05000445/FIN-2014003-08
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Finding | |
|---|---|
| Title | Failure to Follow Procedure to Provide Adequate Work Instructions |
| Description | The inspectors reviewed a self-revealing finding for the failure to properly plan and review work activities to ensure equipment and personnel safety. Specifically, the licensee failed to ensure the work instructions met the requirements of Procedure STA-606, Control of Maintenance and Work Activities, Revision 32. As a result, during the implementation of a modification, personnel used an inadequate work instruction and cut the incorrect cable which caused a loss of all offsite power to the safety-related 6.9 kV busses on both units. The licensee suspended the modification activities, repaired the damaged offsite power cable, and restored offsite power to the safety-related 6.9 kV busses. The licensee entered the finding into the corrective action program as Condition Report CR-2013-012287. The failure to follow procedure and provide adequate work instructions was a performance deficiency. The performance deficiency was more than minor because it was associated with the procedure quality attribute of the Initiating Events Cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Using Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings, and Appendix A, Exhibit 1, Initiating Event Screening Questions, the finding was determined to be of very low safety significance (Green) because although the finding involved the complete loss of a support system that caused an initiating event, it did not involve the loss of affected mitigation equipment. The finding has a human performance cross-cutting aspect associated with avoiding complacency because the licensee failed to ensure that work planning personnel planned for the possibility of mistakes and latent issues and did not implement appropriate error reduction tools [H.12]. |
| Site: | Comanche Peak  |
|---|---|
| Report | IR 05000445/2014003 Section 4OA3 |
| Date counted | Jun 30, 2014 (2014Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | D Proulx G Guerra J Kramer J Watkins L Brandt L Carson N Greene R Kumana S Alferink W Sifre W Walker |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Comanche Peak - IR 05000445/2014003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Comanche Peak) @ 2014Q2
Self-Identified List (Comanche Peak)
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