05000416/FIN-2009003-05
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Finding | |
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| Title | Failure to Respond to Control Room Alarms in Accordance with Plant Procedures |
| Description | A self-revealing noncited violation of Technical Specification 5.4.1(a) was reviewed involving a failure to follow the fire alarm response procedure during afire in the reactor feedwater pump area. The operators failed to investigate the source of a smoke alarm for an hour, allowing a fire to develop beyond the incipient stage before it was discovered. On November 17, 2008, a fire ignited in oil-soaked insulation on the reactor feedwater Pump B. After two weeks of plant operation following a refueling outage, during the November 17 shift turnover meeting, a fire alarm was received in the control room and was acknowledged by an operator. No notifications were made to the shift manager, and no operator or fire brigade member was dispatched. One hour after shift turnover, during normal operator rounds the turbine building operator discovered the fire in the reactor feedwater pump room. The fire brigade was dispatched to extinguish the fire. The licensee entered this condition in the corrective action program as condition report CR-GGN-2008-06584.The finding was more than minor because it was associated with the initiating events cornerstone attribute of human performance and affected the associated cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. The finding was assessed by performing a bounding analysis using Appendix M of Inspection Manual Chapter 0609. The bounding analysis indicated that the change in core damage frequency would be 4.24 x 10-7 over a 1-yearassessment period, indicating that this finding was of very low safety significance. This finding has a crosscutting aspect in the area of human performance with a work practices component for failure to use proper self-checking techniques commensurate with the risk of the assigned task to ensure the work is performed safely because operators failed to use self-checking techniques when acknowledging the reactor feedwater pump fire alarm |
| Site: | Grand Gulf  |
|---|---|
| Report | IR 05000416/2009003 Section 4OA3 |
| Date counted | Jun 30, 2009 (2009Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | R Smith A Barrett G Miller B Correll |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Grand Gulf - IR 05000416/2009003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Grand Gulf) @ 2009Q2
Self-Identified List (Grand Gulf)
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