TGI_3819P12343A01_c1v1.pdf

FOUO

FOUO: Public availability to be determined under 5 USC 552

TASK GROUP INSTRUCTION

AIM REV 20.11.4.0 (OCTOBER 2020)

TGI COMPONENT NAME: TYPE: PHASE: REPEAT: CHANGE:

NO.: BLST/PP 9-86-5-W AY A 0 1

SHIP/HULL NO.: SHIP/HULL NAME: SYSTEM: PROJ/WO NO: CASREP CAT:

LCC-19 USS BLUE RIDGE 19P

CU PHASE TITLE:

F/O - REPAIR & PRESERVE STRUCTURAL MEMBER & REPAIR OVBD DISCH PIPING IN 9-86-5-W

PREPARING ACTIVITY:

PREPARED BY: CODE PHONE DATE

SHUUICHI OOTSUBO 231B. 315-243-7152 23 DEC 2023

APPROVED BY: CODE PHONE DATE

RYOUTA TAKAGI 231B. 315-243-4502 23 DEC 2023

CONCURRED BY: CODE PHONE DATE

CONCURRED BY: CODE PHONE DATE

CONCURRED BY: CODE PHONE DATE

CONCURRED BY: CODE PHONE DATE

REASON FOR WORK/NEED FOR CHANGE:

Direction from project team to remove JCN ER01-ZAW8.

CHANGE INSTRUCTIONS:

CH1: Remove JCN ER01-ZAW8. (11/05/2024)

SPECIAL REQUIREMENTS:

SURFMEPP

This Work Affects a Fire Zone Boundary. Fabrication and/or Staging of a Non-Flammable Closure is Required

CLEANLINESS FOR PIPING SYSTEM/EQUIPMENT LEVEL III

CLASS P-2 PIPING

WORK CERTIFICATION SIGNATURES

COMPLETION OF WORK REVIEW: BADGE NO.: SHOP/CODE: PHONE: DATE:

ACCEPTANCE OF COMPLETED WORK

PHYSICAL INSPECTION PHYSICAL INSPECTION COMPLETED: BADGE NO.: SHOP/CODE: PHONE: DATE:

REQUIRED:☐YES ☒NO

RECORDS REVIEW: BADGE NO.: SHOP/CODE: PHONE: DATE:

TGI NO.: BLST/PP 9-86-5-W AY A 0

FOUO

SHIP: LCC-19 CHG/VER: 1/1

LIST OF EFFECTIVE PAGES

SHT NO. CHG NO. SHT NO. CHG NO. SHT NO. CHG NO. SHT NO. CHG NO. SHT NO. CHG NO.

1-7 QA28

(1)

J 1-2 M-1 Sketch (1)

1. SCOPE/PURPOSE

1.1 Title: Structural Member and Overboard Discharge Piping in Fresh Water Ballast (9-86-5-W); repair and preserve

1.2 Location of Work:

1.2.1 Fresh Water Ballast (9-86-5-W)

1.2.2 Self Service Storeroom (6-86-1-A)

1.2.3 Engine Room (8-86-0-E)

1.2.4 Underwater Hull Weather, Frames between 93 and 94, Starboard

1.2.5 Distillate Fuel or Ballast (9-86-1-F)

1.3 Identification:

1.3.1 Quantity (One EA), Fresh Water Ballast, 9-86-5-W

Capacity: 32,307 Gallons

1.3.2 Quantity (2 EA), Manhole Cover Plate(s) for 9-86-5-W

Manhole No(s).: 6-86-1 and 6-97-1 Size: 15 Inches x 23 Inches Material: Steel

1.3.3 Quantity (2 EA), Bolting Ring for Manhole Cover Plate(s) for 9-86-5-W Manhole No(s).: 6-86-1 and 6-97-1 Material: Steel

1.3.4 Quantity (2 EA), Vertical Ladder for Manhole 6-86-1 and 6-97-1 in 9-86-5-W Material: Aluminum Alloy

1.3.5 Quantity (5 SF in Total), Interior Surfaces of Shell Plating in 9-86-5-W Remarks: See Sketch Enclosure-01 for location

1.3.5.1 Quantity (4 SF), Shell Plating, between Frames 94 and 96, and Stringers 9 and 11, Starboard

1.3.5.2 Quantity (One SF), Shell Plating, between Frames 86 and 87, and Stringers 8 and 9, Starboard

1.3.6 Quantity (One Lot), 1C Ship Service Turbine Generator (SSTG) Seawater Overboard Discharge Piping, runs through 9-86-5-W Remarks: See Sheet 3 (PLAN 23-D) and Sheet 4 (SECTION 30-A) of 2.10 for details

1.3.6.1 Quantity (One Lot), Pipe (Item No. 17 of 2.10)

FOUO

SHIP: LCC-19 CHG/VER: 1/1

Size: 10 Inch NPS (10.750 Inch OD x 0.500 Inch WT) Material: C-Steel Specification: ASTM-A106

1.3.6.2 Quantity (One EA), Flange, Special (Item No. 11 of 2.10) Size: For 8 Inch Material: OS, 45.9# Specification: MIL-S-22698 Remarks: See Sheet 3 (DETAIL 19-B) of 2.10 for detail.

1.3.6.3 Quantity (One EA), Shell Ring (Item No. 14 of 2.10)

Size: 10 Inches Diameter Material: OS, MIL-S-22698 GR B, 25.5 LBs Plate Remarks: See Section 30-A and Detail 27-D, Sheet 4 of 2.10 for details

1.3.7 Quantity (One EA), Zinc Anode in Overboard Discharge Pipe in 9-86-5-W, Frames between 93 and 94 Type: ZHS Size: 6 Inches x 6 Inches x 1-1/4 Inches Thickness, Cut from 6 Inches x 12 Inches x 1-1/4 Inches Zinc Anode Remarks: See Detail 27-D, Sheet 4 of 2.10 and General Notes 24 of 2.14 for details

1.3.8 Quantity (23 SF), Tank Side Surface of Overboard Discharge Pipe in 9-86-5-W, where new material is installed and disturbed by the hot work

Remarks: See Section 30-A of 2.10 for location details.

1.4 Security Classification: None.

1.5 Initial Condition:

1.5.1 Potential Lead Hazard

1.5.2 Dry Dock Work

1.5.3 Critical Coated Area: CCNY-LCC19-001-25 for the area listed in 1.3.8.

1.6 Contractor work start date: 1/12/2026

1.7 Contractor work completion date: 5/15/2027

2. REFERENCES:

REF.

NO.

DOCUMENT

/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV CHG

NO.

COPY

REQ’D

(Y/N)

SOURCE

DOC

(Y/N)

PARA SEC PG CHP

1 NSI FY-25 NAVSEA Standard Items - ORG N 2 LI FY-25 Local Standard Items - ORG N

3 TM S9086-

CJ-STM-

010/CH-075

Fasteners 7 N

4 DWG 100-

2491003

SHELL PLTG & STGR FRAME 51

1/2 -102 1/4 CL TO 4 TH DECK

G Y AL

L

5 DWG 101-

2491024

WEBS FR 88, 90, 92, 94 & 96 H Y AL

L

6 DWG 103-

2491036

1ST PLATF PLTG FR 52-98 G Y AL

L

7 DWG 114-

2491157

TRANSV BHD FR 76 & 86 N Y AL

L

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SHIP: LCC-19 CHG/VER: 1/1

REF.

NO.

DOCUMENT

/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV CHG

NO.

COPY

REQ’D

(Y/N)

SOURCE

DOC

(Y/N)

PARA SEC PG CHP

8 DWG 114-

2491158

TRANSV BHD FR 98 &109 K Y AL

L

9 DWG 114-

2491162

Wing Tank BHD FR76-98 D Y AL L

10 DWG 120-

6855258

S/A LCC19-1168D SHIP SERVICE

TURBINE GENERATOR

SEACHEST MODIFICATION

ENGINE ROOM

- Y AL

L

11 MIL MIL-

STD-1627

Bending of Pipe or Tube for Ship Piping Systems

C N

12 TM T9074-

AS-GIB-

010/271

Requirements for Nondestructive Testing Methods

1 N

13 MIL MIL-

STD-2035

Nondestructive Testing Acceptable Criteria

A N

14 DWG 120-

2424226

Seachest Guidance Standard Surface Ships Non-Nuclear Systems

C Y AL

L

15 TM T-9630-

AB-MMD-

Corrosion Control Assessment and Maintenance Manual (CCAMM)

3 N

16 TM NAVSEA

4790/14

Tank and Void Structural and Coating Condition Survey (MRC G1N5)

- N

3. APPENDICES:

3.1 Appendix “J” TGI Job Summary Information Sheet

3.2 Appendix "M" TGI Material List

3.3 Appendix “D” Deficiency Form

4. GENERAL REQUIREMENTS:

4.1 Not Applicable.

5. PROCEDURE:

5.1 Accomplish the requirements of 099-902YO of 2.2 for each tank listed in 1.3.1.

5.1.1 Accomplish the requirements of 009-107 of 2.1.

5.1.1.1 Ensure General Cleaning must be Level III.

5.1.2 Accomplish installation of each manhole cover for each tank listed in 1.3.1 in accordance with Figure 075-4-1 of 2.3.

5.2 Weld fill, drill, and tap a total of 10 each stripped manhole cover bolting ring holes for each tank listed in 1.3.1 as designated by the SUPERVISOR. See 5.12.5.

5.2.1 Accomplish the requirements of 009-12 of 2.1, including Table 2, Column A, Lines One through 7.

5.3 Repair each tank listed in 1.3.1, based on the CCIMS assessment report as designated by the SUPERVISOR, using 2.4 through 2.9 for guidance. See 5.12.4 through 5.12.6.

5.3.1 Vee-out and weld a total of one linear feet of each deteriorated and damaged weld. Each area of repair must include deck, bulkhead, shell plating, and overhead.

FOUO

SHIP: LCC-19 CHG/VER: 1/1

5.3.2 Chip and grind each surface flush in way of each repair.

5.3.3 Base metal weld buildup a total of 60 square inches of each plate defect in the tank.

5.3.3.1 For bidding purposes the base metal weld buildup must be one quarter inch thick.

5.3.3.2 Surface must be ground to sound metal prior to base metal weld buildup.

5.3.3.3 Fill each local pit and groove with weld metal prior to application of each principle build-up layer.

5.3.3.4 Grind each surface of completed base weld metal buildup smooth if greater than 1/8 inch above plate surface.

5.3.4 Remove existing, fabricate, and install new a total of 10 square feet of deteriorated plate.

5.3.5 Remove existing, fabricate, and install new a total of 4 linear feet of defective stiffener.

5.3.6 Accomplish the requirements of 009-12 of 2.1, including Table 2, Column(s) A, Lines One through 7.

5.3.6.1 Accomplish nondestructive testing in accordance with Line 11.

5.3.7 Accomplish the requirements of 009-25 of 2.1 for an air hose, water hose, or vacuum box test of each new insert weld seam. Allowable leakage: None.

5.4 Accomplish the requirements of 009-32 of 2.1, including Table 4, Line(s) 17, for tank side surface, and Table 3, Line(s) 25, for interior compartment side surface of each cover plate listed in 1.3.2.

5.5 Accomplish the requirements of 009-32 of 2.1 for each bolting ring listed in 1.3.3.

5.6 Accomplish the requirements of 009-32 of 2.1, including Table 4, Line(s) 27 for each vertical ladder listed in 1.3.4.

5.7 Accomplish the requirements of 009-32 of 2.1, including Table 4, Line(s) 17 for each area listed in 1.3.5.

5.8 Remove existing, fabricate, and install new 1C SSTG seawater overboard discharge piping listed in 1.3.6, using

2.10 for guidance.

5.8.1 Bend each new pipe in accordance with 2.11.

5.8.2 Accomplish the requirements of 009-12 of 2.1, including Table One, Column(s) A, Lines One through 10.

5.8.3 Accomplish the requirements of 009-12 of 2.1, including Table 2, Column(s) A, Lines One through 7.

5.8.3.1 Accomplish ultrasonic (UT) inspection of each new weld of shell ring listed in 1.3.6.3 in accordance with Detail 27-D of 2.10 and Paragraph 6 of 2.12. The accept or reject criteria must be in accordance with Class One, Paragraphs 8 of 2.13.

(I)(G) “UT INSPECTION”

5.8.4 Accomplish the requirements of 009-71 of 2.1 for hydrostatic test, using clean, fresh water at 50 PSIG, for new and disturbed 1C SSTG seawater overboard discharge piping systems.

5.8.4.1 Document shop hydrostatic test results on QA Form 28 Enclosure-02-1.

5.8.5 Accomplish the requirements of 009-25 of 2.1 for a local hose test of each new weld of pipe, longitude, and shell ring listed in 1.3.6. Allowable leakage: None.

FOUO

SHIP: LCC-19 CHG/VER: 1/1

5.8.6 Accomplish the requirements of 009-25 of 2.1 for a completion air test of each tank listed in 1.3.1. Test pressure must be 2 PSIG. Allowable drop in pressure: None.

5.9 Remove existing, fabricate, and install new each zinc anode listed in 1.3.7 in accordance with 2.10 and 2.14.

5.9.1 Accomplish the requirements of 009-12 of 2.1, including Table 2, Column(s) A, Lines One through 7.

5.10 Accomplish the requirements of 009-32 of 2.1, including Table 4, Line(s) 17, for each area listed in 1.3.8.

5.10.1 Submit new coating data applied to the SUPERVISOR in accordance with 2.15 and 2.16.

5.11 Accomplish the requirements of 009-32 of 2.1 for each new and disturbed surface. See 5.12.10.

5.12 Notes:

5.12.1 Planner: Code 231B S. Ootsubo, 243-7152

Planner: Code 232 S. Takagi, 243-1972 Planner: Code 234 Y. Inomata, 243-4536 Engineer: Code 250 K. Matsunari, 243-5816

5.12.2 Work Integration Manager (WIM): Code 333 T. Yaginuma, 080-5419-0598

5.12.3 This TGI meets the intent of DDG CSWT File Nos. 123-133 and 123-142.

5.12.4 CCIMS assessment of each tank listed in 1.3.1 will be accomplished by SRF-JRMC (TGI No.

3819P12343I01), and the Project team will provide the assessment report with engineering evaluation under DL process for front loading structure repair.

5.12.5 Removal and installation of interferences, and gas free operation, preservation of boundary spaces relating to front loading structure repair are not included in this TGI. They will be covered by a DL in the future based on Contractor submitted condition report.

5.12.6 Materials for structure members relating to front loading repair will be provided in the future as a DL based on Contractor submitted condition report.

5.12.7 This TGI is in response to Condition Report No(s). NNR01072-8-03 from Sumitomo Heavy Industries, Ltd.

Dated 02-JUNE-2021.

5.12.8 Work per this instruction involves cutting an access (or removal of a door) through a fire zone bulkhead, through the hull of the ship above the turn of the bilge, through ventilation components (ducting, plenums, etc.), or through any air-tight, fume-tight or watertight bulkheads normally used to control air flow in the event of a shipboard fire. A nonflammable closure is required in accordance with COMNAVSEASYSCOM MSG R 261400Z JUL 12. The closure, if not continuously in use, shall be staged near the access, readily visible and accessible, so that any emergency responder can install the closure to affect proper air flow onboard the ship.

5.12.9 2.16 is available on P:\C200\C225\Enclosures\C231\Tank and Void Structural and Coating Condition Survey

(MRC G1N5).

5.12.10 Preservation work for disturbed exterior surface of shell plating will be covered by ICN 3819P11001 (KTR

TGI).

5.12.11 Replacement of wester sleeve for overboard discharge piping will be covered by ICN 3819P16301 (KTR

TGI).

5.12.12 Removal and installation of sea valve will be covered by ICN 3819P52001 (KTR TGI).

FOUO

SHIP: LCC-19 CHG/VER: 1/1

5.12.13 Opening, initial cleaning, and closing of each space listed in 1.2.5 will be covered by ICN 3819P12319 (KTR

TGI).

5.12.14 JCNs ER01-ZAL5, ER01-ZAS8, ES01-NP1Z, ES01-NP26, and ES01-L111 are related to this TGI.

5.13 Government Furnished Material (GFM):

5.13.1 SRF-JRMC will provide GFM listed in Appendix ”M”.

5.14 SRF-JRMC will provide the following service work: (TGI No. 3819P12343S02)

5.14.1 [C740] Crane and crane rigging service.

5.14.2 [X99E] Utility service, electrical.

5.14.3 [X99M] Utility service, including water supply, steam supply, and low pressure air supply except onboard blasting work.

5.14.4 [C106.1] Safety inspection for SRF-JRMC employees.

5.14.5 [C106.2] Gas free inspection for SRF-JRMC employees.

5.14.6 [C133] QA inspection for (G) symbol(s) and review of coating application data.

5.14.7 [C135] QA inspection for (G) symbol(s).

5.14.8 [C250] Technical support.

FOUO

J-1

SHIP: LCC-19 CHG/VER: 1/1

APPENDIX "J"

TGI JOB SUMMARY INFORMATION SHEET

SYSTEM: PLANT NO.: COMPONENT NAME: TYPE: PHASE: REPEAT: CU PH

VERSION:

CASREP

CAT:

BLST/PP 9-86-5-W AY A 0 1

CU PHASE TITLE:

F/O - REPAIR & PRESERVE STRUCTURAL MEMBER & REPAIR OVBD DISCH PIPING IN 9-86-5-W

PRIMARY COMPONENT:

COMPONENT UNIT LIST (FOR ASSEMBLIES):

UH FR40-98 STBD UH SW 9-86-5-W PP BLST 9-86-5-W TK CMPT 6-86-1-A MSCMPT 8-86-0-E

MS SW 8-86-0-E PP MANHOLE 6-86-1 HA MANHOLE 6-97-1 HA

ATTACHMENT LIST:

1. ENCLOSURE-01 (3819P12343A01-Sketch.pdf) saved on 21-DEC-2023 0000.

2. ENCLOSURE-02 (3819P12343A01-QA28.docx) saved on 22-DEC-2023 0000.

ZONE MANAGER: ZONE: COMPARTMENT: LEVEL: FRAME: SIDE:

YAGINUMA ,TAKEHIDE

JO: KO: TOTAL MAN HRS: PLANNING ACCEPTANCE:

3819P12343 A01

TOTAL MAT’L COST TOTAL DURATION:

CU PHASE DESCRIPTION:

The purpose of this TGI is to repair and preserve structural member and repair overboard discharge piping in fresh water ballast (9-86-5-W).

Location of Work:

Fresh Water Ballast (9-86-5-W) Self Service Storeroom (6-86-1-A) Engine Room (8-86-0-E) Underwater Hull Weather, Frames between 93 and 94, Starboard Distillate Fuel or Ballast (9-86-1-F)

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

5.1 LBR HRs 22 KE PC

5.2 SFTR HRs, WELD HRs, QA HRs, PNTR HRs 22 KE PC

5.3 SFTR HRs, WELD HRs, CARP HRs, PNTR HRs, QA HRs 22 KE PC

5.4 PNTR HRs, QA HRs 22 KE PC

5.5 PNTR HRs, QA HRs RGRS HRs 22 KE PC

5.6 PNTR HRs, QA HRs, SFTR HRs 22 KE PC

5.7 PNTR HRs, QA HRs 22 KE PC

5.8 PFTR HRs, WELD HRs QA HRS, IMCH HRs, SFTR

HRs, PNTR HRs, CARP HRs, RGRS HRs

22 KE PC

5.9 SFTR HRs, WELD HRs, QA HRs 22 KE PC

5.10 PNTR HRs, QA HRs 22 KE PC

5.11 PNTR HRs, QA HRs 22 KE PC

FOUO

J-2

SHIP: LCC-19 CHG/VER: 1/1

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

Dewatering and Cleaning Work CFM for marine chemist, tank watch cost, gaskets, fastener, and MISC.

22 MQ CS

Structural Work CFM for all paints, thinner, grit including waste disposal cost, fire watch and tank watch cost, MT and UT inspection cost, lead sampling/analysis cost, air compressor rental cost and fuel oil cost for air hose test, and MISC such as electrode, gases, temporary closure and covering material, and other consumable.

22 MQ CS

Preservation Work CFM for all paints, thinner, tank watch cost, copper grit, garnet compressor, dryer, air conditioner, fuel oil, disposal cost, and MISC such as covering material, enclosure, and other consumable.

22 MQ CS

Piping Work CFM for fire watch cost, tank watch cost, air compressor rental cost and fuel oil cost for local air hose test, gases and misc such as electrode, saw blades, plastic bag/sheet and etc.

22 MQ CS

Process Funding Document 10 CT OM

Version-01: remove JCN ER01-ZAW8. C231B R Takagi 11/5/2024 Y/Y/N

V-01

FOUO

M-1

SHIP: LCC-19 CHG/VER: 1/1

APPENDIX “M”

TGI MATERIAL LIST

SYSTEM: PLANT NO.: COMPONENT NAME: TYPE: PHASE: REPEAT: CU PH

VERSION:

CASREP

CAT:

BLST/PP 9-86-5-W AY A 0 1

CU PHASE TITLE:

F/O - REPAIR & PRESERVE STRUCTURAL MEMBER & REPAIR OVBD DISCH PIPING IN 9-86-5-W

MATERIAL REFERENCES

REF

NO.

DOCUMENT/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV

1 6855258

JOB ORDER: KEY OP:

3819P12343 A01

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

001 M ANODE,CORROSION PRE,

ORDER FOR KTR

ORIG: C231B, S. OOTSUBO,

243-7152

9B 5342 002777559 NA 4 N 40045012 1/EA

402 11 1 M PLATE,ME, ORDER FOR KTR

ORIG: C226 T.YAMAGUCHI,

070-7787-2060

3FT X 3FT

9B 9515 001533270 NA 4 N 40045003 9/SF

403 14 1 M PLATE,ME, ORDER FOR KTR

ORIG: C226 T.YAMAGUCHI,

070-7787-2060

2FT X 5FT

9B 9515 001533248 NA 4 N 40045004 10/SF

404 17 1 M PIPE, METAL, PIPE, METAL,

SEAMLESS,

SPEC: ASTM A106 GRADE B,

SIZE: 10" IPS X 0.500" THK,

SCHEDULE 60(XS),

MATL: CARBON STEEL,

QTY: 10 FT (ONE

CONTINUOUS LENGTH

REQUIRED) X 2 EA,

ORDER FOR KTR

ORIG: C226 T.YAMAGUCHI,

070-7787-2060

9B 4710 LL4890102 NA 4 N 40367456 20/FT

NOTES:

FOUO: Public availability to be determined under 5 USC 552 SHEET_____OF_____

☐ NUCLEAR APPENDIX "D"

DEFICIENCY FORM

☐ NON-NUCLEAR

1. SHIP/HULL NO.: 2a. DL or DR No.

(Circle One)

2b. REVISION: 3a. COMPONENT NAME: 3b. TYPE: 3c. PHASE: 3d. REPEAT:

LCC-19 BLST/PP 9-86-5-W AY A 0

4a. ICN: 4b. KEY OP: 5. LOC SPACE/LVL: FRAME: P/S/C: 6. CAUSED BY:

3819P12343 A01

7. DESCRIPTION:

8. ORIGINATOR: NAME: BADGE: SHOP/CODE: DATE: PHONE NO.:

9. CORRECTIVE ACTION:

10. EVALUATOR: NAME: BADGE: SHOP/CODE: DATE: PHONE NO.:

FOR NON-NUCLEAR USE ONLY

11. RFD/RFW REQ’D ☐ LAR REQ'D ☐

ILS MOD REQ’D ☐

SRD/PLAN REV REQ'D ☐

DWG NO.: _____________________ S/A NO.: ___________________

12. ISOLATION SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.:

SATISFACTORY:

13. SUBSAFE OQE RECORD? SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

YES ☐ NO ☐

14. CORRECTIVE ACTION SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

COMPLETE:

15. INSPECTION REQ’D? INSPECTION COMPLETE/SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

_________:YES ☐ NO ☐

16. RECORDS REVIEW SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

COMPLETE (DR ONLY)

DL’s ISSUED

(DR ONLY)

FOUO: Public availability to be determined under 5 USC 552 SHEET_____OF_____

☐ NUCLEAR Deficiency Form Continuation Sheet ☐ NON-NUCLEAR

1. SHIP/HULL NO.: 2a. DL or DR No.

(Circle One) 2b. REVISION: 3a. COMPONENT NAME: 3b. TYPE: 3c. PHASE: 3d. REPEAT:

LCC-19 BLST/PP 9-86-5-W AY A 0

Shuuichi.Ootsubo.ja Text Box

SKETCH

3819P12343A01 ENCLOSURE-01 Sheet 1 of 1

Shuuichi.Ootsubo.ja_1 Text Box Identification: 1.3.5.1

Shuuichi.Ootsubo.ja_2 Text Box Identification: 1.3.5.2

COMUSFLTFORCOMINST 4790.3 REV D CHG 2

31 Mar 2022

SHOP TEST RECORD Page 1 of 1

QA FORM 28 (6/05) Planning must fill in blocks identified by a prior to issuing

1. SHIP HULL NO. 2. JCN 3. LWC/SHOP 4. CWP/REC SER NO. 5. SYSTEM/COMPONENT/ROTATABLE POOL SER NO.

USS BLUE RIDGE LCC19 ES01-L111 KTR N/A SEAWATER OVERBOARD

DISCHARGE PIPING

6. REFERENCES: TEST REF (E.G., MS, TECH MAN) & OTHER REFS (E.G., VLV DWG) 7. TEST GAGE RANGE /INSTRUMENT USED SERIAL NO. CAL DUE DATE 8. RELIEF VLV SET POINT

A. S9086-RK-STM-010/CH-505 Rev. 6

B. DWG 120-6855258 Rev. “-“

C. .

D. .

9. TEST REQUIREMENTS & RESULTS

TEST TYPE KEY H = STRENGTH AND POROSITY/ELEVATED PRESSURE

TEST J = MECHANICAL JOINT TIGHTNESS ST = SEAT TIGHTNESS OP = OPERATIONAL O = OTHER

(SPECIFY): ______________________

TE

ST

T Y

PE

(S

EE

K

EY

) PARAGRAPH

DESCRIBING

VALVE POSITION

AND POINT OF

ENTRY

REF

LTR

GAGE

USED

(LTR

FROM

BLK 7)

REQUIRED

MEDIUM

MEDIUM

USED

REQUIRED

PRESSURE

ACTUAL

PRESSURE

MINIMUM

DURATION

ACTUAL

DURATION

ALLOWED

LEAKAGE

ACTUAL

LEAKAGE SAT/UNSAT SIGNATURE, BADGE NO. & DATE

H 5.8.4 A,B Clean Fresh Water

50 PSIG 30 minutes None.

10. REMARKS. (CRAFTSMAN/QAI SUBMIT A DF TO RESOLVE UNSAT DATA)

11. QA INSPECTOR/SHOP SUPERVISOR SIGNATURE/BADGE NO. (RECORD

REVIEWED FOR FINAL ACCEPTANCE)

DATE 12. QAS SIGNATURE/BADGE NO. (RECORD HAS BEEN REVIEWED FOR

COMPLETENESS)

DATE

3819P12343A01 ENCLOSURE-02-1 TOTAL 1