TGI_3819P31003A05_c0v0_redact.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.: SA 79243K SSDG AY A 0 0

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

LCC-19 USS BLUE RIDGE 19P

CU PHASE TITLE:

*(RE) F/O – S/A 79243K, REPLACE SSDG, ESLP SS/EDG GENSET UPGRD

PREPARING ACTIVITY:

PREPARED BY: CODE PHONE DATE

KAZUKI UCHIMURA 233 080-9350-1432 17-FEB-2025

APPROVED BY: CODE PHONE DATE

MASAHIRO HOSONO 233 080-9350-1455 17-FEB-2025

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:

CHANGE INSTRUCTIONS:

SPECIAL REQUIREMENTS:

CLEANLINESS FOR PIPING SYSTEM/EQUIPMENT LEVEL II AND III

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.: SA 79243K SSDG AY A 0

FOUO

SHIP: LCC-19 CHG/VER: 0/0

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

1. SCOPE/PURPOSE

1.1 Title: S/A 79243K, Ship Service Diesel Generator, Extended Service Life Program Ship Service/Emergency Diesel Generator Generator-set Upgrade; replace

1.2 Location of Work:

1.2.1 Ship Service Diesel Generator (SSDG) No. One (5-121-1-E)

1.2.2 Distillate Fuel or Ballast (9-127-1-F)

1.2.3 Escape Trunk (5-131-1-T)

1.2.4 Passage and Aft Battle Dressing Station (4-123-3-L)

1.2.5 Aft Electric Rewind Shop (4-121-1-Q)

1.2.6 Mooring Station No. 7 (4-121-5-Q)

1.2.7 DC Shop Office (4-125-1-Q)

1.2.8 Medical Storeroom (4-125-3-A)

1.2.9 Medical Storeroom (4-128-1-A)

1.2.10 DC Shop (4-129-1-Q)

1.2.11 Freeboard Weather, Frames between 129 and 133, Starboard

1.3 Identification:

1.3.1 Quantity (One EA), Existing Ship Service Diesel Generator (SSDG) Set Mfr: Caterpillar Inc Engine Model: 3516B Engine Serial Number: 9AN00322 Engine APL: 66A030008 Generator Spec: 1825KW, 480VAC, 60Hz, 3 Phase Remarks: See Item R1 of 2.3 for details

1.3.2 Quantity (One EA), New Ship Service Diesel Generator (SSDG) Set Mfr: Caterpillar Inc Engine Model: 3516E Engine Arrangement Number: 549-7519 Engine Configuration: Vee 16, 4 Stroke-Cycle-Diesel Generator Spec: 2000KW, 450VAC, 60Hz, 3 Phase Remarks: See Item One of 2.3 for details

1.3.3 Quantity (One Lot), Cold Potable Water Piping with Shower and Eye Washer Assembly Size: One Inch IPS (1.315 Inch OD X 0.065 Inch WT)

FOUO

SHIP: LCC-19 CHG/VER: 0/0

Material: Copper Specification: MIL-T-24107 Remarks: See Sheet 5 (Zone 37-B) and Sheet 6 (Detail 43-A) of 2.8 for location details.

1.3.4 Quantity (One Lot), Soil Drain Piping

Size: 3 Inch IPS (3.500 Inch OD X 0.095 Inch WT)

4 Inch IPS (4.500 Inch OD X 0.109 Inch WT) Material: Cu-Ni Alloy Specification: MIL-T-16420 Remarks: See Sheet 2 (Zone 2-A) of 2.9 and Sheet 17 (Part Plan 131-A) of 2.10 for location details.

1.4 Security Classification: None.

1.5 Initial Condition:

1.5.1 Dry Dock Work

1.5.2 Potential Lead Hazard

1.5.3 Potential Asbestos Hazard

1.6 Contractor work start date: 1/12/2026

1.7 Contractor work completion date: 8/5/2027

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 FY25 Standard Items - ORG N 2 LI FY25 Local Standard Items - ORG N

3 DWG 345-

8574540

GENSET UPGRADE EQUIPMENT

ARRANGEMENT SSDG MACHY

RM & SSDG EOS

B Y AL

L

4 DWG 649-

DIMENSIONS - INSTALLATION

FOR LCC-19 PROGRAM

06 Y AL

L

5 DWG 113-

8578065

SCD 9243 SS/EDG GENSET

UPGD FOUNDATION

INSTALLATION & PREFAB SSDG

B Y AL

L

6 PDD 300-

ELM-250197

ALIGNMENT PROCEDURE OF

DIESEL ENGINE & GEN SET

CPLG FOR UPGRADED EDG &

SSDG

- Y AL

L

7 PDD 300-

ELM-250198

FLUSING PROCEDURE OF

DIESEL ENGINE FOR UPGRADED

EDG & SSDG

- Y AL

L

8 DWG 509-

7542667

POT WTR & LP AIR PP INCDT

SSDG

C Y 5, 9 DWG 528-

4346218

COLLECTINGHOLDING &

TRANSFER SYSTEM PIPING

ARRANGEMENT AFT FR121 5TH

DK

C Y AL

L

10 DWG 516-

7542668

S/A LCC 1276K LCC 19 MISC

PIPING SYSTEMS MODS INCID

SS DIESEL GENERATOR

C Y AL

L

3. APPENDICES:

3.1. Appendix “J” TGI Job Summary Information Sheet

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SHIP: LCC-19 CHG/VER: 0/0

3.2. Appendix "M" TGI Material List

3.3. Appendix “D” Deficiency Form

4. GENERAL REQUIREMENTS:

4.1 Not Applicable.

5. PROCEDURE:

5.1 Remove the equipment listed in 1.3.1 in accordance with 2.3.

5.1.1 Disassemble the equipment for unshipping, using 2.4 for guidance.

5.2 Install the equipment listed in 1.3.2 in accordance with 2.3 through 2.5.

5.2.1 Disassemble for shipping and assemble the equipment on board in accordance with the procedure provided by OEM (CAT Hawthorne), using 2.4 for guidance.

5.2.1.1 Install each blanking plate onto the diesel engine until installation.

5.2.2 Measure and record the crankshaft deflection of the diesel engine in accordance with Notes 2 and 4-1 through 4-4 of 2.6.

(V) “CRANKSHAFT DEFLECTION” (First Measurement, Notes 4-1 of 2.6)

(V) “CRANKSHAFT DEFLECTION” (Second Measurement, Notes 4-2 of 2.6)

(V) “CRANKSHAFT DEFLECTION” (Third Measurement, Notes 4-3 of 2.6)

(V)(G) “CRANKSHAFT DEFLECTION” (Fourth Measurement, Notes 4-4 of 2.6)

5.2.3 Measure and record the crankshaft thrust clearance of the diesel engine in accordance with Notes 3 and 4-1 through 4-4 of 2.6.

(V) “THRUST CLEARANCE” (First Measurement, Notes 4-1 of 2.6)

(V) “THRUST CLEARANCE” (Second Measurement, Notes 4-2 of 2.6)

(V) “THRUST CLEARANCE” (Third Measurement, Notes 4-3 of 2.6)

(V)(G) “THRUST CLEARANCE” (Fourth Measurement, Notes 4-4 of 2.6)

5.2.4 Measure and record the coupling alignment of the diesel engine in accordance with Notes 6 and 7-1 of 2.6.

(V) “COUPLING ALIGNMENT” (First Measurement)

5.2.5 Accomplish the coupling alignment of the equipment in accordance with Notes 6, 7-2 and 7-3 of 2.6.

(V) “COUPLING ALIGNMENT” (Second Measurement, Notes 7-2 of 2.6)

(V) “COUPLING ALIGNMENT” (Third Measurement, Notes 7-3 of 2.6)

5.2.6 Measure and record the coupling alignment of the equipment in accordance with Notes 6 and 7-4 of 2.6.

(V)(G) “COUPLING ALIGNMENT” (Final Measurement)

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SHIP: LCC-19 CHG/VER: 0/0

5.2.7 Accomplish the requirements of 009-92 of 2.1 for the equipment.

5.2.8 Measure and record the flywheel runout of the diesel engine in accordance with Notes 8 of 2.6.

(V)(G) “FLYWHEEL RUNOUT”

5.2.9 Drill and ream each generator support foot and foundation in accordance with Notes 5 of 2.6. Fit and install each new dowel.

5.3 Accomplish the requirements of 009-09 of 2.1 for the diesel engine of the equipment listed in 1.3.2.

5.4 Accomplish the lube oil flushing for the diesel engine of the equipment listed in 1.3.2 in accordance with 2.7.

(I)(G) “EXTERNAL FLUSHING”

(I)(G) “FINAL FLUSHING”

5.5 Remove existing and reinstall each potable water piping listed in 1.3.3 for supporting of shipping work for each new equipment, using 2.8 for guidance.

5.5.1 Accomplish the requirements of 009-87 of 2.1 for each potable water piping.

5.5.1.1 Accomplish the requirements of 009-09 of 2.1 for chlorination and bacteriological tests. Analysis and testing conducted by a qualified Japanese laboratory (accredited by ISO 17025 or equal) are authorized by the

SUPERVISOR.

5.5.1.2 Record results of chlorination and bacteriological tests on a Laboratory Analysis Record(s) and DD Form 686, and submit one legible copy, in hard copy or approved transferrable media, of completed record(s) and form(s) to the

SUPERVISOR.

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

5.6 Remove existing and reinstall each soil drain piping listed in 1.3.4, for supporting of shipping work for each new equipment, using 2.9 and 2.10 for guidance.

5.6.1 Accomplish the requirements of 009-09 of 2.1 for the certification process.

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

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

5.8 Notes:

5.8.1 Planner: Code 233 K. Uchimura, 080-9350-1432

Planner: Code 231B A. Suzuki, 243-0968 Planner: Code 231B Y. Yoshihara, 243-9984 Planner: Code 231B N. Kurokawa, 243-0108 Planner: Code 232 M. Fudo, 243-4512 Planner: Code 234 T. Shibano, 243-3583

5.8.2 OEM (CAT Hawthorne) will provide the procedure to uncouple the gensets and remove them from the skid and to facilitate rigging onboard the ship. The blanking plate and lifting beams will be packaged with the gensets from the OEM. NSWCPD will have a contract with the OEM in place for support in bringing the gensets onboard and coupling the diesel and generator together and will assist in bringing the gensets onboard the ship.

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SHIP: LCC-19 CHG/VER: 0/0

5.8.3 Opening, initial cleaning, and closing of each space listed in 1.2.2 will be covered by TGI No(s)

3819P12308A01 (KTR TGI).

5.8.4 Preservation work for new and disturbed surfaces of each space listed in 1.2.2 will be covered by TGI No.

3819P12308A01 (KTR TGI).

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

(KTR TGI).

5.8.6 Periodic Maintenance Requirements (PMR) and Naval Surface Warfare Center Philadelphia Division (NSWCPD) will provide one person on-site to resolve any technical issues that may arise.

5.8.7 PMR Technical Representative:

Point of Contact: Mr. Edward (Bud) Twigg, 243-4242 Email Address: edward.twigg.ctr@srf.navy.mil

5.8.8 NSWCPD On Site Installation Coordinator (OSIC):

Point of Contact: Mr. Brian Lopez, 445-238-7002 Email Address: brian.o.lopez.civ@us.navy.mil

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

5.8.10 JCN EE01-L107 is related to this TGI.

5.9 Government Furnished Material (GFM):

5.9.1 All GFM listed in each S/A drawing will be provided as kitted material.

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

5.10 SRF-JRMC will provide the following service work: (TGI No. 3819P31003S02)

5.10.1 [C740] Crane and crane rigging service.

5.10.2 [X99E] Utilities service, electrical.

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

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

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

5.10.6 [C133] QA Inspection for (G) symbol(s).

mailto:edward.twigg.ctr@srf.navy.mil

FOUO

J-1

SHIP: LCC-19 CHG/VER: 0/0

APPENDIX "J"

TGI JOB SUMMARY INFORMATION SHEET

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

VERSION:

CASREP

CAT:

SA 79243K SSDG AY A 0 0

CU PHASE TITLE:

*(RE) F/O – S/A 79243K, REPLACE SSDG, ESLP SS/EDG GENSET UPGRD

PRIMARY COMPONENT:

COMPONENT UNIT LIST (FOR ASSEMBLIES):

POTW 5-121-1-E PP #1 SSDG GE #1 SSDG DE #1 SSDG FD SEW 5-121-1-E

PP

ATTACHMENT LIST:

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

YAGINUMA ,TAKEHIDE

JO: KO: TOTAL MAN HRS: PLANNING ACCEPTANCE:

3819P31003 A05

TOTAL MAT’L COST TOTAL DURATION:

CU PHASE DESCRIPTION:

The purpose of this TGI to replace ship service diesel generator, extended service life program ship service/emergency diesel generator generator-set upgrade.

Location of Work:

Ship Service Diesel Generator (SSDG) No. One (5-121-1-E) Distillate Fuel or Ballast (9-127-1-F) Escape Trunk (5-131-1-T) Passage and Aft Battle Dressing Station (4-123-3-L) Aft Electric Rewind Shop (4-121-1-Q) Mooring Station No. 7 (4-121-5-Q) DC Shop Office (4-125-1-Q) Medical Storeroom (4-125-3-A) Medical Storeroom (4-128-1-A) DC Shop (4-129-1-Q) Freeboard Weather, Frames between 129 and 133, Starboard

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

5.1 ELEC , SFTR , WELD , OMCH , RGRS , CARP , LBR ,

INSL , PNTR , PFTR , QA

22 KE PC

5.2 ELEC , SFTR , WELD , OMCH , RGRS , CARP , LBR ,

INSL , PNTR , QA

22 KE PC

5.3 QA 22 KE PC

5.4 OMCH , PFTR , RGRS , LBR , QA 22 KE PC

5.5 PFTR , WELD , QA 22 KE PC

5.6 PFTR , WELD , QA 22 KE PC

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J-2

SHIP: LCC-19 CHG/VER: 0/0

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

5.7 PNTR , QA 22 KE PC

Electrical Work CFM: for banding material, fasteners, insulation tape, plastic bags, rope, and other consumable.

22 MQ CS

Rigging Work CFM: for staging for unshipping/shipping, fastener, transportation cost, mobile crane cost, forklift cost, material of temporary padeye, MT inspection cost, fire watch cost, gas, electrode, lead sampling/analysis cost, asbest sampling/analysis cost, adhesive, anchor pin, tyvex suit, ---continue to below---

22 MQ CS

---continued from above--- masking tape, deck covering material, plastic bag, all paints, thinner and misc such as covering material and other consumable.

22 MQ CS

Machinery Work CFM: for dowel, gasket, muslin bag, flushing oil, filter element, hose, and MISC such as rags, sandpapers, plastic bag/sheet, cleaner, lubricant etc.

22 MQ CS

Piping Work CFM: , marine chemist cost, fire watch cost, lead analysis cost, disinfection material cost, bacteriological analysis cost, air compressor rental cost, fuel oil cost, MISC such as pipe hanger, argon gas, welding rod, saw blades, painting material, plastic bag/sheet etc.

22 MQ CS

Process Funding Document. 10 CT OM

FOUO

M-1

SHIP: LCC-19 CHG/VER: 0/0

APPENDIX “M”

TGI MATERIAL LIST

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

VERSION:

CASREP

CAT:

SA 79243K SSDG AY A 0 0

CU PHASE TITLE:

*(RE) F/O – S/A 79243K, REPLACE SSDG, ESLP SS/EDG GENSET UPGRD

MATERIAL REFERENCES

REF

NO.

DOCUMENT/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV

JOB ORDER: KEY OP:

3819P31003 A05

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

100 M INSULATI, ORIG C231B N.

KUROKAWA 243-0108

ORDER FOR KTR

9Q 5640 008096312 NA 4 N 50455354 40/EA

101 M ADHESIVE, ORIG C231B N.

KUROKAWA 243-0108

ORDER FOR KTR

9B 8040 002738708 NA 4 Y 50455106 2/GL

102 M TAPE,TEX, ORIG C231B N.

KUROKAWA 243-0108

ORDER FOR KTR

9B 8315 002671632 NA 4 N 50455356 2/RO

103 M CAP, ORIG C231B N.

KUROKAWA 243-0108

ORDER FOR KTR

9Z 5340 LL4601470 NA 4 N 50457408

100/EA

104 M INSULATI, ORIG C231B A.

SUZUKI, 243-0968

ORDER FOR KTR

9Q 5640 008096312 NA 4 N 40/EA

105 M ADHESIVE, ORIG C231B A.

SUZUKI, 243-0968

ORDER FOR KTR

9B 8040 002738708 NA 4 Y 2/GL

NOTES:

FOUO

M-2

SHIP: LCC-19 CHG/VER: 0/0

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

106 M TAPE,TEX, ORIG C231B A.

SUZUKI, 243-0968

ORDER FOR KTR

9B 8315 002671632 NA 4 N 2/RO

107 M CAP, ORIG C231B A. SUZUKI,

243-0968

ORDER FOR KTR

9Z 5340 LL4601470 NA 4 N

100/EA

400 M COUPLING,TUBE, 4"IPS, CN

90-10, BW

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9B 4730 007225474 NA 4 N 10/EA

401 M SLEEVE,, SLEEVE, 3-1/2"IPS,

BW, 90/10, 200PSI

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4462371 NA 4 N 10/EA

402 M COUPLING,TUBE, 3"IPS, CN

90-10, BW

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9B 4730 007225473 NA 4 N 3/PG

403 M COUPLING,TUBE, 2"IPS, CN

90-10, BW

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9B 4730 005423290 NA 4 N 10/EA

404 M COUPLING,TUBE, 1-1/2"IPS,

CN 90-10, BW

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9B 4730 007225467 NA 4 N 2/FV

405 M SLEEVE,, SLEEVE, 2"IPS, BUTT

WELD, CNA 70-30, 200 PSI,

810-1385880

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4462301 NA 4 N 10/EA

406 M COUPLING, COUPLING,

1/4"IPS, SW, 70/30, 400PSI,

NSN: 4730-01-491-6568 SMIC

CODE X3.

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4462249 NA 4 N 30/EA

407 M BACKINGR, BACKING RING, 4"

IPS, CU-NI 90/10, 200 PSIG,

MIL-STD-22

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4558786 NA 4 N 10/EA

408 M BACKING RING, BACKING

RING,

SIZE: 3-1/2"IPS,

MATL: CU-NI 90/10,

PRESSURE: 200PSIG,

MIL-STD 22D.

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

LL4558785 NA 4 N 10/EA

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M-3

SHIP: LCC-19 CHG/VER: 0/0

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

409 M BACKING, BACKING RING,

SIZE:2"IPS,

MATL: CU-NI 90/10,

PRESSURE: 200PSIG,

SPEC: MIL-STD-22

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4558779 NA 4 N 10/EA

410 M BACKING,, BACKING RING,

3"IPS, CU-NI 90/10, 200PSIG,

MIL-STD-22

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4558783 NA 4 N 10/EA

411 M BACKING, BACKING RING,

2"IPS, CNA 70/30, 200PSIG

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4558817 NA 4 N 5/EA

412 M BACKING, BACKING RING, 1-

1/2"IPS, CNA 90/10, 200PSIG

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

9C 4730 LL4558777 NA 4 N 10/EA

413 M SLEEVE, 1"IPS, BW, SLEEVE,

1"IPS, BW,CUNI 90/10,200 PSI

ORDERED FOR KTR, ORG:

C234,T. SHIBANO, TEL: 243-

LL4903761 NA 4 N 5/EA

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 SA 79243K SSDG AY A 0

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

3819P31003 A05

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 SA 79243K SSDG AY A 0