05000244/FIN-2009002-02
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Finding | |
|---|---|
| Title | Inadequate Risk Management Results in Loss of Normal Control Room Annunciators |
| Description | A Green self-revealing finding was identified on February 5, 2009, when Ginna failed to review applicable internal operating experience and implement compensatory actions to minimize the consequences associated with replacement of the annunciator cards, in accordance with CNG-OP-4.01-1000, Integrated Risk Management, Revision 00200. Specifically, CNG-OP-4.01-1000, requires work activities that are considered medium risk to have contingency plans based in part on operating experience. As a result, when the power supplies were inadvertently de-energized, restoration of the alarm panels was delayed until recovery work instructions were prepared and implemented. Ginnas corrective actions include adding a trouble shooting plan to work packages for annunciators that depicts how to restore failed annunciators, revising CNGOP-4.01-1000, to incorporate a checklist of equipment important to the emergency plan in the screening section of the risk process, and having an senior reactor operator review the final weekly schedule for maintenance that could possibly impact equipment used by the emergency plan. This finding is more than minor because it is associated with the design control attribute of the Mitigating Systems Cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. When the annunciator panels were deenergized, the ability of operators to identify and respond to off-normal plant conditions was degraded. Using Phase 1 of IMC 0609, Appendix A, the inspectors determined that the finding was of low safety significance (Green), because the finding did not represent a loss of system safety function; did not represent an actual loss of safety function of a single train for greater than its Tech Spec allowed outage time; did not represent an actual loss of safety function of one or more non-Tech Spec trains of equipment designated as risk-significant per 10CFR50.65, for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />; and did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. This finding has a cross-cutting aspect in the area of human performance because Ginna personnel did not appropriately plan work activities by incorporating risk insights and the need for planned contingencies, compensatory actions and abort criteria, which directly contributed to the loss of power to the control board annunciator panels and declaration of an UE (H.3.a per IMC 0305) |
| Site: | Ginna  |
|---|---|
| Report | IR 05000244/2009002 Section 4OA3 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | Finding: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | S Ibarrola W Cook D Silk G Dentel J Hawkins K Kolaczyk L Casey M Marshfield |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Ginna - IR 05000244/2009002 | |||||||||||||||||||||||||||||
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Finding List (Ginna) @ 2009Q1
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