Certificate of Functional Configuration

Audit/Physical Configuration Audit

(OR EQUIVALENT)

CERTIFICATION SIGNATURE PAGE

CONFIGURATION ITEM NAME PART NUMBER/SERIAL NUMBER DATE

An FCA/PCA has been conducted with results noted below and on the attached sheets.

FCA #1 - Certification of Qualification Test (Plus Attachment FCA #1)

FCA #2 - Certification of Deviations/Waivers (Plus Attachment FCA #2)

PCA #1 - Certification of Product Baseline (Plus Attachment PCA #1)

PCA #2 - Fabrication/Inspection Records

PCA #3 - Technical Documentation Control System Review

PCA #4 - Drawing Review (Plus Attachment PCA #4)

PCA #5 - Review of Shortages and Unincorporated Design Changes (Plus Attachment PCA #5)

We certify that the Configuration Item listed above has

Conditionally completed an FCA/PCA or its equivalent and this audit will be closed when all Action
Items written against this audit are declared closed.

Successfully completed the FCA/PCA or equivalent and is hereby declared closed.

CUSTOMER PRODUCT DEVELOPER

ENGINEERING PANEL ENGINEERING PANEL

QUALITY ASSURANCE REPRESENTATIVE QUALITY ASSURANCE REPRESENTATIVE

CONFIGURATION MANAGEMENT REPRESENTATIVE CONFIGURATION MANAGEMENT REPRESENTATIVE

FCA/PCA CO-CHAIR FCA/PCA CO-CHAIR

GRC 2069 (MAY 11)

 Certificate of Functional Configuration
Audit/Physical Configuration Audit
(OR EQUIVALENT)
CI/CSCI NUMBER PART NUMBER/SERIAL NUMBER

NOMENCLATURE MANUFACTURER

DEVELOPMENT SPECIFICATION NUMBER PIA/PMP

FCA #1 Qualification Test Procedures and Results

The qualification test/analysis results have been reviewed to ensure that testing is adequate, properly done,
and certified. Test procedures and interface documents have been reviewed to assure that the documents
have been approved. We certify that the test data sheets have been reviewed to assure that the test was
witnessed as required, and that the

Procedures and results reviewed satisfy the requirements and are accepted.

Procedures and results reviewed do not satisfy the requirements.

Attachment FCA #1 is the list of documents reviewed and deficiencies found.

FCA #2 Review of Deviations/Waivers

A review of all deviations/waivers to engineering documentation that have been approved was conducted.
The purpose was to determine the extent to which the hardware/software undergoing FCA vary from
applicable engineering documentation and to form a basis for satisfactory compliance with this
documentation. We certify that all applicable deviations/waivers have been reviewed with the following
results:

There are no deviations/waivers against the CI/CSCI.

All deviations/waivers were reviewed. A list of approved and unapproved deviations/waivers is

attached.

Attachment FCA #2 is the list of approved and unapproved deviations/waivers and the related discrepancies
and/or comments.

GRC 2069 (MAY 11)

 Certificate of Functional Configuration
Audit/Physical Configuration Audit
(OR EQUIVALENT)
CI/CSCI NUMBER

PCA #1 Certificate of Product Baseline

A purpose of this PCA was to ensure accuracy of the technical documentation (i.e., item specification and
product drawings) and to identify the Product Baseline.

We certify that the configuration item listed herein has been formally audited against its technical
documentation and that the configuration item's Product Baseline is

Acceptable
Conditional - See Action Items

Attachment PCA #1 lists the Product Baseline for the above CI/CSCI.

PCA #2 Fabrication and Inspection Records

Fabrication and inspection records have been reviewed to verify that they properly and accurately describe the
work accomplished and that the configuration of the item is accurately documented. Fabrication/Inspection
records used for "in-process" inspections contain (a) nomenclature and part numbers that agreed with the
drawings and (b) reflect the requirements of the released design configuration noted above. We certify that
these are

Acceptable
Not Acceptable - See Action Items

Configuration Verification

Configuration inspections conducted during the in-process operations verified that the configuration of the
hardware conforms to the technical documentation. The inspections verified that no differences exist between
"as-built" and "as-designed" configurations except as documented in the fabrication/inspections records and
this certificate. We certify that these are

Acceptable
Not Acceptable - See Action Items

Certification and Acceptance Test Procedures (CATP) and Results

The Certification and Acceptance Test Procedures and results have been reviewed to ensure that testing has
been completed and verified in accordance with PIA/PMP requirements. Acceptance testing was conducted
with approved Acceptance Test Procedures and results were accurately documented. We certify that these
are

Acceptable
Not Acceptable - See Action Items

GRC 2069 (MAY 11)

 Certificate of Functional Configuration
Audit/Physical Configuration Audit
(OR EQUIVALENT)
CI/CSCI NUMBER

PCA #3 Technical Documentation Control System Review

A review of the technical documentation and control system was performed to ensure that the drawing system
and associated release system and QA system - used to control the drawings that were used during the
"in-process" physical inspections - provide drawings that have been reviewed to verify accuracy and that they
adequately define the configuration of the item so that it can be manufactured, tested, and inspected.

The hardware/software provider's system requires that technical documentation used for the 'in-process"
inspections: a) were released through an official controlled release system; b) met the quality and age
restrictions for engineering change incorporation described in the approved Configuration Management Plan
and applicable drawing requirements manual; c) provided continuity from top-level assemblies to piece-parts;
d) accurately describes the item being inspected.

We certify that

The technical documentation control system is acceptable.

The technical documentation control system is not acceptable. See Action Items.

PCA #4 Drawing Review

A review was performed comparing the drawings to the physical equipment to ensure that the latest drawing
changes had been incorporated into the equipment, that part numbers appearing on the equipment agree with
part numbers listed on the drawings, and that the drawings were complete and accurately describe the item. A
list of drawings reviewed is attached hereto as Attachment PCA #4.

We certify that

The drawings are complete and accurately describe the item being audited.

Discrepancies were found between the drawings and the item being audited. See Action Items.

PCA #5 Review of Shortages and Unincorporated Design Changes

Shortages and unincorporated design changes on the attached list have been reviewed and recommended
corrective action has been provided.

We certify that

There are no shortages or unincorporated design changes.

Attached is a list of shortages and/or unincorporated design changes with recommended corrective action.

Attachment PCA #5 is the list of shortages and/or unincorporated design changes, and the recommended
corrective action required.

GRC 2069 (MAY 11)

 Qualification Test Procedures
and Test Results
CI/CSCI NUMBER NOMENCLATURE

SPECIFICATION NUMBER TEST PROCEDURES

SPECIFICATION
REFERENCE
DESCRIPTION TEST RESULT
TP REFERENCE

GRC 2069 (MAY 11)

 Review Deviations/Waivers

CI/CSCI NUMBER NOMENCLATURE

DEVIATION/WAIVER DESCRIPTION
NUMBER

GRC 2069 (MAY 11)

 Product Baseline Listing

CI/CSCI NUMBER NOMENCLATURE

DOCUMENT/DRAWING UNINCORPORATED
NUMBER TITLE REVISION CHANGES

GRC 2069 (MAY 11)

 Documentation/Drawings
Reviewed
CI/CSCI NUMBER NOMENCLATURE

DRAWING TITLE
NUMBER

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 Shortages and Unincorporated
Design Changes
CI/CSCI NUMBER NOMENCLATURE

DESCRIPTION CORRECTIVE ACTION

GRC 2069 (MAY 11)

 FCA/PCA
Action Item
CI/CSCI NUMBER DATE

NOMENCLATURE
PAGE 1 OF

PROJECT/PROVIDER AUDIT LOCATION AL NUMBER

FINDING/OBSERVATION

RECOMMENDED SOLUTION/ACTION

CATEGORY

I Hardware/Software may not be delivered until this Action is closed.

II Documentation clean up will not holdup hardware/software delivery.

INITIATOR (Name, telephone number) ASSIGNED TO

PROVIDER CO-CHAIR CUSTOMER CO-CHAIR

CLOSURE (Attach documentation, if required)

PROVIDER CO-CHAIR APPROVAL CUSTOMER CO-CHAIR APPROVAL

GRC 2069 (MAY 11)

 FCA/PCA
Action Item Instructions

1. Review - Enter the appropriate CI/CSCI and nomenclature in the blank spaces provided.

2. Project/Provider - Enter what defines the subject of the action to be taken or

correction to be made.

3. AL Number - Enter a number to be used for tracking purposes.

4. Finding/Observation - Define the problem. An Action Item may only be written against
a contractually binding requirement. The problem must be written to fully define the
requirement and the violation of that requirement.

5. Recommended Solution/Action - Provide a suggested solution that would satisfy the

closure of this Action Item.

6. Category - To be assigned by FCA/PCA Co-Chairpersons.

7. Closure - Evidence of closure action taken.

GRC 2069 (MAY 11)