05000318/FIN-2016002-03
From kanterella
Jump to navigation
Jump to search
Finding | |
|---|---|
| Title | Failure to Implement Engineering Change Procedures Results in Plant Trip |
| Description | The inspectors documented a self-revealing, Green finding for Exelons failure to implement procedures for engineering changes. Specifically, Exelon failed to address the full scope and critical parameters associated with a modification to a steam generator feed pump (SGFP). As a result, the 22 SGFP turbine pedestal studs were improperly torqued, resulting in the SGFP shifting, becoming misaligned, and eventually resulting in the failure of the turbine to pump coupling. This resulted in the unexpected tripping of the 22 SGFP on December 1, 2015, and operators inserting a manual reactor trip as required by procedure. The inspectors determined that Exelons failure to properly implement procedures CNG-CM-1.01-1003, Design Inputs and Change Impact Screen, Revision 00601, Attachment 12; CNG-CM-1.01-2000, Scoping and Identification of Critical Components, Revision 00201; and CNG-FES-007, Preparation of Design Inputs and Change Impact Screen, Revision 00010 was a performance deficiency that was a performance deficiency that was within Exelons ability to foresee and prevent. Exelons corrective actions included, replacing the failed coupling, verifying the torque on the 21 SGFP using a HYTORCTM, and developing an adverse condition monitoring plan for Unit 1s SGFPs. Exelon conducted a root cause evaluation (RCE) and developed corrective actions to preclude repetition (CAPR) including implementation of Exelon procedure HU-AA-1212, Technical Task Risk/Rigor Assessment, Pre-Job Brief, Independent Third Party Review, and Post-Job Review, Revision 007 and conducting critical parameters and rigor training for engineering personnel including the expectations for three pass reviews and verification of assumptions. The inspectors reviewed IMC 0612, Appendix B, Issue Screening, and IMC 0612, Appendix E, Examples of Minor Issues and determined the issue is more than minor because it was associated with the Design Control Attribute of the Initiating Events Cornerstone and adversely impacted the associated 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 performance deficiency resulted in a reactor trip from full power on December 1, 2015. The inspectors evaluated the finding using IMC 0609, Attachment 4, Initial Characterization of Findings, issued on June 19, 2012, and IMC 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, Exhibit 1, Initiating Events Screening Questions, issued on June 19, 2012 and determined the finding to be of very low safety significance (Green) because the finding did not cause a reactor trip and the loss of mitigation equipment relied upon to transition the plant from the onset of the trip to a stable shutdown condition. The inspectors determined that the finding had a cross-cutting aspect in the area of Human Performance, Documentation, because Exelon failed to develop and maintain complete and accurate engineering change packages (ECP), work orders (WO), and maintenance procedures.[H.7] |
| Site: | Calvert Cliffs  |
|---|---|
| Report | IR 05000318/2016002 Section 4OA2 |
| Date counted | Jun 30, 2016 (2016Q2) |
| Type: | Finding: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | A Dimitriadis A Rosebrook C Roettgen J Petch M Modes R Clagg |
| CCA | H.7, Documentation |
| INPO aspect | WP.3 |
| ' | |
Finding - Calvert Cliffs - IR 05000318/2016002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Finding List (Calvert Cliffs) @ 2016Q2
Self-Identified List (Calvert Cliffs)
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||