05000324/FIN-2009004-02
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Finding | |
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| Title | Failure to Follow Plant Procedure Caused Loss of E2 Bus |
| Description | A self-revealing Green non-cited violation of Technical Specification (TS) 5.4.1, Procedures, was identified when the licensee failed to follow procedure 0PICCNV023, Calibration of Westinghouse & Scientific Columbus Teleductors. During the performance of the calibration, procedural steps were not performed correctly and the E2 electrical bus was inadvertently deenergized, requiring the emergency diesel generator #2 to auto-start and reenergize the bus. Emergency diesel generator #2 auto-started and the E2 bus transferred from off-site power. After the event, the licensee halted the maintenance on the E2 bus instruments and restored off-site power to the E2 bus. The event was entered into the licensees corrective action program as NCR #344300. The finding was determined to be more than minor because the finding was associated with the Initiating Events Cornerstone attribute of configuration control and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. The finding affected configuration control because correct test switch alignment was not maintained. The finding also affected the cornerstone objective because loss of the E2 bus represented an upset to plant stability. The inspectors determined the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of findings, Table 4a for the Initiating Events Cornerstone. The finding was determined to be of very low safety significance (Green) because the finding was a transient initiator that did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available. The finding has a cross-cutting aspect in the Human Performance cross cutting area, Work Practices component, because the licensee failed to implement adequate error prevention techniques while performing plant procedure 0PIC-CNV023, Calibration of Westinghouse & Scientific Columbus Teleductors. Specifically, technicians did not utilize adequate error prevention techniques to prevent them from operating the wrong test switch when calibrating instrument 1-E2-AG6-VTR (H.4(a)) |
| Site: | Brunswick  |
|---|---|
| Report | IR 05000324/2009004 Section 4OA3 |
| Date counted | Sep 30, 2009 (2009Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | P Capehart G Kolcum S Rose J Polickoski J Reece C Welch R Musser R Clagg |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Brunswick - IR 05000324/2009004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Brunswick) @ 2009Q3
Self-Identified List (Brunswick)
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