ML20211C866
| ML20211C866 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 10/09/1986 |
| From: | DETROIT EDISON CO. |
| To: | |
| Shared Package | |
| ML20211C861 | List: |
| References | |
| FOIA-86-370, FOIA-86-A-147 11.000.52, NUDOCS 8610220044 | |
| Download: ML20211C866 (10) | |
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DEV_IATION AND CORRECTIVE ACTIO_N REPORTING 1.0 PURPOSE 1.1 This procedure defines the corrective action system that controls identifying, documentina, evaluating, reporting, and trending of significant conditions adverse to quality and nuclear safety.
This orocedure implements the applicable requirements contained in QAPA 1 QAPR 15, and QAPR 16.
1.2 This procedure also defines the corrective action systee for other conditions adverse to quality, including selected nonsafety-related items.
2.0 _ SCOPE 2.1 The deviation and corrective action reporting system described in this procedure shall be implemented for the following conditions:
2.1.1 Significant conditions adverse to quality of safety-related activities, items and services.
2.1.2 Conditions adverse to quality of safety-related activities, items and services.
D 2.1.3 Nonsafety-related activities, items or services where the conditione require corrective action to present recurrence.
NOTE:
Unless otherwise stated in this procedure, the term CAQ (or " condition adverse to quality") encompasses the 7 'a%
nditions.
'Qp 2.2 This systen may smented for nonsafety-related activities, or serviceY v)* hilureaffectsplant availability or items personnel safety.
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' ?'l 2.3 The implementation of this system is not required for equipment problems which may be corrected using the PN 21 work order process and which require no corrective action to prevent recurrence.
N 2.4 This procedure applies to the following organizations:
2.
haclear Oper c ior.m organizattons p e r f a c t r.,
oper.: tm.
maintenance, modifications, procurement or any other activities addressed by the Naclear Operations Management Plan.
8610220044 861009 PDR FOIA PUNTE86-A-147 PDR N
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2.4.2 Contractors, suppliers and Edison organizations whose activities are required to conform to Nuclear Operations directions, reethods and procedures as established in procurement documents.
2.4.3 Contractors, suppliers and Edison organizations that work to.their own methods and procedures which require Nuclear Operations approval to accept a deviation from Edison contract / purchase document technical or quality requirements.
3.0 REFERENCES
3.1 Quality Assurance Program Requirements (QAPRs) 3.1.1 QAPR 1, Organization 3.1.2 QAPR 15, Nonconforming Materials, Parts, or Components 7
3.1.3 QAPR 16, Corrective Action 3.2 Fermi 2 Technical Specifications, Section 6.0 3.3 Nuclear Operations Program Description (NOP) 106, Design Change Program 1
3.4 Nuclear Operations Interfacing Procedures (NOIPs) 3.4.1 NOIP 11.000.49, Document Control and Records Management 3.4.2 NOIP 11.000.55, Conditional Releases 3.4.3 NOIP 11.000.120, 10 CFR 21 Reports 3.4.4 N01P 11.000.125, ceneral Regulatory Reporting
- cquirements 4.0 DEFINITIONS 4.1 Conditions of Quality 4.1.1 Con,dition Adverse to Qaality (CAQ) - Any problem that e f fr:te :Sc q.;1i*v -f 6+f-ty-reic t'
t.r_
c1....
or prcgt.u.
li. i s i t.
l ud e. taalurcs, L !!.n;Licus, deficiencies, deviations, defective material and f
equipment, abnormal occurrences, and nonconformancea.
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11.000.52 Rev. 1 Page 3 Significant CAQ - A CAQ is considered significant when Tc is a Technical Specification violation, a sub-4.1.2 stantial safety hazard as defined by 10 CFR 21, a i
repetitive CAQ or a condition that could preventfrom performing a fun a
system or component to:
in a safe Shut down the reactor and maintain it e
shutdown condition, or I
Remove residual heat from the reactor, or o
Control the release of radiosctive material, or e
Mitigste the consequences of an accident, r
e The cause of such conditions, violations NOTE:
or hazards shall be determined and corrective action taken to prevent recurrence.
Corrective Action - As used under the provisions of this those stepa taken to 4.2 corrective action involves action procedure, In general, implementarion of corrective correct a CAQ.
with erescribed procedures of the la carried _out i'n accordance Corrective action may include Terrorming organtascion.
4
~ispedtate, remedial, and corrective action to prevent recurrence.
In:sediate Action - Action taken upon discovery of the CAQ to provide for safe operation, personnel safety, 4.2.1 and notification of appropriate supervisors or managers.
or disposi-Femedial Action - Action taken to correct tion an identified CAQ or to improve an identified 4.2.2 the action taken This action is usually not l
condition.
to prevent recurrence of the CAQ and is usually taken l
after initiation of immediate setion, if required, and Disposition after initial evaluations and reviews.
categories for nonconforming items are as follows:
f Revork - A
- nonconforming item may be classified
rework" if it can be brought into complete confor-1.
mance by recaachining, reasse:r,bly, or other cor-I the rective measures that do not otherwise affect cri* erie.
The rework ite 's origital necute :-
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is inspectec to origir.G requ:r n -
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Repair - A nonconforming ites may be classified
" repair" if it can be restored to a condition such that the item can reliably perform its intended function even though it does not completely conform to original requirements. A technical justification for relaxation of requirements is necessary for a " repair" dispoc_ition, except where codes or specifications permit such repair and the repair is made as specified therein. The repair is inspected to revised /new acceptance criteria prior to final acceptance of the item.
3.
lise-As-Is - A nonconforming item may be classified l
"use-as-is" when a documented technical justifi-
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cation is provided to substantiate that it will l
not adversely affect the ability of the item to perform its intended function or when reevaluation l
of the acceptance criteria determines that relax-ation of requirements is in order.
NOTE:
Disposition of an item may involve' issuance of a conditional release according to the requirements of NOIP
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11.000,55.
4.
- A nonconforming item m y be classified a
' reject" if it adversely affects the ability of
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g the item to perform its intended function and be economically reworked or repaired.
cannot 5.
Other - A nonconforfaiag item may be classified as W r" when rework, repair, use as-is, or reject does not apply. This classification may also be used when more than one of the other classifica-tions apply. This say identify downgrading of equipment / material for other use as specified in the DER disposition. An evaluation performed by engineering or management personnel should be completed for an "other" disposition.
4.2.3 Corrective Action To Prevent Recurrence (CATPR) - CATPK is directed at the root cause or origin of a Idoblem and contributing factors to prevent its repetition.
The root cause addresses the specific basic origin of the occurrence.
Such corrective actions may involve redesign, revisior. of a written requirenert, reettir -
c4 r. : c, f p e r s o n n e l, a d d a r4 r : c :;e r. s cor. : : 01 s c-in6 pee tion steps, and development of personnel, including supervision, indoctrination, training, qualification, etc.
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I 11.000.52 Rev. 1 Page 5 Corrective Action Review Board (CARB) - A board responsible for and evaluation of DERs. There are two 4.3 ~the processing, review, Fermi 2 as follows:
C ARBS at CARB-N.P. - The plant CARB consists of a minimum of l
4.3.1 the Superintendent - Nuclear three members:
Production, a section head from Nuclear Production, the Supervisor - Operational Assurance (OA) (or their designated alternates), and, if appropriate, a repre-if different }
sentative from the initiating organization The than those already represented on CARB-N.P.
Superintendent, Heintenance Operations; Superintendent, or a section head acts as chairman of and Modification; and schedules meetings on a regular basis as C ARB-N.P.
reports are originated.
Nuclear Operations CARB consists of a 4.3.2 C AR B-N.O. - The A chairman appointed by the
~ minimum of three members:
Hanager of Nuclear Operations, a supervisor from Nuclear Engineering (NE), a section head from Nuclear Quality Assurance (NQA) (or their designated alter-nates) and, if appropripte, a representative from the s
than those alreadv initiating organization if different represented on CARB-N.O.
Meetings are held as DERs are originated, or when individual CARB member reviews require-a group meeting.
i k When necessary to support reportability efforts, a licensing representative may attend CARB meetings.
4.3.3 (DER)_ - The corrective action document f
Report 4.4 pcviation/ Event used to document a CAQ.
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i 4.5 DER Number j
Reference Number - A preprinted number appearing on the
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DER form which aerves to identify the DER for reference 4.5.1 i
purposes up to the point of CARB evaluation and DER l
control number assignment.
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Control Number - Actual DER identification number assigned by the CAC following CARB approval of the DER.
4.5.2 4.6 Item - Any level of unit assembly, including structure, system, I?57ystee, suba ssembly, material, par t s, or components.
that doce not c c:i f ; rr-tc 4.7 Nonconf orming item. - An itemThis could include purchased defective materials requirements.
or installed failed equipment.
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Nonconf orming Services - Services performed by suppliers, do not conform to 4.8 or Edison organizations that
- tractors, requirements.
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i l).000,52 Rev. I Page 6 4.9 Work Order (PN-21 and At tachment Al - A work request in the context used in this procedure form which, is also used to document equipeent malfunctions and specify corrective measures in the f orm of maintenance.
5.0 RESPONSIBI!.ITIES 5.1 The CARBs are responsible for the processing and review of DERs for reportability and for approving proposed corrective action of I
DERs.
f 5.2 The NQA organization is f
responsible for the following:
5.2.1 Participating as a member of both CARBs and in the review, eval ua t i on, DERs.
and concurrence of safety-related l
i 5.2.2 Perfoming and reporting on trend analysis of all l
DERs as part i
of the NQA Trend Analysis Program.
5.2.3 Perfeming a completion review of the corrective action documented on the DER fom and verifying the j
effective implementation of corrective action.
i 5.2.4 Assigning a Corrective Action Coordinatot t
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status of N.O. DER forms.
(CAC) to log l4 the I-5.2.5 Reporting the status of all DERs to enanagement monthly basis.
on a 5.3 The foiloving:Naclear Production organisation is responsible for the 5.3.1 Controlling nonconforming items in the plant inadvertent use or installation.
to prevent 5.3.2 Initiating a DER if it appears that corrective mainte-nance alone, being performed under a PN-21, will not F
resolve the cause of the problem.
$.3.3 Assigning a CAC to log the status of N.P. DER foms I
5.3.4 Assigning the Chaiman and appointing the Nuclear Production members of the CARB-N.P.
5.3.5 A ne l y: i r, f el: o<
, cf W re nionens that pe r f orrance of plant to stuu operations and maintenance.on similar items does not result CAQ.
in a recurrence of the 5.3.6 Perfoming and reporting on other trending activities as determined by the Superintendent Nuclear Production.
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, 5.4 The Nuclear Engineering organization or its designee is respon-aible for the following:
5.4.1 Assuring that any design-related CAQ is resolved so variations to design and modifications to items or services resulting from perf ormance of corrective action are completed.
5.4.2 Providing engineering analysis when required to support corrective action, and providing disposition, when required, by evaluating nonconiorming items.
5.4.3 Revising and issuing, as necessary, engineering documents and changes to reflect the as-built and any modified conditions resulting from corrective action.
5.4.4 Participating as a member of CARB-N.O. in the review and evaluation of DERs.
5.4.5 Providing technical justification for the disposition of nonconf orming items identified as "use-as-is" or
" repair."
5.5 The Onsite Review Or;anization (OSRO) is responsible for reviewing and investigating CAQ that are violations of the l
Technical Specifications and f orwarding reporta covering its t
i evaluation and recommendations to prevent recurrence to the Manager - Nuclear Operations and the Naclear Safety Review Group i
(NSRC). This responsibility is defined by the OSRO Charter in l
Section 6.5.1.6 of the Technical Specifications.
5.6 All Nuclear Operations organizstional unit supervisors and personnel are responsible for the following, as appitcable:
I 5.6.1 Determining the need for initiating a DER when a CAQ is identified.
5.6.2 Promptly notifying their immediate supervisor whenever they discover a CAQ.
5.6.3 Assigning evaluators for a DER as reque st ed,
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5.6.4 When assigned as evaluator, identifying the root cause of the reported condition, defining any action needed t o locate and correct similar conditions elsewhere,
p;cycetni r+1edia l ccr re n s ve e:: len, e-? ; rc;;.
action to prevent recurrence ot the condition.
5.6.5 Assuring effective and timely implementation of cor.ective action and obtaining a revised completion -
l' date f r om CARB when a due da t e cannot be met.
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11.000.52 Rev. 1 Page 6 5.6.6 Escalating interorganisational disagreements co the DER process completed correc,tive action,or the acceptability of propose to the next level of mana gement for resolution.
5.7 The Supervisor - Licensing is responsible for c final evaluation for reports filed pursuant oordinating the ments.
to 10 CFR 21 require-1 5.8 The warehouse supervisor is responsible inadvertent use. forming items placed in warehouse storage to pr event their 5.9 The Authorized Nuclear Inspector (ANI) is review and concurrence of DERs that document AS responsible for the
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noncompliances.
o e-related i
6.0 GENERAL 6.1 Nuclear Operations personnel shall document coyered.
a CAQ when di s -
6.2 When an equipment-spe:ific problem is identifi d a ppa re nt that it is a CAQ until it is evaluated.
e, it may not be DER or both, and either of these documenta m a
a PN-21 or a result of the other.
When this occura, ssaed as a the other document shall be referenced on each.the identifyinE number cf 6.3 l
When a CAQ is identified as a result of a revi 1
l corrective action docunents for Edison approval) j e
transcribed to a DER by the responsible org shall be initiating corrective action.
anization prior to The fact that it external agency shall be noted on the DER resulted from an 6.4 DERs originated by Nuclear Production should b CARB - N.P. (see Section 7.1.4).
e submitted to i
I 6.5 disagreements resulting from review of a DERThe I
o ve l
6.6 DERa alone cannot be used to effect changes that say result design changes; I
according to the applicable Nuclear Engineering procfrom j
performed
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F3 O W mi t. ', 1"LC AU EEU/ICEi s.
6.7.1 Installed nonconforming items or nonconforming s identified during auditing activities ervices inspections, review, general observation of plant or by any other methcf shall be documented, reportedac ti vi t ie s n
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21.000.01 Page 1 of 1 i
Typical Duties and Responsibilities Nuclear Shift Supervisor (NSS) 1.
Assuce s the cont rol room command function during plant emergencien and maintains an overall perspective of the plant status at all times.
2.
Acts as the short term Emergency Director as specified in the Emergency Plan and initiates Radiological Emergency Response Plan Implementing Procedures as required.
3.
Provides direct supervisino of the Noelpar Assistant Shift Supervisor and is responsible for all conduct of operations while on shift.
4.
Observes and/or direct s r.ajor p!snt evolut ion s.
5.
Is renponsible with the STA t o complete the Post Scram Data an d Evaluation Form after an unschedule d reac t or serain.
6.
Is responsible for shutting the reactor down when he determinen that the sa fety of the reac tor in in jeopardy or when ope rat ing paramet er=
exceed any reactor protection system allowable value and automatic s hut down doen not occur.
7.
Is responsible for the safe and ef ficient operation of equipment in g
accordance with FSAR, Operat ing License, Procedures and Policies of DECO.
8.
Is responsible for report ing to Operat ions Enginee r infomat ion i npe r t ari t to the safe and efficient oper at ion of the plan t.
9.
Is responsible for proper maintenance and contro! of the Nuclear Sh;f t Supervisor Log.
10.
When assigned as Fuel Handling Supervisor, perfoms and/or direct s work in connection with reactor fuel handling operat ion 9 such as preparation, transfer, loading and unloading of new or spent f ue l.
11.
Is responsible for conducting or delegating periodic tours of the plant per Step 6.18 and t aking appropriate action to correct unsat is f ac tory c ondit ions.
12.
Is responsible for authorizing Radiation Work Permit s.
13.
Is responsible for ensuring that evaluation of events which occur is properly conducted and the documentation of such evaluation is i
forwarded to the Operations Engineer.
(Log Entries may be used to l
t at ie f t fer.t?d;*.; a '. d da r i.tstie-re;uir nants.
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21.000.01 Enclosure Page i of i Tvpical Duties and Responsibilities Shif t Operations Advisor their responsibilities by Assist the NSS, N ASS and NSO in carrying out assisting and advising, as necessary, utilising his commerical BWR 1
operating experience.
they are being Observe actuation of annunciators to ensure that promptly and properly addressed with necessary actions taken.
2.
3.
Observe plant parameters to ensure they are reasonable, nonnal or proper for current pl ant conditions, and that any abnormal parameter is properly addressed.
4 Review planned plant evolut ions to ensure that proper procedures and e q ui pme nt are available and personnel are prepared to carry out that e volut ion.
5.
Evaluate unplanned plant evolutions and assist in determining cause recommending appropriate actions.
and current turnover meetings to ascertain status of plant, Advises on matters as requested a 3 6.
At tend shif t problems, and planned activities.
of fer suggestions 'as appropriate to improve the shif t s' objective of I operation of the plant.
maintaining safe, proper and efficient they are being followed and recommende to ensure 7.
Review procedures and systems to preserve operating f.:faty.
changes to procedures evolutions or activitt**
When necessary, recomnend suspension of plant B.
shutdoen.
and, if required, recommend a plant between the operating shift personnel and the If any disagreement Shif t Operations Adviser arise, resolution will be onde by the 9.
Operations Engineer, t
043085