05000440/FIN-2009003-09
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Finding | |
|---|---|
| Title | Loss of Shutdown Cooling Water Flow to Reactor Vessel |
| Description | A finding of very low safety significance and associated NCV of 10 CFR Part 50,Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed when technicians performed maintenance on protected equipment without implementing risk management techniques specified in station procedures. This resulted in a loss of shutdown cooling flow to the reactor coolant system. Specifically, the licensee established Normal Operating Procedure NOP-OP-1005, Shutdown Defense in Depth, Revision 10, as the implementing procedure to manage risk during shutdown conditions. The licensee failed to implement the significant risk management actions prescribed in procedure NOP-OP-1005 for maintenance on protected equipment. This resulted in a blown fuse in the reactor protection system causing a loss of shutdown cooling flow to the reactor coolant system. The licensee replaced the fuse and restored shutdown cooling. This issue was entered into the corrective action program as CR 09-58110.The finding was more than minor because it was associated with the equipment performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the finding resulted in a loss of reactor decay heat removal event while the reactor was shutdown. Using IMC 0609, Appendix G, Shutdown Operation Significance Determination Process, Checklist 8, the inspectors determined that the finding did not require a Phase 2 or Phase 3 analysis because the plant had appropriately met the safety function guidelines for core heat removal, inventory control, power availability, containment integrity, and reactivity control. The issue did not need a quantitative assessment and screened as having very low safety significance using Figure 1. This finding has a cross-cutting aspect in the area of human performance, work control, per IMC 0305 H.3(a), because the licensee did not appropriately plan the work activity consistent with nuclear safety, incorporating risk insights, job site conditions, or the need for planned contingencies, compensatory actions, and abort criteria |
| Site: | Perry  |
|---|---|
| Report | IR 05000440/2009003 Section 4OA3 |
| Date counted | Jun 30, 2009 (2009Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | M Wilk M Marshfield M Phalen D Jones M Franke J Bashore R Leidy J Cameron R Murray C Tilton J Coroju-Sandin |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Perry - IR 05000440/2009003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2009Q2
Self-Identified List (Perry)
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