05000346/FIN-2014005-02
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Finding | |
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| Title | Inadequate Procedural Guidance During Restoration From Valve Maintenance Results in Feedwater Heater System and Plant Power Transient |
| Description | A self-revealed finding of very low safety significance and associated NCV of Technical Specification (TS) 5.4.1(a) were identified when the licensee failed to provide proper procedural guidance for the restoration from valve maintenance on HD291G, a manual isolation valve for the level controller for HD291A, the emergency drain valve for High Pressure (HP) Feedwater Heater No. 14, on November 13, 2014. Specifically, the licensee's restoration instructions did not isolate HD291A prior to restoring its associated level controller. As a result, when a perturbation in the level controller during restoration caused HD291A to rapidly reposition to the fully open position, the resulting HP Feedwater Train 1 transient caused HP Feedwater Heaters 14, 15, and 16 to trip
The change in plant efficiency that resulted momentarily drove plant power slightly above 100 percent This finding was associated with the Initiating Events Cornerstone of reactor safety and was of more than minor significance because it directly impacted 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. The inspectors evaluated the finding using IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power. Using Exhibit 1, the inspectors determined that the finding screened as very low safety significance because all screening questions for the Initiating Events Cornerstone of reactor safety were answered No. This finding als was determined to have a cross-cutting component in the area of human performance, work management aspect, because during the work planning process for this maintenance activity the licensee failed to identify the risk associated with not isolating the HP Feedwater Heater No. 14 Emergency Drain Valve, HD291A, prior to restoring its associated level controller to service. |
| Site: | Davis Besse  |
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| Report | IR 05000346/2014005 Section 1R13 |
| Date counted | Dec 31, 2014 (2014Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.13 |
| Inspectors (proximate) | A Schwab D Kimble J Beavers J Cameron M Mitchell R Baker R Morris T Briley |
| Violation of: | Technical Specification - Procedures Technical Specification |
| CCA | H.5, Work Management |
| INPO aspect | WP.1 |
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Finding - Davis Besse - IR 05000346/2014005 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Davis Besse) @ 2014Q4
Self-Identified List (Davis Besse)
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