05000263/FIN-2016003-01
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Finding | |
|---|---|
| Title | Failure to Follow Procedures While Performing Activities Affecting Quality |
| Description | Inspectors identified a self-revealed finding of very low safety significance (Green) and associated Non-Cited Violation (NCV) of Technical Specification 5.4.1.a, on June 24, 2016, when the licensee failed to follow procedures while performing activities affecting quality. Specifically, the licensee failed to accomplish activities affecting quality in accordance with FPGDOC03; Procedure and Work Instruction Use and Adherence, in that operators performed the Standby Gas Treatment (SBGT) A Train, Quarterly Test (025301) and failed to follow steps in that procedure. This resulted in an unanticipated trip of the turbine building ventilation and reactor building exhaust plenum fans causing an increase of steam chase temperatures which had the potential to upset plant stability by initiating a Group 1 Isolation. Immediate corrective actions included restoring ventilation to reduce the steam chase temperature, and entering the issue into the licensees Corrective Action Program (CAP 1526310). The inspectors determined that the licensees failure to follow procedures while performing activities affecting quality was a performance deficiency requiring evaluation. The finding was determined to be more than minor because it adversely impacted the Initiating Events Cornerstone attribute of Human Performance in the area of human error, and affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to follow procedures resulted in conditions that had the likelihood to upset plant stability and challenge critical safety functions, in this case, the potential to initiate a Group 1 Isolation due to high steam chase temperatures. The inspectors evaluated the finding in accordance with IMC 0609 and determined it to be of very low safety significance (Green). The inspectors determined that the contributing cause that provided the most insight into the performance deficiency was associated with the cross-cutting area of Human Performance, Avoid Complacency; Individuals recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Individuals implement appropriate error reduction tools [H.12]. |
| Site: | Monticello  |
|---|---|
| Report | IR 05000263/2016003 Section 1R15 |
| Date counted | Sep 30, 2016 (2016Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.15 |
| Inspectors (proximate) | B Jose D Krause G Hausman K Riemer P Zurawski S Bell |
| Violation of: | Technical Specification - Procedures |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Monticello - IR 05000263/2016003 | |||||||||||||||||||||||||||||||||||
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Finding List (Monticello) @ 2016Q3
Self-Identified List (Monticello)
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