A self-revealing finding of very low safety significance and associated
NCV of
TS 5.4.1 was identified on December 19, 2014, due to the licensees failure to follow Procedure FPMAFME01,
Foreign Material Exclusion and Control. Specifically, workers failed to implement and adhere to the
foreign material exclusion (
FME) control requirements for a Level 1
foreign material exclusion area when replacing the Unit 1
reactor coolant pump (
RCP) seals and associated piping during Refueling Outage 1R29. The failure to implement and adhere to the
FME control requirements resulted in introducing foreign material into the
reactor coolant system and the subsequent degradation of the #12
RCP seal in December 2014 and January 2015. The seal degradation led to two Unit 1 reactor shutdowns. Corrective actions for this issue included replacing the
RCP seal, flushing the seal piping and establishing a process to review work document quality to ensure that appropriate programmatic requirements were included. The inspectors determined that the failure to follow Procedure FPMAFME01 was more than minor because it was associated with the equipment performance attribute of the
Initiating Events cornerstone and impacted the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. The inspectors utilized Attachment 0609.04, Initial Characterization of Findings, and determined that this issue was of very low safety significance because each question provided in
IMC 0609, Appendix A, Exhibit 1,
Initiating Events Screening Questions, was answered No. The inspectors concluded that this finding was cross-cutting in the Human Performance, Work Management area, because the organization failed to implement a process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority. In addition, the work process failed to include the identification and management of risk commensurate to the work and the need for coordination with different groups or job activities (H.5).
