ML20215K129
| ML20215K129 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 08/13/1986 |
| From: | Zill R EVALUATION RESEARCH CORP. |
| To: | |
| Shared Package | |
| ML20215J430 | List:
|
| References | |
| CPP-021, CPP-21, NUDOCS 8610270391 | |
| Download: ML20215K129 (11) | |
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- ~0NCONTROLLED COPY P,E, 1 o, 7
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FOR lt!E0ftMAIl0N ONLY.
O C0i\ TROLLED COPY CONTROL NO.M@o /A EVALUATION RESEARCH CORPORATION COMANCHE PEAK RESPONSE TEAM PROJECT PROCEDURE FOR QA/QC ISSUE-SPECIFIC ACTION PLANS PROCEDURE NO: CPP-021 REVISION: 1 ISSUE DATE: 08/13/86 CPSES PROJECT CORRECTIVE ACTION l
Prepared by: Date: !I!
l Approved by: Date: 7/ /3~' 7d l OnJSife Q epresentative Approved by: s Date: 8 :;L!d[.
QA/(C Review Team Leader /
/
DR D K 50 0 45 A PDR
g CPP-021
, Rsvision: 1 1.0 PURPOSE This procedure establishes the method to determine the adequacy of action proposed by the Comanche Peak Steam Electric Station (CPSES)
Project to correct specific deviations and/or deficiencias reported l by the QA/QC Review Team.
Moreover, this procedure establishes the methods to plan and document verifications of approved corrective actions to ensure their effective implementation as required.
2.0 APPLICABILITY 1
This procedure'is applicable to: deviations determined by the CPSES Project to be reportable; constructions deficiencies; and adverse trends identified by the QA/QC Review Team in conjunction with Comanche Peak Response Team (CPRT) activities.
3.0 REFERENCES
3.1 CPP-010. " Preparation of Deviation Reports."
f 3.2 CPP-Oll, " Evaluations of Adverse Trend Analyses, Construction Deficiencies, and QA/QC Program Deficiencies."
3.3 CPP-016, " Safety-Significant Evaluations of Devistion Reports."
3.4 CPP-017 " Preparation of QA/QC Program Deviation Reports."
l 3.5 CP-QP-16.3, " Processing CPRT Deviation Reports / Observation Notices."
3.6 CP-QP-16.(Later), "CPRT Evaluation and Reinspection Program."
3.7 CPP-004, " Project Working Files."
l 4.0 GENERAL The QA/QC Review Team transmits Deviation Reports (Construction l
Deviations); QA/QC program deviations and deficiencies; analyses of l l adverse trends; and Safety-Significant Evaluations (Construction Deficiencies) in accordance with established procedures. (See References 3.1 through 3.4.) l Accordingly, References 3.5 and 3.6 address the methods by which l responsible CPSES Project personnel process the noted deviations and deficiencies to ensure that acceptable actions to correct the O unsatisfactory conditions are documented and effectively implemented.
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CPP-021 Ravicion: 1 To that end, responsible QA/QC Review Team personnel and the Senior
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( ,f Review Team (SRT) of the CPRT review corrective action recommenda-tions submitted by the CPSES Project of: each construction deficiency; adverse trend; QA/QC program deficiency. Furthermore, l the QA/QC Review Team verifies that the actions, as approved, are effectively accomplished.
4.1 Responsibilities 4.1.1 QA/QC Review Team Leader The RTL is responsible to determine the adequacy of corrective action proposals and obtain the (dis) approval of the SRT in those determinations.
In addition, the RTL reviews and approves Verification of Corrective Action Plans and Verifications of Corrective Action.
4.1.2 Senior Review Team, CPRT The SRT reviews determinations by the RTL relative to the adequacy of corrective action proposed by the CPSES Project. Moreover, the SRT is the final arbitrator should the RTL and the CPSES Project d(sagree in the adequacy of any corrective actions proposed by the O CPSES Project.
4.1.3 QA/QC Issue Coordinators The responsible QA/QC Issue Coordinator reviews and, as i required, approves Verification of Corrective Action Plans and Verifications of Corrective Action.
4.1.4 QA/QC Corrective Action Coordinator l l The QA/QC Corrective Action Coordinator ensures that l l verifications of approved corrective action are conducted in a timely manner.
4.1.5 QA/QC Records Administrator The QA/QC Records Administrator distributes and controls memorandums, Verification of Corrective Action Plans, and Verifications of Corrective Action.
4.2 Policy Activities performed under this procedure shall conform to the policies contained in the latest CPRT Program Plan and the ERC Management Program Plan.
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CPP-021
, Rsvision: 1
! Should an' activity be designated the responsibility of the QA/QC Corrective Action Coordinator or a QA/QC Issue l Coordinator, 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 j None, j
5.0 PROCEDURE
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5.1 Review and Approval of Proposed Corrective Action The RTL ensures that the corrective action recommendations submitted by the CPSES Project are adequate based on the criteria specified in Attachment 6.1. -
Accordingly, the RTL ensures that the results.of corrective action reviews are documented onteemoranduma entitled "CPSES Project Corrective Action" addressed to the CPSES QC l l Coordinator. The memorandum specifically references the appropriate QA/QC observation / memorandum / report / analysis, indicates the signature (dis) approval of the RTL and the SRT, and includes, as an attachment, a copy of the corrective action submitted by the CPSES Project. Should the proposed corrective action be unacceptable, the memorandum also denotes the reason (s) and the date within 15 calendar days of the date
! of the memorandum, that resubmittal is required to ensure timely corrective action.
Resubmittals by the CPSES Project are reviewed and approved the same as the initial submittal.
NOTE: Should the CPSES Project maintain that the l proposed corrective action is acceptable, the RTL refers the matter to the SRT for resolution.
Memorandums signed by the RTL are forwarded to the QA/QC Records Administrator for distribution and control in accordance with Paragraph 5.4.1.
5.2 Verification of Corrective Action Plans 5.2.1 Documentation The responsible QA/QC Issue Coordinator ensures the O timely preparation of plans to verify the corrective action, as approved, on a form similar to Attachment 6.2. Plans should be established prior to the 4
CPP-021
. Rsvision: 1 O implementation of the approved corrective action and, as required, be specific relative to the scope of the verification process, the schedule for performing any verifications, any necessary material / services, and the
. appropriate accept / reject criteria.
Plans shall require confirmation of corrective action by an independent CPRT reinspection, or by CPRT personnel witnessing the reinspection performed by the CPSES Project. Plans shall specify the basis for any exceptions to the requirements of this instruction.
Each plan shall be established prior to any verification of the approved corrective accion.
Any additional pages necessary shall be consecutively numbered and the total number of pages entered on the fifst page.
5.2.2 Review and Approval The responsible QA/QC Issue Coordinator and the RTL -
review each Verification of Corrective Action Plan to ensure that it is complete, accurate. comprehensive, and provides an acceptable method to verify the approved corrective action, then they' sign and date the form.
NOTE: Should the responsible QA/QC Issue Coordinator also be the preparer, he or she enters "N/A" in the appropriate " APPROVED BY" block.
Approved Verification of Corrective Action Plans are farwarded to the QA/QC Records Administrator for retention in the file marked (later). Each responsible QA/QC Issue Coordinator retains a copy of their plan (s) for reference during the verification process.
5.3 Verification of Corrective Action 5.3.1 Documentation The QA/QC Corrective Action Coordinator maintains a l matrix to ensure that verifications of acceptable corrective actions are conducted in a timely manner.
The matrix denotes information necessary to ascertain whether the verification of corrective action was performed on the date scheduled; the name of the QA/QC Issue Coordinator responsible for performing the verification, whether the corrective action was (un) satisfactorily implemented, etc.
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CPP-021
. Revision: 1 O The responsible QA/QC Issue Coordinator ensures that verifications of approved corrective actions are documented by marking the RTL's/SRT's memorandua l
maintained by the QA/QC Records Administrator "C/A
.- VERIFIED (UN) SATISFACTORY. REFER TO ATTACHMENT," then indicates his or her name, and the date the
- verification was performed.
The attachment (similar to Attachment 6.3) provides information relative to the verification. That is, whether the implementation of the corrective action was completely satisfactory; performed in a timely manner; 4
any unacceptable conditions, etc.
- 5.3.2 Review and Approval l The responsible QA/QC Issue Coordinator and the RTL review Verifications of Corrective Action to ensure that they provide clear, complete, and objective evidence relative to the reported disposition, then they sign and date the form.
NOTE: Should the responsible QA/QC Issue Coordinator also be the pr,eparer, he or she enters "N/A" in the appropriate " APPROVED BY" block.
The RTL refers reports of unsatisfactory corrective action implementation to the SRT for resolution.
Reports of satisfactory corrective action implementation are forwarded to the QA/QC Records Administrator for distribution and control in
- accordance with Paragraph 5.4.2.
, 5.4 Distribution and Control The QA/QC Records Administrator maintains records associated with CPSES Project corrective action in the file marked (later). Records associated with corrective action proposed by the CPSES Project, e.g., the RTL's memorandum, or verifications planned, are segregated from records associated j
wiLL corrective action verified by the QA/QC Review Team to be satisfactory, e.g., the RTL's memorandum marked "C/A VERIFIED i SATISFACTORY.." with the Verification of Corrective Action attached.
5.4.1 RTL's Memorandums The QA/QC Records Administrator distributes the RTL's memorandums endorsed by the SRT which accept /rsject corrective action proposed by the CPSES Projec.t on 1 uniquely numbered transmittals which include provision l
for the CPSES QC Coordinator to acknowledge receipt. l 1
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, l CPP-021
. Revision: 1 4
In addition, the QA/QC Records Administrator maintains
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records to ensure that the CPSES QC Coordinator is in l receipt of all applicable memoranduas, e.g., a file of transmittals forwarded to and recein d from the CPSES
. QC Coordinator. Copies are distributed to the:
QA/QC Coordinating Engineer CPRT Program Director,
! Responsible QA/QC Issue Coordinator, and the QA/QC Corrective Action Coordinator. l
! Copies sent to the QA/QC Corrective Action Coordinator l ensure verification of corrective action in a timely manner.
5.4.2 Verifications of Corrective Action The QA/QC Records Administrator distributes approved Verifications of Corrective Action to the CPSES QC l t Coordinator. Copies are distributed'to the CPRT
, Program Director, the QA/QC Coordinating Engineer, and the QA/QC Corrective Action Coordinator.
5.4.3 Records Turnover i
Upon the satisfactory completion of each verification, i the QA/QC Records Administrator assembles the l
appropriate RTL's memorandum, the approved Verification of Corrective Action Plan, the approved verification of l corrective action, and any pertinent data for transmittal to the CPRT Central File in accordance with i Reference 3.7. l 6.0 ATTACHMENTS l
l 6.1 Corrective Action Requirements / Criteria..
6.2 Verification of Corrective Action Plan (Sample).
6.3 Verification of Corrective Action (Sample).
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i Attachusnt 6.1
- C?P-021 Revision: 1
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i l Page 1 of 2 CORRECTIVE ACTION REQUIREMENTS / CRITERIA i
In general, the response should address the deficiency requiring corrective action.
1 CAUSE Ensure that the feature (s) of the existing control (s) that permitted the observed condition (s) to occur is described. Instructions, procedures, etc., comprise the controls; activities, as performed, constitute implementation. TypicalJy, the causative feature will be one, or a combination, of the following:
- a. Established controls lack provisions to prevent the observed condition or to check for it. Ensure that the specific lack is identified.
, b. Established controls contain ambiguous, conflicting, or -
inappropriate requirements thus increasing the likelihood of the observed condition to occur. Ensure that,the ambiguity, conflict, and/or inappropriate requirements 1,s identified.
- c. Failure to follow one of more of the requirements of the established controls due to specific reasons. Ensure that the requirements which were not followed and the reason why are identified.
EXTENT OF CONDITION i
I Ensure that the extent of the same or similar conditions within the
- population / area / item from which the sample was drawn is identified and l how the extent was determined. The extent of the condition must usually be determined by survey or investigation. In some cases, the extent may be inferred or deduced based on the nature of the reinspection / review or the condition.
ACTION TO CORRECT EXISTING CONDITION I
Ensure that the actions necessary to correct both the reported L
conditions and the same or similar conditions that were found to exist l when the extent of the condition was determined is identified. Any l decision not to correct all existing conditions of the reported type shall be justified in terms of lack of effect on quality. The measures l to be taken to correct possible degradation of quality in design work completed due to the type of condition reported shall also be addressed.
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L Attcchs nt 6.1 4 . CPP-021 Revision: 1 i ACTION TO PREVENT RECURRENCE Ensure that the action necessary to prevent the reported or similar
- j. conditions from recurring is described, e.g., the programmatic actions I to be taken, such as procedure changes, institution of specific training, modificaticn of special processes, etc. Such actions are expected to eliminate the cause(s) identified. It is unacceptable to caution individuals to be "more careful" or to " comply with requirements". It is acceptable to revise existing procedures / instructions so that they better match the controls that are actually being practiced, provided such controls have been determined to be adequate under governing requirements. It is unacceptable to change
, such procedures / instructions merely to relax requirements unless existing procedures / instructions can be clearly shown to exceed regulatory requirements.
COMPLETION DATES When extenuating circumstances prevent completion of the action within
- 60 calendar days, the schedule to complete the actions to' correct and '
prevent the reported and any similar conditions shall be provided.
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Attachu nt 6.2
- CPP-021 Revision: 1 Page 1 of 1 VERIFICATION OF CORRECTIVE ACTION PLAN COMANCiiE PEAK RESPONSE TEAM VENIFICATION OF CORRECTIVE ACTION PLAN PACE I 0F INSTRUCTIONS:
DOCUMENT THE PLAN FOR VENIFYING TliE ACTION TO CORRECT THE UNSATISFACTORY CohDITION(S) DESCRIBED IN THE REPORTED DEVIATION (S) REFERENCED BELOW.
REFERENCES (INCLUDE THE NUMBER AND DESCRIPTION):
PLAN (ATTACH ADDITIONAL PAGES AS REQUIRED):
i k
l PREPARED BY: DATE:
APPROVED BY: DATE:
QA/QC ISSUE COORDINATOR APPROVED BY: DATE:
Q4/QC REVIEW TEAM LEADER CPP-021.1, Revision 0 1553-15297-HI O l
a Attachm:nt 6.3
. CPP-021 Revision: 1 Page 1 of 1
.I VERIFICATION OF CORRECTIVE ACTION !
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COMANCHE PEAK RESPONSE TEAM VERIFICATION OF CORRECTIVE ACTION PACE 1 0F INSTRUCTIONS:
VERIFY BY REINSPECTION / REVIEW THAT THE CORRECTIVE ACTION APPROVED BY THE QA/QC REVIEW TEAM LEADER / SENIOR REVIEW TEAM CONCERNING THE REPORTED DEVIATION (S) REFERENCED BELOW hAS (HAVE) BEEN COMPLETED AND SATISFACTORILY IMPLEMENTED.
VERIFIED CONDITION (Which supports the results indicated below):
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O RESULTS:
THE VERIFIED CONDITION DOES/DOES NOT COMPLETELY AND SATISTACTORILY IMPIDtENT THE CORRECTIVE ACTION AS REQUIRED.
PREPARED BY: DATE:
APPROVED BY: DATE:
QA/QC ISSUE COORDINATOR APPROVED BY: DATE:
QA/QC REVIEW TEAM LEADER CPP-021.2, Revision 0 1553-15297-X1 O .
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