05000346/FIN-2012004-01
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Finding | |
|---|---|
| Title | Operator Error Restoring Essential MCC to Service Renders TS Equipment Inoperable |
| Description | A self-revealed finding of very low safety significance and an associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, were identified for the licensees failure to properly implement the procedure for restoring power to motor control center (MCC) E16B. Specifically, the operator repositioned circuit breakers at the incorrect MCC, inadvertently removing power from plant equipment supplied by MCC E16A and causing an unplanned entry into Technical Specification (TS) Limiting Condition for Operation (LCO) 3.3.15, Condition A, for an inoperable channel of station vent normal range radiation monitoring. As an immediate corrective action, the operating crew performed steps to restore the unintentionally lost loads associated with MCC E16A and exited LCO 3.3.15 Condition A in a timely manner. This finding was associated with the Barrier Integrity Cornerstone because a high radiation level in the station vent, as measured by the radiation monitors, is used to detect a potential threat to control room personnel and automatically isolate the control room normal ventilation system. The inspectors determined that the finding was more than minor because, if left uncorrected, the failure to follow plant procedures and the mispositioning of plant equipment would have the potential to lead to a more significant safety concern. The inspectors evaluated the finding using IMC 0609, Appendix A, the Significance Determination Process for Findings At-Power. The inspectors used Exhibit 2 Barrier Integrity Screening Questions for the Control Room, Auxiliary, Reactor, or Spent Fuel Pool Building. The finding screened as very low safety significance (Green) because it only represented a degradation of the radiological barrier function provided for the control room. The finding had a cross-cutting aspect in the area of human performance, work practices component, because personnel failed to use human error prevention techniques to ensure that work was performed safely. |
| Site: | Davis Besse  |
|---|---|
| Report | IR 05000346/2012004 Section 1R13 |
| Date counted | Sep 30, 2012 (2012Q3) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | J Neurauter A Wilson D Kimble J Bozga J Cameron T Briley |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Davis Besse - IR 05000346/2012004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Davis Besse) @ 2012Q3
Self-Identified List (Davis Besse)
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