05000305/FIN-2011002-04
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Finding | |
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| Title | Partial Loss of Offsite Power Caused by Less Than Adequate Interface and Oversight of Switchyard Modification Work |
| Description | A finding of very low safety-significance was self-revealed for the failure to adequately control relay testing for switchyard breaker installations under Design Change WO KW100691871. Specifically, on March 10, 2011, Dominion Electrical Transmission technicians deviated from standard work practices to test a relay via an internal corporate server, which caused a partial loss of offsite power to the plant through the loss of the main auxiliary transformer backfeed to safety-related bus 6. Licensee corrective actions included a human performance and safety stand-down for substation personnel on the day of the event, the development of a mitigating strategy that outlined expectations and implemented increased direct supervision on critical tasks, and the development of a formal memo describing expectations related to the restricted use of the server for performing remote testing of control functions. The finding was determined to be more than minor because, if left uncorrected, the finding had the potential to lead to a more significant safety concern. Specifically, had a different breaker been inappropriately tripped, the station could have experienced a total loss of offsite power. The inspectors concluded that the finding could be evaluated using Inspection Manual Chapter 0609, Appendix M, Significance Determination Process Using Qualitative Criteria. Specifically, the inspectors qualitatively evaluated the finding by applying the spent fuel pool questions in the Fuel Barrier column of Table 4a, Attachment 4. The inspectors answered No to all three questions and determined that the finding was of very low safety significance (Green). The finding has a cross-cutting aspect in the areas of human performance, work practices, because supervisory and management oversight of work activities, including contractors, was not implemented for this evolution (H.4(c)). |
| Site: | Kewaunee  |
|---|---|
| Report | IR 05000305/2011002 Section 4OA3 |
| Date counted | Mar 31, 2011 (2011Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | A Shaikh E Sanchez-Santiago M Holmberg R Langstaff R Winter J Jandovitz J Cassidy M Kunowski R Krsek K Barclay R Jones |
| CCA | H.2, Field Presence |
| INPO aspect | LA.2 |
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Finding - Kewaunee - IR 05000305/2011002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Kewaunee) @ 2011Q1
Self-Identified List (Kewaunee)
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