05000263/FIN-2011002-01
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Finding | |
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| Title | Inadequate System Isolation during Check Valve Maintenance |
| Description | A finding of very low safety significance and associated NCV of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed when the licensee failed to adequately implement the requirements of their fleet tagging procedure, a procedure affecting quality, during maintenance on the safety-related CST-88 B low pressure coolant injection (LPCI) fill line check valve. This failure resulted in an unintentional breach of the condensate service water (CSW) system and subjected workers to a potentially contaminated, pressurized water source. Additionally, at the time of the breach, the CSW system was one of the water sources being credited in support of the shutdown safety function of inventory control. The licensee entered this issue into the corrective action program (CAPs 1275935 and 1275963) and took immediate corrective actions to restore the check valve to its installed configuration to terminate the water leakage. At the time of this report, the licensee had assembled a team to perform a root cause evaluation. The inspectors determined that the licensees failure to adequately implement their tagging process to protect workers and equipment from the effects of breaching the pressurized CSW header during maintenance on a safety-related check valve was a performance deficiency because it was the result of the failure to meet a requirement, the cause was reasonably within the licensees ability to foresee and correct, and should have been prevented. The inspectors screened the performance deficiency per IMC 0612, Power Reactor Inspection Reports, Appendix B, and determined that the issue was more than minor because the performance deficiency could have reasonably been viewed as a precursor to a more significant event. In this instance, the performance deficiency resulted in an unintentional breach of the operating CSW system and subjected workers to a potentially contaminated, pressurized water source. Additionally, at the time of the breach, the CSW system was one of the water sources being credited in support of the shutdown safety function of inventory control. As a result, this finding was evaluated under the Initiating Events Cornerstone. The inspectors applied NRC IMC 0609, Significance Determination Process, Appendix G, Shutdown Operations Significance Determination, Attachment 1, to this finding. The finding was determined to have very low safety significance because it did not adversely affect core heat removal, inventory control, power availability, containment control, or reactivity guidelines. This finding has a cross-cutting aspect in the area of Human Performance, work control, because the licensee failed to appropriately plan work activities by incorporating job site conditions impacting plant systems and components (H.3(a)). |
| Site: | Monticello  |
|---|---|
| Report | IR 05000263/2011002 Section 1R20 |
| Date counted | Mar 31, 2011 (2011Q1) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.2 |
| Inspectors (proximate) | N Shah A Dahbur K Riemer M Phalen S Thomas D Jones P Voss C Tilton P Cardona-Morales |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Monticello - IR 05000263/2011002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Monticello) @ 2011Q1
Self-Identified List (Monticello)
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