ML20136H341
| ML20136H341 | |
| Person / Time | |
|---|---|
| Site: | Fort Saint Vrain  |
| Issue date: | 07/15/1985 |
| From: | Singleton L PUBLIC SERVICE CO. OF COLORADO |
| To: | |
| Shared Package | |
| ML20136H203 | List: |
| References | |
| Q-16, NUDOCS 8508200272 | |
| Download: ML20136H341 (18) | |
Text
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Q-n Issue 6 0 Service Public FORT ST. VRAIN NUCLEAR GENERATING STATION Page 1 of 16 PusuC seRvlCE COMPANY OF COLORADO 7_~m n,n V;
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[ FTJ ST.!VRA'IN?j TITLE:
CORRECTIVE ACTION SYSTEM
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~ f C 6 2 9 JUL 9.1985 EFFECTIVE REVIEW DATE q-15-85 1.0 PURPOSE This procedure describes the requirements and practices employed for preparing, processing, and implementing Corrective Action Requests (CAR) and Management Corrective Action Requests (MCAR) to promote prompt implementation of required corrective i
measures, and defines the escalation process to effect CAR l
resolution.
2.0 APPLICABILITY This procedure applies to all FSV organizations responsible for
/)
actions required to prevent the occurrence or recurrence of U
conditions adverse to quality.
3.0 GENERAL REQUIREMENTS 3.1 Documented procedures are provided to assure that conditions adverse to quality which could cause failures, malfunctions, deficiencies, deviations, defective material or equipment, and nonconformances are identified and corrected in a timely manner.
3.2 Detected conditions adverse to quality are investigated and documented to determine the cause of the condition, actions taken to correct the condition, actions taken to prevent recurrence, and the date when corrective actions will be complete.
3.3 Conditions adverse to quality are reported to affected PSC management, and if appropriate, are presented for review l
by PORC and NFSC. CAR's or MCAR's which may involve NRC l
reportability per Technical Specification AC7.5.2 are l
reported to Technical Services upon issuance.
3.4 Any individual or organization may initiate corrective action requests.
Interdepartmental requests for corrective action will be submitted to the QA Operations
- Manager, v
8508200272 850006 DR ADOCK 05000267 g
PDR FORM (B)372 22 3642
Q-16 Issue 6 0 Service
- Public FORT ST. VRAIN NUCLEAR GENERATING STATION Page 2 of 16 PUBUC SERVICE COMPANY OF COLORADO (nI sJ 3.5 The following are examples of situations which could warrant issuance of a CAR.
3.5.1 Failure to follow appropriate approved procedure.
_ 3.5.2 Deficiencies in existing procedures such that their continued use could result in conditions adverse to quality.
3.5.3 Failure to implement action to resolve deficiencies in a timely manner.
3.5.4 Other corrective action conditions as determined necessary by Divisional or Departmental Managers.
l 3.6 CAR's are to be resolved at the lowest level of management l
possible and preferably by the supervision of the area or l
organization needing to address corrective action and the l
initiator of the CAR.
l 3.7 Differences in interpretations, priorities, justification, l
and such are reviewed by succeeding levels of management l
until resolved.
Under certain conditions, findings will l
require escalation through the management chain for O) l ultimate resolution by the Vice President, Electric
(_/
l Production.
l 3.8 The following are conditions which are considered as l
warranting escalation:
l 3.8.1 Failure to respond by the required date.
l 3.8.2 Failure to provide a schedule for implementation of l
l corrective action when the action cannot be l
completed by the required date.
i l
3.8.3 Failure to adequately implement agreed upon l
corrective action commitments by specified dates.
l 3.8.4 Unacceptable response to specific findings.
l 3.8.5 Inability of individual groups to mutually agree l
upon acceptable resolution of specific findings l
l generated.
l l
3.9 Any one or more of the following conditions may indicate the need for an MCAR.
l 3.9.1 Corrective action conditions involving repetitive violations or continuing trends where past
- O corrective actions have not been effective.
l
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- PUBLIC SERVICE COMPANY OF COLORADO O
l 3.9.2 Executive Management is not notified by other means of the initial occurrence of conditions significantly adverse to the quality of safety-related items or quality affecting services.
l 3.9.3 Corrective action conditions concerning management level personnel disregarding established procedures for the safe operation of the plant.
l 3.9.4 Other corrective action conditions as determined necessary by the Manager, Quality Assurance, Divisional, or Departmental Managers.
l 3.10 Effectivness of the Corrective Action System is determined by the QA Operations Manager (QAOM), who is responsible for Corrective Action Requests (CAR) and trending for Nonconformance Reports (NCR) and issues quality trend reports to affected FSV managers. Trend reports on CAR's and NCR's are issued on a periodic basis.
l 3.11 The
- Manager, Quality Assurance is responsible for reviewing the status of unresolved corrective actions which are more than 30 days overdue.
The review determines if any of the items may be closed by cancellation based on management judgment or by initiating O
specific actions to resolve the open items.
i l
3.12 A unique serial number for each CAR /MCAR is obtained on request from the QA Computer Specialist.
The requestor will furnish the QA Computer Specialist with a brief description of the CAR /MCAR and the name of the department which will receive the CAR /MCAR.
l 3.13 The QA Computer Specialist will maintain a computerized and CAR /MCAR file which will also serve as a CAR /MCAR log will generate weekly reports required for control and follow-up.
QA Computer Specialist shall maintain an up-to-date The l
3.14 hard copy suspense file for all open CAR's and MCAR's.
l 3.15 The QA Computer Specialist transmits completed original the CAR's and MCAR's to the Records Center after updating Status Keeping System.
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4.0 PROCEDURE 4.1 PROCEDURE FOR CORRECTIVE ACTION REQUEST (CAR)
Block numbers listed in the following steps correspond to those on the sample shown on Attachment Q-16A unless otherwise indicated.
RESPONSIBILITY ACTION INITIATOR 1.
Identifies the need for corrective action. (See Step 3.5 for example criteria.)
a)
Block 1, enters signature and date of request.
b)
Block 2,
enters a clear description of the discrepant condition.
c)
Block 3,
enters the justification or requirement for the need for corrective
{]
action.
d)
Block 4,
enters recommended action to correct the discrepancy.
2.
Forwards CAR to supervisor, or, if the CAR is an audit finding, to the Supervisor, QA Auditing.
INITIATOR'S SUPERVISOR /
SUPERVISOR, QA AUDITING 3.
Reviews CAR for appropriateness.
a)
Block 5, enters signature and date of approval.
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J V
b)
Block 6, enters serial number obtained from QA Computer Specialist.
The numbers will be assigned to each CAR per_
the following example:
85-001 the first 2 digits are the
- year, the last 3
are sequentially assigned numbers.
c)
Block 7,
enters the date the CAR serial number was assigned.
d)
Block 8,
assigns the department responsible for the required corrective action.
4.
Forwards CAR to QA Operations Manager.
(3
't)
QA OPERATIONS MANAGER (QA0M) 5.
Reviews CAR for appropriateness.
If approved:
a)
Block 9, enters signature and date of issuance authorization, b)
Block 10, enters the date the disposition is due.
This is 15 working days after the CAR issuance is authorized.
6.
Sends copy of CAR to QA Computer Specialist for inclusion in QA-CAR book.
If the CAR appears to involve NRC reportability per Step 3.3, forward a copy of the CAR to Technical Services.
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[V 7.
Forwards CAR to manager of responsible Division for divisional i
distribution.
If not approved:
a)
Block 12, enters reason request was rejected, then initials and dates.
b)
Block 17, enters signature and date.
c)
Places copy of rejected CAR in QA-CAR book and sends copy to initiator's supervisor or Auditing Supervisor, as appropriate, d)
Sends original CAR to QA Computer Specialist.
Resp 0NSIBLE DEPARTMENT 8.
Reviews and dispositions CAR.
a)
Block 11, enters, if known, the cause of the discrepant condition, b)
Block 12, enters the action taken to correct the discrepancy.
c)
Block 13, enters the action taken to prevent recurrence.
d)
Block 14, enters the scheduled completion date of corrective
- action, e)
Block 15, enters the signature of the preparer of the disposition and the date.
f)
Block 16, enters the signature of the person, other than the preparer of the disposition, providing departmental approval and the date.
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v 9.
Forwards original CAR to QA Operations Manager.
Note:
When corrective action has been completed, notify the QA Operations Manager.
If corrective action cannot be completed by the scheduled completion date, send the QA Operations Manager an updated scheduled completion date and include a reason for the extension.
QA OPERATIONS MANACIR
- 10. Coordinates evaluation of disposition response to determine appropriateness of committed corrective actions using the following guidelines:
a)
The disposition accurately addresses the discrepant conditions.
(~
b)
The disposition provides a
(
resolution which will preclude recurrence of the discrepant condition (s).
11.
If response is acceptable, coordinates follow-up upon scheduled completion date and verifies implementation of the stated corrective action.
a)
Documentation can be provided which supports the disposition.
- 12. When corrective action is implemented as stated on the CAR disposition, the QA Operations Manager will:
a)
Block 17, enter signature and date signifying the disposition is adequate and closing the CAR.
i I
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Q-16 Issue 6 0 service
b)
Block 18, indicate whether or not a copy of the CAR is required to be forwarded for review to PORC per AC 7.1.2 step Sa thru Sk, NFSC per AC 7.1.3 step 7a (5), (6) or (8),
or Technical Services per AC 7.5.2(a) or (b).
13.
Forward original of the completed CAR to the QA Computer Specialist.
14 If the corrective action is acceptable, but corrective measures have not been implemented as stated l
on the CAR disposition, or if the l
response is not acceptable, the QA l
Operations Manager may proceed with l
the CAR escalation process in l
accordance with Section 4.2 of this l
procedure.
p l
4.2 PROCEDURE FOR ESCALATING CORRECTIVE ACTION REQUEST (CAR)
, V l
RESOLUTION RESPONSIBILITY ACTION l SUPERVISOR, l QA TECHNICAL l SUPPORT l
1.
Determine.s if a condition warrants l
escalation (see Step 3.8 for l
criteria).
l 2.
Notify QA Operations Manager that escalation may be warranted.
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v l QA OPERATIONS MANAGER 3.
Evaluates the reported condition.
l 4.
,I f condition involves a failure to l
respond to the CAR by the required l
date, the QA Operations Manager l
will send a written notice to the l
manager of the department to whom l
the CAR is assigned.
l a)
The notice will state that the l
response is
- overdue, and l
require an immediate response l
to the CAR which includes an l
explanation of why the l
response was delinquent.
l b)
A copy of the notice is sent l
to the appropriate Division l
Manager and to the QA Computer l
Specialist.
l S.
If the condition involves a
(3 l
scheduling
- problem, the QA il l
Operations Manager will send a v
l written notice to the manager of l
the department to whom the CAR is l
assigned.
I a)
The notice will state that the l
scheduled completion date is l
- overdue, and require an l
immediate response which l
includes an explanation of why l
corrective action was not l
completed on the required l
date, and a date by which I
corrective action will be l
completed.
l b)
A copy of the notice is sent l
to the appropriate Division l
Manager and to the QA Computer l
Specialist.
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l 6.
If the corrective action is l
acceptable, but corrective measures l
have not been implemented as stated l
on the CAR disposition, the QA l
Operations Manager will send an l
explanatory letter to the l
appropriate manager, and a copy to l
the appropriate Division Manager l
and to the QA Computer Specialist.
l Note:
CAR's will remain the l
responsibility of the assigned I
department and will not be l
considered closed until the QA l
Operations Manager accepts the CAR l
disposition and closes the CAR.
l 7.
If the response is not acceptable, l
returns a copy of the CAR to the l
responsible department manager with l
an explanatory letter and sends a l
copy to the appropriate Division l
Manager and to the QA Computer l
Specialist.
O v
a)
A new response date will be included in the letter.
l RESPONSIBLE DEPARTMENT 8.
Assure that the concerns l
communicated are understood and l
clear, prepare response to address l
the condition noted, and provide l
the action necessary to resolve the l
situation.
l 9.
Forward response to QA Operations l
Manager.
l QA OPERATIONS MANAGER
- 10. Evaluate response and determine l
appropriateness of committed l
actions.
l 11.
If results are satisfactory, no l
further escalation is required.
O rowicim.m.sess
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l
- 12. If results are not satisfactory, l
inform the
- Manager, Quality l
Assurance by memo of the condition l
with a summary of the issue and l
actions taken to date.
l MANAGER, QUALITY ASSURANCE
- 13. Evaluate reported condition.
l 14.
Inform the responsible Division l
Manager of the condition, actions l
taken and apparent differences to l
be resolved.
l
- 15. Determine the need for issuance of l
a Management Corrective Action I
Request to highlight the problem and obtain resolution.
l 16.
If the condition identified is not l
resolved by commitments reached as l
a result of actions taken under l
Step 14 OR Step 15
- above, C]
l escalation to the Vice President, l
Electric Production will be l
effected.
l 4.3 PROCEDURE FOR REQUESTING MANAGEMENT CORRECTIVE ACTION RESPONSIBILITY ACTION QA OPERATIONS MANAGER, DIVISIONAL, l
OR DEPARTMENTAL MANAGER l
1.
Determines whether a condition appears to warrant issuance of a Management Corrective Action l
Request (MCAR).
(See Step 3.9 for criteria.)
2.
Notify the
- Manager, Quality Assurance that an MCAR may be warranted.
MANAGER, QUALITY ASSURANCE 3.
Following notification that an MCAR may be required, evaluates the (Q
reported condition.
/
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4.
If it is determined that an MCAR is required, requests issuance of MCAR.
INITIATOR 5.
Prepares MCAR for issuance:
a)
Block 1, enters signature and date of request.
b)
Block 2,
enters a clear description of the discrepant condition.
c)
Block 3,
enters the justification or requirement for the need for management corrective action.
d)
Block 4,
enters recommended action to correct the discrepancy.
O 6.
Forwards MCAR to QA Operations Manager.
QA OPERATIONS PANAGER 7.
Reviews MCAR for appropriateness.
a)
Block 5, enters signature and date of approval, b)
Block 6, enters serial number obtained from QA Computer Specialist. The numbers will be assigned to each MCAR per the following example:
85-001 The first 2 digits are the
- year, the last 3
are sequentially assigned numbers, c)
Block 7,
enters the date the MCAR serial number was assigned.
8.
Forwards MCAR to Manager, Quality O
Assurance.
FoMMICl372 22 3043
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Reviews MCAR for appropriateness:
a)
Block 8,
assigns the depart-ment responsible for the required Management Corrective Action.
b)
Block 9, enters signature and date of issuance authorization.
c)
Block 10, enters date the disposition is due.
This is 15 working days after the MCAR is authorized for issuance.
- 10. Sends copy of MCAR to QA Computer Specialist for inclusion in QA-MCAR book.
If the MCAR appears to involve NRC reportability per Step 3.3, forwards a copy of the MCAR to Technical Services, ss
- 11. Sends copy of MCAR and cover letter to Vice President, Electric Production.
- 12. Forwards MCAR to Manager of responsible Division with cover letter for divisional distribution.
RESPONSIBLE DEPARTMENT 13.
Reviews and dispositions MCAR:
a)
Block 11, enters, if known, the cause of the discrepant condition.
b)
Block 12, enters the action taken to correct the discrepancy.
c)
Block 13, enters the action taken to prevent recurrence.
d)
Block 14, enters the scheduled completion date of corrective action.
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Block 15, enters the signature of the preparer of the disposition and the date, f)
Block 16, enters the signature and date of approval by Division Manager.
14.
Forwards MCAR to Manager, Quality Assurance.
MANAGER, QUALITY ASSURANCE
- 15. Reviews and evaluates disposition.
- 16. When cprrective action has been completed, the Manager, Quality Assurance will coordinate evaluation to determine appropriateness of committed corrective action and verify implementation of stated corrective actions using the guidelines of Step 4.1.10 and 4.1.11.
- 17. If corrective action is acceptable, the Manager, Quality Assurance will:
a)
Block 17, enter signature and date signifying disposition is adequate and closing the MCAR.
b)
Block 18, indicate whether or not a copy of the MCAR is required to be forwarded to
- PORC, NFSC, or Technical Services, using the guidelines listed in Step 4.1.12b.
18.
Forwards original of the completed MCAR to the QA Computer Specialist and a copy to the Vice President, Electric Production.
19.
If the corrective actions are unacceptable or require additional corrective measures, the Manager, Quality Assurance will return a copy of the MCAR with a written n
notice to the responsible Division
()
Manager specifying what actions are FORM (Cl372 22 3843
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V deemed necessary to close the MCAR.
a)
Sends a copy of the notice to the Vice President, Electric Production and a copy to the QA Computer Specialist.
Note:
A new response date will be included in the notice.
l 4.4 CORRECTIVE ACTION EFFECTIVENESS
SUMMARY
REPORT l
4.4.1 The Corrective Action Effectiveness Summary Report is a textual and graphic report prepared on a periodic basis to aid in identifying trends detrimental to quality.
l 4.4.2 Examples of CAR activities addressed in this report include:
a)
Total CAR's written
(]
b)
Total CAR's closed v
c)
General, status of open CAR's.
l 4.4.3 Examples of CAR trends monitored via this report include:
a)
Failure to follow procedures b)
Inadequate procedures c)
Document control d)
Calibration l
4.4.4 Examples of NCR activities addressed in the report include:
a)
Total NCR's written b)
Total NCR's closed c)
General, status of open NCR's l
4.4.5 Examples of NCR trends monitored via this report include:
a)
Incorrect material received.
b)
Damaged material c)
Records and Documentation problems d)
Changes in material e)
NDE inconsistencies v
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5.0 REFERENCES
5.1 FSAR Appendix B, " Quality Assurance Program for Plant Operation".
5.2 Techaical Specification AC 7.1.3, " Administrative Control" Technical Specification AC 7.1.2, " Administrative Control" Technical Specification AC 7.5, " Reporting Requirements" 5.3 Procedure G-8, " Compliance with 10CFR21 Requirements" 5.4 Procedure Q 4, " Procurement Document Control" 5.6 Procedure Q-7,
" Control of Procured Materials and Services" 5.7 Procedure Q-15, " Control of Nonconforming Items" 6.0 ATTACHMENTS Q-16A " Corrective Action Request Form" Q-16B " Management Correction Action Request Form" FORM (C)372 22 3H3
(
i
Attach. Q-16A Issue 6 0 Public FORT ST. VRAIN NUCLEAR GENERATING STATION Page 1 of 1 SOTVICO*
PUBLIC SERVICE COMPANY OF COLORADO
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F RT ST, VRAIN NUCLEAR GENERATING STATION 0 Public pusuc senvics comeAm oF COLORADO Service-CORRECTIVE ACTION REQUEST m
CAR NO.
W DATE asa o asseomst oarl ASSIGNED TO-C NED C PROD C QA INITLATOR DEPARTMENT APPROVAL fSSUANCE AUTHORIZED esHWeamag.
'Oays sS4n4Yuat.
iDarsi 1
esconarungs
,garg, DISCREPANT CONDITION i
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JUSTIRCATON/ REQUIREMENT RECOMMENDED ACTION RESPONSIBLE DEPARTME NT DISPOSITION SCMEDULED COMPLETON DATE PREPAREDSY DEPARTMENT A QVAL U
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oars.
.s.onarues.
, oa rs -
CAUSE OF DISCREPANT CONQlTION O
ACTION TO CORRECT DISCREPANCY ACTION TO PREVENT RECURRENCE O
FOR O A OPERATIONS MARIAGE R USE ARECTIVE ACTCN COMPLUE TECN SERV REQ'O C YES U NO h
PORC REQ D C YES C NO NFSC REQ'O O YEs C No Gaur.x4ma FORMICl372 22 3643
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Attach. Q-16B Issue 6 Public FORT ST. VRAIN NUCLEAR GENERATING STATION Page 1 of 1 SerVlCe*
PUBLIC SERVICE COMPANY OF COLORADO r
FORT ST. VRAIN NUCLEAR GENERATING STATION 0 Public pusu: SERVICE COMPANY OF COLORADO Service-MANAGEMENTCORRECTIVE ACTION u CAR No.
REQUEST o,rg atQ 0 mESPONSE DATE ASSIGNED TO:
C NED C PROD C QA INITIATOR DEPARTMENT APPROVAL ISSUANCE AUTHORIZED O
e
,sionarume<
' oats.
isionarvasi roarsi
.SimaNas' coare DISCREPANT CONDITION O
JUSTIF6 CATION / REQUIREMENT RECOMMENDED ACTION RESPONS85LE DEPARTMENT DISPOSITION SCMEDULED GQMPLETION DATE PREPARED BY DEPARTMENT APPAQvAL O
O O
searuae.
< on vs.
.smaruas,
. oats, CAUSE OF DISCREPANT G.ONDITION O.
ACTION TO CORRECT DISCREP ANCY ACTION TO PREVENT AECURAENCE O
FOR RSANAGER. O A USE CORRECME ACTION COMPWE TECM SERV RE0'O C YES C NO g
h PORC REQ'O C YES C No NFSC REQ'O C YES C NO
,,7, w v r. nuim FORM (C)372 22 3643
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