benefit from a better understanding and ownership of the instrument and control components of their
systems, particularly the software components.
Shift Performance: During observation of the Denitrator High Temperature Interlock Surveillance, it was
noted that uncontrolled changes were made to the wiring of the Denitrator Control Cabinet (CM-1-4).
This change was introduced through the Maintenance Job Request process. Since it did not go through the
change process, it did not receive sufficient engineering and safety review and it did not get entered into
the USQD process. The management review of this event was observed. It was a thorough process that
identified causal factors and effective resolutions. Discussion of the unapproved change to the Denitrator
Control Cabinet revealed that some personnel could benefit from training on identification of changes.
Conclusion: The objective has not been met.
Software components of facility systems are not graded as required by the Configuration
Management Program. As a result, changes to software may not be appropriately
controlled, and may fail to enter the USQ process. (Post Start)
Some system design features that are important to safety are not adequately controlled by
system documentation. (Post Start)
Implementation of the USQ process does not fulfill the intent of 10 CFR 830.203 or its
associated guidance document. (Pre-Start)
Uncontrolled changes were made to the wiring of the Denitrator Control Cabinet. (Pre-
Team Leader: ________________________