05000285/FIN-2011005-01
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Finding | |
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| Title | Failure to Follow Procedure Results in a Loss of Reactor Coolant |
| Description | A self-revealing non-cited violation of Fort Calhoun Station Technical Specification 5.8.1 occurred due to the licensees failure to follow a procedure for placing the reactor coolant system level monitors into service. This failure resulted in the inadvertent draining of approximately 1,800 gallons of reactor coolant to the reactor coolant drain tank. This issue was entered into the licensees corrective action program as Condition Report 2011-2890. The inspectors determined that the licensees failure to follow Procedure OI RC 1A, RCS Instrumentation Operating Instruction, was a performance deficiency. This was a result of the licensees failure to properly implement a required procedure, and was within the licensees ability to foresee and correct and should have been prevented. This performance deficiency was more than minor because it could be reasonably viewed as a precursor to a significant event, i.e., could lead to a complete loss of reactor coolant inventory. The inspectors evaluated this finding using Inspection Manual Chapter 0609, Attachment 4, and determined that this finding is associated with the Initiating Events Cornerstone, specifically the primary system loss-of-coolant accident initiator contributor. Since the finding affected the safety of the reactor during a refueling outage, the inspectors further evaluated the finding using Inspection Manual Chapter 0609, Appendix G, Shutdown Operations Significance Determination Process. Using Attachment 1 of Appendix G, the inspectors determined that a Phase 2 analysis was required because the finding increased the likelihood of a loss of reactor coolant system inventory. A senior reactor analyst determined that the Phase 2 analysis was White, requiring a Phase 3 analysis. The Phase 3 analysis determined that the finding was of very low safety significance (green) because the leak path was small enough to allow sufficient time for operator action. This finding has a cross-cutting aspect in the area of human performance associated with the component of work practices because the licensee failed to communicate human error prevention techniques, such as self- and peer-checking. |
| Site: | Fort Calhoun  |
|---|---|
| Report | IR 05000285/2011005 Section 1R04 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.04 |
| Inspectors (proximate) | J Kirkland P Elkmann C Graves L Carson J Clark D Reinert J Wingebach |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Fort Calhoun - IR 05000285/2011005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Fort Calhoun) @ 2011Q4
Self-Identified List (Fort Calhoun)
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