05000528/FIN-2008003-02
From kanterella
Jump to navigation
Jump to search
Finding | |
|---|---|
| Title | Failure to Resolve Discrepancies Between Installed Equipment and Work Instructions Results in Mispositioning Event |
| Description | A self-revealing finding was identified for the failure of operations and maintenance personnel to follow Procedure 01DP-9ZZ01, \"Systematic Troubleshooting,\" and resolve a discrepancy with a work instruction prior to proceeding with troubleshooting. Specifically, maintenance and operations personnel did not resolve an error in Work Order 3174332 when troubleshooting Breaker NBN-S01A that failed to trip, resulting in a loss of the non-vital electrical bus that supplied power to the nuclear cooling water and normal chilled water systems. This issue was entered into the licensee\'s corrective action program as Palo Verde Action Request 3174647. The finding is greater than minor because it is associated with the initiating events cornerstone attribute of configuration control and affects the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown and power operations. Using the Manual Chapter 0609 Appendix G, \"Shutdown Operations Significance Determination Process,\" the finding is determined to have very low safety significance because the finding did not result in a loss of shutdown safety functions. This finding has a crosscutting aspect in the area of human performance associated with work practices because maintenance and operations personnel proceeded in the face of uncertainty or unexpected circumstances H.4(a) (Section 1R12.2) |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2008003 Section 1R12 |
| Date counted | Jun 30, 2008 (2008Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | G Apger G George G Miller J Adams J Bashore J Melfi J Razo L Ricketson M Catts M Hay P Elkmann R Treadway W Sifre |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
| ' | |
Finding - Palo Verde - IR 05000528/2008003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Finding List (Palo Verde) @ 2008Q2
Self-Identified List (Palo Verde)
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||