05000528/FIN-2009003-04
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Finding | |
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Title | Inadvertent Decrease of Pressurizer Level Due to Personnel Error |
Description | A self-revealing noncited violation of Technical Specification 5.4.1(a), Procedures, was identified for the failure of operations personnel to follow procedural requirements during a planned plant startup. Specifically, on May 27,2009, operations personnel did not take actions to lower turbine load after synchronizing the generator to the offsite electrical distribution grid during cooldown, causing a pressurizer low level alarm and a loss of pressurizer heaters. This issue was entered into the licensee\'s corrective action program as Palo Verde Action Request 3336555.The finding is more than minor because it is associated with the human performance attribute of the Initiating Events Cornerstone 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 Manual Chapter 0609.04, Phase 1 Initial Screening and Characterization of Findings, the finding was determined to have a very low safety significance because the finding did not result in exceeding the technical specification limit for identified reactor coolant system leakage, did not affect other mitigation systems, did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available; and did not increase the likelihood of a fire or internal/external flood. This finding has a crosscutting aspect in the area of human performance associated with decision making because operations personnel failed to properly implement their roles in communicating between applicable operational personne |
Site: | Palo Verde ![]() |
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Report | IR 05000528/2009003 Section 1R20 |
Date counted | Jun 30, 2009 (2009Q2) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71111.2 |
Inspectors (proximate) | R Treadway L Carson J Adams J Melfi S Alferink M Young M Hay J Bashore M Catts P Jayroe S Hedger |
CCA | H.13, Consistent Process |
INPO aspect | DM.1 |
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Finding - Palo Verde - IR 05000528/2009003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2009Q2
Self-Identified List (Palo Verde)
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