05000445/FIN-2009002-03
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Finding | |
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| Title | Failure to Follow Procedure Causes Unplanned Load Change (Section 4OA3.2) |
| Description | A self-revealing noncited violation of Technical Specification 5.4.1.a was identified for the failure of operators to follow procedural requirements when reducing turbine load. As a result, operators transposed two digits and inadvertently reduced turbine load from 1273.7 megawatts to 1237.5 megawatts instead of 1273.5 megawatts. In response to the transient, the control rods automatically inserted approximately 17 steps to maintain programmed reactor coolant system temperature. The licensee entered the finding into their corrective action program as Smart Form SMF-2009-000028. The finding was more than minor because it was associated with the human performance attribute of the initiating events cornerstone, and directly affected the cornerstone objective to limit the likelihood of those events that upset plant stability during power operations. Using Manual Chapter 0609, Attachment 4, Phase 1 - Initial Screening and Characterization of Findings, the finding was determined to have very low safety significance (Green) because it did not contribute to the likelihood of mitigating equipment being unavailable. The cause of the finding was related to the Human Performance crosscutting component of work practices for the failure to use self and peer checking techniques H4.a] (Section 4OA3.2). |
| Site: | Comanche Peak  |
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| Report | IR 05000445/2009002 Section 4OA3 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | J Braisted P Goldberg G Guerra C Smith G Pick W Walker B Tindell W Sifre M Young A Fairbanks J Kramer |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Comanche Peak - IR 05000445/2009002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Comanche Peak) @ 2009Q1
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