05000400/FIN-2010003-01
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Finding | |
|---|---|
| Title | Failure to Follow Procedure to Install the Load Block 5 Auxiliary Relay |
| Description | A self-revealing Green NCV of TS 6.8.1, Procedures, was identified for the licensees failure to follow procedure PIC-E069, Sequencer Electomechanical Timing Relays; D.C. Pick-Up, D.C. Drop-Out, A.C. Pick-Up, and A.C. Drop-Out. Specifically, the licensee failed to properly reinstall the Load Block 5 Auxiliary Relay, resulting in the automatic start of B Motor Driven Auxiliary Feedwater (MDAFW) pump and water flowing to all three steam generators. Operators immediately secured the B MDAFW pump. The licensee entered this issue into their corrective action program (CAP) as action request (AR) #381672. As corrective action, the licensee removed and correctly installed the relay followed by a successful post maintenance test. Additionally, the licensee plans to revise ADM-NGGC-0104, Work Management Process, to require the work implementer to specify which mitigating actions and/or human performance barriers will be used for critical steps. The failure to follow procedure PIC-E069 section 7.6 for the restoration of the load block 5 auxiliary relay was a performance deficiency. The violation was more than minor because it is associated with the procedure quality attribute of the Mitigating Systems cornerstone, and it affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, it resulted in the automatic start of the B MDAFW pump and water flowing to all three steam generators. Using IMC 0609, Significance Determination Process, Phase 1 screening worksheet of the SDP this finding was determined to be of very low safety significance because it was not a design or qualification deficiency confirmed to result in a loss of operability or functionality, did not represent a loss of system safety function, did not result in a loss of safety system function for a single train for greater than TS allowed outage time, did not result in a loss of safety function of one or more non-TS trains of equipment designated as risk-significant for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, and did not screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. The finding has a cross-cutting aspect of Human error prevention, as described in the Work Practices component of the Human Performance cross-cutting area because the licensee did not apply sufficient human error prevention tools to ensure the correct installation of the relay (H.4(a)) |
| Site: | Harris  |
|---|---|
| Report | IR 05000400/2010003 Section 1R19 |
| Date counted | Jun 30, 2010 (2010Q2) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.19 |
| Inspectors (proximate) | R Hamilton J Austin R Musser C Fletcher P Lessard |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Harris - IR 05000400/2010003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Harris) @ 2010Q2
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