05000424/FIN-2014003-01
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Finding | |
|---|---|
| Title | Inadequate Maintenance Procedure Results in a Failed MSIV and a Manual Reactor Trip |
| Description | A self-revealing non-cited violation (NCV) of 10 CFR 50 Appendix B Criterion V, Instructions, Procedures, and Drawings, was identified for failure to provide adequate work instructions in the maintenance procedure used for main steam isolation valve (MSIV) maintenance. Specifically, maintenance procedure 26854-C, Main Steam Isolation Valve Actuator Maintenance, used to perform maintenance on Rockwell MSIV(s), did not provide adequate instructions for installing the lower manifold/cylinder O-ring during reassembly. This resulted in a pinched O-ring on 1HV3006B, a subsequent failure of the O-ring causing the MSIV to fail closed, and a manual reactor trip. The licensee conducted a root cause investigation and entered the event into their corrective action program (condition report (CR) 800018). The licensee replaced the Oring, performed an extent of condition evaluation for all other MSIVs, and revised the maintenance procedure to include specific instructions for the installation of the lower manifold/cylinder O-ring. The finding was more than minor because it was associated with the procedure quality attribute of the reactor safety - initiating events cornerstone and it adversely affected the 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 failure to provide an adequate procedure with adequate instructions for ensuring proper O-ring installation resulted in the failure of the Unit 1 loop 1 outboard MSIV hydraulic actuator causing the loop 1 MSIV to fail closed and a subsequent manual reactor trip due to lowering steam generator water level. Because the inspectors answered No to all of the IMC 0609 Appendix A (dated June 19, 2012) Exhibit 1, Section B, Initiating Events Screening Questions, the inspectors concluded that the finding was of very low safety significance (Green). The inspectors determined the finding had a cross-cutting aspect of resources in the human performance area, because the maintenance procedure used to install manifold/cylinder O-ring did not provide adequate instructions for the proper installation of the O-ring. |
| Site: | Vogtle  |
|---|---|
| Report | IR 05000424/2014003 Section 1R12 |
| Date counted | Jun 30, 2014 (2014Q2) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | Self-revealing |
| Inspection Procedure: | IP 71111.12 |
| Inspectors (proximate) | A Alen A Nielsen C Dykes F Ehrhardt G Ottenberg M Cain M Speck S Sanchez T Chandler W Loo |
| Violation of: | 10 CFR 50 Appendix B Criterion V |
| CCA | H.1, Resources |
| INPO aspect | LA.1 |
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Finding - Vogtle - IR 05000424/2014003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Vogtle) @ 2014Q2
Self-Identified List (Vogtle)
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