05000327/FIN-2011005-01
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Finding | |
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| Title | Failure to Follow Procedure for Loss of Power Diesel Generator Start Instrumentation Surveillance Testing |
| Description | A self-revealing non-cited violation of Unit 2 Technical Specification (TS) 6.8.1.a was identified for the licensees failure to follow station procedures during the performance of a surveillance testing activity. While performing degraded voltage/load shed relay testing associated with the 2B 6.9kV shutdown board, the use of improper test equipment and the incorrect connection of test equipment resulted in a control power circuit fuse being blown, which caused inoperability of an emergency diesel generator and a motor driven auxiliary feedwater train. This issue was entered into the licensees corrective action program as Problem Evaluation Report (PER) 415324. The finding was determined to be greater than minor because it was associated with the human performance attribute of the mitigating systems cornerstone and affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to follow procedure steps resulted in inoperability of the 2B emergency diesel generator and the 2B motor driven train of auxiliary feedwater. Using Inspection Manual Chapter (IMC) 0609, Significance Determination Process, Attachment 4, Phase 1 - Initial Screening and Characterization of Findings, the finding was determined to be of very low safety significance (Green) since it did not represent an actual loss of safety function of a single train for greater than the associated TS allowed outage time. The cause of this finding was determined to have a cross-cutting aspect in the area of Human Performance associated with the Work Practices component. The licensee failed to adequately implement human error prevention techniques such as self and peer checking (e.g. concurrent verification) while connecting test equipment. Additionally, maintenance personnel failed to question the use of test equipment which was different than what was specified in the procedure (i.e. proceeding in the face of uncertainty). |
| Site: | Sequoyah  |
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| Report | IR 05000327/2011005 Section 1R22 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.22 |
| Inspectors (proximate) | S Shaeffer C Young M Speck R Baldwin J Hamman W Deschaine |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Sequoyah - IR 05000327/2011005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Sequoyah) @ 2011Q4
Self-Identified List (Sequoyah)
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