05000305/FIN-2009005-06
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Finding | |
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Title | Inadequate Work Instructions Lead to Component Cooling Water Relief Valve Lift and Surge Tank Level Drop |
Description | A finding of very low safety significance and associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed for the failure to have adequate work instructions in place during the isolation of component cooling water (CCW) flow in the reactor coolant pump vaults. Specifically, the inadequate valve isolation sequence and the speed at which the outlet valves were closed caused CCW system relief valves to lift and rapidly drain the component cooling water surge tank while the CCW system was supporting the residual heat removal system for decay heat removal. In response to the issue, the licensee implemented compensatory corrective actions to modify the tagout and hang tags on the appropriate CCW isolation valves. The inspectors determined that the finding was more than minor because it was associated with the Initiating Events Cornerstone attribute of configuration control and affected 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 determined that the finding could be evaluated in accordance with IMC 0609, Appendix G, Shutdown Operations SDP. The inspectors used Checklist 3 contained in Attachment 1 and determined that the finding required a Phase 2 analysis since the finding increased the likelihood that a loss of decay heat removal would occur. The Region III senior reactor analyst performed the assessment using Appendix G, Attachment 2, Phase 2 Significance Determination Process Template for PWR [Pressurized Water Reactor] During Shutdown, and determined that this issue is best characterized as a finding of very low safety significance (Green).This finding has a cross-cutting aspect in the area of human performance, resources component, because the licensee did not maintain long-term plant safety by maintenance of design margins. Specifically, the work instruction did not adequately account for the low design margin that existed between the system operating pressure and the relief valve setpoints when both CCW pumps were running (H.2(a)). |
Site: | Kewaunee ![]() |
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Report | IR 05000305/2009005 Section 1R20 |
Date counted | Dec 31, 2009 (2009Q4) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71111.2 |
Inspectors (proximate) | D Mcneil R Ruiz J Cassidy T Bilik M Phalen M Garza D Chyu M Kunowski S Burton K Barclay J Bozga M Jones |
CCA | H.6, Design Margins |
INPO aspect | WP.2 |
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Finding - Kewaunee - IR 05000305/2009005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Kewaunee) @ 2009Q4
Self-Identified List (Kewaunee)
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