05000282/FIN-2009004-02
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Finding | |
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| Title | Failure to Perform Adequate Risk Assessment Prior to Performing Troubleshooting Activities Renders Instrument Inverter Unavailable and Causes Unplanned Shutdown Safety Color Change |
| Description | A self-revealed finding of very low safety significance and a Non-Cited Violation of 10 CFR 50.65(a)(4) was identified on September 14, 2009, due to the licensees failure to perform an adequate risk assessment prior to performing troubleshooting activities on radiation monitor 1RE-12. The failure to perform the adequate risk assessment resulted in the performance of maintenance activities which resulted in rendering the 14 instrument inverter unavailable and changed the Unit 1 Shutdown Safety Assessment risk for 120 Volt instrument power from Green to Yellow (a higher risk condition). Corrective actions for this issue included restoring the 14 instrument inverter to an available status and reinforcing identification of critical steps and risk management to maintenance and operations personnel. This finding was more than minor because it was associated with the equipment performance attribute of the Mitigating Systems cornerstone. In addition, the finding impacted the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. This finding was of very low safety significance, because although the finding failed to meet Step III.A.(2) of Checklist 2 to Inspection Manual Chapter 0609, Appendix G, Attachment 1 (since the work activity had significant potential to impact operability of the power supply), the finding did not meet the criteria for findings that required a quantitative assessment. The inspectors determined that this finding had a cross-cutting aspect in the area of Human Performance, work planning, because the licensee failed to plan and coordinate this work activity consistent with nuclear safety (H.3(a)). Specifically, the licensee failed to incorporate risk insights, job site conditions, risk to other plant components, and the need for compensatory measures into the work plan |
| Site: | Prairie Island  |
|---|---|
| Report | IR 05000282/2009004 Section 1R20 |
| Date counted | Sep 30, 2009 (2009Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | C Moore C Thomas D Betancourt D Mcneil F Tran J Giessner K Stoedter M Holmberg M Thorpe _Kavanaugh N Valos P Zurawski R Jicklin |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Prairie Island - IR 05000282/2009004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Prairie Island) @ 2009Q3
Self-Identified List (Prairie Island)
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