ML102120041
| ML102120041 | |
| Person / Time | |
|---|---|
| Site: | Prairie Island  |
| Issue date: | 07/08/2010 |
| From: | Butterworth H, Travieso-Diaz M Northern States Power Co, Pillsbury, Winthrop, Shaw, Pittman, LLP, Xcel Energy |
| To: | Atomic Safety and Licensing Board Panel |
| SECY RAS | |
| Shared Package | |
| ML102120039 | List: |
| References | |
| 50-282-LR, 50-306-LR, ASLBP 08-871-01-LR-BD01, FP-PA-ARP-01, Rev 27, RAS 18336 | |
| Download: ML102120041 (81) | |
Text
FP-PA-ARP-01 Revision: 27 Issue Date: 07/08/2010 Nuclear Department Fleet Procedure Page 1 of 81
Title:
CAP Action Request Process Approval:
Henry H. Butterworth Director, Operations Standards INFORMATION USE Procedure should be available, but not necessarily at the work location.
Procedure may be performed from memory.
User remains responsible for procedure adherence.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 2 of 81 Table of Contents Page 1.0 PURPOSE.........................................................................................................................3 2.0 APPLICABILITY...............................................................................................................3 3.0 RESPONSIBILITIES.........................................................................................................4 4.0 DEFINITIONS...................................................................................................................6 5.0 REQUIREMENTS...........................................................................................................12 6.0 RECORDS......................................................................................................................29
7.0 REFERENCES
................................................................................................................29 7.1 SOURCE DOCUMENTS.......................................................................................29 7.2 REFERENCE DOCUMENTS................................................................................29 7.3 COMMITMENTS....................................................................................................31 8.0 REVISION
SUMMARY
...................................................................................................32 9.0 ATTACHMENTS.............................................................................................................32
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 3 of 81 1.0 PURPOSE 1.1 This procedure describes the CAP Action Request (AR) Process. It is the expectation of management that this procedure be made available to all employees to document any problems or concerns regardless of significance or status of resolution.
1.2 This procedure establishes the process for documenting and tracking the resolution of issues at each site. It provides the framework to ensure that deviations from performance expectations, including conditions adverse to quality, employee concerns, operability issues, functionality issues, and reportability issues are promptly identified, evaluated, and corrected as appropriate.
1.3 This procedure meets the requirements of 10 CFR Part 50, Appendix B criteria XV and XVI; and the Nuclear Quality Assurance Topical Report.
1.4 This document supports the implementation of renewed license aging management programs, specifically for elements related to corrective action and confirmation of corrective action. This document also supports Monticellos NRC License Renewal Commitment {C008} related to generation of an action request whenever non-conforming conditions are found.
2.0 APPLICABILITY 2.1 It is the responsibility of all personnel to ensure that administrative work is performed in compliance with applicable station procedures or controls. This procedure establishes the framework for standards and expectations required to conduct business to ensure consistency and thoroughness, and to achieve operational excellence.
2.2 The Action Request (AR) Process involves the following:
- 1.
Identification and documentation of problems, issues, and concerns of all types.
- 2.
Defining the work process necessary to resolve open issues.
- 3.
Defining the safety and/or economic severity of an issue.
- 4.
Prioritizing work activities to resolve issues.
- 5.
Assigning the appropriate person and due date.
- 6.
Planning, executing, and managing oversight of work activities.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 4 of 81
- 7.
Reviewing the work performed to assure adequate resolution of the open issue.
- 8.
Providing data to effectively identify declining performance.
3.0 RESPONSIBILITIES 3.1 All personnel SHALL be responsible for compliance with assigned actions per this process.
3.2 The Owed To is the Management/Supervisor assigned responsibility for the CAP.
The Owed To SHALL:
- 1.
Assign work activities.
- 2.
Review and approve new Action Requests.
- 3.
Review and approve completed action requests.
- 4.
Review and approve due date extension requests in accordance with Attachment 2.
- 5.
Ensure Trend Codes are entered.
- 6.
Ensure ACE and RCE assignments are graded and closed in a timely manner.
- 7.
Ensure effectiveness reviews of corrective actions are performed to prevent recurrence.
- 8.
Ensure AR records are Authenticated prior to completing the AR.
- 9.
Ensure reassignment of CAP ARs when individuals within your department leave the company.
- 10. Ensure all Conditions Adverse to Quality (CAQs) are resolved when CAPs are closed.
3.3 The Assigned To is responsible for a specific CAP-related task (Assignment). The Assigned To SHALL:
- 1.
Make operability declaration and reportability determinations (SROs).
- 2.
Update AR records when appropriate.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 5 of 81
- 3.
Complete assignment(s) by the due date.
- 4.
Make Operating Experience determinations (Performance Assessment).
- 5.
Ensure reassignment of CAP ARs when individuals within your department leave the company.
3.4 All personnel are responsible for identifying and documenting problems, issues and concerns including conditions adverse to quality, failures, malfunctions, deficiencies, deviations, defective material and equipment, and non-conformances. Problems, issues and concerns are to be entered into the CAP process even if resolved at the time of identification in order to facilitate performance trending.
3.5 The following positions/organizations have specific responsibilities for compliance with this procedure:
- 1.
AR Originator
- 2.
Senior Reactor Operator (SRO)
- 3.
CAP Owed To
- 4.
Plant Manager
- 5.
Performance Assessment
- 6.
Nuclear Oversight (NOS)
- 7.
Licensing/Regulatory Affairs/Compliance
- 8.
CAP Coordinator / Liaison
- 9.
Records Management
- 10. Performance Assessment Review Board (PARB)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 6 of 81 4.0 DEFINITIONS 4.1 Adverse Assessment Finding: An NOS Finding that warrants a Corrective Action to Prevent Recurrence (CAPR) and an effectiveness review (EFR) at NOS management discretion. Factors that are considered include:
Recurring and/or longstanding issues for which previous corrective actions have been ineffective or unsustainable in correcting the condition Cross-functional or safety culture issues impacting multiple departments Substantial organizational leadership issues within a department or multiple departments Programmatic breakdown or weakness that results in an ineffective program or key aspects of a program Falsification of QA records Identification of a chilling environment See DP-NO-IA-01, Internal Assessments for more information.
4.2 Adverse Trend: An increase in the frequency of occurrence of similar events or events with similar causes, an unexpected decline in performance in equipment or an organization, or a sustained (e.g., > 2 months) worsening in performance of groups, processes, or programs which result in actual or potential moderate or significant impact to the plant and/or the organization.
4.3 Assigned To: The individual responsible for completing the activity described in the Action Assignment by the assignment Due Date.
4.4 CAP Action Request (CAP AR): The electronic or paper documentation of an issue including any associated or pertinent information, and reviewer and screener comments.
4.5 Apparent Cause Evaluation (ACE): An analysis technique that identifies the apparent cause of a problem or condition, the extent of that condition, and ensures that the issue has been corrected (see FG-PA-ACE-01, Apparent Cause Evaluation Manual).
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 7 of 81 4.6 Assignment/Sub Assignment: Assignment (see Attachment 6) that is initiated as a result of an Action Request. The Assignment/Sub Assignment documents the work performed under each Action Request.
4.7 Authentication
The certification confirming a document is accurate in each significant aspect. This certification is accomplished by an individual(s) who is competent to make that determination and can attest to the accuracy of the statements, facts or representations presented.
4.8 CAP Owed To: This individual (Manager/Supervisor) ensures that the assignments resolve all identified issue(s), and is held accountable for the resolution of the issue(s).
4.9 Common Cause Evaluation (CCE): An evaluation method to determine the cause of several related events. The CCE manual as a stand alone process was retired (common cause analysis as a tool was included in the RCE Manual), but the Passport evaluation AS type still exists.
4.10 Condition Adverse to Quality (CAQ): Failures, malfunctions, deficiencies, deviations, defective material and equipment and non conformances that:
- 1. Affect or have a reasonable potential to affect the operability or functionality of critical (maintenance rule) systems, structures or components, OR
- 2. Violate applicable codes, regulations, orders, Technical Specifications or license requirements having nuclear or radiation safety significance, OR
- 3. Materially impact:
Security related activities Radiation protection related activities, including radioactive material shipping or radiological environmental monitoring ISFSI activities Emergency Preparedness, OR
- 4. Involve the application of managerial and administrative controls that directly impact the above areas.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 8 of 81 All conditions adverse to quality are addressed in the corrective action program as a Level A, B or C issue.
4.11 Condition Evaluation (CE): This evaluation defines the scope of the issue to be resolved and identifies the corrective action to be implemented. This is not a cause evaluation.
4.12 Corrective Action (CA): An action that is performed to correct a condition or address the cause of a condition identified in CAP ARs.
4.13 Corrective Action to Prevent Recurrence (CAPR): Actions taken to correct the cause of a Significant Condition Adverse to Quality (SCAQ). CAPRs are required for any SCAQ regardless of the type of evaluation performed. CAPRs of an SCAQ are internal commitments.
4.14 Degraded Condition: Refer to FP-OP-OL-01 4.15 Effectiveness Review (EFR): An evaluation performed following the implementation of Corrective Actions to Prevent Recurrence (CAPR) to determine if the actions have effectively reduced the frequency of occurrence, reduced the consequences of the condition, or prevented recurrence of the identified problem(s) by the SAME cause(s).
The evaluation also ensures that other unforeseen or adverse consequences were not introduced by the corrective actions.
4.16 Extent of Condition: The extent to which the causes or effects of a problem have impacted other plant processes, equipment, or human performance. An extent of condition evaluation should assess the effects (symptoms) across different disciplines or departments, programmatic activities, human performance, and equipment.
4.17 Finding (i.e., NOS Finding): An NOS identified issue that warrants NOS tracking and follow-up. This includes issues regarding the failure to effectively implement and/or adhere to the elements of the NSPM QATR, and to meet industry standards such as INPO Performance Objectives and Criteria, INPO/EPRI Guidelines, and INPO Accreditation Objectives/Guidelines. Other factors that are considered include:
Early indications of declining performance in programs, processes and behaviors Noteworthy GAP to industry standards Adverse trends in performance Safety Culture issues affecting one department
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 9 of 81 Failure to directly meet a licensing basis requirement See DP-NO-IA-01, Internal Assessments, for additional information.
4.18 Functional/Functionality: Functionality is an attribute of System, Structure, or Component (SSC) that are not controlled by Technical Specifications. An SSC is functional or has functionality when it is capable of performing its specified function, as set forth in the Current Licensing Basis (CLB) for the site. (See FP-OP-OL-01) 4.19 Functionality Assessment (FA): A process used to assess the functionality of an SSC described in the CLB when a degraded or non-conforming condition is identified.
(See FP-OP-OL-01) 4.20 Functionality Declaration: A decision by a Licensed Senior Reactor Operator on the operating shift crew that there is a reasonable expectation that an SSC is capable of performing its specified function, as set forth in the CLB. (See FP-OP-OL-01) 4.21 Ineffective corrective action: A completed action in Passport, and either the associated condition is still in existence, or the cause of the condition remains active.
Additional specifics follow:
The required action was not fully performed. This includes the case where non performance was recognized in the closure documentation, but an insufficient basis was provided for non performance.
The required action was performed, but the action as designed was not sufficient to address the cause or condition.
4.22 Nonconforming Condition: Refer to FP-OP-OL-01 4.23 Operability Declaration: A decision by a Senior Licensed Operator (SRO) or the operating shift crew that there is a reasonable expectation that an SSC can perform its specified safety function. (See FP-OP-OL-01) 4.24 Operability Determination: A declaration whether or not an SSC can perform its specified safety function following identification of a condition which may affect operability. (See FP-OP-OL-01) 4.25 Operability Recommendation: The technical analyses and associated conclusions, including a description of any required compensatory measures, regarding operability of an SSC. (See FP-OP-OL-01)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 10 of 81 4.26 Potential Trend: Performance trends that are selected for further review under the CAP Program identified through cognitive review or performance analysis.
4.27 Proprietary Information: Information that is deemed a trade secret or is confidential or privileged commercial or financial information to be withheld from public disclosure.
(See FP-R-LIC-02, Regulatory Correspondence) 4.28 Protected Activity: An activity that involves the identification and resolution of potential safety concerns, violation of license conditions, or violations of NRC regulations. Personnel who engage in protected activities are protected by law against adverse employer actions including discharge or actions relating to compensation, terms, conditions, or privileges of employment {C004}. The identification and resolution of all problems, issues and concerns, regardless of their relationship to regulatory requirements, are considered protected activities.
4.29 Root Cause Evaluation (RCE): An evaluation that identifies the most fundamental cause(s) of a problem or condition, over which the organization has control and that, when eliminated, will prevent recurrence of the same and similar problems. (See FG-PA-RCE-01, Root Cause Evaluation Manual) 4.30 Significant Condition Adverse to Quality (SCAQ): A condition adverse to quality that represents a serious threat to the radiological safety of plant workers (radiation protection) or the public (nuclear safety).
4.31 Severity Levels:
NOTE:
Guidance on Severity Level Classification is provided in Attachment 1.
4.31.1 Significant severity level is the highest and most important. In most cases, significant events are the result of multiple barrier failures or programmatic breakdowns. There is considerable investigation into the cause of the identified condition.
Level A - Includes Significant Conditions Adverse to Quality (SCAQ), issues of significant regulatory concern or public interest, or issues with significant economic impact. Attachment 1 provides examples of Level A type conditions.
4.31.2 Non-Significant ARs document problems for which a repeat occurrence (while always undesirable) can be tolerated.
Level B - Level B conditions typically result in moderate impact to the plant and/or organization. Attachment 1 provides examples of Level B type conditions.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 11 of 81 Level C - Level C conditions typically result in minor impact to the plant and/or organization. Attachment 1 provides examples of Level C type conditions.
Level D - A Condition NOT Adverse to Quality that is an improvement, suggestion or enhancement to improve business practices, programs or plant performance. Level D items may be changed to non-CAP ARs.
4.32 Sub-Assignment: An assignment performed to support completion of a primary assignment. Sub-assignments should be used when there is a need to coordinate dependent actions with multiple discipline groups. Sub-assignments may also be used to coordinate complex dependent actions.
4.33 Urgency: The value of accomplishing an action in a timely manner. The higher the urgency, the more critical it is to add resources or work continually on an action so that it is accomplished as soon as feasible.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 12 of 81 5.0 REQUIREMENTS - Corrective Action Program (CAP) AR Returned 5.2 - Submit Action Request OPR/FR Required?
5.4 - Assign Operability Recommendation to Responsible Group Make Operability Recommendation Yes No 5.9 - Perform Evaluation ACE or RCE Is the parent A/R Level A?
A B
Yes No C
Activity Closed All Activities Closed?
5.21 - AR Records Retention No Reassign or Due Date Extension 5.7 - Assign Eval Assign to Responsible Person A
B 5.13 - Assign Work Assignment to Responsible Person 5.15 - Perform Work Assignment Reassign or Due Date Extension Yes C
5.17 - NOS or Licensing Review 5.20 - CAP OWED TO - Review and Complete AR Yes Returned Returned If Req If Req Returned 5.10 - Approve Evaluation 5.16 Complete Assignment 5.1 - Identify
- Problem, Improvement or Request 5.3 - AR Approval Non-SRO Review 5.3 - AR Approval SRO Review 5.8 - Accept Evaluation 5.14 - Accept Work Assignment Perform Operability Recommendation per (FP -OP-OL-01) 5.6 - Initiation Evaluation Assignment 5.12 - Initiate Work Assignment 5.5 - AR Screening and Processing 5.11 - Corrective Action Program AR Trending Returned 5.18 - RCE/ACE Quality Grading 5.19 - PARB Review Yes
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 13 of 81 5.1 Issue Identification AR Originator The CAP (Corrective Action Program) Action Request (AR)
Process SHALL be used to document and track all problems, issues and concerns. Conditions adverse to quality (CAQ) are required by the quality assurance program to be documented, tracked, and resolved using CAP action requests.
Contact the Shift Manager immediately with any plant equipment, operability or reportability concern. Initiation of an AR does not absolve the individual from this notification expectation.
NOTE:
QF-0573 is available to assist engineers in evaluating complex issues to determine if a non-conforming or degraded condition exists.
(see Attachment 18 for more information)
IF doubt exists whether a CAP should be initiated, THEN initiate the CAP. In addition, column C in Attachment 1 contains examples of events and conditions when CAP initiation is appropriate.
CAPs should be initiated in a timely manner after a problem has been identified (e.g., by end of shift or day). Do not wait to perform additional diagnosis or cause analysis.
Specify that 10 CFR Part 21 applies if the problem involves a potential defect or nonconformance in a Quality Level 1 (QL-1) part or component, including commercially dedicated items (See FP-R-LIC-04, 10 CFR 21 Reports; See QF-0708, 10 CFR 21 Reportability Evaluation Form).
Initiators of CAPs for security issues should take care not to include Safeguards Information (SGI) and further care should be taken to avoid compilation of non-Safeguards Information that when combined may constitute Safeguards Information.
The originator of the AR SHALL notify the shift manager to take the necessary actions to preserve any evidence or damaged equipment to minimize the loss of information that may help determine the cause of the problem. Refer to FP-PA-ARP-02, Attachment 1, for quarantine guidance.
Consider saving defective parts that are collected during performance of a work activity or procedure and maintaining the parts or equipment in the condition in which they were found so that accurate fault analysis can be made.
Identify problem, improvement, or request
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 14 of 81 5.1 continued IF the parts or equipment are susceptible to environmental degradation, are radioactive, or are contaminated, THEN wrap, cover or relocate them to a suitable area to prevent degradation of the parts and the spread of contamination.
5.2 Action Request Initiation AR Originator (INPROG)
- 1. IF the electronic AR Process system is unavailable or the Originator does not have computer access, THEN CAP ARs SHALL be manually submitted using the Action Request Form (Form QF-0400). 2, Process Continuity should also be referenced for loss of electronic AR processing.
- 2. Initiate a CAP AR by completing the electronic AR form and providing sufficient detail. Refer to Attachment 13
{C004}
- 3. Complete the ACTION REQUEST NOTES tab of the AR initiation template with:
any immediate actions taken, (A) why the condition occurred (O), and any recommendations (R).
- 4. IF the condition warrants a work request or PCR type AR, THEN generate a WR/PCR and cross reference the CAP and WR/PCR to each other.
- 5. IF a work request is generated, THEN a CAP does not need to be written UNLESS the equipment is on the critical equipment list, is maintenance rule related, is security equipment, or if some analysis of the equipment problem is needed or desired. When in doubt, initiate a CAP.
- 6. Route the AR to a Manager/Supervisor for approval, or to the A-SRO group if the issue meets the criteria for SRO review as provided in step 5.3.
Submit Action Request
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 15 of 81 5.3 Action Request Approval Managers/Supervisors OR Non-SRO Review:
- 1. Determine whether the CAP AR requires review by a SRO, or if it can bypass the SRO review. A SRO SHALL review the CAP AR if the issue:
affects plant operation, plant equipment, security equipment, or Emergency Response Facility equipment.
potentially involves external agency notification (NRC, EPA, etc.),
involves Technical Specification or Technical Requirement Manual compliance, or presents an immediate threat to personnel safety.
- 3. IF SRO Review is NOT Required, THEN review the CAP and ensure the standards of Attachments 9 and 13 are met. {C004}
- a. Complete this review within three working days.
- b. Document any comments or information related to their review, or may return it to the Originator for more information or clarification.
NOTE:
Managers, Directors, and Vice Presidents may review and approve their own CAP ARs for entry into the corrective action program. They also may forward CAP ARs they initiate to their respective supervisor for review and approval.
- 4. Approve the AR and forward it for Screening. Proceed to Step 5.5.
OR NOTE:
Supervisors are NOT permitted to alter any information provided by the originator of the AR without the concurrence of the originator.
Supplementary or clarifying information may be added in the notes field of the AR by the supervisor or by other personnel.
AR Approval
-Non-SRO Review AR Approval-SRO Review
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 16 of 81 Senior Reactor Operator SRO Review:
- 1. The SRO SHALL determine and document the following items, where applicable:
For more detail on evaluating Operability, see FP-OP-OL-01.
- b. Operability Status (Operable, Inoperable, Operable but Degraded, Operable but Non-Conforming, Not Applicable) of any affected structure, system or component.
- c. Functionality Status (Functional, Non-Functional, Function but Degraded or Non-Conforming) of an SSC credited in the Current Licensing Basis.
- d. Basis for Operability - documentation of the basis or justification used for the immediate (initial) operability declaration.
- e. Compensatory Actions - documentation of any compensatory actions taken to support operability /
functionality
- f.
External Agency Notification - documentation of any external notification or reporting requirements. This includes any notification or reporting requirements completed or pending.
Potential notifications for reporting (e.g.,
10CFR50.73 Part 21, etc) should be documented for evaluation in a CE Assignment created at the time of CAP SRO Review.
- g. Unplanned LCO Action Statement Entry -
documentation of any unplanned action statement entry.
- h. IF the CAP involves Emergency Response Facility functionality or equipment, THEN ensure the issue is addressed within FP-OP-OL-01, Operability/Functionality Determination.
For Immediate Operability Determinations, refer to FP-OP-OL-01.
5.3 Continued
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 17 of 81 5.3 Continued
Refer to Attachment 13, Expectations for Use of the Corrective Action Program. {C004}
- 3. IF an Originator generates a QF-0400, Action Request Form that relates to a CAQ or SCAQ but omits his or her name, THEN forward the QF-0400 to the CAP coordinator to consult with the site employee concerns program manager in accordance with FP-EC-ECP-01 Employee Concerns Program.
5.4 Prompt (follow-up) Operability Recommendation Requested Senior Reactor Operator Responsible Person Supervisor/Active SRO When appropriate, the SRO SHALL use the CAP AR Process to assign an Operability Recommendation (OPR) to the appropriate individual per approved procedure.
- 1. The prompt (follow-up) Operability Recommendation SHALL be performed in accordance with FP-OP-OL-01
- 2. The SRO should contact the Supervisor of the work group responsible for completion of the Operability Recommendation.
- 3. Upon completion of the Operability Recommendation, the SRO SHALL review the Operability Recommendation make an Operability Declaration.
- 5. IF the Immediate Operability is not supported by the Operability Recommendation, THEN the responsible person SHALL immediately notify the SRO.
- 6. The SRO SHALL notify either the CAP Coordinator or the CAP Screening Team Chair that the CAP must be re-screened.
Assign Operability Recommendation to Responsible Group Make Operability Recommendation Perform Operability Recommendation (FP-OP-OL-01)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 18 of 81 5.5 Action Request Screening and Processing Plant Manager or Director Operations Standards Refer to Attachment 7 for the AR Screen Team Charter.
- 1. The CAP Coordinator/assignee runs the AT-0075 AR Screening and the AT-0191 Non Cap Report and distributes them to the Screen Team in advance of the Screening meeting or call.
NOTE:
NOS Adverse Assessment Findings and NOS Findings should normally be assigned as Level A and B CAPs, respectively.
- 2. The Screen Team discusses each AR as described in, Screen Team Charter.
- 3. The CAP Coordinator/assignee updates the CAP AR as directed at Screening, makes the required assignments, and applies keywords in Passport. (Refer to JFG FL-CAP-PAS-001G CAP Coordinator for guidance)
- 4. IF an AR can be completed at screening, THEN the CAP Coordinator/assignee applies trend codes and completes the item.
- 5. When two CAPS have similar issues and screen team determines that CAP 2 can be closed to CAP 1, cross-reference the CAPs and initiate a CA from CAP 1 to ensure that all issues from CAP 2 are addressed.
PCR, ITAR, or GAR), THEN complete the following steps to maintain a link to any attachments:
Download any attachments from the CAP to the computer desktop, change the CAP to the new AR type, then re-upload the attachments into Sharepoint.
- 7. For issues entered into the Corrective Action Program that concern or require interface with agencies outside of the CAP process, a nuclear department representative SHALL be designated to assign any required CAP evaluations or actions. This individual is not responsible for performing the action or evaluation, but is responsible for ensuring the CAP process is followed.
- 8. IF an evaluation is needed, THEN proceed to step 5.6.
- 9. IF an evaluation is NOT needed, THEN proceed to step 5.11 AR Screening And Processing
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 19 of 81 5.6 Initiate Evaluation Assignment for: Root Cause, Apparent Cause, Maintenance Rule Evaluations, Condition Evaluations, or 10 CFR 21 Evaluation Performance Assessment Group
- 1. IF an Adverse Assessment Finding is issued by Nuclear Oversight (NOS), THEN the CAP SHALL have a cause determination (RCE or ACE), a CAPR, and an EFR {C005}.
- 2. For NOS AAFs or Findings, initiate an OTHA for NOS to review the completed evaluation.
- 3. When the purpose of the evaluation is not obvious from the parent CAP, provide a clear and specific statement of the objective of the evaluation, including any special lines of inquiry identified by CAP Screening Team (e.g., past operability, EOC, Human Performance Event Investigation, or Common Cause Analysis for adverse trends).
5.7 Assign Evaluation Assignment Supervisor or Manager
- 1. Assign causal evaluations pertaining to design basis reviews to an individual with appropriate integrated knowledge, or to a team that has the appropriate regulatory, operational, engineering and design basis knowledge. {C003}
- 2. Provide a Due Date for the evaluation of 30 days or less.
NOTE:
Due dates for RCEs and ACEs that provide the basis for an LER should not be extended such that it would challenge the submittal schedule for the LER without the concurrence of the Regulatory Affairs Manager. See FP-R-LIC-09.
Timely resolution of conditions adverse to quality is a fundamental objective of the CAP program and monitored with a key performance indicator. It is within managements discretion (supervisor or above) to establish a due date that is outside the default duration guidance, based on how long it will take to get the job done at the expected level of effort commensurate with urgency. Document the basis for exceeding the default duration date.
- 3. Assign an urgency level in the Pri field as follows:
1 - IMMEDIATE - evaluations from Level A CAPs 2 - HIGH - evaluations from Level B CAPs 3 - MEDIUM - evaluations from Level C CAPs Assign Evaluation Assignment to Responsible Person Initiate Evaluation Activity
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 20 of 81 5.8 Accept Evaluation Assignment Assigned To
- 1. The Assigned To should review the Assignment and the due date and determine the following:
- that they understand the assignment,
- that the assignment is assigned to the right person, and
- Whether the assignment can be completed by the due date.
- 2. The Assigned To may either request that the Assignment be changed to another person, or accept responsibility for the Assignment.
- 3. The Assigned To may request a due date change.
NOTE:
The time that assignments spend in INPROG status is included in average age calculations.
- 4. It is the Responsibility of the Owed To to resolve any reluctance to accept assignments.
- 5. The goal for assignment processing is for assignments to be accepted within 7 days of notification.
5.9 Perform Evaluation Assignment Assigned To
- 1. The Assigned To SHALL perform the requested evaluation in accordance with the appropriate administrative guidance or expectation. See FG-PA-ACE-01, Apparent Cause Evaluation, or FG-PA-RCE-01, Root Cause Evaluation Manual.
- 1. Significant conditions adverse to quality SHALL have actions to prevent recurrence (CAPR), and an effectiveness review (EFR). {C002}
- 2. Initiate an EFR for non CAPRs when it is prudent to verify effectiveness (e.g., adverse trends, primary corrective actions related to equipment ACEs, AFIs from Internal and External Assessments).
3.
IF new operability/reportability/functionality concerns are identified, THEN notify the shift manager immediately.
- 4. IF a new problem or condition adverse to quality is identified, THEN initiate a CAP.
- 5. IF during the evaluation it is determined that 10 CFR Part 21 is applicable, THEN refer to FP-R-LIC-04.
Accept Evaluation Perform Evaluation
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 21 of 81 5.9 Continued
- 6. IF the Assignment cannot be completed by the due date, THEN follow guidance provided in Attachment 2.
- 7. When appropriate, initiate request for Severity Level change or Level of Effort change in accordance with.
- 8. When appropriate, disposition non-conforming items per 1.
- 9. Following completion of the Assignment, document the work completed for review and approval in accordance with Attachment 4.
- 10. Contact CAP originator as needed to ensure an adequate understanding of the problem exists
- 11. IF an open evaluation exists that is evaluating a similar problem, THEN the evaluations may be consolidated per section 5.15.5.
- 2. Additional Assignment Initiation (If Applicable)
- 1. IF your evaluation concludes that a SCAQ is or may be present, THEN take the initial CAP back to the AR screening team for possible upgrade and RCE assignment.
- 2. IF, following completion of the evaluation, an additional action is found necessary, THEN the Assigned To SHALL initiate a new Assignment in accordance with step 5.12 of this procedure.
5.10 Approve Evaluation Assignment For evaluations, the documented work should be reviewed for adequacy and completeness by the scheduled due date as follows: (Refer to Attachment 9 for detailed supervisory review and approval guidance.)
Confirm that all actions identified to be taken in the evaluation have appropriate action assignments and/or cross references.
Confirm that all actions identified in the evaluation as being complete have, in fact, been completed.
If all requirements have been satisfactorily completed with the appropriate documentation, the activity should be approved.
IF all requirements are NOT completed or documentation is inadequate, THEN the activity should be returned to the responsible individual for additional work. Justification for returned activities should be written in the Assignment Notes.
Approve Evaluation Owed To
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 22 of 81 5.11 Trend Coding CAP Liaison Following completion of the evaluation assignment, the CAP Liaison (or appropriate person) applies the applicable trend coding in the parent CAP
- record, completes the trend code attribute, completes the trend coding assignment.
Trending should be performed as applicable. The CAP Trend Code Manual and the DRUM Manual may be used for additional information. (See JFG FL-CAP-PAS-002G CAP Liaison for guidance.)
5.12 Initiate Work Assignment Owed to Actions that address conditions adverse to quality SHALL be initiated from severity level A, B, or C CAPs and tracked to completion. Refer to Attachments 4 & 6.
- 1. Write the assignment, ensuring that it includes the following:
Assignment Type - Identification of the type of work activity being requested (Corrective Action, Effectiveness Review, etc.)
Identification of the responsible individual Identification of Mode Change Restraint Assignment of any special due date requirement Identification of Nuclear Oversight or Licensing review Actions should follow the SMARTS model:
S-Specific:
Clearly state the desired end result or action; i.e. someone not involved in the development of the action would know exactly what to do M-Measurable:
Quantitative parameters exist that allow measurement of corrective action completion by a reviewer A-Accountable:
Identify a specific person/group responsible for the action and obtain acknowledgement of the person or group R-Reasonable:
The action should be within the control of the person/organization assigned to perform the action T-Timely:
Provide reasonable due date that allows sufficient time to complete the action before a repeat event is possible due to the same cause S-Sustainable (CAPRS)
The action is embedded within the structure of a station program and not solely personnel dependant.
- 2. Work assignments that meet the criteria provided in 4 may be considered for a management exception from performance indicators.
Initiate Work Assignment Corrective Action Program AR Trending
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 23 of 81 5.13 Assign Work Assignment Responsible Supervisor
- 1. Review the assignment.
- 2. Verify that the Assignment has been made to the proper individual.
NOTE:
Passport combines CAQ attribute, CAP severity, and action urgency to develop an overall action priority. The action priority is a value from 99 (highest) to 1 (lowest). The priority is displayed on the AT-0085 report. {C006}
- 3. Assign an urgency level to the action in the Pri field using the default guidance. Specific circumstances may dictate different urgency assignments than the default guidance:
1 - IMMEDIATE - Actions to correct serious concerns with safety or quality 2 - HIGH - Actions to correct conditions, actions to address causes of conditions prior to continuation or next performance (including EOC actions), actions to prevent recurrence, or time critical actions that address high risk situations (e.g., interim actions) 3 - MEDIUM - Actions to correct RCE contributing or ACE apparent causes or actions with moderate risk 4 - LOW - Action that address lower risk situations or other non-time critical activities 5 - NONE - OTHA enhancements or other non corrective actions (e.g., grading or trending)
- 4. Provide a Due Date for the Assignment according to the following guidance:
Urgency 1 and 2 actions should be completed as soon as feasible.
Urgency 3 actions should be completed within 90 days.
Urgency 4 actions should be completed within 180 days.
- 5. Due dates beyond the default guidance:
Timely resolution of conditions adverse to quality is a fundamental objective of the CAP program and monitored with a key performance indicator. It is within managements discretion (supervisor or above) to establish a due date that is outside the default duration guidance, based on how long it will take to get the job done, at the expected level of effort commensurate with urgency.
Document the basis for exceeding the default due date.
- 6. IF a due date extension is requested, THEN Indicate appropriate review and approval in accordance with.
Assign Work Assignment to Responsible Person
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 24 of 81
- 7. IF the Assignment has been improperly assigned or requires resource-loading adjustment, THEN change and note the justification for the reassignment.
- 8. Obtain Manager or Supervisor buy-in prior to an Assignment to another work group. Real time two way communication is expected.
- 9. For actions that impact fleet processes, obtain buy-in of the Peer Group Lead for the affected process, and the Peer Group contact(s) at the other fleet facility.
5.14 Accept Work Assignment Assigned To
- 1. The Assigned To should review the Assignment and the due date and determine the following:
- that they understand the assignment,
- that the assignment is assigned to the right person, and
- whether the assignment can be completed by the due date.
- 2. The Assigned To may either request that the Assignment be changed to another person, or accept responsibility for the Assignment.
- 3. The Assigned To may request a due date change.
NOTE:
The time that assignments spend in INPROG status is included in average age calculations.
- 4. It is the Responsibility of the Owed To to resolve any reluctance to accept assignments.
- 5. The goal for assignment processing is for assignments to be accepted within 7 days of notification.
5.15 Perform Work Assignment Assigned To
- 1. The Assigned To SHALL perform the work assignment in accordance with the appropriate administrative guidance or expectation.
When appropriate, initiate request for Severity Level change in accordance with Attachment 3.
- 2. When appropriate, disposition non-conforming items per 1.
- 3. IF the Assignment cannot be completed by the specified due date, THEN follow guidance provided in Attachment 2.
Accept Work Assignment Perform Work Assignment 5.13 Assign Work Assignment Continued
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 25 of 81 5.15 Continued
- 4. IF during the performance of an Assignment it is determined that a new Assignment is needed to address an aspect of the AR, THEN:
- a. Obtain Manager or Supervisor buy-in prior to initiation of a new Assignment for another work group.
- b. IF additional action is necessary following completion of the Assignment, the Assigned To SHALL initiate a new Assignment in accordance with step 5.12.
NOTE:
Do not close out an Assignment to another Assignment for the sake of extending in whole or part the Assignment due date.
- 5. IF similar, related or repetitive Assignments exist, THEN these may be consolidated into a single Assignment for tracking purposes IF the following criteria are met:
Consolidated Assignments are cross-referenced.
The earliest due date takes precedence Closure is to assignments of equal or higher severity level The remaining open Assignment is updated to include any details of expanded scope of requested work being added from the Assignments being closed.
- 6. IF a modification is necessary to resolve a condition adverse to quality, THEN initiate a corrective action per Attachment 4.
- 7. IF the CAP AR was identified as requiring NOS or Licensing (regulatory or licensee commitments) review, THEN contact NOS (see step 5.17 of this procedure).
- 8. When creating CAPRs that change/revise procedures, ensure that the RCE/ACE CAPR is referenced in the procedure being changed (bases, references, commitments, etc.)
- 9. When site response to an SOER changes/revises a procedure, ensure the SOER is referenced in the procedure being changed (bases, references, commitments, etc.)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 26 of 81 5.16 Complete Assignment Assigned To
- 1. The Assigned To SHALL perform and complete the Assignment as stated.
Refer to Attachment 4, Documentation Expectations &
Guidance.
5.17 NOS or Licensing Review NOS or Licensing
- 1. Complete the review of actions from CAPs identified as requiring NOS or Licensing (regulatory or licensee commitments) review.
- 2. IF the completed Assignment is not acceptable to NOS or Licensing, THEN document the basis for the determination and initiate a CAP.
5.18 RCE/ACE Quality Grading Designated Personnel - ACE PARB - RCE Root Cause Evaluations and Apparent Cause Evaluations associated with Level A & B CAPs will undergo a Quality Grading following completion of the evaluation. Quality grading for Level C CAP RCE/ACEs is optional.
When an ACE or RCE is assigned, an ACE or RCE grading Assignment is also created by the Screen Team to ensure timely grading of these evaluations. The grading Assignment should be independent of the group performing the evaluation.
RCE grading guidance is located in the FG-PA-RCE-01, Root Cause Evaluation Manual and QF-0432.
ACE grading guidance is located in the FG-PA-ACE-01, Apparent Cause Evaluation Manual and QF-0430.
Once the ACE or RCE is completed, complete and transcribe the ACE or RCE Grading sheet into the electronic grading assignment.
NOS or Licensing Review Complete Assignment RCE/ACE Quality Grading
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 27 of 81 5.19 PARB Review of CAP Level A Issues PARB A Performance Assessment Review Board (PARB) exists at each site and the Fleet office. The PARB members represent all major site work departments and operate under FP-PA-PAR-01, Performance Assessment Review Board.
NOTE:
PARB review of completed items is NOT an in-line review. Assignments and CAP ARs may be closed prior to PARB review. However, PARB may direct that additional actions be taken.
- 1. PARB will accept as written, accept with minor comments, or reject completed RCEs and Level A ACEs.
- 2. The PARB chairman may request that a technical review of the complete action plan be conducted per Attachment 10, Corrective Action Technical Review Panel Charter.
- 3. IF an A level ACE or RCE is rejected, THEN a new CAP SHALL be written and the ACE or RCE re-opened and revised to address the PARB concerns.
5.20 CAP Owed To Review and Complete AR CAP Owed To The CAP AR Owed To is held ultimately accountable for resolution of the issue.
The CAP AR should be completed as soon as the last assignment is completed, not to exceed 30 days.
- 1. Review the CAP using Attachment 9 and ensure that all the assignments are complete, the completed assignments have adequately addressed the issue, the issue has been properly resolved.
- 2. IF all assignments have been completed with the appropriate documentation, THEN the CAP SHALL be completed.
- 3. IF all assignments are NOT complete, but appropriate justification for non-performance is acceptable, THEN the CAP may be completed.
- 4. IF the assignment is completed but all requirements are NOT fulfilled, or if documentation is inadequate, THEN re-open and return it to the Assigned To for additional work.
PARB Review of Level A Issues (RCE/ACE)
CAP Owed To Review and Complete AR
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 28 of 81 5.20 Continued State the reason for returning the assignment in the Notes section with any new actions initiated to resolve the gaps noted.
Assign a new due date for the re-opened assignment that is commensurate with the additional work to be performed and the appropriate urgency for the work to be completed.
Initiate a new CAP AR for returned/re-opened assignments to document that the corrective actions were insufficient to resolve the issue. Reference the original CAP AR and state what actions were taken.
- 5. IF NOS/Licensing Review is required, THEN verify that all affected assignments have been reviewed.
- 6. IF ACE/RCE grading is needed, THEN ensure the assignment is complete and the grades are entered.
- 7. Verify that the trend code has been entered in the AR. Have the CAP Liaison trend code the AR if necessary.
- 8. Authenticate the CAP AR and all attached documents to verify that the correct and complete information will become a quality record.
- 9. Complete the AR.
- 10. The document becomes a record as soon as it is completed and it cannot then be altered, (except for changes to trend codes and keywords). IF the record must be supplemented, THEN a supplemental records form QF-2110 must be completed and submitted with the concurrence of the OWED TO.
5.21 AR Records Retention CAP Coordinator or Admin.
- 1. Prepare and assemble the CAP AR, associated assignments and attachments for record entry according to FG-G-REC-01.
AR Records Retention
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 29 of 81 6.0 RECORDS 6.1 Applicable records generated by this procedure SHALL be retained at the site/fleet in accordance with their records retention program requirements.
7.0 REFERENCES
7.1 SOURCE DOCUMENTS 7.1.1 10 CFR 50, Appendix B, Criterion XV 7.1.2 10 CFR 50, Appendix B, Criterion XVI 7.1.3 Equal Employment Opportunity/Non Harassment Policy 7.1.4 FP-R-LIC-04, 10 CFR 21 Reports 7.1.5 FP-PA-ARP-03, Non-Cap Action Request Process 7.1.6 FG-PA-CAE-01, Corrective Action Effectiveness Review Manual 7.1.7 FP-OP-OL-01, Operability Determination 7.1.8 NSPM-1 Quality Assurance Topical Report 7.1.9 NRC Regulator Issue Summary 2005-20, Revision to Guidance Formerly Contained in NRC Generic Letter 91-18, Information to Licensees Regarding two NRC Inspection Manual Sections on Resolution of Degraded and Nonconforming Conditions and on Operability.
7.1.10 PI CAP AR 01145695-35 is the basis for the guidance developed for Attachment 18, Issue Discovery Checklist 7.2 REFERENCE DOCUMENTS 7.2.1 FP-EC-ECP-01, Employee Concerns Program 7.2.2 FP-R-LIC-04, 10 CFR 21 Reports
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 30 of 81 7.2.3 FP-OP-OL-01, Operability Determination 7.2.4 FG-PA-RCE-01, Root Cause Evaluation Manual 7.2.5 FG-PA-ACE-01, Apparent Cause Evaluation Manual 7.2.6 FG-E-ARP-01, "Disposition of Non-Conforming Items" 7.2.7 FP-PA-ARP-02, Augmented Incident Evaluation 7.2.8 FP-PA-OE-01, Operating Experience Program 7.2.9 QF-0400, Action Request Form 7.2.10 QF-0430, ACE Grading Sheet 7.2.11 QF-0432, RCE Report Evaluation 7.2.12 QF-0429, Standard Screen Team Agenda 7.2.13 QF-2110, Record Supplemental Information 7.2.14 QF-0573, Issue Discovery Checklist 7.2.15 CD 5.20, Fleet Modification Program 7.2.16 Code of Federal Regulations, 10CFR 50.7 Employee Protection 7.2.17 Code of Federal Regulations, 10CFR50, Appendix B Quality Assurance Criteria for Nuclear Power Plants and Fuel Reprocessing Plants.
7.2.18 Code of Federal Regulations, 10 CFR 54, Requirements for Renewal of Operating Licenses for Nuclear Power Plants 7.2.19 Code of Federal Regulations, 10 CRF 21, Reporting of Defects and Non-Compliance 7.2.20 NUMARC 93-01, Industry Guidance for Monitoring the Effectiveness of Maintenance at Nuclear Power Plants
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 31 of 81 7.2.21 NUREG-1865, Safety Evaluation Report Related to the License Renewal of the Monticello Nuclear Generating Plant 7.2.22 JFG FL-CAP-PAS-001G CAP Coordinator 7.2.23 JFG FL-CAP-PAS-002G CAP Liaison 7.2.24 FG-G-REC-01, Preparing Action Request PDFs for Transition to Records 7.2.25 FP-OP-PRC-01, Plant Operating Review Committee 7.2.26 FG-R-LIC-06, NRC Performance Analysis 7.2.27 FG-PA-CAE-01, Corrective Action Effectiveness Review Manual 7.2.28 FG-PA-CTC-01, CAP Trend Code Manual 7.2.29 NSPM-1 Quality Assurance Topical Report 7.2.30 FP-R-LIC-02, Regulatory Correspondence 7.2.31 QF-0708, 10 CFR 21 Reportability Evaluation Form 7.2.32 FP-PA-PAR-01, Performance Assessment Review Board 7.2.33 DP-NO-IA-01, Internal Assessments 7.2.34 EPRI - Clearance and Tagging Guidelines for Nuclear Electric Generating Stations 7.2.35 FP-R-LIC-09, Licensee Event Reports 7.3 COMMITMENTS 7.3.1 PINGP {C001} Prairie Island - CA01001641-17, Provide severity level examples for category 10 EAL threshold declarations for Site, General Emergency, Alert and Unusual Events.
7.3.2 PINGP and MNGP {C002} Prairie Island and Monticello (01010870-11) - Identify that SCAQs require CAPRs.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 32 of 81 7.3.3 MNGP {C003} Monticello - CAPR00623668 assign personnel with integrated Knowledge or Team for significant design basis issues.
7.3.4 NSPM {C004} (PINGP, MNGP): NRC Confirmatory Order EA-06-178 Alternate Dispute Resolution (ADR) of Employee Protected Activity. (AR01070334).
7.3.5 NSPM {C005} (PINGP, MNGP): NSPM QATR section C.1 through commitment to NQA-1 Supplement 18S-1 (also see CAP 1186023).
7.3.6 PINGP {C006}: CAPR 01166830 action priority scheme.
7.3.7 MNGP {C007} CAPR for CAP 01209649 7.3.8 MNGP {C008} Monticello - M05009A, AR 00829851, Site documents that implement aging management activities for license renewal will be enhanced to ensure an AR is prepared in accordance with plant procedures whenever non-conforming conditions are found (i.e., the acceptance criteria is not met) 8.0 Revision Summary 8.1 Revised attachment 4 to provide clearer guidance on appropriate closure and tracking of CAP items to non-CAP items 8.2 Revised attachment 6 to provide a clearer definition/purpose of CA action type and added CAPA action type 8.3 Revised attachment 7 screening team charter to require a current SRO licensed participant to meet quorum 9.0 ATTACHMENTS 9.1, Corrective Action Program Severity Level Determination 9.2, Due Date Extension Request Guidance 9.3, Severity Level Reclassification & RCE/ACE Exception Guidance (CAP ARs only) 9.4, Action Closure Guidance
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 33 of 81 9.5, Good Catch Criteria 9.6, Action Request & Assignment Types 9.7, Fleet CAP Screening Charter 9.8, Risk/Uncertainty Investigation Level Matrix 9.9, Corrective Action Program Supervisor Review/Approval Guide 9.10 0, Corrective Action Technical Review Panel Charter 9.11 1, Disposition of Non-Conforming Items 9.12 2, Process Continuity 9.13 3, Expectations for Use of the Corrective Action Program.
9.14 4, Management Exception Criteria 9.15 5, Cross-Cutting Issue Evaluation 9.16 6, Prompts for Potential Issues of Significant Regulatory Concern (PWR) 9.17 7, CAP Liaison Responsibilities 9.18 8, Issue Discovery Checklist
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 34 of 81 ATTACHMENT 1 CORRECTIVE ACTION PROGRAM SEVERITY LEVEL DETERMINATION Guidance for Table Use:
The attached matrix contains specific examples for each of the Severity Levels, but is not intended to be an all-encompassing listing.
This matrix should be utilized as a guide for determination and assignment of Severity Levels to ARs. The Screening Team has ultimate authority for severity level assignment. Non-adverse to quality CAPs should be assigned as a C level or above significance level if a higher level of effort is judged to be appropriate.
Event Categories:
Category 1 - Reactivity Management/Fuel Handling Category 13-Technical Specification Category 2 - Reduction in Defense in Depth Category 14-Plant Operation & Equipment Related Category 3 - Industrial Safety and Fire Category 15-Security Category 4 - Condition Reportable to the NRC Category 16-Management Discretion Category 5-Foreign Material Exclusion Category 17-Conditions Identified by Independent Agencies Category 6 - Adverse Trend Category 18-Training Category 7-Programmatic Breakdown Category 19-Equipment Design Category 8-Radiation Protection Category 20 - Configuration Control Category 9-Maintenance Rule and MSPI Category 21-Environmental Safety Category 10- Emergency Plan Category 22-Chemistry Category 11-Quality Assurance Program Category 23-Clearance and Tagging {C007}
Category 12-Plant Transient Unplanned Power Change
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 35 of 81 ATTACHEMENT 1 (CONTINUED)
CORRECTIVE ACTION PROGRAM SEVERITY LEVEL DETERMINATION Level A Issues Level B Issues Level C Issues Level D Issues Category 1 - Reactivity Management/Fuel Handling Reactivity management event.
Degraded ability to control or monitor reactivity Exceeding reactivity related TS limit Unplanned reactivity change greater than 0.5% delta-K/K Unexplained rod motion Uncontrolled dilution A core thermal hydraulic instability An inadvertent criticality Fuel damage Near miss event A rod drop accident as a result of uncoupling Any mis-oriented or mis-loaded fuel bundle discovered after criticality Reactivity management event or near miss that does NOT meet Level A criteria.
Unexpected feedwater temperature change A failure to meet a physics test acceptance criteria A mis-positioned control rod An unexplainable reactivity change Exceeding any fuel preconditioning guideline Impairment of the ability to control or monitor reactivity Minor (non-consequential) reactivity management related issue.
An unplanned entry into the restricted areas on the Power/Flow Map Malfunction of fuel handling equipment which causes a suspension of fuel handling activities for greater than one hour Reactivity management program or controls improvements.
Improvement suggestions to prevent fuel-handling events.
Category 2 - Reduction in Defense in Depth Reduction to margin of safety.
Loss of offsite power & onsite power for
>15 minutes Degradation of decay heat removal capability in violation of plant TS Unanticipated loss of RCS SSA flooding Uncontrolled breech of containment closure RCS over pressurization Unanticipated loss of water from the RCS Interface System over pressurization Failed administrative barriers or equipment protection functions, where other barriers remain functional preventing an event.
Unplanned entry into an LCO Action Statement Internal flooding in the area of safety related equipment or potential to reach safety related equipment.
Fire or other external hazard in the area of safety related equipment or potential to reach safety related equipment Failed administrative barriers or equipment protective functions.
Near miss that could have resulted in a Level A or B condition Nuclear safety administrative barrier or equipment protection controls improvements.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 36 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 3 - Industrial Safety and Fire (also see category 23)
Industrial safety incident.
OSHA defined:
Lost time incident Incident resulting in 3 or more employees hospitalized fatality Fire challenging plant operation, radiation controls or plant security Hazardous spill resulting in E-plan entry or injury Fire that requires a classification under the Emergency Plan Industrial safety issues.
Significant safety concerns All other OSHA Recordable events Work related injury or illness that prevents completion of shift Restricted Duty or Medical Treatment Case Negative impact on plant personnel health and/or safety (e.g., bacteria in drinking water, unsanitary conditions, etc.)
Minor injuries/accidents.
Minor potential safety concerns First Aid or Minor Injury case Near miss case Improper or non-use of required safety equipment Failure to provide required notification for demolition or renovation involving asbestos Industrial safety improvements.
Category 4 - Condition Reportable to the NRC (See Attachment 17 for additional information on Regulatory Concerns)
Reportable events.
Major wildlife kills (endangered species)
Major chemical/oil spill NRC reportable (10CFR21, 10CFR71 &
NRC reportable (10CFR73.71(d)); see App G to 10CFR73 NRC Reportable (10CFR50.72, 10CFR20 or 10CFR50.9)
LERs, conditions reportable per 10CFR50.73 NOTE: Exclude security loggable events resulting from security equipment issues.
NRC Reportable (10CFR72.75)
Reportable events NOT covered by Level A.
NOTE: Exclude security loggable events resulting from security equipment issues.
Minor events that are NOT reportable under 10CFR21, 10CFR71, 10CFR50.72, 10CFR50.73, & 10CFR72.75 10CFR73.71 loggable events; see App G to 10CFR73 NOTE: Exclude security loggable events resulting from security equipment issues.
Improvements in environmental response or monitoring processes.
Category 5-Foreign Material Exclusion Loss of FME controls.
RX vessel & RCS Refueling canal Spent fuel pool Other foreign material in safety related SSC which makes the SSC inoperable or indeterminate FME concerns indicating a loss of control:
Discrepancies in a FME control area inventory closeout Significant failure to follow FME process requirements Foreign material retrieved from a FME Zone 1 Minor FME program compliance issues that have been resolved.
Foreign material which has been retrieved and which did not cause damage (non FME Zone 1)
FME control documentation not properly completed.
FME program improvements
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 37 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 6 - Adverse Trend Adverse Trend:
Of recurring conditions that are related to Human Performance, Safety Conscious Work Environment and Problem Identification and Resolution issues Of recurring safety significant equipment Other recurrent trends adverse to quality as determined by management (FP-OP-PRC-01 Attachment 3)
Adverse Trend of recurring conditions.
Potential or Actual Trend of recurring conditions.
None Category 7-Programmatic Breakdown Significant programmatic breakdown or weakness.
High percentage of trainee Training Program failures Programmatic breakdown or weakness.
Missed fire rounds Quality document significant and multiple technical errors Equipment isolation admin errors Documentation errors Unqualified personnel performing task Administrative procedure/program non-compliance w/ insignificant consequence.
Programmatic improvements Procedure enhancement Category 8-Radiation Protection Technical Specification Locked High Rad Area event Very High Radiation Area event Unplanned radiation exposure events greater than 100 mrem TEDE Unplanned onsite release to environment exceeding ODCM Significant contamination event outside the RCA Uncontrolled Radioactive Material outside of the Protected Area above the plants release criteria*
High Radiation Area controls violation 10CFR20 Posting violation Significant contamination event within the RCA Unnecessary collective dose of
>500 mrem for a job Unplanned dose to an individual of 10 mrem Uncontrolled Radioactive Material outside an RCA but within the Protected Area above the plants release criteria*
Personnel contamination event >
50,000 cpm Personnel contamination events >100 CPM Unplanned spread of contamination to clean areas within the RCA Exceeding dose projection by >25%
for jobs >500 mrem Inadequate RWP or rad worker practices Unnecessary generation of significant amounts of solid or liquid rad waste ED dose alarm or unplanned dose rate alarm Radiation Protection program improvements
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 38 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 9-Maintenance Rule and MSPI Maintenance Rule (a) (1) system classification.
Maintenance Rule Functional Failures leading to (a)(1) status Repeated failures of a SSC to meet its performance criteria Mitigating Systems Performance Index (MSPI) monitored system turns White, Yellow or Red.
Maintenance Rule Functional Failures No Margin remaining in Green for MSPI system.
Failure to meet system performance criteria Potential negative trends in MR system performance.
Improvements to the Maintenance Rule program Category 10- Emergency Plan E-Plan issues or events.
E-Plan declaration (NUE or above).
Significant failure of Emergency Plan program or equipment.
Failure to implement a Risk Significant Planning Standard (RSPS) during an actual event o
Classification o
Notification o
Onsite Assessment o
PARs Critique failure to identify that an RSPS was not met during a drill or exercise Any NRC finding of a failure to meet a RSPS Failure to implement a Planning Standard (PS) for an actual event classified Alert or higher EAL found to be non-conservative, such that a Site Area or General Emergency would not be declared at the correct time or condition. {C001}
E-Plan program issues or events not meeting Level A criteria Failure to implement a planning standard (PS) during an actual event classified UE o
Planning Standards are in 10CFR50.47 Failure of a critique to identify that a PS was not met during a drill or exercise Any failure to meet a PS EAL found to be non-conservative, such that an Alert or Unusual Event would not be declared at the correct time or condition. {C001}
Emergency Plan equipment or ERF found not functional EP Equipment issue for which necessary compensatory measures were not implemented in a timely manner Failure to obtain minimum staffing during exercises/drills and/or callout drills Failure to meet one or more drill/exercise objectives Failure of a duty team member to respond to a callout drill or actual event while on duty Low level E-Plan program or equipment deficiencies Failure of a duty team member to obtain a replacement when unable to respond in a timely manner.
Degraded emergency plan equipment or ERF.
Improvements or enhancements to EP related programs, documents or practices
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 39 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 11-Quality Assurance Program NOS Adverse Assessment Finding Falsification of Quality Assurance Records Substantial administrative control non-compliance Substantial organizational or programmatic breakdown found by assessment Ineffective program due to programmatic deficiencies or inadequate program implementation Identification of chilling environment NOS Finding Quality or rigor of QA records LTA Consequential non-compliance with QA program requirements Programmatic deficiencies or inadequate program implementation which DO NOT cause a program to be classified as ineffective Failure to directly meet a licensing basis requirement Minor Procedural or administrative control non-compliance A single example of a failure to follow a site procedure A single example of non-conservative decision making or a lack of a questioning attitude Lost/Missing Record QA Program or administrative improvements.
Category 12-Plant Transient Unplanned Power Change Note: Unplanned Power Change is defined for this item to mean that the power change was not planned within the last 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. The duration of the power change is not a factor in CAP Level determination. However, the duration of a power change can be a factor for management discretion when deciding if a Level A is warranted.
Large plant transients/events Reactor or Turbine Trip.
Unplanned power changes >10%
Unplanned, reportable Safety System actuation.
Unexpected safety related equipment response Safety related equipment response NOT as expected.
Greater than 5%, less than 10%
unplanned power changes.
Unplanned Safety System Actuation Unplanned Capability Loss Factor exceeds KPI goal Unexpected equipment response Non-safety related equipment response NOT as expected Greater than 2%, less than 5%
unplanned power change Unplanned Capability Loss Factor exceeds 1/2 of the KPI goal Improvement suggestions to prevent plant transients or events.
Category 13-Technical Specification Violation of TS Safety Limit or Limiting Safety System Setting.
Failure to take TS required action within the completion time Unplanned Technical Specification LCO Action Statement entry.
Missed or late TS SR (when the LCO is applicable)
Minor issues that affect, but do not impact Technical Specifications or Safety Related equipment.
Instrument out of tolerance Also see Category 23 Improvement suggestions to prevent challenges to Technical Specification compliance.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 40 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 14-Plant Operation & Equipment Related (also see category 23)
Loss of shutdown core cooling.
Potential loss of shutdown core cooling.
Loss of non-essential cooling to components.
Improvement suggestions to prevent challenges to shutdown core cooling.
Non-conservative Reactor Protection System set point.
Reactor Protection System set point found out of calibration.
Non-Reactor Protection System set point found out of calibration.
Improvements to prevent challenges to Reactor Protection set points.
Technical Specification required SSC experienced complete loss of safety function Unplanned TS LCO Action Statement entry.
Unexpected equipment response Operable/Nonconforming, But Degraded equipment Non-Safety Related equipment failures or malfunctions Unexpected Control Room alarms Equipment performance/reliability improvements.
Critical equipment failure with significant station impact.
Critical equipment degradation or failure.
Maintenance avoidable rework with adverse impact (e.g., critical equipment)
QC inspection rejects with impact ANII inspection rejects Minor equipment degradation or failure is threshold for corrective action program involvement, but CAP is not required unless it involves critical equipment.
Failed post maintenance tests QC Receipt Inspection/Overage, Shortage, Damaged, and Discrepant (OSD&D) report items.
SSC requiring aging management with long term effect NPMR equipment issues /
enhancements.
Category 15-Security NRC reportable (10CFR73.71(d)):
Sabotage Suspected tampering Compromise of site security See App G to 10CFR73 Security Reportable Events (e.g.,
failures of the Security or AA/FFD Program)
Unplanned degraded barriers Planned event causing an unplanned compensatory measure (e.g.,
maintenance activity on one system takes out another, unexpected, system).
FFD or Fatigue Rule violation 10CFR73.71(c) Security loggable events (e.g., lost badges, Vital Area door violations, failed equipment requiring compensatory measures, etc.); see App G to 10CFR73 Similar Near Miss events FFD or Fatigue Rule Issues Note: Exclude security loggable events resulting from security equipment issues.
Security Program improvements.
Category 16-Management Discretion Event requiring higher attention as determined by Management.
Dominant drivers identified during stream analysis of significant issues.
Any event that needs attention as determined by Management.
Any event that needs attention as determined by Management.
Not applicable
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 41 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 17-Conditions Identified by Independent Agencies NRC Performance Indicator degraded to non-GREEN.
Potential greater than GREEN NRC Finding (WHITE, YELLOW, RED)
NRC potential cross-cutting issue aspects with 3 or more identified issues during the previous 4 quarters plus present quarter (See FG-R-LIC-06)
NRC notice of violation that requires a response in writing, enforcement, conference, or notice of civil penalty.
National Academy for Nuclear Training accredited training program on probation NRC Severity Level I or II Traditional Enforcement (TE) violation, or 2 or more Severity Level III TE violations or 3 or more Severity Level IV TE violations during the previous 12 months.
RCEs SHALL be required for all NRC items that fall in Level A of Category 17, within the time frame specified by NRC response.
NRC Green Finding NRC Severity Level III or IV Traditional Enforcement violation NRC Performance Indicator Green to White alarm threshold exceeded NRC potential cross-cutting issue aspects with 2 identified issues during the previous 4 quarters plus present quarter Non-cited violation INPO area for improvement (default level)
INPO review assist visit recommendations requiring a response SOERs (default level)
NOTE: An NRC violation that crosses the threshold for a RED KPI for frequency of cross cutting aspects will require a RCE that should review the trend in performance.
(See FG-R-LIC-06)
INPO negative comments NEIL inspection findings ANII findings All other NRC identified items (e.g.,
inspection, observations)
NRC Information Notices and Regulatory Information Summaries INPO SENs, SERs, and Topical Reports Improvement suggestions
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 42 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 18-Training Significant Training Program deficiencies that could result in a program being placed on Probation.
High percentage of Training Program failures High Non-licensed operator initial or requal exam failure rate.
Ineffective Training High trainee (non-operator) exam or course failure rate Repetitive performance problem due to inadequate Training Training Self-Assessment AFIs Trainee unexcused absence from Training Addition/cancellation of Training w/in 4 weeks of scheduled date Training Observation feedback that requires Training Program revision Examination security is compromised Technically inaccurate material is used to conduct a training activity Any crew failure during simulator evaluation Simulator unavailability that results in or could have resulted in lost training time Laboratory facility or equipment unavailability that results in lost training time Any population of trainees where
>20% and >2 individuals fail an exam or evaluation STC/CRC/TAC not held as scheduled within the quarter Training designed to improve performance that does not result in the expected improvement Exam analysis identifies deficiencies in exam construction or grading Trainee excused absence from Training due to:
Acts of Nature Personal Illness Family Emergency Response to emergent plant issue Training Program improvement suggestions Category 19-Equipment Design Design deficiency on risk significant equipment or system that renders the equipment or system inoperable Design deficiency on risk significant equipment or system that adversely impacts the performance or reliability of the equipment or system. These deficiencies are most often nonconformances.
Design deficiency on non-risk significant equipment or system that adversely impacts plant operations or personnel.
Equipment or system design enhancements
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 43 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 20 - Configuration Control (also see category 23)
Loss of configuration control that has or could have a significant effect on the Operability / Functionality of the plants safety, safety systems, or Maintenance Rule systems or has been determined to be a significant adverse trend by management o
Wrong quality level part installed in safety related or maintenance rule system resulting in inoperable system o
Mispositioned device in an in-service safety-related system or Maintenance Rule system that causes system to be inoperable Loss of configuration control that has or could have a significant effect on the plants efficiency, Operability /
Functionality, of non-safety systems or personnel safety.
Loss of configuration control with low potential to affect reliability of Station safety system or Maintenance Rule system o
Wrong quality level part installed in safety related or maintenance rule system with no affect on Operability /
Functionality.
o Mispositioned device in an in-service safety-related system or Maintenance Rule system with no impact on Operability /
Functionality Loss of configuration with low potential to affect plant efficiency, non-safety systems or personnel safety.
Loss of configuration control with no effect on Station safety system or Maintenance Rule system Operability
/ Functionality but associated with a QA Topical Report program:
o Safety system piping and Instrumentation diagram drawing error or corrections to other update priority code 0 engineering documents that are used by operations to manipulate the plant o
Corrections to previously validated equipment database fields Loss of configuration control with no effect on plant efficiency or personnel safety:
o Corrections to Calculations, Vendor Technical Manuals, or other update priority code 1 engineering documents that are used to support the plant design or used by maintenance o
Mispositioned device in a non-safety related or non-Maintenance Rule system that does not effect safe reliable operation of the Station Configuration control improvements Drawing corrections or corrections to other engineering documents that are historical in nature or are not used to support maintenance or routine station activities, or other update priority code 2 or 3 engineering documents Corrections to unvalidated equipment database fields.
Since the majority of the equipment database is not fully validated, it cannot be used as a sole source for information, therefore corrections to unvalidated fields in the equipment database is an enhancement
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 44 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 21-Environmental Safety Release >ODCM dose or dose rate limits Uncontained petroleum product spill >50 gallons Uncontained hazardous substance spill
>reportable quantity Any release which violates any applicable regulatory requirement AND causes or may cause substantial adverse health or environmental effects Enforcement Action/Notice of violation by US EPA or MPCA Exceeding an ODCM effluent limit Routine release >50% of ODCM dose or dose rate limit Unplanned radiological release to unrestricted areas Contained petroleum product spill >50 gallons Uncontained petroleum product spill >5 gallons but <50 gallons Contained hazardous substance spill >reportable quantity Uncontained hazardous substance spill <reportable quantity Violations related to environmental permits or regulations Non-consequential ODCM implementation failure Failure to obtain a REMP sample (HU performance, equipment, or weather issue)
Groundwater or surface water sample >reporting level for radioactivity in environmental samples Petroleum product spill >1 pint but <5 gallons Contained petroleum product spill <50 gallons Contained hazardous substance spill <reportable quantity Fish kill or aquatic life loss of any amount in the canal or river Administrative/minor error on radioactive effluent release form with no impact Environmental enhancement Category 22-Chemistry Shutdown due to chemistry Entry into EPRI Chemistry Action Level 2 or 3 Exceeding a Fuel Warranty Operating Limit Entry into EPRI Chemistry Action Level 1 Entry into EPRI Closed Cooling Action Level Laboratory equipment persuasive bias on QC chart Failure of Laboratory QC program Chemistry instrumentation out of service (instrument failure)
Exceeding EPRI Diagnostic parameter Good Practice value Sample result exceeding Administrative limit Chemistry improvements
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 45 of 81 Level A Issues Level B Issues Level C Issues Level D Issues Category 23-Clearance and Tagging {C007}
Unexpected Energy is found by workers inside clearance boundary.
Clearance boundary found to have gap that could allow energy into boundary while work is in progress.
Work conducted outside clearance boundary (e.g., wrong component worked on.)
Manipulation of tagged component.
Work performed w/o clearance when clearance should have been in place.
Clearance released when work is still in progress.
Clearance/tagging process activity that places the plant in a trip or transient condition (e.g., 72-hour LCO or less, loss of vacuum, etc.)
Problem is discovered after tags hung and verified, but before workers sign on Tags are hung on wrong component and planned boundary is not intact Unplanned/unknown hazard found during maintenance walkdown Worker at work but not signed on to correct clearance Clearance request found to inadequately describe required boundary, after written and verified Clearance process activity places plant in unplanned, self-revealing LCO or higher-level plant risk /
inadequate plant configuration Problem discovered before clearance is approved Inadequate description of work to be performed in clearance/work request Clearance is written and found to be incomplete Previously unidentified LCO caught prior to issuing clearance (after being screened for plant condition and operational impact)
Clearance documentation error /
omission with no impact on plant safety Clearance errors with no impact on safety system or Maintenance Rule system Operability / Functionality or personnel safety Tag errors other than red tag errors not resulting in unacceptable plant configurations (e.g., caution tags or information tags.)
Other problems
- Labeling issues or drawing issues interfere w/clearance prep.
- Clearance request rejected by operating authority as inadequate to support writing clearance.
- Worker/holder does not sign off clearance.
Process efficiency or process improvement items, not threats to process barriers such as:
Process delays (e.g.,
clearance not prepared in time to support schedule).
Missed process steps that do not bypass review or holder barriers.
Coordination issues (schedule milestones not met)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 46 of 81 ATTACHMENT 2 DUE DATE EXTENSION REQUEST GUIDANCE
- 1.
When it is determined that the assigned due date should be extended, the assigned individual needs to contact the CAP Owed To and provide a basis for why the extension is appropriate. The following items should be addressed in the extension basis, and documented in the In-Progress Notes:
Why the due date cannot be met Whether interim actions are needed to minimize the potential for problem recurrence When determining the new due date, ensure it has the support and resources needed.
- 2.
If the Owed To concurs with the extension, the request needs to be presented to the appropriate level of Supervision or Management described in the matrix, who will review the extension request and approve or reject the extension request. The OWED TO or assigned individual should then document approval in the In-Progress Notes section of the Assignment as a General Note.
- 3.
Grading, trending, PARB and Excellence Plan assignments are not subject to the requirements for due date extensions, nor are they counted for any performance indicator measuring CAP inventory or average age.
- 4.
Due date extensions are defined as due date changes after the assignment was initially moved out of Notify status.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 47 of 81 ATTACHMENT 2 (Continued)
DUE DATE EXTENSION REQUEST GUIDANCE CAP Assignment Extension Approvals Matrix**
Severity Level First Extension Second Extension Subsequent Extension A - CAPR PARB PARB PARB A - All other assignment types Plant Manager /
Business Support Manager / Engineering Director / Fleet Director/Fleet General Manager Vice President Vice President1 B
Manager Plant Manager /
Business Support Manager /
Engineering Director /
Fleet Director/Fleet General Manager Vice President1 C
Supervisor Department Manager Plant Manager /
Business Support Manager /
Engineering Director /
Fleet Director/Fleet General Manager 1 D
Owed To Owed To Owed To 1 After second extension the overall need for the activity should be evaluated.
Notes:
- 1. Evaluations and actions in response to Adverse Assessment Findings should not be extended without the concurrence of the Nuclear Oversight (NOS) Manager or his/her assignee.
- 2. Due dates for RCEs and ACEs that provide the basis for an LER should not be extended such that it would challenge the submittal schedule for the LER without the concurrence of the Regulatory Affairs Manager. See FP-R-LIC-09.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 48 of 81 ATTACHMENT 3 SEVERITY LEVEL RECLASSIFICATION &
RCE/ACE EXCEPTION GUIDANCE Requirements AR Screen Team approval SHALL be obtained in order to change any Severity level classification, or to not perform an assigned evaluation. All changes SHALL be supported by documentation as indicated below. Documentation of any change and the basis for the change SHALL be captured in the Notes section of the AR as a General Note.
Significant Conditions Adverse to Quality are required to include actions to prevent recurrence (CAPR).
Severity Level Reclassifications For Severity Level reclassifications, describe why the issue does not meet the assigned severity criteria (Attachment 1) and describe which severity criteria the issue does meet.
Two or more CAP assignments addressing the same issue should be combined and closed to one CAP and SHALL take the highest classification level of the combined CAPs.
Level of Effort Exceptions For RCE or ACE non-performance, provide justification for not completing the requested evaluation. The downgrade justification SHALL discuss why the current organization or process is no longer susceptible to the concern, AND provide the basis for why an extent of condition of legacy conditions is not warranted. Examples of exception criteria follow:
The issue has been previously evaluated or identified as a result of an extent of condition review under a previous assessment. The cause is understood and corrective actions are being implemented. If this is a repeat event the request SHALL discuss timeliness of corrective actions and the need for additional interim actions.
The cause, corrective action, and extent of condition are simple and known. This knowledge may be the result of previous assessments.
The issue involves designation of a Maintenance Rule system as a(1) and an analysis that meets the intent of NUMARC 93-01 will be conducted under the Maintenance Rule Program. The analysis must 1) evaluate organizational and programmatic causes as outlined in Attachment 1 to FG-PA-ACE-01, or 2) be accomplished by performing an ACE.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 49 of 81 ATTACHMENT 4 ACTION CLOSURE GUIDANCE
- 1. Actions that address:
C CAPS associated with Conditions Adverse to Quality, or A or B CAPs SHALL NOT be closed to GARs, ITARs, PMCRs, ECs, ECRs, TRRs, or other Passport AR types outside the Corrective Action Program, with the exceptions and clarifications provided below.
Severity level C CNAQ CAPs may be closed to non CAP Passport AR types.
NOTE:
For Action Tracking purposes, cross-references need to be generated from within the CAP/assignment and Check Boxes left in the Checked State unless otherwise specified. Generating cross references within the CAP with check boxes means the CAP cannot be closed unless the cross referenced action is complete.
NOTE:
Prior to initiating any assignments, the Owed-To needs to ensure that alignment on the action and an appropriate due date is achieved with the group that controls the action (e.g., Production Planning, Procedures, Engineering, or Training). Collaboration is necessary to ensure that the due date standards of CAP and those of other processes are met (or compromises agreed to, when necessary). The agreed upon due date should be the same on both the CAP assignment and exterior process activity (PCR, WO, etc).
NOTE:
Refer to Attachment 6 when determining whether a CAPA, CA, or CAPR should be used to track work outside of a CAP AR.
- a. PCRs:
C level CAPs - Cross-reference the CAP to the PCR (remove Check Box) and close the CAP (a separate action to track completion is not required).
A and B level CAPs - Initiate a CAPR, CA, or CAPA to track the PCR to completion or CANCELLED and cross-reference the assignment to the PCR (create cross reference from the assignment).
Actions to track PCRs are complete when the revised document has been issued and any required training has been delivered.
If the requested PCR for an A/B CAP is CANCELLED, then the CAP Owed-To will need to determine whether additional actions are required to address the condition or cause.
- b. WRs:
C level CAPs - Cross-reference the CAP to the WR (remove Check Box) and close the CAP (a separate action to track completion is not required).
A and B level CAPs - Initiate a CAPR, CA, or CAPA to track the WR to completion or CANCELLED and cross-reference the assignment to the WR (create cross-reference from the assignment).
Actions to track WR are complete when the WR or WO Task that corrects the condition AND any associated PMT/RTS is at a FINISHED status in Passport.
If the requested WR/WO for an A/B CAP is CANCELLED, then the CAP Owed-To will need to determine whether additional actions are required to address the condition or cause.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 50 of 81 ATTACHMENT 4 (Continued)
ACTION CLOSURE GUIDANCE
- c. WOs C level CAPs - Cross-reference the CAP to the WP and associated WO Task (if known) and close the CAP (a separate action to track completion is not required).
A and B level CAPs - Initiate a CAPR, CA, or CAPA to track the WO Task to completion or CANCELLED and cross-reference the assignment to the WP and WO Task (if known - create cross-reference from the assignment).
Actions to track WO are complete when the WO Task that corrects the condition AND any associated PMT/RTS is at a FINISHED status in Passport.
If the requested WO for an A/B CAP is CANCELLED, then the CAP Owed-To will need to determine whether additional actions are required to address the condition or cause.
- d. ECs:
C level CNAQ CAPs - Cross-reference CAP to the EC (remove Check Box) and close the CAP (Separate action to track completion is not required).
C level CAPs that address a Condition Adverse to Quality - Initiate a CA or CAPA to track the EC to MODIFIED or CANCELLED status and cross-reference the assignment to the EC (create cross-reference from the assignment).
A and B level CAPs - Initiate a CAPR, CA, or CAPA to track the EC to MODIFIED or CANCELLED status and cross-reference the assignment to the EC (create cross reference from the assignment).
If the requested EC is CANCELLED, then the CAP Owed-To will need to determine whether additional actions are required to address the condition or cause.
To assist in meeting significant milestones to EC completion, separate assignments may be utilized as follows:
Action Description Assigned To When Initiated Obtain authorization for the Study Phase of the modification, with scope, funding and schedule defined.
Project Manager or Responsible Engineer After CAP Initiation Track EC to APPROVED status Project Engineer or Responsible Engineer After PRG approval for EC Design Phase Track EC to turnover to operations Project Manager or Responsible Engineer After PRG approval for EC Implementation Phase
- e. ECRs:
C level CNAQ CAPs - Cross-reference the CAP to the ECR (remove Check Box) and close the CAP (a separate action to track completion is not required).
C level CAPs that address a Condition Adverse to Quality - Initiate a CA or CAPA to track the ECR to ACTIONED status and cross reference the assignment to the ECR (create cross-reference from the assignment). After the ECR is ACTIONED, initiate an assignment to track the subsequent EC in accordance with the guidance above.
A and B level CAPs - Initiate a CAPR, CA, or CAPA to track the ECR to ACTIONED status and cross reference the assignment to the ECR (create cross-reference from the assignment). After the ECR is ACTIONED, initiate an assignment to track the subsequent EC in accordance with the guidance above.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 51 of 81 ATTACHMENT 4 (Continued)
ACTION CLOSURE GUIDANCE If the final disposition of the ECR is any status other than ACTIONED, then the CAP Owed-To will need to determine whether additional actions are required to address the condition or cause.
- f.
KPI ARs C level CNAQ CAPs - Cross-reference the CAP to the AR (remove Check Box) and close the CAP (a separate action to track completion is not required).
C level CAPs that address a Condition Adverse to Quality - Initiate a CA or CAPA to track the KPI AR to completion or CANCELLED and cross-reference the assignment to the KPI AR (create cross-reference from the assignment).
A and B level CAPs - Initiate a CAPR, CA, or CAPA to track the KPI AR to completion or CANCELLED and cross-reference the assignment to the KPI AR (create cross reference from the assignment).
Actions to track KPI ARs are complete when the KPI has been implemented in the live KPI spreadsheets and the revised basis document has been posted to the web.
If the requested AR is CANCELLED, then the CAP Owed-To will need to determine whether additional actions are required to address the condition or cause.
C level CNAQ CAPs - Cross-reference the CAP to the AR (remove Check Box) and close the CAP (a separate action to track completion is not required).
C level CAPs that address a Condition Adverse to Quality - Initiate a CA or CAPA to track the AR to completion or CANCELLED and cross-reference the assignment to the AR (create cross-reference from the assignment).
A and B level CAPs - Initiate a CAPR, CA, or CAPA to track the AR to completion or CANCELLED and cross-reference the assignment to the AR (create cross reference from the assignment).
If the requested AR is CANCELLED, then the CAP Owed-To will need to determine whether additional actions are required to address the condition or cause.
- 2. Adequate Documentation for Completed Assignments The Assignment documentation contains sufficient level of detail such that a technically competent individual can read the Assignment requirement and the completed Assignment documentation and determine whether the Assignment has been thoroughly and accurately completed.
An evaluation should define the scope of the issue to be evaluated and identify the corrective actions necessary to correct the situation.
Any unique supporting documentation (memos, unserialized reports, informal calculations, correspondence, external documents, etc.) should be attached to the electronic Action Request record for retention and review.
Any non-unique supporting documentation (formal calculations, formal letters/memos, approved procedures, etc.) should be referenced in the electronic Activity Request record, or linked within Passport (e.g., PCRs). References should include the document number and revision number.
Assure safeguards, classified, proprietary, or personal identifying information that is not otherwise publicly available is not included in documentation attached to CAPs.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 52 of 81 ATTACHMENT 4 (Continued)
ACTION CLOSURE GUIDANCE
- 3. Adequate Documentation for Justification for Assignment Non-performance Assignments associated with Corrective Actions to Prevent Recurrence (CAPRs) from RCEs or ACEs cannot be closed if they have not been completed unless a revision to the evaluation is made and PARB approval is obtained.
Assignments associated with Corrective Actions to Prevent Recurrence from NOS Adverse Assessment Findings cannot be closed unless Nuclear Oversight concurrence is obtained.
Assignments associated with the resolution of Operable But Non-Conforming or degraded conditions cannot be closed if they have not been completed without approved justification for the as-is condition.
The justification for partial or non-performance of a requested work activity SHALL contain sufficient detail such that a technically competent individual can read the Assignment requirement and the justification and logically conclude that the Assignment is not required.
As an example, this could include a cost-benefit comparison or a determination that the correction action is not required.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 53 of 81 ATTACHMENT 5 GOOD CATCH CRITERIA Action Request Good Catch and Well Documented Criteria
- 1. CAP Action Requests that meet any of the following criteria may be considered for Good Catch designation by the Screening Team:
The problem identified is outside the Originators normal job expectation.
The problem identified is not addressed by procedures, forms, logs, policy or specific expectation.
An error trap was identified in an approved procedure, instruction, work plan, form or log prior to an error occurring.
The problem identified has been long standing, but was not previously identified or detected by others.
An Adverse Trend or recurring problem was identified.
The problem was identified by extraordinary effort or rigor, even if within the Originators normal job scope.
The problem involves a near miss, especially if it is the CAP initiators own near miss
- 2. CAP Action Requests that meet all of the following criteria may be considered for Well Documented designation by the Screening Team:
The problem is well researched and clearly documented with supporting facts and detail.
The corrective actions taken are well defined, appropriate, add value, and well documented.
The corrective actions recommended are well defined, appropriate, add value, and well documented.
The identification of the problem was timely.
- 3. Good Catch or Well Documented Action Requests are documented in the Action Request following designation by the Screening Team.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 54 of 81 ATTACHMENT 6 ACTION REQUEST & ASSIGNMENT TYPES The following Assignment (AS) types are available in Passport and are authorized for use in implementation of the Corrective Action Program. Other Assignment Types may not be used for CAP ARs.
Action Request Type 1.
CAP - Corrective Action Program originating record (FP-PA-ARP-01)
Assignment Types - Evaluations 1.
ACE - Apparent Cause Evaluation - used for the tracking and documentation of apparent cause evaluations for CAP type Action Requests. ACEs are initiated when apparent cause determination and/or extent of condition assessment is determined to be necessary.
(FG-PA-ACE-01) 2.
CE - Condition Evaluation - used for the tracking and documentation of condition evaluations for CAP type Action Requests. CEs are initiated when the necessary corrective action to address a CAP AR is not known.
3.
MRE - Maintenance Rule Evaluation - used for the tracking and documentation of evaluations of equipment failures for CAP type Action Requests to address the Maintenance Rule Program requirements.
4.
OPR - Operability Recommendation - used for the tracking and documentation of prompt (follow-up) Operability determinations for CAP type Action Requests. OPRs are initiated when Technical Specification equipment or Technical Specification support equipment is found to potentially be in a degraded or nonconforming condition. SRO or CAP AR Screen Team determine that additional documentation is necessary to support the Operability call of a system, structure or component within the scope of the Operability determination process.
(FP-OP-OL-01) 5.
RCE - Root Cause Evaluation - used for the tracking and documentation of root cause evaluations for CAP type Action Requests. RCEs are initiated when root cause determination is determined to be necessary. (FG-PA-RCE-01) 6.
HUEE - Human Performance Event Evaluation - used for the tracking and documentation of Human Performance Event Investigation (HUEI) for CAP type Action Requests. HUEIs are initiated to document lessons learned and to trend performance errors. (FP-PA-HU-01) 7.
P21E - 10 CFR Part 21 Evaluation - used to track and document evaluations of potential defects or nonconformance in Quality Level 1 (QL-1) parts or equipment, including commercially dedicated items. (FP-R-LIC-04) 8.
ODM1 - Type 1 Operational Decision Making Issue - used to track and document development of a Type 1 ODMI. (FP-OP-ODM-01) 9.
ODM2 - Type 2 Operational Decision Making Issue - used to track and document development of a Type 2 ODMI. (FP-OP-ODM-01)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 55 of 81 ATTACHMENT 6 (continued)
ACTION REQUEST & ASSIGNMENT TYPES
- 10. FA - Functionality Assessment - used to assess the functionality of an SSC described in the CLB when a degraded or non-conforming condition is identified. (FP-OP-OL-01)
- 11. OEE - Operating Experience Evaluation - used to evaluate external OE items for applicability and to determine appropriate actions to prevent similar events from occurring.
- 12. EFR - CAP Effectiveness Review - used for the tracking and documentation of Effectiveness Reviews for CAP type Action Requests. (FG-PA-CAE-01)
Assignment Types - Corrective Actions The following assignments are available as corrective actions under CAP type ARs:
1.
CA - Corrective Action - used for the tracking and documentation of actions that accomplish the following:
NOTE:
The ACE manual allows for a decision to not have an action to address a contributing cause. However, if the decision is to initiate an action to address a contributing cause, then the action needs to be a corrective action.
Correct a Condition Adverse to Quality or Significant Condition Adverse to Quality Address Root Causes that do not require CAPRs Address Apparent Causes that do not require CAPRs.
Address Contributing Causes found in Root Cause Evaluations (per requirements of FG-PA-RCE-01) and Apparent Cause Evaluations (per requirements of FG-PA-ACE-01) 2.
CAPA - Corrective Action Program Activity - Used for tracking assignments that reside in other processes (e.g., non CAP AR types such as PCRs, WOs, TRRs, etc.) AND that are not required to be a corrective action. CAPAs are excluded from corrective action backlog metrics, but are under the umbrella of the corrective action program so that assignment protocols such as the due date extension process remain in effect.
3.
CAPR - Corrective Action to Prevent Recurrence - actions taken to correct the cause of a Significant Condition Adverse to Quality (SCAQ). CAPRs are required for any SCAQ regardless of the type of evaluation performed. CAPRs of a SCAQ are internal commitments.
4.
OBD - Operable but Degraded - used for the tracking and documentation of corrective actions to resolve Operable But Degraded conditions for CAP type Action Requests.
5.
OBN - Operable But Non-Conforming - used for the tracking and documentation of corrective actions to resolve Operable Non-Conforming conditions for CAP type Action Requests.
6.
OPB - Operator Burden Tracking Action - Assigned to track operator burdens and contains details on the impact of the operator burden.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 56 of 81 ATTACHMENT 6 (Continued)
ACTION REQUEST & ASSIGNMENT TYPES Assignment Type - NON Corrective Action The following assignments are available in Passport to aid in the administration of the Corrective Action Program, but are NOT corrective actions:
NOTE:
See Attachment 2 for guidance on due date extensions.
1.
ACG - ACE Grading Assignment - created every time an ACE is assigned to ensure ACE review and grading is performed prior to CAP closeout.
2.
PARB - Performance Assessment Review Board Assignment - used for the tracking and documentation of Assignments assigned by the PARB.
3.
RCG - RCE Grading Assignment - created every time an RCE is assigned to ensure RCE review and grading is performed prior to CAP closeout.
4.
TRND - Trend Analysis Assignment - used for creating Trend assignment for CAP Liaisons in CAP space. (FG-PA-CTC-01) 5.
XPLA - Excellence Plan assignment used only for administrative tracking of actions related to the Excellence Plan.
6.
OTHA - General non-corrective action or administrative activity.
7.
OEA -Operating Experience Action - actions used for administration of the Operating Experience Program such as supervisory reviews of OEEs or actions to distribute Internal or External Operating Experience (FP-PA-OE-01)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 57 of 81 ATTACHMENT 7 CAP SCREENING CHARTER PURPOSE:
The purpose of the Corrective Action Program Screen Team (Screen Team) is to facilitate site management ownership of the Corrective Action Program (CAP) Action Request inventory through the Screening activities:
For conditions that are identified as generic (applicable to multiple generating sites) a Fleet CAP may be issued to provide assignment to a Fleet Manager for work management purposes (work efficiency in determining actions, evaluations, etc, that have multi-site applicability). However, for any CAQ, it is required that a CAP also be issued at the affected site(s) to ensure that site-specific factors for the condition are evaluated and site specific actions to address the condition are considered. This further ensures awareness and ownership of the condition by the generating site, and is required by the QA Plan.
At the time of screening, IF the CAP AR is determined to be a Condition Adverse to Quality (CAQ) impacting one of the sites, THEN contact the affected site(s) for generation of a site specific CAP to ensure the appropriate Operability, Functionality, and reportability reviews are conducted.
CORE BUSINESS:
The primary functions of the Screening Team are to determine:
- Conformance of the CAP to Attachment 13
- Condition Adverse to Quality attribute (SCAQ, CAQ, CNAQ)
- Severity Level (Attachment 1 contains example guidelines)
NOTE:
Program/process owners should generally be assigned as the Owed To for CAPs in which their program/process played a significant role
- Owed To:
CAP Level Organizational Position A
Manager B
Supervisor - Manager for more significant CAPs C
Supervisor
- Mode Change Restraints
- Default Evaluation Level (also see Attachment 8)
CAP Level Default Evaluation A
RCE B
ACE C
Documentation in accordance with Attachment 3 is required for A & B CAPs for deviation from the default evaluation level as determined by using guidance in Attachment 8 or the table above.
- Potential trends that needs CAP initiation
- Return for more information
- If any CAPs should be classified as good catches
- If feedback to originator is needed (e.g., if CAP is closed to trend when action is recommended).
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 58 of 81 ATTACHMENT 7 (Continued)
CAP SCREENING CHARTER
- For CAPs closed to trend or actions taken, whether sufficient information exists in the CAP to serve as an adequate historical record (e.g., CAP clearly describes the actions that corrected the condition) - guidance for when CAPs can be closed to processes outside of CAP can be found in.
- Concurrence with:
o Operability / Functionality/Reportability determination and status o INPO Nuclear Network notification determination o OE recommendation per FP-PA-OE-01 o NOS review determination o 10CFR21 assessment needs o Maintenance Rule evaluation determination
- Ensure evaluation is assigned and scoped to consider, and document as applicable, age-related degradation of components
- Urgency level for new actions
- Conformance of action to SMART criteria
An Action Request that contains a statement that may be considered harassment and /
or prohibited by law may be immediately removed or edited to remove the offending aspects from publication. Consistent with our Equal Employment Opportunity/Non-Harassment Policy, an Action Request that contains statements based on race, religion, color, gender, national origin, age, sexual orientation, disability unrelated to job performance, veteran status or any other basis prohibited by federal, state or local law, may be removed or edited to remove the offending aspects from publication. In all such cases, the technical concerns relating to safe plant operations or conditions adverse to quality will be retained in the public record for evaluation in accordance with Section 6 of this procedure.
EMERGENT BUSINESS:
- Review root cause team charters upon request.
- Review and approve any request to change the severity level assigned to a CAP.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 59 of 81 ATTACHMENT 7 (Continued)
CAP SCREENING CHARTER COMPOSITION:
A Job Familiarization Guide (FL-CAP-SCI-001G) for Corrective Action Screen Team should be completed for each primary and alternate member prior to that person functioning on the team.
Fleet The Screen Team Chair is the Director, Operations Standardization or the Performance Assessment Manager. A quorum includes the chair plus four Managers/Directors. Members that comprise the quorum should represent expertise in six of the following disciplines:
- Operations
- Maintenance
- Engineering
- Production Planning
- Radiation Protection
- Performance Improvement
- Training
- Licensing
- Security
- Information Technology
- Projects In recognition of NOS role as an independent oversight body, NOS is not allowed to satisfy a quorum slot.
Site NOTE:
Any of the following quorum positions may be filled by the assistant manager of the same title (e.g., Assistant Plant Manager for the Plant Manager) without counting as a designee.
The ScreenTeam Chair is the Plant Manager. A quorum includes the chair, Operations Manager,
Engineering Director or Manager, and two of the following positions: Maintenance, Production Planning Manager, Business Support Manager, Radiation Protection/Chemistry Manager, and Training Manager. One member should hold a SRO license at the facility or be designated by the Plant Manager that has specific knowledge of Plant Technical Specifications. No more than three members should be designees. When the Plant Manager is not the Chair, the person designated to be the Chair may fulfill two roles (i.e., 4 members satisfy the quorum, but the Chair counts as a designee).
The Plant Manager may implement screening subcommittees to address special, non routine CAP screening business (e.g., action backlog reviews). The quorum required SHALL be documented.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 60 of 81 ATTACHMENT 7 (Continued)
CAP SCREENING CHARTER TEAM MEETINGS:
Fleet Screen Team meetings should be held once per week. Site meetings should be held at least 3 times per week. Schedule can be adjusted at discretion of the Screen Team Lead, depending upon need to meet (volume of CAPs). Screen Team members are expected to review the ARs and be familiar with them prior to scheduled meetings.
IMPLEMENTATION:
The Screen Team Chair is the final decision maker for CAP Screening decisions, and is responsible for:
Conducting the Screen Team meetings Ensuring any necessary corrective or improvement actions are initiated Identifying an alternate chair, if needed Identifying and establishing qualification and competence of Screen Team members and alternates.
The Performance Assessment Group will:
Coordinate the Screen Team meetings Use the Standard Screen Team Agenda (QF-0429) for guidance for routine meetings.
Obtain necessary inputs from the line organizations responsible for concurrence items identified under core business.
Perform the administrative duties to assign CAP ARs and Assignments to the responsible persons as dictated by the Screen Team.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 61 of 81 ATTACHMENT 8 RISK/UNCERTAINTY INVESTIGATION LEVEL MATRIX PURPOSE This matrix allows a quick but systematic risk informed evaluation of the level of effort that should be applied to a CAP. For most CAPs, Attachment 1 of this procedure provides adequate guidance. For CAPs involving potentially significant levels of industrial, radiological or nuclear safety risk, coupled with screening team uncertainty regarding level of effort, this matrix can help determine what the appropriate evaluation should be. The matrix is intended to avoid the situation where undue or misplaced confidence exists, and an inappropriately low level of effort is selected.
METHOD Step 1 Determine what the actual or potential consequences are for the CAP in question. Be careful to consider what is not known about the event or condition, and how severe the unrealized consequences could be.
Step 2 Determine what the probability of recurrence is within the time frame that the evaluation will be completed, and use the Risk Assessment table to select the overall risk level of the CAP.
Note:
Step 3 Determine how much is known about the cause of the event or condition. Usually some confidence exists that direct causes are known, but partial should only be selected if the direct causes are verified and confidence exists that the more underlying causes are understood.
Step 4 Determine what portion of interim corrective actions are known from all actions that are necessary to prevent recurrence in the short term. Use the Uncertainty Assessment table to select the overall uncertainty level of the CAP.
Step 5 Based on the risk and uncertainty selected, use the Investigation Level table to select the appropriate evaluation type.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 62 of 81 ATTACHMENT 8 (Continued)
RISK/UNCERTAINTY INVESTIGATION LEVEL MATRIX No Partial Yes No High Uncertainty High Uncertainty Medium Uncertainty Partial High Uncertainty Medium Uncertainty Low Uncertainty Yes Medium Uncertainty Low Uncertainty Low Uncertainty Uncertainty Assessment Cause Known Actions Known High Medium Low High High Risk High Risk Medium Risk Medium High Risk Medium Risk Medium Risk Low Low Risk Low Risk No Risk None Probability of Recurrence Actual or Potential Consequences No risk Risk Assessment High Uncertainty Medium Uncertainty Low Uncertainty High Risk RCE Full ACE Partial*
ACE Medium Risk Full ACE Partial*
ACE CE CA No Risk Investigation Level Selected Uncertainty Risk Correction Only Why did it Happen?
How can it be fixed?
How important is it?
Can it happen again?
Assuming no CAs are taken.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 63 of 81 ATTACHMENT 9 CORRECTIVE ACTION PROGRAM SUPERVISOR REVIEW/APPROVAL GUIDE PURPOSE:
To improve the quality of Action Requests Requirements:
NOTE:
Managers/Supervisors are not authorized to change the AR type from CAP to any other AR type, or to change the severity level on a CAP without approval from the CAP Screen Team.
NOTE:
IF an employee leaves the company, THEN their supervisor is responsible for making sure all open CAPS and assignments have been reassigned prior to the employee leaving (whenever possible) or the CAPS and assignments will be reassigned to the supervisor.
Action Request Review/Approval
- 1. The Owed To Supervisor should typically review newly created ARs within one working day after they are assigned to them. The supervisor review should not exceed three working days.
- 2. The reviewer should ensure that the AR is concise; all required fields are filled in, and includes all necessary information so that the Screen Team can properly assess the issue and create appropriate Assignments to correct the condition.
NOTE:
Do not use the REJECT option, it is not allowed under this procedure.
- 3. IF the AR needs clarification, more information OR if there is inappropriate wording, THEN return it to the Originator with a Note on what needs correction. The Supervisor should attempt to contact the Originator to discuss concerns.
- 4. IF during the review/approval process it is determined the issue requires SRO review, THEN change the Owed To to the SRO group and forward it to them. IF the issue requires immediate attention, THEN verbally contact the Shift Manager.
- 5. IF the AR is acceptable, THEN Approve the AR, change the Owed To to the Screen Team and forward the AR.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 64 of 81 ATTACHMENT 9 (Continued)
CORRECTIVE ACTION PROGRAM SUPERVISOR REVIEW/APPROVAL GUIDE Condition Evaluation (The purpose of the Condition Evaluation is to determine what corrective actions are necessary to correct the situation)
- 1. Review the CAP parent record to understand the issue.
- 2. Review problem statement in the detailed description of the CAP.
- 3. Review the Originator comments (why occurred, immediate actions, recommendations).
- 4. Ensure the completed activity as documented addresses the requested action.
- 5. Ensure Condition Evaluation disposition is documented in the appropriate sections.
- 6. Review the resolution of the issue, and ensure it adequately addresses the problem as stated.
- 7. Ensure corrective actions have been created for all required actions.
For other evaluation types, ensure a quality evaluation is performed, i.a.w. the references below.
Apparent Cause Evaluation - Reference FG-PA-ACE-01, Apparent Cause Evaluation Manual Root Cause Evaluation - Reference FG-PA-RCE-01, Root Cause Evaluation Manual Operation Experience Evaluation - Reference FP-PA-OE-01, Operation Experience Program
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 65 of 81 ATTACHMENT 9 (Continued)
CORRECTIVE ACTION PROGRAM SUPERVISOR REVIEW/APPROVAL GUIDE AR Completion/Closure NOTE:
The CAP AR Owed To is held ultimately accountable for resolution of the issue.
NOTE:
IF an employee leaves the company, THEN their supervisor is responsible for making sure all open CAPS and assignments have been reassigned prior to the employee leaving (whenever possible) or the CAPS and assignments will be reassigned to the supervisor.
The CAP AR should be closed within 30 days of the last assignment completion.
- 1. Review the CAP parent record to understand the issue.
- 2. Ensure all the completed Assignments are documented and address the requested action. The documented work should be reviewed for adequacy and completeness.
NOTE:
For Assignments completed by the Owed To supervisor, it is recommended that another supervisor perform the review.
- 3. Review the associated/referenced supporting documentation to ensure it supports the closure as described. Ensure all required documentation to support closure is attached or referenced.
- 4. Verify all required Assignments are actually/fully completed (i.e. procedure change implemented, calc issued, personnel trained).
- a. If all requirements have been completed with the appropriate documentation, the Assignments should be accepted.
- b. If all requirements are NOT completed, but appropriate justification for non-performance is documented, the Assignment may be accepted. It is not necessary to provide justification for closure of C and D level CAPs closed to the Work Request/Order, or PCR type ARs that are appropriately cross-referenced.
- c. If all requirements are NOT completed or documentation is inadequate, the Assignment(s) should be returned to the responsible person for additional work. It is not necessary to return C or D level CAPs closed to the Work Request/Order or PCR type AR that are appropriately cross-referenced.
- d. Justification for return of the Assignment should be documented in the record with any new actions initiated to resolve gaps noted.
- e. A new CAP A/R SHALL be initiated to document that corrective actions were insufficient to resolve the issue.
Reference the original CAP AR and state what actions were taken.
Recommend that the new CAP be closed to trend.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 66 of 81 ATTACHMENT 9 (Continued)
CORRECTIVE ACTION PROGRAM SUPERVISOR REVIEW/APPROVAL GUIDE
- f.
Identify if any additional actions are required based on the completion of this Assignment. If so, ensure that additional Assignments have been created to track the action. (DO NOT close the assigned action and create a new action without performing the required action)
- g. If NOS/Licensing Review is required, verify that all affected Assignments have been reviewed.
- h. If ACE/RCE grading is needed, ensure the Assignment is complete, and the grades are entered.
- i.
Verify that the AR has been trend coded and the applied codes are appropriate.
- j.
Review the attachments to the AR and verify that they should be part of the quality record.
NOTE:
The document becomes a record as soon as it is COMPLETE and it cannot then be altered, (except for changes to trend codes and keywords).
- k. Complete the AR.
- l.
IF the record must be supplemented, THEN a supplemental records form QF-2110 must be completed and submitted with the concurrence of the OWED TO.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 67 of 81 ATTACHMENT 10 CORRECTIVE ACTION TECHNICAL REVIEW PANEL CHARTER Purpose and Scope:
The purpose of the Corrective Action Program Technical Review Panel is to ensure corrective actions taken for higher significant issues are:
Appropriate for the condition identified, (i.e. will correct the issue)
Address identified insights, Completed as specified, and Effectively resolve the issue.
The panel may be charged with performing a multi-discipline review of:
Corrective actions from Level A and/or B CAPs.
Apparent Cause Evaluations The review items are selected following the Owed Tos approval.
The panel will be established based on need and remain in effect until the Site VP or Plant Manager agree that such reviews are no longer necessary.
Composition:
The panel is composed of representatives from Engineering, Operations, Training, RP/Chemistry, and Maintenance. A member of the panel or individual from the Performance Assessment group will act as a recorder. The Chairman will be selected by PARB.
Representatives from 3 disciplines are required to be present for a quorum.
NOTE:
Assignments re-opened by the panel for revision or additional work should be assigned a new due date commensurate with the priority of the issue and the work to be completed. Additional detail documenting the reason the assignment was re-opened and additional expectations for closure should be added to the Assignment Description.
Deliverables:
The panel will determine the disposition of each item brought to the panel for review:
Accept Return for additional work or documentation (reject)
For open CAPs requiring additional work or documentation, Performance Assessment will update the CAP AR stating the date of the meeting and the action needed.
IF a completed CAP requires additional work or documentation, THEN re-open the CAP to address the deficiency.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 68 of 81 ATTACHMENT 10 (Continued)
CORRECTIVE ACTION TECHNICAL REVIEW PANEL CHARTER Implementation:
Items outside the expertise of the review panel will be referred to appropriate organization(s) for review.
The appropriate organization will report back to the review panel within one week with their determination.
The panel will reach a decision on the item by consensus. The Chairman will act as the decision maker if a consensus decision can not be reached A member of the Panel or an individual from the Performance Assessment group will take notes. The notes will be used to update the CAP AR with the results of the panel review. The Assignment will then be completed if accepted. Items not accepted will be returned to the Owed To for additional work or documentation. Notes from the Panel review will be provided to the Panel Chairman for the purpose of presenting results to the Performance Assessment Review Board.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 69 of 81 ATTACHMENT 11 DISPOSITION OF NON-CONFORMING ITEMS Disposition of Non-Conforming Items
- 1. Determine if the Action Request is ASME Section XI or Supplier Related.
- 1. IF the Action Request is ASME Section XI related, THEN a special review SHALL assure that the Section XI ISI Coordinator and Authorized Nuclear In-service Inspector reviews this condition.
- 2. IF the Action Request is Supplier Related, THEN Nuclear Oversight Supplier Assessment SHALL be notified.
- 2. Items which are quality assurance related SHALL be dispositioned by one of the following methods:
A.
Reject
- 1. Item scrapped or returned to vendor.
- 2. If returning to vendor, note the purchase order number in the Action Request assessment.
B.
Repair (Restore the item such that it will function reliably and safely even though conformance to original requirements is not satisfied.)
- 1. Items should be repaired per the Modification or Engineering Equivalency (EQV-type Engineering Change) process, as applicable. An Engineering Change (EC) of some type is required. See FG-E-ARP-01, "Disposition of Non-Conforming Items" for detailed instructions.
- 2. Any proposed changes, waivers, or deviations SHALL be described in the Action Request assessment.
- 3. When installed plant equipment is dispositioned as repair, the as-left equipment condition SHALL be screened in accordance with the 10CFR50.59/72.48 process. Normally, the screening is done in conjunction with the Modification, Equivalency, or other EC type which accomplishes the repair.
C.
Rework (Restore the item to specified requirements)
- 1. Rework in accordance with the applicable work control process. Reference the appropriate work control document number.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 70 of 81 ATTACHMENT 11 (Continued)
DISPOSITION OF NON-CONFORMING ITEMS D.
Accept (Use-As-Is)
- 1. Include a technical justification in the Action Request assessment or reference an Engineering Change (EC) or 10CFR50.59/72.48 Evaluation or Screening.
- 2. Any proposed changes, waivers, or deviations SHALL be described in the Action Request assessment or the AR SHALL reference the applicable Engineering Change (EC) and cross-reference the EC to the CAP. IF an EC is not used to document the proposed change, waiver or deviation, THEN the Action Request SHALL be reviewed by an Engineering Manager (Acting as Design Authority as described in CD 5.20). An Engineering Change (EC) is required if any Facility Configuration Information (drawings, calculations, etc.) is affected. See FG-E-ARP-01 "Disposition of Non-Conforming Items" for detailed instructions.
- 3. When installed plant equipment is dispositioned as accept, the as-left equipment condition SHALL be screened in accordance with the 10CFR50.59/72.48 process. A use-as-is disposition is a defacto modification to the plant.
The 10CFR50.59/72.48 screening or evaluation, as applicable, SHALL be performed and a copy appended to the Action Request or referenced in the EC.
Equipment within the scope of the operability determination process SHALL NOT be declared operable prior to resolution of all discrepancies unless specific action is taken to assure that any discrepancy will be resolved prior to the item being used to perform a specified safety function.
Items, which are not quality assurance related, should be dispositioned by one of the methods listed above.
Items, which are to be dispositioned by repair or rework, may be corrected prior to having the Action Request approved as long as the repair or rework will not destroy evidence needed for the root cause investigation.
Items that are repaired or reworked SHALL be reinspected or retested in accordance with the applicable work control process prior to acceptance.
A. Reinspection or retesting of non-conforming aspects SHALL be identical or equivalent to original inspection and testing and documented on the work control document used to repair or rework the item.
B. Items that are to be returned to stock are to be reinspected.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 71 of 81 ATTACHMENT 12 PROCESS CONTINUITY
Purpose:
This instruction provides guidance for actions to be taken in the event that the CAP Action Request Processs supporting software becomes unavailable. The intent of these actions is to ensure that the Corrective Action Process can continue to be used by the site to identify, review and take mitigating actions for conditions adverse to quality, conditions with immediate safety concerns, conditions that require Operability / Functionality reviews or conditions that are reportable to outside agencies. This instruction also provides guidance for long-term actions in the event the software is unavailable for a period greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
Process Continuity Actions The following graded actions SHALL be considered as a minimum to ensure process continuity:
A.
If the CAP Action Request Software becomes unavailable use form QF-0400:
- 1. Originators SHALL identify and document conditions adverse to quality, conditions with immediate safety concerns, conditions that require Operability / Functionality reviews or conditions that are reportable to outside agencies using form QF-0400 in accordance with the instructions of this procedure.
B.
If the CAP Action Request Software is unavailable for a period exceeding 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> re-create screening cue:
- 1. The CAP Coordinator SHALL attempt to identify significant issues that may reside in the Screening cue prior to the Screening Team meeting by querying the SRO that had duty during the software outage period, and by reviewing the Operations Log for significant issues. The Cap Coordinator SHALL create a QF-0400 as appropriate for the issues identified.
- 2. The CAP Coordinator or the AR Administrator SHALL assemble QF-0400 forms and distribute them to the AR Screening Team for review and action assignment in accordance with Attachment 8.
C.
If the CAP Action Request Software is unavailable for a period exceeding 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> identify time critical assignments:
- 1. The AR CAP Coordinator SHALL convene the CAP Liaisons to identify time critical CAP Assignments coming due.
- 2. The CAP Liaisons should help Assignees within their area of responsibility recover and recreate lost data to open CAP Action Assignments.
Recovery Upon returning to service and stabilizing as functioning software, the AR CAP Coordinator should convene a team to input data, review and verify existing data that may have been affected, i.e., recent Action Requests, recent Action Assignments or, to the extent practicable, CAP Action Request records that may have been open at the time of the software failure.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 72 of 81 ATTACHMENT 13 EXPECTATIONS FOR USE OF THE CORRECTIVE ACTION PROGRAM {C004}
Background:
The Corrective Action Program (CAP) is the primary process used to capture and track resolution of conditions adverse to quality. It is the expectation of Management that the CAP AR process be used by all site employees to document all problems and concerns regardless of significance or status of resolution.
The NRC has created regulations that protect any individual who identifies problems from any type of retaliation or discrimination based solely on identification of the problem (10CFR50.7). The identification of problems in the CAP program are considered Protected Activities that requires certain expectations to be met in the documentation, review, analysis and resolution of problems. This attachment describes the general expectations for use of the Corrective Action Program.
General Expectations:
o A desired cultural characteristic within a nuclear organization is to promote the identification and resolution of conditions adverse to quality in an open non-confrontational environment.
Inappropriate behaviors and actions taken by an individual processing a CAP can have far reaching negative impact on the culture. CAP users should exercise care to preserve the organizational culture that promotes a Safety Conscious Work Environment.
o All personnel are expected to use the corrective action program to document problems. The corrective action program is a tool to identify and resolve problems, it should not be viewed as a tool to harm or damage the reputation or credibility of an individual, group, or organization.
o The problem statement in a CAP should be a clear statement of facts that includes the standard of performance, the observed or discovered performance, and how the performance deviates from the standard. Personal opinions not supported by fact should be avoided.
o When initiating an Action Request (AR), additional information should also be added to put the issue into the proper context such as the environmental conditions, past performance history, external influences, past corrective measures that were not effective, etc.
o The additional questions required on CAP initiation (immediate actions taken (A), why the condition occurred (O), and recommendations (R)) should also be answered from a factual basis with delineation of subjective statements in the description when necessary (i.e.: potential cause for a subjective why response).
o Use of individual names, personal ID numbers, or other means to single out individual performance is prohibited. Generic position titles or organizations should be used when that information is relevant to identification and resolution of the problem.
o Do NOT include the following in CAPs:
o Safeguards or security sensitive information o Proprietary information
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 73 of 81 ATTACHMENT 13 (continued)
EXPECTATIONS FOR USE OF THE CORRECTIVE ACTION PROGRAM {C004}
o Information withheld from public disclosure pursuant to 10CFR2.390 o Certain INPO/WANO information, including evaluation, review, assistance, and accreditation reports or portions thereof o Information subject to FERC requirements o Company sensitive information Such information may be generally referenced in CAP ARs with directions on where specific documentation can be obtained.
o Profanity, demeaning, inflammatory, harassing, or other unprofessional language should not be used in the documentation of the problem, analysis, or corrective actions.
o If the initiator is challenged by the reviewer/approver on the words used to describe the problem, they should work toward some common ground of understanding on how the problem could be better stated. If an agreement can not be reached, the initiator retains the right to state the problem as they feel it should be documented.
o The initial CAP reviewer/approver has the responsibility to understand the problem, ensure the problem is clearly stated, and ensure that appropriate immediate and interim actions and notifications are taking place. The reviewer / approver SHALL NOT reject a CAP.
o Assignment of CAP activities (evaluations, corrective actions, etc.) should be made to the individual or group who is most capable of determining the best course of action or most effective response to a problem. Assignments should not be used as a punitive tool toward the individual or group who identified the problem.
o The review and acceptance of evaluations or corrective actions should be based on established standards of quality. Completed assignments or corrective actions should not be rejected solely as a punitive measure toward the individual or group who identified the problem.
o During the investigation of any CAP issue, if another issue is identified that is, our could be, considered a condition adverse to quality or a significant condition adverse to quality then another action request (AR) SHALL be initiated.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 74 of 81 ATTACHMENT 14 MANAGEMENT EXCEPTION CRITERIA Management Exception to Performance Indicators NOTE:
If this block is checked for an Assignment, that Assignment is NOT included in the CAP Performance Indicators. No Management Exception is allowed for manpower considerations.
- 1. IF the Assignment requirement meets any of the following criteria, THEN it may be considered for exception from the CAP Performance Indicators.
- 1. The Assignment is dependent on unusual plant conditions or alignments (outage, reduced power, defueled, etc.).
- 2. The Assignment is dependent on parts or services with a long lead time.
- 3. The Assignment is part of a long-term project plan with established milestones and due dates (implement improved technical specification, plant modification, drawing upgrade project, Engineering Change, etc.).
- 4. The Assignment involves an effectiveness review scheduled in the future to allow for Corrective Action implementation.
- 2. Obtain the appropriate due date extension authorization according to Attachment 2.
- 3. Document the justification for the Management Exception in a note attached to the assignment.
Exceptions to Performance Indicators require Plant Manager approval.
- 4. Mark this Activity for Management Exception from Performance Indicators.
- a. In CAP assignment types CA or EFR, select the Attributes Chiclet.
- b. Double click in a blank space to add a new attribute.
- d. Return to the Attribute list.
- e. The Management Exception attribute is now added. Enter Y for the value.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 75 of 81 ATTACHMENT 15 CROSS-CUTTING ISSUE EVALUATION
- 1. Internal Tracking/Evaluation
- a. ACEs and RCEs will be reviewed by the evaluator to determine if the causes have cross-cutting components or aspects. QF-0436 will be used to make this determination, and includes designation of trend codes.
- b. When the CAP for the ACE or RCE is trend coded, the CAP Liaison will enter the cross cutting aspect in Passport.
- c. Licensing will conduct trend analysis and document the results in the FPERG.
- 2. External Tracking/Evaluation
- a. Based on Nuclear Regulatory Commission Exit Meetings, Regulatory Affairs will track identified cross-cutting aspects and components.
- 3. Required Action Matrix If any of the triggers (number of impacts) in the action item matrix are reached within a 12 month rolling period, Regulatory Affairs will generate a corrective action document so the issue evaluation can be screened and assigned.
Cross-Cutting Areas: Human Performance or Problem Identification and Resolution Evaluation Type Number of Impacts Action NRC Finding Aspect 2
CE NRC Finding Aspect 3
ACE NRC Finding Aspect 4
RCE Cross-Cutting Area: Safety Culture Evaluation Type Number of Impacts Action NRC Finding Aspect 1
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 76 of 81 ATTACHMENT 16 PROMPTS FOR POTENTIAL ISSUES OF SIGNIFICANT REGULATORY CONCERN (PWR)
I. Reportable if (Note 1):
- Unit shutdown required by Tech Specs
- Tech Specs violated, such as:
o Exceeded Completion Time for a Condition (with firm evidence of when condition started) o Late surveillance (and then surveillance failed) o Deviation from Tech Specs
50.54(x)
- Degraded Condition o Fuel cladding degraded o RCS pressure boundary degraded o Containment degraded
- Unanalyzed condition o Failure to meet single failure criteria o Missing fire barrier
- Specified system actuation (unplanned) o RPS actuation o Containment isolation (more than one system or more than one MSIV) o ECCS actuation o Aux Feedwater actuation o Containment Spray or CFCU actuation o EDG start o Diesel cooling water pump start
- Loss of safety function (both trains; no assumed single failure)
- Common cause failure of multiple trains or multiple systems
- Rad release (airborne or liquid above threshold)
- Fire, toxic gas release, or rad release
- Transport of contaminated person to hospital
- News release or notification of other government agency of:
o Fatality o Inadvertent rad material release o Killed endangered species
- Loss of EP capability:
o Assessment (control room instruments or ERCS) o Offsite response (loss of access to plant or EOF, multiple siren failures) o Communication (loss of red phone/ENS)
- Unauthorized person given access to protected area
- Security responders out of position
- Positive FFD test on supervisor or licensed operator Notes:
- 1. Based on NUREG 1022, Rev 2, and review of internal and external OE (LERs and Event Reports).
- 2. Equipment issues typically need past Operability evaluation (that determines how long the SSC was inoperable) as an input to a reportability evaluation.
- 3. Other conditions may be reportable under this criterion.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 77 of 81 ATTACHMENT 16 (Continued)
PROMPTS FOR POTENTIAL ISSUES OF SIGNIFICANT REGULATORY CONCERN (PWR)
II. Potential Performance Indicator Issue if:
III. Potential Greater Than Green Finding if:
- Reactor At-Power o If as-found condition caused actual inoperability of Tech Spec or risk-significant component(s) for a defined time period (e.g., beyond Tech Spec completion time for Tech Spec component),
then consult PRA engineer for a risk assessment.
- EP (Ref. NRC IMC 0609, App B) o Planning Standard (PS) or Risk Significant Planning Standard (RSPS) function failure or degraded o Failure to implement PS or RSPS during Alert or higher
- Occupational Rad Safety (Ref. NRC IMC 0609, App C) o Actual dose > 25 person-rem or more than 4 occurrences (if 3-year rolling average collective dose > 135 person-rem/unit.
o Overexposure o Substantial potential with compromised ability to assess dose o Substantial potential for whole body exposure in VHRA
- Public Rad Safety (Ref. NRC IMC 0609, App D) o Public exposure > 0.005 rem or > 5 occurrences o Impaired ability to assess effluent dose with a failure to assess dose o > App I or 10CFR20.1301(d) o Impaired ability to assess environmental impact with a failure to assess impact o Rad limit exceeded by > 5x (or accessible to public) o Breach of package during transit with loss of contents or breach of package > Type A o Certificate of Compliance with major contents deficiency o Low level burial ground nonconformance - access denied or Part 61.55 waste underclassification
- Operator Requal (Ref. NRC IMC 0609, App I) o Three or more crews with unsatisfactory performance during annual operating test o <75% of all operators pass all portions of the exam o Grading error results in passing a crew that should have failed o Exam/operating test/scenario integrity compromised without immediate comp measures
- Steam Generator Tube Integrity (Ref. NRC IMC 0609, App J) o One tube cannot sustain 3x.PNO or 3x.PMSLB o Tube burst during normal operations (or found susceptible to burst)
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 78 of 81 ATTACHMENT 16 (Continued)
PROMPTS FOR POTENTIAL ISSUES OF SIGNIFICANT REGULATORY CONCERN (PWR)
IV. Potential for Substantive Crosscutting Finding if:
- NSPM Alarm threshold reached on one or more crosscutting aspects.
V. NRC Enforcement Actions
- Notice of Violation/Cited Violation
- Notice of Deviation
- Proposed Imposition of Civil Penalty
- Confirmatory Action Letter
- Order
- Demand for Information
- 1.
- Notice of Special Inspection or Augmented Inspection Team Two reports are available to review the status of Mode Change Restraints.
AT-0246
- 1. Open: what has to be done for each mode change
- 2. Closed: completed assignments accepted by the action performers supervisor WO report WM-0221 Outage Mode Change Report
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 79 of 81 ATTACHMENT 17 CAP LIAISON RESPONSIBILITIES NOTE:
Personnel assigned CAP Liaison responsibilities are required to complete FL-CAP-PAS-002G Periodically review the CAP Report card and notify line management of issues.
Maintain proficiency in casual analysis, and mentor department members performing casual analysis.
Reviews department CAPs on a daily basis. Ensure follow-up occurs when needed (insufficient/incorrect information on CAP, work request or PCR not initiated when needed, etc.).
Support orientation and training of department employees in the CAP process.
Perform trend coding on department CAPs per FG-PA-CTC-01.
Monitoring progression of evaluation/action assignment and notifying line management when assignments are not accepted in a timely manner.
Department Action Tracking subject matter expert.
Coordinating the department DRUM meeting and report generation per FG-PA-DRUM-01.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 80 of 81 ATTACHMENT 18 ISSUE DISCOVERY CHECKLIST Potentially degraded or non-conforming conditions affecting Structures, Systems or Components (SSCs) are identified during the conduct of day-to-day work, particularly in engineering. These conditions could be identified during activities such as audits, vendor document reviews (e.g., studies, reports - draft or final), design changes, plant inspections or Industry Operations Experience Review. The Issue Discovery Checklist, QF-0573, provides a systematic approach for Engineering when evaluating complex issues or conditions to determine if a degraded or non-conforming condition exists in a manner that is consistent with the expectations and requirements of the Corrective Action Program described in this procedure. Questions and missing information are resolved as part of the process to obtain necessary information to make this determination.
QF-0573 may be used to vet technical issues that could potentially constitute a condition adverse to quality when complete information is not necessarily or readily available.
Regardless of the conclusion (adverse condition or non-adverse condition), when this tool is used, a CAP will ultimately be generated.
NOTE:
Step 5.1 states, Contact the Shift Manager immediately with any plant equipment, operability or reportability concern. Initiation of an AR does not absolve the individual from this notification expectation.
An example of this requirement would be upon determination of a potential impact to in scope Technical Specification equipment or regulatory required equipment to alert the Shift Manager of the potential issue.
- 1.
IF the questions/issues impact Technical Specification Functions or supporting Technical Specification Functions, THEN a CAP should be generated by the end of the shift.
- 2.
IF the questions/issues are potentially non-conforming or degraded, THEN the Issue Discovery Checklist, QF-0573, may be used. In all situations, CAP initiation should be completed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />.
Addressing Discrepancies Identified During Day to Day Engineering Work
- 1.
Objective evidence (data, additional documentation, verification of assumptions) is needed to validate whether the potential condition actually exists and/or results in a degraded or nonconforming condition.
- 2.
Discrepancies are items that may be a nonconformance or may have potential safety significance. Discrepancies are screened as part of the corrective action process to determine if the item impacts OPERABILITY of safety related equipment.
- 3.
When screening indicates that a discrepancy has the potential to impact the OPERABILITY of a system or component, formal OPERABILITY and reportability determinations are initiated by generation of a CAP. These determinations document the concern and safety significance. Further actions are taken as necessary to comply with Technical Specifications to ensure safe operation of the plant.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 81 of 81 ATTACHMENT 18 (Continued)
ISSUE DISCOVERY CHECKLIST
- 4.
A potential degraded or nonconforming condition is an apparent hardware or documentation discrepancy that requires validation to determine if it impacts any MNGP/PINGP SSC and is actually a degraded or nonconforming condition.
- 5.
A NONCONFORMING CONDITION results from the failure to meet the CURRENT LICENSING BASIS or a situation in which quality has been reduced because of factors such as improper design, testing, construction, or modification in a manner that could impact an SSCs operation.
- 6.
QF-0573 may be used for technical issues that could potentially constitute a DEGRADED or NONCONFORMING CONDITION with respect to MNGP/PINGP Current Licensing Bases. This checklist is expected to have limited application.
- 7.
Once the DEGRADED or NONCONFORMING CONDITION is confirmed to exist, the condition SHALL be immediately reported to the Shift Manager. FP-OP-OL-01, Operability / Functionality Determination, will then be used to determine impact of the DEG/NC on the Operability or Functionality of the affected SSC.
- 8.
QF-0573 is a structured review to determine if the CURRENT LICENSING BASIS is met and if not, specify exactly what part is not met. The focus is on deficiencies that could result in an SSCs failure to perform its function. For example, a testing deficiency that involves the actual test conditions should be described as being distinct from a testing deficiency that appears to be limited to documentation.
Part II of QF-0573 should be worked continuously and reviewed by an Engineering Supervisor within the first 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> from identification.
IF at any time it is determined that the answer to any of the questions on the form is YES, THEN complete the section following the questions AND notify the Shift Manager.