A self-revealing finding was documented for the licensees failure to provide adequate procedures for maintenance and installation of the main generator and
exciter. As a result, work activities using those procedures produced conditions which led to high turbine vibration, which on November 17, 2008, prompted control-room operators to manually initiate a
reactor trip. This failure was a performance deficiency with respect to a self-imposed licensee policy which requires Managers and Supervisors to ensure that procedures are adequate to assure nuclear safety. This finding is addressed in the licensees corrective action program within Action Request 306903. In that Action Request, one corrective action is to correct the affected procedures. This finding is more-than-minor because it affected the Equipment Performance attribute of the
Initiating Events cornerstone, and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability during power operations. When evaluated per Attachment 4 of Manual Chapter 0609, this finding screened to very low safety significance (Green) because it did not contribute to both an initiating event and the likelihood of a loss of mitigating equipment or functions. This finding has a crosscutting aspect of supervisory and management oversight, as described in the Work Practices component of the Human Performance cross cutting area because the licensee failed to provide adequate oversight to the work activities associated with turbine-generator reassembly (
H.4(c))
