05000382/FIN-2017002-05
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Finding | |
|---|---|
| Title | Failure to Perform Maintenance on the Correct Safety-Related Component |
| Description | The inspectors reviewed a self-revealed, non-cited violation of Technical Specification 6.8, Procedures and Programs, and Regulatory Guide 1.33, Quality Assurance Program Requirements, which occurred due to the licensees failure to perform field work on reactor coolant loop 2 shutdown cooling warm-up valve, SI-135A. Specifically, mechanical maintenance technicians, who were assigned work on safety injection train A, erroneously performed work on safety injection train B on reactor coolant loop 1 shutdown cooling warm-up valve, SI-135B. As a result, both trains of emergency core cooling systems were simultaneously inoperable, which placed the plant in a 1-hour technical specification shutdown action statement. The licensee entered this condition into their corrective action program as Condition Report CR-WF3-2017-01433. The licensees corrective actions included a revision of the model work order to require concurrent verification for component identification, and adding the valves to the protected equipment list for when the opposite train is inoperable.The performance deficiency was more than minor because it was associated with the configuration control attribute of the Mitigating Systems Cornerstone and adversely affected its objective to ensure availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, when the mechanics worked on valve SI-135B instead of valve SI-135A, they simultaneously made both trains of emergency core cooling systems inoperable. The inspectors screened the finding in accordance with NRC Inspection Manual Chapter 0609, Significance Determination Process. Inspection Manual Chapter 0609, Attachment 4, Initial Characterization of Findings, instructed the inspectors to use Appendix A, Significance Determination Process for Findings At-Power. Using Appendix A, Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding to be of very low safety significance (Green) because it: (1) was not a deficiency affecting the design or qualification of a mitigating structure, system, and component; (2) did not represent a loss of system and/or function; (3) did not represent an actual loss of function of at least a single train for greater than its technical specification allowed outage time or two separate safety systems out-of-service for greater than its technical specification allowed outage time; and (4) did not represent an actual loss of function of one or more nontechnical specification trains of equipment designated as high safety-significant in accordance with 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 />.The finding had an avoid complacency cross-cutting aspect in the area of human performance because individuals did not recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes, and did notimplement appropriate error reduction tools. Specifically, maintenance technicians repeatedly visited the incorrect work location and didnt properly verify the valve number to ensure they would work on the correct component [H.12]. |
| Site: | Waterford  |
|---|---|
| Report | IR 05000382/2017002 Section 4OA3 |
| Date counted | Jun 30, 2017 (2017Q2) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71153 |
| Inspectors (proximate) | F Ramirez C Speer B Correll S Graves N Greene R Kopriva J O'Donnell G Miller |
| Violation of: | Technical Specification |
| CCA | H.12, Avoid Complacency |
| INPO aspect | QA.4 |
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Finding - Waterford - IR 05000382/2017002 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Waterford) @ 2017Q2
Self-Identified List (Waterford)
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