05000397/FIN-2009005-05
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Finding | |
|---|---|
| Title | Digital Electro-Hydraulic Leak Results in Reactor Scram |
| Description | The inspectors reviewed a self-revealing finding for the failure of the licensee to provide an adequate procedure for the installation of an o-ring in the digital electro-hydraulic system. Specifically, failure to provide the methods and details for the preparation, review, approval, and implementation of procedures contributed to the improper installation of an o-ring in the digital electro-hydraulic system. This improper installation resulted in a failure of the o-ring seal, a leak in the digital electro-hydraulic system, and a subsequent manual reactor scram. The licensee entered the issue into the corrective action program and conducted a root cause evaluation. This finding was more than minor because it is an equipment performance issue that affected the Initiating Events Cornerstone objectives to limit the likelihood of those events that upset plant stability. Specifically, use of a less than adequate procedure during the installation of an o-ring in an accumulator lower block in the digital electro-hydraulic system resulted in a failure of the o-ring seal, a subsequent leak in the digital electro-hydraulic system, and a manual reactor scram due to a decreasing digital electro-hydraulic fluid inventory as indicated by a low low-level alarm for the digital electro-hydraulic tank (initiating event). The finding was of very low risk significance because the finding did not result in the loss of a safety function of a single train for greater than its technical specification allowed outage time. The cause of the finding is related to the crosscutting aspect of human performance with a resources component, because the licensee failed to provide adequate procedural requirements for oring installation work H.2(c) |
| Site: | Columbia  |
|---|---|
| Report | IR 05000397/2009005 Section 4OA3 |
| Date counted | Dec 31, 2009 (2009Q4) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | L Ricketson P Elkmann R Cohen W Walker M Hayes R Schmitt |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Columbia - IR 05000397/2009005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Columbia) @ 2009Q4
Self-Identified List (Columbia)
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