05000293/FIN-2015002-01
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Finding | |
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| Title | Ineffective Corrective Actions leads to Loss of Decay Heat Removal |
| Description | Green. A self-revealing Green finding was identified when residual heat removal (RHR) pump B experienced cavitation during refueling and maintenance outage (RFO) 20 that was a result of inadequate corrective actions associated with equipment used to determine flow rate. Specifically, prior to placing augmented fuel pool cooling (AFPC) mode in service on April 26, 2015, Entergy did not ensure that the temporary flow transmitter was properly setup and calibrated because corrective actions from 2011 were not adequate to ensure proper setup in the future. As a result, when operators went to raise flow in accordance with their procedural requirement, RHR pump B experienced cavitation and operators secured the pump because the flow transmitter was inaccurately reading low. Entergys immediate corrective actions included entering the issue into the corrective action program (CAP) as condition report (CR)-2015-3724, re-calibrating and setting up the ultrasonic flow meter, and establishing a second ultrasonic flow meter to ensure proper flow. Inspectors performed a walkdown to ensure proper operation of the ultrasonic flow meters, and confirmed similar readings between the two flow meters on April 27, 2015. The finding is more than minor because it is associated with the equipment performance attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the B RHR pump was secured from AFPC mode 2 on April 26, 2015 when the installed ultrasonic flow meter did not read properly, leading to operation of the B RHR pump outside of flow limits specified in procedure 2.2.85.2 and cavitation of the pump. This finding was evaluated in accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 2, Section C.6 of IMC 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Initial Screening and Characterization of Findings, the inspectors determined that this finding is of very low safety significance (Green) because while the performance deficiency resulted in the B RHR pump being secured due to cavitation, it did occur when the refuel canal/cavity was flooded and did not increase the likelihood of a fire or internal/external flood that could cause an shutdown initiating event. This finding has a cross-cutting aspect in the area of Problem Identification and Resolution, Evaluation, because Entergy staff did not thoroughly evaluate the issues associated with the ultrasonic flow meter in 2011 and 2013 to ensure that resolutions address causes and extent of conditions commensurate with their safety significance. Specifically, Entergys corrective action process did not thoroughly evaluate and develop appropriate corrective actions for CR-2011-1847 and CR-2013-2857 to ensure the cause was addressed to prevent challenges using ultrasonic flow meters during AFPC for both mode one and mode two. |
| Site: | Pilgrim |
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| Report | IR 05000293/2015002 Section 1R04 |
| Date counted | Jun 30, 2015 (2015Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.04 |
| Inspectors (proximate) | B Dionne B Scrabeck E Carfang E Knutson E Miller J Furia M Jimenez R Mckinley S Pindale T Burns |
| CCA | P.2, Evaluation |
| INPO aspect | PI.2 |
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Finding - Pilgrim - IR 05000293/2015002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Pilgrim) @ 2015Q2
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