05000237/FIN-2009005-09
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Finding | |
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| Title | Failure to Ensure a Safety-Related Plug was Ordered and Installed in the 2/3 Emergency Diesel Generator Turbo Lube Oil Y Strainer |
| Description | A finding of very low safety significance and associated NCV of 10 CFR Part 50, Appendix B, Criterion IV, Procurement Document Control, was self-revealed for the licensees failure to ensure a safety-related plug was ordered and installed where required in the 2/3 EDG turbo lube oil Y strainer. Instead, a non-conforming part was installed, which resulted in a one-half gallon per minute oil leak and removal of the diesel generator from service. The issue was entered into the licensees CAP as IR 926605. Corrective actions included inspection of all other diesel generators to ensure the nonconforming condition did not exist on another machine, revising the procurement documents to ensure that future parts include a pressure retaining pipe plug with approved material, and adding a requirement for a quality inspection to be performed to inspect the strainer for metallic pipe plug in blow down port. Individual procedure compliance issues were addressed through the stations performance improvement initiatives. The finding was determined to be more than minor because the finding was similar to IMC 0612, Appendix E, Example 5 c because an incorrect and inadequate part was installed and the system was returned to service. This performance deficiency impacted the Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. A Phase 3 SDP risk evaluation was performed by the regional Senior Risk Analyst who determined the risk significance of the finding to be less than 1.0E-6/yr delta core damage frequency (CDF) and less than 1.0E-7/yr delta LERF, which represents a finding of very low safety significance. Failure of plant personnel to question the plastic shipping plug before the equipment was installed and returned to service was not in compliance with MA-AA-716-008, Foreign Material Exclusion Program, and, therefore, inspectors determined that this event was cross-cutting in Human Performance, Work Practices, Procedural Compliance for failure of personnel to follow the procedure. H.4(b |
| Site: | Dresden  |
|---|---|
| Report | IR 05000237/2009005 Section 4OA3 |
| Date counted | Dec 31, 2009 (2009Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | R Jickling C Moore C Phillips D Melendez Colon D Sand F Ramirez J Benjamin J Draper J Mcghee L Kozak M Holmberg M Mitchell M Ring |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Dresden - IR 05000237/2009005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Dresden) @ 2009Q4
Self-Identified List (Dresden)
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