05000261/FIN-2016001-03
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Finding | |
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| Title | Failure to Follow Procedure for a Light Indication Replacement |
| Description | The inspectors identified a Green NCV of TS 5.4.1.a, for the licensees failure to adequately implement procedure OMM-001-11, Logkeeping, while performing maintenance. Specifically, the licensee replaced a local light indication for PCV-1716, a containment instrument air isolation valve, which resulted in a plant transient, without a senior reactor operator (SRO) being contacted, as required per procedure. As corrective action, the licensee replaced the blown fuse, issued a standing instruction to initiate a work request for all light bulb replacements, and submitted a procedure revision request to add more detailed guidance for lightbulb replacement. The licensee entered this issue into their CAP as CR 1991686. The failure to contact an SRO prior to changing out a local light indication for PCV-1716 as required by procedure OMM-001-11 was a performance deficiency. The performance deficiency was more than minor because it was associated with the human performance attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during power operations. Specifically, because the SRO was not contacted, an assessment and management of risk associated with the replacement of the light indication was not performed, and resulted in a plant transient. The inspectors evaluated the significance of the finding using IMC 0609 Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, Exhibit 1, Section B and determined the finding to be of very low safety significance (Green) because the finding did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available. The performance deficiency had a cross-cutting aspect of Avoid Complacency in the area of Human Performance because the individual performing the lightbulb replacement did not recognize and plan for the possibility of mistakes, latent issues, and inherent risk. |
| Site: | Robinson  |
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| Report | IR 05000261/2016001 Section 1R13 |
| Date counted | Mar 31, 2016 (2016Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | A Nielsen C Scott D Bacon G Hopper J Parent K Ellis W Loo |
| Violation of: | 10 CFR 50 Appendix A Technical Specification - Procedures Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Robinson - IR 05000261/2016001 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Robinson) @ 2016Q1
Self-Identified List (Robinson)
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