05000271/FIN-2011005-02
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Finding | |
|---|---|
| Title | Loss of Shutdown Cooling due to Tag-Out Error |
| Description | A self-revealing NCV of very low safety significance of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified because drawing B191301, Sheet 576, Control Wiring Diagram - Emergency Heater Drain Valve Diagram was not of the appropriate quality to allow tagging activities to be accomplished in accordance with the drawing. As a result of the inadequate drawing, the wrong breaker was selected to be tagged out, which resulted in an unexpected loss of shutdown cooling for 12 minutes. Entergy took immediate corrective action to restore shutdown cooling and entered this issue into their corrective action program (CR-VTY-2011-04203). The inspectors determined that Entergy\\\'s tag-out of the distribution breaker to Vital AC subpanel A due to a drawing error was a performance deficiency that was reasonably within Entergy\\\'s ability to foresee and correct. This finding is more than minor because it is similar to the more than minor statement in example 4.b. of IMC 0612, Appendix E, Examples of Minor Issues, where an operator inadvertently operated the wrong component and caused a transient. Additionally, the finding is more than minor because it affects the objective of the Initiating Events cornerstone to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The inspectors determined that this finding was of very low safety significance (Green), using IMC 0609, Appendix G, Checklist 7, BWR Refueling Operation with RCS Level >23\\\'. This determination was based on the fact that the finding did not degrade Entergy\\\'s ability to recover decay heat removal once lost, and that the temperature increase was small enough that it did not represent a loss of control. The inspectors determined that this finding had a cross-cutting aspect in the Human Performance cross-cutting area, Resources component, because components in the tagging database were not labeled correctly |
| Site: | Vermont Yankee  |
|---|---|
| Report | IR 05000271/2011005 Section 1R20 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | D Silk S Rutenkroger J Noggle T Burns D Kern R Bellamy S Rich |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Vermont Yankee - IR 05000271/2011005 | |||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Vermont Yankee) @ 2011Q4
Self-Identified List (Vermont Yankee)
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