05000333/FIN-2016003-01
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Finding | |
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Title | Inadequate Preventive Maintenance Results In Transformer Failure and Reactor Scram |
Description | A self-revealing Green finding (FIN) was identified for Entergy staffs failure to properly implement the requirements of EN-DC-324, Preventive Maintenance Program, Revision 16, to ensure proper preventive maintenance (PM) was implemented for non-safetyrelated 4KV transformer 71T-5. Specifically, Action Request (AR) 127566, PM change request to perform inspection, cleaning, and electrical testing of 4KV transformer 71T-5 was retired without a review by engineering as required by the PM program. As a result, transformer 71T-5 remained in service beyond its effective life without proper condition monitoring and maintenance, leading to its failure and a reactor scram on June 24, 2016. Entergy staff developed corrective actions to address the failure which included replacement of the transformer and re-establishing the condition monitoring and PM task. Entergy also performed an extent of condition review that confirmed the PM to clean, inspect, and test similar non-safety-related dry-type transformers was still active and performed within its required frequency. This finding is more than minor because it is associated with the Equipment Performance attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, Entergy staff failed to ensure an adequate PM was in place for transformer 71T-5. The PM to ensure adequate cleaning and testing was cancelled in 2011, and transformer 71T-5 ultimately failed on June 24, 2016, resulting in a manual reactor scram. In accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 1 of IMC 0609, Appendix A, The Significance Determination Process for Findings AtPower, issued June 19, 2012, the inspectors determined that this finding is of very low safety significance (Green) because although the performance deficiency caused a reactor scram, it did not result in the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. The inspectors did not assign a cross-cutting aspect to this finding because it is not indicative of current licensee performance. Specifically, the performance deficiency was determined to have occurred in 2011, the guidance in ENDC-324 is clear regarding the PM change process, and no additional failures to follow the process have resulted in significant reactor transients. |
Site: | FitzPatrick ![]() |
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Report | IR 05000333/2016003 Section 4OA3 |
Date counted | Sep 30, 2016 (2016Q3) |
Type: | Finding: Green |
cornerstone | Initiating Events |
Identified by: | Self-revealing |
Inspection Procedure: | IP 71153 |
Inspectors (proximate) | A Burritt B Sienel E Miller R Rolph S Barr |
INPO aspect | |
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Finding - FitzPatrick - IR 05000333/2016003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (FitzPatrick) @ 2016Q3
Self-Identified List (FitzPatrick)
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