05000454/FIN-2015004-03
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Finding | |
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| Title | Failure to Implement Protective Tagging Procedure Requirements |
| Description | A finding of very low safety significance and associated NCV of Technical Specification (TS) 5.4.1.a, Procedures, was self-revealed during the Unit 1 refueling outage that ended on October 2, 2015, as a result of the licensees failure to implement the requirements of OP-AA-109-101, Clearance and Tagging Program. Two instances of personnel failing to implement the procedural requirements were identified. First, on September 18, 2015, workers in the switchyard performed a preventative maintenance task to replace the breaker and removed the old breaker with the danger tag still attached. Additionally, on September 28, a deficient clearance order for the Unit 1 polar crane was put in place to support maintenance, and the clearance order did not incorporate temporary plant configuration changes. The licensee entered both issues in the Corrective Action Program (CAP). The site performed a work stand down with switchyard workers to reinforce the procedural requirements following the first issue and with all operators qualified to prepare and approve clearance orders to communicate the second event, potential consequences, and procedural implementation shortfalls. The site also performed a review of all open temporary configuration changes with clearances to ensure equipment was properly tagged out. The inspectors determined that the licensees failure to implement the requirements of OP-AA-109-101, Clearance and Tagging Program, was a performance deficiency. The inspectors reviewed IMC 0612, Appendix B, Issue Screening, and determined that the issue was more than minor because, if left uncorrected, the performance deficiency could result in a more significant safety concern. Specifically, failure to implement the requirements of the protective tagging program could result in a direct challenge to nuclear safety through an initiating event, barrier degradation or damage to equipment necessary to mitigate an event. The inspectors determined that while the Initiating Events Cornerstone attributes of Equipment Performance and Human Error best addressed the specific performance deficiencies identified, more than one cornerstone was potentially affected since the performance deficiency affected programmatic control of equipment configuration. The inspectors utilized IMC 0609, Appendix G, Shutdown Operations Significance Determination Process, dated May 9, 2014, to evaluate the significance. After evaluating plant conditions at the time the examples occurred, the inspectors used Attachment 1, Phase 1 Initial Screening and Characterization of Findings, Exhibit 2, Initiating Events Screening Questions, and answered all of the questions such that the issue was screened as Green or very low safety significance. The common element to these two examples was the lack of familiarity of the individuals with the process and their understanding of the indications present. As a result, inspectors assigned a Human Performance cross-cutting aspect of Training (H.9). |
| Site: | Byron  |
|---|---|
| Report | IR 05000454/2015004 Section 1R20 |
| Date counted | Dec 31, 2015 (2015Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | A Shaikh B Palagi C Thompson G Hansen J Cassidy J Draper J Jandovitz J Mcghee L Smith M Holmberg V Meghani |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.9, Training |
| INPO aspect | CL.4 |
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Finding - Byron - IR 05000454/2015004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Byron) @ 2015Q4
Self-Identified List (Byron)
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