ML050870090
| ML050870090 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 04/23/2004 |
| From: | - No Known Affiliation |
| To: | Office of Nuclear Reactor Regulation |
| References | |
| CAP056010, FOIA/PA-2004-0282 | |
| Download: ML050870090 (1) | |
Text
Point Beach Event Free Clock Reset Spent Fuel Pool Cooling Inadvertently Isolated (CAP056010)
What Happened?
On April 23, Electrical Maintenance (EM) Personnel were performing work in support of the "Bolted Faults" correction project (IWP 01-128*E-FN MCC 1B42 Bus Bracing Installation). A pre-job briefing was performed which included the use of error-reduction tools especially the "Are You Ready Checklist".
Craft personnel then proceeded to the work area. At the work area "Error Precursors" were reviewed and the "Are You Ready Checklist" was implemented. An EM went to the 2B52-321 IM (W21B Aux Bldg) breaker. A second EM and a "Peaker" Helper performed a peer check and concurred that the breaker ID that the first EM was indicating was correct. The first EM then contacted the control room from the 2B32 panel to request permission to open the breaker and received permission. This EM then returned to the breaker area and opened breaker 2B52-3212M (A SFP Cooling Pump) instead of breaker 2B52-321 IM (W21B Aux Bldg Fan). (Breaker 2B52-3212M is directly adjacent to 2B52-321 IM.)
This condition existed for approximately 3.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br />. Operations discovered that the spent fuel pool pump was not running during their rounds. Operations closed breaker 2B52-3212 M and then opened breaker 2B52-321 IM to implement appropriate configuration per the IWP steps. Operations then performed a verification of breaker positions in steps 3.6.4 through 3.6.10 of IWVP 01-128*E-FN MCC IB42 Bus Bracing Installation. Work was suspended on the Bolted Fault Modification.
Whiy did this happen?
While peer checking was performed, it was not re-performed prior to actually taking the critical action of repositioning the breaker. Placing the phone call to Operations was an interruption, which is an error likely situation.
How Could This Event Have Been Prevented?
A PEER Check at the "critical" step would have prevented this event. The critical step was the actual manipulation of the breaker following the interruption. STAR is an important tool to use when interrupted. Placekeeping is another tool that helps with interruption. Flagging (using some identifier for correct breaker) prior to going to phone the Control Room would also have prevented the error.
N1That are the Human Performance Lessons Learned From This Event?
A recovery plan has been developed so that the Bolted Fault Project may continue. The recover plan includes specific human performance improvements including:
- The work plans will be upgraded to add a specific line requiring initials for peer or concurrent checks to reinforce the responsibilities of the peer checkers
- Pre-Job Briefs will emphasize the use of human performance error reduction tools including discussing the "worst thing that could happen" for each job including the type of error that could lead to that event and the potential consequences.
All of us deal with interruptions. Are we sure that our placekeeping skills are up to the challenge?
I ED0