05000335/FIN-2009003-02
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Finding | |
|---|---|
| Title | Failure to Follow Procedure When Placing Shutdown Cooling In-Service |
| Description | A self-revealing NCV of Technical Specification (TS) 6.8.1.a and Regulatory Guide (RG) 1.33 was identified for the licensee failing to implement a written procedure for general plant operations. The normal operating procedure 2-NOP-03.05, Shutdown Cooling, was not implemented as written when drain valve V7207was mistakenly closed by a non-licensed building operator when it was required to be open when placing the A shutdown cooling train in service. Specifically, the closing of valve V7207 removed a required drain path for known valve seat leakage past containment spray boundary valve 2-MV-07-03 which resulted in unplanned adjacent intersystem leakage into the containment spray system from the reactor coolant system. This issue was entered in the licensees corrective action program as CR2009-15198.The finding was more than minor because it affected the Configuration Control attribute of the Initiating Events cornerstone and the valve misposition could be reasonably viewed as a precursor to a significant event. Using the NRC Manual Chapter 0609, A Significance Determination Process,@ Appendix G, Shutdown Operations Significance Determination Process, Checklist 3, the finding was determined to be of very low safety significance because Core Heat Removal, Inventory Control, Power Availability, Containment Control, and Reactivity Guidelines were all met. A contributing cause of the finding is related to the cross-cutting area of Human Performance, with a work practices component. Specifically, the operator failed to implement expected human error prevention techniques such as procedure place keeping and self-checking to ensure the valve was positioned properl |
| Site: | Saint Lucie  |
|---|---|
| Report | IR 05000335/2009003 Section 4OA2 |
| Date counted | Jun 30, 2009 (2009Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | A Nielsen G Kuzo L Lake R Aiello T Hoeg S Sanchez B Collins M Sykes D Forbes |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Saint Lucie - IR 05000335/2009003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Saint Lucie) @ 2009Q2
Self-Identified List (Saint Lucie)
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