05000397/FIN-2011005-01
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Finding | |
|---|---|
| Title | Failure to Follow Work Instructions when Fabricating a Gagging Device for Main Condenser Hotwell Surge Bypass Valve |
| Description | The inspectors reviewed a self-revealing finding for the licensee\\\'s failure to follow work instructions. Specifically, mechanics failed to properly implement Work Order 01188696, Task 7, when fabricating the gagging device used to maintain main condenser hotwell surge volume bypass valve closed during planned maintenance. As a result, on November 2, 2011, a rapid, unexpected rise in hotwell level and conductivity and a rapid drop in condensate storage tank level occurred. Subsequent review revealed that the gagging device installed on the main condenser hotwell surge volume bypass valve failed, which allowed a vacuum drag flow path of condensate storage tank water to the main condenser hotwell. Following identification, the licensee re-fabricated a gagging device in accordance with engineerings specifications. This issue was entered into the licensee\\\'s corrective action program as Action Request AR 00251720. The finding was more than minor because it affected the design control attribute of the Initiating Events Cornerstone objective to limit the likelihood of those events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Using Inspection Manual Chapter 0609.04, Phase 1 Initial Screening and Characterization of Findings, the inspectors determined this finding to be of very low safety significance (Green) because the finding did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available. The inspectors determined that this finding had a cross-cutting aspect in the area of human performance associated with the decision making component because the licensee failed to implement roles and authorities as designed when fabricating the gagging device for COND-V-170 H.1(a) |
| Site: | Columbia  |
|---|---|
| Report | IR 05000397/2011005 Section 1R12 |
| Date counted | Dec 31, 2011 (2011Q4) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | P Elkmann W Walker J Groom M Hayes |
| CCA | H.13, Consistent Process |
| INPO aspect | DM.1 |
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Finding - Columbia - IR 05000397/2011005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Columbia) @ 2011Q4
Self-Identified List (Columbia)
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