evaluation of amended response to, verification of ...action and closure of deficiency report (dr)...

I

Department of Energy Washington, DC 20585

AUG 19 2002 QA: QA

J. S. Whitcraft Bechtel SAIC Company, LLC 1180 Town Center Drive, M/S 423 Las Vegas, NV 89144

EVALUATION OF AMENDED RESPONSE -TO, VERIFICATION OF CORRECTIVE ACTION AND CLOSURE OF DEFICIENCY REPORT (DR) YMSCO-01-D-064 RESULTING FROM THE OFFICE OF QUALITY ASSURANCE (OQA) AUDIT BSC-ARC-01-06

The OQA staff has evaluated the amended response to, verified the corrective action of DR YMSCO-01-D-064 and determined the results to be satisfactory. As a result, the DR is considered closed.

The evaluation performed confirmed that there were no implementation issues, and therefore this deficiency has no impact on "Q" items or activities.

If you have any questions, please contact James Blaylock at (702) 794-1420.

am B. urthy, Acting Di ector

OQA:RBM-1666 Office of Quality Assurance

Enclosure: DR YMSCO-01-D-064

Printed with soy ink on recycled paper

1 -x

J. S. Whitcraf -2- AUG; 19 2002

cc w/encl: N. K. Stablein, NRC, Rockville, MD Robert Latta, NRC, Las Vegas, NV S. W. Lynch, State of Nevada, Carson City, NV Engelbrecht von Tiesenhausen, Clark County, Las Vegas, NV V. J. Barish, LLNL, Livermore, CA M. G. McDaniel, BSC, Las Vegas, NV T. J. Wall, BSC, Las Vegas, NV W. J. Glasser, NQS, Las Vegas, NV D. G. Opielowski, NQS, Las Vegas, NV J. R. Dyer, DOE/YMSCO, Las Vegas, NV C. E. Hampton, DOE/YMSCO, Las Vegas, NV D. G. Horton, DOE/YMSCO, Las Vegas, NV J. M. Replogle, DOE/YMSCO, Las Vegas, NV B. M. Terrell, DOE/YMSCO, Las Vegas, NV V. W. Trebules, DOE/YMSCO, Las Vegas, NV

OFFICE OF CIVILIAN RADIOACTIVE WASTE MANAGEMENT

U.S. DEPARTMENT OF ENERGY ')6 WASHINGTON, D.C. s/Zq ' /

ORIGINAL qjo OA gler% CIrA.

DEFICIENCY/CORRECTIVE ACTION REPORT

,PC•.Wo ne.9, etihan and Procedure Preparation, Review, and Approval 2. Related Report No.:

(superseded) BSC-ARC-01-06

3. Responsible Organization: Yucca lountai 4. Discussed With: Site Characterization ( ceM•YMScon Bechtel SAIC Company, LLC (296i Nancy Williams. Larry Trautner, Ken Beall. et. al

5. Requirement: Attachment 6, Section 5.1b) states in part: "Provide explanatory or descriptive information that may help the user perform a step or

sequence of steps in a "Note," if applicable Notes- 1) Shall not include action steps . .

NOTE: AP-5.1Q, Rev. 2, ICN 0, effective 4/27/01 contains the same requirement.

6. Description of Condition: Contrary to the above, AP-9.2Q, Rev. 0, ICN 0, BSCN 00 1, Sections 5.2.1e) and 5.2.1g) contain action steps and/or requirements as

notes Additional examples of procedures that contain notes as action steps are as follows

LP-CAL-004Q-M&O, Rev. 0'ICN 0, BSCN 001, Analytical Balance Calibration, Section 5.3d)l).

AP-17.1Q, Rev. 2, ICN 0, (effective 4/30/01), Record Source Responsibilities for Inclusionary Records, Sections 5.5 a) & c)

AP-12. IQ, Rev.O, ICN 1, Control of Measuring and Test Equipmeint and Calibration Stindards, Section 5.5.5c), & Section

5.7.1b).

7. in4ktor:

Ij ýýw 2&4Date 5/02/01l

9. Does a stop work condition exist? INot required for a DR)

E-Yes El No If Yes, Check One:,[--A E B IC ED

victor J. Barish,rr. - .. .... , 10. Recommended Actions: "

a) Review all "Q" procedures to identify the existence of all similar-violations.

b) Revise affected procedures to correct the errors.

c) Review recent performance of affected procedures to identify instances where the

requirement/action steps of the NOTES identified in a) above were bypassed; evaluate

the effect and take appropriate corrective action.

11. QA Revie 12. Response Due Date: AR •T. •arpr Date' 517/01 10 working days from issuance

13. DOQA IssuanceApral

Printed Name Robert W. Clark signatu Date

22. Corrective Actions Verified 23: Closure A/pprov by:

--QAR~ Date /IbZ ~ 000A ~Date9/ ) Exhibut AP-1 6.1Q.1 -Rev. 12/20/1 999

ENExiiSUARE / Q. 1 )N S

8.Z DEFICIENCY REPORT

LI CORRECTIVE ACTION REPORT

NO .-. --01.-D-064

PAGE 1 OF

I'

I

TYPE RESPONSE

El Initial OFFICE OF CIVILIAN DR/CAR NO YMSCO-01.D-064

C1 Complete RADIOACTIVE WASTE MANAGEMENT PAGE I OF 1

El Amended U.S. DEPARTMENT OF ENERGY WASHINGTON, D.C. QA: QA

DEFICIENCY/CORRECTIVE ACTION REPORT (RESPONSE) 14a. Immediate Actions. None Compliance Date: N/A

14. Remedial Actions: Upon determination of extent of condition the following remedial actions will be taken:

I. Those Q procedures with action statements in notes with potential immediate safety implications (those statements with a man-machine, man-environment interface) will be identified for modification under the scope of this deficiency.

2. On a sample basis, for remaining Q procedures with action statements in notes, the procedure sponsor organization will evaluate the note for implementation issues.

a) Identified issues • ill be evaluated for adverse impact and DRs will be initiated, as necessary'. b) Based on the results of this evaluation a determination will be made if further evaluations are required.

3. For those Q procedures with actions in notes, and no corrective actions required from items I or 2. DARs will be initiated. No further tracking for these procedures will be accomplished under the scope of this deficiency.

15. Extent of Condition: To determine the extent of condition all Q procedures will be reviewed by the respective procedure sponsor organizations to identify procedures with action statements in notes. The YMP Project Manager will submit an amended response to this DR by July 30, 2001 identifying the results of this review and the planned actions and schedule for the procedures with action statements in notes.

16 Cause (Attach results of root cause determination prepared in accordance with AP-16 4Q for a significant deficiency) The cause is the failure to implement AP-5.IQ in procedure preparation and review relative to ensuring that action statements are not included in procedure notes.

17. Action to Preclude Recurrence: The requirements of AP-5. IQ relative to notes will be a topic of discussion at the DOE Project Manager's staff meeting as well as the BSC General Manager's staff meeting, with direction to include this topic at each manager's staff meeting.

This action will be completed by July 16, 2001

18 Due Date: July 30, 2001 19. Resp nse by. SFor submittal of complete response

El For completion of corrective action Datel ! 4.- Phone4-13o I

20 Evaution • A cct Partially Accept El Reject 21. Concurre ce:

QAR • -"" .. .. Date t,/2/oI 1 o0 A i""'4 Date "7//l ee-6 _-I*Lp .. -___,C_/I-_611_,&/a/

Exhibit AP-16 1Q.1 Rev. 11,12,uI I9

8. EDDR/CAR

OFFICE OF CIVILIAN El Stop Work Order

RADIOACTIVE WASTE MANAGEMENT U.S. DEPARTMENT-OF ENERGY NO YMSCO-01-D-064

WASHINGTON, D.C. PAGE OF QA: QA

DEFICIENCY/CORRECTIVE ACTION REPORT/STOP WORK ORDER CONTINUATION PAGE

INITIAL RESPONSE (6/14/01) - COMMENTS

A. The Response focuses on identifying the-existence of a'condition labeled as having a "potential ýimmediate safety imfplication",

such condition having been created by the failure to comply with the identified requirements in the development and maintenance

of a procedure. The potential for creation is not unique to "Q" procedures. It can occur in a "non-Q" as well as a "Q"' procedure, but

the Respionse sp'ecifically'limits the applicatioh of the identification, evaluation, and correction'process to "Q" procedures onle.

disregarding the "non-Q" source. It is expected that the "non-Q" source will be similarly assessed and corrected, as necessary. in

accordance with the 'ýorrective action plan developed to address CIRS Item Identification Number 1657, which poses the question

of action steps in NOTES in "non-Q" procedures; therefore, the corrective action plan for this DR can be limited to actions

regarding "Q" procedures....

B. In order to provide reasonable assurance that the execution of the corrective action plan by multiple "respective procedure

sponsor organizations" will be uniform and credible, the Complete Response, due 7/30/01 with content as described in Block 15,

Extent of Condition, should also address the following points: .

0 Definitions of Terms

Important terms such as "potential immediate safety implications" and "action statements", should be defined.

Without clear definitions the conclusions dependent on a common understanding of important terms wiilI have no

uniform referenceable basis.

* Action Specification

Assuming that the presently undefined term "potential immediate safety implications" refers to a condition which, if

otherwise uncorrected, could present a substantial threat to the safety of workers or the public, reacting to the

discovery of such a condition by referring to an action vaguely described as "identified for modification" has no

meaning and certainly does not convey the sense of urgency with which such a discovery should be treated. The

actions to be taken on an irmmediate, priority basis need to be clearly stated.

"* Sampling Plan- ...

The sampling plan to be applied to the evaluation of procedure performance for the existence of implementation

issues needs to be clearly described or specified. Selectiohi or development by each "procedure sponsor organizations"

"could be inconsistent and, therefore, should not be allowed

ý•,T Ha ar pqf

QAR - ,.. Date

Exhibit AP-16.1Q.2

-2 ,/d6

'Rev 06/01/1999

Extent of Condition for YMSCO-01-D-064

Q Procedures

2 3 4 5 6 7 9 Q? Notes Immediate From Q Implementation If #2 and #4 are If #6 Is

(Yes/N wlAction Safety Issue Population, Issues (Yes/No) Yes, Correct Yes, o) Steps (Yes/No) Identify Under Dr-064 & DR#

Procedure No. Procedure Title DOE Sponsor Current BS (Yes/No) Implementation Identify

Sponsor Assessment Proposed Sample (X) Completion

Date

AP 2 1 Q Indoctrination and Training of Personnel DOE/OPM&A R Minin HR Y N N N/A N N/A N/A Establishment and Verification of

AP 2 2 Q required Education and Experience.. DOE/OPM&A D Shelor HR Y N N N/A N N/A N/A AP 2 12 0 Peer Review DOE/OPE S Mellington CSO y y N X N N/A N/A

AP 2 14 Q Review of Technical Products and Data ENG y N N N/A N/A N/A N/A Tracers, Fluids, and Materials Data

AP 2 17 Q Reporting and Management SS&FS y y N N/A N/A N/A N/A Quality Assurance Requirements and

AP 2 19 Q Description Requirements Matrix DOEIYMSCO R Dyer CA Y y N N N/A N/A N/A AP 2 20 Q Self-Assessment DOE/YMSCO R. Dyer QA Y y N X N N/A N/A

Quality Determinations and Planning for AP 2 21 Q Scientific Engineering and . ENG Y y N X N X N/A AP 3 4 Q Level 03 Change Control ENG y y N N/A N/A N/A N/A AP 3 9 Q Interface Management Process DOE/OQA R W Clark ENG y y N N/A N N/A N/A

AP 3 10 Q Analyses and Models ENG Y Y N N/A N/A N/A N/A AP 3 11 Q Technical Reports ENG Y Y N N/A NIA N/A N/A AP 3.12 Q Calculation, ENG y y N NIA N/A N/A N/A AP 313Q Design Control ENG y N N/A N/A N/A N/A N/A AP 3 14 Q Transmittal of Input ENG y y N N/A N/A N/A N/A AP 3 15 Q Managing 1 echnical Product Inputs ENG Y N N/A N/A N/A N/A N/A AP 317Q Impact Reviews ENG y N NIA N/A 'N/A N/A N/A AP 3 19 Q Specifications/Drawings ENG y y N N/A N/A N/A N/A AP 3 20 Q Technical/Design Verification ENG y N N/A N/A N/A N/A N/A

Plan and Procedure Preparation, AP 5 1 Q Review, and Approval DOE/OPC V Trebules GA Y N N N N/A N/A N/A AP 520 Testing Work Packages CSO Y N N/A N/A N/A N/A NIA AP 6 1 Q Controlled Documents DOE/OIM R Wells CIO Y N N N/A N/A N/A N/A

AP 6 28 Q Document Review DOE/OPC V Trebules GA Y N N N N/A N/A N/A AP 7 4 Q Evaluation ci Suppliers DOE/OQA R W Clark GA Y

Submittal. Review. and Acceptance of AP 7 50 Deliverables DOE/OPC V Trebules ENG Y Y N X N N/A N/A AP 7 6Q Procurement of Items and Services PROC y y N X N N/A N/A AP 7 7 Q Acceptance of Items and Servicei CA Y y N N/A N N/A N/A

Qualification and Certification of AP 9 20 Nondestructive Examination CA Y Y N X N N/A N/A

General Quality Control Inspection and AP 10 1 Q Testing CA Y Y N X N N/A N/A

Development, Approval, and Control of AP 10 2 Q Inspection awid Test Checklists QA Y y N X N N/A N/A

General Inspection and Test Personnel I AP 1030 Certification CA Y Y N X N N/A N/AAP 104Q Work Packaie Review Q GA V V N X N N/A N/

Prepared by YMP &6/2001


Q Procedures

2 3' 4 5 6 7 9 Q? Notes Irnmediate From 0 Implementation If #2'and #4 are If #6 Is

(Yes/N wlAction Safety Issue Population, Issues (YesINo) Yes, Correct Yes, 0) Steps (YesINo) Identify Under Dr-064 & DR#

Procedure No. Procedure Title DOE Sponsor Current BS (YesINo) Implementation Identify I Sponsor Assessment Proposed

Sample (X) Completion Date

Control of Measuring and Test AP 1210 Equipment and Calibration Standards CSO Y Y N X N N/A N/A AP 152Q Control of Nonconformances ' DOE/OQA R W. Clark OA Y N, N X N N/A i N/A

Management of Conditions Adverse to AP161Q Quality " ' I . .,DOE/OQA R W Clark OA V _Y

AP 163Q Trend Evaluation and Reporting DOE/OQA R W Clark QA Y AP 164Q Root Cause Determination DOE/OQA R W. Clark CA y

Record Source Responsibilities for AP 17.10 Inclusionary Records DOE/OIM R N Wells CIO Y Y N X N N/A N/A

DOE/OPE R. Spence APAC.1Q Expert Elicitation DOE/OLRC S Brocoum CSO Y N NIA N/A N/A N/A N/A AP 18 2 0 Supplier Surveys/Audits Q QA VY

AP OM-006Q Work Request/Work Order Process, SS&FS y Y_ N/A N/A N/A N/A N/A AP SI.1Q Software Management DOE/OIM R Wells CIO Y Y N N/A N/A N/A N/A AP Sill 10 Scientific Notebooks CSO Y N NIA N/A N/A N/A N/A

Qualification of Unqualified Data and the AP Sill 2Q Documentation of Rationale, DOE/OPE S. Mellington CIO Y Y N X N NIA N/A

Submittal and Incorporation of Data to - AP Sill 3Q- Te'chnical Data Management System CIO Y Y N X N N/A N NIA

Developmeat, Review. Online Placement, and Maintenance of

AP Sill 4Q Individual .... CIO Y N NIA N/A N/A N/A N/A Yucca Mountain Site Characterization

AP Sill 50 Proiect Field Verification - DOE/OPE CIO Y Y N N/A N/A N/A , N/A Geophysical Logging Programs for

AP Sill 6Q Surface-Based Testing Program DOE/OPE CIO Y Y N N/A N/A LN/A NIA Control of the Electronic Management of

AP SV.1Q Information, DOE/OIM R Wells CIO Y N N N/A N/A N/A N/A LP-1 OQ-M&O Organization CA Y N N N/A N/A N/A N/A

LP 1.1Q-o.CRWM Oirganlzaton DOE/OCRWM I. Itkin [OE/OQA Y _ -_Control and Reporting of Tracers, I

LP 2 1Q-M&O Fluids, and Materials Used in ESH Y N NIA 'N/A N/A N/A N/A

LP 2 2Q-OCRWM Maintenance of the QARD and ISMOAP DOE/OQA R W Clark CA Y_ LP 2 4Q-OCRWM Quality Assurance Programs Controls DOE/OQA CA Y LP 2 5Q-OCRWM Management Assessment DOE/OQA GA Y

Document Input Reference System LP 3 210-M&O Reference Research and Verification CIO V N N N/A N/A N/A N/A

Technical Review and Approval of LP 3 22Q-M&O Construction Submittals ENG Y Y N N/A NIA NIA N/A

Software Configuration Management I I LP 3 23Q-M&O DIRS Research and Verification CIO Y N N NIA NIA N/A ,NIA LP 3 24Q-M&O MGR Interface Control Documentation ENG Y Y N N/A NIA X N/A

LP 4.1Q-OCRWM Procurement Actions DOE/OPS J Adams PROC Y Y N N/A N NIA NIA LP 4 2Q-OCRWM Procurement of Services DOE/OATI PROC Y Y N N N/A N/A N/A

Prepared by YMP 8/W/2001


Q Procedures 2 3 4 5 6 7 9

Q? Notes Immediate From Q Implementation If #2 and #4 are If #6 Is (Yes/N w/Action Safety Issue Population, Issues (Yes/No) Yes, Correct Yes,

o) Steps (Yes/No) Identify Under Dr-064 & DR# Procedure No. Procedure Title DOE Sponsor Current BS (Yes/No) Implementation Identify


Date

LP 5 1Q-OCRWM Document Preparation DOEIOLRC S. Brocoum CIO Y y N X N N/A N/A Review of Procurement Records for Use

LP 16 10-OCRWM in the Verification Confirmation .. DOE/OQA R W Clark PROC Y LP 17.1Q-BSC Processing Inclusionary Records CIO Y Y N X N N/A N/A

LP CAL-001Q-OCRWM Calibration of Compaction Molds QA Y N N X N N/A N/A Calibration of Type B Pressure Air

LP CAL-002Q-OCRWM Meters QA Y N N X N NIA N/A LP CAL-003Q-OCRWM Calibration of Volume Measures CIA Y N N X N N/A N/A

LP CAL-004Q.M&O AnaMical Balance Calibration ESH Y Y N X N N/A N/A LP CON-001Q-M&O Traced Water System SS&FS Y Y N N/A N/A N/A NIA LP CON-002Q-BSC Field Engineering Impact Reviews ENG Y N N/A N/A N/A N/A N/A

Calibration of Turbine Flow Meter for LP ENG-001-M&O Water Flow SS&FS Y Y N N/A N/A NIA N/A

Measuring Air Temperature and Air LP ENG-004Q-M&O Velocity During the Ventilation Test SS&FS Y Y N N/A N/A NIA N/A

Use of Tnmble GPS Geoexplorer for LP ESH-024Q-M&O Collection of Location Information ESH Y N N/A N/A N/A N/A N/A

Laboratory Geotechnical Testing of Soil, LP GEO-001Q-M&O Rock, and Angregato Samples CSO Y N N/A N/A NIA N/A N/A LP GEO-002Q-BSC Laboratory Dynamic Rock/Soil Testing CSO Y N N/A N/A NIA N/A N/A

Verification of Digital Geophysical Log LP GL-O01Q-M&O Data CSO Y N N/A N/A NIA N/A N/A

Forensic Evaluation of Geophysical Log LP GL-002Q-M&O Data CSO Y N N/A N/A N/A N/A NIA

Analysis of Geophysical Logs and LP GL-003Q-M&O Associated Depth-Related Borehole CSO Y N N/A N/A N/A N/A N/A

Verification of Data Entry into the TSPA LIP IM-OOIQ-M&O CSO Y N NIA N/A N/A NIA N/A

Tests and Checks of Meteorological LP MM-001Q-M&O Measunng and Test Equipment ESH Y Y N X N N/A N/A

Tests, Checks, and Performance Audits LP MM-002Q-M&O of Meteorological Equipment ESH Y Y N X N N/A N/A

Routine Operations and Maintenance of LP MM-003Q-M&O Meteorological Equipment ESH Y Y N X N N/A N/A LP MM-004Q-M&O Meteorological Data Processes ESH Y N N/A N/A NIA NIA N/A

ESF Equipment/Hydrocarbon Leak LP OM-027Q-M&O Inspection SS&FS Y Y N N/A N/A N/A NIA

Control and Distribution of Surveying LP OM-035Q-BSC Documents SSFS Y Y N N/A N/A N/A N/A

Accuracy Test for Electronic Distance LP OM-0360-BSC Meters SS&FS Y Y N N/A N/A N/A N/A LP OM-037Q-BSC Control of Survey Equipment SS&FS Y Y N X N N/A N/A LP OM-038Q-BSC Surveying SS&FS Y Y N N/A N/A N/A N/A LP OM-039Q-BSC Water Meter Flow Check SS&FS Y Y N N/A N/A N/A N/A

Tracers, Fluids, and Materials :. LP OM-0400-BSC Estimating, Accounting, and Reporting SS&FS Y V N N/A N/A N/A N/A LP OM-041Q-BSC Water Use and Control - Subsurface SS&FS V N N/A N/A N/A N/A

Prepared by YMP 8/6r2001



Q? Notes Immediate From Q Implementation If #2 and #4 are If #6 Is (Yes/N wlAction Safety Issue Population, Issues (YeslNo) Yes, Correct Yes,

Current BS ) Steps (Yes/No) Identify Under Dr-064 & DR# Procedure No. Procedure Title DOE Sponsor (Yes/No) Implementation Identify Sponsor Assessment Proposed i


Ground Support Walkdown, LP OM-0420-BSC' Maintenance and Repair SS&FS Y N N NIA N/A NIA NIA

Sampling and Testing of Freshly Mixed LPQC-001Q.OCRWM Concrete and C66crete-Related .. OA Y Y N X N , N/A N/A

Laboratory Curing, Compression Testing, and Reporting for Cementious

LP QC-005Q-OCRWM ... GA Y Y N X N NIA N/A LP OC-0060-OCRWM Inspection of Test Devices GA Y Y N X N NIAr- N/A

Bromide (Br) Ion Tracer Water Sampling LP OC-015Q-OCRWM and Testing -A Y Y N X N N/A N/A

, Scientific Investigation of Economic, LP RS-001Q-M&O Demographlc, and Agricultural ESH Y N N/A NIA N/A N/A N/A

Field Logging, Handling, and LP SMF-002Q-M&O Documenting Borehole Samples SS&FS Y Y NIA' N/A N/A NIA N/A

SCalibration of Sample Management, LP SMF-007Q-M&O Measuring, and Test Equipment ) SS&FS Y N N NIA N/A N/A N/A

i I Magnetic Particle Examination -Yoke LP SPP-015Q-OCRWM Dry Powder Visible - - O _ QA Y Y N X N N/A N/A o, _ IReceiving, Handling, and Storage of . LP WP-0010-OCRWM Metallic Te't Specimens CSO Y N N/A N/A N/K N/A N/A

NLP 2-00 Determination of lmportance Evalu•tions ENG Y Y N N/A N/A N/A N/A Documentation of Title III

NLP 3-29Q Implementation Actions ENG Y N N/A N/A NIA N/A N/A ESF Walk-Down for Quality Affecting I

NLP 3-35Q Ground Support _-_' SS&FS Y N N/A' NIA N/A N/k- N/A YMP Site Construction Field Work

NLP 5-30 Authorization Process SS&FS. Y Y N N/A N/A NIA' N/A -Framatome Cogema Fuel and

Framatome Technologies Incorporated NLP 7-30 -... -_SS&FS Y N N/A NIA N/A N/A N/A

NLP SIII.3Q Borehold History Reports CSO Y N N/A- N/A N/A NIA N/A - - i Software Configuration Secretanat

NWI CM-001Q Responsibilities _ _ _ _CIO Y N N NIA- N/A N/A N/A NWI DS-0020 Field Drillintl Support Activities ....... _ SS&FS Y V N N N/A NIA NIA N/A

Logging, Handling, and Documenting NWI DS.004Q ESF Non.. SS&FS Y N N N/A N/A N/A NIA

ESF, Sanitary Sewer System Operations I NWI ESF-006Q and Maintenance SS&FS Y Y N N/A NIA N/A N/A

Visual Observation of Drainage Ditches NWI ESF-0130 and Graded Roads and Pads SS&FS Y Y N X N N/A N/A

Rockbolt and Rockbolt Accessory NWI ESF-0190 Installation ENG Y Y Y X N- 8/31/2001 N/A NWI ESF-020Q Rockbolt Pull Testing Procedure ENG Y Y Y X N 8/31/2001 -N/A

Diesel-powered Equipment Emissions NWI ESF-0210 Testing and Control Procedure SS&FS Y N N NIA N/A N/A NIA NWI ESF-023Q Concrete Batch Plant Operations ISS&FS N N N/A N/A N/A N/A

Prepared by YMP 8/8/2001

Extent of Condition for YMSCO-O1-D-064

Q Procedures

2 3 4 5 6 7 9 Q? Notes Immediate From Q Implementation If #2 and #4 are If #6 Is

(YesIN wlAction Safety Issue Population, Issues (YesINo) Yes, Correct Yes, PCurrent BS 0) Steps (Yes/No) Identify Under Dr-064 & DR#

Procedure No. Procedure Title DOE Sponsor Cur oret (YeslNo) Implementation Identify Sponsor Assessment Proposed


NWI ESF-026Q Welding Procedure Specifications 98Q SS&FS Y N N N/A N/A N/A N/A Welder/Welding Operator Performance

NWI ESF-027Q Qualification SS&FS Y N N N/A N/A N/A NIA Welding Electrode Control for "Q"

NWI ESF-028Q Welding SS&FS Y Y N X N N/A N/A Certification of ShotCrete Nozzle

NWI ESF-0290 Operators SS&FS Y y N N/A N/A NIA NIA NWI ESF-038Q Identification and Control of Items SS&FS Y y N N NWI ESF-042Q ShotCrete Placement SS&FS Y Y N N/A N/A N/A N/A NWI ESF-044Q Construction Planning and Control SS&FS Y y N N/A N/A N/A N/A Subsurface Controlled Drilling and

NWI ESF-0460 Blastinc Operations SS&FS Y N N N/A N/A N/A N/A Receipt and Handling of Materials and

NWI ESF-047Q Items PROC Y N N N/A N N/A N/A NWI ESF-048Q Cast-ln-Plkce Concrete ENG Y Y X N 8/31/2001 N/A NWI ESF-049Q Steel Set Jacking/Expansion SS&FS Y N N/A N/A N/A N/A N/A NWI ESF-051Q Tunnel Discharge Wastewater Re-use SS&FS Y N N N/A N/A N/A N/A Release Readiness, Cleanup. and

NWI ESF-055Q Reporting SS&FS Y y N N/A N/A NIA N/A Removal of Whole and Other Specimens from Samples by the

NWISMF-0010 Sample.. SS&FS Y N N N/A N/A N/A N/A Transport, Receipt, Admittance, and

NWI SMF-002Q Processing of Borehole Samples SS&FS Y N N N/A N/A N/A N/A

Examination of Borehole Samples NWI SMF-003Q Curated at the Sample Management SS&FS Y N N N/A N/A N/A N/A

Use of the Trimble GPS for Determining NWI SPO-001Q Surface Locations SS&FS Y N N/A N/A N/A N/A N/A NWI SPO-002Q Seismic Refraction Surveying SS&FS Y N NIA NIA N/A NIA N/A Use of a Tracer Gas for Determining

NWI SPS-OOIQ Atmospheric Contamination of the SS&FS Y N N N/A N/A N/A N/A Incorporation of Data into the Site and NWI TDM-003Q Engineering Properties Database CIO Y N N X N N/A N/A NWI TDM-004Q Incorporation of Data into the TDMS's CIO Y N N X N N/A N/A Review and Maintenance of Metadata in

NWI TDM-0O5Q the ATDT.. CIO Y N N X N N/A N/A Processing and Placement of

NWI TDM-006Q Documents to the RTN Web CIO Y N N X N N/A N/A Maintaining the Geographic Information

NWI TDM-007Q Database CIO Y N N X N N/A N/A GAP 2-3 Classification of Permanent Items ENG Y N N N/A N N/A N/A QAP 2-6 Readiness Review ENG Y N N/A N/A N/A N/A N/A GAP 2 6 Readiness Review DOE/YMSCO R Dyer QA Y N N/A N N/A N/A N/A QAP 28 Surveillance DOE/OQA R W Clark QA Y GAP 18 1 Auditor Qualification DOE/OQA R W. Clark GA Y QAP 18 2 Internal Audit Program DOE/OQA R W Clark GA V

Prepared by YMP 816/2001



Q? Notes Immediate From Q Implementation It #2 and #4 are If #6 Is (Yes/N w/Action Safety Issue Population, Issues (Yes/No) Yes, Correct Yes,

o) Steps (Yes/No) Identify Under Dr-064 & DR# current BS (eIo mlmnainIetf

Procedure No. Procedure Title DOE Sponsor Sponsor (YesANo) Implementation Identify o SpnsorAssessment Proposed ,


Item Classification and Maintenance of YAP 2.7Q, the Q-List DOE/OPE S. Mellinton ENG Y N N/A N/A NIA - NIA NIA YAP 3 7Q Request for Clarification DOE/OQA R W. Clark ENG Y N N/A NIA N N/A N/A

YAP 13,1Q Borehole Protection and Access DOE/OQA R. W. Clark SS&FS Y Y N N/A N/A N/A N/A Submittal, Review, and Approval of

YAP SII 1Q Requests for YMSC . % DOE/OPE R. Spence OA Y Y N N/A NIA N/A N/A Y * ,.• Requesting Samples for Examination at

YAP SIt 20 the YMSC . - DOE/OPE R. Spence SS&FS' Y N N/A N/A NIA NIA " N/A Collection, Submission, and Documentation of non-Core and non

YAP SIt 4Q Cutting. DOE/OPE R Spence SS&FS Y N N/A N/A N/A N/A , NIA Documentation of Standardized

YAP Sill 6Q Geotechnlcal Borehole Logglngi DOEIOPE R Spence SS&FS' Y N N/A N/A N/A N/A NIA

j.1,

Prepared by YMP 816r2001

I I I

£TYPE RESPONSE

C] Initial OFFICE OF CIVILIAN DR/CAR NO. YMSCO-oi-D-064 El Complete RADIOACTIVE WASTE MANAGEMENT PAGE 1 OF orX0

21 Amended U.S. DEPARTMENT OF ENERGY WASHINGTON, D.C. QA: QA

DEFICIENCY/CORRECTIVE ACTION REPORT (RESPONSE) 14a. Immediate Actions None Compliance Date: N/A

14. Remedial Actions: Upon determination of extent of condition the following remedial actions will be taken:

1. Those Q procedures with action statements in notes with potential immediate safety implications (those statements with a man-machine, man-environment interface) will be identified for modification under the scope of this deficiency.


a) Identified issues will be evaluated for adverse impact and DRs will be initiated, as necessary. b) Based on the results of this evaluation a determination will be made if further evaluations are required.

3. For those Q procedures with actions in notes, and no corrective actions required from items I or 2, DARs will be initiated. No further tracking for these procedures will be accomplished under the scope of this deficiency.

Amended response dated 08/06/01 (see attached continuation sheet)

15 Extent of Condition To determine the extent of condition all Q procedures will be reviewed by the respective procedure sponsor organizations to identify procedures with action statements in notes. The YMP Project Manager will submit an amended response to this DR by July 30, 2001 identifying the results of this review and the planned actions and schedule for the procedures with action statements in notes.

Amended response dated 08/06/01 (see attached continuation sheet) 16 Cause (Attach results of root cause determination prepared in accordance with AP-16 40 for a significant deficiency) The cause is the failure to implement AP-5.IQ in procedure preparation and review relative to ensuring that action statements are not included in procedure notes. Amended response dated 08/06/01: No change to the root cause was identified during extent of condition determinations.

17. Action to Preclude Recurrence: The requirements of AP-5.1Q relative to notes will be a topic of discussion at the DOE Project Manager's staff meeting as well as the BSC General Manager's staff meeting, with direction to include this topic at each manager's staff meeting.

This action will K. completed by July 16, 2001 Amended response dated 08/06/01: Actions to preclude recurrence were completed on July 31, 2001

18. Due Date: August 31, 2001 19. Response by. El For submittal of complete response E] For completion of corrective action Q • Date I/r(0/ 'I Phone'q4-13"

20 Evaluation EAccept EL Partially Accept ,xReject 21. ConcurrenFe:

OAR6 - HA-__ _+ Date

Rev 12/20/1999 / / 1ý 1-1

r

Exhibit AP-1 6.1 Q I

8. E)DR/CAR OFFICE OF CIVILIAN E Stop Work Order

RADIOACTIVE WASTE MANAGEMENT' U.S. DEPARTMENT OF ENERGY NO YMSCO-01.D-064

WASHINGTON, D.C. PAGE 2 . OF

QA: QA

DEFICIENCYICORRECTIVE ACTION REPORTISTOP WORK ORDER CONTINUATION PAGE COMPLETED RESPONSE -CONTINUED

-14. Remedial Actions (cofitinued) (amended response dated 08/06/01):

1. The Q procedures with action statements in notes were reviewed to determine if the action statements represented potential immediate safety implications (those statements with a man-machine, man-environment interface). The f•ollowing three procedures were determined to have this condition and will be modified to correct this condition by August 31, 2001. (It was determined that the situation did not warrant ECNs due to the nature of the specific actions, current work activities, and confirmation through review of objective evidence that the actions were being implemented.)

NWI-ESF-019Q, Rockbolt and Rockbolt Accessory Insfallation .

NWI-ESF-020Q, Rockbolt Pull Testing Procedure

NWI-ESF-048Q, Cast-In-Place Concrete 2. Of the Q procedures with action statements with notesjust less than half were evaiuated to confirm that the actionls

were being implemented. -

a) No issues were identified as a result of this evaluation.

b) Based on this result of this evaluation no additional evaluations are required. 3. Based on the results of the evaluation from items I and 2, and discussions on 07/26/01 between OQA, BSC. and

YMP support personnel, it was determined that DARs are not warranted for those procedures with actions in notes that did not have a potential immediate safety implication.

Refer to attached "Extent of Condition for YMSCO-01-D-064" that identifies the Q procedures evaluated under items I and 2 and the results of the evaluation.

15. Extent of Condition (continued) (amended response dated 08/06/01):

Q procedures were reviewed to identify procedures with action statements in notes. Sixty-five procedures were identified with action statements in notes. Refer to attached "Extent of Condition for YMSCO-01-D-064" that identifies the Q procedures reviewed and the results of the review. The evaluation performed under item 14, Remedial Actions confirmed that there were no implementation issues, and therefore this deficiency has no impact on Q items or activities.

Exhibit /1 *� '�

Exhibit // '/, u'

I

8. ')DR/CAR

OFFICE OF CIVILIAN El Stop Work Order RADIOACTIVE WASTE MANAGEMENT

U.S. DEPARTMENT OF ENERGY NO YMSCO-01-D-C64

WASHINGTON, D.C. PAGE 10F_2

QA: QA


A. REASONS FOR REJECTION

I. Block 15 of the Complete/Amended Response indicates "Sixty-five procedures were identified with action statements in notes". The attached spreadsheet, "Extent of Condition for YMSCO-01-D-064" indicates seveny procedures with "Notes W/Action Steps" ("Y" record in Column 3).

2. Three procedures are identified as having action statements that represent "potential immediate safety implications", which are to be "modified to correct this condition by August 31, 2001". While the Response goes on the state that the ECN process will not be

used, it does not state what process will used, but presumably this will be through a procedure revision or ICN. Prior to submission of the Complete/Amended Response, which removed the requirement of the Initial Response to file DARs against procedures with action statements and no implementation issues, DARs D977, D979, and D980 had been filed against the three procedures in question Inasmuch as implementation of certain action steps in otherwise unidentified notes is relied on as a reason for not changing these procedures by ECN, literal application of the Requests of these DARs ("Remove notes from procedure") will disrupt the processes of these three procedures. Furthermore, it is clear that, if the process to address the Remedial Actions of the Initial Response had been properly followed, DARs would never have been filed against these procedures.

3. Results of review for eleven "Q" procedures are not included in the attachment "Extent of Condition for YMSCO-01-D-064". These are:

PROCEDURE AP-16.1Q AP-16.3Q AP-16 4Q AP- 1 8.2Q LP-I.IQ-OCRWM LP-2.2Q-OCRWM LP-2.4Q-OCRWM LP-2.5Q-OCRWM QAP 2.8 QAP 18.1 QAP 182

SPONSOR DOE/OQA DOE/OQA DOE/OQA DOE/OQA DOE/OCRWM DOEiOQA DOE/OQA DOE/OQA DOE/OQA DOE/OQA DOE/OQA

4. In accepting the Initial Response, OQA noted on a Continuation Page that the Complete Response should address, as described, Definitions of Terms, Action Specification, and Sampling Plan. None of these points is addressed in the Complete/Amended Response.

5. The Response attachment "Extent of Condition for YMSCO-01-D-064" identifies DOEiOQA as the "DOE Sponsor" for AP

3.9Q. The correct entry should be DOE/OATI.

Exhibit AP-16.1Q 2

1/ //�

R"ev U0IUM I i199

(

8. [DR/CAR

OFFICE OF CIVILIAN Lj Stop Work Order

RADIOACTIVE WASTE MANAGEMENT U.S. DEPARTMENT.OF ENERGY ,- NO YMSCO-01-D-064

WASHINGTON, D.C. - -, PAGE 2 OF 2

QA: QA

DEFICIENCY/CORRECTIVE ACTION REPORT/STOP WORK ORDER CONTINUATION 'PAGE

B. ACTION REQUIRED

Revise the Complete/Amended Response to:

I. Resolve the question regarding the number of procedures identified with action statements in notes. (A.! above)

2. Describe the action being or to be taken to ensure that action steps in procedures. noted as "being implemented", are not

inadvertently removed from the three procedures identified as having "potential immediate safeiy implications" durin'g the

procedure "modification" process. (A.2 above)

3. Provide review results for eleven procedures. (A.3 above)

4 Provide the responses requested on the Continuation Page to OQA acceptance of the Initial Response. (A.4 above)

5. Correct the "DOE Sponsor" assignment for AP-3.9Q. (A.5 above)

-3. T. Har5er, QAR Date

Exhibit AP-16 1Q.2

/� r

m n

Kev. 06,0 1

TYPE RESPONSE

E Initial OFFICE OF CIVILIAN DR/CAR NO YMSCO-0I-D:064

El Complete RADIOACTIVE WASTE MANAGEMENT PAGE 1 OF 1

[ Amended U.S. DEPARTMENT OF ENERGY WASHINGTON, D.C. QA: QA

DEFICIENCYICORRECTIVE ACTION REPORT (RESPONSE) 14a. Immediate Actions: None Compliance Date: N/A

14. Remedial Actions: Upon determination of extent of condition t-he following remedial actions will be taken.

I. Those Q procedures with action statements in notes with potential immediate safety implications (those statements with a man-machine, man-environment interface) will be identified for modification under the scope of this deficiency.


a) Identified issues will be evaluated for adverse impact and DRs will be initiated, as necessary. b) Based on the results of this evaluation a determination will be made if further evaluations are required.

3. For those Q procedures with actions in notes, and no corrective actions required from items I or 2, DARs will be initiated. No further tracking for these procedures will be accomplished under the scope of this deficiency.

Amended response dated 10/29/01 (see attached continuation sheet)

15. Extent of Condition To determine the extent of condition all Q procedures will be reviewed by the respective procedure sponsor organizations to identify procedures with action statements in notes. The YMP Project Manager will submit an amended response to this DR by July 30, 2001 identifying the results of this review and the planned actions and schedule for the procedures with action statements in notes.

Amended response dated 10/29/01 (see attached Extent of Condition for YMSCO-01-D-064)16 Cause: (Attach results of root cause determination prepared in accordance with AP-16 4Q for a significant deficiency ) The cause is the failure to implement AP-5.1Q in procedure preparation and review relative to ensuring that action statements are not included in procedure notes. Amended response dated 10/29/01: No change to the root cause was identified during extent of condition determinations.

17. Action to Preclude Recurrence: The requirements of AP-5.IQ relative to notes will be a topic of discussion at the DOE Project Manager's staff meeting as well as the BSC General Manager's staff meeting, with direction to include this topic at each manager's staff meeting.

This action will be completed by July 16. 2001Amended response dated 10/29/01: Actions to preclude recurrence were completed on July 31, 2001

18. Due Date 11/14/01 19. Response by ,6X -,4 /1*•o"2T54/ D For submittal of complete response

ElFor completion of corrective action \s~l t £ib~ 20 Accept E Partially Accept I- Reject 21. rence:

QA• o - •fa-1- Date 000A Date

Exhibit AP-16.1Q.1 Rev 12/20/1999

/7 � -I

8 [DDR/CAR

OFFICE OF CIVILIAN El Stop Work Order

RADIOACTIVE WASTE MANAGEMENT U.S. DEPARTMENT OF ENERGY . NO YMSCO-01-D-064

WASHINGTON,.D.C., PAGE OF

"QA: QA

DEFICIENCYICORRECTIVE ACTION REPORTISTOP WORK ORDER CONTINUATION PAGE

COMPLETED RESPONSE - CONTINUED

14. Remedial Actions (continued) (amended response dated 10/29/01):

1. The Q procedures with action statements in notes were reviewed to determine if the action statements

represented potential immediate safety implications (those statements with a man-machine, man

environment interface). The following three procedures were determined to have this condition and were

modified to correct this condition.

NWI-ESF-0 19Q. Rockbolt and Rockbolt Accessory Installation

NWI-ESF-020Q, Rockbolt Pull Testing Procedure

NWI-ESF-048Q, Cast-In-Place Concrete

2. On a sample basis, as identified in the attached Extent of Condition for YMSCO-0 1 -D-064, procedures

with action siatements with notes were evaliated to confirm that the actions were being implemented.

a) No issues were identified as a result of this evaluation.

b) Based on the result of this evaluation no additional evaluations are required.

3. DARs have been initiated for those Q procedures with actions in notes.

This following addresses the "Actions Required" as a result of the rejected response by the Quality Assurance

Representative (QAR) d6ted 8/22/01. The Action Required are re-stated followed by the responise to that Action Required.

Action Required - Item 1. Resolve the question'regarding the number of procedures identified with action statements in notes.

Response to Item 1. The procedures with action statements in notes are shown in the attached matrix.

Action Required - Item 2 Describe the action being taken to ensure that action steps in procedures, noted

as "being implemented". are not inadvertently removed from the three procedures identified as having "potential immediate safety implications" during the procedure "modification" process.

Response to Item 2. The three procedures were reviewed after being revised on 8/31/01 and it was verified that the verbiage in all of the Notes was incorporated into the body of the procedure. No verbiage in the

Notes, which contained action statements, was removed from the procedures.

Exhibit AP-1 6.1Q 1 Rev 12/2011999

V)


U.S. DEPARTMENT OF ENERGY WASHINGTON, D.C.

8 GIDRICAR EZ Stop Work Order

NO YMSCO-01-D-064

PAGE OF QA: QA

DEFICIENCYICORRECTIVE ACTION REPORT/STOP WORK ORDER CONTINUATION PAGE COMPLETED RESPONSE - CONTINUED

Action Required - Item 3 Provide the review results from the 11 procedures.

Response to Item 3. The OQA Representative completed the review of the procedures noted in the Rejection letter. The results of the OQA procedure evaluation indicated there were no immediate safety issues, and no issues warranting a deficiency report. Document Action Requests (DARs) were written against those procedures that were identified as having action steps in the procedure notes. The results of the evaluation have been added to the matrix.

Action Required - Item 4 Provide the responses requested on the Continuation Page to OQA acceptance of the Initial Response. (In accepting the Initial Response. OQA noted on a Continuation Page that the Complete Response should address, as described. Definition of Terms. Action Specification. and Sampling Plan. None of these points is addressed in the Complete/Amended Response.)

Response to Item 4. Definition of Terms: In a meeting with the Director, Office of Quality Assurance. Yucca Mountain Project management. and BSC management on October 23, 2001 it was agreed definitions of the terms were not required.

Action Required - Item 5 Correct the "DOE Sponsor" assignment for AP 3.9Q.

Response to Item 5. The DOE sponsor for procedure AP 3.9Q was corrected to show the correct sponsor as Office of Acceptance, Transportation and Integration.

Exhibit AP-16 1Q 1 Rev. 12/20/1999 f I,, /Iu

I

I,

OFFICE OF CIVILIAN RADiOACTIVE WASTE MANAGEMENT


8. �DRJCAR8. S•DRJCAR

0I Stop Work Order

"NO YMSCO-01-D-064

PAGE OF

QA: QA


REQUEST FOR EXTENDED PROCESSING

Determination of extent of.condition and rerriedial actions are complete. Additional time is required to accept the amended response and verify correciive actions based on discussions with OQA on October 23. 2001.

YMP DOE=44oi

Exhibit AP-16 1Q 1 I-�ev IaLUlw�JR2ev 12,'-IUI9 ,7 , "_,)Exhibit AP-1 6 IQ 1

Extent of Condition for YMSCO 01 D-064

0 Procedures

2 3 4 5 6 7 9 10 0? Notes Immediate From 0 Implementation If #2 and #4 are It 16 IsI #2 Is Yes, and #3

(Yes/ w/Action Salety Issue Population, Issues (Yes/No) Yes, Correct Yes, Is Yes, Identify

Current No) Steps (Yes/No) Identify Under Dr-064 & DR# DAR# Procedure No. Procedure Title DOE Sponsor BSC (Yes/No) Implementation Identify


Date

AP 2 I 0 Indoctfinalion and Tiaining of Personnel DOE/OPM&A R Mining HR Y N N/A N/A NI/A N/A N/A N/A Eslabhshi el and Verilfcaitoin of

AP 2 2 0 required Education and Expenence DOE/OPM&A D Sheioi FIR Y N N/A N/A N/A N/A N/A N/A AP 2 12 0 Peer Review DOE/OPE S Mellinglon CSO y y N X N N/A N/A 0953

AP 2 14 0 Review of Technical Products and Daia ENG Y N N/A N/A N/A N/A N/A N/A Tracers, Fluids, and Malerials Data

AP 2 170 Reporltng and Management SS&FS y y N N/A N/A N/A N/A 0976 Quality Assurance Requirements and

AP 2 19 0 Description Requirements Matrix DOE/YMSCO R Dye, CA Y y N N/A N/A N/A N/A 0959 AP 2 200 SelI-Assessment DOE/YMSCO R Dyer CA Y y N X N NWA N/A D974

Quality Determinations and Planning for AP221 0 Scienific Engineering and ENG y y N X N N/A N/A 0928 AP 2 23 Q Work Reques/Work Order Process SS&FS y y N N/A N/A N/A N/A D1217 AP 3 4 0 Level 03 CI'ange Control ENG y y N N/A N/A N/A N/A D924 AP 3 9 0 Interlace Managernint Process DOEIOATI ENG y y N N/A N/A N/A N/A Dt033

AP3 10O Analyses and Models ENG Y y N N/A N/A N/A N/A 0933 AP 3 110 technical Reports ENG Y y N N/A N/A N/A N/A 0932 AP 3 122 0 Calculations ENG Y y N N/A IVA N/A N/A 0934 AP 3 13 0 Design Control ENG Y N N/A N/A N/A N/A N/A N/A AP 3 14 0 1 ransmittal of Inpul ENG y y N NA N/A N/A N/A procedure canceled AP 3 150 Managing Technical Product Inputs ENG y N N/A N/A N/A N/A N/A N/A AP 3 17 0 impact Reviews ENG y N N/A N/A N/A N/A N/A N/A AP 3 190 SpecificationsfDrawings ENG Y Y N N/A N/A N/A N/A 0975 AP 3 200 technical/Design Verilication ENG Y N N/A N/A N/A N/A N/A WA

Plan and Procedure Preparation, AP 5 Q a Review, and Approval DOE/OPC V Trebules OA Y N N/A N/A N/A N/A N/A N/A AP 5 2 0 Testing Work Packages CSO Y N N/A N/A N/A N/A N/A N/A APe6 0 Controlled Documents DOEJOIM R Wells CIO Y N N/A N/A N/A N/A N/A N/A AP6 28 0 Documenl Review DOE/OPC V TretbJles CA Y N N/A N/A N/A N/A N/A N/A AP 7 4 0 Evaluation of Suppliers DOE/OOA R W Clark CA Y N N/A N/A N/A N/A N/A N/A

Submittal Review, and Acceptance ol AP 7 50 Deliverables DOE/OPC V Trebules ENG Y Y N X N N/A N/A 0973 AP 7 6 0 Procurement ol Items and Services PROC Y y N X N N/A N/A 0972 AP 7 7 0 Acceptance of Itenms and Services CA Y Y N N/A N/A N/A N/A D914

Qualiicaltion and Certlifcatioi ol AP 920 Nondestructive Exirinalion OA Y Y N x N N/A N/A 0909

General Qualily Conlrol Inspection and AP 10 10 Testing CA Y V N X N N/A N/A 0903

Development, Approval and Control of AP 1020 Inspection and Test Checklists GA Y Y N X N N/A N/A 0911

PIM dtnr•u b YMP I (Vt1 "001

it

8 (EDR/CAR OFFICE OF CIVILIAN 0i Stop Work Order

RADIOACTIVE WASTE MANAGEMENT U.S. DEPARTMENT OF ENERGY NO YMSCO01-OD-064

WASHINGTON, D.C. PAGE 1 OF 1

QA: QA


COMPLETE/AMENDED RESPONSE (10/30/01) - COMMENT

At a meeting with the Director, OQA, YMP management, and BSC management on October 23.2001, it was agreed that verification of corrective action completion will also include assessments by OQA of the adequacy of those actions as shoNn in ten (10) procedure changes completed in response to Document Action Requests (DARs) filed as products of the plan. As procedure changes occur, YMSCO should identify each procedure and change identification to the QAR

Cj1'• Harper/AAA ( Date

Exhibit AP-16.1Q.2

I4/0

iRev 06/Ul1l1999

8. EiDR/CAR

OFFICE OF CIVILIAN [] Stop Work Order

RADIOACTIVE WASTE MANAGEMENT U.S. DEPARTMENT OF ENERGY NO YMSCO-O1-D-064

WASHINGTON, D.C. PAGE OF

QA: QA


VERIFICATION OF CORRECTIVE ACTION- YMSCO-01-D-064

Completion of corrective action was reported on 11/15/01 by e-mail Hampton/Distribution, Subj: DR-64.

Verification review of actions taken indicates that performance to date to correct the Extent of Condition has been ineffective. The

details of the verification review are contained in the Attachment.

In summary, the attached detailed notes indicate:

"* Of 25 procedure change actions reviewed, fiv-e-(5) failed to correct the Description-of Condition and one (1) result

could not be determined

"* Two (2) other procedure change actions were 'und'ertaken after identification of the Description of Condition, both of

which actions did not implement appropriate changes to correct the'condition adverse to quality.

* Three (3) procedure change actions in process-at the same time as the review to determine the Extent of Condition

were subsequently completed and issued without addressing the identified conditions adverse to quality.

* One (1) procedure, which was referred to the QAR by others, classified during the review to determine the Extent of

Condition as not containing any action steps'in NOTES has been shown to contain two NOTES with action steps.

There is no indication that this procedure reqiiires cofrection.

" Four (4) Document Action Requests are still deferred by the Responsible Individuals indicating a lack of appreciation

of the need to correct one or more conditions adverse to quality in procedures for which they are responsible.

" In almost two-thirds of the procedure change actions the content/composition of the Change History fails to comply

with the directions of AP-5. IQ, i e., DR number is not referenced as a reason for the change action.

GK faeQAR Ram Murthy, Acting Director/OQA

Datei

1114 uu1u IlExhibit AP-16.1Q.2

D/at /o

Date

Kiev. 06

z

C

ATTACHMENT TO

CONTINUATION PAGE

VERIFICATION OF CORRECTIVE ACTION - YMSCO-01-D-064

OBJECTIVE EVIDENCE REVIEWED

A. In the OQA acceptance of the Complete/Amended Response date 10/30/01 a COMMENT was appended as follows:

At a meeting with the Director, OQA, YMP management, and BSC management on October 23, 2001, it was agreed that verification of corrective action completion will also include assessments by OQA of the adequacy of those actions as shown in ten (10) procedure changes completed in response to Document Action Requests (DARs) filed as products of the plan. As procedure changes occur, YMSCO should identify each procedure and change identification to the QAR.

Ten (10) procedure were identified and included as an attachment to the report of completion of corrective action (E-mail, Hampton/Distribution/Subj: DR 64, dated 11/15/01).

The following summarizes the conclusions of the assessment'of the adequacy of the ten (10) procedures identified. The NOTES provide the details of each assessment and related conclusion.

PROCEDURE ASSESSMENT NOTES IDENTIFICATION CONCLUSION

AP-3.4Q FAILED I AP-3.12Q PASSED 2 AP-3.19Q PASSED 3 AP-7.7Q PASSED 4 AP-9.2Q PASSED 5

AP-10.3Q PASSED 6 AP-SIII.5Q PASSED 7 AP-SIII 6Q PASSED 7

LP-OM-027Q-M&O FAILED 8 NWI-ESF-049Q PASSED 9

YAP-SIl IQ PASSED 10

NOTE I

AP-3.4Q - DAR D929 was filed against AP-3.4Q, Rev 2, ICN I, on 7/5/01. The DAR provides "examples" of NOTES with action steps, citing six (6) of a total of seven (7) NOTES in the procedure. Rev 2, ICN 2,

effective 9/27/01, references DAR D929 in the Change History. The Rev 2, ICN 2, change activity removed all NOTES from AP-3.4Q.

In the change activity to produce Rev 2, ICN 2, the NOTE in Attachment 5, para c), and its content were

deleted and not reflected elsewhere. The deletion is inappropriate. The content of the NOTE in Rev 2, ICN

1, states a requirement to be applied during a BCP cost analysis. It expresses a prohibition against the use

of certain practices, which would tend to obscure or confuse the true cost of a BCP. The description of the

prohibition needs to be restated in AP-3.4Q.

FAILED verification review.

�L�)

C

NOTE 2

AP-3A12Q - DAR D934 was filed against AP-3.12Q, Rev 0, ICN 4, on 7/6/01. The DAR provides four (4) "examples" (out of a total of thirteen NOTES in Rev 0, ICN 4), which contain a•tion steps, most of which

determinations are of questionable validity. DAR D934 is on the DAR Database as CLOSED. In

developing Rev I the scope of the procedure was expanded to include "analyses" as well as "calculations"

(Ne\" title: Design Calculations and Analyses) and the process was reformatted and reorganized. The

product of the change action (Rev 1) contains no NOTES of any kind. The Change History does not

reference YMSCO-01-D-064; however, it does state: "Also removed all NOTES". The single former

NOTE that does appear to direct action [5.1.3 j)] has been included as a process step in Rev 1 [5.2.3 k)].

Corrective action is complete and verified. At the time of this review (1 1129101), Rev I had been approved

(9,'25/01), but not yet issued. Estimated date of issue is 12/21/01 to coincide with the issue of a number of

other interfacing procedures.

This superseding action is acceptable.

PASSED verification review.

NOTE 3

AP-3.19Q - DAR D975 was filed against AP-3.19Q, Rev 0, ICN 5, BSCN 1, on 7/17/01. That procedure

was superseded by AP-3.19Q, Specifications, Rev 1, effective 9/27/01. DAR D975 is on the DAR Database

as CLOSED. There is no reference to YMSCO-01-D-064 in the AP-3.19Q, Rev 1, Change History;

however, there is a statement that "notes with action steps were incorporated in procedure steps". AP

3.19Q, Rev 0, ICN 5, BSCN 1, contained 27 NOTES. With the exception of an irrelevant use of the term

"NOTES" in Attachment 3, there are no other NOTES in Rev 1. DAR D975 does not specifically identify

the discrepant NOTES of AP-3.19, Rev 0, ICN 5, BSCN 1. However, in view of the fact that Rev 1

represehts a new purpose, scope, and proceis to be applied now toonly specifications (AP-3.19Q formerly

addressed both specification and drawýings) further consideration of NOTES with action statements in the

superseded procedure is not useful. Rev I contains no pertinent NOTES of any kind.



NOTE 4

AP-7.7Q - DAR D914 was filed against AP-7.7Q, Rev 0, ICN 0, on 6/26/01. The DAR specifically

references the locations of three (3) NOTES in Rev 0, ICN 0, which represent all NOTES in the procedure.

DAR D914 is on the DAR Database as CLOSED. AP-7.7Q, Rev 0, ICN 1, refers toYMSCO-0I-D-064 in

the Change History and has folded all three (3) former NOTES into the description of the steps in which the

NOTES were formerly located. The procedure change action (Effective: 10/18/01) corrects the DR's

Description of Condition by simply removing all NOTES and properly including the information where it

belongs.



2

NOTE 5

AP-9.2Q - DAR D909 was filed against AP-9.2Q, Rev 0, ICN 0, BSCN 1,6/20/01. The DAR specifically references the location of four (4) NOTES in Rev 0, BSCN 1, of a total of thirteen (13) NOTES All four NOTES have been properly corrected in AP-9.2Q, Rev I (Effective: 9/4/01). The remaining NOTES, none of which contains an action step, are repeated in Rev 1. DAR D909 is on the DAR Database as CLOSED Change History for Rev I refers to YMSCO-01-D-064.



NOTE 6

AP-10.3Q - DAR D905 was filed against AP-10 3Q, Rev 0, ICN 1, BSCN I, on 6/26/01. The DAR specifically refers to two (2) NOTES in Rev 0, ICN 1, BSCN 1, of a total of sixteen (16) NOTES Both NOTES have been properly corrected in AP-10.3Q, Rev I (Effective: 9/4/01). The remaining NOTES, none of Nhich contains an action step, are repeated in Rev 1. While the Change History for Rev I does not refer to YMSCO-01-D-064, it does refer to DAR D905, Ahich traces to the DR. However, DAR D905 "as still shown on the active DAR Database as ACCEPTED, i.e , yet to be acted on, as late as 12/26/01, approximately three and one-half months after the procedure action prompted by it was completed.



NOTE 7

AP-SIII.5Q and AP-SIII.6Q were combined and superseded by AP-SIII.8Q, Rev 0 (Effective: 10/26/01), in response to the corrective action plan related to YMSCO-01-D-101. DAR D970 (AP-SIII.5Q) and DAR D971 (AP-SIII.6Q) are on the CLOSED DAR Database. Neither DAR specifically identifies the discrepant NOTES of the related procedure. Although the DARs have been moved to the CLOSED DAR Database, the Change History for AP-SIII.8Q does not reflect an)y action taken as a result ofYMSCO-0 I -D-064 in regard to the two procedures (AP-SlIl 5Q and AP-SIlI 6Q) superseded by it. With the exception of the irrelevant use ofthe term "NOTE" in Attachments I and 12, there are no other NOTES in AP-SIII.SQ. Ho%%ever, in view of the fact that AP-SIlI 8Q, Rev 0, represents a new purpose, scope, and process to be applied to the functions formerly addressed by AP-SIII 5Q and AP-SIII 6Q, further consideration of NOTES %%ith action statements in those superseded procedures is not useful. AP-SII.8Q contains no pertinent NOTES of any kind.



NOTE 8

LP-OM-027Q-M&O - DAR D1002 was filed against Rev 0, ICN 0, on 7/18/01. Rev 0, ICN I, was issued to be effective on 10/8101. DAR D1002 is on the DAR database as CLOSED. There is no reference to YMSCO-01-D-064 in the Rev 0, ICN 1, Change History, nor does the History include other statements that

might be viewed as a change action in response to action steps in NOTES. Since DAR D1002 does not specifically identify the discrepant NOTES of Rev 0, ICN 0, there is no way to tell if the deficiency reviewer's observations have been corrected in the Rev 0, ICN 1, action.

In addition, the following NOTES containing action steps in Rev 0, ICN 0, have survived the procedure change action intact, i e , they are the same NOTES containing action steps in Rev 0, ICN 1:

3

(

"* The three (3) NOTES in Attachment 2, DAILY EQUIPMENT CHECKLIST INSTRUCTIONS

"* The one (I) NOTE in Attachment 8, TBM Maintenance Daily Checklist


NOTE 9

NWI-ESF-049Q - DAR D981 was filed against Rev 0, ECN 1, on 7/16/0l.That procedure was superseded

by LP-OM-043Q-BSC, Steel Set Jacking/Expansion, Rev 0, effective 10/01/0 1. DAR D981 is on the DAR

Database as CLOSED. There is no reference to YMSCO-01-D-064 in the LP-OM-043Q-BSC Change

History, nor does the History include other statements that might be viewed as a change action in response

to action steps in NOTES. D981 does not specifically identify the discrepant NOTES of NWI-ESF-049Q

The fate of the three (3) NOTES in Rev 0, ECN 1, is as follows:

* 3.1.5 (1"t NOTE) - Incorporated in 5.1 a) of LP-OM-043Q-BSC, Rev 0 0 3.1.5 (2nd NOTE) - Deleted. Redundant to information in 5.1 b) of LP-OM-043Q-BSC, Rev 0

* 3.3 - Incorporated verbatim into 5.3 b) of LP-OM-043Q-BSC, Rev 0. Not a NOTE with an action step



NOTE 10

YAP-Sll IQ - DAR D962 N"as filed against Rev 3, ICN 1, BSCN I, on 7/12/01.That procedure was

superseded by AP-Sll.2Q, Same Title, Rev 0, effective 10,26/01. DAR D962 is on the DAR Database as

CLOSED. There is no reference to YMSCO-01-D-064 in the AP-SI1.2Q Change History nor does the

History include other statements that might be vie%%ed as a change action in response to action steps in

NOTES. DAR D962 does not specifically identify the discrepant NOTE(S) of YAP-SII.1 Q. Of twelve (12)

NOTES in YAP-SII.IQ, three (3) survived intact, none of which is viewed as containing an action

statement. In view of the fact that the PROCESS of AP-SII.2Q represents a substantial change from that of

YAP-SII.IQ to address the same PURPOSE, further consideration of NOTES 1.ith action statements in

YAP-SII.IQ is 'not useful. This superseding action is acceptable.


B. In addition to the verification assessments detailed above the following related procedure change

activities were also assessed:

PROCEDURE ASSESSMENT NOTES IDENTIFICATION CONCLUSION

AP-2.12Q PASSED 11

AP-2.23Q - FAILED 12

AP-7.5Q PASSED 13

AP-SI.IQ PASSED 14

AP-Slli.3Q- "-FAILED _15.

LP-ENG-004Q-M&O PASSED 16

LP-MM-002Q-M&O INDETERMINATE 17

LP-QC-0060-OCRWM PASSED 18

NLP-2-OQ - - FAILED 19

NWI-ESF-019Q 'PASSED 20

NWI-ESF020Q PASSED, 21

NWI-ESF-048Q PASSED 22

4 VJ7

AP-3 I IQ PASSED 23 AP-10.2Q PASSED 24 AP-10 4Q PASSED 25

NOTE 11

AP-2.12Q- DAR D953 was filed against AP-2.12Q, Rev 0, ICN 2, on 8/13/01. The DAR is explicit in that it specifically identifies the one NOTE in Rev 0, ICN 2, considered to be discrepant. Rev 0, ICN 3 superseded Rev 0, ICN 2, on 8/31/00. The Change History for Rev 0, ICN 3, does not reference YMSCO01-D-064, nor does the History include other statements that might be viewed as a change action in response to action steps in NOTES. Review of Rev 0, ICN 3, shows that the identified discrepant NOTE has been removed. YMSCO-01-D-064 action is complete.



NOTE 12

AP-2.23Q - During the period of review to determine the Extent of Condition, AP-OM-006Q, Work Request/Work Order Process, Rev 0, ICN 3 was in effect. That procedure contained 10 NOTES at least one of which must have been evaluated as containing an action step; therefore, the "Y" in column #3 of the matrix of results provided with the Complete/Amended Response. No DAR was filed to identify the discrepant NOTE or NOTES and to correct this condition This procedure was superseded by AP-2 23Q, Rev 0, Work Request/Work Order Process (Effective: 914101). The Change History for Rev 0 does not note action in response to YMSCO-01-D-064, nor does the History include other statements that might be viewed as a change action in response to action steps in NOTES.

There are two concerns with this transition as follows:

"* It is not immediately obvious where the NOTES from AP-OM-006Q went. Two NOTES survived intact as NOTES in AP-2.23Q while others have disappeared. Not knowing which NOTE or NOTES of AP-OM-006Q were evaluated to produce the "Y" in column #3 of the matrix, it is not clear that the discrepant NOTE(S) has been corrected.

"* A number of new NOTES, i e., not in AP-OM-006Q, have appeared in AP-2.23Q, Rev 0, many of "hich (7) appear to be NOTES containing action steps. These are located as follows:

5 2.7 a); 5.3.2.7 a); 5 4.1 e), 5 5.2 1 e), 5 6.1; 5.6 3.2 b) 3); and 5.7 1 c)

AP-2 23Q, Rev 0, must be reviexed in accordance \%ith the Remedial Action Plan of the Initial Response to:

"• Determine that the discrepant NOTE(S) of AP-OM-006Q have, in fact, been corrected in the transition to AP-2 23Q, and

"• Evaluate all NOTES in AP-2.23Q to determine if the Description of Condition of the DR exists at any point in this new procedure.

The review results must be documented and, if indicated by the results, appropriate corrective actions must be initiated. The latter issue raises a question regarding the effectiveness of the action to prevent recurrence.

The additional review noted above was performed. That review confirmed that the Description of Condition was not corrected in the procedure change action. DAR D1217 was filed against AP-2.23Q, Rev 0, on 9,/25/01 to "incorporate notes with action statements into the steps of the procedure, or delete as appropriate". This DAR is not specific. The e\planation for the failure to address the Description of

5

Condition was given as: "The reason that they (the NOTES) were not corrected was because AP-2.23Q was in development prior to mandatory training on DR-064".

Not only were existing NOTES not corrected in the development of AP-2.23Q, but alsoladditi6nal NOTES conforming to the Description of Condition were generated, implying no communication between DR reviewers and procedure revision preparers, presumably in the same pr'ocedure sponsor organization.


NOTE 13

AP-7.5Q - DAR D973 was filed against AP-7.5Q, Rev 0, ICN 2, on 7/16/01. The DAR does not specifically identify the discrepant NOTE(S). Rev 0, ICN 3, was issued to be effective an 11/21/01. The Change History for this chainge does not reference YMSCO-01-D-064 or DAR 973 or include ariy other words that might be viewed as a change action in response to actio6 steps in NOTES. DAR D973 is on the CLOSED DAR Database.

In the transition to Rev 0, ICN 3, nine (9) NOTES in ReV 0, ICN 2, were addressed as follows:

* 2 NOTES were deleted with no process impact * 5 NOTES were incorporated into appropriate process steps

1 NOTE survived intact with no action statement 1 NOTE simply had the "NOTE" identification removed.


NOTE 14

AP-SL.IQ - DAR D947 was filed against AP-SL.IQ, Rev 3, ICN 1, ECN I, on 7/11/01. The DAR specifically identifies the single NOTE evaluated as containing an action statement.'AP-Sl.IQ, Rev 3, ICN

2, refers to DAR D947 in the Change History. DAR D947 is on the DAR Database as CLOSED. The

change action deleted the discrepant NOTE of paragraph 5.6.3 b). The action called for in th" deleted

paragraph is adequately addressed in 5.6.4 a).



NOTE 15

AP-SIIl.3Q - During the period of review to determine the Extent of Condition, Rev 0, ICN 4 to AP

SIll.3Q was in effect. That procedure contained 3 NOTES, at least one of which must have been evaluated

as containing an action step; therefore, the "Y" in column #3 of the mai'rix of results provided with the

Complete/Amended Response No DAR was filed to identify the discrepant NOTE or NOTES and to

correct this condition. Rev I (Effective: 8/1/01) superseded Rev 0, ICN 4. In Rev, I, one NOTE was simply

incorporated into the statement of subparagraph 5 1.6 5), the NOTE from paragraph 5.2.1 b) of Rdv 0, ICN

4, was simply deleted, and the NOTE in Attachment 8, which is an action statement, was passed unchanged

from Rev 0, ICN 4, to Rev I, ICN 0. The Change History for Rev I does not noteýaction in response to

YMSCO-01-D-064.

Rev 1 needs to be reviewed to determine that the discrepant NOTE or NOTES were, in fact, corrected in

the Rev I development and review process.

FAILED verification review (Rev 1, ICN 0).

+6

(.

The additional review noted above was performed. That review confirmed that the Description of Condition was not corrected in the procedure change action. DAR Di222 was filed against Rev 1 on 9/27101 to "rewrite the note in Attachment 8 into an action step". This DAR is specific. The explanation for the failure to address the Description of Condition was given as: "During the period to determine the extent of condition to the subject DR, a revision was being processed for AP-SIII.IQ", implying no communication between DR reviewers and procedure revision preparers, presumably in the same procedure sponsor organization.

As of 12/3101 DAR D1222, in addition to five other ACCEPTED DARs, was open on the DAR Database

NOTE 16

LP-ENG-004Q-M&O - DAR DI015 was filed against LP-ENG-004Q-M&O, Rev 0, ICN 0, on 7/18/01. The DAR is not specific. Rev 1, ICN 0, was issued to be effective on 10/26/01. The Change History for this change does reference YMSCO-0I-D-064. D1015 is on the CLOSED DAR Database. There are no NOTES in Rev 1, ICN 0. Since Rev 1, ICN 0, represents a major rewrite and reorganization of the process, further consideration of NOTES " ith action statements in the superseded procedure is not useful Rev 1, ICN 0, contains no NOTES of any kind.



NOTE 17

LP-MM-002Q-M&O - DAR D957 was filed against LP-MM-002Q-M&O, Rev 0, ICN 0, on 7,13/01. The DAR is not specific. Rev 0, ICN 1, "•as issued to be effective an 11/30/01. The Change History for this change does not reference YMSCO-01-D-064 or DAR D957; however, it does state: "Revised Notes statements". DAR D957 is on the CLOSED DAR Database. Since DAR D957 does not specifically identify the discrepant NOTES of LP-MM-002Q-M&O, Rev 0, ICN 0, and a considerable number of NOTES still exist in Rev 0, ICN 1, (approximately 40 NOTES, 17 WARNINGS, and 5 CAUTIONS), there is no %%ay to tell if the deficiency reviewer's observations have been corrected in the superseding procedure, LP-MM-002Q, Rev 0, ICN 1.

INDETERMINATE verification review.

NOTE 18

LP-QC-006Q-OCRWM - DAR D912 was filed against LP-QC-006Q-OCRWM, Rev 0, BSCN 1, on 6/26/01. The DAR specifically identifies the single NOTE evaluated as containing an action statement. LPQC-006Q-OCRWM, Rev I, ICN 1, refers to YMSCO-0I-D-064 in the Change History The change action folded the discrepant NOTE of paragraph 8 of Attachment 3 into the paragraph as the second and third sentences of the paragraph.



NOTE 19

NLP-2-OQ - During the period of review to determine the Extent of Condition, Rev 5, ICN 3, to NLP-2-OQ was in effect. That procedure contained 4 NOTES at least one of which must have been evaluated as containing an action step, therefore, the "Y" in column #3 of the compilation of results provided with the Complete/Amended Response. No DAR was filed to identify the discrepant NOTE(S) and to correct this condition. This procedure was superseded by Rev 5, ICN 4 (Effective: 8/1/01). The 4 NOTES of Rev 5, ICN 3, were incorporated directly and verbatim as NOTES into Rev 5, ICN 4. The Change History for Rev

7

C,.

5, ICN 4, does not note action in response to YMSCO-01-D-064. It is clear that whatever NOTE(S) in Rev

5, ICN 3, was evaluated to produce the "Y" in column #3, that NOTE(S) is now contained in Rev 5, ICN 4.

FAILED verification review. (Rev 5, ICN 4)

Subsequent to the above analysis and as a result of it, DAR D1201 was filed against NLP-2-OQ, Rev 5,

ICN 4, on 9/20/01 with the folloing DESCRIPTION OF REQUEST:

This procedure contains NOTES that could be construed as action steps. These NOTES need to be

incorporated into the body of the procedure.

NOTE 20

NWI-ESF-019Q - DAR D977 was filed against NWI-ESF-019Q, Rev 1, ICN 0, on 7/16/01. This was one

of three procedures where an action statement in a NOTE was judged to present a potential immediate

safety implication. The DAR is not specific. Sixteen (16) NOTES existed in Rev 1, ICN 0 Rev 1, ICN I.

was issued on 8/31/01. All NOTES were appropriately addressed in the procedure change activity. The

Change History refers to YMSCO-01-D-064.



NOTE 21

NWI-ESF-020Q - DAR D979 was filed against NWI-ESF-020Q, Rev 0, EICN I,BSCN-1, on 7/16/01. This

was one of three procedures where an action statement in a NOTE was judged to present a potential

immediate safety implication. The DAR is not specific. Five (5) NOTES existed in Rev 0, EICN 1. Rev 0,

ICN 1, was issued on 8/31,/01. All NOTES were appropriately addressed in the procedure change activity.

The Change History refers to YMSCO-01-D-064.



NOTE 22

NWI-ESF-048Q - DAR D980 was filed against NWI-ESF-048Q, Rev 0, ICN 0,BSCN 1, on 7/16/0 1. This

was one of three procedures where an action statement in a NOTE was judged to present a potential

immediate safety implication. The DAR-is not specific. Twenty-two (22) NOTES existed in Rev 0, ICN 0.

Rev 0, ICN 1, was issued on 8/31/01. All NOTES were appropriately addressed in the procedure change

activity. The Change History refers to YMSCO-01-D-064.



NOTE 23

AP-3.1 lQ- DAR D932 was filed against AP-3.1 IQ, rev 2, ICN 0, 7/6501.The DAR provides "examples"

of NOTES with action steps, citing four (4) NOTES in the procedure. Rev 3 was issued on 12./21/01. There

is no reference to YMSCO-01-D-064 in the Rev3 Change History, noi does the History iri6lude other

statement that might be viewed as a change action in response to action steps in'NOTES. This revision

represents an entirely new process with no NOTES in the procedure. In view of the fact that the PROCESS

of Rev 3 represents a substantial change from that of Rev 2 to address the same PURPOSE, further

consideration of NOTES with action statements in Rev 2 is not useful.

8

31 ' -1

Af I



NOTE 24

AP-10 2Q - DAR D91 I was filed against AP-10 2Q, Rev 1, ICN 0, on 6/26/01. The DAR is specific in that it specifies four (4) NOTES with action steps. Rev 2 was issued on 12/17/01 All NOTES were removed in the change action with those with action steps incorporated into the verbiage of the appropriate step. The Change History for Rev 2 properly cites YMSCO-01-D-064.



NOTE 25

AP-10 4Q- DAR D910 was filed against AP- 10 4Q, Rev 0, ICN 0, on 6,'26/01. The DAR is specific in that it specifies t~o (2) NOTES with action steps. Rev I was issued on 12/17/01. All NOTES were removed in the change action with those with action steps incorporated into the verbiage of the appropriate step. The Change History for Rev I properly cites YMSCO-01-D-064.



C. Other performance issues:

1 AP-3.10 - DAR D933 was filed against AP-3.10Q, Rev 2, ICN 4, on 7/6/01 and ACCEPTED by the RI on 7/9/01. ECN 01 to Rev 2, ICN 4, was issued on 8,22/01. Rev 2, ICN 5, %,as issued to be effective 11/21/01. The Change History for Rev 2, ICN 5, refers only to incorporation of ECN 01. There is no reference in the Change History to either YMSCO-01-D-064 or DAR D933 nor does it include other words that might be vielded as a change action in response to action steps in NOTES. On 12/4/01, DAR D933 was shown on the DAR Database as ACCEPTED, i e, still not addressed.

Apparently, the Rev 2, ICN 5. change action was undertaken only to address incorporation of ECN 01 (Ninety day limit) %%hile ignoling six ACCEPTED DARs, including D933, that were open against AP-3 IOQ at the time of the change action. Furthermore. DAR D933 is not specific in that it does not identify the details of the results of the YMSCO-01-D-064 procedure review action

2. LP-4.1Q-OCRWM, Rev I, ICN I, was issued to be effective on 10/09/01. This procedure change action apparently %ýas undertaken only to revise the APPLICABILITY Section of the procedure and ignored the existence of both DARs D782 (Filed- 4/10/01) and D945 (YrVMSCO-01D-064 related) (Filed: 7/11/01). Furthermore, DAR D945 is not specific in that it does not identify the details of the results of the YMSCO-01-D-064 procedure review action.

3. LP-SMF-002Q-M&O - During the period of re% iew to determine the Extent of Condition, Rev 0 (Effective: 4/7/00) to LP-SMF-002Q-M&O was in effect. It is still (12/3/01) in effect. This procedure contains 7 NOTES (as well as 7 WARNINGS) at legst one of which must have been evaluated as containing an action step; therefore, the "Y" in column #3 of the matrix of results provided with the Complete/Amended Response. No DAR was filed to identify the discrepant NOTE or NOTES and to correct this condition. In view of the reference in the Complete/Amended Response to a "determination" made at a meeting on 7/26/01 that DARs would not be "warranted (as they were in the Remedial Action desci ibed in the Initial Response) for those procedures with

9 > 'j ,0

C

actions in notes that did not have a potential immediate safety implication", it appears that the

existence of at least one action statement buried in at least one NOTE in this procedure will not be

communicated to the Resporisibie Indiidual for correction.

Subsequent to the above analysis and as a result of it, DAR D1226 was filed against LP-SMF

002Q-M&O, Rev 0, ICN 0, on 10/2/01 to "Remiove• action statemrnents from nrotes,and place

action statements in the body of the procedure. Revise notes to contain only nonI action.

statements". DAR 1226 is not specific.

4. The actions by Responsible Individuals (RI) related to four (4) DARs are not responsive to the

intent of the corrective action plan :

Actions required to respond to four (4) DARs [D8 I1 against LP-CAL-004Q (filed.

5/02/01; D930 against LP-3.4Q-M&O(filed: 7/13/01); D956 against LP-MM-001Q

M&O (filed: 7/20/01), and D958 against LP-MM-003Q-M&O (filed: 7/210/01)] have

- been DEFERRED. In effect, these actions leave in place at least one unspecified

action step in a procedure NOTE to be corrected at some unspecified time in the

future. These actions piesent the possibility of creating the conditions considered to

be adverse by the corretciive action plan during the time prior to actual correction of

the Description of Condition. These RI actions rijtst be revised to ACCEPT the DAR

and assign a PREPARER to revise the affected proc'edure to correct the condition.

-5. The matrix of results provided with the Complete!Amended Response reports that the'review

undertaken to determine the Extent of Condition identified no NOTES with action statements in

NWI-SMF-002Q. At the time of the review Rev 1, ICN 0, BSCN 1, was in effect and is still

(12/5/01) in effect. The NOTES in paragraphs 3.4.1 and 3.5.2 constitute action steps required to'

support the process No DAR has been filed to correct those statements.

6. In coming to PASS or FAIL conclusions in Parts A and B above, the QAR ignored, but noted in

the assessment notes, failures of the procedure Change Histories to present information in

compliance with the directions of AP-5.IQ. If instructions for the content/composition of a

Change History wvere to be enforced as a matter of verbatim compliance, the following procedure

actions, classified as PASSED, would change to FAILED:

AP-2.12Q, AP-3 10Q, AP-3.12Q, AP-3.19Q, AP-7.5Q, AP-10.3Q, AP-SI.IQ, AP-.

SII.2Q, AP-SIII.8Q, and NWI-ESF-049Q

- -2 - 1

"3• /9'

TYPE RESPONSE:

F] Initial

n- Complete

Pl Amended

OFFICE OF CIVILIAN DR/CAR NO. PAGE 1

RADIOACTIVE WASTE MANAGEMENT U.S. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

YMSCO-01-D-064

OF 1 QA: IeW

Z�So if 2-�7/oz..

DEFICIENCYJCORRECTIVE ACTION REPORT (RESPONSE)14a. Immediate Actions: No change from previous response

Compliance Date:

14. Remedial Actions: The below corrective actions address the Verification of Corrective Action comments dated January 18, 2002. (1) "Q" procedures that have open Document Action Requests (DARs) related to this DR will be revised/ICN and all notes in them

will be incorporated into the procedure action steps as an editorial change, by removing the word "Note", as appropriate. (2) "Q" procedures that had DARs related to this DR which have been closed, but failed verification, will be revised/ICN as necessary and all notes in them will be incorporated into the procedure action steps as an editorial change by removing the word "Note" as appropriate. (3) The Change History of each "Q" procedure affected by this DR will include a reference to i;R-0 . his includes those procedures that may have already been processed by removal of action steps in procedure Notes. \ I- Z, 01,15. Extent of Condition: No change from previous response

16. Cause: (Attach results of root cause detemination prepared in accordance with AP-16 4Q for a significant deficiency) No change from previous response

17. Action to Preclude Recurrence: In addition to the previous response, procedure AP-5.1Q has been revised to delete the requirement of allowink No ,in procedures. (reference Revision 3, Attachment 6, paragraph 5. 1b) which states that Notes shall not be used in procedures.. e.I,, 2 5*- -,,2 "

18. Due Date: 7/23/02 19 Pesponse by, Donald G. Horton/DOE Deputy Director - Technical n For submittal of complete response

El For completion of corrective action 1•n l//Gte/7/ Phone 4-..i•

20. Evaluation: E?] Accept r-PartiallyAccept R-Rj,? 21. Concur /e QAR Date 7./7./O2.. - DOQA Date f

L Rev. 12/2011999

I .

Eh~xibltAP-16.1Q.1 '•

J

* *¼

F


U.S. DEPARTMENT OF'ENERGY WASHINGTON, D.C.ý

a- [R DR/CAR E] Stop Work Order

NO YMSCO-01-D-064 p69 PAGE OF I //z4•o;

DEFICIENCYICORRECTIVE ACTION REPORT/STOP WORK ORDER CONTINUATION PAGE

RREQUEST FOR EXTENDED PROCESSING

A request for extended processing is being made based on a new commitment and direction to 'evise all "Q"procedures that have

action steps in procedure Notes, rather than wait for the Document Action Request to be processed for each respective procedure,

or to wait for the procedure to come up for normal revision. It is noted that procedure AP 5.1Q has been revised to not allow Notes

in procedures. The scope of this DR involves approximately 50 Q procedures. The impact of revising these 50 procedures, either through the

Interim Change Notice (ICN) or by a formal revision, will cause a delay in completion of corrective action to close this DR. Some

I I procedures are in the old format (i.e. Nevada Work Instructions or Nevada Line Procdures), and haaveto be revised to Line

Procedure or Administrative Procedure formats without the benefit of using the ICN process. Based on the amount of work to be

done,g for completion ocorrective action for this DR is requested until July 23, 2002.

Scr/rZac

DonPorton, DO Technical Director

Ken Hess, BSC General Manger

( / Date:

/A DA Date:

r9.... r,�,fl4I4ODC

Exhibrt AP-16.1Q.2 5�, �

K~ey. UO/U II I 1|!

Exhibit AP-1 6.1 Q.2

1 C



QA: QADEFICIENCY/CORRECTIVE ACTION REPORT/STOP WORK ORDER CONTINUATION PAGE

APPROVAL SIGNATURES FOR REQUEST FOR EXTENDED PROCESSING FOR DR .sc-6-1-rD-'[2-Uq(EXTENDED PROCESSING REQUESTED UNTIL 7&3/L62/-)

1

DOE Pr ct Manager

Acting, Director. Office of Quality Assurance

Date

Date 2 Date

APPIIROVAL SIGNATURE FOR REQUEST FOR EXTENDED PROCESSING GREATER THAN 365 DAYS FOR DR1~ryo•.-o-D_(aq (EXTENDED PROCESSING REQUESTED UNTIL

Date

0f ~ ff

Rev 06/01/1909

qL)

8 2JDR/CAR LI Stop Work Order

Noms~W-o6i-b-o PAGE OF

CIA: QAI

1ý7

M O*- IIILl #r"- IQ• Itj 4_r"

Submittal Page of . 1. DR/CAR NO. YMSCO-0I-D-•

2. Check if Amended .2OFFICEOF CIVILIAN PAGE OF

Check if also Initial Response L] RADIOACTIVE WASTE MANAGEMENT QA: QA

3. Extended Processing 'U.S.,DEPARTMENT OF ENERGY

D No ElYes (If yes,-submit WASHINGTON,D.C. Extended Processing request)

DEFICIENCY REPORTICORRECTIVE-ACTION REPORT COMPLETE RESPONSE 4. Extent of Condition: (Amended response will be required if all Extent of Condition investigations are not complete and documented

herein)

No change from previous response..

5. Impact: (Provide an impact statement relative to waste isolation and safety, and impact to other work, if any)

No change from previous response.

6. Remedial Actions: (Document all actions necessary to address the results of the Extent of Condition)


7. R Root Cause (For a significant CAQ, attach results of formal root cause determination prepared in accordance with AP-16.4Q)

F/ Apparent Cause


8. Action to Preclude Recurrence: (Address those actions necessary to prevent the identified cause from recurring)

The remainin g action to close this deficiency will be to revise/ICN the procedure AP-5.1Q, Plan and Procedure Preparation, Review, and Approval. The revision/ICN will contain a statement to the effect that Notes in existing procedures are to be considered part of

the procedure text and implemented accordingly. This is in addition to the procedure requirement already in place that precludes the

use of notes in procedure revisions/changes. Actions to Preclude Recurrence will be completed by August 16, 2002. jjc 8-12-02 dr064c.far

9. Due Date for Completion of Corrective Action: 10. Responsible Manager.

August 16,2002 S_. Es" C-. I'1 -0 Prirnted Nai=e ,gn thre Date

11. QAR Evaluation.-] Accept []Partially Accept El Reject 12. QAM CI currence:

Printed Name Signature 1) 'Date Plinted Name I Signature "Date

AP-16.1Q.8 Rev. U•3!~t-ZUU."

r • .

Submittal Page of



-. 7

1.

i2'DRICAR/QO ElI swo

NO YMSCO-01-D-064 PAGE OF

QA: QA

CONDITION ADVERSE TO QUALITY CONTINUATION PAGE

In the amended response to YMSCO-01-D-064 dated January 28, 2002, three (3) actions were identified for completion:

1 Completed open document action requests to remove Notes, 2. Revise those that failed verification, and, 3. Include a reference to YMSCO-01-D-064 in the change history of the affected procedures.

The QAR was notified by e-mail dated July 9, 2002, from James Whitcraft, that all corrective actions were completed. The QAR initiated verification by reviewing "Q" procedure in the current OCRWM Program Document database. With only a limited review, three (3) "Q" procedures were identified that had Notes with action steps. Whereas there were no problems in the 67 procedures identified in the initial extent of condition, the QAR concluded that the initial effort was inadequate. BSC disputed the initial verification results and sought to elevate the issue to the Director, OQA for resolution.

As a result of a resolution meeting on August 5, 2002, with Ram B. Murthy, Don Krisha, Lester Wagner, and James Blaylock, an agreement was made to revise AP-5. IQ to mandate all action steps in "Q" procedures would be mandatory.

An amended response to YMSCO-01-D-064, dated August 13, 2002, was submitted. The revision to AP-5.1Q had been processed with an effective date of August 16, 2002.

Since notes with action steps were not considered mandatory, the revision to AP-5.IQ making such notes a procedural requirement

resolves this issue. The existing notes in current procedures will be removed whenever the document is revised.

Based on the above, it is recommended that the DR be closed

Q A R : " = • - . 7 -Th ,

Date~ 1ezý-c-?

AP-16.1Q 2 Rev. 03/25/2002

40 1/ '•

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AP-16.1Q 2 Rev. 03/25/2002