ML051460519

Event Investigation Report

ML051460519
Person / Time
Site:	Point Beach
Issue date:	04/23/2004
From:	- No Known Affiliation
To:	Office of Nuclear Reactor Regulation
References
FOIA/PA-2004-0282
Download: ML051460519 (3)

Text

013 ~2-951~P0 Evens gnQ n Report Complete the evaluation of the human performance event using the following, as applicable:

1. Date and Time of the event: 4/23/04 -1430 (between 1400 and 1500 per Tom Jessessky the SRO who directed the breaker operation).

2. Personnel InvolvNJ7 fI;tn

_,(Peaker), anL .3OpsM/E)[

- SRO).

3(Mtn M/E),

3. Department/Group Involved: Maintenance - Electrical & Operations

4. Program/Work Process/Activity Involved: Work was in progress IAW IWP 01-128*E-FN MCC 1B42 Bus Bracing Installation - CRIPAB Fan Realignment, paragraph/step 3.6.7, Breaker manipulation.

5. Unit: PBNP Unit 1

6. Mode/Power Level: Mode 6 Refueling Shutdown

7. Describe the inappropriate action and conditions that led up to the event. Consider the following in this description:

a. Was a conscious decision made or not made by the individual(s) involved?

Although Error Reduction Tools were used appropriately throughout performance of the IWP, at the moment of the eventC 2 did not use STAR .. - Jdid verify they were operating e correct breakers Jiost focus on the breaker manipulation while communicating o the telephone and did not re-verify he was on the correct breakert 1~eer checked initially, but "moved out of the way of the phone cord' 'nd did not watch the breaker manipulation. A note in the procedure warned of loss of status Jjght indication directly before the step for the breaker manipulation.?L --

ailed to use STAR and review action taken for expected results. . ailed to "review" based on previous step perf rmance. In previous steps, the Ops SRO verified loss of indicationt jfelt nothing was wrong and went on since he didn't hear anything fromc J

b. Was the event a result of rule non-compliance, misapplication of a rule, or applying an incorrect rule?

The event was rule non-compliance since the IWP step was not performed as written.

c. Was the individual fully trained/knowledgeable of the task?

Informabon i t record was deleted in aecweWMFroan i of Wtrmo X-/9

d. Did the individual make an error in judgment?

Yest ailed to use STAR after being distracted by phone 6 communiations with OPS. He also did not perform the "review" step of STAR after manipulating the wrong breaker.

e. Was an intended action not performed due to shortcuts taken or inadequate tracking?

No.

f. Was the individual overconfident or was their mental/physical state a factor?

L avas tired due to the long outage hours worked, but he does not believe this contributed to the error.

k

g. Did the supervisor not identify error likely situations and error precursors?

The Supervisor DID identify error likely situations in the brief and peer check was discussed and used during this situation. The "Are You Ready Checklist" and '"Error Precursors" were covered during the pre-job brief and again in the field as required by the Electrical GS.

h. Was there a process or organizational failure that led to this error (see table on next page)?

No.

8. Summarize the inappropriate action in one sentence as follows:

(WHO) (WHAT) (THE REQUIREMENT)

(Where the Requirement is found) (WHY if known) l: pened breaker 2B52-3212M - "A" SFP Cooling Pump instead of breaker 2452-3211M - W21B Aux Bldg Fan as found in IWP 01-128*E-FN step 3.6.11.

9. Based on what you have learned, describe the error likely situations that were present at the time of the event.

a. What Error Reduction Tools were not used or not used effectively? What Error Reduction Tools could have been used to prevent this event? Clearly state which is the one tool, which if used, would have had the greatest chance of being successful.

STAR was not used appropriately. If vould have "stopped' fter being distracted the event would have een prevented. Also i , JEad "reviewed", the consequences of the event would have been lessevere.

b. Are these Error Reduction Tools going to provide the barriers to prevent recurrence? Where else should these barriers be applied?

Yes, and they shall be applied at all times Human Performance Failure Modes (From the NMC Trend Code Manual)

• Inattention

• Bored

• Distracted & Interrupted

• Multi-Tasking

• Time & Schedule Pressure

• Fear of Failure

• Spatial Disorientation

• MindsetlPreconceived Idea

• Inadequate Motivation

• Shortcuts Taken

• Unfamiliar or Infrequent Task

• Misdiagnosis

• Inadequate Knowledge of Standards

• Flawed Analytical Process or Model

• Inadequate Knowledge of Fundamentals

• Over Confident

• Inadequate Verification

• Cognitive Overload

• Inadequate Tracking (Place Keeping)

• Tired & Fatigued

. Habit/Reflex

• Lapse of Memory

• Imprecise Communication

• Wrong Assumptions

• Work Around

• Tunnel Vision Process Failure Modes (From the NMC Trend Code Manual)

• Critical Actions Not Verified X Person Specified Not Able to Perform Task.

• Excessive Verifications a More Than One Person Specified to Perform Task a No Process Monitoring No One Specified to Perform Task

• Only Monitoring Problems 0 No Acceptance Criteria Organizational Failure Modes (From the NMC Trend Code Manual)

• Inadequate Prioritization

• Inadequate Communication among Organizations

• Inadequate Trust

• Inadequate Communication within an Organization

• Inadequate Self Assessment

• Lack of Commitment

• Inadequate Planning

• Inadequate Knowledge

• Inadequate Teamwork

• Inadequate Emerging Issues Management

• Inadequate Program

• Insufficient Staffing Management

• Inadequate Span of Control

• Inadequate Levels in Organization