05000528/FIN-2008002-06
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Finding | |
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| Title | Failure to Follow Procedures Resulted in Water Transfer from the Spent Fuel Pool (Section 4OA3) |
| Description | A self-revealing non-cited violation of Technical Specification 5.4.1.a was identified for the failure of operations personnel to follow procedures. Specifically, on January 13, 2008, operations personnel failed to properly implement Procedure 40OP-9PC06, \\\"Fuel Pool Cleanup and Transfer,\\\" Revision 41, for operating the pool cooling cleanup system, resulting in pool cooling cleanup Filter PCN-F01B bypass Valve PCN-V061 being improperly aligned. This resulted in the inadvertent transfer of 300 gallons of spent fuel pool water to the refueling water tank. This issue was entered into the licensee\\\'s corrective action program as Condition Report/Disposition Request 3121713. The finding is greater than minor because it is associated with the configuration control and human performance attributes of the barrier integrity cornerstone and affects the cornerstone objective to provide reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Using the Manual Chapter 0609, \\\"Significance Determination Process,\\\" Phase 1 Worksheets, the finding is determined to have very low safety significance because the finding did not result in loss of cooling to the spent fuel pool; the finding did not result from fuel handling errors that caused damage to the fuel clad integrity or a dropped assembly; and the finding did not result in a loss of spent fuel pool inventory greater than ten percent of the spent fuel pool volume. This finding has a crosscutting aspect in the area of human performance associated with work practices because the licensee failed to use adequate human error prevention techniques, such as pre-job briefings, to ensure that the pool cooling cleanup system activity was performed safely H.4(a). (Section 4OA3 |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000528/2008002 Section 4OA3 |
| Date counted | Mar 31, 2008 (2008Q1) |
| Type: | NCV: Green |
| cornerstone | Barrier Integrity |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | R Treadway P Elkmann G Werner L Carson J Melfi G Warnick M Hay J Bashore M Catts |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Palo Verde - IR 05000528/2008002 | ||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2008Q1
Self-Identified List (Palo Verde)
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