05000305/FIN-2011005-05
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Finding | |
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| Title | Unanticipated Closure of Emergency Diesel Generator B Output Breaker |
| 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 implement a procedure for an activity affecting quality. Procedure OP-KWOSP- DGE-003B, Diesel Generator B Semi-Annual, required electrical maintenance personnel to check only the voltage of the emergency diesel generator (EDG) B output breaker Relay 52C/1-603; however, the electricians checked voltage and then attempted to check resistance of the relay. Specifically, after successfully testing for voltage, an electrician then selected a resistance setting for the volt-ohm meter (VOM) in an attempt to perform a continuity check of the relay, which was not prescribed by the procedure. The electricians actions resulted in the closure of the EDG output Breaker 1-603, and EDG B was paralleled to the grid out-of-phase. The licensee initiated a CR and took remedial corrective actions that included additional testing and inspections of EDG B to ensure that no damage occurred to the equipment as a result of the system transient, followed by the successful completion of post maintenance testing. At the end of the inspection period, the licensee was performing a root cause evaluation to determine the cause of the event and to develop additional corrective actions related to the organizational performance issues. The inspectors determined that the finding was more than minor in accordance with IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, because the finding was associated with the MS Cornerstone attribute of Equipment Performance, and adversely impacted the objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the attribute of equipment performance impacted the availability and reliability of EDG B and could have resulted in the catastrophic failure of the generator. The inspectors determined that the finding could be evaluated using the SDP in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Phase 1 - Initial Screening and Characterization of Findings, Table 4a, for the MS Cornerstone, dated January 10, 2008. The inspectors answered No to the MS questions and screened the finding as having very low safety significance (Green). The inspectors determined that this finding has a cross-cutting aspect in the area of Human Performance - Work Practices, because the maintenance personnel and supervision failed to communicate and ensure human error prevention techniques were used, such as holding formal pre-job briefings, and self and peer checking. The licensee also failed to ensure that these techniques were used commensurate with the potential risk of the assigned task, such that work activities were performed safely. Finally, during these maintenance activities, the inspectors concluded that licensee personnel proceeded in the face of uncertainty. |
| Site: | Kewaunee  |
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| Report | IR 05000305/2011005 Section 1R19 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.19 |
| Inspectors (proximate) | D Mcneil R Winter K Riemer J Cassidy D Betancourt K Barclay N Feliz-Adomo M Jones J Beavers V Myers S Shah M Ziolkowski |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Kewaunee - IR 05000305/2011005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Kewaunee) @ 2011Q4
Self-Identified List (Kewaunee)
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