ML20062M757

Intervenor Exhibit I-MFP-65,consisting of Mgt Summary, Rev 00,NCR DC0-93-MM-N002, Control of M&Te,

ML20062M757
Person / Time
Site:	Diablo Canyon
Issue date:	08/19/1993
From:	AFFILIATION NOT ASSIGNED
To:
References
OLA-2-I-MFP-065, OLA-2-I-MFP-65, NUDOCS 9401110185
Download: ML20062M757 (20)

Text

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- 2 7,83' 3 3 3 OL./} - 2., k W 3 W'$'t t- w=P- di s A NCR DCO-93-MM-N002 Rev. 00 8//9/93

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DRAFT: . April 12, 1993 l i

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MANAGEMENT

SUMMARY

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During 1RS, from September 2, 1992 to November 20, 1992, Quality Assurance Audit 92038I, identified several instances where  ;

Mechanical Maintenance failed to document in the PIMS usage database that M&TE items were issued or used on certain Work Orders as required by procedure. This appears to be a repeat of one of the problems identified under NCR DCO-90-MM-N089. In 1991, PG&E received a Notice of Violation due to failure by -

Mechanical Maintenance to properly use, maintain, and-document M&TE items. Among the issues discussed by the NRC was QE l Q007878. This finding was issued by QA under audit 90812T to address Mechanical Maintenance failure to document usage of M&TE on Work Orders.

This draft, dated April 12, 1993, provides the meeting minutes from the April 12, 1993 TRG meeting. The revised text below' also includes comments from the TRG membets.-This TRG will not reconvene unless some difficulties are encountered in the investigative actions presently open.

j This NCR will be signed by the TRG members'and-sent to the PSRC.  ;

NCR to PSRC ECD: April 26, 1993. .

NCR closure ECD: August 16,.1993.

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s NCR DCO-93-MM-N002 Rev. 00 DRAFT: April 12, 1993 NCR DCO-93-MM-N002 CONTROL OF M&TE I. Plant Conditions Plant conditions are not applicable to this event.

II. Description of Event A. Summary:

During Quality Assurance Audit 92038I, conducted during 1RS, several errors were noted where Mechanical Maintenance had not documented in the PIMS usage database or on the summary page of the Work Order all the M&TE used for a number of Work Orders which is cortrary to the requirements of Administrative Procedures AP D-450 and AP C-40S3.

B.

Background:

Contrary to Administrative Procedure AP D-450,

" Calibration and Control of M&TE" certain M&TE was issued and used for applications other than those recorded in the PIMS usage database.

Contrary to AP C-40S3 "Use of PIMS Work Order i$odule" and various other maintenance procedures, the identification of certain M&TE used.was not recorded on the hard copy of the associated Work Order.

C. Event

Description:

I

, 1 During 1R5, from September 2, 1992 to November 20, '

1992, Quality Assurance Audit 92038I, identified I several instances where Mechanical Maintenance failed j to document usage of M&TE in the PIMS usage database and/or on Work Orders as required by Administrative l Procedure AP D-450 " Calibration and Control of M&TE" l and AP C-40S3 "Use of Pims Work Order Module". In '

several separate Work Orders such as R0098912, C0104163 and R0098920, the M&TE items were recorded either in the Work Order or on associated data sheets. However, the PIMS usage database did not reflect that the items t

were issued and used for those particular Work Orders.

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NCR DCO-93-MM-N002 Rev. 00 t

DRAFT:: April 12, 1993 Without this information in the usage database, the '

ability to evaluate an out-of-tolerance. condition on the end use is questionable, since the database'does not match the Work Orders.where the M&TE was used.

In'other examples, Work Orders R0098912, C0104'163 ' and :

C0101726, the PIMS usage databaseEindicated M&TE items had been issued.and.used for these Work Orders yet.the  ;

identification number for the piece of. equipment had-not been recorded in the Work Order, nor on-the data sheets. This appears to be a repeat of.one of the problems identified under NCR DCO-90-MM-N089. In 1991,  :

PG&E received a Notice of Violation due to failure by -!

Mechanical Maintenance to properly use, maintain,fand. -;

document M&TE. Among the issues discussed by the NRC was QE Q007878. This finding was. issued by QA under.

audit 90812T to address Mechanical Maintenance' failure. ,

to document usage of M&TE on Work Orders.

The following table lists the M&TE identified in the ,

work order, but not listed in'PIMS (ref. QE Q0010250)..

WO# METE ID 1ESCRIPTION R0098912 432.37.12 TORQUE WRENCH-  :

" 960.20.14 DIAL CALIPER e C0104163 *442.15.09' TORQUE WRENCH

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• NOTE: CALIBRATION-DUE DATE INACCURATELY RECORDED. ]

AS 7/24/92. THE ACTUAL CALIBRATION DUE DATE j IN PIMSLIS'1/20/93. l l

R0098920' '965.18.03 DIALLINDICATOR

• 965.50.01- DIAL INDICATOR.

• NOTE: CALIBRATION DUE DATE INACCURATELY RECORDED AS 2/25/92. THE. ACTUAL CALIBRATION DUE DATE IN PIMS IS 2/25/93.

The following M&TE was identified'in PIMS!as being used for the indicated Work Orders but was not" documented in the Work Order.

WO# M&TE ID DESCRIPTTON R0098912 965.18.02  : DIAL INDICATOR R0098912- 442.22.08 TORQUE WRENCH 93NCRWP\93MMN002.PGD Page 3 of 17

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R0098912 965.10.29 -DIALJINDICATOR- I R0098912 M-M-58 ' CRANK SHAFT DISTORTION GAUGE R0098912 965.15.10- DIAL INDICATOR R0098912 M-M-1065 . DIAL INDICATOR ]

C0104163 M-M-433 TORQUE WRENCH-C0101726' 441.91.12 TORQOMETER L. Inoperable Structures, componenta, or Systems.that Contributed to the-Event:

None.

E. Dates and Approximate Times for Major Occurrences:

September 2, 1992 through November 20, 1992: Event.date. During QA audit 92038I,.several failures"to document usage of M&TE were identified.

F. Other Systems or Secondary Functions-Affected:

None.

G. Method of Discovery:

Quality Assurance Audit 920381.

H. Operator Actions: 1 N/A.

+, .

I. Safety System Responses:

N/A III. Cause of the Event A. Immediate=Cause:'

Failure to properly follow procedures regarding the recording of M&TE usage'in_WO's, .and to update the PIMS usage database with the Work Order number indicating-where the equipment was used.

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B. Determination of Cause:

See Root Cause Anal'ysis attached.

C. Root Cause:

Personnel error. -Inattention to details in'that plant personnel failed to comply with applicable Administrative Procedures by ucir.g:M&TE-for applications in other than those listed in'PIMS'and by '

failing to record the identification of certain M&TE use, in the hard copy of the associated Work order.  !

D. Contributory Causes:

1. Ineffective management commitment to the M&TE proc _am.

2. Personnel not held accountable.

IV. Analysis of the Event '

A. Safety Analysis: I A review of the quality findings identified in QA Audit 92038I, raised concerns that Out of Tolerance (OOT). i M&TE usage may not have been evaluated.for impact on, plant installed safety-related equipment.because it was l not listed in PIMS. These conceu.s,were identified and i evaluated.

The following are the results.of M&TE thSt'was evaluated: *

1. 432.37.12 A0282334 10'/24/92 identifies torque wrench OOT10 20.lbft. Acceptable pre and post verifications performed on 9/17/92 and_10/2/92 0 60 lbft.

2. 960.20.14 No OOT

3. 442.15.09 No OOT

4. 965.18.03 No OOT

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6. 442.36.03 A0195925 06/22/90.

A0216725.02/04/91. ,

both AR's are not near use-time frame.

7. M-M-3 08 - A0281294 ;10/17/92. LCatastrophic. failure,-

(OD_ Micrometer l dropped).- No previous Out-of tolerance l conditions, micrometer. ,

considered good until known, time of i failure. (Micrometer dropped after use).:

8. 965.15.10 No OOT

9. 965.40.01 No OOT

10. M-M-160 . No OOT '

l '_ . 432.65.02 No OOT 4

12. 965.50.01 No OOT i Based on the above evaluations, no. safety-related work has been.affected by_out-of-tolerance equipment.- Therefore, no safety issues.were identified and the health and safetyJof'the public were not adversely affected by this event.

B. Reportability:

1. Reviewed under QAP-15.B and determinedEthat this.

event has occurred at a frequency whichLindicates:

that past action to. prevent: recurrence was i ineffective and additinaal management attcntion is l necessary.

2. Reviewed under 10:CFR 50.72-and 10 CFR.50.73 per.

i NUREG 1022 and determined not toEbe reportable.

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This problem does not require a 10 CFR 21 report.

4. This problem does not require reporting via an INPO Nuclear-Network entry.

5.

Reviewed under 10 CFR 50.9 and determined not to be reportable,_since this event does not have a significant implication for public health and safety or common defense and: security.

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6. Reviewed under the criteria of AP C-29 requiring the issue and approval of an OE and determined that an OE is not required.

V. Corrective Actions A. Immediate Corrective Actions:

1. Correct discrepancies fcund in Work Orders and the M&TE database for the Mechanical, Electrical and I&C audits.

RESPONSIBILITY: J. Mellinger DEPARTMENT: Work planning center Tracking AR: A0290683, AL # 16 STATUS: COMPLETE B. Investigative Actions:

1. Work with HPES to evaluate the M&TE issue process for human engineering contributing causes.

RESPONSIBILITY: J. MacIntyre i DEPARTMENT: Materials Tracking AR: A0290683, AE # 01 STATUS: . COMPLETE.

2. Evaluate M&TE which has been identified as not originally entered.in the PIMS database to determine if any out-of-tolerance existed and determine its impact on the equipment operability.  ;

RESPONSIBI;;TV- J. MacIntyre DEPARTMENT: Materials-Tracking AR: A0290683, AE # 02 c t

STATUS: COMPLETE.

3. Take a random sample of 12 outage work orders and 12 non-outage work orders,-to determine if the M&TE was accurately documented on the work order and in PIMS.

RESPONSIBILITY: N. Gaudiuso DEPARTMENT: NECS - GC Tracking AR: A0290683, AE # 03 STATUS: COMPLETE.

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4. Take a random sample of 12 outage work orders and )

12 non-outage work orders, to determine if-the M&TE was accurately documented on the work order and in PIMS. I RESPONSIBILITY: J. Nystrom DEPARTMENT: Work Planing Center Tracking AR: A0290683, AE'/ 04 STATUS: COMPLETE.

5. Take a random sample of 12 outage work orders and 12 non-outage work orders, to determine if the M&TE l was accurately documented on the work order and in  ;

PIMS.  !

RESPONSIBILITY: W. Unks DEPARTMENT: Materials Tracking AR: A0290683, AE # 05 STATUS: COMPLETE. I I

6. Determine how the corrective action to develop a I lesson plan for recurrent training in accordance with NCR DCO-90-MM-N089.has been implemented.

RESPONSIBILITY: T. Leinberger DEPARTMENT: Training Tracking AR: A0290683, AE # 06 STATUS: COMPLETE. .

7. Determine the feasibility of having the mechanical  !

maintenance foreman verify the accuracy of the M&TE i usage database in PIMS during the work order closure review. <-

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RESPONSIBILITY: W. Jacks e i

DEPARTMENT: Mechanical Maintenance Tracking AR: A0290683, AE / 07 STATUS: COMPLETE.

8. Review current practices regarding:

a. issuance of M&TE during back shift ani outside of normal tool room hours

b. other departments' practices (e.g., long-term issuance, procedural compliance with AP D-450).

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DRAFT: April 12, 1993 RESPONSIBILITY: J. MacIntyre' .;

DEPARTMENT: Materials ,

Tracking AR: A0290683, AE # 08-  !

STATUS: COMPLETE.

i l 9. Perform a follow-up assessment of M&TE.during the upcoming outage (2R5).

RESPONSIBILITY: H.'Karner ECD:. 6/15/93 l DEPARTMENT: -QA (QAAM)  !

Tracking JUR: A02906283, AE'# 09 STATUS: ASSIGNED.

10. Operations to select a random sample of 24 l completed STP's and perform a' review for

traceability of STP's versus.PIMS. .

RESPONSIBILITY: R. Luckett L l

DEPARTMENT: _ Operations (OPS),

Tracking AR: A0290683;-AE # 11  !

! STATUS: COMPLETE. ,

C. Corrective Actions to Prevent Recurrence:

l 1. Distribute a policy memo to Maintenance-Services, l personnel directing foremen and foreman assistants .

l to check that'M&TE is. properly l recorded ~in'PIMS and-  ;

i on the work order.

RESPONSIBILITY: J. Bard DEPARTMENT: Mechanical Maintenance i Tracking AR: A0290683,'AE #10 i l Outage Related? ~ No '"

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OE Related? No i l

j' NRC Commitment? No CMD Commitment? No ..

j i STATUS: COMPLETE. ,

2. Establish an M&TE database maintenance training  ;

module designed to benefit'STA's and tool clerks. '

Evaluate the use of computer base training.for this  !

module. .

RESPONSIBILITY: D. Clifton ECD: 05/30/93 DEPARTMENT: Training. ,

Tracking AR: A0290683, AE'# 12 Outage Related? No 93NCRWP\93MMN002.PGD Page 9 of 17  !

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.t OE-Related? No I

'NRC Commitment? No ,

CMD Commitment?1 No STATUS: ASSIGNED. .

3. Establish a. system'under which'PIMS securityJaccess ,

to M&TE database will be1 restricted:to._-personnel' '

who have satisfactorily completed the_M&TE database . ,

maintenance training.

RESPONSIBILITY: J.;MacIntyre ECD: 07/04/93" i DEPARTMENT:. . -Materials.

Tracking AR: A0290683,_AE # 13 Outage Related? No ,

OE'Related? No NRC Commitment? No CMD: Commitment? No.

STATUS: ASSIGNED.

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4. Revise'AdministratlveLProcedure MA2.ID1 to incorporate,all M&TE use at DCPP i'ncluding OPS. In.

this revision highlightfmanagement-expectations.

RESPONSIBILITY: .J. .MacIntyre1 ECD: 07/04/93 DEPARTMENT: Materials.

Outage Related? No-OE Related?~ No NRC Commitment? No l CMD Commitment? No

5. Establish'a security system limiting access.to the M&TE tool cribs .to. or',' those who have successfully .

completed the M&TE training module..

RESPONSIBILITY

J. MacIntyre' ECD:'07/04/93 l DEPARTMENT: Materials.

l Tracking'AR: ~A0290683, AE # 15 -

l Outage Related? No OE Related? No-I NRC Commitment? No CMD Commitment? No D. Prudent Actions.

None.

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I NCR DCO-93-MM-N002 Rev.-00 l DRAFT: ' April 12, 1993 VI. Additional Information A. Failed Components:

None.

B. Previous Similar Events:

i NCR DCO-90-MM-N089 - Mcchanical Maintenance M&TE.

1.

Previous-QC and QA audit findings identified a 3 significant number of M&TE program impl'ementation t deficiencies.

The root cause was' determined to be inattention to-

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detail, inadequate acceptance of, and insufficient.

l management attention to M&TE program. requirements. '

I&C will assume- responsibility for calibration and '

issue of all Mechanical Maintenance M&TE equipment.

l Review and revise M&TE procedures to address quality concerns and ensure compliance with  :

regulatory requirements. l

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j 'he corrective actions to-prevent recurrence i

included assigning a tool clerk to.the Mechanical Maintenance tool crib;. remove all due-or past due__ '

calibrated tools from the tool. crib; change the lock on the tool cribrand train personnel on l handling and checking M&TE. '

i The above or**ective actions to prevent recurrence {

were ineffective in. preventing this event.' '

C. Operating Experience Review

1. NPRDS:

Not applicable.

2. NRC Information Notices, Bulletins, Generic i Lettests:

! None.

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3. INPO SOERs and SERs:

None.

l D. Trend Code:

Responsible department PG, and cause code A1.

m. Corrective Action Tracking:

1. The tracking action request is A0290683.

2. Are the corrective actions outage related?

None.

F. Footnotes and Special Comments:

i l NCR DCO-93-QA-N003 - DCPP/TES M&TE INTERFACE.

l From February 16 through 18, 1993, during audit 93007I of TES measuring and test equipment (M&TE), the QA auditors identified that'Dwyer Manometer model 1430 had not been properly calibrated. The-manometer had been sent from DCPP to TES for calibration. TES had calibrated the micrometer head, but had not. calibrated

the rest of the instrument.

The root cause and corrective actions for this NCR'have not yet been determined. Therefore this NCR could not have prevented the events in NCR 93-MM-N002.

I G.

References:

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1. QE Q0010250. Control of M&TE.

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2. Random search of work orders during.1RS.

3. Audit 92038I H. TRC Meeting Minutes:

1. On January 19, 1992, the TRG convened and {

considered the following:

Review of the event.

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DRAFT: April 12, 1993 Review of the management summary.

The QA audit pointed out the fact that there still i

is a problem with M&TE.

This problem with M&TE traceability is not limited to the diesel. .50% of the time the data on M&TE is ,

inconsistent. 1 The problem is not as big as11n 1989. +

Seven-investigative actions were' issued.as described in V B 1 through 7. ,

t It was agreed that HPES needs to talk'to people l

involved with M&TE and find out how confusing the -

I vsrk orders / procedure sheets are, and then come-back and look at the human engineering aspect.

TRG TO RECONVENE ON FEBRUARY 9, 1993 TO REVILW THE RESULTS OF THE INVESTIGATIVE ACTIONS. ,

2. On February 9, 1993 the TRG reconvened and considered the following:

Reviewed results of investigative actions assigned ,

at the previous meeting. It would seem feasible.to have the MM foremen / foreman assistants check the l M&TE on 100% of all work orders during their revi~ew and closure. I&C and EM already do this. A-new' j corrective action was assigned to issue a policy-memo to begin performing this check. This is essentially alreadyla~ requirement in C-4053 (generically), and we do not want.to add this level of detail to the procedure. ]

It was pointed out that incorrect M&TE status was- )

caused by the method OPS uses to update the PIMS- ]

database. That there was a problem with'an accelerometer not being checked out in PIMS which resulted in traceability concerns.

The training's action from the previous NCR was to revise the lesson plan on M&TE. 'M&TE-is discussed in pre-outage training for non-PG&E personnel , and in JPM's and normal everyday work for PG&E. .

personnel. This. current training appears adequate.

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NCR DCO-93-MM-N002 Rev. 00 DRAF1: April 12, 1993 Action for HPES to review the personnel statements will need more time - they will use the recent D/G 2-3 issue to look at human engineering issues.

For the continuation of this NCR, J. MacIntyre will be the TRG chairman. Open issues still to be addressed include: (a) issuance of M&TE during back shift and outside of normal tool room hours, (b) other departments' practices.(e.g., long-term issuance, procedural compliance with AP D-450), and (c) a QA follow-up assessment during the outage.

This TRG is tentatively scheduled to reconvene on February 23, 1993 at 3 PM.

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3. On February 23, 1993 the TRG reconvened and l considered the following:

Review of the investigative actions results.

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Reviewed a letter from J. Dye to the STA's to )

include the IRD transducers in the M&TE update of j the data sheet.

Three potential corrective actions were reviewed. I

a. Anyone responsible to issue M&TE should be ,

qualified. l

b. Only qualified personnel.should have access to the tool crib.

c. Only qualified p:.sonnel should have access to the PIMS M&TE database.

OPS M&TE is maintained in the Unit 2 shift foreman (SFM) office by the on shift technical assistant (STA).

Discussion on whether both NCR's on M&TE should be rolled into one or handle each nonconformance separately. Regulatory Compliance position was that it would be more effective to roll both-NCR into ones The rest of the TRG agreed that each NCR addressed a different issue and there would be no point in consolidating them.

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l NCR DCO-93-MM-N002 Rev. 00 DRAFT: April 12, 1993 A concern about control'and backfit'of the M&TE database was expressed.

It was agreed that the M&TE traceability problem- ,

was within the scope of the TRG. j One investigative action;was initiated ~as follows:

Operations to select a random sample of 24  :

completed STP's'and perform a review for.  :

traceability of STP's versus PIMS.

Four corrective actions to prevent recurrence were issued as described in V;C 2 through 5.

Review of the root cause analysis. A new contributory cause was established to the effect

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J that management expectations-were not clearly communicated therefore not followed. . Personnel were not' held accountable.

Review of the trend code. This item will be ,

discussed later.

l TRG TO RECONVENE ~ON MARCH- 15,-1993 AT 3:PM TO REVIEW THE-RESULTS OF THE NEW INVESTIGATIVE ACTION AND THE NEW CORRECTIVE ACTIONS.

4. On March 15, 1993 the TRG. reconvened and. considered. H the following:  !

Review of the NCR write-up.

Reviewed the root.cause analysis.

Regulatory Compliance.will update and revise:the write-up to include the root cause analysis as recommended by the TRG and send it-for comments by the TRG members after review-by the chairman and QA.

If any problems are encountered by the TRG chairman or QA-as a result of the investigative actions ~

currently open, the TRG will reconvene at the discretion of the TRG' chairman.

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i If no problems are encountered as a result of the- .

investigative actions presently open, the following. j plan of actions will take place:

1. By March 22,'1993- . Regulatory Compliance _tof ,

submit the updated root  ;

cause and write-up toothe '

TRG members.

2. By March 29, 1993 ..The TRG members to-submit?

their. comments'to Regulatory (Compliance.(P.

Dahan) and the TRG,  :

chairman.

3. By April 5,11993- TRC members complete the l

JCR sign-off.-  ;

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4. By April 26, 1993 The NCR-will be submitted I to the PSRC.-

The voting members and the following individuals ,

will sign the NCR I 1. . J. Bard.(Mechanical Maintenance). ':

l 2. J.:Mellinger-(Work Planning Center).- 1

! 3. D. Clifton-(training).

NCR CLOSURE ECD:. August l16, 1993.

5. On April 12, 1993 the TRG reconvened'to' sign off l

t the NCR for PSRC.

QA brought up the. fact that they had recently.

identified potential M&TE traceability problems  :

! with the 2RS STP V-15. I John MacIntyre,Lthe chairman brought up the fact' that this.vas " raw" data and that we need to, wait for the completed-QA Audit to evaluate.the i effectiveness of corrective actions taken to date.

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It was decided.by the TRG.that.this.NCR should' bel l signed and submitted to the PSRC.

It was left to the discretion of'the chairman to  !

call another meeting of the TRG or proceed with the~  !

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NCR DCO-93-MM-N002 Rev. 00 DRAFT: April 12, 1993

plan of actions as established at the last TRG for the closure of this NCR, l

i NCR TO BE SUBMITTED TO PSRC FOR REVIEW AND APPROVAL ASAP.

l I. Remarks: ,

None.

J. Attachments.

Root Cause Analysis.

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NCR DCO-93-MM-N002 Rev. 00 DRAFT: April 12, 1993 CONTROL OF M&TE ROOT CAUSE ANALYSIS Page 1 of 2 EFFECT CAUSE EVTDENCE BARRIER M&TE program not being Usage is not being Quality Procedure AP D-450.

followed. documented. Assurance Audit 92038I.

Usage is not being documented. 1. Workers are not Quality Procedure AP D-450.

recording tool ID Assurance on work orders, or Audit 92038I.

2. Tools are being used w/o being recorded in PIMS, or

3. Tools are being removed from the tool crib during off hours w/o being checked out.

1. Workers are not recording ROOT CAUSE: HPES review. Potential:1.Have the tool ID on work orders. Inattention ~to foremen check that details. M&TE is properly Procedure not recorded in the W/O followed. and the PIMS database before ACTCMP.

2. Positive discipline.

3. Training.

2. Tools are being used w/o Other jobs share Quality Potential: Have being. recorded in the PIMS equipment in the Assurance foremen check that database. field w/o Audit 92038I. M&TE is properly recording recorded in the issuance. W.O. and the PIMS database before ACTCMP.

CC.- Contributory Cause.

O O

__..m_ _ . . . . _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

i l . >

NCR DCO-93-MM-N002 Rev. 00 DRAFT: April 12, 1993 Page 2 of 2 EFFECT CAUSE EVIDENCE BARRIER Other jobs share equipment in Workers don't Quality Procedure AP D-450.

i the field w/o recording bother to Assurance issuance. communicate M&TE Audit 920381.

usage to the tool clerks.

Workers don't bother to ROOT CAUSE: HPES review Potential: 1.

communicate M&TE usage to the Inattention to Personnel Positive tool clerks. details. statements. discipline.

Procedure not 2. Training.

followed. CC1. Ineffective management commitment.

3. Tools were' removed from the ROOT CAUSE: A0293329 Potential: 1. Limit crib during off hours w/o Inattention to PIMS access to being checked out detail personnel who have completed database maintenance training

2. Limit access to the cribs to personnel who completed database maintenance training

3. Positive 3

discipline ,

i 4

_ _ . . _ ., _ m. . _ . _ . _ - - _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ __-___m __ .m -_ _ -c _ . _ _ _

]

NCR DCO-93-MM-NOO2 Rev. 00 i DRAFT: April 12, 1993 CC1. Ineffective management ROOT CAUSE: HPES review Potentfal: 1. Add commitment to the M&TE program Management e :panded

, inattention to explanation of detail management i j expectations to  !

MA2.ID1

t. 2. Subsequent to l these events, additional

~

management support i for M&TE was  ;

provided with the l establishment of t the Tool Management Group.

CC. Contributory Cause.

4 e

4 f

j =

I . .