05000529/FIN-2013005-02
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Finding | |
|---|---|
| Title | Failure to Replace Oil Soaked Insulation Results in a Fire |
| Description | The inspectors reviewed a Green self-revealing finding for the licensees failure to promptly identify and correct an adverse condition. Specifically, the licensee failed to identify that operating limits for main feedwater pump (MFP) vapor extractors did not prevent lube oil leakage, and insulation surrounding the Unit 2 train A MFP became soaked with oil. As a result, the oil soaked insulation, exposed to hot surface temperatures over time, became degraded and initiated a fire in the turbine building, resulting in declaration of an unusual event. No violation of regulatory requirements occurred because the finding occurred on non-safety secondary plant equipment. The licensee entered the finding into the licensees corrective action program as Condition Report Disposition Request 4458504 and 4452395. The failure to promptly identify and correct an adverse condition was a performance deficiency. The performance deficiency is more than minor, and therefore is a finding, because it was associated with the Initiating Events Cornerstone and was a precursor to a more significant event which resulted in a fire and an emergency declaration. The inspectors assessed the significance of the finding in accordance with NRC Inspection Manual Chapter (IMC) 0609, appendix A, Significance Determination Process for Findings At-Power, using Exhibit 1, Initiating Events Screening Questions. The finding required a detailed risk evaluation because it resulted in increasing the fire frequency. A Region IV senior reactor analyst performed the detailed risk evaluation. The bounding change to the core damage frequency was 1.0E-7/year (Green). The most prominent core damage sequences included a transient coupled with various failures of the auxiliary feedwater and main feedwater pumps. The automatic runback function of the feedwater control system helped to minimize the change to the core damage frequency. The inspectors determined the finding has a cross-cutting aspect in the area of problem identification and resolution associated with the operating experience (OE) component because the licensee failed to implement and institutionalize OE through changes to station processes, procedures, equipment, and training programs to ensure MFP turbine vapor extractors are operated appropriately and that fire hazards associated with oil soaked insulation are promptly identified and corrected. |
| Site: | Palo Verde  |
|---|---|
| Report | IR 05000529/2013005 Section 4OA2 |
| Date counted | Dec 31, 2013 (2013Q4) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | T Brown D Reinert I Anchondo J Laughlin J O'Donnell L Carson M Baquera N Taylor S Graves |
| CCA | P.5, Operating Experience |
| INPO aspect | CL.1 |
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Finding - Palo Verde - IR 05000529/2013005 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palo Verde) @ 2013Q4
Self-Identified List (Palo Verde)
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