05000382/FIN-2012004-04

Finding

Title

Failure to Adequately Access and Manage Risk Before Performing Maintenance Activities Associated with NON-STANDARD Lifts

Description

The inspectors identified a non-cited violation of 10 CFR 50.65(a)(4) because the licensee did not assess and manage the increase in online risk involved with maintenance activities that lifted heavy loads over safety related equipment. Specifically, the licensee did not assess and manage the integrated plant online risk prior to performing heavy load lifts in the train B dry cooling tower fan area when installing a temporary work platform to support the steam generator replacement project. As a result, the licensee did not implement additional risk management actions as required by their procedure EN-WM-104, OnLine Risk Assessment. The licensee entered this condition into the corrective action program as CR-WF3-2012-4195 and CR-WF3-2012-4489. The immediate corrective action taken to restore compliance was to re-evaluate and change the integrated risk classification from a normal risk to a high-risk level and implement the required risk management actions. The failure to adequately assess and manage overall plant risk prior to performing maintenance activities that lifted heavy loads over the train B dry cooling tower fan area was a performance deficiency. The performance deficiency was more than minor because it was associated with the human performance attribute of the Initiating Events cornerstone and affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the licensees failure to identify non-standard lifts over safety related equipment as high risk prevented the licensee from taking additional risk management actions to limit the likelihood of an event that would upset plant stability. The inspectors used NRC Inspection Manual 0609, Attachment 4, Initial Characterization of Findings, to evaluate this issue. The initial screening directed the inspectors to use Appendix K Maintenance Risk Assessment and Risk Management Significance Determination Process to determine the significance of the finding. In accordance with NRC Inspection Manual Chapter 0609, Appendix K, a senior reactor analyst determined that the finding was very low safety significance (Green) because the bounding risk deficit was approximately 1E-7/year. The inspectors concluded that the finding reflected current licensee performance and involved a cross-cutting aspect in the decision making component of the human performance area because the licensee did not make safety significant or risk significant decisions using a systematic process to ensure safety was maintained

04
Site:	Waterford
Report	IR 05000382/2012004 Section 1R13
Date counted	Sep 30, 2012 (2012Q3)
Type:	NCV: Green
cornerstone	Initiating Events
Identified by:	NRC identified
Inspection Procedure:	IP 71111.13
Inspectors (proximate)	P Elkmann M Davis D Allen W Sifre J Laughlin R Cureton R Azua D Overland C Speer
CCA	H.13, Consistent Process
INPO aspect	DM.1
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v • d • e

Finding - Waterford - IR 05000382/2012004

1(0)2(2)3(3)4(4)5(5)6(0)7(2)8(6)9(0)10(0)11(0)201(0)202(1)301(0)403(4)404(2)405(0)503(0)801(0)1(0)15(0)

IR 05000382/2012004: 1 2 3 4

Finding List (Waterford) @ 2012Q3

CCA Matrix: 2012Q3

	Q	CCA	Title
05000382/FIN-2011005-01	2011Q4	H.14	Inoperable Train of Containment Cooling System
05000382/FIN-2011005-03	2011Q4		Failure to Periodically Update the Updated Final Safety Analysis Report
05000382/FIN-2011007-08	2011Q4	P.6	Failure to Adequately Manage the Risk Involved with a Maintenance Window for the Turbine Driven Essential Feedwater Pump
05000382/FIN-2011007-07	2011Q4	H.14	Failure to Provide an Adequate Basis for Temperature Limits of Auxiliary Component Cooling Water Pump Motor Bearings
05000382/FIN-2011007-06	2011Q4		Failure to Establish an Analysis of the Effect of Reverse Rotation of Dry Cooling Tower Fan Motors Resulting from a Tornado Event
05000382/FIN-2011007-05	2011Q4		Failure to Establish an Analysis to Support the Adequacy of the Four Inch Bulkhead Drain to Protect the Ultimate Heat Sink During Flood Events
05000382/FIN-2011007-04	2011Q4		Failure to Provide Adequate Preventive Maintenance Procedures for Aluminum/Copper Electrical Connections to the Ultimate Heat Sink Transformers
05000382/FIN-2011007-03	2011Q4		Failure to Provide an Adequate Basis for Extrapolation of Vendor Supplied Pump Net Positive Suction Head Values
05000382/FIN-2011007-02	2011Q4		Failure to Establish an Adequate Containment Spray Pump Design Basis Verification Surveillance Test
05000382/FIN-2011007-01	2011Q4		Failure to Assure Design Basis Input was Correctly Translated into Design Basis Calculations
05000382/FIN-2011005-05	2011Q4		Failure to Follow Work Order Instructions to Install a Swagelok Fitting on a Main Feedwater Isolation Valve Tube Connection
05000382/FIN-2011005-04	2011Q4	H.7	Failure to Translate Tornado Impact on the Ultimate Heat Sink During a Refueling Outage
05000382/FIN-2011005-02	2011Q4	P.5	Failure to Identify and Correct a Condition Adverse to Quality Associated with the Main Feedwater Isolation Valves
05000382/FIN-2012002-01	2012Q1		Failure to Develop Preventive Maintenance Tasks for Critical Limit Switches on Component Cooling Water Inlet Isolation Valves
05000382/FIN-2012002-02	2012Q1	H.7	Failure to Identify and Perform Testing to Demonstrate Performance of SAFETY-RELATED Valves
05000382/FIN-2012007-02	2012Q1		Failue to Calculate Adequate Cooling Provided to Diesel Generator B within Required Time
05000382/FIN-2012007-01	2012Q1		Failure to Adequately Evaluate the Impact of Fire Damage on the Dry Cooling Tower Fans
05000382/FIN-2012202-01	2012Q2	P.1	Security
05000382/FIN-2012003-02	2012Q2	H.14	Failure to Provide Adequate Design Control Measures for Verifying or Checking the Adequacy of the Ultimate Heat Sink Thermal Performance Analysis
05000382/FIN-2012003-01	2012Q2	H.7	Failure to Establish Adequate Procedural Guidance to Control Feedwater Heater Level Control Valves
05000382/FIN-2012004-03	2012Q3	P.2	Failure to Identify and Correct a Torn Diaphragm of a SAFETY-RELATED Air Operated Valve Associated with the Emergency Feedwater System
05000382/FIN-2012004-04	2012Q3	H.13	Failure to Adequately Access and Manage Risk Before Performing Maintenance Activities Associated with NON-STANDARD Lifts
05000382/FIN-2012004-02	2012Q3	P.2	Failure to Identify and Correct Degraded Conditions Associated with the Auxiliary Component Cooling Water Heat Exchanger Outlet Temperature Control Valve
05000382/FIN-2012004-01	2012Q3	P.5	Failure to Establish Procedural Controls to Ensure That Licensed Operators Could Perform Immediate and Time Critical Operator Actions Associated with Security and Fire Events
05000382/FIN-2012008-01	2012Q3	P.5	Failure to Promptly Determine the Operability of the Emergency Diesel Generators
05000382/FIN-2012008-02	2012Q3	H.6	Failure to Take Corrective Action Associated with Emergency Feedwater Pump AB
05000382/FIN-2012008-03	2012Q3	H.6	Failure to Take Timely Corrective Action to Establish a Basis for Flood Control Measures
05000382/FIN-2012008-04	2012Q3	H.8	Failue to Ensure Operator Knowledge of Equipment Status
05000382/FIN-2012008-05	2012Q3	H.8	Failure to Develop Effective Corrective Actions to Preclude Repetition
05000382/FIN-2012403-01	2012Q3		Security
05000382/FIN-2012403-02	2012Q3	H.14	Security
05000382/FIN-2012403-03	2012Q3	H.10	Security
05000382/FIN-2012403-04	2012Q3	H.9	Security

Self-Identified List (Waterford)

	Q	Title
05000382/FIN-2011005-06	2011Q4	Licensee-Identified Violation
05000382/FIN-2012003-03	2012Q2	Licensee-Identified Violation
05000382/FIN-2012008-06	2012Q3	Licensee-Identified Violation

[Waterford Findings full list]

05000382/FIN-2012004-04

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