05000272/FIN-2017001-01
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Finding | |
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| Title | Loss of Unit 1C 4kV Vital Bus due to Inadequate Activity Risk Screening |
| Description | A self-revealing Green finding (FIN) was identified when PSEG did not screen the risk associated with replacing the Unit 1C emergency diesel generator (EDG) output breaker in accordance with WC-AA-105, "Work Activity Risk Management." Specifically, on December 14, 2016, the Unit 1C 4 kilovolt (kV) vital bus was inadvertently de-energized when the Unit 1 C EDG output breaker, which was removed without adequate risk mitigation actions, made contact with the switchgear (SWGR) cubicle door containing relays for bus differential current protection. PSEG entered this issue into their corrective action proggram (CAP) as NOTF 20751669 and performed apparent cause evaluation (ACE) 70191319. PSEG's corrective actions (CA) included inspecting the involved relay and re-energizing the vital bus. The finding was determined to be more than minor because it was associated with the equipment performance attribute of the Mitigating Systems cornerstone and affected the cornerston's objective of ensuring the availability, reliability, and capability of systems relied upon to mitigate the consequences of an accident. The inspectors evaluated the finding in accordance with IMC 0609, Appendix A, Exhibit 2, and determined the finding was Green because it did not affect the design of qualification of a mitigating SSC, and did not represent an actual loss of function or system. The finding had a cross cutting aspect in the area of Human Performance, Work Management, because the work process did not include the identification and management of risk commensurate to the work and the need for coordination with different groups or job activities. Specifically, PSEG did not identify the level of medium risk associated with the work activity, did not manage the level of risk commensurate wiht the work, and did not coordinate appropriate mitigating actions with different work groups. |
| Site: | Salem  |
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| Report | IR 05000272/2017001 Section 1R13 |
| Date counted | Mar 31, 2017 (2017Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | A Ziedonis F Bower J Furia J Schoppy P Boguszewski P Finney S Pindale |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Salem - IR 05000272/2017001 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Salem) @ 2017Q1
Self-Identified List (Salem)
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