05000280/FIN-2008005-02
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Finding | |
|---|---|
| Title | Inadequate Review of Vendor Information Led to Unit 1 Manual Reactor Trip |
| Description | A Green self-revealing Finding was identified for failure to provide adequate vendor oversight for non-safety related work, which led to the incorrect installation of balance weights on the Unit 1 main turbine. As a result, the turbine experienced high vibrations during startup on April 20, 2008, which required the insertion of a manual turbine and reactor trip. The licensee entered the deficiency into the corrective action program for resolution (CR 096233). Corrective actions to correct the balance move, implement peer review requirements, and procedural changes that require independent verification of the balance move location and weight have been implemented. A violation of regulatory requirements was not identified. The finding is greater than minor because it had an actual impact on safety, it led to a plant trip, and 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, evaluated per Attachment 4 of the SDP, screened to very low safety significance (Green) because it did not contribute to both an initiating event and the likelihood of a loss of mitigating equipment or functions. The cause of the finding is related to the cross-cutting element of human performance work practices. Human error prevention techniques such as peer checks were not invoked by the licensee (H.4(a)). (Section 4OA3.2 |
| Site: | Surry  |
|---|---|
| Report | IR 05000280/2008005 Section 4OA3 |
| Date counted | Dec 31, 2008 (2008Q4) |
| Type: | Finding: 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.12, Avoid Complacency |
| INPO aspect | QA.4 |
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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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