05000336/FIN-2008003-02
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Finding | |
|---|---|
| Title | Inadequate Maintenance Instructions Causes Reactor Coolant System Unidentified Leakage in Excess of Technical Specification Limits |
| Description | The inspectors identified a Green NCV of 10CFR50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for Dominions failure to provide adequate maintenance instructions for replacing the gaskets on the B low pressure safety injection (LPSI) pump suction line. Specifically, the work order did not contain torque requirements; as a result, the flanged joint was over-torqued and caused the flexitallic gasket to fail. Debris from the gasket prevented the B LPSI pump suction isolation valve from closing, and caused a reactor coolant system leak in excess of Technical Specification limits. Dominion declared an Unusual Event. Dominion replaced the gasket and repaired the valve. The performance deficiency was Dominions failure to provide adequate maintenance instructions for assembling the flanged connection, including appropriate torque values. This finding is more than minor because it is associated with the Human Performance attribute of the Initiating Event Cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown, as well as power operations. The inspectors conducted a Phase 1 screening in accordance with IMC 0609, Appendix G, Shutdown Operations Significance Determination Process; a quantitative assessment (Phase 2) was required because the finding increased the likelihood of a loss of RCS inventory. The Phase 2 analysis resulted in the finding being screened as having very low safety significance (Green) because the change in core damage frequency was in the range of low 1E-7. The finding has a cross cutting aspect in the area of Human Performance, Resources, because Dominion did not ensure complete, accurate, and up-to-date work packages for the replacement of the gaskets in the B LPSI pump suction line. H.2(c) (Section 4OA3.1) |
| Site: | Millstone  |
|---|---|
| Report | IR 05000336/2008003 Section 4OA3 |
| Date counted | Jun 30, 2008 (2008Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | T Moslak J Lilliendahl J Benjamin J Krafty D Orr S Shaffer B Norris J Commiskey H Gray E Burket |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
| ' | |
Finding - Millstone - IR 05000336/2008003 | |||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Millstone) @ 2008Q2
Self-Identified List (Millstone)
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