ML042080167
| ML042080167 | |
| Person / Time | |
|---|---|
| Site: | Vermont Yankee File:NorthStar Vermont Yankee icon.png |
| Issue date: | 04/24/2004 |
| From: | Thayer J Vermont Yankee |
| To: | Office of Nuclear Reactor Regulation, Vermont Yankee |
| References | |
| FOIA/PA-2004-0267 | |
| Download: ML042080167 (2) | |
Text
SY n B
Sienel, Beth From:
Sent:
To:
Subject:
Thayer, Jay Saturday, April 24, 2004 2:39 PM VTY - All Users Yellow Memo Please review the attached Yellow memo describing a significant human performance error. As we complete the final reassembly of the plant and restore systems; communication, coordination, and accurate handoffs and turnovers are the tools that will help ensure our safetyl
- Thanks, Jay 2004Yellow moRWCU.doc (39 K]
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k April 24, 2004 Memorandum:
Vermont Yankee Personnel From:
Jay Thayer-Site VP 4
Subject:
Start of RWCU pump without a suction path The Event:
Condition Reports 2004-1398 and 2004-1428 were written to document the inability to establish RWCU system flow after the RWCU pump was started on 04/22/04 and then again on 04/23/04.
The problem was that the system suction valves in the RWCU pump room and drywell were left closed after a Local Leak Rate Test (LLRT). The test line-up was not restored in anticipation of an additional as-left LLRT that wvas subsequently cancelled.
What went right?
Accurate procedure place keeping of the test procedure clearly indicated the valve line up status for the RWCU pumps. This assisted in quickly identifying the cause of the event.
What went wrong?
- A system was -left in a test line up, however other work delayed the test from being completed as originally scheduled.
HU TRAP - TASK INTERUPTION IV;
- Several shifts passed with the system in the test line up. Test tags typically used to alert operators to the unusual line up were not in place.
- HU TRAP - VAGUE GUIDANCE M
What's the message?
- These events indicate a breakdown in the use of our HU tools!
- TURNOVER was the key HUMAN PERFORMANCE TOOL that would have allowed everyone involved to avoid trying to start a pump with no suction path.
- Don't assume anything!
- Write it DOWN!
OVER COMMUNICATE!
Any questions regarding YOUR Safety?
Contact your supervisor or one of our site Safety Representatives-Wayne Boyd (ext 5668) or John Boothroyd (ext 5524)
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