TGI_38K5216704_A01_c0v0.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.: HATCH ASSY 1-428-1 AY A 0 0

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

DDG-114 USS RALPH JOHNSON K52

CU PHASE TITLE:

F/O - OVERHAUL WTRTT HATCH AND SCUTTLE 1-428-1 IN WEA DK AND FAB BRACE ROD

PREPARING ACTIVITY:

PREPARED BY: CODE PHONE DATE

TSUBASA KOSUGE 231A 315-243-4371 13-NOV-2024

APPROVED BY: CODE PHONE DATE

YUUJI NAKAMURA 231A 315-243-6041 13-NOV-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:

CHANGE INSTRUCTIONS:

SPECIAL REQUIREMENTS:

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

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.: HATCH ASSY 1-428-1 AY A 0

FOUO

SHIP: DDG-114 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 M1-4

1. SCOPE/PURPOSE

1.1 Title: Overhaul of Watertight Hatch and Scuttle 1-428-1 in Weather Deck and Fabrication of Brace Rod;

accomplish

1.2 Location of Work:

1.2.1 Main Deck Level Weather, Frame 428, Starboard

1.2.2 Passage (2-410-0-L)

1.3 Identification:

1.3.1 Quantity (One AY), Brace rod Assembly for Watertight Hatch 1-428-1

Remarks: See 2.3 for material and details

1.3.2 Quantity (10 SF), Rubber Insulation on Interior Side of Hatch Panel of Watertight Hatch 1-428-1

Material: Form Rubber, NH Armaflex, 3/4 Inch Thickness

1.3.2.1 Quantity (3 SF), Rubber Insulation on Interior Side of Scuttle Panel of Watertight Scuttle 1-428-1

Material: Form Rubber, NH Armaflex, 3/4 Inch Thickness

1.3.3 Quantity (One EA), Hatch, Watertight

Hatch No. :1-428-1 Size: 36 Inches x 48 Inches Material: Steel Type: Ramped Low Profile Individually with Ramp 8 Dogs

1.3.3.1 Quantity (One EA), Scuttle, Watertight

Scuttle No.:1-428-1 Size: 21Inches Diameter Panel: Steel Coaming: CRES Type: Ramped Low Profile Quick Acting with Ramp 3 Dogs

1.3.4 Quantity (4 EA), Label Plate, Watertight Hatch

1.3.4.1 Quantity (One EA), Label Plate, Exterior

Material: CRES, Type-II of 2.9 Inscription: 1st. Line: 1-428-1

2nd. Line: PASSAGE 3rd. Line: 2-410-0-L

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SHIP: DDG-114 CHG/VER: 0/0

1.3.4.2 Quantity (One EA), Label Plate, Damage Control Closure Classification, Exterior

Material: CRES, Type-II of 2.9 Remarks: Figure-D of 2.9

1.3.4.3 Quantity (One EA), Label Plate, Interior

Material: Aluminum Alloy, Type-I of 2.9 Inscription: 1st. Line: 1-428-1

2nd. Line: WEATHER

1.3.4.4 Quantity (One EA), Label Plate, Damage Control Closure Classification, Interior

Material: Aluminum Alloy, Type-I of 2.9 Remarks: Figure-D of 2.9

1.3.5 Quantity (4 EA), Label Plate, Watertight Scuttle

1.3.5.1 Quantity (One EA), Label Plate, Exterior

Material: CRES, Type-II of 2.9 Inscription: 1st. Line: 1-428-1

2nd. Line: PASSAGE 3rd. Line: 2-410-0-L

1.3.5.2 Quantity (One EA), Label Plate, Damage Control Closure Classification, Exterior

Material: CRES, Type-II of 2.9 Remarks: Figure-D of 2.9

1.3.5.3 Quantity (One EA), Label Plate, Interior

Material: Aluminum Alloy, Type-I of 2.9 Inscription: 1st. Line: 1-428-1

2nd. Line: WEATHER

1.3.5.4 Quantity (One EA), Label Plate, Damage Control Closure Classification, Interior

Material: Aluminum Alloy, Type-I of 2.9 Remarks: Figure-D of 2.9

1.3.6 Quantity (10 SF), Compartment Insulation on Interior Side of Hatch Panel of Watertight Hatch 1-428-1

Material: Anti-Sweat, Polyimide, 3/4 Inch Thickness, MIL-DTL-24688, Type II

1.3.6.1 Quantity (3 SF), Compartment Insulation on Interior Side of Scuttle Panel of Watertight Scuttle 1-428-1

Material: Anti-Sweat, Polyimide, 3/4 Inch Thickness, MIL-DTL-24688, Type II

1.4 Security Classification: None.

1.5 Initial Condition:

1.5.1 Potential Asbestos Hazard.

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SHIP: DDG-114 CHG/VER: 0/0

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

3 DWG 8100-

1252-0236 Hatches, Structural (Steel) Assemblies & Details

AH Y SE

E N

OT

E

4 DWG 167-

7062377

HATCH AND SCUTTLE LIST SHIP

WIDE

- Y 7F, 8H

5 DWG 8100-

1252-0235

Hatches Structural (Steel) Arrangement

K N

6 DWG 8100-

1253-0237

SCUTTLE STRUCURAL(STEEL)

WTQA 3 & 4 DOG

ARRANGEMENT

R N

7 DWG 8100-

1253-0238

SCUTTLE STRUCTURAL(STEEL)

WTQA ASSEMBLIES & DETAILS

AF N

8 TM

SYSTEMS &

SPECIFICAT

IONS

SSPC Painting Manual Volume 2 - N

9 PDD 602-

ELM-150531

SRF-JRMC STD ELM LABEL

PLATE FOR CLOSURE

A Y AL

L

10 PDD 635-

ELM-230114

SRF-JRMC Std ELM Sub Matl of Elastomeric Plstc Foam for Hull Insul

- Y AL

L

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 Fabricate and install each new brace rod listed in 1.3.1 in accordance with 2.3, using 2.4 and 2.5 for guidance.

5.1.1 Template details from existing hatch for new fabrication of each brace rod.

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

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

5.2 Remove each existing rubber insulation listed in 1.3.2.

5.3 Remove existing hatch and scuttle panel of each hatch listed in 1.3.3, using 2.3 through 2.7 for guidance.

Masato.Endo.ja Typewritten Text

14 JUL 2025

Masato.Endo.ja Typewritten Text

26 NOV 2025

Masato.Endo.ja Cross-Out

Masato.Endo.ja Typewritten Text

1/11/2025 C-1209 M. ENDO 11030028

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SHIP: DDG-114 CHG/VER: 0/0

5.3.1 Disassemble dog assembly.

5.3.1.1 Clean each part free of dirt, grease and foreign matter.

5.3.2 Remove existing gasket and label plate(s) of each hatch.

5.4 Accomplish the requirements of 009-32 of 2.1, including Table 2, Line(s) 9, for exterior surfaces and Table 3, Line(s) 25, for interior surfaces of hatch and scuttle panel of each hatch listed in 1.3.3.

5.4.1 Near-white blast clean for each hatch and scuttle panel. Accomplish each requirement of Surface Preparation Specification SSPC-SP 10 of 2.8.

5.5 Prepare and align hatch and scuttle panel of each hatch listed in 1.3.3 for reinstallation, using 2.3 through 2.7 for guidance.

5.5.1 Fabricate and install new gasket conforming to A-A-59588 Class 3B Grade 30.

5.6 Reinstall hatch panel and scuttle of each hatch listed in 1.3.3, using 2.3 through 2.7 for guidance.

5.6.1 Reassemble dog assembly.

5.6.1.1 Lubricate each dogging mechanisms.

5.6.2 Adjust each dogging mechanism for unobstructed operation and to obtain 100 percent centered contact with the imprint of chalk in the center three-fifths of the gasket.

5.7 Accomplish the requirements of 009-25 of 2.1 for a chalk test of each hatch and scuttle listed in 1.3.3.

5.8 Accomplish the requirements of 009-25 of 2.1 for a local air hose test of hatch and scutle panel gasket and knife edge mating area of each hatch listed in 1.3.3. Allowable leakage: None.

5.9 Accomplish an operational test of each hatch and scuttle listed in 1.3.3 to assure unobstructed operation.

Allowable sticking or binding: None.

(V)(G) “OPERATION TEST”

5.10 Fabricate and install new each label plate listed in 1.3.4 and 1.3.5 in accordance with 2.9.

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

5.11 Accomplish the requirements of 009-11 of 2.1 to install each new compartment insulation listed in 1.3.6 in accordance with 2.10.

5.11.1 Accomplish the requirements of 009-32 of 2.1 for top surface where new insulation is installed.

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

5.13 Notes:

5.13.1 Planner: Code 231A T. Kosuge, 243-4371

5.13.2 WPC will copy the following pages in reference.

REF. 2.3: Sheets 78, 80, 86, 87B, and 88B.

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

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SHIP: DDG-114 CHG/VER: 0/0

5.13.4 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.

5.13.5 JCN ER09-L027 is related to this TGI.

5.14 Government Furnished Material (GFM):

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

5.15 SRF-JRMC will provide the following service work: (TGI No. 38K5216704S02).

5.15.1 [C740] Crane and crane rigging service.

5.15.2 [X99E] Utility service, electrical.

5.15.3 [X99M] Utilities service, including low pressure air supply, water supply, and steam supply.

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

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

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

FOUO

J-1

SHIP: DDG-114 CHG/VER: 0/0

APPENDIX "J"

TGI JOB SUMMARY INFORMATION SHEET

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

VERSION:

CASREP

CAT:

HATCH ASSY 1-428-1 AY A 0 0

CU PHASE TITLE:

F/O - OVERHAUL WTRTT HATCH AND SCUTTLE 1-428-1 IN WEA DK AND FAB BRACE ROD

PRIMARY COMPONENT:

COMPONENT UNIT LIST (FOR ASSEMBLIES):

HATCH 1-428-1 HA SCUTTLE 1-428-1 HA

ATTACHMENT LIST:

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

YAGINUMA ,TAKEHIDE

JO: KO: TOTAL MAN HRS: TOTAL MAT’L COST TOTAL DURATION: PLANNING ACCEPTANCE:

38K5216704 A01 361 $12,633.26 0

CU PHASE DESCRIPTION:

The purpose of this TGI is to overhaul watertight hatch and scuttle 1-428-1 in weather deck and fabricate brace rod.

Location of Work:

Main Deck Level Weather, Frame 428, Starboard Passage (2-410-0-L)

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

FOUO

J-2

SHIP: DDG-114 CHG/VER: 0/0

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

FOUO

M-1

SHIP: DDG-114 CHG/VER: 0/0

APPENDIX “M”

TGI MATERIAL LIST

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

VERSION:

CASREP

CAT:

HATCH ASSY 1-428-1 AY A 0 0

CU PHASE TITLE:

F/O - OVERHAUL WTRTT HATCH AND SCUTTLE 1-428-1 IN WEA DK AND FAB BRACE ROD

MATERIAL REFERENCES

REF

NO.

DOCUMENT/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV

JOB ORDER: KEY OP:

38K5216704 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 SPINDLE,HATCH, ORGI: C231A

T. KOSUGE

243-4371

ORDERED FOR KTR

9B 2040 014197132 NA 4 N 43175027 8/EA

002 M BEARING,SLEEVE, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 3120 014841528 NA 4 N 43175031 8/EA

003 M BUSHING,SLEEVE, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 3120 014841530 NA 4 N 43175033 16/EA

004 M WASHER,FLAT, ORIG: C231A

T. KOSUGE

243-4371

ORDERED FOR KTR

9B 5310 014844047 NA 4 N 43175036 16/EA

005 M NUT,SELF-LOCKING, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 5310 014502851 NA 4 N 43175037 8/EA

006 M PLUNGER,DETENT, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 5340 014207020 NA 4 N 43175039 8/EA

NOTES:

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M-2

SHIP: DDG-114 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

007 M PIN,COTTER, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 5315 014198257 NA 4 N 43175040 4/EA

008 M WASHER,FLAT, ORIG: C231A

T. KOSUGE

243-4371

ORDERED FOR KTR

9B 5310 014815484 NA 4 N 43175042 4/EA

009 M PIN,STRAIGHT,HEADLE, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 5315 014871105 NA 4 N 43175055 4/EA

010 M RUBBER , ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 5330 013717183 NA 4 N 43175058 30/FT

011 M SPRING, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 5360 014209907 NA 4 N 43175063 3/EA

012 M SCREW,CAP,HEXAGON ,

ORIG: C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 5305 014508865 NA 4 N 43175056 3/EA

013 M SPINDLE,MECHANICALL,

ORIG: C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 3040 014498455 NA 4 N 43175059 1/EA

014 M BUSHING,SLEEVE, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 3120 014207110 NA 4 N 43175064 1/EA

015 M BUSHING,SLEEVE, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 3120 014207113 NA 4 N 43175066 1/EA

016 M SETSCREW, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 5305 009806819 NA 4 N 43175069 1/EA

017 M PIN,SHOULDER,HEADLE,

ORIG: C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 5315 014501351 NA 4 N 43175071 1/EA

018 M COLLAR,SPINDLE, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 2040 014198601 NA 4 N 43175073 1/EA

019 M INSULATION, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9Q 5640 013713263 NA 4 N 43175065 1/SH

020 M INSULATION, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9Q 5640 013713262 NA 4 N 43175068 1/SH

021 M INSLULATION, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9Q 5640 013837815 NA 4 N 43175070 4/SH

022 M ADHESIVE, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 8040 002738708 NA 4 Y 43175075 1/GL

FOUO

M-3

SHIP: DDG-114 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

023 M ADHESIVE, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 8040 005508835 NA 4 Y 43175106 1/GL

024 M TAPE, 2", ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 8315 002671632 NA 4 N 43175089 1/RO

025 M TAPE, 3", ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 8315 002671633 NA 4 N 43175093 1/RO

026 M TAPE, 4", ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 8315 002671630 NA 4 N 43175095 1/RO

027 M BRACE PIN, ORGI: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

BRACE PIN, SIZE: 3/4"DIA X 1-

3/8"LENGTH, MATL: NAVAL

BARASS, IAW: BIW DWG 8100-

1253-0238 PARTS NUMBER 80.

LL9303991 NA 4 N 2/EA

028 M PIN,COTTER, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

9B 5315 014196004 NA 4 N 43175074 1/HD

029 M PIPE, ORGI: C231A T. KOSUGE

243-4371

ORDERED FOR KTR

9B 4710 009619174 NA 4 N 43175076 6/FT

030 M BAR, METAL 1/4" DIA, ORIG: T.

KOSUGE

243-4371

ORDERED FOR KTR

BAR, METAL, ROUND, 1/4"DIA,

STEEL, MIL-S-22698 GR A CL U

LL4588701 NA 4 N 2/FT

031 M SLEEVE, SWAGING, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

SLEEVE, SWAGING, FOR 1/16"

DIA WIRE ROPE, SPEC:

MS51844, MATL: CRES 304,

BIW CATALOG NO: 02332-027,

NSN: 4030-01-088-2952, DO

NOT CROSS NSN 4030-01-590-

7203 (AAC-Y)

LL9000281 NA 4 N 4/EA

032 M WIRE ROPE, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

WIRE ROPE, DIA: 1/16",

CONSTRUCTION: 7 X 7, MATL:

CRES 316. BIW CATALOG NO:

50033-007, DO NOT CROSS

NSN: 9505-00-554-1420. BIW

CATALOG SHOWS THIS NSN,

BUT THIS IS JUST WIRE, NOT

WIRE ROPE.

LL9000282 NA 4 N 4/FT

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M-4

SHIP: DDG-114 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

033 M PIN, TOGGLE, BALLED, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

PIN, TOGGLE, BALLIED, DWG

8100-1252-0236 SH88 PT NO.

721, SIZE: 1/2" DIA X 1" GRIP

RANGE, MATL: CRES 316 (PIN

AND TOGGLE END), BIW CAT#:

54055-170, NSN: 5315-01-419-

LL9300590 NA 4 N 2/EA

034 M BRACE END, ORIG: C231A T.

KOSUGE

243-4371

ORDERED FOR KTR

BRACE END, MALE, CASTING,

CAST STEEL, BUSHIPS DWG:

805-1624071 PC 73, BIW PATT

M252-111-73 ASTM A27 GR 60-

30, BIW DWG: 8100-1252-0236

REV: AH PC: 715

LL7014932 NA 4 N 2/EA

035 M BAR,METAL,3/8"DIA, ORIG:

C231A T. KOSUGE

243-4371

ORDERED FOR KTR

BAR, METAL, ROUND, 3/8 "DIA,

STEEL, MIL-S-22698 GRADE

AH-36, CL U.

LL9005766 NA 4 N 2/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:

DDG-114 HATCH ASSY 1-428-1 AY A 0

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

38K5216704 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:

DDG-114 HATCH ASSY 1-428-1 AY A 0