ML050870116
| ML050870116 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 04/23/2004 |
| From: | - No Known Affiliation |
| To: | Office of Nuclear Reactor Regulation |
| References | |
| CAP052697, CAP056010, FOIA/PA-2004-0282 | |
| Download: ML050870116 (2) | |
Text
MAINTENANCE HUMAN CLOCK RESET Days Since Last Clock Reset: 2 Goal: 20 Days The following information is to be used at Maintenance shift briefs to present timely OE on an event that reset the Maintenance Hutman Perobrmance Clock Clock Reset Based On: Procedure Non-Compliance - Station Mechanic Electrician Opens Incorrect Breaker, which w'as adjacent to the Breaker specified in the Installation W\\ork Plan.
CAP Number: CAP056010 (4/23/04)
Background:
Electrical Maintenance Personnel performing work in support of the "Bolted Faults" correction project (IWP 01-128*E-FN MCC 1B42 Bus Bracing Installation).
Event Outline: Pre-job briefing performed i ith use of error-reduction tools including specifically the "Are You Ready Checklist".
Craft personnel proceeded to the work area.
At the work area "Error Precursors" and "Are You Ready Checklist' were reviewed/implemented.
An EM went to the 2B52-3211M (W21B Aux Bldg) breaker. A second EM and a "Peaker" Helper also observed the breaker ID the 15' EM was indicating was the subject of the IWP step and essentially concurred with it being the correct breaker per this peer check.
The IV 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 2B52-3211M1 (W21B Aux Bldg Fan).
Corrective Action Taken: Operations closed breaker 2B52-3212 M and then opened breaker 2B52-3211M 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 IWP 01-128*E-FN MCC 1B42 Bus Bracing Installation.
Human Performance Investigation started.
Operating Experience: Prior station wrong component event - Plant electricians altered voltage on the incorrect battery charger. Went to the wrong component -
both components in same room (CAP052697).
References:
CAP056010, CAP052697
MAINTENANCE HUMAN PERFORMANCE CLOCK RESET Days Since Last Clock Reset: 2 Goal: 20 Days Error Reduction Tools That Mav Have Helped In This Event: STAR, Placekeeping
- Some identifier of correct breaker prior to going to phone to call Control Room, PEER Check - following the distraction.
Human Performance Failure Modes: (A5) Distracted and Interrupted, (A9) Time &
Schedule Pressure, (J5) Inadequate Verification, (A4) Tired & Fatigued, (ARI)
Critical Actions Not Verified ACEMAN Performance Barrier Failures: Worker Practices, Procedures/Work Instructions Attachment(s) Provided: None