05000458/FIN-2015001-02
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Finding | |
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| Title | Inadequate Engineering Change and Work Instruction Review Results in Reactor Recirculation Pump Trip |
| Description | The inspectors reviewed a self-revealing finding for the licensees failure to properly implement Procedure EN-DC-115, Engineering Change Process, when developing engineering change notice ECN 39186, to ensure that no adverse impacts on the plant were would be encountered. Specifically, when installing new Emergency Response and Information System equipment in the main control room, using ECN 39186, the reactor recirculation pump A unexpectedly tripped, resulting in a reduction in power from 85 percent to 67 percent power. The licensee entered this issue into their corrective action program as Condition Report CR-RBS-2014-06685. The failure to follow Procedure EN-DC-115, to ensure that no adverse impacts were encountered during the implementation of ECN 39186, is a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it is associated with the Initiating Events Cornerstone attribute of design control, and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, implementation of a plant modification resulted in an unexpected trip of the running recirculation pump which led to an unplanned downpower from 85 percent to 67 percent power. The inspectors initially screened the finding in accordance with Inspection Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power. Using Inspection Manual Chapter 0609, Appendix A, Exhibit 1, Initiating Events Screening Questions, the inspectors determined this finding is of very low safety significance (Green) because the finding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown. This finding has a cross-cutting aspect in the area of human performance associated with Teamwork: Individuals and work groups communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety is maintained. Specifically, individuals and work groups did not communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety was maintained [H.4]. |
| Site: | River Bend  |
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| Report | IR 05000458/2015001 Section 1R18 |
| Date counted | Mar 31, 2015 (2015Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.18 |
| Inspectors (proximate) | A Barrett B Parks G Warnick I Anchondo J Sowa N Greene P Elkmann P Hernandez |
| CCA | H.4, Teamwork |
| INPO aspect | PA.3 |
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Finding - River Bend - IR 05000458/2015001 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (River Bend) @ 2015Q1
Self-Identified List (River Bend)
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