05000315/FIN-2011005-02
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Finding | |
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| Title | Failure to Follow the Clearance Procedure During Maintenance on Safety-Related Equipment |
| Description | One self-revealed finding of very low safety significance with an associated NCV of TS 5.4.1.a was identified for the failure to implement a procedure required during maintenance on safety-related equipment. The licensee did not follow the clearance procedure while performing maintenance on the Unit 1 reactor vessel head vent assembly. Specifically, workers did not verify that the head vent assembly was isolated from the reactor vessel prior to attempting to remove the vent hose as required by the clearance procedure. Consequently, maintenance workers breached a pressurized system that was not isolated, which resulted in a more than expected amount of reactor coolant being released from the system. For corrective actions the licensee immediately isolated the leak, modified the clearance procedure with additional instructions and communicated lessons learned to the workers. This issue was entered into the licensees CAP as AR 2011-12207. This finding was related to the Initiating Events cornerstone and was more than minor because it adversely affects the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The finding is associated with the attribute of human performance. Specifically, performing maintenance on a pressurized plant system without verifying the system was properly isolated increased the likelihood of events that challenge plant stability while shutdown. This finding was of very low safety significance because the safety function guidelines for core heat removal, inventory control, power availability, containment integrity, and reactivity control were met in accordance with a phase 1 screening using Appendix G to IMC 0609 for shutdown operations significance determination. This finding is associated with a cross-cutting aspect in the work control component of the human performance cross-cutting area. Specifically, the outage command center did not adequately coordinate work activities between maintenance and operations to ensure the reactor vessel head vent hose assembly was properly removed |
| Site: | Cook  |
|---|---|
| Report | IR 05000315/2011005 Section 1R20 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | J Lennartz T Go P Laflamme A Shaikh E Sanchez S Shah E Davidson |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Cook - IR 05000315/2011005 | |||||||||||||||||||||||||||||
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Finding List (Cook) @ 2011Q4
Self-Identified List (Cook)
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