05000361/FIN-2009005-07
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Finding | |
|---|---|
| Title | Inadequate Circulating Water System Maintenance Procedures Contribute to Unit 2 Inadvertent Reactor Trip |
| Description | The inspectors identified a finding for the failure of maintenance personnel to use the standards described in Procedure SO23-XV-2, Troubleshooting Plant Equipment and Systems, in developing procedures and work plans to adequately perform, test, and communicate maintenance activities on Unit 2 circulating water gate 5. Specifically, from September 5 through September 13, 2009, maintenance personnel did not have adequate procedures in place to perform corrective maintenance on Unit 2 circulating water gate 5. The attempts to repair gate 5 were repeatedly unsuccessful due to inadequate planning, execution, postmaintenance testing, and communication. This finding was entered into the licensees corrective action program as Nuclear Notifications NNs 200580999 and 200718204. The finding is greater than minor because the performance deficiency was a precursor to a significant event (reactor trip). 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 control because maintenance personnel failed to incorporate actions to address the need for work groups to communicate, coordinate, and cooperate with each other during activities in which interdepartmental coordination is necessary to assure plant and human performance H.3(b) (Section 4OA3) |
| Site: | San Onofre  |
|---|---|
| Report | IR 05000361/2009005 Section 4OA3 |
| Date counted | Dec 31, 2009 (2009Q4) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | L Ricketson G Guerra R Lantz P Elkmann J Adams J Reynoso G Warnick C Osterholtz A Fairbanks M Bloodgood R Schmitt |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - San Onofre - IR 05000361/2009005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (San Onofre) @ 2009Q4
Self-Identified List (San Onofre)
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