05000282/FIN-2008005-04
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Finding | |
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Title | Operator Manipulates Incorrect Component due to Failure to Follow Procedures |
Description | One self-revealed finding of very low safety significance and an associated NCV of Technical Specification (TS) 5.4.1 was identified on October 13, 2008, due to an operators failure to follow procedures during refueling activities. The failure to follow procedures resulted in a loss of seal injection flow to the 11 reactor coolant pump due to the manipulation of a Unit 1 seal injection valve rather than a Unit 2 seal injection valve. Corrective actions for this issue included communicating this event to all Operations personnel, resetting the operations departments event free clock and providing additional training of the use of human performance tools. The inspectors determined that this finding was more than minor because if left uncorrected, a continued failure to follow procedures could lead to the incorrect operation of additional plant equipment and become a more significant safety concern. The inspectors determined that this issue was of very low safety significance because the finding would not result in leakage that exceeded any TS limit and because the finding would not have affected other mitigation equipment. Specifically, the reactor coolant pumps were designed to be able to operate without seal injection flow for several hours as long as the component cooling water supply to the thermal barrier heat exchanger remained within allowable ranges. The inspectors concluded that this finding was cross-cutting in the Human Performance, Decision Making area because the operator failed to use the systematic process for implementing procedures when deciding which valve needed to be manipulate |
Site: | Prairie Island |
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Report | IR 05000282/2008005 Section 1R20 |
Date counted | Dec 31, 2008 (2008Q4) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71111.2 |
Inspectors (proximate) | D Mcneil G O'Dwyer J Giessner K Stoedter L Haeg P Zurawski R Jickling R Winter T Bilik |
CCA | H.13, Consistent Process |
INPO aspect | DM.1 |
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Finding - Prairie Island - IR 05000282/2008005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Prairie Island) @ 2008Q4
Self-Identified List (Prairie Island)
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