05000352/FIN-2012005-02
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Finding | |
|---|---|
| Title | Failure to Revise EDG Tank Cleaning Work Instructions |
| Description | A self-revealing Green NCV of Technical Specification 6.8.1, Administrative Controls-Procedures, was identified because Exelon did not implement procedure use and adherence requirements when workers changed the scope of work on emergency diesel generator (EDG) fuel oil day tanks and did not revise the work instructions when they determined that work could not be performed as written. This resulted in EDG D13 accruing approximately 40 hours4.62963e-4 days <br />0.0111 hours <br />6.613757e-5 weeks <br />1.522e-5 months <br /> of unplanned unavailability between December 14 and 16, 2012. Exelon entered the issue into their CAP as IR 1453737, conducted a human performance review board, drained and flushed the tank to restore fuel oil quality, and initiated an ACE. This finding was more than minor because it was associated with the Human Performance attribute of the Mitigating Systems cornerstone and affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The finding was determined to be self-revealing because it was revealed through the receipt of alarms during operation which required no active and deliberate observation by the Exelon staff. The finding was determined to be of very low safety significance (Green) in accordance with Section A of Exhibit 2 of IMC 0609, Appendix A, The Significance Determination Process for Findings at Power, because the finding did not represent an actual loss of function a single train for greater than the TS allowed outage time. This finding had a cross-cutting aspect in the area of Human Performance, Work Practices, because Exelon did not ensure that personnel followed procedures H.4(b). Specifically, work order procedural steps to clean the fuel oil tank were not completed as directed by the work order and a procedurally required change to written work instructions was not implemented when station personnel determined that the fuel oil tank cleaning would be based on the need to clean the tank as determined by tank inspection results. |
| Site: | Limerick  |
|---|---|
| Report | IR 05000352/2012005 Section 1R19 |
| Date counted | Dec 31, 2012 (2012Q4) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.19 |
| Inspectors (proximate) | E Dipaolo J Caruso P Kaufman M Gray A Rosebrook S Barr R Nimitz J Hawkins C Newport J Demarshall |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Limerick - IR 05000352/2012005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Limerick) @ 2012Q4
Self-Identified List (Limerick)
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