05000410/FIN-2015001-02
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Finding | |
|---|---|
| Title | Failure to Perform an Adequate Review of Planned Work Activities Results in a Manual Reactor Scram |
| Description | The inspectors documented a self-revealing Green finding (FIN) for Exelons failure to properly review a work package associated with the replacement of a reactor vessel level recorder as required by MA-AA-716-234, FIN Team Process, Revision 8. Specifically, on February 18, 2015, control room operators manually scrammed Unit 2 when reactor vessel water level unexpectedly rose above desired limits during a planned replacement of Unit 2 reactor vessel level recorder 2ISC-LR1608. The unplanned rise in reactor water level occurred when daisy chained leads associated with the level recorder were lifted, which caused an interruption in the feedwater level control circuit. The inspectors determined that Exelons failure to ensure measures were in place to address the impact on reactor vessel level prior to level recorder replacement in accordance MA-AA-716-234 was a performance deficiency that was reasonably within Exelons ability to foresee and correct and should have been prevented. This finding is more than minor because it is associated with the human performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, Exelon did not ensure measures were in place to prevent an adverse impact on the feedwater level control system during level recorder replacement. This resulted in a rapid rise in reactor water level and subsequent manual reactor scram. In accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 1 of IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, issued June 19, 2012, the inspectors determined that this finding is of very low safety significance (Green) because while the performance deficiency caused a reactor scram, it did not result in the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. The finding has a cross-cutting aspect in the area of Human Performance, Avoid Complacency, because Exelon failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk even while expecting successful outcomes. Specifically, Exelon did not ensure measures were in place to address the impact of the level recorder replacement on the feedwater level control system. |
| Site: | Nine Mile Point  |
|---|---|
| Report | IR 05000410/2015001 Section 4OA3 |
| Date counted | Mar 31, 2015 (2015Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | A Rosebrook D Schroeder E Miller G Stock H Gray K Kolaczyk |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Nine Mile Point - IR 05000410/2015001 | |||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Nine Mile Point) @ 2015Q1
Self-Identified List (Nine Mile Point)
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