05000483/FIN-2008005-05
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Finding | |
|---|---|
| Title | Failure to Adequately Implement Plant Equipment Control Tagout Procedure |
| Description | The inspectors identified a self-revealing noncited violation of Technical Specification 5.4.1.a, Procedures, after improper restoration of the essential service water supply to the emergency diesel generator Train A lubricating oil cooler resulted in significant water flow into the emergency diesel room on October 22, 2008. Two restoration evolutions associated with the essential service water and the emergency diesel generator systems had been proceeding in parallel. The reactor operator restoring the emergency diesel generator assumed the essential service water supply was to remain isolated to the emergency diesel generator and thus changed the already approved worker protection assurance Clearance 71899 to leave the oil cooler drain valve open with no tag. Starting the essential service water pump pressurized the drain valve and produced significant water spray flow into the emergency diesel generator room until noticed by a diesel vendor representative about 30 minutes later. This finding was greater than minor because if left uncorrected the deficiencies could become a more significant safety concern. The finding affected the Mitigating Systems cornerstone. Using Manual Chapter 0609.04, Phase 1 - Initial Screening and Characterization of Findings,\" this finding is determined to be of very low safety significance since this finding was not a design or qualification deficiency, did not represent a loss of system or train safety function and did not screen as potentially risk significant due to a flooding initiating event using the criteria on the characterization worksheet. This finding had a crosscutting aspect in the area of human performance associated with the work practices component because the licensee\'s pre-job briefing, self- and peer-checking, and proper documentation of activity were inadequate to overcome worker protection assurance clearance process problems and an inexperienced operating supervisor. These less than adequate worker practices resulted in personnel proceeding in the face of uncertainty H.4(a) (Section 1R20) |
| Site: | Callaway  |
|---|---|
| Report | IR 05000483/2008005 Section 1R20 |
| Date counted | Dec 31, 2008 (2008Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | L Ricketson D Dumbacher R Kopriva D Stearns J Adams V Gaddy J Groom |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Callaway - IR 05000483/2008005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Callaway) @ 2008Q4
Self-Identified List (Callaway)
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