TGI_38HVC66501_A03_c0v1.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.: FOOT BRK & BOX SHEAR AY A 2 0

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

YR-85 YR 85 HVC

CU PHASE TITLE:

*F/O-ACCOMPLISH S/A YR-1117D, INSTALL FOOT SHEAR MACH, BOX & PAN BRK 1-18-0-Q

PREPARING ACTIVITY:

PREPARED BY: CODE PHONE DATE

HIROSHI MATSUBAYASHI 232. 315-243-4509 30-MAR-2026

APPROVED BY: CODE PHONE DATE

HIDEMI SENDA 232. 315-243-5615 31-MAR-2026

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:

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.: FOOT BRK & BOX SHEAR AY A 2

FOUO

SHIP: YR-85 CHG/VER: 0/1

LIST OF EFFECTIVE PAGES

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

1-5 J-1 M1-5

1. SCOPE/PURPOSE

1.1. Title: S/A YR-1117D, Foot Shear, Box and Pan Brake, install

1.2. Location of Work:

1.2.1. Pipefitter, Sheetmetal, Shipfitter Shop (1-18-0-Q)

1.2.2. Shop Stores Strm/Issue Room No.2 (2-30-0-A)

1.2.3. Electronics Shop (2-42-0-Q)

1.2.4. Contractor Facility

1.3. Identification:

1.3.1. Quantity (2 EA), Stowage Rack in 1-18-0-Q

Item No: R1 and R2 of 2.5

1.3.2. Quantity (One EA), Existing Tube Flaring Machine

Item No: R3 of 2.4 and 2.5

1.3.3. Quantity (One EA), Cabinet in 1-18-0-Q

Item No: R4 of 2.5

1.3.4. Quantity (One EA), Existing Swage Machine

Item No: R5 of 2.5

1.3.5. Quantity (One EA), Existing Workbench

Item No; R6 of 2.5

1.3.6. Quantity (2 EA), Box Brake Mounting Pad on Deck Plating in 1-18-0-Q Material: OS, MIL-S-22698 GR-B, 40.8 LBs Plate Remarks: See Sheet 3 Plan 20-A of 2.6 for detail

1.3.7. Quantity (4 EA), Foot Shear Mounting Pad on Deck Plating in 1-18-0-Q Material: OS, MIL-S-22698 GR-B, 40.8 LBs Plate Remarks: See Sheet 3 Plan 23-A of 2.6 for detail

1.3.8. Quantity (One EA), Cabinet Foundation on Deck Plating in 1-18-0-Q Remarks: See Sheet 3 Detail 18-A of 2.6 for material and detail

1.3.9. Quantity (4 EA), Tie Down Staple on Structural Member in 1-18-0-Q Material: Steel, ASTM A108 GR-1018, 1/2 Inch Diameter Round Bar Remarks: See Sheet 4 Detail 32-A of 2.6 for material and detail

1.3.10. Quantity (One EA), New Foot Shear

Part Number: PEXTO, No.152

FOUO

SHIP: YR-85 CHG/VER: 0/1

Item No: 11 of 2.6 Weight: 1000 lbs / 455 kg

1.3.11. Quantity (One EA), New Box and Pan Brake

Model F6-48-12 Item No: 12 of 2.6 Weight: 1725 lbs / 783kg

1.3.12. Quantity (One EA), Cabinet in 1-18-0-Q

Item No: One of 2.6 Remarks: See 2.6 for detail

1.3.13. Quantity (One EA), Mobile Swager Cart

Remarks: See Sheet 5 Detail 34-A Assy No. A1 of 2.6 for material and detail

1.3.14. Quantity (One EA), Power System

Remarks: See 2.7 for details.

1.3.14.1. Quantity (One EA), Stuffing Tube on Deck Plating in 1-18-0-Q, Frames between 52 and 53, Starboard

1.3.14.2. Quantity (One EA), Stuffing Tube on Deck Plating in 1-18-0-Q, Frames between 46 and 47, Starboard

1.3.14.3. Quantity (One Lot), Mounting Stud for Receptacle and Cable Way on Stanchion Frame 48, Starboard

1.3.15. Quantity (One Lot), Main Deck Plating, Frames between 46 and 53, Starboard Remarks: See 2.6 for base material and detail

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:

1.7. Contractor work completion date:

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 FY26 Standard Item - ORG N 2 LI FY26 Local Standard Items - ORG N

3 LAR VAR-

YR85-0004

Foot Break and Box Shear Installation

- - Y ALL

4 LAR

YR1117D/Y

R85/0075

Break & Shear Install Clarification - - Y ALL

5 DWG 610-

8894016

SHIPALT YR-1117D

FOOT BREAK AND BOX SHEAR

REMOVALS

- - Y ALL

6 DWG 610-

8894017

SHIPALT YR-1117D

FOOT BREAK AND BOX SHEAR

INSTALL

- - Y ALL

FOUO

SHIP: YR-85 CHG/VER: 0/1

REF.

NO.

DOCUMENT

/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV CHG

NO.

COPY

REQ’D

(Y/N)

SOURCE

DOC

(Y/N)

PARA SEC PG CHP

7 DWG 302-

8974902

SHIPALT YR-1117D

POWER SYSTEM

MODIFICATIONS FOOT SHEAR

AND BREAK BOX

- - Y ALL

8 MIL MIL-

STD-2003

Electric Plant Installation Standard Methods for Surface Ships and Submarines

B - 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 SHIPALT YR-1117D in accordance with 2.3 through 2.7.

5.1.1. Remove each existing stowage rack listed in 1.3.1, tube flaring machine listed in 1.3.2, cabinet listed in 1.3.3, swage machine listed in 1.3.4 and workbench listed in 1.3.5 in accordance with 2.3 through 2.5.

5.1.2. Fabricate and install each new mounting pad, foundation, and tie down staple listed in 1.3.6 through 1.3.9 in accordance with 2.4 and 2.6.

5.1.2.1. Accomplish the requirements of 009-12 of 2.1, including Table 4, Column(s) A, Lines One through 7.

5.1.3. Install the new foot shear listed in 1.3.10 in accordance with 2.3, 2.4, and 2.6.

5.1.4. Install the new box and pan brake listed in 1.3.11 in accordance with 2.3, 2.4, and 2.6.

5.1.5. Install each new cabinet listed in 1.3.12 in accordance with 2.4 and 2.6.

5.1.6. Fabricate each new mobile swager cart listed in 1.3.13 in accordance with 2.4 and 2.6.

5.1.6.1. Accomplish the requirements of 009-12 of 2.1, including Table 4, Column(s) A, Lines One through 7.

5.1.7. Install the existing Swage Machine listed in 1.3.4 on the top of the new mobile swager cart listed in 1.3.13 in accordance with 2.3, 2.4 and 2.6.

5.2. Accomplish electrical removals, modifications and installations of the system listed in 1.3.14 in accordance with 2.6 and 2.7.

5.2.1. Electrical installations must be in accordance with 2.8.

5.2.2. Remove each existing stuffing tube listed in 1.3.14.1 and 1.3.14.2 in accordance with 2.5 and 2.7.

5.2.3. Accomplish build up weld of remaining hole(s) on each existing deck plating listed in 1.3.15 where removal of the stuffing tube listed in 1.3.14.1 and 1.3.14.2, using 2.6 for guidance.

------------------------------------------------------------------------------ Rose, Aaron J. C1209.4

FOUO

SHIP: YR-85 CHG/VER: 0/1

5.2.3.1. Accomplish the requirements of 009-12 of 2.1, including Table 4, Column(s) A, Lines One through 7.

5.2.3.2. Accomplish the requirements of 009-25 of 2.1 for a local air hose test of each new weld of each deck plating listed in 1.3.15. Allowable leakage: None.

5.2.4. Install each new stud listed in 1.3.14.3 in accordance with 2.6 and 2.7.

5.2.4.1. Accomplish the requirements of 009-12 of 2.1, including Table 4, Column(s) A, Lines One through 7.

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

5.4. Notes:

5.4.1. Planner: Code 232 H. Matsubayashi, 243-4509

Planner: Code 231A R.Yajima, 243-2791 Planner: Code 233 S.Ogawa, 090-6170-8579

5.4.2. Work Integration Manager (WIM): Code 312 Dean Vanderwege, 243-3199

5.4.3. New each foot shear and box and pan break will be provided by Puget Sound Naval Shipyard (PSNS).

5.4.4. Remarks: Accomplish Shipalt YR-1117D on YR85 per reference 2.4, 2.5 and 2.6. On reference 2.6, item R4 shall be turned over to PSNS Detachment Yokosuka for disposition; contents of items R1 & R2 to be redistributed by the Detachment.

5.4.5. Deferred from TGI 38HVA66501A01.

5.4.6. JCN Y852-5006 is related to this TGI.

5.5. Government Furnished Material (GFM):

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

5.6. SRF-JRMC will provide the following service work: (TGI No. 38HVC66501S01)

5.6.1. [C740] Crane and crane rigging service.

5.6.2. [X99E] Utility service, electrical.

5.6.3. [X99M] Utility service, including low pressure air supply, water supply, and steam supply.

5.6.4. [C106.1] Provide safety inspection for SRF-JRMC employees.

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

5.6.6. [C133] QA inspection for (G) symbols.

TGI NO.: FOOT BRK & BOX

SHEAR

AY A 2

FOUO

M-1

SHIP: YR-85 CHG/VER: 0/1

APPENDIX “M”

TGI MATERIAL LIST

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

VERSION:

CASREP

CAT:

FOOT BRK & BOX SHEAR AY A 2 1

CU PHASE TITLE:

*F/O-ACCOMPLISH S/A YR-1117D, INSTALL FOOT SHEAR MACH, BOX & PAN BRK 1-18-0-Q

MATERIAL REFERENCES

REF

NO.

DOCUMENT/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV

1 610-8894017 2 302-8974902

JOB ORDER: KEY OP:

38HVC66501 A03

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 7 1 M PLATE,METAL, ORDER FOR

KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 9515 001533268 NA 4 N 50555208 16/SF

002 13 1 M BAR,METAL, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 9510 005962313 NA 4 N 50525182 5/FT

003 14 1 M SCREW,CAP, SCREW, CAP,

HEAD: HEX, SPEC: SAE-J429

GRADE 5, SIZE: 1"-8UNC-2A X

1-1/2" LG, MATL: STEEL,

FINISH: ZINC PLATED, 5EA/PG

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5305 LL9814037 NA 4 N 51327478 4/EA

004 15 1 M CASTER,SWIVEL, ORDER FOR

KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5340 016414776 NA 4 N 50525183 4/EA

NOTES:

SHEAR

AY A 2

FOUO

M-2

SHIP: YR-85 CHG/VER: 0/1

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

005 17 1 M SHEET, M, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 9515 002375413 NA 4 N 50525186 1/SH

006 18 1 M TIE DOWN STRAP, HIGH-

TENSION TIE DOWN STRAP

WITH LATCH HOOKS, WIDTH:

2”, MATL: NYLON FABRIC, MAX

LENGTH: 12 FT, FIXED END

LENGTH: 36”, CAPACITY: 1,660

LBS, END FITTING TYPE:

HOOK, BUCKLE STYLE:

RATCHET, END FITTING &

BUCKLE MATL: ZINC-PLATED

STEEL,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 3990 LL9814038 NA 4 N 51327480 2/EA

007 M INSULATI, ORDERED FOR KTR

ORIG: C231A R. YAJIMA

243-2791

9Q 5640 008096312 NA 4 N 50555082 4/SH

008 M INSULATI, ORDERED FOR KTR

ORIG: C231A R. YAJIMA

243-2791

9Q 5640 008096315 NA 4 N 50555086 8/EA

009 M STANDOFF, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5340 002829526 NA 4 N 50525168 1/HD

010 M WASHER,L, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5310 001947356 NA 4 N 50525170 1/HD

011 5 1 M NUT,SELF, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5310 013587622 NA 4 N 50525174 8/EA

012 6 1 M ANGLE,STRUCTURAL, ORDER

FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

3B 9520 009545666 NA 4 N 50525175 16/FT

013 7 2 M BACK BOX, BACK BOX, 15

DEGREE ANGLE, BOX HUB

SIZE: 3/4” NPT, MATL: CAST

ALUMINUM, COLOR: GRAY,

**GSA ADVANTAGE

AVAILABLE**

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5935 LL9814008 NA 4 N 50527469 2/EA

014 9 1 M PLATE,ME, 1F X 1F

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 9515 014092741 NA 4 N 50525180 1/SF

015 M WASHER,L, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5310 005825965 NA 4 N 50525172

100/EA

016 4 1 M SCREW,CAP,HEXAGON H,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5305 015048942 NA 4 N 50525173 8/EA

017 8 1 M NUT,SELF, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5310 016234029 NA 4 N 50525178 16/EA

018 10 1 M ANGLE,ST, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 9520 002774911 NA 4 N 50525181 40/FT

SHEAR

AY A 2

FOUO

M-3

SHIP: YR-85 CHG/VER: 0/1

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

019 3 2 M PLUG,CONNECTOR, ORDER

FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

1H 5935 015639799 NA 4 N 50525157 1/EA

020 5 2 M CLOSURE CAP, WATERTIGHT

CLOSURE CAP ASSEMBLY,

MATL: PLASTIC, COLOR:

GRAY,

NSN: 5935-01-601-3637(NO

MANAGEMENT DATA),

**GSA ADVANTAGE

AVAILABLE**

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5935 LL9814006 NA 4 N 50527467 1/EA

021 6 2 M CLOSURE CAP, WATERTIGHT

CLOSURE CAP ASSEMBLY,

MATL: PLASTIC, COLOR:

GRAY,

NSN: 5935-01-601-3634(NO

MANAGEMENT DATA),

**GSA ADVANTAGE

AVAILABLE**

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5935 LL9814007 NA 4 N 50527468 1/EA

022 M NUT,PLAI, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9Q 5310 007616882 NA 4 N 50525171

100/EA

023 2 2 M RECEPTACLE CONNECTOR,

WATERTIGHT RECEPTACLE

CONNECTOR, VOLTAGE

RATING: 480VAC, AMPS: 20,

PHASE: 3, NUMBER OF WIRES:

4, COLOR: RED,

**GSA ADVANTAGE

AVAILABLE**

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5935 LL9814004 NA 4 N 50527465 1/EA

024 M NUT,PLAI, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5310 009138881 NA 4 N 50525169 1/HD

025 15 1 M CASTER, CORROSION

RESISTANT SWIVEL CASTER,

WHEEL DIA: 5”, WHEEL WIDTH:

1-3/16”, WHEEL/TREAD MATL:

POLYURETHANE RUBBER,

WHEEL CORE MATL: NYLON

PLASTIC, MOUNTING PLATE

SIZE: 4-1/8” X 3-3/8”,

BRAKE/LOCK TYPE: WHEEL

BRAKE AND SWIVEL LOCK,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

9B 5340 LL9814039 NA 4 N 51327481 4/EA

SHEAR

AY A 2

FOUO

M-4

SHIP: YR-85 CHG/VER: 0/1

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

026 1 2 M RECEPTACLE CONNECTOR,

WATERTIGHT RECEPTACLE

CONNECTOR, VOLTAGE

RATING: 100 - 130VAC, AMPS:

16, PHASE: 1, NUMBER OF

WIRES: 3,

COLOR: YELLOW, NSN: 6150-

01-656-3753, **GSA ADVANTAGE

AVAILABLE**

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 6150 LL9814075 NA 4 N 50817439 1/EA

027 8 2 M STUFFING TUBE, ORDER FOR

KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5975 008084064 NA 4 N 50525158 2/EA

028 13 2 M CABLE,POWER,ELECTRI,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 6145 012019498 NA 4 N 50525164 80/FT

029 M PLATE,METAL, PLATE,METAL,

MIL-S-22698, 20'L X 5'W X

1"THK, STEEL UNS K02102

9B 9515 001533264 NA 4 N 51575154 1/PM

030 10 2 M PACKING, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5330 011082552 NA 4 N 50525160 2/AY

031 12 2 M CABLE,POWER,ELECTRI,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 6145 012022795 NA 4 N 50525162 120/FT

032 1 1 M CABINET, DRAWER, CABINET,

DRAWER, EXTRA WIDE, WITH

5 DRAWERS, SIZE: 45” W X 59”

H X 27-3/4" D, HOUSING

COLOR: VIDMAR GRAY

(COLOR CODE: S23321),

DRAWER COLOR: VIDMAR

GRAY (COLOR CODE: S23321),

**GSA ADVANTAGAE

AVAILABLE**

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 7125 LL9814036 NA 4 N 50697512 1/EA

033 4 2 M CONNECTOR,PLUG,ELEC,

WATERTIGHT CONNECTOR

PLUG, VOLTAGE RATING:

480VAC, AMPS: 20, PHASE: 3,

NUMBER OF WIRES: 4,

COLOR: RED,

**GSA ADVANTAGE

AVAILABLE**

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5935 LL9814005 NA 4 N 50527466 1/EA

034 1 2 M POWER STRIP,ELECTRI,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 6150 016563753 NA 4 N 50525152 1/EA

035 M SOUND CO, ORDERED FOR

KTR

ORIG: C231A R. YAJIMA

243-2791

9Q 5640 007565866 NA 4 N 50555085 1/SH

SHEAR

AY A 2

FOUO

M-5

SHIP: YR-85 CHG/VER: 0/1

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

036 9 2 M O-RING, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5331 011737962 NA 4 N 50525159 2/EA

037 16 1 M SHEET,METAL, ORDER FOR

KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 9515 005420173 NA 4 N 50525184 1/SH

038 19 1 M SCREW,CAP,HEXAGON H,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5305 016458474 NA 4 N 50525187 16/EA

039 M STANDOFF, ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

7787-1968

9B 5340 002726544 NA 4 N 50525167 1/HD

040 M PLATE,METAL, ORDER FOR

KTR

REORDER FOR DOC#

50555208

ORGI: C232 H.MATSUBAYASHI,

243-4509

9B 9515 001533264 NA 4 N 51435133 16/SF

041 14 2 M CABLE,POWER,ELECTRI,

ORDER FOR KTR

ORIG: C226 R.FUKUDA, 070-

9B 6145 012020672 NA 4 N 50525166 15/FT

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:

YR-85 FOOT BRK & BOX SHEAR AY A 2

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

38HVC66501 A03

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:

YR-85 FOOT BRK & BOX SHEAR AY A 2