05000528/FIN-2008003-03
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Finding | |
|---|---|
| Title | Inadvertent Decrease in Reactor Water Level Due to Personnel Error |
| Description | A self-revealing noncited violation of Technical Specification 5.4.1, \"Procedures,\" was identified for the failure of operations personnel to adequately implement Procedure 40DP-9OP19, \"Locked Valve, Breaker, and Component Tracking.\" Specifically, on May 14, 2008, Valve SIA-V421 was found out of its locked closed position one and one-half turns open resulting in approximately 930 gallons of water being inadvertently transferred from the reactor coolant system to the refueling storage water tank. This issue has been entered into the licensee\'s corrective action program as Palo Verde Action Request 3174527. The failure to ensure the valve was properly closed resulted in an inadvertent reactor vessel level decrease. The finding is more than minor because it is associated with the configuration control attribute of the initiating events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown operations. A Phase 2 analysis was required because using Manual Chapter 0609, Appendix G, \"Shutdown Operations Significance Determination Process,\" Attachment 1, the inspectors determined that the finding actually resulted in a loss of reactor coolant system inventory. Using the Phase 2 worksheets in Attachment 2, this was determined to be a loss of level control precursor event. The initiating event likelihood for this finding was determined from Table 1 of the worksheet and the resultant core damage frequency was determined to be 1E-8, therefore the finding screened as having very low safety significance. The finding has a crosscutting aspect in the area of human performance associated with work practices because the licensee failed to use human error prevention techniques such as self-checking H.4(a) (Section 1R22) |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2008003 Section 1R22 |
| Date counted | Jun 30, 2008 (2008Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.22 |
| 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 |
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Finding - Palo Verde - IR 05000528/2008003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2008Q2
Self-Identified List (Palo Verde)
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