05000263/FIN-2015002-04
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Finding | |
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| Title | Failure to Fill the Reactor Cavity in Accordance with Refueling Preparation Procedure |
| Description | The inspectors identified a finding of very low safety significance and an associated NCV of TS 5.4.1, Procedures, on April 15, 2015, when the licensee failed to implement procedure 9001, Reactor Well & Dryer-Separator Storage Pool Filling Procedure, for refueling preparation activities. Specifically, when faced with indications that the condensate storage tanks (CSTs) did not contain enough water inventory to complete outage critical path reactor pressure vessel (RPV) flooding activities, the licensee failed to implement 9001 procedure steps for using prescribed equipment and methods to fill the reactor cavity. With the proceduralized methods unavailable, operators used the site decision-making process to utilize demineralizer water hoses to fill the cavity rather than processing required 9001 procedure changes. This issue was entered into the licensees CAP (CAP 1474891). Immediate corrective actions included action to initiate the procedure change process for 9001 and department communication to Operations regarding the incident, emphasizing that the decision making process is not a substitute for the procedure change process. The inspectors determined that the failure to fill the reactor cavity in accordance with the 9001 reactor well filling procedure was a performance deficiency requiring evaluation. The inspectors evaluated IMC 0612, Appendix E, and did not find any similar examples of minor issues. The inspectors determined that the finding was more than minor in accordance with IMC 0612, Appendix B, because if left uncorrected, the performance deficiency had the potential to lead to a more significant safety concern. Specifically, the operations crews use of the decision-making process to support outage critical path by bypassing proceduralized steps and performing activities using methods contrary to the procedure could lead to a more significant safety concern. In addition, if performed incorrectly (i.e. without flushing the hoses prior to use), the use of demineralizer hoses could introduce foreign material into the core and challenge the integrity of the fuel cladding barrier. The inspectors evaluated the finding using IMC 0609, Attachment 4, Phase 1 Initial Screening and Characterization of Findings, which required an analysis using IMC 0609 Appendix G, the Shutdown Operations SDP since the reactor was in Mode 5 (refueling). The finding was assessed in accordance with IMC 0609 Appendix G, Attachment 1, Exhibit 4 for Barrier Integrity and determined to have very low safety significance. The inspectors concluded that this finding was cross-cutting in the Human Performance, Conservative Bias aspect because of the failure of the individuals to use decision-making practices that emphasize prudent choices over those that are simply allowable, and the failure to ensure that proposed actions are determined to be safe in order to proceed, rather than unsafe in order to stop [H.14]. |
| Site: | Monticello  |
|---|---|
| Report | IR 05000263/2015002 Section 1R13 |
| Date counted | Jun 30, 2015 (2015Q2) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | K Riemer M Ziolkowski N Mcmurray P Voss P Zurawski R Elliott S Bell T Bilik |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.14, Conservative Bias |
| INPO aspect | DM.2 |
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Finding - Monticello - IR 05000263/2015002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Monticello) @ 2015Q2
Self-Identified List (Monticello)
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