procedure to check for an improper valve line-up. |
| Site: | Pilgrim |
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| Report | IR 05000293/2015007 Section 4OA5 |
| Date counted | Mar 31, 2015 (2015Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 93812 |
| Inspectors (proximate) | C Cahill D Schroeder E Burket E Dipaolo H Nieh J Lilliendahl S Pindale T Dunn |
| Violation of: | Technical Specification |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Pilgrim - IR 05000293/2015007 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Pilgrim) @ 2015Q1
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