05000286/FIN-2008004-02
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Finding | |
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| Title | Failure to Follow Maintenance Procedures Results in Degraded EDG for 37 Days |
| Description | A self-revealing, non-cited violation (NCV) of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified when maintenance personnel improperly performed a maintenance procedure that resulted in two adjacent cylinders of the 33 emergency diesel generator (EDG) being locked-out without fuel oil supply for approximately 37 days. Entergy entered this issue into the corrective action program, performed a root cause evaluation, performed extent of condition inspections of similar EDGs on-site, instituted immediate procedure changes to preclude recurrence, and communicated the human error attributes that contributed to the event to plant personnel. The inspectors determined that the finding was more than minor because it was associated with the Human Performance attribute of the Mitigating Systems cornerstone, and impacted its objective to ensure the availability and reliability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the locked-out cylinders degraded the full rated capacity of the EDG and unavailability hours were utilized to resolve the high exhaust temperatures identified during surveillance testing on July 11, 2008. This finding was determined to be of very low safety significance (Green), using Phase 3 guidance contained in IMC 0609, Determining the Significance of Reactor Inspection Findings for At-Power Situations. Specifically, a bounding analysis was performed with the conservative assumption that the 33 EDG was considered inoperable for 37 days. The inspectors determined that this finding had a cross-cutting aspect in the area of Human Performance, in that maintenance personnel did not utilize self-check, peercheck, and documentation skills that would have prevented the event. Specifically, maintenance personnel failed to verify that all fuel injection pump control latches were not engaged prior to the installation of injection pump covers, and required signature verification that indicated successful completion of this step in the applicable maintenance procedure. |
| Site: | Indian Point  |
|---|---|
| Report | IR 05000286/2008004 Section 4OA3 |
| Date counted | Sep 30, 2008 (2008Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | A Koonce B Bickett J Commiskey J Noggle K Young P Cataldo S Barr T Nicholson |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Indian Point - IR 05000286/2008004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Indian Point) @ 2008Q3
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