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A finding of very low safety significance, … A finding of very low safety significance, with an associated non-cited violation of Technical Specification (TS) 5.4, Procedures, was self-revealed when a vacuum was inadvertently drawn on the AB Fuel Oil Storage Tank (FOST) during preparations for surveillance activities. The vacuum caused an indication of lowering level in the tank, alarms, and an unplanned TS Limiting Condition for Operation (LCO) action statement entry. The licensee was performing work activities in preparation for a leak test of the FOST. The general sequence of activities should have been a loosening of the vent filter for the tank, a transfer of fuel from the FOST to the Emergency Diesel Generator (EDG) day tanks, removal of the FOST from service, and finally removal of the vent filter so test equipment could be connected to the tank. Due to ambiguous work instruction steps and activities not being adequately controlled to ensure the proper sequence occurred, workers first removed the vent filter completely and placed a Foreign Material Exclusion (FME) bag over the vent. When operators later transferred fuel, a vacuum was drawn in the tank and level appeared to be going down. Utilizing a manual method of level measurement (which had also been affected by the vacuum), operators determined fuel was actually being lost from the tank to the environment. Shortly thereafter, the bag was found and removed, and level restored to normal (there was no actual loss of fuel). Technical Specification 5.4, Procedures, states, in part, that written procedures shall be established, implemented, and maintained covering the applicable procedures recommended in Regulatory Guide 1.33. Regulatory Guide 1.33 states, in part, that maintenance that can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. Contrary to these requirements, the FOST surveillance was performed with inadequate instructions and was not coordinated appropriately. The licensee entered the issue into the CAP and performed a root cause analysis. The performance deficiency was more than minor because it adversely impacted the Configuration Control attribute of the Mitigating Systems cornerstone, whose objective is ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The finding screened as Green, or very low safety significance, utilizing IMC 0609, Appendix A, The Significance Determination Process for Findings at Power. Specifically, all questions were answered no under Section A of Exhibit 2 for Mitigating Systems, since that was the affected cornerstone. The FME bag was installed, which rendered the AB FOST inoperable, for approximately 16 hours. This was less than the TS allowed outage time of 48 hours. The finding had an associated cross-cutting aspect in the human performance area, specifically, H.5, Work Management. Work activities should be planned, controlled, and executed with nuclear safety as the overriding priority. Contrary to the tenets of the cross-cutting aspect, the work was planned and executed with inadequate work instructions. Further, there was a lack of coordination between a number of work groups and activities associated with the test.s and activities associated with the test.

Discovered date

23:59:59, 31 December 2014 +

Docket

05000315 + and 05000316 +

Event date

23:59:59, 31 December 2014 +

Finding integer

2 +

Finding type

Non-cited violation +

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Hours

1.851852e-4 d (0.00444 hours, 2.645503e-5 weeks, 6.088e-6 months) + and 5.555556e-4 d (0.0133 hours, 7.936508e-5 weeks, 1.8264e-5 months) +

INPO aspect

WP.1 +

Identified by

Self-revealing +

Inspection Manual Chapter

NRC Inspection Manual 0609/Appendix A, The Significance Determination Process (SDP) for Findings At-Power +

Inspection procedure

IP 71111.15, Operability Determinations and Functionality Assessments +

Inspection report

IR 05000315/2014005 +

Inspector

M Phalen +, J Cassidy +, E Sanchez +, J Lennartz +, Kenneth Riemer +, John Ellegood +, Tony Go +, Thomas Taylor +, Michelle Garza + and Matthew Mitchell +

Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.

12:58:41, 25 September 2017 +

Person