ML042080443
| ML042080443 | |
| Person / Time | |
|---|---|
| Site: | Vermont Yankee File:NorthStar Vermont Yankee icon.png |
| Issue date: | 03/02/2004 |
| From: | Bronson K Vermont Yankee |
| To: | Office of Nuclear Reactor Regulation, Vermont Yankee |
| References | |
| FOIA/PA-2004-0267 | |
| Download: ML042080443 (2) | |
Text
Message-Page-I of I Sienel, Beth From:
Bronson, Kevin Sent:
Tuesday, March 02, 2004 12:25 PM To:
VTY - All Users
Subject:
Yellow Memo on Tubing Failure during HPCI surveillance Please open and read the Yellow memo attached, and discuss within your work areas how this can apply to you.
There are multiple opportunities for lessons learned and inprovements.
Thanks, Kevin (Remember, Safety and Quality first and foremost!)
Kil A11 VflnA
Yeiowv eino March 2, 2004 Memorandum:
Vermont Yankee Personnel From:
Kevin Bronson, General Manger Plant Operations
Subject:
Use of Incorrect Tubing during HPCI Surveillance The Event:
Condition Report 2004-0436 identified the use of incorrect instrument tubing during the HPCI pump surveillance performed on February 26, 2004. White plastic tubing with a nominal rating of approximately 700 psig was used in a system with an operating pressure of approximately 1100 psig.
To support the pump surveillance, a high pressure discharge pressure test gauge was connected at an instrument rack using the plastic instrument tubing. When the Auxiliary Operator valved in the test gauge for the first time, a small pinhole leak developed and was immediately isolated.
The test gauge line was replaced with identical tubing and when the gauge was valved in the second time, the tubing split and the Operator was wetted slightly. The test line was then isolated. I&C obtained the proper tubing, and the surveillance was completed.
What went right?
RP was present at the job site.
The operator notified the control room after experiencing the first tubing leak.
What went wrong?
The tubing failure posed an industrial safety threat to the operator and other personnel in the area.
Operations did not exhibit a strong questioning attitude after the initial leak was identified. They assumed that the tubing was defective.
There is no formal process to identify the pressure rating of temporary instrument tubing.
The HPCI pump was operated longer then necessary, resulting in unnecessary water inventory being sent to Radwaste.
Where did we get lucky?
No personnel were injured or contaminated.
No plant equipment was damaged.
What's the message?
We cannot depend upon luck to keep us safe. We cannot depend upon luck to keep us error-free.
The failure of test equipment due to over pressurization poses a serious industrial safety threat.
We must PAY ATTENTION. We must capitalize upon our KNOWLEDGE AND TRAINING. Furthermore, we must employ a strong QUESTIONING ATTITUDE at all times to ensure that we're doing the right thing in the right manner.