05000346/FIN-2015002-01
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Finding | |
|---|---|
| Title | Licensee-Identified Violation |
| Description | Error in Procedure Use and Execution Results in Steam Feed Rupture Control System Logic Channel 1 Unplanned Inoperability During Testing Appendix B of 10 CFR Part 50, Criterion V, Instructions, Procedures, Drawings requires, in part, that activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings. Contrary to this requirement, on May 29, 2015, two maintenance technicians failed to adequately perform procedure DB-MI-03205, "Channel Functional Test/Calibration and Response Time of RCP Monitor (RC3601) to SFRCS Logic Channel 1 and RPS Channel 1." Specifically, the technicians did not perform a portion of a step during the safety system testing procedure even though the step required concurrent verification and was signed off by both technicians as being completed. During the performance of Step 8.1.4.a.2, the technicians were required to: "Remove two (2) of the knurled screws stored on TB5R (terminal block) and screw them into the shorting bars for TB6L terminals 3 and 4." Although the technicians appropriately removed two knurled screws from TB5R as specified, they did not insert the screws into the shorting bars for TB6L terminals 3 and 4 as was also required by the procedure step. Later, during the restoration steps for DB-MI-03205, the technicians recognized that the knurled screws had not been inserted into the shorting bars for TB6L terminals 3 and 4 as required; they stopped work after placing equipment in a safe condition and reported the error to supervisory personnel. While RPS Channel 1 was already inoperable and in "bypass" for the testing that was in progress, because of the procedure compliance error plant operators were forced to declare the affected SFRCS Logic Channel 1 inoperable and place it in a tripped condition to comply with the requirements of TS 3.3.11, Condition A. The maintenance technicians performing the testing were removed from duty pending an investigation. To recover from the error and restore the operability of RPS Channel 1 and SFRCS Logic Channel 1, plant management directed that the test procedure be re-briefed and performed over using different maintenance technicians. The DB-MI-03205 procedure was successfully completed under enhanced supervisory oversight later that same day and both RPS Channel 1 and SFRCS Logic Channel 1 were restored to an operable status. The objective of the Mitigating Systems Cornerstone of Reactor Safety is to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). A key attribute of this objective is human performance, and specifically, configuration control. In accordance with NRC IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, the inspectors determined that the violation was of more than minor significance in that it had a direct impact on this cornerstone objective. The licensees failure to complete DB-MI-03205 as written resulted in the unplanned inoperability of SFRCS Logic Channel 1, and needlessly extended the time RPS Channel 1 was inoperable and in a bypassed condition. The licensee had entered this issue into their CAP as CR 2015-07685. An apparent cause evaluation was commissioned and corrective actions taken and planned included, but were not limited to:
A lessons learned communication was provided to each station workgroup during a stand down conducted on June 1, 2015 An enhancement is planned to DB-MI-03205 to split the applicable procedure step into two distinct actions, with the concurrent verification being required for specifically installing the knurled screws; an An interim action was established to ensure a consistent standard of concurrent verification / independent verification performance within the station's maintenance organization. Specifically, this action required all concurrent verification / independent verification maintenance steps have direct oversight by a qualified maintenance supervisor. |
| Site: | Davis Besse  |
|---|---|
| Report | IR 05000346/2015002 Section 4OA7 |
| Date counted | Jun 30, 2015 (2015Q2) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Licensee-identified |
| Inspection Procedure: | |
| Inspectors (proximate) | D Kimble J Cameron J Rutkowski M Mitchell P Lee T Briley A Schwab |
| Violation of: | Technical Specification - Procedures Technical Specification |
| INPO aspect | |
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Finding - Davis Besse - IR 05000346/2015002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Davis Besse) @ 2015Q2
Self-Identified List (Davis Besse)
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