I n s t i tu t e o f N u c l e a r Po w e r O p e r a t i o n s

Maintenance
Fundamentals
Bryant Hearne– INPO Lead Maintenance
Evaluator MA/WM
January 24, 2018
© 2018 Institute of Nuclear Power
Operations
Topics
• MA Fundamentals vs HU Tool Usage
• Maintenance IER (L2 17-009)
• MA Fundamentals (INPO 15-001)
• MA Core Fundamentals – MM, EM,
IC
• MA Fundamentals – Case Studies
• The Station’s Perspective

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 What are HU Tools?

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 What are MA Fundamentals?

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 HU Tools vs MA Fundamentals

Performance

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 HU Tools vs MA Fundamentals

Human Performance Technical

Tools Fundamentals
Oversight & Training

Sustained
Performance

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 Maintenance Model

Craftsmanship
MA Tech
Fundamentals
Generic Fund
(FME, Safety, RW Practices, etc)

PU&A-NP.1
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MA Fundamentals IER L2 17-9
Since January 2015, maintenance technical fundamental
weaknesses contributed to 12 reactor scrams, 18 power
reductions, 10 outage impacts and additional
consequential events.

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Operations
 Maintenance Fundamentals IER
L2 17-9
To address this ongoing trend, a decision was made to
develop an INPO Event Report (IER) associated with
maintenance technical fundamentals.

In May 2017, a group of:

• 30 representatives
• 16 different stations
• 10 different fleets
• Reviewed ~400 industry events

Identified causes and develop recommendations to drive

performance improvement.
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AFIs

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2016 AFIs

Maintenance Fundamentals

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© 2018 Institute of Nuclear Power Operations
2016 AFI Causes – MA
Leadership

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Maintenance Fundamentals IER

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Maintenance Fundamentals IER L2 17-9

4 most prominent weaknesses in

maintenance technical fundamentals:
• Anti-movement devices.
• Lifting and landing of electrical leads.
• Leak-path sealing devices and tubing
fitting installation.
• Electrical component assembly
practices.

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 Maintenance Fundamentals IER L2 17-9
Anti-movement devices
• On August 31, 2016, high vibration occurred on a feedwater pump turbine
as the result of a cracked pump/turbine coupler, requiring a power
reduction to 58 percent for repairs. The coupling hub retention nut had
loosened because an incorrect setscrew had been installed (ICES 324342).
• On March 23, 2016, a motor-driven auxiliary feedwater pump room cooler
failed, resulting in the pump being declared inoperable. The setscrew for a
sheave installed in the cooler a few days earlier had backed out because of
inadequate torqueing (ICES 322111).

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 Maintenance Fundamentals IER L2 17-9
Lifting and Landing Leads
• On January 23, 2017, a power reduction was initiated because a turbine stop valve began
oscillating. A degraded lug crimp connection was discovered inside the valve junction box.
Technicians conducting maintenance had failed to inspect and perform a basic tug test of the ring
lug crimps and consequently left a faulty connection in place (ICES 407273).
• On September 6, 2016, a manual scram was initiated as the result of high reactor water level
caused by feedwater flow oscillations. Technicians did not terminate a neutral common wire
between an encoder and a digital controller, resulting in the wire remaining loose (ICES 324322).

In the picture to the right, electricians incorrectly installed

test leads into the motor rotation terminals of the test device,
which applied current to the circuit and caused an arc flash
on the safety-related battery charger, ultimately leading to a
power reduction of the plant.

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 Maintenance Fundamentals IER L2 17-9
Leak path sealing and Tube fitting installation
• On December 3, 2016, a heater drain pump tripped, requiring a power reduction to 91
percent. Technicians did not ensure that two tubing fittings were properly reconnected
(ICES 325785).
• On October 30, 2016, a mechanical seal assembly flange on a heater drain pump
began leaking, resulting in rising bearing temperatures and necessitating a power
reduction to 85 percent. Technicians had assumed the need for a gasket in reassembly
of the mechanical seal without questioning the absence of one during disassembly.
Consequently, they mistakenly installed a gasket over an O-ring, creating various new
leak paths (ICES 325497).
• On the right, In June 6, 2016, a leak was discovered
in a main turbine electrohydraulic control supply line,
requiring the main turbine to be taken offline. An O-ring
had been improperly installed and was misaligned within its
fitting (ICES 323488).

© 2018 Institute of Nuclear Power Operations

 Maintenance Fundamentals IER L2 17-9
Electrical component assembly
• On May 5, 2015, a unit experienced an automatic scram due to a loose current
transformer connection. A recommended torque value had been ignored in the
course of maintenance because the work was considered to be skill-of-the-craft
(ICES 316675).
• On June 6, 2016, a safety chiller was taken offline because of an elevated
temperature in one phase of the motor starter. Consequently, the unit was required
to enter a 72-hour limiting condition for operation (LCO). Preventive maintenance
technicians had improperly torqued a cable termination on the chiller motor starter
Phase A dashpot relay (ICES 323298).
• On April 28, 2016, during a surveillance channel test on the reactor core isolation
cooling (RCIC) system, technicians connected relay blocks to the wrong contacts,
resulting in a trip signal and rendering the RCIC inoperable (ICES 322800).
• On September 18, 2015, an instrument air compressor unexpectedly tripped.
Technicians had incorrectly installed a 440-V motor contactor coil in lieu of the
correct 110-V contactor coil (ICES 319738).
• On July 24, 2015, a reactor recirculation pump tripped, resulting in the need to enter
single-loop operations. Electricians had improperly configured a pickup relay setting
dial tensioning spring, contributing to a false overload signal, which, in turn, led to a
loss of power in the adjustable speed drive system (ICES 317894).

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Maintenance Fundamentals IER L2 17-9

CAUSE of technical fundamental weaknesses are

as follows:
• Weak addressal of maintenance technical fundamentals
by supervisors and managers during work preparation,
prejob briefings and work execution
• Failure of maintenance supervisors, superintendents,
managers and oversight organizations — including
corporate oversight — to observe for and enforce
continually the correct application of technical skills
• Failure to use training effectively to renew and reinforce
worker technical knowledge and skill

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 Maintenance Fundamentals IER - Lessons Learned

• INABILITY TO RECOGNIZE DEFICIENCIES AND ERRORS

• Complacency and Overconfidence.
• Senior workers not New workers.
• INADEQUATE WORK EXECUTION
• Overemphasis of HU Tool usage and Procedure
Compliance.
• INADEQUATE OVERSIGHT
• FLS and Managers not looking for Technical
behaviors.
• INSUFFICIENT TRAINING TO MAINTAIN TECHNICAL
FUNDAMENTALS
• Perishable and not in continuing training (Skill-of-the-Craft).
• Compression fitting, Set Screws, Torqueing, Lug assembly,
Control lifted leads, etc.
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 INPO Maintenance Fundamental
Documents

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 Maintenance Worker Fundamentals 1
(INPO 15-001)
Workers are qualified, proficient, and prepared to perform
high-quality corrective and preventive maintenance.
• Workers prepare in advance of work. If they are not
proficient with the task they seek help of senior
technicians to ensure high-quality maintenance. MA-1.7
& MA-1.19
• Determine needed tools and test equipment and ensure
they are used properly. MA-1.11
• Maintain work areas and open equipment clean and free
of foreign material during and after work. MA.1-13
• Maintain situational awareness to prevent inadvert
equipment actuation. MA.1-14

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 Maintenance Worker Fundamentals 1
(INPO 15-001)
Workers are qualified, proficient, and prepared to
perform high-quality corrective and preventive
maintenance.
• Work only when authorized and only when
equipment is aligned for maintenance. MA.1-8
• Conduct skilled maintenance by applying proper
techniques and using correct repair parts.MA.1-5
• Ensure material is collected, preserved, and
details are documented when abnormal
conditions are encountered. MA.1-22

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 Maintenance Worker Fundamentals 2
(INPO 15-001)
Workers communicate and document technical
information effectively. Workers prepare in
advance of work.
• Clearly communicate work plans and statuses
during briefings, turnovers, and handoffs.
Workers advocate the maintenance technical
position in troubleshooting, maintenance
strategies, and operating practices. MA-1.20
• Provide feedback to improve work instructions,
procedures, and processes. MA-1.21

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 Maintenance Worker Fundamentals 3
(INPO 15-001)
Maintenance workers know their trade.
• Know the basic design and key functions of
equipment and components as they relate to
maintenance. MA.1-1
• Understand the risk significance of performing
maintenance correctly. Know the criticality and
the impact to operators of equipment/components
being touched. MA.1-2 & WM.1-2
• Know how to read plant drawings and vendor
manuals. MA-1.4

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 Maintenance Worker Fundamentals 4
(INPO 15-001)
Maintenance worker actions are deliberate and
conservative.
• Anticipate and validate equipment responses
from maintenance. MA.1-17
• Search for and recognize abnormal conditions
during repairs, troubleshooting, and preventive
maintenance. MA.1-23
• STOP and obtain help or clear direction from
supervision when faced with uncertainty;
unexpected results or changing conditions.
MA.1-15 & MA.1-18
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 Maintenance Mechanical Fundamental
Examples, (INPO 05-004)
• Know basic bolting and mechanical joint
requirements to minimize the potential of leaks.
• Have a thorough knowledge of pump and valve
repair standards and the risks associated with
improper maintenance of these components.
• Understand their role in leak mitigation
strategies.
• Understand torque requirements and the
importance of bolt lubrication, hardware makeup
and torqueing patterns.
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 Maintenance Mechanical Fundamental
Examples, (INPO 05-004)
• Have a thorough knowledge of different gasket
materials and the appropriate gasket to be used
for each application.
• Understand foreign material exclusion control
requirements, and be a station leader in
supporting the program.
• Understand rigging, lifting and material
handling technical requirements as well as
rigging team roles and responsibilities, and be
a station leader in support of the program.
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 Maintenance Mechanical Fundamental
Examples, (INPO 05-004)
• Understand tool use, and use the appropriate tool for
the work task assigned.
• Understand pump curves and application in system
response.
• Maintain high standards for configuration control.
• Understand piping fit-up requirements and the
potential impact for improper pipe alignment.
• Have a thorough understanding of test equipment to
include but not be limited to hydrostatic pressure test
equipment, torque wrench design and application, and
pressure gauge application and sensitivity.

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 Maintenance Electrical Fundamental
Examples, (INPO 05-004)
• Demonstrate established practices for lifted and landed
leads to prevent inadvertent contact in energized
circuits, and maintain high standards for configuration
control of these leads.
• Understand the requirements for lead bend radius and
the associated risks for not maintaining proper bend
radius.
• Understand the requirements for hardware
configuration of high-energy lead re-installation and
the potential impacts for not maintaining the
configuration per design.

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 Maintenance Electrical Fundamental
Examples, (INPO 05-004)
• Have a thorough knowledge of how to read
drawings, and refer to the drawings in the field
as appropriate.
• Have a thorough knowledge of the station
electrical safety program, and be a station
leader in support of it.
• Have an understanding of the different breaker
designs used at the plants and an
understanding of the critical attributes of each
breaker design.
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 Maintenance Electrical Fundamental
Examples, (INPO 05-004)
• Have a thorough understanding of battery
maintenance to include the potential risks, and
battery degradation and battery monitoring.
• Have a thorough understanding of test
equipment used in electrical maintenance,
including design, operating instructions and
applicability.
• Use insulating material as appropriate to
minimize inadvertent contact with energized
circuits.
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 Maintenance IC Fundamental Examples,
(INPO 05-004)
• Understand the system response and potential
risks associated with performing surveillance
tests.
• Have a thorough understanding of test
equipment used in instrument and control
maintenance, including design, operating
instructions and applicability.
• Use insulating material as appropriate to
minimize inadvertent contact with energized
circuits.
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 Maintenance IC Fundamental Examples,
(INPO 05-004)
• Use appropriate test leads for the job to
minimize inadvertent contact with energized
circuits.
• Understand hysteresis and how it affects
equipment calibration and repeatability of
calibration.
• Have a thorough understanding of differential
pressure instruments and the effects on the
instrument from having air trapped in the test
lines.
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 Maintenance IC Fundamental Examples,
(INPO 05-004)
• Understand the requirements for fitting installation and
the limits for disassembly and reassembly of fittings,
particularly compression fittings.
• Understand the requirements for lifted and landed
leads, and maintain high standards for configuration
control of these leads.
• Have a thorough understanding of electrical
terminations to include lead bend radius, terminal lug
installation and termination tightness requirements.

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 Maintenance Fundamental
Case Studies

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 Case Study 1
During maintenance on a safety-related auxiliary feedwater
pump, mechanics improperly aligned the linkage for the speed
control governor.
• The mechanics were given the work package the morning of
execution and instructed to go directly to the field and start the
maintenance.
• The work package did not contain details for aligning the
linkage for the governor.
• The technical manual required the use of specialized tooling
to align the linkage, but the mechanics did not refer to the
technical manual and the tooling was not included in the work
instructions.
• Although the mechanics had not performed the task prior,
they aligned the linkage in accordance with what they knew
from similar governor systems.
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 Case Study 1 - answers
Fundamentals that were not applied.
• Prepare for work – Perform required walkdowns and
review instructions in advance of work. MA-1.7 & MA-
1.19
• Determine needed tools and test equipment. MA-1.11
• Conduct skilled maintenance by applying proper
techniques and using correct repair parts. MA-1.10
• Provide feedback to improve work instructions, procedures,
and processes. MA-1.21
• Ensure the high quality work is performed. MA.1-5
• STOP and obtain help or clear direction from supervision
when faced with uncertainty; unexpected results or
changing conditions. MA.1-15 & MA.1-18
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 Case Study 2
During calibration of an nuclear instrument a technician
inadvertently contacted an adjacent relay in the cabinet
causing an electrical ground in the reactor protective
system and a subsequent reactor scram.
• The technicians were experienced and had performed
the task several times before successfully.
• The technicians used an insulated screwdriver,
however the insulation was damaged in several places.
• The technicians did not perform a one minute matters
review of the cabinet when it was opened to determine
potential hazards within the cabinet,
• No prejob briefing was held because of the experience
of the technicians.
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 Case Study 2 - answers
Fundamentals that were not applied.
• Determine needed tools and test equipment and
ensure they are used properly. MA-1.10
• Maintain situational awareness to prevent
inadvertent equipment actuation, equipment
damage, and injury to self and others. MA.1-14
• Conduct skilled maintenance by applying
proper techniques and using correct repair parts.
MA-1.10
• Understand risk significance of performing
mtnce incorrectly. MA.1-1 & MA.1-2
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 Case Study 3
During reassembly of a safety-related chiller the
mechanics did not properly install the coupling bolts
hardware. This resulted in delays in making the chiller
operational.
• The mechanics were qualified for bolting and
torqueing
• The work instructions did not provide detail on the
hardware makeup of the coupling bolts.
• The mechanics had never performed work on a chiller
previously.
• The mechanics incorrectly placed the flat washer on
the nut and the lock washer on the bolt.

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 Case Study 3 - answer
Fundamentals that were not applied.
• Conduct skilled maintenance by
applying proper techniques and using
correct repair parts. MA-1.10
• Know the basic design and key
functions of equipment and components
as they relate to maintenance. MA.1-1
• Know how to read plant drawings and
vendor manuals. MA.1-4
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 The Station’s Perspective
What are the top 2-3
maintenance technical
fundamental concerns for each
discipline at your station?
• Mechanical-?
• Electrical-?
• IC-?

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 The Station’s Perspective
What actions are being performed
to address the concerns?
• Mechanical-?
• Electrical-?
• IC-?

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 Stations PIC Data

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 Questions?

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