05000298/FIN-2008005-05
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Finding | |
|---|---|
| Title | Procedure Violation Causes Augmented Off-gas System Isoloation |
| Description | A self-revealing finding was identified regarding the licensees failure to follow procedural requirements during system maintenance. Specifically, licensee personnel failed to heed a cautionary note in a maintenance procedure, resulting in an inadvertent isolation of the augmented off-gas system. The licensee entered this issue into their corrective action program as Condition Report CR-CNS-2008-08405. The finding is more than minor because it affected the plant equipment attribute of the public radiation safety cornerstone, and affected the cornerstone objective to ensure adequate protection of public health and safety from exposure to radioactive materials release into the public domain as a result of routine civilian nuclear reactor operation, in that the release rate through the elevated release point increased over five hundred percent as a result of the system isolation. Using Inspection Manual Chapter 0609, Appendix D, Public Radiation Safety Significance Determination Process, the finding was determined to be of very low safety significance because it did not represent a failure to implement an effluent program or result in public dose greater than 10 CFR 50 Appendix I criterion. The cause of this finding is related to the human performance crosscutting component of work practices because licensee personnel failed to stop in the face of uncertainty when unexpected labeling was discovere |
| Site: | Cooper  |
|---|---|
| Report | IR 05000298/2008005 Section 4OA5 |
| Date counted | Dec 31, 2008 (2008Q4) |
| Type: | Finding: Green |
| cornerstone | Pr Safety |
| Identified by: | Self-revealing |
| Inspection Procedure: | |
| Inspectors (proximate) | K Clayton G Guerra N Taylor P Elkmann C Graves S Garchow G Miller M Chambers |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
| ' | |
Finding - Cooper - IR 05000298/2008005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Cooper) @ 2008Q4
Self-Identified List (Cooper)
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