05000293/FIN-2009004-04
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Finding | |
|---|---|
| Title | Human Error Resulting in Unplanned High Pressure Coolant Injection (HPCI) Isolation |
| Description | A self-revealing, NCV of very low safety significance (Green) of Technical Specification (TS) 5.4.1, Procedures, was identified for a procedure error which resulted in the inadvertent isolation of the High Pressure Coolant Injection (HPCI) system. Specifically, Entergy procedure 8.M.2-2.6.3, HPCI High Steam Line Temperature, which describes the conduct of continuity checks of temperature switches, was not adequately implemented and caused the HPCI system to isolate. Corrective actions have included revising the procedure to include a step requiring concurrent verification for resetting the temperature switch, and a wait time of five minutes before Entergy proceeds to test the next switch. This finding is more than minor because it is associated with the Equipment Performance attribute of the Mitigating Systems cornerstone and affected the cornerstone objective to ensure the availability of systems that respond to initiating events to prevent undesirable consequences. The finding was determined to require a Phase II analysis because the finding resulted in an actual loss of system safety function. Using the Pilgrim pre-solved initiating event sequences and an exposure time of less than three days with the HPCI system unavailable, the Phase II estimation determined this finding was of very low safety significance (Green). The inspectors determined that this finding had a cross-cutting aspect in the Work Practices component of the Human Performance cross-cutting area because Entergy did not conduct effective self or peer checks to ensure that continuity checks were adequately performed. H.4(a |
| Site: | Pilgrim |
|---|---|
| Report | IR 05000293/2009004 Section 4OA3 |
| Date counted | Sep 30, 2009 (2009Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | E Huang W Raymond R Rolph B Smith M Schneider G Newman S Rich D Jackson |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Pilgrim - IR 05000293/2009004 | |||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Pilgrim) @ 2009Q3
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