05000440/FIN-2009004-02
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Finding | |
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Title | Maintenance Errors Cause Loss of Division I ECCS Electical Powers |
Description | A finding of very low safety significance (Green) and associated non-cited violation of Technical Specification 5.4.1 was self-revealed when the licensee failed to follow Nuclear Operating Procedure (NOP)-WM-3001; Work Management PM Processes. Specifically, step 4.5.5 of NOP-WM-3001 states, If a General Nuclear Preventative Maintenance (GNPM) Order cannot be completed as planned due to ... replacement of a failed or degraded component, then the MWC Supervisor shall take appropriate actions in accordance with the flow diagram in Attachment 6 ... During the performance of work order 200297036, for safety related 480-V breaker EF1A03, the supervisor directed a 4-point switch be replaced as part of the work order; however, no evaluation of the change in scope was completed and a CR was not written as required by Attachment 6 of NOP-WM-3001. The failure to evaluate the replacement lead to the loss of power to a number of safety related components. The licensee entered this item into their corrective action program as CR 09-63681. The licensees immediate action included entry into the appropriate technical specifications, restoration of the lost electrical power bus and restoration of emergency core cooling systems which were made inoperable as a result of the power loss. The finding was determined to be more than minor because the finding was associated with the Mitigating Systems cornerstone attribute of human performance and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, the inadequate work planning caused a loss of electrical power to bus EF-1-A, the safety-related 480 V power supply to Division 1 components placing the plant in an orange probabilistic safety analysis risk condition. The inspectors determined the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, Table 2, the inspectors determined that core decay heat removal was degraded. Using Table 4a, Characterization Worksheet for IE, MS, and BI Cornerstones, the inspectors assessed the finding as having very low safety significance (Green) because no loss of safety system function occurred and no loss of function of a single train occurred for greater than its TS-allowed outage time. This finding has a cross-cutting aspect in the area of human performance, work control per IMC 0609 H.3(b) because the licensee did not plan and coordinate work activities consistent with nuclear safety. Specifically, licensee personnel failed to plan and coordinate the replacement of an auxiliary switch in breaker EF1A03 thereby not incorporating the impact of the changes to the work scope or activity on the plant and human performance |
Site: | Perry ![]() |
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Report | IR 05000440/2009004 Section 4OA3 |
Date counted | Sep 30, 2009 (2009Q3) |
Type: | NCV: Green |
cornerstone | Mitigating Systems |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71153 |
Inspectors (proximate) | M Munir M Marshfield M Phalen G Wright J Bashore J Cameron P Voss R Murray |
CCA | H.5, Work Management |
INPO aspect | WP.1 |
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Finding - Perry - IR 05000440/2009004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Perry) @ 2009Q3
Self-Identified List (Perry)
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