05000455/FIN-2016003-02
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Finding | |
|---|---|
| Title | Failure to Use Alteration Log Resulted in Fuel Oil Leak |
| Description | A finding of very low safety significance and an associated NCV of Technical Specification (TS) 5.4.1.a, Written Procedures, was self-revealed on August 24, 2016, when a fuel oil leak of approximately one-eighth gallon per minute was identified coming from a tubing connection after the Unit 2 Train B (2B) DG was started for routine surveillance testing. Technicians replaced a fuel oil relay during the previous shift and did not use the procedurally required tools to track alterations made to each individual input line as required by MAAA716100, Maintenance Alteration Process. The issue was entered into the licensees CAP as IR 02707888. As part of their corrective actions, the leak was promptly repaired by tightening the fitting after the diesel generator was shut down; and the technicians reviewed human performance error prevention techniques, including proper use of the Maintenance Alterations Log, with supervisors. The inspectors determined that the issue was more than minor because it was associated with the Configuration Control attribute of the Mitigating Systems Cornerstone and adversely impacted the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to tighten all fittings during a maintenance activity resulted in a substantial fuel oil leak that could have resulted in a fire or could have impacted the availability of the diesel generator if the tubing had loosened further or become disconnected during a design basis event. The finding was determined to be of very low safety significance, or Green, in accordance with IMC 0609, Significance Determination Process, Attachment 0609.04, Initial Characterization of Findings, Appendix A, The Significance Determination Process (SDP) For Findings at Power, because the inspectors answered Exhibit 2 Mitigating Systems Screening Question A.1 as Yes since the diesel generator remained operable and functional until the fitting was repaired. The inspectors assigned a cross-cutting aspect in the Avoiding Complacency element of the Human Performance Area (IMC 0310 H.12) to this finding because judicious implementation of human performance error prevention tools could have prevented the failure to properly tighten the fitting, even if the Alterations Log was not used as required. |
| Site: | Byron  |
|---|---|
| Report | IR 05000455/2016003 Section 1R15 |
| Date counted | Sep 30, 2016 (2016Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.15 |
| Inspectors (proximate) | C Thompson E Duncan G Edwards G Hansen J Draper J Mcghee K Pusateri |
| Violation of: | Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Byron - IR 05000455/2016003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Byron) @ 2016Q3
Self-Identified List (Byron)
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