ML18031B234

Rev 2 to Generic Procedure Corrective Action, Part I, Section 2.16 of QA Manual

ML18031B234
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Site:	Browns Ferry
Issue date:	01/04/1987
From:	Rob Parker, Roemer F TENNESSEE VALLEY AUTHORITY
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ML18031B233	List: ML18031B232 ML18031B234
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PROC-870104, NUDOCS 8703100371
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ENCLOSURE 2 TENNESSEE VALLEY AUTHORITY NUCLEAR QUALITY ASSURANCE MANUAL CORRECTIVE ACTION GENERIC PROCEDURE PART I, SECTION 2.16

('EVISION LEVEL:

DATE:

6-18-86 11-10-86 1-4-87 PREPARED/REVISED:

TECHNICAL REVIEW:

N/A N/A N/A QA REVIEW:

4~ p),gQ B.J.

SUBMITTED BY:

Chlel, Quality Systems 8ranch APPROVAL: oirectpf, oivisjpn pf Nuclear Quality Assurance 870ssaom PDR ADQCK i 870soz 05000259 P PDR

Part I, CORRECTIVE ACTION Sec. 2.16 2 TitIe: N Rev.

REVISION LOG REVISION DATE DESCRIPTION 6-18-86 New procedure based on Criterion XVI to Appendix 8 of 10 CFR 50. This procedure delineates essential control elements for Corrective Action for the Office of Nuclear Power.

(RIMS QA Record No.: L16 860602 229) 11-10-86 This procedure has been completely rewritten to meet: (a) Sequoyah startup commitment which is identified in the U2 forced Outage Report as activity 200050404 and in Volume 1, Revision 1, of the Corporate Nuclear Performance Plan as commitment item 6 (Corporate Commitment Tracking System control number NCO-86-0156-037); (b)

Institute of Nuclear Power Operations commitment which is identified as Finding (2.9A-2); and (c) an internal audit commitment which is identified as NCO-CAR-86-017R. Thi s revision satisfies these commitments and provides for: a) standardized approach for processing and controlling conditions adverse to quality (CAQs), b) a single form to be used for documenting CAQs, and c) a standardized definition for significance. This revision maintains compliance with commitments made to the Nuclear Regulatory Commission in .

response to Sequoyah's Order Modifying License (EA 85-49).,

(RIMS QA Record No,: L16 861110 628) 1-4-87 Changes in Revision 2 were based on the review of the procedure in preparation for its implementation.

Revisions were made throughout the procedure to provide clarifications in understanding of the processing of the CAQR.

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REVISION LOG REVISION DATE DESCRIPTION 2 (Cont'd) Major changes included: 1) Revising paragraph 6.1.4 as to when a test deficiency is a CAQ. 2) Deleting the requirement (reference paragraph 7.2.2.2) when the CAQR initiator and management reviewer agree that a CAQ is not valid, the CAQR is filed as a QA record. 3) Revised paragraph 8.2 to allow escalation requirements to be waived based on extenuating circumstances, made the responsible QA manager and his peers involved in the first level of escalation, the Director of DNQA in the second level, added a third level of escalation, and added requirements to process the CAQ after escalation has been satisfactorily resolved. 4) Revised paragraph 10.0 by deleting paragraph 10.1 which tied the evaluation of potential generic implications to Operations Experience Review Program.

5) Revised paragraph 11.4 by adding a requirement for ANII to review the remedial corrective action. 6) Added a new paragraph for the ANI or ANII to verify completion of the remedial corrective action and, 7) Revised paragraph 16.2 to address the type of trend information to be provided to management, frequency at which trend reports are to be prepared, and the responsibility for preparing trend reports.

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1.0 PURPOSE This procedure establishes measures which ensure that conditions adverse to quality (CAQs) are promptly identified, documented, evaluated., corrected,.and reported to management in a manner consistent-with their importance to safety, and that, when appropriate, actions are taken to prevent their recurrence.

It is not the intent of this procedure to prohibit or inhibit any immediate corrective -action which may be deemed necessary by plant management to protect the health and safety of the public and employees.

2' SCOPE 2.1 , The requirements of this procedure apply to CAQs, as defined in paragraph 4.2, which may affect those activities, systems, structures, or components within the scope of the Office of Nuclear Power (ONP) quality assurance (QA) program. This includes safety-related items and related activities as well as items and programs subject to the limited QA program.

2.2 The following are not under the scope of this procedure:

2.2.1 Problems identified during routine in-process checks such as drawing checks, in-process inspections, and procedure reviews except as specifically required in paragraph 6.0.

2.2.2 Suggestions for program improvements; 2.2.3 Problems handled via maintenance request which are not significant in accordance with paragraph 4.11 or are not specifically required to be documented on a Condition Adverse to Quality Report (CAQR) by the requirements of paragraph 6.0.

2 '.4 Information regarding Security Safeguards which is handled in accordance with applicable ONP Security Safeguards Information Procedures.

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2.2.5 CAQs discovered at supplier's facilities which are handled in accordance with Procurement Quality Assurance Branch procedures or Nuclear Fuel's supplier CAQ control procedures.

2.2.6 Deficiencies currently reported as Radiological Incident Reports and Security Degradation Reports need not be reported in accordance with this procedure unless the deficiency is "significant" as defined in paragraph 4.1.1.

2.2.7 The method and logic for determining NRC reportability is not covered by this procedure.

2.3 There may be other specific actions-and reports other than those imposed by this procedure which are required by codes and regulations for specific types of CAQs. These specific actions and reporting requirements are covered by applicable implementing procedures.

3.0 REFERENCES

3.1 10 CFR 50, Appendix B, Criterion XV, "Nonconforming Materials, Parts, and Components," and Criterion XVI, "Corrective Action."

3.2 TVA Topical Report (TVA-TR75-1A), Sections 17.1.15 and 17.2.15, "Nonconforming Materials, Parts, or Components,"

Section 17.1.16, "Corrective Action," and Section 17.2.16, "Adverse Conditions and Corrective Action."

3.3 ANSI N18.7-1976/ANS 3.2, "Administrative Controls and Quality Assurance for the Operational Phase of Nuclear Power Plants," (Sections 5.2.11 and 5.2.14) as endorsed by Regulatory Guide 1.33, Revision 2, February 1978. ~

3.4 ANSI N45.2-1971, "Quality Assurance Program Requirements for Nuclear Power Plants," (Sections 16 and 17) as endorsed by Regulatory Guide 1.28, Revision 0, June 7, 1972.

3.5 American Society of Mechanical Engineers, Boiler and Pressure Vessel Code, Section III, Division 1, "Nuclear Power Plant Components", Subsection NCA, Article NCA-4000, "Quality Assurance."

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3.6 American Society of Mechanical Engineers, Boiler and Pressure Vessel Code,Section XI, "Rules for Inservice Inspection of Nuclear Power Plant Components."

4' DEFINITIONS 4.1 d administrative responsibilities related to coordination of the corrective action program including report routing, CAQ tracking, assigning trending codes, and record maintenance. The following are CAQ coordinators:

4.1.1 Division of Nuclear Engineering, Engineering Assurance (DNE-EA) when the initiator is in Knoxville; 4.1.2 Site QA organization when the ini tiator is part of any site organization including DNE, Division of Nuclear Safety and Licensing (DNSL) and Division of Nuclear Construction (DNC), and Site QA; 4.1.3 Nuclear Quality Audit and Evaluation Branch (NQA lt EB) for Division of Nuclear Quality Assurance (DNQA) audit findings; and 4.1.4 DNQA Quality Systems Branch (QSB) for any organization not covered above.

4.2 CA(bs Adverse conditions include nonconforming material, parts, or components; failures; malfunctions; deficiencies; deviations; hardware problems involving noncompliance with licensing commitments, specifications, or drawing requirements; abnormal occurrences; and nonhardware problems such as failure to comply with the operating license, technical specifications, licensing commi'tments, procedures, instructions, or regulations. Unsubstantiated conditions are not defined as CAQs.

4.3 Corrective Action The action taken to correct a CAQ. As used in this procedure, corrective action includes remedial corrective action and recurrence control actions.

4.4 Mana ement Reviewer Immediate supervisor of the initiator of the CAQR, or an individual or group designated as a reviewer by'>> the organization which initiated the CAQR.

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4.5 0 erable 0 erabilit . A system, subsystem, train, component, or device shall be operable or have operability when it is capable of performing its specified function.

Implicit in this definition shall be the assumption that all necessary attendant instrumentation, controls, normal and emergency electrical'ower sources, cooling or seal water, lubrication or other auxiliary equipment that are required for the system, subsystem, train, component, or device to perform its function are also capable of performing their related support function (see attachment 5).

4.6 Recurrence Control Actions designed to address the root cause of a CAQ and to prevent the CAQ from recurring.

4.7 Remedial Corrective Action Actions taken to correct the specific CAQ which has been identified.

4.8 ~Re air The process of restoring a nonconforming characteristic to a condition such that the capability of an item to function reliably and safely is unimpaired, even though the item still may not conform to the original requirement.

4.9 Rework The process by which a nonconforming item is made to conform to prior specified requirements by completion, remachining, reassembling, or other corrective means.

4.10 Root Cause The underlying reasons for the existence of the CAQ. pss 4.11 when it meets the criteria listed below. Until a CAQ has been confirmed as meeting one of these criteria, it shall not be considered as significant.

4.11.1 A CAQ that has occurred with a frequency as to indicate that past recurrence control action has been ineffective (this does not apply to deficiencies which are handled through normal, planned rework cycles Le.g., weld repair] when the

, frequency of failure is not deemed to be excessive>.

4.11.2 A CAQ which indicates gross or widespread noncompliance with procedural requirements which could negate the effectiveness of QA controls imposed by the ONP QA program. A CAQ falls in this category when it involves:

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4.11.2.1 A widespread failure to address the requirements of procedures and instructions; 4.11.2.2 . A widespread failure to train and instruct personnel in QA program requirements including safety-related work activities; or 4.11.2.3 A. widespread or deliberate failure to manage

. or supervise personnel in carrying out their assigned duties and responsibilities as related to the QA program.

4. 11. 3 For a plant wi th a Construction Permit (CP):

4.11.3,1 Any condition that could, if left uncorrected, result in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded, or that could result in the nuclear power plant being:

A. In an unanalyzed condition that substantially could compromise plant safety; and B. In a condition that is outside the design basis of the plant.

4.11.3.2 Any condition that alone could prevent the fulfillment of the. safety function of structures or systems that are needed to:

A. Shut down the reactor and maintain it in a safe shutdown condition; B. Remove residual heat; C. Control the release of radioactive material; or D. Mitigate the consequences of an accident.

4.11.4 For a plant with an Operating License (OL):

4.11.4.1 Any event or condition that resulted in the condition of the nuclear power plant, including its principal safety barriers, being seriously degraded or that resulted in the nuclear power plant being:

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A. In-an unanalyzed condition that substantially compromised plant safety;

. B. In a condition that was outside the design basis of the plant; or C. 'n a condition not covered by the plant's operating and emergency procedures.

4.11.4.2 Any event or condition that alone could prevent the fulfillment of the safety function of structures or systems that are needed to:

I A. Shutdown the reactor and maintain it in a safe shutdown condition; B. Remove residual heat; C. Control the-release of radioactive material; or D. Hitigate the consequences of an accident.

4.11.4.3 Any event where a single cause or condition caused at least one independent train or channel to become inoperable in multiple systems or two independent trains or channels to become inoperable in a single system designed to:

A. Shut down the reactor and maintain it in a safe shutdown condition; B. Remove residual heat; C. Control the release of radioactive material; or D. Hitigate the consequences of an accident.

I 5.0 RESPONSIBII ITIES 5.1 The initiator is responsible for recording the identified CAQ on a CAQR.

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5.2 The management reviewer in the organization initiating, the CAQR is responsible for the following:

5.2.1, Reviewing. the CAQR for validity.

5.2.2 Reviewing the CAQR for potential impact on operability, and 5.2.3 Identifying the organization with lead responsibility for determining corrective action and for responding to the CAQR.

5.3 The organization, which is assigned responsibility for responding to the CAQ (i.e., the Responsible Organization) is responsible for the following:

5.3.1 Determination of remedial corrective action, 5.3.2 Determination of significance, 5.3.3 Determination of whether a CAQ requires a review for potential generic implications, 5.3.4 Determination, when required, of the root cause and recurrence control, 5.3.5 Obtaining approvals of proposed corrective actions, and 5.3.6 Providing for verification of corrective action completion, as required.

5.4 The CAQ coordinator is responsible for the following:

5.4.1 Assi gni ng a number to each CAQR; 5.4.2 Entering the information about the CAQ, including trending codes, into the Tracking and Reporting of Open Items (TROI) System; maintaining the status of open CAQs in TROI, and entering appropriate closure information into TROI; 5.4.3 Escalating to higher levels of management any CAQ which meets the criteria of paragraph 8.0; and 5.4.4 Reporting to management on performance of the corrective action program.

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5.5 DNQA and DNE-EA are responsible for:

5.5.1i Serving as CAQ coordinator, and 5.5.2 Approving proposed corrective action in accordance paragraph 11.0 and verifying completion of corrective action in accordance wi'th paragraph 12.0.

5.6 The site Plant Operations Review Staff (PORS) is responsible for the following actions:

3.6.1 For a CAQ determined to potentially affect operability:

5.6.1.1 Determining whether the CAQ affects unit operability, 5.6.1.2 Determining the reportabili ty requirements of CAQs under 10 CFR 21, 10 CFR 50.72, and 10 CFR 50.73, as applicable, 5.6 ' For a CAQ affecting unit operability:

5.6.2.1 Determining the significance of CAQs, 5.6.2.2 Ensuring expeditious development and implementation of a corrective action plan.

5.7 DNE is responsible for:

5.7.1 Approving "repair" and "accept-as-is" dispositions of CAQs involving deviations from engineering specified requirements except for those dispositions involving fuel assembly and fuel-related components 5.7.2. Reviewing CAQs for generic implications for which DNE is the Responsible Organization.

5.8 The Division of Nuclear Services, Nuclear Fuel Engineering Branch, is responsible for approving "repair" and "accept-as-is" dispositions of CAQs involving fuel assemblies or fuel-related components.

5.9 DNSL is responsible for:

5.9.1 Units with a construction permit, determining the reportability requirements of CAQs under 10 CFR 50.55(e) and 10 CFR 21.

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5.9.2 Reviewing CAQs, other than those reviewed by DNE, for generic implications.

5<<10 All TVA managers are responsible for assuring that CAQs are promptly documented, reported, evaluated, and corrected in accordance with the requirements of this procedure.

6.0 CA s SUBJECT TO THE SPECIFIC RE UIREMENTS OF THIS PROCEDURE The following is a.list of CAQs and potential sources of such CAQs which are subject to the requirements of this procedure.

6.1 Any confirmed degradation, damage, failure, malfunction, or loss of plant structures, systems, and components that could adversely affect the performance of a safety-related function (i.e.,

nonconformances). This would include but not be limited to material failure, abnormal or unexpected wear, manufacturer defects, failure to function as intended, and repetitive failures. Specific examples of nonconformances covered by this procedure are as follows:

6.1.1 Deficiencies in the approved design which adversely affect hardware.

6 ~ 1.2 In-process inspection rejections which cannot be returned to meet original requirements using the original procedure acceptance criteria and methods.* (Other inspection rejections shall be documented and handled in accordance with the requirements of applicable procedures.)

6.1.3 Receipt inspection rejections, except that CAQRs need not be issued for items on hold (and not installed) awaiting documentation.

6 ~ 1 .'4 Test deficiencies involving failure of the item being tested to meet documented test acceptance criteria. CAQRs need not be written for minor procedure revisions and maintenance activities (e.g., replacing indicating lights) necessary to facilitate test performance.

Note: It is not required that Maintenance Requests (MRs) be entered into this system. Only those MRs describing significant problems (per paragraph 4.11) are required to be processed as CAQRs or those specifically included by this section (e.g., MRs which address a problem identified in a QA audit or surveillance).

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6;2 CAQs resulting from external inspections, reviews, and audits such as:

6.:2.1 NRC inspections, 6.2.2 Nuclear insurance company audits,,

6.2.3 INPO audits, 6.2.4 Fire protection and loss prevention audits, 6.2.5 ASME Code reviews, and 6.2.6 Authorized Inspection Agency surveillance reports.

Note: Internal and external audit and review findings are not automatically classified as CAQs. Each finding must meet the definition before being classified and processed as a CAQ.

6.3 CAQs identified during or resulting from internal audits, surveillances, and reviews such as:

6.3.1 DNQA audits, reviews, and surveillances, 6.3.2 Nuclear Manager's Review Group (NMRG) reviews, 6.3.3 ONE EA audits, and 6.3.4 PORS and Independent Safety Engineering Group (ISEG) reviews.

6.3.5 Employee Concern Program Investigation Reports 6.4 Failure to comply with requirement documents such as technical specifications, procedures, instructions, regulations, Program Manual Procedures (Area Plans), or this QA Manual.

6.5 Adverse trends identified by trend analysis.

6.6 Procedures found to be deficient in technical or QA content, or the failure to have and/or use a procedure when a procedure is required'.7 CAQs previously reported on:

6.7 ' Corrective Action Reports (CAR)

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6.7.2 Discrepancy Reports (DR) 6.7.3 Nonconforming Condition Reports (NCR) 6.7.4 Significant Condition Reports (SCR) 6.7.5 Problem Identification Reports (PIR) 6.7.6 'udit Deviation Reports 6.7.7 Site Fuel Discrepancy Reports

.6.7.8 Site Fuel Status Reports 6.7.9 Nonconforming Item (NCI) Tags and Log 6.7.10 Licensee Reportable Event Determinations (LRED) and Potential Reportable Occurrences (PRO). Note that LRED and PRO forms shall continue to be used to evaluate reportability but any related CAQs shall be documented on CAQRs in accordance with the requirements of this procedure The specific CAQ forms mentioned above shall no longer be initiated for processing new CAQs after this procedure is implemented. Pre-existing CAQs documented on the CAQ forms listed above may continue to be processed in accordance with applicable controlling procedures or may be "rolled over" to the CAQR form at responsible manager's discretion. The requirements of this procedure shall not be applied to currently open CAQs which are documented on the above forms (i.e., backfitting is not required). Current implementing procedures for the above CAQ shall remain in effect until the corresponding CAQs are closed or "rolled over."

6.8 Notification of Indications (NOIs) and Drawing Discrepancy Reports (DDRs) shall be reviewed for identification of a CAQ and the review documented on the NOI and DDR. If the NOI or DDR identifies a CAQ, a CAQR shall be initiated and the CAQR number recorded on the NOI or DDR.

7.0 PROCESSING OF CA Rs NOTE: If at any time during the processing of a CAQR, the CAQ is determined:

l. To potentially affect operability, a copy of the CAQR shall be sent to PORS of the potentially affected plant.

2. To adversely affect the health and safety of the public and employees, the affected nuclear site director shall be immediately notified.

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3. To be potentially reportable, a copy of the CAQR shall be immediately sent to the organization responsible for determining reportability.

The responsibilities and requirements for initiating, processing, and closing CAQRs are as follows (see Attachment 2 for line-by-line instructions):

7.1 The requirements .for documenting specific types of CAQs on a CAQR are as follows: (These CAQs shall be processed by the respective organizations identified in paragraph 4.1).

7.1.1 CAQs identified by internal or external organizations shall be documented on a CAQR when identified rather than waiting on completion of the audit or evaluation or on receipt of a formal report.

7.1.2 The organization responsible for responding to documents submitted by INPO, NRC, inspection agencies, and other external agencies (see paragraph 6.2) shall evaluate the document to determine if it identifies a CAQ. If the document identifies a CAQ and a CAQR has not been previously initiated to document the CAQ, then the Responsible Organization shall initiate the CAQR.

NOTE: When a CAQ is adequately documented on a report or letter from an external agency (e.g., an NRC Inspection Report) this report may be referenced on the CAQR rather than entering information from it which describes the CAQ. When this approach is taken, the applicable report shall be attached to the back of the CAQR and will become an official part of the CAQR package. Information required by the CAQR form which is not included on the external agency's (e.g., TVA affected system number) report must be entered on the CAQR form.

7.1,3 ISEG and NMRG reports shall be evaluated by the manager of the area being reviewed to identify CAQs and initiate CAQRs, as appropriate.

7.1.4 Substantiated employee concerns that meet the definition of a CAQ shall be documented by management of the affected organization.

7.1.5 Other audit, surveillance, and review groups such as DNQA and EA shall initiate CAQRs as they find CAQs.

F 1.6 For CAQs identified by TVA organizations, the person finding a CAQ (i.e., the CAQR initiator) shall:

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7.1.6.1 Determine to the extent practical that the CAQ is a valid CAQ.

7.1.6.2 . Promptly record the CAQ on Part A of the CAQR in as adequate detail so that the impact on operability, significance, root cause, corrective action, and recurrence control can be determined. If the CAQR results from a generic

~

review, the description of the "new" CAQ shall so state and .reference the original CAQR.

7.1.6.3 Sign and date the CAQR and transmit (may be hand-carried to expedite) the CAQR to the management reviewer.

7.2 The management reviewer shall perform the following reviews within three working days of the date that the initiator signed the CAQR.

7.2.1 Review the CAQR for completeness and clarity and provide any needed clarification.

7.2.2 Review the CAQR for validity. If the validity is I

questionable or indeterminate, provide for expeditious investigations as needed to determine whether a CAQ is involved. If the CAQ is not in the manager's area of expertise, the manager shall request knowledgeable assistance as needed to complete the reviews required by this paragraph and paragraph 7.2.4.

7.2.2.1 If the management reviewer agrees that a CAQ is valid, then he shall perform the action described in paragraphs 7.2.3 and 7.2.4.

7.2.2.2 If the initiator and management reviewer agree that the CAQ is not valid, the proposed CAQR shall be discarded.

7.2.2.3 If the initiator and management reviewer disagree about the validity of the CAQ, then the CAQ shall be handled in accordance with paragraph 8.1.

7.2.3 Identify the organization responsible for responding to the CAQR ('i.e., the Responsible Organization). Obtain help from the CAQ coordinator, if needed, in making this determination.

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7.2.4 Review the CAQR for potential impact on operability of a nuclear unit (see attachment 5), and indicate the results of this review in Part A of the CAQR. If the CAQ potentially impacts operability, the CAQR shall be hand-carried or telecopied to the CAQ coordinator.

7.2.5 The management reviewer shall sign and date the CAQR and send the CAQR to the CAQ coordinator. The date that the management reviewer signs the CAQR is called the origination date.

7.2.6 If the management reviewer cannot complete his review within three working days, he shall send (may be hand-carried to expedite) a copy of the CAQR to the CAQ coordinator indicating that the documented gotentiai CAQ is being evaluated and the expected completion date of the review. The CAQ coordinator shall assign a CAQR number, enter the CAQ into TROI (clearly indicating that it is a potential rather than confirmed CAQ>, and enter an action item for completion of the review by the indicated date.

When the management reviewer completes the evaluation, the management reviewer shall either instruct the CAQ coordinator to cancel the potential CAQ (see paragraph 7.2.2.2), process it as an invalid CAQ (see paragraph 8.1.3), or process it as a confirmed CAQ.

7.2.7 When applicable, the management reviewer shall notify the organization responsible for tagging, segregating or otherwise controlling affected nonconforming items in accordance with NQAN, Part I, Section 2.15.

7.3 The CAQ Coordinator shall:

7.3.1 Assign a CAQR number in accordance with Attachment 3.

7.3.2 Q'"

telecopy the CAQR to the CAQ coordinator at the affected site for handling in accordance with paragraph 9.0.

7,3.3 Within three working days of the date the management reviewer signed the CAQR (i.e. the origination date),

distribute copies of the CAQR as follows:

7.3.3.1 Send the original CAQR to the Responsible Organization for action (If the "Responsible Organization" has been notified via telecopy in accordance with paragraph 7.3.2, then another copy of the CAQR is not necessary provided the telecopy included all required information).

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7.3.3.2 Send copy for information to DNQA-QSB.

7.3.3. 3 Send copy of the CAQR to RIHS.

7.3.4 . Enter. information about the CAQR, including related trending codes, into:TROI in accordance with the TROI User's Guide. This shall include an action item for the Responsible Organization to develop and obtain approval of a corrective action plan within the specified time frame.

7.4 The Responsible Organization shall:

7 .4. 1 within seven working days of the origination date, perform the following actions and complete Part 8 of the CAQR:

7.4.1.1 Determine whether the CAQ is significant in accordance wi th the criteria specified in paragraph 4.11 and mark Part 8 of the CAQR accordingly. If the CAQ is determined to be significant, a copy of the CAQR 'shall be transmitted immediately to the organization assigned responsibility for determining reportability.

If the CAQR has been referred to PORS because of the affect on operability, the determination of significance shall be coordinated with the potentially affected PORS organizations.

7.4.1 ~ 2 Determine whether a review for potential generic implications is needed and mark Part 8 of the CAQR accordingly. If the CAQ is determined to require a review for generic implications, a copy of the CAQR shall be sent to the designated review organization for handling in accordance with paragraph 10.0. A review for potential generic implications is always required for significant CAQs, and CAQs which are confirmed to have an impact on operability.

7.4.1.3 Determine whether root cause analyses and recurrence control are required. Root cause analysis is always required for NRC violations, TVA audit findings, CAQs affecting operability, and significant CAQs. These actions may be required for other CAQs as determined by the Responsible Organization.

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7.4.2 Hithin 30 calendar..days of the origination date, develop a corrective action plan. The corrective action plan shall consider any possible generic implication of the CAQ within the initiating organization, such as division or site, and shall not be limited to merely addressing the specific CAQ that was identified. Development of the corrective action plan .includes the following actions:

7.4.2.1 Determine the remedial corrective action and enter it in Part C of the CAQR; 7.4 '.2 Determine the root cause of the CAQ, if required, and enter it in Part D of the CAQR; 7.4.2.3 Determine recurrence control measures, if required, and enter them in Part 0 of the CAQR; 7.4.2.4 Determine the scheduled completion dates for the-implementation of the remedial corrective action and recurrence control, and enter the dates in Parts C and D of the CAQR, respectively.

Scheduled completion dates which are dependent on events occurring may be tied to an event such as "two weeks after Unit 2, Mode 2" instead of an actual date. Events based on schedules are only to be used when performance of the corrective action is retricted by the event and a firm schedule cannot be established for the event; 7.4.2.5 Coordinate corrective action and scheduled completion dates with affected organizations; and NOTE: In lieu of putting the information in paragraphs 7.4.2.1 through 7.4.2.5 on a CAQR, the CAQR may reference another document such as a response to an NRC violation or a Licensee Event Report that contains this information. Hhen this approach is taken, the applicable. report shall be attached to the back of the CAQR and will become an official part of the CAQR package. Any required, information not contained on the referenced report must be entered on the CAQR.

7.4.2.6 Designate the organization(s) responsible for verifying completion of the corrective action in accordance with paragraph 12.0.

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7.4.3 Submit the CAQR far approval of the proposed corrective action and of associated scheduled completion dates in accordance with paragraph 11.0.

7.5 The organization responsible for approving the proposed remedial corrective action and recurrence control shall perform the required reviews and indicate approval or disapproval on the CAQR in accordance with paragraph 11.0. The CAQR shall then be returned to the Responsible Organization. If the proposed corrective action is disapproved, the disapproval shall be explained on a continuation sheet and a copy shall be sent to the CAQ coordinator for updating TROI.

7.6 Following approval of the proposed corrective action, the Responsible Organization shall send copies of the CAQR to the CAQ coordinator and shall begin implementation of the approved corrective actions. The Responsible Organization shall also monitor the performance of other organizations that are responsible for implementing corrective actions.

7.7 The CAQ coordinator shall:

7.7.1 Enter the approved actions, RIHS accession number of the approved CAQR, and due dates into TROI; 7.7.2 Periodically report status of CAQs to management in accordance with paragraph 14.0.; and 7.7.3 Transmit the CAQR to RIHS.

7.8 The Responsible Organization shall:

7.8.1 Nhen required, request extensions to scheduled completion dates in accordance with paragraph 13.0; 7.8.2 Notify the CAQ coordinator of the status of the CAQ when requested; and 7.8.3 Nhen the approved corrective action is completed, send the CAQR to the organization(s) responsible for verifying completion of the corrective action as specified in paragraph 12.0, and a copy of the CAQR to the CAQ coordinator for updating TROI.

7.9 The organization responsible for verifying corrective action shall:

7.9.1 Perform the required verification as required by paragraph 12.0.

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7.9.2 Sign and date the-CAQR, verifying that the approved corrective action has been correctly implemented. If the action has not been correctly implemented, indicate the problem on the CAQR and return it to the Responsible Organization with an information copy to the CAQ coordinator to update TROI.

7.9.3 For hardware-related CAQs, verify the removal of nonconformance tags.

7.10 The Responsible Organization shall send the CAQR containing verification signatures to the CAQ coordinator for closure.

7.11 The CAQ coordinator shall:

7.11.1 Ensure that all required information has been entered on the CAQR; 7.11.2 Update TROI in accordance with the requirements of the TROI User's Guide to indicate that the CAQR is closed; 7.11.3 Ensure that the CAQR is maintained as a QA record; and 7.11.4 Distribute copies of the completed CAQR to:

7.11.4.1 The CAQR initiator, 7.11.4.2 RIMS, 7.11.4.3 Affected organizations, and 7.11.4.4 Nuclear Safety Review Board (NSRB) for significant CAQs and CAQs which are confirmed to affect operability.

NL 8.1 Nhen there is a disagreement about the validity of a reported CAQ, the CAQ shall be escalated as follows:

8.1.1 If the initia.tor and management reviewer disagree as to whether a CAQ is valid, the management reviewer shall provide expeditious escalation of the CAQR to the next higher level of managements 8.1.2 If this higher level of management agrees that the CAQ is valid, then processing of the CAQR shall continue per paragraph 7.2.3.

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8.1.3 If this level of management believes that a CAQ is not involved, then a justification for this conclusion and a dated signature shall be entered in Part A of the CAQR in the "Description of Condition" space. The original CAQR shall. then be transmitted to the CAQ coordinator who shall assign a CAQR number; file the CAQR as a QA record, and transmit a copy of the-CAQR to the initiator.

8.2 The following paragraphs describe the process of escalation of CAQs due to failure to comply with timeliness and effectiveness requirements.

8.2.1 CAQs shall be resolved in the most timely and effective manner practicable and at the lowest possible level in the organization.

8.2.2 In order to achieve desired results, criteria have been established to involve higher levels of management in a process to achieve timely and effective corrective actions. This process ensures that the response to and/or resolution of CAQs and the implementation of the associated corrective action are not delayed, stalemated, or otherwise inhibited by disagreements between lower- and middle-level management or by their lack of attention.

8.2.3 Management shall be provided monthly reports of all CAQRs not being processed in accordance with timeframe requirements of this procedure as required by paragraph 14.0. These reports identify CAQRs requiring increased management attention in order to avoid escalation. These reports shall be analyzed by site QA, EA, and QSB to identify adverse trends associated with timeliness in accordance with the requirements of paragraph 16.2.

8.2.4 The escalation requirements normally do not apply to the following unless failure to correct the problem in a timely manner would increase the significance of the problem:

8.2.4.1 Vendor problems or other receipt inspection problems related to items not issued for use.

8.2.4.2 Problems related to in-process work which has not been accepted (inspection/test deficiencies).

8.2.4.3 Problems which are obviously isolated and not generic or programmatic in nature.

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8.2.5 Escalation requirements may be waived under extenuating circumstances, such as, when the Manager of ONP issues policy directives that slow down or delay a major scope of work. This type of situation may be considered as an acceptable basis for rescheduling corrective action completion dates without escalation penalty when approved in writing by the Director of DNQA. (This approval may be for a class of CAQs or for specific CAQs.)

8.2.6 First Level of Escalation When lower and middle levels of management fail to comply with the timeliness and effectiveness requirements of this procedure, CAQRs shall be'scalated by the CAQ coordinator for resolution by the responsible QA manager and management of the responsible organization. A copy of escalation shall be sent to the Director of DNQA. Escalation shall occur under the following circumstances:

8.2.6.1 When the significance of the CAQ warrants early involvement of upper-management as determined CAQ coordinator or line management.

by'he 8.2.6.2 When a required response is more than 30 calendar days late.

8.2.6.3 When the second extension of the original corrective action completion date is requested for significant CAQRs or a third extension is requested for nonsignificant CAQRs.

8.2.6.4 If, after the committed date to complete corrective action has passed, it is determined that the corrective action is 1ncomplete or ineffective based on a second follow-up verification.

8.2.6.5 When the initial and second response to the CAQ are determined unacceptable by the organization responsible for approval of the proposed corrective action.

8.2.7 Second Level of Escalation If resolution of an escalated CAQ is not progressing satisfactorily through the process described above, the affected QA manager shall escalate the matter to the Director of DNQA for resolution with the responsible site director, staff manager, or division director. The Director of DNQA is authorized to waiver the escalation process in the following situations:

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8.2.7.1 Based on. extenuating circumstances identified in paragraph 8.2.5.

8.2.7.2 .Although the escalation timeliness milestone has been reached, resolution of the CAQ is progressing satisfactorily.

The waiver of escalation shall be withdrawn if it is determined that satisfactory progress is no longer being achieved.

8.2.8 Third Level of Escalation If resolution of an escalated significant CAQ is not progressing satisfactorily through the process described above, the Director of DNQA shall escalate the matter to corporate management for resolution.

8.2.9 Once the specific issue that caused escalation has been satisfactorily resolved, the escalation issue shall be closed and subsequent reports will not reflect the CAQR as being in escalation status.

8.2.10 The process of escalation shall be documented on a CAQR continuation page and the documentation shall be maintained as a QA record and traceable to the CAQR. This documentation shall include actions taken to resolve the CAQ, justification for not escalating- the CAQ, and the basis for removing the CAQ from escalation status.

9.0 HANDLING OF CA s WHICH POTENTIALLY AFFECT PLANT OPERABILITY 9'.1 If a CAQ is determined to potentially affect operabi i ty of a1 nuclear unit (as defined in attachment 5), it shall be immediately hand-delivered (or telecopied if initiated offsite) to the CAQ coordinator at the affected site. The initiator's CAQ coordinator shall verify that the CAQR was received by the CAQ coordinator at the affected site, and shall enter an action item into TROI for completion of the site's review of the CAQR.

9.2 The site CAQ coordinator shall hand-carry the CAQR to the PORS.

9.3 Within three working days of receipt, PORS shall determine and document in Part 8 of the CAQR whether the CAQ affects operability.

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9.3.1 If effect on operability cannot be determined, PORS shall request additional information from the CAQR initiator, management reviewer, or other appropriate personnel. If the effects on operability can only be determined after

. extensive investigations, PORS shall ensure that the proposed corrective action established by the Responsible Organization includes an action item for determination of operability. The CAQ coordinator shall be notified in writing of this situation.

9..3.2 If operability is not affected, PORS shall document on a continuation sheet attached to the CAQR the basis for this determination and shall return the CAQR to the site CAQ coordinator. The site CAQ coordinator shall update TROI and send a copy of the CAQR to the Responsible Organization (if other than the site) for integration into the CAQ "package".

9.3.3 Determine reportability under 10 CFR 21, 10 CFR 50.72, or 10 CFR 50.73; mark Part B of the CAQR accordingly, and initiate such reporting in accordance with applicable procedures. If reportable under 10 CFR 50.72, immediately notify plant management. l 9.3.4 If operability is affected, PORS shall:

9.3.4.1 Determine if the CAQ is significant in accordance with paragraph 4.11, and mark Part 8 of the CAQR accordingly.

9.3.4.2 Determine whether other sites may be potentially affected by the CAQ. If so, immediately telecopy them an information copy of the CAQR (unless they have already been notified).

9.3.4.3 Ensure the expeditious preparation, approval, implementation, and verification of any site actions required as a result of the effect on operability and record these actions on Part C, of the CAQR in the "Description of the Proposed Disposition."

9.3.4.4 Provide for, the recording of corrective actions taken or planned, approvals, and verifications on the CAQR.

9.3.4.5 Return the CAQR, via the site CAQ coordinator, to the CAQ coordinator of the Responsible Organization (if other than the plant) for updating TROI.

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9.3.4.6 The CAQ.coordinator shall transmit the CAQR to the Responsible Organization for integrating into the CAQ "package."

10.0 DETERMINATION OF GENERIC IMPLICATIONS 10.1 CAQs requiring a review for potential generic implications shall be reviewed as follows:

10.F 1 CAQRs for which ONE is the Responsible Organization shall receive a generic review by DNE-EA.

10.1.2 Other CAQRs requiring a review for potential generic implications shall be. reviewed by DNSL.

10.2 The above reviews shall be completed and documented within 10 working days of the origination date. Justification for determining that a CAQ is not generic shall be documented on a continuation sheet attached to CAQR.

10.3 CAQRs distributed by DNSL or DNE-EA to potentially affected-organizations for further review and/or action shall have the appropriate assignments entered into and tracked in TROI by the appropriate organization identified in paragraph 10.2.

10.4 Potentially affected organizations shall respond within 30 calendar days of the origination date as to whether they are affected. If affected, the identification number of any resulting CAQR shall be included with the response. If not affected, the response shall include the justification.

11.0 APPROVALS OF PROPOSED CORRECTIVE ACTIONS The Responsible Organization shall obtain any required approvals for proposed remedial corrective actions. These shall be as follows:

11.1 DNE shall approve any "repair" or "accept-as-is" dispositions involving the deviation from engineering specified requirements.

The following dispositions do not require DNE approval.

ll.l.l "Repair" or "accept-as-is" dispositions which will result in a variance from operations or DNC-imposed requirements but which do not violate engineering specified requirements.

11.1.2 Part number changes which do not involve a change in item characteristics.

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11.1.3 A CAQR which specifies a "repair" disposition which is covered by an applicable DNE-approved repair procedure.

11.2 DNE approval on a particular CAQR does not constitute an implicit waiver of a need for DNE approval of subsequent identical CAQRs.

Any waivers must be documented and granted on a case-by-case basis.

11.3 Division of Nuclear Services, Nuclear Fuel Engineering Branch, shall approve any "repair" or "accept-as-is" dispositions involving fuel assemblies or fuel related components.

11.4 The remedial corrective action of CAQs for ASME Section III and Section XI Code related items and activities shall be made available for review by representatives of the Authorized Inspection Agency (Authorized Nuclear Inspector or Authorized Nuclear Inservice Inspector).

11.5 The applicable QA organizations shall approve the proposed corrective action for CAQs which they initiated. In the case of CAQs requiring DNE approval of "accept as is" or "repair" dispositions, QA's approval responsibility is limited to ensuring that DNE has reviewed the proposed disposition.

11.6 For licensed nuclear units and tentatively transferred systems, proposed repair and accept-as-is dispositions for hardware-related-CAQs and all proposed corrective action for significant CAQs require PORC review and plant manager approval.

11.7 The site quality manager shall perform an independent review and approval of the corrective action for site initiated significant CAQs for which DNC or the nuclear site director are the Responsible Organization. This independent review shall include determination that the corrective action appears to,adequately address the root cause.

11.8 DNE shall provide for an independent review and approval of the corrective action for significant CAQs for which DNE is the Responsible Organization. This independent review shall include determination that the corrective action appears to adequately address the root cause.

11.9 DNQA-QSB shall provide for an independent review and approval of the corrective action for significant CAQs assigned to offsite organizations other than DNE. This independent review shall include determination that the corrective action appears to adequately address the root cause.

1 1.10 Corrective action for other CAQs must be approved by the designated manager in the Responsible Organization.

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11.11 Proposed corrective actioas require the documented concurrence on the CAQR of organizations (other than the Responsible Organization) who are required to implement the corrective action.

12 0 ~ VERIFICATION OF CORRECTIVE ACTION COMPLETION 12.1 The Responsible Organization shall indicate the verification action that shall be required to close the CAQR as follows:

12.1.1 The site QA organization, is required to verify proper completion of repair or rework dispositions as required by inspection hold points in applicable work instructions.

12.1.2 DNQA or EA shall perform, within 60 calendar days of the scheduled complete date, verification that all corrective actions were implemented for:

12.1.2.1 All significant CAQs, and 12.1.2.2 All CAQRs which they initiated.

12.1.3 The need for verification for other CAQs shall be determined by the Responsible Organization.

12.2 The remedial corrective action of CAQs for ASME Section III and Section XI Code related items and activities shall be made available for verification of completion by the Representatives of the Authorized Inspection Agency (Authorized Nuclear Inspector or Authorized Nuclear Inservice Inspector).

12.3 Verification activities shall be documented.

13 0~ APPROVAL TO EXTEND COMPLETION DATES When extensions to completion dates are needed, they shall be requested in writing with justification in time to obtain approval before the'ue date. Such requests shall be approved by the responsible nuclear site director, division director, or staff chief. For CAQs initiated by the QA organization, QA concurrence for the proposed due date extension is also required. Documentation of this approval shall be transmitted to the CAQ coordinator to update the due date in TROI.

14.0 REPORTING TO MANAGEMENT 14.1 Management, including the Chairman of NSRB, shall be kept informed on a monthly basis of corrective action status through reports containing information such as:

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14.1.1 The number of CAQRs issued and closed, 14.1.2 The number of open: CAQRs at the end of the reporting period, 14.1.3 The average age of open and closed CAQRs, 14.1.4 The number of CAQRs escalated and the status and description of each escalation, and 1.4.1.5 The number of CAQRs which were not processed in accordance within the timeframes of this procedure.

14.2 Each site quality manager shall prepare a corrective action report for his site, EA shall prepare a report for DNE, and QSB shall prepare reports for other managers including a summary report for the Manager of ONP's office. DNSL may prepare separate reports for management on the status of commitments and of the experience review program.

15.1 'A revision to a CAQR is required when information previously entered on the CAQR is changed. The CAQR number shall remain the same and the revision level shall be advanced by one number. The CAQR need not be revised for minor changes such as correcting misspelled words. Such minor changes shall be handled by drawing a single line through the error, adding the corrected wording, and initialing and dating.

15.2 When legibility cannot be maintained for a revised CAQR, a new CAQR is required.

15.3 Revised information on CAQRs shall receive the same reviews and approvals as the original CAQR, except for extension approvals which are approved in accordance with paragraph 13.0.

15.4 All revised CAQRs shall be routed to the CAQ coordinator for updating TROI.

16.0 TRACKING AND TRENDING OF CA s 16.1 ~Trackin 16.1.1 All actions required to resolve CAQs shall be tracked to completion by the CAQ coordinator. This includes:

16.1.1.1 Remedial corrective actions.

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16.1.1.2 Root cause analysis.

16.1.1.3 Recurrence control actions.

16.1.1.4 Review for potential generic implications.

16.1.1.5 Review by PORS for effect on unit operability.

16.1.1.6 Required responses, evaluations, and approvals to which specific mandatory timeframes are assigned by this procedure.

16; 1.1.7 Scheduled completion dates of. corrective actions.

.16.1.2 All such tracking shall be accomplished by the CAQ coordinator using TROI and in accordance with the TROI User's Guide.

16.1.3 TROI shall identify the RIHS accession number of actions approved on CAQRs.

16.2 ~Trend1n 16.2.1 Corporate and line management shall be kept informed on a monthly basis of CAQ trends utilizing CAQ information prepared and entered into the TROI data base in accordance with the TROI User's Guide. The type of trend information to be sorted and provided to management shall be based on such items as:

16.2.1.1 Organization causing CAQs.

16.2.1.2 CAQs associated with 10 CFR 50 Appendix B criteria such as document control, test control, and corrective action.

16.2.1.3 CAQs associated with a major scope of work such as radiological control, fire protection, and maintenance.

16.2.1.4 Root cause, e.g., CAQs associated with inadequate procedures and personnel errors.

16.2.1.5 Significance (number significant).

16.2.2 Each site quality manager shall prepare a trend report for his site, EA shall prepare a report for ONE, and QSB shall prepare reports for other managers including a summary, report for the manager of ONP's office.

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16.2.3 Site QA, EA, and QSB shall analyze CAQ trend information in their respective area in order to identify any apparent adverse trends. QSB shall further analyze CAQ trend information from a corporate viewpoint in order to identify any apparent adverse trends. Apparent adverse trends shall be investigated to the extent necessary to confirm or deny their existence. If confirmed, a significant CAQR shall be initiated and processed in accordance with this procedure.

1.6.2.4 Managers from other organizations shall analyze CAQ trend information provided by paragraph 16.2.2 and other information contrived from TROI in order to identify adverse trends and initiate significant CAQRs when adverse trends are confirmed.

17.0 INTERORGANIZATIONAL TRANSFER OF CA Rs Generally, CAQs shall be documented and resolved within the organization.

which identified the CAQ with the responsible QA organization serving coordinator;- When it is necessary to transfer responsibility for as'AQ CAQs and related actions between organizations, it shall be accomplished, as follows:

17.1 If the Responsible Organization wants another organization to determine proposed corrective action, such assistance may be requested in any way the Responsible Organization prefers with no formal transfer of responsibility involved. (For example, DNC at wants DNQA-QSB help in developing corrective action for "'ellefonte a programmatic CAQ.)

17.2 If the Responsible Organization wants another organization to implement corrective action, the concurrence of that organization shall be obtained and an appropriate action item charged to that organization in TROI. (For example, Browns Ferry Operations wants the ONP central office to change a corporate standard to resolve an audit deviation.) These organizations (other than the Responsible Organization) that are responsible for, implementing corrective actions as defined in the CAQR, shall coordinate changes to or rescheduling of the corrective action with the Responsible Organization.

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17.3 If the Responsible Organization is different from the CAQR initiating organization, the initiator's CAQ coordinator shall forward the CAQR to the CAQ coordinator for the Responsible Organization. (For example, if DNC at Sequoyah wanted the Power Service Shops to serve as responsible organization for a motor rewinding problem, the CAQR, Part A, would be completed and submitted through Sequoyah site QA organization to DNQA-QSB for handling. DNQA-QSB would assign the CAQR number, enter the CAQR in TROI and send -it to the Power Service Shops for processing.)

Receipt acknowledgment is required for such transfers. The transferring organization shall indicate in the transmittal memo the extent to which it wishes to be involved in approval of proposed corrective actions.

18.0 UPGRADING OF SIGNIFICANCE QA organizations have the authority to upgrade CAQs to "significant" based on frequency of recurrence (paragraph 4.11.1) or on the widespread nature of the problem (paragraph 4.11.2). Such upgrading shall be aa documented with justification on a continuation sheet attached to the CAQR, and shall be*transmitted to the Responsible Organization for action and to the CAQ coordinator for updating TROI.

19.0 STOP NORK

19. 1 Line managers have the responsibility and authority to stop work within their area of responsibility when, due to a CAQ, further

.'a!

Aa processing of affected activities or items may adversely affect the health and safety of the public and employees.

19.2 Assessing and verifying organizations (i.e., DNQA and EA) are responsible and have the authority to pursue necessary corrective action to control further processing, delivery, installation, or use of nonconforming hardware. This also includes authority to terminate an activity through stop work orders until proper evaluation can be made and adequate corrective action can be applied. Such stop work orders shall be issued in writing to the responsible nuclear site director or division director by the Manager of EA, site quality manager, or by the Director of DNQA.

2D.D QA RECORDS 20.1 CAQRs and associated documents shall be handled as lifetime QA records in accordance with NQAM, Part I, Section 2.17.

20.2 RIMS shall be utilized for permanent record storage.

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21.0 IMPLEMENTATION RE UIREMENTS 21.1 This procedure is issued for training and implementation by all affected organizations no later than March 30, 1987.

21.2 The Director of Nuclear Training shall provide the development of training presentations on this 'new process for implementation throughout affected organizations. This training shall begin with SQN and onsite and offsite organizations which support SQN approximately January 5, 1987, and shall be completed for all organizations prior to procedure implementation (March 30, 1987).

21.3 TVA managers shall be responsible for assuring that affected personnel complete the training for this new process within the required timeframe.

21.4 The Director of DNQA;shall coordinate the implementation of this procedure in support of SQN startup and use by other organizations. DNQA-QSB shall provide, as needed, part-time representatives to organizations during this period to assist in preparing implementing instructions, resolving problems, evaluating training, and drafting revisions to the NQAM.

22.0 ATTACHMENTS 22.1 Attachment 1 - CAQR 22.2 Attachment 2 Instructions for Preparing CAQRs 22.3 Attachment 3 CAQR Numbering Scheme 22.4 Attachment 4 Mandatory Timeframes for the Corrective Action Process 22.5 Attachment 5 Guidelines for Potential Operability Determinations General Revision 0477k-8612l9 TVA 7842C (ONP 3 85)

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ATTACHMENT 1 Page 1 of 3 SHEET 1 QF 3 CA R (I) CAQR NO.

RE V. (2)

RIMS ACCESSION NUMBER~ (0)

PART A DESCRIPTION OF THE CAO PLANT/PROJECT (IAI UNIT l2AI VENDOR SYSTEM ( AI VENDOR'S ADDRESS (6A)

COMPONENT (4A) CONTRACT NO.

ASMET YESQ NOQ (SA) REFERENCES REOUIREMENT VIOLATED (10AI SOURCE OF REOUIREMENT VIO(.ATED (1)A)

DESCRIPTION OF CONDITION (12A) ct RECOMMENDED CORRECTIVE ACTION (OPTIONAL) (IBA) flK hf'AOR PATE (IOA) TEL. NO. (ISA)

INITIATED BY INITIATOR'S ORGANIZATION OATEITIME CAO DISCOVERED (16 A I MANAGEMENT REVIEWER (ITAI DATE (17AI T(T(.E (I 1 A I RESPONSISLE ORGANIZATION (16AI AFFECT ON OPERABIUTY (19A) are 10 2Q 00 COMMONQ SON 1Q 2Q COMMONQ OPERABILITY OF NUCLEAR UNIT IS 0 IS NOTQAFFECTEO.

IF 'YES'. INDICATE AFFECTED UNITS. WBN IQ 2Q COMMON Q BLN 10 20 COMMONQ CAO COORDINATOR DATE RECEIVED (20A)

PROCESSED BY (21A) DATE (21A)

TRENDING CODES (22AI D I STR I 8 UTI ON PLANT ILLA U> LLJ IT>LLJ ACT>T>TT I>I LLLJ >I> LLIJ ORGANIZ ATIONIMGR BF B SOW

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<<OCTOVAT TIOLATTO RIMS 0 NRC RES UANVf*CTVATA ORIGINATOR OTHER STOPS>nON ONt ICMAUINT LLJ RIMS ACCESSION NUMBER (2)

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ATTACHMENT 1 (Cont'd)

Page 2 of 3 SHEET 2 OF 3, CAQR:

RIMS ACCESSION NUMBER PART B

~ (3)

EVALUATION (1) CAQR NO.

RE V.

AFFECT ON OPERABIL(TY (18)

DOES THIS CAO IMPACT UHIT OPERABILITY7 YES Q NO Q IF 'TES'OTIFIEO FET. IIOII. ANOIOII OFERATIONS AT ON TIN DATE SIGNIFICANCEIREPORTABILITY SIGNIFICANT CAO REPORTABILITY REVIEWED BY DATE PORS YES 0 NO 0 YESO NOQ (28) 4ESPONSIBLE ORGANIZATION YES 0 NO 0 YESO HO 0 (38)

IF RfPORTABILITY BLOCK IS CHECKED 'YES'N ITEM 38, GIVE h COPY TO THE ORGANIZATION RESPONSIBLE FOR DETERMININQ Rf PORTABILITY IMMEDIATELY: SENT TO (~8) DATE t~>~ TIME GENERIC REVIEW A REVIEW FOR POTENTIAL GENERIC IMPLICATIONS IS 0 IS NOT 0 REQUIRED. EVAt.UATED BY lALWAYS REQUIRED FOR SIGNIFICANT CAO'8) NRC VIOLATIONS, AUDIT FINDINGS, CAO'8 AFFECTING OPERABILITYN) (78) (78)

COPY OF CAOR SENT TO ON FOR NAME PATE PERFORMANCE OF A GENERIC REVIEW. (78)

ROOT CAUSE ANALYSIS/RECURRENCE CONTROL 4 AHIZA IOH ROOT CAUSE AHALYS)S RECUIREDT YES P NO P t88) APPROVED BY RECURRENCE CONTROL REQUIRED'7 YESO NO 0 (68) (88) (68) lALWAYS RfOUIRED FOR SIGNIFICANT CAO'S, NRC VIOLATIOHS, AUDIT FINDINGS, CAO'S NAME DATE AFFECTING OPERABILITY.) (68)

IF fITHER ARE RECUIRED, FILL OUT PART 0 OF THIS CAOR.

PART C REMEDIAL CORRECTIVE ACTION DISPOSITION METHOD t2c) DESCRIPTION OF PROPOSED DISPOSITION

~

RETURN TO VENDOR Uc)

REWORK REPA)4 ACCEPT AS IS SCRAP OTHER (DESC4IBE) 0 OTHER INFORMATION NO.TAOS FLAOEO REPAIR/ WORK P U NO.

WAS ENGINEERIHQ REQM'7 Vgl ATED YES Ho t5C) ORGAN 4ESPOHSIBLE FOR C/A (7CI E:P ITIOH YES HO )

SCHf DULED COMPLETION DATE (6C)

VERIFICATION RETEST Q REINSPECT Q AUDITOR FOLLOW UP Q OA REVIEW Q SUPV. REVIEW Q REQUIREMENTS OTHER (DESCRIBE) 0 APPROVALS NAME DATE NAMF APPROVAL PROPOSED BY (10 C) (10 C) (15C) (15C) (18C) (15C)

SUPV. APPROVAL (11C) (11C) PORC REVIEW DATE DNEIDNS APPROVAL (12CI (12 C) U6C) (18CI AIA ACCEPTANCE (13 C) (13 C) PLANT MANAGER DATE OA APPROVAL (1lcI (1iC) (3)

OTHE4 APPROVAL (15CI AIMS ACCESSION HO.

VERFICATION NAME DATE APPROVED CORRECTIVE ACTION HAS BEEN COMPLETED AND IS READY FOR VERIFICATION (17 C)

VERIFICATION COMPLETE (16 C) (16 C)

ALL TAGS REMOVED (10C) (IQC)

CAOR SHEET 2 CLOSED (20C) 120C)

AIMS ACCESSION NUMBER (3)

General Revision 0477k-&61219 TVA 7842C (ONP 3 85)

Part I,

Title:

CORRECTIVE ACTION Sec. 2.16 2 No. Rev.

ATTACHNENT 1 (Cont'd)

Page 3 of 3 SHEET 3 OF 3 QN

~ CA R.. .(I) CAQR NO.

REV. (2)

AIMS ACCESSION NUMBER (3)

PART D ROOT CAUSE ANALYSIS/RECURRENCE CONTROL ROOT CAUSE OF THE CAQ . (10) ..

PROPOSED RECURRENCE CONTROL ACTIONS (20)

ORGANIZATION RESPONSIBLE FOR AECUAAENCE CONTROL SCHEDULED COMPLETION DATE ( 0 V ERIF ICATION SUPERVISOR REVIEW OC INSPECTION TEST AUDITOR FOI4OWUP OA AEVIE REOUIREMENTS OTHER IOESCAIBE) 4D APPROVALS NAME DATE NAME DATE A VAL PROPOSEO BY (90) (100) (100)

SUPV. APPROVAL PORC AEVIEW (GE (10D)

OATS DNE/DNS APPROVAL (70) (70) (100)

PLANT MANAGER QA APPROVAL (3)

OTHER APPROVAL (9D) (90) AIMS ACCESSION NO VERIFICATION OF RECURRENCE CONTROL NAME DATE APPROVED RECURRENCE CONTROL COMPLETE READY FOR VERIFICATION (110) (110)

VER IF ICATION (120) (120)

CAQA SHEET 3 CLOSED (130) (130)

RIMS ACCESSION NUMBER (3)

Genera1 Revision 0477k-861219 TVA 7242C (ONP.3 85)

Part I, CORRECTIVE ACTION Sec. 2.16 2

Title:

No. Rev.

ATTACHMENT 2 Page 1 of 10 INSTRUCTIONS FOR PREPARING CA Rs

l. The use of the CAQR is mandatory for all ONP organizations and alterations to this form are not permissible.

2. Since the CAQR is used to document many types of CAQs, some information will not be applicable and shall be marked "NA."

'3. Each organization may develop supplemental or continuation sheets as they feel necessary to include any division or site-unique information.

4. Sheet 1 is used to record the information necessary to complete sheets 2 and 3. Sheet 1 is re uired to be attached to both sheet 2 and sheet 3 whenever sheet 2 and sheet 3 are transmitted or closed since it contains the descri tion of the CA . Sheets 2 and 3 may be processed, tracked, and resolved as separate issues. Closure of either sheet 2 or sheet 3 may occur independently of each other. The procedure addresses the information on sheets 2 and 3 separately to emphasize their parallel and independent processing. In many cases, the same organization will be responsible for supplying the information on both sheets 1, 2, and 3. In this case, sheet 2 and 3 ~ma be distributed and processed together and only handled separately when either sheet 2 or sheet 3 is ready to be closed.

5. Part A provides information pertinent to completing the information required for sheet 2 and sheet 3. Part 8, Sheet 2, contains the decision blocks for indicating operability, significance, reportability, generic implications, root cause analysis, and recurrence control. If these blocks are checked "no," then Sheet 3, Part D, is not applicable and shall be disregarded, and only Sheet 1, Part A, and Sheet 2, Parts B and C, shall be needed to document and correct the identified CAQ. Part C, Sheet 2, is employed to document the remedial corrective action, and it includes the spaces to record the required reviews, approvals, and verifications. Part D, Sheet 3, is used to document root cause analysis and recurrence control, and it contains the spaces to record the required reviews, approvals, and verifications.

General Revision 0477k-861219 TVA 7842C (ONP.3 85)

Part I,

Title:

CORRECTIVE ACTION Sec. 2.16 2 No. Rev.

ATTACHMENT 2 (Cont'd)

Page 2 of 10 NUMBER COMPLETED BY INSTRUCTIONS CAQ Coordinator Enter the appropriate CAQR number. Each sheet of

.the CAQR shall have the same number.

CAQ Coordinator Enter appropriate revision level Each sheet of or responsible the CAQR may have a different revision level.

organization

3. CAQ Coordinator Enter the RIMS Accession Number as required by the procedure.

PART A lA Initiator Identify location of CAQ by plant/project.

2A Initiator Identify applicable unit number.

3A Initiator Identify applicable system.

4A Ini ti ator Identify applicable component.

5A Initiator Identify name of vendor applicable for hardware and services.

6A Ini ti ator Identify address of vendor applicable only if 5A is completed.

7A Initiator Identify applicable contract number applicable for hardware and services.

8A Initiator Identify with a "Yes" response when ASME Section III hardware is involved.

9A Initiator Include, as appropriate, drawing numbers, specifications, report numbers, procedure numbers, or any other document providing information pertinent to the CAQ. Also, include violation number if CAQR is initiated or any other unique number NRC as a result of another CAQR or document internal or external to TVA.

10A Initiator Identify the requirement that was violated or not implemented.

General Revision 0477IR-861219 VA 7842C (ONP.3 85)

Part I, CORRECTIVE ACTION Sec. 2.16 2

Title:

No. Rev.

ATTACHMENT 2 (Cont'd)

Page 3 of 10 NUMBER COMPLETED BY INSTRUCTIONS PART A llA Initiator Specify the source of the requirement. Additional information to be added to this space includes any identifying numbers of reports or a generic CAQR number from which this CAQ was written.

12A Ini ti ator Describe the CAQ. The description of the CAQ may include the location, type of condition, quantity of items, and any special identification numbers such as heat, lot, mark, model, serial, drawing, or system. Attach applicable figures, tables, or other supporting information. Information shall be described in sufficient detail to determine the precise scope of impact on the plant.

Information, if known, such as items affected, failure modes, and known consequences, shall be provided.

13A Initiator Initiator may recommend corrective action.

14A Initiator Sign and date and specify telephone extension.

15A Initiator Identifies his or her organization.

16A Initiator Identify the time and date that the CAQ was discovered.

17A Management Sign and date and specify title. (For CAQs Reviewer or identified by the auditing organization, Higher Level the lead auditor is the management reviewer.)

Manager (if CAQ is escalated) 18A Management Identify organization responsible for responding Reviewer to CAQ. The information should include at least the branch level 19A Management Identify, based on criteria in attachment 5, if Reviewer operatility at a nuclear unit could potentially be affected, and if "yes" marks spaces indicating potentially affected units.

General Revision 0477k-861219 TVA 7842C (ONP 3 85)

Part I, CORRECTIVE ACTION Sec. 2.16 2

Title:

No.

N Rev.

ATTACHMENT 2 (Cont'd)

Page 4 of 10 NUMBER COMPLETED BY INSTRUCTIONS PART A 20A CAQ Coordinator. . Identify date CAQR is received.

21A CAQ Coordinator Identify person distributing CAQR and date distributed.,

22A CAQ Coordinator Identify the appropriate trend codes in accordance with the TROI Users Guide.

23A CAQ Coordinator Checks appropriate block for distribution.

or Responsible Organization General Revision 0477k-861219 TVA 7842C (ONP 3 85)

Part I,

Title:

CORRECTIVE ACTION Sec. 2.16 2

~

No. Rev.

ATTACHMENT 2 (Cont'd)

Page 5 of 10 NUMBER COMPLETED" BY INSTRUCTIONS PART 8 18 Plant Operations Identify whether operabi 1 i ty is affected.

Review Staff, If "yes" specify the date and time of (PORS) operations notification.

28 PORS If 18 is marked "yes," PORS identifies whether the CAQ is significant in accordance with the criteria specified in paragraph 4.11, whether the CAQ is reportable, and sign and date.

38 Responsible Identify whether the CAQ is significant in Organization accordance with the criteria specified in paragraph 4.11, whether the CAQ is potentially reportable, and sign and date.

48 Responsible If response to 38 is "yes," identify the Organization organization to whom the CAQR was sent. Also identify the time and date.

58 Responsible Identify whether a review for generic implications Organization is required. If response is "yes," indicate to whom the CAQR is sent to perform the generic review.

68 Responsible Identify whether root cause analysis or recurrence Organization control is required.

78 Responsible Sign and date, and identify'rganization of Organization individual performing 58 and 68.

88 Supervisor, Supervisor of individual signing 78, sign and Responsible date, and identify title.

Organization General Revision 4Q 0477k-861219 TVA iac2C (ONP 3 85)

Part I,

Title:

CORRECTIVE ACTION N Sec. 2. 16 Rev.

ATTACHMENT 2 Page 6. of 10 NUMBER COMPLETED BY INSTRUCTIONS PART C 1C Responsible Describe how the correction shall be Organization and accomplished to resolve the CAQ. As PORS appropriate, include a full discussion of the design changes made, revision made to existing specifications, training, issuance of new specifications, and other similar information. (If 1B is marked "yes," PORS also completes the information.)

2C Responsible Indicate the appropriate disposition method Organization applicable only for hardware. Nhen the disposition "accept-as-is" is marked, the justification for this marking shall be entered. The justification shall include an evaluation to assure that the safety-related function of the item has not been impaired.

If DNE is contacted for prior oral approval, enter the name of the DNE contact and the date. For "accept-as-is" disposit'ion for an DNE specified requirement, the CAQR is referred to DNE for approval. For "accept-as-is" disposition involving fuel assemblies or fuel-related components, the CAQR is referred to Division of Nuclear Services, Nuclear Fuel Engineering Branch for approval.

3C Responsible Specify the number of Nonconformance Organization Tags required applicable only for hardware.

4C Responsible Specify the procedure or acceptanc'e criteria Organization used to rework or repair of the hardware. For a "repair" disposition involving a DNE or Division of Nuclear Services, Nuclear Fuel Engineering Branch, specified requirement where an approved repair procedure does not exist; the CAQR is referred for approval to DNE or Division of Nuclear Services, Nuclear Fuel Engineering Branch, for fuel assemblies or fuel related components.

5C Responsible If the CAQ is a result of a specified Organization DNE or DNS requirement that was violated, then mark ";he space "yes."

General Revision 0477k-861219 vA ic42C (ONP 3 85)

Part I,

Title:

CORRECTIVE ACTION N

Sec. 2.16 2 Rev.

ATTACHMENT 2 (Cont'd)

Page 7 of 10 NUMBER COMPLETED BY INSTRUCTIONS PART C 6C Responsible -If the CAQ occurred as a result of a lack of Organization a specified DNE or Division of Nuclear Services, Nuclear Fuel Engineering Branch, requirement, or the corrective action cannot be determined, then mark the space "yes."

7C Responsible Identify the organization responsible for Organization performing the remedial corrective action.

8C Responsible Identify the scheduled completion date of the Organization remedial corrective action.

9C Responsible Identify the appropriate method of Organization verification. QA review is required for DNQA and EA initiated CAQRs and all significant CAQs.

10C Responsible Individual proposing the remedial Organization corrective action signs and dates.

llC Supervisor of Sign and date indicating approval of Responsible remedial corrective action.

Individual 12C DNE or Division Sign and date to indicate eithel approval of Nuclear with the proposed remedial corrective action Services, or approval of remedial corrective action Nuclear Fuel furnished by DNE or Division of Nuclear Engineering Services, Nuclear Fuel Engineering Branch, Branch as appropriate.

13C Authorized Sign and date to indicate acceptance for Inspection ASME Section III or Section XI Code-related Agency (ANI items and activities.

or ANII) 14C DNQA or EA Sign and date indicating approval for all CAQs for which EA or DNQA initiates all CAQs resulting from QA audits, and all significant CAQs.

General Revision 0477k-861219 TVA 7842C (QNP 3 85)

Part I,

Title:

CORRECTIVE ACTION Sec. 2.16 2 No. Rev.

ATTACHMENT 2 (Cont'd)

Page 8 of 10 NUMBER COMPLETED BY INSTRUCTIONS PART C 15C As Appl i cabl e This space provides a place for additional approvals as deemed necessary 16C PORC and Plant For licensed nuclear units and tentatively Manager transferred systems, repair and accept-as-is dispositions for hardware-related CAQs, and remedial corrective action for significant CAQs, PORC signs and dates to indicate that they reviewed the disposition and/or remedial corrective action and Plant Manager signs and dates to indicate approval of the disposition and/or remedial corrective action.

17C Manager Sign and date to indicate that remedial Responsible for corrective action is completed and ready for Preforming verification.

Corrective Action 18C Organization Sign and date to indicate that Responsible for verification is complete.

Verification Note: Nhen more than one organization is required to verify the remedial corrective action, the additional signatures and dates shall be recorded on a continuation sheet attached to the CAQR. The continuation sheet shall contain what portion of the remedial corrective action is being verified complete.

19C Responsible Sign and date to indicate that all Organization Nonconformance Tags have been removed.

20C Supervisor, Sign and date closing CAQR, Sheet 2.

CAQ Coordinator General Revision 0477k-861219 TVA 7S>>'2C (ONP 3 85)

Part I,

Title:

CORRECTIVE ACTION Sec. 2.16 2

< Rev.

ATTACHMENT 2 (Cont'd)

Page 9wf 10 NUMBER COMPLETED BY INSTRUCTIONS PART 0 1D Responsible Identify the root cause of the CAQ.

Organization Responsible Identify the recurrence control of the CAQ.

Organization 3D Responsible Identify organization responsible fo' Organization performing recurrence control and identify scheduled completion date.

4D Responsible Identify the appropriate method of Organization verification. QA review is required for DNQA and EA initiated CAQRs and all significant CAQs.

5D Responsible Individual responsible for providing the Organization information in 1D, 2D, and 3D sign and date.

60 Supervisor, Review and approve the information in 10, Responsible 20, and 30.

Organization 7D DNE or Division Review and approve the information in 10, of Nuclear 2D, and 3D affecting engineering, if Services, Nuclear applicable, or furnish the information for Fuel Engineering for 10, 20, or 30 if requested.

Branch P 8D DNQA or EA Concur with the information in 2D and 3D for CAQs originated as a result of audits, surveillances, and inspections.

9D As Applicable This space provides a place for additional approvals as deemed necessary.

General Revision 44 0477k-861219 TVA 78~2C (ONP 3 85)

Part I, CORRECTIVE ACTION Sec. 2.16 2

Title:

No. Rev.

ATTACHMENT 2 (Cont'd)

Page 10"of 10 NUMBER COMPLETED BY INSTRUCTIONS PART D 10D PORC and Plant For licensed units and tentatively Manager -transferred systems, PORC signs and dates to indicate that for significant CAQs they have reviewed the recurrence control action and the Plant Manager signs and dates to indicate approval of the recurrence control action.

11D Manager Respons- Sign and date indicating completion of ible for Perform- recurrence control action and that the ing Recurrence action is ready for verification.

Control 12D Organization- Sign and date to indicate that verification Responsible is complete.

for Verification NOTE: Nhen more than one organization is required to verify recurrence control, the additional signatures and dates shall be recorded on a continuation sheet attached to the CAQR. The con-tinuation sheet shall contain what portion of the recurrence control that is being verified complete.

13D Supervisor, Sign and date closing CAQR, Sheet 3.

CAQ Coordinator General Revision 0477k-861219 TVA 7842C (ONP 3 85)

art I, CORRECTIVE ACTION Sec. 2.16 2

Title:

No. Rev.

Attachment 3 3?age 1 of 2 CA R NUMBERING SCHEME X X X X X X X X X X X For Explanation I IV See Below Designates the plant when applicable BF Browns Ferry SQ Sequoyah NB Natts Bar BL Bellefonte CH Chattanooga KX Knoxville JA Joint SS Support Service II. Designates the CAQ Origin and/or CAQ Coordinator Code Descri tion of Ori in CA Coordinator DNQA Audit CAQs NQA 8( EB DNE-EA Audit CAQs DNE-EA Other DNE-Knoxvi le1 CAQs Site QA Surveillance CAQs Site QA Other Site CAQS INPO Audit Items NRC Deviations and Applicable CAQ Violations Coordinator All other CAQs Central Office CAQs OSB General Revision 0477I4-861219 TVA 7842C (ONP 3 85)

Part I,

Title:

CORRECTIVE ACTION >>Sec. 2.16 Rev.

2 Attachment 3 Page 2 of 2 III. Designates the Calendar. Year 86 1986 January to December 87 1987 January to December 88 1988 January to December 89 1989 January to December IV. Identifies CAQ numbers assigned by each CAQ Coordinator 0001 through 9999. These 4 numbers may represent audit or surveillance numbers but the combination of I, II, III, IV, and V will always represent a unique CAQ number.

V. Identifies an optional field which designates the sequential number of CAQs identified during one audit, surveillance, inspection, etc., e.g.,

BFA860001D01 through BFA860001D06 identifies 6 CAQs identified during Browns Ferry audit 0001.

General Revision 0477k-8612l9 TVA 78<<'2C lONP 3 85)

Co A

0Z A CD

'D CD C)

C)

K7 X7 CD HAHOATORY TIMEFRAHES FOR THE CCRRECTIVE ACTIOH PROCESS n

d 0 PROCEDURE TIRE tlNITS FOR m

PARAGRAPH ACT I OH EACH ACTION IH DAYS n

1. 1.6 Person (hereinafter called "Initiator" of CA()R) discovers a CA(1 I~

D C

Prcnptly 1.1.6.2 Initiator records CAQ and date of discovery on 1.1.6.3 the CARR, and signs the CA()R 3 (Working) 1.2.2.3 Itznagetnent revieuer arqletes revieu of CA9 1.2.5 including escalation, signs CA()R (origination date) and foruards to CARR Coordinator Ttp 3 (Working)

CD

~I C) 1 (Q>rking)

I CX) t.s.s est eee d'estd dist ie tes ttd organization for action Cetic te the eseeesieie IO (Workint))

0 m I 30 (Calendar) 1.4. l Responsible organization determines if cd is significant, 30 (Calendar) cchether a review for generic irplications is needed, and uhether root cause analyses and recurrence control are required.

IO. I CAOs shall be revieiced for potential generic Icplications by DHSt or OHE-EA.

l0.4 Potentially affected organizations shall revieu CA()Rs for generic l vp1 l catl ons ~

zO TZ 1.4.2 Responsible Organization determines recnedial corrective action CD and, if required, root cause and recurrence control, and scheduled A ccrpletion date for rccnedial corrective action and recurrence ~ rr control, if required.

C), ~ '

0400k CZI I

CO

Part I,

Title:

CORRECTIVE ACTION N

Sec. 2.16 2 Rev.

ATTACHMENT 5 Page 1- of 1 GUIDELINES FOR POTENTIAL OPERABILITY DETERMINATIONS Operable Operability has previously been defined in paragraph 4.5 as:

Operable Operability A system, subsystem, train, component, or device shall be operable or have operability when it is capable of performing its specified function. Implicit in this definition shall be the assumption that all necessary attendant instrumentation, controls, normal and emergency electrical power sources, cooling seal water, lubrication, or other auxiliary equipment that are required for the system, subsystem, train, component, or device to perform its function are also capable of performing their related support function.

Generally, to determine potential effect on operability is to ascertain if the condition described in the CAQ affects the operability of a system or component required by the technical specifications such that it cannot perform its safety-related function during a design basi s event. Note that this guideline requires that the deviation or deficiency is within the licensing basis of the plant and does not differ from applicable regulatory requirements committed to by TVA for the particular nuclear in question. 'ite This guideline also requires that the component or system be confirmed (by calculations, evaluations, vendor letters, etc.) not to be capable of performing its safety-related function required by the technical specification and not its design-related function.

Confirmed degradation, damage, failure, malfunction, or loss of plant equipment performing functions important to safety are conditions which may potentially affect unit operability.

Failure to follow or create standards to comply with 10 CFR 50 Appendix B or TVA criteria is not in itself a condition potentially affecting unit operability.

General Revision 49 0477k.-861219 A 7542c (ONP 3 85)