05000313/FIN-2009002-04
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Finding | |
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| Title | |
| Description | The inspectors documented a self-revealing finding because an auxiliary operator failed to follow procedure instructions that prohibited the use of torque amplifying devices on plant valves. The operators used such a device on a main generator hydrogen skid valve and inadvertently disassembled the valve. The subsequent hydrogen leak started a fire. Control room operators manually tripped the reactor and entered Mode 3. The failure to follow the procedure in this instance was not a violation of NRC requirements because the hydrogen system was not safety related. The licensee entered this issue into their corrective action program as Condition Report ANO-1-2009-0254. The finding was more than minor because it was associated with the Human Performance attribute of the Initiating Events Cornerstone and it directly affected the cornerstone objective to limit the likelihood of those events that upset plant stability during power operations, and is therefore a finding. Using the Inspection Manual Chapter 0609, Significance Determination Process, Phase 1 Worksheet, this finding had very low safety significance because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available. This finding had a crosscutting aspect in the area of Human Performance associated with Work Practices H.4(a), in that licensee personnel failed to use human error prevention techniques, such as self and peer checks and STAR (stop, act, think, and review), and failed to stop in the face of uncertainty or unexpected circumstance to ensure that work activities were performed safely and without consequence. Specifically, the auxiliary operator did not use human error techniques, nor did the operator stop the hydrogen addition evolution when unexpected circumstance arose |
| Site: | Arkansas Nuclear  |
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| Report | IR 05000313/2009002 Section 4OA3 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | K Clayton A Sanchez J Josey J Clark S Rotton |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Arkansas Nuclear - IR 05000313/2009002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Arkansas Nuclear) @ 2009Q1
Self-Identified List (Arkansas Nuclear)
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