05000302/FIN-2009002-03
From kanterella
Revision as of 19:37, 20 February 2018 by StriderTol (talk | contribs) (Created page by program invented by StriderTol)
(diff) ← Older revision | Latest revision (diff) | Newer revision → (diff)
Finding | |
|---|---|
| Title | Inadequate Peer and Peer Checking Resulted in Connecting Improper Test Equipment and a Manual Plant Trip |
| Description | A self-revealing finding was identified for the failure to follow procedure HUMNGGC- 0001, Human Performance Program, which required workers to perform self and peer checks to ensure the correct action is performed on the correct component. Specifically, during meter calibration activities, workers performing voltage checks failed to perform adequate self and peer checks when connecting test equipment. As a result, incorrect test equipment was connected resulting in blown fuses, the loss of several secondary plant pumps, and ultimately a manual plant trip. Corrective actions include: move relay work identified in the extent of condition review from on-line to outage to prevent recurrence, revise maintenance procedures associated with calibration of meters and relays to incorporate human factoring from lessons learned from this event, and perform an analysis of and incorporate best practices in procedures regarding how plant risk is assessed for activities that could cause transients. The finding was more than minor since it affected the human performance attribute of the Initiating Event Cornerstone and resulted in an event that upset plant stability. Specifically, the failure to properly utilize human performance tools such as self and peer checking as specified in HUM-GGC-0001, Revision 2, resulted in the connection of incorrect test equipment, the loss of several secondary plant pumps and ultimately led to a manual reactor trip. The inspectors assessed the finding using the SDP and determined that the finding was of very low safety significance (Green) since it did not contribute to the likelihood of a loss of coolant accident, did not contribute to a loss of mitigation equipment, and did not increase the likelihood of a fire or internal/external flood. The cause of the finding is related to the cross-cutting area of Human Performance with a work practices aspect (H.4(a)). Specifically, workers did not utilize proper self and peer checking |
| Site: | Crystal River  |
|---|---|
| Report | IR 05000302/2009002 Section 4OA3 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | R Reyes T Morrissey S Rose R Aiello D Mas-Penaranda R Berryman J Hamman M Sykes A Alen |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
| ' | |
Finding - Crystal River - IR 05000302/2009002 | |||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Finding List (Crystal River) @ 2009Q1
Self-Identified List (Crystal River)
| |||||||||||||||||||||||