05000298/FIN-2011003-08

Finding

Title

Failure to Follow Procedure Results in Degraded Emergency Diesel Generator

Description

The inspectors identified a noncited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, regarding the licensees failure to follow written work instructions. Specifically, the inspectors identified that maintenance personnel, when unable to follow written instructions on torquing emergency diesel generator bolting due to mechanical interference, then used alternate methods. These methods contributed to the subsequent loosening of the bolting and degrading the capability of the emergency diesel generator. The licensee entered this issue into their corrective action program as Condition Report CR-CNS-2011-07653. The performance deficiency is more than minor since this failure to follow procedures resulted in a degraded emergency diesel generator which impacts the equipment performance attribute of the Mitigating Systems Cornerstone, and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). The finding was evaluated using Manual Chapter 0609.04, Phase 1 Initial Screening and Characterization of Findings, and was determined to be of very low safety significance (Green) because there was not a design or qualification deficiency that resulted in a loss of operability or functionality, it did not create a loss of system safety function or of a single train for greater than the technical specification allowed outage time, it did not represent an actual loss of risk significant equipment, and it did not affect seismic, flooding, or severe weather initiating events. The finding was determined to have a cross-cutting aspect in the area of human performance, associated with the work practices component, in that, personnel do not proceed in the face of uncertainty or unexpected circumstances. Specifically, when unable to torque emergency diesel generator bolting by following their written procedures, licensee personnel proceeded in the face of uncertainty by using alternate torque methods.

08
Site:	Cooper
Report	IR 05000298/2011003 Section 4OA5
Date counted	Jun 30, 2011 (2011Q2)
Type:	NCV: Green
cornerstone	Mitigating Systems
Identified by:	NRC identified
Inspection Procedure:
Inspectors (proximate)	G Pick J Josey L Ricketson M Chambers M Young N Greene V Gaddy
CCA	H.12, Avoid Complacency
INPO aspect	QA.4
'
v • d • e

Finding - Cooper - IR 05000298/2011003

1(0)2(6)3(12)4(7)5(9)6(5)7(0)8(6)9(1)10(0)201(0)202(1)301(0)403(0)501(0)

IR 05000298/2011003: 1 2 3 4 5 6 7 8 9 10 11 12

Finding List (Cooper) @ 2011Q2

CCA Matrix: 2011Q2

	Q	CCA	Title
05000298/FIN-2010004-02	2010Q3	P.2	Failure to Follow Procedure Results in Repeat Equipment Failure
05000298/FIN-2010004-01	2010Q3	H.14	Failure to Adequately Monitor the Performance of the Screen Wash System
05000298/FIN-2010005-03	2010Q4	P.5	Failure to Adequately Assess and Manage Risk During Maintenance Activities
05000298/FIN-2010006-01	2010Q4	P.1	Inadequate Post-Fire Safe Shutdown Procedures
05000298/FIN-2010006-02	2010Q4	H.14	Failure to Monitor the Performance of the Emergency Lights Against the Maintenance Rule Criteria
05000298/FIN-2010005-01	2010Q4	H.14	Failure to Implement Fire Protection Plan Requirements Related to Hot Work Activities
05000298/FIN-2010005-02	2010Q4	H.14	Failure to Assess and Manage Risk for Electrical Switchyard Impacting Maintenance
05000298/FIN-2010005-05	2010Q4		Diesel Generator Overspeed Governor Loose Bolting Issue
05000298/FIN-2010005-06	2010Q4		Failure to Update Flood Protection for Safety Related Buildings
05000298/FIN-2010005-04	2010Q4	P.3	Failure to Have Guidelines for the Choice of Protective Actions During an Emergency Consistent with Federal Guidance
05000298/FIN-2010007-04	2010Q4	P.5	Inadequate Design Control
05000298/FIN-2010007-06	2010Q4	S.2	Faulty General Electric Switches
05000298/FIN-2010007-01	2010Q4	H.7	Failure to Translate Design and Operating Requirements into Procedures
05000298/FIN-2010007-02	2010Q4	H.14	Failure to promptly Correct Conditions Adverse to Quality
05000298/FIN-2010007-03	2010Q4	H.7	Inadequate Test Control
05000298/FIN-2010007-05	2010Q4	H.14	Ice Deflector Pontoon Barge Storage in Service Water Discharge Canal
05000298/FIN-2010007-07	2010Q4		URI 05000298/2007011-07, Fuel Oil Storage Tank Required Submergence To Prevent Vortexing And Available Volume Are Marginal Without Accounting For Instrument Uncertainties
05000298/FIN-2010007-08	2010Q4		URI 05000298/2007011-08, High Pressure Coolant Pump Swap-Over from Emergency Condensate Storage Tank to Torus Vortex Calculation
05000298/FIN-2011009-01	2011Q1	P.2	Inadequate Post-Fire Safe Shutdown Procedures
05000298/FIN-2011002-02	2011Q1	P.3	Failure to Assess and Manage Risk for Maintenance That Could Impact Initiating Events
05000298/FIN-2011002-04	2011Q1	P.3	Repeat Failure to Follow Procedure for Initiating Condition Reports
05000298/FIN-2011002-03	2011Q1	H.8	Failure to Adequately Implement Foreign Material Exclusion Controls
05000298/FIN-2011002-01	2011Q1	H.14	Failure to Properly Evaluate All Senior Operator License Holders during Annual Operating Test
05000298/FIN-2011002-05	2011Q1	H.14	Failure to Notify the NRC within Eight Hours of a Nonemergency Event
05000298/FIN-2011003-08	2011Q2	H.12	Failure to Follow Procedure Results in Degraded Emergency Diesel Generator
05000298/FIN-2011006-05	2011Q2	H.14	Failure to Correctly Translate Design Requirements into Installed Plant Configuration
05000298/FIN-2011003-01	2011Q2	H.14	Failure to Assess Potential Adverse Effects on Internal Flooding Analysis
05000298/FIN-2011008-01	2011Q2	H.8	Unclear Work Instructions
05000298/FIN-2011008-02	2011Q2	H.5	Failure to Recognize Work Order Risk
05000298/FIN-2011008-03	2011Q2	H.12	Failure to Implement Human Performance Procedure
05000298/FIN-2011008-04	2011Q2	H.14	Failure to Revise Unclear Work Instructions
05000298/FIN-2011008-05	2011Q2	H.5	Failure to Perform an Adequate High Radiation Area Briefing
05000298/FIN-2011008-06	2011Q2	H.12	Failure to Follow Radiation Protection Job Coverage Procedures
05000298/FIN-2011003-04	2011Q2		Communication of an NRC Inspectors Presence by Station Personnel
05000298/FIN-2011006-02	2011Q2	P.2	Failure to Report Conditions Prohibited by Technical Specifications and Safety System Functional Failures
05000298/FIN-2011006-03	2011Q2	P.2	Failure to Perform 10 CFR 50.59 Evaluation for Design Change
05000298/FIN-2011006-04	2011Q2	P.2	Failure to Take Action for an Ineffective Corrective Action
05000298/FIN-2011003-02	2011Q2	P.2	Failure to Follow Procedure Results in Inadequate Operability Determinations
05000298/FIN-2011003-03	2011Q2	H.4 H.5	Failure to Follow Procedure Results in Personnel Contaminations
05000298/FIN-2011003-05	2011Q2	H.11 H.12	Failure to Follow Radiation Work Permit Requirements
05000298/FIN-2011003-06	2011Q2		Failure to Correctly Translate Design Requirements into Installed Plant Configuration
05000298/FIN-2011003-07	2011Q2		Failure to Adequately Assess and Manage Risk When Disabling A Hazard Barrier
05000298/FIN-2011003-09	2011Q2	H.6	Failure to Initiate Condition Reports for Nonconformances Identified During System Walk Downs
05000298/FIN-2011003-10	2011Q2	P.1	Failure to Promptly Correct an Adverse Condition Related to Emergency Core Cooling System Venting
05000298/FIN-2011006-01	2011Q2	P.1	Failure to Promptly Identify and Correct Conditions Adverse to Quality

Self-Identified List (Cooper)

	Q	Title
05000298/FIN-2010004-03	2010Q3	Licensee-Identified Violation
05000298/FIN-2010403-01	2010Q4	Security
05000298/FIN-2011002-06	2011Q1	Licensee-Identified Violation
05000298/FIN-2011003-11	2011Q2	Licensee-Identified Violation
05000298/FIN-2011003-12	2011Q2	Licensee-Identified Violation

[Cooper Findings full list]

05000298/FIN-2011003-08

Navigation menu

Search