05000250/FIN-2013004-03
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Finding | |
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| Title | Failure to Provide Adequate Instructions during Maintenance on the Gland Seal Steam System |
| Description | A self-revealing finding was identified due to the licensees failure to provide adequate work instructions for throttling the Unit 3 gland seal steam bypass valve. As a result of the licensees inadequate work instructions, an operator opened the spill bypass valve on the gland seal steam system until system steam pressure dropped and allowed air in-leakage through the turbine gland seals. This resulted in a reactor trip and the main condenser was unavailable for reactor decay heat removal until vacuum could be restored. The licensee entered this issue into their corrective action program as action request 1847369 and revised the system operating procedure to address operation of the bypass line around the spillover control valve. The inspectors determined the performance deficiency was more than minor because it was associated with the configuration control attribute of the initiating events cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during power operations. Specifically, the failure to provide adequate work instructions for the operation of the gland seal steam spillover bypass valve resulted in a reactor trip with the main condenser unavailable for reactor decay heat removal until vacuum could be restored. The inspectors screened the finding and determined that the finding was a transient initiator contributor which required a detailed risk analysis because the finding resulted in a reactor trip with a loss of condenser vacuum. A bounding analysis was performed by a regional Senior Reactor Analyst who concluded that the finding resulted in an increase in core damage frequency of less than 1E-6/year and, therefore, was a Green finding of very low safety significance. The finding was associated with a cross-cutting aspect in the work control component of the human performance area because the licensee did not adequately incorporate the need for planned contingencies, compensatory actions or abort criteria to ensure that throttling the gland seal steam spillover bypass valve would not result in a reactor trip and loss of the main condenser H.3(a). |
| Site: | Turkey Point  |
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| Report | IR 05000250/2013004 Section 4OA2 |
| Date counted | Sep 30, 2013 (2013Q3) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | A Klett G Kolcum J Rivera M Endress M Riches R Reyes R Taylor T Hoeg W Pursley |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Turkey Point - IR 05000250/2013004 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Turkey Point) @ 2013Q3
Self-Identified List (Turkey Point)
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