ML20235R620
| ML20235R620 | |
| Person / Time | |
|---|---|
| Site: | Comanche Peak  |
| Issue date: | 07/16/1987 |
| From: | Hausel J, Zill R EVALUATION RESEARCH CORP. |
| To: | |
| Shared Package | |
| ML20235R515 | List:
|
| References | |
| CPP-011, CPP-11, NUDOCS 8710080128 | |
| Download: ML20235R620 (14) | |
Text
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Evitui110N RESEiRCs CORPORiT10N 70R INFORMATION ONLY COMANCHE PEAK RESPONSE TEAM PROJECT PROCEDURE FOR QA/QC ISSUE-SPECIFIC ACTION PLANS PROCEDURE NO: CPP-011 REVISION:
3 ISSUE DATE: 07-17-87 O
EVALUATIONS OF ADVERSE TREND ANALYSES, CONSTRUCTION DEFICIENCIES, AND QA/QC PROGRAM DEFICIENCIES Prepared by:
Date:
Approved by:
h Date: 7- //a -h On-Site QA Re sentative Approved by:
2//(,/'M7 Date:
Q Review Team Leader 8710000128 871002 PDR ADOCK 0500 5
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.. C P P-O l l '
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' Revision: 3 1.0 PURPOSE This' procedure establishes the methods to investigate' sets of Out-of-Scope Observations and/or' deviations and 'wh6re pos'sible, detect any.. adverse trends.
Moreover,1this procedure establishes the methods-.to ensure that' all deficiencies,-including adverse trends, unclassified-d'eviations,.and unclassified. trends'are investiga'ted for root / contributing cause(s) and'the generic implications of the.
identified cause(s) considered.
Finally, this procedure.'addhesses the methods to conduct additional reinspection / documentation reviews.as required,.
2.0 APPLICABILITY This procedure is applicable to purchased.saflety-r' elated equipmen't and material as well as safety-related. hardware constructed'ati Comanche Peak Steam Electric' Station,' Units..!1, 2, and areas' common to both' units and the' associated QA/QC program.
3.0 REFERENCES
3.1 CPP-020,."Out-of-Scope Observations.'l 3.2 CPP-010. " Preparation of Deviation Reports."
3.3 PAG-04, " Guide on Root Causes and Generic Implications."
3.4 CFRT Program Plan, Appendix D, " Guidelines on Sample Expansion" 3.5 CPP-018, "QA/QC Interface'with the Design Adequacy Program."
4.0 GENERAL Sets of Out-of-Scope Observations and/or deviations,. prepared in accordance with References 3.I and 3.2 respectively, are investigated to identify any adverse trends. Furthermore, each reported deficiency, including. unclassified' trends, adverse trends, and unclassified deviations is' investigated _to determine'its root / contributing cause(s).
Subsequently,.the generic implications 1
of any identified'cause(s) are determined.
i 4.1 Responsibilities l
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.4.1.1 QA/QC Issue Coordinators / Lead Discipline Engineers.
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QA/QC' Issue Coordinators / Lea'd Discipline, Engineers review sets of.Out-of-Scope Observations.and/or t
deviations to' identify any adverse trends. They conduct-root / contributing cause(s) investigations of'each 2
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_________I_____.____.___._.___l_..;
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a CPP-011 Revision: 3 9
deficiency, including unclassified trends, adverse trends, and unclassified deviations to determine the generic implications of each identified cause.
As required, they prepare plans / analyses and initiate sample expansions and reinspection of the deficient / susceptible treas, populations, or stratums.
4.1.2 Programmatic Issues or Engineering Manager and the QA/QC Review Team Leader The responsible manager and the QA/QC Review Team Leader (RTL) review and approve plans / analyses.
4.1.3 QA/QC Records Administrator
.The QA/QC Records Administrator distributes and controls plans / analyses in accordance with this procedure.
4.2 Policy 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),
f Should an activity be designated the responsibility of a QA/QC Issue Coordinator / 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 Asverse Trand A deviation or set of deviations and/or Out-of-Scope Observations which exhibit attributes of a discernible commonality that is likely to have resulted in an undetected deficiency in the affected area, population, or stratum.
4.4.2 Construction Deficiency Any identified construction deviation that has been determined to be safety-significant.
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CPP-011 Revision: 3 4.4.3 Construction Deviation a.
Any identified discrepancy 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.
b.
Any identified discrepancy, discovered during document review for inaccessible or non-recreatable items or attributes, which is related to-documentation of construction or installation of safety-related hardware that has been determined to constitute a verified failure to document the construction or installation of a safety-related structure,' system or component in accordance with safety-significant attributes and criteria i
contained in design drawings and specifications or
{
in installation / inspection procedures / requirements.
4.4.4 Generic Implication A determination with respect.to whether O(b root / contributing cause(s) represent isolated occurrences, or non-isolated or generic weaknesses within the affected area, or generic weaknesses that are more broad in nature.
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, unclassified 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.
(*)
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l
, CPP-011' Revision: 3~
p 4.4.7-- QA/QC Program Deviation f
G 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.
4.4.8 Unclassified Deviation and Unclassified Trend-~
A deviation, or set of' deviations, or trend which, without any safety-significant considerations.with' respect to the. deviation, or. adverse trend analysis with respect to the trend, warrants a root / contributing-cause(s) investigation, generic impl1 cations analysis-LI of the identified cause(s), and specification of.
corrective actions. Should"such a' determination;be made, performing a safety significance evaluation on 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 Adverse Trend Analysis i
I Sets of Out-of-Scope Observations and/or deviations are g
reviewed to identify any adverse trends.
-J 5.1.1 Analysis The QA/QC Issue Coordinator / Lead Discipline Engineer 1
reviews sets of Out-of-Scope Observations and/or devintions to identify those unacceptable characteristics which appear to be repetitive :and which
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may cause a deficiency in that, or another area, 1
population, or stratum.
For example, a hypothetical trend of significantly undersized welds, although-determined not to constitute a deficiency for the i
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, documents the analysis in the Results Report.
j NOTE: An Adverse Trend Analysis may be prepared at 4
any time an unacceptable characteristic as
'J 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).
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CPP-011 Revision: 3 5.2 Root Cause(s) and Generic Implication Analyses (s)
Upon the identification of a deficiency, including an unclassified trend, an adverse trend, or an unclassified I
deviation, the QA/QC Issue Coordinator / Lead Discipline Engineer performs a review to determine its root / contributing cause(s) and, where possible, to identify any areas, populations, or stratums that are susceptible to the same condition. Reference 3.3 and Attachment 6.2 may be used as guides to identify common root causes.
However, the QA/QC Issue Coordinator / Lead Discipline Engineer should postulate any additional root / contributing causes that are appropriate.
5.2.1 Analysis Based upon the causes(s) of the problem the QA/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, er stratums that exhibit the same unacceptable f')
characteristic.
U The QA/QC Issue Coordinator / Lead Discipline Engineer
)
ensures that the result of the root / contributing cause(s) and any generic implication analysis is documenced in accordance with Attachment 6.3 or in the Results Report.
5.3 Sample Expansion Should a deficiency be reported, or an unclassified trend, an adverse trend, or an unclassified deviation, be identified, additional reinspection / reviews of any deficient and suspect areas, populations, or stratums are. conducted, as required, and the results evaluated. (See Reference 3.4.)
The QA/QC Issv.e 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.
NOTE:
Sample Expansion Plans shall indicate the signature concurrence of the CPRT engineering statistics advisor.
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l CPP-011 Revision: 3
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5.4 Review and Approval l
Analyses and plans are reviewed and approved prior to any additional evaluations / reinspection. Upon the completion of I
a satisfactory review, the reviewers endorse the analysis /
plan. Plans, Adverse Trend Analysis and Root Cause and Generic l
Implication Analysis forms are sent to the QA/QC Records 1
Administrator for distribution and control in accordance with i
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 Programmatic Issues or Engineering Manager The responsible manager reviews analyses / plans to ensure that they are logical, technically correct, supported adequately by the referenced documentation, j
and that there are reasonable justifications for the stated conclusion and any recommended actions.
5.4.2 QA/QC Review Team Leader The RTL reviews analyses / plans approved by the responsible manager to ensure that they are consistent with the policies and intent of the CPRT.
'~h 5.5 Distribution and Control
[V The QA/QC Records Administrator transmits copies of approved Adverse Trend Analysis and Root Cause 'and Generic Implication l
Analysis forms to the CPSES QC Coordinator for'further processing.
The QA/QC Records Administrator documents transmittals of approved Adverse Trend Analysis and Root Cause and Generic Implication Analysis forms on uniquely numbered memorandums which include provision for the CPSES QC Coordinator to acknowledge receipt. In addition, the QA/QC Records i
l Administrator maintains records to ensure that the CPSES QC l
Coordinator is in receipt of the analyses, e.g.,
a file of transmittals forwarded to and received from the CPSES QC Coordinator.
l A copy of each analysis transmitted to the CPSES QC l
Coordinator is also sent to the:
QA/QC Interface Coordinator TUGC0 Coordinating Engineer CPRT Program Director Adverse trend, root cause, and generic implication analyses
(S with design concerns are sent to the DAP RTL for action in
(,)
accordance with Reference 3.5.
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CPP-Oll Revision: 3 l
The QA/QC Records Administrator maintains:
e Adverse Trend Analyses forms (refer to Sections 5.1-and 5.2) in the file marked (ISAP Number)'- 5.
l Root Cause and Generic Implication Analyses forms I
(refer to Section 5.3) in the file marked XXX-7.
Additional reinspection / documentation' reviews and I
sample expansion plans (refer to'Section 5.4) in the l
file marked (ISAP Number) - 6.
l 6.0 ATTACHMENTS
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I 6.1 Adverse Trend Analysis.(Sample and Instruction) j 6.2 Common Root Causes i
6.3 Root Cause and Generic Implication Analysis (Sample and I
(
Instruction) l I
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f 6.1 f.
CPP-Oll' Revision:
3 Page 1 of.3 (v)
ADVERSE TREND ANALYSIS J
1 COMANCHE PEAK RESPONSE TEAM ADVERSE TREND ANALYSIS POPULATION / WGRK ACTIVITY / ITEM DESCRIPTION -
.(1) 035ERVAILONS AND/OR DEVIATIONS REVIEWED s
(0)
ANALYSIS (3)
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CONCLCSION
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[ } A TREND IS NO NT.
[ ] A TREND IS APPARENT. (EIPI.AIN)
[ ] AN ADVERSE TREND IS APPARENT.
(EX'/ LAIN)
(4)
(5)
[ ] A CONST. CONCERN EXISTS (6){ ] ADDITIONAL EVALUATION / REINSPECTION IS REQUIRED DUE TO THE APPAAENT ADVERSE TREND (5)
( ) A DESIGN CONCERN EXISTS (5)
( ) NO CONCERN EXISTS (6)( ) ADDITIONAL EVALUATION /lLEINSPECTION IS NOT REQUIRED.
PREPARED BTs APPROVED BY:
APPROVED BYt p
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CPP-011.1A. Revision 3
- s..1 CPP-011 Revision:
3
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' ADVERSE TREND ANALYSIS (Continuation Sheet)
CCMANCHE PEAK RESPONSE TEAM-ADVERSE TREND ANALYSIS POPL1ATION/ GRK ACTIVITY / IIEM DESCRIPTION W
(1) l ANALYSIS (Cont'd)
(3)
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CPP-011.18. Revision 0 2
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-Attachmant 6.1 j.-
CPP-011 Revision:
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-INSTRUCTION FOR COMPLETING-1 ls
-FORMLCPP-011.1-
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" ADVERSE TREND ANALYSIS" I
The QA/QC Issue Coordinator / Lead Discipline Engineer enters:
l (1) The description of the applicable population / work activity /d. tem.
1 I
(2),The identification of the applicable. records reviewed.
l
.(3) The methodology used to identify adverse trends.
)
For example:
1 "The referenced documents were reviewed to-identify j
-unacceptable attributes.in deviations that appear to be repetitive and which,may cause a deficiency in the same, orf another area,' population', or stratum."
i (4) The conclusion based on a review of'the referenced records--
l reviewed.
(5) A check to' indicate whether a construction, dAsign, or'no concern' exists.
(6) A check to indicate whether additional. evaluation / reinspection is t
(un)necessary.
(7)
Signature as preparer and date.
The responsible manager and.the RTL review the analysis.as specified in
- I Section 5.4.
Upon completion of.a satisfactory review they enter their l
signatures and approval;date(s) in'the appropriate' blocks on'the form.-
i The SSEG Supervisor initials the form.
3 l
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s Attechm:nt 6.2 CPP-011 Revision:
3 Page 1 of 1 l/~)
COMMON ROOT CAUSES
%/
PROGRAM / PROCEDURE RELATED DESIGN / MFG / INSTALLATION No procedure Craftsmanship Outdated Procedure Improper Equipment Procedural Technical Content Incorrect Material Contradictory Procedures Contamination Inadequate Procedure Abnormal Wear Lubrication i
Weld Related MANAGEMENT /QA RELATED Abnormal Temperature Abnormal Pressure Training Abnormal Flow Manpower SET PT Drift Timeliness / Scheduling Valve Misalignment l
Supervision Open Circuit i
Personnel Cert / Qualification Short/ Ground Housekeeping Bad Controls Inadequate Dept. Interface Defective Connection 6
Overload Defective Circuit DOCUMENTATION RELATED Cyclic Patigue
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Vibration / Cavitation
(.,,)]
Document Control Obstruction Missing Documentation Dirt / Crud Incomplete Documents Corrosion / Erosion Misfiled Documents Natural End of Life l
Incomplete Records Hi-Rad Environment Hi-Hunidity PERSONNEL RELATED Poor Maintenance Design Error Typo's/ Illegibility Inaccuracy Procedural Noncompliance Work on Wrong Component Personnel Error 51'
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1 Attachu nt 6.3 l
CPP-011 Revision:
3 Page 1 of 2-
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. ROOT CAUSE AND GENERIC IMPLICATION ANALYSIS I
i
. COMANCHE PEAK RESPONSE TEAM ROOT CAUSE AND GENERIC IMPLICATION ANALYSIS l
l POPULATION / WORK ACTIVITY / ITEM DESCRIPTION
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(1)
'l IDENTIFICATION AND DESCRIPTION OF THE APPARENT PROBLEM l
(2)
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ROOT / CONTRIBUTING CAUSE(S) ANALYSIS O
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l (3) l GENERIC IMPLICAT10h ANALYdIS I
(4) i l
PREPARED BY:
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4.3 CPP-011 Revision:
3 9
INSTRUCTION FOR COMPLETING FORM CPP-011.2
" ROOT CAUSE AND GENERIC IMPLICATION ANALYSIS" 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 reference to other documents which may be attached to the form.
(3) Document the results of the root / contributing cause(s) analysis in this section.
Reference 3.3 and Attachment 6.2 of this procedure may be used as guidance in the analysis.
Additional potential h
root / contributing causes should 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. ^
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.
populations, or stratums.
The following factors should be O
considered when analyzing the potential scope of the concern:
Time period in which the deficiencies occurred.
Procedure (s) used.
Personnel who performed the work.
QC or other personnel who checked the work.
Area of the plant.
System (s) involved.
Type of component or commodity involved.
4.
Supplementary pages may be added to document the analysis as required.
(5) The preparer signs and dates the analysis.
The responsible manager i
and the RTL review the analysis as specified in Section 5.4.
Upon i
the completion of a satisfactory review, they enter their signatures and approval date(s) in the appropriate blocks on the form.
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