05000341/FIN-2014004-03
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Finding | |
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| Title | Failure to Promptly Correct a Condition Adverse to Quality on EDG 11 |
| Description | A finding of very low safety significance with an associated non-cited violation of 10 CFR 50, Appendix B, Criterion XVI, Corrective Action, was self-revealed on March 20, 2014, when operators manually shut down emergency diesel generator (EDG) 11 while it was running for surveillance testing during the Cycle 16 refueling outage. A fire had ignited due to oil pooling underneath insulation on the engine exhaust manifold from a gasket leak on the front engine cover. The licensee failed to take timely corrective action after increased smoke was previously observed coming from underneath the exhaust manifold insulation on December 12, 2012. As immediate corrective actions, the licensee replaced insulation on the exhaust manifolds of all 4 EDGs with a different configuration to eliminate the seam that was located right under the corner of the front cover, retightened the bolts on the front engine covers of all four EDGs, and applied sealant to the area of the leak on the EDG 11 front engine cover until the gasket could be replaced. The finding was of more than minor significance because it was associated with the equipment performance attribute of the Mitigating Systems Cornerstone and adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, the failure to promptly initiate corrective action when a degraded condition was identified on EDG 11 resulted in a fire, manual engine shutdown, and an Alert emergency declaration during a surveillance test run. The finding was a licensee performance deficiency of very low safety significance because it: (1) was not a deficiency affecting the design or qualification of a mitigating SSC, (2) did not represent a loss of system safety function, (3) did not represent an actual loss of safety function of at least a single train for greater than its Technical Specification (TS)-allowed outage time, (4) did not represent an actual loss of safety function of one or more non-TS trains of equipment designated as risk significant for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> during shutdown with the reactor cavity flooded, (5) did not degrade a functional auto-isolation of RHR on low reactor vessel level, and (6) did not screen as potentially risk significant due to a fire, seismic, flooding, or severe weather initiating event. The inspectors determined this finding affected the crosscutting area of human performance due to the licensees failure to implement a process of planning, controlling, and executing work activities such that safety is the overriding priority. The work management process (H.5) includes the identification and management of risk commensurate to the work; however, due to complacency and failure to appropriately apply operating experience involving EDG exhaust manifold fires on Fairbanks-Morris engines, the licensee did not appropriately manage the risk associated with delaying corrective action for the adverse condition identified about 112 years prior to the event. |
| Site: | Fermi  |
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| Report | IR 05000341/2014004 Section 4OA2 |
| Date counted | Sep 30, 2014 (2014Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | B Dickson B Kemker J Nance P Smagacza Dahbura Shaikh B Kemker J Bozga M Kunowski M Learn P Smagacz R Edwards S Bell |
| Violation of: | 10 CFR 50 Appendix B Criterion XVI Technical Specification |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Fermi - IR 05000341/2014004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Fermi) @ 2014Q3
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