05000397/FIN-2011005-03
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Finding | |
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| Title | Missed Procedural Step Results in Secondary Containment Pressure Excursion |
| Description | The inspectors reviewed a self-revealing non-cited violation of Technical Specification 5.4.1.a, for the licensees failure to follow procedures. Specifically, on November 2, 2011, operators failed to follow Procedure SOP-HVAC/RB-START, Reactor Building Ventilation Start, Revision 2, by skipping a required step for restoration of reactor building ventilation to the normal alignment following testing of secondary containment isolation valves. As a result, when the reactor building ventilation fans were started, secondary containment pressure increased rapidly to a peak positive pressure of approximately 0.29 inch of water, while secondary containment is normally maintained at 0.6 inch of water vacuum to meet its design basis function. When operators completed of the surveillance test of the secondary containment isolation valves, operators entered Procedure SOP-HVAC/RB-START at Step 5.1.5 which started the fans. The operators should have entered the procedure at Step 5.1.1 which would have placed pressure controller REA-DPIC-1B in manual. This step was necessary since the response time of the controller was not rapid enough to compensate for the rapid changes in air flows associated with a fan start. An event investigation concluded that the missed procedural step was caused by poor planning and preparation and less than adequate self and peer checks. This issue was entered into the licensees corrective action program as Action Request AR 00251613. The finding was more than minor because it affected the human performance attribute of the Barrier Integrity Cornerstone objective to provide reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Using Inspection Manual Chapter 0609.04, Phase 1 Initial Screening and Characterization of Findings, the inspectors determined this finding to be of very low safety significance (Green) because it only represented a degradation of the radiological barrier function provided for by the standby gas treatment system. The inspectors determined that this finding had a cross-cutting aspect in the area of human performance associated with the work practices component because the licensee failed to use human error prevention techniques such as self and peer checking H.4(a) |
| Site: | Columbia  |
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| Report | IR 05000397/2011005 Section 1R22 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.22 |
| Inspectors (proximate) | P Elkmann W Walker J Groom M Hayes |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Columbia - IR 05000397/2011005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Columbia) @ 2011Q4
Self-Identified List (Columbia)
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