ML20215K026
| ML20215K026 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 08/21/1986 |
| From: | Zill R EVALUATION RESEARCH CORP. |
| To: | |
| Shared Package | |
| ML20215J430 | List:
|
| References | |
| CPP-011, CPP-11, NUDOCS 8610270319 | |
| Download: ML20215K026 (14) | |
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- EVA'LUATION RESEARCH CORPORATION CONTROLLED COPY CONTROL NORC -mln COMANCHE PEAK RESPONSE TEAM PROJECT PROCEDURE FOR ALL ISSUE-SPECIFIC ACTION PLANS PROCEDURE NO: CPP-011 REVISION: 2 ISSUE DATE: 08/21/86 O
'd EVALUATIONS OF ADVERSE TREND ANALYSES, CONSTRUCTION DEFICIENCIES, AND QA/QC PROGRAM DEFICIENCIES Prepared by: Date: N Approved by: < Date: 2/ [
On-Site QA $ presentative #
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l 'A Approved by: Date: 3 }/ Nb QA/QC Review Tea $ Leader / /
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8610270319 861010 PDR ADOCK 05000445 A PDR
CPP-011
, Revision: 2
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1.0 PURPOSE l
This procedure establishes the methods to investigate associated sets of observations and/or deviations and where possible, detect any adverse trends.
l Moreover, this procedure establishes the methods to ensure that all deficiencies including adverse trends, unclassified deviations, unclassified trends, and special cases are investigated for root / contributing cause(s) and the generic implications of the identified cause(s) considered.
Finally, this procedure addresses the methods to conduct additional reinspections/ documentation reviews as required.
l 2.0 APPLICABILITY This procedure is applicable to safety-related hardware constructed at Comanche Peak Steam Electric Station, Units 1, 2 and areas common to both units and the associated QA/QC program.
3.0 REFERENCES
l 3.1 CPRT Program Plan, Appendix D " Guidelines on Sample Expansion"
- 3.2 CP-QP-16.3, " Processing CPRT Deviation Reports / Observation Notices."
4 4.0 CENERAL Associated sets of observations and/or deviations are investigated to identify any adverse trends. Furthermore, each reported deficienc3 including unclassified trends, adverse trends, unclassified deviations and special cases are investigated to
! determine their root / contributing cause(s). Subsequently, the I
generic implications of any identified cause(s) are determined. l As required, any affected areas, populations, or stratums are further evaluated / reinspected. Additional evaluations /
reinspections will, when coupled with a root cause and generic implication analysis, establish whether the deficiency was an isolated occurrence. Any additional evaluations /reinspections may
, include a portion of, or the entire, deficient area, population, or stratum.
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CPP-011
. Revision: 2 i( ) 4.1 Responsibilities 4.1.1 QA/QC Issue Coordinators / Lead Discipline Engineers QA/QC Issue Coordinators / Lead Discipline Engineers review associated sets of observations and/or deviations to identify any adverse trends. They conduct
- root / contributing cause(s) investigations of each deficiency including unclassified trends, adverse trends, unclassified deviations and special cases to determine the generic implications of each identified cause. As required, they prepare plans / analyses and initiate sample expansions and reinspections of the deficient / susceptible areas, populations, or stratums.
4.1.2 Deputy Program ranagers and the QA/QC Review Team Leader l
The responsible Deputy Program Manager and the QA/QC l
- Review Team Leader (RTL) review and approve plans / analyses.
4.1.3 QA/QC Records Administrator The QA/QC Records Administrator distributes and 1 . controls plans / analyses in accordance with this
'[ procedure.
4.2 Policy i
- Activities performed under this procedure shall conform to the policies contained in the latest Comanche Peak Response Team (CPRT) Program Plan, ERC Management Program Plan, and applicable QA/QC Issue Specific Action Plans (ISAPs).
Should an activity be designated the responsibility of a QA/QC l Issue Coordinator / Lead Discipline Engineer, or higher, it may l be delegated by that individual to an individual under his or her supervision.
l l 4.3 Conflicts l
In the case of a conflict between this procedure and the documents referenced in Section 4.2, the latter shall govern.
i 4.4 Definitions 4.4.1 Adverse Trend A set of related observations and/or deviations which exhibit attributes of a discernible commonality that is likely to have resulted in an undetected deficiency in O the affected area, population, or stratum.
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CPP-011
. Revision: 2 4.4.2 Construction Deficiency Any identified construction deviation that has been determined to be safety-significant.
4.4.3 Construction Deviation Any identified error related to construction or installation of safety-related hardware that has been determined to constitute a verified failure to construct or install a safety-related structure, system, or component in accordance with safety-significant attributes and criteria contained in design drawings and specifications or installation procedures /
requirements. Construction deviations are identified on DRs.
4.4.4 Generic Implication A deduction based upon a review of the root cause of an adverse trend, deficiency, or unclassified deviation that links the deficient area, population, or stratum with another in which the same condition may exist.
4.4.5 Root Cause The feature (s) of the procedure, instruction, or activity in effect at the time the work was performed that permitted the deficiency, adverse trend, or unclassified deviation to occur.
4.4.6 QA/QC Program Deficiency Any identified QA/QC program deviation meeting one or more of the following criteria:
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- Inadequacy of a QA/QC program element such that
! substantive revision of the program or other corrective action is required to bring it into compliance with the regulatory requirements, FSAR commitments or other licensing commitments; or
- Extensive evaluation would be required to determine the effect on the quality of construction.
4.4.7 QA/QC Program Deviation Any verified failure of the QA/QC Program to meet regulatory requirements (i.e., 10 CFR 50, Appendix B),
FSAR commitments or other licensing commitments.
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CPP-011 Revision: 2 4.4.8 Unclassified Deviation and Unclassified Trend A deviation, a set of related deviations, or trend which, without any safety-significant considerations, warrants a root / contributing cause(s) investigation, generic implications analysis of the identified cause(s), and specification of corrective action.
4.4.9 Special case A deviation, or set of related observations / deviations determined by the RTL and the Senior Review Team to warrant a root / contributing causes investigation and generic implications analysis of the identified cause(s).
5.0 PROCEDURE 5.1 Adverse Trend Analysis
! Associated sets of observations and/or deviations are reviewed to identify any adverse trends.
5.1.1 Analysis O The QA/QC Issue Coordinator / Lead Discipline Engineer reviews associated sets of Out-of-Scope Observations and/or DRs to identify those unacceptable characteristics which appear to be repetitive and which may cause a deficiency in that, or another area, population, or stratum. For example, a hypothetical trend of significantly undersized welds, although determined not to constitute a deficiency for the sample evaluated, may have the potential to be a deficiency in another area, population, or stratum.
Accordingly, the QA/QC Issue Coordinator / Lead Discipline Engineer prepares an Adverse Trend Analysis in accordance with Attachment 6.1 or, for ISAP VII.c, documents the analysis in an Appendix to the Results Report.
NOTE: An Adverse Trend Analysis may be prepared at any time an unacceptable characteristic as described above is apparent.
Should the Coordinator / Lead conclude that there is an adverse trend, an investigation is made as to its root / contributing cause(s) and the generic implication of any identified cause(s).
5.2 Root Cause(s) and Generic Implication Analyses Upon the identification of a deficiency, including an unclassified trend, an adverse trend, an unclassified i deviation, or a special case, the QA/QC Issue Coordinator / Lead Discipline Engineer performs a review to determine its 5
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CPP-011 Revision: 2
) root / contributing cause(s) and, where possible, to identify any areas, populations, or stratums that are susceptible to the same condition. Attachment 6.2 may be used as a guide to identify common root causes.
However, the QA/QC Issue Coordinator / Lead Discipline Engineer should postulate any additional j root / contributing causes that are appropriate.
5.2.1 Analysis Based upon the causes(s) of the problem the OA/QC Issue Coordinator / Lead Discipline Engineer determines its generic implications in any other areas, populations, or stratums that are susceptible to the same condition.
For example, there may be evidence which links a deficiency to inadequate inspection. That is, one or more inspectors may have accepted welds that were subsequently determined to be significantly undersized.
Therefore, it can be deduced that the same inspector (s) may have accepted welds in other areas, populations, or stratums that exhibit the same unacceptable characteristic.
The QA/QC Issue Coordinator / Lead Discipline Engineer ensures that the result of the root / contributing O cause(s) and any generic implication analysis is documented in accordance with Attachment 6.3 or, for ISAP VII.c documents the analysis in an appendix to the Results Report.
5.3 Sample Expansion Should a deficiency be reported, or an unclassified trend, an adverse trend, an unclassified deviation, or special case be identified, additional reinspections/ reviews of any deficient and suspect areas, populations, or stratums are conducted, as '.
required, and the results evaluated.
The scope of additional evaluations /reinspections will, when coupled with the results of any root cause and generic implication analyses (Refer to Section 5.3), be of sufficient size to reasonably ensure that no other deficiency exists in the deficient and/or suspect ares (s), population (s), or stratum (s).
The QA/QC Issue. Coordinator / Lead Discipline Engineer consults with the CPRT engineering statistics advisor to determine the expanded sample size, area, population, etc., then submits the sample expansion plan for review and approval in accordance with Section 5.4.
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CPP-011 Revision: 2
- 5.4 Review and Approval Analyses and plans are reviewed and approved prior to any additional evaluations /reinspections. Upon the completion of a satisfactory review, the reviewers endorse the analysis /
plan. Plans, Adverse Trend Analysis and Root Cause and Generic Implication Analysis forms are sent to the QA/QC Records Administrator for distribution and control in accordance with Section 5.5. Adverse trend analyses and generic implications analyses documented in Appendices to Results Reports are distributed and controlled by the CPRT Senior Review Team.
5.4.1 Deputy Program Managers l Deputy Program Managers review the analyses / plans to i ensure that they are logical, technically correct, supported adequately by the referenced documentation, and that there are reasonable justifications for the stated conclusion and any recommended actions.
I 5.4.2 QA/QC Review Team Leader l
The RTL reviews analyses / plans approved by the responsible Deputy Program Manager.to ensure that they l are consistent with the policies and intent of the CPRT.
5.5 Distribution and Control The QA/QC Records Administrator transmits copies of approved Adverse Trend Analysis and Root Cause and Generic Implication i Analysis forms to the CPSES QC Coordinator for further
- processing in accordance with Reference 3.4.
The QA/QC Records Administrator documents transmittals of approved Adverse Trend Analysis and Root Cause and Generic Implication Analysis forms on uniquely numbered memorandums i which include provision for the CPSES QC Coordinator to acknowledge receipt. In addition, the QA/QC Records l
Administrator maintains records to ensure that the CPSES QC i Coordinator is in receipt of the analyses, e.g., a file of l
' transmittals forwarded to and received from the CPSES QC Coordinator.
A copy of each analysis transmitted to the CPSES QC l 2
Coordinator is also sent to the:
QA/QC Coordinating Engineer
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External Source Issues Deputy Program Manager.
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CPP-011
- Revision: 2 Adverse trend, root cause, and generic implication analyses with design concerns are sent to the DAP RTL for action by the DAP.
The QA/QC Records Administrator maintains:
Adverse Trend Analyses forms (refer to Sections 5.1 l and 5.2) in the file marked (ISAP Number) - 5.
Root Cause and Generic Implication Analyses forms l (refer to Section 5.3) in the file marked (ISAP Number) - 5.
Additional reinspections/ documentation reviews and sample expansion plans (refer to Section 5.4) in the file marked (ISAP Number) - 5.
6.0 ' ATTACHMENTS 6.1 Adverse Trend Analysis (Sample and Instruction) 6.2 Common Root Causes 6.3 Root Cause and Generic Implication Analysis (sample and Instruction) 4
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Attechmant 6.1
_ CPP-011 Revision: 2 Page 1 of 3 O
V ADVERSE TREND ANALYSIS COMANCHE FEAK RESPON3E TEAM ADVERSE TREND ANALYSIS F0FtlLATION/ WORK ACTIVIIY/ ITEM DESCRIPTION (1)
OBSERVATIONS AND/OR DEVIATIONS REVIEVED (2)
ANALYSIS (3)
O CONCLUSION 65L \ V
[ ] A TRD D IS NO .
( ) A TREND IS AFFARE T. (EIFIAIN)
( ) AN ADVERSE TREND IS AFFARDT. (EEFIAIN) l l (4) l (5) ( ) A CONST. CONCERN EEISTS (6)( ) ADDITIONAL EVALUATION /REINSFECTION IS REQUIRED DUE i TO THE AFFARElf! ADVERSE TRDD
( (5) ( ) A DESIGN CONCERN EEISTS (5) ( ] NO CONCERN IIISTS (6)[ ] ADDITIONAL EVALUATION /REINSFECTION IS NOT REQUIRED.
PRErARED BY: AFFROVID ST: AFFROVID SY:
(7) (7)
I UITE" OtPUTY PROGRAM MCR DATE M F UKTE" CFF-Oll.lA Revisios !
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Attachm:nt 6.1
, CPP-Oll Revision: 2 ADVERSE TREND ANALYSIS (Continuation Sheet) ;
COMANCHE PEAK RESPONSE TEAM ADVERSE TREND ANALYSIS POPL1ATION/ WORK ACTIVITY / ITEM DESCRIPTION (1)
ANALYSIS (cont'd)
(3) l l
s CPP-011.18. Revision 0 2
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t Attachm2nt 6.1
, , CPP-011 Revision: 2
} INSTRUCTION FOR COMPLETING s./ FORM CPP-011.1
" ADVERSE TREND ANALYSIS" f'
The QA/QC Issue Coordinator / Lead Discipline Engineer enters:
(1) The description of the applicable population / work activity / item.
(2) The identification of the applicable records reviewed.
(3) The methodology used to identify adverse trends.
For example:
"The referenced documents were reviewed to identify l unacceptable attributes in deviations that appear to be repetitive and which may cause a deficiency in the same, or another area, population, or stratum."
(4) The conclusion based on a review of the referenced records reviewed.
(5) A check to indicate whether a construction, design, or no concern exists.
(6) A check to indicate whether additional evaluation / reinspection is I
O (un)necessary.
(7) Signature as preparer and date.
The responsible Deputy Program Manager and the RTL review the analysis l as specified in Section 5.4. Upon completion of a satisfactory review they enter their signatures and approval date(s) in the appropriate blocks on the form. The SSEG Supervisor initials the form.
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Attachmsnt 6.2
.. CPP-011 Revision: 2 O
Page 1 of 1 v COMMON ROOT CAUSES PROGRAM / PROCEDURE RELATED DESIGN / MFG / INSTALLATION No procedure Craftmanship Outdated Procedure Improper Equipment
- Procedural Technical Content Incorrect Material
- Contradictory Procedures Contamination Inadequate Procedure Abnormal Wear Lubrication Weld Related Abnormal Temperature MANAGEMENT /QA RELATED Abnormal Pressure i
Training Abnormal Flow Manpower SET PT Drift Timeliness / Scheduling Valve Misalignment Supervision Open Circuit Personnel Cert / Qualification Short/ Ground Housekeeping Bad Controls Inadequate Dept. Interface Defective Connection Overload Defective Circuit
! DOCUMENTATION RELATED Cyclic Fatigue Vibration / Cavitation Document Control Obstruction Missing Documentation Dirt / Crud f Incomplete Documents Corrosion / Erosion Misfiled Documents Natural End of Life Incomplete Records Hi-Rad Environment Hi-Humidity PERSONNEL RELATED Poor Maintenance Design Error
! Typo's/ Illegibility Inaccuracy Procedural Noncompliance Work on Wrong Component Personnel Error 1
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Attacinant 6.3
. CPP-011 Revision: 2 Page 1 of 2 O. ROOT CAUSE AND GENERIC IMPLICATION ANALYSIS COMANCHE PEAK RESPONSE TEAM ROOT CAUSE AND GENERIC IMPLICATION ANALYSIS POPULATION / WORK ACTIVITY /ITDt CESCRIPTION (1)
IDENTIFICATION AND DESCRIPTION OF THE APPARENT PROBLEM (2)
.l R00TiCo m I m INc CAusu s> m u sis y O
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l (3)
GENERIC IMPLICATION ANALTsIs (4)
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PREFARED BYs AFF30VED BTs APPROVED BTs (5) (5)
DATE DEM FM ER W1 REVIEW TEAM LDR DATE CFF-011.1. Revision 2 1
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Attachmsnt 6.3
, . CPP-011 Revision: 2 INSTRUCTION FOR COMPLETING FORM CPP-011.2 i " ROOT CAUSE AND GENERIC IMPLICATION ANALYSIS' i
l The QA/QC Issue Coordinator / Lead Discipline Engineer enters:
(1) The description of the applicable population / work activity / item in which the deficiency occurred.
(2) Provide the identification and description of the deficiency being analyzed. This may be accomplished by isference to other documents
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which may be attached to the form.
(3) Document the results of the root / contributing cause(s) analysis in this section. Attachment 6.2 of this procedure contains a list of common potential root causes which may'be used as guidance in the i
analysis. Additional potential root / contributing causes shobid be included as a part of the analysis if appropriate. Supplementary pages may be added as required.
(4) Document the results of the generic implication in this section.
l The postulated root / contributing cause(s) are to be considered in this analysis. The purpose of the analysis is to determine whether the condition being analyzed could occur in other areas, i
O populations, or stratums. The following factors should be considered when analyzing the potential scope of the concern:
Time period in which the deficiencies occurred.
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- Procedure (s) used.
l Personnel who performed the work.
l QC or other personnel who checked the work.
l l Area of the plant.
Syster(s) involved.
l Type of component or commodity involved.
l l Supplementary pages may be added to document the analysis as required.
l (5) The preparer signs and dates the analysis. The responsible Deputy l Program Manager and t>< RTL review the analysis as specified in l Section 5.4. Upon the etspletion of a satisfactory review, they enter their signatures and approval date(s) in the appropriate blocks on the form.
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