05000368/FIN-2016002-01

Finding

Title

Failure to Incorporate Vendor Guidance in Work Order

Description

The inspectors identified a finding for the failure to incorporate vendor instructions in a work order. Specifically, the licensee exceeded the vendor specified torque values and performed the work with the component in service, contrary to vendor cautions, breaking the glass, wetting the auxiliary feedwater pump, and necessitating the unplanned shutdown of the main feedwater pump. The licensee replaced the ruptured sight glass and repaired and tested the wetted components. The licensee documented the issue in Condition Report CR-ANO-2-2015-04832. The failure to incorporate vendor instructions in a work order is a performance deficiency. The finding is more than minor because it adversely affected the procedure quality attribute of the mitigating systems cornerstone and adversely affected the cornerstone objective to ensure the reliability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, the performance deficiency resulted in the Unit 2 auxiliary feedwater pump and main feedwater pump B being rendered unavailable. The inspectors evaluated the finding with NRC Manual Chapter 0609, Appendix A, The Significance Determination Process (SDP) for Findings At-Power, dated June 19, 2012, Exhibit 2, Mitigating Systems Screening Questions. The inspectors determined that the finding required a detailed risk evaluation because the finding involved an actual loss of function of auxiliary feedwater and one train of main feedwater, designated as having high safety significance in accordance with the licensees maintenance rule program, for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. A senior reactor analyst performed a detailed risk evaluation and determined that the increase in core damage frequency was 1.3E-7/year (Green). The analyst assumed that all feedwater pumps were available until the time of the leak and that any increase in core damage frequency resulted from the unavailability of the pumps after the leak. The emergency feedwater system remained available to mitigate the increase in core damage frequency of this finding. The inspectors determined this finding has a cross-cutting aspect in the human performance area of Work Management because the primary cause of the performance deficiency involved the failure to identify and manage risk commensurate to the work and the need for coordination with different groups or job activities (Section 1R12). [H.5]

01
Site:	Arkansas Nuclear
Report	IR 05000368/2016002 Section 1R12
Date counted	Jun 30, 2016 (2016Q2)
Type:	Finding: Green
cornerstone	Initiating Events
Identified by:	NRC identified
Inspection Procedure:	IP 71111.12
Inspectors (proximate)	A Barrett B Tindell M Tobin N O'Keefe
CCA	H.5, Work Management
INPO aspect	WP.1
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Finding - Arkansas Nuclear - IR 05000368/2016002

1(6)2(3)3(1)4(4)5(0)6(0)7(21)8(6)9(4)10(0)11(0)301(0)401(0)402(0)403(0)404(2)405(0)11(1)

IR 05000368/2016002: 1 2 3

Finding List (Arkansas Nuclear) @ 2016Q2

CCA Matrix: 2016Q2

	Q	CCA	Title
05000313/FIN-2015003-02	2015Q3		Failure to Promptly Correct a Condition Adverse to Quality Involving Motor Control Center Bus Stabs
05000368/FIN-2015003-01	2015Q3	H.12	Failure to Follow Procedure Results in Increased Reactor Coolant Activity
05000313/FIN-2015004-03	2015Q4		Failure to Properly Translate the Design Requirements for the Unit 1 Decay Heat Vault Rooms Being Sealed (
05000313/FIN-2015004-01	2015Q4	H.13	Failure to Assess Risk for Switchyard Work
05000313/FIN-2015004-02	2015Q4	H.12	Failure to Identify and Correct Rain Water Accumulation in the Emergency Diesel Generator System Exhausts
05000368/FIN-2016001-02	2016Q1		Failure to Follow Design Control Requirements for Pump Seal Cooler Replacements
05000313/FIN-2016007-17	2016Q1		Determine Impact of Modifying Fire Seals for Flood Protection
05000313/FIN-2016007-14	2016Q1	H.3	Failure to Properly Implement the Corrective Action Program
05000368/FIN-2016007-08	2016Q1		Inadequate Flow Monitoring of Unit 2 Service Water to Emergency Feedwater Pump Suction Supply
05000368/FIN-2016007-07	2016Q1		Failure to Maintain Service Water Design Cooling to the Unit 2 High Pressure Safety Injection Pump Seal and Bearing Coolers
05000368/FIN-2016007-05	2016Q1		Failure to Include Unit 2 Service Water Pump Supports in the ASME Code Section XI Inservice Inspection Program
05000368/FIN-2016001-03	2016Q1		Blocked Drain Results in Emergency Feedwater Pump Inoperability
05000313/FIN-2016001-01	2016Q1	H.4	Failure to Assess and Manage Hot Work Risk
05000313/FIN-2016007-15	2016Q1	P.1	Failure to Maintain Structural Design Clearances inside the Unit 1 and 2 Reactor Containment Buildings
05000368/FIN-2016001-04	2016Q1	H.12	Failure to Inject Service Water with Corrosion Inhibitors during Refueling Outages
05000313/FIN-2016007-11	2016Q1	P.5	Pressurizer Block Valve Not Installed in the Qualified Environmental Configuration
05000368/FIN-2016007-10	2016Q1	P.6	Failure to Develop an Operability Decision-Making Issue for Degraded Condition on Safety Injection Tank
05000313/FIN-2016007-02	2016Q1	P.6	Inadequate Effectiveness Reviews for Corrective Actions to Prevent Recurrence
05000313/FIN-2016007-01	2016Q1	P.3	Failure to Complete Extent of Condition Reviews for the Stator Drop Significant Condition Adverse to Quality Event
05000313/FIN-2016001-05	2016Q1	P.2	Failure to Identify and Repair Intermittent Card Failure Leads to a Reactor Trip
05000313/FIN-2016007-16	2016Q1	H.7	Failure to Properly Calibrate Unit 1 Reactor Building Atmospheric Particulate Radiation Monitor RE-7460
05000313/FIN-2016007-12	2016Q1	P.1	Failure to Perform Predictive Maintenance on Safety-Related Medium-Voltage Switchgear
05000313/FIN-2016007-03	2016Q1	H.14	Inadequate Operating Experience Evaluations
05000313/FIN-2016007-04	2016Q1	H.14	Inadequate Control of Monitoring for Wall Loss in the Service Water System
05000313/FIN-2016007-13	2016Q1	H.1	Failure to Update Probabilistic Risk Assessment Model in a Timely Manner Results in Failure to Submit Complete and Accurate Information
05000313/FIN-2016007-09	2016Q1	H.5	Emergency Feedwater Pump Casing Wall Loss Not Monitored
05000313/FIN-2016007-06	2016Q1	H.6	Failure to Correct Degraded Unit 2 Train B Emergency Diesel Generator Heat Exchangers Service Water Flow and Degraded Unit 1 Containment Coatings
05000313/FIN-2016009-01	2016Q2		Inadequate Loop Flow Testing
05000368/FIN-2016009-04	2016Q2		Failure to Adequately Establish Ignition Frequencies for the Risk-Informed Fire Protection Program
05000368/FIN-2016009-03	2016Q2	H.3	Failure to Ensure that the Assumptions in the Engineering Analysis Remain Valid
05000368/FIN-2016009-02	2016Q2		Inadequate Procedure Used as a Compensatory Measure
05000368/FIN-2016002-02	2016Q2		Failure to Clean Main Feedwater Lube Oil Reservoir Leads to Reactor Power Reduction
05000368/FIN-2016002-01	2016Q2	H.5	Failure to Incorporate Vendor Guidance in Work Order

Self-Identified List (Arkansas Nuclear)

	Q	Title
05000313/FIN-2015404-01	2015Q3	Licensee-Identified Violation
05000313/FIN-2016001-06	2016Q1	Licensee-Identified Violation
05000313/FIN-2016007-18	2016Q1	Licensee-Identified Violation
05000313/FIN-2016007-19	2016Q1	Licensee-Identified Violation
05000368/FIN-2016007-20	2016Q1	Licensee-Identified Violation
05000313/FIN-2016007-21	2016Q1	Licensee-Identified Violation
05000368/FIN-2016002-03	2016Q2	Licensee-Identified Violation

[Arkansas Nuclear Findings full list]

05000368/FIN-2016002-01

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