05000397/FIN-2009004-02
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Finding | |
|---|---|
| Title | Failure to Perform Back-up Monitoring |
| Description | The inspectors reviewed a self-revealing finding for the failure of Energy Northwest to implement the standards and guidance provided in Operations Instruction OI-09, Operations Standards and Expectations, Revision 24. As a result, an operator failed to ensure that the turbine lube oil exhauster system was adjusted to within its normal operating band after valve manipulations to clear an alarm in the control room. This resulted in a loss of an air-to-oil seal within the main turbine, which ultimately led to a manual plant scram. This finding is more than minor because it affected the human performance attribute of the initiating events cornerstones objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. This finding was determined to be of very low safety significance (Green) due to not contributing to both the likelihood of a reactor trip and the likelihood of mitigation equipment or functions not being available. A cross cutting aspect in human performance was identified with a work control component because Energy Northwest failed to incorporate actions to address plant conditions that may affect work activities H.3(b) |
| Site: | Columbia  |
|---|---|
| Report | IR 05000397/2009004 Section 4OA3 |
| Date counted | Sep 30, 2009 (2009Q3) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | E Uribe J Bashore M Hayes R Cohen W Walker |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Columbia - IR 05000397/2009004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Columbia) @ 2009Q3
Self-Identified List (Columbia)
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