05000327/FIN-2012007-01
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Finding | |
|---|---|
| Title | Reactor Trip Due to Improper Preferred Inverter Maintenance |
| Description | A self-revealing finding was identified for the licensees failure to properly implement work procedures during the performance of a preventive maintenance (PM) activity associated with the Unit 1 Preferred Inverter. The improper performance of selected steps with the system in an inappropriate configuration to support the activity caused an electrical transient and loss of the preferred power board which resulted in a turbine trip and automatic reactor trip. The licensee entered this issue into their corrective action program as PER 405141 and implemented corrective actions to include guidance for operations supervisory review of work documents prior to returning equipment to service. The inspectors reviewed IMC 0612, Appendix B and determined that the finding was more than minor because it adversely impacted the human performance attribute of the initiating events 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, it resulted in sudden closure of all main turbine governor valves from 100% power, which ultimately led to an automatic reactor trip. The inspectors reviewed IMC 0609, Attachment 4 and determined that the finding was of very low safety significance (Green) because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigating systems would not be available. This finding was determined to have a cross-cutting aspect in the area of human performance, the component of work control, and the aspect of work activity coordination, H.3(b), due to the failure to appropriately coordinate this work activity consistent with nuclear safety. Specifically, the necessary interdepartmental communication and coordination between operations and maintenance work groups was inadequate to assure proper performance and accomplishment of the work activity in accordance with the procedure, including establishing proper plant conditions to support the work activity as well as understanding the potential operational impact of the proposed maintenance. |
| Site: | Sequoyah  |
|---|---|
| Report | IR 05000327/2012007 Section 4OA3 |
| Date counted | Mar 31, 2012 (2012Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | S Shaeffer C Young R Clagg |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Sequoyah - IR 05000327/2012007 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Sequoyah) @ 2012Q1
Self-Identified List (Sequoyah)
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