ML20078Q558
| ML20078Q558 | |
| Person / Time | |
|---|---|
| Site: | South Texas  |
| Issue date: | 06/24/1994 |
| From: | Mias L HOUSTON LIGHTING & POWER CO. |
| To: | |
| Shared Package | |
| ML18065B259 | List: |
| References | |
| NUDOCS 9502210311 | |
| Download: ML20078Q558 (38) | |
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. HOUSTON LIGHTING AND POWER COh(PANY SOUTH TEXAS PROJECT l
. ELECTRIC GENERATING STATION I PLANT PROCEDURES MANUAL 4
STATION PROCEDURE ;
NON SAFETY-RELATED (O) ;
t Corrective Action Program RPOP03-ZX.4002d .
Rev.5 Page 1 of 38 APPROVED: '
> o W)f.t&o L /I?hY YM l'54 Plant hianager Dat'e Approved Date Effective PROCEDURE USE CONTROL: REFERENCED -
Table of Contents Eggg 1.0 Purpose and S cope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 l 2.0 D e fini ti ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 l 3.0 Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 ;
4.0 Pro c e d ure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 i r
4.1 Station Problem Report (SPR) Initiation . . . . . . . . . . . . . . . . . . . . . . . . . . 9 4.2 SPR Screening .......................................... 10 4.3 SPR Action Assignments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 4 4.4 S PR I nvestigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.5 Evaluation of Investigation Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4.6 Corrective Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.7 Plant Operations Review Committee (PORC) Review . . . . . . . . . . . . . . . . 17 !
4.8 S PR Cl o scout . . . . . . . . . , . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 9502210311 950216 :
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Corrective Action Pronram OPGP03.ZX-0002 Rev.5 Page 2 of 38 l
Table of Contents - Continued East ;
4.9 Replacement or Voiding an SPR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 j 4.10 SPR Revisions and Supplements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 l 4.1 1 Trend Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.12 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 :
5.0 Re ferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 6.0 Support Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 I
Addendum 1 - Typical Station Problem Report Form . . . . . . . . . . . . . . . . . . . . 25 t Addendum 2A - Category I through 3 SPR Requirements and Examples . . . . . . 28 -
Addendum 2B - Category 4 SPR Requirements and Examples . . . . . . . . . . . . . . 29 Addendum 2C - Category 5 SPR Requirements and Examples . . . . . . . . . . . . . . 30 Addendum 2D - Category 6 S?R Requirements and Examples . . . . . . . . . . . . . . 31 Addendum 3 - Action Assignments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Addendum 4 - Typical SPR Action Completion Verification Form . . . . . . . . . . . 33 Addendum 5 - Typical SPR Extension / Deletion Request Form . . . . . . . . . . . . . . 34 Addendum 6 - Typical SPR Approval / Closure Form . . . . . . . . . . . . . . . . . . . . . 35 j Addendum 7 - Guidelines For Operability Determination . . . . . . . . . . . . . . . . . . 36 i i
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1.0 Purpose and Scone 1.1 This procedure establishes the program for the identification, documentation, reporting, tracking, trending and resolution of Deficiencies and Significant i Deficiencies identified a'. STP. ,
l.2 Scope !
1.2.1 This program provides a method to assure that Deficiencies and t Significant Deficiencies are promptly identified, reported, and corrected.
i 1.2.2 This program specifies trending requirements for SPRs. l 1.2.3 This program does not include identification and reporting of equipment :
nonconformances per the Work Process Program (0PGP03-ZA-0090) ,
unless the nonconformance meets the Hardware Deficiency criteria in t Section 2.11.
1.2.4 This program does not replace corrective mechanisms such as Field !
Changes (FC), Procedure Feedbacks, MED changes, MPL changes,etc. If !
the condition represents a Deficiency or Significant Deficiency, an SPR t shall be written. l l
1.2.5 This program does not include adverse conditions identified by Procurement Qua'.ity Assurance (QAP-1.5). ;
r 2.0 Definitions (
2.1 Adverse Trend - A series of occurrences in which the frequency may be cause {
for concern and warrant consideration of corrective actions. :
2.2 Apparent Cause - The best estimate of the cause of the problem based upon probability and the investigator's judgement and experience. :
2.3 Approval Authority - The manager (or designee) responsible for approval of l investigations and/or corrective actions.
i 2.4 Causal Factor - Any situation or condition that, if it had not existed, would have - l prevented an event from occurring or would have lessened the severity of the i event. )
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Corrective Action Pies-m OPGP03-ZX-0002 Rev.5 i Page 4 of 38 l 2.5 Compensatory Action - Action taken to temporarily address a deficient condition until permanent remedial or corrective actions can be implemented. ;
2.6 Deficiency (Condition Adverse to Quality) - A condition in which a failure, ;
deviation, or inadequacy exists in a quality related process, document, or activity. !
This does not include equipment nonconformances (Hardware Deficiency). I i
2.6.1 Documentation errors, power plant transients, adverse trends, security l infractions, human performance errors, test or procedure errors, abnormal !
occurrences or conditions, and any other error-induced event which may ,
occur at STP.
2.7 Corrective Action - Action taken to prevent recurrence of an identified event or !
to eliminate or minimize the identified causal factors of the event.
2.8 Category - A classification assigned to each Station Problem Report (SPR) based ;
upon type and severity of the condition or event. Addendum 2A through 2D provides examples of each category. l 2.9 Event Review Team - A group ofindividuals, under the direction of a designated !
team leader, who investigate and evaluate Significant Events for causal factor l
determination and propose corrective action to preclude recurrence.
2.10 Generic Implications - The term used to describe the commonalities between j causal factors or problems. These items are sometimes referred to as broader :
ramifications, broader implications, systematic faults, or common mode errors. i 2.11 Hardware Deficiency - A component failure documented on a Service Request l (SR) that requires action to prevent recurrence: failures, defects, deviations, l malfunctions, or conditions of plant equipment / materials that render the ;
equipment inoperable or negate its ability to perform its safety function. Implicit in this definition is equipment which is used to satisfy Technical Specifications or other regulatory commitments regardless ofits QA classification. Examples of l these are component failures that result in the following or document repetitive !
hardware failures:
2.11.1 An entry into a Limiting Condition for Operation (LCO) Action l Statement (or outside an LCO). !
2.11.2 A loss of shutdown or spent fuel pool cooling capability.
2.11.3 A significant reactivity transient !
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$ Corrective Action Pre-i-i OPGP03-ZX-0002 I Rev.5 I
Page 5 of 38 2.11.4 A plant transient greater than 5% reactor power. j 2.11.5 An unplanned unit derate. j i
2.11.6 A plant shutdown. !
2.11.7 An unplanned unmonitored radioactive release.
2.11.8 A plant transient that requires operator action to mitigate the ;
consequences. :
i 2.11.9 A personnel injury.
- 2.11.10 A Reactor Trip 2.11.11 An ESF Actuation. l l
2.11.12 Damage to major equipment (i.e., large motors and pumps, heat !
exchangers, turbines, diesel generators, etc.)
i 2.12 Human Performance Enhancement System (HPES) - A method ofidentifying, reporting and correcting human performance related issues developed by the :
Institute of Nuclear Power Operations (INPO). 1 2.13 Investigator's Manual - A manual provided to SPR investigators that includes !
details on performing causal factor analyses, developing corrective actions, !
formatting of draft LERs and responses to NOVs, and cause and event codes for j trending. !
i 2.14 Non-Consequential Event: An event where no adverse consequences occurred, but could be considered a precursor to a more serious event. (i.e. "near miss")
(SOER 92-01) l 2.15 Operability Review - The' activity conducted or requested by the Shift Supervisor l to determine whether a specified Technical Specification related stmeture, I system, or component (SSC) is operable. This review only applies to SSCs that I are in an indeterminate operability state. This review does HQI include review of components that are inoperable at the time the SPR is generated.
2.16 Problem Review Group - A management group, consisting of the Plant Managers and representatives from Operations, Maintenance, Engineering, Nuclear Assurance, Licensing and CAG.
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2.17 QA/QC Deficiency SPR - Those deficiencies or significant deficiencies identified ;
by QA/QC during quality verification activities (audits, surveillances, i assessments, reviews). <
2.18 Remedial Action - Action taken to restore a previously acceptable condition or l capability. j 2.19 ~ Reportability Review - The process used to determine if an issue is reportable to !
an outside agency, usually documented in memorandum format.
2.20 Reporting Manual - A controlled manual that contains a compilation of reporting criteria and pertinent information pertaining to those reports that are applicable to STP.
2.21 Root Cause - A fundamental causal factor that, if corrected, should prevent ;
recurrence of an event or adverse condition.
2.22 Significant Deficiency (Significant Condition Adverse to Quality) - Conditions that: :
2.22.1 Are reportable per 10CFR50.72,10CFR50.73,10CFR21, or other NRC :
reporting criteria (routine reports to the NRC are excluded). Conditions l that document actual or potential NRC Notices of Violations or .!
Deviations or that have a direct adverse effect on the safety of the plants per the Operating License and Technical Specifications are included. !
2.22.2 Involve administrative, procedural or operational errors that demonstrate j fundamental misunderstanding of or noncompliance (breakdown of l quality processes) with operational, regulatory, or nuclear safety ;
requirements. j 2.22.3 Are recognized by Plant Management as having a greater than acceptable f recurrence rate.
2.22.4 Are considered significant by the PRG for reasons other than those !
I which fall into the above categories.
2.23 Station Problem Report (SPR) - The identification form and investigation report t for Deficiencies and Significant Deficiencies. !
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Corrective Action Proiisii OPGP03-ZX-0002 Rev.5 Page 7 of 38 i 2.24 Systematic Problem Solving Process (SPSP) - The problem solving process developed at STP that provides methods to conduct a problem investigation, determine causal factors, and develop corrective actions.
2.25 Threshold - A value established for various trend codes based on historical activity, or otherwise acceptable level, and is used as an indicator of an adverse l trend. l 2.26 Trend - The general movement over a period of time of some statistical change j that indicates a prevailing tendency or inclination. ;
3.0 Resnonsibilities 3.1 ANY PERSON associated with STP who identifies a Deficiency or Significant Deficiency is responsible for initiating a Station Problem Report (SPR) in ,
accordance with the requirements of this procedure.
3.2 The Shift Supervisor is responsible for the following: i 3.2.1 Reviewing the reported abnormal conditions or events, placing the plant in a safe condition as required and activating the Emergency Plan, if ;
necessary.
3.2.2 Determining if notification of regulatory agencies is required due to the !
abnormal condition or event and making the appropriate notification except as allowed by 4.2.11. >
3.2.3 Determining if an Operability /Reportability Review and/or a Mode restraint is required. Signing the SPR indicates that the reviews have been conducted.
3.3 The Corrective Action Group (CAG) Administrator or designee is responsible for the following:
3.3.1 Assigning and updating a unique number, and preliminary event code (s) to each SPR. -
3.3.2 Ensuring causal factor analysis is performed on Category 1-3 SPRs.
i 3.3.3 Tracking SPR actions.
F 3.3.4 Administration of the SPR Trending Program.
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l Corrective Action Program OPGP03-ZX-0002 Rev.5 j Page 8 of 38 3.3.5 Transmitting SPRs to the Plant Operations Review Committee.
l 3.3.6 Assigning a qualified CAG individual or department to perform investigations.
3.4 The Problem Review Group (PRG) is responsible for the review of each Station Problem Report and assignment of a category and an administretive disposition to '
ensure appropriate resources are applied to the investigation. PRG is also responsible for approving adverse trend SPR investigations.
3.5 PORC is responsible for reviewing SPRs that meet the review criteria of Technical Specification 6.5.1.6.
3.6 The Approval Authority for a department is responsible for the following:
3.6.1 Assuring that investigations assigned to their department determine causal factors for Category 1 through 3 SPRs.
3.6.2 Providing prompt responses to other departments to support investigations.
f 3.6.3 Assuring that a qualified investigator is assigned to a Category 1 through 4 SPR investigation.
'l 3.6.4 Committing to perform, and performing, remedial and corrective actions and verifying completion of SPR commitments.
3.6.5 Evaluating trend reports for possible management actions.
i 3.6.6 Approving completed SPR investigations.
3.6.7 Approving extensions for Corrective Actions.
3.6.8 Approving Category 5 SPRs that are to be closed and trended. ;
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- Page 9 of 38 i 3.7 The Quality Assurance (QA) and Nuclear Quality Control and Material Testing *
(QC) Departments are responsible for the following:
3.7.1 Assigning investigation due dates to SPRs initiated as the result of an l audit finding. I i
3.7.2 Verifying the acceptability of responses to QA/QC Deficiency SPRs. l 3.7.3 Verifying the remedial, compensatory and corrective actions for QA/QC i Deficiency SPRs are implemented.
1 3.7.4 Conducting reviews of specific items as requerted by management. ;
i 3.8 Nuclear Licensing is responsible for performing reportability reviews for SPRs not reviewed by the Shift Supervisors or Security Force Supervisor.
3.9 Investigators are responsible for: ;
3.9.1 Investigating and preparing SPR investigation reports in accordance with !
the Investigator's Manual
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3.10 The Security Force Supervisor is responsible for:
I 3.10.1 Reviewing security related SPRs to determine reportability and making '
the necessary notifications.
t 3.10.2 Ensuring appropriate remedial actions are taken for security related l SPRs.
l 4.0 Procedure !
t 4.1 Station Problem Reoort (SPR) Initiation i 4.1.1 Any person at STP who identifies or becomes aware of a Deficiency or l Significant Deficiency as specified in Section 1.2 shall write an SPR by following the directions on the SPR Form (Addendum 1). Addendum 2A through 2D gives examples of the type of occurrences within each ;
Category. !
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4.1.2 ne initiator provides the SPR to their supervisor. Sign off by the i supervisor constitutes review, n9.t approval. The SPR validity SHALL NOT be determined at this time. His step may be skipped if a i supervisor is not available and the SPR documents a significant !
deficiency. ,
l 4.1.3 Hand carry the Station Problem Report to the appropriate Shift Supervisor (Unit 1 SS if the SPR is common or both) and/or Security Force Supervisor.
4.1.4 The initiator and/or supervisor should consider whether any reportability, i operability, or security concerns exist. !
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4.1.4.1 For SPRs where operability /reportability concerns are obvious or might be present, contact the Shift Supervisor immediately ,
and deliver the SPR to the Control Room.
4.1.4.2 For SPRs where security concems are obvious or might be present, contact the Security Force Supervisor immediately and i deliver the SPR to Security, r 4.1.5 The initiator / supervisor / Shift Supervisor / Security Force Supervisor shall take appropriate remedial or compensatory actions as necessary and record those actions on the SPR form. :
4.2 SPR Screenine 4.2.1 If any personnel, including CAG and Licensing, become aware that the !
SPR could involve a reportable event or an operability concern, then ;
verbally contact the affected Control Room and immediately deliver the ;
SPR to the Shift Supervisor. (SPR 920201) l I
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} Rev.5 Page 11 of 38 4.2.2 The Shift Supervisor shall make an initial operability determination based i on the guidance in Addendum 7. The time between the validity l' :
determination of the nonconformance and the initial operability determination shall be commensurate with the safety significance of the nonconformance, but should normally not exceed 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. Initial operability determinations for conditions with allowed outage time less than 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> and which have a shutdown action statement should normally be completed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The Plant Manager may extend the time for review and approval of the initial evaluation, if appropriate. i Time extensions should be allowed only when there is a reasonable expectation that the outcome will be positive.
The results of operability evaluations requested of other departments by the Shift Supervisor shall be delivered to him immediately upon ;
completion.
i The allowed outage time for a condition found to be inoperable begins at the time the Shift Supervisor determines the condition to be inoperable, which may occur after the initial operability determination per Addendum 7.
4.2.3 If PRG determines that the issue does not represent a Significant Deficiency or a Deficiency, then the SPR shall be voided, the reason for voiding annotated on the SPR, and the initiator notified.
4.2.4 If PRG determines that the issue represents a human performance issue, a multi-discipline peer evaluation board may be convened.
4.2.5 All SPRs that have been identified as QA/QC Deficiencies shall be processed.
4.2.6 Upon collection of the Station Problem Reports, CAG will review each j Station Problem Repcrt. This review includes consideration of: l 4.2.6.1 Repetitiveness of the Condition, 4.2.6.2 Generic implications of the Condition, and (
4.2.6.3 Mitigating / corrective action taken or initiated. l l
Corrective Action Procram OPGP03-ZX-0002 Rev.5 Page 12 of 38 4.2.7 CAG shall assign an SPR Number and preliminary Event Codes, and update the SPR tracking and trending system as necessary.
4.2.8 Each Station Problem Report will be presented to the Problem Review Group (PRG) within two workdays of their receipt by the CAG.
4.2.8.1 Station Problem Reports deemed to be significant and warrant prompt management attention should be presented to the PRG on the day of their receipt.
4.2.8.2 Other Station Problem Reports should be researched during the two workdays to allow trending and to enhance administrative disposition suggestions to the PRG. They will be deHvered to the PRG the following workday.
4.2.9 The PRG reviews each Station Problem Report package, and assigns category, actions (i.e., investigations, report, etc.) and a responsible manager.
4.2.10 After PRG review, the SPRs shall be returned to CAG.
4.2.11 If Licensing determines that the SPR is reportable, then Licensing shall immediately coordinate with the affected Control Room to make any necessary notifications. ,
4.2.12 CAG shall close Category 6 SPRs after event codes have been entered in the SPR Trending Program.
4.3 SPR Action Assicnments 4.3.1 The CAG Administrator or designee shall make assignments as directed i by the PRG. Due dates, and extension of due dates shall be in accordance with Addendum 2A through 2D for investigations and Addendum 3 for other assignments.
4.3.2 If a Reportability Review action was requested by the Shift Supervisor, then the condition shall be further reviewed against the reportability criteria of the Reporting Manual.
Corrective Action Proeram OPGP03-ZX-0002 Rev.5 Page 13 of 38 4.3.3 If a reportable condition or an operability concern is determined to exist during a Reportability or Operability Review, then the Shift Supervisor - ,
and CAG shall be verbally notified immediately.
4.3.4 If the Shift Supervisor disagrees with the Operability or Reportability Review conclusions, then Operations Management shall coordinate a resolution. ,
4.3.5 If an SPR requires a report to the NRC (e.g., Licensee Event Reports j (LER) or Notice of Violation (NOV)), then the following apply.
4.3.5.1 Draft reports are due in accordance with Addendum 3 and shall identify root cause(s) and corrective action (s) that have been accepted by line management. !
4.3.5.2 The approval authority responsible for the investigation .
maintains ownership of the issue until the report is issued by Nuclear Licensing. -
i 4.3.6 Completion of Category 5 SPRs. i 4.3.6.1 The Approval Authority may determine that no further action is required by noting or attaching the reason, signing for closure, and returning the SPR to CAG. !
t 4.3.6.2 No investigation is required.
4.3.6.3 A completed Category 5 SPR shall, as a minimum, have a -
description of the event (the original problem description may ;
be acceptable), and a list of any remedial or compensatory actions completed or planned.
l 4.3.6.4 SPRs investigations as a result of a QA audit finding must be ,
completed (or extension obtained) within the date assigned.
Investigations shall state the remedial / corrective actions.
Planned actions must include scheduled completion dates.
(SPR 931965) !
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Corrective Action Freewii OPGP03-ZX-0002 Rev.5 Page 14 of 38 4.4 SPR Investinations 4.4.1 SPR Investigator requirements are listed in Addendum 2A through 2B.
There are three " levels" ofinvestigation:
4.4.1.1 Category I through 3 SPRs may be investigated by an Event Review Team in accordance with Event Review Team (0PGP03-ZX-0006) with the determination of root cause(s) and corrective actions to prevent recurrence.
4.4.1.2 Category 1 through 3 SPRs may be investigated by a person or group of persons trained in root cause analysis with the determination of root cause(s) and corrective actions to prevent recurrence.
4.4.1.3 Category 4 SPRs are investigated by a person trained in root cause analysis with the determination of apparent cause.
4.4.1.4 "Non-qualified" individuals may conduct investigations on Cat I through 4 SPRs under the guidance of a " qualified" investigator who reflects approval on the document. (SPR 932429) 4.4.2 Due dates are based on Category as listed in Addendum 2A through 2D.
SPR investigations resulting from a QA Audit shall be completed within 30 days. (ANSI N-45.2.12) 4.4.3 Extension of SPR investigation due dates is allowed as listed in Addendurm 2A through 2B. For QA/QC Deficiency SPRs, concurrence shall be obtained from QA/QC.
4.4.4 The SPR investigator shall determine the remedial, compensatory and corrective action and obtain Approval Authority concurrence.
4.4.4.1 The investigation's Approval Authority shall coordinate with the affected department's Approval Authority to determine due dates and obtain approval by the affected department.
4.4.4.2 If LER, NOV or Special Report actions have been previously sccepted, then a reference to the submittal is acceptable instead of a signature from the Approval Authority.
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Rev.5 l Page 15 of 38 4.4.4.3 Uncompleted actions will require the establishment of due dates. ;
r 4.4.5 The SPR Report Format is defined in Addendum 2A through Addendum !
2D. For Category 1-3 SPRs, documentation substantiating the !
investigation findings shall be included in the report.
l 4.4.6 The investigator and approval authority shall note completion of the :
investigation by attaching the completed SPR Approval Closure Form j (Addendum 6) to the front of the report.
4.5 Evaluation ofInvestination Results 1 4.5.1 For QA/QC Deficiency SPRs, CAG shall notify QA/QC when an j investigation report is received.
4.5.2 QA/QC shall evaluate the response to QA/QC Deficiency SPRs for adequacy.
4.5.3 CAG evaluates the response to all Category 1-4 SPRs, not written by QA/QC, for adequacy. If the response is not acceptable, then the investigation is reopened with a new response due date. ;
4.5.4 The PRG evaluates and approves the response to all adverse trend SPRs. ;
4.5.5 If an SPR investigation is reopened, then the responsible organization .l shall perform the following: i 4.5.5.1 Resolve any items that caused the SPR investigation to be reopened.
4.5.5.2 Generate a revised response.
1 4.5.5.3 Return the SPR to the CAG by the new response date.
4.5.6 If the response to a QA/QC Deficiency SPR is determined to be acceptable, then QA/QC notes its acceptance on the SPR Approval Closure Form (Addendum 6) and returns the package to the CAG.
4.5.7 CAG shall update the SPR tracking system as necessary.
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4.5.8 CAG shall update the event code (s) in the SPR trending program as necessary.
4.5.9 CAG shall forward a copy of the completed SPR investigation to the initiator, the investigating department, and any affected department (s).
t 4.6 Co-rective Actions 4.6.1 CAG shall track remedial, compensatory, and corrective action as defined l in Addendum 2A through 2D:
4.6.1.1 Tracking an action in dual systems (Service Requests) should _l not be done.
4.6.1.2 All documents generated to ensure completion of actions shall have the commitment marked on the document. !
4.6.2 Extension / deletion of remedial, compensatory or corrective action due ,
dates (DR 91-042, SPR 920457) 4.6.2.1 For NRC related items, extensions shall be made in accordance .
with NGP-135 (Interactions with the NRC). !
4.6.2.2 An extension shall be requested by submitting an l Extension / Deletion Request Form (Addendum 3) to the PRG if f an action can not be completed by the due date. l l
4.6.2.3 Deletion requests shall be signed by the management level that -!
made the original commitment. Deletions must have !
concurrence from the affected department (s) and tbc CAG, or ;
QA for QA audit corrective actions, or Nuclear Licensing for i NRC commitments.. l 4.6.2.4 Justifications for extensions / deletions shall be provided. !
4.6.2.5 The extension / deletion request shall explain why the safety and reliability of plant will not be adversely impacted. i
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4.6.2.6 If an extension is granted for an action that is the prerequisite -
for other actions, then CAG may extend the associated actions :
without receiving an individual extension request (s).
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Corrective Action Pronram OPGP03-ZX-0002 Rev.5 Page 17 of 38 4.6.2.7 For Non-QA/QC Deficiency SPRs, the PRG shall review the extension / deletion request and the CAG Administrator sign if approved. If disapproved, a copy shall be sent back to the requestor. j 4.6.2.8 For QA/QC Deficiency SPRs, QA/QC and the PRG shall concur with the extension / deletion request.
4.6.3 Category 1 through 4 SPR items shall be closed by the appropriate Approval Authority by com,-Uting the SPR Action Completion Verification Form (Addendum 4) and forwarding to CAG.
4.6.4 For NRC related items, objective evidence shall be submitted with the SPR Action Completion Verification Form (Addendum 4) to CAG who '
forwards them to Licensing.
4.6.5 Category 5 SPR action items may be closed by the appropriate Approval .
Authority by completion of Part 4 of the SPR form.
4.7 Plant Ooerations Review Committee (PORC) Review 4.7.1 If an SPR describes an event that meets the PORC review criteria as defined in Technical Specification 6.5.1.6, then the CAG shall submit a copy of the completed SPR investigation to PORC.
t 4.7.2 PORC shall evaluate the SPR and document its review.
4.7.3 Disapproved SPRs shall be returned to the CAG Administrator for further processing.
t 4.8 SPR Closcout 1 4.8.1 Category 1 through 4 SPRs are closed by CAG when the investigation i and all actions are complete by completing the SPR Approval Closure i Form (Addendum 6).
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Corrective Action Proeram OPGP03-ZX-0002 Rev.5 Page 18 of 38 :
4.8.2 Category 5 SPRs are recommended for closure by the responsible l Approval Authority wheti the issue has been corrected or is being tracked i appropriately under another tracking system. The Approval Authority j notes closure on the SPR Form and returns the SPR to CAG with documentation of corrective action completion or method of tracking the !
open item. Actions closed to other processes must reference the SPR. If l the resulting action is cancelled, the Approval Authority must address the j initial SPR for additional actions. If new actions are required, the '
Approval Authority is responsible for their development and i implementation. l 4.8.3 CAG shall notify QA/QC wheneve.: .erification is required for QA/QC Deficiency SPRs. -
i 4.8.4 Category 5 and 6 SPRs are closed after review by CAG. i 4.8.5 The CAG Administrator or designee transmits closed SPRs to RMS for '
retention.
4.9 Replacement or Voidine an SPR l 4.9.1 If the original copy of an SPR is lost or destroyed during processing, [
then the CAG Administrator shall designate a copy as the new original. g 4.9.2 An SPR is voided as follows: !
4.9.2.1 Justification for voiding shall be noted on or attached to the ;
SPR.
4.9.2.2 If the PRG agrees, the SPR is voided.
4.9.2.3 The CAG shall update the tracking system, forward a copy of -
the SPR to the initiator and transmit the SPR to RMS. ,
4.10 SPR Revisions and Sucolements t
4.10.1 Typographical errors or non-intent changes may be corrected by line out, ,
initial and date prior to closure. !
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Corrective Action Proeram OPGP03-ZX-0002 -
Rev.5 Page 19 of 38 4.10.2 A SPR should be revised if the change is useful or necesssry.
4.10.2.1 Closed SPRs should not be revised based on new events or conditions.
t 4.10.2.2 Revisions shall be marked using change bars and are denoted by "Rev.1,2,3, etc." in the margin adjacent to the change bar.
4.10.2.3 The Approval Authority shall sign and date the SPR Approval Closure Form (Addendum 6).
4.10.3 For issues oflimited scope, SPR supplements may be used. Supplements may be initiated by any department. The following applies to the use of ;
supplements:
4.10.3.1 Supplements shall be in the form of memoranda from the !
issuing department to the CAG Administrator.
4.10.3.2 A copy of the supplement shall be provided to the affected departments.
i 4.10.3.3 CAG approval of the supplement must be noted on the memorandum.
4.10.3.4 To delete a remedial or corrective action, the criteria of 4.6.2 ,
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apply.
4.10.3.5 To add a remedial or corrective action, the department generating the supplement shall obtain concurrence from the proposed action department.
l 4.10.4 If the completion of remedial, compensatory, or corrective action results in the need for additional actions, the SPR shall be revised or supplemented (SPR 920457).
4.11 Trend Analysis I
4.11.1 Trend Data 4.11.1.1 Event codes shall be as listed in the Investigator's Manual.
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Corrective Action Program OPGP03-ZX-0002 Rev.5 Page 20 of 38 4.11.1.2 Cause codes shall be based on the INPO Human Performance Enhancement System (HPES) Causal ?? actor Worksheet contained in the Investigator's Manuai.
4.11.2 CAG will establish weighted mean values for each major event and cause trend category based on SPR Category and total number of SPRs written.
4.11.3 Trend thresholds shall be as follows:
4.11.3.1 Any data point that reaches one standard deviation of the -
weighted mean is a management warning.
4.11.3.2 Any data point that reaches two standard deviations of the weighted mean is an adverse trend.
4.11.4 Evaluation of Trends 4.11.4.1 The CAG shall evaluate trend data for the following:
- a. Determine if a threshold has been exceeded.
- b. Determine if an abnormally high level of causes or events exist.
- c. Determine if there are improvements in areas with identified adverse trends.
- d. Determine whether the frequency of data collection or the codes being monitored should be changed to better detect adverse trends.
- e. Determine if thresholds require revision to detect adverse trends.
4.11.4.2 A evaluation shall be performed periodically (semiannually as a minimum) by the CAG to assess the overall trends and identify adverse trends.
4.11.4.3 Trend information and graphs that do not represent adverse trends should be retained for a period of six months by the CAG.
l Corrective Action Proxiwii OPGP03-ZX-0002 l Rev.5 Page 21 of 38 4.11.5 Adverse Trends :
4.11.5.1 If the CAG Administrator determines that an adverse trend i exists, then an SPR shall be generated. l 4.11.5.2 If management action has already been taken, then an SPR may not be required. ;
4.11.5.3 If a recurrence of adverse trends is identified, previous actions 4 to prevent the trend should be reevaluated for effectiveness and ;
timeliness.
4.11.6 SPR Trend Reports i
4.11.6.1 SPR trend reports shall be generated at least quarterly. l 4.11.6.2 SPR trend reports shall cover the last year.
4.11.6.3 The CAG Administrator shall distribute periodic SPR trend !
reports to affected managers. l i
4.12 Documentation !
4.12.1 SPRs shall be retained for the life of the plant plus 75 years.
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t 4.12.2 The trending summaries and reports generated through the implementation of this procedure shall be submitted to the Records Management System (RMS) as a quality record.
5.0 Reference.s l 5.1 10CFR20 j 5.2 10CFR21 t
5.3 10CFR50 Appendix B l 5.4 10CFR50.72 l
5.5 10CFR50.73 5.6 10CFRS6 ;
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Corrective Action Pronram OPGP03-ZX-0002 l Rev.5 ;
Page 22 of 38 5.7 10CFR 71.95 5.8 10CFR73.71 ,
5.9 10CFR190 5.10 19 TAC 5.11 33CFR 153.203 5.12 40CFR 112.4 ,
5.13 49CFR 173.441 5.14 49CFR 173.443 5.15 DR 92-010 ,
5.16 DR 91-042 ,
5.17 EPA Permit 0064947 5.18 OPGP03-ZX-0006, Event Review Team 5.19 Generic Letter 91-002 5.20 INPO HPES Coordinator Manual, INPO 86-016, Revision 3 (June 1991) 5.21 NGP-135, Interactions with the NRC 5.22 LER 88-063 (MATS 8802270, Vortex Breakers) 5.23 [ DELETED]
5.24 NUREG 1022 and Supplements 5.25 Operational Quality Assurance Plan 5.26 OPGP03-ZO-0012, Plant Chemistry Specifications 5.27 Reporting Manual !
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Corrective Action Program OPGP03-ZX-0002 !
Rev.5 l
- Page 23 of 38 j 5.28 ANSI N45.2.12 ;
r 5.29 OSDP02-ZS-0024, Security Incidents, - l 5.30 SPR 920128 (MATS 9200505, Excesive Cooldown) 1 5.31 SPR 920201 (MATS 9200794 Delayed Entry into Tech. Spec. 3.0.3) l 5.32 Technical Specification 3.0.3 5.33 Technical Specification 6.5.1.6 5.34 Technical Specification 6.12.2 .
5.35 TWC Permit 01908 ,
5.36 Updated Final Safety Analysis Report (UFSAR) 5.37 SPR 920457 i
5.38 Operating Experience Review OTH93-045, NUREG-1275 - Human Performance ;
in Operating Events j 5.39 INPO Significant Operating Experience Report (SOER) 92-1, Reducing the !
Occurrence of Plant Events Through Improved Human Performance !
i 5.40 SPR 932429 i 5.41 SPR 931965 5.42 Quality Assurance Procedure (QAP) 1.5, Deficiency Reporting i
5.43 OPGP03-ZA-0103 - Plant Change Form Processing i
5.44 OPGP05-ZN-0005 - Justification for Continued Operation i 5.45 NRC Generic Letter 91-18 5.46 OPGP05-ZN-0001 - Preparation of Requests for Enforcement Discretion f l
5.47 SPR 940754 !
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Corrective Action Procram OPGP03-ZX-0002 Rev.5 Page 24 of 38 6.0 Sunoort Documents 6.1 Addendum 1 - Typical Station Problem Report Form 6.2 Addendum 2A - Category 1 through 3 SPR Requirements and Examples 6.3 Addendum 2B - Category 4 SPR Requirements and Examples 6.4 Addendum 2C - Category 5 SPR Requirements and Examples 6.5 Addendum 2D - Category 6 SPR Requirements and Examples 6.6 Addendum 3 - Action Assignments 6.7 Addendum 4 - Typical SPR Action Completion Verification Form 6.8 Addendum 5 - Typical SPR Extension / Deletion Request Form 6.9 Addendum 6 - Typical SPR Approval / Closure Form 6.10 Addendum 7 - Guidelines For Operability Determination i i
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1 Corrective Action Program OPGP03-ZX-0002 Rev.5 Page 25 of 38 ADDENDUM 1 TYPICAL STATION PROBLEM REPORT FORM ~
(Page 1 of 3) f
&TP 44RDeG (Q$/94) $0uTh TLAA& PAhECT ELECling ENLatafssG $!aTION OPNIX-0002 STATION PROBLEM REPORT cae canos, Di De Os Da Os Delseun PART t IDENTIFICATION OF CONCERN A.umt # D i O couurm snaum =aw otPt O O soin Pasion aeme ma nas i=c ,
DSctPOW DaE ilut f1END 04 Iluf usutDa1E SLIPEIMBosh DA1E 1h4 teNa1UsE (NOT a[gJets) couwtuts S. PaceLlu DC30erfMW 5 c. air em.c saron, on === aeno va,En 3 co==uana wrv aviaoo E
I g ggunga, ( ) cow 1muatou MIT AT1Aoc svsuu smuPoucut naut CCWpCMDrf ha kaso total enttimactuuse Pos Part 100ssW110N FEL m M EC $ Op aCM 00 YATWh.
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. Corrective Action Pronram OPGP03-ZX-0002 ,
Rev.5 Page 26 of 38 ADDENDUM 1 TYPICAL STATION PROBLEM REPORT FORM (Page 2 Of 3) su m swensun/te)uva PART 2: REPORTABILITY m as pysy 4, page me Tsuip T4 T A L587 i LHf 3 tr ACluAliet esilAnne sesAL S. OPUlASIUTY)tPtpTAtsin N1EmameA1MN
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f Corrective Action Program OPGP03-ZX-0002 Rev.5 Page 27 of 38 ADDENDUM 1 TYPICAL STATION PROBLEM REPORT FORM (Page 3 of 3) i SPR No. REV.
SPR CONTNUAT10N SHEET PAGE OF NOTE 5FCTKP8 TO WHtcM ADOf710NAL INF00LMAT10N APPt.ES 0
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1 Corrective Action Procram 0PGP03-ZX-0002 Rev.5 Page 28 of 38 ADDENDUM 2A CATEGORY 1 THROUGH 3 SPR REOUIREMENTS AND EXAMPLES (Page 1 of 1)
Denaltion Significant Deficiency lavestigation Type Investigator (s) Investigator (s) qualification Due Date Due Date Extension Root Cause Event Review Team as SPSP or equivalent root cause Normally Written by Analysis assigned by management analysis trained .5 30 Approval or qualified investigator calendar Authority to days PRG l Reports Format Approved By As described in the Investigator's Manual, Appendix I Approval Authority Tracking Investigation Remedial, compensatory, and corrective actions By due date to completion l tsy due date to completion Examples Category 1 Events or occurrences that are expected to happen rarely. They constitute events for which the consequences are serious and the expected regulator interest will be high.
Category 2 Esents or occurrences that occur periodically and mainly constitute Reportable Events".
Caterory 3 Events or occurrences that are less serious in nature but still constitute a Significant Deficiency..
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Corrective Action Program OPGP03-ZX-0002 Rev.5 Page 29 of 38 ADDENDUM 2B J CATEGORY 4 SPR REOUIREMENTS AND EXAMPLES ,
(Page 1 of 1) l mamm Definition Defici;ncy Inestigation Type Investigator (s) qualification Due Date Due Deze Estension .
Detennination of Apparent SPSP or equivalent root cause Normally < 60 Verbal notification by Approval Cause analysis trained calendar days Authority to PRG l
Reports Format Approved By As described in the Investigator's Manual, Appendix I; no Approval Authority {
generic implications required.
Tr: eking Investigation Remedial, compensatory, and corrective actions By due date to completion By due date to completion Examples Events or occurrences that are less serious in nature but still constitute a Deficiency. Investigation will be performed by a department. ;
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Corrective Action Procram 0PGP03-ZX-0002 Rev.5 Page 30 of 38 l
ADDENDUM 2C CATEGORY 5 SPR REOUIREMENTS AND EXAMPLES (Page 1 of 1)
Definition Deficiency IIestigation Tvpc Investigator (s) Due Date Due Date Estension None None None None Reports Format Approved By Lisi remedial / compensatory action on SPR Form Approval Authority Tracking investigation Remedial, compensatory, and corrective actions None None. Approval Authority notifies CAG that SPRs are complete, as required Enception
- prs generated as a result of a QA/QC audit finding 1all require a response within 30 days ofissuing the audit report. Corrective actions that can st be completed at the time the response is submitted shall include a schedule date. These actions shall be tracked. l i
Esemples l t
Events or occurrences that are less serious in nature but still constitute a Deficiency, however, cause determination is not required unless requested by 6epartment. Identification of corrective action is required.
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Corrective Action Procram OPGP03-ZX-0002 Rev.5 Page 31 of 38 ADDFIiD'JM 2D CATEGORY 6 SPR REOLIFEMENTS AND EXAMPLES '
(Page 1 of 1)
Definition Deficiency hvestigation Type Investigator (s) Due Date Due Date Estension None None None None Reports Format Approves'. By None - SPR is closed None - SPR is closed Trrcking Investigation Remedial, compensatory, and corrective actions None None complete, as required Esamples Esents or occurrences that are less serious in nature but still constitute a Deficiency, however, cause determination is not required. Appropriate remedial actions hase aircady been implemented. Events and occurrences will be evaluated to detect adverse trends.
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Corrective Action Procram OPGP03-ZX-0002 Rev.5 Page 32 of 38 ADDENDUM 3 ACTION ASSIGNMENTS (Page I of I)
Action Dee Date Report Format Approved / transmitted Due Date Extension Investigator regelresneets by (type /whenength)
Operability Review Normally $ Memorandum to Shift Supervisor with Approval Authonty Verbal / Plant Manager None 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. copy to CAG, other Unit. m / as required (SPR 920201)
Reportability Review Normally 5 Memorandum to ShiR Supervisor with Approval Authonty Verbal / Plant Manager None 5 working copy to CAG, other Unit. ""# with Licensing / as required days ch m ~a (SPR 920201)
' Dr3A reports to Normally S LER format as defined in Investigators Approval Authonty Verbal / Approval SPSP or equivalent root cause analysis Licensing (NOV, 10 working Manual Authority / 5 calendar trained LER) days. days NOTES:
(I) If the Shift Supervisor disagrees with the results of the review, Operations Management shall coordinate a resolution.
(2) The condition shall be fbrther reviewed against the criteria in the Reporting Manual
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Corrective Action Pronram OPGP03-ZX-0002 !
Rev.5 j Page 33 of 38 l ADDENDUM 4 l TYPICAL SPR ACTION COMPLETION VERIFICATION FORM l (Page 1 of 1)
{
- 1. SPR#: Action Item # (If Known): !
NRC Related [ ] Yes [ ] No ;
- 2. ACTION #(s) STATEMENT (s) i i
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- 3. THE ABOVE ACTION HAS BEEN VERIFIED COMPLETE BY- I Attached
- l Yes No i a) Document (s) # [] [] l l
- [] []
- [] [] -l
- [] []
- [] [] i Describe !
b) l
- 4. DATE(s) COMPLETE: I AUTHORIZING SIGNATURE: /
Date !
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- VERIFICATION DOCUMENTS SHALL BE PROVIDED FOR NRC RELATED ISSUES !
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Corrective Action Pronram OPGP03-ZX-0002 Rev.5 Page 34 of 38 ADDENDUM 5 TYPICAL SPR EXTENSION / DELETION REOUEST FORM (Page 1 of 1)
To: Problem Review Group From: i
Subject:
Request for Extension / Deletion: SPR #
An extension is requested for the following Staten Problem Report (SPR) item: a O Remedial / Compensatory Action (s)(describe): j i
l O Corrective Action (s)(describe):
O Investigation This commitment is O Intemal O Extemal (i.e., NRC, INPO) !
I This item was originally due (Daic) !
This item has been extended time (s) before.
The current due date is (Date) ,
The proposed due date is (Date) t Justification for extension' deletion (i.e., list specific higher priorities, current status, why original schedule would not be met):
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i State why this action will not affect the plant if not completed as scheduled or deleted (i.e., discuss compensatory measures, schedule sensitivity, risk consideration, etc.)
i Approval Authority Date CAO Administrator (as required) Date l
QA (as required) Date
a
.., 4 Corrective Action Program OPGP03-ZX-0002 Rev.5 Page 35 of 38 ,
ADDENDUM 6 l TYPICAL SPR APPROVAL / CLOSURE FORM (Page 1 of 1)
BTATION PRogLEM REPORT SPR 8 REGARDING Category APPROVALS ORIGINAL REV 1 REV 2
($leneture/Date) (5fonature/Date) (Signature /Date)
PREPARER Approval Authority REVIEW / APPROVAL PORC ORIGINAL REV 1 REV 2
! 1 YES ( Iwo (signature /Date) (Stenature/Date) (signature /Date)
CAC/PRG (Adverse Trend) l QA (IF APPLICABLE)
PORC (Mtg No./Date)
FLANT MGR CLOSURE APPROVALS ORIGINAL REV 1 REV 2 (Signature /Date) (Signature /Date) ($lenature/Date)
CAG ADMIN.
QA (IF APPLICABLE) 6
i Corrective Action Pronram OPGP03-ZX-0002 !
Rev.5 Page 36 of 38 ;
ADDENDUM 7 !
GUIDELINES FOR OPERABILITY DETERMINATION '
(Page 1 of 3)
The purpose is to determine if the structure, system, or component (SSC) in queshon is capable of l performing its specifed function.
(
Verificaten of operability is supplemented by continuous and ongoing processes such as: i
- Day-to-day operation of the plant .
- implementation of programs such as inservice testing and inspecten !
- Plant walkdowns or tours ! '
- Observations from the control room
- QA activities such as audits end reviews ;
- Engineering design reviews including design basis reconstitution. !
r Without any information to the contrary, once a SSC k established as operable, it is reasonable to !
assume that the SSC should remain operable, and the previously stated verifcations should provide }
that assurance. However, whenever the ability of a SSC to perform its specifed function is called !
in question, operability must be determined from a detailed examination of the nonconformance. l The determination of operability for SSCs is to be made promptly, with a timeliness that is ;
commensurate with the potential safety significance of the nonconformance. If the Shift Supervisor i chooses initially to declare a SSC operable, he must have reasonable expectation that the system ;
is operable and that the prompt determination process will support that expectation; otherwise, the i SSC should be declared inoperable immediately. ;
The measure of" reasonable" should be a function of the safety significance of the nonconformance l and the magnitude of the uncertainty. t i
- 1. When reasonable technical judgement indicates that the nonconforming SSC is capable of ,
performing its specifed safety function if required, the equipment should be declared operable. -
I
- a. If there is reasonable assurance that the SSC is capable of performing its specifed )
safety function and the determination process will support this expectation, but there l are some remaining concems or uncertainties, the equipment can remain ooerable until further evaluation can resolve the concems.
- b. If the initial evaluation indicates that the nonconformance is irrelevant to the safety j function of the equipment, the equipment should remain ooerable i
. c. If any immediate corrective actions, such as temporary braces or other attematives or " fixes," can be used quickly to provide reasonable assurance that the equipment will function until corrective action can be completed, the equipment should remain operable my .-
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4 Corrective Action Proeram OPGP03-ZX-0002 Rev.5 Page 37 of 38 ADDENDUM 7 GUIDELINES FOR OPERABILITY DETERMINATION (Page 2 of 3)
- 2. When reasonable technicaljudgement indicates that the nonconforming SSC is not capable of performing its specified safety function if required, the SSC should be declared inoperable
- a. A conditional release (Reference 5.43) should be completed when the SSC and' corrective actions will result in the plant operating:
+ within the licensing basis,
+ within the Technical Specifications, and
+
in a safe condition.
- b. A JCO (Reference 5.44) should be prepared when the SSC condition and the correctrve action will result in the plant operating:
outside the licensing or design basis,
+
within the Technical Specifications, and
+
in a safe condition.
- c. An enforcement discretion (Reference 5.46) should be requested when the SSC condition and corrective actions will result in the plant operating:
+ outside the licensing or design basis,
+
outside the Technical Specifications, and
+
in a esfe condition.
- 3. The Shift Supervisor or station management may request additional support from other departrnents to determine reportability and/or operability.
- 4. Resolution of the nonconformance shall follow the process shown in the flow chart in this Addendum.
Corrective Action Pronram OPGP03-ZX-0002 Rev.5 Page 38 of 38 ADDENDUM 7 GUIDELINES FOR OPERABILITY DETERMINATION (Page 3 of 3) i F
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