05000389/FIN-2009002-04
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Finding | |
|---|---|
| Title | Failure to Implement Adequate Process Controls during Maintenance Activities Resulted in a Manual Reactor Trip |
| Description | A self-revealing finding was identified for failure to implement adequate process controls to minimize risk during maintenance on the Unit 2, 5B feedwater heater high level limit switch resulting in a manual reactor trip on June 4, 2008. No violations of NRC requirements were identified because the feedwater heater drain system is nonsafety related. The licensee entered the issue into the corrective action program as condition report (CR) 2008-18858. Corrective actions included development of specific procedural direction for controlling and insulating energized control circuit leads during work evolutions using the risk management process, design modifications to address vulnerability when performing maintenance on level switches, and evaluation of industry best practices for training and handling of energized leads. The finding was more than minor because it resulted in a manual reactor trip. The finding was associated with the human performance attribute and affected the Initiating Events cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as at power operations. Using the NRC Manual Chapter 0609, ASignificance Determination Process,@ Attachment 609.04, Phase 1 screening worksheet, the finding was determined to be of very low safety significance because it was a transient initiator but did not increase the likelihood that mitigation equipment would not be available. The cause of the finding is related to the cross-cutting area of Human Performance, with a work control component. Specifically, the licensee did not adequately plan work activities to minimize the risk of grounding the energized leads (H.3(a)) |
| Site: | Saint Lucie  |
|---|---|
| Report | IR 05000389/2009002 Section 4OA3 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | M Sykes R Bernhard S Ninh S Sanchez T Hoeg |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Saint Lucie - IR 05000389/2009002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Saint Lucie) @ 2009Q1
Self-Identified List (Saint Lucie)
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