05000528/FIN-2010002-02
From kanterella
Jump to navigation
Jump to search
Finding | |
|---|---|
| Title | Mispositioning of Valve Renders Essential Chiller Inoperable |
| 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, between December 24, 2009 and January 26, 2010, refrigerant head pressure bypass control valve 2-EWBV-349 was in the locked open position as opposed to its required position of locked closed. This issue has been entered into the licensee\'s corrective action program as Palo Verde Action Request 3430116 which included corrective actions to train operations personnel on the requirements for independent verification. The finding is more than minor because it is associated with the configuration control attribute of the Mitigating Systems cornerstone and affected the cornerstone objective of ensuring the reliability and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Using Manual Chapter 0609.04, Phase 1 Initial Screening and Characterization of Findings, the finding was determined to require a Phase 2and Phase 3 analysis by a senior reactor analyst, because the finding resulted in an actual loss of safety function of a single train for greater than its technical specification allowed outage time. A senior reactor analyst performed abounding Phase 3 significance determination and found the finding to be of very low safety significance (Green) because the dominant core damage sequences only included a failure of multiple auxiliary feedwater pumps and because the chiller was only inoperable for a narrow range of initiating events. The finding has a cross-cutting aspect in the area of Human Performance associated with work practices because the licensee failed to use human error prevention techniques such as self and peer checking commensurate with the risk of the assigned task |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2010002 Section 1R15 |
| Date counted | Mar 31, 2010 (2010Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.15 |
| Inspectors (proximate) | M Catts M Baquera G Guerra R Lantz R Treadway L Carson J Bashore |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
| ' | |
Finding - Palo Verde - IR 05000528/2010002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Finding List (Palo Verde) @ 2010Q1
Self-Identified List (Palo Verde)
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||