05000275/FIN-2013004-01
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Finding | |
|---|---|
| Title | The failure to use procedures to perform corrective maintenance
on an emergency diesel generator |
| Description | The inspectors reviewed a self-revealing non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, after the licensee performed corrective maintenance on a diesel fuel oil system leak without appropriate documentation or procedures. This resulted in the fuel oil header not being properly primed or vented, which rendered an emergency diesel generator inoperable. The licensee entered the condition into the corrective action program as Notification 50561918. The failure to use procedures to perform corrective maintenance on an emergency diesel generator was a performance deficiency. The performance deficiency was more than minor because it was associated with the human performance attribute of the Mitigating Systems Cornerstone, and it adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences and is therefore a finding. Using Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings, and Appendix A, Exhibit 2, Mitigating Systems Screening Questions, this finding was determined to be of very low safety significance (Green) because it was not a design or qualification deficiency, was not a loss of the system or function, and did not represent an actual loss of function of a single train for greater than its technical specification allowed outage time. The finding had a cross-cutting aspect in the area of human performance, associated with the work practices component, because licensee staff did not communicate human error prevention techniques, such as proper documentation of activities, and did not use this technique commensurate with the risk of the assigned task, such that work activities are performed safely. Specifically, the system engineer recognized the possibility of introducing air into the system, but assumed that operators would have filled and vented the system using the appropriate procedure, while operators did not use a procedure to tighten the leaking fitting and refill the priming tank. |
| Site: | Diablo Canyon  |
|---|---|
| Report | IR 05000275/2013004 Section 4OA2 |
| Date counted | Sep 30, 2013 (2013Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | L Carson N O'Keefe W Sifre T Hipschman J Laughlin B Parks I Anchondo L Micewski C Hale |
| Violation of: | 10 CFR 50 Appendix B Criterion V Technical Specification Technical Specification - Procedures |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
| ' | |
Finding - Diablo Canyon - IR 05000275/2013004 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Diablo Canyon) @ 2013Q3
Self-Identified List (Diablo Canyon)
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