05000220/FIN-2009003-01
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Finding | |
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| Title | Failure to Follow Startup Procedure for Second Stage Reheaters Leads to Turbine Trip |
| Description | A self-revealing non-cited violation (NCV) of Technical Specification (TS) 6.4, Procedures, was identified when operators did not follow the operating procedure when placing the Unit 1 second stage main steam reheaters in service during plant power ascension. The resultant uneven turbine heating caused an increase in turbine vibrations that led the control room operators to rapidly reduce power and trip the turbine, which, in turn, cause an automatic initiation of the high pressure coolant injection (HPCI) system. As corrective action, the operating procedure was revised to provide improved guidance on placing the second stage main steam reheaters in service. This issue was entered into the corrective action program (CAP) as condition report (CR) 2009-2238.The finding was more than minor because it is associated with the procedure quality attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The finding is of very low safety significance because the finding did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available, and did not screen as potentially risk significant due to external events. The finding had a cross-cutting aspect in the area of Human Performance, Work Practices, because the operators did not follow the procedure for placing the second stage main steam reheaters in service |
| Site: | Nine Mile Point  |
|---|---|
| Report | IR 05000220/2009003 Section 1R20 |
| Date counted | Jun 30, 2009 (2009Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | D Dempsey G Dentel E Knutson P Kaufman |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Nine Mile Point - IR 05000220/2009003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Nine Mile Point) @ 2009Q2
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