05000390/FIN-2015004-05
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Finding | |
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| Title | Core Barrel Lift Error Resulted in Unintended high Dose Rates |
| Description | A self-revealing NCV of TS 5.7.1, Procedures, Programs and Manuals, was identified when the unit one core barrel (CB) was raised above the height limit specified in licensee procedure1-MI-68.003, Removal and Replacement of the Unit 1 Reactor Vessel Lower Internals, Revision 0003. Specifically, step 6.11[20] states in part, ...slowly raise the lower internals package UNTIL the lower internals is at or above EL. 75910 as indicated by the break of the laser indicator on the wall target. On October 5, 2015, while moving the CB from the storage stand to the reactor vessel, the CB was inadvertently lifted approximately three feet higher than the 75910 elevation and required radiation protection (RP) intervention to stop the lift when dose rates in and around containment exceeded anticipated levels. The licensee entered this issue into the CAP as CR 1090220. Corrective actions included stand-downs with each crew to review expectations for critical steps, increased field oversight, and revision of the lift procedure to clarify the steps regarding use of the laser indicator. This finding was determined to be greater than minor because it was associated with the Occupational Radiation Safety Cornerstone attribute of Human Performance, Program and Processes (procedures for monitoring and RP controls) and adversely affected the cornerstone objective of ensuring adequate protection of worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. The finding was evaluated using the Occupational Radiation Safety Significance Determination Process. The finding was not related to As Low As Reasonably Achievable planning, nor did it involve an overexposure or substantial potential for overexposure, and the ability to assess dose was not compromised. Therefore, the inspectors determined the finding to be of very low safety significance (Green). This finding involved the cross-cutting aspect of Human Performance, Work Management [H.5] because distractions at the work location contributed to the failure to recognize that the CB had been raised above the procedural limit. |
| Site: | Watts Bar  |
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| Report | IR 05000390/2015004 Section 2RS1 |
| Date counted | Dec 31, 2015 (2015Q4) |
| Type: | NCV: Green |
| cornerstone | Or Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71124.01 |
| Inspectors (proximate) | A Blamey A Nielsen C Even E Patterson J Eargle J Hamman J Nadel J Panfel J Rivera -Ortiz M Magyar M Read P Cooper R Baldwin R Carrion W Pursle |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Watts Bar - IR 05000390/2015004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Watts Bar) @ 2015Q4
Self-Identified List (Watts Bar)
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