05000374/FIN-2015002-02
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Finding | |
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| Title | Inadvertent Operation of Circuit Breaker Affecting Unit 2 Train A Residual Heat Removal Suppression Chamber Spray Isolation Valve (235Y-2 C3) |
| Description | A finding of very low safety significance (Green) and associated NCV of Technical Specification (TS) 5.4.1, Procedures, was self-revealed when the licensee failed to properly preplan and perform maintenance in accordance with written procedures and instructions appropriate to the circumstances. Specifically, on May 14, 2015, the Work Order (WO 1643222) for testing of the motor for the Unit 2 reactor core isolation cooling (RCIC) water leg pump and involving operation of the motors breaker did not include precautions or restrictions to prevent the inadvertent operation, by bumping, of the adjacent breaker for the safety-related Unit 2 A residual heat removal (RHR) suppression chamber spray isolation valve. Workers inadvertently bumped and opened the breaker for the RHR valve and rendered the system inoperable. The finding was determined to be more than minor because it was associated with the Mitigating Systems Cornerstone, and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the licensee failed to provide a work order appropriate to the circumstances of the juxtaposed breakers. The subsequent, inadvertent opening of the 2A RHR suppression chamber spray isolation valve breaker, unexpectedly rendered the valve inoperable. This negatively impacted the RHR suppression chamber spray systems ability to reduce suppression chamber pressure by removing one of the required two spray paths. The inspectors determined the finding to have very low safety significance (Green). This finding has a cross-cutting aspect in the area of Human Performance, Avoid Complacency, because configuration control and error prevention techniques (robust barriers) in an existing licensee procedure were not appropriately implemented due to the failure of individuals to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes (H.12). Specifically, licensee staff failed to implement the guidance found in procedure HU-AA-101, Human Performance Tools and Verification Practices. |
| Site: | LaSalle  |
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| Report | IR 05000374/2015002 Section 1R13 |
| Date counted | Jun 30, 2015 (2015Q2) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | A Dunlop C Hunt D Chyu D Krause J Robbins M Holmberg M Kunowski R Ruiz R Zuffa |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - LaSalle - IR 05000374/2015002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (LaSalle) @ 2015Q2
Self-Identified List (LaSalle)
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