05000324/FIN-2014005-02
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Finding | |
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| Title | Failure to Follow Emergency Diesel Generator No. 3 Monthly Load Test Surveillance Procedure |
| Description | A Green self-revealing NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified for the failure to conduct the number 3 EDG monthly load test in accordance with the prescribed technical specification surveillance test procedure. Specifically, plant personnel performing the load test on EDG3 manually synched the generator out-of-phase to its corresponding emergency bus, causing equipment damage to the collector ring and brushes and the silicon controlled rectifier (SCR) circuitry. The licensee documented the issue in their CAP, completed a prompt investigation, and performed a root cause evaluation. The EDG was immediately repaired and additional corrective actions include: 1) revise all EDG monthly load test procedures with cautions to emphasize the importance of synching the generator properly and performing the steps of the procedure as prescribed; and 2) install synch check relays on all manually paralleled generators. The finding was more than minor in accordance with IMC 0612, Appendix B, because it is associated with the Mitigating Systems Cornerstone attribute of Human Performance, 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, plant personnel performing the local load test on EDG3 manually synched the generator out-of-phase to its corresponding emergency bus, resulting in extended EDG3 inoperability and equipment damage to the collector ring, brushes, and the SCR circuitry. Utilizing IMC 0609, Appendix A, Exhibit 1, effective July 1, 2012, the finding screened as Green by answering no to the question related to an actual loss of function of one or more non-technical specification trains of equipment designated as high safety-significant in accordance with the licensees maintenance rule program for >24 hrs. The finding had a cross-cutting aspect in the area of Human Performance related to the aspect of Avoid Complacency, in that individuals failed to recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes, and implement appropriate error reduction tools. In this event, the operators had an inaccurate risk perception that the evolution of increasing load on the EDG was more critical than synching the generator properly. This was emphasized during the pre-job brief and not identified by the supervisory oversight of the evolution. |
| Site: | Brunswick  |
|---|---|
| Report | IR 05000324/2014005 Section 1R22 |
| Date counted | Dec 31, 2014 (2014Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.22 |
| Inspectors (proximate) | A Scarbeary G Hopper G Kolcum M Bates M Catts M Schwieg |
| Violation of: | 10 CFR 50 Appendix B Criterion V Technical Specification Technical Specification - Procedures |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Brunswick - IR 05000324/2014005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Brunswick) @ 2014Q4
Self-Identified List (Brunswick)
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