05000389/FIN-2014002-03
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Finding | |
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| Title | Failure to Provide Detailed Work Instructions Resulted in Degraded Debris Filter System Performance and resulted in a Manual Reactor Trip |
| Description | A self-revealing finding was identified for the licensees failure to provide adequate work instructions. The maintenance work instructions for a debris filter system (DFS) backwash valve motor operator did not contain adequate details to ensure the motor operator was installed correctly. The incorrectly installed motor operator prevented the DFS from mitigating an influx of algae into the circulating water system and ultimately resulted in the need for operators to manually trip the reactor. The licensee entered this issue into the corrective action program (CAP) as action requests (ARs) 1878615 and 1911638. Corrective actions included properly installing the DFS backwash valve motor operator. The performance deficiency was more than minor because it was associated with the equipment reliability attribute of the initiating events cornerstone and adversely affected the cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during power operations. Specifically, the 1A2 DFS backwash valve was installed incorrectly in August 2012. This degraded the components ability to mitigate an algae intrusion event on May 31, 2013, and resulted in a manual reactor trip. The finding was determined to be of very low safety significance (Green) based on Exhibit 1, Initiating Events Screening Questions, found in Inspection Manual Chapter 0609, Significance Determination Process, Appendix A, SDP for Findings At- Power (June 19, 2012). This was due to the fact that the finding did not cause a loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. The cause of this finding was associated with a cross-cutting aspect of providing complete and accurate documentation in the documentation component of the human performance area. Specifically, the licensee did not provide work instructions with enough detail to properly reinstall the1A2 backwash valve motor operator (H.7). |
| Site: | Saint Lucie  |
|---|---|
| Report | IR 05000389/2014002 Section 4OA3 |
| Date counted | Mar 31, 2014 (2014Q1) |
| Type: | Finding: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | D Rich J Reyes J Rivera T Morrissey W Loo W Pursley |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Saint Lucie - IR 05000389/2014002 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Saint Lucie) @ 2014Q1
Self-Identified List (Saint Lucie)
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