ML20199C874
| ML20199C874 | |
| Person / Time | |
|---|---|
| Site: | Susquehanna  |
| Issue date: | 10/22/1997 |
| From: | Brown W PENNSYLVANIA POWER & LIGHT CO. |
| To: | |
| Shared Package | |
| ML20199C865 | List: |
| References | |
| NASI--507, NASI-00-507, NUDOCS 9711200176 | |
| Download: ML20199C874 (18) | |
Text
. _
. PROCEDURE COVER SHEET
. NUCLEAR DEPARTMENT PROCEDURE I N
. O ,' , 4 .1 -
CORRECTlVE ACTlON PROCESS NASI-00-507 9 %
EFFECTIVENESS ASSESSMENT Revision 0
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'4r OUALITY CLASSIFICATION: APPT. OVAL CLASSIFICATION:
O QA Program @ Non-QA Program O Plant O Non-Plant
@ instruction EFFECTIVE DATE: /4-J ,0. 9 7 PERIODIC REVIEW FREQUENCY: N/A PERIODIC REVIEW DUE DATE: N/A RECOMMENDED REVIEWS:
None.
Procedure Owner: W. L. Brown - APS Senior Engineer Responsiva Supervisor: APS Supervisor Responsible FUM: NAS Manager Responsible Approver: NAS Manager FORM NDAP-QA 00021, Rev. 2, Page 1 of 1 97112 P pObh {5 BOO pga B7
- NASI 00-507 j
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Procedure Revision Summary
Title:
Corrective Action Process Effectiveness Assessment -
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NASI 00-507 r; , R vision 0 P:g) 3 cf 18
, ' TABLE OF CONTENTS
' SECTION ' PAGE 1.0 PURPOSE ,4 2.0 . POLICY / DISCUSSION 4 3.0 - REFERENCES - 5 4.0 RESPONSIGILITIES 5 5.0 DEFINITIONS 7 ,
'6.0L PROCEDURE 7 ;
6.1__ Project Initiation - 7 6.2 Team identifica"na and Commitment 7 6.3 Assessrrent Preparation 8 6.4 Problem Area Classification . 9 6.5 EvaluatviPotential Problem Areas 9 6.6 Intervie'v Line Management and Process Owner 11-6.7 Evaluation of Key Attributes to the Effectiveness of 11 Corrective Actions 6.8 Verify and Validate Problem Areas 12 6.9 - Develop Observations 12 6.10 - Development of Problem Statements and Process Strengths 12 6.11 Finalize Results 13 6.12 initiate Corrective Action 13 6.13 Future Assessment Improvement 14 7.0 - RECORDS 14 ATTACHMENTS ATTACHMENT PAGE A Corrective Action Process Effectiveness Checklist 15-16 (Form NASI-00-507-1)
B- Corrective Action Process Effectiveness Evaluation- 17-18 (Form NASI-00-507-2)
' NASI 00 507
. Revision 0 P ga 4 of 18 1.0 PURPOSE The purpose of this instruction is to describe a consistent approach for periodically assessing the effectiveness of the Corrective Action Process.
2.0 POLICY / DISCUSSION Effectiveness of the Corrective Action Process should be determined through follow-up of examples of potentially ineffective corrective actions and analysis of Corrective Action Process indicators. Corrective action effectiveness should be determined through information on the current frequency and significance of previously identified problems. This information can be obtained by conducting observations in the problem areas and conducting interviews with individuals familiar with the problem areas.
An optimum approach to determine the effectiveness of the Corrective Action Process is to use a combination of compliance-based and performance-based assessment techniques.
Compliance-Based Approach includes:
. Review of related procedures.
- Evaluation to determine if procedures meet the requirements.
. Evaluation to determine if the procedures are adequately implemented.
. Identification and correction of gaps.
Performance-Based Approach includes:
. Review of performance results.
. Evaluation to determine if problems are adequately fixed. -
. Cause determinat!on for problems not fixed.
. Correction of problems and causes of problems.
The general objectives of conducting an assessment of the Corrective Action Process are to:
. Determine the overall effectiveness of the Corrective Action Process. .
. Identify process strengths and weaknesses.
. Identify conditions adverse to quality.
. Recommend solutions to fix problems and causes of problems.
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I 3.0 '. REFERENCES q j
{ 3.1 - NDAP-00-0110 Nuclear Department Self-Assessment
- 3.24 NDAP-QA-0702 Condition Report !
- 3.3 NASP_-00-501 Conduct of Assessment Projects !
!3.4 ' ' NASI-00_-501 Assessment Project Plans 3.5 INPO 96-006 : Performaace Objectives & Criteria for Nuclear Generating Stations .
4.0 - RESPONSIBILITIES 4.1 Supervisor-APS. ,
4.1.1 Ensures that AM Nrsonnel are provided with the resources and training necessary to achieve effective implementation of this instruction.
4.1.2 Assists APS personnel in scoping and planning the assessment project.
4.1.3 Provides support in formation of an adequate assessment team. -
4.1.4 - Participates in meetings and/or discussions with customer to help focus customer expectations, APS_ role in the assessment and obtaining commitment from the customer to develop an action
- - plan in response to the assessment report, i .
l 4.1.5 - Assures implementation of this procedure. -
t M.2 Assessment Team Leader /Facilitator 4 2.1 Otains customer's expect:Itions for the assessment (schedule l requirements, cost limits, special project deliverables, etc.).
L 4.2.2 Prepares an assessment plan using the guidance contained in "
L NASI-00-501 that includes the following items.
. Objective (e.g., to determine the effectiveness of the L Corrective. Action Process and improve process and corrective action effectiveness).
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NASI-00 507
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. Scope (should include full assessment of complete Corrective Action Process and a review of follow-up effectiveness).
. Identification of customer and process owner.
. Methodology (This procedure can be referenced as the methodology to be used.)
Assessment Team (Identification of team members and their qualifications.)
. Deliverables.
4.2.3 Assures that an adequate team is assembled to perform the assessment.
4.2.4 Schedules and conducts a team kick-off meeting. The following itemc should be presented and addressed at the kick-off meeting.
. Overview of assessment project plan and schedule.
. Team member responsibilities, roles, availability, and commitment.
. Overview of methodology or indoctrination and training of the team. (The Corrective Action Process Effectiveness Checklist contained in Attachment A should be used.)
. Other items, as appropriate.
4.2.5 Assures that the assessment plan is followed and the steps outlined in the Corrective Action Process Effectiveness Checklist conta;oed in Attachment A are accomplished.
4.2.6 Assures that the Corrective Action Process Effectiveness Evaluation Form (Attachment B) is completed.
4.2.7 Prepares a final assessment report.
4.2.8 Assures implementation of this procedure.
4.3 Assessment Process Services (APS) personnel are responsible for implementing this procedure for assigned projects.
NASI-00 507-Revision 0 l P ge 7 cf 18 5.0 DEFINITIONS Definition of Key Terms can be found in NASP-00-501, Paragraph 5.0.
5.1 Problem Area Classification -The process of reviewing and evaluating a sample of Condition Reports to identify similar recurring coriditions and grouping those examples under deficiency headings that relate to.a -
weakness in one of the attributes of an effective Corrective Action Process.
5.2 Process Owner - An individual with responsibility for the process assessed and with the authority to implement appropriate correctiva action.
5.3 Customer - The indimual who requests or directs that an assessment project be conducted. The Customer sets the expectations for the project and is the person to whom the assessment project results are directed.
6.0 PROCEDURE 6.1 Project initiation - Assessment activities to evaluate the effectiveness of j
the Corrective Action Process are performed on a periodic basis.
Corrective Action Process Effectiveness Assessments will be initiated by either the Manager-NAS and/or the Corrective Action Process Owner.
6.2 Team Identification and Commitm at - The Supervisor-APS, l assessment customer, team leader and/or team facilitator should work l together to build an assessment team that will be sufficient in numbers and contain the necessary expertise, knowledge and experience to assure success of the assessment. The Supervisor-APS and the l assessment customer should assure that the selected team members will l be sufficiently excused from their regular duties to meet the demands of the assessment. The customer and the team leader and/or facilitator should assure that the appointed team members are able to,-and do commit to, their role in conducting the assessment.
6.2.1 Criteria for Team Leader /Facilitator
. Experience in assessment techniques and methodology.
. Knowledge of Corrective Action Process.
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. Broad perspective of plant operation.
[ . Credibility with Management, Supervision and Team.
. Good communication skills.
. Management skills needed to keep team focused on objectives.
. High standards.
d NASI-00 507 Revision 0 Pago 8 of 18 6.2.2 Criteria for Team Members e Knowledge of assessment techniques and methodology.
. Experience and/or knowledge of Corrective Action Process.
. Good communication skills.
. High standards.
6.3 Assessment Preparation The following information should be obtained and reviewed by the team prior to starting the assessment.
6.3.1 Description of the Corrective Action Process, NDAP-QA-0702, Condition Report.
6.3.2 List of CRs since last assessment or some predetermined date.
6.3.3 List of adverse trends identified by the Corrective Action Process.
6.3.4 LERs and other high level events.
6.3.5 Previous Corrective Action Effectiveness Assessments or Evaluations.
6.3.6 INPO evaluations and assists in area, if any.
6.3.7 NRC Corrective Action Process Audits, inspections, etc.
6.3.8 Internal Corrective Action Process OA Audits.
6.3.9 List of problem areas that indicates either ineffective correct've acuons or programmatic problems that could result in ineffective corrective actions.
6.3.10 Other related information from internal sources (QA, ISES, QC, ERTs, Self Assessments, etc.).
6.3.11 Other related information from external sources (Industry Events, CMAP, etc ).
NOTE: Start a list of potential problem areas.
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NASi-00 507
- R:: vision 0 Page 9 of 18 6.4- Problem Area Classification
~ Using a sample of Condition Reports selected and other gathered 1 information, sort the data into functional areas. Then, group the data with- !
common symptoms of observed performance weakr: esses into categories. !
Grour.ing such as:
. Mispositionings
. Contamination Control e Control of Temporary Modifications
- Maintenance Practices, etc.
Note: The INPO Performance Objectives can be used.
At this initial stage, do not group items for more complex issues, such as procedure compliance, supervisory involvement, etc.
6.4.1 Classify this raw information under appropriately selected deficiency headings,
- a. Post the deficiency heading.
- b. Place each sample under a deficiency heading. Include tha date, a brief description, and the reference (CR number).
- c. As the number of examples grow, the deficiency starts to become a developing potentia; problem area.
- d. Move examples around, if a nurnber of examples start to form a new pattern, or finer deficiency, create a new deficiency heading.
- e. Avoid developing a potential problem area with one or two examples, unless they are very significant on their own.
6.4.2 Compile a list of potential problem areas using the deficiency headings and examples generated above.
6.5 Evaluate Potential Problem Areas ,
Review the list of problem areas for the following:
6.5.1 Review the chronological development of the potential problem areas.
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NASI-00 507 Revision 0
. Papa 10 of 18 6.5.2 Determine if repeat incidents have occurred. If so, why?
6.5.3 Determine if documented evidence (or preventive) actions were of sufficient quality and timeliness to prevent recurrence.
6.5.4 Determine if documented cases (or industry assessments) were of suf0cient quality and timelinen to prevent recurrence.
6.5.5 Determine if the list and analysis oi ;v9vious occurrences were of sufficient quality and timeliness to identify potential adverse trends.
6.5.6 Determine if adverse trends were identified and if broader corrective actions were taken as a result of the adverse trend.
6.5.7 Evaluate and then categorize the identified problem areas and associated examples using the following attributes of effective Corrective Action Processes.
. Examples that may indicate problems with condition identification.
. Examples that may indicate problems with condition evaluation.
. Examples that may indicate problems with the identificatio' or correction of adverse trends. Include CFAR (an NPRDS application)in this area.
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. Examples that may indicate problems with timeliness or effectiveness of corrective actions.
l . Examples that may indicate problems with inadequate follow-up on the effectiveness or monitoring of corrective l actions.
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. Examples that may indicate problems with effectively incorporating industry experience.
I Also note examples that indicate that the attributes are routinely met or exceeded.
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- 6.6 Interview Line Management and Process Owner -
4 6.6.1 - Interview line management in the particular area being assessed and ask for their perceptions on the effectiveness vf the .-
Corrective Action Process and ask for any particult 1xamples of observed weaknesses. Update the list of potentia. , roblem areas to include these examples for follow-up. -
During the interviews, emphs. size the following:
. Topics where managers / supervisors suspect improvements -
could be made (ask for examples, if possible).
. Topics of specialinterest to manager / supervisor.
. Topics where manager / supervisor believes performance is strong.
6.6.2 Provide a copy of the Problem Area List to the Process Owner and obtain his/her comments and perspective.
6.7 Evaluation of' Key Attributes to the Effectiveness of Corrective Actions identify items that can not be obtained frnm reviewing Condition Reports by implementing the following activities. Update the list of problem areas as appropriate.
6.7.1 Conduct observations of field activities and conditions and conduct intcrviews with personnel to verify that conditions meeting the criteria for reporting are being identified and reported. -
6.7.2 Obtain and analyze precursor adverse trends that should be included as a part of line self-assessment activities and reported as Level 3 Condition Reports.
6.7.3 Conduct interviews with line personnel to ensure that lessons learned from previous industry or in-house experience is being effectively communicated and incorporated.
NASI-00 507 Revisi:n 0 PCg312cf18
. 6.8 - Verify and Validate Problem Areas--
l Verify and validate the examples documented in the problem area list to determine if they are applicable examples. Place valid examples under the appropriate attribute category. Note: To assess the area of condition evaluation, additional follow-up and observations of the CR process will have to be performed.
6.9 Develop Observations Evaluate the data gathered in performing the activities described in 6.4 through 6.8 and document the results as " observations". These observations will provide the basis for grading and commenting on the effectiveness of the Corrective Action Process. (See Attachment B).
Follow-up on the examples included in the documented observations to understand why the particular step (s) of the Corrective Action Process was ineffective. Document these results in the observations.
Use the following guidance when developing observations.
6.9.1 Document the chronological development of the examples and the corrective actions.
6 9.2 Provide sufficient details to determine problem (programmatic cause) with the Corrective Actiun Process. Consider using key words to help focue on the problem.
6.9.3 Provide cause and impact of example (e.g., repeat incident or increased potential for a repeat incident).
6.9.4 Document the extent of the issue based on observations and/or interviews and/or document reviews.
6.10 Development of Problem Statements and Process Strengths Based on the number and significance of examples found ;n each area (or performance that consistently meets or exceeds expectatiens), develop problem statements (and strengths). Verbally present these problem statements and strengths, along_with supporting examples and causes 'to the assessment team for agreement and buy-in. Follow-up and modify, as appropriate.
Use the following guidance when developing problem statements.
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- 6.10.1 . Classify identified problems by the step of the Corrective Action
, Process adversely impacted.
.6.10.2 Use the key words developed as part of the observations to assist in classification.
6.10.3 The most frequent and/or most significant examples in a particular area are the candidates for problem statements, 6,10.4 Typically need at least three examples to develop problem statements.
6.11 Finalize Results Finalize the observations, problem statements and strengths. Using Attachment B, Corrective Action Process Effectiveness Evaluation, provide an assessment grade and comment in each of the attribute areas.
Team leader will compile and integrate the results and presant results to the customer.
Key Points to Use When Finalizina Results
. Must be readable to customer and plant management, c:
- Communicate the facts with appropriate perspective (a problem or opportunity to improve),
e Answer the question 'SO WHAT7", i.e., 'So what if this condition exists, what are the adverse consequer.:?s**
. Provide the extent as well as the significance of each fact.
- Present causes of problems that are known.
6.12 Initiate Corrective Action Based on results, team leader will request that the customer initiate corrective action whenever a 4 or 5 grade is obtained to improve process performance of escalate the issue if more than one effectiveness review indicates that performance remains at the 4 or 5 grade level (i.e., the problem is not being resolved). The next periodic assessment will follow-up on previously identified effectiveness review issues.
. NASI-00 507
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T.0 - RECORDS-There are no QA records ger'erated as the result of this procedure.
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Attachmint A NASI 00-507 Rev.0
, Page 15 cf 18 L CORRECTIVE ACTION PROCESS EFFECTIVENESS CHECKLIST
~ COMPLETED? ACTMTY
- 1. Obtain and review NDAP-QA 0702 to obtain an understanding of the overall process. If the NDAP is in the process of being updated, obtain a draft copy.
2 Obtain and review the results from previous corrective action effectiveness reviews, evaluations, audits, etc. This may include extemal assessments (e.g., NRC, INPO).
Identify problem areas that indicate either ineffective corr 3ctive actions or programmatic problems thmt could result in ineffective corrective actions. Develop problem area list.
- 3. Obtain Condition Reports since the last effectiveness review (or the time period scoped for the assessment). Sort the Condition Reports into the areas that are included in the scope of the assessment (e.g., Operations, Maintenance, System Engineering, Health Physics, Chemistry, etc.).
- 4. Using the method of Symptom Classification, sort the Condition Reports into the following categories based on attributes of effective corrective action processes:
- a. Examples that may indicate problems with condition identification.
- b. Examples that may indicate problems with condition evaluation.
- c. Exampes that may indicate problems with the identification or correction of adverse trends. If applicable, include CFAR (an NPRDS application)in this area.
- d. Examples that may indicate problems with the timeliness or effectiveness of corrective actions,
- e. Examples that may indicate problems with inadequate follow-up on the e ffectiveness or monitnring of corrective actions.
- f. Examples that r ay indicate problems with effectively incorporating indtstry experience (if industry experience is included in the scope).
Also note examples that indicate that the attrioutes are routinely met or excoeded.
S. Document the examples and add to the problem area list to be reviewed lat 3r.
, 6. Intnrview line mailagement in the particular area being assessed and ask fcr their perceptions en the effectiveness of the corTective action process and ask fo r any particular ex amples. Update the problem area list to include these examples for later follow-up.
- 7. Update the problem area list to include items that could not be obtained fro n a review of Condition Reports, but that are key attributes to the effectiveness of correc ive acticcs, including:
- a. Observations of field activities and conditions and interviews with persannel to verify that conditions meeting the criteria for reporting are being identified ar d reported.
- b. Obtaining and analyzing precursor adverse trends that should be inclujed as a part of line self assessment activities and reported as Level 3 Condition Reports.
c, interviews with line personnel to ensure that lessons teamed from pretlous industry or in-house experience is being effectively communicated and incorpora ed.
Form NASI-o0-507-1, Rev. o. Page 1 of 2
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- Attachment A NASI.00-507 Rev.0 Page 16 of 16
- 8. Provide a copy of Problem Area List to the Process Owner and obtain customer's
. comments and perspective.
- 9. Perform observations of field activities and conditions to identify if the following is consistently occurring:
- a. Conditions are being identified and reported as required.
I b. Corrective actions from previous problems have been taken and are effective,
- c. Lessons teamed from Industry and in-house experience are being effectively communicated and incorporated into day-to-day activities.
Also identify new examples that could indicate problems with the effectiveness of corrective actions.
, 10. Follow up on previously identified examples in the problem area list to verify and validate if they are applicable examples and,if so, which of the various attribute categories the examples belong. To assess the area of condition evaluation, additional follow-up and 1 observations of the CR f'rocess will have to be performed.
11 Document the results of Steps 4 and 10 as " observations". These observations will ~
provide the basis for the grades and comments on the Corrective Action Process Effectiveness Evaluation Forms cot:tained in Attachment B.
- 12. Follow-up on the examples included in the observations to understand why the particular q step (s) of the corrective action process was ineffective. Document these results in the observations.
- 13. Based on the numter and significance of examples found h each area (or performance that consistently meets or exceeds expectations), develop problem statements (and l strengths). Verbally present these problem statements and strengths, along with I
supporting examples and causes to the assessment team for agreement and buy-in.
Follow up and modify appropriately based on this discussion.
- 14. Present the results to the customer for IJview and comment. Based on this discussion, follow-up and modify the results as appropriate.
- 15. Complete the observations, problem statements and strengths. Using the Corrective Action Process Effectiveness Evaluation Forms contcined in Attachment B, provide an assessment grade and comment in each of the attr%ute areas. Provide all of this information to the team leader for review and approval. Team leader to compile and integrate the results and present it to the customer.
j 16. Based on results, team leader will request that the customer initiate corrective action whenever a 4 or 5 grade is obtained to improve performance pl escalate issue if more than one effectiveness review indicates that performance remains at the 4 or 5 grade level (i.e., the problem is not being resolved). The next penodic assessment will follow-
- . up on previously ider'tified effectiveness review issues.
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- 17. Based on experience using this process, update the attributes, grading criteria and overall process to improve its affectiveness for the next assessment.
Form NAsI o0-So7-1. Rev. o. Face 2 M 2
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n e CORRECTIVE ACTION PROCESS EFFECTIVENESS EVALUATION
!~ . NO - Not eteerud; I - hereto er eseeeds some Semederd; 2 - A sataw pewherma , __ q ehe fieanderd; 3 -Two er shree submar pretteses kapiummmmeng she Sammemed; 4 Dame nas emmmisemmey ruse esmodeed
. (4 5. e.-pa-s); 5 s SingneArmee proberes ," _ . dW (etsher sigmIAcame prohdema, or >5 enemiples) l GRAPES AND COhel4ENTS
[ - STANDARDS AND CRTTERIA 7
- 1. Conssetton keenemarmanna. Condmons tiet meet tne cribune for Level t,2,3 CR reporung are NO .1 2- .3; 5 4L y sew-idenedied and quickly and consisterer ordered into the process .
COIAENTS:
- a. - The time behmeen the conston bebig tSecovered and See reporgng are rniremeed (by the end of the shdt or end of the day) b.-
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- l. - Precursor adwcree trends are idereRed and reported before more slyilAcant coneuens occur. ~!
- ' c. Conehens are consisterey idereRed try Wie tArecey inwelved vuork group (inclueng ist ene superwurirs). l Sorne condmons are idereRed by ingiscted vuork groups. A foer consalone are himnhAnd by 2rul Ane superweerwt and anove and inemmed QA. Eidemol penges do not identWy Level 1,2, and 3 condmons sist t have not been previouslyidenN81ed. ,
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. 2. Cosedleton Evalesseiose. Consmens are assigned the approprtete esgnlAcance level,9ee generO 2.
90 0 1 3 - S-j- __f _ and foot causes are appropriately determined, Wie appropriate achens are idereRed and conwW, and buportert seemes (eipeAcance rowleur and CR irevealigaton) are binncJ for troneng in COASENTS a timely enanner. DJote West Nais a:Artende is assessed by W est See ellecetvessoas of U corrective actioses.
- s. The siondicance lev + is asesgned sullhin 3 days of conellon idenbecomon and the apprepnele
- j. ..m_. . type is e sagned
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- b. Actual and potenhos consequences and genenc _. ' A, are appropnetaty and - .:^i !
, detemuned and factored into Wie signiAcanz level
, c. Previous ireernal operahng esquertenz is used to help determine the genene irrynem8==is of the conehon and is factored ireo the siendicence lovet
- w Root cause anefyssa and cause detonninselon are appropresse to prevent recurrence-. For Level 1 -
I condec.% and Level 2 consmiens requiring a rest cause, the teamens ydef prowtous casrectrue armens
} from irgiouse or hsustry opereding engionence toere kiegocSwe are idenleed (if mW). l j e. Recocrimended aceans arie determined, approved, and appropriately seeigned v. thin 30 days. The A
, me*==is ,.J.;i address Wie cousse, are comenurdested and assigned to the appropetsee ineviduads. '
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, (Reportable Level 1 consuono are completed vuedn 20 days of beire assignett) t 1
- 3. - Adverse resens. Adverse trende are klenAAnd, causes testemened, and oceans assigned in a thesly NO 1 2- 3 4 5.
!. menner COGAENTS.
a Potenhof adve se trends are identlAed try en4nn CR rewtow of prowlous simder problems and seeigned for '
investgehenr hin3 days ThetendisvestAndand mu a aand, N veAd.the causes and acsons are idenhAnd, eeelped, agreed to and approved uGNn 30 days. - .L
- b. Petereal adverse trends are idenuand by speartesty regiouse of the CR / d=a-, ard assigned for .
investgeNon oughin 3 days. The tend isirertRed and q and, N valid, the causes and arsons are ,
glenhAed, assigned, agreed to and appewed suithiri 30 days.
c Procursor cctdeaans are analyzed (Level 4), aderse trends are idenhAed, venfied, wuf v=M= tad by J
quenergy reviews of precuraar conehens and are entered as Level 3 conehens: The causes and actans !
e,s usereAnd sea.gned. agreed to ar.d approved eveun 30 days. Note 19 eat sos;rces ofinfonseeston I uere en n cR se ,, newmeesenens resusisi voisi have so be reviemmt
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, Rev.0 PageISof)8 4 STANDARDS AND CRITERIA GRADES AND COMMENTS
- 4. - Cv,.w. . Acnons. Conedsve achone are taken m a tanely and efleceve memer NO t 2 3, 4 5:
, a. Immer%9e corrective ashens and schans to corred condemns are taken so tiet Die consequmces of Ihe COnAENTS:
- , imrr=h=8= probeam are fregated and the chance of immedste recurrence is reduced. Tiese achons are taken before another acevey occurs tuhich can here a happen agem and could incbde - . ~.- y schons uned longer term carroceve actons are impsemented
- b. Longer term corredive ndlons (adions to preverd recurrence) are taken before actrylbes or condhons i
east vehsch incresee tht, dience of a recurrence or watun 6 months aner the aceans are amongned Some !
longer term achons (e g . needng outages or modWicahone) may take longer.
- c. l
, If correctare actons to proverd securrence for Level 1 and 2 constihcas have not been ;6.. M and F another condlhon occurs, edher;
^
e : A risk determmaton is made to justWy the ceigrief turung of the correctrue achons.
e Compensatory achons are tehen to meumue recurrence untR correchve actons are complete l s
a The inmeng of the corredwe adens is modered to prevent further recurrence 'I
- d. ' The longer term conoceve actions address the causes and entert of the problem such that problem
. recurrence is elimmsted (i e., t!'ese are the right correctrue achons).
. o. Ineffeebwe or uncanofy correc e ive achons are iderdified communicated, and yr.y. _ , escalated
, f.
I Achon item backlogs are ofP1: lively priertuod and per-hrony restowed to minsmae 9:e prah=Nesy or ,i recurrence
- 5. Effecthrerness of Corrective Acelons. The effacevoness of wredsve actions Dom level 1 and 2 MO 3
' 1 -2 4 5 .
condalons and adverse trends are montored and fogoused4Ap to auquet correcepve adlons to prewert 't !
recurrence CORAAENTS:
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- a. On-8ne CR reviews are conducted for 3 years fonovulng compleMan of correcthe adlons tehen to power
- recurrence of level 1 and 2 condbons and adverse trends. If the condalon or advera trend rosa, M -
irwessgebon is corwsw*A and corrW wNhin 30 days that empkins why prowlous conecSwe th and previous industry proverdwe acsons were ineffedeve and to ider tWy addRinne conecthe ac$cus: to eterunste recunence
- b. Fonon-up effh cheds are conducted for levet 1 and 2 conduons and adverse trends. These ernmes observenons os acthese and constions, interweves, and documord and data r.1deses, Problems keenedied are f==*=r* to course conect and acquet prewtous cerveceve oceans and psevert fimure -
r.m ,
- 6. Les= : . Learned trem tredustry E , Mr. Prewerteve actors trem industry Emperterme see NO 3 1 2- 4 5.
. effecdvely L.. M to preclude a simAer hhouse event.
CORAAENTS:
- a. Industry Empertance is approprestely acesseea for stysr=hady and in a timely menner, This includes an SSES programmene seveser and a reviour of SSES program efiedimenses.
~ b, Prevensve acnons are totuun in e emely and effect!ve menner (see 84. above). .
- c. Portoec effectveness revims are pertonned to aqust actons to produde hhouse events (see SS i abovet OVERALL ASSESSMENT (Averase of sti areas): MONTH OF ASSESSMENT:
AREA OR FUNCTIONAL GROUP ASSESSED: ,
ASSESSM ENT PERFORMED BY: ,
i i
PHOVIDE COPY OF COMPLETED FORM TO:
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