05000311/FIN-2017009-01
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Finding | |
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| Title | Failure to Follow Troubleshooting Procedure for BIT Relief Valve Leakage |
| Description | Analysis. The inspectors determined that PSEG's performance of activities on the HHSI system that were beyond those documented in the approved troubleshooting instructions was a performance deficiency that was reasonably within PSEG's ability to foresee and correct, and should have been prevented. This finding was more than minor because it was associated with the equipment performance attribute of the Mitigating System cornerstone in Inspection Manual Chapter (IMC) 0305, "Operating Reactor Assessment Program," and adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, failure to execute the troubleshooting plan as written resulted in HHSI system inoperability and adversely affected the availability, reliability, and capability of both trains of the HHSI. This performance deficiency required a detailed risk evaluation (ORE) in accordance with IMC 0609, "Significance Determination Process," Appendix A, screening questions in Exhibit 2, "Initiating Events," because the finding affected other systems used to mitigate a loss of coolant accident (LOCA), namely high head safety injection. Specifically, due to a failure of the 2SJ1 0, the 2SJ4 and 2SJ5 valves were de-energized, isolating HHSI. Operators declared both trains of HHSI inoperable which resulted in a loss of the high head safety function. The inspectors and a Region I Senior Reactor Analyst (SRA) conducted a bounding ORE and determined this finding to be of very low safety significance (Green). The leakage was determined to be sufficiently below the leak rate bounding a small break LOCA and the risk of the leak itself was considered to be minimal. The impact on the loss of HHSI system was evaluated using the Salem Standardized Plant Analysis model with both trains of HHSI out-ofservice, assuming at power operations, and resulted in a core damage frequency risk increase of less than 1 E-6. This was due in large part to the short exposure period of the degraded condition. Recognizing that the unit was shutdown and coming out of an outage with very little decay heat, the actual risk of core damage was considerably lower and the potential for impacts from a large early release was negligible. In accordance with IMC 0310, "Aspects Within Cross Cutting Areas," this finding had a crosscutting aspect in the area of Human Performance, Procedure Adherence, in that individuals did not follow processes, procedures, and work instructions. Specifically, PSEG operators in the field performed actions outside of the written instructions while performing troubleshooting activities in the field to investigate lowering pressure in the Unit 2 BIT. [H.8] Enforcement. TS 6.8.1, "Procedures and Programs," states, in part, that "written procedures shall be established, implemented and maintained covering the applicable procedures recommended in Appendix 'A' of Regulatory Guide (RG) 1.33, Revision 2, February 1978." RG 1.33, Section 9, "Procedures for Performing Maintenance," states, in part, that "maintenance that can affect the performance of safety-related equipment should be properly preplan ned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances." MA-AA-716-004, "Conduct of Troubleshooting," Revision 12, is one administrative procedure controlling the conduct of maintenance involving troubleshooting that can affect the performance of safety-related equipment. Step 4.1.4 of MA-AA-716-004, states that any need for changes to an approved troubleshooting plan requires that the plan be revised and reapproved. Work is to be stopped in the field until the plan is revised and reapproved. Contrary to the above, on November 23, 2015, PSEG did not properly implement procedures related to the performance of maintenance involving troubleshooting of a safety-related system. Specifically, while troubleshooting the Unit 2 BIT and its associated relief valve (2SJ1 0), PSEG personnel did not follow procedure MA-AA-716-004 when changes to the approved troubleshooting plan were implemented. The 2SJ1 0 relief valve was mechanically agitated in the field without stopping work in the field to revise and reapprove the documented instructions in the troubleshooting plan. Mechanically agitating the 2SJ1 0 relief valve outside of the documented instructions in the troubleshooting plan resulted in increased RCS leakage that exceeded the TS limit for unidentified RCS leakage and Unusual Event entry criterion and caused TS inoperability of both trains of the HHSI. PSEG operators immediately isolated the RCS leak, and declared both trains of high head safety injection inoperable, entered TS 3.0.3, and conducted a cooldown to Mode 5. PSEG entered this in their corrective action program (CAP) as 20711368, performed a prompt investigation, and commenced an apparent cause evaluation. Because this finding was of very low safety significance and was entered into PSEG's CAP, this violation is being treated as an NCV consistent with Section 2.3.2.a of the NRC's Enforcement Policy. (NCV 05000311/2017009-01, Failure to Follow Troubleshooting Procedure for BIT Relief Valve Leakage) |
| Site: | Salem  |
|---|---|
| Report | IR 05000311/2017009 Section 4OA5 |
| Date counted | Sep 30, 2016 (2016Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | |
| Inspectors (proximate) | M Scott |
| Violation of: | Technical Specification - Procedures |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Salem - IR 05000311/2017009 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Salem) @ 2016Q3
Self-Identified List (Salem)
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