**CORRECTIVE ACTION/ISSUE MANAGEMENT & CONTINUOUS IMPROVMENT**

**1.0 Objective**

The objective of this surveillance is to verify that contractor
personnel are effectively managing environment, safety, and health
issues. The activities included in this surveillance help the Facility
Representative determine whether safety issues identified through
internal contractor, and external DOE or Defense Nuclear Facilities
Safety Board evaluation programs are resolved consistent with the level
of safety importance. It further verifies continuous improvement
programs are in place and functional.

**2.0 References**

2.1 10 CFR 830.120, *Quality Assurance Requirements*

2.2 DOE O 414.1A, *Quality Assurance*

2.3 DOE O 232.1A, *Occurrence Reporting and Processing of Operations
Information*

4.  DOE G 450.4-1A, *Integrated Safety Management System Guide*

2.5 48 CFR 970.5204, *Department of Energy Acquisition Regulations
(Clauses to be used in addition to or in place of DOE/Contractor
Contract)*

2.6 DOE M 232.1-1A, *Occurrence Reporting and Processing of Operations
Information*

**3.0 Requirements Implemented**

This surveillance is conducted to implement the RL Functions,
Responsibilities, and Authorities Matrix (FRAM) Nos. 4007 and 5262. This
surveillance verifies implementation of aspects of DOE O 232.1A, 10 CFR
830.120, DOE O 414.1, and Core Expectation #5 of DOE G 450.4-1A Volume
II Appendix E.

**4.0 Surveillance Activities**

The following activities are performed to evaluate the effectiveness of
the contractor\'s implementation of the issues management/continuous
improvement program:

Activity 1 - Review the established processes for identifying
deficiencies and providing feedback.

Activity 2 - Examine the corrective action/issues management process.

Activity 3 - Examine processes addressing opportunities for improvement

**Surveillance Guideline**

**CORRECTIVE ACTION/ISSUE MANAGEMENT & CONTINUOUS IMPROVEMENT**

Surveillance No.:

Facility:

Date Completed:

**Activity 1 - Review of issue identification and feedback processes**

[Yes]{.underline} [No]{.underline} [N/A]{.underline}

\_\_\_ \_\_\_ \_\_\_ 1. Is there a clearly defined Management Assessment
(self-assessment) process? \[10 CFR 830.120 (c)(3)(i)\]

The FR should consider:

\- Assessments are conducted in a routine and planned manner (Ex: Per a
master assessment schedule).

\- The master assessment schedule is of sufficient breadth to cover all
key aspects of the facility or activity; especially safety. However, it
should also be tailored to provide emphasis on areas of known weakness.

\- Assessments are conducted with the aid of an approved checklist/lines
of inquiry. This facilitates consistency and helps the assessors to look
at issues/areas they might not otherwise think of but are important to
management and the improvement process.

\- Personnel tasked with performing the assessments are trained and
qualified on the assessment process and are sufficiently cognizant,
technically, of the areas they assess. A critical factor is ensuring
clear expectations are defined and understood for documenting
deficiencies in a manner that clearly specifies the requirement, and the
conditions contrary to the requirement.

\_\_\_ \_\_\_ \_\_\_ 2. Is there a clearly defined process for
independent assessment? \[10 CFR 830.120 (c)(3)(ii)\]

The FR should consider:

\- An example of such a process would be the Facility Evaluation Board
implemented by the integrating contractor, FDH or the Conduct of
Operations assessments conducted by RL.

\- A contractor\'s/project\'s Quality Assurance organization may perform
this function.

\- Is there a process in place where the independent assessment group
reviews the progress of the corrective action process to ensure an
endless cycle of assessment groups documenting deficiencies, facilities
failing to adequately correct the deficiencies, the assessment group
comes back a year later and finds the same problems does not occur?

\_\_\_ \_\_\_ \_\_\_ 3. Is there a clearly defined process in place for
categorizing and tracking deficiencies? \[10 CFR 830.120 (c)(1)(iii)\]

The FR should consider:

\- Is there a single system or multiple systems? Single systems such as
DTS, HATS etc tend to ensure consistency and prevent issues from being
\"forgotten\" or not being raised to sufficient levels of management.

\- If there is only one system, does it track opportunities for
improvement stemming from mechanisms like work logs, procedure change
requests, beneficial suggestion boxes, safety committee meetings etc? If
not, is there a clearly defined process to ensure these improvement
items are rigorously tracked through closure including a means that
provides feedback on disposition of the item to the originator?

\_\_\_ \_\_\_ \_\_\_ 4. Is there a clearly defined process that
describes how deficiencies should be documented?

The FR should consider:

\- The process requires that a requirement be clearly stated. (Ex: 10
CFR 835, Article 342 states, \"...\")

\- The process requires the condition to be clearly documented. (Ex:
Contrary to the above requirement(s), ...)

**Activity 2 - Examine the issues management process (General)**

Note: The Facility Representative selects a sample of deficiency
resolution packages and verifies they contain adequate information to
demonstrate actions have been taken to effectively prevent recurrence of
deficient conditions.

[Yes]{.underline} [No]{.underline} [N/A]{.underline}

\_\_\_ \_\_\_ \_\_\_ 1. Is there a clearly defined process that ensures
identified issues are corrected in accordance with the importance of the
problem and the work they affect? \[10 CFR 830.120 (c)(1)(iii), DOE M
232.1\].

The FR should consider the following:

\- The process verifies that a requirement has been clearly stated. (Ex:
HSRCM Article 342 states, \"...\")

\- The process requires verification the cited requirements are
contractually binding/an agreed upon set of standards. \[48 CFR
970.5204-2 (b) (5)\]

\- The process verifies the condition has been clearly documented. (Ex:
Contrary to the above requirement(s), ...)

\- The process requires a thorough, [documented]{.underline} extent of
condition review. (Ex: If the condition is one mislabeled component, the
extent of condition review should clearly demonstrate it was an isolated
event or an indicator of a programmatic breakdown in a labeling program,
independent verification process etc. for that system or the entire
facility).

\- The process encourages the extent of condition review to include
discussions or interviews with the person who identified the condition,
field walk downs etc. Whatever is necessary to understand the issue(s).

\- The process requires a review of tracking systems and/or discussions
with workers and supervisors to determine if similar deficiencies have
been identified or have occurred in the past.

**NOTE:** It is critical the extent of the condition is fully understood
prior to continuing with the process or the process will not be fully
effective.

\- The process requires a risk ranking be assigned to each deficiency in
accordance with the graded approach.

\- The process requires documentation of a brief description of the
rationale utilized to arrive at the risk value assigned. (Stating \"used
table XX in procedure YY\" is not sufficient. The description should be
narrative such that the verifier/validator can understand the thought
process behind the decision).

\- The process requires a root cause analysis process be conducted for
each deficiency identified. The type of analysis and the rigor of the
analysis should be commensurate with the graded approach.

\- The process requires documentation of the root cause analysis
technique utilized and brief description of the causal factors
identified.

\- The process requires clearly written, easily verifiable corrective
actions be developed that, if adequately implemented, will prevent
recurrence of the deficiency. (Ex: \"Train appropriate employees\" is
not an adequate corrective action. \"Develop required reading and
document all Operations and Maintenance personnel have read and
understood the required reading by use interviews, discussions, and use
of a training roster\" is more appropriate wording.)

\- Does the process require a review of corrective actions in the system
to ensure that less than effective corrective actions are not repeated
over and over again?

\- Does the process require complex corrective actions to be broken down
into sub-actions with discrete dates to facilitate tracking of the
progress of the action? (Ex: Assess the adequacy of the training program
could be broken down into assigning a team lead, developing an
assessment plan etc.)

\- Does the process require assigning a responsible manager to each one
of the corrective actions?

\- Does the process assign realistic due dates to the corrective actions
in accordance with the importance of the deficiency the action is
designed to correct?

\- Does the process provide specific performance indicators to senior
facility/project management so they can hold personnel assigned
corrective actions accountable for completing the actions in a timely
manner?

\- Does the process require documentation of an explanation
demonstrating how the cited corrective actions address each one of the
causal factors and why they will effectively prevent recurrence. (NOTE:
This step is critical as it provides a means of self-checking. If a
person can not explain how a corrective action addresses a causal factor
and why it will prevent recurrence of that causal factor as well as why
the aggregate of the corrective actions will prevent recurrence of the
cited deficiency/condition, the process was not adequately conducted.)

\- Does the process require verification and validation of the
corrective actions prior to closing the issue package and removing the
deficiency from a tracking system?

Note: It is critical that the issue package contain as much detailed
documentation as possible regarding the extent of condition review, the
risk ranking and root cause process, the rationale behind why the
corrective actions were to be effective, documentation of what was done
during implementation of the corrective actions etc. If all this
information is present, it greatly facilitates the verification and
validation process. Without it, the verifier/validator will have to
virtually repeat the entire process in order to determine if it was
adequate.

\- Does the process require field verification that the corrective
actions were adequately implemented? For example, this could include
reviewing procedures/work packages, verifying postings are adequate
after a windy period, assessing performance during a drill, interviewing
personnel, reviewing training rosters etc.

-   Does the process require documentation of what was done during the
    verification and validation process? This enhances discipline in the
    process and provides objective quality evidence for independent
    reviewers that are checking the effectiveness of the issue closure
    process.

**Activity 2A - Examine the issues management process (PHMC Specific) --
Deficiency Evaluation Group**

Note: This activity should include attendance at DEG meetings and review
of selected Deficiency Tracking System packages.

[Yes]{.underline} [No]{.underline} [N/A]{.underline}

\_\_\_ \_\_\_ \_\_\_ 1. Are deficiency evaluations being conducted by,
at a minimum, the CAM representative and the Fluor Project Hanford (FPH)
Point of Contact (POC) (HNF-PRO-052, Rev 3, Section 2.3)?

\_\_\_ \_\_\_ \_\_\_ 2. Are the CAM Rep and FPH POC adequately
trained/qualified (currently by having completed Root Cause Analysis
Basics \[course 170015\], Root Cause Analysis Techniques \[course
170026\], and FPH Risk Evaluation Training \[course 004210\]
(HNF-PRO-052, Rev 3, Section 2.13)?

\_\_\_ \_\_\_ \_\_\_ 3. Are personnel performing field verifications
and/or validations adequately trained/qualified (currently by having
completed Verification and Validation Process \[course 004211\]
(HNF-PRO-052, Rev 3, Section 2.13)?

\_\_\_ \_\_\_ \_\_\_ 4. Are risk rank values being correctly assigned
(HNF-PRO-052, Rev 3, Section 2.5.1)?

\_\_\_ \_\_\_ \_\_\_ 5. Are root causes being correctly determined and
documented (HNF-PRO-052, Rev 3, Section 2.5.2)?

\_\_\_ \_\_\_ \_\_\_ 6. Are corrective actions being selected which
address the results of the causal analysis based on the graded approach
to prevent recurrence (HNF-PRO-052, Rev 3, Section 2.5.4)?

\_\_\_ \_\_\_ \_\_\_ 7. Are cognizant personnel and completion dates
being designated for each corrective action specified (HNF-PRO-052, Rev
3, Section 2.5.4)?

\_\_\_ \_\_\_ \_\_\_ 8. Are Price Anderson Amendment Act screenings
being performed and documented (HNF-PRO-052, Rev 3, Section 2.5.3)?

\_\_\_ \_\_\_ \_\_\_ 9. Are determinations and documentation of whether
issues have broader applicability and whether a lessons learned
evaluation should be performed included (HNF-PRO-052, Rev 3, Section
2.5.8 and 9)?

\_\_\_ \_\_\_ \_\_\_ 10.Is DOE being notified of extensions to DOE
identified deficiencies (HNF-PRO-052, Rev 3, Section 2.6.3)?

\_\_\_ \_\_\_ \_\_\_ 11.Is objective evidence or closure statements
substantiating the completion of corrective actions being included in
closed packages (HNF-PRO-052, Rev 3, Section 2.7.3)?

\_\_\_ \_\_\_ \_\_\_ 12.Are all RRV 4 or 5 deficiencies being
independently verified by Performance Assurance (HNF-PRO-052, Rev 3,
Section 2.8.1)?

\_\_\_ \_\_\_ \_\_\_ 13.Is there evidence that some percentage of RRV 3
deficiencies are being randomly selected for independent verification
(HNF-PRO-052, Rev 3, Section 2.8.2)?

\_\_\_ \_\_\_ \_\_\_ 14.Is field verification being performed using the
checklist A-6002-690 (HNF-PRO-052, Rev 3, Section 2.8.4)?

\_\_\_ \_\_\_ \_\_\_ 15.Are standardized tracking reports which include
the following being provided to management (HNF-PRO-052, Rev 3, Section
2.11.2):

-   Weekly report of deficiencies with a RRV of 3, 4, or 5;

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-   Weekly report of open deficiencies;

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-   Monthly report of DOE Facility Representative deficiencies; and

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-   Weekly reports of deficiency tracking data (e.g. Number of
    delinquencies, number of new deficiencies, number of closed
    deficiencies, and number of open deficiencies)?

\_\_\_ \_\_\_ \_\_\_ 16.Are monthly trending reports which include the
following being provided to management (HNF-PRO-052, Rev 3, Section
2.11.3):

-   Distribution of reason code;

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-   PAAA reportability; and

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-   Distribution by cause code (root and direct)?

\_\_\_ \_\_\_ \_\_\_ 17.Are adverse trends being documented and
evaluated through the Deficiency Evaluation Process (HNF-PRO-052, Rev 3,
Section 2.11.5)?

**Activity 2B - Examine the issues management process (ERC Specific) --
Environmental Restoration Contractor Corrective Action Tracking System
(ERC-CATS)**

Note: This activity should include attendance at monthly CATS meetings
and review of selected CATS packages.

[Yes]{.underline} [No]{.underline} [N/A]{.underline}

\_\_\_ \_\_\_ \_\_\_ 1. Has the Quality Program Manager designated an
ERC-CATS Coordinator (BHI-MA-02 2.2, Rev 1, Section 3.4)?

\_\_\_ \_\_\_ \_\_\_ 2. Does the Quality Program Manager chair a monthly
meeting of applicable ERC management to provide status on the activities
in the ERC-CATS (BHI-MA-02 2.2, Rev 1, Section 3.4)?

\_\_\_ \_\_\_ \_\_\_ 3. Does the Quality Program Manager provide monthly
status reports and requested special reports to ERC management
(BHI-MA-02 2.2, Rev 1, Section 3.4)?

\_\_\_ \_\_\_ \_\_\_ 4. Does the Quality Program Manager provide
quarterly adverse condition status reports to RL (BHI-MA-02 2.2, Rev 1,
Section 3.4)?

\_\_\_ \_\_\_ \_\_\_ 5. Does the ERC-CATS Coordinator maintain and
update the ERC-CATS database (BHI-MA-02 2.2, Rev 1, Section 3.5)?

\_\_\_ \_\_\_ \_\_\_ 6. Does the ERC-CATS Coordinator compile the
monthly and quarterly for the Quality Program Manager (BHI-MA-02 2.2,
Rev 1, Section 4.3)?

**Activity 2C - Examine the issues management process (PNNL Specific) --
Assessment Tracking System (ATS)**

Note: This activity should include review of selected ATS packages.

[Yes]{.underline} [No]{.underline} [N/A]{.underline}

\_\_\_ \_\_\_ \_\_\_ 1. Are all events or conditions documented on an
occurrence report, Radiological Problem Report, or Price Anderson
Amendments Act related Quality Problem Report documented and corrective
actions managed in ATS (Standard Base Management System, 1. Tracking
Corrective Actions, Required Procedure, general instruction)?

\_\_\_ \_\_\_ \_\_\_ 2. Are external assessments, Independent Oversight
Assessments, Internal Audits, and Type A or B Investigations of
management systems or that identify deficiencies or improvement
opportunities related to management systems being managed in ATS
(Standard Base Management System, 1. Tracking Corrective Actions,
Required Procedure, general instruction)?

\_\_\_ \_\_\_ \_\_\_ 3. Do the set of corrective actions for the ATS
report (Standard Base Management System, 1. Tracking Corrective Actions,
Required Procedure, Step 6):

-   describe the immediate actions taken to stabilize the condition, if
    addressing a deficiency or a condition that represents immediate
    risk to workers, the public, or the environment;

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-   describe actions that address the cause as well as the symptoms and
    represent a potential improvement;

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-   contain adequate information to allow a competent individual,
    without detailed knowledge of the condition/issue, to clearly
    understand how the proposed action addresses the associated
    condition, and conclude the action is appropriate; and

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-   ensure commitments, related to actions, are achievable with the
    available resources and within the defined schedule?

\_\_\_ \_\_\_ \_\_\_ 4. Do closure packages contain the objective
evidence (such as documents developed as part of the corrective action,
inspection reports, test reports, training plans and training attendance
sheets) necessary to ensure actions have been adequately closed
(Standard Base Management System, 1. Tracking Corrective Actions,
Required Procedure, Step 10)?

\_\_\_ \_\_\_ \_\_\_ 5. Are both condition owners and assessment owners
conducting reviews to ensure actions have been adequately completed
(Standard Base Management System, 1. Tracking Corrective Actions,
Required Procedure, Steps 11 and 13)?

**Activity 3- Examine processes addressing opportunities for
improvement**

**Note:** This process should be designed to address issues that may not
be entered into formal deficiency tracking systems.

\_\_\_ \_\_\_ \_\_\_ 1. Are there clearly defined processes that empower
workers to have a strong questioning attitude and provide feedback to
managers and supervisors in an effort to achieve continuous improvement?
\[48 CFR 970.5204-2(c)(5), DOE G 450.4-1A Volume I Chapter III section
4.5.1\]

The FR should consider:

\- Typical processes to achieve this are:

-   Observations during internal and external assessments and
    surveillances.

-   Safety meetings. This includes large formal safety meetings with
    safety councils as well as small lunch box safety meetings with
    single work groups.

-   Beneficial suggestion boxes

-   Work logs

-   Procedure change requests

-   Email messages

-   Critique meetings

\_\_\_ \_\_\_ \_\_\_ 2. Is there a process in place for documenting and
tracking opportunities for improvement? \[48 CFR 970.5204-2(c)(5), DOE G
450.4-1A Volume I Chapter III section 4.5.1\]

The FR should consider:

\- Does the process assign actionees to each of the documented
opportunities for improvement?

\- Does the process assign and track due dates by which the actionee
must have a disposition complete addressing the opportunity for
improvement?

\- Does the process require the actionee or a supervisor to close with
the originator to ensure the originator is satisfied with/understands
the disposition and why management feels it is adequate?

\- Does management hold personnel accountable for completing
dispositions as well as the actions included in dispositions in a timely
manner?

\- Does management hold personnel accountable for closing with
originators before items are considered complete and removed from
tracking systems?

\_\_\_ \_\_\_ \_\_\_ 3. Is there a clearly defined process in place to
review and update, for DOE approval, its safety performance objectives,
performance measures, and commitments annually? \[48 CFR 970.5204-2
(e)\]

The FR should consider:

\- Significant changes to scope and or mission that have the potential
to affect the approved system description.

\- The process looks at indicators such as occurrence reports, FR
monthly reports, FEB reports etc. to determine if trends indicate a
weakness in the system description that needs to be addressed.

\- The process receives input from internal assessment mechanisms
designed to address the effectiveness of ISMS implementation.

\- The process reviews input from employee concerns, safety committee
meetings, and worker suggestion programs.

\- Does the process require a review of corrective actions/processes put
in place to address gaps identified in previous update reviews to ensure
they were adequately implemented?

\- Does the process require a review of list B (48 CFR 970.5204-78) to
ensure changes to DOE directives are adequately incorporated in to the
System Description?

OTHER:

NOTES/COMMENTS:

PERSONNEL CONTACTED:

ISSUE PACKAGES REVIEWED:

FINDINGS:

Finding No.:

Description:

OBSERVATIONS:

Observation No.:

Description:

FOLLOWUP ITEMS:

CONTRACTOR MANAGEMENT DEBRIEFED AND RESULTS:

Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
\_\_\_\_\_/\_\_\_\_\_/\_\_\_\_\_

Facility Representative