05000313/FIN-2008004-03
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Finding | |
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| Title | Failure of Feedwater Heater High Level Drain Valve Due to Maintenance (Section 4OA3) |
| Description | Inspectors documented a self-revealing finding for the failure to follow Procedure EN-HU-102, \\\"Human Performance Tools,\\\" Revision 4, which required that workers perform self checks and peer checks to ensure that the correct work was being performed on the correct equipment. Specifically, workers, who were returning from a break to resume preoutage preparation for feedwater heater replacement, failed to perform a self check, or obtain a peer check, and worked on the wrong component. They cut two instrument air lines to the Unit 1 Feedwater Heater E-4A high level drain Valve CV-3068. This caused the valve to fail full open and drain the feedwater heater. Plant personnel captured this finding in the corrective action program as Condition Report ANO-1-2008-0924. The failure to follow Procedure EN-HU-102 was a performance deficiency and, therefore, a finding. This finding was more than minor because it was similar to nonminor Example 4.e in NRC Manual Chapter 0612, Appendix E, \\\"Examples of Minor Issues.\\\" Specifically, the failure to comply with the procedure resulted in the valve failing open. The finding was evaluated for significance using NRC Manual Chapter 0609, \\\"Significance Determination Process,\\\" and determined to be of very low safety significance (Green) because as a transient initiator, the finding did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available. Inspectors determined that the finding had a crosscutting aspect in the area of Human Performance associated with Work Practices because the craftsman did not utilize self and peer checking techniques H.4(a) (Section 4OA3). |
| Site: | Arkansas Nuclear  |
|---|---|
| Report | IR 05000313/2008004 Section 4OA3 |
| Date counted | Sep 30, 2008 (2008Q3) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | P Elkmann D Stearns T Mckernon A Sanchez J Josey B Larson |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Arkansas Nuclear - IR 05000313/2008004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Arkansas Nuclear) @ 2008Q3
Self-Identified List (Arkansas Nuclear)
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