05000361/FIN-2009002-01
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Finding | |
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| Title | Failure to Follow Procedures when Performing Maintenance on the Auxiliary Feedwater System |
| Description | A self-revealing non-cited violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures and Drawings, was identified for the failure of maintenance personnel to follow maintenance order instructions to fully remove fuses to establish conditions necessary to perform valve testing on the auxiliary feedwater system. Instead of removing the fuse entirely from the fuse holder, maintenance personnel only removed one side of the fuse and left the other side inserted. This inappropriate maintenance practice caused plastic deformation on the associated side of the fuse holder, which impacted the design configuration of the auxiliary feedwater control system, and its ability to perform its required design function under all design basis accident conditions. This finding was entered into the licensees corrective action program as Nuclear Notification 200253911. The finding is greater than minor because it is associated with the configuration control attribute of the Mitigating Systems Cornerstone and affects the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors evaluated the issue using the Significance Determination Process (SDP) Phase 1 Screening Worksheet for the Initiating Events, Mitigating Systems, and Barriers Cornerstones provided in Manual Chapter 0609, Attachment 4, Phase 1 Initial Screening and Characterization of Findings. The inspectors determined that this finding represented a loss of the system safety function for the ability to provide secondary heat removal during a station blackout. This required that a Phase 2 estimation be completed. Because the Phase 2 assumptions significantly overestimated the risk related to this finding, the senior reactor analyst conducted a Phase 3 evaluation to provide a bestestimate risk assessment. The analyst calculated that a total ACDF of 4.4 x 10-7, therefore this finding is of very low risk significance (Green). The finding has a crosscutting aspect in the area of human performance associated with work practices because maintenance personnel did not comply with expectations regarding procedural compliance to follow the procedure as written without deviating from its intent H.4(b) |
| Site: | San Onofre  |
|---|---|
| Report | IR 05000361/2009002 Section 1R12 |
| Date counted | Mar 31, 2009 (2009Q1) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | P Elkman T Steadham J Reynoso G Warnick C Osterholtz M Hay |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - San Onofre - IR 05000361/2009002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (San Onofre) @ 2009Q1
Self-Identified List (San Onofre)
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