ML20202J585
| ML20202J585 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 05/12/1986 |
| From: | Bajada E, Hansel J EVALUATION RESEARCH CORP. |
| To: | |
| Shared Package | |
| ML20202J051 | List:
|
| References | |
| CPP-010-01, CPP-10-1, NUDOCS 8607170108 | |
| Download: ML20202J585 (15) | |
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EVALUATION RESEARCH CORPORATION ~ a COMANCHE PEAK RESPONSE TEAM PROJECT PROCEDURE FOR QA/QC ISSUE-SPECIFIC ACTION PLANS PROCEDURE NO.: CPP-010 REVISION NO.: 7 ISSUE DATE: 05/12/86 (e
%J PREPARATION OF DEVIATION REPORTS l
T Prepared by: Date: hh Approved by: k_ b S,'ggo Date: 8!42[IS On-Site QA Represent ve Approved by: u[ Date: D
& /d QA QC Review Team' Leader
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8607170108 860711 PDR ADOCK 05000445 l A PDR
CPP-010 Revision: 7 N.
(G 1.0 PURPOSE This procedure establishes the method to prepare, process, and control reports of deviations.
2.0 APPLICABILITY This procedure is applicable to safety-related hardware constructed, final QC accepted, and reinspected at Comanche Peak Units 1, 2 and areas common to both units.
3.0 REFERENCES
3.1 CPP-016, " Safety Significance Evaluations of Deviation Reports."
3.2 CPP-011. " Evaluations of Adverse Trend Analyses, Construction Deficiencies, and QA/QC Program Deficiencies."
3.3 CP-QP 16.3, " Processing CPRT Deviation Reports / Observation Notices."
-s 3.4 CPP-009, " Performance of Reinspection and Documentation g j Reviews."
3.5 CPP-018, "QA/QC Interface with the Design Adequacy Program."
3.6 CPP-004, " Project Working Files."
3.7 CPP-020 "Out-of-Scope Observations."
i j 4.0 GENERAL Qualified QA/QC Review Team personnel perform field reinspections of specific hardware and reviews of appropriate documents in accordance with established procedures and instructions. Should an attribute deviate from specified acceptance criteria, the inspector / reviewer initiates a Deviation Report (DR).
Subsequently, DRs are reviewed for validity and, as required, evaluated by the Safety Significance Evaluation Group (SSEG) in accordance with Reference 3.1, reviewed for root cause and generic implication (see Reference 3.2), and processed for reportability by TUGC0 (see Reference 3.3).
4.1 Responsibilities 4.1.1 QA/QC Deviation Report Originators (Refer to Table f- g 4.1-1)
U Responsible QA/QC Review Team personnel initiate reports which document each apparent difference between 2
CPP-010 Revision: 7 O a specific attribute and the item / process reinspected / reviewed and those deviations that appear to be common to the entire population or work activity.
Originators also review reports they initiated and which were determined to be inaccurate and/or were classified as invalid during the review process.
QA/QC Inspectors initiating reports are responsible to tag and release hardware associated with DRs as required.
4.1.2 Reviewers (Refer to Table 4.1-1)
"First reviewers" determine whether or not the DR accurately documents a difference in the observed condition and the specified criterion, "Second reviewers" provide confirmation of the first reviewer's decision and determine the validity of the DR.
Each reviewer documents the results of their review and distributes reports in accordance with this procedure.
Table 4.1-1 Os DEVIATION REPORT ORIGINATORS / REVIEWERS REVIEWERS Originator First Second
! or
- Lead Discipline Inspection Issue i
Inspector Supervisor Coordinator Discipline Engineer Lead Engineer Supervisor l
l Issue Coordinator Supervisor QA/QC RTL
- In addition, the QA/QC Review Team Leader (RTL), the responsible Supervisor, and the SSEG Supervisor review all unclassified i
deviations and those reports which document deviations that appear to be prevalent in a population or work activity.
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CPP-010 Revision: 7 4
g-4.1.3 QA/QC Review Team Leader The QA/QC RTL performs reviews as required and is the final arbitrator of differences with a second reviewer's determination regarding the validity of DRs.
4.1.4 QA/QC Records Administrator The QA/QC Records Administrator distributes and controls reports sent from the reviewers in accordance with this procedure, maintains memorandums which supersede / cancel previously issued DRs, and makes entries, as required, in Verification Packages.
4.1.5 QA/QC Lead Discipline Engineers / Coordinators The QA/QC Lead Discipline Engineers / Coordinators ensure that recipients of DRs are advised when a DR is cancelled.
l 4.2 Policy Activities performed under this procedure shall conform to the policies contained in the latest Comanche Peak Response Team f-- Program Plan, ERC Management Program Plan, and the applicable
, (g)
Issue-Specific Action Plan (ISAP).
f Should an activity be designated as the responsibility of a Lead Discipline Engineer, or higher, it may be delegated by that individual to an individual under his or her supervision.
4.3 Conflicts In the case of a conflict between this procedure and the documents referenced in Section 4.2, the latter shall govern.
4.4 Definitions 4.4.1 Deviation Report A form used to document an apparent difference (deviation) in an attribute from that defined as acceptable and based on approved design documents which is observed while verifying the acceptability of that attribute.
4.4.2 (Construction) Deviation A verified failure to construct or install a safety-
. related structure, system, or component in accordance l with safety-significant attributes and criteria l contained in design drawings and specifications or
~ installation procedures / requirements.
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CPP-010 Revision: 7 -
V 4.4.3 Unclassified Deviation A deviation, or set of related deviations or trend which, when it is determined that no safety-significant evaluation will be performed, leads to a root cause investigation and generic implications analysis of any identified root cause(s) and specification of corrective action (s). Should such a determination be made, performing a safety significance evaluation of the unclassified deviation (s), or an adverse trend analysis of the unclassified trend would serve no purpose and shall not be accomplished.
5.0 PROCEDURE 5.1 Initiation Should responsible QA/QC Review Team personnel (Refer to Table 4.1-1) determine that a (construction) deviation exists, or
< there appears to be a deviation common to the population or work activity, they shall initiate a DR in accordance with Attachment 6.1.
Inspectors shall identify the hardware associated with each
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(construction) deviation by attaching a tag in a conspicuous louation. Tags shall, as a minimum, indicate:
DR NO: (Number)
ID: (Item Number)
ERC: (Signature of Inspector and Date)
It is unnecessary to tag any of the hardware which comprises the population or work activity associated with a common deviation. However, should a common DR be issued that, in effect supersedes any (construction) DRs, any tags attached previously to the deviating hardware may remain intact.
Upon the completion of DRs in accordance with Attachment 6.1,
, originators forward them to the first reviewer.
5.2 Review and Approval Reviews are conducted by responsible personnel in accordance with the following procedures. Should a reviewer determine I that a subsequent review is unnecessary based upon this procedure, he or she marks those portiors of the DR "N/A" (not applicable).
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CPP-010 Revision: 7 .
\s / 5.2.1 First Reviewer First reviewers ensure that DRs forwarded from the originator state the applicable criteria and the apparent difference that caused the initiation of the DR. They also ensure that DRs are otherwise complete, accurate, and consistent with the requirement of this procedure. Accordingly, he or she checks the block on the form marked "YES", then signs and dates it.
Should the first reviewer disagree with the originator's assessment of the finding, he or she checks the block marked "NO" and provides reasonable justification in the appropriate block on the form, then obtains the concurrence of the originator.
NOTE: Should the originator concur in the first reviewer's determination that the finding does not differ from the specified criterion, the originator ensures that any associated hold tag is immediately removed.
Should the originator maintain that the finding does differ from the specified criterion, he or she checks the block on the form marked "PENDING", then N signs and dates it.
NOTE: Should the originator disagree with the first reviewer's determination, any associated hold tag and previous reference remains intact.
Upon completion of reviews in accordance with this paragraph, the first reviewer sends DRs:
Determined to be erroneous and which indicates the originator's agreement to the QA/QC Records Administrator for control.*
Determined to be accurate to the second reviewer.*
Which indicate the originator's disagreement to the second reviewer.*
- For ISAP VII.b.2, VII.b.3, and VII.c, this may be accomplished upon transmittal of the Verification Package in accordance with Reference 3.4. Also see Paragraph 5.3.1.
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CPP-010 Revision: 7 fm (s- 5.2.2 Second Reviewer Second reviewers provide confirmation of the first reviewer's decision and/or make determinations relative to reports which indicate disagreement between the originator and the first reviewer. Second reviewers determine when a deviation or set of related deviations which, without any safety-significant considerations, warrants a root cause investigation and generic implications analysis of any identified root cause(s) and specification of corrective action (s) in accordance with Reference 3.2.
The QA/QC RTL, responsible Supervisor, and the SSEG Supervisor supplement the confirmations / determinations of the second reviewer relative to unclassified deviations. They also review all DRs which address a common deviation to ensure that they depict a deviating condition that is prevalent in the population or work activity and to ensure that any necessary data is provided.
i Should the deviation be relative to inspector certification, the responsible QA/QC Lead Discipline Engineer shall sign and date the form adjacent to the
! % first reviewer to indicate his or her concurrence. The
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\s- engineer lines out the entry on the Verification Package Contents form and indicates that the DR was l forwarded to the ISAP I.d.1 Issue Coordinator. The engineer removes the appropriate DR originals from the package and transmits them directly to the ISAP I.d.1 l
Issue Coordinator in accordance with Paragraph 5.3.1.
i The ISAP I.d.1 Issue Coordinator validates and further l evaluates the DR in accordance with ISAP I.d.1.
Accordingly, the second reviewer evaluates the reported condition. For exanple:
Reviewing applicable drawings / diagrams, notes, Design Change Authorizations (DCAs), Component l, Modification Cards, etc. to determine if the l
reported condition conforms to the approved design.
Should the reported condition conform to the I
approved design at the time of the original inspection and be exempt from any later design changes, the report is considered invalid.
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CPP-010 Revision: 7 l
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- Reviewing Nonconformance Reports (NCRs) issued f in accordance with Reference 3.3 and any contractor controlled Deviation Report to determine if the reported condition duplicates one previously reported.
I Should the condition noted in QA/QC !
reinspection / review be the subject of a i previously issued NCR, or contract controlled )
deviation report, the DR is considered invalid. i
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l Should a previously issued NCR or contractor :
1 controlled deviation report disposition the reported condition as " repair" or "use as is" and incorrectly records the actual condition, the (QA/QC) DR is considered valid.
l Reviewing applicable Safety Analysis Report, Regulatory and/or industry standards / '
requirements.
Should the condition, as reported, be invalid, the second reviewer records reasonable justification which supports the conclusion on the form, then signs and m dates it.
The second reviewer ensures that any information used
! in the validation process is traceable to an acceptable source document and is referenced on the form. Any attachments are indicated on the form.
Should the results of the review indicate that the reported condition is invalid, the second reviewer obtains the concurrence of the originator and the first reviewer (s), or individuals acting in those capacities should they no longer be assigned to the Project (indicated by their signatures and dates on the form).
Otherwise, the second reviewer enters "N/A" in the spaces provided for those signatures.
NOTE: Should the reported condition be invalid, the l
originator ensures that any associated hold l
tag is immediately removed.
The QA/QC RTL is the final arbitrator of any unresolved differences.
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CPP-010 Revision: 7 p
k Upon completion of reviews in accordance with this paragraph, the second reviewer signs and dates the DR, then forwards those determined to be:
Invalid and which indicate the concurrence of the originator and the first reviewer; to the QA/QC Records Administrator for control.*
Valid; to the QA/QC Records Administrator for distribution and control.*
Unclassified; to the responsible Supervisor for confirmation and further reviews by the SSEG Supervisor and the QA/QC RTL.*
The QA/QC RTL, the responsible Supervisor, and the SSEG Supervisor initial and date unclassified DRs and those DRs that are common to the population or work activity adjacent to the "SECOND REVIEWER" block.
- For ISAP VII.b.2, VII.b.3, and VII.c, this may be accomplished upon the transmittal of the Verification Package in accordance with Reference 3.4. Also see Paragraph 5.3.1.
5.3 Distribution and Control
[\
-/ 5.3.1 Reviewers With the exception the QA/QC RTL, the responsible Supervisor, and the SSEG Supervisor performing reviews of DRs which address an unclassified or common l deviation, reviewers sending DRs to another reviewer, or the QA/QC Records Administrator document the transmittal in a memorandum which includes, as applicable, the:
Report number.
f ISAP number when other than ISAP VII.c.
1 Whether the DR is valid or invalid.
The date of (in) validation.
Whether the DR is considered " unclassified."
l First reviewers also provide a copy of each transmittal l and a copy of each DR (without attachments) to the responsible Supervisor for information and the QA/QC l Coordinating Engineer.
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CPP-010 Revision: 7
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N- 5.3.2 QA/QC Records Administrator The QA/QC Records Administrator normally transmits copies of valid DRs received from the second reviewer (refer.to Paragraph 5.2.2) to the SSEG Supervisor for analyses, the CPSES QC Coordinator for further l processing in accordance with Reference 3.3, and the QA/QC Interface Coordinator for action as required per Reference 3.5. However, unclassified DRs and those reviewed by the ISAP I.d.1 Issue Coordinator are transmitted to the SSEG Supervisor for information only, as safety-significant evaluations for those DRs are unwarranted. DRs reviewed by the ISAP I.d.1 Issue Coordinator are also transmitted to the appropriate first reviewer for use in the collective evaluation.
The QA/QC Records Administrator documents transmittals of valid DRs on uniquely numbered memorandums which include provision for the CPSES QC Coordinator to l acknowledge receipt. In addition, the QA/QC Records Administrator maintains records to ensure that the CPSES QC Coordinator is in receipt of all valid DRs, l e.g., a file of transmittals forwarded to and received from the CPSES QC Coordinator. A copy of the i
_s transmittal and a copy of each DR (without attachment)
(/
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is sent to the QA/QC Coordinating Engineer for information.
The QA/QC Records Administrator maintains DRs reviewed by the ISAP I.d.1 Issue Coordinator in the file marked VII.c-5. DRs that are not associated with any specific Verification Packages, including those that are unclassified and those that are common to the population / work activity, are filed with the applicable ISAP.
The QA/QC Records Administrator maintains memorandums that, in effect, cancel DRs previously determined to be valid in the appropriate Verification Package, or when Verification Packages are not required, with the applicable ISAP.
NOTE: Memorandums added to the Verification Packages shall be recorded, as required, on the Verification Package Contents form and applicable DRs clearly marked " CANCELLED.
Refer to (Names)'s memo dated (date)."
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CPP-010 Revision: 7
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_s/s 5.4 Revision
, Should a DR be prepared that, in effect, will supersede any DRs issued previously, or should it be necessary to make a change to a DR that would alter its finding or disposition, the cognizant individual prepares a new DR which includes the necessary change (s), is identified by the next appropriate DR number, and clearly denotes " SUPERSEDES (DR Number)." When numerous DRs are superseded, e.g., when a DR common to the population / work activity supersedes any DRs issued.previously, it is advisable to denote " SUPERSEDES THE DRs NOTED ON THE ATTACHMENT" and identify each of the affected DRs on the attachment.
f In addition, the cognizant individual prepares a memorandum which is addressed to " File" and provides a reasonable i explanation regarding the change. The memorandum notes the superseded and superseding DR numbers. The memorandum, with
{ the new DR attached, is routed for review. Except when a DR that is common to a population or work activity supersedes any
- (construction) deviations issued previously and the additional l review and approval of the QA/QC RTL, the responsible l Supervisor, and the SSEG Supervisor is required, the new DR is
{
reviewed, approved, distributed, and controlled the same as
! the one it supersedes.*
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- For ISAP VII.b.2, VII.b.3, and VII.c, this may be accomplished upon the transmittal of the Verification Package in accordance with Reference 3.4.
NOTE: Memorandums and superseding DRs, other than I.d.1 DRs, added to the Verification Packages shall be recorded, as required, on the Verification Package Contents forms and applicable DRs clearly marked " SUPERSEDED.
REFER TO (New DR Number)." Should a I.d.1 DR be superseded, the required memorandum is listed on the Verification Package Contents form as " MEMO DATED (Date) RE: DR (Number) to I.d.1 Issue Coordinator" and a copy, without the referenced DRs, is included in the Verification Package.
Otherwise, the cognizant individual shall make any innocuous cihngestoDRsinaccordancewithReference3.6andensure that any previous recipients of the DR are advised of its current status by distribution of the revised DR.
5.5 Cancellation Should there be documented evidence that, in effect, cancels a .
previously validated and issued DR, the cognizant QA/QC j Discipline Engineer ensures that the recipients of those DRs j are advised by memorandum of their correct status.
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CPP-010 Revision: 7 ,
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The memorandum is addressed to " Distribution", provides a reasonable explanation regarding the cancellation, and is routed for review and approval to the same organizations
/ disciplines that performed the previous review and approval.
Determinations relative to cancellations shall be traceable to an acceptable source document.
Copies of the memorandum are forwarded to the individuals noted for distribution, e.g., the:
Responsible QA/QC Supervisor or Issue Coordinator SSEG Supervisor QA/QC Interface Coordinator QA/QC Coordinating Engineer QA/QC Records Administrator CPSES QC Coordinator l Should the DR be cancelled, e.g., the item was determined to be an invalid sample, the cognizant QA/QC Discipline Engineer shall prepare an Out-of-Scope Observation in accordance with i Reference 3.7 to address the unsatisfactory condition reported on the cancelled DR.
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, 6.0 ATTACHMENTS l 6.1 Deviation Report (Sample and Instruction).
6.2 Flow Diagram - Initiating a Deviation Report. l l
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Attachment 6.1 CPP-010 Revision: 7
/^'s Page 1 of 2
!,j ERC DEVIATION REPORT CCMANCHE PEAK RESPONSE TEAM ERC DEVIATION REPCRT (DR)
ORIGINATOR DAIE DR NLhBER (2) (2)
(1)
UNII IDENTIFICAIICN OF ITEM (3) O osE O Two O comox SYSTEM AND LOCAILON (5)
)
REQUIREMENT (CHECKLIST ITEM NO.
(6) r%
k N
OEVIATICN 3 g .
(7) l 0 rEs O so O PE-DtNo (INCt:DE ausrTrICirIcN is REacIRED)
DAIE ORIGINAIOR DAIE FIRST REVIFJER VALID DR O rEs O no (INCtcDE aus:IrICA: ION is REQUIRED)
FIRST REVIEWER DATE DATE ORIGINAIOR DATE SECOND REVIEWER i
CPP-010.I. Revision 3 l (
- Attachment 6.1 CPP-010 Revision: 7 f-~x
'-~ INSTRUCTIONS TO COMPLETE FORM CPP-010.1 "ERC DEVIATION REPORT (DR)"
Originators initiate DRs by entering:
(1) The unique DR number. For example:
I-S-CONC-001 - DR 1
--- Unique Number, e .g . , 1, 2, 3, etc.
--- Deviation Report Designation l --Dash Unique Verification Package Number (for ISAP VII.c), or "I" for reinspections for "R" for reviews of documentation and the ISAP number, e.g., R- VII.a.7.
For DRs that are common to the population or work activity, enter " GEN" in lieu of the unique Verification Package Number, e.g., I-S-CONC-GEN-DR1, or R-VII.a.2-GEN-DRI.
- ) (2) Signature as originator and date.
s_/
(3) The identification of the equipment, mater,ial, component, procedure, e.g.,
" bolts on Cire. Water Pump " Include the applicable drawing number and l revision.
(4) The appropriate unit (s),
i (5) The system and location including elevation, column /line designation, etc.,
or " UNKNOWN" or "N/A" if applicable.
(6) The criterion, i.e., attribute, by which the item was measured and found unacceptable. Reference the source of the specific requirement, e.g., the QI checklist item number.
NOTE: Each DR shall describe only one attribute.
(7) A description of the deviation. Include sketches and additional pages as required.
NOTE: Reference to any attachment shall be made on the DR. Any i
attachment shall indicate the appropriate DR number. The total
' number of pages of any attachment shall be determinable.
Upon completion, the originator forwards DRs to the appropriate first reviewer (refer to Table 4.1-1) for review in accordance with Section 5.2.*
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- For ISAP VII.b.2, VII.b.3, and VII.c this may be accomplished upon the transmittal of the Verification Package in accordance with Reference 3.4.
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! Attachment 6.2 CPP-010 Revision: 7 Page 1 of I d
INITIATING A DEVIATION REPORT OR -
IST REVIEWER PLACES HOLD TAG h F AS D(QU{R(Q YYES NO DEVIATION YES g ORIGINATOR FROM CR TERION y sm hNO(!NCLJUS) 80END(INCLJLT 3 !TH I VIEWE
% :2, y M
@ U s% sO I Y RE INSPECTOR CERT YES Y g y 2ND REVIEE R h
NO 540(INCJUS)
OA/nc *ECO*05 2 40 CR VALID NO gy 7 ?
ADMINISTRATOR gg Q 7 g se YES fES FOR y y y O!STRIBUTION AND @YES I YES CONTROL ORIG N TOR y 3,y l
2ND PEVIEWER Mb ME'I~o M l Y
g3 PROCESS PER CPD-025 NO AG#EE NO QA/0C RTL CR COPHON INTERCEDES WITH 2ND REV!E9ER OR UNCLASSIFIED
?
HOLD TAG RE"0VED N AS REQUIRED Y T INO(INCJUS) l RES SLE SUPV.
b"- e 24- SSEG SUPERVISOR 1
'IECESSARY !
CATA i
@YES &W
\ YES "EETS C0!TE0!"N
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