05000440/FIN-2008004-07
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Finding | |
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| Title | Loss of Configuration Control of the Hydrogen Water Chemistry Injection System Resulting in High Radiation Levels (Section 4OA3.3) |
| Description | Green. A finding of very low safety significance was self-revealed on June 28, 2008,when high radiation alarms for all four main steam lines were received in the controlroom during a plant power maneuver. Specifically, maintenance technicians failed toadhere to procedures and manipulated a hydrogen water chemistry control system whileperforming a surveillance test associated with the plant off-gas system. The off-gassystem surveillance test procedure did not address operation of the hydrogen waterchemistry control system and the technicians were not trained to operate the system.As part of their immediate corrective actions, the licensee corrected the system lineup toreduce radiation levels and entered the issue into their corrective action program.This finding was considered more than minor because the manipulation of plant systemsthat are different from those specified in the authorized work procedure would become amore significant safety concern if left uncorrected. In this case, the finding led to anunexpected increase in radiation levels in areas accessible to plant personnel and wasassociated with the operating equipment lineup of the configuration control attribute ofthe Initiating Events Cornerstone and adversely affected the cornerstone objective oflimiting the likelihood of events that upset plant stability. The finding was determinedthrough a SDP analysis to be of very low safety significance as no mitigation equipmentor functions were affected and no actual increase in personnel exposure occurred. Thisfinding has a cross-cutting aspect in the area of Human Performance as defined inIMC 0305 H.4(b), because the organization failed to ensure that personnel do notproceed with a task in the face of uncertainty. No violation of NRC requirementsoccurred. (Section 4OA3.3 |
| Site: | Perry  |
|---|---|
| Report | IR 05000440/2008004 Section 4OA3 |
| Date counted | Sep 30, 2008 (2008Q3) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | M Wilk J Robbins D Reeser M Phalen R Baker M Franke T Taylor J Cameron R Murray |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Perry - IR 05000440/2008004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2008Q3
Self-Identified List (Perry)
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