05000219/FIN-2008005-01
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Finding | |
|---|---|
| Title | Conduct of Maintenance Procedure Not Properly Implemented |
| Description | A self-revealing non-cited violation (NCV) of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, occurred when Exelon did not perform an adequate self-check and did not properly use test equipment during 480 VAC breaker maintenance on November 7. Specifically, during the maintenance, a human performance error occurred causing a phase to phase fault and an arc flash, and resulted in the loss of safety related equipment and an automatic halon system actuation in the 480 VAC room. In response, Exelon entered this issue into the corrective action program and implemented actions to address work practice deficiencies. The 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 shutdown as well as power operations. Using Appendix G, Shutdown Operations Significance Determination Process, of Manual Chapter 0609, Significance Determination Process, the finding was determined to have very low safety significance (Green) because it did not increase the likelihood of a loss of reactor coolant system (RCS) inventory, did not affect the licensees ability to terminate a leak path or add inventory to the RCS, or degrade the licensees ability to recover decay heat removal in the event it was lost. The performance deficiency had a cross-cutting aspect in the area of human performance because Exelon did not properly implement human error prevention techniques, such as self and peer checking H.2(c). (Section 1R12 |
| Site: | Oyster Creek |
|---|---|
| Report | IR 05000219/2008005 Section 1R12 |
| Date counted | Dec 31, 2008 (2008Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | P Kaufman S Pindale J Kulp M Ferdas T Setzer R Nimitz N Perry R Bellamy C Crisden |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Oyster Creek - IR 05000219/2008005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Oyster Creek) @ 2008Q4
Self-Identified List (Oyster Creek)
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