05000254/FIN-2008005-01
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Finding | |
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| Title | Failure to Remove FME Device |
| Description | A self-revealed finding of very low safety significance was identified for failure to remove a foreign material exclusion device from the thrust bearing oil supply line of a feed pump during maintenance on November 3, 2008. The pump was returned to service with increased monitoring following the work activity on November 5 and was shut down for repair on November 7 after the control room received a bearing high temperature alarm. Immediate corrective actions for the equipment condition included lowering power to get flow within the capacity of two feedwater pumps, shutdown of the 1B pump, removal of the plug, correct reassembly of the oil line, and pump restart. Corrective action following the site investigation included retraining provided to Maintenance staff for documentation requirements and expectations for thorough post-maintenance inspections. The inspectors determined that failure to remove the foreign material exclusion plug was more than minor because if left uncorrected, this behavior could lead to damage of safety-related or risk-significant equipment and thus become a more significant safety concern. The issue impacted the Mitigating Systems Cornerstone objective of ensuring the availability, reliability and capability of systems that respond to initiating events to prevent undesirable consequences. The finding is of very low safety significance (Green) because the problems with a single feedwater pump did not impact the function, reliability or capability of the other two and the issue did not affect other mitigating systems. The inspectors determined that this finding was cross-cutting in the area of Human Performance Work Practices in that error prevention techniques such as self/peer checking and proper documentation of activities were not utilized commensurate with the risk of the assigned task (H.4 (a)). Failure to remove the plug in non-safety related equipment is not an activity affecting quality subject to 10 CFR Part 50, Appendix B, Criterion V. Therefore, while a performance deficiency was identified, no violation of NRC regulatory requirements occurred. (Section 1R19 |
| Site: | Quad Cities  |
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| Report | IR 05000254/2008005 Section 1R19 |
| Date counted | Dec 31, 2008 (2008Q4) |
| Type: | Finding: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.19 |
| Inspectors (proximate) | R Winter R Orlikowski C Matthews W Slawinski C Brown B Palagi R Baker M Ring J Mcghee J Tapp B Cushman |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Quad Cities - IR 05000254/2008005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Quad Cities) @ 2008Q4
Self-Identified List (Quad Cities)
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