05000455/FIN-2011011-01
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Finding | |
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| Title | Self-Revealing Failure of the 2A Diesel Generator Upper Lube Oil Cooler |
| Description | A preliminary finding of low to moderate safety significance (White) and an apparent violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was self-revealed when the 2A Diesel Generator (D/G) was required to be shutdown during routine monthly surveillance testing on November 17, 2010, when a flange connection on a spool piece connected to the upper lube oil cooler failed, resulting in a significant oil leak. The cause of the failure was that Work Order 1206254, Clean Tube Side of Lube Oil Coolers, did not contain appropriate acceptance criteria to ensure proper reassembly of the spool piece for the upper lube oil cooler following maintenance on January 17, 2010. Specifically, the work order package did not contain a final torque verification to ensure that the spool piece flange bolts were torqued to required values, which resulted in the leak. The licensee entered this issue into the correction action program as Issue Report (IR) 1141591, properly re-installed the spool piece, and returned the 2A D/G to service on November 21, 2010. The inspectors determined that this finding was more than minor, because it was associated with the Human Performance attribute of the Mitigating Systems cornerstone and impacted the cornerstone objective of ensuring the availability of systems that respond to initiating events to prevent undesirable consequences. The NRC assessed this finding through a Phase 3 Risk Evaluation of the Significance Determination Process and made a preliminary determination that it was an issue of low to moderate safety significance (White). The cause of this finding was related to the Work Practices component of the Human Performance cross-cutting area since licensee personnel proceeded in the face of uncertainty or unexpected circumstances during the upper lube oil cooler maintenance activity. |
| Site: | Byron  |
|---|---|
| Report | IR 05000455/2011011 Section 1R12 |
| Date counted | Mar 31, 2011 (2011Q1) |
| Type: | Violation: White |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | B Bartlett E Duncan J Robbins N Valose Duncanm Satorius P Lougheed R Zimmerman S Orth S West |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Byron - IR 05000455/2011011 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Byron) @ 2011Q1
Self-Identified List (Byron)
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