05000327/FIN-2011002-01
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Finding | |
|---|---|
| Title | Reactor Trip due to Unplugged Steam Dump Load Reject Controller |
| Description | A self-revealing finding was identified for the licensees failure to perform adequate post-maintenance testing, as specified by procedures SPP-8.3, Post- Modification Testing, revision 10, and NPG-SPP-06.3, Pre-/Post-Maintenance Testing, revision 0, in conjunction with a work order which implemented a plant modification on Unit 1 and included the relocation of the steam dump load reject controller. This resulted in a manual trip of Unit 1 following a turbine trip from 26 percent rated thermal power due to the steam dump load reject controller power supply not being properly connected. The licensee entered this issue into their corrective action program as PERs 285349. The licensee implemented corrective actions to include a revision to post-modification testing procedures to require an additional post maintenance testing (PMT) review for large/complex modifications, as well as revision to applicable maintenance procedures to require verification for plugin type connections. The finding was determined to be greater than minor because it was associated with the equipment performance attribute of the initiating events cornerstone 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, this finding resulted in a reactor trip. Using IMC 0609, Significance Determination Process, Attachment 4, Phase 1 - Initial Screening and Characterization of Findings, the finding was determined to be of very low safety significance (Green) because although it did contribute to the likelihood of a reactor trip, it did not contribute to the likelihood that mitigating systems will not be available. The cause of this finding was determined to have a cross-cutting aspect of Work Planning, in the area of Human Performance associated with the Work Control component. The work planning processes failed to identify the need to include steps to verify the operational status of the controller following completion of the activity, considering the physical conditions and requirements associated with relocating the device. H.3(a). |
| Site: | Sequoyah  |
|---|---|
| Report | IR 05000327/2011002 Section 4OA3 |
| Date counted | Mar 31, 2011 (2011Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | R Rodriguez E Guthrie P Higgins C Young M Speck J Montgomery W Deschaine |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Sequoyah - IR 05000327/2011002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Sequoyah) @ 2011Q1
Self-Identified List (Sequoyah)
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