05000389/FIN-2016001-02
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Finding | |
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| Title | Failure to Provide Detailed Work Instructions Resulted in a Unit Transient |
| Description | A self-revealing finding was identified for the licensees failure to provide adequate work instructions for the circulating water system 1B1 traveling water screen drive motor replacement. Specifically, the inadequate work instructions resulted in a plant transient in order to remove the associated circulating water pump (CWP) from service. This issue was placed in the licensees corrective action program (CAP) as action request (AR) 2095560. The licensee completed the following corrective actions: (1) Counsel all maintenance supervisors in regard to having a questioning attitude and to seek guidance if unsure; (2) Rewire the 1B1 traveling screen drive motor for the proper rotation; (3) Install labels indicating the proper rotation for all eight traveling screen drive motors; (4) Submit document change requests to update the total equipment database; (5) Update all work orders (WO) for the remaining screen drive starter replacements to provide motor rotation direction and mark the post-maintenance test (PMT) step as a critical step, and; (6) Change clearance requests for traveling screen work to include directions to have electricians on station prior to returning the control switch to automatic. The failure to provide adequate work instructions for replacement of the 1B1 traveling screen motor was a performance deficiency (PD). The PD was more than minor because it was associated with the procedure quality 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 inadequate WO instructions resulted in installing the 1B1 traveling screen drive motor incorrectly on December 4, 2015. After the maintenance, the system automatically started and the screen rotated backwards. The backward rotation allowed accumulated debris to be transported to the 1B1 debris filter system (DFS) filter and caused it to overload. The resulting high differential pressure (DP) on the DFS filter necessitated the need to lower unit power (plant transient) and required removal of the 1B1 CWP from service. The finding was determined to be of very low safety significance (Green) based on Exhibit 1, Initiating Events Screening Questions, found in IMC 0609, Significance Determination Process, Appendix A, Significance Determination Process (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 inspectors determined the cause of this finding was associated with a cross-cutting aspect of ensuring risks are evaluated and managed before proceeding in the Challenge the Unknown component of the human performance area. Specifically, the licensee did not have a healthy questioning attitude and did not recognize the need to seek guidance when installing a new circulating water system traveling screen motor [H.11]. |
| Site: | Saint Lucie  |
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| Report | IR 05000389/2016001 Section 4OA2 |
| Date counted | Mar 31, 2016 (2016Q1) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | J Panfel J Reyes J Rivera L Suggs T Morrissey W Pursley |
| CCA | H.11, Challenge the Unknown |
| INPO aspect | QA.2 |
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Finding - Saint Lucie - IR 05000389/2016001 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Saint Lucie) @ 2016Q1
Self-Identified List (Saint Lucie)
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