05000254/FIN-2008002-03
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Finding | |
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| Title | Unit 2 Isolation of Reactor Building Ventilation and Auto Start of Standby Gas Treatment |
| Description | A self-revealing finding of very low safety significance and a NCV of Technical Specification (TS) 5.4.1 was identified on March 14, 2008, when operators transferring power using procedure QCOP 6800-03, Essential Service System, caused an unplanned isolation of the reactor building ventilation system and automatically started the standby gas treatment system. QOP 6800-03, Essential Service System, implements the TS 5.4.1 procedure requirements as provided in Regulatory Guide 1.33. Procedural steps in QOP 6800-03 did not include adequate instruction to transfer power without impacting the safety systems, in that, the procedural instructions directed the operators to take the bypass switch for radiation instruments out of the bypass position, but did not direct them to verify that there was no isolation signal present. Corrective actions included revising the affected procedure and briefing operating crews on the circumstances surrounding the event. The failure to implement adequate procedural directions for transferring electrical power without challenging safety-related equipment was more than minor because it impacts the Barrier Integrity Cornerstone attribute of Structures, Systems and Components and Barrier Performance for reliability of Containment Isolation Structures, Systems, and Components. If the condition were to go uncorrected, the Containment Isolation function could be impacted. This finding was determined to be of very low safety significance because the finding impacted only the radiological barrier function of the control room and standby gas treatment systems, and the systems functioned as designed. The inspectors also determined that the operators implementing the procedure had the opportunity to identify the procedural deficiency either during the job preparation activities or while executing the procedural steps, if they had verified the trip signals were cleared prior to moving the switch. Properly executed self-checking and peer-checking would have identified the possible action and provided the operators with the opportunity to prevent the challenge to the safety-related system components. The inspectors identified the deficient use of Human Performance tools as a contributor to the event and therefore determined that the event was cross-cutting in Human Performance, Work Practices, Prevention (H.4(a)). (Section 4A03 |
| Site: | Quad Cities  |
|---|---|
| Report | IR 05000254/2008002 Section 4OA3 |
| Date counted | Mar 31, 2008 (2008Q1) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | A Barker B Cushman C Mathews D Jones J Mcghee K Stoedter M Ring R Jones W Slawinski |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Quad Cities - IR 05000254/2008002 | ||||||||||||||||||||||||||||||||||||||
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Finding List (Quad Cities) @ 2008Q1
Self-Identified List (Quad Cities)
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