05000254/FIN-2008002-04
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Finding | |
|---|---|
| Title | 1/2 \"A\" Diesel Fire Pump Oil Leak and Fire |
| Description | Green: A self-revealing finding of very low safety significance and a NCV of TS 5.4.1 was identified due to the failure to establish, implement, and maintain procedures associated with the fire protection program. Work instructions, Work Order 787787-01, performed on the 1/2 A diesel fire pump in September 2007 did not specify the thread sealant to be used in the work activity and the mechanics used a material that subsequently resulted in an oil leak and subsequent fire on December 22, 2007, caused by oil-contaminated insulation. Corrective actions included revision of model work orders for the pump to include guidance for using high temperature thread sealant and performance expectations for work planners to include identification of thread sealant for similar tasks. Additionally, maintenance personnel were briefed on the issue of workers failing to identify and/or replace the oil-contaminated insulation pad while replacing the turbocharger oil supply hose during a corrective maintenance activity. Inspectors determined the issue was more than minor because the procedural deficiencies were a precursor to an oil leak and subsequent insulation fire that impacted the reliability and availability of the 1/2 A fire pump. The finding was determined to be of very low safety significance because the 100 percent capacity B pump was not impacted and the operator actions after removing the combustibles could have made the A pump available shortly after the event. The inspectors determined this failure to be cross-cutting in the area of Problem Identification and Resolution due to the failure of multiple individuals to investigate the condition of the insulation that was near the oil leak and thereby failing to identify the oil contamination of that insulation in time to prevent the impact to the diesel fire pump (P.1(a)). (Section 4A03 |
| Site: | Quad Cities  |
|---|---|
| Report | IR 05000254/2008002 Section 4OA3 |
| Date counted | Mar 31, 2008 (2008Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | A Barker B Cushman C Mathews D Jones J Mcghee K Stoedter M Ring R Jones W Slawinski |
| CCA | P.1, Identification |
| INPO aspect | PI.1 |
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Finding - Quad Cities - IR 05000254/2008002 | ||||||||||||||||||||||||||||||||||||||
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Finding List (Quad Cities) @ 2008Q1
Self-Identified List (Quad Cities)
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