05000382/FIN-2011003-04
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Finding | |
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| Title | Failure to Implement Work Order Instructions to Restore a Feedwater Heater Drain Valve |
| Description | A self-revealing finding occurred because maintenance technicians did not follow written procedures during the calibration of a level switch that controls feedwater heater drain valve FHD703A. Specifically, the technicians did not perform concurrent verification checks as required by documented work order instructions (WO-00180716) and procedures to ensure that personnel restore and/or manipulate components to the correct position following maintenance. As a result, the feedwater heater drain valve was left in a closed position, which caused a spurious isolation of a string of feedwater heaters. The isolation of the feedwater heaters caused operators to down power the reactor to approximately 72 percent. The licensee entered this issue into their corrective action program for resolution as CR-WF3-2009-7420. The immediate corrective actions included restoring the feedwater heater drain valve to its proper position. The finding was more than minor because it was associated with the human performance attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the human error caused an event that upset plant stability during power operation. The inspectors evaluated this finding using Inspection Manual Chapter 0609 Attachment 4, Phase 1 Initial Screening and Characterization of Findings. The inspectors determined that the finding was of very low safety significance (Green) because it 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 had a crosscutting aspect in the work practices component of the human performance area because the licensees personnel proceeded in the face of uncertainty or unexpected circumstances. |
| Site: | Waterford  |
|---|---|
| Report | IR 05000382/2011003 Section 4OA2 |
| Date counted | Jun 30, 2011 (2011Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | D Overland S Makor N Greene C Smith P Elkmann M Davis L Carson R Azua |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Waterford - IR 05000382/2011003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Waterford) @ 2011Q2
Self-Identified List (Waterford)
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