05000456/FIN-2009005-03
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Finding | |
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| Title | Failure to Follow Work Instructions During Restoration of 2SX173 |
| Description | A Green finding and an associated Non-Cited Violation of Technical Specification 5.4.1 was self-revealed for the failure to follow procedures during the restoration of the essential service water supply valve to the engine driven cooling water pump for the 2B auxiliary feedwater pump (2SX173) following scheduled maintenance. This issue resulted in a water hammer occurring in the essential service water system. The licensee walked down the system to ensure that the essential service water system was not damaged. Additionally, the licensee developed training actions to emphasize procedural adherence. The inspectors determined the finding was more than minor because it impacted the Human Error attribute of the Mitigating System Cornerstone to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). The inspectors performed a significance evaluation in accordance with IMC 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Operational Checklist for both PWRs and BWRs Checklist 4, and determined that the finding did not increase the likelihood of a loss of RCS inventory, degrade the licensees ability to terminate a leak path or add inventory, or degrade the licensees ability to recover decay heat removal) DHR once it is lost, therefore the issue screened as one of very low safety significance (Green). This finding has a cross-cutting aspect in the area of Human Performance, because the work supervisor did not make safety-significant or risk-significant decisions using a systematic process, especially when faced with uncertain or unexpected plant conditions, to ensure safety is maintained (H.1(a)). The supervisor did not seek further guidance surrounding the observed conditions upon arrival at the work site |
| Site: | Braidwood  |
|---|---|
| Report | IR 05000456/2009005 Section 1R15 |
| Date counted | Dec 31, 2009 (2009Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.15 |
| Inspectors (proximate) | A Garmoe B Dickson B Metrow B Palagi J Gall M Holmberg M Mitchell M Perry R Jickling R Ng R Skokowski |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Braidwood - IR 05000456/2009005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Braidwood) @ 2009Q4
Self-Identified List (Braidwood)
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