Provide complete identification of the plant unit and all reactor coolant system valves subject to preventive maintenance. Ensure all tag numbers and technical specifications are accurately recorded.
Nuclear Facility Identifier Code
Reactor Unit Number
Reactor Coolant System Configuration
Two-Loop PWR
Three-Loop PWR
Four-Loop PWR
BWR Recirculation Loop
CANDU Primary Heat Transport
Other
Primary Loop Identifier
Valve Tag Numbers (list all valves requiring maintenance)
Detailed Valve Specifications
Valve Tag Number | Valve Type | Nominal Size (inches) | Pressure Class | Manufacturer | Safety Class (Seismic Category) | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | RC-MOV-101A | Motor-Operated Gate | 12 | Class 1500 | Velan | Safety Class 1 | |
2 | RC-MOV-101B | Motor-Operated Gate | 12 | Class 1500 | Velan | Safety Class 1 | |
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Work Order Number
Scheduled Maintenance Start Date/Time
Scheduled Maintenance Completion Date/Time
Maintenance Type Classification
Routine Preventive Maintenance
Deferred Maintenance Resolution
Post-Modification Testing
Corrective Maintenance
Surveillance Testing
Other
Last Maintenance Date
Does this maintenance require containment vessel access?
Select all containment access pathways required:
Equipment Hatch
Personnel Airlock North
Personnel Airlock South
Cavity Access Port
Refueling Canal
Confirm that all work will be performed outside radiological controlled areas or in low-dose zones only.
Upload valve location diagram and system isometric drawing
Complete radiological work permit prerequisites and verify personal protective equipment readiness. All dosage readings must be current and within administrative limits.
Primary Technician Name
Primary Technician ID Number
Current Dosimeter Reading (mSv)
Projected Total Dose for This Task (mSv)
Remaining Dose Allocation Until Next Monitoring Period (mSv)
Has ALARA review been completed and documented?
ALARA Review Document Reference Number
STOP WORK - ALARA review must be completed before proceeding. Contact Radiation Protection Department immediately.
PPE Inspection and Readiness Verification
Not Applicable | Failed Inspection | Marginal Condition | Acceptable | Optimal Condition | |
|---|---|---|---|---|---|
Disposable coveralls (Tyvek or equivalent) inspected and defect-free | |||||
Double-layer gloves (inner and outer) properly sized | |||||
Safety boots with contamination covers | |||||
Full-face respirator or SCBA unit tested and functional | |||||
Hearing protection rated for industrial noise | |||||
Safety harness and lanyard for elevated work | |||||
Portable dosimeter and alarm setpoints verified |
Respiratory Protection Equipment Required
None Required - Low Dose Area
Half-Face APR with P100 Filters
Full-Face APR with P100 Filters
SCBA - Self Contained Breathing Apparatus
Supplied Air System with Escape Bottle
Has fit test been completed for required respirator within the last 12 months?
CRITICAL DEFICIENCY - Fit test must be current. Work cannot proceed without valid fit test certification.
Maximum Expected Dose Rate at Work Location (mSv/hr)
Will continuous air monitoring be required during maintenance?
Continuous Air Monitor (CAM) Unit Serial Number
Select all required supplementary protective equipment:
Portable Ventilation System
Contamination Control Tent
Decontamination Station
Emergency Eyewash Station
Whole Body Counter Access
Portable Shielding
Remote Handling Tools
Describe any radiological hazards or contamination concerns specific to this valve maintenance
Upload radiological survey map and RP briefing checklist
CRITICAL SAFETY SECTION - Verify each isolation and depressurization step before proceeding. Any 'No' response requires immediate stop-work evaluation and corrective action. All verifications must be independently confirmed by a second qualified individual.
1.0 - System one-line diagram reviewed and isolation boundaries marked?
Describe corrective action required before proceeding
2.0 - All upstream and downstream isolation valves closed, locked, and tagged?
Identify which isolation valves are not secured and explain
3.0 - Motor-operated valve power supplies disconnected and LOTO applied at MCC?
Specify which MOVs remain energized and justification
4.0 - Pneumatic/hydraulic actuator supplies isolated and bled down?
Detail which actuators remain pressurized and controls in place
5.0 - System pressure verified at zero psig on at least two independent gauges?
Record actual pressure readings and gauge locations
6.0 - All system drain valves opened and verified flowing to waste collection?
Identify blocked drains and alternative depressurization path
7.0 - Temperature verified below 120°F (49°C) before breaking containment?
Record actual system temperature (°F)
8.0 - Blind flanges installed at all identified break points?
Specify which break points lack blind flanges and protective measures
9.0 - Containment isolation valves verified closed on both primary and backup systems?
Describe isolation deficiency and compensatory measures
10.0 - LOTO verification walkdown completed by independent verifier?
STOP WORK - Independent verification is mandatory. Contact Shift Manager and Safety Engineer before proceeding.
List all LOTO tag numbers and corresponding equipment isolated
Isolation Valve Status Verification
Valve Tag Number | Closed & Secured | LOTO Applied | LOTO Tag Number | Verifier Initials | Verification Timestamp | ||
|---|---|---|---|---|---|---|---|
A | B | C | D | E | F | ||
1 | RC-ISO-101 | LOTO-2847 | JS | 6/30/2025, 6:00 AM | |||
2 | RC-ISO-102 | LOTO-2848 | JS | 6/30/2025, 6:05 AM | |||
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Primary Isolation Technician Signature
Independent Verifier Signature
Upload marked-up system one-line diagram showing isolation boundaries
Execute hydrostatic testing in accordance with ASME Section XI or equivalent code requirements. Record all test parameters and witness all hold periods. Any deviation from specified test pressure or leakage criteria requires immediate stop-work and engineering evaluation.
Test Pressure (psig)
Test Pressure Tolerance (+/- psig)
Required Pressure Hold Duration (minutes)
Maximum Allowable Pressure Drop During Hold (psi)
Has test gauge been calibrated within the last 90 days?
Calibration Due Date
CRITICAL - Uncalibrated gauges invalidate test results. Replace with calibrated gauge before proceeding.
Test Medium
Demineralized Water
Boronated Water
Nitrogen Gas (Pneumatic)
Other
Test Medium Temperature (°F)
Is test medium temperature within 30°F of ambient temperature?
CAUTION - Temperature differential may affect pressure readings. Allow thermal equilibrium or apply temperature correction factor.
Hydrostatic Test Data Log
Time | Pressure Reading (psig) | Temperature (°F) | Visual Leak Observed | Technician Observations | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | 6/30/2025, 2:00 PM | 500 | 72 | Initial pressurization - no leaks | ||
2 | 6/30/2025, 2:15 PM | 2485 | 73 | Reached test pressure - stable | ||
3 | 6/30/2025, 2:45 PM | 2480 | 73 | End of hold period - pressure drop 5 psi acceptable | ||
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Was pressure drop within acceptable limits?
Document pressure drop value and initiate condition report for engineering evaluation
Were any leaks observed during hold period?
Describe leak location, size, and probable cause. Initiate corrective action request.
Was post-test drain and dry-out procedure completed?
Explain why drain/dry-out was not completed and document compensatory measures
Select all test phases successfully completed:
Pre-test system fill and vent
Gradual pressurization to test pressure
Pressure hold period
Visual leak inspection
Depressurization and system restoration
Post-test system normalization
Summary of test results and any anomalies observed
Upload test pressure chart recording and photographic evidence
FINAL AUTHORIZATION - This section must be completed by authorized signatories only. All preceding sections must be fully documented and any deficiencies resolved before requesting final approval. This authorization permits system restoration and return to normal operations.
Have all sections of this form been completed in full?
INCOMPLETE FORM - Return to originating technician to complete all mandatory fields before submittal for sign-off.
Were any stop-work conditions identified during maintenance execution?
Summarize stop-work issues, corrective actions taken, and final resolution status
Documentation Quality and Completeness Review
Unacceptable | Minor Deficiencies | Acceptable with Notes | Fully Compliant | Exceeds Standards | |
|---|---|---|---|---|---|
Section 1 valve identification data accurate and complete | |||||
Section 2 radiological controls properly established | |||||
Section 3 isolation and LOTO verifications documented | |||||
Section 4 hydrostatic test results within acceptance criteria | |||||
Photographic evidence supports maintenance activities | |||||
All anomalies properly documented with condition reports |
Is system ready for return to service?
Specify remaining work items or restrictions preventing system restoration
Operational Readiness Status
Full Release - No Restrictions
Conditional Release - See Notes
Hold - Additional Work Required
Hold - Engineering Evaluation Pending
Special conditions, restrictions, or limitations for system operation post-maintenance
Final Authorization Signatures
Signatory Role | Printed Name | Authorization Number | Signature Date/Time | Digital Signature | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | Maintenance Supervisor | Robert Chen | AUTH-MS-4521 | 6/30/2025, 4:00 PM | ||
2 | Radiation Safety Officer | Dr. Sarah Mitchell | AUTH-RSO-892 | 6/30/2025, 4:15 PM | ||
3 | Chief Nuclear Officer | James Rodriguez | AUTH-CNO-001 | 6/30/2025, 4:30 PM | ||
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I certify that all work has been performed in accordance with approved procedures and that the system is safe for return to service.
CERTIFICATION DENIED - Cannot approve system restoration without full compliance certification.
Upload all supporting documentation, condition reports, and as-found/as-left condition photos
This operational authorization form is now complete. Retain in plant records for minimum 10 years or per facility record retention schedule. System restoration may commence upon final CNO signature.
To configure an element, select it on the form.