05000277/FIN-2009002-01
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Finding | |
|---|---|
| Title | Inadequate Work Instructions Result in Inadvertent ESF Actuation |
| Description | A self-revealing NCV of 10 CFR 50 Appendix B, Criteria V, Instructions, Procedures and Drawings was identified when inadequate work instructions resulted in a momentary shorting of a terminal lead during maintenance, which caused an inadvertent Unit 3, primary containment isolation valve (PCIV) signal and entry into a one-hour shutdown Technical Specification (TS) Action Statement on March 3, 2009.Specifically, the work instructions allowed the technicians to lift and manipulate energized leads on a safety-related pressure switch without providing any guidance as to the risk and consequences that inadvertent grounding of those energized leads could cause. Because the risk and consequences were not considered and an inadvertent grounding occurred, a PCIV signal resulted that closed normally open valves on both the containment atmosphere control (CAC) system and the instrument nitrogen system containment penetrations. In addition, both PCIV valves on containment atmosphere dilution (CAD) system were rendered inoperable which required the operators to enter an unplanned one-hour TS Action Statement(3.6.1.3.B) and would have required a plant shutdown within the following 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />. Corrective actions included replacing the blown fuse, entering the issue into the CAP, and making a required 60 day verbal report to the NRC. The finding is more than minor because it could reasonably be viewed as a precursor to a significant event. Specifically, the failure to assess the risk of inadvertent grounding of energized leads on safety equipment could pose a credible hazard as an initiating event during plant operation. The finding was of very low safety significance because the valves in question failed closed and did not represent an actual open pathway in the physical integrity of reactor containment. This finding has a cross-cutting aspect in the area of human performance (work control) because the licensees work instructions did not provide appropriate risk insights regarding the risks associated with potential grounding of the energized leads. H.3(a |
| Site: | Peach Bottom  |
|---|---|
| Report | IR 05000277/2009002 Section 1R13 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | M Brown G Johnson R Fuhrmeister F Bower J Tomlinson P Krohn E Torres |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Peach Bottom - IR 05000277/2009002 | |||||||||||||||||||||||||||||||||||||
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Finding List (Peach Bottom) @ 2009Q1
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