05000461/FIN-2008002-02
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Finding | |
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Title | The Licensee Discovered That The Wrong Component Was Installed In The B Turbine Driven Reactor Feed Pump Oil Pressure Sensing Logic |
Description | A finding of very low safety significance was self-revealed by the automatic runback of the turbine driven reactor feed pump during post-outage power ascension. The licensee discovered that the wrong component was installed in the B turbine driven reactor feed pump oil pressure sensing logic. The inspectors determined that the licensee failed to perform an adequate post-maintenance test in accordance with procedures. This issue resulted in an unexpected power change from 54 percent power to 46 percent power. The licensee entered the issue into the corrective action program, performed tailgate discussions with technicians and work planners on the oil pressure switch configurations, and ensured that vendor purchase specifications for pressure switches were up-to-date in the materials and work management computer system. The inspectors determined this issue was more than minor because it was associated with the Human Performance attribute of the Initiating Events Cornerstone and affected the cornerstone objective of limiting the frequency of those events that upset plant stability. Specifically, the failure to perform adequate post-maintenance testing of pressure switch 1PS-FW135 permitted the wrong component to be installed and placed in service. This deficiency ultimately resulted in an unplanned plant transient. The finding was of very low safety significance because this issue did not increase the likelihood that mitigation equipment or functions would not be available. The inspectors also concluded that the failure of the technician to properly follow calibration procedure 8801.01 during the initial calibration of this switch represented a cross-cutting issue in the area of Human Performance, Work Practices (H.4(b)), because licensee personnel failed to follow procedures in regard to pressure switch calibration |
Site: | Clinton |
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Report | IR 05000461/2008002 Section 1R19 |
Date counted | Mar 31, 2008 (2008Q1) |
Type: | Finding: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71111.19 |
Inspectors (proximate) | R Jickling J Cassidy D Tharp B Dickson M Mitchell J Neurauter M Ring D Jones V Meghani S Mischke R Russell |
CCA | H.8, Procedure Adherence |
INPO aspect | WP.4 |
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Finding - Clinton - IR 05000461/2008002 | |||||||||||||||||||||||||||||||||||||
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Finding List (Clinton) @ 2008Q1
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