05000237/FIN-2009003-03
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Finding | |
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| Title | Instrument Air Isolation Valve Mispositioning on April 26, 2009 |
| Description | A finding of very low safety significance and associated Non-Cited Violation of Technical Specification Section 5.4.1 was self-revealed when the Unit 2 instrument air system had a significant pressure drop because a non-licensed operator failed to follow procedure DOP 4700-01, Instrument Air System Startup, Revision 46. The violation was placed into the licensees corrective action program (CAP) in Issue Reports 911794 and 893376. The non-licensed operator was relieved from duty. Both the non-licensed operator and the unit supervisor were counseled for the failure to perform expected work practices. The licensee also found that this event was similar to other problems discussed in the licensees Root Cause Report 893376, Operations Cyclic Performance. Multiple corrective actions were assigned in Root Cause Report 893376 to address a lack of operations supervision enforcing department standards. Using the guidance contained in IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Disposition Screening, dated December 4, 2008, the inspectors determined that the finding was more than minor because the finding could be reasonably viewed as a precursor to a significant event. Specifically, the failure to follow procedure resulted in an instrument air (IA) transient that could have resulted in a unit scram if the IA system had not been recovered in a timely manner. The inspectors determined the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of findings, Table 4a, for the Initiating Event Cornerstone. The inspectors determined that the finding represented an increase in the likelihood of a reactor trip and the likelihood that mitigation equipment would be unavailable because the finding increased the likelihood of a loss of instrument air (LOIA) event. Therefore, the finding required a phase 2 SDP evaluation. The duration of the condition was less than three days. Using the SDP usage rules from IMC 0609, Appendix A, Determining the Significance of Reactor Inspection Findings for At-Power Situations, the inspectors increased the initiating event frequency for the LOIA event by one order of magnitude for the three day exposure period. The result was an estimated change in core damage frequency of less than 1.0E-6/yr. As a result, the finding was determined to be of very low safety significance (Green) based on the phase 2 SDP evaluation. This finding had a cross-cutting aspect in the area of Human Performance, Work Practices because the operator did not use the expected human performance techniques. H.4.(a) (Section 4OA3) |
| Site: | Dresden  |
|---|---|
| Report | IR 05000237/2009003 Section 4OA3 |
| Date counted | Jun 30, 2009 (2009Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | D Melendez-Colon W Slawinski C Phillips M Bielby J Benjamin T Go J Draper S Edmonds |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Dresden - IR 05000237/2009003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Dresden) @ 2009Q2
Self-Identified List (Dresden)
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