05000250/FIN-2017001-01
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Finding | |
|---|---|
| Title | Inadequate Operational Decision-Making Procedure Implementation Results in Feedwater Heater Water Hammer |
| Description | Green: A self-revealing finding was identified for the failure to adequately implement OP-AA-105-1000, Operational Decision Making (ODM) procedure that was used to establish plant conditions for the repair of the Unit 3 condensate tube leak in the 3B feedwater heater (FWH). The failure to implement all the steps of OP-AA-105-1000, Operational Decision Making, to establish plant conditions for the repair of the Unit 3 condensate tube leak in the 3B FWH was a performance deficiency. The performance deficiency was determined to be more than minor because it was associated with the configuration control and procedure quality attributes of the initiating events cornerstone and adversely affected the cornerstones objective to limit the likelihood of events that upset plant stability. Specifically, not implementing the ODM procedure steps 2.3, Rigorous Evaluation, and Steps 2.5, Effective Implementation, of Attachment 3, resulted in an incorrect revision to procedure 3-ONOP-081.02 which led field operators to close the extraction steam to the 5B FWH too quickly and without due-precaution to prevent a rapid decrease in the 5B FWH shell pressure and caused significant water hammer and resulted in a fast load reduction and reactor trip. Using Inspection Manual Chapter (IMC) 0609, Appendix A, The Significance Determination Process (SDP) for Findings at Power, the inspectors determined that the issue had very low safety significance (Green) because the event did not cause both a reactor trip and a loss of mitigating equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. The finding was assigned a cross-cutting aspect of resources in the area of human performance, in that, leaders ensure that personnel, equipment, procedures, and other resources were available and adequate to support nuclear safety. Specifically, the ODM team did not ensure that the revised procedure was adequate to preclude water hammer. [H.1]. |
| Site: | Turkey Point  |
|---|---|
| Report | IR 05000250/2017001 Section 4OA2 |
| Date counted | Mar 31, 2017 (2017Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | D Orr J Reyes L Suggs |
| CCA | H.1, Resources |
| INPO aspect | LA.1 |
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Finding - Turkey Point - IR 05000250/2017001 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Turkey Point) @ 2017Q1
Self-Identified List (Turkey Point)
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