05000255/FIN-2014002-04
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Finding | |
|---|---|
| Title | Introduction of Foreign Material Into the SW System |
| Description | A finding of very low safety significance and an associated non-citied violation of Technical Specification (TS) 5.4.1, Procedures, was identified by the inspectors when licensee personnel failed to follow procedure EN-MA-118, Foreign Material Exclusion (FME), during work on the safety-related critical service water (SW) system during refueling outage (RFO) 1R23. Specifically, Sections 5.2[1] and 5.2[6] of EN-MA-118 stated that planners and procedure writers should evaluate FME considerations for work activities and include job-specific FME controls in work instructions and procedures. Additionally, EN-MA-188 stated that during the planning stage, the planner should designate the FME Zone type, risk level, pathways to FME sensitive equipment, and work practice restrictions, as applicable, in all work packages. However, adequate controls were not established and documented when the decision was made to use an inflatable bladder inside the SW system when work was being performed on the system. As a result, on two separate occasions during RFO 1R23, bladders were inadvertently entrained into the return header of the SW system by the relative vacuum created by system flow. The licensee entered this issue into their CAP as CR-PLP-2014-00715, Vacuum was So Great that Bladder was Ripped Off Lanyard and Lost in Piping, and CR-PLP-2014-01176, FME Bladder Lost During Work Near CV-0823. As part of their corrective actions, the licensee successfully completed a comprehensive SW system test, which validated acceptable system parameters. The inspectors determined that this finding was more than minor in accordance with IMC 0612, Appendix B, Issue Screening, because if left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern. In accordance with Checklist 3, PWR [Pressurized Water Reactor] Cold Shutdown and Refueling Operation RCS [Reactor Coolant System] Open and Refueling Cavity Level < 23' Or RCS Closed and No Inventory in Pressurizer Time to Boiling < 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br />, following the loss of the first bladder, and Checklist 4, PWR Refueling Operation: RCS Level > 23' Or PWR Shutdown Operation with Time to Boil > 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> And Inventory in the Pressurizer, following the loss of the second bladder of Attachment 1, Phase 1 Operational Checklists for both PWRs and BWRs [Boiling Water Reactors], of IMC 0609, Appendix G, Shutdown Operations Significance Determination Process, the inspectors determined that mitigation capabilities were not adversely impacted. Additionally, utilizing Table 1, Losses of Control, of IMC 0609, Appendix G, the inspectors determined there was no loss of control. As a result, the finding screened as having very low safety significance (Green). This finding had an associated cross-cutting aspect in the Work Management (H.5) component of the Human Performance cross-cutting area because the licensee did not implement a process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority. In particular, 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. |
| Site: | Palisades  |
|---|---|
| Report | IR 05000255/2014002 Section 1R20 |
| Date counted | Mar 31, 2014 (2014Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | A Garmoe A Scarbeary E Duncan E Sanchez Santiago G Hansen J Cassidy J Lennartz M Jones M Phalen T Bilik T Taylor |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | , |
| INPO aspect | WP.1, WP.1 |
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Finding - Palisades - IR 05000255/2014002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palisades) @ 2014Q1
Self-Identified List (Palisades)
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