05000387/FIN-2016008-02
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Finding | |
|---|---|
| Title | Failure to Implement and Maintain Quality Procedure Results in Control Room Chiller Inoperability |
| Description | The inspectors identified a Green NCV of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for failure to implement and maintain a quality procedure, MT-GE-021, Chiller Maintenance and Inspection. This resulted in the safety related 0K112A chiller being operated outside of its design specifications and being declared inoperable. Specifically, on January 9, 2014, a system engineer directed the maintenance personnel to overcharge 0K112A with R-114a refrigerant, which led to higher power consumption by the chillers compressor motor, and the failure of the next biennial surveillance test on December 10, 2015 due to excessive compressor motor current. Susquehanna entered the issue into the CAP, conducted testing to establish the proper refrigerant charge, removed the excess refrigerant, and revised the procedure. The finding was determined to be more than minor because it was associated with the Mitigating System cornerstone attribute of Equipment Performance and adversely affected the associated cornerstone objective to ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). The refrigerant overcharge condition resulted in the 0K112A chiller being inoperable and unable to fulfil its safety function to cool safety related switchgear and equipment during accident conditions for a period of 23 months. In accordance with IMC 0609.04, Initial Characterization of Findings, and Exhibit 2 of IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, the inspectors determined a detailed risk evaluation would be required because the finding involved an actual loss of function of at least a single Train for greater than its Technical Specification allowed outage time of 30 days. A detailed risk assessment was performed by a Region 1 Senior Reactor Analyst (SRA). The SRA determined the finding to be of very low safety significance (Green.) This finding had a cross-cutting aspect in the area of Human Performance, Procedure Adherence because individuals did not follow processes, procedures, and work instructions. Specifically, for many years maintenance and engineering personnel relied upon informal work practices vice referring to the procedure when charging the chillers with refrigerant. [H.8] [Section 4OA2.1.c(2)] |
| Site: | Susquehanna  |
|---|---|
| Report | IR 05000387/2016008 Section 4OA2 |
| Date counted | Sep 30, 2016 (2016Q3) |
| Type: | NCV: Green |
| cornerstone | Mitigating Systems |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 71152 |
| Inspectors (proximate) | A Rosebrook A Siwy D Schroeder M Draxton T Daun |
| Violation of: | 10 CFR 50 Appendix B 10 CFR 50 Appendix B Criterion V |
| CCA | H.8, Procedure Adherence |
| INPO aspect | WP.4 |
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Finding - Susquehanna - IR 05000387/2016008 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Susquehanna) @ 2016Q3
Self-Identified List (Susquehanna)
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