05000416/FIN-2010002-02
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Finding | |
|---|---|
| Title | Failure to Follow Work Instructions Results in Loss of Buss and a Plant Transient |
| Description | The inspectors reviewed a self-revealing finding for a failure to follow work instructions resulting a in loss of 480V power to a bus and a plant transient. Specifically, contract workers were directed by work instructions to enter into a motor control center via its top cable tray to run cables to a spare breaker. Contrary to this, the contract electrical workers deviated from approved work instructions, causing a phase to ground short that tripped the motor control center and resulted in a plant transient. The licensee entered this issue into the corrective action program as Condition Report CR-GGN-2010-01404. This finding is more than minor because it was associated with the initiating events cornerstone attribute of human performance, and it affected the associated cornerstone objective to limit the likelihood of those events that upset plant stability and that challenge critical safety functions during shutdown, as well as during power operations. Using the Inspection Manual Chapter 0609, Significance Determination Process, Phase 1 Worksheet, the inspectors concluded that the transient initiator did not contribute to both the likelihood of a reactor trip and to the likelihood that mitigation equipment or functions would not be available. As a result, the issue was of very low safety significance (Green). The cause of this finding has a crosscutting aspect in the area of human performance associated with work practices because the supervisor of the workers failed to ensure the contract workers followed the approved work instructions as require |
| Site: | Grand Gulf  |
|---|---|
| Report | IR 05000416/2010002 Section 4OA3 |
| Date counted | Mar 31, 2010 (2010Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | G Guerra R Smith A Barrett W Sifre M Young V Gaddy B Rice |
| CCA | H.2, Field Presence |
| INPO aspect | LA.2 |
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Finding - Grand Gulf - IR 05000416/2010002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Grand Gulf) @ 2010Q1
Self-Identified List (Grand Gulf)
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