05000456/FIN-2018002-02

Finding

Title

Work Instruction Error Results in Reactor Coolant System Pressure Transient

Description

A self-revealed finding of very low safety significance (i.e., Green) was identified due to the licensees failure to follow work instructions while performing a digital upgrade to plant control systems. Specifically, while performing maintenance on the volume control tank (VCT) level transmitter on April 10, 2018, maintenance personnel failed to properly track the steps being performed while simultaneously working on multiple packages. This resulted in the Unit 1 reactor coolant system (RCS) experiencing a pressure transient and the actuation of a VCT relief valve.

02
Site:	Braidwood
Report	IR 05000456/2018002 Section 1R15
Date counted	Jun 30, 2018 (2018Q2)
Type:	Finding: Green
cornerstone	Initiating Events
Identified by:	Self-revealing
Inspection Procedure:	IP 71111.15
Inspectors (proximate)	D Kimble D Betancourt E Fernandez T Go C Hunt D Sargis S Sheldon M Porfirio L Torres E Duncan
CCA	H.3, Change Management
INPO aspect	LA.5
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v • d • e

Finding - Braidwood - IR 05000456/2018002

1(0)2(3)3(2)4(0)5(0)6(0)10(0)11(0)12(0)13(0)301(0)410(0)411(1)412(0)503(0)

IR 05000456/2018002: 2 3 1

Finding List (Braidwood) @ 2018Q2

CCA Matrix: 2018Q2

	Q	CCA	Title
05000456/FIN-2017003-01	2017Q3	H.11	Failure to Implement Adequate Radiological Controls for Treated Liquid Radioactive Effluents Containing Tritium
05000456/FIN-2017008-01	2017Q4		Failure to Prevent Secondary Missiles Following a Postulated HELB
05000456/FIN-2017008-02	2017Q4		Inadequate Blow Out Panel Design Control
05000456/FIN-2017008-03	2017Q4		Failure to Properly Correct Errors in Design Analysis for Main Steam Line Break in Main Steam Tunnel
05000456/FIN-2017008-04	2017Q4		Untimely Corrective Action for Secondary Missiles
05000456/FIN-2017008-05	2017Q4		Inaccurate Analysis of Record
05000457/FIN-2018002-01	2018Q2	H.9	Inadequate Detail in Maintenance Work Instructions Resulted in Failed Gearbox Oil Cooler Head Gasket and Inoperable 2B Auxiliary Feedwater Pump
05000456/FIN-2018002-02	2018Q2	H.3	Work Instruction Error Results in Reactor Coolant System Pressure Transient
05000456/FIN-2018002-03	2018Q2	H.4	Inadequate Test Activity Coordination Results in Unintended Valve Actuation and Reactor Coolant System Pressure Drop

Self-Identified List (Braidwood)

[Braidwood Findings full list]

05000456/FIN-2018002-02

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