05000528/FIN-2012002-02
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Finding | |
|---|---|
| Title | Failure to Assess and Manage Risk Prior to Troubleshooting on 4.16 kV Bus Supply Breaker Hand Switch |
| Description | The inspectors reviewed a self-revealing non-cited violation of 10 CFR 50.65a(4), for the licensees failure to assess and manage an increase in risk prior to planned maintenance activities. Specifically, on January 25, 2012, the licensee failed to include the potential to deenergize a 4.16 kV bus when working on a control room hand switch in the risk assessment for Unit 2, resulting in an unplanned reactor power cutback. The licensee plans to revise procedures, as a corrective action, to develop and implement a structured operational risk assessment process for use by the senior reactor operator when authorizing un-scheduled work to commence in the field. The licensee entered this issue into the corrective action program as Palo Verde Action Request (PVAR) 4036588. The licensees failure to assess and manage an increase in risk prior to planned maintenance activities was a performance deficiency. The performance deficiency is more than minor, and therefore a finding, because it affects the equipment performance attribute of the Initiating Events Cornerstone and its objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Because the licensee utilizes a qualitative risk assessment for these maintenance activities, Manual Chapter 0609, Appendix K, Maintenance Risk Assessment and Risk Management Significance Determination Process, Flowchart 2, could not be used to determine the risk significance of the finding. Using the qualitative review process of Manual Chapter 0609, Appendix M, Significance Determination Process Using Qualitative Criteria, the finding is determined to have very low safety significance (Green) because it did not result in any additional loss of defense in depth systems, and an assessment by the senior reactor analyst determined the increase in risk due to the initiating event was very small. This finding had a cross-cutting aspect in the area of human performance associated with the resources component because the licensee failed to ensure complete and accurate procedures and work packages are adequate to assure nuclear safety |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2012002 Section 1R13 |
| Date counted | Mar 31, 2012 (2012Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | G Guerra R Lantz M Brown E Uribe M Baquera D Reinert S Hedger D Bradley |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Palo Verde - IR 05000528/2012002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2012Q1
Self-Identified List (Palo Verde)
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