05000269/FIN-2017004-01
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Finding | |
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Title | Failure to Identify Sensitive Equipment During Modification Results in Loss of Safety Function |
Description | A self-revealing Green non-cited violation (NCV) of Oconee Nuclear Station Technical Specification (TS), Section 5.4, Procedures, was identified for the licensees failure to identify sensitive equipment in a work area that warranted implementation of compensatory measures as required by station procedure AD-EG-ALL-1180, Engineering Change (EC) Walkdowns. During the design and planning phase of a station modification, the licensee failed to identify sensitive components located in the subject work area and subsequently failed to implement adequate protective measures as defined in station procedures to prevent plant impacts during modification installation. The licensee entered this issue into their corrective action program (CAP) as nuclear condition report (NCR)02131608 and implemented corrective actions to identify other positionable components required for emergency power source operability that would require the use of protective measures, as defined by AD-OP-ALL-0204, Plant Status Control, in order to prevent inadvertent operation. The licensee created a formal Engineering department communication which included lessons learned from the event and familiarization with the EC walkdown checklist. The signs on the governor actuator cabinets were also revised to emphasize the sensitive nature of the equipment. The licensees failure to properly identify sensitive equipment and implement compensatory measures to prevent plant impacts as required by station procedure AD-EG-ALL-1180 was a performance deficiency. The performance deficiency was determined to be more than minor because it was associated with the human performance attribute of the mitigating systems cornerstone and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the performance deficiency resulted in the loss of the emergency AC power path function for 11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> and 31 minutes. The finding was assessed using IMC 0609, Attachment 4 and IMC 0609, Appendix A. Inspection Manual Chapter 0609, Appendix A required a detailed risk evaluation because the finding represented a loss of system and/or function. A regional senior reactor analyst (SRA) performed the detailed risk evaluation using SAPHIRE Version 8.1.6 and a modified Version 8.50 of the SPAR Model for Oconee. The SRA developed two change sets to model the total exposure time for the finding. The first simulated a common cause failure of both Keowee units with an exposure time of 7 hours8.101852e-5 days <br />0.00194 hours <br />1.157407e-5 weeks <br />2.6635e-6 months <br />. The second simulated the failure of both Keowee units while the standby buses were energized by the Lee Station for 5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />. The result was less than 1E-6 for each Oconee unit, which would be a finding of very low significance (Green). The inspectors utilized IMC 0310, Aspects Within the Cross-Cutting Areas, dated December 4, 2014, and determined the finding had a cross-cutting aspect of work management in the area of human performance, in that the organization failed to implement a process of planning, controlling, and executing work activities such that nuclear safety is the overriding priority. The work process failed to include the identification and management of risk commensurate to the work and the need for coordination with different groups or job activities. (H.5) |
Site: | Oconee |
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Report | IR 05000269/2017004 Section 4OA3 |
Date counted | Dec 31, 2017 (2017Q4) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71153 |
Inspectors (proximate) | E Crowe N Childs J Parent B Collins W Loo M Meeks A Nielsen J Panfel R Williams F Ehrhardt |
Violation of: | Technical Specification - Procedures |
CCA | H.5, Work Management |
INPO aspect | WP.1 |
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Finding - Oconee - IR 05000269/2017004 | ||||||||||||||||||||||||||||||
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Finding List (Oconee) @ 2017Q4
Self-Identified List (Oconee)
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