05000361/FIN-2009002-07
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Finding | |
|---|---|
| Title | Failure to Follow Procedure for Aligning a Reactor Coolant System Ion Exchanger |
| Description | A self-revealing non-cited violation of Technical Specification 5.5.1.1 was identified for the failure of operations personnel to follow procedures to place Ion Exchanger ME074 in service which resulted in an interruption of letdown flow and diversion of approximately 160 gallons of reactor coolant to the radiological waste system. This finding was entered into the licensees corrective action program as Nuclear Notification 200319240. The finding is greater than minor because it is associated with the configuration control attribute of the Initiating Events Cornerstone and affects the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Using the Manual Chapter 0609, Significance Determination Process, Phase 1 Worksheets, the finding is determined to have very low safety significance because the finding 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 crosscutting aspect in the area of human performance associated with work practices because the licensee did not properly use human error prevention techniques H.4(a) |
| Site: | San Onofre  |
|---|---|
| Report | IR 05000361/2009002 Section 4OA3 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | P Elkman T Steadham J Reynoso G Warnick C Osterholtz M Hay |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - San Onofre - IR 05000361/2009002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (San Onofre) @ 2009Q1
Self-Identified List (San Onofre)
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