ML19347E079
| ML19347E079 | |
| Person / Time | |
|---|---|
| Site: | Fermi |
| Issue date: | 04/14/1981 |
| From: | Tauber H DETROIT EDISON CO. |
| To: | Harold Denton Office of Nuclear Reactor Regulation |
| Shared Package | |
| ML19347E080 | List: |
| References | |
| EF2-52-884, NUDOCS 8104150327 | |
| Download: ML19347E079 (4) | |
Text
"-
e Detroit 20C0 Second Ave %e Harry Tauber
?nbnE.M"**
f (4 ::.V;%c-d.
Dg APR 141981 m r
" EwY" EF2 - 52,884
'. % 'Q' s,'@f Mr. Harold R. Denton, Director United States Nuclear Regulatory Commission Office of Nuclear Reactor Regulation Washington, D.
C.
20555
Dear Mr. Denton:
Reference:
Enrico Fermi Atomic Power Plant - Unit 2 NRC Docket 50-341
Subject:
Human Factors Design Review of the Enrico Fermi 2 Control Room Enclosed you will find a copy of " Human Factors Design Review of Enrico Fermi 2 Control Room" which was written by a survey team of the BWR Owners Group Control Room Improvements Committee.
This survey was conducted during a two week period ending January 29, 1981.
l Attachment A is an outline of a Detroit Edison review l
followed by Attachment B containing detailed comments of the subject report.
If you have any questions, please let us know.
Sincerely,
/ 1
,Nv./.
- . i. k. %,
Enclosure l
cc:
L.
L. Kintner l
B.
Little 6'lI l
81o us o 3yt
O O
~
ATTACHMENT "A" Human factors in the design of control rooms has been a policy of Detroit Edison Company since 1965. All plants, fossil or nuclear, built since have used a control room task force - a multidiscipline approach (Operations, I&C and other engineers, Research Psychologist, Designers, training etc.) to design a control room. As a design iterative process, this task force, used a full scale mockup to identify any man machine problems - before a cut on the panels was made.
A two week human factors design review of the Fermi 2 control room was made by an independent survey team of BWR owners group. Detroit Edison employees assisted the team but were not a part of review and evaluation process. The review of survey team was quite broad including items such as procedures review, training, etc.
We are submitting the total report, though you may find sections in the report such as procedures review, maintenance and surveillance procedures, training and manning etc. not directly applicable to l
your forthcoming review.
The report outlines various items which may be enhanced. As pointed out in the report, we have reviewed these items and separated these into three categories:
1.
Items where enhancement may prove useful. We will modify these.
2.
Items where enhancement as suggested will need a more thorough review. We are presently considering these.
3.
Items where enhancement as suggested in the report if attempted will either be of very limited benefit, or in some cases, may lead to confusion in emergencies.
The above three categories are covered in detail under the ' Comments Simimary',
Attachment B, enclosed. We have not attempted to comment on items related to Sections 6, 8 and 9 as they will be a part of a separate NRC review.
0 0
ATTACHNENT B
' Comments Summary' Category 1 Items:
These are items where we feel enchancement may be beneficial. These items will be corrected. For correlating these items see Appendix A of the BWR Survey team report.
Iteam with evaluation products of 9-12 (High Priority Items)
Items listed under A2.2, A2.3, A3.3, A3.4, A3.5, A4.2 (with the exception of blue color lights), and B2.1 (indicating devices will be marked per Edison Standard 61721-2960 during plant startup) will be enhanced as described in the survey team report.
Items with evaluation products of 8 (Medium Priority Items)
Items listed under B2.7, B3.10, C2.9 will be enhanced as described in the survey team report. Item F1.7: The present system is a construction communication network. A two channel radio communication system shall be installed before the commercial plant operation.
Items with evaluation products of 6 (Low Priority Items)
A.2.2:
Lines of demarcation are being added as a means of panel enhance-ment on panels 601, 602, 804, 805, 806, 808 and 817.
A.2.5:
Engraving is being added for graphic displays on P805 and P806 (off gas panel)
Items lis ted under A3.2, AS.1, AS.2, A5.10, AS.11, B2.8, B2.11, B4.7, A2.10 I
(positive indication for SRV is planned), B5.1 (except IRM range switches covered under Category 3), B5.2, C2.1, and C2.8 will be enhanced as described in the report.
l 1
Items based on evaluation product of 4 Items listed under A2.4 (see reply for A.2.2 under items with evaluation products of 6), A2.6, A2.9, A2.10 (wherever practical such as panels 804, 805 and 806), A2.11 (wherever practical and it does not confuse with mimic), AS.6, AS.7.
Item B2.6 - casing pressure indicator was planned to be removed and is removed. It is not a system requirement and item R3.11 for Arm-Disarm collar on trip switches and round handled switches. The Pistol-grip switches have been used at other Deco plant I
and our experience indicates no problem in these cases.
l l
l
i ATIACHMENT B (contd)
' Comments Summary' Category 2 Items:
These ar'e items where enhancement as suggested will need a more thorough review. Enhancements for the following items is under consideration. For correlating these items, see Appendix A of the BWR survey team report.
Items with evaluation products of 9-12 (High Priority Items)
Items listed under B2.3 - indicating meter scales for indicators on panels 808, 817, 602, 603 and 804 (as outlined in the report). Meters on panels 809, 810 and 811 are a Detroit Edison Corporate Standard and have been found useful in our system. These are treated as Category 3.
Items with evaluation product of 8 (Medium Priority Items)
Item F1.6.
Items with evaluation product of 6 (Low Priority Items)
Items listed under C1.1, D3.7 and F3.1, B2.12.
Items with evaluation product of 4 (Lowest Priority Items)
Items B2.13 and B5.10.
Category 3 Items:
Items where enhancement as suggested in the report if attempted will either be of very limited benefit or may lead to human factor problems during normal or abnormal plant operation. To correlate the items below to the BWR survey team report, the page numbers are given in parenthesis.
These are the items:
A3.6 (page 34); items B2.2, B3.3 and B3.5 (page 35); items C2.3 and C2.7 (page 36); items B2.5, B2.18, B3.5, B3.6 and C6.4 (page 37); items A1.1 and AS.3 (page 38); items A7.1, B2.9, B4.1 (page 39); item C1.3 (page 40);
items AS.4, B5.8 (page 42); items C5.6, F6.7 and F7.7 (page 43); F1.8 If required, explanation for some of the above items will be provided to the NRC survey team during the upcoming review during the week of April 27, 1981 i
BWR OldNERS GROUP
(,
ColffROL ROOM IMPROVDENTS COM(ITTEE HUMAN FACTORS DESIGN REVIEW OF ENRICO FERMI 2 CONTROL ROOM
SUMMARY
REPORT Prepared By Date
/[ M i
i R. Flinn
(
General Electric Comp y Reviewed Date 3/
/
G. R. Mullee!
General E ectr e Company
/
7!,24/V/
Approved By-Date Gebert, Team Leader Iowa Electric Power & Light Company 4
e e-y- -. --.
-,---w-e,
.w-.,-,,.,m
-w--
,c.
,yr
IMPORTANT NOTICE REGARDING CONTENTS OF THIS REPORT Please Read Carefully This report contains information regarding the Control Room Survey performed under the direction of the BWR Owners' Group with the assistance of General Electric Company. The only undertakings of General Electric Company respecting information in this document are contained in the contract between Detroit Edison Company and General Electric Company, NSSS Contract Amendment 4, and nothing contrained in this document shall be construed as changing the contract. The use of this information by u;yone other than l
Detroit Edison Company, or for any purpose other than that for which it is intended, is not authorized; and with respect to any unauthorized use, neither General Electric Canpany nor the BWR l
Owners' Group make any representation or warranty, and assume no l
liability as to the canpleteness, accuracy, or usefulness of the l
information contained in this document.
l i
l
e Table of Contents
(
1.0 INTRODUCTIN 1
2.0 PANEL IAYOUT AND DESIGN 4
2.1 General 4
2.2 Anthroposetrics and Control Room Arrangement 4
2.3 Demarcation Lines and Mimics 5
2.4 Control / Display Grouping 5
2.5 Color Coding 6
2.6 Labels 6
30 INSTRUENTATIM AND HARDWARE 8
31 General 8
l 32 Indicators 8
33 Recorders 9
3.4 Indicating Lights to 35 Switches to 4.0 ANNUNCIATORS 12 4.1 General 12 4.2 Window Design and Grouping 12 4.3 Audible and Visual Alarms 13 4.4 Usefulness of Annunciators 14 5.0 c09 UTERS 15 I
6.0 PROCEDURES 16 6.1 General 16 6.2 Availability and Accessibility 16 6.3 Format and Content 16 6.4 Procedure Revision 17 6.5 Los Keeping 17 i
l
Table of Contents (cont'd)
(
7.0 CONTROL *. ROOM ENVIRWENT 18 7.1 General 7.2 Communications Systems 18 73 Lighting 19 7.4 Noise Levels 19 8.0 MAINTENANG AND SURVEILLANG PROGDURES 20 9.0 TRAINING AND MANNING 21 10.0 12R ANALYSIS
SUMMARY
22 11.0 OPERATW INTERVIEW SUM 1ARY 23 12.0 EERENCY PROGDURE WALKTHROUGH SLHMARY 26 l
12.1 Introduction 26 i
12.2 Task Analysis and Walk Through Of Emergency 27 Procedure Guidelines 13 0 SUMfARY 31 APPENDICES A.
CHECELIST ITEMS TO B2 REVIEWED FOR CDRRECTIVE ACTION 33 B.
OPERATOR INTERVIEW CDMENTS 44 C.
PHOTOGRAPHS i
k ii
. -... - - - ~ -.
1.0 INTRODUCTION
This report summarizes results obtained during a two week human i
factors design reviet of the Fermi 2 control room completed January 29, 1981.. A survey team comprised of operations and engineering personnel from two utilities performed the evaluation with the assistance of consultants free General Electric Company and the Massachusetts Institute of Technology. Detroit Edison has already devoted considerable effort to human factors considerations in their 1
control roce design process. Because Femi is still in a construction phase, the survey team was unable to evaluate many items. These will be identified in the summary report with a reconmiendation that each be reviewed at a later date.
The survey consisted of three phases: (1) interviews with eight of the plant operators, (2) comparison of control room panels with checklist standards derived from previous surveys and accepted human factors standards to identify potential design problems which could concibute to operator error, and (3) task analysis and walkthroughs of selected emergency situations using the emergency procedure f
guidelines.
Results of the Control Room survey are presented here in three levels of detail. Sections 2.0 through 9.0 sunniarize results obtained from the Control Room Review Checklists, each section beginning with a discussion of the scope of the review and listing general conclusions drawn from the evaluation. Following this, a more detailed discussion of each topic is provided, including specific examples for which modifications may be beneficial. Finally, a complete list of all items not in full compliance with checklist criteria, prioritized by numerical evaluation techniques, has been provided as Appendix A for convenience in resolving open items. Supporting photographs are provided in Appendix C.
The intent of this report is to identify areas of control room design for which modifications should be considered. These are stated as general problems with the understanding that correcticri of these i
items should be on a control roce wide basis. While specific examples have been provided where possible, this document is not
..m-r,
..-...._.mm,...w.
- -, - -.,..~_ _._-. -- -._----_-
m._.
designed to serve as an all inclusive list of every component needing correction, i.e., every switch and every label. Nor is it intended to recommend specific corrective action for the concerns discussed.
Here, human factors concerns requiring attention are identified; actual control roce modifications implemented to satisfy these concerns must be a more intensive effort involving a concerted, multidisciplinary approach considering all aspects of the problse.
Topics such as control panel layout should be given very careful consideration prior to instituting a change; such concerns involve many inter-related ideas which must be considered in parallel.
Inputs should be obtained from operations, engineering, training and human factors personnel.
SURVEY TEAM MEMBERS John Gebert Iowa Electric Light and Power Company -
team leader Public Service of Oklahoma Jim Tolson General Electric Company Bob Flinn General Electric Company Ken Ross Massachusetts Institute of Technology l
Paul Nicholson
(
David Lannin Massachusetts Institute of Technology l
Assisting the survey team from Detroit Edison Company were:
Gopal Shama l
Gene Preston l
Gerry Richards l
l l
l l
I 1
2
._m______
i e
i i
i l
l Table I i
I l
The surwy was conducted on the following panels:
I i
I P601 P808 P817 i
P602 P809 l
P603 P810 P804 P811 I
P805 P812 i
l P806 P813 i
l P807 P816 1
)
a i
1 I
i I
k I
l 1
i 3
i
i l
1 "D t A G RA rn
.f.
CONTRot, ROCM ARIUL4GDENT FI.Alff/ UNIT MMT1 FROCDURE I
_ natz comorts
[ PbO3 k
g. ~,, c_, m j
0y
/ / /
N
/ / /
N t
/
NND n N
O b
c uo rc,s emum o
g e ( ;
l:n1 l e arl
=
e.
g 9
}
I N
2 g
]
eo >
S
? $
1 4
l
~
e e
g u p
'l r-l 'i s 3 0
r w
a s
@ E m
(
40 5
l h.t k, e$ o s.
e.
k O
p
/
gy n nn
/o o
4/ Md evd S.199 ~ "N l
- )IQd L iEk-i 3A
l 2.0 PANEL LAYOUT AND DESIGN 2.1 General Control panel layout and design were evaluated against checklist e
atAndartis covering anthropometric guidelines, panel arrangement, j
mimics and demarcatimi lines, control / display gmuping, color codes, labels, temporary modifications and traffic patterns. As a result of i
this review disa.assed in detail below, the following recomendations are offered as general areas in which modifications should be considered:
(1) While there was extensive use of mimic lines, there are numerous areas whare the increased use of demarcation lines to seperate controls and indications of different systems which are located on the same control surface would be valuable, (2) In some cases labels and nameplates located below recorders are rather obscured from a nomal standing position. (3) some inconsistancy exists for the color of indicating lights used in various systems.
2.2 Anthropometrics and Control Room Arrangement Control panels were measured and compared to guidelines based on a 5th percentile female to 95th percentile male range of operators.
All panels were higher than recomended. The following concerns were noted on all panels. Controls and indicators above or below recomended heights.
1)
Annunciator height is above recommended limits (114" vs 88" recomended) 2)
Panel depth is slightly greater than recomended (31" vs 28" recomended)
I k
(
2.3 Demarcation Lines and Mimics Extensive use of simic control layodts was observed, and was t,
generally favored by operational personnel. Where such simics were used, the layouts were usually well organized and easy to follow, l
with f1'ow paths clearly identified. Exceptions to this were the Off l
Gas system (P806) and Condensate and Feedwater Hester systems (P805).
The use of demarcation lines to seperate switches and indicators of different systems were pointed out in many areas by the survey team and the operators, but could be applied more extensively (see photos 17, 18, 19, and 20). In addition to enclosing related displays, demarcatial lines may be used to differentiate related subsystems.
2.4 Control / Display Grouping An important aspect of panel organization is the manner in which related controls and displays are grouped. Effective arrangements can greatly facilitate component identification and ease of operation. In general, it is desirable to avoid large, undifferentiated matrices of controls and indicators and to maintain consistent relative placement of components between repetitive subgroups; functional groupings and control relationships should be readily discernable from panel layout. Mimic designs seem to be favored by operators in this respect but in many cases a system may not readily lend itself to this type of arrangement.
In such cases, optimum panel layout should utilize grouping of displays by syster or component, demarcation lines, and hierarchical labeling systems. Coordinated use of these three techniques contributes such toward providing organized, effective component l
arrangementa.
5
(
Component arrangement within groupings should also follow accepted standardized conventies, usually a left-to-right or top-to-bottom ordered sequence. Examples of a noncompliance are the filter domineraliser indicators (P816) that read fma right to left, and the diesel tanks an arranged in the order of 3, 4,1 & 2 from top to bottom. (Photo 1 and 2.)
i 2.5 color Coding Red and green color coding of lights seemed to be uniferely applied to valve position indication, meaning "open" and " closed" respectively, blue for bus energized, white for breaker trip, and amber for caution. Amber and white lights were used for many applications, as were red and green when applied to situations other than valve position.
On panel P816, blue and white are both used to indicate fire, P808, some "No Flow" lights are whita, others are yellow, and on P804, the 345KV Bus 301 status light is red instead of diue. The Mimic on the turbine panel has the same colors for main steam and the turbine shaft (see photos 22 and 23). These examples indicate a need to review color applications and tomalize a consistent standard.
2.6 Labels Closely related to techniques discussed above for panel arrangements is the need for an effective labeling system. Identification of related panel elements can be greatly facilitated through increased use of an hierarchical labeling system. As a single illustration, the vacuum breaker switches en panel P808 use repetitive labels under the push buttons. Hierarchical labeling would provide more effective component groupings.
Check valve test switches (P603 & P602) do not indicate the positions on the labels. (Photo 3 & 4) Reset buttons were inconsistant in that not all were engraved with "Re. set".
(Photo 6 & 7).
6 l
r r-wrw-g-s-wu
--ww--,.--*---e--ew.--- =,
..we
-e-Wmw--ewe'mg,'-
ec~
-ee*-w,--eawe
--m+.e,qyam-
,.--%e,n
,-+4y
=,
+w.p,e,_-ne,m.,m_y,,,_ _ - _ _ _, _ -,
o,.
9
In scue cases, switch labels were in conflict wif.h switch function.
For example the label on P808 says " Filter Fire" but the push button switches say "open" and " closed" (see photo 29)..The wording of a
labels could be improved in many instances, accurately stating the device function as succintly and clearly as possible. Tags are not used a the control boards but a tssique system of applying magnetic numbered buttons to the effected controls has been implemented. Each number corresponds to an ites on a status board which hangs below the operating surfaces of each panel. This system eliminates the possability of a tag obscuring an indication or switch position, which might lead to an operator error.
2.7 From the operators primary control station, all segments of the control panels are in view except the apron and sloping surfaces of P601 and P602. The trend recording and one CRT display mounted on the operators desk blocks those panels if the operator is sitting at the desk. (Photo 8) 7
(
30 INSTRGENTATICN AND HARDWARE 31 ceneral Control room instrumentation and hardware were evaluated against checklist standards addressing controllers, indicators, recorders,
indicating lights, and switches. Conclusions drawn in each of these areas are discussed in detail below. The following reconnendations are provided as general areas in which modifications should be considered:
(1) Control room indicators and recorders should be reviewed to determine which wou'd benefit from the addition of markings or color coding to indicate nomal/abnomal ranges. (2)
Indicator sa211r.5 practices should be reviewed. Cases were noted of odd divisions, sa excessive number of divisions, or scaling in units which require conversion by the operator. (3) Most multipoint recorders have no point select or fast speed capability. (ll) Better marking is needed for emergency switches such as turbine trip, HPCI turbine trip, etc.
32 Indicators Opportunities for improvement were observed in the area of indicator scaling practices, both in the scale divisions themselves and the units used. For optimum readability, it is desirable that indicators use a maximum of nine intemediate marks between numbered subdivisions, and that numbered markings be in decimal multiples of one, two or five. Inconsistance were found in this regard, and were pointed out by several operators during the course of the review.
Another problem involving the choice of units was noted in vacuum instruments with scales in inches absolute, setpoints in inches vacuum. The dual scale circular indicators had numerals oriented radially rather than in upright position. (Photo 9) i 8
The relationship between direction of control movement, and the response directims of its related indication should follow accepted population stereotypes, e.g., right or clockwise to increase, left or counterclockwise to decrease. While these conventions were found to be generally followed in the control room, a few exceptions were noted. For the emergency diesel, controls fcr speed and voltage adjust requim counterclockwise action for increasing, although increase on the related indicators is clockwise (see photo (12). In contrast, the voltage control for the main generator uses the nomal, clockwise-to-increase motion. A similar problem was noted universally with GEMAC controllers; a downward movement of the thumbwheel produces an upward movement of the setpoint tape. Nearly all operators felt that the IRM range switches were reversed. (Photo 10) Drywell cooling fan switches have high speed to the lef t, slow to the right. (Photo 11) 33 Recorders Potential improvements on a control room wide basis of the readability of multipoint recorders was identAfied even though most had not yet been placed in service. The basic concern was the lack of fast speed or point select capability, which could result in time l
delays in reading a specific point. Correlations of pen to monitored parameter is an important factor to consider when addressing multipen recorders. In nost cases different colors should be utilized on multipen recorders to differentiate markings, trat the distinction could be made more obvious on the recorder nameplate. For example, labels could be printed with the color used in the related pens.
l l
9
3.4 Indiestina Lishts Where indicating lights are used in the control roca to provide infomation on system status, consideration must be given to the i
source of their input signal, a direct signal being prefered. For instance, valve open indication should ideally be supplied from a position switch on the valve itself rather than from the actuation signal. As an important example, it was found that the position indication for the relief valves was from the actuation solenoid.
Positive indication for the relief valves is provided in the relay room by means of tailpipe temperature sensor recorder. (Plans are underway to provide positive indication in the control roce).
35 Switches Control panel switches were reviewed for adequate labeling, reachability, operability, and consistency in control direction.
When operated, a switch handle should not obscure its position markings or label, and should clearly indicate direction. A concern l
l was observed in this respect with pistol grip handled switches (Photo
- 12) and round handled switches in use on some of the control boards, their shape providing somewhat ambiguous indication of position (photo 14).
Size, shape and color coding of switch handles is an effective operator aid and has been considered in the Ferini control room.
These methods have been used to distinguish between pump and valve control switches. For example, by making a pump control switch a different type, the operator can quickly locate it in the midst of a large matrix of valve control switches. On switches with arining collars, it was difficult to tell the position of the collar because the marking was oriented away from the operator.
l 10 l
1
Certain switches, due to their potential importance, require that the operator be able to immediately locate them. If they are identical to other switches surrounding them, this may be difficult for the operator to do in a time critical situation. Switches found which could be better distinguished were the push-button type trip switches.
I l
l l
l t
l 11 i
l
4.0 ANNUNCIATORS i
4.1 General The annunciator system was evaluated against checklist criteria addresains window design and grouping, the audible and visual alams,
annunciator procedures, maintenance and the usefulness of the present alarms. Based on this review and inputs from operator interviews, the following general recomendations are provided as areas in which modifications should be considered:
(1) Arrangement of annunciator l
windows within panels could be improved, grouping similar components together, and aligning annunciators with equissient. (2) The annunciator system could be more fully effective as a diagnostic aid for the operator during major transients. (3) Some hand written labels are in the annunciator windows. These areas are discussed in greater detail below.
4.2 Window Design and Grouping To obtain necessary information from the large number of annunciators actuated during a transient, a logical grouping of alam windows is desirable. Annunciators should be located near the related system controls and indications, grouped by system, and distinction provided between warnings and informational type alarms. Generally, windows were found to grouped above related displays, although panel P816 was an exception. Within a panel, alarms were usually grouped by system but these groupings could be improved and made more discernable.
However, it is recognized that many factors may make obtaining optimum arrangements very difficult. The large size of the annuncitstor windows and the labeling made it relatively easy to read the legends from the operators table.
Many different types of alarms may be found within the annunciator panels; e.g., trips, equipment status, and parameters exceeding a limit. These are presently grouped by degree of severity, the most severe near the top, making the operators task of locating and responding to the most significant alarms during a transient easier.
12
~.
This has been enhanced by color ooding major trips and warnings and segregating them from equipment status indications. Alam windows were color coded in the order of red, sost severe; amber, less severe; and white, least severe. In addition, there were blue windows for systems in test. The blue and red windows were difficult to read unless the alam was lighted.
Several examples were found of multiple choice annunciators: RBCCW pump differential pressure high/ low, " trouble" alams, a combined l
alarm for low and high off gas recombiner temperature, and reactor water level high/ low. These types of alarms, requiring entirely different operator responses for the same annunciator, should be avoided when possible; grea'er specificity should be provided.
43 Audible and Visual Alarms The audible annunciator alarm was universally considered acceptable by the operators interviewed (see sound survey, Section 7.4). It was suggested that the alarms should be directionalized to indicate the associated panel at which action must be taken. At present there is a single audible signal in each of the three major panel segments. Each has a different tone to differentiate it from the others, but there still may be difficulty in determing the specific panel where the visual alam has occured.
Currently, an acknowledge button is provided at each of the panels.
In order to quiet the control room during a transient, the operator only needs to press the silence button at the operators station.
Placement of annunciator acknowledge buttons was found to be consistent from panel to panel, always on the front section. It was noted that, upon clearing, the annunciators do not blink but go out au tomatic.a'.ly. Unless the operator was looking at that alarm at the time, he would be unaware that the alam condition had cleared or when it cleared.
i 13
I 4.4 Usefulness of Annunciators The adequacy of alarms provided was also exsmined, primarily through discussions with operators even though there has been little operating experience on which to evaluate it.
Most of the operators suggested a "first out" feature be added to the annunciator system to assist the cperator in determining what his immediate action should be.
Secondly, a system for quickly associating the alarm windows with the corresponding annunciator response procedure is needed. It is suggested that an alpha numeric matrix be used identifying each set of annunciators by row and column.
14
5.0 COMPUTERS An evaluation of selected human factors aspects of plant computer design and operability was performed, covering the computer console, capabilities, CRT's, and typers. In general, good compliance was found wi'th checklist criteria in these areas. However, not all of the design and operability features could be covered by the review due to the incompleteness of the system. The CRT screens were large and well positioned for an operator at the panels. There was no system or program names, only log item numbers. Readability could be significantly increased by increasing contrast and reducing glare by means of hoods. The color standard being used is not Fermi 2 specific.
I l
15 l
l I
6.0 PROCEDURES 6.1 General Plant procedures were reviewed and evaluated in terms of availability, access, romat, content, use of reference material and methods of revision. Also included was a review of administrative procedures covering plant logkeeping practices. It should be noted that no attempt was made here to evaluate the technical content of procedures. Fire protection and fuel handling procedures were not evaluated as they were just being written. Heavy attention was given i
to the administrative procedure which delt with procedure preparation to assure that all elements of the check list were addressed.
6.2 Availability and Accessibility A set of the available procedures was present in the control room and sets of schematics and piping diagrams were also available in an immediately adjacent area. The temporary procedure storage system in use, while having some good features, could be improved. Currently, procedures are filed in large binders by activity, e.g.,
administrative, operations, etc. Binder color coding indicating normal, emergency, annunciator, Health Physics emergency, administrative and fuel handling procedures has been implemented.
Within the procedure binder itself, no index tabs are provided for rapid procedure location, requiring the operator to leaf through the folder until reaching the cberect page. There was no provision for
' storing check lists that would be used with the procedures such as value lineups and switch check off. There was also little or no laydown space at the panels for procedures to give the operator hands-free operation.
6.3 Fomat and Content A practice in use was that of highlighting immediate actions for ease of recognition. The tomat was star.dardized using word processing to define page spacing, type size and layout. There was some weakness noted in the instructions for the use of standardized nomenclature, l
system designaticris and the use of as-labeled names for components, systems and process units.
i 16 l
F
Diagrams and tables which are referenced in the procedure should be placed in the body of the procedure near the referencing step rather than at the back of the procedure.
Careful'. consideration should be given to the placement of cautionary steps. Generally, where supplied these have been placed immediately prior to, or subsequent to the pertinent step in the body of the procedure. Similarly, extremely critical steps should be identified, the conditions given under which instruments may be inaccurate, and the use of backup indications stressed. Normal expected system response, alam setpoints, and contingency actions including guidance on manual override should be given. These should all be included in the administrative procedure 12.07 and consistently followed in l
writing procedures and revision of old procedures.
6.4 Procedure Revision A controlled method of procedure review and revision is in effect.
However, only major changes, which change the intent of the procedure, and temporary changes are addressed. A clarification needs to be made concerning changes which only involve such things as changing notes, cautionary statements, scales or other minor items.
Operator walk through of procedure changes which effect systems is not mandated, nor is feedback to the operator required concerning resolution of recomended changes. The need for prompt distribution of revisions to the control room should be stressed. Finally, there should be implemented a system by which the operator can quickly determine the latest approved revision of a procedure at any time, such as access to the SISI computer program from the control room.
6.5 Log Keeping Log keeping procedures are reasonably complete. Some procedures need updating to include both signature and date on the checkoff sheets.
Marking of recorder charts is only requird at midnight or when replacing paper. Reconstruction of events is easier if the charts l
are marked at the start of each shif t.
Clarification of what occurances should be logged, with entry and exit times, was mentioned
(
by several operators and should be considered.
17 i
70 cowrROL ROOM ENVIRONENT 7.1 Ceneral The evaluatice of control room environmental facters included a review of,ocemunications systems, audible alams, lighting and noise, emergency response capabilities and housekeeping considerations. The most apparent area for improvement here concerns noise levels, a universal complaint among operators interviewed. Involved in this consideration are the consunication systes, control roca acoustics, audible alaras, and noise distractions as discussed below. Heating and air conditioning were only temporary installations and were not evaluated related to noise level.
7.2 communications Systems Only one PA channel is in use at the plant, for use by construction personnel. This presents a distraction to operators in that superfluous page messages continually come over the control room speaker. Operations personnel carried hand held two way radios when out in the plant and could be contacted in nearly all areas. An i
improved radio network will be established as plant startup nears.
It will cover all areas with the restricticm that transmissions may not be made in the relay room or computer room to prevent interferance with plant electronics.
At the time of the survey, only one handset for plant communications was available, located at the operator's desk. In order to talk to his assistant while operating a system, he must stretch the cord to the appropriate panel, a physical impossibility for the outer panels.
Sound powered phones can be plugged into existing jacks on the front of the panel. Permanant extensions located at the panels themselves l
should be considered. Methods of handling communications in casualty situations should be reviewed. Operator comments indicate telephone connunications are a concern and scoetimes a distraction.
18 l
l w.--
,--w--
sw--
e--
t r-" " -w+w-+
wwt'+
re-v-=e-----+-*-+----T='--e'wo'*-*-w-v-
-+e'*--
r---='C-
= - - - *
'-N
'-wr7
T-v--
- ' ' ' - ' - --r--"
7.3 Lish ting Light levels were checked at each control room panel, the operators desk, computer console, procedure file and control rom tables.
1 Based on a reconneded minimum of 30 foot-candles, levels were adequate in most general areas. However, because of the overhang of the upper section of the panels, the vertical sections were of ten shadowed. With 30 to 50 foot candles of illumination on the apron section, the vertical sections were below minimum value. If the lighting was turned up to provide the proper level on the vertical section, the glare from the apron surface made it difficult to tell if the value pushbuttons were on or not. It was suggested that diffusers be used in the fixtures to give better distribution from the incandesent bulbs. Flouresent lights are not used in the control Poom.
Emergency lighting was not checked as it is still being hooked up.
7.4 Noise Levels In a sound survey, background noise registered approximately 60 db, which is within the acceptable range. With annunciators actuated, a reading at the operator's desk measured approximately 71 db. This is acceptable for sustained exposure during transients. Consideration I
should be given to increasing the number of audible alar =s to each panel rather than one in each of the three panel segments as now l
exists. This would quickly direct the operators attention to the l
l location of the alam.
19
s.
8.0 MAINTENANG PROGDURES Maintenance and surveillance activities were reviewed only in areas that directly involve control roca operational personnel. This included operator maintenance functions, jumper and lif ted lead controit, methods of control board modification, tagout procedures,
spare part availability and general maintenance procedures. Good compliance with checklist criteria was found in these areas, although several specific suggestions for improvement are included in Appendix A.
One item should be highlighted, and that is that the jumpers used in the plant should be a distinctive color so that they would be readily identifed amid other panel wiring.
20
90 TRAINING AND MANNING These areas received a very limited review, due to the construction statur of the plant, covering only areas specifically required by the Contro*. Room Survey. However, as discussed in Sectica 11.0, the operator interviews did identify the plant training program as a major concern, indicating a desire for more detailed, plant specific informatica, and in-plant training in addition to classroce.
l Therefore, it is felt that the content of the training program should be reviewed.
A special interview was set up with the training supervisor for discussion of the future plans and to discuss seme of the operator comments. The delay of the fuel load date by more than two years was one reason for the low demand for intensive training. Assurance was j
given that the level of training was going to be increasing very soon and continuing until fuel load. A major concem by operators was i
that training had been on a "Go-Stop-Go" basis as various systems l
were being operated for flush and checkout.
l Emphasis should be placed on providing instruction for the effective use of the computer and CRTS, when they became operable, as they can be very useful tools for monitoring plant performance and efficiency as well as displaying transient data. Also, training should be provided in the limitations of various control room instrtaientation and conditione under which they may become inaccurate.
On control room manning, no deep review was done due to the plant not being in operation. Two guideline had not yet been addressed. The i
first was a procedure limiting the number of hours an operator may l
work in a given period of time. The second was guidance to evaluate the mestal and physical condition of on-coming shif t operators on a daily basis. Both issues need to be considered and appropriate procedures written.
l 21
10.0 ER ANALYSIS SIMMARY There are no LER reports for Fermi 2.
This section is not applicable for NIOL plants.
e 22
11.0 OPERATOR INTERVIEW SIMtARY 11.1 General t
A total of eight operators were interviewed by the survey team, including two Nuclear Shif t Supervisors, and six Nuclear Supervising Operators, three with SRO and three with RO license or certification (RO's). Pertinent comments from these interviews have been included where necessary in other sections of this report as support for conclusions drawn in the control roce review and procedure walkthroughs. A complete' list of all interview consents is also attached as Appendix B to this report. In this section an attempt has been made to categorize responses in order to identify common areas of operater concerns. Based on this review, the following items were found to be mentioned most frequently and as such should be given particular attention.
o Shif t Turnover - 1/2 hour should be allowed for the transfer of plant status infomation frca the off-going to the on-coming shift.
t o
Training - The present training program needs improvement.
l o
There is no training program on computer use.
o Instructors should teach systems in-plant as well as in the class room. Contract instructors do not knew the system as it is layed out in the plant.
o Pipes and valves in the plant should be color coded the same as on the control panel minic.
o Reactor feedpump turbine controls should be near the reactor level controls. "RPS Bus Tripped" alarm should be en P603 instead of P809 & 810.
I 23
o Communications are very poor to some areas of the plant.
Improved commtmication is needed between the control room and relay room and between control rocui and shift supervisors office.
o A'better procedure is needed which defines what is and is not a valid los entry.
~
o Information flow fmm management to the operators could be improved.
o IRM range switches are difficult to correlate the action with the desired result. EDG switches tum to the left to raise.
o Recorder pens should be color coded with the scale. Recorder nameplates are obscured by recorder overhang.
o Indication on back of panels and in relay room are needed on control room panels. eg RPV temperature, SRV tailpipe temperature, turbine vibration, ARM. Also need feedwater temperature indication in the control room.
o Cocponents on Off Cas mimic are not engraved.
I o
First out annunciator is needed to determine the cause of system trip. Checking post trip typer output is too slow and it takes the operator away from the control boards.
I o
RPS lights need to be on P603 o
A better system is needed for determining annunciator window number,elpha numeric matrix suggested. Blue windows have glare and are difficult to read unless illuminated.
l o
Procedures written by contractors are too detailed and too wordy.
o The chain of comand is not clearly spelled out by procedure, especially during abnormal condition.
i 24 l
o P805, feedwater and condensate panel and P806, Off gas panel were generally regarded to be difficult to imderstand and operate.
Generai~ satisfaction was expressed by the operators in the layout of the control roca, the use of siaic and color coding, the type of switches, indicators, recorders and lights which were used, and the annunciator system. P805 and P806 were criticized as being too cluttered and difficult to follow the flow path. The need for improvements in the communication system was pointed out, particularly with regard to the relay room. The area most criticized was the training program, more for the go-stop-go schedule than for content. Several indicators were mentioned which the operators felt should be moved to the front of the control panels.
s l
25
[
12.0 EMER2NCY PROCEDURE 12.1 Introduc tion Because plant-specific emergency procedures were still in the process at being isieveloped at the time of the survey, walkthrough and task analyses were performed based upon the Emergency Procedure Guicelines prepared by the BWR Owners Group (it is understood that Detroit Edison will structure their plant-specific procedures around these Guidelines). This technique enabled the survey team to evaluate the effectiveness of control room design during transient conditions in l
which the operator must respond according to steps defined in the guidelines. For each section of the Guidelines, the availability at necessary instrtmentation was considered. This was followed by a walkthrough of a sample scenario in which the relative locations of displays were evaluated. Results of this review suggest the following recomendations may be appropriate:
1.
Annunciators should be provided for all parameters possessing limits requiring entry into the guidelines.
2.
Indicator and recorder range markings should identify action levels discussed in the guidelines.
3 Certain modifications of display methods could enhance the effectiveness of the control room as an operator aid during transient conditions.
l 4.
Some information potentially useful to the operator is not imediately available in the control room.
Responding to a major transient with the current design would l
S.
probably require the presence of at least three operators in the l
control room.
26
Resolution of the above concerns will be largely dependent upon the form and content of the final written procedures. In addition, many of these aspects at control room design are intimately related to development and installation of a Safety Parameter Display System (SPDS). Et is suggested that work in these three areas must be a closely coordinated, integrated process if optimum results are to be obtained.
i 12.2 Task Analysis and Walkthrough of Emergency Procedure Guidelines As the first step in analyzing control room design with respect to the Guidelines, all parameter limits defined as entry conditions were identified. Since exceeding any one of these limits transfers the operator from normal to emergency procedure, he must be insiediately aware of the existence of such a condition. This line of reasoning leads to the conclusion that the presence of any condition requiring entry into the guidelines should be indicated by actuation of an annunciator, or otherwise called to the oparator's attention.
Examination of available alams disclosed the following points:
o Annunciators were provided for only five of the seven entry l
conditions. No alarms are available for high torus temperature or group isolatims. To evaluate the status of the containment isolation systems, the operator must check the Primary Containment Isolatim System mimic.
o Torus water level and reactor water level alams utilize a comon annunciator for both high and low level conditions.
o An annunciator is provided on panel 603 for the low water level scram trip. Similarly, alarms for high/ low primary containment pressure high/ low are provided en both panels 602 and 603 Providing separate alarm indications for each channel on panels 603 and 602 appears to be of little value to the operator.
l l
l l
27
o An attempt has apparently been made to insure that annunciator windows clearly convey the intent of the alars. For instance, one window reads " ADS REACTOR H O LEVEL LOW" instead of merely 2
stating " low wate level." However, a few windows could still be improved in this respect. On panel 602 one window reads "DIV I/II TORUS WATER LEVIL HIGH/ LOW," another reads " SUPPRESSION CHAMBER LEVEL HIGH."
From the wording, it is not clear that the second is actually the point at which HPCI pump suction tranafers from the CST to the suppression pool. In another instance one annu.1ciator is provided on panel 603 reading
" PRIMARY CONTAIN!ENT PRESSURE HIGH/ LOW," a second on panel 602 reading " CONTAINMENT DIV I/II PRESS HIGH/ LOW," and a third, also on panel 602 reading " CONTAINMENT DIV I/II PRESS HIGH 2 PSIG."
The relationship of these three windows is not obvious from the wording. In all cases, the purpose of the alarm should be made clear through appropriato nomenclature or inclusion of setpoints.
The emergency procedure guidelines written by the BWR Owners Group may be considered in one respect as a series of action levels associated with various plant parameters which guide the l
operator through increasingly degraded conditions. Thus, for the operator to adequately respond in accordance with the guidelines, the parameters addressed must be readily available and the corresponding limits discernable. These two considerations in turn require that the instrtanentation be physically located in the control room, that related displays which must be directly correlated be in close proximity to one another, that sufficient range and accuracy be provided, that instrtments be easily readable in time critical situations and that appropriate limits be marked on meter and recorder scales or signaled through alarms. Analysis at the control room design I
with these points in mind disclosed the following concerns:
{
l 28 i
I- - -
o Some parameters are presently not available in the control room. Scram solenoid lights and relief valve tailpipe temperatures are located in the relay room. No indications of RHR discharge pressures are provided at all. (Plans are to provide positive indication of relief valvo position in the control room) o The bulk torus temperature recorder is placed across the room from all other related indications. (Plans exist for relocation.)
o A multipoint recorder has been used to display drywell and torus air and water temperatures. Alternate means of presentation may enable the operator to obtain data more quickly and easily. The use of a fast speed and point select capabilities should be considered.
o The guidelines require the use of bulk suppression pool water temperature and average drywell atmosphere temperature.
o Certain steps within the guidelines address limits which may require instrument ranges in excess at those currently used.
Because the actual limits are based on calculations yet to be performed and the scales at many instruments are presently in the process of being changes, this consideration could not be actually evaluated at the time of the survey.
l The operator's required response during transient conditions o
calls for monitoring RPV water level and pressure and containment temperature and pressure fmm multipie indications.
[
In the current control room layout, related channels are of ten separated on different panels, sometimes in slightly different arrangements (as on panels 601 and 602).
29
o A given parameter covered by the guidelines may possess several action levels. Suppression pool level alone has at least eight limits of concern to the operator. Limits e action levels of immediate concern to the operator should be marked in some fashion on the indicator or recorder. This may include such points as the top of active fuel and two-thirds core coverage, nomal operating limits and vacuum breaker elevation for torus level, and low pressure injection systems shutoff head for reactor pressure.
o Some limits discussed in the guidelines are "two dimensional,"
i.e., the operator must correlate two different parameters and plot the resulting operating point on a graph defining the pemissible operating regions. In a time critical situation l
this severely compounds the operator's workload and requires careful design of both control room layout and procedures. The j
two parameters involved should at least be situated in proximity to each other with the associated graph provided nearby.
However, a more innovative approach may prove more satisfactory, perhaps involving two dimensional CRT plots or X-Y recorders.
This area of the guidelines should be given extremely close attention as actual plant specific procedures are prepared.
Potentially of most concern in this respect are limits involving torus temperature, as the bulk torus temperature recorder is located across the room on panel 808.
1 1
s 30 I
13.0
SUMMARY
The conclusions discussed in this report are in general applicable to all panels and are presented with the understanding that must be considered for all panels though only one or two examples may have been liated. The frequency varies from panel to panel with P806, P807 and 816 showing the highest incidence of evaluation products of six or greater.
Use of mimic, lines of demarcation, and diversification of controls has been used effectively to assist the operator on panels where instrument density is heavy.
Improvements can be made in areas pointed out in the action items where mimic is missing or color code discrep-ancies were noted. Many areas are receptive to additional grouping or similar controls or segregation between systems on the same control surface by demarcation lines.
Label practices should be reviewed and erroneous or misleading labels replaced.
The feedwater and condensate panel P805 and the off gas panel P806 received the most operator criticism. They were considered confusing even though there was ample use of mimics. Engraving of the equipment symbols on P806 would improve the understand ability of the process flow path.
Moving recorders from back panels and from the relay room to the front of the control room panels will bring information to the operator which would enhance transient response. As the various systems are put into service the normal operating ranges and alarm points should be marked on the indicator and recorder scales.
31
In stamsary, the Fermi 2 control room was found to show attention to hinan factors engineering having many good features. Some potential areas for further human factors enhancements have been identified.
I l
l i
I l
l l
32
Appendix A The following list is a compilation of all checklist items for which control room enhancements should be considered, prioritized by evaluation products.
These evaluations ' products represent the product of numerical ratings for degree of compliance with checklist criteria, and the potential for non-compliance with the criteria causing operator error. Within each category, the concerns have been grouped by subject, according to checklist headings. The specific checklist item is cross-referenced for each item.
This appendix is presented as a list of human factors design criteria which merit attention in the present control room; it is not intended to be an all
~
inclusive list of specific components. However, it is tmderstood that enhancement action will be considered on a control roaa wide basis.
No specific recommendations for enhancement action have been given here.
Resolution of these questions must be performed as a solution to a set of inter-related concerns, sometimes in conflict with each other. Considerations should include engineering practicality, possible detremental effects upon safe operation due to the change itself, the importance and frequency of use of the components themselves, and the consequences of required operator retrainirs.
33
Enhancement is Reccessended for the Following Items Based on Evaluation Products of 9-12 A.
Panel Layout and Design A2.2 Demarcaticri lines would enhance the seperation of seal oil control from lube oil controls on P804.
A2.3 Mfalo added to show the interconnection between the valves and the thid system would improve the operators understanding of the system
'in P806.
A3 3 The relaticrtship between the radiation alarm light and the reading on the multipoint recorder is not readily apparent on P816 (Photo 16)
A3 4 Lines of demarcation could be used to seperate the control matrix on P806 (Photo #18), P808 (Photos 19, & 20) and P817.
A3 5 consideration should be given to using hierarchical labeling and demarcation to identify the EDL/ fan relationship on P808 and Diesel / fan relationship on P817.
A3.6 Panel P805 has indicators which are located outside the anthropcmetric guidelines.
A4.2 There is an inconsistancy on panel P816 on the color of light used for indicating " fire". Blue color is used on an adjacent panel to indicate " bus energized."
(Photo 21) On P804, the inconsistancies are in the mimic colors for (1) exhaust steam from the HP turbine (photo 22) which, according to the Fermi standardized color code, should be azure green, (2) main steam from the control valves (Photo
- 7) which should be moes green and the turbine shaf t mimic (photo 23) which should be a cole other than that used for steam.
34
B.
Instrtamentation and Hardware B2.1 This guideline deals with marking of indicating devices to show nomal, abnomal, safe or unsafe, expected or unexpected ranges of operation, and nearly all panels were non compliant.
B2.2 There was glam on all panel apron sections, however P816 seemed to be more than any other.
B2 3 Inappropriate scales were found on a number of indicators. The following is a listing of those for which corrective action is reconsnanded.
P808-SBG flow in percent, reactor bldg air temp in percent, turbine building atznosphere d/p in percent, turbine b1dg air temp in percent, I
reactor bldg control center d/P in percent.
P809 - All voltmeters scaled 0-1507 regardless of bus voltage.
P810 - same as 809 P811 - same as 809 P817 - SBGT flow in percent, reactor b1dg control center d/P in percent.
P602 - Drywell pressure in inches H2, EECSW Hx flow in percent, 0
post accident reactor pressure in inches H 2, diesel service water 0
flow in percent, drywell pump level with no units.
P603 - Core plate d/P in percent, steam flow / feed flow recorder no units, feedwater flow through startup line in percent.
P804 - Hydrogen cooler temperature scale 0-2 x 100, main steam to RLL in percent, condenser vacuum in psia while trips are known in inches Hg.
B3 3 All panels with recorders were noncompliant with this guideline to have the alam point identified on the scale.
l l
B3 15 All panels with recorders were non compliant with the guideline to l
have the recorder scales marked with the nomal or abnomal, safe or unsafe, expected or unexpected range of operation.
I 35 l
C.
i C2.3 Annunciator windows with blue color were not easily read when not illuminated. The guideline statts that the annunciators should be easily read when stationed at the panel. The panels which were of 1
the most concern were P601, P602 and P806.
C2.7 This guideline addresses multiple choice annunciators. All panels had some degree of non-compliance particularly P809 and P810.
D.
Procedures E1.5 Storage space is needed for extra check off sheets, valve lineups and instrtment check sheets in the control room.
I j
E1.6 The guidelines suggest a procedure be placed in the control room for the operation of both mr.nual and automatic controllers. This procedure has not yet been written.
E2.3 This item of non-compliance is regarding the need for an index in the front of each procedure binder showing procedure number and name.
E2.6 Individual procedures should be seperated using index tabs with procedure name on each.
E.
Maintenance and Surveillance G3.2 This guideline requires that permanent modifications be incorporated into the operating procedures. This is not presently done because of the continuing construction.
F.
Training and Manning H2.1 A procedure has not yet been implemented to limit the number of hours an operator may work in any given period.
l H2.2 A procedure has not yet been implemented to evaluate the physical and mental condition of on coming shift operators on a daily basis.
36
Enhancement Should be Strongly Considered fe the Following Items with Evaluation Products of 8 B.
Instrtmentation and Hardware B2.5 Pointers on indicators obscure graduation marks, numerals or process units. Photos 9, 24, 25 and 30. Panels most effected are P810, P811 and P816.
B2.7 On P810, EDG control turns lef t to raise, indicator moves clockwise.
B2.18 This guideline recommends that multiple range meters have color coded or marked scales for differentiation.
B3.5 There is no switchable high speed on trend recorders or on multipoint recorders.
B3.6 The multipoint recorders do not have a point select feature.
B3.10 There was no indication of pen color associated with the recorder scales in some cases, although work was underway to upgrade.
(
C.
Annunciators C2 9 Annunciators should be provided with alpha numeric code in addition to legends for prompt response and positive procedure identification.
C6.4 Alarm lights extinguish when alarm clears rather than flash at slower rate as reccmended in the guidelines.
E.
Procedures E3 3 The procedures do not require that as-labeled designations be used for components, systems and process units.
F.
Control Room Environment F1.6 This item of ooncern is that the control room communicaticn system is not designed for hand free operation.
l l
F1.7 Only one channel of radio communication is available in the control
(
room. The interoom is a construction communication network.
37
Enhancement Should be Considered for the Following Items Which Had Evaluation Products of 6 A.
Panel Layout and Design A1.1 Some control room and back panels had indicators and controls outside the anttimpcmetric standards. Scae consideration oculd be given to relocating those which are most frequently used.
A2.2 More use of lines of denarcation to encicae related displays would enhance operator efficiency.
A2.5 Some graphic displays have symbols which are not engraved for identification, for example the off gas recombinerc.
A2.10 Graphic displays are not always complete with start and end point.
See photo 26, main steam on P804 has no start point. Photo 27 mimic on P806 incomplete.
l A3 2 Order fcr some components does not follow convention of lett-to-right, top-to-bottom. See photos 1 and 2.
AS.1 Auxiliary boiler duplex meters should be labeled as to which pointer is assigned to which variable.
AS.2 control air pressure to dehydration unit #2 is missing a scale.
AS.3 System designation is not generally shown on instetanent nameplates.
l A5 10 Incorrect label P808. " Discharge" misspelled, incorrect lines for
" Filter Fire". See photos 28 and 29. P807 south feedwater valve control label has misspelled word. P812 need nametag to indicate pen color / input signal relationship.
l AS.11 P804 key lock name tags are above the switch while convention is to place tags below. Also positions of switch are not marked.
l 38 W
l A7.1 &
Viet of desk sections of P6C?, part of P603 and part of P804 are blocked from viet from the operators normal station by CRT and trend recorders. Photo 8.
~
B.
Instrumentation and Hardware B2.8 Correlation between ARM alare lights and recorder point is not clearly defined (Photo 16).
B2 9 Relatively large gap between indices and pointed on some indicators.
See photo (30.
B2.11 P602 wide range water level sale incorrect. HPCI suction and discharge pressure use same scale, and suction pressure will be pegged low when operating. Limits of scale for post accident reactor and torus level not numbered. See photo 31.
B2.12 Scale graduations greater than the recommended number in the guideline (nine) occur on many panels. Thcee which were noted as being the most non compliant were P603, P807, P810, P811, P816.
t Examples on P603 were CRD charging pressure, 20 units; Recire pump seal pressure, 25 units; reactor pressure, 20 units; recire suction / discharge pressure,15 units.
B4.1 Blue power available lights on P809 and P810 are not highly distinctive when lit.
B4.7 P601 relief valve position is implied by the state of the solenoid.
B5.1 The following are examples of switches which do not operate in l
accordance with expectations. P603 - IRM range switches, P804 see photo 46, fast to lef t, slew to right; P809, P810, see photo 12, raise to lef t, lower to right; P808, P817, see photo 13, high speed to lef t, low speed to right.
I 39
._ ~.
l B5.2 Switches do not have positions clearly marked. See photos 3, 4 and 5.
Panels on which this item was given a 6 evaluation product were P602, 603, 804, 805, 806, 809, 810, 811 and 812.
C.
Annunciators C 1.1 Annunciators not in annunciated box by specific system or not above related controls. P807 fire pumps. condenser water box temperature, condensate pump alarms; P806, circulating water pump controls; P811, relay house alams.
C 1.3 Panels P809 and P810. Auto close annunciator in same grouping as trouble alams.
C2.1 Hand written alarm notati m on P809 and P810.
C2.8 Not all tmuble lights are colored P811. On P601 see spare nameplates are yellow.
D.
Computer D3 7 CRT display items are identified by log number rather than by system or program name.
l E.
Procedures E1.1 A full set was not available in the control room because they are in the process of being written.
E3 2 The use of abbreviatims is addressed in the administrative procedures but the requirement for proper gramer, use of synonyms,
acronyms, and proper terminology was not.
E4.11 Charts, graphs and diagrams were at the back of the procedures rather than integraded into the body of the procedure as needed to directly supplement steps.
l 40 1
i
., - -, - ~
l l
E4.19 Procedure prerequisites referred to other procedures as an entry condition instead of standing alone.
E5.1 Procedure referanos contained items which were not available to operators'.such as ANSI standards, FSAR, Reg Guides.
t I
E6.1 Revision procedure do not provide a controlled method to assure
(
operator walk through to verify correctness, understanding and l
ability to use.
I E6.3 Feedback to the operator regarding resolutien of recoinnended changes l
was not assured by procedure.
E6.7 Prompt distributial and updating of control room procedures was not assured by procedure.
E6.10 The procedure for incorporating minor changes such as to scales er process units, cautionary notes, charts, graphs etc. should be revieved for clarity and understanding.
F.
ENVIRCNENT F3 1 Lighting on the "C" surfaces was determined to be below the guidelines when the "a" and "b" surfaces were within the required range.
u F3 2 When the lighting level was raised to provide ample illumination of the "c" surface, there was glare from the "a" and "b" surface.
G.
MAINTENAN
& SURVEILLANG G2.3 No approved jtaper of a distinctive color was required by procedure.
41
Enhancement May Be Beneficial for the Following Items, Based on an Evaluation Product of 4 A.
Panel Layout and Design A2.4 There are ' opportunities fcr the increased application of lines of demarcatico to distinguish between primary and secondary flow paths.
A2.6 Some mimic is missing on P806.
A2.9 Mimic lines should have arrows to show direction of flow wherever applicable.
A2.10 Mimic should show starting and end points.
A2.11 More demarcation lines can be used to integrate switches, pumps, valves, flow paths etc.
AS.4 Labels cr legend plates could be increasingly used to identify panels by function.
j A5.6 Labels and legend plates are not consistant in lettering e.g., white on black vs black on white.
AS.7 An opportunity for hierarchical size coding of labels exists on P816.
B.
Instrumentation and Hardware B2.6 Casing gas pressure indicator on P804 moves opposite to the l
guidelines.
1 B2.13 Scaling subdivisions are not consistant with the guideline practices of 1, 2 or 5 divisions.
B5.8 Labels below recorders tend to be obscured by recorder overhang.
B5.10 Throttle valves are not distinctly identified on P601 & P602.
B5.11 Switch handles tend to obscure switch position indication, making it d'.fricult to determine the position of the switch.
l 42
C.
Annunciators C5.6 There is no first out feature fe high priority alarus.
D.
Capu ter
~
D3 4 There is no Fermi 2 unique color standard for CRT displays. GE specification is followed.
E.
Procedures E4.13 Procedure content could be improved to include expected normal results such as ficu rate, current alams, expected normal, etc.
E7.4 Include an instructim for recording and logging verbal instructions and feedback en execution.
F.
Control Room Environment F1.8 Ccamunicatim system is not physically adjustable for individual users.
F6.7 Provision for handling of telephone communication when the operator I
is occupied should be considered.
F7.7 Seating to be used at the consoles is not height adjustable.
l l
\\
l I
k 43
Appendix B The following is a complete list of all operator coastents. Repetitive items have not been duplicated here; see Section 11.0 for discussion of common operator concerns. The responses have been abbreviated where possible and as sudt are not verbatim. However, the intent of the reply has been adhered to as cicealy as possible. Refer to actual comment sheets for detailed responses. No attempt has been made in this section to judge the validity of the operators' criticisms or to make any reconmiendation fe action. All coastents are mpeated here as a means of transmitting operator concerns to plant management for further review.
Panel Layout and Design Color coded gage bezels would be helpful.
Color code values and piping the same as on the panels.
Reactor feed pump turbine controls should be nearer reactor water level controls.
P805 is very confusing.
Some recorders are too high to be read by a short person with bifocal
(
glasses.
Changing chart paper on high recorders is difficult.
Torus water temperature recorder too high.
Mimics sometimes do not identify components fr example, off gas.
There are too many water level indicators on different panels.
All feedwater indicators should be distinctly marked fe quick identification.
1 Seperation requirements cause large distances between related components.
l Operator console blocks view of panels to the lef t from normal j
operator station.
l Intensity of red and green lights in valve switches is not adequate on some panels with a lot of glare.
There is too anch mimic on the feedwater and condensate panel and on l
the off gas panel.
1 Some labels are poorly worded and difficult to understand.
Markings to seperate systems and similar components could be improved.
6 NN
l a
Controls or Instrumentation Needed in the Control Room Neutron monitoring system should be in the control roce.
RPV temperature recorder should be moved fra the relay roam to the i
control room.
Safety relief valve tail pipe temperature recorder.
Area rad acnitor.
Turbine Supervisory should be out front.
Feedwater temperature indication is needed.
Scram solenoid lights should be in the control roce and in the relay l
room.
We could use a first-out annunciator system.
RPS bus failure alam should be moved to P603 from P809 and P810.
TIP recorder should be in the control room.
Instruments and Controls Which are Difficult or Confusing to Operate The IRM range switches work opposite to what was taught. They don't l
correspond with the desired result.
The emergency diesel switches turn to the lef t to raise, right to lower.
t Area rad monitor lights are difficult to correlate with recorder points.
Instrumentation Hardware The multipen recorders do not have good correlation between pen and scale.
l Recorder paper not matched with indicator scale.
Backlighted indicators are hard to read.
Too many parameters are measured on one recorder.
l Iabels under recorder is hard to read because of overhang.
No point select capability is available on multipoint recorders.
Changing recorder paper is difficult on recorders mounted too high.
Annunciators First-out feature is needed.
A more direct method of determining annunciator window number is needed.
Annunciator window location for same alarm should be standardized.
a Colored plastic covers cause glare, especially blue labels.
Some labels are ambiguous, "TDR Scram Actuated" P805 45
Annunciators (cont'd)
Some could be better grouped, i.e. condensate system.
An operator wants to know imediately what scramed his plant, not go i
through a shutdown and then consult his typer (in support of first-otit feature).
If there is a problem, too many windows will light up, too many nuisance alams.
Annunciator audible alarm too loud and high pitched.
Operator must abandon panels to consult typer to find cause of problems.
Procedures Operating procedure include too much detail,should only have specific instructions.
A formaal sheet is needed for verification of equipment status and valve lineup.
Procedures are too restrictive, allows no room for operator judgement.
Index tabs have numbers only, difficult to correlate system to proesdure.
A standardized procedure is needed for what constitutes a valid log entry.
Control Room Environment Commtnications is needed between the control room and the shirt l
supervisor.
Connunications is needed between the control room and relay room.
l Two telephones are needed at the operators desk.
1 Glare makes scoe annunciator difficult to read.
l l
Control roan congestion is always a problem, especially during a casualty.
Temporary radios are marginal and can not be used in the relay room.
A multichannel page system is needed.
Many areas cannot be reached by radio.
1 46 l
l
- - - - - -.., - -. _ ~, - -.. - -
Training Training has been erratic and infrequent.
System training is self taught because the instructor don't know the layout.
Need more in-plant systems training.
There is no computer training.
What little training there is has been Stop and Go.
A refresher on theary is needed.
- An even flow of training should be maintained.
Manning There appears to be adequate coverage with the present manpower plan.
We will know better as we approach startup.
Shitt Change Thirty minutes should be set aside for shif t change.
Additional time should be paid for required reading, reviewing procedure changes, etc.
A half hour overlap is needed with a written turnover sheet.
l l
l l
47
The following issues were not included in the Survey and should be addressed 5
at a future t.ise.
1.
Section B1 when controllers are put into operation.
2.
Section B2 when indicators am put into operation.
3 Section B3 when recorders are put into operation 4.
Sections D2.4, 2 5, 2.6 on computer capability.
5.
Sections D4.2 and D4.3 for alarm typers.
6.
E13 Insure a complete set of as-built diagrams and schematics are placed in the control room.
7.
E1.4 Place a set of up to date Tech Specs in the control room.
8.
When emergency procedures, Health physics Emergency Procedures, Fire Protection Procedures and Fuel Handling Procedures are written, review them with Sections E3 and E4.
9.
Review the communication system that is installed with Section F.1.
{
- 10. Review energency lighting with section F6.8.
I l
j
- 11. Review control room heating and ventilating with Section F4.
1 l
l
- 12. Review fire fighting equipment, protective clothing, breathing apparatus l
and portable radiation monitoring equipment with Section F6.
- 13. Review control room noise levels with Section F7 when the nomal heating and ventilating system is operational.
l l
t
+
l a-
- d e w Nr E
y w ---- E-3 3-m
+
7 jp g, _..
- p. 3,
..e w g ~.
r-j x
_ 7 x-1 n.
w 7.is) m.
o
=,aa
.. g t.,
.u. r, 1
3 e.
m-i E
E g
i 4
hF e
.v<
E.
-Q l
p3 l
Nk N
. h; ! {i t W h !
i J U ki
' t fr \\
1 l
rhctes
- r. c, 2
? CP :r.er.t s q ;or.:es to nct *' ;, ; cw 3 t 3,q j n,q y p.jg g ;;.q3,
l l
i j
l l
l l
)
i l
1 L
i
.?
l. ~.
'.;$,W *J &
I
.." [. g : l a)Wf.lyldN; k
..4. y ; M. 2_f
~J. q *.
- q.. __j.[
y tt
_.l
..s,
.x y
w k _ L,
.,a
~.' - ',.,-
)
. W '-'
1
.;- - r,m,...
. A. g, y
1,
,1-s
-v.s y
. - N, 4
t ^
- f.. '
j r*
q
-is m.,.
p
.4 y*
g-
~
4%
.. ';3 4 g; -
n-as f, ?
4-,~
}
h E. '2 * ;
j' '.
r 3
g,';,gy a
sui
,. s
.. t r-s e.c,
g..
y-g.
,.. l ',, ','g
, y; I
1
.* ~. _ ;
'e s
j_
3 agu.n,c,e
_., gq;s
.g,3.,, -
-a og,.
_v 2
g c
.
--s
- g. w L
w. a.4 p
=
k
.ese aWIBO est d
I
===y,_
-m. w w s
3
M
. 7-b~,.
5 i
j
' r
- ~. g.: *. $.,, $s n %',~ ;. t..+
M
+
f,ty *,Ih;) 'l (f
..iT
,;.v
.j'}. ( 's-J[3 p.. ; $
P
~
.. ~..
..w;c,
l }
'l.' '
e m
-c.'. - <^s! re. -
j'
~
-[
,..,h
,_~.,,
g
-1 g+
.5
., 1..
g.-,
,a s
y
-lzh ' ';'_
g.
. R 'V' Q
f'*
^
t_ _ f,.,
k ~t.. -
.pj'.l-y
\\
.1.1 i $;;3; c.
e
,n.p l);y,. g_ eyg M
/t ~..
_n e-G f
.. -+
y c,.
p,;c P5Lu i
i
\\
(
l l
l l
l
)
'hotos 46 2nd e'
'e3at t u t t 0 r.3 wer e 0 ' inconsi3 tent design, l
l
c.
,4
-[
.i -
p e
,s
'F
,, 9 y
Y -
l ' f.,,
y ie c,
. (,
l i
,v y..
&,. s 4
r g:.. g.,
e
'
- p y
m t, g
.c s
~
y
['
'l i,, * - y
+
's g. <. -
,, j
-~
4-
. 7 + +
,o p g.} '
. g
.. s
~,
q,
- c-
%s
.t
~ ' s e,
., -g,
N y
.s.
'o ap <
u,,
2 g.
n c,.
o
+
w
~
.t.
l
'~
( _ T h',y,.
.,f
... eg,
.y
(,
.u.
y
... f~. ; -
~
3
,,. r,.
+
73 f -
., 7,25.,.
s
,i
?....
%,+.
r s
l
.2,
.i}-
f
<>j.
}. -.., '
..':... O c
?..
y
- r t.
-'.+.,.4..
s
,n f,y
- 4. e r
+
st g-
> i _ ' W*.: ',
'k g
.. l :W:
- *4
(+
L 's 4
e,
,,, - ~,,..~
~
4 d-
)
g3..
y
, ', $. o-i 3
g j g..
e
, -, +
-v c5.-
2 e4 4 4
s%
g.
,h,f 1
3 g
~
g_ _
-f[,
W-
.t.7. ( **% J.
'..t..,,,., ',,.%,
.y f9*-
-.; c.,,.., f, '
l
, y.:.. :
4 c.
K;
,.m s
2
.. )w.-...w
..6 r
.y..
W
+ *
- b. >Y g -
g
. y e
4 w.
w, i
.y -
e
,..e
,y.
=
N
<^ f* '
(-
y.
l
- U,..
-'.~:.
- Q N,
~
'MM + ne= _w s
V p
y' e
~
~
. +
'f v
I V
.b
. #*" p
_ ",. ' -f
.j#
J
.'- p
^
bl-.la ?T 5 p,.
h, PT
% % Q ' '..
L
.. i", p
(
W. ;,
n...
j.
t.'.
.r-s g
... 7 4
t l
.: e f.
.s q
3 4 fe.,.
4pu l
, w
~;-
y
=
M
.;W j:
Y
~
a t
9-
.x
. 4..
3
. aq
+
.,,f
~
w s
g '.-
~.*
+
..t I
2* '
.L
~
..i - -
z
' +
+.
l.
.~
- c..,
r
?
~.
~ -
% (3
{
4 4
~ gg
+
y s
e-
~ '
e
. g.,
t v,,..
r
. h:
y c
c 7
q 34-1'
. r
., y
't w-
' g g4 4
7'
'4 s.
. - 9
,i g
, +.
3 g
.. i..
,i W..
1 4
.s g
3 e
- e
^
,s j, ' '.
-y,
[ '
Is'.
4, j m
.. c ' %.,
4.s '
+ -
w t
),>
t
'- )
w
+
9
.M.
A
...f.4 s
E s,.
l i
f ~
A y.
.s.
., ' m
,4,
?
l F
,e 1
~~.
n 4
~ 9 W.
\\..
+
1
~
~
gg g,,e
+
+
/
n w
..s.l.'.
.,\\
...s..... y.., f ',., (( y ',g:; = f,K d.x
- p. 'g f y 7,,9 g., n, r
[ g.
a
,m Y
kew 'n p
w 6
m i.6 i
i c,
-i --
s.i i i ii
.i.
i - -
ii--
ii
. i i
=,-
., - ',, A g.
.I
.4
,,9pM.-
.uk
- ""-9
. ',f.,M; y
/
., 4 ' ' [? '
[,'
,., ' sp
- y,
_r W ' {.g
.;..y y,
[,
'e
-, ' - r
'., -i.
14
,I7,
I' k.**
g
[
'.e
' 'f
. 5,,a%
, #4'* C.'
t f,p'
.e
.pa :.
5 n.
- y
... w-4
.a-y
%,. "y. - r,. ;.,
.,. y., k
_g ais',.'
8%*.
4 - yt,
.q q 4
I
,.,if;k %;O g [m.. Qgg f ' ' I j'* 8 Mg. y '., %g,.
J.::,. L,a-
'. a p a M( w ;m.
2:. 4.4.: - '
Mp.
h,$ p' h.
m
.,. w m,7',.c 1. ;',q.A.if.ya. :.g.' v.. ngy*:i'.w
.. s
'.I a,
e W
b.t
/
.,O. '21gx...+; n..a y '*
I.
q ) ' g. h,-
p. ' / -
.3 ha,
.,,7 3
glp
- 4
?'
4p
[3.,,
i d.
'Q 4
Y Y
.,gg.-4 5
3
}_.
l.
k 5
.'e.
4 '\\
't-g y), r f.'
y J r I
W L i[. ~.
l.
U
' '.. ;[
i
. T' '
I
'((. *
,,.e*[
'. ~ t.[,
"l-
~ }f'.{ s, -
4
^3
'..I'.
f.
4 -}.
-,M Q* y k - *
- T., V:,.{
y'[ [Y
-M*'
4
'8-e 4),
b+
q 6
..g-
. ;d
. 9 4, 4
.)
4 f
(. I h k
4..
3-
,7
'g' '
~;4
% = N.
e k.-{ 7.)uw (y,
"( [$ $
g...
.a
-- +
p as r,:*.
g..,
i 3
kf, }
./
f f.If l' '
hV-s ::p. #.
,. - ~
pg,;+.a py < - f[,;"..':%
.y
.. -.... "a. h T.
s.y p%yk...
ab.
Y' ~{.'
h
.~
. y-
,w c'
_s,.
. 1 8'. /. r.
g', - +'
V'e b
'i i, -
4,
.s ? r
?
G i.f g
. - N k>
f.
N k
p.s
- \\'
}?
b
'v
%,,I f,.'
e,.
~
- y..M*
.... v:
,.. ~
y.
h
?
p6
.6 N
.s.,
c 2-i 97* ' l 11ge' v4, 7
s.-s
- i4
.'A'.',',8
- Q,..s.
a s.
r w -
y;..
y.
w..
- TA
'k.**i;+
- a
'1
- s. k.- y.
. u,,.
! n 1
w.
- 4..,g>;e,
+
f g,g,g
'a y (,:.
.g"[. y;,..
(
y
.v <
'.. W s.
,z
. w.
. t.w -
Sp &, a-Jg._...... _" t Q,.
')
., c..
f.;. :.'.
/
?
g :,, s
. p4.
3..,
s..,
_g 1.r y-r.g 4 f.,
.: - f:. %...
e
' M$gk ' h.. \\
-k
- g,p %
. pk % - e n : -
b.
Q[fphll Q g? 3<14g
- 4 % &'r.MWf yQ' _ y &. i
'['
gf
^ Q:
~
s>4-
, Q :;.
e,y p[.,..y -*:~.f,.;' ' Q ; j
- y l
g9h
. z.ug :
iW
^^j
' %Q. ~
- r. g 2 L Qe_ '.: %;
&.!y.P1 V
~.3.. %.*u
. M.4..-.
r,w+ s *
.. ; r.g. '; %
.a, r* L. t.ie g
,y+v.;-.,
- +s-
.a+
- 4.,
,* C'; -.,..,'.;' ' '~, ' *M
);
1 w..A m
]y ;.;# - --. l : ' M,. <:.
g*,,
- ,. &[.
r, ;,,. %
g.r@n,x.w:p,,.
~..
,,.4 1
n~
v
- % ' ;. ~-
~
&.4,w ~ ; '.,. ;
..,ka.:
.n.s
. 4
~.. g.<,
a s, %
%.=y
.,... >., _,., n w.,
-f?'f{' i.,.
f n,
~
l ~~
?
- ; [ x..,_.
.y'.,
w&, :. Q. wk, ' Y _r.[
3*
.4
?
e ~,,i. r
- u.
7,
=,..,
.s e'
' si, ' d.
,k.'ij! # e.j[ s-h, 7 =,
.,s
.i s,
. Br*
3 '/... e ->
, 7 %.,'. -.
- - lf
-r'
- ? My 7
. l Q:,., p+. C ' f. A.
. - ~%
N
-n!
s R..
q.3 *..\\- j. Tn,,...t,, >* r r2 M g.
,'..~c-7
- ..=
c.Q% A,!., '
-..Q g.
as
,L.
- q; l:
'n.
f.y...,,,?
+
%q yr
- s..
4t
..o+ 4,g*.,'<,-e,*Q 4 !r.4
...- s
- '.. p
= -- a$ ?s.
s,n.. yy1
,-:q -
r w.1
.r.
..,,.. g
-t 7ss - ;..; *'.,
4.l g. % y,%
- 4 r
s g,
j y.,, 7 g..
- p;,))m..
.-..4,.
.' t
~
"o
.w.
- f. [.[
~
p3 MJ.-
- yp ', _;{./'
, ? 'n Q.gr l
~
er s.$..,,e c..<,
c..
4
., ; q
& \\g' l J.f..,f. ;,. h.~. p..j_f.....}[ J.,QQ.7.- V:k.
4
,p ' $ f..
_ Q. 3... r g?p. % ~ ? g.;!Lj.,Q.}l.,ppQ.p 4
a W.%.*.%
- n. i n @ c *.
. -,.... 5
, v
', %g...
~ 9 M.
f,."..< -
. ~:
- ' J i
.+.t. '..p' C p.,
4 99.o.$pg:k
~
4
,J:.;,' %e.
A,*=
&,..'.$.w-
~% :.,
,.v.
, ::)..
s.
. y.
u
-% g -
.y
+
'?
- . r Ag. <.
.c.
- ..<a a
.r
,r
. <...,a. s. ?.E
+a
. -. f' g - 1 sp j..
>..a,
. r-4 1p
=>
- '.*g>-=.p,.
sh' sh2' ~:n
- .y-; - s -
d@'-'. ' 'v t
,.~.,'r.;'*' " g'W.?;g,g' Y
?
. wa..,,.*
4*l
..T+'
,,s r
'?
fr
. [l
- J.-)
%U
. ga. "
V. W-y -
4
- l $('..;l ' 5.
-Y" I-
- >$(
'se aE,, -'*
~ '.i. j_.,.. -
., j
}h
+
3
,.q
$.g. y* ?., $ - Ql aV,'.*.s ',
~
9y s -g 3~ },
s,e.,. e,,.
n.
,.,. s.:..
l, ft.
&'%', ~' ~ ':
't
..q%..,. N. '.*lA',,...' il' c., y<w,.,'
' v'
-.. ~
+
a a
.%; e a.%
s
.v s
o.
. p,
- e. n., -- Q..,.. - -
u n
g,1.,
._.e
~. & &+q,.
- g :w_ f.. v.*.,.'.y.,a,,,;.... ;.z _;.
.%.1
, s > '%.c.. ?,9,,.;
- 1.,
9,.:. -
....way
.,,) /
.p
..~. 4 2
2 -
+
y v.q,n. - :. -
. a, g. p :.
a.,:~
-9
,0
.s 1.
4 3
u
$ $ $ M _h.yh%, $h., g[h)
? ;-
.b
. / y, rm ? g%
, g%;.,-'; ^.q.:Q '
. q 4. r rWJj %. (h-..,
s
..;.4,
( h 3.
y. $ 1. $.,fD M v..
+
A:
.. *^ ~
%.~
2 p,.
[
n.,...
u a
v.
% %. 4 c., e..
u
~
..g--
',., 4...* m,'; 5,f $M. bi' Q
w.
J B ' 9 ;. =,; e N,
~
p i
4.;
..-a w
.. e
, ' ~.
...~
, 2,,,,,,,a,.r
.o
... ; L
'.4 sv 1
u.-
~
_..v.s,
s e
' ^.
Y + r
.s.~
u e~
4
','2.
i^
~
, h,*
+
s ;n -
1{
l, ' _
% ~..
- ~.. -
'Q,
%)g.
g'4, 4
tu-s.
..1/j...
r$,,
t.
~<
^
.. 4
.?.m-N 4
1..
+ '
+- -
e-3
+
+
.E-r
,j.
e-
, +
gx -
/~
~
3 g
(
MI '
'a
+
9
(
- .. -- A sm er
, y'
- '-+
e 3
-J.
+
.qg u~'.,
yr
- ..,p
.t
.an 4-
,,Q r*.
4 n
- 9... > 8, #+
v r.
g, ).,
%.- m; tg,;
'l; a'
+- '.
+
O r-sc v.
s.
i y
- x
.pg m.
l
.+
, w
...y'.
, e
- . Q e....
1, i p
~..
i*
y e-x
(
,-p.
c
.,,,a
)
I e
c.-.
de g,,,
d
,c
'e e g W
Q
,yJ 7.. m ;- -
an
..~.
- jpg,
- - V, p.
%.=
v 3
f
.2.
. j y
4 s. 5 t
.?,-
t.
e.
m...
. y u.
n, r
p.
~
k 98.
s J.*e
- 4,E n
n, C
=*
t,A-
- a.
- 49
. p g..
+
+
t
.w.
w., r... t,.,.-
.A s
Y n.
en
.w ',,
4 s
-. p-404 l
a' s.-
g... t,.-
T gy 4,.-
2 7.'
'*Q
,, y y-y'
+
+
+
2"
..WF...
_ y
+4 g
q g
. 4
.... ' = -
N
.g.
~
[
., JY.
' ^ h l-9 5
_ gna g_',_f y
r y,.
[_
,,n.
p
!- A
.r
.- e
...?
y w
, e
.g.
=
4 y
t
,,. i
.s
-r W
y
"^ g k., '
y l ' '
l ll f.-s
~
e s
a, '
.g g
P,
, +,
gn
.g.
^
1 g
4 -
p g
g f-
)l$kq * ;i..*'
o I~
[
l
~
a-
- .+.-- ' r
.s s.
+
, p --
x 4-y Sf~ '*
n, 4
~s
=.
4.
s
- p 5
.s s
+
++
h*
s
'G =,*.:
. 4
+ ',
~
4 s -
~
l
' /.- ;'
' i:
4 s
., - Q,,-?
t,
=. g
.1...
g -
g.
g.., ' ~,.
S,
[
g y.
2 y
s n
-, 2 a
4
,j
- ~..
L
. +
2 i.
,; e N
.,*w t
r j<
.7
- .y -
g,.
i
. f *i c
y y
e
.,: _ ?
' ^
...' t g
_s e3 4... ~,.
3 7
g I
'y g
r..
- *.y
~-:.
=
-5.
+-
^ -
..g.
p.
N.o s
.,;g '
y 4
a '
(
4
.Q,9 p
p,,,,.
_ Wg. -
.a.,
- 7..-
4
/.
yj...
+,
.g<
say gme g..
s,.
.N
?
.'t r.
.b, I
- y;r.9 q/n...:c.6M i
i 1 3 ' T.i e ~ 4.'
y if,L,,swie
- .. ; ; Ag tg....
-..u s ;,.,
- +
p -
,j.-
.r 4pte; -
2 4,.
~
a y
g
-4
?~
.jf.L..
h
. f,}.
l _ _'
p,..
r.,,o 4 5. 4 d +
,} 13,.. h _-..
g.;
4
. -M e-ss
_', lGv
y.., y4.. :
~.
1
,.. s..
4.
v,:w.
9 - :..
v.m
- . ~.
.- a.
,c F!
^ '. '9**
.4
"'%+.,
-3..
9 5
,g i
- 4.
.., m ,Ir, E.-
l
~
p MpM,.
'g,.,.
e s' s s
1
$3g
/
J.
4 0
1
,N,.
l h
')
fE J u r( U n: alj\\.]ti I
J l
" ' * ~ :3 2 ; r. j 3-
a ' ? '. ' r.
7 W ;' 'O
- ^ /pc e n *, li j nc*
,, y
,'-for*,-q,
_r
-; a
-*'T"
' W * * 'n
- 3.9. 3 '-
!. s ; ; r.>
,3>;,
4 I
l f(
k
.n $4 y
Th,b * '
ih
> b- [
n.,.
. Av ?
4 mus 'm 24.
p,r.
y
,7,'y
/,
I b.'k k
g
$'s# '
~ 't
^ ?
~
3 m' w
%k.
as p.
?p 8
g
' y,',
8 d
f 3
s
~, 79
,a-93 g e,m a,
a 3,... c '...
~
i t
o. ~,%,..
V.s e,..
7.,.
g 4
,+- 4
- a,
- -3
'M
.. g.g
,d. [.y,'
.%?,..,f%...' f,(,(,. - '
'..,}
a
. -r g( p..Y c..90.
i
,,y m. s.
.g
.9
~,
- fki,
,l
.]
j.
T
. y'*g,g d,g,.
'i' *
,L f
. - ^-
' V.
'.D o.
be a
~..,.,'
s
, 7
,e c
r t
,,A g -
.1
,8
- gg.
j
'o f
. t
.. '. ; _.' n te
~ g-,. -g
.,e,'
-.i.
- u.
p
.-1.e.y..b y *. ; ?,,. ', '.
$....=.
,,e l
......'.g.-- '.*
+
f
-,i.,
- '4,i %
.}',-
'?
--' i4. '.
- 3..
{.Q '.'
,+. a. w. Qs..,<,,,+.
p q
, f, p,,..; _..
g,,
%s.
r..,
n.,,
~.
A. w s.g, [. 4,
.<e, '. '
gM
- -- 9..
'.4 i
A p,rl
- -~ - -- - -
i
+,..
...s
. < ; 3,.
4.
. ~ <.
fg. r% : p./. ;}v.. -
-4, -,
su g,
.,p.
'f
.2..,.,.
- c..
A a7 -
o
.. a..
A n*
.:....,:, 2 e,*
r p,
L;
~
. :... ;,. ~ y 4...
4
)--
e.
yq:
p.
i.',
,,s u.
s
'..s:
' t.:.
,, 4E - r-
- 1. ',
- O.,L. w%, '.
?.
na
.^
- r...
.~
l,,
'S hg.-' f;,.-l il.
t
..N y __..
e-g
^
./,
- ~.QCE f =_
.'2-
.'y
~
A
,re,.p..,
x e
s
.'y
_,_.:.,.. ~ " ~~
yye;y
.'yJ
.?.
.,q; y,
, @g.
.. J.P. '.
G.
2..
i
....s
~
1.
g :
y ep
. tj,'.
& 'g <
l p-a.
m..
..%' m. M%
y
. f,!:-
.7, 313.
,'f'i g
's 1,t>,,.-....
.x' y
s +
.,; 5.
.' ~._.sr,.
r I :,.
..p.g '
.. r.
- v. s s'..'
M - %g4 9 4
1 n
l
'R
\\
t.
~ ~, _ _ ' ).' .h
.f'
.y x. (..,3
~.,.
~
l -
~
- :i ~
4' a
,.'. y k
d'
! r '.. '
o l
~
- 1 s
1 y
, t :
l s
1 l.
1.
1 l i.'-
g 3
+
l
. (e, 4
.a.
, 7
)
[
O
~*
g, s
'K.
} -+,
n M"'
M e
p t
W.,
i
-- - g t,
..T (. 2 M$
2
- a..
,* 4
.e,
. W. f *
.{,
- %a *
- l#
(
,g.h
.*.a......e ***
Sa*
, d.p
.d.,..
?
,A*. g.,,...
s ssa, -
~ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _
.gq tlbb'.k..A
' t,:'. E E
O q...
s..
1 1.
- ;. f f, -
37
.^
.v
,.. ~
~
3
.'.. j ', :..1
{, y l
~
_k.*[
.H
,,. ;. 3.. jf. '
_ r-
~. f-*
e s
w.
g x
y
~
/+
y c
,. a. r.
. a-
.a.
/
- e,.
, s, '.
,9..
- "[~",.
[.
- ^
.a. y e
.-.y. o. Q.
ye.
4 _, a.., <.,. psi., -
z.
. r
_.,...f...,
- 'I~
- p..g.. mar 3
[I " '
'I 4
-,3-r
. 6
.i L.: ;:
d i.144 f @sd t.
4 J
Pf;; :?! '-
wp.
'F9 f,,l.: ', '
- 9.g*
W
_ ; f nJ
-f ps Y 7;
v-2,b:e..
@(.? g_., !Q4 gins
= ? ?g.
g
. j ac n.^;
1 w,., e 1
w, _.. n ;.:...
h
[.. M
, j,.
.a.g,r.. g.g.. -.
b.;.T.~ 7 58%.8mes.
wu-y. 3, w 7-c c
9 w - _-.
5 4 y
i a
1
.y zien
_._N
g [ '=
[')", l? ".
[-[,k.0,'
'.:, [' 'l
,hf;
'I
.i ~
(
)
g..
,1
!,o a F.-7...
- <,. pl j. : ; g,
.,y; +,.g \\ 'g. +.. ;,. -
.y
,,,.Jf
' 4'
- * 'g'y 4
.. L.
c.
',, y *, _ '.m _
{M{ g..
SgM...
g~,'
4
.(,.,
p...g h 're V'.s..'
i ' f..:. '/' -; -.
- j. :. j
..9.,
L...y0 3.
Afs.
. p.,.,.
1
.g.
y...;
_.7
.u u
. s. l:..,....
..g
,..a
'ff; f y (;' _ y.,...Q*
.Q,[-
c
- [
[}A,_
f..'N ?s
.... ' _ ' f.. 4< h 2'
s,: ;
~
s
.. ',.y c
,. j
.ca,a :......n.. f e,. c.c,. <.. '
- s.v;. :
4
. e1.
,o J, }... p,.,.c -
s. '
.m
$p< *.
- Q g.gY,. ' E b-To,..M a;,, t W
1.
.h
,7: 4 9,s<:..
~
. 4
..wy,..
4
.s
- 4. s.
?) s.,,.,. _.+, 7. g. CW..,. -
6 %,
- 2. y..- :
9,.. '
f,'; Wwve.9; y f, q
$c:
... kJ '
g a
x...
- r...,.
.... v' i
.V : e..'..yr s.,c,7.,3
.F.. '
u 4.e
. rr r.
p t
.p g
- 7., f a A..s,,.. :
- a.
1 m. > (-..
q-
. vy w
.. _ _.. g..:
"p'
. %_ vm $ f ',... '.'
j
,.. yn. :.
.............r
'.,.. gJrl i
y,.,
+..?
),
,f.
A-M. - eq, e p r,.t,,*g {.s. ".: p,._.r :
4
.~
.,I
- .Ac,' ;1.;
- o....
1 i-:
,Y1.' l.:. g,?
y 2
. s.n
.. / ;-
...s
$$$Wg.-...l'4
.:1.
~ f D, 5.f.' s.. f.41 A - w. u FA. a,,.-
h.p,. t '
n..$,
.-. a
- c..p '..
3 % ' g d_ k :.c',
p:; '. v:.+-
, ; ~,}...
L$p.sy!"
'.n
.s r;
y.
. 4. +,
- f.,. _. J
~ h' -. >},j.
. W j.
n, h.,[,
(.
y
,'((
},.- ( (
Q..'.
W g_.QQg %." -, '
N;'-
.;!wta -.. 1.v $., I
.h,
+
WW y,w o
2,. ;
4.-
- 4. f ' Q*;f, h W.;._'. '[
4
..f.;p.
g%gd-, n.g.).,? n,y n.,,,#::.yy Y
4 w
>:+
y :.p+ f4,
f:r,... A +
6 h%(. %:%2.q /.:. M g. %
A
.. p M -
W q '.
p;p.,u,. 9.. }^..
r 4..g
-A t
9 %...
v.3g.e ?,+ g y& FQg %q.%u - ~
c#;...,.w q. ~..gp.
$g
, v%, %g., g
~ < -
5.7< '
'pp j t..
x.s.
f...
g y
- f y
'c
/
y.3 4.... :?. *
~.
..p C::;.
',y.,.
%.e %.
r
'.. _ n.\\
i v [..
,m r { '.
4
,.3
-M-.
i, t
i
.......,.... p
. ~..
s.
~.
1
,.y p...,,.gc ;t*m.... av
' i l f."L.
i :; a-...;-
. - Q...;. g y. 9
- y.. ;
', y '... y.Y
%q
n
,(
j
\\
l
(
l 2
%g..
-_ us
- .m ~..; ammmmme w...
.u
. f,,; U
- k'
- ;o; 23
- .-.
.5"".
'. k :,
. n 1. y'.,
. h'.
f,_
.... ?? '
,i :
5v n
.~
. _. / - =.
. 4.
I 39.;
i 1
g
~ -
p.w %.:
p1 o...
Jr
- i. aman ' 3 s : -
- h w {[, M l
- 1,
/,
,Ap**
>.h a
- r -
. }
_ 3: -.:s:
s.
-gu..
~
" b ] E3f ~.- f r,E3;'. Q-
'}Il m S.
g y
y s.. :a x
=-
. r 4-
+
,c.
s*r x., ;'y.
. - s t..
3 c
n<.-
_g a
M
'. -, ;. ;. n,.
. ',.,4.-
...,.. - s.
3 e,
=*.
- ~-
.1 -
4, l
f,..
?
^
. >...- le[. k e.
}j.'L, ' _ ' ' _ '
~
l l
c.: L
.p ;.,,
e LM I
p' f y U n U nlu' h f'% 'R ta s
i i
1 I
I I
=".c t os < 22 and <:23 z
'. 2P OCding Wa3 i ".CC r i i 3 t ent On the SteaI'1 3 7 3 t e..
1 l
l l
I l
l
(
I l
h 5
i l
t I'
6 r
f I
l 1
l 4.f. ' Jn g -.
- t
.1 g
.g 5"
',,,g T
c
_3-w d..r d IM.,-.,
g.g a.-
~y' O
.s
+
,-.Ws ' _
- . g
' ' 'y"- *,
- s,."'
,t e
-.m;
,i ' _) f.y%
+.~,' !-
?
, #.~-'*
g
... ' 7. f;i...
.c C'.. '.,,;..
.A l.,
!.~.
.<+f
- . _5,,
- O k
.]
_e
,Y
- r
's
+,.
.F
^ i~ g.
S
-E, g.,,
- g...
u s.. ~ '
's
[. " (
+
e '. _,'g,.
ir.
_ s. i.
gg x,.
- 7 p.
s
~ y -,
i......,,
s et
, ' s,' '
43,.,
t,..
a
. W y-a,
?
f, ylg j
t,
s
. p y, - c., :-_
T
.g l
$m, )
4
.l.
i)t4
!t
?ct:s
- v. 2 -:?
r i r.c w ' r :ar ; ' i.- t 9 ~3
- ::ra
'li a - ir c " :3.
9 I
(
I l
i l
L
~
l l
}M.,, '.$.h. 'p[.
y.
.g*-
g y.
- j=e-. k, **..a[
'l
- . J
,*1 i
, : ' i *.,,'.
}
\\
, Y,
a.
.A
\\
^ -,
y* ' v.e..sT.4 y ;:
r
..a I
t.. -
- a. :
l t
\\
p,.
,. h,,.
- s. -
Y,.-
. \\
. _, g.., 4 ' '. ' k...,..'., ' $ 7 bh
?'h l %..
- Y..,
l t
- c....-
l m.
- ~
. (,.
g g.e y~.
N;_.t.
l
. g.,
.q,,
p..
~.4 '. *h,,..j?,
,,[
, '._ - L
.)k
- .?
Ol: g.....
l'
's. :..
,', ?.T
..*, w i,.s,
.. h. f:,,., *,. 1 3
=
4 g.;.
s.
m=4, ' -.i..
-u
,.. ~.
- . s. s,
,.-.., t. -,..
. i
. w,,7 a,
+
.s
..e;
. b..
,n 4 4,;...,.
e.
'.,;, ',' a... :.. h-f4 2, -
.h...
. '.,,.T,.,. 2.. 5 y,, w,
'. L
- q 'v~. :..
., s.
b.
v.
..... :. s.. - -.
.,ss x..
I, - T. [k J.. ) % I - '"'
\\r, I *-
.,.-[
g y
4 g'
4A
- , a:. 2.
~~ya
~.. ' {,, ',. y - - Q:_.
'. k #
?: ; ~. ', '.-
.L 5
..u.,. o'"
y
- g g, y y 3,4 -,
-,, a.
.)
j 4,h. gh*, f;. ' #. -
,,' P"7., *,*
'*M*.
s
. v.v.
y..l
, j
${ ' eeuh, 'MeeDa., f M( +,.4,..a;,'.
~,,
',...,p N
.f q.,.
,-k
,'a f
.g'
'. #.y ~ ? y-("2 'v, '
~$.
M(" L ~ ;. ', f ' a.
-l ;
~
y
,,q, 3, h.,,f
,,e
);
.g f y
-,g3g-
.y g.r.
p, e4
.e.,,
.j.,
.. j.
.3.
y QF,,..
c
--.6 e-e
.g y
pa g,.
%,,,,,g., yy
=
..-.m 9g w ka.u..
e-w-
<,y
,g3.
y v.
.,.., x,....:.w. m..
7 gA g,.i
. gq ' *.9 %.. ~.
n 15
[. 2 't
- s b
e 48.) $.sy,. y
['
,s
- }g,Q ; *&
k v
L v :.
,,4 y'
yM5, ?,.
...xf p..
5.
., s? s.
,_g, %.%L
'.. q.p.
-M'-
t*i A..,. g..'. - -
. -,,p f. -
4.;
.yn l.b**
4*
~A.
o 1,9}. k...
/
, 4 w.. $a -.,,..
g...
4
. ;?~g)
- y. jt')(m m:
- y. p
,' l ['
5 '.. * '. ' '
J ' ~ M, N(
.,, lc g
~:~"
- 4
%y p.
.c r
,' gM gm.. j.
. $*. I, k ' '.j I, ' d. +..
I t.
M f M.1 r
t
,. 4
..g
- a..
,*g. w
- E; Q*4.?& l== ' ~ s s.
g Yg
,. 9 *.T,
.gt A j m
,A.
1.
r -
t>
\\},;t.fp'.:Ygngjghj;'i'l V
Q. ! $.~ #
>.? & s Q Q,; F {I..Q' p
^.
i f'??- ' Yp.yl 'l. s. -
ayf _ s pf -
n~.*.
3:
- y,
. ly1 llpl}.
h..h-~A}. :-.. A. c.<? j f ' f'rwm q-f
_ h..l.f.-f'e.}.}' k
- 4 c
--e
~
r
- } ~j...gf .".
~ y,',[- Q M fl% h,,',,,
W-
~. <..
.. n. ^,.... q;-
. ?,t 4 r. g V'.. &.
.$,./
,.c...
.o _.
gy 9' & ~,.,
'p p ~_
s-
. 06 -
r ;fl j.s 4,}y ?.
[9 -
O-tr e
.- 9 *, f. ~
, h',- (.p 'g,3.gl ?.'
c'
.. U N1 7
. '. y, ~
4 q: yV y
>f
- f.
f
- g 4
s, 3.a
.n n
. r-
.? w A, :.:,-
.m m, o.
g.~ -
<s s
f, T,
i
,7 y r,m,[ ;
A,-
",; [!
k$, g} g, asme '.t. g.de.-
.4. ',.Jl1..'. r f,,%.yn
. 3 y
e e, g.. A ')
P.-
,i v/ !..
.s *
- ?.
C
.._4
- g, p.g..,..,.,,
+-
(
s
'. *ry. Q '..v?
s.,. ' f ?
,. '. 'Mi l.'.,
-{..
0.2.~ $.-'
,h
(*.!*'% N,% * ),. < ' '. '.
. - : y,'r..
- . 'y.*'., fs Y.
i.
g.,
ps
- ;_.. a
- :'
. +
. so1 io,-
c
- .,?. :.[
.,:*,u.
,n -
a e
i 'sl.,:.>;
., 7
,g
.r.
.g.. i
" -. ' w 3..
i hD. '.
- /, N. 'I v.+
- ) j
, 'e.1I s
}~$6 -** >
i+5. Y-
' ]o J. g #$. k. k.,,,.
[f.
g 3-Q, [y ;,gi,
V.j f g4N;-
- . g. T 1.'
c
~
- r'
, ; (... *?.,,6...,6 7. ' :...'..
- ; 5, ' -
- g..,,. [..
5[ f
,.., "W< J g' I. ?$ s 2
7..
- .y
- 4..
.L... ;n...t,.
a.,, g.,
~,q,
,, e.e.. k ' N.,
3 Lngv:s g.n., p
.'v...-
.d
.Ar%g,
..n
- r
+:
- -'WO. < h,[,9,+1 Ig*d
- c'Ls,..." p ek. g.w
- . s lt
%> E a..%
(,
y.
a
. t,t*%
39x w
~
g,,..4g:.4y. Vf9 e * ;:q M y*
'6,%.
-7.<' g.
a4*
. M Ag ' -
's.U...
W.. ::
-t '. '>
v
? *.,
x 2 v -r.
(
I. ^'. + + ** h*
. h.
[.
[
f. E.f)S..@NMVMOk[@e.....a.N5 AQm.M;'(..'[.'f':[7 ^
t '
d mg.. r, y,. e,p..: s.. e c.: =c c..c w.v..
h? Y. h W ' '..
a v
..wr
... 9.
scw.
N-f'
-. 'q'\\p;! N.Y N f g? -h$yy. Y?Q.e?-y.g ?
$-f n
wnw.nyr up3 ep. e
I s.
,y.
,- -.,. 3.y.m,,y..
- u. y,-c
,..,s s
3.,,g
._,.y 3., y 2.... g a.g... '
s,..1,.
s.
i
$.' ' g. ? *,p e -,
41R.,
r
- i ',.-,
t.
l r. s
.* ; ; p. c g "
t l
el g g en s.s n
. r* nm,
y -
k,g4.
j.f
%.N
-[. ; ; % %*[1fE ' l l
w t.
3.
g t
.,. g.
s.
D ', '" f,,).,l,..!.
4[
.. y+p 5Qfg ; r,.
Y+
a i
-,4
' a r....
...W. t..s y
- 91. <%... m
.. y ~.,
.6
.m
).
&;,.~%;f:t'e.~LT.nf;.;f..-
, t
{..
ta-M4 2 um
- t.- p
+
> /
,c, u,. ', q.
3 w,v. -...
- a..
- 1, frK. ?g.i.
tj.r.,p, p.; _.
. s ur" m
r.,
..n 7
ga, h ;.*p ;4 x Q.y + W.
.n. '..%. s h ',
- q,
.. r
. s
., ~
a n
.6 w
e
>g,
.m
.. n
..~q n.
m" s..
- :4. Y y
- :. :.+ v. ;
-v
.,p 4 -
.r - ",c
. w
.. y '~ y- ' *. ' _q. w m).
v.
c c
.[ '4.f *A *,n
,(,;3-c-his.lt, L p.r-yVed ;. --. y-e %p. ' * *"'
u k >4..y--
,. f - g. 5 g. a' d.%. j._ -.
t e y gy 7 p.7. ;
w q.,
9 W
i
,I
.p
.u a
'. M. g, ^%. J.-
.g W ~gP;w' t, f.f,a
.A 5
+
,1 c
es 3e.
s e
?
.J.
4.
y-.d..
Auf~.,.g, ^ a R : '.f&.T Od}o -
- " '[*
y,: D_ ;ay :fg. -.
-."... Y,
- -f,if
- l..' '
wi
'..V*.*+
- ~
I{.
. & [ (4 AnW 5Y -
'l 2.
- :.~
^ b -.rs-b '+ 6) I <
)
&n a'h' k &.. ws}-
N
?
f
(_.Y l : b.}K 7,yh L.
.p*
c.
. g shJ f,t. nr aw y,
(
.g
~
s
_,v. W a+
' sty '
te '. p' ga %,, g'
{:
.. sep. ;
s,., s, j [. y-
- n. ;..m - -.
..;.wfic & ;
.s s _,, k..
p '.'. '
.g 7, W:
s %,> &n -,..
1
-(,
~
,3 3
4 t
.' ? 4ded#, m
- l
-.m & l *. -
a 1
'a
.m8ngh'-
. y y..
- ; ".4% $ n% y V-
- % & a.:;.
.. 3.p w
... s.u.u
.L,.<
l,.-
w
- v. -
_y
- p. +
+b. -.
Y
.. g '...[
Y
. 4 y %,;.. h 4
l
. 'h.g.'
q-4.- Qh,.
l 7 bef_;'3. ;
} uW Q, : '
- i.,,.c 6,.,..,
'.., k..'E U ' :
f}..b
," 7ae: d.f Li y;., s.Q.. 1 l,.:.
p ~., i c
y yn;...4
=.
. v
- y ' m s.
4 :e ;.-
n
- y.w_pg.,
l
, a.e.,~,,.
<y
..y
?.
v w
- <.=(*.f-h 'c,.#
- - 1,y
' f...- 1..e g.
= (
,7.-.
w
,y P }-
Un*
- ^ -
4e Wf
. 9,
.l.. / "g g
l y>
~
9,
.e c.
= ;.
- e.,..,. -
e 3c, q - -.-
s
.. ~
u y
.x,u-
.. e.
.n.
_, - +
,S..+
.,3 s'
5.
... ;, y.
,+
i
, + +
s,
- 7
' ".m,sw
.r y
.e
. 3
. - e. t a,
- s. e
~
4
'4
- y ;7
(
l
- 4 '. ;. ~.
..r s
.j..
+..
J f
,-
- 7
.G*.
- e
- L,,
- ;.7 ' '.,.
5
- e..
w
.,.w'-
e
.,, ~
-,,4
,.j ' c s
eg e.
9
- +...
?
t..
s
. w-h
' 7 y
/.
4.., -
~
+'.
m.
..s
- c..-. p '.
pf
- [ j.,
4*,
./
. l l-l
- q s
.. ;. +
- }.,,,
g.-
r e
x w*
_ =
+
s.
.gi 4
a
~
l'.;
t R
J-nt ' -
ke
's t
o 4"+
y-
. +.-
. ~.
sxn 2...
c
~.. - - r 1
V:
1
,j,=.
~ '
.R
.,.4. 3
.s
.7 y.
f
,,:,y, ; '.
.' g-r
.^e '.
a.
.g.
.,.1
,{..
J.. -,
w
.s i
+.
w
..,s
+
\\
c.
~
.s l
=
.s
+
c; r-A 1
+-
g 7,
e
?
%*.=-
+
s i.'
J.
v 4.
- i t.
e
,a
.,...'I i
4 e.-
4
= -,
p w
f,s
".,i,.,.
..s
~;
m,
. }
g +. < b '., - -
v
,8 n..
t.
/
j
.w 1
s
...t.
~
.,y q.,. -' J. '
.G ni.~
r
. t
(-
l
- ~;.,, e,;
, $v_,
s
.-g a.
r *
=
,0.'. @,4 ks*% u -
c % M -A *, W;7_; W p# g...
'"$:%$,,,,.. -.. ;.,. s
. p l.,.. : je g,-
s
,.. 4
'. A.9tu
'hn%,,,p h s.
..L ng~;:..-
+
- n. qp_"
i'% y,, q,4
% q#
~j.
g
-g
,- ]
} _.,.
.A4 (w8 ' ~ i :"r.-.e
. v; - -'
r.. q ;. :. :.; -. +
as *- },.~
~,-'e-e
~"~~,3 sj u n
t
-s
. :t 6
-.M.A.*
<+
m,i s.t 1
..t y
- 9..-; e..
. -- y ;.
]
s.
3.
,os
,9
- p-e ; cq -
^
ah
/
^ E
~-
l.^ h, 4 -. 1MQ L 3,..' % A,.-Q Of
'g&
,',_l
- ?
~.-
&g, u..},,;
.l
-hp 4,..,
2,[ ' $,:- l ; 4 i_
s. '.. M. ;.
' T
?.
Rx y _ k_ f 'Q
..' n -. ~... g ~, ; Q >.,..4,,_
L.
a.
~'p g g. j f f y, (
u.
.. Q 'g,
D!
4 Q ",
'.3 r..
, - (y ;,,,.
m o
... _, _ 'w%
v -, %je. p.
~.
.y.
~,,
s y c.
3
-s.
..f..
& :; s
.y..-
L' 2
-~
. w. L%..,4f (,.,__;.5p
-Q c
. y '.
~
c
. y l...;,'y
-.f ' )
_-r, y
y -
a.-
e,
... g,..
,t.
3 V
~
^
gt....- -..
r :h9, on, %y.,
.v 4,
f
, K ', &., [
.'..-h
.y
.'. Q.y.
4..
.. -.:. g u. :..;
g.,.
4 g v,p.s.;.._..,
3, 4,,-,
- f,
4 s
g -
..., 4
',? p -.g ' M. Mh N@Q1 s
N ','.' V; r.
(.,l ' 4. ?. v %yC.;
C4 s *.'
a-
{
. ' y. %w.?.kf -
a
-y p-
.,.t
-y...
Y'..
A.
s.n ~ p rgy -
-y
.,. ' y
- ys
-4,.,
', <-,1 L-y..
.. Q*g:- ^',...%'
.h. AA
.., ~., r Q.
r ~q
. ' ' {
..,;\\
M.
[^.JgN%&
w:
- -...s
~.
- i.
s
+, %.
%y.
y". ;;3..y"
.e
.ll..
.,;M.,
.e 3-
,,y
. J
,..g
^, pg.
p.
- 4,;,
e h,.[pfy;.g
, :4 }.y, y
t'e. ;A.
.V
%. :- '..,'*7s d -.,... -...
^"
o
.,,,;, '.. y _,.
,-g y a
.... J4..
., 4 +t g
x
_l s;
y-
.a
,..?, '
e. h MS[, k. _.e{,
..s.
s.
3
'Ec.% e ' p.
.', [ ' s G J.
q
- y.
.a W
y.
'g.
....j_
'6'..
. c'-
sgw,.
.x
, ' 4:
e
- w.
- se, :.... 'y
..* - y N.J.
-i
.. A m.
0,s g"t'..
Yat
..r.
Y*
1 6,
.,,.y - q *.':.y.
y :.: s,g et
..Y
- m
.s s
, - : j y
pff-.
+, -
.,.n,,
. [. g. y
,.. +
g.
-.77,5 *
,e,.
-.u 7f. U - ',
(a
- s... :. ;
,,4....-
2
, (. ;. f 4 a. a. -
m..
.. ~ r
~: A
- 3. '... ~
?.- l -- c"I g [. = g;---
f.
yg.,,. "'.
.. 3 1 g, 't. -
~'
-r-y
,g'
- m;,
4...,
[ '
s., Q,,.
^ W M,
' ;. fn
%l [ ' _
^
j (,,.,
v.
_ _ _ G M.x 3%
y 1
i
% e.'
,Mr J;T;. %my,.
.... - F,.
O d
h1hlh*.
?'
f,,A
. E Y -f
??
..g-g_ J.9 * -
}
1y
.3-o
.A % f 'g. y
'.V f. l,
'. 1%'..g ; 3 ;y;. 4} p,
.r 3,
.w p n
- wp'
\\. p
.r L:.,,, g n
i
.-i. g.,'
4
'.,ii Q "
?
...* _j
.M;
{.
.+.;
, q. ;,s p. w
,L-M.
b,.
r
-(F &m w,..,, + ' }^h lQ,.,
v
- y 1.;.
..s
?i. h.a' (... k';f R_
I-
'R l -
- */
g
[e vk k
.Y
-l
, ..>Q.m-7,! n. n s.v,.. f , z %r x ' n Sl4 g.. ,,.~ _ j , +.j. 'c-h
- T.,' r
<.n. s. ' ** j.,..',\\.g )% j %.* y.,' '~ f
- 5 },.~
- .' b.
f. 5.f l# h N '. ',, '. ' '.' I ' k l.. % i.K..'. ,' k. Dy *nl.. A e. c n . ' ?,
- N 4
, JQg y + ab. ;. .A. ' r. cd. 2y.g g., i,S ij.f g# t y . n, y4.. -' - %., ').., (%% 3. - p y..+ p y, a,v,. [ e>- e:%s,.. y,".. ',, "_.gg -f ~
- N. "~'
~. N '$ t' ' 'I ^ 4 'J' . ', '..,,n,- - -} *.;.,*;. ,) ...g g 7p. g _p' ~ ...y.. v w r. . ~,.....~ g... q _.. g I~ y,..dt +w,... y. / ~ p- .g 9,..,. ,.yj x34< Y ? ;. '< .f k w I ir e'... [ ' +. ~~L N.' N . ~, f_, y 'Y, N'. yk.h " ~ *
- e.
%4 I 'O ,l,,h.,-. f*,. h,$Jj ". 5 Y W J'th 8#'.-ia g-[ 3- .I t 4 YE. ' .C*g %..v. M k '[ j' ' \\.'.$ '.l. g 'i ~.... -
- g..& '1 3 - g - 'kD ' y (v-l.A,~. - -
o l 3 w4 l NY ' * ~ .,N ~' 3' g ;.. y p. x,. ~.g:. t. yl,Q'.. a p. .),p g.$,3;;u 'y.- %' g.fl ?v
- ,y,
r . g e ;,,. t v 9 -,._. 3.y.. ? n
- e. N p
9.,, ', ' ; '? ...y _.,g; i g g 4F- - 9 s g.) g +,. ' a ? x4 T / />, s < Q... % ,.,,b 6 m L -+. ' 3. .L 9 . V- -l g4 ", 8 ',s a ' > h ! " ; ;' g y..4}., f, '. [ "'. '..[--.- J, f., - :rp%,.g4 Y,j. '., ',,, ;,. y,- <:.... p, ,0*g ^ 3 k .,x e , K ,s., \\ - g.
- n. '.
- Q,.., ', y
.4 7.- 't .e = g
- gr#f ~,, \\ < y
- ) W f. D.
3,, ; 'j > v. 4 .s l J h 'l *,( ' ' * - },.,.y j'. .,. y. %. 4
- -". N f--'4
",) g ; ', .e-. E, [ ', g g; 1' 5 h* A[ %.W-% 1 4.gj + L< A -.?
- %..:.4 n 2
,v c.* 5., y v .n ; y* vi t
- -..l t.. '
q A p k, $g,.. : f- [, },',%s,.efv f. y > Q. Y.- ,*F ,^ ..: 3 W ,, 4 w, +. 1 t.*'. \\ );,. l,k%g. J.'( ")'.. ( 'g - *... h h- /* e : ( .. 4;. m _.v -s y, %,%_ my ,s ~ - 7 ..,i f j.. 4-g-. [,p. 3 -.. .,9..;,,;. 4. 3 ;;,c; 7 L.,. (_ ... :, 7, ' '['5, ~ '-- = - :s e..,6 ? . s,; 3 ,foi n'. :., .,.a,. ~ e. 'x' .,e / , ',.'.,',c,, -,,.. ~. y s
- s
' } 't
- g. -.
_w 4'. , g ~.' ~ _, fe m i. rn - a e.. ,,.e J. V u;., .,. +.-e, m.
- e..
v ~ , p ;'. # -y : w, -.(. r s s 5. .s '. ,g m < g + '. ,, * - Q?, ',, ' ' S y .e..'. .^ .. ~. ,.c. ..,n,.. _. - - j p ,.[.. .u... c ,K. .*' ',j f '.'. {....'. '.'. n.. -4 - a q ~n .'9" 4 ?,_ [ ,% _\\ ' * . gy1 . - 9.,.. v.
- y....
....y. a g .. ~. y u *.- . y,,. y- ,,s.. ',%, Q ',. & '.. % / i; l 6.... t ...s, ',i 4 qq.n '[ fy 'g y8 ,u% y... :.. 'Q.A r,9 7 f '., ' . V 4 n y ,s s _Q,
- - }1 t ix '. -
wa s w ? 'j Q@/ a+ . r y 1 \\ ,. m ~ r. .:. ^ .. - ~ t.
- c,e. 1.*A.. s,. 3 4
. N '. J.w. ; J. - p(. .:. w + ..c.. . "tb..t./.,.,,.4,., ''.)' M p%e. 4 3 .,/,,....,...,, 6. a. P- ==== 4 j pg rr ~ 3 4' mad-y,,..,w..,g,*,.. m ,d 3 y. u- -t,.,. / ..g M,fM 'h,:.. s.- s .i.-....}' * ' ' '. V~...... '
- 36,
1 g 'w. ,. ( 1 s. :. -
- e. ' #. '..
1,.j k l k \\ v y,.p'. . t.. a 4 p, '.,; j '... > 5 4 ,e 4 . 'b-i .~
- p; h'.
., s. .c ,,4 t g" 3 g,, h.>a. -
- t. r.
k. Ic,. ~* i . %k't=.
- A
~ l.3-g ,.\\. ?'*; y a. ' ^ .. y,l o. 1., i.~. . 1. -. i . ;f h.,Y .? - f 'yenQ . a \\ ;.. _. ^ ~ j '*W * - r E 6 .m.. .ar l. 's .t l e ~ . [_ i, h l ~ a ~ e g l 4 a s 3 l.. ^ ~ 4 4, ,g. n ~ de 9-g g ~ .p ~ .f v, ,\\ n' ~ Q. s - g-.. m -
- 7..g 4. f,....
~ W.,.-.a s: W.k. w u se - s L .;. t y.';. &. y,, a. y J.g. n.. a.:h ;,., *.,, :,* n.p. ;. .:n,.*
- 4 +;
. 4 . '. c. rq. n. 4.. ; g /. >x i,A ^ l + C =dy% _' --K 17 ~ A. .-y. a. O w . m ,l' P i [.e p . + ^ . -g ,$.N' \\ 4 ..ks [f - [' ^,f I' * * ' *
- A.+
g .. "[ $$A,'.9( N. r[ [., ' '.
- k [, ' '
7 f
- s' ~ ].h.,
5'-%E. e. [ a , N% ' ' -;d[ ]~ { f.g '., , i.. A g,,. ',., ,w
- , 4.
'. ', =y"., J
- j.. _.
Ytr 3 ' ~y ...{. - y,QL- 'q l- . j. - + - y,
- 5%
J x rA.
- q 4
M. q,. g... g - S.,, y, ~,.., y-a.. f.- - ' '.,.,... -,..,x -y~ c
- 5..
'- A r, y .., 43., , r-4 % y. g j,,. 4. 7.,,., .,#e .e 4 g,,...v. -( a; "<g .f.../g g 4f.'f'1 c- .e v= i. W e,.. 4 _. * .)
- - i y
,_., +. - /... + / ei 3 'C ,+-9 p,..,sd, 6 ..f ' **# e. '}&jf - l 4* e ', j k) )I. * ~ 'I n. k.% ;,_ ' l jb.., -f. - =. .m... ll. l f
- g..,. s...,...
g e- , m x ...,w,,.t., ;..:a,,,w .q ~. - 4 g-~.-a. m,,. ... _. m. e A y a.,.y k ., a, . m..r
- u. q -
.4 ;..s,y. pr.. y 7%;. ,.t. c s ..w..q.x.. A.m,2 - :.. t ... "w .r <., i. 3 -.. s. ..a a , _ y J\\.y m3., f'z. *, f. m si e s . t 3.,4.,L-Q. - ~. 4 y.V. _ T.(., x (;,g. 4. eg%.. ;.,.., n,y. .d... a .y 1 ' ~. - r,.... 4, s. .s.... a ' n4..x. T.. s. - m.M,4. ~,,m. ".~ . e' ~ ..~..s ^ ' ' W.- .P..v.g tw '
- t..is; -
~v v.,. h w~J.u.*
- a..: ~. w'.
.A.r h..a '. n%,. w.. 'e ~,, '... 1.T
- s.4-1, r -
h *$%. (4 '. ' y' e, '- - :
- Uf'.' 'sq :. e'".
"y% .g y y. 'n c . ~ ..a. e.. t ,, y,y . 3.< _=..,; + } g*n s ..v .,, + b.s ......x A sur s. .-, c-3. ..... y...., m . % c 4.:-. 1 .,.2 e v > c g- . ;},,.4f.. #. ' 'I + [; ~ 'l.5 % ~ . f ARV1 3 Qg .~ ' If = t'; ' p k..,,% ,y
=
pJ,
,8 \\,,'
to- '
- I
.s gp e
6 y,
- ssY s ~ "
g....,,
't ' 5f',-
4-7.1.. (
h 3
i =
[
4
,,. 4 m.
.. ~
'm
.,y
.n,,
g-
+
'g***
[-
D' -
-4 7 -*
.g.#g&,+...,.
4.-
.pv. wmg. 'I-33 b
0 A.'
.e "em
,9
~ $'
.*. v.
',, ;j
- f.
Q
-f,
+..
a--
p
.p
., 3
,,c,(=c 4*
p..n s
r
. w e
kg.
'T.,
4
-* i. k, _,
e
... h +c..'
.y gait 4
t
+%~
v
,y *w
-- %t'+-
y M
9
- 4
. m
.r.~.
n-
- x s
,e
.. c
-~..,?.. J' 1
4
, _ _,. 3
. f. ~ y,. '
- - - g
- y s.,
.s
. i,Q
-,.3
- * 'f.
4, n
y g
e 'kl0 W.'
A 4
g t
m
_^
r
., A. sk~ :
~ '
t 6
m x
3g,-
r 1
+-
f
,.1
. r,-,
- Y
- v
..,4k
'-+, **
o s.
4-
~
e
' _. 4'
--.C ; ~
-. =..
.s
~,
J:
- r A
q*
4 3.
a
. ~ - ' ^
a m.-i..:.'.'-
e
=
j-3
[
+1
'r..
O s
[,,
4 e
,,'M
+
.O IS t
p4 *.
3
- r
'l
~
- ..,....w l
.y
/
2
- - ;.. ~..
+
- 1 7.. ;
j g
y-
' ^ ^
g
- j.
- b S
g
+
<f
,, 3 er g
7 _
7,
je:
~
. 4,
+
"s 4
4 m
- . a.
e,,
k g
m
.w M
- 6
~..:
'.e s
- 'i
.'+N 7.
'.e.
i ~.
w "
. h 4
s' 3
. s
,r
, 4' z
a y
' (.
- 2 3.
g., -
. L. ' ; '.
- , R' s i.
x
. 'i t
I
'g -
fi'..,, +. "
,..)'
. ;. s ",.
- 4. -
t p,,
e
- '.'.N t
~,
g.
7
.4.
- M M
,..y VM
" Q y '.". W. *'.. - a
%. 40, 4
,_ j
... a
' g,. ', m ' i l ", 9.
y, ay,ed, y.; ",
f
.*r
. %_,,p
-,'-3'
' A, ;
\\
'.: L,,u tM
- R G_
y.. ~
i st 1
,9, ih..,,.-...,
A fy Hr
..,l p
g.,
e
=
4 -
- p. ;., ' ;
.,A%
.*..g
- ts,,.
w-.
,r. A ;.
+],g,o j-eliq
,w t
c
. g
., o y.=w l
.d
.E
'W h
- $ f
'r, e 6
'e W;
t,'^-
k' (4*
~g y J 1-J e A.
- t. - ' -
- k - C. a 7. %p.6 - f1 h a' $ ;#*l7' * -
W g "^t g y, *#%' "2f(
- k.,
s
- h c
=
tfe' q
{ W W[,. 3 j
(
.h,
,7 i...y 4-
.. g.
4 y i. +.
)J y rq%.
, p -y,
.=v
_,.,, n.4) y ;..,
y q
_ g,
3',f,. '
..hhj, h Whh[
.. _ f f.3 h
l
~
A 6,. -h.
N.kh k
,94
,,g yh rl.L.
- -. k A. '
. f' p, p ;,..fy, ( WJ f.
f.,.,,W Q A.'* - '., '
4
- %.M % %g '..
- ~
4
.am we
.n f-3.67 T.Q%.'
_ ( j i}
- N %' g #.- 4d J
y f.
7.-
.y..,
4_e :.,e f
'e jr,N}:
- l. ( 69 sum (W-l.,
' -y$'
j, W
4 j
- wn
'a-
~
r M..., L...
y,
(
- c '.}*
- j g,
J q-3-
gg{
{
M
., [ C -
1 g
.i.
g.3
.')..
j
.a.
=. 4 4 w.y
. y-,
1.~.4 9.,,,-
A).E,L-'.,.[ f7,
. a.-p */ ~
h I
O
' k'I y\\% -,
, ^
)$,%
'I*h'-
, A,.... s -' / 5-af.s'. 2 '
g
.' Y #
. }E % W W 2 '
3 A
- - l y i a
f
- . y
,e g.?
t,e
<.;. *. ne g.;.
4
- i j3
% w; JP 4 e
7 y
p.
h I
a b'
{-
-(.
y; 4f
- 19 ;
~~
'* [.[
- e
&.,'.7,J. y,,4 4
>A,,g_,-. % q f
..h t '.;
-J
,i '..
AWs
~ ~..
g <
s, e -
. w.7
[
d" I
V,,
4
'4 Q.
a s.
,9 s
y..g n,.
5
_ r g.,
4,,
..s,
~
U p. "/
c h3.p y.k.* *, *.. f p f' % -
-+. * [, ',
I* ;
.4 yf,,. '
e d,,,'
-4 2
v g.
y
,sg ' *
^ y -
.s,,-
.t':
n,.
- y
+..
- [ g.7.
j
/,t s
~
t sa-
- c. r -
,,'..p*
k
.a e"," 8[ * '
-'.i,'.
+.
., O, 3,
. y~.
.g
? -
...?
t
+m) ge.
.; y
- .'a..
.,*t+
s,
- t.
~
4 evi
.:? ;,
--4..,
- ~
s
,[
',. g...
4, 7
v.g fg (,
(,f
%*'r,
,c-
.e
-J.
g
+
. u(
4
-4. y S.
,.f(
.g w
s6 a.
!, 'gS.y-
. {,
+
.} l-
' 1.,,
^, " _.
's._.
.y 4.-Y y
-.-. j, y,.
s
=.,,.
, s y, 4
,1.'
2
-;l e
a ;.
,p
. 4g,.
g ' -,'
- [._,[ L-
%. [-
+
w z.
_-;.g S 9 '.
.I.~i-#,,
u-
..e.
c.
e y
S. }O
[','
,P
[.' h
- ee
.,, - (rf f
~,
a
~ -
. ['
-,, J c.
4g*h \\
[,
^ -
,r
[p.-.
0 a
.Sc..
- r.,,
1 s
5s l.
l " f 4.%.,,
l..
f._*-$'.
e g.-,.
g'-
,4 l
/
(
_y_
- t v ^+
- 4-b
.k
[ ' ;.
34.,
.'. +
4
,; :j ^' - Q :..; ; i _
',.R p K y'k-[,..,-
- t
.. ~.,
(
,.,.t.
.,g., e.
., a,,
w,f
.g
..f w.m. -
- ,,,,n, i,
u._
c - v, '.. '.
y--
s s.
JC g
.4 -
t.
.- y; - -
.s
,+.
.v e '-
p..
. 4- >
r s
(
+
T Aj 4
^ e,
~
f
' i v>
'f j h. ".
- " e
.- i m.
. ; -,(,'
f,'. - }.
1.**y ',.:. +
7.s
- 7
-..+ - ;
g
.g '
7, l
g.,.,
49
., ~ < -..,, #
3
.,. -. =
+
g_,
,,2.,
.+
l
.M i '
(
f.
~
4
).
q.,,,,-- :
U,'. '.'
[ 4, -
,,. 1 k,,
",[, -,
./
.#,4 9. *,g. m. y.
L
'- t is
'. ' t yz
,. 3 s,
m
(
-i s
m l'f
.L
- i,
[
~
\\.,
.n
%g. -
l 9
e.
g-g q.
'k
^
,. ',,, p. e':.
l
\\.. ;.,~. ?.,
l l
- . m ew 1
%.. -... g.~ ; --
y w.+
-,_,n'
,g 2
^ ~. ~
. ' 1,v,1... '
. ". ; w... 4,m
,,...', ~'. F - i '
~.
C-.. ' ;. ^-.
).6 %,
r, 7
~-
'.g.
w.
'2 l
I j
i
,', : $,, 0 $"s *..'.
a.,...
-.s*.
n
~.
/,y 4 5
- J. t - 2 ;$-
l
- . 6A r
,4 m L 4.*\\.
a.,
e-.
a
....y c'
g
., ~.
$.Cg ",
=. ; :
m
-i:
c.-
f.
A...;N
' *ivk*
, W,s g.
l-g'.
~
-