ML102460734
Text
NSP000044 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.
- 7. Ensure effectiveness reviews of corrective actions are performed to prevent recurrence.
- 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).
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
- 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 5.3 - AR Approval 5.6 - Initiation Non-SRO Review Evaluation A Assignment 5.1 - Identify Problem, 5.2 - Submit Action 5.5 - AR Screening Improvement or Request and Processing Request No 5.3 - AR Approval OPR/FR SRO Review Required? 5.12 - Initiate B Work Assignment Yes Perform 5.4 - Assign C Operability Operability A Make Operability Recommendation Recommendation Recommendation per to Responsible (FP -OP-OL-01) Group 5.7 - Assign Eval 5.8 - Accept 5.11 - Corrective Assign to 5.9 - Perform 5.10 - Approve Is the parent Evaluation Action Program ACE or RCE No No Activity Closed Responsible Evaluation Evaluation A/R Level A?
AR Trending Person Reassign or Due Date Extension Returned Yes Yes Yes Returned 5.17 - NOS or 5.16 Complete If Req 5.18 - RCE/ACE 5.19 - PARB Licensing Review Assignment Quality Grading Review B If Req C Reassign or Due Date Extension Returned 5.13 - Assign Work Assignment to 5.14 - Accept 5.15 - Perform All Activities 5.20 - CAP OWED 5.21 - AR Records Work Assignment Yes TO - Review and Responsible Work Assignment Closed? Retention Person Complete AR Returned Returned
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 13 of 81 5.1 Issue Identification The CAP (Corrective Action Program) Action Request (AR)
Process SHALL be used to document and track all problems, Identify problem, issues and concerns. Conditions adverse to quality (CAQ) are improvement, or required by the quality assurance program to be documented, request tracked, and resolved using CAP action requests.
Contact the Shift Manager immediately with any plant AR Originator equipment, operability or reportability concern. Initiation of an AR does not absolve the individual from this notification expectation.
QF-0573 is available to assist engineers in evaluating complex issues to determine if a NOTE: 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.
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 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).
Submit Action Request Attachment 12, Process Continuity should also be referenced for loss of electronic AR processing.
AR Originator 2. Initiate a CAP AR by completing the electronic AR form (INPROG) 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.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 15 of 81 5.3 Action Request Approval Non-SRO Review:
-Non-SRO SRO, or if it can bypass the SRO review. A SRO SHALL Review review the CAP AR if the issue:
- affects plant operation, plant equipment, security Managers/Supervisors equipment, or Emergency Response Facility equipment.
- potentially involves external agency notification (NRC, EPA, etc.),
- involves Technical Specification or Technical Approval- Requirement Manual compliance, or SRO Review
- 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}
Supervisors are NOT permitted to alter any information provided by the originator of the AR without the concurrence of the originator.
NOTE: Supplementary or clarifying information may be added in the notes field of the AR by the supervisor or by other personnel.
- 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.
Managers, Directors, and Vice Presidents may review and approve their own CAP ARs for entry NOTE: 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.
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 5.3 Continued items, where applicable:
- a. Immediate actions taken as a result of the CAP AR For more detail on evaluating Operability, see NOTE: 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.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 17 of 81 5.3 Continued 2. Following completion of the review, the SRO approves the AR and forwards it for Screening.
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 When appropriate, the SRO SHALL use the CAP AR Process Recommendation Requested to assign an Operability Recommendation (OPR) to the appropriate individual per approved procedure.
Assign Operability Recommendation to 1. The prompt (follow-up) Operability Recommendation Responsible Group SHALL be performed in accordance with FP-OP-OL-01
- 2. The SRO should contact the Supervisor of the work group Senior Reactor Operator responsible for completion of the Operability Recommendation.
Perform Operability Recommendation 3. Upon completion of the Operability Recommendation, the (FP-OP-OL-01) SRO SHALL review the Operability Recommendation make an Operability Declaration.
- 5. IF the Immediate Operability is not supported by the Make Operability Operability Recommendation, THEN the responsible Recommendation 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 Supervisor/Active SRO re-screened.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 18 of 81 5.5 Action Request Screening and Refer to Attachment 7 for the AR Screen Team Charter.
Processing
- 1. The CAP Coordinator/assignee runs the AT-0075 AR Screening and the AT-0191 Non Cap Report and AR Screening distributes them to the Screen Team in advance of the And Processing Screening meeting or call.
NOS Adverse Assessment Findings and NOS NOTE: Findings should normally be assigned as Level A Plant Manager or and B CAPs, respectively.
Director Operations Standards
- 2. The Screen Team discusses each AR as described in Attachment 7, 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,
- 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
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 19 of 81 5.6 Initiate Evaluation Assignment 1. IF an Adverse Assessment Finding is issued by Nuclear for: Root Cause, Apparent Oversight (NOS), THEN the CAP SHALL have a cause Cause, Maintenance Rule determination (RCE or ACE), a CAPR, and an EFR {C005}.
Evaluations, Condition Evaluations, or 10 CFR 21 2. For NOS AAFs or Findings, initiate an OTHA for NOS to Evaluation review the completed evaluation.
- 3. When the purpose of the evaluation is not obvious from the Initiate Evaluation Activity 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 Performance Assessment Group Common Cause Analysis for adverse trends).
5.7 Assign Evaluation Assignment 1. Assign causal evaluations pertaining to design basis reviews to an individual with appropriate integrated knowledge, or to a Assign Evaluation team that has the appropriate regulatory, operational, Assignment to engineering and design basis knowledge. {C003}
Responsible Person
- 2. Provide a Due Date for the evaluation of 30 days or less.
Supervisor or Manager Due dates for RCEs and ACEs that provide the basis for an LER should not be extended such NOTE: 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
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 20 of 81 5.8 Accept Evaluation 1. The Assigned To should review the Assignment and the due Assignment date and determine the following:
- that they understand the assignment, Accept Evaluation
- that the assignment is assigned to the right person, and
- Whether the assignment can be completed by the due date.
Assigned To
- 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.
The time that assignments spend in INPROG NOTE: 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 1. The Assigned To SHALL perform the requested evaluation in Assignment 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.
Perform Evaluation 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).
Assigned To
- 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.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 21 of 81
- 6. IF the Assignment cannot be completed by the due date, 5.9 Continued THEN follow guidance provided in Attachment 2.
- 7. When appropriate, initiate request for Severity Level change or Level of Effort change in accordance with Attachment 3.
- 8. When appropriate, disposition non-conforming items per Attachment 11.
- 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.
For evaluations, the documented work should be reviewed for 5.10 Approve Evaluation adequacy and completeness by the scheduled due date as Assignment follows: (Refer to Attachment 9 for detailed supervisory review and approval guidance.)
- Confirm that all actions identified to be taken in the evaluation Approve 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 Owed To 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.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 22 of 81 Following completion of the evaluation assignment, the CAP 5.11 Trend Coding Liaison (or appropriate person)
- applies the applicable trend coding in the parent CAP Corrective record, Action Program
- completes the trend code attribute, AR Trending
- completes the trend coding assignment.
Trending should be performed as applicable. The CAP Trend CAP Liaison Code Manual and the DRUM Manual may be used for additional information. (See JFG FL-CAP-PAS-002G CAP Liaison for guidance.)
Actions that address conditions adverse to quality SHALL be 5.12 Initiate Work Assignment 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 Initiate Work Assignment 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 Owed to 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 The action is embedded within the (CAPRS) structure of a station program and not solely personnel dependant.
- 2. Work assignments that meet the criteria provided in Attachment 14 may be considered for a management exception from performance indicators.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 23 of 81
- 1. Review the assignment.
5.13 Assign Work Assignment
- 2. Verify that the Assignment has been made to the proper individual.
Assign Work Passport combines CAQ attribute, CAP severity, Assignment to and action urgency to develop an overall action Responsible Person NOTE: priority. The action priority is a value from 99 (highest) to 1 (lowest). The priority is displayed on the AT-0085 report. {C006}
Responsible Supervisor
- 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 Attachment 2.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 24 of 81
- 7. IF the Assignment has been improperly assigned or requires 5.13 Assign Work resource-loading adjustment, THEN change and note the Assignment justification for the reassignment.
Continued
- 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 1. The Assigned To should review the Assignment and the due date and determine the following:
- that they understand the assignment, Accept Work Assignment
- that the assignment is assigned to the right person, and
- whether the assignment can be completed by the due date.
Assigned To
- 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.
The time that assignments spend in INPROG NOTE: 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.
- 1. The Assigned To SHALL perform the work assignment in 5.15 Perform Work Assignment accordance with the appropriate administrative guidance or expectation.
Perform When appropriate, initiate request for Severity Level change in Work Assignment accordance with Attachment 3.
- 2. When appropriate, disposition non-conforming items per Assigned To Attachment 11.
- 3. IF the Assignment cannot be completed by the specified due date, THEN follow guidance provided in Attachment 2.
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.
Do not close out an Assignment to another Assignment for the sake of extending in whole or NOTE:
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 1. The Assigned To SHALL perform and complete the Assignment as stated.
Complete Assignment Refer to Attachment 4, Documentation Expectations &
Guidance.
Assigned To 5.17 NOS or Licensing 1. Complete the review of actions from CAPs identified as Review requiring NOS or Licensing (regulatory or licensee commitments) review.
- 2. IF the completed Assignment is not acceptable to NOS or NOS or Licensing Licensing, THEN document the basis for the determination and Review initiate a CAP.
NOS or Licensing Root Cause Evaluations and Apparent Cause Evaluations 5.18 RCE/ACE Quality Grading 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.
RCE/ACE Quality Grading 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 Designated Personnel - ACE Cause Evaluation Manual and QF-0430.
PARB - RCE Once the ACE or RCE is completed, complete and transcribe the ACE or RCE Grading sheet into the electronic grading assignment.
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 27 of 81 5.19 PARB Review of CAP A Performance Assessment Review Board (PARB) exists at Level A Issues 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.
PARB Review of Level A Issues (RCE/ACE) PARB review of completed items is NOT an in-line review. Assignments and CAP ARs may NOTE: be closed prior to PARB review. However, PARB 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 The CAP AR Owed To is held ultimately accountable for and Complete AR resolution of the issue.
The CAP AR should be completed as soon as the last assignment is completed, not to exceed 30 days.
- all the assignments are complete, AR
- the completed assignments have adequately addressed the issue,
- the issue has been properly resolved.
CAP Owed To
- 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.
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 1. Prepare and assemble the CAP AR, associated assignments and attachments for record entry according to AR Records FG-G-REC-01.
Retention CAP Coordinator or Admin.
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 Attachment 1, Corrective Action Program Severity Level Determination 9.2 Attachment 2, Due Date Extension Request Guidance 9.3 Attachment 3, Severity Level Reclassification & RCE/ACE Exception Guidance (CAP ARs only) 9.4 Attachment 4, Action Closure Guidance
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 33 of 81 9.5 Attachment 5, Good Catch Criteria 9.6 Attachment 6, Action Request & Assignment Types 9.7 Attachment 7, Fleet CAP Screening Charter 9.8 Attachment 8, Risk/Uncertainty Investigation Level Matrix 9.9 Attachment 9, Corrective Action Program Supervisor Review/Approval Guide 9.10 Attachment 10, Corrective Action Technical Review Panel Charter 9.11 Attachment 11, Disposition of Non-Conforming Items 9.12 Attachment 12, Process Continuity 9.13 Attachment 13, Expectations for Use of the Corrective Action Program.
9.14 Attachment 14, Management Exception Criteria 9.15 Attachment 15, Cross-Cutting Issue Evaluation 9.16 Attachment 16, Prompts for Potential Issues of Significant Regulatory Concern (PWR) 9.17 Attachment 17, CAP Liaison Responsibilities 9.18 Attachment 18, 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. Reactivity management event or near Minor (non-consequential) reactivity Reactivity management program
- Degraded ability to control or monitor miss that does NOT meet Level A management related issue. or controls improvements.
reactivity criteria.
- An unplanned entry into the restricted
- Exceeding reactivity related TS limit
- Unexpected feedwater temperature areas on the Power/Flow Map Improvement suggestions to
- Unplanned reactivity change greater change
- Malfunction of fuel handling prevent fuel-handling events.
than 0.5% delta-K/K
- A failure to meet a physics test equipment which causes a
- Unexplained rod motion acceptance criteria suspension of fuel handling activities
- Uncontrolled dilution
- A mis-positioned control rod for greater than one hour
- A core thermal hydraulic instability
- An unexplainable reactivity change
- An inadvertent criticality
- Exceeding any fuel preconditioning
- Fuel damage guideline
- Near miss event
- Impairment of the ability to control or
- A rod drop accident as a result of monitor reactivity uncoupling
- Any mis-oriented or mis-loaded fuel bundle discovered after criticality Category 2 - Reduction in Defense in Depth Reduction to margin of safety. Failed administrative barriers or Failed administrative barriers or Nuclear safety administrative
- Loss of offsite power & onsite power for equipment protection functions, where equipment protective functions. barrier or equipment protection
>15 minutes other barriers remain functional
- Near miss that could have resulted in controls improvements.
- Degradation of decay heat removal preventing an event. a Level A or B condition capability in violation of plant TS
- Unplanned entry into an LCO Action Unanticipated loss of RCS Statement
- SSA flooding
- Internal flooding in the area of safety
- Uncontrolled breech of containment related equipment or potential to closure reach safety related equipment.
- RCS over pressurization
- Fire or other external hazard in the
- Unanticipated loss of water from the area of safety related equipment or RCS potential to reach safety related
- Interface System over pressurization equipment
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. Industrial safety issues. Minor injuries/accidents. Industrial safety improvements.
- OSHA defined:
- Significant safety concerns
- Minor potential safety concerns
- Lost time incident
- All other OSHA Recordable events
- First Aid or Minor Injury case
- Incident resulting in 3 or more
- Work related injury or illness that
- Near miss case employees hospitalized prevents completion of shift
- Improper or non-use of required
- Restricted Duty or Medical safety equipment
- Fire challenging plant operation, Treatment Case
- Failure to provide required notification radiation controls or plant security
- Negative impact on plant personnel for demolition or renovation involving
- Hazardous spill resulting in E-plan entry health and/or safety (e.g., bacteria in asbestos or injury drinking water, unsanitary
- Fire that requires a classification under conditions, etc.)
the Emergency Plan Category 4 - Condition Reportable to the NRC (See Attachment 17 for additional information on Regulatory Concerns)
Reportable events. Reportable events NOT covered by Minor events that are NOT reportable Improvements in environmental
- Major wildlife kills (endangered species) Level A. under 10CFR21, 10CFR71, 10CFR50.72, response or monitoring
- Major chemical/oil spill NOTE: Exclude security loggable events 10CFR50.73, & 10CFR72.75 processes.
- NRC reportable (10CFR21, 10CFR71 & resulting from security equipment issues.
10CFR50.73) 10CFR73.71 loggable events; see App G
- NRC reportable (10CFR73.71(d)); see to 10CFR73 App G to 10CFR73 NOTE: Exclude security loggable events
- NRC Reportable (10CFR50.72, resulting from security equipment issues.
LERs, conditions reportable per 10CFR50.73 NOTE: Exclude security loggable events resulting from security equipment issues.
- NRC Reportable (10CFR72.75)
Category 5- Foreign Material Exclusion Loss of FME controls. FME concerns indicating a loss of Minor FME program compliance issues
- FME program improvements
- RX vessel & RCS control: that have been resolved.
- Refueling canal Discrepancies in a FME control area
- Foreign material which has been
- Spent fuel pool inventory closeout retrieved and which did not cause
- Other foreign material in safety related
SSC which makes the SSC inoperable process requirements
- FME control documentation not or indeterminate
- Foreign material retrieved from a properly completed.
FME Zone 1
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: Adverse Trend of recurring conditions. Potential or Actual Trend of recurring None
- Of recurring conditions that are related conditions.
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)
Category 7- Programmatic Breakdown Significant programmatic breakdown or Programmatic breakdown or weakness.
- Equipment isolation admin errors
- Programmatic improvements weakness.
- Missed fire rounds
- Documentation errors
- Procedure enhancement
- High percentage of trainee Training
- Quality document significant and
- Unqualified personnel performing Program failures multiple technical errors task
- Administrative procedure/program non-compliance w/ insignificant consequence.
Category 8- Radiation Protection
- Technical Specification Locked High
- High Radiation Area controls
- Personnel contamination events >100
- Radiation Protection Rad Area event violation CPM program improvements
- Very High Radiation Area event
- 10CFR20 Posting violation
- Unplanned spread of contamination
- Unplanned radiation exposure events
- Significant contamination event to clean areas within the RCA greater than 100 mrem TEDE within the RCA
- Exceeding dose projection by >25%
- Unplanned onsite release to
- Unnecessary collective dose of for jobs >500 mrem environment exceeding ODCM >500 mrem for a job
- Inadequate RWP or rad worker
- Significant contamination event outside
- Unplanned dose to an individual of practices the RCA 10 mrem
- Unnecessary generation of significant
- Uncontrolled Radioactive Material
- Uncontrolled Radioactive Material amounts of solid or liquid rad waste outside of the Protected Area above the outside an RCA but within the
- ED dose alarm or unplanned dose plants release criteria* Protected Area above the plants rate alarm release criteria*
- Personnel contamination event >
50,000 cpm
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
- Maintenance Rule Functional
- Failure to meet system performance Improvements to the classification. Failures criteria Maintenance Rule program
- Maintenance Rule Functional Failures
- No Margin remaining in Green for
- Repeated failures of a SSC to meet its performance criteria
- Mitigating Systems Performance Index (MSPI) monitored system turns White, Yellow or Red.
Category 10- Emergency Plan E-Plan issues or events. E-Plan program issues or events not Low level E-Plan program or equipment Improvements or enhancements
- Significant failure of Emergency Plan
- Failure to implement a planning documents or practices program or equipment. standard (PS) during an actual event Failure of a duty team member to obtain a
- Failure to implement a Risk Significant classified UE replacement when unable to respond in a Planning Standard (RSPS) during an o Planning Standards are in timely manner.
actual event 10CFR50.47 o Classification
- Failure of a critique to identify that a Degraded emergency plan equipment or o Notification PS was not met during a drill or ERF.
o Onsite Assessment exercise o PARs
- Any failure to meet a PS
- Critique failure to identify that an RSPS
- EAL found to be non-conservative, was not met during a drill or exercise such that an Alert or Unusual Event
- Any NRC finding of a failure to meet a would not be declared at the correct RSPS time or condition. {C001}
- Failure to implement a Planning
- Emergency Plan equipment or ERF Standard (PS) for an actual event found not functional classified Alert or higher
- EP Equipment issue for which
- EAL found to be non-conservative, such necessary compensatory measures that a Site Area or General Emergency were not implemented in a timely would not be declared at the correct manner time or condition. {C001}
- 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
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
- NOS Finding Minor Procedural or administrative control QA Program or administrative
- Falsification of Quality Assurance
Records
- Consequential non-compliance with
- A single example of a failure to follow
- Substantial administrative control QA program requirements a site procedure non-compliance
- Programmatic deficiencies or
- A single example of non-conservative
- Substantial organizational or inadequate program implementation decision making or a lack of a programmatic breakdown found by which DO NOT cause a program to questioning attitude assessment be classified as ineffective
- Lost/Missing Record
- Ineffective program due to
- Failure to directly meet a licensing programmatic deficiencies or basis requirement inadequate program implementation
- Identification of chilling environment 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 Unexpected safety related equipment Unexpected equipment response
- Improvement suggestions to
- Reactor or Turbine Trip. response
- Non-safety related equipment prevent plant transients or
- Unplanned power changes >10%
- Safety related equipment response response NOT as expected events.
- Unplanned, reportable Safety System NOT as expected.
- Greater than 2%, less than 5%
actuation.
- Greater than 5%, less than 10% unplanned power change unplanned power changes.
- Unplanned Capability Loss Factor
- Unplanned Safety System Actuation exceeds 1/2 of the KPI goal
- Unplanned Capability Loss Factor exceeds KPI goal Category 13- Technical Specification
- Violation of TS Safety Limit or Limiting
- Unplanned Technical Specification Minor issues that affect, but do not impact Improvement suggestions to Safety System Setting. LCO Action Statement entry. Technical Specifications or Safety Related prevent challenges to Technical
- Failure to take TS required action within
- Missed or late TS SR (when the equipment. Specification compliance.
the completion time LCO is applicable)
- Instrument out of tolerance
- Also see Category 23
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 Improvement suggestions to components. prevent challenges to shutdown core cooling.
Non-conservative Reactor Protection Reactor Protection System set point Non-Reactor Protection System set point Improvements to prevent System set point. found out of calibration. found out of calibration. challenges to Reactor Protection set points.
Technical Specification required SSC
- Unplanned TS LCO Action
- Non-Safety Related equipment Equipment experienced complete loss of safety function Statement entry. failures or malfunctions performance/reliability
- Unexpected equipment response
- Unexpected Control Room alarms improvements.
- Operable/Nonconforming, But Degraded equipment
- Critical equipment failure with significant
- Critical equipment degradation or
- Minor equipment degradation or
- NPMR equipment issues /
station impact. failure. failure is threshold for corrective enhancements.
- Maintenance avoidable rework with action program involvement, but CAP adverse impact (e.g., critical is not required unless it involves equipment) critical equipment.
- QC inspection rejects with impact
- Failed post maintenance tests
- ANII inspection rejects
- SSC requiring aging management with long term effect Category 15- Security
- NRC reportable (10CFR73.71(d)):
- Unplanned degraded barriers
- 10CFR73.71(c) Security loggable Security Program improvements.
- Sabotage Planned event causing an unplanned events (e.g., lost badges, Vital Area
- Suspected tampering compensatory measure (e.g., door violations, failed equipment
- Compromise of site security maintenance activity on one system requiring compensatory measures,
- Security Reportable Events (e.g., system).
- Similar Near Miss events failures of the Security or AA/FFD
- FFD or Fatigue Rule Issues Program)
- FFD or Fatigue Rule violation Note: Exclude security loggable events resulting from security equipment issues.
Category 16- Management Discretion
- Event requiring higher attention as Any event that needs attention as Any event that needs attention as Not applicable determined by Management. determined by Management. determined by Management.
- Dominant drivers identified during stream analysis of significant issues.
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
- NRC Green Finding
- INPO negative comments Improvement suggestions to non-GREEN.
- NRC Severity Level III or IV
- NEIL inspection findings
- Potential greater than GREEN NRC Traditional Enforcement violation
- ANII findings Finding (WHITE, YELLOW, RED)
- NRC Performance Indicator Green
- All other NRC identified items (e.g.,
- NRC potential cross-cutting issue to White alarm threshold exceeded inspection, observations) aspects with 3 or more identified issues
- NRC potential cross-cutting issue
- NRC Information Notices and during the previous 4 quarters plus aspects with 2 identified issues Regulatory Information Summaries present quarter (See FG-R-LIC-06) during the previous 4 quarters plus
- NRC notice of violation that requires a present quarter Reports response in writing, enforcement,
- Non-cited violation conference, or notice of civil penalty.
- INPO area for improvement (default
- National Academy for Nuclear Training level) accredited training program on
- INPO review assist visit probation recommendations requiring a
- NRC Severity Level I or II Traditional response Enforcement (TE) violation, or 2 or
- SOERs (default level) more Severity Level III TE violations or 3 or more Severity Level IV TE NOTE: An NRC violation that crosses the violations during the previous 12 threshold for a RED KPI for frequency of months. cross cutting aspects will require a RCE RCEs SHALL be required for all NRC that should review the trend in items that fall in Level A of Category 17, performance.
within the time frame specified by NRC (See FG-R-LIC-06) response.
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
- Ineffective Training
- Trainee unexcused absence from Trainee excused absence from deficiencies that could result in a
- High trainee (non-operator) exam or Training Training due to:
program being placed on Probation. course failure rate
- Addition/cancellation of Training
- Acts of Nature
- High percentage of Training Program
- Repetitive performance problem due w/in 4 weeks of scheduled date
- Personal Illness failures to inadequate Training
- Training Observation feedback that
- Family Emergency
- High Non-licensed operator initial or
- Training Self-Assessment AFIs requires Training Program revision
- Response to emergent requal exam failure rate.
- Examination security is compromised plant issue
- Technically inaccurate material is Training Program improvement used to conduct a training activity suggestions
- 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 Category 19- Equipment Design
- Design deficiency on risk significant
- Design deficiency on risk significant
- Design deficiency on non-risk
- Equipment or system design equipment or system that renders the equipment or system that adversely significant equipment or system that enhancements equipment or system inoperable impacts the performance or adversely impacts plant operations or reliability of the equipment or personnel.
system. These deficiencies are most often nonconformances.
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
- Loss of configuration control with
- Loss of configuration control with no
- Configuration control could have a significant effect on the low potential to affect reliability of effect on Station safety system or improvements Operability / Functionality of the plants Station safety system or Maintenance Rule system Operability
- Drawing corrections or safety, safety systems, or Maintenance Maintenance Rule system / Functionality but associated with a corrections to other Rule systems or has been determined o Wrong quality level part QA Topical Report program: engineering documents that to be a significant adverse trend by installed in safety related or o Safety system piping and are historical in nature or are management maintenance rule system with Instrumentation diagram drawing not used to support o Wrong quality level part installed in no affect on Operability / error or corrections to other maintenance or routine safety related or maintenance rule Functionality. update priority code 0 station activities, or other system resulting in inoperable o Mispositioned device in an in- engineering documents that are update priority code 2 or 3 system service safety-related system or used by operations to manipulate engineering documents o Mispositioned device in an in- Maintenance Rule system with the plant
- Corrections to unvalidated service safety-related system or no impact on Operability / o Corrections to previously equipment database fields.
Maintenance Rule system that Functionality validated equipment database Since the majority of the causes system to be inoperable
- Loss of configuration with low fields equipment database is not
- Loss of configuration control that has or potential to affect plant efficiency,
- Loss of configuration control with no fully validated, it cannot be could have a significant effect on the non-safety systems or personnel effect on plant efficiency or personnel used as a sole source for plants efficiency, Operability / safety. safety: information, therefore Functionality, of non-safety systems or o Corrections to Calculations, corrections to unvalidated personnel safety. Vendor Technical Manuals, or fields in the equipment other update priority code 1 database is an engineering documents that are enhancement 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
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
- Exceeding an ODCM effluent
- Non-consequential ODCM
- Environmental limits limit implementation failure enhancement
- Uncontained petroleum product spill >50
- Routine release >50% of
- Uncontained hazardous substance spill
- Unplanned radiological release weather issue)
>reportable quantity to unrestricted areas
- Groundwater or surface water
- Any release which violates any
- Contained petroleum product sample >reporting level for applicable regulatory requirement AND spill >50 gallons radioactivity in environmental causes or may cause substantial
- Uncontained petroleum product samples adverse health or environmental effects spill >5 gallons but <50 gallons
- Petroleum product spill >1 pint
- Enforcement Action/Notice of violation
- Contained petroleum product quantity spill <50 gallons
- Uncontained hazardous
- Contained hazardous substance substance spill <reportable spill <reportable quantity quantity
- Fish kill or aquatic life loss of any
- Violations related to amount in the canal or river environmental permits or
- Administrative/minor error on regulations radioactive effluent release form with no impact Category 22- Chemistry
- Shutdown due to chemistry
- Entry into EPRI Chemistry Action
- Entry into EPRI Chemistry Action Chemistry improvements Level 2 or 3 Level 1
- Exceeding a Fuel Warranty
- Entry into EPRI Closed Cooling Operating Limit 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
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 Problem is discovered after tags hung Problem discovered before clearance is Process efficiency or process inside clearance boundary. and verified, but before workers sign on approved improvement items, not threats
- Clearance boundary found to have gap
- Tags are hung on wrong component
- Inadequate description of work to be to process barriers such as:
that could allow energy into boundary and planned boundary is not intact performed in clearance/work request
- Process delays (e.g.,
while work is in progress.
- Unplanned/unknown hazard found
- Clearance is written and found to be clearance not prepared in
- Work conducted outside clearance during maintenance walkdown incomplete time to support schedule).
boundary (e.g., wrong component
- Worker at work but not signed on to
- Previously unidentified LCO caught
- Missed process steps that worked on.) correct clearance prior to issuing clearance (after being do not bypass review or
- Manipulation of tagged component.
- Clearance request found to screened for plant condition and holder barriers.
- Work performed w/o clearance when inadequately describe required operational impact)
- Coordination issues clearance should have been in place. boundary, after written and verified
- Clearance documentation error / (schedule milestones not
- Clearance released when work is still in
- Clearance process activity places omission with no impact on plant met) progress. plant in unplanned, self-revealing safety
- Clearance/tagging process activity that LCO or higher-level plant risk /
- Clearance errors with no impact on places the plant in a trip or transient inadequate plant configuration safety system or Maintenance Rule condition (e.g., 72-hour LCO or less, system Operability / Functionality or loss of vacuum, etc.) 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.
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 Plant Manager / Vice President Vice President1 assignment types Business Support Manager / Engineering Director / Fleet Director/Fleet General Manager B Manager Plant Manager / Vice President1 Business Support Manager /
Engineering Director /
Fleet Director/Fleet General Manager 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.
For Action Tracking purposes, cross-references need to be generated from within the CAP/assignment and Check Boxes left in the Checked State unless NOTE: otherwise specified. Generating cross references within the CAP with check boxes means the CAP cannot be closed unless the cross referenced action is complete.
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 NOTE: 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).
Refer to Attachment 6 when determining whether a CAPA, CA, or CAPR should NOTE: 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 Project Manager or After CAP Initiation Phase of the modification, with Responsible Engineer scope, funding and schedule defined.
Track EC to APPROVED status Project Engineer or After PRG approval for Responsible Engineer EC Design Phase Track EC to turnover to operations Project Manager or After PRG approval for Responsible Engineer 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:
The ACE manual allows for a decision to not have an action to address a NOTE: 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)
Program/process owners should generally be assigned as the Owed To for CAPs NOTE:
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 CE 3/4Documentation 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 Attachment 4.
- 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
- Initiation of FP-R-EP-04 by the EP Manager for CAPs involving ERF functionality or equipment 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 NOTE:
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 Any of the following quorum positions may be filled by the assistant manager of the NOTE: 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: *Partial ACE means an ACE with a more limited scope (e.g., no EOC or OE evaluation).
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 Why did it Happen? Uncertainty Cause Known Assessment No Partial Yes Actions No High High Medium Known Uncertainty Uncertainty Uncertainty How can it Partial High Medium Low be fixed? Uncertainty Uncertainty Uncertainty Yes Medium Low Low Uncertainty Uncertainty Uncertainty Can it How important happen again? Assuming no CAs is it?
are taken.
Investigation Uncertainty Level Selected High Medium Low Risk Assessment Probability of Recurrence Uncertainty Uncertainty Uncertainty High Medium Low Risk High RCE Full ACE Partial*
Actual or High High Risk High Risk Medium Risk ACE Potential Risk Medium Full ACE Partial* CE Consequences Medium High Risk Medium Medium Risk ACE Risk Risk Low Partial* CE CA Low Low Risk Low Risk No Risk Risk ACE None No risk No Risk Correction Only
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:
Managers/Supervisors are not authorized to change the AR type from CAP to any NOTE: other AR type, or to change the severity level on a CAP without approval from the CAP Screen Team.
IF an employee leaves the company, THEN their supervisor is responsible for NOTE: 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 The CAP AR Owed To is held ultimately accountable for resolution of NOTE:
the issue.
IF an employee leaves the company, THEN their supervisor is responsible for NOTE: 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.
For Assignments completed by the Owed To supervisor, it is NOTE:
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.
- 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.
The document becomes a record as soon as it is COMPLETE and it cannot NOTE: 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.
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 NOTE: 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 If this block is checked for an Assignment, that Assignment is NOT included in NOTE: 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 Action Impacts NRC Finding Aspect 2 CE NRC Finding Aspect 3 ACE NRC Finding Aspect 4 RCE Cross-Cutting Area: Safety Culture Evaluation Type Number of Action Impacts NRC Finding Aspect 1 RCE
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):
- Rad release (airborne or liquid above
- Unit shutdown required by Tech Specs threshold)
- Tech Specs violated, such as:
- Fire, toxic gas release, or rad release o Exceeded Completion Time for a
- Transport of contaminated person to hospital Condition (with firm evidence of when
- News release or notification of other condition started) government agency of:
o Late surveillance (and then surveillance o Fatality failed) o Inadvertent rad material release o Deviation from Tech Specs o Killed endangered species NOED
- Loss of EP capability:
50.54(x) o Assessment (control room instruments
- Degraded Condition or ERCS) o Fuel cladding degraded o Offsite response (loss of access to plant o RCS pressure boundary degraded or EOF, multiple siren failures) o Containment degraded o Communication (loss of red phone/ENS)
- Unauthorized person given access to o Failure to meet single failure criteria protected area o Missing fire barrier
- Security responders out of position
- Specified system actuation (unplanned)
- Positive FFD test on supervisor or licensed o RPS actuation operator o Containment isolation (more than one system or more than one MSIV) o ECCS actuation Notes:
o Aux Feedwater actuation 1. Based on NUREG 1022, Rev 2, and review o Containment Spray or CFCU actuation of internal and external OE (LERs and Event o EDG start Reports).
o Diesel cooling water pump start 2. Equipment issues typically need past
- Loss of safety function (both trains; no Operability evaluation (that determines how assumed single failure) long the SSC was inoperable) as an input to
- Common cause failure of multiple trains or a reportability evaluation.
multiple systems 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
CAP Action Request Process Revision 27 FP-PA-ARP-01 Page 79 of 81 ATTACHMENT 17 CAP LIAISON RESPONSIBILITIES Personnel assigned CAP Liaison responsibilities are required to complete NOTE: 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.
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.
NOTE:
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.