05000220/FIN-2013010-02
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Finding | |
|---|---|
| Title | Configuration Control error results in loss of a vital DC Bus |
| Description | The inspectors documented a self-revealing Green finding of CENGs Conduct of Maintenance procedure, CNG-MN-1.01-1000, because CENG personnel failed to verify they were on the proper equipment prior to commencing maintenance activities. Additionally, Risk Management Activities recommended by CNG-OP-4.01- 1000, Integrated Risk Management, such as temporary barriers and signs were not hung to for the protected #12 SDC train and vital 125 VDC battery bus to ensure workers did not assess protected equipment. The inspectors determined that CENGs failure to follow procedures which resulted in a loss of the vital DC battery bus 12 was a performance deficiency that was within CENGs ability to foresee and prevent. Specifically, a CENG contractor did not follow station procedures for control of maintenance by failing to verify he was on the proper equipment prior to commencing maintenance activities, and station personnel did not implement all risk management actions for protected equipment as directed by station risk management procedures. The performance deficiency was determined to be more than minor because the inspectors determined it affected the configuration control aspect of the Initiating Events cornerstone and adversely affected the associated cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The inspectors determined this finding had a cross-cutting aspect in the area of Human Performance, Work Practices, because CENG did not ensure that work practices support human performance. Human error prevention techniques, such as holding prejob briefings, self- and peer-checking, and proper documentation of activities were not completed. Additionally, by not implementing the recommended risk management activities, a tool to ensure a more effective self-check by the worker was removed. Because this performance deficiency does not involve a violation and is of very low safety significance, it is identified as a Finding. |
| Site: | Nine Mile Point  |
|---|---|
| Report | IR 05000220/2013010 Section 4OA3 |
| Date counted | Sep 30, 2013 (2013Q3) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | W Schmidt B Bickett D Roberts D Schroeder E Monteith R Lorson R Zimmerman W Dean |
| Violation of: | Technical Specification - Procedures |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Nine Mile Point - IR 05000220/2013010 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Nine Mile Point) @ 2013Q3
Self-Identified List (Nine Mile Point)
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