05000361/FIN-2011003-03
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Finding | |
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Title | Failure to Appropriately Assess and Manage Risk for Work in Unit 3 Intake |
Description | A self-revealing noncited violation of 10 CFR 50.65(a)(4), Requirements for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants, was identified for the failure of work control and operations personnel to adequately assess and manage the increase in risk associated with maintenance on the Unit 3 fish elevator. Specifically, on March 29, 2011, a stop log was installed in the Unit 3 intake structure without informing the Unit 2 control room operators or establishing measures to maintain adequate Unit 2 saltwater flow to ensure the operability of the component cooling water system. Immediate corrective actions included verifying and monitoring Unit 2 train A component cooling water operability and taking actions to restore saltwater cooling flow and component cooling water/saltwater cooling heat exchanger differential pressure to normal. This issue was entered into the licensees corrective action program as Nuclear Notification NN 201395115. The performance deficiency is more than minor and therefore a finding because it is associated with the operating equipment configuration control attribute of the Mitigating Systems Cornerstone and affects the associated cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Using Manual Chapter 0609, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process, Flowcharts 1 and 2, the finding was determined to have very low safety significance because the incremental core damage probability deficit was less than 1E-6 and the incremental large early release probability deficit was less than 1E-7. This finding has a cross-cutting aspect in the area of human performance associated with the decision-making component because work control and operations personnel did not communicate decisions and the basis for decisions to individuals that needed to know the information in order to perform work safely and take appropriate risk management actions. |
Site: | San Onofre |
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Report | IR 05000361/2011003 Section 1R13 |
Date counted | Jun 30, 2011 (2011Q2) |
Type: | NCV: Green |
cornerstone | Mitigating Systems |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71111.13 |
Inspectors (proximate) | C Alldredge C Osterholtz E Uribe G Guerra G Warnick J Reynoso J Tapp J Watkins N Greene P Elkmann R Lantz S Achen S Hedger Z Hollcraft |
CCA | H.10, Bases for Decisions |
INPO aspect | CO.2 |
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Finding - San Onofre - IR 05000361/2011003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (San Onofre) @ 2011Q2
Self-Identified List (San Onofre)
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