05000263/FIN-2015001-05
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Finding | |
|---|---|
| Title | Two Emergency Diesels Inoperable Due to Human Error |
| Description | A self-revealing finding of very low safety significance and an NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures and Drawings, was identified on December 28, 2014, due to the failure to properly implement Procedure 0187-02B, 12 Emergency Diesel Generator /12 ESW [Emergency Service Water] Monthly Pump and Valve Tests. Specifically, operations personnel failed to comply with Step 42 which directed the 12 EDG local governor control switch to be lowered to idle setting. The failure to implement the actions directed by Step 42 resulted in the 11 EDG being inoperable. Corrective actions for this issue included procedure revisions to require: protection/flagging of redundant equipment when technical specification equipment is declared inoperable for any reason, including planned maintenance and surveillance; peer checking or concurrent verification for manipulation of operable technical specification related equipment; and all equipment manipulations require a hard match (between procedure and equipment labeling). This issue was entered into the licensees corrective action program (CAP 1460675). The issue was more than minor because if left uncorrected, the failure to properly implement procedures associated with safety-related equipment would have the potential to lead to a more significant safety concern. Specifically, the failure to follow procedure resulted in the 11 EDG being made inoperable coincident with the 12 EDG being inoperable. The inspectors utilized IMC 0609 and determined that the issue was of very low safety significance. The inspectors determined that the contributing cause that provided the most insight into the performance deficiency was associated with the cross-cutting area of Human Performance, Avoid Complacency aspect because of a failure of individuals to implement error reduction tools [H.12]. |
| Site: | Monticello  |
|---|---|
| Report | IR 05000263/2015001 Section 4OA3 |
| Date counted | Mar 31, 2015 (2015Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | I Hafeez J Beavers J Neurauter K Riemer M Davis M Learn M Mitchell M Ziolkowski P Voss P Zurawski S Bell T Bilik |
| Violation of: | 10 CFR 50 Appendix B Criterion V Technical Specification Technical Specification - Procedures |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Monticello - IR 05000263/2015001 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Monticello) @ 2015Q1
Self-Identified List (Monticello)
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