05000280/FIN-2008005-01
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Finding | |
|---|---|
| Title | Inadequate Work Instructions Result in Actuation of Unit 1 Safety Injection Train B |
| Description | A Green self-revealing non-cited violation (NCV) of Technical Specification 6.4.A.7 was identified for failure to provide adequate work instructions for corrective maintenance on the safety injection (SI) system. The inadequate work instructions led to an inadvertent actuation of the Unit 1 B train of safety injection on October 29, 2008. The proposed corrective actions are to provide guidance/restrictions in the work planning process to assure appropriate reviews are obtained, commensurate with the safety significance of the work. The finding is greater than minor because it had an actual safety impact by causing a SI and if left uncorrected could lead to a more significant safety issue. The finding is associated with the human performance attribute of the Reactor Safety Initiating Events cornerstone and adversely affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The finding is determined to be of very low safety significance (Green) based on a Phase 3 SDP analyses performed by a regional Senior Reactor Analyst. This finding has a cross-cutting aspect in the area of human performance, decision making, because the decision to continue with the planned work was made without a complete understanding of either the effects of the job steps or the worst case possible unintended consequences (H.1(b)). (Section 4OA3.1 |
| Site: | Surry  |
|---|---|
| Report | IR 05000280/2008005 Section 4OA3 |
| Date counted | Dec 31, 2008 (2008Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | J Nadel J Reece C Welch E Lea D Arnett G Mccoy R Hamilton W Loo H Gepford M Reichard |
| CCA | H.14, Conservative Bias |
| INPO aspect | DM.2 |
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Finding - Surry - IR 05000280/2008005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Surry) @ 2008Q4
Self-Identified List (Surry)
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