05000298/FIN-2009005-12
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Finding | |
|---|---|
| Title | Failure to Follow Procedure For Control of Material |
| Description | A self-revealing finding was identified for the licensees failure to follow Administrative Procedure 0.47, Control of In-Process Material, Specifically, a maintenance technician violated the procedure by obtaining a spare o-ring from an uncontrolled toolbox and that o-ring was then installed in the Main Turbine Control Valve 3 hydraulic fitting. The o-ring was the wrong size and caused a hydraulic leak that required taking the turbine off line and shutting down the reactor from 70 percent power. The licensee entered this issue in their corrective action program as CR-CNS-2009-09606. The finding is more than minor because it adversely affected the configuration control attribute of the 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, in that this finding resulted in a condition that prompted a plant shutdown from 70 percent power. In accordance with Manual Chapter 0609, Attachment 4, the inspectors used the Phase 1 Initial Screening and Characterization worksheet to determine that the finding has very low safety significance because it did not result in the loss of any system safety function. The cause of this finding is related to human performance cross cutting component of work practices because the involved maintenance personnel proceeded in the face of uncertainty when obtaining replacement o-rings H.4(a) |
| Site: | Cooper  |
|---|---|
| Report | IR 05000298/2009005 Section 4OA3 |
| Date counted | Dec 31, 2009 (2009Q4) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | N Taylor P Elkmann D Stearns V Gaddy M Chambers E Uribe M Bloodgood D Reinert N Okonkwo M Vasquez |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Cooper - IR 05000298/2009005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Cooper) @ 2009Q4
Self-Identified List (Cooper)
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