arlington, virginia 22201 · 2012-11-21 · courtyard marriot (9011760q) 805 russell avenue...

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CORPORATION 2500 WILSON BOULEVARD, SUITE 202ARLINGTON, VIRGINIA 22201

(703) 276-9300FAX: (703) 276-9310

Memorandum

To: Observers to the Quality Audit of EM-343

From: Norman Frank, Audit Team Leader ;

Subject: Observer/Team Meeting

Date: August 9, 1991

Enclosed is your copy of the auditors' notebook for the August 26-30, 1991 audit of EM-343,the Waste Vitrification Branch of Environmental Restoration and Waste Management.

There will be a meeting from 8:30 a.m. until 9:00 a.m. on August 26, 1991 for the observers andthe audit team. At this meeting, we will cover the basic audit plan and how the audit will beconducted. We will try to answer any questions you have at that time.

The meeting will be in the Trevion II Building. Please meet in the lobby at 8:15 a.m. A mapof the Germantown, MD area is provided in the auditors' notebook. A good hotel to stay at isthe Comfort Inn located less than 1 mile from the building. The address is:

20260 Goldenrod LanePhone: 1-301-428-1300 (direct)Phone: 1-800-221-2222 (toll free)

Please call me if you have any questions or need additional information.

,e2Le _4tcdeMt/ #14

I 4 k C IO i

9108140248 910826PW-R WASTEW -1 PDR

fbI /##

DOE HEADQUARTERS

AUDIT HQ-91-003

of EM-343

Environmental Restoration andWaste Management,

Waste Vitrification Branch

Germantown, MD

August 26, 1991through

August 30, 1991

lw-wzzzl76/B/

465John Buckley, NRC

-' 7 -

Audit No. HQ-91-003Contents of Audit Binder

Notification Letter and Audit Plan

* Notification Letter* Audit Plan* DOE Memorandum from John W. Bartlett to EM-1 dated

October 29, 1990 (provides authority to audit)* DOE Memorandum providing observers

General Information

* DOE Shuttle Bus Schedule between Germantown and ForrestalBuilding

* Map of DOE Germantown area* Copy of EM-30 telephone directory* ATL's temporary lodgings:

Courtyard Marriot (9011760Q)805 Russell AvenueGaithersburg, MD 20879Phone 301-670-0008

EM Audit Team AssignmentsSPP Index with Team Assignments

* SPP List arranged by Audit Team* List of Observers* Observers' Protocols

* Audit Observer Inquiry form

Technical Documents

* Report of a May 1991 review of the EM Standard PracticeProcedures led by P. Slattery

Past Evaluations by HQ

* Statement that there have been no previous audits* Surveillance HQ-SR-91-011, SPP 4.11 and SPP 4.12

(technical reviews)

Blank CARs

* 5 CAR sheets* 5 CAR continuations sheets

Audit Checklist

* 91-003, Programmatic checklist

Quality Assurance Program Description

* DOE/EM/WO/01* DOE/EM/WO/02 1/05

-,^Procedures

% t* Consolidation/Revision Information* Specific procedures to be audited by the individual* Note: for observers, a complete set of the procedures

will be provided

A'9

Ei!G adz?40)

United States Government Department of Energy

memorandum/ DATE: JUL 2? 1991

REPLY TO RW-3ATTN OF.

OFFICE OF CIVILIAN RADIOACTIVE WASTE MANAGEMENT (OCRWH) QUALITY ASSURANCESUBJECT: (QA) AUDIT HQ-91-003 OF THE VITRIFICATION PROJECTS BRANCH (EM-343)

TO: Associate Director, (EM-30)

Please be advised that a team from OCRWM, Office of Quality Assurance(OQA), will conduct a QA audit of the EM-343 QA Program andimplementation, where possible, during the period August 26-30, 1991.Current plans will be for the audit team to hold a preaudit meeting onMonday, August 26, 1991, beginning at 9:00 a.m., at your facilities inGermantown, MD. Please arrange for the appropriate personnel to attendthe meeting. The postaudit meeting is tentatively scheduled for 1:30p.m. on Friday, August 30, 1991. I would like to request that you makethe necessary arrangements for the locations where the preaudit andpostaudit meetings will be held and notify me within 10 days prior to thedate of the preaudit conference. The audit team will also need ameeting/working room during the performance of the audit.

All activities performed by EM appropriate to its role in the developmentand qualification of the waste form through August 1991 shall be subjectto audit.

The audit will focus on the following areas:

OA PROGRAM ELEMENTS

1 - Organization2 - Quality Assurance Program3 - Design Control (including software and scientific investigation)4 - Procurement Document Control5 - Instructions, Procedures, and Drawings6 - Document Control7 - Control of Purchased Items and Services15 - Control of Nonconforming Items16 - Corrective Action17 - Quality Assurance Records18 - Audits

The audit of implementation will be primarily based upon the currentrevisions of your implementing procedures and/or procedures that were ineffect when the activity was performed.

K>.

TECHNICAL AREAS

Auditors will review and evaluate activities to determine adequacy in thefollowing areas:

1. Qualifications of technical personnel

2. Understanding of procedural requirements as they pertain to thedevelopment and qualification of waste forms.

If the audit team identifies a need to verify additional programmatic ortechnical areas during the audit, they will be added to the auditchecklist(s) and verified accordingly.

The audit team will consist of:

Robert W. ClarkNorman C. FrankJames J. GeorgeDonald E. MillerCraig G. WalengaClyde D. MorellThomas E. RodgersLouis Wade

DOE, Washington, D.C.CER Corp., Arlington,CER Corp., Arlington,CER Corp., Arlington,CER Corp., Arlington,CER Corp., Arlington,CER Corp., Arlington,CER Corp,, Arlington,

VAVAVAVAVAVAVA

Audit ManagerAudit Team LeaderAuditorAuditorAuditorAuditorAuditorAuditor

Observers from the State of Nevada, U.S. Nuclear Regulatory Commission,or other interested parties may also accompany the team. You will benotified of these observers prior to the audit.

If you have any questions, please contact Robert Clark at (202) 586-1238or FTS 896-1238 or Norman C. Frank at (703) 276-9300.

Donald 0. Horton, DirectorOffice of Quality Assurance

Enclosure:Audit Plan, HQ-91-002

cc:

F. Peters, RW-2, FORSD. Shelor, RW-30, FORSR> Millner. RW-40, FORSC. Gertz, RW-20, Las Vegas, NVS. Cowan, EM-30, TREV.H. Frei, EH-34J. Hennessey, EH-343K. Chancey, EM-343J. Gilray, NRC, Las Vegas, NVK. Hooks, NRC, Washington, DCW. Belke, NRC, Washington, DCR. Loux, NWPO, Carson City, NVE. von Tiesenhausen, Clark County, Las Vegas, NVS. Bradhurst, Nye County, Tonopah, NVK. Whipple, Lincoln County, Pioche, NV

A

Audit PlanAudit Number: HQ-91-003

Audit of Office of EnvironmentalRestoration and Waste Management (EM)

An audit of EM-343, Vitrification Projects Branch, will be conducted the weekof August 26-30, 1991 in their offices in Germantown, MD. The audit will beconducted by:

Norman C. Frank, CER Corporation Audit Team LeaderDonald E. Miller, CER Corporation AuditorJames G. George, CER Corporation AuditorCraig G. Valenga, CER Corporation AuditorClyde D. Morell, CER Corporation AuditorThomas E. Rodgers, CER Corporation AuditorLouis Wade, Roy F. Weston Auditor

Observers from the State of Nevada, the NRC, the Edison Electric Institute(EEI), and other interested parties will be invited to participate.

Audit Scopm

The audit will include the activities of EM-343, Vitrification ProjectsBranch, related to the development and qualification of waste forms.Activities up to the time of the audit will be included in the scope.

The implementation of the following criteria will be evaluated during theaudit:

1 - Organization2 - Quality Assurance Program3 - Design Control (including software and scientific investigation4 - Procurement Document Control5 - Instructions, Procedures, and Drawings6 - Document Control7 - Control of Purchased Items and Services

15 - Control of Nonconforming Items16 - Corrective Action17 - Quality Assurance Records18 - Audits

The auditable requirements will be drawn from the October 1990 issue of theEnvironmental Restoration and Waste Management (EM) Quality Assurance ProgramDescriptions (DOE/EM/WO/01 and 02), applicable Standard Practice Procedures,and documents pertaining to the development and qualification of waste forms.

Preliminary Audit Schedule

Audit Team Briefing August 26 8:30 amPreaudit Meeting August 26 9:00 amConduct of Audit August 26 9:30 am - 4:00 pm

August 27-29 8:30 am - 4:00 pmAugust 30 8:30 am - 12:00 pm

Postaudit Meeting August 30 1:30 pm - 2:30 pmDaily Audit Team Debriefing 4:00 pmDaily Summary to EM-343 8:30 pm

Enclosure

The audit may be extended as necessary to ensure adequate coverage of eachcriteria to be audited.

Audit Checklists and Annexes:

91-003 QA Prograimatic ChecklistAnnex A DOE Procedure on Protocol (July 1987)Annex B NRC Draft QA Procedure for Observing DOE/OGR ELRS

Prepared

Approved

Approved

by:^ onC. Frank, " oration

/Adit Team Leader ~`

Robert W. Clark, DirectorHeadquarters Quality Assurance Division

by:*Donald G. Hortoh, DirectorOffice of Quality Assurance

Date: 7

Date: 7XL-fdjI

Date: 72 9/9 /

OE F 43258(849)

United States Government Department of Energy

3emorandumDATE: OCT 2 9 1990

REPLY TOATTN OF: RW-3

SUBJECT: Qualification of Office of Environmental Restoration and WasteManagement (EM) Quality Assurance Prftora to Support High-Level Waste Form Production

TO,

Acting Director, Office of Environmental Restoration and WasteManagement, EM-1

The Office of Civilian Radioactive Waste - iManagement (OCRWM) hasevaluated your request for assistance in the qualification ofquality assurance programs for the Waste Storm ProduceruOganizations. This memorandum provides ocRWM's position onqualification of EM's quality assurance program, as well asquality assurance programs for Waste Form FrcducerOrganizations that are involved in the startup and operation ofwaste processing facilities. This includes Oparations Offices,Project Offices and Operating Contractors (i.e., West ValleyNuclear Services and Westinghouse Savannah River Corporation).The position stated herein is based on discussions with andendorsement by the OCRWM Office of Quality Assurance and theNuclear Regulatory Commission (NRC).

OCRWM is not on the critical path for EM's Quality AssuranceProgram. OCRWM's only r;*l is the review and acceptance of theEM High-Level Waste Quality Assurance Program Description(QAPD) document, DOE/EM/WO/02. Submittal of that QAPD forOCRWM review should be after EX approval. The review of the EMQAPD will be conducted in accordance with the requirementscontained in the OCRWM Quality Assurance Requirements Document(DOE/RW-0214) in effect when the Quality Assurance ProgramDescription is submitted. Quality Assurance ProgramDescriptions from Operations Offices, Project Offices andsOperating Contractors are not subject to review and acceptanceby OCRWM. OCRWM does, however, request that these QAPDs besubmitted for information subsequent to their approval. EM'sand other QAPDs will be provided by OCRWX %o the NRC forinformation only. Should the NRC or OCRr>d have questions onQAPD content, OCRWM will address those questions to yourattention.

In addition to the review for acceptance of the EM QualityAssurance Program Description, OCRWM will conduct audits andsurveillances of activities performed by EM. On occasion,OCRWM will observe EM verification activities as well asactivities performed by Operation Offices, Project offices andOperating Contractors. The latter will be performed in concert

2

with EM's overview of such activities. In either case, theNRC, the State of Nevada, and other affected organizations areextended the opportunity to observe OCRWM verification of High-Level Waste Form Production Activities. Notification will beprovided to EM by OCRKM in advance of such activities.

We believe the position stated herein fully supports EM'squalification effort and provides OCRWM with an appropriatelevel of assurance regarding waste form production. There havebeen staff level discussions between EM, NRC, and OCRWM on thisissue. Please contact me or Mr. Donald G. Horton at 586-8858if you or your staff have any quest,*ns regardino--khis issue.

Efi&e of Civilian RadioactiveWaste Management

CERCORPORATION 2500 WILSON BOULEVARD. SUITE 202

ARLINGTON, VIRGINIA 22201

(703) 276-9300FAX: (703) 276-9310 August 6, 1991

1050-0078File No.: 100.100.201

100.110.24110791003

Mr. Donald G. HortonDirectorOCRWM Office of Quality AssuranceUnited States Department of Energy1000 Independence Avenue, S.W.Washington, DC 20585

SUBJECT: DOE CONTRACT NO. DE-ACO1-90RW00178; OBSERVERS FOR EM AUDIT

Dear Mr. Horton:

In the notification letter to EM concerning the August 26-30 audit we stated, "you will be notified of...observers prior to the audit." The attached preliminary draft letter forwards this information to EM.

Clark, Esmeralda, Eureka, Lincoln, and White Pines Counties, NV; Inyo County, CA; and the State ofNevada have been contacted by the Audit Team Leader, but no observers will be coming.

Should you have any questions, please do not hesitate to give me or Norman Frank a call at (703)276-9300.

Sincerely,

Marc J. yerProgram ManagerCER Corporation

MJM/D/ac

Attachment: Draft memo to EM-30

cc: B. Clark, DOE-HQC. Rueter, DOE-HQR. Minning, DOE-HQW. Booth, WestonCentral Records Facility

K.>

RW-3

OBSERVERS FOR THE OFFICE OF CIVILIAN RADIOACTIVE WASTE MANAGEMENT(OCRWM) AUDIT HQ-91-003 OF THE VITRIFICATION PROJECTS BRANCH (EM-343)

Ms. Jill E. Lytel, Associate Director (EM-30)Office of Waste OperationsU.S. Department of EnergyForrestal Building100 Independence Avenue, S.W.Washington, D.C. 20585

The following people will be observers on the Augustaudit of EM-343. Please arrange for these people tobuildings and offices we will be visiting during the

26-30, 1991,have access toaudit.

James T. Conway, USNRC,(has NRC badge)

John T. Buckley, USNRC, ,,(has NRC badge)

Phili Niedzielski-Eichner, Nye County, NVi_ U.S. Citizen

!! ash, TESS, has an,&+-4U00fi~fidgeThomas R. Colandrea, EEI

11 U.S. Citizen

U.S. Citizen

'p U.S. Citizen

If you have any questions, please contact Bob Clark at (202) 586-1238 orFTS 896-1238 or Norman C. Frank at (703) 276-9300.

Donald Horton, DirectorOffice of Quality Assurance

Attachments

cc: C. Hampton, YMSCPOD. Spence, YMSCPOC. Gertz, YMPOR. Loux, State of NevadaS. W. Zimmerman, NWPO, Carson City,K. Whipple, Lincoln County, NVM. Baughman, Lincoln County, NVJ. Bingham, Clark County, NVD. Bechtel, Clark County, NVEnglebrecht von Tiesenhasuen, ClarkS. Bradhurst, Nye County, NVB. Raper, Nye County, NV

NV

County, Las Vegas, NV

cc: P. Niedzielski-Eichner, Nye County, NVR. Campbell, Inyo County, CAR. Michener, Inyo County, CAG. Derby, Lander County, NVP. Goicoechea, Eureka, NVC. Schank, Churchill County, NVC. Jackson, Mineral County, NVF. Sperry, White Pine County, NVL. Vaughan, Esmeralda County, NVK. Hooks, NRC, Washington, D.C.J. W. Gilray, NRC, Las Vegas, NVW. Belke, NRC, Washington, D.C.S. Cowan (EM-30) TREVM. Frei (EM-34) TREVJ. Hennessey (EM-343) TREVK. Chacey,(EM-343) TREVF. Peters, HQ, (RW-2) FORSC. P. Gertz, HQ, (RW-20) Las Vegas, NVD. E. Shelor, HQ. (RW-30) FORSR. A. Milner, HQ, (RW-40) FORSR. J. Brackett, TESS, HQ (RW-3) FORS

DOE Shuttle Bus ScheduleGERMANTOWN - D.C.

ROUTE "A" ROUTE "B"

Southbound Northbound

DepartsGermantown

ArrivesForrestal

DepartsForrestal

7:158:309:45

11:0012:151:302:454:005:30

a.m.a.m.a.m.a.m.p.m.p.m.p.m.p.m.p.m.

8:20 a.m.9:35 a.m.

10:50 a.m.12:05 p.m.1:20 p.m.2:35 p.m.3:50 p.m.5:05 p.m.6:30 p.m.

7:15 a.m.8:30 a.m.9:45 a.m.

11:00 a.m.12:15 p.m.1:30 p.m.2:45 p.m.4:00 p.m.5:30 p.m.

ArrivesGermantown

8:20 a.m.9:35 a.m.

10:50 a.m.12:05 p.m.1:20 p.m.2:35 p.m.3:50 p.m.5:05 p.m.6:30 p.m.

xii

GERMANTOWNAREAMAP

-6y-

117ldwh=

ciermanto wn

K>

Route Name Phone LocationSymbol Number Lco

K>Office of Statistical Standards

EI-70 DirectorYvonne M. Bishop .586-2222

EI-72 Director, Quality Assurance DivisionDouglas R. Hale ......... 586-2315

EI-73 Director, Data Collection Services DivisionJohn Gross ...... 586-2308

OFFICE OF ENVIRONMENTAL RESTORATION AND WASTE MANAGEMENT

EM-1 DirectorLeo P. Duffy ...... 586-7710

EM-1 Assistant to the DirectorMelinda Downing....................................................................................... 586-7710

EM-1 Technical AssistantThomas C. Elsasser ............ 586-2979

EM-1 Special AssistantDavid C. Durham .......... 586-2979

EM-1 Special AssistantEllen Uvingston-Behan .............. 586-2979

EM-2 Deputy DirectorPaul D. Grimm ........ 586-7709

EM-2.1 Director, 5-Year PlanRichard J. Aiken ......... 586-4373

EM-3 Executive AssistantMichael C. Sellers .................................................. 586-2979

Office of Planning and Resource Management

EM-10 Associate DirectorJames E. Dieckhoner (Acting) ..................... ............................. 586-1665

EM-12 Director, Administrative Management DivisionRaymond E. Gibson ................................................ 586-2661

EM-13 Director, Financial Management and Policy DivisionEli B. Bronstein ................................................ 586-8899

Office of Quality Assurance and Quality Control

EM-20 Associate DirectorRandal S. Scott .................................................. 586-8754

EM-22 Director, Environmental Compliance DivisionMichael H. Kleinrock ............. 586-0338

EM-23 Director, Safety and Health Compliance DivisionOwen 0. Thompson ............ 353-7910

EM-24 Director, Engineering and Cost Evaluation DivisionVincent Fayne ........ 586-0126

Office of Waste Operations

2F-081 /FORS

2F-081 /FORS

1 E-256/FORS

7A-049/FORS

7A-049/FORS

7A-049/FORS

7A-049/FORS

7A-049/FORS

7A-049/FORS

7A-049/FORS

7A-049/FORS

GA-208/FORS

GA-208/FORS

GA-208/FORS

6B-138/FORS

8H-050/FORS

438/TREV

8H-050/FORS

K>

EM-30

EM-30

EM-32

EM-32

EM-321

EM-322

Associate DirectorJill E. Lytle......................................................................................................Deputy Associate Director

Stephen P. Cowan.....................................................................................Director, Site Operations Division

Jam es E. Dieckhoner................................................................................Deputy Director

Joseph A. Colem an...............................................................................Chief, Eastern Operations Branch

Elizabeth Jordan....................................................................................Chief, Western Operations Branch

Joseph Boda..........................................................................................

20

586-0370

353-7100

353-7105

353-7105

353-7116

353-7111

6B-170/FORS

355/TREV

339/TREV

341 /TREV

343/TREV

337/TREV

Route Name Phone onSymbol NaeNumber Lcto

K M-323 Chief, Corrective Activities Branch.J/ Leanne Waldo Smith.

EM-33 Director, Program Support DivisionJames A. Turi.

EM-331 Chief, Regulatory Compliance BranchLee E. Stevens.

EM-332 Chief, Resource Management BranchJohn E. Yanoski.

EM-34 Director, Waste Management Projects DivisionMark W. Frei.

EM-341 Chief, Construction Management BranchRam B. Lahoti.

EM-342 Chief, W.I.P.P. BranchSteven P. Schneider.

EM-343 Chief, Vitrification Projects BranchKenneth A. Chacey.

EM-35 Director, Technical Support DivisionJohn C. Tseng.

EM-351 Chief, Technical Support Branch(Vacant) .

EM-352 Chief, Waste Minimization BranchJmaes V. Antizzo.

Office of Environmental Restoration

353-7130

353-7147

353-7142

353-7154

353-7201

353-7210

353-7201

353-7186

353-7170

353-7174

353-7180

347/TREV

375/TREV

305/TREV

349/TREV

323/TREV

327/TREV

316/TREV

315/TREV

366/TREV

370/TREV

370/TREV

EM-40

IM-40

EM-42

EM-421

EM422

EM-423

EM-424

EM-43

EM-431

EM-432

EM-433

EM-44

EM-441

EM-442

EM-443

r"EM-45

EM-451

Associate DirectorRoger P. Whitfield ............................................... 586-6331Deputy Associate Director

John E. Baublitz ................................. "Il,.......... 353-8100Director, Eastern Area Programs Division

James J. Fiore ............................................... 353-8141Deputy Director

Donald C. Fulmer ............................................... 353-8144Chief, Eastern Area Off-Site Branch

James W. Wagoner II ............................................... 353-8147Chief, Eastern Area On-Site Branch

Donald C. Fulmer ............................................... 353-8144Chief, Eastern Area Decontamination/Decomissioning Branch

William E. Murphie ............................................... 353-7216Chief, Feed Materials Production Center

Kimberly A. Hayes (Acting) ................... 353-8154Director, Program Support Division

William Wisenbaker (Acting) ..................... 353-8105Chief, Regulatory Compliance Branch

Douglas Smith ................... 353-8113Chief, Resource Management Branch

Brian F. McCully ................... 3534126Chief Program Integration Branch

Gale P. Turi (Acting) ................... 353-8118Director, Northwestern Area Programs Branch

Dr. Sally A. Mann (Acting) ..................... 353-8161Chief, Northwestern Off-Site Branch

Dr. Sally A. Mann (Acting) ................... 353-6436Chief, Northwestern On-Site Remediation Branch

John C. Lehr ................... 35348164Chief, Northwestern Decontamination/Decomissioning Branch

John C. Lehr (Acting) ................... 353-8164Director, Southwestern Area Programs Division

Ralph Lightner ..................... 353-8180Chief, Southwestern Off-Site Remediation Branch

Dr. Ralph G. Lightner (Acting) ................... 35348180

21

6B-158/FORS

225/TREV

104/TREV

106/TREV

122/TREV

106/TREV

306/TREV

306/TREV

209/TREV

205/TREV

219/TREV

209/TREV

156/TREV

D-436/GTN

160/TREV

160/TREV

145/TREV

145/TREV

RouRou

Symi

U EM-45

EM-45

Office

EM-50

EM-50

EM-52

EM-53

EM-54

EM-55

ER-1

ER-2

ER-2

ER-6

ER-7

ER-8

ER-8.1

ER-8.2

ER-9

Office

ER-10

ER-11

ER-13

ER-131

ER-132

ER-14

ER-141

ER-142

ER-15

te0ol

Name Phone Location

2 Chief, Southwestern On-Site BranchJohn A. Aiquist.

3 Chief, Southwestern Decontamination/Decomissioning BranchRay Greenberg.

of Technology Development

Associate DirectorClyde Frank.Deputy Associate Director

Gloria S. Patton.Director, Institutional & Technology Integration Division

Susan M. Prestwich.Director, Program Support Division

Lawrence H. Harmon.Director, Research and Development Division

Stephen C. T. Lien.Director, Demonstration Testing and Evaluation Division

Carl L Cooley.

OFFICE OF ENERGY RESEARCH

DirectorDr. James F. Decker (Acting).

Deputy DirectorDr. James F. Decker.....................................................................................Executive Director

Dr. David B. Nelson.Director, Science and Technology Affairs Staff

Dr. Philip M. Stone.Director, Scientific Computing Staff

David B. Nelson.Director, Office of Assessment and Support

Joseph R. Maher.Director, Facility Safety Division

Joseph R. Maher (Acting).Director, Environmental and Health Protection Division

James K. Fartey (Acting).Director, Office of Subseabed Disposal Research

Dr. W alter L Warnick (Acting).....................................................................

of Basic Energy Sciences

Associate DirectorDr. Donald K. Stevens.Deputy Associate Director

Dr. Louis C. lanniello.Director, Materials Sciences Division

Dr. Iran Thomas.Chief, Metallurgy & Ceramics Branch

Dr. Robert J. Gottschall.Chief, Solid State Physics & Materials Chemistry Branch

Dr. B. Chalmers Frazer.Director, Chemical Sciences Division

Dr. Robert S. Marianelli.Chief, Fundamental Interactions Branch

Dr. Allan H. Laufer.Chief, Processes & Techniques Branch

Dr. F. Dee Stevenson .Director, Engineering & Geosciences Division

Dr. James S. Coleman.

22

353-8184

353-8190

586-6382

353-7260

353-7924

353-7940

353-7911

353-7286

586-5434

586-5434

586-5430

586-9942

353-5800

353-4097

353-4097

353-2314

353-3122

353-5565

353-3081

353-3427

353-3428

353-3426

353-5804

353-5820

353-5802

353-5822

174/TREV

173/TREV

6B-158/FORS

470/TREV

412/TREV

464/TREV

404/TREV

408/TREV

7B-058/FORS

7B-058/FORS

78-058/FORS

7B-040/FORS

G-215/GTN

F-235/GTN

F-235/GTN

F-235/GTN

F-327/GTN

J-304/GTN

J-304/GTN

J-317/GTN

J-322/GTN

J-325/GTN

G-334/GTN

G-340/GTN

G-341 /GTN

G-363/GTN

( Office of Wastqj erationsEM!2

Jill Lytle. Associate DirectorSteve Cowan, Deputy Associate DirectorKris Morris, Policy & Program AnalystCarolyn McCall, SecretarySusan Sappington, SecretaryTech Asst, (vacant)

I

(

I

[Site Operations, EM-32James Diecdwoner. DirectorJoseph Coleman. Depu"y DirectorCheryl Seymour. SecretaryVYM Spec.. (vcant)

-~~~~~~~~~~~~~~~

* Program Support, EM-33* James A. Turi, Dfrector* Depu Director, (vacant)

Secretary, (Vacanl)

iWaste Mgmt Projects, E

Mark Frel. DirectorDepuo y Director. (vacant) EClaire Picaredla. SecretaryTech Asst. (vacant) V Technical Support, EM-35

John Tseng, DirectorSecretary. (vacant)

I

I�1I

-ii I I -II IIEastern Operations Branch,EM421Betsy Jordan. ChiefNancy Ohler. SecretaryKay Whtasdd. Env. Prot Spec.Michael Torbert, WM EngineerMary Burandlt WM EngineerBryan Wesd. WM EnglneerWM Spec.. (vacant)WM Spec.. (vacant)Western Operation Brnch,EM422Joseph Boda, ChiefSecretaiy. (vcent)Warren Black, Env. Prot. Spec.Jim Keenan, WM EngineerAndrew OrIfth, WM EngineerGordon Langle. Env. Prot. Spec.WM Engineer (vacant)

Central Operations Branch,EM04"Leanne Smith. ChiefCathy Fauble, SecretaryPeter Slebach, Env. EngineerJane TSIrUoo. Env. Prot. Spec.Josh Williams, WM EngineerMan Zenkowich. WM EngineerJeff Kenridge, WM EngineerWM Spec. (vacant)WM Spec.. (vacant)

Regdatory Compliance Branch,EM-331Lee Stevens. ChiefAmy Rand. SecretaryLydia Chang, Env. Engr.Greg Duggan, Env. Prot. Spec.Don Henninger, Env. Prot. Spec.John Stewart, Env. Prot. Spec.Dave Levenstin, WM Spec.Btty Shaddeford . WM Spec.

OA Program Mgr., (vacant)Safly Analysis EARFMINfvacant)Heafth Phy., (vacant)Fac Safely Appr.. (vacant)OA Spec.. (vacant)

Resource Management Branch,EM.32Jack Yanoeld, ChiefSecretary. (vacant)Banty Gaffney, Program AnalystBarbara Hammond,Program AnalystDebra Vogt. BPudget AnalystMaureen ODel, Program AssistantBudget Analys (vacant)Admin. Asst.. (vacant)Program Operations Support Branch,EM-333Chief. (acant)Secretary. (vacant)Doti Whitt. Program AnalystGen. Engr.. (vacant)Gen. Engr.. (vacant)Phys. Scientist, (vacant)Contract Spec., (vacant)Admin. AssX..(vacant)

-Constrction Management Branch,EM-341Ram Lahoti. ChiefSecretary, (vacant)Jim Davis, WM EngineerWM Engineer (vacant)Gen. Engr.. (vacant)Gen. Engr., (vacant)Gen. Engr.. (vacant)Gen. Engr., (vacant)

WIPP Projects Brunch,EM-342Steve Schneider. ChiefSecretary. (vacant)Jay Rhoderick. Waste Iso. ScientistMark Duff, Phys. ScientistDouglas Tonkay, WM EngineerWM Engineer (vacant)Gen. Engr.. (vacant)Phys. Scientist. (vacant)Program Analyst. (vacant)

Vitrfication Projects Branch,EM-343Ken Chacey, ChiefKrystal Carter, SecretaryTomn Gutmann. Gen. EngineerTed Mcintosh, Gen. EngineerVirgil Trice, Chem. EngineerHenry Walter. Phys. ScientistJack Hennessey, FbyLSciaath__Oienna Truskelt, WM EngineerHa Nguyen. WM Engineer

Technical Support Branch,EM.351Chief, (vacant)Mary Jane Wisenbaker, SecretaryMary Pearl, Writer-EditorJonathan Kang. WM EngineerTerry Plummer, Env. Prot. Spec.WM Engineer (vacant)WM Engineer (vacant)Haz. Waste Prog. Mgr., (vacant)HLW Prog. Mgr., (vacant)

Waste Minimization Branch,EM-352James Antizzo. ChiefSecretary. (vacant)Rebecca Redeker. Mgmt InternWaste Min. Info. Spec.. (vacant)

On Board 62Named Actions 2Vacancies 6Immediate Needs 17High Priority 23

Total 11021t4/91

CDIVISION OF WASTE

MANAGEMENT PROJECTS(EM-34)

MARK FREIDIRECTOR

I

C

-- ICONSTRUCTION MANAGEMEN1

BRANCH(EM-341)

RAM LAHOTICHIEF

IWIPP PROJECT

BRANCH(EM-342)

STEVEN SCHNEIDERCHIEF

IVITRIFICATION PROJECTS

BRANCH(EM-343)

KEN CHACEYCHIEF

.

EASTERN AREA PROJECTS

JAMES DAVIS L MARK DUFFJAY RHODERICK

DOUGLAS TONKAY

PR.A EC UPR.

3PROGRAM TECH SUPPORTOFFICE . PROGRAM MGR

OLENNA TRUSKETT H -I TECHNOLOGYDEVELOPMENT PROGRAM

HENRY WALTER I1 I I

--

ACENTRAL AREA PROJECTS PROJ. DOCUMEtIATION

ESSAB (ESAR) SCHEDUUNGaA ACTIVIES

JACK HENNESSEY

BUDGET LIAISONPROG. EXECUTION GUIDANCE_ MILESTONE SYSTEM

CONST. PROJ. DATA BASEKA NGUYEN

.

WESTERN AREA PROJECTS'p

I ~~~~IIWEST VAULEY DEFENSE WASTE HANFORD WASTE

DEMONSTRATION PROCESSING FACILITY VFRIFCATIN fACIL

PROJECT T 1VR RTEDMcNTSHj TOMGUMANj VIGI RICE.

:112 /!'J I

During the audit Norman Frank will be staying at:

Courtyard Marriot (9011760Q)805 Russell AvenueGaithersburg, MD 20879Phone: 301-670-0008

-

D: \N0RM\AUDITS\EM\TEAMASS2

EM Audit Team AssignmentsAudit Manager:Audit Team Leader:

Robert Clark, DOE/OQANorman C. Frank

Team A

Team B

Louis Wade and Clyde Morell(scientific investigation)]

[Criteria 1,2,3

Don Miller and Jim George [Criteria 4,7,15,16]

Team C Craig Walenga and Tom Rodgers(facilities and software),5,6,17,18]

[Criteria 3

8:30 am Teamand ObserverBriefing

8:30 am

ATL - BriefEM Managementand Crit. 2B - Crit. 4/7C - Crit. 6

8:30 am

ATL - BriefEM ManagementA - Crit. 3B - Crit. 15C - Crit. 3

8:30 am 8:30 am

ATL - BriefEM ManagementA - Crit 3B - Crit. 16C - Crit. 18

9:00 am to10:00 amPreauditMeeting

ATL - BriefEMManagementA, B, andC - Meetwith finalEM staff;consolidatecomments,results, andCARs

10:00 amAuditA - Crit.B - Crit.C - Crit.

145

A - Crit. 1 A - Crit. 2/3 A -.Crit. 3 A, B, and C - pmB - Crit. 4 B - Crit. 7 B - Crit. 15 Meet withC - Crit. 5 C - Crit. 6 C - Crit. 17 final EM Postaudit

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ ~ ~~~~~~st a f f M e e t i n g

4:00 pm Team 4:00 pm Team 4:00 pm Team 4:00 pm TeamDebriefing Debriefing Debriefing Debriefing

Criteria Covered by the Audit

1-7, and 15-18

STANDARD PRACTICE PROCEDURE SPP 1.01Page 1 of 5Rev. 0EffectiveDate 02/02/90

INDEX OF HIGH-LEVEL WASTESTANDARD PRACTICE PROCEDURES

FOR QUALITY ASSURANCE

Section 1.0 -

SPPNumber

v-I .01

QUALITY ASSURANCE PROGRAM OVERVIEW

Tite al

Index of High-Level Waste Standard PracticeProcedures for Quality Assurance

vision

0

Section 2.0 - CONTROL OF PROGRAM DEFINING DOCUMENTS

SPPNumber Revisin

v,2-01 Standard Practice Procedures 0

v.03 Quality Assurance Program DescriptionPreparation, Maintenance, and Control

0

..,2.04

Section 3.0 -

SPPNumber

V-3.01

Control of the Standard Practice ProceduresManual

5W~w Apt '6" a a Aot^"QSj';

TRAINING AND CERTIFICATION

Preparation and Maintenance of Plans forPersonnel Training, Indoctrination, andOrientation

0

C.

Co

0

4.02

v4.03

Preparation and Conduct of Personnel Training,Indoctrination, and Orientation

Certification of Quality Assurance AuditPersonnel

Documentation of Surveillance and ReviewPersonnel Qualifications

0 A

fr0

0 Ar

SPP` 1.01Page 2 of 5Rev. v IEffectiveDate 02/02190

W.05

Section 4.0 -

SPPNumber

V4.01

k4.02

,-4.03

-404

4.05

'-4.06

4.08

4.09

14-10

1A.11

&-4.12

4.13

Administration of Personnel Certification andQualification Records

PROGRAM CONTROL AND VERIFICATION

M laPlanning and Scheduling of EvaluationActivities

Administration of Quality Assurance Audits

Conduct of Quality Assurance Audits

Administration and Conduct of Surveillance

Administration of Technical Reviews

Conduct of Technical Reviews

Administration of Peer Reviews

Conduct of Peer Reviews

Review of Operations Offices Quality AssuranceProgram Descriptions and Procedures

Review of Waste Acceptance Process TechnicalDocuments

Review of Program Execution GuidanceDocuments

Participation in Evaluation Activities Led byExternal Organizations

0

Revision

0

0

0

0

0

0

0

0

0

0

0o

A, co

Co

CO4

A-,C

A

A

13

13

0

SPP 1.01Page 3 of 5Rev. 0EffectiveDate 02/02/90

Section 5.0 -

SPPNumbgr

1.5C01

&02

wS.03

5.04

dk5.05

4.06

Section 6.0 -

SPPNumber

-6.01

w8.02

v6.03

L-6.04

v6.05

NONCONFORMANCE, DEVIATION, ANDCORRECTIVE ACTION CONTROL

Deviation Reporting and Disposition

Management Action Request

Control of Unsatisfactory Conditions (Stop WorkOrders)

Disposition of Deviations Identified By OutsideOrganizations

Review of Unusual Occurrences

Control and Disposition of Deviations andRecommendations for Improvement by OutsideOrganizations

DOCUMENTATION CONTROL

Official HLW Office Files

Preparation of Correspondence

Incoming Mail

Commitment Control

Controlled Documents

Re0ision

0

0013

0

0

0

13

Revision

0

0

0

0

0

C

CC-

C.

C-,

SPP 1.01Page 4 of 5Rev. 0EffectiveDate 02/02190

Section 7.0 -

SPPNumber

-f.01

QUALITY RECORDS MANAGEMENT

Preparation, Transfer, and Receipt of QualityRecords

Revision

0 C

V.02 Quality Records Management 0

Section 8.0 - PROGRAM COORDINATION, EVALUATION,REPORTING

AND

SPPRevilso

8.01 Coordination of Reviews and Evaluations byOutside Organizations

0 A

w6.02

48.03

Quality Assurance Program Evaluation andAssessment of Adequacy and Effectiveness

Review and Reporting of Quality AssuranceProgram Progress and Status

0

0

Section 9.0 -

SPPNumbrer

V9.01

PROJECT MANAGEMENT

Titl

Preparation and Maintenance of the ProgramSchedules

Revision

0 A4

w9.02

p9.03

HLW Monthly Progress Reporting

Preparation and Maintenance of the WorkBreakdown Structures (WBS)

0

0 A-

SPP 1.01Page 5 of 5Rev. 0EffectIveDate 02/02/90

Section 10.0 - PROGRAM IMPROVEMENT

SPPNumber

w.01

Itl

Identification and Analysis of Adverse QualityTrends and Problems

Planning and Conduct of Quality Improvement

Differing Staff Opinions and Allegations

Revision

0

0

0

A

10.02

410.03

13A

EM AUDITPROCEDURES ARRANGED BY AUDIT TEAM

SPPNumber

TEAM "A"

1.01

3.01

3.02

3.03

3.04

3.05

4.01

4.04

4.05

4.06

4.08

4.09

4.13

8.01

8.02

8.03

Title

Index of High-Level Waste Standard Practice Procedures for QualityAssurance

Preparation and Maintenance of Plans for Personnel Training,Indoctrination, and Orientation

Preparation and Conduct of Personnel Training, Indoctrination,and Orientation

Certification of Quality Assurance Audit Personnel

Documentation of Surveillance and Review Personnel Qualifications

Administration of Personnel Certification and QualificationActivities

Planning and Scheduling of Evaluation Activities

Administration and Conduct of Surveillance



Administration of Peer Reviews

Conduct of Peer Reviews

Participation in Evaluation Activities Led by External 0Organizations

Coordination of Reviews and Evaluations by Outside Organizations

Quality Assurance Program Evaluation and Assessment of Adequacyand Effectiveness

Review and Reporting of Quality Assurance Program Progress and Status

Revision

0

0

0

1

SPPK-i Number

9.01

9.02

9.03

10.01

10.03

TEAM "B"

1.01

4.10

4.11

4.12

<va, 5.01

5.02

5.03

5.04

5.05

5.06

10.02

TEAM "C"

1.01

2.01

Title

Preparation and Maintenance of the Program Schedules

HLW Monthly Progress Reporting

Preparation and Maintenance of the Work Breakdown Structures (WBS)

Identification and Analysis of Adverse Quality Trends and Problems

Differing Staff Opinions and Allegations

Index of High-Level Waste Standard Practice Proceduresfor Quality Assurance

Review of Operations Offices Quality Assurance ProgramDescriptions and Procedures

Review of Waste Acceptance Process Technical Documents

Review of Program Execution Guidance Documents

Deviation Reporting and Disposition

Management Action Request

Control of Unsatisfactory Conditions (Stop Work Orders)

Disposition of Deviations Identified by Outside Organizations

Review of Unusual Occurrences

Control and Disposition of Deviations and Recommendations forImprovement by Outside Organizations

Planning and Conduct of Quality Improvement

Index of High-Level Waste Standard Practice Procedures forQuality Assurance

Standard Practice Procedures

Revision

0

0

0

0

0

0

0

0

2

sPPNumber

2.03

2.04

2.05

4.01

4.02

4.03

4.05

4.06

4.13

6.01

6.02

K>1~ 6.03

6.04

6.05

7.01

7.02

Title

Quality Assurance Program Description Preparation, Maintenance,and ControlControl of the Standard Practice Procedures Manual

Selective Application of QA Activities

Planning and Scheduling of Evaluation Activities

Administration of Quality Assurance Audits

Conduct of Quality Assurance Audits



Participation in Evaluation Activities Led by External Organization

Official HLW Office Files

Preparation of Correspondence

Incoming Mail

Commitment Control

Controlled Documents

Preparation, Transfer, and Receipt of Quality Records

Quality Records Management

Revision

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

3

The observers on this audit are scheduled to be:

James T. Conway, USNRCJohn T. Buckley, USNRCPhillip Niedzielski-Eichner, Nye County, NVFrank Nash, TESSThomas R. Colandrea, EEI

PUT 25. ;9s8

HLW DIVISION PROCEDURE FOR CCNDUCTINGOBSERVATION AUDITS OF DOE HIGH LEVEL WASTE

REPOSITORY PROGRAM QA AUDITS

1.0 PURPOSE

This procedure describes the High-Lovel Waste Manaqement Division's methodologyfor conducting observation audits of quality assurance (QA) audits performed bythe Oepartment of Energy (DOE). These audits may be perform.d on DOE, itscontractors and subcontractors, Its participating organizations, and mayinclude contractor audits of their subcontractors. For example, the staff mayobserve a USGS audit of one of their contractors.

The primary objective of the Nuclear Ragulatory Commissions (NRC) observationaudit program Is to gain confidence that the DOE is implementing a programwhich meets the NRC's OA program requirements established In 10 CFR 60,Subpart G. This confidence Is gained by assessing DOE's ability to Identifyand correct problems through their audit program. Observation audits will bethe principal means for the staff to assess the implementation of the DOEprogram prior to the start of extensive site characterization activities.Observation audits also enable the staff to provide guidance to the DOE on QAprogram implementation and the overall DOE audit program. The staff willfollow-up on staff concerns with respect to the audit and/or deficienciesidentified by the audit team. This will assure the staff that correctiveaction Is being performed and QA programs are being properly implemented.

2.0 OBJECTIVE

The objective of this procedure is to describe techniques for assessing theoverall effectiveness of a quality assurance program audit conducted In the DOEprogram. Guidance on the following areas Is provided:

(a) Qualifications required for the observers.(b) Responsibilities(c) Criteria for selection of audits for observation(d) Areas to be observed(e) Protocol during the observation audit(f) Reporting requirements(g) Follow-up 0

3.0 QUALIFICATIONS IF THE OBSERVERS

Personnel selected for observation audits shall have experience or trainingcamensurate with the scope, complexity, or special nature of the activities tobe audited (e.g., technical observers shall be selected based on theireducation and experience in the technical area being audited). The observersshall be selected based on the following qualifications: auditing and technicalexperience, education, auditor training, communication skills, and knowledge ofQA, technical, and regulatory requirements. All observers shall meet therequirements of ANSI/ASME HQA1-1983 for auditor qualifications.

The training program for observers should address the following:

3.1 (a) The basics of the audit process

I

(b) Appiicable requirements documents

(c) COE/NRC protocol for observers

(d) Conduct of observers

Attenoance and successful completion of an exam covering the topics aboveshould be completed prior to any staff maemer participating as an observer.

4.0 RESPONSIBILITIES

The following identifies the responsibilities of individuals involved in theobservation audit process:

4.1 Operations Branch Chief(a) Approval of observation audit schedule.(b) Reviewing and approving the final report.(c) Transmitting the final rtport to the DOE.

4.2 Functional Section Leaders (QA and technical sections)(a) Preparation of observation audit schedule in consultation with P/M

and technical branch (QA Section Leader only)(b) Selection of observers.(c) Assuring that observers are indoctrinated and trained for the audit

observation This information shall be documented and retained.(d) Concurring on final report.(e) Revising observation audit procedure as needed.

4.3 Project Manager (HLOB)(a) Coordinating the arrangements for the observation, including meeting

notices for the State, letters to DOE, coordinating with TRB and QAsection tU assure integration.

(b) Acting as the principal spokesperson for the NRC during the audit.P/N will rely on functional staff to explain observations or othertopics within their discipline.

(c) Ensuring during the audit that all concerns, positions, methods, etc.are consistent with Comission and Office policies.

(d) Writing the transmittal letter to DOE.(e) Co-authoring report.(f) Integrating evaluations of technical section and OA section

observers, as necessary.(g) Leading observation audit team during the audit.

4.4 Observers(a) Evaluating the DOE audit program In accordance with this procedure,

reviewing pertinent background information (such as the DOE auditplan, previously identified open items, the checklist, the QA plan,and any necessary technical procedures or documents).

(b) Completing the checklist described In Attachment A.(c) Writing the report (for their area of responsibility).(d) Concurring on report.(e) Explaining NRC observations to DOE audit team, as necessary.

2

Technical suff memors wiln be primarily responsible for evaluating t!%eeffectiveness of the DOE audit team In assessing the quality of the tecrnicalwork. QA staff will primarily be responsible for evaluating the audit team'sassessment of the controls applied to work. Because these areas overlap, &nobecause individual team members may possess qualifications In areas outside oftheir specific responsibilities, QA and technical staff should cooroinate andintegrate their review of the DOE audit.

5.0 CRITERIA FOR SELECTION OF AUDITS FOR OBSERVATION

The selection of audits for observation should be based on the following:

(a) The importance of the activity being audited (for example, criticalpath activities which provide site characterization data which areimportant to public radiological health and safety and/or wasteisolation).

(b) The time since the last audit (NRC, DOE, WIPO, ate).(c) The results of previous audits, observation audits, or other reviews

by NRC or DOE, particularly- those which identified major concerns.

The OCRWM Consolidated Audit Schedule should be used for determining whichaudits are plannec by DOE.

6.0 AREAS TO BE OBSERVED

See Attachment A for instruction on the areas to be observed and the use of achecklist to document results.

7.0 PROTOCOL DURING AUDIT

During the observation audit, the staff shall conduct themselves in aprofessional and cooperative manner. Observers should coordinate with the DOEaudit tea leader to assure that the effectiveness of the audit teas is notdisrupted. Observers are encouraged to participate fully by furnishing theirquestions, observations, and reco mendations to the DOE audit team leader.Efforts should be made by the observer to minimize direct questions of theaudited organization. It ay be necessary to exclude observers from certainportions of the audit (such as procurement actions that are in-process, orsensitive personnel records). Observers should obtain a copy of the auditchecklist as-soon as it Is available and should prevent predisclosure of thelist to the audited organization.

All staff concerns should be communicated to the audit team leader in a clearand timely mannr. Observers shall indicate the acceptable areas of the auditprogram as well as express concerns, or recomendations to the DOE audit teamleader prior to leaving the site. Every attempt should be made to expresstheir concerns daily to the DOE audit team leader. Whenever possible, theobservers should attend the entrance and exit meetings and audit teas caucuses.The observers should also express their concerns about the adequacy andimplementation of the audited organization's OA program to the audit teamleader prior to the exit meeting. Observer concerns about the conduct of theaudit should be addrtssed only to the audit team leader unless directedotherwise by the audit teas leader. The audit teas leader should be given theopportunity to respond to staff concerns. The observer should consider any new

3

Information orovided to determ1r* if concerns are still valid. Efforts snoulcbe mace to reacn *greement with the aucit team lcacer On the nature of theconcern and where necessary, that appropriate corrective action will be taken.All observations should be based on facts and personal opinions should beavoided.

8.0 REPORTING REQUIREMENTS

A report shall be written upon completion of the audit and will be sent to theOtrector, Office of Systems Integration and Regulations, Office of CivilianRadioactive Waste Management, Department of Energy. The OOE Project Office(WMPO), the State of Nevada, and the organization that conducted the auditshall also receive a copy of the report. The report shall evaluate the overalleffectiveness of the DOE audit in assessing the implementation of the QAprogram. Needed improvements In the audit, which would make future auditsacceptable to the staff, should be identifted. The areas addressed in thechecklist (Attachment A) should be Included in the report to the extent thateach was observed. In addition, each report shall address the audit results.The report should address the positive as well as the negative aspects of theaudit.

The format of the report should Include the following headings:

8.1 Sumnary(a) Objective of audit and audit observation(b) Scope of audit(C) Main conclusions on overall effectiveness of audit and major areas

needing lmprovement.

8.2 Introduction(a) Contents of report (observations, DOE findings, audit team embers,

etc.)(b) Dato(s) of audit observation and the organization being observed(c) General background information about the audited organization (e.g.,

their scope of work and importance to safety or waste isolation.

8.3 Audit Purpose and Scope(a) Based on DOE's and NRC's perspective(b) OA criteria and technical work audited

8.4 Audit Team Members and Observers (name, title, and affiliation)

8.5 NRC Observations of the Audit Team(a) Addresses each area described In the checklist (Attachment A) to the

extent that each was observed.(b) Conclusions should be based on facts. Subjective Judgments should be

minimized.(c) Supporting detail (i.e., examples) should be provided as necessary to

clearly support the observations.

8.6 PrelIminary Results/Findings of Audit T*am(a) Attach & copy of the draft rtsults or sumiarize the results.

8.7 Appendices may be attached which address specific observations such as:

4

(a) Observations and open items with respect to th1 &ucitedorganizatlon's QA program identified by the audit coserver.

9.0 FOLLOW-UP

The staff may elect to observe follow-up audits or surveillances by DOE whichare needed to verify that the Audited organization Is Implementing thenecessary corrective action. Likewise, follow-up audits by the staff nay benecessary to ensure that those recommendations for improving the DOE auditprogram are being implemented. It is the responsibility of the observers totrac1. all staff concerns. All concerns shall be docuented and subsequentlyclosed out upon satisfactory resolution of the concern. The actions taken toresolve the issue shall be documented.

10.0 REFERENCES

ASME/ANSI NQA-1-198310 CFR Part 50 Appendix 8OCRYM Consolidated Audit ScheduleDOE Memo on Observer Protocol (July 14, 1987)

S

ATTACHMENT A

AREAS TO BE OBSERVED AND CHECKLIST COMPLETION

This attachment provides guidance on the areas to be addressed before or duringthe observation audit. A checklist (attached) shall be used which docuoentsthe area investigated and the results. The checklist Is Intended to be a guidefor the audit observers. Observers should rely on their professional judgementIn deciding which areas to emphasize or di-emphasize in the checklist. Thestaff should place a greater focus on performance of the audit team rather thanjust programmatic compliance. This means did the audit team verify that theaudited organization's QA program Is producing quality products (i.e., reports,data, test procedures) and the documentation necessary to defend that work inlicensing. In addition, concerns should be put Into perspective. For example,does a missing signature have a negative effect on the effectiveness of theaudit? If not, the staff should clearly indicate that a noncompliance existsbut It did not result in reduced product quality. The product, In this case,is an effective audit.

6

HLWM QIVISION OBSERVATIONAUDIT CHECKLIST

1. Observation Audit No:

2. Observer

3. ate(s) of Audit:

4. Audited Organization:

S. Audit Conducted By:

PROCEDURE: The areas listed should be addressed either before or during the

audit. When information used to support staff conclusions is obtained by

verification of documented evidence, appropriate documents should be

referenced. However, in those instaUnces where only verbal information car be

obtained, this shall be noted and the person contacted documented, so that

appropriate follow-up action can be taken to verify that supporting

documentation exists.

The observation audit number shall be placed on each successive checklist

sheet. In addition. upon completion of the respective checklist, the NRC

observer shall sign and date each checklist sheet in the space provided.

Lastly, for those areas not covered or not applicable (MA) the auditor shalldocument this and provide justification in the *RESULTS* section of thechecklist.

The following checklist has been organized in relative order of importance.

This will emphasize audit performance rather than procedural compliance.

Staff should not be limited to only those questions on the list, but should

pursue any others which will assist In achieving the objective of the

observation audit.

7

ANXI.

Oepartment of EnergyWashingion OC 20585

JUL 1 1§87

Seat. an Tribal Representataies (Liat Attached)

At the last Quality Assurance Coordinating Group seeting DOE, State.Tribal and NRC representatives discussed the polcy that should be usedwith regard to the participatioa of State, Tribal and HC representativesan DOE audits. It appears that a geeral, comssus was resched waso the

meeting participants on a procedure for participating In the DOE QAauditing procam Details are in the attached draft policy statesent.

Ye are pleased to Invite your review of the enclosed draft polcystatesent and would appreciate known of any rmalnin concerns you mayhive.

Stephm S. WeAsocate "Dirctor forCGologic Iapositorieso Offlce of

Ci1llan IlEoactlTs vasts maSamac

Enclosure

SAIC/T&MSS

MAY 2 7 1988

CCF RECEIVED

CQkbmnn th, U.S. Comaauw i &ememud - /77.10)

EUMc~OSURE 0

PO:.LC !C' t PAER: :2A::N OF STATE. =2ZAL LqD KRC PI= % LTA::v'ZSAS CasuVuLS CN DC1 AxU 5:S

:he OA Karlger of OCK will furnish to the State, Tribal a= XILCreprsenatacves a schedule of audits planned by DOE--HQ (OGE) and by theDOE project offices. 3ecause of frequent cstges to the uctedule, theschedule vL%1 be updated at approzisaaely aouthly Intervals and copiesfurnished to the Stae, TrTibaL and NlC represenatcives.

2. O( and the project offices wvil *ae every effort to send an auditnoaification at least 30 days prior to aeo QA audit. Tho auditnotification will. whenever possible, include an audit pi=« and adescription of the scope of the audit. Copies of OCI audit notificatlonswinl be furnished to KkC and to asl State and Tribal representativas;copies of project audit notifications 'ill be furnished to NC and to theaffected State and Tribal representatives.

3. State, Tribal and DC representarive my request to participate in anyaudit. lquests aneed not be in writing. Telephone contacts to requestparticipation ares

OG1 - Carl Newton - (202) 586-5059SWIP - Pierrs Sagec - (509) 942-7250WM_ - JAs Slaylock - (702) 295-1125SiLO - Jerry lcse - (806) 374-2320

State, Tribal and H C representatives who wish to participate will makeevery effort to contact the DO representative at least tva weeks prior tothe audit so that arrangamnts for their perticipation cm be mde.

4. When a request to participate is received by DO from a States, Tribal orXIC representatuie, it LS DOB's policy to mks every ressoable effort tohonor the request. Wgbo m11 audit tans are used by DON, and requestsfor maT obervnrs an received, It may be ecessary for DON to Ulsitparticipatiom (but Ln no e vet to leJ than oem observer perorganizational *tityr, I-es, ome from tCb ffected State, oe from achaffected Tribe, mg one from XC), so that the auditiAg process wiLI tcbe hampered by an ezcessiTv amber of observses. In instances when thelimot of oa observer per affected party wi£l still result in au excessiveobserver to auditor ratio, DOE wiLl comtact the affected parties d seekvoliutary reductious. It is espected the parties wil asks everyreasonable attmpt to accomodats DON's requests.

"PE8T AVAILBLE cPr

5. Observers ot DOE audits vtll be under the authority of the audit teasleader (or sub-teas leder If the team is divided during the audit).Observers re encouraged to participate fully by furnishing theirquestions, observationt and recommendations to the audit team leader (orsub-teas leader). Direct interactions between observers and audit*epersonnel vill generally be discouraged and It say be necessary to eaeaptobservers fros certain portions of an audit (such as procurement actionsChat are in-process, classified material, or sensitive personnelrecords). The DOE policy Is that every effort Is to be ma&d to lisit suchexemptions and to Include observers as full participants In al aspects ofthe audit possible.

6. The State, Tribal and NRC representatives who vlll be participating in aQA audit aro to be furnished a copy of the audit checklist as oon as itis avalLable. A target date of ten days prior to the audit vii beattempted. The State, Tribal and NRC representatives who receive auditchecklists are, of course, to keep their contents confidential and to not,under any circumstances, divulge its contents to representatives of theorganization to be audited.

7. DOE encourages observers to receive formal QA auditor training and QL leadauditor trailing. Every effort to accommodate State, Tribal and NRCrepresentatives in DOE sponsored training courses Is to be made. Thereare, however, no DOE requirements for observers to bare LO such training.

J. DOE invites observers to express conce=2 and rec endatioas an theaudite's QL program to the audit tea leaer for Uis coesideratIn inpreparing the audit report. DOE also invites observations oan the conductof the audit and solcits recomendations an bo v Mat Improve ouraudit process. Observers vii be afforded an opportuity to speak at exitmeetings following each audit. Regulr oppomrtats are to be providedto observers during the cour" of the audit sad at the quarterly QCCmeeting for Sctte, Tribal and NC representatives to dscus theircomenats and reco mendations.

4*v AT ILA~BLE copr

AUDIT OBSERVER INQUIRY

Audit. No.

Log No.

Name

Reauirement Reference

f,%"gV0";Mti^o

Question/Concern

Response

Observer's Acknowledgement

Cleared for Submittal to Audit Participant: _eadAuditor/_Lead______________

Lead Auditor/ Lead Technical Specialist

Audit Team Leader


Audit. No.

Log No.

Name

Requirement Reference

Organization_

Question/Concern

Response


Cleared for Submittal to Audit Participant:Lead Auditor/ Lead Technical Specialist

Audit Team Leader


Audit. No. _

Log No.

Name

Reauirement Reference

(ArGn4.watinn

Question/Concem

Response



Audit Team Leader


Audit. No.

Log No.

Name

Reouirement Reference

Organization.

Question/Concem

Response



Audit. No.

Log No.

Name

Requirement Reference

Organizationr

Question/Concern

Response



Audit Team Leader

K&l~ 7'7 ?/MEMORANDUM

Date: July 16, 1991

Subject: Report of EM-343 Informal Review

To: Kenneth A. Chacey, ChiefVitrification Projects Branch, EM-343U.S. Department of Energy

Attached '; the original report andduring the informal review of EM-343.as you feel appropriate.

a copy with the backupThe report is for your

material collectedinformation and use

Patrick L. SlatteryTeam Leader

a al tonT inMember

AtacmenI

M546S

U.S. DEPARTMENT OF ENERGYOFFICE OF ENYIROMEhlAL RESTORATION

AND WASTE MANAGEMENTOFFICE OF WASTE MANAGEMENT

VITRIFICATION PROJECTS SKNCH

INFORMAL REVIEW

ORGANIZAT1ON EVALUATED: U.S. Department of Energy, Office ofEnvironmental Restoration and WasteManagement, Division of Waste ManagementProjects, YVtrification Projects Branch (EM-343)

DATE OF REPORT: June 14, 1991

DATES OF REVIEW: May 20-22, 1991

LOCATION: DOE Headquarters. Trevion I and Trevion II Buildings

REVIEW RESULTS:

The review was performed to identify any weak areas in the Eff-343implementation of their Quality Assurance (DA) Program so that qualityimprovements could be initiated and problems corrected. The Review was toK.>1 include evaluating the Standard Practice Procedures (SPPs) for adequacy ofimplementation by EM-343. EI;-343 had not attempted to invoke all 43 SPPs w1thitNM-343 at this time but placed emphasis on 15 of the SPPs. In several cases, theIS procedures had not been implemented by EM-343 to the degree that theprocedures practicality for day to day use could be evaluated nor possibleimprovements be determined. Therefore the team concluded that EM-343 has notreached full implementation of the QA Program. The team has discussed severalpotential Improvement areas in the Attachment. It also appeared to the team thatImplementation may be slowed by an tpparent lack of a comprehensive understandingof the QA Program by EK-343 personnel and in-house QA resources.

Because of the purpose of the review, the team discussed some general suggestionsfor improvement with EM-343. No Deviations and Corrective Action Reports werewritten since the team concluded that the procedures had not been fullyimplemented at this time. The team recommends that EM-343 evaluate the areas forpotential improvement and take necessary actions.

PATRICZK L. SLA' V1'RY2 WALTONTeam Leader m Member

Attachment

Specific Observations ano Discussions

1. EM-343 OA Program Definition

There is no clear definition of the EM-343 QA program. Currently, there is noofficially designated EM-343 (in-house) QA Program Manager. EM-343 personnelmust be involved in many of the SPPs in addition to the 15 procedures that wereoriginally emphasized. An example of SPPs that also apply to the EM-343 staff,but were not invoked on the original matrix, are those procedures pertaining toaudits/surveillance, certification of personnel, QAPM Monthly Reports, andconduct of technical reviews. At this time, the SPPs do not cover involvementwith procurement quality (especially of services such as support contractors) orfor quality control of software (if used in technical reviews of Safety AnalysisReports, etc.).

2. Procedural implementation and conformance to Drocedures

Some of the procedures are clearly written for EM-343 performance with many ofthe procedures only requiring EM-343 participation.

Review of EM-343 implementation of the 15 emphasized procedures found severalrequirements were not implemented by EM-343. Subcontractors were performing someof these activities vice designated EM-343 representatives. However, several SPP

K>__J requirements (e.g., available listings of personnel for record access, annual QAprogram evaluation, provisions identified for dual record storage, records notbeing validated, personnel not signing/dating documents) were not being met.

3. Records Management

EM-343 has established a file cabinet for QA records and elected to have a dualstorage container in the Trevion I building. Very few records were maintainedpresently in the QA Records file cabinet in EM-343 or their 'dual" storage areain Trevion I location. (As mentioned above the records are not being validatedat this time). Most of the records reviewed had some errors including:signatures missing, orientation modules not identified on attendance sheets,missing records, incorrect data transfer, original records not available, and insome cases what the record represented was not clear. At the time of thesurveillance, some records called for in SPPs were requested to be reviewed.Some records for SPPs 3.01, 6.05, and 9.02 had been entered into the QA recordsfile cabinets. Records for SPPs 2.01, 2.03, 3.03, 3.04, 4.01, 4.02, 4.04, 4.10,5.02, 5.03, 5.04, 7.02, 10.01, and 10.03 had not been entered into the "QArecords file cabinets". The team did not believe that attendance lists for QAorientation SPPs orientation which are being maintained in several locations meetthe definition of a QA record, nor would Trevion I meet the requirements for"sufficiently remote to eliminate the chance of exposure to a simultaneoushazard".

Review of the Index to Division of Waste Management Projects Files indicates someQA records are probably filed in the HLW Project files and not the "QA recordsfile cabinet" at this time. Examples would be the review and approval of SARs,

Procurement, ORRs, Title I and II, etc. Therefore, these documents are not beingprotected by dual storage at this time.

4. Orientation/Training

Training assessments have been made and approved for EM-343 personnel. However,there does not appear to be a basis for these assessments (i.e., no jobanalysis). Normally three requirements were specified as mandatory training.Two of the training sessions are orientations and none of the training would stopa person from performing their day-to-day duties. Other classroom training hasbeen identified as desirable training but was not considered mandatory.

The assessment for the individual expected to be designated QA Program Managerdid not include auditing techniques.

There is presently no in-house certified EM-343 lead auditors nor do any of thetraining assessments indicate that certain people will be expected to obtaincertification.

The training assessments reviewed by the team only reflected formal classroomtraining. On-the-job training and reading assignments should be recognized andutilized. It was the team's understanding that neither individual, primarilyinvolved with quality records management had read or been told to read DOE Order1324.2A or the Vitrification Projects [Branch] Records Management Policies andRequirements document.

5. Document Control

The EM-343 designated QA records file cabinet contained several ControlledDocument Master Lists. Instead of a list of documents that EM-343 would control,this turned out to be lists, which identified controlled documents that wereknown to be currently assigned to EM-343 personnel as of January 1991. Severallists were missing, and there was no established frequency to update the lists.Consideration should be given to how EM-343 controls the QAPD, SPP's, Policiesand Requirement documents, Memorandum of Agreement, procurement document-specification, etc... that are originated, approved and issued by EM-343. It wasalso noted that some of the controlled documents appeared to take an excessivetime for distribution. An example of this situation was the VitrificationProjects Records Management Policies and Requirements document which was approvedby EM-30 on 8/30/90 and was distributed approximately 6 months later on 2/28/91.

It is also unclear on how "Golden Sheets" have been distributed and controlled,and how SPP changes are to interact with such sheets. One of the team membersindicated his controlled copy of the SPP's did not contain the Gold Sheets.

6. Inattention to Detail

A few items are mentioned below because small errors can add confusion toimplementation or impair communication because of the many participants involvedwith this program.

* On May 14, 1991, one memo from EM-343 specifies that BOM/SAIC willbe the lead support organization for audits/surveillance. On thesame day another memo from EM-30 assigns implementation

responsibility to PTSO for the quarterly and annual evaluation andassessment schedule. The distribution lists for these two memos aredifferent and in neither memo are all persons responsible forimplementing portions of the memos (i.e., portions of the EM-343 QAProgram) included on distribution.

* The May 14, 1991, memo from EM-30 that distributed the approved E&Aschedule did not attach an E&A schedule with an approval signaturealthough the team was told that the schedule had been approved onMay 6, 1991.

* The team was requested to perform this review during May 23-24.These dates were moved up to May 20-22 by the team and with EM-343agreement. The approved E&A schedule, which gets wide distribution,does not indicate this review but does indicate that a surveillanceis to be performed in June 1991. If external parties wanted toobserve or participate in this review, they would not have beenaware of the dates of the review.

There have been no previous audits ofDOE/EM by DOE/RW. There have been threesurveillances conducted by DOE/RW, ofwhich only one report is issued. Theissued report is included in thisauditor's binder.

The previous surveillances are:

HQ-SR-91-011, July 16-18, 1991, covering SPP 4.11 and SPP 4.12(report included).

HQ-SR-91-016, August 6-8, 1991, covering SPP 7.01 and SPP7.02.

HQ-SR-91-014, August 20-22, 1991, covering SPP 3.03 and SPP3.04.

OFFICE OF CIVILIANRADIOACTIVE WASTE MANAGEMENT

US. DEPARTMENT OF ENERGYWASHINGTON, D.C.

4 CAR NO. ODATE:

SHEET! OFGA

WBS NO__

' Controlling Document 1 2 Related Report No.

REV. 10/90A

INSTRUCTIONS FOR THE PREPARATION OFOFFiCE OF CIVILIAN RADIOACTIVE WASTE MANAGEMENT

CORRECTIVE ACTION REQUEST

Initiator

1. Enter the document and revision which has not been complied with.

2. Enter the number of the report for the activity that resulted In Identifying the adverse condition (i.e., Audit ReportNo., Surveillance Report No.). Enter WA if there Is not a related report.

3. Enter the organization responsible for the adverse condition (e.g., USGS, RW-40).

4. Enter the name of the individual with whom the CAR condition was discussed.

5. State or paraphrase the requirement In narrative, concise form including specific reference (paralsection no.) tothe governing document (block 1).

6. Describe the adverse condition found, In concise narrative form including reference to examples discovered. (Useand refer to continuation sheet, if needed.)

7. Provide a recommended action that would be acceptable.

B. Enter your name and date.

Director. OQA (or designee)

9. Check applicable box.

10. Enter the date the response is due from the responsible organization.

11. Enter the individual (name and title) who is responsible for responding to the CAR.

12. Circle N if a Stop Work Order was not Issued or Y If one was Issued.

13. Sign and date the CAR.

14. Obtain from the CAR Coordinator the next sequential number from the CAR log and enter the date the CAR IsIssued.

QA Representative

15. Document the objective evidence used during verification.

16. Sign and date when corrective action is verified and accepted.

Director, OQA

17. Verify CAR Is acceptable for procedural compliance; sign and date.

REV. 10190A


U.S. DEPARTMENT OF ENERGYWASHINGTON, D.C.

14 CAR NO._

DATE:

SHEET: OF

CAWBS NO_

I o o g c tR a '*u 9 i lt o

' Controlling Document I' Related Report No.

REV. 1O90A

INSTRUCTIONS FOR TiE PREPARATION OFOFFICE OF CIMIUAN RADIOACTIVE WASTE MANAGEMENT


Initiator


2. Enter the number of the report for the activity that resulted in identifying the adverse condition (i.e., Audit ReportNo., Surveillance Report No.). Enter N/A if there is not a related report.



5. State or paraphrase the requirement In narrative, concise form including specific reference (paraisection no.) tothe governing document (block 1).

6. Describe the adverse condition found, In concise narrative form Including reference to examples discovered. (Useand refer to continuation sheet, if needed.)


8. Enter your name and date.

Director. OOA (or designee)




12. Circle N if a Stop Work Order was not Issued or Y if one was issued.


14. Obtain from the CAR Coordinator the next sequential number from the CAR log and enter the date the CAR isIssued.

OA Representative


18. Sign and date when corrective action Is verified and accepted.

Director, OQA


REV. 1090A



14 CAR NO.

DATE:

SHEETOF_ -

QAWBS NO.:__

It- VI I *

' Controlling Document i Related Report No.

REV. 10/00A

INSTRUCTIONS FOR THE PREPARATION OFOFFICE OF CIILIAN RADIOACTIVE WASTE MANAGEMENT


Initiator


2. Enter the number of the report for the activity that resulted in identifying the adverse condition (i.e., Audit ReportNo., Surveillance Report No.). Enter N/A If there is not a related reporL



5. State or paraphrase the requirement In narrative, concise form including specific reference (para./section no.) tothe governing document (block 1).

6. Describe the adverse condition found, In concise narrative form including reference to examples discovered. (Useand refer to continuation sheet, If needed.)


S. Enter your name and date.





12. Circle N if a Stop Work Order was not Issued or Y If one was issued.


14. Obtain from the CAR Coordinator the next sequential number from the CAR log and enter the date the CAR isissued.

QA Representative



Director. OQA


REV. 10t90A



14 CAR NO._

DATE.

SHEEMT OF

N AWBS NO._________

I 1Controlling Document I 2 Related Report No.

REV. 10190A

INSTRUCTIONS FOR THE PREPARATION OFOFFICE OF CIVILIAN RADIOACTIVE WASTE MANAGEMENT


Initiator


2. Enter the number of the report for the activity that resulted In identifying the adverse condition (i.e., Audit ReportNo., Surveillance Report No.). Enter N/A if there is not a related report.

3. Enter the organization responsible for the adverse condition (e.g.. USGS. RW-40).


5. State or paraphrase the requirement in narrative, concise form including specific reference (paraisection no.) tothe governing document (block 1).

6. Describe the adverse condition found, In concise narrative form including reference to examples discovered. (Useand refer to continuation sheet, If needed.)


8. Enter your name and date.

Director. OOA (or designee)



11. Enter the individual (name and title) who is responsible for responding to the CAR

12. Circle N If a Stop Work Order was not Issued or Y if one was issued.



QA Representative


16. Sign and date when corrective action Is verifed and accepted.

Director, OQA


REV. 10/90A



14 CAR NO____DATE:

SHEET. OFQA

WBS NO.__

I' Controlling Document I I Related Report No.-

REV. 10190A

INSTRUCTIONS FOR THE PREPARATION OFOFFICE OF CIVILIAN RADIOACTIVE WASTE MANAGEMENT


Initiator


2. Enter the number of the report for the activity that resulted in identifying the adverse condition (i.e., Audit ReportNo., Surveillance Report No.). Enter NWA if there is not a related report.



5. State or paraphrase the requirement In narrative, concise form including specific reference (para/section no.) tothe governing document (block 1).

6. Describe the adverse condition found, in concise narrative form including reference to examples discovered. (Useand refer to continuation sheet, if needed.)


S. Enter your name and date.





12. Circle N if a Stop Work Order was not Issued or Y if one was Issued.



QA Representative15. Document the objective evidence used during verification.


Director, OGA

17. Verify CAR is acceptable for procedural compliance; sign and date.

REV. 1O90A



CAR NO.

DATE.

SHEET: OF

6.. a 0 �6

S I. S

REV. 10i0



CAR NO._DATE:SHEET: OF

0�* a * 9

. .. 6

REV. 10190



CAR NO.DATE.

SHEET. OF

S.. £ 0 �0

S S. S

REV. 10/90



CAR NO. O

DATE.

SHEET. OF

aISin.h�nSIYJ�&[email protected]�e1UI.L�

S * 6

REV. 10/90



CAR NO. O

DATE:

SHEET: OF

0** £ 6 * 6

S I. a

REV. 10190

vJ K'J


U.S. DEPARTMENT OF ENERGYWASHINGTON. D.C.

SHEET 1 OF 14AUDIT/SURVENJANCE/NSPECTION

so. HO-91-003

* A A aqM96"(1

ORGANIZATION EVALUATED

EM-30

DATES OF EVALUATION

S12/:LLO- 3 0/1/

Clvde Morell ".Q1P(I 1 /[XJ EXTERNAL

[ I INTERNAL

[X] AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY_

CONCURRED BY

DATE g/i/

M1/A 7"'v f _ _

APPROVED B ; 2 IF

DATE

_ DADATE

I. .L ,

CONTROLLING DOCUMENT (Title, Number, Revision) ACTiViTY EVALUATEDQuality Assurance Program Description DOE/EMWO/02, Rev. 0 Criterion 1 - Organization

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Section 1.0 OrganizationVerify that the Interface with OCRWM and other DOE offices aredearly defined and understood. Review QA Interactions.(DOE/EMNO/02) (Pam. 1 .0a)

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. 891



SHEET 2 OF 14

AUDMITSURVEILLANCEANSPECTION

NO. HIOM-M1.

Crit. I oz.29 I C-'*11 . 0 - 0 -n,.$]INq11 15O

I I - -II- - I

ITEMNO. CHARACTERISTIC TO BE EVAWATED

REMARKSRecord objective evidence reviewed, methodof verification, personnel contacted

RESULTS

I 4. 4.

2

3

4

Fig. 1.0.2 shows the QA function delegated to a Support Contractor.Verify that EM retains control of OA. (RW 0214 Para. 1.2)Note: DOE may delegate the work but still retains responsibility andaccountability.

Is the responsibility and authority of each organization dearlyestablished and documented. (NQA Supp. 1S-1 Para. 3.1)

Are interfaces between organizations and changes theretodocumented? (NQA-1 Supp. IS-1 Para. 3.2)Note: Section 1.0 of the QAPD does not address all the organizationsIdentified In Fig. 12.1-1.

Section 1.0 Para. 2.0 addresses Vitrification Projects Branch.Subsequent paragraphs address committees, offices and branches

REV. 8191

y i SSK. ' \'1 I~OFFICE OF CIVILIAN

RADIOACTIVE WASTE MANAGEMENTU.S. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

SHEET 3 OF 14AUDIT/SURVELLANCE/NSPECTION

NO. HO-1 -003

/02 - 01--It IC £ £ 0~~~~~~~~110-1 (;n I

ITEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

5

6

Verify the organization Independence of the Vitrification BranchtFXfor production responsibilities. (RW214. Para. 2.2)Note: Section 1.0 Para. 1.2.1 (2a) states the branch chief responsiblefor cost, schedule, technical requirements and quality assurance.

Verify that organizations above, below and related to the VitrificationProjects Branch are established.Note: Section 1.0 Para. 1.2.1 (2)a. states that these organizations areshown on Figure 1.2.1-1.

T T

a J. 1

REV. Ml91

4

I4 K) \~ 'IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 14

AUDITISURVEILLANCEPINSPECTION

NO. HO-91-003

IIIIIII[11 AIR II0 *

ITEMNO. CHARACTERISTiC TO BE EVALUATED


RESULTS

l I .4

7

9

Is the organization line between the Office of Environment QAQC,(EM20) and EM343 dearly established (Section 1.0 Para. 1.2.1(2)c

Is the organization for OA for the DOE Operations Offices at RL, SR,CH & ID dearly established? (Section 1.0 Pam. 1.2.1(2)b)a) Have letters of delegation been Initiated to these offices?

What Is the chance of the Material Steering Committee (MSC)?a) Who is responsible for the MSC?b) Who verifies of the MSC?c) Verify that the MSC reviews the activities of the MIO In

accordance with SPP 4.13.

* 4 4

REV. 8d91

J \1 Ja*-O-

I

OFFICE OF CIVILIAN SHEET 5 OF 14

RADIOACTIVE WASTE MANAGEMENT AUDITSURVELLAME(INSPEcMON

U.S. DEPARTMENT OF ENERGY No. H10910-3

=C-rglt | WASHINGTON, D.C.

iTEM REMARKSNO. CHARACTERISTIC TO BE EVALUATED Record objective evidence reviewed, method RESULTS

of verification, personnel contacted

10 Verify RWs participation on the Material Steering Committee (MSC)Review notification, attendance, agenda reports and dispositionand deliberations. Section 1.0 Para. 1.2.1(5)b

11 Ask the same questions for UdAet. ceqr t CultWkIA06 rae'riri.,ovl A " i fl M te'rdk

12 Review the chance of the Materials Integrated Office (MiO)(a) What RW needs Impact M10 and how are these needs tracked?

[Section 1.0 Para. 1.2.1(7)](b) Is *special projects' defined.(c) Does MIO control special projectststudies.(d) Review monthly progress reports.(e) Review Peer Reports. See SPP 4.09(f) Verify MSC review of MlO activities. [Section 1.0, Para.

1.201(7)](g) Verify the qualification of the personnel of M1O (Section 1.0,

Para. 1.2.1)Personnel selected to perform or verify activities affecting quality shallhave education, experience, and training commensurate with theminimum requirements specified. Relevant education and experienceshall be verified. Documentation for affected organization training andqualification program shall Include the objective, content of theprogram, attendees, and date of attendance.

_______ . I

REV. M1I

K) '1-OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 6 OF 14

AUDIT/SURVEILLANCEONSPECTION

NO. HO-91-03

O1 -Crit IC a a 0 -~ ~~ ~~~~ 0 -

I1 I i- -

iTEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

4. 4 4

12

13

The suitable proficiency of personnel performing activities that affectquality Is maintained through Indoctrination and training.Indoctrination and training Is verified through the audit, surveillanceand trend program.

Review the Materials Characterization Center (MCO) activities -(a) is there a character or contract?(b) Does M1O provide test parameters.(c) Are tests controlled In accordance with RW 214 Section 11 and

NQA BR 11 and Supp. 11.S.1* Test requirements and acceptance criteria.* Specified requirements* Test procedures* Calibrated Instrumentation.* Appropriate equipment* Trained personnel* Environmental condition.* Test results(Section 1.0 Para., 1.2.1(8)a)

1. . 4

REV. M1



SHEET 7 OF 14

AUDITISURVELLANCENSPECTION

NO. H91 -003

ot.Pe2- Oa, If I

i I a


REMARKSRecord objedive evidence reviewed, methodof verification, personnel contacted

RESULTS

1 4.

14

16

Verify the qualifications of the MGC staff.

Verify organizational reporting relationship to the vitrifications branchoffice.

Verify RW Input Into MCC review reports, meeting reports andcorrespondence. [Section 1.0 Para. 12.1(8)bJ

REV. 8/91

K)OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 8 OF 14

AUDITISURVEILLANCEANSPECTION

NO. HO-91-003

OA - Crft. IA £ 0 ~~~~~1MOOM I-F0 -



RESULTS

. .

17

18

19

Review MCC program plan and monthly report. Is the monthly reportdistributed to DOE HO and Operation Offices?[Section 1.0 Para. 1.2.1 (8)b]

Does EM or RW monitor the activities of:WGWAOperations Office, RW, SR, CH & IDReview audit schedules, audit reports, surveillance reports, inspectionreports, trip reports.Review and directives, comments or observations. (General)

Verify the control of WAC. WCWA MIO and MCC review: Charters,contracts, specification. Is the "Chain of Command! and reportingresponsibility established? (General)

__________ I. I

REV. a 1

yJ K) KY~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~'I--/

I


RADIOACTIVE WASTE MANAGEMENT AUDrT/SURVELLANCEA1NSPECTION

U.S. DEPARTMENT OF ENERGY N4o. Hob01 -3

a; e ritNaIWASHINGTON, D.C.

C ~~~Ii11 U l]A Eel; L0 --

ITEMHREMARKSNO. CHARACTERISTIC TO BE EVALUATED Record objective evidence reviewed, method RESULTS


20 Where Is the Vitrification Projects Branch Chief located? If he Islocated at HO verify lines of authority, responsibility to other groupson Fig. 1.2.1-1 (Section 1.0, Para. 1.2.2a)

21 Verify that the HLW Quality Assurance Program Manager is assignedand meets the following prerequisites:(1) Is at a level equivalent to the other positions reporting to the

Vitrification Projects Branch Chief.(2) Has knowledge and experience In quality assurance and

management.(3) Has the authority and resources to do the following:

* Verify that the organization's and sub-tier organizations'quality assurance programs are kmpiemented effectively andadequately.

* Ensure that further processing, delivery, Installation, oroperation is controlled until a nonconformance, deficiency, orunsatisfactory condition Is properly dispositioned, orrecommend stop work to the Vitrification Projects BranchChief.

* Review and recommend approval or disapproval of qualityassurance programs, revisions to programs, and theInterpretations of the programs.

(4) Does not have other duties or responsibilities that could preventfull attention to quality assurance program matters.

(5) Has freedom from cost and schedule considerations when theyare opposed to quality considerations.

I

REV. S91

-k--I~~~~~~~~~~~~~~~~~~~~~~OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 10 OF 14

AUDITISURYEILLANCENSPECTION

NO. HO-91-003

os:?.- c. A, IM.A I 0



RESULTS

l I. . ..

22

23

24

(6) Has access to the Vitrification Projects Branch Chief and theDirector of Waste Operations when necessary to identify andresolve unresolved quality concerns. (Section 1.0, Para. 1.2.2b)

Verify that the QA Specialist has been assigned by the supportservices contractor. (Section 1.0 Pam. 1.2.2c)

Verify that the support services contractor has performed the followingtasks:(1) Recommending the organization of the HLW Quality Assurance

Program and the assignments for execution responsibility asappropriate.

(2) Recommending the organization and staffing plan and level forconducting the quality assurance practices necessary to fulfillDOE's responsibility for establishment and adequacy of theProgram.

(3) Administratively controlling the Quality Assurance Specialists.(Section 1.0 Para. 1.2.2c)

REV. 8191

yJ KJOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 11 OF 14

AUDIT/SURVELLANCONSPECTION

NO. HO-91 -00

O.-cv- C&t I. I -- - -* £ - 0 I



RESULTS

I t t

25 Verify that the QA Program Manager and QA specialist are assignedand have the documented authority to do the following:(1) Gain access to work areas and identify quality problem(2) Initiate, recommend, or provide solutions to quality problems

through designated channels.(3) Verify implementation of solutions.(4) Determine the adequacy of facilties and equipment provided to

carry out approved procedures and Instructions.(5) issue special Instructions necessary to execute his or her

responsibilities.(6) Notify responsible management of unsatisfactory work or

unapproved practices, and if necessary, stop unsatisfactory workor control further processing, deliver, or Installation ornonconforming materials. (Section 1.0, Para. 1.2.3)

REV. 891

v~OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 12 OF 14

AUDIT0SJRVELLANCONSPECTION

NO. HO-1 -003

0oZ- Cr Ite /* a I W-'131 L km0if I11

1~~~~~~~~~~~~~~~~~~~~I~



RESULTS

4 I- 1

26

27

The Vitrification Projects Branch Chief has performed the followingspecific tasks:(1) Organizing the D&Q Quality Assurance Program and assigning

execution responsibility as appropriate(2) Ensuring that each Operations Offices' organization give the

person responsible for quality assurance sufficient authority toassess and Identify quality problems; to irritate, recommend, orprovide solutions; and to verify implementation of solutions.

(3) Arranging for the support and assistance needed to Implementthe D&Q Quality Assurance Program.

(4) Maintaining technical and administrative control of individualsunder his or her supervision that perform quality assurancerelated activities. Is objective evidence available to supportthese activities? (Section 1.0, Para. 1.2.4)

Review results of verification of the QA program.a) Is the extent of QA controls as determined by the OA program

manager consistent with the production activities?b) What is the approval circuit for QA procedure prepared by the

QA program manager?c) Review Auditsurvelilance schedules, report and follow-up

activities. (Section 1.0, Para. 1.3.1)

REV. 891

yj' K)~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\ 1OFFICE OF CIVILiAN


WASHINGTON, D.C.

SHEET 13 OF 14

AUDITISURVELLANCEOINSPECTION

NO. HO-91003

O;L -cevi I9 - -.~~~~~

[TEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

28

29

30

The GA Project Manager and QA Specialists are subcontractorpersonnel. Verify continuity of the assignments. Report on anypersonnel turnover which may have an adverse affect on the program.(General) Identify a DOE person responsible for overseeing thisposition and what measurements In pace to assure accountability(RW214, RW4, Section 1, Para. 1.2)

Review the Quality Engineering function. Verify:a) Assignments (DOE or Contractor personnel).b) Establishment of program requirementsc) Status reporting.d) Planning.e) Reporting) Record retention

g) Quality improvementh) Nonconformance controli) Trend analysisD Training and indoctrinationk) Interface with OA, HO and other groupsSection 1.0, Para. 1.3.1 (s)J

Verify qualification to QA personnel have been evaluated and verified.(Section 1.0, Para. 1.4.1)

______ I I

REV. /91



SH-EET 14 OF 14

AUDITISURVEILLANCOnNSPECTION~

NO. HO-91-OO5

o;~ a -'r I* h - -.~~~~~~1-



RESULTS

.5 4. 4

31

32

33

Verify that communications are established and In use. Have qualityproblems been communicated, evaluated, dispositioned anddistributed? (Section 1.0, Para. 1.5)

Assess the effectiveness of formal versus Informal communication andthe judgment factor. (Section 1.0, Para. 1.5)

Verify that Quality Assurance appears on the agenda of monthly andquarterly meetings. Review QA and OCRWM attendance andparticipation. (Section 1.0, Para. 1.5)

REV. E91

OFFICE OF CMUANRADIOACTIVE WASTE MANAGEMENT


SHEET t OF 9

AUDrT/SURVEitJANCERNSPECTMON

No. HQ-91-003

. £ m


EM-30

DATES OF EVALUATION

8/26-30/91

M0[X EXTERNAL

l ]INTERNAL

Pq AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY Fred Bearham DATE 9- 1-f Iv

CONCURRED BYdA S DATE

APPROVED B 7 DATE7 ~ ~~~~~~~~ _7 - /"'00

CONTROLLING DOCUMENT (Thle, Number, Revision) ACTIVITY EVALUATEDQuaray Assurance Program Description DOE/EMN'O02, Rev. 0 Criterlon 2 - Qualny Assurance Program

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTS

of verification, personnel contacted .

1 Verify the EM 331 is included on an organization chart What Is theinterface between EM 20 and EM 331 ?(DOEIEM/0i2 Section 2.0 Para. 22.2a)

'INDICATE RESULTS: SATISFACTORY (SAT). UNSATISFACTORY (UNSAT), NOT APPLiCABLE (NWA)

REV. 81



WASHINGTON, D.C.

SHEET 2 OF 9AUDMIISURVEILLANCEANSPECTIONNO. HO-91-OO

M* I a6 *0 -



RESULTS

.9 1�

2

3

Is the responsibility for performance of the annual assessmentestablished? EM 20 and EM 343 appear to both havethis responsibility (DOEfEM/WO102 Section 2.0 Para 2.2.2b)

Verify that the annual assessment has been performed. Reviewreports and follow-up activtes.(DOE/EM/W0102 Section 2.0 Para. 2.2.2b)

______ I. 1

REV. 8/I

I



SHEET 3 OFAJJDITISURELLANCEiINSPINO.HO-Ol-cO_

9-cTION

INI I. R3-9 2B E11- s :[]11



RESULTS

4. .4 1

4

5

6

Review objective evidence that the QA Program Manager Is assignedand performs the foflowing:* Participation In multi-discipline audits and reviews.* Review and acceptance of program plans and procedures* Review and concurrence with proposed corrective actions resulting

from audit findings of deficiency.* Execution of certain design control and document control activities* Execution of certain development and qualification control activities.(DOE/EMNWO/02 Section 2.0 Parm. 2.2.3)

Is there a detailed job description for QA personnel? Verifycompliance with NQA-1 Supplement 2S-1. 2S-2 2S-3 and 2S-4. DoesEM identify this requirement In job description? Is a copy of NQA-1available at the EM office?DOE/EM/WO/02 Section 2.0 Para. 2.3.1)

Review annual assessment reports for accuracy, completeness, (isscope fully addressed?) distrbution, management review and follow-up. (DOE/EMWO/02 Section 2.0 Para. 2.2.3(4))

4 1.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

REV. e/91

OFFICE OF CMLIANRADIOACTIVE WASTE MANAGEMENT


SHEET' 4 OF 9

AU SURVELLANCONSPECTION

NO. H-91-003

1111111 41T II I 1SA I* 0a e-

p p~~~~~~~~~~~~~~~~~~~~~~~~~ I



RESULTS

6 4 p

Verify that annual assessments address the following purposes:* The effectiveness of Implementation* The adequacy of planning and control* The effectiveness of corrective action* The adequacy of the organizational structure, staffing, and training* The adequacy of the management reporting system.[Section 2.0 Para. 2.2.3(4)]

Verify the Independence and qualification of assessment teammember [DOEIEMNWO/02 Section 2.0 Para. 2.2.3 (4)]

Is there provision for Interim management assessment In specialcircumstances such as adverse trend, significant change Inmanagement, significant change In program or resultof the communication process? (General)

REV. 891

K) \-OFFICE OF CMLIAN


WASHINGTON, D.C.

SHEET 5 OF 9

AUrrIs1URVEILANCErNsPEcTnON

NO. HO-1 -003

02 ) )- Crt L .

I I III



RESULTS

4 4- I

10

11

12

Is it understood that commitment to commits to NQA-1 BasicRequirements and supplements?(DOE/EMWO/02 Section 2.0 Para. 2.3.1)

Table 2.32.1 identifies procedures that have been delegated to alower organization. What is the status of these procedures? Reviewschedule and approval process.(DOE/EMNVO/02 Section 2.0 Para. 2.3.2)

Does Waste Operations (EM30) issue and control program executionguidance document? (DOE/EMt/WO/02 Section 2.0 Para. 2.3.3)

REV. 8191

/



\ I

sHEET 6 OF 9AUJDMIURVELANCEANSPECTION

NO. H#41-003

1 - ~~~~~~ ' -t*

I ~~~I II



aRESULTS

. .I t

13

14

15

Verify that QA programs are established by each Operations Office &Operating Contractor. Review evidence of programs from SavannahRiver, Hanford, Idaho and West Valley for current revision, approvaland document control.[DOEIEM3W0102 Section 2.0 Para. 2.3.3.(1)

Verify that Operating Office and OperatingContractor QAPDs identify Items andactivites included In the Waste AcceptanceProcess. (DOE/EMVWO0A2 Section 2.0Parm. 2.3.3(12)]

Verify that programs address the following:* Research and development that Is essential to qualification of the

waste form* Control of materials, equipment, facilities, and processes that are

essential to the certification of canistered waste forms* Processing operations that are essential to the certification of

canistered waste forms.(DOEIEMIWO/01 Page 2 Para. 3.0)

1. 1 1

REV. 91

NL 4 \ J

I

OFFICE OF CIVILIAN SHE ET 7 OF 9RADIOACTIVE WASTE MANAGEMENT AUMM/WSURVELLANCONSPECTION

U.S. DEPARTMENT OF ENERGY NO. HO-91003

0 o - 2rt, . WASHINGTON, D.C.

ITEM REMARKSNO. CHARACTERISTIC TO BE EVALUATED Record objective evidence reviewed, method RESULTS


16 Verify Implementation of the coordination activity.(a) Is the activity adequately staffed by quaified experienced

personnel?(b) Are the coordinating groups or Individuals Identified?(c) Review objective evidence of interface coordination with OCRWM,

Operations Office, Qualifiers(d) Are the following elements evident In the coordination process?

(1) The control of documents through the implementation ofdocument procedures.

(2) The control of communications using communication controlprocedures.

(3) The performance of, and participation In, technical and peerreviews.

(DOE/EWMOI02 Section 2.0 Para. 2.5.1)

17 Does Para. 2.6.2 limit the QA program to the following elements?2.6.1 Quality assurance program activities, which include those majorelements listed below, are performed as described in other sectionsof this program description.* Program* Organization* Document Control* Audits and Reviews* Nonconformance Control* Corrective Action* Reporting* Records(DOE/EMNWo/02 Para. 2.6.2

I

______ I. I

REV. 819l

tI K)~~~~~~~~~~~~~~~I,-OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET e OF 9

AUOITISURVEILLNCEJINSPECTION

NO. HO403

I I

NTEMNO. CHARACTERISTiC TO BE EVALUATED


RESULTS

I.

is

19

20

Para. 2.6.2 states 'these manuals each contain copies of the qualityassurance program implementing documents listed in Figure 2.3.2-1.A brief description of those procedures Is contained In Attachment Ill.Review the Intent and implementation of this requirement(DOE/EM/WO/02 Para. 2.6.2)

Para. 2.7 identifies responsibilities for Waste Operations (EM30) andVitrification Projects Branch (EM 343). Review the Interface. Is thereoverlap or duplication of responsibility?(DOE/EMNVO/02 Para. 2.7)

Are the organizations over which the Vitrification Projects Branch hasoverview, defined? [DOE/EMlWO/02 Para. 2.7.1(3)]

I. I. I.

REV. 8/91

J L JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 9 of 9

AUDITISURVEULLA NSPECTMON

NO. H"1-003

O7.2 -c

I I .~~~~~~~~~~~ ' . * B -



RESULTS

9. 4 1.

21

22

Verify that the Vitrification Project Branch has performed thefollowing activities for each organization. Review schedules andreports.(a) Review of QA plans and procedures(b) Survellance of activities affecting quality.(c) QA auditor(DOE/EM\NO/02 Para. 2.7.1(3)a)

Verify that approved procedures are In place to control the activitiesreferenced In attribute #23. (DOE/EMNWO0V2 Para. 2.7.1 (3)b)

REV. s9i

I yJ---

OFFICE OF CIVIUANRADIOACIVE WASTE MANAGEMENT

U.S. DEPARTMENT OF ENERGYWASHINGTON. D.C. -

SHEET I OF 2AUDrTISURVELLANCO/NSPECTIONNo. HO-91 -O0

5 a £ 1 e t~;I 11]XRII --- ----

I I I


EM-30

DATES OF EVALUATION

8/26-3Q091

L Wade AW ;J5pq EXTERNAL

1 I INTERNAL

Mi AUDIT

[ I SURVEILLANCE

[1 INSPECTION

PREPARED BY

%-CONCURRED BY

_ DATE t-1-4/

DATE

DATE I/f 1

_ ,

APPROVED B 6:z��--.IO"

CONTROLLING DOCUMENT (Title. Number, Revision) ACTIVITY EVALUATEDQuality Assurance Program Description DOE/EMIWJO02, Rev. 0 Criterion 3 - Design Control

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objecive evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Verify that Waste Operations has delegated the responsibility fordesign control activities, Including operatinai readiness review toOperations Office. (Para. 3.1.1)

2 Waste Operations retains the responsibility for "selecled technical andpeer reviews". The selection of the reviews Is the option of theVitrification Projects Branch Chief. Demonstrate the process used todetermine what receives a technical or peer review (Para. 3.1.1)

REV. 1I90

II JI 2OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 2AUDITJSURVELLANCEOINSPECTION

NO. H0-91-003

OA - Ol~t it 3a 1~~ ~~~~~~~ h M"A 111912M1t 62S ...

NIEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

I I. 1*

3

4

5

Demonstrate that Technical Reviews and Peer Reviews areconducted In acrdance with approved procedures. (Para. 3.1.1)

Verify that the Vitrification Projects Branch monitors and periodicallyaudits the Operations Offices' design control practices, to ensureproper Implementation and adequacy. (Para 3.2.2)

Demonstrate how revisions to the Waste Acceptance Specification(WAS) Is communicated to the producers to require them to revise theWaste Form Compliance Plan (WCP) and the Waste FormOuaiffication Report (WOR) accordingly. (0.3 of Introduction) (RW-214, Appendix B)

REV. I1190

\. J \I \



SHEET 1 OF 4

AUDITISURVELLANCErNSPECTION

NO. HQ-91 -003

V A A f-

I A


EM-30

DATES OF EVALUATION

8/1a4- 30/7/

D.E. Miller 2 F6D EXTERNAL

1 I INTERNAL

K AUDIT

l I SURVEILLANCE

I ] INSPECTION

PREPARED BY

CONCURRED BY Jf/fS

_ DATE I1 z2- 9/eJ DATE

_, DATE /7/9/

_ ,

APPROVED BY Hi00 .A lal '.6z

CONTROLLING DOCUMENT (TiUle, Number, Revision) ACTMTY EVAfUATEDOuality Assurance Program Description DOE/EMW/0i2, Rev. 0 Criterion 4 - Procurement Document Control


I Verify the types of procurement activities conducted.(DOE/EMIW0/02, Paragraph 4.1.1)* Assignment of program execution to Operations Offices.

* Procurement of Administrative and Technical support throughcompletion bids.

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N!A)

REV. 11/90

yJ JoOFFICE OF CIVILIAN

RADIOACTIVE WASTE MANAGEMENTUS. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

SHEET 2 OF y

AUDIT/SURVELLANCEANSPECTION

NO. HO A91-003

9 A £ A~fi it]-4 *0 R61f



RESULTS

4 9

2

3

4

Determine how many Operations Offices have been assignedprogram extension responsibilities and what these responsibilities area[DOE/EM/WO/02, Paragraph 4.1.1(1)]

Verify that quality assurance requirements have been assigned tooperations offices. (Paragraph 4.2.1)a Review supporting documentation

Verify that support contracts specify both Technical and OARequirements [Paragraph 4.1.1(2)]

.4 .4 .4

RYE. IU9O



SHEET__ OF~ Y

AUDrTISUJRVERILANCOnNSPECTION

NO. HO A.9-003

02- cr. 9Ml £ MIOA910 -01411



RESULTS

4. 4 4

Determine how EM has passed grading requirement down to theoperations offices.(Paragraph 4.2.1)

Determine K the procurement documents Include the followingInformation:* Scope of work* Technical & regulatory requirements* Quality assurance program requirements* Right of Access* Special QA requirements are specified which must be complied with* Documentation requirements* Nonconformance control

Verify that Procurement Documents arereviewed by the affectedorganizations and the reviews are documented.(NOA-1 Basic Requirement 4 and 4S-1)* Verify that an agreement has been reached.

REV. 1I190

y 1I/ K) \ /I



stirET_ OF 7

AUDITISUJRVELLANCOJNSPECTMO

NO. HO A.91-003

6)2- cki~'f *A I I 0 -



RESULTS

9. 9 I.

8 Verify that changestrevisions are reviewed In the same manner as theoriginal. (NQA-1, BR-4 and 4S-1

I i. a

REV. 1/90

I IJ



SHEET I OF SAUDrT/SURVEILLANCMNSPECTIONNo. HO-91 0-

=0p A I 6*10-M1:6 mIX0 11


EM-30

DATES OF EVALUATIONS26-MI1

[X EXTERNAL

(I INTERNAL

[XI AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY L Wade y _DATE 8IQI'uA DATECONCURRED BY AII/

APPROVED BY _ Zt!/ DATE

CONTROLLING DOCUMENT (Tile, Number, Revision) ACTIVIlY EVALUATEDQuality Assurance Program Description DOE/EMFWO/02, Rev. 0 Criterion 5 - Instructions, Procedures & Drawings

REMARKSITEM CHARACTERISTiCS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Has Waste Operations established a management procedures systemthat prescribes methods for performing quality-related activities?(Para. 5.1.1)

2 Are procedure used by the Vitrification ProJeds Branch prepared hIaccordance with an approved procedure which prescribes a formatand Identification system to be used? (Para. 5.1.) implementation(Para. 6.1.1)

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NWA)

REV. 8I91

1%-JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 3AUDIrISURVELLANCEMNSPECTION

NO. HO-91-003

02-Cw4. 5-S a a *a * 0 --~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

______ 9

3

4

Verify that the procedures are organized under a managementprocedure system that is administered by a Procedure Coordinatorwho controls the Issue of procedures. (Para. 5.12)

a) identify and review the management procedure system.

b) identify the procedure coordinator.

c) Identify and review the procedure used by the coordinator tocontrol the procedure.

Verify that the Verification Projects Branch Chief has audited or hasarranged for independent audit of the practices to ensureImplementation and adequacy (Para. 5.1.3)

1. 1 1

REV. I91



SHEET 3 OF 3AUDrITSIMVELLANCEAINSPECTION4NO. H0491.00

Wel- 11 I R -0] 141 .



RESULTS

L 4 4

5

6

Verify that procedures, Instructions, and drawings prepared by orissued by EM have been subjected to an Independent review by aqualified reviewer. (Pars 5.1.4)a) How are reviewers qualified.

Verify that the Vitrification Projects Branch has monitored andperlodicafly audited the Operations Offices documentation practices.(Para. 5.2.2)

.1 4 I

REV. sas

y I, .\ I

OFFICE OF CIVIUANRADIOACTIVE WASTE MANAGEMENT


SHEET 1 OF 6AUOITiSURVELLANCEMONSPECTION

No. HO-91-003

I I I


EM-3o

DATES OF EVALUATION8Q2643091

(XJ EXTERNAL

[I TERNAL

[XI AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY L Wade _DATE _______ _

CONCURRED BY JW

APPROVED BY- apt 311

DATE

DATE r,4,4,

CONTROLLING DOCUMENT (Tlitle, Number, Revision) ACTIVITY EVALUATEDQuality Assurance Program Description DOE/EMNtVOi2, Rev. 0 . Criterion 6 - Document Control

REMARKS *

ITEM CHARACTERISTICS TO BE EVALUATED Record ojective evidence reviewed, method RESULTSof verification, personnel contacted

1 Has waste operations established and Implemented a documentcontrol system that fulfills the quality assurance program requirementsand applies to documents prepared by EM. (Para. b.1.1)

2 Verify that the Quallty Assurance Program Manager and the QualityAssurance Specialists have reviewed the document control systemand have confirmed it's readiness to function prior to Implementation(Para. 6.1.1)


REV. 11I90

J \



SHEE 2 OF 6

AUDrTSURVELU.ANCOJNSPECTIONNO. HO-91-00

0 ;z- mr¶.- 4

I I



RESULTS

I. 4. 4.

3 Verify that Virification Projects Branch Documents that are related toor that affect quality, are controlled by procedure and that theprocedure addresses the following. (Para. 6.1.2)

(1) Uniformity of format of Initial and subsequent Issuances.(2) Proper Identification of the originator and date of origin of

document, and a mechanism for verifying the authenticity ofInformation.

(3) Procedures for the review, approval, Issuance, and revision ofdocuments by the organizatbn are established.

(4) InItial Issuance of document for use at locations where theactivity will be performed prior to commencing the work.

(5) Prompt and accurate issuance and distribution, Including amechanism for receipt control, of both the original documentand subsequent document revisions to prevent Inadvertent useof superseded material and to replace document sin workareas In a timely manner.

(6) Efficient revision of documents when necessary to carily,correct, augment, or update the content of a document, whilepreserving the Integrity of originally approved and releasedInformation.

(7) Example of controlled documents are this QAPD and theStandard Practice Procedures.

REV. I1VW

I



SHEET a OF 6ALIMIiSURVELUMANCNSPECTMONO. H041I 403

S011 INI0 - 041 l LiW]10 ei14


REMARKSRecord objective evidence reviewed, methodof veriication, personnel contacted

RESULTS. .

4

5

6

Verify that procedures standardize the identification, format andnumbering of controlled documents (Para. 6.1.3)

Verify that controlled documents have been reviewed for adequacy bythe Quality Assurance Program Manager. (Para. 6.1.3)

Verify that provisions are In place for documents to be reviewed andcomments resolved before final approval. (Para 6.1.3)

(a) Review documentation of the review sequence and assurerecords are maintained.

1. .

REV.I 1VW

I



\ ISHEET 4 OF 6AUDrIISURVELLANCEnNSPECTION

NO. HO-91-03

C) 2 Crt-t. t

I I I~ a



RESULTS

7

9

Verify the changes or revisions to controlled documents receive thesame review and acceptance. (Para. 6.1.3)

Verify the Branch Chief has established an appropriate periodic reviewschedule for the accepted controlled document. (Para. 6.1.3)

Verify that the Vitrification Projects Branch maintains a isting ofquality assurance administrative and technical procedures and thatthese procedures are under a receipt control system (Para 6.1A)

REV. 1/90

J Lif \ I

OFFICE OF CIViLIANRADIOACTIVE WASTE MANAGEMENT


SHEET 5 OF 6

AUDITISURVELLANCEINSPECTION

NO. H04914)03

0L2- Cf it. 4S £ -' 0 * 0 -.9124116Ifm



RESULTS

.9 I* I

10

11

12

Verify that the procedure coordinator reviews the documentdistribution listing at least bi-monthly to follow-up on any delinquentrecelpt pages. (Par. 6.1.4)

Verify that the master distribution list Is maintained current(Para. 6.1.4)

Verify that the Quality Assurance Program Manager participates Inand monitors the execution of the document control system. (Para.6.1.5)

.1 1 I

REV. I V90



SHEET 6 OF 6AUDoTISURVEJLUNCEANSPECTIoM

NO. HO-0

* a a -amleaggme S lG-E



RESULTS

4- 4 4

13 Verily that periodic audits of the document control system areperformed. (Para. 6.1.5)

REV. 11/90

yJ K) <I



SHEET 1 OF 2AUDITISURVELLANCE/INSPECTIONNo. HO-91-oo

9 £~~~~~~~~115r;191413

I I a~


EM-30

DATES OF EVALUATION8126-30/91

PX EXTERNAL

[ ]INTERNAL

pq AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY Fred Bearham DATE i-2-9l

CONCURRED BY BAIYAPPROVED BY 0 -

6 DATE

_ DATE . Z

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDQuality Assurance Program Description DOE/EMNWO/02, Rev. 0 Criterion 7 - Control d Purchased Items and Services


1 Verify that the PEGDs and Support Contracts establish the following:* What Is to be accomplished?* What Is to accomplish it?* How is it to be accomplished?. When is it to be accomplished?(NQA-1 BR-7, 7S-1)

*INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. 11190

I



SHEET OF_ __AUDrTISURVEILLANCEIINSPECTIONNO._HO A.el-oo

I

* £ - 0~~~~~~ 1 1



RESULTS

5 4. 4.

2

3

4

Determine which standard DOE administrative procedures and DOEOrders are used to Control Administrative Support Contracts.[Para. 7.1.1(2)]

Verify that the administrative procedures and DOE Orders Identifiedin item 2 meet the requirements of DOE/RW-214, R.4 (General)

Verify that Waste Operations has performed overview activities forproper implementation and adequacy. (Para. 7.1.1 and 7.2.4)

1 . 4

REV. 11190

�- J yJ

OFFICE OF CNIIUANRADIOACTIVE WASTE MANAGEMENT


SHEET I OF 7AUDITJSURVEILUANCENSPECTIOM

No. HO A.91 .003

I I I


EM-30F. Bearham p 9 knV4 EXTERNAL

[ ] INTERNAL

Pi AUDIT

[I SURVEILLANCE

[ I INSPECTION

PREPARED BY

CONCURRED BY AY7

.DATE F ',7- V

DATE

DATE k&&DATES OF EVALUATION

61AL - 3c)/9/APPROVED BY 2'e z

CONTROLLING DOCUMENT (Tile. Number, Revision) ACTIVITY EVALUATEDQuality Assurance Program Description DOE/EM/WOJ02, Rev. 0 Criterion 15 - Control of Nonconforming Items


1 Verify that EM-30 has established procedures for control ofnon-conforming items. (DOE/EWNVO/02 Pam. 15.1-1)

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NIA)

REV. 11/90

k-J \1 '/



SHM__EA OF 7

AUDITISUJRVELLANCEIINSPECTION

NO. HO A.g1-00

OA-- cpqr. Is-

I a IZ ~ ~



RESULTS

* *9

2

3

4

Does EM-343 retain control of the nonconformance program forall offices? EM-32, EM-33, EM-331 RL, SR, CH, ID?

Is this procedure applicable only to canistered waste?(DOE/EMlWO/02 Para. 15.1.3)

Verify reference to IOCFR21Is It applicable?Is It posted?Is traininglindotrlnation conducted?Is the reporting process defined?(DOEIEM/WO/02 Para. 15.1.4)

REV. 1 1/90

~ )I \, J- �' / \' 'I



AUDITISURVELLANCOJNSPECTION

NO. HO AAIl-003

)A.- crt~. I 5

a W I I I



RESULTS

t

5

6

7

Verify that the vitrification Project Branch Chief 'periodicallfyaudits the program. (DOEIEMIOW/02 Par. 15.1.5)

Verify that QA Program Manager periodically" analysis DCARsfor "trends. Define or clarify "periodically' and "trends'(DOE/EMWNO/02 Parm. 15.1.6)

Verify that 0slgnificant" results of trend analysis are distrbuted toEM-343 Branch Chief, EM-30 and EM-20 and EM-1. Is slgnificantrdefined?

J.

REV. I 1190

II J, JX%0.0'

I

OFFICE OF CIVILIAN SHEET i OF 7

RADIOACTIVE WASTE MANAGEMENT AUDflT5URVEILANCEflNSPECTKXN

U.S. DEPARTMENT OF ENERGY NO. HO A.1-03

O c- dr ti ) WASHINGTON, D.C.

ITEMREAKNO. CHARACTERISTIC TO BE EVALUATED Record objective evidence reviewed, method RESULTS


8 Operations offices are required to controls that Include the following:(1) Nonconforming Items or activities are Identified, documented,

segregated (where practical), reviewed, and dispositioned.Affected organizations are notified of the nonconforming Items oractivities (induding design consideration and computer codes), Ifthe disposition Is other than a scrap or rework.

(2) Documentation Identifies the non-conforming item or activitiesdescribes the nonconformance, the disposition of thenonconformance, and the Inspection requirements; and Includessignature approval of the disposition. Nonconformances arecorrected or resolved before Initiating the properitoneal testprogram on the Item.

(3) Provisions are established for identifying those Individuals orgroups, Including the quality assurance organization, who areassigned the responsibility and authority to approve thedispositioning and closeout of nonconforming items.

(4) Nonconforming Items are segregated, where practical, fromacceptable Items and identified as nonconforming until they

are properly dispositloned.(5) Acceptability of rework or repair Is verified by reinspecting the

Items as originally inspected, or by a method that Is at least equalto the original Inspection method. Inspection, rework, and repairprocedures are documented.

(6) Nonconformance reports dispositloned 'use as Is,- "use asrepaired," or "used as modified" are made part of the Inspectionrecord and forwarded to Operations Office management

(7) Nonconformances reports are periodically analyzed to show quality trends. The significant results are forwarded to managementfor review and assessment. Is Em-3O or EM-343 In the approval clrcuit for these procedures? Are they available for review?(DOE/EM/WO/02 Para. 15.2.1)

I

C C

REV. 11/90

yJ�' K) K)



SHEET E OF 7AUDITISURVEILLANCEflNSPECTION

NO. HO A.91-003

O6 C - 15-

- N 4M~ am *] 2C 4£ £3 41 - 4 1



RESULTS. .

9 Verify that the following requirements of NQA-1 are addressed andunderstood9.1 Identification

(a) Identification of nonconforming items shall be bymarking, tagging, or other methods which shall notadversely affect the end use of the item. Theidentification shall be legible and easily recognizable.

0) If identification of each nonconforming item is notpractical, the container, package or serrated storagearea, as appropriate, shall be identified.

9.2 SegregatIon(a) Nonconforming items shall be segregated, when

practical, by placing them In a dearly identified anddesignated hold area until properly dispositioned.

(b) When segregation is Impractical or impossible due tophysical conditions, such as size, weight, or accesslimitations, other precautions shall be employed topreclude Inadvertent use of non-conforming item.

I , I

REV. 1 V90

y)IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET O' FAUDITISURVELLANCEANSPECTIMt

NO. HO A.91-003

0 L ~- abA Is--

0~~~~~~~



9.3 Disposition

Control further processing, delivery, Installation, or use of anonconforming Item shall be controlled pending an evaluationand an approved disposition by authorized personnel.

9A Personnel

Personnel performing evaluations to determine a dispositionshall have demonstrated competence In the specific are theyare evaluating, have an adequate understanding of therequirements, and have access to pertinent backgroundinformation.

Note: Background Information may Include: historical date,specifications, drawings, procurement Information,manufacturing date, other DOE experience, Industry standards,federal regulations, NRC Input. this should be verified asappropriate.

REV. 11190

y J K\Y-1



SHEET 7 OF 7AUDITISURVEILLANCEIINSPECTIONNO. HO A.gl1oo

JCA- C r it, 15-

is~~~~~~~~~~ I £ -- 0 -mm ,



RESULTS. .

9.5 DispositIon

The disposition, such as us-as-is, reject, repair or rework, ofnonconforming items shall be Identified and documented.Technical Justification for the acceptability of a nonconformingItem. dispositioned use-as-is repair shall be subject to designcontrol measures commensurate with those applied to theoriginal design. The as-built records, If such records arerequired, shall reflect the accepted deviation.

9.6 Repaired or Reworked items

Repaired or reworked items shall be reexamined In accordancewith applicable procedures and with the original acceptancecriteria unless the nonconforming Item dispositioned hasestablished alternate acceptance criteria.(ASME NQA-1 Supplement 15S-1)

________ . I

REV. 11190

1'J ) \ J



SHEET 1 OF 6AUDISURVELLANCEINSPECTIONNO. HO-91-003

9 *1Al £ " * N tm


EM-30

DATES OF EVALUATION

[X EXTERNAL

[]INTERNAL

[XI AUDIT

[ I SURVEILLANCE

1 1 INSPECTION

PREPARED BY Fred Bearham 29 i6

CONCURRED BY M

APPROVED ByE < 2,

DATE r-,7- B

DATE

DATE_ f J

8/26-30/91 I'7I-do,... _

CONTROLLING DOCUMENT (Thtle, Number, Revision) ACTIVITY EVALUATEDOualiy Assurance Program Description DOE/EMW0O02, Rev. 0 Criterion 16 - Corrective Action


I Verify that EM-30 through EM-343 has established a corrective actionsystem to Include the following:(1) Evaluation of nonconformances to determine the need for

corrective action and slgnfficatn conditions adverse to quality.Evaluation Is In accordance with established prcedures andcriteria.

(2) Corrective actio Includes Identification of root cause(s) and actionto prevent recurrence.

(3) Documented review, by quality assurance spedalist, to deterineadequacy of the corrective action.

(4) Follow-up reviews by quality assurance specialist, to verify theproper Implementation of the corrective action.

REV. 1119O

1



SHEET__ TOF _Y

AMPI~SUJRVELLANCO/NSPECTMO

NO. NO A.91-003

Oa - Cr�t' 14

I I I I-



RESULTS

1. .4 .4

¶

2

3

(5) Identification of significant conditions adverse to quality,Identification of the root cause(s), resolution of genericInpflcations, trending and review by an appropriate level of WasteOperations management. (DOE/EMWVO/02 Para. 16.1.1)

Are guidelines established to differentiate between significant andnon-significant conditions? (DOE/EMiWO/02 Para. 16.1.1)

Verify that the corrective action program has been periodicallyaudited. Review schedules, reports and follow-up activities.(DOE/EMIWO/02 Para. 16.12)

REV. u11so

J/ ykI/



SHEET 3 OF 5AUDITISURVELLANCONSPECTION

NO. HO A.91-003

O;L - c, �r. / b

r *



RESULTS

I 4 4

4

5

Operations Offices are required to establish and implement acorrective action system to Include the same elements as the EM-30System. Verify that the system Is Implemented and Isaudited by EM-30. (DOEIEM/WO/02 Para. 16.2.1)

Waste Operations, through the Vitrification Projects Branch, hasestablished and Implemented a system for corrective actionfor cond-tions which affect the development and qualfication of an acceptablecanistered waste form product and/or production process.This corrective action system requires conditions adverse to qualitysuch as failures, ononconformances, malfunctions, deficiencies anddefective material and equipment be reported throughnonconformance and unusual occurrence reporting procedures.Quality assurance activities found deficient In reviews and audits ofOperations Offices are aiso reported. The corrective action systemIncludes the following elements:(1) Evaluation of nonconformances to determine the need for

correctie action and significant conditions adverse to quality.Evaluation is In accordance with established procedures andcriteria. Correcitve action is required for nonconforamnces thatare significant conditions adverse to quality, repetitive, orconcern Inadequate disposition of deviations.

REV. I 1/90

K; J K)OFFICE OF CIVILIAN

RADIOACl1VE WASTE MANAGEMENTU.S. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

SWU__ETFJ5Z....

AUMIISUJRVELLANCE/INSPECTION

NO. HO A.91-003

0o2- CI-ItI/A

--- - 0 -



RESULTS

t t

(2) Corrective action Includes Identification of root cause(s) and actionto prevent recurrence.

(3) Documented review, by a quality assurance specialist, todetermine adequacy of the correckive action.

(4) Follow-up reviews by quality assurance specialists to verify theproper Implementation of the corrective action.

(5) IdentIfication of significant conditions adverse to quality,identification of the root cause(s), resolution of genericimplicatlons, trending [reference Section 1.3.1(3)], and review byan appropriate level of Waste Operations management. Thisdocumened review Includes the definition of corrective action anthe action to prevent recurrence.

The Vitrification Projects Branch Chief, assisted by the OualityAssurance Program Manager and the Quality Assurance Specialists,executes the corrective action system relating to development andqualification activities, and arranges for periodic independent auditof the system to endure Implementation and adequacy.

REV. 11/90

K'J K)

I

OFFICE OF CIVILIAN sHMT _O sRADIOACTIVE WASTE MANAGEMENT AUDRISURVELUANCEINSPEC11ON

U.S. DEPARTMENT OF ENERGY No. HO A.91W003

ok -t - I LWASHINGTON, D.C.


of verfication, personnel contacted

7 Operations offices are required to establish and Implement acorrective action system which supports development and qualificationactivities. Each system will Include the foflowing elements:(1) Evaluation of nonconformances to determine the need for

corrective action. Evaluation Is In accordance with establishedprocedures. Correcftve action Is required for nonconformancesthat are significant conditions adverse lo quality, repetitive, orconcern Inadequate dispositon of deviations.

(2) Corrective action Includes Identification of root cause(s) and actionto prevent recurrence.

(3) Documented reviews by the Operations Office quality assuranceorganization to determine adequacy of the corrective action.

(4) Follow-up reviews by the Operations Office quality assuranceorganization to verify the proper Implementation of the correctiveaction.

(5) Identification of significant conditions adverse to quality,Identification of root cause(s), trending, resolution of genericimplications, and review by appropriate levels of management.This documented review Includes the definition of corrective actionand the action to prevent recurrence.

8 Vitrification Projects Branch monitors Operations Offices' correctiveadio systems related to development and qualification activities, andperiodically audits those activities to ensure Implementation andadequacy.

I

REV. 11190



SHEET 1 OF 5

AUDIT/SURVELLANCEi1NSPECTION

No. H1-91-003

W4C £11i A41tjdll

I I~~~~~~~~~~


EM-30

DATES OF EVALUATION

N.C. Frank zigs[(X EXTERNAL

l I INTERNAL

[XI AUDIT

[ I SURVEILLANCE

I I INSPECTION

PREPARED BY.1

CONCURRED BY A//

DATE _______

DATE

DATEAPPROVED BY A x-L i L8/26-l91

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDQuallty Assurance Program Description DOEAEMNWO/02, Rev. 0 Criterion 17 - Quality Assurance Records


1 Verify that quality records are Identified In the WCP and/or the WOR(Para. 17.1.1b)

REV. 11190

y~~~~~~~~~j KU ~~~~~~~~~~~~~1-OFFICE OF CIVILIAN


WASHINGTON, D.C.

'SHEET A F 5AUDMITSURVELLANCEWISPECTION

NO. HO A.91-OO

o;L--cr*z 17

I I - I I



RESULTS

4 4 .4

2

3

Veriy that a plan has been developed to capture those recordsgenerated prior to Issuance to the WCP and/r the WOR.

Review seven packages that have been transferred to RW. VerifyIdentification, packaging, and transfer met:(1) The records package wil be identified as either ORP x.x.x.

(Qualty Records Package), ARP x.x.x (Administrative RecordPackage), or RTP xx. (Record Turnover Package), with theox.x xw being the DOE-designated project identifier.

(2) The Waste Form Producers do not assign Quaifty Levels toWaste Acceptance Process activities. However, all activitiesrelating to the quality of the canistered waste form and is PRwill be accomplished under a quality assurance program that isequivalent to a Quality Level I (OtQ) program within RW. As aresult, QL-1 will be the Quality Level identifier for all qualityrecord sent to RW by the Waste Form Producers.

(3) A Table of Contents will accompany the package, with theabove package identifier ad Quality Level hi the upper rightcomer of the first page.

(4) The records package will be sent to RW using a transmittalform.(Para. 17.1.1b)

REV. I1/90

K~y K) K



AMMMIURELLANCMnNSPECTION

NO. HO0 A.91-03

0-g- c,,t 17

a I - 0 -I --



RESULTS. .

4

5

6

For those same records packages, verify the records are legible,accurate, authenticated, identified and retrievable.

Review the scope of the records program and the content of the OARecords. Verify the scope and contents accurately represents thework done by or through EM (Pam. 17.1.1.c)

Verify that responsibilities are defined for* the definition and Implementation of record activities, particularly

In the retention and safe storage of records.

* for record creation, transmittal, retention, and maintenanceconsistent with applicable codes, and standards (Para. 17.1 .1b)

REV. I 1/90



SH__E _JOF E2

AUDITISU1RVELLANCEI1NSPECTION

NO. HO A.91-003

o2-Crit. 17* A A * 0 --~~~~~~~~~~~~~~~~~~~~~



RESULTS

7

a

View the facilities for storing records. Verify that:* Suitable facilities for the storage of records are described and

utilized.

* Work not directly associated with the records program Isprohibited within the records storage facility.

* Smoking, eating, ordrinking Is prohibited throughout the recordsstorage facility.

(Para. 17.1.1b)

View two facilities for storing documents and records prior to beingreceived In the quality record control storage area. Verify that:* Criteria are established and described for determining when a

document becomes a quality assurance record subject to thecontrols of this section and the retention periods for suchrecords.

* Controls are estabflshed and described for controlling,protecting, and maintaining those records before they areentered and stored In the quality record control storage area.

(Para. 17.1.1.b)

REV. I 190



WASHINGTON, D.C.

SHM _TJ _0F .5

AUCIFl7SURVELLANCOINSPECTION

NO. NO A.91-003

oa~ - cVirtI )7

* I A *A4 * 4ml



RESULTS

* 4 .1.

9

10

11

12

Review two laboratory, field, or log books, two data sheets, two datareduction documents, and one software program. Verify the methodof documentinglrecording, reviewing, and confirming accuracy asdescribed. (Para. 17.1.1b)

Determine the extent of assignment of records preparation andcollection, storage, and maintenance assigned to Operations offices.Review the documentation that works this assignment(Para. 17.1.2)

Determine the number of Quality Assurance Specialists assisting theQA Program Manager In Implementation of the records system.(Para 17.1.3)

Verify that the QA Program Manager has either performed an audit orarranged for an Independent audit of the records system to ensureImplementation and adequacy. (Para. 17.1.3)

REV. 11190

-N. I/ k, -J 11-�



SH-EET I OF 6

AUDrTISURVELLANCOnNSPECTION

No. HO-91I-O03

I I


EM-30X1 EXTERNAL

[1 INTERNAL

[XI AUDiT

[ ] SURVEILLANCE

[ 1 INSPECTION

PREPARED BY Fred Bearham 3

CONCURRED BY AV/M

_ ATE ___1 __

DATE

DATEDATES OF EVALUATION

8/26-30191APPROVED BY !7

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDQuality Assurance Program Description DOEIEMWA0/02, Rev. 0 Criterion 18 - Audits


1 Review annual audit plan and the quarterly status.(a) Verify both external and Internal audits are performed.(b) Verify that each Operations Office Is scheduled for audit by EM.(c) Verify that new contractors are added to the schedule (See teom

12)(Para. 18.1.1 and 18.1.2a)

REV. 11190

K ) KJOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2- OF /

AUDIT/SURVELLANCOINSPECTION

NO. HO A.91-M0

Op-- 0c-i4. iS

p a & ~;-W' -Isx03W 0M -6 -

IrEMNO.

2

3

CHARACTERISTIC TO BE EVALUATEDREMARKSRecord objective evidence reviewed, methodof verification, personnel contacted

RESULTS

Reviewes the audit plan for two Operation Offices. Verify it Included:(a) An objective evaluation of quarty-related practices, procedures

and Instructions; the effectiveness of Implementation; and theconformance with policy directives.

(b) The evaluation of work areas, activities (including personneltraining and Indoctrination), processes, and teams.

(c) Review of documents and records to ensure that the qualityassurance programs are effective and properly Implemented.

(d) Evaluation of Identified elements of Interface control with respectto Operations Offices' Internal activities, as well as Interfacingactivities with contractors.

(Para. 18.1.2b)

Determine whether any unscheduled audits were needed orperformed. (Para. 18.1.2c)

- I

REV. I9V

K; K) \ "OFFICE OF CIVILIAN

RADIOACiTVE WASTE MANAGEMENTU.S. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

SHEET J O OF A~

AUDITISURVERILACOINSPECTION

NO. HO A.91-M0

5A - Crt, I?

* * a a £ 6 -



RESULTS

4. 4 .4~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

4

5

Review the detailed plan for four audits to verify:* it addresses the quality of products and technical work as well as

programmatic compliance.* previous Internal and external audits and the Impact of changes

In personnel, organization, and the quality assurance programwere evaluated during Its development.

* it Includes a written checkdist of Items to be investigated.* it Includes a preaudit and a postaudit meeting.(Para. 18.1.3a)

Review four audit reports(a) Verify that the need for corrective action is established and the

audit results are documented.(b) Verify each audit report Includes a statement on the status and

adequacy of the QA Program and on the QA Programeffectiveness.

(Para. 18.1.1 and 1B.1.3b)

REV. 11/90



SHM___T F_______AUDrITSURVEIJANCEiINSPECTIONNO. NO0 A.9I-003

1C aA1:11 0 - 0 W]



RESULTS

I I

Obtain the names of the auditors for the four audit reports. Verify thatthe audit team:* was certified In accordance with Section 2.7 of the QAPD.* did not have direct responsibility for the areas being audited.* included technical personnel to assess the quality of the products

and technical works.(Para. 18.1.3c)

Verify that formal responses to the audit findings were provided.(Para. 18.1.3c)

Verify that formal responses to the audit findings were provided.(Para. 18.1.4)

REV. I 1/90

\) KJ \ JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET T 0 OF L

ALIDITISURVELLANCEI1NSPECTION

NO. HO A.91-003

O ,- Cr itV )'_ h - I

F - I ~~~~~~~~~~~~~~~~II



RESULTS

4 I I

9

10

11

Determine how the corrective action Is monitored. Determine if anyreaudits have been performed. (Para. 18.1.4)

Reviewthe previous four monthly progress and status reports. Verifythat audit summaries are Included. (Para. 18.1.5)

Verify that a trend analysis has been done on waudit reports and dataeand that the reports were provided to management? Determinewhether management responded to the reports. (Para. 18.1.5)

REV. 11190



SHEET 6 OF _AUDSITSURVEILLANCEANSPECTION

NO. HO A.91-003

0,11) 0 - 0-r it, ) T

* & a -M1nm U6FIIM



RESULTS. .

12

13

Verify that all areas of the D&Q OA program where the requirementsof DOE/RW-0214 are being Implemented have been audited on anannual basis. (Par. 18.1.6)

Verify that the activities and practices were audited uponImplementation. These activities are to include:(1) The preparation, review, approval, and control of quality

assurance program description, designs, specifications.procurement documents, Instructions, procedures, and drawings.

(2) The determination of those sie operations that affect the Integrityof development and qualification activities.

(3) Requests for proposal and evaluation of bids.(4) Indoctrination and training program.(5) Interface control among DOE offices and major project

participants.(6) Calibration and nonconformance control systems.(7) Quarterly assurance program commitments.(8) Activities associated with computer codes.(Para 18.1.6b)

REV. 11/90

~~- _J 1111-~~~ -



SHEET I OF 5AUDITISUJRVELLANCEA1NSPEC11ON

No. HO-g1-oo3

*Il I 11A.


EM-30

DATES OF EVALUATION

8/26-30/91

IX] EXTERNAL

[ ] INTERNAL

[XI AUDIT

[ ) SURVEILLANCE

I I INSPECTION

PREPARED BY L Wade

CONCURRED BY ,/

_ _ . DATE sI9lo5DATE

DATE qWJL,7

APPROVED BY , .. ,w., ,1-7.4701, z

DOCUMENT (litle, Number, Revision) ACTIVITY EVALUATEDStandard Practice Procedures, SPP 201, Rev. 0 implementation of SPP 2.01

REMARKSNO. CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTS

of verlication, personnel contacted

1 Verify that the SPP Coordination Log Is being completed andmaintained current. (5.a.4)

2 Verify that SPP's are prepared In the format specilied In AttachmentB. (5.a.5)


REV. 8MI

le

~. I K) k JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 5AUDIT/SURVELLANCONSPECTIONNO. H0491-003 ~-

S'f'p A -0J* a -m~ I W:; S- X&S~



4 I

3

4

5

Verify that appropriate reviewers have been designated to review theSPP (5.a.7)

Demonstrate how reviewers are selected and how their qualificationsare determined and verified. (5.a.8)

I.e It would seem that a technical reviewer would have differentqualifications than a GA or administrative reviewer.

Verify that reviewers are conducted, comments are documented andproperly resolved (5.a.8-10)

.4 .4 .4

REV. 8/1

y IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 3 OF 6

AUDITISURVELLANCEAINSPECTION

NO. HO-91.00

spe;9oI

I I p~~~~~~~~~~~



RESULTS

t

6

7

a

Verify that reviewers agree with the resolution of comments asevidenced by signatures on the SPP Coordination Log (5.a.15)

Verify that SPP's are approved by the manager and agreed to by theOA specialist's on the SPP coordination log (5.a.17 & 18)

Verify that the SPP Coordinator maintains the Index (Attachment D)current, obtains the managers approval and distributes In accordancewith reference 3.a. (5.b1-4)

Note: The reference to 3.a should be changed to 3.b

REV. 8/91

K)I \ J-R%_0 - - -



SHEET 4 OF 5

AUDITISURVELLANCEIINSPECTION

NO. HO-91 -003

s r' 2a-&J4WE 1 -'ii- et]M]a *13'



RESULTS. .

9

10

Verify that revisions to SPP's follow the same steps as the originaland the portions revised are Identified. (5.c.1&2)

Veriy that the SPP Coordinator prepares the following quality recordsIn accordance with reference 3.b (5.d.1)

Note: The reference to 3.b should be changed to &.ca. Each SPP and revision as Issued.b. SPP Coordination Log for each SPP revision.c. Each revision of the SPP Index.d. Review and comment form from each reviewer of each

SPP.

REV. 8M91



SHEET 6 OF 5AUDIT/SURVEILLANCEAINSPECTIONNO. HO-e -003

SF," V-0I I I Temuim. treT11117117inA h A S -



I I ,.

11

12

Verify that the SPP Coordinator maintains the following records forworidng and historical purposes (5.d.2)a. Copies of previously Issued revisions and reviewers comments.b. Current SPP originalc. Copy of SPP coordination log for each revision.

Verify that an annual review of SPPs Is conducted and those requiringrevision are Identified and revisions processed (5.e.13)

REV. we1

/

y J K)



SHEET I OF 7AUDITISURVELLANCEMNSPECTION

No. HO91-O03

i I

ORGAIZATION EVALUATED

EM-3O

DATES OF EVALUATION

8t26-30/91

[X EXTERNAL

[ 1 INTERNAL

[XI AUDIT

[ I SURVEILLANCE

I I INSPECTION

PREPARED BY Clyde Morell

CONCURRED BY d/>

APPROVED B

DATE 81 C\

- DATE

7 Sg,[ 7' DATE 471-7Z

DOCUMENT (Tite, Number, Revision) ACTIVITY EVALUATEDQuality Assurance Program Description Preparation, Maintenance, and Control SPF 2.03, Rev. 0 <ZZtsc 5 7 v_"


1 Identify who the manager is responsible for controlling andImplementing this procedure.

2 Review position description to determine if the manager is qualified toperform the assigned task.

* INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NIA)

REV. M91

ii K) \- J



SHEET 2 OF 7

AUDITISURVEILLANCEIINSPECTION

NO. HO-91-003

:5fb0-3

I A

rrEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

4 t I

3

4

5

Review training requirements to determine the manager has beentrained prior to performing or directing the preparation of a draftQAPD.

Identify the QAPD preparer for draft QAPD DOEiWO/02, Rev. 0.

Verify the QAP preparer has prepared a draft QAPD as outlined In6(a-1, a-2 & a-3).

REV. 8W1I

. I}-- - -



SHEET S OF 7

AUDIT/SURVEILLANCEANSPECTION

NO. HO-91-003

S PFP ;t.V

I I p p~0 .



RESULTS

l l l

6

7

a

Identify reviewers for the draft OAPD.

Verify that the manager has established and approved a reviewcriteria.

Verify that the reviewers are using the approved review criteria for theQAPD review.

REV. as 1

J' K)OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 7

AUDWIT/SURVEKLLANCE"NSPECTION

NO. HO-1 -003

S~P A-0 3C 0 - 0 --



RESULTS

4. 9 4

9

10

11

Verify that the reviewer have documented their comments In writingon the review/comment form reference 3c on that the reviewer hasannotated a hard copy of the draft OAPD.

Verify that the manager has resolved all comments on thereview/comment form on the annotated QAPD. (SPP 2.03, Section 5)

Verify that subsequent revision and comments are controlled by themanager In accord with step 1 through 4.

REV. 8/91



SHEET 5 OF 7

AMDITISURVELLANCENSPECTION

NO. HO-91-003

SPP 120:

I I III


REMARKSRecord obqective evidence reviewed, methodof verification, personnel contacted

RESULTS. .r I.

12

13

14

Verify that the manager Initiates a QAPD coordination log andperforms the requirement of b(1) steps (a) through (c) and b(2).

Verify that the reviewer has signed and dated the appropriate blankof review/comment form to denote agreement with each part of theOAPD under question.

Verify that the reviewer forwards the package (I.e QAPD, thereview/comment, and the coordination log to the manager forprovisional approval.

.4 I

REV. Ml91



SW-ET 6 OF 7

AUDMITSURVELLANCEANSPECTION

NO. HO-91-OM~

Sr P Qbe)3

I I~~~~~~~~~~~~~~~~~~



RESULTS

9 I 4

15

16

17

Verify that the manager performs the steps b(5) through b(8).

Revisions. Verify that the manager performs the steps of c(1) through(2).

Annual QAPD Review. Verify that the QAS performs the step of c(1)& (2).

REV. E/91



WASHINGTON, D.C.

SHEET 7 OF 7

AUDITISIJRVELLANCMNSPECTION

NO. HO-91-3

5PP A.L'3

e a £ II- 0 .- .n d D e



RESULTS

4 1 4~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

18

19

20

Control and Distribution. Verify that the SPP Coordinator performssteps 5e.(1) through e.(u).

Verify how uncontrolled QAPDs are distributed and Identified.

Records. Verify that the SPP Coordination performs the steps of f(1)through f(2).

REV. 8/91

I K)

OFFICE OF CiMlLIANRADIOACTIVE WASTE MANAGEMENT


SHEET I OF 3AUDITiSURVELLANCE" NSPECTION

NO. HO-91-003

I I a0


EM-30

DATES OF EVALUATION

81"0191

PX EXTERNAL

[] INTERNAL

[XI AUDIT

[ I SURVEILLANCE

( I INSPECTION

PREPARED BY L. Wade

CONCURRED BY _,VA

DATE VV/rI/c_ .

APPROVED BYf- 0,0 ' /f

DATE

DATE

DOCUMENT (TiI., Number, Revision) ACTIVITY EVALUATEDControl of the Standard Practice Procedure Manual, SPP-2.04. Rev. 0 Implementation of SPP 2.04

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verifcation, personnel contacted

1 Verify that the SPP Coordinator maintains an approved SPPdistributlon list including any revisions (5.a.1&2)

2 Demonstrate how the approver Is selected and what qualificationsand/or level of authority he/she has (5.a.3)


REV. 8/91

Ji \ I



SHEEr 2 OF 3

AUDITISURVELLOANCINSPECTMO

NO. HO-91-00

SPP) 2.Dd/

S £ I 0 - 0~ I



RESULTS

* 4 4

3

4

5

Verify that the SPP Coordinator has assigned and distributedcontrolled copies of the SPP Manual to those on the Est (5.a.4-8)

Verify that manual holders comply with the transmittal Instructions,completes Part B of some and returns It as Indicated (5.a.9)

Verify the SPP Coordinator assures the transmittal memorandum Isreturned and If not, appropriate action Is taken (5.a1 0-12)

REV. 891



WASHINGTON, D.C.

SHEET 3 OF SAUDIT/SURVEILLANCEIINSPECTION

NO. HO-1-003

spr A, 0y

Om, 0 INN S i

ITEMNO. CHARACTERISliC TO BE EVALUATED


RESULTS

. .I 1*

6 Verify the SPP Coordinator maintains the receipts or logs recordingreceipt status for SPP manuals or manual revisions. [5.b1 (a)]

* 4. 4.

REV. 891

K I K) \' I

OFFICE OF CIVLIANRADIOACTIVE WASTE MANAGEMENT


SHEET 1 OF 2AUDITISURVELLANCEINSPECTION

NO. HO-91-003

9 I A~ ~I --


EM-30

DATES OF EVALUATION

8/2640/91

[X EXTERNAL

[ ] INTERNAL

pq AUDIT

[ I SURVEILLANCE

[ I INSPECTION


CONCURRED BY

DATE BnI fAi4 DATE

_ ,,

APPROVED BY ag ~ DATE 2k/9L

CONTROLLING DOCUMENT (Tkle. Number, Revision) ACTIVITY EVALUATEDSelective Application of Quality Assurance Activities, SPP 2.05. Rev. 0 Implementation of SPP 2.05


I Verify that this procedure has been issued.

2 If this procedure has not been Issued, what controls are In place toimplement QAPD DOEJEM/WOi2 [Para 2.7.1(1)]

* INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. OI91

yJOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 2

AUDIT/SURVELLANCEINSPECTION

NO. HO-91-003

SPP 2-~

* £ £ 44i is

ITEMNO.


aRESULTSCHARACTERISTiC TO BE EVALUATED

I I

3

4

5

identify DOE management resonsible for Implementing this QAPDrequirement of graded quality assurance program.

Verify assigned personnel are trained prior to peforming work.

Review completed reviews Implementing this requirement.

REV. 8/91

JI \� ii



SHEET I OF 6AUDITISURVEILLANCEIINSPECTIONNO. HO-91-003

. ,;~~~~~~~11-AIkWT14iS ill -ay-A Lii [e go


EM-30

DATES OF EVALUATION

[X] EXTERNAL

[]INTERNAL

pC] AUDIT

( I SURVEILLANCE

[ INSPECTION

PREPARED BY C. Morefl C hm' 9E

CONCURRED BY uIC/

_DAT14gI

. DATE

_ DATE fi/iLAPPROVED BYz p " a826-30t91

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDPersonnel Training, Indoctrination and Orientation (TI&O) SPP 3.01. Rev. 0 Implementation of SPP 3.01

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of veril'cation, personnel contacted

I Verily that a Training Coordinator Is assigned(Para. 5.a.1) SPP 3.01


REV. 81I

JK)



SHEET 2 OF 6

AUDITMSURVELLANCEINSPECTION

NO. HO-1403

,<F P S' oIF d - 0 --&] ,110 N -1Rl

I I I - - I - -



RESULTS

l. I .4

2

3

4

Review the TI&O training schedule and plan. Verify that it addressesappropriate personnel and TI&O modules. Review Attachment B.(SPP 3.01, Para. 5.a.1)

Verify that manager has assessed the annual TI&O needs ofpersonnel performing quality related actities are personnelperforming quality related activities identified under their cognizance.(SPP 3.01, Para. 5.a.2)

Review Ti&O worksheet for completeness, accuracy and legiblity.(SPP 3.01, Attachment A)

REV. 8f91

I K>OFFICE OF CILIAN


WASHINGTON, D.C.

SHEET 3 OF 6AUDITISURVEILLANCEANSPECTIONNO. HO-1 -003

5PP 3.o0

91 4 h 0



RESULTS. .

I I

5

6

7

Is the difference between quality related functions, quarty achievingfunctions and quarty assuring functions clearly defined(SPP 3.01, Para. 5.a.4)

Verify that the needs assessment Is Incorporated kfto the TI&O plan(SPP 3.01. Para. 5.a.6.)

Verify that the plan and schedule was distributed by January 1990.(SPP 3.01, Para. 5.b.1)

I S S

REV. Ml9i

- -



SHEET 4 OF 6

AUDITISURVELLANCEINSPECTIONNO. HO-91 003

.Sp7 :5.oI

S I I S - S -- E



RESULTS. .

8

9

10

Verify that the training Coordinator has coordinated and monitoredoutside training courses (SPP 3.01, Para. 5.b.3)

Verify the adequacy of the Implementation of the procedures.a) Are aill personnel performingb) Do training modules address the subject matter and needs of

trainers.c) Are the strengths and weaknesses of the 11&0 process identified

and evaluated. (SPP 3.01, Para 5.a.2)

Are the Manager identified. Reviewed organization charts and jobdescriptions (SPP 3.01, Para. 4.a.1)

REV. 8&91

~ l J- -. I K I

OFFICE OF CVILIANRADIOACTIVE WASTE MANAGEMENT


SHEET 5 OF 6

AUDITISURVEL AEIWNECTI

NO. HO91-003

Is PP 3. '/I~~~~~~~~~~~~S'AB-0-

ITEMNO. CHARACTERISTiC TO BE EVAWATED


RESULTS

9 t T

11

12

la

How was TI&O controlled prior to issue of the SPPs? (General).

Has a matrbi, or similar document, been prepared to identify and trackI&TO requirements? (General).

Verify that the documentation required by the procedure Is preparedand stored In accordance with SPP 7.01 (SPP 3.01, Para 5.d.1)

I. I. I

REV. 891



SHEET 6 OF 6AUMSIURVELLANCEnNSPECTION

NO. Ho--m03

SPP 3~

I a a a a~~~~~ aa aB B -

ITEMNO. CHARACTERiSTIC TO BE EVALUATED


RESULTS

9 I

14 Verify QA Input Into the TI&O process (SPP 3.01, Para. 4 General)

L L J.

REV. 8/91

t-J \-J -J

OFFICE OF CMIUANRADIOACTIVE WASTE MANAGEMENT


SHEET I OF 5AUDITISURVELLANCEllNSPECTIONNO. HO-91-O03

I I


EM-30

DATES OF EVALUATION

8626-30/91

P[ EXTERNAL

[ INTERNAL

[XI AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY C. Morell

CONCURRED BY AW ,

APPROVED BY' -

_ DATE w

DATE

DATE

CONTROLLING DOCUMENT (nile, Number, Revision) ACTIVITY EVALUATEDPreparation and Conduct of Personnel T. I & 0) SPP 3.02, Rev. 0 Implementation of SPP 3.02


1 Review lessons for clarity, scope, content (Is the subJect matteraddressed) SPP _02, Para. 5.a.6) - See other attributes In procedure.


REV. 8191

K]~~~~~~~~~~~~~~~~~~~~~~~



SHEET 2 OF 5

AUDIT1SURVEILLANCEANSPECTION

NO. HO-91M03

5ff'.107

I - -1~~p & I 0 -

I I I

RlEMNO. CHARACTERISTiC TO BE EVALUATED


RESULTS

4 1* t

2

3

4

Verify that subject matter experts review and comment on lessonplans (SPP 3.02, Parm 5.a.5)

Verify that lesson plans are approved by the QA specialist and themanager (SPP 3.02, Pars. 5.a.7)

How does the manager ensure that personnel received QAIndoctrination (SPP 3.02. Para. 5.b.1)

1. a

REV. 8/91



SHEET 3 OF S

AUDrTISURVEILLANCOJNSPECTION

NO. HO091-03

sr'I 5, ~

* A yAllr 1i *;tqs ModMii" -



RESULTS

4 4. 4.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

5

6

7

Verify that personnel have received QA Indodrination and re-indoctrinatlon at 3 year Intervals. Review documentation

(SPP 3.02, Para. 5.b.1)

Verify that project specific Indoctrination classes have been conducted(SPP 3.02, Para 5.b.2)

Review the evaluation of each parlicpant for satisfactory completionof training. (SPP 3.02. Para. 5.c.6)

4 4

REV. 891

I \' I\1 I



SHEET 4 OF 5AUDWFSURVEILLANCEIMNPECTIONNO. HO-91 00

.:FPP 3. 0-

p a a 0 - 0 --~A a



RESULTS

_______ I.

a

9

10

Verify that personnel assigned to altered training sessions havecompleted the training. (SPP 3.02, Para 5.c8)

Verify that TI&O sessions have been conducted when QA instructionsare revised. Check the procedure Issue process to determine recentIssues. (SPP 3.02, Pam 5.c.9)

Verify that TI&O modules are administered, analyzed, evaluated andrevised. (SPP 3.02, Para. 5.d.)

I I. I

REV. 8?91

~~~ 1J~~KOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 6 OF 5

AUDITISAMRVEILANCEIINSPECTION

NO. HO-M003

s-p p 3.O0:L

I I p~~~~~~~~~~~~~~~~~~



RESULTS

I t t

11 Verify that lessons are developed in accordance with establishedguidelines (SPP 3.02, Attachment A)

I. .&

REV. 8191

L NI



SHEET I OF 8

AUDITJSUJRVELLANCEANSPECTION

No. HO-91-003

9& a £ -4 AY14110 1


EM-30

DATES OF EVALUATION

8/26-30/91

[X] EXTERNAL

[ ] INTERNAL

[XI AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY Louis R. Wade o km

CONCURRED BY a/AAPPROVED BY _ _ _ _ _ _ _ _ _

DATE 8-1-91

DATE

DATE ok

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDCertification of Quality Assurance Audit Personnel SPP 3.03, Rev. 0 Implementation of SPP 3.03


1 Verify the auditor examiner Is certified In accordance with thisInstruction (General).


REV. 11/90

/ " J---- I \.-- I



SHEET 2 OF 8

AUDIPSURVEILLANCEANSPECTION

NO. HO-91-CO

SPP 3.03 Rev. 0 Conlt

9 A A *AN :t] e*N4610110 --



RESULTS

1 4 4

2

3

4

Verify that auditorsilead auditors from outside organizations havebeen certified per SPP 3.03 or their certifications under anotherapproved program confirmed In writing (General)

Verify that an audits coordinator (CPC) has been assigned (5.a)

Verify the CPC selects candidates to be considered for certificationusing the Audit Task Description, Obtains the necessary supportingdocumentation and forwards to the Certifying official for evaluation ofthe candidates. (S.a.1, 1-4)

__________ I I

REV. I 1/90



SHEET 3 OF 8

AUDISURVEILLANCEOlNSPECTION

NO. H091-003

SPP 3.03 Rev. 0 Con't

~~E I I -- -a - -



RESULTS

t .7

5

6

7

Verify the Certifying Official evaluates the candidate and documentsthe results on the Certification of Quaiffication Form, Attachment C,and forwards to CPC. (5.a.4, a-e)

Verify the CPC reviews the documentation for adequacy andcompleteness Including verification of the credit allocation andprepares a notification of Certification Memorandum, Attachment E(5.b.1).

Veriy the CPC enters the certification data and Information on theRecertification Schedule, Attachment F. (5.b.2)

L 4 4

REV. 11190

/ \1 I/I \ I'



SHEET 4 OF 8

AUDITISURVEILLANCEMNSPECTION

NO. HO-91M003


p p~~~~~~~~~~~~~~~~~~~~~~~M



RESULTS

I t 4.

8

9

Verify the CPC; (5.c.1-3)

a. Maintains the Recertification Schedule in accordance with SPP3.05. (Refer to SPP-3.05 checklist).

b. Issues a recertification notice to the certifying official and theaffected person at least five (5) weeks prior tot he required datafor recertification.

c Provides the Certifying Official with the original certificationdocumentation and any additional supporting documentationaccumulated on an annual basis.

Verify that the certifying officer has evaluated the documentation andupdated the certification for annual evaluation and signs a newCertification Certificate (5.c.4&5)

REV. I 1/90



SHEET 5 OF 8

AUDITISURVELLANCEAINSPECTION

NO. HO-91 -003

SPP 3.03 Rev. 0 Conlt

S A A *A -~~~~~~~~~~~~~~~



RESULTS

. .

10

11

12

Verify the CPC transmits the Certificate to the person and theirsupervisor using the Notice of Certification Memorandum (5.d.1)

Verify that the following quality records are maintained In accordancewith SPP 7.01 (5.d2)a. Certification Certificateb. Certification of Auditor Oualification form

Verify that the OAS maintains the original certification documentationIn the persons certification and training file In accordance with SPP3.05. (Refer to SPP 3.05 checklist) (5.d.3)

REV. 1 V90

y J <\I ,,OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 6 OF 8AUDITSURYVELLANCE" NSPECTION

NO. HO-91-003


S a 0 * 01 o *IA 1tm =--



RESULTS

. .

13

14

Verify that Auditors meet the following minimum quaflfications(Exhibit-1 Para. 3)a) Training

1. Codes, standards and regulations2. Audit techniques, OTT etc.3. Demonstrate knowledge of audit instructions and

requirements of clients QAPD and DOE documents.Education and experience (5 points minimum)Communication skins

b)C)

Verify that Auditors Quarfications are maintained as follows(Exhibit 1 Para. 4)a) Maintenance of proficiency;b) Requalification

.4 �.

REV. 11/90

_ \~~~~~~~~~~~~~~~~~~I\ I/



SHEET 7 OF 8

AUDITlSURVEIlANCEIINSPECTION

NO. HO-91-03


4 -l -.-

rrEMNO. CHARACTERISl1C TO BE EVALUATED


RESULTS

I.

Verify that Lead Auditors meet the following minimum qualifications.(Exhlbit-2 Para. 3)a) Education and Experience (10 pts. min.)

1. Education ( 4 pts. max.)2. Experience (9 pts. max.)3. Other (2 pts. max.)4. Rights of management (2 pts. max.)

Verify that Lead Auditors have received training in the following areas.(Exhibit-2 Para. 3c)a) DOE Order 5700.6, dient instructions and requirements, NQA-1

etc.b) General structure of QA program 18 criteria.c) Auditing techniquesd) Audit planninge) On the job training

Verify that Lead Auditors qualifications are maintained as follows(Exhlilt-2 Para. 4)a) Maintenance of proficiencyb) Requalification

5 4

REV. 11U90

J JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 8 OF 8AUDITISURVELLANCEflNSPECTIONNO. HO91-O03


C 0 * 0 ~~~~~~~IC I- .



RESULTS

. .

18

19

20

Verify that auditor examines meet the following minimum qualifications(Exhibit 3-Para. 3)a) Education and experience (10 pts min)

1) Education (4 pts. max.)2) Experience (9 pts. max.)3) Other (2 pts. max.)4) Rights of management (2 pts. max.)

Verify that Auditor examiners have received training In the followingareas (Exhibit 3-Para. 3c)a) NOA-1 and other nuclear related codes and standardsb) General structure of QA programc) Auditing techniquesd) audit planninge) On-the-job training

Verify that auditor examiners qualifications are maintained as follows(Exhibit 3-Para. 4)a) Maintenance of proficiencyb) Requalification

1. .4 .4

REV. 11/90



SHEET I OF 3AUDITIMMRELLANCEANSPECTION

No. HO-91 -M0

I ~~~~~I -- I --- =


EM-30

DATES OF EVALUATION

8/26-30/91

pq EXTERNAL

[1 ]INTERNAL

[XI AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY L 10.2J4gd..

CONCURRED BY 8q&

APPROVED B

A&Z DATE 1 -L. /

DATE

DATE h/i/ft

CONTROLLING DOCUMENT (Rio. Number, Revision) ACTIVITY EVALUATEDDocumentation of Surveillance and Review Personnel Qual. SPP-3.04, Rev. 0 kIrplementation of SPP 3.04

REMARKSINEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Verify that surveillance personnel are selected, evaluated andqualified In accordance with Section 5 of this procedure(SPP 3.04, Para. 5.a)


REV. 8M91



SHEET 2 OF 3

AUDITISURVELLANCEMNSPECTION

NO. HO-91-03

I I I I



*9 4.-

2

3

4

Verify that participation I a survey or review Is documentation on partIV of the Surveillance amd Review qualification form.(SPP 3.04, Para. 5.a.5)

Verify that surveillance and review personnel are requalified and thethe requalification schedule Is maintained (SPP 3.04. Para. 5.c)

Verify that requaliftcatbon notices are sent out at least 5 weeks priorto requaiiflcatbn date. (SPP 3.04. Para 5.c2)

______ 4. a

REV. 891

k ,1



SHEET 3 OF 3

AUDITISURVELLANCEMNSPECTION

NO. HO-91-OO3

'5tp'P 3O5Y

*a II W-61A1-lk49ia r kl 0



RESULTS

a 4

5

6

Verify that the CPC reviews qualifications on an annual basis.(SPP 3.04, Para. 5.c.3)

Verify that surveillance and review personnel are qualified byeducation and experience.(SPP 3.04, Attachment A Para. 3.) Pam 5.b2)

- I

REV. SB1

KOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 1 OF 3


No. HO-91-003

0 A~ ~ ---


EM-30

DATES OF EVALUATION

lX] EXTERNAL

[ ]INTERNAL

[Xm AUDIT

[ I SURVEILLANCE

I I INSPECTION

PREPARED BY L.IJUnM eAt'

CONCURRED BY &0

APPROVED BYz 4wt• 7Z

DATE JN'ji

DATE

DATE -a&8/26-30/91

. . .

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDAdministration of Personnel Certification & Qualification Records, SPP-3.05, Rev. 0 Implementation of SPP 3.05


1 Verify that the following documentation is on file for each person:

(a) Standard Resumes (Attachment A).

(b) Documentation of training act ivties(whichsupportqualificationorcertification requirements) including results of any examination.

(c) Audit, Surveillance and Review Participation Records(Attachment B and C).

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UINSAT), NOT APPLICABLE (N/A)

REV. 91

SJ K) I--OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 3

AUDIT/SURVEILLANCE/INSPECTION

NO. HO-91-003

5PP3O

*411 A IIWE - z .E



RESULTS

(d) Verification of education documentation.

(e) Job descriptions/task qualification requirement documents

(f) Physicians certification of physical ability (such as eye sight)when applicable. (SPP 3.05, Pam 5.a)

Verify that the CPC maintains files under the following tabs:Certification Documentation,Training Documentation, Resume,Education Verification, TaskQualification Requirements, andMisceflaneous(SPP 3.05, Para. 5.a.5)

2

.1 I I

REV. 691



SHEET 3 OF 3

AUDITISURVEILLANCEINSPECTKRN

NO. HO-91 -003

5 FP 5.-5

e ' "a f1K*U4qnrr0T *



RESULTS

4 1 4

3

4

5

Verify that are certification and requalification schedule Is maintainedby the CPC. (SPP 3.05, Para. 5.a.6)

Verify that files updated whenever there are annual evaluations,extensions or changes in status. (SPP 3.05, Para 5.a.6)

Verify that the forms required by this procedure are completed and onfile. (SPP 3.05, Para. 6)

I 4 1.

REV. M/l

K>

OFFICE OF CMUANRADIOACTIVE WASTE MANAGEMENT


SHEET 1 OF 6AUDITiSURVELLIAMEANSPECTIONNO. HO-91 -003

I - -- I~ -~


EM.30

DATES OF EVALUATION

i26-30/91

pq EXTERNAL

[ ] INTERNAL

[XI AUDIT

[ I SURVEILLANCE

( I INSPECTION

PREPARED BY Craiq Walenoa 4vp 13��CONCURRED BY A//

APPROVED BY 7 _ g2

DATE L-iI-ff

DATE

DATE 7/d

DOCUMENT (Tit, Number, Revision) 2r2/9o ACTIVITY EVALUATEDPlanning and Scheduling of Evaluation Activities SPP 4.01, Rev. 0 Planning and Scheduling

ITEM REMARKSOEM. CHARACTERISTICS TO BE EVALUATED Record obective evidence reviewed, method RESULTS

of verifkcaton, personnel contacted

1 Evaluate SPP 4.01 to determine If the procedure is consistent with theEM QAPD, DOEIEWWO/02. Fbowchart the procedure. Is theprocedure adequate, complete, and correct and does It appear to beimplementabte?

2 Obtain the iong range evaluation and schedule described In SPP 4.01.5.b for the subsequent three fiscal year. Determine who Is the EAS,the appropriate organizational directors and who is the ProgramCoordinator.


REV. 8M1

~ Jii

2



SHEET 2 OF 6

AUDITPSURVELLANCENSPECTION

NO. HO-91 403

S F7eq, DjS £ S - 0~~~~~~~~~~~~~~~~~~~~~~

IEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

.0 1 6

3

4

5

Discuss with the EAS how the SPP 4.01, 5.afb,c and d process IsImplemented. Does It appear to be adequately Implemented? Doesthe EAS appear knowledgeable of process? Has the EAS beentrained to SPP 4.01 ?

Discuss with the Program Coordinator or (PC) this process. Does thePC appear knowledgeable In the process? Has the PC been trainedto SPP 4.01 ?

During the discussions with the PC and EAS and through your ownreview assessment, Is the Long Range Plan and Schedule adequatefor the scopes of work that are on-going or will be conducted? Is theschedule for the next 3 fiscal year from the past Sept. 15?(SPP 4.01, Para. 5.d.) Check various SPPs for evaluation criteria.Are technical reviews schedules? (SPP 4.01, Para 4)

£

REV. r91

2OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 3 OF S

AUDIT/SURVELLANCENSPECTION

NO. HO-91- 03

5, P12 Al r'0 /

I I I



RESULTSI I

Determine if each Organizational Director and Program Coordinatorshas been sent or has received the last (9/90) Long Range andSchedule. SPP 4.01, S.d. Has this distribution been done throughthe PC? SPP 4.01. Para. 5.d.2. note.

Determine if each Organizational Director and Program Coordinatorwill receive the 9/91 Long Range Plan are not yet approved, discussthe EAS and PC the status of the plan and schedule and if the SPP4.01, Para. 5.d.1 requirement Is to be met(DOE/EMWNO/02 Page 2, Para. 3.1)

Was the R&D effort documented? Are historical files maintained?(DOE/EMWVO/02 Page 3, Para. 4.2)

I. 1

REV. 8/91

� J \' 1) I\- ')OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 6AUDITISURVEILUANCEIINSPECTIONNO. HO-91-03

5PP 9,'V/

I I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~


REMARKSRecord objedive evidence reviewed, methodof veriication, personnel contacted

RESULTS

4. 4 4

9

10

11

Obtain a copy of the Annual Evaluation Plan and Schedule andevaluate adequacy of the plan and schedule based on the approvedlong range plan and schedule and planned work. (SPP 4.01, Para.5.e2)

Discuss with the EAS the establishment of the annual evaluation planand schedule. Does the EAS appear knowledgeable?

Discuss with the EAS the establishment of the annual plan andschedule. Doe the EAS appear knowledgeable?

REV. 891

' Ii

OFFICE OF CIVILIANRADIOACTlVE WASTE MANAGEMENT


SHEET 5 OF 6

AUDMIMURVELLANCEINSPECTION

NO. HO-91-03

*5pp qr tiS B~~~~~ ~~~~~~~~~~~ I

I I ~~~~~~~~~~~~~~~~III



RESULTS

* 4 1.

12

14

Has the PC approved the Annual Evaluation Plan and Schedule?(SPP 4.01, Para. 5.f)

Determine Nf fiscal 1991 Annual Plan and Schedule was distrbutedthrough the Program Coordinator to the PC and the organizationaldirectors. SPP 4.01 52.d(nots) and 5.g. Spot check the PC and theorganization directors to see If they have a copy.

Obtain the fiscal 1992 Annual Plan and Schedule. Has the PCapproved It? Has it bee distributed as described In item 13? K not,discuss with the EAS and PC the current status of the plan andschedule.

I. I I

REV. 891

yJ k.J~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~\OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 6 OF 6AUDITISURVELLANCEflNSPECTION

NO. HO-91-003

sGPP ' to//* £ £ h *~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

1 9

15

16

17

Obtain the 4 quarterly fiscal 1991 Evaluation Plans and Schedules.Have they been approved by the PC? (SPP 4.01, Para. 5.1)

Evaluate each Quarterly Evaluation Plan and Scheduile against theAnnual Plan and Schedule? Does It adequately address the Annual?

Determine If each of the 4 quarterly plans and schedule have beesent through the Program Coordinator to the PG and theorganizationai directors by the 1st day of each fiscal quarter duringfiscal 1991. Note SPP 4.01, Para. 5.1.2 (note) Indicates the fiscalquarters are January, April, July, October.

I I

REV. 8/91

L ,\ JI k I

OFFICE OF CiVIUANRADIOACTIVE WASTE MANAGEMENT


SHEET 1 OF 2AtJOITSURVELLANCOINSPECTIONNjo. HQ-91 -00

Wallis I 11110. � I iORGANIZATiON EVALUATED

EM-30

DATES OF EVALUATION

[XI EXTERNAL

[ ]INTERNAL

pq AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY Clyde Mor 11 V

CONCURRED BY t& g

APPROVED BY 7 z;4

DATE_____

L DATE

_ DATEerd"3091 0~010' J-

I..

CONTROLLING DOCUMENT (lit!e, Number, Revision) ACTIVITY EVALUATEDAdministration of Ouality Audits SPP 4.02, Rev. 0 Implementation of SPP 4.02



1 Request - Position description of the Program Coordinator.

2 Request - Position description of the Audits coordinator.

3 Request - Position description of the Audit team leader.

^ INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. SS I

Jo \1 I/I \� I


U.S. DEPARTMENT OF ENERGYWASHINGTON, D.C

SHEET 2 OF 2AUDMTISURVELLANCERNSPECTION

NO. HO-91 403

5f, P Ji. 0 -'I-

1110 -- lififfffl & I010 - 0 lop-



RESULTS

0. 4. 4.

4

5

6

Verify that the position descriptions are In line with the responsibilitiesIdentified In steps 5.a.(1) through (15), 5.b.(1) through (10), 5.c.(1)through (5), and 5(d).

Verify that the Individuals assigned to these positions have beentrained prior to performing work to this procedure.

Section 5.b.(e) states that the PC signs and dates the audit transmittalletter and returns to the QAS for dispositioning. The QAS has notbeen defined in this procedure. Please clarify.

I. I I

REV. 8/91

K-,~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



SHEET I OF 4

AUDITISURVEILLANCEiNSPECTION

NO. HO-91=003

C £


EM-30

DATES OF EVALUATION

[X] EXTERNAL

[1 INTERNAL

[XI AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY L Wade W ° %

CONCURRED BY JW 'O

APPROVEDBY < _ r

DATE f-Z1-L

DATE_

_DATEAfI?/L8/26-3091

. . .

CONTROLING DOCUMENT (tile, Number, Revision) ACTIVITY EVALUATEDConduct of Quality Assurance Audits, SPP 4.03, Rev. 0 T-P iate~tIAiob Ad SIP? 951 3_

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Reocrd objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

I Demonstrate how the audit team leader determines the specificreviews and Investigations to be made during the audit to match thestatus of activities. (Par. 5.a.2)

2 Verify the audit team leader prepares the final audit scope andplanning document induding the list of requirements and Implementingprocedures (Par. 5.a_3)

INDICATE RESULTS: SATISFACTORY (SAT). UNSATISFACTORY (UNSAT), NOT APPLICABLE (NIA)

REV. 8I1

Yj KY~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I 1OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 4

AUDITiSURVEILLANCEMNSPECTION

NO. HO-91-003

:5p P s9-39 £ 0 * 0 --~~~~~~~~~~~~~~~~~~~~~



RESULTS

I 4 4

Demonstrate how the extent and depth of the audit Is determined andIs this determination documented (5.a.3)

Verify that audit checklist (attachment A) are prepared and contain asa minimum; (Para. 5.a.6)a) Audit ID. number,b) Detailed I.D. of attrbutes,c) Identification of requirements

Verify the audits team leader assembles the audit planning packageand obtains the review approval of the QAS (Para. 5.a.7-10)

.5 - 4.

REV. 8/91

\1 -)OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 3 OF 4


NO. HO-91 -00

V.p qo5V,0

* £ £ -~fAl 11d~ifl=4 N4[



RESULTS

I I

6

7

8

Verify that audits have been conducted on activities In a timelymanner In order to identify potential or real deficiencies In the earlystages of the activity. (Para. 5.d)

Verify that deviations identified during the audit are documented on aDCAR In accordance with SPP-5.01 (Para. 5.d.9&10)

Verify that checklists are completed appropriately during the courseof the audit. (Para. 5.d.11&12)

REV. 8191

J I\1 .1ii \ I



SHEET 4 OF 4

AUDIT/SURVEILLANCEnNSPECTION

NO. HO-91-003

5pp V9,o3C 0 * 0 --~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

OEMNO. CHARACTERISlIC TO BE EVALUATED


RESULTS

9 I I

9

10

Verify that audit reports are prepared In accordance with AttachmentB and have been signed by the audit team leader and team members.(Para. 5.f.1-3)

Verify the audit report, Including deviation reports, completed auditchecklist, and the final audit planning package to the GAS In a timelymanner to ensure Issue of the final report within 30 days of the post-audit conference. (Para. 5.f.5)

REV. "91

~ i J/ �%LJ



SHEET 1 OF flAUDITISURVELLANCEINSPECTION

NO. HO-91-003

S111i 411 liiii i I -


EM-30

DATES OF EVALUATION

[X EXTERNAL

[] INTERNAL

IX] AUDIT

1 I SURVEILLANCE

1 I INSPECTION

PREPARED BY Louis R. Wade ISPCONCURRED BY 4

DATE __-_/__

eZ- DATE

DATEAPPROVED BY ,f ;7 -Jol8J26-30/91

DOCUMENT (Tftle, Number, Revision) ACTIVIlY EVALUATEDAdministration and Conduct of Surveillance SPP 4.04, Rev. 0 SPP 4.04 _ mf act4a V

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objedive evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Verify that the Survef fance Coordinator plans and schedulessurveiflance In accordance with SPP 4.01 (General)(Refer to cA for SPP 4.01

2 Verify that personnel who perform surveillance are qualified hiaccordance with SPP 3.04 (General)(Refer to CA for SPP 3.04)

* INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NPA)

REV 8I91

f ki \i



SHEET 2 OF r4AUrDI/SURVELLANCEINSPECION

NO. HO-1 -003

9 I I I 0 * Sruam



RESULTS

9 1 I

3

4

5

Verify the surveillance coordinator has ensured that evaluators areaware of assigned surveillance activities and;has determined the need for unscheduled surveillances (5.a. 1&2)

Verify the evaluator has Identified and collected Input material andprepare a surveillance guide sheet-Attachment B. (5.a.4)

Verify the evaluator has established a file for each surveillance activityand assigned a unique number and completes the activity status log(5.a.60

.1 .1 1

REV. 5d91

k ) I\' ')OFFICE OF CIVLIAN


WASHINGTON, D.C.

SHEET 3 OF jefAUDUTSURVELLANCEMNSPECTION

NO. HO-S1 -003

6-pp -/o0

I A I~~~~~~~~~* £A - S - 0 -



RESULTS

9 4

6

7

8

Verify that(5.b.1 -5)

surveillances have been conducted and documented.

Verify that deviations are documented in a rcodance SPP 5.01 (5.b.7)(Refer to cfi for SPP 5.01)

Verify the evaluator upon completion of the report doses out the fileon the surveillance activity and updates the surveillance activiy log(S.c.3)

REV. 8M91

A-) -OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF


NO. HO-91-003

Spp 9.c1/* £ £ -I 0 - --~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

I

9

10

11

Verify that results of surveillance activities are transmitted to themanagement of the organization being evaluated. (5.C.4)

Verify that surveillance reports are retained as quality records Inaccordance with SPP 7.01. (Refer lo c/ for SPP 7.01)

Verify the surveillance coordinator maintains the following records forworkingthistorical purposes. (5.d.2)a) surveillance guide sheetsb) surveillance activity logc) surveillance reports

I I. I

rE. 891



SHEEr I OF aAUrTSURVELLArCfNSPECWTON

NO. HO-91-003

S I


EM-30

DATES OF EVALUATION

S26-30/91

P] EXTERNAL

[] INTERNAL

p[X AUDIT

[1 SURVEILLANCE

[ I INSPECTION

PREPARED BY C. Mc

CONCURRED BY 4lt

)MreII9 DATE $ foI oIt

APPROVED BYe

DATE

DATEV7

CONTROLLING DOCUMENT (fltis. Number, Revision) ACTIVITY EVALUATEDAdministration of Technical Reviews SPP-4.05, Rev. 0 Implementation of SPP 4.05



1 Verify that the SPP is applied to:* Review Group composition and qualifications* Review Group funding* Initiation of Reviews* Processing of Review Reports* Records Control(SPP 4.05 Para. 4)

2 Verify that a charter has been established for a EM TRG to review theWAPs WCPs, and WORs. of each of the Vitrficatbn projects:a) Savannah Riverb) West Valleyc) Hanford


REV. Ml

J k ) .\- JOFFICE OF CMLIAN


WASHINGTON, D.C.

SHEET 2 OF a

AUDITISURVELLANCMfNSPECTMO

NO. HO-91-00

SFP V, 057-

IaI I I



RESULTS

1 9 9

3

4

What is the process used to decide which documents are subject toreview? (SPP 4.05, Para. 4)

How does the Review Coordinator ensure that documents requiringreview do not bypass the system?(SPP 4.05 Para 4) (SPP 9.03 Para. 4.a.7)

REV. 8 91

j' 1 J \ JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET S OF S

AUDITiSURVEElANCEANSPECTIONNO. HO-91-003

p p L1-. D57

S £ 9 ~~~~ ~~-mmn--



I

RESULTS

.9 t

5 How Is the coordination of the folbowing various activibies controlled?Review several packages. Verify each step Is performed.

a. Establishment of the Technical Review Group

Pedonner Acdon

Review Coordinator (1) Appoint Techncal Review GroW (TRG)Chakrman.

Materals Integration (2) Appodnt Executive Searetery (ES) Office (MO)

Review Coordnaor (3) Appeoes appointmenti d e ES

TRG Chairan.h ES (4) Recmnmend eneobers for TR3 caegnop.(See Attadcnent A.

Review Coordinator (5) Apprms appontment d TRG car grWmembership.

TRO Chaiman, ES (6) Appoint technical consultants to the TRG asneeded.

Review Ckoorinator (7) Aanges for adequate funding to avpprt TR1adblvties throughout the year.

(SPP 4.05 Para. 5.a)

REV. 8/9l

') N\1 /i



SHEET 4 OF SAUDIT/SURVEILLAN1CENSPECTIONNO. H041 .00

SPF' 91,05

p 1- 6 -

I I a I -



RESULTS

5a b. Documentation of TRG Quallflcatlon

Performer Aedin

TFG Chirman (1) Obtahis doacmerdatn fom each reviewronp menber to nhkide:

(a) Resume (swe Machmert B).

(b) Satemern d Irndendence (seeAlta h et C).

(c) 0uaikxin hifoaton (see Aadzmnnt0).

(2) Forwasrdsqu~ailonstatementsit ESbtrhico a kito the technkal document

review fie.

ES

Review Coidlaor

(SPP 4.05 Para 5.B)

(3) Mantain qualffication staemerts andprovides a copy d them lo the ReviewCoordnatr as tbey are generated.

(4) Aswes th the minimum quafrcatindescribed h Aachment E are met.

(5) bIsues Reviewer Cerffilcaton COetfcate (seeAtachment F)

REV. 6/91

J JI K ,'



SHEET 5 OF a

AUDfTISURVELLANCEPNSPECTION

NO. H40-91 -003

Sf'!r 9.. 05-

E N 1*A91393I4f11 r FRO M



RESULTS

4. 4 4

5b c. Initlation of Technical Review

Pedaoner Adion

Operations Offlce (1) Forwards package to work to be reviewed tote Review Coordnator.

(2) Provides Inxpt So Statemert df Work (SOW)for the Review Coorinatora use.

Review Coriator (3) Prepares and appoes finalized SOW for theTRG

(4) Authortres t review df Ite package by theTRt3.

(5) Logs the docinents en th Review Log(Attachment ).

(6) TransmIts the SOW and package dt work lobe reviewed b tho TRQ Chalnnan.

TRO Chairnan (7) Forwards the SOW and package df worklo bereviewed to the ES.

Executive Secretary (8) Establishes a technical review documant I6and a reviewerms data package for eachreview.

TRFI Chalman (9) hiliates the tchal review In accordancewith SM 4.06

(SPP 4.05 Para. 5.C)

REV. MI91



SHEET 6 OF aAUDITISURVEILLANCEnlNSPECTIONNO. HO-91-003

s 9o e-05-

I~~~~~~~~~


REMARKSRecord objective evidence reviewed, methodof verlication, personnel contacted

RESULTS

_

Sc d. Processing of the Prelbimnary Review Report

Petonner

TRG Chairan

Review Ceordialor

Operations oOffice

Review Coordiaor

TRG Chairman

Review Coordinat

(SPP 4.05 Para. 5.D)

Adion

(1) Trnsmt prelminauy review repoet [seeparamaph 4.a(4)J to the Review Coordinator.

2) Reviews and rnarsmits he prelnary reviewport g mIe Operations Office and docnent

generator.

(3) Responds to li comments codaind hI theprennary review repod and ormards theresponses o the Review Coordinator

(4) Review and transffts he responses receivedby the TRG Chairman.

(5) Coordinates response resolution with theOperations Office tough the ReviewCoordnalor.

(6) Concurs with responses after resodtion

(7) Ensures that ad commnents are dosed out andthat th3e 3 concurs with the resolution d thecomrments.

REV. 8191



SHEET 7 OF eAUDITISURVELLANCEMNSPECTIONNO. HO-1-03

5w,' %'/

*1 m0 0 --



RESULTS

6 4 4

5d

5e

e. Processing of the Final Review Report

Pedornier Adion

TRG Chaiman

Review Coordirator

(SPP 4.05 Para. 5.E)

(1) Transmits the final review repor [seeparagraph 4.A(5)) to th Review Coorinalor.

( Tranmits the fial review report and theconespon g revised materials (or sediontheo) trough agxqxlate dcamels.

(3) Records any conunents and date coioetionlhe Review Log (Antadcnerd G).

f. Records

Performer

Review Corldinator

Acton

(1) Prepares the Technical Review Record lies Iaccordance with SPP 7.01 to hrcue thefolowing

(a) Package beng vsinftted for review.

() BO.

(c) Fnal review report

(do Reviewer quaification statements.(SPP 4.05 Para. 5.F)

REV. 8/91



\ /ISHEEr s OF SAUDITISURVELIANCEINSPECTION

NO. HO- -003

seP9 Y, 05-C~~~~~~fl~[ie] :0 N461f T

I I a I~~~~~~~)



RESULTS

6 Verify that the following documents areproperly completed and filed.

a. Attachment A - Technical Review Group Composition

b. Attachment B - Standard Resume Content

c. Attachment C - Statement of Reviewer Independence(Example)

d. Attachment D - Reviewer Qualification Form (Example)

e. Attachment E - Minimum Qualifications for the TechnicalReview Group

I. Attachment F - Certification Certificate (Example)

g. Attachment G - Review Log (Example)

h. Attachment H - Simplified Flow Diagram for PadageReview

(SPP 4.05 Para. 6)

REV. 8/9M

K' \1J`\-



SHEET 1 OF 4

AUDITISURVEILLANCEnNSPECTION

No. HO-91-003

F I I - - I I


EM-30[Xq EXTERNAL

[1 ]INTERNAL

[XI AUDIT

l I SURVEILLANCE

[ I INSPECTION

PREPARED BY L.. *tek Im

CONCURRED BY JA'

DATE .L-Z-$

DATE


8/26-30/91APPROVED BY -

CONTROLLING DOCUMENT (litle, Number, Revision) ACTIVITY EVALUATEDConduct of Technical Reviews SPP 4.06, Rev. 0 Implementation of SPP 4.06


NO. of verification, personnel contacted

1 Verify that documents requiring review are Identified and that reviewsare conducted or scheduled. (SPP 4.06 Para. 1)

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NWA)

REV. 11MO

'~~~~~~~~~~~~~~~~~~~~~~~~~LJ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ I, /



SHEET 2 OF 4

AUDITISURVEILLANCEINSPECTION

NO. HO-91 -00

S5F' Al, v /

9 . ~~~~ ~~4090 so 0 --I



RESULTS

I I

2

3

4

Verify that the requirements of SPP 4.05 have been complied withprior to review. (SPP 4.06)

Is there any evidence that documents requiring review have by-passed the system? (SPP 4.06 Para. 1)

Are time constraintsschedules established? (SPP 4.06 Para. 5.b.2)

REV. 11190



SHEET 3 OF 4AUDrTIsURVELLANCEANSPECTIONNO. HO-9103

P5 -pp ioLb

S £ 0 * 4~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



0RESULTS

5

6

7

Verify that comments are recorded n the Review Comment Record(RCR) (SPP 4.06 Para. 5.b.3)

Verify that TRG comments are Integrated Into one RCR and receivedTRG member concurrence (SPP 4.06 Para. 5.c.1)

Verify that the TRG chairman has documented majority andminority positions. (SPP 4.06 Para. 5.c.3)

REV. 11/90



SHEET 4 OF 4

AUDITISURVEILLANCEIlNSPECTION

NO. HO-91-003

5 PP Al,c h'

I IIa



RESULTS

4. J.

8

98

Verify that the preliminary review report accurately reflects the group'somments. (SPP 4.06 Para. 5.c.5)

Verify that response resolution have been Incorporated into the finalreview report. (SPP 4.06 Pars. 5.d)

REV. 11/90



SHEET 1 OF 2AUDITriURVELLANCEIINSPECTIONNo. HO-91 -003

I - a I


EM-30

DATES OF EVALUATION

[X EXTERNAL

[ ]INTERNAL

p[X AUDIT

1 1 SURVEILLANCE

[ IINSPECTION

PREPARED BY L . 10A06 FADCONCURRED BY

APPROVED B

DATE -7-IL

DATE_

DATE f/zLYL-%. %, I

8/26-30/91 -�

CONTROLLING DOCUMENT (fTtle, Number, Revision) ACTIVITY EVALUATEDAdministration of Peer Reviews SPP 4.08, Rev. 0 Implementation of SPP 4.08


1 Verify that sequential steps for processing the preliminary PeerReview Report are followed. (SPP 4.08 Para. 5.d)


REV. 11/90

� j JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 2


NO. HO-91 -003

E5JP 9 111 3

I 11111111IM41111101a 01,4 119 M i II 4



RESULTS

l I. . .

2

3

Is the report reviewed and approved by Management.(SPP 4.08 Para. 5.e) prior to review. (SPP 4.05)

Verify that all preliminary comments are disposed of prior to Issuefinal report (SPP 4.08 Para. 5.e)

REV. 11J90

yJ

OFFICE OF CIVILIANRADIOAClIVE WASTE MANAGEMENT


SHEET 1 OF 5

AUDITISURVEW=AEICMNSPECTION

No. HO-91 -003

I I I I


EM-30

DATES OF EVALUATION

8/26-30191

(XI EXTERNAL

[ ]INTERNAL

[Xq AUDIT

[ I SURVEILLANCE

[ I INSPECTION


CONCURRED BY

APPROVED BY

t'. A d DATE 4/

DATE

, 2 -WDATE /I.,- Adz |

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDPeer Reviews SPP 4.09, Rev. 0 Date 2/02/90 Peer Reviews


I QARD-DOEJEMNWO/02 Section 3.0- Design Control Para. 3.2.1 states"Operations Offices Are Required to exercise design control practiceIn accordance with specific requirements..." 'The practices Includethe following: ...(15) Peer Reviews...."

Identify who at EM DOE Headquarters is responsible for themanaging of the Peer Review Function. (RW 214 Rev. 4, Paragraph1.3 delegation of work states in part '... Program Participant delegateswork - a qualified Individual from within the delegating office shall bedesignated office shall be designated as accountable for the qualityof the designated work'.) Ask for a DOE memo designating someoneIn Headquarters to oversee the peer reviews being done by theOperating office.

How Is the need for a Peer Review established? (SPP 4.09, Para. 1)


REV. 8/91

y J K->OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 5

AUDITISURVELLANCEONSPEC1TIN

NO. H-091-003

spp iA019 A h 0 - 6~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

rTEMNO. CHARACTERISTiC TO BE EVALUATED


RESULTS

9 I- I

2

3

4

5

Request the job description of the EM Headquarters designatedindividual to oversee the peer review of the Operations Office.

Is the person responsible for determination of the need for a PeerReview identified. (SPP 4.09 Para 4)

Review several Peer Reviews for compliance with this SPP.(SPP 4.09 Para. 1) report. (SPP 4.08 Para. 5.e)

Verify that the requirements of SPP 4.08 we complied will prior to thereview. (SPP 4.09)

________________________________________ I I

REV. 8191

S' J

OFFICE OF CIVILIANRADIOACTiVE WASTE MANAGEMENT


SHEET 3 OF S

AUDITISURVEILLANCE/INSPECTION

NO. HO-91-003

'5j-,? so9

S. I "I T

ITEMNO. CHARACTERISTlIC TO BE EVALUATED


RESULTS

I I- I

6

7

8

Verify that the attributes in Attachment A are addressed.(SPP 4.09 Para. 5.b.2)

Verify that comments are Incorporated Into RCRE have Groupconcurrence (SPP 4.09 Para. 5.c)

Verify that comments are dispositioned prior to Issue of the finalreport. (SPP 4.09 Para. 5.a)

4 . I

REV. 8&91

� J \ I/- I I



SHEET 4 OF 5

AUDIT/SURVEILLANCEA1NSPECTION

NO. HO-91-003

£ *I~~~



RESULTS

I I

9

10

11

Verify Management ReviewlApprove/Assessment/Audit or Evaluationof the adequacy of this procedure. (General)

Verify that completed attachments are on file. (SPP 4.09 Para. 6)

Review Completed Peer Review to verily compliance with Section 5.0,Section 6.0, and Appendix A through C.

J. I I

REV. /91

I-



SHEET 5 OF 5

AU DITSURVEILLANCE" NSPECTION

NO. HO-1-003

s~pf AY, o'M .£ &lif * S --i*]2,I

a- a- p~IE M

rIEMNO. CHARACTERISTIC TO BE EVAWATED


RESULTS

4. ¶

12

13

How was T1&O controlled prior to Issue of the SPPs? (General)

Has Peer Review been done of quality activities completed prior tothe Implementation of the SPP 5.

REV. W91

'Ij N\' '



SHEET 1 OF 8AUDrISURVELLANCEINSPECTION

No. HO-91-003

Ia a * -


EM-30

DATES OF EVALUATION

8/26-30/91

[XI EXTERNAL

I1INTERNAL

PXI AUDIT

I I SURVEILLANCE

[I INSPECTION

PREPARED BY Don Miller

CONCURRED BYAW

022 2 DATE A-7- 91

APPROVED BY

DATE

P- > DATE �w�L_ As i

DOCUMENT (Ttl, Number, Revision) Review of Operations ACTIVITY EVALUATEDOffice QA Program Descriptions & Procedures, SPP 4.10, Rev. 0 Criterion 5


I Determine the Operation Office's requiring QA Program Description'sand Procedure review. (Para. 4.0)

2 Verify that the requirements for Quality Assurance ProgramDescriptions and Procedures are defined In Procurement Documentsand Address the foblowing:

* Adequately Identify quality related activities

* Identifies at what level the documents require review andapproval.

' Determine who the QASs are. (Para. 4)

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT). NOT APPLICABLE (WA)

REV. 8/91

J ' I



SHEET 2 OF SAUDITISURVELLANCOfNSPECTION

NO0. HO-91 -00

.5pp 9,/D

S .



RESULTS

4 4. 4.

3

4

5

Verify that Operations Offices OA poram descriptions have beenreviewed (SPP 4.10, Paragraph 1)

Is a checkicst used for review process? (SPP 4.10. Para. 4.0)

Who determines which OA programs are subject to review(SPP 4.10, Para. 4.0)

4 I I

REV. S91



SHEET 3 OF a

AUDIT/SURVEILLANCEINSPECTION

NO. HO-1 -003

.5pp Y /O

NT 1- 0S A -*]a el1,4i



RESULTS

T I

6

7

Verify that the OA has performed the following functions:(1) Receives request for assistance from a DOE-HLW Program as

needed to perform reviews.

(2) Locates and ensures receipt of the descriptions and proceduresfrom the Operations Offices and logs the descriptions andprocedures In the Quality Assurance descriptions andProcedures review Log (Attachment B to SPP 4.11)

(3) Secures approval of the flist and obtains program executionguidance, if necessary, to compile all descriptions andprocedures for review.

I 1.

REV. 8M1

Y/ \1 1)OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 8

AUDITISURVELLANCEI1NSPECTION

NO. HO-914O03

yr t 'i(f XI I I~~~~~~~~~~~~UM



RESULTS

6 (4) Identifies and provides the HLW Program a list of qualityassurance program descriptions and procedures requiringroutine review.

(5) Establishes a review file for each description or procedure to bereviewed.

(6) Identifies additional comments for selected review based on thedocuments Importance to quality, extent of revision and content.

REV. 891



SHEET 5 OF aAUDrIPSURVEILLANCEMNSPECTIONNO. 140-91-00

5-P P ' 9/ '

Sa * IA111wl 0 1 E E -M

I II - -



RESULTS

I 4

6

7

(7) Coordinates with the HLW Program Manager and DivisionManagers, id appropriate, the assignment of the programdescriptions or procedures to receive review.

(8) Assigns the description or procedure to the appropriate reviewerfor review. (SPP 4.10, Para. 5.a.)

Has the evaluator performed an adequate review. Check severalreviews for completeness, accuracy, and Identification of errors oromission. (SPP 4.10, Para. 5.b.3)

a ,. I

REV. 8/91



SH-EET 6 OF a

AUDWTSURVEILANCeIINPECTIONNO. H04-=0

s5PP 9f /

p a 6 -~o141121 9419 0 I 6 M I



RESULTS

7. 1

S

g

10

Verify the completeness of the review.(a) Are all quality requirements identified and addressed.(b) Are references to codes and standards correct. Check dates,

titles revision and applicability. (SPP 4.10, Para. 5.b.3)

Is the difference between comments and deviations dearlyestablished? (SPP 4.10, Para. 5.c)

Are comments categorized as mandatory and non-mandatory?(SPP 4.10, Para. 5.d)

I I. I

REV. 891



SHEET 7 OF aAUDITMSURVELLANCEMNSPECTIONNO. HO-91-03

5PP di, oA I ---- m94ou



RESULTS

I t I.

11

12

13

Has the evaluator assessed the reviewed procedure's successpotential (SPP 4.10, Para. 5.b.4)

What safeguards are in place to prevent this procedure from being by-passed. (General)

Verify that a Review Comment Record form Is prepared for eachreview. (SPP 4.10, Para. 5.d)

.4 I I

REV. 8/91

'.1 \ I/OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET a OF a

AUDITISURVEILLANCE" NSPECTION

NO. HO-S1 .003

Sp P 9, / D

I I ~~~ ~ ~~~~~~~~~~~~~I a a



RESULTS

T I

14

15

Verify that the QAS has:(a) consolidated comments(b) distributed review results(c) updated the review log

(SPP 4.10, Para. 5.d)

Verify that the review file contains the following QA Records(Para. 5.e.1)* document control* guide sheets* review comment sheet* deviations* any review notes or other pertinent data relevant to the review.

4 L

REV. e91



SHEET 1 OF 11AUDITISURVELLANCEnNSPECTIONNO. HO-91-003

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - I~~- -- -

I a


EM-30

DATES OF EVALUATION

826-30/91

[X EXTERNAL

[ ]INTERNAL

[XI AUDIT

[ I SURVEILLANCE

I INSPECTION

PREPARED BY Dim

CONCURRED BY A6A

APPROVED

DATE L .7-9

DATE

DATE

_,

,^ , _ _ ^ c

a~~~~~~~~~~

CONTROLLING DOCUMENT (Ill., Number, Revision) ACTIViTY EVALUATEDReview Waste Acceptance Process Technical Documents SPP 4.11 Rev. 0 Implementation of SPP 4.11

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record obective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Verify that SPP 4.11 is availableat work stations (Page 1)

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NJA)

REV. 11190

/ "I------ M.-



SHEET 2 OF 11AUDITISURVELLANCENSPECTIONNO. HO-91 -03

5p:p Y, /II £ I



RESULTS

_______ I I

2

3

4

Verify objective evidence thatassigned personnel are familiarwith SPP 4.11 and documentsreferenced therein (SPP 3.04,SPP 4.01 and SPP 7.01)See EM/WODt2 Para. 2.1.7(Para. 3 A, B & C)

Have any bwer tier documentsbeen Issued to control thereview

Verify that reviews of technicaldocuments address the followingattributes.a. Applicabilityb. Correctnessc Adequacyd. Completeness (Para 4)

I I.

REV. 1t 0



SHEET 3 OF 11AUDITSURVELLANCONSPECTION

NO. Ho91-003

D'5 f A/. /I9 A A 0 - 0 --

ITEMNO. CHARACTERISTIC To BE EVALUATED


RESULTS

4 4 1-

5

5a

6

Are review of technical documentsindepth and critical (Para. 4).

Were any review of technicalreviews performed prior toissuance of this SPP. I so,did reviews meet the Intentof this SPP? (General).

Are technical documents reviewedto determine if QA requirementsare complete, correctly stated,Inspectable, and controlled.(Para. 4).

REV. IISO



SHEET 4 OF 11AUDrITSURVEILLANCEi1NSPECTIONNO. HO-91-003

vp A-/.f//

* I £ S * Sa I



RESULTS

£ I- I

7

7a

Note: Check for quantitative,qualitative acceptance criteriatolerances, references to codesand standards. (Para. 4)

Verify that the review activityis adequately controlled.

Is there a lg of kcomingdocuments and an assignedreviewer?

1.

REY. 19



SHEET 5 OF t1

AUDITISURVELLANCE/INSPECTION

NO. HO-91 -003

S5PP All"

I I I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

I t 4

7b

7c

a

What safeguards are there toendure that no documentsbypasses the system?

Is there a schedule forturnaround of the review?Is an alternate reviewerassigned In the principalreviewers absence? (General).

Review several technicaldocument review. Look forcompleteness, clarity,consistency and approval(General).

REV. 1I90



SHEET 6 OF 11

AUDITISURELLANCEOINSPECTION

NO._HO-41 -003

.

:5pp /. //- I

I p~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

9. 4

9

10

11

Are comments resolved In atimely manner? (General)Check population and averageresponse time.

Verify that the steps in thereview process are performedand documented as necessary(Para. 5)

Has E.M. performed an indepthreview of document reviewactivities? (General).

6 4

REV. I1=90

JL



SHEET 7 OF 11

AUDTSURVELIMCEMNSPECTION

NO. HO-91 003

5pp &9,//

11 S f & A :~ N P W..R I -.

I I I p~~~~~~~~~~~~~~-



RESULTS

12

13

14

Is the responsibility forsupervision of the reviewprocess dearly defined?SPP 4.01 (Para 5)

Has the QA specialistIdentified and listed docu-ments for which reviews arerequired or recommended?(Para 6A)

Verify that reviewers arequalified In accordance withSPP 3.04. How Is this docu-mented.

REV. 11190

II.OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET a OF IIAUDrTISURVEILLANCEANSPECTIONNO. HO-91-3

5pp9q //

I p~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

l I..

15

16

17

Are reviews consistent. Checkreviews of similar documentsperformed by various personnel.(General).

Review several document packages.a. Is there an Index to Indicate

what should be In the file?b. Are files dearly labelled.c. Is access controfled.d. Is there a tracking system to

indicate the status of eachreview.

Para. 5C(2) requires the reviewerto forward notes and pertinentdata to the preparer. Para. 5C(3)requires the QAS to file pertinentdata. Is this a conflict?Para. 5.

I I

REV. I 190



SH-EET 9 OF 11

AUD~ITSURVEILLANCEflNSPECTION

NO. HO-91-003

6.PP q 9/I

Il i a F. I I



RESULTS

'B I. T

la Have EM personnel received training/Indodrination In SPP 4.11 and 4.12(QAAP 2.1 and 5.1.3)

What Is the approval circuft forSPPs. EM/WO/02, Para. 2-1.

What Is the applicability of SPP?(General)

20

.1 1. 1.

REV. 1V90

y}. v)OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEEr 10 OF 11

AUDMIUSURVELLANCEI1NSPECTION

NO. HO-1 -003

;5pp A1,11

C a £ 0 - 4 --~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

l. I4

21

22

23

Are SPPs the property of PDC, EM,or RW. (Lead Page SPP's)

Why Isn't the 18 criteria formatadopted. (EM/WOM2 Para. 6.1 and5.1.2)

Is there a matrix showing relation-ship between SPP'sfand otherprocedures. (EMIW/02 Para. 2.1.6)

4 - I

REV. 1 V90

N



SHEET 11 OF 11

AUDITISURVEILLANCE"ANSPECTION

NO. HO-1 .003

5pq, / /

* a aMX111 M .- 0 -



.1 1.-

24

25

Review results of EM surveillance,audits and reviews of SPP 4.11 and4.12.

Are SPP's prepared In accordancewith QAAP Section 5.

1. 1

REV. 1/90

OFFICE OF CIVILANRADIOACTIVE WASTE MANAGEMENT


SHEET 1 OF aAUDITrSURVEILLANCEWINSPECTIONNo. HO-91.003

e a 1r 1* n afl o :0 I1~


EM-30

DATES OF EVALUATION

8&26-3091

Don Millar 2 I-[XI EXTERNAL

[] INTERNAL

[XI AUDIT

1 I SURVEILLANCE

[ I INSPECTION

PREPARED BY_ __ ........... _. . _ ,

CONCURRED BY t/AA-DATE &-;- '7/

>z DATE

_ DATE 4V;OiLAPPROVED BY ,:_. gaz&4

CONTROLLING DOCUMENT (Ttle, Number, Revision) Review of Program ACTIVITY EVALUATEDExecution Guidance Documents (PEGDS) SPP 4-12, REV. 0 Implementation of SPP 4.12

REMARKS ENEOM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, methodRESULTS


1 Verify objective evidence that assigned personnel are familiar withSPP 4.12 are documents referenced therein.(See EMNVWO/2 Para. 2.1.7)

2 Have any lower tier documents been issued to control the reviewac~ty. (Par. 4, General)

^ INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. 891

~ JJ

/ >1OFFICE OF CIVILIAN


WASHINGTON, D.C.

SH-EET 2 OF SAUDrr/SURVELLANCO/NSPETOMNNO. HO-91.00

5;pp z/,)X=

S ' £ -4S * S -



RESULTS

N I

3

4

4a

Verify that reviews of technical documents address the foblowingattributes.a. Applicabilityb. Correctnessc. Adequacyd. Completeness

Are review of technical documents indepth and critical (Para. 4).

Were any reviews of PEGDS performed prior to Issuance of this SPP,if so, did reviews meet the Intent of this SPP (General).

REV. 8191

L )-



SHEET 3 OF S


NO. HO-91-00

:5P1P7 l 4 / -2a * 41-.f -1190411241 RI - S -."

I I p~~ ~ ~~~~~~~~~~~~~~~~~~~~ I



RESULTS

5

6

6a

Are P.E.G. documents reviews to determine, I QA requirements arecomplete, correctly stated, inspectable, and controlled.(Para. 5.b.3).

Note: Check for quantitative, qualitative aceptance criteria tolerances,references to codes and standards. (EM/NVO/2, Para. 5.1.1.)

Verify that the review activity Is adequately controlled(EMWO/02, Para 4.1.1)

Is there a lg of Incoming documents and an assigned reviewer.(Para. 5.a.5)

_______ I I

REV. MI91



SHEET 4 OF a

AUDrrISURVEILLANCEA1NSPECTIONNO. H04FO003

S.P P J�-' J -7-pi '1S a-*31iS


REMARKSRecord objective evidence reviewed, methodof verfication, personnel contacted

RESULTS

. .

6b

6c

7

What safeguards are there to ensure that no documents bypasses thesystem (General).

Is there a schedule for turnaround of the review. Is an alternatereviewer assigned In the principal reviewers absence (General).

Review several PEGD reviews. Look for completeness, clarity,consistency and approval (General).

REV. 8/91

>2OFFICE OF CIVILIAN


WASHINGTON, D.C

SHEEr 5 OF a

AUDrTISURVELLANCEJINSPEcTION4NO. HO-91-03

.5F'r qI / 2?& -a -~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS. .

a

9

10

Are comments resolved In a timely manner. (General)Cheo population and average response time.

Verify that the steps In the review process are performed anddocumented as necessary. (Para. 5)

Has E.M. performed an Indepth review of document review activities.(General).

4 4 4

REV. MI91

1I I/OFFICE OF CtVILIAN


WASHINGTON, D.C.

SHEET 6 OF e

AUDMISURVELLANCEnNSPECTIONNO. HO-91 003

5FF' q '/ 2-

p ~~~~~~~~~~~~I I



RESULTS

9* t

11

12

13

Is the responsibility for supervision of the review process cdearlydefined. (SPP 4.01, Para 5)

Verify that reviewers are qualified In accordance with SPP 3.04. Howis this documented?

Are reviews consistent. Check reviews of similar documentsperformed by various personnel. (General)

I i. a

REV. 6/91



SH-EET 7 OF a

AUDITISURVELLAN4CENSPECTIONNO. HO-91-03

5PP ',2.

RIW& 01 11W*191S 6 --1 1


REMARKSRecord objective evidence reviewed, methodof verfficaton, personnel contacted

RESULTS

4 I .9

14

15

16

Review several document packages.

a. Is there an Index to Indicate what should be in the file?b. Are files dearly labelled?c. Is access controlled?d. Is there a tracking system to Indicate the status of each review.

Is distribution of review results and resolution of comments performedIn accordance with Para. 5.b.

Have EM personnel received trainingAndoctrinatlon In SSP 4.12.(QAAP 2.1 and 5.1.3)

C C C

REV. 8/91

K) K>OFFICE OF CIVILIAN


WASHINGTON, D.C.

sHEEr 8 OF 8AUDOISURVELLANCEINSPECTnON

NO. H041003

sPP 4t/Z9 A f M *



RESULTS

I I

17 Review results of EM surveillance, audits and reviews of SPP 4.11and 4.12.

.3 I I

REV. 8&91

i J \ I



SH-EET 1 OF 3AUDITISURVELLANCEJINSPECTIONNo. 1-1-91 -O03

S01N11N . ~ 4 0 - -


EM-30

DATES OF EVALUATION

'Sc"�L"�WAk�N[X EXTERNAL

[] INTERNAL

pq AUDIT

I I SURVEILLANCE

1 I INSPECTION


CONCURRED BY ii/1I

DATE _ _

DATE

DATE £?:1itAPPROVED BY Z r

R6-30191I.~~~ ~ ~ ~ .L

CONTROLLING DOCUMENT (Title. Number, Revision) ACTIVITY EVALUATEDParticipation In Evaluation Activities Lead By External Organization, SPP 4.13. Rev. 0 SW /,5 _3

REMARKSIOEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTS


1 Identify completed External Evaluation Activities based on scope ofscheduled evaluations. [SPP 3.01, Para. 5.aP()]

2 Verify that the QAS confirms the schedule date with the organizationleading the evaluation activity.


REV. 8M1



SHEET 2 OF_

AUDITJSURVEILANCENSP

NO. H40-1003

='ECTION

SPI, L/,/a

S a i *a S~~~~~II W of -



RESULTS

3

4

5

Verify that the QAS completes Part 1 of the Extemal EvaluationParticipation Record and submits for approval.

Verify the QAS has been trained to perform the tasks Identified In thisprocedure.

Participation In External Aklvitles verify that the participants performsthe steps I through 3 (notrng deviations) (Para. 5.b)

I. .&

REV. a/91

yJ� <2, IY



SHEET 3 OF 3AUDrTIS1JRVELLANCEANSPECTIONNO. HO-91-40

51pP- 49' f-31111111'0 *1 Om I



RESULTS. .

I.

6

7

Evaluation of performance verify that the particpant performs thesteps 1.2 & S.

Records. Verify the QAS prepare the External Evaluation ParticipationRecord as a quality record In atcordance with SPP 7.01

I 6

REV. 8/91

y) K)~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~IOFFICE OF CIVIUAN


WASHINGTON. D.C.

SHEET 1 OF 6

AUDITISURVELLANCEflNSPECTION

NO. HO-91-003

9 A A~~~~~~~~~~~~~1


EM-30

DATES OF EVALUATION

rX] EXTERNAL

[ ] INTERNAL

IX] AUDIT

[ I SURVE

l I INSPE(

'2255nPREPARED BY D. Miller

:ILLANCE

.,TION

CONCURRED BY ___

APPROVED BY -- 7 -

DATE ff-2 21

DATE

DATE8a26-30/91

DOCUMENT (Ttle, Number, Revision) ACTIVITY EVALUATEDDeviation Reporting and Disposition, SPP-6.01, Rev. 0 Implementation of SPP 5.01

REMARKSINEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTS

NO. of verification, personnel contacted

1 Determine K any organization responsible for providing correctiveaction for a deviation has been non responsive or untimely. if so, hasthe Implementing organization evaluated the deviation to determinethe need for escalated management attention. (Para. 4.0)* Determine what criteria was used for evaluation and where this

criteria Is documented.


REV. 8a91

K'~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



SHEET 2 OF 6

AUDITPiURVELLANCEANSPECTION

NO. HO-91 -03

Sp P 5- 0C 4 *~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I I I p -i~~q111111:91; 4



RESULTS

I I

2 Identification and documentation of deviations (Para. 5.a.1-4).Determine If deviations are promptly Identified by evaluators and thatthe evaluators:* Discuss the deviation with the organization responsible for Item or

activity;* Confirms that the deviations exists;* Verify how this Is done.* Confirms that the condition has not been documented;* Determine what happens if the deviation has already been

documented.* Documents the deviation on a Deviation and Corrective Action

Report (DCAR);* Initiates a nonconforming Item tag for deviations Involving

hardware;* Determine what happens if the Item Is not hardware orientated,

such as database, documents, procedures, etc.

I I I

RIEV. I91

.'11�-�



SHEET 3 OF 6

AUDIPSURVELLANCEMNSPECTION

NO. HO-91=003

5PP sOJ0

E -- Al-. 11WMZ9vMA 6 X



RESULTS

. .

3

4

Verify that the DCAR Administrator has established a DCAR workingfile and the file contains the following documents: (Para. 5.a.5, s.c.4,5.e.7, 5i.6* Copy of the original DCAR and all revisions* Copy of transmittal memorandum or letter* Copies of all proposed dispositions* Copies of all proposed corrective actions* Copies of all accepted/rejected corrective actions and dispositions* Copies of all correspondence related to dispositions and corrective

actions for the Initiating organization and responsible organizationfor each DCAR.

Verify that the DCAR Administrator has established a Log and the Logcontains the Information listed in attachment E. Verify that the log isup-to-date.

__________ . I

REV. I91



SHEET 4 OF 6

AUDITlSURVELIANCEMNSPECTlON

NO. HO-91 -003

-9pp 5s, 0-- ---- * -

I a I a p

NEMNO. CHARACTERISTiC TO BE EVALUATED


RESULTS

l l4.

5

6

Evaluation of deviations for corrective action reporting (Significance)(Para. 5.b.1-5)Verify that the evaluator:* evaluates the deviation against the criteria listed In attachment C:* documents if corrective action Is required* Ensures the responsible organization Is notified of the adverse

condition requiring control In order that they may take appropriateaction. Determine how this is done.

Deviation and Corrective Action Report (Para 6.c.1-9)A. Verify that the evaluator

* Obtains concurrence that corrective action Is required fromthe manager.

* Issues and transmits the DCAR via memorandum or letter tothe responsible organization.

* Forwards the DCAR to the DCAR Administrator for filing.

B. Determine how the evaluator verifies Items containing deviationsare segregated or otherwise controlled to preclude Inadvertentuse.

C. Determine how the evaluator expedites responses whennecessary.

4 1 J.

REV. 8/91

K] \~



SHEET 5 OF 6


NO. HO-91-003

SPP r5DI

9


REMARKSRecord objective evidence reviewed, methodof veriication, personnel contacted

RESULTS

I* I

7

8

Receipt of Proposed Dispositions/Corrective Actions (Para. 5.d.1 & 2)A. Determine how the responsible organization transmits the

proposed disposition and corrective action.B. Verify that the date of receipt for each proposed disposition and

corrective action are logged.

Evaluation of Proposed Disposition/Corrective Action (Para. 5.e.1 -7 &5.f.1-10)Verify that the evaluator:

Evaluates the adequacy of the proposed disposition for solvingthe specified problem.

Determine the actions necessary to accept the disposition.

Determine the actions necessary to reject the disposition.

Verify that the evaluator notifies the responsible organization ofthe accepted or rejected disposition.Verify the if Corrective Action Is requested, the evaluationincludes:* Reason for the deviation (root cause)* Action taken/proposed to Investigate and correct any similar

work in which the same deviation may exist and was topreviously Identified.

* Managers approval (Section 9 of DCAR)Verify that when a DCAR is revived the DCAR Administratoropens a new entry In the log.

.4 .4 .4

REV. 891

� j J�4LI I

I


RADIOACTIVE WASTE MANAGEMENT AUDITISURVELIANCEIMNSPECTnON

U.S. DEPARTMENT OF ENERGY NO. HO-91 -003

SppS WASHINGTON, D.C.

ITEM ~~~~~~~~~~~REMARKSITEM CHARACTERIS71C TO BE EVALUATED Record objective evidence revieweci, method RESULTSof verification, personnel contacted

8 What criteria Is used to determine if the deviation Is reportable as anUnusual Occurrence?

Determine what the DCAR Administrator does with the original DCARand with the revised DCAR. (Para. 5.f9)

9 Verification and Closure of the Dispositioned ActionlCorrective Action(Para. 5.h.1-6 and 5.g.1-9)Verify that the evaluator:

During disposition monitors progress and when complete verifiesthat the actions taken to correct the deviation and correctiveaction, If applicable, have been completed satisfactorily and asscheduled.

* Verifies the action taken to prevent recurrence Is satisfactory.* Verifies the action to Investigate and correct any similar work Is

satisfactorily complete.* Documents the verification activities.* Ensures the removal of any nonconforming item (tags) only after

verifying satisfactory completion of all disposition actions.Determine how controls are removed from items other thathardware.

* When corrective action taken Is unacceptable Issues a revision tothe DWAR and coordinates with the organization responsible forcorrective action to obtain further action.Determine what course action would follow an unacceptablecorrective action.

* Issues correspondence to Inform the Involved parties of thedosure of the corrective action.

I

REV. Ml91

Jo \__/yJ

K->



SHEET I OF 3AUDrTISURVELLANCEI1NSPECTIONNo. HO-91 -O0

I I A


EM-30

DATES OF EVALUATION

8M26-3W91

MX EXTERNAL

[ ]INTERNAL

[XI AUDIT

SURVEILLANCE

J INSPECTION

PREPARED BY D. Miller Z/f

CONCURRED BY AAA 7

APPROVED BYl;7 I+

DATE _____

DATE

DATE _11&

. .

DOCUMENT (Title. Number, Revision) ACTIVITY EVALUATEDManagement Action Request, SPP-5.02, Rev. 0 Implementation of SPP 5.02


1 Determine I any Internal or External MARs have been Issued.

2 Determine I the MARS(s) were responded to within 15 days.


REV. 891

\4~~~~~~~~~~~~~~~~~)~~\1 "



SH-EET 2 OF~ 3

AUDITISURVELLANCEI1NSPECTION

NO. HO0-91 -003

-5FPP 5o 2L.

I I a



RESULTS

t 1 4.

3

4

5

Verify that the evaluator has evaluated late MARs for escalation to thenext level.

Determine the responsible level of management for the followingMARs.* LevellI* Level 2* Level 3

Verify that a MAR Log has been established, unique numbersassigned, and dates entered for tracking purposes.

REV. 8/91



SHEET 3 OF 3AUDITISURVEILLANCO/NSPECTIONNO. H40-91-003

.5 pP 5-0Z2

0-~~~~*£ A-.*0-



RESULTS

.4 I 4

6

7

Verify that the MAR Is in the appropriate DCAR working file.

Verify that MARs are prepared and maintained as quality records.

REV. 8/1

y) K>~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~,I,



SHEET 1 OF 3AUDIT/SURVEILLANCElNSPECTIONNO. HO-91-003

mm* - a I


EM-30

DATES OF EVALUATION

8/26-30/1

[X EXTERNAL

[ 1 INTERNAL

[XJ AUDIT

[ ] SURVEILLANCE

I I INSPECTION

PREPARED BY D. Miller 2 vL

CONCURRED BY I/AA

APPROVED BY

DATE tQ'7-q/

r DATE

- DATE00,"00 - - ., 740

DOCUMENT (Ttle, Number, Revision) ACTIVITY EVALUATEDControl of Unsatisfactory Conditions (SWO) SPP 5.03, Rev. 0 Implementation of SPP 5.03

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTS


1 Determine if ary unsatisfactory conditions have been identified and Ifany Stop Work Orders have been Intliated.

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (WA)

REV. MI

\1 -) ~~~~I\OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 3

AUDITISURVEILLANCEfNSPECTION

NO. HO-O1 -003

5Pf s5o2-S & a *& S - S



RESULTS

Determine who has GA responsibility and authority to Initiate actionsto control or to stop an activity Identified as unsatisfactory. Determinehow this authority Is Implemented.

What happens to the UAD after it goes to management.

According to the FARS and DEARS, the Contracting Officer is theonly one who can Stop Work. How Is this accomplished.

Verify that a Urgent Action Directive (UAD) Log has been establishedand updated as required. (Para. 5.b.3)

Verify that an Urgent Action Directive working file has beenestablished and contains the following Information:

Copies of Urgent Action Directives

4. 4 4

REV. 8191



SHEET 3 OF 3AUDIT1iURVELLANCEINSPECTION

NO. HO-g1-003

,SPP 5-;.03

IllS IllS^|11 | i. 11.Su 1;^ &|1;&I A A



RESULTS. .

5

6

7

Determine how the Urgent Acdon Directive and the DCAR are trackedthru closure.

Determine what constitutes a UAD record.

Determine how the unsatisfactory work.

6 1. 1~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

REV. 8/9i

J j2 I~~~~~~~~1-1



SHEET 1 OF 3AUDITISURVELLANCENSPECTIONNO. HQ-91-003

p & �


EM30

DATES OF EVALUATION

8/2630191

[X EXTERNAL

[ ] INTERNAL

[XM AUDiT

{ I SURVEILLANCE

[ I INSPECTION

PREPARED BY D. Miller

CONCURRED ByA&

DATE P-2- I/

_ 7

APPROVED ed:/Z>

DATE

DATE 4I/7/*

DOCUMENT (Titie, Number, Revision) ACTIVITY EVALUATEDDisposition of Deviations Identified by Outside Organizations, SPP 5.04, Rev. 0 Implementation of SPP 5.04

ITEM REMARKSNO. CHARACTERISTICS TO BE EVALUATED Record objectve evidence reviewed, method RESULTS


1 Determine i any deviations have been Initiated and issued concerningDefense Waste, Waste Acceptance Specification (WAS) or theFederal Repository Ucense Application. (Para. 4)

Verify that the WAS has been Issued. if it hasn't then why is itlisted? The WAPSs should be the documents referenced.

Verify that OCRWM approves any deviations concerning theabove.

* INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT). NOT APPLICABLE (N/A)

REV. 8 9I

/I I I



SHEET 2 OF 3

AUDITISURVELLANCEAlNSPECTION

NO. HO0-91-003

-5PP s5.C

* A A *A - 0 --~A

I I II



RESULTS

I 4

What Is the purpose of this procedure?

How will this procedure be used for deviations identified from auditingorganizations submitted on the (General)

Verify that a commitment log has been established and is maintainedIn current status. (Para. 5.a.2) (General)

How provides the disposition? (General)

C . 4

REV. 8 91

'�- I/IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 3 OF 3

AUDITISURVELLANCEJINSPECTION

NO. HO-el-COw

sypF 505'O

I I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

4 t I

5

6

What Is meant be defining the disposition? (Para 5.a7)

How is the request for assistance made verbal or In writing? (Para.5.b.1)

.1 . .

REV. Ml91

\ I



SHEET 1 OF 4

AUDITISUJRVELLANCEWISPECTION

No.~ HO-91-003

molC I a 1~ 1.I a a


EM-30

DATES OF EVALUATION

826-30/91

pg EXTERNAL

[1 INTERNAL

p[] AUDIT

I I SURVEILLANCE

1 I INSPECTION

PREPARED BY Don Miller 'J)

CONCURRED BY

APPROVED

DATE F-2-`9

DATE

DATE L44L

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDReview of Unusual Occurrences, SPP 5.05, Rev. 0 Criterion 16 - Corrective Action

REMARKS 0

ITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Determine If any UORs have been received and what type ofevaluation has been requested. (Para. 5.a.1)Ust the UORs received:From:Date of ReportSubject of UORClosure Date:


REV. 8/1

~~ J .,, -')~~_ KOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 4

AUDITlSURVEILLANCEANSPECTION

NO. HO-91M3

:5Pp r7o!T

#C £4 - --1ffde~tl *1,,( -

p p p~~~~~~~~~~~~~~~~~~~~

ITEMNo. CHARACTERISTIC TO BE EVALUATED


RESULTS

9.

Interview the responsible Manager and determine the purpose of thefollowing: (Para. 4.a2.a-c)a) Initial UOR -

* Define established timeframe

b) Interim UOR

c) final UOR

Determine how UORs are tracked through closure. (General)

Determine what criteria Is used to evaluate the UOR for programmaticsignificance such that it adversely affects or potentially effects theperformance, reliability, or safety of a facility. (General)

I ,. I

REV. 8/91

-�- -J \1 ) \' �)OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 3 OF 4

AUDITISURVEIUANCEPINSPECTION

NO. HO-91-003

I~~~~~~~~~



RESULTS

1 7

5

6

Verify that final UORs correctly retain the information provided in theinitial and interim reports and that the final UOR contains thefollowing: (Para. 5.a.5.a-d)* Determination of cause

* Adequacy of disposition

* Adequacy of action to prevent recurrence

* Generic applicability to other features or facilities Internal orexternal to DOE.

Verify the review memorandum or letter fully addresses the reviewrequest. (Para. 5.a.7)Verify that memorandum or letter dearly Indicates "No Comments%.

I.

REV. 891

\i <IOFFICE OF CIVILIAN

RADIOAClIVE WASTE MANAGEMENTU.S. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

SHEET 4 OF 4

AUDITISURVELLANCEANSPECTION

NO. HO91 003

S P? £505-

a a *a~~ I 4 I



RRESULTS

Verify if comments are made, the comments are clear and actionitems are clearly defined. (Para. 5.a.7)

Determine how deviation that have not been documented areIdentified. (Para. 5.a.8)

* Verify that DCARs are prepared.

Verify that the following are designated as QA records and processedin accordance with SPP 7.01: (Para. 5.b.1)* Copies of UOR

* Related correspondence

* Key working papers

________________________________________ I I

REV. a91

JI \1 1) 1



SHEET 1 OF 5AUDIT/SURVELLANCE/INSPECTIONNo. H"iQ -03

* y lI Y 1 )F_ _ _ , _ _ I


EM-S3

DATES OF EVALUATION

S/26-30i91

[X EXTERNAL

(IRlSTERNAL

m AUDIT

I I SURVEILLANCE

1 I INSPECTION

PREPARED BY J. George

CONCURRED BY

DATE F -7 I/

6

APPROVED !? Q

P DATE

DATE Z/i4LDOCUMENT (Title, Number, Revision) Control & Disposition of Deviations & ACTIVITY EVALUATED

Recommendations for Improvement by Outside Organizatlons!. SPP 5.06, Rev. 0 Control and Disposition for Deviations


1 Section 2, page 1. requires that the procedural process ! ... apply onlyto the organization(s) that has adopted this SPP for Its own use orthat has had it Invoked by contractual....means!.

Verify by Interviews with appropriate personnel and/or review ofobjective evidence?:

1. List who are the affected organizations.2. Identify how the SPP Is adopted or Involved.3. Verify that the process Is In use for those organizations for whom

it has been adapted or Invoked.

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N*A)

REV. Ml91

/ I/I k~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1 I



SHEET 2 OF 5

AUDITISSURVELLANCEA1NSPECTION

NO._HO414003

5P4' 5-,cOb

I I I I



RESULTS

l I- .1

2 Section 4. first paragraph, page 1, states In part '... reports andrecommendations are a likely result of... evaluation by externalorganizations...may be received In various formats...referred togenerically as external program evaluation reports. The coordinationof these external evaluations are addressed In SPP 8.01:.

Verify by review of objective evidence that1. Extemal organizations are reviewing and recommending

improvements.A. Provide a list of those organizations.B. Review several of the reports for content and format and

determine If they provide the appropriate information.2. The coordination of these evaluations Is In accordance with SPP

8.01.

REV. 8/91



SHEET 3 OF 5AUDITISURVELLANCEANSPECTION1NO. HO-91-003

5p~ps70'O

I I 01111I lil41RVII p&10M ~



RESULTS-I t 1*

3

4

Section 4, second paragraph, first sentence, page 1, state that eachdeviation and recommendation for Improvement will be evaluated andan appropriate response will be prepared In the time framerequested".

Choose several examples and verify by review of objective evidencethat each deviatiornecommendation is:

1.2.3.

Evaluated,Has an appropriate response,Is prepared In the requested time frame.

Section 5, paragraph, items (2) and (3), page 2.

Verify by review of objective evidence that the DCAR Administrator1. Establshes a working file for each external program evaluation

report and;2. Enters each report in the Commitment Control Log in accordance

with SPP 6.04

1 1. 1

RE. 8/91

i

OFFICE OF CIVILIAN SHEET 4 OF 5RADIOACTIVE WASTE MANAGEMENT AUwrr/suRvEL1NCEnmsPEc110N

U.S. DEPARTMENT OF ENERGY NO. H-91-003

5ep ink WASHINGTON, D.C.

S". .6^1 : 6|: . *;l s E",


of verif'ication, personnel contacted

5 Section 5, paragraph a, Item (4), page 2.

Verify by review of objective evidence and Interviews with personnelthat the 'evaluators reviews external program evaluation and reportsidentified deviations hi accordance with SPP 5.01.1. Review how and what criteria are used lo Identify deviations.

6 Section 5, paragraph b, Items (1) through (4) and (7) through (10),pages 2 through 4.

Choose several examples from the 'Commitment Control Logb andverify by review of objective evidence that the 'evaluatorw of eachdeviation or recommendation for Improvement:1. Evaluates for appropriateness;2. Develops an appropriate course of action that Includes either the

A. Actions taken.B. Proposed Actions orC. Rejection;

3. Documents the above actions, Including reasons for rejections;4. Obtains Manager concurrence for Initial responses;5. Initiates corrective actions;6. Monitors irpiemerntation of corrective actions Including

A. Using the Commitment Control Program andB. Informs Manager through normal progress reporting;

7. Verifies Implementation and;8. Documents Implementation as appropriate and forwards to

Manager for signature.

I

I. C

REV. e/91

J I\1 I/



SHEET S OF 5AWITISURrELLUEANSPECTION

NO. HO-91 003

'5PP 5-09 a a~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



RESULTS

t .9 4

7 Section 5, paragraph C. Item (1), page 4.

Verify through interviews with personnel and review of objectiveevidence that the DCAR Administrator ensures the external programevaluation report file contains:1. The External Program Evaluation Report2. All initial, Interim and final response correspondence.

Additionally verify that the report files are pared as QA records Inaccordance with SPP 7.01

1. Review several examples.

REV. S1M

y'j II



SHEET I OF 2


NO. HQ-91-003

=0SR £


EM-30

DATES OF EVALUATION

pq EXTERNAL

I ] INTERNAL

[XI AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY N.C. Frank 3aUA-.

CONCURRED BY A¢

APPROVED BY t;

DATE ZL2Ack

DATE

DATE S/2LiLSI26-30/91

DOCUMENT (Tfle, Number, Revision) ACTIVITY EVALUATED 0Official HLW Office Files, SPP 6.01, Rev. 0 Office File Operation

REMARKS *

NEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

I Verify the Program Coordinator has designated, In writing, one ormore File Administrators. [5.1.(1)

2 Verify that the File Administrator assigns file numbers to documents.5Ub(1 )

*INDICATE RESULTS: SATISFACTORY (SAT). UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. 8S1

IJ- I

ii



SHEET 2 OF 2AUDrr/sURVEILLANCOnNSPECTIONNo0 "H-O-Ai.. _._ . ,_ wwv

ap GF 1 - I

An II T" so I lo 11 * ;1 1~~erf th1ieAmnsrto anan it fayatrtos



RESULTS

l I .4.

3

4

Verily the File Administrator maintains a fist of any alterations,additions, or deletions to the HLW Office File Guide. (5.b.(3)]

See QAPD checklist for Criterion 17.

REV. 8d91

--- 7OFFICE OF CIVIUAN


WASHINGTON. D.C.

SHEET I OF 2

AUDITIMIRVELLANCEI1NSPECTION

No. HO-91.OO3

.

.

I

4 4~~~~~~


EM-30

DATES OF EVALUATION

[XJ EXTERNAL

[ 1 INTERNAL

[XI AUDIT

I I SURVEILLANCE

1 I INSPECTION

PREPARED BY N.C. Frank

CONCURRED BY M/ADATE 8__ __

_.

.,o DATE

APP ROVED, B DATEAug. 26-30, 1991

CONTROLLING DOCUMENT (Title. Number, Revision) ACTIVITY EVALUATEDPreparation of Correspondence, SPP 6.02. Rev. 0 Preparation and Handling of Corresponding

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record obfective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Verify that the originator of the correspondence prepares outgoingcorrespondence La.w. DOE Order 1325.1A and Attachment A.[5.a(1 )J

2 Review five outgoing letters against Para. 5.a and Attachment A.Record any discrepancies noted.


REV. astI

J \ I------ 16-1 -.d-



SHEET 2 OF 2

AUDrTISURVEILLANCEIINSPECTION

NO. HO-91-00

5V 4.O2..

I ~ I I -



RESULTS

l I. ..

3

4

Ask secretary to explain 5.b.(1) concerning wi other than theoriginating secretary."

Review the commitment control log for the five outgoing letters. Noteany discrepancies.

REV. 8/91



SHEET 1 OF 2AUDITPSURVEILLANCEIINSPECTION

NO. HO-91-003I

* £


EM-30

DATES OF EVALUATION

8126 30191

mX EXTERNAL

[ I INTERNAL

[Xm AUDIT

[ I SURVEILLANCE

l I INSPECTION


CONCURRED BY _,A _

DATE 8/_ _ I

_-

DOCUMENT (Title. Number, Revision)Incoming Mail, SPP 6.03. Rev. 0

ACTMVITY EVALUATEDProcessing of Incoming Mail


1 Review the Incoming Mall Routing and Handling Matrixu Verify it:* Is filled out* has been concurred with by potential recipients.* has been concurred wit by the Qualty Assurance Specialist

2 Explore how change to the matrix are made and controlled. Verifythat a file of each revision Is kept [5.a(4),(5) and 5c(1)]

^ INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (WA)

REV. 8/91

� J \1 �) I\' ')OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 2

AUDIT/SURVELLANCEANSPECTION

NO. HO-91-003

5 f' & .

I ~~~I II



RESULTS

I I. t

3 Request the Correspondence Control Clerk to process threerepresentations pieces of Incoming mail. Verify processing Is doneas described In Paragraph 5b.

REV. a/91

\' j \' J



SHEET 1 OF 2AUDITGSURVELLANCE/INSPECTION

NO. HO-91-003

S011 II N . 11 O 0219


EM-S3

DATES OF EVALUATION

8i26-30/91

X] EXTERNAL

[]INTERNAL

p[X AUDIT

[ I SURVEILLANCE

(] INSPECTION


CONCURRED BY A

DATE ___ ___

sL DATE

_ DATE

-

DOCUMENT (Title, Number, Revision)Commitment Control, SPP 6.04, Rev. 0

REMIARKSITEM CHARACTERISTiCS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Determine whether John W. Bartlett's October 29. 1 990 letter to EM-1was included In commitment control.

2 Review seven commitment data sheets for completeness andInclusion on the commitment log. 15.a(1) through (7)]

INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (WIA)

REV. 8 91



SHEET 2 OF 2AUDIT/SURVEILLANCEINSPECTION

NO. HO -003

5pp IAoqf

p . I M14i900 -61,4 n I



RESULTS

1 1

3

4

Review the last three commitment logs. Verify:* distributed weekly to reviewer and Quality Assurance Specialist

[5.a.(8)]* commitments sorted by due date with most recent ones first [5.a(6j* new entries Indicated with an asterisk [5.a(5) note]

Trace three commitments from October 1990 through to closure.Verify:* for commitments not met, a new date is scheduled [5.b.(3) and (4)I* updated status Is received from reviewers [5.c(1 )J* CCC advises the reviewerof commitments more than 10 days past

due [5.c.(3)]

I. S I

REV. 8&91

I



SHEET 1 OF 1

AUDI17SURVEILLANCEANSPECTION

NO.io H-R91-003 I.-

I9 5 5


EM-30[X EXTERNAL

[ ] INTERNAL

[PI AUDIT

[ I SURVEILLANCE

I I INSPECTION

PREPARED BY N.C. Frank .3C DATE On)/{ I.i I

DATES OF EVALUATION

Aug. 26-30, 1991

DATE

DATE 4d0/sI.-

CONTROLLING DOCUMENT (Tile, Number, Revision)Controlled Documents, SPP 6.05, Rev. 0

ACTIVITY EVALUATED

H o~~~~ -- o4�REMARKS v

ITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

I Determine who makes copies, established the distribution list,establishes receipt control prior to step 5.a(1).15-a(1)]

2 Verify that the assignee routes controlled documents to the documentcontrol.

INIAERESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. 891

� J� J-



slimT I OF492

AwrTisumiREILuLANCMsPEcTixiiNo. HO-91-003

R, M , 1 I :19124011411M --

-. - ��C � I I


EM30

DATES OF EVALUATION

SP26-30/91

[X EXTERNAL

[ ]INTERNAL

[Xi AUDIT

I I SURVEILLANCE

I 1 INSPECTiON

PREPARED BY Craia Walenna

CONCURRED BY A

APPROVED

, DATE 8f/91

DATE

DATE_____

_ ,

. ,

DOCUMENT (lItie, Number, Revision) ACTiVY EVALUATEDOA Records SPP 7.01, Rev. 0 & SPP 7.OZ Rev. 0 Implementation of SPP 7.01 & 7.02

REMARKSITEM CHARACTERISTiCS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of Verification, personnel contacted

I a. Identify during the survellance specific Individuals who performedwork lAW a procedure. Verify that the persons Eisted have hadthe training and qualifications necessary to conduct the work.

The attached list incdudes:* Name* Work performed* Procedures applicable* Training* Ouals

b. Interview several people In each category to determine theirfamiliarity with the procedure they Implement.

c. Do the persons have controlled copies of procedure that arecurrent?

'INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NWA)

REV. /91

~~- j ." ')~~~~~~~K



SHIEEr 2 O 9AUDMISURVELLANCONSPECTIONNO. HO-91 4CO3

.5?F' 7 a I J�- 7, 0;1-S a S~I - =S

19 p9I9111ip



RESULTS

e .9

2

3

4

Verify Quality Record Index is established IAW SPP 7.01, 5.a.1 and2 and SPP 6.01 (item #4)

Check if the ORI has been approved by the appropriate DOEinterface. Determine who Is on appropriate DOE Interfacel (item #4)

Has the ORI been adequately and correctly incorporated within the fileguides listed In SPP 6.01 ? Address adequacy of SPP 6.01 file listingversus EM program.

.5 -

REV. 8i1e



SHEET 3 O

AUDITISURVELLANCEANSPECTIONNO. HO-91-00

5P60 -7.,O) tc 7,02-

I I I I I



RESULTS

______ I- I

Determine period of time that program has been Implemented. Hasthe QRI been kept current as required by SPP 7.01, 5.a.5.

a. Identify who is required lo receive the ORI (that Is, documentpreparers) IAW SPP 7.01, 5.a.6.

b. Verify that the preparers have:1. received;2. or have been sent the latest QRI.

c. How are new document preparers provided with the list? Thatis, have there been new employees since the last list wasdistrbuted? (Item 4)

Check the Central Records Facility for any receipt of EM recordspackages. Log ten packages of various types if more than 10 arefound. These records package will be used to verify Implementationof SPP 7.01 and 7.02

£ I I

REV. 8I91

ki~~~~~~~~~~~~~~\OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 O (AUDIFJSURVELLANCEANSPECTIONNO. HO-G1-CO

5*p P7I0 * 7 0.O2,

I I I I a

nIEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

l. I .4

8

9

Identify the Qualfty Records Coordinator and interview the person todetermine - what criteria are used to determine what are acceptablerecords. SPP 7.01, 6.c.4 (item 4)

Obtain from the records system two relatively recent recordspackages from each of the following Quality Records types:* HLW kistrutions * (QRi)* HLW QAPD * WAS & WCP records* Audit * Deviation and CAR* Surveillance * Q Records Indexes and logs* Peer review * WQR* Document Review * PRUst the record packages obtained. How many records packages areIn the records system? (item 14)

£ C. I

REV. E91

J \� jI ii k I



SHEET 5 OF X7AUDITISURVELLANCENSPECTION

NO. HO-91-003

SP P 7.J 0)4 7.0 2-.

a I 1 0 - S --~~M :0 I

iTEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

t *9 6

10

11

Using the records packages obtained, determine that the:a) Quality Record Verification Sheet Is completed adequately and

completely IAW SPP 7.01, 5.b.8 and SPP 7.02, 5.d.1-4?b) Quality Records Inventory List completed adequately and

correctly SPP 7.01. 5.c.1?c) Do the quality records meet SPP 7.01, 5.b.2 through 5.b.7 and

5.b.9?d) Is the Quality Record Log completed and accurate?

SPP 7.02, 5.d.5

When retrieving the documents In item 12, determine the following:(1) Filed IAW the Index system(2) Environmental conditions meet SPP 7.02, 5.d.7(3) Controlsfor access established and effectively Implemented. Are

they adequate? SPP 7.02, 5.d.8(4) Ensure authorized access 1ist Is maintained current, that Is, list

doesn't contain names of EM personnel and contractors nolonger associated with EM.

(5) Verify that smoking, eating, drinking being prohibited throughoutthe records facility? DOE/EMMNO/02.17.1.1, Para.2, Sub Para. 7

REV. Ml1



J

SHEET 6 O -

AUDITISURVELLANCEIINSPEC1ION

NO. HO-91-00

Sfplp 7.0/ 4 7,02-

p & £ S -~~~~~~~11I 19T 5-- -

I iaI



RESULTS

12

13

14

Discuss with ORC records are stored to maintain duplicate storage.SPP 7.02, Section 4, Para. 3 and 5.d.9.

Discuss with ORC how records are turned over to RW?DOEIEMiWO/02, 17.1.1. Para. 2

Discuss with ORC who the file administrators as provided for In SPP7.02, 5.a and 5.b and 5.c. (Item 4)

REV. 891

; II �



SHEET 7 OF 7AUDITISURVELLANCEANSPECTION

NO. HO-9100

-Sf'P 7. 0) - 7,O2-~

Li A I *1 (e ml

I I a~ I I



RESULTS

..~~~~~~~~~~~~~~~~~~-- -

15

16

17

Review the Quality Records Log to Identify records that have beentransferred and the storage location. Discuss how the process Ishandled by addressing three different packages that were transferred.

Through discussions with personnel, ask who Is formally tasked withimplementing the Quality Records System and where that functionalassignment exists.

For several file administrators, interview these persons and obtain theRIDs form for each filing station. Verify that appropriate DOEconcurrence for the Block 8 disposition Instructions.

Have them explain the RlDs approval process.

Verify that Quaflty Records are listed as lifetime' as defined InSPP 7.02, 4.a(3) and SPP 7.01, 4.a.(3)

I I.

REV. 8/91



SHEET 1 OF 4

AUJDrSURVEILLANCEI1NPECTION

No. HQ-91-003

-

_

I

I B~~~~~~~~


EM30

DATES OF EVALUATION

8126-30i91

pq EXTERNAL

( ] INTERNAL

Pq AUDIT

[ ] SURVEILLANCE

I I INSPECTION

PREPARED BY i, wDa

CONCURRED BY =/A

APPROVED

, * . DATE f- 7 *

DATE

DA DATEIe-, R;Z. ~~~~~~~~~~~~.

CONTROLLING DOCUMENT (Titl, Number, Revision) ACTIVITY EVALUATEDCoord. of Reviews & Evaluation by Outside Org. SPP8.01, Rev. 0 Implementation of SPP 8.01


1 Determine what activities are subject to this SPR(SPP 8.01 Para. 1)


REV. 1190



SHEET 2 OF 4

AUDITISURVEtLANCENSPECTION

NO. HO-91 003

SP?7 jT,o/

e ~~~~~~~f-Aie]0 - -

I I --



RESULTS. .

______ I

2

3

Has the Memorandum of Understanding (MOU) been Issued?(SPP 8.01 Para. 4)

Has the Program Coordination or Quality Assurance Specialistperformed the following activities:

(1) Receives notification of scheduled reviews or evaluations byexternal organizations.

(2) Notifies the Quality Assurance Specialist (OAS) as to thereview or evaluation schedule and scope.

(3) Acts as the Coordinator for the owner/sponsor of the programand serves as primary contact for the external review andevaluation team.

1. S S

REV. 11/90



SHEET 3 OF 4

AUDITISURVELLANCE1NSPECTION

NO. HO-1 -003

5PP 19oi0

* a a *a - S -.~~~MO

flEMNO. CHARACTERISTIC TO BE EVALUATED


RESULTS

1 .9 .9

3 (4) As requested by the external review or evaluation team:(a) Arranges for meeting facilities, notification

attendance key owner/sponsor personnel at meetings.(b) Arranges for work space for the external review or

evaluation team.(c) Coordinates activities to provide assistance and

arranges for access to owner/sponsor personnelactivities, files, and records.

and

(5) Prepares notes on the review or evaluation teams concernsand assists In darifying Issues.

REV. 11190

IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 4

AUDITISURVELLANCEtlNSPECTION

NO. HO-Q14-03

5fPP 89,OI

I I ~ w C



RESULTS

l. l .4

3

4

(6) Routinely apprises the Program Coordinator and affectedowner/sponsor Directors of external organizations concerns.

(7) Responds promptly to review and evaluation findings Inaccordance with SPP 5.05. (SPP 8.01 Para. 5.a)

Is this procedure mandatory. Has it been invoked for this audit?Note: it appears that the Intended purpose does not requireproceduraflztion.

I & I

REV. 1 V90



SHEET I OF 4AUOITISURVEILLANCEn1NSPECTION4No. HO-91 -003

W0p 1 II l ar a16-


EM-30

DATES OF EVALUATION

812640191

[X EXTERNAL

I INTERNAL

[XI AUDIT

[ I SURVEILLANCE

1 I INSPECTION

PREPARED BY L. W--&5

CONCURRED BY

*0 DATE _7___

PL. DATE

_ DATE f44fAPPROVED BY^ _

CONTROLLING DOCUMENT (Title, Number. Revision) ACTIVITY EVALUATED .QA Program Evaluation & Assessment of Adequacy & Eff. SPP 8.02. Rev. 0 Implementation of SPP 8.02

REMARKSTEOM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTS


1 Review the last annual assessment for the following:CompletenessApplicability (was the scope addresed?)Compliance with this SPRQualification of assessment personnelFollow-up of Corrective ActionSchedule (was the assessment performed on time and within 12months from the previous assessment?)Planning (use of checklist, research and notification.Performance, reporting and distribution of the report.(SPP 8.02 Para. 4)

'INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NWA)

REV. 11/90

k\ IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 4AUDITISURVELLANCEflNSPECTIONJNO. HO-01-06

SP?' ?,(2-.QA S - SI-

I I



RESULTS

. .

2 Verify that the QAS Is performing the following:Assess the adequacy ofthe research and data collection process.

(1) Routinely collects Information In order to assess the effectivenessof the quality assurance program during the year Including:a) Results of Organizational Evaluation Activities.b) Organizational Quality Progress and Review Reports.c) Quality Trend Reports.d) Quality Problem Reports.e) Results of any special reviews conducted during the year.f) Field Office Evaluation and Assessment of Contractors.

(2) Each year In January, reviews the collected Information anddetermines If any additional data Is necessary to adequatelyassess the Ouality Assurance Program.

1 .4 .4

REV. 1 1190



SHEET 3 OF 4

AUDITISURVELLANCEnINSPECTION

NO. HO-91 003

Spp g',oZ 2-

I ~~~~~~~~~~~~~~~~~~~~~~~~III



RESULTS

2

3

(3) If additional Information,is necessary, obtains It throughappropriate means.

(4) Using the collected Information, Identifies a&omplishments,problem areas, quality trends, and evaluation results. Thenassesses the adequacy and effectiveness of program practicesand Instructions. SPP 8.02 Para. 5A

Is there provision for an Intermediate assessment to addressproblems Identified during the year? (SPP 8.02 Para 1)

REV. 11/90



SHEET 4 OF 4

AUMIT&JRVEILLANCEINSPECTION

NO. HO-91003

SPP 7, 02..

. a 0 * 0If -



RESULTS

4 I I

4

5

Verify that the Assessment Report has been prepared and distributed.(SPP 8.02 Para. 5.b.1)

Verify that the report has been reviewed by management and actiontaken to address adverse trends.General Note: This SPP does not address corrective action ormanagement review.

C C C

REV. 1190

~~..2 \' 'WOFFICE OF CIVLIAN


WASHINGTON. D.C.

SHEEr 1 OF 3AUDFTiSURVELLANCEANSPECTION

No. HO-91 -003

W9 - 1 AL A411,1 a1:6i"6111


fen en

DATES OF EVALUATION

826-30/91

mq EXTERNAL

[ I INTERNAL

[m] AUDIT

I I SURVEILLANCE

[ I INSPECTION

PREPARED BY Z. Jt4ft

CONCURRED BY J/

APPROVED Bee

DATE Ax- i- A/

DATE

DATE . __4L

A,

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDReview & Reporting of QA Program & Status SPP 8.03, Rev. 0 Implementation of SPP 8.03

REMARKSITEM CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contaded

I Are status reports prepared monthly as required by this SPP?(SPP 8.03 Para. 1)


REV. 11/90



SHEET 2 OF 3AUDITISURVELLANCEANSPECTIONNO. H14-91-03

5pp F-0 39 a a -~~~~~~~~~~~~~~~~

ITEMNO. CHARACTERISTIC TO BE EVAWATED

REMARKSRecord objective evidence reviewed, methodof verification. personnel contacted

RESULTS

4 I I

2

3

Verify that the OAS review GA Program activities each monthIncluding:

(a) Operations Office Quality Status(b) Results of Evaluation Activities(c) Quality Problem Reports(d) Quality Trend Reports(SPP 8.03 Para. 5.A)

Is the report a paperwork review or Is It generated as a result of sitevisits? (General)

REV. 11190

~~~ -i \' 1)~ ~~~~~~~~~~~OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 3 OF 3


NO. HO-91-003

SPP f 03,

I I I~



RESULTS

4. 4. 4.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

4 Verify that the report Is distributed and reviewed by management Areany Corrective Actions generated as a result of the report?(SPP 8.03 Para 5.b)

I

REV. 11190

J j



SHEET 1 OF 6AUDIT/SIREILLANCEINSPECTION

No. HO-91-003

C~~~~~~~~~~lqnl


EM-30

DATES OF EVALUATION

[XI EXTERNAL

[J INTERNAL

[XI AUDIT

[ 1 SURVEILLANCE

[ I INSPECTION

PREPARED BY Z A2Jb.

CONCURRED BY A/YA

i. .DATE

DATE

DATE 4/_ #7

APPROVED BW26-30J91

CONTROLLING DOCUMENT (lite, Number, Revision) ACTMTY EVALUATEDPreparation and Maintenance of the Program Schedules SPP 9.01, Rev. 0 Implementation of SPP 9.01

REMARKSITEM CHARACTERISTlICS TO BE EVALUATED Record objective evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 Identify what schedules are being controlled under this procedure.

* INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (NWA)

REV. e91

I J

0 IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEEr 2 OF 6

AUDITMiURVEILLANCEnINSPECTION

NO. HO-1 -003

£5pp '9.0I

I I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~II



RESULTS. .

2

3

4

Verify that the foflowing schedule data Is available:

a) Milestone dates.b) Supporting schedules.c) Operation office schedulesd) Program Schedule(SPP 9.01 Para. 4.0)

Has the program revised, updated and reissued no less than quarterly(SPP 9.01 Para. 4.0)

Does the program Incorporate all of the Individual schedules relatedto different portions of the operation. Verify that all EM groupschedules are addressed. (SPP 9.01 Para. 4.0)

a - a

REV. M91

~ J J1.......

2,OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET S OF

AUDMISURVELLANCONS

NO. HO-91-003

6FETON

npip I e'/I-M III~~~~~~ £



RESULTS

4 5 a

5

6

7

Does the schedule provide a credible basis for evaluatbn planning?(SPP 9.01 Para. 4.0)

Are the schedules of all non-EM groups addressed? Verify Interfaceswith OCRWM (General)

Is the schedule coordinator assined? Verify that the followingactivities are performed:(1) Initiates the Program Schedule development by requesting

Information from operations which are responsible for kndividualsegment schedules.

REV. 891

~~ j .\' j~~kOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 6

AUDR/ISURVELLANCEJINSPECTION

NO. HO-1-003

SPP q.*/

i 4:901;1:101 I If -I

p p~~~~~~~~~~~~~~~~~~~~~~~~ I



RESULTS

7 (2) Requests, as a minimum, the following schedule iformation forselected milestones within the segment schedules:a) Segment Identification.b) Wilestone description.c) Status or progress remarks.d) Completion due date.e) Forecast Completion date.f) Responsible Manager.g) Person responsible for next action.h) Date of the data.

(3) Reviews each submittal for completeness and obtains anyneeded additional Information

(4) Assembles data Into a draft program schedule.

. .4.

REV. 8M91

II \ J�' / \ /



SHEET 5 OF 6

AUDITISURVEILLANCOfNSPECTION

NO. HO-i4)03

se'p 60I

9 h A *h S - S ~~a --


REMARKSRecord oblective evidence reviewed, methodof verlfkcatbon, personnel contacted

RESULTS

t I

(5) Incorporates comments Into a Program Schedule.

(6) Establishes a supporting data base as a basis for scheduleInformation.

(7) Reviews Program Schedule for Items of responsibility andverifies listing of all needed actdtles (Program Coordinator

REv. av1

J \I/



SH1EET 6 OF 6AUDrT/SURVELLANJCEIINSPECTIONNO. HO-91-00

5PP e:-1O/

I I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I



4 4.

(8) Concurs with the Program Schedule and forwards to the DOEdesignate for review and approval.

(9) Distributes the Program Schedule to the DOE selected personnel,QAS, Operations Offices, and Operating Contractors whichprovided Input, with notice of the monthly update cycle and duedate of required statusimgress input

10) Flnaflzes the supporting schedule data base.

Verify that the program is maintained In accordance with this SPRVerify that data submitted by contributors Is reviewed, corrected,assembled and distributed. (SPP 9.01 Para. 5.B)

8

6 4 6

REV. 8/91



SHEET 1 OF 4

AUDITISURVELLANCENSPECTION

No. HO-91-003

* 1£ a"u. ~~- ---


EM-30[XI EXTERNAL

[ ]INTERNAL

[Xq AUDIT

[ I SURVEILLANCE

( I INSPECTION

PREPARED BY t , &6)nm6 Al

CONCURRED BY 40i

APPROVED BY r (d

DATE of 2-7-I I

DATE


8t26-30/91

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDHLW Monthly Progress Reporting SPP 9.02. Rev. 0 Implementation of SPP 9.02


1 Verify that the Program Control Assistant Is assigned and that monthlyand quarterly reports are prepared, assembled, reviewed anddistributed. Is there a control log or similar document.(SPP 9.02 Para. 1)


REV. 11/90

J \I/I \ I



SHEET 2 OF 4

AUDITISURVELLANCEANSPECTION

NO. HO-1 -003

SF1'q 0~2-

I 1 -- I~~~a HE I4IM 1110 S124 -Z



RESULTS

I I* I

2 Verily that the monthly report Includes the following:

(a) Work change approved and In process.

(b) Changes in principal agreements.

(c) Significant program accomplishments Including events,milestones met, and major alterations.

(d) Contractor reports (uniform reporting system - DOE 1332.1A)as per contractual agreements andlor working agreements.

(e) Monthly Ouarterly Assurance Program Progress and StatusReport (See SPP 8.03)

(f) Latest Project Schedule. (See SPP 9.01) (SPP 9.02 Para. 5a)

REV. 11W90



SHEET 3 OF 4

AUDITISURVELLANCEllNSPECTION

NO. HO-91-003

'5PP 1.2-p 1 I" 1 ii£l41I4144-f Tn i_9TW

I II iI



RESULTS

4 4* 1

3

4

5

Is the monthly drafted In accordance with the guidance In DOE Order4700.1 at the EM office. Does 4700.1 address monthly and quarterlyreports) (SPP 9.02 Para. 5.a.2)

Verify that the monthly report Includes a section to reflect quarityassurance program progress and status. (SPP 9.02 Para. 5.a.2)

Verify that Program Coordinator reviews and distributes reports. Isthe DOE designate Identified? What Is the distribution of the reports?(SPP 9.02 Para. 5.a.4)

REV. 1 1190

v)~~~~~~~~~~~~~~~~~~~\ 1OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 4

AUDIT/SURVELLANCEA1NSPECTION

NO. HO-91-003

5P g q, 2-~

IIIII[41A I WE*001LW-91u~,141



RESULTS

t 1 1

6

7

Verify review and approval of the reports by DOE designate.(SPP 9.02 Para. 5.a.5)

Review historical files. Verify sequential filing, retrievability anddisposition of review comments. (SPP 9.02 Para. 5.b)

REV. I t90

~~~~6' / k J I~~~~~~~~~~~~~~~~~~~~~~~~~~~~\' I/



SHEET 1 OF 6


No. HO-91 -003

a ~*a i


EM-30

DATES OF EVALUATION

8/26-30/91

rX1 EXTERNAL

[ ] INTERNAL

[XI AUDIT

[ ] SURVEILLANCE

[ ] INSPECTION

PREPARED BY J-. &)dM

CONCURRED BY J A

DATE 9--V

DATE

DATE

_ _7

APPROVED BY/f I' 1-

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDPreparation and Maintenance of WBS SPP 9.03, Rev. 0 Implementation of SPP 9.03

REMARKSiNEO CHARACTERISTICS TO BE EVALUATED Record objective evidence reviewed, method RESULTS


1 Determine if this SPP Is subject to audit. Review applicable sectionof DOE order 4700.1 Project Management System.(SPP 9.03 Para. 3.a)


REV. 11190

y) K)OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 6

AUDMISURVELLANCEIINSPECTION

NO. HO-91-003

5PP q-e23I a I -~~~~~~~~~~~~~ 0 - -- ~~a



RESULTS

I. t t

2

3

4

Does the WBS format comply with DOE/MA-0295, WBS Guide?(SPP 9.03 Para. 3.b)

Is the Program Management Plan developed hI accordance with DOEorder 4700.1? (SPP 9.03 Para. 4.a.7)

Verify that the Program Control Assistant Is assigned performs thefollowing activities:

REV. 11190



SHEET 3 OF 6

AUDITISUJRVELLANCEANSPECTION

NO. HO-91-00

SpFP 9'LO3re* I MM - 0"



RESULTS

4 (1) Obtains Work Breakdown Structure from each support contributorfor HLW work and forwards to the Program Coordinator.

(2) Reviews each WBS to assure each meets requirements of DOE4700.1 and DOE/MA-0295 and coordinates as required withcontributors

(3) Integrates the first 3 levels of each WBS and the WBS Into theSWBS In a flow diagram format. (See Attachment A for sample).

REV. I1/90



SHEET 4 OF 6

AUDITISURVEILLANCEANSPECTIONI

NO. HO-91 -003

"5F F cy',o.5

9 A A * 6~~~~~~1T



RESULTS

4 (4) Develops and documents the SWBS DIctionary In accordancewith DOEIMA-0295 on forms DOE F1332.10 and DOE F1332-11.(See Attachment B for samples.)

(5) Reviews the SWBS and SWBS Dictionary and secures DOEapproval.

(6) Reviews and returns the approved document to the ProgramControl Assistant.

REV. I 1190

yIOFFICE OF CIVILIAN

RADIOAClIVE WASTE MANAGEMENTU.S. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

SHEET 5 OF 6

AUDrTISSJRVELIANCE/INSPECTION

NO. HO-91 -00

F9 A 4 II £ *-1M,0:0;I:[]I 0&I Mon

I A I



RESULTS

t "9 4

4

5

(7) Coordinates or performs the Incorporation of the SWBS into theHLW Program Plan and Incorporate of the SWBS Flow Diagramand Dlctionary Into the DWPF Program Management Plan inaccordance DOE 4700.1

(8) Assembles the SWBS, HLW WBS, CWBS and DWPF-PO WBSdata and Information Into a database for background of WBSdevelopment for reviews and later revisions.(SPP 9.03 Para. 5.a.8)

Verify that the SWBS Is revised, distnbuted, approved andIncorporated Into the Program Plan In accordance with this procedure.(SPP 9.03 Para. 5.b)

REV. 11190



SHEET 6 OF 6

AUDMISURVELLANCEANSPECTION

NO. HO-91-cO

I I ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~



RESULTS

I 4. 4.

6 Verily that the Program Control Assistant maintains a file with WBSbackground Information for working and historical purpose. Is theofficial SWBS In the program plan. Is the SWBS Dictionary in theprogram management plan. Verify that Attachment A & B areproperly completed and Included In files.(SPP 9.02 Para. 5.c)

REV. 11190

\� j %, - j

OFFICE OF CIVILANRADIOACTIVE WASTE MANAGEMENT


SHEET 1 OF 5AUDITISURVELLANCEMNSPECTIONNO. HO-91-003

9 01 V4 a£.


EM-30

DATES OF EVALUATION

826-30/91

[XP EXTERNAL

( lINTERNAL

[X] AUDIT

I1 SURVEILLANCE

[1 I NSPECTION

PREPARED BY Louis R. Wade

CONCURRED BY AA

DATE 8-1-91

7- DATE

DATE J&1WAPPROVED BY

CONTROLLING DOCUMENT (Title, Number, Revision) ACTIVITY EVALUATEDIdentification and Anlaysis-Trends SPP 10.01, Rev. 0 Implementation of SPP 10.01

REMARKSiEMO CHARACTERISTICS TO BE EVALUATED Record objecive evidence reviewed, method RESULTS


1 SPPIO.01 Is the Quality Assurance Specialiste (OAS) assigned?(SPP 10.01 Para. 5a


REV. 11190

yj <2~~~~~~~~~~~~~~~~~~~~~~~~~~~~~'IOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 2 OF 5

AUDiTISUJRVEILLANCEIINSPECTION4

NO. HO-91403

$5PP)O' U

I I I i I



RESULTS

4. 4 J.

2 Verify that the QAS has monitored program feedback Information andIdentified trends/problems [SPP 10.01 Parm. Sa (1&2)]

______ a i

REV. 11J90

I


RADIOACTIVE WASTE MANAGEMENT AuoD[msuRvEI,* wcE NsPEcWNU.S. DEPARTMENT OF ENERGY NO. HO-91003

5FP ) o, 0o/ WASHINGTON, D.C.

3 Verify that the OAS has reviewed the following feedback sources:*Adverse quality trend/proglem reports*Audit reports*Change orders and changes In basic data

Contractor progress and status reports*Contractor reported non-conformances and deviations

N Design review reports*oDeviation and corrective action reports

3 Inspector, examinatin and test results* Operational readiness review reports* Peer review reports* Procurement document review reports*Quality assurance program progress and status reports*Reviews and evaluations by outside organizations* Reviews and evaluations by Internal trganziations* Surveillance reports* Technical documents review reports* Unusual ocurrence reports

Is the review documented? Is there a matrix showing each feedback,date received, review data and trend analysis?

4 Verify that advers trends are documented on Attachment B.[SPP 10.01 Para. 5a(3)]

REV. 11/90

K; J K. �/



SHEET 4 OF 5


NO. HO-91-OOO

15pp /0,0j

a - III



RESULTS

______ I

5

6

7

Verify that the adverse quality trend/problem Is analyzed by the QAS.Is the root cause Identified? [SPP 10.01 Para. 5.b(1 &2)]

Verify that DOE Program Manager concurs and approveds theadverse quality trend/problem report (AOTR). before and afteranalysis by the QAS. [SPP 10.01 Para. 5a(4) and Sb(4)]

Verify that the Program Managers are familiar with this SPP and itscontents (General)

________________________________________ a

REV. I 1/90

\i \JOFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 5 OF 5

AUDITISIAVELLANCEflNSPECTION

NO. HO-Q1 -00

5P'?o.I -II I a I~~~~~~~~~~~~~~~~



RESULTS

9 I 4

8

9

What Is the Involvement of the Branch Chief In problem resolution?(General)

The SPP does not address (a) corrective action (b) prevention ofrecurrence or (c) dissemination of trend analysis to avoid similarproblems at other EM iocations (General)

REV. 1 OI



SHEET I OF 4AUDITISURVELUMEANSPECTIONNo. HO-91-003

9 I4


EM-30

DATES OF EVALUATION

8/26-30/91

[X EXTERNAL

[1 INTERNAL

[XI AUDIT

[ 1 SURVEILLANCE

( I INSPECTION

PREPARED BY James George

CONCURRED BY &

APPROVED B

e-1 -- 'DATE 8-1-91

7P- DATE

_ DATE 5.7/fe, .

CONTROLLING DOCUMENT (Tile, Number, Revision) ACTMITY EVALUATEDPlanning and Conduct of Quality Improvement SPP 10.02, Rev. 0 Implementation of SPP 10.02

REMARKSIEOM CHARACTERISTiCS TO BE EVALUATED Record objective evidence reviewed, method RESULTS

of verfication, personnel contacted

1 Section 2. page 1. requires that the procedural process ...apply onlyto the organization(s) that has adopted this SPP for is own use orthat has had it Invoked by contractual...means,.

Verify by Interviews with appropriate personnel and/or review ofobjective evidence:1. iUst who are the affected organizations.2. Verify that the process is in use for those organizations for whom

it has been adapted or Invoked.


REV. 1I10



SHEET 2 OF 4

AUDITISURVELLANCEnNSPECTION

NO. HO-91-C00

Spp JO1 ,2p

I I p

ITEMNO. CHARACTERISlIC TO BE EVALUATED

REMARKSRecord obiective evidence reviewed, methodof veriHication, personnel contacted

RESULTS

S I I

2

3

Section 4, page 1, states In part that -this Instrction addresses theplanning...forthose quafltytrends...identified...In accordance with SPP10.01.

Verify by Interviews with personnel and review of objective evidencethat those adverse quality trends andibr problem Identified andanalyzed In SPP 10.01 are Improved through the use of thisprocedure.

Section 5, pages 1 through 3. contains paragraphs b. and a. withtitles, but does not contain a paragraph a. Verify whether this is anoversight or a typographical error.

4

REV. 11/90



SHEET 3 OF 4AUOITISURVEILANCE/INSPECTIONNO._HO-41-O3

SF P I 0, ID 2-

*M hl - 0 - -



RESULTS

l. l 4

4 Section 5, items (1) through (7), pages 1 and 2. Verify by Interviewswith personnel and review of objective evidence that the QASpecialist:I. Initiates quality Improvement, planning by

a. Documents each adverse qualitytrend/problem on a QualityTrend/Problem Report' for and;

b. Logs the quality trendcproblem on a 'Quality ImprovementLogo;

2. Monitors Improvements developed to address root causes (howIs this accomplished.

3. Monitors contributors to identified trends/problems (how Is thisaccomplished?);

4. Documents proposed Improvements In a plan which containsa. plan for Implementation andb. schedule for implementation;

5. Obtains HLW Program Manager review/approval;6. Distributes to other selected Program Managers (how Is this

determined?);7. Prepares the quality record and;S. Logs approval of the Improvement actions on the 'Quality

Improvement Log.

.1 4 1.

REV. 1/90

2OFFICE OF CIVILIAN


WASHINGTON, D.C.

SHEET 4 OF 4

AZJDrTISURVEIU.ANCOJNSPECTION

NO. HO-91 003

5Fpp 1,IO2L. IC & £ *& At*]a] oe] 0N4

I I I~~~~~~~~~~~~~~~~~~~~



RESULTS

I 1 t

5

6

Section 5, paragraph b, Items (2) and (3). page 2

Verify by review the objective evidence that the QAS informs theprogram manager of quality Improvement progress.1. How Is this activity accomplished?

Additionally, verify that the QAS verifies accomplishment of qualityImprovement actions and logs the completion date on the 'QuaiftyImprovement Logo.

1. How and where Is the verification documented?

Section 5, paragraph c, Item (1), page 3.

Verify by review of objective evidence that the QA Specialist preparesthe 'Quality Improvement Logs and 'Plans' as QA Records. Chooseseveral at random and verify they have been processed Inaccordance with SPP 7.01.

REV. 11/90

jI ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~



SHEET 1 OF 4AUDITISURVELLANCERNSPECTION

NO. HO-91-003

MfS a hll l


EM-30

DATES OF EVALUATION

[XI EXTERNAL [XJ AUDIT

[ I SURVEILLANCE

[ I INSPECTION

PREPARED BY C. Morell

CONCURRED BY

%-, \A SCI ATE4(42I

DATE

r g2e _ DATEAPPROVED BY48/26-30191 �r

CONTROLLING DOCUMENT (rille, Number, Revision) ACTIVITY EVALUATEDDiffering Staff Opinbns and Allegations SPP-1 0.03, Rev. 0 Implementation of SPP 10.03

REMARKSIlTEM CHARACTERISTICS TO BE EVALUATED Record objedive evidence reviewed, method RESULTSNO. of verification, personnel contacted

1 SPPO.03Verify that staff are aware of this SPP and familiar with Its' contentReview traininglindoctrinatlon records and Interview staff.(SPP 10.03, Para. 4)

'INDICATE RESULTS: SATISFACTORY (SAT), UNSATISFACTORY (UNSAT), NOT APPLICABLE (N/A)

REV. 8191



SHEET 2 OF 4AUDITSURVELLANCEAlNSPECTION

NO. HO-91 -=

5PP 0 ,o)o3*El 6ie ly-tl~ iv el1,441m



I 1�

2

3

4

Verify that differing opinions and allegations are assigned andidentification number are logged by the affected manager

Is it required that all differences of opinion be documented?Note: There may be Instances where staff have disagreed with QA orsafety issues and not documented it. (SPP 10.03, Para. 1.0)

Verify be review of documentation Interviews with staff that thesequential procedural steps are followed.a) Identification of an issueb) Discussion between Manager and Concemed Individual (C.I.)c) Identification and logging of the issued) Resolution and notification to C.I.e) Concurrence by C.I.f) Escalation to higher management or DOE (if necessary)g) Closure documented in the log. (SPP 10.03, Para. 5.a&b)

I .1

REV. 8`91



SHEET 3 OF 4


NO. HO-91-OOG

~5pp J d 010

III I



RESULTS

Verify that staff are advised of the procedure regarding externalallegators.Note: This Is a potentially sensitive issue and It Is Important that staffare aware. As Interviewers how they would respond to an externalallegator. [SPP 10.03. Para. 5.C.(1)J

What is the procedure for notifying the external allegator regardingresolutions? The employee receiving the allegation should ask theallegator If they wish to be notified and how.ISPP 10.03, Para. 5.c.(2)J

Review available documentation of external allegations.(SPP 10.3, Para. 5.d)

I 1. 5

REV. 8/91

SI J I\' -/JOFFICE OF CIVILIAN

RADIOACiTVE WASTE MANAGEMENTU.S. DEPARTMENT OF ENERGY

WASHINGTON, D.C.

SHEET 4 OF 4


NO. H-Ol-003

;5p P/of o59 £ £ -~~~I -. -

I I III



RESULTS

4. , .4

8

9

Are other managers informed? [SPP 10.3, Para. 5.c.(11 )]Note: Look for lessons leamed. If an allegation Is received on oneproject are other projects notified?

a) Is compliance with this procedure verified?auditslsurveillance reports. (DOE RW 0214, Para. 2.9)

Review

b) Verify that site personnel have received Indoctrination (DOE RW0214, Para. 2.8

REV. &91