05000346/FIN-2017004-03
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Finding | |
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| Title | Failure to Prescribe Appropriate Work Instructions for an Activity Affecting Quality |
| Description | A self-revealed finding with an Apparent Violation (AV) of Title 10 of the Code of Federal Regulations (CFR) Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, and an associated violation of technical specification (TS) 3.7.5, Emergency Feedwater (EFW), was identified on September 13, 2017, due to the licensees apparent failure to prescribe appropriate work instructions for an activity affecting quality of the safety-related auxiliary feedwater (AFW) system. Specifically, the licensee apparently did not provide appropriate instructions to maintain an adequate amount of oil in the AFW turbine bearing oil sumps, resulting in the failure of AFW 1 on September 13, 2017. The licensee entered this issue into the CAP as CR201709443 and CR201709857, immediately replaced the damaged bearing, and updated the lubrication manual data sheets to include sight glass marking dimensions per vendor guidance. The apparent performance deficiency was determined to be more than minor because the finding was associated with the Mitigating Systems cornerstone attribute of equipment performance and potentially adversely affected the cornerstone objective of ensuring the availability, capability and reliability of equipment that respond to initiating events. Specifically, the apparent performance deficiency resulted in the failure of the AFW 1. Using IMC 0609, Attachment 4, Initial Characterization of Findings, and IMC 0609 Appendix A, The Significance Determination Process for Findings at Power, issued June 19, 2012, the finding was screened against the mitigating systems cornerstone. The inspectors determined the finding represented an apparent actual loss of function of at least a single train for greater than its technical specification allowed outage time. Therefore, a detailed risk evaluation will be performed by a regional senior reactor analyst. Because the safety characterization of this finding is not yet finalized, it is being documented with a significance of to be determined (TBD). The inspectors determined this finding affected the cross-cutting aspect of challenge the unknown in the area of Human Performance, where individuals stop when faced with uncertain conditions. Risks are evaluated and managed before proceeding. Specifically, licensee personnel apparently did not stop when faced with uncertain conditions in the preventive maintenance procedure for replacing the AFPT sight glasses. Although the replacement of the AFPT 1 inboard bearing sight glass occurred in 1997, the licensee had the opportunity to challenge the lack of detail in the work instructions in late 2014 when the AFPT 2 outboard bearing sight glass was replaced. [H.11] |
| Site: | Davis Besse  |
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| Report | IR 05000346/2017004 Section 4OA2 |
| Date counted | Dec 31, 2017 (2017Q4) |
| Type: | AV: TBD |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | D Mills J Beavers M Bielby J Cassidy M Doyle N Feliz M Garza J Neurauter J Rutkowski J Wojewoda J Cameron |
| Violation of: | 10 CFR 50 Appendix B Criterion V Technical Specification |
| CCA | H.11, Challenge the Unknown |
| INPO aspect | QA.2 |
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Finding - Davis Besse - IR 05000346/2017004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Davis Besse) @ 2017Q4
Self-Identified List (Davis Besse)
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