05000272/FIN-2009005-02
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Finding | |
|---|---|
| Title | Inadequate Maintenance of the 22CCHX SW Outlet Butterfly Valve |
| Description | A self-revealing NCVof TS 6.8.1, \\\"Procedures and Programs,\\\" was identified because bolting between the valve body and actuator for 22SW356 broke causing the valve to partially close. This caused a degradation of shutdown core cooling by causing an unplanned reduction in SW flow through the only available CCHX. Valve 22SW356 failed because PSEG did not establish adequate maintenance procedures for valve actuator installation. PSEG completed corrective actions to replace 22SW356 using high strength bolts, with loctite adhesive and at the correct torque to secure the valve to the actuator. This issue was placed in PSEG\\\'s corrective action program. This finding is more than minor because it is associated with the equipment performance attribute of the Mitigating Systems cornerstone and it adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, use of an inadequate maintenance procedure for the manual valve operator installation on 22SW356 led to the bolting failure and partial closure of this manual butterfly valve. The inspectors evaluated the significance of this finding using IMC 0609, Appendix G, \\\"Shutdown Operations SDP,\\\" Attachment 1, Checklist 3 and determined that a Phase 2 analysis was required because the valve failure increased the likelihood that a loss of decay heat removal will occur due to a failure of the system itself or support systems. The senior reactor analyst (SRA) performed a Phase 2 analysis per IMC 0609, Appendix G, Attachment 2 and determined that the finding was of very low safety significance (Green). The finding is not greater than Green because the change in core damage frequency is substantially less than 1E\\\"6. This finding has a cross cutting aspect in the area of Human Performance because maintenance on 22SW356 was performed in 2002 with an inadequate procedure andwork instructions H.2(c). The procedure did not prescribe high strength bolts, loctite adhesive and correct torque, and, before the 22SW356 failure occurred, PSEG had not identified the errors and had planned to use the procedure and work instructions for the preventative maintenance valve replacement originally scheduled for October 2009. (Section 1R12.b.2 |
| Site: | Salem  |
|---|---|
| Report | IR 05000272/2009005 Section 1R12 |
| Date counted | Dec 31, 2009 (2009Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | D Schroeder M Patel S Pindale J Furia P Presby H Balian A Burritt E Bonney |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Salem - IR 05000272/2009005 | |||||||||||||||||||||||||||||||||||||
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Finding List (Salem) @ 2009Q4
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