05000286/FIN-2008002-05
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Finding | |
|---|---|
| Title | Failure to Follow Procedures Results in Loss of Safety Bus 5A |
| Description | A self-revealing, Green, non-cited violation (NCV) of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified, because maintenance technicians improperly performed a surveillance test and caused the loss of 480 volt safety bus 5A and the automatic start and loading of the 33 emergency diesel generator. Entergy communicated the human error attributes that contributed to the event to plant personnel and entered this issue into the corrective action program. The inspectors determined that the finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events cornerstone, and impacted its objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. This finding was determined to be of very low safety significance, using Phase 1 guidance contained in IMC 0609, Determining the Significance of Reactor Inspection Findings for At-Power Situations. Specifically, that the finding did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available. The inspectors determined that this finding had a cross-cutting aspect in the area of Human Performance, in that maintenance technicians did not follow procedures as written. Moreover, the underlying contributor to the event was that the technicians did not utilize self-check and peer-check skills that would have prevented the event, and proceeded in the face of unexpected circumstances. (H.4(a) |
| Site: | Indian Point  |
|---|---|
| Report | IR 05000286/2008002 Section 1R22 |
| Date counted | Mar 31, 2008 (2008Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.22 |
| Inspectors (proximate) | A Koonce E Cobey P Cataldo S Barr |
| CCA | , |
| INPO aspect | QA.4 |
| ' | |
Finding - Indian Point - IR 05000286/2008002 | |||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Indian Point) @ 2008Q1
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