05000352/FIN-2011004-02
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Finding | |
|---|---|
| Title | Failure to Provide Adequate Restoration Instructions for Turbine Control Valve Online Maintenance |
| Description | A Green, self-revealing finding was identified because Exelon did not provide adequate instructions for restoration of the Limerick Unit 2 number three turbine control valve (CV #3) following maintenance. During a fill and vent activity of the electro-hydraulic control (EHC) supply line for CV #3, a void in the system piping resulted in a low pressure condition at the next-in-series control valve, CV #1. The pressure drop actuated a relayed emergency trip system (RETS) pressure switch, generating a reactor protection system (RPS) 'S' side half scram signal. Combined with an 'A' side half scram signal that was previously inserted into RPS due to the CV #3 being maintained closed, an automatic reactor scram resulted. The inspectors determined that Exelon's failure to provide adequate instructions for restoration of CV #3 from maintenance was a performance deficiency. The issue was more than minor because it was associated with the Procedure Quality attribute of the Initiating Events cornerstone, and it affected the cornerstone objective of limiting the likelihood of events that upset plant stability. Specifically, on May 29, 2011, Limerick Unit 2 experienced an automatic reactor scram during restoration of turbine CV #3 from maintenance. The restoration instructions in the work order (WO) did not provide sufficient guidance to address the presence of a large air void in the EHC system that had the potential to cause EHC pressure fluctuations and resulted in a reactor scram. The finding was determined to be of very low safety significance (Green) in accordance with IMC 0609 Attachment 4, Phase 1Initial Screen and Characterization of Findings, because the finding did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available. This finding had a cross-cutting aspect in the area of Human Performance, Decision-Making, because Exelon did not use a systematic process to make a risk-significant decision when faced with uncertain or unexpected plant conditions. Specifically, Exelon did not recognize the potential risk of the CV #3 EHC fill and vent restoration activity, and they failed to conduct a thorough technical review of the restoration plan. |
| Site: | Limerick  |
|---|---|
| Report | IR 05000352/2011004 Section 4OA3 |
| Date counted | Sep 30, 2011 (2011Q3) |
| Type: | Finding: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | K Mangan N Sieller S Hammann T Moslak A Rosebrook A Ziedonis D Roberts E Dipaolo E Miller J Ambrosini J Kulp J Lilliendahl J Nicholson |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Limerick - IR 05000352/2011004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Limerick) @ 2011Q3
Self-Identified List (Limerick)
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