05000255/FIN-2011005-02

Finding

Title

Failure to Control Packing Configuration of Pressurizer Spray Control Valves

Description

A finding of very low safety significance was self-revealed on September 16, 2011, when the packing for CV-1057, one of two pressurizer spray control valves, failed resulting in unidentified Primary Coolant System (PCS) leakage in excess of TS limits. As a result, the licensee manually tripped the reactor and declared an Unusual Event was declared. The licensee failed to maintain the configuration of the plant in accordance with the design. No violation of regulatory requirements was identified, however, the licensee failed to implement an Entergy procedure, a self-imposed standard. Contrary to the licensees Configuration Management procedure, EN-DC-105, the intended packing configuration was not installed during RFO 21. Specifically, end rings integral to the design were omitted. As immediate corrective action, the licensee repacked CV-1057 and checked the consolidation of the sister valve, CV-1059. The licensee also entered the issue in their CAP as CR-PLP-2012-04620 and performed a root cause analysis. The inspectors determined the failure of the packing due to inadequate configuration management was a performance deficiency warranting further evaluation with the Significance Determination Process. The performance deficiency was more than minor because it affected the Initiating Events Cornerstone attribute of Design Control and adversely impacted the objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, the issue resulted in PCS leakage greater than TS limits, a manual reactor trip, and declaration of an Unusual Event. The issue screened as Green, or very low safety significance, in a Phase 3 SDP evaluation performed by regional Senior Reactor Analysts. The finding had a cross-cutting aspect in the area of Human Performance associated with the Resources component. Specifically, the licensee failed to ensure that complete, accurate, and up-to-date design documentation, procedures, and work packages were available and adequate to ensure nuclear safety for maintenance on the pressurizer spray control valves (H.2(c))

02
Site:	Palisades
Report	IR 05000255/2011005 Section 4OA2
Date counted	Dec 31, 2011 (2011Q4)
Type:	Finding: Green
cornerstone	Initiating Events
Identified by:	Self-revealing
Inspection Procedure:	IP 71152
Inspectors (proximate)	C Zoia J Cassidy J Ellegood T Taylor M Learn A Scarbeary L Rodriguez
CCA	H.7, Documentation
INPO aspect	WP.3
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v • d • e

Finding - Palisades - IR 05000255/2011005

2(5)3(9)4(7)5(4)6(0)7(0)8(5)9(4)10(0)12(1)13(1)14(9)15(1)16(1)17(0)19(0)403(3)404(0)405(2)501(0)9(3)18(0)

IR 05000255/2011005: 1 2 3 4

Finding List (Palisades) @ 2011Q4

CCA Matrix: 2011Q4

	Q	CCA	Title
05000255/FIN-2011002-04	2011Q1		Inadequate Procedural Controls for Liquid Radioactive Waste
05000255/FIN-2011008-02	2011Q1	H.7	Test Results for Diesel Fuel Oil Tanks Not Evaluated
05000255/FIN-2011008-01	2011Q1	H.2	Failure to Assure Adequate Resolution for Remote Visual Examinations
05000255/FIN-2011008-03	2011Q1	P.1 P.1(a)	Tank T-10A Not Age Managed for Effect of Identified Water
05000255/FIN-2011008-04	2011Q1	H.2	Flow Accelerated Corrosion Program Acceptance Limits Not in Accordance with Design Standard
05000255/FIN-2011008-05	2011Q1	H.7	Failure to Implement Adequate Oil Sampling and Analysis Aging Management Program
05000255/FIN-2011002-03	2011Q1		Failure to Maintain Switchgear Weather Proof
05000255/FIN-2011002-02	2011Q1	H.2	Violation of Fatigue Rule Requirements
05000255/FIN-2011002-01	2011Q1	P.5	Failure to Account for Potential Age-Related Degradation in EDG Governors
05000255/FIN-2011403-01	2011Q1	H.14	Security
05000255/FIN-2011003-08	2011Q2	P.2	Failure to Adequately Manage Changes to the ODCM, Problem Identification & Resolution
05000255/FIN-2011003-09	2011Q2		Failure to Update SAMGs
05000255/FIN-2011003-05	2011Q2		Application of EAL Scheme During Drill
05000255/FIN-2011003-04	2011Q2		Turbine-Driven Auxiliary Feedwater Pump Trip
05000255/FIN-2011003-06	2011Q2	P.3	Failure to Include The Steam Generator Mausoleum in the Groundwater Protection Risk Ranking Program, Problem Identification & Resolution
05000255/FIN-2011003-03	2011Q2		Failure to Establish a Back-up Radiation Monitor
05000255/FIN-2011003-02	2011Q2		Failure to Establish a Back-up Radiation Monitor
05000255/FIN-2011003-01	2011Q2	H.14	Failure to Evaluate Reactor Vessel Head Corrosion During Visual Examination, Human Performance, Decision Making
05000255/FIN-2011003-07	2011Q2		Anomalous Environmental Samples
05000255/FIN-2011009-04	2011Q3	H.2	Void Size Acceptance Criteria is Non-Conservative
05000255/FIN-2011009-03	2011Q3	P.5	Procedures Were Not Appropriate To Address Gas Accumulation Issues
05000255/FIN-2011009-02	2011Q3	H.2	GL 2008-01 Design Reviews Did Not Adequately Assess the Potential to Accumulate Voids Within Piping Systems
05000255/FIN-2011009-01	2011Q3	H.14	Failure to Adequately Evaluate the Enclosure Installed Over the 1F/1G Buses
05000255/FIN-2011012-01	2011Q3		Adequacy of SW Pump Couplings
05000255/FIN-2011004-04	2011Q3		Failure to Maintain SAMGs
05000255/FIN-2011405-01	2011Q3	H.8	Security
05000255/FIN-2011004-07	2011Q3		Incorrect Instructions to Operators in Appendix R, Post-Fire Alternate Safe Shutdown Procedure
05000255/FIN-2011004-03	2011Q3	H.9	Failure to Implement the Approved Emergency Classification Scheme
05000255/FIN-2011004-02	2011Q3	H.4	Unauthorized Entry to High Radiation Area
05000255/FIN-2011004-01	2011Q3	H.2	Failure to Control Dose to Worker in Locked High Radiation Area
05000255/FIN-2011014-07	2011Q4	H.14	Failure to perform an Adequate Operability Evaluation
05000255/FIN-2011016-01	2011Q4	P.5	Failure to Prevent Recurrence of a Significant Condition Adverse to Quality
05000255/FIN-2011015-02	2011Q4		Operators did not inform management an at-the-controls reactor operator left the at-the-controls area of the Control Room without providing a turnover to a qualified individual or obtaining permission from the Control Room Supervisor.
05000255/FIN-2011013-01	2011Q4	H.13	Improper Lubrication of Turbine Driven Auxiliary Feedwater Pump Linkages
05000255/FIN-2011014-03	2011Q4	H.8	Failure to Implement Human Performance Tools and to Perform an Infrequently Performed Test or Evolution Brief
05000255/FIN-2011014-04	2011Q4	H.9	Failure to Comply With Work Hour Rules for Non-Covered Workers
05000255/FIN-2011014-05	2011Q4	H.12	Failure to implement Emergency Operating Procedure Immediate Actions
05000255/FIN-2011014-06	2011Q4		Failure to Establish a Procedure for the Loss of a DC Bus and the Simultaneous Loss of Two Preferred AC Power Sources
05000255/FIN-2011014-09	2011Q4		Potential Loss of Preferred AC Sources in Harsh Environment
05000255/FIN-2011005-02	2011Q4	H.7	Failure to Control Packing Configuration of Pressurizer Spray Control Valves
05000255/FIN-2011014-08	2011Q4		Failure to Maintain Design and Procurement Control of the 125-Volt DC System
05000255/FIN-2011014-01	2011Q4		Failure to Report a 10 CFR 50.72 Notification for an 8-hour Non-Emergency Report
05000255/FIN-2011014-02	2011Q4	H.12	Failure to Have Adequate Work Instructions For Work Performed on Panel D11-2
05000255/FIN-2011005-01	2011Q4	H.9 H.2(b)	Failure to Establish Maintenance Procedures For Safety Related Breakers in Pane; D11-2

Self-Identified List (Palisades)

	Q	Title
05000255/FIN-2011002-05	2011Q1	None
05000255/FIN-2011403-02	2011Q1	Security
05000255/FIN-2011403-03	2011Q1	Security
05000255/FIN-2011405-02	2011Q3	Security
05000255/FIN-2011004-05	2011Q3	Licensee-Identified Violation
05000255/FIN-2011004-06	2011Q3	Licensee-Identified Violation
05000255/FIN-2011005-03	2011Q4	Licensee-Identified Violation
05000255/FIN-2011005-04	2011Q4	Licensee-Identified Violation

[Palisades Findings full list]

05000255/FIN-2011005-02

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