05000247/FIN-2009003-01
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Finding | |
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| Title | Inadequate Design Change Package for Installation of Main Boiler Feed Pump Control System Tubing |
| Description | The inspectors documented a self-revealing finding of very low safety significance because Entergy engineers did not provide adequate guidance in a design change package for installation of tubing in the 21 main boiler feedwater pump (MBFP) control system that eventually led to the tubing failure and an unplanned trip of the reactor plant. Entergys design change procedure required that instructions delineating installation precautions be provided in the design change package. Entergys corrective actions included repairing the affected tubing, identifying and replacing similar tubing on the 22 MBFP, and examining Unit3 MBFPs to identify the extent of the condition. Entergy staff placed this issue into the corrective action program and performed a root cause analysis. The finding was more than minor because it was associated with the design control attribute of the Initiating Events cornerstone and affected its objective to limit the likelihood of events that affect plant stability and challenge critical safety functions during shutdown, as well as power operations. Specifically, the incorrectly installed MBFP control tubing resulted in a loss of the 21 MBFP and, ultimately, a reactor trip due to low steam generator water level. The inspectors determined that the finding was of very low safety significance (Green) using the Phase 2 Indian Point Unit 2 risk-informed inspection notebook, in accordance with IMC0609, Appendix A, Determining the Significance of Reactor Inspection Findings for At-Power Situations. The inspectors determined there was no cross-cutting issue associated with the finding because the performance deficiency did not reflect current licensee performance. Specifically, the performance deficiency occurred several years ago and was outside the current assessment period, and procedures have since been improved in the design control, work control and vendor control processes that reduced the likelihood of vendors working one quipment without sufficient training or work instructions. |
| Site: | Indian Point  |
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| Report | IR 05000247/2009003 Section 4OA3 |
| Date counted | Jun 30, 2009 (2009Q2) |
| Type: | Finding: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | C Hott D Johnson E Huang G Malone J Noggle M Gray O Ayegbusi S Mccarver |
| INPO aspect | |
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Finding - Indian Point - IR 05000247/2009003 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Indian Point) @ 2009Q2
Self-Identified List (Indian Point)
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