TGI_3819P13411A01_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.: STRL MBR 4-109-7-Q 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 AND PRESERVE STRUCTURAL MEMBER IN 4-109-7-Q

PREPARING ACTIVITY:

PREPARED BY: CODE PHONE DATE

YUUICHI YOSHIHARA 231B. 315-243-9984 21-JUN-2024

APPROVED BY: CODE PHONE DATE

RYOUTA TAKAGI 231B. 315-243-4502 21-JUN-2024

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:

Correction of Rev. of Ref. No. 7 is required.

CHANGE INSTRUCTIONS:

CH1: Correct Rev. of Ref. No. 7. (08/22/2024)

SPECIAL REQUIREMENTS:

This work affects a fire zone boundary. Fabrication and/or staging of a non-flammable closure is required.

HOT WORK IN MAGAZINE AND ADJACENT SPACES IAW S6740-AA-SAF-010 AND NAVSEA OP 4

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.: STRL MBR 4-109-7-Q 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.

1-6 J1-2 M1-3 Sketch (1-14)

1. SCOPE/PURPOSE

1.1 Title: Structural Member in 4-109-7-Q; repair and preserve

1.2 Location of Work:

1.2.1 Diesel Exhaust Piping Space (4-109-7-Q)

1.2.2 Gear Locker (3-109-11-A)

1.2.3 Freeboard Weather, Frames between 111 and 113, Starboard

1.2.4 SD Storeroom (4-98-9-Q)

1.2.5 Void (5-98-1-V)

1.2.6 Crew Living Space (5-109-0-L)

1.2.7 Crew Washroom, Water Closet, Shower, and Decontamination Station (5-104-1-L)

1.3 Identification:

1.3.1 Quantity (1,090 SF), Structural Plating in 4-109-7-Q

Reading Point: 12 Inches x 12 Inches Grid Pattern Remarks: See 2.5 through 2.7 for base material

The area excepts structural shapes

1.3.2 Quantity (One Lot), Structural Member in 4-109-7-Q

Remarks: See 2.8 for detail

1.3.2.1 Quantity (One EA), Shell Plate, Sponson Shell, Frames between 111 and 113

Material: HTS, MIL-S-22698 GR-DH36, 12.75 LBs Plate

1.3.2.2 Quantity (One EA), Web Frame 111 1/2 on Shell Plate listed in 1.3.2.1

Material: OS, MIL-S-22698 GR-A, 10 Inches x 4 Inches x 15 LBs I-T

1.3.3 Quantity (One Lot), Structural Member in 4-109-7-Q

1.3.3.1 Quantity (One Lot), Transverse Frame 112 1/2 on Shell Plating and Sponson Shell Plating

Remarks: See 2.5 and 2.6 for base material, and Sheet 3 Figure-1a and Figure-1a-1 of Sketch Enclosure-01 for location detail

FOUO

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

1.3.3.2 Quantity (One Lot), Web Frame 112 on Shell Plating and Sponson Shell Plating

Remarks: See 2.5 and 2.6 for base material, and Sheet 4 Figure-1b, and Sheet 5 Figure-1b-1 and Figure-1b- 2 of Sketch Enclosure-01 for location detail

1.3.3.3 Quantity (One Lot), Transverse Frame 111 1/2 on Shell Plating and Sponson Shell Plating

Remarks: See 2.5 and 2.6 for base material, and Sheet 4 Figure-1c and Sheet 6 Figure-1c-1 of Sketch Enclosure-01 for location detail

1.3.3.4 Quantity (One Lot), Transverse Frame 110 1/3 on Shell Plating and Sponson Shell Plating

Remarks: See 2.5 and 2.6 for base material, and Sheet 6 Figure-1d-1 and Sheet 7 Figure-1d-2 of Sketch Enclosure-01 for location detail

1.3.3.5 Quantity (One Lot), Transverse Frame 109 2/3 on Shell Plating and Sponson Shell Plating

Remarks: See 2.5 and 2.6 for base material, and Sheet 7 Figure-1e of Sketch Enclosure-01 for location detail

1.3.3.6 Quantity (One Lot), Vertical Stiffener on Shell Plating and Transverse Bulkhead Plating Frame 109

Remarks: See 2.5 and 2.6 for base material, and Sheet 8 Figure-1f-1 and Figure-1f-2 of Sketch Enclosure-01 for location detail

1.3.3.7 Quantity (One Lot), Lateral Support on Longitudinal No. 22, Frame 111

Remarks: See 2.5 and 2.9 for base material, and Sheet 9 Figure-1g-1 and Figure-1g-2 of Sketch Enclosure- 01 for location detail

1.3.3.8 Quantity (One Lot), Toe Bracket on Longitudinal No. 23, Frames between 109 and 110, Inboard Side

Remarks: See 2.5 and 2.9 for base material, and Sheet 10 Figure-1h of Sketch Enclosure-01 for location detail

1.3.3.9 Quantity (One Lot), Toe Bracket on Longitudinal No. 24, Frames between 109 and 110, Inboard Side

Remarks: See 2.5 and 2.9 for base material, and Sheet 10 Figure-1i of Sketch Enclosure-01 for location detail

1.3.3.10 Quantity (One Lot), Longitudinal No. 21 on Third Deck Plating, Frames between 110 and 111

Base Material: OS, MIL-S-22698 GR-A, 12 Inches x 4 Inches x 22 LBs I-T Remarks: See Sheet 11 Figure-2a of Sketch Enclosure-01 for location detail

1.3.3.11 Quantity (One Lot), Longitudinal No. 21 on Third Deck Plating, Frames between 109 and 110

Base Material: OS, MIL-S-22698 GR-A, 12 Inches x 4 Inches x 22 LBs I-T Remarks: See Sheet 11 Figure-2b of Sketch Enclosure-01 for location detail

1.3.3.12 Quantity (One Lot), Longitudinal No. 22 on Third Deck Plating, Frames between 109 and 110

Base Material: OS, MIL-S-22698 GR-A, 12 Inches x 4 Inches x 22 LBs I-T Remarks: See Sheet 12 Figure-2c and Figure-2d of Sketch Enclosure-01 for location detail

1.3.3.13 Quantity (One Lot), Longitudinal No. 25 on Third Deck Plating, Frames between 111 and 112

FOUO

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

Base Material: OS, MIL-S-22698 GR-A, 12 Inches x 4 Inches x 22 LBs I-T Remarks: See Sheet 13 Figure-2e of Sketch Enclosure-01 for location detail

1.3.3.14 Quantity (One Lot), Web Frame 112 on Third Deck Plating, Longitudinals between No. 24 and No. 25

Base Material: OS, MIL-S-22698 GR-A, 17.85 LBs Plate Remarks: See Sheet 13 Figure-2f of Sketch Enclosure-01 for location detail

1.3.3.15 Quantity (One Lot), Third Deck Plating, between Frames 110 and 111, and Longitudinals No. 23 and No. 24

Base Material: OS, MIL-S-22698 GR-A, 15.3 LBs Plate Remarks: See Sheet 14 Figure-3 and Figure-3-1 of Sketch Enclosure-01 for location detail

1.3.4 Quantity (1,850 SF), Entire Interior Surface of Diesel Exhaust Piping Space (4-109-7-Q)

Remarks: The area includes exhaust piping space side of access cover plate(s)

1.4 Security Classification: None.

1.5 Initial Condition:

1.5.1 Potential Asbestos Hazard

1.5.2 Potential Lead Hazard

1.6 Contractor work start date: 1/12/2026

1.7 Contractor work completion date: 6/12/2027

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 T9074-

AS-GIB-

010/271

Requirements for Nondestructive Testing Methods

1 N

4 TM S9086-

DA-STM-

010/CH-100

Hull Structures 4 N

5 DWG 100-

2491008

SPONSON & STGR AFT FR 76-1/2 G Y AL

L

6 DWG 100-

2491005

SHELL PLTG & STGR FRAME 102

1/4 STERN CL TO 4 TH DECK

F Y AL

L

7 DWG 100-

2491006

SHELL PLTG & STGR FR 102¼-

STERN - ABV 4TH DK

L Y AL

L

8 PDD 100-

ELM-240306

RPR PLAN OF DEFORMED

SPONSON SHELL & WEB FR 111

1/2 IN DSL EXH PP SP (4-109-7-Q)

- Y AL

L

9 DWG 114-

2491176

STRUCTURAL DETAILS AE Y 11,

10 DWG 113-

2491129

FDN MISC – 3RD DK F Y 20

3. APPENDICES:

FOUO

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

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 ultrasonic thickness measurement (UTM) on each structural plating listed in 1.3.1 in accordance with Paragraph 6.7 of 2.3, and 2.4, using 2.5 through 2.7 for guidance.

5.1.1 Submit one legible copy, in hard copy or approved transferrable media, of a report listing results of the requirements of 5.1 to the SUPERVISOR.

5.2 Remove existing, fabricate, and install new each structural member listed in 1.3.2 in accordance with 2.8.

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

5.2.2 Accomplish the requirements of 009-25 of 2.1 for a local air hose test of each new weld of each shell plate listed in 1.3.2.1. Allowable leakage: None.

5.3 Accomplish weld repair of deficient welds, mechanical gouges, and mechanical hole on each existing structural member listed in 1.3.3 in accordance with 2.5 and 2.9, using 2.6 and 2.10 for guidance. See 5.9.7.

5.3.1 Gouge out the deficient welds.

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

5.3.3 Accomplish the requirements of 009-25 of 2.1 for a local air hose test of each new weld of each third deck plating listed in 1.3.3.15. Allowable leakage: None.

5.4 Accomplish the requirements of 009-32 of 2.1, including Table 3, Line(s) 18, for each area listed in 1.3.4.

5.5 Confirm that all personnel have exited the space prior to closure of the space listed in 1.2.1. Designate one person to account for all personnel who may have entered the space.

5.6 Accomplish the requirements of 009-32 on 2.1 for each new and disturbed surface.

5.7 Notes:

5.7.1 Planner: Code 231B Y. Yoshihara, 243-9984

Planner: Code 231B N. Kurokawa, 243-0108 Planner: Code 234 M. Eguchi, 243-0978 Engineer: Code 250 N. Takanishi, 243-4331

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

5.7.3 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.

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

5.7.4 Opening, initial cleaning, and closing of each space listed in 1.2.5 will be covered by TGI No. 3819P12372A01

(KTR TGI).

5.7.5 Preservation work for new and disturbed exterior surfaces of freeboard will be covered by ICN 3819P11001

(KTR TGI).

5.7.6 This TGI is in response to CCIMS report No. CCIMS-G1N6-LCC19-071-23 from TGI No. 3819M11006I04.

5.7.7 This TGI clears DFS LCC-19-1034-2023 in its entirety.

5.7.8 JCNs EA05-L089 and ES01-NNYW are related to this TGI.

5.8 Government Furnished Material (GFM):

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

5.9 SRF-JRMC will provide the following service work: (TGI No. 3819P13411S02).

5.9.1 [C740] Crane and crane rigging service.

5.9.2 [X99E] Utility service, electrical.

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

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

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

5.9.6 [C133] QA inspection for (G) symbol(s).

5.9.7 [C250] On-site engineering support for weld repair.

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:

STRL MBR 4-109-7-Q AY A 0 1

CU PHASE TITLE:

F/O - REPAIR AND PRESERVE STRUCTURAL MEMBER IN 4-109-7-Q

PRIMARY COMPONENT:

COMPONENT UNIT LIST (FOR ASSEMBLIES):

CMPT 3-109-11-A MS CMPT 4-109-7-Q MS

ATTACHMENT LIST:

1. ENCLOSURE-01 (3819P13411A01-Sketch.pdf) saved on 15-JUN-2024 0000.

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

YAGINUMA ,TAKEHIDE

JO: KO: TOTAL MAN HRS: PLANNING ACCEPTANCE:

3819P13411 A01

TOTAL MAT’L COST TOTAL DURATION:

CU PHASE DESCRIPTION:

The purpose of this TGI is to repair and preserve structural member in 4-109-7-Q.

Location of Work:

Diesel Exhaust Piping Space (4-109-7-Q) Gear Locker (3-109-11-A) Freeboard Weather, Frames between 111 and 113, Starboard SD Storeroom (4-98-9-Q) Void (5-98-1-V) Crew Living Space (5-109-0-L) Crew Washroom, Water Closet, Shower, and Decontamination Station (5-104-1-L)

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

5.1 SFTR HRs, RGRS HRs 22 KE PC

5.2 SFTR HRs, WELD HRs, SMTL HRs, INSL HRs, CARP

HRs, PNTR HRs, LBR HRs, RGRS HRs, QA HRs

22 KE PC

5.3 SFTR HRs, WELD HRs, BLRM HRs, INSL HRs, PNTR HRs, RGRS HRs, QA HRs

22 KE PC

5.4 INSL HRs, PNTR HRs, RGRS HRs, QA HRs 22 KE PC

5.5 SFTR HRs 22 KE PC

5.6 PNTR HRs, QA HRs 22 KE PC

Structure Work CFM: $ for fire watch cost, confined space watch cost, tank watch cost, asbestos sampler/analysis cost for compartment insulation, lead sampling/analysis cost, pin/adhesive for compartment insulation, marine chemist cost, air compressor rental cost and fuel oil cost for air hose test, fastener, gasket, ---continue to below---

22 MQ CS

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J-2

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

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

---continued to from above--- and misc such as electrode, gases, temporary closure/covering material, tybek suit, tape, and other consumable.

22 MQ CS

Boiler and Lagging Work CFM: $ for asbestos sample and analyze cost, paints, plastic bag/sheet, tyvck suit and MISC.

22 MQ CS

Preservation Work CFM: $ for all paints, thinner, grits including disposal cost, confined space watch cost, tank watch cost, UTM inspection cost, sampler/analysis lead, air compressor, dryer, fuel oil, air conditioning, and MISC such as covering material and other consumable.

22 MQ CS

Process Funding Document 10 CT OM

Version-1: correct Revision of Ref. No. 7. C231B R. Takagi, 08/22/2024. 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:

STRL MBR 4-109-7-Q AY A 0 1

CU PHASE TITLE:

F/O - REPAIR AND PRESERVE STRUCTURAL MEMBER IN 4-109-7-Q

MATERIAL REFERENCES

REF

NO.

DOCUMENT/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV

JOB ORDER: KEY OP:

3819P13411 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 PLATE,ME, ORIG: C231B,

Y.YOSHIHARA, 243-9984

ORDER FOR KTR

SIZE: 4 FT X 5 FT

9B 9515 001533368 NA 4 N 41635246 20/SF

002 M TEE-BAR, I-T SHAPE, , TEE-

BAR, I-T SHAPE, SPEC: MIL-S-

22698 GRADE A, NOMINAL

SIZE: 10” X 4” X 15 LBS, WEB

THK: 1/4” (0.230”), FLG THK:

1/4” (0.270”), MATL: STEEL OS,

*REMARKS: CUT FROM 10”

(9.99”) DEPTH X 4" (4.00")

FLANGE X 15 LBS W-SHAPE

TO T-SHAPE, TWO SIDES OF

ONE FLANGE REMOVED

10 FT CONTINUOUS LENGTH X

1 EA

9B 9520 LL9308333 NA 4 N 41907510 10/FT

003 M INSULATI, ORIG: C231B,

Y.YOSHIHARA, 243-9984

ORDER FOR KTR

9Q 5640 008096312 NA 4 N 41635248 10/EA

NOTES:

FOUO

M-2

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

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

004 M CAP,SNAP, ORIG: C231B,

Y.YOSHIHARA, 243-9984

ORDER FOR KTR

9B 5325 007377648 NA 4 N 41635249 70/EA

005 M TAPE,TEX, ORIG: C231B,

Y.YOSHIHARA, 243-9984

ORDER FOR KTR

9B 8315 002671632 NA 4 N 41635250 1/RO

006 M TAPE,TEX, ORIG: C231B,

Y.YOSHIHARA, 243-9984

ORDER FOR KTR

9B 8315 002671633 NA 4 N 41635252 1/RO

007 M ADHESIVE, ORIG: C231B,

Y.YOSHIHARA, 243-9984

ORDER FOR KTR

9B 8040 002738708 NA 4 Y 41635244 1/GL

400 M SILICA PIPE COVER, SILICA

PIPE COVER, 18"IPS X 2"THK X

36" LG, THERMO-1200, SILICA

PIPE COVER, NON-ASBESTOS,

MIL-DTL-2781

ORDER FOR KTR

C234 M. EGUCHI, 243-0978

9Q 5640 LL9305170 NA 4 N 41957480 4/EA

401 M INSULATION BLOCK,TH, SIZE:

12" X 36" X 2-1/2" THK, 7 EACH

PER BOX

ORDERED FOR KTR

ORIG: C234 M. EGUCHI 243-

9Q 5640 002671591 NA 4 N 41645303 4/BX

402 M SILICA PIPE COVER,, SILICA

PIPE COVER, 14" IPS X 2" THK

X 3 FT LONG, NON-ASBESTOS,

ORIG:CODE 234 M. EGUCHI,

243-0978

ORDERED FOR KTR

9Q 5640 LL9301047 NA 4 N 41957479 4/EA

402 M SILICA PIPE COVER,, SILICA

PIPE COVER, 14" IPS X 2" THK

X 3 FT LONG, NON-ASBESTOS,

ORIG:CODE 234 M. EGUCHI,

243-0978

ORDERED FOR KTR

9Q 5640 LL9301047 NA 4 N 42327471 4/EA

403 M CEMENT,INSULATION,H,

CEMENT, 45 LB/ BG,

ORIG:CODE 234 M.EGUCHI,

243-0978

ORDERED FOR X57

9Q 5640 002264540 NA 4 Y 41645307 3/BG

404 M ADHESIVE, ADHESIVE FOR

CLOTH,

ORIG:CODE 234 M.EGUCHI,

243-0978

ORDERED FOR KTR

9B 8040 002738708 NA 4 Y 41645314 3/GL

405 M INSULATION BLOCK,TH,

ORDERED FOR KTR

C234 K.FURUKAWA, 243-0978

6” X 36” X 3” THK (12 PER ONE

BOX)

9Q 5640 002671592 NA 4 N 41645299 4/BX

406 M CLOTH,PL, ORIG: C234, M.

EGUCHI, 243-9982

ORDERED FOR KTR

9B 8305 001487364 NA 4 N 41645422 1/RO

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M-3

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

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

407 M INSULATI, INSULATION,

FIBROUS GLASS, THERMAL,

BLANKET WITHOUT BINDER,

UNFACED, SIZE: 5FT W X 45FT

L X 1"THK, MIL-DTL-32585,

TYPE I, FORM 3, FACING A,

NSN: 5640-00-173-6591 (NSN

MISTAKENLY INDICATES

FACING D, BUT CORRECT

ITEM IN THIS NSN IS

UNFACED.)

ORIG:CODE 234 M.EGUCHI,

243-0978

ORDERED FOR KTR

9Q 5640 LL9607458 NA 4 N 41657404 2/RO

408 M GASKET MATERIAL,SHE, C234

M. EGUCHI, 243-0978

ORDERED FOR KTR

GASKET 1/16 3125SS

9B 5330 015287526 NA 4 N 41645294 2/SH

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 STRL MBR 4-109-7-Q AY A 0

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

3819P13411 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 STRL MBR 4-109-7-Q AY A 0

LOCATION MAP OF WELD REPAIR IN 4-109-7-Q

SKETCH

ENCLOSURE-013819P13411A01 SHEET 1 OF 14

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