05000272/FIN-2011003-02
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Finding | |
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Title | Inadequate Control of Switchyard Maintenance |
Description | A Self Revealing finding of very low safety significance was identified on April 1, 2011, because 500 KV load break disconnect 3T60 failed to operate upon the restoration of switchyard maintenance. This caused a four hour delay in the restoration from a single source of offsite power, the exit from a 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> Limiting Condition for Operation (LCO), and the extension of a yellow probability risk assessment (PRA) condition. PSEG investigation revealed that the vendor, who was conducting maintenance on the 3T60 disconnect, removed the motor control fuse holder that was not part of the tag out for the maintenance. PSEG determined that the cause of the disconnect not closing was that PSEG did not adequately brief and control the maintenance evolution. PSEG entered this event into the corrective action program as notification 20503254. The performance deficiency was more than minor because it was associated with the human performance attribute of the Initiating Events cornerstone, and it adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions. Specifically, not following the PSEG procedure for the management and oversight of supplemental personnel caused a four hour extension into a 72 hour8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> LCO in which Salem units 1 and 2 had only one source of offsite electrical power. The finding was evaluated under IMC 0609, Attachment 4, Phase 1 screening, and was determined to require additional evaluation. The finding was subsequently evaluated in Phase 3 utilizing a pilot implementation of NRCs SAPHIRE 8 risk analysis SDP interface tool using the Salem specific standardized plant analysis review (SPAR) model, and confirmed to be of very low safety significance (GREEN). This performance deficiency has a cross-cutting aspect in the area of human performance, because PSEG did not ensure supervisory and management oversight of the vendor work activity. Specifically, PSEG personnel did not conduct an adequate pre-job brief with the vendor, did not assign a supervisor to provide in-field supervision, and did not conduct an adequate post-maintenance restoration walk down of the 3T60 switchyard maintenance. |
Site: | Salem ![]() |
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Report | IR 05000272/2011003 Section 1R13 |
Date counted | Jun 30, 2011 (2011Q2) |
Type: | Finding: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71111.13 |
Inspectors (proximate) | D Schroeder R Fuhrmeister J Furia E Gray A Burritt M Balazik P Mckenna C Douglas |
CCA | H.2, Field Presence |
INPO aspect | LA.2 |
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Finding - Salem - IR 05000272/2011003 | ||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Salem) @ 2011Q2
Self-Identified List (Salem)
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