05000528/FIN-2009004-03
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Finding | |
|---|---|
| Title | Failure to Follow Procedures Results in Loss of Ventilation to Safety-Related Equipment |
| Description | A self-revealing noncited violation of Technical Specification 5.4.1.a, Procedures, was identified for failure of fire protection personnel to adequately implement a functional test procedure. Specifically, on September 21, 2009, fire protection personnel failed to correctly implement procedural steps resulting in the inadvertent actuation of fire dampers in the Unit 1 control building ventilation system during functionality testing of the CO2 fire suppression system. This issue was entered into the licensee corrective action program as Palo Verde Action Request 3381290.The finding is more than minor because it is associated with the human performance attribute of the mitigating systems cornerstone and affects the cornerstone objective of ensuring the reliability, availability and capability of systems that respond to initiating events to prevent undesirable consequences. 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 a loss of system safety function, an actual loss of safety function of a single train for greater than its technical specification allowed outage time, or screen as potentially risk significant due to a seismic, flooding, or severe weather initiating event. This finding has a crosscutting aspect in the area of human performance associated with work practices because work control activities did not use human error prevention techniques, such as self-checking or peer-checking, so that work activities are performed safely H.4(a |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2009004 Section 4OA3 |
| Date counted | Sep 30, 2009 (2009Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | R Treadway J Melfi M Hay J Bashore M Catts |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Palo Verde - IR 05000528/2009004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2009Q3
Self-Identified List (Palo Verde)
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