05000254/FIN-2013002-01
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Finding | |
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| Title | Failure To Follow Clearance Order Instructions |
| Description | A finding of very low safety significance and associated non-citied violation of Technical Specifications 5.4.1.a, Procedures, was self-revealed on March 13, 2013, when operators placing a clearance on the Unit 1 analog trip system de-energized the Unit 2 analog trip system resulting in a Unit 2 half-scram. The operators that opened the wrong breaker did not follow the instructions in the clearance order brief as required by OP-AA-109-101, Clearance and Tagging, and misidentified the inverter on the south wall of the cable spreading room as the Unit 1 analog trip system inverter when it was actually the Unit 2 inverter. The operators did not use the concurrent verification techniques specified in the pre-job briefing for ensuring that the inverter was the correct component to be manipulated, and did not implement the clearance order as written. Immediate actions taken were removal of the implementing operators qualifications and briefing to all operating personnel. Inspectors determined that the issue was more than minor because it adversely affected the Reactor Safety Initiating Events Cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during power operations. The performance deficiency challenged the configuration control attribute of the objective for operating equipment lineups. The inspectors determined the finding could be evaluated using the Significance Determination Process (SDP) in accordance with IMC 0609, Appendix A, The Significance Determination Process For Findings At-Power. The inspectors answered all questions of Exhibit 1, Initiating Events Screening Questions, for transient initiators and support system initiators. Questions in both categories were answered No, and the finding screened as very low safety significance, or Green. Inspectors determined that a significant contributor to this finding was the failure of the operator performing breaker manipulation to verify the component label matched the clearance checklist and card in accordance with the site standard, HU-AA-101, Human Performance Tools and Verification Practices. As a result, inspectors identified that this issue had a cross-cutting aspect in the area of Human Performance - Work Practices for failure to use the human performance techniques to ensure that the work tasks are performed safely and individuals do not proceed in the face of uncertainty |
| Site: | Quad Cities  |
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| Report | IR 05000254/2013002 Section 1R20 |
| Date counted | Mar 31, 2013 (2013Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | R Orlikowski J Mcghee V Meghani B Cushman A Shaikh B Winter C Mathews V Myers |
| Violation of: | Technical Specification - Procedures Technical Specification |
| INPO aspect | |
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Finding - Quad Cities - IR 05000254/2013002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Quad Cities) @ 2013Q1
Self-Identified List (Quad Cities)
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