05000440/FIN-2009002-06
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Finding | |
|---|---|
| Title | Maintenance on HPCS System resulted in Emergency Operating Procedure Entry |
| Description | A finding of very low safety significance and associated NCV of Technical Specification Section 5.4.1 was self-revealed on February 3, 2009, when the control room received an unexpected high pressure core spray (HPCS) pump room sump level high alarm and entered Emergency Operating Procedure (EOP) 3, Secondary Containment Control. The licensee did not properly control a maintenance activity on the HPCS system resulting in unexpected water spray in the HPCS pump room. As part of their immediate corrective actions, licensee personnel recovered from the drain down of the system and entered the issue into their corrective action program. This finding was considered more than minor because it was associated with the human performance attribute of the Initiating Events cornerstone and adversely affected the cornerstone objective of limiting the likelihood of events that upset plant stability. The event challenged shutdown operations as operators entered the EOP and responded to reports of significant water spray entering the pump room. The finding was determined, through an SDP analysis, to be of very low safety significance as no mitigation equipment or functions were affected. The primary cause of this finding was related to the cross-cutting aspect in the area of Human Performance per IMC 0305 H.3(a)because the organization failed to appropriately plan work activities that impact plant structures and systems, and failed to ensure appropriate contingencies were in place to perform a maintenance activity |
| Site: | Perry  |
|---|---|
| Report | IR 05000440/2009002 Section 4OA3 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | M Munir M Wilk J Robbins J Cassidy G Hausman T Bilik M Phalen G Wright M Franke R Leidy J Cameron |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Perry - IR 05000440/2009002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2009Q1
Self-Identified List (Perry)
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