ML20209C389
| ML20209C389 | |
| Person / Time | |
|---|---|
| Site: | Sequoyah  |
| Issue date: | 01/23/1987 |
| From: | TENNESSEE VALLEY AUTHORITY |
| To: | |
| Shared Package | |
| ML20209C049 | List: |
| References | |
| 209.2(B), 209.2(B)-R01, 209.2(B)-R1, NUDOCS 8702040261 | |
| Download: ML20209C389 (16) | |
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c TVA EMPLOYEE CONCERNS REPORT NLMBER: 209.2(B)
SPECIAL PROGRAM REPORT TYPE:
SEQUOYAH ELEMENT REVISION NLMBER: 1 TITLE:
Q-LIST Impact and Significance of Q-List PAGE 1 0F 15 Differences a
REASON FOR REVISION:
1.
Revised to incorporate SRP and TAS comunents, add chronology, and add Section 10, Corrective Action.
PREPARATION PREPARED BY-
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///f/87 SIGNATURE
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REVIEW CGMIIILE:
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DATE sY
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SIGNATURE DATE l
CONCURRENCES I lS
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I B702040261 87o127
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//7 % (j 7 SIGNATURE DATE
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SIGNATURy /
DATE APPROVED BY:
MU$AE-i-2s-37 alu ECSP MANAGUt DATE /
MANAGER'0F NUCLEAR POWER DATE CONCURRENCE (FINAL REPORT ONLY)
SRP Secretary',s signature denotes SRP concurrences are in files.
TVA EMPLOYEE CONCERNS REPORT NLSWER: 209.2(B)
SPECIAL PROGRAM REVISION NLSWER: 1 PAGE 2 0F 15 1.
CHARACTERIZATION OF ISSUE (S):
Concerns:
Issues:
IN-85-407-001 a.
The documents (Q-Lists or equivalents)
"CSSC Q-List is not accurate, used on SQN to identify the applic-Not all components covered by ability of QA program controls are not QA program are listed. QE accurate and complete.
(This issue is Department has list that docu-addressed in Element Report 209.1 (B),
ments the inaccuracies. The not in this report.)
CSSC Q-List is used to detemine if QC inspections are required.
b.
The use of inadequate Q-Lists (or equi-CI has no further information."
valents) on SQN could have adversely affected the establishment of appro-IN-86-087-004 private QA program controls on items that "Significant differences exist are related to plant safety. By in the content of the Nuclear reference to an inadequate Q-List, the Power 'Q' List and the Critical possibility exists that "Non-Q" items Structures, Systems and Compo-are installed in a safety-related nents (CSSC)
'Q' List. Many system.
items originally placed on the NUC Power 'Q' List are not c.
Various Q-Lists (or equivalents) exist reflected on the CSSC 'Q'
- List, on SQN, which are different in content.
which could adversely affect (This issue is addressed in Element Report establishment of appropriate 209.1 (B), not in this report.)
quality controls on items which are related to plant safety.
d.
The engineering design group does not Nuclear Power concern.
No provide input to the Q-Lists (or specifics provided.
CI has no equivalents) on SQN.
(This issue is further information."
addressed in Element Report 209.1 (B),
not in this report.)
IN-86-090-001 "NUC PWR (No name/ dept. given) issued a Critical Structures, Systems and Components List (CSSC) that does not include all items identified on the site
'O' List (No specifics given). This was done with-out Office of ENG, ENG Design Group input / approval (The originator of the site 'Q' List). By referring to the CSSC, the possibility exists for installing 'Non-Q' items in a Safety-Related System. CI has no additional infomation.
NUC POWER concern."
01300 - 01/15/87
1 TVA EMPLOYEE CONCERNS REPORT NUMBER: 209.2(B)
SPECIAL PROGRAM REVISION NLMBER: 1 PAGE 3 0F 1S 2.
HAVE ISSUES BEEN IDENTIFIED IN ANOTHER SYSTEMATIC ANALYSIS? YES NO X Identified by Not applicable Date Not applicable Documentation Identifiers:
Not applicable 3.
DOCUMENT NOS., TAG NOS., LOCATIONS, OR OTHER SPECIFIC DESCRIPTIVE IDENTIFICATIONS STATED IN ELEMENT:
None 4.
INTERVIEW FILES REVIEWED:
a.
Expurgated file for IN-86-090-001. This file contained a l
copy of the Employee Concern "K" form and copies of documents previously reviewed by this evaluator.
b.
Expurgated file for IN-85-407-001.
This file contained l
copies of the Employee Concern "K" fonn, ECTG Administrative forms, and documents previcusly reviewed by this evaluator.
c.
Expurgated file for IN-86-087-004. This file contained l
copies of the Employee Concern "K" fonn, ECTG administrative forms, and documents previously reviewed by this evaluator.
5.
DOCUMENTS REVIEWED RELATED TO THE ELEMENT:
See Appendix A.
6.
WHAT REGULATIONS, LICENSING C0l#11TMENTS, DESIGN REQUIREMENTS, OR OTHER APPLY OR CONTROL IN THIS AREA?
See Appendix A.
7.
LIST REQUESTS FOR INFORMATION, MEETINGS, TELEPHONE CALLS, AND OTHER DISCUSSIONS RELATED TO ELEMENT.
See Appendix A.
0130D - 01/15/87
TVA EMPLOYEE CONCERNS REPORT NLMBER: 209.2(B)
SPECIAL PROGRAM REVISION NLMBER: 1 PAGE 4 0F 15 8.
EVALUATION PROCESS:
The evaluation of concerns in this element is predicated on the findings and conclusions of element report 209.1 (B): that the accuracy and completeness of the SQN CSSC List has not been adequately verified by TVA.
a.
Reviewed SQN practices and procedures to determine the use of the SQN CSSC List.
Interviewed cognizant TVA personnel as necessary.
b.
Assessed the potential for the use of an incomplete or inaccurate SQN CSSC List to adversely impact appropriate QA program control measures on items and activities related to plant safety.
9.
DISCUSSION, FINDINGS, AND CONCLUSIONS:
Chronology:
05/70:
Construction pemit issued for SQN Units 1 and 2 03/77:
Construction Specification N2G-877 provides additional instruction to Construction for identifying safety-related structures, systems, and components 04/78:
The CSSC List developed and issued by Nuclear Power for the Operations QA program 09/80:
Operating license issued for SQN Unit 1 0 9 / 81 :
Operating license issued for SQN Unit 2 10/82:
OEDC-20PD-5 Rev.1 assigns EN DES the responsibility of preparing a detailed identification of structures, systems, and components covered by the QA program (Q-List) 01 / 8 3 :
Office of Engineering (OE) issues the WBN Q-List for 1 year trial use 01300 - 01/15/87
TVA EMPLOYEE CONCERNS REPORT NLSWER: 209.2(B)
SPECIAL PROGRAM REVISION WlDEER: 1 PAGE 5 0F 15 01 /8 5:
Discrepancies surface among the various WBN Q-Lists, leading to issue of NCR W-269-P in 08/85 and subsequent reporting to the NRC as a 10CFR50.55(e)
"significant deficiency" in 10/85 02/85:
Responsibility for maintaining the SQN CSSC List transferred to the Site Director from QA organization 03/85:
SQN Administrative Instruction AI-39 provides for maintenance of the SQN CSSC List by the CSSC Review Committee 06/85:
Employee Concern IN-85-407-001 received by TVA 07/85:
Employee Concern IN-85-688-003 received by TVA 08/85:
Employee Concerns IN-86-087-004 and IN-86-090-001 received by TVA 06/86:
SQN Generic Concern Task Force issues Report G0R-16-16 Rev.1, Investigation of Employee Concern IN-85-688-003 Discussion:
a.
The three employee concerns associated with Element 209.2 relate to the existence of different Q-Lists on Watts Bar Nuclear Plant (WBNP), the accuracy of the lists, and the effect of using those lists.
Although these concerns resulted from specific applications and conditions at WBNP, they have been classified as generically applicable to the other TVA nuclear plants, including Sequoyah, because the potential exists for similar deficiencies in the related lists of the other facilities.
The investigation for Element 209.2 is limited to the issue of whether the use of inadequate Q-Lists (or equivalents) on SQN could adversely affect the establishment of appropriate QA program controls on items and activities related to plant safety.
The related issues of accuracy and completeness of the lists are addressed in Element Report 209.1, and certain infomation from that report is repeated here for continuity l
and to minimize cross referencing.
01300 - 01/15/87
TVA EMPLOYEE CONCERNS REPORT IR98ER: 209.2(B)
SPECIAL PROGRAM REVISION Nt#EER: 1 PAGE 6 0F 15 b.
"Q-List" is a generic term used by the nuclear power industry to describe a listing of the plant structures, systems, and components subject to the Quality Assurance (QA) program requirements of 10CFR50 Appendix B.
The fomat and detail of Q-Lists used in the nuclear power industry vary from sumary type lists containing only first-level identification to extensive listings with subcomponent identification and detailed data.
The only "Q-List" type document used on Sequoyah is identified as the Critical Structure, Systems, and Components (CSSC) List, and is of the sumary type.
It is a working document, with everyday use in the activities of the Operations organization, such as modifications, maintenance, and procurement.
However, the SQN CSSC List is used only by the Operations organization; and the list was not used by Construction or Engineering at SQN.
This limitation on use of the CSSC List apparently stems from its development by the Nuclear Power (NUC PR) organization for application to the Operational QA program.
TVA is only recently coming to the more typical nuclear power industry practice, in which a Q-List document is developed and used during the design and construction phase of a project by the various organizations.
To accomplish the purpose of a Q-List, Engineering issued individual system drawings (P& ids, flow diagrams, etc.)
identifying the safety-related structures, systems, and components on SQN.
These drawings, rather than the SQN CSSC List, were used as the source documents by Construction to detemine the items and activities requiring QA program control s.
Construction Specification N2G-877 contains Construction guidance for identifying items requiring QA program controls.
Prior to revision 5, N2G-877 contained generalized convenience listings of safety-related items; however, these were used only as guidelines and do not constitute a "Q-Li st. " The current revision of N2G-877 (Rev. 5) allows Construction to use a' "Q-List" (91QL series drawings) as an alternate to the system drawings for identification of items requiring QA program controls, but up to this date this alternate method has not been used by Construction.
1 01300 - 01/15/87
TVA EMPLOYEE CONCERNS REPORT NLSSER: 209.2(B)
SPECIAL PROGRAM REVISION NLSSER: 1 PAGE 7 0F 15 4
Therefore, this investigation of potential negative impact from using inadequate "Q-Lists" applies only to the use of the SQN CSSC List by the Operations organization.
c.
Review of the case file documents shows that the SQN CSSC List is an integral part of procurement, maintenance, and modification activities at SQN. The SQN procedures ( App. A, 5.1, 5.n, and 5.0) that control these activities typically cite the CSSC List as the detenninant of safety-related (CSSC) items and activities.
Proper classification as CSSC vs non-CSSC is fundamental for incorporating appropriate quality program requirements in the governing documents.
Misclassification of an item or activity as non-CSSC could cause essential requirements and activities, such as the following, to be omitted from procurement, maintenance, and modification processes:
4 i
o Reviews for adequacy of technical and quality requirements o
Supplier QA program requirements o
Documentation o
Inspections and tests o
Record retention f
o Special requirements and procedures, such as 10CFR21 d.
Review of the revision history of the SQN CSSC List showed many additions since its initial issue. Sequoyah l
Administrative Instruction AI-39 requires that added items must be evaluated (and the CSSC List revised as necessary) prior-to declaring the affected equipment operable. This procedure includes issuing deficiency reports as needed to document the resolution of items previously processed as non-CSSC.
Discussions with cognizant TVA personnel indicated that most additions to the SQN CSSC List occurred as a part of plant l
i modification actions rather than from reclassification of items or correction of omissions in the list.
In addition, the Chairman of the CSSC Review Consnittee indicated that to his knowledge there have been no cases identified at SQN of the installation or use of nonqualified items as a result of errors in the SQN CSSC List.
01300 - 01/15/87
TVA EMPLOYEE CONCERNS REPORT MlM8ER: 209.2(B)
SPECIAL PROGRAM REVISION NLM8ER: 1 PAGE 8 0F 15 e.
TVA policy docuents, including the Nuclear Quality Assurance Manual (NQAM), commit the Division of Nuclear Engineering (DNE) to developing and maintaining a Q-List for each TVA nuclear plant. These lists will be used by all divisions within a plant to maintain uniformity. Thus, the SQN CSSC List should eventually be superseded by an SQN Q-List.
ID-QAP-2.7, governing the development, control, and application of a Q-List for each nuclear plant, has undergone several revisions extending the implementation consnitment for the SQN Q-List.
It now states that the Q-List will be put into effect at a date mutually agreed to by DNE and the Site Di rector.
However, the development and implementation of the SQN Q-List will apparently not occur until after completion of the upgrade and revision activities currently in progress for the WBN Q-List.
Review of the SQN CSSC Review Consnittee Meeting Minutes (6/85 through 4/86, App. A, 5.u) indicates that the determination of proper CSSC classification for neerous items has been deferred to the pending DNE-developed Q-List.
l The effect of potential errors, as they relate to past procurement, maintenance and modification processes has not been addressed.
Findings:
a.
To date, the SQN CSSC List has been used only by the Operations organization; the list was not used by Construction or Engineering on SQN. Therefore, the potential effects of using an inaccurate or incomplete SQN CSSC List are limited to Operations activities, which include procurement, maintenance, and modification.
b.
SQN procedures that control procurement, maintenance, and modification activities of the Operations organization establish the SQN CSSC List as the base reference for identifying safety-related (CSSC) items or activities.
Erroneous classification as non-CSSC could result in omission of essential requirements and activities.
c.
No specific deficiencies in the SQN CSSC List were identified in the review of the case file materials.
4 0130D - 01/15/87
TVA EMPLOYEE CONCERNS REPORT NUMBER: 209.2(B)
SPECIAL PROGRAM REVISION NUMBER: 1 PAGE 9 0F 15
==
Conclusions:==
The conclusions of this Element Report are subordinate to those of Sequoyah Element Report 209.1, which concludes that it is prudent for TVA to perform a confirmatory review of the accuracy and completeness of the SQN CSSC List, and that those items previously deferred by the SQN CSSC Review Cannittee should be resolved.
Sequoyah Element Report 209.1 also concluded that the on-going activities of the SQN CSSC Review Cannittee provide a reasonable assurance that there are not major problems with the SQN CSSC List.
The evaluation team considers the issues relating to the possibility that use of an inadequate SQN CSSC List could adversely affect QA program controls on items related to plant safety to be valid for SQN.
This conclusion is based on the significant role of the SQN CSSC List in SQN procedures controlling procurement, maintenance, and modification activities within the Operations organization. An inaccurate or incomplete SQN CSSC List could result in misclassification of an iten or work activity as not being safety-related (CSSC), resulting in omission of QA program requirements.
This could adversely affect the establishment of appropriate QA program controls on items affecting plant safety, which would require resolution prior to restart.
Further TVA followup actions related to this element depend on the results of the corrective action for Sequoyah Element Report 209.1.
- 10. CORRECTIVE ACTION:
TVA has subnitted a corrective action plan (TCAB-021). This plan provides that if the corrective action for Sequoyah Element 209.1 discloses inaccuracies or omissions in the SQN CSSC List, the items will be dispositioned (prior to restart if appropriate) in accordance with the established procedures for conditions adverse to quality.
The evaluation team concurs with the TVA corrective action plan.
i l
l 01300 - 01 /15/87
TVA EMPLOYEE CONCERNS REPORT NLMBER: 209.2(B)
SPECIAL PROGRAM REVISION NUMBER: 1 PAGE 10 0F 15 l
APPENDIX A 5.
DOCUMENTS REVIEWED RELATED TO THE ELEMENT:
a.
10CFR 50, Appendix B, Quality Assurance Criteria for Nuclear Power Plants and Fuel Reprocessing Plants, Criterion II,
" Quality Assurance Program" b.
Regulatory Guide 1.29, Rev. 2, Seismic Design Classification, (02/76) c.
Regulatory Guide 1.26, Rev. 2, Quality Group Classifications and Standard for Water-Steam, and Radioactive Waste Containing Components of Nuclear Power Plants, (06/75) d.
SNP FSAR, Section 3.2 (Amendnent 3), " Classification of Structures, Systems and Components" e.
SNP FSAR, Section 17 (Amendnent 3), " Quality Assurance" f.
TVA Topical Report TVA, TR75-1A (Rev. 8), Quality Assurance Program Description for the Design, Construction, and Operation of TVA Nuclear Power Plants g.
Nuclear Quality Assurance Manual, Part V, Section 2.7 (ID-QAP-2.7), Rev. O, "Q-List," (06/18/86)
Nuclear Quality Assurance Manual, Appendix A, "CSSC Lists -
h.
All Plants," (07/29/85) 1.
Construction Specification, N2G-877 (Initial Issue through Rev. 5), Identification of Structure, Systems, and Components Covered by the Sequoyah Nuclear Plant Quality Assurance Program J.
SNP Construction Procedure, P-24 (Rev. 6), Inspection and Test Status, (05/07/82) k.
SNP Adninistrative Instruction, AI-39. Rev. 2, Critical Structures, Systems and Components - (CSSC), (01/09/86) 1.
SNP Adninistrative Instruction, AI-19, Part III, Rev. O,
" Plant Modifications: Modification Request," (06/03/86), and Part IV, Rev.18, " Plant Modifications: After Licensing,"
(07/07/86) m.
SNP Standard Practice, SQA134, Rev. 8, Critical Structure, Systems and Components (CSSC) List, (01/27/86) 01300 - 01 /15/87
TVA EMPLOYEE CONCERNS REPORT NLMBER: 209.2(8)
SPECIAL PROGRAM REVISION NLMBER: 1 PAGE 11 0F 15 APPENDIX A (Cont'd) n.
SNP Standard Practice, SQN2, Rev. 20, Maintenance Management System, (09/11/86) o.
SNP Standard Practice, SQA45, Rev. 22, Quality Control of Material and Parts and Service, (09/11/86) p.
NSRS Investigation Report I-85-422-WBN, (10/04/85) q.
WBNP NCR No. W-269-P, (08/26/85) r.
Letter from Mills, TVA, to Adensam, NRC, (A27831107026), "TVA Docket No. 50-327 & 50-328, TVA Response to Items 2.1 and 2.2 of NRC Generic Letter 83-28," (11/07/83) s.
Letter from 01shinski, NRC, to White, TVA, (L44860429173),
" Report Nos. 50-327/86-11 and 50-328/86-11," (04/22/86) t.
Letter from Gridley, TVA, to Grace, NRC, (L44860627800),
Subject:
" Response to Inspection Report 50-307/86-11 and 50-328/86-11," (06/27/86) u.
Minutes of SQN CSSC Review Committee Meetings:
Meeting 85-02, (S53 850730 825), (06/26/85)
Meeting 85-03, (S53 851101 980), (09/10/85)
Meeting 85-04, (S53 851203 903), (11/14/85)
Meeting 86-01, (SS3 860219 840), (01/14/86)
Meeting 86-02, (S53 860423 814), (04/15/86)
Meeting 86-03, (SS3 860514 940), (04/24/86) v.
TVA memo from Whitt to Parris, (no RIMS), NSRS Investigation Report I-85-422-WBN, (10/11/85) w.
TVA memo from Howard to Ennis, (no RIMS), " Employee Concern Investigation Report Transmittal Response,"
(12/06/85) 0130D - 01/15/87
TVA EMPLOYEE CONCERNS REPORT WlMBER: 209.2(B)
SPECIAL PROGRAM REVISION NLM8ER: 1 PAGE 12 0F 15 l
APPENDIX A (Cont'd) x.
TVA memo from Whitt to Ennis, (No RIMS), " Corrective Action Response Evaluation (I-85-422-WBN, Item 2)," (01/08/86) y.
TVA memo from Whitt to Ennis, (No RIMS), " Corrective Action Response Evaluation (I-85-422-WBN, Items 1, 3, 4)," (01/08/86) z.
TVA memo from Raulston to Gridley, (845 860306 260),
Final 10 CFR 50.55(e) Report on NCR W-269-P R1, (03/06/86) aa.
TVA memo from Fortenberry to McNutt, (no RIMS), "SQN -
Engineering (Related Employee Concerns - Subcategory / Element 209.1 ( B )," 10/06/86) b b.
TVA memo from Abercrombie to Brown, (S03 861205 807), "SQN -
ECTG Element Report 209.2 SQN - Engineering Category -
Corrective Action Plan (CAP)," (12/05/86) cc.
Letter from McNutt to Parkinson, (TCAB-021), " Employee Concern Evaluation Program - Sequoyah Restart Program -
Corrective Action Plan (CAP)," (12/08/86) dd.
TVA memo from Fortenberry to McNutt, (SS3 870106 942), "SQN -
Employee Concern Evaluation Report - SQN Element 209.1(B),"
(01/05/87) 6.
WHAT REGULATIONS, LICENSING CGMITMENTS, DESIGN REQUIREMENTS, OR OTHER APPLY OR CONTROL IN THIS AREA 7 a.
10 CFR 50, Appendix B, Criterion II, " Quality Assurance Program" b.
Regulatory Guide 1.26, Quality Group Classifications and Standards for Water-Steam, and Radioactive Waste Containing Components of Nuclear Power Plants c.
Regulatory Guide 1.29, Seismic Design Classification d.
SNP FSAR, Section 3.2, " Classification of Structures, Systems, and Camponents" e.
SNP FSAR, Section 17.0, " Quality Assurance" f.
TVA Topical Report, TVA-TR75-1A, Quality Assurance Program Description for Design, Construction, and Operation g.
TVA Nuclear Quality Assurance Manual (NQAM), Section 2.7, "Q-List," and Appendix A, "CSSC Lists - All Plants" 01300 - 01 /15/87
1
\\
TVA EMPLOYEE CONCERNS REPORT NUMBER: 209.2(B) 1 SPECIAL PROGRAM REVISION NUMBER: 1 PAGE 13 0F 15 APPENDIX A (Cont'd) h.
Construction Specification, N2G-877, Identification of Structure, Systems, and Components Covered by the Sequoyah Nuclear Plant Quality Assurance Program.
i.
SNP Administrative Instruction, AI-39, Critical Structures, Systems and Components - (CSSC) j.
SNP Administrative Instruction, AI-19, Part III, " Plant Modifications: Modification Requests," and Part IV, " Plant Modifications: After Licensing" k.
SNP Standard Practice, SQA134, Critical Structure, Systems, and Components (CSSC) List 1.
SNP Standard Practice, SQN2, Maintenance Management System m.
SNP Standard Practice, SQA45, Quality Control of Material and Parts and Services 7.
LIST REQUESTS FOR INFORMATION, MEETINGS, TELEPHONE CALLS, AND OTHER DISCUSSIONS RELAlto TO ELEMENT.
a.
Request for Information (RFI), SQN-563, (09/15/86) b.
RFI, #SQN 564, (09/15/86) c.
RFI, #SQN 576, (09/18/86) d.
RFI, #SQN 583, (09/22/86) e.
RFI, #SQN 619, (10/06/86) f.
RFI, #SQN 641, (10/16/86) g.
Telecon, L. J. Anderson, Bechtel, with R. W. Fortenberry, TVA, IOM 258, (09/18/86) h.
Telecon, L. J. Anderson, Bechtel, with D. T. Clif t, TVA, IOM 272, (09/24/86) 1.
Telecon, L. J. Anderson, Bechtel, with D. T. Clift, TVA, IOM 273, (09/29/86) 01300 - 01/15/87
TVA EMPLOYEE CONCERNS REPORT NUMBER: 209.2(B)
SPECIAL PROGRAM REVISION NUMBER: 1 PAGE 14 0F 15 APPENDIX A (Cont'.d) j.
Telecon, L. J. Anderson, Bechtel, with D. T. Clift and R. Olson, TVA, IOM 306, (10/09/86) k.
Telecon, L. J. Anderson, Bechtel, with D. T. Clift /R. W.
Fortenberry, TVA, IOM 308, (10/09/86) 1.
Telecon, L. J. Anderson /R. A. Wolters/J. B. Violette, Bechtel, and D. T. Clif t/R. W. Fortenberry, TVA, IOM 520, (12/17 and 18/86) m.
Letter, G. L. Parkinson, Bechtel, to G. R. McNutt, TVA, BLT-084, (12/23/86) n.
Letter, G. L. Parkinson, Bechtel, to G. R. McNutt, TVA, BLT-097, (01/15/87) 01300 - 01 /15/87
TVA EMPLOYEE CONCERNS REPORT NLM8ER: 209.2(8)
SPECIAL PROGRAM REVISION NLM8ER: 1 PAE 15 F 15 CATD LIST The following CATD identifies and provides corrective actions for the findings included in this report:
209.02 SQN 01 (12/05/86) 0130D - 01/15/87
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S GENERIC KEYHORD A
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KEYNORD B CONCERN SUB R PLT BBSH INVESTIGATION S
CONCERN KEYNORD C NUMBER CAT CAT D LOC FLQB REPORT R
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i MANY ITEMS ORIGINALLY PLACED ON THE 4
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$0 PROPRIATE QUALITY CONTROLS AN ITEMS i
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