05000306/FIN-2011004-08
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Finding | |
|---|---|
| Title | Unit 2 Reactor Trip due to Mis-operation of Substation Breakers |
| Description | A self-revealed finding of very low safety significance was identified by the inspectors due to personnel incorrectly implementing Procedure FP-G-DOC-03, Procedure Use and Adherence. Specifically, maintenance personnel failed to adequately review, identify and correct potential problems associated with Procedure 5AWI 15.1.9, Substation Work Control, to ensure that electrical substation (switchyard) high risk and/or critical activities conducted in November 2010 were appropriately observed. As a result, personnel failed to identify that a wire was not properly installed. The failure to install the wire led to the mis-operation of multiple substation breakers, a turbine trip, and a Unit 2 reactor trip on May 9, 2011. The licensee initiated corrective action documents, Corrective Action Program (CAPs) 1284948 and 1284787, to document this event. Corrective actions for this issue included installing the wire and revising procedures to ensure that vulnerabilities associated with substation high risk/critical work activities were appropriately addressed. No violations of NRC requirements were identified due to substation components being non-safety related. The inspectors determined that the failure to correctly implement FP-G-DOC-03 was a performance deficiency that required a SDP evaluation. The inspectors determined that this issue was more than minor because it was associated with the protection from external factors attribute of the Initiating Events Cornerstone. This finding also impacted the cornerstone objective of limiting the likelihood of events that upset plant stability and challenged critical safety functions during shutdown as well as power operations. The inspectors determined that this issue was of very low safety significance because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment would not be available. The inspectors concluded that this issue was cross-cutting in the Problem Identification and Resolution, CAP area, because the licensee had not implemented and institutionalized operating experience associated with the performance of substation activities through changes to processes, procedures, equipment and training programs |
| Site: | Prairie Island  |
|---|---|
| Report | IR 05000306/2011004 Section 4OA3 |
| Date counted | Sep 30, 2011 (2011Q3) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | C Zoia D Betancourt J Beavers J Giessner K Stoedter M Phalen N Feliz Adorno P Cardona Morales P Elkmann P Zurawski S Shah V Meghani |
| CCA | P.5, Operating Experience |
| INPO aspect | CL.1 |
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Finding - Prairie Island - IR 05000306/2011004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Prairie Island) @ 2011Q3
Self-Identified List (Prairie Island)
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