05000341/FIN-2016001-09
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Finding | |
|---|---|
| Title | Inadvertent Reactor Water Low Level Reactor Protection System Actuation Due to Operator Error |
| Description | A finding of very low safety significance with an associated NCV of Technical Specification (TS) 5.4, Procedures, was self-revealed when a valid automatic reactor scram signal and isolation signal for multiple primary containment isolation valves was actuated. A reactor operator, who was maintaining RPV water level and reactor pressure following a plant scram, did not initiate reactor core isolation cooling (RCIC) system flow in time to maintain level above the Level 3 reactor protection system actuation setpoint. As an immediate corrective action, control room operators promptly restored RPV level by manual operation of the RCIC system. The licensee entered this issue into the corrective action program and provided remedial training for the reactor operator in the simulator, communicated lessons learned from this event with other licensed operators, and subsequently implemented improvements for licensed operator training and procedure changes to incorporate a revised strategy for manual control of RPV level and pressure control with main steam line isolation valves closed. The performance deficiency was of more than minor safety significance because it was associated with the Human Performance attribute of the Initiating Events cornerstone and adversely affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the human performance error unnecessarily challenged a plant protection feature, which resulted in a valid automatic reactor scram signal and isolation signal for multiple primary containment isolation valves. In addition, the finding was sufficiently similar to Example 4(b) in IMC 0612, "Power Reactor Inspection Reports," Appendix E, "Examples of Minor Issues," for not of minor safety significance since the error resulted in a valid automatic reactor scram signal and isolation signal for multiple primary containment isolation valves. The finding was determined to be of very low safety significance since it did not cause a reactor scram and a loss of mitigation equipment relied upon to transition the plant to a stable shutdown condition (e.g., loss of condenser, loss of feedwater). The inspectors concluded this finding affected the cross-cutting aspect of resources in the human performance area. Specifically, the licensees evaluation identified the reactor operator had been performing a complicated task for a long period of time without adequate rest/recovery periods [IMC 0310, H.1]. |
| Site: | Fermi  |
|---|---|
| Report | IR 05000341/2016001 Section 4OA3 |
| Date counted | Mar 31, 2016 (2016Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | B Dickson B Kemker J Nance P Smagacz |
| Violation of: | Technical Specification - Procedures |
| CCA | H.1, Resources |
| INPO aspect | LA.1 |
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Finding - Fermi - IR 05000341/2016001 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Fermi) @ 2016Q1
Self-Identified List (Fermi)
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