05000324/FIN-2012003-01
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Finding | |
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| Title | Failure To Follow Plant Procedure Caused Loss of E1 Bus |
| Description | A self-revealing Green NCV of Technical Specification (TS) 5.4.1, Procedures, was identified when the licensee failed to follow procedure 0MST-DG11R, Diesel Generator 1 Loading Test. During the preparation for the test, procedural steps were not performed correctly and the E1 electrical bus was inadvertently de-energized, requiring emergency diesel generator (EDG) 1 to auto-start and re-energize the bus. Once EDG 1 was supplying power to bus E1, the licensee exited from the surveillance procedure and restored offsite power to bus E1. The licensee entered the issue into their corrective action program as Action Request (AR) 529330.
The inspectors determined that the failure to follow procedure 0MST-DG11R, Diesel Generator 1 Loading Test, was a performance deficiency. The finding was determined to be more than minor because the finding was associated with the Initiating Events Cornerstone attribute of human performance and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, loss of the E1 bus adversely affected the shut down units defense-in-depth for the electrical power availability key safety function. Since Unit 1 was shut down at the time of the event, the findings significance with regard to Unit 1 was evaluated using IMC 0609 Appendix G, Shutdown Operations Significance Determination Process. Since one offsite transmission network remained available to Unit 1 during the event, per Checklist 7 of IMC 0609 Appendix G, Attachment 1, the finding did not require a quantitative assessment. Therefore, the finding is of very low safety significance (Green) for Unit 1. Unit 2 was at power and was also affected by the finding. IMC 0609 Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, Table 4a for the Initiating Events Cornerstone was used to determine that the finding is of very low safety significance (Green) because the finding is 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 0MST-DG11R, Diesel Generator 1 Loading Test. Specifically, technicians did not utilize adequate error prevention techniques to prevent them from connecting test recorders incorrectly. |
| Site: | Brunswick  |
|---|---|
| Report | IR 05000324/2012003 Section 4OA3 |
| Date counted | Jun 30, 2012 (2012Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | A Nielsen D Melendez-Colon M Miller R Musser M Catts K Ellis M Schwieg A Guzzetta |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Brunswick - IR 05000324/2012003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Brunswick) @ 2012Q2
Self-Identified List (Brunswick)
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