05000263/FIN-2015002-06
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Finding | |
|---|---|
| Title | Loss of Electrical Buses and Shutdown Cooling (SDC) Due to Inadequate Procedure Adherence |
| Description | A self-revealed finding of very low safety significance and an associated NCV of Title 10 of the Code of Federal Regulations (CFR), Part 50, Appendix B, Criterion V, Instructions, Procedures and Drawings, was identified due to the failure to properly implement Procedure 0304-01, Safeguard Bus Loss of Voltage Protection Relay Unit Calibration Safeguards Bus No. 15. Specifically, electrical maintenance workers failed to comply with Step 20 which directed the installation of a jumper between terminals ZX10 and ZX11 in an electrical panel, when they incorrectly installed the electrical jumper between terminals ZX11 and ZX12. This resulted in the loss of the Division I safety related 4160 Volts Alternating Current (Vac), 480 Vac, and 125 Volts Direct Current (Vdc) electrical buses, which subsequently led to the loss of shutdown cooling (SDC) for approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> and 15 minutes. Initial corrective actions for this issue included immediately invoking strict plant status controls to focus efforts on recovery, restoring the electrical buses and SDC to operation, and reinforcing risk recognition and human performance tools. This issue was entered into the licensees CAP (CAP 1477351) and a root cause evaluation (RCE) was in progress at the time this inspection period concluded. The inspectors determined that the issue was more than minor because it adversely impacted the Initiating Events Cornerstone attribute of Human Performance and Configuration Control, and affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The inspectors utilized IMC 0609, Appendix G for shutdown operations 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 the failure of licensee individuals to implement error reduction tools and the failure of the organization to plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes [H.12]. |
| Site: | Monticello  |
|---|---|
| Report | IR 05000263/2015002 Section 4OA3 |
| Date counted | Jun 30, 2015 (2015Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | K Riemer M Ziolkowski N Mcmurray P Voss P Zurawski R Elliott S Bell T Bilik |
| Violation of: | 10 CFR 50 Appendix B Criterion V |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Monticello - IR 05000263/2015002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Monticello) @ 2015Q2
Self-Identified List (Monticello)
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