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| Quarter | Site | Title | Description | |
|---|---|---|---|---|
| 05000425/FIN-2013002-01 | 2013Q1 | Vogtle | Inadequate Operations and Maintenance Procedures Results in High RCP Seal Leakoff Flow and Manual Reactor Trip | A self-revealing non-cited violation (NCV) of 10 CFR 50 Appendix B Criterion V, Instructions, Procedures, and Drawings was identified for failure to provide adequate work instructions in the operations procedure used to change out the reactor coolant system (RCS) filter. Specifically, operations procedure 13213-1/2, Backflushable Filter System, which is used to change out the RCS filter, did not provide adequate instructions and/or precautions to prevent excessive air intrusion (and the subsequent localized crud burst within the chemical and volume control system (CVCS) late in core life) when flushing and venting the RCS filter housing. The licensee conducted a root cause investigation and entered the event into their corrective action program (condition report (CR) 597293). The licensee immediately created a Standing Order for Operation of CVCS in relation to RCP seals, and revised procedure 13213-1/2, Backflushable Filter System to provide instructions to significantly reduce the amount of air intrusion from changing out the RCS filter. The finding was more than minor because it was associated with the procedure quality attribute of the reactor safety - initiating events cornerstone and it adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to provide adequate work instructions to operations personnel resulted in a localized crud burst at the reactor coolant pump (RCP) seals causing RCP seal leakoff flow rates to exceed administrative limits for continued pump operation and a subsequent manual reactor trip. Because the inspectors answered No to all of the IMC 0609 Appendix A (dated June 19, 2012) Exhibit 1, Section B, Initiating Events Screening Questions, the inspectors concluded that the finding was of very low safety significance (Green). Since the inadequate procedures have existed since plant startup, this violation is not indicative of current licensee performance and does not have an associated cross-cutting aspect assigned. |
| 05000424/FIN-2013002-02 | 2013Q1 | Vogtle | Inadequate Maintenance Procedures Results in Failure of the Inboard Bearing on the Unit 1A CCW Pump #1 | A self-revealing non-cited violation (NCV) of 10 CFR Part 50 Appendix B, Criterion V, Instructions, Procedures, and Drawings was identified for failure to provide appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished. Specifically, procedure 27080-C, CCW Pump Maintenance, did not provide adequate direction as to the duration of and instrumentation required to properly perform a post-maintenance test that would detect a misalignment between the pump and motor shafts. The licensee entered this issue into their corrective action program as CR 526268, and revised maintenance procedure 27080-C to specify the proper post maintenance testing required after rebuilding CCW pumps. The finding was more than minor because it was associated with the equipment performance attribute of the mitigating systems cornerstone and it adversely affected the cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, the post-maintenance test performed after rebuilding the Unit 1A component cooling water (CCW) pump #1 failed to identify excessive misalignment between the motor and pump shafts, which subsequently resulted in the catastrophic failure of the inboard pump bearing once the pump was returned to service. Because the inspectors answered No to all of the IMC 0609 Appendix A (dated June 19, 2012) Exhibit 2, Section A, Mitigating Systems Screening Questions, the inspectors concluded that the finding was of very low safety significance (Green). The inspectors determined that the cause of this finding was related to the work control component of the human performance cross-cutting area due to less-than-adequate procedures. Specifically, the maintenance procedures used to reassemble the CCW pumps did not provide adequate direction as to the duration of and instrumentation required to properly perform an adequate post-maintenance test. |
| 05000424/FIN-2013002-03 | 2013Q1 | Vogtle | Human Performance Error Renders 1A CS Pump Inoperable | A self-revealing non-cited violation (NCV) for failure to meet the requirements of plant Technical Specification (TS) 5.4, Procedures was identified. While realigning equipment to support the filling and venting of the Unit 2 containment spray header the system operator inadvertently closed 1HV-9017A, refueling water storage tank (RWST) suction to Unit 1 containment spray (CS) pump A. As a result, the 1A CS pump was temporarily rendered inoperable. The valve was subsequently re-opened and the pump was declared operable. The licensee entered the issue into their corrective action program (CR 608718). This finding is more than minor because it is associated with the human performance attribute of the barrier integrity cornerstone and it adversely affected the cornerstone objective to provide reasonable assurance that physical design barriers (fuel cladding, reactor coolant system, and containment) protect the public from radionuclide releases caused by accidents or events. Specifically, the performance deficiency is a human performance error which affected the availability, reliability, and capability of the Unit 1 A train containment spray system to limit and maintain post accident conditions to less than containment design values. Because the inspectors answered No to all of the IMC 0609 Appendix A (dated June 19, 2012) Exhibit 3, Section B, Barrier Integrity Cornerstone Screening Questions, the inspectors concluded that the finding was of very low safety significance (Green). The inspectors determined that the cause of this finding was related to the work practices component of the human performance crosscutting area due to less-than-adequate human error prevention techniques. Specifically, peer checking techniques were less than adequate. |
| 05000424/FIN-2012003-01 | 2012Q2 | Vogtle | Failure to Follow Procedures Renders Safety Related Battery Chargers Inoperable | The inspectors identified a self-revealing NCV of Technical Specification (TS) 5.4.1, for two instances of failure to properly implement approved maintenance procedures and work order instructions. Specifically, maintenance electricians inadvertently removed the 2BD1CB safety related battery charger from service while attempting to perform a routine quarterly battery surveillance on the 2DD1CB battery charger. When the 2BD1CA/2BD1CB Trouble alarm was received in the control room, the operators immediately contacted the electricians and the work was halted. Battery charger 2BD1CB was restored to service within 31 minutes. In the second instance, maintenance electricians inadvertently rendered both battery chargers for the 1CD1 safety-related battery inoperable during load-sharing adjustments on the 1CD1CB battery charger. The licensee restored the 1CD1CA battery charger to service within a few minutes. The licensee entered both of these issues into their corrective action program (CR 445343 & 457102 respectively). The inspectors concluded that this finding was more than minor because it impacted the Reactor Safety Mitigating Systems Cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences and affected the cornerstone attribute of equipment performance. Specifically, the unintentional opening of the AC input breakers to the 2BD1CB, 1CD1CA and 1CD1CB battery chargers resulted in the chargers being declared inoperable for several minutes. The inspectors used the Phase 1 Initial Screening and Characterization of Findings (IMC 0609.04 Exhibit 1) to characterize the finding. Since the inspectors answered No to all of the Table 4a Mitigating Systems Cornerstone questions, the inspectors concluded that the finding was of very low safety significance (Green). The inspectors determined that the cause of this finding was related to the Work Practices component of the Human Performance cross-cutting area due to less than adequate procedure use and self/peer checking. |
| 05000424/FIN-2012003-02 | 2012Q2 | Vogtle | Licensee-Identified Violation | TS limiting condition of operation (LCO) 3.5.4 Condition D requires that the RWST be returned to operable status with a completion time of 1 hour. If the RWST is not returned to operable status within 1 hour, TS LCO 3.5.4 Condition E requires that the unit be placed in Mode 3 within 6 hours and in Mode 5 within 36 hours. Contrary to the above, the licensee aligned the seismically qualified RWST to the non-seismically qualified SFPP system in Mode 1 for periods greater than one hour. The licensee inappropriately believed that manual operator compensatory actions could be used to maintain the RWST operable. Consequentially, no LCO required actions were taken. The licensee entered this condition in its corrective action program as CR 408441. This finding was assessed using IMC 0609, Phase 1 screening worksheet of Attachment 4 and was determined to be of very low safety significance (Green) because the finding represents a qualification deficiency confirmed not to result in the loss of functionality of the RWST. |
| 05000424/FIN-2012003-03 | 2012Q2 | Vogtle | Licensee-Identified Violation | 10 CFR 50 Appendix B, criterion V requires that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, and that these instructions, procedures, or drawings include appropriate quantitative or qualitative acceptance criteria for determining that important activities have been satisfactorily accomplished. Contrary to the above, maintenance procedure 27599-C Rev. 2.2, EDG Fuel Oil Filter and Strainer Maintenance provided inadequate guidance for draining the fuel oil filter prior to replacement. As a result, on May 25 maintenance personnel inadvertently rendered the 1B EDG inoperable by draining the fuel header while attempting to replace the east fuel filter. When contacted for assistance a few hours later, engineering and operations personnel recognized this degraded condition and the diesel was declared inoperable. The licensee documented this event in their corrective action program as CR 460607. This finding was assessed using IMC 0609, Phase 1 screening worksheet of Attachment 4 and was determined to be of very low safety significance (Green) because the finding did not represent the actual loss of safety function of a single train for greater than its TS allowed outage time. |