05000346/FIN-2016001-04
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Finding | |
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| Title | Less than Sufficient Work Package Documentation and Instructions Resulted in an Inadequate Part Being Installed into the Plants Integrated Control System |
| Description | A self-revealed finding of very low safety significance (Green) was identified for the licensees failure to include an adequate bench check for a replacement integrated control system (ICS) module that was installed into the system during the plants 2014 refueling outage (RFO) into the work package instructions for that activity. Specifically, a defeat switch on the replacement Module 528 for the ICS rapid feedwater reduction (RFR) circuit installed as preventative maintenance during the plants 18th RFO was incorrectly wired and not detected during pre-installation checks. The incorrectly wired module prevented the ICS RFR function from occurring during the unit trip on January 29, 2016, which contributed to the Steam Generator (SG) No. 1 high level condition and the resultant steam and feedwater rupture control system (SFRCS) actuation. This issue was entered into the licensees CAP. Corrective actions taken by the licensee included replacement of ICS Module 528 with a spare properly configured for the RFR defeat switch function. Additionally, a proper data package to enable bench checking ICS Module 528 to verify the capability of the module to perform its intended function was created. The licensee also created training and lessons learned from this event. This finding was of more than minor safety significance because it affected the design control and procedure quality attributes of the Mitigating Systems cornerstone of reactor safety, and adversely impacted the cornerstone objective of ensuring the availability, reliability, and capability of the units main feedwater (MFW) system and main condenser for decay heat removal. The finding was determined to be of very low safety significance because it did not represent a deficiency affecting the design or qualification of a mitigating system, structure, or component (SSC); it did not, in and of itself, represent a loss of system and/or function; it did not represent an actual loss of function of at least a single train for greater than its Technical Specification (TS) allowed outage time, or two separate safety systems being out-of-service for greater than their TS allowed outage times; and it did not represent an actual loss of function of one or more non-TS trains of equipment designated as high safety significant in accordance with the licensees maintenance rule program. The inspectors determined that the finding had a cross-cutting aspect in the area of human performance. The inspectors assigned the cross-cutting aspect of Documentation to the finding because the licensee had failed to ensure that the instructions and other work package guidance available to maintenance personnel performing the ICS Module 528 replacement had contained provisions for an adequate bench check of the module prior to its installation. |
| Site: | Davis Besse  |
|---|---|
| Report | IR 05000346/2016001 Section 4OA3 |
| Date counted | Mar 31, 2016 (2016Q1) |
| Type: | Finding: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | D Kimble J Cameron T Briley L Alvaredo |
| Violation of: | License Condition |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
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Finding - Davis Besse - IR 05000346/2016001 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Davis Besse) @ 2016Q1
Self-Identified List (Davis Besse)
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